Texas 2011 - 82nd Regular

Texas House Bill HB3744 Compare Versions

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1	1	82R25156 E
2	2	By: Gonzales of Hidalgo, Schwertner, Coleman, H.B. No. 3744
3	3	et al.
4	4	Substitute the following for H.B. No. 3744:
5	5	By: Kolkhorst C.S.H.B. No. 3744
6	6
7	7
8	8	A BILL TO BE ENTITLED
9	9	AN ACT
10	10	relating to the reimbursements for certain services provided to
11	11	Medicaid recipients and reimbursement adjustments relating to
12	12	those services.
13	13	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
14	14	SECTION 1. Section 531.001, Government Code, is amended by
15	15	adding Subdivisions (4-a) and (4-b) to read as follows:
16	16	(4-a) "Potentially preventable complication" means a
17	17	harmful event or negative outcome with respect to a person,
18	18	including an infection or surgical complication, that:
19	19	(A) occurs after the person's admission to a
20	20	hospital or long-term care facility;
21	21	(B) results from the care, lack of care, or
22	22	treatment provided during the hospital or long-term care facility
23	23	stay, as applicable, rather than from a natural progression of an
24	24	underlying disease; and
25	25	(C) could reasonably have been prevented if care
26	26	and treatment had been provided in accordance with accepted
27	27	standards of care.
28	28	(4-b) "Potentially preventable readmission" means a
29	29	return hospitalization of a person within a period specified by the
30	30	commission that results from deficiencies in the care or treatment
31	31	provided to the person during a previous hospital stay or from
32	32	deficiencies in post-hospital discharge follow-up. The term does
33	33	not include a hospital readmission necessitated by the occurrence
34	34	of unrelated events after the discharge. The term includes the
35	35	readmission of a person to a hospital for:
36	36	(A) the same condition or procedure for which the
37	37	person was previously admitted;
38	38	(B) an infection or other complication resulting
39	39	from care previously provided;
40	40	(C) a condition or procedure that indicates that
41	41	a surgical intervention performed during a previous admission was
42	42	unsuccessful in achieving the anticipated outcome; or
43	43	(D) another condition or procedure of a similar
44	44	nature, as determined by the executive commissioner.
45	45	SECTION 2. Subchapter B, Chapter 531, Government Code, is
46	46	amended by adding Sections 531.02115 and 531.02117 to read as
47	47	follows:
48	48	Sec. 531.02115. REIMBURSEMENT METHODOLOGY FOR MEDICAID
49	49	INPATIENT HOSPITAL SERVICES. (a) To incentivize controlling costs
50	50	and improving efficiency, the commission shall, subject to
51	51	adjustments required by this section:
52	52	(1) convert the reimbursement methodology used under
53	53	the Medicaid program to reimburse inpatient hospital services to an
54	54	all patient refined diagnosis-related groups (DRG) methodology;
55	55	and
56	56	(2) establish a statewide standard dollar amount (SDA)
57	57	rate that is based on the average of all hospital costs associated
58	58	with providing services under the Medicaid program during the
59	59	preceding fiscal year.
60	60	(b) In converting to the reimbursement methodology under
61	61	Subsection (a)(1), the commission shall, to the extent possible,
62	62	examine reimbursement methodologies, including nationally
63	63	implemented reimbursement methodologies, that address historical
64	64	disparities in the provision of health care services to women,
65	65	children, and persons with mental illnesses.
66	66	(c) The commission may adjust rates determined using the
67	67	factors under Subsection (a) to ensure the equitable reimbursement
68	68	of hospitals for inpatient services by adjusting the rates as
69	69	necessary to take into account different markets and provider
70	70	responsibilities, including by making rate adjustments to account
71	71	for:
72	72	(1) whether a hospital is a teaching institution;
73	73	(2) market wage indexes; and
74	74	(3) whether the hospital is a state-designated trauma
75	75	facility or a burn center.
76	76	(d) The commission shall adjust rates determined using the
77	77	factors under Subsection (a) to provide incentives for hospitals to
78	78	provide higher quality of care. To provide the incentives, the
79	79	commission shall establish a hospital value-based purchasing
80	80	program that includes quality standards established by the
81	81	executive commissioner by rule, other than quality standards
82	82	relating to potentially preventable readmissions and potentially
83	83	preventable complications. Incentives provided under the program
84	84	must be based on whether a hospital meets, or improves the
85	85	hospital's performance with respect to meeting, those quality
86	86	standards. Under the program, the commission may:
87	87	(1) reduce a hospital's reimbursement rates by two
88	88	percent each fiscal year the hospital fails to meet, or to make
89	89	progress toward meeting, the quality standards; and
90	90	(2) use 50 percent of the money saved as a result of
91	91	the reimbursement rate reductions to award hospitals that meet, or
92	92	make progress toward meeting, the quality standards.
93	93	(e) Notwithstanding Subsection (d)(1), the commission may
94	94	reduce reimbursement rates as provided by that subsection only by
95	95	the following percentages:
96	96	(1) one percent for the state fiscal year beginning
97	97	September 1, 2012;
98	98	(2) 1.25 percent for the state fiscal year beginning
99	99	September 1, 2013;
100	100	(3) 1.5 percent for the state fiscal year beginning
101	101	September 1, 2014; and
102	102	(4) 1.75 percent for the state fiscal year beginning
103	103	September 1, 2015.
104	104	(f) Except as provided by Subsection (g), this section does
105	105	not apply to a hospital:
106	106	(1) located in a county with a population of less than
107	107	50,000 according to the 2000 federal decennial census;
108	108	(2) owned or operated by this state;
109	109	(3) whose inpatients are predominately individuals
110	110	under 18 years of age as described under Section
111	111	1886(d)(1)(B)(iii), Social Security Act (42 U.S.C. Section
112	112	1395ww(d)(1)(B)(iii));
113	113	(4) classified as a rural referral center under
114	114	Section 1886(d)(1)(C)(i), Social Security Act (42 U.S.C. Section
115	115	1395ww(d)(1)(C)(i));
116	116	(5) that is a sole community hospital as defined under
117	117	Section 1886(d)(1)(D)(iii), Social Security Act (42 U.S.C. Section
118	118	1395ww(d)(1)(D)(iii)), that is not located in a metropolitan
119	119	statistical area as defined by the United States Office of
120	120	Management and Budget; or
121	121	(6) that is a critical access hospital as defined
122	122	under Section 1861(mm)(1), Social Security Act (42 U.S.C. Section
123	123	1395x(mm)(1)).
124	124	(g) The commission shall reimburse hospitals described
125	125	under Subsection (f) for inpatient care services in a manner that is
126	126	consistent with provision of payments for inpatient care services
127	127	under Title XVIII, Social Security Act (42 U.S.C. Section 1395 et
128	128	seq.).
129	129	(h) This subsection and Subsection (e) expire September 1,
130	130	2017.
131	131	Sec. 531.02117. REIMBURSEMENT ADJUSTMENTS. (a) Subject to
132	132	Subsection (b), using the data collected under Section 531.02116
133	133	and the all patient refined diagnosis-related groups (DRG)
134	134	methodology implemented under Section 531.02115, the commission
135	135	shall to the extent feasible adjust Medicaid reimbursements to
136	136	hospitals, including payments made under the disproportionate
137	137	share hospitals and upper payment limit supplemental payment
138	138	programs, in a manner that penalizes a hospital based on the
139	139	hospital's failure to reduce potentially preventable readmissions
140	140	and potentially preventable complications.
141	141	(b) The commission must provide the report required under
142	142	Section 531.02116(b) to a hospital at least one year before the
143	143	commission adjusts Medicaid reimbursements to the hospital under
144	144	this section.
145	145	(c) This section does not apply to a hospital described
146	146	under Section 531.02115(f).
147	147	SECTION 3. Section 531.913, Government Code, is transferred
148	148	to Subchapter B, Chapter 531, Government Code, redesignated as
149	149	Section 531.02116, Government Code, and amended to read as follows:
150	150	Sec. 531.02116 [531.913]. COLLECTION AND REPORTING OF
151	151	CERTAIN [HOSPITAL HEALTH] INFORMATION [EXCHANGE]. (a) [In this
152	152	section, "potentially preventable readmission" means a return
153	153	hospitalization of a person within a period specified by the
154	154	commission that results from deficiencies in the care or treatment
155	155	provided to the person during a previous hospital stay or from
156	156	deficiencies in post-hospital discharge follow-up. The term does
157	157	not include a hospital readmission necessitated by the occurrence
158	158	of unrelated events after the discharge. The term includes the
159	159	readmission of a person to a hospital for:
160	160	[(1) the same condition or procedure for which the
161	161	person was previously admitted;
162	162	[(2) an infection or other complication resulting from
163	163	care previously provided;
164	164	[(3) a condition or procedure that indicates that a
165	165	surgical intervention performed during a previous admission was
166	166	unsuccessful in achieving the anticipated outcome; or
167	167	[(4) another condition or procedure of a similar
168	168	nature, as determined by the executive commissioner.
169	169	[(b)] The executive commissioner shall adopt rules for
170	170	identifying potentially preventable readmissions of Medicaid
171	171	recipients and potentially preventable complications experienced
172	172	by those recipients. The [and the] commission shall collect
173	173	[exchange] data from [with] hospitals on present-on-admission
174	174	indicators for purposes of this section.
175	175	(b) [(c)] The commission shall establish a [health
176	176	information exchange] program to provide a [exchange] confidential
177	177	report to [information with] each hospital in this state that
178	178	participates in the Medicaid program regarding the hospital's
179	179	performance with respect to potentially preventable readmissions
180	180	and potentially preventable complications. To the extent possible,
181	181	a report provided under this section should include potentially
182	182	preventable readmissions and potentially preventable complications
183	183	information across all payment systems. A hospital shall
184	184	distribute the information contained in the report [received from
185	185	the commission] to health care providers providing services at the
186	186	hospital.
187	187	(c) A report provided to a hospital under this section is
188	188	confidential and is not subject to Chapter 552.
189	189	(d) This section does not apply to a hospital described
190	190	under Section 531.02115(f).
191	191	SECTION 4. (a) As soon as possible after the effective date
192	192	of this Act, but not later than September 1, 2012:
193	193	(1) the Health and Human Services Commission shall
194	194	convert the Medicaid hospital services reimbursement methodology
195	195	to an all patient refined diagnosis-related groups (DRG)
196	196	methodology as required by Section 531.02115(a), Government Code,
197	197	as added by this Act, under which hospitals are reimbursed for the
198	198	provision of services under the Medicaid program at a rate that is
199	199	based on the statewide standard dollar amount (SDA) rate also
200	200	required under that section; and
201	201	(2) the executive commissioner of the Health and Human
202	202	Services Commission shall adopt the quality standards for use in
203	203	the hospital value-based purchasing program as required by Section
204	204	531.02115(d), Government Code, as added by this Act.
205	205	(b) The Health and Human Services Commission shall provide
206	206	reimbursements to hospitals for the provision of services under the
207	207	Medicaid program using the reimbursement rates in effect on August
208	208	31, 2011, until the commission meets the requirements of Subsection
209	209	(a)(1) of this section. After the commission implements that
210	210	methodology and notwithstanding any other law, the commission may
211	211	not use appropriated money to provide reimbursements under any
212	212	other methodology.
213	213	(c) Notwithstanding Sections 531.02115(d) and (e) and
214	214	531.02117, Government Code, as added by this Act, the Health and
215	215	Human Services Commission may only implement the hospital
216	216	value-based purchasing program as required by Section
217	217	531.02115(d), Government Code, as added by this Act, or otherwise
218	218	adjust reimbursement rates as provided by this Act after the Health
219	219	and Human Services Commission converts the Medicaid hospital
220	220	services reimbursement methodology and establishes the statewide
221	221	standard dollar amount (SDA) rate under Section 531.02115(a),
222	222	Government Code, as added by this Act.
223	223	(d) Not later than September 1, 2012, the Health and Human
224	224	Services Commission shall begin providing performance reports to
225	225	hospitals regarding the hospitals' performances with respect to
226	226	potentially preventable complications as required by Section
227	227	531.02116, Government Code, as transferred, redesignated, and
228	228	amended by this Act.
229	229	SECTION 5. If before implementing any provision of this Act
230	230	a state agency determines that a waiver or authorization from a
231	231	federal agency is necessary for implementation of that provision,
232	232	the agency affected by the provision shall request the waiver or
233	233	authorization and may delay implementing that provision until the
234	234	waiver or authorization is granted.
235	235	SECTION 6. This Act takes effect immediately if it receives
236	236	a vote of two-thirds of all the members elected to each house, as
237	237	provided by Section 39, Article III, Texas Constitution. If this
238	238	Act does not receive the vote necessary for immediate effect, this
239	239	Act takes effect September 1, 2011.