In its Report to the 85th Legislature, the Sunset Advisory Commission recommends breathing 12 more years of life into the Texas Medical Board and goes into great detail about TMB's oversight of physicians who prescribe "extremely addictive and dangerous drugs, particularly drugs designed for patients with chronic pain, as some of these drugs contribute to an epidemic of addiction and overdose throughout the country." The commission recommends "the board target its inspections of pain management clinics toward the top prescribers, that the board more effectively monitor prescribing patterns through the newly enhanced Prescription Monitoring Program [PDMP], and that physicians and physician assistants be required to search the program and review a patient's prescription history before prescribing dangerous pain medications."
TMA opposes mandatory PDMP searches and recommends better use of evolving technology to combat doctor shopping and opioid diversion.
At the Dec. 9, 2016, Sunset Advisory Commission public hearing on TMB, Ray Callas, MD, chair of TMA's Council on Legislation, testified on the issue. During the 2015 legislative session, TMA worked for the passage of Senate Bill 195 by Sen. Charles Schwertner, MD (R-Georgetown). SB 195 moved the PMP from the Texas Department of Public Safety to the Texas State Board of Pharmacy. While the PDMP "appears to be running on a robust platform" and is easier to use, Dr. Callas said the technology should be used in a "meaningful and practical way."
"We do want to work with you [sunset commission] to make sure that we are harnessing this new technology … in a way that helps physicians provide better care for our patients. I do want us to be mindful of imposing additional burdens on physicians and patients and the special needs of patients in emergency situations, those suffering through cancer treatment, and those dealing with pain management in end of life care," he said.
In regard to the PDMP, the sunset commission specifically recommends:
- Beginning Sept. 1, 2018, require physicians and physician assistants to search it and review a patient's prescription history before prescribing opioids, benzodiazepines, barbiturates, or carisoprodol.
- If the legislature adopts the recommendation above, exempt prescribers who prescribe such drugs to a cancer patient or a patient in a hospice setting but only if the prescriber includes on the prescription the patient’s diagnosis or the basis for the exemption.
- Clarify statute and provide direction for the board to monitor physician and physician assistant prescribing patterns of controlled substances.
The commission's report also addresses TMB informal settlement conferences, a matter attorneys and medicine alike have long been concerned about. In scathing written comments TMA submitted to TMB in July 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. The proposed rules appeared to be a clarification of how the board already conducts ISCs. But after critical comments from TMA and other stakeholders, TMB chose not to adopt the rule amendments.
At the Dec. 9, 2016, Sunset Advisory Commission public hearing, Dr. Callas also testified on the need to address the board's disciplinary investigations of physicians. "The board should be required to share with the physician complete copies of each of the expert reports with all identifiers of the expert reviewer, except specialty, redacted." He also testified the board should be granted greater leeway to impose a remedial plan for minor administrative or technical violations of the Medical Practice Act that do not involve allegations of substandard care or patient harm. "Right now, a physician is allowed a lifetime maximum of one remedial plan. We believe that restriction should be lifted and left to the board's discretion for these minor administrative violations," he said.
Here's a summary of the commission's enforcement recommendations for TMB:
- As part of an informal settlement conference for a case involving an allegation of a standard of care violation, require the board to share with the subject license holder a copy of each preliminary written report produced by each expert physician reviewer for the license holder's case, not just the final report currently required by law.
- Require at least one of the Texas Physician Assistant Board members participating in an informal settlement conference as a panelist to be a board member who is a licensed physician assistant.
- As part of their evaluation of whether a physician has committed a violation of the standard of care, require members of the informal settlement conference disciplinary panel to consider whether the physician was practicing complementary and alternative medicine.
- Authorize the board to offer a remedial plan — which is a nondisciplinary action for less serious violations — for a physician at most once every five years, instead of once per lifetime.
- Remove the duplicative requirement that the board's formal complaints filed with the State Office of Administrative Hearings be sworn to.
For more about TMA's call for fair TMB informal disciplinary hearings, read "On Trial" in the November 2016 issue of Texas Medicine.
Action, Feb. 15, 2017