Action: Oct. 15, 2015

TMA Action Oct. 15, 2015   News and Insights from Texas Medical Association

TMA Tells DOJ Aetna-Humana Merger Would Be Bad for Texas
Having ICD-10 Problems? TMA Wants to Know
CMS Finally Releases Stage 3 Meaningful Use Rule
Another Post-Tort Reform Record for New Texas Physicians
AMA, TMA Tell Feds to Speed Up Release of MACRA Funds
Physicians Now Have Expanded Access to Naloxone
Texas Submits 1115 Medicaid Waiver Extension Application
Updated Federal HIT Plan Contains Strategies TMA Supports
New TMF Network Aims to Improve Adult Immunization Rates
The Value Modifier Program: Improve Performance, Payment
Don't Lose Out! Win $5,000 for Your Champion of Health
This Month in Texas Medicine

TMA Tells DOJ Aetna-Humana Merger Would Be Bad for Texas

With a highly concentrated health insurance market in Texas, the acquisition of Humana by Aetna would result in less competition in the state. And that would be bad for physicians and consumers. That's what the Texas Medical Association told William Baer, assistant attorney general in the Department of Justice's Antitrust Division, in a letter

The 2010 Horizontal Merger Guidelines and an American Medical Association analysis (login required) of the merger, titled Competition in Health Insurance: A Comprehensive Study of U.S. Markets, found the proposed merger would likely enhance market power for the combined company in these Texas markets and market segments: 

  • Combined HMO, PPO, and POS market: El Paso, San Antonio, and Corpus Christi;
  • HMO market: Houston-Sugarland-Baytown, Austin-Round Rock, and San Antonio; and
  • PPO market: El Paso, San Antonio, Houston-Sugarland-Baytown, Corpus Christi, Fort Worth-Arlington, Austin-Round Rock, Victoria, and Killeen-Temple-Fort Hood. 

And TMA sounds the alarm on the newly combined company's potentially enhanced ability to set prices for physician services. "Since the large majority of health care services provided by physicians are paid for by insurers and other third-party payers, physicians must be able to secure adequate payment from insurers in order to cover all operative costs and remain profitable," TMA wrote. The association added that Texas' many one- to three-physician groups "may have very little negotiating leverage to allow them to secure favorable pricing terms."

The letter, signed by Joseph Valenti, MD, chair of TMA's Council on Socioeconomics, goes on to warn of health plans' unfettered price-setting power as a means of forcing physician practices out of business. TMA says this can occur in two ways:  

  1. Unilaterally reducing contract prices below the actual cost to produce services, or
  2. Excluding the physician from the plan network. 

"Physicians who are forced out of business may permanently leave patient practice or relocate, reducing the local availability of medical services and causing harm to patients due to the reduced availability of medical care," TMA wrote.

TMA also raises concern over anticompetitive effects in the Medicare Advantage market. The merged health plans would control 36 percent of that market in Texas, the letter states. 

For more about the Aetna-Humana merger, check out the cover story in the December issue of Texas Medicine

Competition in Health Insurance: A Comprehensive Study of U.S. Markets is free to AMA members. The study is also available to nonmembers. To order a copy, visit the online AMA Store, or call (800) 621-8335 and mention item number OP427113.

Having ICD-10 Problems? TMA Wants to Know

Oct. 1 was the mandatory date to switch to the ICD-10 coding system. The government's paltry "grace period" notwithstanding, all claims to Medicare, Medicaid, commercial insurers, and other payers with a date of service on or after Oct. 1 must use ICD-10. If you run into problems submitting claims, email TMA Payment Advocacy or send a report to TMA's Hassle Factor Log. TMA staff will monitor the reports and contact health plans, Medicare, or Medicaid. 

If your practice is behind in its ICD-10 preparation, or if you're just looking for some tips and tools to make the new system work more smoothly, see TMA's ICD-10 Resource Center.

TMA has these additional tools to help:  

  • Check out TMA's on-demand webinar Essentials in ICD-10 Coding. This webinar dives into the ICD-10 code set and delivers a deeper understanding for practice staff who touch diagnosis data — managers, billers, coders, front desk, and clinical staff who will gain confidence in working with the codes.
  • TMA is offering physicians the e-MDs ICD-10 Code Search Tool at no cost, as a benefit of membership. Using a combination of keyword filters, anatomical locations, gender, and age, the tool offers a highly intuitive way to build a narrow list of billable ICD-10 codes based on user preferences. 
  • Register for on-demand recordings of ICD-10 planning and implementation courses

Also, check out the CMS ICD-10 Transition Checklist and the blog of ICD-10 Ombudsman William Rogers, MD. The blog has information about tools that are available to assist those who need help with the switch.

Questions? Contact the TMA Knowledge Center by calling (800) 880-7955, Monday-Friday, 8:15 am-5:15 pm CT, or by email.

CMS Finally Releases Stage 3 Meaningful Use Rule

After much anticipation among the medical community, the Centers for Medicare & Medicaid Services (CMS) has released the meaningful use modification rule. While TMA staff members continue to comb through the rule in detail, this much is clear in regard to your meaningful use 2015 reporting:  

  • Physicians participating in the meaningful use program can attest for any continuous 90-day period from Jan. 1, 2015, to Dec. 31, 2015.  
  • The requirement for 5 percent of your patients to view, download, or transmit their health information has changed to at least one patient seen by you during the electronic health record (EHR) reporting period.  
  • The requirement for 5 percent of patients to send a secure electronic message to their physician is now a yes/no statement attesting that the secure message functionality is enabled during the EHR reporting period. 

TMA asked for relief on the patient engagement measures multiple times and is pleased to see that CMS listened.  


The rule combines modifications for meaningful use in 2015 to 2016, as well as the Stage 3 rule, which is optional in 2017 and required for all physicians in 2018. This chart shows updated objectives and measures for meaningful use 2015 through 2017. 


Physicians have until Feb. 29, 2016, to report on their 2015 meaningful use measures. 

Details on the modification rule and the Stage 3 rule will be presented during the fall TMA Medicare: Now and Tomorrow seminar series (Nov. 3-Dec. 3). Sign up now.   

If you have questions about the meaningful use program or other practice technologies, email TMA's Health Information Technology Department or call (800) 880-5720.

Action TMLT Ad 10.15    

Another Post-Tort Reform Record for New Texas Physicians

As it has for four of the past seven years, the Texas Medical Board licensed a record number of new physicians for the fiscal year that ended Aug. 31, surging past the 4,000 mark for the first time in history. 

The board licensed a record 4,295 new Texas doctors last year, up 301 (7.5 percent) from the previous year's record of 3,994. The number of license applications received (5,377) also broke the record of 5,150 set in 2014. 

"Twelve years since the passage of our historic 2003 medical liability reforms, we continue to attract new physicians to Texas in record numbers," said Austin internist Howard Marcus, MD, chair of the Texas Alliance For Patient Access. "I don't at all find that to be a coincidence."

AMA, TMA Tell Feds to Speed Up Release of MACRA Funds

The federal government needs to kick it in gear and release funds for "the development of quality measures and technical assistance to small practices" authorized by the Medicare Access and CHIP Reauthorization Act (MACRA). That's the gist of an Oct. 7 letter from the American Medical Association to Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andrew Slavitt. TMA signed on to the letter in support of expeditious release of the critical funding.

Come 2019, physicians can participate in one of two major payment tracks: the fee-for-service Merit-Based Incentive Payment System (MIPS), which boosts or docks physician pay based on their quality and cost performance, or one or more alternative payment models (APMs), such as accountable care organizations, medical homes, bundled payments, or other initiatives.  

"We have repeatedly called for federal funding to support quality measure development and were pleased that MACRA included funding for this purpose (section 102) as well as additional funding for technical assistance to help small practices comply with requirements of the [MIPS] and/or transition to an alternative payment model (section 101). Key to achieving the legislation's goals is the availability of an adequate portfolio of appropriate quality measures, along with meaningful technical assistance to practices that meet the needs of the various physician specialties for improving the care of their patients," the letter states.

The AMA letter cites MACRA's authorization of funding to the tune of "$15 million per year for each of fiscal years 2015 through 2019, for a total of $75 million, to fund the development of physician quality measures for use in the MIPS." MACRA also authorizes "$20 million per year from fiscal years 2016 through 2020 for technical assistance to small practices of up to 15 professionals — especially those in rural areas, health professional shortage areas, and medically underserved areas." To date, the government hasn't released those funds.

"We are therefore troubled by HHS' lack of expediency in addressing this critical need, especially in view of the fact that adjustments under MACRA's [MIPS] are likely to be based on a performance year that begins on January 1, 2017, and the CMS deadline for measures to be considered for the 2017 reporting period closed in June," the letter states.

TMA, AMA, and dozens of state and national organizations call on CMS to promptly release funds to support development of "actionable and relevant measures that improve patient care and allow physicians to comply with the program" and for the U.S. Department of Health and Human Services to "partner with state and specialty medical societies on this initiative. Medical societies are trusted sources of information and guidance within the physician community, and their involvement in technical assistance initiatives would ensure active and direct physician engagement."

For more about the new payment systems that will replace Medicare's Sustainable Growth Rate formula, read "SGR Is Gone. Now What?" in the September issue of Texas Medicine.

Physicians Now Have Expanded Access to Naloxone

Senate Bill 1462 by Sen. Royce West (D-Dallas), supported by TMA during the legislative session, gives physicians authority to prescribe the lifesaving opioid antagonist naloxone not only to patients but also to family members or friends of those who may be at risk of an overdose. The law, effective Sept. 1, also allows a person or organization acting under a standing order to distribute an opioid antagonist and allows pharmacies to dispense the drug. 

The new law provides liability protection for prescribers who, acting in good faith with reasonable care, prescribe an opioid antagonist. 

The American Medical Association Task Force to Reduce Opioid Abuse updated the AMA website to include tools and resources to help physicians in co-prescribing naloxone to patients at risk of overdose.

The Centers for Disease Control and Prevention has guidance on prescribing opioids for chronic pain. Visit Prescribe to Prevent to access guidance for clinicians, information on naloxone products, and links to training for consumers.

 TMAIT Action Ad 6.15

Texas Submits 1115 Medicaid Waiver Extension Application

Texas has submitted the 1115 Waiver Extension Application to the Centers for Medicare & Medicaid Services (CMS). Texas' five-year 1115 Medicaid Transformation Waiver will expire Sept. 30, 2016, unless the government grants a renewal or extension. The submitted cover letter, application, and interim evaluation report have been posted on the Texas Health and Human Services Commission (HHSC) website

TMA President Tom Garcia, MD, told HHSC Executive Commissioner Chris Traylor in a letter the association "absolutely supports renewal of the waiver beyond its initial five years." In the letter, TMA says the funding from the waiver "will help communities maintain or expand indigent care initiatives; support important delivery system reform and improvement projects begun under the initial waiver; and continue to test novel, emerging ideas to improve health care access and outcomes among low-income Texans."

Texas received a waiver in 2011 to allow it to expand Medicaid managed care statewide, to establish a new uncompensated care pool for safety net hospitals and health professionals, and to establish and fund innovative projects to improve availability and quality of services to Medicaid and uninsured Texans. Federal and state funds sustain the waiver, with primary funding coming from large hospital districts.

While TMA supports renewing or extending the waiver — the funding from which is critical to Texas' health care safety net — the association also recognizes that the transformation envisioned by the waiver remains elusive because of the lack of meaningful and ongoing input from community-based physicians. CMS and HHSC must undertake changes to the waiver to rectify the lack of true collaboration among facilities and physicians, TMA says, adding that Texas must increase Medicaid payments to physicians to sustain any delivery system changes achieved by the waiver.

For more on the waiver, read "1115 Medicaid Waiver Up for Renewal" in this month's issue of Texas Medicine.  

Updated Federal HIT Plan Contains Strategies TMA Supports

The Office of the National Coordinator for Health Information Technology (ONC) has published its final Federal Health IT Strategic Plan 2015-2020, which lays out the federal government's health information technology (HIT) priorities. In February, when the plan was in its draft stage, TMA submitted a comment letter to Karen DeSalvo, national coordinator for HIT.

"The big picture for HIT is that usability, interoperability, and standardization produce safety, and there is no safety in EMRs without these critical elements," wrote Matt Murray, MD, chair of TMA's Ad Hoc Committee on Health Information Technology.

Dr. Murray created a summary that demonstrates how TMA advocacy can be instrumental in influencing change at the federal level.  

"A major theme of our letter was poor usability of EHRs. Perhaps our strongest comment was that 'the greatest impediment to the effective use of health IT is the poor usability of EHRs.' In one of our descriptions of poor usability we stated that 'sometimes safe use of EHRs results in untenable work flows' for physicians. The draft plan had not included any strategy to improve usability, and it had made no reference to the adverse impact technology can have on clinician work flow. The revised plan now includes a specific strategy to 'Improve health IT usability and clinician workflow by fostering innovation through policies and methods.' Another new strategy brings additional attentiveness to physician work flow issues," Dr. Murray states in his summary.

His summary concludes: "Our letter alone is certainly not responsible for these and other positive changes that were made to the draft strategic plan, as it was just one letter out of 400 that ONC states they received. However, one should acknowledge that without letters like ours, changes would not have been made. This is what makes the extraordinary time we (physicians and TMA staff) spend on advocacy issues worthwhile." 

New TMF Network Aims to Improve Adult Immunization Rates

Despite the availability of effective vaccines to help prevent influenza, pneumonia, and shingles, immunization rates for adults remain significantly low. To help boost these numbers for Medicare beneficiaries, the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) has established the Immunizations Network for physicians and other health care professionals.

The network's goal is to improve referrals for tracking and reporting immunizations via certified electronic health records and evaluate opportunities to enhance payment by reviewing practice workflow processes. The TMF QIN-QIO provides these services at no cost. Learn more about the network from this downloadable fact sheet

The network is just one of three physician-focused programs recently established by the TMF QIN-QIO to help physicians save time, improve patient care, and reduce costs associated with meeting certain CMS requirements. The other two networks, which focus on behavioral health and value-based improvements, such as Medicare's Physician Quality Reporting System and value-based payment modifier program, help physicians benefit from — and not be penalized by — Centers for Medicare & Medicaid Services mandates. 

For more information on participating in one or more of these networks, visit the TMF QIN-QIO website. Please note visitors will have to log in or register for a free account to view some of the site content. 

Read more about TMF's networks in the December issue of Texas Medicine 


The Value Modifier Program: Improve Performance, Payment

By Clifford Moy, MD, medical director for behavioral health, TMF Health Quality Institute

As the Centers for Medicare & Medicaid Services (CMS) continues to refine and expand the physician value-based payment modifier program, physicians and health care providers must understand and stay current with the new methodology in order to achieve performance goals for better payment. The value modifier combines Physician Quality Reporting System (PQRS) quality measures, cost measures, and a payment adjustment for physicians. 

To help accomplish that, TMF Health Quality Institute — the Medicare Quality Innovation Network Quality Improvement Organization (QIN-QIO) for Texas, Oklahoma, Arkansas, Missouri, and Puerto Rico — provides free education and technical support to help physicians and health care providers meet the evolving value modifier requirements. 

TMF has a successful history of working with physicians and physician practices across the state to help them meet the reporting requirements for various programs, including PQRS. TMF now also works with physicians and physician practices to provide free assistance to help them meet the requirements of the value modifier program. Part of that assistance is to help physicians and physician offices understand how the value modifier is calculated. The scoring is noted within the Quality and Resource Use Report (QRUR). Below are some recent updates related to the QRUR: 

  • On Sept. 9, 2015, CMS made available the 2014 annual QRURs to every group practice and solo practitioner nationwide. Groups and solo practitioners are identified in the QRURs by taxpayer identification number (TIN).
  • The 2014 annual QRURs show how groups and solo practitioners performed in 2014 on the quality and cost measures used to calculate the 2016 value modifier. For groups with 10 or more eligible providers who are subject to the 2016 value modifier, the QRUR shows how the value modifier will apply to physician payments under the Medicare Physician Fee Schedule (PFS) for physicians who bill under the group's TIN in 2016. For all other groups and solo practitioners, the QRUR is for informational purposes only and will not affect their payments under the Medicare PFS in 2016.
  • Authorized representatives of group and solo practitioners can access the 2014 annual QRURs on the CMS Enterprise Portal using an Enterprise Identify Data Management account with the correct role. For more information, visit How to Obtain a QRUR
  • CMS established a 60-day informal review period that begins after the release of the 2014 annual QRURs to request a correction of a perceived error in CMS' 2016 value modifier calculation. The informal review period for the 2016 value modifier is open through Nov. 9, 2015. For more information about the 2014 annual QRURs, visit the CMS 2014 Annual Quality and Resource Use Reports webpage.  

The TMF QIN-QIO Value-Based Improvement and Outcomes Network provides more information about these topics, as well as upcoming educational events and resources. If you aren't already a member of this network, create a free account, and then join the Value-Based Improvement and Outcomes Network. As a member benefit, quality improvement consultants will work directly with you and your staff to help you understand reporting requirements and ensure your practice receives the reimbursements it is entitled to. 

Email Suzie Buhr, TMF QIN-QIO quality improvement consultant, with questions and for more information, or call (214) 477-1407.

Clifford Moy, MD, serves as TMF's medical director for behavioral health. He supports TMF's medical directors on the Texas Medicaid & Healthcare Partnership project and helps develop and operationalize behavioral health quality improvement opportunities. Dr. Moy is board-certified by the American Board of Psychiatry and Neurology.

Don't Lose Out! Win $5,000 for Your Champion of Health

Oct. 30 is the deadline to nominate a program in your town or city that promotes healthy lives and healthy communities. Winners receive a $5,000 grant. The 2016 TMA Foundation John P. McGovern Champion of Health Award focuses on exceptional projects that address urgent threats to the public's health and those that further the TMA Foundation's mission: to help physicians create a healthier future for all Texans.

Established in 1995, the award has recognized local and statewide programs for innovative and effective ways of reaching Texans. It is named after John P. McGovern, MD, a philanthropist and humanitarian who founded the John P. McGovern Foundation in Houston. Dr. McGovern established a permanent TMA Foundation endowment that supports this award. 

Download the nomination form today. The entry deadline is Oct. 30, 2015. Winners are notified in December, and the award presentation is Jan. 30, 2016, at the TMA 2016 Winter Conference at the Hyatt Regency Austin. Visit the TMA Foundation webpage, or contact the foundation at (800) 880-1300, ext. 1664, or (512) 370-1664 for more information about the program and a list of past winners.

This Month in Texas Medicine

The October issue of Texas Medicine features a cover story on the new MCAT and its components that focus on concepts such as self-identity, social stratification, and multiculturalism. In the issue, you'll also find information on a new law that allows physicians to prescribe an opioid antagonist to a person in danger of an opioid-related overdose; renewal of the 1115 Medicaid waiver; products to help practices stay in compliance with HIPAA privacy and security regulations; and a new TMA-backed law that calls on health plans to clean up their network directories.

Click to launch the full edition in a new window.  

Texas Medicine RSS Feed

Don't want to wait for Texas Medicine to land in your mailbox? You can access it as an RSS feed, the same way you get the TMA Practice E-Tips RSS feed.

E-Tips RSS Feed

TMA Practice E-Tips, a valuable source of hands-on, use-it-now advice on coding, billing, payment, HIPAA compliance, office policies and procedures, and practice marketing, is available as an RSS feed on the TMA website. Once there, you can download an RSS reader, such as Feedreader, Sharpreader, Sage, or NetNewsWire Lite. You also can subscribe to the RSS feeds for TMA news releases and for Blogged Arteries, the feed for Action.   

This Just In ...

Want the latest and hottest news from TMA in a hurry? Then log on to  Blogged Arteries.  

Deadlines for Doctors

TMA's Deadlines for Doctors alerts you and your staff to upcoming state andfederalcompliance timelines and offers information on key health policy issues that impactyourpractice.      

Nov. 9, 2015

Humana Code Edit and Policy Change Notifications

Last Day to File an Informal Review Request to Appeal Errors in Your Medicare PQRS Feedback Report and QRUR

TMA Education Center

The TMA Education Center offers convenient, one-stop access to the continuing medical education Texas physicians need. TMA's practice management, cancer, and physician health courses are now easier than ever to find online.  


Medicare Now and Tomorrow
Nov. 3-Dec. 3

Conferences and Events

2015 TMA Advocacy Retreat
Dec. 4-5
Omni Barton Creek Resort in Austin

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Last Updated On

December 09, 2016