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The Senate Committee on Health & Human Services met on August 23, 2022 to hear invited and public testimony on the health care workforce to:

  • Study the impact of the global pandemic on the health care workforce in acute and long-term care.
  • Identify health care staffing challenges and examine how staffing services and payment models changed the economics of the health care workforce.
  • Identify and recommend ways to increase the health care workforce pipeline.

This report is intended to give you an overview and highlight of the discussions on 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 Remarks

  • Chair Kolkhorst – Addressing struggles facing Texas healthcare workforce in response to COVID
    • CDC allowed the country to go back to normal last week but there are still lingering effects to the COVID response in our healthcare industry
    • Every sector of our society (teachers, pilots, etc.) affected by workforce shortage
    • Applauds all healthcare workers for their work during the pandemic
    • Healthcare sector lost 500,000 workers since February 2020: Healthcare workers needed childcare and were excluded by mandatory vaccinations
    • Cost to taxpayers high due to price of surge staff
    • Now that COVID has settled, need to evaluate what went well and how improvements could have been made to adjust in Texas healthcare moving forward
    • Need to build workforce in healthcare industry and consider efficacy of licensing requirements
  • Hall – Agrees with chair about looking forward; have been victims of things outside of their control so need to focus on what they can control and do better
    • CDC admitted they lied and caused Texas legislature to do harm to Texans, need to make decisions outside guidance of federal government
  • Chair Kolkhorst – Collaboration with higher education and public education committees will be essential for workforce development

 

Invited Testimony on Healthcare Workforce

Panel 1

Dr. Lisa Wyman, Department of the Center for Health Statistics

  • Statistics she’s offering is from 2018-2019, does not include COVID pandemic numbers
  • Projected number of family medicine physicians shows shortage, by 2032 will increase to 21%
  • Every region of Texas facing this shortage, biggest shortage in Rio Grande Valley and Gulf Valley
  • Texas Physician Pipeline Model shows need for physicians who complete degree and residency in state
  • Number of registered nurses and nurse practitioner shortage of 57,000 by 2032
  • Campbell – Asks Wyman why they didn’t consider COVID impact in number
    • Didn’t do so intentionally, package projection was commissioned a couple of years ago
    • Expects to have the projections with COVID impact for next session
  • Campbell – How many nurses left due to vaccination requirement?
    • Don’t have numbers on that
  • Chair Kolkhorst – We need to understand what we lost due to vaccine mandates, essential to collect this information; how do you collect this information?
    • Will collect survey this fall form nurses but didn’t do it last fall with data available by the start of session
  • Perry – If that data was available, we should have it today; Data show a projected surplus of nurses in panhandle region, what are they doing different to produce that?
    • Suspects surplus is due to Texas Tech Nursing School pipeline in the area
  • Hall – What impact did mandatory vaccine requirements have on shortage? Unacceptable we don’t have that information
    • Didn’t account for that information in this report
  • Chair Kolkhorst – Public hospitals could not have vaccine mandates? We need to understand what policies put in place affected costs to taxpayers
    • Not sure about that
  • Campbell – What is the formula you use to calculate shortage projections?
    • Use national surveys- Population plus community need (disease, age, disasters, etc.) and projected workforce availability, microsimulation model
  • Hall – Have you done a survey of medical professionals who left the practice? Need to do that to better encourage people back into the profession
    • No, haven’t done that yet but will be included in the fall survey
  • Chair Kolkhorst – Dept of State Health Services handled surge staffing and federal funds; has federal government given you funds for nursing surveys?
    • No but we have sufficient staffing to do so
  • Chair Kolkhorst – Do we have program that incentivizes recruitment of healthcare workers to move them to needed areas in Texas?
    • Not yet but a good idea

 

Bryan Daniel, Chairman and Commissioner, the Public for the Texas Workforce Commission

  • On Friday released July 2022 numbers, which he’ll review and then look forward
  • Set 9th consecutive record on more payroll jobs than any previous time in Texas
  • 72,800 jobs added to economy with increased civilian labor force
  • Unemployment rate down to 4.0%
  • Robust workforce economy back to pre-pandemic levels
  • Most industry growth in education & health services, professional & business services, and transportation & trade services (10 of 11 have shown growth this year)
  • In 2022, added more jobs Jan-June than any time before
  • Growth in May of 2020 lagged depending on industry- 150,000 jobs disappeared in healthcare immediately; Some jobs came back online faster than others during pandemic
  • Don’t measure exact people but rather trends, which shows 18% shortage in healthcare workers across the state
  • 10 years prior to COVID saw need for healthcare workers that has accelerated; for every 1 nurse looking for a job there’s 3 open positions
  • Patient care technicians and nursing physicians especially which is now a 1:10 ratio
  • 700,000- 800,000 worker shortage currently
  • Shortage was already an issue, which COVID exacerbated
  • Opportunity in that healthcare wages have continue to rise (10% over pre-COVID rate) that have driven workers to: 1) Look outside of their geographic areas for jobs (urban areas offering higher wages), 2) Switch occupations, 50% of workers coming from other jobs
  • Tool to combat shortage includes skills development funds
  • Need to let employers lay out plans to get people on career paths that bring them through profession; entry at patient care technician level with good retention creates a strong pipeline
  • Designated $15M for worker preparation apprenticeship program, which uses partnerships between state agencies and community colleges; from Dept. of Labor federal funds
  • Need to help employers align their sources for talent in a hurry
  • Chair Kolkhorst – how do you break out categories of healthcare workers?
    • Do some but can break them down further for the committee
  • Perry – Is there a required nurse ratio to patient care in hospital systems? Expresses hesitation in using national data source for projection data
    • Wyman – Has the sense that there is; projections include healthcare demands and not just vacancies
  • Campbell – No mandatory ratio of nurses to patients but hospitals have sense of how many they need but already too short staffed; Data on nursing shortage due to vaccine mandate?
    • Daniel – Had a statewide hotline for nurses to call if they had issues with this: 4,400 complaints, 1,000 associated with unemployment claim
  • Campbell – Apprenticeship grants to help find faculty for nursing programs?
    • No specific program to support faculty positions but some assistance for training costs
  • Campbell – Dual high school credit courses to bring them into LVN?
    • Yes, much promise with that across many skilled positions; the more we can use them the shorter the ramp to get them fully licensed
    • Healthcare apprenticeship program helps get students into residency and applied experience roles
  • Chair Kolkhorst – Have information on 4,400 cases about vaccine mandates? Did they come back into the workforce?
    • Yes, we have same information; can’t get all outcomes but can get what fields they were in
  • Chair Kolkhorst – Those nurses that filed unemployment- how many still receiving it? How are people making a living if they’re not fully employed but not on unemployment?
    • Of 4.5M nationally, almost all have rolled off due to time restriction but can get more information on this; stopped supplemental payment over a year ago
    • People are finding new ways to make a living without a full-time job like through gig economy or on tips as a service worker so not fully employed but not on unemployment
    • Some people went back to school, growing the workforce shortage
  • Chair Kolkhorst – Checking work requirements in unemployment system?
    • Yes, high level of scrutiny and people have ease of job search via digital access
  • Chair Kolkhorst – Helping community colleges and ISDs buy equipment from JET grant funds?
    • Yes, through general funds at $15M per biennium; legislature added $50M for next biennium to fill demand, not just in healthcare

 

Elizabeth Mayer, Policy Director, Texas Higher Education Coordinating Board

Charles Contéro-Puls, Deputy Assistant Commissioner for Student Financial Aid Programs

  • 2001 NSRP funds increase in licensed nurses; 87th legislature restructured program that allocates funding based on institutional increases to make funding more predictable
  • First year residency increases needed and has been major focus; Since 2017 the legislature increased funding for this to create 1:1 ratio in Texas residencies
  • Loan repayment strategy aimed at healthcare workforce provides $7,000 a year for 5 years to students at public and private institutions; additional GEAR funds allocated in 2021 to part-time faculty
  • HIPSA applicants agreed to serve at least 4 years in correctional facilities or mental health facilities
  • Mental Health Professionals Loan Repayment Program has low availability of funding
  • Campbell – Physician in repayment program only recruited by those without a loan, not those who already paid off their loan? What about other incentives for those who paid their loans?
    • Mayer – Correct, but can’t speak to that
  • Campbell – Nursing repayment program funding only for faculty?
    • Mayer – Correct
    • ContĂ©ro-Puls – Operated at ability to fund all eligible applicants for program and recently expanded program with GEAR funding to part-time faculty as well as full-time
    • Bottleneck in faculty to educate but sufficient interest in program
  • Chair Kolkhorst – Do we have too many repayment programs? Are they too stratified? Senator Nichols requested Chair focus on this issue
    • ContĂ©ro-Puls – Can’t really say but loan repayment programs focused on healthcare are oversubscribed, especially in mental health field and particularly with LPCs
  • Chair Kolkhorst – If we funded more, are there clinical settings able to meet the demands?
    • Mayer – 107 eligible nursing programs based on growth, only 42 programs received funding; not all funding tapped due to this limitation
  • Perry – If program has growth and gets funded, were they provided funding to fill capacity? Should be funding their capacity to ensure the programs serve as many students as possible
    • Mayer – No, because that’s how the rider is written
  • Campbell – How do you fund growth? Do you look at barriers to growth? Wants recommendation to make programs more equitable
    • Mayer – Funds based on number of additional graduates
  • Chair Kolkhorst – Do y’all give funding for a new nursing program? Who has final say on apprenticeships available to students? Thinks this is important
    • Mayer – Yes, but also goes through Board of Nursing so community colleges or hospitals must go to one or both to start a new nursing program
    • Will check with Board of Nursing to figure out who has final say
  • Chair thanks Dr. Hellerstedt for his service since he’s retiring this year

 

Panel 2

Katherine Thomas, Executive Director, Texas Board of Nursing

  • Been in her position 27 years
  • Wants to comment on observation that Texas Tech is increasing enrollment in her area; among top 10 is also Gaylin College and UT Arlington
  • Nurse Licensure Compact valuable during pandemic; been a member since 2000 and newly revised in 2018
  • Impact of COVID on nurses caused more stress, anger from public, workplace violence
  • 5% was cut which they’re excited to get back in next session; some staff send to homes
  • Have hybrid model but planning to move into George H. W. Bush Building on Friday
  • .5M licenses issued to nurses; APRN and RN populations have increased year over year, but LVN populations decreased though, so big concern
  • Need more elder care for aging population
  • In 2021, 3,500 applicants for nursing licenses, showing a big increase
  • 2,019 schools of nursing in the state, all entry-level
  • Average days for complaint resolution: 88-90% resolved in 6 months
  • Texas pass rates dropped a bit this year but well-above national average
  • Testing centers initially closed but re-opened in May 2020 and remained open at 100% since then
  • Barriers to new nurses: faculty shortages and clinical space availability; consortiums help increase clinical space available
  • Nursing licensing averaged 10 business days before COVID but went up to 20 days during pandemic, attributed to staff shortage at all levels of agency; now averaging 15 days
  • Agency flexibility with budget would be huge help; had trouble delaying hiring of people with positions open over a year they can’t fill, especially in IT, lawyers, and nursing (hospital salaries are more competitive)
  • Up to 50% of clinical experiences can be in virtual simulations, the waiver for which is about to expire in September
  • Long-term care untapped source of nursing clinical placement; trying to increase interest in long-term care among nursing students
  • Campbell – How many nurses lost job due to COVID vaccine requirements?
    • Don’t know; don’t collect that data but hospitals might be able to speak more to that data
  • Campbell – How many clinical hours for 2-4-year nursing student required?
    • Don’t mandate that, depends on program; can get average for each level for the committee
  • Campbell – Can you come up with some incentives for nursing students to work in long-term care facilities?
    • Yes
  • Campbell – How can we increase the number of LVNs in Texas?
    • Scope of practice dependent on their education but can speak more with committee about that
  • Campbell – How can we increase clinical space for students?
    • Expand to long-term care and consortiums that work together to find every space available and assign students accordingly
    • Provide an online component to supplement in-person hours like UT Arlington
  • Blanco – What is being done to assign student to rural clinical spaces?
    • Majority of nursing programs want to open in a populated areas with hospitals and other medical facilities nearby
    • Some rural areas have an arrangement with the school
  • Blanco – Did testing centers being closed during the pandemic lead to a backlog?
    • Only a backlog initially, not an issue now
  • Hall – Office gotten lots of complaints from doctors of being harassed by medical board for practicing good medicine with early COVID interventions; How do we encourage doctors and nurses to pursue similar approaches? (Rhetorical)
  • Chair Kolkhorst – Who determines number of clinical hours required?
    • No one really but done mostly by college or university based on program rules; they’re examined if school is getting into trouble with lack of clinical experience
  • Chair Kolkhorst – What about ratio of faculty to students on clinicals? Is it time to go to 12:1 ratio?
    • Ratio is 10:1 but can use clinical preceptors and double that amount; No one at schools is asking for new ratio because of preceptors
    • Schools of nursing have gotten creative to recruit faculty, including part-time hiring
    • Nursing education pays less than clinical facilities
  • Chair Kolkhorst – Do you allow clinicals to be done at hospitals at night? What’s barrier for long-term care clinical placements?
    • Yes, and on weekends
    • Long-term care facilities allowed but many students don’t want to go there for their hours, many not exposed to what experience is like
  • Chair Kolkhorst – You approve some hospital-based nursing programs without Higher Education Coordinating Board? Concerned about supplanting existing programs
    • Law allows diploma programs to be approved but haven’t gotten an application in years; don’t see it as a problem for competition
    • Have limited capacity issues in certain areas so need to look at those issues, especially their ability to recruit faculty
  • Chair Kolkhorst – You have open positions inter-agency? Is it an appropriations issue?
    • Independent board but compete with private sector and other state agencies for these positions to it’s a budget issue; need more money for salaries and resources
    • Causing a backlog and will show committee those outcomes

 

Stephen Brint Carlton, Executive Director, Texas Medical Board

  • Speaking to current licensure process and potential for improvement
  • Medical board overview given
  • Issues over 15,000 new licenses a year in two-step process of screening and licensing within average of 51 days; issuing licenses in 15-30 days on average
  • 5,300 providers offered emergency licenses in just 24 hours
  • New phase of pandemic means immediate need for practitioners has declined
  • Telemedicine requirements were relaxed during COVID
  • $.5M in processing feeds accumulated this year for compact licensing, allowing doctors to work in other states within compact agreement
  • Additional licensure personnel needed, requests more funding for this
  • International medical school graduates face additional hurdles to get licensure; proposes using post-graduate U.S. clinical experiences as criteria for licensure rather than undergrad schooling
  • Campbell – What changes were you referring to relating to licensure apart from budgeting?
    • Mostly international student changes he suggested
  • Campbell – No longer using emergency pathway to license physicians?
    • We are as along as emergency pathway is in effect; don’t feel quality of care has suffered from this
  • Campbell – Telemedicine care may have suffered due to automated services in which patients don’t speak to a physician but are charged. What are you doing about this?
    • Haven’t seen an increase in number of complaints about this but if they do, they’ll investigate that
  • Hall – On fast track of emergency licensure, what did you leave out of the process? Concerned about doctors who lost licensing in other states being able to get one in Texas
    • Look at disciplinary/criminal history report and licensure in another state
    • Knows of isolated incidents of licensure that was revoked in other states but rare and board makes careful assessment on this
  • Hall – Wants doctors who prescribed preventative COVID treatments to have records expunged and fines refunded by the board
    • If someone did get letter from the board, it wasn’t related to prescription but on whether there wasn’t an adequate medical record associated with case
  • Blanco – Interstate compact: HB 1616 was passed last session to fund 7 FTEs, how is it working and affecting access to care for rural communities?
    • Process is working well; since March 1 issued 103 licenses of 100+ LOQs
    • Doesn’t have data with him on what areas the doctors provide care in but can investigate practice addresses and provide it to the committee
  • Campbell – Do you give recommendation to doctors on whether to wear a mask?
    • We do not
  • Campbell – Do you know why they’re still using masks in hospitals?
    • Depends on the hospital’s policy, could be residual from pandemic requirements
  • Chair Kolkhorst – In nursing facilities, patients still must wear a mask and haven’t seen a person’s face in over 2 years due to CMS requirement; should be a personal choice
  • Hall – How many licensed doctors with clinical experience work on staff of medical board?
    • Two on investigative staff plus one medical director who are not determining standard of care, that is for expert staff members
  • Chair Kolkhorst – This committee has direct oversight of the board; need to acknowledge mistakes were made during pandemic that should be learned from and corrected

 

Panel 3

Stephanie Allred, Director of Licensing & Credentialing, Texas Health and Human Services

  • Long term care facilities had challenges meeting staffing requests; regulation citations ensured
  • HHSC has allowed for some flexibility during pandemic and shortage, including allowing nursing time to count toward certification and licensing
  • Waiver revoked to allow nurses to work in nursing facilities while seeking certification, leading to 7,000-8,000 worker shortage so requesting waiver extension
  • Report on target to be submitted to legislature by November 1st
  • Campbell – Working to get nursing aids certified now?
    • Yes, encouraging them to go through waiver program to work while pursuing certification with expedited training
  • Perry – 5-week period for training and licensing?
    • Yes, but fluctuates depending on exam wait times but now there are online options to take tests, though skills exam is in-person only
  • Cliff of 500 CNAs in October?
    • Yes, can get testing data from vendor
    • We’re now above pre-pandemic levels of nurse aids statewide
  • Campbell – Can use clinic hours in certification and training process?
    • Yes, 100 hours total with 60 of which are classroom training, 40 are clinical training
    • Nursing facility experience now counts as classroom training; separate program for nurse aids

 

Scott Schalchlin, Associate Commissioner, State Supported Living Centers

  • Data from Sept 2017 shows state is down 20% of workforce in healthcare workers
  • Slowing in turnover but above pre-pandemic levels
  • Shortage affects many positions across healthcare, all of which are important; food services a good example
  • State supported living centers and hospitals showing increase in overtime and affecting budget in overtime costs
  • Have 700 mental health center beds offline due to staff shortages so not able to serve as many patients
  • Staff shortages cost more on the back end
  • Numerous retirements contributing to shortage; also young families left industry due to lack of childcare available
  • Chair Kolkhorst – Expresses concern millions of dollars invested in ASH and SASH but money not productive if staffing not available
    • Due to competition with private sector, which is paying better; Would love to be able to pay staff $22 an hour to recruit more applicants
  • Chair Kolkhorst – Do state hospitals use clinicals?
    • Some do, some don’t; some decreased number of clinical rotations but not sure why
    • Rotations not as appealing as the relationships they develop during long-term care
  • Perry – Market will correct to cap for services in private sector, but government jobs have no caps; need to make some changes to wages but by session they will adjust a bit in the economy
  • Healthcare jobs are difficult and new generation not wanting to get into the field due to challenges of that workforce

 

Panel 4

Dr. Cynthia Weston, Associate Professor and Dean, Texas A&M School of Nursing

  • Challenges in recruiting and retaining nursing workforce
  • Current students interested in undergraduate nursing programs still showing strong candidate pool but distance learning and graduate programs decreasing
  • These nurses working on frontlines with competing personal and professional demands
  • Students apply to multiple programs simultaneously but don’t have numbers on students qualified but not enrolling
  • Seats for nursing programs increasing
  • Barriers to increasing enrollment due to shortage of clinical sites for students
  • Securing clinical placements challenging, making students travel up to 2 hours to complete clinical experiences
  • Costly for nursing programs to buy into consortiums with no guarantee of placements
  • Facilities limit the clinical groups and number of students for their programs
  • Lack of qualified faculty a challenge because salaries not competitive
  • Mobile school-based clinics offering a solution to serve rural areas using, in part, funding from cancer prevention and research fund
  • 35% increase in nursing enrollment in Texas over past 10 years but there are retention issues, especially following COVID; workforce is fatigued
  • Patients becoming indignant in face of COVID; physical and verbal abuse ensued
  • Lack of senior and experienced nurses to help mentor nursing students, decreasing workplace satisfaction
  • No GME equivalent funds for nursing students and preceptor availability
  • Evidence-based strategies for retention: organizational support, compensation, flexibility for family balance, and ability to pursue additional education and higher positions
  • Policy investments in Texas have increased nursing outcomes through Texas Higher Education Funding Board, incl. Nursing Shortage Reduction Program, Nurse Faculty Reduction Program, & Nursing Innovation Grant Program
  • Salary gap between practice and clinical education a national challenges; need to incentivize nurses to stay through salary increases and bonuses
  • Nurse practitioners must contract with physicians currently, which needs to change
  • Recommendations: 1) Increase funding support for 3 effective policy programs, 2) Addressing workplace violence and salary gaps, 3) Remove outdated regulation on nursing contracts
  • Campbell – Has A&M looked for pathways for nurse practitioners to go into medical school? Making a statement, not seeking a response
  • Chair Kolkhorst – How should we address workplace violence?
    • No consequences for assaulting a nurse right now like there would be a police officer, suggests some consequences be instated
    • Nurses prepared to deal with patients who are confused but other family members even being violent against nurses
  • Perry – Brings up vulgarity and violence also speaks to the situation in classrooms right now

 

Michelle Trubenstein, Dean of Health Sciences, Blinn College

  • Offers 2-year associate of science degrees in dentistry, emergency health services, radiological services, etc. where students can apply their workplace experience to degree
  • Challenges:
    • Lack of available clinical space- need additional clinical partnerships and statewide approach to increase clinical spaces
    • Hiring qualified faculty- in high demand and community colleges competing with private sector
    • Investments in equipment and facilities to train students, including simulations; requesting reimbursements for these costs
  • Chair Kolkhorst – How could state help?
    • Currently limited access to some facilities with high competition for LVNs, who don’t get to go into acute care settings so being pushed out of clinicals there
    • Need help not being pushed out of critical/acute care facilities, which is needed for nursing students to be qualified
  • Chair Kolkhorst – How do you determine how many hours are needed?
    • Based on experiences in understanding what times it takes to get a student to a competent nursing skillset
  • Wants to see panel to come up with answers in defining clinical sites and where state could make a difference; doesn’t want to supplant programs

 

Dr. Lori Rice-Spearman, President, Texas Tech University Health & Science Center

  • Texas Tech trying to improve healthcare access to West Texas residents
  • Provides 22% of all healthcare workforce for state of Texas
  • Nursing program grown by 195 slots in past year per request of community health leaders
  • Strong clinical partnerships critical to supporting and training workforce
  • Graduate medial training program provides 600 slots per year
  • Surgery residency program with funding support from state and private sources provides 10 residencies annually; a model for future growth
  • Rural family medicine program in partnership with rural providers; students spend 1 year in urban setting then 2 years in rural areas
  • Key workforce multiplier during pandemic; retained 73% of West Texas participants
  • $20M allocated by state to expand program with $10M in private funds allowed state of the art anatomy lab, expanding to 70+ slots and will grow to 100
  • Public-private partnership allows them to work closely with local hospitals to fill gap for CAN requirement, allowing student matriculation to BA level
  • Chair Kolkhorst – Concern with private forces coming into Texas for high demand for clinical sites to be able to charge more; wants to get more info on this
    • Trubenstein – Aggies Assist Program allowed healthcare students to be paid by local private hospitals to fill void in market
  • Perry – Concern with private sector coming into cadaver market to upcharge
    • Works with community related to donated bodies to ensure gross anatomy labs have enough cadavers
    • Some for-profit universities paying for clinical rotations, up to $1,500-$5,000 per rotation, taking slots away from public university students

 

Dr. Jair Soares, UT Health in Houston Medical School

  • Workforce need for behavioral health
  • Psychiatric Center at UT Health received funds from state over past 3 years which allowed them to increase capacity to 538 beds
  • Behavioral Sciences trains over 2,000 students annually, faculty of 125, and research team growing
  • Present at 137 behavioral health clinics, including trainees
  • 25% of general population with behavioral health issues now increased to 35% post-COVID
  • Tried to fill gap with telehealth, growing from 2 to 20 FTEs
  • Training needs are large with multidisciplinary approach; need to find more clinical placing with state support
  • Proposes new school of behavioral health sciences in psychiatry for children, psychologists, nursing, addiction counselors, etc. including more fellowships
  • $10.5M per year requested to start new school
  • Home to largest psychiatric hospital in the country thanks to previous state support
  • Have been active member of Texas Childhood Mental Health Consortium to help link children to treatment as needed
  • Formula rate of 2.0 rather than 1.0 requested to train more professionals in behavioral health
  • Chair Kolkhorst – 264 beds by end of 2023. How many do you have now?
    • Capacity now 96 beds with first unit and can open new unit every month or two, but depends on ability to staff them
  • Chair Kolkhorst – If they were to create new school of behavioral health, would it help with workforce shortage in behavioral health hospitals statewide?
    • Absolutely, counselors the first line of identifying issues in children and intervening

 

Panel 5

Stephen Hines, President, Atta Staff Medical

  • Specialize in medical staffing, giving unique perspective on staffing end
  • Two sets of clients: nurses (mostly RNs and CNAs) and client facilities (hospitals)
  • Facility types: Acute, nursing homes, rehabilitation, memory care, corrections, schools, etc. in clinical staffing
  • Don’t have luxury of hiring recent grads, facilities require at least 2 years of experience
  • ICU, med-surge, specialty nurses, OR nurses have highest shortages
  • Staffing concern important to understand: pre-COVID most acute hospitals always wanted to improve patient quality but saw increased demand in 4-year degree nurses, away from LVNs and medical assistants
  • During COVID, staffing shortages in acute hospitals led to increased hiring of LVNs and medical assistants; temporary job but high pay
  • Nursing homes increased their salaries in turn
  • Now has more LVNs and medical assistants who aren’t being hired by acute hospitals again, more being hired for flu clinics
  • 1/3 physician referrals going to home health and away from skilled nursing
  • Never seen such an amazing pivot as healthcare professionals pulled off during COVID
  • They don’t set rates, hospitals do; there are normal rates and crisis rates they pay during natural disasters and pandemics that cause shortages in workforce
  • Hospitals cannot afford crisis rates during non-crisis times without subsidies but nurses still asking for that payment
  • Masking mandate didn’t cause many nurses to leave, most leaving because they’re exhausted and want high pay rates as incentive to continue working
  • Has over 1,000 nursing requests each day, filling about 30% of those
  • Has large order pool of 1,300 direct hire nurses; labor and delivery especially hard to find
  • Chair Kolkhorst – What is the difference between contract and direct hire?
    • Contract nurses work for his company, under W-2; Has 350 healthcare employees in Texas right now
    • Direct hire allows medical facility to pay employment agency fee for specialized medical professionals; charge 15-30% of their annual salary
    • Travelers are paid differently through Meal Lodging Allowance (MLA); must live 75 miles from facility, which is a tax-free per-diem allowance, subsidizing their salary
    • PRN work is as-needed, more skilled nurses going there
  • Chair Kolkhorst – Where did you get your talent from? Do staffing agencies like you drive up salary costs for hospitals?
    • 70% referrals from other nurses, 30% job boards/advertising/job fairs
    • Never worked to actively steal nurses from one location to charge more to same hospital
    • Specializes more in local nurses, not travel nurses
    • Travel nursing not as popular now due to inflationary costs
  • Perry – Some nurses checked out of permanent arrangement and want a more contract-based employment dynamic?
    • Yes, that’s true. Their retention rate was higher pre-COVID though
  • Chair Kolkhorst – Out of all the acute hospitals, what percentage of nurses would be filled by staffing agencies right now?
    • Different for every hospital but most try to keep it at 30% of their staff is contract-based
  • Chair Kolkhorst – When does the market settle back down post-COVID?
    • Not this year; but not sure when it’ll settle down, if ever
  • Perry – Will the market pull back? I think we’re going to see a market correction in next 6 months, not at pre-COVID rates but below what we have now
    • Yes, I just can’t predict when; hospitals understand market changed and are offering more than pre-COVID rates but less than peak-crisis rates
    • Nurses currently making quality of life decisions to get out of acute care; many nurses traumatized from COVID

 

Kevin Warren, President & CEO, Texas Health Care Association

  • Been over 28 months that long-term care staff have been battling COVID and they’re exhausted; looking for policy solutions to address these issues
  • Working doubles, seeing colleagues leave, putting more pressure on them
  • Seen 9.3% decline in long-term care workforce since March 2020; almost 5x the decline of what hospitals have seen
  • 1 hours per patient day was suggested by CMS for balance of quality of care before COVID but not possible with current staffing
  • 100% of long-term care provider respondents in 2021 said they had shortage in CNA staffing
  • 78% of respondents say they’re using agency staffing to help fill gaps, causing 2-3x increase in cost of staff
  • Staffing agency individuals sometimes not showing up for work or leaving mid-shift when they know they can find work elsewhere the next day
  • Retention also difficult, facilities trying to be more flexible to attract employees
  • Facilities seeing average increase of 20-24% increase in salaries without commensurate reimbursement
  • Prevention and protection of COVID still a concern, especially so in long-term care/nursing facilities
  • Chair Kolkhorst – How do we get out of these federal requirements for COVID PPE in nursing homes when the PHE is ending?
    • Prevention still important but also need to consider the onus it’s putting on employers and hindering their ability to hire staff
    • Funding hinders on compliance so not much you can do unless federal government changes regulations
  • Chair Kolkhorst – What else can we do to enhance care are nursing facilities?
    • Need to reconnect relationships between nursing facilities and nursing homes to rekindle the quality of care for these patients
    • Need to address villainization of healthcare workers from pandemic
    • Need to address that next generation makes moral and ethical decisions about where they want to work and how healthcare employers can better articulate their values to attract workers
  • Chair Kolkhorst – Of your workforce, how many nurses declined to work in a facility to require a vaccine?
    • All acute hospitals required the vaccine, only 3 nurses declined and quit

 

Jennifer Banda, Texas Hospital Association

  • #1 challenge for hospitals is their workforce shortage, exacerbated by COVID
  • Trained and qualified staff was crucial to getting through pandemic and hourly wages have doubled as a result
  • Expanding capacity for acuity services required recruitment and retention bonuses, salary increases, and increased benefits
  • Data showing workforce costs in 2022 up 33% since start of pandemic
  • 2021 survey found 50% of healthcare workers feel burnt out and 25% say they’re considering leaving the industry all together
  • For a long term difference, legislature can increase pipeline of caregivers across the state by passing policies that find and employ faculty & increase clinical space
  • 15,709 candidates were turned away from Texas nursing schools
  • Mental health training facilities only funded at $2M for the biennium, which should be increased
  • Healthcare shortages cover a broad array of positions

 

John Henderson, President and CEO, TORCH

  • Works for 158 rural hospitals in Texas
  • Staffing costs reported from rural hospitals increased during pandemic
  • Early retirements, staff sickness, and burnout leading to poor retention
  • Travel burden is an issue in most geographically isolated parts of the state
  • Clinical sites are a bottleneck; proposing to hospitals that offering a clinical site a potential solutions to shortage
  • Appreciates funding for workforce programs for rural communities such as loan forgiveness, apprenticeship, upskilling, sponsorship, and retention programs
  • Chair Kolkhorst – How do we not supplant existing clinical rotations?
    • Banda – Clinical sites need to be expanded at hospitals
  • Chair Kolkhorst – Heard for-profits are paying for those clinical sites? Need to put you in charge of figuring this piece out; is going to change the market
    • Not aware there was differentiation with the way those clinical sites are being procured
    • Need to partner with HRIs, community colleges, and other institutions of higher education
  • Chair Kolkhorst – Were many cost drivers discussed last panel; need to get more into the workforce
  • Chair Kolkhorst – Employment data on those you lost because of vaccine mandates?
    • Henderson – Do not have that data; should be an effort to identify why employees have left
    • Hospitals are now required to have a vaccinated workforce and are required to have a policy for exemptions due to religious/medical needs
  • Chair Kolkhorst – Every hospital is mandated to have a vaccinated workforce?
    • Henderson – When federal vaccine mandate went into place last fall
  • Perry – Do most hospitals allow exemptions in practice? Notes a hospital in his district lost much of workforce due to not allowing exemptions
    • Must allow exemptions, maybe in certain situations
  • Perry – Do not like the hospital system currently, are many who feel like they are not valued, not treated fairly; do members survey employees?
    • State collects turnover and retention data; can find out if members want to share reasons for leaving
  • Perry – Getting the sentiment that they can make more money from less employees
  • Chair Kolkhorst – Utilize staffing agencies? What percentages
    • Henderson – Vast majority must use staffing agencies; varies by type of role and location some are at 60% vacancies
  • Chair Kolkhorst – Slight dip in salaries?
    • Henderson – Is improving, but not as fast as we would hope
  • Chair Kolkhorst – What are you seeing in cost reimbursements for hospitals?
    • SB170 has had stabilizing effect on helping get payments to rural hospitals, which are doing alright financially now

 

Jack Frazee, Director of Government, Texas Nurses Association

  • Nursing Shortage Reduction Coalition report provided with data on this issue
  • Texas Nursing Workforce Plan looking for ways to address needs without expanding footprint of government
  • Been working with governor’s office about nursing faculty being a 50/50 mix of full and part time to try and get loan forgiveness for part-time faculty
  • Current pro-rated amount is limited to full-time and set at $7,000 a year for 5 years, so needs to be adjusted for part-time; Change statute on amount awarded
  • No mandatory nurse to patient ratios in Texas; 2 models to deal with nurse staffing, Texas uses committee that gives advice to management to set appropriate policies on staffing
  • Supplemented by prohibition on mandatory overtime but exception in PHE; nurses have been working outside of this prohibition during COVID
  • Need to reinvigorate nurse staffing committees
  • Nursing Innovation Grant Program gone toward simulation training for clinical hours in recent years but expires in 2023
  • Need to ensure all assets for simulation training critical for licensure are secured
  • Funds from program come from Texas Tobacco Lawsuit Settlement
  • Worked hard to bring forward a bill on workplace violence prevention (HB326), which died in committee last session
  • Focuses on de-escalation training and committees at hospitals coming up with policies to protect nurses when these instances occur
  • Chair Kolkhorst – Seeking additional input to update code to potentially increase funding for Nursing Shortage Reduction Program through HB4471; Happy to lead on this

 

Public Testimony

Jennifer Kent, President, Victoria College

  • Sees their role to provide solutions to nursing shortage
  • Boasts one of passage highest rates of nurse practicing exam
  • Full-time faculty positions a big part of their success
  • Able to retain regional talent at 80%
  • External constraint based on clinical practice capacity; using virtual training labs as a remedy and valuable instructional resource not to replace in-person patient interactions but as a complement
  • Concerned with for-profit nursing institutions from outside of Texas
  • CHS has partnered with Jersey College to open a nursing program for 144 students which are taking clinical time slots from Victoria College students
  • Chair Kolkhorst – How many nurses are you registering each year?
    • Registering 100+ nurses each year; Jersey College students taking clinical spots, not complementing those our students were occupying
    • Doing clinical locations at every eligible clinical site in their area right now; if they had more clinical sites they could train more nurses
  • Chair Kolkhorst – How many clinical hours required?
    • State sets a window, they’re in the middle of that window
  • Chair Kolkhorst – For profit schools now paying for clinical rotations?
    • Haven’t seen it at Crossroads but heard of it happening in the state
  • Chair Kolkhorst – How many first-generation students?
    • More than 50% and most from generational poverty
  • Chair Kolkhorst – Cost for nursing degree?
    • $12,000-$13,000 in total; Jersey College is $47,000, impacting first-gen students most
    • Graduate 80-90 LVN students per year

 

Alyse Meyer, VP Advocacy, Leading Age Texas

  • Non-profit aging provider including retirement, assisted living, and nursing facilities
  • Recommendations:
    • Incentives like loan forgiveness don’t exist in home-care sector; should be offered through a bill next session
    • Promote more partnerships and include PTEC and early college prep HSs for nursing
    • Connect foster youth to career opportunities in nursing home care
    • Get 8,000 TNAs tested who are on waiting list before October deadline of completing it within 4 months of completing training program; HHSC oversees the testing
    • HHSC should apply for more civil money penalty projects made available to nursing facilities to focus on recruitment and retention
  • Chair Kolkhorst – Requests information on foster youth programming; requests written testimony

 

Maureen Milligan, Teaching Hospitals of Texas

  • Clinical issue being addressed by Teaching Hospitals of Texas for nurses, physicians, pharmacists, and psychologists
  • Requests to invest in clinical capacity for nursing
  • Invest like graduate medical education with grants for medical residencies but for nurse clinical positions
  • Want funding for preceptors who work with nursing students in hospitals, which currently have no funding
  • Grant programs for innovation

 

Sandra Batton, Provider Alliance for Community Providers of Texas

  • Provides services for people with developmental disabilities in group homes
  • 30% of group homes don’t have sufficient staffing to meet needs
  • Provide transportation, medicine, counseling, life skills, emergency support, etc. but are paid less than fast food workers; goal of at least $15 an hour

 

Dr. Shaylee Gupta, Texas Dental Association

  • Worker shortage for dental practices exacerbated by lack of PPE and dental equipment from supply chain issues
  • Pandemic interrupted patient access to dental care
  • Texas can improve access via:
    • Increased Medicaid reimbursements to dental programs aligned with today’s dollars
    • Redistribute dentist workforce through Dental Education Loan Repayment Program
    • Increase funding for Texas dental schools to offer debt alleviation for dental students; highest rate among healthcare workers
  • Chair Kolkhorst – commend dentists for ability to control COVID spread within their practices
    • Less than 1% transmission of COVID in dental facilities during pandemic

 

Sonya Burns, Self

  • Waitlist for county jails over 2,500 people, number of MSU going up
  • Every MSU case she works on are persons with IDDS, most of whom are already getting highest level of care
  • Most felony charges for those individuals come from calls from group homes with violence against their caretakers
  • Hundreds of beds are offline; those online 50% are 365 plus days of long-term housing
  • Unprecedented need for more beds due to Austin State Hospital redesign, poorly done
  • Behaviors of patients beyond anything they’ve seen before due to long periods of time in a jail cell
  • Need to pay workforce to correctly calculate how many beds they need in state hospitals
  • Texas is on track to become California in terms of number of homeless and incarcerated individuals if these issues aren’t addressed

 

Carole Smith, Executive Director, Private Provider Association of Texas

  • Workforce crisis continues to have adverse effect on people with IDDs
  • Providers not able to provide competitive wages to employees, forcing many to close down
  • High turnover of administrative staff and owners prevalent
  • IDD providers burdened with changes to billing system for waiver providers, which have many glitches
  • Chair Kolkhorst – Which funds?
    • Billing systems for home and community-based services waiver
    • Did away with outdated system and moved to TMHP, but facing significant challenges to providers
    • Some providers only able to pay half their employees

 

Ellen Bowman, Self

  • Cares for her 35-year-old granddaughter who has multiple disabilities
  • In 2019, her condition deteriorated with limited mobility; took 3 years to find a specialist
  • NCOs need broader provider base; need more accountability on providers to improve quality of life for those with disabilities
  • Need increased wages for caregivers

 

Allison Moore-Boulware, Hogg Foundation for Mental Health

  • Create a pipeline for public mental health system
  • Pay for internships for master’s level social workers and counselors; if they get placements in Texas they’re more likely to stay
  • Then pay for supervision hours, which cost thousands of dollars for students
  • Pay for their licensing fees and allow them to be eligible for existing loan repayment program for mental health professionals
  • Pay for program at same rate as physician loan forgiveness program; increase from $2M to $14M
  • No new applicants for program in 3 years due to high costs

 

Wendy Garrett, Buckner Retirement Services

  • Non-profit ministry providing care to seniors with 6 locations across Texas since 1954
  • Serves 1,300 individuals with 800 employees
  • Staffing in long-term care has always been challenging but especially after COVID; recently lost 10% of workforce with over 100 open positions they’re unable to fill
  • Been combatting staffing shortages with increased wages, higher sign-on bonuses, mental health benefits, daily pay, int’l recruiting of RNs, and reimbursement of benefits
  • Wants state to consider loan repayment programs for nurses

 

Susan Murphree, Disability Rights Texas

  • Offering comments based on calls for people needing community services who are unable to hire enough nurses and attendants to ensure their plans of care of filled
  • Need to find solutions for facilities and people with high level of needs who require care
  • Attendant and nursing wages and benefits need to be improved; needs to be prioritized

 

Brent Smith, CEO, Hopkins County EMS, President of EMS Alliance

  • EMS has been facing staffing shortages for many year, exacerbated by COVID
  • Largest competitors for employees are hospitals; made difficult to provide sufficient EMS services
  • Don’t have access to supplemental staffing funding like hospitals but even if they had it there may have been no one to send
  • $21.7M in ARPA funding helped educate EMS professionals; hoping to increase EMS workforce statewide by 10% with funds
  • Funds won’t enrich any EMS agency or offset high fuel prices; will only go toward recruiting and training EMS professionals

 

Randy Martin, President, Texas Society for Health System Pharmacists

  • 10,000 pharmacists and 16,000 pharmacy technicians working in hospitals across Texas
  • Challenges they face include:
    • Lack of qualified pharmacy technicians at acute care hospitals, up to 20-30% shortage nationally and 40% turnover rate
    • All compounding IV medications prepared by qualified pharmacy technicians, not enough training of these professionals for strong pipeline
  • Recommendations:
    • Include pharmacy technician for acute care hospital training in plans to improve healthcare worker pipeline
    • Include more clinical pharmacy residencies as well

 

Marjorie Costello, CAO, Disability Services of the Southwest, Lifespan Home Health, CDS in Texas

  • Represents over 12,000 Texans with disabilities and seniors as well as 14,000 personal care attendants
  • Seen recent tragedies among Texans with IDDs; recounts several stories about this
  • $8.11 current wage for personal care attendants, which only the legislature can correct; asked for this for over 15 years, begging for an increase to remedy this issue

 

Denise Gray, Kenmar Residential Services

  • Supported people with intellectual disabilities as private provider for over 40 years
  • Need for improved direct care; wages and stability in workforce essential
  • Residents post-COVID who have always been engaged in the community have not been able to do so without adequate staffing
  • Staff turnover high, leading to quality-of-care issues; 30% open positions with 100% turnover
  • Requesting wage increases for these workers to stabilize workforce
  • Chair Kolkhorst – These 3 and 4 bed waiver homes?
    • Company has ICF and IDD residencies as well as home and community based residential facilities; been forced to close numerous facilities and turn away patients with higher behavioral issues due to low staffing
    • Facilities in Abilene, Dallas, and Houston- all with staffing issues

 

Jeff Humber, VP, Payer Relations for Accent Care

  • Based in Dallas with 13,000 employees and 10,000 patients on Medicaid
  • Hoped to see increase of caregiver applications following the supplement to UIB going away last June but not the case
  • Other service industries were better able to flex their wages to draw those applicants
  • Tied to 17-year-old Medicaid wages and can’t adjust accordingly to recruit talent; some must abandon communities and licenses in the process
  • Need long term funding strategy to end this exodus
  • Chair Kolkhorst – Do you have a plan in place with recommendations?
    • Have studies they can share with the committee

 

Brooke Schweitzer, Self and Texas Academy of Physician Assistants

  • PA’s work under authority of physicians and train alongside them
  • Appreciate approval of ability to sign their patients’ death certificates, alleviating paperwork backlog
  • During COVID, PA’s stepped up to support intensified patient care but still barriers that prevent them to practicing to their full capability and training capacity
  • PA’s can help fill gaps by expanding their capabilities with the skills they’re already trained to do such as prescribing medicine, making end of care determinations, doing consults, and carrying out follow-up meetings
  • Chair Kolkhorst – Requests written testimony; are PA’s called doctors?
    • Not in a clinical setting but many have doctorate degrees so considered doctor in educational administration setting

 

Carol Rabilas, Mary Lee Foundation

  • Organization for individuals with IDDs
  • Unable to pay staff and can’t pool enough staff to cover their locations
  • HCS program projected to be $200,000 in debt this year
  • Programs have closed in Travis County; many clients looking for placements, but no group home spaces available
  • Livable wage in Austin is $18 an hour but can’t provide that with current funding streams through reimbursements
  • Additional fees from temp agencies putting them in debt
  • ARPA money provided shouldn’t be used to increase wages, but its an insult to those working in this field during COVID because not an investment in the future; been using those funds as bonuses

 

Chase Bearden, Coalition of Texans with Disabilities

  • Community attendant wages at frontline to ensure quality base care for individuals with disabilities
  • Texas started with money follows the person to move people out of nursing homes and institutions but payrate now is causing system to break down
  • Real dangers exist to patients when these workers don’t show up for work on a given day
  • Need competitive wages ($15 per hour in first year, $17 in second year), paid vacation, paid sick days, and benefits for these workers; it’s not enough right now
    • Many of these workers will come off state provided benefits because their wages are currently so low

 

Terry Karricher, Self

  • Caretaker of her daughter, who has a disability
  • Never been able to use all of her respite or attendant care hours because cannot find enough people to meet her full-time care needs
  • Should require MCOs contractually to give caretakers a living wage & be able to shift hours and dollars when needed
  • HHSC should hold MCOs accountable regarding budget transparency when dollars are budgeted and not used
  • For Texas to be pro-life, must be pro-life to care for all Texans, not just at birth

 

Kirk Parsons, COO, Southwest LTC Services

  • Look into quality of nursing programs
  • Increased staffing regulations to improve quality of care
  • Need to work collaboratively to work on meeting these requirements and patient needs
  • Agencies with policymaking capabilities need to be part of conversation to ensure policies aren’t burdensome
  • Chair Kolkhorst – When can we do away with mask mandate at nursing homes?
    • Mandate still in place from CMS and CHHSC; never had mask mandate for influenza outbreaks but do for COVID

 

Mary Neronho, A Pineywoods Home Health Care Services, Texas Association of Homecare and Hospice

  • Thanks the committee for FMAP funds that are going to community attendants
  • As an agency owner, she’s paying $10-12 an hour even though they’re only reimbursed for $8 an hour
  • Office staff hasn’t seen increase in staff in years and not included in FMAP funding, which is only for direct care staff
  • Requirements for HHSC treat office staff as unskilled professionals, making it so they’re paid less than direct care staff
  • Reporting negative in budget this year for this first time in years and able to provide care in less counties

 

Hannah Medah, Protect Texas Fragile Kids

  • Enormous crisis in home healthcare that requires multi-pronged approach with short- and long-term solutions
  • Record profits reported among MCOs
  • Solutions from working group provided to committee in her submitted report
  • Alternative models of care pilot structure not in keeping with legislative direction currently
  • Long-term cost effectiveness essential for consideration by this committee and legislature
  • Texas can and must do better to protect vulnerable Texans
  • Families need more flexibility in how they spend dollars and use hours
  • Chair Kolkhorst – requests written testimony

 

Rachel Hammon, Executive Director, Texas Association for Homecare and Hospice

  • Gives overview of scope of care of organization
  • Home care often overlooked but safety net to provide quality care for vulnerable individuals
  • Human and economic cost to current situation
  • HHSC needs to:
    • Raise pay rate
    • Create community care payment advisory council
    • Develop strategic plan for adequacy issues and workforce shortages
    • Promote home health agencies as a viable clinical site for nursing students
  • Chair Kolkhorst – How do you meet 10:1 ratio at home?
    • Students can come observe at that location and some 1:1 ratio hands-on opportunities could work

 

Casey Dickerson, Director of Client Services, Down Home Ranches

  • An HCF and ICF provider with lingering staffing crisis in direct care
  • Increased pay to $16 an hour and saw an immediate increase in staff but now $100,000 budget deficit
  • First time in 2 years haven’t had managers covering direct care shifts
  • Want increase in direct care pay to at least $15 an hour and increased professionalization

 

Linda, Self and Texas Parent to Parent

  • Presenting a package of testimonies they’ve collected
  • Haven’t been able to find an attendant in 2 years
  • Requests HHSC adds 16- and 17-year-olds to home hire in class in HCS
  • Change start date of annual renewal so case managers start early and get their paperwork to HHSC in time; causing pay delay of 2 months to attendants
  • Need way to move minutes worked during the day for attendants more efficiently because currently too bureaucratic and unmanageable
  • Needs to be a before and after report for displaced patients who are placed in home locations that don’t meet their needs
  • Don’t give waivers to MCOs, postpone it indefinitely
  • Chair Kolkhorst – What’s causing 2-month delay?
    • Used to be automatic but not with EVV

 

Cindy, Self

  • Mother of daughter with disability who use host home option, 24-hour care
  • Concerned about rate of pay for host home caretakers at $50.98 a day (only $2.12 an hour over 24 hours)
  • Transfer of services from provider agencies to local authorities has led to lack of compensation and lack of continuity of care
  • Asks for reinstatement of service coordination as a billable service through service provider agency to decrease staff turnover and increase quality of life outcomes
  • Person directed planning should be added as billable service
  • Chair Kolkhorst – Requests written testimony

 

Whiney Primo, Self

  • Mother of son with disabilities with IQ under 20
  • Services by HCS waiver and supplement wages with their own money, still having issues finding staffing to provide him adequate care
  • He requires two caretakers at all time due to his size but can’t have two caretakers at once according to HCS policies so she has to be with him and can’t work
  • Using waiver to pay his grandparents to provide him care
  • Need more flexibility in how to use waiver and can’t find care at medial facilities due to short staffing and his high level of need

 

Ray Hymel, Texas Public Employees Association

  • Emphasizes importance of pay of state employees, especially given inflation
  • Increased pay to direct care staff at state supported living centers has made dent in staff turnover

 

Sheila Hemphill, Texas Right to Know

  • Presenting report on danger of products exempt from investigation and safety during public health emergencies
  • No investigations, labeling, or compliance regulations for medicines at that time
  • Need to require product safety in Texas when they’re not required by federal law
  • Hopes for call for immediate halt of COVID-19 vaccine