House County Affairs Committee – June 11, 2014 Hearing

Below is the HillCo client report from the June 11 House County Affairs Committee hearing.

The House County Affairs Committee heard testimony from the medical schools and health science centers on the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver. The committee also considered the following interim charge:

Examine population growth in Texas counties and the impact the growth has had on housing, available land resources, businesses in Texas, as well as the impact of growth on the state's economy. Evaluate Texas's preparedness to respond to future growth and ensure economic stability.

Populations Growth

Dr. Lloyd Potter, Texas State Demographer

The population of Texas in 2013 was 26.5M
Have seen a large population growth, 387K between 2012-2013
46% of the growth is from net migration, the rest is from the natural cycle of deaths and births
¼ of the counties in Texas are in the top 40 counties nationally
87% of the population of Texas lives along and east of the I35 corridor
Gonzalez – why are some of the counties losing population?
- Kids are leaving their homes in rural areas to the more urbanized ones for work or school, and the older population remains in rural Texas
- More jobs need to be created for people to move to rural Texas
SE of Bexar County there is growth due to the Eagle Ford Shale
Kolkhorst – do you think the population will continue to increase due to the fracking of the Eagle Ford Shale?
- Yes
Coleman wants to see the trends so they can predict what the population will look like in 20 years
Dallas and Harris have experienced a lot of people moving out of the core and into unincorporated areas due to gentrification and raising costs in city centers
- People moving out for more affordable housing have longer commute times and quality of life declines
There are 500 people moving to Texas a day
- Infrastructure is increasingly becoming a problem and could eventually dissuade employers from coming to Texas
Gonzalez asked for recommendations to prepare for the population growth
- One challenge is teen births which leads to poverty and profoundly effects the next generation
  - We have the highest rates in the country
- Education for young Latino population
- Address electricity issues and water issues

T. Michael O’Connor, Sheriff’s Association

Population growth has effected them significantly – some of their officers cannot even live in the county due to increasing costs
MHMR has become an increasing problem and it feels like the movie “Groundhog Day”
- Feel like the jail is a quasi-MHMR facility that is unqualified to address behavioral health issues
- The inmate’s healthcare (Medicaid or Medicare) are suspended as soon as an individual enters the jail so it puts the financial burden on the counties
  - This is a Texas law
  - Cost savings to the state, but just pushes the cost down to the counties
Gonzalez – are current law enforcement officers not being paid the cost of living?
- Based on the county, but no
- Gonzalez wants to make sure they are getting paid a living wage

Paul Sugg, Texas Association of Counties

Each County has individual challenges:
- Transportation and infrastructure
  - Roads are being destroyed by heavy traffic and there is no local money to fix them
- Prop 1 – people want the money for transportation improvements
- Counties are working well with TXDOT
- Water concerns and they want Prop 6 implementation
- Access to health care in many areas of the state is problematic
- Need mental health diversion options
- Concern on how to continue to pay for EMS and firefighters
- Would like access to the GR dedicated funds that are just sitting there
  - Kolkhorst believes that Straus is committed to looking into this
- Juvenile Justice – the bad guys on the border are using kids to commit crimes because it is easier to get them out of jail
- Would like funds to restore the county courthouses

John Dahill, Texas Conference of Urban Counties

Tremendous growth in his counties
Unincorporated areas are growing at a rapid pace
Challenges are transportation, water and sewage
People in the state want local government to find ways to save them money, but they need monies local

Scott Norman, Texas Association of Builders

Population growth is both a benefit and burden
Texas has led the nation in housing starts in the past 6 years
93,000 single family houses built last year
360,000 multiple family houses built last year
Job and population growth drive their business
Houston will build more houses this year than the entire state of California
Coleman – at one point I think every single major homebuilder was from Houston
Top issues:
- Water supply
  - Need water and waste water to build houses
- Transportation
  - Prop 1 will not supply all the need because it doesn’t pay for maintenance, just improvements
  - In 4 decades highway use has increased 238% but capacity has grown only 19%
  - Coleman – I think we can fix the tax credit problem
- Labor Force (massive labor shortage)
  - Average age of the baby boomers with technical skills is 55-65 and are retiring
  - Pushing hard for career and technical training to boost work force
  - Jobs are waiting, just need to educate kids

John Carlton, Texas Association of Fire and Emergency Districts

Are used generally to cover the unincorporated areas and some municipalities
With the population growth there is a great need for more emergency and fire districts to cover the increased need
Need to find a way to get enough funding to provide services to the community
- Long term droughts
- Can no longer draw water from the lakes to put out fires
- Workforce is low and it is a challenge to find the funding to train new individuals
Kolkhorst – the drought is causing great angst and we need to find a solution
Coleman – the coordination piece of this is through the COGS
Gonzalez – is the current method sustainable for the next decade?
- Hard to anticipate but believes it is

1115 Waiver

Jeffery Levine, UTHSC Tyler

Region with 28 counties
Majority population is African American and half is rural
2012 data shows that they have poorer health outcomes than most of the state
Project valuation of 166M
- Behavioral health integration
- ER diversion
- Self-management of chronic diseases
- Training medical residents to identify and manage depression
  - Large number of residents remain in east Texas after graduation
- Community health worker training program
- Mobile asthma units to schools
  - Want 4000 children served by the end of the waiver
Physician recruitment is difficult for the region

Francisco Gonzalez-Scarano, UTHSC San Antonio

Goal is to have a robust GME program
50 students per class, want to have 50 GME positions in the RGV
Use practice plan funds as an IGT match
Hidalgo County is anchor
Coleman – this waiver is creating jobs
Increased primary medicine slots in the school
Epilepsy project in Laredo
Implemented dental programs
Reaching out to patients to address any mental health issues
Coleman – encouraged by the dental programs because dental issues are a common reason for children to miss school

Thomas Murphy, UTHSC Houston

Family physician in SE Harris County
The wavier has been transformational for community and patients
Serves 1100 Medicare patients
Admission to hospitals is less than 50% for traditional Medicare patients
Provide same day service
Working to remove the mental health stigma
Increased accessibility with extended hours
514 new patients in one month, scrambling for providers
Coleman – is there still a huge influx of providers that want to come to Texas?
- Yes, but there is a high need all over the state
San Antonio and Austin region is viewed as the most favorable area in the US

Andrew Casas, UT Physicians, Houston

Using practice plan dollars for IGT
Community health workers program
- Bayshore and 4 other regional clinics
- Waiver helped to fill the financial gaps and bring behavioral health specialists into the clinics
Established a 24 hour nurse line where a nurse can access EMR in real time
Gonzalez – the waiver is only 5 years, is there concern that CMS won’t extend it?
- It would be catastrophic
- GME slots in the valley would not be able to be continued
- Transformation will take more than 4-5 years
- Have had to reserve some dollars in the case of non-renewal and they are left on the hook for rent, equipment, etc.

Katrina Lambreck, UTMB Galveston

28 projects
Transition of care plan
Expansion of primary care
Chronic illness management
Increasing data reporting cap
- Believes it is an important piece of the waiver
Increased recruitment of docs, NPs and PAs
Working to increase enrollment in the school of nursing
Care management registry
Development of disease management registries
IGT is 22M for UTMB and some external partners
Project valuation is 200M
Interested in increasing GME, but there are some logistical problems

Bruce Meyer, UT Southwestern

Enrolled 160 primary care providers into an integrated health record that exchanges information with many institutions and programs
Stickland – are patients notified?
- Structured program to educate the patients
Kolkhorst – we passed HB 300 that has huge penalties for policy violations
43 sites NQCA certified
Sickle cell facility with 24/7 hotline
Depression screening and treatment program for all patients
Reached the maximum number of students they can train
Stickland – I feel like Tarrant County is being punished
We are trying to fill gaps in the health care system not pick winners and losers
Large GME program (3^rd in the state)
- Grown 45% over the past 6 years
Coleman – by laying out what the needs of the state it gives us the ability to help

MD Anderson, Louis Foxhall and Oliver Bogler

Colorectal cancer screening project
- Reached out to FQHCs to identify individuals for the program
Smoking cessation program
Mobile mammography program
Obesity program
GME program – 1200 trained at MD Anderson
- Residency and fellows
Try to match growth to the community need
Nursing education program
- Nurses do clinical rotations
- Giving masters and PhDs to nurses
Kolkhorst – of the foreign people that MD Anderson trains, do they stay?
- Will get hard data but yes
They are overproducing PhDs, so they are focusing on recruiting higher quality students
There are fewer biomedical science jobs than PhDs being produced
Trying to train PhDs to be suitable for other jobs outside of academia

Dr. Steven Burke, Texas Tech Health Science Center

23 DSRIP projects
Primary care expansion
Chronic illness management
Want to produce more family practice physicians in the region
- Nationwide, less than 10% of docs choose family medicine
- Family Medicine Acceleration Program in Amarillo and Lubbock
- Permian Basin has increased family medicine residencies
Expanded 2 community care clinics
Expanded EMR database to identify individuals with potential for heart disease
Patient navigators
Breast cancer fellowship program
Psych program for NPs and PAs
IGT came from institutional funds

Dr. De La Rosa, Texas Tech El Paso

Over a 12 year timeframe, separated from Texas Tech Lubbock
10 projects
Increase primary care
Recruiting 4 neurologists to El Paso (interventional neurologists)
New training for gynecology surgery and breast cancer
Increasing access to care
Recruitment challenges

UTHSC Ft. Worth

6 projects focused on improving health care, patient experience and reducing costs
Leveraging current practices but making them better in an innovative way
Discharge planning for the elderly utilizing NPs and PAs
Identifying individuals in the community to support physical health with medication adherence and disease management via mobile phone technology
- Project is in early stages
- Kolkhorst – sobering to thing about sustainability
Stickland – the cell phone project sounds like a horrible idea
14.5M IGT from practice plan
Project value is 77M-87M
Stickland is concerned that his community is being disadvantaged

LeAnn Ran, A&M Health Science Center

They do not have a teaching hospital
Anchor of 2 RHPS, 8 (214M AF) and 17 (278M AF)
4 dental school projects
- Need additional in rural areas
Coleman is concerned that dentistry will shrink and not grow bigger
Expanded dental clinic hours
School-based sealant project
Opened 2 new dental clinics co-located with health care clinics
Texas A&M Physicians have 7 projects
Expanding primary care and preventative services
- Expanding clinic hours and hiring new providers for the uninsured
Rural fellowship program for underserved areas
Telepsychology project
- Kolkhorst – are you coordinating with the MHMRs?
- Yes
- Patient feedback is very positive
Coleman believes that this will help a lot of people
Patient centered medical homes
Evidence based self-wellness program for the elderly
Post discharge care coordination
Home based palliative care before hospice is needed

Paul Ogden, A&M Health Science Center

Geographically diverse
In five years they have increased from 300 students to 800
Top ranked dental, medical and pharmacy schools
Using state grants and waiver funds to establish new residency programs
- 6 family medicine GME spots in Victoria in 2015
New undergrad health program
309 pharmacists added to the workforce since 2010
Trying to graduate nurses that can teach and train new students in the nursing school
- Forensic nursing program to address the shortage

Tim Lafrey, Seton – Trish Young, Central Health – Gregory Fenves, UT

Have a partnership with Central Health and UT called the community care collaborative (CCC)
Projects are 220M for 5 years
Hired 200 additional providers
Opened a psychiatric emergency department last month
- Have had 376 encounters with average time spent in the facility 14 hours
- Immediate home run and innovative idea that has great results
Seton is building the new hospital on the land leased to Central Health from UT
Coleman – does Seton have clinics?
- 90 outpatient, 3 primary care clinics for UC and Medicaid
Coleman – Brackenridge will be closed?
- Will not see a decrease in charity care – forming partnerships to ensure that there is the supply for care
Gonzalez asked about charity care
- Central Health has CommUnity Care in 24 FQHCs and they fun other safety net clinics like People’s Community Clinic
CCC has 15 projects
CCC allows for Central Health and Seton to jointly manage the patient population
Coleman – this relationship is very different
- 1995 Brackenridge was owned by the city and entered into a partnership with Seton to run the hospital – Central Health inherited the long term lease
- Seton has the full financial risk to operate Brackenridge
Kolkhorst – in the 1^st pass did only Seton receive DSRIP money?
- Yes, but others got some in the second round
UT partnered with Seton due to their 400 staff and residency slots
Gonzalez – will I be able to get emergency contraception at the new hospital?
- Yes
Dell Children’s and St. David’s are going to provide services Seton cannot provide regarding Women’s Health
There are SANE nurses trained in sexual assault victim cases at St. David’s medical center – that is where victims are treated
Coleman asked for all documentation of the arrangement
Seton serves individuals up to 375% FPL, Central Health 200% FPL
Gonzalez asked for a document regarding how students can (or cannot) access emergency contraception
UT wants to train physicians not as individual practitioners but to work in integrative care teams