The Budget

Finally, the verdict is in on the conference committee report: Both chambers still have to vote on the budget, but the agreed-upon template from the committee members was released yesterday and more was revealed today. More details continue to dribble out in small amounts at a time; the decision-making continues to be a very fluid and iterative process. And remember that it’s not over ‘til it’s over. Items can be added that increase or decrease “final” decisions made so far, agreements can fall apart before the final legislative step, and then there are always the governor’s potential vetoes, which can occur up to 20 days after the end of session.

That said, as of today, here’s what the conference committee has done:

budget blogSo good news on the formula—although all universities and health-related institutions are still not up to the desired 2001 levels of funding, this increase is a step in the right direction.

We asked specifically to maintain our hospital base, and the Legislative Budget Board recommendations to the Legislature did just that. In turn, the Legislature did also.

With a 42 percent increase in enrollment and a scarcity of space for student group learning and study, the passage of funding for a new interprofessional educational building is a welcomed gift from the Legislature. Although House and Senate will conference on this issue, UTMB should receive a minimum of $59 million for the building and hopefully up to the $68 million amount recommended by the House.

Budgeteers have put more emphasis on formula funding and less on new or increased special item funding—few institutions received more than a small portion of their requests for special project funding; some received none. Conference awarded UTMB $8.2 million, which is designated for the construction of an infectious diseases treatment facility for UTMB Hospitals. In addition, Rep. Wayne Faircloth was instrumental in getting statutory language adopted that was necessary to allow the Health and Human Services Commission to distribute federal or other funds to UTMB for infectious disease treatment. Funding for TDCJ’s Correctional Managed Health Care program is directed to both Texas Tech and UTMB; UTMB receives about 80 percent of the funds because of the number of units operated and because UTMB treats those patients requiring higher acuity of care (i.e., hepatitis C, cancer, surgical cases and others). For operation of the units and medical, mental health and hospital acute care, the Legislature appropriated $84 million over the next biennium. This will bring funding in line with what is currently being spent in correctional health care, since there is a shortfall this biennium.

Although we had requested raises for correctional health care unit staff, the original recommendations from both House and Senate contained no designated funding for this area. Thankfully, as conference went forward, conferees championed that cause and their efforts resulted in an allocation of $60 million for staff salary increases over the biennium.

With funding issues moving toward closure, the House and Senate will work Saturday and Sunday to complete the packed calendar of bills awaiting passage or rejection before the stroke of midnight June 1.

Remember to go forth and do good—and to do it well!

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Good News on Tuition Revenue Bonds from the Hill

For the past decade, UTMB has been dreaming of a new building to house its educational programs—specifically, an interprofessional educational center that focuses on shared lab, learning and simulation programs to provide the most appropriate learning environment in which to train future care providers. That vision is one more step closer to reality with action taken by the Senate on Tuesday.

House Bill 100 had been approved by the House and sent to the Senate; the Senate had its own version of an omnibus facility construction bill that would permit the new construction and remodeling of educational/research buildings on campuses across the state. During the past two legislative sessions, similar proposals died a slow and painful death in the waning days of the legislative process. But this year, after a decade of drought in construction funding, the Senate agreed (in part) with the House, passed out its version of the construction funding bill, and sent it back to the House for conference.

Discussion regarding the construction of new facilities (and remodeling of outdated facilities) was heated, with almost everyone weighing in with their version of what should or should not be done. Senator Schwertner proposed an amendment that would have linked his proposal for a tuition increase cap to the building appropriation. Others, like Senators Kolkhorst and Ellis, proposed that tuition be re-regulated. Although the rhetoric was extensive, the bill ended up passing with only five Senators opposed: Birdwell, Burton, Hall, Huffines and Van Taylor. Senator Larry Taylor of Galveston County voted for the bill; he has also chaired the Senate Education Committee and served as a leading proponent for the investment in higher education space.

For UTMB the passage (and further tweaking of the bill by the conference committee) is quite meaningful. UTMB has had a 43 percent increase in student enrollment over the past four years. Since Hurricane Ike in 2008, enrollment has increased from 2,600 to over 3,200. This substantial growth (ranked 5th in the entire nation among universities) continues to tax facilities on our Galveston campus.

As UTMB wraps up construction of the new Jennie Sealy Hospital and the Clinical Services Wing, as well as final remodeling of the John Sealy Hospital, efforts will focus on the design of and fundraising for the new Interprofessional Educational Building. Tuition Revenue Bond funding from the state will be a huge help in building the new facility.

Tax Relief and Other Hot Items!

The House and Senate are still working out the mysterious “tax relief” measures; the Senate has wanted an increase in the homestead exemption, but the House has favored a sales tax reduction. A compromise will likely contain a homestead exemption decrease and a reduction in the business margins tax. We should know the favored formula within a few days.

Higher education formula funding is also scheduled for a 3 percent increase; details are imminent. The chambers also are sorting out the methodology for distributing special research funds for higher education institutions through the Texas Research University Fund (TRUF) for the flagships, the Texas Research Incentive Program (TRIP) and the newly proposed Governor’s University Research Initiative (GURI). So, among the TRUF, TRIP and GURI, the state’s research universities should see new sources of potential funding available to them. Proposed changes also would provide funds from the Texas Enterprise Fund (TEF) for a new category of university research commercialization awards. Next will come a proposal to end the acronyms in legislation!

On the Agenda

On Wednesday, the House will discuss Senate Bill 18, which proposes new Graduate Medical Education funding for the state. HB 3078 also will be heard; this bill addresses a uniform pre-nursing curriculum. HB 3348 does likewise, along with authorizing the Texas Higher Education Coordinating Board (THECB) to allow certain public junior colleges to offer baccalaureate degree programs (especially nursing).

With just a few days left in the 84th regular session, much remains to be done and much of it is of interest to UTMB and its mission. We’ll keep you posted as we learn more.

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Where Are We?

The timer on my iPhone says there are 13 days left in the 84th Session of the Texas Legislature before adjournment, or sine die! At midnight on the 140th day (June 1), Cinderella’s coach turns back into a pumpkin, the horses are white mice again, and the excitement of the royal ball and the search for a wife for the prince all end abruptly. Such are the waning days of the legislative session. Some parts of the story end happily; others, sadly. As in the storybook, Cinderella always wins in the end, and the wicked stepsisters get their just deserts when all is said and done. In politics, history will anoint who’s a Cinderella and who’s a stepsister.

As we face that stroke of midnight on June 1, what would an observer say about the players in this legislative session? The orchestra is led by two very competent and powerful conductors, the Speaker of the House and the Lt. Governor. There are 31 Senate players and a cast of 150 in the House. No one is a bit player. There have been some top performances delivered by newcomers to the scene; there have been some less-than-stellar moments that will, no doubt, be chronicled in statewide media, such as Texas Monthly and Texas Tribune. But with respect to UTMB:

Senator Larry Taylor has taken a lead role on numerous issues of great importance to the Gulf Coast—in particular UTMB—and for the state as a whole.

Representative Wayne Faircloth has gone where few have gone before; he can never be accused of being timid. Take a peek at his 10-minute debate (scroll down to the 4/09/15 archive and the debate begins at the 2hr 50min mark) with seasoned House member and soon-to-be candidate for Houston’s Mayor, Sylvester Turner. In an effort to eliminate funding restrictions for UTMB and Galveston County, Rep. Faircloth stood his ground and delivered a vote in favor of his position. He did the same with a key funding issue related to the establishment of a state infectious diseases treatment center (again at UTMB). In fact, that amendment sailed through so fast that leadership was left scurrying around wondering what happened.

And, Rep. Greg Bonnen took on his own brother (Dennis Bonnen, the House Speaker Pro Tempore) in a debate over water rights for Galveston County.

At 125 days into the session, the numbers tell a story! Look for yourself:

Day-125 Statistics—84th vs. 83rd Legislature (Regular Sessions)

blog chart crop

The House has passed out more bills than in the previous session, but the Senate has moved quite a bit slower. Friends of the Senate likely feel that their work has been of greater priority to the state—quality versus quantity. The House might not agree with that interpretation, citing that it has been more focused and that its leadership has been very effective in moving bills along at an aggressive pace. The Senate might argue that the House was slow to take up its bills on the House side; the House might argue the same against the Senate. But no matter how they get there, at the end of the day, both chambers will have to find a way to work together if significant legislation will make it into the public domain.

While budget and policy issues have languished, there has been a spirited debate on any number of social issues that has diverted time and attention. To name a few:

  1. Immigration reform similar to Governor Perry’s executive order from last December continues to move forward in the Legislature. At the same time, new reports from demographers for the state note that immigration from Latin American counties is at an all-time low in Texas and that immigration from Asian counties has increased by 42 percent.
  2. Last week, members from both chambers continued to grapple with settling their differences on tax cuts, restraints on local property tax increases, state ethics cases, border security, and the right to carry handguns.
  3. HB 4105 opposing same sex marriage continued its fight to live in the House.
  4. House Public Education Chairman Jimmie Don Aycock threw in the towel Thursday evening, giving up on his finely crafted education finance package of $3 billion after the Senate sent word that it would not act on the bill even if it passed in the House. The sentiment seems to be “let the courts decide.”
  5. The reintroduction of “deep fat fryers” and soda pop machines in public schools by Agriculture Commissioner Sid Miller touched off major controversy from proponents for healthier diets for kids. As you may recall, then-Agriculture Commissioner, later-Comptroller Susan Combs tossed those items out of schools a decade ago—in this pediatrician’s opinion, all the better for child nutrition!

And what about higher education?

Prospects look good for the passage of legislation to fund Tuition Revenue Bonds (UTMB’s TRB would help build a much-needed interprofessional education building) and for an increase in education formula funding. UTMB remains hopeful for an increase in base funding for the hospital and for TDCJ to receive increased funding for the Correctional Managed Care program that will include funding for employee salary increases. We continue to work with our agency partners to educate legislators about the importance of this funding.

All of those details have to be worked out in the next 13 days! If they aren’t, then I will become one of those grumpy pumpkins that terrorize the graveyards of dead bills.

Stay tuned!

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With a Little Help from Our Alumni

During a recent Development Board meeting at UTMB, a number of questions were asked about the status of UTMB’s funding requests from the state legislature. Obtaining access to new members of the legislature is always difficult. I commented that I really could use some help in getting an appointment to see our new Lt. Governor, Dan Patrick. Within an hour I had a call from Development Board member Michele Purgason, volunteering her time to help set up a meeting with Lt. Governor Patrick to discuss UTMB’s need for support related to our exceptional growth in recent years.

Michele is a UTMB School of Nursing graduate and has some great stories of her time as a cheerleader with the Houston Oilers. She married Tom Purgason, a graduate of UTMB’s School of Medicine. After his residency training, Tom and Michelle made their home in Arlington, Texas, where they built a highly respected internal medicine practice and raised their children. Their daughter Ashley is an alumna of UTMB’s Graduate School of Biomedical Sciences, where she was distinguished for her research in aerospace medicine as well as her service as a student member of the UT System Board of Regents.

Michele has been a trusted advisor and mentor for several successful candidates for elected office over the years. In her role as president of the Arlington Republican Women’s Club, she had met then-Senator Dan Patrick and kept in touch with him during his successful campaign for Lt. Governor.

When Michele called Lt. Governor Patrick’s office and asked for an appointment to discuss UTMB, her request was immediately granted. She called me, and said, “We have an appointment next Wednesday at 4:30! Can you be there?” We seized the opportunity.

Lt. Governor Patrick received us with great hospitality and revealed an extensive knowledge of UTMB’s research in infectious diseases, our safety net role in the delivery of regional trauma services and our role in health professions workforce development. We had the opportunity to expand his understanding regarding future potential threats in the area of emerging infectious diseases. We also discussed how UTMB’s requested research funding in this area, as well as hospital funding we’ve requested (similar to that provided to other state-owned hospitals), would benefit Texans.

We left the meeting feeling pleased that we had been able to state our case and be heard, and delighted to know that there are alumni like Tom, Michele and Ashley Purgason who daily look for ways to further our mission of improving health for the people of Texas and around the world.

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A Visit to the White House

In March, I had the opportunity to participate in a Government Relations Academy as a mentor for the America’s Essential Hospitals (AEH) group (formerly the National Association of Public Hospitals). Our UTMB executive vice president and Health System CEO Donna Sollenberger is on their Board of Directors. As a part of the Academy, we paid a visit to the office of Domestic Policy at the White House.

No, I did not get to meet with President Obama, nor the First Lady. On a prior visit I did get to greet the First Dog in the actual residence. He has his own security detail.

When people visit the “White House” for the purpose of providing information to policy analysts, that visit actually takes place in one of the many auxiliary buildings next to the residence. Security is still the same and consists of passing through multiple screenings contingent upon advance background checks and clearances. Our meeting was in the Eisenhower Building, which in itself is a beautiful piece of architecture.

Eisenhower Annex

Eisenhower Building

The meeting was productive in that we had the opportunity to discuss any subject that we wanted to with the domestic affairs staff. I had heard so many rumors about the imminent demise of the Medicaid 1115 Waiver that I asked the staff member if that was indeed true. He replied promptly that he had heard nothing of that issue, and responded that he would check into it.

He did ask me for a description of “how” the 1115 Waiver was making a difference in Texas. I provided him some specific examples of projects in our 1115 program that Craig Kovacevich and Katrina Lambrecht have so effectively administered, and I described the personal cases with which I was familiar: how lives were changed because of the expanded reach through education, disease management programs, telemedicine, hospital readmission reductions, and the learning collaborative that enables program leadership to share best practices.

As we left the meeting, staff asked for my card. As I handed it to him, he said, “I would like to talk more about the 1115.” Thinking this was a formality, I doubted that I would ever hear back from him. So I was quite shocked when I got a call from Bruce Siegel, president and CEO of AEH, that Domestic Policy Council staffer Tim Gronniger wanted to meet and finish the conversation we had started related to the 1115 Waiver.

Tim and AEH staff

Mr. Gronniger and AEH staff

Bruce is very strategic policy expert. He immediately seized the opportunity to invite me to attend meeting #2 with Tim and his staff, along with Dr. Mitch Katz, representing the Los Angeles 1115 Waiver program, and LaRay Brown, senior vice president of the New York City Health and Hospital Corporation.

Craig and Katrina provided me with a comprehensive list of our outstanding 1115 Waiver projects, and Dr. Maureen Milligan, president and CEO of Teaching Hospitals of Texas, put out a request on my behalf to regional anchors for the waiver all over the state of Texas to send examples of their favorite projects. I had an abundance of information to sift through for the April 29 meeting in DC.

On Tuesday evening, I flew to Washington and joined Bruce and his colleagues for breakfast to plan the meeting with Tim Gronniger at the White House. We walked over to the White House gates after numerous detours because of increased security procedures. Finally, we worked our way through the multiple checkpoints and found our way to the Domestic Policy conference room on the third floor of the Eisenhower Building.

Bruce made the introductions and we immediately plunged into our personal explanations of “why” the 1115 Waiver has played such an important role in the transformation of health care and the improvement in access and quality in America’s health care marketplace. Since every minute counts in meetings like this, there was no small talk or comments on the beautiful Washington weather. We immediately got down to business.

My colleague from L.A. described the tremendous impact the 1115 Waiver has had on the improvements to access to care in their entire hospital and clinic system and the marked decrease in readmissions they’ve seen for patients with chronic health problems. He addressed their improved ability to address those social determinants of health that impact patients and their families, such as food security, housing, transportation, prescription medicine access and health wellness education.

My turn came to describe Texas’ and UTMB’s programs. I sensed Tim’s desire to hear more about the individual impact to patients and evidence of real transformation in the system.

I told him the story of Tyler County Hospital in Woodville, Texas, and its DSRIP (Delivery System Reform Incentive Payment) project designed to improve patient satisfaction, value-based purchasing and access to “after hours” care. I also told him of my firsthand knowledge of that hospital, having been born there six decades ago. I described the impoverished “eastern border” of Texas, which is home to a diverse population with high incidence of chronic disease, premature death, serious mental health disorders, food and housing insecurity, unemployment and overall lack of access to health care.

I told him about Dr. Wright, the CEO and administrator of Tyler County Hospital, and her passion to improve access to care and patient satisfaction. I shared the success of her efforts and the fact that she had just informed us that the hospital had receive a 5 Star rating from CMS (the highest ranking obtainable) as a result of their 1115 improvement efforts. I described the pride in the hospital’s staff that led them (on their own time) to repaint and decorate the hospital cafeteria and break areas for staff and families of patients.

I also shared the multiple improvements that have occurred in the delivery of mental health services in the entire 16-county Region 2, for which UTMB is the anchor. Improvements have included the Burke Center’s collaboration with law enforcement, outpatient providers, supportive housing options and comprehensive care clinics.

Other innovative programs resulting from the 1115 Waiver include the use of Community Health Workers and their inclusion now in Texas as certified health profession workers, as well as the collaborative work among the Texas Medical Board, Health and Human Services Commission, UTMB and the DEA to ensure access to prescription medication for behavioral health patients in underserved areas and delivery of psychiatric services to children.

LaRay Brown provided an overview of the challenges faced in the New York City health department and the challenges facing access to services. In spite of East Texas and NYC being polar opposites in many respects, both share many of the same barriers to health care access, food insecurity, housing issues and other social determinants that diminish the wellness of the community.

At the conclusion of our session, I played a two-minute video of the work done to open a cancer treatment center in Childress, Texas, with partners from Texas Tech—demonstrating the power of the 1115 Waiver to bring about transformations in health care that would not have occurred without that startup funding and technical support. This powerful video brought home the message of transformation for remote cities across our state.

Now it is wait-and-see time. Will our visit and talks make a difference? Who knows? We can only hope that the power of those personal accounts and glimpses into the impact zone of health care transformation will make a difference. Meanwhile, visionary people like Donna Sollenberger, Katrina Lambrecht and Craig Kovacevich will continue the battle for improved health on the front lines, both in Galveston and in rural Texas.

I boarded a plane at DC’s Reagan Airport a couple of hours later and headed back to Austin, where another messaging battle is raging. What will the state legislature do to improve access to health care for those individuals in Texas who remain uninsured and without adequate access to health care? It is all too easy to stereotype the disenfranchised as lacking personal accountability or being irresponsible, but in truth most of our state’s uninsured are working people who simply make too little money to afford the high cost of health insurance.

In the end, all of us pay for that care through higher insurance premiums so that hospitals can shift costs and recover their losses on the delivery of care to the uninsured. This has been an age-old problem in health care. In truth, it is a hidden tax on every American and every American business that provides health care benefits for its employees.

As Texas continues to seek solutions to the crisis facing health care in the state—or the lack thereof for significant parts of our population—we must come to grips with how to ensure access to care for vulnerable populations. Like it or not, the costs are greater when we do nothing because of the negative impact on our state’s future productivity. Pay now or pay (more) later! Never a good choice!

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A Discussion on Telemedicine

I recently had the pleasure of participating in a panel discussion on telemedicine during the Texas Tribune’s Symposium on Health Care.

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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

cmc chart blog

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senate cmc

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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