The testimony below was submitted to the Texas House Committee on Health Care Reform on August 4-5, 2022, by the Texas Conservative Coalition Research Institute (TCCRI).
Texas Conservative Coalition Research Institute
House Committee on Health Care Reform
August 4-5, 2022
Regarding the Committee Interim Charges 1 & 3
1): Study the implications of excessive health care costs on the efficacy of Texas Medicaid and the private health insurance market and the resulting impact on individual Texans, businesses, and state government.
• Examine the interaction of specific factors of health care affordability such as transparency, competition, and patient incentives. Make recommendations to expand access to health care price information to allow consumers to make informed decisions regarding their care;
• Examine the impact of government benefit, administrative, and contractual mandates imposed upon private insurance companies and their impact on employer and consumer premiums and out-of-pocket costs, including the effects of specific benefit and any-willing provider requirements. Make recommendations for state and agency-level mandates and regulations that could be relaxed or repealed to increase the availability and affordability of private health coverage options in the state;
• Review access to and affordability of prescription drugs.
3) Evaluate innovative, fiscally positive options to ensure that Texans have access to affordable, quality and comprehensive health care, with an emphasis on reaching low-income and at-risk populations. The evaluation should include a study of strategies other states and organizations have implemented or proposed to address health care access and affordability. Make recommendations to increase primary health care access points in Texas.
Over the past several years, the Texas Conservative Coalition Research Institute (TCCRI) has convened a series of task forces during the legislative interims to study a number of health care issues covered by the charges being heard by the Select Committee over the following days, ranging from Medicaid to private sector issues. While TCCRI has offered numerous recommendations over the past two biennia, today’s remarks and policy recommendations will focus on the impact of government regulations and mandates, including any-willing-provider requirements; the need for greater transparency and empowered consumers; and initiatives to increase access to care. Each of these policy areas corresponds to, and supports, the tenants of TCCRI’s TX Healthcare Project: Affordability, Accountability, Accessibility. These are the crux of any successful health care system and, though they are inexorably linked, must be independently addressed.
Affordable Coverage Through Less Government Intrusion
Unfunded government mandates within the health coverage marketplace may take several forms ranging from mandated contractural terms between two private entities to government price controls. However, two common forms of this practice include mandated benefits and any willing provider (AWP) laws. While benefit mandates are often designed to impact a relatively small number of the covered population, every insured person contributes to the cost of each one through increased premiums. Although some mandates may appear harmless, and well-intentioned in many cases, each and every one contributes to an increase in overall premiums.
Benefit Mandates
A significant amount of the consternation around the Affordable Care Act (ACA) was due to its sweeping benefit mandates, designated by the law as essential health benefits (EHBs), and for playing a role in putting the commercial market into a state of crisis after the bill’s passage. Most policy experts, regardless of their stance on mandated benefits, agree that they drive up the cost of coverage, capable of causing an increase in monthly premiums between one and five percent per benefit.[i] The ACA requires that plans cover ten categories of “essential benefits” include maternity care, mental health and substance abuse disorder care, and oral and vision care coverage for children.[ii]
Often times, benefit mandates are difficult to reject because they seem to be limited to conditions that only impact a small number of the population, and/or because they concern products and services for sympathetic populations, such as cochlear implants for child deafness, or treatment for certain conditions related to craniofacial abnormalities (a mandate bill for each of those two issues has been filed in past sessions, with the former having passed into law). However, authorities on health policy warn against falling into this trap because mandates have a cumulative effect. One policy expert explains:
In general, it’s politically palatable for lawmakers on both sides of the political aisle to pass benefit mandate after benefit mandate. This legislation shields them from being called out for explicit tax increases, and the per member per month (PMPM) cost of each imposed on policyholders is miniscule...
The insignificant cost of each standalone bill also makes mandate legislation politically feasible for special interests and other medical providers to get their way, which explains why there are now 2,200 mandates nationwide – up from almost zero in the 1970s. But the issue becomes problematic when multiple bills are introduced simultaneously.[iii]
Benefit mandates have grown exponentially over the years and, as one economics professor explains, each mandate comes with its own trade off that should be carefully considered by lawmakers, who must decide whether the cost is justified or whether it will be ultimately detrimental to employers that drive the U.S. economy.[iv]
Any Willing Provider (AWP) Mandates
Under managed care, a health plan contracts with certain providers that make up the plan’s network. The majority of Americans with private health insurance are enrolled in some form of managed care.[v] In addition to this coverage in the commercial market, the State of Texas utilizes managed care in its employee and teacher group coverage plans, as well as in Medicaid and the Children’s Health Insurance Program (CHIP).
By only contracting with certain providers, health plans have the opportunity to negotiate lower prices and, most importantly, adopt standards that may restrict lower-quality providers from joining their networks. This applies to medical and pharmacy benefits, and allows free market principles to positively influence the health care marketplace.
Researchers at the Washington Legal Foundation explain how health plans, and ultimately health care consumers, achieve greater cost savings and better services through exclusive pharmacy networks (emphasis added):
Many networks are highly exclusive. The greater a network’s exclusivity, the more customers a member pharmacy can expect. The prospect of a large number of customers creates intense competition for exclusive networks; this competition leads pharmacies bidding for network membership to offer higher discounts in order to join the network. It is well understood that cost savings resulting from this exclusivity are generally passed on to consumers in the form of lower premiums, lower out-of-pocket costs, and better services.[vi]
Since the 1980s, there have been attempts through various AWP laws to require that health plans include certain provider groups and/or hospitals in their networks.[vii] Proponents of such laws argue that they “level the playing field,” particularly for independent practitioners, and provide greater choice to consumers.[viii] While the AWP concept may on the surface appear good for patients, experience has proven that these mandates actually have the opposite effect. AWP laws adversely impact consumers by driving up the costs of care (thereby further reducing access to low-cost, high-quality insurance coverage) and restricting competition.[ix] One analyst described it thusly: “The preponderance of evidence and economic logic would counsel emphatic rejection of new or even existing AWP … laws.” To expound on that notion:
The laws themselves suppress competition at the provider level in the name of enhancing competition at the point of service level. And by design they also suppress price competition at the point of service level, since all agree to the insurers’ terms of what to charge consumers. They want consumers to have access to all providers but for price variation to the consumer to be off the table. But if all providers offer the same price to consumers and if all providers are in every plan, then no plan is different from another, either. So in practical effect, strong AWP laws … also suppress competition at the plan level.[x]
The Federal Trade Commission (FTC) also has a strong history of opposing attempts to pass or enforce AWP laws deeming them anti-competitive and, ultimately, anti-consumer. Researchers quote the FTC, when discussing a state-sponsored AWP law, as saying, “AWP laws, ‘preempt competition among providers, instead of protecting the interest of patients. In other words, such laws appear to protect competitors, not competition or consumers.’”[xi]
In a separate letter to federal Centers for Medicare and Medicaid Services (CMS), the FTC explains that AWP laws “can also limit competition by restricting the ability of insurance companies to offer consumers different plans, with varying levels of coverage, cost, and choice. These restrictions on competition may result in insurance companies paying higher fees to providers, which generally lead to higher premiums, and may increase the number of people without coverage.”[xii]
By eliminating competition among providers and prohibiting health plans from employing innovative and quality-based contracting standards, AWP mandates can have the perverse effect of lower-quality, higher-priced care and even reducing the availability of health insurance for Texans.
Policy Recommendation: Reject Unfunded Mandates
TCCRI has long supported rejection of unfunded government health care mandates in any form, be they benefit, price or rate controls, contractural, or administrative. The 88th Legislature should unwind any mandates that are not currently required by federal law and continue to reject all newly proposed mandates. Texas has a long history of preventing government mandates from impacting the free market’s ability to provide innovative, high-quality, cost-effective solutions across all industries. Allowing government mandates to dictate the daily operations of private sector businesses will only lead to negative outcomes for Texas healthcare consumers. In addition to the anti-competitive environment and rising healthcare costs that mandates usher in, they also set a dangerous precedent of allowing the government to dictate to private businesses with whom who they must contract and, in some cases, the terms of a contract between two private entities. Benefits that are very limited and only apply to a small percentage of enrollees must still be rejected, as allowing even a small mandate begins the path down a slippery slope that makes it very difficult to draw a line on which mandates are, and are not, acceptable. For this reason, mandates should be rejected in all forms.
Policy Recommendation: Reject Government Price Controls
Although addressing prescription drug costs is an admirable goal, government price controls are never the answer. The United States produces the most scientifically advanced, innovative medications in the world, due in large part to free market principles that provide companies the incentive to compete and create life-saving drugs. Implementing government price controls represents a reversal from the current market-based competition-driven approach in favor of practices that are predominately found in single-payer healthcare systems. These policies completely ignore the resources involved in scientific advancements and bureaucratic requirements (e.g., the cost of research and development and the decades it can take for a drug to reach the market).[xiii] While price control policies may result in short-term savings, the long term costs to such short-sighted policies are reductions in research, innovation, and ultimately, in availability of treatments.
Policy Recommendation: Require a Fiscal Impact Statement on Legislation Containing Health Coverage Mandates
In the 87th Legislative Session, HB 2600 (Paul, et. al.) would have required the Legislative Budget Board (LBB) to prepare a fiscal impact statement for any bill or join resolution containing a health plan mandate, including new benefit, rate, contractural, or administrative requirements. Such information is critical, as the current fiscal note process captures only costs to the state budget. Therefore, unless a requirement applies to a state-funded plan, no costs are reported, regardless of the impact on Texas families and employers. Although the bill was jointly authored by members of both parties, passed unanimously from House State Affairs, and was placed on the General State Calendar, it was never ultimately heard on the House floor.
The 88th Legislature should pass the language in HB 2600 (87R) to ensure policymakers have access to this vital information.
Policy Recommendation: Pass a Mandate-Free Catastrophic Coverage Option
In the 85th Session, HB 4213 (Phillips) was filed and would have authorized health plans to offer catastrophic health benefit plans, free of any state-mandated health benefits. If passed, this legislation would have augmented SB 541(83R) (Williams/ Sp: Taylor), which allows employers and health maintenance organizations (HMOs) to offer plan options free of certain state mandates. Current law, as a result of SB 541, allows employers and plans to waive many state-specific mandates, but does still prescribe some benefits that must be covered, such as certain pre-existing conditions and serious behavioral health conditions.[xiv] It is also important to remember that when SB 541 was passed in 2003, it was done so in a pre-ACA world and largely geared towards group health plan offerings. HB 4213, as filed, would have amended the same section of the Insurance Code as SB 541 to include an additional option for a completely mandate-free catastrophic plan for group plans and individual consumers.
Though HB 4213 did not proceed past the House committee stage, the 88th Legislature should make this legislation a goal for the upcoming session. Although some catastrophic coverage options are available to purchase in the private market, removing the requirement for any mandates could encourage other carriers to provide additional competitive offerings.
Catastrophic plans are often attractive coverage options for young, healthy individuals. According to a report by United States Census Bureau, individuals age 26 have the highest uninsured rate of any age group, followed by peers in the later 20s.[xv] This stands to reason, as individuals in this age group are no longer eligible for coverage as dependents of covered parents (this ends at age 26 under the ACA), and many are likely facing the choice of whether or not to purchase insurance coverage for the first time. As one noted healthcare policy expert explains, “Healthy people tend to buy insurance based on price. Sick people, however, look at likely out-of-pocket costs for their illnesses and want broader networks.”[xvi] So, while a catastrophic plan is not for everyone, it could provide a great value for someone who does not see the need to pay a large monthly premium for regular primary care and prescription drug coverage, but does recognize the value of a lower cost plan that would cover health emergencies.
Policy Recommendation: Continue to Explore and Offer Non-Traditional Coverage Options
During the 87th Session, lawmakers passed HB 3752 (Frank, et. al.) and HB 3924 (Oliverson, et. al.) allowing the Texas Mutual Insurance Company, which has historically handled workers’ compensation coverage, and the Texas Farm Bureau to begin offering health coverage options to eligible members. Both bills enjoyed broad bipartisan support from members across the state, demonstrating that the need to offer an array of choices to meet various consumer needs supersedes geographical boundaries and party lines. This innovation should be applauded, and the 88th Legislature should continue exploring options for non-traditional coverage, including through the increased use of association health plans (AHPs) and multiple employer welfare arrangements (MEWAs). The key to the expanded use of such coverage options is to refrain from over-regulation, which will increase their costs and diminish their flexibility and value to the marketplace.
Accountable Consumer Choices Through Greater Transparency
In today’s era of Amazon, Costco, and Google, consumers are conditioned to competitively shop for goods and services. The concept is simple. Consumers want lower prices, so they shop for the best value and, metaphorically speaking, vote with their feet by taking their business to the retailer with the best pricing. Merchants, in turn, respond to this demand by lowering costs to vie for a greater share of the market. This is the free market at its finest: consumer demand fosters healthy market competition that ultimately drives down costs for everyone. However, although American consumers have embraced this concept with vigor in almost every aspect of their daily lives, this practice has not translated to the way in which we locate and access our health care services.
The key difference between the healthcare marketplace and virtually all other areas of the consumer market is the ability to easily compare prices. Although multiple studies and polls have shown that consumers would like to shop for the best value in health care,[xvii],[xviii],[xix] the current system is not intrinsically built to encourage, or in many cases even facilitate, price comparison.
Price comparison shopping also has benefits beyond finding the lowest costs. Industry experts have found that once consumers start to engage in researching their healthcare options to find the best prices, they start to look at other comparisons too, such as quality metrics.[xx] Once patients begin to explore health care prices, they are more likely to also become engaged in exploring the quality and safety of their care as well.[xxi]
Texas has taken important steps in this regard, passing some of its first price transparency legislation almost 15 years ago and, more recently, addressing surprise medical billing, requiring hospitals to report certain pricing information, and establishing an all-payor claims database to better compare costs across various patient and payer mixes. While the work done to date is vital, the next step in the process to drive true change is to equip and incentivize consumers to alter their practices and begin choosing high value care.
Prices vary widely in health care due to a variety of factors. The same x-ray on the same kind of machine can fluctuate in price from a few hundred to thousands of dollars if the x-rays are performed in different locations.[xxii] However, most consumers often do not think to shop around for the best price for something like a diagnostic imaging test and, even if they wanted to, it can be difficult to find the actual price of the test or procedure. Most information that can be obtained by consumers will quote the insured’s out-of-pocket expenses. And, while this is a critical piece of the equation, this information does not capture the total cost to the healthcare system. For instance, a patient may pay only a slighter higher co-pay or deductible for choosing to have an orthoscopic knee procedure in a hospital rather than an ambulatory surgical center (ASC), but the cost to the health care system could be thousands of dollars more. While this may not significantly impact the patient in the short-term, these cumulative costs contribute to higher out-of-pocket expenses in the future in the form of premium and cost sharing increases.
Right to Shop Model
One model, known as Right to Shop, has enjoyed some early successes in the private market and has been authorized in both the ERS and TRS systems within Texas. The Right to Shop concept is simple: A provider prescribes a medical service, such as an MRI. The patient then calls a toll-free line or goes to a website operated by the insurer or employer to research options and prices, and then chooses the best location at the best value. After receiving the MRI at the location of his or her choice, the patient then receives a cash benefit based upon the shared savings for choosing the best value care. The crux of this program’s success lies in the ability of consumers to access quick, accurate, and transparent cost comparisons.
Private companies that have implemented these programs have seen positive changes. One study looked at early data from 29 employers that began implementing shared savings programs in 2017 finding that, even with minimal participation in the first year as the program rolled out, the employers saved more than $2 million and saw overall reduction of about 2 percent for covered services.[xxiii] While these are modest gains, the crucial takeaway is that consumers will comparison shop when they are empowered to do so, and this competition bends the cost curve.
It should be noted that, in the private market, a right-to-shop policy could be considered profit sharing. Lawmakers should ensure that no existing laws or regulations impede employers’ or insurers’ ability to implement this type of program if they so choose, but should not mandate such arrangements in the private sector. These types of incentive plans can, and should, grow organically in the free market. This idea should however be explored within state government, where services are funded by taxpayer dollars.
New Hampshire became the first state to operate an incentive-based program for its state employees in June 2010.[xxiv]After just over three years of operation, the state found that almost 90 percent of its enrollees had “shopped” at least once, with two out of three shopping every year and receiving an incentive payment.[xxv] Savings during that timeframe averaged around $670 each time a service or procedure was shopped,[xxvi] with the state saving more than over $12 million, while providing over $1 million in incentives to consumers.[xxvii] The State of Kentucky implemented a Right to Shop model in 2015 to help reign in growing healthcare costs for state employees.[xxviii] Within about three years that program had resulted in more than $13 million in savings for the state’s taxpayers with employees cumulatively earning about $2 million in incentives for choosing best value care.[xxix] According to the National Conference of State Legislatures (NCSL), several other states have since passed legislation fostering Right to Shop models, either by implementing it as part of the state’s health benefit coverage, or by establishing frameworks or incentives for private insurers to build such programs.[xxx]
Texas took its first steps towards Right to Shop for public employees covered by the Employees Retirement System (ERS) and the Teacher Retirement System of Texas (TRS) during the 86th Legislature. Since then, budget riders in the General Appropriations Act have directed ERS and TRS to incentivize participants to shop for lower cost care within their respective health plans to achieve shared savings.
Policy Recommendation: Continue Right to Shop in ERS and TRS, Identifying and Addressing any Impediments to the Initiative
The budget riders adopted the past two sessions were key steps in promoting transparency and competition within state-funded healthcare coverage and should be continued. However, lawmakers should consider adding language to the current riders directing ERS and TRS to identify any barriers to widespread and successful implementation of the program, address any impediments that are within the agencies’ purviews and notify the Legislature of any that require statutory changes. This initiative has real potential not only to educate and empower state employees to take ownership of their healthcare decisions, but also to save finite taxpayer resources.
Legislators could also consider variations on the incentive offered through Right to Shop if they are a better fit for the Texas ERS and TRS models. For instance, if cash rebates are legally or administratively cumbersome for the agencies to administer, the state might look at rebates in the form of premium or out-of-pocket discounts for enrollees who choose best value care. The following policy, below, would ease the ability of the state and private insurance companies to offer these types of incentive models.
Policy Recommendation: Revise Regulations that Stifle Innovation
While state leaders should not mandate that private businesses implement any type of profit-sharing, lawmakers should ensure that no existing laws or regulations prevent private businesses from employing innovative initiatives aimed at engaging consumers in better healthcare decisions.
One particular section of the Texas Insurance Code warrants further exploration and a possible revision to make certain that employers and insurers can implement Right to Shop-like programs if they so choose. The Texas Insurance Code § 541.056 is an anti-inducement statute and serves a valid purpose in preventing potentially unscrupulous practices in selling insurance policies. However, a portion of the existing code could be construed to prevent companies from utilizing incentive or shared-savings models. Subsection (a) reads, in part (emphasis added):
....it is an unfair method of competition or an unfair or deceptive act or practice in the business of insurance to... directly or indirectly pay, give, or allow or offer to pay, give, or allow as inducement to enter into a life insurance contract, life annuity contract, or accident and health insurance contract a rebate of premiums payable on the contract, a special favor or advantage in the dividends or other benefits of the contract, or a valuable consideration or inducement not specified in the contract...
Statute does provide for limited exceptions to these prohibitions, such as health-related services and premium adjustments for group insurance policies,[xxxi] but does not appear to clearly allow for a shared-savings arrangement. In addition, the 80th Legislature passed HB 1847 (Hancock/ Sp: Averitt) to allow health plans to offer certain “noninsurance benefits” to enrollees. State statute defines this type of benefit as being “reasonably related to the type of policy or certificate issued” and provides the following examples:
(1) discount cards for health care programs, vision care programs, dental care programs, prescriptions, physical fitness programs or facilities, or other similar programs;
(2) financial planning, will preparation, or similar services; and
(3) contributions for educational savings on behalf of a policyholder or certificate holder.[xxxii]
While TDI did adopt administrative rules that allow the agency to examine and determine “reasonable relation” outside of the specific examples provided by law,[xxxiii] there is no mention or exception for a Right to Shop- type program. Because shared-savings models were not prevalent when this statue and associated rules were adopted, it makes sense that current law might not allow for such innovation. Since these models are becoming more commonplace, the Legislature should consider amending current statute, and directing TDI to amend rules, to clarify that shared-savings programs (be they actual shared savings, or out-of-pocket cost reductions), as set forth in a model similar to the Right to Shop concept, do not violate anti-inducement or anti-rebate laws.
Policy Recommendation: Ensure Price Transparency Requirements are Uniformly Applied
Hospital and prescription drug pricing are often, and understandably, the center of discussions on the need for pricing transparency in the healthcare marketplace. Ambiguity in hospital charges versus actual costs, lack of clarity regarding which providers within a hospital’s emergency department are “in-network,” and questions around how much research and development costs are built into drug pricing have led many transparency initiatives to focus on these areas. However, transparency, and the competition it fosters, only work if it is uniformly applied to all facets of the healthcare system.
Too often in today’s world of ever-increasing healthcare costs, various providers and entities are quick to point fingers and blame one another for skyrocketing costs. And, while there are some clear outliers that should be addressed, a lot of the confusion and helplessness consumers feel over trying to shop for the best value care could be addressed by ensuring that all areas of the healthcare marketplace are subject to the same price transparency standards. Hospitals and drug manufacturers are crucial to this equation, but so too are physicians, anesthesiologists, radiologists, pharmacists, and all providers on the care delivery spectrum.
Accessible Care Through Licensure Reform
Texas has a longstanding and well-established healthcare provider shortage. In 2015, Merritt Hawkins released an extensive report examining the adequacy of the state’s physician workforce. The results were not encouraging, ranking Texas among the lowest ten states for the number of actively practicing physicians per 100,000 residents, with 2.2 million Texans residing in small counties that were served by only 2.5 percent of the state’s entire physician workforce.[xxxiv] While this study is worth noting because it is Texas-focused, it is admittedly growing dated. Unfortunately, more recent studies show this trend continues to head in the wrong direction.
Later studies have again ranked Texas near the bottom of the nation in having an adequate number of physicians to meet demand, a problem that is compounded by the fact that a growing percentage of Texas doctors are nearing retirement age.[xxxv] While the state has invested in new medical schools and residency slots, one academic, who is also a medical doctor, posited that even if every Texas medical school graduate stayed within the state to practice medicine, it still would not meet the state’s demand.[xxxvi] A Texas Department of State Health Services (DSHS) report found that by 2030 the additional need for primary care physicians across the state will have grown by 67 percent.[xxxvii] And it bears mention that this research was conducted prior to the worldwide outbreak of the coronavirus, which only served to add additional stress to an already over-burdened healthcare system. Today, only five of Texas’ 254 counties do not have a primary care provider shortage, with the term “provider” including non-physician professionals.[xxxviii]
Although primary care and physician shortages offer some of the starkest statistics, similar data exists regarding lack of access to dental care in many parts of the state (especially rural),[xxxix] as well as reports of problems accessing timely emergency eye care.[xl] The bottom line is that Texas has access-to-care issues for multiple provider types- these challenges are not strictly limited to primary care physicians and specialists.
Over the past several sessions, the Texas Legislature has passed a number of laws to increase the availability of certain healthcare providers, including establishing new medical schools and residency slots; increasing access to telehealth and telemedicine platforms; and allowing greater licensing reciprocity with states participating in interstate licensure compacts. While these policies represent great strides in helping our growing state address quickly expanding demand, more can be done in the 88th Legislative Session.
There are trained non-physician healthcare professionals ready to step in and help fill some of the existing need, but they are prohibited from doing so by restrictive licensure laws. Lawmakers should look to pass bills in the upcoming session that permit such providers to “practice at the top of their licenses,” allowing them to fully exercise the education, training, and scope conferred by their current licensure.
Policy Recommendation: Allow the Independent Practice of Advanced Practice Registered Nurses (APRNS)
Texas is one of only about a dozen states that fully restricts the practice of APRNs.[xli] While many states allow these highly trained providers to establish independent practices, Texas only allows them to practice under the delegation authority of a licensed physician. This not only prevents APRNs from establishing practices in underserved areas of the state, but also results in these providers leaving Texas to move to neighboring states that do allow them to practice at their top of their licenses.
The time has come to place Texas on par with most of our neighboring states and grant APRNs independent practice authority, as set forth in last session’s HB 2909 (Klick) and SB 915 (Hancock). These bills would have made various changes to laws governing APRNs, most significantly allowing them to practice as independent practitioners. The legislation would not have altered the scope of practice of these providers, meaning that an APRN would still have had to operate under current requirements regarding education, training, and certification standards, and to continue to adhere to the Texas Nursing Practice Act and Board of Nursing (BON) rules.[xlii] However, the legislation would have removed the requirement that APRNs practice under a delegation agreement with a licensed physician and would have centralized the regulation of APRNs at the BON (APRNs are currently regulated by both the BON and Texas Medical Board).
Although some opponents might argue that allowing this independent practice could place patient safety at risk because there is no physician oversight, this policy change would have little effect on the actual manner in which APRNs care for their patients. Rather, this legislation would remove a cumbersome and costly hurdle to practice and is a critical step towards increasing access to care in areas of the state where that care might not be otherwise available.
Policy Recommendation: Allow Dental Hygienists to Administer Local Anesthesia
Texas is also one of only five states that does not permit dental hygienists to administer local anesthesia, with many other states having allowed this practice for decades.[xliii] Allowing dental hygienists who have been properly trained to administer local anesthesia (the numbing of teeth and gums) without having to wait for the dentist to come by and administer the medication, only to then allow the hygienist to proceed with his or her job, would increase the efficiency of the dental office and offer greater convenience for the patient. This could also increase access to routine oral care in some areas. Dental hygienists in Texas are able to practice independently to a limited degree in certain settings, with the goal of increasing access to oral health care. These settings include school-based health centers, nursing facilities, and community health centers. [xliv] The authority to administer local numbing could allow hygienists practicing in these settings to perform routine oral care that they might not otherwise be able to provide because it would be too uncomfortable for the patient without anesthesia.
Policy Recommendation: Explore Enhanced Use of Pharmacists in Care Delivery
While pharmacists have traditionally been associated strictly with filling prescriptions, over the years that role has evolved to include greater patient interaction and a larger responsibility as part of the patient care team. Data from the National Pharmacist Workforce Survey found that approximately 90 percent of community pharmacists now administer vaccines (up from 15 percent in 2004); more than 80 percent assist in drug level monitoring and therapeutic drug interchange; 73 percent order laboratory tests; almost 70 percent provide medication therapy management services; and a majority play a key part in dispensing and counseling on drugs to reverse the effects of opioid overdose.[xlv],[xlvi]
The delivery of immunizations is a key example of how pharmacists have increased access to a healthcare service and benefitted not only the individuals receiving the immunization, but also general population. However, pharmacists are uniquely placed to be better utilized to provide even more in-depth services.
Given the fact that medication misuse, be it over- or under-utilization, is responsible for about $300 billion in costs in the U.S. each year,[xlvii] and that in any given month patients may have more regular interaction with a pharmacist than other provider types, it only makes sense that pharmacist’s role would grow into one that encompasses preventive care and disease management. By actively helping to ensure that patients are using medications appropriately, pharmacists can play a vital role in reducing hospital admissions and re-admissions for conditions that can be managed by proper medication usage.[xlviii]
One example where pharmacists have been able to increase patient adherence and outcomes is in administering long-acting injectable mental health drugs, with research finding that, “[p]atients who receive their long-acting antipsychotic medications at an alternative injection center, typically a pharmacy, and remained in the program for more than 6 months were 4.5-fold more likely to be adherent to their medication than those within the program who did not select the medication administration offering.[xlix],[l]
Lawmakers in the upcoming session should explore opportunities to maximize the role of pharmacists in the delivery of care where appropriate for patients who may not otherwise see a provider on a regular basis.
Policy Recommendation: Permit Physicians and Nurses to Maintain a License to Practice Upon Leaving Active Military Service
HB 548 (Frank) from the 87th Regular Session would have allowed physicians and nurses to maintain a license to continue practicing medicine in Texas upon leaving active military service, on the condition that the license is still valid and in good standing. These providers are currently able to practice in Texas while on active-duty status, but that authority is revoked upon leaving active-duty service. Adopting such legislation in the 88th Session would admittedly impact a relatively small number of providers but could increase access in the areas where they reside, and could entice these veterans to remain in Texas if they are able to continue to practice their profession upon leaving military service.
About TCCRI
The Texas Conservative Coalition Research Institute (TCCRI) was founded in 1996 by a group of state leaders determined to implement conservative public policies in state government. TCCRI has distinguished itself as a leading state-based think tank and has been very successful in living up to its mission of shaping public policy through a principled approach to government. Its research reports, Task Forces, and policy summits have been instrumental in generating proposals that are shaping Texas government and influencing a new generation of conservative leadership.
The work of TCCRI is based upon four core principles: Limited Government, Individual Liberty, Free Enterprise and Traditional Values. Together, they form our LIFT principles and underpin all TCCRI Task Forces, conferences, and publications. Each principle guides our Board and Staff.
ENDNOTES
[i] Bihari Michael, M.D. “Mandated Health Insurance Benefits Explained: Health benefit mandates are controversial.” Verywellhealth. Updated September 2, 2021. Available at: https://www.verywellhealth.com/mandated-health-insurance-benefits-1738931. [ii] See Healthcare.gov. “What Marketplace health insurance plans must cover.” Available at: https://www.healthcare.gov/coverage/what-marketplace-plans-cover/. [iii] Restrepo Katherine. “Want Affordable Health Insurance? Scale Back on Benefit Mandates.” Forbes. April 5, 2017, available at: https://www.forbes.com/sites/katherinerestrepo/2017/04/05/want-affordable-health-insurance-scale-back-on-health-benefit-mandates/?sh=266e9be05573. [iv] Bailey James, Webber Douglas. “Hidden Costs of Health Benefit Mandates.” Real Clear Policy. June 16, 2015. Available at: https://www.realclearpolicy.com/blog/2015/06/17/hidden_costs_of_health_benefit_mandates_1334.html. [v] United States Census Bureau. “Percentage of People by Type of Health Insurance Coverage: 2020.” September 2021. Available at: https://www.census.gov/content/dam/Census/library/publications/2021/demo/p60-274.pdf. [vi] Klick, Jonathan and Wright, Joshua D., “The Anti-Competitive Effects of ‘Any Willing Provider’ Laws,” Washington Legal Foundation: Legal Backgrounder Vol. 27 No. 4, March 2012. Available at: https://s3.us-east-2.amazonaws.com/washlegal-uploads/upload/legalstudies/legalbackgrounder/3-23-12KlickWright_LegalBackgrounder.pdf. [vii] America’s Health Insurance Plans, “Analysis: How Any Willing Provider Makes Health Care More Expensive,” September 23, 2014, p.1. [viii] Klick Jonathan, Wright Joshua D. “The Anti-Competitive Effects of ‘Any Willing Provider’ Laws,” Washington Legal Foundation: Legal Backgrounder Vol. 27 No. 4, March 2012. Available at: https://s3.us-east-2.amazonaws.com/washlegal-uploads/upload/legalstudies/legalbackgrounder/3-23-12KlickWright_LegalBackgrounder.pdf [ix] Ibid. [x] Nichols, Len M., George Mason University, College for Health and Human Services, Center for Health Policy Research and Ethics, “Deju Vu? The Debate Over Any Willing Provider Laws May Return, Sad to Say,” Issue Brief #2, September 2014, p. 5. [xi] Klick, Jonathan and Wright, Joshua D., “The Anti-Competitive Effects of ‘Any Willing Provider’ Laws,” Washington Legal Foundation: Legal Backgrounder Vol. 27 No. 4, March 2012, p.3. Available at: https://s3.us-east-2.amazonaws.com/washlegal-uploads/upload/legalstudies/legalbackgrounder/3-23-12KlickWright_LegalBackgrounder.pdf. [xii] Federal Trade Commission, “Comments on Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs,” Letter to CMS, March 7, 2014. Available at: https://www.ftc.gov/system/files/documents/advocacy_documents/federal-trade-commission-staff-comment-centers-medicare-medicaid-services-regarding-proposed-rule/140310cmscomment.pdf. [xiii] https://www.actuary.org/content/prescription-drug-spending-us-health-care-system [xiv] Tex. Insurance Code Chapter 1507. [xv] Conway Douglas. “Adults Ag 26 Had Highest Uninsured Rate Among All Ages, Followed by 27-Year-Olds.” United States Census Bureau. October 26, 2020. [xvi] Goodman, John C. “High-Deductible Health Insurance: The Good, The Bad, and The Ugly.” Forbes. March 11, 2018, available at: https://www.forbes.com/sites/johngoodman/2018/05/11/high-deductible-health-insurance-the-good-the-bad-and-the-ugly/?sh=529f8dfc7b18. [xvii] Foundation for Government Accountability. “New Poll Find Voters Want the Right to Shop for Health Care.” January 29, 2018. Available at https://thefga.org/poll/right-to-shop-poll/. [xviii] The Foundation for Government Accountability. “Voters Support Healthcare Price Transparency.” September 2020. Available at: https://thefga.org/poll/voters-support-health-care-price-transparency/. [xix] YouGov Poll for LUGPA. “New Survey Finds 91% of Americans Want Healthcare Price Transparency.” April 1, 2020. Available at: https://www.lugpa.org/americans-wanthealthcare-price-transparency. [xx] Hotstetter, Martha and Klein, Sarah. “Health Care Price Transparency: Can it Promote High-Value Care?” Commonwealth Fund. Available at: https://www.commonwealthfund.org/publications/newsletter-article/health-care-price-transparency-can-it-promote-high-value-care. [xxi] Ibid. [xxii] See Save on Medical. “Five Imaging Procedures with the Largest Cost Variance.” April 7, 2017. Available at: https://www.health-peek.com/five-imaging-procedures-largest-cost-variance/. [xxiii] Livingston, Shelby. “Employers save money by paying workers to shop for healthcare.” Modern Healthcare. March 4, 2019. Available at: https://www.modernhealthcare.com/payment/employers-save-money-paying-workers-shop-healthcare. [xxiv] Willingham Sara. “Compass SmartShopper Program.” Memo to employees. New Hampshire Department of Administrative Services. June 28, 2010. Available at: https://das.nh.gov/hr/documents/compass%20memo.pdf. [xxv] Archambault Joshua. “Right to Shop: The Next Big Thing in Health Care.” Forbes. August 5, 2016, Available at: https://www.forbes.com/sites/theapothecary/2016/08/05/right-to-shop-the-next-big-thing-in-health-care/?sh=1920765f4f60#399d35188fbc. [xxvi] Ibid. [xxvii] Ibid. [xxviii] Rhoads Jared. “Right to Shop for Public Employees: How health care incentives are saving money in Kentucky.” Foundation for Government Accountability. March 8, 2019. Available at: https://thefga.org/wp-content/uploads/2019/03/RTS-Kentucky-HealthCareIncentivesSavingMoney-DRAFT8.pdf. [xxix] Ibid. [xxx] National Conference of State Legislatures. “Transparency of Health Costs: State Actions.” Available at: https://www.ncsl.org/research/health/transparency-and-disclosure-health-costs.aspx. [xxxi] Tex. Insurance Code § 541.058. [xxxii] Tex. Insurance Code § 1701.061(a)(b). [xxxiii] 28 Tex. Admin. Code § 21.4804. [xxxiv] https://dfwhcfoundation.org/wp-content/uploads/2015/04/mhaNTREC2015studyfinal.pdf [xxxv] https://www.houstonpublicmedia.org/articles/news/texas/2018/04/12/278991/doctor-shortage-in-texas-could-impact-patient-care-for-seniors/ [xxxvi] https://www.statesman.com/story/news/2018/08/15/commentary-the-fix-to-texass-doctor-shortage-lies-abroad/9967697007/ [xxxvii] https://dshs.texas.gov/legislative/2018-Reports/SB-18-Physicians-Workforce-Report-Final.pdf [xxxviii] https://www.ruralhealthinfo.org/charts/5?state=TX [xxxix] https://www.ruralhealthinfo.org/charts/9?state=TX [xl] https://www.texastribune.org/2019/02/04/texas-optometrists-prepare-legislative-fight-over-power-treat-patients/ [xli] https://www.aanp.org/advocacy/state/state-practice-environment [xlii] See Board of Nursing, “Frequently Asked Questions- Advanced Practice Registered Nurse.” Available at: https://www.bon.texas.gov/faq_practice_aprn.asp#t5. [xliii] https://www.adha.org/sites/default/files/7521_Local_Anesthesia_by_State_0.pdf [xliv] Tex. Occupations Code § 262.1515 [xlv] American Association of College of Pharmacies. “National Pharmacist Workforce Study 2019.” January 2020. Available at: https://www.aacp.org/sites/default/files/2020-03/2019_NPWS_Final_Report.pdf. [xlvi] CVS. “The Role of Pharmacists in a Changing Healthcare Environment.” January 26, 2017. Available at: https://cvshealth.com/thought-leadership/the-role-of--pharmacists-in-a-changing-health-care-environment. [xlvii] Ibid. [xlviii] Ibid. [xlix] Pharmacy Today. “Beyond Vaccines: Pharmacists improve patient access to injectable medications,” February 2018. Available at: https://www.pharmacytoday.org/article/S1042-0991(18)30146-4/pdf. [l] U.S. Pharmacist. “Should You Add Medication-Administration Services?” June 12, 2018. Available at: https://www.uspharmacist.com/article/should-you-add-medicationadministration-services.