The Health and Human Services Commission held a public hearing on July 16, 2015 to discuss the extension of the 1115 Waiver and to hear public testimony.
Welcome and Opening Remarks
- Current waiver lasts through 9/30/16
- Proposed effective date for extension of 1115 Waiver is 10/1/16 through 9/30/21
- HHSC plans to submit the draft waiver to the Governor’s office in late August or early September
- Governor would submit the extension request to CMS by 9/30/16 at which time HHSC will post the request to their website.
- There were 5 main goals of for the waiver. Texas has made progress towards all five goals:
- Expand Medicaid managed care statewide
- Develop and maintain a coordinated care delivery system
- Improve health outcomes while containing costs
- Protect and leverage federal match dollars to improve the healthcare infrastructure
- Transition to quality-based payment systems across managed care and hospitals.
- There were three main components to the waiver:
- Statewide Medicaid managed care through STAR, STAR+ PLUS, and Children’s Medicaid Dental Services Program
- Uncompensated Care Pool: Provider reimbursement to offset uncompensated care costs
- DSRIP Pool: Incentive payments to hospitals and other providers for infrastructure and innovation through 20 Regional Healthcare Partnerships (RHPs)
Managed Care
- Managed Care includes STAR, STAR+ PLUS, and Children’s Medicaid Dental Services Program
- A brief overview of these programs was given
- The Changes since 2011 under the 1115 Waiver have included:
- Statewide Medicaid Managed Care
- Added populations
- Added services that were originally only fee for service
Delivery System Reform Incentive Program (DSRIP)
- Overtime the UC pool has gone down slightly and DSRIP pool has gone up slightly – all funds for these pools combined is $29 billion through the last five years (Roughly 58% federal funding)
- The DSRIP Pool extension will include $3.1 billion for each year of the extension period. (This is the same amount as the previous waiver period)
- More time is needed to evaluate project outcomes and lessons learned
- Through DSRIP Protocols, HHSC may propose one or more of the following uses for funds from the $3.1 billion annual pool not allocated to continuing projects
- Alternate transformative projects from narrower menu based on lessons learned
- Bring smallest projects up to minimum valuation level
- Add funds to a shared performance bonus pool for regions that make improvements on key measures
- HHSC wants to streamline DSRIP to lessen the administrative burden on providers
- Other ideas under consideration for extension request:
- Require DSRIP projects to report Medicaid IDs of patients served by projects
- Require all DSRIP and UC hospitals to provide emergency department admission, discharge, and transfer (ADT) information to their regional or state-level HIE
- HHSC would provide Medicaid ADT information to MCOs for them to share with providers to improve care coordination
Uncompensated Care Pool
- Texas has total of $11 billion from UC pool
- Texas’ UC burden has not decreased and the existing funding sources do not offset all UC costs for Medicaid and uninsured patients
Concluding statements on 1115 Waiver
- HHSC will request to continue all three components of 1115 Waiver
- Texas has made progress related to all five outlined goals
- The only change HHSC will request to the STCs is to extend DSRIP and UC pools for five more years
- HHSC will review input received during 30 day public comment period. HHSC will post a summary of public comment and how it was incorporated into the extension proposal.
Public Testimony:
Cam Clabrink – Frontera Healthcare Network and Texas Association of Community Care Centers
- Frontera serves 5 rural counties in region 13
- 30% of patients are uninsured even after increases
- District projects should be complemented by extended coverage
- Coverage expansion will bring 128 billion tax dollars to Texas as opposed to 34 billion in current waiver
Grace Chimene – League of Women Voters of Texas
- Pediatric nurse practitioner
- Appreciates the innovations by 1115 waiver
- Texas has highest percentage of uninsured patients and should expand coverage
- High rates of uninsured patients puts financial stress on hospitals
Dr. John Asbury, Pediatrician – On behalf of self
- 80% of patients are CHIP
- Has not seen positive benefit of 1115 Waiver on children in his area
- The uninsured rate is still too high – 1 million kids and 3 million adults in Texas
- Quality of care is as important as quantity
- We should increase reimbursement rate for Medicaid providers
- Increase medical care provider education levels
- Continue to increase MHMR funds
- Expand Medicaid up to 200% of poverty
- Improve efficiency of medical homes
Mary Del Peterson – Driscoll Children’s Hospital
- 70% of patients are on Medicaid
- Major focus of the hospital has been decreasing pre-term birth rates
- Children’s hospitals and health plans are safety nets that serve children across the state
- Payment rates need to increase
- CMS’s metrics for projects are based on older adults and not on children and pregnant women who are the majority of Medicaid patients
Regina Rogoff – People’s Community Clinic
- People’s Community Clinic provides high quality healthcare for Medicaid patients
- Supports the renewal of the waiver
- Coverage needs to be expanded
Nicole Seeger (Seeker) – National MS Society
- Overall employment rate for people with MS is 30-45%
- MS is one of most expensive chronic illness
- Urge Texas to maximize federal funds by renewing waiver and providing more coverage
Hugh Simmons – Austin Travis County Integral Care
- Fully supports efforts to renew 1115 waiver as they have made wonderful progress and would benefit from more time
- 11 Projects undertaken focus on behavioral health giving better care
Tom Wadkins – March of Dimes
- March of Dimes works to prevent birth defects
- 1115 is beneficial to this goal and should be extended
- We still have too many uninsured women
- Access to preconception and pre-natal care are necessary and save tax dollars long term
Sarah Cook – Central Health Travis County
- 1115 waiver has accomplished a lot
- Public funding equity problem must be solved for entities that supply their own IGT
- Projects are building infrastructure for Travis County
- Coverage should be expanded to low income Texans
- Delivery system is fragmented without establishing systems of care
- Data sharing should be rewarded
Maureen Milligan – Teaching Hospitals of Texas
- Support continuing DRSIP and increasing UC funding
- Waivers have been successful, but we need more time to recognize successes
- Waiver has triggered unparalleled level of collaboration and innovation especially in behavioral health
- For essential safety net providers, they should have continued access to UC funding
Laura Guerra Cardus – Children’s Defense Fund
- Support renewing 1115 waiver
- Also ask to include coverage expansion in negotiations for renewal
- Without renewal, a reduction to waiver uncompensated care funds should be expected
- HHSC should educate Governor and other policy makers about consequences if we lose 1115 Waiver
Bee Morehead – Texas Impact
- Coverage expansion needs to be part of Waiver conversation
- Waiver fills gaps, but it cannot be used as substitute for expansion
- Agency could quantify what Texas misses out on without expansion
Anne Dunkelberg – Center for Public Policy Priorities
- Appreciate work on waiver, but we support further improvements
- Simplification is important
- Best Practices should be built into all Medicaid models
- Best outcome for Texas with respect to waiver is 1115 renewal paired with expanded coverage
Susan Murphree – Disability Rights of Texas
- Support renewal of waiver
- Continue to expand on consumer assistance for individuals seeking coverage by continuing to look at Ombudsman services available
- We should maximize federal funding