Waiver Watch #3: "Hospital Transformation Waiver" details emerge; First Hearing on "SB 7 Waiver" held

The following is PART 3 of a "Waiver Watch" series contributed by Anne Dunkelberg, Center for Public Policy Priorities. Since my last Waiver Watch post:

  1. HHSC held a March meeting of their Executive Waiver Committee (EWC) working group for the Hospital waiver,
  2. The “Clinical Champion” working group has worked with HHSC to develop a draft menu of service/payment/delivery reforms, and
  3. The Legislature held a first hearing related to the other 1115, which we are calling the SB 7 waiver.

What follows are some high points, links, issues and questions that will need to be addressed:

1. The EWC Meeting:   

HHSC is meeting monthly with federal Medicaid officials at the Centers for Medicaid & Medicare Services (CMS).

Uncompensated Care: On March 1 HHSC sent a proposal to CMS for approval for how hospitals will be paid for uncompensated care and for the gap between Medicaid and Medicare payment rates—“the UC protocol”.  One challenge is figuring out how to cost out certain kinds of free care to the uninsured (doctors and pharmacy costs) that have not been part of the old “UPL” system that the waiver replaces.

Who Decides? It was re-emphasized that so-called “anchor” hospitals that serve as a central administrative hub for each Regional Healthcare Partnership (RHP) are not ‘Gatekeepers” who dole out the waiver funds or dictate the roles of other RHP partner hospitals and entities.

However, there was discussion that if there are more partners and activities looking for waiver funding than there are local public matching dollars available to fund those projects, that SOMEONE will have to decide how the funds will be allocated.  HHSC staff acknowledged that this was an important issue for them to establish some policy on, but again said that the anchor hospital should not be put in the position of making those calls.

2. "Clinical Champion" Work Group Puts Forth “DSRIP” Reform Menu: Clinical experts from across the state are helping HHSC develop a menu of required and optional reform elements for hospitals and RHPs to work and choose from.  Hospitals asked HHSC to get a draft out for review as early as possible, because input from beyond the working group members will be essential.

Members stated that the DSRIP pool funds should not be use to replace any current funding (no “supplantation”), but should be reserved for NEW investments.

Challenge: how to make DSRIP standards ambitious enough for the big urban systems, but still flexible enough to allow for the more modest capacities of rural hospitals.

Which Dollars are OK? A set of Legal principles for Intergovernmental Transfers from the HHSC Counsel is being reviewed by HHSC commissioner and should be share “soon”.

Who Does What? If the County Hospital is in the RHP, and anti-obesity investments are being funded, does the county hire the contractor to build a walking trail, or does the hospital?

County MHMR Centers/Authorities:  There is great interest in whether and how these entities (which typically have public funds that might be available for match), will be partners in the RHPs.  HHSC has acknowledged that they need to clarify policy on this sooner rather than later.

Be sure to check here for HHSC updates:  http://www.hhsc.state.tx.us/1115-waiver.shtml

3. The SB7 Waiver: The 2011 Legislature also authorized a different 1115 waiver (article 13 of SB 7, special session), directing HHSC to seek exemption from federal minimum Medicaid eligibility, benefits, and co-pay standards.  (Confused?  Refer to our Waiver Watch #1: What’s up with Medicaid Waivers? Why Should I Care, and How to Keep Up? )

SB 7 created a special House-Senate committee for this project, and their first hearing was on 2/29.  You can watch the whole thing here, or see a list of who testified, and also check out agency presentations made at this hearing by HHSC and DADS.

HHSC emphasized that federal Medicaid  law does place some limits on what can be “waived” in federal law; that is, exceptions are not allowed to some federal Medicaid standards.  Both agencies indicated state and federal interest in new pilots to merge Medicaid and Medicare care management for seniors and Texans with disabilities who are on both programs , that is the “dual eligibles.”

Agencies and lawmakers greatest interest seemed to be in program changes for seniors and Texans with disabilities.  Agency officials indicated that making changes to the non-elderly Medicaid program would be more realistic after 2014, assuming implementation of the Affordable Care Act (ACA- health reform), which will make many of  the parents of the 2.6 million Texas children in Medicaid eligible for coverage for the first time.

CPPP testimony focused on the need for Texas and the US to reform health care across the entire system, not just Medicaid, because xix costs have actually grown more slowly than Medicare or the private sector.  The graphic below shows how the US spends dramatically more than any other industrialized nation  per citizen – even though we leave millions without access to care and have poorer health indicators than average. What’s Next?  My next "Waiver Watch" post will update you on draft documents and proposed policies for the Hospital waiver that HHSC has made public.  Stay tuned!