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A BILL TO BE ENTITLED
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AN ACT
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relating to adoption of alternative payment method pilot programs |
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for the provision of health care services to certain state |
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employees. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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ARTICLE 1. EMPLOYEES RETIREMENT SYSTEM OF TEXAS |
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SECTION 1.01. Chapter 1551, Insurance Code, is amended by |
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adding Subchapter K to read as follows: |
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SUBCHAPTER K. ALTERNATIVE PAYMENT METHOD PILOT PROGRAM FOR |
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PROVISION OF HEALTH CARE SERVICES |
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Sec. 1551.501. DEFINITIONS. In this subchapter: |
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(1) "Alternative payment system" includes: |
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(A) a global payment system; |
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(B) an episode-based bundled payment system; |
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(C) a pay-for-performance payment system; |
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(D) a blended payment system; and |
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(E) another system other than fee-for-service. |
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(2) "Blended payment system" means a system for |
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compensating a physician or health care provider that includes one |
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or more features of a global payment system, a pay-for-performance |
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payment system, and an episode-based bundled payment system. |
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(3) "Clinical integration" means a network of health |
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care providers implementing an active and ongoing program to |
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evaluate and modify practice patterns by the network's participants |
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and create a high degree of independence and cooperation to control |
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costs and ensure quality. |
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(4) "Episode-based bundled payment system" means a |
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system for compensating a physician or health care provider for |
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arranging for or providing health care services to participating |
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enrollees that is based on a flat payment for all services provided |
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in connection with a single episode of medical care. |
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(5) "Global payment system" means a system for |
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compensating a physician or health care provider for arranging for |
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or providing a defined set of covered health care services to |
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participating enrollees for a specified period that is based on a |
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predetermined payment per enrollee for the specified period, |
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without regard to the quantity of services actually provided. |
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(6) "Participant" means an eligible individual who |
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participates in the group benefits program. |
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(7) "Participating enrollee" means an eligible |
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participant who uses a physician or health care provider |
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participating in a pilot program operated under this subchapter. |
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(8) "Pay-for-performance payment system" means a |
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system for compensating a physician or health care provider for |
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arranging for or providing health care services to participating |
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enrollees that is based on the physician or health care provider |
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meeting or exceeding certain defined performance measures. A |
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pay-for-performance payment system may include the provision of |
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bonuses to or the sharing of realized savings with physicians and |
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other health care providers. |
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(9) "Pilot program" or "program" means any alternative |
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payment method pilot program established or extended under this |
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subchapter, as appropriate. |
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(10) "Plan year" means the period beginning on |
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September 1 and ending the following August 31. |
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Sec. 1551.502. ADMINISTRATION BY BOARD OF TRUSTEES; |
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DEVELOPMENT AND IMPLEMENTATION OF PILOT PROGRAMS. (a) The |
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administration and implementation of all programs and plans adopted |
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under this subchapter are vested solely in the board of trustees. |
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To provide for the efficient and cost-effective administration and |
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management of the programs established under this subchapter, all |
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contracting, purchasing, procurement, and program and project |
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related responsibilities related to the administration or |
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management of the programs are vested solely in the board of |
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trustees. |
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(b) The board of trustees may work with the administering |
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firm of a self-funded health benefit plan established in accordance |
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with Section 1551.208 to establish one or more pilot programs under |
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which physicians and health care providers who provide health care |
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services to eligible participants are compensated under an |
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alternative payment system. A pilot program shall test |
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alternatives to traditional fee-for-service payments made under |
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the group benefits program. |
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(c) The board of trustees shall administer a pilot program |
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established under this subchapter and may adopt rules, plans, and |
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procedures and enter into contracts and other agreements as it |
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considers appropriate and necessary to administer this subchapter |
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under the authority described by Subsection (a). |
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(d) To ensure effective operation of a pilot program, the |
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board of trustees shall establish reasonable limits for |
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participation and may limit participation in a pilot program to: |
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(1) one or more regions of the state; or |
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(2) one or more organized networks of physicians, |
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hospitals, and other health care providers. |
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(e) Notwithstanding any bidding or procurement requirement |
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or other requirement set forth in law or rule, the board of |
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trustees, with respect to a pilot program, has sole discretion to |
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amend an agreement as necessary to comply with this subchapter. |
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(f) A pilot program implemented under this subchapter must |
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be operated for at least one plan year, and may be extended as the |
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board of trustees finds appropriate on consideration of the quality |
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of the services provided and the related cost-effectiveness of the |
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program. |
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(g) The board of trustees may elect to continue as a |
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permanent program a pilot program extended under Subsection (f). |
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The permanent program is subject to the requirements of this |
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subchapter in the same manner as a pilot program. |
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Sec. 1551.503. STANDARDS; CLINICAL INTEGRATION. To the |
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extent practicable, a pilot program operated under this subchapter |
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must be based on nationally recognized quality of care standards |
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and evidence-based best practices, and must include policies |
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designed to promote clinical integration of health care providers |
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and other policies and practices as necessary to ensure |
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high-quality and effective health care services. |
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Sec. 1551.504. ALTERNATIVE PAYMENT SYSTEM. (a) Each pilot |
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program operated under this subchapter must ensure that: |
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(1) a physician or health care provider is available |
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for each participating enrollee; and |
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(2) a payment made for health care services provided |
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by the pilot program under an alternative payment system is made in |
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a manner that appropriately compensates each physician or health |
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care provider for the services provided. |
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(b) The board of trustees may: |
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(1) contract with appropriate entities, including |
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qualified actuaries, to assist the board in determining appropriate |
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payment rates for a pilot program; and |
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(2) modify a payment rate adopted under this section |
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as necessary to adjust the rate for inflation. |
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Sec. 1551.505. EVALUATION OF PILOT PROGRAM; PARTICIPATING |
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ENROLLEE INPUT. In accordance with the continuing study required |
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under Section 1551.062, the board of trustees shall develop a |
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process to evaluate a pilot program operated under this subchapter. |
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The evaluation process must solicit the opinions of participating |
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enrollees on: |
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(1) the availability and quality of the health care |
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received through a pilot program; and |
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(2) the costs incurred for health care provided |
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through a pilot program, including copayments, fees for service, |
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and other analogous costs. |
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SECTION 1.02. Section 1551.202, Insurance Code, is amended |
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by adding Subsection (d) to read as follows: |
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(d) The board of trustees shall ensure that a coverage plan |
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provided to a participant in a pilot program implemented under |
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Subchapter K is at least equivalent to the basic coverage plan. |
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SECTION 1.03. The board of trustees of the Employees |
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Retirement System of Texas shall develop one or more alternative |
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payment method pilot programs to be implemented under Subchapter K, |
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Chapter 1551, Insurance Code, as added by this Act, as soon as |
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practicable, but not later than September 1, 2010. |
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SECTION 1.04. Not later than the 30th day before the date on |
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which eligible participants may participate in a pilot program |
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established under Subchapter K, Chapter 1551, Insurance Code, as |
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added by this Act, the board of trustees of the Employees Retirement |
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System of Texas shall provide written information to those |
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participants that provides a general description of the |
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requirements for the program as adopted under Subchapter K, Chapter |
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1551, Insurance Code, as added by this Act. |
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SECTION 1.05. The board of trustees of the Employees |
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Retirement System of Texas shall include as part of the annual |
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report required by Section 1551.061, Insurance Code, results of a |
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pilot program established under Subchapter K, Chapter 1551, |
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Insurance Code, as added by this Act. |
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ARTICLE 2. EFFECTIVE DATE |
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SECTION 2.01. Except as otherwise provided by this Act, |
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this Act takes effect September 1, 2009. |