Texas Healthcare Transformation & Quality Improvement Program Medicaid Section 1115 Demonstration Aka “The Waiver” Leslie Carruth, MBA Office of Health Affairs CS&E September 26, 2013

Through the Storm Health Care Reform Public Policy

Medicaid State-federal partnership enacted in 1965 to provide health insurance coverage to eligible persons CMS issues policy & rules for State Plans Minimum guidelines for eligibility, services States may expand coverage FMAP average = 57%; Texas 58.5% Texas Medicaid agency is HHSC

Texas Perspective Escalating cost burden Highest rate of uninsured in US Frayed or non-existent safety net Political philosophy

Federal perspective  Escalating cost burden  Affordable Care Act - March 2010  Expanding Medicaid eligibility in 2014  Supreme Court decision June 2012 –Medicaid expansion is optional for states

Health Care Reform: Triple Aim Improving the patient experience of care  Including quality & satisfaction Improving the health of populations Reducing the per capita cost of health care  Dr. Don Berwick –CMS Administrator, July 2010 to December 2011

Medicaid waivers  Section 1115 Research & Demonstration Projects  Section 1915(b) Managed Care Waivers  Section 1915(c) Home & Community-Based Services Waivers  Texas has a 1915(b) and (c) waivers  All states: about 400 current/pending waivers

Section 1115 Demonstrations  HHS Secretary may approve demonstration projects that give States additional flexibility to design & improve their programs  Purpose: demonstrate & evaluate policy approaches such as  Expanding eligibility to individuals who are not otherwise Medicaid or CHIP eligible  Providing services not typically covered by Medicaid  Using innovative service delivery systems that improve care, increase efficiency, and reduce costs Must be “budget neutral” to the federal government

HHSC Proposal to CMS  Dual purpose  Expand existing Medicaid managed care programs, STAR and STAR+PLUS, statewide  Establish two funding pools to assist providers with uncompensated care costs and promote health system transformation –Improve care delivery systems and capacity while emphasizing accountability and transparency, and requiring demonstrated improvements at the provider level for the receipt of such payments  No mention of expanding coverage

Budget Neutral Proposal June 2011 Projected Texas Medicaid Costs FY ($Billions)

Budget Neutral?

CMS Approves Texas 1115  HHSC gets the news December 12, 2011  Waiver period is Oct 1, 2011 to Sept 30, 2016  Planning Year, DY 1, ends Sept 30, 2012 –Develop new UC tools based on cost reporting –Organize into RHPs –Program Funding & Mechanics Protocol August 2012 –DSRIP Planning Protocol (projects menu)

DSRIP and UC Pools

RHPs  20 Regional Healthcare Partnerships  Vary in size: 2 to 47 counties  Tier 1 to 4  DSRIP allocated by formula  Anchor –Not the Banker –Guides, coordinates, administers  Critical variance in IGT capacity

Players Performing Providers IGT Entities Inherent conflicts –Transformation by Hospitals? –Public vs Private Entities –Integrating primary and behavioral care oWho leads? Critical variance in IGT capacity (worth saying twice)

DSRIP Categories  Category 1 Infrastructure development  Category 2 Program innovation and redesign  Category 3 Population-focused improvement  Category 4 Clinical improvements in care

Project Design Responsive to community need Strategic Sustainable Impact on target population  Medicaid and low-income uninsured

Milestones & Metrics Primarily menu driven in Category 1, 2 & 3 Standardized for Category 4 Pay for reporting; data from HHSC

Quality Issues  Metrics – appropriateness, baselines  Process or Outcome  Time Horizon

Project Valuation NOT cost-based reimbursement Incentive payments Project impact on waiver aims Quantifiable Patient Impact (summer 2013) Art rather than science

Learning Collaboratives  Added requirement by CMS  RHP level and state-wide  Implications for CS&E  Your expertise will be an asset

UT’s Role Convened Academic Medicine/HHSC meetings Code Red 2012 UTMB and UTHSC Tyler serve as Anchors UTHSCSA in South Texas White paper to include GME projects Participated in UC Tools development

UT’s DSRIP Participation There’s no such thing as a free lunch.

Progress report  DY 2 ends Monday. Time to report metrics  Projects are not yet fully approved thru DY 5  Initial approval received May 2013  QPI required in July  Resubmissions approved a few weeks ago  Category 3 metrics not yet clearly defined  Bright spot – late achievement allowable

Questions? Thank you!