Less than a month-and-a-half remains until the Texas Legislature adjourns, and recent weeks provided encouragement for many of medicine's foremost interests in the 2017 session.
As lawmakers in both chambers passed respective budget proposals — which they'll now have to reconcile in a lean budget year — TMA continued working to protect priorities that support its mission of improving the health of all Texans. Meanwhile, a number of important medicine-backed measures have advanced to committee hearings, out of committees, and out of the Senate, providing promising signs for continued progress. Just as encouragingly, some worrisome scope-of-practice measures that TMA opposes have thus far stalled.
The early morning hours of April 7 saw the Texas House conclude a 15-hour debate by approving a $218.2 billion state budget for 2018–19, a figure within overall striking distance of the $217.7 billion budget the Senate approved in March. Now, it's up to the two chambers to reconcile their budget differences.
The House budget included a number of encouraging provisions and amendments for medicine as lawmakers navigated this year's financial constraints. Rep. Armando Walle (D-Houston) stepped up to preserve Medicaid eligibility levels, benefits, and services. Representative Walle won adoption of an amendment to the House budget that prevents the Medicaid "federal flexibility rider" from being used to cut benefits or services or to change Medicaid program eligibility. TMA member physician Rep. J.D. Sheffield, DO (R-Gatesville), and Rep. Four Price (R-Amarillo) signed on to the amendment. Representative Price and Rep. Garnet Coleman (D-Houston) also limited the damage the federal flexibility rider could do to Medicaid, introducing their own amendment to protect "medically necessary services to eligible children." Proposed amendments to cut funding for tobacco cessation, to medicine's relief, didn't make it into the House's final budget.
TMA member Rep. John Zerwas, MD (R-Richmond), introduced one of the most pivotal parts of the House budget, tapping into the state's Economic Stabilization Fund — also known as the rainy day fund — for $2.5 billion. Using the rainy day fund is expected to be one of the biggest sticking points between the House and Senate, whose leader, Lt. Gov. Dan Patrick, is opposed to using the state's economic reserve fund.
The Senate passed its version of the budget on March 28. It includes provisions that would add more than $30 million in funding for graduate medical education expansion; allocate $244 million for mental health and add funding for state hospitals; appropriate $264 million for women's health preventive services; and add $393 million for medical education-related programs. However, the Senate plan also includes a rider reducing Medicaid general-revenue funding by $410 million; would cut staff and services at the Texas Department of State Health Services, including infectious disease and public health preparedness reductions; would cut 25 percent from the Physician Education Loan Repayment Program; and would cut 11 percent from the EMS and Trauma Care Training Program. TMA is working with lawmakers to ensure the cuts to Medicaid do not affect physician payment rates or patient care.
Scope, Protecting Physicians, and Telemedicine
At press time, none of the measures seeking to allow nonphysician practitioners to foray into practicing medicine had made much headway in either chamber. That's good news for medicine and TMA, which is closely tracking every attempt to infringe on the physician's scope of practice. As TMA lobbyist Dan Finch told physicians at this month's First Tuesdays at the Capitol event, "So far, none of the bills have been heard, which is good, and the longer we go without them being heard is good."
Measures to protect physicians from professional interference and maintenance-of-certification (MOC) discrimination earned hearings this month. An MOC measure by TMA physician Sen. Dawn Buckingham, MD (R-Lakeway), earned a hearing on April 11. Senate Bill 1148 would prevent hospitals and health plans from using MOC as the sole determinant for denying privileges or access to a managed care plan panel. Houston neurologist Kim Monday, MD, testified for TMA in support of the legislation. The Texas Hospital Association testified on the bill. The American Board of Medical Specialties testified against it.
And Senate Bill 833 by Sen. Bryan Hughes (R-Mineola) would help protect against nonprofit health corporations that interfere with a physician's professional judgment. TMA is working with Senator Hughes to strengthen the bill by adding protections to prevent retaliatory actions against physicians who advocate for patient care.
On another long-contentious issue, a TMA-supported effort to clarify the role of telemedicine in Texas has earned Senate approval. Senate Bill 1107 by Sen. Charles Schwertner, MD (R-Georgetown), defines a valid practitioner-patient relationship through telemedicine and clarifies that the standard of care remains the same for telemedicine treatment as it does for an in-person visit. SB 1107 passed by a 31-0 vote. One key aspect the bill does not address is the issue of physician payments for telemedicine care.
Sunset and the Prescription Mandate Issue
The issue of how to combat opioid abuse and diversion continues to center around just how to use the state's new prescription drug monitoring program (PDMP), which launched last September. Senate Bill 316 by Sen. Juan "Chuy" Hinojosa (D-McAllen), which addresses those issues, made it out of the Senate last Wednesday.
The bill incorporates many of TMA's recommendations to use the new and evolving technology the Texas PDMP offers. TMA's list of recommendations includes authorizing the Texas State Board of Pharmacy to alert physicians, other prescribers, and pharmacists when it detects patterns of prescribing and dispensing that may constitute doctor shopping.
Unlike the sweeping recommendations from the Texas Sunset Advisory Commission to mandate checks for all controlled substances, SB 316 limits the required checks to four classes of controlled substances: opioids, benzodiazepines, barbiturates, and carisoprodol. Beginning Sept. 1, 2018, SB 316 would require physicians to check the PDMP before prescribing a Schedule II medication in any of the listed classes. Mandated checks on prescriptions for all four classes of drugs in Schedules III-V would follow a year later, Sept. 1, 2019.
House Bill 3040 by Rep. Cindy Burkett (R-Sunnyvale), the Texas Medical Board sunset bill, has been set for a hearing Tuesday in the House Committee on Public Health. The bill currently includes the mandated PDMP check for all controlled substances that are opioids, benzodiazepines, barbiturates, and carisoprodol. Senator Hinojosa is carrying the Senate's version of the TMB sunset legislation.
Progress on the Insurance Front
TMA-backed efforts to hold health plans accountable for surprise bills for out-of-network services earned a major boost in the past month, with one major bill earning approval from the full Senate and another key measure earning a hearing in the House Committee on Insurance. A TMA-supported measure to address insurance companies' potentially detrimental step therapy protocols also made it through one chamber.
On the surprise-medical-bill front, Senate Bill 507 by Sen. Kelly Hancock (R-North Richland Hills) passed the Senate 29-2 on March 28. SB 507 would keep the current $500 threshold for bill mediation, but expand the mediation process to all out-of-network physicians and providers at certain in-network facilities as well as certain in-network facilities where patients receive emergency care. Also, in early April, TMA testified in the House Committee on Insurance in support of House Bill 2760 by Rep. Greg Bonnen, MD (R-Friendswood). HB 2760 would hold insurance companies accountable by requiring them to update their practitioner directories every business day. The measure would also require the plans to remove a terminated physician from the directory within two days and would introduce health plan review requirements for the state's insurance department. Senator Hancock is sponsoring a similar measure, Senate Bill 2210.
The Senate also aligned with TMA and Senator Hancock on April 3 when it passed his Senate Bill 680. That measure would allow physicians to override insurers' step therapy protocols. It would also prohibit insurers from requiring patients to fail more than once on a prescription drug before trying the next step in their drug treatment plan.
Public Health Hope
Several of TMA's highest-priority public health measures have all made encouraging legislative movement. But tough battles remain for those initiatives: banning texting while driving, raising the tobacco age to 21, and parents' right to know about the number of vaccine exemptions in a public school.
A statewide ban on texting while driving earned the approval of the Texas House on March 16 when House Bill 62 by Rep. Tom Craddick (R-Midland) passed by a 114-32 vote. However, the ban proposal is expected to encounter stiff resistance in the Senate. HB 62's companion measure in that chamber, Senate Bill 31 by Sen. Judith Zaffirini (D-Laredo), made it out of the Senate Committee on State Affairs.
The push for parents' right to know their child's risk to contract a vaccine-preventable disease continued last week when House Bill 2249 by Representative Sheffield earned a hearing from Chair Four Price (R-Amarillo) in the House Committee on Public Health. HB 2249 would make de-identified campus-level immunization data, including exemption data, available to parents and the public. That data would give parents of students who can't be vaccinated ― such as immunocompromised children ― more detailed information than the district-level immunization stats the state currently publicizes. Although there was overwhelming testimony provided by physicians on the importance of vaccinations, there was also testimony and misinformation by parents and children on the other side about their right to choose and about all of the bullying they encounter.
The Public Health Committee also heard the Tobacco 21 measure, House Bill 1908 by Rep. John Zerwas, MD (R-Richmond), in late March. Houston neonatologist Charleta Guillory, MD, testified for TMA at the hearing in support of HB 1908. Dr. Guillory noted in written testimony that on average, 90 percent of adult smokers start smoking in their teen years, and 95 percent begin before age 21. Raising the age required to buy tobacco can significantly improve public health outcomes, she said. TMA is seeing opposition to HB 1908 from the tobacco industry.
Although last year's hysteria over the spread of the Zika virus is in the rearview mirror, much remains for medicine to learn about the mosquito-borne and sexually transmitted illness. That's why TMA is supporting House Bill 3576 by Rep. R.D. "Bobby" Guerra (D-Mission), which would bolster Texas' Zika surveillance system. The House Committee on Public Health heard testimony on HB 3576 last Tuesday, and TMA submitted testimony supporting the bill.
"HB 3576 will help us ensure Texas has a strong reporting system and ― when necessary ― we can contribute to and increase awareness of new and emerging infectious diseases," TMA said. "This is important since we now fully understand these diseases can be brought to Texas in mere hours."
TMA's final First Tuesdays at the Capitol for this session, scheduled for May 2, gives physicians one last chance to gather en masse and let lawmakers know what issues matter most to them. Register now!
Joey Berlin, associate editor of Texas Medicine, prepared this special supplement to Action.
Action, April 17, 2017