The House Committee on Human Services met on April 24 to take up the following interim charge:

  • Review the history of Medicaid Managed Care in Texas and determine the impact managed care has had on the quality and cost of care.
  • Review initiatives that managed care organizations (MCOs) have implemented to improve quality of care and determine whether MCOs have improved coordination of care.
  • Review the Health and Human Services Commission’s (HHSC) oversight of MCOs, and make recommendations for any needed improvement.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. This report is not a verbatim transcript of the hearing; it 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

 

Opening Comments

  • Chair Raymond – Looking at this as similar to a Sunset review
  • Rep. Rose – Received witness information for this hearing at the last minute, difficult to prepare
  • Raymond – Having another hearing on May 9 in the capitol, and another on August 29 in Hidalgo County, also anticipating a late September hearing on HHSC riders

 

Charles Smith, Health and Human Services Commission

  • Chair Raymond – Before you begin the overview, would be good for you to update us on contracting at HHSC
    • Contracting issues did not affect client services delivered
    • Scoring errors in procurement for South Texas contracts were significant, effective contracting/procurement is essential to HHSC & changes are underway
    • Will not resume procurement until I’m sure we are ready
    • Realigned QAT, now reports to Interim Deputy Commissioner for contracting
    • Secured the data entry on the evaluation tool
    • Bringing on a quality control team to look at evaluation numbers, in process of re-training and adjusting staff
    • Also conducting an audit of the entire procurement process, bringing on a consultant
    • Looking into shifting away from Excel spreadsheets for evaluation data entry, hoping to begin in late Summer
    • HHSC had processes in place, but staff did not follow
    • There is a vast difference in procurement problems and contract oversight issues that will be discussed today; Contract oversight is a vastly different issue
  • Raymond – We’ve created such a large agency, can be difficult to manage all of the functions; I don’t believe that anything criminal has happened
  • Raymond – Need to recognize that agency is too large to be perfect
  • Rep. Frank – How big did you say the evaluation tool data sheet was? And what was the root cause of the failure?
    • The spreadsheet has 200 worksheets, very intricate
    • Have asked questions about the specifics and have not received satisfactory answers
    • Had problems with portions of the spreadsheet being pasted over sections with complex formulas
    • Also saw issues where procedures requiring communication with purchasers were not followed; Purchasers did not follow appropriate scoring process and failed to do due diligence in locating documents
    • Problems largely due to human error
  • Raymond – Might need to make sure everyone is put on notice, there are a lot of contracts out there
  • Frank – Part of cause might also be the large amount of data, more data means more opportunity for error
    • Understood, exploring CAPPS functionality
  • Rep. Minjarez – Did staff willfully disregard these processes or was is a lack of training, something else?
    • Willful disregard in my opinion, which is why the staff responsible are no longer at HHSC
  • Link to HHSC presentation on contract oversight
  • Smith highlights the budget pie chart on pg 2
  • Will look into utilization reviews, will look into bending cost curve to help avoid costly care for conditions like diabetes; These things can be avoided if we look at the preventative factors for each individual
  • Raymond – Began thinking of expectant mothers with type 2 diabetes, condition is very costly; Working to prevent this could also lead to healthier outcomes for children
  • Majority of Medicaid cost growth is due to caseload growth, roughly 35% increase from 2009 to 2016
  • However, total per capita cost growth is 5.8% over this period while US overall healthcare spending has grown 30.4%; indicative that Texas Medicaid is working to decrease costs
  • Frank – Guessing that increase in population is responsible for some of caseload growth, what is the rest from
    • We attribute the largest portion to population growth, also legislative changes that have added programs
    • Stephanie Muth, HHSC – Part of the difference is also due to where the population is growing in Texas
  • Rep. Klick – Would some of the increase be from ACA coming into effect and some eligible people now enrolling?
    • Smith, HHSC – Yes
    • Dual demonstration, ceiling changes, etc. tied into this
  • Rep. Klick – Some of those on CHIP were bumped over into ACA as well
  • Raymond – So the ACA led to expansion of Medicaid in Texas

 

Stephanie Muth, Health and Human Services Commission

  • Medicaid program has kept annual cost growth down, have seen these positive metrics coupled with a reduction in preventable admissions and readmissions
  • HEDIS measures have also grown 5-10% from 2013 to 2016
  • Gives overview of HHSC health plan report cards, allows clients to give feedback
  • Frank – Do you know how similar the data we collect is to the commercial market?
    • Staff is looking into this alongside ERS and TRS, can return with specific information
  • Frank – Measuring ourselves against ourselves doesn’t seem the best
    • HEDIS measures compare across public and private industry, hospitals have specialized tools to help compare themselves as well
  • Purpose of report cards is to give consumers an informed choice
  • Will likely hear about work down on quality and alternative payment models from health plans today
  • Medicaid is far out ahead of commercial market on alternative payment models, require 25% of payments linked to alternative payment models with 10% at-risk
  • Pay for quality programs exist on medical and dental sides, percentage of capitation is at-risk in these programs
  • Highlights pg 8 chart giving an overview of growth of managed care model
  • Managing >40 contracts currently, pg 9 gives an overview of MCO numbers
  • Raymond – Why do we only have two MCOs for dental programs?
    • 2 is the minimum, had 3 originally, but only 2 began services
  • Raymond – There is dental contracting coming up and requires at least 2?
    • There is and yes
  • Raymond – Does the CHIP program contract have the at least 2 requirement as well, it has 17 MCOs?
    • That is at least 2 per service area, population size in some service areas necessitates more than 2
  • HHSC focuses on the lifecycle of a contracting, has a robust readiness review process for contracts and a lot of effort goes into spinning up contracts
  • Biggest change in moving to managed care is in oversight and administration of Medicaid; every piece of HHSC is involved in contract management and oversight
  • HHSC sets standards for reporting financial data, sets cap on administrative expenses, and there is a profit-sharing percentage for profits above a certain amount
  • Raymond – Can you speak to recent news articles referring to bonuses paid on certain contracts?
    • SAO looked at the Superior contract and had a different interpretation of the affiliate language
    • HHSC agreed that language needed to be clarified
    • Smith, HHSC – Important distinction, HHSC is not changing language to fit the practice, but clarifying existing practice
    • In this case, the entity was working with other affiliates within their organization & under the same company structure
    • Muth, HHSC – Intent in contract is not to dictate how compensation should occur for employees within a private company, rather HHSC focuses on the administrative cap and overall profits
  • Raymond – Do you feel that the SAO understands that now?
    • Smith, HHSC – Cannot respond for them, have done everything possible to make them understand & will work to make this clear
  • Frank – You will make clear that bonuses are allowed or what?
    • We will make clear that this situation doesn’t trigger the affiliate restriction and that bonuses are allowed within the same organization
  • Frank – Would hate to have a situation where we don’t allow people to pay for performance
  • Pg 12 gives an overview of HHSC contract oversight, contracts are managed and overseen by specialized teams, audits look deeply into contracts and MCOs
  • If audits find any issues, HHSC will go back and adjust up or down on rebates
  • SAO audits can occur even before HHSC internal audits due to timelines, but internal audits did not have same affiliate interpretation as SAO
  • Pg 13 gives overview of administrative cap and profit sharing
  • Raymond – Do you have a breakdown on individual MCOs and where they fall on the profit scale?
    • Muth, HHSC Can provide this, most MCOs are below the 3% administrative expenses cap
  • In the last 7 months, HHSC has implemented a new review process for health plans where HHSC conducts an onsite biennial review of PA policy, contracting staff, etc.
  • Also have 3rd party biennial performance audits that look at self-reported MCO data and operational processes
  • Raymond – PA is a big issue, we don’t want a repeat of the TMHP problems; Have been made aware of issues where claims aren’t being paid even with valid PA and evaluation and proof that information was submitted by providers
  • Raymond – Need to continue working on the PA portion to check this for validity & make sure HHSC is involved as an agency
    • Have some asks coming up related to this
    • Certainly one of the primary issues raised with provider groups is the claims processing issue where proper documentation is submitted & claims are denied
    • HHSC does handle individual claims, but can be better at look at trending and analysis of complaints
  • Raymond – OIG should be able to assist with this, if it turns out they are not properly paying claims it’s either waste or fraud
  • Highlights pg 16 overview of Utilization Reviews conducted by nurses, can only do a small number of these, but have discussed with OIG how these functions overlap
  • Looking at shifting staff where available, legislature budgeted for 20 UR teams and HHSC is looking at using existing resources to fill these spots
  • HHSC has many remedies available: plans of action, corrective action plan, liquidated damages, suspension of default enrollment, and contract termination
  • Raymond – Can you speak to the liquidated damages?
    • Pg 18 highlights LDs that have been assessed over time, HHSC is seeing a moderate increase in assessment and collection of LDs
  • Raymond – Have discussed with other members that the LDs collected are a very small percentage, which means you are either very successful or not assessing enough
    • Smith, HHSC – Correct, HHSC is trying to do a better job of oversight
    • Not intending on having a quota for LDs or anything similar, but looking to work with and train contractors and hold them and our staff accountable
  • Raymond – I think the MCOs just need to feel comfortable that you’re serious
    • Muth, HHSC – Consistency and predictability is key for us
  • HHSC is recommending several next steps:
    • Maximize current contract resources – Implement an Annual Review of MCO deliverables to identify deliverables that no longer contribute to evaluation of outcomes and performance
    • Consider service delivery area reconfiguration for future procurements – Engage stakeholders in development of potential new configurations
    • Utilization review expansion – Seek resources to expand STAR+PLUS utilization reviews and include reviews for STAR Health and STAR Kids programs
  • HHSC is not looking to re-do service areas currently, but looking to issue an RFI for providers, plans, consumers, etc. to give input on how they would like to see them changed
  • Raymond – Do you have the authority to change these service areas?
    • Yes
  • Still working on exceptional items, but UR teams and UR expansion is a focus area
  • Smith, HHSC – Still moving into managed care and away from fee-for-service, looking to shift some of these resources and process is maturing
  • Also looking into LAR needs regarding staff and IT
  • MCOs are good partners, will be working with them to figure out how to better incentivize the system

 

David Harmon, Superior HealthPlan

  • Provides background info on his work for children in need in Florida and transition to Texas to oversee Superior’s managed care program
  • One of our first specific directives was to better manage psychotropic drugs for children in foster care, have seen a 42% reduction in prescribing and other metrics since 2005
  • Raymond – Can you break this down somewhat in terms of age? Have had age restriction legislation in the past
    • Most prescribing is in older children, certainly look at all children
  • Raymond – Asking if use has been reduced most in younger children?
    • Can get this info, was much smaller denominator for younger children versus older children and effect could look very large
  • Superior’s process is much less burdensome than Florida’s which required court order for prescription; good metrics tide to efficient process
  • Also developed an electronic health passport, working constantly with consumers to improve functionality
  • Worked together with HHSC to develop a program to give immediate eligibility for children entering the system
  • Superior is statewide, mitigates portability issues when children move regions
  • STAR+PLUS allows Superior to be flexible and innovative; allowed for trauma training programs and crisis residential services programs
  • Foster care Centers of Excellence allow access to quality providers, providers must meet a variety of quality metrics; currently 3 in the state
  • Texas’ managed care structure is very supportive of Superior
  • Raymond – Would like to hear aspects that Texas could do better as well
  • Rep. Keough – Can you tell us a bit more about the trauma programs and how you implemented that?
    • Use national curricula to train providers on trauma-focused cognitive behavioral therapy, were able to get a lot of providers trained in a short period of time
    • Need to look at other modalities as well for those who are not receptive to CBT
  • Rep. Swanson – How has your rate of providers dropping out changed over the years?
    • STAR health program began in 2008, it’s our most popular program and more providers have signed up than in our other Medicaid program
    • STAR was confusing as the “STAR” name is in every health program, but have not seen a huge dropout
  • Swanson – Do you think this has improved or did I have a really bad experience?
    • Would think this is due to transition from fee-for-service to managed care, but looking at our numbers we have not had significant turnover
    • Service coordinators exist to help out where there is difficulty

 

Frank Dominguez, El Paso Health

  • El Paso has a large population to serve and constantly working to improve service for members
  • Have worked to build relationships with providers to facilitate needed services
  • Have worked with providers within the community to reduce preventable ER visits; had a group of providers approach El Paso Health and offer to help by staying open after hours
  • El Paso Health then created an incentive program to help staff night clinics, allows members to receive quick services from local doctors & helps avoid costs from ER visits
  • Also responded to issues with preventative medicine and spun up programs to help distribute these medications
  • HEDIS measures reflect the positive progress of El Paso Health
  • Would ask that legislature look at each community individually and respond to unique needs
  • Accountability is also a key need for providers and MCOs
  • Raymond – What can be done to improve quality across the state?
    • I sit down with providers and member forums to help understand what their needs are, need to focus on providers as partners
  • Raymond – Are you getting more providers or experiencing turn over?
    • Have a larger network currently, we have two check runs a week to keep communication open; also work to ensure payments are not obstructed
    • Our philosophy is to not pass on regulatory complexity to providers and consumers
  • Raymond – Would hope to do this for the whole system, will likely hear more of this from providers at May 9 hearing
  • Frank – What is the legislature and state doing to make your job easier and harder?
    • Reporting process is very burdensome

 

Don Langer, UnitedHealthcare

  • Culture is an important part of running an efficient and effective program
  • Presents video on job training & pathway partnership with Fort Bend ISD
  • Also have new programs within STAR Kids; school liaison program assists students with health struggles & STAR Kids transition specialists program assists students aging into STAR+PLUS
  • These programs were not available in the fee-for-service program

 

Mary Dale Peterson, Driscoll Health Plan

  • Provides an overview of children’s dental services program improvements through Driscoll, began a program and encouraged providers to adopt; eventually became a Medicaid benefit and led to drastic reduction in ER visits
  • Driscoll has also made large strides in decreasing pre-term births and mortality
  • Have seen diabetes rates of up to 40% in the Rio Grande Valley, can be difficult to manage; Driscoll tracks this and other conditions like Zyka virus
  • Raymond – Is there anything that we can do on pre-term birth risk?
    • Maternal Mortality Task Force has been very helpful
    • Numbers have been revised and corrected, but we are still twice as bad as some other states and opioid overdose deaths are very concerning

 

Tisch Scott, Amerigroup

  • Presents video on care coordination challenges faced by members & assistance provided by Amerigroup staff
  • Managed care provides cost effective care and better outcomes, fee-for-service limits cost control and care coordination
  • Managed care also allows for value-added benefits like housing assistance and specialized programs focusing on specific conditions
  • Frank – Our question is what we do to incentivize corporations and members?
    • Amerigroup runs a rewards card program to incentivize members to seek out preventative care services
  • Frank – Asking all MCOs, how long on average do you keep a patient? Have more reason to incentivize preventative care if patients stay with you
    • CHIP has been pretty consistent, STAR sees pregnant moms rolling off and that is why we see a change
  • Frank – So you literally give them a reward system
    • Exactly
    • Peterson, Driscoll – We will need to attack this problem on multiple fronts to create healthy habits, challenging for pregnant women who might only be under care for 5 months
  • Raymond – “Don’t mess with Texas” campaign helped with littering, we need to start healthcare messaging from the day children start school
    • Actually has roots in utero, a mother’s healthy diet during pregnancy predisposes children for better outcomes
  • Amerigroup handles members from all products except foster care, one of the first MCOs
  • Amerigroup focuses on integration of differing categories of care
  • Currently 40% of payments are going to alternative payment methods and 50% of member base is aligned
  • Metrics show 90% of membership is satisfied, have seen an 18% decrease in ER cost over the last year
  • Maintain service coordinators for IDD members, one of the challenges is that there are no bridge services between inpatient and outpatient & service coordinators assist with this
  • Have held stakeholder sessions that led to a coordinated care clinic (CareMore Care Center) in Tarrant County, provides physician, behavioral health, and disease management with local partners
  • Also running enhanced quality programs for nursing facilities and attendants, opiate programs rolling out, telehealth to communities with access to care issues, service coordination technologies

 

Darnell Dent, FirstCare Health Plans

  • Raymond – How do you feel about your provider network? How many counties do you have?
    • We have 143 Counties, there are spots within the state where we don’t have enough providers, particularly in behavioral health
  • Raymond – Aside from behavioral health, what is the main reason?
    • A lot of this is a matter of distance or geography
  • Klick – Aren’t many of your counties medically underserved as well?
    • Yes
  • March of Dimes has rated Texas ‘D’ for premature births, premature births are a significant cost driver; Expecting the Best program was created in 2008 to respond & provides access to Makena 17P which can help increase length of pregnancy and reduce pre-term births
  • Fee-for-service complicated provisions of these types of services & there is a high rate of drop off for mothers needing this treatment
  • Under managed care, can assess quickly, provide extensive case management services, coordinate getting order for 17P, and provide homecare to administer needed injection
  • Also staff a 24-hour information hotline for mothers
  • FirstCare has seen good outcomes based on this effort, reduced costs for hospitalizations, etc.
  • Shares story of a good outcome for an expectant mother under FirstCare

 

Anne Rote, Molina Healthcare, Texas Association of Health Plans

  • Nursing facility program carve-in in 2015 was a drastic situation, state was rolling out demonstration programs at the same time
  • Best part of the carve-in was the collaboration between MCOs, HHSC, and providers; Molina’s biggest takeaway was to set up nursing facilities as a specific department and hire personnel with nursing facility background
  • Led to shared experience and opened communication between new providers
  • Provider Advisory Committee also helped establish relationships, respond to concerns, and develop training materials
  • Also implemented a pay-for-quality program, $10/member/month was paid to nursing facilities for each of 7 quality metrics; $2.5 million to date, saw a 21% decreased hospital admission rate at facilities with good metrics
  • Raymond – IS there anything you
    • Thanks legislature for helping Molina to incent providers by allowing 95% of fee schedule
    • It is a challenge as every MCO has as broad a network as possible
  • Raymond – There are some folks trying to argue that you are intentionally trying to have fewer providers
    • Have not heard this in general, but have heard individual stories of access challenges
    • Would like to see more participation in the community
  • Rose – Thanks Ms. Rote for her work in taking care of constituents in HD 110

 

Crystal Brown, Protect TX Fragile Kids

  • Shares experience of medically fragile child, nursing is extremely important
  • Have had no member portal access, have not had any explanation of benefits, since STAR Kids rollout we have not gotten mail notification of denials or approvals
  • Raymond – Do you get email?
    • We get nothing
    • CVS in Texas overbilled our MDCP budget for Superior without the nursing hours being filled, submitted a formal complaint to the OIG on Monday
    • Superior personnel backed out of meeting after this was discovered
  • United is not sitting at negotiation with Driscoll in Corpus Christi
  • HHSC is aware of all of these issues, portal access, CVS overbilling, etc.
  • Raymond – May 9 hearing is designed for members with issues, would like you to get as many names and examples possible before the May 9 hearing for more extensive testimony
  • Child Neurology in Central Texas will drop BlueCross if they don’t start paying, all pediatric neurologists at Dell Children’s are part of this

 

Hannah Mehta, Protect TX Fragile Kids

  • Transition to managed care has caused a harmful disruption to fragile children’s care, life-threatening delays, access issues, etc. are heard of every day
  • Vital services are being denied and delayed regularly, model does not fit medically fragile patient base
  • HHSC predominantly ignores experience of members, complaints are frequently closed without investigation or resolution
  • Providers are forced to wait a minimum of 30 days for an MCO to respond before going to HHSC
  • HHSC’s reports to the legislature regarding complaints are very inaccurate
  • Families who have relied on MDCP program for years are suddenly being denied eligibility, including children on life support; has been raised with HHSC since April 2017
  • Provider assessments can limit and delay care
  • Service Coordinator turnover rates do not allow them to do their stated jobs, caseloads are massive
  • MCOs are also requiring caseworkers to attend PCP appointments, burdensome
  • MCOs are using therapy rate cuts as an excuse to deny services; treating long-term care as short-term acute events
  • Raymond – Not the first time I’m hearing this, would like to hear responses from HHSC and MCOs at the May 9 hearing after testimony from members
  • Raymond – We need to take care of this if it is 4 or 5 children, but need to look into the bigger problem if it exists

Nathan Thomas, Self

  • Shares personal experience in caring for medically fragile son, MDCP was initially very helpful under the fee-for-service, but son was not allowed back on MDCP after the family left the state and returned
  • Without MDCP, care has massively regressed; MDCP care is pro-life

 

Jamie Dudensing, Texas Association of Health Plans

  • Plans are very committed to providing high-quality affordable health care
  • Metrics show extensive Medicaid use; 1/5 Texans is on Medicaid, 1/3 Texans with disabilities is on Medicaid, etc.
  • Plans help connect Texans to care, no entities providing case management before health insurance model was adopted
  • Fee-for-service did not offer access to things like pre-natal care, no accountability for network adequacy, no coordination, etc.
  • Managed care also brought a focus on health & wellness, preventative care; many of these programs are not state funded and are examples of health plans re-investing profits into the health care system
  • Managed care also allows for expanded non-medical wellness services
  • Expansion of managed care under STAR+PLUS and cost savings resulted allowed for an elimination of waitlists; would need to move back to waitlists without managed care
  • Frank – Waiting lists for what?
    • Community-based Alternatives program had 60,000 member list, was made an entitlement under managed care
  • Frank – Thinking about waitlists for special needs adults and other areas, trying to think on taking savings from one area and moving it elsewhere
  • Managed care created budget certainty, shifted risk burden from state to managed care, expanded health and wellness program, kept cost growth low, caps administrative costs
  • Raymond – Do you care to comment on the 30.4% spending growth nationally?
    • Health care trends have been slowing down the last 3-4 years, drug costs spiked, but also have begun to come down
  •  Roughly 90% of every dollar is spent on health care
  • Regarding the managed care contract, it is 470 pgs with 8,500 deliverables, with transparent online access
  • Frank – Trying to understand 8,500 deliverables, can you give me some examples?
    • Could be network adequacy requirements, service coordination status and visits, complaint handling, PA policy, etc.
  • Frank – I appreciate thoroughness, but this seems like it would be hard to oversee
    • HHSC has spoken before and has committed to modernizing the contracting process & will make sure deliverables are important to Texas
  • Details of performance and funding through Financial Statistical Reports is also posted online
  • HHSC also maintains an External Quality Review Organization to monitor MCO quality, these reports are also online
  • Metrics adjust based on quality of plans, 3% of premiums are at risk for cheating quality metrics
  • Frank – How many quality metrics can you get dinged for?
    • Right now, it’s the HEDIS measures, depends on the product line
    • Also on the PPUs
  • Newest initiative is value-based contracting, trying to move away from paying for service to paying for quality, HHSC is currently working on contracting for this
  • Most plans are already participating in these type of measures (Nursing Home Incentive program under Molina, etc.)
  • Quality metrics are also being incorporated under the 1115 waiver and MCOs are working these into provider relationships
  • Raymond – How many states have Medicaid managed care?
    • Don’t know exactly, but it is the majority
  • Raymond – Are there 3 or 4 states viewed as the best performing?
    • There isn’t really a report card or ranking system built around this
  • Raymond – What are some of the other states doing that we are not?
    • Last 10 years, have been invited by other states because they want to copy us
  • Raymond – Have you gone to conferences and seem some example of a best practices?
    • Yes, some of the information is how best to move into value-based purchasing
    • You don’t tend to pull out whole systems from other states
    • State Medicaid Director conference is probably the most informative
  • Raymond – Would like to have some testimony on this portion prepared for the May 9 hearing, perhaps an area that needs a study on performance/cost
    • Worthwhile, but cost metrics are very good, should focus on larger systemic problems facing managed care
  • Frank – Could you provide some of the long-term health outcomes that are improving?
    • I have quite a few of them ready, looking mostly to HEDIS measures, ER visits, preventable events, provider increases, etc.
  • Frank – We have no incentives on the user for wellness issues
    • This is always a hard question under the Medicaid program
  • Value-based payment initiatives need some caution, however, providers are at different levels of readiness and could push providers out unnecessarily
  • Recommendations
    • Important to establish goals and vision of Medicaid program, would help align program
    • Full transition to health insurance system will reduce confusion and complexity
    • Would also be helpful to name the health care system in Texas
    • Important to ensure transparency in the program
    • Interested in moving to real-time dashboard for metrics and quality outcomes
    • Contract management should be modernized, deliverable matrix should be up-to-date and hosted online in one place
    • Maintain stability in the program and address procurement issues, should thoroughly study potentially large changes like price bidding
    • Support quality, innovation, and flexibility; Medicaid is moving towards quality-based contracting & innovation and flexible approaches are important
  • Raymond – One of the things that I hear is “can we do more?” to not have great differences in PAs for members
    • Negative consequence of this would be a loss of flexibility in the program
    • Differs by region many times because the situation is different, many are for safety purposes
  • Raymond and Dudensing discuss member complaints and concurrent submission to differing organizations
  • Raymond – Would be useful to have complaints sent to MCOs also be automatically sent to OIG and HHSC, would provide a system of checks and balance
    • Muth, HHSC – Some of PA is related to best practices, but in some areas it also related to reducing fraud and abuse
    • Dudensing, TAHP – One example is incontinent care supplies and doctors who were not providing care
  • Raymond – Important considerations is who is to blame; you can blame doctors, but someone was signing off on these as if services were being delivered
    • Good conversation to look at these pieces, but standardizing all of this would move back to fee-for-service mindset and eliminate innovation and flexibility
  • Raymond – There has to be a way for members to come together and agree to some things, not necessarily the state telling people what to do
    • I think you would be surprised as to what PAs are used for
  • Raymond – Would they be used for the medically fragile children who were present earlier?
    • Therapy is an area with a PA, but I think this was the only area I heard earlier
  • Raymond – I will ask them to get very specific on the May 9 hearing, I think it goes beyond therapy
    • Some of these people may get denied by their employer insurance and that denial needs to appear in Medicaid systems before services can wrap around; this does need to be looked at

 

Kay Ghahremani, Texas Association of Community Health Plans

  • Provides background information on community health plans and their role in the health care system
  • All 12 community health plans are also part of TAHP, they share the same PBM, and shared management strategies are in place such as Pharmacy & Therapeutics Committee
  • Community health plans are also involved in marketplace and employer health coverage
  • Medicaid program in Texas is advanced, has been providing care to children with complex needs for longer than other states; Though there is a limitation on population served, no Medicaid expansion, etc.
  • Community health plan model is used nationally and has been very effective in many states
  • Gives overview of Texas companies:
  • Cautions that there is a statutory protection for hospital-sponsored community plans, removing this protection would not only affect the plan, but also the hospital system
  • Frank – So there are 21 MCOs, 12 are community, all are in TAHP, and 12 in TACHP
    • 19 total with 11 community plans doing Medicaid now
  • Frank – From a marketshare standpoint it is 2 million involved in community plans, so roughly half?
    • Around 1.6 million
    • Dudensing – It is also a product line consideration, differing numbers are involved in different programs
    • There is also a large amount of competition, plan compete for the contract, providers, and member choice
  • Frank – So there are 19 in the state, but in some places there are only 2 to choose from?
    • Depends on locale, Houston is large and has 5
    • Ghahremani – National plans are larger as they are the only ones doing STAR+PLUS and they are operating in more service areas
  • Community plans maintain partnerships for physicians within the hospital systems, provides a vast knowledge base
  • Hospital systems and MCOs are natural environments for experimenting with alternative payment methods
  • Community health plans have deep roots and partner with many community programs like housing authorities, etc., also national entities like the EPA

 

John Hawkins, Texas Hospital Association

  • Regarding 1115 waiver, UC and DSH pools are funded from Medicaid savings
  • New waiver is seeing some funds pulled out of the UC pool, 2-year transition & working closely with HHSC to get this implemented
  • Budget neutrality portions and targeted rate increases, should help
  • Would continue to support oversight improvements, should be focused more on outcomes and hold plans accountable for those outcomes
  • Would caution that oversight duties should be clarified between agencies, can cause confusion within this overlap
  • Need to look at what is happening to DSRIP projects, particularly in mental health
  • There is a lot going on in the value-based purchasing space, need to make sure efforts are coordinated
  • Raymond – Is the private market doing significantly more on this front?
    • Not necessarily, continuing to build on our base will be good
  • Big cost drivers are inappropriate ER usage, readmission, and behavioral health screening

 

Patsy Tschudy, Cantex Continuing Care

  • Managed care transition has been a huge issue, particularly in the nursing home space; will require a lot of effort to correct some issues
  • Have been working with many entities like HHSC to work on reduction of anti-psychotic use and avoiding hospitalizations
  • There have been a lot of initiatives through CMS and the QAPI programs, effort of the providers and not necessarily the MCOs
  • 5 MCOs work with nursing homes in Texas, have seen continual delay in rolling out quality incentive programs; likely has resulted in missed opportunities & hoping HHSC is looking at this closely
  • Were promised service coordination when we transitioned to managed care, but it has not been realized as it could have been; MCOs should expand role and give coordinator ability to execute physician orders at bedsides without having to move through red tape
  • Managed care saw accounts receivable cost go up 5 times, still triple compared to where it was before managed care
  • Claims continue to be overpaid, underpaid, etc.
  • Managed care has meant consistent delays in processing claims, challenges in obtaining authorizations for care, providers needing to dedicate unpaid resources to managing MCOs
  • Raymond – Looks like there is a $114 million difference for you between February of last year and February of this year, were you being overpaid before this; are claims not being paid?
    • Took as some time to get data implemented on all providers web portals, claims person needs to go through several different online resources to submit a clean claim
    • Shouldn’t be so challenging to submit a claim and get it paid first time
  • Raymond – This is an example of this not working as they should; our metrics may be improved, but providers are still serving a population in need
    • Would like to see service coordinators facilitate these types of issues, but have been told they are not trained for this

 

Ryan Van Ramshorst, Texas Medical Association, Texas Pediatric Society

  • Managed care is seedbed for innovative practices, cost-effective
  • Medicaid is 95% managed care and provides opportunities in value-based purchasing; there are chances for HHSC to coordinate MCOs and providers to focus on innovative treatments
  • Care coordination is not always working as planned, members are not always familiar with care coordinators
  • However, some MCOs are also embedding care coordinators into practices given high enough volume
  • Effective models are out there, but not all MCOs are exploring these things
  • Only about 40% of TX physicians are willing to accept new Medicaid patients, number one reason is lack of proper payment; Medicaid rates are often only 60% of Medicare and far below commercial rates
  • Administrative burden and red tape is also very prevalent, PA policies can very widely between MCOs (i.e. one allowing a PA for 3 therapies with one from, and one requiring 3 forms)
  • Clinic edits are also not obvious and vary between plans, even drugs on the PDL may not be available without a PA
  • Frank – There seems to be some streamlining that could be done regarding forms, etc.?
    • Dudensing, TAHP – There are some things, standard provider credentialing forms, etc.
    • Have been meeting with providers to discover some of these issues, could be beneficial to go through a similar exercise on PAs to find ways to make it simpler but maintain flexibility

 

Will Francis, National Association of Social Workers

  • Have concerns from the provider perspective, many providers want to work in Medicaid, but have run into issues with MCOs and HHSC is not very helpful
  • Would love to see an independent health plan monitor at HHSC
  • Providers are held to much higher standards than MCOs, providers can have payments recouped for minor errors whereas MCOs often receive no punitive action
  • Would like to see managed care and TDI rules align
  • Would like to see an independent provider ombudsman
  • Value-based payment options are fantastic, but reporting was a large challenge for behavioral health providers in Medicare

 

Columba Wilson, Self

  • Shares personal experience of trouble finding care for grandson
  • Rose – Asks Wilson to meet with her privately to discuss what she would like help with

 

Danny Saenz, Self

  • Shares personal story of being unable to find attendants; rate cuts and low wages make this difficult

 

Closing Comments

  • Raymond – Will continue to build on testimony on May 9