TMA Comments on 1115 Medicaid Waiver

May 15, 2014

The Honorable Garnet Coleman, MD, Chair
House Committee on County Affairs
PO Box 2910
Austin, Texas 78768-2910 

Dear Chairman Coleman:

On behalf of the Texas Medical Association, thank you for the opportunity to provide input on the Texas Healthcare Transformation and Quality Improvement 1115 Medicaid Waiver. 

The association strongly supported the waiver from its inception not only because of the vital funding it would provide to Texas’ safety net hospitals over the life of the agreement, but also because of its potential to improve health care delivery and health outcomes for uninsured and Medicaid patients. 

As you know, at the outset of the waiver planning process, many of our members were frustrated by the lack of meaningful, local engagement of community-based physicians, particularly since one of the stated waiver goals was to foster collaboration among hospitals, physicians, and other providers. Although a number of the 20 Regional Health Partnerships (RHPs) ended up devising pragmatic, creative strategies for reducing some of the perennial hurdles their low-income patients face when trying to obtain needed medical care, such as too few primary care and/or specialty physicians, cultural or language barriers, the lack of after-hours care in community clinics or offices, and incoherent care coordination for the chronically ill, other RHPs only used the process to reinforce the status quo and developed projects that simply benefitted the current hospital-centric environment. 

TMA believes that the RHPs’ focus should align with the association’s Healthy Vision 2020 strategic plan, which calls on the state, among other things, to increase investment in prevention to reduce rates of chronic disease; to strengthen and expand the state’s community-based behavioral health system in order to help decrease incarceration rates and inpatient mental health admissions; to increase the state’s health care workforce;  and to encourage the development of patient-centered medical homes as a means to increase effective and efficient health care delivery. 

In spite of these caveats, TMA strongly supports renewal of the waiver beyond its initial five years. The dollars will help communities maintain or expand the important projects begun under the initial waiver as well as test novel, emerging ideas to improve health care access and outcomes among low-income Texans. As the state contemplates what modifications Texas should make to the waiver, first and foremost we ask that HHSC revisit potential mechanisms for ensuring that private practicing physicians – in addition to their academic and hospital-based peers – are actively engaged in developing, implementing and evaluating local projects. Many of the waiver initiatives may not directly benefit community-based physician practices, but they will benefit their patients. For example, by expanding the availability of psychiatric and substance abuse treatment, primary care physicians who may have been reluctant to co-manage mentally ill patients now have resources they need to provide such care within their own practices.

One possible approach to better engaging community-based physicians would be to appoint an independent physician advisory committee for each RHP composed of county medical society physician representatives and practicing community and academic physicians (to the extent the latter practice within the region) to ensure that physicians are actively involved with the RHP in designing, implementing, and evaluating projects. Each committee would be required to convey its recommendations not only to its RHP but also to HHSC and the general public to ensure greater transparency. 

Today’s health care environment is highly competitive, a situation that tends to foment distrust among physicians, hospitals and other key stakeholders. We know that in many communities the waiver has strained local relationships between doctors and hospitals. Exclusion of physicians from the initial waiver planning and funding has already resulted in community-based physicians discontinuing programs designed to serve uninsured patients. The state must establish a clear expectation that hospital districts and counties that fund the state’s portion of the waiver will collaborate meaningfully with their local community-based doctors, on whom the Medicaid program strongly depends. 

Further, we believe that HHSC needs to align, to the extent possible, the waiver quality improvement initiatives with those that will be implemented by the Medicaid HMOs. Local health care delivery systems are stretched thin trying to provide appropriate care for growing Medicaid and uninsured populations. If the hospital districts/counties, Medicaid HMOs and the HHSC quality-based payment process each adopt different quality-improvement activities, we do not believe it will be possible for physicians, hospitals, and providers to implement them all given the finite human and financial resources needed to successfully launch and maintain quality-improvement projects.

Over the coming months, we look forward to working closely with you and HHSC on waiver renewal discussions.


Austin I. King, MD, President
Texas Medical Association
cc:  John Holcomb, MD, Chair, TMA Select Committee on Medicaid, CHIP and the Uninsured

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