TMA Testimony of John Holcomb, MD
Joint Committee on Aging
August 28, 2018
Committee Charge: Discuss Issues Relating to Access to Care and Veterans
The Texas Medical Association, representing more than 51,000 physician and medical student members, thanks Chairwoman Campbell and members of the Joint Committee on Aging for the opportunity to offer testimony on our aging Texas population, especially regarding Texas veterans and access to health care. My name is Dr. John Holcomb; I’m a pulmonologist from San Antonio, treasurer of the Bexar County Medical Society, and a TMA delegate. I’m also a veteran who served in the U.S. Army for 23 years.
Texas State Veterans Homes
An estimated 1.5 million veterans live in Texas, out of which 1,120 reside in one of eight Texas State Veterans Homes. State veterans homes, like other long-term care facilities, are home to some of the state’s most vulnerable residents who are unable to live independently due to serious acute or chronic illnesses. Thus anyone living or working in a veterans nursing home is more likely than most to be exposed to communicable diseases because of the compromised health of the residents, close living environment, and increased risk of exposure from visiting friends and family. Communicable diseases such as influenza and infections from multidrug resistant organisms (MDROs) disproportionately affect veterans home residents compared with the general population.
Influenza, which is vaccine-preventable, and MDRO infections consistently cost our state and country considerably in both dollars and lives lost. During the 2017-18 influenza season, more than 10,000 Texans died as a result of influenza-related illnesses, and 77 percent of these were aged 65 or older. MDROs have been estimated to cost the United States up to $20 billion annually. Infection control is consistently the No. 1 infraction by health care facilities and long-term care facilities, and according to data from the Texas Health and Human Services Commission, Texas State Veterans Homes are no different. In four of the past five years, infection control violations were the most-cited infraction, with a 75-percent increase from 2016 to 2017.[ 4]
While facilities are required to report disease outbreaks to local public health authorities, it is critical for them to have a relationship and plan with local public health before any outbreak. Surveillance, testing, and chemoprophylaxis should be prioritized. Local health departments could help veterans nursing homes develop plans to have either on-site capability for rapid influenza testing or access to an off-site, contracted lab for 24-hour turnaround. With plans in place, responses to outbreaks can be quicker and more effective.
Understanding who may be at highest risk during a potential influenza outbreak is critical for an effective response. In part, we could better understand this if we knew vaccine coverage at each facility. Currently, all Texas long-term care facilities, including veterans homes, are required to offer influenza and pneumococcal vaccines annually to all residents and staff. Each health care facility in Texas also is required to create and implement an employee vaccination policy. Facilities are required to keep a record of receipt of or exemption from vaccination for employees and residents. However, tallying this coverage information and making it available could help public health keep up to date on how successful facilities are in terms of promoting and implementing vaccinations and monitoring vaccine coverage. Furthermore, veterans and their families will be better informed about the quality of facilities in regards to best public health practices.
Adult Safety Net Program
Outside the state veterans nursing home population, any uninsured adult, including aging veterans aged 55 to 68 who are not enrolled in Medicare or Medicaid, is eligible to receive low-cost vaccines under the Adult Safety Net Program. This program supplies publicly purchased vaccine at no cost to enrolled physicians and health care providers. The program was created by the legislature through the Texas Department of State Health Services (DSHS) Immunization Unit to raise the immunization coverage levels and improve the health of Texans. Aging adults not only are at risk for contracting vaccine-preventable infectious diseases themselves, but also risk spreading these diseases to infants who are too young to be vaccinated. Therefore, funding programs such as Adult Safety Net protects the health of all Texans, both young and old.
Access to Health Care for the Aging Population
Twelve percent of Texans are over age 65. While Medicare provides coverage to almost all, accessing physician and other health care services still remains difficult, particularly for those residing in rural communities, where a disproportionate number of seniors live.
According to TMA’s biannual survey, 65 percent of physicians accept all new Medicare patients and another 18 percent accept with limits. But the percentage of physicians who accept patients known as “dual eligibles” — seniors poor enough to qualify for both Medicare and Medicaid — is much lower: Only 50 percent accept all new duals, while another 31 percent accept with limits. The discrepancy is due to a 2011 decision by the Texas Legislature to discontinue payment of duals’ Medicare coinsurance whenever the amount Medicare pays for a physician service is higher than what Medicaid would pay for the same service, a frequent scenario given Medicaid’s low payment rates. Medicare requires all enrollees to pay 20 percent of the cost of physician services. However, in 1997, Congress exempted duals from making these payments with the understanding states would do so instead. Texas’ decision to discontinue the payments resulted in a 20-percent payment cut for physicians who treat dually eligible patients.
Aging Texans who live in rural parts of the state deal with additional barriers to accessing health care. Of Texas’ 254 counties, 170 are defined as rural. Three million residents, nearly 20 percent, reside in rural areas, including 18 percent of the state’s elderly population. In rural communities, patients often cannot find a physician to treat them at all. Out of the 254 counties, 29 counties lack any direct care physicians, while another 72 counties have five or fewer primary care physicians. Finding a specialist is even more of a challenge. In addition to limited options for see practicing physicians, rural seniors also must deal with other barriers that can prevent them from seeking care, including far distances to drive to medical appointments, lack of reliable public transportation, and lack of community resources.
Compounding Texas’ shortage of rural physicians is the alarming rate of rural hospital closures over the past several years. While the factors contributing to rural hospital closures vary by community, insufficient funding is shared across counties. Rural hospitals depend more heavily than their urban counterparts on Medicare and Medicaid, both of which are notoriously low payers, and have higher rates of uncompensated care. Between 2010 and 2017, 78 rural hospitals closed nationwide. Twelve were in Texas. Rural hospitals often serve as the health care safety net, providing services when no other options are available. Studies indicate that rural hospital closures have resulted in residents traveling 20 to 30 miles for health care and often farther for specialized care. For many rural seniors, such distances are a hill too far; thus they forgo care. While medical care can be provided in a number of settings, we must pay attention to how rural hospital closures affect aging Texans.
Telemedicine is one way to increase access to health care for aging patients in rural areas. However, telemedicine is meant to supplement traditional medical services, not replace them, since not all care can be provided remotely. When thoughtfully implemented, telemedicine can be used to ensure aging patients with chronic conditions like diabetes consult with their physician between appointments, not only saving them from a commute to and from a physician’s office but also facilitating better patient compliance with a care regimen. Medicare and Medicaid both have payment structures in place for telemedicine. Yet Texas will need to invest in infrastructure, such as broadband access, to enable telemedicine connections in remote communities.
As Texas’ population ages, state policymakers must implement cost-effective, pragmatic measures to ensure seniors can get safe, timely care. For aging veterans, this includes funding the Adult Safety Net Program as well as other programs that protect them and their families from exposure to potentially deadly, communicable diseases, such as requiring state veterans homes to publish protocols for quickly responding to an infectious disease outbreak within their facility. Moreover, these facilities should be required to publicize the vaccination rates of their staff. To improve access to care, Texas must invest resources to ensure that aging Texans can obtain timely physician services close to home. Reinstating Medicaid payments of coinsurance for dual-eligible patients — the sickest and poorest seniors — would go a long way to improving care for this population. But we also encourage you to consider investing in infrastructure to promote and expand adoption of telemedicine.
TMA stands ready to work with this joint committee and members of the veterans health care community to implement steps that could have tremendous positive impact on aging Texas veterans across the state. I am happy to answer questions at this time.
 Texas Workforce Investment Council, “Veterans in Texas: A Demographic Study,” https://gov.texas.gov/uploads/files/organization/twic/Veterans_in_Texas_2016_Update.PDF, accessed Aug. 17, 2018.
 Texas Department of State Health Services, 2017-2018 Texas Influenza Surveillance Activity Report, www.dshs.texas.gov/IDCU/disease/influenza/surveillance/2017-2018-Texas-Influenza-Surveillance-Activity-Report/18Wk24Jun22.pdf, accessed June 27, 2018.
 Centers for Disease Control and Prevention, Antibiotic Resistance Threats in the United States, 2013, www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf, accessed Jun. 11, 2018.
Texas Health and Human Services Commission, Top 12 Federal Health Citation Rollup for 8 State Run Nursing Facilities FY13 TO FY17 and All Federal Health Citation Rollup for 8 State Run Nursing Facilities FY 18, data provided Aug. 20, 2018.
 Rural & Community Health Institute — Texas A&M University. (2017). What’s Next? Practical Solutions for Rural Communities Facing a Hospital Closure.
 U.S. Census Bureau. (2010). Texas: 2010: Population and Housing Unit Counts. www.census.gov/prod/cen2010/cph-2-45.pdf, accessed Aug. 22, 2018.
 Texas Organizations of Rural & Community Hospitals. (n.d.).
 U.S. Department of Health and Human Services, Office of the Inspector General. (2003). Trends in rural hospital closure: 1990-2000. https://oig.hhs.gov/oei/reports/oei-04-02-00610.pdf, accessed Aug. 21, 2008.
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