CS&E September 26, 2013
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Transcript of CS&E September 26, 2013
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Texas Healthcare Transformation & Quality Improvement Program
Medicaid Section 1115 DemonstrationAka “The Waiver”
Leslie Carruth, MBAOffice of Health Affairs
CS&E
September 26, 2013
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Through the Storm
Health Care Reform
Public Policy
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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
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Texas Perspective
• Escalating cost burden
• Highest rate of uninsured in US
• Frayed or non-existent safety net
• Political philosophy
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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
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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
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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 8 1915(c) waivers All states: about 400 current/pending waivers
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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
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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
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Budget Neutral Proposal June 2011
Projected Texas Medicaid Costs FY 2012-2016 ($Billions)
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Budget Neutral?
Without Waiver With WaiverPatient Care $146.92 $112.24Supplemental pmts $7.91 $42.59Total $154.83 $154.83
Financing SourceFederal (FMAP = 58.5%) $90.57 $90.57State General Revenue $60.97 $46.58Local IGT $3.28 $17.67$ bil l ions
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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)
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DSRIP and UC Pools
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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
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Players
• Performing Providers
• IGT Entities
• Inherent conflicts
– Transformation by Hospitals?– Public vs Private Entities– Integrating primary and behavioral care
o Who leads?
• Critical variance in IGT capacity (worth saying twice)
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DSRIP Categories
Category 1 Infrastructure development
Category 2 Program innovation and redesign
Category 3 Population-focused improvement
Category 4 Clinical improvements in care
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Project Design
• Responsive to community need
• Strategic
• Sustainable
• Impact on target population Medicaid and low-income uninsured
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Milestones & Metrics
• Primarily menu driven in Category 1, 2 & 3
• Standardized for Category 4• Pay for reporting; data from HHSC
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Quality Issues
Metrics – appropriateness, baselines
Process or Outcome
Time Horizon
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Project Valuation
• NOT cost-based reimbursement
• Incentive payments
• Project impact on waiver aims
• Quantifiable Patient Impact (summer 2013)
Art rather than science
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Learning Collaboratives
Added requirement by CMS
RHP level and state-wide
Implications for CS&E Your expertise will be an asset
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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
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UT’s DSRIP Participation
The University of Texas System
UTSW UTMB* UTHSC H UTHSC SA UTMDACC UTHSC T* UTHSC SA UT SystemRHP 9 RHP 2 RHP 3 RHP 6 RHP 3 RHP 1 RHP 5 STX Net Federal
* Anchor * Anchor
DY 1 Payment $6.47 $6.76 $5.66 $2.80 $1.64 $5.70 $4.13 $33.16(based on Proposed DY 2-5)
Proposed (DY 2-5)Category 1 $82.76 $57.80 $81.81 $48.78 - $25.85 $20.85 $317.85Category 2 $49.30 $31.97 $54.59 $17.70 $25.41 $47.72 $16.66 $243.35Category 3 $22.17 $18.71 $17.85 $8.88 $15.57 $17.19 $5.65 $106.01Category 4 $3.36 $11.13 $0.00 $0.00 $3.77 $0.00 $0.00 $18.26Total $157.59 $119.60 $154.25 $75.36 $44.76 $90.75 $43.16 $685.47 % of Total RHP Proposed $ 19% 51% 12% 12% 3% 36% 25%
Assume FMAP = 58.5% ($ mi l l ions)
Proposed DSRIP Project Valuations - Net Federal Amounts
There’s no such thing as a free lunch.
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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
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Questions?
Thank you!