1999 Legislative Compendium: Health and Human Service Agencies Sunset

[ Health and Human Services Commission | Texas Department of Health | Texas Department of Mental Health and Mental Retardation | Texas Cancer Council | Center for Rural Health Initiatives ]

State law requires all agencies to undergo a periodic review to evaluate an agency's mission, administrative efficiency, and programmatic competence. Review of an agency is performed by the Sunset Advisory Commission, a legislative body comprising four senators, four representatives and two public members. Once an agency has undergone sunset review, the legislature has three options: 1) continue operating the agency as is, 2) combine the agency with another, or 3) abolish the agency. In 1999, all health and human service agencies underwent sunset, giving TMA an opportunity to influence the day-to-day management and operations of these entities. All of the agencies involved in the review - TDH, TDHS, and HHSC, to name three - have a direct impact on the lives of millions of Texans and virtually all physicians interact with one or more of their programs (Medicaid, rural medicine, public health, mental health, etc.).

Though much of the sunset debate was esoteric and technical, TMA advocacy resulted in several key victories for medicine. Below is a round up of the major sunset reforms for each health and human service agency. 

Health and Human Services Commission

In 1991, the legislature established HHSC to act as an umbrella organization for all health and human service related agencies in Texas.  The goals of the commission's enabling legislation were to increase health service coordination and delivery, enhance interagency communications and collaboration, promote efficient use of state and federal health care dollars, and strengthen and carry out needs surveys and forecasting.

HHSC sunset review found that, despite much effort, the structure of HHSC itself impeded steps needed to improve coordination among the health and human service agencies. As a result, the legislature adopted several bold measures to strengthen HHSC's role as an oversight agency. HB 2641 by Representative Gray and Senator Brown contains the following reforms:

Gives the commissioner of health and human services the authority to hire and fire agency directors and commissioners. Hiring an agency director will require the approval of the agency's board and the governor. However, to fire a director, the HHSC commissioner only needs the consent of the board. (Under current law, agency directors are employed by the agency board or policymaking body.) Additionally, HHSC will have authority over many agency functions, including:

  •  Daily operations. 
  •  Personnel and employment issues. 
  •  Contracting, purchasing, and related policies. 
  •  Information resources. 
  •  Coordination of activities between agencies. 
  •  HHSC and the agencies must develop performance measures to evaluate the effectiveness of each agency in achieving mutually defined goals. 
  •  States that each agency also is required to notify HHSC before proposing a new rule. The point of this provision is to promote greater coordination of services and policymaking across various agencies. 
  •  Directs HHSC to hire a full time medical director. This provision, strongly supported by TMA, will ensure clinical input into the agency's day-to-day operations and rulemaking. 
  •  Transfers administration of the Medicaid managed care program to HHSC. As part of HHSC's management of the Medicaid managed care program, the agency is required to appoint a new statewide Medicaid managed care advisory committee comprising physicians, hospitals, health plans, patient advocates, and state agencies. 
  •  Specifies that HHSC is responsible for planning and managing the use of all federal funds in a manner that maximizes Texas' access to federal dollars. 
  •  Directs HHSC to develop several reports prior to the 2001 legislative session. Reports topics include:
         Delivery of mental health and substance abuse services in Texas, including an inventory of all existing services; and
         Subacute care. The report will focus on the state's capacity to provide such care, how subacute care impacts patient quality, impact of services on Medicaid, and feasibility of managed care for subacute care services. 
  • Creates a Legislative Oversight Committee to monitor HHSC's progress in implementing sunset recommendations.

Texas Department of Health

Through the TDH sunset bill (HB 2085) presented numerous opportunities for legislative mischief - such as scope of practice incursions - the bill made it through the legislative process relatively smoothly thanks to the dedicated efforts of Representative McCall, Senator Brown, and other sunset bill sponsors.  The bulk of this lengthy bill implements standard sunset review provisions relating to the administration and the operation of the Texas Board of Health and advisory councils that report to the board (for example, board member training, conflict of interest policies, etc.)  Additionally, the bill clarifies TDH's authority to impose administrative penalties on various entities or professionals licensed by the department.  Despite the technical nature of the bill, amny of its provisions will directly benefit patients, physicians, and health care providers.

Of primary interest to physicians and patients are provisions within the bill directing TDH to work toward the integration of Medicaid and nonMedicaid health care delivery programs administered by the agency. Specifically, the bill states that TDH should blend different programs' health policy development, service delivery, and contract management functions. The goal of this provision is to streamline services and promote continuity of care between and among programs. A pilot to test the integration of Medicaid and non-Medicaid programs must be implemented by Sept. 1, 2000. The project will operate until Sept. 1, 2001, at which time successful elements of the pilot may be continued. An interim progress report on the pilot must be completed by September 2000. A detailed report evaluating the success of the integration pilot, including benefits and limitations of expanding the pilot further, must be completed by September 2002.

To minimize paperwork and administrative hassles for contracted physicians or health care providers, the bill also specifies that the agency shall develop an integrated contract administrative system. This includes developing uniform contract terms, establishing a mechanism to allow contractors to bid on multiple programs without submitting duplicate paperwork, and combining contract monitoring activities.

Other key provisions:

  • Directs the Board of Health to hire a medical director to oversee Medicaid managed care and the new Children's Health Insurance Program. TMA recommended this provision to assure ongoing and routine clinical input into the operation of these important programs.
  • Requires TDH to study the impact of Medicaid managed care on physicians, providers, and patients. A report must be presented to the legislature by Nov. 1, 2000.
  • Obligates TDH to hire an independent auditor to assess the financial health and performance of Medicaid contractors. Contractors include vendors providing claims payment, quality monitoring, utilization review, patient enrollment, provider enrollment, etc. Similar provisions were included in HB 2896 (see "Medicaid").
  • Requires TDH to produce a comprehensive strategic and operational plan biannually. The report must, at a minimum, include a statement of aim and purpose for each of the department's missions, including: prevention of disease, promotion of health, indigent health care, protection of parents' right to direct the health care and upbringing of their children, health care facility regulation, licensing of health professionals, and other health-related functions performed by the agency.
  • The comprehensive plan also will analyze how TDH can combine information gathering and management functions. The analysis must address whether data collected by TDH are relevant and necessary as well as if the information could be collected or disseminated more effectively. 

Other topics the comprehensive plan must cover are:

  •  An assessment of the services provided by TDH and whether those services should continue; 
  •  A method for improving public input into TDH's assessments of health needs in Texas, how services can be better integrated, and the factors TDH should consider before adopting rules affecting providers or recipients of TDH services; 
  • A comprehensive inventory of health-related information resources that meet TDH established criteria for usefulness and applicability to local health departments, patients, physicians, and providers of services that are related to TDH's missions, as well as to nonprofit entities or businesses with missions related to health.
  • Requires the board to develop a checklist that the agency will follow to obtain early input and advice on the development of TDH rules. The checklist must include methods for identifying stakeholders who will be affected by a rule and how their input will be solicited. The checklist may include negotiated rulemaking, advisory committees, informal conferences, etc. If TDH fails to comply with this section, adopted rules cannot be challenged because the checklist was not followed. However, if TDH is unable to solicit significant input from stakeholders on a particular rule, the agency must explain in writing its reasons to the board.
  • Directs TDH to encourage its Medicaid contractors to use electronic transactions to the extent feasible.
  • Requires TDH to publish information relating to final enforcement action taken by the department, including any sanctions imposed, against facilities or health professionals regulated by the agency. Exceptions are granted where other laws assure confidentiality. Sanction information must be made readily available to the public through the Internet or toll-free numbers. Additionally, TDH is required to publish an annual analysis of its enforcement actions and trends.
  • Requires TDH to assure cost-based reimbursement to federally qualified health centers and rural health clinics participating in Medicaid. (Federal law allows states to phase-out cost-based reimbursement for rural health clinics.)
  • Stipulates that TDH, in conjunction with the state auditor, must comprehensively evaluate the department's regulatory functions. The analysis, which must be completed by Nov. 1, 2000, will include a review of 1) the rules affecting or supporting the agency's regulatory efforts; 2) inspection efforts, including its scheduling of inspections and consistency between inspections; 3) investigative practices, including investigations resulting from a complaint; 4) use of sanctions; 5) enforcement actions, including the time it takes to initiate and complete such actions; and 6) efforts to enforce compliance with applicable laws and rules.
  • At TMA's suggestion, language also was included to require the study to evaluate the consistency and appropriateness of inspectors' training. The provision is in response to complaints by rural health clinics and psychiatric facilities that inspections are not always consistent. TDH must also evaluate whether inspectors are familiar with the types of facilities they are inspecting as well as the types of care provided. Additionally, TDH must assure that inspectors' skills and knowledge remain current.
  • Creates a new EMS advisory council to advise the Board of Health on rules and regulations pertaining to emergency medical services, including EMS personnel certification and performance, training programs, EMS personnel examinations, and medical supervision of basic and advanced life support. Among the 15-person council will be an emergency physician, EMS medical director, representatives from an urban and rural trauma facility, pediatric trauma or emergency physician, trauma surgeon or nurse, fire chief from a municipality providing EMS, an officer or employee of a private EMS provider, volunteer EMS provider, and two public members.
  • The bill also authorizes the commissioner of health, with advice and counsel from the trauma service area regional advisory council chairs, to fund regional EMS and trauma care systems out of monies from the EMS and trauma care system fund.
  • Allows EMS operators to provide medical information to the public during an emergency call if the operator has successfully completed an EMS operator training program and holds a designated certificate. The board is required to develop a protocol that must be used to provide medical information, such as a flash card system or other system that makes information readily available and understandable to EMS operators. The board also must establish minimum standards for approval of training programs and certification and decertification of instructors.
  • An EMS operator who is trained and certified cannot be held liable for damages arising from sharing medical information, according to the protocol, so long as such information was shared in good faith.
  • Amends the abortion facility licensing standards to include physician practices that perform 300 or more abortions in a 12-month period. This number does not include abortions the physician believes will prevent the death or serious physical impairment of the patient. Language referring to mental impairment was removed. The provision was accepted by TMA and Texas Academy of Obstetricians and Gynecologists.
  • Requires TDH to develop an educational program for minors that teaches that sexual activity before marriage may have psychological and physical consequences. The program must also teach teenagers ways to recognize and respond to unwanted physical and verbal sexual advances, emphasize the importance of attaining self-sufficiency before becoming sexually active, and inform adolescents that alcohol or drug use increases a person's vulnerability to unwanted sexual advances. 

 Texas Department of Mental Health and Mental Retardation

Sunset legislation for the TDMHMR was filed by Senator Frank Madla and Representative Gray. SB 358 includes many provisions to improve long-term statewide planning, increase input of local community centers, and improve coordination with other state agencies. It authorizes the department and the Texas Commission on Alcohol and Drug Abuse to designate local behavioral health authorities that will provide a single point of entry for mental health and substance abuse services. These authorities will supervise the delivery and integration of mental health and substance abuse services in their region to ensure consistent quality of care and access.

The department will be required to develop model program standards for mental health services across the state and a plan for the provision of services at state-operated institutions to ensure that the medical needs of the most medically fragile persons are met. The department will be required to develop a report regarding the most efficient long-term use and management of the department's campus-based facilities. The department and the Texas Rehabilitation Commission will be required to come to agreement on the roles and responsibilities of each agency regarding shared client populations. TDMHMR will undergo sunset evaluation again in 2011.

Texas Cancer Council

The Texas Cancer Council successfully completed its sunset review, enabling the agency to continue until 2011. The Sunset Commission's final report characterized TCC's accomplishments and its effectiveness as a small agency devoted to implementation of the State's Cancer Plan. Overall, the report was very positive and included only minor changes, primarily to diversify representation on the Board of Directors.

Center for Rural Health Initiatives

Despite early predictions that the legislature would merge the Center for Rural Health Initiatives with another state agency, the center survived the sunset process intact. Widespread and long-term dissatisfaction with the center's operations sparked the intense speculation about the agency's future. However, TMA and other rural advocacy organizations rallied to the center's defense, arguing that rural health is too important to Texas to be subsumed within another agency. Supporters instead advocated key provisions to resolve the center's shortcomings.

Reforms adopted by the legislature included:

  • Requiring at least half of the CRHI Executive Committee to live, work, or practice in rural communities. "Rural" is defined as counties with populations of 50,000 or fewer.
  • Adding governmental officials and employers to the executive committee (in addition to health care professionals such as physicians, pharmacists, nurses, etc.).
  • Requiring CRHI Executive Committee members to receive training on the center's history, programs and advocacy efforts, and budget. The provision is standard for most agencies, but will be helpful in ensuring that the center's governing body is well grounded in the agency's operations and program development.
  • Directing the executive committee to develop policies for soliciting public input into agency activities.
  • Directing the center to develop a rural health work plan that identifies 1) how the agency will help rural communities improve rural health; 2) ways for the state to address unmet rural health care needs; and 3) ways that the state can integrate federal, state, and local public health programs with other public and private initiatives. The center must present its first work plan by Oct. 1, 1999.
  • Requiring the center to undertake a study on the feasibility of a visiting physician program to provide relief for rural physicians. In performing the study, the center must involve practicing rural physicians, medical schools, public health schools and other interested stakeholders. Factors to be addressed by the study include anticipated utilization, costs, insurance requirements, training, and reimbursement arrangements. Results of the study are due by November 2000.

Agency Sunset Staff Contacts
Matt Thompson, Legislative Affairs: (512) 370-1355
Helen Kent Davis, Governmental Affairs: (512) 370-1401
Gayle Harris, Public Health: (512) 370-1670 

Overview  |  Market Fairness/Managed Care Reform   |  Medicaid/Medicaid Managed Care  |  Public Health  |  Mental Health  |  Rural Health  |  Scope of Practice   | Medical Licensure, Discipline, and Credentialing  |  Medical Education  |  Long-Term Care and End-of-Life Issues  |  Tort Reform/Liability  |  Workers' Compensation