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John O’Hearn Region 14 Anchor Contact Director of Regional Development Medical Center Health System.

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Presentation on theme: "John O’Hearn Region 14 Anchor Contact Director of Regional Development Medical Center Health System."— Presentation transcript:

1 John O’Hearn Region 14 Anchor Contact Director of Regional Development Medical Center Health System

2   March 1 st, 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

3   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

4   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, Waiver Background

5   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 Waiver Background

6   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)

7   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)

8   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

9   Andrews  Brewster  Crane  Culberson  Ector  Glasscock  Howard  Jeff Davis  Loving  Martin  Midland  Presidio  Reeves  Upton  Ward  Winkler RHP 14 Counties

10   Tier 4 RHP the RHP contains less than 3 percent share of the statewide population under 200 percent FPL as defined by the U.S. Census Bureau: American Community Survey for Texas (ACS);  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: 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

11   Regional Healthcare Partnership (RHP) maps were finalized on May 30, 2012  RHP 14’s First meeting was held on June 15 th, 2012  Participating entities met twice a month  Mix of WebEx and Face-to-face  Meetings covered updates, timelines, and general program knowledge Planning Process

12   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

13   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 RHP14_Sep5.pdf Community Needs Assessment

14   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

15   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

16   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

17   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 %  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

18   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

19   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

20   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

21   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

22   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

23   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

24   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

25   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

26   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

27   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

28   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

29   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

30   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

31   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

32   Hospital Allocations  Non-Hospitals Allocations Category Funding Distribution DY2DY3DY4DY5 Cat. 1&2No more than 85% No more than 80% No more than 75% No more than 57% Cat. 3At least 10% At least 15%At least 33% Cat. 45%10-15% DY2DY3DY4DY5 Cat. 1& %No more than 90% No more than 80% Cat. 30-5%At least 10% At least 20%

33   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

34   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

35   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

36   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

37   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, All revised plans are due back to Anchor.  Monday, October 29, Friday, November 2, Plan will be posted on Texasrhp14.com, link will be provided.  October 31, MCHS will submit first 3 sections to HHSC.  Monday, November 5, Final Pass 1 Plans will be sent to HHSC. Timeline- Region 14

38   John O’Hearn, MHA Director of Regional Development 1115 Waiver Region 14 Anchor Contact Medical Center Health System PO Box 7239 Odessa, TX Office Cell Fax Contact

39  Questions


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