Action: Dec. 15, 2016

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

TMA Wins MACRA Improvements, Wants More
TMA Offers Health System Reform List to House Leaders
2017 Medicare Fee Schedule Includes Less Than 1-Percent Pay Increase
Make Medicare Participation Decision Before Dec. 31
HHS Warns of HIPAA Email Phishing Scam
Partial Victory for Medicine in New VA Policy
TMA, Specialties Lay Out Legislative Priorities
Don't Miss First Tuesdays at the Capitol in 2017
HIT Tools and Resources at Your Fingertips
Final New Rules for Fetal Tissue Disposal Set to Take Effect Dec. 19

Texas Announces Additional Local Zika Cases in Cameron County
DSHS: Consider Mumps in Symptomatic Patients in Wake of Current Outbreak
Announcing the Top Internal Medicine Mentors of 2016
New App Supports Medication-Assisted Treatment for Opioid Use Disorder
MACRA Penalties Reprieve Makes Accountable Care Program Essential
TMF Launches Chronic Care Management Learning and Action Network
Register for Live Event on MACRA and the New Quality Payment Program
TMA Poster Session Doctor's Choice Award Could Be Yours
Physician, Medical Student Journalists: Enter TMA Contest
This Month in Texas Medicine

TMA Wins MACRA Improvements, Wants More

Medicine won some relief in the Centers for Medicare & Medicaid Services' (CMS') final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA). Responding to medicine's vehement concerns, CMS decided physicians who at least try to comply with the new rules next year will see no penalty in their payments in 2019, the first year the penalties were set to apply. That's because starting in 2017, physicians' performance on various quality, cost, technology use, and practice improvement measures determines cuts or bonuses in their payments two years later.

Check out the newly updated version of TMA's Five-Step Checklist for MACRA Readiness (login required) to ensure your practice is prepared for the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs).

In addition to reduced reporting requirements under Medicare's new Quality Payment Program, TMA and organized medicine won other significant improvements that create a more palatable transition period, including a broader exemption for small practices with few Medicare patients or little revenue inform the program.

Of TMA's 50 recommendations to improve MACRA, CMS completely accepted 21, partially accepted 13, and rejected 16. Among the most significant improvements for 2017:  

  • A broader exemption that excludes physicians who see fewer than 100 Medicare patients or submit Medicare charges of less than $30,000. The draft rule originally set the low-volume threshold at $10,000. 
  • Reduced reporting requirements to avoid a penalty in 2019. Any physician who successfully reports one quality measure or one of the new improvement activities will earn enough credit to avoid a 4-percent payment cut in 2019. 
  • A simpler system that gives physicians and groups leeway to pick the most meaningful quality measures and reporting mechanisms for their practices and their patients. 
  • Eliminating the cost category in calculating physicians' overall performance scores.
  • A shortened performance period that allows physicians to report quality and technology use data for 90 days, instead of a full calendar year, to be eligible for a bonus. 

TMA will continue to work with CMS and the Texas congressional delegation to rewrite and reform ongoing problems identified in the draft regulations that stuck in the final rule. Here's a list of further improvements TMA would like to see: 

  • Keep and/or raise the low-volume threshold to exempt physicians from the Merit-Based Incentive Payment System (MIPS). Although CMS increased the initially proposed low-volume threshold, many physicians still will have no possibility of a positive return on the investment in the cost of reporting. 
  • Keep the MIPS performance threshold as low as possible for as long as possible. CMS set the MIPS performance threshold at 3 points, but only for 2017. To reduce the negative impact on small practices, CMS should continue to set the composite performance threshold as low as possible. CMS plans to increase the performance threshold in 2018, and beginning in 2019, will use the mean or median final score from a prior period. Setting the threshold higher results in a larger number of physicians who receive penalties and larger incentive payments to large practices that can absorb the necessary administrative costs to facilitate full compliance and reporting.
  • Create and apply a "hold harmless" policy. No payment penalty should be created for and applied to physicians when a technology vendor (electronic health record [EHR], registry, other) commits data collection and/or data submission errors that result in poor quality performance scores or failed reporting, especially when the issue is out of a physician's control. TMA strongly urges Congress and CMS to create physician protections for these instances.
  • No quality or cost measure should be used unless it can be properly attributed and risk-adjusted, and all measures must be developed and/or vetted in collaboration with the medical profession and relevant stakeholders, not just CMS. In the final rule, there is no improvement to risk adjustment. No financial incentives of any kind should be based on measures that are not properly attributed and risk-adjusted. Physicians should not be penalized for factors not in their control. Volume minimums on all measures should be set high enough to avoid the statistical volatility of small numbers. Additionally, all measures must be adequately vetted with input from the medical profession and relevant stakeholders, and must be developed and maintained by appropriate professional organizations that periodically review and update these measures with evidence-based information in a process open to the medical profession. 
  • Remove the requirement for all-payer data. Although the law is permissive on this subject, it does not require the use of all-payer data. CMS has finalized the requirement for all-payer data for three of six reporting methods. In 2017, physicians reporting through registries, qualified clinical data registries, and EHR systems must report all-payer data, whereas physicians who report via claims, web interface, or patient experience survey/CAHPS need report only on Medicare Part B patients. This would result in an inequitable assessment of quality performance among physicians and practices. Medicare bonus payments and payment penalties based on all-payer data are wrong. Physicians should not be rewarded or penalized based on variations in payer mix. 
  • Design a system that provides real-time feedback and meaningful data to physicians. CMS reports it can only provide feedback on performance as often as data are reported, which currently is on an annual basis. Timely access to feedback reports is vital for physicians to identify gaps in care and performance to make improvements where necessary within the performance period. CMS should allow submissions of data more frequently throughout the year to provide timely feedback for performance corrections or compliance issues, and avoid delays in performance improvement that result in payment penalties. CMS reports it plans to leverage the vendor community to disseminate data contained in performance feedback reports in the future. If and when such a process is created, physicians should not have to pay practice or technology vendors extra fees for such data and information that CMS currently offers annually at no cost. 

TMA Offers Health System Reform List to House Leaders

In response to outreach from U.S. House Majority Leader Kevin McCarthy (R-Calif.), House Ways and Means Committee Chair Kevin Brady (R-The Woodlands), and other House Republican leaders, TMA provided a list of nine health care policy suggestions for the next Congress to consider. 

The House leaders asked the nation's governors and state insurance commissioners to submit suggestions for replacing the Accountable Care Act and improving Medicaid. Our list includes ACA, Medicare, and Medicaid reforms that are consistent both with TMA policy and with the proposals already laid out by President-Elect Donald Trump and House Speaker Paul Ryan. 

"Most of the flaws of the ACA — its errors both of commission and omission — remain," TMA President Don Read, MD, wrote. "We believe that the 2016 elections bring an excellent opportunity to rebuild America's health care systems in ways that can be extraordinarily meaningful for our patients and the physicians who care for them." The suggestions in Dr. Read’s letter are:  

  • Replace ACA subsidies.

In their place, Congress should establish universal, advanceable, refundable tax credits (age and cost-of-living adjusted) for individuals and families who do not have access to employer-sponsored coverage. These credits should be available through multiple portals, not just the health insurance exchange. Any credits in excess of the insurance premium can be deposited into health savings accounts. 

  • Repeal the employer mandate.
  • Keep ACA protection of insurance for people with preexisting conditions, as long as they have continuous coverage.  

While Congress was debating ACA, TMA conducted 16 town hall-style meetings on health reform across Texas with more than 3,000 patients and physicians participating. At every meeting, both patients and physicians called on Texas legislators and Congress to prohibit health insurance companies from excluding coverage for patients with preexisting conditions. Patients need access to health care coverage, especially when they suffer from an ongoing medical condition.

Enact the Texas Medicaid Solution to increase coverage for low-income adults and require some of the administrative cost savings to be used to fund fee increases for physicians. 

The Texas Solution calls for a comprehensive plan that:  

  • Improves patient care;
  • Draws down all available federal dollars to expand access to health care for poor Texans;
  • Gives Texas the flexibility to change the plan as our needs and circumstances change;
  • Clears away Medicaid's financial, administrative, and regulatory hurdles that are driving up costs and driving Texas physicians away from the program;
  • Relieves local Texas taxpayers and Texans with insurance from the unfair and unnecessary burden of paying the entire cost of caring for their uninsured neighbors; and
  • Pays physicians for Medicaid services at a rate at least equal to Medicare payments. 
  • Give physicians the ability to contract directly for any and all Medicare services.  

As increasing numbers of baby boomers reach Medicare age, flexibility in Medicare is necessary to ensure patients have access to a physician. One way to accomplish this is to allow Medicare patients to see any physician of their choice. Physicians should be allowed to enter into direct contracts with Medicare patients, without forcing patients to forego their Medicare benefits even when they opt out of the Medicare program. 

  • Repeal the ban on physician hospital ownership.  

Throughout the health care debate, the Mayo Clinic, Cleveland Clinics, and Texas' Scott & White Hospitals were held up as the gold standard for how to deliver efficient and high-quality care. All these institutions have one thing in common — they are physician-owned and physician-led. Now, these types of institutions are banned. A provision in ACA actually prevents physicians from establishing hospitals that participate in Medicare. ACA makes future hospital ownership illegal for physicians who go to medical school, obtain a license to practice medicine, care for Medicare patients, and then want to refer their Medicare patients to a hospital in which they may have ownership. If a physician had already owned a hospital, ACA severely limits how that hospital can expand and operate.

This provision of ACA limits patient choice; inhibits patients' access to high-quality, low-cost medical care; and prohibits physicians from making the clinical and business decisions we believe are best for our patients. 

  • Enact Texas-style medical liability reforms for the entire country.   

Texas has gained nearly 60,000 new physicians to take care of Texas patients since passage of our landmark medical tort reforms in 2003. Many of these new physicians practice high-risk specialties such as emergency medicine, neurosurgery, pediatric intensive care, and pediatric infectious disease. Texas patients now can get more timely and convenient care when needed. Some 28 rural Texas counties have added at least one obstetrician since the passage of Texas' medical liability reforms, including 11 counties that previously had none. The emergency care provisions have saved lives by helping ensure Texas patients have access to critical and timely care. The 2003 liability reforms have worked. They've lived up to their promise. Sick and injured Texans now have more physicians who are more willing and able to give them the medical care they need.

The rest of the nation will benefit from Texas-style reforms. We must ensure, however, that any federal law does not modify or change reforms now in Texas law. 

  • Expand use of health savings accounts and allow (untaxed) employer health reimbursement account contributions to be used for individual insurance purchase.  

We support innovative experiments in health care financing that attempt to control costs, maintain quality, and broaden access to care through implementation of market-based principles. We also believe Medicare beneficiaries should be permitted to make tax-free contributions to health savings accounts. 

  • Repeal the Independent Payment Advisory Board (IPAB).  

The 15-member IPAB has the authority to control Medicare spending. IPAB can make recommendations that lead to decreases in Medicare spending only through lower payment rates to physicians. IPAB recommendations would become law automatically unless Congress passes a law to reach the same budgetary savings. The issue of Medicare spending is too important to be left in the hands of an unaccountable board with decisions based solely on cost.

"Physicians and our patients are demanding significant change," Dr. Read wrote. "We look forward to working closely with you, the White House, the Texas members of the U.S. Congress, Texas Gov. Greg Abbott and his administration, and the Texas Legislature in the coming months and years to accomplish these ambitious goals."

The TMA Board of Trustees, Council on Socioeconomics, and other entities will continue to work to identify priorities for Congress to consider.

2017 Medicare Fee Schedule Includes Less Than 1-Percent Pay Increase

The Federal Register published Medicare's 2017 final fee schedule rule on Nov. 15. It updates payment policies and rates for services furnished under the Medicare Physician Fee Schedule on or after Jan. 1, 2017. Although the original proposed rule included an expected fee schedule cut, the final rule increases the fees by a very small amount, less than one-quarter of 1 percent. 

Other provisions include:

  • Very small changes to the geographic adjusters and to many relative value units (RVUs), so the combined effect will be small changes to most payments;
  • Part B annual deductible for 2017 is $183;
  • A new required place of service code for telehealth services and a few new codes that can be billed via telehealth;
  • A new required modifier and reduced payment for radiology procedures using film to encourage the move to digital;
  • Payment now allowed for non-face-to-face prolonged evaluation and management (E/M) services;
  • New payable G codes for behavioral health integration services;
  • Reworked coding and payment for all mammography services, temporarily using G codes until new CPT codes can be finalized;
  • Simplified requirements for chronic care management services; and
  • A reminder that qualified Medicare beneficiaries, who are also covered by Medicaid, may not be directly billed for co-insurance and deductibles. 

In addition, the final rule addresses other topics related to the Medicare program, such as release of certain Medicare Advantage bid data and Part C and Part D Medical Loss Ratio data, enrollment requirements for providers and suppliers in Medicare Advantage, and the Medicare Diabetes Prevention Program expanded model. For more details on the Diabetes Prevention Program model test, visit the fact sheet for that portion of the rule.

The complete fee schedule is available for download from the Novitas website

Make Medicare Participation Decision Before Dec. 31

Physicians who see Medicare patients have until Dec. 31 to make changes to their participation status for 2017. The American Medical Association has updated information describing Medicare participation options and frequently asked questions. 

Although many physicians are appropriately focused on preparing for the new Quality Payment Program (QPP) in 2017, the QPP will not affect physicians' Medicare payment rates and participation decisions until 2019. Rather, for 2017, payment adjustments will be determined by physicians' 2015 participation in the existing Medicare payment programs: the Physician Quality Reporting System, electronic health record meaningful use, and the Value-Based Modifier Program. 

Those facing penalties in 2017 due to these programs may want to review AMA's "Know Your Options" guide before the deadline.

For physicians who are considering a change in their Medicare status:   
  • If you want to change from participating (PAR) to nonparticipating (non-PAR), or vice-versa, you can make that change only during the annual enrollment period, from Nov. 14 through Dec. 31 each year. The change would be effective on the first of the next year. To switch effective Jan. 1, 2017, submit your change before Dec. 31, 2016. 
  • If you are currently non-PAR and you want to opt out of Medicare entirely, you can do that at any time by submitting an affidavit to the Medicare carrier (Novitas) within 10 days after signing your first private-pay contract with a patient.
  • If you are currently PAR, you may opt out effective the first date of each calendar quarter, i.e., Jan 1, Apr 1, July 1, and Oct 1. Your opt-out affidavit must be received by the Medicare carrier at least 30 days before the start of the calendar quarter. A PAR physician who wants to opt out effective April 1, 2017, must have his or her affidavit to the carrier no later than March 1, 2017.  

HHS Warns of HIPAA Email Phishing Scam

The U.S. Department of Health & Human Services (HHS) Office for Civil Rights (OCR) recently warned covered entities and their business associates about an email that disguises itself as an official communication from HHS. The email, commonly known as a phishing email, prompts recipients to click a link regarding possible inclusion in the HIPAA Privacy, Security, and Breach Rules Audit Program, and directs individuals to a nongovernmental website marketing a firm's cyber security services.

The phishing email originates from the email address and directs individuals to a URL at This is a subtle difference from the official email address for the HIPAA audit program, OSOCRAudit[at]hhs[dot]gov. Such deviousness is typical in phishing scams.

In no way is the firm associated with HHS or OCR. In the event that you or your organization have a question about the legitimacy of an apparently official communication from the agency regarding a HIPAA audit, please contact OCR via email at OSOCRAudit[at]hhs[dot]gov.

You can take steps to protect your practice from security and technology risks. Visit TMA's Ransomware and Cyber Security Resource Center for more information. 

Action TMLT Ad 10.15  

Partial Victory for Medicine in New VA Policy

Nurse anesthetists have been excluded from a new Department of Veterans Affairs' (VA's) policy that permits certified nurse midwives, nurse practitioners, and clinical nurse specialists to practice independently of direct physician supervision. Certified registered nurse anesthetist (CRNA) anesthesia practice will continue to require anesthesiologist supervision.

Before adoption of the new policy, TMA joined more than 75 national specialty societies and state medical associations in voicing their strong opposition to the proposed rule. TMA and the organizations outlined their concerns in a letter to David J. Shulkin, MD, VA undersecretary. The letter urged the VA to consider policy alternatives that prioritize team-based care rather than independent nursing practice.

The Coalition of State Medical Societies, of which TMA is a member, also sent a strongly worded letter to the VA, stating, "Our veterans have earned and deserve the highest quality and best care, but this rule would lower the standard of care for veterans around the country." That letter pointed out, for example, that CRNAs "do not have the 12,000 to 16,000 hours of clinical training and nearly a decade of formal postgraduate education and residency training that enables anesthesiologists to prevent and respond competently and swiftly in critical emergencies before, during and after surgery."

The American Medical Association says it is "disappointed" by the VA's decision to allow most advanced practice registered nurses within the VA to practice independently of a physician's clinical oversight, regardless of individual state law. 

AMA issued this statement regarding the VA's adoption of the rule:

Providing coordinated, physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans, especially given the highly-complex medical care that veterans often require. The nation's top health care systems rely on these physician-led teams to achieve improved care and patient health, while reducing costs. We expect the same for our country's veterans, and look to these systems as evidence that physician-led, team-based models of care are the future of American health care.

We would also like to acknowledge the VA for clarifying that radiology studies can only be performed and read by individuals who are credentialed in radiology. With over 10,000 hours of education and training, physicians bring tremendous value to the health care team. All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine, in addition to the valuable care provided by advanced practice nurses and other primary care clinicians that are part of the care team.


TMA, Specialties Lay Out Legislative Priorities

The best feature of TMA's biennial Advocacy Retreat, always scheduled just a month before the new Texas Legislature convenes, is the opportunity for TMA and nearly two dozen state specialty societies to stand in front of their peers and explain their key issues for the coming session. TMA spent several hours Dec. 3 in a conversation about how to address priorities, recognizing some of the unique patient care needs of the specialty societies. "The one thing we definitely need is not to have splintering in the House of Medicine," said TMA Council on Legislation Chair Ray Callas, MD. "Let's work together as a team."

Led by Dr. Callas and TMA Vice President for Advocacy Darren Whitehurst, TMA's lobby team laid out the top legislative issues TMA has been working on for months. They include the state budget, insurance reform, scope of practice, telemedicine, the Texas Medical Board, and public health priorities.

The most-frequently mentioned priorities for the 23 specialty societies that participated were:  

  • Surprise bills and preserving physicians' ability to bill for out-of-network services;
  • Scope of practice, an especially dicey issue this session because all of the health professionals' licensing agencies are up for sunset review;
  • Telemedicine;
  • Opioid addiction and the prescription drug monitoring database;
  • Maintaining the momentum TMA has built for expanding graduate medical education; and 
  • Medicaid funding and administrative hassles.

Don't Miss First Tuesdays at the Capitol in 2017

Your patients and your profession need you to be a lobbyist for a day. Mark your calendar now to join the Party of Medicine in Austin for First Tuesdays at the Capitol during the 85th Texas Legislature on Feb. 7, March 7, April 4, and/or May 2, 2017. The March 7 event is designated the official TMA Alliance First Tuesday, as well the young and newly licensed physician event. The April 4 event is dedicated to medical students and residents. Registration is now open.

TMA's comprehensive 2017 legislative agenda advocates what's best for patients and their physicians, from preserving physicians' right to bill for services to improving Medicaid payment rates and reducing red tape and hassles.

If you're traveling to Austin from out of town for First Tuesdays, reserve your room for the Monday before each event at the Doubletree Suites by Hilton Hotel by calling (800) 445-8667. Don't forget to mention you are attending TMA's First Tuesdays at the Capitol event for the special room block rate of $219 for February, March, and April and $209 for May. Hotel rooms in Austin are in demand during legislative sessions, so make your reservations now.

You also can reserve a room online, but make sure to enter the correct group code for your stay (February: FTC, reserve by Jan. 16; March: TAT, reserve by Feb. 13; April: CAP, reserve by March 13; and May: TUE, reserve by April 10). For more information or to register, visit the TMA website, or call (800) 880-1300, ext. 1363.

HIT Tools and Resources at Your Fingertips

TMA works diligently to give you the tools you need to tackle the challenges of technology. Whether you need help selecting an electronic health record (EHR) or understanding the EHR incentive program or information on e-prescribing, TMA has the resources. You can find links to all of these tools on the Technology page of the TMA website.

  • EHR Product Evaluation Tool   MembersOnlyRed
    This tool compares the most-used EHRs in Texas by functionality and pricing.
  • EHR Buyer Beware: Issues to Consider When Contracting with EHR Vendors
    This paper discusses eight important EHR contract terms you should consider before signing an EHR contract.
  • EHR Incentive Program Resource Center
    This resource center provides details and instructions sheets for the Medicare and Medicaid EHR incentive programs.
  • Texas Regional Extension Center Resource Center
    Regional extension centers (RECs) have been established across the country, with four in Texas, to give physicians in-depth assistance in selection, implementation, and meaningful use of an EHR. This helps to ensure eligible physicians meet the requirements to earn the EHR incentives. Visit the resource center for details on location, eligibility, and contact information.
  • E-Prescribing Resource Center
    Physicians should e-prescribe now to prevent the Medicare penalty and earn the Medicare bonus. Benefits of e-prescribing include medication reconciliation, medication history, eligibility, and formulary information. Visit the resource center for help with e-prescribing. 
  • Ransomware and Cyber Security Resource Center
    Ransomware has reached Texas, and its emergence highlights the importance of up-to-date security. Use this resource center to access articles and education on cyber security and ways to protect your practice.

If you have questions about these health information technology (HIT) tools and resources or if you need additional help, contact the TMA HIT Helpline at (800) 880-5720 or by email.

Final New Rules for Fetal Tissue Disposal Set to Take Effect Dec. 19

Over the summer, the Texas Department of State Health Services (DSHS) posted draft revisions to its administrative rules on special waste from health care facilities. DSHS adopted the final rules on Dec. 9.

In August and October, TMA and the Texas Hospital Association submitted joint comments requesting clarification on several proposed changes in the rules. 

DSHS addressed a few points raised by TMA, but several areas remain unclear. While scheduled to become effective on Dec. 19, a lawsuit has been filed that may have an impact on implementation. In the interim, physicians should be aware of the following components of the adopted rules: 

  • The adopted rules apply to any termination of pregnancy that occurs within a health care-related facility. 
  • The rules address the disposition of all fetal remains, but they exempt fetal remains that are expelled outside of a health care facility. Other exemptions include fetal tissue used for research, testing, or as requested by a family for interment. 
  • All health care-related facilities will be required to dispose of fetal tissue through interment.
  • Neither birth certificates nor death certificates are required for the proper disposition of fetal tissue that weighs less than 350 grams. 
  • DSHS has assured TMA that neither the patient nor the physician would be responsible for the cost of interment, as these would be the responsibility of the health care facility.

TMA continues to be in contact with DSHS on these rules. Look for updates in future issues of Action.

 TMAIT Action Ad 6.15  

Texas Announces Additional Local Zika Cases in Cameron County

The Texas Department of State Health Services (DSHS) and Cameron County Department of Health and Human Services have identified four additional cases of suspected locally transmitted Zika virus disease in Cameron County. The cases were part of the follow-up to the state's first case of Zika likely transmitted by a mosquito in Texas, announced on Nov. 28. 

While the risk of exposure in Brownsville is thought to be low, in accordance with U.S. Centers for Disease Control and Prevention (CDC) guidance, DSHS recommends all pregnant Brownsville residents and those who travel there on or after Oct. 29 be tested for Zika. Residents and frequent travelers, who visit Brownsville on a daily or weekly basis, should get routine Zika testing once during the first trimester of pregnancy and once during the second trimester. Pregnant women with limited travel should discuss it with their doctor and be tested based on when the travel occurred. Because of the risk of sexual transmission, the same recommendations apply to women who have sex without a condom with a partner who is a Brownsville resident or traveler.

Health care professionals can find more detailed testing guidance in the CDC health alert. DSHS is also emphasizing its previous guidance to test pregnant women who have Zika symptoms or who travel to Mexico or other areas where mosquitoes are spreading Zika.

DSHS says the additional patients in Cameron County live in close proximity to the first case. Though the investigation is ongoing, the infections were likely acquired in that immediate area. The patients reported getting sick with Zika-like symptoms between Nov. 29 and Dec. 1 and were likely infected several days earlier, before mosquito control efforts intensified in that part of Brownsville. None are pregnant women. Testing of people living in an eight-block area around the homes of the identified cases continues but has yet to show any additional evidence of Zika transmission in the rest of that larger area.

"These cases were found through careful public health work and collaboration at the local, state, and federal levels," said John Hellerstedt, MD, DSHS commissioner, "and we’ll continue to follow through with the investigation and additional surveillance to identify other cases and other places experiencing local mosquito transmission of Zika. That information will be crucial to any future public health guidance."

DSHS says it's also important that health care professionals continue to be on the lookout for Zika and pursue testing pregnant women who have traveled to Mexico or other areas where Zika is spreading and testing anyone with symptoms compatible with Zika. More specific guidance for clinicians is available at

"The combination of mosquito control and colder weather has decreased mosquito activity in Cameron County and greatly decreased the probability of more widespread mosquito transmission of Zika right now," Dr. Hellerstedt said. "However, winters are mild in southern Texas, and mosquito populations can rebound even during short periods of warmer weather. Whenever you see mosquito activity, protect yourself and your family from bites." You can do that by: 

  • Using Environmental Protection Agency-approved insect repellent.
  • Using air conditioning or window and door screens that are in good repair to keep mosquitoes out of homes.
  • Wearing long pants and long-sleeved shirts that cover exposed skin.
  • Removing standing water in and around homes year-round, including water in trash cans, toys, tires, flower pots, and any other container that can hold water. 

Prompted by the additional cases, the Texas Health and Human Services Commission is expanding the Medicaid benefit for mosquito repellent indefinitely for residents of Cameron County, as state health officials collect more information about the scope of transmission in Texas.

Zika virus is transmitted to people primarily through the bite of an infected mosquito, though it can also spread by sexual contact. The four most common symptoms are fever, itchy rash, joint pain, and conjunctivitis. While symptoms are usually minor, Zika can also cause severe birth defects, including microcephaly and other poor birth outcomes in some women infected during pregnancy. 

DSHS recommends pregnant women avoid traveling to locations with sustained local Zika transmission, including Mexico. Pregnant women should also use condoms or avoid sexual contact with partners who have traveled to those areas. Travelers and the general public can find more information at

DSHS: Consider Mumps in Symptomatic Patients in Wake of Current Outbreak

A Nov. 30 health advisory from the Texas Department of State Health Services (DSHS) encourages physicians to consider mumps as a diagnosis in patients with unilateral or bilateral swelling of the parotid or salivary glands preceded by a low-grade fever, myalgia, malaise, or headache. 

The advisory comes after investigation of two mumps outbreaks in North Central Texas. One outbreak occurred in Dallas County involving five adults. Another outbreak occurred in Johnson County involving 10 cases primarily in children.

Texas requires diagnosis or suspicion of mumps to be reported. DSHS urges physicians not to wait for a laboratory confirmation of mumps to report suspected cases. Mumps reports should be made to your local health department or by calling (800) 705-8868.

According to DSHS, physicians should also consider mumps in patients who have traveled outside the state or who have come into contact with those infected with mumps. Several counties in Arkansas have reported mumps cases.

DSHS specifies that up to 20 percent of those infected may be asymptomatic. Other rare complications of mumps include deafness, pancreatitis, oophoritis, meningitis, and encephalitis. 

Physicians should collect the following specimens for all patients suspected of having mumps: 

  • Buccal swab (preferred) for viral isolation and PCR testing. 
  • Blood drawn and submitted for serological testing to detect IgM antibody.

Announcing the Top Internal Medicine Mentors of 2016

Just last month, the Texas Chapter of the American College of Physicians (Texas ACP) hosted an awards ceremony to honor an illustrious group of internists. Each year, these physicians answer the call to strengthen the practice of primary care in Texas by serving as preceptors to budding medical students through the General Internal Medicine Statewide Preceptorship Program (GIMSPP). 

Physicians honored at the awards ceremony are among the longest serving GIMSPP preceptors in the state (listed below). Combined, they have trained 127 medical students in various primary care settings. Emerald Awardees were recognized for 20 or more years of service while Decade of Service Awardees were honored for 10 years of GIMSPP service. 

Physicians interested in serving as a GIMSPP preceptor can submit an availability form for 2017. Preceptors spend between two and four weeks during the summer providing daily, personal instruction to medical students. In many cases, this experience solidifies the students' commitment to work in primary care. 

Preceptorship selections will be announced in March with all student matches completed no later than April. Currently, more than 100 students are waiting to be matched. Help the practice of primary care flourish by signing up to be a GIMSPP preceptor today.

GIMSPP 2016 Emerald Awardees

Allan Rowan Kelly, MD, of Fort Worth, has served as a GIMSPP preceptor to 24 students. For the past six years, he has pursued geriatric practice innovation. He currently makes rounds at hospitals, nursing homes, rehabilitation hospitals, and assisted living facilities, and sees patients in his office. 

William M. Mania, MD, of Richardson, has provided mentorship through GIMSPP to 30 students. An avid traveler, he currently practices medicine from his Richardson office where he always keeps his door open to additional student mentees.

Louis A. Torres, Jr., MD, of Plano, has served as a GIMSPP preceptor to 26 students since 1995. By reinforcing the uniqueness of each patient, Dr. Torres helps students learn how to develop personalized care plans, taking into account insurance, financial and social status, age, mobility, and individual beliefs.

Larry A. Warmoth, MD, is commander of the 149th Medical Group, 149th Fighter Wing at Lackland Joint Base San Antonio. He has provided mentorship to 14 students through GIMSPP. Currently, Dr. Warmoth serves as the chief of staff of Covenant Medical Center in Lubbock, as well as an assistant professor of medicine at Texas Tech University Health Science Center School of Medicine.

GIMSPP 2016 Decade of Service Awardees

Margaret R. Hayden, MD, of Tyler, has mentored eight students through GIMSPP. She currently practices at Tyler Internal Medicine Associates with special interests in preventive medicine, women's health, and cardiovascular evaluation and management. Dr. Hayden also serves as a preceptor for The University of Texas at Tyler nurse practitioner degree program.

Michael S. Marshall, MD, has served as a preceptor for seven students through GIMSPP. Dr. Marshall is a board-certified internist and pediatrician. He currently works as a practicing physician and is the chief medical officer for the Methodist Health System in Dallas. 

William H. Pieratt, DO, of College Station, has served as a GIMSPP preceptor to nine students over the course of his career. In addition to GIMSPP service, he is currently the course director for internal medicine and director of the Longitudinal Integrated Medicine program at the Texas A&M College of Medicine.

Aaron L. Samsula, MD, has mentored nine students through GIMSPP and also served on the Texas ACP's Medical Students Committee for several years. He was cochair of Texas ACP's council of early career physicians. He currently practices outpatient general internal medicine in Plano.

New App Supports Medication-Assisted Treatment for Opioid Use Disorder

According to the U.S. Centers for Disease Control and Prevention, overdoses from opioids, including prescription pharmaceuticals and heroin, killed more than 28 million people in 2014. That's more than any year on record. As part of the U.S. Department of Health and Human Services opioid initiative, the Substance Abuse and Mental Health Services Administration (SAMHSA) developed MATx, a free mobile app that provides immediate access to information about medication-assisted treatment (MAT) for opioid use disorder.

MATx helps practitioners provide effective, evidence-based care to patients living with an opioid use disorder. The app features: 

  • Information on medications approved by the U.S. Food and Drug Administration for use in the treatment of opioid use disorder and treatment approaches for practitioners;
  • Clinical support tools, such as treatment guidelines, ICD-10 coding, and continuing education opportunities; and
  • Access to critical helplines and SAMHSA's treatment locators. 

MATx is available for free download on Apple and Android mobile devices. 

MACRA Penalties Reprieve Makes Accountable Care Program Essential

TMA has some good news for physicians feeling apprehensive about future success under the Medicare Access and CHIP Reauthorization Act (MACRA). The Centers for Medicare & Medicaid Services (CMS) basically halted penalties for 2019, which means you still have time. If you're looking to make an informed, methodical shift to value-based care but don't know where to start, the 2017 Accountable Care Leadership Program is your one-stop solution.

Over the course of 10 months, participants will learn how to succeed as care is financed, organized, and delivered in new ways under MACRA. This in-depth program digs deep into risk-based payment initiatives, clinic-based balanced scorecards, the development of accountable care organizations (ACOs), and patient-centered medical homes. Strategies for effective negotiation, conflict management, and stakeholder reliance will also be addressed.

The 2017 leadership class will be limited to 30 participants, so submit your application as soon as possible. The deadline is Jan. 6.

Physicians who graduated from the program describe it as "eye opening," adding "population-based health management was such a confusing subject until this program," which also provided "the clearest information I've ever received on MACRA and MIPS."

Since 2012, ACOs across the nation have brought in more than $1.2 billion in Medicaid savings. Join the Accountable Care Leadership Program to learn how you can build on these savings and influence how value-based care affects your practice and your patients. 

Program participants will earn more than 95 hours of continuing medical education credit. For complete coursework details, requirements and participation fees, visit the TMA website. 

PC Action Ad Aug 13

TMF Launches Chronic Care Management Learning and Action Network

Care management is one of the critical components of primary care that contributes to better health for patients and reduced health care expenditures. The Centers for Medicare & Medicaid Services (CMS) introduced a non-visit-based payment code for chronic care management (CCM) services on Jan. 1, 2015. Clinicians can be paid for providing 20 minutes a month of care coordination services to their Medicare fee-for-service patients who have two or more chronic conditions. 

Medicare's payment structure for eligible clinicians is approximately $42 per month (CPT code 99490) for providing non-face-to-face care and care coordination services to eligible patients. Read the Chronic Care Management Business Case for Participation to learn more about the benefits of offering CCM services and joining the CCM network. 

The TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) is helping clinicians identify eligible patients and will assist with processes such as billing, documentation, and service tracking tools, as well as providing educational tools, resources, and events. Download the CCM fact sheet to learn more about working with the TMF QIN-QIO, and join the Chronic Care Management network.

In addition, TMA Practice Consulting provides these coding and documentation services, for a fee, available for continuing medical education credit:

  • Coding and Documentation Review: a comprehensive analysis of a physician's coding and documentation techniques presented in a written report with specific findings and opportunities for improvement. 
  • Coding and Documentation Training: on-site training for physicians and staff on the coding and documentation guidelines, customized to the practice's specialty. 

A TMA consultant certified as a professional coder and medical auditor performs these services. For expert assistance, email TMA Practice Consulting, or call (800) 523-8776.

Register for Live Event on MACRA and the New Quality Payment Program

Join your colleagues on Jan. 7, 2017, to hear from experts on MACRA, what it means for physician practices, and how you can prepare for the shift to value-based payment.

TMA, the Travis County Medical Society (TCMS), and Dell Medical School will cohost a live education session on the Medicare Access and CHIP Reauthorization Act (MACRA) and new Quality Payment Program (QPP). The event will take place Saturday, Jan. 7, 2017, from 9 am to noon at the Dell Medical School Health Learning Building in Austin. 

Program Details

MACRA: New Quality Payment Program and the Move to Value-Based Care

Speakers, followed by Q&A:  

  • Steve Steffensen, MD, chief of the Learning Health System at Dell Medical School, will serve as moderator.
  • Mark McClellan, MD, senior policy advisor at Dell Medical School, will provide national context for MACRA and an overview of the two tracks in the QPP.
  • Robert K. Cowan, MD, president of the Travis County Medical Society, will provide an introduction to the Merit-Based Incentive Payment System (MIPS).
  • Anas Daghestani, MD, chief executive officer and medical director of medical home, population health, and clinical quality at Austin Regional Clinic, will discuss how to prepare for MIPS.
  • Elizabeth Teisberg, executive director and professor at Dell Medical School, will discuss working together to further value-based care. 


Space for this event is limited to 120 people. To reserve your spot now, visit the TCMS website for registration details, email tcms[at]tcms[dot]com, or call (512) 206-1270. The registration fee is $20 per person. Parking will be available in The University of Texas at Austin surface lot 108, adjacent to the Health Learning Building.

For the latest information on the new Medicare Quality Payment Program, visit the TMA MACRA Resource Center.

TMA Poster Session Doctor's Choice Award Could Be Yours

TMA's Poster Session competition is one of the most widely visited, extensively discussed continuing medical education (CME) instillations at the annual TexMed conference.

TMA invites you to share your medical insights while getting the kudos your work deserves. Poster abstracts will address a spectrum of physician competencies and modalities. These can range from local-level breakthroughs, such as a new method for improving patient handoffs in the operating room setting, to broader research, like an assessment of the protocols for AB plasma transfusions in emergency care settings. 

Abstracts will be judged by TMA physician experts, and the top three winners from each category will receive a cash prize. TexMed physicians will vote one outstanding poster for the coveted Doctor's Choice Award.

Submit your abstract, and mark your calendar to attend TexMed 2017 in Houston. Registration is free for TMA members. Selected abstract authors will be invited to the author-hosted CME Poster Session on May 6. 

Submission categories for 2017 include Quality Research, Quality Improvements and Clinical, with a focus this year on Disaster Medicine and Emergency Preparedness, and Enhanced Perioperative Recovery. Submissions are due March 17. For complete details, visit the TMA website

Physician, Medical Student Journalists: Enter TMA Contest

Do you write a medical column or articles for your local newspaper or magazine? Do you host a health-focused segment on a local TV or radio station? If so, enter your work in the TMA Anson Jones, MD, Awards contest.

TMA will celebrate its 60th year of honoring Texas journalists for excellent medical news reporting in 2017. The Physician Excellence in Reporting category is just for you: It recognizes physician and medical-student reporters who regularly contribute to general interest media aimed at a Texas public audience. (Eleven other award categories honor professional journalists in print, television, radio, and online media.)

Enter today. Any news story published or broadcast in 2016 is eligible. TMA will accept entries until Jan. 10, 2017. You also can nominate a colleague or a local professional journalist (nonphysician) who is an outstanding medical journalist.

Visit the Anson Jones webpage for complete contest details. If you have questions, call Tammy Wishard, TMA outreach coordinator, at (800) 880-1300, ext. 1470, or (512) 370-1470, or email ansonjones[at]texmed[dot]org.

This Month in Texas Medicine

The December issue of Texas Medicine features a cover story on Texas' exit from the federally funded refugee resettlement program, which assists refugees with relocating to the United States by helping them find jobs, learn English, and get basic health and social services. In the issue, you'll also find coverage of federal language access requirements for patients with limited English proficiency, the movement to eliminate the U.S. Medical Licensing Exam Step 2 Clinical Skills test, and Texas' rising maternal mortality rate.

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.  

On-Demand Webinars

HIPAA Training for Staff and Compliance Officers

Medicare and MACRA: Get Clarity and Direction!

Conferences and Events

2017 TMA Winter Conference
Jan. 27–28, 2017
Hyatt Regency Austin

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