R Douglas Curran, MD
oughly 1,000 projects intended to improve care await review by the Texas Health and Human Services Commission (HHSC). Most of the initiatives aim to expand pri- mary and specialty care, integrate access to behavioral health services, and improve safety, among other goals. Pending feder- al approval, they could get under way as early as May. The waiver provides certain, albeit lim- ited, paths for physician involvement. Doc- tors in some regions forged partnerships in
projects they hope will advance real and necessary Medicaid transformation.
But the financing mechanism — which, based on Texas’ ex- isting structure, largely puts public hospital districts in control of selecting projects and distributing the waiver money — ap- pears in some cases to be creating bureaucracies and funding disputes that overshadow the waiver’s goals and are catching lawmakers’ attention. Those hospitals are largely responsible for putting up the state’s portion of program money — $12 billion — to get another $17 billion in matching funds from the federal government.
Some physicians say the issues relegated them to the side- lines of a $29 billion program that favors hospital-controlled projects, despite doctors’ key role in caring for underserved patients and defining reforms. The process is playing out differently across the state, and
as the second year of the five-year waiver gets under way, many agree it is too early to rate its success. HHSC officials acknowledge that the process is not perfect. “Whenever you change how you are spending money, some
are going to be happier than others, and this is a big change,” said Lisa Kirsch, HHSC’s deputy director for the 1115 Health- care Transformation Waiver. “But this is a big step in the right direction, hopefully making good changes in the health care system and creating more transparency in where funds are go- ing and how they are earned.” To some extent, however, the waiver could expose, if not perpetuate, some of the flaws in the old hospital financing system it seeks to replace.
Hospital Medicaid payments have been “cobbled togeth-
er” from a mix of federal, state, and local dollars, historically funded mostly by public hospitals but shared with private fa-
cilities, says former HHSC commissioner and now Texas Medi- cal Association consultant Don Gilbert. While the waiver offers some new alternatives, “it is clearly going to move the majority of the funds to public hospitals,” which account for just 16 percent of Medicaid inpatient care and about half of inpatient indigent care, he says. “It remains to be seen how transformational this waiver will be if the great majority of funding misses those that actually provide the bulk of the care.”
Physicians generally agree the goals of the waiver are wor-
thy. But, asks Fort Worth obstetrician-gynecologist G. Sealy Massingill, MD, are physicians worthy partners in any system reform?
“Physicians not only are responsible for the delivery of vital
care to our patients, but we have the knowledge and expertise to help shape how that care should be delivered in the most efficient and cost-effective way,” the Tarrant County Medical Society (TCMS) president said.
REFINANCING AND REFORMING INDIGENT CARE The Texas Health Care Transformation and Quality Improve-
ment Program, known as the 1115 waiver, is a response to a push by state lawmakers to control Medicaid costs through an HMO model. The move allows states to pay health plans a set monthly fee per patient to encourage efficient care. Federal rules require reduced hospital UPL payments under
HMOs. To protect the safety net funding, however, the Texas Legislature won approval from the federal government in 2011 for a demonstration waiver that allows the state to keep that money in exchange for a more accountable and quality- and cost-driven system. The waiver replaces the UPL system with two funding pools that combine local tax monies to get additional federal fund- ing. One stream will offset eligible hospitals’ incurred uncom- pensated care costs and the costs for physicians, clinics, and pharmacists affiliated with the hospitals. A new pool — the Delivery System Reform Incentive Payment Pool (DSRIP) — will pay for improved performance. Eligible participants — hospitals, physicians, and community mental health centers, for example — could receive bonus payments if they develop new care delivery strategies and demonstrate improved cost and quality outcomes. That is a risk-based feature not part of the old UPL program. HHSC designated 20 RHPs throughout the state to develop multipartner plans for their communities’ needs, each led by an “anchor” public hospital district or other entity putting up the funding.
John T. Holcomb, MD
14 TEXAS MEDICINE March 2013
Gilberto A. Handal, MD
Jim Walton, DO
Physician practices can collaborate on waiver activities in two ways. Those working in academic health science cen- ters that received funding under the UPL system can receive either the uncompen- sated care or reform initiative funding. Community physicians can partner in re- form initiatives through the RHPs.
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