Regional Healthcare Partnership 14- Plan

Presentation

John O’Hearn Region 14 Anchor Contact

Director of Regional DevelopmentMedical Center Health System

March 1st, 2012- Switch to Medicaid Managed Care

Upper Payment Limit (UPL) Program no longer viable Supplemental Funding crucial to Texas Hospitals

New Source of Funding identified though 1115 Waiver Protects UPL funding and expands pool of money Based of California Model Initial conversations started in July 2011 Places decisions regarding health care delivery system

improvements in the hands of local hospitals and hospital districts, rather than a top-down, one-size-fits-all approach.

Includes entities outside of hospitals

1115 Waiver Background

HHSC surveyed large urban hospitals in Texas to identify potential DSRIP projects (October 2011).

HHSC hosted an RHP Planning Summit focusing on DSRIP development with representatives from hospitals, associations and leadership offices (November 2011).

Clinical Champions created in February to provide clinical input into DSRIP project selection.

20 Regional Healthcare Partnerships were formed (May 2012)

The RHPs are based on distinct geographic boundaries that generally reflect patient flow patterns for the region

The RHPs have identified local funding sources to help finance the non-federal share of DSRIP payments for Performing Providers

The RHPs have identified an Anchoring Entity to help coordinate RHP activities

1115 Waiver Background

Program Funding and Mechanics (PFM)

Protocol: Outlines the minimum number of projects, organization of the RHP Plan, plan review process, required reporting, funding allocations, project valuation, and plan modifications. Approved August 31, 2012

RHP Planning Protocol: menu of projects, milestones, and metrics eligible for DSRIP funds. Approved September 26, 2012

1115 Waiver Background

Uncompensated Care Pool (UC)

Pays hospitals based on uncompensated care costs reimbursable today and additional uncompensated care costs not being reimbursed today, such as costs for clinics, physicians, and pharmacies. Payments will be based on costs, not charges.

Delivery System Reform Incentive Payment Pool (DSRIP) Payments for system improvements identified in Regional

Healthcare Partnerships delivery system reform and improvement plans.

Plans will identify approaches, baseline data, and timelines for transforming and improving indigent and Medicaid health care systems to improve clients experience, increase quality, and better manage costs in Medicaid and indigent programs.

1115 Waiver Background

A transfer of public funds from a governmental

entity or entities to HHSC. Any unit of local government, such as:

•Public hospital •Hospital District •County •City •Local Mental Health Authority

Intergovernmental Transfers (IGT)

A governmental entity can IGT if:

The funds are in the governmental entity’s administrative control

The funds are not federal funds The funds are public funds, not private funds There is no statutory or constitutional requirement that relates

to the funds The funds are not impermissible provider-related donations

Private Medicaid providers can support community activities, and local governments that make IGTs may take account of that support in deciding whether to make an IGT that will be used to fund Medicaid payments to those providers.

Intergovernmental Transfers (IGT)

Coordinating the development of a community needs

assessment for the region Engaging stakeholders in the region, including the public Coordinating the development the 5-year RHP Plan that best

meets community needs in collaboration with RHP participants; Ensuring that the RHP Plan is consistent with Attachment I, Attachment J, and all other State/waiver requirements

Facilitating RHP Plan compliance with the RHP Plan Checklist Transmitting the RHP Plan and any associated plan

amendments to HHSC on behalf of the RHP Ongoing monitoring and annual reporting (as required in

paragraph 20) on status of projects and performance of Performing Providers in the region

Ongoing communication with HHSC on behalf of the RHP.

MCHS’s Role as Anchor

Andrews Brewster Crane Culberson Ector Glasscock Howard Jeff Davis Loving Martin Midland Presidio Reeves Upton Ward Winkler

RHP 14 Counties

Tier 4 RHP An RHP is classified in Tier 4 if one of the following

three criteria are met: (1) the RHP contains less than 3 percent share of the statewide population under 200 percent FPL as defined by the U.S. Census Bureau: 2006-2010 American Community Survey for Texas (ACS); (2) the RHP does not have a public hospital; or (3) the RHP has public hospitals that provide less than 1 percent of the region's uncompensated care.

RHP 14

Regional Healthcare Partnership (RHP) maps

were finalized on May 30, 2012 RHP 14’s First meeting was held on June 15th,

2012 Participating entities met twice a month

Mix of WebEx and Face-to-face Meetings covered updates, timelines, and

general program knowledge

Planning Process

Executive Committee

Diverse Mix of Volunteers Member Organizations

Medical Center Health System- Hospital District Odessa Regional Medical Center- Private Hospital Midland Memorial Hospital- Hospital District Scenic Mountain Medical Center-Private Hospital Permian Regional Medical Center- Hospital District Big Bend Regional Medical Center-Private Hospital Reeves County Hospital District- Hospital District Texas Tech University Health Sciences Center-Academic Medical

Center Permian Basin Community Centers- Local Mental Health Authority West Texas Centers- Local Mental Health Authority BCA- Odessa- Private Mental Health Facility Ector County Health Department- County Health Department

Planning Process

Prepared by Brandon Durbin, Discovery

Healthcare Consulting Group, LLC & Terri Conner, Healthcare Outcomes Research Consulting

Used to identify gaps in service and overall need Factors in Strong Population Growth Limited Resources (Space and People) County Health Rankings

RHP14_Sep5.pdf

Community Needs Assessment

Kevin Nolting, Kevin Nolting Consulting Michael Spivey, Spivey Health Law Brandon Durbin, Discovery Healthcare

Consulting Group, LLC Terri Conner, Healthcare Outcomes Research

Consulting Lance Ramsey, Gjerset and Lorenz Eric Weatherford & Lane Greer, Brown

McCarroll Don Gilbert

Planning Process-Consultants Involved

2.29% of total state funding Demonstration Year 1 (DY1) $11,426,916 Demonstration Year 2 (DY2) $52,563,813 Demonstration Year 3 (DY3) $60,928,316 Demonstration Year 4 (DY4) $65,179,128 Demonstration Year 5 (DY5) $70,846,879

Five Year Total of $260,945,051

RHP 14 DSRIP Allocation

Anchor receives 20% of funding Remaining 80%

Remaining DY 1 RHP DSRIP funding (less the Anchoring Entity DY 1 DSRIP) shall be allocated to Performing Providers based on an allocation formula. The allocation formula divides an RHP Plan's estimated dollar value of a Performing Provider's DSRIP projects in Categories 1-4 over the DYs 2-5 period by the total value of the RHP's DSRIP projects over the DYs 2-5 period. The resulting percentage is then multiplied by the RHP's remaining DY

DY1 Allocation Formula

Hospitals receive 75% of initial funding Non-Hospitals receive 25% of initial funding

10%-Local Mental Health Authorities 10%-Academic Medical Centers 5%- County Health Departments

Hospital Allocations based on: Participation in UPL and/or DSH required to receive Pass 1 Funding The hospital's percent share of Medicaid acute care payments in SFY 2011-

25% The hospital's percent share of total SFY 2011 Medicaid supplemental

payments made to all potentially eligible hospital providers in the RHP (former UPL program)-25%

The hospital's percent share of uncompensated care in the RHP. A hospital's uncompensated care is measured by its FFY 2012 Hospital Specific Limit (HSL) or hospital's charity care costs reported in the 2010 Annual Hospital Survey trended to 2012 by an annual trend rate of approximately 2 percent (4 percent total trend over the two-year period) -50%

Pass 1 Allocations

If there are unused DSRIP allocation amounts

after the first pass, the RHP may redirect the unused allocations to fund new projects. An individual hospital provider is not limited to its

DSRIP allocation in the second pass. Physician practice groups not affiliated with

academic health science centers and new hospitals may participate in DSRIP projects if they identify a source of non-federal match.

Pass 2 Allocations can’t be determined until all Pass 1 projects are submitted

Pass 2

25 percent allocation of unused Pass 1 DSRIP funds to

“new” Performing Providers 15 percent to new hospitals. 10 percent to physician practices not affiliated with an

academic health science center. 75 percent allocation to Performing Providers that have

Pass 1 projects Each Performing Provider is allocated a proportion based

on the funding of Pass 1 projects in DYs 2-5. Within an RHP, Performing Providers may combine their

individual Pass 2 DSRIP allocations to fund a DSRIP project.

Pass 2

A minimum number of major safety net

hospitals must participate in DSRIP as Performing Providers Tier 4 At least 1 – MMH and MCHS qualify

RHPs shall fund a minimum percent of the Pass 1 DSRIP allocated to non-profit and private hospitals based on Tier level. Tier 4 At least 5%- RHP 14 qualifies

Pass 2 Eligibility

Category I: Infrastructure Development

Lays the foundation for the delivery system through investments in people, places, processes and technology. Pay for performance.

Category II: Program Innovation & Redesign Pilots, tests and replicates innovative care models. Pay for

performance. Category III: Quality Improvements

Health care delivery outcomes improvement targets tied to Category 1 and 2 projects. Pay for outcomes.

Category IV: Population-based Improvements Requires all RHPs to report on the same measures. Pay for

reporting

1115 DSRIP Waiver Categories

MCHS- Medical Center Health System MMH- Midland Memorial Hospital ORMC- Odessa Regional Medical Center TTUHSC- Texas Tech University Health Sciences Center PRMC- Permian Regional Medical Center RCHD- Reeves County Hospital District WCMH- Winkler County Memorial Hospital MCHD- Martin County Hospital District WMH- Ward Memorial Hospital CMH- Crane Memorial Hospital BBRMC- Big Bend Regional Medical Center SCMC- Scenic Mountain Medical Center CH- Culberson Hospital McCamey- McCamey County Hospital District PBCC- Permian Basin Community Centers WTC- West Texas Centers BCA- BCA Permian Basin ECHD- Ector County Health Department MHD- Midland County Health Department

Acronym List

1. Expand Primary Care Capacity

MCHS (3), PRMC, ORMC (2), MMH (2), WCMH, CMH, WTC, TTUHSC (2) 2. Increase Training of Primary Care Workforce

TTUHSC 3. Implement and Use a Chronic Disease Management Registry 4. Enhance Interpretation Services and Culturally Competent Care

MCHS, MMH 5. Collect Accurate Race, Ethnicity, and Language (REAL) Data to Reduce

Disparities 6. Expand Access to Urgent Care and Enhance Urgent Medical Advice

MMH 7. Introduce, Expand or Enhance Telemedicine/Telehealth

ORMC 8. Increase, Expand and Enhance Dental Services 9. Expand Specialty Care Capacity

TTUHSC, ORMC (2), PBCC, MMH 10. Enhance Performance Improvement and Reporting Capacity

Category 1: Infrastructure Development

Behavioral Health Projects 11. Implement technology-assisted services

(telemedicine, telehealth and telemonitoring) to support, coordinate or deliver services

12. Enhance service availability to appropriate levels of care

13. Development of behavioral health crisis stabilization services as alternatives to hospitalization

14. Develop Workforce enhancement initiatives to support access to providers in underserved markets and areas

Category 1: Infrastructure Development

1. Enhance/Expand Medical Homes

CH 2. Expand Chronic Care Management Models

MCHS, TTUHSC, ORMC (2), MMH/MHD Collaboration, RCHD 3. Redesign Primary Care

TTUHSC 4. Redesign to Improve Patient Experience 5. Redesign for Cost Containment 6. Implement Evidence-based Health Promotion Programs

MCHS, MMH, TTUHSC 7. Implement Evidence-based Disease Prevention Programs

MCHS/ECHD Collaboration, RCHD 8. Apply Process Improvement Methodology to Improve

Quality/Efficiency MCHS(2), ORMC

9. Establish/Expand a Patient Care Navigation Program MCHS, ORMC, MMH

Category 2: Innovation and Redesign

10. Use Palliative Care Programs MCHS, MMH

11. Conduct Medication Management 12. Implement/Expand Care Transitions Programs

MMH, McCamey Behavioral Health Projects 13. Provide an intervention for a targeted behavioral health population to

prevent unnecessary use of services in specified setting 14. Implement person-centered wellness self-management strategies 15. Integrate Primary and Behavioral Healthcare Services

WTC 16. Provide virtual psychiatric and clinical guidance to primary care

providers 17. Establish improvements in care transitions from inpatient settings 18. Recruit, train and support consumers of mental health services to

provide peer support services 19. Develop Care Management Function that integrates primary and

behavioral health needs of individuals

Category 2: Innovation and Redesign

CMS Outcomes definition:

“… measures that assess the results of care experienced by patients, including patients’ clinical events, patients’ recovery and health status, patients’ experiences in the health system, and efficiency/cost.”

All Category 1 & 2 projects must have one or more associated Category 3 outcomes.

Outcomes measured are based on a specific patient population served by the project. Broken into Outcome Domains (OD)

DY 2&3 focus on Process Milestones and DY4&5 focus on Improvement Targets

Category 3: Quality Improvements

OD-1 Primary Care and Chronic Disease Management

MMH-Controlling High Blood Pressure McCamey focusing on Diabetes care HbA1c poor control

OD-2 Potentially Preventable Admissions MCHS-Uncontrolled Diabetes Admissions

OD-3 Potentially Preventable Readmissions (30-day) MCHS focusing on All-Cause Readmissions

OD-4 Potentially Preventable Complications and Healthcare Acquired Conditions ORMC and MCHS- Sepsis Mortality

OD-5 Cost of Care OD-6 Patient Satisfaction

CMH, WTC, PBCC, and RCHD are focusing on Patient satisfaction OD-7 Oral Health

Category 3: Quality Improvements

OD-8 Perinatal Outcomes

MCHS focusing on Early Elective Deliveries OD-9 Right Care, Setting

PRMC, Winkler, and Culberson are focusing on ED Appropriate Utilization

OD-10 Quality of Life/ Functional Status OD-11 Addressing Disparities

MMH 68 Nurse Navigation for disparity group OD-12 Primary Care and Primary Prevention

TTUHSC- Increase Cervical and Colorectal Cancer Screening OD-13 Palliative Care

MMH and MCHS focusing on Pain Assessments and ICU stays within the last 30 days of life

Category 3: Quality Improvements

Hospital only category

Exemption for Rural Hospitals A hospital is not a state-owned hospital or a hospital that is

managed or directly or indirectly owned by an individual, association, partnership, corporation, or other legal entity that owns or manages one or more other hospitals and: (1) is located in a county that has a population estimated by the United

States Bureau of the Census to be not more than 35,000 as of July 1 of the most recent year for which county population estimates have been published; or

(2) is located in a county that has a population of more than 35,000, but that does not have more than 100 licensed hospital beds and is not located in an area that is delineated as an urbanized area by the United States Bureau of the Census.

Non-hospitals and exempt hospitals can put 100% of dollars into other 3 categories.

Category 4:Population Focused Improvements

Potentially preventable admissions (PPAs) 30-day readmissions Potentially preventable complications (PPCs) Patient-centered healthcare, including patient

satisfaction and medication management Emergency department

Optional Domain 6 Initial Core Set of Measures for Adults and Children in

Medicaid/CHIP- If a hospital chooses to report this domain, they are then eligible to claim the full 15% for reporting.

Category 4:Population Focused Improvements-

Domains

Hospital Allocations

Non-Hospitals Allocations

Category Funding Distribution

DY2 DY3 DY4 DY5

Cat. 1&2 No more than 85%

No more than 80%

No more than 75%

No more than 57%

Cat. 3 At least 10%

At least 10%

At least 15%

At least 33%

Cat. 4 5% 10-15% 10-15% 10-15%

DY2 DY3 DY4 DY5Cat. 1&2 95-100% No more

than 90%

No more than 90%

No more than 80%

Cat. 3 0-5% At least 10%

At least 10%

At least 20%

Uncommitted DSRIP funding During DY2, if an RHP does

not propose to use its uncommitted DSRIP funds, HHSC will redistribute the available DSRIP to RHPs with interest and funding to implement new projects in DY3 and who met the broad participation requirement in Pass 1

New DSRIP projects, new Performing Providers, and/or new IGT Entities may be added in DY2 for implementation in DY3.

Other plan modifications will be allowed for: Changes to milestones/metrics for existing projects. Changes to outcome improvement targets. Deletion of projects.

Plan Modifications

A milestone bundle for Categories 1 or 2 may consist of

multiple metrics. A metric must be fully achieved to be eligible for payment

An outcome improvement target for Category 3 may be partially achieved to be eligible for partial payment

All measures within a Category 4 domain must be reported to be eligible for payment

Carry-forward is allowed for Categories 1, 2, and 3 until the following demonstration year Requires a narrative of the current status of

milestones/outcome improvement targets and plan to achieve milestones/targets within the following demonstration year.

Additional Details

Twice a year, Performing Providers are required to report on

achievement of milestone bundles/outcome improvement targets to be eligible for incentive payments.

IGT entities will review the reported performance. HHSC and CMS will have 30 days to approve or request

additional information. DSRIP will be paid twice per year based on approved reports.

Turnaround on payment should be similar to DSH Reporting period of October I through March 31: the

reporting and request for payment is due April 30. Reporting period of April I through September 30: the

reporting and request for payment is due October 31.

Reporting and Payment Schedule

Sep. 21 – Oct. 19 – PPs complete Pass 1 DSRIP, including Categories 1-4 narratives within the RHP Plan

Template and all steps in the workbook Oct. 10 – Anchor workbook, Pass 2 workbook for PPs, and Pass 3 (Anchor Pass) workbook for PPs posted Oct. 22 – Nov. 2 – Anchors review & compile Pass 1 DSRIP submitted by PPs and ensure requirements

are met.  Anchors work with PPs to adjust narratives and workbooks as needed. Oct. 31 – Anchors submit Sections I, II, & III of RHP Plan Template and Community Needs

Supplements electronically to HHSC Nov. 5 – Anchors generate Pass 2 funding for all participating Pass 2 PPs and send to PPs Nov. 5 – 9 – Anchors post Pass 1 DSRIP for public comment Nov. 6 – 19 – PPs complete Pass 2 DSRIP, including Categories 1-4  narratives within the RHP Plan

Template and all steps in the workbook Nov. 16 – Anchors submit Pass 1 DSRIP to HHSC with all sections of the RHP Plan completed

for Pass 1.  Estimated IGT must be identified for all DSRIP. Nov. 20 – Dec. 6 – Anchors review & compile Pass 2 DSRIP submitted by PPs and ensure requirements

are met. Anchors work with PPs to adjust narratives and workbooks as needed. Dec. 7 – 14 – Anchors identify any DSRIP funding available after Pass 2 and complete Anchor Pass (if

applicable) in collaboration with PPs and IGT Entities. Dec. 17 – 21 – Anchors post Pass 2 & Anchor Pass DSRIP within complete RHP Plan for public comment Dec. 31 – Pass 2 and Anchor Pass projects within complete RHP Plan due to HHSC CMS has 45 Days to review plans

Timeline- HHSC

Tuesday, October 16, 2012: All Pass 1 Projects and

Workbooks due Thursday, October 18, 2012: RHP Plan Presentation Wednesday October 24, 2012: Executive Committee

Meeting to review project. Friday, October 26, 2012- All revised plans are due back to

Anchor. Monday, October 29, 2012- Friday, November 2, 2012-

Plan will be posted on Texasrhp14.com, link will be provided. October 31, 2012- MCHS will submit first 3 sections to

HHSC. Monday, November 5, 2012- Final Pass 1 Plans will be sent

to HHSC.

Timeline- Region 14

John O’Hearn, MHA

Director of Regional Development 1115 Waiver Region 14 Anchor ContactMedical Center Health SystemPO Box 7239Odessa, TX 79760Office 432-640-2429Cell 432-770-5077Fax 432-640-1118

Contact

Questions