Action: Feb. 15, 2017

TMA Action    Feb. 15, 2017   News and Insights from Texas Medical Association

UHC Delays Beacon Lab Benefit Program
Sunset Commission Calls for Mandatory Pain Med History Checks
Victory: Anthem-Cigna Merger Blocked by Court
Medicare Meaningful Use Attestation Deadline Extended
Meaningful Use Penalty Reconsideration Form Deadline
Practice Websites Targeted in ADA Shakedown
Comptroller Releases Health Care Spending Report
Confused About Quality Reporting? Get Help From TMF and TMA

MACRA: Propose Your Own Physician-Focused Payment Model
ACIP Publishes 2017 Immunization Schedules
Registration Open for the Texas Primary Care and Health Home Summit
New Infographic Promotes Child Care Worker Vaccinations
TMAF Honors Endowment Innovation Campaign Donors
This Month in Texas Medicine
Political PrognosisChallenges in Austin, Change in Washington

UHC Delays Beacon Lab Benefit Program

Strong opposition from organized medicine pushed UnitedHealthcare (UHC) to put on hold an expansion of its Laboratory Benefit Management Program, which would have been extended to fully insured commercial plan patients in Texas effective March 1. 

TMA and the Texas Society of Pathologists (TSP) received confirmation of UHC's decision in January after meeting with UHC in December. According to the UHC website, the program aimed to "improve the quality of outpatient laboratory services, support evidence-based guidelines for patient care, and lower costs" for UHC members. TMA, TSP, and 20 Texas medical specialty societies have serious reservations about the program.

In a Feb. 6 letter to Texas legislators, TSP President Tim Allen, MD, JD, and 20 Texas medical specialty societies say the "program will add new incremental costs to every patient treated by Texas physicians," adding a call for lawmakers to "prevent or delay implementation of this inappropriate program."

The program began and is still running in Florida in collaboration with Beacon Laboratory Benefit Solutions (BeaconLBS), a subsidiary of LabCorp, which specializes in laboratory management services. All outpatient lab services for patients who are part of the program are subject to new requirements, including advance notification and medical policies. Ordering and rendering physicians use BeaconLBS Physician Decision Support (PDS) technology for lab services, which UHC made available Jan. 1 to physicians in its Texas networks.

These physicians continue to have access to the PDS tool, and UHC encourages them to use it when ordering Decision Support Tests, but it is not required. UHC says the PDS tool technology makes it easier to choose the right tests and labs for patients based on evidence-based guidelines and industry best practices. To register, visit, and select Physician Login. 

When the program first rolled out as a pilot in Florida, Texas was also going to be a pilot state. TMA fought to get Texas removed from that original pilot program and discussed the issue regularly in meetings with UHC officials. TMA staff will continue to discuss the association's concerns about the impact of the program on ordering physicians and pathologists and will work with TSP and the other specialty societies to make UHC aware of the concerns.

TMA agrees with TSP physician members' concerns about UHC's program. They worry it: 

  • Creates a new administrative burden for the referring physician; 
  • Takes away physicians' right to choose a consultant (pathologist or laboratory);
  • Creates "network within network" steerage based solely on payment; 
  • May deny payments to contracted physicians who present a "clean claim" for reasons outside their control; and
  • Starts medicine down a slippery slope: If they can do this to one specialty, they can do this to all specialties. 

TSP Immediate Past President Kevin Homer, MD, notified specialty society members in a Nov. 14, 2016, letter that the organization was gathering information about BeaconLBS, including a phone meeting with key UHC representatives, BeaconLBS, and LabCorp. Additionally, in communication with the Florida Society of Pathologists, Dr. Homer wrote that TSP learned referring physicians in Florida "are commonly non-compliant with BeaconLBS, and that laboratories are simply not being paid for testing performed on UHC patients in those cases. UHC has not provided detailed data regarding Beacon's success in achieving its quality, utilization, or physician experience goals."

Dr.  Homer added: "Cost alone should never drive health care choices independently of quality. While UHC claims the Beacon program is beneficial, TSP believes it ignores the negative consequences that BeaconLBS will have on patients, doctors, and quality of care. We believe that the fundamental right of a physician to choose the most appropriate laboratory for his or her patients results in better outcomes for patient care, test quality, and total cost of care."

Talking points UHC recently shared with TSP state that UHC "is committed to supporting physicians as we implement the Laboratory Benefit Management Program in Texas. We will continue to work with physicians by providing access to the Lab Physician Decision Support tool while delaying claim denials associated with the Texas program initially communicated to begin March 1, 2017." UHC indicated the delay gives the insurer "time to make further refinements to the program based on data, experience, and feedback from Texas care providers. We encourage you to leverage the Physician Decision Support tool now to help you gain familiarity with the process and to enhance coordination when ordering tests." 

Sunset Commission Calls for Mandatory Pain Med History Checks

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.

Victory: Anthem-Cigna Merger Blocked by Court

In a significant win for organized medicine and the nation's patients, federal judge Amy Berman Jackson blocked the proposed Anthem-Cigna merger. She found that the merger would have substantially lessened competition for the sale of health insurance to national employers, resulting in higher prices and diminished prospects for innovation.

Anthem Inc. planned to take over Cigna for $50 billion. American Medical Association findings show the Anthem-Cigna merger would enhance market power in 85 metropolitan areas within 13 states: California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, and Virginia.

TMA member physicians voiced strong opposition to the merger, asserting it would expand insurers' waistlines and wallets, while leaving doctors and patients with the heartburn of fewer choices and higher costs. Indeed, Judge Jackson concluded that an enhanced ability to coerce physicians to accept lower payment would not benefit consumers and "would erode the relationship between insurers and providers" and “reduce the collaboration” that is essential to innovation in payment and delivery. 

The judge rejected the insurers’ arguments that lowered physician payment would benefit consumers and justify the merger.

Medicare Meaningful Use Attestation Deadline Extended

The Centers for Medicare & Medicaid Services (CMS) extended the meaningful use attestation deadline for the Medicare electronic health record (EHR) incentive program to March 13. The Medicaid meaningful use attestation deadline remains March 16. 

  • Medicare participants must attest to meaningful use via the (CMS) portal no later than 11:59 pm PT on March 13. 
  • Medicaid participants must attest via the Texas Medicaid EHR incentive program portal no later than March 16. Log in to your account on the Texas Medicaid & Healthcare Partnership home page, then click the Texas Medicaid EHR incentive program link in the Manage Provider Accounts section. Reminder: This is the last opportunity for eligible physicians to enter the Medicaid meaningful use program. 

Visit the Texas Health and Human Services Health Information Technology website for detailed instructions based on your program year. 

Many participants will be attesting on the day of the deadline. TMA encourages you to attest sooner, rather than later, to avoid any problems. CMS will not make exceptions for participants who miss the deadline. 

CMS has released the 2016 attestation worksheet, which allows you to log the meaningful use measures to use as a reference when attesting to meaningful use.   

If you have questions about the meaningful use program, contact TMA's Health Information Technology Department by email, or call (800) 880-5720.

   Action TMLT Ad 10.15 

Meaningful Use Penalty Reconsideration Form Deadline

If you received a letter from the Centers for Medicare and Medicaid Services (CMS) stating that you are subject to a penalty for not meeting the meaningful use requirements during the 2015 electronic health record (EHR) reporting period and feel there’s been an error, you have until Feb. 28 to submit the reconsideration form to CMS.

For more guidance on completing the application, review the Reconsideration Instructions or e-mail pareconsideration[at]provider-resources[dot]com.

If you have questions about the meaningful use program, contact TMA's Health Information Technology Department by email, or call (800) 880-5720.

Practice Websites Targeted in ADA Shakedown

An Austin attorney is sending demand letters to physicians and providers across the state alleging that their websites are not accessible to people with visual disabilities and that he will sue them unless they pay him $2,000 plus attorney fees.

On February 13, 2017, Chief United States District Judge for the Western District of Texas (San Antonio Division) Orlando L. Garcia granted Concentra Operating Corp.’s (Concentra) Motion to Dismiss a lawsuit filed against it by Omar Weaver Rosales.  The lawsuit was just one of many filed, or threatened to be filed, by Mr. Rosales over physicians' and providers' websites.

Jim Harrington, a veteran civil rights attorney from Austin who himself spent decades fighting for Americans with Disabilities Act (ADA) enforcement, says he knows of at least 20 instances around the state where Mr. Rosales has threatened lawsuits over physicians' and providers' websites. At least two dozen inquiries have come to TMA through the Knowledge Center and Office of the General Counsel."

This is about as close to a shakedown as you can get," Mr. Harrington said. "Rosales sends a draft of a suit, (often) with himself as plaintiff, to scare people into paying him $2,000. This is a perverted use of the ADA. The law was designed to help the disability community, not make lawyers rich."

Mr. Rosales already faces sanctions and a $176,000 fine imposed by U.S. Magistrate Judge Mark Lane, of Austin, over his actions against Mr. Harrington in hundreds of lawsuits he filed alleging violations of the ADA. In those cases, Mr. Rosales sued small businesses over parking lot violations. The State Bar of Texas has opened an investigation into Mr. Rosales’ activities.  To add information to the investigation, physicians may send their complaint and related materials to:

Rita Alister
Assistant Disciplinary Counsel
State Bar of Texas
P. O. Box 12487
Austin, TX 78711
(512) 427-1350, (877) 953-5535
fax: (512) 427-4167

Judge Lane's sanction of Mr. Rosales also included a referral to the Disciplinary Committee of the Western District of Texas. While the committee’s proceedings are confidential, physicians who feel Mr. Rosales’s actions toward them are relevant to this investigation may forward any materials received from Mr. Rosales to: 

 Karl Bayer
Chair, Disciplinary Committee of the Western District of Texas
14900 Avery Ranch Blvd., Ste. C200
Austin, TX 78717

 cc:   U.S. District Clerk
501 W. Fifth St., Ste. 1100
 Austin, TX 78701

TMA's Office of General Counsel has identified several resources for medical practices concerning websites and ADA compliance. These include information from the U.S. Department of Justice, the  Employer Law Report, and  eMedia Law Insider. TMA staff use online checking services, such as, to check for potential ADA problems on the TMA website.

Legal articles in Action or on the TMA website are intended to help physicians understand the law by providing legal information on selected topics. These articles are published with the understanding that TMA is not engaged in providing legal advice. When dealing with specific legal matters, readers should seek assistance from their attorneys.

Comptroller Releases Health Care Spending Report

Texas Comptroller Glenn Hegar issued a report examining health care-related spending by 68 state agencies and higher education institutions from 2011 to 2015. 

"As the legislature begins to examine state spending, I'm pleased to provide lawmakers with essential information about one of the most significant components of the Texas budget," Mr. Hegar said. "New medical technology and prescription drugs, uncompensated and indigent care, chronic disease, an aging population, increased utilization, and provider shortages are among some of the factors that have contributed to Texas' rapid rise in health care spending."

The report includes an analysis of all state government health care spending and an in-depth look at the five state agencies reporting the largest share of that spending — the Texas Health and Human Services Commission (59.1 percent), the Department of Aging and Disability Services (11 percent), the Texas Department of State Health Services (4.9 percent), the Employees Retirement System (4.4 percent), and the Teacher Retirement System (3.1 percent).

Together, these agencies accounted for 82.5 percent of all state health care spending in 2015. The report also features a section on health care spending by counties, which play an important role in health care delivery and also have experienced escalating costs.

Among the report's findings: 

  • In 2015, Texas spent $42.9 billion on health care, representing 43.1 percent of all state appropriations. 
  • During 2011–15, state health care expenditures increased by 19.7 percent, a rate exceeding the growth of inflation and the Texas population in the same time period. 
  • In Texas, health care spending represents about 12 percent of gross state product. 

Confused About Quality Reporting? Get Help From TMF and TMA

Reporting deadlines for the Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS), Value-Based Payment Modifier, and meaningful use programs are fast approaching. This data submission timeframe is happening at the same time CMS is rolling out the new Quality Payment Program, Merit-Based Incentive Payment System (MIPS), and advanced alternative payment models required by the Medicare Access and CHIP Reauthorization Act (MACRA). Are you confused about the alphabet soup of quality reporting? If so, get help from the TMF Quality Innovation Network and TMA Practice Consulting. 

The TMF Quality Innovation Network hosts free educational events for the benefit of physicians, hospitals, and other health care professionals. Register for the TMF Quality Innovation Network's Physician Quality Reporting System (PQRS) and Meaningful Use Open Forum to ask questions and learn details for the final reporting and attesting of 2016 PQRS and 2016 meaningful use. This open forum will take place Thursday, Feb. 16, from noon to 1 pm CT. Recorded events are also available, including An Overview of the Quality Payment Program for 2017, presented by CMS Chief Medical Officer David Nilasena, MD. Learn more about upcoming events by visiting and clicking on Events. A recording of the forum will be available two weeks after the events. You can access it on TMF's Recorded Events page.

TMA Practice Consulting offers quality improvement services to help prepare physician practices for the upcoming transition under MACRA. TMA's practice management consultants can conduct a MACRA readiness assessment of your practice and provide customized on-site assistance to help 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 in 2017. TMA is dedicated to working with you and your practice to earn an incentive payment, not just avoid the penalty. To learn more, email TMA Practice Consulting, or call (800) 523-8776.

 TMAIT Action Ad 6.15    

MACRA: Propose Your Own Physician-Focused Payment Model

Have you been reading up on the Medicare Access and CHIP Reauthorization Act (MACRA) and the new Quality Payment Program? Are the Merit-Based Incentive Payment System and advanced alternative payment models (APMs) not good fits for your practice and specialty? If they're not, consider proposing your own physician-focused payment model. Register today to learn about this opportunity and how to submit a strong proposal.

MACRA repealed the Sustainable Growth Rate (SGR) formula for updating payment rates under the Medicare physician fee schedule and required the Centers for Medicare & Medicaid Services (CMS) to replace it with two new payment paths: the fee-for-service MIPS program and incentives for participation in APMs. CMS implemented the first performance period for MIPS and APMs under the new Quality Payment Program framework on Jan. 1. However, MACRA also specifically encourages the development of physician-focused payment models and created the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to review and make recommendations regarding proposals to the secretary of the Department of Health and Human Services.

PTAC will host a webinar on Monday, Feb. 27, from 1 pm to 2 pm CT on How to Submit a Proposal to PTAC: Clarifications and Tips for Submitters. A question and answer session will be held after the presentation. Submit your questions in advance by emailing PTAC[at]hhs[dot]gov with the subject line "webinar question." A recording and slides will be sent to all registrants after the webinar.

Before you participate in the webinar, learn the basics by visiting the PTAC website and read the FAQs. Visit the TMA MACRA Resource Center to stay current on all things MACRA. 

ACIP Publishes 2017 Immunization Schedules

The U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has released the 2017 immunization schedules for children and adults

Changes to the recommended immunization schedule for children and adolescents aged 18 years and younger include: 

  • Elimination of live attenuated influenza vaccine,
  • Updated human papillomavirus (HPV) vaccination recommendations that include the new two-dose schedule for children who start the series before age 15 years, and 
  • Addition of children aged 9–10 years for the HPV vaccine, indicating children in this age group may be vaccinated (even in the absence of a high-risk condition). 

The 2017 adult immunization schedule also features these changes

  • Elimination of the live attenuated influenza vaccine during 2017 flu season, and
  • Updated HPV recommendations for adults who did not complete the HPV vaccination series as children or adolescents.

Registration Open for the Texas Primary Care and Health Home Summit

This year's Texas Primary Care and Health Home Summit will be the fifth annual statewide conference focused on expanding access to high-quality, person-centered primary care for Texans and their families. Sponsored by TMA, the summit will offer stakeholders the opportunity to learn about innovative primary care models, including the health home. 

Attendees will become conversant with best practices for innovation in primary care and will have opportunities to interact with program experts at various stages of implementation. Register now to attend the summit May 11–12 at the Sheraton Gunter in San Antonio.

The summit's goal is to provide opportunities for participants to hear from practitioners who have been successful in making transformational changes to their practices. The summit will offer practical, tangible, and useful tips and tools to help practices at all stages of their transformation. Check out the agenda.

This year's summit will appeal to primary care practices of all sizes and affiliations. It will include sessions on readiness for value-based contracting, integrating behavioral and oral health into primary care, building effective teams, population health strategies, improving chronic care management, and successful business models for the health home. Sessions will cover creating a pediatric health home and will provide an update on STARKids. Thursday morning pre-summit sessions are available for those who want to explore topics in greater depth. There will be additional opportunities for practices to share their successes and best practices with their peers. 

Participants will leave the summit with:   

  • An understanding of the health home and how it promotes accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective health care.
  • Awareness of best practices to improve the primary care practice for all types of patients (children, adolescents, adults, and individuals with special needs and/or chronic diseases).
  • An understanding of value-based contracting and how practices can participate in it.
  • Knowledge about the elements of accountable care organizations (ACOs) with the opportunity to learn from successful ACOs in Texas.
  • Examples of successful integration of behavioral health services into primary care practices. 
  • A focus on consumer engagement and strengthened partnerships among families, physicians, and the health care system. 

For additional information, visit the summit website.

PC Action Ad Oct 13

New Infographic Promotes Child Care Worker Vaccinations

Bacteria and viruses can spread easily in a child care center, putting those who work with children — and the kids themselves — at greater risk of contracting vaccine-preventable illnesses. TMA's new infographic, Vaccinations for Child Care Workers, lists the shots recommended for people who work with children: flu, pertussis, chickenpox, and measles. 

Download the new bilingual infographic to your website, post it on social media, or order printed copies to display in your office. You also can ask your local day care centers to post a copy in their facilities.

The child care worker vaccination infographic is the latest addition to the family of infographics offered by TMA's Be Wise — ImmunizeSM program. TMA previously produced infographics on flu, human papillomavirus (HPV), whooping cough, and adult vaccinations

To order hard copies, email Tammy Wishard, TMA's outreach coordinator, or call (512) 370-1470 or (800) 880-1300, ext. 1470. 

Be Wise – Immunize is a joint initiative led by TMA physicians and medical students, and the TMA Alliance. It is funded in 2017 by TMA Foundation thanks to major gifts from H-E-B and TMF Health Quality Institute, along with generous contributions from physicians and their families. 

Be Wise — Immunize is a service mark of the Texas Medical Association. 

TMAF Honors Endowment Innovation Campaign Donors

The TMA Foundation (TMAF) recognized more than 100 TMA and TMA Alliance members who collectively donated $1 million to TMAF's Endowment for Innovation Campaign (EIC) on Jan. 28 during TMA's Winter Conference.

TMAF President Deborah A. Fuller, MD, thanked those early campaign donors for contributing more than three-quarters of the EIC's $1.25 million goal. This incredible support launches the second phase of EIC's goal to raise the remaining $250,000. Gifts to the campaign have the potential to increase TMAF's General Endowment to $2.25 million. At this level, TMAF will be able to support more impactful and highly visible TMA initiatives.

EIC started with a $50,000 gift from a TMA past president and his wife, who challenged TMAF to increase the capacity of its General Endowment.

TMA Foundation invites the TMA and TMA Alliance communities and friends of medicine to join the effort to bring a "Healthy Now" and a "Healthy Future" to more Texans.

Political Prognosis: Challenges in Austin, Change in Washington

One month into Texas' 2017 legislative session, the ramp-up is beginning as medicine and lawmakers prepare for what's certain to be a flurry of activity related to health care.

TMA and friends of medicine are facing the challenges of what's already been called a tight budget year, trying to convince lawmakers to maintain as much funding as possible for key programs as cuts inevitably loom. Meanwhile, lawmakers and other interested observers are keeping one eye on Washington, DC, where the beginning of a new presidential administration has brought with it a promise to repeal and replace the Affordable Care Act — but with large uncertainty about when that repeal will happen or what an ACA replacement will look like. 

TMA's four physician member-representatives all earned important committee assignments for this session. Rep. John Zerwas, MD (R-Simonton), is chair of the Appropriations Committee, which also counts Reps. J.D. Sheffield, DO (R-Gatesville), and Greg Bonnen, MD (R-Friendswood), among its members. Representative Sheffield also earned a spot on the Public Health Committee, where he's serving as vice chair, and on the Rules and Resolutions Committee. In addition to his reassignment to the Appropriations Committee, Representative Bonnen is also serving on the Energy Resources Committee. Medicine's newcomer to the House of Representatives, Rep. Tom Oliverson, MD (R-Houston), sits on the Public Health, Insurance, and House Administration committees. 

On the Senate side, Lt. Gov. Dan Patrick distributed multiple committee assignments to all three of TMA's physician-senators, including two chairmanships. Sen. Charles Schwertner, MD (R-Georgetown), is once again chairing the Health and Human Services Committee. Senator Schwertner also was appointed to the Business and Commerce, State Affairs, and Finance committees. Sen. Donna Campbell, MD (R-New Braunfels), is chairing the Veterans Affairs and Border Security Committee. Senator Campbell also joins Senator Schwertner on the Business and Commerce Committee and was appointed to the Education and Intergovernmental Relations committees. Medicine's newest voice in the Senate, Sen. Dawn Buckingham, MD (R-Lakeway), will be busy with four committee appointments in her first year at the Capitol, sitting on the committees for Health and Human Services, Higher Education, Nominations, and Veterans Affairs and Border Security.

For a complete listing of Texas Senate and House Committees, see and

Budget Challenges

The early days of the 2017 session indicated legislators will have their work cut out for them on the only thing they're required to do every odd-numbered year: Pass a biennial budget.

When the Senate and House unveiled their initial proposed budgets in January, the two chambers were about $8 billion apart. The $213.4 billion Senate budget was the more austere of the two. It included $103.6 billion in state general revenue, while the House budget included about $108.9 billion. The House budget totaled $221.3 billion across all funds and proposed to spend about $2 billion more for health and human services than the Senate version.

Graduate medical education would get a boost in both budget proposals. The initial Senate budget offered an increase of $44 million for graduate medical education (GME) expansions. However, that budget also makes a $14.3 million cut to a separate program that helps medical schools pay for resident training. The House version adds about $30 million in new money for GME expansions but would reduce the state GME formula funding program for the medical schools by half as much as the Senate's cut.

Senator Schwertner is chairing the Senate Finance Committee's Workgroup on Health Care Costs, a subcommittee executing a deeper dive on the budgets of health-related state agencies and looking for cost containment in Medicaid, correctional managed care, the Employees Retirement System, and the Teacher Retirement System. State Comptroller Glenn Hegar's Texas Health Care Spending Report showed state health care costs increased by nearly 20 percent from fiscal years 2011 to 2015. TMA lobbyist Michelle Romero says TMA will continue to make the point to lawmakers that caseload, rather than utilization, is the primary cost-driver in Medicaid.

Sen. Jane Nelson (R-Flower Mound), chair of the Senate Finance Committee, demonstrated a commitment to providing as much funding as possible for medical education during committee budget talks in late January. When she asked the Texas Higher Education Coordinating Board how much money the state would need to reach the desired ratio of 1.1 first-year residency slots for every medical school graduate, the board told her it would require an additional $18 million. "If I find more money," Senator Nelson said, "that's where I'll put it." The state needs to add almost 600 GME positions by the year 2022 to meet the 1.1-to-1 goal.

Another Senate Finance Committee workgroup is examining special items that help provide funding for medical education, research, and funding for separate campuses for health-related institutions. While the proposed House budget kept special-item funding at about the same level as in the current budget, the proposed Senate version all but eliminated more than $1 billion in special-item funding. Senator Nelson asked the health-related institutions to prioritize their special items, hoping to use an available pool of about $300 million to save as many of the prioritized ones as possible.

Balance Billing and Health Plan Tactics

Surprise medical bills continue to be an ongoing headache for patients who weren't aware that a practitioner who treated them wasn't in their health insurance network, even if the care had been provided at an in-network facility. The blame for large, unexpected out-of-pocket costs has sometimes fallen on physicians who balance bill for their services. In response, some states have pursued strong restrictions on balance billing, such as Connecticut, where it is now considered an unfair trade practice.

But TMA believes that physicians have the right to bill for their services and that the real problem at the root of surprise medical bills is the inadequacy of narrow health plan networks. TMA is working with lawmakers to create protections for consumers that will address network adequacy issues while still allowing physicians to bill for the services they provide. TMA wants health plans to be accountable to current network adequacy requirements and exhibit more transparency, providing accurate directories of every practitioner within that health plan's network.

TMA is also working to expand the bill mediation process to include more out-of-network physicians and practitioners. Senator Hancock has already filed legislation to address the mediation aspect. For patients in PPO plans, mediation is currently available to dispute out-of-network bills of more than $500 from certain facility-based physicians. Senator Hancock's SB 507 would keep the $500 threshold but open up mediation to bills from freestanding emergency rooms and many other out-of-network practitioners.

SB 507 also would require insurers to give patients a firmer grasp of their mediation rights. The legislation would require mediation-eligible medical bills for an out-of-network claim to contain a "conspicuous, plain-language explanation of the mediation process," including a statement that the bill is for out-of-network services that may be eligible for mediation, with an explanation of the mediation process.

TMA and friends of medicine are also taking on health plans' tactics in step therapy protocols, in which insurers sometimes require patients to demonstrate failure on a particular prescription drug multiple times before the health plan will authorize the next "step" in their prescription treatment plan. Senator Hancock's SB 680 would prohibit insurers from requiring patients to fail a prescription medication more than once, and also would allow for physician override if an insurer attempts to deny the next step in their treatment.

"No patient should be forced to repeat a treatment that doesn't work just because their insurance company doesn't want to pay for the next level of care," Senator Hancock said in a release after filing SB 680.

Medicaid and an Uncertain Future

The beginning of President Donald Trump's administration brings with it the prospect of repealing and replacing the Affordable Care Act and, with that, a potential overhaul of Medicaid. Tom Price, MD, the nation's new secretary of Health and Human Services, proposed turning Medicaid into a block grant program two years ago in his role as chair of the House Budget Committee, and talk of a block-grant system is picking up steam both in Washington and at the state level.

Receptive lawmakers are selling a block grant as a vehicle to give states complete control and flexibility over their Medicaid programs. But TMA chief lobbyist Darren Whitehurst says the prospect of a block grant has more questions surrounding it than answers at this point, such as whether a federal block grant would include coverage for the Medicaid expansion population. 

TMA supports a Texas-run health care solution for the state's low-income families, seniors, and Texans with disabilities, as opposed to a federal solution. However, TMA also wants to protect coverage and access to health care services for Texas' most vulnerable populations. TMA and the Texas Hospital Association have created a Task Force on Medicaid Block Grants that is working on a joint Medicaid reform proposal.

While they wait to see what unfolds with Medicaid at the federal level, lawmakers are working within the constraints of the initial budget proposals at the state level, where the House proposal included more funding for Medicaid than the Senate version. The House's base budget offered $65.1 billion for Medicaid, about $4 billion more than the Senate.

Sen. Juan "Chuy" Hinojosa (D-McAllen), an ally for TMA in its attempts to foster fairer Office of the Inspector General (OIG) investigations of alleged Medicaid fraud, has filed legislation that would aid medicine on that front. Senate Bill 293 requires the executive commissioner of the Texas Health and Human Services Commission to adopt rules on "what constitutes an ongoing significant financial risk to the state and a threat to the integrity of Medicaid." Those are two pieces of the standard OIG must currently demonstrate in order to withhold payments from a practitioner it believes committed fraud.


The rapid advancement of technology has provided challenges for medicine, which is striving to make sure there's a place for any tool that can help deliver care to patients while at the same time maintaining the accepted standard of care. Whether a physician provides care in the same room as the patient or remotely via the telephone or other newer technologies such as videoconferencing, TMA believes the standard of care must remain the same, and physicians should have access to relevant clinical information about the patient in order to make a diagnosis.

TMA lobbyist Dan Finch said the association had been working on legislation consistent with those two principles that would neither be advantageous nor disadvantageous to a particular telemedicine provider's business model. On Monday, Medscape reported stakeholders had reached agreement on a compromise draft bill that would consider a telemedicine practitioner and a patient to have a valid practitioner-patient relationship under certain requirements. The bill would direct the state medical board, board of nursing, physician assistant board, and the board of pharmacy to jointly adopt rules to define valid prescriptions resulting from a telemedicine visit. Ray Callas, MD, chair of TMA's Council on Legislation, said more work remained on the draft bill. Senator Schwertner told Medscape he doesn't believe telemedicine providers should be able to prescribe controlled substances, but he supports the bill because telemedicine "is an important technology that has the potential to improve access, especially in rural and underserved areas, and potentially could have some cost savings as well."

Public Health

TMA lobbyist Troy Alexander says sizable public health cuts in the new budget proposals may be difficult for the Texas Department of State Health Services (DSHS) to recover from and don't bode well for some of the state's disease programs. Core priorities of TMA and the Texas Public Health Coalition during this session include funding for treatment of both communicable and noncommunicable diseases and legislation addressing vaccines. 

Notably, TMA is taking another crack at addressing parents' right to know school campus immunization data. DSHS publishes data on vaccinations and nonmedical vaccine exemptions at the school district level for each school year. For parents of children who can't be vaccinated, such as those in an immunocompromised state, district-level data leaves unanswered questions about how safe their child might be at a particular school. A bill to mandate de-identified campus-level vaccine exemption percentages passed only one chamber during the 2015 session, but TMA was planning another similar measure in 2017, with Representative Sheffield among the champions of a right-to-know bill in the House and Sen. Kel Seliger (R-Amarillo) planning to carry a companion measure in the Senate.

A statewide texting-while-driving ban is again drawing TMA support. Sen. Judith Zaffirini (D-Laredo) and Rep. Tom Craddick (R-Midland) have once again filed bills to ban the practice, making it a misdemeanor punishable by a fine of $25 to $99. Repeat offenders would be subject to a fine between $100 and $200. Representative Craddick's bill is House Bill 62. Senator Zaffirini's bill is Senate Bill 31. TMA and the Texas Public Health Coalition also support a push to raise the legal age for smoking and possessing tobacco to 21. 

Tackling Drug Diversion, Doctor Shopping

Moving the state's prescription drug monitoring program (PDMP) to the oversight of the Texas Board of Pharmacy in September 2016 was a change TMA greatly supported. Now, with the new PDMP in place, TMA is backing further refinements to the way Texas handles prescription drug distribution, supporting the use of technology — rather than physician mandates — to tackle opioid diversion and "doctor-shopping."

TMA is advocating for licensees of prescriber licensing boards to automatically be registered with the state PDMP, as well as for the pharmacy board to have authorization to issue "push out" notifications to prescribers and pharmacies when PDMP data suggests doctor-shopping.

However, it's likely some lawmakers will attempt to put the onus on Texas physicians with legislation requiring doctors to check the PDMP before issuing any controlled substance prescription. TMA lobbyist Dan Finch says even if it only takes a few minutes each time to check the PDMP, it adds up in a hurry for prescribers and pharmacists.

"It is small for every encounter," Mr. Finch said. "It is large for the total numbers."

Kickoff First Tuesdays Event Draws More Than 200

First Tuesdays at the Capitol got off to a strong start in February, with more than 200 member physicians and medical students and TMA Alliance members participating in this year's first "White Coat Invasion" to talk to lawmakers about TMA's legislative priorities. This session's other First Tuesdays events are scheduled for March 7, April 4, and May 2. Register here.

Joey Berlin, associate editor of Texas Medicine, prepared this special supplement to Action. You can reach him by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

This Month in Texas Medicine

The February issue of Texas Medicine is a symposium on infectious diseases. The special edition of the magazine features clinical articles that cover ethical challenges related to infectious diseases, emerging infectious diseases, future epidemics, the infectious disease outbreak investigation process, health care-associated infection prevention, antimicrobial resistance, the hygiene hypothesis, and infectious disease physician workforce needs.

Check out our digital edition

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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.   


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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. 

PQRS: Last Day for Claims-Based Reporting

Medicare EHR Incentive Program Attestation Deadline for 2016 Participation

PQRS: Last Day for Dual Participation in PQRS and the Medicare Electronic Health Record (EHR) Incentive Program

PQRS: Last Day for Electronic Reporting Using an EHR via EHR Direct and EHR Data Submission Vendors

PQRS: Last Day for Qualified Clinical Data Registries (QCDRs) — QRDA Format


Medicaid EHR Incentive Program Attestation Deadline for 2016 Participation

PQRS: Last Day for Group Practice Reporting Option (GPRO) Web Interface

PQRS: Last Day for QCDRs — XML File Format

PQRS: Last Day for Qualified Registries

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.  


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Conferences and Events

TexMed 2017 
May 5-6

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Last Updated On

February 15, 2017