Legislative Update

May 13, 2011

House Hits Deadline

Thursday marked the last day for the House to consider House bills on 2nd reading on the general calendar (Friday was the last day for the House to consider House bills on 3rd reading). Many bills are now dead but could certainly resurface in amendment form. Those issues that would be detrimental to kids' health or the practice of pediatrics are being watched extra closely as a result.

Senate Names Budget Conferees

Lieutenant Governor David Dewhurst on Monday named Senators; Steve Ogden (R-Bryan), Juan “Chuy” Hinojosa (D-Corpus Christi), Robert Duncan (R-Lubbock), Jane Nelson (R-Flower Mound) and Tommy Williams (R-The Woodlands), to serve as the Senate conferees on HB 1, the 2012-2013 state budget. The announcement allowed representatives of both chambers to begin working through the differences in the House and Senate versions of HB 1. Much of their work has taken place behind closed doors. On Friday, Senator Ogden announced that a special session is likely because while progress has been made, the conferees work is slow going.

House Delays Bills Addressing Fiscal Matters

The House spent most of the week incrementally delaying review of a series of bill that identify additional funding for HB 1. On Thursday, House Appropriations Chairman Jim Pitts (R-Waxahachie) once again delayed the measures indicating that Senate versions of the same bills were in Calendars and could be debated next week. The delay avoided an almost certain meltdown of the House calendar allowing additional bills to be heard before Thursday's midnight deadline. Before delaying the bills, Rep. Pitts urged the passage of school reform legislation (currently stalled in each chamber) indicating that without the school reform and fiscal matter bills, funding in HB 1 will need to be cut further. Without these legislative efforts, state funding for schools is short $8 billion and payments to school districts will stop by February 2013. He also said Medicaid is underfunded by $5 to $6 billion and that funds would run out by March 2013.

HB 400 Attracts Bad Amendments for Student Health

House Bill 400, by Rep. Rob Eissler (R-The Woodlands), relating to flexibility for public schools to administer primary and secondary education efficiently died on the House calendar Thursday at midnight. The bill, which among other things would have lifted the state's student-teacher ratio in lower grades, faced a great deal of opposition and was pulled off the calendar multiple times on technicalities.

On Friday night, May 6, the House of Representatives spent hours debating the bill. During the contentious debate, the House approved an amendment that would strip the requirement for Texas students in grades 3-12 to participate in annual physical fitness assessments. Also under consideration, though not adopted (because the discussion was abruptly halted due to a technicality) was an amendment to remove requirements for coordinated school health.

Campus Carry Provision Amendment Lives

The Senate on Monday voted 21 to 10 to amend SB 1581, by Sen. Steve Ogden, with language allowing concealed handguns to be carried inside institutions of higher education. Senate Bill 1581 addresses state fiscal matters related to public and higher education. The bill itself was later passed by the full Senate 19 to 12. The matter now goes to the House for review.

Bills on the Move...

HB 359, by Rep. Alma Allen (D-Houston), relating to corporal punishment was passed by the full House (87 to 56) on Thursday a day after it failed to pass (69 to 73). The bill restricts school district employees from disciplining a student only if a parent has provided written consent to the district. The bill was amended to exclude counties with a population of less than 50,000 as well as to allow parents to forbid paddling of their children if they submit a written statement in opposition before the school year begins.

Republican lawmakers were divided on the issue with some saying it was a government overreach while others said the measure actually strengthened local control by giving school districts the freedom to choose how to discipline students.

Corporate Practice Update – Excerpt from the TMA Hotline (5.12.11)

Yesterday, Gov. Rick Perry signed into law a bill to allow small hospitals in rural Texas to employ physicians. The new law puts strict employment protections in place for physicians that protect their clinical autonomy and independent medical judgment. Texas is probably the only state in the country to pass protections of this magnitude. Senate Bill 894 by Sen. Robert Duncan (R-Lubbock) and Rep. Garnet Coleman (D- Houston) allows critical access hospitals, sole community hospitals, and hospitals in counties of 50,000 or fewer to employ physicians. Most of these hospitals are run by local governments. The bill contains many features that protect the physician's clinical autonomy against the corporate practice of medicine. SB 894:

• Places the responsibility for all clinical matters – bylaws, credentialing, utilization review, and peer review – under the medical staff.
• Guarantees physicians' independent medical judgment.
• States that all physicians – employed or independent – are subject to the same rights and responsibilities.
• Requires the medical staff to designate a chief medical officer (CMO) who must be approved by the hospital board. The CMO has the duty to report to the Texas Medical Board (TMB) that the hospital is hiring physicians under this bill and that the CMO is the contact for TMB. The CMO has a duty to report instances of interference to TMB.
• Allows employed physicians to participate in the selection of their liability insurance and have the right to consent to settle in a liability action.

May 6, 2011

Senate Approves State Budget

After several hours of debate on Tuesday, the Senate failed to reach the two-thirds approval it needed to suspend the Senate rules to take up and consider the Committee Substitute to House Bill (CSHB) 1, the 2012-2013 budget bill. Senate Finance Chairman Steve Ogden announced from the floor that upon suspension of the rules he would lay out an amendment stripping the legislation of $3 billion dollars used from the state's Rainy Day Fund and replace it with other cuts and funding assumptions. The bill had been blocked for days by divisions largely along party lines which placed some Republicans, concerned about using additional money from the state's Rainy Day Fund, against some Democrats that felt the budget doesn't spend an adequate amount of dollars.

As you'll recall, the Senate version of the budget spends $12 billion more than the House version. The House chose not to spend any of the Rainy Day Fund in passing the 2012-2013 budget although they did use money from the Fund, $3.1 billion, in passing HB 274, by Rep. Jim Pitts (R-Waxahachie), the supplemental appropriations bill, which provides necessary funding for the current 2010-2011 budget. House leaders spent the Rainy Day Funds after coming to an agreement with the Governor that no further Rainy Day Fund money would be spent on the budget.
On Wednesday, Lieutenant Governor David Dewhurst, pulled up the CSHB 1, citing a rarely used parliamentary procedure which says on Wednesdays, House bills can be addressed before the regular order of business. This maneuver did away with the need for the full Senate to first suspend the regular order of business to take up the budget bill. Therefore a 2/3 approval of the Senate wasn't necessary.

Senator Ogden laid out his amendment, approved in a party vote (19 Republicans to 12 Democrats) which removed the use of the Rainy Day Fund money and in doing so, reduced funds for Medicaid by $1.25 billion (which is achieved by deferring payment in this budget for August 2013 to September 2013) and reduced spending across all agencies (except for public education and bond payments) by 1.2% in 2013, unless the Comptroller certifies that sufficient revenue is available to provide appropriated amounts. The Committee Substitute to House Bill 1 was then approved by the Senate in a similar 19 to 12 vote.

The CSHB 1 was later referred back to the House where they refused to consent to the changes made by the Senate and the bill was referred to conference committee so those differences could be ironed out. Speaker of the House Joe Straus named Representatives; Jim Pitts (R-Waxahachie), Sylvester Turner (D-Houston), John Zerwas (R-Houston), John Otto (R-Dayton) and Myra Crownover (R-Denton), to serve as the House representatives on the conference committee. The Senate has yet to name their conferees.

Campus Carry Amendment Causes Stir in the Senate

Senator Judith Zaffirini (D-Laredo) quickly withdrew from consideration SB 5, relating public institutions of higher education, including the administration, operation, financial management, and reporting requirements of those institutions, on Tuesday after Senator Jeff Wentworth (R-San Antonio) tacked on an amendment allowing concealed handguns to be carried on college campuses. The amendment was approved in a 19-12 vote.

As you will recall, Senator Zaffirini pulled SB 5 down last week after it became apparent that Senator Wentworth intended to run an amendment. Turning controversial legislation into amendment form is a parliamentary tactic that can be used when legislation itself has stalled.

The bill was withdrawn after a long debate during which several Senate Democrats offered amendments to the Senator Wentworth amendment to reduce its impact. Only one, offered by Senator Rodney Ellis (D-Houston), which prohibits insurance companies from increasing their premiums to universities and colleges from licensed handguns being allowed on their campuses, was adopted.

Impact of the Proposed Budget on Children's Hospitals

The Texas Pediatric Society has for many years collaborated with the Children's Hospital Association of Texas to advocate on issues of importance to children's health. Inevitably the Medicaid cuts proposed in HB 1, the 2012-2013 proposed budget, will have a larger impact on children's hospitals because they see a larger amount of Medicaid patients than other hospitals. Emily Ramshaw sheds light on what the proposed cuts will mean for children's hospitals in Monday's edition of the Texas Tribune. Bryan Sperry, president of the Children's Hospital Association of Texas, is quoted as saying that on average, “nearly 60 percent of the patients treated at the seven nonprofit children's hospitals he represents are on Medicaid. In South Texas, he said, that figure can reach 80 percent.” A full copy of the article is attached.

Bills on the Move

House Bill 2038, by Rep. Four Price (R-Amarillo), relating to prevention, treatment, and management of concussions affecting public and private school students participating in interscholastic athletics, passed the House. Under the bill, schools would be required to establish concussion management teams and follow a protocol developed by state education officials in collaboration with physicians to deal with students who get concussions during school-sponsored athletic practices or other events. Students who are diagnosed with a concussion or who are suspected to have sustained a concussion would be immediately removed from play and would not be allowed back on the field until a physician signs a release.

HB 1942, by Rep. Diane Patrick (R-Arlington), defines bullying and calls on school districts to produce policies that prohibit bullying. The policy must make students aware of their options for seeking assistance, protect "whistle-blowers," establish procedures for notifying parents and guardians about incidents of bullying, and set out counseling options for both the victim and the bully. It also allows school boards to transfer a bully – as opposed to a victim – to a different classroom and different school, if necessary.

HB 2636, by Rep. Lois Kolkhorst (R-Brenham), charges the Health and Human Services Commission with creating and appointing a Neonatal Intensive Care Unit Commission (NICU) to study and make recommendations regarding NICU operating standards and reimbursement through Medicaid for services provided to an infant through the NICU. Members of the Commission include four neonatologists (at least two of whom must practice in a level IIIC NICU), one general pediatrician, one representative from a level II NICU and two OBGYNs.

April 29, 2011

Bills on the Move

A bill that would require individuals new to college campuses to be vaccinated against bacterial meningitis was passed by the Senate in a 29 to 2 vote. Authored by Senator Wendy Davis (R-Fort Worth), the bill seeks to expand current statue which only requires college freshman living in dorms to be vaccinated. The measure will now go to the House for review. The House version of the bill, HB 1816 by Rep. Charlie Howard (R-Sugar Land), has been set on the House Calendar for Monday, May 2.

Senate Bill 23, by Senator Jane Nelson (R-Flower Mound), relating to efficiencies and cost savings in health and human services and other regulatory agencies, was unanimously approved by the Senate on Thursday. The bill achieves savings by expanding Medicaid managed care into South Texas and carving-in prescription drug sales into managed care among other things. The savings achieved in this bill are already allocated in the proposed 2012-2013 budget.

The Senate unanimously approved SB 1177 by Senator Nelson on Tuesday. The bill relates to health care facilities' adoption of a policy on vaccine preventable diseases. The Texas Pediatric Society collaborated with the Texas Medical Association and the Texas Hospital Association in approaching Senator Nelson with this bill. The bill now goes to the House for review.

Senate Bill 224 by Senator Jane Nelson was also passed by the full Senate on Tuesday. The bill establishes a program to recognize public schools with successful health and fitness programs. It moves now to the House.

The House on Tuesday approved HB 127 by Rep. Carol Alvarado (D-Houston) which further refines the types of beverages that may be sold on public school campuses. The bill will now be considered in the Senate.

Senate in Budget Meltdown

The Senate leadership spent much of the week attempting to garner enough support to allow HB 1, the 2012-2013 budget bill, to be discussed by the full Senate. A two-thirds (21 Senators) consensus must be reached before the bill can be debated. Typically a simple majority allows for debate but HB 1 would spend $3 billion from the state's Rainy Day Fund and rules governing the fund dictate a two-thirds vote. Opposition is coming from both sides of the aisle. Some Republicans oppose use of the Rainy Day Fund and favor the House's more bare bones budget approach. Some Democrats fear the proposed cuts are too draconian.

Lieutenant Governor David Dewhurst complicated matters early in the week by indicating to the press that he did not support moving additional money out of the Rainy Day Fund; however, he followed that complaint with a press release on Wednesday indicating that he "strongly supports" the Senate version

of the budget. As a reminder, the Senate version of HB 1 spends approximately $12 billion more than the version approved by the House.

Amendment Gives New Life to Guns on Campus Legislation

Senator Jeff Wentworth (D-San Antonio) surprised his colleagues in the Senate on Wednesday when he moved to place his legislation that would allow individuals with concealed handgun licenses to carry guns on college campuses on another piece of legislation in the form of an amendment. The bill, by Senator Judith Zaffirini (D-Laredo), reduces reporting requirements for universities and includes language to drive down tuition rates. Senator Zaffirini pulled down her bill shortly after the Wentworth amendment was proposed. Senator Zaffirini indicated that if Senator Wentworth was successful in amending her bill she would have no choice but to kill her bill.

Turning controversial legislation into amendment form is a parliamentary tactic that can be used when legislation itself has stalled. The bill is expected to be brought back up for discussion next week.

April 25, 2011

Senate Finance Reviews Soda Tax Bill

Dr. Stephen Pont testified in support of SB 1007 by Senator Eddie Lucio (R-Brownsville) related to the imposition of taxes on certain beverages on behalf of the Texas Pediatric Society (TPS) on Monday, April 18. Dr. Pont told members of the Senate Finance Committee that, "sugar-loaded drinks, unlike tobacco and alcohol, are not only legal for children to buy, but—thanks to a marketing juggernaut that spends hundreds of millions of dollars targeting children—they are also disproportionately purchased by young consumers."

Multiple witnesses opposed the measure ranging from the American Beverage Association whose witness stated that "taxes don't necessarily make people healthier" to the League of United Latin American Citizens (LULAC) whose witness testified that the measure would unfairly target Texas' Latin American population.

Rules governing the legislative process dictate that tax bills must originate in the House. That rule, combined with a general lack of legislative interest in raising taxes, deflate the chances that SB 1007 will move very far however it was a very worthwhile public health discussion. Click here, to read Dr. Pont's testimony.

Patricia Kilday Hart wrote a commentary outlining the dismal response the soda tax bill received in committee which ran in the Houston Chronicle on April 25. To read her piece in full, visit the following link: http://www.chron.com/disp/story.mpl/metropolitan/7535277.html.

Senate Health Committee Discusses ImmTrac

Senate Bill 56 by Sen. Judith Zaffirini (D-Laredo) was considered by the Senate Health and Human Services Committee on Tuesday, April 19. The bill, which would alter the current consent process for the registry by making it opt-out, was left pending in committee. Dr. Julie Boom testified in favor of the bill on behalf of TPS, the Texas Medical Association (TMA), the Texas Academy of Family Physicians (TAFP) as well as the Texas Immunization Partnership, which provides advocacy and education on immunization issues.

Dr. Boom told committee members that she and her staff along with a health economist at the University of Texas conducted analyses to delineate the cost of the immunization registry's current consent process. "We learned that regardless of when or where a family is consented, significant nurse or staff time must be used to successfully complete the ImmTrac consent process at a cost of $1.4 million per year." Dr. Boom stressed that "moving to an opt-out system would save approximately one million dollars a year." Click here, to read her testimony in full.

A House version of the bill, HB 574 by Rep. Donna Howard (D-Austin) was heard Wednesday, April 13 in the House Public Health Committee. Dr. Jason Terk testified in favor of the bill on behalf of the groups outlined above. HB 574 was also left pending in committee.

Public Health Committee Discusses Raw Milk and Scope

House Bill 75, by Dan Flynn (R-Van), which would permit the sale of raw milk and raw milk products at farmer's markets, farm stands, flea markets, food cooperatives or fairs, was discussed during an all-night House Public Health Committee hearing, Wednesday, April 20. Dr. Kimberly Avila Edwards, a practicing pediatrician and assistant professor of pediatrics at the Texas Center for the Prevention and Treatment of Childhood Obesity, located at Dell Children's Medical Center, testified against the bill on behalf of TPS, TMA and TAFP.

Dr. Avila Edwards told Committee members that "there is no validated evidence to provoke a change in Texas' public policy on raw milk sales, or to support that presumed benefits of consuming raw milk outweigh the well-established risks." Her full testimony can be seen here . More than a dozen witnesses testified in favor of the bill including individuals that claim that raw milk works for children who have allergies to pasteurized milk, a chiropractor that said raw milk helps address environmental allergies in many of her younger patients as well as raw milk producers. Only a handful of individuals turned out to oppose the bill including an individual representing Texas' dairy farmers and two representatives of local public health offices. The bill was left pending in committee.

The Public Health Committee also heard testimony on three bills that would allow advance practice nurses to practice independent of physician oversight; HB 915 by Rep. Wayne Christian (R-Center), HB 708 by Rep. Kelly Hancock (R-North Richland Hills) and HB 1266 by Rep. Garnet Coleman (D-Houston). TPS collaborated with TMA and TAFP in providing testimony opposing the bills. Dr. Gary Floyd, current AAP Chapter Chair and Executive Vice President of Medical Affairs for the JPS Health Network, joined Dr. Tricia Elliott, director of the UTMB Family Medicine Residency Program, in opposing each bill. In their testimony, Drs Floyd and Elliott addressed the differences between physicians and APNs in terms of education and training and spoke to increased utilization among patients seen solely by an APN.

Dr. Floyd told committee members that " it's important to understand that their scope does not include independent diagnosis or prescribing treatments for disease processes. Those functions are reserved for physicians under Texas law and are considered medical acts," he said. "We do believe APNs are vital to our service, but we think it should be done in a physician-led, team-based approach." All three bills were left pending in committee.

Senate Finance Approves Budget

The Committee Substitute for House Bill 1, the 2012-2013 budget bill, was passed by the Senate Finance Committee on Thursday, April 21, in an 11 to 4 vote. Those Senators voting against the bill were; Sen. Dan Patrick (R-Houston), Sen. Eddie Lucio (D-Brownsville), Sen. John Whitmire (D-Houston) and Sen. Judith Zaffirini (D-Laredo). The $176.5-billion budget spends roughly $12 billion more than the version passed by the House. Unlike the House, the Senate proposes to use $3.1 billion from the Rainy Day Fund. The full Senate is expected to debate HB 1 this week if they can get the 21 votes needed to allow debate.

April 8, 2011

House Passes HB 1

The House on Sunday voted 98 to 49 in favor of HB 1, its version of the budget bill, by Rep. Jim Pitts (R-Waxahachie), after two days of debate. The vote was along party lines with the exception of two Republicans; Rep. Aaron Pena (Edinburg) and David Simpson (Longview), who joined Democrats in voting against the bill.

House Bill 1 includes significant across the board cuts as no new revenue was used to fill the budget shortfall. As you'll recall, agreement was reached between legislative leadership and the Governor's office to use a portion of the rainy day fund to help pay for the supplemental appropriations bill (the bill which completes funding for the 2010-2011 biennium) but that agreement included the caveat that no additional money would be pulled from the fund for 2012-2013.

Over 370 amendments were filed. Of those adopted, highlights are listed below.*

Article II, Health and Human Services

• There are a number of riders that increase appropriations, contingent on passage of legislation that increases revenue including:
  • Up to $20 million general revenue for Tobacco Cessation from the corpus of the Permanent Fund for Health Tobacco Education and Enforcement (rider by Rep. John Zerwas R-Houston).
• A good number of riders move general revenue (GR) from Family Planning:
  • $7 million GR to Autism
  • $14 million GR to Children's Mental Health
  • $9 million GR to Children with Special Health Care Needs

Article IX, General Provisions

• A rider from Rep. Craig Eiland (D-Galveston) would appropriate $240 million GR, contingent on passage of legislation establishing an assessment on subscription video service providers, for Early Childhood Intervention, DFPS Prevention Programs, Tobacco Cessation, and Mental Health Community Hospitals.
• A legislative intent rider says general revenue cannot be used to compel a person to purchase or to enforce a requirement that a person purchase health insurance.
• Another rider says appropriated funds may not be used to implement or comply with an unfunded federal mandate, including a federal regulation, for which federal reimbursement did not cover the cost.
• Several riders by Rep. Joaquin Castro (D-San Antonio) reduce general revenue for the House, Senate and Legislative Council budgets and move the money to various programs (Children with Special Health Care Needs, Communities-in-Schools or Comprehensive Rehabilitation).

The closing speeches given before the vote were quite compelling regardless of your position on the proposed budget. None was more compelling than that from Rep. Sylvester Turner (D-Houston), Vice-Chair of the House Appropriations Committee. Rep. Turner received the 2007 TPS Child Advocacy Award for his work on behalf of the Children's Health Insurance Program. To view the speech which touches on the needs of Texas children, visit this link: http://www.youtube.com/watch?v=E_G9kAASTRY

The Senate continues to work on its version of the budget, SB 1.

Senate Health Approves Health Care Worker Vaccination Policy

Senate Bill 1177, by Sen. Jane Nelson (R-Flower Mound), was considered by the Senate Health and Human Services Committee on Tuesday. The bill relates to health care facilities' adoption of a policy on vaccine preventable diseases. The Texas Pediatric Society (TPS) joined the Texas Medical Association (TMA) and the Texas Hospital Association in initiating this legislation which requires health care facilities to develop and implement a policy to protect its patients from vaccine preventable diseases. The legislation outlines components required of policies which range from requiring employees to receive vaccines to specifying which vaccines an individual must receive based on the level of risk the individual presents to patients.

Dr. Charles Lerner, a physician and the medical director of hospital epidemiology and employee health for the Methodist Health Care system in San Antonio, testified in favor of the bill on behalf of TPS, TMA and the Texas Academy of Family Physicians. Dr. Lerner who is also the past president of the Texas Infectious Disease Society and current chair of TMA's Committee on Infectious Diseases told committee members that "numerous published medical studies show that when health care workers are immunized, patient mortality is reduced almost by half. Additionally, there is evidence that preventing influenza reduces patient hospitalizations and death from heart, chronic lung and kidney disease, as well as from diabetes." Click here to read his testimony in full.

The bill was voted favorably out of the Committee and was referred to the Senate Local Calendar, an expedited process reserved for local bills or ones with unanimous support.

House Approves Bill Banning Texting While Driving

On Friday, the House of Representatives gave final approval, 107 to 16, to HB 243 by former Speaker Tom Craddick (R-Midland) relating to the creation of an offense for certain uses of a wireless communication device while operating a motor vehicle. The bill prohibits anyone operating a motor vehicle to send a written communication via a wireless communication device unless the vehicle is stopped and defines the term "text-based communication" to include; a text message, instant message and email.

TPS supported this bill (and several similar bills) when it was considered in the House Transportation Committee. The bill will now be referred to the Senate for review.

Fiscal Matter Subcommittee's List of Fiscal Options Leaked

A list of funding options being considered by the Senate Finance Subcommittee on Fiscal Matters led by Senator Robert Duncan (R-Lubbock) was leaked on Thursday. As you may recall, the Subcommittee was charged by Lieutenant Governor David Dewhurst to find $5 bill in non-tax revenue. The list was obtained by Empower Texas, a group that advocates for fiscal conservatives, and posted on their website. Items reportedly under consideration include:

• $590 million from moving Tobacco Permanent Health Funds set aside in a tobacco lawsuit settlement in the 1990s from a dedicated account into a general revenue account.
• $379 million would come from doing the same thing with the Permanent Public Health Fund.
• $47 million from cutting the tax stamp discount for cigarette distributors.
• $115.3 million by collecting a surcharge when Texans buy fuel-inefficient vehicles.
• $75 million by releasing 1,000 elderly prison inmates under supervision for serious medical conditions.
• $200 million from ending the sales tax exemption for Blue Cross on taxable items bought under federal contracts.

To view the list in full, visit the following link: http://www.ttara.org/files/document/file-4d9e2b76b6739.pdf

*Amendment summary attributable to Kathy Eckstein with the Children's Hospital Association of Texas.

April 1, 2011

Vaccine Bill Discussed in Senate Education

Senate Bill 1107 by Sen. Wendy Davis (D-Fort Worth) seeks to expand the requirement for bacterial meningitis vaccination to all college students. Current state law only requires students living on campus to be vaccinated. Greg Williams whose son, Nicolis, died in February of bacterial meningitis testified in favor of the bill when it was heard in Senate Education this week. Nicolis, who was a freshman attending Texas A&M University, didn't make the university's list for on-campus housing and therefore wasn't aware of the requirement.

Several people who either survived bacterial meningitis or who lost family members to the disease testified in favor of the legislation. Six individuals testified against the legislation citing varying reasons for their opposition ranging from opposition to forced immunization to their assertion that vaccination causes illnesses such as bipolar disorder.

Dr. Carol Baker, Executive Director of the Texas Children's Hospital Center for Vaccine Awareness and Research, as well as Professor of Pediatrics, Molecular Virology and Microbiology at Baylor College of Medicine spoke in favor of the bill on behalf of the Texas Pediatric Society (TPS), Texas Medical Association (TMA) and Texas Academy of Family Physicians (TAFP) as well as on behalf of the Texas Immunization Partnership which provides education and advocacy on immunization topics (testimony is attached). Dr. Baker, who serves as current chair of the Advisory Committee for Immunization Practices for the Centers for Disease Control and Prevention, discussed the prevalence of the disease and addressed the many misstatements raised in the hearing by anti-vaccination advocates. The bill was left pending in committee.

As you may recall we also support a House version of this bill that was considered by the House Public Health Committee earlier this session. HB 1816, by Rep. Charlie Howard (R-Sugar Land), was unanimously voted out of the House Public Health Committee on Wednesday.

Concussion Management

The House Public Health Committee on Wednesday discussed HB 2038 by Rep. Four Price (R-Amarillo) relating to the prevention, treatment, and management of concussions affecting public and private school students participating in interscholastic athletics. Dr. T.J. Spinks, a pediatric neurosurgeon in Austin and Co-Director the Dell Children's/Seton Hospitals Concussion Program, testified on the bill on behalf of TPS, TMA and TAFP (testimony attached). The bill, which seeks to improve care for high school athletes, takes a comprehensive approach to treating concussions by calling for a number of things including education for students and parents, requiring schools to develop medical teams (comprised of a physician, and to the greatest extent practical; athletic trainer and neuropsychologist) and mandating education for members of the medical team.

TMA established an Ad Hoc Committee on Student Athlete Concussions to review and discuss the many bills filed on this topic. TPS was represented on this Committee by Dr. Spinks and Dr. Jason Terk, a pediatrician in private practice. In addition to reviewing the various bills, the group reviewed the Texas University Interscholastic League's (UIL) policy on concussions developed by the UIL Medical Advisory Committee which is to be implemented in the fall of 2011. The Committee found the UIL policy demonstrated a commitment to implementing solid evidence-based recommendations. They also concluded that the UIL Medical Advisory Committee is well positioned to react to new scientific evidence and appropriately and expediently change their recommendations to maximize the quality of care provided to young athletes.

Dr. Spinks testimony reflected the Ad Hoc Committee's discussion. He stressed that as our understanding of concussions is still evolving, and has changed markedly over the past several years, one of the greatest challenges is to implement a system that is flexible enough to incorporate new scientific guidelines as they develop. His testimony is attached.

Fitnessgram Reporting

Dr. Stephen Pont, a pediatrician and Medical Director of the Texas Center for the Prevention and Treatment of Childhood Obesity at Dell Children's Medical Center testified in favor of SB 226 on behalf of TPS, TMA and TAFP along with the Texas Public Health Coalition, which represents thousands of public health advocates. Senate Bill 226, by Sen. Jane Nelson (R-Flower Mound), relates to reporting individual student performance on a physical fitness assessment instrument to the Texas Education Agency and was heard Thursday by the Senate Education Committee.

Fitnessgram, is a physical education assessment and reporting program required under current law for children in grades 3 through 12. It measures a child's aerobic capacity, muscular strength, muscular endurance, flexibility and body composition. Senate Bill 226 seeks to enhance this data by requiring school districts to provide the results of individual student performance without identifiers such as a student's name, social security number or date of birth. The data is currently reported in aggregate form.

Dr. Pont told committee members that allowing Fitnessgram data to be reported in this manner will provide data that shows the direct correlation between physical fitness and academic achievement and will allow administrators and teachers from a low-academically performing school to compare/contrast their physical activity programs with programs from higher-performing schools. Just as school administrators can look at TAKS results, pinpoint low scores and identify where additional resources should be allocated, Fitnessgram scores can provide similar guidance. Dr. Pont's full comments are attached.

Senate Bill 226 was approved by the Senate Education Committee and sent to the Senate Local Calendar which is typically reserved for less controversial bills.

Senate Finance Adopts Parts of Article II Recommendations

The Senate Finance Committee on Thursday considered and adopted a portion of the budget recommendations made by the Subcommittee on Medicaid/Article II (the health and human services component of the budget). About $300 million in general revenue was added to the Subcommittee recommendations since they last met. Of that $300 million: $110 million went to further restore physician rates (holding rates at the current 2% interim rate reductions, rather than the additional 1% cut); $64 million to fund the Department of Assistive and Rehabilitative Services' (DARS) outstanding requests, including $56 million to increase service hours in Early Childhood Intervention (ECI); $21 million for the Department of Family and Protective Services (DFPS) Prevention Programs; $21 million for the Department of State Health Services' (DSHS) Tobacco Prevention and Cessation. A number of items were left pending for later discussion.

Budget Debate Hits House Floor

On Thursday, the full House debated and approved in a 100 to 46 vote, HB 4 by Rep. Jim Pitts (R-Waxahachie), which addresses approximately $1.5 billion in cuts necessary to balance the current budget for fiscal years 2010-2011. They also approved in an almost unanimous vote, 142 to 2, HB 274 also by Rep. Jim Pitts which took a portion of money from the state's rainy day fund ($3.1 billion of the $9.4 billion available) to further aid the 2010-2011 budget.

Today, lawmakers began discussing HB 1, by Rep. Jim Pitts, the 2012-2013 budget bill which cuts about $23 billion dollars from current spending levels. Over 300 amendments were pre-filed so a lengthy debate is expected. Amendments had to be revenue neutral or create a reduction. At 4:30pm the House had only made it to amendment 62. Although a full analysis will have to be completed after the debate, several amendments have been adopted which strip money from DSHS for family planning programs and allocates those dollars to other areas of the budget including ECI and autism programs housed at the DARS.

March 18, 2011

Budget Talks Continue -- House

The House Appropriations Committee on Tuesday voted along party lines to approve HB 4 by Rep. Jim Pitts (R-Waxahachie), the supplemental appropriations act which pays for the balance of the 2011 fiscal year with Democrats voting for the bill and Republicans voting against the bill. There was unanimous support however for HB 275 by Rep. Pitts which allows money to be pulled from the Economic Stabilization Fund (AKA the Rainy Day Fund). The vote ended days of negotiation among the Legislative leadership on use of the Rainy Day Fund. House Appropriations Committee Chairman Jim Pitts wanted the leadership's blessing on use of a portion of the fund to improve the comfort level of House Appropriations Committee members forced to take a vote.

In a press release distributed just prior to the vote, Governor Perry said he'd reached an agreement with Texas Comptroller Susan Combs and House Speaker Joe Strauss on partial use of the Rainy Day Fund, making it clear he continues to oppose using the Rainy Day Fund to close the 2012-2013 shortfall. “As we craft the next two-year budget, Texas leaders will continue to focus on a more efficient, fiscally responsible government, essential state services, and private sector job creation," he said. "I remain steadfastly committed to protecting the remaining balance of the Rainy Day Fund, and will not sign a 2012-2013 state budget that uses the Rainy Day Fund.”

The House Appropriations Committee is expected to vote on HB 1 by Rep. Pitts, the 2012-2013 budget bill early next week. The bill hasn't changed much from when it was first proposed. Physicians and other health care providers will still receive a 10% reduction in Medicaid payments and vast cuts are still proposed within Article III, the education component of the budget, which among other things, zeros out the primary care preceptorship program. This is of course one step in the process. Once the bill is voted on in Committee it goes to the full House for discussion and then moves onto the Senate for additional review.

In other news, Comptroller Susan Combs on Monday delivered a letter to lawmakers identifying $300 million more in revenue for the 2012-2013 biennium thanks to an increase in sales tax receipts during the first part of 2011. That puts the total revenue available for certification by the Comptroller at $72.5 billion. The additional dollars freed up money already committed in the budget specifically $2 billion for health and human service agencies the largest chunk of which went to funding Medicaid caseload for 2012-2013.

Budget Talks Continue -- Senate

Senate Finance Chairman Steve Ogden (R-Bryan) on Monday asked the Senate Finance Subcommittee on Medicaid to serve as the Article II Workgroup for the Senate Finance Committee. As in the House, the Senate Article II Workgroup deals with all things related to health and human services. The group worked throughout the start of the week exploring both the funding requests from the health and human services agencies as well as continuing to discuss cost savings initiatives within the Medicaid program (the focus of their original charge). They focused the latter half of the week on funding priorities within the health and human service agencies. Each health and human service agency has been asked to identify their top 3 funding priorities with special consideration paid to safety net programs. Health and Human Services Commissioner Tom Suehs has been asked to further prioritize each of the agencies priorities.

Busy Week for Committees

On Tuesday, TPS collaborated with the Texas Medical Association and the Texas Academy of Family Physicians in providing written comments opposing HB 400 by Rep. Rob Eissler (R-The Woodlands). House Bill 400 is an omnibus public education bill relating to flexibility for public schools to administer primary and secondary education efficiently but includes a section that guts current requirements for Fitnessgram, a state mandated physical education assessment and reporting system, by limiting assessment to only those students participating in physical education. This change effectively eliminates most high school students from being assessed. To read that testimony in full, click here.

TPS also supported bills limiting corporal punishment in schools (HB 359 and HB 916 by Alma Allen D-Houston) and opposed bills that would allow concealed handguns to be carried on college campuses (HB 86 by Rep. David Simpson R-Longview, HB 750 by Joe Driver R-Garland, HB 1167 by Van Taylor R-Plano).

Bill Filing Facts

March 11 marked the last day bills could be filed in the House and Senate. In total, 5,873 bills have been filed compared to 7,324 filed in 2009. The breakdown by House and Senate is provided in the chart below courtesy of the Texas Legislative Services.

BILL FILING STATISTICS *There are reserved numbers which is why the total count doesn't match the last number
Bill Type	2011	2009	+/-
House Bills	3801	4697	-896
Senate Bills	1871	2439	-568
House Joint Resolutions	153	139	14
Senate Joint Resolutions	48	49	-1
Totals	5873	7324	-1451

February 25, 2011

Medicaid Cost Containment Discussion

The Senate Finance Subcommittee on Medicaid was busy this week examining potential cost containment strategies within Medicaid. Physicians and other providers were the focus of the Senate Finance Medicaid Subcommittee on Wednesday. Details about that discussion follow under the APN Independent Practice heading.

The Subcommittee started out the week hearing from Health and Human Service Commissioner Tom Suehs on proposed hospital-focused cost savings initiatives ranging from dissuading non-emergent use of the state's emergency rooms to reducing elective c-sections before 39 weeks. As written, the Senate budget is $9.9 billion short of the dollars needed to sustain the current Medicaid program. The subcommittee heard from a hospital panel comprised of five leaders including representatives of Baylor Health Care System and Texas Children's Hospital who explained what budget cuts would mean to their institutions.

Tuesday the panel reviewed cost savings within the Medicaid managed care arena. Dr. Mary Dale Peterson, President of Driscoll Children's Health Plan, was one of five health care professionals to testify. Dr. Peterson described several innovate programs the health plan has implemented in efforts to control cost by promoting prevention. She told committee members that cuts in payment rates to physicians would undermine efforts by Texas health plans to provide appropriate access to care within Medicaid. 

House Appropriations Makes Progress

The House Appropriations Committee met this week to hear recommendations on the articles of the budget related to the criminal justice system, transportation, etc. while the Subcommittees focused on Article II (health and human services) and Article III (education) wrapped-up their work. Unfortunately, with no new revenue identified the committee isn't well positioned to make many changes to the budget as filed.

The Texas Tribune on Wednesday morning hosted a live blog focused on health care reform. House Appropriations Article II Subcommittee Chairman John Zerwas (R-Houston and an anesthesiologist) participated on the panel saying for the first time publicly that he is supportive of using the rainy day fund to address some of the needs within the proposed budget. He indicated that he'd support coming close to depleting the Rainy Day Fund – maybe within $ 1 billion – because it is indeed raining. Rep. Zerwas said that if he went home after session with a budget that looks like it does and $5 billion in the bank he was "going to get a spanking." To read more, go to: http://www.texastribune.org/texas-health-resources/health-reform-and-texas/liveblog-reform-or-bust-/. 

APN Independent Practice

Efforts to expand advance practice nurses' authority continue at the Capitol. On Tuesday, Senator Dan Patrick (R-Houston) filed Senate Bill 846 related to the scope of practice of advance practice nurses at certain sites serving medically underserved populations. The bill would allow advance practice nurses to provide limited health services without the delegation or supervision of a physician at a site serving a medically underserved population. Obvious concerns are associated with providing a two-tier level of care to Texas patients.

Also on Tuesday, the Senate Finance Medicaid Subcommittee ran through a list of proposed APN-related cost savings initiatives. The proposals included:

1. Changing Medicaid billing practice to allow APNs to bill Medicaid directly at 92% of physician payment levels when they treat a patient and the physician doesn't see the patient during their office visit. This proposal would not affect the medical practice act as it still requires the APN to provide care through delegation/supervision.
2. Allowing APNs to provide direct care in state-supported living centers and state homes. The Department of Aging and Disabilities is still investigating the cost savings associated with the proposal but the Health and Human Services Commission has indicated it will save approximately $1.2 million.
3. A pilot program allowing APNs to practice independently. HHSC predicts the proposal to save $400,000.

Members of the Senate Subcommittee including Senator and family physician, Bob Deuell (R-Greenville), raised concerns about the cost analyses provided and cited research that doesn't show cost savings can be achieved through allowing APNs to practice independently. Senator Judith Zaffirini (D-Laredo) asked why many of the APN proposals didn't show significant cost savings yet they were part of a cost saving initiative discussion. The debate will continue in the coming days as Senate Finance leaders continue to search for ways to save money in the current budget environment.

Also, this week, the San Antonio Express News ran an editorial supporting independent practice for APNs. The editorial urged legislative leaders to pass a bill allowing APNs to practice independently citing improved access to care and enhanced cost savings. To read the article, visit the following link,http://www.mysanantonio.com/business/article/It-s-time-to-pass-Texas-nurse-bill-1025863.php.

Remember that there are several excellent issue briefs at your disposal, under the Primary Care Coalition heading, dispelling these and other myths related to independent practice. You can find those on the TPS website under Advocacy, Legislative Update. 

Raw Milk

Legislation has been filed in both the House and Senate (HB 75 Rep. Dan Flynn (R-Van) and SB 237 Sen. Bob Deuell (R-Greenville) relating to the regulation of raw milk and raw milk products. The bills, which are identical, seek to allow raw milk sales in retail environments. Efforts are underway by both bill authors to amend the legislation so that the raw milk and raw milk products may only be sold in farmer's markets. The TPS Infectious Disease and Immunizations Committee along with the Executive Legislative Committee have reviewed the legislation and have shared information related to the risks associated with the consumption of raw milk to both offices. The Dallas Morning News ran an article on the legislation last Sunday, which you can read at:http://www.dallasnews.com/news/state/headlines/20110220-legislation-would-allow-wider-sales-of-raw-milk.ece. Supporters of this legislation spent Monday at theCapitol. 

Coming Next Week…

Legislation promoting smoke free environments will be heard in both the Senate Health and Human Services and House Public Health Committees. Senate Bill 355 by Sen. Rodney Ellis (D-Houston) and HB 670 by Myra Crownover (R-Denton) seek to eliminate smoking in certain work and public places.

The House Appropriations Subcommittee on Article II is slated to begin marking-up their budget recommendations. The goal is to have formal recommendations in place to report to the full Appropriations Committee sometime during the week of March 7.

February 18, 2011

House Appropriations Begins Examining the Budget

Late last week, House Appropriations Committee Chairman Jim Pitts (R-Waxahachie) named subcommittees to facilitate discussion of the budget. Representation and physician, John Zerwas (R-Houston), will chair the subcommittee on Article II, the health and human services component of the budget. He is joined in that work by Representatives Warren Chisum (R-Pampa), Dawnna Dukes (D-Austin), Craig Eiland (D-Galveston), Susan King (R-Abilene) and Charles Schwertner (R-Georgetown).

The subcommittee went straight to work, hearing from agency leaders and listening to hours of public testimony. On Monday, TPS collaborated with the Texas Medical Association (TMA) and the Texas Academy of Family Physicians (TAFP) to submit testimony written by Dr. Richard Adams, a developmental specialist at Scottish Rite Children's Hospital in Dallas, outlining our concerns with the cuts to the Early Childhood Intervention program, a component of the Department of Assistive and Rehabilitative Services.

Dr. Michael Foulds, former chair of pediatrics at the University of Texas Health Science Center in San Antonio, spoke on behalf of TPS, TMA, TAFP and groups representing the OBGYNs, outlining our opposition to the proposed cuts in Medicaid and CHIP funding. Asked whether doctors could sustain any level of cuts to payments he tactfully answered no given how low rates already are and the time it takes physicians to work with low-income patients who may be sicker or struggle with health literacy. To see his comments, please visit: http://www.txpeds.org/webfm_send/1535. Many kudos go out to Dr. Louis Appel, a pediatrician and medical director of People's Community Clinic in Austin.  He waited over 5 hours to testify before having to leave. Dr. Foulds testified in his absence.

The Department of State Health Services is undergoing examination by the Subcommittee today. Dr. Philip Huang, a family physician, and the health authority and medical director for the Austin/Travis County Health and Human Services Department, testified in support of many of the chronic disease and prevention programs housed in the agency. Testifying on behalf of TPS, TMA and TAFP, Dr. Huang urged Committee members to support the state's abilities to meet its public health needs.  His full testimony can be seen at: http://www.txpeds.org/webfm_send/1538. Written testimony outlining the devastating impact proposed cuts to mental health programming will have to the state was also submitted on behalf of TPS, TMA, TAFP and the Federation of Texas Psychiatry.

Speaker Releases House Committee Appointments

On Wednesday, February 9, Speaker of the House Joe Straus released his committee appointments. He named Beverly Wooley (R-Houston) Speaker Pro Tem and Tom Craddick Dean of the House (reserved for the longest continuously serving member of the House). He also created three select committees:

• Select Committee on State Sovereignty
• Select Committee on Voter Identification and Voter Fraud
• Select Committee on Election Contests

This action brought the House one step closer to beginning to address the budget and other pressing needs. As referenced above, the Committee on House Appropriations went straight to work meeting that afternoon. All House committees are expected to begin meeting in the coming days.

Senate Takes Closer Look at Medicaid

Senate Finance Chairman Steve Ogden (R-Bryan) established a Medicaid Subcommittee to allow members of Finance to further examine the budget issues surrounding the public health program. The group is being chaired by Sen. Jane Nelson (R-Flower Mound) and is comprised of Senators Juan Hinojosa (D-Corpus Christi), John Whitmire (D-Houston), Bob Deuell (R-Greenville), Judith Zaffirini (D-Laredo), Kevin Eltife (R-Tyler) and Tommy Williams (R-The Woodlands). Their plan is to spend three weeks focusing on various aspects of the program.  Invited testimony is being requested from agency officials and providers. This week the Subcommittee honed in on issues including optional services and fraud and abuse.

Medicaid Payment for Vaccine Administration

On February 15, Dr. Scott Schams provided testimony on behalf of TPS and TMA at an HHSC rate hearing, focusing comments on payment for the new vaccine administration codes – 90460 and 9041. Testimony outlined the need to provide physicians with adequate payment for this important service, and detailed the problems caused for practices by the delayed implementation of the new codes. To read written comments submitted by TPS, please go to:http://www.txpeds.org/webfm_send/1534. We have since learned that CMS has put a cap on the amount state Medicaid programs can provide for vaccine administration, and are working at the national level to address this payment ceiling.

Comptroller Updates Cost of Obesity

Texas Comptroller, Susan Combs, released “Gaining Costs, Losing Time: The Obesity Crisis in Texas” on February 4. The report updates a 2007 cost analysis of obesity and its related disorders to the state. According to the report, obesity-related costs Texas' businesses $9.5 billion in 2009.  Left unaddressed, the Comptroller says that obesity could cost employers $32.5 billion a year by 2030. Follow this link to see the report in its entirety,http://www.window.state.tx.us/specialrpt/obesitycost/.

“Texas Seeks Medicaid Waiver, but Prognosis is Poor”

Emily Ramshaw explores the issues surrounding Texas petitioning the federal government for a waiver to reform Medicaid spending. Approaches to reduce the state's share of Medicaid spending have attracted increased attention as the budget shortfall has grown.  Her article can be found in today's edition of The Texas Tribune. You can access the article at the following link: http://www.texastribune.org/texas-health-resources/health-reform-and-texas/texas-seeks-medicaid-waiver-but-prognosis-is-poor/.