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Opinion and Commentary from TMA

A Chance For Your Patients to Meet You Face-to-Facebook

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Mehta selfie

What does Plano psychiatrist Sejal Mehta, MD, do during a regular workday?  

What routines does she regularly perform, and what does she do when she’s not in her practice?

Dr. Mehta, the chair of TMA’s International Medical Graduate section, gave about 6,000 people a look into her daily life Tuesday when she took over the Texas Medical Association (TMA) Facebook page.

Dr. Mehta posted regular updates throughout the day, including her morning routine, staff meetings, and speaking for a TMA Physician Health and Wellness ethics CME course.

Once a month, TMA gives a member physician the opportunity to host its Facebook page. If you or one of your colleagues is interested in hosting the page, send us a direct Facebook message or email Jen Rios at TMA.

Below are some excerpts from Dr. Mehta’s takeover:

Good morning! I’m Dr. Sejal Mehta and I’ll be hosting the TMA Facebook page today. I’m looking forward to sharing a glimpse into my daily routine with you. Just a heads up that I’m a psychiatrist — this means that while there’s never dull moment in my life, there certainly won't be any jazzy pictures of surgeries or procedures. I look forward to getting ready everyday with my morning rituals including Pooja (meditation and prayers) and then some masala chai.  

Mehta 2

I drive more than 100 miles a day, every day. And believe it or not, I love every minute of it. Inspirational speeches, music, and phone calls are part of my daily drive routine. Here I am getting ready to hit the road.

Mehta 4

I feel very privileged to work alongside Dwight Lacy, CEO of Millwood Hospital in Arlington and Robert Bennett, MD, Medical Director at Millwood. Our goal is to provide best possible care to individuals in their most vulnerable times. We are setting the bar very high.  

Mehta 5

This is our treatment team meeting. This is where staff comes together to discuss each case, formulate a treatment plan, create after care plans, and ensure the utmost care is being met. 

Mehta 8

When I get home I like to reach out to my son and daughter, who are both are in college out of state. Seeing them puts a smile on my face. Here is a picture of my family.

Congress Puts CHIP Back on Course

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CHIP blog photo

The news was almost lost amid the furor over the government shutdown and immigration politics. But it did happen. Funding for CHIP was extended for six more years on Monday.

Federal funding for CHIP, which provides health coverage for almost 400,000 Texas children, expired Sept. 30. Since then, members of Congress have given lots of verbal love to CHIP but claimed to be unable to find the money to finance the program for another six years. Over the ensuing 114 days, families worried, states made and began to exercise contingency plans, and Congress propped up the program for a few more months. 

All of those problems melted away yesterday when — in the span of about 12 hours — the Senate and then the House passed, and then President Trump signed the bill that reopened the federal government and puts CHIP on firm footing for the next six years.

“In this day and age, the only thing we have to be certain about is uncertainty itself,” said TMA President Carlos J. Cardenas, MD. “Six years of dependable CHIP funding is good news for the state budget, for Texas children, for their families, and for the physicians who care for them.”

CHIP covers physician and dentist visits, hospitalizations, prescription drugs, and more for kids up to age 18 whose families make too much to qualify for Medicaid but too little to afford commercial insurance. 

It’s a good deal for the families. They pay annual enrollment fees of $50 or less, and copays for office visits and medications of $3 to $35.

It’s a good deal for the state treasury. Children are generally healthy and not very expensive to insure. Since passage of the Affordable Care Act (ACA) in 2010, the federal government has picked up an “enhanced share” of the costs. For Texas this year, that’s 93 percent. So Texas taxpayers pony up about $70 million for a program that costs almost $1 billion. The April 2017 enrollment stats show CHIP covers 393,000 children in Texas; about 36,000 Texas women also receive prenatal care and post-delivery checkups with CHIP funds.

Under the law passed Monday, the enhanced rate stays in place through fiscal year 2019, it drops to 82.5 percent in fiscal 2020 and reverts to its pre-ACA match of 71 percent by fiscal 2021.

It’s not a bad deal for physicians. Even though CHIP pays the same low rate as Texas Medicaid, it generates far fewer complaints about paperwork and bureaucratic interference.

It's a good deal for the federal treasury as well — in the perverse world of Washington economics. According to the Congressional Budget Office, the net cost of the six-year extension is only $800 million, and a 10-year extension actually would have decreased the federal budget deficit by $6 billion. 

And, of course, it’s a great deal for the CHIP kids themselves. It helps them stay healthy, in school and on the job, and out of the emergency department.

Fontenotes: Three Things to Watch in 2018

(U.S. Congress) Permanent link

By Sarah Fontenot

As 2018 peeks over the horizon, it promises to be another year of health care headlines and talking heads, with political free-for-alls, wins, and losses.

Sarah FontenotThere will be many things to keep track of, including (presumably) some issues we don’t even know about yet.

But I promise you there will be at least three things to be watching in the year to come, and I would like to give you a quick preview of each.


Please read on!

1. Will there be an Obamacare Repeal & Replace 2.0?

Politicians do not return to the scene of their most significant defeats, and the Senate is not known for picking up controversies that die on their chamber floor.

That explains why, after the Senate bill to defeat Obamacare failed in July, Senate Majority Leader Mitch McConnell (R-KY) announced “that the Senate will give up on its bill to replace” the Affordable Care Act (ACA) and focus on repeal only “in the next two years.”

After the second defeat in August, McConnell described the future of the effort as “murky” and said that Republicans in the Senate would talk with Democrats to find measures on which the two parties might be able to agree.

A surprising third blitz for repeal and replace under a bill co-sponsored by Sens. Lindsey Graham (R-SC) and Bill Cassidy, MD (R-LA) died without a vote on Sept. 26, and the party moved on to the Tax Bill.

With three strikes out*, many watchers thought 2017 would bring the end to the “Repeal & Replace” fervor. (*More depending on how you count the bills.)

Accordingly, on Dec. 22 McConnell told the Associated Press he was skeptical at best about revisiting Obamacare in the Senate. On the 29th (pointing to the loss by Roy Moore in Alabama that brought the GOP Senate majority to one seat) he reiterated that in 2018 the Senate would “probably move on to other issues.”

But has anyone told Sen. Lindsey Graham?

On Dec. 21, Graham tweeted: "To those who believe — including Senate Republican leadership — that in 2018 there will not be another effort to Repeal and Replace Obamacare — well you are sadly mistaken."

A week later, Graham announced his commitment with Senator Cassidy to renew the push in 2018 for their bill that failed in the fall.

Is the Senate poised to begin “Repeal and Replace 2.0?”

Be watching.

2. Will the Insurance Markets be Stabilized?

In a Fontenotes last April I explained the controversy surrounding subsidies to insurance companies under the ACA in some detail. I returned to the issue in October to highlight the bipartisan effort led by Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) to save the subsidies after an executive order from President Donald Trump stopped them.

Those same subsidies will be a “hot topic” for Congress moving into 2018. There is significant disagreement among Republicans about continuing to reimburse insurance companies under the ACA formula, particularly in the House of Representatives. As I described in my previous Fontenotes, the result of that debate could significantly raise the cost of insurance on the ACA exchanges, and arguably for the rest of us as well.

But no one will be watching what happens next more closely than Sen. Susan Collins (R-.ME).

You will remember that Senator Collins was a crucial vote for the GOP in 2017; she voted (or announced her intent to vote*) against all three “Repeal and Replace” efforts in the Senate.

(*Her announced intention to vote against Graham-Cassidy was “the final death blow” to the bill that died with a whimper- not an actual vote.)

And then came the Tax Bill in December.

Explaining her vote (again crucial) to pass the tax bill, Senator Collins “told reporters she had an ‘ironclad’ commitment from McConnell and Vice President Mike Pence to pass legislation by the end of the year to stabilize Obamacare premiums.”

But that didn’t happen.

With a now one-vote majority in the Senate, can the GOP leadership afford not to keep that promise to Senator Collins in 2018? And if broken, how will it affect her vote on her other choice health care issues, such as protecting Medicare?

I am confident Senator Collins will be watching to see what happens with the Alexander/Murray compromise to subsidize the insurance markets.

And so should you.

3. Will CHIP be Saved?

The Children’s Health Insurance Program [CHIP] was created in 1997 as a joint federal-state program to provide health insurance to low-income children whose families are not eligible for Medicaid, but are too poor to be able to afford insurance.

It currently offers free or reduced-cost health care to nearly 9 million children, with some states taking the option under the law to cover pregnant women as well.

From its inception, CHIP has enjoyed “unusually strong bipartisan support,” yet this fall its funding fell victim to the other pressures on Congress, and “disagreements between the House and Senate over how to offset funds.” (Congress did not begin to start with the necessary legislation to renew its funding until October, although they have known for two years that funding was set to expire Sept. 30.)

A $3 billion stop-gap measure passed in December was supposed to keep the program alive until March 2018, but that is proving to be not true.

CHIP is an issue that affects all states, but some are running out of money more quickly. In November, Texas requested $90 million from the Centers for Medicare & Medicaid Services to keep its program running through February, and received $135 million in mid-December. Wisconsin (which by state law must continue coverage even if the federal government reneges) announced it would lose $115 million a year if Congress does not act. Pennsylvania only has enough funds to last until February, which will mean “176,000 children are going to be without health insurance.” (Notice all three examples are “Trump States.”)

The Trump Administration and many states are “fervently” searching for additional stopgap measures while waiting for Congress to address the funding issue.

However, with Congress having to return to the budget in January – as well as other “daunting” tasks such as budget caps, DACA, disaster relief, and now sexual harassment procedures – how will CHIP fare?

More to the point: How will CHIP be measured by those (such as Speaker Paul Ryan) who hope 2018 will be the year when entitlement reform is a priority?

Lots of people are worried about the future of CHIP, but only Congress can save it. Will they?

Be watching.

Want to know more?

Keeping track of how DC is changing health care is a full-time job. There are a number of resources I rely on, but none are more valuable to me than “The Health 202,” a Power Post from the Washington Post. It is written by Paige Winfield Cunningham and is exceptional. Here are some end of year examples I think you would enjoy:

I highly recommend you sign up to get Paige’s posts directly. (A “Sign Me Up” button appears at the end of each post I just listed.)

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers. Visit her website.

Introducing the TMA LAC ― The Limited Acronym Campaign

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Alphabet soup photo

Physicians swim in an ocean of acronyms and abbreviations. Some are scientific (pH, O2, DNA), and some are clinical (COPD, ESRD, ABG). You went to school for years and years to learn and understand those critical concepts.

The most maddeningly, annoying, and hard-to-remember acronyms have to be the bureaucratic acronyms imposed on you from the desk jockeys in Austin and Washington.

Last week, Editor David Doolittle and I chuckled sadly over these sentences that were poised to appear in Texas Medicine Today

  • You have to submit 2017 data to the CMS QPP by March 31 of this year for MIPS and APMs; and
  • MedPAC is ready to see Congress blow up MIPS just one year after its launch.

Thankfully, we rewrote them to put some standard English in there.

The genesis of this alphabetical nightmare seems to be the growing self-importance of our government agencies and the people who work for them. The bureaucracies themselves and the programs they run all have multi-word, important-sounding names.

In Texas, we no longer have a state Health Department. It’s now the Texas Department of State Health Services (DSHS).

I did a little research on the history of the U.S. Centers for Medicare & Medicaid Services (CMS). When President Johnson signed the bill into law, the new programs were administered by the Bureau of Health Insurance. In 1977, it became the much more important sounding Health Care Financing Administration (HCFA). In 2001, it transitioned to CMS. I’m not sure of the real distinction among a bureau and an administration and a center, but I can say that Google has no mention of the Bureau of Health Insurance being called “BHI.”

Of course, every time one of these agencies implements (translation = “starts”) a new program, it comes up with a Name Full of Capitalized Words and an accompanying acronym. Unfortunately, none of these alphabet tricks do anything to improve the quality of the project ― or the quality of health care you provide.

All of this is the predicate for a new project here at the Texas Medical Association. I call it the TMA LAC – the Limited Acronym Campaign. The basic premise is this: We won’t use or introduce any acronyms related to the work we do for you simply because they’re easier to type. Our mission is to help Texas physicians overcome the challenges they encounter in the care of patients ― not to make it harder.

The most important reason for the LAC is to avoid forcing you to remember or decipher even more confusing terms and letter combinations. I’m also trying to make sure we don’t fall into the trap of acronym-induced highfalutinitis. 

The first outlawed acronym under the LAC is “CMS” – for county medical society. There’s no reason to conflate the bedrock of TMA’s grassroots membership with a hated federal bureaucracy.

Also, the TMA organizational chart includes the HOD (House of Delegates), COL (Council on Legislation), and TMAA (TMA Alliance). That’s fine shorthand for us to use in house, but we don’t have to impose it on you.

And finally, we have our Programs of Capitalized Words … but I’m nixing the acronyms. Hard Hats for Little Heads can be “Hard Hats” on second reference, but not HHLH. Be Wise ― Immunize can be “Be Wise,” but not BWI. And the Hassle Factor Log can stay just like that; you won’t be reading about the HFL.

In the meantime, we’ll focus our real energies on finding easier ways for you to report the HbA1c levels of your T2D patients to the CMS QPP ― or maybe sign on to the plan to blow up the QPP altogether.

CHIPping Away at a Long-Term Extension

(U.S. Congress) Permanent link

CHIP blog photoMore than 100 days have elapsed since the Children’s Health Insurance Program (CHIP) expired, and as yet there’s no deal to renew the program permanently, despite proclamations of its importance and feigned dismay at its lack of funding.

Lawmakers passed a continuing resolution, or stopgap spending bill, in late December before leaving Washington for the holidays. That continuing resolution expires Jan. 19, which coincidentally is when some states will get close to running out of funds, even though the short-term appropriation of $2.8 billion was intended to last through March.

The continuing resolution funds Texas’ CHIP program through March, with some contingency funding available after that should talks break down and progress screech to a halt. But 450,000 Texas children and pregnant women are counting on leadership in Congress to ensure contingencies do not need to be activated.

The recently passed Tax Cuts and Jobs Act, which in part eliminated the individual insurance coverage mandate, could drastically reduce the amount of funds needed for CHIP: A five-year extension will add about $800 million to the deficit, a significant reduction from the original $80 billion price tag. A 10-year extension would save roughly $6 billion, based on a new score from the Congressional Budget Office.

The complicated reasoning for the reduction follows several tracks:

  • States’ federal match rate would return to the level in place before the Affordable Care Act became law, from 93 percent to 69 percent, thus reducing expenditures.
  • Without individual mandates, premiums could go up, which would mean larger subsidy payments. Covering children and pregnant women in CHIP yields a larger reduction in spending related to marketplace coverage.
  • No CHIP funding, or even a reduction, could cause parents to cover their children through the marketplace, increasing federal spending.
  • Regulatory changes have made marketplace coverage for children more expensive, increasing federal spending.

All of this is to say that, essentially, the tax bill and regulatory changes have made marketplace coverage more expensive. Therefore, the federal government would spend less covering children and pregnant women through CHIP because of reduced expenditures on Medicaid and subsidies.

There is consensus among federal legislators to renew CHIP and optimism that full funding, instead of month-to-month piecemeal nickels and dimes, will happen in the very near term. 

The unknown is the vehicle:  

  • It could be a primary component of a continuing resolution due by Jan. 19, 
  • It could be a component of a full government budget if that budget is prepared by Jan. 19, or 
  • It could materialize as a stand-alone CHIP bill. 

TMA will continue to monitor the situation and let you know how you can help break any log jam.


Fix the Broken Windows of the Medical Profession

(Under Pressure) Permanent link

window story photo
  By Suneel Dhand, MD

This story was originally published on and is reprinted with permission.

I am honored to be a member of the medical profession. Being a physician is a great job and a highly rewarding thing to do. One of the aspects that I like most, unlike so many other desk or number jobs, is that you can never go home in this line of work thinking that you haven’t done something good with your day (if you do, there’s something seriously wrong).

The everyday interactions with patients and families ― getting to know them and using one's skills to serve them — are not only deeply rewarding but also very humbling. It’s those positive interactions that sustain me, even on the worst days. I have zero regrets about becoming a physician, something that I’ve also written about previously.

Having said all of this, it’s no secret there’s an epidemic of physician burnout and job dissatisfaction out there. This is for a multitude of reasons, but everything ultimately boils down to a monumental loss of autonomy and independence among doctors, as there’s been a dramatic shift of power and clout away from individual physicians and toward administrators and the business side of health care. Somewhere along the journey, we have lost our direction completely. Unfortunately, in many ways, we have nobody but ourselves to blame collectively because for any large group of respected people to surrender so much autonomy so quickly, a lack of strong leadership must always be a factor.

I am a huge fan of the "broken windows" theory of getting a grip on a problem. In the 1980s and early 1990s, New York was a city in terminal decline. Growing up in England, I knew many people who came back from trips to America telling us about how terrible and dirty the city was. Times Square was basically a no-go area full of aggressive panhandlers. It was a dangerous and scary place. Enter Mayor Giuliani in 1994, and the city underwent a rapid transformation. I understand that some aspects of what Mayor Giuliani did were viewed by (some) as controversial, but not wanting to get into politics, the results were unquestionable. The broken windows theory of turning around New York City went something like this: Heavily target the minor offenses first. Zero tolerance for broken windows, graffiti, and other things such as “squeegee men” who would aggressively approach you when your car was at a red light. So the philosophy goes: Clamp down on the small infringements, and the bigger things will take care of themselves.

The results of this clampdown for New York City were indisputable. By the time I first visited America in 1998 ― New York City being my first stop on a countrywide tour with my family ― Manhattan had become one of the safest and most pleasant places in the country. There was a visible police presence on every street corner, and the city was immaculately clean. Whatever people say — drastic circumstances call for drastic actions. Even today, Manhattan is still one of the safest cities in America, and tourists from all over the world give glowing accounts of their stay in the Big Apple (in fact, low-level crime is actually much lower than in many European cities, including my home city of London). Thank you, Mayor Giuliani.

We all probably have our own personal experiences of how true the broken windows theory is and its everyday applicability. Teaching children good behavior is one such example, when not allowing major bad habits to flourish starts with forbidding the small things first. But let’s get back to health care. For positive change to occur, consider these seven broken windows for physicians:

1. Completely reject the word “provider.” I have written previously about the implications of the now universal use of the word “provider” and have also penned an open letter with the chief executive officer of the American Board of Physician Specialties, William Carbone, to all medical societies and organizations. The word really has taken over, especially evident during the last decade. I am equally shocked by how new residents are being churned out of some of the most prestigious academic centers in the country (my experiences are with the ones in Boston) and are adopting the word so casually, happily describing themselves as “providers” on correspondence, including their social media accounts. The business and marketing world really has done a number on us and has run rings around the medical profession. Unfortunately, physicians are also very naïve as a group in understanding the immense power of words and how not calling ourselves “doctors” or “physicians” anymore is extremely bad for our profession. I personally am okay with many other terms if a more encompassing one is required for certain correspondence, including “clinician” or “practitioner” — but "provider" is deliberately dehumanizing and, also in my view, an insult. If you refuse to use the word and call people out on it, they will stop calling you one. It should be removed from all administrative correspondence including information technology (IT) systems.

2. Insist on a good physician lounge in your hospital. It’s so much more than a physician lounge. It is a marker of professional respect and autonomy. This (very small) job perk has rapidly fallen away. I recently wrote an article on this, which went viral online, being shared more than 20,000 times. That’s because it struck a chord with thousands of physicians who have seen it happen. Lobby for its return in the hospital where you work, and encourage physicians to use it again in their downtime — even for brief meetings.

3. Stand your ground with administrators. As much as hundreds of thousands of employed physicians across the country have a fraught and tense relationship with their administrators. Let’s be realistic: Administrators are very much needed in any organizational structure, and health care desperately needs good ones. However, if you sense that any directive is coming through that will interfere with, or be detrimental to, frontline care, it’s crucial that you sensibly and, of course, diplomatically stand your ground. If you don’t stick up for good health care and your patients, nobody else will.

4. Fix electronic health records. Almost every current study of physician job satisfaction and career burnout lists the burden of cumbersome and clunky electronic medical records at or near the top of the list of everyday frustrations. It’s an issue that is almost invisible to bureaucrats and administrators, but no doctor went to medical school to spend the vast majority of his or her day filling out click boxes and typing out bloated notes for billing purposes. Most electronic medical record systems (I’ve worked with nearly all of them, and in my opinion they all suck) can be optimized in small ways to improve workflow and reduce the “click burden.” What it does require is relentless feedback to your hospital IT department to do so (remember, the main vendor has no motivation whatsoever to improve things because it has a monopoly once the system is installed). Electronic medical records are one of the only examples of technology where the end-user is not the “customer” (imagine how bad the iPhone would be if it worked like that). The companies sell to administrators, so it’s up to physicians to be as vocal as they can.

5. Keep other physician perks. Being a physician is one of the most intense and grueling jobs one can have. Practicing medicine is not for the faint-hearted. Yes, everyone in health care works hard — but no profession should be actively losing things. Are other useful perks like car parking, a nice office, or cleaning services being taken away from you? Well, they shouldn’t. What about the other useful workflow issues, such as the transcription service axed to save costs (now stuck with tremendous inefficiency, with what used to be a thorough, logical note dictated in five minutes now becoming a series of tick boxes, typed sentences, and incoherent computer-generated mishmash)? It may take multiple emails, phone calls, or face-to-face meetings, but you should insist on keeping job perks that a professional of your level of education and intelligence deserves. If the executives in your hospitals have reserved parking spots and secretaries to make their lives easier, there is no way that the physicians should not!

6. Collegiality. No profession is anything without collegiality. It’s one of the reasons why the physician lounge issue is so important. Doctors need to see themselves again as a unified profession — not one that is fragmented where everyone is in their own little corner specialty. Get to know as many specialists as you can, organize social events where all physicians can mingle, and talk to each other about how you can get things done. Along the same lines, the link between primary care and hospital-based specialists has been breached by the fact that primary doctors no longer come to the hospital (even as a hospital medicine doctor myself, I see immense drawbacks to this). We need to restore communication among all physicians, especially primary care physicians.

7. Professional respect. I am all for respecting everyone I work with, and health care is a team-based effort. But when it comes to a clinical situation, the physician is the leader of the team. Period. However, there are lots of ways in which I’ve noticed physicians nowadays being treated much more as “coworkers” rather than as the team leaders they are (and to be fair, physicians also need to step up to the mark). One such example I’ve noticed is that many colleagues in the hospital now immediately address doctors by their first name instead of “doctor.” Now, I’m not someone who minds being called by my first name, and thankfully most people ask first — but I just find it inappropriate when someone in the hospital, who may actually be much younger than me (frequently also including administrators), walks up and calls me off the bat by my first name. Interestingly, I have heard feedback that this actually tends to happen much more to female than male doctors. Every physician has earned the title and deserves to be addressed as such initially in the professional setting. Again, this is not to sound haughty — but most doctors will find anything else a bit uncomfortable and not protocol. The same applies to certain other professionals — university professor, airline pilot, or even military personnel — titles are the norm of introduction until told otherwise.

These are just seven of many relatively low-hanging fruit scenarios in which physicians can, on a daily basis, work toward making sure they retain their professional status. Most of them are free or with minimal associated cost. Remember, we are an ancient and noble profession, and being a doctor is very special. It’s a privilege to use our education and skills to help people get better each and every day. If you want to advocate for the medical profession, deal with low-level stuff, and the rest will start to take care of itself. Of course, there are undoubtedly much bigger things than the seemingly small things noted above: reimbursements, overwhelming bureaucracy, and information technology, to name just a few. They will all have their time and place to be dealt with. But, doctor, start fixing those broken windows first.

Suneel Dhand is an internal medicine physician and author. He is the founder of DocSpeak Communications and cofounder of DocsDox. He blogs at his self-titled site, Suneel Dhand.

Photo Credit: Wikipedia


145 Days: It’s About Time, JAMA

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By Steve Levine

A coworker suggested that maybe their workflow got all “JAMA-ed” up. I don’t think so.

It looks like the 145 days it took the Journal of the American Medical Association (JAMA) to publish a 279-word, five-paragraph response to a commentary that ran in August 2017 is exactly the slow and methodical pace the JAMA editors intend.

That kind of approach is well-suited to clinical articles, where the author’s science and reasoning deserve strict scrutiny.

But when you’re dealing with opposing opinions on an important health care policy issue, the dialogue needs to move quite a bit faster.

Here’s what happened.

  • On May 29, 2017, the Texas Legislature passed Senate Bill 1148 by Sen. Dawn Buckingham, MD (R-Lakeway). Strongly backed by TMA, the bill created a new law to protect Texas physicians against mandatory maintenance of certification tyranny.
  • Ten weeks after the bill passed, on Aug. 7, 2017, JAMA published a commentary from a former chair of the American Board of Internal Medicine Board of Directors. Dallas internist David H. Johnson, MD, called SB 1148 a "threat to professional self-regulation" by physicians and went on to write that the bill "weakens [physicians'] claim to self-regulation by establishing a precedent for additional governmental intervention into the practice of medicine." 
  • Three days later, on Aug. 10, TMA President Carlos J. Cardenas, MD, wrote his five-paragraph response to Dr. Johnson’s commentary. He agreed on the importance of self-regulation to the profession. 
  •  "It encompasses our responsibility and our authority to establish and enforce standards of education, training, and practice," Dr. Cardenas wrote. "We routinely defend that responsibility and authority in advocating against the intrusion of all third parties — such as government, private insurers, hospital administrators — into the practice of medicine." 

     But physicians in Texas and across the country, he argued, do not see the certifying boards as "self." 

     "They are, instead, profit-driven organizations beholden to their own financial interests," Dr. Cardenas wrote. "In fact, they are now one of the outsiders intruding into the practice of medicine." 

  •  If Dr. Cardenas was hoping for a robust conversation on an issue that’s critically important to U.S. physicians, he didn’t count on the JAMA processes, starting with an automatic four-week delay before his response even went to an editor. Then, after about two weeks of editorial review and revision, JAMA informed Dr. Cardenas on Oct. 25 that his rebuttal had been accepted for publication.
  • It took another 69 days ― until Jan. 2 of this year ― before his words actually made it into print. All told, 145 days passed from when Dr. Cardenas submitted his response until it was published; that’s five days longer than the entire 2017 session of the Texas Legislature.

As a leading medical journal, JAMA rightly goes beyond purely clinical or scientific studies. In fact, the journal includes this among its critical objectives: “To foster responsible and balanced debate on important issues that affect medicine, health, health care, and health policy.”

JAMA timeline2

But when that debate happens so slowly that it becomes disjointed, when it happens so slowly that even glacial-pace lawmakers already might have decided an issue and gone home, JAMA is missing an important mark. Perhaps the editors need to expend a little more energy on another of their critical objectives: “… to produce a publication that is timely …”

In an age when you can post a response to an online news article immediately, when you can get a letter to the editor published in less than a week, 145 days just won’t cut it. 


CHIP Rings In a New Year – Sort Of

(U.S. Congress) Permanent link

By Jennifer Perkins

CHIP story photo

According to a recent survey by the T.H. Chan School of Public Health at Harvard University, renewing funding for the Children’s Health Insurance Program (CHIP) is the public’s top priority for Congress.

Yet here we are, three months past its expiration, with no resolution in sight despite a fresh new year full of promise and hope. 

The Continuing Resolution, or stopgap spending bill, lawmakers passed before leaving Washington for the holidays provided $2.85 billion for CHIP and $550 million for community health centers through March 31, but a long-term, bipartisan deal remains elusive.

Democrats and Republicans are divided over how to pay for the program. A five-year extension of CHIP would cost about $80 billion.

The House passed a five-year extension, but Democrats objected to using funds from the Affordable Care Act’s (ACA’s) prevention and public health fund, and reducing Medicare benefits for lottery winners and wealthy enrollees.

A bill that cleared the Senate Finance Committee in November did not detail how the program would be funded and was never taken up by the full chamber.

Since 1997, when CHIP was enacted with bipartisan support, it has provided critical health care services to children in working families who earn too much to qualify for Medicaid but too little to afford private health insurance. In fact, CHIP has helped cut the number of low-income, uninsured children across the country by 80 percent, dramatically increasing access to health care. Figures from the Texas Health and Human Services Commission show that CHIP covers more than 400,000 children here.

CHIP provides states with significant design flexibility to meet the specific needs of their child populations. And because CHIP is a program built specifically for children, its benefit design — which emphasizes receiving medical services in a primary care setting — and its robust provider network meet children’s unique needs. CHIP is particularly successful in accommodating children with special health care needs.

Research by the Government Accountability Office shows that CHIP coverage has more comprehensive benefits and is more affordable than either marketplace or employer-sponsored coverage. Congress simply must continue federal funding of CHIP at the enhanced matching rate in effect for each state as of Sept. 30, 2017, in accordance with the 2018-19 General Appropriations Act. In Texas, that enhanced matching rate is 93 percent.

Loss of CHIP coverage would mean almost 400,000 vulnerable Texas children would be forced into the expensive, unstable individual marketplace, likely resulting in much worse access to health care. After the natural disasters that recently ravaged Texas, including Hurricane Harvey, disrupting or eliminating coverage for children could be disastrous to their health.

Texas’ fiscal health would suffer as well. Returning CHIP to its previous match rate of 69 percent, its funding level before the ACA expanded it, would result in the loss of several billion dollars of federal funding at a time when we can scant afford the reductions and would not have time to plan. Eliminating CHIP altogether would mean billions in additional expense — tremendous unaffordable costs — and drastic cuts that children do not deserve.

Simply put, not extending CHIP would place an untenable burden on Texas’ budget and residents at a time when Texas added more residents than any other state in the previous year. With an end-of-March deadline looming, letters informing families of cuts would need to be sent in February. Texas children deserve a much better Valentine than that.