Action: Sept. 15, 2016

TMA Action Sept. 15, 2016   News and Insights from Texas Medical Association

TMB Adopts Call Coverage Rules
TMA, AMA Oppose Bill That Would Threaten Patient Safety
TMA Backs Definition of Emergency in Obstetrical Case
Register Now for TMA Fall Conference: MACRA, Zika, What's Next?
Texas Hits Record for New Physician Applications
New Rules Say You Must Address Language Barriers
TMA, California, Florida Form Joint Venture
HHSC Offers STAR Kids Webinar for Physicians

TMA Offers New Cyber Security and Ransomware Tools
Register for the Texas Quality Summit
Surgeon General Calls on Physicians to End Opioid Abuse Epidemic
Donors Met the Challenge and Won a Matching TMAF Grant
GETAC Committee Applications Due on Sept. 30
Register for CDC Pink Book Immunization Training in Austin
This Month in Texas Medicine

TMB Adopts Call Coverage Rules 

At its Aug. 25 meeting, the Texas Medical Board (TMB) voted to adopt without change its recently proposed call coverage rules. The rules outline requirements for two models for call coverage: a reciprocal call coverage arrangement for physicians in the same or similar specialty and a nonreciprocal arrangement that does not require reciprocal call coverage.

The reciprocal model closely resembles traditional call coverage arrangements and requires either a written or oral agreement that the covering physician is responsible for meeting the standard of care and providing to the requesting physician a report of the patient care provided. The nonreciprocal model is more prescriptive. A nonreciprocal agreement must be in writing and include terms that:

  • Establish the covering physician's responsibility for meeting the standard of care; 
  • Provide a list of physicians who may provide call coverage;  
  • Establish the covering physician's ability to have access to medical records; and 
  • Require the covering physician to furnish a report to the requesting physician within certain times, depending on the circumstances of the care provided.

Previously, TMA weighed in strongly against the board's initially proposed call coverage rules, which one Dallas physician called "totally bizarre and dangerous." The proposed rules had stated that physicians who enter into call coverage agreements "are contractually obligated and mutually responsible for meeting the standard of care" for established patients and for sharing documentation of any call coverage provided. 

TMA asked the board to withdraw the proposed rules and start over. "Physicians are, and should be, responsible for their own acts, not for the acts of other physicians solely due to on-call arrangements," then-TMA President Tom Garcia, MD, wrote in TMA's formal letter to TMB. "Physicians are, and should be, responsible for exercising reasonable care in making on-call arrangements, but cannot and should not be held liable for the acts of another physician who accepts on-call responsibility, and vice-versa. On-call arrangements do not involve 'delegated' acts in which the physician is supervising another health care worker."

TMB withdrew the version of the rules requiring mutual responsibility in call coverage arrangements and subsequently proposed the now-adopted version that addressed physician concerns. The adopted rules state that the standard of care responsibility rests only with the covering physician.

For more information, read "The Future Calls" in the July issue of Texas Medicine 

TMA, AMA Oppose Bill That Would Threaten Patient Safety

TMA and the American Medical Association have serious concerns about proposed federal telemedicine legislation that would preempt state laws governing medical licensure, medical practice, and professional liability. The legislation would change the originating site of care from the patient's location to the physician's location, ostensibly to enable telemedicine across state lines for patients in the TRICARE program. TMA signed on to AMA's letter to Congress to object to the serious threat to important and demonstrated patient safety protections provided by adherence to licensure and medical practice laws in the state where the patient receives services.  

AMA and the Federation of State Medical Boards (FSMB) have been closely tracking the National Defense Authorization Act for Fiscal Year 2017 (S 2943), which passed the U.S. House and Senate and is now moving to a conference committee to reconcile the differences between the versions. TMA and AMA take issue specifically with the "Enhancement of Use of Telehealth Services in Military Health System, Location of Care" provision in the Senate bill that passed on June 14. This provision is not contained in the companion legislation that passed the House of Representatives on May 18.

AMA has communicated to the Senate Armed Services Committee, leadership, and individual Senate offices the strong physician opposition to the Location of Care provision. TMA supports AMA's efforts to have the provision removed.

The key points AMA and FSMB shared with Congress include:  

  • Both organizations strongly support adoption of telemedicine and have sought to develop and implement policies, rules, and mechanisms that would expand access to care via telemedicine in a safe and accountable manner. 
  • The practice of medicine occurs where the patient is located, rather than where the physician or provider is located. This approach is patient-centered, time-tested, and practice-proven. It ensures state medical boards have the legal capacity and practical capability to regulate physicians treating patients within the borders of their state and to attest that those physicians meet the qualifications necessary to safely practice medicine. Each state establishes its own licensing and medical practice standards, regulations, and laws that meet the needs of the patients receiving care within the state's borders. 
  • This Location of Care provision would compromise patient safety by making it exceedingly difficult and potentially impossible for patients and state medical boards where medical care is rendered to address improper or unprofessional care. The ability of patients, and other interested parties, to quickly and accurately identify and report concerns to the applicable state medical board of jurisdiction and actively support the medical board investigation will be hampered. Altering the applicable law to the state where the provider is located would place the burden solely on the patient to navigate through the complaint filing and investigatory process across one or more state lines. 
  • The Location of Care provision raises constitutional questions and would create an ambiguous medical regulatory structure, as it is unclear if the physician must adhere to the Medical Practice Acts (laws and standards) of his or her state of licensure or the state of the patient's location. The latter would embroil patients, state medical boards, and health care professionals in costly conflicts of litigation ancillary to the issue of whether appropriate medical care was provided. 
  • This Location of Care provision creates an inefficient and unworkable system where, in theory, each individual state board would be required to regulate medical practice across the nation, affecting 9.4 million TRICARE beneficiaries around the world. Yet, a state board's legal authority does not extend beyond the state; investigations and application of state medical practice laws stop at the border's edge. 
  • The current fee structure of the state board licensing and renewal system allows state boards to use their limited resources to fund investigations and subsequent prosecutions of physicians suspected of unprofessional medical conduct in the state where the medical care was rendered. This proposal would create a significant and unsustainable financial burden on the state board where the physician is licensed, forcing the board to conduct its disciplinary proceedings and use its limited resources, at a much greater cost, to be able to conduct investigations in other states. 

Telemedicine regulation in Texas has received a lot of attention from the medical community and the courts. Last April, telemedicine company Teladoc filed a federal antitrust lawsuit against the Texas Medical Board (TMB). One month later, U.S. District Judge Robert Pitman granted Teladoc's request for a temporary restraining order and preliminary injunction that blocks TMB's telemedicine rule, which prohibits prescription of dangerous drugs or controlled substances without a "defined physician-patient relationship." That includes a physical examination via face-to-face visit or in-person evaluation, as TMB defines those terms in the rules. The injunction will continue until Teladoc's federal antitrust lawsuit against TMB is resolved. 

TMA Backs Definition of Emergency in Obstetrical Case

Last month, TMA signed on to the Texas Alliance for Patient Access' (TAPA's) friend-of-the-court brief to support the application of the willful and wanton standard in a lawsuit involving emergency obstetrical care. TMA, TAPA, and other signatories contend emergency care provisions apply to medical care provided in an obstetrical unit without the pregnant patient first having been evaluated in a hospital's emergency department. 

A Denton obstetrician-gynecologist's reaction to a 2011 shoulder dystocia birth in which the baby was born with neurologic dysfunction in his right arm rests at the heart of a negligence lawsuit now in the hands of the Second Court of Appeals in Fort Worth. The appeals court will look at whether shoulder dystocia elevates a delivery to emergency care according to the law, and if so, whether the parents of the child must establish gross negligence on the part of the physician.

A district court previously ruled in favor of the physician and his practice, which argue the plaintiffs must show the physician acted with willful and wanton negligence. The court's ultimate decision has implications for a number of physicians in emergency care situations, including emergency department physicians and practitioners in obstetrics units and surgical suites.

The brief says both traditional emergency rooms and obstetrical units serve as emergency departments for pregnant women. Requiring the patient to first receive care in a traditional emergency department for the statute to apply, TAPA wrote, "would create an absurd and illogical result" and make physicians face a "disparate application" of that law.

"Should doctors and health care providers be encouraged to waste precious time and resources arbitrarily routing pregnant patients through a traditional emergency department in order to receive the protection of the Statute, ignoring what is in the best interest of the patient's medical treatment? Certainly not!" the brief states. "The plain language and intent of the Statute is clear."

For more information about the case, read "The Right Standard?" in the October issue of Texas Medicine 

Register Now for TMA Fall Conference: MACRA, Zika, What's Next?

Register today for the 2016 TMA Fall Conference at the Hyatt Regency Lost Pines Resort and Spa, Sept. 23–24. This free member benefit offers you the opportunity to reconnect with colleagues and learn more about the Medicare Access and CHIP Reauthorization Act (MACRA), telemedicine, and the Zika virus from the experts. The General Session programming will offer 3.5 hours of AMA PRA Category 1 CME Credits™.  

Stop by the TMA Member Services booth to learn more about TMA's endorsed vendor and group discount programs (including the exclusive trip to experience the lakes of Italy), see the latest MACRA education and resources, and explore all of the other benefits your TMA membership offers.

Online registration ends Friday, Sept. 16, but you can also register when you arrive, starting on Friday, Sept. 23. For more information about the conference, sleeping room availability, the onsite flu shot clinic, and the full agenda for the General Session, visit the TMA Fall Conference website. Questions? Email the TMA Knowledge Center, or call (800) 880-7955, Monday–Friday, 8:15 am–5:15 pm CT. 

  

Texas Hits Record for New Physician Applications

The Texas Medical Board (TMB) finished is fiscal year last month having received a record number of new physician applications. TMB received 5,544 new applications, up 3 percent from the previous year's record 5,377 applicants. 

Texas licensed 4,093 new physicians for the year. That figure is down 202 from the previous year but still the second highest on record.

"We continue to trend in the right direction," said Austin internist Howard Marcus, MD, chair of the Texas Alliance for Patient Access, "yet there remains a strong demand for health care workers."

TMB received more than twice as many physician applications this year than at the height of the state's liability crisis 13 years ago.

Thirteen years ago this month, Texas voters approved Proposition 12. The constitutional amendment affirmed the legislature's authority to set damage caps for hard-to-quantify pain-and-suffering-type awards in health care lawsuits. Within months, the epidemic of lawsuit abuse was reversed, and the exodus of physicians stopped, especially those practicing in the emergency department, says Dr. Marcus.

"One hundred eighteen Texas counties have seen a net gain in emergency medicine physicians since the passage of reforms. That includes 53 counties that previously had none," he said. "That turnaround would not have occurred without the passage of our landmark reforms."

The state's senior population has grown 50 percent since 2003, Dr. Marcus says. Meantime, the number of geriatricians serving that senior population has increased four-fold.

"Today Texas doctors can focus on providing the best care for their patients with fewer unfounded legal threats," he said.

New Rules Say You Must Address Language Barriers

Oct. 16, 2016, brings a new requirement for a sign to post on your practice walls, as well as a plan for fulfilling its promise. TMA’s new white paper MembersOnlyRed has all the details about accommodating your patients with limited English proficiency (LEP). 

New rules from the U.S. Department of Health and Human Services (HHS) lay out a compliance framework for physicians and health care providers regarding all types of discrimination, including discrimination against individuals with LEP. 

The framework, explained in detail in the new white paper from the TMA Office of General Counsel about accommodating people with limited English proficiency, includes factors to help you determine the reasonable steps you must take to provide these individuals meaningful access.

For example, what is the nature of your communication with patients who speak another language? How often do you encounter patients of a specific language? What resources are you realistically able to provide?  

In addition, you'll be required to: 

  • Post a notice of consumer rights providing information about communication assistance; and
  • Post taglines in the top 15 languages spoken by LEP individuals in Texas, indicating the availability of such assistance. The white paper lists these languages and a link to translations from HHS. 

The rules implement the nondiscrimination provision, Section 1557, of the Affordable Care Act, which prohibits discrimination against individuals on the basis of race, color, national origin (which includes limited English proficiency), sex (this includes discrimination on the basis of  gender identity), age, or disability.

Note that the new discrimination rules apply to any entity that has a health program or activity, any part of which receives federal financial assistance from HHS. HHS says most physicians will find themselves subject to Section 1557 and thus must comply with the requirements of the rules. You should consult with your legal counsel to determine the application of the rules to your particular situation.

If you have questions, contact the TMA Knowledge Center by phone at (800) 880-7955 or by email.

TMA, California, Florida Form Joint Venture

TMA and the medical associations of California and Florida have formed PSO Services, LLC, a physician services organization with a national scope. The new company will offer a suite of market-based services to support physicians who want to remain independent during this time of increasing government regulation and changing payment models. Working to leverage the trust that physicians place in their state associations, PSO Services will focus initially on developing physician-owned networks to enter into value-based care contracts and manage population health.  

The three medical associations will have equal ownership in the venture, and each will provide two directors to the board. TMA Immediate Past President Tom Garcia, MD, and TMA Chief Executive Officer Lou Goodman, PhD, will serve as TMA's directors. Lance Lewis, the chief financial and operating officer of the California Medical Association, is the chief executive officer of PSO Services, LLC. The company will reach out to other state medical associations that are interested in supporting independent physicians with these services. 

HHSC Offers STAR Kids Webinar for Physicians

If you participate in Medicaid, don't forget about the STAR Kids managed care program coming Nov. 1. The legislature directed the Texas Health and Human Services Commission (HHSC) to develop the managed care program specifically designed for children aged 20 years and younger who have disabilities.  

HHSC will conduct physician and family training sessions on the program this month. For training dates and locations, visit the website. Additionally, HHSC is hosting a free STAR Kids webinar for health professionals; the STAR Kids Provider Information Session Webinar will take place Sept. 27 from 3:00 to 4:30 pm CT. 

If you can't participate in the live webinar, you can access a recording later.

According to HHSC, participation in the STAR Kids program is required for those who are 20 years or younger, covered by Medicaid, and meet at least one of these criteria:  

  • Receive Supplemental Security Income (SSI);
  • Receive SSI and Medicare;
  • Receive services through the Medically Dependent Children Program (MDCP) waiver;
  • Receive services through the Youth Empowerment Services (YES) waiver;
  • Live in a community-based intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) or nursing facility;
  • Receive services through a Medicaid Buy-In program;
  • Receive services through any of the Department of Aging and Disability Services (DADS) intellectual and developmental disability (IDD) waiver programs: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); or Texas Home Living (TxHmL). 

STAR Kids will provide acute care services, such as physician office visits, hospitalizations, and prescription drugs, as well as long-term care services and support. Those who enroll in the STAR Kids program will choose a health plan, as well as a primary care physician or clinic that will provide basic medical services and provide referrals to a specialist when needed, HHSC says.  

  

TMA Offers New Cyber Security and Ransomware Tools

Ransomware has reached Texas, and its emergence highlights the importance of up-to-date security. Health care is particularly vulnerable to the ransomware threat. KPMG's 2015 Health Care and Cyber Security Survey, which polled 223 U.S.-based health care executives, found four-fifths of respondents said cyber attacks had compromised their information technology.  

Several large health systems have been high-profile ransomware targets. When smaller practices are the target, the perpetrators adjust their ransom demands accordingly. You can take steps to protect your practice.

TMA is raising awareness and educating physicians on ways to manage security and technology risks. A new webinar, Cyber Security and Ransomware: Protect Your Practice, is available in the TMA Education Center. The webinar outlines how to mitigate cyber risk and respond appropriately in the event of a breach or ransomware demand.

TMA's new Ransomware and Cyber Security Resource Center offers cyber security articles, education resources, consulting services, and endorsed vendor information — all in one place. 

If you have cyber security questions, call TMA's Health Information Technology Department at (800) 880-5720, or send an email.

Register for the Texas Quality Summit

This fall, TMA is hosting a unique event designed to help you improve performance, increase efficiency, and continue to deliver high-quality care. Join your colleagues for the Texas Quality Summit Nov. 18–19, and get the latest resources and hands-on training to take your practice to the next level. Register now, as seating is available to a limited number of participants on a first-come, first-served basis. 

The Texas Quality Summit, cohosted by the TMA Council on Health Care Quality and the American College of Medical Quality (ACMQ), begins with a powerful pre-conference workshop, ACMQ's Quality Improvement and Patient Safety Workshop, on Friday, Nov. 18. Next, attend the full-day summit on Saturday, Nov. 19, for in-depth presentations, physician panels, and case studies addressing quality strategies to enhance your practice. Programming will include an update on health population trends in Texas, transitioning to value-based care, alternative payment models, implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), and much more. 

The 2016 Texas Quality Summit will be held in Austin at the TMA building in the Thompson Auditorium. Discounted room rates are available to attendees at the Doubletree, conveniently located across the street from the TMA building. 

Space is limited, so register online today, or visit the TMA website for more information. 

For more information about the summit, read "Learn From the Experts" in the October issue of Texas Medicine

Surgeon General Calls on Physicians to End Opioid Abuse Epidemic

Last month, U.S. Surgeon General Vivek H. Murthy, MD, emailed a letter to 2.3 million health professionals asking them to lead a national movement to turn the tide on the nation's prescription opioid epidemic. 

The letter stresses the need for education to treat pain safely and effectively and references the U.S. Centers for Disease Control and Prevention's Guideline for Prescribing Opioids for Chronic Pain. The surgeon general calls on physicians to screen patients for opioid use disorder and connect them with evidence-based treatments. He encourages his colleagues to talk about and treat opioid addiction as a chronic illness, "not a moral failing."

Visit Turn the Tide Rx to join with clinicians and public health advocates from across the country in an effort to end this epidemic.

Texas has taken action to reduce deaths from opioid overdoses. The Texas Pharmacy Association (TPA) implemented an expansive physician-authorized standing order regarding the dispensing of naloxone/narcan, a fast-acting antidote that can be administered to someone who is overdosing on opioids. Effective Aug. 1, the standing order allows qualified Texas pharmacists to dispense naloxone to patients and/or family members or friends of patients who have a medical need. 

Pharmacists can act under the standing order only after they have completed a one-hour course accredited by the Accreditation Council for Pharmacy Education and in coordination with TPA. Naloxone can be supplied as an intramuscular injection, intramuscular auto-injector, or intranasal spray. The intranasal formulation is considered off label and is delivered through an atomizer. 

For more information, read "Standing Against Addiction" in this month's issue of Texas Medicine

At the national level, the American Medical Association Task Force to Reduce Prescription Opioid Abuse is focused on reducing the inappropriate prescribing of opioids and the growing crisis of heroin overdose and death. The task force includes physician leaders and staff from across the nation. For more information, AMA members can log in and download the Task Force Overview document.

Donors Met the Challenge and Won a Matching TMAF Grant

The TMA Foundation's (TMAF's) generous Star Donors have won a $10,000 challenge grant from the John P. McGovern Foundation in Houston. 

This is the 10th year the John P. McGovern Foundation has challenged TMAF with a grant for its Star Campaign for all matching donations of up to $10,000. Contributions by donors, and the match from the John P. McGovern Foundation, are bringing nearly $28,000 to help improve the health of all Texans.

Read more on TMAF's webpage.   


PC Action Ad May 13 

GETAC Committee Applications Due on Sept. 30

If you'd like to serve on a Governor's EMS & Trauma Advisory Council (GETAC) committee, you have until midnight on Sept. 30 to submit your application to the Texas Department of State Health Services (DSHS). Committee members serve three-year terms. Download the application form. 

Committees include Air Medical, Education, EMS, Injury Prevention, Medical Directors, Pediatric, Stroke, Trauma Systems, Disaster Preparedness, and Cardiac Care. DSHS will accept applications electronically. Be sure to use the submit button/email address printed on the application to ensure DSHS receives your application.

Committees consist of up of 11 members. Committee appointments are open to anyone seeking either reappointment or initial appointment. 

The Office of EMS/Trauma System Coordination Group will work with the GETAC council chair and committee chairs to coordinate the selection process. The announcement of new or reappointed committee members will be made at the Nov. 19–21 GETAC meeting. 

Note: If your appointment to a committee expires in 2016, you must reapply to be considered for reappointment to that committee. To check when a term expires, visit the DSHS website.

For information, email Colin Crocker, or call (512) 834-6700, ext.2706.

Register for CDC Pink Book Immunization Training in Austin

The U.S. Centers for Disease Control and Prevention (CDC) will present live CDC Pink Book training on the epidemiology and prevention of vaccine-preventable diseases Oct. 25–26 at the Omni Austin Hotel at Southpark. Register today.  

CDC National Center for Immunization and Respiratory Diseases faculty will present a comprehensive review of immunization principles, as well as vaccine-preventable diseases and the recommended vaccines to prevent them. The event will cover the most up-to-date immunization information from the Advisory Committee on Immunization Practices. 

The Texas Department of State Health Services Immunization Unit has reserved a block of rooms at the hotel with a government rate of $135 per night. Reserve your room.

All attendees will need a copy of the Pink Book. You may choose to download it free of charge from the CDC website, or purchase a book with registration before Oct. 15. 

For more information, visit the Pink Book training website. If you have questions, email Linc Allen at DSHS. 

This Month in Texas Medicine

The September issue of Texas Medicine features a cover story on maintenance of certification exams that doctors say are exhausting to prepare for and largely feature multiple-choice questions that entail regurgitating facts often irrelevant to what they see in daily practice. In the issue, you'll also find coverage of what TMA is doing to educate doctors on a new law that requires Texas physicians who diagnose a child with Down syndrome to provide parents with information on the disorder. The September issue highlights TMA's recommendations to improve the Centers for Medicare & Medicaid Services' proposed rule to implement MACRA; standing pharmaceutical orders for naloxone, used to rescue those who overdose from opioids; and resources physicians can use to prevent employee theft in their practices.

Click to launch the digital edition in a new window.

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This Just In ...

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Deadlines for Doctors

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

9/25/16
Medicaid Reenrollment Deadline

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.  

Seminars

Medical Records: Most Wanted Answers  
Straight From a Lawyer's Mouth: Answers to Your Legal Questions
Human Resources Seminar
E&M Coding Made Easy 

MACRA Webinars

MACRA: Technology's Secrets to Success (Sept. 20) 
MACRA: Participate or Penalty? You Decide.
MACRA Quality Reporting — Do It Right or Don’t Get Paid 

Conferences and Events

TMA Fall Conference 2016
Sept. 23-24
Hyatt Regency Lost Pines

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Last Updated On

December 05, 2016