Update on TAFP’s policy priorities
By Jonathan Nelson
The 87th Texas Legislature will reach its halfway point on March 22 and while uncertainty around the pandemic and the great Deep Freeze Disaster of ’21 got things off to a slow start, action at the State Capitol is picking up. TAFP has joined many other organizations in efforts to reinforce our public health infrastructure, fight back against efforts to allow nurse practitioners to practice medicine independently, ensure adequate payment for COVID testing, and more. And we have provided testimony in numerous hearings, both virtually and in person.
TAFP Treasurer Emily Briggs, MD, MPH, testified before the Article II Subcommittee of the House Appropriations Committee on March 1, making the case for drawing down available federal funding to extend health care coverage to uninsured Texans. “More than five million lack health care coverage – a number that undoubtedly grew last year,” she said. “Five million is a difficult number to fathom, but they are the people who make our economy hum and our lives easier, such as grocery clerks, home health aides, or even the contract utility workers who repaired downed power lines following Texas’ arctic event…. By extending health care coverage to low-wage working adults, the state will provide them the freedom to start a small business, go back to school, or move or change jobs without worrying whether they’ll have health care coverage.”
She went on to articulate several of your Academy’s policy priorities. Here’s a mid-session update on TAFP’s legislative advocacy objectives.
Medicaid and CHIP
Texas continues to lead the nation in the percent of its population that lacks health insurance. The pandemic has only exacerbated that problem. Now is the time to tackle this problem and make reforms to provide access to high-quality, continuous, and affordable health care to all Texans.
- TAFP supports finding a Texas solution for extending comprehensive health care coverage to low-income, working-age adults.
- TAFP supports removing administrative barriers that make it difficult to enroll or to stay enrolled in Medicaid and CHIP.
- TAFP supports the implementation of 12-months continuous coverage for children enrolled in Medicaid.
- TAFP supports securing Medicaid coverage for mental health collaborative care, allowing physicians, psychiatrists, behavioral health providers, and case managers to work together to coordinate care.
Although leading up to the session, it looked like the state budget would be tight, now we know Texas is about to receive a huge influx of federal stimulus money from the COVID-19 relief package. This offers lawmakers a tremendous opportunity to make major investments in the state’s health care infrastructure, particularly in Medicaid and CHIP. Physicians in these programs haven’t seen an increase in reimbursements in almost two decades. According to a recent Health Affairs article, Medicaid in Texas pays about 58% of Medicare rates on average for primary care services.
Using federal stimulus dollars, the Legislature could establish a permanent fund similar to the Graduate Medical Education Expansion Grant program or the Rural Health Facility Capital Improvement Program, which was established by Texas’ tobacco lawsuit settlement. The Legislature could use dollars generated from the fund to direct the Health and Human Services Commission to pay for targeted Medicaid physician rate increases tied to either outcomes or provider network needs.
- TAFP calls on the Legislature to increase physician payment rates in Medicaid and CHIP.
Telemedicine payment parity
During the pandemic, physicians and patients have adopted telemedicine as never before. As part of COVID-19 emergency measures, telemedicine services have been paid at the same rate as in-office services. TAFP supports ensuring that covered services be paid by health plans at the contracted rate, whether the service is provided in person or via telemedicine.
- TAFP supports telemedicine payment parity.
Scope of practice
It just wouldn’t feel like a legislative session without a huge scope of practice battle, and this time around is no different. The nurse practitioner organizations are back once again with a bill that would allow APRNs without any physician collaboration to prescribe pharmaceuticals up to schedule III and in some situations, schedule II; order, perform, and interpret diagnostic tests; and prescribe medical devices. According to the Texas Medical Practice Act, those actions comprise the definition of the “practice of medicine.” As always, TAFP will fight this effort vigorously.
- TAFP opposes any effort to allow APRNs to prescribe dangerous pharmaceuticals; to order, perform, and evaluate diagnostic tests; and to prescribe medical devices and durable medical equipment without physician collaboration or involvement.
Health care cost transparency
An all-payer claims database is a centralized database that collects medical claims data from public and private sources. This data is used by researchers and policymakers to launch initiatives to improve quality and health outcomes while lowering costs. Among a broader consumer audience, such a database leads to greater transparency and the ability for patients to “shop around” for health care services by providing information on how much services cost across providers, facilities, and locations.
In a September 2020 letter to the House Select Committee on Statewide Health Care Cost, TAFP President Jake Margo, MD, wrote: “On the path from fee-for-service medical care to value-based care, gathering data to fully understand health care spending and utilization across a state or patient population is critical.”
Access to claims data enables researchers to paint a more complete picture of where health care dollars go and the types of health care visits that patients make. This information is crucial to determining where savings could be found. That is why 18 states have or are establishing all-payer claims databases to facilitate this data collection.
- TAFP supports the creation of a statewide all-payer claims database using the Center for Healthcare Data at the University of Texas Health Science Center at Houston to collect, process, and analyze health care claims and encounters to improve the quality of health care in Texas.
Our state’s 38 family medicine residency programs are the lifeblood of our primary care physician workforce, preparing more than 300 new family physicians for practice each year. During the COVID-19 pandemic, these clinics have proven their worth by providing consistent and comprehensive outpatient primary care to their communities, implementing new telemedicine and safety protocols, and working to reduce the strain on overburdened hospitals.
For decades, the Legislature consistently funded our state’s family medicine residency programs through the Texas Higher Education Coordinating Board. Although many of these residency programs receive some benefit from GME formula appropriations for Texas’ health-related institutions, dedicated coordinating board funds are the only direct state support these programs receive.
In recent years, this funding has been inconsistent and has varied dramatically, putting existing residency programs in jeopardy. Even as the state has increased the number of residents in training, the amount of THECB funding for family medicine residents has withered, dropping from $14,300 per resident each year in 2011 to $5,400 in 2021.
According to a report from the Department of State Health Services, the state will need approximately 3,400 more primary care physicians than it is on track to produce by 2030 to meet demand. Yet the base budget being considered now cuts the Family Practice Residency Program from $5 million a year to $4.75 million.
- TAFP calls on the Legislature to restore funding to the Family Practice Residency Program to $10 million each year.
- TAFP supports maintaining funding for other THECB programs designed to support the recruitment and training of primary care physicians in Texas and to ensure the appropriate distribution of those physicians, including the Statewide Preceptorship Program, the Physician Education Loan Repayment Program, and the State Rural Training Track Grant Program.
As a member of the Texas Women’s Healthcare Coalition, TAFP joins many organizations advocating for policies that increase access to high-quality care for women in all walks of life. Many of those policies focus on pregnancy, maternity, and postpartum care. Consider this information from testimony TWHC presented to the Article II Appropriations Subcommittee.
“In 2018, almost one out of 10 Texas births were to a woman who received late or no prenatal care. Additionally, almost one in nine Texas births were preterm, and one in 12 infants were born at a low birthweight. Moreover, alarming racial and ethnic disparities persist, with Black infants twice as likely to die within the first year of life compared to white and Hispanic babies, and with Black mothers having a disproportionately high percentage of pre-term births and low-birth weight babies.
“Not only does a woman’s access to health care impact her own health, as the [Texas Maternal Mortality and Morbidity Review Committee] highlighted, but access to health care is essential for future healthy pregnancies and births. Healthy pregnancies lower costs by reducing expensive neonatal intensive care stays for infants and prevent maternal health complications. For example, in FY2015, the average cost to cover a full-term newborn’s first year of life under Medicaid was $572, while the average cost for a pre-term, low birth weight newborn’s first year of life was $109,220.”
Healthy Texas Women and the Family Planning Program are two state initiatives designed to provide access to women’s health and family planning services. According to reports from the Texas Health and Human Services Commission, HTW and FPP saved the state a combined $139.7 million in 2019 alone.
- TWHC and TAFP call on the Legislature to prioritize funding for women’s health programs including the Family Planning Program, Healthy Texas Women, and the Breast and Cervical Cancer Services Program.
- TWHC and TAFP support extending Medicaid postpartum coverage from 60 days to 12 months.
- TWHC and TAFP support removing enrollment barriers for patients in Healthy Texas Women.
For more information about the Texas Women’s Healthcare Coalition and its work during the 87th Texas Legislature, go to https://www.texaswhc.org/.
Legislators may have heard the complaints of patients and physicians about the increasing burdens health plans inflict through the overuse of prior authorizations. Several bills have been filed addressing different aspects of the practice.
- TAFP supports requiring the Texas Department of Insurance to audit health plan compliance with statutory prior authorization timelines for approvals and denials.
- TAFP supports limiting the ability of health plans to deny emergency care claims based entirely or in part on what final diagnoses are eventually recorded.
- TAFP supports prohibiting prior authorization for health care services that are state-mandated benefits.
- TAFP supports limiting repetitive prior authorization requirements that compromise continuity of care for medical services and prescription medications for patients on appropriate, chronic, stable therapy.
Prescription Monitoring Program
TAFP joined TMA, the Texas Orthopaedic Association, and the Texas College of Emergency Physicians in asking the Legislature to appropriate funds to assist the statewide integration and maintenance of the Prescription Monitoring Program. In a letter to the Senate Finance Committee, the organizations said, “The PMP served as one of the Texas Legislature’s tools for addressing ‘doctor shopping’ by individuals who are attempting to acquire prescription drugs for inappropriate purposes.” The program allows physicians to review a patient’s prescription history through their electronic health record.
- TAFP supports ongoing funding for the Prescription Monitoring Program to keep software up to date and to continue the statewide integration process.
Tobacco and vaping
As a member of the Texas Public Health Coalition, TAFP supports a wide range of efforts to strengthen the state’s public health infrastructure and to address public health concerns. Last session, the coalition successfully advocated for the Tobacco 21 campaign, as SB 21 increased the legal age from 18 to 21 for a person to buy cigarettes, e-cigarettes, or other tobacco products. This session, the coalition has a few more policy goals.
- TPHC and TAFP support strengthening the regulation of tobacco and e-cigarette products in Texas.
- TPHC and TAFP support requiring licensure for vaping retailers.
- TPHC and TAFP support the prohibition of the sale of flavored cigarettes, e-cigarettes, and tobacco products.
Texas’ immunization registry, ImmTrac, plays a crucial role in how physicians and health departments administer vaccines. As it exists, ImmTrac is an opt-in system, meaning once minors become adults, they have to consent to keep their records in the registry. If they don’t, their records are destroyed. This is a major objective of TPHC.
- TPHC and TAFP support reform measures that would convert the state’s immunization registry to an opt-out system and simplify consent barriers in the program.
For more information about the Texas Public Health Coalition and its work during the 87th Texas Legislature, go to https://www.txphc.org/.