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The House Public Health Committee met on April 5 to consider the following interim charge:
 
Study the impact of chronic disease in Texas and identify the major regional chronic health challenges.  Review the types of health data collected by the state related to chronic disease and how the data is utilized to improve health care.  Study state programs targeting chronic disease, including the Texas Health Improvement Network, and identify the direct and indirect costs associated with obesity, tobacco, and other related chronic health conditions including impacts to Medicaid, ERS, TRS, University of Texas System, Texas A&M University System.  Identify public health interventions for chronic disease and preventative healthcare services that improve health outcomes and reduce cost.
 
John Hellerstedt, Commissioner, Department of State Health Services

  • Case count for Zika virus in Texas is 27 cases; all are directly or indirectly related to travel
    • There is no evidence that Texas mosquito populations are infected with Zika
  • There is no reason to believe Texas will have a situation like Brazil because we have very different living conditions here, however it is probable that there will be local mosquito transmission of Zika at some point
  • Discussion of efforts in other states and within Texas to educate the public about mosquito avoidance and eradication

 
Jana Zumbren, Assistant Commissioner for Disease Control and prevention, Department of State Health Services

  • Focusing discussion on preventable and controllable chronic diseases
  • Chronic diseases account for 75% of Texas annual health care expenditures; these will increase as the population ages
  • In 2010, 10% of Texans were 65 or older; expect that number to grow to 17% by 2050
  • Of the top 10 causes of death for Texans, 8 are chronic diseases including heart disease and cancer
    • Most can be affected by medical management changes and lifestyle changes
  • Texas cancer rates are lower than in other states
  • There are health disparities related to age but there are also disparities related to race and income levels
  • Discussion of disease incidence rates and death rates among different race categories; rates tend to be higher for Hispanic and African American populations; rates are also higher for aged populations
  • Rep. Elliott Naishtat asked about insufficient data for four regions of the state
    • Due to lack of reporting; collecting data from hospitals; trying to ramp up reporting  as required by a budget rider from last session
  • Naishtat asked if there is any reason why reporting is not mandatory
    • This is no statute that mandates it
  • Rep. John Zerwas asked about public health region 2; seems to be very high in all categories
    • The percentages for regions are not adjusted for race, age, ethnicity, etc.; if adjusted for those variables it would look different; that area has a high share of older people; region 2 is the Wichita Falls area
  • 25% of Texans had diabetes in 2014; this disease is growing at a rapid rate
  • Persons with behavioral health conditions are also more heavily impacted by chronic diseases
  • Need to be focusing on health disparities, social risk factors (poverty, lack of transportation, lack of education, lack of support system) and lifestyle changes that can help bring these numbers down
  • For the greatest chance of success everyone has to be a part of a system that creates support within families, work sites, schools, places of worship, etc.; without these supports it is extremely hard to make changes to avoid chronic disease
  • Heart disease and stroke program was funded this year at $3.25 million; using it toward educational efforts and rider 67 activities which provided funding to UT which runs a collaboration of heart and stroke research activities
  • Very small cancer control program funded at $359,000 this year; mostly working with partners to reduce risk vectors like tobacco use, exercise, etc.
  • Diabetes prevention and control was funded around $1 million for this year; self-management education, research and studies; have been successful in reducing the number of people who move from pre-diabetes into further stages
  • Using tobacco prevention and cessation funding to work with local communities to develop educational programming, targeted media and a cessation hotline; smoking prevalence has gone down from 19% to 14% in the last 3 years
    • Monitoring the use of electronic cigarettes; prevalence of use in younger populations is relatively high
  • Texas Healthy Communities program provides grants to local communities to help them assess their chronic disease prevention programs and develop comprehensive strategies to address particular diseases
  • School Health Program leverages success by working with school district to provide technical assistance and educational information to implement pilot and other projects
  • Naishtat asked about comorbidities; is that data studied differently
    • Yes; chronic disease conditions do not have mandated reporting like infectious disease so the data is incomplete; mostly comes from surveys and self-reporting; chronic disease program is working closely with the state hospitals to determine relevant occurrences and extending that to LMHAs to support them in educational efforts to support their clients with comorbidities; these populations tend to have a higher rate of comorbidities
  • Rep. Garnet Coleman asked about the drops in rates for many diseases
    • Probably mostly to do with the improvements in health care and medication management, etc.

 
Porter Wilson, Executive Director, Employee Retirement System

  • Costs in the program tend to be higher for older populations; this is important because ERS is an aging population; today over 36% of population is over the age of 60
  • Population is 55% female which has a higher cost association as well
  • United Healthcare’s national book of business has an overall risk factor that is 38% lower than that of just the ERS population
  • Spouses drive a higher cost for the plan; may have to do with the ability of the state to engage employees more easily than the spouses
  • Zerwas asked if the spousal trend carries through insurance policies nationwide
    • It seems to be unique compared to United’s national book of business
  • Claims costs for ERS are much higher than other employer based plans for United when looking at specific disease care
  • Diabetes prescriptions are one of the highest drug spends for ERS
  • There is a large focus on trying to prevent Type 2 diabetes; recently launched a new program that is technology based and engages employees in actively managing and working to reduce their weight
  • Discussed tobacco cessation programs within the plan and other programs to help manage chronic diseases

 
Ken Welch, Deputy Director, Teacher Retirement System

  • Focusing on Active Care program and not the retiree program
  • Participants are younger; average age is 34.5 years old
  • Dependent children make up 25% of the program
  • Predominantly female; 75% of employees
  • Members are predominantly in rural areas; 54% of membership; the rest are split fairly evenly between suburban and urban
  • Over half of inpatient treatment is related to obstetrics
  • About $1.6 billion spent last year; 80% medical and 20% pharmacy
  • Discussed chronic disease rates within the TRS population
    • For hypertension, and diabetes average spend per member, per month is about 3 times that of a healthy member
    • For tobacco related conditions the average spend is about 5 times higher
  • Costs are relatively low for pharmacy spend because generics are used whenever possible; use step therapy
  • Have charged Aetna (health plan manager) and CVS Health (pharmacy benefit manager) to increase care coordination and management to increase adherence

 
Katrina Daniel, Chief Benefits Officer, Teacher Retirement System

  • TRS participates in a  wellness program that provides incentives and awards for “teams” of employees who reach certain goals and achievements
  • Rep. Bobby Guerra asked if there are more women involved in the program than men
    • The program is focused on the employee side of the population which is predominantly female
  • Various disease prevention programs are estimated to save the program $47 million per year
  • TRS funds smoking cessation programs and drugs at no cost to the member
  • Sheffield asked about smoking cessation program; which drugs are used
    • Not sure
  • Sheffield noted these are expensive but can be effective; how many are successful
    • Not sure about that
  • When a patient is identified with a chronic disease they are targeted for case management; participation is over 90%
    • A nurse will contact the patient, they will be engaged in active monitoring as well as supportive monitoring
  • 72% of participants in disease management program have two or more chronic conditions
  • Case management focuses a little more on high cost claimants; can actively monitor what is going on in each situation
  • Participate in a program to target high risk pregnancies to try and affect healthy pregnancies
  • Guerra asked if there is communication between ERS and TRS to try and share best practices
    • Yes both formal and informal; that is done to implement new programs and practices as well as to share information
  • Chair Myra Crownover asked if participants are asked to disclose whether they are smokers
    • No; there was not legislation directing TRS to do so

 
Kevin McGinnis, Executive Director of Risk Management and Benefits Administration, Texas A&M University System

  • Chronic conditions are an epidemic
  • If employees are not engaged they will not make decisions to help with their condition
  • Cover 30,000 lives; about 8,300 retired members
  • Roughly 40% of members have at least one chronic condition
  • Once a disease is identified the plan wants the pharmacy spend to be as high as possible which points to adherence
  • Making funds available to individual entities to develop health management programs
  • If a member does not have an annual exam with a physician members pay an additional premium; 90% compliance rate
  • Self-declared tobacco users pay an additional premium similar to ERS
  • Pharmacy benefits cover cessation programs similar to the other two programs
  • Naishtat asked about the annual exam requirement
    • Insurer dumps a file that shows all members who have had an annual exam; there is the ability for members to check online
  • Have a program that helps members with weight management
  • Looking at waiving copays for chronic diseases and free supplies for participating in a diabetes coaching program

 
Dan Stewart, Associate Vice Chancellor, University of Texas System

  • Health care cost per member per month average is $300; $125 for prescription drugs
  • More than 75% of chronic health care claims can be attributable to lifestyle conditions
  • A little over 50% of enrollees are in the employee only category

 
Laura Chambers, Director of Group Insurance, University of Texas System

  • Working very closely with members to focus on medication adherence
  • Express Scripts (pharmacy benefit manager) has a program specifically to guide lifestyles and work on adherence; members are much more likely to interact with a pharmacist
  • 53% of members receive an annual exam which is provided at no cost
  • Have found that offering multiple programs to engage with individuals on different levels helps to achieve the greatest participation
  • There is a direct correlation between support from university department heads and participation in the wellness programs
  • Discussion of the wellness programs provided by the system
  • Cover 100% of tobacco cessation benefit including drugs
  • Recommends that all state agencies and entities become tobacco free
  • Stewart noted employees have time off to vote, time off to go to funerals, etc., but do not have time off for a physical exam
    • Rep. Rick Miller wondered if that would require a state directive

 
Emily Zalkovsky, Deputy Director for Medicaid/CHIP Policy and Programs, Health and Human Services Commission

  • Texas Medicaid served 5.1 million clients in FY15
  • For FY14 Medicaid spent $1.75 billion on chronic disease care
  • A high number of members who smoke and especially those who are obese are found to have chronic diseases
  • Service coordination is a fundamental part of STAR+PLUS program in Medicaid
  • MCOs have disease management programs for various diseases as well as value added services to market to members which can address chronic disease as well
  • Performance improvement projects are a federal requirement for all Medicaid managed care programs
    • A lot of the projects focus on chronic disease
  • 49 DSRIP projects focus on obesity prevention or weight management
  • 28 DSRIP projects focus on tobacco cessation
  • At least 270 DSRIP projects focus on prevention, treatment and management of diabetes
    • Many of these also work with individuals with other chronic health conditions

 
Dr. David Lakey, Associate Vice Chancellor for Population Health, University of Texas

  • Much of the funding that flows through Medicaid and other programs goes toward the prevention, treatment and management of chronic disease
  • Chronic disease is a huge driver of the state mortality rate
  • Tobacco is the number one killer in Texas; right after that is obesity
    • About 18% of Texans smoke and about 2/3 of the population is either overweight or obese
  • Obesity
    • Overall cost to society is over $500,000 in a lifespan for one obese individual
    • US costs related to obesity have doubled in the last decade
    • Average healthcare costs of obese individuals is 42% higher than a non-obese person
  • Susan Combs, when Comptroller, looked at the cost to business of dealing with obesity
    • Recommended partnering with the private sector to develop strategies for healthy eating and physical activity
    • Recommended recognizing schools for improvements in health and physical fitness
    • Recommended restoring physical education in public schools
    • Recommended making products that can be bought with SNAP benefits healthier, and allowing SNAP benefits to be used at farmers markets
    • Recommended allowing CPRIT to invest in obesity research
  • Tobacco is a huge driver of poor health, mortality and the costs the state is incurring related to health insurance
    • Need to get better at ensuring Texas children do not start smoking
    • Need to get better at eliminating exposure to second hand smoke
  • Comprehensive tobacco control programs are the number one recommendation to control this problem
    • Smoke free policies reduce heart attacks in a community
    • There is not an adverse effect on business
  • UT Austin has been funded to put together a database to find what tobacco policies are on any campus in Texas
    • Only about half have smoke free campuses
  • East Texas is the most unhealthy part of the state for a number of different reasons
  • In Oklahoma, through a Governor’s initiative, all state entities have become smoke free locations
  • There are a lot of programs the state has put in place and that employers have put in place that aren’t being utilized; utilization needs to improve
    • Sharing information between ERS and state agencies could help to identify problems within each agency that need to be addressed

 
American Heart Association

  • Smoking is not a habit, it is a chronic disease
  • There are innumerable health risks and effects that come from smoking
  • More needs to be done to ensure the effective cessation of smoking around the state
  • Over 70 scientific studies looking at legislative smoking bans have found that these bans are effective in reducing cardiovascular disease
  • Texas is only one of ten states left in the US that does not have a statewide ban
  • Increasing cigarette taxes and general price increases do well in decreasing smoking in the young populations and low income populations

 
Dr. Eduardo Sanchez, Texas Public Health Coalition

  • Promoting health in the state can only occur through a systematic approach
  • Healthy lifestyles start at the earliest phases of life
  • Healthy people do better at work and are more productive

 
 
Public Testimony
 
Rene Garza, Texas Pharmacy Association

  • Independent pharmacy owner
  • Pharmacists can serve an important role in communities; can support physician’s teams in helping with medication adherence and wellness

 
Michael Muniz, Pharmacist

  • Today’s pharmacists focus on patient care and wellness first and dispensing second
  • Have developed and implemented educational programs to assist people with management of routine and complex health issues
  • Have been working on a medication synchronization program and have implemented the program with over 300 individuals already
  • Guerra asked what can be done at the legislature to assist in these efforts
    • Need to be able to be reimbursed for these services
  • Guerra asked what type of reimbursement; Medicaid, indigent, insurance requirement?
    • The asks will eventually come; these programs show an increase in quality of life and a decrease in costs and once the pilot programs have been around a while and start to spread the asks will come

 
Tom Banning, Texas Academy of Family Physicians

  • How we define primary care in Texas
    • Encourages over use of services and doesn’t allow time for the doctor to spend with the patient
    • Average primary doctor only spends 7-10 minutes with each patient, not allowing enough time to address other comorbidity issues
  • It is pretty well assumed that 5% of the population drives over 50% of the costs to the state
    • Need to be developing programs that target the super utilizers

 
Olga Rodriguez, Deputy Director, Texas Association of Community Health Centers

  • Discussed efforts to share information with DSHS
  • Being a patient centered medical home is a key to what community health centers are doing to affect chronic conditions
    • Urging lifestyle changes needed to improve care
  • Need to close the coverage gap and provide parents of Medicaid/CHIP eligible children with treatment options

 
Salil Deshpande, Chief Medical Officer, United Healthcare Community Plan for Texas

  • United employs more than 15,000 Texans and insures nearly 4.3 million Texans
  • Texas ranks 34 in the US in overall health
  • Have lowered smoking rate 20% in the past 2 years
  • Obesity rate is rising nationwide but Texas outpaces the US with a higher than average obesity and diabetes rate
  • United is empowering members to make smart, health decisions by communicating with them through mobile apps
  • Rep. Sarah Davis asked who would be the best person to discuss the decisions to drop PPO plans in Harris County and the huge shakeup in hospital systems regarding them being dropped from networks for exchange plans
    • Will provide that information

 
Cam Scott, American Cancer Society Cancer Action Network

  • Tobacco control is paramount
  • DSHS does a great job with the small amount of money they receive
  • Obesity is a huge issue as well; putting more physical education back into schools would be a huge step forward
  • Commended CPRIT; They have delivered over 2.7 million preventative services to Texans; this investment is saving lives right now

 
Laura Cardis, Children’s Defense Fund

  • The focus on chronic disease is essential to the future wellbeing of the state
  • Chronic disease affects 50% of adults and 25% of the children in Texas
  • 2/3 of deaths are attributable to chronic illness
  •  Nearly 400,000 individuals living in the coverage gap have a mental illness; when parents have coverage children are more likely to have access to care
  • Discussed the benefits including additional federal funds that would come from closing the coverage gap

 
Adriana Kohler, Texans Care for Children

  • Obesity is a growing problem; 31% of low income kids from 2-5 years old are overweight or obese in Texas
    • They are 5 times more likely to be obese or overweight as adults
  • Ask the state to continue supporting very important obesity prevention programs