The House Committee on Appropriations S/C on Art. II met on March 4, 2021 to hear testimony on and discuss COVID impact on mental and behavioral health, information technology in Arti. II, and MCO performance and accountability.  Witness materials and other handouts can be found here.

This report is intended to give you an overview and highlight of the discussions on the various topics taken up. It is not a verbatim transcript of the discussions but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

COVID-19 and Mental/Behavioral Health

Andy Keller, Meadows Mental Health Policy Institute

  • Speaking on mental health impacts of COVID; health care workers, children, others are experiencing significant negative mental health issues
  • Entire population will be facing stress & trauma coming out of the pandemic, projections show increased likelihood of suicide and overdose
  • Recommendations incl. emphasizing collaborative care, continuing to scale up Texas Child Mental Health Care Consortium
  • Capriglione – Very large numbers, in some cases tripling or quadrupling anxiety and depression; I believe them to be accurate, see this in constituency; where do you think this is coming from?
    • Deep loss and feelings of injustice drive depression; loss of friends, jobs, etc.
    • Physiologically similar to grief; lack of social support, financial resources, compound issues
    • In many times we’re talking about mild depression, but can get worse if unaddressed
  • Capriglione – Asks after funding and long-term effects
    • There are opportunities to ramp up in the initiatives, need to spend wisely on evidence-based services and addressing needs
    • Have seen disproportionate effect on communities of color, collaborative care has been more effective in these communities
  • J Johnson – Can you speak to audio telehealth component
    • Telehealth has been extremely beneficial for rural health care, audio-only can be just as effective as video or in-person
  • J Johnson – Also benefits those without computer or broadband access, would you agree?
    • Absolutely, phones can be carried with you and provide privacy as well
  • Rose – Emphasizes need to do more on mental health; study says that mental health issues increase risk of COVID?
    • Study looked at various countries for mental health impact of COVID, found that stress worsens, new mental illnesses were being found, and that people were much more susceptible to COVID
    • Not surprising when looking at research, people with mental illness are much more susceptible to comorbidities generally, also co-indicating with other factors like poverty
  • Howard – Concerned about overdose statistics, at the beginning of pandemic saw data that overdose deaths went down
  • Howard – Every panel we have on just about any issue talks about disproportionate impact on communities of color; do you have recommendations on how to move forward with that
    • Not sure on the overdose data, we had a slight dip due to anti-opioid efforts, but those statistics got much worse over the pandemic
    • Not treating mental health like other diseases, we expect people to find mental health care, we do not screen for these issues
    • Putting this care at the family doctors will address issues with communities of color
    • Need to look at care equity, need resources focused on this and integration into HHS
  • A Johnson – Could you speak to how cost savings come with early intervention in incarcerated population
    • Very important, interventions in Harris County were very important pilot
    • Cheaper to put someone in jail for a night than the hospital, but need to look at this differently
    • Harris Center is a fantastic program, but haven’t shifted away from law enforcement-led approach; Austin has added a new option for 911 focused on mental health which is great, lots of problems with sending law enforcement for health care response
    • Need to empower health care providers to be able to respond
  • A Johnson – Early intervention & medication can keep people from destabilizing and committing crimes, correct?
    • Absolutely, early intervention and diversion at point of crisis to health care instead of law enforcement
  • A Johnson – UT Health psychiatric center is being built out now, critical part of infrastructure
  • A Johnson – Would you agree that funding early intervention for human trafficking victims will be critical for breaking cycle of victimization
    • UT Health needs operational money to run that new center, Harris County and UT Health are the models for state health care systems
    • Absolutely right on human trafficking
  • Capriglione – Seen significant issues in children and adolescents, saw this in Communities in Schools
    • Critical program, mental illnesses are pediatric illness that begin largely by age 14

Sonja Gaines, HHSC

  • Have been able to respond fairly quickly to COVID impact; provides overview of outreach and crisis services at HHSC, 24-hour call center has been working very well
  • Changes to programs in pandemic response has essentially been an unintentional pilot program
  • Important to communicate with providers on important aspects of response; HHSC had frequent contact at the beginning of the pandemic and stood up support resources
  • Were able to relax certain requirements like grant and contract performance measures to better support providers
  • Seeing huge increases to telehealth and audio services, seeing greater engagement with care
  • Highlights HHSC public education on resources and safe practices, opioid outreach, etc.
  • Highlights operations of Coordinating Councill; networks between 28 state agencies receiving mental health funding
  • Large numbers of people have reported negative mental health effects, lowered access to mental health resources, increased usage of telehealth
  • Have virtually eliminated waitlist for outpatient services, also implemented SB 633 to identify gaps, looked at reallocating resources to address needs, etc.
  • Howard – Are there rule adjustments that you would like to see continues? Lessons learned?
    • Laundry list too exhaustive to go through here, there were a number that were useful
    • Video & audio has been working to take care of vulnerable populations; doesn’t work in every situation but has been beneficial
  • Howard – Have such a short time to take action; anything you can share would be appreciated

Lee Johnson, Texas Council of Community Centers

  • Represents 39 mental health centers around the state, contracts with HHSC to provide services for SMI, IDD, and substance abuse
  • Provides overview of community center response to COIVD; pivoted rapidly to remote services
  • Seeing increased acuity amongst population needing critical care
  • Recommendations incl. continued reimbursement parity for all modes of service delivery, sustain providers flexibilities for service delivery, support agency standards for services delivered, standardize service codes, support increasing aces to broadband, and continue developing Community Care Behavioral Health model
  • Many providers in our system built out telehealth service under 1115, allowed rapid shift when pandemic hit
  • Should finish work on state mental hospital redesign, incl. funds for operational costs
  • Local psychiatric bed purchasing continues to be a significant need
  • Should continue to strengthen hotline infrastructure, 988 national suicide hotline designation was an important step
  • Capriglione – Would like to know more specifics on standardizing codes in relation to MCO
    • Quite extensive, can circle back with you
  • Howard – We will have MCOs this afternoon, can you give me a brief explanation?
    • All providers partner with multiple MCOs, important to have consistency in service codes authorized as part of effort to determine which remote services are effective
  • Howard – Whose responsibility is that?
    • Medicaid service codes, would defer to Medicaid director
    • TMHP certainly provides guidance
  • Capriglione – Point is to make sure service codes are consistent given new services
  • Howard – New 1115 waiver and things like Public Health Provider Charity Pool will help continue services; do you see challenges with things like DSRIP going away
    • New waiver substantially alleviates concerns, but there are continued concerns under DSRIP like hospital-based crisis care
    • Some criminal justice programs like mental health deputies also impacted
  • Howard – Need to have a better understanding of this, certainly pleased about extension, but without DSRIP and Medicaid expansion we lose a lot of programs
  • A Johnson – Want to ensure rules are flexible enough for service delivery to use multiple methods like video conferencing and audio-only, etc.
    • What we would recommend is what’s seen in HB 4 to ensure audio-only is available
  • A Johnson – Want to make sure audio-only doesn’t just mean phone number; some may need wifi support that isn’t video-based
    • Need to be as broad as possible
  • A Johnson – Are you worried of increased child abuse reporting after we get back in contact after COVID?
    • Yes, certainly possible to see an increase and need to be ready

Kia Carter, Cook Children’s Hospital

  • Provides overview of Cook Children’s and provision of care; one of two hospitals that offers continuum of care services with behavioral health via counselors, psychiatrics, etc.; filters children into inpatient and outpatient services as appropriate
  • Have seen rises in suicide attempts and psychiatric consults presenting to the hospital, continually seeing record highs and parallels CDC data
  • Partially due to pandemic, but rates were also rising before the pandemic
  • Virtual school has been extremely difficult for children and adolescents, doesn’t provide the same structure, socialization, staff support, and meals
  • Limited resources are the biggest barriers for continues support in the community; reimbursement for mental health services is not the same as other health care reimbursement
  • Have seen parents use hospital ER almost like a mental health clinic
  • Video, virtual, and telephonic services are extremely important to continue supporting mental health
  • Children have had an extremely difficult time finding bed placements, Cook admits those unable to find beds to the medical floor and the psychiatry team will treat
  • Bed status is a huge problem across the state
  • Child psychiatry treats the entire family, Cook tries to support parent and child access; important to treat all individuals involved as stressors are complex and interrelated
  • Asking committee for ways to improve reimbursement and payor source for mental health
  • Have also struggled with autism care, very underserved population that can wait for weeks for bedspace; appropriate care is ABA and this is not approved by Medicaid
  • Capriglione – What does it cost for a parent to go private pay versus Medicaid reimbursement
    • Cost difference is about 50%, first visit is around $300 for private practice, Medicaid is about $120
  • Capriglione – Cook Children’s is incredible, thankful for them being in Tarrant County; asks after wait time given shortage of resources
    • In-person typically about 3-6 months, has gotten better due to remote services
  • A Johnson – Telehealth and giving you options to eliminate wait times is important, can you help to prevent us from restricting the definition of telehealth too much?
    • Yes

Karen Watts, Parkland

  • Provides overview of Parkland operations and COVID response; pandemic strained health system like never before, lessons learned and flexibility have helped
  • Grateful for RAC help
  • Asking for full funding of Medicaid rates, targeted funding for behavioral health, incl. funding for North Texas state hospital
  • COVID has strained mental health system, psychiatric care is generally full at Parkland
  • Workplace violence has been a danger for nurses & staff; legislature should increase funding for behavioral health services
  • Howard – Intrigued by workplace violence increase, what is causing this?
    • Increased stress, COVID, fragile support system, etc.
  • Howard – What modifications are you putting in place to help protect staff?
    • Many techniques, whistles, psychological support programs, training, etc.
  • Howard – Appreciates this being brought up, need to protect staff

COVID-19 and Mental/Behavioral Health Public Testimony

Cynthia Humphrey, The Association of Substance Abuse Programs

  • Provides overview of the Association
  • Substance abuse problems have increased due to the pandemic
  • Appreciates support of rider 64 during last budgeting cycle on increased rates and services for women
  • Need to focus on human trafficking & maternal mortality as related issues
  • Still some rules for chemical dependency that need to be waived for telehealth to work going forward
  • Social distance need has meant that some capacity for care has suffered
  • Howard – Asks after waiver needed for chemical dependency facilities
    • Licensure issues, currently large reliance on counselors, rules waiver allowed interns to be used for telehealth services and would like this to continue

Lee Spiller, Citizens Commission on Human Rights

  • We don’t know much about COVID and mental health yet, much of the data is preliminary
  • Need to tie mental health funding to relevant outcomes, not capturing metrics on suicides so cannot know if programs are working; initial data from several Texas counties showed teen suicides trending downwards
  • Pandemic has created opportunity for schools to question kids about mental health without parental consent; can generate CPS calls

Information Technology in Article II

Maurice McCreary, HHSC

  • Highlights his role at HHSC as COO, HHSC IT operations
  • Trying to align IT with future business needs, trying to embed reliability into the 10-year plan

Ricardo Blanco, HHSC

  • Link to Modernization Plan
  • Speaking on the IT modernization plan, rider 175; part of the directive was to provide a plan to LBB & Gov’s Office, delivered on Oct. 1, 2020; also required to post modernization plan to the website, available to the public
  • Needed to describe HHSC’s project management process, identify resources requires, and desired outcomes
  • Currently working on the Business Enablement Platform, passed during the 86th
  • Highlights portions of plan; currently working on Phase I enhancing network capacity & security, this was very important during first part of pandemic to expand services
  • Needed to deploy public-facing upgrades, database upgrades, etc. rapidly due to COVID
  • Phase II will work on data analytics, systems that funnel high dollar amounts, end-of-life and end-of-service systems
  • HHSC IT security program aligns with TX’s cybersecurity framework, cyber attacks have increased dramatically since onset of COVID pandemic & remote work has emphasized needs; HHSC continues to mature security measures
  • HHSC has hired consultants/3rd parties to identify security threats
  • Highlights COVID response; created IT COVID task force, deployed tech for those without laptops, increased bandwidth, etc.
  • Highlights work force strategies used to encourage employee engagement, customer support
  • Capriglione – 10 year roadmap will drive all of this, can you give some understandable examples to share with constituents?
    • Yes
  • Capriglione – What are we going to be able to do in 10 years that we can’t do today?
    • Trying to do a lot of the front-end work in the next 2-3 years, problem is that lack of funding could extend the plan past 10 years
    • Inherited a lot of technical debt when consolidating agencies
    • Working to replace end-of-life tech, don’t want to reach end-of-service
  • Capriglione – Asks about security & data breaches; have heard of issues with subcontractors
  • Capriglione – Had a problem with Accenture subcontractor BRSi where a lot of Medicaid data was released, part of the issue is we unsure whose data was released; what remedies do we have for these subcontractors?
    • We have data use agreements, confidentiality agreements, standards for security
  • Capriglione – This subcontractor would’ve broken the data use agreement in my opinion, are they still a subcontractor with the state?
    • Worked through contract management side, not under the IT contracting division
    • McCreary, HHSC – Can look at liquidated damages for damage to HHSC systems; go back to Accenture and ask for these
    • Looking at expanding all requirements to contractors and subcontractors and kicking them off the network if they don’t comply
  • Capriglione – I think that makes sense
  • A Johnson – This was one of the largest health care data breaches ever, are we able to be assured that the group that caused the injury is not still a provider for HHS info?
    • They are still a provider
    • Blanco, HHSC – We worked with vendors to identify issue and how to ensure it doesn’t happen again; cut them off early into the incident to ensure it didn’t spread
    • We need to review corrective action plans to restore confidence
    • Want to also make sure that contractors/vendors are following the same requirements as HHSC for data
  • A Johnson – Is the company that allowed the security breach still receiving funds as a vendor?
    • Vendor still has that contract
  • A Johnson – Right now 49% of your tech is end-of-life? 90% by 2023?
    • Correct
  • A Johnson – So tech used by IT will die in a couple of years?
    • End of life means plans will need to be made, end-of-service means the option is no longer available
  • A Johnson – Concerned about tech being implemented becoming obsolete, how can we be sure that we’re not throwing money away with the 10 year plan?
  • Capriglione – Good way to think of end of life is having the ability to patch and update, end-of-life means no more patches or updates to cover issues
    • Clarifies that this is end of service, end of life is when products are no longer sold
  • Dean – Tagged everything related to IT in the 85th
  • Capriglione – A lot of this comes from exceptional items, good point and will look into this
  • A Johnson – Can any congressional relief coming be used to address end-of-service issues?
    • Will take that back and investigate

Roberto Beaty, DSHS

  • HHSC supports DSHS in IT services, incl. internet, helpdesk, applications management, and liaison with DIR
  • DSHS projects are managed through HHSC IT governance program, DSHS focuses on meeting program objectives
  • Highlights how COVID has increased check-ins on applications development
  • Highlights DSHS IT projects like ImmTrac2
  • 20 large IT projects have been initiated since onset of COVID, from $200k to $19 million and administered in concert with HHSC and DIR

Donna Sheppard, DSHS

  • Portion of DSHS business operation exceptional item is related to IT, $27.2 million of total ask
  • DCS services @$21.8 million for the biennium; incl. app updates, cloud services, etc.
  • $5.4 million over biennium for public health registries assessment, long-term IT solution for blood, birth defects, infectious disease, etc. registries
  • Request is to obtain 3rd party to review roadmap
  • Howard – Are registries fully interoperable with others in the health care community? Is there a single entry for the registries?
    • Beaty, DSHS – No single entry for the registries, one of the challenges we have
  • Howard – Regarding ImmTrac2, how much has state spent to update registries to comply with opt-in laws?
    • Will need to get back to you
  • Howard – Do you believe switching to opt-out will save the state money?
    • Sheppard, DSHS – Working on that analysis now
  • A Johnson – Your system is on the verge of failing and Texans could be hurt, if we had the ability to upgrade the system at this point, what would that look like? E.g. federal relief
    • Many systems received upgrades due to recent federal awards, though these funds can’t be used on base projects; ImmTrac and others benefited
  • A Johnson – Does your exceptional item request put us at par with federal relief?
    • Bulk of that request is for DCS, keeps DSHS in compliance with DCS requirements and keeps system stable
  • A Johnson – Does that solve the problem of software being unworkable by 2023?
    • Beaty, DSHS – Yes for some applications, DSHS evaluates the ability to upgrade; many issues involve projects that are unallowable for federal awards
  • A Johnson – 10-year plan doesn’t make sense if software will be obsolete by 2023, hoping we don’t recreate the same problem; what would you need right now to update properly?
    • 10-year roadmap is to modernize and consider a large portfolio of applications, some of the end-of-service issues apply to foundational software rather than current applications
  • A Johnson – At some point different systems don’t work together & upgrading piecemeal can be detrimental versus investing everything at one time; question is if we were able to do everything today, what number would that be?
    • Don’t have a total, registry funds would help inform DSHS’ info on what full update would cost
  • Capriglione – Regarding doctors being unable to collect suicide data in a timely manner, can you explain where this data is held and how we can get this data as quickly as possible?
    • Jeremy Triplett, DSHS – Awarded grant by CDC to collect this information, phased approach that worked on different regions of the state
    • Data is linked on a monthly basis to vital statistics, working with counties to collect additional info from LEOs
  • Capriglione – How do counties get that info into your system, do we help them?
    • First step is to go to counties with automated systems who can provide quick info, rural counties will be more difficult
  • Howard and Triplett and discuss CDC guidelines
  • Howard – IS the grant precluding us from using the info on a more timely basis?
    • I don’t believe so, haven’t collected data before so wanted to ensure it was correct and validated before being used
  • Howard – So we can perhaps start using it real-time after validation?
    • Can look into this
  • Capriglione – Do you have data for January of this year?
    • Have data, but getting data into the system may not be accurate so far
  • Capriglione – Is December’s information in?
    • We would’ve received it, would need to find out if staff has had time to enter it
  • Capriglione – People are trying to figure out how COVID has affected people; is the number of suicides going up?
    • Can look at info and get you a report

Lisa Kanne, Department of Family and Protective Services

  • Provides overview of DFPS IT operations; supports agency and external partners like CASA
  • Key systems include IMPACT case management, statewide intake e-reporting system for nonemergency referrals, PEIRS reporting system

Managed Care Organization Performance and Accountability

Victoria Grady, HHSC

  • Provides overview of rate setting, public input process, and aspects that go into setting rates; incl. new techs, Medicare changes, litigation, federal policy changes, etc.
  • Have recently been more proactive about rate setting, held open forum on rate setting last month
  • Capriglione – How many rates are there?
    • 45k-60k rates are reviewed per year, some are reviewed twice per year
  • Capriglione – Every rate is reviewed every year?
    • Once every 2 years
  • Capriglione – This includes hourly rates for therapists, goods?
    • Yes, DME, surgery reimbursement, nursing facilities and LTC, etc.; anything under the Medicaid program
  • Capriglione – Who holds the hearings?
    • Commissioner is typically not present, likely myself or my staff
  • Capriglione – What are the factors that decide the rates?
    • For many acute services we try to have a rate that is between 50-80% of Medicare
    • Hospital services have not been updated since 2013, waiting until we have appropriations; nursing facilities are similar, haven’t been updated since 2014
    • If there is a really significant impact, HHSC often pends decisions to wait for legislative input
  • Capriglione – Who pays for increases?
    • This is added into reimbursement method under Medicaid, without appropriation it can get added into shortfall
  • Capriglione – Do we check to make sure the rate goes to the intended target? Do we audit this?
    • Typically MCOs and providers look to fee schedule for basis of negotiations
    • Very common for contracts to dictate a certain percentage of FFS schedule
  • Capriglione – Is that in our contract with the MCO or provider contracts with MCOs?
    • This is in contracts between providers and MCOs, these can also include alternative payment models, subcapitated rates, etc.
    • Fee schedule serves as a barometer
  • Capriglione – So we dictate a rate and MCOs can say they will only pay 75%? This is mind-boggling; what’s the point of us setting the rate?
    • There are limited circumstances under federal law where we can tell MCOs what to pay
    • Reason to set rates is for FFS clients, also those who join Medicaid before they select MCO are still delivered services under the FFS schedule
  • Capriglione – Why don’t we have any limits? They can go 0% to 100%, whatever they decide
    • MCOs must still have enough providers to ensure sufficient network
  • Capriglione – When you determine the rate, is this what you think is a fair rate?
    • Very limited by available appropriations, typically don’t make adjustments until it falls outside 50-80%
    • There is some discretion, public comment process comes into play here
  • Capriglione – But we don’t ask the MCOs how much they paid for services?
    • We receive encounter data showing the paid amount, but don’t have the contract
  • Capriglione – We know what they did pay and we know what the rates we set were; do we have data that says on average MCOs are paying more or less?
    • Defers to other witness
  • J Johnson – TMA report recently said only 31% of TX physicians accept Medicaid
    • Not sure I can answer that, can follow up
  • J Johnson – Who set the 50-80% limits?
    • Developed in response to 2008 litigation, did not have rate review system at all before this; established biennial fee review process and put methodology into TAC rule
  • J Johnson – I don’t recall HHSC asking for more appropriations for rate increases; do you advocate for this? Haven’t seen info from HHSC asking to get us rates to ensure adequate networks
    • Did not include any requests for rate increases as an exceptional item, we do have percentages on providers, info on what is needed to increase, and breakdowns
  • J Johnson – Asks for explanation based
    • Rate that providers should be paid based on methodology is not always what they are paid; have data on this that we can provide
  • J Johnson – Would be helpful for certain programs like Healthy Texas Women
  • J Johnson – Kicked 8k people off of Medicaid through Planned Parenthood, is there some method to get these patients reassigned?
    • Stephanie Stephens, State Medicaid Director, can better answer this question
  • J Johnson – Would be interested in rate analysis, significant issues with provider rates and headed towards access to care crisis
  • Gates – Currently MCOs handle 94%, FFS is 6%, Is it only new patients under FFS until they find an MCO?
    • Includes new patients, but also includes populations not in managed care like IDD
  • Gates – Providers and MCOs can have a contract with alternate rates, do we share in profits?
    • Defers to Chief Actuary on this
  • J Johnson – There is no requirement that MCOs meet minimum rate schedule?
    • There are limited exceptions, federal law allows us to direct payment from MCOs
    • Nursing homes and rural hospital rates must meet minimum FFS schedule, passed by the legislature
  • J Johnson – So we can require them to pay minimum rate schedule in other services?
    • Would be legislative decision, would need to seek approval from federal partners and meet requirements for quality goals; requires annual reapproval
  • J Johnson – Have a hard time understanding federal government not wanting to put more money into provider pay

Rachel Butler, HHSC

  • Provides overview of how MCOs are paid, rate setting; capitation rates are set prospectively unilaterally by HHSC
  • MCOs take on the financial risk to provide services, if actual costs are greater than fixed premium amounts and payments, then MCOs lose money; HHSC is protected from excessive MCO profits through experience rebates
  • Highlights actuarial review of rate certification, requirements, and methodology; rates are based on pooled experience, average actual costs
  • Risk adjustments are applied to certain rates and services
  • Capriglione – What is the risk adjustment for? Does the MCO use it to estimate? Does the state use it to determine rates?
    • Yes, state uses this to develop a factor that compares MCO population; budget neutral adjustment
  • Capriglione – So certain MCOs get more or less based on risk, so the experience rebate is essentially risk adjusted based on revenue; revenue is based on risk and loss is based on projected risk
  • HHSC relies on historical data as submitted by MCOs, articulates what MCOs are actually paying and services delivered; capitation rates are not based on assumption that MCOs are using FFS
  • Capriglione – Because they’re not
    • They have flexibility
  • Highlights data validation and approval; HHSC validates data, External Quality Review Organizations evaluate
  • Common adjustments incl. benefits policies, cost containment and other efficiency adjustments
  • Don’t adjust for everything, looking for material items and items important to the legislature
  • Trend assumption is developed to smooth cost spikes
  • After adjustments, then make acuity adjustments for specific MCOs
  • Occasionally need to make mid-year rate changes for unexpected events
  • Partway through rate setting for FY2022, COVID has altered usability of data from the previous year, actuaries will meet on planned changes to Medicaid programs and whether adjustments are warranted
  • Preliminary rates are established, sent to LBB, then sent to MCOs; MCOs can comment, after HHSC approves final rates than contracts are amended
  • Actuarial reports are posted to the HHSC website
  • Capriglione – Before all of the MCOs tell us they aren’t making money, I had some questions
  • Capriglione – We know the rates we set, and we know how much was paid to providers, do we compare these to determine payments?
    • From HHSC perspective, looking at this data more from rate setting perspective, varies by region and likely down to what the market will bear
  • Capriglione – Do we know how much MCOs pay providers?
    • Yes, through encounter data
  • Capriglione – So we know how much the provider is paid and what we set the rate at; we should be able to figure out this difference; important to the conversation on profit, if you don’t pay the full rate you’re more likely to have a profit
  • Capriglione – Each MCO knows exactly what these numbers are
  • Capriglione – Regarding capitation, do we change what we pay on a more frequent basis than contract drafting?
    • Federal law requires prospective 12 month rate setting, rates are based on actual reported expenditures of MCOs
  • Capriglione – How much you pay providers kind of determines how much people utilize services, insufficient rates drive providers out of market
    • Defers to other witness
  • Dean – So we don’t pay rebates unless the MCOs make money?
    • Complex calculation
  • Dean – They don’t get a rebate if they lose money, we share in the rebate if they make money up to a certain percent?
    • Correct
  • Dean – What financial info do we ask as part of our evaluation?
    • Defers to procurement staff
    • Stephanie Stephens, HHSC – Typically requesting data to prove financial solvency
  • Dean – I heard you only take a look at cash reserves?
    • Would need to get back to you on that
  • Dean – From a business perspective we want to look at the entirety of their financial position
  • Dean – What is a mandatory contract?
    • Typically MCOs affiliated with a hospital district
  • Dean – So we can dictate contracts if they are associated?
    • If they respond to the RFP and they disclose they meet the contract, we are required to contract to the extent they can do the work
  • Dean – Do we perform audits? Do we have this in our contracts?
    • We do audit FSRs, one of the data sources are claims or encounter data
    • Also look at premium data, revenue
    • After a year closes there is a data lag to give time to claims to close out, then independent auditors perform additional validation
  • Dean – Do we follow the legislation that set up the system in 2013?
    • Would need more information, wasn’t here in 2013
  • Dean – Rider 22, what’s the issue here?
    • Requires HHSC to set benchmarks for financials and performance to be used for contracting at MCOs
    • Have looked at considering performance with an eye to other states; challenge is that our procurement process has to be competitive for both incumbents and non-incumbents; can be subjective to look at other state data
  • J Johnson – Is there a different capitated rate set for each MCO?
    • Butler, HHSC – Majority are MCO specific, challenging to set some rates for small populations individually
  • J Johnson – What is a typical rate per person?
    • Varies considerably based on cost profile and benefits; some dental rates are $10, some MDCP rates are $14k
  • J Johnson – Asks after profits
    • Measure profits through FSRs, share profits over 3%
  • J Johnson – Somewhat incentivized to deny care, if they don’t pay claims they get to keep that amount
  • J Johnson – Concerned about 3%, what is the role of saying that MCOs are paying enough or aren’t unreasonably denying claims
    • Stephens, HHSC – Have a range of oversight tools, one of which is utilization review which looks at different data like PAs
    • Continuing to improve oversight process
  • J Johnson – Who sets the PAs? Do you have input?
    • Requirement is that they provide medically necessary covered Medicaid services, within that they can manage utilization and set PAs in this area
  • J Johnson – So HHSC is not involved
    • Recent legislation directed HHSC to implement requirements on the PA process
  • J Johnson – State should have some vested interest to ensure clients are getting care they need
    • We do, there are several avenues of utilization review, e.g. did an MDCP survey in 2020
  • J Johnson – Do you also review whether procedures are medically necessary? Do you review these determinations?
    • There are some requirements on certain specialists having access to equivalent peers, can get back to you on specifics
    • Also putting other safeguards in place for members
  • J Johnson – Frustrating for recipients to receive care due to lack of providers, treatment recommendations are not followed, services are denied, etc.
  • Gates – When you set capitation that is what the state pays for each patient?
    • Yes, per member per month
  • Gates – And this is set to some degree on hindsight, if you did have plans paying half the rate it would catch up to them in the next cycle?
    • Butler, HHSC – Correct
  • Gates – While some may contract at a lower rate, they may need to pay more or above services, so they have all the downside risk
  • Gates – on FFS, state handles overhead for all those members?
    • FFS clients are still being administered by the state
  • Gates – Did HHSC have a much higher employment level when state was managing everything?
    • Would agree with that in terms of managed care clients
  • Gates – Is MCO overhead limited?
    • When we set capitation rates we target the average per program
    • If they can’t operate less than average it will be a financial strain
  • Gates – IF you know an MCO is a bad operator, can that lead to higher rates
    • In general, there are certain things we can address in the rates and certain things that aren’t; we have an admin cap
  • Gates – What’s the likelihood where one or two bad operators can cause a higher rate? Sound like you have a lot of tools to watch them next year
    • We look at all MCOs on roughly a weighted average, difficult for smaller MCOs to run as efficiently, though they don’t necessarily influence the model
  • Gates – Do you have the tools to monitor them closer in the next year?
    • Yes, we have the tools, what’s become tricky is knowing if tit’s reasonable for the health plan to have an admin structure higher than the average
  • Gates – Can a claim be denied? How do they get declined? Aren’t they eligible?
    • Would defer back to another witness
    • Stephens – to the extent it’s been determined medically necessary they should have received it
  • Capriglione – utilization rate, is there correlation between how much we pay providers and access to care?  Does rate setting impact people having access to care?
    • Lot to unpack there
    • You may not have providers in your network
    • Require MCO to provide providers – network adequacy
    • Have seen managed care model has improved preventive care
  • Capriglione – have seen research on this?
    • Sure there is, but do not know a study off the top of her head
  • Walks through slides, first slide details operational oversight also talked about utilization reviews, oversight can also be conducted with auditors
  • Have multiple stages of remedy for non-compliance such as corrective action plans
  • Have process to assign people MCO who did not choose one
  • Use data for rate setting and calculating rebates and then do audits of it to validate the information
  • Next slide explains rebate of calculation
  • MCOs are required be federal regulation quality assessment – improvement and maintain approach
    • Part of approach is performance improvement process
    • Look for MCOs to identify how they will improve performance
  • Dashboard has an array of measures that are tracked, if they don’t meet standards for 2/3 of the measures then they can implement remedies
  • They also issue report cards for each plan – score of MCO from 1-5 stars
  • Number of quality additions that incentivize quality improvement
    • 3% of capitation program is at risk
    • Different metrics can be set for each program
    • Part of goal of pay for quality program is they will use metrics with their own providers
  • Newest quality initiatives is value based enrollment – considering value and how much enrollment they received; number of factors are looked at and weighted differently
  • Capriglione – report cards based on customer, not financial
    • Correct customer survey and quality metrics
  • Will get them details on who gains enrollment and loses enrollment
  • Capriglione – why percentage?
    • Weighted roughly equally, they could be changed
    • Started phasing it in September, relatively new
    • Opportunities to continue to tweak as we go forward
  • A. Johnson – not everyone in Texas is covered by Medicaid? Smaller segment of Texas we address with these services? Believe we have highest rate of uninsured children across nation?
    • Pretty large amount around 4.3 million
    • Yes state has option where they could provide more care
    • Believes we do have highest rate of uninsured
  • Capriglione – Asks after enrollment
    • Can get you details about who gains and loses enrollment
  • Capriglione – Why 40/20/40?
    • Wanted to consider cost and quality, weighted roughly equally, relatively new
  • Capriglione – You can give us what those numbers are?
    • Yes
  • A Johnson – Not everyone in TX is covered by Medicaid, even in covered categories we’re only covering certain children, women, etc.; missing the gap between Medicaid and private insurance
    • Missing pretty large section of population at >4 million
  • A Johnson – We have the highest rate of uninsured children in the nation
    • I believe that’s true
  • A Johnson – We have non-profit MCOs and for-profit MCOs; if I’m a for-profit MCO then I want to be in the sweet spot of 6.9% profit
    • IN standard year that would be a pretty high profit
  • A Johnson – If my motivation is to make money and I have a profit obligation, I’m wanting to deny, reduce payments to physicians, etc.
    • If an MCO maximized profit by not providing care, we would pick that up in oversight and take action
  • A Johnson – At what point do we tell for profit companies that they’ve gone too far?
    • Don’t typically see these higher levels, can get you prior percentages; percentage determinations are policy decisions
  • A Johnson – If we received more federal funds would it enable us to cover more children?
    • There would still be a state cost, would be a policy decision
  • A Johnson – And at this moment our policy decision is to have the highest rate of uninsured children in the nation
  • Gates – Can a MCO provide some benefits not covered by the state, e.g. a weight loss program?
    • There’s different mechanisms MCOs can use, could fall under value-added services that the state doesn’t pay for
  • Gates – If a member has a traumatic accident at $100,000, are they covered?
    • Yes, if they are covered under Medicaid
  • Gates – So these expenses inform the rate as well?
    • There are outlier provisions
  • Gates – Asks after provider participation
    • We measure network adequacy, MCOs must have providers available within a certain time & distance of members
    • If MCO didn’t have a provider it would be picked up in network adequacy review
  • Gates – Only 31% of providers are in Medicaid, but at the end of the day aren’t there enough providers to serve Medicaid need?
    • We see that MCOs meet standards for primary care, OBGYN, prenatal, etc.
    • I think there can be challenges in rural areas or certain specialties, but MCO must still find a way to give member access
  • Gates – To me it sounds like you have all the tools necessary to ensure compliance
    • We have the opportunity to identify key metrics and further define high and low performing plans
  • Gates – And you have tools to bring someone into compliance? You definitely have the tools on the profit side, maximum they can make is 12% and the downside has no limit; can you eventually bar an MCO and deny contracts?
    • We don’t expect plans can operate on losses perpetually
    • We have an array of tools to promote value on cost and performance
  • Howard – On value-based enrollment, is it correct that a certain percentage of payment must be under value-based care?
    • Yes
  • Howard – What is the requirement for this FY?
    • In 2018 it was 10% at risk, 25% total; increases year over year until 2021 which is 25% risk, 50% total

State Auditor’s Office

Lauren Godfrey, State Auditor’s Office

  • Objective of audit was to determine if HHSC has processes and controls to determine if MCOs
  • We determined that HHSC address MCO noncompliance through liquidated damages and corrective action plans; found that they have made improvements in this, but there is a backlog and no way of applying plans for certain contract terms
  • As of July 2019, HHSC had not finalized calculations for liquidated damages since Sept. 2017; significant backlog causes difficulties for MCOs and contribute to noncompliance
  • Highlights methodology to determine liquidated damages; most significant damages are base don utilization reviews and based on ability of MCOs to provide coverage
  • HHSC staff individually calculates damages and sometimes makes errors, but errors did not change overall totals
  • HHSC does not have a process in place to determine MCO noncompliance so could not apply contract actions; largely on utilization reviews
  • Noncompliance identified by HHSC largely due to unallowed admin expenses
  • HHSC had significant weaknesses in access to systems used for damages, communicated these confidentially
  • Capriglione – Unallowable administrative costs increased significantly in a short period of time
    • HHSC has a process through contracts with external auditors, but this is not done until after MCO data is used to set rates
  • Capriglione – Looks like HHSC has a lot of tools, but there are significant issues in assessing damages and calculating costs
  • A Johnson – Can you explain noncompliance?
    • Means MCOs are not complying to contract provisions
  • A Johnson – What areas is this in
    • Was across the entire spectrum
  • A Johnson – Can we say we are monitoring these agencies given this?
    • Certainly monitoring MCOs, this is how they got to liquidated damages amount
    • But SAO did identify areas where monitoring could be strengthened
  • Gates – So are they collecting all these liquidated damages?
    • Yes
  • Capriglione – Maybe 4 years there was a penalty given of $100 million, but actual collections were about $10 million
    • In our audit we found all assessments had been collected
  • Capriglione – But there were calculation errors?
    • Errors amounted to less than 1%

Jamie Dudensing, TAHP

  • Provides overview of TAHP and MCO members, system of managed care
  • State sets a premium, pays plans that premium, and plans are at full risk for losses with caps on admin and profits
  • Provides an overview of managed care programs; STAR, STAR+PLUS, STAR Kids, etc.; designed around certain populations
  • Studies have shown significant savings to the state since 2009, in Medicaid managed care cost growth has stayed at 1% or 2% per year, lower than similar programs through TRS, etc.
  • MCOs have improved access, have improved providers participating
  • MCOs also show improved outcomes in terms of hospital stays and reduced ER visits, seeing better utilization rates
  • Rate setting processes are very strong, premiums set by HHSC, certified by independent actuaries, LBB, and CMS
  • Overview of quality metric surveys; HEDIS, CAP, Potentially Preventable Events, Pediatric Prevention Program, etc.
  • HHSC hired Mercer as third party to create and implement recommendations for procurement process
  • Concerned about Rider 22 tilting balance of value and high quality providers in Medicaid program
  • Capriglione – Page 7, are all of those metrics used in procurement process?
    • HHSC would support the use of those metrics, though programs pick and choose certain metrics that align with their priorities
    • Ex: CAPS metric for member satisfaction, HEDIS as quality measure and CDPS for efficiency
  • Dean – Why don’t you like Rider 22? Bill passed in 2013, did it not lay out some of these metrics?
    • SB 7 from ‘11 and ’13 introduced the default enrollment process, which ensures quality and laid out oversight benchmarks
    • Not opposed to Rider that requires HHSC to build benchmarks,
    • Hospitals and physicians in value-based contracts are paid more to incentivize quality and reduce ER visits, but we’re paying them 100% regardless of if there are less ER visits, on top of the extra payment for value-based contract
    • We’ve asked HHSC to put metrics in supplemental program to reduce the double expenditure
  • Dean – How do these facilities stay in business at 2.6% profit? Do we go through their financials when qualifying them?
    • I represent the plans, can’t speak for agencies. Agencies are designing new procurements with Mercer
  • Howard – Reminiscent of HMOs in the 70’s which ensure quality outcomes rather than fee for service; the concept is efficient, but the reality is very complicated
    • Yes, we perform a significant number of audits and utilization reviews
    • On finance side, HHSC has over 20 years of experience and has become accurate in rate setting process; consistently in 2.6% range
  • Howard – What happens to the plans if the actuarial assumptions are off base?
    • Lose money. Sometimes thought utilization would be higher, like this year for example. Texas is protected because we must share profits back to the state
  • Howard – In regards to timely prenatal care, fee for service was only 12%?
    • 20 years ago, yes
    • Notes that those metrics are from HEDIS, the same structure used today
  • Howard – Women don’t enroll into Medicaid until they’re pregnant, and many don’t know they’re pregnant until a month or so in.
    • Texas has created rapid enrollment, don’t want to put them in managed care
    • CHIP is immediate enrollment
  • Howard – What happens when plan is not profitable to state?
    • Nothing in that year; state has budget certainty through premiums and takes loss
    • Going into the next year, depends on what area went over budget
    • If the overuse of funds came from proper utilization of services, could consider upping the budget
    • If overuse comes from admin, make strides in efficiency and budgeting
  • Howard – Can you clarify priorities – patient outcomes and cost efficiency?
    • Yes, and quality initiatives
  • Howard – What is the real impact of rider 22 and how it affects the plans?
    • I think it would put us in a dangerous spot that makes us emphasize profits over patients
    • Rider is more than procurement criteria, says that HHSC may eliminate low-performing plans, can lead to heavy incentives to ensure you’re not operating at a loss
    • Also directs HHSC to develop consequences for what we’re contractually obligated to do
  • Howard – So you’re saying that you’re obligated under the entitlement to meet needs of the patient, but if the needs cost more than what you’ve been told you can spend, you will get punished?
    • Yes, performance metrics are important, but shouldn’t punish plans when talking about medical part of the premium
  • Dean – I’m sure the rider can be rewritten by the House and Senate, don’t need to keep all provisions
    • Operations are different than procurement, very important to us that metrics be fair and tested, nationally-based, etc.
    • HHSC has flexibility to ensure these are the right metrics
  • Capriglione – References two MCOs getting 2 out of 5 stars on report card
    • Report card uses all the same metrics
    • Good idea would be a real-time dashboard, would cost dollars, but could inform targeted response to conditions on a regional basis
  • Dean – Would be nice to be able to drill down on all that data
    • Would be extremely valuable, e.g. could click on dashboard to see network adequacy data
  • Dean – Would be interesting to build out IT components to drill down on quality, preventable care, etc.; identifying issues specific to regions, etc.
    • I think one of the best examples is preventable readmissions for psychiatric care

Mark Sanders, Superior Health Plan

  • Speaking on design of managed care
  • Provides overview of TDI regulation of financial solvency of health plans
  • Procurement office evaluates various questions presented in RFP, like needs for capital, etc.
  • Rate setting process promotes program efficiency, rates are developed as fixed payments to health plans from a program perspective and between comparative service areas
  • Health plans report detailed data through FSRs, info is audited by the state via external firms
  • Encounter data and FSRs are reconciled with each other as well
  • Plans offer non-Medicaid services through value-added services, but not covered
  • Superior does incentivize prenatal visits
  • 3% premium is at risk, part of the checks & balance of pursuing profit while ensuring members have access to services
  • Admin cap also drives efficiency, excess costs will come out of pocket
  • Rate will be established roughly 65-80% by other plans in your region, drives efficiency
  • Highlights health plan service coordination and care management
  • Superior tracks hospital visits to determine which were avoidable
  • Raney – How did your plan fair in the 2019 procurement that was cancelled?
    • We added 2 more service delivery areas, hit the cap of areas we could be involved in
  • Rose – Isn’t the main point to deliver quality health care?
    • Yes; we do want to see services for our members; a lot of state measures hold Superior accountable, want to be able to write about these measures in the procurement
    • Appropriate care will also save Superior ER visits and money
  • Rose – Do we see variability in costs across the health plans year to year
    • Yes, things like unusually high flu costs, high NICU costs, etc.
  • J Johnson – If we expand Medicaid, does your plan have the ability to absorb new members?
    • Plans would bid on prospects, cannot comment beyond that

Don Langer, United Health Care Community Plan of Texas

  • Texas Medicaid program is very solid; very strong oversight and quality incentives
  • Agree that financial performance is very important, quality is critical; must consider access, complaints, etc. in procurement and operational oversight
  • Rider 22 has unintended consequences as written, incentivizes MCOs to manipulate provider networks, push members to different MCOs, save money ahead of patient care

Karen Love, Cook Children’s, Texas Association of Community Health Plans

  • Provides overview of Cook Children’s operations
  • Cost efficiency is an important part of the system, but must be balanced by access to care, keeping members and providers satisfied
  • Cook has performed very well in the market, willing to incur losses to serve children in the plan
  • Mix of community and national health plans is key to competition and choice
  • Rider 22 is likely to result in unintended consequences, would like to work with legislature and agency to use existing data to support outcome goals
  • A Johnson – At a tipping point in TX; people keep saying TX is performing well but care is suffering for some, opportunity to undo some harm and get funds to increase quality of care; if we had the avenue to provide care to more children, would like more information
    • Regarding children eligible, but aren’t enrolled, 800k range currently; Cook has people daily trying to find these children
    • Medicaid expansion is primarily about uninsured adults, pediatric system will likely not benefit much from this; a number of plans could absorb new volume
  • Regarding report cards, these are a forced ranking of all plans in the state
  • Capriglione – My only point is, whatever happens here, we have been using an evaluation; concerned if it is performative or if we evaluate and make participation decisions based on data
  • Capriglione – When suggesting we use these, people who brought these up seem to say no we shouldn’t; is this what you’re going to say?
    • No, we could; it is a forced ranking of all plans, but doesn’t keep up with overall pace of progress
    • Plans could all be above 90%, but 90% gets 1 star, and 91% gets 2 stars, etc.
    • Doesn’t indicate poor performance, just indicates performance relative to others

Kay Ghahremani, Texas Association of Community Health Plans

  • Important to continue to have large number of plans and diversity of plans given size of the state
  • Regarding value-based enrollment, TACHP plans gained membership under this methodology in 11 of 12 services, 40% is based on cost efficiency
  • One health plan did go out of business, was only doing STAR Kids and attracted 85% of medically fragile children
  • 4 health plans in our association are owned by hospital districts, mandatory contracts apply to this group, but must meet extensive requirements
  • Rider 22 is not really needed, Mercer came out with comprehensive report with procurement recommendations and process in ongoing; also a Deloitte report on contract management that spurred changes
  • Capriglione – Report came out in 2018, when were the HHSC problems?
    • Those were procurement problems, Deloitte report applied to contract management
    • On the procurement side, Mercer report laid blueprint for changes which HHSC is in process of; this is why recent procurements were pulled back
  • Howard – Regarding plans losing money sometimes, one plan lost money due to large populations of medically fragile children; what reasons do other plans lose money for?
    • Driven by membership

Greg Thompson, Amerigroup

  • Testifying in support of Rider 22, Amerigroup is the only MCO in support; Amerigroup supports holding MCOs accountable for cost, quality, satisfaction; left association to have these conversations
  • Current system of rate setting gradually increases cost of health care in Texas
  • Rider 22 requires agency to implement laws passed in SB 7 over 10 years ago
  • Highlights aspect of competitive managed care market
  • Rider 21 in the Senate, all plans support this one; key difference between the two is that House version includes accountability provisions
  • Gates – Many factors go into setting rates; isn’t rider 22 setting up a situation where you have a low performing MCO who can possibly be taken out of the system every year
    • Rider 22 creates a baseline performance index to rate plans, not intended to be the only factor in procurement
  • Gates – Seems like agency has the tools currently to set metrics and determine best value; everyone is meeting minimum standards
    • State has very strong quality metrics; HEDIS, MCQA, etc., but these metrics don’t measure cost
  • Gates – Cost is only one metric, also have satisfaction, etc. that goes into rating; almost taken aback by the amount of oversight
    • There are significant contract oversight provisions, but the objective measures aren’t used in procurement; this is an aspect of rider 22
  • Gates – Maybe we need to make sure agency enforces measures they have?
    • They do enforce measures, but do not use objective metrics
  • Rose – Amerigroup created the model?
    • Amerigroup brought the rider to the table, discussions that Amerigroup started on cost led to the rider
  • Rose – Who created the baseline model?
    • Highlights cost performance index in written materials
  • Rose – Amerigroup is the only group supporting the rider out of everyone heard, what’s really going on?
    • We brought this discussion to have a conversation on cost, wanted to have a discussion on SB 7 which focused managed care on cost, quality, and satisfaction
  • Rose – I’m just trying to figure out the concern
    • The problem is that plans will lose money to factors like large populations, etc.; but system allows plans to consistently lose money year over year and remain in business
  • A Johnson – Do you have children’s hospitals?
    • CMC, Cook; we do not have Texas Children’s
  • A Johnson – So those hospitals may be treating children with increased needs; would you say your networks meet this
    • Our network meets all adequacy standards for TDI and HHSC, obligated to provide care for members; very competitive system in Houston
  • A Johnson – If you have a nonprofit hospital group and an MCO providing for medically fragile children – just clarifying on the rider, you’re the only one asking for it and it seems like potentially we’re comparing apples and oranges and this isn’t a fair comparison
    • Amerigroup has high risk members in the Houston market, excellent care is provided at the best value
  • A Johnson – If business & profit were our only marker, would likely not see care for certain medically fragile individuals
    • Don’t understand the question
  • Raney – If we’re concerned about price and cost increase, why are we looking at 1%/month, rates that look lower than private market
    • Certain market events will drive up cost
  • Raney – Seems like we’re complaining about costs going up when they aren’t really going up
    • Some plans lose money consistently
  • Raney – How do they stay in business?
    • Agree with this, can’t answer how they do
  • Howard – If costs were part of procurement, what would be different?
    • Costs as part of procurement is part of what legislature asked agency to do with SB 7
  • Howard – What would be different? What would the outcome be?
    • Looking at costs, projected there were about $1 billion in inefficiencies, saying that Medicaid could be much more efficient
  • Howard – What would I see that’s different?
    • High efficiency and high performing plans look at cost every day, based on data other plans have lost money consistently over time
  • Howard – You’ve pivoted every time I’ve asked; still trying to understand what I would see that is different?
    • What we are asking for is an index to be created for objective measures
  • Howard – I understand what you’re proposing, but you don’t seem to have been able to answer this question
    • You will see a program that is high-performing, drives innovation; when you start looking at costs, efficiencies will be shared with state through rebates and can be reinvested back into the community
    • Highlights efficiencies in Amerigroup
  • Howard – Not sure how dots connect between these efficiencies and other plans
    • If you reward contracts for efficient plans, over time the program will see increased efficiency overall
  • Capriglione – We want plans focused on cost to encourage plans that want to make people not even need complex care on the plan; e.g. cheaper to provide postpartum care for 12 months because in the long run it will save money
  • Capriglione – The other side is that while plans are trying to profitable, we also want to ensure that they help people
  • Rose – It sounds like Amerigroup is trying to get rid of the competition; you’re saying other plans are losing money, with these metrics these plans could be forced out
    • We are not looking to create a system where plans are exiting every year
  • Rose – You said Amerigroup brought the idea to look at costs, what will happen is these plans will be kicked off; if the only profitable group is Amerigroup, then they will be left
    • There are many plans in Texas that make money, over half do
    • Rider 22 creates even and equitable playing field & intends to support high performing health plans; we support diversity in the playing field

Public Testimony

Terry Carriker, Protect TX Fragile Kids

  • Should think about carving medically complex population apart from general
  • Cost containment and efficiency typically means reductions in services, delays for medically fragile population
  • MCOs have narrowed networks by cutting rates and driving out willing providers to create preferred lists
  • Would like a budget rider to study network adequacy for specialty providers, incl. DME
  • J Johnson – Have heard testimony all day long about access, but there’s a difference between primary care access and access to specialty care; there is a severe shortage of specialty care in Medicaid
    • There are pockets of shortage, in Austin we tend to do better
  • J Johnson – What is the process you have to go through to appeal a wrongful denial?
    • Can be arduous, band aids were passed last session; specialty providers are used to this unfortunately

Rebecca Galinsky, Protect TX Fragile Kids

  • Still discussing the same issues as when we started of adequacy and access
  • Legislation was passed during the 86th, but HHSC has refused to implement key components and tried to change intent; no desire on part of HHSC to monitor MCOs and hold them accountable
  • No floor or ceiling MCOs are required to maintain in contracting rates, medically complex kids require highly trained specialists and require significant time investment and support staff
  • Denial of care, denial of equipment, shrinking networks, etc. have hit families hard

Adrienne Trigg, Texas Medical Equipment Providers Association

  • Only 20% of membership is willing to take Medicaid due to admin burden and cost; 135 counties have no supplier, rate reimbursement has remained flat while costs have gone up
  • No floor or ceiling for Medicaid rates
  • Medically fragile kids are at risk during emergency situations, winter storm severely impacted families and back up systems can’t be budgeted for, supplies were difficult to obtain
  • Need to support SB 1207 from last session
  • Also hope that there would be no penalty for out-of-network care, could also empower families as parties to the contracts; recent class actions were dismissed as families were not party