Maintain Level of Care Standards for Neonatal and Maternal Hospitals

TMA Testimony by Eugene Toy, MD

Senate Health and Human Services Committee
Senate Bill 749
Relating to Level of Care Designations for Hospitals That Provide Neonatal and Maternal Levels of Care

Testimony Submitted on behalf of

  • Texas Medical Association
  • Texas Academy of Family Physicians
  • Texas Pediatric Society
  • American College of Obstetricians and Gynecologists – District XI (Texas) 
  • Texas Association of Obstetricians and Gynecologists

March 5, 2019

Good afternoon, Chair Kolkhorst and committee members. Thank you for the opportunity to testify. I am Eugene Toy, MD, a practicing obstetrician and gynecologist speaking today on Senate Bill 749 on behalf of the Texas Medical Association; Texas Association of Obstetricians and Gynecologists; American College of Obstetricians and Gynecologists, Texas Chapter; and the other specialty societies listed above. For full disclosure, I also am the former chair of the Neonatal Intensive Care Unit (NICU) Council and its successor, the Perinatal Advisory Council (PAC). I continue to serve on the PAC as a member.

We applaud Senator Kolkhorst’s commitment to improving birth outcomes for both mothers and babies. Well before her election to the Senate, as a House member, she championed legislation to establish the NICU Council and its successor, the Perinatal Advisory Council. During the 2017 special session, she authored Senate Bill 17 to strengthen the role and responsibilities of the state’s Task Force on Maternal Mortality and Morbidity. Thanks to her efforts, Texas is well on its way to having a more coordinated, evidence-based system of care for newborns and pregnant women.

Hospitals in Texas that provide care to newborns and/or pregnant women must obtain designation based on their clinical capabilities and resources. Designation for hospitals that provide care to newborns took effect last September. To date, the Texas Department of State Health Services (DSHS) has designated 234 hospitals to provide neonatal care, ranging from Level 1 – nurseries for generally healthy babies – to Level IV – facilities that provide critical care to the most premature newborns. Beginning on Sept. 1, 2020, hospitals providing maternal care also must be designated. 

Like all new quality improvement initiatives, hiccups have occurred. In a state as large and geographically diverse as Texas, it is quite challenging to design a system that will promote best practices and high quality of care while accommodating disparate hospital and community resources. Case in point: Our organizations are aware the current maternal level-of-care rules inadvertently excluded family physicians from providing on-call obstetrical care in rural facilities, something SB 749 attempts to fix. The rules certainly must be flexible enough to accommodate our rural areas, while also ensuring patient safety in the event of an emergency obstetrical surgical situation. Our organizations are working together on language we believe will address physicians’ concerns while protecting patient health. 

SB 749 also seeks to clarify that designated facilities can use telemedicine and telehealth for on-call physician consultations. Telemedicine and telehealth are important tools for physicians and hospitals – tools we definitely support. At the same time, we must be careful that telemedicine is not seen as a replacement for an actual physician when an urgent or emergency situation arises. Rural facilities, regardless of the size of the medical staff, still must ensure an actual physician is available to arrive on-site for urgent needs, such as if the mother requires an unexpected C-section or begins to hemorrhage.    

Of particular concern to our organizations is language within the bill allowing hospitals to seek waivers from one or more requirements relating to the neonatal or maternal designations. Already, the rules provide flexibility for hospitals to operate at a level best suited to their capabilities. When a hospital cannot satisfy a particular level of care requirement, the state works with the facility to determine a more appropriate designation level or to develop a plan for achieving a higher level. The rules also ensure that each hospital medical staff retains discretion for how to manage individual patients.  

Regarding the ability of rural hospitals with neonatal Level II designations to care for premature babies, the PAC very purposefully, painstakingly, and openly debated the ability of these hospitals to care for babies with low gestational age. The current rules reflect the consensus that the absolute safest care for premature babies – those born seven to nine weeks early or weighing roughly 2.5 to 3.5 pounds – born in a rural facility 75 miles or more from the nearest Level III or IV neonatal facility should receive the same care as if born at a higher-level facility. 

Waivers certainly have a place to accommodate extraordinary circumstances. But if hospitals can seek waivers to exempt themselves from one or more evidence-based designation requirements, then we believe waivers will threaten the credibility of the entire designation process and the years of effort to establish consistent, Texas-specific, evidence-based systems of care for mothers and babies. Why would a hospital allocate dollars and resources to achieve a certain level of care knowing a competitor could seek a waiver exempting it from the same requirements?  

If there are systemic issues with one or more elements of the standards, then we believe the best approach would be to refer them back to the Perinatal Advisory Council to ensure an open, deliberate process to consider potential revisions to the rules if necessary. This also helps to ensure stakeholders must openly debate revisions rather than using an opaque waiver process to make changes. Trauma hospitals after all have no similar waiver process to our knowledge. Yet, through the governor’s EMS and Trauma Council, stakeholders are able to openly deliberate concerns about the trauma rules and seek revisions as needed. 

We do support establishing an appeal mechanism, though we recommend it be based on the process used for trauma hospitals. 

The neonatal and maternal designation standards are new. It takes time – and patience – to find the right balance. As the state and stakeholders navigate the process, we urge lawmakers to stay focused on the original purpose of establishing neonatal and maternal levels of care in the first place – to provide a statewide system that promotes safe, high-quality, medically appropriate care to improve birth outcomes for mothers and babies.

As SB 749 moves through the legislative process, we look forward to working with you to improve Texas’ perinatal system.

Thank you for the opportunity to testify.

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Last Updated On

March 08, 2019