The Texas Medical Board (TMB) has begun inspecting Texas practices
registered with the board as providing office-based anesthesia (OBA) to ensure
compliance with Chapter 192 of board rules. Practices that provide OBA must register with the
board, pay a biennial fee of $210 per physician, and identify the level of
anesthesia services provided at each practice site.
According to the TMB website, the board will give physicians at least five days'
notice before inspection and will request information from registered physicians
at or before the time of inspection.
On May 23, the Centers for Medicare & Medicaid Services (CMS) announced
it's partnering with Texas to test a new model for providing Medicare-Medicaid
enrollees with more coordinated care. The demonstration builds on Texas’
STAR+PLUS Medicaid HMO program in six counties: Bexar, Dallas, El Paso, Harris,
Hidalgo, and Tarrant. In total, 168,000 individuals will be eligible to enroll
in the demonstration.
Under the demonstration, Medicare-Medicaid Plans (MMPs) will cover Medicare
benefits in addition to the existing set of Medicaid benefits they currently
offer under STAR+PLUS, allowing for an integrated set of benefits for
Texas physicians who care for dual-eligible patients say they see the need
for better coordination but remain concerned about how well the demonstration
project will work.
"I'm all for saving money in a program that's very fragmented. It's crazy to
have to go to Medicaid for some things and Medicare for others. And from the
patient side, it would be simpler if it works out the way it shows on paper,"
San Antonio pulmonologist John Holcomb, MD, told Texas Medicine in an
article in the May 2014 issue
of the magazine. "But the devil is always in the details, and we just don't
have much faith that managed care companies are really going to do what needs to
be done to coordinate care for these patients."
To ensure each MMP can serve Medicare-Medicaid enrollees, all participating
plans must first meet core Medicare and Medicaid requirements, state
procurements standards, and state insurance rules. Each plan must also pass a
comprehensive readiness review operated by CMS and the state.
Enrollment is set to begin March 1, 2015, with one month of opt-in-only
enrollment. Passive enrollment will be phased in over six months starting April
Currently, Medicare-Medicaid enrollees navigate multiple sets of rules,
benefits, insurance cards, and health providers (Medicare parts A, B, D, and
Medicaid). CMS says many dual-eligible patients suffer from multiple or severe
chronic conditions and could benefit from better care coordination and
management of health care and long-term services.
In July 2011, CMS announced the opportunity for states to partner with CMS
through one of two models:
- Managed fee-for-service model: A state and CMS enter into an agreement by
which the state would be eligible to benefit from savings resulting from
initiatives to improve quality and reduce costs for Medicare and Medicaid.
- Capitated model: A state and CMS contract with health plans or other
qualified entities that receive a prospective, blended payment to provide
enrolled Medicare-Medicaid enrollees with coordinated care.
Texas' demonstration falls under the capitated model.
Texas currently operates the STAR+PLUS program, which provides managed care
services to Medicaid members with disabilities or those aged 65 and older,
including those dually eligible for Medicaid and Medicare. Eligible Medicaid
members receive long-term support and services through participating health
Under Texas' demonstration, MMPs will cover Medicare benefits in addition to
the Medicaid benefits currently covered through STAR+PLUS. CMS says the change
will allow MMPs to offer Medicare-Medicaid enrollees an integrated set of
benefits to more comprehensively address their individual service needs.
Visit the Texas Health and Human Services website for additional
information about the STAR+PLUS program in Texas and the demonstration.
The Centers for Medicare and Medicaid Services (CMS) on May 9 awarded
Ohio-based KEPRO the Beneficiary and Family-Centered Care (BFCC) Quality
Improvement Organization (QIO) Program contract for Texas, 32 other states, and
the District of Columbia.
CMS stated in a news release KEPRO "will be responsible for ensuring
consistency in the review process with consideration of local factors important
to beneficiaries." The agency also said the award is part of a restructuring
effort "to gain efficiencies, to eliminate any perceived conflicts of interest,
and to better address the needs of Medicare beneficiaries using BFCC QIOs to
focus on providing patients a voice through conducting quality of care reviews,
discharge and termination of service appeals, and other areas of required review
in various provider settings."
The selection of KEPRO and Maryland-based Livanta, LLC — which will represent
17 states, Puerto Rico, and the Virgin Islands — is phase one of restructuring,
aimed at allowing the contractors to "support the program's case review and
monitoring activities separate from the traditional quality improvement
activities of the QIOs."
In the second phase — expected in July — CMS will award contracts to
organizations that will work directly with physicians, hospitals, other health
professionals, and communities on data-driven quality initiatives to improve
patient safety, reduce harm, and improve clinical care and transparency at
local, regional, and national levels.
CMS will introduce the program changes Aug. 1.
TMF Health Quality Institute Director of Communications and External
Relations Emilie Fennell notes the BFCC QIO contract award pertains only to the
review portion of the QIO program.
She says CMS has made significant changes to its national QIO program.
"The biggest change is there will be two new types of QIOs, and organizations
are not allowed to serve as both types of QIO," Ms. Fennell said.
She clarifies BFCC QIOs will be responsible for protecting Medicare patients
by reviewing individuals' concerns about their care. Because TMF pursued the
quality improvement portion (phase two) of the Medicare QIO contract, the
organization could not pursue the case review contract.
"TMF Health Quality Institute has elected to focus on quality improvement
technical assistance. This contract is scheduled to be awarded in July, and we
look forward to building on TMF's decades of quality improvement work in the
state," she said.