Action: Aug. 1, 2017

TMA Action Aug. 1, 2017   News and Insights from Texas Medical Association

Legislature Returns to Renew Medical Board
Zika Update: Testing Finds Texas Case; CDC Guidance Updated
Increase in Cyclospora Cases Prompts Call for Quick Testing, Reporting
Medical Societies to UnitedHealthcare: Rethink Consultation Payment Change
Cigna Changes Opioid Coverage Policy; Announcement Raises Questions
TMF Can Help You Navigate MIPS Improvement Activities
Get Hip to HIPAA Rules With Training From HHS, TMA

AMPAC Program Takes the Pain Out of Running a Campaign
Be Aware of Sodium Cyanide Capsules Used on Texas Ranches
Give Helmets During Hard Hats Month in October
Need Some Public Health Cash? Deadline Approaching!
Register for TMA’s Fall Conference
This Month in Texas Medicine

Legislature Returns to Renew Medical Board

The 85th Texas Legislature returned to Austin July 18 for its first called special session. Senate and House members, led by Lt. Gov. Dan Patrick and Speaker Joe Straus, have 30 days to address the 20 topics identified by Gov. Greg Abbott starting with the Texas Medical Board (TMB) sunset bill and other sunset legislation.

Without legislative action, TMB will begin a wind-down period beginning Sept. 1, and the Medical Practice Act will vanish on that date. During the regular session that ended May 29, lawmakers could not come to an agreement on the reauthorization of TMB and four other professional licensing boards. That stalemate forced the special session.

The Senate's TMB sunset bills — Senate Bill 20 and Senate Bill 60 by Sen. Van Taylor (R-Plano) — have both been received by the House and await committee referral. SB 60 is needed to finance the agency for the 2018–19 budget period. SB 20 extends the life of TMB and the Medical Practice Act through Sept. 1, 2019.

The House's TMB sunset bill — House Bill 1 by Rep. Larry Gonzales (R-Round Rock) — won final approval on the House floor July 25 with no opposition. The House version of the TMB funding bill — House Bill 2, also carried by Representative Gonzales — passed the lower chamber on July 28. Both have been received by the Senate, where they await referral to committee.

Either House Bill 1 or Senate Bill 20 now needs to pass the other chamber for TMB to be reauthorized.

TMA reached out to all 31 senators and 150 representatives urging them to act swiftly in renewing TMB and the Medical Practice Act.

"Preventing the Sunset of the TMB and the Medical Practice Act are critical to Texas, to its physicians, to our patients, and to the state's economic stability," TMA President Carlos J. Cardenas, MD, wrote to the lawmakers. "The ramifications of inaction are, to a certain degree, unknown — and they raise unanswered questions that should give you pause:

  • Are medical licenses still valid with no Medical Practice Act?
  • Can anyone practice medicine? Or can no one?
  • Can physicians perform medical procedures and give medical orders for lifesaving patient care?
  • Can prescriptions be written or filled?
  • Can physicians who practice unsafe medicine be sanctioned or stopped?
  • Can Texas medical schools continue to teach our next generation of physicians?”

TMA has long advocated for a strong but fair medical board. The agency has already undergone the complete sunset review. Several of the Sunset Advisory Commission's key recommendations were addressed by legislation that passed during the regular session. TMB can accomplish most of the others administratively.

"Those remaining issues that require statutory changes can and should wait until the 2019 regular session," Dr. Cardenas wrote.

Lawmakers Turn to Other Issues 

Governor Abbott opened the agenda for the special session to 19 additional items after the Senate passed the sunset bills. The issues specifically of interest to medicine include:

  • Legislation prohibiting financial transactions between a governmental entity and an abortion provider or affiliate of the abortion provider.
  • Legislation restricting health plan and health benefit plan coverage for abortions.
  • Legislation strengthening the laws applicable to the reporting of abortions and abortion complications to the state.
  • Legislation enhancing patient protections contained in the procedures and requirements for do-not-resuscitate (DNR) orders.
  • Legislation continuing the operation and expanding the duties of the Maternal Mortality and Morbidity Task Force to ensure action is taken to reduce the maternal mortality rate in Texas.

Bill author Sen. Charles Perry (R-Lubbock) praised TMA's thoughtful contributions to Senate Bill 11 regarding DNR orders. But the bill passed out of the Senate on July 26 with no amendments to clarify that complying with the legislation would result in protections similar to what exists in all the other advance directives provisions, as TMA pointed out in a letter to the senator. The bill has been received by the House where it awaits committee referral. The bill's House companion, House Bill 12 by Rep. Greg Bonnen, MD (R-Friendswood), is scheduled for a hearing in the House State Affairs Committee on Aug. 1.

Debate around the Maternal Mortality and Morbidity Task Force has been uncontroversial so far, and the expectation is the task force's expiration date will be extended. Senate Bill 17 by Sen. Lois Kolkhorst (R-Brenham) passed the Senate on July 25 and has been received by the House, where it, too, awaits committee referral. Its companion bill, House Bill 9 by Rep. Cindy Burkett (R-Sunnyvale) received preliminary approval on the House floor July 31.

Financing raises for schoolteachers as proposed in Senate Bill 19 has become somewhat contentious because the Senate version of the funding is expected to come from a temporary diversion of funds designated for Medicaid managed care organizations. TMA sent a letter to Sen. Jane Nelson (R-Flower Mound), chair of the Senate Finance Committee, expressing concerns about that diversion. Senator Nelson has promised the "loan" will be repaid. Senate Bill 19 passed the Senate on July 26 and has been received by the House, where it awaits committee referral.

TMA submitted testimony on House Bill 215 by Rep. Jim Murphy (R-Houston) regarding additional reporting requirements for abortions. While neutral on the bill, TMA sought to reinforce that in an emergency, the physician's focus must be on saving the patient. HB 215 was reported favorably from the House State Affairs Committee on July 27 and awaits scheduling to be heard on the House floor. Its Senate companion, Senate Bill 72 by Sen. Bryan Hughes (R-Mineola), passed the Senate July 25 and, you guessed it, is awaiting committee referral in the House.

Subscribe to TMA's Legislative News Hotline to stay up to date on TMB sunset and the other health care issues the governor is asking lawmakers to consider in the 30-day special session. 

Zika Update: Testing Finds Texas Case; CDC Guidance Updated

Remember back in April when the Texas Department of State Health Services (DSHS) recommended expanding testing of pregnant women and people with Zika symptoms in six South Texas counties?

Well, guess what? Those tests helped health officials determine that a Hidalgo County resident, whose identity officials have not released, who previously had a Zika infection was most likely infected in Texas. 

If true, it would be the first known instance of mosquito transmission in the continental United States this year, officials say.

"Because the individual has not traveled outside the area or had any other risk factors, the infection was probably transmitted by a mosquito bite in South Texas sometime in the last few months," DSHS said in a statement. "Laboratory testing shows the individual is no longer at risk of spreading the virus to mosquitoes."

Thousands of Zika tests have been performed since the expansion in April, officials say. Although there is no evidence of ongoing Zika transmission in the state at this time, officials will continue to monitor both humans and mosquitoes, and they're encouraging you to remain vigilant as well, particularly if a patient has a rash combined with fever, joint pain, and eye redness.

In the meantime, the Centers for Disease Control and Prevention has updated its nationwide interim guidance for health care providers who care for pregnant women with possible Zika virus exposure.

The updated guidance is in response to "declining prevalence of Zika virus disease in the … Americas" and "emerging evidence indicating prolonged detection of Zika virus immunoglobulin M (IgM) antibodies."

"As the prevalence of Zika virus disease declines, the likelihood of false-positive test results increases," the CDC said.

Key recommendations include: 

  1. All pregnant women in the United States and its territories should be asked about possible Zika virus exposure before and after the current pregnancy, at every prenatal care visit.
  2. Pregnant women with recent possible Zika virus exposure and symptoms should be tested to diagnose the cause.
  3. Asymptomatic pregnant women with ongoing possible exposure should be offered Zika virus nucleic acid testing (NAT) three times during pregnancy.
  4. Asymptomatic pregnant women who have recent possible exposure but without ongoing possible exposure are not routinely recommended to have testing.
  5. Pregnant women who have recent possible Zika virus exposure and who have a fetus with prenatal ultrasound findings consistent with congenital Zika virus syndrome should receive testing to help establish the etiology of the birth defects. Testing should include both NAT and IgM tests.
  6. Zika virus IgM testing as part of preconception counseling to establish baseline IgM results for nonpregnant women with ongoing possible Zika virus exposure is not warranted.

These guidelines and more can be found on the CDC's website. And, as always, check out TMA's infectious resources online

Increase in Cyclospora Cases Prompts Call for Quick Testing, Reporting

Things move quickly sometimes, particularly when it comes to parasites.

And when they do, as a physician you are sometimes asked to move with haste, too.

So it's best to get moving because at least 100 cases of Cyclospora infection have been reported to the Texas Department of State Health Services (DSHS) this year, including a spike of 68 cases during June and July. However, no common exposure source has been identified.

The cases have been spread out across the state, with the largest concentrations in urban counties, DSHS information shows.


So to better identify possible common exposures, DSHS is telling physicians to test patients who show symptoms and to report cases to their local health department quickly.

Testing shouldn't be an issue because symptoms include "profuse diarrhea [that] can last weeks to months and may relapse," according to the advisory. "Additional symptoms may include anorexia, fatigue, weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting, and low-grade fever."

"Diagnosis of cyclosporiasis requires submission of stool specimens for 'Ova and Parasite' testing with additional specific orders for Cylclospora identification or testing by molecular methods (e.g., polymerase chain reaction [PCR], or a gastrointestinal [GI] pathogen panel test) that include detection of Cyclospora," according to a health advisory. "A single negative stool specimen does not exclude the diagnosis; three specimens are optimal."

If you're looking for more information about Cyclospora infection, check out the Centers for Disease Control and Prevention's website.

Medical Societies to UnitedHealthcare: Rethink Consultation Payment Change

TMA never stops working for you. Because you work hard to keep Texans healthy. It's the least we can do for you.

So when UnitedHealthcare (UHC) announced in June that it will no longer pay for consultation codes, TMA joined more than 35 other medical and specialty societies to push back. The change will be effective Oct. 1, UHC says.

In a letter to Niel Patel, MD, medical director of reimbursement policy for UHC, the societies said the policy "will only create another barrier" to physicians' ability to care for patients, in light of "widespread changes afoot for the United States health care system."

The letter requests that UHC reconsider or delay the policy to give physicians time to learn to code properly under the new policy.

The societies' concerns centered around several major themes, including: 

  • Coordination of care: "It is important that UHC continue to recognize the additional work that goes into providing a consultation and coordinating care amongst other treating physicians."
  • Education, particularly for physicians who do not bill Medicare and are unaccustomed to the "crosswalk" between codes: "We hope that if UHC moves forward with this policy change that it will provide its network providers with the education necessary to properly code claims in order to avoid payment disruptions."
  • Payment, specifically UHC's claim that changes to evaluation and management (E&M) codes will make for a "budget neutral experience": "If UHC does not pay for E&M codes at an amount comparable to consultation codes, it will result in a financial burden to practices that provide consultations."
  • Coding abuse data, which UHC said was part of the reason for the change: "If abuse was occurring, we believe that UHC should address it with the physician(s) involved and not implement a broad policy that penalizes physicians who bill and document these codes correctly."
  • Confusing payer policies: "UHC is the only commercial payer that we know of that will no longer pay for consultation codes; it will be very difficult for practices to implement coding practices that are different for only one commercial payer; not to mention the time and attention necessary to review and implement coding crosswalks between the consultation and E&M codes to avoid payment delays and denials."
  • Future audits: "We ask that UHC provide guidance and assurance that specialists will not suddenly see an increase in audits due to a change in their billing practices." 

So we're working for you. As always, stay tuned to Action for updates. 

Action TMLT Ad 10.15

Cigna Changes Opioid Coverage Policy; Announcement Raises Questions

Here's something you might not have seen: Cigna has changed its formulary and processes for short- and long-acting opioids to focus primarily on new prescriptions.

The insurance company claims it announced the change, which took effect July, in letters to physicians and providers and enrollees in March and June.

The changes are part of a "coordinated, comprehensive response" to the growing opioid-use crisis in the United States, Cigna said in a letter dated June 2.

"These change are based on the Centers for Disease Control and Prevention (CDC) opioid recommendations," the letter says. "The intent is to promote the use of alternative treatment options, when clinically appropriate, to minimize first-time exposures to these highly addictive drugs. Specifically: 

  • Prior authorization of coverage will be applied to prescription claims for customers new to therapy on long-acting opioids. With the potential for dependence, these changes help ensure dose, duration, and intent of the prescription are clinically appropriate.
  • Quantity limits will be applied to prescription claims for customers new to therapy on short acting opioids.
  • Additional drugs that will have quantity limits applied are: 
    • High dose prescriptions (per FDA [U.S. Food and Drug Administration] drug safety dosing recommendations)
    • Cough agents with codeine (per FDA drug safety dosing recommendations)."  

Some customers will be excluded from the changes, including patients with cancer, sickle cell disease, and those in hospice, Cigna said. 

If you wish to read Cigna’s full opioid therapy policy, you can find it on Cigna's website

Now, it's no surprise that a health plan is implementing such changes in light of the current opioid-use crisis. But a few aspects of the announcement beg some questions, including concerns that a "focus primarily on new prescriptions" could indicate that established prescriptions would also require prior authorization. The lack of a timely notification is also concerning. 

Check future editions of Action for updates.

TMF Can Help You Navigate MIPS Improvement Activities

New and improved. You hear that term all the time. But new isn't always an improvement, and just because something's been improved doesn't mean it's new.

However, if you're a Merit-Based Incentive Payment System (MIPS)-eligible physician, a new reporting category can improve your chance of avoiding a payment penalty in 2019.

Now that's an improvement! An Improvement Activities category, to be exact.

So what is it?

Well, Improvement Activities is one of four performance categories within MIPS, a payment path under the new Quality Payment Program (QPP) that was created by the Medicare Access and CHIP Reauthorization Act (MACRA). 

Because the category is new it's generating a lot of questions.

Well, lucky for you the TMF Health Quality Institute and TMA have plenty of answers.

So let's begin. 

First of all, you know what an Improvement Activity is, correct? It's basically any activity that improves clinical practice, such as annual registration in the Prescription Drug Monitoring Program, engaging patients and families to help improve the system of care, implementing fall screening and assessment programs, and improving practices that engage patients before they visit. 

So now that we're on the same page, if you're MIPS eligible (you can find out here), you will need to attest to having completed as few as one improvement activity — and possibly up to four — for at least 90 days for the 2017 MACRA transition year. If you do not, you'll receive a 4-percent cut in Medicare payments in 2019. Ouch.

Your practice model, size, and location, as well as which MIPS participation option you've chosen, will determine whether you have to report just one activity or four. 

If you're just doing the bare minimum, or test option, for 2017, you only have to report one activity that was completed for at least 90 days to avoid a penalty in 2019. If you're shooting for a bonus payment and reporting for 90 days or the full year, the requirement is up to four activities to get full credit for either option. 

Visit CMS's QPP website to review the list of 92 improvement activities and find out how many activities your practice has to complete.  

If this still doesn't make sense, you're not alone. You're also in luck because TMF's Quality Innovation Network Quality Improvement Organization (QIN-QIO) is available for support. And — get this — just working with TMF's QIN-QIO actually counts for several activities under the Improvement Activities category. That's a win-win!

TMF has a whole bunch of QPP fact sheets to help you select the Improvement Activities that are right for your practice. You can find them here, along with other helpful resources.

You can also check out TMA’s MACRA Resource Center, which is just jam-packed with information.

Get Hip to HIPAA Rules With Training From HHS, TMA

What can I say about HIPAA rules?

Quite a lot, actually. 

You can, too. You just have to know what you can say.

And that's what makes HIPAA rules so tricky: Because practices of all types and sizes must comply with them, the rules are flexible and scalable. But that means there isn't a single standardized program that can properly train employees of all entities.  

So how are you, or your employees, supposed to know exactly what the rules require?

Well, let me steer you to the U.S. Department of Health and Human Services' (HHS') free continuing medical education on HIPAA.

See, the department's website has links to plenty of training opportunities, including: 

And you just know TMA has everything you need to stay HIPAA compliant, including links to white papers and fact sheets, HIPAA compliance consulting services, education courses, and more. 

You can check out all of TMA's HIPAA resources at our website or by calling the TMA Knowledge Center at (800) 880-7955. 

 TMAIT Action Ad 6.15

AMPAC Program Takes the Pain Out of Running a Campaign

You got that ambition. We can tell.

You've been practicing for a while and have been active in your specialty, your professional societies (including TMA, thank-you very much), and your community. You're now thinking, "I'd like to be more involved in politics. I’ve got ideas that will make the world a better place."

That's great. But — there's always one, isn't there? — your knowledge of campaigning is limited to kissing babies and making lapel buttons. That's just not enough these days.

Well, good news is coming at the end of this sentence: Registration for the American Medical Association Political Action Committee's (AMPAC's) Campaign School is now open.

That's right, my future rising political star, AMPAC has developed a comprehensive program that will mold you into a winning political strategist and will help you elect friends of medicine — maybe even a great friend like you.

Recognized as one of the top programs in the country, the Campaign School "is renowned for its use of a simulated campaign for the U.S. House of Representatives, complete with demographics, voting statistics, and candidate biographies," AMPAC said on its website. "Participants are broken into campaign 'staff' teams, and apply what they learn in real life exercises in strategy, vote targeting, social media, paid advertising and public speaking. Insider tactics are taught by experts from both sides of the political spectrum."

Physicians, residents, and medical students interested in politics are all welcome to attend. In fact, campaigning can be way more than a full-time job, so spouses are encouraged to sign up, too.

So go ahead and sign up online. Or call (202) 789-7455. Or email politicaleducation[at]ama-assn[dot]org. How you get in touch is up to you.

Good luck!

Be Aware of Sodium Cyanide Capsules Used on Texas Ranches

Here's your annual announcement that the Texas Wildlife Services Program (TWSP) uses sodium cyanide capsules in a spring-loaded device — called the M-44 — to control animals that might eat cows and sheep.

Wait. Say what?

That's right. The Texas A&M AgriLife Extension sent out an announcement last month informing the medical community that these capsules "may, at times, be used on ranches in your area to control predation of livestock and spread of disease caused by certain wild animals."

"Although human exposure to the chemical during proper authorized use may be unlikely, the TWSP is required to notify various medical facilities that M-44 sodium cyanide capsules may be used locally," the announcement said. "This is an annual notification."

So although it's unlikely that you'll have to treat a person exposed to one of these capsules, the AgriLife Extension must make you aware that it's a possibility.

The announcement includes details on how to treat a patient exposed to sodium cyanide. You could also call the Texas Poison Center Network Helpline at (800) 222-1222.

Give Helmets During Hard Hats Month in October

A lot of scary things happen in October: Halloween, the World Series (if your team's losing), and stock market crashes.

You know what else is scary? Children riding bicycles without helmets. Frightening.

But, you can help reduce the risk by hosting a Hard Hats for Little Heads bike helmet giveaway in October.

Why in October? Well, that's TMA's annual Hard Hats for Little Heads month (but you can host events anytime of the year). A helmet giveaway is a great opportunity for you to urge kids in your community to "Get moving. Stay safe. Wear a helmet." You can also help TMA get closer to covering all of Texas' 254 counties.

Physicians, medical students, county medical societies, and TMA Alliance chapters can host events. TMA has a lot of great ideas for events, including pairing with a local fall festival or National Night Out event. 

And don't worry about a thing. TMA provides everything you need for a successful event — free helmets, banners, event signage, promotional flyers, educational handouts, and media relations support. We even provide some extra publicity by announcing all events around the state.

Free helmets? That's right. When you buy up to 50 helmets, TMA will match your purchase with free helmets. Helmets are $7.60 each, including shipping. Be sure to order your helmets and other supplies at least a month in advance.

Additionally, the Texas Academy of Family Physicians and the Texas Pediatric Society, Texas Chapter of the American Academy of Pediatrics, will cover the cost of up to 25 helmets for their members, and TMA matches that. So family physicians and pediatricians can get up to 50 helmets at no cost. And you can buy more helmets at TMA's low price.

So help make the world a less-frightening place. Request an order packet by emailing Tammy Wishard, TMA's outreach coordinator, or calling (800) 880-1300, ext. 1470, or (512) 370-1470. 

Hard Hats for Little Heads is supported in 2017 through a TMA Foundation grant thanks to top donors — Blue Cross and Blue Shield of Texas, an anonymous physician and spouse, TMAF Make-A-Difference donors, and the Baptist Health Foundation of San Antonio — and generous gifts from TMA and TMA Alliance members, and friends of medicine.   

  PC Action Ad Sept 13

Need Some Public Health Cash? Deadline Approaching!

Did you know that since 1998, the TMA Foundation (TMAF) has been providing community grants to help prevent disease and injury?

That's almost 20 years of helping medical societies and alliance and medical student chapters keep their communities safe and healthy.

We're talking bone marrow donor programs, diabetes awareness days, traveling health fairs, immunization clinics, and childhood obesity awareness initiatives. The list goes on and on.

If you want to be a part of this legacy, TMAF is now accepting applications to its 2017–18 Medical Community and Medical Student Leadership Grants programs. 

There are two deadlines: Aug. 15 and Dec. 15

County medical societies and alliance chapters may apply for up to $7,000, and TMA medical student chapters may apply for up to $3,000 for grants to support their community health improvement initiative. 

Find out more and apply online at the TMAF website

Register for TMA’s Fall Conference

Registration is now open for the 2017 TMA Fall Conference, which is scheduled for Sept. 15-16 at Hyatt Regency Lost Pines Resort and Spa. This free member benefit lets you reconnect with colleagues and learn more about what's new in Texas health care.

This year's programming features a recap of the 85th Texas legislative session. It also includes a discussion of the long- and short-term effects of abuse and neglect and other adverse childhood experiences, as well as an overview on the new law surrounding telemedicine.

Register today, and make your room reservation at the Hyatt Regency Lost Pines. For more information about the conference, visit the TMA Fall Conference webpage

Questions? Email the TMA Knowledge Center or call (800) 880-7955 Monday through Friday, 8:15 am to 5:15 pm CT.

This Month in Texas Medicine

The August issue of Texas Medicine takes a comprehensive look at how medicine fared during the regular session of the Texas Legislature. For nearly five months, TMA pushed hard to advance the interests of Texas physicians and the state's health care landscape, succeeding on several important fronts. Medicine's victories in the regular session included opening up surprise billing mediation to more patients; a groundbreaking new definition of telemedicine; a statewide ban on texting and driving; and a prohibition on discrimination against physicians based on maintenance of certification. The magazine also looks at how the success of organ donation has created a seemingly never-ending discrepancy between demand and supply.

Check out our digital edition

Texas Medicine RSS Feed

Don't want to wait for Texas Medicine to land in your mailbox? You can access it as an RSS feed, the same way you get the TMA Practice E-Tips RSS feed. 

E-Tips RSS Feed

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.  

This Just In ...

Want the latest and hottest news from TMA in a hurry? Then log on to Blogged Arteries.

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. 

CMS Quality Payment Program Deadlines  

Last Day of the Final Determination Period for 2017 Advanced Alternative Payment Models

Last 90-Day Period for the 2017 MIPS Performance Year

Last Day of the 2017 MIPS Performance Year

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.  

On-Demand Webinars

Innovation in Education for Cardiovascular Risk Patients: Heart Healthy Diet and Lifestyle

Making Discussions About Death and Dying Easier

HIPAA Training for Medical Office Staff

About Action       

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If you have any technical difficulties in reading or receiving this message, please notify our managing editor, Shari Henson. Please send any other comments or suggestions you may have about the newsletter to the Action editor.

Last Updated On

August 02, 2017