Stakeholder Perceptions of Strengths and Challenges in Texas' Healthcare Transformation and Quality Improvement Program

Texas is a large, geographically and demographically diverse state, presenting opportunities and challenges in implementation of statewide programs such as Medicaid.  In 2011, Texas received approval from the Centers for Medicare and Medicaid Services (CMS) for a 5-year 1115(a) Medicaid Waiver Demonstration Project aimed at increasing access to care, improving quality, and decreasing cost.  Two elements of the waiver are an Uncompensated Care (UC) program for hospitals and incentivizing innovation through the Delivery System Reform Incentive Program (DSRIP).  The state sought to address previous challenges by creating Regional Healthcare Partnerships (RHPs) for local assessments, planning, service delivery, and monitoring for UC and DSRIP activities.  A stakeholder survey was conducted in 2014 to identify organizational experiences regarding the waiver, and perceptions of strengths and challenges of waiver implementation.  Survey results were analyzed using a mixed methods approach.  Stakeholders acknowledge the waiver is providing valuable resources for system transformation at the community-level and the regional approach to implementation is viewed favorably, although there are variations at the RHP-level. Stakeholders identified challenges to implementation, including frequent Program changes, limited project options, and applicability of outcome measures across provider types.  The identification of these strengths offers evidence of successful implementation using a regional approach. The identified challenges suggest potential revisions to the waiver in future years for Texas and provide recommendations for other states.