Categories
General Healthcare Costs Healthcare Disparities Mental Health Public Health Women's Health

Let Me Be Brief: Maternal Mortality

A series of briefs by Texas Medical Students

By: Radhika Patel and Sanika Rane

Maternal mortality continues to be one of the more pressing public health issues in Texas. In December 2022, Texas’ Maternal Mortality and Morbidity Review Committee released a report reviewing pregnancy-related deaths in Texas since 2019 1. The review found that despite policies implemented to prevent these cases, there has been little improvement in rates since 2013, with Texans continuing to experience above-average rates of pregnancy- & childbirth-related deaths – about 12 deaths per month with 89% of cases being preventable 1. The report also found that 19% of pregnancy related deaths were attributed to discrimination, with people of color, particularly Black patients being at the highest risk of pregnancy related discrimination and subsequently the highest risk for maternal mortality.

So what gaps remain to be addressed? In a recent issue of Texas Medicine, TMA announced that “women’s reproductive health” and “Medicaid coverage for women and children” amongst its priorities to address in the 2023 legislative agenda 2 . The federal administration has developed a Maternal Health Blueprint specifying policies on Extending Postpartum Medicaid Coverage; A Maternal Mental Health Hotline; Investments in Rural Maternal Care; No More Surprise Bills; and Better Trained Providers (addressing implicit bias), and in February, Dr. Jackson Griggs testified on behalf of TMA at the Texas Senate Finance meeting seeking adequate state funding for maternal & child health – the written testimony highlights similar issues regarding maternal mortality in Texas (more below) 3. Currently, there are a number of bills proposed this legislative session to address some
of these issues:

Medicaid coverage

  • In the last session, House Bill (HB) 133 requesting extension of coverage for 12 months postpartum was passed by Texas’ House of Representatives – but the Senate reduced this to 6 months, causing the expansion to be stuck requiring waiver approval by the federal government 4
  • Due to this, despite Medicaid covering half of births in Texas, insurance still only extends coverage to 2 months postpartum – with nearly one-third of maternal deaths in Texas occurring after this coverage ends 5
  • Medicaid will undergo further “unwinding” this year as Texas restarts disenrollments – currently, a pregnant woman earning up to 198% of the FPIL can be covered by Medicaid through 60 days after pregnancy 6; but on day 61, she must earn less than 17% to maintain her coverage ($3,733 for a family of three), leading to loss of coverage for many 7. In Texas, rates of delayed and foregone preventive care for children and adults have increased, resulting in potentially missed and delayed diagnoses.
  • Gregg Abbott has even stated that one of his budget priorities is to request funding for 12 months of Medicaid postpartum services 8.
  • Bills proposed this session to expand Medicaid coverage to 12 months postpartum include House Bill (HB) 56 (currently still in Health Care Reform committee) & Senate Bill (SB) 73 (currently still in Health & Human Services committee).

Racial disparities

  • Nationally, Black people giving birth are three times more likely to die than their white counterparts – and twice as likely in Texas.9
  • Bills proposed this session addressing racial disparities include:
    • HB 663: Creating an unbiased maternal mortality and morbidity data registry for Texas.
      • Passed vote in the House, now in the Health & Human Services committee in the Senate.
    • HB 1164: Obtaining funding to conduct a study specifically investigating maternal mortality and morbidity among Black women in Texas.
      • Passed vote in the House, now in the Health & Human Services committee in the Senate.
    • HB 1162 & 1165: Establishing requirements for medical provider licensing should include hours for cultural competency and implicit bias training.
      • Both still in the Public Health committee

Life-saving care

  • Maternal death rates have been found to be 62% higher in contraception-restriction states like Texas 10
  • In two Texas hospitals, 57% of patients were reported to have significant maternal morbidity as a result of state-mandated management of obstetrical complications (like access to life-saving medication) compared to 33% in states without such legislation. On average, patients were withheld life-saving care for 9 days, simply being observed instead as their conditions worsened – before they eventually developed complications severe enough to be qualified as an immediate threat to maternal life for physicians to legally take action under Texas law. 11
  • Bills proposed this session addressing life-saving care include:
    • SB 79 & HB 3000: Ensuring that current restrictions will not negatively impact pregnant patients requiring termination for their care, including not being susceptible to criminal penalties.
      • Both still in the State Affairs committee.
    • HB 1953: Establishing exceptions to current restrictions to ensure that physicians are able to provide life-saving care to high-risk patients in their third-trimester.
      • Currently still in the Public Health committee.

Mental health resources

  • 84% of pregnancy-related deaths were preventable – leading underlying issues varied by race & ethnicity, including: mental health conditions (23%) (suicide and overdose/poisoning) disproportionately affecting Hispanic & non-Hispanic White people. 12
  • In Texas, rising rates of drug abuse, suicide, and domestic violence reflect the mental anguish and distress so many patients face – suicide and homicide represented 27% of pregnancy-related deaths with homicides most often perpetuated by the individual’s partner 1
  • Establishing funding to allow PCPs to provide up to 4 postpartum depression screens in the year following delivery, especially given the current shortage of both adult & child psychiatrists, may help address these issues. 8
  • Bills proposed this session addressing mental health resources include:
    • HB 3724: Establishing a maternal mental health peer support pilot program for perinatal mood and anxiety disorder.
      • Currently still in the Health Care Reform committee.
    • HB 2873: A strategic plan for improving maternal health, including improving access to screening, referral, treatment, and support services for perinatal depression.
      • Passed vote in the House, now awaiting vote in the Senate.

Maternal health deserts

  • Texas leads the country in maternal health deserts – communities with limited or no local prenatal and maternity care services, even for insured women – jeopardizing the health of expectant mothers and their unborn babies.8
  • Bills proposed this session addressing maternal health deserts include:
    • HB 3626: Implementing a public outreach campaign to increase the number of maternal health care professionals in rural areas.
      • Currently still in the Health Care Reform committee.
    • HB 617 & SB 251: Establishing a pilot program for providing telemedicine and telehealth services in rural areas.
      • HB 617 passed & signed into law by Governor Abbott, effective 9/1/2023.
      • SB 251 passed vote in the House, now in the Jurisprudence committee in the Senate.
    • HB 1798 & SB 663: Developing a strategic plan for providing home and community-based services under Medicaid to children and mothers, especially in low-resource settings.
      • HB 1798 passed vote in the House, now in the Health & Human Services committee in the Senate.
      • SB 663 currently still in the Health & Human Services committee.

In summary, please consider the following goals for advocacy this session:

  • Ensuring safe access to life-saving procedures.
  • Extending Medicaid coverage to 12 months postpartum for all mothers in Texas.
  • Increasing access to evidence-based community and crisis mental health and substance abuse services.
  • Addressing gaps in medical education to prevent the impact of racial discrimination on maternal mortality, including cultural competency & implicit bias.
  • Improving access to comprehensive healthcare in rural settings and maternal health deserts.

Since most of these bills are still being discussed within committees, it is an especially pertinent time to speak with the representatives sitting on these committees and urge them to move the bills forward to be voted on and signed into law. Stay informed about issues pervading your communities, reach out to your local representative to ask for their support on proposed bills, and engage in this legislative session by joining physician advocates at the Capitol!

Resources

  1. Texas Maternal Mortality and Morbidity Review Committee and Department of State
    Health Services Joint Biennial Report 2022. Accessed January 26, 2023.
    https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Joint-Biennial-
    MMMRC-Report-2022.pdf
  2. Texas Medicine March 2023. www.qgdigitalpublishing.com. Accessed April 1, 2023.
    https://www.qgdigitalpublishing.com/publication/?m=55178&l=1
  3. House TW. FACT SHEET: President Biden’s and Vice President Harris’s Maternal Health
    Blueprint Delivers for Women, Mothers, and Families. The White House. Published June 24,
    2022.https://www.whitehouse.gov/briefing-room/statements-releases/2022/06/24/fact-sheet-
    president-bidens-maternal-health-blueprint-delivers-for-women-mothers-and-families/
  4. Klibanoff E. Texas health agency says its plan to extend maternal Medicaid coverage is “not
    approvable” by feds. The Texas Tribune. Published August 4, 2022. Accessed April 1, 2023.
    https://www.texastribune.org/2022/08/04/texas-medicaid-postpartum-application/
  5. Waller A. Maternal health care advocates applaud new state law to extend Medicaid coverage,
    but say it doesn’t go far enough. The Texas Tribune. Published August 27, 2021.
    https://www.texastribune.org/2021/08/27/texas-medicaid-maternal-mortality-health
  6. Comments on the Status of the Texas Maternal Health Coverage Bill. Texans Care for
    Children. Accessed April 1, 2023. https://txchildren.org/posts/2022/5/4/comments-on-the-
    status-of-the-texas-maternal-health-coverage-bill
  7. Maternal deaths are public health and health equity problems. They’re also preventable. |
    Kinder Institute for Urban Research. Kinder Institute for Urban Research | Rice University.
    https://kinder.rice.edu/urbanedge/maternal-deaths-are-public-health-and-health-equity-
    problems-theyre-also-preventable
  8. Texas Medical Association. Senate Finance Committee – Senate Bill 1, Article II Hearing
    Texas Health and Human Services Commission. TMA; 2023
  9. Salahuddin M, Patel DA, O’Neil M, Mandell DJ, Nehme E, Karimifar M, Elerian N, Byrd-
    Williams C, Oppenheimer D, Lakey DL. (2018) Severe Maternal Morbidity in Communities
    Across Texas. Austin, TX: University of Texas Health Science Center at Tyler/University of
    Texas System.
  10. Declercq, E., Barnard-Mayers, R., Zephyrin, L., & Johnson, K. (2022, December 14). The U.S.
    Maternal Health Divide: the Limited Maternal Health Services and Worse Outcomes of States
    Proposing New Abortion Restrictions. Www.commonwealthfund.org.
    https://www.commonwealthfund.org/publications/issue-briefs/2022/dec/us-maternal-health-
    divide-limited-services-worse-outcomes
  11. Nambiar, A., Patel, S., Santiago-Munoz, P., Spong, C. Y., & Nelson, D. B. (2022). Maternal
    morbidity and fetal outcomes among pregnant women at 22 weeks’ gestation or less with
    complications in 2 Texas hospitals after legislation on abortion. American Journal of Obstetrics
    & Gynecology, 0(0). https://doi.org/10.1016/j.ajog.2022.06.060
  12. CDC Newsroom. (2016, January 1). CDC. https://www.cdc.gov/media/releases/2022/p0919-
    pregnancy-related-deaths.html
Categories
General Healthcare Costs Healthcare Disparities Public Health

Let Me Be Brief: Medicaid Expansion in Texas

A series of briefs by Texas Medical Students

By: Ryan Sorensen, Aaron Pathak, Aishani Khosia

What is Medicaid?

Medicaid is a program established by the federal government in 1965 as a solution to the coverage gap that many marginalized groups faced due to the inaccessibility of private health insurance.¹ Funded jointly by the federal and state government, Medicaid became an option for health insurance for low-income, older, and disabled members of society. While partly federally funded, the program criteria, benefits, eligibility, etc all falls under the ruling of each state.2

In 2010, passage of the Affordable Care Act developed an even more comprehensive reform, with the goal of making insurance coverage and healthcare access accessible to a greater population. The ACA called for Medicaid expansion,3 which if adopted by each state would allow for more flexible eligibility- addressing the existing coverage gap that continues to remain an issue. Expansion of Medicaid would allow for individuals to be eligible to receive benefits through Medicaid on an income-basis, as long as household income did not exceed 138% of the established Federal Poverty level.4

How would Medicaid Expansion help Texans?

Texas leads the nation in the number of uninsured individuals in the state, with a reported rate of 18% according to data collected in the 2021 Census.5 For many who do not qualify for Medicaid or receive employer-sponsored health insurance, the barrier to insurance lies in the high cost of marketplace plans. With over 5 million uninsured individuals in Texas, Medicaid expansion would allow for increased access to care and improved health outcomes by expanding eligibility to include underserved and vulnerable populations above the poverty line.6

The pivotal 2002 report: Care without Coverage released by the Institute of Medicine has since been strengthened by findings that continue to show a direct relationship between mortality risk and the lack of health insurance.7 A literature review by the Kaiser Family Foundation showed that ACA expansion was correlated with better health outcomes and was specifically related to improvements in areas of cancer diagnosis and treatment, transplants, smoking cessation, behavioral health, and treatment of opioid disorders.8 Health insurance and health outcomes are undeniably interconnected, making Medicaid expansion a necessary legislative agenda to improve the health of Texans and address existing health inequities.9

A current bill to specifically advocate for is: Bill SB 343- Relating to the expansion of eligibility for Medicaid to all individuals for whom federal matching money is available. This bill was introduced by Nathan Johnson in January, and it was read in April and referred to the Health and Human Service Senate Committee for review.

How has the TMA advocated in the past?

The TMA for many years has advocated for the expansion of medicaid through the promotion of articles that show the health benefits of medicaid expansion in Texas. In 2019, 2020, and 2021 the TMA published articles showing public support, public health benefits, and fiscal benefits of allowing medicaid expansion in Texas.10 Furthermore, former TMA President Dr. Doug Curran testified in support of HB 565 introduced by Representative Coleman in the 2019 legislative session, although the bill did not make it past committee.11 TMA Policies 190.032 (Medicaid Coverage and Reform) and 190.036 show the TMA’s support in accepting additional funds from the federal government for increasing Medicaid access while also urging the government to develop new, more sustainable systems than the current Medicaid expansion plan.12,13 TMA Policy 190.037 (Medicaid Work Requirements) also states that the TMA opposed any lifetime
limits or reduction in access for Medicaid enrollees.14 Through medical student advocacy, it is important to support these lobbying efforts by the TMA in passing Medicaid expansion. It is important for the MSS to increase knowledge about the coverage gap between Texas’ current Medicaid system and the income needed to afford health insurance from the Affordable Care Act marketplace to decrease our state’s uninsured population.The federal government is slated to pay 90% of the total costs of Medicaid expansion,15 greater than the normal 50-78% that the federal government pays for current enrollees. This expansion will not only make healthcare more accessible for low-income Texans who fall in the coverage gap, but also increase the fiscal stability of safety-net hospitals that currently have to pay for people in this coverage gap through increased local property taxes.

Fast Facts

  • Medicaid expansion in Texas would provide health insurance coverage to approximately 2 million low-income Texans who are currently uninsured.16
  • States that have expanded Medicaid have seen improvements in health outcomes, including lower rates of mortality, better access to preventive care, and improved management of chronic conditions.17
  • Expanding Medicaid in Texas could help address health disparities by providing access to healthcare for low-income and minority populations who are disproportionately
    uninsured. 18
  • Medicaid expansion in Texas would also save taxpayers money by reducing the amount of uncompensated care provided by hospitals and other healthcare providers.19
  • Expanding Medicaid in Texas would result in significant net fiscal benefits for the state. According to a report by the Urban Institute, the federal government would cover 90% of the costs of expansion, and the state would save money on healthcare and other programs that currently serve uninsured individuals.20
  • The Texas Hospital Association has estimated that Texas hospitals would see a $34 billion reduction in uncompensated care costs over a 10-year period if Medicaid were expanded.21
  • Expanding Medicaid in Texas would generate more than $100 billion in economic activity and create 200,000 jobs over 10 years, according to a study by the Perryman Group.22

References

  1. Center on Budget and Policy Priorities. (n.d.). Introduction to Medicaid. https://www.cbpp.org/research/health/introduction-to-medicaid.
  2. Medicaid.gov. (n.d.). Home. https://www.medicaid.gov/medicaid/index.html.
  3. HealthCare.gov. (n.d.). Affordable Care Act (ACA) – Glossary.
    https://www.healthcare.gov/glossary/affordable-care-act/.
  4. Kaiser Family Foundation. (2023). Status of State Medicaid Expansion Decisions: Interactive Map.
    https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/#:~:text=The%20Affordable%20Care%20Act’s%20(ACA,FMAP)%20for%20their%20expansion%20populations.
  5. Mykyta DCand L. (2022). Decline in share of people without health insurance driven by increase in public coverage in 36 states. Census.gov. https://www.census.gov/library/stories/2022/09/uninsured-rate-declined-in-28-states.html
  6. Rachel Garfield, K.O. (2021). The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid – Issue Brief – 8659-10. KFF. https://www.kff.org/report-section/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-issue-brief-8659-10/#endnote_link_508791-3.
  7. Kilbourne AM. (2005). Care without Coverage: Too Little, Too Late. J Natl Med Assoc. 97(11), 1578.
  8. Guth, M. (2023). The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020 – Report. KFF. https://www.kff.org/report-section/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-report/.
  9. Sommers BD, Baicker K, Epstein AM. (2012). Mortality and access to care among adults after state Medicaid expansions. New England Journal of Medicine. 367(11), 1025-1034. doi:10.1056/nejmsa1202099.
  10. Texmed. (n.d.). Medicaid Expansion. https://www.texmed.org/Search/Keywords/?Keyword=Medicaid+expansion.
  11. Doolittle, D. (n.d.). More than 1 million more Texans could be covered, report shows. Texmed. https://www.texmed.org/Template.aspx?id=50436.
  12. Texmed. (n.d.). Medicaid Expansion: Why It Matters to Texas. https://www.texmed.org/Template.aspx?id=43009&terms=medicaid%20expansion.
  13. Texmed. (n.d.). Medicaid Expansion: FAQs. https://www.texmed.org/Template.aspx?id=46586&terms=medicaid%20expansion.
  14. Texmed. (n.d.). Medicaid Expansion: Economic Impact. https://www.texmed.org/Template.aspx?id=48322&terms=medicaid%20expansion.
  15. Center on Budget and Policy Priorities. (n.d.). Medicaid Expansion: Frequently Asked Questions. https://www.cbpp.org/research/health/medicaid-expansion-frequently-asked-questions.
  16. Kaiser Family Foundation. Medicaid in Texas. Retrieved from https://www.kff.org/medicaid/state-indicator/texas/
  17. Kaiser Family Foundation. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. Retrieved from https://www.kff.org/medicaid/report/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/
  18. National Academies of Sciences, Engineering, and Medicine. Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors. Retrieved from https://www.nap.edu/catalog/23635/accounting-for-social-risk-factors-in-medicare-payment-identifying-social
  19. The Commonwealth Fund. The Cost of Not Expanding Medicaid in Texas. Retrieved from https://www.commonwealthfund.org/blog/2019/cost-not-expanding-medicaid-texas
  20. Urban Institute. The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis. Retrieved from https://www.urban.org/sites/default/files/publication/32696/413136-The-Cost-and-Coverage-Implications-of-the-ACA-Medicaid-Expansion-National-and-State-by-State-Analysis.PDF
  21. Texas Hospital Association. The Economic Benefit of Expanding Medicaid in Texas. Retrieved from https://www.tha.org/Public-Policy/State-Federal Issues/Medicaid-Expansion
  22. The Perryman Group. Economic and Fiscal Benefits of Medicaid Expansion in Texas. Retrieved from https://www.texmed.org/Template.aspx?id=47027
Categories
General Healthcare Costs

Let Me Be Brief: Graduate Medical Education (GME) Funding

A series of briefs by Texas Medical Students

By: Parker Davis, Ashlynn Mills, Priya Patel

The history of graduate medical education (GME) funding is complex with many competing interests, from teaching hospitals and government agencies that foot the bill to faculty physicians and residents themselves. The establishment of Medicare in 1965 marked the beginning of significant federal subsidization of residency training.1,2,3 Initially uncapped, financial support from Medicare was meant to be a temporary measure until more permanent systems of GME funding could be established.4 Today, Medicare remains the single largest monetary contributor to residents’ education. Direct graduate medical education (DME) covers resident and faculty salary and benefits, plus administrative overhead.5 Indirect graduate medical education (IME) was established to help alleviate the additional costs of running a teaching hospital related to a more complex patient panel and research expenses.4 However, concerns about inflating healthcare costs and the looming threat of a physician surplus in the 1980-90s prompted the curtailing of GME spending. Thus, the formulas used to calculate a hospital’s DME provided full funding for each “Full-Time Equivalent” (FTE; employed resident) only for the duration of the initial residency period or 5 years, whichever was shorter. PGY-6+ residents comprised only a fraction of an FTE, and the hospital received less money per senior resident.6 Additionally, the Balanced Budget Act of 1997 limited the number of residents at a given hospital that were eligible for DME, limiting a hospital’s maximum DME by the number of residents it employed in 1996.7

As indications for a national physician shortage emerged in the early 2000s, the conversation surrounding GME began to change. The focus became how to reconcile the myriad of funding streams and best support the growth of the next generation of physicians while eliminating excess spending. Even as the American Association of Medical Colleges (AAMC) was calling for expansion of medical school seats across the country, the 2010 Simpson-Bowles Commission recommended a reduction in average GME compensation, an attempt to reign in government spending in the midst of the economic recession.6 More recently, the US Department of Health and Human Services aimed to integrate GME funding streams from Medicare, Medicaid, and the Children’s Hospital into a single consolidated program, distributed jointly by the Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services Administration.8

The Texas Medical Association (TMA) was established to lobby on behalf of physicians at the state and federal levels to promote physician autonomy, protect the patient-physician relationship, and minimize regulatory intervention in the practice of medicine from insurers and other nonmedical entities. Created in the late 1970s, the Medical Student Section (MSS) is a voice for medical students within the TMA with the goal of improving medical education and advocating for the future of medicine.9 In the saga of GME, one of the TMA’s primary objectives has been to retain graduates of Texas medical schools in Texas. TMA advocacy has focused on supporting the growth of GME, both financially and in terms of the total number of seats.10,11,12 The acuity of the physician shortage was emphasized with the national population growth rate and was again highlighted during the COVID-19 pandemic, as patients experienced long wait-times and shortage of resources. In response, six new medical schools have opened in Texas since 2016, and some of the established nine medical schools have increased their class sizes.

However, even as the number of Texas medical school graduates is rising, the number of residency positions available remains stagnant.13 More positions are necessary to increase the physician workforce, which calls for an increase in GME funding. The TMA postulates a target ratio of 1.1:1 first-year GME slots per medical school graduate.14 Not only does this ratio provide enough residency spots for every medical student in Texas, it also gives graduates from out-of-state schools a reason to consider Texas when deciding where to bring their talents. Conversely, allowing the number of positions to dwindle provides a catalyst for a mass migration of graduates out of the state, taking with them a substantial revenue stream. It is thus imperative that GME remains a top priority for lawmakers. The consequences of allowing funding to fall by the wayside are too drastic to ignore. For the sake of the nation’s health, legislators must ensure that medical school graduates have the opportunity to take that necessary next step toward becoming a physician.

Fast Facts

  • The $2.3 trillion Consolidated Appropriations Act of 2021 authorized relief funding for community development financial institutions. It provides funding for 1,000 new Medicare-supported GME slots beginning FY 2023, adding up to 200 positions annually.15 In 2021, Texas graduated almost 2,000 medical students.16 Texas needs to stabilize the physician workforce by allocating additional funds to the 2024-2025 Texas Higher Education Coordinating Board’s (THECB) physician development programs. Health related institution formula funding recommendations for the 24-25 Biennium provide the lowest percent increase for both Instruction and Operations (18.8%) and GME funding (19.3%). 17 These areas directly impact the ability of the state to attract faculty and residents to fill the much needed and growing physician workforce gap.
  • The 84th Texas Legislature, Regular Session, consolidated the Unfilled Residency Position Program, the New and Expanded Residency Program, and the Resident Physician Expansion Program into the single GME Expansion Program. The funding allowed the new positions created in 2014 and 2015 to be maintained and to provide enough funding to support the addition of approximately 130 new residency positions.
  • The 86th Texas Legislature, Regular Session, provided $157.2 million to support GME Expansion Programs. As a result, an estimated 2,000 residency positions received funding support in FY 2020 and FY 2021.
  • While adding new residency positions and programs is admirable and will contribute to the state’s 1.1 to 1 ratio goal, it is also important that the state’s existing residency programs receive adequate funding and support.
  • The closing of two family medicine residency programs resulted in reduced access to health care in the communities of Wichita Falls and Corpus Christi, further contributing to physician distribution challenges.

Funding Requested

  • Additional funding requested: $34 million for the State GME Expansion Grant Program to maintain residency positions created through the program to date, and to maintain the1.1:1 state target ratio. GME Expansion Program funding has supported the creation of 472 new first-year residency positions between 2014 and 2021 to accommodate the increase in the number of medical graduates resulting from the opening of new medical
    schools.
  • Additional funding requested: $20.5 million to replace recent budget cuts to the Family Practice Residency Program and enable annual grants of $15,000 per family medicine resident.18
  • $1 million to activate the State Rural Training Track Grant Program for creation of rural residency training programs (HB 1065 passed in 2019 but was not funded).
  • $30 million one-time endowment to sustain the State Physician Education Loan Repayment Program and recruit physicians to the state’s most underserved areas.
  • $2.14 million for the Joint Admission Medical Program so it can keep pace with recent increases in medical school enrollments.

Related Bills (congress.gov)

No currently proposed Texas Legislature (capitol.texas.gov).

  1. H.R. 9424 – 117th Congress
    Introduced in House (12/05/2022)

    Creating Access to Residency Education Act of 2022
    Sponsor: Castor, Kathy [Rep.-D-FL-14] (Introduced 12/05/2022) Cosponsors: (0)
    Committees: House – Energy and Commerce
    This bill requires the Centers for Medicare & Medicaid Services to award matching funds to teaching hospitals or other graduate medical education training programs for medical residency
    training programs in states where there are fewer than 44 medical residents per 100,000 people. Recipients must cover one third of the costs for primary care residency training programs and
    one half of the costs for programs in other fields.
    Latest Action: House – 12/05/2022 Referred to the House Committee on Energy and Commerce.
  2. H.R. 3671 – 117th Congress
    Introduced in House (06/01/2021)

    Doctors of Community Act or the DOC Act
    This bill reauthorizes and provides mandatory funding for graduate medical education programs operated by teaching health centers.
    The bill sets out funding levels through FY2033. Funding for FY2034 and beyond equals the preceding fiscal year’s amount adjusted for medical inflation.
    Latest Action: House – 06/02/2021 Referred to the Subcommittee on Health.
    S.1958 — 117th Congress (2021-2022)
    Introduced in Senate (06/07/2021)

    Doctors of Community Act or the DOC Act
    DOC Act
    Sponsor: Murray, Patty [Sen.-D-WA] (Introduced 06/07/2021) Cosponsors: (8)
    Committees: Senate – Health, Education, Labor, and Pensions This bill reauthorizes and provides mandatory funding for graduate medical education programs operated by teaching health centers. The bill sets out funding levels through FY2033. Funding for FY2034 and beyond equals the preceding fiscal year’s amount adjusted for medical inflation. Latest Action: Senate – 06/07/2021 Read twice and referred to the Committee on Health, Education, Labor, and Pensions
  1. H.R.8508 – Rural Physician Workforce Production Act of 2022 – 117th Congress (2021-2022)
    Sponsor: Rep. O’Halleran, Tom [D-AZ-1] (Introduced 07/26/2022)
    Committees: House – Ways and Means; Energy and Commerce
    Latest Action: House – 07/26/2022 Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined
    by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
  2. H.R.949 — 117th Congress (2021-2022)
    There is one summary for H.R.949. Bill summaries are authored by CRS.
    Introduced in House (02/08/2021)
    Expanding Teaching Health Centers Act of 2021
    This bill provides funding through FY2023 to the Department of Health and Human Services to establish and expand medical residency training programs at teaching health centers.
    Latest Action: House – 02/09/2021 Referred to the Subcommittee on Health. (All Actions)

Sources

  1. House report number 213, 89th Congress, 1st session. https://www-govinfo-gov.foyer.swmed.edu/app/details/STATUTE-79. (1965), Accessed 13th February 2023.
  2. Guss D, Prestipino AL, Rubash HE. Graduate medical education funding: a Massachusetts General Hospital case study and review. J Bone Joint Surg Am. 2012;94(4):e24. doi:10.2106/JBJS.K.00425
  3. Stevens R. American medicine and the public interest. New Haven and London: Yale University Press; 1971.
  4. Schuster BL. Funding of Graduate Medical Education in a Market-Based Healthcare System. Am J Med Sci. 2017;353(2):119-125. doi:10.1016/j.amjms.2016.11.027
  5. Solomon IH, Normandin E, Bhattacharyya S, et al. Neuropathological Features of Covid-19. N Engl J Med. 2020;383(10):989-992. doi:10.1056/nejmc2019373
  6. He K, Whang E, Kristo G. Graduate medical education funding mechanisms, challenges, and solutions: A narrative review. Am J Surg. 2021;221(1):65-71. doi:10.1016/j.amjsurg.2020.06.007
  7. Iglehart JK. Medicare, graduate medical education, and new policy directions. N Engl J Med. 2008;359:643-50.
  8. HHS.gov. FY 2019 Budget & Performance.
    https://www.hhs.gov/about/budget/fy2019/index.html?language=es. Published 2019. Accessed February 13, 2023.
  9. TMA House of Delegates. “TMA 2025 Goals.” TMA 2025 Goals, Texas Medical Association, 10 Apr. 2019, https://www.texmed.org/goals.aspx.
  10. Texmed.org. 200.016 Graduate Medical Education.
    https://www.texmed.org/Template.aspx?id=43064. Published 2016. Accessed February 15, 2023.
  11. Texmed.org. 200.045 Needed Growth in Graduate Medical Education Programs. https://www.texmed.org/Template.aspx?id=43093. Published 2017. Accessed February
    14, 2023.
  12. Texmed.org. 205.022 Federal Title VII Graduate Medical Education Grant Program. https://www.texmed.org/Template.aspx?id=43034. Published 2022. Accessed February 14, 2023.
  13. Price, Sean. “Unfreezing GME: A Boost to Federal Funding for Residencies by Sean Price Texas Medicine October 2021.” Texmed, Texas Medical Association, Oct. 2021,
    https://www.texmed.org/Template.aspx?id=57888.
  14. Sorrel, Amy Lynn. “Legislative Priority #1: Scope of Practice Encroachments, Graduate Medical Education Funding.” Texmed, Texas Medical Association,
    https://www.texmed.org/Template.aspx?id=60988.
  15. Robeznieks, A. (2022, March 16). 1,000 new GME slots are coming. CMS must not hamper their use. American Medical Association. Retrieved February 14, 2023, from
    https://www.ama-assn.org/education/gme-funding/1000-new-gme-slots-are-coming-cms-must-not-hamper-their-use
  16. Michas, F. (2022, June 8). Total Medical School graduates in the U.S.by State. Statista.
    Retrieved February 14, 2023, from https://www.statista.com/statistics/1270398/total-
    medical-school-graduates-in-the-us/
  17. Formula advisory committees – Texas Higher Education Coordinating Board. (n.d.). Retrieved February 14, 2023, from https://www.highered.texas.gov/about-us/advisory committees/formula-advisory-committees/
  18. https://reportcenter.highered.texas.gov/reports/legislative/graduate-medical-education-
    report-an-assessment-of-opportunities-for-graduates-of-texas-medical-schools-to-enter-
    residency-programs-in-texas-fy2020/

Helpful Resources

  1. https://www.texmed.org/uploadedFiles/Current/2016_Advocacy/Texas_Legislature/312018_Physician_Workforce.pdf
  2. https://reportcenter.highered.texas.gov/reports/data/formula-funding-recommendations-
    2024-2025/
  3. https://reportcenter.highered.texas.gov/reports/legislative/the-graduate-medical-
    education-report-october-
    2022/?muraadminpreview&muraadminpreview&mobileformat=true
  4. Texmed.org. 205.024 Medicare and Medicaid Graduate Medical Education Funding.
    https://www.texmed.org/Template.aspx?id=43036. Published 2016. Accessed February 14, 2023.
Categories
General Healthcare Costs Healthcare Disparities Mental Health Public Health

Let Me Be Brief: Addressing The Texas Mental Health Crisis

A series of briefs by Texas Medical Students

By: Jasmine Liu-Zarzuela, Isreal Munoz, Rozena Shirvani

Background

Addressing the Texas mental health crisis is a multifaceted challenge that requires the coordination of various entities and an approach that addresses the underlying causes. Some of the most important aspects of addressing the national mental health crisis is increasing access to mental health care services, improving mental health literacy among the general public, and promoting a collaborative effort between various sectors of society, including government agencies, healthcare providers, schools, employers, and community organizations.¹ Collaboration can help ensure that mental health resources are accessible, that policies and regulations support mental health, and that individuals receive the care and support they need to maintain appropriate mental health.

In accordance with the mental health of minors, The American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP) and the Children’s Hospital Association (CHA) declared a National State of Emergency
in Children’s Mental Health in 2021.² It is estimated that 16.5% of children under 18 have at least one mental health disorder, but about 49% did not receive treatment or counseling from a professional.³ To combat this, the 86th Texas Legislature created the Texas Child Mental Health Care Consortium that funded the Texas Child Health Access Through Telemedicine (TCHATT) initiative, which provides telehealth services at no cost to the school or students, such as mental health evaluations, short term therapy, psychiatric care, and referrals to long term treatment to students of participating districts.4 It is important to support funding for these initiatives as they aim to have resources in every school district in Texas; however, only about a third are estimated to be involved.4

TMA Policy

In June 2022, The TMA submitted written testimony that emphasizes the increasing need for mental health resources in Texas, particularly with the aftermath of the COVID-19 pandemic and incidences of gun violence, such as the Uvalde incident.5-8 In fact, Texas has had more school shootings than any other state since 2012 with 43 incidents.9 In this testimony, TMA strongly encourages the importance of firearm safety promotion, mental health investments, and adolescent, family, and community interventions that foster resilience in the midst of childhood adversity. A key issue for the TMA agenda at the 2023 legislative session is preventing suicide and supporting Texans’ mental health. The TMA also has many policies aimed at increasing funding and coverage for services including:

  • 55.033 Children’s Mental and Behavioral Health- supports improved
    access to mental health services and payment systems that fully integrate mental health care services in primary care10
  • 145.019 Mental Health Equitable Treatment and Parity- supports lobbying state and federal government to increase scope of limited parity laws to include all mental health disorders and supports state funding for pilots to improve treatment 11
  • 215.019 Public Mental Health Care Funding & 215.020 Improved Funding for Mental Illness and Substance Use Disorder(s) – supports increasing funding from Texas Legislature for the mental health care system 12,13
  • 100.022 Emergency Psychiatric Services- supports funding to sustain and expand state investments to redesign mental health crisis services 14

Fast Facts

  1. 198 (out of 254) Texas counties are considered Health Professional Shortage Areas for mental health.15
  2. An additional 23 Texas counties are considered a mental health Health Professional Shortage Area for low-income populations. 15
  3. 221 of 254 (87%) of Texas counties lack adequate mental health resources. 15
  4. Among adults with serious mental illness, only 64.8% received mental health services in the past year. 16
  5. The economic burden of mental illness in the United States is estimated to be $193.2 billion in lost earnings per year. 17

 Current Bills

Senate Bill 672 is a current bill that advises Texas Medicaid to construct a mental health collaborative care model.

Call to Action

It is imperative that medical professionals and students acknowledge the rising national mental health crisis and further promote awareness and create policy to ultimately improve health outcomes.

Resources

  1. https://www.apa.org/news/press/releases/2022/11/mental-health-care-strains
  2. https://www.texmed.org/uploadedFiles/Current/2016_Advocacy/Texas_Legislatur
    e/TMA-written-testimony-mental-health.pdf

References

  1. Saxena, S., Funk, M., & Chisholm, D. (2020). World Health Assembly adopts resolution on mental health. The Lancet Psychiatry, 7(8), 655-656. https://doi.org/10.1016/S2215-0366(20)30306-5
  2. AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. (n.d.). Aap.org. Retrieved March 17, 2023, from https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/
  3. Spotlight 1: Prevalence of mental health services provided by public schools and limitations in schools’ efforts to provide mental health services. (n.d.). Bing. Retrieved March 17, 2023, from
    https://nces.ed.gov/programs/crimeindicators/ind_s01.asp
  4. Texas child health access through telemedicine (TCHATT). (2021, July 27). MMHPI – Meadows Mental Health Policy Institute; Meadows Mental Health Policy Institute. https://mmhpi.org/project/texas-child-health-access-through-
    telemedicine-tchatt/
  5. Kathirvel, N. (2020). Post COVID-19 pandemic mental health challenges. Asian journal of psychiatry, 53, 102430.
  6. Vadivel, R., Shoib, S., El Halabi, S., El Hayek, S., Essam, L., Bytyçi, D. G., … & Kundadak, G. K. (2021). Mental health in the post-COVID-19 era: challenges and the way forward. General psychiatry, 34(1).
  7. Shanbehzadeh, S., Tavahomi, M., Zanjari, N., Ebrahimi-Takamjani, I., & Amiri-Arimi, S. (2021). Physical and mental health complications post-COVID-19: Scoping review. Journal of psychosomatic research, 147, 110525.
  8. Ren, F. F., & Guo, R. J. (2020). Public mental health in post-COVID-19 era. Psychiatria danubina, 32(2), 251-255.
  9. States With the Most School Shootings. (2022, May 27). Usnews.com. Retrieved March 17, 2023, from https://www.usnews.com/news/best-states/articles/2022-
    05-27/states-with-the-most-school-shootings
  10. 55.033 Childrens Mental and Behavioral Health. TMA Policy . (2022, June 14). Retrieved March 16, 2023, from
    https://www.texmed.org/Template.aspx?id=42554&terms=children+mental+
    health
  11. 145.019 Mental Health Equitable Treatment Parity . TMA Policy. (2022, June 14). Retrieved March 16, 2023, from https://www.texmed.org/Template.aspx?id=42846&terms=mental+health+equitable+treatment
  12. 215.019 Public Mental Health Care Funding. TMA Policy. (2021, July 21). Retrieved March 16, 2023, from https://www.texmed.org/Template.aspxid=43155&terms=public+mental+health+care+funding
  13. 215.020 Improved Funding for Mental Illness and Substance Use Disorders.TMA Policy . (2020, October 29). Retrieved March 16, 2023, fromhttps://www.texmed.org/Template.aspx?id=43156&terms=improved+funding+for+mental+illness
  14. 100.022 Emergency Psychiatric Services. TMA Policy. (2018, August 20). Retrieved March 16, 2023, from https://www.texmed.org/Template.aspx?id=42696&terms=psychiatric+services
  15. Special committee to protect all Texans. (2022). Texmed.org. https://www.texmed.org/uploadedFiles/Current/2016_Advocacy/Texas_Legislature/TMA-written-testimony-mental-health.pdf
  16. Mental illness. (n.d.). National Institute of Mental Health (NIMH). Retrieved March17, 2023, from https://www.nimh.nih.gov/health/statistics/mental-illness
  17. Mental disorders cost society billions in unearned income. (2015, September 19).National Institutes of Health (NIH). https://www.nih.gov/news-events/news-releases/mental-disorders-cost-society-billions-unearned-income
Categories
Clinical General Healthcare Costs Healthcare Disparities Law Public Health Quality Improvement

On Public Charge

A step forward or a step back from self-sufficiency?

By: Souma Kundu

At the start of 2020, I remember the Trump administration celebrating what it saw as a victory for “self-sufficiency,” and “protecting law-abiding legal citizens from undue tax burdens”. Following a battle in the lower court, in a much-anticipated Supreme Court ruling, the court sided 5-4 with the administration, allowing enforcement of the 2019 expansion of the Public Charge rules.

This court ruling on Public Charge marks only the latest iteration of a policy dating back to the 1882 Immigration Act. While the definition and enforcement has varied over time, the essence of the law remains true to its origins: immigrants who are deemed unable to take care of themselves without becoming dependent on public assistance are unsuitable for American citizenship and therefore denied entry. Historically, public charge was determined by a holistic review of an applicant’s circumstances including age, health, financial status, education and skills. The use of public benefits for cash assistance and long-term institutionalization could be considered in this review, but other programs such as nutritional/housing assistance or public insurance were not included. In 2019, the United States Citizenship and Immigration Services (USCIS) expanded on the existing criteria to consider public benefits such as supplemental nutrition assistance, Medicaid or public housing. Additionally, it stipulated that the use of any of these public benefits for more than twelve months within any 36 month period may classify an applicant as a “public charge” effectively making them ineligible for permanent residency.

At the heart of this policy’s long-standing history is a deep-rooted belief that self-reliance is inextricably linked to the worth of an individual. It also posits that requiring public assistance is not only a burden to society, but one that is unlikely to be paid off or utilized for eventual gain.

But is this policy, and its predecessors really helping us increase self-sufficiency? Or is it robbing the US of its vast current and future population of contributing citizens? Even more pressing in 2020, is the impact of enforcing public charge during a pandemic leading to an underutilization of health care and resources only to increase morbidity and mortality across the nation?

From the lens of a healthcare worker, the general concern that efforts to rehabilitate lead to dependence baffles me. In medicine, from a sprained ankle to a surgery, achieving ultimate goals of “returning maximum function” all depend on how we can aid the healing process along the way. Generally, the use of a brace to offload the weight of a broken foot is not contested. Neither is the need for physical therapy to retrain our muscles after injury. But when it comes to rehabilitation of a person, our nation is much more skeptical of the process.

The abundance of research in the US and other countries on long-term effects of various welfare programs such as cash assistance, nutrition, and housing, point to the overwhelming benefits to the health of the recipients. Interestingly, benefits can also be seen towards community, by way of increased rates of labor participation, education attainment, employment status and productivity (Banerjee, Blattman, et. al). In a 2019 study on long-term economic impacts of childhood Medicaid, researchers found Medicaid-eligible children had higher wages starting in their twenties with wages increasing as they age. By the time these children reach age 28, their expected annual tax on earnings will return 58 cents for each Medicaid dollar spent to the government (Brown 2020). Providing basic human needs can be life changing – and it seems not just an ethical imperative, but a sound investment.

As many physicians, policy makers, immigration lawyers and researchers have feared, the changes to public charge determination is adding fear and confusion, resulting in underutilization of services available to immigrant families. Even programs such as the Children’s Health Insurance Program (CHIP), which is exempt from public charge review, have experienced a decrease in utilization.  An early impact study of public charge since enforcement began in February 2020, showed a 1% increase in the US’ noncitizen population that was associated with a 0.1% drop in child Medicaid use, estimated as a decline in coverage of 260,000 children. Researchers attribute this drop in enrollment to the fear and misinformation spreading amongst immigrants around public charge (Barofsky 2020).

As a medical student in San Diego where roughly two-thirds of our county’s population is Spanish-speaking, the impact of fear-mongering could not be more clear. Since the start of the pandemic, our once overflowing children’s hospital emergency department has been eerily quiet. Parents are worried for the safety of their families at the cost of health consequences from delays in care. At a time when access to medical care is imperative, our patients without documentation fear being turned away, or worse, turned in.

Meanwhile, disenrollment affects more than just immigrant families foregoing public assistance. Safety-net hospitals which rely heavily on Medicaid and CHIP payment are estimated to be at risk for a loss of $68 billion in health care services for Medicaid and CHIP enrollees (Raphael 2020). A drop in Medicaid enrollees will lead to increases in uncompensated care, lower Medicaid and CHIP revenue, alongside the cost of complications and emergencies secondary to foregoing early/preventive care. The fear and reluctance that public charge has created is not a simple reduction in federal spending, but rather a shifting of the burden with downstream financial havoc.

With the ample evidence that negates the assertion that the use of public assistance dooms one to a lifetime of dependency, and evidence to the contrary, that foregoing use has downstream effects on society, I urge us to rethink the dominant narrative around welfare and its implications for our nation. If we reject the belief that we must limit the use of public resources in favor of nurturing our communities most in need, we are much more likely to manifest our nation’s values of self-sufficiency and unlocking its potential. I’m not asking you to give up on self-reliance, I’m asking you to invest in it.


References:

  1. Blattman C, Jamison J, Green E, Annan J. The returns to cash and microenterprise support among the ultra-poor: a field experiment. SSRN Journal. Published online 2014.
  2.  Banerjee AV, Hanna R, Kreindler G, Olken BA. Debunking the stereotype of the lazy welfare recipient: evidence from cash transfer programs worldwide. SSRN Journal. Published online 2015.
  3. Brown DW, Kowalski AE, Lurie IZ. Long-term impacts of childhood medicaid expansions on outcomes in adulthood. Review of Economic Studies. 2020;87(2):792-821.
  4. Barofsky J, Vargas A, Rodriguez D, Barrows A. Spreading fear: the announcement of the public charge rule reduced enrollment in child safety-net programs: study examines whether the announced change to the federal public charge rule affected the share of children enrolled in medicaid, snap, and wic. Health Affairs. 2020;39(10):1752-1761.
  5. Raphael JL, Beers LS, Perrin JM, Garg A. Public charge: an expanding challenge to child health care policy. Academic Pediatrics. 2020;20(1):6-8.
Categories
Clinical General Healthcare Costs Innovation Quality Improvement Technology

Let Me Be Brief: Principles of Value-Based Health Care

A series of briefs by Texas Medical Students

By: Sanjana Reddy, Tsola Efejuku, and Courtney Holbrook

In the seminal 2006 text, Redefining Health Care, Harvard Business School professors Michael Porter and Elizabeth Teisberg describe a healthcare market with a “positive sum” game; a market where all professional and economic incentives are aligned towards the maximization of “value,” defined as the “the quality of patient outcomes relative to the dollars expended.”1 Value in health care is the measured improvement in a patient’s health outcomes for the cost of achieving that improvement.1 Value-based care transformation is often conflated with cost reduction methods, quality improvement, or even evidence-based care guidelines. Rather, the goal of value-based care is to enable healthcare systems to improve health outcomes for patients over the full cycle of care. Tiesberg further elucidates three key dimensions (the Triple C’s) for measuring patient outcomes: capability (the ability for patients to do what is important to them), comfort (relief from emotional and physical suffering), and calm (reducing the chaos of navigating the healthcare ecosystem).2

In the U.S., improving patient-centered outcomes has become a highly discussed topic with ABIM’s Choosing Wisely program3, American College of Physicians’ High Value Care initiative4, and even major publications like the American Journal of Medicine’s recurring column on high-value care practice.5 In response to escalating healthcare costs, the Centers for Medicare & Medicaid Services (CMS) and other payers have shifted from traditional fee-for-service payments to value-based reimbursements such as the CMS Merit-Based Incentive Payment System (MIPS).6 Value-based health care empowers the clinician-patient relationship, places care delivery decisions at the expertise of a coordinated clinical team, and focuses on outcomes that matter most to patients.

The leadership of professional organizations, such as the Texas Medical Association (TMA), is invaluable to the process of defining and upholding the principles of value-based health care for systems and individual practitioners. Current TMA policy recognizes the need to advocate for high-value care principles in undergraduate and graduate medical education (Res. 201-A-18)7 and the adoption of the Choosing Wisely campaign (265.023).8 Although the evidence-based model (265.018.)9 previously adopted by the TMA does not encompass the full principles of the value-based decision making model, TMA resolutions on Cost Effectiveness (110.002)10 and Cost Containment (110.007)11 reinforce the need for cost-effective utilization of care.

On the federal level, exceptions to key legislation have been enforced recently to further advocate for value-based healthcare options. In November 2020, the CMS and Department of Health and Human Services Office of the Inspector General (OIG) released new exceptions to the Anti-Kickback Statute and the Stark law, effective January 19, 2021. These exceptions now allow more providers to participate in coordinated and value-based care arrangements that can improve quality and outcomes, lower costs, and increase health system efficiency, without the fear of severe criminal or civil legal backlash.12

The practice of value-based health care, although strong in theory, is not without flaws. The primary weakness of this system is that physicians are often responsible for things out of their control, such as referred providers’ costs and pre-existing conditions.13 This system requires widespread buy-in from all providers in order to collectively reduce costs and increase quality of care—effectively changing the culture of health care. Notably, this system inherently disincentivizes caring for patients of low socioeconomic status, particularly minorities, who inevitably generate higher costs due to health disparities.14 Weinick et al. emphasize adding a metric to the value-based healthcare system that addresses equity in health care. Their guide illustrates how to utilize value-based health care to reduce racial disparities, primarily by appending equity in pay-for-performance models.15

Goals of the Medical Student Section include staying informed about current policies regarding value-based health care since these policies are constantly changing and significantly affect reimbursement rates. Medical students are afforded the opportunity to learn about the principles of value-based health care from the very beginning of their training. Knowing the alphabet soup of value-based care (MIPS, APM, MACRA, etc.) will benefit patients and providers alike by improving outcomes, reducing costs, and maximizing reimbursements. In an effort to emphasize value-based health care early in the practice of medicine, the American Board of Internal Medicine sanctioned the Dell Medical School Value Institute for Health & Care’s STARS (Students and Trainees Advocating for Resource Stewardship) program. Over the past few years, student representatives across the country have met to learn about the principles of high-value care, review the Choosing Wisely campaign, and start their own initiatives at their respective medical schools. In Texas, students at UTHSC San Antonio’s Long School of Medicine created an ongoing Value-Based Health Care elective and degree distinction pathway. Dell Medical School offers online instructional modules and is a leader in patient-centered outcomes research. Medical students have a tremendous opportunity to impact high-value care through education, research, and student-led initiatives.


References:

  1. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. 2006. Boston, MA: Harvard Business School Press.
  2. Liu TC, Bozic KJ, Teisberg EO. “Value-based healthcare: person-centered measurement: focusing on the three C’s.” Clin Orthop Relat Res. 2017;475:315–317.
  3. https://www.choosingwisely.org/
  4. https://www.acponline.org/clinical-information/high-value-care
  5. https://amjmed.org/advancing-high-value-health-care-a-new-ajm-column-dedicated-to-cost-conscious-care-quality-improvement/
  6. https://www.cms.gov/newsroom/fact-sheets/quality-payment-program
  7. Texas Medical Association. Policy Compendium. Evidence-Based Medicine 265.018.
  8. Ibid. High-Value Care in Undergraduate and Graduate Medical Education 200.054.
  9. Ibid. Choosing Wisely Campaign 265.023.
  10. Ibid. Cost Effectiveness 110.002.
  11. Ibid. Cost Containment 110.007. 
  12. Modernizing and Clarifying the Physician Self-Referral Regulations Final Rule (CMS-1720-F). CMS. Accessed May 27, 2021. https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-final-rule-cms-1720-f.
  13. Burns, J. “What’s the downside to value-based purchasing and pay for performance?” Association of Health Care Journalists. September 6, 2014. https://healthjournalism.org/blog/2014/09/whats-the-downside-to-value-based-purchasing-and-pay-for-performance/.
  14. “Value-Based Health Care Must Value Black Lives,” Health Affairs Blog, September 3, 2020. DOI: 10.1377/hblog20200831.419320
  15. Weinick, Robin & Rafton, Sarah & Msw, & Walton, Jim & Do, & Hasnain-Wynia, Moderator & Flaherty, Katherine & Scd,. (2021). Creating Equity Reports: A Guide for Hospitals.
Categories
Clinical General Healthcare Cost Healthcare Costs Healthcare Disparities Innovation Patient-Centered Care Primary Care Quality Improvement

Let Me Be Brief: Medicaid Expansion

A series of briefs by the Texas Medical Students

By: Ammie Rupani and Alwyn Mathew

In 2019, 18% of Texans had no form of health insurance.1 650,000 Texans have lost their health insurance due to unemployment during the pandemic. The rate of uninsured Texans is staggering and has only been worsened by the pandemic. During this critical time, we must talk about Medicaid Expansion and the potential solutions for millions of people with no health insurance. As a medical student, I have seen patients defer life-saving medications such as insulin in order to afford rent or groceries. Consequently, these choices have brought such people to the Emergency Room in diabetic ketoacidosis, which could have been easily avoided with regular insulin treatments. Stories like this are far too common in Texas, and it is important to recognize such outcomes are easily preventable with improved access to health insurance coverage. How can we as students learn to treat people, when the system we are bound to  practice in is perpetuating their very diseases?

Retrieved from Texas Comptroller

Medicaid is a health insurance program managed through the Federal Centers for Medicare and Medicaid Services (CMS). Medicaid is currently jointly funded by the Federal and State governments with the Federal government matching each dollar the State spends. Texas Medicaid is primarily a fee-for-service model that has poor reimbursement rates and high administrative burden that discourages physicians from accepting Medicaid in their practice. Currently, Texas Medicaid coverage is only offered to children, pregnant women, seniors, and people with severe disabilities, who also fall below a certain income threshold. For example, a single mother making minimum wage at her  full-time job is not eligible for Medicaid because she earns too much. However, she does not qualify for Federal subsidies covering some of the insurance cost because she does not earn enough. The Patient Protection and Affordable Care Act of 2010 would help address this woman’s dilemma since Medicaid Expansion would cover all individuals with incomes up to 138 percent of the Federal Poverty Level, amounting to $16,643 for individuals and $33,948 for a family of four. Medicaid Expansion would provide a health insurance option to an estimated 2.2 million uninsured low-wage Texas adults.2

Although the original arguments against Medicaid Expansion in Texas focused on States’ rights and limiting Federal dependence on funding, the primary opposition to this program was the Federal mandate. In 2012, the US Supreme Court ruled that the Federal government could not mandate the Expansion of Medicaid in any State, leading to Texas and several States opting out of the program. Realizing the benefits and improvement in health outcomes, several States have since adopted the Expansion program offered through CMS, including Arkansas (2014) and Louisiana (2016). Currently, Texas spends nearly $40 billion (State and Federal funds) for the Medicaid program, with a 60-40% distribution between the Federal and State Government respectively.3 Expansion would be fiscally sound for Texas as it will reduce the strain on our State budget and draw in more Federal resources. Looking past the dollar amount, it is crucial that medical students and other healthcare professionals recognize the benefits of improved access and early medical intervention that can be achieved through Medicaid Expansion.3


TMA’s Legislative Recommendations4
  • Develop a meaningful, statewide health care coverage initiative using federal dollars to:
    • Extend meaningful coverage to low-income uninsured working-age adults, and
    • Establish a state-administered reinsurance program to reduce premiums for people enrolled in marketplace
  • Provide 12-months’ comprehensive coverage for women who lose Medicaid 60 days
  • Establish 12-months’ continuous coverage for children enrolled in Medicaid, the same benefit given to children enrolled in the Children’s Health Insurance Program.

  1. Accounts TCof P. Uninsured Texans. Retrieved from- https://comptroller.texas.gov/economy/fiscal-notes/2020/oct/uninsured.php
  2. How Many Uninsured Adults Could Be Reached If All States Expanded Medicaid? – Tables. KFF. https://kff.org/report-section/how-many-uninsured-adults-could-be-reached-if-all-states-expanded-medic aid-tables/. Published June 25, 2020.
  3. Federal and State share of Medicaid Spending, 2019, Kaiser Family Foundation- retrieved from – https://kff.org/medicaid/state-indicator/federalstate-share-of-spending/?dataView=1&currentTimeframe=0 &sortModel=%7B%22colId%22:%22State%22,%22sort%22:%22desc%22%7D
  4. Provide Meaningful Health Care Coverage for Uninsured Texans. Texmed. https://texmed.org/Template.aspx?id=55300.
  5. Status of state medicaid expansion decisions: Interactive Map, 2021. Retrieved from- https://kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
Categories
Clinical General Healthcare Costs Opinion Patient-Centered Care Reflection

Excellent, good, or fair? How accurately can patient satisfaction surveys measure quality of care?

Last week I had my semiannual dentist appointment. Right after I stepped out the door, I received an email: Dental Office – Patient Satisfaction Survey. Hi, thank you for visiting the dental office. Please take a minute to complete the survey…. Was it a déjà vu? Didn’t I just fill this out recently? Oh wait no. That was for the hygienist? Or was it for that new periodontist? Maybe it was my other specialists?

So besides rating my favorite restaurants and shops on Yelp and Google, now my clinics and insurance companies also want to know how I would rate my doctors– how splendid!

To my surprise, when I clicked the link, the questions were trickier than I expected. According to the email title, it seemed like the survey was about my dentist, but 75% of the questions were about the clinic itself: Waiting time in reception area, appointment phone call answering friendliness, waiting room neatness, office decoration….(Wait…my dentist is responsible for decoration? Great, let’s talk about changing the interior lighting and repainting the wall at the next appointment). As I was filling out the questionnaires, my head started to spin with my own questions: It was a normal checkup appointment, will “fair” be good enough? But I remembered I had given the hygienist an “excellent,” and honestly I couldn’t tell which one was better…oh boy! How are they going to use my answers? Who will be reading my survey responses? Who will be affected by my answers?

To me, it’s difficult to judge the doctors’ performance fairly. I can measure a finance manager by his portfolio performance, a designer by how many designs have been ordered, and a lawyer by how many lawsuits she has won. But judging a doctor is more like judging a piece of artwork: there’s a lot of subjectivity. How do I know Dr. ABC is better than Dr. XYZ? By my test result? Or by the number of medications they prescribe? Like with my dental visit, I couldn’t really tell the difference between that cleaning from the previous ones. Interestingly, some physician groups use patient satisfaction surveys to allocate bonuses [1]. That would make the weight of responsibility seem heavier; I would hate to find out that my dentist lost his Christmas bonus because of my thoughtless answers.

Needless to say, it’s difficult for management to evaluate every department and employee in a large organization. I truly hope that upper management does not blindly rely on this “big data” to determine a doctor’s career path. I would very much like my doctor to focus on my health, instead of for him or her to be driven by monetary incentives and to act as a salesperson. If the survey data is used for allocating the budget, perhaps the survey needs to be transparent about how the clinic is going to use the result: “This survey is for quality training purposes only” or “this survey is for determining the best doctor of the month and who gets the nearest parking spot.” I suspect that knowing the purpose of the survey helps the respondent think twice before jotting down comments or complaints. It might motivate patients to actually finish the survey (I would very much like to meet the saintly soul who is able to finish 30 ambiguous questions without losing their temper). Also, I would like to suggest that since we are giving patients such power, perhaps we can give some power to the physicians too and allow them to rate their patients (like how Airbnb and Uber lets hosts/drivers grade their guests/riders).

Surveys and ratings can be important sources of information. If I need to find a new doctor or specialist, the first thing I do is go on Yelp and sort the list by how many stars they have. Some industries routinely rely on survey systems to improve their customers’ experiences [2].

I understand that the idea behind patient satisfaction surveys is to encourage more communication. But at the end of the day, I believe that the doctor and the patient should have a strong mutual trust that enables them to communicate and give feedback freely and respectfully, without needing to rely on 30 ambiguous survey questions.

 

Reference:

  1. White, B. (1999, January 01). Measuring Patient Satisfaction: How to Do It and Why to Bother. Retrieved April 17, 2018, from https://www.aafp.org/fpm/1999/0100/p40.html
  2. Columbus, L. (2018, April 22). “The State of Digital Business Transformation, 2018.” Retrieved April 25, 2018, from https://www.forbes.com/sites/louiscolumbus/2018/04/22/the-state-of-digital-business-transformation-2018/#761f84535883


Edited by Shaun Webb

Photo credit: Steve Harris

Special thanks to Blog Associate Editor, Janie Cao, for some last-minute content revisions

To learn more about the author, please visit her website here

Categories
General Healthcare Cost Humour Lifestyle Opinion Pharmacology Psychiatry Psychology Public Health Reflection

Well, Well, Well: Products and services compete for shelf space in trendy wellness market, but are they worth your money?

When a friend recently asked me to join them for a class at Inscape, a New York-based meditation studio that New York Magazine described as the “SoulCycle of meditation”, I was skeptical. On the one hand, I usually meditate at home for free, so paying almost $30 for a meditation class seemed a bit silly. On the other hand, my meditation practice had dropped off considerably since the beginning of the year. Maybe an expensive luxury meditation class was just what I needed to get me back into my regular practice. Stepping off bustling 21st Street into the clean modern space, I heard the sounds of, well…nothing. It was incredibly quiet. Before getting to the actual meditation studios, I had to pass through Inscape’s retail space. The minimalistic shelves hold a variety of supplements, tinctures, and powders that include unique ingredients like Reishi medicinal mushrooms and cannabidiol extract. Many contain adaptogens, herbal compounds that purport to increase one’s resistance to stress, though their efficacy has never been quantitatively proven.[1] These products’ promises run the gamut from shiny hair and stress relief to aura cleansing. I may be a super-skeptic, but even I am not immune to the lures of top-notch marketing. With great consideration, I purchased one of the many magical powders for sale labeled as ‘edible intelligence.’

Since wellness has become trendy, a considerable space in the retail market has opened for associated products dedicated to helping people live their best lives. As Amy Larocca pointed out in her June 2017 article The Wellness Epidemic, “[In the wellness world] a loaf of bread may be considered toxic, but a willingness to plunge into the largely unregulated world of vitamins and supplements is a given.” Even a recent episode of Modern Family poked fun at the wellness trend when Haley Dunphy applied for an ultra-competitive job with fictional wellness guru Nicole Rosemary Page. During her interview at Page’s Nerp company headquarters, Page laments, “People say that Nerp is nothing more than a con-job, a cash grab vanity project from a kooky actress. I want to turn Nerp into the next Disney-Facebook-Tesla-Botox. It’s a world changer.” Though Page is a fictional character, I can’t help but wonder whether the character was inspired by the very real Amanda Chantal Bacon, the founder of Moon Juice, which bills itself as an adaptogenic beauty and wellness brand. Bacon’s Moon Dusts retail for $38 a jar and come in varieties such as Spirit, Beauty, and Dream.

The bottom line is that a sense of well-being needn’t come at the price of thirty-plus dollars an ounce. In fairness to those who choose to spend lavishly, I believe that plunking down a chunk of cash might create an intention to use and derive value from a product, thus positively influencing one’s perception of how well the product works. Rest assured, however, that living with intention and gratitude can be just as easily accomplished without spending any money at all. Carving out time in the day to create a small ritual for yourself can be as simple as spending a few minutes in the morning listening to jazz as you drink your first cup of coffee or allowing yourself to become immersed in a good book before drifting off to sleep. These simple acts allow us to bestow kindness upon ourselves that is especially important in our stressful and busy lives as medical students. My suspicion is that by performing such rituals with intention, we derive much of the same benefit whether our mug is filled with the trendy mushroom coffee or just plain old Folgers.

I’m always thinking about ways I can improve my own well-being, but as graduation approaches I also find myself thinking about how these practices might help my patients as well. One of my fundamental goals as a future psychiatrist will be to help my patients see the value in themselves and in their own lives. I predict that for many of my patients, achieving this goal will depend perhaps on medications but also on the deployment of simple wellness tactics such as I described. I’m not going to lie…I’m still intrigued by many of the wellness products that can be found in places like Inscape, Whole Foods, and the Vitamin Shoppe, especially when I think about the potential benefits they might have for my future patients. I figure that if these products do even half of what they promise to, some of them might even be worth the money. So what happened when I added a sachet of intelligence powder to my usual morning smoothies? Pretty much nothing. At one point, I got excited when I began to feel my fingers getting tingly. Then I realized I had been leaning on my ulnar nerve. Not so brainy after all.

[1] Reflection Paper on the Adaptogenic Concept, Committee on Herbal Medicine Products of the European Medicines Agency, May 2008.

 

Photo credit: Open Grid Scheduler / Grid Engine

Categories
Clinical General Healthcare Costs Law Opinion Patient-Centered Care Primary Care Public Health Reflection

Discontinuity in Care

My resident tries fairly hard to take care of his patients. When he is with them, I catch him paying attention to all sorts of details that he could have easily let slip past. So it made it all the more difficult when I saw him enraged. When he opened up his list of clinic appointments one morning, on the list was a patient he did not want to see. It was not just that she was a new patient to him. It was not just that her problem list went on like a run-on sentence. It was that both were true, and my resident was still expected to see her in only 15 minutes.

While chart reviewing, he learned that the only consistency in this patient’s medical care at our clinic had been a history of inconsistent providers—and based on their notes, none of them had the complete story. “Why am I even seeing her?!” my resident asked rhetorically, as he frantically searched for answers he knew he did not have the time to find. I wondered, too. This visit seemed to benefit no one except the Billing Department, and even that would depend on whether the Medicare reimbursements actually made it through.

That patient’s experience was hardly unique, though. While rotating through various specialties as a medical student, I have met several patients who were passed from one provider to another. Maybe the provider had to switch services. Maybe they left the institution for better opportunities elsewhere. The reasons were myriad. Stories like those suggest that continuity of care may still only be a priority in primary care literature.

I think one reason for this reality is a lack of incentives to keep doctors and patients together. In any field, including medicine, we see money driving people’s attention and vice versa. Since our country has historically kept primary care on the back burner, there is little evidence to believe that practical incentives for continuity of care will spontaneously appear in the near future.

So, for the primary care fans out there, it might be worth it to start speaking up.

 

Photo credit: Norbert von der Groeben/Stanford School of Medicine, posted by National Center for Advancing Translational Sciences