1 Tex. Admin. Code § 354.1729 - Definitions
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.
Notes
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