Ad Hoc Committee on Managed Care and Insurance

To meet and support its charges, the committee undertook activities to: develop and promote a strategic legislative plan for identified key managed care and insurance issues; identify and develop physician experts and representatives for testimony, interviews, and presentations on the key issues; encourage unity among the different membership segments and specialties impacted by the key issues; gather and plan distribution of data and information needed to support TMA positions on the key issues; and promote fair and equitable negotiations between insurance companies and physician practices.

Twenty TMA member physicians were appointed to the committee by TMA Council on Legislation chair, Austin King, MD. Additionally, three individuals representing external stakeholder groups also were appointed. Manny Alvarez, MD, member of the Council on Legislation was appointed chair of the committee. Dr Alvarez established four subcommittees to oversee development of the issues under the purview of the committee: Subcommittee One -Transparency, non-contracted physicians, "balance billing," network adequacy; Subcommittee Two -Tiered networks, pay-for-performance programs; Subcommittee Three - Standardized managed care contracts, rental PPO networks, uniform policy provision law (UPPL); Subcommittee Four -  Federal Issues - Employee Retirement Income and Security Act (ERISA), Medicare payment adequacy. Dr Alvarez appointed a chair for each subcommittee.

Through a series of conference calls and face-to-face meetings, the subcommittees discussed their assigned issues, defined the problem and how patients and physicians are impacted by the problem, reviewed current TMA policy, and developed guiding principles which were submitted to the Councils on Socioeconomics and Legislation.  The councils have approved the following committee recommendations:

1. Transparency/non-contracted physicians/"balance billing"/network adequacy : Support legislation or rulemaking that will establish the responsibility for necessary disclosure to patients as that of the entity that controls the information. Consult and coordinate with other health care stakeholders the most efficient manner in which to provide access to patients.  Support legislation or rulemaking that will establish network adequacy standards to ensure health care access for patients.
2. Smart Cards : Build upon current law to encourage the completion of the financial transaction concurrently with the provision of medical services.  Urge inclusion of real-time adjudication of claims and payment of deductibles at point-of-service in any modification to current statute.
3. Tiered Networks/Economic Credentialing : Pursue multiple avenues utilizing current law that may offer tools to prevent the use of tiered networks as an incentive to limit medically necessary care. Initiate discussions with the Department of Insurance and Attorney General to determine whether current law offers a solution.
4. Pay-for-performance : Ensure that any such programs offer only incentives to physicians who practice in accord with accepted standards of practice as set by physicians based upon evidence-based criteria and the AMA developed standards.  Close scrutiny of any federal or state regulatory proposal is recommended.
5. Uniform Policy Provision Law (UPPL): Support legislation to repeal UPPL.  Urge Council on Legislation to consider pursuing as part of TMA's legislative agenda if such legislation is not filed by others.
6. Standardized Managed Care Physician Contracts : Support legislation for standardized contracts.  The specific contract language should not be negotiated during the legislative session.
7. Rental PPO Networks and Third-Party Administrators (TPA): Support AMA model legislation or other similar provision/language. Seek passage of state legislation that will ensure only authorized discounts on physician services are taken. Continue to encourage the Texas Department of Insurance to utilize current insurance code provisions that may alleviate the problem. 
8. ERISA Reform : In collaboration with the AMA, other state medical associations, and other similarly affected stakeholders: propose and actively support federal legislation clarifying that ERISA preemption does not apply to physician/insurer contracting issues; develop, propose, and actively support federal legislation that requires all third party payers serving as administrators for ERISA plans to accept assignment of benefits by patients to physicians; and develop and support federal and state legislation prohibiting "all products" clauses or linking participation in one product to participation in other "tied" products administered or offered by third party payers or their affiliates.
9. Medicare Payment Adequacy : Develop appropriate alliances with other state medical associations, the AMA, and other similarly affected stakeholders to pursue national legislative and regulatory remedies to address the Medicare SGR methodology and related access and practice viability problems. In collaboration with others, develop an advocacy plan to address the SGR methodology problems and achieve meaningful Medicare payment reform. Support consistency with the AMA pay-for-performance recommendations should Medicare payment reform include a pay-for-performance component.

Recommendation 1:  That the Texas Medical Association approve the recommendations for guiding principles developed by the Ad Hoc Committee on Managed Care and Insurance.

Recommendation 2:  That the TMA continue strong advocacy based on these principles in appropriate legislative, legal, or regulatory venues.

TMA House of Delegates: TexMed 2007