Action: Nov. 1, 2016

TMA Action Nov. 1, 2016   News and Insights from Texas Medical Association

Court Sides With TMA in Final Ruling on Chiropractic Scope of Practice Lawsuit
Preview Your PQRS Performance Scores by Nov. 11
Vote Early by Friday — or on Election Day
CMS Releases PQRS Feedback Reports, QRURs
Check Your EHR Certification Compliance for Meaningful Use, MACRA
Updated TMA White Paper Delves Into Corporate Practice of Medicine Doctrine
Texas Quality Summit Confronts the Changing Face of Medicine; Register Now

CDC Recommends Only Two HPV Shots for Younger Adolescents
Navigate Health Care's Rocky Future: Join TMA's Accountable Care Leadership Program
DSHS Reminds Pregnant Women Who Travel to Mexico About Zika Testing
TMF Announces 2016–17 Physician Practice Quality Improvement Award
Tools Help Reduce Inappropriate Prescribing of Antipsychotic Medications
This Month in Texas Medicine

Court Sides With TMA in Final Ruling on Chiropractic Scope of Practice Lawsuit

We won! In a final judgment by Travis County District Court Judge Rhonda Hurley, TMA prevailed in its long-held declaration that the Texas Board of Chiropractic Examiners' (TBCE's) rules permitting chiropractors to make medical diagnoses and perform other medical procedures exceed the chiropractic scope of practice. 

By voiding the rules, Texas chiropractors can't perform vestibular-ocular-nystagmus (VON) testing. The court also specified that the definitions of "musculoskeletal system" to include "nerves," "subluxation complex" as a "neuromusculoskeletal condition," and use of the term "diagnosis" by TBCE in its rules all exceed the scope of practice as defined by the Texas Occupations Code.  

TMA has always maintained that expanding chiropractors' or any other practitioner group's scope of practice requires legislative action to amend state laws governing licensees in Texas. It is not something the regulatory boards can do on their own.

TMA and the chiropractic board have a history of litigation. TMA prevailed in its lawsuit over TBCE rules that allowed VON testing by chiropractors. TMA sued the board in early 2011 and emphasized to the court that allowing some chiropractors to perform VON testing puts Texans' health in danger and that the diagnostic test is outside chiropractors' scope because "the eyes and ears are not part of the spine or musculoskeletal system of the human body."

The trial court sided with TMA, but TBCE appealed the decision. TMA asked the Third Court of Appeals to uphold the trial court ruling, saying in part that:  

  • The vestibular system isn't part of the spine or musculoskeletal system;
  • The vestibular testing rules unlawfully authorize chiropractors to practice medicine; and
  • The Chiropractic Act doesn't authorize chiropractors to make a "differential diagnosis" of a patient's medical condition. 

In a previous case challenging TBCE's rules on needle electromyography and spinal manipulation under anesthesia, the Court of Appeals held that there were unresolved fact issues that required the court to reverse the trial court's judgment. The case was remanded to the trial court for a full trial on the merits and as before, TMA prevailed.

Learn more about TMA's scope of practice efforts

Preview Your PQRS Performance Scores by Nov. 11

The Centers for Medicare & Medicaid Services (CMS) will publicly report performance scores on the Physician Compare website by the end of the year. The scores are based on quality data submitted for the 2015 Physician Quality Reporting System (PQRS) program year. CMS is currently offering physicians and group practices an opportunity to preview their scores as they will appear on Physician Compare. Look at your scores now; the preview period ends Nov. 11.

For step-by-step guidance on how to preview your performance scores, refer to the Guide to Physician Compare Preview Period. To learn more about which measures are targeted for public reporting, refer to the following CMS guides:  

If your performance scores are incorrect or if you have questions about your quality data, contact Physician Compare by email. For complete details about the Physician Compare Initiative, visit the CMS website. For information on quality reporting for the 2016 PQRS program year, visit the TMA PQRS and VM Resource Center

Vote Early by Friday — or on Election Day

Only one week remains in the national nightmare of the 2016 elections. Early voting in Texas runs until this Friday, Nov. 4. Election Day is Tuesday, Nov. 8.

"While the top of the ticket has drawn much of the attention in this very strange political year, many down-ballot races are looking to be quite close, so it is absolutely crucial for you to turn out and vote in these contests," said TEXPAC Board of Directors Chair Brad Holland, MD.

"TEXPAC has followed the recommendations of practicing physicians across Texas to put together an outstanding list of judicial and legislative incumbents and challengers whom we believe medicine should support. These men and women earned medicine's endorsement. They deserve your vote."

The slate of TEXPAC-endorsed candidates include two Texas Supreme Court members: for Place 5, Justice Paul Green; and for Place 9, Justice Eva Guzman.

You can vote at any early voting location in the county where you live. Contact the Early Voting Clerk for State and County Elections in your county for early voting hours and locations. Polls will be open from 7 am to 7 pm on Election Day. Remember: You need to bring a photo ID or other acceptable form of identification.

"Please vote early, or vote on Election Day, but vote!" Dr. Holland said. "Encourage your family, friends, colleagues, staff, and patients to vote, as well." 

CMS Releases PQRS Feedback Reports, QRURs

If you submitted data to Medicare's Physician Quality Reporting System (PQRS) for the 2015 program year, now is the time to review your quality reports. The reports include information about your quality and cost performance and whether you'll get hit with penalties or receive bonus payments. Access and review your reports now, as the deadline to appeal any errors is Nov. 30, 2016.

Quality Reports

On Sept. 26, Medicare announced the release of two quality reports. The first report is the 2015 PQRS feedback report, which contains information about your quality performance and whether you will receive a payment cut in 2016. If you receive the penalty, you will get a 2-percent pay cut on a per-claim basis under the 2017 Medicare Physician Fee Schedule (PFS). 

The second report is the annual Quality and Resource Use Report (QRUR), a component of Medicare's Value-Based Payment Modifier program. The QRUR provides detailed information about your quality and cost performance and how you compare with your peers. Under this program, Medicare used data on quality measures submitted to PQRS for the 2015 program year and data on cost measures and claims-based quality measures obtained from 2015 claims data to calculate the 2017 value modifier for all solo physicians and group practices. The value modifier is determined using a quality-tiering approach, and the annual QRUR indicates your quality tier designation: high, average, or low quality and cost. Depending on the designation, your payments will be adjusted up or down on a per-claim basis under the 2017 Medicare PFS. 

Please note that reviewing your PQRS feedback report and QRUR is part of the TMA Five-Step Checklist for MACRA Readiness. Analyzing your quality reports now will help you prepare for MACRA's new Merit-Based Incentive Payment System (MIPS). Additionally, TMA reminds physicians that Medicare had data issues and calculation errors in its quality reports last year, resulting in revised reports and mass confusion. For this reason, it is important that you review your reports as soon as possible to make sure your data are correct and you don't receive a penalty in error. 

Appeals Process 

If you disagree with Medicare's analysis of your performance or believe your data are incorrect, submit what is called an "informal review request" by Nov. 30, 2016. This is the only appeals process Medicare has for the PQRS and value modifier programs. Once a request has been submitted, Medicare will review your data again and respond to you through email within 90 days of your submission.  

Where to Turn For Help

TMA Practice Consulting offers quality improvement services to help prepare physician practices for the upcoming transition under the Medicare Access and CHIP Reauthorization Act (MACRA). TMA's practice management consultants can conduct a MACRA readiness assessment of your practice and provide customized on-site assistance to help you with your practice's specific needs. The assessment will focus on clinical processes, electronic health record optimization, and workflow improvement opportunities to help increase your MIPS scoring. TMA is dedicated to working with you and your practice to earn an incentive payment, not just avoid the penalty. To learn more, email[at]texmed[dot]org, or call (800) 523-8776.

You also can turn to the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) for help. Under contract with Medicare, the TMF QIN-QIO provides education and technical assistance to solo physicians, group practices, and other health care professionals for Medicare's quality programs. For help with your quality reports or the informal review request process, contact Suzie Buhr at TMF QIN-QIO at (214) 477-1407 or by email. To learn more, join the TMF Value-Based Improvement and Outcomes Network

Visit TMA's PQRS and VM Resource Center for guidance on quality reporting for the 2016 program year and the MACRA Resource Center to learn about how these programs will be combined to create the new MIPS program.  

TMAIT Action Ad 6.15  

Check Your EHR Certification Compliance for Meaningful Use, MACRA

It's important to make sure your systems are compliant with the electronic health record (EHR) certification requirements for the meaningful use program and the Medicare Access and CHIP Reauthorization Act (MACRA). Certification ensures the EHR system has all the necessary capabilities, functionalities, and security required so physicians can successfully attest to the Centers for Medicare & Medicaid Services (CMS) programs. Physicians must use at least a 2014-certified EHR to meet the meaningful use requirements for the 2017 program year. In 2018, physicians must have an EHR that meets the 2015 certification requirements for MACRA. 

For the MACRA program, the advancing care information (ACI) category of the Merit-Based Incentive Payment System (MIPS) replaces the current meaningful use program. Contact your EHR vendor to inquire about its MIPS readiness plan and how the vendor can help you achieve success in MIPS.  

  • To meet the requirements of the ACI category, you must have an EHR system. If you do not currently use an EHR, you will have to select, purchase, and implement one. Be sure the product you select is certified. TMA has numerous resources to help you with selection.
  • If you currently use an EHR, check with your EHR vendor to ensure the product you use will be appropriately upgraded as program requirements change. As vendors upgrade, the product must be certified. The next upgrade will be to the 2015 certification criteria, which is optional in 2017 and required in 2018. View the list of certified products here.  

Here are some things to consider when speaking to your EHR vendor: 

  • If you do not see your EHR vendor listed with the correct certification year, ask your vendor about its timeline so you can adequately prepare and perform testing before going live with the upgraded product.
  • Is there a cost associated with the upgrade?
  • Will any new training be required? 

You can direct questions related to EHRs and other office technologies to TMA's Health Information Technology Department by phone at (800) 880-5720 or by email

Updated TMA White Paper Delves Into Corporate Practice of Medicine Doctrine

"The Corporate Practice of Medicine," TMA's latest white paper, focuses on the development of the corporate practice of medicine prohibition, current applications and prohibitions, potential exceptions to the law, key considerations in relevant corporate practice of medicine court cases, and penalties for violations of the corporate practice of medicine doctrine. 

Texas has enacted laws to keep nonphysician practitioners and corporate entities out of the practice of medicine. The corporate practice of medicine doctrine ensures physicians are able to exercise professional medical judgment relating to a patient's health care needs without financial or other outside pressures. TMA staff has revised and updated this popular white paper based on recent changes in the law.

During the 2011 legislative session, working with the Texas Hospital Association, the Texas Organization of Rural & Community Hospitals, then-Senate State Affairs Committee Chair Robert Duncan (R-Lubbock), and other legislative leaders, TMA crafted a compromise on several physician employment bills. They give some hospitals greater latitude to employ doctors but impose some of the strongest protections in the nation for physicians' clinical autonomy and independent medical decision making.

The 2011 law allows employment of physicians by small hospitals, generally in counties of 50,000 or fewer, with strong protections for independent medical judgment and medical staff responsibility for all clinical policies from privileges to credentialing to utilization review. Texas law also requires the hospital's chief medical officer to report to the Texas Medical Board any instance of administrative interference in clinical or patient care decisionmaking.  

Texas Quality Summit Confronts the Changing Face of Medicine; Register Now

For many practices to remain successful, especially under Medicare Access and CHIP Reauthorization Act (MACRA) requirements, effective population health management is now a primary focus. To help physicians advance quality care as a core value of their practice, with an eye toward the future of accountable care, TMA developed the interactive 2016 Texas Quality Summit

The summit begins as a pre-conference workshop on Friday, Nov. 18, with quality improvement scenarios and group exercises highlighting the tools and theories of leadership necessary for successful quality and patient safety programs. On Saturday, Nov. 19, the summit offers a series of expert physician panels for a broader audience, as well as presentations on quality, value, and payment. Programming throughout the event will address population health trends in Texas, concrete steps for transitioning to value-based care, in-depth discussion of alternative payment models, and implementation of Medicare's new Quality Payment Program. 

The Texas Quality Summit, cohosted by the TMA Council on Health Care Quality and the American College of Medical Quality, offers continuing medical education credit on Friday, Nov. 18, for 5.25 AMA PRA Category 1 Credits™ designated as ethics and/or professional responsibility, and also on Saturday Nov. 19, for 7.25 AMA PRA Category 1 Credits™ designated as ethics and/or professional responsibility. Seating is limited on both days, so register early to secure your space. 

The meeting takes place 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. 

For more information, visit the TMA website or read "Learn From the Experts" in the October issue of Texas Medicine

Can't attend the Quality Summit? Don't miss the opportunity to attend TMA's MACRA seminar.

Action TMLT Ad 10.15   

CDC Recommends Only Two HPV Shots for Younger Adolescents

The Centers for Disease Control and Prevention (CDC) recommends 11- to 12-year-olds receive two doses of human papillomavirus (HPV) vaccine at least six months apart rather than the previously recommended three doses to protect against cancers caused by HPV infections. Teens and young adults who start the series later, at ages 15 through 26 years, will continue to need three doses, CDC says.

"Safe, effective, and long-lasting protection against HPV cancers with two visits instead of three means more Americans will be protected from cancer," said CDC Director Tom Frieden, MD. "This recommendation will make it simpler for parents to get their children protected in time."

Based on a review of the medical literature, the Advisory Committee on Immunization Practices (ACIP) voted to recommend a two-dose HPV vaccine schedule for young adolescents. CDC and ACIP reviewed data from clinical trials showing two doses of HPV vaccine in younger adolescents (aged 9 to 14 years) produced an immune response similar to or higher than the response in young adults (aged 16 to 26 years) who received three doses.

Generally, preteens receive HPV vaccine at the same time as whooping cough and meningitis vaccines, according to CDC. Two doses of HPV vaccine given at least six months apart at ages 11 and 12 will provide safe, effective, and long-lasting protection against HPV cancers, CDC says. Adolescents aged 13 to 14 are able to receive HPV vaccination on the new two-dose schedule, as well.

CDC will provide guidance to parents, health professionals, and insurers on the change in recommendation. The Food and Drug Administration last month approved adding a two-dose schedule for 9-valent HPV vaccine (Gardasil 9) for adolescents aged 9 through 14 years. CDC encourages clinicians to begin implementing the two-dose schedule in their practices to protect their preteen patients from HPV cancers. 

Navigate Health Care's Rocky Future: Join TMA's Accountable Care Leadership Program

New Medicare Access and CHIP Reauthorization Act (MACRA) rules released last month demonstrate that value-based health care is officially here to stay. Regardless of whether the phrases "accountable care" and "value-based care" cause you heartburn or your heart to flutter, TMA's 2017 Accountable Care Leadership Program can help demystify the paradigm shift. Applications are now open, and participants will earn more than 95 hours of continuing medical education credit. 

The Accountable Care Leadership Program transforms physicians into leaders, proverbial lighthouses who guide their community through the changing waves of health care regulations. Over the course of 10 months and 11 modules, participants explore the framework for accountable care organizations (ACOs), risk-based payment initiatives, and the development of patient-centered medical homes. By focusing on a series of case studies, physicians will also determine whether (and how) team-based managed care can enhance their ability to improve clinical outcomes and patient satisfaction. 

Currently, more than 470 ACOs nationwide provide care for nearly 9 million seniors, achieving more than $1.2 billion in savings since 2012. This is your opportunity to join the future of health care and influence how value-based care will affect you, your practice, and your patients. 

Submit your application today to become a forward-thinking leader on effective, value-based care. Apply early, as the 2017 Accountable Care Leadership class will be limited to 30 participants. For complete coursework details, program requirements, and participation fees, visit the TMA website.   

DSHS Reminds Pregnant Women Who Travel to Mexico About Zika Testing

The Texas Department of State Health Services (DSHS) has issued a health alert to remind pregnant women who cross the border into Mexico that Zika testing is available to them. DSHS encourages them to discuss testing with their physicians. Current Centers for Disease Control and Prevention (CDC) guidelines recommend Zika testing for any pregnant woman who has traveled to a country with ongoing Zika transmission, including those who regularly cross the U.S.-Mexico border.

DSHS also reminds health care professionals to assess their pregnant patients for possible Zika virus exposure at each prenatal care visit. CDC and DSHS recommend testing for Zika antibodies as a part of routine prenatal care during the first and second trimesters in pregnant women with an ongoing risk of Zika exposure.

This reminder is especially important for pregnant women with regular, frequent travel to any part of Mexico during the peak mosquito season of August through October or who have a sexual partner who crosses the border weekly or more often.

DSHS is interested in expanding the amount of Zika testing being done in Texas, particularly in communities along the border considered to be at a higher risk of local transmission because of their geography and history of outbreaks of dengue, a similar virus spread by the same types of mosquitoes. Pregnant women are a particular focus because of the risk of birth defects associated with Zika. They should avoid travel to countries with a CDC Zika travel notice and prevent sexual transmission by using condoms or not having sex with partners who have traveled to those areas. 

Additionally, everyone can help prevent the spread of Zika by mosquito bites by: 

  • Using Environmental Protection Agency-approved insect repellent. (Repellents are safe to use during pregnancy when applied according to the label instructions.)
  • Wearing long pants and long-sleeved shirts that cover exposed skin.
  • Using air conditioning or window and door screens that are in good repair to keep mosquitoes out of their homes. 
  • Removing standing water in and around homes, including water in trash cans, toys, tires, flower pots, and any other container that can hold water. 

DSHS says Texas has had 229 reported Zika cases, all related to travel, including two cases transmitted via sexual contact with someone infected overseas and two infants who were infected before birth. For more information on Zika, including the latest testing criteria for health care professionals, visit the DSHS website.  

PC Action Ad July 13

TMF Announces 2016–17 Physician Practice Quality Improvement Award

Physician practices continue to make great strides in providing reliable preventive services by using health information technology and effective care management methods. TMF Health Quality Institute wants to recognize practices for their hard work. TMF is once again sponsoring the Physician Practice Quality Improvement Award program

The application process is simple. Review the criteria, identify any gaps that exist in your practice, work to fix those gaps and monitor your quality data, and complete an online application between April 1, 2017, and June 10, 2017.

Any practice in Texas, Arkansas, Oklahoma, or Puerto Rico with one or more licensed physicians providing care for Medicare fee-for-service patients is eligible to participate in the award program. All practicing providers must not have been disciplined or excluded by any federal or state regulatory agency, licensing board, or health care facility in the past five years.

Practices must meet established thresholds in all four categories, which include: 

  1. Exemplary performance on nationally recognized clinical outcome measures,
  2. Regular use of population care management methods,
  3. Participation in data reporting quality initiatives, and
  4. Implementation of tools and processes to promote patient engagement and improve the patient's experience. 

All practices meeting or exceeding the criteria will receive an award. Award recipients will receive a commemorative plaque to display in their practice and recognition through a media campaign. For more information, email ppqualityaward[at]tmf[dot]org

Upcoming Events

The TMF Quality Innovation Network hosts regular events for physicians, hospitals and other health care professionals. Mark your calendars and plan to attend. You can learn more by visiting and clicking on the Events tab.

Join the TMF Quality Innovation Network open forum event to learn about upcoming changes related to meaningful use and the Physician Quality Reporting System. You will have the opportunity to ask questions and interact with peers, as well as TMF Quality Innovation Network consultants. This open forum will take place Wednesday, Nov. 16, from noon to 1 pm CT. Register today.

Tools Help Reduce Inappropriate Prescribing of Antipsychotic Medications

Antipsychotic prescribing for patients with dementia has received intense scrutiny lately. Data suggest that in some Texas facilities physicians add new diagnoses, such as schizophrenia, to residents' clinical records to justify antipsychotic use, even in residents without a history of mental illness. According to the Texas Health and Human Services Commission (HHSC), inappropriate use of antipsychotic medications can harm people with dementia, as noted in the Food and Drug Administration's black box warning, which appears on a prescription drug's label and is designed to call attention to serious or life-threatening risks. 

Yet, in spite of increased mortality risk, HHSC notes that antipsychotics continue to be used as a chemical restraint in nursing home residents with dementia but no underlying mental health issues.

The U.S. Centers for Medicare & Medicaid Services (CMS) is aware of this issue. CMS conducts focused dementia care surveys targeting nursing homes with high antipsychotic use for people with dementia. HHSC says these surveys help ensure facilities provide high-quality, person-centered care and use more non-pharmacological approaches to dementia care.

Physicians play a key role in reducing the inappropriate use of antipsychotic medications. HHSC has created tools to help provide education and resources for prescribers as part of an initiative to reduce inappropriate prescribing of antipsychotic medications. The Texas Department of Aging and Disability Services also has initiatives that help prescribers improve dementia care. Visit the HHSC Appropriate Use of Antipsychotic Medications webpage to access these tools.

This Month in Texas Medicine

The November issue of Texas Medicine features a cover story on the Texas Medical Board's (TMB's) informal settlement conferences (ISCs), which defense attorneys who represent physicians say have become similar to administrative hearings, without the guaranteed accompanying protections. In scathing written comments TMA submitted to TMB in response to the board's proposed ISC rules, TMA said ISCs have become "more and more formal, prescriptive, and regulated," without giving physicians a fair forum to defend themselves. In the issue, you'll also find coverage of HIV pre-exposure prophylaxis, which can prevent patients from getting the virus; complaints TMA has received from several physicians that three of the state's biggest health plans are taking up to eight months to credential them; and a Houston palliative care and hospice physician's account of her family's experience caring for her terminally ill father.

Check out our digital edition

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.  

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 and MACRA: Get Clarity and Direction!
Nov. 1: Dallas
Nov. 2: Tyler
Nov. 3: Fort Worth
Nov. 9: El Paso
Nov. 15: Houston
Nov. 16: San Antonio
Nov. 17: Corpus Christi
Nov. 30: Austin  

Can't make it to the seminar? Attend the live webcast on Nov. 30.

Conferences and Events

2016 TMA Advocacy Retreat
Dec. 2-3
Omni Barton Creek Resort

About Action       

 Action, the TMA newsletter, is emailed twice a month to bring you timely news and information that affects your practice

To change the email address where you receive Action, go to Member Log-In on the TMA website, then click on "Update Your TMA Demographic Information (including newsletter subscriptions and preferences)."

To unsubscribe from Action, email TMA's Communication Division at tmainfo[at]texmed[dot]org.

If you have any technical difficulties in reading or receiving this message, please notify our managing editor, Shari Henson. Please send any other comments or suggestions you may have about the newsletter to Crystal Zuzek, Action editor.

Last Updated On

September 26, 2018