Texas Hospital Assoc.

85th Legislature invests in behavioral health and physician workforce

Special to Medical Journal – Houston BY TED SHAW, President/CEO, Texas Hospital Association

On Memorial Day, the 85th Legislature came to a close. At the time of this writing, the specter of a special session lingers as lawmakers have unfinished business, at least according to Lieutenant Governor Dan Patrick. But, assuming Governor Abbott does not call a special session, lawmakers go back to their home districts, and state agencies begin the rulemaking process to implement new laws.

For Texas hospitals, the legislative session covered a wide range of issues. There were more healthcare-related bills filed during the 85th Legislature than in any other previous session. The Texas Hospital Association tracked more than 1,000 bills. These were bills that would change how we care for patients, serve our communities, and run our businesses. Some we supported; many we did not.

The state budget for 2018-19 – how much the state will spend and on what – was one of the more challenging items. Despite Texas’ wide tax base and diversified economy, the recent drop in oil prices brought a loss of tax revenue and about $10 billion less for budget writers to appropriate for state operations and programs.

With these tight financial circumstances, it is particularly notable, therefore, that lawmakers in the 85th Legislature put some significant resources in two key areas: graduate medical education and behavioral health care.

Texas long has had too few physicians to meet the health care needs of its growing population. Statewide, there is a severe shortage of primary care physicians, as well as specialists in a number of disciplines, including pediatrics and geriatrics. The number of psychiatrists and other behavioral health care professionals is insufficient to serve all Texans living with mental health or substance use issues.

One of the most effective ways to increase the number of physicians in the state is to increase the number of physicians who train here. In 2015, lawmakers appropriated funds to increase the number of graduate medical education training opportunities in Texas. Lawmakers in the 85th Legislature continued this tradition by appropriating $90 million for health-related institutions to continue the same level of state funding for current graduate medical education programs and added funding for new GME programs at The University of Texas Austin and The University of Texas Rio Grande Valley.

In addition, to expand GME training opportunities, the state budget provides $97 million in all funds – an increase of $44 million over the prior biennium. These funds may be used for:

GME planning and partnership grants to hospitals, medical schools and community based ambulatory patient care centers; new or existing GME programs to increase the number of first-year residency positions; unfilled first-year residency positions; and grants to GME programs that received a similar grant in 2015.

On the behavioral health front, legislators built on the work done by the Select Committee on Mental Health during the interim. That committee identified multiple areas of needed improvement for the state’s behavioral health care system. And lawmakers responded.

The 85th Legislature appropriated more than $7.5 billion for behavioral health including $3.6 billion for Medicaid and CHIP behavioral health services. Of the $4 billion appropriated for non-Medicaid behavioral health services, $63 million will be used to address the current and projected waitlists for community mental health services for adults and children, and $366 million will be used for construction and repairs at state hospitals and other inpatient mental health facilities.

Although not part of the budget decisions, legislators also took steps to increase the number of providers available to treat Texans with substance use issues. Licensed chemical dependency counselors now will be eligible for educational loan repayment assistance as other behavioral health professionals currently are through the Loan Repayment Program for Mental Health Professionals. To be eligible for financial assistance, LCDCs must serve indigent and low-income populations.

Finally, the Texas Department of Insurance will have more authority to fully enforce the existing mental health parity law so that Texans with depression, for example, will be treated the same, in terms of benefits or provider access, as someone with a physical health condition such as diabetes or congestive heart failure.

Budgets and laws always are about choices and priorities. In its choices, the Texas Legislature demonstrated its commitment to making Texas a healthier place to live and work.

The fight against opioid abuse

Special to Medical Journal – Houston BY TED SHAW, President/CEO, Texas Hospital Association

Last month, the Centers for Disease Control and Prevention issued final guidance for the prescribing of opioid medications in outpatient settings for adults with chronic pain. The voluntary guidelines make recommendations for when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, followup, and discontinuation; and assessing risk and addressing harms of opioid use. The guidance followed several other actions by the federal government to address opioid abuse, including:

• almost unanimous passage by the U.S. Senate of the Comprehensive Addiction and Recovery Act;

• President Obama’s budget recommendation for $1 billion to expand access to opioid abuse treatment; and

• the U.S. Food and Drug Administration’s announcement that it would include “black-box” warnings on immediate-release opioids.

Opioids include legal prescription pain relievers, such as oxycodone, hydrocodone and methadone, and illegal heroin.

Texas lawmakers also have taken steps to address opioid abuse. With the passage of Senate Bill 1462 in the last legislative session, individuals suspected of having an opioid-related drug overdose will have expanded access to so-called opioid antagonists. These are medications designed to block the effects of opioids and reverse overdoses in most cases if given in time. The law, effective last September, allows opioid antagonists to be prescribed under a standing order, rather than to a named individual and explicitly grants distribution authority to a variety of entities and health care personnel.

All of these initiatives reflect the growing urgency among state and federal lawmakers and the health care community to address the national problem of opioid addiction, abuse, and overdose.

In Texas alone, total health care costs associated with opioid abuse approach $2 billion. And these are just health carerelated costs; that amount does not include the costs of lost wages and productivity, incarceration, social services, and other societal costs.

Since 1999, the amount of prescription opioids sold in the U.S. has nearly quadrupled as more products entered the market, health care providers became more sensitive to the needs of patients with chronic pain, and understanding increased of the physical and emotional consequences of not addressing chronic pain. Nationwide, in 2012, providers wrote 259 million prescriptions for opioid pain relievers. Yet, while the number of painrelief prescriptions increased, Americans did not report a corresponding decline in the amount of pain experienced.

What has increased, however, is the number of Americans dying from drug overdoses. According to the CDC, more people died from drug overdoses in 2014 than in any other year on record. The majority of these drug overdose deaths (more than six out of ten) involved an opioid. Nearly 80 Americans die every day from an opioid overdose. And this is a public health problem that affects every community in Texas and every age, socioeconomic and racial and ethnic group.

For Texas hospitals, the fight against opioid abuse takes many forms, including caring for those who have overdosed on opioids, those seeking to end their opioid addiction, and infants born to opioid-addicted mothers. It also includes being able to identify individuals who are relying on hospital ERs for medically unnecessary prescription opioid refills. Houston Methodist Hospital, for example, uses the Texas Department of Public Safety’s Prescription Access in Texas online database to identify individuals who may be abusing prescription medications. Through the DPS system, ER personnel have access to a list of pharmacies that have filled prescriptions for controlled substances for an individual. This allows health care providers to see not only prescription history but also if the patient has received prescriptions from multiple providers.

Hospitals clearly are on the front lines of opioid abuse treatment and prevention. But, a problem of this magnitude cannot be solved by hospitals alone. A multifaceted and concerted effort is needed that encompasses education, prevention, treatment, and rehabilitation and involves the entire health care community as well as the support of state and federal lawmakers.

Yesterday, Ebola. Today, Zika. Tomorrow...?

Special to Medical Journal – Houston BY TED SHAW, President/CEO, Texas Hospital Association

At a time in the calendar when the flu usually dominates our health news, this year we have a new scene stealer. The Zika virus.

Mosquito-borne, the Zika virus has grabbed international attention primarily because of its devastating effects on developing fetuses. An estimated 4,000 babies in Brazil alone are thought to have been afflicted with the Zika virus, which is suspected to be linked to the fetal deformation known as microcephaly, in which infants are born with smaller-than-usual brains. Depending on the severity, microcephaly can cause developmental delays, dwarfism, mental retardation, and seizures. Infectious disease experts are hard at work investigating the full impact of the Zika virus on pregnant women and developing fetuses. No treatment or vaccine for the virus is available.

At the time of this writing, mosquitos carrying the Zika virus have not yet crossed the border into the United States. Cold comfort though when the infection has already been found in 21 countries in the Caribbean as well as and North, Central, and South America, and the World Health Organization predicts the virus will eventually spread to all but two countries (Canada and Chile) in the region.

Dealing with new and emerging infections is not unchartered territory for Texas hospitals. In 2014, Texas hospitals were at the epicenter of the Ebola virus in the U.S. The disease had ravaged several countries in Africa, but until a patient traveling from Liberia entered a Dallas hospital in September 2014, there had never before been a single case of Ebola diagnosed in the U.S. In the intervening months, the Centers for Disease Control and Prevention issued updated and revised diagnosis and treatment guidelines; new protocols governing screening and the use of personal protective equipment for health care workers are being followed; and specialized Ebola treatment centers are designated. In just 16 short months, the entire health care community in Texas and the nation is exponentially more prepared and equipped to handle a patient with the Ebola virus.

But Texas hospitals know that it is not enough just to react to known threats. Identifying potential dangers and developing response plans before a crisis occurs is part of hospitals’ vital role as the first line of defense against threats to the public’s health. This is particularly true with respect to infectious diseases because viruses do not respect geographic boundaries.

Just as roads and bridges are the essential physical infrastructure for a thriving economy, hospitals are the essential infrastructure for safeguarding the public’s health. This infrastructure requires support, maintenance, and investment. Equipment, staff, emergency medical supplies, training, and education are just a few of hospitals’ nuts and bolts that create a sound public health infrastructure.

Yet, funding to support such an infrastructure hasn’t kept up with the need. Federal funding specifically for hospital emergency preparedness has dropped by more than half since its inception following the September 11, 2001 terrorist attacks. From $515 million per year in 2003, funding for the Hospital Preparedness Program was down to less than $230 million in the fiscal year 2015. And this is funding for all of the nation’s hospitals.

At the same time, Texas hospitals have fewer discretionary funds to dedicate to emergency preparedness and public health activities. Repeated Medicare and Medicaid funding cuts combined with a persistently high uncompensated care burden resulting from the state’s large number of uninsured residents have left Texas hospitals with fewer funds to invest in emergency preparedness.

The emergence of Ebola in the U.S. and the imminent threat of the Zika virus are known. We can plan and prepare accordingly. But a clear and present danger exists from what is not known. Now is not the time to ask hospitals to be on the front lines of protecting the nation’s public health without equipping them with the necessary resources. Texas hospitals need lawmakers to reject further cuts to Medicare and Medicaid funding for hospital services, reduce the number of uninsured, and increase federal Hospital Preparedness Program funding. Our nation’s health depends on it.

Building the health care infrastructure

Special to Medical Journal – Houston BY TED SHAW, President/CEO, Texas Hospital Association

March 2016

Texans take pride in the fact that our state is one of the fastest-growing in the nation. People move here for the jobs, the economic growth, and the way of life. The state demographer estimates that by 2050, the population will top 54 million – double what it is today.

With this growth, however, come challenges. Traffic and building a transportation infrastructure to accommodate this many Texans almost immediately come to mind as logistical and fiscal challenges. But just as challenging is having a health care infrastructure that can deliver timely and quality health care to this many people. Fundamental to this infrastructure is workforce – the physicians, nurses, and allied health professionals who deliver care. Unfortunately, the state is starting from a disadvantaged position. We already have a lower-than-average physician to population ratio. Among the most severe shortages are those for primary care physicians, endocrinologists, psychiatrists, geriatricians, and pediatric subspecialists. Add to this explosive population growth, and we have a significant access to care problem.

In our complex and changing health care environment, any discussion of workforce adequacy also needs to include nurses and allied health professionals, all of whom are essential members of the healthcare team. But right now in Texas, there is a documented shortage of nurses and a number of types of allied health professionals. The Texas Center for Nursing Workforce Studies estimates that between 2005 and 2020, the demand for registered nurses in Texas will rise by 86 percent. However, supply will grow by only 53 percent, leaving Texas 71,000 full-time equivalents short of its needs. There are also shortages of pharmacists; radiological technologists; medical lab technologists; surgical scrub techs; hospital-based physical therapists, audiologists and speech-language pathologists; and ultrasound techs.

Hospitals, academic medical centers, and other health-related institutions are major financial supporters of GME in Texas that carries an estimated conservative price tag of $150,000 per year per resident. Texas is one of a handful of states that does not pay for GME through the Medicaid program. It funds a fraction of GME expenses through a formula allocation of $4,400 per resident. Medicare is also a supporter, but its contribution is capped at the level provided in 1996. This means that of the state’s approximately 6,100 residency slots, more than 2,000 are ineligible for any Medicare GME funding and require full funding from the residency programs and hospitals themselves. In addition, even for Medicare GME-funded slots, residency programs pay about two-thirds of the training costs.

In the absence of additional state funding, training more physicians, so desperately required to meet the health care needs of a growing population, would require additional investment from hospitals and health systems at a time when they are already dealing with significant reimbursement rate cuts and a large number of uninsured patients.

Fortunately, the state legislature has responded. In each of the last two legislative sessions, lawmakers have appropriated funds to increase the number of graduate medical education opportunities for physicians in training. These positions are essential because physicians who train here are more likely to stay here and build practices. Conversely, those who leave the state for training are less likely to return to Texas to practice.

Last month, the Texas Higher Education Coordinating Board announced the award recipients of $49.2 million in grants to support the expansion of graduate medical education opportunities in Texas. These grant funds are being disbursed to 23 Texas medical schools, hospitals, and health systems to support 65 training programs and 224 residency positions in 2016 and 459 positions in 2017. The funded positions are in internal medicine, pediatrics, family medicine, emergency medicine, obstetrics and gynecology, psychiatry, neurology, and surgery.

These funds are absolutely essential to address the state’s serious physician shortage and the access difficulties it creates for residents across the state.

In addition, since 1999, Texas has used funds from the Texas Tobacco Lawsuit Settlement to address the state’s nursing shortage. These grants have been essential for promoting innovation in the education of initial RN licensure nursing students. The 84th Legislature extended this funding through 2019 to make nursing students and faculty education, recruitment, and retention an explicit state priority.

Texas lawmakers have made a significant investment to foster a healthy health care provider workforce and sustain the backbone of the state’s health care infrastructure. Sustaining and building this investment will be essential in future years.

What’s next for reducing the number of uninsured in Texas?

Special to Medical Journal – Houston BY TED SHAW, President/CEO, Texas Hospital Association

Texans without health insurance have the remainder of January to purchase private coverage from the federal health insurance marketplace,, and, depending on their income, qualify for tax credits to reduce the cost of that coverage.

So far, nearly 1.2 million Texans have enrolled. This is more than the total number who purchased coverage in 2015, positioning the state possibly to enroll close to 2 million residents by the end of open enrollment. As a result, Texas could further reduce its uninsured rate that already fell from 22 percent in 2013 to 19 percent in 2014.

Improvement to be sure, but we still have work to do.

Texas continues to lag behind other states in reducing the number of uninsured residents. For a variety of reasons, the state still leads the nation in both the number and percentage of residents without health insurance. Part of the reason is inaction on the part of state leadership to provide a means for low-wage working Texans to get health coverage, either through traditional Medicaid expansion or a private alternative. The result is that more than 1 million Texans lack access to affordable health insurance. Figuring out a path forward to affordable coverage for these Texans is important not only to reduce the number of uninsured but to keep our workforce healthy and productive and our economy strong.

In addition, we still have work to do because an insurance card by itself is not a guarantee of access to care or improved health care outcomes. We know that for some residents with marketplace insurance, high deductibles and cost sharing are a burden. If the insurance is too expensive to use, it is not useful. We also know that for others, narrow provider networks are limiting access to needed specialists and facilities. These are both issues that we need to apply our collective will and thought to improve.

Fundamentally, however, for patients and providers alike, more insured Texans is a good thing. Clinically and financially, our health care system works better when more people are connected to the health care delivery system and are not on the fringes, delaying needed care and relying on hospital emergency departments.

Texas hospitals understand this fact and have long been committed to reducing Texas’ uninsured population. Most recently, during open enrollment for 2016, they are leading an effort to enroll as many eligible but uninsured Texans as possible in marketplace coverage through the Insure Health. Insure Texas campaign. Using the campaign’s resources, Texas hospitals of all sizes are delivering the key messages of health insurance affordability and availability. Through social media, radio ads, billboards, digital ads, and direct mail to uninsured patients, Texas hospitals are covering the state with the simple but highly effective message that affordable health insurance is available. The website sees daily traffic from individuals from Childress to Fort Worth to Houston to Laredo and cities in between.

Our work does not end on Jan. 31 just because open enrollment ends. As trusted members of their communities, Texas hospitals will continue to advocate for further reductions in the number of uninsured, help the newly insured understand and appropriately use their health insurance coverage and work to eliminate barriers that impede meaningful access to needed health care services.