Special Report - January 2006
The following report is based on a presentation delivered Nov. 19, 2005, at the biennial TEXPAC Retreat by TMA President Robert T. Gunby Jr., MD; William W. Hinchey, MD, chair of the TMA Board of Trustees;David Henkes , MD, chair of the TEXPAC Board of Directors; and Louis J. Goodman, PhD, TMA executive vice president and chief executive officer. To download a complete copy of TMA's Healthy Vision 2010, 2nd edition, see the TMA Web site http://www.texmed.org/Template.aspx?id=4578.
Every other year, Texas medicine's leaders - the Texas Medical Association, TEXPAC, and the TMA Alliance - gather to plan and scheme and dream about tomorrow. What a great opportunity to translate our policy, what we stand for, into political action.
In 1994, TMA published "Health System Reform for Texans." It came in response to the proposed Clinton health plan, but went far beyond the threat of the day. The document outlined the health system reforms that Texas physicians supported. It laid out TMA's long-term strategy. The Wall Street Journal dubbed it "The Texas Manifesto."
For the ensuing 10 years, TMA followed that blueprint. All of our major initiatives - managed care reform, Medicare and Medicaid, tort reform - flowed from the "Manifesto." With the passage of comprehensive liability reform in 2003, we checked off the final item from our 1994 list.
By the summer of 2004, it was apparent that Texas suffered from the lack of a clear and consistent health care policy. Efforts to shape health care direction were more about curbing the costs of publicly funded programs than about promoting the health of the people of this state. Budget pressures and rising health care costs meant that state lawmakers would look for ways to spend even less on health-related services.
Without a blueprint for a responsive and cost-effective health care system, Texans could expect to see a continued chipping away of the health care infrastructure, without regard or appreciation for the long-term consequences. Texas medicine once again had the opportunity to fill this void with a new manifesto, a comprehensive health care vision for the state, reflecting the principles of good medicine and cost-effective delivery systems.
This realization coincided with the beginning of the TMA Board of Trustees' strategic planning process, "TMA 2010." One of the four major goals for TMA 2010 is to "ensure continued success in legislative, regulatory, and legal interventions to enhance the statewide environment in which Texas physicians practice medicine." What better way to ensure continued success than with a focused, long-term strategy?
Healthy Vision 2010 articulates the voice of medicine. The recently released second edition refines our message. It allows Texas medicine to perform a terrific service for this state. It allows us to assume the leadership role in preparing our state for the health care challenges of the future - not for political gain but for our patients' sake.
Very soon, TMA will convene a Texas health care summit. We'll bring together the thought leaders, the political leaders, and the business leaders to search for common ground and to encourage them to buy in, to support, and to participate in our Healthy Vision.
Texas' health care system is sick and getting sicker. We have continuously growing demand for services that patients and employers can't afford to buy from physicians and hospitals that can't afford to sell those services at today's prices.
Texas' population is growing rapidly and should reach 25 million by 2010. Texans are growing older, fatter, and poorer, and are less well-educated. Preventable diseases will significantly increase morbidity and mortality, as well as financial costs for all contributors to the health care system. All of this will significantly increase the demand for health care.
The epidemic of obesity - nearly two-thirds of Texas adults are overweight or obese - is responsible for a huge jump in the number of Texans with diabetes, which in turn increases our risk for heart disease and stroke. The direct and indirect costs of obesity-related illnesses in Texas already exceed $10 billion per year.
Texas is the uninsured capital of America. More than one in four Texans lack health care coverage. We now lead the nation in the percent of uninsured adults, the number of uninsured working adults, and both the percentage and number of uninsured children.
As health insurance costs for employees and employers rise, fewer employers offer and fewer employees take health insurance benefits. When these people and their families get sick, doctors and hospitals must eat much of the cost of their care. That translates into more premium increases, leading more employers to drop coverage and leaving more people without insurance, further perpetuating the vicious cycle.
Shrinking lists of covered benefits, stricter utilization controls, and actual cuts in reimbursement rates all drive physician income down. An unsustainable formula forces Congress to save Medicare fees from free fall every year. Texas Medicaid and CHIP reimbursements are now lower than in 1992 in real dollars, even worse when you factor in inflation. Prompt pay still isn't prompt.
On the bright side, medicine's 2003 tort reform is starting to pay off. In 2005 alone, all five of Texas' largest physician liability insurers announced rate cuts that, together, will save Texas physicians nearly $50 million annually. We are seeing the promised increased access to care for patients, especially in the "war zone" areas of Texas and in high-risk specialties.
As Americans spend more and more on health insurance, the share of each dollar devoted to care decreases and the portion that goes into managed care's pocket increases. The profits of health insurance companies increased by 10.7 percent in 2004, continuing a long-standing trend. Administrative costs for private health insurance have increased from $85 per person covered in 1986 to $421 in 2003.
Health plans find new ways to squeeze doctors and shortchange patients. Inadequate networks leave patients facing large, unexpected bills. Plans are trying to outlaw balance billing. Tiered networks are thinly veiled attempts at economic credentialing.
The Treatment Plan
All in all, not a pretty sight. The treatment plan will need to be intensive to fix all that ails Texas health care. We must enact changes in our private and government health care programs ... among individual Texans, health plans, employers, doctors, and hospitals - in Austin and in Washington.
Our prescription calls for accountability, efficiency, and effectiveness.
We cannot underestimate the stakes. A healthy Texas depends on healthy Texans. A healthy Texas economy depends on a healthy Texas workforce. Healthy Texans depend on a robust health care system - healthy physician practices and hospitals. Healthy Texans depend on making healthy lifestyle choices and informed health care decisions.
We must break the vicious cycle of uninsurance. This is the critical intervention. We must relieve the unrelenting pressure the uninsured apply to government-financed health care programs, safety net hospitals and emergency rooms, private practice physicians, and employers and employees who buy health insurance. Healthy Vision 2010 calls on medicine, business, and government to suggest and test different combinations of premiums, copays, deductibles, and benefits that work best for different populations.
We must make sure the Texas health care dollar is actually spent on health care - not elsewhere. Healthy Vision 2010 calls on the state to make an honest assessment of Medicaid managed care models. We're confident that an objective analysis will find that it's not in our patients' best interest, it's not in the taxpayers' best interests, and it's not in Texas' best interest to keep sending our tax dollars to out-of-state Medicaid HMOs.
We must find ways to encourage our patients to take better care of themselves. Healthy Vision 2010 says we must start with the young. It calls for even more daily physical activity for schoolchildren and a crackdown on the junk food in school vending machines.
One medical error is one too many. A commitment to a culture of patient safety can save thousands of lives, improve the quality of life for hundreds of thousands of our patients, and save billions of dollars. Healthy Vision 2010 calls on all Texas hospitals, physicians, health care facilities, and other practitioners to endorse the principles of the Institute for Healthcare Improvement's 100,000 Lives Campaign and to implement them wherever possible.
Finally, you can't listen to the evening news without hearing about the promise of electronic health records (EHRs) and health information networks. This technology is supposed to make our practices more efficient, help us better manage patients with chronic illnesses, and avoid medication errors. Healthy Vision 2010 calls for creative financing (for example, reimbursement systems that recognize these new costs) to help physician offices, hospitals, clinics, and other health care facilities buy interoperable EHRs, put them in place, and learn how to use them.
TEXPAC Is the Tie
How does TMA transform these policy recommendations into a successful legislative process? Through politics. TEXPAC is the tie. TEXPAC is the largest and strongest voice of the Texas physician community. TEXPAC is composed of physicians, alliance members, medical students, and residents, all with one objective: to create a healthier Texas. We are more than 6,000 strong.
TEXPAC helps elect candidates who understand and appreciate medicine's interests, priorities, and issues. TEXPAC facilitates interaction between the physician community and elected leaders. Personal relationships are important in medicine and they are just as important in politics. We help build relationships between our legislators and their physician and alliance constituents.
The candidate education process is a three-legged stool; TEXPAC bases endorsements on where the candidate stands on our issues, the candidate's chances of winning the election, and the local physician community's perception of the candidate.
Candidates who seek the TEXPAC endorsement receive a briefing book that outlines medicine's issues as discussed in Healthy Vision 2010 . The book explains why physicians feel the way they do about the issues and asks some questions:
- On access to care, how does the candidate feel about increasing physicians' reimbursement for Medicaid, CHIP, and Medicare reimbursement?
- On health plans, should physicians be able to balance-bill patients for out-of-network services?
- Would the candidate be willing to invest more resources into the war on obesity?
- Where does the candidate stand on expanding allied health practitioners' scope of practice?
- Would the candidate support incentives to help physicians implement health information technology in their offices?
The candidates' answers to those and other questions, plus local physicians' impressions and TEXPAC's assessment of their chances of winning, determine whether the voice of medicine will speak on their behalf in the election. That's how policy drives the politics.
But for that to work, all Texas physicians must help us help medicine. Currently, only 12 percent of TMA members are TEXPAC members. That means that less than 12 percent of Texas physicians are carrying the load for the rest of the state. If TEXPAC is one of the largest and best respected political action organizations in Texas with only 12 percent of the physicians as members, think how much more we could further the agenda of medicine if all physicians were members. Basic membership in TEXPAC is $125, and there are special recognition categories for the $300 Club and the Capitol Club ($1000). Check out TEXPAC at www.texpac.org. Get involved and join TEXPAC today.
Healthy Vision 2010 Diagnostic Summary
Preventable diseases will significantly increase morbidity and mortality for children and adults and financial costs for all contributors to the health care system over the next few decades.
- Texas is the uninsured capital of America. The uninsured pay the physical price; all of us pay the fiscal price. Roughly half the cost of caring for this huge portion of the population is borne by taxpayers, employers that offer health insurance benefits, and families that pay health insurance premiums.
- The constraints and demands of managed care have increased administrative expenses and paperwork that distract from patient care. Health plans' payment practices and government budget constraints have reduced physicians' revenue and damaged patients' access to care.
- As Americans spend more and more on health insurance, the share of each dollar devoted to care decreases and the portion that goes into managed care's pocket increases. Health insurance companies saw a 10.7-percent increase in profits in 2004, continuing a long-standing trend.
Health Vision 2010 Treatment Summary
All Texans must have ready access to affordable, high-quality medical care. But that picture of good health is distant and cloudy. The physicians of Texas strongly believe that the intertwined triple guideposts of accountability, efficiency, and effectiveness will set us on the road to good health.
Goal #1: Accessible and affordable health care for all Texans
Texas' health professionals must collaborate with the business community, public and private payers, employers, and employees to devise and test initiatives that make health insurance companies offer coverage that is more broadly accessible, affordable, and portable.
Texas must direct more health care dollars into direct patient care.
Texas must build an adequate, home-grown supply of appropriately trained physicians.
Texas must invest in the public health infrastructure needed to protect the public in response to natural disasters, epidemics, and bioterrorism.
Goal #2: Increase prevention and personal accountability
Goal #3: Wise and effective use of health care information technology
- Texas must devise a plan to bring interoperable electronic health records to all physician practices to save lives and save money.
- Texas and the nation must encourage public/private sector collaboration on a plan that will make developing and using health information technology affordable for physicians, hospitals, and providers.
Goal #4: Protect patient safety
Texas health care professionals must support an environment conducive to reporting preventable errors and developing strategies to prevent and correct them.
A strong and fair Texas Medical Board must protect the public safety while it brings new Texas physicians into clinics, exam rooms, and hospitals as quickly as possible.
- Limited licensed health care practitioners must practice within the arena safely defined by their knowledge, skills, training, and experience.
Goal #5: Humane and cost-effective end-of-life care
Texans must ensure that our spending on health care resources during patients' final days, weeks, and months matches their individual desires.
Texans must do everything possible to prevent needless pain.
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