By: Nelson S.B. No. 7
A BILL TO BE ENTITLED
AN ACT
relating to strategies for and improvements in quality of health
care provided through and care management in the child health plan
and medical assistance programs designed to achieve healthy
outcomes and efficiency.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. QUALITY-BASED OUTCOME AND PAYMENT INITIATIVES.
(a) Subtitle I, Title 4, Government Code, is amended by adding
Chapter 536, and Section 531.913, Government Code, is transferred
to Subchapter D, Chapter 536, Government Code, redesignated as
Section 536.151, Government Code, and amended to read as follows:
CHAPTER 536. MEDICAID AND CHILD HEALTH PLAN PROGRAMS:
QUALITY-BASED OUTCOMES AND PAYMENTS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 536.001. DEFINITIONS. In this chapter:
(1) "Advisory committee" means the Medicaid and CHIP
Quality-Based Payment Advisory Committee established under Section
536.002.
(2) "Alternative payment system" includes:
(A) a global payment system;
(B) an episode-based bundled payment system; and
(C) a blended payment system.
(3) "Blended payment system" means a system for
compensating a health care provider or facility that includes at
least one or more features of a global payment system and an
episode-based bundled payment system, but that may also include a
system under which a portion of the compensation paid to a health
care provider or facility is based on a fee-for-service payment
arrangement.
(4) "Child health plan program," "commission,"
"executive commissioner," and "health and human services agencies"
have the meanings assigned by Section 531.001.
(5) "Episode-based bundled 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 that is based on a
flat payment for all services provided in connection with a single
episode of medical care.
(6) "Exclusive provider benefit plan" means a managed
care plan subject to 28 T.A.C. Part 1, Chapter 3, Subchapter KK.
(7) "Global payment system" means a system for
compensating a health care provider or facility for arranging for
or providing a defined set of covered health care services to child
health plan program enrollees or Medicaid recipients for a
specified period that is based on a predetermined payment per
enrollee or recipient, as applicable, for the specified period,
without regard to the quantity of services actually provided.
(8) "Hospital" means a public or private institution
licensed under Chapter 241 or 577, Health and Safety Code,
including a general or special hospital as defined by Section
241.003, Health and Safety Code.
(9) "Managed care organization" means a person that is
authorized or otherwise permitted by law to arrange for or provide a
managed care plan. The term includes health maintenance
organizations and exclusive provider organizations.
(10) "Managed care plan" means a plan, including an
exclusive provider benefit plan, under which a person undertakes to
provide, arrange for, pay for, or reimburse any part of the cost of
any health care services. A part of the plan must consist of
arranging for or providing health care services as distinguished
from indemnification against the cost of those services on a
prepaid basis through insurance or otherwise. The term includes a
primary care case management provider network. The term does not
include a plan that indemnifies a person for the cost of health care
services through insurance.
(11) "Medicaid program" means the medical assistance
program established under Chapter 32, Human Resources Code.
(12) "Potentially preventable admission" means an
admission of a person to a health care facility that could
reasonably have been prevented if care and treatment had been
provided by a health care provider in accordance with accepted
standards of care.
(13) "Potentially preventable ancillary service"
means a health care service provided or ordered by a health care
provider to supplement or support the evaluation or treatment of a
patient, including a diagnostic test, laboratory test, therapy
service, or radiology service, that is not reasonably necessary for
the provision of quality health care or treatment.
(14) "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
health care facility;
(B) may have resulted from the care, lack of
care, or treatment provided during the health care facility 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.
(15) "Potentially preventable event" means a
potentially preventable admission, a potentially preventable
ancillary service, a potentially preventable complication, a
potentially preventable hospital emergency room visit, a
potentially preventable readmission, or a combination of those
events.
(16) "Potentially preventable hospital emergency room
visit" means treatment of a person in a hospital emergency room for
a condition that does not require emergency medical attention
because the condition could be treated by a health care provider in
a nonemergency setting.
(17) "Potentially preventable readmission" means a
return hospitalization of a person within a period specified by the
commission that may have resulted 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 in consultation
with the advisory committee.
(18) "Quality-based payment system" means a system for
compensating a health care provider or facility, including an
alternative payment system, that provides incentives to the
provider or facility for providing high-quality, cost-effective
care and bases some portion of the payment made to the provider or
facility on quality of care outcomes, including the extent to which
the provider or facility reduces potentially preventable events.
Sec. 536.002. MEDICAID AND CHIP QUALITY-BASED PAYMENT
ADVISORY COMMITTEE. (a) The Medicaid and CHIP Quality-Based
Payment Advisory Committee is established to advise the commission
on establishing, for purposes of the child health plan and Medicaid
programs administered by the commission or a health and human
services agency:
(1) reimbursement systems used to compensate health
care providers and facilities under those programs that reward the
provision of high-quality, cost-effective health care and quality
performance and quality of care outcomes with respect to health
care services;
(2) standards and benchmarks for quality performance,
quality of care outcomes, efficiency, and accountability by managed
care organizations and health care providers and facilities;
(3) programs and reimbursement policies that
encourage high-quality, cost-effective health care delivery models
that increase appropriate provider collaboration, promote wellness
and prevention, and improve health outcomes; and
(4) outcome and process measures under Section
536.003.
(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,
representatives of managed care organizations, and other
stakeholders interested in health care services provided in this
state, including:
(1) at least one member who is a physician with
clinical practice experience in obstetrics and gynecology;
(2) at least one member who is a physician with
clinical practice experience in pediatrics;
(3) at least one member who is a physician with
clinical practice experience in internal medicine or family
medicine;
(4) at least one member who is a physician with
clinical practice experience in geriatric medicine;
(5) at least one member who is a consumer
representative; and
(6) at least one member who is 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.
Sec. 536.003. DEVELOPMENT OF QUALITY-BASED OUTCOME AND
PROCESS MEASURES. (a) The commission, in consultation with the
advisory committee, shall develop quality-based outcome and
process measures that promote the provision of efficient, quality
health care and that can be used in the child health plan and
Medicaid programs to implement quality-based payments for acute and
long-term care services across all delivery models and payment
systems, including fee-for-service and managed care payment
systems. The commission, in developing outcome measures under this
section, must consider measures addressing potentially preventable
events.
(b) To the extent feasible, the commission shall develop
outcome and process measures:
(1) consistently across all child health plan and
Medicaid program delivery models and payment systems;
(2) in a manner that takes into account appropriate
patient risk factors, including the burden of chronic illness on a
patient and the severity of a patient's illness;
(3) that will have the greatest effect on improving
quality of care and the efficient use of services; and
(4) that are similar to outcome and process measures
used in the private sector, as appropriate.
(c) The commission may align outcome and process measures
developed under this section with measures required or recommended
under reporting guidelines established by the federal Centers for
Medicare and Medicaid Services, the Agency for Healthcare Research
and Quality, or another federal agency.
(d) The executive commissioner by rule may require managed
care organizations and health care providers and facilities
participating in the child health plan and Medicaid programs to
report to the commission in a format specified by the executive
commissioner information necessary to develop outcome and process
measures under this section.
(e) If the commission increases provider reimbursement
rates under the child health plan or Medicaid program as a result of
an increase in the amounts appropriated for the programs for a state
fiscal biennium as compared to the preceding state fiscal biennium,
the commission shall, to the extent permitted under federal law and
to the extent otherwise possible considering other relevant
factors, correlate the increased reimbursement rates with the
quality-based outcome and process measures developed under this
section.
Sec. 536.004. DEVELOPMENT OF QUALITY-BASED PAYMENT
SYSTEMS. (a) Using quality-based outcome and process measures
developed under Section 536.003 and subject to this section, the
commission, after consulting with the advisory committee, shall
develop quality-based payment systems for compensating a health
care provider or facility participating in the child health plan or
Medicaid program that:
(1) align payment incentives with high-quality,
cost-effective health care;
(2) reward the use of evidence-based best practices;
(3) promote the coordination of health care;
(4) encourage appropriate provider collaboration;
(5) promote effective health care delivery models; and
(6) take into account the specific needs of the child
health plan program enrollee and Medicaid recipient populations.
(b) The commission shall develop quality-based payment
systems in the manner specified by this chapter. To the extent
necessary, the commission shall coordinate the timeline for the
development and implementation of a payment system with the
implementation of other initiatives such as the Medicaid
Information Technology Architecture (MITA) initiative of the
Center for Medicaid and State Operations, the ICD-10 code sets
initiative, or the ongoing Enterprise Data Warehouse (EDW) planning
process in order to maximize the receipt of federal funds or reduce
any administrative burden.
(c) In developing quality-based payment systems under this
chapter, the commission shall examine and consider implementing:
(1) an alternative payment system;
(2) any existing performance-based payment system
used under the Medicare program that meets the requirements of this
chapter, modified as necessary to account for programmatic
differences, if implementing the system would:
(A) reduce unnecessary administrative burdens;
and
(B) align quality-based payment incentives for
health care providers or facilities with the Medicare program; and
(3) alternative payment methodologies within the
system that are used in the Medicare program, modified as necessary
to account for programmatic differences, and that will achieve cost
savings and improve quality of care in the child health plan and
Medicaid programs.
(d) In developing quality-based payment systems under this
chapter, the commission shall ensure that a managed care
organization, health care provider, or health care facility will
not be rewarded by the system for withholding or delaying the
provision of medically necessary care.
Sec. 536.005. CONVERSION OF PAYMENT METHODOLOGY. (a) To
the extent possible, the commission shall convert reimbursement
systems under the child health plan and Medicaid programs to a
diagnosis-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.
(b) Subsection (a) does not authorize the commission to
direct a managed care organization regarding how the organization
compensates health care providers and facilities providing
services under the organization's managed care plan.
Sec. 536.006. TRANSPARENCY. The commission and the
advisory committee shall:
(1) ensure transparency in the development and
establishment of:
(A) quality-based payment and reimbursement
systems under Section 536.004 and Subchapters B, C, and D,
including the development of outcome and process measures under
Section 536.003; and
(B) quality-based payment initiatives under
Subchapter E, including the development of quality of care and
cost-efficiency benchmarks under Section 536.204(a) and efficiency
performance standards under Section 536.204(b);
(2) develop guidelines establishing procedures for
providing notice and actionable valid information to, and receiving
input from, managed care organizations, health care providers,
including physicians and experts in the various medical specialty
fields, health care facilities, and other stakeholders, as
appropriate, for purposes of developing and establishing the
quality-based payment and reimbursement systems and initiatives
described under Subdivision (1); and
(3) in developing and establishing the quality-based
payment and reimbursement systems and initiatives described under
Subdivision (1), consider that as the performance of a managed care
organization, health care provider, or health care facility
improves with respect to an outcome or process measure, quality of
care and cost-efficiency benchmark, or efficiency performance
standard, as applicable, there will be a diminishing rate of
improved performance over time.
Sec. 536.007. PERIODIC EVALUATION. (a) At least once each
two-year period, the commission shall evaluate the outcomes and
cost-effectiveness of any quality-based payment system or other
payment initiative implemented under this chapter.
(b) The commission shall:
(1) present the results of its evaluation under
Subsection (a) to the advisory committee for the committee's input
and recommendations; and
(2) provide a process by which managed care
organizations and health care providers and facilities may comment
and provide input into the committee's recommendations under
Subdivision (1).
Sec. 536.008. ANNUAL REPORT. (a) The commission shall
submit an annual report to the legislature regarding:
(1) the quality-based outcome and process measures
developed under Section 536.003; and
(2) the progress of the implementation of
quality-based payment systems and other payment initiatives
implemented under this chapter.
(b) The commission shall report outcome and process
measures under Subsection (a)(1) by health care service region and
service delivery model.
[Sections 536.009-536.050 reserved for expansion]
SUBCHAPTER B. QUALITY-BASED PAYMENTS RELATING TO MANAGED CARE
ORGANIZATIONS
Sec. 536.051. DEVELOPMENT OF QUALITY-BASED PREMIUM
PAYMENTS; PERFORMANCE REPORTING. (a) Subject to Section
1903(m)(2)(A), Social Security Act (42 U.S.C. Section
1396b(m)(2)(A)), and other applicable federal law, the commission
shall base a percentage of the premiums paid to a managed care
organization participating in the child health plan or Medicaid
program on the organization's performance with respect to outcome
and process measures developed under Section 536.003, including
outcome measures addressing potentially preventable events.
(b) The commission shall report information relating to the
performance of a managed care organization with respect to outcome
and process measures under this subchapter to child health plan
program enrollees and Medicaid recipients before those enrollees
and recipients choose their managed care plans.
Sec. 536.052. PAYMENT AND CONTRACT AWARD INCENTIVES FOR
MANAGED CARE ORGANIZATIONS. (a) The commission may allow a
managed care organization participating in the child health plan or
Medicaid program increased flexibility to implement quality
initiatives in a managed care plan offered by the organization,
including flexibility with respect to network requirements and
financial arrangements, in order to:
(1) achieve high-quality, cost-effective health care;
(2) increase the use of high-quality, cost-effective
delivery models; and
(3) reduce potentially preventable events.
(b) The commission, after consulting with the advisory
committee, shall develop quality of care and cost-efficiency
benchmarks, including benchmarks based on a managed care
organization's performance with respect to reducing potentially
preventable events and containing the growth rate of health care
costs.
(c) The commission may include in a contract between a
managed care organization and the commission financial incentives
that are based on the organization's successful implementation of
quality initiatives under Subsection (a) or success in achieving
quality of care and cost-efficiency benchmarks under Subsection
(b).
(d) In awarding contracts to managed care organizations
under the child health plan and Medicaid programs, the commission
shall, in addition to considerations under Section 533.003 of this
code and Section 62.155, Health and Safety Code, give preference to
an organization that offers a managed care plan that implements
quality initiatives under Subsection (a) or meets quality of care
and cost-efficiency benchmarks under Subsection (b).
(e) The commission may implement financial incentives under
this section only if implementing the incentives would not require
additional state funding because the cost associated with the
implementation would be offset by expected savings or additional
federal funding.
[Sections 536.053-536.100 reserved for expansion]
SUBCHAPTER C. QUALITY-BASED HEALTH HOME PAYMENT SYSTEMS
Sec. 536.101. DEFINITIONS. In this subchapter:
(1) "Health home" means a primary care provider
practice or, if appropriate, a specialty practice, incorporating
several features, including comprehensive care coordination,
family-centered care, and data management, that are focused on
improving outcome-based quality of care and increasing patient and
provider satisfaction under the child health plan and Medicaid
programs.
(2) "Participating enrollee" means a child health plan
program enrollee or Medicaid recipient who has a health home.
Sec. 536.102. QUALITY-BASED HEALTH HOME PAYMENTS.
(a) Subject to this subchapter, the commission, after consulting
with the advisory committee, may develop and implement
quality-based payment systems for health homes designed to improve
quality of care and reduce the provision of unnecessary medical
services. A quality-based payment system developed under this
section must:
(1) base payments made to a participating enrollee's
health home on quality and efficiency measures that may include
measurable wellness and prevention criteria and use of
evidence-based best practices, sharing a portion of any realized
cost savings achieved by the health home, and ensuring quality of
care outcomes, including a reduction in potentially preventable
events; and
(2) allow for the examination of measurable wellness
and prevention criteria, use of evidence-based best practices, and
quality of care outcomes based on the type of primary or specialty
care provider.
(b) The commission may develop a quality-based payment
system for health homes under this subchapter only if implementing
the system would be feasible and cost-effective.
Sec. 536.103. PROVIDER ELIGIBILITY. To be eligible to
receive reimbursement under a quality-based payment system under
this subchapter, a provider must:
(1) provide participating enrollees, directly or
indirectly, with access to health care services outside of regular
business hours;
(2) educate participating enrollees about the
availability of health care services outside of regular business
hours; and
(3) provide evidence satisfactory to the commission
that the provider meets the requirement of Subdivision (1).
[Sections 536.104-536.150 reserved for expansion]
SUBCHAPTER D. QUALITY-BASED HOSPITAL REIMBURSEMENT SYSTEM
Sec. 536.151 [531.913]. COLLECTION AND REPORTING OF
CERTAIN [HOSPITAL HEALTH] INFORMATION [EXCHANGE]. (a) [In this
section, "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:
[(1) the same condition or procedure for which the
person was previously admitted;
[(2) an infection or other complication resulting from
care previously provided;
[(3) a condition or procedure that indicates that a
surgical intervention performed during a previous admission was
unsuccessful in achieving the anticipated outcome; or
[(4) another condition or procedure of a similar
nature, as determined by the executive commissioner.
[(b)] The executive commissioner shall adopt rules for
identifying potentially preventable readmissions of child health
plan program enrollees and Medicaid recipients and potentially
preventable complications experienced by child health plan program
enrollees and Medicaid recipients. The [and the] commission shall
collect [exchange] data from [with] hospitals on
present-on-admission indicators for purposes of this section.
(b) [(c)] The commission shall establish a [health
information exchange] program to provide a [exchange] confidential
report to [information with] each hospital in this state that
participates in the child health plan or Medicaid program regarding
the hospital's performance with respect to potentially preventable
readmissions and potentially preventable complications. To the
extent possible, a report provided under this section should
include potentially preventable readmissions and potentially
preventable complications information across all child health plan
and Medicaid program payment systems. A hospital shall distribute
the information contained in the report [received from the
commission] to health care providers providing services at the
hospital.
(c) A report provided to a hospital under this section is
confidential and is not subject to Chapter 552.
Sec. 536.152. REIMBURSEMENT ADJUSTMENTS. (a) Subject to
Subsection (b), using the data collected under Section 536.151 and
the diagnosis-related groups (DRG) methodology implemented under
Section 536.005, the commission, after consulting with the advisory
committee, shall to the extent feasible adjust child health plan
and Medicaid reimbursements to hospitals, including payments made
under the disproportionate share hospitals and upper payment limit
supplemental payment programs, in a manner that may reward or
penalize a hospital based on the hospital's performance with
respect to exceeding, or failing to achieve, outcome and process
measures developed under Section 536.003 that address potentially
preventable readmissions and potentially preventable
complications.
(b) The commission must provide the report required under
Section 536.151(b) to a hospital at least one year before the
commission adjusts child health plan and Medicaid reimbursements to
the hospital under this section.
[Sections 536.153-536.200 reserved for expansion]
SUBCHAPTER E. QUALITY-BASED PAYMENT INITIATIVES
Sec. 536.201. DEFINITION. In this subchapter, "payment
initiative" means a quality-based payment initiative established
under this subchapter.
Sec. 536.202. PAYMENT INITIATIVES; DETERMINATION OF
BENEFIT TO STATE. (a) The commission shall, after consulting with
the advisory committee, establish payment initiatives to test the
effectiveness of quality-based payment systems, alternative
payment methodologies, and high-quality, cost-effective health
care delivery models that provide incentives to health care
providers and facilities to develop health care interventions for
child health plan program enrollees or Medicaid recipients, or
both, that will:
(1) improve the quality of health care provided to the
enrollees or recipients;
(2) reduce potentially preventable events;
(3) promote prevention and wellness;
(4) increase the use of evidence-based best practices;
(5) increase appropriate provider collaboration; and
(6) contain costs.
(b) The commission shall:
(1) establish a process by which managed care
organizations and health care providers and facilities may submit
proposals for payment initiatives described by Subsection (a); and
(2) determine whether it is feasible and
cost-effective to implement one or more of the proposed payment
initiatives.
Sec. 536.203. PURPOSE AND IMPLEMENTATION OF PAYMENT
INITIATIVES. (a) If the commission determines under Section
536.202 that implementation of one or more payment initiatives is
feasible and cost-effective for this state, the commission shall
establish one or more payment initiatives as provided by this
subchapter.
(b) The commission shall administer any payment initiative
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 payment initiative to:
(1) one or more regions in this state;
(2) one or more organized networks of health care
providers and facilities; 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 payment initiative implemented under this subchapter
must be operated for at least one calendar year.
Sec. 536.204. STANDARDS; PROTOCOLS. (a) The executive
commissioner shall:
(1) consult with the advisory committee to develop
quality of care and cost-efficiency benchmarks and measurable goals
that a payment initiative must meet to ensure high-quality and
cost-effective health care services and healthy outcomes; and
(2) approve benchmarks and goals developed as provided
by Subdivision (1).
(b) In addition to the benchmarks and goals 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. The
efficiency performance standards may not create any financial
incentive for or involve making a payment to a health care provider
or facility that directly or indirectly induces the limitation of
medically necessary services.
Sec. 536.205. PAYMENT RATES UNDER PAYMENT INITIATIVES. The
executive commissioner may contract with appropriate entities,
including qualified actuaries, to assist in determining
appropriate payment rates for a payment initiative implemented
under this subchapter.
(b) As soon as practicable after the effective date of this
Act, but not later than September 1, 2012, the Health and Human
Services Commission shall convert the reimbursement systems used
under the child health plan program under Chapter 62, Health and
Safety Code, and medical assistance program under Chapter 32, Human
Resources Code, to the diagnosis-related groups (DRG) methodology
to the extent possible as required by Section 536.005, Government
Code, as added by this section.
(c) Not later than September 1, 2012, the Health and Human
Services Commission shall begin providing performance reports to
hospitals regarding the hospitals' performances with respect to
potentially preventable complications as required by Section
536.151, Government Code, as designated and amended by this
section.
(d) Subject to Subsection (b), Section 536.004, Government
Code, as added by this section, the Health and Human Services
Commission shall begin making adjustments to child health plan and
Medicaid reimbursements to hospitals as required by Section
536.152, Government Code, as added by this section:
(1) not later than September 1, 2012, based on the
hospitals' performances with respect to reducing potentially
preventable readmissions; and
(2) not later than September 1, 2013, based on the
hospitals' performances with respect to reducing potentially
preventable complications.
SECTION 2. APPROPRIATE UTILIZATION OF CERTAIN HEALTH CARE
SERVICES. (a) Subchapter B, Chapter 531, Government Code, is
amended by adding Sections 531.086 and 531.0861 to read as follows:
Sec. 531.086. STUDY REGARDING PHYSICIAN INCENTIVE PROGRAMS
TO REDUCE HOSPITAL EMERGENCY ROOM USE FOR NON-EMERGENT CONDITIONS.
(a) The commission shall conduct a study to evaluate physician
incentive programs that attempt to reduce hospital emergency room
use for non-emergent conditions by recipients under the medical
assistance program. Each physician incentive program evaluated in
the study must:
(1) be administered by a health maintenance
organization participating in the STAR or STAR + PLUS Medicaid
managed care program; and
(2) provide incentives to primary care providers who
attempt to reduce emergency room use for non-emergent conditions by
recipients.
(b) The study conducted under Subsection (a) must evaluate:
(1) the cost-effectiveness of each component included
in a physician incentive program; and
(2) any change in statute required to implement each
component within the Medicaid fee-for-service or primary care case
management model.
(c) Not later than August 31, 2012, the executive
commissioner shall submit to the governor and the Legislative
Budget Board a report summarizing the findings of the study
required by this section.
(d) This section expires September 1, 2013.
Sec. 531.0861. PHYSICIAN INCENTIVE PROGRAM TO REDUCE
HOSPITAL EMERGENCY ROOM USE FOR NON-EMERGENT CONDITIONS. (a) If
cost-effective, the executive commissioner by rule shall establish
a physician incentive program designed to reduce the use of
hospital emergency room services for non-emergent conditions by
recipients under the medical assistance program.
(b) In establishing the physician incentive program under
Subsection (a), the executive commissioner may include only the
program components identified as cost-effective in the study
conducted under Section 531.086.
(c) If the physician incentive program includes the payment
of an enhanced reimbursement rate for routine after-hours
appointments, the executive commissioner shall implement controls
to ensure that the after-hours services billed are actually being
provided outside of normal business hours.
(b) Section 32.0641, Human Resources Code, is amended to
read as follows:
Sec. 32.0641. RECIPIENT ACCOUNTABILITY PROVISIONS;
COST-SHARING REQUIREMENT TO IMPROVE APPROPRIATE UTILIZATION OF
[COST SHARING FOR CERTAIN HIGH-COST MEDICAL] SERVICES. (a) To [If
the department determines that it is feasible and cost-effective,
and to] the extent permitted under Title XIX, Social Security Act
(42 U.S.C. Section 1396 et seq.) and any other applicable law or
regulation or under a federal waiver or other authorization, the
executive commissioner of the Health and Human Services Commission
shall adopt, after consulting with the Medicaid and CHIP
Quality-Based Payment Advisory Committee established under Section
536.002, Government Code, cost-sharing provisions that encourage
personal accountability and appropriate utilization of health care
services, including a cost-sharing provision applicable to
[require] a recipient who chooses to receive a nonemergency [a
high-cost] medical service [provided] through a hospital emergency
room [to pay a copayment, premium payment, or other cost-sharing
payment for the high-cost medical service] if:
(1) the hospital from which the recipient seeks
service:
(A) performs an appropriate medical screening
and determines that the recipient does not have a condition
requiring emergency medical services;
(B) informs the recipient:
(i) that the recipient does not have a
condition requiring emergency medical services;
(ii) that, if the hospital provides the
nonemergency service, the hospital may require payment of a
copayment, premium payment, or other cost-sharing payment by the
recipient in advance; and
(iii) of the name and address of a
nonemergency Medicaid provider who can provide the appropriate
medical service without imposing a cost-sharing payment; and
(C) offers to provide the recipient with a
referral to the nonemergency provider to facilitate scheduling of
the service; and
(2) after receiving the information and assistance
described by Subdivision (1) from the hospital, the recipient
chooses to obtain [emergency] medical services through the hospital
emergency room despite having access to medically acceptable,
appropriate [lower-cost] medical services.
(b) The department may not seek a federal waiver or other
authorization under this section [Subsection (a)] that would:
(1) prevent a Medicaid recipient who has a condition
requiring emergency medical services from receiving care through a
hospital emergency room; or
(2) waive any provision under Section 1867, Social
Security Act (42 U.S.C. Section 1395dd).
[(c) If the executive commissioner of the Health and Human
Services Commission adopts a copayment or other cost-sharing
payment under Subsection (a), the commission may not reduce
hospital payments to reflect the potential receipt of a copayment
or other payment from a recipient receiving medical services
provided through a hospital emergency room.]
SECTION 3. LONG-TERM CARE PAYMENT INCENTIVE INITIATIVES.
(a) The heading to Section 531.912, Government Code, is amended to
read as follows:
Sec. 531.912. PAY-FOR-PERFORMANCE INCENTIVES FOR [QUALITY
OF CARE HEALTH INFORMATION EXCHANGE WITH] CERTAIN NURSING
FACILITIES.
(b) Subsections (b), (c), and (f), Section 531.912,
Government Code, are amended to read as follows:
(b) If feasible, the executive commissioner by rule shall
establish an incentive payment program for [a quality of care
health information exchange with] nursing facilities that choose to
participate. The [in a] program must be designed to improve the
quality of care and services provided to medical assistance
recipients. Subject to Subsection (f), the program may provide
incentive payments in accordance with this section to encourage
facilities to participate in the program.
(c) In establishing an incentive payment [a quality of care
health information exchange] program under this section, the
executive commissioner shall, subject to Subsection (d), adopt
outcome-based [exchange information with participating nursing
facilities regarding] 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.
(f) The commission may make incentive payments under the
program only if money is [specifically] appropriated for that
purpose.
(c) The Department of Aging and Disability Services shall
conduct a study to evaluate the feasibility of expanding any
incentive payment program established for nursing facilities under
Section 531.912, Government Code, as amended by this section, by
providing incentive payments 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:
(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, 2012, the Department of
Aging and Disability Services shall submit to the legislature a
written report containing the findings of the study conducted under
Subsection (c) of this section and the department's
recommendations.
SECTION 4. 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 5. EFFECTIVE DATE. This Act takes effect September
1, 2011.