TMA Interim Testimony by Joyce E. Mauk, MD, FAAP
Joint Meeting of the House Committees on Appropriations, Subcommittee on Art. II, and General Investigating and Ethics
Submitted on behalf of the Texas Pediatric Society
June 27, 2018
Chair Davis and Committee Members,
Thank you for the opportunity to provide testimony today. My name is Joyce Elizabeth Mauk, MD, and I am a neurodevelopmental pediatrician from Fort Worth testifying on behalf of the more than 4,200 members of the Texas Pediatric Society, the Texas Chapter of the American Academy of Pediatrics.
Like many Texans, my pediatrician colleagues and I were saddened to hear the accounts presented in the Dallas Morning News series. Unfortunately, our members — who care for children in every service delivery area in Texas — are all too familiar with these stories because of their own personal experiences with children covered by managed care. Pediatricians continuously encounter instances of managed care plans placing road blocks — some warranted, many not — between the pediatrician’s recommendations for care and the child receiving that care. These battles are now a way of life in every pediatrician’s office. We must find a way — in the best interest of our children accessing needed care — to create a lasting solution.
Before I get into recommendations to improve Texas’ Medicaid managed care system, I want to address a few contextual points, so that we can get to the heart of the matter:
- First, Medicaid matters. More than 3 million children and 50 percent of all newborn care are covered by Medicaid in Texas, and without Medicaid coverage, these children would go without critically necessary preventive and acute care, which keeps them healthy and thriving in their community. As such, Medicaid needs to be fully funded and supported to get the most for taxpayer dollars.
- Second, Texas pediatricians are not advocating to dismantle the managed care system. The health care system, as a whole, has rightfully moved past fee-for-service in favor of a model that has the possibility and promise of delivering care in innovative ways while reducing overall spending. We must apply ourselves to ensure managed care fulfills this promise in the best interest of children and the physicians who care for them.
- Finally, as originally designed by the Texas Legislature, there is enormous variance in the quality, administrative burden, and innovation present in Medicaid managed care. There are now 20-plus Medicaid managed care organizations (MCOs) serving children in 11 service delivery areas, each with different utilization management policies and prior authorization requirements. Some plans are national, for-profit entities, and some are local, nonprofits. As such, we should be celebrating, promoting, scaling, and standardizing best practices, and holding the low performers accountable.
With those principles covered, I’d like to highlight two general categories of ongoing concerns Texas pediatricians feel need to be addressed to make lasting improvement to Texas’ Medicaid managed care system.
A family searching for subspecialist care and coming up empty-handed hits home for many Texas pediatricians who find it very difficult to refer patients to certain specialists in managed care networks. One of the core responsibilities of managed care is to maintain a robust network of physicians and providers for children to access health care services. While there may be overall physician specialty shortages in certain areas of the state, we know many physicians choose not to participate in Medicaid managed care networks due to payment rates that do not cover the cost of providing care to children.
Medicaid physician rates have not received a meaningful, enduring payment increase in more than a decade. Texas Medicaid physicians are paid anywhere from 58 to 85 percent of what Medicare pays for the exact same service. And each year, they fall further and further behind in covering practice costs as rates are not indexed to any sort of inflation. Medicaid managed care plans can do only so much through value-based incentive payments. The legislature must take it upon itself to increase rates via a pass-through mechanism and attract more pediatric subspecialists to the networks to serve children in need.
Behavioral health services are a particularly difficult challenge for Texas. Our state lacks the professionals to care for individuals with mental health concerns in both the Medicaid and commercial markets. As such, we will have to fashion creative solutions. For example, Child Psychiatry Access Programs have shown great promise in other states.  These programs create statewide or regional hubs made up of a child and adolescent psychiatrist, a master’s- level clinician such as a licensed clinical social worker, and a case manager to provide telephonic consultation and referral resources to primary care pediatricians. These programs broaden the ability for primary care pediatricians to care for children with mental health concerns and leave psychiatrists to care for the truly high-needs population. The House Public Health and Public Education committees are taking up discussion on Child Psychiatry Access Programs tomorrow as a part of their focus on children’s mental health and prevention. In addition, the Medical Child Abuse Resource and Educational Services (MEDCARES) Program, a grant program established during the 81st legislature to improve assessment, diagnosis, and treatment of child abuse and neglect in hospital or academic care settings, is an existing support for areas of the state where mental health services are sparse.  For instance, the Texas Tech University Health Sciences Center in Lubbock (one of the MEDCARES grant recipients) provides evidence-based mental health services for survivors of child maltreatment. The Texas Pediatric Society included a $2 million funding increase for the MEDCARES grant program in its written suggestions for the Department of State Health Services legislative appropriations request to bolster the capacity of existing MEDCARES sites.
Finally, in the areas where health plans do have control over the quality of their provider networks, we need to make sure we are holding them accountable. Senate Bill 760 in the 84th legislature required Health and Human Services Commission (HHSC) to go through a process of revising network adequacy standards to more closely reflect the needs of Medicaid patients. Those revised standards were included in the March 2017 managed care contract amendments. Full compliance of the new standards is required by September 2018, and includes corrective action plans and liquidated damages. Quarterly monitoring reports, corrective action plans, and liquidated damages should be made available to stakeholder groups via the State Medicaid Managed Care Advisory Committee.
In summary, solutions to improve network adequacy include:
- Investing in physician payment rates to attract pediatric subspecialists to managed care networks,
- Developing creative solutions to our behavioral health workforce challenges including creating a Child Psychiatry Access Program to broaden the ability for primary care to manage the majority of mental health concerns in children and further investing in MEDCARES,
- Properly enforcing new network adequacy standards as required by Senate Bill 760, 84th Texas Legislature.
We know this committee and others have heard physicians talk consistently about red tape that threatens to overwhelm those who wish to serve the Medicaid population. However, we now see how harmful this burden can be to the provision of care. Whether it’s arcane and hidden utilization management techniques or prior authorizations that slow referrals to a crawl, each administrative layer has the potential to trip up a busy physician or family and keep a child from prescribed care.
Prior authorizations are probably the largest headache for pediatricians. While a few are rightfully in place to improve quality and efficiency, most prior authorizations are ultimately approved, raising the question about whether they were necessary in the first place. To ease this burden, some plans have begun systematically reviewing all prior authorizations and sunsetting unnecessary ones. Additionally, some plans have begun “gold starring” certain pediatric medical homes that have demonstrated the ability to properly prescribe and refer services, thus making prior authorizations on certain services unnecessary. These are the best practices I referred to earlier that need to be promoted, scaled, and standardized across all of Medicaid.
Care coordination services remain an enigma to many practicing pediatricians in Medicaid. Care coordination should be a defining pillar of managed Medicaid, but it falls short of its potential. Each managed care program type (STAR, STAR Health, STAR Kids) has various eligibility for care coordination, calls it by different names (e.g., care coordination, service coordination, case management), and requires various processes to inquire about using care coordination. Pediatricians are unaware of how to contact a patient’s care coordinator, especially when the family reports not having a relationship with one. These concerns are reflected in the January 2017 Legislative Budget Board report titled, “Improve Care Coordination in Medicaid” and a May 2018 report from HHSC as required by the legislature. Many of the legislative solutions proposed in these reports should be seriously considered by the committee.
In summary, solutions to improve administrative burden include:
- Scaling up and standardizing best practices to decrease and/or eliminate unnecessary prior authorizations, and
- Requiring additional investment of managed care plans in care coordination services with improved communication to physicians on how to use the service for their patients.
The Texas Pediatric Society stands ready to work with the legislature to improve our Medicaid managed care system. While many other small improvements could be made, we offer these five recommendations to help streamline and focus this committee’s work. While it seems like there is lots of work to be done, we must not allow ourselves to become defeatists in this matter. The care and well-being of our children is too important.
 Kaiser Family Foundation State Health Facts. (2016). Medicaid-to-Medicare Fee Index. Note: While these fees reflect the FFS fee schedule, most Texas managed care organizations rates closely track the FFS fee schedule.
 Straus, J.H., and Sarvet, B. (2014). Behavioral health care for children: The Massachusetts Child Psychiatry Access Project. Health Affairs, 33(12), 2153-2161.
 Department of State Health Services. (December 2016). Material & Child Health (MCH) — Medical Child Abuse Resources and Education System (MEDCARES).
 Legislative Budget Board. (January 2017). Improve Care Coordination. Legislative Budget Board Staff Reports.
Health and Human Services Commission. (May 2018). Health and Human Services System and Managed Care Report: As required by Senate Bill 1, 85th Legislature, Regular Session, 2017 (Article II, Special Provision 25).
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