TMA: Why Texas Needs a Stronger Public Health System

TMA Testimony by William S. “Chip” Riggins, Jr., MD, MPH

Sunset Advisory Commission Testimony on Sunset Staff Report: Department of State Health Services 
July 25, 2014

Good afternoon, Madame Chair and members of the commission. My name is Chip Riggins, MD, MPH. I serve as the local health authority and executive director for the Williamson County and Cities Health District. I am board certified in family medicine, public health/general preventive medicine, and aerospace medicine. I’m also a member of the Texas Medical Association’s (TMA’s) Council on Science and Public Health and chair of the Department of State Health Services (DSHS) Preparedness Coordinating Council, and I serve on the Senate Bill 969 panel. It is a pleasure to be here today representing more than 47,000 physicians and medical students of the Texas Medical Association on the sunset staff report for the Department of State Health Services. TMA’s written comments focus on four areas from sunset staff recommendations, but today I will address Issue No. 5 as identified in the sunset staff report.

Issue No. 2:  Mental Health 
We appreciate the significant investments the legislature made in 2013 to strengthen the state’s mental health system. Those funds helped to bolster and sustain a foundation for the state’s community-based mental health and “crisis” services, and provide training for educators to identify children who may need mental health services. As a result, the state can work toward improving Texans’ lives, while reducing its costs.  

Mental illness and substance abuse hurt the Texas economy through lost earning potential, treatment of coexisting conditions, disability payments, homelessness, and incarceration. 

Investing in community-based mental health services ultimately pays for itself through reduced incarceration and emergency department costs. The DSHS figures demonstrate of the billions of dollars spent on potentially preventable hospitalizations; more than a third have comorbidities in mental health conditions.

Mental illness also is strongly associated with high-risk behaviors such as alcohol, tobacco, and illicit drug use, and contributes to health conditions such as obesity and cardiovascular disease. In 2006, the U.S. mental health costs were around $57.5 billion, including the cost of mental health care and the indirect costs of disability caused by mental illness. One recent study estimates Texas spends more than $13 billion each year on mental health.

TMA strongly encourages DSHS to promote communications with physicians on mental health prevention and public resources so physicians know of available referrals for their patients. This is a significant gap in the public health system.

Pediatricians and primary care physicians are the mental health providers in many area of our state. Yet, primary care practitioners are often unaware of the public behavioral health resources available in their communities, especially in rural areas. Thus DSHS needs to be tasked with providing information to health care practitioners on available services and better communication about referrals.

Finally, obstetricians and gynecologists (OB-Gyns) have said they are unaware of or lack referral resources for pregnant women with substance abuse issues (especially on alcohol or opioids).  DSHS must do more to communicate with these physicians about referrals for services and prioritization for this at-risk population.

Issue No. 3: TMA agrees with shrinking the regulatory tasks of DSHS. However, we are concerned about the proposal to eliminate licensure of critical health care professions such as medical physicists and radiologic technologists. Both of these practitioner categories could be transferred to the Texas Medical Board (TMB) for continuation, and in the latter case, better alignment with the noncertified technologist regulation already at TMB.

An even stronger concern is the movement of many regulated professions to a state agency that has little background or expertise in health care matters — the Texas Department of Licensing and Regulation. Is it appropriate to regulate midwives under the same agency personnel as refrigerator repairs? We urge the commission to consider placement alternatives for professions that need regulation.

Texas OB-Gyns, radiologists, psychiatrists, and orthopedic surgeons are providing comments to you on the specific professions of relevance that were recommended for elimination by sunset.

Issue No. 5: While DSHS can do more to provide better coordination of public health services, unfortunately, the way the Texas public health system is defined is the true flaw. The lack of statutory clarity leaves DSHS with little ability to influence standards and basic level of services provided by local health departments. Due to the shared funding responsibilities, DSHS all too frequently is left holding the bag left by local governments hat decide to no longer provide these important fundamental services.

A deliberate, more comprehensive focus on Texas’ public health infrastructure is needed. Texas often comes in last or almost last in many of the key public health indicators when compared with other states.

Today’s public health interventions in Texas should be based on well-established, scientific, evidence-based practices that most of us have adopted and that silently protect 26 million Texans throughout the day. Take for example, public health preparedness planning, disease or outbreak investigation and control, community mobilization, health education, food safety inspections, and vaccinations. Physicians recognize that DSHS regions and local public health agencies help protect their patients. 

Overall, we concur with many of the observations and recommendations in the sunset staff report on Issue No. 5. Texas has a fragmented public health system. As a home-rule state, we recognize the primary role of local government in supporting the population’s health, but in a large and diverse state, we also need strong state-level leadership, clarify of responsibility, and guidance and oversight of all local public health activities. 

Coordination of public health services 
With a decentralized and inconsistently defined public health infrastructure, Texans receive different public health services across the state. DSHS has minimal ability to influence the standards and basic level of services that should be provided by local health departments and districts. DSHS and its regional offices should no longer be expected to fill in during local disease outbreaks or when local officials decide they can discontinue key services. We believe the essential public health services should be available in every community. Recommendations 5.1 and 5.3 would help develop a statewide inventory of services and add transparency to public health agencies so that all Texans can understand how their tax dollars directly support population health. This baseline information also will help inform physicians on services in their communities. 

Public health and medicine 
To be more effective, public health must be closely linked to quality, accessible medical care. Texas physicians are the “boots on the ground” for public health, as they are the first to identify potential infectious disease outbreaks, environmental exposures, or foodborne illnesses. DSHS and local health departments are dependent on timely physician reporting so that communicable diseases can be identified early, and appropriate disease management can be implemented. We believe public health must be better engaged with physicians at the local levels. Physicians can begin to support and collaborate with population health only if we have strong communications with public health agencies about the public health services and gaps in every community. 

TMA supported Senate Bill 969 (82nd legislative session) to establish an advisory committee on core public health services, funding for local public health entities, and the identification of health priorities for Texas. While this panel has been active, we call on the commission to consider expanding its charge. The panel should provide oversight of the public health inventory developed by DSHS and aid in the identification of gaps in local public health services. The panel’s composition should also be broadened to include other public representatives, elected officials, and local stakeholders to address public health infrastructure in Texas. The charge should involve suggestions for a revision of state law on local public health systems. 

Issue No. 7: TMA does not agree with the commission’s recommendations to continue the Texas Health Care Information Collection (THCIC) and has provided a letter on why it should be discontinued from TMA President Austin King, MD. We also defer to the public testimony of the Ambulatory Surgical Centers Association regarding reasons for its discontinuance. 

Conclusion 
As we learn more about the root causes and contributors to both good and poor health, our public health infrastructure will need to adapt to greater demands for population health services. Medicine is an important stakeholder in this system, and we look forward to increasing the involvement of medicine to help improve the state’s public health infrastructure and strengthen public health leadership in our state.

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