By: Nelson S.B. No. 7
A BILL TO BE ENTITLED
AN ACT
relating to strategies for and improvements in quality of health
care and care management provided through health care facilities
and through the child health plan and medical assistance programs
designed to improve health outcomes.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. CHILD HEALTH PLAN AND MEDICAID PILOT PROGRAMS.
Subchapter B, Chapter 531, Government Code, is amended by adding
Sections 531.0993 and 531.0994 to read as follows:
Sec. 531.0993. OBESITY PREVENTION PILOT PROGRAM. (a) The
commission and the Department of State Health Services shall
coordinate to establish a pilot program designed to:
(1) decrease the rate of obesity in child health plan
program enrollees and Medicaid recipients;
(2) improve the nutritional choices and increase
physical activity levels of child health plan program enrollees and
Medicaid recipients; and
(3) achieve long-term reductions in child health plan
and Medicaid program costs incurred by the state as a result of
obesity.
(b) The commission and the Department of State Health
Services shall implement the pilot program in one or more health
care service regions in this state, as selected by the commission.
In selecting the regions for participation, the commission shall
consider the degree to which child health plan program enrollees
and Medicaid recipients in the region are at higher than average
risk of obesity.
(c) In developing the pilot program, the commission and the
Department of State Health Services in consultation with the Health
Care Quality Advisory Committee established under Section 531.0995
shall identify measurable goals and specific strategies for
achieving those goals. The specific strategies may be
evidence-based to the extent evidence-based strategies are
available for the purposes of the program.
(d) Not later than November 1, 2011, the Health and Human
Services Commission shall submit a report to the standing
committees of the senate and house of representatives having
primary jurisdiction over the child health plan and Medicaid
programs regarding the results of the pilot program under this
section. The report must include:
(1) a summary of the identified goals for the program
and the strategies used to achieve those goals;
(2) an analysis of the data collected in the program
and the capability of the data to measure achievement of the
identified goals;
(3) a recommendation regarding the continued
operation of the pilot program; and
(4) a recommendation regarding whether the program
should be implemented statewide.
(e) The executive commissioner may adopt rules to implement
this section.
Sec. 531.0994. MEDICAL HOME FOR CHILD HEALTH PLAN PROGRAM
ENROLLEES AND MEDICAID RECIPIENTS. (a) In this section, "medical
home" means a primary care provider who provides preventive and
primary care to a patient on an ongoing basis and coordinates with
specialists when health care services provided by a specialist are
needed.
(b) The commission shall establish a pilot program in one or
more health care service regions in this state designed to
establish a medical home for each child health plan program
enrollee and Medicaid recipient participating in the pilot program.
A primary care provider participating in the program may designate
a care coordinator to support the medical home concept.
(c) The commission shall develop in consultation with the
Health Care Quality Advisory Committee established under Section
531.0995 the pilot program in a manner that bases payments made, or
incentives provided, to a participant's medical home on factors
that include measurable wellness and prevention criteria, use of
best practices, and outcomes.
(d) Not later than January 1, 2011, the commission shall
submit a report to the standing committees of the senate and house
of representatives having primary jurisdiction over the child
health plan and Medicaid programs regarding the status of the pilot
program under this section. The report must include:
(1) recommendations regarding the continued operation
of the pilot program or whether the program should be implemented
statewide; or
(2) if the commission cannot make the recommendations
described by Subdivision (1) due to an insufficient amount of data
having been collected at the time of the report, statements
regarding the time frames within which the commission anticipates
collecting sufficient data and making those recommendations.
SECTION 2. HEALTH CARE QUALITY ADVISORY COMMITTEE.
(a) Subchapter B, Chapter 531, Government Code, is amended by
adding Section 531.0995 to read as follows:
Sec. 531.0995. HEALTH CARE QUALITY ADVISORY COMMITTEE.
(a) The commission shall establish the Health Care Quality
Advisory Committee to assist the commission as specified by
Subsection (d) with defining best practices and quality performance
with respect to health care services and setting standards for
quality performance by health care providers and facilities for
purposes of programs administered by the commission or a health and
human services agency.
(b) The executive commissioner shall appoint the members of
the advisory committee. The committee must consist of health care
providers, representatives of health care facilities, and other
stakeholders interested in health care services provided in this
state. At least one member must be a physician who has clinical
practice expertise, and at least one member must be a member of the
Advisory Panel on Health Care-Associated Infections and
Preventable Adverse Events who meets the qualifications prescribed
by Section 98.052(a)(4), Health and Safety Code.
(c) The executive commissioner shall appoint the presiding
officer of the advisory committee.
(d) The advisory committee shall advise the commission on:
(1) measurable goals for the obesity prevention pilot
program under Section 531.0993;
(2) measurable wellness and prevention criteria and
best practices for the medical home pilot program under Section
531.0994;
(3) quality of care standards, evidence-based
protocols, and measurable goals for quality-based payment
initiatives pilot programs implemented under Subchapter W; and
(4) any other quality of care standards,
evidence-based protocols, measurable goals, or other related
issues with respect to which a law or the executive commissioner
specifies that the committee shall advise.
(b) The executive commissioner of the Health and Human
Services Commission shall appoint the members of the Health Care
Quality Advisory Committee not later than November 1, 2009.
SECTION 3. UNCOMPENSATED HOSPITAL CARE DATA. (a) The
heading to Section 531.551, Government Code, is amended to read as
follows:
Sec. 531.551. UNCOMPENSATED HOSPITAL CARE REPORTING AND
ANALYSIS; HOSPITAL AUDIT FEE.
(b) Section 531.551, Government Code, is amended by
amending Subsections (a) and (d) and adding Subsections (a-1),
(a-2), and (m) to read as follows:
(a) Using data submitted to the Department of State Health
Services under Subsection (a-1), the [The] executive commissioner
shall adopt rules providing for:
(1) a standard definition of "uncompensated hospital
care" that reflects unpaid costs incurred by hospitals and accounts
for actual hospital costs and hospital charges and revenue sources;
(2) a methodology to be used by hospitals in this state
to compute the cost of that care that incorporates the standard set
of adjustments described by Section 531.552(g)(4); and
(3) procedures to be used by those hospitals to report
the cost of that care to the commission and to analyze that cost.
(a-1) To assist the executive commissioner in adopting and
amending the rules required by Subsection (a), the Department of
State Health Services shall require each hospital in this state to
provide to the department, not later than a date specified by the
department, uncompensated hospital care data prescribed by the
commission. Each hospital must submit complete and adequate data,
as determined by the department, not later than the specified date.
(a-2) The Department of State Health Services shall notify
the commission of each hospital in this state that fails to submit
complete and adequate data required by the department under
Subsection (a-1) on or before the date specified by the department.
Notwithstanding any other law and to the extent allowed by federal
law, the commission may withhold Medicaid program reimbursements
owed to the hospital until the hospital complies with the
requirement.
(d) If the commission determines through the procedures
adopted under Subsection (b) that a hospital submitted a report
described by Subsection (a)(3) with incomplete or inaccurate
information, the commission shall notify the hospital of the
specific information the hospital must submit and prescribe a date
by which the hospital must provide that information. If the
hospital fails to submit the specified information on or before the
date prescribed by the commission, the commission shall notify the
attorney general of that failure. On receipt of the notice, the
attorney general shall impose an administrative penalty on the
hospital in an amount not to exceed $10,000. In determining the
amount of the penalty to be imposed, the attorney general shall
consider:
(1) the seriousness of the violation;
(2) whether the hospital had previously committed a
violation; and
(3) the amount necessary to deter the hospital from
committing future violations.
(m) The commission may require each hospital that is
required under 42 C.F.R. Section 455.304 to be audited to pay a fee
to offset the cost of the audit in an amount determined by the
commission. The total amount of fees imposed on hospitals as
authorized by this subsection may not exceed the total cost
incurred by the commission in conducting the required audits of the
hospitals.
(c) As soon as possible after the date the Department of
State Health Services requires each hospital in this state to
initially submit uncompensated hospital care data under Subsection
(a-1), Section 531.551, Government Code, as added by this section,
the executive commissioner of the Health and Human Services
Commission shall adopt rules or amendments to existing rules that
conform to the requirements of Subsection (a), Section 531.551,
Government Code, as amended by this section.
SECTION 4. MEDICAL TECHNOLOGY; ELECTRONIC HEALTH
INFORMATION EXCHANGE PROGRAM. (a) Chapter 531, Government Code,
is amended by adding Subchapter V to read as follows:
SUBCHAPTER V. ELECTRONIC HEALTH INFORMATION EXCHANGE PROGRAM
Sec. 531.901. DEFINITIONS. In this subchapter:
(1) "Electronic health record" means an electronic
record of health-related information concerning a person that
conforms to nationally recognized interoperability standards and
that can be created, managed, and consulted by authorized health
care providers.
(2) "Health information exchange system" means the
electronic health information exchange system created under this
subchapter that electronically moves health-related information
among entities according to nationally recognized standards.
(3) "Local or regional health information exchange"
means a health information exchange operating in this state that
securely exchanges electronic health information, including
information for patients receiving services under the child health
plan or Medicaid program, among hospitals, clinics, physicians'
offices, and other health care providers that are not owned by a
single entity or included in a single operational unit or network.
Sec. 531.902. ELECTRONIC HEALTH INFORMATION EXCHANGE
SYSTEM. (a) The commission shall develop an electronic health
information exchange system to improve the quality, safety, and
efficiency of health care services provided under the child health
plan and Medicaid programs. In developing the system, the
commission shall ensure that:
(1) the confidentiality of patients' health
information is protected and the privacy of those patients is
maintained;
(2) appropriate information technology systems used
by the commission and health and human services agencies are
interoperable; and
(3) the system and external information technology
systems are interoperable in receiving and exchanging appropriate
electronic health information as necessary to enhance the
comprehensive nature of the information contained in electronic
health records.
(b) The commission shall implement the health information
exchange system in stages as described by this subchapter, except
that the commission may deviate from those stages if technological
advances make a deviation advisable or more efficient.
(c) The health information exchange system must be
developed in accordance with the Medicaid Information Technology
Architecture (MITA) initiative of the Center for Medicaid and State
Operations.
Sec. 531.903. ELECTRONIC HEALTH INFORMATION EXCHANGE
SYSTEM ADVISORY COMMITTEE. (a) The commission shall establish the
Electronic Health Information Exchange System Advisory Committee
to assist the commission in the performance of the commission's
duties under this subchapter.
(b) The executive commissioner shall appoint to the
advisory committee at least 12 and not more than 15 members who have
an interest in health information technology and who have
experience in serving persons receiving health care through the
child health plan and Medicaid programs.
(c) The advisory committee must include the following
members:
(1) Medicaid providers;
(2) child health plan program providers;
(3) fee-for-service providers;
(4) at least one representative of the Texas Health
Services Authority established under Chapter 182, Health and Safety
Code;
(5) at least one representative of each health and
human services agency;
(6) at least one representative of a major provider
association;
(7) at least one representative of a health care
facility;
(8) at least one representative of a managed care
organization;
(9) at least one representative of the pharmaceutical
industry; and
(10) at least one representative of a local or
regional health information exchange.
(d) The members of the advisory committee must represent the
geographic and cultural diversity of the state.
(e) The executive commissioner shall appoint the presiding
officer of the advisory committee.
(f) The advisory committee shall advise the commission on
issues regarding the development and implementation of the
electronic health information exchange system, including any issue
specified by the commission and the following specific issues:
(1) data to be included in an electronic health
record;
(2) presentation of data;
(3) useful measures for quality of service and patient
health outcomes;
(4) federal and state laws regarding privacy and
management of private patient information;
(5) incentives for increasing health care provider
adoption and usage of an electronic health record and the health
information exchange system; and
(6) data exchange with local or regional health
information exchanges to enhance the comprehensive nature of the
information contained in electronic health records.
(g) The advisory committee shall collaborate with the Texas
Health Services Authority to ensure that the health information
exchange system is interoperable with, and not an impediment to,
the electronic health information infrastructure that the
authority assists in developing.
Sec. 531.904. STAGE ONE: ELECTRONIC HEALTH RECORD.
(a) In stage one of implementing the health information exchange
system, the commission shall develop and establish a claims-based
electronic health record for each person who receives medical
assistance under the Medicaid program. The electronic health
record must be available through a browser-based format.
(b) The executive commissioner shall adopt rules specifying
the information required to be included in the electronic health
record. The required information may include, as appropriate:
(1) the name and address of each of the person's health
care providers;
(2) a record of each visit to a health care provider,
including diagnoses, procedures performed, and laboratory test
results;
(3) an immunization record;
(4) a prescription history;
(5) a list of due and overdue Texas Health Steps
medical and dental checkup appointments; and
(6) any other available health history that health
care providers who provide care for the person determine is
important.
(c) Information under Subsection (b) may be added to any
existing electronic health record or health information technology
and may be exchanged with local and regional health information
exchanges.
(d) The commission shall make an electronic health record
for a patient available to the patient through the Internet.
Sec. 531.9041. STAGE ONE: ENCOUNTER DATA. In stage one of
implementing the health information exchange system, the
commission shall require for purposes of the implementation each
managed care organization with which the commission contracts under
Chapter 533 for the provision of Medicaid managed care services to
submit to the commission complete encounter data for each month
that includes all paid and processed claims for the month not later
than the 30th day after the last day of the month to which the data
relates.
Sec. 531.905. STAGE ONE: ELECTRONIC PRESCRIBING. (a) In
stage one of implementing the health information exchange system,
the commission shall develop and coordinate electronic prescribing
tools for use by health care providers and health care facilities
under the child health plan and Medicaid programs.
(b) To the extent feasible, the electronic prescribing
tools must:
(1) provide current payer formulary information at the
time a health care provider writes a prescription; and
(2) support the electronic transmission of a
prescription.
(c) The commission may take any reasonable action to comply
with this section, including establishing information exchanges
with national electronic prescribing networks or providing health
care providers with access to an Internet-based prescribing tool
developed by the commission.
(d) The commission shall apply for and actively pursue any
waiver to the child health plan program or the state Medicaid plan
from the federal Centers for Medicare and Medicaid Services or any
other federal agency as necessary to remove an identified
impediment to the implementation of electronic prescribing tools
under this section. If the commission with assistance from the
Legislative Budget Board determines that the implementation of
operational modifications in accordance with a waiver obtained as
required by this subsection has resulted in cost increases in the
child health plan or Medicaid program, the commission shall take
the necessary actions to reverse the operational modifications.
Sec. 531.906. STAGE TWO: EXPANSION. Based on the
recommendations of the advisory committee established under
Section 531.903 and feedback provided by interested parties, the
commission in stage two of implementing the health information
exchange system may expand the system by:
(1) providing an electronic health record for each
child enrolled in the child health plan program;
(2) including state laboratory results information in
an electronic health record, including the results of newborn
screenings and tests conducted under the Texas Health Steps
program, based on the system developed for the health passport
under Section 266.006, Family Code;
(3) improving data-gathering capabilities for an
electronic health record so that the record may include basic
health and clinical information in addition to available claims
information, as determined by the executive commissioner;
(4) using evidence-based technology tools to create a
unique health profile to alert health care providers regarding the
need for additional care, education, counseling, or health
management activities for specific patients; and
(5) continuing to enhance the electronic health record
created under Section 531.904 as technology becomes available and
interoperability capabilities improve.
Sec. 531.907. STAGE THREE: EXPANSION. In stage three of
implementing the health information exchange system, the
commission may expand the system by:
(1) developing evidence-based benchmarking tools that
can be used by health care providers to evaluate their own
performances on health care outcomes and overall quality of care as
compared to aggregated performance data regarding peers; and
(2) expanding the system to include state agencies,
additional health care providers, laboratories, diagnostic
facilities, hospitals, and medical offices.
Sec. 531.908. INCENTIVES. The commission and the advisory
committee established under Section 531.903 shall develop
strategies to encourage health care providers to use the health
information exchange system, including incentives, education, and
outreach tools to increase usage.
Sec. 531.909. REPORTS. (a) The commission shall provide
an initial report to the Senate Committee on Health and Human
Services or its successor, the House Committee on Human Services or
its successor, and the House Committee on Public Health or its
successor regarding the health information exchange system not
later than January 1, 2011, and shall provide a subsequent report to
those committees not later than January 1, 2013. Each report must:
(1) describe the status of the implementation of the
system;
(2) specify utilization rates for each health
information technology implemented as a component of the system;
and
(3) identify goals for utilization rates described by
Subdivision (2) and actions the commission intends to take to
increase utilization rates.
(b) This section expires September 2, 2013.
Sec. 531.910. RULES. The executive commissioner may adopt
rules to implement this subchapter.
(b) Subchapter B, Chapter 62, Health and Safety Code, is
amended by adding Section 62.060 to read as follows:
Sec. 62.060. HEALTH INFORMATION TECHNOLOGY STANDARDS.
(a) In this section, "health information technology" means
information technology used to improve the quality, safety, or
efficiency of clinical practice, including the core
functionalities of an electronic health record, an electronic
medical record, a computerized health care provider order entry,
electronic prescribing, and clinical decision support technology.
(b) The commission shall ensure that any health information
technology used in the child health plan program conforms to
nationally recognized standards.
(c) Subchapter B, Chapter 32, Human Resources Code, is
amended by adding Section 32.073 to read as follows:
Sec. 32.073. HEALTH INFORMATION TECHNOLOGY STANDARDS.
(a) In this section, "health information technology" means
information technology used to improve the quality, safety, or
efficiency of clinical practice, including the core
functionalities of an electronic health record, an electronic
medical record, a computerized health care provider order entry,
electronic prescribing, and clinical decision support technology.
(b) The Health and Human Services Commission shall ensure
that any health information technology used in the medical
assistance program conforms to nationally recognized standards.
(d) As soon as practicable after the effective date of this
Act, the executive commissioner of the Health and Human Services
Commission shall adopt rules to implement the electronic health
record and electronic prescribing system required by Subchapter V,
Chapter 531, Government Code, as added by this section.
(e) The executive commissioner of the Health and Human
Services Commission shall appoint the members of the Electronic
Health Information Exchange System Advisory Committee established
under Section 531.903, Government Code, as added by this section,
as soon as practicable after the effective date of this Act.
SECTION 5. QUALITY-BASED PAYMENT INITIATIVES.
(a) Chapter 531, Government Code, is amended by adding Subchapter
W to read as follows:
SUBCHAPTER W. QUALITY-BASED PAYMENT INITIATIVES PILOT PROGRAMS FOR
PROVISION OF HEALTH CARE SERVICES
Sec. 531.951. DEFINITIONS. In this subchapter:
(1) "Pay-for-performance payment system" means a
system for compensating a health care provider or facility for
arranging for or providing health care services to child health
plan program enrollees or Medicaid recipients, or both, that is
based on the provider or facility meeting or exceeding certain
defined performance measures. The compensation system may include
sharing realized cost savings with the provider or facility.
(2) "Pilot program" means a quality-based payment
initiatives pilot program established under this subchapter.
Sec. 531.952. PILOT PROGRAM PROPOSALS; DETERMINATION OF
BENEFIT TO STATE. (a) Health care providers and facilities may
submit proposals to the commission for the implementation through
pilot programs of quality-based payment initiatives that provide
incentives to the providers and facilities, as applicable, to
develop health care interventions for child health plan program
enrollees or Medicaid recipients, or both, that are cost-effective
to this state and will improve the quality of health care provided
to the enrollees or recipients.
(b) The commission shall determine whether it is feasible
and cost-effective to implement one or more of the proposed pilot
programs. In addition, the commission shall examine alternative
payment methodologies used in the Medicare program and consider
whether implementing one or more of the methodologies, modified as
necessary to account for programmatic differences, through a pilot
program under this subchapter would achieve cost savings in the
Medicaid program while ensuring the use of best practices.
Sec. 531.953. PURPOSE AND IMPLEMENTATION OF PILOT PROGRAMS.
(a) If the commission determines under Section 531.952 that
implementation of one or more quality-based payment initiatives
pilot programs is feasible and cost-effective for this state, the
commission shall establish one or more programs as provided by this
subchapter to test pay-for-performance payment system alternatives
to traditional fee-for-service or other payments made to health
care providers or facilities participating in the child health plan
or Medicaid program, as applicable, that are based on best
practices, outcomes, and efficiency, but ensure high-quality,
effective health care services.
(b) The commission shall administer any pilot program
established under this subchapter. The executive commissioner may
adopt rules, plans, and procedures and enter into contracts and
other agreements as the executive commissioner considers
appropriate and necessary to administer this subchapter.
(c) The commission may limit a pilot program to:
(1) one or more regions in this state;
(2) one or more organized networks of health care
facilities and providers; or
(3) specified types of services provided under the
child health plan or Medicaid program, or specified types of
enrollees or recipients under those programs.
(d) A pilot program implemented under this subchapter must
be operated for at least one state fiscal year.
Sec. 531.954. STANDARDS; PROTOCOLS. (a) In consultation
with the Health Care Quality Advisory Committee established under
Section 531.0995, the executive commissioner shall approve quality
of care standards, evidence-based protocols, and measurable goals
for a pilot program to ensure high-quality and effective health
care services.
(b) In addition to the standards approved under Subsection
(a), the executive commissioner may approve efficiency performance
standards that may include the sharing of realized cost savings
with health care providers and facilities that provide health care
services that exceed the efficiency performance standards.
Sec. 531.955. QUALITY-BASED PAYMENT INITIATIVES. (a) The
executive commissioner may contract with appropriate entities,
including qualified actuaries, to assist in determining
appropriate payment rates for a pilot program implemented under
this subchapter.
(b) The executive commissioner may increase a payment rate,
including a capitation rate, adopted under this section as
necessary to adjust the rate for inflation.
(c) The executive commissioner shall ensure that services
provided to a child health plan program enrollee or Medicaid
recipient, as applicable, meet the quality of care standards
required under this subchapter and are at least equivalent to the
services provided under the child health plan or Medicaid program,
as applicable, for which the enrollee or recipient is eligible.
Sec. 531.956. TERMINATION OF PILOT PROGRAM; EXPIRATION OF
SUBCHAPTER. The pilot program terminates and this subchapter
expires September 2, 2013.
(b) Not later than November 1, 2012, the Health and Human
Services Commission shall present a report to the governor, the
lieutenant governor, the speaker of the house of representatives,
and the members of each legislative committee having jurisdiction
over the child health plan and Medicaid programs. For each pilot
program implemented under Subchapter W, Chapter 531, Government
Code, as added by this section, the report must:
(1) describe the operation of the pilot program;
(2) analyze the quality of health care provided to
patients under the pilot program;
(3) compare the per-patient cost under the pilot
program to the per-patient cost of the traditional fee-for-service
or other payments made under the child health plan and Medicaid
programs; and
(4) make recommendations regarding the continuation
or expansion of the pilot program.
SECTION 6. QUALITY-BASED HOSPITAL PAYMENTS. Chapter 531,
Government Code, is amended by adding Subchapter X to read as
follows:
SUBCHAPTER X. QUALITY-BASED HOSPITAL REIMBURSEMENT SYSTEM
Sec. 531.981. DEFINITIONS. In this subchapter:
(1) "Potentially preventable complication" means a
harmful event or negative outcome with respect to a person,
including an infection or surgical complication, that:
(A) occurs after the person's admission to a
hospital;
(B) results from the care or treatment provided
during the hospital stay rather than from a natural progression of
an underlying disease; and
(C) could reasonably have been prevented if care
and treatment had been provided in accordance with accepted
standards of care.
(2) "Potentially preventable readmission" means a
return hospitalization of a person within a period specified by the
commission that results from deficiencies in the care or treatment
provided to the person during a previous hospital stay or from
deficiencies in post-hospital discharge follow-up. The term does
not include a hospital readmission necessitated by the occurrence
of unrelated events after the discharge. The term includes the
readmission of a person to a hospital for:
(A) the same condition or procedure for which the
person was previously admitted;
(B) an infection or other complication resulting
from care previously provided;
(C) a condition or procedure that indicates that
a surgical intervention performed during a previous admission was
unsuccessful in achieving the anticipated outcome; or
(D) another condition or procedure of a similar
nature, as determined by the executive commissioner.
Sec. 531.982. DEVELOPMENT OF QUALITY-BASED HOSPITAL
REIMBURSEMENT SYSTEM. (a) Subject to Subsection (b), the
commission shall develop a quality-based hospital reimbursement
system for paying Medicaid reimbursements to hospitals. The system
is intended to align Medicaid provider payment incentives with
improved quality of care, promote coordination of health care, and
reduce potentially preventable complications and readmissions.
(b) The commission shall develop the quality-based hospital
reimbursement system in phases as provided by this subchapter. To
the extent possible, the commission shall coordinate the timeline
for the development and implementation with the implementation of
the Medicaid Information Technology Architecture (MITA) initiative
of the Center for Medicaid and State Operations and the ICD-10 code
sets initiative and with the ongoing Enterprise Data Warehouse
(EDW) planning process to maximize receipt of federal funds.
Sec. 531.983. PHASE ONE: COLLECTION AND REPORTING OF
CERTAIN INFORMATION. (a) The first phase of the development of
the quality-based hospital reimbursement system consists of the
elements described by this section.
(b) The executive commissioner shall adopt rules for
identifying potentially preventable readmissions of Medicaid
recipients and the commission shall collect data on
present-on-admission indicators for purposes of this section.
(c) The commission shall establish a program to provide a
confidential report to each hospital in this state regarding the
hospital's performance with respect to potentially preventable
readmissions. A hospital shall provide the information contained
in the report provided to the hospital to health care providers
providing services at the hospital.
(d) After the commission provides the reports to hospitals
as provided by Subsection (c), each hospital will be afforded a
period of two years during which the hospital may adjust its
practices in an attempt to reduce its potentially preventable
readmissions. During this period, reimbursements paid to the
hospital may not be adjusted on the basis of potentially
preventable readmissions.
(e) The commission shall convert the hospital Medicaid
reimbursement system to a diagnoses-related groups (DRG)
methodology that will allow the commission to more accurately
classify specific patient populations and account for severity of
patient illness and mortality risk.
Sec. 531.984. PHASE TWO: REIMBURSEMENT ADJUSTMENTS.
(a) The second phase of the development of the quality-based
hospital reimbursement system consists of the elements described by
this section and must be based on the information reported, and the
diagnoses-related groups (DRG) methodology implemented, during
phase one of the development.
(b) Using the information reported and the
diagnoses-related groups (DRG) methodology implemented during
phase one of the development of the quality-based hospital
reimbursement system, the commission shall adjust Medicaid
reimbursements to hospitals based on performance in reducing
potentially preventable readmissions. An adjustment:
(1) may not be applied to a hospital if the patient's
readmission to that hospital is classified as a potentially
preventable readmission, but that hospital is not the same hospital
to which the person was previously admitted; and
(2) must be focused on addressing potentially
preventable readmissions that are continuing, significant
problems, as determined by the commission.
Sec. 531.985. PHASE THREE: STUDY OF POTENTIALLY
PREVENTABLE COMPLICATIONS. (a) In phase three of the development
of the quality-based hospital reimbursement system, the commission
shall study the feasibility of:
(1) collecting data from hospitals concerning
potentially preventable complications; and
(2) adjusting Medicaid reimbursements based on
performance in reducing those complications.
(b) The commission shall provide a report to the standing
committees of the senate and house of representatives having
primary jurisdiction over the Medicaid program concerning the
results of the study conducted under this section when the study is
completed.
SECTION 7. PREVENTABLE ADVERSE EVENT REPORTING. (a) The
heading to Chapter 98, Health and Safety Code, as added by Chapter
359 (S.B. 288), Acts of the 80th Legislature, Regular Session,
2007, is amended to read as follows:
CHAPTER 98. REPORTING OF HEALTH CARE-ASSOCIATED INFECTIONS AND
PREVENTABLE ADVERSE EVENTS
(b) Subdivisions (1) and (11), Section 98.001, Health and
Safety Code, as added by Chapter 359 (S.B. 288), Acts of the 80th
Legislature, Regular Session, 2007, are amended to read as follows:
(1) "Advisory panel" means the Advisory Panel on
Health Care-Associated Infections and Preventable Adverse Events.
(11) "Reporting system" means the Texas Health
Care-Associated Infection and Preventable Adverse Events Reporting
System.
(c) Section 98.051, Health and Safety Code, as added by
Chapter 359 (S.B. 288), Acts of the 80th Legislature, Regular
Session, 2007, is amended to read as follows:
Sec. 98.051. ESTABLISHMENT. The commissioner shall
establish the Advisory Panel on Health Care-Associated Infections
and Preventable Adverse Events within [the infectious disease
surveillance and epidemiology branch of] the department to guide
the implementation, development, maintenance, and evaluation of
the reporting system.
(d) Subsection (a), Section 98.052, Health and Safety Code,
as added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is amended to read as follows:
(a) The advisory panel is composed of 18 [16] members as
follows:
(1) two infection control professionals who:
(A) are certified by the Certification Board of
Infection Control and Epidemiology; and
(B) are practicing in hospitals in this state, at
least one of which must be a rural hospital;
(2) two infection control professionals who:
(A) are certified by the Certification Board of
Infection Control and Epidemiology; and
(B) are nurses licensed to engage in professional
nursing under Chapter 301, Occupations Code;
(3) three board-certified or board-eligible
physicians who:
(A) are licensed to practice medicine in this
state under Chapter 155, Occupations Code, at least two of whom have
active medical staff privileges at a hospital in this state and at
least one of whom is an [a pediatric infectious disease physician
with expertise and experience in pediatric health care
epidemiology;
[(B) are] active member [members] of the Society
for Healthcare Epidemiology of America; and
(B) [(C)] have demonstrated expertise in quality
assessment and performance improvement or infection control in
health care facilities;
(4) four additional [two] professionals in quality
assessment and performance improvement[, one of whom is employed by
a general hospital and one of whom is employed by an ambulatory
surgical center];
(5) one officer of a general hospital;
(6) one officer of an ambulatory surgical center;
(7) three nonvoting members who are department
employees representing the department in epidemiology and the
licensing of hospitals or ambulatory surgical centers; and
(8) two members who represent the public as consumers.
(e) Subsections (a) and (c), Section 98.102, Health and
Safety Code, as added by Chapter 359 (S.B. 288), Acts of the 80th
Legislature, Regular Session, 2007, are amended to read as follows:
(a) The department shall establish the Texas Health
Care-Associated Infection and Preventable Adverse Events Reporting
System within the [infectious disease surveillance and
epidemiology branch of the] department. The purpose of the
reporting system is to provide for:
(1) the reporting of health care-associated
infections by health care facilities to the department;
(2) the reporting of health care-associated
preventable adverse events by health care facilities to the
department;
(3) the public reporting of information regarding the
health care-associated infections by the department;
(4) the public reporting of information regarding
health care-associated preventable adverse events by the
department; and
(5) [(3)] the education and training of health care
facility staff by the department regarding this chapter.
(c) The data reported by health care facilities to the
department must contain sufficient patient identifying information
to:
(1) avoid duplicate submission of records;
(2) allow the department to verify the accuracy and
completeness of the data reported; and
(3) for data reported under Section 98.103 or 98.104,
allow the department to risk adjust the facilities' infection
rates.
(f) Subchapter C, Chapter 98, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is amended by adding Section 98.1045 to read
as follows:
Sec. 98.1045. REPORTING OF PREVENTABLE ADVERSE EVENTS.
(a) Each health care facility shall report to the department the
occurrence of any of the following preventable adverse events
involving the facility's patient:
(1) a health care-associated adverse condition or
event for which the Medicare program will not provide additional
payment to the facility under a policy adopted by the federal
Centers for Medicare and Medicaid Services; and
(2) subject to Subsection (b), an event included in
the list of adverse events identified by the National Quality Forum
that is not included under Subdivision (1).
(b) The executive commissioner may exclude an adverse event
described by Subsection (a)(2) from the reporting requirement of
Subsection (a) if the executive commissioner, in consultation with
the advisory panel, determines that the adverse event is not an
appropriate indicator of a preventable adverse event.
(g) Subsections (a), (b), and (g), Section 98.106, Health
and Safety Code, as added by Chapter 359 (S.B. 288), Acts of the
80th Legislature, Regular Session, 2007, are amended to read as
follows:
(a) The department shall compile and make available to the
public a summary, by health care facility, of:
(1) the infections reported by facilities under
Sections 98.103 and 98.104; and
(2) the preventable adverse events reported by
facilities under Section 98.1045.
(b) Information included in the [The] departmental summary
with respect to infections reported by facilities under Sections
98.103 and 98.104 must be risk adjusted and include a comparison of
the risk-adjusted infection rates for each health care facility in
this state that is required to submit a report under Sections 98.103
and 98.104.
(g) The department shall make the departmental summary
available on an Internet website administered by the department and
may make the summary available through other formats accessible to
the public. The website must contain a statement informing the
public of the option to report suspected health care-associated
infections and preventable adverse events to the department.
(h) Section 98.108, Health and Safety Code, as added by
Chapter 359 (S.B. 288), Acts of the 80th Legislature, Regular
Session, 2007, is amended to read as follows:
Sec. 98.108. FREQUENCY OF REPORTING. In consultation with
the advisory panel, the executive commissioner by rule shall
establish the frequency of reporting by health care facilities
required under Sections 98.103, [and] 98.104, and 98.1045.
Facilities may not be required to report more frequently than
quarterly.
(i) Section 98.109, Health and Safety Code, as added by
Chapter 359 (S.B. 288), Acts of the 80th Legislature, Regular
Session, 2007, is amended by adding Subsection (b-1) and amending
Subsection (e) to read as follows:
(b-1) A state employee or officer may not be examined in a
civil, criminal, or special proceeding, or any other proceeding,
regarding the existence or contents of information or materials
obtained, compiled, or reported by the department under this
chapter.
(e) A department summary or disclosure may not contain
information identifying a [facility] patient, employee,
contractor, volunteer, consultant, health care professional,
student, or trainee in connection with a specific [infection]
incident.
(j) Sections 98.110 and 98.111, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, are amended to read as follows:
Sec. 98.110. DISCLOSURE AMONG CERTAIN AGENCIES [WITHIN
DEPARTMENT]. Notwithstanding any other law, the department may
disclose information reported by health care facilities under
Section 98.103, [or] 98.104, or 98.1045 to other programs within
the department, to the Health and Human Services Commission, and to
other health and human services agencies, as defined by Section
531.001, Government Code, for public health research or analysis
purposes only, provided that the research or analysis relates to
health care-associated infections or preventable adverse events.
The privilege and confidentiality provisions contained in this
chapter apply to such disclosures.
Sec. 98.111. CIVIL ACTION. Published infection rates or
preventable adverse events may not be used in a civil action to
establish a standard of care applicable to a health care facility.
(k) The commissioner of state health services shall appoint
a person who meets the qualifications prescribed by Subdivision
(3), Subsection (a), Section 98.052, Health and Safety Code, as
amended by this section, to serve as a member of the advisory panel
established under Section 98.051, Health and Safety Code, on each
expiration date of the term of a member serving on that panel who
met the qualifications prescribed by Subdivision (3), Subsection
(a), Section 98.052, Health and Safety Code, as that section
existed immediately preceding the effective date of this Act, and
who was appointed before that date. In addition, as soon as
possible after the effective date of this Act, the commissioner
shall appoint two additional members to the advisory panel who meet
the qualifications prescribed by Subdivision (4), Subsection (a),
Section 98.052, Health and Safety Code, as amended by this section.
(l) Not later than February 1, 2010, the executive
commissioner of the Health and Human Services Commission shall
adopt rules and procedures necessary to implement the reporting of
health care-associated preventable adverse events as required
under Chapter 98, Health and Safety Code, as amended by this
section.
SECTION 8. LONG-TERM CARE INCENTIVES. (a) Subchapter B,
Chapter 32, Human Resources Code, is amended by adding Section
32.0283 to read as follows:
Sec. 32.0283. PAY-FOR-PERFORMANCE INCENTIVES FOR CERTAIN
NURSING FACILITIES. (a) In this section, "nursing facility" means
a convalescent or nursing home or related institution licensed
under Chapter 242, Health and Safety Code, that provides long-term
care services, as defined by Section 22.0011, to medical assistance
recipients.
(b) If feasible, the executive commissioner of the Health
and Human Services Commission by rule shall establish an incentive
payment program for nursing facilities that is designed to improve
the quality of care and services provided to medical assistance
recipients. The program must provide additional payments in
accordance with this section to the facilities that meet or exceed
performance standards established by the executive commissioner.
(c) In establishing an incentive payment program under this
section, the executive commissioner of the Health and Human
Services Commission shall, subject to Subsection (d), adopt
outcome-based performance measures. The performance measures:
(1) must be:
(A) recognized by the executive commissioner as
valid indicators of the overall quality of care received by medical
assistance recipients; and
(B) designed to encourage and reward
evidence-based practices among nursing facilities; and
(2) may include measures of:
(A) quality of life;
(B) direct-care staff retention and turnover;
(C) recipient satisfaction;
(D) employee satisfaction and engagement;
(E) the incidence of preventable acute care
emergency room services use;
(F) regulatory compliance;
(G) level of person-centered care; and
(H) level of occupancy or of facility
utilization.
(d) The executive commissioner of the Health and Human
Services Commission shall:
(1) maximize the use of available information
technology and limit the number of performance measures adopted
under Subsection (c) to achieve administrative cost efficiency and
avoid an unreasonable administrative burden on nursing facilities;
and
(2) for each performance measure adopted under
Subsection (c), establish a performance threshold for purposes of
determining eligibility for an incentive payment under the program.
(e) To be eligible for an incentive payment under the
program, a nursing facility must meet or exceed applicable
performance thresholds in at least two of the performance measures
adopted under Subsection (c), at least one of which is an indicator
of quality of care.
(f) The executive commissioner of the Health and Human
Services Commission may:
(1) determine the amount of an incentive payment under
the program based on a performance index that gives greater weight
to performance measures that are shown to be stronger indicators of
a nursing facility's overall performance quality; and
(2) enter into a contract with a qualified person, as
determined by the executive commissioner, for the following
services related to the program:
(A) data collection;
(B) data analysis; and
(C) reporting of nursing facility performance on
the performance measures adopted under Subsection (c).
(b) Subsection (a), Section 32.060, Human Resources Code,
as added by Section 16.01, Chapter 204 (H.B. 4), Acts of the 78th
Legislature, Regular Session, 2003, is amended to read as follows:
(a) The following are not admissible as evidence in a civil
action:
(1) any finding by the department that an institution
licensed under Chapter 242, Health and Safety Code, has violated a
standard for participation in the medical assistance program under
this chapter; [or]
(2) the fact of the assessment of a monetary penalty
against an institution under Section 32.021 or the payment of the
penalty by an institution; or
(3) any information obtained or used by the department
to determine the eligibility of a nursing facility for an incentive
payment, or to determine the facility's performance rating, under
Section 32.028(g) or 32.0283(f).
(c) The Health and Human Services Commission shall conduct a
study to evaluate the feasibility of providing an incentive payment
program for the following types of providers of long-term care
services, as defined by Section 22.0011, Human Resources Code,
under the medical assistance program similar to the incentive
payment program established for nursing facilities under Section
32.0283, Human Resources Code, as added by this section:
(1) intermediate care facilities for persons with
mental retardation licensed under Chapter 252, Health and Safety
Code; and
(2) providers of home and community-based services, as
described by 42 U.S.C. Section 1396n(c), who are licensed or
otherwise authorized to provide those services in this state.
(d) Not later than September 1, 2010, the Health and Human
Services Commission shall submit to the legislature a written
report containing the findings of the study conducted under
Subsection (c) of this section and the commission's
recommendations.
(e) As soon as practicable after the effective date of this
Act, the executive commissioner of the Health and Human Services
Commission shall adopt the rules required by Section 32.0283, Human
Resources Code, as added by this section.
SECTION 9. PREVENTABLE ADVERSE EVENT REIMBURSEMENT.
(a) Subchapter B, Chapter 32, Human Resources Code, is amended by
adding Section 32.0312 to read as follows:
Sec. 32.0312. REIMBURSEMENT FOR SERVICES ASSOCIATED WITH
PREVENTABLE ADVERSE EVENTS. The executive commissioner of the
Health and Human Services Commission shall adopt rules regarding
the denial or reduction of reimbursement under the medical
assistance program for preventable adverse events that occur in a
hospital setting. In adopting the rules, the executive
commissioner:
(1) shall ensure that the commission imposes the same
reimbursement denials or reductions for preventable adverse events
as the Medicare program imposes for the same types of health
care-associated adverse conditions and the same types of health
care providers and facilities under a policy adopted by the federal
Centers for Medicare and Medicaid Services;
(2) shall consult with the Health Care Quality
Advisory Committee established under Section 531.0995, Government
Code, to obtain the advice of that committee regarding denial or
reduction of reimbursement claims for any other preventable adverse
events that cause patient death or serious disability in health
care settings, including events on the list of adverse events
identified by the National Quality Forum; and
(3) may allow the commission to impose reimbursement
denials or reductions for preventable adverse events described by
Subdivision (2).
(b) Not later than September 1, 2010, the executive
commissioner of the Health and Human Services Commission shall
adopt the rules required by Section 32.0312, Human Resources Code,
as added by this section.
(c) Rules adopted by the executive commissioner of the
Health and Human Services Commission under Section 32.0312, Human
Resources Code, as added by this section, may apply only to a
preventable adverse event occurring on or after the effective date
of the rules.
SECTION 10. PATIENT RISK IDENTIFICATION SYSTEM. Subchapter
A, Chapter 311, Health and Safety Code, is amended by adding Section
311.004 to read as follows:
Sec. 311.004. STANDARDIZED PATIENT RISK IDENTIFICATION
SYSTEM. (a) In this section:
(1) "Department" means the Department of State Health
Services.
(2) "Hospital" means a general or special hospital as
defined by Section 241.003. The term includes a hospital
maintained or operated by this state.
(b) The department shall coordinate with hospitals to
develop a statewide standardized patient risk identification
system under which a patient with a specific medical risk may be
readily identified through the use of a system that communicates to
hospital personnel the existence of that risk. The executive
commissioner of the Health and Human Services Commission shall
appoint an ad hoc committee of hospital representatives to assist
the department in developing the statewide system.
(c) The department shall require each hospital to implement
and enforce the statewide standardized patient risk identification
system developed under Subsection (b) unless the department
authorizes an exemption for the reason stated in Subsection (d).
(d) The department may exempt from the statewide
standardized patient risk identification system a hospital that
seeks to adopt another patient risk identification methodology
supported by evidence-based protocols for the practice of medicine.
(e) The department shall modify the statewide standardized
patient risk identification system in accordance with
evidence-based medicine as necessary.
(f) The executive commissioner of the Health and Human
Services Commission may adopt rules to implement this section.
SECTION 11. FEDERAL AUTHORIZATION. If before implementing
any provision of this Act a state agency determines that a waiver or
authorization from a federal agency is necessary for implementation
of that provision, the agency affected by the provision shall
request the waiver or authorization and may delay implementing that
provision until the waiver or authorization is granted.
SECTION 12. NO APPROPRIATION. This Act does not make an
appropriation. This Act takes effect only if a specific
appropriation for the implementation of the Act is provided in a
general appropriations act of the 81st Legislature.
SECTION 13. EFFECTIVE DATE. This Act takes effect
September 1, 2009.