Section 354.1691 - DefinitionsThe 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 part of a DSRIP project implemented by a performer during the initial demonstration period that the performer continues in DY7-8, or a new activity implemented by a performer in DY7-8. 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) Demonstration Year (DY) 6--Federal fiscal year 2017 (October 1, 2016 - September 30, 2017).(3) Demonstration Year (DY) 7--Federal fiscal year 2018 (October 1, 2017 - September 30, 2018).(4) Demonstration Year (DY) 8--Federal fiscal year 2019 (October 1, 2018 - September 30, 2019).(5) Demonstration Year (DY) 9--Federal fiscal year 2020 (October 1, 2019 - September 30, 2020).(6) 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.(7) 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.(8) Encounter--An encounter, for the purposes of Medicaid and Low-income Uninsured (MLIU) Patient Population by Provider (PPP) and total PPP, 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) A phone call or text message is not considered an encounter.(9) 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.(10) Initial demonstration period--The first five demonstration years (DYs) of the waiver, or December 12, 2011, through September 30, 2016.(11) Innovative measure--A new measure developed for use in Category C. Innovative measures are pay-for-reporting (P4R) in DY7-8.(12) 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.(13) 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, and/or systems that are associated with the ability to provide high-quality health care.(14) 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.(15) 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.(16) Medicaid and Low-income or Uninsured (MLIU) Patient Population by Provider (PPP)--The number of MLIU individuals in a performer's system for which there was an encounter during the applicable DY. (A) To qualify as a Medicaid individual served, the individual must be enrolled in Medicaid at the time of at least one encounter during the applicable DY.(B) To qualify as a low-income or uninsured individual served, the individual must either be at or below 200 percent of the FPL or must not have health insurance at the time of at least one encounter during the applicable DY.(C) If an individual was enrolled in Medicaid at the time of one encounter during the applicable DY, and was low-income or uninsured at the time of a separate encounter during the applicable DY, that individual is classified as a Medicaid individual served for purposes of MLIU PPP.(17) Medicaid and Low-income or Uninsured (MLIU) Patient Population by Provider (PPP) Goal--The target number of MLIU individuals in a performer's system for which there will be an encounter during the applicable DY.(18) Milestone--An objective of DSRIP performance on which DSRIP payments are based.(19) 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 §RSA 354.1713 of this division (relating to Category C Requirements for Performers).(20) 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.(21) Quality improvement collaborative activity--An activity related to participating in a learning collaborative to improve targeted health outcomes. As included in Category C, a quality improvement collaborative activity is pay-for-reporting (P4R) in DY7-8.(22) Performer--A provider enrolled in Texas Medicaid that participates in DSRIP and receives DSRIP payments.(23) 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.(24) RHP plan update--An RHP plan for the initial demonstration period and DY6 that is updated for DY7-8, as further described in §354.1697 of this division (relating to RHP Plan Update).(25) 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.(26) 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 §RSA 354.1713 of this division.(27) 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 §354.1713 of this division.(28) 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.(29) 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.(30) Total Patient Population by Provider (total PPP)--The total number of individuals in a performer's system for which there was an encounter during the applicable DY.(31) 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.1 Tex. Admin. Code § 354.1691
Adopted by Texas Register, Volume 42, Number 47, November 24, 2017, TexReg 6609, eff. 12/1/2017; Amended by Texas Register, Volume 43, Number 16, April 20, 2018, TexReg 2393, eff. 4/26/2018; Amended by Texas Register, Volume 43, Number 34, August 24, 2018, TexReg 5497, eff. 9/1/2018