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Opinion and Commentary from TMA

No Progress in Hearing on Medicaid Managed Care Organizations

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The light at the end of the tunnel … is a train.

On Wednesday, the Texas House Human Services Committee, chaired by Rep. Richard Raymond (D-Laredo) (above), held the first in what will undoubtedly be a series of hearings on the issues with Medicaid managed care organizations illuminated in the Dallas Morning News’ recent “Pain & Profit” series.

Representative Raymond’s committee heard testimony from two of the managed care  plans that administer the Texas Medicaid program — Superior HealthPlan and AmeriGroup — and from one family who claims their toddler son is in a “persistent vegetative state” because of Superior’s inaction. 

The buck apparently stopped nowhere.

Superior CEO Mark Sanders opened his testimony by asserting the health plan had done nothing wrong in the case of 3-year-old D'ashon Morris, who in October 2016, pulled out his tracheostomy tube, closing off his airway, according to reports. Records show Superior officials had been warned of that possibility if the boy didn’t have a nurse watching him around the clock, which Superior denied, according to reports. 

“We strenuously disagree with the reporting,” Sanders told lawmakers, adding that the Morning News series was one-sided and that company representatives were not contacted until late in the reporting process.

The mother who testified merely asked for an apology, which never came.

"I strongly believe that they don't have any passion for what they do," she said. "I strongly believe that."

In thanking the health plans for their attendance and participation, Chairman Raymond said that the legislature would “stay on” the health plans.

Future hearings are expected to get much more direct and possibly contentious. 

Next session, the legislature is expected to ratchet up its scrutiny of Texas Medicaid, as the state looks for answers to the problems bedeviling the managed care organizations caring for Texas’ most vulnerable populations. 

Despite the failures and let downs so far, there seems to be light at the end of the tunnel. But right now it’s coming from a train headed in health plans’ direction. 

TMA will keep you apprised of developments and progress.

Beating the Drum on CMV Prevention

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Listening to an old TED Talk about world-famous percussionist Evelyn Glennie, I was struck not by her amazing accomplishment as a deaf musician but by the fact that she slowly began to lose her hearing at the age of 2 and was deaf by the age of 12.

“Preventable,” I thought with a sigh. 


Not many things cause progressive deafness in an otherwise healthy young person — other than one incredibly preventable and terrifyingly prevalent virus that does: cytomeglovirus (CMV). 

CMV? That’s the response I get most often from my patients. 

Everyone knows about Zika and how to prevent a Zika infection. Zika to date has infected fewer than 300 people in the United States. through mosquito bites or by their coming into contact with saliva or semen of an infected person.

Everyone knows about fetal alcohol syndrome, the most preventable type of intellectual disability. There are warning labels on every bottle of alcohol and in every bathroom of a facility that serves alcohol. Fetal alcohol syndrome affects 1 in 10,000 infants (.01 percent), and if you add alcohol-related behavioral disorders, that number increases to 1 percent.

CMV infects 2 percent of every pregnancy. Two percent

More children suffer from long-term neurodevelopmental handicaps as a result of congenital CMV infection than either Down syndrome or fetal alcohol syndrome. It is the most common cause of congenital deafness in the U.S. 

And it is a failure of the medical community that patients don’t know about this virus. 

What is CMV? It’s a congenital infection much like Zika. And just like Zika, it’s really not harmful to anyone but a fetus. It causes, but is not limited to, small head size, mental disabilities, seizures, and deafness.

Where does a pregnant woman come into contact with CMV? She almost always is infected by a toddler, usually her own child. The virus is spread most commonly by sharing food with a toddler or allowing the toddler to put her fingers in her mother’s mouth. (Or the father can get it from a toddler and spread it with a kiss). It is also found in urine. 

Anyone who works or lives with a toddler should take precautions if they or their partner is pregnant or considering becoming pregnant. 

These simple things can help reduce the risk: 

  • Do not share foods, drinks, or utensils with young children;
  • Do not kiss young children on or around the mouth; and
  • Wash hands carefully after changing diapers and wiping runny noses or drool from young children. 

Honestly it’s lack of leadership on our part that we have not spread the word. Please consider this an information vaccination. 

CMV infection is preventable, and its effects on our tiniest patients are worth preventing. Join me in shouting it from the rooftops of social media and in the exam rooms.

Kimberly Carter, MD, is an obstetrician-gynecologist in Austin who is serves on the TMA Task Force on Behavioral Health.

Don't miss July’s issue of Texas Medicine magazine, which looks at three congenital infections that are especially problematic in Texas because of their stubborn rates: syphilis, cytomegalovirus (CMV), and HIV.

Stopping Suicide: Three Things Physicians Can Do

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James_Baker_MDRecent celebrity deaths and new data on rising suicide rates from the Centers for Disease Control and Prevention have drawn attention to the problem of undetected and untreated mental illness. Half of deaths by suicide are by people with undiagnosed mental illness.

How can the practicing physician — primary care or specialist—– help address this growing problem? Here are three things each of us can do: 

  • ASK: Perhaps you, like many physicians, are uncomfortable asking patients about suicidal thoughts. It may seem out of place when a patient has come to you seeking help for a respiratory infection or a painful joint. However, the two-question PHQ2 screen (along with screens for anxiety, trauma, and substance abuse) ought to be administered by staff just as frequently as any other vital sign. Or consider routinely asking patients about suicide as part of the annual exam, for example like this: “Given the recent celebrity suicides and publicity about increasing suicide rates, I’ve decided to start asking all of my patients: Have you had any thoughts that you would be better off dead or of hurting yourself in some way?”
  • TREAT: For most of your patients who screen positive for depression, a licensed psychotherapist and you can provide high-quality, evidence-based care. For medication treatment, use a good algorithm as your guide, and use serial PHQ9s in the same way you would follow blood pressure or cholesterol levels. However, high-quality care usually requires medication and psychotherapy and, besides, it is much more comfortable to ask about suicidal thoughts when you have a trusted mental health specialist working at your side. In primary care and multi-specialty practices, consider hiring your own licensed mental health clinician — a mental health social worker, for example. In fact, new Medicare CPT codes encourage physicians to hire mental health specialists into their practices and even pay for informal consultation from a psychiatrist. Indeed, our collective advocacy for expansion of the use of these “collaborative care” codes to Medicaid and to commercial insurance would greatly improve access to mental health care for our patients.
  • EDUCATE: Consider becoming an advocate for universal training in your community in Mental Health First Aid, a program that teaches people how to spot and address the signs of an emerging mental health challenge or crisis. Your local community mental health center has experts in Mental Health First Aid and would welcome you as a partner in spreading the word about the availability of its training sessions. Mental Health First Aid training allows people to feel more comfortable asking about suicide and other mental health challenges. By the way, most severe mental illness emerges in adolescence and early adulthood, so it is especially important to train high school and college educators how to spot a problem. 

Suicide does not discriminate, and neither does major depression or substance use disorder, both risk factors for suicide.

That means that all of your patients are at risk and, in fact, the patient you are most reluctant to ask about it — perhaps your local celebrity — may be the one who most desperately needs someone in whom to confide. Indeed, many people who die of suicide saw a doctor in the months prior to dying.  

Working together with others in our communities, we can ensure that the next opportunity to save a life is not overlooked. 

James Baker, MD, is associate chair in the Department of Psychiatry at The University of Texas at Austin Dell Medical School and a member of TMA’s Council on Science and Public Health.

Call in the Swat Team: Texas Tackling Vector-Borne Diseases

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June 18 TM Cover Story_Jane Siegel600

Vector-borne illnesses have been vexing physicians for centuries. And they still are.

According to the World Health Organization (WHO), illnesses caused by mosquitoes, ticks, and other vectors kill about 700,000 people worldwide each year.

Texas’ warm climate makes it a prime breeding ground for illnesses such as West Nile virus, murine typhus, Zika virus, and other nasty maladies.

In fact, between 2004 and 2016, Texas saw more than 6,000 cases of mosquito-borne diseases, according to the Centers for Disease Control and Prevention (CDC). That includes a spike of 1,992 cases in 2012, almost all of which (1,868) were cases of West Nile virus, CDC reports.

During that time, 2,140 cases of tickborne diseases were reported, CDC figures show.

Just in time for summer, the June issue of Texas Medicine magazine takes an in-depth look at vector-borne diseases in the Lone Star State.

“Texas is probably the most vulnerable state in the union to these diseases,” said Peter J. Hotez, MD, head of the National School of Tropical Medicine at Baylor College of Medicine in Houston.

Texas has all the conditions for vector-borne illnesses to get worse — an exploding population, fast-growing international trade, a warming climate, large pockets of poverty, and lots of the wrong kinds of insects. In addition, numerous roadblocks stymie the availability of new vaccines.  

Unfortunately, experts say testing for such diseases can be difficult, and the state’s methods of disease surveillance remain inadequate.

To help curb the spread of vector-borne illnesses, TMA backed several bills during the 2017 legislative session.

Meanwhile, TMA’s Committee on Infectious Diseases is working on education efforts to teach Texas physicians about vector-borne illnesses that are frequently misdiagnosed or missed altogether. 

Check out the full story, as well as the entire June issue of Texas Medicine, on the TMA website.

Mosquito-Born and Tickborne Disease Cases, 2004-2016

 About the data:
Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System, Annual Tables of Infectious Disease Data. Atlanta, GA. CDC Division of Health Informatics and Surveillance, 2005-2017.

Science Teacher Awards Reward Medicine, Too

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As the TMA Annual Meeting in San Antonio approached this year, I recalled a memorable House of Delegates session four years ago in Fort Worth.

During the opening session on that Friday morning, the winners of the TMA Ernest and Sarah Butler Awards for Excellence in Science Teaching were being announced. To be honest, I was not paying much attention. I was rummaging through the Delegate Handbook, consumed in reference committee minutia, trying to locate my next destination. The house was buzzing with white noise and background chatter. 

Then a name was announced that I had not heard in years, but somehow a reflex triggered something in my consciousness and made me look up at the screen. Sure enough, there was a picture of a face I had not seen in decades: The first-place winner of the high school award was my own biology teacher, Janet Jones, from Jesuit College Preparatory School of Dallas. 

I was stunned, excited, and proud, all at once. She had instilled in me not only a strong desire to strive for excellence in her biology class, but also in the pursuit of a career in medicine as a whole. It was in her class at that very young stage in my life that my interest in medicine was sparked and nurtured to a roaring passion. I was overjoyed she was being recognized. 

Nor was I the only Jesuit student in the audience that day whom Mrs. Jones had inspired to chase that dream. Keller pediatrician Jason Terk, MD, was another delegate who can look back and identify Mrs. Jones as a very influential mentor in his medical journey. 

The awards were to be given out at the TMA and TMA Foundation’s tradition of a noon teacher’s luncheon presided over that year by then-TMA Board of Trustees member (and, now, past president) Don Read, MD. Even though the event conflicted with my Council on Legislation meeting, I knew what took priority in my heart. This luncheon was something I would have to crash. So I did. 

I snuck into the luncheon after it had already started and quietly stood by the side wall as the presentations took place. As Dr. Read handed out the awards with a brief career synopsis for each recipient, I waited for that special moment to arrive. Finally when Mrs. Jones’ name was announced, Dr. Read summarized her amazing teaching career and the impact she personally had on her students. But before he could hand her the award, I had to raise my hand, interrupting the ceremony so I could add my own first-hand knowledge of the special teacher she is, and how she had shaped my own personal journey as a physician. 

I was so proud she was being recognized in this way by the TMA and our philanthropic foundation that raises the funds for this program. Being able to tell her at that moment what she had meant to me … being able to say “thank you” for everything she had done not only for me but for hundreds of Jesuit students through the biology classes — and the Jesuit Medical Society that she founded — was so rewarding. At the conclusion of the presentations, we got together to share some special memories and a very special hug. 



Who knows … perhaps this year other TMA physicians looked up from the House of Delegates floor and saw their own early medical career mentors honored and recognized for the very special teachers that they are. 

Dr. Snyder is a Dallas cardiologist and member of the TMA Board of Trustees. This year’s TMA Ernest and Sarah Butler Awards for Excellence in Science Teaching were presented at TexMed 2018 in San Antonio in May. For more information about the awards and the TMA Foundation, visit