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.
The Texas Department of State Health Services (DSHS) has expanded its Zika testing criteria for residents of the Lower Rio Grande Valley in an effort to quickly identify and respond to new infections of the mosquito-borne virus.
In a health alert issued April 3, DSHS recommended testing for all residents of Cameron, Hidalgo, Starr, Webb, Willacy, and Zapata counties who have a rash plus at least one other common Zika symptom: fever, joint pain, or conjunctivitis. DSHS continues to recommend that all pregnant women in those counties be tested during the first and second trimester.
For all other parts of the state, DSHS and the Centers for Disease Control and Prevention guidelines recommend testing for any pregnant woman at possible risk of Zika exposure or for anyone who exhibits three of the four common Zika symptoms and has traveled to an affected area.
More infections are possible this year because of a mild winter that prevented a break in the mosquito season throughout the southernmost areas of the Rio Grande Valley, state health officials said.
"Zika remains a significant health risk to pregnant women and their babies, and it's only a matter of time until we see local transmission here again," DSHS Commissioner John Hellerstedt, MD, said in a news release that accompanied the alert. "We want to cast as wide a net as possible with testing to increase our ability to find and respond to cases, and the Lower Rio Grande Valley remains the part of the state most at risk for Zika transmission."
To ensure that all cases are identified, DSHS said, the ability to pay should not stop people from getting tested, particularly pregnant women.
"Testing is available through public health labs for individuals who have no payor source or for whom there is a financial barrier to testing," DSHS said. "If the individual is not covered by private insurance or a third-party payor, testing may be obtained through a DSHS laboratory."
For more information about Zika and other infectious diseases in Texas, see the TMA website.
Beginning around May 1, Texas Medicaid and CHIP once again will make mosquito repellent a covered benefit for certain patients to help combat the Zika virus.
The Texas Health and Human Services Commission (HHSC) will offer the mosquito repellent benefit for Zika prevention in 2017 for pregnant women, females aged 10-55, and males aged 14 and older. Compared with last year, the 2017 benefit adds males, at TMA's request, and also increases the age for covered females from 45 to 55. The benefit will be available to eligible individuals through the Medicaid, Medicaid managed care, CHIP, CHIP-Perinatal, Children with Special Health Care Needs (CSHCN), Healthy Texas Women (HTW), and Family Planning programs.
Agency officials say:
- The benefit will end on Dec. 31, 2017.
- Individuals can receive one can per prescription fill with up to two cans per month.
- The standing order, which was in place for last year's benefit, will be available again for the 2017 benefit. The standing order is only available for eligible clients in Medicaid, CHIP, and HTW. The standing order allows pharmacies to fill prescriptions for repellent without contacting the client's physician or other health care provider. Patients can go directly to the pharmacy and present their YourTexasBenefits card to obtain the repellent.
- Family Planning program clients can obtain the repellent directly from their clinics.
- Only CSHCN clients will need a prescription from their physician or provider to obtain the benefit.
HHSC also released new guidelines for billing for Zika testing. (See "State Calls for More Zika Testing in South Texas" for the latest testing recommendations.)
States are waiting for the Centers for Medicare & Medicaid Services (CMS) to issue a specific Zika testing code. Until then, Texas Medicaid will continue to cover three general lab procedure codes that may be appropriate to use when submitting claims for Zika testing: 87798, 87799, and 86790.
A Zika specific modifier is currently in development. The agency will issue instructions to attach the new modifier to one of the recommended codes so that those procedures can be tracked as Zika tests. Medicaid will not require prior authorization for Zika testing. There is no Medicaid rate specific to Zika testing; payments will be made at the rates associated with the codes shown above.
On Wednesday, April 12, TMA conducted its second Tele-Town Hall Meeting on Zika. About 450 Texas physicians joined John Hellerstedt, MD, the Department of State Health Services (DSHS) executive commissioner; David Lakey, MD, former DSHS commissioner and current chair of the TMA Council on Science and Public Health; and other experts in the hour-long call.
Topics included an update on the state's Zika preparedness planning, a briefing on reported Texas Zika cases, and the latest on Zika testing.
If you missed the event or want to review the material covered, check out the recording on TMA's Infectious Disease Resource page.