TMA Says Involve Physicians in Medicaid 1115 Waiver

Texas' five-year 1115 Medicaid Transformation Waiver will expire Sept. 30, 2016, unless the government grants a renewal or extension. TMA President Tom Garcia, MD, told Texas Health and Human Services Commission (HHSC) Executive Commissioner Chris Traylor in a letter the association "absolutely supports renewal of the waiver beyond its initial five years," but with more physician involvement.

To extend or renew the waiver, HHSC has to submit a request to the Centers for Medicaid & Medicare Services (CMS) by Sept. 30, 2015. In the letter, TMA says the funding from the waiver "will help communities maintain or expand indigent care initiatives; support important delivery system reform and improvement projects begun under the initial waiver; and continue to test novel, emerging ideas to improve health care access and outcomes among low-income Texans."

Texas received a waiver in 2011 to allow it to expand Medicaid managed care statewide, to establish a new uncompensated care pool for safety net hospitals and health professionals, and to establish and fund innovative projects to improve availability and quality of services to Medicaid and uninsured Texans. Federal and state funds sustain the waiver, with primary funding coming from large hospital districts.

While TMA supports renewing or extending the waiver — the funding from which is critical to Texas' health care safety net — the association also recognizes that the transformation envisioned by the waiver remains elusive because of the lack of meaningful and ongoing input from community-based physicians. CMS and HHSC must change the waiver to rectify the lack of true collaboration among facilities and physicians, Dr. Garcia says, adding that Texas must increase Medicaid payments to physicians to sustain any delivery system changes achieved by the waiver.

"The association strongly supported the waiver at 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. However, 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, privately practicing physicians, particularly since one of the stated waiver goals was to foster collaboration among hospitals, physicians, and other providers," he wrote. 

Dr. Garcia calls on the state to "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."

The letter suggests HHSC "strongly consider" these waiver revisions: 

  • Establish competitive Medicaid physician payments to attract and retain physicians within Medicaid. 
  • Design a pragmatic, private health insurance initiative to extend coverage to the 1 million Texans earning too much for Medicaid but too little to qualify for federal health insurance subsidies, similar to the thoughtful initiatives designed in Indiana, Michigan, and other conservative states. 
  • Establish an ongoing physician advisory council composed of privately practicing physicians as well as their academic and hospital-affiliated peers to actively assist in the development, implementation, and evaluation of new or renewed Delivery System Reform Incentive Payment (DSRIP) program projects. 
  • Require each regional health care partnership (RHP) to establish a physician advisory committee 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. 

Visit the HHSC website to view the 1115 Waiver Extension Application Draft, attachments, and public notice. HHSC took comments on the draft during July at statewide public meetings. If you were unable to attend a public meeting, you can complete an online survey about the 1115 Waiver Extension Application Draft, specifically the DSRIP program and uncompensated care requests for the extension period. You can also ask questions or submit comments via email by Aug. 5. 

For more information about the 1115 Medicaid Transformation Waiver, visit the HHSC website.

Action, Aug. 3, 2015

Last Updated On

January 06, 2020