The following words and terms, when used in this division,
have the following meanings unless the context clearly indicates otherwise.
(1) Core activity--An activity implemented by a performer
to improve patient health or quality of care. It may be implemented
by a performer to achieve the performer's Category C measure goals
or it may be connected to the mission of the performer's organization.
(2) Delivery System Reform Incentive Payment (DSRIP)
pool--Funds available to DSRIP performers under the waiver for their
efforts to enhance access to health care, the quality of care, and
the health of patients and families they serve.
(3) Demonstration Year (DY) 6--Federal fiscal year
2017 (October 1, 2016 - September 30, 2017).
(4) Demonstration Year (DY) 7--Federal fiscal year
2018 (October 1, 2017 - September 30, 2018).
(5) Demonstration Year (DY) 8--Federal fiscal year
2019 (October 1, 2018 - September 30, 2019).
(6) Demonstration Year (DY) 9--Federal fiscal year
2020 (October 1, 2019 - September 30, 2020).
(7) Demonstration Year (DY) 10--Federal fiscal year
2021 (October 1, 2020 - September 30, 2021).
(8) Demonstration Year (DY) 11--Federal fiscal year
2022 (October 1, 2021 - September 30, 2022).
(9) Denominator--As it relates to a Category C measure's
volume:
(A) the number of Medicaid and low-income or uninsured
(MLIU) cases; or
(B) one of the following, which the performer receives
approval from HHSC to use for the measure:
(i) the number of all-payer cases;
(ii) the number of Medicaid cases; or
(iii) the number of low-income or uninsured (LIU) cases.
(10) Encounter--An encounter, for the purposes of Patient
Population by Provider, is any physical or virtual contact between
a performer and a patient during which an assessment or clinical activity
is performed, with exceptions including those in subparagraph (B)
of this definition.
(A) An encounter must be documented by the performer.
(B) An email, phone call, or text message is not considered
an encounter.
(11) Federal poverty level (FPL)--The household income
guidelines issued annually and published in the
Federal Register by the United States Department of Health
and Human Services.
(12) Initial demonstration period--The first five demonstration
years (DYs) of the waiver, or December 12, 2011 through September
30, 2016.
(13) Innovative measure--F1-T03 (Preventative Care &
Screening: Oral Cancer Screening).
(14) Insignificant volume--For most Category C measures,
the denominator is considered to have insignificant volume if its
volume is greater than zero but less than 30.
(15) Low-income or Uninsured (LIU)--An individual who
is not enrolled in Medicaid or the Children's Health Insurance Program
who meets one of the following criteria:
(A) is at or below 200 percent of the FPL; or
(B) does not have health insurance.
(16) Measure--A mechanism to assign a quantity to an
attribute by comparison to a criterion. As it relates to Category
C, a measure is a standardized tool to measure or quantify healthcare
processes, outcomes, patient perceptions, organizational structure,
or systems that are associated with the ability to provide high-quality
health care.
(17) Measure Bundle--A grouping of measures under Category
C that share a unified theme, apply to a similar population, and are
impacted by similar activities. Measure Bundles are selected by hospitals
and physician practices. All Measure Bundles include required measures,
and some Measure Bundles also include optional measures.
(18) Measure Bundle Protocol--A master list of potential
Category C Measure Bundles and measures, as well as Category D Statewide
Reporting Measure Bundles and measures.
(19) Medicaid and low-income or uninsured (MLIU)--An
individual who:
(A) is enrolled in Medicaid;
(B) is enrolled in the Children's Health Insurance
Program;
(C) is at or below 200 percent of the FPL; or
(D) does not have health insurance.
(20) Milestone--An objective of DSRIP performance on
which DSRIP payments are based.
(21) Minimum point threshold (MPT)--The minimum number
of points that a performer must meet in selecting its Category C Measure
Bundles or measures, as described in §354.1753 of this division
(relating to Category C Requirements for Performers).
(22) No volume--For Category C measures, the denominator
is considered to have no volume if its volume is equal to zero. For
a Category C population-based clinical outcome measure, the numerator
is considered to have no volume if the volume is equal to zero.
(23) Patient Population by Provider (PPP)--The number
of individuals in a performer's system for which there was an encounter
during the applicable DY.
(24) Patient Population by Provider Goal (PPP Goal)--The
target number of individuals in a performer's system for which there
will be an encounter during the applicable DY.
(25) Performer--A provider enrolled in Texas Medicaid
that participates in DSRIP and receives DSRIP payments.
(26) Population-based clinical outcome measure--A Category
C clinical outcome measure that measures emergency department utilization
or admissions for select conditions for all individuals in the Measure
Bundle's target population. It may be required as pay-for-performance
(P4P) or pay-for-reporting (P4R) based on the Measure Bundle and the
hospital's or physician practice's MPT as specified in the Measure
Bundle Protocol.
(27) Regional Healthcare Partnership (RHP) plan update--An
RHP plan update for DY7-8 that is further updated for DY9-10, as further
described in §354.1737 of this division (relating to RHP Plan
Update).
(28) Related strategy--A strategy employed by a performer
to improve performance on a measure.
(29) Significant volume--For most Category C measures,
the denominator is considered to have significant volume if its volume
is greater than or equal to 30.
(30) Statewide hospital factor (SHF)--A factor used
to determine the MPT that takes into account a hospital's MLIU inpatient
days and MLIU outpatient costs compared to all hospitals, as described
in §354.1753 of this division.
(31) Statewide hospital ratio (SHR)--A factor used
to determine the MPT that takes into account whether a hospital's
DY7 DSRIP valuation is higher or lower than would be expected based
on the hospital's MLIU inpatient days and MLIU outpatient costs compared
to other hospitals, as described in §354.1753 of this division.
(32) System--A performer's patient care landscape,
as defined by the performer, in accordance with the Program Funding
and Mechanics Protocol and Measure Bundle Protocol. Essential functions
or departments of a performer's provider type are required components
that must be included in a performer's system definition.
(33) Target population--For a Category C Measure Bundle,
the pool of individuals to be included in a measure denominator for
which a hospital or physician practice is accountable for improvement.
(34) Volume--For Category C measure denominators, the
total number of measured units in the denominator. Volume is used
to determine the size of the population for which improvement is being
measured.
|