Texas seeks to renew Medicaid demonstration despite negative evaluation

Texas is asking the CMS to extend a broad Medicaid waiver program to improve access and quality even though its own evaluation of the program found it has done little to improve access and providers complain it's been administratively cumbersome.

Providers expressed particular frustration to survey officials about an uncompensated-care pool created by the demonstration, under which the state makes supplemental payments to them.

Compared to a prior uncompensated-care reimbursement model, the pool requires burdensome paperwork and spreadsheets and has resulted in uncertain payment dates and amounts, providers said.

"This was particularly problematic because of the demand placed on smaller hospitals with less staff capacity to accommodate the increased paperwork," the Texas Health and Human Services Commission said in its evaluation report released May 29.

In 2011, Texas received federal approval for a waiver providing $4 billion a year for the Texas Healthcare Transformation and Quality Improvement Program, which covers providers' uncompensated-care bills. It also includes the Delivery System Reform Incentive Payment, or DSRIP, which encourages providers to adopt innovative programs that boost quality and cost-effectiveness of care. The waiver also expanded managed Medicaid in the state.

The state is seeking an extension of the waiver and has posted an evaluation of how it has performed up to now. Texas officials did not respond to a request for comment on this story.

The fate of the waiver extension request was in doubt under the Obama administration, which pressed states such as Texas and Florida to expand Medicaid under the Affordable Care Act as the preferred way of increasing access and reducing uncompensated care.

But observers think Texas has a better chance of winning approval from the Trump administration. Florida recently won federal approval for its uncompensated-care waiver program despite that state's refusal to expand Medicaid.

Under the Texas waiver, Medicaid managed care was expanded to more than 160 counties, increasing the total number of beneficiaries in the state's Medicaid managed-care programs to more than 3.5 million.

According to the report, healthcare organizations said getting their staff providers approved as network providers for Medicaid plans has been difficult and slow. Providers said this was because the Medicaid plans are understaffed and have high turnover. This led to lengthy waits for bill payment by the plans.

Texas Medicaid officials had hoped expanding managed care would enhance access to care for low-income residents across the state. But it's not clear that has happened, based on the state's survey results.

"Response was mixed as to whether the expansion of managed care improved access or hindered it," the report said.

Some providers felt the Medicaid managed expansion provided patients more choice in where to get care. They also praised a policy change that lifted a previous limit of three covered prescriptions per month, which helped patients with multiple chronic conditions.

In contrast, other providers said access declined because of the limited type of providers covered. The demonstration excluded public health providers, chiropractors and hospices. In addition, because of the slow credentialing process and increased administrative burdens, many providers decided not to participate in the initiative.