POPULATION HEALTH MANAGEMENT

Volume 00, Number 00, 2016 Original Article

ª Mary Ann Liebert, Inc.
DOI: 10.1089/pop.2015.0192

Design and Implementation of the Texas

Medicaid DSRIP Program

Charles Begley, PhD,1 Jessica Hall,2 Amrita Shenoy, MHA,1 June Hanke, MPH,2
Rebecca Wells, PhD,1 Lee Revere, PhD,1 and Nicole Lievsay3

Abstract

Texas is one of 8 states that have received a Medicaid 1115 Transformation Waiver in which federal supple-
mental payments are being used to incentivize delivery system reform. Under the Texas Transformation Waiver’s
5-year Delivery System Reform Incentive Payment (DSRIP) program, hospitals and other providers have es-
tablished regional health care partnerships, conducted regional needs assessments, and developed and im-
plemented projects addressing local gaps in service. The projects were selected from menus, supplied by the Texas
Health and Human Services Commission and the Centers for Medicare & Medicaid Services, which defined
acceptable infrastructure development and/or program innovation and redesign initiatives. Providers receive
payment for planning the projects and achieving metrics and milestones related to project implementation and
performance. This article describes the major features of the Texas DSRIP model and the resulting im-
plementation and performance to date in the most populous region of the state.

Introduction DSRIP Objectives and Processes

I n December 2011, Texas received federal approval for an

1115 waiver that preserves hospital supplemental pay-
ments under the Upper Payment Limit (UPL) program while
allowing Medicaid managed care expansion.1 The amount of
supplemental funding was capped at $29 billion over 5 years
(2011–2016) based on projections of federal dollars that
would have been spent under the UPL program if the Texas
Medicaid fee-for-service payment model was continued for
services and populations now under capitated managed care.2
The projected funding was divided between an uncompen-
sated care (UC) pool to continue to offset hospitals’ UC costs
and a Delivery System Reform Incentive Payment (DSRIP)
pool to support health services delivery reform. The pro-
portion of the funds supporting the UC pool has declined over
the waiver period, and the DSRIP proportion has increased
from 80/20 in year 1 evolving to 50/50 in year 5. To partici-
pate in the UC pool, hospitals also had to participate in
DSRIP.3 This article describes the specific objectives and
processes of the DSRIP program in Texas and the im-
plementation and performance of resulting projects in the 9-
county Houston region.
Led by a facilitating public hospital or other public entity
(serving as the ‘‘anchor’’), public and private hospitals, public
mental health centers, academic health science centers and
physician practice plans, and local health departments were
invited by the Texas Health and Human Services Commission
(HHSC) to form 20 Regional Healthcare Partnerships (RHPs)
and to develop regional plans supporting system reform
(Fig. 1). Each plan included a needs assessment focused on
identifying gaps in service, particularly for Medicaid and low-
income uninsured populations, goals and objectives that ad-
dress local gaps, and specific projects with implementation and
performance metrics and milestones that would be the basis for
payment. The overall purpose was to incentivize delivery
system reform, reduce unnecessary hospitalizations, and pre-
pare providers for Medicaid capitation.1 The statewide DSRIP
funding pool was divided among regions based on the relative
size of the Medicaid and uninsured low-income population.
The specific amount of incentive payments available to a
provider in a region was based on the amount of local dollars
that could be set aside by the provider for intergovernmental
transfer (IGT) to leverage federal matching payments.3

1
The University of Texas School of Public Health, Houston, Texas.
2
Harris Health System, Houston, Texas.
3
Meadows Mental Health Policy Institute, Houston, Texas.

1
2 BEGLEY ET AL.

FIG. 1. RHP regions in Texas. RHP, regional healthcare partnership.

Figure 2 summarizes the logic model of the Texas waiver
for achieving the Triple Aim4 objectives of improving the
patient experience of care (including quality and satisfac-
tion), improving the health of populations, and reducing the
per capita cost of health care, using DSRIP as a vehicle. The
model reflects how the major features of DSRIP—regional
partnerships among hospitals and other providers, needs
assessments, investments in a specified set of project types
and outcome objectives, and implementation/performance-
based payment—could lead to delivery system reform and
population health improvements.
The allowable types of projects on the infrastructure de-
velopment menu consisted primarily of investments that lay
the foundation for community-based expansions in primary
care, behavioral health care, and specialty care. The type of
projects on the innovation and redesign menu involved in-
vestments in innovative models of primary care, behavioral
health care, and specialty care. Project plans had to contain
descriptions of the staff, space, processes, and technology
that would be the focus of each project. Each provider also
had to provide a rationale for each project, identifying the
local community need addressed.5
The initial design phase also required providers to
identify and value a set of implementation and performance
metrics and milestones for each project that would serve as
the basis for payments. The first step involved estimating
the total dollar value of each project based on an algorithm
that considered the cost of the project, its significance for
population health, and the total amount of funding avail-
able to the provider (based on its IGT and federal match)
for all DSRIP projects. The dollar value of each project was
then allocated to each metric and milestone to determine
payment amounts for each year of implementation and
performance.6

FIG. 2. Texas DSRIP model theory of system change. DSRIP, delivery system reform incentive payment; DY, dem-
onstration year.
TEXAS MEDICAID DSRIP PROGRAM
During demonstration year 1 (DY1), providers were paid
for participating in the regional needs assessments, identify-
ing their IGT levels, and developing and valuing their project
plans. In DY2 and DY3, the focus shifted to achieving project
implementation metrics and milestones such as identifying
new clinic sites, hiring and training staff, developing new
treatment protocols, and beginning to serve new patients or
providing new services to existing patients. Provider pay-
ments were based on reporting that the investments and
processes related to implementing an infrastructure devel-
opment or redesign project were being put in place. In DY3–
5, the focus shifted to achievement of service delivery and
outcome goals.
Service delivery goals were defined in terms of individuals
served or encounters. Some projects naturally lend them-
selves to one type of metric or the other, as providers try to
serve more people (expand primary care) or provide new
services or a better mix of services to existing populations
(increase behavioral health screening in primary care clinics).
Outcome goals were defined in terms of improvements in
health status, changes in service use patterns, increased sat-
isfaction, or behavioral change, depending on the type of
project. Two broad types of outcome metrics were used to
determine payment, either pay for reporting (P4R) or pay for
performance (P4P). Payments based on P4P require a provider
to initially report baseline metrics on a population served (in
DY3 for most projects) and to achieve improvements com-
pared with baseline thereafter (DY4 and DY5). Payments for
P4R require reporting population-based outcome metrics
each year but do not require achieving improvements over
time. P4P improvement targets were determined based on
Improvement-Over-Self (IOS) or Quality Improvement Sys-
tem for Managed Care (QISMC) algorithms. The IOS requires
5% and 10% improvement over baseline in DY4 and DY5,
respectively, for full payment. Payment under QISMC re-
quires providers to close the gap between their baseline and a
national benchmark by similar percentages each year.7
Providers can report achievement of their implementation
and performance metrics twice a year. Payment for achieving
a given target is once per year. Payments can be made for
achievement of a metric up to 1 year late (with agreed-on
‘‘Carry Forward’’), and partial payment (of the initial pay-
ment or Carry Forward amounts) can be made for achieving
less than 100% of the performance metric.7 In addition to
Table 1. RHP3 DSRIP Projects by Type and Approved Incentive Amounts
Projects
Project type Number
Behavioral health care 57
Chronic care management 14
Case management/navigation 16
Emergency care 3 2
Primary care 34
Specialty care 29
Health promotion/disease prevention 15
Other 7 4
Totala 175
a
Percentages may not sum to 100 because of rounding.
DSRIP, Delivery System Reform Incentive Payment; DY, demonstration year; RHP3, Regional Healthcare Partnership 3.
3
reporting performance metrics at the project level, all par-
ticipating hospitals (not non-hospital providers) also have to
report to HHSC on a set of hospital-wide utilization metrics in
DY4 and DY5 that reflect overall performance, including
potentially preventable admission rates, 30-day readmissions
for different conditions, potentially preventable complica-
tions, and emergency room visit rates.8
One other requirement of DSRIP is participation in a
regional learning collaborative, facilitated by the anchor, to
encourage shared learning for meaningful change. The
learning collaborative in each region is expected to organize
groups that identify and work on specific quality and/or
capacity-building activities that are of relevance to partici-
pants across the region. The learning collaborative is used as
another vehicle for building regional cooperation and for
achieving a more coordinated care delivery system.9
Implementation in the Houston Region
Project types and objectives
Regional Healthcare Partnership 3 (RHP3) of the Texas
waiver is one of the greater geographic areas of Houston
(Fig. 1). A total of 26 providers are participating in DSRIP
in the region: 18 hospitals, 2 academic physician practice
plans, 4 local mental health authorities, and 2 local health
departments. These provider organizations, with assistance
from the anchor (Harris Health System—the local public
hospital system) and guided by their own priorities, the
project and outcome menus provided by HHSC and CMS,
and the availability of IGT and federal matching dollars,
developed and valued 175 multipage 4-year project plans
addressing local needs.10
Projects can be categorized into 8 broad types based on
their objectives and target populations: (1) behavioral health
care, (2) chronic care management, (3) case management/
navigation, (4) emergency care, (5) primary care, (6) specialty
care, (7) health promotion/disease prevention, and (8) other
(not categorized). The total number of projects by type and the
approved incentive amounts for achieving all implementation
and performance metrics and milestones over the waiver are
shown in Table 1. A total of 57 projects that address behav-
ioral health care have been implemented across the region,
representing almost a third of all DSRIP projects and 29% of
approved funding. These projects range from expansion of
Approved incentive amounts DY2–5
% $ %
33 583,103,725 29
8 124,815,176 6
9 190,040,100 10
17,026,911 1
20 655,139,279 32
17 258,039,792 13
9 129,599,562 6
87,244,302 4
100 2,045,008,846 100
4 BEGLEY ET AL.

Table 2. RHP3 DSRIP Projects by Type and Projected Goals

Infrastructure Innovation Projected Projected
Total development, and redesign, individuals encounters
Project type projects number/% number/% served DY3–5 provided DY3–5
Behavioral health care 57 26/46 31/54 124,760 112,832
Chronic care 14 3/21 11/79 152,945 —
management
Case management/ 16 2/13 14/88 163,100 347,320
navigation
Emergency care 3 1/33 2/67 10,400 1800
Primary care 34 33/97 1/3 55,050 1,087,197
Specialty care 29 23/79 6/21 25,740 370,320
Prevention/wellness 15 — 15/100 159,095 —
Other 7 2/29 5/71 271,512 378,000
Total 175 90 85 962,602 2,297,469
DSRIP, Delivery System Reform Incentive Payment; DY, demonstration year; RHP3, Regional Healthcare Partnership 3.

community- and hospital-based behavioral health clinics, to
expansion of crisis intervention services, integration of
medical and behavioral health services, case management/
navigation, and community- and clinic-based behavioral
health education. The next largest category is primary care
expansion projects (Table 1). These projects involve ex-
panding existing clinics and establishing new ones. The third
most common type is specialty care expansion. These pro-
jects add specialty care services primarily in community-
based settings. Chronic care management, case management/
navigation, and health promotion/disease prevention also are
addressed by a substantial number of DSRIP projects and
significant funding. These projects establish services in hos-
pitals, clinics, and the community to improve care coordi-
nation and/or increase the availability of preventive services.
The residual category includes a set of unique projects that are
designed to support improved service delivery that range
from disease registries, to pharmacy dispensing redesign
projects, to general quality improvement initiatives.
The broad goals of these project types (infrastructure de-
velopment or innovation/redesign) and their aggregate service
targets (number of individuals served or encounters provided)
are summarized in Table 2. As indicated in the table, most of
the primary care and specialty care projects involve invest-
ments in infrastructure development. The behavioral health
projects are split between infrastructure development (46%)
and innovation/redesign (54%). Projects focused on chronic
care management, navigation/self-management, and emer-
gency care predominately involve innovation and redesign.
The overall service goals of the projects are to treat almost 1
million new individuals in the region in DY3–5 and to deliver
2.3 million new encounters.
In total, the providers selected 115 different metrics for
performance-based payment across all projects. Most se-
lected a single performance metric; some selected 2 or 3. The
most common were changes in health care use, including a
reduction in readmission rates to hospitals and other facilities
(22 projects), an increase in influenza immunization rates (8
projects), and a reduction in emergency department visits (7
projects). Another common type targeted changes in health
status, such as improvement in HbA1c control (14 projects),
improvement in pediatric quality of life (13 projects), im-
provement in behavioral health functioning (9 projects), and
improvement in daily living activities (9 projects). A third
type related to improvement in patient satisfaction (11 pro-
jects), and the final type dealt with changes in health behavior
(4 projects).
Table 3 shows the number of projects of a given type with a
given type of performance metric, or more than 1 type. The
vast majority of projects (78 + 16 + 9 = 103) seek to improve

Table 3. RHP3 DSRIP Projects by Type and Outcome Measure

Health Health Health Health
service Health Behavior service use/ status/ Service use/
Outcomes project type use status change Satisfaction health status satisfaction satisfaction Other Total
Behavioral health care 20 19 — 2 5 10 1 — 57
Chronic care 7 6 1 — — — — — 14
management
Navigation/case 11 2 — — — — 3 — 16
management
Emergency care 2 — — — — — 1 — 3
Primary care 18 9 — 1 4 — 1 1 34
Specialty care 11 11 — 1 6 — — — 29
Prevention/wellness 8 2 3 — 1 — 1 — 15
Other 1 1 — 2 — — 2 1 7
Total 78 50 4 6 16 10 9 2 175
DSRIP, Delivery System Reform Incentive Payment; RHP3, Regional Healthcare Partnership 3.
TEXAS MEDICAID DSRIP PROGRAM 5

Table 4. RHP3 DSRIP Project Performance DY3 and DY4

% of projects
achieving Incentive amounts
No. of Targets % Paid % Carry forward
Project type projects DY3/DY4a $ Available DY3/DY4b DY3/DY4c DY3/DY4d
Behavioral health care 57 72/65 14,303,974/18,555,974 92/71 8/30
Chronic care management 14 71/64 4,462,803/6,467,633 92/63 8/37
Case management/navigation 16 75/38 5,124,207/6,728,619 97/74 6/28
Emergency care 3 100/67 490,484/670,039 100/81 0/19
Primary care 32 81/47 17,295,108/25,660,696 95/77 6/24
Specialty care 28 46/79 7,279,070/10,060,883 84/83 17/17
Prevention/wellness 15 73/80 5,900,770/6,671,349 90/98 10/2
Other 7 100/57 3,021,792/4,420,127 100/71 0/28
Totale 172 72/62 57,878,209/79,235,319 92/76 8/24
a
Percent of projects achieving target metrics in each year.
b
Total dollars available for achievement by year.
c
Percent of total available dollars in a year that were paid during the year.
d
Percent of total available dollars in a year that were carried forward.
e
Percentages may not sum to 100 due to rounding.
DSRIP, Delivery System Reform Incentive Payment; DY, demonstration year; RHP3, Regional Healthcare Partnership 3.

patterns of health service use in the populations they are
serving. This includes all project types. A large number are
trying to improve health status (50 + 10 + 16 = 76). These
projects include all but 1 project type. A much smaller
number (4 + 6 + 10 + 9 = 29) are attempting to change be-
havior or to improve satisfaction. The diversity of perfor-
mance metrics across project types reflects the relatively large
number of outcome measures allowed by the menu and the
classification of certain measures in the menu as non-stand
alone (ie, each provider selecting the metric had to select at
least 1 other metric).
Outcome performance
Most projects began reporting baseline performance met-
rics in DY3 and achievement of improvement targets in DY4.
Performance achievement in DY3 required each provider to
obtain and report numerator and denominator data on their
selected performance metric for the population served (the
percentage of patients with diabetes served with HbA1c poor
control). As discussed, in DY4 project performance,
achievement was based on reporting changes in outcomes
compared with baseline (P4R) (ie, changes in service use or
health status) and/or achieving target improvements com-
pared with baseline (P4P) (5% improvements in service use
rates or health status measures compared with baseline or
reductions in the gap between baseline and benchmark).
Table 4 summarizes the performance achievement of the
172 projects still being implemented in DY3 and DY4 (3
projects have been discontinued) based on data available
through mid-March 2016. As indicated in the table, in DY3,
72% of all projects achieved their baseline performance
metric; 92% of available dollars were received, with 8% of
remaining funds carried forward. Emergency Care projects
and projects in the Other category were the most successful at
achieving DY3 targets followed by Primary Care and Case
Management/Navigation projects. Specialty Care projects
were the least successful (Table 4). Prevention/Wellness and
Specialty Care projects were the most successful in achieving
performance targets in DY4. Primary Care projects were the
least successful. Although not reported in the table, by the end
of DY4, all but 7 projects had achieved their DY3 baseline
reporting and more than 96% of the DY3 Carry Forward
amount was received.
The lower rates of achievement and payment percentages
in DY4, and higher amount of Carry Forward amounts, may
reflect the inherent challenges in achieving population im-
provement targets compared with baseline reporting. How-
ever, there are other possible reasons why the DY4 reporting
goals were not achieved, including continuing delays in
identifying an acceptable metric and in obtaining acceptable
information for reporting a metric. The extent to which the
DY4 performance targets are ultimately achieved and pay-
ments are received will not be known until DY5 reporting is
complete.
Learning Collaborative
RHP3 developed a learning collaborative that consisted of
small working groups of DSRIP providers with common
types of projects—behavioral health, primary care, naviga-
tion, and emergency care, among others—who worked to-
gether to identify and address common issues. The RHP
working groups were guided by the Institute for Healthcare
Improvement’s Breakthrough Series Model to identify topics
and to conduct quality improvement activities.11 The anchor
facilitated routine meetings for shared learning, supported
milestone (outcome) data reporting for each group, provided
a forum for sharing between the groups, and supported a
number of Plan-Do-Study-Act activities. Through the middle
of DY4, RHP3 had successfully established and implemented
6 working groups with different topical focuses, goals, and
outcomes.
The work of the Navigation workgroup illustrates the type
of activity in the learning collaborative. This workgroup was
formed in January 2014 with representatives from providers
who were implementing navigation/case management pro-
jects in various settings targeting different patient popula-
tions. By November 2014, participants identified the need to
collaboratively create a resource inventory tool to assist with
6 BEGLEY ET AL.
appropriately navigating patients between health care sys-
tems. Historically, patients were generally navigated into
delivery systems based on the navigator’s employing orga-
nization. The workgroup reached out to RHP3s DSRIP
participating hospital systems and stakeholders seeking a
commitment from organizations to focus on patients’ needs
over provider interests, and to offer the most efficient and
effective care regardless of organizational affiliation. Over a
6-month period, the workgroup composed a commitment
letter stating this aim that was signed by 14 providers. Using
the commitment letter as a stepping stone, the workgroup
developed an online tool providing RHP3 navigators with
access to information on health care resources throughout
the region and with the ability to make appointments.
Discussion and Conclusion
The Medicaid Transformation Waiver has allowed Texas
to expand capitation-based managed care statewide while
supporting hospital UC costs and incentivizing providers to
invest in health care reform. In RHP3, providers partici-
pating in the DSRIP program have made up-front invest-
ments in 175 projects and, as of the end of DY4, all but 7 of
the 172 continuing projects have achieved their project
outcome goals and received almost 100% of the available
performance-based payments. The percentage of projects
achieving DY4 outcome targets in DY4 was considerably
less than in DY3, and the Carry Forward amounts were
much larger.
Under the DSRIP model in Texas, providers are investing
in projects that are aimed primarily at expanding community-
based primary, specialty, and behavioral health services or at
improving the delivery of these services through improved
service coordination, case management, integration, and
navigation. The projects are addressing a substantial shortage
of community-based behavioral, primary, and specialty
health care identified in the regional needs assessment. This is
a remarkable accomplishment given the challenges in final-
izing project plans, agreeing on the appropriateness and
dollar value of performance metrics for each project, and
making changes along the way in all of these items as dis-
agreements have occurred and been resolved.
Given the debates over project and outcomes selection,
some projects and performance metrics are still being final-
ized as the participants enter the last year of the waiver.12 A
statewide midpoint assessment of performance reporting in
DY3 and DY4, conducted by an external contractor, identi-
fied discrepancies for a number of projects either in the data
being used to report outcomes and/or in the calculations being
made with the data. The discrepancies have led to further
delays in payment and required providers to modify their
methods in future reporting. Nevertheless, providers still
have the potential to receive full payment if they make the
necessary corrections in time for the next reporting period.
The challenges ahead at the project level include
achievement of service expansion and outcome improve-
ment targets set for the fifth year of the waiver while also
reporting late achievement of fourth-year objectives. The
extent to which the projects achieve the performance goals
will be a key indication of the potential success of the
waiver. With the large number of diverse project types and
outcomes, the region and the state also are faced with a
significant challenge to show system-wide changes in ser-
vice delivery and population health. The results of project-
level information on achievements will be helpful. The
reports of hospital-wide measures in DY4 and DY5 (de-
scribed earlier but not yet available) also should reflect the
potential impact of the waiver. A statewide evaluation also
is under way to identify how health care decision making
and processes reflect partnering and collaboration among
providers at the regional level.13 The measures and data
sources for determining the overall impact of the waiver at
the regional or statewide level are under development. This
will require analyses of Medicaid claims data on service use
and cost, provider and patient survey data on indicators of
access to care, behavioral risk factors, utilization of pre-
ventive services, and hospital utilization (emergency room
visits, preventable admissions, and readmissions). Medicaid
claims data are available on a statewide basis to monitor
changes in this population, but there is a lack of data on
health care use of the uninsured other than the statewide
hospital discharge database.
The Texas waiver shares many of the features of 1115
transformation waivers in other states, including provider
selection of projects and performance measures from pre-
approved menus and performance-based payments for
achieving implementation and outcome objectives.14–17 As
in other DSRIP states, Texas providers have achieved the
great majority of their project goals and have received
available funds.16–18 One of the distinctive characteristics of
the Texas waiver was the encouragement of collaboration
among providers at the regional level through the RHPs.19
The regional focus has been strengthened in the recent
waiver in New York that requires the formation of per-
forming provider systems of specific types of providers at
the regional level.19 Another characteristic of the Texas
waiver was the lengthy list of project options and perfor-
mance metrics to give providers flexibility.20 The options
available to providers have become more restricted in the
New York waiver21 and likely will be more restrictive for
Texas in the future if the waiver is extended or renewed.22 A
third characteristic of the Texas model is the focus of
performance-based incentives at the project level. Regional
performance incentives that all DSRIP providers earn a
portion of based on achieving population health improve-
ments at the regional or state level are part of the New York
waiver and likely will be a part of an extended or renewed
waiver in Texas.22
Under the Texas waiver, Medicaid supplemental funding
for safety net services is shifting from relatively unac-
countable payment to hospitals for UC to performance-
based payments to hospitals and other providers for projects
to improve service delivery for Medicaid and low-income
uninsured patients. The participating providers and project
types reflect major shifts in the direction of support of
Medicaid supplemental payments under DSRIP compared
with the former UPL program—most notably from hospital
inpatient care to ambulatory care for the Medicaid popula-
tion and low-income uninsured, particularly those who have
behavioral health conditions. Until the aggregate data are
compiled and analyses are completed, we will not know
whether the successful implementation of projects is sig-
nificantly improving care delivery systems or health out-
comes for Medicaid and low-income uninsured populations.
TEXAS MEDICAID DSRIP PROGRAM
Author Disclosure Statement
Drs. Begley, Wells, and Revere, Ms. Hall, Ms. Shenoy,
Ms. Hanke, and Ms. Lievsay declared the following po-
tential conflicts of interest with respect to the research, au-
thorship, and/or publication of this article: All but one of the
authors (Dr. Wells) were involved in the implementation of
the waiver in the Houston area. Ms. Hall, Ms. Hanke, and
Ms. Lievsay worked for Harris Health System and were on
the anchor team and Dr. Revere, Ms. Shenoy, and Dr.
Begley were paid consultants assisting the anchor team in
various facilitating and reporting activities. The authors do
not believe that their roles create any conflict of interest in
reporting or interpreting the information in the article. Dr.
Wells has a contract with the state to complete a component
of the statewide evaluation of the waiver that has no rela-
tionship to the subject matter in this article.
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Address correspondence to:
Charles E. Begley, PhD
The University of Texas School of Public Health
200 Herman Pressler, E-317
Houston, TX 77030
E-mail: charles.e.begley@uth.tmc.edu