Border Physicians Band Together to Fight for Health Care
Legislative Affairs Feature - June 2002
By Ken Ortolon
Texans living along the Texas-Mexico border believe the powerbrokers in Austin have shortchanged their region for generations -- be it funding for health care, creating educational opportunities, building roads, or developing other infrastructure elements.
El Paso pathologist and former Texas Medical Association President Wm. Gordon McGee, MD, has complained more than once that politicians "spill more money in Austin than we'll ever see."
But when low Medicaid reimbursement rates combined with high volumes of Medicaid and uninsured patients, as well as other factors, began driving physicians out of border communities and threatening the remaining physicians' ability to provide care, the doctors decided to do more than just complain.
In 2001, border physicians created a coalition to advocate for increased funding for Medicaid. Despite a late start, the coalition played a significant role in convincing state lawmakers to approve the first substantial Medicaid provider fee increase in nearly a decade.
Fresh from that victory, the Border Health Coalition now is gearing up to take on a broader array of issues affecting health care on the border in the 2003 session of the Texas Legislature.
El Paso nephrologist Manny Alvarez, MD, who in April was elected to chair the coalition, says the organization is determined that lawmakers hear the concerns of the entire border region.
"Each of the border counties has its problems, but we've never gotten together," Dr. Alvarez said. "Now, as we come together over these common problems we're able to express them loud and clear so that people in the legislature understand and know that we're serious and committed to work for change."
The coalition started as the Border Physician Coalition for Medicaid Access in spring 2001 in El Paso, where low reimbursement rates and high Medicaid patient loads were severely affecting the economic viability of the practices of the city's pediatricians.
"Dr. Alvarez, who was president of the El Paso County Medial Society, called me and said his members were really on him to do something about Medicaid funding," said Alfred Gilchrist, director of the TMA Legislative Affairs Department. After a series of meetings, it was decided that a coordinated approach by physicians along the entire border was needed to influence policy in Austin. The presidents of each county medical society along the border were invited to participate, and El Paso County Medical Society Executive Director Patsy Slaughter agreed to provide staff support. She says the idea was greeted with "very huge interest" from physicians up and down the border.
"The coalition came about because we needed a unified effort," Dr. McGee said. "We would talk to our legislators from El Paso, and the people in Brownsville would talk to their legislators, but we weren't making much of an impact. We felt that if we coordinated our efforts and presented greater numbers it could make a difference."
After a series of conference calls and meetings about common Medicaid problems, the group was ready to make its first foray into the legislative process. In early April, a group of El Paso physicians traveled to Austin to testify before House committees about the need for Medicaid fee increases. Two weeks later, those doctors returned to Austin for more testimony before Senate health and budget-writing committees.
"Then it just snowballed," Ms. Slaughter said. "All the CMS presidents up and down the border got into it because their doctors were suffering just as we were."
Late in the legislative session, physicians from every border county met in Austin for a major push for Medicaid fee increases. The physicians formed teams and fanned out across the Capitol to visit border lawmakers. They also met with the governor and lieutenant governor. Health and Human Services Commissioner Don Gilbert also met with coalition members on several occasions.
"We just kept pounding them about what was going on with Medicaid reimbursement rates," Ms. Slaughter said. "It finally took hold."
The result was passage of a significant fee increase targeted at physicians in the Texas Health Steps/Early and Periodic Screening, Diagnosis and Testing program, along with bonuses for high-volume Medicaid physicians.
Broadening the Scope
With the initial victory on Medicaid, support for the Border Health Coalition is running high, Mr. Gilchrist says. "The [border coalition's] strategy, combined with others, resulted in the largest percentage increase in health and human services spending that we've seen in 20 years, if not ever," he said. "To say that the border physicians are fired up is an understatement."
Dr. Alvarez says those fee increases have provided some relief, but the coalition is not resting on its laurels.
"The increase we received in 2001 has helped some," he said, "but it needs to be continued. We have to see if we can find more money in the 2003 legislative budget, not only for pediatricians but also for those high-volume providers who deal with adults."
The coalition also is broadening its focus to look at other health care issues facing the border. At the top of its agenda is medical liability reform.
"We on the border suffer disproportionately from issues that affect our colleagues across the state," Dr. McGee said. "That is low reimbursement, skyrocketing malpractice costs, and a lack of a good, strong health infrastructure that other communities have."
Dr. Alvarez says these problems make it difficult for border communities to recruit new physicians at a time when the region's population is growing rapidly, creating a real access-to-care crisis.
"Somebody who is told that we have problems with high malpractice premiums, a low percentage of private insurance, high Medicare-Medicaid volumes, and that he or she is likely to get sued more often is not going to be inclined to start a practice here," Dr. Alvarez said. "These are major concerns for anyone who is coming out of medical school or a residency program."
The coalition has begun an aggressive campaign to bring public and legislative attention to bear on this problem. First, the group shortened its name to the Border Health Coalition to reflect the fact that Medicaid is no longer the group's sole focus. The group has developed a strategic plan and is recruiting more physicians into its membership. The TMA Board of Trustees has provided $50,000 in seed money to help the fledgling coalition grow, and individual physicians up and down the border are raising money from their colleagues to finance coalition operations. Mr. Gilchrist says Laredo obstetrician-gynecologist Santiago Gutierrez, MD, has raised $15,000 to $20,000 alone.
The money has allowed the coalition to hire political consultant Jake Fuller to coordinate the group's activity.
Among its first major initiatives since the end of the 2001 legislative session came in April when physicians in the Lower Rio Grande Valley, El Paso, Corpus Christi, and other cities staged a "Day of Awareness" to protest high medical liability premiums. The idea originated with physicians in the Lower Rio Grande Valley but was quickly adopted by doctors in several other counties. On April 8, physicians throughout the border region closed their offices for a day, rallied on courthouse steps, and held news conferences to publicize the impact rising malpractice rates are having on the ability of physicians to keep their doors open. The effort was joined by physicians as far away as Wichita Falls, where similar concerns over skyrocketing liability costs exist.
While the effort initially drew criticism in the media, the physicians were joined by other health care professionals and many of their patients. Newspapers throughout South Texas also editorialized in support of tort reforms backed by the coalition.
At the courthouse rally in Edinburg, Juan Campos, MD, president of the Hidalgo-Starr County Medical Society, urged local judges to enforce requirements that plaintiffs in malpractice cases post a cost bond or submit an affidavit from a medical expert stating that a case has merit. "Legal controls are nonexistent," Dr. Campos said. "The district judges who work right behind me are aggravating the situation and selectively not enforcing the requirements for cases. They have to start using it; we're going to be watching."
How the Other Half Lives
The group's next major undertaking was launched in May when the coalition began inviting lawmakers from across the state to border communities to see how the other half lives. The so-called Border Physician Preceptor Program gives lawmakers from Houston, Dallas, Austin, and other nonborder communities a firsthand look at the problems patients face in getting care and the problems physicians face in providing it. The program will continue through the fall.
With a tight budget being projected for the next biennium and talk already surfacing about the potential need to cut Medicaid spending, the border coalition believes it is critical to show lawmakers from other regions just how seriously that would impact the border.
"We thought it would be a good idea to bring in the legislators who didn't believe the border communities were suffering a heavy problem, that there was a physician shortage, that doctors were paying high malpractice premiums, that some were seeing patients as late as 11 or 12 o'clock at night," Mr. Fuller said. "We want to show that Medicaid is a substantial component in driving the economic engine along the border, in South Texas, and in the southern sector of West Texas. From an economic infrastructure perspective, health care is a greater economic force along the border than it is in Dallas, Houston, or other parts of Texas. Any kind of cutback in Medicaid along the border would be devastating not just for physicians but also for the communities they serve. There would be an adverse economic impact beyond the negative ripple effect on health care, which in turn would damage the already fragile infrastructure along the border."
Lawmakers participating in the program will get a firsthand look at health care delivery on the border, including visits to hospital emergency departments, physicians' offices, and public health clinics.
Meanwhile, the coalition is maintaining a high profile in Austin. In March, Dr. Alvarez represented the coalition before the Senate Health and Human Services Committee, testifying in support of both medical liability reform and additional increases in Medicaid funding. "We hope more action will be taken to strengthen the provider base and therefore improve access to care for Medicaid patients," he told the committee.
That testimony was followed in April when Dr. Gutierrez testified before a joint meeting of the House Appropriations and Insurance committees. And in May, McAllen gastroenterologist Carlos Cardenas, MD, was slated to testify on the coalition's behalf in support of liability reform before the House Insurance Committee.
During his testimony in April, Dr. Gutierrez's belief in the legitimacy of the medical malpractice crisis was challenged by state Rep. Paul Moreno (D-El Paso). "I think there are a lot of frivolous lawsuits," Dr. Gutierrez said. "The reason is the lawyers know that most physicians are not going to want to stick their neck out and fight a case. They'll file a lawsuit because they know you'll eventually probably give them something."
"You actually believe that?" asked Representative Moreno, who said he does not believe many frivolous cases are filed.
"Of course, I do," Dr. Gutierrez responded. "I see it. I live it. It's there."
Getting the Job Done
Mr. Fuller says the goal is to position border concerns among the top legislative issues for 2003 "because when Austin catches a cold, the border is already suffering from pneumonia.
"This coalition has a great deal of potential to influence health care policy across Texas," Mr. Fuller said. "The Border Health Coalition plans to speak in a coordinated voice. We anticipate that medical malpractice will be among the top issues in the 78th Legislature, and we hope our efforts can help legislators craft legislation that can pass both houses and be signed by the governor before the session concludes."
Dr. Alvarez is optimistic of success not only on tort reform but also on Medicaid, even with the projected budget shortfall facing lawmakers.
"We know there are other issues that legislators have to deal with," he said. "But we're committed to the cause that we must increase access to health care for all people in the state of Texas -- not just along the U.S.-Mexico border but everywhere. We know that inner-city problems exist and that they feel the same crunch we do. They have the same kind of tort problems and lack of physicians. We hope that by doing what we're doing it will help them also."
Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.
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