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Louisiana Health Care System

Louisiana Health Care Redesign Collaborative (LHCRC) supported by the U.S. Department of Health and Human Services

Louisiana Healthcare Redesign Collaborative Charter

  1. Mission and Vision of the Louisiana Healthcare Redesign Collaborative

    The mission of the Louisiana Healthcare Redesign Collaborative (Collaborative) is to develop, and oversee the implementation of, a practical blueprint for an evidence-based, quality driven health care system for Louisiana. This blueprint will serve as a guide to health care policy in Louisiana and to the rebuilding of health care in the hurricane-affected areas of the state. The initial mission of the Collaborative is to develop and submit to the U.S. Department of Health and Human Services a comprehensive system-wide Medicaid Waiver and Medicare Demonstration proposal for parishes of the Greater New Orleans area, which is Region 1 of the Louisiana Department of Health and Hospitals (Jefferson, Orleans, Plaquemines, St. Bernard), that will guide the rebuilding of its health care system.

    The Collaborative orientation is therefore both statewide and local. On the one hand, the blueprint for the redesign of the health care system is a matter of statewide health policy. On the other hand, to be relevant, this blueprint needs to be translated into locally appropriate implementation plans, initially targeted at the Region 1 parishes.

    The vision of this Collaborative is that, once implemented, this redesign of Louisiana's health care system generally, and Greater New Orleans specifically, will serve as a model for the nation.

  2. The Purpose of this Charter

    This Charter's purpose is fivefold:

    1. To formalize the commitment of all signatories to the fulfillment of this mission;
    2. To provide a vehicle to minimize jurisdictional differences voluntarily and to allow collaboration for the common interests and needs of the citizens of Louisiana;
    3. To describe the nature of the work required, the timeline for its completion, and the collective Guiding Principles to which the Collaborative will hold itself;
    4. To secure the participation and support of a wide and substantial group of major health care system stakeholders in Louisiana in this work; and
    5. To document the process by which the Collaborative will function, including its organizational structure, roles and responsibilities of those directly involved, and how decisions will be made.
  3. Context
    • The Compelling Need to Redesign the Health Sector

      Health care represents an emerging crisis throughout the U.S. as the mutually- reinforcing issues of cost, quality and the uninsured deepen. Over 15% of the U.S. population is now uninsured, despite the fact that health care consumes 16% of U.S. gross domestic product. Meanwhile, there has been insufficient progress in correcting well-documented quality issues in patient safety, unwarranted variation in clinical care, administrative inefficiencies, and wasteful use of costly resources.

      Based on Medicare data, Louisiana's health care system has ranked among the highest in per capita costs and the lowest in indicators of clinical quality. Louisiana's 21.5% uninsured rate prior to Hurricanes Katrina and Rita was among the nations highest. Funding for the state's hospital-based public health system has faced heavy budgetary pressure in recent years, resulting in difficulty for the public safety net system to meet the demands for care. The private sector has also been affected as pent up demand has forced the overflow of uninsured patients into that system. Cost-shifting, as a result of uncompensated and under-compensated care has further escalated costs in the private sector. For these reasons, the need for fundamental change in Louisiana healthcare was widely acknowledged well before the hurricanes.

      Against this backdrop Hurricanes Katrina and Rita severely damaged the health care infrastructure in the State's coastal regions including Greater New Orleans.

    • Unprecedented Opportunity for Collaboration

      The post-hurricane conditions in Louisiana generally, and Greater New Orleans specifically, have created an unparalleled opportunity to design and implement fundamental change in the financing and delivery of health care in Louisiana. Local stakeholders and political authorities accept the urgency for a more cost-effective, rational, quality-oriented system. Meanwhile, experts across the nation see a great opportunity to reinvent health care in Louisiana to serve as a model for the nation.

    • Culmination of Related Efforts

      The Louisiana Healthcare Redesign Collaborative is grounded in a number of efforts that have been underway pre- and post- Katrina and Rita, including the Governor's Health Care Reform Panel, whose efforts will now be incorporated into this collaborative. The relevant health care work initiated through this panel will continue in the context of this Collaborative.

      Pre and post-hurricane efforts, from which the Redesign Collaborative emerged, all have demonstrated a common commitment to designing and implementing a quality-driven model for health care oriented around primary care.

  4. Signatories of the Collaborative

    The roles of the signatories are to publicly endorse the need for major change in the health care system according to the Guiding Principles, to publicly endorse the collaborative process for creating that change, to stay well-informed about the deliberations regarding change, and to be open to recommendations for change consistent with the Guiding Principles described in this document and supported by emerging objective evidence.

    The Primary Signatories of this Charter are the Governor of the State of Louisiana, the Secretary of the Louisiana Department of Health and Hospitals (DHH), the Louisiana Recovery Authority, the membership of the Louisiana Health Care Redesign Collaborative, parish presidents and the mayors of the areas with direct hurricane devastation, the CEOs of hospitals and other institutions operating in these same areas, the Health Care Regional Consortia (as established throughout the state under the Governor's Healthcare Reform Panel),

    Other signatories are welcome and desired, including individuals of stature representing the primary care community of Greater New Orleans, the communities-at-large in both the Hurricane Katrina and Hurricane Rita-affected areas, professionals or representatives of constituencies of persons with special needs, such as the elderly, persons with disabilities and those needing mental health services.

    Signatories also have the option to disengage from the collaborative process at any time, and indeed are expected to do so, in the event they are unwilling to support recommendations coming forth from this process. Signatories desiring to withdraw from the Collaborative must submit a dated written statement to this effect, and will be asked to specify their reasons for their withdrawal from the collaborative.

  5. Authority

    The Collaborative conducts its work and functions under the direct authority of the office of the Secretary of the Louisiana Department of Health and Hospitals
    The findings and recommendations produced under the direction of this Collaborative through its consensus process, will result in development of a comprehensive system-wide Medicaid Waiver and Medicare Demonstration proposal for the Region 1 parishes which will be presented to the U.S. Secretary of DHHS. The Louisiana Secretary of DHH shall ensure that all areas of the state and Federal governments potentially impacted by these proposals, including the Governor, the Louisiana Legislature, and the Louisiana Recovery Authority, the Louisiana Congressional delegation, and the U.S. Secretary of DHHS, remain informed of the Collaborative's progress.

  6. Collaborative Deliverables

    The Collaborative will develop recommendations for redesigning the entire system of health care in Louisiana. "System" in this context includes public and private health care delivery, public and private health care financing, the shared health information technology and telecommunications infrastructure needed for process redesign, the integration of these elements with social services and other community resources, and the ongoing supply of sufficient health care professionals through recruitment, education, training and retention. The Collaborative will present recommendations for comprehensive Medicaid Waiver and Medicare Demonstration proposals for the Region 1 parishes within three months of its formation.

    The deliverables of this Collaborative are segmented into four phases: Setting direction for near-term decisions and system redesign; redesigning the future system; changing public policy and funding consistent with the redesign; and guiding implementation and infrastructure redevelopment at the local level in the affected areas, consistent with the redesign.

  7. Guiding Principles

    The following principles, together with a sufficient body of objective evidence, will guide the redesign of Louisiana's health care system. These principles are interdependent and, therefore, are meant to be taken together as a whole.

    1. All health care organizations, professional groups, public and private purchasers, and other health system participants will commit themselves to continually reducing the burden of illness, injury and disability, and to improve the health and functioning of the people of Louisiana.
    2. Individuals and their families will be expected to assume personal responsibility to the best of their ability for their own health, supported by public health initiatives and community-based services; individuals and their families will pursue healthful lifestyles, manage known health risks and chronic illnesses, access appropriate health services in a timely manner, make informed health care decisions, accept the practical limitations of standard medical care, and contribute appropriately and within their means to the cost of their coverage and care.
    3. Everyone will have access to, enroll in, and contribute appropriately and within their means to an affordable, dependable public or private insurance program or other mechanism to ensure regular access to a medical home, through which access to a core system of quality-driven health care will be financially secured.
    4. Patient-provider relationships grounded in mutual respect will engage providers and their patients in the common pursuit of desired patient outcomes. Providers will be culturally competent, avoiding disparities in treatment and partnering with patients in decision-making so as to best respond to their individual needs and values.
    5. The foundation of health care delivery will be accessible, integrated, community-based, ambulatory care that is multi-disciplinary. This delivery system will be well suited to disease prevention, to the management of chronic illnesses and disability, and to episodic care. All primary care, specialty care, hospital services, after-care and community-based services will be effectively coordinated and patient-centered.
    6. Health care services will be treated as a valuable resource, prioritized toward care for which objective evidence demonstrates that the patient is likely to receive a beneficial outcome.
    7. Providers will be fairly compensated, and providers and health plans alike will be held accountable for the cost and quality of their services; patient choice and other market forces will reward them for helping to achieve optimal patient outcomes in the most cost-effective way possible.
    8. The health care system will leverage system-wide, interoperable health information technology that meets national standards to: connect patients and clinicians; inform clinical practice; personalize patient care; improve safety; enable transparency of cost and quality of care; improve performance; and improve population health.
    9. The redesigned health care system will support medical education, training, and retention of health care professionals upon which it relies, recognizing the various institutions involved in these efforts.
    10. The health care system will become more cost effective and affordable as the unnecessary utilization of resources is reduced, as financial payments and incentives are more properly aligned, as operational efficiencies are realized, and as inequities in the sharing of system costs are eliminated.
    11. The health care system will be driven by dynamic forces which encourage adaptation to emerging knowledge, patient and population needs, and longer-term economic conditions.
    12. An all-hazards approach for effective emergency preparedness will be incorporated into the health care system.

  8. Addressing short term needs

    Policy makers and those in the health care delivery system should take temporary measures to restore sufficient capacity to meet patient needs during the redevelopment period. Such measures include being practical and resourceful in using whatever resources are available in the affected areas, in order to bridge the time to a better future.

    However, it is expected that any major capital investment in Louisiana health care infrastructure or structural changes in public health care financing will be coordinated with the work of the Collaborative and will conform to its Guiding Principles and emerging findings. The Secretary of DHH will provide regular updates to the Collaborative for input on such efforts being coordinated through DHH that could potentially re-shape the long term redesign issues being addressed by the Collaborative. All other members of the Collaborative whose constituencies are engaged in short term efforts will also report such status at the regular meetings.

  9. IX. Financial Feasibility

    The feasibility of a redesigned health care system will be determined on the basis of satisfying the above guidelines while operating within the same or better total cost structure than that which existed pre-Katrina and Rita. Feasibility will require demonstrating that:

    • over time, good quality of care, including early intervention and compliance with evidence-based guidelines, reduces total cost,
    • a shift from high-cost, low-value services to effective, high value services will produce better outcomes while freeing up the resources needed to make timely interventions in the progression of illness more broadly available to all, including closing the gap for the uninsured,
    • proper alignment of reimbursement and competition for patients will improve both cost and quality simultaneously, and
    • health information technology will enable additional improvements in productivity in patient care.
  10. Organizational Structure and Decision Making

    The Collaborative is responsible to organize its efforts, to develop work plans and keep all Signatories abreast of its progress, its findings and its emerging recommendations, and to respond to their counsel.

    1. The Collaborative

      The Collaborative is composed of the membership designated in House Concurrent Resolution 127 of the 2006 Regular Session of the Louisiana Legislature. The membership provides broad and balanced representation among Louisiana health sector providers, payers, patients, and others whose commitment and participation in the redesign are needed to maximize its prospects for success.

    2. The Chairperson of the Collaborative and Core Team

      The Secretary of DHH will serve as the Chair of the Collaborative. The Chair will preside over meetings of the full Collaborative and facilitate the consensus process. He will ensure objectivity and integrity of the redesign process in accordance with this Charter and Guiding Principles, and ensure that information, considerations, research findings and opinions brought before the Collaborative fully consider diverse points of view and interests, and that the opportunities for influence are properly balanced among all interested stakeholders.

      The Collaborative shall establish workgroups as appropriate to make specific recommendations around topics such as but not limited to Health Resources, Funding and Reimbursement, Quality, and Communication and Outreach and other various major components of redesign. This process will facilitate plan development and allow aggressive timelines to be met.

      The Collaborative will be supported by a Core Team, which will consist of the Chair, and one member from each of the work groups. The Core Team will be responsible for developing a consensus project plan, for executing a comprehensive research agenda, for drafting all project-related documents, and for preparing information for meetings of the Collaborative.

    3. Duties of Membership in the Collaborative

      Members of the Collaborative commit themselves to participate in a process of shared learning and consensus building as the common means for redesigning the health care system in Louisiana and regions thereof. Members advise on the research agenda, participate in specific research activities, and offer their opinions on the validity of research findings and their relevance to various components of the health care system redesign. Members participate actively and professionally in discussions, and serve as spokespersons for their constituency while considering the merits of potential redesign recommendations for the greater good of health care. Members further agree to follow their respective formal processes for regularly contacting their respective constituencies, especially on matters of natural concern to them and provide feedback to the Collaborative from their constituencies.

      At the direction of the Chair on pivotal matters of process, research findings, and potential recommendations, members of the Collaborative are officially charged with the responsibility to solicit their respective constituents' views, to document them in the collective as well as any specific opposing views, and to document this information in writing for submission to the Collaborative for consideration and to be included in the official record of the proceedings of the Collaborative. Such pivotal topics will be identified as such and included on the agendas of the meetings of the Collaborative in which they are to be discussed.

      Members of the Collaborative agree to make their best efforts to attend all regular meetings, which are expected to be held at least biweekly. Members who are unable to attend at least two-thirds of the convened meetings or otherwise fail to contribute to the consensus process as designed may be asked to resign from the Collaborative by the Chair. The constituency represented by a member who resigns will be requested to designate a replacement.

    4. Other Participants

      Various local, national and international experts and technical advisors will be asked or otherwise engaged to contribute to the efforts of the Collaborative. These Experts/Technical Advisors may be either individuals or groups deemed leaders in their field, whose skills and knowledge are essential to completion of core content areas of the evidence-based redesign. They may be drawn from government, academia, or the private sector as appropriate. Members of the Collaborative may nominate them, and based on consensus of the Collaborative, final selection will be made by the Chair or, alternatively, by the Core Team.

      The ongoing engagement of State agency or contracted support services to assist in this work must be approved by the Secretary of DHH.

      Other stakeholders may participate in the evidence-based redesign process as Observers. They will be encouraged to attend and will be provided the opportunity to speak at meetings of the Collaborative. Observers may also choose to provide written comments to the Collaborative for consideration. All Observer comments will be entered into the minutes of the Collaborative. Observers may also be specifically requested to respond to certain draft documents, conclusions or recommendations produced by the Collaborative.

    5. Regional Input

      Regional input and opinion will be formally incorporated into the Collaborative through monthly briefings of the state's Regional Consortia, which are responsible for providing their own input on pivotal decisions as well as soliciting and documenting the views of members of the health care communities in their respective regions for formal submission to and discussion by the Collaborative.

    6. Meeting Frequency, Time, and Location

      The Collaborative shall meet as often as the Chair deems necessary at dates, times, and locations acceptable to the members. Meetings will be designated as "in-person" or "teleconference." The "in-person" meetings must be attended by the member in person (call-ins may be arranged with the Chair in advance). Quorum for these meetings shall be a simple majority. Call-ins may participate in discussions, but they will not be counted toward a quorum and cannot vote. Members may send staff to observe/take notes but staff may not represent or speak for them or vote on their behalf. All meetings of the Collaborative shall be subject to the statutory requirements of the state public open meetings laws.

    7. Decision making

      Decision-making, related to the Collaborative, acceptance of research findings, and the development of final recommendations, will be achieved through a consensus building process based on presentation of facts and thoughtful, objective opinions. Opposing views will be encouraged to be brought forward for discussion.

      When the chair of the Collaborative determines that a consensus view appears to have emerged, the chair will call for an indication of consensus, whereupon members indicate their positions concurrently by a visible expression of opinion - showing positive support, neutrality, or opposition. A demonstration of a sizeable majority will suggest that a final opportunity be given for opposing views to be expressed, after which a final call for consensus will be made. If no progress is made toward the minority view, the chair may deem that consensus has been obtained, and any opposing view will be documented.

      At the discretion of the Chair, a formal polling of the membership's views on various issues before the Collaborative may be indicated. Only appointed members may participate in formal polling of views on issues involving governance or other business items of the Collaborative. Formal expression of views by proxy is not allowed.

    Community Input

    Community input will be sought regularly throughout the process of evidence-based redesign. This process will begin with vetting of the Guiding Principles and continue throughout all planned phases of the project. A 'Forum' series will be created and delivered in communities throughout the state to give layman explanations of the proposed redesign plan and to engage in meaningful dialogue with health care consumers, so as to ensure a broad base of understanding and buy-in by the general public. A series of focus groups and briefings will be held with key constituencies as well as public meetings to garner support and consensus on the redesign of health care in the state. Consumer opinion and input will be documented and formally brought before the Collaborative for consideration

  11. Final Recommendations

    Consensus recommendations for waiver requests adopted by the Collaborative shall be presented by the Secretary of DHH to the Governor, the Legislature, the LRA, and the public at large.

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