See attached & below for our team’s notes on House Health Care Reform from 10-3-22

House Select Committee on Health Care Reform 

October 3, 2022

 

The Committee on Health Care Reform met on October 3rd to hear invited testimony over the following interim charges:

  • Charge 4. Study ways to improve outreach to families with children who are eligible for, but not enrolled in, Medicaid or CHIP, including children in rural areas.
  • Charge 5. Examine the potential impact of delayed care on the state’s health care delivery system, health care costs, and patient health outcomes, as well as best practices for getting patients with foregone or delayed interventions back into the health care system.   The study should consider patient delays in obtaining preventive and primary health services, such as well-child care, prenatal care, screenings for cancer and chronic disease, behavioral health, and immunizations, in addition to delays in seeking urgent care or care for chronic illness.

 

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. 

 

Charge 4. Study ways to improve outreach to families with children who are eligible for, but not enrolled in, Medicaid or CHIP, including children in rural areas. 

Wayne Salter, HHSC 

  • Speaking on children who are Medicaid eligible but not enrolled 
  • How they determine Medicaid eligibility: financial need and patients’ demographic information 
  • 17% uninsured Texans from latest census report, identified 10% of patients who are eligible but unenrolled 
  • Overview of Community Partner Program (CPP)
  • Recently initiated a case assistance affiliate program
  • Focused on staffing eligibility offices, offering part-time work for retired employees who are already trained 
  • Reduced time from person being hired to doing eligibility training by 50% 
  • Seeking additional funding to address other workforce challenges, such as high turnover and vacancy rate 
  • CPP helps patients through application process  
  • Required by law to have out-station eligibility staff, currently have contracts with over 1k out stationed locations 
  • As part of Healthy Kids Act, AES partnered with MHP Salud to provide data on the number of patients that are insured or receiving Medicaid; data used for community outreach
  • Looking for ways to partner with more local outreach programs in addition to MHP partnership
  • Started expansion of CPP, implemented an evidence-based recruitment method. Looking to increase presence in high poverty areas
  • Addressing issue of difficulty in resetting passwords, plan on using multi-factor authentication 
  • The Pizza Tracker is a customer service initiative where individuals will be able to follow the life of their application from submission to the final eligibility decision
  • Looking to improve phone interactions by reducing the time it takes caller to talk to an agent 
  • Frank- Do you have the numbers broken down over people who are eligible for Obamacare subsidies but not using it? 
    • I do not but we can follow up 
  • Frank- Are you trying to let people know about the Obamacare subsidies with your outreach? 
    • Absolutely. When we determine an individual is not eligible for Medicaid, we refer them to the marketplace 
  • Frank- So do you have a general overview for why people aren’t going on Medicaid or Obamacare when they are eligible? 
    • Most of our employees are interacting with people who are not eligible for Medicaid 
  • Frank- But then aren’t they eligible for Obamacare? 
    • I don’t know exactly 
  • Guerra- Can you define conditional offer of employment? 
    • Our intent to hire you based on if you pass your background screen 
  • Guerra- Can you define high performing employees? 
    • Exceeding on performance evaluation. Taking on additional responsibilities to benefit the agency 
  • Chair Harless- When will password problem be resolved? 
    • Looking to implement in first quarter of 2023 
  • Chair Harless- What about wait times on phones? 
    • Already seeing improvement 
  • Chair Harless- Is part of the problem the technology you have? 
    • Mainly focused on increasing staffing, but always continuing to review technology needs 
  • Rose- Feels a more immediate remedy to password issue is necessary. Not trying to beat up on agency, just seems that there is always an issue for Medicaid patients. If we expand Medicaid will we be able to track people better? 
    • I don’t think I can answer that question 
  • Rose- I think you can you just don’t want to. Thank you anyways 
  • Walle- You’ve shown us estimates of uninsured people from latest census, correct? 
    • Yes correct 
  • Walle – Does access to an accurate census impact your numbers? 
    • Our data is only as good as the data we get 
  • Walle – And of those uninsured some of them could be eligible based on the income levels were talking about?
    • Right. That would be reflective of the 10% we’ve identified.
  • Walle – Do you have any technology that has been used in other states that could be used to help with outreach to uninsured individuals?
    • We don’t currently have that technology. What I will say about this population is that it is unknown. Based on the census data, we’ve identified the 10% who are eligible but not enrolled. This 77%, there’s a lot of different variables as to why we can’t dig into that. Not only would we have to identify them but also see if they were eligible in the first place.
  • Walle – Right because there’s no way for you guys to specifically know who they are and how to target them. Other than people from this population coming to an agency or hospital etc. Would you say that’s fair?
    • I would say that’s fair.
  • Walle – But in the private sector when you go online to buy something, there’s algorithms that try to target people. Like if you type in something about a fishing rod, in 10 seconds there’s somebody targeting you with an ad about new fishing gear. Is that something the agency has looked at?
    • We haven’t looked into that. That’s something we could come back to as we have our technology discussions moving forward
  • Walle – Are there technologies like this being used in other states that the agency could use to better target individuals who are not insured?
    • It’s possible
  • Walle – If someone wants to reach out to agency to see if they are eligible, how do they do that?
    • 211, online at Texas Benefits, in person at offices or community sites
  • Walle – Is there an app that allows individuals to upload application and related forms?
    • Yes we currently have an app that allows individuals to do those things. Our website also allows people to use their home computers and scan to upload documents and applications
  • Chair Harless- Do you know how many people you are looking to staff?
    • Looking to fill remaining 400 vacancies
  • Rose- Most people who are eligible for these services may not have access to a computer. What services are you offering?
    • They can go to community partner sites and offices
  • Rose- Where is this information located? How would they know?
    • Website. Working locally to spread info about these services
  • Klick- Hearing about pregnant women whose prenatal care starts later because of wait time to receive services during application process. Do you have any programs looking specifically at this issue?
    • No special programs currently, but we are looking at how to increase visibility for that population.
  • Klick – The delay means prenatal care begins later, which often results in worse outcomes, so I hope we can work to improve that
  • Klick – Are you proposing that health plans established during public health crisis be made permanent? Because that is likely a good idea.
    • Those are the conversations we are having right now
  • Klick – The 211 number has definitely needed some upgrades. It might be worthwhile to talk to some users of this service to see what changes they would like to see
  • Bucy – This report is encouraging. Second the opinion on urgency of password reset process
  • Bucy – What is the turn around time on people hearing about their applications?
    • With increasing staff we have made progress on backlog
  • Bucy – By end of next month you think applications will be responded to in 30 days or less?
    • Yes
  • Bucy – What are we doing to find people to follow up after public health crisis?
    • We have initiated an ambassador program to focus on this. Letting people know they don’t have to wait until the end of PHE to update
  • Bucy – How are you getting ahold of them?
    • Mainly through community partner program, reaching out through media
  • Bucy – Other than money, what do you need legislature to do to identify these kids that are eligible but not using Medicaid over next 2 years
    • We want to come back with a holistic answer for you. Of course funding and technology, but there’s definitely other things
  • Bucy – Let’s get a tangible look so we aren’t just talking money, but policy and legislation
  • Chair Harless – 700,00 30 days out seems unacceptable
    • Our staff vacancies contributed to that as well as influx of applications
  •  Chair Harless- What number would be acceptable to you?
    • 95%  returned according to federal guidelines
  • Klick – What about those that are on the exchange and then discover they are eligible for Medicaid?
    • Those are sent to state directly
  • Klick – Could those contribute to the 700,000 still sitting out there waiting to be identified?
    • It could, but would be a very small percentage

 

George Hernandez, University Health 

  • If we provide care without compassion, then we aren’t really providing high quality care
  • Partnership with UT Health for over 50 years
  • Want to take resources to where the need is via centers and mobile services
  • Information technology is extremely important, allows us to provide care better and more quickly
  • Vaxxed over a quarter million people for covid with virtually no wait, attributes this to IT investments made in previous years
  • Primary area of service is Bexar county, but reaches 7 surrounding counties
  • In trauma area P which reached Uvalde
  • We get a lot of uninsured people in and around Bexar County, amounting to about $30 mil in unfunded care
  • Gives a strong incentive to get people on Medicaid and other programs like CHIP
  • Partnership with HHSC for over 20 years to employ their members in our hospitals and centers
  • Since 2019 we have had over 300 “boots on the ground” events to get children enrolled in these programs
  • Work with chamber of commerce in rural counties to know what events are going on and how best to get involved with communities
  • Community first has a lot of individuals enrolled in Medicare and CHIP, working to update those enrollments now instead of waiting for end of PHE
  • Community First enrollment assistance, step by step guides on website and paper format
  •  Walle – Do you have an idea, of the folks you are starting to recertify, how many would actually requalify?
    • Don’t know off the top, only way to find out is to reach out to all of them
  • Walle – You have specific data for Bexar and surrounding counties. Are you working with health plans themselves or just people in your network?
    • Both
  • Walle – Not everyone has access to this important technology. Do you all actually go door to door?
    • Our major outreach is targeting specific neighborhoods and holding events there at the community centers. Not necessarily going door to door
  • Walle – You mentioned being first response to Uvalde, but they aren’t in your counties, correct?
    • No but they fall within our trauma region. We are the closest level 1 trauma center to the situation.
  • Walle – What about mental health services?
    • Center for Health Care Services is our mental health partner. We are the sponsoring agency for them.

 

Alex Mendoza, Texans Care for Children  

  • Health insurance is critical for regular medical care for children, makes them more likely to meet milestones later in life 
  • We have the highest uninsured rate in the country for kids, Texas falling behind with enrollment and staying enrolled 
  • Low-income families with complex situations often don’t think they are eligible even though their kids are, lots of families don’t even know their children are eligible 
  • Lack of funded outreach programs limits state’s ability to provide resources and manage the end of the PHE 
  • Parents face barriers while attempting to enroll their children, such as- lost time while trying to reset passwords, 211 is only available during the day when many parents are at work, wait time for 211 
  • Really important eligibility worker vacancies get filled because those are the people who are processing the applications 
  • Application process is long, followed by long waiting period for application to be processed 
  • Currently a child can only be enrolled in one program even though they are eligible for both 
  • Legislature can adopt express lane eligibility so that children can be provided with all services they are eligible for  
  • Texas would not be the first state to adopt ELE, other states have seen success 
  • Newborns are missing access to Medicaid services, losing important medical services during a critical point in their life 
  • Inconsistencies with mothers enrolled in Medicaid when giving birth but child’s Medicaid is not activated  
  • Circulating handouts in hospitals and birth centers so mothers and families are educated on what to do before leaving 
  • Schools are becoming increasingly important places for kids to access care services 
  • End of the PHE has potential to create chaos for families if Texas legislature doesn’t ‘unwind’ it strategically 
  • By end of the year there will be a new wave of applications to review, and difficulties with the process previously discussed will be exacerbated  
  • Rose – You presented some seemingly ‘no brainer’ solutions. Have we done any legislation in the past related to eligibility? 
    •  We’ve potentially seen some legislation through HHSC with some of these proposals, specifically express lane eligibility  
  • Bucy – Can we expand on the express lane eligibility (ELE), what that would look like tangibly? 
    • HHSC has an integrated app system, meaning SNAP, Medicaid and related programs all have the same app. You would just need to check which one you are applying for 
    • A family might be primarily focused on applying for SNAP and not know that they are also eligible for Medicaid. Under ELE the agency could also check the families eligibility for other programs 
    • This would be a proactive measure the state could take to get services to those 400,000 kids who are eligible for services but not enrolled 
  • Bucy – So it would be a single application you could use to apply for all programs? 
    • It would allow the state to notify families that while we were checking their SNAP application, we found they were also eligible for Medicaid 
  • Bucy – You think that needs to be a legislative policy? 
    • I believe so, yes sir. 

 

Bee Morehead, Director Texas Impact

  • Providing ideas on working through faith and community organizations to increase Medicaid and CHIP uptake for eligible children in Texas 
  • Post covid, a lot of faith-based organizations are trying to find the best ways to support their communities, making them a large potential pool of community partners 
  • Texas Impact helped to establish community partners program (CPP) with HHSC 
  • Faith and community based organizations are a great way to granularly get into communities, but they are not casual or low cost partners; they require significant training and support 
  • If the legislature plans on leaning into those community programs, they need to be doing so with the resources and support it will require  
  • Out station eligibility workers are a top-down approach, people coming from professions to help community 
  • A more bottom-up approach to consider is promotores, parish nurses, and parent mentors who can do the same job  
  • Legislatures are uniquely positioned to recruit assistors in your local districts 
  • CPP created house district level maps that overlay zip codes with high concentrations of Medicaid eligible but unenrolled children with locations of faith and community based organizations 
  • Those maps were given to some legislative offices 
  • If the house members committed to interacting with the community partners in your district that would likely have a measurable impact on volunteer turn out 
  • Data is important, but its not a substitute for relational recruitment 
  • The Inner Agency Coordination Group (ICG) and Texas Nonprofit Council have statutory responsibilities that make them ideal partners for this committee 
  • ICG was first body of its kind in the country 
  • Those bodies identify gaps in state services that faith and community based groups could fill  
  • To ensure they have the capacity, you would likely need to fund the agency to hire temporary staff
  • Medicaid expansion is crucial to this charge
  • When parents don’t have insurance they are less likely to insure their children even if the child is eligible
  • Even if the child has Medicaid or CHIP, they are less likely to get care under those programs if parents don’t have insurance
  • Really encourage looking at Medicaid expansion because of the benefits to people in the state

 

David Preston, Texas Association of Community Health Centers (TACHC)

  • TACHC represents 73 federally funded health care centers that serves over 1.7 mil Texans 
  • These HCC’s offer medical, dental, behavioral health, pharmacy, and vision services all under one roof 
  • When centers provide services to eligible but unenrolled children, they absorb the cost of providing care at the expense of other services and reaching new patients 
  • This means these patients are taking up funds that could be used by those who are truly uninsured and not eligible for other coverage or programs 
  • Outreach Enrollment Department has streamlined app process for Medicaid  
  • CPP has 3 levels of partnerships: 1) Offering a computer for public use, 2) Having staff there to help assist and enroll, 3) Case assistance navigators who help the public, patients and all with case management 
  • All 5 of TACHC outreach enrollment staff are level 3 case navigators 
  • Brief explanation of out station eligibility workers and duties 
  • Found that many patients and clients don’t even know where to start the enrollment process, or start the application then stop because they don’t understand the questions 
  • This is when they seek our assistance and out station eligibility workers are essential  
  • Get notifications once all enrollment materials are collected from out station eligibility worker; contact patient to let them know stats; process takes 30 minutes and have responses back within a few days 
  • 2021 provided 6500 touchpoints to help patients get healthcare coverage, misconceptions about enrollment keep these people from getting help for example if previously denied think they can’t reapply 
  • Eligibility concerns offer challenges; parents working on citizenship may forgo enrolling their children even though those children are citizens etc.  
  • Many parents prefer in person support; deterred by long wait times at HHSC office; reliable transportation and health issues determine if patients go get support  
  • Estimate 2/3 of 1260 uninsured children at health center would qualify for Medicaid  
  • Need to expand out station eligibility works to get more children enrolled; community partner programs excellent way to help  
  • Recommendations include leveraging federal funds to increase eligibility access through out station eligibility workers, fund the community partner program to provide grants; invest in public awareness campaigns with community partners to enroll more children with the end of the public health emergency coming up  
  • Families are extremely mobile with living arrangements 
  • Challenges to communicate next steps for clients with end of public health emergency such as updating their contact information  
  • Support efforts to amplify messaging about end of health emergency and steps that families need to take  
  • Chair Harless – Do you not enroll children when they come see you? 
    • We do eligibility screening on all patients, but some don’t want to take the time to visit; always offer appts and walk ins at a later date 
  • Walle- been regions of state where FQHCs have had a more robust presence; major metropolitan and some rural communities have been growing footprint of FQHCs is that correct?  
    • Right, public health emergency has taken real toll on CHC and depends on center the level of outreach 
  • Walle- there are FQHCs in particular regions that have done a good job expanding; partly funded by federal government correct? 
    • Yes we are a federally funded center and have 50 counties in our footprint  
  • Walle-Right but for FQHC there wouldn’t be a clinic in that particular region? 
    • We wouldn’t have one down here, no 
  • Walle- You said that center is in Wichita Falls; is there any center in that region that offers services similar to a FQHC? 
    • Not that I’m aware of  
  • Walle- These are community led clinics right; part of the business model is to get folks enrolled because you offer services at a sliding fee scale 
    • Yes, we do offer a sliding fee scale ; people who are eligible and don’t enroll are taking money that is typically routed to patients that are eligible  
  • Walle- Was there some point during the passage of ACA that we have a navigator program? 
    • Yes, we have three certified health application counselors at our center; if they don’t qualify for Medicaid or CHIP we screen them for the health insurance marketplace  
  • Walle- is that a similar model that you mentioned in your outreach and enrollment coordinators? Staffed and paid for by FQHC? 
    • Correct, one paid for by state but our 5 enrollment people are paid for by QHC  
  • Walle- Five statewide? 
    • Five in our footprint up there 
  • Walle- Each FQHC also has their own outreach enrollment workers? 
    • It depends, some may community partners, some may have out station eligibility worker some may not 
  • Walle- Don’t get any state funding correct? 
    • Not that I’m aware of  
  • Walle- Previous session we put in $20 M into incubator dollars; would some state dollars be helpful in expanding services for enrolment, hiring staff, or additional clinic 
    • Definitely helpful, reaching people in rural community very helpful; some families have to drive too far to these centers  
  • Walle- Satellites could be helpful in reaching those communities? 
    • Yes, had call from local hospital that child needed to be and had a pediatric practitioner in one of our FQHCs see a child through the community helper program; child uninsured and dad had no idea how to begin process  
  • Walle- I would assume millions are in that situation that don’t know about qualification; with Chairman Phan about doing more in helping clinics like yours that can get folks out of the emergency room in the next session  
  • Frank- They do a great job of providing healthcare on the ground; Yall have people helping with Medicaid enrollment, use own funds to do that but if you take from uninsured to insured you are incentivized to that correct? 
    • Yes, we do that’s how these centers came about 
  • Frank- You see about 1. 7 million Texans each year; would like to see what the uptake is in different communities, how they compare in terms of access; is that something yall could provide? 
    • Yes I’m sure 
  • Frank- 600k between adults and kids that yell see are uninsured, any more data to see about their eligibility for Medicaid? 
    • Not here but can get you more information on that

 

Anne Dunkelberg, Every Texan, Children’s Health Coverage Coalition  

  • When chip was launched in 99 session, first time that Texas Medicaid had done outreach; enrollment shot up with this, set national record of how quickly they enrolled
  • Success was based on relying on community networks and partners program is the latest version of this but there is no funding for the partners right now
  • Hard for this system to gain hold in rural towns; should reestablish funding to make program stronger
  • Support making sure that FQHCs application sisters, around 400 around state, have greater integration with all of the entities working together in a more coordination way
  • Appropriated $15 M in first biennium of CHIP roll out for outreach and community-based orgs; dwindled after that and no funding now
  • Hoping to refund the program
  • Child population increased 33% from 5.9 to 7.9 million since 2000
  • Uninsured rate for children has gotten worse in the last three years; with end of public health emergency children will have to be recertified
  • Issue of having lost over 237,000 kids from the rolls most likely due to anxiety among families with mixed immigration status; one parent isn’t a US citizen meaning have green card and undocumented; heightened fear if you enroll US citizen child could prevent getting US citizenship
  • 1 out of every 4 Texas children has a parent that’s not a US citizen
  • Recommend we do a targeted outreach dedicated to correcting misinformation keeping green card and US citizen children from getting enrolled
  • will require updated training for eligibility staff; complicated areas where mistakes can be made
  • Good examples in WY, IO, VA to look to
  • Have updated data from census 21 data; should be more reliable; shows tiny improvement in children’s uninsured rate
  • Have big challenge to keep eligible children enrolled
  • Walle- On recommendation for more robust outreach could you clarify that of 1 in 4 Texas children you stated how many households that is?
    • I would have to guess something like half of that number; would have to just guess right now
  • Walle- Legislature at some point funded outreach then stopped and we suffered from that
    • There’s money being spent on HHSC staff; issue of not having money for community partners to help get bandwidth to help people sign up
    • Statistically, a lot of people are more likely to get a kid enrolled with one-on-one assistance
  • Walle- Providers take it upon themselves to act as outreach groups for hard to reach communities but need statewide help?
    • Yes, these providers at not everywhere plenty of counties without FQHCS; structure of current program tends to seat in places with existing resources; need extra resources to fund these rural areas
    • May be catholic charities, smaller health clinics that are not FQHCs that don’t have the money in budget to take on that role

 

Charge 5 – Examine the potential impact of delayed care on the state’s health care delivery system, health care costs, and patient health outcomes, as well as best practices for getting patients with foregone or delayed interventions back into the health care system.   The study should consider patient delays in obtaining preventive and primary health services, such as well-child care, prenatal care, screenings for cancer and chronic disease, behavioral health, and immunizations, in addition to delays in seeking urgent care or care for chronic illness. 

Dr. David Lakey, University of Texas  

  • Discusses consequences of not getting healthcare for different conditions and the importance of screenings and primary care
  • Delayed care very prevalent during COVID, 1/3 of nonelderly adults reported delayed healthcare
  • Gallup data 2019, nationwide 25% of Americans postponed medical care due to cost for a serious condition, higher rates of delayed care for black and Hispanic individuals
  • Individuals with life threatening diseases even go without care, cites a study where 16 of people with heart failure went without care
  • Healthcare costs go up significantly when people delay care and end up in the emergency room
  • Prenatal care needs a lot of work, 10% of women in the state receive not or late prenatal care, 21% of women in state get below adequate care; risks for low birthweight, preterm birth go up
  • 10 year delay between mental health symptoms and when PPD women begin mental health care; very significant detrimental events because of lack of mental health care
  • Health care can be delayed due to debt that would accumulate, insurance difficulties (Texas has highest level in nation), number of healthcare providers are too low
  • Life expectancy correlated to density of primary care providers; study in JAMA
  • 224/250 counties are health professional shortage areas, 248 are mental health professional shortage areas
  • Experiment in VA system; with weight list of more than 31 days mortality rates were 21% higher
  • Goes further into negative results of delayed care during COVID and for patients with cancer
  • Learned about importance of telemedicine and keeping people on government programs during COVID
  • Legislature should extend Medicaid coverage for a full year, and look at how they address cancer care for the uninsured should do programs for colon cancer etc.; delayed cancer screening because of cost of test
  • FQHCs lookalikes in state or expansion is very helpfully for filling gaps, can support them through telehealth
  • Local mental health authorities are very important; Uvalde had a 40% vacancy rate in mental health before the events occurred
  • Need to increase and diversify the healthcare workforce, PCPS are essential for basic care and health services; ethnic diversification important, individuals want to see doctors that look like them
  • Using community health workers is effective to link individuals to the care they need
  • Need to work on healthcare environment being more patient centric, decrease bureaucratic things
  • Need to address social determinants of health and how individuals can get healthcare
  • In Texas, pilot program Healthy Mujeres provides prenatal or contraceptive care and has been extremely impressive; HHSC looking at giving them additional dollars to expand
  • Need to do better on educating patients and people; destigmatized mental health
  • Chair Harless- telemedicine is a problem in rural communities where internet access is limited isn’t it?
    • Broadband is challenge, but can do better in moving it out
    • Involved in Texas Child Health Access Through Telemedicine has been challenging with broadening that infrastructure
  • Telemedicine can be used better to support primary care providers in the state of Texas; ability to connect providers to specialist for a joint appointment for the patient should be done
  • Frank- Curious how costs for healthcare are twice as much as the rest of the first world; if we know that is a big part of the reason of delay of care what are you and the university system doing to help drive down costs? Shouldn’t cost $20,000 for the average family
    • All payer claims databased will be useful to see cost of care and use analytically; continued focus on safety of patients and best practices important; need address social determinants in general
  • Frank- I’m talking about at the hospital levels at the drug levels; seems NGOs government funded orgs should be leading the way to address the costs?
    • With so many uninsured it influences the cost for everyone else; a part of it but not the whole picture; need to address workforce challenges
  • Frank- state law requires people to provide pricing but its almost impossible to get out any hospital; people get the run around and cant get info; is there anything we can do legislatively or you as a system?
    • Don’t have a specific recommendation on that today; but it could help people make decision; cant speak for all universities but will continue to try to work on that issues
  • Oliverson- When were looking at lets say Medicaid through socioeconomic criteria we find a pretty good crossover of folks that have poor access to healthy eating; is that something that we should be pursuing in terms of low hanging food?
    • That’s absolutely true
  • Oliverson- How can we be more proactive with food deserts etc.?
    • I think you are correct; if you are in a food desert you aren’t going o eat the fruits and vegetables you need to decrease risk of obesity and disease
    • There are SNAP programs etc; amount of hunger in college students could be a focus; should direct Medicaid to look at social determinants and making people with certain programs able to get in that program
  • Oliverson- So Medicaid pays for medication; is there an argument that could be made that food is medicine from a scientific standpoint?
    • Absolutely food is medicine; can have a dramatic impact on your ability to be healthy with things like hypertension etc.
  • Oliverson- Does that save the system money over time? Does it lower healthcare costs in the future?
    • I think through the short term you may not see that but as you prevent kidney disease and dialysis, diabetes and amputations, there are a variety of costs linked to diets; it’s a smart investment
  • Walle- As I understand in particular to the maternal mortality rate there is talk about a 24 month coverage of insurance, proper birth spacing; for moms on Medicaid you extend this insurance; do have an opinion on the time frame when it comes to delayed impact of care?
    • The longer the better for the mother and child; if she drops off after a year and gets pregnant again and receives delayed care she won’t be as healthy through the new pregnancy
  • Walle- for reimbursement for breast and cervical cancer it would be reimbursed if they are diagnosed but not for colon cancer?
    • Yes, under state of Texas we have a program for breast and cervical cancer; under this program if a woman is diagnosed, we get them the treatment they need and their survival is much better
    • Don’t do this for colon cancer but have an easy way to test for this; trying to fund screening but have to figure out workaround if they get a positive to get the individual the care that they need; dependent upon investigators network
    • Rates in Texas for colorectal cancer screening are remarkably lower
  • Walle- UT Houston houses the claims collection data base?
    • Yes, the school of public health is one of the only ones certified to look at that
    • Seeing this data can help answer the legislatures questions
  • Rose- prior to the pandemic, district 110 had the two highest zip codes with the most chronic illness and food deserts where in this area; DNA is a part of health especially with African Americans correct?
    • People are doing long term gene impact related to trauma and what can result
  • Rose- I want to be clear that its not just people not eating healthy it is also genetic; need to continue to have this conversation when it comes to social determinants
  • Klick- some people that aren’t able to afford care have coverage and people are paying more for copays and deductibles; have you seen any studies that break that down?
    • Yes some deductibles are high enough that people wont seek health care is not only copay but also deductible; fits into overall cost of healthcare; example of that is mental health with cash based psychiatrists
  • Long term need to address cost and copay and get more providers

 

Blaise Duran, Employees Retirement System of Texas  

  • HealthSelect plans cover more than 500,000 Texans and the largest plan covers 80% of participants
  • HealthSelect of Texas is a point of service plan; participant has to select primary care and get a referral from primary care for a specialist
  • Preventative care over pandemic data shows screening for cervical, colorectal, and breast cancer screening show that there was reduction in number of preventive screening in 2020 (presented on calendar year basis not fiscal year); rebound in 2021 to almost pre-pandemic levels
  • Corresponding reduction in number of diagnosis; didn’t reduce as much as screenings so hopefully people who needed screenings most got those; uptick in 2021
  • Cost per case for these cancers show that there wasn’t a significant impact to cost in 2021, small uptick in 2020; Year to year cost per case is volatile
  • As you miss screening, cancer gets caught later and it becomes even more expensive
  • Childhood immunization decline in 2020, 2021 driven by reduction in number of flu vaccines received by participants, DTAP MMR received at similar rates to previous years; less flu in general with social distancing
  • For heart disease looks at number of claimants and average cost per case; again a downtick in 2020 but cost has remained relatively flat; not seeing untreated cases that go too far and result in high cost case
  • Diabetes care and management looks at number A1c screening and total costs, costs of comorbidities included, has been increasing each year to be expected; medically increase is driven by direct cost of the treatment of COVID-19
  • Screening for diabetes back to pre-pandemic rates
  • Had virtual visits and telemedicine visits
  • Virtual visits first offered in 2017 with no copay to patients; steadily increasing, not highly utilized until the pandemic; Reinstated copay for virtual visits this summer after they were waived during COVID

 

Katrina Daniels, Teacher Retirement System of Texas 

  • Administer two healthcare programs, one for active members and one for retirees with 240,000 members; both plans together spend about $4 B per year; experienced COVID expenditures during pandemic
  • Appropriation from previous legislative session received $721 M in federal funds to offset premium in active care and retiree care; able to give retirees basically a premium refund of $448; able to hold active care premiums constant
  • Programs are funded separately, for active care all funds except federal come from employer in the form of premiums
  • Dip in non-COVID costs in 2020 from people deferring care and saw increase in COVID costs; 7-10% decrease in preventive care
  • Active care is single biggest source of data and largely self-funded
  • Issue of most popular plan being the high deductible plan to get people more engaged in care; data shows employees are not availing themselves of HSA and instead deferring care
  • Have put in place two primary care plans with copays for doctors visits and pharmacy; been movement towards this plan
  • Cost can be an issue for members; premiums for auxiliary staff may be around 17% of their salaries
  • Premiums are much lower than other peers yet see more cost sharing among members
  • Preventive screenings rate being low are less reflective of COVID and more related to high deductible most likely
  • Work to make plans more affordable include getting federal funds, offering first dollar coverage, implemented pilots around musculoskeletal conditions, specialty care drug program to cover out of pocket cost by PBM, lowering Medicare advantage plan deductible, working towards transparency in contracts and to members
  • Frank- Most things cost more than deductible regardless of whether you shop or not it just causes you to defer; have you explored providing incentives for people to shop?
    • That is something we do; we initially put it around certain shoppable events for which quality is not a big variation
  • Frank- I think it’s important because we have no market forces on the cost of healthcare; what are you doing?
    • It’s around shoppable events; radiological services are a great example; want members to pick the most affordable option; working with BlueCross
    • Putting incentives in place for doctors to steer people to lower cost care
  • Chair Harless – what is the actual incentive
    • For members it’s a financial incentive that varies but is up to $500
  • Frank- within TRS they have higher cost areas in some regions; What are we doing from a TRS standpoint to try and get cost containment on that?
    • Absolutely, do things to help control number of units consumed; cost of care is big issue that varies state by state; varied cost of premiums reflect the cost of health care in that region
    • We only spend 3% of funds on administration all other funds go to healthcare claims, we spend $80M at UT Southwestern system; wrote letter to ask them to think about the cost for employees
  • Vendor for active care is locked in a negotiation that is scheduled to terminate at the end of the day
  • Frank- allowing the people on these plans to see how much things cost will be helpful in having them be mindful
  • Bonnen- when you refer to no difference in quality to shoppable, I would caution you because there is a big difference in quality that isn’t recognized in what we pay; could be difference between having patients get repeat services due to poor quality of first service for example with MRIs
  • Bonnen- with BlueCross $4000 versus $400 example, it doesn’t make any sense on either end of the spectrum; not okay on either end and that’s where we are right now; should allow more patients top be involved and see what it costs
  • Bonnen- quality can actually drive costs down; can get a lower price and higher quality

 

Dr. Kenneth Mitchell, St. David’s Healthcare, Texas Hospital Association 

  • In early 2020, many hospitals cancelled or delayed surgeries and procedures, some required to delay nonemergent care; goal was to preserve hospital capacity as COVID impact increased
  •  Non-emergent procedures doesn’t mean that it isn’t critical to the health of the patient
  • Very little true elective surgery in acute care hospitals; most are performed in outpatient and private
  • About 30% of Americans have delayed care during the pandemic; result is that hospitals are seeing sicker patients; number of reports in the media from physicians increased mortality in heart attacks in the field, more ruptured appendix because of delay of seeking care, led to increase length of stay by almost 10% from 2019-2021
  • 37% of PCPS feel patients’ chronic conditions have noticeably worsened
  • Concerns about impact of maternal health and higher risk deliveries
  • At the same time hospital expenses has increased significantly data from 2019-2021 shows drugs up 36.9%, labor cost up 19.1% roughly half of a hospitals overall expense, supply cost up 26%
  • Total 31% increase in expenses over this time period
  • Cost of contract laborers up 200% since the start of the pandemic, around $100+ per nurse is not sustainable for hospitals
  • Thanks labor resources given from state
  • Need to reassure patients are safe places during pandemic, have moved past this fear now; any plan should focus on populations who are at high risk and have historically limited access to healthcare
  • Austin has high level of coordination throughout EMS, hospitals, etc; call between these groups are very valuable
  • Austin Covid Healthcare Task Force worked on informing people that hospitals are safe and had accessibility to at risk community at front of goals
  • COVID still impacting healthcare system as a whole; staffing shortages are worse, hospitals running at or near capacity as state grows, burnout and fatigue huge
  • Challenging year financially for hospital systems; large operational losses; will take years to recover form burnout and replenish workforce
  • However, staffing turnovers are starting to decline; travel nurses returning; increasing number of applicants enrolling in nurse education programs

 

Dr. Valerie Smith, Texas Pediatric Society, Texas Medical Association  

  • Support policy efforts such as the full funding of exceptional item 2 regarding critical eligibility workforce needs, enrolling newborns, and funding the community partners program (CPP)
  • CPP doesn’t provide funding to community based organization, only provides enrollment
  • If my clinic could apply for state grants through the CPP program would be able to continue and expand services
  • Important of primary care medical home in addressing delays of care; medical home is a partnership where trusted physician partners with a family to establish regular and ongoing care among other private and public services
  • MCOs assists with care coordination but also required to identify a primary care provider to serve as a medical home for the patient
  • Importance of medical home for the 43% of children who are on Medicaid demonstrates an effective cost saving model
  • Robust outreach during covid including resources and toolkits for immunizations and back to office
  • Measures to separate symptomatic patients and well patients in clinic, used phone and EMR outreach,
  • rates of well care visits and immunizations have not fully recovered to pre-pandemic levels
  • seen that many factors for Texas health have increased during the pandemic such as stress; children coping with mental health issues at increasing rates
  • compared with 2019, proportion of mental health visits to the emergency ages 5-11 by 24%, ages 12-17 increased by 31% nationally
  • changes from and during COVID have led to increases in obesogenic factors for many demographics
  • Has affected my practice, every day identifying a child with anxiety or depression
  • Primary care such as well child visits are key to keeping children family, include immunizations, developmental screening, monitoring mental and behavioral health concern
  • Need your investment in the primary care system, now addressing mental and behavioral health concerns in offices, CPAN has strengthened ability to address mental health instead of having to refer patients out
  • Personal experience with CPAN such as identifying an ESL therapist for a deaf patient
  • Based on Medicaid data reported to CMS only 79% of children between 3-6 years old had a well care visit in 2018
  • Encourage committee to seek solutions that address full issue and not look just at pandemic
  • Urge committee not to pursue policies that fragment the primary care medical home
  • Older children and adolescents often come into the office for school required immunizations; very important for addressing mental and behavioral health concerns in these visits as some families don’t feel comfortable scheduling a sick visit for mental health
  • Fragmenting care to one off transactional exchange at pharmacies erodes progress to give families continuous care at primary care provider; patients have relationship with their primary care provider
  • Any policy approach should ensure it serves most vulnerable children
  • Most pharmacies are unwilling to participate in Texas’s vaccines for children program
  • Texas has struggled with influenza vaccinations based on need to improve rate would be supportive of a limited expansion of flu and COVID shots given at pharmacies to children down to the age of 3 if the pharmacies participate in the Texas vaccines for children program and provide vaccines equitably
  • Direct DSHS to implement a public health campaign to encourage Texans to get back to their health homes and see their doctor
  • Eliminate copays for primary care in employee and teacher retirement systems; eliminating copays reduces healthcare spending through reduced emergency room visits
  • Hold MCOs accountable for getting families into primary care; outreach should happen through texting to increase responses
  • Increase funding in states GME program and other education programs
  • Need to adequately compensate physicians in all areas of the state; address low Medicaid rates, need enough physicians enrolled in Medicaid
  • Texas has the second highest percentage of physicians who don’t participate in Medicaid; provider rates haven’t been raised in over 20 years
  • HHSC has recognized issue in 24-25 LAP exceptional item 12 with a consolidated rate request including wellness visits for kids and birth related and women health surgery
  • Should require payment parody for services via telehealth, must be on par with services provided in person
  • Guerra- Seems to be quite a bit of lack of coordination with hospitals during the pandemic; my son was scheduled to have a cancer surgery during the pandemic, and it was shut down; why does one hospital have a totally different attitude about certain conditions than other hospitals?
    • Dr. Kenneth Mitchell- I don’t think I will have a very satisfactory answer; no good playbook, there were widely varying city ordinances and different approaches about interpretation of orders during pandemic
    • Lots of fear on part of physicians in 2020, wide variation from systems and different counties had different needs
    • During early stages of lockdown weren’t truly defining what was elective; early on interpreted as only truly life-threatening procedures allow
  • Guerra- I gathered that after talking to numerous health providers across the state; only comment is that I hope in the future there is more discussion about what is considered elective
  • Klick- Guidelines as far as bed capacity can make an impact correct?
    • Yes there was guidance about how much bed capacity hospitals should reserve; before first wave hospitals were basically empty; in retrospect probably overreacting
  • Klick- also attempting to conserve PPE initially
    • Exactly right
  • Bucy- are we short on the number of pediatricians we need across the state? What can we do about that?
    • Smith- pre-pandemic only about 2/3 of kids getting good childcare; very multifactorial; depends on region like some rural areas that have real need for pediatricians
  • Preceptor program helps connect medical students to primary care early on in their career
  • Payment rates for Medicaid and CHIP very low, reimbursement codes don’t carry over for every code; need to pay people so they aren’t taking a loss; need consistent stable form of revenue for orgs and provider
  • Other states that have increased rates have resulted in number of providers who provide Medicaid increasing

 

Jack McCrary, Advanced Maternity Innovations  

  • Prenatal care issue in Texas, ranks 43rd in maternal deaths, 10.8% of livebirths premature, March of Dimes rating of a D; Each preterm birth cost Texas $62,000, total cost of $2.5 annually
  • Increasing quality issues for POC; preterm birth among black women is 46% higher than other demographics; Texas ranked as worst state for access to prenatal care by March of Dimes
  • Urge committee to consider telemedicine and remote fetal monitoring to deliver cost effective and quality health care
  • Marco analysis viewpoint show possibility of annual saving of $4.9 Bm supported by empirical evidence sourced from march of dimes, TMA¸ and others
  • No known data can account for influx of illegal aliens and changes in abortions laws
  • Texas mothers and babies should be treated with equality and reach the underserved
  • Capriglione- You said Texas has the fifth highest number of C sections, why is that?
    • Looking at the doctors the answer is that a lot of it has to do with patient choice, factors that create a situation in which a doctor or patient can choose timing, and that C sections pay more than vaginal deliveries
    • Dallas has second highest C second pay in the country
  • From the payer’s perspective there’s not an objective measure of the progress of induction in a patient; allows flexibility on determination of C section or vaginal delivery

 

Dr. Debra Patt, Texas Oncology  

  • 220 clinics across state, see 70,000 new cancer patients a year
  • Observe delays in screening that have led to delays in cancer diagnosis; first six months of pandemic cancer screening down 40-90% in breast, cervical, and rectal cancer screening
  • Saw subsequent delays in diagnosis, biopsies and surgeries, delays still exist today
  • Seeing more metastasis in breast cancer which increases mortality and chemotherapy
  • Takes time to manifest; mathematical modeling shows that in ten years there will be an increase in mortality by 12%
  • Should rethink how we consider other cancers like colorectal cancer
  • First time I see a patient see if they are eligible for emergency Medicaid program; opportunities there for cancer patients
  • Challenges in prior authorization that limits care because it delays care 7-28 days; need to ensure timeliness of prior authorization
  • Nursing shortages exacerbated by pandemic; legislature has taken real steps to reduce shortages and eliminate bottleneck to supply chain of nurses; some cancer clinics less operational because of staffing inadequacies
  • White bagging pharmaceuticals practices which is an alteration of normal process of care delivery; insurance might demand it to go through outside pharmacy and patients then have to pay at pharmacy and ship it to clinic where it is administered
  • This causes additional delays in care and this practice is being observed already
  • Telemedicine has really been helpful for care delivery, roughly 5-40% of our visits weekly; can save lives on telemedicine
  • Have hired virtual workforce for telemedicine including palliative care services

 

Tiffany Jones-Smith, Texas Kidney Foundation  

  • Chronic kidney disease (CKD)costs Texas $4.8 B per year
  • Study of over 52,000 adults from 2014-2019 adults show management ranged $7200-$11,879 and for stage 5 without renal replacement is $87,538 -$124,271
  • CKD can cause heart failure, stroke, myocardial infarction and the costs are in the tens of thousands
  • Foundation does early detection of kidney disease which is the way to stop kidney disease
  • National Medicare spending for CKD exceeded $120 B in 2017, 33.8% of total Medicare fees for service spending, on individual level annual spending was $16,000 and $19,000 for people with CKD and diabetes
  • Silent but deadly campaign is a 3-year initiative by foundation to screen 24,000 people and follow year over year to see progression of kidney disease; support from Bear country; should support this if wish to have impact on CKD
  • We are the little non-profit that could
  • Found a company called Healthy IO with a screening kit that could be taken at home and asks for 10,000 test kits for free; brought these tests and did resting from Feb 2- June 30 and tested 2,000 Texans with this test
  • Way to stop CKD is through early detection and non-profits are coming up with innovative ideas to solve this
  • Legislators should think about how this problem is front-loaded not identifying people early on in stages 1 and 2; communication breakdown with test results to patient from the doctor; should require doctors to test for kidney disease and report results
  • Should require DNA testing for transplant candidates who may have genetic allele for kidney disease; genetic link to descendants of west sub-Saharan Africa for kidney disease; in negotiations with company that makes test for the gene to bring it to Texas for free for the underserved
  • Point of care testing can also be done with a simple finger prick like community health centers and churches
  • Walle- Any cancer diagnosis is a difficult experience to go through but having it without health insurance compounds the stress and anxiety; do you have an idea as a percentage of how many folks come to you without health insurance?
    • Patt- I think it’s a moving target; a lot of sources to plug people in on what they qualify for; not the best use of healthcare resources even when you have communities that really rally around these patients
  • Walle- do you see folks with health insurance that delay care because of costs or other factors?
    • Yes, the rising cost of drugs in cancer care can make patients chose to not take a more appropriate low toxicity medicine because of cost
  • Walle- do you see some of these treatments are completely cost prohibitive even with health insurance?
    • It’s rare that it happens but it can happen; rarely do people avoid choosing the best medicine; but my practice has every patient see a financial counselor to identify funding resources so I’m sure it happens more in other places
  • Walle- Most of our patients want to go to a specific hospital in Houston; do you see differences in facilities or providers that provide different levels of care?
    • Care isn’t identical in different sites of service; my center has 70 clinical trials, a proton center etc.; but in my opinion we give the highest quality of cancer care that people can have
    • Real success in cancer care isn’t only survival but living on your terms and being able to be present in your family through getting great care in your community
    • Great partners in value; private clinics are half the cost of hospital cancer center
  • Capriglione- Are you saying some insurance companies want to direct patients somewhere else with white-bagging?
    • Generally we have all our providers under on roof and some of the drugs we are giving are biologic and can be toxic at high doses; when an insurance company mandates white-bagging they get a revenue benefit
  • Capriglione- so they must know a lot about the medication too, right?
    • The patient would give us their credit card information to pay for the biologic then it would be shipped to us to infuse
  • Capriglione- Wouldn’t it be more accessible to more patients if you did try to take cost into account?
    • The truth is that most of the time when you steer it doesn’t diminish cost just changes revenue for insurance and causes delays for care
  • Capriglione- wouldn’t it be better for the patient overall if the doctor administers the medication but doesn’t receive reimbursement for doing so
    • Yes you would like to think that there’s never any financial implication; but the supply chain of drug delivery is really complicated and to be able to purchase drugs and keep the right inventory it is very expensive
  • Capriglione- what is the percentage that is charged or reimbursed if you do it in the same clinic
    • I don’t know the answer to that question
  • Mitchell- for kidney disease there’s a family of medications that are doing a great job at slowing progre3ssion of kidney disease but the people that need them the most can’t afford them; prices out the underserved and its technically a built-in delay of care; could we not do something about that?
  • Capriglione- the market is finding ways to make medication cheaper, but it still seems to me that there is a lot of middlemen
    • It’s important to give cost saving when you can when it doesn’t disrupt care; in my line of work there are biologic similar that are sort of like a generic that are cost saving; not all healthcare institutions use these; need transparency
  • Capriglione- Wouldn’t transparency regarding the medication reimbursement amount be great
    • I totally agree with the idea of transparency; need to make sure it’s the same across all organizations; on average cancer care is half the cost in centers and we would be champions of transparency as long as it’s all the same across the board
  • Oliverson- Doctors aren’t authorized under the state of Texas to dispense medications in your office; they have to be dispensed by al licensed pharmacist; you are not able to bill for dispense for the medication under state law; to your point you have the genotype of this specific cancer and formulating these medications for the specific patient
  • Oliverson- delivery systems are specific to an individual person’s cancer cell; I think what we are talking about with the white bagging is barrier to being able to make adjustments on site
    • Yes and given dose intensity matters; we had a clinical trial that looked at us of immunotherapy and chemotherapy in specific deadly breast cancer and it was approved by the FDA
    • Impairing ability to do these real time adjustments by filling it at our pharmacy is not in the best interest of our patients
  • Oliverson- the cost between filling at affiliate PBM pharmacy and your pharmacy is not what this is about; there are few specialty pharmacies approved under most PBMs that aren’t owned by or affiliate of PBM; more about keeping all the eggs in one basket
  • Oliverson- what you are saying is that to give you the best shot of curing cancer I can at the same lower cost as a hospital center or PBM pharmacy adjust your medication on the fly and that may cure your cancer?
    • Right
  • Klick- can you weigh in on site neutral payment for chemo infusion?
    • chemotherapy costs half the price in a private clinic as it does in a hospital-based clinic for commercial payers so there’s a 2-4 fold difference depending on the center
  • Klick- and the care is pretty equivalent?
    • Certainly I think we provide the best quality of care in the communities; the thing that the hospitals provide that we don’t have is a lot of other ancillary services that we have to seek in our communities, but we have invested in some of those things in person and virtually
  • Klick- so it could reduce cost if we decided on a site neutral payment?
    • Yes

 

Dr. Jennifer Potter, UT Health San Antonio 

  • Grateful to have substance use disorder included in this conversation; it impacts our communities and we have more people living with addiction than we do have living with Alzheimer’s disease
  • Texas pays over $40 B annually to address addiction and we all see consequences of delays in addressing substance abuse in our day to day lives
  • There is a gene environment interactions that occur in the context of where we live and it can be generational; adverse life experiences can impact how genes respond
  • Social determinants of health have a tremendous impact on outcomes and cause delays of care
  • The complexity that Texas faces makes it useful to think of this as a public health framework; treatment piece is a small part of the issues that can guarantee a successful outcome
  • Don’t want people in hospitals want people in primary care setting and doing preventive work
  • Access for substance use disorders is a significant issue only 1 in 10 individuals with substance use disorder receive treatment in Texas and fewer get access to evidence based treatment; incidences in new so of Uvalde alcohol used disorder involved talks about intersection of substance use and all of the issues we care about elevating people lives
  • State dollars given to UT San Antonio for Be Well Texas; had unique opportunity to think of ourselves as the grout in a set of tiles if you will; trying to fill gaps in local systems and give them resource
  • We are underserved in terms of healthcare workforce than can treat substance use disorders so we provide training and education across the state through telemedicine so everyone has access to same quality of learning
  • Dispense funds to local communities to treat substance use disorder and provide training and technical assistance; can look at how state university system can help work to improve communities
  • Virtual clinics so people can be provided with telehealth treatment medication and therapy; medications can be mailed to their homes and we have no cost labs
  • All of this is funded on block grant dollars from the fed; looking at alternative payments

 

Titilope Fasipe, Texas Children’s Hospital  

  • Treat over 1200 children with sickle cell disease; complications been seen in any organ of the body and cause excruciating pain episodes; predominantly affects those of African descent
  • Sickle cell is the most common cause of stroke in children, estimated 100,000 people with sickle cell in the United States, lifespan is decades shorter than average
  • Nearly 5000 babies are born with sickle cell traits, but we don’t know how this affects the babies as they grow up
  • Details the history of sickle cell drug treatment in the United States and diagnosis
  • Need to address delayed care in sickle cell disease, children can live to adulthood if they receive comprehensive care
  • Gap of implementation of guidelines in treatment of sickle cell disease at multiple stages of disease; delays in vaccines, penicillin, and fever protocols lead to early death in childhood due to sepsis; delays in screening for risk of stroke
  • pediatric to adult care gap and adult providers are limited leading to premature mortality
  • national guidelines state that sickle cell should be triaged at a high level; essential to prevent death and disease
  • Recommendations from sickle cell task force and sickle cell advisory committee in Texas have led to a better understanding of how to improve care for sickle cell
  • asking for you to ensure every person with sickle cells in Texas has access to competent care; will require enacting health policy that reduces disparities and inequities and improves lifespan outcomes
  • Frank- looking at measured outcomes I really don’t see any good data on mental health diseases; is there any good data on how successful we are in the mental health arena or substance use?
    • There are quality indicators, but the challenge is that healthcare systems have not always embraced substance abuse disorders and mental health
    • There are two medications to treat opioid abuse disorder; data shows that these medications cut the mortality rate in half
  • Frank- I think there are parts of this that are a disease but it seems to me there are also differences but were using the same work for both things and I think it’s hard to reconcile
    • Issue is that with substance use disorder the choices that individual makes and consequences of addiction are pretty propound and associated with incarceration and family violence key is whether things precede the disorder
    • Would reject notion that we can’t treat this as a disease because we see neurological changes in the brain
  • Frank- when I look at the studies there’s a complete lack of hey here’s the way we treat it
    • You hit the nail on the head; we don’t have standards of treatment; industry is regulated heavy and many people don’t go to an evidence based program
    • Remember a lot of this co-occurs with a mental health disorders and is generational; much of it is a learned behavior and not necessarily a choice for children who grew up seeing substance use
  • Oliverson- can you expound on the evidence based and community based treatment? The social stigma is still there so people delay the treatment and sometimes think it’s a matter of will power; What were you talking about when you said evidence based treatments
    • We run the National Institute on Drug Abuse clinical trials network that is building a randomized trial treatment portfolio looking at medications to treat all types of substance abuse disease
    • Had a paper demonstrating first effective medication combination to address methamphetamine disorder
  • Oliverson- is it similar to Naltrexone?
    • They are different the two marijuana trials are first in class and not opioid antagonist
  • Oliverson- So these are treatments aimed to reduce recidivism which the frustrating thing with drug abuse disorders because it takes what it takes to get better; so when we are talking about highly addictive substances the recidivism rate is through the roof
    • All of these the primary outcome in the trials is abstinence and we do look at reduction as a secondary outcome; I would also include alcohol use disorder
  • Oliverson- Could you expound on treatments that are in the pipeline? Were close to a possible genetic cure for sickle cell so if we are just looking at this from a dollars perspective curing the disease is better than management of chronic disease; can you put a frame of reference on this?
    • We don’t know if these cure the disease permanently; 15 years is the official mark but so far these people are good;
    • Burden of sickle cell disease is huge but there will be people who wont meet criteria for a cure
  • Oliverson- what would that be
    • Bone marrow transplants are only available to those with a match in the family or matched donor; not available to the majority
    • With gene therapy you have to fix an abnormal gene to make healthier red blood cells but still have damaged sickle cell gene there
    • If you try to do a curative before too much therapy to your organs, you are more likely to be successful; eventually will drop the clinical trials age to young children
    • Still need two pronged approach with therapies and a cure hopefully; can manage with a good treatment plan but it’s a disease that has disparities
    • Currently 4 therapies for sickle cell and more are being developed
    • Gene therapy is very rigorous and complicated
  • Oliverson- So its also an expensive cure? How much?
    • Yes expensive. Many still in research trials, so no price
    • Thalassemia has been FDA approved, but not sure how to extrapolate for sickle cell
  • Oliverson- Thinks the state should get behind this. Seems obvious that if you can cure someone of a disease at a young age you should. Potentially could add to persons lifespan, or is that unreasonable?
    • That is like music to my ears, but still very utopian
    • Doctor mentioned the social determinants of health. Even with an FDA approved drug, the majority of people who could use it are not getting it
    • Comes back to those social determinants of health like stigma, lack of access to quality care
    • So many barriers. Shocking that we are still seeing strokes in children in America with the medical advancements we have
    • Born in Nigeria, where disparities are because of the healthcare resources they have access to. Understandable why this would cause these disparities
    • In America, we have the healthcare but people aren’t able to access it
    • There needs to be a multi-pronged approach to get all sickle cell patients a cure where and when they need it
    • Right now we need to focus on therapies to regulate the situations until we get to that point of “perfect” access to treatment for everyone
  • Oliverson- does the medical home model help overcome some of these doctors?
    • Yes. Exactly what we need for SC
    • Allows comprehensive care for each individual
    • Rural or urban communities without comprehensive centers can use telehealth to get them access to services
    • Still so much to discuss on this, but don’t want to take too much time
  • Oliverson- Of course. Maybe stop by my office, would love to work together on this. It sounds like we can cure this disease so we should.
    • This has been wonderful. Also grateful for Rep. Klick who has been very passionate about this topic
  • Bucy- Can you speak to the importance of HB 3673 from last session?
    • Last session it was wonderful to see that bill on paper
    • We don’t even know how many people in TX have the disease. Newborn screening is our best guess and its not thorough
    • That bill was trying to address how to account for stewardship for sickle cell in your sate
    • Not trying to promote the bill but explain it
    • Texas isn’t currently part of the CDC sickle cell data collection program
    • Important for understanding where focus and resources need to go and how we get to the point of curing the disease
  • Bucy- I appreciate that and I’m sure this committee will be in favor of supporting this cause

 

Carol Howe, American Diabetes Association

  • About 2.7 mil Texans live with diabetes, about 1/3 of adults have prediabetes
  • Cost of diabetes in Texas for 2017 exceeded $2 bil. If we looked at 2022 so far it would almost certainly surpass that 
  • Most people with pre diabetes don’t know they have it. Missed opportunity for preventative care 
  • Delay in diagnosing results in delay in care 
  • Most people find out they have it once they are presenting symptoms 
  • Patients with diabetes who don’t get regular care results in delay of care 
  • Example of patient who was brought to ER because of vomiting, headaches, slurring speech, confused. He was in a diabetic hyperglycemic state, meaning he had extremely high blood sugar
  • Several years prior to this the patient had been told by primary care doctor that he had high blood sugar. They gave him written info on how to care for himself. He had not returned for primary care since
  • Prevention and care would have made a huge difference in his situation
  • Believe that best approach is people having access to affordable and comprehensive care
  •  Opportunities to raise awareness and outreach offers, and connect people with marketplace health care plans
  • Some people qualify for federal tax credits making it affordable to the state
  • We have the power to make positive changes. Appreciative and impressed by the committee’s work and dedication

 

Alec Puente, American Heart Association 

  • Risk of dying of heart disease has increased by 4% since pre-pandemic 
  • Not distributed evenly. Black people have a 5-fold greater risk of dying from heart disease 
  • The pandemic disruption in routine care has contributed to this increase 
  • Even minute delays in care between having a heart attack or stroke and getting CPR or to the ER greatly impact chances of survival
  • Important to encourage Texans with chronic disease to seek regular care and establish relationships with health care providers
  • Want to thank rep Oliverson for support last session on policy to train all 911 operators on CPR coaching
  • Hope next session we can continue to uincreas4e the number of Texans who can provide CPR
  • Texas Cardiovascular disease and stroke council and Healthy heart for Texas are finalizing AHA legislative rec and would be a great resource for further information going into next session

 

Terry Wilcox, Patients Rising 

  • We urge that reasons for delays in patient care and the outcomes are investigated and corrected
  • Hard to think that when patients need care most, they can not be given the care they need due to barriers that are completely out of their control
  • Story of patient “Spencer”, who suffered from back pain and had to go through Step Therapy before being able to get an MRI
  • MRI showed a herniated disk that required surgery, but it was already too late. Spencer suffered nerve damage as a result of step therapy and continues to experience chronic pain
  • Story of patient “Betty” who suffered with chronic and acute sinusitis and after months of antibiotics it was determined she needed surgery.
  • Surgery scheduled for a month later, but was canceled at the last minute because doctor could not get prior authorization required from her insurance company
  • Pressure of increasing pharmacy prices. People having to spend more of their money on treatments or even abandon treatment due to lack of finances
  • Story of patient “Darla” whose specialty meds require a significant portion of her income. She had been able to receive copay assistance so that she could afford treatment, however in 2019 she learned the assistance she was getting no longer applied to her deductible
  • Darla’s insurer had implemented a copay accumulator. Her premium was already about $700 a month and her deductible was $8100 a month.
  • Small business owners (like Darla) are stuck with highest rates in the country and usually do not meet the thresholds for any support, leaving them functionally uninsured
  • The uncertainty with medication access and time spent coordinating with insurance caused Darla significant delays in accessing care
  • 14 states have passed legislation prohibiting this copay accumulator, some states like Texas have similar bills in their state legislature
  • In many instances states with no bans on these accumulators have far higher average premium increases than states who have implemented bans. Seems that there is little to no correlation, and that insurance premiums are increasing all around
  • Requiring patients to delay care, pay more up front, and go through inefficient processes does little to promote affordable and transparent care. It also certainly does not help patient outcomes
  • While coverage can’t be denied for pre-existing conditions, payers can make it nearly impossible to obtain coverage
  • Accessing available care is a challenge in itself at basic levels
  • Patients Rising Concierge is a service that helps get patients to the care they need. Transportation support and caregiving are the top things people need help with
  • Even when care is available it is not always affordable or accessible
  • Recommends a support service for those who have been denied Medicare eligibility and deferred to the marketplace
  • This committee can enact reforms that make quality care more affordable, accessible and transparent
  • Frank- What does the concierge service provide?
    • A lot of navigating to get patients to the right resources
    • It would be beneficial for the state to have one established program that connects all the smaller ones like our
  • Frank- There’s a lot of money to be made in confusion. Figuring out if its transparency or services like this that are beneficial is important.

 

Khrystal Davis, Texas Rare Alliance 

  • It takes an average of 7 years to get a rare diseases diagnosis, usually involving 2-3 misdiagnoses
  • Nearly 3 million Texans have a rare disease. People with rare diseases are hospitalized twice as often and are much longer
  • A quick and pre-symptomatic diagnosis will help decrease the delay in care rare disease patients experience
  • Suggests a three-pronged approach including expanding newborn screening, funding Project Baby Dillo, and providing funding to biomarker testing
  • Tx screens 400,000 newborns yearly
  • Can be improved by screening for conditions as they are added to the RUSP (and even before) and creating a place for pilot screening programs
  • TX is behind in screening for 3 conditions recently added to RUSP
  • Recommends one time funding of $4 mil for Project Baby Dillo to improve access to diagnoses for critically ill Texas newborns
  • Recommends providing coverage for precision medicine and biomarker testing to improve accuracy in getting the right diagnoses and treatment to the patient in a timely manner
  • Recommends maintaining the vendor drug program design for Medicaid and chip in the HHSC
  • Recommends Texas ban the use of QALY for rationing healthcare
  • Recommends more research in the rare disease community in Texas

 

 

Hannah Mehta, Protect TX Fragile Kids

  • Gives brief overview of pediatric medical complexity community statistics in Texas
  • Texas needs to be prepared for the number of families who provide hospital level care in home for their children to exponentially increase as a result of the recent Dobbs decision
  • Families need consistent supports for a stable medical baseline
  • Families can’t just go to the store to get necessary supplies for children with complex medical conditions. Access to critical supports and supplies can create significant delay in treatment and care for these children
  • Patients with the highest needs experience the largest gaps in access to services in Texas
  • It is not that Texas is lacking funds, but how taxpayer dollars are being used
  • The current system is not set up to support these children and families on a long term basis
  • These families have often been characterized as “complainers” always wanting more
  • The Dobbs decision will result in more children being born with disabilities and complex medical needs
  • State needs to shift from a one-size-fits-all attitude to a focused and detailed approach
  • In the next session the legislature should act to set up a directed payment program similar to what is currently in nursing homes for this population
  • The legislature should direct the agency to set up a phased implementation of an alternative model pilot through the Dell medical school
  • The legislature should also set up a neutral governance board through the Dell Medical School that reports back to the legislature

 

Jessica Boston, Texas Association for Homecare and Hospice 

  • The pandemic showed how homecare prevented delay in care and allowed more people to receive critical care
  • Workforce challenges across industries in Tx providers are less capable of providing services to children, seniors, and those with disabilities
  • THHA are facing worker shortage and increased cost for nursing and long term services
  • This is causing an issue with access to services for the medically fragile
  • The home healthcare industry is fighting to keep its doors open despite the demand for services being higher than ever

 

Cindy Weston, Texas Nurse Practitioners Association  

  • Delay in access to primary care is affecting all demographics in Texas
  • Recs increasing access to primary care workforce
  • Number of nurse practitioners continues to grow, and many are prepared in primary care
  • Delegation agreement is contributing to delay in care, many states have gotten rid of this agreement
  • Suggests this agreement be waived after a nurse practitioner has been working for a certain number of years
  • This could allow for lower healthcare costs for the state and an increase in healthcare workers
  • Healthcare programs can be created that integrate physical and mental health
  • Currently have funding for a program that combines primary care with mental health services
  • Gives example story of patient who was connected with a psychiatric nurse practitioner after seeing her primary care physician
  • Recommends continuing to advance value based transformative efforts, such as accountable care organizations and alternative payment models
  • Chair Harless- You mentioned states had lifted time period requirements. What is the time period?
    • Depends on state. Some states don’t have any delegation requirement.
  • Klick- During PHE the governor signed some waivers for PA’s and for nurse practitioners. Those are still in place?
    • That is correct
  • Klick- So no formal agreement is required is that true?
    • It is true the gov waived the requirement for a delegation. The TBN interpreted that as a direct response to the PHE, so they were narrower in their view of who that applied to and when
  • Klick- We have NP’s that work in military facilities that don’t have that requirement is that correct?
    • Yes. The VA, dept of defense, and all branches of military don’t have a delegation requirement
  • Klick- So removing this requirement is something we could do that would improve access to care but not be a hit to GR in the budget?
    • It’s a no cost solution
  • Klick- I think it’s time we let professionals do what they were trained and educated to do

 

Janith Mills, TAPA

  • Wants to improve outreach to families of children who are eligible for Medicaid or CHIP but are not enrolled, especially in rural areas
  • PA’s are well suited to provide high quality care to a broad group, and can be used to help resolve the delay of care
  • Mental health care for children is not often covered by Medicaid
  • Proposes three ways to help increase access to care through PA’s: Modernize relationship between the physician and PA, allow PA’s to become a managing partner in healthcare practices in which they are minority owners, and expand current delegated schedule to include the ambulatory outpatient setting