the region’s plan, which integrates the medical society’s na- scent medical home, Project Access Tarrant County, into a de- livery system reform project.
The network of volunteer physicians, hospitals, and chari- table community clinics will partner with FQHCs, ambulance services, and others to expand primary care to the homeless and underserved patients and keep them out of the emergency department unnecessarily. TCMS Executive Vice President and Chief Executive Officer Brian Swift says regional leaders must get community partici- pants to the same table. The local anchor and safety net hos- pital, JPS Health Network, worked with the medical society to address its area’s problems. “This is a work in progress. But our region has recognized the value in what we were doing and that in working together, we save the whole system in the long haul,” he said. Athens family physician Douglas Curran, MD, is working
toward the same goal in partnering with East Texas Medical Center Athens (ETMC) to set up an urgent care clinic. His fam-
ily medicine practice would provide after-hours care to Medic- aid and uninsured patients with nonemergent conditions, help relieve the emergency department of unnecessarily expensive care, and keep patients healthy. In rural areas like Athens, getting waiver support is critical to maintaining access to care, Dr. Curran warned. The reduction in supplemental hospital funding under the waiver could be a big hit to ETMC, the only hospital in Ath- ens, Dr. Curran says. “If we don’t get some of this money and get our project to work, it will affect our ability to care for patients.”
MISSED OPPORTUNITIES THE GOALS
But physicians also point to some missed opportunities along the way that could undermine the waiver’s potential. Despite a provision to include county medical society in- put, physicians in Bexar County have been “completely left out of the process” while hospitals there wrangle over fund- ing, San Antonio internist John T. Holcomb, MD, says. He was TMA’s representative to the state’s executive waiver committee, which oversaw early development of the program.
Participants in the Medicaid 1115 waiver are working on a variety of initiatives that tackle four main areas of change in health care delivery to Texas Medicaid and indigent patients. Read all about the waiver at
www.hhsc.state.tx.us/1115-waiver.shtml.
Infrastructure development: Expand primary and specialty care ca- pacity, increase primary care workforce training, introduce or enhance telemedicine, and develop behavioral health services.
Program innovation and redesign: Enhance or expand medical homes, expand chronic care management models, implement evidence-based disease prevention programs, and establish or expand patient naviga- tion and transition programs.
Quality improvements: Assess the effectiveness of the first two types of intervention above, prepare data systems, create quality and cost outcome measures, and establish reporting standards, baselines, and improvement targets.
Population health improvements (hospital only): Report on potential- ly preventable admissions, 30-day readmissions, potentially prevent- able complications, patient-centered health care (patient satisfaction and medication management), and emergency department admissions and transfers.
16 TEXAS MEDICINE March 2013
The waiver was billed as a com- munity-driven effort, he says, but lit- tle occurred to meaningfully engage those on the front lines actually pro- viding the care, namely physicians. Instead, that community input got lost to an overly bureaucratic process: The state developed a predetermined menu of projects for 20 different regions to choose from. That process has resulted in hundreds of proposals submitted to HHSC, all of which still require an- other layer of approval from outside state and federal authorities on what constitutes valuable care.
“This is not the way you go about health care reform,” said Dr. Hol- comb, chair of TMA’s Select Commit- tee on Medicaid, CHIP, and the Un- insured. State officials “did not start from trying to improve the health of Texans. They started with, ‘How can we get $30 billion over five years?’” The waiver also requires RHPs to submit a community needs assess- ment with their plans. But HHSC acknowledged that many based their work on previous research for their areas, rather than conducting it anew.
In El Paso County, that meant there was no group effort to collab-
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