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Texas Hospital Assoc.

Texas hospitals support fair treatment of Texans with behavioral health conditions

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

Each year, one in five Texans experience a behavioral health condition like depression or anxiety. But, only 60 percent of those individuals get treatment. Some individuals do not seek care, but others who want treatment are unable to get it. A myriad of factors play into why some Texans might not seek behavioral health treatment, but for some individuals with health insurance that includes coverage for behavioral health treatment—through private insurance and most Medicare and Medicaid managed care plans—accessing allowable behavioral health treatment can be a challenge.

For many insured Texans, getting treatment for physical health conditions can be easier than for behavioral health conditions. Often the cause is managed care plans’ differential treatment of covered benefits for physical health conditions like diabetes than of benefits for behavioral health conditions.

A new state law, passed during the last Texas legislative session, however, should help. House Bill 10 empowers the Texas Department of Insurance, the state agency that regulates insurers and health plans, to better enforce the longstanding federal law requiring health plans to treat benefits the same for behavioral health conditions as for physical health conditions.

Although the federal law, the Mental Health Parity and Addiction Equity Act of 2008, has been in effect for a decade, gaps remained in applicability and enforcement. Until recently, for example, Medicaid managed care organizations, which cover more than 80 percent of Texas Medicaid enrollees, were exempt from parity requirements. In addition, the state’s failure to fully enforce parity requirements left gaps in access to allowable behavioral health services for individuals with private health insurance. The consequences of these gaps are significant and include delays in treatment, worsening of conditions and mental health crisis. Hospital emergency departments then are the only available source of treatment.

An estimated one in eight emergency department visits in the U.S. stems from a mental health or substance use need, even though most general acute care hospitals are not set up to handle psychiatric emergencies. This number has only increased in recent years. The result is medical staff diverted from patients in need of other critical treatment for trauma, heart attacks or broken bones, for example, to care for individuals who would be better served in a specialized behavioral health environment or who should have received preventive or intervention services in community-based care settings.

In addition to allowing the Texas Department of Insurance to better enforce the federal mental health parity law, House Bill 10 requires the Texas Health and Human Services Commission to establish a behavioral health ombudsman to which consumers may report mental health parity violations and a workgroup to study and make recommendations to limit parity violations and increase enforcement. THHSC’s behavioral health ombudsman is available to answer consumers’ and providers’ questions and help with concerns about access to care through public or private health insurance plans. Consumers can report parity violations to the ombudsman by submitting questions or complaints online, by phone, mail or fax. Through participation on the parity workgroup, Texas hospitals are providing examples of parity violations they see to identify solutions to improve access to care. Texas’ behavioral health hospitals often see parity violations in the form of “fail first” requirements, prior authorizations, peer reviews and medical necessity disqualifications. In its testimony to the workgroup, Texas hospitals have offered informal recommendations to improve access to care, including encouraging the state to examine managed care plans’ denial practices.

In addition to normalizing treatment for behavioral health treatment, eliminating differences in how care for physical and behavioral health conditions is reimbursed and administered will improve access to medically necessary treatment, improve behavioral health outcomes and reduce crisis as well as reduce hospitals’ uncompensated care costs – clinical and financial outcomes that are better for all Texans.

Legislative Interim: Texas hospitals’ year-round policy work

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

Packed with lively debates, committee hearings that continue into the early morning hours and nonstop news coverage, it’s no surprise that Texas’ biannual legislative sessions get all the attention for addressing the state’s public policy needs.

Because Texas’ legislative sessions last for about four months every two years, there’s a misconception that work on these policy issues occurs part-time. In reality, however, work on the state’s policy priorities occurs year-round.

The interim—the period between the end of one legislative session and the beginning of the next—is just as busy and just as important, and Texas hospitals have a vital role.

In the 140 short days of the legislative session, Texas lawmakers introduce bills and shepherd them through a labyrinth of procedural hoops and deadlines, with the hope that they will become law. This timetable leaves little time to tease out complex issues, so policymakers use the interim to study important issues or “interim charges” prior to the upcoming session. The Speaker of the Texas House of Representatives and the Lieutenant Governor kick off the interim work by distributing “charges” or specific topics for the committees in their respective chambers to study, consider in legislative hearings and issue recommendations.

Texas hospitals, in turn, use the interim to educate lawmakers on issues and policy priorities that will inform their upcoming legislative agenda and identify meaningful solutions to some of the industry’s most pressing challenges.

In addition to county revenue tax caps and funding for trauma hospitals, lawmakers are considering a number of interim charges that impact Texas hospitals leading up the 2019 legislative session next January, including the impact of opioid misuse and substance use, the state’s use of the “Rainy Day” Fund, federal health care reform, health care cost transparency and workforce issues. Also consuming much of the interim focus is Hurricane Harvey.

Nearly every committee in the Texas Senate and House of Representatives will study different aspects of the hurricane—from the public health response to how the state will better prepare for future disasters.

The interim is a time for looking ahead to the next legislative session, but it’s also a time of rulemaking to implement the laws of the previous session.

The legislature grants state agencies rulemaking authority to implement the laws it passes and enforce day-to-day compliance with those laws. The Texas Health and Human Services Commission, for example, sets new or amends existing health policy through its rules.

Engaging THHSC on its rules is another opportunity for Texas hospitals to affect policy decisions in the interim. If a proposed rule would have significant consequences for Texas hospitals or patients, Texas hospitals submit written comments requesting clarification or specific rule changes and attend administrative hearings on the rule.

This interim will be marked by Texas hospitals’ work to comply with the new $25 billion Medicaid 1115 Waiver. In order to obtain this funding, THHSC must set new policies and amend existing ones to govern the distribution of vital hospital supplemental payments. Implementing the new funding policy to regulate uncompensated care payments that cover some of hospitals’ costs for care provided to the uninsured is first up on the rulemaking agenda.

The months leading up to the 2019 legislative session are an opportunity for the Texas hospital community to advance good health care policy so that all Texas hospitals can continue providing the best possible care to patients in every community across the state. 

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.

Quality improvement in an era of change

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

Zero harm and the best quality health care have always been the hallmarks of Texas hospitals’ work.

In recent years, public and private payers have increased the use of financial incentives and penalties to accelerate hospitals’ quality and patient safety initiatives while also reigning in costs.

According to the Centers for Medicare & Medicaid Services, per capita health care costs reached more than $10,000 last year, and health care spending consumed almost 20 percent of the nation’s gross domestic product.

Quality measures and public health outcomes trail behind those of other developed counties, and despite significant coverage gains, about 28 million Americans—9 percent of the population— still lack health insurance.

Providers and consumers alike can recognize that fundamental changes are needed to make the U.S. health care system work better, but reconciling what changes are needed, who is responsible for those changes and which reform efforts are most promising is no small task.

The shift to a payment system that rewards insurers, hospitals, doctors and other providers for high quality, efficient clinical care is still a work in progress.

The federal government’s plans to implement sweeping Medicare payment reforms were disrupted by multiple efforts to repeal the Affordable Care Act.

CMS eventually canceled the ACA-required implementation of the Medicare bundled payment programs for heart attacks, bypass surgeries and certain joint replacement surgeries. Under the now-canceled bundled payment programs for heart attacks and bypass surgeries, hospitals would have been financially accountable for the cost and quality of all care associated with heart attacks and bypass surgeries. If implemented on the intended Jan. 1 start date, the cardiac payment models were estimated to save Medicare $160 million over five years.

Other value-based purchasing programs are also facing scrutiny, including the hospital readmissions reduction program and the merit-based incentive payment system created under the Medicare Access and CHIP Reauthorization Act of 2015.

Yet, while the movement towards rewarding value isn’t a straight path, progress is being made toward improving health care quality.

The Texas Hospital Association supports the state’s nearly 500 hospitals and health systems in their quality and patient safety work by leading initiatives that help hospitals collect, analyze and more effectively use their data and engage them in quality improvement initiatives to improve patient outcomes.

From reducing hospital-acquired infections to reducing avoidable readmissions, THA currently works with 350 Texas hospitals on numerous state and federally sponsored clinical initiatives, which are yielding impressive results and better patient care.

While this work continues, new bundled payment opportunities are emerging. CMS’ new Bundled Payments for Care Improvement Advanced will align financial incentives for hospitals and physicians for 32 episodes of care for Medicare patients. Additionally, it will measure performance across seven quality measures, including hospital readmissions.

As the shift to value continues and takes on different forms, Texas hospitals will continue their well-established missions to provide the safest, best quality care to Texas patients. 

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.