Committees in both chambers of the Texas Legislature are studying complex issues throughout this year to prepare for the next legislative session in 2019. As the year progresses, we’re periodically looking at the health care-related issues lawmakers are tackling and how TMA is advocating for medicine on those fronts.
Fixing Medicaid MCOs’ flaws
TMA offers potential solutions to grave managed care problems
Medicaid managed care in Texas is far from perfect, and media coverage over the summer made that clear in sickening detail.
The Texas Medical Association responded by offering prescriptions for some of managed care’s problems that a Dallas Morning News series highlighted in June.
TMA President Douglas Curran, MD, shared the association’s recommendations — including more accountability for managed care organizations (MCOs) and stronger care coordination — in written remarks for a joint Texas House committee hearing June 27. The House General Investigating & Ethics Committee has oversight of the Texas Health and Human Service Commission’s (HHSC’s) management of Medicaid managed care contracts. It held the joint hearing along with a House Committee on Appropriations budget subcommittee.
Dr. Curran wrote that “Pain & Profit,” the Dallas Morning News series, “highlighted serious flaws in Medicaid’s ability to ensure children and people with disabilities get the care they need to lead full and healthy lives to the extent of their abilities.”
One article in the series detailed the story of a boy who was born with significant health problems and developed a habit of pulling the tracheostomy tube out of his throat.
Superior HealthPlan, the MCO paying for the child’s care, fought to end one-on-one nursing care for the boy, ultimately arranging care for the child using a ratio of one nurse to two children, according to the report. A home health agency official wrote to the state accusing Superior of “unethical” behavior during that fight.
In October 2016, when the boy and another child were both under the care of one nurse in a foster home, he dislodged his trach tube and began choking while the nurse was caring for the other child, the newspaper reports. The boy was left brain dead as a result, it says. Superior then finally provided 24-hour nursing care, and the state concluded its 2:1 ratio of children to nurses violated federal law, according to the report. The home health official again wrote to the state, calling the tragedy a “direct result of the failed policies and callous actions of a managed care organization contracted … to provide health care services to Texas Foster Children.” To read the story, visit tma.tips/dmnmedicaid.
“Sadly,” Dr. Curran wrote to the committees, “what I read reflects not only my own experiences dealing with Medicaid managed care organizations … but also that of many of my colleagues: struggling to find specialists accepting new patients, wading through convoluted prior authorization and appeals processes, and spending hours on the phone attempting to find and arrange care coordination for medically complex patients.”
TMA’s recommendations for improvement include:
- Enhance accountability and oversight of MCOs: Texas must assess whether HHSC requires more resources to do its job. TMA urged lawmakers to support hiring a senior chief medical officer for oversight of medical and clinical policy issues. Also, while poorly performing plans should be penalized appropriately, the state also must reward plans and physicians that perform well, Dr. Curran wrote.
- Strengthen care coordination: The connections between different levels of care that patients need aren’t routinely being made, Dr. Curran wrote. The role of care coordinators should be modified to help practices facilitate specialty and long-term care, and physicians should have a mechanism to quickly and easily connect to a patient’s care coordinator.
- Increase physician payments: Texas Medicaid physician fee-for-service rates haven’t increased meaningfully in nearly two decades, Dr. Curran noted, and they aren’t indexed for inflation. TMA survey data shows when Medicaid payments go up, so does physician participation in Medicaid. “As the saying goes, you cannot squeeze blood from a turnip,” Dr. Curran wrote. “Even among well-run, well-regarded Medicaid MCOs, finding and keeping subspecialty physicians and even some primary care physicians is a growing challenge.”
- Streamline administrative procedures: The state must eliminate silly and onerous red tape for Texas Medicaid to improve its efficiency and effectiveness. Dr. Curran noted TMA has collaborated with MCOs to create a centralized organization for physicians to obtain credentials for any of the state’s 19 Medicaid plans.
TMA also recommends expanding value-based payment initiatives, which have resulted in some physician practices receiving improved payments. That includes incentives for providing expanded hours or for increasing the number of children who received well-child visits. (See “Remodeling Medicaid,” July 2018 Texas Medicine, pages 16-21, or visit www.texmed.org/remodelingmedicaid.)
“Yet such bonus payments cannot overcome the fact that payment per service is below physicians’ practice costs. Furthermore, legislatively mandated funding cuts to Medicaid MCOs potentially imperil the ability of plans to expand or maintain value-based payment initiatives,” Dr. Curran warned. “Without investment of new state dollars targeted to Medicaid physician services, the ability to maintain innovative MCO-physician collaborations will teeter on the edge.”
Telemedicine: Next Steps
TMA stresses payment problems as universities work to leverage technology
It should now be easier than ever to bring medical care to the most remote areas of Texas. With telemedicine now more clearly defined in state law, the Texas Medical Association is trying to improve access to care in rural and underserved areas.
So are state university systems, such as Texas Tech University Health Sciences Center (TTUHSC), which offers a broad base of telemedicine education programs aimed at training practitioners in the university’s vast West Texas service area.
But even after the crucial passage of Senate Bill 1107 in 2017, there’s work to do on access to care, and the Texas House of Representatives is looking at the issue further.
SB 1107, a TMA-driven measure, established a clear framework for telemedicine in Texas and clarified the patient-physician relationship required for using telemedicine. (For more information, visit TMA’s telemedicine page at www.texmed.org/telemedicine.)
Austin telemedicine internist and psychiatrist Thomas Kim, MD, touted the potential of telemedicine in June, when he represented TMA before the House Committee on Public Health. The committee was examining ways to improve access to care in both rural and urban medically underserved areas, including the role of telemedicine.
But Dr. Kim also raised the issue of physician payments for telemedicine services, an area where questions remain. TTUHSC also sees payment as a challenge, even as its telemedicine programs garner rapidly growing attention, says Billy Philips Jr., PhD, the center’s executive vice president for rural and community health.
Telemedicine’s capabilities, challenges
Dr. Kim, a member of TMA’s Council on Legislation, told the Committee on Public Health telemedicine can potentially avoid re-hospitalizations, divert unnecessary visits to the emergency department, and support health systems with otherwise unavailable specialists. There’s growing evidence telemedicine can improve the care of both acute and chronic conditions, he testified. But he also noted 14 hospitals have closed in Texas since 2010, possibly “because our health system does not keep people well.”
“It bears mentioning that SB 1107 also includes a requirement that payers publicly publish their telemedicine reimbursement policies,” Dr. Kim said in written testimony delivered to the committee. “It does not require them to reimburse, but simply to share whether and how they do so. To date, I have yet to find a policy of any actionable value. Some payers have even elected to carve out a telemedicine benefit reserved for a dedicated vendor, but not for their contracted physicians, which places us in an impossible situation.”
He also told the committee that saving critical access hospitals in Texas requires “supporting those who keep people out of the hospital with telemedicine policies that do not handcuff contracted physicians.
“To be clear, I would be delighted if the payers would reimburse a covered service delivered via telemedicine with parity, but I would be satisfied if payers simply allowed physicians to explore telemedicine options without risking their contract and negatively impacting their entire panel of patients,” Dr. Kim wrote.
Texas Tech’s Dr. Philips, like TMA, says a remaining challenge is “how our payer community actually conceives of the payment for these services.”
SB 1107 was a considerable win for TTUHSC’s telemedicine program “because it gave us a common set of definitions,” Dr. Philips told Texas Medicine. TTUHSC’s service area consists of Texas’ 108 westernmost counties and their vast, sparsely populated rural landscapes.
“If you think about this area, it’s about the size of the country of Germany. It’s a huge area: 131,000 square miles of territory,” Dr. Philips said. “When you think about the advantages that telemedicine brings in a setting like that, to populations that are far from each other and with relatively scarce resources in both personnel and infrastructure, then a technological solution like telemedicine is an important one to bring access to care to rural-living populations.”
- TTUHSC operates telemedicine clinics in a number of disciplines, including internal medicine, cardiology, pediatrics, and oncology. Its other telemedicine programs include:
- TexLa Telehealth Resource Center: A federally funded partnership with the Louisiana Health Care Quality Forum that provides technical assistance, training, and guidance to implement telehealth for practitioners in both states;
- Frontiers in Telemedicine: A simulation laboratory where students learn how to handle situations commonly seen in telemedicine and telemental health, and are tested on their competency;
- Next Generation 9-1-1: A program that trains emergency medical service units to use telemedicine while on the go, and is focused on areas that lack adequate trauma services; and
- The Telemedicine Wellness Intervention Triage and Referral Project: A mental health screening program using telemedicine to identify junior high and high school students with mental health issues.
In June, TTUHSC also completed its Point of Care Ultrasound, or POCUS, Project, which trained clinicians on using handheld ultrasound machines at the point of care.
Texas Tech isn’t alone among state universities in throwing considerable resources behind telemedicine. The University of Texas Medical Branch at Galveston is implementing the UT System Virtual Health Network, which the Board of Regents approved in 2016.
“I think it’s important in the future for Texas for all of us who run telemedicine programs around the state to find a way to put our networks together for the benefit of rendering the best health care we can to people who otherwise would be disenfranchised,” Dr. Philips said. “I’d like to see us develop a statewide network that allows sharing expertise and access, and for better outcomes.”
Tex Med. 2018;114(9):32-35