By Joey Berlin and Sean Price
Once again, the Texas Medical Association asked to take your temperature, and you opened your mouth. Well, in fact, you opened your emails. You told us what you think. And as always, the results told TMA a lot about the state of Texas medicine today. TMA’s 2018 Survey of Texas Physicians asked members about their legislative priorities, payer relationships, and practice environment, scope of practice concerns, and much, much more. TMA conducted the email survey in monthly installments between January and August 2018. Here are some highlights.
Legislative and Regulatory Priorities
Public Health
Scope of Practice
Insurance
Medicaid
Practice Management
Legislative and Regulatory Priorities
Jason Terk, MD, chair of TMA’s Council on Legislation, says the survey’s look at physicians’ most pressing legislative and regulatory concerns are indicative of a dreaded B-word – a word he says needs to be retired.
That word is “burnout,” and Dr. Terk says it’s a misnomer because it incorrectly “indicates that there’s something wrong with a physician.” Whatever word you use, TMA physicians’ ranking of legislative priorities reflect the various forms of interference and bureaucratic tear gas driving doctors away from their calling.
Ten topics were “very important” state legislative priorities to at least 60 percent of Texas physicians. Eighty percent of doctors put defending the 2003 medical liability reforms and opposing intrusion by commercial payers at the top of the list. The next three – reducing administrative and regulatory burdens; opposing government intrusion; and reducing hassles originating from health plans – also were among physicians’ federal legislative concerns.
“There are just a whole host of things that physicians are experiencing now that are effecting a death-by-a-thousand-cuts type of experience for physicians, and it’s impacting our ability to execute the mission in providing care to people,” Dr. Terk said. “That is the cause of what is inappropriately called ‘burnout’ for physicians.
“It really is more along the lines of, ‘I’m expected to perform the mission of patient care, but I have things that are beyond my control that are preventing me from performing that mission.’ This is an untenable situation for physicians that ends up driving them away from medicine, or driving them to even worse outcomes,” Dr. Terk added, noting the high physician suicide rate.
Some of those same topics were reflected in an open-ended question asking Texas physicians about their biggest challenges. The perennial answer: “inadequate/decreasing payment/economic survival” got the nod from one-fifth of respondents, followed by third-party interference in medical practice, and concerns about the uninsured and underinsured.
On that last topic, TMA once again asked physicians which government measures they would support or oppose for covering Texas’ nation-leading uninsured population. Several such solutions earned broad support from survey-takers, with nearly 90 percent supporting funding or subsidies for charity care. Increased funding for outpatient charity care clinics also was overwhelmingly popular. More than 70 percent favored expanding the Children’s Health Insurance Program, and more than 60 percent support expanding Medicaid.
Public Health
Texas’ need for better mental health services – and
encouraging signs of progress on that front – explain why physicians ranked
improving the state’s mental health workforce as a top public health priority,
says Thomas J. Kim, MD, an Austin psychiatrist and internist who is on TMA’s
Council on Legislation.
Primary care physicians have
become de facto mental health providers because of the state’s lack of mental
health professionals, he says.
“When I speak with my primary
care colleagues, they tend to highlight the widespread lack of available
specialist support,” Dr. Kim said. “To be clear, primary care [physicians]
carry much of the water when it comes to mental health services, but if
patients don’t respond well they quickly feel out of their element and unsure
of how to proceed. We need to do a better job at supporting them.”
State elected officials apparently
agree. The 2017 Texas Legislature passed a package of bills that boosted mental
health resources, and efforts to do more in the current session – backed by TMA
– seem to have strong support, Dr. Kim says.
“We’re seeing significant interest
in the legislature and the media around the difficulties that we’re having
caring for each other,” he said.
At the time TMA conducted this
portion of the 2018 survey last January, maternal health was not among the
response choices, but the issue has since climbed up the ladder of TMA’s top
public health priorities.
From the choices offered in the
survey, physicians also ranked efforts to improve vaccination and combat
obesity as major concerns.
Texas now sees regular outbreaks
of reportable diseases like measles – a direct result of parents refusing to
vaccinate their kids, says Eduardo Sanchez, MD, former commissioner of the
Texas Department of State Health Services (DSHS). Texas physicians recognize
the need to improve the flow of science-based information on vaccines to offset
inaccurate anti-vaccine websites on the internet, he said. "You can’t make good decisions
if you don’t have good information,” said Dr. Sanchez, who is now chief medical
officer for prevention and chief of the Center for Health Metrics and
Evaluation for the American Heart Association in Dallas.
Likewise, physicians’ No. 3
priority, the need for higher fitness and nutrition standards in schools, is
clear because they can see in their exam rooms that obesity is rising among
both adults and children, Dr. Sanchez says. Between 1995 and 2016, the
prevalence of obesity more than doubled in Texas, from 15.9 percent to 33.6
percent, according to DSHS.
The survey also showed strong
physician support for anti-smoking measures, especially raising the statewide
age for tobacco purchases from 18 to 21.
“Physicians are driven by data,”
said Alice Gong, MD, a San Antonio neonatologist and chair of TMA’s Council on
Science and Public Health. “We have data that shows that most kids get addicted
in their adolescent years. And if they don’t have access, then you’re less
likely to have addiction.”
Bills pending in the Texas
legislature would raise the age limit statewide, and some local governments
have already done so. In 2018, San Antonio became the first large city to raise
the minimum age for tobacco purchases to 21.
“When the city council heard
[the proposed ordinance] that day, there were a lot of kids who came forward
and said, ‘You need to do this,’” Dr. Gong said. “So the population that’s
being targeted by the people who want to sell [tobacco] products is saying they
don’t want it.”
Scope of Practice
Keeping the practice of medicine in the hands of physicians is an increasingly important issue to TMA members, the 2018 survey shows.
Two years earlier, 56 percent of physicians listed “prevent scope expansions” as one of their top state legislative priorities. In 2018, that number jumped to 62 percent, making it one of 10 priorities to poll at 60 percent or more.
Retired Waco psychiatrist J. Clay Sawyer, MD, is chair of the Federation of Texas Psychiatry, of which TMA is a member. The federation attempts to promote the “common professional interests” of psychiatrists and the best interests of patients and those who do or might need mental health care, among other aims. A longtime warrior when it comes to preserving proper scope, Dr. Sawyer believes that should be medicine’s top priority.
“Scope of practice isn’t a turf issue for us. It’s a patient safety issue,” Dr. Sawyer said. “People who want to act as physicians without gaining the training that physicians require are doing their patients a disservice, to say the least. It’s lower quality of care, and it’s just not safe. They’re not trained to look at all the different things that are going on like physicians are. It’s something that most of us feel very strongly about. And I would still rank it at the top of the list.”
TMA has held firm that physicians can delegate prescribing privileges to advanced practice registered nurses (APRNs) or physician assistants (PAs), but must act in a supervisory role in those scenarios.
More than a third of survey respondents say they delegate prescribing to an APRN or PA, and 45 percent of those physicians say they’re comfortable delegating Schedule II medications. TMA also asked physicians about any prescribing parameters they place on APRNs and PAs to whom they delegate. About one-third delegate prescribing based on the individual experience of an APRN or PA.
Insurance
TMA’s aggressive push in recent sessions for more-adequate insurer networks has included an effort to hold health plans responsible for maintaining correct and updated network listings. While some of the survey data on health plan directory listings have improved, a lofty share of physicians – more than 80 percent – reported notifying health plans of an incorrect listing in their directory.
Contractual relationships between physicians and the state’s major payers are on the decline. The median number of each physician’s PPO contracts continued its steep drop, as did the success of physicians’ attempts to join health plan networks. Thirty percent of physicians reported the insurance companies told them their plans were full or not enrolling new physicians.
Houston-area emergency physician Mounang Desai, MD, says the drop in PPO contracts is an indicator of marketplace consolidation, and the survey indicates that health plans are trying to narrow networks.
“[Health plans] say they want to increase [access]. But evidence shows right here, [the percentage of physicians who say they’ve] received a contract [is] going down. They’re reducing access.”
And insurers’ administrative policies aren’t scoring any points, either.
Twenty percent of physicians surveyed say their patients have been required to use payer step therapy protocols against the physician’s medical judgment, and a majority say controls like prior authorization cause the quality of care to suffer.
Austin oncologist Debra Patt, MD, a member of TMA’s Council on Legislation, says these insurer protocols aren’t going away. But she says medicine needs policies to make sure utilization management makes sense, and that physicians need to partner with health plans to enhance both care delivery and value. If that partnership doesn’t happen, she says, payers will use such tactics “as a blunt instrument to control care delivery,” which will make patient care substandard.
“You see in the survey some frustration by doctors in navigating utilization management policy to get patients the care they need. When I write for an imaging study on a patient with cancer who needs a lesion in their lung followed up on, and it’s declined by insurance, that’s not good patient care,” Dr. Patt said. “But frequently, payers implement these techniques to try to have better control of their costs.”
Medicaid
Low payments and slogging through layers of red tape have long deterred Texas physicians from participating in Medicaid, and have kept those that do see these patients barely hanging on. But the latest survey results show significant opportunity within the program to boost participation, says Mary Dale Peterson, MD, chief executive officer of Driscoll Health Plan.
Nearly half of physicians said they would accept more Medicaid managed care patients if “certain conditions” improved, such as if they received incentive payments or had to deal with less paperwork.
Drilling down to specific reforms, a majority of physicians said they were “somewhat” or “very” likely to take more Medicaid patients with changes like streamlined prior authorization requirements, a simplified vendor drug program, and better care coordination.
TMA is backing bills in the 2019 legislative session that would increase Medicaid payment rates and reduce hassles like unnecessary prior authorization requirements.
“With the continued shortage of physicians in Texas … I think the competition is really commercial rates,” Dr. Peterson said.
She adds that Texas Medicaid doesn’t have enough physicians “to get timely appointments for everybody that we would like to have timely appointments for.
“We’re going to continue to see challenges as a growing state in the overall shortage of physicians,” she said. “If your practice is full with commercial members, there’s no reason to have a lower-paying Medicaid (rate).”
Practice Management
Independent physicians have endured a regulatory and financial squeeze for the past decade, and TMA’s latest survey results show that’s changing the way they practice medicine, says George Osuchukwu, MD, a Victoria nephrologist and member of TMA’s Council on Practice Management.
Growing oversight by the U.S. government and insurance companies combined with declining pay from government and private sources make staying in business much tougher for solo practitioners and small practices, he says. In the TMA survey, 20 percent of physicians cited “economic survival” as one of their biggest challenges.
“People have seen their overhead go from 30-35 percent to about 50-55 percent, and it’s more difficult to stay in practice,” Dr. Osuchukwu said.
While the percentage of solo practitioners, group practice employees, and group owners has remained essentially flat since 2014, the longer-term trend shows a decline, says Allen Schultz, MD, an Abilene family medicine specialist and chair of the Council on Practice Management.
Regulatory and financial pressures have “shaken out all those practices that weren’t able to adapt and make the necessary changes,” said Dr. Schultz, a solo practitioner himself. “And now there are no additional places to cut. We’re already down to bone.”
Meanwhile, the number of physicians working as hospital employees jumped 25 percent from 2016 and tripled since 2012. The number of physician practices wholly owned by a hospital or hospital system rose from 11 percent in 2014 to 19 percent in 2018. And the percentage of Texas physicians who say they are group-practice employees made a big jump in the early years of this decade.
“There’s uncertainty in the market, and because of that people have tried to get more certainty,” by affiliating with hospitals and other large organizations, Dr. Schultz said. “They’ve gone to the institutions with the largest pockets.”
That “certainty” may come with its own cost: Physicians cited corporate practice/loss of autonomy as one of their biggest challenges. More than half of respondents reported feeling at risk of losing their independence in clinical decisionmaking.
To preserve that autonomy, physician practices are increasingly striking deals like the one The Austin Diagnostic Clinic (ADC) made when it merged in 2018 with St. David’s HealthCare, which is partly owned by HCA Healthcare. The 130-physician multispecialty practice negotiated to contract with HCA, rather than be owned outright, and is governed by a board made up of both ADC and HCA physicians.
“That has given us a seat at the table [in making decisions],” said Dr. John Villacis, MD, an allergist and chairman of ADC who also sits on the Council on Practice Management.
Another constant pressure: Electronic health record (EHR) costs. Most EHR systems are user-unfriendly in multiple ways, says Dr. Schultz, so those costs come at physicians in many ways.
“You can’t just measure the plain dollar costs,” he said. “It’s the stress, the extra work, the decreased efficiency that goes along with this.”
Nevertheless, EHRs are gradually gaining acceptance. This is partly because Medicare quality payment programs encourage EHR use and because more physicians are becoming comfortable with incorporating EHRs into their work, says Dr. Osuchukwu. He speculates that the relatively small group with no plans to adopt an EHR is probably made up of older physicians who don’t see Medicare patients and who plan to retire soon.
Tex Med.
2019;115(5):15-23
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