Action: July 19, 2011

TMA Action July 19, 2011
News and Insights from Texas Medical Association


INSIDE: CMS: Stop Us Before We Do Something Stupid


CMS: Stop Us Before We Do Something Stupid
Some Money Left in PELRP
Getting Preexisting Coverage Easier
Medicaid HMO Expansion Begins Sept. 1
HIEs Necessary for Meaningful Use
Texas Physicians Get EHR Incentive Checks
State Surveys H1N1 Awareness

TMA Seminars Explain ACOs
POEP, TSU Cancer Conference Rescheduled for July 29
Heads Up for TMA's 2011 Fall Conference
This Month in Texas Medicine
Do You Twitter? Follow TMA

CMS: Stop Us Before We Do Something Stupid

Medicare says it will lower payments to physicians by 29.5 percent at the end of the year, a cut so drastic that even the man in charge says it must be stopped.

"This payment cut would have serious consequences, and we cannot and will not allow it to happen," said Centers for Medicare & Medicaid Services (CMS) Administrator Donald Berwick, MD. "We need a permanent SGR [Sustainable Growth Rate] fix to solve this problem once and for all. That's why the president's budget and his fiscal framework call for averting these cuts and why we are determined to pass and implement a permanent and sustainable fix."

Medicare payments are based on the SGR formula, established by the Balanced Budget Act of 1997. The fee reduction will take effect Jan. 1 unless Congress acts, either by replacing the SGR with a fair payment system, or, as it has done in for the last decade, passing last-minute legislation to stop the SGR-mandated cuts and institute small increases.

In March, the Texas Medical Association joined the American Medical Association and several other state medical societies to urge Congress to "begin working in a bipartisan, bicameral manner" to eliminate the SGR "and lay the groundwork for adoption of broader physician payment and delivery reforms."

"Last year, Congress was required to act five times to pass short-term measures (for as short as one month) to stop Medicare physician payment cuts scheduled for 2010," the groups said in a letter to Congress. "On three occasions Congress failed to act before cuts were implemented, causing disruptions in processing Medicare payments. These payment uncertainties and delays created serious problems for many physician practices and jeopardized seniors' access to care."

Ultimately, the letter said, "Congress and the Administration worked together in a bipartisan manner" to stop the planned fee cuts and stabilize Medicare physician payments through 2011. "It is our hope that Congress can again work together this year to end the cycle of temporary patches once and for all and develop a long-term and meaningful solution to this issue."

Earlier this month, AMA said its supports legislation to repeal the Independent Physician Advisory Board (IPAB) created by the health system reform bill to reduce Medicare spending. AMA says the IPAB would make physicians subject to double jeopardy under both the IPAB and the SGR.

The latest CMS fee proposal [PDF] updates several physician incentive programs, including the Physician Quality Reporting System, the e-Prescribing Incentive Program, and the Electronic Health Records Incentive Program. It also includes proposed quality and cost measures to establish a new value-based modifier that would reward physicians for providing higher quality and more efficient care.  

What's at Stake
The Congressional Budget Office (CBO) published a report summarizing the impact and budgetary costs of various SGR fixes. 

According to its analysis, the 10-year budgetary cost of a corrected fee schedule update formula that allows small annual increases to partially offset increasing physician practice operating costs now exceeds $350 billion, and the more Congress postpones the problem, the larger the price will be. Nonetheless, Congress may opt for another temporary patch, and the CBO report describes the options:   

  • "Clawback" options temporarily over-ride the SGR cuts, then allow fees to gradually fall back to the target level, with no single-year cut exceeding 7 percent. 
  • "Cliff" options also apply a temporary fix, but allow the fees to fall back to target levels immediately after the temporary period expires.     

The report details various possibilities for both types of congressional action and for various types of permanent SGR revisions and replacements. Some examples include:  

Percent Increase


Effective Period

Cuts After Effective Period

5-Year Cost (Billions)

10-Year Cost (Billions)




-43% in 2015






 Limited annual





Through 2021




A quick look at the numbers shows why Congress has been using the "cliff" option in recent years and why permanent changes are difficult.  

CMS will accept comments on the proposed rule until Aug. 30 and plans to issue a final rule by Nov. 1. Comments can be submitted electronically at or by mail to CMS, Department of Health and Human Services, Attention: CMS-1524-P, PO Box 8013, Baltimore, MD 21244-8013.

Visit TMA's Medicare Meltdown Action Center  for more information about TMA's Medicare advocacy efforts for physicians and patients.  

 Some Money Left in PELRP

Although the legislature cut funding for the underserved area Physician Education Loan Repayment Program (PELRP) by 78 percent to $5.6 million in this year's session, the Texas Higher Education Coordinating Board says it has enough money to provide loan repayment to physicians currently in the program for at least three of their four-year service commitments. That assumes maximum annual loan payouts and no dropouts.

According to information on the THECB website, the agency will use current biennium funds to make repayment awards in fiscal years 2012 and 2013. That is possible because lawmakers actually appropriated more money for the program in 2011-12 than was needed. The agency will continue to explore options for issuing loan repayment awards for service periods ending after Aug. 31, 2013.

"In the event that funds are not appropriated for this purpose in the 2013 legislative session, current participants will be released from their service obligations," the board stated.

The board will not accept new applications for PELRP participation during the next two years, officials said.


Getting Preexisting Coverage Easier

Physicians can help patients obtain immediate health insurance coverage for preexisting conditions, now that the federal government has relaxed eligibility requirements.

Previously, patients had to submit a letter from a private insurer denying coverage because of a preexisting condition before obtaining coverage under the Pre-Existing Condition Insurance Plan (PCIP). Now, patients can submit a letter from a physician, physician assistant, or nurse practitioner dated within the preceding 12 months stating that they have or had a medical condition, disability, or illness. The letter must include the patient's name and medical condition, disability, or illness, and the name, license number, state of licensure, and signature of the physician, physician assistant, or nurse practitioner.

PCIP is a health coverage option for patients who have been uninsured for six months or more due to a preexisting condition. Enrollees have a choice of three plan options: Standard Plan, Extended Plan, or HSA Plan. Each plan has different premium costs, calendar year deductibles, prescription deductibles, and prescription copays.

The plans:

  • Cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs;   
  • Do not charge a higher premium because of a person's health condition; and
  • Do not base eligibility on income.   

The Texas Department of Insurance (TDI) says rates for the three insurance options under the plan were reduced 23.6 percent on July 1. PCIP rates are based on age, but there is no age limit for coverage, TDI said, adding that the maximum annual out of-pocket cost is $5,950 for in-network and $7,000 for out-of-network care. PCIP rates are lower than those in the Texas Health Insurance Pool, which also is for patients with preexisting conditions, and there is no exclusionary period for preexisting conditions. Complete coverage is available immediately. 

For more information, call the Texas Consumer Health Assistance Program at (855) 839-2427 or click here  


Medicaid HMO Expansion Begins Sept. 1

On Sept. 1, the Texas Health and Human Services Commission (HHSC) will begin Phase I of its Medicaid HMO expansion, converting the Medicaid Primary Care Case Management model to the Medicaid HMO model in the 28 counties contiguous to the current Medicaid HMO service delivery areas of Bexar, El Paso, Harris, Lubbock, Nueces, and Travis counties. As part of the conversion, the state also will create a new service delivery area – Jefferson – consisting of 11 counties in Southeast Texas. 

A list of counties included in Phase I and health plans providing coverage in those counties is posted online [PDF]. 

HHSC proposed the Medicaid HMO expansion last summer to reduce Medicaid costs. The Texas Legislature recently approved the change as part of a multipronged Medicaid cost containment initiative. Officials expect Phase I to save about $35 million, and Phase II, which will convert all remaining Texas counties to the HMO model in March 2012, to save an additional $385 million.

Medicaid-enrolled children, pregnant women, and low-income parents living in one of the 28 contiguous counties must select a STAR HMO, while adult Medicaid enrollees with disabilities who reside in the community must select a STAR+PLUS HMO. STAR+PLUS plans also will provide long-term care services for patients dually eligible for Medicaid and Medicare (Medicare will continue to cover acute care services). Children with disabilities receiving Supplemental Security Income (SSI) benefits may voluntarily enroll in STAR+PLUS. (STAR Health, which provides coverage for children in foster care, is not affected by the changes.) 

In June, the state mailed enrollment packets to Medicaid patients in the 28 counties. Patients must select a health plan and primary care physician by Aug. 12. Patients who do not select a plan will be assigned one by the state.

For more information about the contiguous county expansion, including sample enrollment packets sent to patients, visit the HHSC website    



HIEs Necessary for Meaningful Use

Exchanging data is one of the 15 required measures physicians must meet to achieve meaningful use for the federal Medicare or Medicaid incentives. The objective for this particular measure states that a physician must have the "capability to exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results) among providers of care and patient authorized entities electronically." Connecting to a local health information exchange (HIE) enables data exchanges.

Earlier this year, 17 Texas HIEs received grants from the Texas Health Services Authority (THSA) through funds provided by the federal Office of the National Coordinator for Health Information Technology (ONC). The purpose of the program is to fund electronic health information exchange networks to support higher quality, safer, and more efficient health care. 

Texas physicians planning to exchange clinical data should commit to participating in a local HIE. Doing so does not prevent you from participating in another HIE, especially since some regions have multiple HIEs. 

The benefits of HIE participation include:   

  • Exchange of patient data among disparate health care systems;  
  • Improved patient safety with a clinical record that follows the patient to all providers, regardless of point of care;
  • Prevention of redundant communication and care through shared information;  
  • Facilitation of e-prescribing, receipt of medication history, electronic lab ordering and receipt of lab results, allowing users to meet meaningful use standards for community data exchange; and,  
  • Improved community health outcomes as a result of comprehensiveness and continuity of patient data.   

For more information about HIEs and what questions physicians should ask before joining an HIE, read, "The Gift of Sharing" in the February issue of Texas Medicine. 

Physicians needing help with meaningful use and the federal electronic health record incentives may receive help from one of four Texas regional extension centers. For more information and eligibility requirements, visit the Texas Regional Extension Center Resource Center  on the TMA website, call the TMA Health Information Technology Helpline at (800) 880-5720, or email

Texas Physicians Get EHR Incentive Checks

Denise Casper, DO, of Bridgeport, is one of many Texas physicians to receive an incentive payment through the Medicare electronic health record (EHR) incentive program. Dr. Casper implemented a certified EHR system in her practice and attested to 90 days of meaningful use to receive the first-year payment of $18,000.

Denise CasparTo date, physicians and other health care professionals in the Medicare and Medicaid EHR incentive programs received more than $83 million in payments.

"The quick release of EHR incentive dollars is a clear message to physicians that these programs are not just bureaucratic talk from Washington. There is real money flowing to deserving physicians," said Matt Murray, MD, chair of the North Texas Regional Extension Center and vice Chair of TMA's ad hoc Committee on Health Information Technology. 

Eligible physicians who reach "meaningful use" of a certified EHR can receive up to $63,750 in incentives from Medicaid or $44,000 from Medicare through the 2009 federal stimulus package. Visit TMA's Medicare and Medicaid EHR incentive program instruction pages for more detailed information.

Nationally, more than 60,000 physicians and other providers have signed up to receive services from the regional extension centers (RECs). Four Texas RECs, each equipped with teams of experts, are ready to provide on-site consultation to help your practice reach the meaningful use criteria and earn incentive dollars. Federal subsidies lower the cost of consulting, valued at $5,000, to $300 for primary care physicians.

To learn more about available services, program eligibility, and federal incentive guidelines, visit the Texas Regional Extension Center Resource Center on the TMA website, call the TMA Health Information Technology Helpline at (800) 880-5720, or email  


State Surveys H1N1 Awareness

The Texas Department of State Health Services (DSHS) commissioned the Texas AgriLife Extension Service to find out how much physicians and other health care professionals know about H1N1 influenza in Texas. The AgriLife Extension Service, an educational agency of the Texas A&M University system, is conducting an Internet survey that should take about 15 minutes to complete.

DSHS will use information from the survey to assess how aware physicians and other health professionals were regarding the H1N1 pandemic and also how they were involved in responding to H1N1. This will tell the agency how to better plan communications and materials for physicians and others who care for patients in a pandemic.   

If you have any questions or concerns, email John Burlinson at DSHS, or call him at (512) 458-7111, ext. 3705.  





TMA Seminars Explain ACOs

If you are thinking about joining an accountable care organization (ACO) or if you don't know what an ACO is, TMA has the answers you need in a series of seminars across Texas this summer. The series, What Health Reform & "Accountable" Care Mean to Physicians, will address whether ACOs are an opportunity or challenge, understanding and negotiating employment contracts, new payment models, and health information technology.

Loosely defined, an ACO is a collaboration of health care providers who accept responsibility for the costs, quality, and effectiveness of care delivered to a defined patient population. The Centers for Medicare & Medicaid Services will launch the ACO model as a voluntary program no later than January 2012. And although ACO regulations have not been finalized, many hospitals and physicians are rushing to form collaborations – worried they'll be locked out of the market as ACOs expand beyond Medicare. TMA will conduct a free webinar update when the rules are finalized.

You may earn 3 hours of continuing medical education credit by attending one of the seminars. Physicians who are insured with the Texas Medical Liability Trust and complete this course will earn a 3-percent discount (not to exceed $1,000), which will be applied to their next eligible policy period.  

TMA does not endorse participation in an ACO or any other postreform program. Physicians are encouraged to be wary, to be informed, and to take the time to learn about these systems, understand their differences, and what they can mean to their practice and their patients.


POEP, TSU Cancer Conference Rescheduled for July 29

Breast cancer, human papillomavirus infection and vaccine, prostate cancer, and pain management will be among the topics discussed at the 2011 Texas State Cancer Advocacy Movement for Colleges and Outreach 3rd Annual Cancer Symposium, July 29, at Seton Medical Center Williamson, Round Rock.

The conference, which will run from 8 am to 2 pm, is a joint project of TMA's Physician Oncology Education Program (POEP) and Texas State University (TSU). Click here [PDF] to view the flyer.

Physicians may earn up to 5 hours of continuing medical education credits by attending the conference. Registration fees are $75 for physicians and $50 for physician assistants and nurses. Seton employees and affiliates will receive a discounted registration fee.

To register, e-mail Leslie Jones at POEP or call her at (800) 880-1300, ext. 1671, or (512) 370-1671.   

What Can Practice Production Numbers Tell You?

Consider these factors if your production isn't consistent.

A practice management tip from
TMA Practice Consulting


Heads Up for TMA's 2011 Fall Conference

Join leaders from across Texas for the 2011 TMA Fall Conference Friday and Saturday, Oct. 21-22, at the Hyatt Regency in Austin.

Mark your calendar and be on the lookout for more information on this important event. TMA conferences are designed by and for physician leaders.


This Month in Texas Medicine

The July issue of  Texas Medicine  details TMA's effort to reform the Texas Medical Board, reports on the board's crackdown on pill mills, and explains why a new medical school admissions test may be on the horizon. It also tells you why the Cancer Prevention and Research Institute of Texas is a lifesaver, and how Texas colleges are training high-tech workers for your office. You'll also find a wrap-up of TexMed 2011.

Texas Medicine RSS Feed

Don't want to wait for Texas Medicine to land in your mailbox? You can access it as an RSS feed, the same way you get the TMA Practice E-Tips RSS feed.  


E-Tips RSS Feed

TMA Practice E-Tips, a valuable source of hands-on, use-it-now advice on coding, billing, payment, HIPAA compliance, office policies and procedures, and practice marketing, is available as an RSS feed on the TMA website. Once there, you can download an RSS reader, such as Feedreader, Sharpreader, Sage, or NetNewsWire Lite. You also can subscribe to the RSS feeds for TMA news releases and for Blogged Arteries, the feed for Action


Do You Twitter? Follow TMA

As part of its work to explore new communications technologies, TMA regularly publishes on Twitter, the hot, 140-character "micro-blogging" service.

If you Twitter, follow TMA to get practice management tips, news bits, and political chatter – and we'll follow you, too. If you don't know what we're talking about, click here to check it out.

What are TMA-member physicians saying on Twitter each day about health care, politics, science, and more? You don’t need a Twitter account to be part of the conversation. The TMA Member Physicians Daily comes out around 10 am each day. You can subscribe via e-mail or RSS feed. TMA’s own Twitter feeds reach more than 20,000 unique individuals online each week.


This Just In ...

Want the latest and hottest news from TMA in a hurry? Then log on to Blogged Arteries. You can hear the latest Podcast TMA episodes and read the most recent news from Action and Texas Medicine


TMA Seminars

Practice Management, Ext. 1421

Medical Records & Documentation in a Post-Reform World
7/20      Houston
8/3        San Antonio    

  Recorded Web Seminars

Avoiding RAC Audits
Communication Skills: Why Bother?
Evaluating Your Medicare Options
Prepared for ICD-10?
Meaningful Use
Medical Records-Consent for Treatment of Minors
Patient-Physician Relationship
Patient Satisfaction
Professional Courtesy: Waiving Copays, and Charity Care Requirements
 Revenue Cycle Management  

Physician Health and Rehabilitation, Ext. 1342

Family Systems: The Impact of Marriage and Family on Physicians
9/10         Amarillo
10/20       El Paso

Challenging Behaviors, Recovery, and Physician Health Programs
9/16-17   San Antonio

About Action

Action, the TMA newsletter, is e-mailed twice a month to bring you timely news and information that affects your practice.

To change the e-mail address where you receive Action, go to Member Log-In on the TMA website, then click on "Update Your TMA Demographic Information (including newsletter subscriptions and preferences)."

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If you have any technical difficulties in reading or receiving this message, please notify our managing editor, Shari Henson. Please send any other comments or suggestions you may have about the newsletter to Larry BeSaw, Action editor.


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