Not surprisingly, partisan political wrangling has delayed congressional action on funding that states need to prepare for and fight the Zika virus. And now it's mosquito season. Texas is home to 85 different species of mosquito, including the Aedes aegypti, the primary carrier of Zika.
"It is only a matter of time before one of those mosquitoes bites an infected traveler and then passes the disease on to another Texan," TMA President Don Read, MD, wrote in a letter to the Texas congressional delegation. "Local and state public health officers in Texas are working hard to prepare for that day, but we need help. We have the experience and expertise necessary, but our public health infrastructure is not up to a task of this magnitude."
Lab testing — especially of pregnant women — monitoring travelers, and keeping Texans informed about the state of the disease all need bolstering from federal dollars. "We already have waited too long," Dr. Read wrote. "We need that action now. Several months from now will be too late."
In Washington, D.C., Congress has been dragging its feet on funding to help the United States prepare for and battle the Zika virus. President Barack Obama requested $1.9 billion in emergency funds in February. In May, the House offered a plan that includes just under $700 million. The Senate's plan includes $1.1 billion.
In May, Houston obstetrician Catherine Eppes, MD, whose high-risk pregnancy clinic has been overrun by women concerned about Zika infection, told the Senate Health and Human Services Committee Texas needs to find more ways to screen pregnant women for the Zika virus. "The combination of a relatively new but profoundly significant disease with little knowledge about the exact timing and rates of transmission, and complex, often inaccessible testing options leaves pregnant women and physicians frustrated," the member of the TMA Committee on Maternal and Perinatal Health said. "I think doctors would benefit from statewide dissemination of the options and costs for testing within our state and city health departments."
Dr. Eppes also recommended Texas Medicaid and the Women's Health Program be authorized to support the screening and testing of their eligible populations.
The Texas Department of State Health Services (DSHS) reports that as of May 25, Texas had 36 confirmed cases of Zika virus disease. Of those, 35 were in travelers infected abroad and diagnosed after they returned home; one of those travelers was a pregnant woman. One case involved a Dallas County resident who had sexual contact with someone who acquired the Zika infection while traveling abroad. Nationally, as reported by the U.S. Centers for Disease Control and Prevention (CDC), 157 pregnant women in the continental United States and another 122 in U.S. territories, primarily Puerto Rico, had tested positive for the infection as of May.
DSHS is testing for Zika virus at its public health lab in Austin. CDC encourages Texas physicians to report suspected Zika virus cases to DSHS.
According to DSHS, Aedes aegypti mosquitoes can be found in Texas, particularly in urban areas in the south and southeast portions of the state. While there is no evidence of local transmission by Texas mosquitoes yet, state health officials have implemented Zika virus prevention plans in anticipation of increased mosquito activity and the potential for local mosquito transmission.
At a recent Texas Public Health Coalition "University of Health" educational session, former and current Texas health commissioners, the chair of TMA's Council on Science and Public Health, and a public health officer in the lower Rio Grande Valley gave legislative staffers an in-depth look into how Texas is preparing for the Zika virus.
"We in public health would not be doing our job if we weren't planning for the eventuality that Zika would become locally transmitted," John Hellerstedt, MD, DSHS commissioner, told the crowd. "Large areas of Texas could be impacted." Coalition Vice Chair John Carlo, MD, stressed Texas should focus on the state's poorest communities, where decent housing and access to health care are lacking and where a Zika outbreak would have a devastating effect. Eduardo Olivarez, chief administrative officer for Hidalgo County Health and Human Services, spoke about the need for coordinating a patchwork of state and local agencies in the fight against a difficult foe. "You're not going to be able to spray this problem away," he said.
To help ensure Texas physicians have all they need to diagnose the virus, DSHS has updated its texaszika.org website with a supplemental testing information form and polymerase chain reaction (PCR) and serology specimen criteria form. The PCR test can confirm the presence of Zika virus. Serologic testing can detect Zika infection in people who may not have had symptoms, and the test can be conducted up to 12 weeks after infection. DSHS says a positive serologic test result requires confirmatory testing to pinpoint Zika because it can cross-react with other viruses, such as dengue.
DSHS is working with local officials in the Rio Grande Valley area, a potential hot spot for Zika virus transmission, to monitor mosquito activity. The agency reports spot trapping in the area in February yielded no Aedes aegypti mosquitoes. DSHS urges communities to consider expanding their surveillance in coordination with local mosquito control efforts.
The disease can cause fever, rash, muscle and joint aches, and red eyes, and also has been linked to the birth defect microcephaly and other poor birth outcomes in some women infected during their pregnancy.
To help prevent the spread of Zika virus in Texas, DSHS also developed flyers and door hangers (available in English and Spanish) you can use in your office to educate your patients on protecting themselves from the disease.
CDC issued Update: Interim Guidance for Prevention of Sexual Transmission of Zika Virus — United States, 2016. CDC's recommendations apply to men who have traveled to or reside in areas with active Zika virus transmission and their sex partners.
TMA and the Texas Association of Obstetricians and Gynecologists have prepared guidance for physicians on the Zika virus and pregnant patients.
State health officials continue to encourage people to follow travel precautions. CDC is advising pregnant women to delay travel to foreign countries where Zika is being transmitted.
General information about Zika virus
Information for clinicians
Protection against mosquitoes
Zika virus travel notices
TMA and Texas physicians cheered when Congress repealed Medicare's Sustainable Growth Rate (SGR) formula last year. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) not only removed the constant threat of Medicare payment cuts, but it also promised to simplify the ever-tightening thicket of federal regulations that strangle physicians' practices.
TMA is less than enthusiastic, however, about the Centers for Medicare & Medicaid Services' (CMS') plans to implement the new law. TMA is studying the 426 pages of proposed MACRA regulations carefully and sent TMA chief lobbyist Darren Whitehurst and Angie Ybarra, TMA's director of clinical advocacy, to Washington for in-depth discussions with the American Medical Association and national specialty societies. A TMA staff team listened carefully to two MACRA briefing sessions that AMA set up with CMS officials.
According to TMA Chief Executive Officer Louis J. Goodman, PhD, here are the association's topline observations so far:
- MACRA is far more complex, confusing, and controlling than the Physician Quality Reporting System, meaningful use, and value-based modifier programs it is replacing.
- Compliance will be especially difficult for small practices that may end up with Medicare payment penalties, even if they spend the time and money to jump through all the new regulatory hoops.
- The system of bonuses and penalties pits physician practices against one another so that there will be winners and losers, regardless of how well all practices "perform" on these new quality standards.
TMA needs physician feedback (email macra[at]texmed[dot]org) as it develops detailed official comments on the draft regulations. In the meantime, the association urges physicians from practices of all sizes to visit TMA's MACRA Resource Center to learn about the new law and proposed regulations.
In addition, read "Bracing for MACRA" in the July issue of Texas Medicine to learn about the new quality-based payment pathways Congress designed to replace the SGR and how TMA is helping practices navigate the labyrinthine Medicare payment paradigm.
Thanks to lobbying from TMA and organized medicine, the Centers for Medicare & Medicaid Services extended the deadline for physicians and other health professionals, including advanced practice nurses and physician assistants, to reenroll in Medicaid to Sept. 25, 2016. The initial deadline for reenrollment, driven by a provision in the Affordable Care Act (ACA), was March 24.
According to the Texas Health and Human Services Commission (HHSC), all physicians participating in Medicaid who have not met all ACA revalidation requirements must do so through reenrollment by Sept. 24, 2016. To avoid disenrollment and possible claims payment disruption, Texas Medicaid officials urge physicians to submit a reenrollment application before June 17, 2016.
The reenrollment requirement applies to physicians and other health professionals who participate in Medicaid managed care, traditional fee-for-service Medicaid (each active Texas Provider Identifier suffix), the Texas Vendor Drug Program, and in long-term care services administered through the Texas Department of Aging and Disability Services.
If an application has deficiencies but is submitted by June 17, HHSC says there will not be gaps in payment after Sept. 24, if the physician makes a good faith effort to resolve application errors. Applications submitted after June 17 will be processed, but HHSC cannot guarantee those applications will be completed by Sept. 24, which could result in physician disenrollment from Texas Medicaid and denial of payment.
TMA and Texas Medicaid officials encourage Texas physicians to get ahead of the complex reenrollment process.
Acute Care Physicians Reenrolling Through Texas Medicaid and Healthcare Partnership
Ordering- and Referring-Only Physicians
Ordering- and referring-only physicians are those whose only relationship with Texas Medicaid involves ordering or referring services for Medicaid clients. They also must enroll with Texas Medicaid as participating physicians.