Working the Capitol
By Joey Berlin Texas Medicine August 2018

1.25 mental health 

Committees in both chambers of the Texas Legislature are studying complex issues throughout this year to prepare for the next legislative session in 2019. As the year progresses, we’re periodically looking at the health care-related issues lawmakers are tackling and how TMA is advocating for medicine on those fronts.

Opioids, cost transparency, and Medicaid: Three seemingly perennial issues that will once again take center stage when the Texas Legislature reconvenes in January.

Four Texas Medical Association physicians represented the House of Medicine over two days of Senate Health and Human Services Committee hearings in late March, making sure medicine’s best interests stay on lawmakers’ minds. TMA also testified at the May 15 meeting of the House Select Committee on Opioids & Substance Abuse. Here are some highlights:

Opioids and substance abuse

The Senate health committee looked at substance abuse and opioids during its March 22 hearing. Among other things, the committee is charged with:

  • Reviewing state-funded substance use prevention, intervention, and recovery programs; 
  • Recommending ways to improve substance use-related health outcomes for pregnant women enrolled in Medicaid and the Healthy Texas Women program; and 
  • Examining recent legislative efforts to curb overprescribing and doctor-shopping.  

Aug_18_TM_LegeAffairs_DuttonDallas anesthesiologist Richard Dutton, MD, and San Antonio orthopedic spine surgeon Adam Bruggeman, MD, represented TMA. 

Dr. Dutton, chief quality officer for U.S. Anesthesia Partners, said opioids, when appropriately used, play an important role in anesthesia. He told the committee physician prescribing behavior is changing rapidly, with a focus on “multi-modal” pain relief.

“Basically, the concept is, emphasize non-addicting medications — so non-steroidals, Motrin, Tylenol, gabapentinoids, regional anesthesia, physical therapy, other adjuvant techniques — before giving opioids. And that allows us to minimize the amount of opioids we’re using for folks,” he said. “We’re also very interested in … measuring how much narcotic we give, how many patients are exposed to narcotics during anesthesia, and then how quickly we get them off opioids in the long run.”

Another critical piece, Dr. Dutton said, is working with hospitals and surgeons to prescribe ongoing pain relief post-surgery.

“Those requirements are changing very rapidly, obviously,” he said. “We’re seeing a very significant reduction in standing-dose opioid prescriptions that are one-size-fits-all, when in fact we need to adjust these very specifically [for] individual patients and what they need.”

Dr. Bruggeman, who’s board-certified in addiction medicine, noted it’s important to discuss not only the people dying of substance-use disorder, but also the people “living with this problem.” He stressed the need to have the state’s prescription drug monitoring program (PMP) integrated into physician workflows. 

Aug_18_TM_LegeAffairs_Bruggeman“We already have doctors who are stressed, who are spending more time on computers than they are taking care of patients,” he said. “It’s critical that the more things that we can do to integrate and make it faster [so doctors can] take care of patients, and spend more time counseling them about why that opiate may not be appropriate, would be beneficial and would reduce our opiate usage, specifically regarding whether or not it’s used across multiple states.”

Houston family physician Troy Fiesinger, MD, testified in front of the House opioids committee at its May 15 meeting to evaluate recent legislation on the state’s PMP. In 2016, the state launched its new monitoring program, PMP Aware, after lawmakers transferred the program from the Texas Department of Public Safety to the Texas State Board of Pharmacy.

Dr. Fiesinger told the committee medicine needs to improve how it treats pain and addresses opioids. On the positive side, he said he’s a big fan of the PMP.

“I remember the old way. The DPS officer came to the office and said, ‘Do you know so-and so? We have some problems with so-and-so.’ [We’d say], ‘Yeah, you know, we never quite trusted so-and-so.’ Fifteen years later, now it’s an easy-to-use website that I can access fairly quickly,” Dr. Fiesinger said. “I can get extensive information. I can check the doses of a new patient [who] can’t remember how much Adderall they take, and make sure they’re not getting it from different people.”

Cost transparency

Lt. Gov. Dan Patrick also tasked the Senate health committee with studying the state’s efforts to increase health care cost transparency and recommending ways to make health care fees more public. The committee examined that charge on March 21.

Dallas anesthesiologist David Bryant, MD, spoke on behalf of TMA and the Texas Society of Anesthesiologists (TSA). He told the committee TMA and TSA are in favor of working with the legislature to create better cost transparency tools that give Texas consumers good data to make smart health care decisions. Dr. Bryant said the biggest missing component preventing that from happening is information from insurance companies.

“The provider, at the time he delivers service, doesn’t know a whole lot of things that allows him to give an accurate estimate,” Dr. Bryant testified. “He doesn’t know the specifics of the consumer’s plan, what the copays [are], what the deductibles are, or even whether or not he’s in the patient’s network. As we know, there are a number of large payers. But there are a lot of different plans out there amongst those major payers, and so it’s almost impossible to tell at the time of service whether or not I as a provider may be in network or out of network on that plan.”

Medicaid managed care

Along with cost transparency, the March 21 hearing tackled Medicaid managed care quality and compliance. San Antonio pediatrician Ryan Van Ramshorst, MD, chair of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured, told the committee Medicaid is at the same time an “innovation laboratory” for value-based care and “incredibly burdensome,” with confounding paperwork and red tape.

On the positive side, Medicaid’s transition to value-based payment features an emphasis on quality outcomes, he said, sharing several examples of existing managed care programs that show promising results. (See “Remodeling Medicaid,” July 2018 Texas Medicine, pages 16-21, www.texmed.org/RemodelingMedicaid/.)

“Something that I’ve benefited from in my personal practice is co-locating a mental health professional [in the same facility]. That way, as a general pediatrician, when I have that teenager who has depression and now is starting to cut, I can contact the child psychiatrist and get that support. So there are value-based payment initiatives that are going far.”

 

Tex Med. 2018;114(8):44-45
August 2018 Texas Medicine Contents
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Last Updated On

August 01, 2018

Joey Berlin

Associate Editor

(512) 370-1393
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Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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