Policy Principles for Medicaid and CHIP Legislative Initiatives: The Texas Medical Association supports the following policy principles to guide the evaluation of Medicaid and CHIP budget and legislative initiatives and association advocacy efforts:
A. Ensure patient access to timely, medically necessary primary and specialty health care services. Physician participation in Medicaid is perilously low in many parts of the state. Statewide, fewer than 50 percent of Texas physicians participate in the program, with the number steadily dropping. While the most severe shortages are among subspecialists, particularly those who treat children, access to primary care physicians also is declining.
Physicians are the backbone of a cost-effective system. Without them, the state's efforts to increase preventive care, improve treatment for the chronically ill, and reduce inappropriate emergency room utilization will falter. Competitive reimbursement is a critical component of building an adequate and stable primary and specialty physician network.
Promote use of a "medical home" for all patients to coordinate and manage preventive, primary, specialty, and ancillary services and to assure more cost-effective use of resources.
Advocate enactment of competitive Medicaid and CHIP reimbursement rates. Medicaid rates average 70 percent of Medicare and 50 percent of commercial, failing to cover the costs of providing services. As practice overhead costs rise and payment from other payers stagnates or declines, physicians must make the difficult economic decision to leave Medicaid.
B. Promote cost-effective, proactive, and appropriate use of medical services. Long-term health care cost savings are predicated not only on encouraging appropriate utilization of health care services but also on preventing the need for those services in the first place. Texas should proactively promote preventive health services within Medicaid as well as early identification and intervention for patients at risk for - or who already have developed - a chronic illness. Additionally, Texas must expand opportunities to educate patients about appropriate use of the health care delivery system, preventive care, and basic self-care.
Advocate use of health risk assessment for at-risk patients.
Support legislative initiatives to educate patients of all ages, but particularly children, about healthy lifestyles, including exercise and nutrition.
Advocate enactment of initiatives that educate parents about basic self-care techniques and prevention..
Promote use of standardized and centralized "ask a nurse" programs as a means to reduce inappropriate emergency room utilization by Medicaid and CHIP patients.
C. Simplify Medicaid regulatory requirements and streamline the delivery system. The complexity of the Medicaid program is a key factor in deterring physician participation. The proliferation of multiple Medicaid managed care plans and models, for example, split a straightforward delivery system into many components, each with distinct administrative, eligibility, and payment requirements. To make the program more attractive to physicians, Texas should consider options to streamline the Medicaid delivery and payment systems. Efforts also should be made to reduce unnecessary paperwork and their attendant costs.
For patients, the program also is fraught with administrative burdens, including navigating the same complex delivery system physicians contend with. Simplifying the eligibility process is a key component of all the other principles because it encourages patients to seek cost-effective treatment and preventive care from their medical home.
Maintain children's Medicaid simplification and extend those reforms, when feasible, to other populations.
Pursue Internet-based or "smart card" technologies that integrate eligibility, claims submission, and health and human service programs under one platform.
Promote use of community-based HMOs and physician-led accountable care organizations and other emerging innovative models within the Medicaid delivery system, including patient-centered medical homes.
D. Promote and improve health care quality. The foundation of an efficient, effective delivery system is high quality care. Yet measuring quality is notoriously difficult. Texas should work collaboratively with physicians and health care providers to devise realistic, clinically driven ways to measure and improve quality across the spectrum of care.
Advocate Medicaid HMO use of incentive payments for physicians who achieve predetermined, physician-driven performance standards, such as immunization rates, disease management participation, and well-child exams.
Support "e-medicine" efforts that enhance patient care, physician-to-patient and physician-to-physician communications, and outreach. E-medicine must be appropriately compensated.
Reward prevention and wellness promotion as well as innovative treatment and delivery alternatives, such as physician and clinic support of health education, after-hours services, or participation in disease management.
Explore opportunities to incorporate enriched health care education into school curricula (e.g., education that focuses on prevention, nutrition, fitness, and immunizations).
Develop protocols for appropriate transfer of patients from the nursing home to hospitals and from state schools to hospitals. Physicians indicate a common occurrence is transportation of a nursing home or state school patient to an emergency department for routine care that could be treated safely and effectively within the nursing home/school.
E. Assure accountability among all elements of the Medicaid system. Each component of the Medicaid program - patients, physicians, providers, community, and government - has a shared responsibility toward making Medicaid successful. Medicaid policies should articulate, promote, and reward, when met, those responsibilities. For example, physicians have an obligation to practice high quality, evidenced-based medicine as well as to promote preventive care. Patients should help with treatment decision-making, comply with treatment protocols, and begin to assume a nominal share of the cost of care; communities should recognize their unique role in educating patients about the health care system and how to use it.
Promote the purchase/underwriting of long-term care insurance to defray state costs of nursing home coverage.
Advocate federal reform to allow implementation of fair, nominal, sliding-scale cost sharing (similar to the CHIP model) for Medicaid patients. Cost sharing must be easy for the state and health care providers to administer.
Advocate simplification of the Medicaid Preferred Drug List, including an open, accessible process for classifying drugs as preferred or nonpreferred:
Require use of generic drugs when available; all generics would be available without prior authorization unless there is a safety concern.
For brand name drugs, continue use of the supplemental rebate process, but apply it only to drugs whose properties are available in more than one product (e.g., Lantus is the only long-acting insulin, but it requires prior authorization because the manufacturer refused to provide a rebate. Under this proposal, Lantus would remain available. If another brand or generic became available with the same properties, then HHSC could seek a supplemental rebate process so long as at least one drug with the needed properties remained available without prior authorization).
Promote publication of the relative price of Medicaid and CHIP drugs so that physicians are aware of the costs of prescribed drugs.
Promote physician "counter detailing" to encourage evidence-based prescribing of prescription drugs and long-term changes in physician prescribing behavior.
Require the HHSC Pharmaceutical and Therapeutics (P&T) Committee to conduct clinical and safety discussions in public to assure that stakeholders understand rationale for classifying a drug as preferred or nonpreferred.
Establish a formal appeal mechanism when drugs are not approved based on quality.
Require the P&T Committee to establish liaisons to specialty physician organizations to assure broader clinical input regarding drugs on the Preferred Drug List.
Require the Drug Utilization Review Board membership include a mix of physicians to represent the diverse Medicaid population, including pediatricians, obstetricians, primary care physicians and pediatric and adult psychiatrists.
Require HHSC to clearly specify which preferred prescription drugs on the Preferred Drug List are subject to additional clinical edits.. Such information should be easily searchable on the VDP website, Epocrates, and the Medicaid HMO pharmacy benefit manager websites.
Require HHSC to provide timely notice of proposed clinical edits and to solicit input from appropriate physician specialties on the criteria. HHSC should provide the rationale for the proposed clinical edit, the potential cost-savings, if any, and the name of the entity that proposed the change.
Require Medicaid HMOs to adhere to prompt payment provisions, except where the statute conflicts with federal law, and assure that any standardized contracting legislation applies to Medicaid and CHIP plans.
Educate physicians and patients about how to report actual fraud and abuse within Medicaid and CHIP, while educating policymakers that clerical and billing errors are not tantamount to fraud.
Require fraud and abuse reports prepared by the Medicaid Office of Inspector General, comptroller, and other oversight agencies to distinguish within their reporting statistics relating to inadvertent coding and billing errors and those relating to actual fraud. State payment recoveries stemming from billing errors are not the same as those resulting from fraud.
F. Maximize use of all available funding streams. Texas should continue to identify options for accessing and maximizing federal Medicaid funds. Texas also should explore mechanisms to use county indigent health care dollars to attract additional Medicaid funds that could be used to subsidize coverage for uninsured patients. Local governments spend substantial tax dollars on health care for uninsured or underinsured patients. Matching these funds potentially could provide Texas additional dollars to fund innovative partnerships that reduce the number of uninsured patients.
Support restoration of Medicaid and CHIP services reduced or eliminated during the 78th legislative session, including, but not limited to, full restoration of:
Medicaid graduate medical education;
Funding for public mental health services, particularly for children;
Adult Medically Needy Program;
Advocate enactment of federal waivers that allow Texas to draw down additional federal matching funds.
G. Recognize the necessity of an adequate, diverse physician and allied health professional workforce. An adequate, diverse medical workforce is critical to the efficient functioning not only of Medicaid but also of all public and private health care systems in Texas. Medicaid is critical to the workforce debate for two reasons: (1) the program historically has offered significant funding to train future physicians by providing funding for graduate medical education, and (2) Medicaid patients account for the bulk of the workload in medical schools, residency programs, and community clinics where medical students and residents receive valuable, real-world training. Ignoring the growing indications of physician and allied health professional shortages will be at the peril of the entire Texas health care delivery system.
Actively promote restoration of funding for Medicaid graduate medical education and physician residency programs.
H. Encourage innovative partnerships between the public and private sectors to address shared health goals. Government and the private sector each play an important role in the financing, regulation, organization, and innovation of health care. Too often, however, those spheres of influence remain separate, failing to recognize the relative strengths of each. Texas should explore ways to integrate public and private health insurance initiatives to address the mutual concerns of improving quality care and patient safety, reducing the number of uninsured, and promoting prevention and wellness.
A good example of private-public partnerships is TMA-supported legislation passed last year that encourages blending Medicaid funds with employer subsidies to purchase affordable health insurance for uninsured workers. Texas should consider expanding these initiatives and exploring other innovative options.
I. Recognize the diversity of the Medicaid population and devise strategies to address the unique health care needs and costs of each. Medicaid often is evaluated and discussed as one, monolithic system. In fact, it is many. Medicare serves primarily an adult, aged population; private health plans serve primarily healthy, working adults. Medicaid, however, insures a range of populations with vastly different needs (children, individuals with disabilities, the elderly) and in vastly different settings (acute vs. long-term care, community vs. institutions). Medicaid reforms require developing strategies appropriate for the diversity of the populations served and the cost drivers inherent to each.
Collaborate with the governor, lieutenant governor, speaker and legislative leaders to identify potential changes to federal Medicaid and CHIP statutes that would benefit the state, patients, and physicians.
J. Recognize the interdependence of Medicaid and the public health system. As one of the largest health care systems in Texas, Medicaid plays a critical role in supporting public health services. The two most notable examples are disease detection and prevention, services that ultimately benefit not just Medicaid patients but all Texans.
Strengthen the public health infrastructure.
Support public health programs aimed at preventive health care, including immunizations, maternal and child health, cancer screening and prevention, and disease detection and surveillance.
Provide incentives for physicians to work closely with public health agencies to coordinate major initiatives (AHCM-MAC Rep. 1-1-04; amended SC-MCU Rep. 1-A-15)