Action: Dec. 1, 2017

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

A Holiday Lump of Coal: CHIP Families Could Receive Termination Notices This Month
Analysts: Ending ACA Cost-Sharing Payments to Affect Middle Class
Texas HPV Vaccination Rates Lagging Behind National Rates, Study Shows
Planning to Tell the Feds What You Think of the RACs? Deadline Pushed Back

TMA Is Taking Action; Seriously, We’re Literally Taking Action Away
AMA House Tackles Scope Challenges, Payment Problems
Physician, Med Student Journalists: Enter TMA Contest
This Month in Texas Medicine

A Holiday Lump of Coal: CHIP Families Could Receive Termination Notices This Month

Families enrolled in the Children’s Health Insurance Program (CHIP) could receive letters later this month stating that their coverage will end in January unless the federal government acts swiftly to restore federal funding for the program.

Federal lawmakers allowed funding for CHIP, which provides health coverage for almost 400,000 low-income Texas children, to expire Sept. 30 despite strong bipartisan support.

Texas has sufficient funds to continue coverage through January 2018. But it must receive official approval from the Centers for Medicare & Medicaid Services (CMS) to continue to use its allotment.  

State officials have asked CMS to allow Texas to retain $90 million of its $190 million CHIP balance to maintain coverage through Jan. 31. CMS is expected to approve the request, but that might not happen before the state is legally obligated to notify families that their CHIP coverage will end. By law, Texas must give notification at least 30 days in advance. 

Furthermore, even with the CMS approval, coverage will expire by Feb. 1, 2018, unless Congress renews funding. While TMA and state officials are cautiously optimistic lawmakers will do the right thing, Congress is not expected to take up the budget until the end of December — several weeks after Texas’ notices must be sent.

Unless federal or Texas lawmakers provide funds in the interim, state officials on Dec. 14 will begin notifying families who apply for coverage that their eligibility will last only one month. Letters informing currently enrolled families that their coverage will end in January will be sent Dec. 22.  

TMA and other state medical societies in October sent letters to the majority and minority leaders of the U.S. Senate and House of Representatives exhorting them to support legislation that would extend funding for CHIP. Gov. Greg Abbott and members of Texas’ congressional delegation, including Senate Majority Whip John Cornyn, continue to support funding reauthorization.

Analysts: Ending ACA Cost-Sharing Payments to Affect Middle Class

By Joey Berlin 

The Trump administration made a splash in October by announcing an end to government subsidies that help insurers provide discounts to low-income enrollees in the Affordable Health Care marketplace.

However, analysts say it won't be low-income people who will feel a financial hit from President Donald Trump's decision on the cost-sharing reduction (CSR) payments. Instead, people with higher incomes pick up the tab, analysts said.

After the administration's announcement, 18 states and the District of Columbia sued in an attempt to force CSR payments to continue, but a federal district court judge rejected that suit. At press time, lawmakers reportedly were working on a possible legislative solution that would authorize the CSR payments.

ACA requires health plans to provide eligible customers discounts on copays and deductibles; otherwise, they must back out of their federal contracts. For those who remain, raising premiums is the only option to recoup the costs. Many health plans already have requested premium hikes for 2018 in anticipation of the subsidy cut.

The premium hikes won't affect the low-income enrollees the CSR payments are meant to help, as those people receive tax credits that increase accordingly with any rise in premiums.

"Enrollees who qualify for premium subsidies — which are separate and unaffected — won't have to pay much more, though they may need to switch plans to keep their rates steady," a CNN Money article said. "But middle-class Americans who earn too much to get premium subsidies could get walloped by higher rates."

A Kaiser Family Foundation (KFF) analysis found that premiums in states using (like Texas) will "rise substantially" overall, but lower-income consumers receiving premium tax credits will pay less in 2018 than they did in 2017. 

The analysis found that on average, a 40-year-old person who makes $35,000 per year and is eligible for a premium tax credit would pay 36 percent less in premiums for the lowest-cost bronze plan, 6 percent less for the lowest-cost silver plan, and 12 percent less for the lowest-costing gold plan. Subsidized enrollees with lower incomes will see even lower premiums, according to the analysis. In fact, in nearly 1,700 counties, the premium tax credit would cover the full cost of an ACA bronze plan for a 40-year-old who makes $25,000 per year, the analysis said. 

Action TMLT Ad 10.15

Texas HPV Vaccination Rates Lagging Behind National Rates, Study Shows

By Sean Price

Texas is rapidly falling behind the rest of the country in vaccinating young people against human papillomavirus (HPV), according to a report released this week by The University of Texas System Office of Heath Affairs.

The report, based on recent data from the Centers for Disease Control and Prevention, shows a widening gap between the Texas and the U.S. rates for adolescents who have received at least one dose of HPV vaccine.

The vaccine protects against seven strains of HPV that can cause genital warts and several cancers, including cervical, throat, and penile. It is recommended for 11- and 12-year-old girls and boys, though older teens and young adults can get immunized, too.

In 2013, there was only a 0.5-percentage-point difference between the national rate of 34.6 percent and the state rate of 34.1 percent for young Texas males. By 2016, that gap had widened to 11.7 points: 56 percent nationally, and 44.3 percent in Texas.

For females in 2013, there was only a 1.1-percentage point difference between the national rate of 57.3 percent and state rate of 56.2 percent. But by 2016, the national rate was 65.1 percent, while Texas’ rate was 54.5 percent, a 10.6-point gap.

"I'm struck that we have fallen behind [in recent years], and the gap continues to widen between us and other states," said David Lakey, MD, UT System vice chancellor for health affairs and chief medical officer.

Four other states — Mississippi, South Carolina, Utah, and Wyoming — have lower HPV vaccination rates, according to the report. 

The report also found that HPV vaccination rates vary greatly in different regions of the state.

In El Paso County, for instance, the 2016 estimate for up-to-date vaccinations was 66 percent, which is higher than every other state except Rhode Island. Meanwhile, in Dallas County, the rate was 23.9 percent, lower than every other state and the District of Columbia.

Dr. Lakey, who is chair of TMA’s Council on Science and Public Health, says several factors pushed up the El Paso rate. The region has a high Hispanic population, which as a group is more accepting of vaccinations, Dr. Lakey says. But he says the biggest factor has been a concerted push to vaccinate young people by the region's medical community.

"They are making it more of a routine," Dr. Lakey said. "For pediatricians — and other doctors — when kids come in, they don't have that separate conversation that makes the HPV vaccine sound unusual or scary. It is considered as a regular vaccine that you're going to get in the adolescent visits."

Dr. Lakey says Texans are accepting of vaccines overall, but misinformation about the HPV vaccine has caused people to shy away from it. The UT System study points out that there is a 36-percentage gap between the number of young people who get the regular Tdap vaccine for tetanus, diphtheria, and pertussis, and those who receive the HPV vaccine.

Dr. Lakey says physicians have to take the lead in educating the public.

"I think physicians need to understand their leadership role, both in the community and with their patients to recommend the vaccine," he said. 

More information on HPV and vaccinations can be found at the TMA's HPV Resource Center.

Planning to Tell the Feds What You Think of the RACs? Deadline Pushed Back

By David Doolittle

There are a lot of ways to spend the first week of December: decorating or shopping for the holidays, dusting off your winter wardrobe, getting your 2017 tax documents in order.

But if you were planning to spend this week offering feedback about recovery audit contractors (RACs) — and you know who you are — I’ve got some news for you: The deadline to submit comments is Dec. 8, but the Centers for Medicare & Medicaid Services (CMS) will continue to review comments after that date.

AMA pushed for the extended comment period during a meeting earlier this year with CMS, which runs the RAC program.

AMA officials were concerned that specialty societies wouldn’t have enough time to properly review the RAC topics before the deadline because of the AMA Interim Meeting in November and the Thanksgiving holiday.

If this all makes sense to you, and you want to see the CMS topics up for review this month, check out the CMS website.

If all of this has you scratching your head, here’s a crash course: The Medicare Fee for Service RAC Program is designed to help CMS identify and correct improper Medicare payments. Four auditing firms are paid commissions to review payments made to practices, clinics, hospitals, and more in an effort to recoup overpayments and return underpayments.

More information can be found on the CMS website. AMA has worked to ensure the program is favorable to physicians.

TMA and the Coalition of State Medical Societies repeatedly have urged Congress to intervene, saying, “Medicare pays RACs like bounty hunters to find potential overpayments made to physicians.”

 TMAIT Action Ad 6.15

TMA Is Taking Action; Seriously, We’re Literally Taking Action Away

By David Doolittle

I have good news and bad news for you.

I’ll give you both at the same time: Starting in January, you will no longer receive Action every two weeks. In fact, TMA is doing away with most of our regularly scheduled email newsletters.

Why is that?

Well, it’s all part of major changes TMA is making to three of our publications — the magazine, website, and emails — so we can get information that’s important to you as quickly as absolutely possible.

You can read all about the changes to the magazine in the December issue, and you’ll be able to see them for yourself starting in January.

In this space, though, I’d like to tell you about the changes we’ve made to our website and newsletters. 

If you didn’t know, TMA has published a variety of newsletters on a regular basis targeted to specific member interests. These would be published daily, twice-monthly, monthly, and once a quarter.

Starting Jan. 2, you can kiss those goodbye.

Instead, TMA will begin sending you emails Monday through Friday afternoons that consist of the latest stories published on our website, 

Most importantly, you’ll be able to control the types of stories you’ll receive. Basically, only the types of stories you wish to read will be sent to you daily. Just log into the TMA website and manage your preferences in your profile.

Only interested in stories specific to young physicians? Manage that in your preferences.

Want only legislative news or legal stories? Specify that in your preferences.

Do you want only to receive practice management tips? You get the idea.

All of these stories will live on our revamped Texas Medicine webpage, which will feature the most recent and important stories as well as links to other news, videos, information, and blog posts. That page is scheduled to go live Jan. 2, 2018.

If you’ve got any questions about all of this, let me know directly by calling (512) 370-1385 or emailing David Doolittle

AMA House Tackles Scope Challenges, Payment Problems

By Steve Levine 

Fueled by a historically rare consensus on major issues, the American Medical Association House of Delegates took swift action to address many of the difficulties that frustrate physicians these days.

"Texas physicians should be quite pleased by what the AMA House accomplished at this meeting," said David Henkes, MD, of San Antonio, chair of the Texas Delegation. "The new policies enacted and the directives for action given to AMA leaders will make a real difference in our day-to-day practices."

About 100 Texas physicians and medical students representing the Texas Medical Association, various sections, and national specialty societies took part in the Nov. 11-14 interim meeting in Honolulu. Former TMA President Sue Bailey, MD, of Fort Worth, presided over her fifth session as speaker of the house. The sole resolution TMA brought to Hawaii won unanimous approval.

Texans Share Lessons of Harvey

From staffing shelters, to providing “mental health first aid,” to helping physicians rebuild flooded practices, organized medicine was a critical piece of the response to Hurricane Harvey, a panel of Texas leaders said at a special forum on disaster medicine.

Lessons learned from hurricanes Katrina, Rita, Ike and others ensured that the Texas Gulf Coast was better prepared and in a better position to respond to the storm and the flooding it caused, explained AMA Board of Trustees member Russ Kridel, MD, who organized the forum, and trauma surgeon Ken Mattox, MD, a renowned expert on disaster readiness.

Evacuees at Houston’s two mega-shelters received help from a broad array of emergency, primary care, and specialty care physicians. “Many of them didn't want to leave [the shelter], they were getting such great service,” Harris County Medical Society CEO Greg Bernica quipped.”

Beaumont anesthesiologist Ray Callas, MD, explained that good working relationships among physicians and local, state, and national elected officials helped ensure that the government’s response met critical needs on the ground. 

Dallas psychiatrist Les Secrest, MD, discussed how storm victims and first-responders alike can benefit from a trained and friendly ear. “Just listen nonjudgmentally,” he said. “The conversation will lead from hopelessness to hopefulness.”

TMA President Carlos J. Cardenas, MD, thanked the AMA, the Physicians Foundation, and physicians and medical societies nationwide for helping TMA make more than $1 million available in disaster relief grants so practices could reopen their doors to patients. “When we have members in need, all of us come together to help our colleagues,” he said. “You never know when a hurricane may be coming to a home near you.”

Houston emergency physician Diana Fite, MD, and John Carlo, MD, of Dallas, a member of the AMA Council on Science and Public Health, also participated in the forum.

A “Consistent National Strategy” on Scope Incursions

The AMA house adopted a trio of resolutions to help protect patient safety and prevent inappropriate independent practice by nonphysician practitioners. The latest threats include the APRN (Advanced Practice Registered Nurses) Multistate Compact, the “doctor of medical science” degree pushed by physician assistants in some states, and the broad medical screening tests offered by nonphysician vendors.

A multi-specialty and multi-state coalition – including Texas – pushed delegates to adopt a resolution calling on AMA to convene a physician workgroup to create a “consistent national strategy,” a public relations plan, and legislative language to oppose the nationwide drive for nonphysicians’ independent practice. 

The APRN Compact, which three states already have adopted, would allow APRNs to practice without physician supervision or oversight. Medicine so far has been able to stop all attempts to pass “doctor of medical science” legislation.

The house also endorsed a six-part policy on nonphysician screening tests to protect patients and to ensure adequate follow-up. Texas delegate Michelle Berger, MD, of Austin, persuaded the delegates to adopt an amendment that would require screening test vendors to send copies of the results to the patient’s primary care physician.

Modifier 25 Pushback

The house reacted strongly to news that some commercial health insurance companies are reducing or disallowing payments for claims with modifier 25, which physicians use when a patient receives evaluation and management (E&M) services, and a procedure on the same day. Delegates directed AMA to use “any legal means possible” to ensure that health plans pay both fees at the full rate when physicians use modifier 25 appropriately.

“Health insurers that reduce or deny payment for E&M services associated with procedures performed on the same day are needlessly forcing patients into multiple visits and delaying the provision of necessary care,” said AMA President David O. Barbe, MD.

Burnout Needs More Than a Band-Aid

To address growing rates of physician burnout — and its associated impact on patient care — several medical groups asked AMA to help health systems and medical societies develop programs and services to help physicians cope. 

Others argued that AMA should focus instead on correcting the root causes — such as government overregulation, check-the-box demands from electronic health records, and insurer and hospital meddling in patient care. 

Sugarland internist Elizabeth Torres, MD, agreed with that approach. “I'm depressed because I want to focus on patient care, but I cannot,” she said. “Giving me an antidepressant isn't going to help.”

The Physicians Foundation 2016 Survey of American Physicians found physician morale to be the lowest in Texas, which also has the largest percentage of physicians working in solo or small practices that have the fewest resources to combat or comply with external demands.

Delegates referred the matter to the AMA Board of Trustees, which promised “an aggressive and comprehensive response in an expedited manner.”

Texans in Action

In addition to Dr. Bailey on the podium and Dr. Kridel on the AMA board, other Texans served at the meeting and won new leadership spots. Houston’s Arlo Weltge, MD, served on the Reference Committee on Amendments to Constitution and Bylaws, and Melissa Garretson, MD, of Stephenville, was a member of the Reference Committee on AMA Governance and Finance. Numerous Texas physicians continued their service on AMA councils and committees.

San Antonio surgery resident Michael Metzner, MD, was chosen alternate delegate to the AMA house from the Residents and Fellows Section. Texas medical students won these spots representing Region 3 in the house: 

  • Luis Seija, from the Texas A&M Health Science Center College of Medicine — regional delegate;
  • Sinan Bana, also from Texas A&M — alternate delegate;
  • Rouzbeh Kotaki, from The University of Texas Rio Grande Valley School of Medicine — alternate delegate; and
  • Aaron Wolbrueck, from the University of North Texas Health Science Center at Fort Worth Texas College of Osteopathic Medicine — alternate delegate. 

The Texans bid a fond farewell to Clifford Moy, MD. The Frisco psychiatrist first joined the Texas delegation as a medical student in 1984. His tenure included a stint as chair of the AMA Council on Long Range Planning and Development.

Other Issues Merit Action

Delegates addressed various other economic, legislative, and public topics, including: 

  • Adopting a resolution originally written by the TMA Medical Student Section to oppose legislation or administrative actions that hurt access to federal child nutrition programs.
  • Continuing its push to hold national certifying boards’ feet to the fire by stating that fees for maintenance of certification (MOC) should reflect fairly the cost of developing and administering the tests.
  • Adopting new policies to encourage routine depression screening in pregnant and postpartum women, and directing AMA to advocate for legislation to establish maternal mortality review committees to analyze deaths that occur during pregnancy or within the first year after childbirth. 
  • Voting to oppose any further legalization of marijuana or cannabis for recreational or medicinal purposes, to encourage states to use cannabis tax revenue for public health purposes, and to support research to determine the medical consequences of long-term cannabis use.
  • Urging the federal government to help Puerto Rico and the U.S. Virgin Islands’ hurricane recovery by funding adequately their Medicaid programs. Dr. Kridel said the move would “provide support for the medical and public health needs of their residents, and help provide needed care and restore access to health care services.”
  • Asking for a recommendation, to be completed by June, for a payment policy to address the site-of-service differential — the difference between what Medicare pays for services provided in hospital-owned facilities vs. independent physician practices.
  • Adopting new policy providing guidance, consultation, and model legislation on peer review immunity and protection from retaliation.
  • Asking the AMA Board of Trustees to tackle unconscionable drug pricing and to push for transparency from pharmacy benefit managers. “Greater transparency among pharmaceutical manufacturers, pharmacy benefit managers and health plans will shed light on the rationale for drug price increases and why patients pay what they do for their medications,” said AMA President-elect Barbara L. McAneny, MD. 
  • Directing the AMA Board of Trustees to decide how to address the potential antitrust implications of a pharmacy or drug store chain buying a health insurance company.

    PC Action Ad June 13

Physician, Med Student Journalists: Enter TMA Contest

Do you moonlight as a medical reporter? Maybe you write a medical column or articles for your local newspaper or magazine. Or perhaps you host a health-focused segment on a local TV or radio station. If so, get recognized for your work in the TMA Anson Jones, MD, Awards contest.

“Physicians have a unique ability to explain difficult concepts and give insight into complex issues, and local media outlets are perfect forums for this,” said  2017 physician winner Sidney C. Roberts, MD, of Lufkin. “I can think of no better way to educate a wide local audience.” 

The Physician Excellence in Reporting category is designed for physicians and medical-student reporters who regularly contribute to general-interest media aimed at a Texas public audience. (Eleven other award categories honor professional journalists in print, television, radio, and online media.)

Dr. Roberts said receiving the Anson Jones award validated the importance he places on his role beyond the clinic. “I am first and foremost a physician, but I believe one of my duties is to educate the community about health care issues in a way that positively impacts their health.” (Read Dr. Roberts’ winning article.)

Enter your work today. Any news story published or broadcast in 2017 is eligible. TMA will accept entries until noon on Jan. 10, 2018. You also can nominate a colleague who is an outstanding medical journalist — or a local professional journalist (nonphysician). 

TMA has honored Texas journalists for excellent medical news reporting for more than 60 years. Visit the Anson Jones webpage for complete contest details. 

If you have questions, call Tammy Wishard, TMA outreach coordinator, at (800) 880-1300, ext. 1470, or (512) 370-1470, or email

This Month in Texas Medicine

The December issue of Texas Medicine focuses on Senate Bill 507, by Sen. Kelly Hancock, which expands balance billing mediation to all physicians and other practitioners who provide out-of-network services at certain in-network facilities, and also expands mediation to out-of-network emergency care. Other articles look into a constitutional challenge to the state's Advance Directives Act; reference pricing, which has emerged as a potential strategy for health plans to keep premiums low and address the problems that managed care plans are facing; and steps physicians can take to prepare for natural disasters and other sudden calamities.

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 on the TMA website (may not work with all browsers). Or, download an RSS reader, such as Feedreader, Sharpreader, Sage, or NetNewsWire Lite, to have the feed delivered to your desktop or mobile device. You also can subscribe to the RSS feeds for TMA news releases and for Blogged Arteries, the feed for Action

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, also is available as an RSS feed. This is a valuable resource for your office staff, as well.

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 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       

 Action, the TMA newsletter, is emailed twice a month to bring you timely news and information that affects your practice

To change the email address where you receive Action, go to Member Log-In on the TMA website, then click on "Update Your TMA Demographic Information (including newsletter subscriptions and preferences)."

To unsubscribe from Action, email TMA's Communication Division at

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

December 18, 2017