Budget, TMA-backed Bills on the Move

With roughly six weeks to go in the Texas Legislature's 2013 session, lawmakers are near the finish line in drafting a state budget for the next two years. The process has been rather smooth sailing compared to last session as medicine marches closer to accomplishing its goals of reversing the drastic cuts from 2011.

Meanwhile, even though the House of Representatives ditched a budget amendment to explore expanded coverage options for the working poor in Texas, a budget conference committee will discuss the issue because it is included in the Senate version of the budget.

TMA-backed bills to reduce red tape, regulate payers' under-the-table activities, and promote immunizations move full steam ahead. But medicine is working hard to fend off sneak attacks that use measures to weaken the Texas Medical Board to undermine the beneficial effects of medical liability reforms.

The House approved its version of the state budget in early April, about two weeks ahead of schedule, after wading through numerous amendments. TMA Vice President for Advocacy Darren Whitehurst says budgeteers have historically taken their time in crafting a final two-year budget.

Now, the Senate and House will appoint a conference committee to reconcile the differences between the two budgets by early May. The House budget stands at $198.3 billion for 2014-15, and the Senate version is $195.5 billion, representing a 2- to 3-percent increase over the current budget.

Mr. Whitehurst says the gaps between the two are not too wide in terms of health care funding. Both increase spending in key TMA priority areas, including graduate medical education, women's preventive health care, and mental health.

Making Medicaid Better 
During the House budget debate, Rep. Lon Burnam (D-Fort Worth) ultimately withdrew an amendment that would have opened the door for state-federal negotiations over Medicaid expansion. A similar rider remains in the Senate budget directing the Health and Human Services Commission to develop an expansion plan should state-federal negotiations ever come about. Such a plan must include cost-saving measures such as establishing sliding-scale copays, deductibles, and premiums; health savings accounts; reduced uncompensated care costs; and wellness and pay-for-performance initiatives.

TMA supports a plan to expand coverage for the working poor that fits Texas and includes significant reforms to the Medicaid program. Some of those reform efforts already are under way.

TMA testified in support of House Bill 2731 by Rep. Richard Raymond (D-Laredo), which would streamline the myriad Medicaid HMO administrative requirements that end up needlessly costing physician practices extra time and money. TMA lobbyist Michelle Romero says that bill "would go a long way toward improving the program. This is a nonbudget way to help doctors save money in their practices."

Such measures, she says, are needed because funding has not materialized this session to boost overall physician Medicaid payments and alleviate earlier cuts to payments for treating patient dually eligible for Medicare and Medicaid. Also, the Senate in late March approved Senate Bill 7 by Sen. Jane Nelson (R-Flower Mound), which looks to save money by expanding Medicaid HMOs to people with disabilities and nursing home residents. The move is projected to save $8.5 million in 2014.

TMA also continues to advocate for fair treatment by the Office of Inspector General (OIG) when doctors are accused of Medicaid fraud and has worked with the agency to resolve the due process issue.  

Voted out of the Senate in April was Senate Bill 1803 by Sen. Joan Huffman (R-Houston). It improves due process and transparency in the OIG process when a physician is accused of a "credible allegation of fraud" or Medicaid overpayment. Meanwhile, House Bill 1536 by Rep. Bobby Guerra (D-Mission) is pending in the House Human Services Committee. It would ensure physicians' due process rights through an administrative hearing before – not after – officials try to recoup an overpayment. Sen. Chuy Hinojosa (D-McAllen) sponsors the companion bill, Senate Bill 785.

Red-Tape Bills Advance
The red tape for physicians doesn't stop with Medicaid, and key TMA-backed legislation to help physician practices improve efficiency is moving.

The Senate approved Senate Bill 166 by Sen. Bob Deuell, MD (R-Greenville), which would allow practices to check in patients using the electronic strip on the back of their driver's licenses. The House companion, House Bill 395 by Rep. Lyle Larson (R-San Antonio), is pending in the House Technology Committee. House and Senate committees also took up bills that would sync the renewal of physicians' Department of Public Safety controlled substances registration with the Texas Medical Board's medical license renewal process.

House Bill 1032 by Rep. John Zerwas, MD (R-Simonton), requiring the Texas Department of Insurance to appoint a workgroup to design a standard prescription drug prior-authorization form for all payers, was approved by the House Insurance Committee with only one nay vote. Senate Bill 1216 by Sen. Kevin Eltife (R-Tyler) and House Bill 1604 by Rep. Sarah Davis (R-Houston) would do the same for health care services, but neither has been heard yet.

Senate bills 1609 and 1610 would help clear up some unintended hassles for doctors trying to comply with a 2011 medical records privacy statute – House Bill 300. SB 1609 standardizes privacy training requirements for employees in individual physician practices, while SB 1610 clarifies that physicians need only comply with Texas privacy laws and federal statutes in notifying patients of a breach that may cross state lines.

Meanwhile, TMA testified against a hassle-factor bill that TMA lobbyist Patricia Kolodzey described as a "back-door way to prohibit balance-billing," and address unexpected out-of-pocket costs patients are stuck with for going out of a health plan's network. House Bill 2838 would require physicians and other health care professionals to give patients a binding quote on the price accepted as payment in full for services they plan to provide – something difficult for doctors to predict – in writing and at least 48 hours in advance, or doctors must forfeit payment.          

On the other hand, House Bill 1406 by Rep. John Smithee (R-Amarillo) attempts to address balance billing by requiring health plans to share how they calculate out-of-network payments for their enrollees. It also attempts to define "usual and customary charge" to mean the 99th percentile of the actual charges by a physician or provider who doesn't participate in the health plan network. TMA supports health plans' disclosure of their out-of-network methodology, but has concerns with putting a specific payment rate in statute.

TMA supported "silent PPO" bills HB 620 and SB 822. The bills would regulate these activities for the first time and prohibit health plan networks or companies from selling, leasing, or sharing privately negotiated physician payment rates without doctors' consent. Both won approval from their respective House and Senate committees. 

Similar protections are included in the Medicaid version, Senate Bill 1221 by Sen. Ken Paxton, which would bar health plans from using a Medicaid-based fee schedule for reimbursement for services other than Medicaid, unless the physician or provider had agreed to that fee schedule. The Senate State Affairs Committee approved it. 

Preserving Medical Board Reforms
A battle is under way to preserve TMA-won reforms to TMB's complaint system and tort reforms. A handful of bills attempt to open up confidential complaints at the board and disclose the identity of physician expert reviewers involved. TMA leaders say the legislation would undermine the board's mission of protecting Texas patients and undo reforms meant to ensure a fair disciplinary process, prevent unnecessary lawsuits, and protect patients from harassment by bad doctors.

Also raising alarm bells is a telemedicine bill, House Bill 1806 (by Representative Smithee), that would subvert current TMB regulations requiring a face-to-face encounter between a physician and patient and permit diagnosing over the telephone. TMA also backs a measure to ensure physicians get paid fairly for telemedicine services like telephone consults – particularly when health plans already pay vendors for those services. 

On the scope-of-practice front, TMA continues to put out fires, which appear smaller than usual this session.

TMA hopes an attempt to have advanced practice registered nurses (APRNs) and physician assistants (PAs) bill for their Medicaid services separately from physicians they practice with and at a reduced rate – resulting in an 8-percent payment cut for APRNs and PAs – will be scuttled. TMA believes the measure would undermine team-based care models like Senate Bill 406 by Senator Nelson, an agreed-to bill by physicians, nurse practitioners, and PAs. It would replace current site-based restrictions for prescriptive delegation and supervision with a more flexible, collaborative model. That bill goes to the House Public Health Committee now that it has cleared the Senate.

Immunizations Front and Center
TMA-backed legislation to ban smoking in certain work and public places appears to be losing ground, but medicine has made headway on a pair of immunization bills. The Senate approved Senate Bill 63 – allowing minors who are pregnant or who already have children to consent to their own immunizations – and Senate Bill 64 – requiring licensed child-care facilities to develop and implement an immunization policy.

Physician leaders oppose Senate Bill 1013 by Sen. Larry Taylor (R-Friendswood) to allow pharmacists to vaccinate children aged 7 years and older. They told the Senate Health and Human Services Committee that passage of the bill would fragment health care delivery, undermine medical homes, and cause children to forego complete medical evaluations. TMA lobbyist Troy Alexander also says recent data show Texas ahead of national averages for child vaccination rates and a better strategy would be to target the gaps.

The House and Ways Committee approved legislation – House Bill 1310 by Rep. Angie Chen Button (R-Richardson) – that allows physicians to deduct vaccine purchase costs from taxable revenues. On obesity, the Senate approved Ssenate Bill 684 making the now-required physical fitness assessments for schoolchildren optional. TMA opposes it

TMA supports Senate Bill 303, an end-of-life bill that passed out of committee and is poised for deliberation on the Senate floor. TMA leaders say the legislation protects the current processes under the Texas Advance Directives Act for resolving conflicts out of court. Opponents seek to eliminate the review process, a move that could force doctors to violate their moral beliefs and professional ethics.

Amy Lynn Sorrel, associate editor of Texas Medicine, prepared this special supplement to Action.

 Action, April 15, 2013