A Special Update for TDCJ Correctional Managed Care Employees + A Reminder for All University Employees

There have been many specific questions related to the status of the CMC budget.

Remember your civics and Texas government course? (Of course you do; you took it in the 7th grade.) The House and the Senate each produce a budget. Those budgets are put together for the next two years of operations of each state agency. Sometimes the House and Senate budgets look alike, but sometimes they look very, very different. This is the normal ebb and flow in the process.

This year, each budget looks vastly different from the other one. TDCJ and CMC budget items are allocated to Article V, having to do with criminal justice, prisons, the Department of Public Safety, and the like. This Article fared no better than others in each chamber, with marked differences in the overall as well as the specific allocations to budget items. Overall, it looks like this going to be a topic of serious consideration for the to-be-named conference committee. (See my April 20 blog post for more information on the conference committee process.) In past sessions, CMC has usually been discussed in more detail during Conference Committee.

Correctional Health Care LAR HB 1 Comparison

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So what does this mean? The House of Representatives put $84.9 million into its budget for CMC, but put it all into the first area designated for health care services (hospital and clinics). This amount covers the shortfall from the past biennium in building the next two-year budget and also allocates resources for predicted growth in costs related to like pharmaceuticals and treatment of elderly patients with chronic diseases.

The House did NOT allocate any monies for capital equipment, expansion of services (building back staff to 24/7 operations in selected sites) or for employee salaries increases. Rather, Representatives put these items into Article XI, the “wish list” Article. This means that they did not provide funding for the items, but they did leave the discussion open in the Conference Committee.

The Senate provided less money for the CMC enterprise than did the House: $50.5 million to be exact. Senators put $20 million into continuing operations of health care services, which creates quite a substantial shortfall for the next two years. The Senate made no provisions for pay raises in Article XI. They did fund the entire amount requested for capital and for expanded operations.

As you can see, the proposed budgets are vastly difference. So how does this get resolved? In Conference Committee.

What does that mean? The House and Senate leadership (the Speaker of the House and the Lt. Governor, respectively) will each appoint five members to a Conference Committee to meet and go through the budget article by article. They are called upon to reach a compromise that is acceptable to each chamber of the Legislature. For CMC in Article V, the Conference Committee will have to evaluate the money allocated in the budget for the program and decide how to spend those funds for the coming two years. Members could decide to “find the money” for employee raises, for capital, and/or for expansion of services. Sending this work to Conference Committee also means there is another step in the process, and funding decisions regarding correctional health care have not been finalized.

In “finding the money,” the Conference Committee has the option of adding more money to the allocation or subtracting funds from it. (It works both ways!) If the House or the Senate members have a compelling reason to add or subtract funds, they could do so in creating a final budget for each house to approve. And of course, that final budget would have to be acceptable to the Governor in order to obtain his signature and pass to become law.

We, along with leadership from the partner agencies, have been meeting with legislators and their staff throughout this session regarding the importance of all these CMC items, and in particular salary increases. We will continue to work with the Legislature on funding for CMC during the conference process. Nothing is “over” until the final gavel.

Now for the reminder: Many people working in CMC and other parts of the university have asked us about contacting their local elected officials regarding their thoughts and concerns about the budget and other matters. Expressing one’s opinion to elected officials is every American’s right, but for both state and federal employees, contact with officials must be done in the proper manner in order to comply with state and federal law.

Employees cannot make contact with Legislators on state time, or using state resources like telephones, computers, printers, email addresses, or paper and stamps. And no employee may speak as a representative of UTMB unless specifically invited to do so by university leadership. But all employees are free to contact a federal or state official to express opinions about any matter on their own time, using their own resources, and speaking on behalf of themselves as individuals. The state has created the following web site to help members of the public learn more about the Legislature, legislation under consideration and representatives for each district: www.capitol.state.tx.us.

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A Twisted Path into the Disenchanted Forest

AKA: Leave a trail of bread crumbs so you can find your way back to reality!

Politics are not going “as usual” in Austin this session. There are lots of twists, turns, switchbacks, and trap doors on the journey to Oz. We have been doing a lot of visits with members and office staff these past few days, trying to get a sense of where they are heading. The answer is more often than not, “Beats me! We are on divergent paths.”

Hopefully the paths will converge before all is said and done. The House voted out its budget a few weeks back, and its version of formula funding, hospital base funding and inter-professional education building TRB ($67.8 million) were as expected for UTMB. There is also a more generous addition to the CMC base of ($84 million), but not for capital improvements at the units, staff raises or expansion of services.

The Senate version of the budget is not as good for UTMB since it has less for our TRB request ($59 million) and much less for CMC ($54 million, which includes base, capital and expansion of services, but nothing for employee raises).

So both budgets will head to Conference Committee. Members will be named at a future date, but we can guess from the Senate side that it will include Chairman Nelson and Vice Chair Hinojosa, and most likely Senators Schwertner (Health and Human Services Committee) and Huffman (State Affairs), and perhaps Taylor (Education). From the House will be Appropriations Chairman Otto and Vice Chair Sylvester Turner, and maybe three of the following Representatives: Zerwas, Ashby, Price, Crownover, Sarah Davis or another. These 10 individuals from both chambers of the Texas Legislature will have the onerous task of reconciling their budgets into one document that can be supported by Senate, House and Governor.

Conference committee members will take all Articles of the budget and review them one by one, comparing where each chamber is on the issues and trying to find common ground. That process usually works. But, this time the chambers have pretty wide disparities in the items they feel are priorities and worthy of funding, so it is not just a matter of finances but also of ideology. That ideological split within the majority party could potentially be used by the minority party to leverage a few items on their priority list. We will have to be patient and wait to see where it all ends up!

At present, it is fair to say that the House and Senate budgets are miles apart in regards to their budget priorities, and there is serious skepticism from major leaders that they will be able to reconcile those differences during the scheduled session (ending May 31). Many staffers have cancelled vacation plans and members are extending rentals in Austin preparing for the worst-case scenario — a Special Session during June.

It could be a long hot summer! The voice from the Governor’s Mansion has been pretty quiet, unlike that of former Governor Perry, who frequently nudged the Legislature in the direction he wanted it to go. It has been Governor Abbott’s style to leave the Legislature to do its job; after all, he has given them clear instructions in his initial address and the Governor’s recommended budget. The Governor is likely waiting like the rest of us to get a damage estimate from the conference committee and go from there with some more “instructions” about what he will or will not sign related to the budget.

In addition, both houses disagree on the promised tax cut proposals, with the Senate wanting a property tax cut and a decrease in franchise taxes on businesses and the House wanting to reduce sales tax and increase homestead exemptions without a tax cut on property. Right now there are no real words of compromise but lots of shouting at each other through the media. I would predict that will continue for a few more weeks, with the rhetoric becoming increasingly impassioned from both chambers.

The gun bill literally misfired this week when Rep. Trey Martinez Fisher raised a point of order as it came to the House floor. The point of order — a violation of committee rules in which the record of testimony was filled with errors related to persons testifying for and against the bill — was sustained and the bill was sent back to the committee to be “fixed” (we hear they have brought in a gunsmith to work on it). It will make its way back to the floor for reconsideration, where it will likely pass. Although most of the state’s universities (except A&M) have gone on record opposing the right to carry on university campuses, the Legislature’s love affair with guns has not waned. Over 50% of the House members are already co-sponsors of the bill.

As you know, many consider the right to bear arms a birth right, and it can be a Republican “litmus test” (like opposition to abortion) for the truly conservative members. One mis-vote on such “litmus test” issues can result in the member not getting re-elected in the future. So, it is going to be a hard sell to find members willing to move against the party line and vote common sense on the guns-on-campus issue. After all university campuses are filled with young adults with immature neurological systems frequently exposed to and inexperienced with alcohol; that combined with gunpowder in many minds is a recipe for disaster. And, one must also be somewhat concerned about the wisdom of allowing anyone to carry weapons in hospitals, clinics or mental health facilities.

We do have an acceptable amendment excluding the GNL from campus carry; it should move ahead unimpeded. The NRA actually looked it over and stamped their seal of approval on it! There will certainly be efforts in the House to amend the bill to provide a safe environment on college campuses, in courts of law, health clinics and hospitals, and other places of public assembly and sometimes high emotion.

Emotional testimony seems to be trumping scientific facts, studies, reason and even common sense in hearings. A bill requiring all athletes to have an EKG (and maybe a cardiac ultrasound) as routine pre-participation screening for sports in the 9th and again in the 11th grade is sailing through the House unimpeded. This is in spite of testimony from the Texas Pediatric Society and children’s cardiologists citing that the testing is too costly and would impact too few kids. Economic issues on this specific topic are ignored despite the expert testimony. It reminds me of the misguided recommendation to screen all athletes for steroid abuse that was later repealed. We have a lot of legislators providing guidelines for medical practice at the moment without a careful review of the scientific literature.

On another front, the Texas Medical Board (TMB) issued its guidance related to telemedicine practice. Dr. Alex Vo of UTMB has been a godsend in providing advice and recommendations to the board. He has created a great positive relationship with Executive Director Mari Robinson of the TMB, who values his guidance and expertise. The board rules will not impair UTMB’s current telemedicine practice. According to one’s viewpoint, the rules may actually improve our access and ability to offer patients improved access. Mari Robinson is also helping us with DEA-related issues by assisting with the request to include MHMR clinics as accepted telemedicine sites. One of my recent blog posts covers this subject.

Graduate medical education recommendations will also be a major part of the conference process since both House and Senate have placed money in the budget for this program, but not exactly the same allocation of resources. This will be a matter of discussion also for future resolution.

On a different subject, the Senate did vote out Senate Bill 200 by Jane Nelson to partially consolidate the state’s massive health and human services system. The original intent was to consolidate the entire effort into a single multipurpose conglomerate to improve efficiency, lower operational costs and provide better services to clients. However, those intentions got sidelined due to the controversy surrounding the outsourcing and contracting of services to external vendors by the Health and Human Services Commission (HHSC).

Instead of proceeding with the anticipate consolidation of the existing five state agencies, the Senate has recommended that HHSC (which administers Medicaid programs and oversees the other four agencies) merge with the Department of Aging and Disability Services (DADS) and the Department of Assistive and Rehabilitative Services to form one agency next year. The other two agencies — the Department of State Health Services (which oversees public health as well as mental health services) and the Department of Family and Protective Services (which manages children and adult protective services) — would be added to the mix in the future. The timing of the merger would be determined by a committee of four Senators, four House members and three public citizens.

Audits of HHSC by both the Governor’s Office and the State Auditor brought public attention to serious lapses in the handling of private contracts. It was apparent that the contracting processes had not followed usual state protocols to ensure competitive bidding. Those issues and some “perks” provided to HHSC staff became lightning rods for the media. An FBI investigation continues to look at the contract irregularities, and several senior staff members associated with these alleged errant activities have resigned.

Executive Commissioner Dr. Kyle Janek remains the head of the massive HHSC agency, which boasts 54,000 employees and a budget in excess of $34 billion. The Texas Tribune quoted Governor Greg Abbott on April 15, 2015, as saying, “It is now clearer than ever that the Texas HHSC has been riddled with operational, managerial, structural and procedural problems that go far beyond any individual or contract. That is unacceptable.” Anyone interested in public health in Texas will want to keep an eye on how things go for HHSC.

Big agenda items in the next few weeks include a resurrection of “the Right to Open Carry” bills and the appointment of a conference committee to iron out the wrinkles in the budget. Of course, there will also be a host of other bills hitting the floor of the House and Senate.

Be on the lookout for the dire wolf in our own version of “Game of Thrones.” You never know what will fall to the sword next.

Stay tuned for “Sights to Behold.”

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Telemedicine Rules Handed Down by Texas Medical Board

The Texas Medical Board (TMB) delivered on its promise of a new set of rules defining the do’s and dont’s for the practice of telemedicine.  The issue has been a highly charged one because the TMB has been in litigation with a private company related to the use of commercial telemedicine in the state.  The aforementioned company has much at stake, with over $15 million in annual revenues from their practice in Texas alone, where they have provided care for over 140,000 clients.

The primary controversy has been related to the physician-patient relationship.  The TMB has insisted that telemedicine services should be limited to patients with an established doctor-patient relationship through a face-to-face encounter.  The use of phone service consultations for the delivery of health care to a patient unknown to the treating physicians and the lack of ability to offer follow-up services to the patient have been points of concern to the medical board.

The company had the following to say in an April 10th article from the Houston Chronicle: “Unfortunately, the Texas Medical Board’s decision to adopt a new rule takes away Texans’ access to a safe, affordable and convenient health care option that many have depended upon for more than a decade.   As Texas’ population booms, health care expenses climb, and the shortage of primary care physicians grows, telehealth is a solution for patients dealing with common, non-emergency issues.  This rule change only serves to intensify these problems without providing any benefit to Texans.”

However in the same article, TMB President Dr. Michael Arambula is quoted as saying, “The rules represent the best balance of convenience and safety by ensuring quality health care for the citizens of Texas.  However, a telephone medicine scenario that allows a physician to treat an unknown patient without any objective diagnostic data and no ability to follow up with the patient sacrifices the patient’s safety for convenience.”

In testifying against the rule, Bill Hammond, CEO of the Texas Association of Business, said, “There’s no question whatsoever that this is about doctors protecting other doctors’ income.  It’s about dollars.  It’s not about better health care.  This regulation would be a death knell for telehealth.”

But on closer inspection, the policy may not be as bad as some would portray it. It in fact does expand access to telehealth technology to a greater audience.  At the crux of the argument are massive amounts of misinformation confounded by generational and knowledge gaps in understanding the application of teletechnology.  Many of the opponents to the expansion of telemedicine services largely base their argument on their perception that the quality of services is inferior to traditional office visits and see problems with the lack of an established doctor-patient relationship.

On the other side, proponents of the expanded use of telemedicine feel like traditional physicians are trying to protect their geographic turf and insulate their patients from intrusion of specialists.  These individuals also see the benefits of the use of telemedicine’ including improved in quality of services, improved access, and decreased patient costs.

This week has also been “telemedicine bill week” at the Capitol.  Multiple bills have been heard in the House Public Health Committee related to expansion of telemedicine services as the technology continues to be recognized for its potential to deliver health care and mental health services to hard-to-reach parts of the state in both an effective and cost-efficient manner.

Working in collaboration with the Office of Health Policy & Legislative Affairs, UTMB’s Dr. Alexander Vo, Vice President, Telemedicine and Health Services Technology, has created an effective working relationship with the TMB, the Health and Human Services Commission, and members of the Legislature regarding the expanding frontiers of telemedicine and health population management.  Dr. Vo’s pioneering work in the area of telemonitoring in the management of population health is positioning UTMB to become more aligned with government programs that base reimbursement on improvement of patient health outcomes.

To reconcile the misunderstandings associated with the media’s reporting of the TMB’s actions this past week, the board put out the following press release.

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On the Eastern Front: Washington may be undergoing a thaw!

We always have to keep one eye on Austin and the other one on Washington.  This week, while the Texas Senate has been passing out a state budget that is vastly different from that passed out of the House several weeks back, the US Congress has also been at work – of sorts, considering that the Senate went on a two week vacation after the House had passed out the legislation.

Three weeks ago, the US House of Representatives took up the Sustainable Growth Rate (SGR) issue related to Medicare reimbursements.  For the past 12 years, that issue has evaded resolution by the US Congress.  In fact, the Congress has put 17 temporary Band-Aids on the issue, passing just-in-time stop-gap measures to keep the Medicare program and physician reimbursements on-line.  This time, failure to resolve the issue would have resulted in a 21 percent reduction in reimbursements to physicians serving Medicare patients.

To the surprise of many political pundits, Speaker John Boehner and Democratic leader Nancy Pelosi worked out a bipartisan plan that passed the House 392 to 37.  That plan creates a new “Merit-Based Incentive Payment System,” along with other alternative payment models that focuses on quality, value and accountability in the Medicare payment system. Over a five-year period, this system will replace the old volume-based payment program (i.e., payment for number of services performed) for one that focuses on rewarding physicians for improved quality of care and better patient outcomes.  More care management will be emphasized in the new payment system.

The new plan throws out the old Medicare physician payment rates, which were set through a formula based on economic growth (the SGR) and replaces it with a half-percent increase in each of the next five transition years as the system moves toward a value-based reimbursement methodology.  Financial rewards would prioritize physician use of the “patient-centered medical home,” chronic care management, better care coordination models, and use of data leading to quality improvement and transparency.

After their holiday, the US Senate on April 14 passed HR 2, the Medicare Access and CHIP Reauthorization Act of 2015 by a vote of 92 to 8. The act repeals the SGR formula and reframes Medicare reimbursement to incentivize quality.  On an almost unrelated subject but one of interest to those of us in health care, the bill also included a two-year extension of funding for the Children’s Health Insurance Program (CHIP).

In addition to addressing the Medicare payment issue – which has dragged on for over a decade, leaving patients and physicians uncertain about the future of the Medicare system – the reauthorization act also includes other items of benefit for physicians:

  • The current Medicare quality reporting programs will be streamlined and simplified into a merit-based incentive payment (MIPS) which will reduce the aggregate level of financial penalties physicians could have faced.
  • The legislation protects physicians so medical liability cases cannot use Medicare quality program standards and measures as a “standard” or “duty of care.”
  • The system will include incentive payments for physicians who participate in alternative payment models and meet certain benchmarks and thresholds established in those models.
  • Smaller medical practices will receive technical support to participate in alternative payment models or the new fee-for-service incentive program.

The legislative package sets up two tracks for physicians to receive payments:

  1. Track 1 would essentially maintain the status quo.
  2. Track 2 would allow doctors to place patients into a risk-based payment model which would qualify them for the alternative payment track and receive higher reimbursements starting in 2019.

It also provides:

  • Extension of CHIP funding by two years
  • The allocation of $7.2 billion in additional funding for community health centers
  • A six-month delay in enforcement of the CMS “two midnight” payment policy for short hospital stays where hospitals get paid on an outpatient basis if the patient’s stay doesn’t span two midnights in the hospital

Senator Orin Hatch described the final passage of the SGR reform as a “monumental achievement.”

All 8 votes against the SGR reform came from Republicans who favored paying for the cost of the bill by other budget reductions.  Among the “no” votes were Senators Ted Cruz and Marco Rubio; Rand Paul voted for it.

The legislation’s passage allows each party to “spin” the win their own way.  For Democrats, its passage marks the addition of funds for children and the poor; for Republicans, the bill introduces new models of payment that pave the way for quality improvement and cost reductions in the Medicare system.

Has Congress found a new way to work together?  One could only hope so!

The legislation now passes to the White House for President Obama’s signature, which is anticipated to take place with plenty of ceremony in the next few days.

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A Change of Season – And So Much More

For the 84th Session, January and February were spent congratulating other legislators; introducing constituents, friends, clubs and organizations visiting “your Capitol”; jockeying for committee appointments; and the usual meets, greets and speeches. Lots of fanfare and love during those first two months!

March is supposedly the windy month or so my Mama said—and it was! The winds of change blew gale force through the Capitol as subcommittees and committees were appointed, with lots of new faces and the work of formulating a budget taking place against a backdrop of continuing accolades on the House and Senate floors each day for visiting groups from back home and special delegations from everywhere. The Capitol was teeming with people like an ant hill preparing for its queen. Committee members arrived early and worked until late at night, building a budget in each house. Overall, they did a pretty darn good job with the instructions provided by leadership.

As discussed in the last Ben’s Blog, the House and Senate have done their jobs to create a suitable budget. So what could go wrong?

Well, is the glass half empty or half full? Depends upon your viewpoint, doesn’t it?

Some will likely say that there is not enough money to fund the proposed budget, even though the budget is $2 billion below the state’s spending cap and it would leave $21 billion left in unexpended funds and the Rainy Day Fund. Some will gaze into a crystal ball, note that oil prices have decreased, and brace themselves for a “worst case” scenario. They will desire to preserve fiscal resources and at the same time push for increased tax cuts, especially on businesses (a Franchise Tax reduction) and personal property (which could total as much as $250 a year for the average homeowner). Budget cuts and tax cuts will be touted as necessary to stimulate an anticipated sluggish economy.

Still others will cite the dynamic Texas economy that not only survived the national recession but THRIVED in spite of it. They will note the marked increase in jobs in Texas and the increased number of taxpaying residents in the state. They will note that expanding populations must have more in the way of state services, especially public and higher education, transportation, public safety, access to health care, and all the other government-related services that go along with that thriving economy. They will see the glass is “half full” and needing to be topped off with additional resources that ensure the continued success of Texas and Texans.

One group sees opportunity and welcomes change; the other sees threats on the horizon and seeks to preserve the status quo. It is from these ends of the spectrum that our Legislature must negotiate a final budget in a conference committee composed of members from the House and Senate.

I’ll write more about that process in a future post, but in general, the conference committee must take into account a number of critical needs as they negotiate the state’s final budget for FY2016 and FY2017. Among the issues our Legislature must consider:

Increasing Cost of Health Care—The marked increase in the cost of health care is not a pretty picture, any way you view it. More and more hospitals are facing closure. Although that has been especially true for small rural and community hospitals, many of the larger urban safety-net hospitals are now dealing with severe shortages in revenues. Why?

Patients who were able to purchase health insurance through the federal Affordable Care Act (ACA) are availing themselves of nearby for-profit hospitals. Since Texas elected not to expand Medicaid, the safety net hospitals are still the primary source of care for the uninsured. And that is something that Texas still has in abundance. The demand there has outstripped the ability of the usual array of safety net hospitals to meet the needs of their patients. Both Harris Health (the Harris County Hospital District) and Parkland Hospital just posted the poorest financial performances they have experienced in years.

Just how bad is it? There is talk of downgrading Ben Taub’s Level 1 Trauma Center to a Level 3 facility, because they do not have the space and/or physician support to continue to be a full-service Level 1 Trauma Center.

Such a change would have a huge, negative impact on the Southeast Texas region. We currently have three trauma centers, two available by air ambulance. If the third (Ben Taub) closes, then that leaves only Memorial Hermann in Houston and UTMB on the island to cover the needs of more than 7 million people in an 18-county area. A downgrade in Ben Taub’s trauma center status could trigger a true medical emergency in the area. Sheer growth of population is already stressing trauma services. Without adequate access to Level 1 Trauma Services, major businesses will not relocate here, in turn stressing the economy of the whole region.

Increasing Cost of Health Care in Prisons—The state’s prison health care costs continue to go up every year in spite of both UTMB and Texas Tech health care providers using all the right tools—such as electronic health records, special pharmacy pricing, pharmaceutical reclamation programs, best-practice treatment protocols, strict utilization review, creative staffing, Six Sigma and other programs to ensure maximum efficiency. The fact is that the prison population is static but the number of offenders older than 55 years is increasing at rate of more than 10 percent every year. With the graying of the prison population come all of the diseases that accompany aging, such as diabetes, heart disease, lung disease, psychiatric illness, and cancer. And roughly 28 percent of the overall prison population has hepatitis C associated with past substance abuse. Providing a constitutionally appropriate level of care for patients with these costly chronic illnesses will become more challenging over time.

State retiree health care costs—As retired state employees enrolled in TRS and ERS live longer, they will consume greater amounts of health care resources. It will take at least $850 million to make the TRS fund “whole” and another similar amount to address ERS.

Transportation—Another major expense item facing the state is the diverse transportation needs driven by the thriving Texas economy. There is always a price to pay for success, and the roads, rails and ports that support Texas are all crying out for a piece of the financial pie! Harvesting Texas’ oil has proven to add to the wear and tear on Texas highways. Have you been on south I-35 to Laredo recently? One pothole leads to another bigger pothole. The same can be said for I-20 and I-10, and even the smaller Farm-to-Market roads from the 1960s are worn. Who knows when I-45 South from Houston to Galveston will ever be finished? The price for these major and evolving infrastructure needs is not small—a minimum of $5 billion and perhaps as much as $10 billion.

And lastly, EDUCATION—There seems little doubt that the issue of public school financing is far from resolved. The House has placed almost $3 billion into the budget in their effort to stave off future lawsuits on school finance. The irony of the present lawsuit is that many of the plaintiffs who found fault with the prior funding scheme have now become “wealthy” districts because of the oil and gas revenues being recovered in their tax districts. For this reason, their case may no longer have merit based on inadequate funding. It is anyone’s guess as to how the Supreme Court of Texas will rule on the school funding issue, but that decision will affect every man, woman and child throughout the state.

Higher education is still reeling from the devastating reductions in formula funding imposed on them in 2001. It has been a decade and a half and higher education is still feeling the impact of inadequate funding, including higher tuition for students (which amounts to a tax on students and parents); the financial freezing out of thousands of students who desire a college education but lack financial resources; and ultimately educational programming that fails to meet national and international standards, especially in the sciences, engineering, mathematics and technology.

For nearly a decade, universities have not enjoyed state support for the construction of new facilities, while student populations have doubled or tripled in many cases. I have been asked if we are using UTMB facilities to our maximum ability (like at night and on weekends). I reply “yes” and assure any doubters that seeing is believing. Resources to build new facilities on our university campus are a must this session, and failure to respond to the growing demand puts our historic education mission at risk. When I am asked if we are using technology, I reply “Yes.” But there is a limit to how many courses one can take online and still get a high-quality education in the health sciences. Some things are better learned in person. Organic chemistry lab at home in the kitchen usually does not turn out well!

For UTMB and our fellow academic medical centers, the “higher education” issue extends beyond graduation. Every city now wants its own medical school. Texas is a great and geographically diverse state, and it is good that we produce an adequate supply of physicians and other health care professionals. But the lack of graduate medical education (GME) programs means that many of the students we educate at Texas taxpayer expense have to seek GME opportunities in other states. About half of those Texas medical school graduates who leave the state for residency training will never return home to Texas to practice, whereas most of those who stay in Texas for their GME training end up practicing here. It is a pretty simple value proposition! If a state is going to retain the medical school graduates it has invested in already, it must provide an abundance of diverse GME slots to attract those students. The $60 million designated for additional GME funding is a great start, but it is a drop of water in a five-gallon bucket that clearly needs additional contributions.

As a leader in this nation, Texas must take an aggressive role in addressing the key success factors to ensure that it remains an economically attractive place for families to live and work. That means that we have to settle for nothing less than excellence in public education and that the higher education road is paved with a solid foundation to attract external students. Our health care system must be the best value in the nation, meaning that quality is high and cost is low. All of our citizens must enjoy access to health care if we are going to interrupt the cycles of costly chronic illness. We must be able to traverse our state safely and efficiently using air, rail and roadways. Our cities and neighborhoods must be safe and well-planned to support families from all walks of life.

How we spend our state’s resources is a real reflection of our state’s priorities. We must hold ourselves accountable for the right outcomes in our strategic budget planning. In Texas, we only get 140 days every two years to make these decisions. We need to get them right.

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Let the Budget Negotiations Begin!

The past month has flown by for us working the Austin legislative shift. The month has been filled with subcommittee meetings related to the construction of the state’s future biennial budgets for 2016-2017. As you may recall, the House Appropriations Committee and the Senate Finance Committee are charged with developing their own versions of the state budget. Each does that by appointing subcommittees for each “Article” in the state’s adopted budget.

Articles of particular interest to UTMB include Article II (Health and Human Services), Article III (both public and higher education), and Article V (public safety, including all matters related to, prisons, probation and correctional health care services). Other Articles also may impact UTMB interests, so we monitor them all, but Articles II, III and V are our chief focus.

Each subcommittee reviews the recommendations related to their budget section from the Legislative Budget Board (LBB) and hears testimony from heads of those affected agencies, schools and/or individuals. For instance, when hearing about offender health care, the subcommittee may concern itself with historical financial information from the LBB, priorities raised by TDCJ, as well as comment from the general public.

After deliberation (which this year was open to the public in House Appropriations’ process and for the most part closed to the public in Senate Finance’s), the subcommittee formulates its own recommendations related to the allocations that they are willing to commit to the budget. Those recommendations are then presented to the entire committee for review, consideration, change and eventual adoption. The adopted budget then moves to the floor of the House or the Senate for debate, review and adoption.

On Tuesday, March 31, the House’s version of the recommended budget HB-1 was debated on the floor of the House. It was quite a prime-time event, worthy of an Emmy nomination, but it would be hard to place in one category. Drama? Comedy? Reality TV?

The debate began at noon on Tuesday and concluded at 5 a.m. Wednesday. One could feel the drama as each section of the budget and the 350 attached amendments were reviewed. (That’s right—350 amendments!) The House in many cases had to vote on the amendment to the amendment to the amendment! During one section as a member proposed moving funding from AIDS education to abstinence education, the questioning became rather personal as related to the bill sponsor’s sexual history, i.e. “Hold old were you when you first had sex?” On the other hand, there were points of levity interspersed with times of passionate speeches about health care access, the needs of our veterans, the need to protect children, and the expansion of women’s health care services.

When all was said and done, the House voted to approve a $209.8 billion budget for the state’s next biennium, with a generous allocation to education. Even in their largesse, the House left untapped over $8 billion in the Rainy Day Fund and another $11 billion in unspent resources, for a total of more than $19 billion in available funds. The House could have added in another $2 billion to improve education, shore up TRS or address a myriad of other problems. But members chose not to do so, citing fears of economic recession in the future tied to declining oil prices (and decrease in tax revenue derived from oil and gas production).

So where does the House action leave UTMB?

Based upon our original priority list, here is where we are:

  1. Formula funding has increased over prior years as requested, but not as much as any of the academic or health-related institutions would have liked. We are still not back to the requested 2001 levels of funding before the steep reductions in that decade. The House increased formula funding by 3 percent over the filed bill.
  2.  Regarding our requested financing for a new interprofessional education building, the House approved Tuition Revenue Bond payment reimbursement that would permit UTMB to acquire $67.8 million in funding for the proposed $90 million student educational building. We had great support on that issue from Representatives Greg Bonnen and Wayne Faircloth, who both proved to be effective advocates for our need, based on our 42 percent growth in enrollment.
  3. Our hospital base was maintained as requested. The House placed all three of our special item requests and our request for an additional $11.3M for the hospital into Article XI, often referred to as the “Wish List.” They sit there with $34 billion (yes, with a “B”) other requests. We will work to have at least one of the requests float to the top during the budget conference time with the Senate.

Of special concern is the legislature’s lack of interest in considering our request for a special mission-specific formula for our hospital. The two other state- funded health-related institution hospitals are funded through a mission-specific formula that is considered along with the instruction formula, making a biennial increase to their hospital’s base funding much more likely, and cuts to that funding much more unlikely.

We would like for UTMB’s hospital to be funded through a similar mechanism, since we were the first public hospital in Texas and are still a vital part of the state’s trauma, specialty, and primary care network. But when the mission-specific formula request was brought to House Appropriations by Rep. Bonnen, objections from a Dallas representative that it would be “another new formula” led to the subcommittee deciding not to even include it on the lengthy Article XI wish list. We have been told that the subcommittee hopes to study formulas in general during the interim period between legislative sessions, and our hospital formula issue could be considered then.

Regarding correctional health care, the House funded in the TDCJ budget request the entire amount of the proposed base increase request; in HB-2 (the Supplemental Appropriations Request), they funded another $50 million to pay for shortfalls in the current biennium (meaning, 2014-2015). In HB-1 Article V, the House placed the capital requests, funds for employee salary increases, and funds to expand hours of operations and the hiring of additional staff in Art. XI wish list. As noted below, we will have to wait for a House/Senate conference committee to do its work before we know the final say on these items.

senate finance

Senate Finance Committee

In the Senate, the story is quite similar regarding UTMB’s primary agenda, since the Senate and House budget processes mirror one another.

  1. The Senate chose to also increase funding for formula in its budget, so that is good! The Senate formula increase was an additional 2 percent increase over the filed bill.
  2. The Senate chose to deal with institutional improvements in a different manner, funding slightly less than the full request for each institution. For UTMB, the education building funding is at $59.325M, compared to the $67.8M full request that is funded in the House version. The hospital base was maintained also in the Senate version of the budget. Although we wanted more added to the base through a formula mechanism as discussed above, no action has been taken on that. However, the formula request, plus a request for an additional $11.3M for the hospital, were included in the Senate’s Article XI “Wish List”.
  3. Lastly, UTMB’s Emerging Infections proposal was placed on the short list produced by the subcommittee for funding from Article XI. In the end, the Senate Article XI was expanded to include all exceptional item requests and is as long as the House’s Article XI, but we take it as a hopeful sign that the Emerging Infections request had initially been selected for a short list.

Concerning the TDCJ requests, the Senate was less generous overall than the House. The Senate allocated $20 million of the requested amount for rebasing the next biennial budget, they passed over raises for the employees, but did fund capital requests and expansion of services at the fully requested amounts. So as the House and Senate go into conference on Article V (TDCJ – CMC) issues, there is work yet to be done to resolve their budget differences. (I’ll cover the conference committee process in more detail in a future installment.)

What else is going on?
As you have likely heard one of the big issues in Austin has been regarding the right to bear arms, and more specifically where that right can be exercised. Although University of Texas System Chancellor William McRaven has gone on record before the House and the Senate opposing any legislation that would welcome the carrying of firearms on university campuses, the Senate passed out that legislation. The bill has passed the House committee and is on its way to the House Calendars Committee, where a date for its House floor debate will be set.

Chancellor McRaven with UTMB SOM Students at the Capitol

Chancellor McRaven with UTMB SOM Students at the Capitol

The issue is quite relevant and unique to UTMB since we not only have a prison hospital on our campus but also the Galveston National Laboratory (GNL). The right to carry would jeopardize the reauthorization of our GNL since the extensive and strict federal security requirements could not be met if guns were allowed in the facility. It could cost UTMB over $50 million in federal research funds. Our Austin team has had great support from Sen. Larry Taylor, who has worked with the bill’s Senate and House authors (Sen. Brian Birdwell and Rep. Allen Fletcher) to produce an acceptable-language addition to the bill that exempts the GNL. The bill has passed out of the House Committee with the GNL exemption in it, and we have been told that if the bill passes the full House, the Senate will accept the exclusion of GNL when the bill comes back to the Senate for concurrence. The bill already maintained the current prohibition of carrying a firearm in a hospital or prison.

What about Graduate Medical Education (GME)?
Well, that also received attention from both houses, with Sen. Jane Nelson making good on her promise to ensure increased funding on the Senate side. The House Appropriations Committee did likewise. Several new programs hosted by the Coordinating Board. The House chose to fund less in this area than did the Senate, but it is likely that a reasonable compromise will be reached in the conference committee. The message that Texas must have additional GME slots to accommodate the expanding number of graduates from Texas medical schools has clearly been heard.

So what’s next?
In a couple of weeks, the Lt. Governor and the Speaker of the House will each name members to form a conference committee to review the combined budget proposals line by line. In that process, members will seek compromises on budgets that can be accepted by both houses. Then that product will move to each body for a vote.

Although the proposed budget in the House is a good start when compared to prior budgets, some would say that it falls short in public education spending. Others would also note that Texas roads and rail need more transportation funding. The Legislature also has failed to fill a rather large ($768 million) shortfall in TRS’s health plan. The Legislature did move forward to fill a hole in the state employee retirement plan (ERS). There were also some victories for Child Protective Services with increased funding, along with a small but highly sought increase to attendant care pay for individual home care programs.

There have been no significant changes in funding in the Medicaid program on a per-unit basis other than increases driven by increases in enrollment. Specifically there is no money dedicated for Medicaid expansion.

The proposed “tax relief” package will actually decrease the revenues collected by the state and add to the likelihood of more shifting of resources among programs.

Stay tuned as the journey continues!

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Fast Start

The 2015 Legislative Session got off to an accelerated start! We’ve hardly had time to respond to usual business with the massive number of meetings and hearings that abound.

So what is different this time?

For starters, we have a whole new team in Austin. All executive leadership has changed from Governor to Land Commissioner. And over half of the legislators (House and Senate) have served less than two terms in their districts. The Speaker of the House, Joe Straus, is the only person to return to his “old job” and that was with a recorded landmark vote of House members, only 19 of whom were opposed. Straus set a rigorous pace by naming committees and chairs in record time, and by shuffling up the leadership roles and distributing the talent around the table.

In the Senate, newly elected Lt. Governor (and President of the Texas Senate) Dan Patrick likewise, named his committees quickly, with Senator Jane Nelson continuing to chair the powerful Senate Finance Committee and Senator Charles Schwertner assuming the role of chair of the very important Health & Human Services Committee.

UTMB’s legislative agenda remains unchanged from this past fall when we provided testimony before the House, Senate and Legislative Budget Board. UTMB’s top priorities remain:

1. Growth in formula funding to support our educational programs for students, necessary university infrastructure for that purpose, and research critical to solving the health problems of the state and nation. All state universities share this same agenda item since the Legislature in 2001 reduced the allocation for formula funding (the amount that the state provides toward student education at public universities) and then went on to deregulate tuition in 2003. Of course, with fewer funds from the state, universities’ only option to cover increased educational costs has been to increase tuition. Increasing formula funding should offer students some future relief from tuition increases.

2. UTMB has grown its student population by 42.4 percent since 2006. In fact, UTMB is ranked the fourth fastest growing university in the US in a survey published this week. With that growth (up from 2,600 when Hurricane Ike flooded its way through our campus to over 3,200 with this year’s fall enrollment), UTMB needs more space for student study groups, lectures, laboratories, and related activities. UTMB leadership’s answer has been to construct a new multipurpose, interprofessional education building on the west end of the Galveston campus. Without that investment, UTMB will not be able to continue to expand its enrollment to address future health care workforce needs of Texas. UTMB is asking the state for a Tuition Revenue Bond or other funding mechanism to provide $67.8 million toward that new facility; the remainder of the proposed $90 million building would come from philanthropy and university financing.

3. UTMB’s renovations and new buildings that have emerged from the wake of Hurricane Ike are now coming on-line, and with that comes the depreciation expense of those buildings in our budget. UTMB needs additional funds in its Health System budget to cover those expenses. Both UT MD Anderson and UTHealth Northeast (Tyler) have “formulas” that drive biennial increases in their hospital budgets. In the past UTMB has sought similar treatment from the Legislature but without success. UTMB is asking the Legislature to treat UTMB with equity regarding the base hospital increases received by other UT System hospitals.

4. All Health Related Institutions have asked for “special item” appropriations to fund university improvement projects and/or research deemed vital to the overall success of the university that also benefits the state and nation. UTMB has asked for three critical areas of support:

Combating Texas’ Emerging Infections ($8.55 million over two years)

i. Expands UTMB’s expertise in combating emerging infections by fostering collaboration with other Texas research institutions
ii. Focuses on the development of artificial organs and tissues that mimic human organs to facilitate the testing of drugs and vaccines
iii. Builds on the substantial federal and state investment in UTMB’s Galveston National Laboratory

Trans-Texas Vaccine Institute ($8 million over two years)

i. Creates a multi-agency institute to support collaborative projects that expedite the development and production of needed vaccines
ii. Builds on the success of UTMB’s interdisciplinary Sealy Center for Vaccine Development, and maximizes impact of expertise found through Texas’ higher education community
iii. Bolsters UTMB’s recent designation as a World Health Organization recognized vaccine center, and helps propel Texas to the forefront of vaccine development in the nation

Regenerative Medicine Matching Grant ($6 million over two years)

i. Provides two years of funding to leverage the recent four-year, $3 million per year Moody Foundation grant focused on reversing trauma induced alterations in the brain and spinal cord
ii. Supports multidisciplinary projects to create agents capable of reversing trauma induced alterations of the brain and spinal cord

Governor Greg Abbott delivered his first “State of the State” address to a combined session of the Texas House and Texas Senate and received an enthusiastic welcome from members of both chambers. Abbott stressed the importance of Texas charting an aggressive course for the future, outlined his budget priorities and listed five items that he placed on his “emergency agenda” – early education, higher education research initiatives, border security funding, transportation funding and ethics reforms.  That agenda simply means that the Legislature is asked by the Governor to make those items a priority for early action during the session.

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The End is…..Near?

Midnight Monday, May 25, 2013, was supposed to herald the end of the 83rd Legislative Session. Some described the whole session as a very long Seinfeld episode—much talk, little action. But in the waning days, it is readily apparent that this has been one of the most productive sessions, with less conflict among members, in recent memory. The litany of potentially divisive issues from past years was absent, so members were able to build trust and rapport with each other over issues of mutual concern, like public education, water availability, transportation, higher education, public safety and the state’s economy.

In addition, the large number of “freshmen” legislators proved to be an asset with their new ideas and open, innovative minds focused on problem solving. The House even instituted a “purple tie” day each Thursday to reminded Republicans (red) and Democrats (blue) that together (red + blue = purple) they worked for common outcomes for the benefit of Texans.

For UTMB, the session was not without its ups and downs since the university is subject to a multitude of funding articles in the budget and impacted by no small number of regulatory changes and Health and Human Services budgetary changes. Even Public Safety in Article V impacts UTMB since it deals with the state’s prison system. As is always the case, the real financial impact often cannot be seen until the dust settles and the effects of the myriad individual funding changes have been analyzed.  But for now, our results fall into the following general patterns related to our legislative appropriation requests:

  1. UTMB asked for growth in formula funding to support the education of our health professions workforce, to provide necessary infrastructure and to build our research infrastructure. Formula funding for the next biennium will increase by approximately $24.5 million. Overall, Chairman John Otto and others of the House Appropriations subcommittee on higher education elected to put more money into formulas to be used at the discretion of the university than to fund special projects and exceptional items as in times past.
  2. UTMB asked for a continuation of the 2012-2013 funding levels for the UTMB Hospital and Health System and for the creation of a Hospital Formula to protect us from drastic General Revenue reductions like we experienced in the last session. The House Appropriations Committee (HAC) was not inclined to create a hospital formula for UTMB at this time, even though both UT Health Science Center at Tyler and UT MD Anderson Cancer Center both have mission-based formulas. Instead, the higher education subcommittee of HAC decided to perform an interim study on that subject and take a look at all higher education and health-related education funding formulas to ensure equity among institutions. The Legislature did respond favorably to our request for an addition to our hospital base by adding $10 million for the biennium since no formula was forthcoming.
  3. Although UTMB and other Health Related Institutions requested exceptional item funding for specific research projects, the House Appropriations Committee elected to forgo those appropriations and fund formulas instead.
  4. At the close of the session, the Tuition Revenue Bond (TRB) bill was caught up in last-minute conference committee deliberations and failed to pass out of the Legislature. This will be placed on the agenda for the special session; UTMB has a $40 million request for funding of a new educational building on the Galveston UTMB campus; the request has been approved by both the House and Senate, but it has not released from conference. That means a new bill will have to find its way through the special session for this purpose. We already know that the bill filed for the special session will lower all TRB requests by 15 percent, reducing our $40 million request to $34 million. But our legislative delegation will work to achieve maximum funding, consistent with what other institutions receive.
  5. Correctional health care funding was an issue of great controversy in prior sessions. However, in the 83rd session under the new contractual arrangement with TDCJ, UTMB has been paid monthly for its provision of health care services by TDCJ so there was no need for a Supplemental Appropriations Request. Instead, the Legislature was able to focus fully on the current and future needs of the correctional health care delivery system. In the end, they agreed upon the following appropriation of $61.7 million for correctional health care funding for the 2014-15 biennium:

Total Appropriation UTMB Portion*
Adjustment to Base $30.6M $27M
Salary Adjustment $16M $12.4M
Capital $54M $4.9M
Restore Staffing $9.7M $3.8M
Total
$61.7M
$48.1M

*Remaining portion goes to Texas Tech University.

There is a host of other changes that we will discuss, but of major importance is UTMB’s continued growth in resources to finance its health care operations, research and educational programs, and community benefits programs. Looking back over the past four sessions, we see the following pattern:

Biennium Appropriation Amount
2008-2009 $457.7M
2010-2011 $566.6M1
2012-2013 $474.2M2
2014-2015 $506M3

  1. Base adjustment after Hurricane Ike; does not include $150 million in Ike matching dollars or $150 million TRB for construction of new Jennie Sealy Hospital.
  2. Reduction of 16.65 % from prior biennium mostly in GR funding reflecting large state GR reductions in higher education; not inclusive of extension of $150 million Ike match
  3. Does not include $11.4 million increase in benefits or potential TRB for educational building.

The state budget is a composite of Senate Bill 1, House Bill (HB) 1025, HB 6, HB 7 and Senate Joint Resolution (SJR) 1—and a lot of sweat equity. Overall, the state budget saw a very modest increase driven by population growth and public school enrollment growth.

  • SB 1 reflects a 3.7 % increase in overall appropriations over the last biennium.
  • SJR 1 sends to voters in November 2013, a referendum on a constitutional amendment to establish the State Water Implementation Fund.
  • HB 1025 is a supplemental bill that puts $2 billion into the water resources fund (if the voters approve SJR 1) and additional money in public education.
  • SB 7 is the fiscal management bill, which consolidates all of the budgets into one ledger.

Public education received serious attention from both parties during the 83rd session. For the state’s public schools, most would agree that this was a winning session. Most of the draconian reductions from the 82nd session were restored and, moreover, the number of end-of-course exams required to graduate from high school was reduced from 12 to 5. Standards were also changed at the high school graduation requirements allowing schools to issue three degrees based upon credit hours, acknowledging the fact that not all high school graduates will head for college.

  • SB 2 expanded the state charter school system and HB 5 changed high school testing and graduation requirements as mentioned earlier.
  • The authority for oversight of charter schools was transferred from the State Board of Education to TEA.

Higher Education

  • HB 29 requires public universities to offer incoming students a four-year, fixed-rate tuition option.
  • SB 215 renewed the authority of the Texas Higher Education Coordinating Board but with some modifications/restrictions in its authority. The bill restricted the THECB from permitting the American University of the Caribbean from sending medical students to Texas for training and changed the rules for the TEXAS Grant program.
  • SB1907 does NOT permit campus carry of concealed handguns, but it does allow CHL holders to store firearms and ammunition in locked cars on college campuses.

Criminal Justice

  • SB213 was passed to reform and reauthorize the state’s prison system, permitting TDCJ leadership to decide how best to address their capacity issues.
  • Corrections-related budget bills also provided for salary increases for correctional officers and for health care employees in the system.
  • Additional reforms expanding membership of the Correctional Managed Health Care Committee were also passed, adding four new members (two from the mental health profession and two from state medical schools). Both UTMB and Texas Tech also retrain a physician member of the committee. The committee’s scope changes to production of the Offender Health Plan and quality oversight; contracting is now the sole responsibility of TDCJ.

Health Care

  • SBs 7, 8 and 58 by Senator Jane Nelson, chair of the Senate Health and Human Services Committee, targeted Medicaid fraud, transitioning of acute and long-term care services and expansion of behavioral health services. The GOP stand against Medicaid expansion also passed in the form of an amendment to SB 7, banning coverage for low-income adults.
  • SB149 allocated another $600 million over the biennium to CPRIT after the addition of measures to better prevent conflicts of interest at the agency
  • Senator Charles Schwertner’s SB 1106 assures independent pharmacies of more transparency when negotiating rates with Medicaid managed care organizations.
  • SB 1803 and SB 1106 protect Medicaid providers’ due process rights during investigations of fraud allegations and decreases administrative burdens on providers who contract with multiple Medicaid managed care plans.
  • Scope of practice for advanced practice nurses and physician assistants was also revised to increase to level of their training while still requiring physician oversight.

Immigration

  • Bills aimed at creation of a driver’s permit for undocumented immigrants failed, as did other immigration reform measures.

Special Session

As the House and Senate adjourned Sine Die around 5 p.m. on Memorial Day—neither having completed the full book of business set out for the session—the Governor issued a call for a Special Session to begin at 6 p.m. that same day. The only item the Governor has formally placed on the agenda is the unfinished business of redistricting. The House and Senate have appointed committees to study that issue in light of prior legislative action and state and federal court comments. The Legislature will bring forth recommendations to stay with the current districts as utilized in the 2012 elections or to recommend changes. Whatever transpires is sure to be surrounded with highly charged debate.

Other issues may find their way onto the special session agenda. Senator Kel Seliger has already filed a bill for TRBs for state universities totaling almost $2.6 billion. Other issues related to transportation funding, social issues such as abortion and drug testing for Temporary Assistance for Needy Families aid recipients, may also find their way on the agenda.

June will be a busy month for those linked to the Legislature so cancel those vacations and stand alert!

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100 Days and Counting …

As I write this, we are 105 days into the 83rd Legislative Session. It is time to take stock of where we are and what we have to get done prior to Sine Die on May 28! 

Both the Senate and House have wrapped up their budget proposals with minor (and in some cases MAJOR) tweaking continuing to occur. The President of the Senate has appointed five members to the Conference Committee; they will be joined by five members from the House appointed by the Speaker to put the final touches on the budget for the next two years. 

Conference Committee Membership, 83rd Legislative Session

Senate House
Tommy Williams Jim Pitts
Chuy Hinojosa Sylvester Turner
Jane Nelson Myra Crownover
John Whitmire John Otto
Robert Duncan John Zerwas

The agreed upon budget will have to then pass both houses and go to the Governor for his signature. The Governor may veto the budget and send it back to the Legislature for more work (which almost certainly ensures a special session), he can sign the budget, or he can express his disapproval of the budget by not signing it and simply letting it become law at the will of the Legislature.

As we take stock of the progress made by the Legislature over the past several months, the Senate wins the race in that it has heard as many bills at this time during the session as it did in the entire 82nd Legislative Session. However, the House has passed out only about a third of the number of bills as it did in the prior session. The House’s deliberate pace many be a way of minimizing the debate (and controversy) of certain issues.

Specific actions of interest include the following:

  • SB 143 (Nelson), which allocates $11.5 million in the next budget for Graduate Medical Education
  • SB 329 (Huffman), which prohibits minors from using tanning beds because of the increased link to melanoma in young adults
  • SB 822 (Schwertner), which regulates companies or networks that sell, lease or share physician discounts without the physician’s consent
  • HB 63 (Craddick), which bans texting while driving a motor vehicle (Distracted driving costs the US economy $3.5 billion each month; the impact to Texas is thought to be $3.6 billion annually.)
  • HB 3791 (Zerwas), which has a hearing scheduled this week in House Appropriations; if passed it could serve as a future vehicle for Medicaid expansion in Texas (see below for more information)
  • CSHB 1025, the Supplemental Appropriations Bill, which passed out of the House Appropriations Committee this past week and is on its way to the Senate (This bill provides the requested $39 million Supplemental Appropriations Request to cover the estimated funding shortfall for correctional health services.)
  • $17 million allocated by the House to the Higher Education Coordinating Board for 2014-2015 as additional funding for GME start-up programs

Additional bills related to health care scope of practice are pending, including one which lowers the age limit to 6 for pharmacists to administer vaccinations to children. This has been opposed by the Texas Society for Pediatrics based upon presumed negative impacts on the medical home initiative and adverse impact on health and developmental screening. 

Another proposal that would expand the ability of physical therapists to see patients directly for musculoskeletal problems has met with opposition from the orthopaedic surgery and physician community. Likewise, an initiative that would affirm licensure for clinical laboratory scientists has met with opposition from organized commercial medical laboratories who cite increased personnel costs as their main objection.

Overall the issue of health profession shortages continues to gain much attention during the legislative session; however, there is yet to be an acceptable agreement on the best approach to deal with scope-of-practice and access issues.

The House Appropriations Committee met on Tuesday, April 23, and passed out Zerwas’ bill (HB 3791), which focuses on the following summary from the TMA website:

The legislation would create a ‘Texas’ solution for covering the working poor in Texas. The bill consists of four key components:

  • Structure: First choice for coverage for low-income Texans would depend on the state receiving an unrestricted block grant from the federal government to run Texas' current Medicaid program.
  • Funding streams: If the state cannot obtain a block grant, the Texas Health and Human Services Commission (HHSC) would funnel the money in concert with the Texas Department of Insurance (TDI) to purchase private health insurance policies for people under 133 percent of [federal poverty level].
  • Payment: The bill includes reforms that Texas can implement concurrently with a block grant, such as cost-sharing, which means Medicaid recipients would pay a percentage of the coinsurance and/or deductible.
  • Oversight: The bill creates a committee to oversee the implementation of the program. State leaders would appoint members of the committee.

Representative Zerwas said, "This is not expansion of Medicaid. This is creation of a new program that leverages our partnership with the private sector. This is not an entitlement program." He added, "I understand the political radioactivity surrounding this particular bill. This would have a profound impact around the provision of care … and ultimately see a benefit to the taxpayers."

House Appropriations also moved Texas’ water issues a step closer to a House vote by proposing that $2 billion from the Rainy Day Fund (HB 11) be used to address the state’s water shortage.

Both House and Senate Conference Committee members have started their work on crafting a budget for the state. This is the time that meetings start early in the day and go far into the night. It is also the time that lobbyists and citizens start vocalizing their personal support for issues in that budget.

And in an unexpected twist to an otherwise quiet legislative session, the House voted to NOT extend the Lottery Commission at the time of this blog’s writing. That means there is suddenly a $2.2 billion gap in the revenue projections for the budget (including the potential for UTMB to lose more than $10 million in dedicated indigent care funding for the 2014-2015 biennium). This new development adds quite a challenge for the Legislature as members work to reach agreement on budget.

 

ADDENDUM:  After realizing the adverse impact on their budget, the House revisited their earlier decision in the afternoon to sunset the Lottery Commission and reversed itself to extend the Commission, thus avoiding a derailment of their budget work over the past 105 days.


It’s not over until it’s over, so as always, stay tuned for updates.

 

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Budget Buzz

 The Texas 83rd Legislative Session is well past its midpoint, and Senate and House financial leadership have crafted a straightforward, no-nonsense budget to take to their colleagues in the House and the Senate. The Senate voted out its budget this past week, and after several tweaks on the House side, their budget will be ready for consideration by the whole House on Thursday, April 4. We will witness House members engage in a lengthy floor discussion and vote for passage with a generous number of amendments, then a conference  committee made up of members from both houses will iron out the differences between the two chambers and reach consensus for the approval of both houses.

So where are we at UTMB in all this? We are glad to see the emphasis placed by both houses on restoration of funding in the formula to support the operations of our educational programs and to support the operation of our hospital. Although we would like for our hospital appropriation to be placed into a mission-specific formula, it appears that formula changes will be reviewed  in a more in-depth fashion during this next interim period between legislative sessions. Timing is everything!

What about the university exceptional item requests? These continue to reside in Article XI of the Senate Budget, which means they can be brought back up for discussion and/or funding if sufficient funds are available in the final days of the session. But, in reality, the mood among members of the Legislature has been to place additional funding into the overall educational support funding rather than in special projects for each university. UTMB has found a strong advocate and friend in alumnus and former faculty member Dr. Greg Bonnen. Dr. (State Representative) Bonnen from Friendswood has filed an amendment to the House version of the budget that would place an additional $1.5 million of funds into UTMB’s operation of the Galveston National Laboratory to offset federal cuts anticipated through the sequester. 

Representative Eiland will also offer up an amendment to restore funding from the unclaimed lottery proceeds to UTMB’s Indigent Care Fund to $10 million per year (rather than the reduction to less than $5 million per year in the current budget).

Correctional Managed Care’s budget requests have found some favor, especially in the Senate with the past two years’ shortfalls added to the base budget, plus an overall base budget increase in anticipation of the increased costs associated with medical inflation. In addition, the Senate has added funding to support salary adjustments for employees (who have had no increase in more than four years), funds for capital improvements (especially digital radiology equipment) and funds for restoration of staffing at selected units.

The issue of provider representation on the Correctional Managed Health Care Committee came up this week in the Senate during a vote on recommendations to restructure the committee. The proposed legislation would have eliminated representation from Texas Tech Health Sciences Center and from UTMB on the committee. Interventions by Senator Robert Duncan and Senator Tommy Williams thwarted that effort, and the Senate adopted language that reconfigures the CMHCC membership to include both Tech and UTMB. as well as two members from other medical schools and two members from the mental health profession.

There is much going on beyond the financial issues that have plagued the state for the past several sessions. The House voted unanimously this past week in support of creating a new mega-university in the Valley under the auspices of the UT System. That university would consolidate UT Brownsville and UT Pan American into a single entity and add a medical school. The university would be eligible for Permanent University Fund (PUF) funding and would immediately undertake the development of a medical school/health sciences center. Support for the new university would come from PUF, local contributions and the UT System. No name has been selected for the university; that will be left to the discretion of the UT System Board of Regents. The addition of a medical school serving South Texas is hailed as a way to address the health care provider shortages that have plagued that region for decades.

Senator Nelson’s Scope of Practice bill (SB 406) has left the Senate and is headed for the House. That bill expands the ability for physician assistants and advanced practice nurses to expand their scope in prescription authority but continues to call for them to report to a physician team leader. Leadership from the Texas Nursing Association, the Texas Academy of Physician Assistants, Texas Pediatric Society and Texas Medical Association have all weighed in to support the bill. In addition, there is another bill that proposes the expansion of the physician assistant education programs in Texas by the addition of a “fast track” for individuals with prior health care experience, such as certified military medics and international medical graduates.

The topic of guns on campus is back for another round of discussions at the Capitol. The right to carry a concealed weapon (with permit) onto a university and/or  hospital campus has resulted in considerable discussion. UT System Chancellor Cigarrora weighed in on the discussion with the following statement, in a Feb. 24, 2011 letter to Governor Rick Perry:

 “I have great respect and value the authority of the Legislature to make this important public policy decision, and I recognize the variety of opinions surrounding it. …Yet parents, students, faculty, and administrators, and the institutional law enforcement have all expressed to me their concerns that the presence of concealed handguns on campus would contribute to a less-safe environment, not a safer one.”

At the Capitol, most of you might already know that a concealed weapon permit gains you access to the building’s interior without going through the usual metal detector and/or security screening process. Some writers have speculated that the Capitol itself probably has more people carrying concealed firearms than any other building in the state! Texans feel strongly about their right to carry, so expect a healthy discussion on this issue. Remember that during the last session the Legislature approved the shooting of feral hogs with automatic weapons from helicopters! Anything is possible. The UTMB Faculty Senate has gone on record as being opposed to concealed carrying of weapons on campus.

Public education continues to be a topic of healthy dialogue in both chambers, with proponents of school vouchers, increases in funding for schools, changes in graduation requirements, changes in testing requirements, and reviews of core curriculum standards all getting generous discussion and action. The House passed out a hefty school package last week and added $1 billion in funding as they voted out their budget recommendations from House Appropriations.

This week’s activities should set the stage for the House to vote their revised version of the Senate budget, and then for a Conference Committee made up of House and Senate members to review and take action on that budget. As always, stay tuned for more.

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