House Health Care Reform – August 5, 2022

House Health Care Reform met on August 5 (continued from Thursday, August 4th) to hear invited testimony on the following interim charges. An archive of the hearing can be found here.

• Study the implications of excessive health care costs on the efficacy of Texas Medicaid and the private health insurance market and the resulting impact on individual Texans, businesses, and state government
• Examine the interaction of specific factors of health care affordability such as transparency, competition, and patient incentives. Make recommendations to expand access to health care price information to allow consumers to make informed decisions regarding their care;
• Examine the impact of government benefit, administrative, and contractual mandates imposed upon private insurance companies and their impact on employer and consumer premiums and out-of-pocket costs, including the effects of specific benefit and any-willing-provider requirements. Make recommendations for state and agency-level mandates and regulations that could be relaxed or repealed to increase the availability and affordability of private health coverage options in the state;
  • Review access to and affordability of prescription drugs;
• Monitor the implementation of, and compliance with, current price transparency requirements and study ways that the state can support patients and increase competition. Make legislative and administrative recommendations, as appropriate;
• Evaluate innovative, fiscally positive options to ensure that Texans have access to affordable, quality and comprehensive health care, with an emphasis on reaching low-income and at-risk populations. The evaluation should include a study of strategies other states and organizations have implemented or proposed to address health care access and affordability. Make recommendations to increase primary health care access points in Texas.

This report is intended to give you an overview and highlight of the discussions on the various topics taken up. It is not a verbatim transcript of the discussions but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

Invited Testimony: Special Medication Waste

Dr. Darin Okuda, Prof. of Neurology at UT Southwestern in Dallas

• Board certified neurologist, sub-specializes in neuroimmunology and primarily cares for MS patients
• Director of the MS and neuroimmunology program; founded program 6 years ago called Neuro-innovation program that improves solutions to change healthcare in US
• Explains that MS patients have immune systems that attack optic nerves and spinal cords, no cure; #1 reason young people are neurologically disabled, more common than trauma injuries
• MS patients treated over 20-30 years with rising costs for treatments, often costing over $100,000 per patient; mostly preventative care/drugs
• Wants to speak specifically about special medication waste:
  • Started a project in 2017 to understand the disposition of MS therapies/drugs that go unused, and many therapies being returned
  • In 2018, patients could return their unused therapies; identified a lot of waste and collected over $6 mil in returned therapies over 12 months
  • Identified that in 60% of instances people were transitioning from one therapy to another for non-medical reasons:
  • Patients were being forced by a third-party payer to take a drug they couldn’t afford, they saw something new come out on the market and wanted to try it, or didn’t like the frequency they had to administer the drug
• Created AI models to predict how soon someone may come off a certain therapy
• Discovered if there was decent insurance, patients would get a 3-month supply of MS therapy at average price of $119,000; could get a 3-month refill after 7 days or a 1-month refill after 5 days into treatment
  • Creates a huge waste if people get negative side effects and don’t want to continue treatment
  • Leads to patients selling their excess treatments online, giving away to friends/family, flushing them down toilet
• Drugs have no value in the hands of these patients but worth a lot on the market; sees drugs being pushed on patients
• Sees need for reduction in healthcare costs and ability to return unused drugs for some financial return to patient if it’s not being used; wants to see solutions for this problem to stop
  • Proposed recertification for redistribution/resale, hold manufacturers accountable for disposal of amassed therapies, State of Texas to give refunds to unused drugs, or allowance of an exchange program
• Challenge: chain of custody and don’t know how drugs were stored, so can’t be used as an asset
• Harless – Asks what UTSW does with specialty drugs when they’re returned by patients
  • For now, the drugs are housed in clinic room; now must scale back what they put in there because there’s over $25 million in drugs in that space and its overwhelming
• Harless – Asks about shelf life of drugs
  • Developed an app that allows patients to return drugs to UTSW and provides a shipping label with expiration date and product # so has lots of data
  • Identified vast differences in race/ethnicity; African Americans are 50% less likely to tell doctor about side effects compared to other groups
  • Patients prescribed drugs they can’t afford and then the value of drug wiped out once in their hands, even if they don’t use it
• Klick- What form do MS therapies come in?
  • Pills, capsules, injectables but not infusible
  • Klick mentions donation program for unused drugs and suggests his patients could benefit from them
  • Asks whether it would be wise to not prescribe as many days of drug, but he says that’s not his choice as a doctor but up to third parties;
  • Okuda says some officials at third party drug distributors claim they weren’t aware of this issue of over-prescription, but they benefit from the waste
  • Recognizes cycle of abuse where patients continue to receive more drugs than they need
  • Klick mentions her mother had RT whose room was full of boxes of drugs before she passed
• Dr. Bonnen – What the solutions are for the state as far as options to intervene; sees options as putting up guard rails so people are prescribed less drugs from onset but says it may be odd for the state to take on that role, or intervene on back-end to collect surplus
  • Option 1: strongly encourage manufacturers to exchange treatments returned from patients that are unused and sealed for a new product
  • Bonnen wonders if making manufacturers pay on the backend would help prevent them from over-prescribing
  • Okuda says not necessarily, that’s the role of the specialist pharmacy
  • Employers are covering costs of these drugs, not health insurance companies
  • Option 2: Implement some form of refund through the state
  • Promotes the mobile app to help track recovered drugs, he has not refunded any patient any money to date for millions of dollars’ worth of drugs because he can’t
• Harrison – What conversations he’s had with specialty pharmacies and how those conversations have gone
  • Yes, he’s had conversations with all parties in this process, each with their respective top concerns
  • Pharmacy benefit managers should look at whether their drugs are not being used because it puts his group at risk because drugs not helpful, being wasted, and symptoms are progressing for patients
  • Has data that has not yet been released on magnitude of waste and clinical outcomes (ER, Urgent Care, hospital visits) after transitioning off a drug; pharmacy benefit managers want that data because they want to understand their risk
• Walle – What makeup of his practice is who are on Medicare, Medicaid, private insurance, or uninsured
  • 80% commercial, 20% Medicare on his campus- Medicare patients go to Parkland Hospital
  • Asks whether treatment pay scale are different in commercial vs public
  • Okuda says its complicated and varied; drug manufacturers support when it’s a newly released drug but out of pocket expenses are most painful to patients
  • Asks what access is like for patients who are privately or publicly insured vs uninsured:
  • Okuda – Access is dictated by third party administrators; Parkland has access to high quality MS therapies but need more support for these patients
  • Uninsured won’t receive remarkably different care; difference is in clinical surveillance once they’ve received a drug
• Harless – Is there anything prohibiting you from limiting the term of the prescription when you write it?
  • Typically in 6 month to 12 month buckets due to amount of work in pre-authorization approvals;
  • Third party administrators approve for longer periods than 3 months but doesn’t see it as a major issue
  • Sees it as lack of ability to turn off that access and stop receiving drugs they want to refuse
  • The reverse distributor will return drugs to the distributor but can’t return too much because it will hurt their relationship with the distributor

Texas Health & Human Services Commission:

Review of who they cover; How managed care works; 1115 waiver; Quality of care and outcomes

Michelle Aledo, Health and Human Services (No formal comments, present as a resource)

Stephanie Stephens, Health and Human Services

• Stephens giving overview of program and Wood going over budget

• 5.5 million Texans in Medicaid and CHIP, receiving increased federal funding for Medicaid during the current health emergency
• Slide 3: Medicaid- entitlement program (financial and non-financial criteria), CHIP- allotment program
• Slide 5: Income limits by Medicaid type of eligibility; Texas at federally required limit except for pregnant women and those receiving long-term care benefits
• Medicaid does cover services not available in the commercial space
• Operate Medicaid through Manage Care (contracted through monthly capitation payment, 95% of clients served this way) and Fee for Service (contract with an entity that pays those claims directly)
  • Slide 8: Evolution of Manage Care in TX, didn’t reach 95% over night
  • Manage Care’s largest group is STAR (served children, kids with disabilities)
  • Contracts separately with dental providers for children
• 13 service delivery areas in the state
• Major focus on Managed Care oversight, monitor whether people have timely access to services, reviews services for under and over utilization, work to improve quality of care, audit finances, review MCO’s operations, policies, and procedures prior to a major rollout
• Remedies: corrective action plans, liquidated damages, and contract termination or suspension of enrollment
• Medicaid always evolving in TX but looking to make improvements in 4 major areas:
  • Continuing to move services into managing care, especially for those with disabilities, as of 9/20/23
  • Increasing access to services, HB4 from last leg session allows more teleservices
  • Improving quality care, Rider 20 in budget led them to develop benchmarks for quality and efficiency for manage care organizations; Developed methodology across 4 different areas
  • Strengthen operations and oversight; members can have external medical review from an independent entity
• More info on quality initiatives through manage care:
  • To promote transparency, have Texas Healthcare learning collaborative portal with quality measures and results of quality programs for manage care organizations
  • Medical and Dental P for Q program- measure performance and if funds are recouped from lower performing MCOs, they’re redistributed to higher performing MCOs
  • Overall, MCOs have improved performance since implementation
  • Contracts promote alternative payment models- many arrangements on fee for service basis
  • Have contractual targets for MCOs to move percentages of their total and at-risk payments into APMs, holding constant for 2022 and looking to implement increased targets in next year
  • Some people opt not to enroll in manage care programs, so they added incentives to enroll people into those programs each month; added value into the auto-enrollment process
  • MCOs performance can earn higher enrollment based on high value score
• Provider quality measures:
  • Hospitals are measured on PPRs and PPCs up to 2% reduction on in-patient stay payments based on their performance on these two measures
  • DPPs allow them to direct payments to providers through manage care based on 5 payment programs tied to quality
  • Quality monitoring program- early warning statue for high-risk nursing facilities and provide technical assistance to move them toward best practices

 

Trey Wood, Chief Financial Officer for HHC Commission

• Slide 26: Funding in agency that goes through budget with appropriated and off-budget dollars; 61% of funding for client services, 11% for SNAP benefits, 21% in off-budget supplemental payments, 2% in facility-based services, 3% for administration. .5% for procurement, IT, financial services
• Slide 27: FMAP is how state is reimbursed, updated annually; 60.8% for FY2022 before additional 6.2% for federal emergency
• Slide 28: Families First COVID Relief Act offered for CHIP and Medicaid expenditures, so far the state has received 5.7B in additional Medicaid funding and 6.2M in Healthy Texas Women Program
  • Been tracking the tipping point when expenditures exceed monthly benefit of 6.2%, which he estimated we reached in May of 2022
• Slide 29: Have up to 12 months to complete any pending eligibility actions, can begin them up to 60 days before first disenrollments start
  • Disenrollments can’t start until first month after PHE ends, then need a full redetermination with 30-day response window
  • Fed government had agreed to give 60 days-notice of end of health emergency
  • Anticipated it will end in October of 2022 meaning they will receive increased FMAP through December of 2022 and will begin disenrollments in November of 2022
• Slide 30: Tipping point analysis
• Slide 31: Key budget drivers of Medicaid program
  • Assuming pubic health emergency ends in December, the expect Medicaid caseloads to increase by 12.9% in FY22 followed by a 5.2% decrease in FY23
  • CHIP cases expected to decrease by 51% this year followed by an increase of 87% next year due to current back and forth between children and CHIP Medicaid
  • If they go into Medicaid they stay there under health emergency but that reverts after it ends
  • Expect cost per client this year to decrease 7% then increase of 3.2% next year
• Slide 32: caseload of Medicaid history
• Slide 33: focus on caseload history since health emergency began; increase because they can’t disenroll anyone under PHE
• Slide 34: shows cost over time of Medicaid for full-benefit clients; anticipate dip in 2022
• Slide 35: cost growth trends in Texas Medicaid and a whole with lower cost growth than national average
• Slide 36: compares caseload population vs their cost, with children highest enrolled group but lowest cost per person
• Slide 37: estimated Medicaid shortfall at $3.7 billion for biennium to be addressed in next session
• Slide 38: renewed 1115 waiver program to expand risk-based managed care statewide
• Slide 39: various programs covered by Stephanie
• Slide 40: Did get initial approval for 1115 waiver, which was denied; Texas sued and CMS withdrew recension in April 2022 and reasserted waiver terms are in effect
• Delivery of System Reform Incentive Program ended Sept 30, 2021, payments will go through next year for this program
• Uncompensated Care Program was maintained through 2030, pool was resized twice from $3.9B to $4.5B primarily to hospitals
• Directed Payment Programs estimated values: NAPES ($491M), CHIRP ($6B), QIPP ($1B), TIPPS ($670M), BHS ($188M), RAPPS ($12.5M)

Texas Health & Human Services Commission Q&A

• Rose – Asks about HB33 and new developments, extension of the waiver
  • Extends postpartum coverage for 6 months; to implement it, the state submitted a 1115 waiver amendment
  • CMS said its not approvable and requested confirmation but haven’t received a response as to why so still pending
  • Said it didn’t align with federal regulation, which indicates the policy needs to be 60 days from when pregnancy ends
  • Rose wants to know if there’s an appeal process or what can be done to get this waiver amendment through
  • Stephens says they don’t require action but they’re doing everything they can to learn more and find policy solutions to get it passed
• Walle – Asks what the cost is for expanding the 6-month extension in HB33
  • Budget accounted for adjustments
  • Asks how it relates to public health emergency and women potentially getting kicked off- today pregnant women are getting continued coverage but if health emergency ends in October (13^th), they don’t know if it’ll be extended so HB33 would cover that gap
  • Expect to hear by August 13^th is the federal government will end health emergency
  • They don’t know an exact number of how many women would lose coverage because they need to reassess case criterion
  • 1.4M anticipated women need full redeterminations who would likely be ineligible of 2.7M who generally need to be reassessed
• Capriglione – Asks about the assumption the TX legislature made that the federal government would provide some funds to the services provided through HB33 but if the PHE ends in the fall, will the federal government still send a check if there’s not an approval?
  • Without continuous eligibility, the state wouldn’t be able to draw down those federal dollars
  • Capriglione expresses frustration that Texas will need to change the law to fit the federal government’s specific requirements, leaving many women without healthcare beyond 60 days of her pregnancy
• Rose – Claims the way the law was originally written, it would have been approved
  • Stephens says fed government has approved 12 months but can’t speak for CMS
  • Rose asks for data on utilization of post-partum programs, but Stephens says some women avoided medical care during PHE
• Walle – Clarifies that federal law incentivized states to do a 12-month extension through a state plan amendment, not the 6 months the legislature ultimately agreed to as a waiver
  • The federal government would have gone through a different approval process for a state plan amendment than a waiver, which would have been more likely to pass
• Frank – Asks if it was not approved due to how the law was worded rather than the length of the extension
  • CMS verbally pointed to the fact that the federal regulation does not stipulate how the pregnancy ends
• Bucy – Asks whether other states have been approved for 12 months; Yes
  • If we go back to 12 months, is that approvable? Can’t say but CMS has approved 12 months though not clear on what other states did to get them approved
  • Bucy says the House needs to research those states who got 12 months approved and work to get it passed as such in both chambers
  • Will there be data on continuous coverage and its health impact? Will show up in how we see service delivery and quality during time PHE was active and policy effect on public health, though data will be delayed per usual
  • Qualified but not enrolled Texans? Numbers from 2019 internal analysis show pre-continuous eligibility of 550,000 individuals of uninsured population
  • Divided between adults and children? No, they don’t have it today but could see if its possible
  • How do we identify these individuals? No, based on forecasts across the state
  • Bucy wants to find new ways to enroll eligible children, points to organizations later in the hearing who may speak on it
  • How can we in the House do a better job of finding these uninsured kids who are eligible and getting them coverage? (Rhetorical)
  • How is the 211 system working? Seen an overwhelming system with a wait time of 30 minutes for people who call and want to talk about their benefits
  • Always looking at ways to modernize; working with vendor who provide greeting but are experiencing workforce challenges
  • How can we modernize that system better? Want to continue to have those conversations around innovation and technology improvements
  • How are we doing on touching 5.5M people in 12 months? Electronic sources and asking people for updated income information to determine eligibility
  • Most people access through mytexasbenefits.com, then calling 211 for general questions; community partner program works with children’s hospitals, food banks, homeless clinics, etc. to provide information to eligible populations
  • What’s the trigger to remove people when they don’t provide updated income information? Send electronic and paper notification that they need information, if no response they’re disenrolled during a certain period
  • How are we doing on the backlog applications? Have a backlog on SNAP applications but have gotten some flexibility from federal government due to PHE, usually require interviews but that’s been bypassed
  • Prioritizing getting out of the backlog now; need help to fund, recruit, and retain staff, now are offering sign-on stipends and pay increases
• Harless – Asks whether wait time is more a technology or staffing issue; say mostly a HR problem than technological
• Harrison – Asks who at CMS they spoke with; names Judith Cash
  • Have any discussions on this topic occurred with Director of CMCS? No; he suggests that is something to consider
  • Have we submitted anything in writing to CMS to explain exact federal regulatory statute? Yes, between Stephens and Cash
  • Were other state’s approvals under modifications to waivers or under SPA? CMS approved under SPA to her knowledge
  • Did Texas consider making appeal under SPA rather than waiver? No, due to state plan option which is usually done via a waiver
  • Brings up program integrity, waste, and fraud; 1 of 4 dollars in Medicaid was an improper payment in the US due to eligibility issues
  • Asks who we’re monitoring this to ensure we’re helping those who need it most; have a program integrity unit but can get numbers on exactly how much they’ve saved; try to get good data about eligibility from the onset
  • Do we do mid-year reviews for eligibility? For some in months 3-8 of annual cycle do income checks
• Walle – Asks whether TX Medicaid would have capability to help mothers for a stand-alone 12-month extension and how much it would cost
  • Considering options but haven’t costed it out yet, can send committee more information
• Dr. Bonnen – Asks about TX regulation not being tied to when the pregnancy ends
  • CMS interprets that the state’s intention to apply the law does not start from when the pregnancy ends
  • He suspects its due to the federal government wanting the law to also apply to women who have an abortion, which the state law would not
  • Stephens says the way the pregnancy ends is the first issue CMS raised, so it may not help to extend law to 12 months
  • Wants to know monthly cost of Medicaid after tipping point of PHE; Wood estimates $150M a month
  • Explain who is receiving uncompensated care; designated to hospitals who need charity care allocation, each hospital has its own policy to determine how much care their provide that’s uncompensated
  • Hospitals are mostly being paid at 90% of commercial rates under CHIRP, YURIP, and ASYA programs
• Rose – Wants to clarify that Medicaid is for people who need the services such as children and disabled individuals, those who meet the income threshold, and pregnant women, who are eligible throughout their whole pregnancy through their second month after birth
• Harrison – Asks if there has been fiscal analysis on whether 6.2% FMAP increase would be outweighed by increase in state costs from covering so many people who lack standard eligibility criteria
  • The tipping point shows that the funds available are not sufficient to meet costs and needs in the system; asks for report on that information

Panel 1: Ways to Increase Medicaid Access for Children & the PHE

Alec Medoza, Senior Policy Associate for Health for Texans Care for Children

• Texans Care for Children works to improve the quality of life for children across the state
• Wants to discuss the opportunity to slash the uninsured children rate across Texas, increasing the enrollment of currently eligible kids
• Will offer 2 solutions: Removing barriers and proactively enrolling children in healthcare
• Texas has highest children’s uninsured rate across the country by far at 12.7%, national average of 5.7%
• Access to healthcare affects all parts of their lives and helps them succeed in school, earn higher wages, and become healthy adults
• Close to 1 million uninsured children in 2019, only 84.5% of those eligible were enrolled
• PHE has potential to cause chaos for families and providers when it ends if state doesn’t intervene when 5.5 million Medicaid applications will need to be processed in 6-8 months
• Unintended barriers to family enrollment:
  • Not any easy process- if you forget your password, can be arduous to log in and access health information and applications
  • Can only call 211 or go to Texas benefits office to reset password; many offices closed without a re-opening date
  • Illustrates complexity and difficulty of phone tree; wait times with 211 can be over an hour
  • Number of vacancies of staff within HSSC- caused long delays in processing applications and prevents Texas from meeting federal guidelines on processing Medicaid applications
• Innovative policy solutions to enroll eligible children in healthcare:
• Express Lane Eligibility (ELE)- current enrollment process allows children to be enrolled only in one program despite their eligibility for other programs
  • Ex: SNAP but not Medicaid; legislature can adopt ELE that allows state flexibility and more efficient system to enroll children in multiple programs by using kids’ information from Medicaid to automatically enroll them in SNAP
  • Alabama, SC, Louisiana have done this with much success; SC saved $1.9M
  • TX legislature would need to pass legislation to allow ELE to be utilized
• Texas newborns are not getting connected to Medicaid coverage during key moment of development
  • If woman is enrolled in Medicaid when she gives birth, her child is automatically eligible as well for 4 years but many mothers don’t know; 65,000 children/babies in 2018 were eligible but not enrolled
  • TX legislature can require HSSC to use current data to issue a separate number for newborns before they are born so their coverage isn’t missed
  • Develop and circulate information about this benefit at hospitals for new mothers
  • Allow Texas schools to receive Medicaid reimbursements for health/mental health resources through SHARS Program
  • Schools currently can get reimbursements only for students with disabilities and IEPs
• Allowing Texas schools to receive Medicaid reimbursements through SHARS
  • Helps students access mental health resources
  • Only for students with disabilities and IEPs right now
  • Wants to open it up for all Medicaid eligible students at these schools
  • Missouri expanded Medicaid reimbursements for schools allowing mental health professionals to serve students at these schools
  • Would better leverage federal funding and provide better access to mental health resources
• Barriers and solutions:
• Investing in 211 call centers to lower wait times
  • Establish a call-back center rather than requiring people to wait on hold
  • Establish a separate call line for resetting a password
  • Need to invest in system to hand current call load and high call volume soon after PHE ends
• Automate and modernize auto-enrollment processes so they don’t have to go through 211 processes
  • Many families have had to move during pandemic due to loss of employment and housing before renewing Medicaid so mailing reminders may not be most useful form of outreach
  • Could contract USPS to get more updated information about residences
• Pay for state workers and agencies should be increased to be competitive to commercial sector

 

Anne Dunkelburg, Every Texan

• Provides background on Every Texan, formerly Center for Public Policy Priorities
• Wants to discuss opportunities for Texas to reduce number of uninsured people
• There’s a lot of confusion about who can get Medicaid and who doesn’t, especially since under ACA those under poverty line cannot access it
  • Some people too poor to get generous subsidies in the marketplace
• Of 38 states who have coverage for “childless adults” in the lowest income bracket have a state plan amendment, 7 have extension through 1115 waiver
• Wants to focus on 1.4 million in uninsured program who could be picked up under a Medicaid extension, 800,000 of which are under the poverty line
  • Texas eligible for bonus of federal funding of $3.5B (one time) conservatively, which could provide fiscal benefits
• Congress was considering temporary opportunity for Texans in poverty to use marketplace in most recent legislation but not certain
• 60% of adults in poverty who can’t access marketplace are employed full-time, disproportionately people of color

Stacy Pogue, Every Texan

• Removing barriers to healthcare for Texans, especially for children
  • Means investing in adequate staff to man enrollment resources, modernizing those resources through new technology and data, and removing roadblocks
• Reiterates HHSC is understaffed, causing a backlog in Medicaid and SNAP applications
  • Families are losing SNAP benefits even though they renewed on time because of it
• Administrative barriers on Your Texas Benefits: need full-case access to update your address, funneling more people back to 211
  • Staffing issues to be exacerbated after end of PHE
  • Likely to see a substantial loss of coverage for Texans who are eligible for Medicaid
• Proposed solutions:
  • Rebuild adequate staffing levels
  • Reduce inefficiencies through automation and data (data-driven automatic renewals only at 7% in Texas right now, far below national average)
  • ¼ kids in Texas has a parent not a US citizen, so keep those kids in mind
  • Maintain record-breaking enrollment on healthcare.gov, which has made healthcare more affordable through subsidies

Panel 1 Q&A

• Frank – Better access to healthcare and sees insurance as a worse proxy for it; access to Medicaid doesn’t mean low-income people have access to a qualified doctor
  • We need to focus on access not just financial process; Do you focus on that?
  • Dunkelberg – financial security of healthcare is as important as access
  • Medicaid has its problems and failings but she wants to get everyone into the boat of guaranteed affordable health insurance access
  • Frank – the numbers don’t reflect anyone pulling out of Medicaid
  • Between 2017-2020, before freeze went into place, 240,000 kids lost coverage and uninsured rate went up, need to encourage non-citizen parents to get their kids enrolled
• Oliverson – Texas at 84.5% of kids eligible enrolled, national average 92%. Are we doing so bad?
  • Doesn’t like idea of auto-enrollment, Texans are capable of enrolling on their own;
  • Wants to work with them to know more about 15% who aren’t enrolled
  • Mendoza – These kids should be enrolled and working parents may face barriers to enroll their kids
  • Dunkelburg – We can do better; 100% enrollment may not be entirely feasible but we can reduce barriers
  • Oliverson – Wants to see SNAP work better and increase access to healthy foods, looking for someone to work with on this issue
  • Pogue – Will follow up with SNAP experts to discuss options to provide healthier foods through benefits
  • Oliverson – Under 1296 what are your thoughts on state creating its own state-based exchange?
  • Pogue – Technology more cost effective now but only gets you so far and huge undertaking, no guarantee of long-term cost saving; needs to best serve vulnerable Texans
• Rose – Social determinants such as food deserts that limit access to fresh produce
• Lujan – Disappointed in HSSC that Texans can’t change their password online; 211 shouldn’t be difficult to fix up; we need to do better at leveraging technology
• Bucy – Big priority is making sure kids can access healthcare who are eligible; wants to simplify process and allow people to sign up for multiple programs at once
  • Mendoza – HHSC can use data already available to streamline processes with legislation
  • Mendoza – We can identify these students through more outreach through schools
  • Dunkelburg – Impact of Medicaid expansion in Texas would allow more people to climb socio-economic ladder, mental health benefits, protection from medical debt
  • Dunkelburg – Rural counties w/o hospitals or doctors and waiver direct-to-payment programs don’t help uninsured; need to provide preventative care
  • Dunkelburg – If I could do one thing to fix Medicaid, it would be to go administrative renewal system that uses most recent wage data
• Harrison – Negative net budget on state budgets that have expanded Medicaid

Topic 2: Access to Coverage

Panel 1: Increasing Access to Care and Improving Quality

Dr. Fred Cerise, CEO of Parkland Health

• Gives overview of how Parkland is improving access to healthcare in Dallas and Parkland statistics/background
• 75% of patients uninsured or on Medicaid; Has more demand than they can meet
• Not driven to structure business toward what payers will cover
• Have 13 primary care centers in Dallas through own clinics and community partners
• Email consultation program to help move information to specialists to get diagnosis so patients don’t have to go to them; possible through integrated system
• Bed shortage at psychiatric hospital
• State can improve access through:
  • Support HHSC proposal at IMD exclusion to state can pay for psychiatrics health costs at these facilities
  • Support ability for provider-based entities to have integrated system
  • Expand broadband access for virtual care
  • Increase support for healthcare workforce
  • Medicaid waiver program- focus on true delivery systems through system with provision of all services including CT scans, chemo, etc.
• Chair Harless – Are you starting to get nurses back?
  • No, spending $8M a month on contract labor
• Rose – Thanks Cerise for all that he does

 

Rachel Bowden, Texas Dept. of Insurance

• 1332 waivers are based on section 1332 of ACA, allowing states to take their own approach to federal healthcare reform; 13 states have them
• Waivers include employer mandate, individual mandate, minimum standards for qualified health plans, out of pocket maximums, exchange requirements, etc.
• Can’t waive guaranteed issue, pre-existing issues restriction, required coverage for prevent services, etc.
• Must be budget neutral for federal government
• Premium tax credits is where federal funding comes from
  • $6.83B for Texas benefitting 1.6M people
• Reinsurance programs constitute most waivers; state investment into marketplace matched by federal pass-through funding
• SB2087 added TFI authority to apply for federal funds and waivers
• Through reinsurance, Texas could reduce premiums 3-10% benefitting 200,000 Texans
• Uncertainty around extended subsidies: Inflation Reduction Act extends them into 2023 and beyond
• SB1296 gave them rate review authority; silver-loading ensuring all cost-sharing reduction costs are being paid for on silver exchange premiums
  • Rate of 1.35, increasing premiums for silver plans but offers more purchasing power
  • Geographic rating areas changed into 27 areas incorporating rural and urban areas where people are most likely to seek care
• Rates for 2023 not final yet
• Goal of reinsurance is to reduce total premiums; helps people getting subsidies and hurts those who aren’t
• Colorado Option- Specific premium reduction targets enforced through rate hearings; controversial approach
  • Save money through reinsurance and reduced premium targets to invest state subsidies that enhance subsidies or fill in gaps in structure
  • Reinsurance waivers states can do without their own exchange
• 5 buckets of state models to interact with ACA- we are not enforcing ACA provisions, nor do we have authority to do so
  • Other states use federal marketplace and enforce ACA directly through state authority or collaborative enforcement agreement with CMS
  • Others take on plan management authority
  • State-based marketplace with federal platform or fully-state model

Blake Hudson, Health Plans at Work

• Discusses importance of coverage to not postpone needed care
• 48% of Texans have employer-based care
• Employers say they need good healthcare plans to attract good employees
• Expect more plans next year
• Cut down to 30 counties that only have one provider from 100
• Texas uses risk-based capitated care program with experience rebates, giving the state budget certainty
• 2009-2017 Texas taxpayers were saving $5B under Medicaid Managed Care and health outcomes went up; 95% of services carved into Managed Care now
• State agency is overwhelmed; MCOs came to agreement under Case Assistance Affiliates (new type of community partner) allowing MCO staff to support eligibility redetermination
  • Wants to keep this and allow MCO’s to continue to support in next leg session
• Supports covering coverage gap
• Need to help non-medical factors that affect people’s health like access to healthy food
• 61% of Medicaid spending goes to long-term care and disability populations
• Caseload growth is cause of increase in costs
• 2021-2022 13% increase in premiums across the state
• ¾ of growth in private market spending due to price increases
• Private equity involvement in healthcare provider space of increasing concern, increasing bills for patients
• Abuse of facility fees seen as significant issue with ambiguity in billing around whether procedure was done at hospitals or other facilities
• Proposed solutions:
  • Incentives to help people make smart choices to help people find low-cost high-value care
  • Look at making sure value-based care is being allowed everywhere they can
  • New alternative plan arrangements to skip insurance code but meet federal requirements and get tax credits/discounts
  • Eliminate anti-competitive agreements
  • Ban abusive facility fees, needs to happen; $672B in savings
  • More transparency in private equity buy-ups
  • Price transparency, giving information about everything included in patient charges
  • Quality transparency, lessen barriers to sharing this information
  • Look at mandates that drive up cost of coverage, look at cost passed to employers and families that pay those premiums

Panel 1 Q&A

• Frank – You cannot negotiate facility fees out of a hospital contract? Drives consolidation of doctors
  • Hudson – Wants to bring solutions but don’t negotiate on each code, just discounts; makes them look like the bad guys
  • Frank – This is the exact same situation with the PBMs
• Oliverson – Consolidation is a problem but y’all made to the marketplace by making billing too complex for providers and favoring big providers
  • Optum, your company, employs the most doctors in the state and need to be willing to turn that on yourselves, not just look at us to clean up your mess
  • Hudson – Pushing back and wants less government intervention and to let the market work it out
  • Oliverson – Don’t point the finger and say you don’t have a stake in causing the problem
• Harrison – Wants to talk about individual market and problems ACA caused it; We now have 14 plans by how many were there before the ACA?
  • Hudson – Not sure, but would guess more with lower premiums
  • Harrison – STLDI impact on insurance market? Wants to work with Hudson afterwards and get more data on this
  • Hudson – They exist in marketplace when they didn’t before

Panel 2: Overview of Employer-Based Market

Glenn Hammer, Texas Association of Business

• Employer-based market divided into two areas: smaller and larger employers (50+ employees)
  • Smaller employers looking for fully funded plans regulated by the state, offloading financial risk to insurance company
  • Larger employers self-insure health plans and inherit risk
• Their concern: smaller employers need more options in the marketplace
• Proposed solutions:
  • Build upon legislation from last session by Oliverson and Frank on creating new products for health coverage that didn’t require state healthcare mandates
  • Avoid opposing new regulations on companies that utilize HARISA regulated health plans
  • Low taxes, light regulatory scheme
  • Legislature to extend coverage of post-partum coverage from 6 to 12 months
  • Legislature to continue to support a system of intellectual property
  • Reduce cost of healthcare through better diet, more sleep, exercise

Annie Spellman, State Director for NFIB in Texas

• Member-governed organization; cost of health insurance top concern for their members and uncertainty over economic conditions, government actions, taxes, etc.
• 34% of members said inflation is biggest problem for them, highest rate since 1980
• 69% said they had to increase their prices
• -61% said they don’t expect economic situation to improve in coming months
• 50% of members have positions they cannot fill due to labor shortage
• 48% of members have increased compensation for their employees, wages, and benefits
• Opposed to health insurance mandates
• Texas is third highest in country for most insurance mandates, creating less affordable marketplace, especially for small businesses

Rachel Means, CEO of Employee Benefits Consulting

• Business model based on employee benefits program, not a broker
• A small-business owner as well with 220 employees across businesses
• Builds healthcare plan from the ground up with each employer, gives case studies on a few examples of clients she’s worked with to provide savings in healthcare costs for employers and their employees
• Asks committee to not impose more mandates

Panel 2 Q&A

• Oliverson – Much of the cost in the healthcare system is in back-office when employers want simplicity
  • Thinks it’s a very workable mechanism to do what Means does to cut out the middleman/red tape financial and time waste
  • Hope her testimony inspires small business to look at direct primary care and direct contracting as a serious alternative
• Frank – In healthcare, incentives are all misaligned, set by politicians; Market will adjust if it’s allowed to adjust

Topic 3: Increasing Access to Care and Improving Quality

Panel 1: Increasing Access to Care and Improving Quality

Dr. John Carlo, Physician and CEO of Prism Health North Texas

• Need to reduce healthcare costs and improve affordability
• Goals:
  • Reduce number of people who cannot afford healthcare
  • Achieve high-value care
  • Better utilize existing healthcare resources
  • Reduce healthcare disparities
  • Eliminate waste and inefficient care
• Proposed solutions:
  • Pursue all federal dollars Texas is eligible for and bring them in-state
  • Invest more in healthcare through tax dollars
  • Extend post-partum care to 12 months, very important to Texas Medical Association
  • Value-based healthcare (providers get paid if patients achieve certain health-based outcomes) needs to be incentivized
  • Increase primary preventive care access
  • Expand programs that bring doctors out to homes to provide care
  • Get more doctors to accept Medicaid since so few accept it now and remove barriers to their enrollment and credentialing process
  • Ensure access to mental health and crisis services
• Concerned about those who will be rolled off Medicaid after end of PHE

Chase Bearden, Coalition of Texans with Disabilities

• Many of members receive service at home through community care service by an attendant, who are front-line workers but are also lowest paid ($8.11 an hour average)
  • Seeing massive issues not being able to find at-home care attendants or agencies for disabled individuals who need support, going to nursing home facilities and hospitals
• Needs to come from an appropriation from the state to ensure HHSC has funds to pay a competitive wage to these workers
• Recommend $15 p/h in first year and $17 p/h in second year, though it would be without benefits or paid leave, to help mitigate this issue
• Interest lists- figure out how to get people into Medicaid waiver programs and off waiting lists
• Non-medical switching happens due to price but can be detrimental to patient health
• ECI Program is very effective at helping kids and need to:
  • Add to 211 questions to guide parents of infants
  • Ensure childcare facilities can recognize a delay in development
  • Ensure private insurance pays their fair share in ECI

Jana Eubank, Executive Director of the Texas Association of Community Health Centers (TACHC)

• Efficacy of Community Health Center Care Model to provide affordable high-quality care for low-income and most vulnerable Texans
• Many communities in Texas don’t have access to community health centers, which provide care to the whole family
• Offer school-based clinics and behavioral health services
• Funded as non-profit with slim margins; rely on third-party reimbursement
• Pillars of program:
  • Located in medically underserved areas or serving underserved populations by federal mandate
  • Has board of directors, 50% of which must be patients of the clinic and reflect the demographics of community being served
  • See everyone who comes through door, regardless of their ability to pay or health status but not a free clinic, have sliding fee scale with price transparency
  • Focused on whole patient and their needs- medical, dental, behavioral, pharmacy, lab, x-ray, vision, addiction, and telemedicine services offered
• Demand for medical services increased by 28%, and 59% increase in behavioral health services
• FQAC Incubator Program was established to provide seed money to develop or grow community health centers across Texas
• Recommendations to expand this model:
  • Continue to support FQAC because more need than funds
  • Increase screening for food, housing, and transportation insecurity to improve health outcomes
  • Increase coverage, including 12 months of support for women post-partum and enrollment support for eligible Texans through increased appropriations
  • Expand school-based clinics
  • Expand behavioral health services
  • Leverage technology for remote patient monitoring through Medicaid
  • Establish pilot program for non-medical factors and cost drivers in Medicaid like food access
  • Workforce development- expand programs for loan repayment for physicians, pharmacists, dentists, nurses, medical assistants, etc.
  • Invest in community based private practices

Panel 1 Q&A

• Harless – Compliments community health care clinics and their work
• Walle – How could you scale up access points to community health care clinics? What amount would you want to see?
  • Eubank – Need was $200M based on needs-assessment statewide; federal grant dollars only meet 23% of their costs
  • Can get committee an estimate of how many more people that money could help
  • Walle – What’s your relationship with the carriers, especially Medicaid? Depends on health plan, market situation of patient, and part of state
  • Walle wants to find more consistent and sustainable funding
• Frank – Praises community health care clinics, which increase access in a way that Medicaid cannot
  • Non-medical switching reform needed to not increase costs to patients or at least not more than 5%, will talk to Stan Lambert about this
  • IDD waitlist needs to be attacked because crucial to vulnerable populations, looking for someone to work with on this; if LA can do it, so can we
• Rose – Wants to see progress on IDD waitlist; may work with Frank on IDD waitlist
• Frank – We did a study on this; not always clear what list the patient should be on and interest groups use patients as pawns
• Bucy – What hoops do you have to jump through to work with Medicaid as a physician?
  • Carlo – we can talk afterwards
• Rose – Mr. Chairman, maybe we could take $600M from Board of County Health and put it toward Texans who need it the most

Panel 2: Innovations and Care Delivery

Dr. Suja Perakathu, Frontier Direct Care

• Direct Primary Care provider with a reformed healthcare platform, removing barriers to access and affordability, improving health outcomes for patients
• No fee associated with each action, unlimited 30-minute visits and zero wait time, texting communication with doctor based on medical needs, not administrative
• Healthcare should encourage and empower people to take ownership of their own health
  • Shares stories of her patients who felt empowered through DPC reformed healthcare platform

Dr. Roger Moczygemba, Direct Med Clinic

• 2004-2013 President of Teledoc Physicians Association and founder of Direct Med Clinic and Free Market Medical Association
• No free market in healthcare without price transparency; helping to create free healthcare market in San Antonio
• Shares case study on Direct Med Clinic providing affordable access to mid-size employer, replicating for the third time this year, saved employer 96% in cost of labs
  • Savings of $174,000 for the employer through direct contracting through DPC
  • Increased patient access to a doctor and telemedicine reduces urgent care and ER visits
  • No patients lost access to insurance during the COVID pandemic
  • Incentivize DCP not insurance to increase care access through small employers
• Recommendations:
  • Provide DCP for state employees
  • Provide voucher to DCP for Medicaid beneficiaries
  • Incentivize small employers to use DCP, not insurance

Dr. Cristin Dickerson, First Primary Care

• Has disabled adult son; wants to speak about why they elect not to use Texas Medical Center and instead uses Spring Branch Clinic because it’s better healthcare for him
• Her employees and their families are insured through DCP model, which they’re very happy with
• Started Green Imaging 11 years ago in Houston to provide affordable medical imaging by buying the excess capacity of the screening imaging so they can bill globally, reducing costs 50%
  • Now in 49 states, moving into 50 this year
• Health plans are ready to be bundled; wants legislature to move money around to make this happen, saving money in the process with great healthcare

Dr. Alina Sholar, CEO of Serenity Medical Centers & CEO of Skin Science School

• Representing Texas 400 and Texas Physicians for Patients PAC, advocating for patients in doctor/patient relationship
• Physician shortage in Texas- 6,200 primary care doctors and 10,000 physicians needed by 2032 to fill gap
• Parents can’t find a doctor to refill their prescriptions because one doctor in the county retired
• Population growth in Texas requires physicians but supply has remained stagnant
• 98% of counties in TX don’t have enough primary care physicians, 1/5 have none
• State and federal loan forgiveness not publicized by medical schools as an opportunity, need to be better utilized
• Texas added more medical schools but doesn’t help because there’s a bottleneck at graduate medical programs
  • Need 88 new graduates per school per year to fill current need but nowhere near that target; with no change only meeting 78% of goal
  • Residency programs outside of state are taking Texas graduates because of shortage in residency programs around the country
• Recommendations:
  • Increase number of residency programs in Texas, funding has been capped for 25 years; majority of those who do residencies in rural areas stay in those areas
  • Aware of bill to be submitted in the next legislative session that addresses unmatched medical graduates who need to find a residency program despite their medical degree
  • “Physician Graduate Act” establishes limited licensure to recent medical graduates to practice in rural communities under supervision of primary care physician; follows rules of Texas Medical Board
  • Cost: Physician graduate can be billed as mid-level physician’s assistant; no significant cost to the state and supervising physician would pay graduate
  • Rural physician gets relief from direct workload

Panel 2 Q&A

• Frank – Require separate license for Physician Graduate Act? No, work under temporary medical license from Texas Medical Board
  • Likes idea but makes him nervous to have graduates without residency experience out in rural areas; DPC is better fit for rural areas in his opinion
  • Already working to use DCP model more in his districts, can revolutionize primary care across the state
  • Sholar – thinks Physician Graduate Act would work well with DPC model
• Chair Harless – Graduated student in the same geographic area as the supervising physician in rural areas?
  • Sholar – Yes, they work side-by-side first and then ultimately within 50-mile radius