Ambitious Agenda

Restoring Cuts, More Physicians Top TMA 2013 Goals 

 Texas Medicine Logo 

Cover Story – January 2013 

 By Amy Lynn Sorrel 
Associate Editor  

Tex Med. 2013;109(1):18-27.

When the curtain rises this month on the 83rd Texas Legislature, organized medicine faces another tight state budget as it seeks to mend the grueling cuts levied last session on various health care programs. That's just one of the many ambitious goals the Texas Medical Association has in its legislative agenda.

More money from increased state revenue and more physicians serving in the legislature may give some wings to TMA's advocacy efforts. TMA will work to restore funding for treating dually eligible Medicare/Medicaid patients and for graduate medical education (GME); mitigate financial and regulatory pressures that have Medicaid physician participation rates at an all-time low; and defend against scope-of-practice infringements, cracks in liability protections, and attempts to undermine physicians' clinical autonomy. TMA also hopes to make headway on public health initiatives like smoking cessation and chronic disease prevention.

But a Republican-dominated legislature bent on belt-tightening will generate substantial headwind as lawmakers seek to get the state budget back in the black while still climbing out of a $27 billion hole from last session. A $4.7 billion shortfall in the current Medicaid budget and increasing caseloads will put the program front and center this session and likely impact other available funding.

Now that the presidential election likely secured the fate of the Patient Protection and Affordable Care Act (PPACA), discussions on state-level implementation of the federal health system reform law – or lack thereof – also should hit the Capitol floor.

Amid those debates, "TMA will be focused on finding ways to utilize the health care delivery system and make it such that physicians can function and have the ability to deliver the care that's needed as we move forward in a much more complicated system," said Dallas psychiatrist Leslie Secrest, MD, chair of TMA's Council on Legislation.

"Our priorities are to maintain the gains we've accomplished, while moving forward in terms of addressing funding issues, medical education, and providing a stable physician workforce. Some things we'll have to look at and ask whether they are broken before we tinker with them. But a lot of physicians might say a lot of things are broken, and we have to ask ourselves, how do we improve them?" he said.

A Better Budget? 

Fort Worth pediatrician Gary Floyd, MD, a consultant to the Council on Legislation and a former chair, says the 2013 Medicaid shortfall and other budget outlays going into this session will "make it difficult" to advocate for new funding for Medicaid or other projects.  

An unexpected boost from sales, oil, and gas taxes spiked 2012 state revenues beyond expectations, possibly generating enough cash flow to cover the Medicaid deficit and other shortfalls, according to the Texas Taxpayers and Research Association, of which TMA is a member.

If the trend holds – a big "if" – there also could be enough funds to cover normal spending demands for 2014-15, though "normal" would not include costs related to a pending school finance lawsuit, for example. Nor is it clear whether enough funding would remain to restore last session's massive cuts or monies diverted to get by, at least without dipping into the state's Rainy Day Fund, a reserve estimated to reach $8 billion in 2013.

Legislative Budget Board (LBB) Assistant Director Wayne Pulver told Texas Medicine that lawmakers this session will need to address more than $11 billion in budget shortfalls and deferrals. They resulted in large part from the 2011 legislature's decision to underfund Medicaid by $4.7 billion in fiscal year 2013 and to defer to fiscal year 2014 nearly $2 billion in some payments to school districts.

Still, Dr. Floyd says that won't stop TMA from pushing for funding it considers essential to preserving access to care or defending against new payment cuts that could harm access.

"We are in the mode of last session. We don't want to lose any ground. And we need physicians to keep seeing these patients," Dr. Floyd said.

A top budget priority for TMA will be to restore Medicaid coverage of the Medicare Part B coinsurance and deductible for dually eligible patients – those covered by both Medicare and Medicaid.

In 2011, the legislature directed the Texas Health and Human Services Commission (HHSC) to limit payment for those patients' services to the Medicaid allowable, meaning that if Medicare paid more for a service, which is almost always the case, the state would not pay any more. The legislature approved the cut because officials estimated it would save nearly $300 million, an amount that since grew to $465 million. Before the change, which HHSC implemented on Jan. 1, 2012, Medicare paid 80 percent of a dual-eligible patient's visit to a doctor; Texas Medicaid paid the other 20 percent and covered the Medicare deductible for those patients.

The cut hit many physician practices hard, particularly those in rural and border areas where doctors serve a disproportionate number of what Dr. Floyd describes as a very vulnerable population of senior patients with complicated conditions and little income to spare.

"These patients have been left out on a limb with no lifeline. They are on fixed budgets, managing pennies," he said. "Not to mention the physicians who are no longer paid a portion of what they were counting on to take care of these patients." That has discouraged, if not prevented, them from continuing to treat the more than 400,000 dual-eligible patients across the state. Some doctors have moved, worked longer hours, or even taken out loans to cope.

Left unaddressed, TMA leaders say those reductions could be compounded by potential Medicaid and Children's Health Insurance Program (CHIP) payment cuts.

Anticipating a slow economy, the LBB instructed all state agencies to include a 10-percent across-the-board reduction in their 2014-15 appropriations requests. For HHSC, that turned into a proposed 1-percent cut to Medicaid and CHIP payments, which TMA opposes.

Sen. Jane Nelson (R-Flower Mound), chair of the Senate Committee on Health and Human Services, "can't imagine additional reductions to physician reimbursement rates next session." The committee also is "gathering information about the impact of changes to dual-eligible payments on access to care as we approach next session."

Similarly, Rep. John M. Zerwas, MD (R-Simonton), acknowledged to TMA Fall Conference attendees in October that the dual-eligible cut was "clearly having a large impact" on access to care and that it was "one place [the legislature] could realistically go back to and take a serious look at, partly because revenues are up. We can't go back and restore all of the cuts, but this is one area we might be able to see remedied."

Stopping a Medicaid Meltdown 

TMA also is advocating for broadening forthcoming PPACA provisions that will increase Medicaid payment rates for certain primary care physicians – specifically, pediatricians, family physicians, and general internists – to Medicare parity to stem the exodus of primary care physicians from Medicaid. HHSC is ready to implement the two-year raise, which spans from Jan. 1, 2013, to Dec. 31, 2014.

TMA would like to see the PPACA rate increase extended through 2014-15 and expanded to subspecialists, without whom it says primary care doctors cannot effectively treat patients.

But the association is prepared for an uphill battle on that front, as well, TMA Vice President for Advocacy Darren Whitehurst says. Even though the federal government is picking up the tab for the primary care rate increase for two years, the costs to increase specialty physician fees will be significant.

"That shows up on the budget as a huge increase in spending and more spending on medical care for the poor than for education. So this could further reinforce Republicans' arguments that Medicaid costs are out of control," Mr. Whitehurst said.

Nor are lawmakers expected to budge in their rejection of an expansion of the Medicaid program prescribed under the federal reform law, which the U.S. Supreme Court declared optional.

"I do not see us expanding Medicaid as directed by the Affordable Care Act," although other avenues for expansion will be a "main debate," Senator Nelson said.

Because payment inadequacies aren't the only headache contributing to a meltdown in Medicaid participation rates, the TMA-led Physician Medicaid Congress is devising a broad legislative and regulatory proposal for reforming the program into one that is viable long-term, says John Holcomb, MD, chair of TMA's Select Committee on Medicaid, CHIP, and the Uninsured.

Onerous billing procedures, inconsistencies across participating HMOs, and Medicaid expansion were just a few items members of the Medicaid congress began tackling at the TMA Fall Conference and will continue to address.  

Add to that list new rules that fail to differentiate between honest mistakes and outright fraud and that expand the Office of Inspector General's (OIG's) ability to hold payments and prosecute under what doctors say is a guilty-until-proven-innocent approach. (See "Guilty 'Til Proven Innocent," December 2012 Texas Medicine.)

"I don't know how we are going to get new doctors into these programs with all of this hanging over their heads," Dr. Holcomb said. "Bringing Medicaid rates to Medicare parity will continue to be a high priority. But all of these other issues could be easily fixed, and the legislature and [HHSC] have seen fit not to address them. We've reached now a bottom line where if we can't offer doctors enough money to pay for their overhead, why would they want to take a risk with the OIG, or take complicated dually eligible patients who take twice as much time as standard patients for half the payment?"

The San Antonio internist and critical care pulmonologist added that participation issues also plagued the Medicaid Women's Health Program (WHP), particularly after the 2011 legislature voted to exclude "abortion affiliates."

Planned Parenthood sued, and the federal government announced federal funding would end Dec. 31 unless the state revokes the law. Texas Gov. Rick Perry subsequently vowed to continue the program with state-only dollars. At press time, the issue of whether Planned Parenthood could participate remained in litigation.

Senator Nelson said there is enough state money to run the program without federal support, "although we need to rethink our approach to ensuring that low-income women have access to preventive care. The federal government's actions on this issue have been disappointing."

At the TMA Fall Conference, the TMA Board of Trustees voted to join the Women's Healthcare Coalition, a statewide consortium of health care organizations and physician practices advocating for the continued viability of WHP.

WHP provides preventive screenings and contraceptives to low-income women who are not pregnant, as well as restoration of funding cuts to family planning programs administered by the Department of State Health Services (DSHS).

TMA praised as a good first step HHSC's decision to rescind a so-called "gag order" that prohibited physicians participating in WHP from even discussing abortion with patients, whether or not it was relevant to their care needs.

But Mr. Whitehurst says the back-and-forth is just "another example of the kind of issues that go into physicians' consideration of whether to participate in programs like WHP and Medicaid. Hopefully, we can get lawmakers to take a step back and ask whether they really want to get in the middle of the patient-physician relationship."  

Cutting the Red Tape 

Meanwhile, the TMA advocacy staff is working to cure other bureaucracies plaguing physician practices through an omnibus "red-tape reduction bill" directed largely at the Department of Public Safety (DPS). (See "Small Problems, Big Impact," December 2012 Texas Medicine.)

The legislation would correct inefficiencies in processing state permits to prescribe controlled substances by moving the process online and making the renewal concurrent with medical license renewals. The bill also aims to ensure that the new DPS online prescription drug-monitoring database remains a secure and user-friendly tool for doctors and does not become an unfunded mandate.

New leadership at the Texas Department of Insurance (TDI) also could influence TMA's legislative and regulatory strategy when it comes to protecting doctors from health insurance plan gimmicks.

In August 2012, Commissioner Eleanor Kitzman was criticized for pulling rules that required insurers to maintain adequate physician and hospital networks and to disclose to patients their out-of-network obligations.

The move undid four years of work involving input from physicians, hospitals, health plans, and consumer groups that culminated in a set of agreed-upon rules former TDI Commissioner Mike Geeslin adopted in 2011. It also calls into question other established insurance regulations and protections TMA has won over the years, Mr. Whitehurst says.

Ms. Kitzman's "responsibility and job and focus should be on the consumer, and what's in the best interest of the people purchasing these products to make sure they are getting something of value," Mr. Whitehurst said. Instead, "she has apparently chosen to look out for the individual interests of health insurance companies."

If that doesn't change, "it probably adds to our legislative agenda because we have no expectation of getting things through on the regulatory side," added Dan Finch, TMA director of legislative affairs.

At press time, newly proposed rules remained open to public comment. TMA advocated for a return to the originally adopted rules at a Nov. 14 hearing.

A TDI spokesman said the agency could not respond to apprehensions about the overall impact of the revisions before the agency finalizes them.

In its preamble to the proposed regulations, TDI acknowledged concerns that the removal of certain provisions "relaxed requirements for insurers." In response, "the department determined that the best approach is to propose revised rules that more clearly express the department's intent to require that insurers provide consumers complete networks, limit insurers' reliance on alternatives to complete networks that provide only limited protections from balance billing, and provide additional substantive protections against balance billing for insureds obtaining out-of-network care in cases of emergency or because no network providers are available," the preamble says. 

Wanted: More Doctors 

Another budget fight will be for additional GME funding, an area that took some of the biggest hits last session.

Lawmakers cut by nearly 75 percent funding for the Family Practice Residency Program operated by the Texas Higher Education Coordinating Board (THECB). The statewide Primary Care Preceptorship Program was not funded, and other primary care GME programs administered by THECB suffered, as well.

Overall GME formula funding declined by about 40 percent, and the legislature eliminated one physician education loan repayment program, while cutting the other by 76 percent.

TMA officials warn that the slashes come at a time when Texas ranks far below the national average in the number of physicians per capita, with shortages in primary care and other specialties.

The 2003 medical liability reforms helped recruit new physicians to the state – an all-time high in 2012 – but barely enough to keep pace with the rapid population growth, Dr. Floyd says. And while Texas expands the number of medical school graduates, the number of residency slots available to train them continues to lag.

TMA continues to work with a consortium of the state's medical schools and teaching hospitals to push for GME positions to exceed the total number of medical graduates by 10 percent.

"We went bottom up last session. We graduated 50 or so medical students more than we had first-year residency positions," and class sizes since have grown to more than 100 students, Dr. Floyd said. "We still need more physicians, and the more secure way to do that is to train them in Texas and get them to stay in Texas."

Rep. Lois Kolkhorst (R-Brenham), chair of the House Public Health Committee, says the spotlight will shine on GME funding this session as a means of responding to the state's growing primary care needs, particularly now that PPACA is likely here to stay.

"Everyone wants a medical school in their backyard. My focus is going to be solely on GME and how we create residency slots," she said, adding that she supports an increased ratio of GME positions to in-state medical graduates. "We are very disappointed in the U.S. Congress freezing the number of Medicare [funded] residency slots, which is just unacceptable with Texas growing at the rate it is. I expect nothing from the federal government, so we will have to be creative, and we're going to need doctors' help to get creative," she said.

Senator Nelson added that medical education debt is a barrier to growing the primary care workforce that requires attention. "Medical school graduates often leave school with more than 100,000 in debt. It is not surprising they choose more lucrative specialties over primary care. We need to make primary care a more appealing path for medical students."            

TMA sees an opportunity this session to restore the state Physician Education Loan Repayment Program and is aiming for 2009 funding levels.

Despite all the penny-pinching, a push by Republican budget hawks to ensure dedicated funds go where they are supposed to – instead of being diverted to cover other gaps like they were last session – could mean loan repayment monies are used as intended. The House Interim Committee on General Revenue Dedicated Accounts met in November to discuss ways to maximize such funds.

"I'm looking for any way to increase [the number of] primary care doctors," Rep. John C. Otto (R-Dayton) said.

THECB Assistant Commissioner Dan Weaver testified at the November hearing that the loan repayment program was intended to encourage physicians to practice in underserved areas by offering up to $160,000 in loan assistance to those who practice in federally designated shortage areas and accept Medicaid and CHIP patients.

The program "was very effective and worked exactly as intended," until it was stopped, Mr. Weaver said. "These are four-year awards, so consistency in funding is very important. We are asking physicians to make a commitment. At the same time, we need the legislature to make the same commitment."

Austin family physician David P. Wright, MD, chair of TMA's Council on Medical Education, testified on behalf of TMA and the Texas Academy of Family Physicians (TAFP). He said the loan repayment program has helped nearly 200 doctors overcome the indebtedness that often poses an obstacle to setting up a practice in rural communities.

"This is probably our best recruitment tool, and if we can get this funded again, TMA is confident we can get even more primary care physicians into rural places," Dr. Wright said. He says TMA supports suggestions to use money dedicated to trauma services to fund enhanced emergency medical training for primary care doctors.

Playing Defense 

TMA also hopes to capitalize on the legislature's interest in budget transparency to ensure fees the Texas Medical Board (TMB) collects stay within the agency.

The resources could provide extra ammunition against anticipated attacks by forces looking to weaken TMB's ability to appropriately discipline bad doctors. Especially susceptible is a TMB reform TMA won in 2011 that prohibits anonymous complaints against doctors. And a weaker medical board could open the door for lawsuit-happy lawyers to erode hard-won 2003 medical liability protections for physicians.

The association also expects to play defense on recurring issues that crop up every legislative session, including end-of-life care, scope-of-practice expansions by nurse practitioners and other allied health professionals, and attempts to undermine doctors' independent clinical judgment in hospital employment situations.

Trial lawyers and right-to-life groups likely will try to chip away at state liability protections by challenging immunities granted to physicians and hospitals in end-of-life care, Dr. Secrest says.

TMA, through its workgroup on end-of-life issues and in collaboration with a coalition of the Texas Catholic Conference, the Alliance for Life, and the Texas Hospital Association, will work to protect physicians' ability to do what's best for patients in their final days. This includes their ability to write "do-not resuscitate" (DNR) orders or withdraw care when it would be futile, while balancing the rights of terminally ill patients and their families to be involved in such treatment decisions.

Dr. Secrest says legislative attempts to require a patient's family to first consent to a DNR order when additional care is unwarranted could mean undue suffering for the patient and may not even be possible in an emergency situation. Past efforts also sought to require indefinite treatment.

"These are medical procedures, and the question is, do we treat them any differently than any other medical procedure? There will be bills filed on end-of-life issues, and we will have to figure out how to separate situations involving DNR orders from those involving the withdrawal of care," Dr. Secrest said, adding that the two are distinct issues.

Dr. Floyd anticipates another showdown with advanced practice nurses (APNs) over independent practice and independent prescribing, despite their lack of education and training to do so. TMA expects similar scope-of-practice expansion activities by optometrists, podiatrists, and chiropractors.

TMA and TAFP, through a joint workgroup, established core principles to help guide their negotiations with APNs and hopefully move toward collaborative practice agreements. Physician assistants (PAs), rather than seek independent practice, have championed with doctors a physician-led, team-based model of care.

Midlevel practitioners "are an important part of our health care team. But it is a health care team, and we are resolved that that team should be led by a physician, who has much more training and experience," Dr. Floyd said.

At the same time, the workgroup seeks common ground with PAs and APNs to resolve what both sides agree are confusing layers of rules governing where and when physicians may delegate their prescriptive authority and the degree of physician supervision needed in various practice sites.

Different sets of rules exist for midlevel practitioners in rural settings and in hospitals for how much time a physician must spend on site and for how many practitioners a physician can supervise.

"We could go a long way toward standardizing [those rules] and removing variation," Dr. Floyd said. "In an electronic age, much can be accomplished through telemedicine to be more efficient, and for both sides, face time might be better spent discussing things like deviations from protocols" and how to improve care.

Such modifications will require legislative and regulatory change, and TMA hopes to reach an agreement with nurse practitioners going into the session, Mr. Finch says. But similar talks stalled in the past when the group said it wanted nothing short of independent practice.

In a Sept. 13, 2012, column in the Fort Worth Star-Telegram, Sandy McCoy, president of the Texas Nurse Practitioners lobby group, said APNs can fill the gap created by primary care physician shortages and that diagnosing and prescribing "are well within the bounds of our education and training. The Texas Legislature should free these qualified providers, allowing us to move into rural and underserved areas that desperately need primary care services."

But there are only 12,000 APNs and 7,500 PAs in Texas, compared with more than 60,000 physicians, Dr. Floyd says. "We don't have enough of any of them. Nor are they flocking to rural Texas."

TMA is willing to work on more flexible supervision rules, for example, to help relieve unnecessary barriers to care, he says. "But things like diagnosing and prescribing remain the practice of medicine. And the legislature has established the medical board to oversee the practice of medicine. We are not willing to budge on that."

Nor will TMA let up in defending physicians' clinical autonomy from interference by hospitals' or other entities' economic interests.

In 2011, TMA preserved the state's ban on the corporate practice of medicine with protections for employed physicians, whether they work in hospital-run health care corporations, rural or urban hospitals, or health care collaboratives.

From credentialing to utilization, by keeping clinical matters in the hands of physicians and physician governance structures, "what we've done is protected doctors' independent medical judgment and the patient-physician relationship. That's where our focus is," Mr. Finch says.

 Public Health Priorities 

Doctors will see TMA go on the offensive when it comes to public health initiatives.

TMA continues to work with the Texas Public Health Coalition on measures that aim to discourage tobacco use and increase cessation through legislation and evidence-based programs; target obesity by using educational and community-based efforts; promote immunizations and disease prevention; and prevent cancer.

TMA also will keep tabs on forthcoming revisions to the state mental health code and likely weigh in with the Texas Society of Psychiatric Physicians, Dr. Secrest added.

Mental health funding saw no cuts last session, and TMA wants to keep it that way.

However, the association's public health agenda could once again run up against the budget and proposed 10-percent reductions to DSHS' 2014-15 funding. And convincing lawmakers that prevention now means savings down the road is no easy task when the legislature's only required duty is to come up with a two-year budget, TMA leaders say.

More revenues, however, might create an opportunity for the association to mitigate the tax that family physicians and pediatricians must pay out of pocket to buy and stock vaccines, not knowing if they will be used.

The typical vaccine costs around $15, but physicians may deduct only the expense of administering it. The 1-percent tax means even if health insurance companies reimburse enough to cover the purchase price of the vaccine, doctors still lose money. And yet the service is critical to overall public health.

TMA would like to see legislation supporting a tax deduction for the actual cost of the vaccine.

"We have some hope that with a better financial situation, this might be an issue the legislature would go for," Mr. Whitehurst said. 

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email. 


Federal Frustrations 

As TMA gears up for the upcoming state legislative session, physicians are closely monitoring the impact of federal issues, from a nearly 30-percent cut in Medicare payment rates to implementation of the Patient Protection and Affordable Care Act (PPACA).

Barring congressional action before this issue of Texas Medicine went to press, this month physicians could see a 27.5-percent Medicare payment reduction as a result of the Sustainable Growth Rate (SGR) formula. Add to that the possibility of another 2-percent Medicare cut slated to take effect under the 2011 Budget Control Act's sequestration provisions as a result of federal lawmakers' failure to address the national debt crisis.

The country's dire fiscal straits are indications that "there is no money anywhere else that's not already being used," U.S. Rep. Michael Burgess, MD (R-Texas), told TMA members at the association's Fall Conference in October. The situation also could mean PPACA implementation "will have to be delayed or sharply restructured."

In letters to congressional leaders, TMA, the American Medical Association, and more than 100 state and specialty medical societies urged Congress not only to nullify the combination of impending Medicare cuts, but also to fix what physicians say is a flawed SGR formula that fails to keep up with the cost of care.

"Now that the election is behind us, whether the SGR will get addressed, and how, are big questions on doctors' minds," said Dallas psychiatrist Leslie Secrest, MD, chair of TMA's Council on Legislation. "Whatever that timeline is, we need a permanent solution. At some point, this becomes a big enough crisis we have to solve it."

That time is now, physicians say. According to TMA's 2012 surveys, 58 percent of Texas doctors accept all new Medicare patients, compared with 66 percent in 2010; only one third of doctors are willing to take all new Medicaid patients, compared with 42 percent two years ago.

Under PPACA, starting in 2013, the federal government will temporarily raise Medicaid rates to Medicare parity for certain primary care physicians. But Medicare still pays only 80 to 85 percent of the cost of care, says Fort Worth pediatrician Gary Floyd, MD, a consultant to the Council on Legislation. Medicaid pays roughly 65 percent of care costs.

"The irony to me is, if nothing is done about the SGR and Medicare rates drop, then the federal government won't have to increase Medicaid rates because they will be almost equal," he warned. "I'm left scratching my head and asking, is this really happening? We will see more physicians drop out."

Federal health system reform already impacts Texas' budget and likely will "continue to consume resources for years to come," said Sen. Jane Nelson (R-Flower Mound), chair of the Senate Committee on Health and Human Services.

Gov. Rick Perry already informed the federal government that Texas will not expand Medicaid as prescribed under PPACA. Nor will Texas establish a state-run health insurance exchange, which means it would be left to the federal government. Senator Nelson "anticipates a discussion this session regarding whether in the future the state should assume control" of its exchange.

House Public Health Committee Chair Rep. Lois Kolkhorst (R-Brenham) said it is unlikely the legislature will bend on expanding Medicaid until some reforms to the costly program are implemented. Texas is working on implementing one Medicaid waiver allowing for the expansion of managed care and likely will seek other flexibility, she says.

"But all of that is in the federal government's court," Representative Kolkhorst said. Nevertheless, "with the PPACA likely moving forward, there has to be discussion on our ability to meet the needs of primary care and how we address the uninsured population in Texas. This becomes a very real conversation in the next session."


TEXPAC Candidates Win Big 

The November general election delivered record victories to Texas members of the house of medicine, who all had at least one thing in common: the backing of the Texas Medical Association Political Action Committee (TEXPAC).

Seven TMA and TMA Alliance members will fill seats in the Texas House and Senate combined, the most to serve at one time.

Winners on the Senate side include Sen. Bob Deuell, MD (R-Greenville), in District 2; Rep. Charles Schwertner, MD (R-Georgetown), in District 5; and Donna Campbell, MD (R-New Braunfels), in District 25.

House victories went to Rep. John Zerwas, MD (R-Simonton), in District 28; TMA Alliance member Susan King (R-Abilene) in District 71; Greg Bonnen, MD (R-Friendswood), in District 24; and J.D. Sheffield, DO (R-Gatesville), in District 59.

Incumbent Democrat Sen. Wendy Davis bested Mark Shelton, MD, in a tough Senate race in Fort Worth for the District 12 seat. Only 1,600 votes separated them.

U.S. Rep. Michael Burgess, MD (R-Texas), reclaimed his congressional seat in District 26.

"One big reason these family-of-medicine candidates did so well is just that – the family of medicine. They all had the financial and organizational support of TEXPAC, and physicians and alliance members turned out in droves to help their campaigns," said TEXPAC Board of Directors Chair Joe M. Todd, MD. "It's great that these men and women – who understand health care problems from the inside – will be serving in Austin and Washington next year."

Drs. Bonnen and Sheffield are among 49 freshman members entering the 2013 legislature – 43 in the House and 6 in the Senate.


TMA's Healthy Vision of the Future 

TMA outlines its strategic roadmap for state and federal advocacy initiatives for the remainder of the decade in Healthy Vision 2020, a comprehensive plan for improving health care and maintaining the viability of physician practices in Texas.

Based entirely on existing TMA policy, Healthy Vision 2020 was reviewed and improved by TMA's policy councils and the TMA Board of Trustees.

Healthy Vision makes eight key recommendations. They are:  

  1. Ensure an adequate health care workforce;
  2. Protect physicians' independent medical judgment;
  3. Promote efficient and effective new models of care;
  4. Repeal harmful and onerous state and federal regulations;
  5. Invest in prevention;
  6. Protect and promote a fair civil justice system;
  7. Provide appropriate state and federal funding for physician services; and
  8. Establish fair and transparent insurance markets for patients, employers, taxpayers, and physicians.

TMA member physicians can read and comment on the plan on the TMA website. You may also order a printed copy from the TMA Knowledge Center by calling (800) 880-7955 or emailing

Texas Medicine has been publishing a section of Healthy Vision each month since July. Section 7, Provide Appropriate State and Federal Funding for Physician Services, is in this issue. 

All articles in Texas Medicine that mention Texas Medical Association's stance on state legislation are defined as "legislative advertising," according to Texas Govt. Code Ann. §305.027. That law requires disclosure of the name and address of the person who contracts with the printer to publish the legislative advertising in Texas Medicine: Louis J. Goodman, PhD, Executive Vice President, TMA, 401 W. 15th St., Austin, TX 78701. 

The Texas Medical Association Political Action Committee (TEXPAC) is a bipartisan political action committee of TMA and affiliated with the American Medical Association Political Action Committee (AMPAC) for congressional contribution purposes only. Its goal is to support and elect pro-medicine candidates on both the federal and state level. Voluntary contributions by individuals to TEXPAC should be written on personal checks. Funds attributed to individuals or professional associations (PAs) that would exceed legal contribution limits will be placed in the TEXPAC administrative account to support political education activities. Contributions are not limited to the suggested amounts. TEXPAC will not favor or disadvantage anyone based on the amounts or failure to make contributions. Contributions are subject to the prohibitions and limitations of the Federal Election Campaign Act.      Contributions or gifts to TEXPAC or any CMS PAC are not deductible as charitable contributions or business expenses for federal income tax purposes. 
    Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation, and name of the employer of individuals whose contributions exceed $200 in a calendar year. To satisfy this regulation,  include your occupation and employer information. Contributions from a practice business account must disclose the name of the practice and the allocation of contributions for each contributing owner. Should you have any questions, call TEXPAC at (512) 370-1361. 

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