take care of fixing the current broken Medicaid system, and we made progress on that. But we have got to take the next step. The reality is, sick children can’t go to school, and sick adults can’t work,” he said, pointing to research showing that health insurance coverage translates to improved health outcomes, better productivity, and lower costs down the line. TMA Vice President for Advocacy Darren Whitehurst adds that TMA will continue to work with the legislature to find an opportunity to draw down additional federal funds to get coverage for the working poor, pointing out that the Texas Legislature’s position on the issue is not unlike its early stance on CHIP before it was created in 1997. “The legislature was not proactive then and didn’t take ad-
vantage of early funding opportunities. But, eventually, finan- cial sensibility drove the process and drove Texas to adopt a [CHIP] model that made sense. We hope to do the same for coverage of the working poor, and we will continue to push for a solution,” Mr. Whitehurst said.
But he acknowledges that coverage for the uninsured was an uphill battle from the start. Gov. Rick Perry has not let up in his staunch opposition to
growing the Medicaid program with strings attached. Texas stands alongside 14 other states that oppose the PPACA ex- pansion plan, largely because of concerns over a lack of state control and additional costs after the federal government stops paying the full tab beginning in 2017. Another six states are still weighing the option, according to the latest Kaiser Family Foundation data. Short of a block grant that would allow states to manage their Medicaid programs on their own terms, Governor Perry and other leaders are reluctant to entertain options for offering Medicaid coverage to low-income populations not currently covered. The federal government, meanwhile, has indicated block grants are off the table. Senator Nelson said the amendment approved by the leg-
islature “clarifies that the provisions of SB 7 do not authorize expansion of Medicaid to low-income adults without legisla- tive approval. We have made great strides in making the pro- gram run more efficiently, but there are limits to what we can accomplish without federal flexibility. The federal government needs to give us the tools we need, such as copays, flexible benefit options, and private market solutions to create a Med- icaid system that is right for Texas.” Representative Zerwas says his proposal would have opened the door to those kinds of options, but even use of the term “expansion” became what he described as “so politically radioactive” that it halted any discussions on the matter. “I was disappointed because I would have liked to see come to the floor for debate and ultimately to a vote what I thought was one of the headline issues for the legislative session, and one that we have largely not had any significant debate on,” he said.
However, the last-minute amendment to SB 7 leaves Texas no worse off than where it started, he says. Although unlike- ly, nothing in the bill precludes the governor or state HHSC commissioner from initiating conversations with the federal
government, and the legislature still would have a say in any agreement reached. Expansion talks were scuttled, but that didn’t stop TMA
from making headway on the kind of changes physicians say are critical to attracting doctors back to the ailing program. One significant step in that direction was Senate Bill 1803
by Senator Huffman and Representative Kolkhorst, which im- proves due process and expediency when a physician is ac- cused of Medicaid fraud or overpayments. (See “Fighting for Fairness,” pages 35–38.) The bill tamps down controversial HHSC regulations released in 2012 by clarifying the definition of a “credible allegation of fraud” and establishing timelines for the Office of Inspector General (OIG) to notify doctors of an investigation and payment holds in the process. TMA Associate Director for Advocacy Michelle Romero says
the bill represents improvements over the original rules but does not go far enough to give physicians adequate due pro- cess and transparency in the OIG’s process. The good news, she says, is HHSC and some legislative committees committed to oversee and report back on the Medicaid fraud investigative process, and OIG has offered to work with TMA on other fixes through the rulemaking process.
“If anything, this [session] did shine a light on the lack of
due process, and we have champions [in the legislature] and hope to get better rulemaking in the interim,” Ms. Romero said.
Other Medicaid reforms were included in Senate Bill 1150
by Sen. Juan “Chuy” Hinojosa (D-McAllen), a Medicaid HMO prompt-pay law that requires HHSC to include a “provider pro- tection plan” in its Medicaid HMO contracts to ensure plans pay claims properly and promptly or face penalties. TMA lead- ers say such safeguards are especially important as lawmakers continue to eye Medicaid managed care expansions to gener- ate savings. SB 7, for example, expands Medicaid HMOs to people with intellectual and development disabilities and nurs- ing home residents, among other provisions. Medicaid physician payment rates overall went untouched,
as lawmakers grappled with adequately funding the program and its increasing caseloads. At the same time, the legislature authorized roughly $23 million in state spending to increase the premiums the state pays to Medicaid HMOs. In an April letter, Dr. Speer informed state budgeteers of the TMA Medicaid Congress’ findings that “grossly inadequate
Rep. John Zerwas, MD
Michael Speer, MD
Rep. J.D. Sheffield, DO
August 2013 TEXAS MEDICINE 29
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68