University of Texas Southwestern Medical Center Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule
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Thank you for the opportunity to comment on the proposed Medicaid Fiscal Accountability Regulations. While the
As background, UT Southwestern is a State institution that operates one of the largest medical schools in the country, the largest public residency and graduate biomedical sciences programs in
As a public institution, an important part of our mission is to deliver care to the uninsured and underserved, providing services that are typically underfunded, but critical to our community and to our state's and nation's health, including specialized care and public health preparedness and response. As a State teaching hospital with a very small operating margin, any significant reduction in supplemental payments will have a disproportionately negative impact on clinical services, and to the extent emergency clinical services must be maintained, on the core essential additional mission of medical education and residency training that we also must maintain to deliver tomorrow's healthcare workforce.
We therefore urge the
Federal Overreach in dictating state and local Medicaid matched funding sources
Although UT Southwestern is a public State institution, it does not receive State appropriations for patient care. Accordingly, UT Southwestern uses our clinical revenue to self-fund Intergovernmental Transfers (IGT) as the only means for us to obtain funds to ensure our ability to meet the needs of uninsured and underinsured patients across the region. Our collective reading of the proposed rule is that disallowance of anything but State revenue for match purposes would preclude UT Southwestern -- a State Teaching hospital -- from further participation in major programs. These include
The specific provisions that together would limit a State teaching hospital's ability to match fund if it does not receive State General Revenue as a source of IGT are as follows:
Proposed 42 C.F.R. Sec. 433.51 State Share of Financial Participation would limit permissible state or local funds that may be considered as the State share. The section changes allowable sources of non-federal share from "public fund? transferred from other "public agencies" to "state general fund dollars appropriated by the state legislature directly to the state or local Medicaid agency; 1GT from units of government, derived from state or local taxes (or appropriated to state university teaching hospitals), and transferred to the state
Proposed 42 C.F.R. Sec. 447.286 Definitions would change the definitions of state government owned or operated, non-state government owned or operated, and privately owned or operated to state government providers, non-state government providers, and private providers. CMS notes it will consider the totality of the circumstances when determining if a provider is defined as non-state government providers, state government provider, or private provider, yet given the restriction outlined below, effectively removes the ability from states to define and determine units of local and state government and UT Southwestern's eligibility for purposes of the Medicaid program.
"State government provider means a health care provider, as defined in Sec. 433.52 of this chapter, including those defined in Sec.447.251 of this chapter, that is a unit of State government or a State university teaching hospital, which has access to and exercises administrative control over State appropriated funds from the legislature or State tax revenue, including the ability to dispense such funds. In determining whether a provider is a State government provider, CMS will consider the totality of the circumstances, including, but not limited to, the following:
(2) In determining whether a relevant entity is a unit of a State government, we would consider the character of the entity which would include, but would not be limited to, whether the entity:
(i) Is described in its communications to other entities as a unit of State government, or otherwise;
(ii) Is characterized as a unit of State government by the State solely for the purposes of Medicaid financing and payments, and not for other purposes (for example, taxation); and
(iii) Has access to and exercises administrative control over State funds appropriated to it by the legislature and/ or local tax revenue, including the ability to expend such appropriated or tax revenue funds, based on its characterization as a governmental entity."
UT Southwestern is also extremely concerned that CMS has not attempted to estimate the fiscal impact of the proposed rule on the Medicaid program, simply claiming the impact is unknown and that it does not "have sufficient data to predict or quantify the impact of the proposed provisions," except for a
We think this is a stark example of the damaging impact of these proposed changes, which would result in a State teaching hospital -- with public service as its mission -- that self-funds participation for the benefit of patients to be disqualified from participation. As a State institution, we struggle to maintain a prudent industry margin of --3% -- by no means do we have the margin to cover
We respectfully request that CMS withdraw this rule and gather all necessary data needed to conduct a detailed analysis before moving forward with the major policy changes proposed in the rule.
DKP/amh
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2019-0169-0001
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