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David Lopez

Harris Health System plans to serve more patients via Medicaid waiver

The story about what they’re going to do leaves a few details out, however.

Harris Health System leaders plan to serve 100,000 new patients in the next three years. That is a 37 percent increase from today, and is particularly ambitious when you consider how many patients the system added in the last year: about 500.

To bridge the enormous gap by the end of 2016, the county hospital district is counting on state and federal approval of a $1.2 billion plan that represents the ambitions of health care providers throughout the region. The plan grows out of the federal government’s decision to grant Texas a waiver from Medicaid rules, allowing it to reimburse providers for charity care and for delivering care in new ways.

The plan, awaiting approval in May, envisions unprecedented cooperation between the district and local private and nonprofit providers.

“That’s a major undertaking. We’re very committed to it. We feel it’s very doable,” Harris Health CEO David Lopez said. “We cannot do it all by ourselves. We need partners with us to help us address the needs of our community.”

[…]

Among the district’s proposals awaiting approval: Build nine new primary care clinics during the next three years, build “quick” clinics next to its emergency rooms where patients who are not in crisis can be seen, outsource more primary care visits to private clinics, and leverage federal funds to support Memorial Hermann and Texas Children’s Hospital’s expansion of primary care services.

Members of Harris County Commissioners Court, which appoints the hospital district’s board, say the waiver plans are too slow in cutting the backlog of patients who cannot get primary care appointments. That waiting list, first identified in fall 2011, is estimated between 91,000 and 104,000 a year.

Commissioner El Franco Lee last week issued a memo with the phrases “reduce waiting lists” and “get patients moving through the system” underlined, calling on Lopez to cut the backlog by outsourcing more doctor visits.

I had a few questions about this after I read the story, so I sent some inquiries to the Harris Health System’s media relations email address. Here are the questions I sent, along with the answers I got:

1. The article says that “the county hospital district is counting on state and federal approval of a $1.2 billion plan”. Where is the money for this coming from? Are there new funding sources being sought, or is this a repurposing of existing funds?

Answer: The $1.2 billion plan in the article refers to the Delivery System Reform Incentive Payments (DSRIP) projects available under the 1115 Medicaid Transformational Waiver Program. Harris Health System serves as the anchor entity for the regional planning for several counties in SE Texas. The Waiver primarily does two things: 1) expands Medicaid managed care to the entire state 2) replaces the Upper Payment Limit (UPL) program with two new pools of funding, The Uncompensated Care Pool and the DSRIP Pool. Detailed information about the proposed local regional health plan may be found at www.SETexasRHP.com.

2. What entities are being asked to approve this plan? What exactly are they being asked to approve? What happens if they reject some or all of it?

Answer: The state of Texas and U.S. Centers for Medicare and Medicaid Services (CMS) will approve all plans.

3. The story says that this plan is unrelated to the Affordable Care Act. How will the plan be affected if the state changes course and decides to pursue Medicaid expansion, or a law is passed that grants counties the authority to pursue it on their own?

Answer: The 1115 Medicaid Transformational Waiver Program should not be affected by Medicaid expansion since it is unrelated. Detailed information about the 1115 Medicaid Transformational Waiver at-large, may also be found at the state’s Web site.

4. Are details of this plan available on the HHS website? If not, is there a document you could send to me with plan details?

Answer: Detailed information about the proposed local regional health plan may be found at www.SETexasRHP.com.

In other words, if you want to know more, you’re going to need to get your wonk on. State Rep. Garnet Coleman has discussed the 1115 waiver before – see here and here for two examples – and there’s some further discussion here. Basically, this is about delivering health care services via public hospitals and their partners more effectively and efficiently, with some extra federal funds available. It’s not fully clear how this will all work out, and there won’t be a decision on the waiver request until May, but this is what’s coming. Let’s hope it lives up to its promise.

Inside baseball with the hospital district

I’m not really sure what I’m supposed to learn from this article about the political relationship between the Harris County Hospital District and Commissioners Court.

New name for HCHD

You have to wonder if David Lopez ever feels like he’s in the circus.

When Lopez, the CEO of Harris Health System, Harris County’s public hospital district, visits Commissioners Court to present a proposal, purchase, or budget, he tends to play the role of target in a precision knife-throwing act, facing a flurry of sharp questions.

So it was last week, when Lopez sought to buy a mothballed outpatient surgery center on the Southwest Freeway for $7.8 million. Frowning court members said it was the first they had heard of the item, and nearly rejected the matter outright before sending it to the county infrastructure director for further study.

It was the latest example of disconnect between the hospital district and the county’s leaders. The district operates separately from the county, but its board is appointed by Commissioners Court and the court approves its annual budget, tax rate and long-term real estate leases and purchases. Aides to the court members attend the board’s meetings to monitor operations and, presumably, report back to their bosses.

Yet, Lopez and HHS cannot seem to get buy-in from the court on a consistent basis.

“The district is adrift in a sea of uncertainty, and they can’t really figure out what they need to do or should do. It’s a moving target,” said Commissioner Steve Radack, the health system’s most vocal critic on the court. “They say one day they need a hospital in this area, then they go to another area, then they come back to the first area. They really don’t know what they want.”

Things that I did learn from this story: Harris Health System, formerly known as the Harris County Hospital District, and Commissioners Court sometimes don’t see eye to eye on what HHS wants to do. Better communication between them might or might not help.

Things that I did not learn from this story: First and foremost, whether an outside observer would be inclined to agree with the HHS’s vision for primary care and prevention or if such an observer would agree with the Court that the HHS isn’t focused enough on primary care and prevention. Or perhaps that observer would tell us that it’s not so much a matter of vision as it is one of execution on HHS’s part or expectations on the county’s. It would also be nice to know what an outside observer thinks the county’s needs are and what the priorities should be, and how those compare to what HHS and the county say HHS is doing. Unfortunately, the whole story was basically a he said/she said, and that left me unable to properly evaluate either side’s position. It’s good to know that HHS and the Court disagree on things, but it would be even better to know, or at least suspect, that one or both of them is talking out of something other than their mouths. I don’t have any way of drawing that kind of conclusion or inference from this story, and that’s a shame.

Counties may try to expand Medicaid on their own

The Washington Post reports on the efforts of county and hospital district officials in some of Texas’ largest counties to bypass Rick Perry’s refusal to expand Medicaid for Texas and seek approval to do it themselves for their own jurisdictions.

It's constitutional - deal with it

George Hernandez Jr., CEO of University Health System in San Antonio, came up with the idea of the alternative, county-run Medicaid expansion, and said he has been discussing it with other officials in his county, Bexar. “They are all willing,” he said. He added that he has also been talking up the proposal with officials in other big counties, such as those including Houston and Dallas, and is optimistic they’ll support the idea.

Robert Earley, CEO of JPS Health Network, the public hospital system serving Tarrant County, which includes the Fort Worth area, said he could see the idea catching on.

[…]

Under the federal health law, the Medicaid expansion would begin in 2014, and would cover people with incomes of up to 133 percent of the poverty level. The federal government would pay the entire bill for the first three years and 90 percent thereafter. If there were a county-backed expansion in Texas, the local hospital districts would tax residents to come up with the 10 percent state share. Texans living in counties that participated in the expansion would be eligible for Medicaid under the less restrictive rules, while those living in the rest of the state would not.

An official from the U.S. Department of Health and Human Services declined to comment on the idea, but said, “We look forward to continuing our dialogue with states . . . as we work to meet the law’s goals.”

Alan Weil, executive director of the National Academy for State Health Policy, said that the idea, despite its challenges, “is certainly not far-fetched.”

Weil noted that there is precedent for a federal waiver of this type: After California declined to take advantage of a provision in the health-care law that allows states to accelerate their Medicaid expansion, the leaders of several counties got permission from the Obama administration to do so on their own.

The Texas proposal, of course, represents more than a temporary bridge to statewide expansion; it could be a permanent arrangement.

“And federal authorities might feel differently about that,” Weil said. “But as a general proposition, could you have different counties with different eligibility standards? I think the answer would be yes.”

We first heard about this a few weeks ago, after the Perry announcement and the sheepish admission by outgoing HHSC Chair Tom Suehs that Medicaid expansion would not cost nearly as much as his agency had first claimed. It’s an interesting approach, one that I could see being allowed to happen, and I admire creativity and perseverance of the officials who are pursuing it, but let’s be clear that it’s at best a kludge designed to work around a bad decision. For one thing, it cannot possibly be more efficient to have up to 254 potentially different standards for eligibility in Texas than just one statewide standard. For another, while I expect that many counties would do this if they are permitted to do so, some others will choose instead to be free-riding parasites on their neighbors; this is another reason why a statewide solution is better. Given the choice between no Medicaid expansion and a patchwork of Medicaid expansion done by the counties, I’ll gladly take the latter – it’s way better than the status quo, and could easily wind up covering a significant portion of the large uninsured population in Texas, many of which are now served by these overburdened hospital districts. But again, it’s a patch that’s being applied to a strictly self-inflicted wound.

And this approach now has a champion in Congress.

Congressman Henry Cuellar is asking the U.S. Department of Health and Human Services if Texas counties can bypass their state government in order to expand Medicaid coverage.

The Laredo Democrat says he supports giving counties the choice. He said he set up a teleconference call with HHS after reading an article in the Washington Post that said some of Texas’ largest counties want to make an end run around Gov. Rick Perry’s opposition to the expanded Medicaid program included in President Obama’s health-care law.

“I will be talking to HHS next week. I want to know if it is up to the Texas Legislature to decide if counties can do their own thing or whether it is something we can make happen at the federal level. I want to do all I can to give counties the choice,” Cuellar said, in an interview with the Guardian in Rio Grande City on Tuesday.

[…]

Cuellar recalled his time in the state legislature when he wanted to give Texas counties the opportunity to expand the Children’s Health Insurance Program. “We do not do as good a job with the CHIP program as other states do and I wanted to negotiate with HHS to give our counties the chance to expand it. I was opposed by the other states. They understood that if Texas sent CHIP money back, they could get some of it,” Cuellar said.

The Washington Post story focused on the larger Texas counties that have large public hospitals and hospital districts. Many border counties do not. Asked if border counties could bypass the state government in order to secure expanded Medicaid coverage under the ACA, Cuellar said he is going to ask HSS if such a maneuver is possible. “I want to see if the border counties can group together. I want to see if we can give them an option,” Cuellar said.

Again, given the constraints of Rick Perry’s obstinacy and antipathy towards non-rich people, that’s a great idea. Any opportunity to bypass the Lege should be grasped with both hands. Make that option available to any group of counties that don’t have a hospital district but want to do right by their taxpayers, too. If there’s any justice, Texas would achieve near-complete coverage by this method. It will probably take something like that to change the status quo. It’s still a stupid way to do business, but you gotta do what you gotta do.

There’s one remaining question that I have about all this, and that’s what Harris County intends to do. Bexar County has been the driving force behind this movement. Harris has the same need and a much bigger population, so its participation would be a big deal. I placed a call and was informed that Harris County Hospital District CEO David Lopez is “not granting interviews” on this topic at this time. Disappointing, but I suppose the politics of this are rather tricky for them, and they want to get as many ducks in a row as possible before deciding on a course of action. If you’re an officeholder in Harris County and you like the idea of providing coverage to the million or so uninsured residents of this county, I suggest you bring this up to Mr. Lopez at your next opportunity. You never know who else might be talking to him if you aren’t.