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Below is the HillCo client report from the October 20 Institute for Health Care Quality and Efficiency Workgroup meeting.

The workgroup met today to discuss recommendations to be made to the full Board of Directors regarding serious and persistent mental illnesses (SPMI) and expanded access to care. The next Board of Director’s meeting will be on November 12, 2014 to vote on the recommendations the Board will submit to the Legislature.
 
Serious and Persistent Mental Illness

  • IHCQE partnered with The University of Texas’ School of Public Health to study SPMI in Medicaid
  • The research used various data sets from DSHS, HHSC and THCIC
  • The process has been much slower than expected due to the lack of standard requirements and procedures in the different agencies, the limited  information that is available explaining these requirements and procedures, and the limited staff available to provide assistance with the process
  • Due to the extended amount of time needed to obtain accurate data from all sources, there will not be specific recommendations made regarding SPMI in time for the Board’s final report to the Legislature
  • Although more work needs to be done identifying SPMI in the Medicaid population, the work done this far has identified some areas regarding data collection that would facilitate a smoother process
  • Based on the research conducted to this point, recommendations are:
    • To develop a data center for state-level administrative data sets with staff dedicated to obtaining and managing this data in a centralized location, while providing technical assistance to internal and external researchers and analysts
      • To develop a single process for access to these data including memoranda of understanding, business users’ agreements, data security evaluation and institutional review board approval
      • The center should collaborate with state and an academic institution with capacity to handle these functions and the resources to conduct statewide research projects to address cost and quality of care issues in Texas
  • Data that has been collected thus far shows that 10% of adults in Medicaid have a SPMI diagnosis
  • As part of SB 58 from the 83rd legislative session, MCOs are integrating behavioral health and primary care
    • MCOs must provide targeted case management services and mental health rehab services
    • MCOs primarily are contracting with local mental health authorities (LMHAs) to provide their members these services
  • The Workgroup discussed “rural care” and the challenge telepsychiatry is facing regarding prescribing Schedule IV drugs due to DEA regulations
  • A question was asked if Texas has the ability to expand Medicaid based on diagnosis
    • Under the 1115 waiver, Medicaid can be extended to additional risk groups
      • New Jersey has extended Medicaid to persons 150% of the FPL that aren’t otherwise eligible for Medicaid
  • Discussion of the difficulty of housing stability for individuals diagnosed with a SPMI

Expanded Access to Care
Discussion of the challenges to expanding access

  • Provider network adequacy
    • Health insurance coverage is not the same as access to care
    • Limited primary care providers, mental health providers and rural providers
  • Efficiency and cost concerns
    • Cost to state budget
    • Overutilization of low value services by newly covered
    • Impact on current insured
    • Increased demand contributes to higher prices, longer wait times
  • Sustainability of safety net
    • Medicaid currently provides care for our most vulnerable populations (low income children, disabled, and elderly)
    • Low reimbursement rates
  • Dependency
    • How to promote pathways to employment and privately financed insurance coverage
  • Lack of reliable information on impact of the ACA
    • Coverage trending up
    • Too early to reliably assess the impact on access, efficiency or quality
  • Considerations unique to Texas
    • Geographic size and diversity
    • Large population in poverty – 20% of state’s population lives at or below FPL
    • Large immigrant population
    • 1115 Medicaid Transformation Waiver
  • Current Law (83R, Senate Bill 7, SEC 6.09)
    • LIMITATION ON PROVISION OF MEDICAL ASSISTANCE. Under this Act, the Health and Human Services Commission may only provide medical assistance to a person who would have been otherwise eligible for medical assistance or for whom federal matching funds were available under the eligibility criteria for medical assistance in effect on December 31, 2013.

 
Funding concerns:

  • Health care needs of uninsured and under-insured Texans will persist with or without expansion
  • FQHC trust fund set to decrease by 70% in 2015
  • DSH payments scheduled to begin phase out in early FY 2016
    • Diminishing DSH funds may exacerbate the funding gap for uncompensated care
  • 1115 Waiver renewal
    • Renewed CMS scrutiny of IGT funds

 
Recommendations:

  • The legislature should grant the HHSC Executive Commissioner authority to negotiate an expanded care proposal with CMS to allow the state to draw down federal matching funds for expanding coverage
  • Expanded care proposal should meet the following requirements:
    • Serve the expansion population through private market alternatives
    • Strong accountability measures for Medicaid clients
    • Focus on population health outcomes
    • Authorization to extend new flexibilities to currently served population, where appropriate
    • Cost neutral to the state after accounting for all local and state and revenue changes
    • No expected increase in long term trend for per capita health care spending in Texas
    • Reform how care is delivered and reimbursed in Texas
  • The legislature should designate resources for an impartial study of key issues for expanded access to care – the study should coordinate with the Institute board and include at least one academic partner
    • The legislature should direct the appropriate state agencies to make any data reasonably necessary to conduct relevant analyses available to the research group under protocols that protect the privacy and security of personal information
  • The legislature should promote the Texas Network Access Improvement Program
  • Support Health Related Institutes to regionally pilot primary care systems
  • Enhance coordination and continuity of services.
  • Use faculty and other providers to serve as primary care providers under Medicaid managed care and practice to the fullest extent under their professional license
  • The legislature should direct HHSC to renew the 1115 Medicaid Transformation waiver
  • The legislature should direct HHSC to develop initiatives to target high-risk, high-cost individuals in Medicaid
  • Create incentives and technical assistance for patient centered medical homes
  • Provide flexibility to pay for evidence based social supports and other non-medical services that lower the total cost of care and improve patient outcomes

 
The legislature should work with stakeholders to transform the Texas healthcare workforce by:

  • Implementing graduate medical education funding changes
  • Establishing initiatives to increase in the number of bilingual health professionals
  • Encouraging the development of team-based models with significant authority granted to APRNs and NPs
  • Authorizing and increasing the number and roles of provider extenders (pharmacists, allied health, community health workers)
  • The legislature should authorize HHSC to improve Medicaid reimbursement
  • Supporting expansion of telemedicine and telemedicine reimbursement
  • Increasing reimbursement to primary care providers by maintaining the national health reform primary care rate increase
  • Researching and creating a solution for DSH funding issues.
  • Pursuing more flexibility for reimbursement of social support services.