Transcript Slide 1

Medicaid 1115 Transformation
Waiver: Where are We Now?
Texas Hospital Association
Annual Conference
Steve Aragón, Chief Counsel
Texas Health and Human Services Commission
Stacy E. Wilson, J.D., Associate General Counsel
Texas Hospital Association
February 14, 2013
Why A Waiver?
 Budget issues during the
2011 session led to need
for cost savings
 Upper Payment Limit
Program - $2.8
billion/year (AF)
 Eliminated due to
statewide expansion of
managed care
 Need to save
supplemental funding to
hospitals
2
What Does This Waiver Do?
 More money available?
– $29 billion over 5 years vs.
$14 billion under UPL
– But budget neutral to the
federal government; i.e.,
feds would have spent the
same amount of money
– IGT capacity
 Creates two funding
pools
– Uncompensated Care Pool
– Delivery System Reform
Incentive Payment Pool
3
Structural Overview
4
UC and DSRIP Funding
DY 1
(2011-12)
DY 2
(2012-13)
DY 3
(2013-14)
DY 4
(2014-15)
DY 5
(2015-16)
Total
UC
$3.7 B
$3.9 B
$3.534 B
$3.348 B
$3.1 B
$17.582 B
DSRIP
$500 M
$2.3 B
$2.666 B
$2.852 B
$3.1 B
$11.418 B
Total/DY
$4.2 B
$6.2 B
$6.2 B
6.2 B
$6.2 B
$29 B
% UC
88%
63%
57%
54%
50%
60%
% DSRIP
12%
37%
43%
46%
50%
40%
5
Regional Healthcare Partnerships
 20 regions
proposed based on
UPL affiliations and
feedback
 Each region has:
– Anchor
– Funding public
entities
– Performing
providers
6
Uncompensated Care Pool
 Uncompensated Care
– Supplements hospitals for
Medicaid underpayment
and uninsured
 Medicaid and uninsured
shortfalls not covered by
DSH
 Additional categories of
Medicaid & uninsured
costs can be claimed
– Physicians
– Clinics
– Pharmacies
7
DSRIP Projects
TYPES OF CATEGORY 1 PROJECTS
•
•
•
•
•
•
Pay for Performance
Expand Primary Care Capacity
Increase Training of Primary Care
Workforce
Implement and Use a Chronic Disease
Management Registry
Expand Urgent Care Access
Expand Dental Services
Behavioral Health Projects
TYPES OF CATEGORY 2 PROJECTS
•
•
•
•
•
TYPES OF CATEGORY 3 OUTCOMES
•
•
•
•
•
•
•
Pay for Outcomes
Primary Care and Chronic Disease
Management
Potentially Preventable Admissions
Potentially Preventable Readmissions
Patient Satisfaction
Cost of Care
Oral Health
Right Care, Setting
Pay for Performance
Expand/ Enhance Medical Homes
Expand Chronic Care Management
Models
Redesign Primary Care
Establish/Expand a Patient Care
Navigation Program
Implement Evidence-based Disease
Prevention Programs
CATEGORY 4 PROJECTS
•
•
•
•
•
•
Pay for Reporting
Potentially Preventable Admissions*
30-day Readmissions*
Potentially Preventable Complications*
Patient-centered Healthcare
Emergency Department (cycle time)
Initial Core Set of Measures for Adults
and Children in Medicaid/CHIP
*Required for UC-only participants
8
SUMMARY OF DSRIP REQUIREMENTS
Performing
Provider
Categories 1 & 2
Category 3
Category 4
Hospital and non-hospital
providers
Hospital and non-hospital
providers
Hospital providers only
PASS 1 PROJECTS AND REQUIREMENTS
Project
Begins
DY 2
RHP Level Requirement
RHP Tier 1
Minimum 20 projects
(at least 10 from Category 2)
RHP Tier 2
Minimum 12 projects
(at least 6 from Category 2)
RHP Tier 3
Minimum 8 projects
(at least 4 from Category 2)
RHP Tier 4
Minimum 4 projects
(at least 2 from Category 2)
DY 2 & DY 3
DY 3 & DY 4
Performing Provider Level Requirement
Must adopt outcome
measures that tie back to
projects in Categories 1 and 2
Must establish outcome
targets by DY 4
6 domains of measures:
• PPAs
• PPRs
• PPCs
• Patient-centered
healthcare
• Emergency department
• Initial Core Set of
Measures for Adults and
Children in
Medicaid/CHIP
DY 2 DSRIP for status report
9
on system changes
DSRIP Funding – DYs 2 – 5
 Pass 1 Funding
– Hospitals – 75%
– Others – 25%
 Pass 2 Funding
– Contingent on meeting
participation requirements
– RHP reallocates unused
funds for new projects
 Pass 3 Funding
– RHP reallocates unused
funds for new projects
10
Project Valuation - Hospitals
DY 2
DY 3
DY 4
DY 5
Categories
1&2
No more
than 85%
No more
than 80%
No more
than 75%
No more
than 57%
Category 3
At least 10%
At least 10%
At least 15%
At least 33%
Category 4
5%
10% - 15%
10% - 15%
10% - 15%
11
DSRIP Projects
 All RHP plans timely submitted
to HHSC
 HHSC has provided feedback
 1,341 Category 1 and 2 projects
– Top Category 1 Project Areas:
 1.1 - Expand Primary Care Capacity
 1.9 – Expand Specialty Care
Capacity
– Top Category 2 Project Areas:
 2.9 – Establish/Expand a Patient
Care Navigation Program
 2.2 – Expand Chronic Care
Management Models
12
Submitted RHP Plans
• All 20 RHPs submitted their complete plans to HHSC
by the December 31, 2012 due date.
• HHSC received 1,335 Category 1 and 2 projects,
totaling $7.6 billion. (Updated from 1,341 projects)
• RHPs proposed Delivery System Reform Incentive
Payment (DSRIP) valuation for Categories 1, 2, 3,
and 4 for DYs 2-5 of $9.9 billion.
• Providers estimated $19.5 billion in Uncompensated
Care (UC) for DYs 2-5.
13
Projects and Outcomes
• Category 1: 655 projects, totaling $4.0 billion
– RHPs ranged from 7 to 91 projects
– Project average value of $6.1 million, range of $44,000 to $57
million
• Category 2: 680 projects, totaling $3.6 billion
– RHPs ranged from 7 to 80 projects
– Project average value of $5.3 million, range of $43,000 to $32
million
• Category 3: 1810 outcomes, totaling $1.7 billion
– RHPs ranged from 14 to 253 outcomes
– Outcome average value of $922,000, range of $2,300 to $19
million
14
Selected Project Areas
 Top Category 1 Project Areas:
• 1.1 – Expand Primary Care Capacity (202
projects)
• 1.9 – Expand Specialty Care Capacity (140
projects)
 Top Category 2 Project Areas:
• 2.13 – Provide an intervention for a targeted
behavioral health population to prevent
unnecessary use of services in a specified
setting (92 projects)
• 2.9 – Establish/Expand a Patient Care
Navigation Program (82 projects)
15
Performing Providers
 383 RHP Participants:
– 224 Hospital Performing Providers
 46 Safety Net Hospitals
 121 Private Hospitals
– 82 UC-only Hospitals
 69 Private Hospitals
– 38 Community Mental Health Centers (CMHCs)
– 20 Local Health Departments (LHDs)
– 12 Physician Practices affiliated with an Academic
Health Science Center (AHSCs)
– 6 Physician Practices not affiliated with an AHSC
16
– 1 Other
Projects by Performing Provider
Type of
Provider
# of Cat. 1 & 2
projects
Average
Project Value
Total Cat. 1 & 2
Project Values
791
$6.03 M
$4.77 B
398
$4.85 M
$1.93 B
CMHCs
297
$4.21 M
$1.25 B
LHDs
74
$4.93 M
$365 M
AHSCs
157
$7.06 M
$1.11 B
Hospitals
Private
17
DSRIP Allocation vs. Valuation
Pass 1 DSRIP Allocation
($10.9 B)
AHSCs
10%
LHDs
5%
Public
Hospitals
27%
Proposed DSRIP Valuation
($9.8 B)
AHSCs
13%
LHDs
4%
Public
Hospitals
41%
CMHCs
10%
CMHCs
15%
Private
Hospitals
48%
18
Private
Hospitals
27%
Funds Available for Plan
Modifications
• $793 million available for additional projects
through plan modifications in DYs 3-5.
• Eight regions used total allocation or have
less than $100,000 remaining.
• Three regions have $100 million or more in
remaining funds (RHP 5 - $342 million, RHP 9
- $129 million, RHP 17 - $100 million).
19
Resources
 HHSC website:
http://www.hhsc.state.tx.us/1115waiver.shtml
 THA website: http://www.tha.org/waiver
20