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In addition, TMA negotiated a waiver provision requiring each RHP to solicit the participation of local county medical societies and include a letter describing the societies’ involve- ment in their proposal.


The short 18-month timeline for implementing the waiver contributed to some hasty planning and confusion, says Anne Dunkelberg, associate director of the Austin-based Center for Public Policy Priorities. “This is a refinancing of the hospital UPL bonus payments.


This does not cover the whole Medicaid program, nor is it limited to Medicaid in that the activities involved and the un- compensated care that gets reimbursed go beyond Medicaid.” The waiver and the HMO expansion operate on separate tracks, which may cross eventually. But for now, “the waiver itself is just one tool in a kit of many things that need to happen” to change health care delivery in Texas, Ms. Dunkelberg says. In addition, much of the waiver money is con- tingent on completing the risk-based projects and hit- ting performance targets the Centers for Medicare & Medicaid Services ultimate- ly must approve, Mr. Gilbert added.


Public hospitals and oth-


MAKING PROGRESS In the first round of waiver funding for the reform projects,


representing roughly $7 billion, 75 percent went to hospitals, 10 percent to community mental health centers, 10 percent to physician practices affiliated with academic health science centers, and 5 percent to local health departments. That’s ac- cording to HHSC figures available last December, when the first round ended. Out of roughly 900 projects submitted, 552 were hospital- based, the rest in community mental health centers (191), aca- demic health science centers (117), and local health depart- ments (55).


er governmental entities putting up the money argue that’s a risk they must bear for unproven innovations and thus earns them a say over where the funds go. Putting just a few pub- lic hospitals in charge of statewide decision making proved problematic, how- ever, and in some cases fur- ther fragmented health care delivery, says Rep. Lois Kolkhorst (R-Brenham). She served on a joint House and Senate commit- tee that oversaw the waiver operations in 2011 and 2012 and now chairs the House Public Health Committee. “There has been concern about who is driving this waiver,” when it was meant to be collaborative, she said. “This could be a very good step. But not done correctly, it could lead to even more expensive health care for the taxpayer.” Texas’ waiver followed California’s scheme, where dozens of public hospitals care for the lion’s share of Medicaid and uninsured patients. But that plan doesn’t necessarily fit Texas’ health care landscape, where that burden is shared, Represen- tative Kolkhorst says.


GET SOME OF THIS MONEY AND GET OUR PROJECT TO WORK, IT WILL AFFECT OUR


“IF WE DON’T


ABILITY TO CARE FOR PATIENTS.”


Ms. Kirsch is “not sur- prised” many of the projects are hospital-focused, given the waiver emerged from a hospital-based UPL pro- gram, “and the public enti- ties putting up the funds for the state match certainly are interested in funding projects at their own institutions.” Still, HHSC encouraged


broad stakeholder engage- ment, asking for letters of support to encourage regions to be transparent and inclu- sive in the process.


That includes physicians, Ms. Kirsch says.


The fact that a majority


of proposed projects center on primary and specialty care expansions (for exam- ple, management models) would suggest physician in- volvement. Many hospitals subcontract with community physician groups and other players like federally quali- fied health centers (FQHCs), for example. And the fact that 10 per-


cent of waiver funding — approximately $873 million — is designated for physician practice groups affiliated with aca- demic health science centers is not insignificant, she added. Physician practice groups at Texas A&M Health Science


Center, for instance, are experimenting with telemedicine to expand psychiatry and other behavioral health services to sur- rounding rural areas with little access to such care. There could still be opportunities for physicians to partici- pate in waiver projects if regions opt to modify their plans after they get under way. New projects also could come up if regions do not use all of their allocated funds or get all of their original plans approved. Tarrant County Medical Society threw its support behind


March 2013 TEXAS MEDICINE 15


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