As hearings get under way and lawmakers scramble to fashion a budget at the halfway mark of the 2015 legislative session, graduate medical education (GME) funding and tax relief remain a focal point for the legislature, and the House of Medicine has made early progress on both fronts. Lawmakers also heard TMA's call to reinstate the Medicaid-Medicare parity payments for primary care.
As the bill count climbed toward the filing deadline in mid-March, however, lobbyists remain vigilant of an unprecedented attempt at scope-of-practice expansion by nurse practitioners. Battles brewed over balance billing restrictions and vaccine exemptions that threaten the practice of medicine and patient safety. And TMA prepared to fight an attempt to repeal last session's bill limiting silent PPOs.
GME Boost, Tax Relief in Sight
As the House Appropriations Committee and Senate Finance Committee aim to finalize their respective 2016-17 budgets this month, both chambers' proposals add funding for GME, women's health care, and mental health care services.
GME stands to get a significant boost: The House and Senate bills add roughly $30 million and $60 million, respectively, to fund residency slot expansions. It will be up to a conference committee to work out the differences. Meanwhile, Senate Bill 18 by Senate Finance Committee Chair Senator Jane Nelson (R-Flower Mound) and Sens. Juan "Chuy" Hinojosa (D-McAllen) and Kel Seliger (R-Amarillo) proposes a set of GME expansion programs that would put that budget money into action to reach a goal of 1.1 slots per medical school graduate. TMA is monitoring the bill to make sure it addresses critical physician shortages across specialties without unnecessarily complicating the GME funding process.
The draft House budget bill also adds to the Department of State Health Services budget for programs in infectious disease prevention ($20 million); tobacco cessation ($10.7 million); primary care and women's health care ($20 million); and neonatal drug abstinence ($17 million). Senate committee budget deliberations are still under way.
However, leaders in the upper chamber stepped out first with their expected push for a tax relief package. Senator Nelson, Lt. Gov. Dan Patrick, and Sen. Charles Schwertner, MD (R-Georgetown), unveiled a proposal that contains $4.6 billion in property and franchise tax cuts and consists of three bills: Senate bills 1 and 7 by Senator Nelson and Senate Bill 8 by Senator Schwertner. A House proposal is not far behind.
More relief for physicians could be on the way thanks to Sen. Kevin Eltife (R-Tyler), who filed Senate Bill 765 to eliminate the $200 annual occupations tax on physicians and other Texas professions. Physicians are subject to both the franchise tax and the occupations tax, and TMA advocates that the double tax is not appropriate.
Medicaid Decisions Ahead
As this report went to press, decisions over Medicaid funding — including how to cover $1.4 billion in cost growth and whether to continue paying select primary care physicians at rates that match Medicare — were a work in progress.
The House Appropriations Committee welcomed and adopted a recommendation by Rep. Four Price (R-Amarillo) to add money to reinstate the Medicaid-Medicare parity payments for primary care starting Sept. 1, 2015. The Affordable Care Act increased the Medicaid primary care payments to Medicare rates for two years using federal funds, but the pay bump expired Dec. 31, 2014.
At a standstill, however, are state-federal negotiations over increasing access to health coverage for the more than 1 million low-income adults who make too much money to qualify for Texas Medicaid but not enough to qualify for the ACA marketplace premium tax credits. Members of the Senate Health and Human Services Committee joined Lieutenant Governor Patrick in a letter asking the Obama administration for more flexibility in managing the Medicaid program to help Texans in this so-called "coverage gap." Their letter specifically asks for:
- Personal accountability requirements, including cost-sharing, missed appointment fees, and health savings accounts;
- Tailored benefit packages;
- Work requirements for able-bodied adults;
- Reduced physician and provider administrative burdens;
- Asset testing as part of eligibility criteria;
- Reinstatement of the active renewal process;
- Customized certification periods;
- Exemption from the ACA health insurance issuer fee;
- Exemption from ACA maintenance of effort requirements; and
- Exemption from hospital presumptive eligibility.
While the legislature has yet to act on the payment cuts to physicians treating dual-eligible Medicare and Medicaid patients, Senator Schwertner filed Senate Bill 760 to increase oversight of Medicaid HMO network adequacy, which TMA supports.
Meanwhile, TMA staff pour over a 122-page proposal to overhaul the Health and Human Services Commission, which administers the Texas Medicaid program. The plan to reorganize and consolidate the state's health agency was recommended by the state Sunset Advisory Commission.
Scope Bills Abound
As expected, the March bill filing deadline was met with a long list of potential scope-of-practice infringements on medicine by physical therapists (PTs), chiropractors, optometrists, and advanced practice registered nurses (APRNs). The bills have drawn opposition from TMA and specialty groups, including ophthalmologists and orthopedic surgeons.
While most of the bills would allow independent prescribing of Schedule II drugs — as typically proposed in past sessions — House Bill 1885 by Rep. Cecil Bell (R-Magnolia) also would allow APRNs to render a medical diagnosis, "the most direct threat on the most fundamental aspect of the practice of medicine we've seen," said TMA lobbyist Dan Finch.
Among the other scope bills TMA is watching:
- House bills 1185 and 1473, also by Representative Bell, would allow APRNs and physician assistants to independently sign official documents, like birth and death certificates, and handicap placards;
- House Bill 1263 by Rep. Richard Raymond (D-Laredo) would give PTs direct access to patients without a physician diagnosis and referral warranting the care;
- House Bill 1413 by Rep. Craig Goldman (R-Fort Worth) would give optometrists the authority to perform some eye surgery; and
- House bills 126, 1174, and 1231 would allow chiropractors to issue handicap placards; conduct physicals for school bus drivers; and examine student athletes for concussions.
TMA also has its eye on end-of-life legislation it says could interfere with physicians' ability to write do-not-resuscitate orders and could create new liability risks. Unlike last session, which saw a comprehensive piece of end-of-life legislation, medicine and lawmakers are tackling the topic piecemeal. So far, TMA supports emerging bills to require hospital ethics committees to adopt a nondiscrimination policy, and to classify artificial nutrition and hydration as ordinary, not extraordinary, care.
Balance Billing, Vaccine Exemptions Take Stage
Balance billing battles are rearing their head again with consumer groups galvanizing around Rep. John Smithee's (R-Amarillo) introduction of House Bill 1638. TMA has concerns with the legislation as filed because it would prohibit any out-of-network physician from seeking payment from patients for balances their insurance company doesn't cover for emergency services. Instead, the bill requires the noncontracted doctors and health plans to go to arbitration to settle payment.
TMA is countering the effort with a new white paper, "Network Inadequacy and Unfair Discrimination in Insurance," which explains how health plans' limited networks, benefits coverage, and payment structures contribute to outstanding bills patients may receive. House Bill 3085 by Rep. Nicole Collier (D-Tarrant) was filed at TMA's request to address some of the market problems outlined in the white paper, namely inadequate networks and inaccuracies of health plan directories. The bill permits the Office of Public Insurance Counsel (OPIC), along with the Texas Department of Insurance (TDI), to monitor network adequacy across the spectrum of HMO, PPO, and exclusive provider organizations (EPO) insurance products, and to file complaints with TDI about inaccurate health plan directories.
TMA is analyzing potential legislative alternatives, too.
For example, TMA supports House Bill 1624 as filed by Representative Smithee, which could help better inform patients of their coverage options and obligations by requiring additional transparency in health plan provider directories.
If physicians so choose, House Bill 616 by Rep. Greg Bonnen, MD (R-Friendswood), would require health plans to pay a set portion of physicians' out-of-network charges based on a state-certified database of geographic-specific charges, such as FAIRHealth.org. TMA is taking a neutral position on the bill, due to its voluntary nature: TMA lobbyist Patricia Kolodzey clarifies that it gives physicians a choice as to whether they wish to pursue this avenue for claim payment for their out-of-network services.
Meanwhile, TMA is monitoring insurance coverage provisions in House Bill 21, which could expand access to investigational drugs, biologics, and devices for terminally-ill patients. The issue is taking stage at the federal level, as well.
Also coming in under the wire were a slew of telemedicine bills TMA is following.
On public health, hearings are under way. While discussions regarding vaccine exemptions got contentious, TMA is working to make sure the heated discussions do not overshadow viable solutions to avoid over-vaccination, reduce state costs, and ease administrative burdens on physicians and families.
TMA physicians testified in support of one such solution put forth by Rep. Donna Howard (D-Austin) and Rep. J.D. Sheffield, DO (R-Gatesville). House Bill 465 would require patients to opt out of the state immunization registry ImmTrac, rather than opt in, and preserve minors' vaccination records until they turn 21, up from 18. Physicians also told the Senate Health and Human Services Committee that Senate Bill 538 by Senator Schwertner would help improve Texas' emergency response to infectious disease outbreaks.
A coalition of House Democrats and Republicans laid out a texting-while-driving ban in House Bill 80, which TMA also supported in testimony. The bill passed out of committee with bipartisan support.
Watch as hearings on medicine's issues speed up now that the bill-filing deadline has passed, and keep up through TMA's Legislative Hotline. TMA's First Tuesdays at the Capitol lobbying events are also a way for you to tell legislators all about medicine's agenda. The last two events will be April 7 and May 5.
Silent PPO Behind-Your-Back Peddling
TMA's previous legislative win now faces repeal.
The hard-won law TMA pushed through the 2013 legislature that makes it harder for PPOs to peddle your services without your say went up for repeal as of March 12, when Sen. Larry Taylor (R-Friendswood) filed bill SB 1231. The current law covers those situations when PPOs contract with you to treat a set number of patients in their network at discounted rates and then sell that discounted in-network rate to whomever they please without telling you. It frequently reaches the point where you can never know which or how many patients you actually have under your PPO network because that's the objective, to cut costs at your expense.
Last legislative session, after almost a decade of effort, TMA shepherded the passage of Senate Bill 822, which squashed the sneaky practice of rental networks/silent PPOs selling or renting physicians' discounted services without their permission. Before SB 822 went into effect in September 2013, such organizations could transfer physicians' discounted rates to other entities without their knowledge or consent and without steering patients to them.
And while the won statute doesn't outlaw the buying, selling, or leasing of a contract rate, it makes it just a little bit harder for silent PPOs to do it behind your back, because it requires entities to first:
- Register with the Texas Department of Insurance (TDI);
- Give physicians a line-item list of all network products covered by a payment contract and separate, corresponding fee schedules; and
- Obtain express authority from and provide prior notification to physicians for each line of business.
It also authorizes TDI to fine companies that don't comply or to revoke their licenses to conduct business. TDI finalized the bill's rules in June 2014.
As reported in Texas Medicine, the bill also makes it easier and cheaper to resolve improper claims because the line-item provision allows physicians to see which fees apply to which networks, specifically HMOs, PPOs, exclusive provider organizations, or Medicare Advantage or Medicaid managed care plans. Companies looking to buy or sell those rates not only must spell out each line of business in physicians' contracts, but also must get physicians' line-item approval.
Signing a contract with one PPO network means physicians are signing up for several other networks, according to Lee Spangler, TMA's vice president for medical economics, because several major PPO networks kept their individual names after consolidating into one ownership. "Even under SB 822, a company can pass on its negotiated contract rates to any number of its subsidiaries," Mr. Spangler said, "But they may do so only in the lines of business the physician has agreed to. The physician's express agreement by type of insurance business is a major step forward"
One contract may include several lines of business, which is why Mr. Spangler urges physicians to carefully scrutinize network contracts and pay attention to which types of coverage they are joining.
Amy Lynn Sorrel, associate editor of Texas Medicine, prepared this special supplement to Action.