Driscoll Children's Hospital's Legislative Priorities INTRODUCTION Driscoll Children’s Hospital (DCH) is a 200-bed non-profit tertiary care children’s hospital located in Corpus Christi, Texas. Founded in 1953 by Clara Driscoll, DCH offers state-of-the-art services and the latest technology for the treatment of newborns, infants, and children with life threatening illnesses and injuries. The hospital’s Medical Staff is comprised of pediatric board-certified specialists in 19 medical and 10 surgical specialties. Working with the Medical Staff are over 1,400 employees including more than 450 nurses. Our referral area covers 33 counties of South Texas, which equates to 31,000 square miles or an area larger than the entire state of South Carolina. Every year more than 6,500 children are admitted for inpatient care, 6,000 patients for surgery, and 65,000 children for outpatient primary and specialty care. DCH was the first hospital in South Texas to provide emergency services exclusively for children and today, we provide emergency care to more than 40,000 children each year. DCH’s ability to achieve our mission to serve all children of South Texas is greatly influenced by the legislation and regulations imposed by the State government. At the close of the 77th Legislative session, strides were made to improve the Medicaid system and to increase the number of children in Texas with health insurance. However, in 2003, the 78th Legislative session begins with a significant financial deficit and a new slate of legislators lacking institutional memory on key health care issues. Due to the expected budget shortfall of nearly $12 billion, health care programs will be at the heart of the debate and in a time where more money is needed to meet the needs of our population, less is expected. DCH must make its voice heard on key health care policy issues that impact the children of South Texas. We will work in collaboration with the Children’s Hospital Association of Texas, Texas Hospital Association, and Texas Medical Association to ensure that meaningful health care legislation is introduced. THE ISSUES Legislative Rider One of DCH’s top priorities for the 2003 legislative session is to renew the legislative rider that prohibits the UT Health Science Center in San Antonio from competing against DCH in South Texas in direct inpatient care and cardiology. Pediatric medicine is regional in nature due to the smaller patient populations and incidence rates. Allowing educational institutions to duplicate services offered by DCH in South Texas saturates the market and decreases the quality of care for children. As with any practice of medicine, volume and experience dictate quality. In other words, the more patients treated by a given physician the greater his/her expertise and scope of practice. Thus, duplication of services leaves South Texas without any established experts in pediatric subspecialty medicine. DCH requests legislative support to preserve the quality of pediatric care in South Texas through the renewal of the DCH legislative rider. Medical Liability The current medical litigation environment and the rising cost of professional liability insurance are directly correlated to access to care. Frivolous lawsuits, coupled with premium increases as high as 300% in South Texas are driving physicians away from the community or into early retirement. Even dismissed cases cost physicians an average of $10,000 to defend and 7 out of 10 malpractice suits are found to be without merit. Serious action must be taken in the legislature in order to ensure access to health care in South Texas, specifically for the pediatric population. For the past decade, the National Association of Insurance Commissioners has labeled Texas as the worst market for medical malpractice. Currently, only three 3 professional liability insurance carriers remain in the state of Texas and some of these refuse to cover physicians based upon the geographic region in which they practice. South Texas is considered a liability “hot spot” with 60% of Corpus Christi physicians and 58% of Victoria and McAllen physicians with liability claims. As a result, it becomes increasingly difficult for South Texas physicians to secure coverage – something they need to get hospital credentials and reimbursement from Managed Care companies. Even if a physician finds a company willing to provide liability coverage, the costs associated with the insurance plan are exorbitant. Children’s Physician Services of South Texas (CPSST), a 501 a under the Driscoll Children’s Health System that employees 17 physicians, is currently covered by Chicago Insurance Company; a company that has already announced its intent to leave the state of Texas. While CPSST successfully negotiated coverage for an additional year, their rates increased by as much as 400%. Physicians are not to the only ones impacted by this crisis. From the hospital’s standpoint, DCH paid $557,030 for medical malpractice excess insurance last year, with a $2 million deductible per event and $ 6 million yearly aggregate deductible. This year, our cost was $1,532,358 – nearly triple the previous year’s cost. We were forced to raise our per event deductible to $3 million and yearly aggregate to $9 million. In other words, DCH is paying $1 million more for much less insurance coverage. Within the last six months, DCH has lost a Pediatric Intensivist and a Pediatric Surgeon, both citing medical malpractice as a primary reason for relocating. Over the last year, 10 physician candidates declined our recruitment offer after realizing the high-risk medical malpractice environment in Corpus Christi. The following chart gives a breakdown of pediatric subspecialists lost due to the environment.
To further exacerbate the problem, numerous studies have been commissioned that provide evidence of the shortage of pediatric subspecialists in this nation with or without the medical liability crisis. Within DCH’s 33 county service area, a substantial shortage of pediatric subspecialists exists, specifically in pediatric radiology (18.90), pediatric anesthesiology (16.90), pediatric hematology/oncology (12.40), pediatric neurology (3.90), pediatric surgery (3.60), and pediatric endocrinology (2.60), and pediatric gastroenterology (2.00). [1] As a result of critical shortages, pediatric subspecialists are forced to work longer hours, seeing more patients and serving on call for days at a time, leading to an increased risk of medical mistakes. DCH supports the Texas Medical Association’s and Texas Alliance for Patient Access’ efforts to strengthen tort reform in the area of medical malpractice litigation. Tort reforms supported by DCH include:
DCH would also encourage the legislature to consider restrictions on legal advertisements. DCH supports insurance carriers allowing installment payments of premiums rather than full prepayment and strengthening the Board of Medical Examiners to further promote patient safety and prevent medical errors. Medicaid/CHIP Funding Texas maintains the third largest Medicaid program in the country. Of the total 2.2 million Medicaid recipients, 62% are children who account for 22% of the program’s cost. Stated differently, more than 1.3 million low-income children in Texas rely on Medicaid for health insurance. On average, it costs Texas just $1,448 per year for each Medicaid eligible child versus $5,662 for adult Medicaid enrollees. Medicaid is a critical safety net for millions of low income children. However, in Texas current projections indicate a $381 million budget shortfall in Medicaid for the current biennium. Over the past 10 years, the Texas Legislature has implemented a number of changes to the state Medicaid program including Medicaid Managed Care, fraud and abuse detection and prevention programs, cost-savings initiatives, and enrollment simplification. While all reforms were intended to reduce costs and improve access, the result has been a cumbersome system with inadequate reimbursement. Children’s Health Insurance Program (CHIP) was developed to cover children that do not qualify for Medicaid, but cannot afford to purchase private insurance policies. The Health and Human Services CHIP Quality of Care Report indicates that after obtaining coverage, 92% of children have a “health care home” and 97% of children are healthy. Texas registered the largest annual increase in the history of the State’s CHIP in 2001, increasing enrollment by 148% from 200,000 in December 2000 to 500,000 in December 2001. Currently in Texas, CHIP caseload projections are exceeding budget, with more than 526,000 children enrolled in the program. In August 2002, the state’s CHIP deficit was estimated at $60 million for the current biennium. Due to higher than projected caseloads and increased costs, questions regarding program limitations, caps on enrollment, and/or decreased outreach efforts have been raised. To maintain these programs in the next biennium, an additional $2.4 billion is needed to cover Medicaid and CHIP. In DCH’s service area, there are more than 459,000 Medicaid enrollees with more than 294,000 between the ages of 0-18. Sixty-five percent of Driscoll Children's Hospital’s revenue comes from Medicaid and as of October 2002 more than 20,000 South Texas children were enrolled in CHIP through the Driscoll Children’s Health Plan. Medicaid and CHIP are essential to poor children’s access to routine medical care, yet the deficit is dictating significant program cuts in the coming session. With such a substantial patient base tied to these two programs and our commitment to providing quality healthcare regardless of ability to pay, DCH has significant concerns regarding adequate Medicaid and CHIP funding during the next legislative session. Cuts in Medicaid and CHIP funding are not the solution. They simply result in more costs for taxpayers, the county, and children’s hospitals through increased uninsured rates, increased ER visits and diminished access to care. Already, there are approximately 1.3 million uninsured Texas children. Further cuts in Medicaid and CHIP funding will result in drastic increases to the number of uninsured children. And, for every $10 cut at the state level, Texas will lose $15.10 in federal funding for this program. DCH supports state policies that expand Medicaid coverage for all poor children, strengthen efforts to enroll children, ensure Medicaid benefits adequately cover medically necessary care for children, and maintain Medicaid disproportionate share payments for pediatric safety net hospitals. DCH supports state policy efforts to improve outreach and enrollment for children in CHIP, as well as ensuring barriers are not created for eligible children. Specifically, DCH supports the following initiatives:
Children with Special Health Care Needs The Children with Special Health Care Needs (CSHCN) program was established in 1933 as the Crippled Children’s program and was designed as a payor of last resort for chronically ill and disabled children under 21 years of age. For years, Children’s hospitals and THA have fought to protect services and reimbursement rates for the CSHCN program. During the 76th legislative session, SB 374 passed renaming the program and expanding program medical eligibility criteria from children with specific diagnoses to special needs children under 21 who have a chronic physical or developmental condition. At the same time, the asset test for financial eligibility was removed and waiting lists were allowed. However, during the last legislative session, several million dollars of CSHCN funding was moved to the Interagency Council of Early Childhood Intervention (ECI) under the guise that program expenses would be reduced due to the CHIP program. Today, there are more than 5,200 clients currently enrolled and 1,500 children on the waiting list for CSHCN coverage. Approximately half of the children on the waiting list are without any other source of health care coverage. The Texas Department of Health (TDH) has projected a shortfall in funding of $7 million during the current biennium. In order to eliminate the waiting list and serve all eligible clients, TDH has requested additional funding through the exceptional item funding process for 2004-2005. Without this additional funding, the waiting list will perpetuate leaving more children without needed health care coverage. During DCH’s last fiscal year, children with CSHCN coverage accounted for more than 520 inpatient and outpatient visits. DCH supports the CSHCN Advisory Committee’s recommendation to maintain the goal of covering all special needs children, but at a minimum to cover those with urgent health care needs. DCH supports the committee’s recommendations to seek additional program funding and to implement utilization review and pre-certification to control costs. Specific proposed actions include:
Health Insurance Coverage Texas is plagued with a health insurance crisis characterized by premium increases, unaffordable coverage, and a significant number of uninsured. According to the Texas Department of Insurance, Texas has the second highest rate of uninsured in the nation, with approximately 4.5 million people lacking health insurance coverage. Seventy-five percent of the uninsured Texans are employed full time, but are unable to secure coverage because of the expense. Many of these non-poor uninsured work for small businesses that simply cannot afford to offer that benefit to employees. Furthermore, despite steadily increasing insurance rates, insurance companies are loosing money and in turn pulling out of the state. In DCH’s service area, more than 640,000 individuals are uninsured, 221,000 of which are less than 19 years of age. During our last fiscal year, DCH provided $6 million in charity care. The economic impact of the uninsured is simply one factor; uninsured individuals seek health care services later and thus, are routinely sicker and require more advanced services. DCH supports efforts to make health insurance affordable for all Texans. Specifically, DCH supports efforts to make health insurance both available and affordable for small business owners by broadening the Texas High Risk Insurance Pool. Public Health Public Health issues are of great concern to Texans. Over the last year, reports and news articles have depicted a problem with our system in Texas citing childhood obesity issues, poor immunization rates, and limited prevention programs. As a provider of pediatric healthcare, DCH strongly believes that addressing health problems early and offering preventative services results in a more healthy society and ultimately, reduces the costs associated with the health care system. Immunizations The latest CDC immunization survey indicates that 74.9 % of Texas children ages 19 through 35 months were fully immunized against seven diseases in 2001, a 5.4% increase over the 2000 rate. With this new data, Texas is ranked as the 43rd state, rather than the 50th state for immunizations. However even with this slight improvement, the Texas rate continues to lag behind the nation’s immunization rate of 78.6% for this series in 2001. According to the 1999 Texas Retrospective Immunization Survey, the 4:3:1 coverage rate at two years of age for children in Public Health Region (PHR) 11 (includes Nueces County and 17 South Texas counties included in DCH’s service area) was 64.9%. The same rate for PHR 8 (includes the remaining counties in DCH’s service area) was 64.6% in 1999. The Texas Immunization Survey in 2000 noted that 64.5% of children in Nueces County and 65.6% of children in Hidalgo County were up-to-date on immunizations, compared to 70.3% for Texas. Looking at immunization rates by race/ethnicity, in Nueces County 70% of white children were immunized and 59.2% of Hispanic children were immunized. In Hidalgo county 72.3% of Hispanic children were immunized. According to the Texas Department of Health, for every dollar spent on the combination vaccine DTaP (diphtheria, tetanus, and pertussis,) $23.40 is saved in direct and indirect costs. Thus, it is imperative for Texas to gain control of the low immunization rates and make this necessary and cost-effective prevention program available to all children. DCH supports the Texas Pediatric Society, Texas Medical Association, Texas Academy of Family Practice Physicians and Texas Academy of Internal Medicine’s recommendations to address Texas’ low immunization ranking. Specific efforts supported by DCH include:
Other Notable Issues DCH will support legislative efforts to address the nursing shortage in Texas and to broaden the State 20 waiver program. Nursing Shortage The population growth in the state of Texas, coupled with the aging of the Baby Boomer population results in a greater demand for highly trained and experienced nurses. However, the rate of RNs per 100,000 population in Texas is well below the national average. RN vacancy rates across Texas hospitals range from 10% to 18%, with a vacancy rate of 9% indicating a significant shortage area. Furthermore, statistics suggest that within 10-15 years, the majority of our current RN workforce will be at retirement age. At the same time, the number of applicants to nursing programs has steadily declined over the last 8 years. While DCH’s RN vacancy rate is low (5%), we have seen it steadily increase over the last two years (up from 3%). The nursing shortage is adding to the access to care issue detailed throughout this document. DCH supports efforts to ensure an adequate nurse workforce is available, including:
State 20 Program After the crisis of September 11, the United States Department of Agriculture eliminated the J-1 visa program for foreign medical doctors. Currently, foreign physicians in Texas can receive a visa to practice medicine through the State 20 program. However, the State 20 program is limited to faculty physicians associated with the Rio Grande Valley Regional Academic Center (RAC). With the substantial shortage of pediatric subspecialists detailed earlier in this document, DCH is at a distinct disadvantage for recruiting or retaining highly trained foreign physicians who have opted to practice in this region. Traditionally, the waiver program helped maintain jobs for U.S. medical graduates. However, this is not the case with pediatric subspecialty medicine. With so few physicians practicing in each subspecialty, foreign medical graduates are helping to fill an unmet need. DCH supports efforts to broaden the scope of the State 20 program to include waivers for non-academic pediatric subspecialists willing to practice in South Texas. DCH opposes the continued practice of limiting waivers to Rio Grande Valley RAC physicians. [1] Driscoll Children's Hospital Pediatric White Paper on Pediatric Subspecialty Shortages |
