The House Committee on Human Services met on March 2 to conduct an organizational hearing and hear invited testimony from state health care agencies. This report covers testimony from the Texas Behavioral Health Executive Council and the Health and Human Services Commission.
This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing 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.
Darrel Spinks, Texas Behavioral Health Executive Council
- Provides an overview of BHEC structure, collaborative body among several state boards designed to address administrative issues with boards attached to HHSC and active state supervision
- Active state supervision plays into sovereign immunity, without this can possibly open state up to suit
- BHEC is in charge of procedural and admin matters, e.g. vetting and granting licenses; boards retain authority to set licensure requirements, scope of practice, CE, etc.
- Have been operating fully since Sept. 2020
- Provides an overview of different divisions at BHEC, neither licensing nor enforcement are fully staffed currently
- Chair Frank – Members get calls for backlog of licenses, when are we going to fix this?
- Likely seeing calls on LPCs and social work, don’t have backlog on other areas
- Doing a lot, but the LPC and social work program are high-volume programs
- Responding to emails and phone calls about complaints also takes time away from application processing
- Trying to get social work and LPCs applications to online-only
- Chair Frank – Appreciate that you’re trying to address the root cause
- Shaheen – You’re looking at applying tech to increase efficiency?
- Yes, has been applied to MFT and LPC programs
- Shaheen – Have you looked at data on increases in efficiency?
- Launched on February 1, hasn’t been going long enough yet
- Also doing other things to track productivity of staff, easy to track enforcement, harder to track applications
- Shaheen – Is it totally paperless?
- Not totally
- Shaheen – Can you go totally paperless?
- Not without asking for money to deal with National Practitioner Data Bank
- Applicants pay for self-query of NPDB, a credit card system could avoid this
- Shaheen – But if this prevents you from hiring new employees, there would be a cost benefit; increasing productivity could be worth automating feed of data from NPDB
- Shaheen – Really encouraged that you’re streamlining and investing in technology
- We had debate at BHEC on taking phone calls, had staff in office one day a week to answer phone calls
- Hinojosa – Have you asked for more FTEs?
- Yes, asking for 4 more FTEs
- Hinojosa – One of the challenges is there has been an increase in fees, but people feel things are taking longer; what percentage of fees go to BHEC?
- All goes to GR, generate a little over $1 million in excess of what it takes to operate the agency
- Hinojosa – Do you have a process that identifies who has been waiting the longest?
- Yes, though difficult to figure out initial application given that much of the data came in bulk when functions were transferred to BHEC
- Causes issues with determining if documentation is complete
- A lot of times it is the applicant calling that kick starts the process
- Hinojosa – You planned to move licensing to online, but you’re under program freeze?
- Have a shared regulatory database that Health Professions Council maintains, changes are being made and we are frozen from altering until it is finished
- Hinojosa – Have they given you a timeline?
- No, they typically don’t take very long
Cecile Young, Health and Human Services Commission
- Link to presentation
- Provides overview of agency structure and operations
- HHSC is not anticipating need for supplemental appropriation due to excess federal funding, FMAP
- Chair Frank – Is there going to be a positive impact?
- We’re anticipating $168 million positive impact
- Highlights budgetary data on slide 3, GR funding has been relatively stable, All Funds has increased by about 8%; highlights fund usage on slide 4
Michelle Alleto, Health and Human Services Commission
- Provides an overview of programs under HHSC & coordination offices, access & eligibility services
- Provides an overview of Medicaid and CHIP division on slide 11
- Caseload trends on slide 12; caseload grew significantly in FY2021 largely due to federal match requiring retaining enrollees in FFCRA; standard FMAP is 61.8%, FFCRA authorizes 6.2% additional
- Expecting caseload to return to pre-pandemic levels following expiry of this requirement
- Chair Frank – Can you explain the FMAP for the benefit of members?
- Federal match, with COVID enhancement at about 68%
- Chair Frank – I thought we were just over 50% and enhancement took it over 60
- Young, HHSC – It is 68% now, FMAP is TX in relation to other states and typically hover around 60%; one of the reasons we don’t have a shortfall
- Shaheen – 68% is paid for by federal government, 32% paid by the state?
- Yes, part of COVID relief
- Shaheen – How long does the FMAP last?
- Until the public health emergency ends, Biden admin plans to carry through 2022
- We do reach an inflection point where it costs the state more money due to caseload growth, expecting this in November
- Shaheen – So in November the caseload may not drop as we expected?
- No, with people staying on the rolls due to requirement it starts costing more money than it gives us
- Policy has also impacted CHIP caseload, cannot disenroll people from Medicaid even when they would go to CHIP; expecting CHIP to rise after end of public health emergency due to these former Medicaid enrollees moving to CHIP at that time
- Slide 14 Highlights programs, incl. 1115 waiver programs (DSRIP, Healthy Texas Women)
- A small percentage of Medicaid members are in FFS, many are those who have not yet been assigned to a managed care program
- Highlights Medicaid Managed Care programs on slide 16; STAR is the largest and STAR Health is the smallest
- Chair Frank – So STAR Health only has one MCO for those in foster care? Every other enrollee has a minimum of 2
- Yes
- Slide 19 highlights waiver types: Research and Demonstration 1115, Freedom of Choice 1915(b), and Home and Community-Based Services 1915(c)
- Gives an overview of Medicaid & CHIP COVID response, incl. testing, treatment & vaccination; maintained eligibility for clients and extended CHIP renewals, expanded telehealth allowance
- Have gotten a lot of feedback from providers that telehealth has been very useful
- Chair Frank – Was telehealth something that required a waiver or did we always have the ability to do it?
- Stephanie Stephens, HHSC – It depends; in general, we can provide services remotely, but there are a few instances where docs require in-person & we need to clarify that we mean face-to-face
- Generally, state has flexibility to provide services remotely
- Chair Frank – COVID has caused us to explore things we might should have looked at before & legislative challenges that we need to break down; if there are still hurdles please let us know, if this can be done administratively then thank you
- Last session, legislature passed bills allowing MCOs to make decisions about remote services
- Chair Frank – Could you talk briefly about the Medicaid spending in your budget, 65% is Medicaid, but there’s also the waiver
- We have a 10-year renewal of the waiver, gives state ability to finance an array of different providers like hospitals, ambulances, rural health centers, etc.
- Happy to be able to provide payments under waiver extension and also DSRIP
- Chair Frank – Is there anyone not getting as much money in terms of supplemental payments? Getting that to us as early as possible would be helpful
- Sure; have tried to maintain or increase total funding to provider groups
- Slide 21 highlights COVID fiscal impact summary; biggest impact is in Medicaid & CHIP via the FMAP enhancement
- Shaheen – Is all of this hitting the state budget?
- These are All Funds numbers, slide highlights cost increase from retaining Medicaid & CHIP clients, positive impact from FMAP
- Highlights Health, Developmental & Independence Services (HDIS), incl. child advocacy, WIC, Health Texas Women, Kidney Health, etc.
- HDIS worked closely with providers and sought waivers, e.g. providing alternatives to WIC food items, arranged telehealth, etc.; looking at telehealth as a regular component of ECI
- Neave – What waiver were sought for the Family Violence Program?
- Worked closely with shelters, counseling and other services could be switched to audio
- Neave – Asks for more information on these types of programs
- Yes, also will include work done over the recent weather event
- Provides overview of IDD, mental health, & substance abuse programs; oversee mental health and substance abuse treatment in partnership with LMHAs, IDD in partnership with LIDDAs; works through Office of Mental Health Coordination
- IDD an behavioral health service has shifted during COVID to make extensive use of remote services, HHSC looking at what to keep
- Highlights Health & Specialty Care System of SSLCs and state hospitals
- Neave – Who is the contact for state hospitals? Dallas area is one of the biggest regions without a psychiatric hospital
- Contact is Mike Maples with HHSC
- COVID has impacted state hospital system, health & safety practices have required limiting admissions & led to uptick in waitlist; hoping to resume normal operations soon
- Chair Frank – Why did state hospitals stop taking patients?
- When COVID hit, started to space out patients to prevent spread and quarantine, lowered census to distribute patients across space available
- Noble – It is my understanding that children’s beds are severely limited and children are not getting a spot?
- Mike Maples, HHSC – In parts of the state we have no demand for children’s services and converted them to adult, other parts have demand
- Children have Medicaid & CHIP at a much higher level and can access community services, unlike adults where state hospitals are the only option
- Hinojosa – SSLCs and state hospitals have been prioritized for vaccination?
- Aletto, HHSC – Yes
- Hinojosa – Will this allow you to loosen admissions policy?
- Maples, HHSC – Absolutely, have not stopped admissions, only slowed them down
- As more get vaccinated admissions will be able to grow; one of the biggest challenges is providing quarantine space to isolate for 14 days
- Hinojosa – I understand it will take longer because of quarantine, do you feel like you have access to adequate vaccine?
- Have administered over 30k vaccines to staff and residents
- Some staff and residents have declined, but continue to vaccinate as possible
- Provides overview of SSLCs on slides 31 & 32
- Vaccinations have been ramping up, strict PPE, testing, and distancing protocols were implemented early on
- Severe Weather Prep for state facilities overview on slide 33
Victoria Ford, Health and Human Services Commission
- Presenting on Regulatory Services Division covering LTC providers, hospitals, child care, licensed professionals, & investigates abuse, neglect, and exploitation
- Will also be talking about contracting and procurement
- Regulatory Services needed to figure out roles and responsibilities for pandemic response, worked with TDEM and local partners
- Hinojosa – Do you feel you have the authority you need to fill this gap? It sounds like you do; local communities felt like they had to fend for themselves, do you have a plan once we’re past this to gather best practices?
- TDEM is the emergency response agency for the state, Texas A&*M did work on reform effort and recommendations
- Regulatory Services knows it will need to define a new normal, goal is to do this at the end of the legislative session and pass new best practices rules
- Slide 41 summarizes Regulatory Services COVID response; created rapid assessment task force and quick response task force in concert with TDEM and local partners
- Nursing facilities saw large challenges in adapting to infection control, visited different facilities to train them in PPE usage and protocols
- Currently operating LTC under 15 emergency rules (5 visitation), acute care has 8, childcare licensing has 1; will be phasing these out for permanent rules with contingencies for public health emergencies
- Slide 46 provides overview of nursing home testing effort in 2020
- Hinojosa – Incredible that you were able to get the testing done
- TDEM & Chief Nim Kidd encouraged action and cemented coordination between agencies
- By the middle of January, 80% of nursing facilities had active COVID cases, only 5 out of 1,222 have not had a COVID case; currently at 50% of nursing facilities with an active case
- 8,822 death at nursing facilities, 49,600 recoveries; does look like we’re getting better at treating COVID, therapeutics are helping
- 53% of assisted living facilities have had a COVID infection, only really about 4% now; assisted living facilities are mostly small facilities without infections
- Regulatory Services staff responded to 16k priority response items over pandemic, 11k were infection control, constantly on site at facilities
- Most challenging aspect of COVID response was limitation on visitation
- Chair Frank – Legislature put in law that it is a resident’s right to receive visitors
- Yes, however these sections are waivable in an emergency, visitation restrictions enacted on this basis
- Compassionate care visits have been available throughout course of pandemic
- Emergency rules say facilities allow essential caregivers to visit, many place time or training restrictions on visitation
- Facilities must attest they meet requirements to have standard visitation, must stop standard visitation in case of an outbreak
- Chair Frank – And the definition of an outbreak is 1, so if you have 200 people an outbreak is, if you have 4 an outbreak is 1
- Not sure if it’s this way for standard visitation, based also upon rates in the community
- Chair Frank – Would be nice to have a concise rules changes primer for the legislature; know that facilities are saying the state isn’t allowing visits at all which is not true, reason they can do this is because we have an EO that allows it
- The EO that allowed restrictions is not in place anymore, the EO in place now says HHSC can decide
- Chair Frank – Without that, there is no facility that cannot allow visitation
- I would take enforcement action; not only the EO< but TAC says they must allow visitors
- If you hear of facilities not allowing visitation for compassionate care and essential caregivers, you need to contact us; would need to investigate for standard visitation
- Chair Frank – This is important, need to spread this info out more; huge issue in the community; hoping we can figure this out
- Will reissue guidance to the agencies that reminds about visitation requirements and will double down on enforcement
- Chair Frank – It is time to penalize people who aren’t allowing visitation
- Have pretty much completed vaccinations at LTC facilities, most have either signed up through the state or federal government
- Vaccines took place largely in January, only about half have had the first shot, half have had the second shot
- Sent out notice asking facilities if they need another clinic, gathering info on if this is needed and how to do this
- If you have COVID, must wait 90 days before vaccination
- There will be people who don’t want it, hope to have response on this notice by the end of the week
- Data will also inform visitation policy moving forward
- Chair Frank – If someone is vaccinated they should be good, if they’ve recovered they should be good
- Recovery immunity is maybe 90 days to 6 months
- Chair Frank – I understand this, still collecting data on vaccine immunity as well and don’t know how long that lasts
- Chair Frank – I would assume that if you’ve had it, it means something; would hope we include those who have recovered in this data
- Agree with you on this point, hoping we have a good sense of direction by the end of this month
- Provides overview of response backlog on slide 52, have a significant backlog of surveys and inspections for nursing facilities and assisted living facilities; aggressively implementing strategies to address the backlog, originally was a 4-year timeline
- Have an exceptional item related to this backlog, staff availability, and changing process for lowest level of investigations
- Chair Frank – We made the decision not to act on them, could also decide to not investigate non-serious issues from 9 months ago
- Required to investigate per federal requirements, addressing this is part of the workload rebalancing
- Hinojosa – Can you give us an idea of what these P2 and P3 investigations are?
- David Kostroun, HHSC – P2 is an immediate threat, but not an emergency situation like a P1
- Could be health & safety complaint that wouldn’t cause immediate harm or death that would need to be investigated at some point; 14-day expected turnaround
- Could be something like a fall
- Hinojosa – So normally needs to be done in 14 days, but now we’re looking at years? Has the federal restriction against investigating been lifted?
- Yes, was lifted in September, but COIV surge happened in September and need to investigate new round of P1 items
- Doubling down on investigations now as the incident rate has dropped
- Highlights emergency preparedness requirements for nursing facilities, assisted living, and hospitals on slide 53-57
- Chair Frank – Several facilities in my district had to go to backup generators and plans during the weather event, at least in my area it worked
- We do have a list of facilities that needed to relocate, needed to shelter, needed generators, etc.; kept a running status report
- Meza – I thought there is a requirement for nursing facilities to have backup generators?
- There is, statute is less clear for assisted living facilities
- Procurement update starting on slide 58
- In March of 2018, contracts had to be cancelled and procurement redone because of scoring issues, a number of executive leadership and contracting personnel at HHSC resigned
- Overhauled processes, hired new slate of procurement staff in 2018, consultant was hired in 2018 and issued a 250-page report with recommendations & have worked on implementation and rebuilt procurement department
- Working out roles & responsibilities for procurement map
- Shaheen – Would be interested in following up with you or leadership to look at the Ernst & Young report; have read articles criticizing $900 million Accenture contract, calling it a failure, and noting that we still pay them $244 million and doing other contracts with Accenture
- Shaheen – Do we not identify problematic vendors? Accenture had issues with the AG’s office; don’t want to go into this now, but these are concerns I have
- Will send the study, Ernst & Young came back this year to evaluate progress, high level summary on slide 60
- Shaheen – So Phase IV report is a progress report on implementation?
- Yes
- Shaheen – Asks after procurement operations
- SB 200 transition; procurement divisions of DADS, DARS, DSHS, etc. joined into HHSC procurement
- At that time, it was still very fractured
- Shaheen – When you do IT procurement, does DIR do this or do you?
- We do, it is a partnership between IT department, procurement, and general counsel; everything works in partnership between divisions
- Shaheen – You have your own IT department?
- Yes, they also control IT-specific requirements like public posting, etc.
- Vendor ranking has been fixed since 2018
- Shaheen – Interested in initial Ernst & Young, Phase IV report, and then a follow up meeting
- Slides 61-63 walk through procurement focus areas
- Chair Frank – Asks for Ernst & Young report to be sent to committee
- Chair Frank – Medicaid MCO contracts that have been put off?
- Created a steering committee and defined approach, hired special project manager for MCO procurements
- Compliance & Quality Control is involved, developing procurement now with entirely new model of executing these procurements
- Chair Frank – It seems like in an MCO setting, the ongoing oversight piece of it is more important than having a huge procurement; if they’re not doing the job, we want to be able to discontinue the relationship; also seems arbitrary to stop the whole process in the future and re-procure
- Review of effective management of contract is the next phase