Doctor’s Orders: TMA's Prescription for a Healthy Texas

Dr.s Orders Small Image 2009 Legislative Agenda: Watch the Video

 

 

 

 

 

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In emergency medical situations, seconds count.

For health care and health insurance reform challenges facing the 81st Texas Legislature, our time also is short.

Our patients no longer understand nor can they navigate today's complicated health care system. Our patients are afraid they can't get or even afford the care they need. Our patients believe our health care system is broken.

Texas state leaders and legislators have the power to fix our broken health care system.

As you arrive in Austin for the 2009 Texas Legislature, we ask that you review our diagnosis and follow the treatment prescribed by the Texas Medical Association in our Healthy Vision 2010: Diagnosis and Prevention .

Texas physicians and our patients strongly support steps that:

  • Add accountability and performance standards to health insurance,
  • Expand access to care for all Texans,
  • Enhance patient safety, and
  • Improve quality of care.

Texas needs a health care system that allows all patients to receive the care they need when they need it.

Removing barriers to affordable, medically needed care is our No. 1 priority.

We know that's a big task, but we're Texans.

Respectfully, and on behalf of our 43,000 physician and medical student members and more than 20 million Texas patients, here is the Texas Medical Association's Prescription for a Healthy Texas .

Health Insurance Company Accountability

 

TMA Prescription for a Healthy Texas  

To cure Health Insurance Headaches:

Rx:  

  • Enact a health insurance code of conduct
  • Give patients information to make appropriate, timely health care decisions
  • Cover routine health care for patients in clinical trials
  • Hold insurers accountable for out-of-network services
  • Regulate preferred provider organizations

Take as directed

Josie R. Williams, MD  

January 2009                       Refill as Needed

Skyrocketing health insurance premiums are making it more difficult for employers to offer their employees coverage. No one feels the challenge more acutely than Texas' small businesses.

Over the past decade, health insurers' have decreased their costs by increasing premiums and offering products with much higher out-of-pocket cost for our patients. Texans end up paying more each year for their health insurance but receive less coverage in return.

Meanwhile, neither physicians nor our patients can easily access accurate information from health insurers to make informed decisions. It has become impossible for us to counsel patients on affordable and efficient treatment plans. To avoid higher costs, patients need current and honest information on copays, deductibles, and health plan networks.

To bring accountability to this multibillion-dollar industry, TMA is asking legislators to support the Health Insurance Code of Conduct 2009 and other legislation. We must hold health insurance companies accountable to the promises they make for the premium dollars Texans pay.

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Health Insurance Code of Conduct 2009

These measures would ensure transparency and accountability in the way health insurance companies conduct business:

  • Health Coverage Cancellations and Rescission : Require insurers to notify patients that rescission of their policy is under consideration prior to the actual cancellation. In addition, the insurer would have to provide a patient all relevant information about why the policy is being revoked and how to initiate an independent review of the decision.
  • Calculation of Premium Quotes : Allow Texas' small businesses' to challenge health insurance premium quotes, and have insurers provide information to justify a premium increase.
  • Calculation of Medical Loss Ratio : Require health insurers disclose how they spend the patient's premium dollar.
  • Unregulated Secondary Networks (Silent PPOs) : Regulate how a physician's contract information is sold, leased, or shared among health insurance companies.
  • Physician Rankings : Require health insurance companies to use scientifically valid criteria to evaluate physicians' performance and disclose those criteria in advance.
  • Claims Processing : Codify a number of the RICO settlement's provisions, which are set to expire in the near future so health insurance companies don't revert to their old, unethical ways of processing claims.

Timely Health Insurance Information
Buying health insurance coverage today is increasingly complex. Insurance companies offer a wide range of plans with different benefits, exclusions, and costs. It is nearly impossible to decipher the sales literature and then make a direct, product-to-product comparison.

Standardized and reliable nutritional labeling has made it much easier for consumers to make better food choices. Consumers can examine 20 different boxes of cereal and easily compare product benefits such as number of calories, percentage of fat, sodium, sugar, and protein. The same standardized system could aid employers and patients when shopping for health insurance.

TMA's "Health Insurance Product Labeling Plan" would require health insurers and their brokers to use standardized reporting measures to help employers and individuals make direct, side-by-side product comparisons.

Once a plan has been selected, patients should have convenient access to benefit information when they are making their health care decisions. Health insurers should make this information easily available. Almost every card in your wallet has some ability to provide data - except your health insurance card. There is absolutely no reason why health insurers cannot provide accurate, real-time information regarding the different benefits and exclusions. 

Routine Medical Care for Clinical Trials
Texans participating in a clinical trial should be able to use their health insurance to pay for routine medical costs - especially when they are suffering from a life-threatening disease or condition.

Twenty-three states require health plans to pay routine medical care costs for clinical trial participants. Medicare does, too. In Texas, however, patients in clinical trials still must pay these expenses out of pocket unnecessarily. This must change.

Accountability for Out-of-Network Services
Employers and patients pay steadily rising health insurance premiums. In exchange, health plans promise a comprehensive network of physicians, and payment for out-of-network medical expenses. When health plans break one or both promises, which happens often, it dramatically increases the out-of-pocket expenses for patients.

Texas must hold health plans accountable for providing comprehensive networks of physicians. We should give TDI authority to hold health plans accountable for developing adequate networks.

TMA opposes health plans' attempts to prohibit balance billing or to establish wholly inadequate payment rates for non-network physicians and hospitals.

TDI needs authority to require health plans to disclose the methods and data they used to set "maximum allowable" amounts.

Regulation of Preferred Provider Organizations (PPOs)
Currently the discounted rates physicians negotiate with health plans are being hijacked by unregulated PPOs. These entities, called "silent" and "rental" PPOs, shop around to find the lowest rate a physician has agreed to with any health plan. Then the PPO sells, resells, or leases that discounted rate to insurance companies, discount brokers, and other unregulated health care businesses without the physician's knowledge or permission. Fourteen states outlaw these arrangements. Texas should, too.

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Texans Need Affordable and Timely Health Care 

TMA Prescription for a Healthy Texas  

To cure Health Care Access Fever:

Rx:  

  • Help physicians set up practice in medically underserved areas
  • Fund graduate medical education 
  • Protect 2003 medical liability reforms
  • Ensure access to a medical home
  • Establish an appropriate Medicaid payment system
  • Ensure all eligible children are enrolled in health care programs
  • Improve mental health funding 

Take as directed

Josie R. Williams, MD  

January 2009                       Refill as Needed

Finding affordable care is the most urgent health care problem facing the state. More than 26 percent of Texans, 5.6 million people, are uninsured. In addition to being the uninsured capital of the United States, Texas also ranks last for employer-sponsored insurance. Only 52 percent of Texans have coverage through their employer. For small businesses - the bulk of Texas employers - the number is even worse: 34 percent.

Cost is the primary culprit. Premiums for employer-based insurance have more than doubled since 2000. The average cost for family health insurance coverage is more than $12,600 annually.

Uninsured patients create higher health care costs for everyone. Without continuous care by a primary care physician or "medical home," these patients must seek care in an emergency room - the most expensive place to receive care. To compound problems, Texas continues to face a physician shortage, especially for primary care physicians. TMA is asking legislators to take these bold steps to make health care more affordable and available to all Texans.

Adequately Fund Texas' Physician Loan Repayment Program
The Physician Education Loan Repayment Program has been one of the most successful models to address the state's physician shortage. However, current funding for the program covers only about a third of the average debt a physician accumulates during his or her 11-plus years of education. Additional funding is needed to restore the program so it can be a valuable tool in recruiting physicians to underserved areas of the state.

Fund Graduate Medical Education (GME)
Texas needs more GME slots to train the number of physicians required to care for our rapidly growing population and reverse our overdependence on other states and countries. It is not good fiscal policy for the state to invest $200,000 in each Texas medical student over four years, and then force graduates to leave the state for residency training. Those new physicians very likely will never return to Texas. TMA calls on legislators to fund medical school expansions and GME slots. We also must restore state appropriations for Medicaid GME, which will also allow Texas to obtain additional federal matching dollars.

Establish Appropriate Payment System for Medicaid
Medicaid and the Children's Health Insurance Program (CHIP) are good buys for Texas, given their generous federal matching dollars. Both programs offer low-income working parents an affordable way to insure their children. Medicaid and CHIP payments to physicians still lag far behind other payment rates, even after the 2007 increases. Physicians want to participate in these programs but in many cases cannot afford to open their practices to Medicaid and CHIP patients. To ensure access to a medical home for these patients, legislators must continue to improve continuity of care and payments through Medicaid for adults' and children's services.

Protect Texas' Medical Liability Reforms
The 2003 liability reforms have worked. They've lived up to their promise. Sick and injured Texans now have more physicians who are more willing and able to give them the medical care they need. In fact, Texas has gained more than 14,000 new physicians representing many high-risk specialties such as emergency medicine, neurosurgery, pediatric intensive care, and pediatric infectious disease.

Physicians enjoy lower premiums and a more competitive liability insurance market. It is critical that we protect the 2003 health care liability reforms, especially the caps on noneconomic damages and emergency care provisions. The emergency care protections have saved lives by helping ensure Texas patients have access to critical and timely care. The threat of lawsuit frenzy could harm Texas' trauma care.

Improve Mental Health Funding
Mental illness costs the state and local governments more than $1.5 billion per year. Each person repeatedly jailed, hospitalized, or admitted to detoxification centers can cost the state $55,000 per year. We must expand the availability of community-based mental health care for adults and children, including prevention and early intervention.

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Ensure High Quality Health Care for All Texans

 

TMA Prescription for a Healthy Texas  

To cure Buyer Beware Virus:

Rx:  

  • Fight for a single health care standard of care for all Texans
  • Protect the patient-physician relationship against corporate interference
  • Preserve retail health clinic oversight and the health care team approach 
  • Eliminate waste and overuse of health care resources

Take as directed

Josie R. Williams, MD  

January 2009                       Refill as Needed

Texas has a shortage of physicians, both primary care physicians and specialists. We currently rank 43rd out of 50 states and the District of Columbia.

The passage of the 2003 landmark medical liability reforms has helped Texas bring more than 14,000 new physicians to take care of Texas patients. However, we still don't have enough physicians to keep up with our robust population growth.

Unfortunately, many seek to fill this void with nonphysician practitioners, corporations, and retail health clinics. Some would prevent physicians from owning a health care facility and/or life-saving equipment. This only further restricts our patients' ability to receive cost-effective and timely care. TMA argues that lowering the standard of care is neither a good solution nor good public policy for improving Texans' access to quality health care.

Ensure a Single Standard of Care for All Texans
TMA is committed to a single high standard of care for all Texans. This means that care is centered on each patient's need and each patient receives high quality care by a well-trained team of professionals supervised by a physician. We must protect the safety of Texas patients and ensure they receive the best medical care by the best person trained to deliver that care. Only physicians have the broad clinical expertise and training to exercise independent medical judgment and serve as the trusted leader of the health care team. Nonphysician practitioners are valuable members of the health care team but are limited by their education, training, and skills as to the level of care they can safely provide.

The Legislature must prevent nonphysician practitioners from expanding their scope of practice beyond that safely permitted by their education, training, and skills.

Protecting the Patient-Physician Relationship
Texas prohibits the corporate practice of medicine. The principle is simple. Only physicians, not corporate entities, are licensed by Texas to provide medical services. The fundamental purpose of this law is to ensure physicians' independent medical judgment.

This independence is critical. It ensures that our patients' medical needs come before a hospital or governmental entity's business needs. TMA opposes efforts to broaden the corporate practice of medicine beyond the current exceptions for medical schools, 501a corporations, and federally qualified health centers (FQHCs). We also believe the Texas Medical Board should be required to maintain current information on the sponsorship, governance, and membership of 501a corporations.

Preserve Retail Health Clinic Oversight
Retail health clinics were designed to give patients access to fast, convenient, and affordable health care. But because the clinics are staffed by advanced practice nurses (APNs) or physician assistants (PAs), they do not provide the same level of care as physicians' offices, urgent care clinics, or minor emergency centers. TMA supports an integrated care model where the APNs and PAs staffing the clinics are appropriately supervised by a physician, refer patients back to the patients' regular physician to ensure continuity of care, refer patients appropriately for additional or follow-up care, and practice within their scope of practice.

Ownership of Health Care Facilities and Equipment
Physician-owned hospitals are not new. Physicians founded many of the nation's first hospitals to ensure appropriate care for their patients. There have, however, been considerable changes in health care financing and coverage over the past decade. These changes drive the debate over who can invest in a facility. TMA believes that responsible ownership, whether by a physician or hospital, should be patient-centered and include a commitment to appropriate peer review of utilization, quality, and safety to ensure the highest quality care for our patients.

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Improve Texas' Fiscal and Physical Health

TMA Prescription for a Healthy Texas  

To cure Our Unhealthy Lifestyle Epidemic:

Rx:  

  • Move aggressively to prevent obesity
  • Enact a statewide smoking ban
  • Fund cancer prevention and detection
  • Improve Texas' immunization rates

Take as directed

Josie R. Williams, MD  

January 2009                       Refill as Needed

 

Heart disease, cancer, and stroke may be the most common causes listed on death certificates. However, the real killers are tobacco, poor diet, stress, and lack of exercise. Studies indicate that at least 50 percent of health care spending is lifestyle-related and could be preventable.

The obesity epidemic threatens Texas' physical and fiscal health. Texans young and old are growing fatter. Nearly 63 percent of Texas adults and 35 percent of Texas school-age children are overweight or obese. Obesity-related diseases such as diabetes, arteriosclerosis, and hypertension are increasing at the same rate as obesity.

Tobacco also exacts a high price from business and taxpayers. In Texas, more than $12.2 billion can be attributed to the costs associated with smoking. The cost per smoker is about $3,391, which includes direct medical and indirect costs.

To improve the physical and fiscal health of Texas, all of us - individual Texans, their families, physicians, health care professionals, government, and health plans - need to focus on wellness and prevention.

Stop the Obesity Epidemic
Obesity and related diseases like diabetes are major factors behind rising health care costs and health insurance premiums. Texas spends $5.3 billion on medical costs related to overweight and obesity. To stop the obesity epidemic, we must focus on preventing obesity rather than treating the diseases that it causes. TMA is asking legislators to pass legislation and funding for a coordinated school health program for all grade levels. We also must fund education on the importance of proper nutrition and physical activity.

Make Texas Smoke-Free
Banning smoking in public places is one of the easiest, simplest, and fastest public health interventions Texas could undertake. Twenty-eight states have adopted smoking bans in restaurants; 22 of these states also prohibit smoking in workplaces. TMA believes it is time that Texas joins these ranks. We are asking lawmakers to pass a statewide ban on smoking in public places. Employers also should receive tax incentives to reward nonsmokers and encourage smokers to participate in tobacco cessation programs.

Cancer Prevention and Detection for Frontline Physicians
Primary care physicians are the front line of cancer prevention and detection. In 2007, the voters passed a constitutional amendment authorizing the state to issue up to $3 billion in bonds to fight cancer. It is important that we use Proposition 15 funding help enhance care for Texas patients and reduce the incidence of cancer in the state by educating physicians about the latest cancer treatments and technological advances.

Improve Texas' Immunization
Immunizations are important, effective, and safe. Each year more than 42,000 adults and 300 children die in the United States from vaccine-preventable diseases and their complications. Physician efforts are essential. Unfortunately, physicians' reimbursements for purchasing, storing, and administering vaccinations do not cover their cost. Physicians also must pay a new state tax on vaccines, a further disincentive for some physicians to provide immunizations. Improving reimbursements to physicians for administering vaccines is important. It ensures children have a regular physician in charge of their care - a medical home - and protects our communities from preventable diseases.

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