The committee met to consider the following interim charges:
 
Study and assess the state's preparedness for public health threats and emergencies including responding to natural disasters and highly infectious diseases.  Review current protocols and examine public health resources to determine if they are sufficient. Identify weaknesses within the public health response framework and make recommendations for improvement.
 
Examine the history of telemedicine in Texas and the adequacy of the technological infrastructure for use between Texas healthcare providers.  Review the benefits of using telemedicine in rural and undeserved areas and current reimbursement practices.  Explore opportunities to expand and improve the delivery of healthcare and identify methods to increase awareness by provider groups, including institutions of higher education, and payers of telemedicine activities being reimbursed in Texas.
 
Telemedicine
 
Nora Belcher, Texas E-Health Alliance

  • Have had at least two bills related to telemedicine filed each year since 1995
  • This field requires continuous learning and maturation due to the constant improvement in technology
  • Telemedicine is no longer a super specialized topic; it is becoming an integral part of the delivery system
  • One of the first telemedicine projects in the country started in Texas in 1989 (Project Bluebonnet)
    • The first legislative reference to telemedicine was an HCR in 1991 congratulating the consortium that put the project together
  • In 1995 the Telecommunication infrastructure Fund and TIF Board was founded and funding was derived from a tax through cell phone bills; TIF board expanded telecommunication infrastructure to libraries, hospitals, schools, etc.
  • In 1997 the private insurance parity law was passed prohibiting non-payment of claims simply for being provided through telemedicine
  • The TIF board hit their statutory cap for granting funds and since then grants have been provided through a program to benefit rural communities
  • There has been exponential growth in Medicaid fee for service billings for telemedicine; yet only spending about $5 million on telemedicine in Medicaid currently
    • Medicare is more restrictive for telemedicine
  • The state has heavily invested in community centers for telemedicine; 34 of 39 have received state funding; infrastructure is growing
  • Chairman Myra Crownover asked what a community center is
    • State acknowledged community centers that provide mental health services; previously called MHMRs
  • Rep. Elliott Naishtat asked why 5 of 39 community centers are not using telemedicine
    • Combination of local decisions, technology being available and staffing
  • Rep. Nicole Collier asked if telemedicine has evolved over its course in the state
    • Absolutely; when telemedicine started there were carts full of equipment that would be rolled from room to room; the equipment has gotten smaller and quality has increased significantly, bandwidth has expanded but is still not as expansive as it needs to be; up-front investment is no longer in the hundreds of thousands; infrastructure is far more widely available; barriers to entry have dropped significantly in the last five years; for large scale operations there is still significant investment required because there needs to be high quality broadband, multiple connections and equipment and backup systems

 
Laurie Vanhoose, Medicaid/CHIP Division, Health and Human Services Commission

  • In 1997 telemedicine benefit in Medicaid was authorized
    • A healthcare service initiated by a physician or provided by a health care provider acting under the supervision of that physician
    • Telemedicine is basically the electronic transmission of health care data
  • Telemedicine in Medicaid is simply an alternative delivery of existing benefits
    • Distant site provider – the physician providing services
    • Patient site provider – the site where the patient is present; must also be licensed to provide Medicaid services and are paid for the visit
  • Collier asked if there are certain conditions where telemedicine works best
    • Any service being provided through telemedicine must be equivalent to a face to face visit
  • Telehealth is basically about the wellness of a client; require a face to face valuation before a provider can bill for telehealth; non-physician services; authorized in 2013
    • Social workers, LPCs, registered nurses, etc.
    • Seeing the most billing codes for services in telepsychiatry
  • Rep. John Zerwas asked if an episode of care is more expensive because two providers are reimbursed
    • The distant site provider is paid for their regular services and the patient site provider is paid a fee for the visit over and above the physician’s services
  • Telemonitoring is the newest benefit in Medicaid; authorized in 2014; requires a physician to monitor; a patient may have a condition that requires monitoring that can be done from their home through a home health entity or a hospital that discharges the patient
  • Rep. Bobby Guerra asked for the distinction between telemedicine and telemonitoring
    • Telemedicine is a service provided in a facility by a physician
    • Telemonitoring is done in the home and currently only for hypertension and diabetes; assumed that it will reduce hospital visits; monitored by home health entity or hospital and reported to a physician
  • Guerra noted he believes there is a huge capacity for savings in telemonitoring because it reduces home visits; would like data on cost savings
    • December HHSC telemedicine, telehealth, telemonitoring report will show these cost savings
  • Collier asked what kind of equipment goes into patients’ homes
    • Equipment that is used to read vitals such as blood sugar levels, heart rate, etc.
    • Medicaid does not pay for the equipment, only for the setup of that equipment
  • Collier wonders if this causes increases to utility bills
    • Belcher noted much of the equipment plugs into the wall and transmits information to a satellite so that broadband is not an issue
  • Managed Care Organizations are implementing really good telemedicine programs
    • DSRIP programs include 80 telemedicine, telehealth and telemonitoring programs as well
  • Codes billed most include pharmacological management, psychiatric diagnostic, psychotherapy; mostly behavioral health services
  • Looking at adding high risk pregnancy and congestive heart failure as a benefit for telemonitoring
  • Zerwas asked what barriers there are in telepsychiatry for pharmaceutical treatment such as the DEA
    • Belcher noted the internet prescribing act continues to be a barrier at the federal level; there is activity trying to resolve that; mostly a barrier for controlled substance prescribing
  • Naishtat asked for information on how reimbursement rates compare to other high telemedicine utilizing states

 
Dr. Alex Vo, University of Texas Medical Branch Telemedicine

  • Care coordination and cost are the major challenges for increasing telemedicine utilization
  • Seeing reduction in care costs, increased access to care and diversion of ER visits in the UTMB program
  • Last year conducted 119,000 tele-visits
  • UTMB clinical focus ranges the entire gamut of medical care; including real time physician care and asynchronous services such as radiology, x-ray diagnoses, etc.
  • Outcomes
    • Diverting a very high number of ER visits in the incarcerated populations and non-correctional settings; including acute conditions and behavioral health conditions
  • Emerging programs include employer based contract care, correctional setting population management, integrated care models for physical and behavioral health
  • Using telemedicine to embed behavioral health providers in primary care settings; significant cost savings are achieved with this model
  • Zerwas asked if there are any areas where telemedicine does not work as well
    • There are limitations in complex patients that need to be seen face to face; patients can be immediately referred to a face to face interaction
  • Crownover asked if fraud and abuse are an issue
    • No; have been using telemedicine for so long that TMB has very refined rules regarding the practice of telemedicine; hard to get out of practice and not be detected; obviously there are bad actors in every field

 
Dr. Billy Phillips, Texas Tech Health Science Center

  • Telemedicine is and should be considered principally a tool for increasing access to health care
  • Texas has a problem with provider shortages in multiple regions and multiple specialties
  • TTU has built a greater capacity for management of high-cost chronic diseases through 1115 waiver projects to create better opportunities for resource utilization
  • Providing telemedicine services to schools for behavioral health and student mental wellness issues, providing a next generation 9-1-1 program to increase positive outcomes
  • Cost savings are significant; flying a patient in West Texas costs $56,000 every hour; determining on-site where most appropriate care can be provided increases efficiency and positive outcomes
  • Most of the telemedicine provided in correctional settings is behavioral health care
  • Technology can often outpace the regulatory capacity to oversee it; TMB has been very sufficient in regulating telemedicine

 
Jamie Dudensing, Texas Association of Health Plans

  • Telemedicine has been rapidly adopted by health insurance companies in the last 3-5 years
  • Employers and consumers are asking for these services because they increase access and reduce costs
    • Expect that in a few years nearly 75% of employers will offer this type of coverage
  • Want to encourage the use of telehealth and telemedicine services; do not want it overregulated and do not want to see adoption of stringent requirements that increase costs
  • Naishtat asked how many health plans offer telemedicine services
    • Do not have that information but there is a huge range of products from Medicaid plans providing services for physician consultation to commercial plans offering an expanding menu of very basic services
  • The private market is working in this area because there is huge demand and satisfaction
  • Crownover noted it is harder to quantify money not spent as a benefit

 
Dr. Thomas Kim, Texas Medical Association

  • 10 years ago teleservices were confined to large institutions providing services to correctional institutions and other large population institutions; now they are widely accessed by a broad array of patients
  • Moved to Louisiana, Georgia, Maryland and Texas and has kept the patient panel from each state using teleservices
  • Encouraging continued expansion of broadband access; this is vital to the growth and improvement of teleservices
  • Licensure requirements are challenging; a physician must maintain a license for each state they provide care in as well as the state they live in
    • TMA supports an interstate licensure compact among multiple states
  • Supports teleservice reimbursement parity
  • Electronic prescription of controlled substances is a safe and effective way to accomplish a critical provider task that provides improvements in outcomes

 
Julie Hall-Barrow, Children’s Health System

  • The first draft of pediatric telemedicine guidelines were drafted in the last few weeks
  • Providing an 1115 waiver project in schools that provides telemedicine services to children
    • Have completed over 2,000 consultations
  • Providing tele-NICU service and tele-ER programs to expand the reach of experts in the state
    • These programs prevent the transportation of babies to a higher level of care which saves money and allows for more expedient provision of care
  • Providing a remote patient monitoring program; monitors liver and kidney transplant patients in their home and transmits data back to providers without the requirement of a physician visit
    • This is not provided as a billable service; just a way to increase quality of care
  • Expanding provider coverage is the main goal of all of these programs; faster access to specialists is very important
  • Zerwas asked about barriers to realizing the full potential of these programs
    • The home is not a billable site for telemonitoring; if a patient is receiving dialysis at home and has no transportation the follow up could be done at home through telemonitoring but it is not billable

 
Public Testimony
 
Kathy Dewitt, Texas Association of Business

  • Telemedicine is very exciting for employers and employees
  • Gives employees the ability to work as opposed to taking off of work for a doctor visit
  • Telemedicine brings health care to a population of people who would normally wait until they were very sick to go see a doctor (millennials); ease of use
  • See this as a win-win for everyone

 
Megan Morgan, ARC of Texas

  • The overlap of telemedicine and telehealth can greatly benefit IDD populations without access to care
  • Need to find the balance between actually improving outcomes and only reducing costs
  • Would like for the state to continue to develop best practices in this area

 
Dr. Kyon Hood, Medical Director, Teladoc

  • Teleservices can be practiced safely and must be considered as a way to reduce the effect of the provider shortage in the state
  • Teladoc provides photograph, video and audio consultations but TMB has only authorized audio consultations so that is the only method practiced in Texas

 
Adam Vandervoort, General Counsel, Teladoc

  • Naishtat asked about the TMB regulations
    • TAC defines telemedicine and includes video but only with an in-person consultation
    • Audio consultations are provided as well as photograph services – but only for asynchronous consultations
  • Guerra asked if there is a distinction between telemonitoring and telemedicine in the TMB rules
    • Not sure as Teladoc does not provide telemonitoring
  • Teladoc is the nation’s largest teleservice provider
  • Have provided 1.25 million interactions
  • Teladoc started in Texas and almost all physicians are resident in Texas
  • 2,387 companies with operations in Texas are Teladoc clients
  • Numerous municipalities are clients of Teladoc as well
  • As long as there have been doctors and telephones, doctors have been treating patients remotely
  • If a doctor is treating a partner’s client or a client they have not seen in a while it is only OK for them to treat common uncomplicated conditions
  • Have not had a single malpractice claim in 1.25 million transactions because physicians are very selective for the conditions that are treated remotely
  • No pharmaceuticals with a street value are ever prescribed; very careful not to over-prescribe antibiotics
  • Teladoc has a 95% satisfaction rate and the number one complaint in the other 5% is that they weren’t prescribed an antibiotic
  • Sheffield asked about certain conditions and how they can be diagnosed remotely
    • There are absolutely conditions that cannot be diagnosed remotely
  • Sheffield noted there are issues with employers not allowing employees to go to the doctor when they have to leave work to do so
    • Definitely do not urge employers into that practice; also only trying to be a supplement to the traditional model, not a replacement for it

 
Kate Murphey, Texas Public Policy Foundation

  • Texas has the strictest telemedicine regulations in the country
  • In April 2015 TMB required a face to face interaction before the patient can engage in telemedicine services; there is an exception to that in mental health cases unless in emergency situations; the face to face visit can be achieved at an approved site still using telemedicine services
  • This is more of a roadblock than a safeguard
  • The exception to the exception in mental health cases goes against the traditional model of suicide hotlines which are extremely common and less professional
  • If a person is privately insured they can call a doctor and talk about their condition, in certain Medicaid cases the home is not a billable site so this cost savings cannot be achieved
  • Rep. Bill Zedler asked how many other states require the prior relationship with a doctor
    • Only Arkansas
  • Rep. Sarah Davis asked if TPPF supports federal trade regulation of state practices that regulate medicine
    • No

 
Ed Stonebraker, CoordiNation Centric

  • Only addressing telemonitoring
  • Telemonitoring is a very difficult benefit to provide to a beneficiary; very fragmented communication structure with a moving billable date
  • Designed software platform to resolve those problems
  • Discussed issues getting prior authorization from MCOs regarding this benefit
  • Despite the challenges it is a great benefit

 
 
Public Health Threats and Emergencies
 
John Hellerstadt, Commissioner, Department of State Health Services
David Gruber, Assistant Commissioner, Department of State Health Services

  • Public health emergency response occurs through mobilization of everyday public health systems
  • Cities and counties may decide to appoint a public health authority
  • It is up to local authorities to what extent they prepare for and address public health emergencies
  • Public health threats can include any number of natural disasters, other physical threats, infectious disease and other emergencies
  • DSHS covers public health services for a majority of Texas counties
  • 60 of 140 local health departments are full service health departments
  • Texas prepares for and evaluates the risk association for all types of public health disasters
  • Texas has a broad range of public health risks due to geography, populations, etc.
  • Within the state’s response plan, DSHS’s role is specific to coordination of public health and medical response to emergencies
  • DSHS serves a role in responding to emergencies related to infectious disease through DSHS laboratories
  • DSHS plays a role in prevention of infectious disease outbreak through the state epidemiologist’s office
  • DSHS regional offices are critical to emergency response
  • After a disaster, DSHS’s role is to go back in and ensure when services resume that they are safe for consumers and citizens
  • Davis asked about RACs, what do they do and what is their role, how are they prioritized
    • Gruber replied that Regional Advisory Committees are critical in both public health and medical response, RACs are the coordinators of efforts between DSHS and regional entities for the medical component of an overarching response; they are exceptionally important
  • Texas is a home rule state so emergency response starts at the local level unless there is no local health department; when response exceeds local capacity the state can step in as requested and the state can in turn request federal aid in response to an emergency
  • Constantly investigating a lot of diseases but certain diseases are focused on based on current threat levels
  • Naishtat asked if meaningful partnerships are fostered in areas where there are not public health authorities
    • Where there aren’t local health authorities, DSHS is the local health authority
  • The mission during a disaster is to protect public health and safety during an event; truly depends on the robustness of everyday activities
  • Examples of response events include Ebola, the West explosion, the Bastrop wildfires, H1-N1; just a small example of the wide variety of events that can occur
  • DSHS helps in recovery efforts as well by supplying staff, equipment, etc. to local entities
  • The Zika virus is currently being monitored in the state; very concerned about this right now
    • A mosquito transmitted virus; symptoms are typically very mild but there is likely a relationship between the virus and birth defects
    • Although there has been a case of Zika in Texas, there is no evidence currently that Texas mosquitos are infected; making efforts to educate citizens about the virus and things they can do to protect themselves
  • Naishtat asked if there is training for local authorities regarding emerging infectious diseases
    • Yes
  • Davis asked about her bill regarding the sentinel surveillance system
    • Will be looking at that asset through the Governor’s infectious disease task force; currently identifying and procuring software that will be put in place toward that goal
    • Have implemented the legislation through rules; there was already a broad infrastructure for monitoring and right now it is being more specialized for the diseases the legislation referenced
  • Davis was not satisfied with the response and asked for better communication surrounding this issue

 
Southwest Texas Regional Advisory Council (STRAC)

  • Regional disaster preparedness for wide range of disasters
  • Has had a major role in most disasters occurring in Texas in the past decade
  • 22 RACs created in 1989
  • Southwest RAC (San Antonio) is larger than most
  • Emergency management, EMS, and public health responses are all linked under RACs
  • Unified consensus building effort has been beneficial in responses and problem solving
  • Views himself as “second responder” to make sure that first responders work well together
  • Regional Barriers
    • Consistent funding for disease control and response are lacking
    • Hospital preparedness funding has been diminished since 2010
  • Addressing state and federal laws that restrict release of critical information is an important effort
  • We need infectious disease centers of excellence
  • Naishtat asks if there are free or low cost programs that provide training for trauma care best practices or do they always cost upwards of $350
    • There are grant funded programs to offset some of training cost for EMS responders
    • It is hard to roll a program out talking to 50 EMS chiefs across Texas, so we want to consolidate meetings to inform EMS chiefs of these programs
  • Davis says there were more than 11,000 people trained for hands only CPR in 10 cities across the state which was a world record
  • Robust emergency medical healthcare system is our best protection against disaster

 
Dr. David Persse, Public Health Authority and EMS Medical Director, City of Houston

  • EMS medical director and Public Health Authority overlap is helpful
    • It has served the City of Houston well through multiple disasters
  • Role of public health is vitally important as well but does not get the public attention compared to law enforcement, fire fighters, and EMS
    • Asks committee to start seeing public health as an arm of public safety
  • Public health army goes out to respond to infectious diseases
    • We need more epidemiologists – this is one of public health’s shortfalls
  • We spend $19.31 per capita on public health, but some states are spending over $100
    • We are entering a “new normal” where infectious diseases are popping up more often because we travel more

 
Judge Rex Fields, Eastland County Judge

  • Has quite a bit to do with public health and public safety as far as emergency management
    • Ability to declare curfew, evacuation
  • Emergency management system works well and Fields appreciates funding for DPS and Division of Emergency Management
  • Public and first responders need to learn the difference between National Weather “watch” and National Weather “warning”
    • Watch means conditions are right for a tornado
    • Warning means the tornado is on the ground
    • You can sign up for texts from National Weather Service
  • Disseminating information to the public is an ever-evolving process especially in rural Texas, and we need best practices for informing the public
  • FEMA recovery process has improved over the years

 
Dr. Brent Kaziny, Texas Children’s Hospital, Texas Hospital Association

  • Texas has more federally declared disasters than any other state
  • Frontline physicians serve as an invaluable resource
  • Standardized Disaster Curriculum does not exist for pediatric care, but should
  • Texas has faced fair share of disasters, and we have many state and federally funded programs for response
    • These are strong assets to our state, but dwindling funding streams put our system at risk
    • Children are often forgotten in planning
  • Difficult to convince policy makers to prepare for things that may not happen, but it makes us better suited to react

 
Dr. James Le Duc, Galveston National Laboratory and Institute for Human Infections, UTMB

  • Large facility with a lot of space dedicated to biocontainment research
    • Half of the building is dedicated to equipment to maintain safety of building
    • Built specifically to withstand hurricanes which so far has been effective
  • Lab designed to include capacity for large number of specimens very quickly
    • We are trying to be proactive in our Zika preparations
  • We have Zika and Ebola and other diseases in our laboratory to research
  • Funding is usually received for disasters, but there needs to be more funding for preparedness and research
  • Collier asks what they are doing with the Zika virus they have to prepare
    • We are trying to make sure we can diagnose the virus
    • We are looking at mosquito vectors to see how it is transmitted and if our domestic species can transmit it
    • We can get animal model with mice to study Zika
    • We have requested federal funding, and just need to do the work because the virus has been under the radar screen for so long

 
Dr. Scott Lillibridge, Director of Health Initiatives for Texas A&M System

  • Notes importance of public health preparedness
  • Texas does well, but we should not be complacent
  • We need advances in technology: surveillance, sensor technology, workforce augmentation
    • Technology is emerging everywhere and we need to continue to work on that gap
  • Engagement with private sector could be improved
    • Much of health care in Texas is done in private sector and engagement can improve preparedness and care
  • Federal government wants to push more vaccine candidates into the market and is doing so in part through Texas A&M system
  • Need to address preparedness for disadvantaged Texans
  • Naishtat asks what unique barriers rural areas face in preparedness
    • Access to technology and medical homes
  • Sheffield asks what the worst three things we are doing that are holding us back
    • We spend so much money on end stage disease and late stage treatment, but we need to move resources into prevention
    • Treating these issues early will save money over time

 
Public Testimony
 
Matt Richardson, Denton County Health Department

  • Requests that when legislators entertain legislation from constituents that they will consult people with “boots on the ground” in public health

 
Christina Thompson, Retired Professor from Texas A&M Corpus Christi

  • Committee needs an analysis of the number and quality of laboratory personnel, but this is not currently possible because they are not licensed
  • Licensure would allow us to plan for shortages and accurately evaluate preparedness
  • If there is no qualified personnel at local level, then detection, diagnosis, and treatment will be delayed

 
Anna Dragsbaek, Immunization Partnership

  • We need to develop vaccines for emerging diseases
  • Flu kills more people than any other vaccine-preventable diseases combined each year
  • Making sure public is vaccinated is important
  • We should consider reducing number of non-medical vaccine exemptions across the state
  • Crownover says we are making progress on addressing misinformation about vaccines causing autism
    • Dragsbaek says the science is clear but allowing non-medical exemptions has made the non-vaccination numbers skyrocket
    • Every county is rising in number of vaccine exemptions

 
Eduardo Olivarez, Hidalgo County Health and Human Services

  • Local public health serves as a central part of detailed and complicated Texas public health response system
  • Local health departments are the true first responders

 
Judy Powell, Parent Guidance Center

  • Vaccines are tested on people of color in under-developed countries  – not on white people
  • We never focus on where our vaccines come from, but it should be a focus when legislating vaccines

 
Andrea Brower, Texas Gun Sense

  • Gun violence is one of the largest public safety threats
  • Robust public awareness campaign like those done for seatbelts, drunk driving, etc. could prevent death and injury
  • There should be a comprehensive study to address gaps in laws that result in death and injury
  • Rep. Cesar Blanco asks what some of the gaps are that she sees in law
    • Most important thing we can do is pass a universal background check law
    • There are fixes with open carry and campus carry that could be addressed

 
Zach Thomas, Dallas County Health and Human Services

  • We have to aggressively go after federal dollars for public health
  • Public health is local and needs funding

 
Philip Huang, Health Authority, City of Austin

  • Public health really happens at the local level
  • Physician expertise is important
  • Tobacco is large cause of preventable issues