Nine comments, nine answers. Three of them change what the deck says. The rest need a clearer explanation, not new facts. Nothing in the deck has been changed yet; this page is analysis plus the decisions we need.
Date: Oct 14, 2026Page numbers: Dr. Sami's "Pg" numbers are deck slide numbersSources checked: Oct 14, 2026Slide links: go to v1, the version Dr. Sami reviewed
The OB global package goes away on Jan 1, 2027. CPT 2027 deletes the global maternity codes (59400, 59510, 59610, 59618, 59430). Every prenatal and postpartum visit will be billed on its own. This answers Dr. Sami's "still pay extra?" question with a strong yes, and it is a new "why now" force the deck does not mention. (Per AAFP and MGMA, Aug 2026; confirm against the AMA CPT 2027 code set.)
Texas Medicaid does not pay the Medicare RPM and RTM codes. Home BP monitoring is paid as S9110 (to a hospital, home health agency, FQHC or RHC, with prior auth) plus 99091 for the physician once per 30 days. UTHealth's own billing compliance page says Texas Medicaid is not paying RTM codes. Slides 15 and 16 assume the Medicare code stack.
Houston Methodist does have MFM physicians. "No MFM division listed" is technically true but will read as wrong to a Houston audience. Methodist has an MFM service page, MFM-certified doctors, and Pediatrix MFM at the TMC hospital. What we did not find is an academic MFM division, an MFM fellowship or a fetal therapy program. Reword slides 7 and 8.
Medicaid health plans, and the cesarean rate for low-risk first births.
The nine items
1. Postpartum law and billing Slide 3Update needed
"Recheck postpartum law is still up to date. Still pay extra billable besides the OB packages?"
Analysis
The law is current. HB 12 extended Texas Medicaid and CHIP postpartum coverage to 12 months. CMS approved it in January 2024 and it started March 1, 2024. Coverage is full benefits for the 12 months after the pregnancy ends. One exception: CHIP Perinatal members do not get 12 months. We found no 2025 session change that cut it back. The 2025 federal Medicaid work requirements target expansion adults, and Texas did not expand, so they should not apply here (our reading, not a sourced fact).
Yes, a lot is billable outside the package.
Commercial and Medicare, through Dec 31, 2026: the global codes cover only routine postpartum care for about 6 weeks. Problem visits, remote monitoring, collaborative care, cardiology, LARC and anything after the global window are billed separately.
Texas Medicaid has no global package. It pays prenatal, delivery and postpartum care as separate services. One postpartum code is paid per pregnancy; problem visits are ordinary office visits. Postpartum depression screening and collaborative care (since 2022) are separate benefits.
From Jan 1, 2027: CPT deletes the global codes, so every outpatient prenatal and postpartum visit is billed on its own for all payers. CMS has proposed optional Medicare maternity G-codes; not final.
Proposed wording
Policy row: "Texas Medicaid/CHIP postpartum coverage is 12 months (HB 12, effective March 1, 2024; CHIP Perinatal excluded)." Add to Payment row: "CPT 2027 retires the global OB codes: from Jan 1, 2027 every prenatal and postpartum visit is billed on its own." What it opens: "A billable, accountable postpartum year. Problem visits, collaborative care and monitoring are billed outside any OB package; Texas Medicaid already pays per visit."
Open
Decision Add CPT 2027 as a sixth "why now" force? Recommended: yes.
Question How will UT Physicians' main commercial payers and the Harris-area MCOs handle pregnancies that cross Jan 1, 2027?
Dr. Sami is right to question it. Houston Methodist does offer MFM care: a service page (consults, prenatal diagnosis, amniocentesis, fetal MRI), MFM-certified doctors at The Woodlands, Willowbrook and West, Pediatrix's MFM group at the TMC hospital, and a Texas Children's MFM office at Methodist West. What we could not find is an academic MFM division, an MFM fellowship or a fetal therapy program. So their MFM looks affiliated or contracted, not academic.
The Level III ceiling is still correct. On the DSHS list (as of Oct 12, 2026), Methodist TMC, Willowbrook and The Woodlands (contingent) are Level III; Memorial Hermann-TMC is Level IV.
Proposed wording
Slide 7 cell: "MFM through affiliated groups (Pediatrix at TMC; Texas Children's at West). No academic MFM division, fellowship or fetal therapy found." Slide 8 bullet: "MFM largely affiliated, not an academic division; no fetal therapy center or MFM fellowship found." Slide 8 notes: replace "They do not list a maternal-fetal medicine division" with "Their MFM coverage comes mainly through affiliated groups; they have no fetal therapy program or MFM fellowship that we could find."
Open
Question Does Dr. Sami know Methodist's actual MFM staffing (employed vs contracted at TMC)? A Houston interviewer will know.
A patient who would normally be admitted gets inpatient-level care at home instead: nurse or paramedic visits twice a day, daily clinician review, remote monitoring, and a team that can arrive within 30 minutes. Medicare pays for it through the CMS Acute Hospital Care at Home waiver, now extended to Sept 30, 2030. Typical conditions are heart failure, pneumonia and cellulitis.
It covers few OB patients for two reasons: it pays Medicare fee-for-service, while pregnant patients are mostly Medicaid or commercial; and labor and delivery cannot happen at home under it. The OB version is home monitoring before and after birth. Texas HB 2727 (2023) added high-risk pregnancy to Medicaid home telemonitoring, but the Sept 2026 Medicaid manual still lists only diabetes and hypertension, so it looks unimplemented.
Local note: Harris Health, which runs LBJ, started a hospital-at-home service in Feb 2024. That is a partner asset worth knowing.
Proposed wording (optional)
"No public postpartum home BP monitoring or home-based antepartum program found."
Open
Decision Push HHSC or the MCOs to implement HB 2727 pregnancy telemonitoring as part of the "home antepartum monitoring" item on slide 10?
Decision Mention Harris Health's hospital at home as an LBJ partner asset?
The test: a blood test of two placental proteins. sFlt-1 rises and PlGF falls as preeclampsia develops, and their ratio predicts who will get worse. Thermo Fisher's test was FDA-cleared in May 2023; Roche's in Feb 2025. The cleared use is women with one baby, 23+0 to 34+6 weeks, already admitted for high blood pressure. A ratio of 40 or more means high risk of severe preeclampsia within 2 weeks.
The pathway: draw the ratio on admission. Low ratio: a plan to shorten the stay and follow up at home with BP monitoring. High ratio: MFM review, steroid timing and transfer planning. Track length of stay, preterm delivery and outcomes.
Limits: one manufacturer-funded US study (PRAECIS, 18 centers; 96% negative predictive value). The test supports judgment; it does not diagnose. For inpatients it is usually bundled into the hospital payment, so the business case is shorter stays, not test revenue.
Proposed wording
Slide 10 cell (optional): "sFlt-1/PlGF blood-test pathway to safely shorten antepartum admissions for hypertension." Slide 19: change "FDA-cleared (Breakthrough), 2023" to "FDA-cleared (Thermo Fisher 2023; Roche 2025)", and in the notes change "23 to 35 weeks" to "23+0 to 34+6 weeks".
Open
Question Which analyzer does the Memorial Hermann-TMC or UT lab run (Roche or Thermo Fisher)? That decides which test is the easy start.
Question Do Texas Children's or Methodist already offer it?
5. Colors on the portfolio slide Slide 11Update needed
"Can you change the colors to make it easier to see?"
Analysis
The four groups are shown only by a thin left border on white cards. Teal, gray and coral are almost the same lightness, so on a projector or for color-blind viewers they blur together. The gray "enabler" color is the same as the body text. The big card numbers are nearly invisible (1.3:1 contrast). And the green, gold and indigo horizon tags add a second set of colors that competes with the groups.
Proposed fix
Group
Header band (white text)
Card fill
Front door
navy #13294B
#E8EEF8
Connected care
deep teal #00695C
#E0F2F1
Data and discovery
rust #B23A1E
#FBE9E4
Enabler
charcoal #4B5563
#F3F4F6
A solid colored band on top of each card with a word label (FRONT DOOR, CONNECTED CARE, DATA, ENABLER), so color is never the only cue.
Darker, larger body text (#374151 at 17px).
Card numbers as a white numeral in a filled circle of the group color.
Apply the same four colors to slide 10 so the two slides match.
Open
Decision Approve this palette, or must we keep UTHealth brand colors? (If brand is required, keep the hues but use darker shades plus fills and labels.)
Question Will it be projected? If so, test the slide on a projector before the meeting.
6. The one 4-physician site table Slide 12Explain only
"One 4-physician site table needs more explanation. What is it telling us?"
Analysis
The message: a new suburban clinic loses money on its own, but makes money for UTHealth and Memorial Hermann together from Year 2. That is why the ask to Memorial Hermann is a funds-flow agreement.
Clinic revenue ($1.19M, $2.61M, $4.13M): what the clinic collects as doctors go from 2 to 3 to 4 and get busier.
Clinic margin (-$1.42M, -$1.04M, -$0.56M): revenue minus the clinic's own costs (salaries, staff, rent, malpractice, build-out). It loses money every year modeled.
Hospital margin at 30% ($0.75M, $1.64M, $2.60M): the clinic's doctors send deliveries and surgeries to Memorial Hermann (154 deliveries in Year 1, 532 by Year 3). The hospital is assumed to keep 30 cents of profit per dollar.
System margin (-$0.67M, +$0.60M, +$2.04M): clinic plus hospital together.
The clinic breaks even alone only at about $106 collected per wRVU; the model assumes $95. On a more conservative hospital benchmark, Year 3 is still about +$1.0M. The arithmetic checks out.
Proposed wording
Title: "One new 4-doctor clinic: loses money alone, profitable for the system by Year 2 ($M)" Rows: "Clinic collections" / "Clinic profit (loss) after its own costs" / "Hospital profit from the clinic's deliveries and surgeries (30% margin)" / "Combined profit, UTHealth + Memorial Hermann". Optional row: "Deliveries / surgeries sent to MH: 154/66, 336/144, 532/228". Caption: "The clinic alone loses money through Year 3. Its deliveries and surgeries earn Memorial Hermann about $0.75-2.6M a year, so the combined system turns positive in Year 2. This is why we ask MH for a funds-flow agreement."
Open
Decision Show the conservative case as its own row, or keep it in the caption?
Question Can we get real numbers for the four assumptions: collections per wRVU ($95), deliveries per doctor (140), hospital net per delivery ($12K), hospital margin (30%)?
"What is application guided pelvic floor therapy entitled to?"
Analysis
What it is: a small vaginal sensor paired with a phone app. It coaches Kegel exercises and records how often and how well they are done. leva (Axena Health) is prescription-only and FDA-cleared for stress, mixed and mild-to-moderate urge incontinence, and for fecal incontinence since 2022. Perifit reports 510(k) clearance; Elvie's status is unverified.
What it is entitled to (payment):
Medicare: remote therapeutic monitoring codes can apply when the practice runs the program (setup 98975; device days 98977 or the new 2026 short code 98985; management time 98980/98981 or new 98979). The device itself is not covered: leva's own code S9002 is not payable by Medicare.
Texas Medicaid: does not pay RTM codes, per UTHealth's own billing compliance office.
Commercial: mixed. Blue Cross Blue Shield of Texas calls home devices like leva "not medically necessary" for urinary incontinence. Cigna issued a positive coverage decision in 2023.
Bottom line: treat it as a clinical tool or a cash item, not a revenue line. It is a modest add-on for Medicare patients only.
Proposed wording
Slide 16 RTM cell: "App-guided pelvic floor trainer: Medicare only; not paid by Texas Medicaid; BCBSTX deems home devices not medically necessary." Slide 14 flow step: "FDA-cleared app-guided trainer (Medicare RTM only; device often not covered)."
Open
Question What share of midlife and pelvic patients are Medicare? That decides whether RTM is worth setting up.
Decision Keep the trainer in the pathway as a clinical step only, with no revenue attached? Recommended: yes.
A standing program, run by the department and hospital together, that makes labor and delivery care consistent and catches problems early. The usual parts:
AIM safety bundles: national checklists for hemorrhage, severe hypertension, safe cesarean reduction, sepsis, cardiac conditions, mental health, substance use and discharge. Texas runs them through TexasAIM; over 98% of Texas birthing hospitals take part.
Team drills for hemorrhage, eclampsia and shoulder dystocia.
Fetal monitoring certification for nurses and doctors.
An OB patient safety nurse, standard order sets and fast case review.
Yale-New Haven's program cut liability payments from $50.7M to $2.9M (1998-2002 vs 2003-2007). That is one site and old data. New: CMS now requires hospitals to have obstetric staff training and an OB quality program by Jan 1, 2027, so part of this becomes mandatory for Memorial Hermann anyway. That makes it an easy partnership.
Proposed wording (optional)
"OB safety program: AIM/TexasAIM bundles, team drills, fetal-monitoring certification, OB safety nurse; meets CMS obstetric training and quality requirements due 2027." Add "(2003-2007 data)" to the Yale evidence.
Open
Question Which TexasAIM bundles and drills do MH-TMC and LBJ already run? Much may already be in place.
Unverified Whether the CMS 2027 phase is still on schedule; provider groups asked CMS to scale it back in 2025.
MCO means Medicaid managed care organization: a private health plan the state pays to run Medicaid and CHIP. Pregnant women in Texas are in the STAR program. The Harris service area plans (as of Sept 2026) are Community Health Choice, Molina, Texas Children's Health Plan, UnitedHealthcare and Wellpoint (formerly Amerigroup).
NTSV cesarean is the cesarean rate for low-risk first births: Nulliparous (first baby), Term (37+ weeks), Singleton (one baby), Vertex (head down). It is the standard national quality measure. Texas is 27.9% (2024) against a national target of 23.6%. California's statewide collaborative brought it down without harming babies.
Why both are on this slide: most savings from fewer cesareans and readmissions go to the Medicaid plans, not the department. So the ask is for the plans to share those savings through contracts that pay for a lower NTSV rate and better postpartum outcomes.
Proposed wording
"Value-based contracts with Medicaid health plans (MCOs: Community Health Choice, Texas Children's Health Plan, UnitedHealthcare, Wellpoint, Molina) that pay for fewer low-risk first-birth cesareans (NTSV; Texas 27.9% vs 23.6% national target), fewer readmissions and better postpartum outcomes." Spell out both terms on first use.
Open
Question What are MH-TMC's and LBJ's own NTSV rates? They are the baseline for slides 27-28.
Caution Texas's Medicaid plan re-procurement was paused in court; check the plan list before naming plans on a slide.
Slides 15 and 16, remote BP billing: the Medicare RPM code stack does not apply to Texas Medicaid. Texas pays S9110 plus 99091 with prior auth and a risk factor. It is unclear whether gestational hypertension or preeclampsia counts as "hypertension" for that rule; ask TMHP or the MCOs.
Slide 15, evidence: a 2025 meta-analysis of randomized trials reportedly found postpartum remote BP monitoring did not cut readmissions and raised ED visits. Unverified We saw only a search summary. Pull the paper before leaning on the UW 0.5% vs 3.7% figure, which is non-randomized.
Slide 16, collaborative care: Texas Medicaid coverage is confirmed (since 2022, with attestation and prior auth after 6 months). Remove "(to confirm)".
Slide 8: The Woodlands Level III is "contingent" on the DSHS list, if precision matters.
Not yet checked: "Texas was the 43rd state" (slide 3 notes) and the "1 in 4 / 80% preventable" figures from the state maternal mortality report.
Deck sources with no link yet: about 30 short source names in the deck (for example ASPRE, PRAECIS, AMA CPT 2026, NEJM AI scribe trial, Sonio, eCoin, KFF births) have no URL in the business plan, so they stayed as plain text. We can find and add those URLs on request.
Decisions needed (for Norman and Dr. Sami)
Decided Oct 14, 2026: all recommendations taken
Norman approved every recommendation below. Slide 11 gets the new palette, and slide 12 keeps the conservative case in the caption. The changes are carried out in deck v2 and business plan v2. See the decision log (D-1 to D-7, in the same order as this list) and the v2 change log. The earlier versions are kept unchanged.
DecisionApply the deck edits on this page? The wording changes for slides 3, 7, 8, 12, 14, 16, 19, 22 and 23, plus the matching business plan text. Recommended: yes, all of them.
DecisionNew slide-11 palette (and slide 10 to match), or keep brand colors with darker shades?
DecisionAdd CPT 2027 as a sixth "why now" force on slide 3? Recommended: yes. It strengthens the postpartum-year story.
DecisionReframe the connected-care revenue for Texas Medicaid (S9110 + 99091) instead of Medicare RPM codes? It is already outside the base-case totals, so the financials do not change.
DecisionDrop the revenue claim for the app-guided trainer and keep it as a clinical step only?
DecisionSlide 12: show the conservative hospital case as its own row?
DecisionFind URLs for the ~30 deck sources that have none yet?
Questions for Dr. Sami
Dr. Sami's local knowledge is worth more than public sources on these.
How is Methodist's MFM staffed at TMC: employed or contracted?
Which lab analyzer does MH-TMC or the UT lab use (Roche or Thermo Fisher)?
Which TexasAIM bundles and drills already run at MH-TMC and LBJ?
Roughly what share of midlife and pelvic patients are Medicare?
Are MH-TMC's and LBJ's NTSV cesarean rates known?
Will the deck be projected? If so, can someone test slide 11 on the room's projector?
Is there a UTHealth brand-color requirement for the deck?
Done today
All citations are clickable. The business plan now has 96 linked sources (each with an anchor, e.g. the source list) plus 30 small inline citation links. The deck's source lines and its key-sources slide link to the same URLs, and clicking a link no longer advances the slide.