Senate Health & Human Services Interim Report Released

The Senate Health & Human Services Committee has released their interim report to the 86th Legislature.

The report addresses many issues, including the state’s response to Hurricane Harvey across multiple health care sectors, Child Protective Services system improvements, opioids, Medicaid quality and contract compliance, health care cost transparency, and implementation of various health care bills from the 85th Session. For more details, including conclusions, background, and sources please view the complete report.

Spotlight on Recommendations

Interim Charge 1A: State Health Response to Hurricane Harvey

• DSHS, in conjunction with TDEM leadership, should consider ways to allow a representative from major health related associations to be located within the SMOC. All public health emergency response information flows through the SMOC. Allowing organizations like THA, TMA, TACCHO, and TAHP to be physically located in the SMOC will create a quicker and smoother information transfer for all parties. These organizations represent thousands of providers, their ability to get information to their members will greatly improve the communication process. If it is not feasible to physically locate more individuals within the SMOC, the agency should consider establishing direct lines of communication with these organizations
• DSHS, in conjunction with TDEM, should ensure local authorities are aware of and have access to an MRC.
• DSHS should consider ways to create and manage state controlled medical volunteer mobile units within each public health region to assist counties that lack a strong medical volunteer force.
• Local emergency response networks, in conjunction with TDEM, should ensure shelters are capable of caring for certain specialty care populations.
• The Legislature should protect previous investments made in the statewide mental health and public health system.
• The Legislature should continue to support mental health programs like Mental Health First Aid and the Mental Health Professional Loan Repayment Program. The Task Force on School Mental Health surveyed teachers across the state and found that teachers would like more information on how to assist students with mental health needs. Mental Health First Aid is a program designed to give individuals the training and tools needed to support those in immediate need. This training is currently provided at local mental health authorities at no cost for school staff.
• The Legislature and HHSC should consider equipping the Rio Grande SSLC with the SSLC system wide electronic medical record.
• The Legislature and HHSC should examine the state of electronic health systems in other state operated health facilities to ensure continuity of care during evacuations caused by future disasters.

Interim Charge 1B: Child Welfare System Response to Hurricane Harvey

• DFPS should monitor ongoing impacts on capacity including how the storm affects the displacement of children, child specific contracts, and families becoming foster parents. CPS is surveying providers to determine what the long-term impacts to capacity will be. CPS is working with providers to determine which families were in the process of becoming foster parents in affected areas, but withdrew their application.
• DFPS should work with providers including Single Source Continuum Contractors (SSCCs) to develop tracking and reporting mechanisms to have real-time data regarding placements, capacity, and shelter needs.
• TJJD and counties should track and measure potential recidivism of families and youth affected by the storm re-entering the system.
• DFPS and TJJD should ensure all providers have plans in place as a part of their emergency preparedness to have appropriate staff, especially in the instance of a disaster to ensure staff in facilities have relief.
• DFPS should define disaster reporting requirements ahead of time by including them as supplemental contract provisions that kick in when an emergency occurs. Streamline protocols to ensure all information requested from providers is requested once, in the same format, and expectations are given to providers. Ensure timeframes for information are specified to providers, and that information is disseminated to all necessary DFPS departments and programs.

Interim Charge 1C: Disaster SNAP Response to Hurricane Harvey

• Increase collaboration with state, county and city officials to establish awareness and understanding of D-SNAP operations and develop an outreach plan that engages local agencies and the media. HHSC intends to work with local officials to create a directory of local points of contact. They will also survey these local contacts to determine the best mode of communication. Prior to the start of hurricane season, HHSC will hold webinars, conference calls, and/or in-person meetings with local officials to explain D-SNAP and develop a strategy for effective collaboration. These activities began in March of 2018 and will be repeated in subsequent years.
• Work with state, county and city officials to pre-select and evaluate potential D-SNAP sites and maintain a list of those sites with routine review. Addressing facility/space challenges by establishing Memorandums of Understanding (MOUs) with local agencies before disaster hits will limit any issues with collaboration during an actual disaster.

Interim Charge 2A: Family-Based Safety Services

• The Legislature should review outcomes from the FBSS pilot in El Paso and consider other pilot program areas to fund in the 86th biennium. Specifically, the Legislature should look at recidivism between families served in the piloted areas as opposed to the legacy system.
• The Legislature should monitor DFPS’ oversight of the FBSS pilot programs, specifically that the DFPS implements monetary incentives and disincentives for failing to meet contractual performance measures.
• Senate Bill 11 (85R) calls for DFPS to revamp performance outcomes for FBSS. These new performance metrics should be added to contracts in January of 2019. The Legislature should monitor, review, and discuss these new performance outcomes with stakeholders.
• The capacity and plethora of FBSS services statewide is largely unknown. DFPS should conduct a needs assessment for these services similar to the capacity needs assessment required in Senate Bill 11 (85R).
• The Families First Act has the potential to utilize federal funds for FBSS services that are funded by General Revenue currently. The Legislature and DFPS need to weigh the benefits and costs of utilizing this new funding source.

Interim Charge 2B: Timely Investigations

• Implement statutory timeframes for investigations of abuse and neglect in substitute care that match the timeframes of investigations of abuse and neglect in biological homes. DFPS requires the same timeframes for an investigation of abuse or neglect for children in conservatorship that it does for children investigated in their biological home. However, these timeframes are not in statute for children in conservatorship. In addition, DFPS does not readily track this information to ensure investigations occur within the timeframes laid out in agency policy.
• Implement statutory timeframes to ensure all children in conservatorship are required to be seen monthly. While this is currently an agency policy, it is not in statute. This would allow the Legislature to more readily receive this data and have sufficient oversight to ensure all children in the CPS system are seen regularly.
• The Legislature and DFPS should look at past agency policy which requires families and children in FBSS to be seen at various timeframes depending on the potential risk of the home, and update agency policy as necessary to ensure children and families remain safe. FBSS services are a vital part of the CPS system, and help ensure children are not unnecessarily removed from a home. However, safety in the home must continue to be the utmost concern, and families that are at a greater risk of abuse or neglect to children in that home should be monitored more closely to ensure that child can continue to remain with his or her family instead of being placed into substitute care.

Interim Charge 2C: Youth Preparedness

• The Legislature should review Senate Bill 1758 report which will be released in December 2018 before entering the 86th Legislative Session to consider a potential need to restructure PAL services and supports for youth in foster care.
• DFPS should consider collecting data on the Tuition and Fee Waiver program, specifically on how many youth are eligible for the program, aware of the program, and utilize the program.
• DFPS and the Legislature should consider expanding opportunities for housing options and resources for youth aging out of care.
• The Legislature and DPFS should review the potential for federal funding streams to fund PAL and transitional living services, and consider the implications of expanding the eligible pool of youth eligible for these programs.
• HHSC, DFPS and the Legislature should examine how former foster youth are notified about the need to re-enroll in Medicaid annually.

Interim Charge 2D: Foster Parent Recruitment and Retention

• Require DFPS to gather and analyze data on how capacity building efforts by DFPS as well as provider capacity efforts are affecting capacity regionally and statewide.
• Require SSCCs to track annual recruitment efforts, and provide that information to DFPS and the Legislature.
• Require all SSCCs to implement a foster parent feedback process to ensure these families are heard, and their needs are addressed and research ways to retain foster parents such as a new foster parent mentor program.
• SSCCs should promote the use of trauma-informed practices.

Interim Charge 3: Substance Use Disorders

Improving Coordination and Data Collection

• Task the Behavioral Health Coordinating Council with the creation of a sub-plan for substance abuse. This would promote consistency in substance use disorder related policy and guidelines across state systems. The Council has been successful in identifying gaps in mental health care, identifying resources to fill those gaps, and promoting cross-agency collaboration. The sub-plan should be created in conjunction with the Medical and Pharmacy Boards and should include: Identification of a local entity responsible for acting as a single point of contact for the Substance Use Disorder sub-plan. The challenges surrounding substance use disorder prevention, treatment, and intervention are not constant statewide. Evaluation of substance use disorder prevalence, service availability, capacity, and gaps both by region and statewide; Planning for the infusion of federal dollars; Reviewing the current status of data collection needs by DSHS vital statistics; Strategies for expanding capacity so more Texans in need can access treatment; Work with institutes of higher education to support the Mental Health Loan Repayment Program for licensed chemical dependency counselors; Strategies for educating providers on appropriate referrals; Strategies for increasing enrollment of MAT providers; Supporting coordination between HHSC and DFPS regarding best practices when a baby is born substance-exposed; Measuring providers’ ability to recognize and provide integrated treatment for co-occurring substance use and mental health disorders; Evaluating strategies for supporting recovery services
• HHSC and DSHS should improve data collection for and reporting on opioid deaths. Additionally, HHSC should improve data reporting on co-occurring SUDs for all mental health clients served and evaluate capacity for treating co-occurring disorders.
• Expand access to Medication-Assisted Treatment. In August 2018, the U.S. Food & Drug Administration issued guidance to encourage development of drugs to treat OUD.

Pregnant and Postpartum Women

• Continue to support initiatives to reduce the incidence and severity of neonatal abstinence syndrome.
• Increase targeted outreach and training for Healthy Texas Women and Family Planning Program providers regarding available SUD community resources and evidence-based screening/referral methods.

Connecting Individuals to Treatment

• Examine opportunities to use telehealth to expand access to SUD treatment.
• Develop methods to refer patients who are flagged by the Prescription Monitoring Program to SUD treatment services.

Interim Charge 4A: Medicaid Quality

• HHSC should hold MCOs financially accountable for not meeting quality metrics. Now that HHSC has refined the P4Q program, timely recoupments should be made from MCOs that do not meet established quality metrics.
• HHSC should implement the incentive program that automatically enrolls Medicaid recipients who did not choose their managed care plan in a managed care plan based on quality as required by Senate Bill 7 (83R).
• HHSC should consider options to enroll Medicaid recipients into managed care as soon as possible, if not immediately upon receiving coverage. Currently, new Medicaid enrollees receive FFS benefits for nearly two months before they transition to managed care. This causes continuity of care issues. Enrolling individuals into managed care would improve outcomes and allows for better quality tracking over time.
• HHSC should better facilitate the ease of data reporting, comparing, and sharing. As Medicaid becomes more outcome focused, HHSC should evaluate what MCOs and providers are required to submit to HHSC. Additionally, different pieces of quality data are published on five different websites. An effort to consolidate all quality information into a single location would be beneficial for MCOs, providers, and decision makers. Any consolidation efforts should consider the inclusion of a real-time, user friendly portal for data collection and presentation.
• The Legislature and HHSC should consider requiring MCOs to be accredited. Of the 40 states that utilize managed care (including D.C.), 30 states require MCOs to obtain accreditation, and 26 of the 30 require National Committee for Quality Assurance (NCQA) accreditation. NCQA publishes streamlined HEDIS and CAHPS data annually, making it easy for providers, MCOs, clients, and decision makers to compare quality by program, by plan, and by state. Rider 61 utilized NCQA data to compare Texas’ MCO performance to other states, however, only Texas MCOs that are NCQA accredited or voluntarily submitted data to NCQA are included in those benchmarks. Ensuring all Texas MCO HEDIS and CAHPS data is reported uniformly to a nationally recognized database will create a more meaningful comparison. Lastly, states can use this accreditation process in lieu of EQRO quality reviews, allowing the EQRO to focus on other areas of interest such as network adequacy.
• Expand opportunities for ACOs in areas where possible, and increase participation in ACOs and PCMHs.
• ERS and TRS should continue efforts to, and share practices that, encourage covered individuals to visit in-network, quality providers. For example, TRS’ presentation to Senate Finance on September 11, 2018 notes that inefficient utilization of emergency rooms is a major cost driver, with 16 percent of visits attributed to freestanding ERS. TRS should consider implementing cost sharing methods similar to those established by ERS to deter patients from utilizing out-of-network freestanding ERs.

Interim Charge 4B: Medicaid Contract Compliance

• HHSC should continue to utilize and expand contract enforcement mechanisms that reflect the managed care environment in order to better hold MCOs accountable.
• HHSC should ensure MCOs maintain adequate networks so Medicaid enrollees have access to all appropriate services, including maternal and behavioral health care. If MCOs fail to maintain adequate networks, HHSC should hold the plans financially accountable. This should also apply to the quality of MCO provider directories.
• HHSC should reconfigure and reduce the number of managed care service delivery areas. The current configuration of SDAs is overly burdensome. Reducing the number of SDAs could reduce the number of contracts, allowing HHSC to focus their oversight efforts. HHSC plans to release an RFI later this year regarding SDA configuration.
• HHSC should implement competitive bidding practices into managed care procurements. CMS requires managed care rates to be actuarially sound, making it difficult to competitively bid full contracts amounts. However, the agency could competitively bid on administration costs or the experience rebate, while keeping unintended consequences in mind. For example, safeguards would need to be established to prevent an MCO that is unlikely to be profitable from underbidding on the experience rebate. If it is determined that competitive bidding would not be beneficial, the agency should consider lowering the profit thresholds of the experience rebate, including lowering the current 12 percent or greater profit cap, or increasing the amounts HHSC recovers.
• HHSC and MCOs should streamline their complaints and appeals processes. A recent report found that HHSC’s processes for logging complaints are not structured or standardized. Complaints can be reported to MCOs, the Ombudsman’s Office, and other areas of HHSC making it difficult to log and track complaints, often causing duplication and redundancy. TDI has a robust method for tracking and resolving complaints. HHSC and TDI should share complaint process best practices.
• HHSC and MCOs should institute a clear and accountable Fair Hearings process, including the use of Independent Review Organizations (IRO) for cases of medical necessity. TDI has a robust IRO process that includes specific response times based on severity of case and requires all appealed denials to be reviewed by the same type of practitioner as the treating practitioner. HHSC should implement a similar IRO process to ensure MCO denials fall within their contractual obligation to cover medically necessary services in the same amount, duration, and scope as is available through FFS Medicaid.

Interim Charge 5: Health Care Cost Transparency

Improve Coordination

• Direct DSHS, OPIC, and TDI to leverage information and efforts. The agencies should jointly: Assess the scope of information provided to consumers; Improve consumer access to education, consumer tools, and healthcare cost data; Evaluate centralizing the state’s transparency resources; Evaluate strategies to improve health insurance literacy across the spectrum of consumers.

Expanding the Usefulness of THCIC Data

• Direct DSHS to pursue efforts to enhance the interpretation, display, and usefulness of THCIC data for consumers.
• Collect the complete dataset from facilities DSHS is authorized to collect from to further enhance analysis of healthcare quality and charges. This should include revising statute to allow DSHS to collect data from Freestanding Emergency Rooms.
• Direct DSHS to continue enhancing Texas Health Data utilization to improve data access to the public.
• Direct DSHS to streamline data review processes for developing legislative and other reports.

Facilities and Providers

• Study facility and patient observation fees to determine which providers should be able to charge them. This study should also include ways to make these fees more transparent to consumers.
• Prohibit the use of misleading language or advertisement regarding a facility being in-network with insurance carriers.
• Give the attorney general authority to bring action against providers who charge consumers “unconscionable” rates. Legislation filed during the 85th Legislative Session would have given the attorney general the ability to pursue action only when the price is 150 percent or more of the average hospital charge for a similar service.

Expand OPIC Activities

• Grant OPIC the ability to file a complaint with TDI upon discovery of an inadequate network, or other network adequacy violations, including the accuracy of provider directories. OPIC should also have the authority to intervene in access plan filings and network waiver filings by health insurers.
• Require EPOs and PPOs to report HEDIS measures to DSHS, and require OPIC to produce annual EPO and PPO report cards along with HMO report cards.
• Add network adequacy as a component of OPIC report cards.

Health Plan Activities

• Require health plans to update their provider directories more frequently.

Interim Charge 6A: Mental Health Implementation

• Continue monitoring the implementation of the behavioral health matching grants passed by the 85th Legislature, including contract execution.
• The Legislature should continue to build on the investments made in the state’s inpatient mental health system by completing the projects initiated last Legislative session.
• HHSC should continue collaborations with state health-related institutions to maximize workforce development and integrated care. The $300 million appropriated was not intended to just add capacity in the system, but also to ensure continuity of care across the entire behavioral health delivery system to reduce re-hospitalization rates. Continuity of care should focus on services available to an individual when they are released from the state hospital system and options to prevent them entering the system. This effort will involve buy-in from the criminal justice system, Local Mental Health Authorities, law enforcement, and other community partners. Collaborations with health-related institutions should assist with maximizing treatment options, growing the behavioral health workforce, and increasing quality of care.
• HHSC and the Legislature should consider options that ensure capacity in rural areas of the state. This could include increased purchased beds at private facilities in counties located a certain distance from a state hospital or expanding the STARCARE, Lubbock County’s LMHA, model that currently exists in the panhandle. STARCARE has operated a jail diversion program in Lubbock County since 1999 via a Memorandum of Understanding (MOU) with the Lubbock County Sheriff’s Department and additional agreements with the Lubbock County Juvenile Justice Center. Their model, which utilizes the 30 bed Sunrise Canyon Psychiatric Facility to provide intensive inpatient care in lieu of a jail or state hospital, has produced positive results and avoided costs.
• The Legislature and relevant agencies should ensure behavioral health care is available to children. The Select Committee on Violence in Schools and School Security studied the availability of behavioral health services available to students and recommended a number of ways to address gaps in care. The Legislature should consider implementing their recommendations. Additionally, current grant programs could be tailored to focus on the needs of children. For example, a portion of the HB 13 dollars were awarded to Texas Tech Health Science Center for the expansion of their school based telehealth program, TWITR.
• The Legislature should adopt relevant recommendations made by the Judicial Commission on Mental Health that impact the state hospital waiting lists. The Judicial Commission on Mental Health was created to develop, implement, and coordinate policy initiatives designed to improve the courts’ interaction with children, adults, and families with mental health needs. It is the judicial system that makes forensic designations and opportunities exist to make appropriate changes in the legal system that will have a positive impact on the inpatient waitlist. For example, in September 2018, the Texas Judicial Council adopted a resolution containing twelve legislative recommendations related to mental health and the judicial system. Recommendations include granting the courts discretion when initially committing an individual to a max security unit rather than mandating all individuals with a certain offense be committed to max security.

Interim Charge 6B: Maternal Mortality and Morbidity Implementation

• Continue to support the rollout of the TexasAIM Initiative and other efforts to improve maternal health and safety. Given that the leading cause of maternal death after 60 days was drug overdose, the pilot for the AIM Bundle on Obstetric Care for Women with Opioid Use Disorder should be closely monitored to prepare for effective statewide implementation.
• Strengthen practices surrounding risk assessment and appropriate referral during pregnancy, delivery.
• Strengthen the maternal death review process. A majority of the cases reviewed by the Task Force were found to have an inaccurate pregnancy status marker on the death certificate. Improvements should include education for death certifiers as well as coding fixes to reduce human errors.
• Ensure maternal health programming targets high-risk populations, especially Black women. The Task Force found that Black women were the most likely to experience pregnancy-related death, regardless of socioeconomic level.

Interim Charge 6C: Child Protective Services Implementation

• In total, 97 bills were passed in the 85th Legislative Session that affected DFPS, and many required substantial reform. While continuing to look for areas of improvement, the Legislature should not duplicate past efforts when addressing CPS during the 86th Legislative Session to allow time for DFPS to implement the many important changes that have been legislatively directed over recent years.
• While the Texas Legislature funded and directed many positive programs and improvements directed at increasing capacity in the Child Protective Services system, most of these programs have not had enough time to produce outcomes. The Legislature should continue monitoring these programs.
• The acuity level of children in the foster care system continues to increase, and measures to ensure all children in care receive necessary services and supports should continue to be addressed by the Legislature. The CANS assessment is only given within 30 days to 30 percent of children in care. All children should be receiving this assessment within 30 days. The EPSDT exam is only given to around 50 percent of children in foster care within 30 days. All children should be receiving this assessment within 30 days.

Interim Charge 6D: Community Based Care Implementation

• The Legislature should continue the expansion of Community Based Care. The speed at which this model rolls out must continue to be driven by the Legislature, and measures of performance and contractual requirements should continue to be a discussion.
• DFPS and HHSC should review future reports and recommendations on how to best structure the rate methodology and payment structure for operation of an SSCC.
• DFPS should begin structuring Stage III contracts to ensure SSCCs are held accountable for children and families that are being served. While no SSCC is currently in Stage III regarding the provision of services in Community Based Care, DFPS should begin working with the Legislature and stakeholders to structure these contracts.

Interim Charge 6E: Long-term Care Implementation

• Continue to monitor implementation of long-term care regulation legislation to ensure HHSC implements changes in a way that is less burdensome on providers.
• Monitor surveyors’ consistency and ensure that providers understand what is expected of them.

Interim Charge 6F: Abortion Reporting Implementation

• The Legislature should continue to work with HHSC and stakeholders to identify and close any reporting loopholes post rule adoption.
• The Legislature should continue to ensure HHSC has the ability to properly track abortion reporting requirements.