Featured: Rep. Richard Peña Raymond, D-Laredo, Chairman of the Texas House of Representatives Committee on Human Services, in December 2017 receiving a Texas Medical Association Patient Protection Award from then-TMA President Carlos Cárdenas, MD, the CEO and Chairman of the Board at Doctors Hospital at Renaissance (DHR Health).
Photograph Courtesy TEXAS MEDICAL ASSOCIATION
Doctors Hospital at Renaissance (DHR Health) helping legislative efforts to improve Texas Medicaid, which provides health insurance to one out of four Valley residents
Proposals by Doctors Hospital at Renaissance (DHR Health) designed to bring major improvements to the state’s Medicaid program – which provides free health insurance coverage to low-income adults, their children, and people with certain disabilities, including 25 percent of Valley residents – were presented to key state lawmakers on Wednesday, August 28, 2018 at the Edinburg Conference Center at Renaissance.
The Texas House of Representatives Committee on Human Services, whose chairman is Rep. Richard Raymond, D-Laredo, was in town as part of its efforts to review the history and future roll-out of Medicaid Managed Care in Texas. Among its duties, the committee is examining the impact managed care has had on the quality and cost of health care throughout the state, and is reviewing initiatives that managed care organizations have implemented to improve the quality and care.
Joining Raymond for the public hearing were fellow committee members Rep. James Frank, R-Wichita Falls, who serves as Vice Chair of the legislative panel, along with Rep. Stephanie Klick, R-Dallas, Rep. Rick Miller, R-Sugar Land, and Rep. Toni Rose, D-Dallas.
Sen. Juan “Chuy” Hinojosa, D-McAllen, Rep. R.D. “Bobby” Guerra, D-McAllen, and Rep. Óscar Longoria, D-La Joya, also dropped by during the state legislative hearing.
Medicaid is the state and federal cooperative venture that provides medical coverage to eligible needy persons. The purpose of Medicaid in Texas is to improve the health of people in Texas who might otherwise go without medical care for themselves and their children, according to benefits.gov, the official benefits website of the US government.
Medicaid in Texas is administered by a state agency, the Texas Health and Human Services Commission (HHSC), which contracts with private firms known as managed care organizations (MCOs). MCOs are licensed by another state agency, the Texas Department of Insurance. HHSC pays each MCO a monthly amount to coordinate health services for Medicaid clients enrolled in those MCOs’ respective health plan.
This arrangement is known as the Medicaid Managed Care System in Texas.
Since one of every seven Texas residents is covered by Medicaid, a $40 billion program (about $23 billion provided by the federal government, with $17 billion of its cost covered by the state), the stakes are high for the Committee on Human Services, which has legislative authority over Medicaid in the Lone Star state.
DHR HEALTH HOSTS KEY LAWMAKERS IN EDINBURG
In order to help South Texans bring their concerns and ideas directly to state lawmakers who will make recommendations later this year for new laws and policies on Medicaid, DHR hosted the public hearing of the Committee on Human Services, which drew legislative, medical, health care, business, and community movers and shakers.
Carlos Cárdenas, MD, the CEO and Chairman of the Board at DHR Health, and immediate Past President of the Texas Medical Association (TMA), testified before the legislative panel, explaining that some, but not all, of the MCOs contracted are denying qualified patients access to life-saving care, are late in paying physicians and other health care providers, or overwhelm those providers with needless paperwork.
“Texas’ Medicaid managed care system faces grave but surmountable challenges that must be addressed with all due haste, beginning with enhanced security not only of the health plans but also of the state’s own actions, including deep funding cuts and insufficient agency staff, jeopardize Medicaid’s ability to care for the neediest among us,” he said.
Cárdenas, who testified on behalf of TMA, said his testimony was intended to focus on “significant deficiencies in the Texas Medicaid managed care program and how Texas can expeditiously correct them.”
Cárdenas emphasized the significance of Medicaid to all Texans.
“Medicaid also is critical to address the state’s most pressing health care challenges, such as improving maternal health, providing treatment for people with substance abuse disorders, and expediting care to abused and neglected children taken into state custody,” Cárdenas noted. “Throughout my career, I have cared for thousands of Medicaid patients and see every day how the program benefits the patients who live in my community. Without Medicaid, millions of poor and low-income Texans would not get the health care services they need to remain productive members of our community.”
ROBERTO MARTÍNEZ, MD: MEDICAID PROTECTS PREGNANT WOMEN AND CHILDREN
Medicaid has a far-reaching impact in deep South Texas as well, added Robert Martínez, M.D., the Chief Medical Officer and Chief Physician Executive for DHR Health.
“I come before you to share our experience with, and our recommendations for, improving the managed care delivery system used to provide Medicaid services to one of every four residents of the Rio Grande Valley,” Martínez told the legislative panel. “At our 530+ bed health system, 44 percent of all admissions and 85 percent of all births are covered by the Medicaid program. The managed care delivery system provides a vital lifeline to health care services for the most vulnerable.”
DHR Health’s chief medical officer urged lawmakers to ensure adequate funding for the Texas Medicaid program as part of recommended reforms.
“Hospitals on average get paid only 70 percent of the cost to provide services to Medicaid patients. Physicians and other providers get paid less. Insufficient funding and inadequate resources jeopardizes access to care for over four million Texans and puts lives at risk,” Martínez said. “DHR Health is proud to provide the highest quality health care to our patients. Our medical team is honored to care for patients as your trusted healthcare provider in South Texas. We simply need your help to improve how managed care works.”
LOCAL IDEAS COULD TURN INTO NEW STATE LAWS AND POLICIES
Following the public hearing, Raymond, the committee’s chairman, share this views on the presentations made in Edinburg, and what will follow in the coming months.
“What we had today were specific examples where providers are saying, this part doesn’t work, or maybe somethings that are working right, and you take from that the existing laws, look at the contracts HHSC has entered into with managed health care and managed plans, and ask, ‘What are we contracting you to do? We are contracting you to set up a network of medical providers and make sure that the 4.5 million patients in Texas who qualify for Medicaid are receiving the services that they need. From today, we will be able to take some of this and work it into legislation that I expect that I and other legislators on this committee will be introducing for next session to try to address some of the shortcomings that we have seen today.”
The 86th Texas Legislature will return to work for its five-month regular session, which begins in early January 2019.
Raymond praised the quality of testimony presented during the Edinburg pubic hearing.
“It was excellent testimony because what we want from witnesses on complicated issue like Medicaid and managed care is to come up and specifically identify the things they see as challenges. If they are negative challenges, they affect the people who we are supposed to be serving, those people who have health care needs and qualify for Medicaid, and need to get some kind of medical attention,” he said.
When serious problems arise in Medicaid, they must be dealt with quickly because the long-term consequences are not acceptable, he added.
“When the system isn’t working well, we are going to have people who need medical attention, but aren’t getting medical attention. At the end of the day, if we don’t take care of them, it will wind up costing us more, because they will end up in the hospital emergency room,” Raymond said. “Once you end up in the emergency room, the cost for taking care of someone skyrockets. That doesn’t help anyone.”
CARLOS CÁRDENAS, MD: THE FUNDAMENTAL OATH OF MEDICINE – “DO NO HARM”
The public hearing in Edinburg came several weeks after the Dallas Morning News published a special investigative series into the problems facing the Medicaid Managed Care System in Texas.
Cárdenas made it a point to direct the lawmakers’ and public’s attention to that newspaper’s findings.
“The Dallas Morning News series, “Pain and Profit”, published in June 2018, was especially painful to read. It highlighted serious flaws in Medicaid’s ability to ensure children and people with disabilities get the care they need to lead full and healthy lives to the extent of their abilities,” he said. “Sadly, what I read reflects not only my experiences dealing with Medicaid managed care organizations (MCOs) but also that of many of my colleagues, such as struggling to find physicians accepting new patients and wading through convoluted prior authorization and appeals processes.”
News media coverage such as the series published by The Dallas Morning News“indicate that the plans in question – as well as the Texas Health and Human Services Commission (HHSC) itself – are too often failing to uphold the fundamental oath of medicine – ‘do no harm,’” Cárdenas said.
In the summary of the its six-part news coverage, The Dallas Morning News provided the following introduction:
Medicaid is the government program that pays for medical care for poor and disabled people in Texas, everything from routine checkups to heart surgery. In Texas, it covers more than 4.5 million people ? 1 out of every 7 residents.
Most of the people we’re talking about are poor kids, with incomes under $22,000 a year for a family of two. Others are elderly and disabled people. Some of them are children so sick that their families can’t pay all the costs of their care. And all foster kids are covered by Medicaid.
The federal government covers almost 58 percent of the cost of Medicaid, or about $23 billion. The state pays about $17 billion.
Traditionally, state workers supervised Medicaid, paying doctors and nurses and medical equipment companies. But the cost of that system started climbing, driven by inflation and the growing cost of health care. And critics complained about fraud, as well as about emergency rooms crammed with poor people who didn’t have doctors.
ENTER “MANAGED CARE”
Like the private sector’s HMOs ? health maintenance organizations ? managed-care companies promise to cut costs by, for example, negotiating lower prices with doctors and hospitals. They also promise to improve the health care of the patients they cover, emphasizing preventive care like vaccinations and hiring experts to help hook people up with the services they need.
Today, almost all of the people on Medicaid in Texas are in managed care. Most of them are cared for by for-profit companies, which the state pays $17 billion a year. Profits are supposed to be limited by the state.
Managed care seems to be helping basically healthy people ? little kids are getting vaccinations and older people are staying out of the hospital.
But The Dallas Morning News has found that this system is failing the most vulnerable Texans:
The disabled, very sick children, foster kids. They aren’t getting nursing care, or medical equipment like wheelchairs. They can’t find doctors or specialists. And there aren’t nearly enough “care coordinators” to help them. Some experts say the only way the for-profit managed care companies can profit off these people is to cut back on their medical treatment. The consequences can be lethal.
ABOUT DOCTORS HOSPITAL AT RENAISSANCE (DHR HEALTH)
According to Roberto Haddad, Counsel for Government Affairs and Policy at Doctors Hospital at Renaissance (DHR Health):
Doctors Hospital at Renaissance (DHR Health) is a homegrown, locally operated, physician-owned health system headquartered in Edinburg, Texas, is Valleywide with over 70 locations throughout the Rio Grande Valley.
With over 4,700 employees, 700 physicians, and 1,400 nurses, DHR Health is proud to offer the highest quality and most comprehensive medical care along the US southern border, offering a full continuum of care in over 70 specialties and subspecialties.
From general acute care services, a Level III Trauma Facility, the only transplant program south of San Antonio, preventative health programs, serving as the flagship teaching hospital for the University of Texas Rio Grande Valley School of Medicine, and a clinical research program, to name a few, DHR Health is committed to addressing all of the health care needs of the Rio Grande Valley while eliminating the need for the community to seek health care services outside the region, which has transformed DHR Health into a national best practice model hospital.
RESPONSIBILITIES AND DUTIES OF MEDICAID IN TEXAS
Medicaid and the Children’s Health Insurance Program (CHIP) help cover medical expenses for children and people with disabilities who meet income requirements. Among the services provided by Medicaid and CHIP, and the constituents which are served by Medicaid and CHIP, are:
Adults can qualify for Medicaid if they have disabilities, care for children, are 65 or older or take part in the Medicaid Buy-In;
An adult who cares for a child my qualify for Medicaid;
Children without health insurance might be able to get low-cost or free health coverage from the Children’s Health Insurance Program;
Children’s Medicaid covers services needed to keep healthy people 18 and younger who come from families with little or no money;
Most Medicaid services (plans) in Texas and all CHIP services are delivered through providers called Managed Care organizations;
Learn more about STAR+PLUS managed care expansion;
Learn more about the new STAR Kids program;
Learn about the new managed care expansion;
The Medicaid Buy-In program offers low-cost Medicaid health services – including community-based services and supports – to individuals with disabilities who work;
Medicaid Buy-In for Children can help pay medical bills for children with disabilities. This program helps families who need health insurance, but make too much money to get traditional Medicaid;
My Children’s Medicaid has helpful tips to keep children healthy, and explains the benefits of the program; and
The Texas Pregnancy Care Network can help mothers find counseling, child care, transportation, life skills classes and more.
DIFFERENCE BETWEEN MEDICARE AND MEDICAID
According to the US Department of Health and Human Services, these are the following key difference between Medicare and Medicaid:
Medicare is an insurance program. Medical bills are paid from trust funds which those covered have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services, an agency of the federal government.
For more information regarding Medicare and its components, please go to http://www.medicare.gov.
Medicaid is an assistance program. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments within federal guidelines. To see if you qualify for your state’s Medicaid (or Children’s Health Insurance) program, see: https://www.healthcare.gov/medicaid-chip/eligibility/
Prepared Remarks Delivered by Carlos Cárdenas, MD, the CEO and Chairman of the Board at Doctors Hospital at Renaissance (DHR Health), on Wednesday, August 29, 2018 before the House Committee on Human Services at the Edinburg Conference Center at Renaissance
Chairman Raymond and members of the committee. I am Carlos Cárdenas, MD, a practicing gastroenterologist from Edinburg, Texas, testifying today on behalf of the Texas Medical Association, which represents more than 51,000 physicians and medical students.
Throughout my career, I have cared for thousands of Medicaid patients and see every day how the program benefits the patients who live in my community. Without Medicaid, millions of poor and low-income Texans would not get the health care services they need to remain productive members of our community. So, I greatly appreciate the opportunity to speak to you on the significant deficiencies in the Texas Medicaid managed care program and how Texas can expeditiously correct them.
TMA shares your utmost goal to make sure Medicaid patients get the right care at the right time. Medicaid is vital to ensuring the health of all Texans. One in seven Texans is enrolled in the program, which amounts to nearly 4.5 million individuals, many of whom are my patients and all of whom, collectively, are our neighbors. Medicaid also is critical to address the state’s most pressing health care challenges, such as improving maternal health, providing treatment for people with substance abuse disorders, and expediting care to abused and neglected children taken into state custody. In this context, The Dallas Morning News (DMN) series, “Pain and Profit”, published in June 2018, was especially painful to read. It highlighted serious flaws in Medicaid’s ability to ensure children and people with disabilities get the care they need to lead full and healthy lives to the extent of their abilities.
Sadly, what I read reflects not only my experiences dealing with Medicaid managed care organizations (MCOs) but also that of many of my colleagues, such as struggling to find physicians accepting new patients and wading through consulted prior authorization and apples processes. Stories like those in the DMN indicate that the plans in question – as well as the Texas Health and Human Services Commission (HHSC) itself – are too often failing to uphold the fundamental oath of medicine – do no harm.
Texas’ Medicaid managed care system faces grave but surmountable challenges that must be addressed with all due haste, beginning with enhanced security not only of the health plans but also have the state’s own actions, including deep funding cuts and insufficient agency staff, jeopardize Medicaid’s ability to care for the neediest among us.
At the same time, we must recognize not all Medicaid MCOs are equal. Some are quite clearly poor performers while others go above and beyond what the state asks of them to ensure their enrollees receive the care they need, including expanding availability of specialty services and improving maternal health outcomes. Texas must learn from and replicate the best practices of the highest-performing plans rather than just punishing the bad apples.
TMA is dedicated to working with lawmakers, state agency staff, and MCOs to reform the system to ensure it does not harm. To that end, we make the following recommendations to address the issues detailed in the “Pain and Profit” series.
Enhance accountability and oversight of managed care organizations
The Texas Health and Human Services Commission is charged with the oversight of Medicaid MCOs. But it is not clear if the agency has sufficient, qualified staff to routinely and systematically scrutinize MCOs’ network adequacy, medical policy development and revisions, appeals compliances, and so forth. It is important for Texas to candidly assess whether the agency itself requires more resources to do the job entrusted to it by the Legislature. While we are pleased with HHSC received approval to hire more contract oversight and clinical staff, more may be needed.
Furthermore, we urge support for hiring a senior chief medical officer embedded with HHSC senior management timely insight and routine oversight of issues relating to health care delivery and medical, including network adequacy and expansion of value-based payment initiatives.
Undoubtedly, it goes without say the HHSC must quickly and meaningfully penalize poorly performing plans and implement timely, appropriate corrective measures. At the same time, Texas must to focus exclusively on removing or punishing MCOs. Plans that perform well, as well as the physicians who participate in their networks, should be recognized and rewarded. For Texas Medicaid managed care to constructively evolve, the state must determine how to quickly replicate and expand the highest-performing plans’ best practices so that Medicaid managed care works better for all.
HHSC also must work with physicians and MCOs to modernize antiquated roles and policies that create unnecessary and/r redundant red tape, such as updating outdated claims adjudication requirements and ensuring timely review and updates to medical policy.
Strengthen care coordination
Care coordination remains inordinately confusion and time-consuming, well short of its intended goals. The intent of care coordination is to ensure patients, particularly those with the most significant needs, get the right care to another, such as from an inpatient stay to the community, where follow-up care may be needed. But these connections are not happening routinely.
Reforming Medicaid care coordination is a high priority for our members. The role of care coordinators should be revised to help practices facilitate specialty and long-term care services. In addition, physicians with patients requiring care coordination must have a mechanism to directly request such services and to easily and quickly contact a patient’s care coordinator. The state also needs to develop distinct definition for “care coordination”, “service coordination”, or similar terms within each Medicaid managed care product to better differentiate what each patient population is eligible to receive.
Simplify appeals process
The current appeals process for Medicaid MCOs is overly complicated and burdensome for patients and physicians. HHSC should streamline the process and ensure physicians and patients have access to an ombudsman or state staff person who is available to facilitate the appeals when necessary. Any reforms to the system must ensure the process is responsive, quick, and flexible to allow both patients and physicians/provides to appeal for medical, surgical and behavioral health procedures, treatments, and medications.
Ensure adequate networks
The DMN articles clearly highlighted a significant barrier to obtaining timely medical treatment through MCOs: Texas’ extremely inadequate network of physicians and providers. While the problem predated MCO expansion, over time the seemingly endless red tape and bureaucracy imposed by some MCOs, combined with low payments, has resulted in more physicians limiting Medicaid participation or leaving altogether. In 2000, 67 percent of physicians accepted all new Medicaid patients. Today, that number is 42 percent.
In 2013, the Legislature enacted Senate Bill 760 by Chairman Charles Schwertner, MD, giving HHSC authority and tools to increase MCO accountability reading the adequacy of their networks. In 2017, HHSC amended its MCO contract to implement stiffer standards. However, HHSC has yet to share detailed information about the plans’ compliance with the new standards, leaving physicians, patients, and lawmakers unsure of where we stand. HHSC must expedite its reporting on SB 760 compliance as well as its recommendations for addressing systematic and plan-level deficiencies.
One idea that HHSC could immediately implement is to publicize details of MCO Corrective Action Plans (CAP). The HHSC website lists the plans subject to corrective measures as well as any associated penalties, but the public cannot access the full CAP without submitting a Freedom of Information Request. Giving the public access to a plan’s CAP would allow stakeholders to more quickly identify system Medicaid MCO problems.
HHSC also should establish a provider ombudsman who is available to document and expeditiously respond to complaints by physicians and providers about network inadequacy.
Increase physician payments
Despite physicians’ broad support for Medicaid as a vital piece of Texas’ health care safety net, physician Medicaid participation will continue to wither unless Texas implements competitive Medicaid payments. As the saying goes, you cannot squeeze blood from a turnip. Even among well-run, well-regarded Medicaid MCOs, finding and keeping subspecialty physicians and even some primary care physicians is a growing challenge. This is because Texas Medicaid physician fee-for-service payment rates – which are what most Medicaid MCOs pay physicians, too – have not received a meaningful, enduring increase in nearly two decades. Physician payments also are not indexed to inflation, meaning that each year Texas fails to increase payments, the farther Medicaid payments fall behind commercial payers and Medicare.
However, TMA survey data clearly show that when Medicaid payments increase, likewise so does physician participation.
Streamline administrative procedures
For Texas Medicaid managed care to work effectively and efficiently, Texas must eliminate redundant, silly and onerous red tape that benefits no one but results in physicians spending less time with their patients. In TMA’s physician survey, 55 percent of respondents stated that simplifying Medicaid paperwork would result in them seeing more patients.
To that end, over the past year, TMA has collaborated with the MCOs to create a centralized organization through which physicians can obtain credentials to participate in any of the 19 Medicaid plans operating in the state.
Furthermore, TMA, the Texas Association of Health Plans and the Texas Hospital Association will co-host a summit in October for our respective leadership to identify five to 10 administrative hassles our organizations can address in a relatively short order. This includes eliminating unnecessary prior authorization requirements, standardizing prior authorization forms, strengthening Medicaid care coordination, improving specialty referral processes, strengthening accountability for MCO and HHS compliant and fair hearing processes, and deploying smart telemedicine initiatives to help physicians better integrate and coordinate care.
TMA also recommends that the committee examine HHSC OIG’s (Office of the Inspector General) oversight role of MCOs to ensure its processes and procedures do not inadvertently duplicate existing health plan audit requirements relating to over and under payment of claims or the MCO’s contractual obligations to investigate waste, fraud and abuse. Duplicative audits and investigations unnecessarily take physicians away from their patients, while increasing overhead costs for physicians, health plans and the OIG alike.
(The OIG’s mission,as prescribed by statute, is the “prevention, detection, audit, inspection, review, and investigation of fraud, waste, and abuse in the provision and delivery of all health and human services in the state, including services through any state-administered health or human services program that is wholly or partly federally funded, and the enforcement of state law relating to the provision of these services.”)
Expand Use of Value-Based Payment Initiatives
Another strategy to increase the number of physicians who see Medicaid patients is to better reward those who partner with MCOs to improve patient health care outcomes and well-being. HHSC contractually obligates MCSs to implement value-based payment initiatives that promote and improve health care quality and access. These new value-based partnerships between physicians and managed care organizations have result in some physician practices, mostly primary care, receiving better payments, including incentives for providing evening and weekend office hours, increasing the number of children who receive well-child care visiting, or boosting the number of women getting early prenatal care.
Yet such bonus payments cannot overcome the fact that payment per service is below physician’s practice costs. Furthermore, legislatively mandating funding costs to Medicaid MCOs potentially imperil the ability of plans to expand or maintain value-based payment initiatives. Without investment of new state dollars targeted to Medicaid physician services, the ability to maintain innovative MCO-physician collaborations will teeter on the edge.
Texas physicians look forward to continue dialogue with lawmakers, HHSC staff, and MCO leadership about improving the Medicaid program for our most vulnerable Texans. If TMA can provide any more information on a particular issues I covered today, please reach out of us.
Prepared Remarks Delivered by Robert Martínez, MD, Chief Medical Officer, Doctors Hospital at Renaissance (DHR Health), on Wednesday, August 29, 2018 before the House Committee on Human Services at the Edinburg Conference Center at Renaissance
CHARGE: The (Texas House of Representatives) Committee (on Health and Human Services) will review the history and future roll-out of Medicaid Managed Care in Texas. The committee will examine the impact managed care has had on the quality and cost of health care throughout the state, and review initiatives that managed care organizations have implemented to improve the quality and care.
The committee will also investigate:
• Whether access to care and if network adequacy contractual requirements are sufficient;
• Provider and Medicaid participants’ satisfaction within STAR, STAR Health, Star Kids, and STAR+Plus managed care programs; and
• The Health and Human Services Commission’s (HHSC) oversight of managed care organizations to make recommendations for any needed improvement.
Chairman and members of the committee, thank you for the opportunity to testify.
My name is Robert Martínez, and I am the Chief Medical Officer for Doctors Hospital at Renaissance (DHR Health) in Edinburg, Texas.
We are honored to be hosting the committee today.
I come before you to share our experience with, and our recommendations for, improving the managed care delivery system used to provide Medicaid services to 1 of every 4 residents of the Rio Grande Valley.
At our 530+ bed health system, 44 percent of all admissions and 85 percent of all births are covered by the Medicaid program. The managed care delivery system provides a vital lifeline to health care services for the most vulnerable.
We believe that the following improvements to managed care are necessary and will help us serve the health and wellness needs of our patients:
• Protecting patients by increasing HHSC oversight over and the accountability of the Managed Care plans. The recent series “Pain and Profit” by the Dallas Morning News has highlighted some serious lapses of care for the most vulnerable. The committee should undertake a wholesale review of the complaint process and promote reforms that provide the commission (HHSC) with timely and actionable data to be able to intervene when necessary and to punish habitual offenders.
• Additionally, we recommend that the commission (HHSC) impanel a board of medical professionals who can be assigned to review and assess complaints, appeals, or advise on other health care delivery issues as they arise. Health plans each have their own Chief Medical Officers and medical staff to review issues, and provide oversight. The commission (HHSC) would be well served by having an internal board of medical professionals to be able to lean on for guidance.
• Simplifying and streamlining the appeals process. Providers should be able to work with the commission to help resolve longstanding issues. The current appeals process is lengthy, burdensome, and changes from plan to plan. Appeals can take up to two or more years to be resolved and complaints to the commission (HHSC) do not necessarily result in corrective action by the plans.
• Protecting providers from having to pay back the health plans for services provided to patients in good faith and in compliance with medical necessity guidelines and our contract with the health plans.
• Ensuring that short medical and behavioral stays are classified based on clinical criteria, the patient’s condition, and the medical judgment of the admitting physician.
• Eliminating the 30-Day Spell of Illness Limitation.
• Improving Care Coordination. Reforms should require health plans to (1) issue a post-acute care coverage determination within 24 hours after receiving the request and (2) improve care coordination with hospital case managers to ensure patients are discharged in a safe and timely manner.
Plans currently only have to make a determination to approve or deny coverage within 72 hours after receiving a request. If the initial authorization is denied, the hospital case management team has to re-evaluate the discharge plan before resubmitting another authorization request. This back and forth results in delays in discharge, increases costs, and potentially puts the patient’s safety at risk.
The health plans should be actively coordinating and planning with the hospital for their members’ post-acute discharge needs from day one. The plans’ case management should be intimately familiar with their members’ needs so that post-acute discharge planning within a 24 hour window should not pose a problem.
Additionally, Texas Medicaid can and should incentivize more care coordination. Care coordination results in better outcomes for patients, reduced costs for Medicaid, and decreased readmissions. Texas generally sets a very low baseline expectation for care coordination. Health plans are neither incentivized to nor paid to provide care coordination services to the majority of their beneficiaries who are not in STAR-PLUS or STAR-KIDS.
We urge this Committee (on Health and Human Services) to look into whether increased care coordination and post-acute care long-term rehabilitation benefits for higher-risk patients with long-term hospital stays could improve outcomes and reduce readmissions.
Additionally, plans are dis-incentivized from expanding care coordination services because current policy deems them administrative expenses, which plans are under constant pressure to contain. Expenses incurred to provide care coordination services should be classified as clinical and not administrative.
Finally, and importantly, I urge this Committee (on Health and Human Services) to work with your colleagues and ensure adequate funding for the Texas Medicaid program. Hospitals on average get paid only 70 percent of the cost to provide services to Medicaid patients. Physicians and other providers get paid less. Insufficient funding and inadequate resources jeopardizes access to care for over four million Texans and puts lives at risk.
DHR Health is proud to provide the highest quality health care to our patients. Our medical team is honored to care for patients as your trusted healthcare provider in South Texas. We simply need your help to improve how managed care works. Thank you for the opportunity to testify in support of important reforms needed for the managed care system.
For more on this and other Texas legislative news stories which affect the Lower Rio Grande Valley metropolitan region, please log on to Titans of the Texas Legislature. For more information, please contact Roberto Haddad, Counsel for Government Affairs and Policy at Doctors Hospital at Renaissance (DHR Health), or Jesse Ozuna, Government Affairs Officer at Doctors Hospital at Renaissance (DHR Health), at 956/362-7165.)