Family medicine in the 85th Texas Legislature

By Jonathan Nelson and Perdita Henry

Coming in to the 85th Texas Legislature, Gov. Greg Abbott, Lt. Gov. Dan Patrick, and Speaker Joe Straus laid out their policy priorities for the session. Among them were: sanctuary cities, the transgender bathroom bill, property tax cuts, school finance reform, school choice, shoring up the foster care and child protective services systems, ethics reforms, Gov. Abbott’s desire to call for a convention of states to amend the U.S. Constitution, and of course, passing a balanced budget.

Nowhere in that list are any big-ticket health care items, and that’s no surprise. In the run-up to the session’s start in January 2017, everyone predicted the Affordable Care Act would be the unchallenged law of the land under President Hillary Clinton, fully funded and completely operational. Why consider options for Medicaid reform like block grants, work requirements, co-pays, and the like?

Consequently, when lawmakers arrived in Austin shortly before President Donald Trump was sworn into office, no policy plans were prepared for what might be possible under Republican rule in both Washington, D.C., and the statehouse. So health care policy was low on the priority list this session. Even so, with more than 6,500 bills filed and fewer than 1,200 passed, the Lege took up a number of issues of interest to physicians and their patients.

The 2018-2019 budget
First on the docket as always was the state budget, and lawmakers knew coming in the fiscal forecast looked grim. Sagging oil prices and our growing population among other things meant the state faced a $6 billion shortfall.

The House and Senate agreed on a budget for the 2018-2019 biennium totaling $216.8 billion in all funds, which included $106.8 billion in state general revenue. The remainder is federal money drawn down by state expenditures for programs like Medicaid and CHIP. Lawmakers also agreed to use $1 billion from the state rainy day fund.

The Legislature funded Medicaid at $62.4 billion, $1.9 billion less than the current biennium, and they appropriated $79.45 billion to Health and Human Services, $1.83 billion less than 2016-2017.

While many other programs related to public health languished this session, the state followed through on its commitment to increase funding for mental health. The budget spends $300 million for replacement or repair of state mental hospitals or other inpatient mental health facilities, and added $160 million for state hospital deferred maintenance. The Legislature also approved $67 million for community-based crisis service provisions, $30 million to reduce homelessness and recidivism, and $67.6 million to eliminate adult and child mental health waiting lists.

Graduate Medical Education
The Legislature continued its recent efforts to expand graduate medical education capacity, increasing GME expansion grants by $44 million and adding $4.3 million to GME formula funding.

Throughout the session, lawmakers on committees of jurisdiction over GME made it clear they were concerned that Texas didn’t have enough during a time of medical school expansion. Senate Bill 1066 by Senator Schwertner requires new medical schools to offer new GME positions to keep pace with the number of medical graduates they produce.

In the last weeks of the session, a program near and dear to family physicians suffered a significant blow. The Family Practice Residency Program is a budget strategy administered by the Texas Higher Education Coordinating Board that dedicates funding directly to the state’s family medicine residency training programs. The program had maintained its funding throughout the budget-writing process in both houses, but when budget conferees met to work out the differences in the two versions, they decided to slash the program by 40 percent, dropping its funding from $16.78 million to $10 million.

TAFP will maintain close communication with the state’s residency programs, studying the effects of this funding cut and making those effects known to the Legislature.

First, do no harm
Once again this session, organized medicine won important legislative battles by ensuring many bad bills didn’t become law. Sometimes the best defense is just a really good defense.

Nurse practitioner organizations were back in force this session with a raft of bills designed to allow advanced practice registered nurses to practice medicine independently. None of those bills succeeded in either the House or the Senate.

On April 25, TAFP member Emily Briggs, MD, MPH, of New Braunfels, testified before the House Committee on Public Health in opposition to House Bill 3395, which would have allowed advanced practice registered nurses to practice medicine independently in counties having no physicians. Briggs told the committee that she shared their goal to expand access to care in rural communities, granting nurses the authority to diagnose and prescribe is not the solution.

She described the complexity and the variance of problems rural physicians treat on a daily basis. “Patients with chest pain, lacerations, burns, broken bones, or a woman in labor. Even highly trained primary care physicians who may have done an extra year of training in rural practice many times do not feel prepared for rural practice. If we want to improve access to care in rural areas, we should strengthen our efforts to recruit physicians from rural communities to medicine. We need to continue to provide loan repayment as a recruitment strategy and we need competitive reimbursement for our Medicaid patients.” The bill didn’t make it out of the committee.

Clearing the way for telemedicine in Texas
After years of lawsuits and friction between large telemedicine providers and the Texas Medical Board, the advancement of telemedicine in the state had reached an impasse. National direct-to-consumer telemedicine firms wanted free rein to sell their services outside of the state’s regulatory oversight and without regard for patients’ existing relationships with their physicians. The medical board rules held that a physician couldn’t treat a patient via telemedicine unless the physician had established a relationship with the patient in a previous face-to-face visit, a stipulation companies like Dallas-based Teladoc found unworkable.

In the months leading up to the start of the legislative session, TAFP, TMA, and the Texas e-Health Alliance drew together a diverse group of stakeholders and over the course of many meetings, brokered an improbable agreement in which all sides could claim victory.

In the end, Gov. Abbott signed into law a measure passed unanimously by both the Senate and House that protects the standard of care for patients, defines the responsibilities physicians must maintain when providing telemedicine services, and allows for innovation and progress in the market.

Senate Bill 1107 by Sen. Charles Schwertner, MD, R-Georgetown, establishes a statutory definition for telemedicine and clarifies that the standard of care for a traditional, in-person medical setting also applies to telemedicine services. In the House, Rep. Four Price added language making it clearer that telemedicine is not a distinct service but a tool physicians can use. The bill also prohibits health plans from excluding telemedicine from coverage just because the care isn’t provided in person.

Under the new law, TAFP fully expects that family physicians in the state can offer telemedicine services to their patients in a safe and efficacious manner and that they will be able to compete with large companies like Teladoc and American Well.

Public health
In a session without much focus on health care and no extra money to spend, public health initiatives gained little momentum, except in the case of a few important mental health issues like the $300 million investment in our state hospitals and other state-funded inpatient mental health facilities mentioned above.

H.B. 2561 by Rep. Senfronia Thompson, D-Houston, seeks to address people’s misuse of, and addiction to, opioid pain medicines. It includes Physician Drug Monitoring Program initiatives to identify potentially harmful prescribing or dispensing patterns or practices that might suggest drug diversion or “doctor shopping.” The prescribing amendment calls for physicians and all other prescribers and dispensers to check the PDMP before prescribing any of the listed classes of medications after Sept. 1, 2019.

To help alleviate Texas’ shortage of psychiatrists, S.B. 674 by Sen. Schwertner creates an expedited licensing process for psychiatrists who are licensed to practice medicine in another state and are board certified.

H.B. 3576 by Rep. Bobby Guerra, D-McAllen, will improve the state’s testing and screening capabilities for infectious diseases, such as the Zika virus.

Women’s health
In a 2016 study published in the journal Obstetrics & Gynecology, researchers found that from 2011 to 2015, 537 Texas women died while pregnant or within 42 days of delivery, compared to 296 from 2007 to 2010. This doubling of maternal deaths made Texas the most dangerous place to give birth in the developed world. Maternal mortality was on the agenda for the 85th Legislature but many of the bills that would help us understand and identify the dangers facing new and expectant mothers failed to pass.

The issue of maternal mortality is a concern all over the country but Texas unfortunately has the distinction of being the worst. In fact, Janet Realini, MD, MPH, president of Healthy Futures of Texas and chair of Texas Women’s Healthcare Coalition, spoke about her concerns during her TAFP Member of the Month interview. “Texas women have the highest maternal mortality rate of any state — higher than many third-world countries,” she said. “Preventive care and contraception are incredibly important in addressing this issue in two ways: preventing unplanned pregnancies that can stress women with health issues and serving as an entry to health care for women with health risks.”

Several representatives arrived at the Capitol with the intention of finding out why Texas women are dying at a higher rate, ensuring they have access to the care needed, and finding out why African-American women — who give birth to 11 percent of babies born but account for almost 29 percent of all maternal deaths — die at higher rates than other women in the state.

Two specific bills aimed to do just that were House Bill 2403 by Rep. Shawn Thierry, D-Houston, and Senate Bill 1929 by Sen. Lois Kolkhorst R-Brenham. H.B. 2403 would have required the Maternal Mortality and Morbidity Task Force to conduct a study of the causes of death in African-American women and S.B. 1929 would have extended the Maternal Mortality and Morbidity Task Force through 2023. Both bills were killed in what has become known as the Mother’s Day Massacre, when more than 100 bills were allowed to expire due to political push-back from the House Freedom Caucus.

At the end of the regular legislative session, only two bills addressing maternal mortality passed. H.B. 1158 by Rep. Sarah Davis, R-West University Place, will make postpartum screenings available to women on Medicaid but will not offer treatment to those diagnosed. Senate Bill 1599 by Sen. Borris L. Miles, D-Houston, requires the Department of State Health Services to post protocol for pregnancy-related death investigations and best practices for reporting those deaths to the medical examiner or justice of the peace of each county.

When lawmakers returned to the Capitol for a 30-day special session, Rep. Kolkhorst filed S.B. 17 to extend the work of the Task Force on Maternal Mortality and Morbidity until 2023. The bill passed and the governor signed it into law.

Funding for Healthy Texas Women and the Family Planning Program remained level for the next biennium, which is a major victory considering the cuts many public health programs sustained this time around.

A rider in the budget directs HHSC to seek a Medicaid 1115 waiver to provide a 90/10 federal match for the Health Texas Women’s program. If the federal government approves the waiver, funding for the program would start in 2019, which could have a significant impact on the budget and structure for women’s health programs in the state.

Your Academy in action
Despite a tough political climate and a difficult budget process, strong physician leadership in TAFP and a well-respected advocacy team represented the specialty well this session, standing in support of family physicians and their patients. Great appreciation goes out to all those members who served as Physician of the Day during the regular session and the special session, and to those members who provided testimony, contacted their representatives and state officials, served as Key Contacts, and supported the Academy’s efforts.