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The House Committee on Public Health met on February 27th to hear from DSHS, TSBP, and HHSC. A video archive of the hearing can be found here.

This report is intended to give you an overview and highlight 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.

 

Department of State Health Services

Jennifer Shuford, DSHS

  • Provides overview of DSHS operations and programs
  • Highlights programs and exceptional items, incl. item to add 6 satellite clinics and mobile clinics to assist in rural health care, item to support EMTF, $21.7m received in SB 8 last session to train more EMS providers
  • Trauma RACs have helped with coordination of new functions like maternal and neonatal levels of care, exceptional item to support RAC functions as they have taken on more over time
  • Provides overview of vaccine programs, Texas Vaccines for Children is the larger of two programs, Adult Safety is the smaller and functions in a similar way
  • Highlights HIV/AIDS prevention programs, exceptional item to make long-lasting injectables available more quickly & another to adopt federal recommendations on enrollment & recertification
  • Tobacco cessation & prevention exceptional item would take us to 8 weeks of therapy in line with national guidelines and relaunch vaping program
  • Implementing new bundles to address maternal mortality & morbidity, expecting significant effect on preventable deaths; voluntary for hospitals and have seen good results
  • Now have data on Fentanyl deaths through 2022, increase has been very dramatic over last 5 years
  • Provides overview of all exceptional items, 9 total $176m in GR over the biennium
  • Oliverson – FDA has now authorized use of OTC COVID/flu test, what impact might that have? Has DSHS made plans to make this accessible to public?
    • COVID home test made testing more likely, adding flu to that is fantastic
    • Haven’t distributed many test kits, continuing to do education on treatments for COVID & flu
  • Oliverson – Do you have any role in or thought about effect on Tamiflu supply? IF you can test for flu at home, more likely to go to doctor?
    • DSHS works to link people to resources, also have a stockpile of Tamiflu
  • Oliverson – Familiar with changes in law allowing medical examiner rather than JOP to conduct autopsy?
    • Have heard of this, can get back to you on this
  • Oliverson – Could be an unintended consequence; deaths that could be homicides should be investigated by medical professionals
  • Oliverson – Statistics on how many people die on first exposure to fentanyl?
    • Data is based on death certificate data and this doesn’t give those details, HHSC might have data
    • Can look at what we have to see if we can get at the data
  • Oliverson – Any data on comorbidity or history of chronic pain?
    • Death certificate data may not capture, but can look at what is available
  • Price – What is the status of PPE, stockpiles, etc.?
    • 8 different groups of RACs across the state have been working with TDEM to maintain visibility on PPE
  • Price – In good shape, more work to be done?
    • Seem to be in a good place right now
  • Price – Who enforces Tobacco 21, purchase of vaping, e-cigarettes, etc.?
    • Not sure who does, DSHS does not; have programs for those caught with tobacco
  • Price – Process to provisionally schedule some substances and get them off the shelves?
    • Don’t have info on this
  • Price – AIM bundles?
    • Have data now on 2018 rollout of obstetrical hemorrhage bundle; hopeful other bundles will be successful
    • Struggle currently is bundles are not having the same amount of success across populations
  • Price – With number of hospitals participating, will we have data earlier than 24 months?
    • 24 months might be the soonest
  • Campos – Where are we at with COVID reporting?
    • Still getting daily reports from hospitals and immediate reporting from laboratories, updating once a week
  • Campos – TB in border area has been a concern, where are we with that
    • Noticed over pandemic the diagnosis of TB decreased slightly, but likely just decrease in identification
    • Border health regions have TB programs that are ready to test and work with institutions across the border; have a binational program as well
  • J Jones – Process for infant screening?
    • Baby has two heel prick panels
  • J Jones – Is there a way to know if a kid is more prone to SIDS?
    • Many diseases are represented in the panel, not sure if any are associated with SIDS
  • J Jones – Line item for what you want to spend within each exceptional item request?
    • Can get this to you
  • A Johnson – On vaccines, are we getting to a point where old diseases are creeping back into a public health crisis? What is the agency able to do with regards to vaccines with debunking misinfo?
    • Have seen some re-emerging vaccine preventable diseases across the US
    • Concerning & thankful we have vaccine programs for uninsured individuals
    • Have partnerships to spread info about importance of vaccines, especially childhood vaccines
  • A Johnson – What are the health care costs long-term with higher morbidity and acuity?
    • Many vaccines prevent conditions that are acute and life-threatening
  • A Johnson – For youth that are non-verbal, those with special needs, do you support better genetic testing? Cost savings long-term?
    • Would need to know exactly which diseases, those we can screen for have an immediate treatment available
    • If treatment is available it would be better to treat as early as possible
  • A Johnson – What can we do with things like fentanyl where data may be anecdotal?
    • There could be other sources of data that may help fill in
  • A Johnson – Would you support getting more data?
    • Certainly from the DSHS perspective
  • Smith – On the vaccinations and outbreaks, data on those vaccinated versus not?
    • None of the individuals in Ohio outbreak were fully vaccinated
  • Smith – With ODs, source of info dies before we can get data
    • With deaths
  • Smith – If we do medical exams on each person would be overloaded
    • They are overloaded, not sure what percentage of deaths have an autopsy performed
    • Trying to increase education of medical certifiers, but does rely on their input
  • V Jones – Could you speak to how DSHS is collecting info on outbreaks and diseases?
    • COVID provided opportunities to update IT system, federal funds allowed for modernization, also updated data sharing and collecting
    • Goal going forward it to continue this
  • V Jones – Difference between what state collects versus what CDC collects?
    • Much of the disease data comes from local health departments, DSHS does have control over the flow
  • Chair Klick – Any update on ICD-10 codes?
    • Determined by WHO, process is generally 1-2 years before a new one is introduced, shorter time period is at national level
    • Could request this of the federal government
  • Chair Klick – Would help with fentanyl data; have also heard of fentanyl being adulterated, any communication on this?
    • Not that I’ve heard of this, collecting data will continue to be an issue
  • Chair Klick – Data is so fragmented & don’t have everyone on same page with actionable data
  • J Jones – Do we look at data for other drugs?
    • We do, tracks death certificate codes for other ODs
  • J Jones – Would like to speak about this later
    • Some of this is on the website, can choose between different OD data and see trends

 

Texas State Board of Pharmacy

  • Chair Klick – Asked for info on bills that may be filed this session on imports, telepharmacy, test & treat, and dispensing

 

Julie Spier, Texas State Board of Pharmacy

  • Provides overview of TSBP operations & mission

 

Megan Holloway, Texas State Board of Pharmacy

  • SB 410 (2005) required TSBP to look at Canadian pharmacies, federal gov sent notice that provisions related to Canadian pharmacies violated federal law
  • In Nov. 2020, rule allowing importation of certain drugs from Canada became effective
  • Aware of HB 25 which would place an importation program under DSHS
  • Telepharmacy systems may be licensed by TSBP, available in certain rural or remote locations
  • Aware of HB 594 which would alter requirements for remote locations and telepharmacy
  • If we were to remove limitations on remote dispensing sites and telepharmacies, would vastly increase number licensed by TSBP; if removing Rx restrictions, TSBP would want to conduct widescale inspections

 

Julie Spier, Texas State Board of Pharmacy

  • If vaccine bills go into effect, TSBP would specific conditions under which pharmacist could administer vaccines
  • On test & treat, no incidents reported on test & treat so far; if bills are passed for COVID, flu, or strep, TMB and TSBP would formulate joint rules
  • Under state law physicians cannot dispense drugs aside from exception for certain rural physicians; TSBP not aware of any physicians dispensing under these exceptions currently

 

Megan Holloway, Texas State Board of Pharmacy

  • Provides overview of PMP, 174k registered users, pharmacies are required to report not later than next day; pharmacists and prescribers, aside from veterinarians, are required to check history

 

Julie Spier, Texas State Board of Pharmacy

  • Pharmacy Act requires Exec Dir to be a pharmacist which limits pool of applicants, not the case for other agencies
  • J Jones – Asks about Canadian imports
    • Wanted to give full history on Canadian pharmacies and imports, federal law has changed and doesn’t line up exactly with what was in SB 410
  • Chair Klick – Some in the seizure and epilepsy community have to import due to unavailability of certain drugs, does TSBP get involved?
    • Not aware of involvement, but can check

 

Health & Human Services Commission

Christine Laguna, HHSC

  • Presentation link
  • Speaking on federal rules for opioid treatment programs
  • SAMHSA provided guidelines for take home dosages and buprenorphine, flexibilities initially allowed due to COVID; SAMHSA has proposed making the flexibilities permanent
  • On Texas Targeted Opioid Response (TTOR), portion of this is Medications for Opioid Use Disorder (MOUD)
  • TTOR programs detailed on Pg 4, opioid treatment programs increase access to three FDA approved medications for treatment of Opioid Use Disorders, allows treatment of comorbid conditions as well
  • Highlights survey data on Pgs 6 & 7
  • MOUD is the gold standard, over time have seen large increases in utilization
  • J Jones – State funds other use disorders?
    • Yes, substance use area has many treatment programs; can get you info
  • Smith – Do you have data concerning avenues by which people become addicted to opioids? Primary sources? Getting them off the street, pharmaceutical disbursement?
    • Can get with team and see if there is a breakdown, there is an assessment when people come in for treatment
  • Smith – Do you have any questions of validity of death data?
    • We get data from DSHS, could be underreported, but don’t have additional data
  • Smith – Concerned about potential dramatic underreporting; limitations?
    • Death certificate data, areas to record opioid related deaths, etc.
  • Campos – How do programs work at the local level?
    • Contract with providers around the state, local to communities they serve?
  • Campos – San Antonio?
    • Can get you this info
  • Chair Klick – Driver’s license requirement?
    • More of a rules question, would defer to resource witness
    • Lauri DeLong, HHSC – Driver’s license is currently required in ruleset
  • Chair Klick – Likely to be changed? Have many in treatment areas without a driver’s license
    • Will be open for discussion when rules are opened
  • Chair Klick – Timeline for changes with TX and federal rules for OTPs?
    • Federal rules are still a proposal, not sure on timeline
  • Chair Klick – Typical timeline at federal level?
    • Closed on February 14th, still need to respond to every statement made
  • Chair Klick – Could still be many months away
    • Possibly
  • J Jones – Would the legislature change policy on driver’s licenses or agency?
  • Chair Klick – This is what it is right now
  • J Jones – So the agency would fix this, we wouldn’t?
  • Chair Klick – Has been some discussion on this, came up during the interim

 

Emily Zalkovsky, HHSC

  • Presentation link
  • Provides overview of home telemonitoring program on Pg 2
  • HB 4 directed MCOs to reimburse for additional home telemonitoring services beyond what was in code, needed to be uniformly across the program, not plan-by-plan
  • HHSC is analyzing cost effectiveness of expanding telemonitoring
  • Utilization data on Pg 4
  • HHSC studied cost impact of teleservices with Texas A&M and included data in 2020 report; saw savings in some areas, costs in others, and an overall increase in costs for clients receiving teleservices; study was limited timeframe, A&M noted that results may be different with longer term study
  • Price – Trying to sort out utilization going up and cost fluctuation, 2020 report had more detail than 2022 report, is there a reason for that? Why does presentation emphasize 202 when there is a 2022 report?
    • A&M contracted for 2020 report, do not have the same level of analysis for the 2022 report
  • Price – Generally speaking costs have increased
    • Agrees, health care costs have generally increased
  • Price – Summary & conclusion in 2022 report said expenditures have decreased, seems in conflict with costs increasing for some services? Related to code change?
    • Costs decreasing while clients increased is referenced in 2022 report
    • For 2020 report, this is a comparison of how many people receive teleservices and their costs
  • Price – what is today’s data showing?
    • Telehealth & telemedicine is a modality, telemonitoring is a service itself
    • Can look for additional info from the A&M study
  • Price – Way to determine what dynamic cost savings may be?
    • Difficult due to limitations, specifically due to telemonitoring
    • Cannot draw any causal conclusions
  • Price – Might be more interaction with pharmacies but less inpatient care; can’t point to anything right now that would say more costs in one area versus less inpatient costs?
    • A&M study does have dollars attached, but doesn’t measure things like avoided hospitalizations
  • Chair Klick – Did Hospital at Home during COVID, are we accounting for this as telemonitoring?
    • Have limited understanding of this, telemonitoring might be a piece of the program, but not sure how it shows up in the data
  • Chair Klick – Averting hospitalizations and associated costs; might be other populations that benefit

 

Closing Comments

  • Chair Klick – Hopeful that we can take up some bills next week