Governor's Signature Caps Successful Legislative Session

The Texas Medical Association's victories in the 2013 legislative session became official when Gov. Rick Perry signed into law TMA-backed bills to reduce the red tape snarling your practice and to give your patients new protections.

 Governor Perry signed bills that:

  1. Reduce your red tape and administrative hassles;
  2. Prevent third-party payers from stealing from you;
  3. Rein in overzealous Medicaid fraud-and-abuse investigations;
  4. Provide tax relief for small businesses;
  5. Establish physician-led medical teams;
  6. Strengthen Texas' physician workforce; and
  7. Protect your medical judgment.

 TMA President Stephen L. Brotherton, MD, said Texas physicians applaud the governor for signing bills "that take important steps to protect patient safety by ensuring the right professional is providing the right care permitted by his or her education, training, and skills; improve Texas' vaccination policies; and dramatically reduce red tape and hassles in a physician's practice that delay patient care."

 Among the bills the governor signed are:

  • House Bill 1803 by Rep. Bill Callegari (R-Katy) and Sen. Joan Huffman (R-Houston), which eliminates bureaucratic red tape and prevents patient care disruptions. Every year, you have to print and mail a paper application to the Texas Department of Public Safety for a Controlled Substances Registration (CSR) permit. The permit sometimes takes several weeks, even months to process. Without it, you can't work in your local hospital or prescribe medications. Under the new law, your CSR permit renewal is due every two years instead of annually, and the state will process the application at the same time as your medical license renewal. You also can reapply for the permit electronically with the Texas Medical Board.
  • Senate Bill 1803 by Senator Huffman and Rep. Lois Kolkhorst (R-Brenham), which improves due process and expediency when a physician is accused of Medicaid fraud or overpayments. The bill clarifies the definition "credible allegation of fraud" and establishes timelines for the Office of Inspector General (OIG) to notify doctors of an investigation and hold payments in the process.
  • Senate Bill 1216 by Sen. Kevin Eltife (R-Tyler) and Rep. Sara Davis (R-West University Place) and Senate Bill 644 by Senator Huffman and Rep. John Zerwas, MD (R-Simonton), which will dramatically reduce the number of preauthorization forms. These two new laws will help to reduce administrative cost and hassles by creating two standardized forms that all health insurers, Medicaid, and the Children's Health Insurance Program will use for preauthorizations. SB 1216 creates one form for medical and health services preauthorizations, while SB 644 creates one form for prescription preauthorizations.
  • Senate Bill 406 by Sen. Jane Nelson (R-Flower Mound) and Representative Kolkhorst, which establishes a more streamlined and less bureaucratic system of supervision and strengthens physician-led patient care teams. Physicians, advanced practice registered nurses, and physician assistants are natural and important partners in patient care. The new law strengthens this partnership but continues to recognize that independent prescribing is the practice of medicine.
  • Senate Bill 63 by Senator Nelson and Rep. J.D. Sheffield, DO (R-Gatesville), which allows minors who are pregnant or who are parents to consent to their own vaccinations. This helps well-intentioned young moms and dads get the shots they need to ensure they don't pass potentially deadly diseases on to their babies.
  • Senate Bill 64 by Senator Nelson and Representative Zerwas, which requires licensed child care centers to create an immunization policy for their staff who work with children.

Darren Whitehurst, TMA's vice president for advocacy, and the TMA lobby team discuss the results of the 2013 session.

The August issue of Texas Medicine will have a complete wrap-up of TMA's accomplishments in the 2013 session. 

TMA Calling Tuesday
Legislators delivered for you and your patients, and TMA wants to make sure you know how the new laws will help you, your practice, and your patients. TMA will conduct a Tele-2013 Legislative Update at 8 pm CDT on Tuesday, June 25. Dr. Brotherton will call you at your home telephone number. All you have to do is stay on the line. He and TMA's lobby staff will discuss the 2014-15 state budget and new laws that will protect you and your patients.

You may ask questions after each topic and use your phone to participate in a survey. You can earn 1 AMA PRA Category 1 Credit™ for your time if you stay on the line for the entire program.

 If you prefer that Dr. Brotherton call you on your cell or office telephone, please contact the TMA Knowledge Center by telephone at (800) 880-7955 or by email  by Monday, June 24.

  Action Special Report, June 19, 2013 

  


 

 TMA Scores Long-sought Wins for Physicians and Patients 

The Texas Medical Association has long beat the drum for bolstering graduate medical education (GME), cutting red tape that hinders patient care, promoting transparent insurance markets, and preventing unqualified health professionals from delivering care outside their expertise. This was the year those and other messages got through to lawmakers and paid off in long-sought, even precedent-setting victories at the conclusion of the 2013 Texas Legislature.

As this article was prepared, all of TMA's priority bills either became law or were on their way to Gov. Rick Perry's desk for signature following House and Senate approval. He has 20 days to act, whether signing it into law, vetoing it, or allowing the legislation to become law without signature.

Key milestones include:

  • First regulation of so-called "silent PPOs" that share physician-contracted discounts without doctors' knowledge or consent; 
  • A new model for physician-led, team-based care, and for future legislative scope-of-practice discussions;
  • Wide-ranging reductions in practice red tape, including development of uniform prior-authorization forms for medications and health care services;
  • Due process protections in Medicaid fraud investigations;
  • Increased access to immunizations;
  • More money for GME, mental health, and women's health; and
  • Preservation of tort reforms and a strong Texas Medical Board.

 Medicine's success this session was due largely to seeds TMA planted early on, says Darren Whitehurst, TMA's vice president for advocacy.

"We took a very good preventive approach," he said. "We did a good job educating legislators back in their districts before the session. We had a good game plan in the political cycle in getting elected people who look to their doctors to understand medicine's issues. And that paid dividends in the legislature."

Even though not all of TMA's bills made it to the finish line, medicine did not lose any ground, TMA leaders add.

Additional money to boost Medicaid physician payment rates never materialized, but rates were not reduced. Reforms to the Texas Medical Board and medical liability laws stayed intact. Heated debates halted compromise end-of-life legislation put forth by prominent pro-life and religious groups in Texas in collaboration with TMA, hospitals, and disability groups. But physicians still have access to existing safe harbors under the Texas Advance Directives Act for resolving conflicts out of court without being forced to violate their moral beliefs and professional ethics.

A Better Budget 
Lawmakers really only have one required task each session, and that's to pass a state budget. Coming off of a grueling 2011 legislative session that resulted in deep cuts for health care, it seemed there was only room for improvement. Overall, TMA leaders say those expectations were met.

With an estimated surplus of $8.8 billion and a healthy $11.8 billion Rainy Day Fund, lawmakers did not have as tight a budget to deal with and got down to business in drafting a spending plan earlier than usual. Even though legislators still took every remaining day of the session to finalize it, medicine emerged with reparations to last session's harsh cuts amid competing interests to increase funding for education and water and infrastructure needs.

As it heads to the governor's desk, Senate Bill 1 by Sen. Tommy Williams (R-The Woodlands) and Rep. Jim Pitts (R-Waxahachie) spends roughly $197 billion in state and federal funding. The bill increases spending for mental health and women's health services and takes steps to reverse some of the GME funding lost last session.

Overall, GME funding was pieced together in the budget and through additional legislation.

GME formula funding, which took a 31-percent hit last session, was restored in the budget with a 15-percent, or $9.5 million, increase over the 2012-13 biennium. House Bill 1025, a supplemental appropriations bill, includes additional money to increase GME residency slots in Texas.

Lawmakers also restored the Family Medicine Residency and State Physician Loan Repayment programs, which were all but eliminated in the last budget cycle. "The quickest way to get physicians out to underserved areas is to offer loan repayment," TMA Associate Director for Advocacy Michelle Romero said.

Senate Bill 143 by Sen. Jane Nelson (R-Flower Mound), which would have established a new grant program at the Texas Higher Education Coordinating Board for new GME positions and set up additional grants to help hospitals fill unused slots, did not cross the finish line, but some provisions were added to House Bill 2550.

This session was the first in a long time in which lawmakers took a hard look at GME in Texas and its impact on ensuring an adequate physician workforce, Ms. Romero says.

Medical education also will get a boost with approval of new medical schools in Austin and the Rio Grande Valley. TMA also helped stop off-shore medical schools from buying up clerkship spots in Texas hospitals and repealed a 2011 law that forced international medical graduates to spend three years working in only medically underserved areas.

Mental health services funding will see one of the largest increases in recent history with more than $225 million in new money targeting a wide array of initiatives to address Texas' mental health needs, including prevention, early identification, community-based services, and inpatient hospital care. That includes $25 million to promote private-public partnerships to improve mental health care delivery.

Women's health services also saw important gains that made up for drastic cuts during last session's budget crunch and a loss of more than $30 million in annual federal funding after the 2011 legislature voted to exclude Planned Parenthood from the former state-federal Women's Health Program. Texas has since replaced it with the state-only Texas Women's Health Program (TWHP).

Women's health funding also was pieced together through several funding streams. In addition to restoring much of the federal family planning funding that the Department of State Health Services lost in 2011, SB 1 allocated more money for preventive care under the Community Primary Care Services Program and for women's health and family planning services. Lawmakers also fully funded the TWHP.

Medicaid Expansion a Bust; Progress on Reforms
Medicaid reform and expansion stole some of the spotlight this session, and while TMA made progress on the former, the latter went nowhere due to stiff Republican opposition to growing the program as proposed under the Patient Protection and Affordable Care Act (PPACA).  

Medicaid physician payment rates went untouched, as lawmakers grappled with adequately funding the program and its increasing caseloads. Meanwhile, a supplemental spending bill covered the $4.5 billion shortfall in the Medicaid program for this year after the 2011 legislature intentionally underfunded it.

Expansion efforts were scuttled, however, including a controversial rider tacked onto the Senate's version of the budget that would have allowed the Texas Health and Human Services Commission (HHSC) to negotiate state-based reforms with the federal government and draw down millions of dollars made available under PPACA. House Bill 3791, a similar bill filed by Rep. John Zerwas, MD (R-Simonton), failed. Left standing, however, was a rider attached to a Medicaid managed care bill, Senate Bill 7, which requires legislative authorization before HHSC or the governor can develop and seek approval for any waiver request to provide Medicaid coverage to currently noncovered populations in Texas.    

TMA continues to support a Texas-specific plan that allows the state to take advantage of extra federal dollars to cover the working poor under Medicaid and that includes significant reforms to the program. Expansion talks may have stalled, but that didn't stop TMA from making headway on the kind of changes physicians say are critical to attracting doctors back to the ailing program.

One significant step in that direction was Senate Bill 1803 by Sen. Joan Huffman (R-Houston) and Rep. Lois Kolkhorst (R-Brenham), which improves due process and expediency when a physician is accused of Medicaid fraud or overpayments. The bill tamps down controversial HHSC regulations released in 2012 by adding some clarity to the definition of a "credible allegation of fraud" and establishing timelines for the Office of Inspector General (OIG) to notify doctors of an investigation and hold payments in the process.

Ms. Romero says the bill represents some improvement over the original rules, but does not go far enough to give physicians adequate due process and transparency in the OIG's process. The good news, she says, is HHSC and some legislative committees committed to oversee and report back on the Medicaid fraud investigative process, and the OIG has offered to work with TMA on other fixes through the rulemaking process.

"If anything, this [session] did shine a light on the lack of due process, and we have champions [in the legislature] and hope to get better rulemaking in the interim," Ms. Romero said.

Other Medicaid reforms were included in Senate Bill 1150 by Sen. Juan "Chuy" Hinojosa (D-McAllen), which requires HHSC to include a "provider protection plan" in its Medicaid HMO contracts to ensure plans pay claims properly and promptly, or face penalties. TMA leaders say such safeguards are especially important as lawmakers continue to eye Medicaid managed care expansions as a way of generating program savings. Senate Bill 7, for example, by Senator Nelson, expands Medicaid HMOs to people with intellectual and development disabilities and nursing home residents, among other provisions.

Red Tape Reduced; "Silent PPOs" Silenced
The red tape for physicians doesn't stop with Medicaid. Some key TMA-backed bills breezed through the legislature to help physician practices improve efficiency and gain back valuable time and money spent away from patient care. Other bills, despite some hiccups along the way, passed the final week of session.

Beginning Sept. 1, physicians and their staff can check in patients using the electronic strip on the back of their Texas driver's license, thanks to the governor's early approval of Senate Bill 166 by Sen. Robert Deuell, MD (R-Greenville), and Rep. Lyle Larson (R-San Antonio).

Backlogs at the Department of Public Safety (DPS) are likely a thing of the past, thanks to House Bill 1803 by Rep. Bill Callegari (R-Katy) and Senator Huffman. Effective Jan. 1, 2014, renewal of the DPS Controlled Substances Registration will become part of physicians' online medical license renewal at the Texas Medical Board.

Physicians also can look forward to a day when they don't have to deal with hundreds of different prior authorization forms from multiple payers. Senate bills 644 and 1216 require the Texas Department of Insurance (TDI) to appoint stakeholder workgroups to design standardized prior authorization forms for prescription drugs and health care services, respectively, across public and private payers.

Privacy training and compliance standards also will be streamlined under Senate bills 1609 and 1610 by Sen. Charles Schwertner, MD (R-Georgetown). The bills, a collective effort between TMA and the Texas Medical Liability Trust, refine and clarify a related law passed last session by aligning state training requirements with federal rules and by closing loopholes that threatened to subject physicians to multiple state privacy standards.

Nor will physicians have to deal with surprise hassles when companies or secondary networks sell, lease, or share their privately contracted discounts without permission, thanks to new regulations on these silent PPOs.

Several sessions in the making, Senate Bill 822 by Senator Schwertner and Rep. Craig Eiland (D-Galveston) establishes rules to identify these companies, subjects them to TDI oversight, and regulates how a physician's contract information may be shared among entities, including obtaining doctors' express authority to engage in such activities. The new law takes effect Sept. 1, 2013.

"These silent PPO practices mislead patients and cause needless, costly hassles for physicians who fall victim to them. The legislation was TMA's No. 1 priority this session for establishing fair and transparent insurance markets for patients, employers, and physicians," TMA President Stephen L. Brotherton, MD, said.

Similarly, Senate Bill 1221 by Sen. Ken Paxton (R-McKinney) ensures physicians know when their discounted contract rates under Medicaid managed care or the Children Health Insurance Program (CHIP) are applied to other products.

Meanwhile, testimony by TMA physicians helped deter a swath of bills that would have required physicians to give patients up-front binding quotes of the price of their care and subject them to both financial penalties and medical board sanctions for deviating from those quotes. TMA supports transparency in health care pricing, but testified such approaches could be administratively burdensome, especially when it is impossible for physicians to predict all the medical services a patient may need, not only by that physician or health care provider but also by other physicians.

Scope, Immunization Successes
This session also was marked by a flurry of scope-of-practice bills by allied health professionals looking to practice beyond their expertise, whether it was chiropractors attempting to conduct mental and physical examinations of school bus drivers, physical therapists seeking direct access to patients without a diagnosis, or pharmacists trying to vaccinate children.

Those efforts went nowhere, however, due to TMA's vigilance at the Capitol and to a new collaborative standard TMA and key lawmakers set for addressing scope-of-practice issues.

Senate Bill 406 replaces current site-based restrictions for prescriptive delegation and supervision with a more flexible, collaborative model for physician-led, team-based care. The legislation resulted from months of negotiations among TMA, the Texas Academy of Family Physicians, advanced practice registered nurses, and physician assistants spearheaded by Senator Nelson and Representative Kolkhorst.

TMA never deviated from the core principle that diagnosing and prescribing remain the practice of medicine, TMA Director of Legislative Affairs Dan Finch says. However, by bringing together various parties on a pre-session compromise, "what we did was change the conversation. Now we have a process and a model for future scope-of-practice discussions."

Similarly, a compromise TMA struck last session with hospital groups over employment paid dividends this year, he says. Whereas last session medicine contended with more than 20 hospital employment bills, this year there were two, both of which adhered to the 2011 legislation that limited direct hiring to rural areas and mandated protections for physicians' independent medical judgment in employment scenarios, among other provisions.

In another scope win, beginning Jan. 1, 2014, physicians and nonphysicians must wear a badge displaying their name, title, photo identification, the department of the hospital they are associated with, and their status as a student, intern, trainee, or resident. With more practitioners pursuing doctorate degrees and using the title "doctor," the law will help patients know who is treating them and those practitioners' qualifications, TMA leaders say.

The Lone Star State also took a "major step forward" in expanding access to immunizations, TMA Associate Director for Advocacy Troy Alexander says. In addition to these public health advances, TMA also led the way in making progress on childhood obesity and in escalating the cost of  tobacco to prevent future use, top priorities for the Texas Public Health Coalition, of which TMA is a member.

Rolled into an omnibus franchise tax bill, House Bill 500 helps primary care physicians provide vaccinations by allowing them to deduct the cost of purchasing and stocking vaccines from their taxable revenue. The legislation also provides tax breaks to small businesses, which includes many physician practices. TMA also worked to preserve existing physician exemptions in the law related to Medicaid, Medicare, CHIP, Workers' Compensation, and other government payers.

Senate Bill 63 by Senator Nelson and rookie physician Rep. J.D. Sheffield, DO (R-Gatesville), allows a minor who is pregnant or a parent to consent to his or her own immunizations. Senate Bill 64, also by Senator Nelson and Representative Zerwas, requires licensed child care facilities to develop and implement an immunization policy for their employees to protect the children in their care from vaccine-preventable diseases.

Another pair of measures aim to further antiobesity efforts by targeting nutrition and physical activity. House Bill 217 by Rep. Carol Alvarado (D-Houston) and Sen. Carlos Uresti (D-San Antonio) reduces the types of sugar-sweetened drinks sold in Texas' public schools, such as sodas, sweetened whole milk, and electrolyte drinks. The state budget also includes additional money to keep the state "FitnessGram" program alive in schools and to collect data to address the state's obesity epidemic.

The August issue of Texas Medicine  will have details of TMA's 2013 legislative victories.

Amy Lynn Sorrel, associate editor of Texas Medicine, prepared this issue of Political Prognosis. 


Action Special Issue, May 29, 2013

 

 


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