| (C) If a hospital's or physician practice's denominator
for a required measure or numerator for a P4R population-based clinical
outcome measure in a selected Measure Bundle for the baseline measurement
period or a performance year has insignificant volume, the measure's
milestone valuations are adjusted in accordance with subsection (e)(2)
of this section.
(5) Milestone valuation. The measure milestones and
corresponding valuations for DY7-8 are as described in subsection
(e) of this section.
(6) MPTs for hospitals.
(A) The MPT for hospitals, with the exception of those
described in subparagraphs (B) and (C) of this paragraph, is calculated
as follows:
(i) First, the hospital's statewide hospital factor
(SHF) is equal to (.64 multiplied by (the hospital's Medicaid and
uninsured inpatient days divided by the sum of all hospitals' Medicaid
and uninsured inpatient days)) plus (.36 multiplied by (the hospital's
Medicaid and uninsured outpatient costs divided by the sum of all
hospitals' Medicaid and uninsured outpatient costs)).
(ii) Second, the hospital's statewide hospital ratio
(SHR) is equal to (the hospital's DY7 valuation divided by the sum
of all hospitals' DY7 valuations) divided by the SHF.
(iii) Third, the hospital's MPT is determined as follows:
(I) If the SHR is less than or equal to 3, the MPT
is the lesser of:
(-a-) the DY7 valuation divided by $500,000; or
(-b-) 75.
(II) If the SHR is greater than 3 but less than or
equal to 10, the MPT is the lesser of:
(-a-) (the DY7 valuation divided by $500,000 multiplied
by (the SHR divided by 3); or
(-b-) 75.
(III) If the SHR is greater than 10 and the DY7 valuation
is less than or equal to $15 million, the MPT is the lesser of:
(-a-) (the DY7 valuation divided by $500,000 multiplied
by (the SHR divided by 3); or
(-b-) 40.
(IV) If the SHR is greater than 10 and the DY7 valuation
is greater than $15 million, the MPT is the lesser of:
(-a-) (the DY7 valuation divided by $500,000 multiplied
by (the SHR divided by 3); or
(-b-) 75.
(B) If a hospital does not have the data needed for
the SHF calculation in paragraph (5)(A)(i) of this subsection, or
if a hospital did not participate in DSRIP during the initial demonstration
period or DY6, its MPT is the lesser of:
(i) the hospital's DY7 valuation divided by $500,000;
or
(ii) 75.
(C) If a hospital has a limited scope of practice,
cannot reasonably report on at least half of the required measures
in the Measure Bundle(s) appropriate for it based on its scope of
practice and community partnerships, and consequently cannot meet
its MPT for Measure Bundle selection, the hospital may request HHSC
approval for a reduced MPT equal to the sum of the points for all
the Measure Bundles for which the hospital could reasonably report
on at least half of the required measures in the Measure Bundle. The
hospital must submit a request for such approval to HHSC prior to
the RHP plan update submission, by a date determined by HHSC. Such
a request may be subject to review by the Centers for Medicare &
Medicaid Services (CMS). If HHSC and CMS, as appropriate, approve
such a request, the hospital's total valuation for DY7 and DY8 may
be reduced.
(7) MPTs for physician practices.
(A) The MPT for physician practices, with the exception
of those described in subparagraph (B) of this paragraph, is the lesser
of:
(i) the physician practice's DY7 valuation divided
by $500,000; or
(ii) 75.
(B) If a physician practice has a limited scope of
practice, cannot reasonably report on at least half of the required
measures in the Measure Bundles appropriate for it based on its scope
of practice and community partnerships, and consequently cannot meet
its MPT for Measure Bundle selection, the physician practice may request
HHSC approval for a reduced MPT equal to the sum of the points for
all the Measure Bundles for which the physician practice could reasonably
report on at least half of the required measures in the Measure Bundle.
The physician practice must submit a request for such approval to
HHSC prior to the RHP plan update submission, by a date determined
by HHSC. Such a request may be subject to review by CMS. If HHSC and
CMS, as appropriate, approve such a request, the physician practice's
total valuation for DY7 and DY8 may be reduced.
(b) Requirements for community mental health centers
(CMHCs).
(1) Measure selection.
(A) A CMHC must select measures from the Community
Mental Health Center Measure Menu of the Measure Bundle Protocol.
(B) Each measure is assigned a point value as described
in the Measure Bundle Protocol.
(C) A CMHC is assigned an MPT for measure selection
as described in paragraph (3) of this subsection.
(D) A CMHC must select measures worth enough points
to meet its MPT in order to maintain its total valuation for DY7 and
DY8. If a CMHC does not select measures worth enough points to meet
its MPT, its total DY7 valuation will be reduced proportionately across
its RHP Plan Update and Categories B-D funds for DY7, and its total
DY8 valuation will be reduced proportionately across its Categories
B-D funds for DY8, based on the point values of the measures it selects.
(E) A CMHC may only select a measure for which its
denominator for the baseline measurement period has significant volume.
(F) A CMHC must select at least two measures.
(G) A CMHC with a valuation greater than $2,500,000
per DY for DY7-8 must select at least one three-point measure.
(2) DSRIP-attributed population. A CMHC must determine
its DSRIP-attributed population to be applied to its selected measures
as specified in the Measure Bundle Protocol.
(3) Measure valuation. A CMHC may allocate its Category
C valuation among its selected measures, provided the following requirements
are met:
(A) The valuation for each selected measure must be
greater than or equal to (the Category C valuation divided by the
number of selected measures) multiplied by 0.75.
(B) The valuation for each selected one-point measure
must be less than or equal to the Category C valuation divided by
the number of selected measures.
(C) The valuation for each selected three-point or
four-point measure must be less than or equal to (the Category C valuation
divided by the number of selected measures) multiplied by 1.25.
(D) If a CMHC allocates to a measure a percentage of
its Category C valuation that is one percent greater than the Category
C valuation divided by the number of selected measures, the CMHC must
provide sufficient justification as specified in the Program Funding
and Mechanics Protocol.
(4) Milestone valuation. The measure milestones and
corresponding valuations for DY7-8 are as described in subsection
(e) of this section.
(5) MPTs. A CMHC's MPT is the lesser of:
(A) the CMHC's DY7 valuation divided by the standard
point valuation ($500,000); or
(B) 40.
(c) Requirements for local health departments (LHDs).
(1) Measure selection.
(A) An LHD must select measures from:
(i) the Local Health Department Measure Menu of the
Measure Bundle Protocol; or
(ii) its DY6 Category 3 pay-for-performance (P4P) measures.
(B) An LHD may not select the same measure from both
the Local Health Department Measure Menu of the Measure Bundle Protocol
and its DY6 Category 3 P4P measures.
(C) If an LHD's DY6 Category 3 P4P measures include
multiple versions of the same measure, the LHD may select multiple
versions of that measure, but the points associated with that measure
will only count once toward the LHD's MPT.
(D) Each measure on the Local Health Department Measure
Menu is assigned a point value as described in the Measure Bundle
Protocol.
(E) Each LHD DY6 Category 3 P4P measure is assigned
a point value as described in the Measure Bundle Protocol.
(F) An LHD is assigned an MPT for measure selection
as described in paragraph (4) of this subsection.
(G) An LHD must select measures worth enough points
to meet its MPT in order to maintain its total valuation for DY7 and
DY8. If an LHD does not select measures worth enough points to meet
its MPT, its total DY7 valuation will be reduced proportionately across
its RHP Plan Update and Categories B-D funds for DY7, and its total
DY8 valuation will be reduced proportionately across its Categories
B-D funds for DY8, based on the point values of the measures it selects.
Cont'd... |
