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The committee met to take up and consider bills. This report focuses only on discussion of the bills below. Chair Schwertner noted the committee will meet again Monday, March 23 to begin hearing testimony on Sunset bills.
 
 
SB 622 – Uresti, Relating to the physician assistant board.

  • PAs are governed by the Texas Physician’s Assistants Board
  • Due to the increase in number of PAs, an increase in members of the board has been suggested
  • Increases the board from 9 to 13
  • Governor must appoint a PA to the board
  • Campbell asked if this bill passed last time
    • Yes; it got caught up in the House
  • Campbell supports the bill

 
Todd Pickard, Texas Academy of Physician’s Assistants

  • There were over 200 complaints filed against PAs last year alone
  • Need a PA on the board to ensure a board member has knowledge of the industry and position

 
Bill left pending
 
SB 695 – Bettencourt, Relating to authorizing patients with certain terminal illnesses to access certain investigational drugs, biological products, and devices that are in clinical trials.

  • Right to try, compassionate use bill
  • FDA currently has compassionate use policy allowing certain patients to receive experimental products
  • The FDA process could take months
  • This bill defines patient eligibility terms; authorizes the use of the drug but does not require the manufacturer to provide it; patient must sign a release form
  • Insurance providers are not required to cover the cost
  • Drug must have passed FDA Phase 1
  • Eight states have passed this bill already
  • Perry noted the bill should be moved forward; need to make sure cost recovery mechanism language is tight enough; don’t want to turn this into a new profit center; don’t want people in vulnerable situations taken advantage of
    • Unless the state adopts a Medicaid rule to take care of this it cannot be a burden to taxpayers
  • Van Taylor asked about language “remains under investigation in a clinical trial” many drugs pass Phase 1 and for whatever reason never progress past that
    • Trying to keep the Phase 1 drugs as the focus; if there is an ongoing Phase 2 trial it should not contaminate the Phase 1 results; Phase 1 is the safety check; this deals with a terminal illness situation and time is of the essence; Phase 1 approval means the risk of injury to the patient is minimal

 
Christina Sandefer, Goldwater Institute

  • In support of the bill
  • Right to try is about saving lives
  • Puts the decision with the doctors and patients
  • The FDA process takes years to go through; there are exceptions for compassionate use but takes hundreds of hours of doctor paperwork and then has to go through a review board
  • Right to try works within the FDA process but gets medications to patients who are out of options and out of time
  • “remains under investigation” means once a drug is past Phase 1 and remains in a clinical trial and has not been pulled from the clinical trial by the FDA
  • Taylor asked if drugs are automatically pulled from investigation if the trials are ceased for some reason such as there not being funds to continue or not being able to find a place to hold the trials
    • That is the type of situation right to try is meant for
  • Taylor noted his broad concern is that FDA is here for a reason; there have been horrific results when the process is eased; not trying to replicate or replace the FDA with a state process?
    • No
  • Taylor asked how a drug past Phase 1 would be pulled out
    • The FDA has a very wide authority to pull drugs for whatever reason they want to; may pull because FDA doesn’t think they are meeting the timeline or critical endpoint concerns
  • Taylor asked why Phase 1 was chosen
    • Because of the time concern; Phase 1 is safety testing; further phases deal more with side effects and dosage and efficacy
  • Taylor asked about liability the state is creating; no cause of action created in the bill for the manufacturer; are we leaving a cause of action against the state
    • There is language that covers any additional person who is involved in the care of the patient

 
Mary Robinson, Texas Medical Board

  • Phase 1 is to determine there are no detrimental effects, not that it is effective; Phase 2 determines if the drug is effective, no time limit on Phase 2; the way liability with the state works is that a state must allow a cause of action; a cause of action against the state does not exist unless the state allows it
  • Schwertner asked about the concern regarding potential physicians that might want to sell hope to patients and could use anything from Phase 1; are we opening up a situation of selling hope on compounds that may not be effective
    • Sandefer responded that patients understand right to try is not about miracle cures; patients have to give consent and they understand the risk; drug companies could give the drugs out for no charge because it could help them through the FDA process
  • Schwertner asked if the next step is requiring insurance companies to cover these drugs
    • Bettencourt noted it would not be under his watch; any law can be abused
  • Schwertner asked if any state’s laws require drugs be given for free
    • Some require that the company not profit and give the drugs at cost; doing so can decrease the number of patients who can get the drug because it may not incentivize the manufacturer to make it available

 
Karen Sloan, Mother of Andrea Sloan

  • In support of the bill
  • Andrea and her friend Michelle tried everything they could do to make an experimental drug available to her
  • The time it took for the FDA to approve the use of the drug for compassionate use was detrimental to her recovery

 
Michelle Wittenburg Andrea Sloan’s Friend

  • Doctors knew they needed to get compassionate use for Andrea
  • MD Anderson was performing the clinical trials on the drug and were aware of its promise regarding efficacy and had no safety concerns, neither did FDA
  • The drug was used on Andrea and began working but she died of complications from pneumonia
  • The 24 day period Andrea had to wait was detrimental and was likely the reason the drug couldn’t save her

 
Dorothy Paredes, Self

  • Diagnosed with breast and ovarian cancer
  • Important to remember that even though there are still questions about certain drugs they can save lives
  • Important the people are given a chance to have the opportunity to live

 
David Bales, Texans for Stem Cell Research

  • In support of the bill
  • There are still serious questions about which Phase should be used in the bill
  • 90% of drugs fail from Phase 2 to Phase 3
  • 13 other states are funding stem cell research and properly funding that would keep people from having to wait until they are terminal to access those drugs
  • If a drug has gone through Phase 1 patients should have access because, at least, the FDA approved their safety

 
Bettencourt closed

  • In these situations, time is the great predator
  • Anything that can be done to reduce the time to bring a possible cure that has passed Phase 1 should be done
  • Up to now 33 states have either passed or are strongly considering this action
  • Schwertner noted his concern is about protecting vulnerable individuals from potentially predatory companies wishing to profit from these individuals
    • Bettencourt noted there is always good and evil in any situation and the good here outweighs the evil
  • Rodriguez asked if any additional steps could be added to the bill to delay concerns about predatory companies
    • Can review legislation already passed by other states to attempt to relieve those concerns

 
Bill left pending
 
SB 760 – Schwertner, Relating to provider access requirements for a Medicaid managed care organization.

  • Deals with Medicaid MCO network adequacy
  • Managed care contracts are valued at $15 billion annually
  • Adequate provider networks are one of the most important functions of these contractors
  • Hear from stakeholders and providers regularly regarding clients having a hard time accessing care
  • Requires HHSC to differentiate between urban and rural areas
  • Requires HHSC to more closely monitor and enforce standards
  • Requires HHSC to perform “secret shopper” monitoring
  • Establishes penalties that may be assessed
  • Requires MCOs to make their provider directories available online and update monthly
  • Requires HHSC to biennially report to the legislature about recipients access to networks
  • Committee sub:
    • Reporting, provider directory, and direct monitoring provision changes
    • HHSC must enforce liquidated damages or withhold payment because of network adequacy issues
    • Requires HHSC to identify provider types eligible for expedited credentialing
  • Improves oversight over managed care and ensures MCOs are being held accountable
  • The state spends a lot of money on managed care and the state needs the full service it is buying
  • Current network adequacy rules are insufficient
  • Perry noted he appreciates the bill; there needs to be a customer complaint process outside of the MCO; have also heard there is a lot of provider switching which makes administration more difficult for MCOs so may need to look at that as well
    • There is a hotline being established
    • There is an expedited credentialing process that will prevent hold-ups; it takes a while for credentialing with some MCOs
  • Reiterated that Texas is paying for a product and those full services need to be provided
  • Kolkhorst has a suspicion that there is a better way to do this than with managed care; sometime models run their course and its becomes time to revamp the model

 
Ryan Van Ramshorst, Pediatrician, Texas Medical Association, Texas Pediatric Society, Texas Academy of Family Physicians

  • In support of the bill
  • Will increase access to needed services
  • One of the most frequent complaints about managed care is that patients cannot receive timely specialty care
  • There is not one board certified pediatric rheumatologist in the San Antonio area in-network
  • Some MCOs are worse than others
  • Support language directing HHSC to develop new network adequacy standards
  • Directories are often outdated and inaccurate
  • Supports language that requires MCOs to find care when specialists are not available
  • Supports the provision requiring HHSC oversight such as the secret shopper provisions
  • Supports the penalty provisions

 
Carol Carver, Clarity Child Guidance Center

  • In support of the bill
  • 80% of their patients receive funding through Medicaid/CHIP and LMHAs
  • Without the bill network adequacy will be inconsistent
  • Many listed psychiatrists on MCO directories are not taking new patients; more than 50%
  • Very large MCOs have the lowest available providers
  • 10-15% of inpatient admissions could be prevented with more adequate community support
  • Just recently received MCO privileges with providers in an emergency care facility opened in 2013

 
Jerry Sloan, Bluebonnet Homes

  • Biggest difficulty is receiving psychiatric services
  • Continually having to search for providers in the local area
  • Calling MCOs to find providers and receive services is very difficult; directories are not accurate

 
Jamie Dudensing, TAHP

  • Testifying on the bill
  • Supportive of strong network adequacy standards
  • Texas already has very strong standards
  • Workforce shortages, low Medicaid rates, administrative burdens are obstacles
  • MCOS have been improving compared to FFS with, in many instances, less money
  • MCOs have improved access to women’s health care
  • 27% increase in adherence to medications for respiratory and heart attack treatments
  • Driscoll has implemented telemedicine to get access
  • MCOs have dramatically improved quality of care outcomes
  • MCOs have strong oversight from HHSC and the Texas program looked at as a model for the country
  • Expedited credentialing provisions in the bill are not consistent with TDI requirements, mainly on recruitment
  • Penalties in the bill are already assessed but are not placed in statute
  • Have some technical concerns around some of the TDI aspects and penalties; very supportive of the rest of the bill
  • The complaint process outside of MCOs goes directly to HHSC
  • Schwertner added that OIG suggests Texas Medicaid program has only heard of 8 violations of network adequacy standards; hard to believe

 
Trey Berndt, AARP

  • Strongly support the bill
  • Very important legislation
  • Complementary to the HHSC Sunset process
  • Managed care members struggle to find specialist care; not getting any help from plans
  • Seems to be up to the individual to solve their own problem in many cases
  • HHSC relies on a dated standard from TDI regarding a specialist being up to 75 miles away; suggest differentiating between rural and urban areas when setting standards
  • Need to set minimum provider ratios
  • HHSC doesn’t have a measurable standard for network adequacy; simply says networks must be sufficient
  • Contract enforcement is fairly passive at HHSC; relies on complaints and self-reported HMO data
  • It is difficult to get providers to enroll in Medicaid but at the end of the day, the plans sign a contract saying they will deliver the networks and they need to do it

 
Charlotte Bosecker, MARC Texas

  • In support of the bill
  • Nonprofit group from Midland
  • Would like the committee to consider more HHSC oversight
  • There are two psychiatrists accepting new patients on the provider lists for plans in Midland; only one will see IDD patients; having problems with that provider as well

 
Michelle Tejada, Audiology Hearing Aid Work Group

  • In support of the bill
  • Would like HHSC to have methodology for determining a sufficient network
  • Would like language in the bill that audiologists do not have to pay up-front for devices
  • Children are waiting too long to receive audiology services in many parts of the state
  • Not having services causes additional expense

 
Gary Jesse, HHSC Medicaid/CHIP Division

  • Kolkhorst talked to Chris Traylor and believes some change is coming on line soon
    • Not entirely sure; will follow up
  • Campbell asked if audiologists must pay for devices up-front
    • Any provider provides the benefit up front then gets reimbursed
  • Campbell noted governments seem to delay reimbursement and make it very difficult; is it reasonable to ask for providers to pay up front
    • Hear this quite often with home modifications and adaptive aids; that is in law; there are requirements surrounding the timing of payments

 
Lynn Brooks, San Antonio Region 8 Medicaid/CHIP Advisory Committee Audiology Work Group

  • In support of the bill
  • Problems with providers paying for devices up front; has driven out many providers
  • Kolkhorst noted that isn’t asking a whole lot

 
Sylvia Negron, Community Advocate

  • In support of the bill
  • Medicaid is losing providers
  • Recommend, in addition to not having audiologists pay for devices, MCOs must be required to be accountable and disclose the option of out-of-network providers

 
Bill Hammond, Texas Association of Business

  • Testifying on the bill
  • MCOs, between 2010-2017 will have saved the state’s taxpayers around $7 billion
  • It is pretty clear that on the supply side the state needs to do a better job; support additional funding for GME and funding for APRNs
  • Texas is far down the list on provider rates
  • Need to look at both sides of the equation
  • Schwertner asked if the witness agrees that when there is a contract and services are being paid for, the state should be receiving those services
  • Taylor knows he has heard substantial issues regarding network adequacy
  • Rodriguez knows managed care has been around for a while and there have been numerous complaints in the El Paso market; there needs to be accountability on contracts from the MCO side
  • A more in-depth study maybe appropriate; with reimbursement rates so low there will always be a problem finding providers
  • Schwertner noted MCOs set their own reimbursement schedule based upon the company; if you look at the stock graphs of Molina and Superior they go from the bottom left to the top right over the last five years; they are making money; as a state we need to focus on revision of health care services to our need
  • Kolkhorst asked if HHSC has substantiated the $7 billion figure referenced earlier
    • Not sure; it is pretty clear than one of the motivating factors to go to this model was to save money
  • Kolkhorst noted she has some concerns with the Vendor Drug program and PBMs and some cost savings are being lost sight of

 
Schwertner closed

  • We can debate the merits of managed care but this bill speaks to the fact that Texas has a contractual managed care environment and contracts should be upheld; there should be penalties for partners who don’t fulfill contractual obligations
  • Have been working hard on network adequacy over the interim and will continue to do so

 
Bill left pending
 
 
Pending Items From Previous Hearings
 
CSSB 203 – Nelson, Relating to the continuations and functions of the Texas Health Services Authority as a quasi-governmental entity and the electronic exchange of health care information.

  • Bill reported favorably
  • Sent to local calendar

 
CSSB 292 – Nelson, Relating to a request for a waiver of the waiting period before human remains may be cremated.

  • Bill reported favorably
  • Sent to local calendar

 
SB 304 – Schwertner, Relating to the abuse and neglect of residents of certain facilities.

  • Have worked with stakeholders to create an acceptable committee substitute
  • Changes in sub:
    • Adds legislative intent to Section 1
    • Makes it clear DADS will revoke a license of an entity with three strikes in 24 months
    • Grants a limited waiver to HHSC executive commissioner so that he may waive a license revocation in certain cases
    • Adds informal dispute resolution language from SB 553; rolled the bill in
    • Changes to the quality monitoring program
    • Delays the effective date to Sept. 1, 2016
  • Committee amendment:
    • Strikes the word “private” from informal dispute resolution language
    • Adopted
  • Rodriguez commended Schwertner for doing a great job addressing concerns raised with the bill
  • Committee substitute adopted
  • Bill reported favorably

 
SB 538 – Schwertner, Relating to the control of infectious diseases.

  • Withdrew old committee substitute to adopt new committee substitute
  • Changes in sub:
    • Limits effect of governors declaration to thirty days; governor can call additional emergencies
    • Requires DSHS to keep family units together if retention is utilized
    • Requires a peace officer to notify an individual of their rights when taken into custody and a health official to re-notify
    • Allows peace officer to arrange transportation of an individual
    • Requires appropriate agencies to review guidance documents for pets and livestock
  • Rodriguez asked about who pays for care where a person with an infectious disease is taken to a hospital; insurance, hospital, individual?
    • If they have insurance then insurance would participate; under federal regulations if they need emergency care the hospital must provide that
  • Rodriguez is still unclear
    • It is important to quickly address potential infectious diseases for the good of the public
  • Committee substitute adopted
  • Bill reported favorably

 
SB 460 – Schwertner, Relating to the licensing and regulation of pharmacists and pharmacies.

  • Withdrew old committee substitute to adopt a new committee substitute
  • Changes in sub:
    • Adds language enabling the board to discipline people committing insurance fraud
    • Narrows scope of boards ability to inspect financial records
  • Committee substitute adopted
  • Bill reported favorably
  • Sent to local calendar

 
SB 519 – Schwertner, Relating to the registration of dental support organizations.

  • Withdrew old committee substitute to adopt new committee substitute
  • Changes in sub:
    • Cleans up some language related to surveys
    • Clarifies the list of business support services should not be construed as limiting
    • Requires DSOs to list which business support services they provide
    • Makes it clear that corrected reports should be filed quarterly if necessary
  • Kolkhorst asked what the reasoning is behind the change from Dental Service Organization to Dental Support Organization
    • It more accurately reflects the support they provide
  • Committee substitute adopted
  • Bill reported favorably