The House Committee on Public Health met on February 27 to take up several bills. This report focuses on HB 10 relating to grants and programs for researching and treating behavioral health and psychiatric issues as well as HB 278 relating to the frequency and location of certain meetings required by a prescriptive authority agreement.
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.
HB 10 (S Thompson) Relating to grants and programs for researching and treating behavioral health and psychiatric issues.
HJR 5 (S Thompson) Proposing a constitutional amendment providing for the issuance of general obligation bonds by the Texas Public Finance Authority to fund research, treatment, and access to services in this state for behavioral health, mental health, and substance use and addiction issues.
Thompson laid out a committee substitute for HB 10
Substitute is intended to add additional medical entities and personnel to the bill, because the bill will be driven by research
Highlights focus on the unknowns surrounding increasing trend in kids to be more suicidal or homicidal
Not building new infrastructure for medical schools, but rather asking them and professional scientists to conduct research
Elizabeth Newlin – Child Psychiatry for McGovern Medical School
Believe the bill will positively change the trajectory for children and their families
Child psychiatry access lines should make it easier for teachers or primary care physicians to consult with a child mental health expert for better understanding a child’s behavior
Highlights policy of schoolteachers being trained in a statewide plan for best practices in behavioral health in the classroom
Highlights how treatment will consider new research that will incorporate individualized treatment and expedite recovery, placing a struggling child back on their developmental trajectory
Sheffield – How much of the behavior with the kids is society, genetics, or new diseases we’re discovering?
Every patient is different, so we only have partial answers right now
The funding from the bill will hopefully allow us to look deeper into the causes of these illnesses, and how they interact with the environment for an individual patient
Frank – How consistent is the advice a child is likely to get throughout the network of different professions?
When things are left to clinical acumen rather than a concrete answer from a brain scan or blood test, there is more variability in the answer you were likely to get
Frank – So we should do brain scans or blood tests?
I think there is potential for that kind of diagnostic test in the future, but we are really early in that science
Consuelo Walss-Bass – McGovern Medical School
These disorders are genetically-induced, caused by mutations
Different patients will cause different combinations of these mutations
Environment is a significant aspect; if a child is genetically at risk, environment has ability to trigger their disorder
Recently, we have gained technology to access brain cells, so we can study the genetic background of a person and how that is changing their mental state
HB 10 will allow us to have the resources we previously did not have access to in the past
Ortega – Is there an age bracket we’re looking at?
We think of disorders as adult disorders because they usually show themselves during the early twenties, but they begin to manifest earlier on, usually triggered by trauma
If you are genetically susceptible to these disorders, this can occur at any age wherein the brain is still developing
We need to catch children who are at risk early, so that they can be treated and perhaps prevent the full disorder from fully manifesting
Denise Zimmerman – Spring ISD
Supports HB 10
As a school counselor, have seen a dramatic rise in mental health concern for our youth
Research shows suicide is second-leading cause of death in children between ages of 10-24
Last January, my school counseling program dealt with 491 cases of mental health crises
Deal with these issues through research and access to mental health providers
Research can make more effective use of time and money when addressing mental health concerns
Wayne Sneed – Austin ISD Police Department
Have experience as mental health supervisor
Testifying in favor of HB 10
Daily mental health crisis incidents demand much of school counselors’ time, taking away from time spent with other students for academic purposes
Age when mental health crisis begins is becoming lower
Zedler – Can you give an idea of how this would be handled? What would be going on before you get involved?
As of now, Austin ISD calls are driven by crisis
Zimmerman – On a school campus, when someone notices suicidal or destructive behavior, the child is sent to the school counselor first. If the counselor thinks they are at high risk, they contact the parents, and if the parents are not receptive, we make a call to CPS
Uchenna Umeh – Texas Medical Association, Texas Pediatrics Society, Federation of Texas Psychiatry
Supports the bill
Patients demonstrate need for strong integrated behavioral health system, has personally witnessed impact of unaddressed mental illness
Shares experience of patients with mental illness and the challenges of treatment; severe consequences of mental illness are getting more prevalent
Discusses suicides resulting from behavioral health issues, widespread issue
Number one cause of suicide is mental illness, but stigma of mental illness is a greater problem
Geren – What are some of the root causes that causes mental illness in children?
In the 1980s, depression in children was unheard of, has gotten much more common
Bullying, social media, mental illness stigma, lack of education in guardians and care providers, etc. are causes
Precursors to suicide are often dismissed
Geren – What are we doing to try and address stigma of mental illness?
Have quit my job & begun talking about it; shares personal experience with mental illness
Other conditions are widely discussed, but mental health issues are not because people are afraid to talk about it; could impact job prospects, socialization, etc.
Geren – So you’re saying dialogue, discussion in public schools and every appropriate environment?
It starts at home, cannot expect public education to parent the child
Talking with children about issues does not cause issues, but create open environment
Teachers, providers, and doctors can be the extenders of the conversation
Allison – Seems like there is a triggering event or trauma setting stigma in play?
No, not a triggering event; most individuals experiencing traumatic events do not take drastic action, mental health issues impact this
Allison – What might a program that prevents this or start the dialogue before this thought process develops?
It is multi-faceted, need to trust teachers as extenders of lessons at home; if teachers are not overburdened and equipped to help
Would like to see more children on TV discussing mental health issues
Medical schools as well could educate the doctors and teach them to handle mental health issues
Allison – How about before you get to the physician, do you see need for more training for teachers in schools before referring to physicians?
Most of the schools I speak in tell me that they have programs in place, possibly they need professionals like myself to assist
Ortega – Do you believe we currently have inadequate medical professionals in this field?
Absolutely, one of my biggest challenges is finding someone to refer patients to
Need to also get past own implicit biases
Ortega – I agree it needs to start at home, but if they don’t get the care they need, the situation will not improve
Shares experience with young patient who committed suicide
Social environment is different today, children are not equipped to deal with these issues
Christie McGarrity – Self
Against HB 10 as currently written
Addiction crisis grant program speaks about disseminating standards for new drugs, does not speak to disseminating research
This can be dangerous, and no representation from palliative care, oncology, anesthesiology, etc.
HHSC, AMA, Human Rights Watch, etc. recommend against setting medication standards for chronic pain
Adopting new standards may take away a homebound person’s career and ability to care of their family
There are people with no other options & homebound in states that have implemented prescribing standards, changing these standards does not combat addiction
Asking for an amendment, prescribing for chronic pain belongs in medical practice and not behavioral health
Zedler – So what you’re suggesting with prescribing is that it is not one-size fits all, standard of care is not only concerned with over-prescribing, but also under-prescribing?
Right
Price – Asks for clarification on if the issue was with the charge to research and disseminate standards on prescription of opioid drugs
That’s the one, possibly could be disseminating research about standards based on what I’m hearing today, maybe the Institute is about research
Price – So the way it is written now, it would encompass disseminating new standards for prescribing opioid drugs, if this was for acute pain you wouldn’t have an issue?
I think in some ways this is very necessary
Price – What I hear is a concern for prescribing standards for chronic pain; there are some current regulatory guardrail around prescription for chronic pain today
TX does a pretty good job of this today
Price – So the fact that it doesn’t say chronic or acute, it just says “prescribing of opioids,” you’re saying it could encompass standards for chronic pain?
And it has happened in other states
Sheila Hemphill – Texas Right to Know
Testifying on the bill
Research shows emphasis on physical root causes to psychiatric dysfunction
Depression, anxiety, and others are commonly associated with electromagnetic fields and consequential interruption of calcium levels
These wireless technologies are currently appearing increasingly in places such as schools and hospitals
1 in 6 children are currently on some form of pharmaceutical medication
Requests for research to focus more on epigenetics rather than genetics
Asks for stronger connection to experts in the field
Judy Powell – Parent Guidance Center
Against HB 10 as it is currently written; parental rights are main concern
Worry if consent is being handled properly; want robust policies if parent wants to be involved in transference process
Concerned about missing stakeholders
Price – Are you talking about the Institute portion of the bill?
Yes, I see the 12 teaching hospitals, the appointment by the Gov., nonprofit mental health member; we didn’t see other organizations involved & I’m sure they would be happy to be involved
Price – So, you want the bill expanded?
Yes, for the inclusion of people who do not rely on drugs as a form of therapy
We wish to see alternative therapies being researched as well
Price – So representation by a member of the Statewide Behavioral Health Coordinating Council, which may or may not be that?
Don’t think this would be full coverage of alternative therapies
Don’t see a robust conflict of interest/privacy policy in HB 10
Research involving genetics especially needs protection, because genetics can significantly impact people, such as those with history of genetic mental illnesses
Zedler – So we need to make sure the information is separated from any names of students?
Yes
There can be issues with insurance or future employment if someone’s susceptibility to mental illness gets out
Margaret Ortiz – Self
Neutral on HB 10
Have noticed a huge nursing crisis
Nursing field is short-staffed, which is dangerous for one-on-one work such as that of patients who suffer from suicidal/homicidal thoughts
We don’t have enough resources
30% of nurses leave the profession within a year of their career
Receive general education before entering the work force; not enough mental health
We need some resources on the frontline to help
Amy Hedkey – Self
Against the bill
Rise of mental health problem in schools won’t be cured by these bills
Suicide rate is higher during the school year, which is not a coincidence
Main proponent of legislative bills is universal screening
Very concerned by expansion of mental health care into school system
Diagnosis of mental illness allows state to involuntarily hold individuals in institution
By 2011, antipsychotics became highest grossing class of drugs, usually to non-psychotic people such as foster children, the elderly, and inmates in prison
History of psychiatric misuse in minority groups shows potential to reoccur during studies of K-12 grade children
There is no evidence medical science allows us to identify future criminals or suicides
There is a clear fear of being diagnosed because of the legal implications
Lee Spiller – Citizens Commission of Human Rights in Texas
Against the bill
Need to discuss this subject more before filing bills on it
More telemedicine causes more concern for harm and suicidal side effects
For past few years, most of the calls we receive are from people in psychiatric hospitals who cannot get out
Have seen some cases where people’s children are admitted to psych hospitals against their will
Risk traumatizing children by putting them in those kinds of situations
Need to be more careful with this topic, and ensure we are bringing everybody to the table
Devon Grider – Self
Neutral on the bill
Has experience as a foster parent
Has met a child that was on five different medications at first, which was an over-prescription; eventually got those medications reduced, but serves as a reminder to consider over-prescription in research
Has encountered another child with homicidal thoughts
Viewed the homicidal tendencies less as a mental issue rather than a learning/education issue
In the Medicaid system, there are few psychiatrists, let alone child psychiatrists
From his experience, does not believe children in foster system understand the seriousness of being prescribed medication, and only told clinicians what they thought they wanted to hear
Rep. Thompson closes on HB 10
Thompson – We don’t know the triggers for mental illness and for individuals to commit suicide or shoot in schools
We must find ways to find those triggers and treat them both medically and non-medically
The bill is designed to be research-driven, to find some answers to the “why’s” behind mental illness, especially in the brains of children
We cannot be afraid of research; it is not intended to do harm or take children away from their homes
Highlight on connection between public education and healthy mind
HB 10 and HJR 5 left pending.
HB 278 (Oliverson) Relating to the frequency and location of certain meetings required by a prescriptive authority agreement.
Oliverson lays out the bill
Envisions more electronic means to make prescriptive agreements
Price – This could be a meaningful change for nurse practitioners. Do you think this will make it easier for them to contract with the delegating physician?
Absolutely
The primary issue now is the requirement of face-to-face meeting, so this opens up the possibility to communicate audibly and visibly through electronic means
Law requires a meeting once a month for collaborations
This service makes it cheaper, less aggravating, and less complex to meet
Elizabeth Ellis – Texas Nurse Practitioners
Supports the bill
Current law requires my face-to-face meeting with the delegating physician, which interrupts my services for patients
This bill would allow us to use technology to comply with the law while allowing more time to be spent with patients
We look forward to the positive impact on patient care
Patricia Aronin – Physicians for Patients, Physicians for Patient Protection
Against the bill as it is written right now
Greatly concerned about the trend of granting the right to practice medicine to non-physicians
Pleased with the changes to supervision making it easier to supervise, but worried it is not stringent enough, which will result in patient harm
Request amendments to the bill
Recommends the bill address supervising physicians’ need to be knowledgeable in the field they are supervising
Crain – You’re talking about when a doctor is licensed, they can practice in any field they feel they are knowledgeable in
No
For example, I won’t have credentials to take on a field I was not trained in
Crain – But the medical license itself has flexibility in almost anything?
I guess they could get away with that
Price – The nurse practitioners under a delegating physician have guardrails protecting what they can or can’t do. So, what they have to do is under guidance, correct?
Correct
Price – So the party that is ultimately responsible for liability from that delegated authority would be the MD?
Yes, sir
Price – What is a realistic arrangement for a supervisor overseeing a practice they don’t specialize in? It seems that would be careless to contract someone to something outside of their medical practice
I agree, however, there are people out there who do not
I think it needs to be added, because the way the bill is written right now is vague
Scott Freshour – Texas Medical Board
Neutral on the bill
Physicians are ultimately responsible for mid-level productivity
The physician must determine the individual their delegating to is trained and has experience in whatever they’re going to delegate
Number of charts to be reviewed is no longer required in statute
Frank – So in these types of relationships, what is the minimum standard for the doctor, given their training and mid-level experience?
No minimum, but you would have to report it in your authority agreement
If the Medical Board received a complaint from a patient, we would look at what the delegating physician did in the prescriptive authority agreement to see if that was reasonable or a failure to adequately supervise
Rep. Oliverson closes on HB 278
Oliverson – Physicians have had this authority for two years now
Simply asking to extend courtesy to nurse practitioners to function alongside their delegating physicians
Everyone seems to agree on the policy from an organization standpoint; level of scope is where issues begin
The focal point should be access; rural communities’ access to care and caretaking teams’ access to each other
HB 278 left pending.