The House Committee on Insurance met on March 16 to take up a number of bills. In order, this report focuses on health care related bills HB 428 (Ken King), HB 293 (Collier), HB 1586 (Lucio), HB 843 (Lopez), HB 907 (Julie Johnson), and HB 1033 (Oliverson). The committee voted out one bill from a previous agenda, all other bills were left pending.
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.
Vote outs
- CSHB 317 voted out unanimously
Bills on Agenda
HB 428 (K King) Relating to health benefit plan coverage for ovarian cancer testing and screening.
- Ovarian cancer mortality rate needs to be dealt with
- CA 125 was added in 2015, HB 428 adds FDA-approved tests for detecting ovarian caner in a well woman exam; add another tool for early detection, does not mandate anything
- Oliverson – CA 125 is already covered under Medicaid, you’re just asking to add other FDA-approved tests?
- Yes, when the previous bill was passed CA 125 was the only option
Jamie Dudensing, Texas Association of Health Plans – Against
- Oppose all new benefit mandates
- When the ACA was passed, new mandates were created, incl. preventative services; preventative services are evaluated and tests aside from CA 125 were rejected because harms outweigh benefits
- FDA and ACOG also recommend against these types of annual screening
- TX leads nation in number of mandated benefits, mandates affect small employers more than anyone else,
- Oliverson – CA 125 is already a mandated benefit, so not creating a new benefit
- It is going against US Preventive Services Task Force, no idea if feds would penalize
- If you create a mandate beyond ACA, you increase cost and the associated needed federal subsidies; there are penalties attached to creating increased costs
- Israel – You’re opposed because of cost being passed to consumers rather than the science
- We’re opposed because of the cost and because it was rejected by US task force
- Israel – If this is approved, would need to be FDA-approved
- Statute allows for asymptomatic annual screening which is what has been rejected by the task force
- Hull – What are some of the screenings discussed and costs?
- Can get you a list of all diagnostic screening and typical charges
- Oliverson – Could help us by helping us understand difference in cost of the screening
- Would like to; Rep. Paul has a bill similar to many other states have mandated fiscal notes discussing costs of items
- Oliverson – That’s more global, asking for info on these
- Can get this to you
Bill Hammond, Texas Employers for Insurance Reform – Against
- Services under the bill did not make the cut under the ACA
- Rep. Paul’s bill analyzing the cost is the most important legislation this session; would help inform about businesses impacted, mandates mostly affect small businesses
- Highlights impact on businesses under 100 employees, new mandates are cost drivers and cause fewer employees overall to receive health benefits
K King closes
- Well woman exam is performed every 2-3 years, not annually, test would only be available if asked for, cost is $80 and would not significantly drive costs compared to preventing mortality
- Argument that it would drive costs for insurance is flawed; coverage is business economics based
HB 428 left pending
HB 293 (Collier) Relating to health benefit coverage for certain fertility preservation services under certain health benefit plans.
- Fertility preservation services for things like IVF are not currently covered, costs are very high & disproportionately affect women & those from low socioeconomic backgrounds
- HB 293 seeks to reduce cost barrier for those risking fertility for medically necessary treatments like radiation therapy & chemotherapy
- Does not include state children’s health plans; allows infertility to be treated as a side effect of cancer
- Large companies have started to recognize need and cover fertility preservation
- CS coming to address federal mandate issue, other bills addressing this have been filed as well
Dr. Terri Woodard, MD Anderson Department of Gynecologic Oncology – Neutral
- Testifying as a resource on behalf of MD Anderson; highlights impact of cancer-related infertility
- Options for those that have become infertile are adoption or 3rd party assistance, but these options are often more expensive
- Fertility preservation services are unaffordable for most people
- Cost and lack of coverage are barriers to treatment, requiring coverage will ensure that those at risk have access to medically necessary services that are a component of comprehensive care
Dr. Karen Albritton, Oncologist – For
- About 10% of all cancer patients see reproductive issues, >80% cure rate for this population, important o consider less long-term side effects and post-cancer quality of life
- Many young adults are not educated about fertility preservation, ASCO have recommended education and offering standard preservation options for a decade
- Impact of not educating is huge while opportunity to consider can improve well-being and outcomes
- Oliverson – Roughly half of the young patients you treat is at risk of permanent infertility?
- Yes
- Oliverson – Are there are procedures where we set aside resources to use later? E.g. setting aside blood products
- There are many organ functions tests done as prep, fertility preservation is no different in acknowledging potential for damage
- Israel – Is this a common or uncommon conversation because of the insurance issue?
- In an informed practice it should eb every single time, but many survivors report never hearing of these issues
Bill Hammond, Texas Employers for Insurance Reform – Against
- Cost of benefit is extremely high, small businesses would be unable to afford
- Israel – Would help me if you had real world examples of how this has increased cost
- Can look into this for specific companies
Dr. Kathryn Hudson, Texas Oncology, Texas Medical Association – For
- HB 293 addresses a huge concern for young cancer survivors
- Cost is typically the biggest concern, without coverage treatments are largely unavailable
- Should be covered like other essential services
Jamie Dudensing, Texas Association of Health Plans – Against
- Opposing all new unfunded benefit mandates
- Not a typical health care service and not typically an insurance benefit
- Definitely in excess of the ACA, Texas could be liable for subsidy costs
- CMS has told Texas that exemption language could violate federal law, concerns about exemptions for qualified health plans
- TRS, ERS, etc. were left out of the bill this session, if legislature wishes to impose costs on small businesses then it should be willing to pay for the benefit itself
- Taken as a whole, unfunded mandates cost a lot of money
Rejan Charney, Self – For
- Shares experience with cancer diagnosis and lack of initial information on fertility preservation; fertility preservation is medically necessary
Tom Whiteside, Self – For
- Shares experience with cancer diagnosis and difficulty finding information for fertility preservation
- Lucky in having resources to pursue fertility preservation on his own, luck should have nothing to do with ability to have children
Rep. Collier closes
- Insulting to have financial impact to small businesses compared to experience of cancer patients; no real data on how this will impact small businesses
- Not discussing last session’s bill
- Will have a CS to address federal mandate issue, will work with stakeholders
HB 293 left pending
HB 1586 (Lucio) Relating to specialty prescription drug coverage.
- CS laid out
- Seeks to protect TX patients for paying higher prices for specialty drugs, applies to drugs prescribed for complex life-threatening conditions; purchased from nearby and in-house pharmacies and frequently adjusted last minute
- Health insurance providers have begun to deny payment unless drugs are pre-mixed; prevents providers from obtaining drugs from nearby pharmacies, controlling dosage, and specifying storage requirements, requires shipping medications which is often less reliable
Sarah Lake-Wallace, Texas Society of Health System Pharmacists – For
- HB 1586 prevents plans from requiring that drugs are issued from network pharmacists
- In Houston, many are requiring to change site of care because of this issue; can cause worse outcomes and higher costs
Carl Isett, Texas Association of Third Party Benefit Administrators – Against
- Having specialty drugs done nearby or in-house is the most expensive place to have this done; managing costs of specialty drugs saves the employer an extraordinary amount of money
- HB 1586 allows specialty drugs to be purchased at the very highest price, would remove safeties in setting up and designing plans
- Oliverson – I agree that cancer therapy is certainly driving a lot of the cost, but we’re entering a new age of tailored medications in cancer treatment
- Oliverson – Hearing from oncologists that inability to modify dosing each visit is what is driving issues; at some level you are putting a price on whether or not it’s valuable to cure cancer given new treatments see good outcomes versus costs of ineffective treatment leading to complications and hospital stays
- Agree, but these medications could still be purchased through the contracted plan provider
- Oliverson – I just want us to think about global costs of curing cancer versus not
Jamie Dudensing, Texas Association of Health Plan – Against
- Opposed to new mandates that we don’t believe drive outcomes, protect patients, etc.; only results in higher profits for providers
- Creates out of network specialty pharmacy situation, destroys fundamental of creating an affordable, quality network in favor of the most expensive sector
- CS would apply far beyond cancer drugs, applies to specialty drugs across the market, incl. pain center medications
- Allows providers to overly inflate these charges and have health plans pay the full billed charges; would be much higher costs discussed during the surprise billing conversation with emergency services
- Also creates safety problems because it removes ability to oversee out of network providers
- Conversation would be different if it was only related to cancer drugs in physicians’ offices; these physicians could easily have in-house pharmacies be in network
- Oliverson – Appreciate comment on oncology piece; allegation has been raised that it is difficult for certain pharmacies without an existing relationship with MCOs and PBMs
- Oliverson – I have not evidence showing tremendous cost disparities between the two categories; would be helpful to have data on average contracted price, what percentage of pharmacies have zero conflicts between PBM and plans
- Oliverson – Hearing that it is almost impossible to become a specialty pharmacy because
- With HB 1586 providers could be out of network with no consequences; have seen providers leave networks in other states with similar situations
- Costs are massive, destroys incentives for cost sharing to receive appropriate care in an appropriate setting
Binita Patel, Memorial Hermann Health System – For
- HB 1586 allows physicians to tailor dosage on the spot; eliminates waste and supports outcomes
- Mailing drugs is not always reliable
- Lack of access and control is dangerous, physicians cannot be certain of storage and handling of medications outside of their control
Bill Hammond, Texas Employers for Insurance Reform – Against
- Cost of HB 1586 is not known
- HB 1586 would blow up specialty networks and possibly allow for billed charges
- Bill would not cover state retirees; state is willing to impose a hidden tax on employers, but not on Texas citizens to provide this benefit
Jim Schwartz, Texas Oncology – For
- Doesn’t make sense that providers would raise prices, insurance companies set the rates; issue is that PBMs/insurance want to provide these drugs to obtain rebates
- Providers controlling dosage could stop waste and save patients money
Steve Paulson, Texas Oncology, US Oncology Network, Texas Society of Clinical Oncology – For
- Untrue that providers would be able to charge more; much of the interest of PBMs/insurance in these drugs is the financial benefit through rebates
- Having drugs nearby or in-house supports patient safety, benefits in being able to supply medications in many situations, e.g. winter storm Uri; medications are often tailored specifically for the patients
- Whitebagging policies will impact patient access and care
Rep. Lucio closes
- We have a problem with the integrity of networking when it comes to pharmacies being on these plans; very short lists are maintained of who gets to be in-network, independent pharmacies are constantly excluded and closures cause quality of care to suffer
CS withdrawn, HB 1586 left pending
HB 843 (Lopez) Relating to health benefit plan coverage for early childhood intervention services.
- CS laid out; provides overview of ECI funding and purpose
- When insurance does not cover, GR must foot bill
- HB 843 is identical to HB 1635 from last year, extends insurance coverage of ECI to ages 0-3
- Paul – What services are covered under this bill and which children?
- List of services, autistic children, speech development delays
- Covered now, but only from 3 and up
- Paul – So want to change it to cover children 0-3?
- Yes
Bill Hammond, Texas Employers for Insurance Reform – Against
- Services are already covered by the state, but shifting burden to small employers and employees
- This version does not cover ERS or TRS, but covers Medicaid; puts burden on taxpayers
- LBB previously assessed the cost @$22 million/year, ERS & TRS were exempted due to this fiscal note
Jamie Dudensing, Texas Association of Health Plans – Against
- Opposing all benefit mandates; could be one that is worth it, but taken as whole the mandates will definitely increase cost of health care
- ECI services are a state program, inappropriate to shift this responsibility onto the cost of individuals and Texas employers
- Irresponsible for state to shift this to employers and not also cover this under ERS
- ECI is a very expensive program, would add significant cost
Kate Johnson-Patagoc, Texana Center
- Provides overview of ECI providers and services; proven effective and reduces overall tax burden and private insurance costs later in life
- LBB recommended strategy in 2017, has been successful in 7 other states
- Only about 30% of families within ECI have private insurance
- Paul – Insurance companies pay at age 3 because diagnosis is available; if we’re paying at 0-3 how would we get a diagnosis?
- Would be based on IFSP, treatment program
- Paul – So parent would speak of issues
- Yes, interdisciplinary team and parents come up with treatment plan
- Paul – Is the initial analysis covered by insurance?
- No, covered by ECI dollars
- State will still need to support ECI services, only 30%
- Paul – In that case what would the state save?
- There is a problem in that there isn’t enough money for children so providers are having to give up children’s contracts
- Hull – So you already bill Medicaid, but this bill includes Medicaid?
- Â Medicaid already covers based on IFSP; would be the same in my opinion
HB 843 left pending
HB 907 (Julie Johnson) Relating to prior authorization for prescription drug benefits related to the treatment of chronic and autoimmune diseases.
- Working on CS, but don’t have one at this time
- Prohibits PAs for treatment of chronic and autoimmune diseases
- 85% of physicians in TX report PAs delay access to necessary care, also interfere with continuity of care
Jamie Dudensing, Texas Association of Health Plan – Against
- Against unfunded mandate eliminating PAs for 80% of the drugs covered by plans; less than 10% of drugs have PAs, but these are very necessary to ensure evidence-based care & safety
- HB 907 essentially gives providers a blank check for these services, one estimate is $500 million annually just in the small employer & individual
- Bill did not have ERS & TRS removed, premiums & state spend will significantly go up
- Risk of adverse events is high, 30% of patients leave with at least one medication error
- Removes check on fraud, waste & abuse
- TAHP supports patient safety, but don’t support eliminating contract requirements
- Step therapy already has exceptions for continuity of care
- Any PA decision you don’t like can be appealed
- Oliverson – You’re saying this affect 80% of drugs?
- Chronic illnesses is very broad; even in just autoimmune this eliminates ability to control costs and checks on patient safety
- Oliverson – Autoimmune diseases have become much more expensive to treat, especially with rise of biologics
- Oliverson – Real solution is at the federal level if we could reform the patent issue at the FDA
- Israel – If someone is on insulin and continuously needs it, would this impact it?
- No, no PAs for drugs on the formulary; plans must cover comparable drugs via the formulary and tend to prefer particular drugs due to negotiated rates
- For insulin, we pretty much have to cover all the insulin drugs due to patent issues, no biologic similar
- Patients often don’t see the PA/step therapy process, pharmacists will sometimes exchange drugs without notifying based on stock
- Israel – So if I’m an AIDs patient on a proven cocktail, would this need a PA?
- Will look into this, but doubt any HIV medications have PAs; there may be safety edits or PAs and safety edits for off-label use
- Paul – If this bill was in effect in the past, could it have increased the opioid issue?
- Really depends, chronic conditions could include back pain, etc.; would say yes based on what is written in the bill
- Hull – If someone has a monthly inhaler for asthma, is there a PA every month
- No, there are issues with dose counters
- Gonzalez – You’re not saying once it’s approved, it neve needs to be approved again?
- If it’s on the formulary, it never needs to be approved
- Gonzalez – So once a patient is approved, is that it?
- If a 3 year old gets approved, we will check that; will always check the safety component
- Oliverson – How long does it take to get something on the formulary? Have heard complaints about lengthy timelines
- Don’t hear about formulary issues taking months or years
- Oliverson – Spoke with rheumatologist who said that 80% of patients had a PA and process was onerous; do we automate these things? Are we trying to make it as painful as possible?
- Automation mostly applies to pharmacies and drugs
- We do want more automation, but physicians seem to like fax machines
- Plans I know have moved PAs to portals, but the real effort to reduce burden and cost is in automation
- Oliverson – I think it would be great and helpful to have information on the PA process
- Have doctors in plans who can speak to this
- A number of states have prohibited paper to force automation
Dr. Lisa Ehrlich, Texas Medical Association – For
- HB 907 is long overdue, have heard many complaints of denials, lengthy PA timelines, etc.
- Have to do PAs on diabetes medications, asthma medications, Lipitor, etc.
- Shares experience of patients whose care was disrupted by PA requirements
- Israel – Missing the patient perspective; asks if HIV/AIDs patients would see PAs for drug cocktails, if insulin sees PAs?
- Differs to another witness; patients of psychiatrists, neurologists, etc. need specific medications continuously and can see issues
- Paul – Was this fully insured or ERISA
- Problems exist across the board
- Paul – Formularies change with insurance companies?
- Yes, will likely need a PA to continue medication; hard to keep up with formulary and changes year-to-year
- Paul – Formulary can change, but can’t change in the middle of a plan
- It can change
- Oliverson – Can’t change for you in a calendar year, but can change in a self-insured market
Dr. John Carlo, Texas Medical Association, Prism Health North Texas – For
- HB 907 very important, 13.5 million live with chronic disease
- Shares experience of HIV/AIDs patient that has seen many treatment interruptions, need to change medications often increases risks of drug-resistant strains, lack of medications wil lead to higher costs later in life
- Study from Alabama determined a $41.60 cost for providers to fill out a PA, majority of the cost of the doctor visit
- Prescription formularies aren’t searchable, often change, difficult to keep up
- Â Bad practice considering 90% of chronic illness medications going through PA are approved
Bill Hammond, Texas Employers for Insurance Reform – Against
- One plan estimated $500 million annual cost, possibly $2 billion on the full insured market
- TX has tight timeline for PA response, significant PA regulations
- ERISA plans could be part of the issue with turnover
- If imposed, should apply to state plans
- Could open up opioid abuse issues with pain management clinics
HB 907 left pending
HB 1033 (Oliverson) Relating to prescription drug price disclosure.
- CS laid out
- Clean up bill for HB 2536 from last session; tweaks law to improve the way the bill operates
- Clarifies that only prescription drugs require disclosures, moves disclosure requirements for pharmaceutical manufacturers from HHSC to DSHS, permits AG to sue if chapter isn’t complied with, reporting shift to annually from quarterly
- CS sets a capped a fee, fixes a drafting error, and removes reporting requirement for Medicaid & CHIP
- Stakeholders have agreed to legislation
Stephen Paul, Department of State Health Services – Resource
- Resource for any questions, no questions asked
Blake Hudson, AARP – For
- Drug prices are very important for seniors and other age demographics
- Original bill had a lookback reporting requirement for significant increases, have seen >200 reports; manufacturers seem to be dodging the requirements by claiming trade secrets, reporting basic information, and general information about usage
- Other states require pricing information before changes to formulary go into effect
- Israel – Is there anything Texas can do about drug cost?
- A number of things Texas can do, e.g. California making delaying generics coming to market illegal
- Can get more specific about reporting, pass price gouging statute, ERS caps
- Waiting on federal action for some avenues
- Israel – For things like insulin which is common & price is going up, nothing we can do?
- Can most certainly pass a price gouging law, AARP would be in support
- Oliverson – Appreciates the support, we were hoping we could catch actions like purchasing a generic and increasing the price 7000%; DSHS is ideally suited to do this
- DSHS is doing a wonderful job on reporting, hope is that DSHS will increase enforcement and compliance
- Oliverson – This is a transparency bill, should come back and enact reform to deal with bad actors uncovered by data collection
Jamie Dudensing, Texas Association of Health Plans – For
- Some of the strongest drug transparency bills were passed last session, one of the issues we’ve seen is several companies are not reporting full info or not reporting timely
- On Medicaid data, we don’t have this data, so more appropriate to have HHSC do this or carve it out
- If there are dollars available, might be good to have DSHS create reports from the data similar to California
- Israel – If there was a legislative solution empowering the AG to act on price gouging, would you support?
- For all of health care, there’s no price gouging protection that exists
- Price gouging is something the state should be protecting patients from; fully insured market is only about 1/3 of covered lives and these regulations would
- Our rates are evaluated and approved, profits are capped and rebated above a certain amount; no problem with everyone else being subject to similar
- Oliverson – Reporting requirements were fixed for PBMs in the CS; welcome ideas for funds for DSHS reports
CS withdrawn, HB 1033 left pending