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The House Committee on Public Health met on September 13th to hear invited and public testimony on the following interim charges:

  • Monitor the agencies and programs under the Committee’s jurisdiction and oversee the implementation of relevant legislation passed by the 87th Legislature. Conduct active oversight of all associated rulemaking and other governmental actions taken to ensure the intended legislative outcome of all legislation, including the following:
    • HB 4 relating to the provision and delivery of telemedicine and telehealth services; and
    • HB 1616 relating to the Interstate Medical Licensure Compact.
  • Study the impact of fentanyl-related overdoses and deaths in Texas. Evaluate existing data collection, dissemination, and mitigation strategies regarding opioid abuse in Texas. Make recommendations to improve coordinated prevention, education, treatment, and data-sharing.
  • Study current telemedicine trends by assessing and making recommendations related to standardizing required documentation healthcare providers must obtain for consent for treatment, data collection, sharing and retention schedules, and providing telemedicine medical services to certain cancer patients receiving pain management services and supportive palliative care.

 

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

 

Opening Comments

  • Chair Klick – Will have a challenging two days of testimony, will be discussing fentanyl overdoses & looking for strategies and solutions, also data collection
  • Texas received $1.3b from the opioid settlement, legislature will be allocating roughly half @$700m

 

Study the impact of fentanyl-related overdoses and deaths in Texas.

Debbie Garza, Texas Pharmacy Association

  • Many issues center on fentanyl, much of which is illegally manufactured and distributed; understand that legal opioids are also an issue
  • Opioid prescriptions are required to be submitted to the Prescription Monitoring Program (PMP) so trends can be tracked in prescribers, pharmacists, and patients; required to check patient’s history before prescribing
  • Legislature funded enhancements to the PMP in 2019 to support EMR integration and NarxCare; NarxCare funding was removed from budget & hoping legislature restores this
  • HB 2174, omnibus opioid bill removed paper prescriptions, increased CE reqs, and mandated practitioners may not prescribe more than 10-day supply for acute pain
  • HB 2088 reqs written notice of safe disposal of opioid prescriptions
  • Retail pharmacies may collect unused prescriptions via voluntary collection receptacles with DEA registration & subject to requirements
  • Pharmacists also work with local LEOs for medication take-back programs
  • Recent legislation allows pharmacists to dispense opioid antagonists, incl. agents like Narcan; would support having a statewide standing order to make Naloxone more readily available
  • FDA extended shelf life for Narcan to three years
  • Pharmacist’s professional judgment is important when preventing opioid abuse; tools like the PMOP are important, but pharmacist judgment ensure proper use of the tools
  • Rep. Guerra – Keeping leftover opioids makes a person feel like a criminal, what can be done to make the public not feel like that? Drop offs at police stations, etc., can be very inconvenient
    • Pharmacists encourage not having those sitting around, legislation in 2019 was supposed to encourage pharmacists to tell patients about how to dispose
    • Many pharmacies likely have receptacles or can provide DisposeRx
  • Guerra – General public doesn’t feel at ease with options, needs to be more effort in advising the public, not sure if hospitals could help
    • Pharmacists would be happy to provide this info, FDA also publishes list of flushable medications
  • Guerra – Just don’t think the message is being relayed to the public
  • Rep. Collier – In Tarrant County there is a disposal mailer request program; appreciate safety precautions with opioid prescriptions, but what happens with a senior population who may misplace medications
    • Many times this is due to insurance company & how soon they will pay for a refill
    • There are processes to work around this, requires conversation with pharmacists and often doctors as well
    • FDA has proposed rules requiring mail backs for opioids, not sure of outcome yet but being discussed; comment period closed on June 21st
  • Rep. Jones – Are you making asks & what are they?
    • 1) legislature should fund NarxCare integration into PMP, TSBP submitted in the LAR and ~$500m, but this goes back to fees on licensees at times
    • 2) Pharmacists being able to assist with Screening, Brief Intervention, and Referral to Treatment (SBIRT) & being able to be reimbursed
  • Jones – Does that come with a cost?
    • It can, could come through insurance, Medicaid, etc.
    • Also asking for 3) a statewide standing order for Narcan, Naloxone, etc.
  • Zwiener – Difference in how Narcan is available now via the statewide order?
    • 2015 allowed for a physician standing order & TPA went and found this physician; part of req was CE, chains may have individual physicians and their own orders, but this is a process to go to
    • Statewide standing order would avoid the preliminary work
  • Zwiener – Who would show up for these agents under a standing order? Those experiencing bad effects or anticipating a reaction?
    • It is a mix, could also be children having bad reactions to opioids
    • For acute or chronic pain, etc.
    • Part of counseling from the pharmacist on new opioid prescriptions
    • Challenge is whether insurance will pay for it, has been a debate
  • Zwiener – Highlights Hayes and significant impact from opioids, what happens when parents want to have Narcan on hand? What is the price?
    • They pay for it, ranges from $75-$125
  • Zwiener – So people can get it, but relatively expensive for a “just in case”
    • And need a standing order, would be easier with a statewide order

 

Brady Mills, DPS

  • Provides overview of DPS drug enforcement operations; seeing material coming in from overseas, fentanyl is produced in Mexico and then shipped to Texas
  • Have seen significant increase in cases from 2019 to 2022; in 2019, very often coming in through clandestine tablets of high quality, from 2020 to now often seen in form of Oxycodone tablets
  • Also seen mixed with other illicit drugs; doses of tablets vary widely
  • Saw drastic increase in cases in 2022, seeing more end user cases in state
  • Partnered with DEA to determine levels of fentanyl in tablets, seeing close to lethal doses in some tablets
  • No state repository for testing data, looking at publishing data to DPS website; could collect data from state, federal, and county sources if reported to DPS
  • Chair Klick – Can you explain what carfentanyl is?
    • Legitimate uses for pain management, carfentanyl is 10x stronger
  • Chair Klick – No quality control on the manufacture of these tablets, doses vary
  • Chair Klick – Have you seen evidence or heard stories from LEOs that some products are in mail and may not be legitimate products
    • Have seen some through the mail, but mostly federal activity
  • Chair Klick – Data aggregation?
    • Aggregate crime records, not doing it for seizures
  • Chair Klick Different agencies at the federal level, etc. aggregate data but we don’t; could identify larger problems if data was aggregated
  • Rep. Smith – Methamphetamine compared to fentanyl samples?
    • Do about 55k tests per year, still seeing powders like methamphetamine and cocaine, but seeing illicit pill numbers escalate dramatically
  • Smith – So there has been a huge increase over last 5 years
    • Yes, seeing an escalation just from 2019 to 2022
  • Zwiener – Are you seeing any change from 2021 to 2022? Heard anecdotally about valium lookalikes, etc.
    • Don’t have the data on this yet, still working with DEA
    • Numbers now based on total cases where fentanyl was identified
    • Predominantly seeing hydrocodone, oxycodone, and acetaminophen
  • Zwiener – Is there any indication that something like test strip availability would change behavior?
    • Test strips would allow people to know if fentanyl was present
    • Other piece is messaging about only taking drugs from pharmacies
  • Chair Klick – These look like legitimate pharmaceutical products
    • Yes, look very like real pills, hard to determine until tested
  • Jones – Seeing fentanyl, oxycodone, hydrocodone, etc. in Harris County; seeing issues with criminalizing addicts, many don’t understand these aren’t prescription drugs
  • Jones – Need to do some kind of education, but won’t stop addicts; need to figure out how to separate the addicts from the perpetrators making the drugs, what would this cost?
    • Looking at building recommendations now
    • DPS is keeping up with drug cases in the lab, not specifically asking at this time
  • Chair Klick – Problem has become so common, does not only affect users, but also those who think they are getting legitimate pills

 

Lisa Wyman, DSHS

  • Speaking on overdoses and death certificates
  • Provides overview of death certificate coding in Texas, medical examiners or JOPs determine causes of death, data is examined by CDC, rates of deaths by demographics, etc.
  • 80% of unintentional fentanyl deaths involve unrelated drugs, benzodiazepines contribute
  • Collier – How is this impacting people of color?
    • Roughly half of all unintentional deaths are occurring in people of color
  • Collier – Fentanyl is a pain management drug, how is it being manufactured?
    • First drugs were skin patches, but for unintentional deaths the individual thinks it is something else
  • Collier – alone it is deadly
    • Alone it is deadly, worse when mixed with cocaine, etc.
  • Collier – Have you looked at where these deaths are occurring?
    • Haven’t, but can look at this
  • Zwiener – How confident are you that you’re collecting most of the deaths given most counties don’t have a medical examiner?
    • Gold standard is toxicology report
    • No ICD-10 code for fentanyl, needs to be listed on the death certificate for DSHS to count it; examiners need to be know how to document this on the certificate
  • Zwiener – Any concern wer’re not capturing deaths?
    • Part of the overall challenge Texas faces with not having medical examiners, could be miscounting or not counting fentanyl-related deaths
  • Zwiener – If these aren’t counted, what type of ways would the death be reported?
    • Good question, can get back to you
  • Jones – Sometimes clients with drug cases will have samples sent to the lab, but toxicology reports aren’t done; sometimes LEOs will submit to DSHS, this takes time
  • Jones – DPS probably doesn’t have the capacity to run toxicology on unexpected deaths; can’t figure out a solution unless we know the numbers we’re dealing with, is there something we can do to require toxicology or tests?
    • DSHS has done outreach in the past to educate on how to fill out certificates better, still more education that can be done
    • Because fentanyl is not its own ICD-10 code, need to look at the certificates
  • Jones – ICD-10?
    • International Classes of Distinction, allows for coding the death certificate with cause of death, but certificate needs to be filled out properly
  • Jones – Who generates the codes?
    • National Center for Health Statistics
  • Jones – Is there a way for us to get a code for this? Seems to me there should be a code
    • Agrees, currently gets coded under synthetic opioids
  • Chair Klick – Also use ICD-9 on other claim forms, etc.; more than just death certificates

 

Brad Fitzwater, HHSC

  • Link to presentation
  • Ultimate source of ICD coding is the World Health Organization
  • Overdoses in TX have risen sharply over recent years, deaths from opioids overall seem to be static but remain at a high level
  • Treatment of choice for opioid use disorder is medication and psychosocial supports, medication decreases overdose, death rates, relapse, withdrawal, criminal justice involvement, etc.
  • Jones – Medication and psychosocial supports?
    • Medication and behavioral health support, proper place to recover, etc.
  • Jones – Does insurance pay for that?
    • Still hit and miss, most insurance companies have some sort of coverage due to parity laws, but degree and criteria varies
  • Zwiener – Do you have data on how much of this problem is related to addiction, mistakes in use, accidental use, etc.?
    • Don’t believe we have this data
  • Zwiener – Is that findable data?
    • Unsure, have talked about this with statistics agencies

 

Kasey Strey, HHSC

  • Provides overview of HHSC’s Texas Targeted Opioid Response (TTOR), started in 2017 to expand access to services for groups at higher risk for opioid use disorders, incl. those in rural areas, those using multiple substances, and those with historically low access to services
  • Prevention, intervention, integrated treatment, and recovery are the focuses for opioid treatment
  • Presents map on services available throughout the state, prevention services are available statewide
  • TTOR run Opioid Misuse Public Awareness Campaign on opioid use dangers and treatment, will be updating website
  • TTOR has expanded access to services for opioid use disorder, roughly 70% have access to services in their area
  • Campos – Had surgery and practitioners made a large number of opioids available, too easy to get access to these medications
    • TTOR offers free CME medical, pharmacy, and social work training units trying to get at this issue
  • Jones – In the legal profession, get to pick CLE courses, could be a requirement
    • Fitzwater, HHSC – There was a bill with a requirement from the TMB for 2 hours of opioid CME, supposed to cover interaction with patients in prescribing opioids
  • Jones – So it already exists?
    • CME requirement is there through TMB
  • Zwiener – So you’re programs are mostly focused on addiction rather than accidental or mistaken use?
    • Trying to address all three aspects, accidental or recreational use is addressed more in front-end prevention
  • Zwiener – Do you feel like you have the resources needed from us to do the work?
    • Could always go further and do more, but do have funds to do a good amount of work
  • Zwiener – Naloxone program running out of money? Did this affect you?
    • Did run out of funds first quarter this year, but contract was extended and increased

 

Jennifer Sharpe Potter, UT Health Science Center San Antonio

  • Not just a fentanyl issue, is an overdose and substance abuse crisis in TX
  • Failed to implement tools to mitigate overdose deaths and other issues in time
  • 1 in 5 people will try illicit drugs, but most don’t develop an addiction, only 10% of these will receive treatment, even fewer with access to evidence-based treatment
  • Urges consideration of science-based, comprehensive approach; will not be successful relying only on health and criminal justice systems
  • Have a problem with contaminated illicit drugs; funding is important and deaths can be prevented
  • Fentanyl test strips are a simple countermeasure to allow individuals to test medications
  • Highlights morenarcan.com,
  • Jones – Asks for the number to access free services?
    • HHSC can provide, highlights morenarcan.com that can assist with individuals or entities wanting Narcan/Naloxone
  • Jones – Shares experience with client in AA; there is a lot of education needed
    • Highlights situations where a parent was able to speak to a peer and receive assistance
    • Peer recovery services are a great example of wraparounds
  • Rep. Price – Have made a lot of progress in recognizing the problem, what is the existing rationale behind current prohibited use or possession of testing strips? Perhaps outdated
    • Collected under drug paraphernalia, but misses mark of what test strips are supposed to do; might be time to see this as something preventing an unwanted death
  • Price – State or federal?
    • Neighbor states can distribute test strips, not a lawyer
    • Not outside the norm for test strips to be used and LEOs look the other way; not sure the prohibition is offering any value
  • Zwiener – Problem is growing, what are getting wrong?
    • Many resources available now, but still struggling to get evidence-based practices out there
    • Have access issues in TX, HHSC has focused on evidence-based practices, scaling is complicated
    • Deaths we’re seeing now are not what we saw in 2005, now in “third wave” of overdose crisis which combines stimulant use and fentanyl use deaths; if we don’t move with trends, then always behind the curve
    • Not a prescription problem anymore, illicit drug use problem
  • Zwiener – So need to address demand side as well?
    • Looks at this differently, not possible to eliminate drugs, more important to navigate behavioral health issues, shame and stigma on seeking help
  • Zwiener – Are there models you could point us to? What makes it more challenging?
    • Number of adolescent and childhood programs not fully implemented in Texas, opportunities to expand on prevention side
    • Need to understand some will develop problems and treatment infrastructure is needed
    • At state level, get into silos and resources are difficult to leverage quickly
    • Data sharing is a challenge
  • Zwiener – If every provider knew evidence-based practices, do we have enough providers?
    • One of the challenges is number of providers, can address this but is complicated by stigma in the community and practice under licensure
  • Jones – Can you explain licenses?
    • For example, prescribing medications is complicated, need to encourage practitioners to use this ability under their licenses
    • The more we have people operating and treating, the better it gets
  • Jones – Does treating mean prescribing medication?
    • Can mean a lot of things, for opioids the only evidence-based treatment we have is medication; in other cases this is psychosocial
    • Hoping for more evidence-based treatment for cocaine and methamphetamine as well

 

Texas Medical Association

  • TMA has dedicated the last decade to finding solutions
  • Focused on illegally manufactured fentanyl; chemists are coming up with new drugs many times more powerful than fentanyl
  • Last decade the problem was overprescribing, this decade we are underprescribing
  • 3 groups are using: 1) those who choose to take it not knowing risks, 2) chronic pain patients, and 3) substance use disorders; ratio depends on part of state & population mix
  • Provides examples of overdose & death in each of these three groups
  • 3 groups are seeing issues via different ways; physicians are afraid to prescribe, some are not getting pain medications and looking for other solutions
  • Realizing there are 3 groups, it is time to change course; 8 recommendations in written testimony, will be talking about 3
  • Should establish workgroup to revisit current law on pain management clinics and inspections; guardrails were needed 12 years ago, but not now, now have the PMP
  • Should implement syringe service programs, safe method to attack substance abuse disorders
  • Should fund physicians accessing the PMP & should look at data software comparing pharmacy sales to pharmacy purchases
  • Should improve education & prevention programs, provide access to test strips, seek funding for overdoses out of ARPA, support data collection, push to update ICD codes

 

Brittney Jones, BayMark Health Services

  • Provides overview of BayMark, large substance abuse service organization providing Medication Assisted Treatment (MAP) that combines medication with psychosocial treatment
  • Reimbursement is low in TX for opioid treatment programs and does not cover costs; should provide adequate reimbursement for Opioid Treatment Programs (OTPs), parity with in-house administration
  • TX also limits ability of OTPs to provide buprenorphine treatments & limits certain services to physicians
  • Should lift state restrictions to allow APRNs, PAs, etc. to provide certain services under a medical director
  • Should remove state residency requirement for OTP staff to allow those from other states to work in TX
  • Collier – Difficulties recruiting & maintaining doctors?
    • Doctors need state driver’s license, must give up out-of-state licenses
  • Collier – Any other positions a medical doctor needs to give up their license in other states? Need to relinquish out of state license to run OTP?
    • Yes, not sure on other positions

 

Public Testimony

Becky Stewart, A Change for Cam

  • Son passed away from mistaken fentanyl ingestion
  • State is failing to educate schools and students; can reach students with a minimal investment of time
  • Free resources and curriculums are available
  • Collier and Stewart discuss importance of educating students, programs in schools
  • Collier – Text programs that connect students to counselors?
    • Encourage students to reach out, educate students to contact staff, etc.

 

Kevin Roy, Shatterproof

  • Advocacy group that supports access to treatment, reducing stigma, and resources for families
  • Cases are rising significantly, has been exacerbated by COVID, increased access to fentanyl
  • Data collection is key, naloxone access is important; must get to root of problem through prevention, youth prevention programs build resiliency and coping strategies & have multi-generational effect
  • Need to look at how public health and public safety work together
  • Zwiener – can you talk about good evidence-based education programs?
    • Highlights Communities That Care program, idea is to engage the whole community, not just school or media messaging

 

Individual, Stericycle

  • Speaking on drug takeback programs; getting people to get rid of drugs they no longer need is essential, but not enough to educate
  • Expanding permanent collection locations is a tangible prevention measure Texas can implement

 

Cynthia Humphrey, Association of Substance Abuse Programs

  • Shares experience with opioid use and recovery
  • Evidence-based peer support services are important, state needs to invest

 

Stephanie Turner, Self

  • Son passed away from fentanyl in 2021
  • Need assistance, no required drug curriculum in schools; should have Narcan in schools
  • Jones and Turner discuss coping strategies
  • Jones – Not an easy “just say no” situation
  • Collier – After the first one it changes the chemical composition, alters judgment; need prevention
    • It happens quickly, affects the lives of numerous students

 

Maggie Luna, Center for Justice and Equity

  • Shares experience with opioid use and recovery; peer supports were the beginning of recovery
  • Need to work to keep people alive until they are ready for help

 

Dr. Monica Dyer, Yanawana Herbolarios

  • Yanawana Herbolarios is a nonprofit providing clinical care and other services in San Antonio
  • Addiction is possible to treat, stigma surrounding addiction is harming access to treatment
  • Genetic risk, environmental and social determinants, etc. influence risk of addiction
  • More Narcan Please needs to be funded or improved
  • Syringe exchange needs to be expanded
  • Test strips are essential for preventing deaths
  • Collier – Who do you propose would use test strips? Users? Medical professionals?
    • For someone who is not intending to take fentanyl
  • Collier – Just don’t want test strips to be the only answer; needs to be in conjunction with other solutions
  • Jones – Occurrence of positive/negative in test strips? Other witness stated part of a pill may not have fentanyl present
    • Pills are mixed together, press the mixture together
  • Jones and Dyer discuss testing pills and presence of fentanyl in pills
  • Jones – Your asks are expanded Narcan access, syringe exchange, test strips, and opioid use screening?
    • Yes

 

Steven Smith, Texas Harm Reduction Alliance

  • Highlights issues with obtaining services, services require ID and often it is difficult for opioid users to obtain appropriate IDs
  • Harm reduction works, individuals need more access to housing, methadone, MAP, etc.
  • Zwiener – Where are the best investments for the state?
    • Outreach and harm reduction supplies
  • Zwiener – What limits what you’re able to do?
    • Can’t do a syringe exchange, helps to open conversations
  • Jones – What are harm reduction supplies?
    • Clean syringes, lead pipes, stims, band aids, etc.

 

Paulette Soltani, Texas Harm Reduction Alliance

  • People THRA serves are impacted by drug war, mass incarceration, lack of access, housing, etc.
  • Asks are 10 authorizing fentanyl testing strips to distribute these across Texas, 2) authorizing syringe exchange programs, 3) expanded naloxone access & availability

 

Britney Ackerson, Corazon Ministries

  • Fentanyl is one piece of the overall overdose issue
  • Shares experience with opioid use and recovery; lack of mental health care led to unaddressed trauma
  • Treatment, judicial, housing, etc. systems are all broken and intertwine to block access to proper care
  • Need more access to harm reduction supplies, including safe smoke kits, safe sex kits, Narcan
  • Need access to long-term mental health care services
  • Jones – Bigger than fentanyl, people will seek whatever makes them comfortable

 

Madeline Santibañez, Corazon Ministries

  • Highlights need for constant contact with clients, long-term support, dignity & respect, additional beds, etc.
  • Harm reduction works, allowed Corazon to get hundreds into detox and treatment
  • Zwiener – Scale of need for beds?
    • Looking for 10x the number, large need for placements & 30 detox beds isn’t enough
  • Need to work to remove silos, work together with mental health institutions

 

Sarah Reyes, Texas Center for Justice and Equity

  • Drug paraphernalia is a state level law that needs to be changed, last session HB 1178 proposed to remove the penalty
  • Should fund trauma-informed and evidence-based drug treatment programs instead of mandatory programs through judicial system, decriminalize paraphernalia and possession, expand state’s 9-1-1 good Samaritan line, increase funding for Narcan, increase education, improve MAP access, expand Medicaid, include people with lived experience
  • Jones – What would you put in place of SAFE drug programs?
    • Counselors in the SAFE P program did not seem to care, should remove long period of ineffective therapy, e.g. very large group therapy sessions, aftercare was not being provided
    • Interviewing professionals to inform recommendations on improving SAFE P
  • Jones – Don’t hear much testimony at hearings from end users of state systems; do we get evidence-based info or studies
    • Chair Klick – We do get evidence-based information periodically, agencies we have oversight over do provide testimony
  • Jones and Klick discuss witnesses providing testimony, Klick notes that invited and public testimony is available & any member of the public can come speak

 

Scott Dionne, Self

  • Did not get any help while incarcerated; started recovery after needing Narcan and using fentanyl
  • Need education in schools to cover gaps, education and resources are not available
  • Jones – Only ask for more funding for harm reduction?
    • And education for students, testing strips, etc., also detox beds and treatment centers; all work hand in hand
  • Jones – Was led you to recovery?
    • Didn’t know about the resources available to help, went into detox as soon as I found out

 

Sam Mayfield, Texans for Strong Borders

  • Fentanyl is being trafficked into the country from China via the Texas-Mexico border, crisis extends beyond border cities

 

Jake Nyder, Parker County Conservatives

  • Fentanyl crisis is a symptom of the unsecure border, cartels are weaponizing migrants to traffic fentanyl

 

HB 4 relating to the provision and delivery of telemedicine and telehealth services

Emily Zalkovsky, HHSC

  • Link to presentation
  • HB 4 continues remote services started during the PHE indefinitely, MCOs to determine which services can be delivered so long as they do not deny required services
  • HHSC report will be coming out later this year
  • Highlights phased implementation on Slide 6, 4 phases, HHSC has implemented up to Phase 3 and is working on Phase 4 this Fall
  • Framework for assessing remote services on slide 8, incl. clinical effectiveness, cost effectiveness, health & safety, client choice & access, federal/state law
  • Audio-only behavioral health services key component of the bill
  • FFS policy changes listed on slide 11, new behavioral health policy changes on slide 12
  • Slide 14 highlights telecommunications for clients of chemical dependent treatment facilities, incl. intake, screening, and assessments, effective as of 3/3/22
  • Allows rural health clinics to bill telemedicine and telehealth services as a distant site on an ongoing basis, effective as of April 2022
  • Planning to allow use of a/v telehealth for service coordination, initial and annual assessments must be in person
  • Attendant care, etc. also required to be done in person
  • HB 4 also required HHSC to adopt and publish guidance for MCOs to communicate with members via text, initially issued December 2021 and revised April 2022
  • Looking at home telemonitoring services that could be covered as well
  • Chair Klick – Do we have a list of allowed services?
    • We do, incl. diabetes, etc.
  • Chair Klick – What about home dialysis?
    • Not allowed in Medicaid policy
  • Chair Klick – Heart conditions, etc., could be looking at other conditions that need monitoring
    • We are looking at cost savings, etc.
  • Because network adequacy standards are based on time and distance, taking telehealth services into account for network adequacy gaps
  • Will continue to engage with stakeholders, 2 rules still moving through the process and will be looking at those as well
  • Price – Which assessment meetings would not be required to be in person?
    • Change in condition that wouldn’t lead to change in level of care or cost ceiling, e.g. change in nursing hours that wouldn’t change the RUG level
    • Level 3 STAR+PLUS
    • For STAR Kids there is a minimum of 1 in person assessment, 3 annual telephonic
    • For STAR Kids Level 2, there was one annual in person, other can now be done telephonic
    • For STAR Kids Level 1, one annual and others can be A/V unless RUG change is required
    • Client can always request in person
  • Price – Highest level of service coordination at Level 1 is MDCP, so face to face every quarter?
    • Would be once per year, other 3 visits could be A/V
  • Price – All annual assessment have to be face to face?
    • For STAR+PLUS level 3, there is no in person requirement as they are not receiving in person attendant services
  • Price – Virtual assessments are allowed under all 3 levels under STAR Kids and STAR+PLUS
    • Assessments are the yearly in-person for waivers, attendants, etc., unless another in person is needed due to RUG change, etc.
    • Service coordination can be virtual
    • If there are 4 visits required per year, one is an assessment which is in-person and others can be remote
  • Price – You mentioned difference between FFS and MCOs, are reqs same depending?
    • STAR Kids and STAR+PLUS are all managed care
    • IDD waiver assessments differ by program
  • Price – I’ve read some of the MCOs have been performing virtual assessments during the PHE, 80-90% of STAR Kids and 40% of other clients using virtual services?
    • Can look at data and get back to you
  • Price – Will everyone need an in-person assessment when the PHE ends?
    • Yes, have been talking about this with health plans on timing
    • Working through how long they will have for compliance, etc. that will be shared
  • Price – Will be a need for additional RNs at this time?
    • They may need to hire more people, depends plan by plan
  • Price – How much will it cost?
    • Don’t have numbers, shouldn’t be a difference pre-pandemic to now as everything was in-person before
  • Price – What services in the clinical and cost assessments turned out to be ineffective?
    • Asked CMS for guidance, CMS stated that the state has to get enough info to meet reqs, look at tools that need to be in-person, observation, mobility, etc. were factors
  • Price – Can understand circumstances where in-person assessments are necessary, but other assessments like environment could be virtual
    • Some questions could be done A/V, but overall some of the questions wouldn’t be clinically effective
  • Price – This would be primarily in MDCP/Level 1?
    • Incl. attendants for daily living
  • Price – Encourage you to use CMS guidance to create a flexible system
    • Will continue to look at this as rules are finalized
  • Chair Klick – Do you consider assessments to be clinical?
    • Will need to refer that back, service coordinator is not the provider but looking at a lot of clinical info
  • Chair Klick – Difficult to find nurses right now, paying a lot more for them
  • Price – How many clients within each group prefer virtual?
    • Not sure, can see if data is available on this
    • Know how many assessments health plans have been doing virtually, but not sure what the preference would be post-COVID
  • Collier – In-person assessments for equipment? I go to the doctor’s location and they ask me what equipment I have at home?
    • This is for LTSS waiver services, asking about equipment in the home
  • Collier – So provider would go to the home and observe
    • Would be the service coordinator who works for the health plan, usually a nurse
  • Collier – They do this once?
    • That would be the once a year assessment, unless a change in condition is needed
  • Collier – Agrees with what Rep. Price said

 

Jessica Lynch, Texas Association of Health Plans

  • Missed opportunity with HB 4 and requirement that only assessments need to be in-person
  • Learned that telehealth is a safe and effective way to provide service coordination and assessments
  • HHSC’s rules don’t fully take advantage of opportunity to fully modernize service coordination & ignore preference of families to continue with virtual service coordination
  • Plans are experiencing resistance to face to face visits now that families are accustomed to remote service coordination
  • Delays and cancellations for in-person visits will negatively impact access and eligibility
  • Over 80% of STAR Kids families, incl. MDCP families, have been choosing telehealth for service coordination
  • Telehealth eases workforce burden by allowing plans to more easily meet needs; shifting assessments to in person would require plans to hire more and increase costs
  • Price – Expense of providing the assessments will be higher?
    • Will need more nurses, even after PHE ends and we unwind members; still anticipate more members than we had pre-pandemic
    • Will also likely see adjustments to who fills in levels of care categories, more members will likely be in Level 1 initially until they settle somewhere else
  • Guerra – Spoke with hospital nurse recently who said that many newly hired nurses are being paid more than doctors; how will this work given the need?
    • Have heard a lot of anecdotal stories which is what TAHP is worried about
    • HHSC has been working with health plans to determine impact of hiring
    • Ramp up will take 6-12 months
  • Guerra – Impact of that?
    • Diverting nurses away from clinical care
  • Chair Klick – Will be discussing nursing and health care workforce tomorrow
  • Collier – Suggesting that requiring in-person visits are onerous or possibly not necessary? If so, when should we have in-person visits? Do health care providers get reimbursed the same amount
    • Reimbursements are the same, cost savings are on transportation & speed of and access to assessments
    • Can all agree that initial assessment is appropriate in-person; expectation of plans after that was that in-person decision was made between member and plan
  • Collier – Doesn’t the state also have a duty to be good stewards of taxpayer dollars?
    • Absolutely, HHSC looks at MCOs to see if we are meeting that duty
  • Collier – So 1 is in-person
    • 1 in-person initial assessment and reassessments in-person for STAR Kids
  • Collier – Why would MDCP children need to be in-person?
    • Population that is using telemedicine the most
  • Collier – MDCP should be eligible for telehealth
    • Agrees; service coordination involves speaking to attendants, nurses, etc., not exclusively relying on video screens & can supplement assessments through telehealth
  • Collier – HHSC has flexibility has ability to listen and make recommendations based on feedback?
    • Yes
  • Collier – They’ll get the same reimbursement & there are savings via transportation; have you identified where you can use those dollars to improve care?
    • Yes, certainly if it is a long-term proposal
    • Also a cost savings in the ability to do assessments back to back, some are 5 minutes long and can do multiple within the travel time
  • If telehealth is considered safe & effective for medical & psychiatric care, should be safe & effective for assessments that are not clinical
  • TAHP is recommending that telehealth be allowed for these assessments; have improved outcomes & will help with nursing workforce shortage; families should choose
  • Price – Wanted to confirm, written testimony states that there is no evidence that telehealth assessment is detrimental to health & in-person visits could impose greater risk for those who have high risk of complications from communicable disease; you don’t have any evidence?
    • Not that I’ve heard
    • Opportunity through remote services has seen interaction skyrocket; evidence points to telehealth being the safer, more effective way to see members

 

Nora Belcher, Texas e-Health Alliance

  • Policy and technology has been moving forward to improve remote services; HHSC embraced tools during the early pandemic
  • Telehealth has become a way to preserve access and continuity of care; now thinking about continuity of care as virtual care, 2-3 years spent using these services
  • Don’t want PHE to end and have people cut off from services
  • Clinical effectiveness is an important standard, can be met; need to look at total cost of care and not just number of visits being provided
  • Need to ensure broadband gets everywhere it needs to be
  • HB 4 fits in with work on mental health services, but telehealth doesn’t create providers & workforce shortage discussion is important
  • Understand not everything can be virtual
  • Need to continue to integrate services, keeps people out of higher cost care; medical need keeps growing
  • Price – Language of the bill was designed to build in as much future flexibility as possible within bounds of federal law; do you think we’re going far enough, are we headed the right direction, does anything need to change?
    • Remote patient monitoring is one area where statute is very explicit & not necessarily in the best interest of the patient; did not get into this with HB 4 as it wasn’t a COVID flexibility
    • Restricting liability to negotiated conditions in the home isn’t appropriate for 2022
    • New tech is also coming out, incl. prescription digital therapeutics
    • Committee could help figure out framework for these things
  • Chair Klick – During the pandemic we were doing hospital at home & using telemonitoring to free up beds; not only freed beds, but also costs
    • Time to revisit this benefit, FQHCs, hospitals, etc. could participate
    • As long as the focus is on keeping people out of higher cost levels of care, could do good things for patients and families

 

Monitor HB 1616 relating to the Interstate Medical Licensure Compact

Dr. Welela Tereffe, MD Anderson

  • Provides overview of Compact, 37 states, incl. D.C., have joined the compact
  • TMB activated portal in March 2022
  • Compact reduces admin burden on doctors and hospitals
  • Withdrawal of PHE emergency waivers would mean care couldn’t continue without enrolling physicians from other states; streamlined admin process has generated great enthusiasm among physicians
  • Strategic plan is to obtain licensure in 14 states, most of which border Texas, others that have potential to benefit from services via MD Anderson
  • Streamlining delivers tremendous cost savings, 1st year savings of $7m
  • Practicing medicine across state lines is complex, legal office has been robustly analyzing telemedicine regulations to create a guide for physicians practicing out of Texas
  • Texas patients have been the greatest users of virtual care since the start of the PHE; stand up of virtual services benefits Texans
  • Proportion of patients receiving cancer care at MD Anderson has increased by 5%

 

Brint Carlton, Texas Medical Board

  • HB 1616 has allowed for faster licenses, currently turnaround is 9 days
  • Letter of Qualification can take more time to issue due to need to meet Compact requirements, currently 24 days & exploring options to reduce

 

Public Testimony

Dr. Matthew Brimberry, Hospice Medical Director, Austin Geriatrics

  • Speaking on the Compassionate Use Program
  • Should expand current program to additional conditions and raise cap on percentage of THC by weight
  • Chair Klick and Brimberry discuss side effects from other drugs, benefits of cannabinoids & how doctors monitor usage
  • Chair Klick – Have strived to keep doctors making the decisions on cannabinoids
    • Opioids are readily available, with Compassionate Use caregiver needs to drive to Austin; need more delivery spots

 

Mike Thompson, Self

  • Compassionate Use patient; program greatly helped with recovery from cancer, originally prescribed opioids but had significant negative impacts on quality of life
  • Should give physicians full discretion over course of treatment under the program
  • THC cap is burdensome, requires patients to take large volumes to achieve desired effects
  • Not allowed to store medication overnight and can cause issues with patient pickup, e.g. patient in El Paso, transporter needs to drive to Austin and back and patient must pick up promptly

 

Study current telemedicine trends by assessing and making recommendations related to standardizing required documentation healthcare providers must obtain for consent for treatment, data collection, sharing and retention schedules, and providing telemedicine medical services to certain cancer patients receiving pain management services and supportive palliative care.

Dr. Welela Tereffe, MD Anderson

  • Speaking on Rider 10 from the 2021-22, telemedicine pilot through MD Anderson for delivery of services to cancer patients with serious palliative care needs, incl. opioid pain management
  • Also included expectation that reports were made to the legislature periodically on number of visits, attendance rates, etc.
  • Cancer patient in palliative care generally has advanced disease with very high symptom burden, difficult to get to appointments in person
  • Telemedicine has resulted in greater overall satisfaction and better access, allowed family members to join in, improves adherence to pain management regimens
  • In 2 years prior to pilot launch, 44k visits for palliative care, 40% in-person, 52% virtual; virtual visits only occurred in 2020 out of that period
  • Virtual visits saw a doubling of attendance, virtual palliative care visits are increasing even as PHE wanes
  • Also asked to monitor if opioids via virtual visits was connected to patient harm due to misuse; not required to monitor PMP, but do as a matter of course
  • Also utilize a case aid to screen palliative patients for risk of opioid misuse
  • Virtual allows for increased engagement, can do pill counting, etc.; when signals for misuse are seen, can transfer patients to in-person and do the tests and addressing patient need
  • Have not identified any safety issues since the launch of the pilot
  • Presents patient satisfaction scores, majority favor virtual care, only small proportion prefer in-person visits
  • Perception of virtual visits has shifted over the course of the PHE
  • Chair Klick – Patients in palliative care are in a great deal of pain generally, intensified by moving around, sure that virtual visits are a benefit to these patients

 

Brint Carlton, Texas Medical Board

  • Physicians practicing telemedicine are subject to the same standard of care as an in-person practitioner; complaints subject to standard disciplinary process
  • Texas has a pre-existing relationship between doctor and patient requirement, but suspended currently under Gov. Abbott order; can establish relationship via telephone
  • Waiver in effect until the disaster declaration is lifted or expires
  • TMB worked on waiver to allow telephone refills for existing chronic pain patients, proposed and adopted a permanent rule

 

Nora Belcher, Texas e-Health Alliance

  • Pandemic exposed gaps in data collection and sharing; telemedicine is required to meet standard of care, incl. documentation requirements
  • Providers were very concerned about documentation requirements; providers were particularly concerned about doing audio-only services for those without a computer
  • Provision for signing physical documentation was not thought out during the PHE; regulatory programs need to allow for documentation in various forms, virtual signatures, etc.
  • Recommends adding language to Chapter 111 of Occupations Code to require boards include compliance options, standardized formats, retention schedules, etc. for A/V and audio-only remote services