Rural Texas Physician

Fall 2014

Rural Texas Physician is a quarterly electronic newsletter catering to physicians in the many rural areas of Texas caring for patients and their communities. TMA’s grassroots membership is the strength of the association. For general inquiries or newsletter comments, email rural@texmed.org.

Nursing Homes Moving to STAR+PLUS March 2015

Starting March 1, 2015, Texans covered by Medicaid who are eligible for STAR+PLUS and live in a nursing facility will get their basic health services (acute care) and long-term care services through STAR+PLUS. People on Medicaid and Medicare (dual eligible) will receive their basic health services through Medicare and their long-term care services through STAR+PLUS Medicaid.

Medicaid requires health plans to pay nursing facilities within 10 days of submitting a clean claim and to provide discharge planning, transitional care, and other education programs related to all long-term care settings.

Access the Texas Health & Human Services Commission (HHSC) presentation on the transition of nursing facility services to managed care.

Here’s a look at HHSC’s timeline for the transition: 

  • Fall 2013 through implementation: Continue stakeholder communications, information sessions, and health professional training. 
  • December 2014: HHSC sends enrollment packets to people in nursing facilities covered by Medicaid and hosts enrollment events across the state. 
  • March 1, 2015: HHSC begins providing nursing facility services through STAR+PLUS health plans. 

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Broadband Access Needed for EHR Incentive Programs

Physicians living in rural areas may struggle with some of the electronic health record (EHR) meaningful use measures, especially if their patients cannot access the information required. For this reason, there is an exclusion related to broadband access. TMA has received calls about how physicians can find out if they are eligible for this exclusion. 

According to the Centers for Medicare & Medicaid Services (CMS), “An eligible professional that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability, according to the latest information available from the FCC [Federal Communications Commission], on the firstday of the EHR reporting period may exclude the second measure of the Patient Electronic Access objective and the Secure Electronic Messaging objective.” 

The FCC’s national broadband map allows eligible professionals to search, analyze, and map broadband availability in their areas. Physicians concerned about patients having access to broadband should review the FCC’s broadband map. 

If you need in-office EHR consulting, TMA recommends you contact the regional extension center (REC) in your area. Visit the TMA REC web page for details on how the RECs can help. 

If you have questions related to the EHR meaningful use program, contact TMA’s HIT Department at (800) 880-5720 or HIT@texmed.org

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Physicians Get Green Light to Treat Families for Infectious Diseases

Texas physicians may now prescribe medications and vaccines to close contacts of their patients to prevent the further spread of infectious diseases. The Texas Medical Board (TMB) announced the change to its rules in the July 25 issue of the Texas Register

The old TMB rule prohibited physicians from providing postexposure prophylaxis (PEP), or treatment administered immediately after exposure to an illness, to family and close contacts of patients with infectious diseases such as pertussis and meningococcal meningitis, unless the physician had already established a professional relationship with the close contacts and family members.  

TMA, along with the Texas Pediatric Society and the Texas Infectious Diseases Society, petitioned the board to change the rule to better enable physicians to implement Centers for Disease Control and Prevention recommendations. Before the change, physicians in Texas could prescribe treatment to nonestablished patients only in cases of sexually transmitted diseases or when the governor declares a pandemic. Read “Protecting the Family” in the August 2014 Texas Medicine. 

Physicians can help prevent infant cases of pertussis by participating in the Texas Department of State Health Services (DSHS) PEP Program. The program strives to prevent secondary cases of pertussis in asymptomatic contacts and to ensure high-risk contacts receive prophylaxis. 

To be eligible for the program, clients must:  

  • Have been exposed to pertussis within the past 21 days; 
  • Be a confirmed close (household) or high-risk contact of a pertussis case; and 
  • Have a barrier to accessing pertussis PEP.  

DSHS defines high-risk contacts as infants younger than 12 months of age, women in their third trimester of pregnancy, and those with preexisting health conditions that may be exacerbated by a pertussis infection. 

Among the barriers to accessing pertussis PEP are an inability to access medical care within a reasonable time and lack of financial resources to pay for medical care or PEP. 

For more information, contact DSHS

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TMA Has Guidance on Prescribing Schedule II Hydrocodone Products

Over TMA’s objections, the Drug Enforcement Administration (DEA) published a final rule in the Federal Register reclassifying drugs that contain hydrocodone combinations from Schedule III to Schedule II. The change took effect Oct. 6.

[Read TMA’s Q&A for Physicians on the Hydrocodone Reclassification.]

The move is designed to help curb the abuse of hydrocodone-containing medications. It would:    

  • Prohibit physicians from delegating advanced practice nurses and physician assistants authority to prescribe these drugs outside of a hospital or hospice setting;
  • Prevent physicians from calling in prescriptions for these medications to pharmacies; and
  • Prohibit refills of prescriptions for these drugs without a patient visit or consultation.   

Additionally, moving hydrocodone combination products from Schedule III to Schedule II will have an impact on Texas physicians’ prescribing practices. According to the Federal Register, after Oct. 6, drugs such as Vicodin will only be prescribed for a 90-day period. The current federal rule allows patients to receive a 180-day supply of this Schedule III drug.

Please note the rule change affects only hydrocodone combination products. Pure hydrocodone already is classified as a Schedule II drug.

The Texas Department of Public Safety (DPS) website has additional information about hydrocodone. DPS also provides an order form for physicians and an order form for nonphysician practitioners

The American Medical Association released a bulletin regarding the reclassification. 

At TexMed 2014 in May, physicians voiced their opposition to the reclassification in testimony before the Reference Committee on Science and Public Health. In its review of TMA’s current policy on hydrocodone, the Council on Science and Public Health also noted the complexity of the issue, agreeing on the need to study it further to develop a TMA position. In the end, TMA’s  House of Delegates reaffirmed TMA’s policy, which states the association “supports the classification of hydrocodone as a Schedule III, not a Schedule II, drug.” 

The Council on Science and Public Health’s review of the policy regarding hydrocodone classification and management noted that while recognizing the public health problems caused by the misuse, abuse, and diversion of prescription narcotics that result in death and addiction, hydrocodone is associated with more drug abuse and diversion than any other licit or illicit opioid. TMA’s opposition to reclassifying the drug hinges, in part, on members’ perception that this would place unnecessary requirements on physicians and additional burdens on patients.

The council agrees that addressing the public health problems of misuse, abuse, and diversion of hydrocodone requires comprehensive and integrated strategies in education, monitoring, and enforcement.

TMA continues to express opposition to the change in classification and to support a focus on physician education. Find more information or access a free course on the safe use of opioids.

For information on prescribing Schedule II drugs, see Texas Medical Board’s online FAQs.

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New Option for Providing LARCs to Medicaid, TWHP Patients

Physicians now have a new option for providing select long-acting reversible contraceptives (LARCs) to their Medicaid or Texas Women’s Health Program (TWHP) patients.

Effective Aug. 1, the Texas Health and Human Services Commission (HHSC) added Mirena and Skyla to the Medicaid drug and device formulary, allowing physicians the option of writing a prescription for the devices instead of buying and billing, as they had to do before the change.

To provide the device using the patient’s pharmacy benefit, a physician will send a prescription to one of two specialty pharmacies contracted with HHSC to provide LARCs: CVS CarePlus Specialty Pharmacy or Walgreens Specialty Pharmacy. HHSC says physicians who have patients in managed care should “work with the patient’s managed care organization (MCO) to determine which pharmacy should receive the prescription form. The MCO may be contracted with a single specialty pharmacy.” The pharmacy will ship the device to the practice. Physicians will then bill the patient’s Medicaid HMO, traditional Medicaid, or TWHP for device insertion only.

For the participating specialty pharmacies’ contact information, visit the Texas Medicaid Vendor Drug Program website

Only Mirena and Skyla are available under the new option, though HHSC continues to negotiate with other LARC manufacturers to provide their products via the pharmacy benefit. 

A LARC obtained through the pharmacy benefit must be used only by the patient to whom the physician prescribed it. However, physicians will be able to return unused and unopened LARC products to the manufacturer’s third-party processor. 

The new option will make it financially viable for many practices to provide LARCs to their Medicaid and TWHP patients. Currently, the buy-and-bill process means the practice is financially on the hook if the device’s acquisition cost exceeds Medicaid payment. Practices may, however, continue to obtain Mirena and Skyla through the existing process.

The Texas Medical Association, along with the Texas Association of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists, Texas chapter, encouraged HHSC to make the change to increase LARC use. 

According to an HHSC analysis provided to TMA, Texas lags the nation in use of LARCs. Yet numerous studies show increased use of long-acting contraception, such as implants or intrauterine devices, substantially reduces rates of unintended pregnancies and helps women better plan and space their pregnancies. HHSC also is researching a TMA-backed initiative to pay for immediate postpartum insertion of LARCs. Increasing LARC use among Medicaid and TWHP enrollees has the potential to improve birth outcomes while reducing Medicaid costs.

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New CMS Rule Slightly Modifies EHR Program

CMS recently published a final rule designed to give physicians more flexibility with the floundering electronic health record (EHR) incentive program. While TMA appreciates that CMS recognized the need for modification, the association says CMS did not go far enough and did not heed most of TMA’s suggested comments.

The flexibility allows physicians to report Stage 1 or Stage 2 using a 2011 or 2014 certified EHR to meet meaningful use in 2014, but only if the 2014 edition of the certified EHR is not available. TMA is concerned that CMS, in trying to add flexibility, has now added another layer of complexity to the program. 

Physicians need to proceed carefully and should refer to the chart below, also included in the CMS press release regarding program flexibility.

 

CEHRT Chart

Physicians with questions about the federal EHR program can still receive assistance from one of the four regional extension centers (RECs), established to specifically assist physicians with the program. Refer to TMA’s education page for EHR continuing medical education (CME) opportunities on the meaningful use program. 

Physicians who have questions related to the EHR meaningful use program can contact TMA’s health information technology (HIT) Department at (800) 880-5720 or HIT@texmed.org

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