The Texas Medical Association will continue to fight federal lawmakers' attempts to cap funding for the state’s Medicaid recipients, as proposed in the American Health Care Act (AHCA), TMA's House of Delegates decided at TexMed 2017 last week.
At its annual meeting in Houston, the house unanimously adopted joint recommendations from the Council on Socioeconomics and Select Committee on Medicaid, CHIP, and the Uninsured to "vigorously advocate" against per-capita restrictions on Medicaid funding.
AHCA passed the U.S. House of Representatives on May 4. U.S. senators have cast doubt on whether they will take up the measure in its current form.
Under the U.S. House version, AHCA would institute a per-capita cap on Medicaid funding allotments, with an option for states to take a block grant instead. Medical organizations, including TMA, have expressed strong concerns about either option.
"Each session, [state] lawmakers squeeze Medicaid even further, establishing more and more unrealistic cost-containment goals," the joint report said. "There really are not additional realistic options to curtail costs under a capped-funding scheme except to reduce benefits, eligibility and payments." Federal block grants have generally resulted in funding decreases, according to a March 2016 study by the Center on Budget and Policy Priorities.
The measure was among dozens of recommendations and resolutions presented to the house by reference committees on socioeconomics, financial and organizational affairs, science and public health, and medical education.
Among the measures delegates adopted were directives for TMA to:
- Strongly advocate for maintaining mandated minimum services, benefits, and cost-sharing requirements for pregnant women and children;
- Work to build the state’s physician workforce to meet the state’s health care needs;
- Support a long-range study to bring funding for medical education, graduate medical education (GME), and other education and training programs in line with the state's workforce needs;
- Monitor maintenance of certification (MOC) reforms;
- Adopt a Disaster Preparedness Planning and Response policy and call for the Texas Department of State Health Services (DSHS) to work with physicians and develop a statewide framework for crisis standards of care; and
- Make recommendations on gender equality and sexual diversity issues, and adopt policy on fighting discrimination, studying best practices for care, and reducing suicide rates.
The majority of the recommendations and resolutions passed the house without any floor debate.
However, one topic that did generate discussion at the general session was a resolution from the Medical Student Section to advocate for increased Medicaid coverage of insect repellent to combat the Zika virus. The house ultimately voted to adopt the resolution, but Houston neurologist Steven Croft, MD, raised an objection over the cost of implementing such coverage.
"It's a waste of money. I'm sorry," Dr. Croft told the house.
But Austin obstetrician-gynecologist Kimberly Carter, MD, and Dallas epidemiologist John Carlo, MD, both expressed support for the resolution. Dr. Carter said increased repellent would prevent not only Zika, but also other mosquito-borne illnesses.
The reference committee's report recommending adoption of that resolution noted those in favor of the resolution had testified that the cost of treating Zika would "far outweigh the cost of providing insect repellent."
See all of the House of Delegates actions on the TMA website.
Keynote Speakers Stress Preparedness, Use of Technology
Crisis management — both physically and online – and preparing for the future were common themes among the keynote speakers at TexMed 2017.
Those who came to TMA's annual conference this year heard from experts in military strategy, active-shooter response, and social media — topics that are of growing importance to medicine.
"We absolutely need well-designated clinical research to guide best practices. But new evidence alone will not drive advances in trauma care," William H. McRaven, chancellor of The University of Texas System and a retired four-star Navy admiral, said in his remarks to the general session on May 5. "We need strong leaders and a concerted determination to keep getting better at caring for the injured to make these advances happen."
Mr. McRaven, who since 2015 has led one of the nation’s largest higher-education systems, spoke on the effectiveness of current military battlefield trauma care and how it can be used in civilian care.
"I have had a front-row seat to the bravery and courage of our great combat surgeons, our docs, our nurses, our medics, our corpsmen, and it has been absolutely spectacular. I’ve seen miracles," Mr. McRaven said.
He said changes in the medical training for all U.S. military members — a directive called Tactical Combat Casualty Care, or TC3 — has reduced preventable battlefield deaths substantially. TC3, Mr. McRaven said, stemmed from a study that determined that most combat deaths were caused by bleeding to death.
The most-effective solution, Mr. McRaven said, has been around for more than four centuries, but has only been put into widespread use on the battlefield in recent years.
"The use of extremity tourniquets has been the most-effective, lifesaving change in prehospital combat casualty care in 40 years since I joined the military, and maybe ever," he said.
TC3 also calls for delivering blood products to patients before they reach a medical facility and the use of a fentanyl lozenge that relieves pain without lowering blood pressure — saving lives of people who have gone into shock.
"The relevance of military solutions is apparent: If you want to save more lives in an attack, we need extremity tourniquets and hemostatic dressings. Imagine the lives saved when that skill becomes as widespread as CPR or the Heimlich maneuver."
Watch Mr. McRaven's full speech here.
Following Chancellor McRaven was New Hampshire physician Kevin Pho, MD, a social media guru also known as KevinMD.
Dr. Pho, who is founder and editor of the popular KevinMD.com blog, spoke of the value of embracing existing technology. By staying up-to-date and active on social media — including Facebook, Twitter, Instagram, and by blogging — physicians not only stay relevant to their patients but also can help drive conversations about medicine.
"In today's transparent era, where patients have as much access to information as their doctors do, we in health care have to redefine ourselves. We need to stop seeing ourselves as gatekeepers of medical and drug information," Dr. Pho said during the May 5 opening session. "If we're to stay relevant, we need to be curators of that information instead. We need to become filters for our patients and elevate wisdom on the web. And with social media, it gives us so many opportunities for us to be those filters and connect with patients."
Rounding out the TexMed 2017 General Session was Pete Blair, PhD — a professor of criminal justice and the executive director of the Advanced Law Enforcement Rapid Response Training Center at Texas State University. Dr. Blair is an expert in active shooter events.
Dr. Blair said on average about 17 active shooter events occur per year in the United States, and as with all disasters, people need to be prepared. In his May 6 speech, Dr. Blair cited research by journalist Amanda Ripley, who wrote the 2009 book The Unthinkable: Who Survives When Disaster Strikes — and Why. Ms. Ripley said people react to all disasters in three stages: denial, deliberation, and a decisive moment of action.
"What she found is that everybody goes through this process," Dr. Blair said. "But the people who survive tend to have thought about this particular disaster beforehand. They sat down and they thought, if this happens to me, what am I going to do? And they spent just a little bit of time preparing themselves. So when they were in the disaster they were able to respond more effectively with better options.”
Meet the Celebrities Who Attended TexMed
TexMed 2017 was a star-studded event, but the stars didn't come from the big screen, Capitol Hill, or even the Billboard Top 100. These were star physicians, medical advocates, and science teachers — all honored for their service, dedication, and outstanding commitment to the practice of medicine.
Throughout its annual meeting, TMA bestowed 30 awards and more than $180,500 to awardees.
The fanfare was boisterous as Robert Gunby Jr., MD, received the 2017 Distinguished Service Award, the highest physician honor awarded by TMA. As a Dallas obstetrician-gynecologist, Dr. Gunby’s storied career spans more than 40 years.
"Dr. Gunby is a man of integrity," former TMA Trustee Dan McCoy, MD, of Dallas, said as he presented the award. "Over the years, he honed his skills of diplomacy, compromise, and negotiations throughout his career. He was really able to refine what he needed to do, and he has accomplished so much, without comprising his principles or what he thought was best for the patients. As his wife says, 'Bob's quality control is set on high.' With everything, he does the very best job that he can."
TMA’s Young at Heart Award was presented to Joel Dunnington, MD, a retired radiologist who in 1987 not only established but also served on TMA's inaugural council of the Young Physician Section.
Cedric K. Dark, MD, an assistant professor of emergency medicine at Baylor College of Medicine, was awarded the C. Frank Webber, MD, Award for his work in fostering the next generation of physician-statesman by focusing on organized medicine through large-scale student engagement and individual mentoring.
The TMA Medical Student Section presented the 2017 Medical Student Section Student of the Year Award to Hayley Rogers, a second-year medical student at The University of Texas Medical Branch School of Medicine. Ms. Rogers has delivered programming on LGBTQ+ health care, and authored several diversity-related policies that were formally adopted by AMA.
Baylor College of Medicine TMA Chapter was bestowed with the 2017 Medical Student Section Chapter of the Year Award. The chapter experienced a surge of members and expanded its community outreach programs to include the collection of more than $20,000 worth of medical supplies for charity.
Mrs. Cheryl Jones is the 2017 recipient of TMA's June Bratcher Award for outstanding service as a pro-medicine grassroots activist. Mrs. Jones was instrumental in the successful campaigns of two candidates who won seats in the 85th Texas Legislature — Rep. Hugh Shine (R-Temple), and Sen. Dawn Buckingham, MD (R-Lakeway).
TMA awarded $120,000 in Minority Medical Student Scholarships to 12 students who will start medical school in Texas this fall. The program is funded by the TMA Foundation (TMAF) with majority support from a trust fund established by Dr. Roberto J. and Agniela (Annie) M. Bayardo The Bayardo Scholars are Dekoiya Burton of Houston, Alexander Cantu of Edinburg, Giselle Castillo of Mission, Sandrine Defeu of Katy, Giuiseppe (Allan) Fonseca of Webster, Lucia Guerrero of El Paso, Victor Hinojosa of Brownsville, Yajaira Jimenez of Brownsville, Tailour Roberson of Frisco, Artraeu Simms of Garland, Selvin Villeda of Royse City, and Adrienne Walker of Duncanville.
TMA also awarded 12 Texas science teachers with the 2017 Ernest and Sarah Butler Awards for Excellence in Science Teaching — which includes $60,500 in prize money. The top three winning teachers — Teresa Kelm, Terri Henry, and Monica Amyett — took the stage at TexMed on Saturday, while all 12 were honored at the state Capitol on Tuesday, May 9 in a House resolution authored by Rep. Ken King (R-Canadian). The program is supported by TMAF with majority support from an endowment established by Dr. and Mrs. Ernest C. Butler of Austin.
For more information about all of the awards and scholarships that TMA offers, or to submit an award nomination, visit the TMA website.
TMA Foundation Gala Sold Out at TexMed
More than 450 guests bid on space-related experiences, political memorabilia, jewelry, and more, while dancing until closing to the Matchmaker Band at the TMAF gala, BLAST OFF! on May 5 in Houston.
Thirty-four table sponsors and nearly 150 more gathered to raise money for initiatives funded by TMAF. These include Walk With a Doc Texas, Hard Hats for Little Heads, and dozens of local health improvement programs sponsored by county medical societies and alliance and medicals student chapters of TMA.
Top sponsors H-E-B, Pfizer Inc., the Texas Medical Liability Trust, the TMA Insurance Trust, UnitedHealthcare, UTMB Health/The University of Texas Medical Branch, TMA, and others ensured the event's success.
Donors contributed $14,150 to the Make-A- Difference drive held at the event to win a matching grant that will protect thousands of young Texans from serious or life-threatening head injury through TMA's Hard Hats program. This is the sixth year an anonymous donor couple offered a matching grant of $10,500. Combined with the matching grant, this means $24,650 will help provide free bike helmets, teach kids and families how to fit a helmet properly, and encourage safe physical activity.
Learn more about the work of TMAF and the programs it makes possible.
Save the Date! TexMed 2018
It’s not too early to begin planning for next year's TMA annual conference. Join us May 18-19, 2018, in San Antonio at the JW Marriott Resort and Spa, which is nestled in the Hill Country on the north side of the Alamo City.
Earlier this month, at the final First Tuesdays at the Capitol event of the 2017 legislative session, TMA lobbyist Darren Whitehurst told physicians he could see the light at the end of the tunnel, but that he'd have to wait until session was over to say "whether it's a train or not." Whether it turns out to be a train or a shining, promising new destination for Texas medicine, that mysterious light is now even closer as just two weeks remain until the session adjourns.
As the Budget Conference Committee continued to work through the differences between the House and Senate versions of the 2018-19 budget, TMA weighed in on those discussions with a detailed letter to conferees. Meanwhile, the House of Medicine is also weathering the flurry of bill activity, amendments, and would-be amendments that always accompanies the closing days of session.
For every incremental victory — such as recent wins on the surprise billing, telemedicine, and step therapy fronts — there's another fight to be waged elsewhere, such as medicine's intense pushback on a bill that would unduly prevent physicians from filing credit reports on patients who don't pay their bills.
Major Progress on Surprise Billing, Step Therapy, and Telemedicine
A victory for medicine's effort to help rein in surprise medical bills only needs Gov. Greg Abbott's signature to become reality. Senate Bill 507 by Sen. Kelly Hancock (R-North Richland Hills) passed the House on May 4 by a 133-12 margin. SB 507 would expand the billing mediation process to all physicians and providers who provide out-of-network services at certain in-network facilities and would also expand mediation to out-of-network emergency care situations. It would keep in place the $500 threshold for mediation that has helped patients resolve thousands of billing disputes. That bill is now headed to Gov. Greg Abbott's desk. Also on the surprise-billing front, House Bill 477 by Rep. Nicole Collier (D-Fort Worth) earned approval from its parent chamber the same week by an 81-63 vote. That TMA-backed measure would require health plans to provide educational materials to policyholders about what's covered in their policies, as well as information relating to their copays, deductibles, coinsurance, and out-of-pocket maximums.
The battle to end years of legal wrangling over telemedicine care in Texas took another big step forward Thursday after the House unanimously signed off on TMA's priority bill to establish a framework for telemedicine care in Texas. Senate Bill 1107 by Sen. Charles Schwertner, MD (R-Georgetown), establishes a clear statutory definition of telemedicine and clarifies that telemedicine must adhere to the same standard of care as an in-person medical visit. Led by Rep. Four Price (R-Amarillo), the House included language that makes it clearer that telemedicine is a tool, and not a distinct service, and further limits a health plan's ability to exclude telemedicine from coverage just because it isn't provided in person. TMA negotiated with the Texas Academy of Family Physicians and the Texas e-Health Alliance to craft SB 1107. The Senate must either accept the House's committee substitute of the bill before it can proceed to the governor's desk or resolve the differences in conference.
May 9 brought another major incremental victory for medicine as Senate Bill 680 by Senator Hancock won approval in the House. SB 680 would allow physicians to continue prescribing an effective medication even if a health plan's step therapy protocols call for a change in medication. It also would expedite the step therapy override process from 52 days to three days. The House made some changes to the version that passed the Senate last month. It now only needs agreement between the two chambers before it can head to Governor Abbott. The House also OK'd a measure that would help medicine collaborate on care on May 6 when it passed TMA-supported House Bill 3124 by Rep. Lance Gooden (R-Terrell). HB 3124 would allow physicians in doctor-led accountable care organizations to receive and share physician-specific comparison data and information.
On the maintenance of certification (MOC) front, TMA is hoping Senate Bill 1148 by Sen. Dawn Buckingham, MD (R-Lakeway), will soon make similar progress. SB 1148 would prohibit hospitals and health plans from discriminating against physicians based solely on MOC and would also bar the Texas Medical Board (TMB) from requiring MOC for licensure or license renewal. Rep. Greg Bonnen, MD (R-Friendswood) is sponsoring the bill, which was heard in the House Public Health Committee on May 9. A substitute for the bill is expected to move forward soon.
TMA is also tackling the corporate practice of medicine with its support of Senate Bill 833 by Sen. Bryan Hughes (R-Mineola), which provides protections for physicians who report that their corporate employer is interfering in the practice of medicine. Currently, TMB collects information on these nonprofit health corporations but does not investigate allegations of corporate interference. The legislation is sponsored by Rep. Morgan Meyer (R-Dallas).
Physicians Help Kill Terrible Disclosure-Form Bill
Physicians answered the call from TMA to stop a highly troublesome piece of legislation, and their advocacy paid off. House members, spearheaded by physician-legislators, led a successful charge to defeat House Bill 4011 by Rep. Dustin Burrows (R-Lubbock), a measure that would have made it much tougher for physicians to get paid for the care they provide. At TMA's urging, about 700 physicians used TMA's Grassroots Action Center to contact their representatives about HB 4011. Under the bill, before providing nonemergency medical services, physicians would have been required to receive a signed disclosure form from a commercially insured patient that itemized the amounts to be billed for each of those services. Failing to obtain the signed form would prohibit a doctor from ever providing information to a consumer reporting agency about the patient's outstanding medical debt. If HB 4011 had become law, health care would have been the only industry subject to such extreme antibusiness requirements. The House defeated the bill Wednesday by a 94-37 vote. Senate Bill 2127 by Sen. Larry Taylor (R-Friendswood), which TMA analysts describe as even worse than HB 4011, is scheduled for a hearing this week in the House Business and Industry Committee.
TMA: Preserve Key Funding
The monetary gap between the House and Senate versions of the state budget isn't overly large — a separation of about $400 million in all funds and $2 billion in general revenue. But both plans feature provisions concerning to medicine. So TMA highlighted "medicine's recommendations for crafting a biennial budget that will promote a healthier Texas" in a letter last week to conference committee members, cowritten with the Texas Pediatric Society, Texas Academy of Family Physicians, and several other Texas physician organizations.
The letter listed the organizations' preferred overarching budget priorities for the legislature:
- Ensure the long-term viability of Texas Medicaid by promoting community-oriented, value-based initiatives while implementing sensible reforms to restrain costs;
- Invest in Texas' public health system to maintain the state's ability to detect disease outbreaks early and to better manage costly chronic diseases, such as asthma and diabetes;
- Enhance initiatives to promote early intervention and treatment of behavioral health disorders, and increase local and state mental health inpatient hospital capacity;
- Sustain preventive health and wellness programs for low-income women and boost outreach to enroll eligible women into these cost-effective programs;
- Promote a robust physician workforce to meet Texas' diverse and growing population; and
- Devote needed resources to ensure children with developmental delays receive timely early childhood intervention services.
The letter vigorously opposed the Senate's proposed $410 million general-revenue reduction to Medicaid, as well as the House's $450 million general revenue cut from Health and Human Services Commission contracts, which would heavily affect Medicaid managed care and, hence, physician fees. Among other requests, it also urged strengthening of the state's public health defense and mental health systems.
"We urge you to use all available means, including Rainy Day funds, to avert cuts that could limit our ability to care for our patients," the letter said.
In its letter to budget conferees, TMA stressed the need to preserve investments in graduate medical education (GME) to expand GME capacity, making it more likely Texas medical students will become Texas physicians. But the budget talks aren't the only place where TMA is hoping to improve GME funding and residency training. Senate Bill 1505 by Sen. Juan "Chuy" Hinojosa (D-McAllen) would create a new source of revenue for the GME permanent fund, drawing from taxes paid on the purchases of "little cigars." And medicine was supporting House Bill 2996 by Rep. Trent Ashby (R-Lufkin), which would establish a new small grant program for rural residency training, and House Bill 2478 by Rep. Sarah Davis (R-Houston), which would establish a new state physician workforce pipeline to increase residency development in psychiatry. However, those two bills didn't survive Thursday's midnight deadline for the House to give initial approval to bills that originated there, spelling the end of the line for the measures unless alternative vehicles for the bills are identified.
Deadline Brings Mixed Public Health Results
In addition to its battle to preserve public health funding in the state budget, TMA maintained its push for its foremost public health priorities — in some cases, in the face of staunch opposition. Unfortunately, some of TMA's priority measures didn't survive last week's House deadlines:
- House bill 3711 by Rep. J.D. Sheffield, DO (R-Gatesville), would require long-term care facilities to make rapid flu testing available to residents and would facilitate statewide collaboration to address multidrug-resistant organisms.
- Representative Sheffield's House Bill 2249 would require the state to disclose vaccination exemption-rate data at the school campus level, rather than just the school district level. The antivaccination community was opposing that bill.
- House bill 1908 by Rep. John Zerwas, MD (R-Richmond), which would make 21 the legal age to buy and sell tobacco products, fell to the pro-tobacco forces and died in last week's logjam.
Meanwhile, a TMA-opposed measure that would mandate preparticipation electrocardiograms (ECGs) and echocardiograms for all school student-athletes also died after Thursday's House deadline passed. House Bill 3476 by Rep. Dan Huberty (R-Houston) would require ECGs, but physicians say the test isn't necessary for every student-athlete, and false positives can ultimately harm students.
Support for Technology-Driven PDMP Measure
The prescription drug monitoring program (PDMP) mandate fight is still on. After the Sunset Advisory Commission recommended a sweeping mandate for physicians to check the PDMP before issuing prescriptions for any controlled substances, TMA went to work to prevent such burdensome requirements, instead proposing more reasonable solutions to combat drug diversion and doctor-shopping. Many of those technology-based solutions are part of Senate Bill 316 by Senator Hinojosa, which was awaiting a hearing before the House Public Health Committee at press time.
TMA's suggestions included in SB 316 include giving the Texas State Board of Pharmacy, which administers the PDMP, explicit authority to issue notifications to physicians and pharmacies when evidence of drug diversion or doctor-shopping emerges. It also would require prescriber licensing boards to monitor the PDMP to identify potentially harmful prescribing and dispensing patterns. SB 316 also limits the mandate to four drug classes: opioids, benzodiazepines, barbiturates, and carisoprodol. Under the current version of the bill, thanks to TMA's advocacy, the mandate would be delayed until Sept. 1, 2019, giving stakeholders valuable time to further study how the PDMP technology can help battle illicit obtainment of prescription drugs. The current version also applies to all prescribers and dispensers in the state — from physicians to dentists to pharmacists to veterinarians. TMA is prepared to support SB 316 when the committee finally takes up the measure.
Joey Berlin, associate editor of Texas Medicine, prepared this special supplement to Action.
Removing patients' Social Security numbers from their Medicare ID cards is needed to protect their privacy, TMA and other medical societies say, but the way it's being handled will cause unnecessary confusion and delays in care.
In a letter to the Centers for Medicare & Medicaid Services (CMS), TMA, the American Medical Association, and other organizations also complained that CMS is implementing the change without valuable feedback from physicians and providers.
The Social Security Number Removal Initiative (SSNRI) is part of the Medicare Access and CHIP Reauthorization Act (MACRA) and requires CMS to remove the Social Security number from Medicare cards out of concerns over identity theft.
"In an age of increased identity theft and fraud, the Medicare patient population deserves the improved security that will be achieved with the SSNRI," the letter said. "This protection should not, however, come at the expense of prompt patient care or provider payment."
Currently, Medicare patients are identified by a health insurance claim number (HICN) that is based on their Social Security number. Under the SSNRI, that number will be replaced by Medicare beneficiary identifiers (MBIs). New identification cards will be sent out in phases over 12 months beginning in April 2018, with outreach and education beginning in January.
Although CMS will accept both HICNs and MBIs during the transition period — from April 1, 2018, to Dec. 31, 2019 — physicians' and providers' systems must be ready to accept the MBI by April 2018 and must use the MBI exclusively starting Jan. 1, 2020.
"We are concerned about a provider’s inability to access a patient's MBI both during and following the transition," the letter says. "If a patient does not bring his or her MBI to his or her appointment [after Jan. 1, 2020], significant delays in patient care or provider reimbursement could result due to the lack of a mechanism for the provider to look-up the patient’s MBI."
The organizations are calling for a contingency system that will allow medical practices to obtain the MBI of a patient who arrives at an appointment without a card. The providers have offered a range of possible solutions, including look-up databases, providing MBIs in electronic eligibility responses, and secure phone systems.
The organizations also have taken issue with being left out of discussions on implementing the change, which CMS has characterized as being "operational in nature," according to the letter.
"We respectfully note that this change will impact all Medicare beneficiaries and that all systems and business processes will need to be able to accept and process the new MBI," the organizations said. "We therefore urge CMS to work with stakeholders to avoid significant problems and again recommend that CMS instead pursue this change through the traditional notice and comment rulemaking process."