Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver Stanley Stewart Project Director, Transformation Waiver Operations June 25, 2012
1115 Waiver: Brief Review RHP Planning RHP Principles Anchoring Entities
Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver Managed care expansion Allows statewide Medicaid managed care services. Brief Review Includes legislatively mandated pharmacy carve-in and dental managed care. Hospital financing component Preserves hospital funding historically provided under the upper payment limit (UPL) program through a new methodology. Creates Regional Healthcare Partnerships (RHPs). Five Year Waiver 2011 2016 Page 3
Brief Review Under the waiver, funds are distributed to hospitals and other providers through two pools: Uncompensated Care (UC) Pool Costs of care provided to individuals who have no third party coverage for the services provided by hospitals or other providers. Delivery System Reform Incentive Payments (DSRIP) Support coordinated care and quality improvements through RHPs to transform care delivery systems. Page 4
RHP Planning Anchors will bring RHP participants and stakeholders together to develop plans for public input and review. Intergovernmental Transfer (IGT) Entities participants with match funds will select incentive projects and identify performing providers to receive payments based on incentive projects. Performing providers will report performance metrics and receive waiver incentive payments if metrics are reached. Page 5
RHP Planning RHP responsibilities include identifying: Regional healthcare partners. Community needs. DSRIP projects to address those needs. Metrics associated with each project and quality objective. HHSC is working with the federal Centers for Medicare & Medicaid Services (CMS) to determine how an IGT entity can fund a performing provider in a different RHP based on certain principles. Total computable payment must stay with the recipient. To reflect current patient flow, this is particularly important for specialty providers, such as children s hospitals and burn care. Page 6
RHP Principles Texas must demonstrate delivery system transformation and quality improvement. Each IGT entity that puts up matching funds for the waiver will direct what and to whom they would like to fund. For all years of the waiver, under both UC and DSRIP, local match is required and determined by IGT entities. This is a voluntary program. RHPs shall provide opportunities for public input in plan development and review. Page 7
Anchoring Entities Anchors coordinate but do not control RHPs and do not control participant IGT funding Each IGT entity determines how to use its funds within the parameters of UC and DSRIP waiver requirements. Each RHP must have one anchoring entity. Anchors need financial solidity. Reimbursement for anchors allowable administrative expenses will require 50 percent match. Page 8
1115 Waiver: Behavioral Health RHP Planning Local Mental Health Authorities DSRIP Projects
1115 Waiver: Behavioral Health Each RHP will engage in a five-year regional planning process to conduct a needs assessment and propose DSRIP projects aimed at addressing regional needs. HHSC expects that behavioral health-related projects will play a large role in the waiver and encourages behavioral health stakeholders to engage in RHP planning. Page 10
1115 Waiver: Behavioral Health The Centers for Medicare and Medicaid Services (CMS) has confirmed that community mental health centers may participate in the waiver in the following ways. IGT Entity Like public hospitals and other governmental entities, the centers may contribute IGT to be used in the waiver to draw down federal matching funds. Performing provider As a public, Medicaid provider, the centers may serve as a performing provider for an approved DSRIP project. Waiver participants must collaborate regionally and include their projects in their region s RHP plan that will be reviewed and approved by HHSC and CMS. Page 11
DSRIP Development Examples of Behavioral Health in draft DSRIP menu DSRIP Category I Infrastructure Development 1 Project Area Intervention Outcome Measures Implement technology-assisted services # of patients receiving (telemedicine, telephonic guidance) to behavioral health services support or deliver behavioral health. through new technology Expand Behavioral Health Access A B C Develop individual health management strategies to address personal and social barriers impeding access to services. Provide an early intervention for a targeted behavioral health population to prevent unnecessary use of services in a specified setting (i.e., the criminal justice system, ER, urgent care etc.). Enhance service availability (i.e., hours, clinic locations, transportation, mobile clinics) to appropriate levels of care. # of patients receiving health management intervention % utilization of behavioral health and substance abuse services for the right patient, in the right setting, in a timely manner % of behavioral health care encounters. Page 12
DSRIP Development Examples of Behavioral Health in draft DSRIP menu DSRIP Category I Infrastructure Development 1 Project Area Intervention Outcome Measures Expand Behavioral Health Access D E F Collaborate with community partners to explore and develop a long-term Crisis Intervention/Stabilization unit. Develop workforce enhancement initiative(s) to support access to providers (i.e., physicians, psychiatrists, psychologists LMSW, LRC, LMFT) in underserved markets and Areas. Expand residency training slots for psychiatrists, child psychiatrists, psychologists and mid-level behavioral health practitioners (LMSW, LPC, LMFT). % of inpatient and outpatient behavioral health services # of behavioral health providers # of residents trained # mid-level providers trained Page 13
DSRIP Development Examples of Behavioral Health in draft DSRIP menu DSRIP Category II Program Innovation and Redesign Project Area Intervention Outcome Measures Develop care management function Evaluation report of integrated that integrates the primary and care management services A behavioral health needs of individuals. including rate of urgent care sought by individuals served 5 Enhance Behavioral Health Services B C Co-locate primary and behavioral health care services. Provide telephonic psychiatric and clinical guidance to all participating primary care providers delivering services to behavioral patients regionally. Cost benefit analysis # of integrated health providers # of encounters # of integrated health providers # of encounters Page 14
DSRIP Development Examples of Behavioral Health in draft DSRIP menu DSRIP Category II Program Innovation and Redesign Project Area Intervention Outcome Measures D Establish post-discharge support for behavioral health/ substance abuse. % of targeted population who received post discharge support from collaborative partner 5 Enhance Behavioral Health Services E Recruit, train and support consumers of mental health services to be providers of behavioral health services as volunteers, paraprofessionals or professionals within the system. ## of encounters provided by peer mentors Rate of non-urgent care seekers Page 15
RHP Development Tools RHP Map Anchor List Other Materials
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Anchoring Entities RHP 1 - The University of Texas Health Science Center at Tyler RHP 2 - University of Texas Medical Branch RHP 3 - Harris County Hospital District RHP 4 - Nueces County Hospital District RHP 5 - Hidalgo County RHP 6 - University Health System RHP 7 - Travis County Healthcare District RHP 8 - Texas A&M Health Science Center RHP 9 - Dallas County Hospital District RHP 10 - Tarrant County Hospital District RHP 11 - Palo Pinto General Hospital District RHP 12 - Lubbock County Hospital District RHP 13 - McCulloch County Hospital District RHP 14 - Ector County Hospital District RHP 15 - University Medical Center of El Paso RHP 16 - Coryell County Memorial Hospital Authority RHP 17 - Texas A&M Health Science Center RHP 18 - Collin County RHP 19 - Electra Hospital District RHP 20 - Webb County Page 18
Other RHP Development Materials Also available on waiver website: Draft DSRIP menu April 2012: HHSC released a draft menu and accepted public comments. May 2012: HHSC reviewed public comments. June 2012: HHSC will submit a revised draft menu to CMS. Draft Program Funding and Mechanics (PFM) Protocol May 2012: HHSC released the draft PFM Protocol, the basis for DSRIP funding and accepted public comments. June 2012: HHSC is reviewing public comments and negotiating with CMS. Page 19
1115 Waiver: Next Steps
August 2012: HHSC will hold an RHP Planning Summit in Austin, Texas. September 1, 2012: RHP plans due to HHSC. Next Steps October 31, 2012: Final RHP plans due to CMS. Page 21
Waiver Communications Find updated materials & outreach details: http://www.hhsc.state.tx.us/1115-waiver.shtml Submit all questions to: TXHealthcareTransformation@hhsc.state.tx.us Page 22