By Adriana Kohler, Kate Murphy, and Josette Saxton
There may not be any crystal balls that can tell you what’s going to happen during the next legislative session, but the interim reports produced by Texas House and Senate Committees can provide some important insight into legislators’ priorities for the next year.
So if you want to get a preview of how legislators will address Medicaid, mental health, CPS, women’s health, and other key issues, we recommend taking a look at the new 152-page interim report from the Senate Health and Human Services Committee.
Like other interim reports, this one reflects the hearings and research the Committee conducted over the course of 2016 on “interim charges” assigned by the Lt. Governor and the views of the Committee Chair, in this case Senator Charles Schwertner. Democratic Committee members included a letter in the report addressing their dissenting views on several topics.
For those of you who haven’t read the full report yet, we’ve pulled out several excerpts and provided our initial reactions to the Committee’s findings in key policy areas. Direct quotes from the report are identified in italics.
Interim Charge 2A: Recurrence of Abuse and Neglect
As part of the Legislature’s focus on CPS, the Committee looked at strategies to prevent child abuse and neglect in Texas and reduce the incidence of related fatalities.
The Committee noted that the agency’s increased reliance on law enforcement and law enforcement resources should be carefully deployed to support and compliment the work of caseworkers and not create an adversarial atmosphere in caseworker interactions with families.
The Committee also highlighted Prevention and Early Intervention (PEI) resources that were specifically geared toward families with prior CPS history, which include Helping through Intervention and Prevention (HIP), Community-Based Family Services (CBFS), and Project HOPES. Unfortunately, many families with prior CPS involvement continue to cycle through the system. Focusing efforts to prevent abuse and neglect in these families is key to breaking this cycle.
The Committee concluded that protecting children is a core function of state government. The state must, therefore, ensure intake screeners and investigators have the information they need to assess risk and classify a case and that prevention services offered by DFPS have good outcomes for kids and families.
We support the following recommendations by the committee:
3. CPS should continue working with CACs [Children’s Advocacy Centers] to ensure the MEP [Multidisciplinary Team Enhancement Program] rollout continues
4. DFPS and the Legislature should carefully monitor the launch of an FBSS single broker model [Foster Care Redesign] of delivering and managing FBSS purchased client services
5. PEI should utilize predictive analytics to locate areas of high risk of abuse and neglect to target prevention efforts and prioritize services delivery.
6. The legislature should consider the efficacy of targeting more prevention resources to families with prior CPS case history.
7. PEI should explore additional outcome measures to determine the effectiveness of targeted prevention programs at improving child welfare and well-being, not just ensuring child safety.
The Texas Legislature should take care to ensure the state does not criminalize, stigmatize, or tear apart families when they consider the following committee recommendations:
1. DFPS should track and utilize the past criminal and CPS history of the alleged perpetrator of abuse and neglect in Texas and other states, recurrence of abuse or neglect tied to the same alleged perpetrator even if the victim is a different child, and cases in which a child living in the same home is subsequently victimized.
2. DFPS should continue to pursue efforts to utilize the expertise of forensic investigators and analysts to more accurately assess risk and determine case disposition and the level of services that a family may need
8. DFPS should review its record retention policy and determine if it is adequate to ensure children’s safety with their biological families.
Interim Charge 2B: High Acuity Foster Kids
The Committee studied the increase in children in the foster care system who have significant trauma or mental health needs and concluded that the state must work to avoid further traumatizing children in its care. Currently, the state needs to work on expanding its capacity and coordinating care in a way that eliminates duplicative services, improves communication, and reduces confusion.
We support all of the Committee’s recommendations in this report, but would note the following either for their importance or to clarify possible issues to consider:
1. Develop a clear, uniform definition of children with “High Needs” that captures not only children in crisis, but also those at an elevated risk of experiencing a future crisis without appropriate access to timely services.
Texans Care for Children believes that including children at risk of developing high needs will be critical to improving the outcomes of children in the state’s care.
2. Expand Services for Children and Families.
No eject/no reject of youth: “No eject/no reject” means that a provider cannot refuse to accept a child in their area nor can the provider kick a child out of their care and make that child someone else’s responsibility. The Committee identified this policy the state could adopt to improve stability for kids in foster care. Texans Care for Children agrees this policy works well in large child placing agencies (CPAs) and in the Foster Care Redesign Region where a single contractor (the “SSCC”) manages a network of providers and CPAs. The Legislature should be mindful that many high performing but small providers and CPAs could be hurt by this policy if it were applied directly to providers and CPAs rather than to a network such as the one in Redesign regions.
Incentivizing Higher Level of Care: Texans Care for Children believes the state should explore a blended rate similar to the one use in foster care redesign. Nineteen other states use a blended rate for their providers. However, when the state looks at setting a blended rate, it must keep in mind that all the state’s current reimbursement rates are set too low. The 19 states that use a blended rate have an average reimbursement rate of $388 per child per day, which is higher than Texas’s current reimbursement for the highest Authorized Level of Care, which is set at $261.
We support all the Committee’s other recommendations aimed at expanding services for children and families without caveat.
3. Develop Statewide Capacity.
Texans Care for Children supports this recommendation and believes it should be coupled with improving our statewide data collection and using a technology like Every Child A Priority (ECAP) that includes matching information and geo-mapping to improve targeted capacity building and placement stability. The ECAP system is currently being used in Region 3b for Foster Care Redesign. If the state is going to move toward Redesign, having a statewide ability to build capacity and measure the need for targeted capacity building would ease the transition immensely.
4. Build an integrated and accountable case management system.
5. Hold CPAs accountable and Pay them for Performance
6. Expand Foster Care Redesign.
Although Foster Care Redesign shows promise, and Texans Care for Children is supportive of the efforts in Region 3b, the state must be mindful of the changes that need to be made to improve data collection, capacity, and contract structure along with increasing funding, resources, and reimbursement rates to ensure continued success in Region 3b and as the state begins to expand to other areas.
7. Strengthen collaboration and communication between providers, CPS, families, and children.
Interim Charge 4: Medicaid Reform/1115 Waiver
During the interim, the Committee looked at tangible effects of the Section 1115 Texas Healthcare Transformation Waiver on improving health outcomes, reducing costs, and increasing access to care for the uninsured. First, the report describes the different components of the 1115 Waiver and how it helps finance health care in our state. The report explains that the Waiver’s components include:
(1) Statewide expansion of Medicaid managed care;
(2) The Uncompensated Care pool (UC), which covers the difference between Medicaid rates paid to providers and their actual costs; and
(3) The Delivery System Reform Incentive Payments (DSRIP) pool, which provides funding to hospitals and other providers for infrastructure development, program innovation (e.g. pilots and new care coordination models), and population-focused projects (e.g., services for people with mental health conditions). There are 1,451 DSRIP projects across almost 300 providers, the majority of which focus on behavioral health and access to primary care.
The Committee then outlined the impact of the 1115 Waiver on access to care, health outcomes, and reduced costs. The report states:
Access to Care: The waiver has certainly maintained access to care by ensuring that hospitals are able to continue to serve Medicaid and uninsured patients. This is particularly true for rural hospitals. DSRIP projects have collectively served over 5.2 million additional individuals through almost 6.5 million additional encounters compared to the service levels they provided prior to implementing the DSRIP projects.
Improved Health: DSRIP participants saw a 16% reduction in ER visits related to diabetes, a 24% increase in cancer screenings, and a 10% decline in hospital readmissions, among other outcomes.
Reduced Costs: The waiver has allowed the state to leverage funding, including previously unmatched funds flowing to Local Mental Health Authorities (LMHAs) in order to draw down increased federal funding.
The report concluded:
The committee fully supports a long-term renewal of the waiver, and HHSC’s proposed renewal application which calls for extending the DSRIP program in its current form.
However, the committee recommends streamlining the thousands of outcome measures to a much more succinct list and typing outcome measures to cost savings, with an increased focus on reducing potentially preventable events.
Throughout the report, it’s clear the Committee’s main goal is to find ways to improve health outcomes and improve the quality of care, while also reducing costs to the state. To that end, the Committee recommended:
- HHSC should aggressively pursue a longer term renewal of the 1115 Waiver;
- HHSC and the Legislature should continue to have a clear focus on bending the cost curve in the Medicaid program; and
- HHSC should try to streamline DSRIP project outcome measures to ensure CMS and the state can accurately measure the cumulative impact of DSRIP projects on health outcomes and cost savings.
The report conclusion also notes that, “under the best case scenario, Texas would secure a block grant to allow the state to operate its Medicaid program in a way that is right for Medicaid beneficiaries and the taxpayers of Texas. However, this would require an act of Congress.”
With the election results now in, there is a lot of uncertainty about the future of health care coverage in Texas and how a new Congress may shape policy in our state.
As discussion of Medicaid block grants heats up in Washington and at the Legislature, it’s important to remember that the Texas Medicaid program essentially covers four low-income groups: children, pregnant women, seniors, and people with disabilities. Proponents of block grants and other proposals that would cut Medicaid must tell us which of these groups they would target for cuts.
Interim Charges 5 & 6: Mental Health
Interim Charges 5 and 6 focus largely on the state hospital system, the mental health system’s capacity to serve both forensic and civil populations in inpatient settings, and diverting individuals with mental illness from the criminal justice system, concluding:
“In addition to sustaining the significant investments made in recent years, lawmakers should focus on expanding inpatient capacity, growing the mental health workforce, and addressing unmet needs across the continuum of care for "high utilizers", individuals whose ongoing serious behavioral and physical health needs manifest themselves in frequent utilization of the crisis stabilization, inpatient psychiatric, hospital emergency room, and criminal justice systems.”
It can be assumed the Senate Committee’s findings and recommendations were made with the adult population in mind. However, its recommendations present opportunities to build and strengthen a continuum of care for kids with mental illness, too:
- Protecting the past investments the Legislature has made in developing the state's mental health system
- Partnering with universities to help address staffing issues in the state hospital and local mental health system
- Expanding the Mental Health Professional Loan Repayment Program
Half of individuals with chronic mental illness begin experiencing symptoms by age 14. Intervening early is our best chance to divert individuals with mental illness from costly inpatient and criminal justice settings. As the state works to advance these recommendations, it should incorporate strategies that address gaps in the systems of care serving children.
Interim Charge 7: TeleHealth
Interim Charge 7 addresses the use of tele-monitoring and telemedicine services to improve management and outcomes for adults and children with complex medical needs, for persons confined in correctional facilities, and those living in rural areas of the state. The Committee identifies two areas where telehealth can be used to increase children’s access to mental health services and supports: in schools and in the foster care system.
The Committee report highlights the Texas Tech University's Telemedicine Wellness, Intervention, Triage and Referral Project (TWITR) that uses telehealth to provide school-based screening, assessment, and referral services to students living in rural areas in West Texas that lack mental health providers. The project has been shown to not only reduce children’s wait times for mental health services, but also to reduce truancy and disciplinary referrals at school and improve academic performance. The Committee recommends this school-based telehealth strategy be considered for expansion into other rural areas of the state that lack adequate mental health providers.
While the committee views telehealth as a useful tool, it sees it as a way to support and strengthen existing doctor-patient relationships, not to supplant them, as noted in the Committee recommendations related to children in foster care:
“The foster care system is currently experiencing an increase in the intensity of the mental health and medical needs of children entering care…Many of these children are not receiving timely access to necessary medical services…Better utilization of telehealth will not, and should not, replace this extensive screening that must be performed by a primary care provider, but telehealth can be used to allow caseworkers and Child Placing Agencies (CPAs) to triage children upon entrance into conservatorship of the state, allowing providers and STAR Health to more quickly connect them with necessary services.”
Interim Charge 9B: Women’s Health Consolidation
The Committee also looked at the recent consolidation of Texas’ women’s health programs. In 2014, the Sunset Advisory Commission directed HHSC to consolidate the state’s three major women’s health programs and place them under one division – HHSC – to promote efficiency and effectiveness. This consolidation resulted in two programs: Healthy Texas Women (HTW) and the Family Planning Program (FPP), both of which launched in July 2016. HTW and FPP provide health screenings and preventive care, such as pelvic exams, pap tests, and family planning services and counseling. HTW also offers screening and treatment for hypertension (high blood pressure), diabetes, and cholesterol – conditions critical to treat before pregnancy so a pregnancy is healthier for both mom and baby and less costly down the road.
The Committee examined how implementation of HTW and FPP is going and called for continued efforts to improve access to women’s health care and family planning:
Despite the advancements in access to comprehensive women’s health services made over the past several years, the Legislature must maintain their investment in women’s health and HHSC must ensure that any access to care issues in underserved areas of the state are proactively identified and immediately addressed. Moving forward, the Legislature should seek to improve access to long-acting reversible contraception (LARCs), improve birth outcomes, and reduce maternal mortality rates, particularly among minority women.
During the interim, two reports came out showing an alarming spike in the rate of pregnancy-related deaths in Texas – making this a big topic of discussion among the Committee. One national study found that the rate of pregnancy-related deaths in Texas doubled between 2010 and 2012. The second report was from the Texas Maternal Mortality and Morbidity Task Force, which looked at 2011 – 2012 cases of maternal deaths and trends in pregnancy complications. The Task Force found that:
- Black women bear the greatest risk for pregnancy-related death;
- Mental health and substance use disorders play a big role in maternal death;
- The majority of maternal deaths occurred more than 42 days after delivery; and
- The leading causes of maternal death are heart attack, overdose by illicit and licit prescription drugs, and hypertension.
Based on these findings, the Task Force made several recommendations including:
- Increasing access to health services during the year after delivery and throughout the interconception period (time between pregnancies);
- Increased provider and community awareness of health inequities;
- Increased screening for and referral to behavioral health services; and
- Promoting bets practices to improve the quality of maternal death reporting and investigations.
The Committee stressed the importance of understanding the root causes of this “disturbing upward trend in maternal mortality.” It called on the Legislature to carefully consider implementation of the Task Force’s recommendations, take steps to improve data used to study maternal mortality, and encourage sharing of best practices to improve maternal and infant health outcomes.
We are pleased to see the Committee’s emphasis on continued investment in women’s health programs and steps to improve maternal and infant health. Specifically, the Committee recommended that the Legislature:
- Continue to prioritize funding for women’s health programs;
- Ensure access to women’s health programs. HHSC should identify and quickly remedy any access to care issues that arise in the state’s women’s health programs;
- Increase access to Long Acting Reversible Contraception through expanded, statewide training opportunities for providers;
- Pursue policies to reduce maternal and infant mortality rates, including careful consideration of the Task Force’s recommendations and leveraging Healthy Texas Babies funding to create a collaborative approach to maternal and infant health.