August 2018 DSRIP Newsletter
Texas 1115 Waiver
A Closer Look at
DSRIP and the Triple Aim
The Evolution of DSRIP Moves Texas Closer to the Triple Aim
Reducing cost, improving health outcomes, and improving overall experience of care are interdependent goals collectively known as the Triple Aim. This concept was created by former CMS administrator Donald Berwick as the United States’ guiding principle to achieve a quality healthcare system. [1] In its current state, the United States out spends comparable industrialized nations in healthcare costs, only to have suboptimal outcomes. Other nations have been able to achieve better quality at a much lower cost in addition to providing health insurance to its citizens.

The DSRIP program was built with the Triple Aim in mind to achieve a higher quality healthcare system. This is the foundation for both iterations of the program despite the differences in protocols. Even before achieving the Triple Aim, Berwick et al. states that certain prerequisites must be in place: a common population recognized to be the unit of concern, external policy constraints, and the existence of an integrator. [2] Table 1 analyzes to what extent each program achieves these pre-requisites and how much closer Texas is to achieving the Triple Aim. The analysis looks at each Triple Aim precondition in the left column and how DSRIP 1.0 and DSRIP 2.0 meet each precondition. The DSRIP boxes in the table indicate qualities of the programs related to the precondition, a summarized result on how it was achieved, and an example of how the precondition was addressed with a targeted outcome such as diabetes.
In all, the DSRIP program has placed Texas on the path closer to achieving the Triple Aim. Both iterations of the DSRIP programs have helped define populations in Texas, created external policies for participants to follow and help drive change, and preliminarily tasked providers with becoming integrators. Consequentially, Texas is at the early stages of meeting the Triple Aim prerequisites and starting population health; though there is still a long road ahead to fully achieving the Triple Aim. Still, the DSRIP programs were never meant to be permanent solutions. The six years of DSRIP 1.0 have just started the process of improving healthcare via the Triple Aim. Though DSRIP 2.0 will continue this effort, it would seem that five years would not be enough to achieve fully integrated population health. Nonetheless, Texas has made large strides from funding for the 1115 Waiver and DSRIP program; the hope is that it will continue to build on these successes once the funds are no longer available.
[1] Block, D.J. (2014). Revisiting the Triple Aim- Are We Any Closer to Integrated Health Care? Physician Executive Journal, 40(1), 40-43.
[2] Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, Health, And Cost. Health Affairs , 27(3), 759-769. doi:10.1377/hlthaff.27.3.759
Funding Social Determinants of Health
Supports Achievement of the Triple Aim
Per the discussion above, Texas has a long road ahead to achieving the Triple Aim. As Texas moves closer to achieving the Aim, providers are increasingly focused on what factors will help them improve patient outcomes and the overall health of the population. One way they can help achieve this is by supporting programs that address the social determinants of health, which is an area of health that is often undervalued and overlooked.

According to the County Health Rankings, the social determinants of health (SDOH) affect 80% of a person’s health outcomes. These are comprised of three large components including health behaviors, the built environment, and socio-economic factors. [3] In populations with Type 2 diabetes and other chronic conditions, SDOHs “are associated with the disproportionate development of 
chronic conditions and challenges encountered when managing them.” [4]

RHP3 knows this all too well. Social determinants have come up as a topic of interest for the Region on a number of occasions, especially with issues like homelessness and food insecurity at the forefront of community concerns. But since the Waiver does not directly incentivize or focus on the social determinants of health, the question remains: where will providers find funding for these efforts?

Sameera Fazili, Senior Community and Economic Development Advisor at the Federal Reserve Bank of Atlanta has some ideas. In May 2018, Sameera gave a presentation via America’s Essential Hospitals on ways to help pay for SDOH interventions. Through a series of partnership examples and case studies, Sameera demonstrates how paying for SDOH advances population health.

The first community partnership Sameera highlights is the importance of identifying and collaborating with a Community and Economic Development (CED) organization. CEDs either focus on “people- or place-based” partnerships in a local community. The people-based partnerships focus on how to get services to people, while place-based partnerships focus on improving a person’s current living environment or how to move them to a new one. Understanding the two types of CEDs is important because it helps providers know which type of CED partner to pursue. Additionally, CEDs have established relationships in the community. They can help build trust within the community, manage cross-sector partnerships, and help healthcare providers gain access to different public, private, and philanthropic funding resources that they otherwise would be ineligible to receive on their own. 

Many CEDs engage in public funding programs such as the Community Reinvestment Act (CRA), which supports housing and neighborhood revitalization work and is overseen by bank regulators such as the Federal Reserve Bank. The CRA requires banks to invest in low and moderate income communities through housing investments and small business lending. This Act incentivizes banks and other private investors by reducing their tax liability when they offer loans or services to these communities.

The second example Sameera highlights is a Community Economic Development partnership through Community Development Financial Institutions (CDFI). CDFIs help providers develop capital stacks. Capital stacks allow providers to combine public, philanthropic, and private funding sources to finance community development programs focused on addressing the social determinants of health. This mixture of revenue enables providers to both fund and finance their projects. Funding consists of an entity paying for a good or service and not expecting any financial return, whereas financing expects a return in the form of capital gains, cost savings, or interest. Capital stacks enable providers to raise more money to put towards an effort by diversifying their funding and preventing them from solely relying on a single grant or other source to fully fund their efforts.
Figure 1 above shows a capital stack. In this example, Sameera illustrates that some investors want a higher return on their investment whereas others expect a lower return. Hospitals and insurance companies can be any type of investor in this stack: whether it’s by making a grant available through its community benefits department, using cash or cash equivalents through the organization’s treasury department as a mezzanine investor, or using organization investment dollars to get a better return similar to any other investments the organization’s treasury is managing.

During the presentation, Sameera also presented a few case studies to help providers apply the concepts discussed earlier in the presentation. The two case studies below specifically highlight two different types of CED partnerships one “people- and place-based” and the other “place-based.”
Prior to pursuing partnerships with local CEDs or CDFIs, consider aligning a region-wide or organizational Community Health Needs Assessment (CHNA) with the community benefits spending at these organizations. Providers should also identify the strengths and weaknesses of their local community development system and identify CEDs and CDFIs in the local community. In RHP 3, some of the local CDFIs include Wells Fargo Bank, Corporation for Economic Development of Harris County, Incorporated, and Covenant Community Capital Corporation. Currently there are 235 local CEDs in Texas including the Southeast Texas Housing Finance Corporation, Amegy Bank, and Christus Health. [5] See more CDFIs here and local CEDs here . To view Sameera's full webinar, you may sign up for an account at America’s Essential Hospitals here .
[3] Our Approach. (2016). Retrieved from http://www.countyhealthrankings.org/our-approach ; some reports and organizations refer to the entirety of this 80% as the social determinants of health as a way to capture all of these non-clinical factors. This report will also refer to the entirety of this 80% as the social determinants of health.
[4] Hill, J., Nielsen, M., & Fox, M. H. (2013). Understanding the Social Factors That Contribute to Diabetes: A Means to Informing Health Care and Social Policies for the Chronically Ill. The Permanente Journal , 17 (2), 67–72. http://doi.org/10.7812/TPP/12-099  
[5] Texas Association of Community Development Corporations. (2018). Retrieved from