Change Not Always Good

Health Agency Reorganization Worries EMS, Medicaid Advocates

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Legislative Affairs Feature -- August 2004

By  Ken Ortolon
Senior Editor

The reorganization of state health and human services agencies ordered by the 2003 legislature blends 12 agencies responsible for disease prevention, mental health, alcohol and drug abuse, Medicaid, and other services into four departments overseen by the Texas Health and Human Services Commission (HHSC).

While Texas physicians generally support efforts to streamline government, reduce bureaucracy, and cut costs, they are concerned about how patients would be affected. Physicians, other health professionals, and patient advocates are asking HHSC to reconsider proposals they fear would impair delivery of emergency medical care and block access to Medicaid and other state services.

The Organizational Chart

Emergency medical services (EMS) stakeholders believe the proposed organizational structure of the new Department of State Health Services (DSHS) would fragment the state's EMS and trauma system when it is finally becoming a cohesive system.

"Historically we've been a group of independent, strong-minded administrators and practitioners who functioned in a silo -- their own organization or their own profession," said Ed Racht, MD, chair of the Governor's EMS and Trauma Advisory Council (GETAC). "Over the past three to four years, we've developed a 'collective think' so that we are one. It's a morphed relationship that allows us to better take care of day-to-day trauma or day-to-day illness or injury."

The Texas Department of Health (TDH) Bureau of Emergency Management holds the system together, Dr. Racht says. But it would be scrapped under the proposed DSHS. The new agency would combine TDH, the Texas Commission on Alcohol and Drug Abuse, the Texas Health Care Information Council, and the mental health portion of the Texas Department of Mental Health and Mental Retardation.

TDH currently is organized into divisions and bureaus according to issues, such as infectious diseases, sexually transmitted disease prevention, and emergency management. Under the structure Health and Human Services Commissioner Albert Hawkins proposes, however, DSHS would be organized by function. Separate units would handle regulatory, licensing, inspection, and other responsibilities.

Dividing current emergency management bureau functions among several new offices "significantly detracts" from EMS and trauma professionals' ability to solve problems collaboratively, Dr. Racht says.

GETAC recommends that EMS and trauma system functions remain one unit because the functions are "critical to public health and safety, are interrelated, and require consistent oversight and coordination."

The Texas Medical Association Committee on Emergency Medical Services and Trauma supports GETAC. So does the Texas Association of Trauma Regional Advisory Councils.

EMS committee Chair Earnest W. Stroupe, MD, says the panel fears the new DSHS units may not adequately communicate and coordinate their activities. "When we've made so many inroads in delivering coordinated trauma care and getting some good, solid EMS systems in the state, no one wants to see it take a step back because no one's watching the process," he said.

HHSC included an EMS/Trauma Coordination Office under the new DSHS Division of Regulatory Services, but stopped short of giving EMS and trauma its own unit.

 "Anytime you make changes, we expect some worries in the community impacted by those, and we want to listen to them very closely," said HHSC spokesperson Stephanie Goodman. She says HHSC is confident it has "developed a structure that builds on the good things, like that emergency system, but also helps achieve some administrative efficiencies ."

Cost Versus Access

Meanwhile, physicians, consumer advocates, and others have raised serious concerns about another element of the reorganization.

The legislation also directed HHSC to explore whether it would be cheaper to integrate the process for determining eligibility for several state services through regional call centers. HHSC says the state spends $700 million annually on eligibility determination for services such as Medicaid, food stamps, Temporary Assistance for Needy Families, and long-term care. It believes call centers would improve patients' access and save money that can be redirected to patient services. It is seeking proposals for a private contractor to run them.

Once the call centers are set up, 81 Department of Human Services (DHS) offices would close, and 643 eligibility workers would be laid off.

The agency also is developing a system to allow low-income Texans to apply for services via the Internet.

However, lawmakers, physicians, and consumer advocates question the projected cost savings. They believe the approach has not been adequately field-tested. A pilot project to test the call center approach has been plagued by problems and is over budget.

The aggressive time line for rolling out the call centers was questioned in a May 16 letter to HHSC from C. Alvin Jones, MD, then-chair of TMA's Committee on Rural Health.

"A hasty implementation is very likely to create gaps in patient coverage, disrupting continuity in patients' medical care," Dr. Jones wrote. He asked the state to take more time and conduct pilot programs before making a final decision.

Advocates also are skeptical that eligibility could be determined on average in seven minutes over the telephone. The current face-to-face interviews take up to 90 minutes.

Commissioner Hawkins faced tough questioning from both Republican and Democratic lawmakers at a Senate Finance Committee hearing in May.

Sen. Gonzalo Barrientos (D-Austin) says HHSC's claims about its eligibility determination proposal are "wondrous spin." He questions whether they are designed to "save money in providing the service or save money by frustrating people who want the services."

Additionally, he says many low-income Texans lack ready access to the Internet and do not have telephones, which would make it difficult for them to use the new systems.

Dr. Jones says many patients in his rural Montgomery County practice lack telephones. Transportation would be a problem for some because first-time applicants still would have to go to DHS offices for interviews.

But Ms. Goodman says that would come at the end of the application process rather than the beginning. And rural residents would not have to travel more than 30 miles to a local office.

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629.

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