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The House Committee on Public Health met on September 13 to hear invited and public testimony on interim charges regarding maternal mortality and morbidity, as well as the implementation of behavioral health grant programs and automatic reinstatement of Medicaid benefits for individuals released from prison.

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.

 

Opening Comments

  • Price – Will be the last interim hearing, covering last two interim charges; report will be drafted after this hearing

 

Review state programs that provide women’s health services and recommend solutions to increase access to effective and timely care.

John Hellerstedt, DSHS

  • Provides overview of agency and Maternal Mortality Task Force over the last 13 months, challenge has been moving from identifying problems to implementing solutions
  • Texas is better at addressing risk factors today due to precision focus from the state, opportunities exist to improve outcomes in the future
  • Have developed a very high-fidelity method of calculating maternal deaths which improves quality of data
  • Partnering with TMA to implement maternal safety initiatives through bundles of clinical care protocols
  • Price – Once the initiatives are underway and the bundles are in place, how long before you start to see or can measure outcomes & know if anything needs to be adjusted?
    • Likely 2-3 years before we have data we can make public
    • However, entire system is about collaborative learning between agency, staff, and hospitals; will be having collaborative meetings and they will submit data on progress
  • Participation in the bundles is voluntary on part of the hospital
  • Task Force completed 89 individual case reviews, looked at maternal deaths up to 365 days after delivery
  • Task Force looked closely at 2012 as the year with a truly anomalous spike in maternal deaths
  •  Risk factors linked to maternal mortality were persistent across socioeconomic factors

 

Lisa Hollier, Maternal Mortality and Morbidity Task Force

  • Of the 89 cases reviewed, 34 were determined to be pregnancy related
  • Price – So when you went back to 2012 that was because of the anomalous data?
    • Yes
  • Price – Does the 89 cases represent all cases?
    • There were some identified through the new advanced ID method that were not reviewed
  • Price – Want to understand how you got to the 89 cases
    • These were the cases identified through the initial ID process
  • Price – And you determined that 34 of these were pregnancy related within 365 days, correct?
    • Yes
  • Price – Does that mean that the remainder of those cases were caused by other factors?
    • Yes, there were also some cases were relation to pregnancy could not be determined
  • Oliverson – When we talk about spike in maternal death in 2012, 100% of those cases were included in that spike?
    • Hellerstedt, DSHS – 89 includes every death for which we could show that the mother had delivered a baby or had a miscarriage in the 365 days prior to her death
    • Spike itself was essentially the result of erroneous data caused by the death certificate process
    • Process made possible for examiner to indicate a pregnancy when there had not been one, as a result the case ID process was improved
    • Improved ID process proved spike was due to erroneous data
    • We have now done additional things to ID more cases not in the original cohort, but that will be review
  • Oliverson – So it’s fair to say that if you were pregnant in 2012 and you passed away, you are in this set of 89 cases?
    • With the addition of 9 additional that were identified through the improved process, but have not yet been reviewed
  • Oliverson – Important to know that this is representative of the maternal mortality picture
  • Burkett – So the evaluation identified that there was no spike in 2012?
    • Hollier – Significant proportion of those deaths were initially reported in error as they had no evidence of pregnancy
  • Burkett – So it holds true for other years as well?
    • Have not looked at prior years
  • Burkett – Would this also include abortion death?
    • Hellerstedt, DSHS – No
  • Burkett – Is there a reason they are not included?
    • This is a case set of women who delivered spontaneously
  • Price – So what was the number reported to have been originally, considering we got to 34?
    • Hollier – Was originally 38/100k, rate was determined to be 14/100k through improved methodology
  • Price – My recollection is we were initially quite alarmed and it was strange we would have poor results compared to its neighbors, does this bring us closer to our neighbors or are we still statistically different
    • Hellerstedt, DSHS – 14.6/100k puts us solidly in the middle of the pack, but we don’t know what would happen if other states looked at the source of the error like we did
  • In addition to IDing pregnancy-relatedness, the Task Force identified contributing factors to these cases & found 5 divided into several groupings
    • Individual & Family Factors – Factors like obesity and hypertension
    • Provider Factors – Inadequate, delayed, or poorly coordinated response
    • Facility factors – Failure to recognize high risk status
    • System & Community Factors – Inadequate care coordination
  • Task Force identified that nearly 80% of pregnancy-related deaths have some chance of being prevented with effective care and management
  • Strong opportunities in addressing cardiovascular disease, infection, preeclampsia, etc.
  • Price – 80% is high statistic to quote for things that are addressable, condition factors seem like it would take longer to address than facility factors which could be corrected tomorrow
    • Hollier – Factors related to providers and facilities are things were we’ve already begun to implement things like Texas AIM program
    • Some of the larger social factors may take longer, but important to get started
  • Price – Are the facility factors and practitioner-related things in the bundles?
    • Yes, there are key factors in bundles: facility readiness, recognition, response, others
  • Oliverson – Hoping to spend some time talking about cardiovascular disease, seems like 10 deaths due to preeclampsia or eclampsia is due to longstanding cardiovascular issues
    • This is a finding seen nationwide as well, about 25% of deaths nationwide are from cardiovascular issues
    • Some of these women have congenital heart disease, other have acquired cardiovascular disease during their lifetime
  • Oliverson – Are these associated with advanced maternal age as well? Pregnancy would obviously increase likelihood of death for 20 year olds with previously undiagnosed conditions, but if this is the case then it is likely a larger problem than just maternal deaths
    • While advanced maternal age is more common, this affects everyone
    • Hellerstedt, DSHS – Absolutely right that this is really getting down into the core functions of public health
  • Oliverson – Some of these would be pre-existing conditions predating pregnancy, indicates to me a general lack of access to care
  • Finding included in report are based both on accumulated data & include issues like increased maternal morbidity and mortality among black women; Majority of maternal deaths were to women enrolled in Medicaid at time of delivery
  • Hellerstedt gave an overview of maternal death factors, drug overdose was leading cause of all maternal death from delivery to 365 postpartum, underscores need for detailed review
  • Sheffield – Were you able to determine if drugs were illicit drugs, prescription drugs, etc.?
    • Not sure if they were obtained legally or illegally, was a mixture of opioids, benzodiazepines; not sure we have means to determine legality
  • Role of hemorrhage in maternal mortality underscores need for Texas AIM as it provides protocols specific to this and has been shown to be effective in other states
  • Hollier gives overview of Task Force recommendations
    • Increase access to services during year after pregnancy, improve continuity of care
    • Screening and appropriate referrals will provide better access
    • Support efforts of DSHS and birthing facilities to implement safety protocols
    • Birthing facilities and clinicians should provide postpartum care planning, especially for women at risk
    • Should increase awareness in affected population and in in population generally
    • Should focus on physical and behavioral care needs of women during process
    • Should continue and streamline process of reviewing deaths
  • Oliverson – Is there any research ongoing as to why African American women have higher rates of obstetric hemorrhage
    • Hollier – African American women are at greater risk for a number of factors that contribute, but no research in Texas currently
  • Oliverson – Is there something nationally? Seems like an odd find that one particular population would experience increased rates of hemorrhage
    • Could be from abruption, we know African American women have higher rates of hypertension and preeclampsia, more likely to have uteran fibroids, etc.
    • Most likely explanation is a umber of smaller factors that contribute to an overall increased risk
    • Hellerstedt, DSHS – Most striking finding to me was the 5 or so factors contributing to each death, dealing with a multidimensional problem & challenge is to identify problems that are tractable
  • Hellerstedt gives history of development of high quality data and safety bundles; implementation of bundles has proceeded rapidly due to willingness of hospitals and personnel
  • 189 hospitals participating accounting for well over 80% of births in Texas
  • Need to improve bundles for opioid use and hypertension
  • DSHS exceptional item 3 outlines what it takes to continue improving maternal health care in Texas; New interventions beyond hospital setting could assist in identifying conditions and increase attention on high risk populations
  • Key piece is rolling out ability for providers to understand what risk factors are; with most deaths there are medically-based interventions that could mitigate risk of death
  • Klick – TX has lost more rural hospitals than any other state; in analyzing data, did loss of rural hospitals have an impact?
    • We did not look at where delivery took place
  • Klick – One of the first things smaller hospitals do is stop delivering babies & ultimately the facilities close, might be worth looking at in the future; access to care issue
  • Price – Good point, so the delayed response factor might not be due to travel alone, but also other reasons
    • Hollier – Cannot recall specific instances, but point is well taken and can be evaluated
  • Price – Would like to hear updates if any of these things show a connection
  • Oliverson – Not uncommon for women to have undiagnosed chronic disease that becomes life-threatening upon pregnancy; did the Task Force look at availability of health care coverage of women at childbearing age vs. those that are pregnant? Is there an access issue?
    • Data we have identified that majority of deaths in 2012 occurred to those with Medicaid at time of delivery, we didn’t have data on coverage at time of death
  • Oliverson – Would be interested in coverage 6 months prior to delivery
    • Hellerstedt, DSHS – We can see if this is available
  • Oliverson – Likely a link there, especially with cardiovascular disease
  • Guerra – When you do look at rural hospitals, make sure you properly define “rural,” many studies are not specific
  • Klick – One of the reasons for skewed data was because of recording of cause of death, were opioid related deaths classified as other causes; concerned that there could be underreporting
    • One area that caused inaccurate data was the relatively new electronic system for certification, spike was linked
    • Hollier – Detailed reviews saw 80% agreement between determined cause of death and death certificate, ~20% of the time cause of death was not what Task Force determined
  • Sheffield – Were you able to tell which of these patients had no prenatal care?
    • We looked at timing of prenatal care, we don’t have results for no care, but we did see that late prenatal care was linked to increase of maternal death
  • Sheffield – Do you want to speak on death certificate changes and how it is being made better?
    • Hellerstedt, DSHS – Rider 36 last session had a full scope effort to increase death certificate accuracy, Vital Statistics has formed work groups to reach out to those we are most concerned about to understand issues and barriers
    • Early in 2019, planning on rolling out TxEVER data system which will be used in death certificate reporting
    • Also looking for ways to incentivize medical training for certifiers
  • Hellerstedt highlights DSHS exceptional item 3 focused on AIM bundle implementation, looking to expand pilot and implement hypertension or eclampsia by 2020

 

Lesley French, health and Human Services Commission

  • Link to HHSC presentation
  • Highlights statistics on Pg 2 showing TX’s low birth outcomes, 34.6 percent of women had unintended pregnancies & did not enter into prenatal care, can have a large impact on this population
  • Pg 4 gives an overview of Better Birth Outcomes initiatives, currently over 30 initiatives focused on advisory workgroups and outreach
  • Maternal and neonatal designation rules have gone into effect & these are the first step in ensuring appropriate care for mothers & children
  • Regarding demographic disparity, pilot program in the Greater Tyler Area is looking at trends and approaches
  • Pg 7, Family Planning Program and Healthy Texas Women have crossover to ensure all mothers are taken care of
  • Cortez – Does this include postpartum depression they could get treatment for?
    • Not a benefit in the FPP, but is a benefit in HTW
    • We do encourage referral and train providers on referrals to community services
  • Pg 8 Breast and Cervical Cancer Services (BCCS), more of a legacy program serving ~30k/year
  • Through Task Force finding, found high usages of substance abuse and postpartum depression needed to be addressed; began a Substance Use Prevention and Treatment Services program to assist
  • Received $27.4 million grant from Substance Abuse and Mental Health Services Administration, have been working to get funds to local communities
  • Have received additional funding for Texas Targeted Opioid Response, working closely with community partners to ensure they have resources available
  • Price – TTOR grant money is geographically limited, correct?
    • Yes, only for high-risk populated urban areas
  • Price – I don’t think this was the case for the SAMSA $27.4 million
    • Will need to follow up with you on this
  • Pg 10, Neonatal Abstinence Syndrome Program is addressing substance abuse in NICUs, pilot program to assist mothers with substance abuse issues in bonding with the child, have been able to reduce NICU stays by up to 33%
  • Cortez – This program was started in San Antonio? Where?
    • Yes, one of the local hospitals, will get this info to you
  • Office of Disability Prevention for Children (ODPC) is a new initiative launched in FY18, focuses on preventable disabilities in children like Fetal Alcohol Syndrome, bike helmets, seatbelts, etc.
  • Klick – HHSC published a report showing that the metroplex area was one of the highest for alcohol use; we need to be aware of issues with alcohol, especially as opioids are receiving the current focus

 

Adriana Kohler, Texans Care for Children

  • Here to talk about impact of maternal health on child & family wellbeing and steps legislators can take to ensure mothers & children are health
  • Steps include policies to support smooth transitions between coverage, improving access to care, improvements and innovations in Medicaid, and steps to improve health equity
  • TX has made progress with infant death and pre-term births, but rates are still higher than national average,
  • Rates vary and worsen according to demographics and geographic area; public health strategies should be tailored to address differences
  • Pre-term and low weight births can be influenced by health of the mother before and during pregnancy
  • Majority of maternal deaths reviewed in case reviews had some chance of being prevented
  • 6 recommendations
    • Give legislative direction to HHSC to auto-enroll women aging out of Medicaid and CHIP into Healthy Texas Women, HHSC report suggested would lead to significant savings due to improved health outcomes
    • State policies must help women improve health before and after delivery, should seek federal waiver for 12 month continuous coverage
    • Mothers cannot take children with them in using Medicaid non-emergency transportation benefit postpartum, not conducive to healthy outcomes
    • TX should promote innovative practices through plans and care models, state policy should support integrated behavioral and physical care
    • TX policy should address and incorporate experiences of different demographics, including support for doulas and community health workers
    • Practices and policies should tackle racism and implicit biases in health care, AIM bundle exists for peripartum racial and ethnic disparities
    • Legislature should restore funding to DSHS to continue tobacco prevention and cessation program, smoking has clear impact on outcomes
  • Price – Do you have any specific suggestion on how auto-enrolment could be improved? Sounds like it is occurring, but not familiar with how it might work
    • Two issues, auto-enrollment happens between pregnant women’s Medicaid and Healthy Texas Women, though additional outreach is needed
    • Auto-enrollment doesn’t exist for 18 years olds currently
  • Burkett – Is the reason women can’t take children with them using transportation benefit state law or agency rule?
    • Federal regulation states benefit is only available to Medicaid beneficiary, TX can seek a waiver & other states have done so
  • Burkett – Are you saying some mothers are not receiving services because providers are being racist?
    • This is a complex question, research and literature show that societal stressors, including racism, lower outcomes, particularly for black mothers
    • Strategies to combat this include doulas and labor support
    • In interviews, have heard that providers treat women differently, this is a large and complex issue, could include policies, standards, best practices, etc.
  • Burkett – And we don’t already have those?
    • Not to my knowledge, AIM bundle can provide some best practices to hospitals
  • Arevalo – Your materials mention that infant mortality rates are more than double national average in some portions of San Antonio, is this broken down by zip code?
    • It is, research is from UT Health System

 

Pamela McPeters, TXProtects

  • Continuum of care along mother’s life and through child’s birth is important; some of the health risks linked with morbidity and mortality are linked with adverse childhood experiences or negative community environments
  • Necessary to address both adverse childhood experiences and adult health stressors to improve outcomes
  • Highlights 3 programs that could help
    • Nurse Family Partnership program addresses all stages of family help, home visit program targeting low-income first-time mothers
    • Alliance for Innovation on Maternal health is a national data-driven initiative seeking to improve health in all areas, provides many bundles for implementation
    • Postpartum Pregnant Intervention Program focuses on those with risk factors of substance abuse
  • Price – Good outcomes shown by NFP program, highlights statistics showing good outcomes and good long-term results in a variety of areas
  • McPeters provides several recommendations
    • Improve access and quality of care, especially to behavioral health care
    • Should strengthen and support state and local efforts to prevent intergenerational health risks related to maternal mortality and morbidity
    • Employ strategies to advance implementation of Texas AIM and other similar efforts
  • Cortez – Appreciates the work and advocacy done by McPeters

 

Implementation of HB 10, HB 13, and SB 292

Sonja Gaines, health and Human Services Commission

  • Link to HHSC presentation
  • HB 10 – HHSC was directed to create ombudsman for behavioral health access to care, creating mental health/substance abuse work group, increasing understanding of rules, and submitting report and strategic plan
    • Legislative report has been completed, MOU has been drafted for the ombudsman, and website is open for providers to submit complaints re: parity
    • Strategic plan is expected to be complete in September 2019
  • Price – Work group has communicated well and has worked very hard during the interim, very pleased with the progress
  • Behavioral Health Matching Grant Programs
    • SB 292 grant, $37.5 million through Rider 82, goal to reduce recidivism, arrests, etc. for individuals with mental illness
    • HB 13 Community Mental Health program grants, $30 million through Rider 83
    • Matching funds required based on county population for HB 13 and SB 292 grants, match and collaboration requirement yielded a lot of local buy-in
  • Guerra – Is it possible for us to see in the future the breakdown of the money? E.g. how much went into support staff, how much went into the program, etc.?
    • Programs provided budgets for services they wanted to provide, we do know how much went into their staff and services
  • Price – If we wanted to if a recipient was using funds and on what, admin vs. program, this is something we have and can be shared?
    • Yes, we know programmatic spending and breakdowns
  • Pg 5, Highlights the SB 292 program breakdown, community projects providing behavioral health care for justice-involved individuals, grants are underway for 14 urban and 10 rural awards, maps on Pg 7
  • Grant programs are tailored to communities to address specific gaps
  • Gives overview of state Coordinating Council which coordinates mental health response between agencies, Council and other agencies helped select grant awards
  • Pg 9 gives detail on HB 13 grants, focused on behavioral health care services for individuals with a mental illness & care coordination, 25 LMHAs were awarded grants, with 16 in rural areas, also 31 non-profit organizations, all will have a July 1 start date despite slowdowns
  • Price – I know there were unavoidable delays on the front end with Harvey and applications & issues with HHSC contracting, can you give us an overview?
    • There was a bit of delay with contracting, pushed us back a couple of months, needed to make sure the scoring was accurate
  • Pg 11 has map of HB 13 grants
  • HHSC working on ways to demonstrate success of programs, planning on reporting clinical outcomes/progress in year 2
  • Price – Optimistic for these grants and programs, my takeaway is that HHSC had a robust response to SB 292 and HB 13
    • HHSC has developed a grants department that will oversee the progress and be able to report to legislature

 

Implementation of HB 337

Gina Carter, Health and Human Services Commission

  • Link to HHSC presentation
  • HB 337 required suspension and reinstatement of Medicaid for individuals confined to a county jail if the county sheriff chooses to notify HHSC of the confinement
  • HHSC had hoped to leverage system that suspends and reinstates Medicaid for children in certain instances, but this was not viable
  • Provided county sheriffs access to the state’s eligibility system to determine if an individual has Medicaid, hoping to develop this into an automated system that will work with HHSC dedicated unit to suspend and reinstate
  • County participation will go live in December, webinars will be run in November & January to educate and reach out to counties
  • Extended phase will look at Appriss system for justice data analytics to see if it will fit the purpose of HB 337
  • Price – Once this is up and running, it sounds like there is a need for human input to suspend the benefit and reinstate; there are systems to help educate on who individuals can reach out to?
    • Correct
  • Price – And there is a pilot?
    • Gaines, HHSC – There is some benefit in having a go-between to help ensure process is followed, individuals with mental health issues are at higher risk on release without benefits
    • Under SB 292 funding, HHSC was able to expand a number of jail system resources
    • Pilot looked to Harris Center, Tarrant County, Texas Panhandle, and Center for Life Resources
    • Home and Community Based Services program also works with high risk individuals, has a relationship with Social Security and can get benefits turned back on much quicker
    • Hoping to see good outcomes in some form, may be in different iterations

 

Spotlight on Public Testimony

Kim Griffin, Nurse-Family Partnership

  • Research indicates that in order to improve outcomes and reduce maternal morbidity & mortality, the health of the mother is important & work needs to be done to treat conditions like obesity, hypertension, etc.
  • Mothers continue to need access to care after delivery as well, gaps exist and Nurse-Family Partnership works to fill gaps by partnering nurses with mothers to help manage care
  • Testifies to the good outcomes seen by the Nurse-Family Partnership

 

Patrick Bresette, Children’s Defense Fund

  • Many organizations around the state have signed on to an initiative to improve outcomes, central recommendation is that care before and after delivery is crucial to improving outcomes
  • Factors affecting outcomes cannot be addressed without consistent and continuous care
  • In many areas there are access issues involving infrastructure, some rural hospitals are struggling
  • Oliverson – Have you seen connections to not having access before pregnancy, undiagnosed conditions, and maternal mortality?
    • No statistics, but have anecdotal experiences with mothers without access to proper care, difficult to provide access and many struggle to make appointments; need an insurance solution
  • Oliverson – Particularly for younger women, your primary care doctor is your OBGYN, is this mainly an insurance problem, or is it because they don’t seek out care?
    • Mothers we tend to speak with recognize the need to get health care, trying to figure out how to get care & would love to have an option for coverage

 

Charlie Gagen, American Cancer Society Cancer Action Network

  • Urges support of tobacco 21 bill again 86th Session, smoking is linked to low birth weights and bad outcomes for infants and children
  • Tobacco deaths far outweigh alcohol deaths statewide, e-cigarette use among youth is increasing and should be discouraged

 

Krista Del Gallo, Texas Council on Family Violence

  • Important to consider intimate partner violence into conversations about reducing maternal mortality and morbidity, presents data on link between domestic violence and poor outcomes
  • HB 2620 in the 83rd created a task force on family violence & work supports conclusions drawn today regarding maternal outcomes
  • SB 17 from 85(1) included domestic violence screening & education materials, Texas Council on Family Violence was appreciative of being included and being given opportunity to share resources
  • Would like to see intimate partner violence concretely addressed in maternal mortality & morbidity report
  • Oliverson – Do you have specific recommendations for us?
    • Would like to speak with Task Force and providers themselves, one recommendation is to support Confidentiality Universal Education Empowerment & Supportive Referral approach
    • Comes from National health Resource Center on Domestic Violence, would like to speak about different approaches with providers on what works
  • Oliverson – So early identification and referrals happen at the doctor’s office, are their education programs, etc. for OBGYN offices?
    • Yes, ipvhealth.org provides many resources and different screening tools to help have these conversations with patients
    • Texas Council on Family Violence sees its role in facilitating partnerships between area providers and local domestic violence programs
  • Oliverson – Asks after support services to help pregnant mothers get out of these situations, do we have resources?
    • Demand always outpaces need, TX has a robust structure with >100 domestic violence programs, TX routinely invests at rates much higher than other states
    • Never enough, but there is a strong program base
  • Oliverson – Do we have appropriate deterrents in place from a legal standpoint?
    • TX has a significant constellation of criminal laws on the books around domestic violence; laws are only as effective & impactful if they are implemented, Council works with law enforcement and courts to provide protections that help support safety long term

 

Molly Clayton. Texas Campaign to Prevent Teen Pregnancy

  • Auto-enrolling into Healthy Texas Women as they age out of CHIP is good policy that will result in cost savings to the state, $58.7 million in savings over 5 year period & would avert 11k unplanned pregnancies
  • Provides statistics on young pregnancies, many want access to effective contraception, but see cost as a barrier
  • Auto-enrollment could serve to eliminate barriers to care

 

Sheryl Draker, Self

  • Fetal Alcohol Syndrome is very pervasive in the United States, but is not recognized enough; 2-5% of births have children impacted by alcohol in utero
  • Many still believe it is okay to have alcohol during pregnancy, but recent data shows otherwise & damage to child is a lifelong disability
  • Oliverson – 15 or 20 years at the start of my practice, alcohol was absolutely discouraged during pregnancy; have noticed in the peri-medical culture that there is an attitude that some alcohol is not a big deal, but potential consequences are significant and lifelong