Rural Texas Physician

Spring 2017

Rural Texas Physician is a quarterly electronic newsletter catering to physicians in the many rural areas of Texas caring for patients and their communities. TMA’s grassroots membership is the strength of the association. For general inquiries or newsletter comments, email rural@texmed.org.

Senate’s Draft Budget Would Cut Loan Program 25 Percent

The Texas House and Senate have begun their final negotiations on the state’s 2018-19 budget. One of the many spending items of contention between the two chambers is the Physician Education Loan Repayment Program.

The Senate’s spending plan would cut 25 percent of the loan repayment program’s current budget, taking $8.45 million and leaving $25.35 million. The budget the House approved funds the program at the current $33.8 million.

The Physician Education Loan Repayment Program is among the state’s most effective ways of recruiting and retaining primary care physicians in physician shortage areas. Many rural areas in Texas depend on it to maintain or improve access to care. The program will cover up to $160,000 in loan repayment for physicians who commit to a practice in an underserved community for four years. More information is available on the program’s website

If the Senate’s proposed cuts go forward, new physicians will be denied the benefits of loan repayment at a time of all-time higher education-related debts, and some medically underserved areas will be denied the opportunity to use this important state resource to help recruit new physicians. TMA will be urging the budget negotiators to accept the House plan for this program.

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 Bills Aim to Boost Rural Residency Training

Rural Texas has a shortage of physicians, and the state has a limited number of rural residency training opportunities. TMA’s Council on Medical Education feels the state needs to do more to increase the number of rural physicians. Two state legislators are trying to do something about that.

House Bill 2996 by Rep. Trent Ashby (R-Lufkin) and Senate Bill 1455 by Sen. Donna Campbell, MD (R-New Braunfels), would establish a rural residency grant program. The goal of the program would be to stimulate interest in rural training tracks by providing funding during the initial stages of development or at least until the Medicare graduate medical education (GME) funding cap is set (three years for urban hospitals and five years for rural). The program potentially could be administered by the Texas Higher Education Coordinating Board as an addition to its GME expansion grant programs. Both bills are currently pending in committee. 

TMA believes rural training can provide benefits at multiple levels: boosting a community’s physician supply and hospital staffing, providing practical training for residents to better prepare them for rural practice, facilitating urban/rural hospital partnerships, and enriching physician recruitment opportunities for rural communities.

The Council on Medical Education has submitted a report on rural training tracks for the TMA House of Delegates to consider next month in Houston at TexMed 2017. The report contains three recommendations: 

  1. Texas needs more targeted programs to diminish the persistent shortage of physicians in rural areas. Recognizing the well-established linkage between where a resident trains and where he or she enters practice, it is important to institute residency training programs in rural areas with the resources to support such training. TMA recognizes the documented benefits of rural training track programs to rural communities and in preparing physicians for rural practice, as supported by research studies.  Accordingly, TMA supports legislative efforts to establish a state program to provide grants to incentivize the development of rural training tracks and other models of residency training designed for rural settings. To promote the success of the grant projects, TMA supports the use of eligibility criteria that take into account the likelihood a residency training program will be able to meet and maintain national graduate medical education accreditation standards and produce physicians who are well prepared for rural practice. 
  2. TMA will promote awareness of the grant opportunities among potential applicants.  
  3. TMA recognizes the stifling effect that Medicare graduate medical education (GME) funding policies have had on GME expansions. TMA strongly supports retention of the current federal payment provision that allows urban and rural hospital sponsors of rural training tracks to qualify for an exception to their respective Medicare GME funding caps. It is important for this exception to continue to allow rural training tracks to qualify for both direct and indirect Medicare GME funding.   

The Reference Committee on Medical Education will take input from physicians on the report’s recommendations on Friday, May 5, from about 9:30 am to noon, at the Marriott Marquis, Level 2, Liberty Meeting Room, as a part of TexMed 2017. All TMA members are welcome to provide comments at the meeting.  

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TMA and Health Plans Tackle Medicaid Credentialing Hassle

TMA and the Texas Association of Health Plans (TAHP) announced a joint effort to reduce red tape and administrative burdens for physicians and providers who participate, or want to participate, in the Texas Medicaid program. The two organizations selected Aperture, LLC, for a statewide credentialing verification organization (CVO) contract to be used by all 20 Medicaid health plans in Texas to streamline the credentialing process.

"Countless Texas physicians want to care for Medicaid patients, but the barrier of Medicaid's bureaucratic red tape and administrative burdens simply discourage them," said TMA President Don R. Read, MD. "We hope simplifying doctors' credentialing and recredentialing process will ease the path for more Texas physicians to see Medicaid patients."

Through the credentialing process, Medicaid managed care organizations (MCOs) gather and assess background information on physicians and providers to confirm they are in good standing, ensure patient safety, and prevent fraud, waste, and abuse. Currently, each MCO gathers this background information separately and with varying deadlines, requiring physicians to submit and resubmit their information to all 20 Medicaid health plans individually and at different times.

The idea of a statewide CVO was endorsed by a bill the Texas Legislature passed in 2015. Under the contract with Aperture, the CVO will be a single source for all credentialing information. That means physicians who wish to participate in more than one Medicaid MCO need only supply their information once. In addition, the Medicaid health plans agreed to adopt a single recredentialing date, so physicians will have to be recredentialed only once for all of the plans. Physician recredentialing for Medicaid HMOs generally occurs every three years.

The project implementation will begin immediately, with statewide operations expected to begin in October 2017.

"We look forward to continuing to work with TMA to establish a one-stop shop for providers that greatly reduces their paperwork burden, ensures a more seamless process, and boosts access to safe, quality care for Texans who rely on the Medicaid program for their health care needs," said TAHP Chief Executive Officer Jamie Dudensing. She added that she is hopeful health plans will include additional lines of business, such as commercial insurance and Medicare, to the CVO project in the future. 

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Feds Award $100 Million in MACRA Help to Small, Rural Practices

The Medicare Access and CHIP Reauthorization Act (MACRA) included funding for organizations to provide support and technical assistance to small and rural practices to help them successfully participate in the Merit-Based Incentive Payment System and alternative payment models. TMA and the American Medical Association have continued to push for this assistance, and the Centers for Medicare & Medicaid Services (CMS) responded to that call by awarding about $20 million to 11 organizations.

The grants cover the first year of a five-year program to provide on-the-ground training and education about the Quality Payment Program for clinicians in individual or small group practices of 15 or fewer clinicians. CMS intends to invest up to an additional $80 million over the remaining four years.

TMF Health Quality Institute is one of the 11 organizations.

The organizations will provide hands-on training to help thousands of small practices, especially those that practice in historically under-resourced areas including rural areas, health professional shortage areas, and medically underserved areas. The training and education resources will be available immediately nationwide and will be provided for free to eligible clinicians and practices.

"Clinicians in small and rural practices are critical to serving the millions of Americans across the nation who rely on Medicare for their health care," said Dr. Kate Goodrich, CMS chief medical officer and director of the Center for Clinical Standards and Quality. Congress "provided the funding for this assistance, so clinicians in these practices can navigate the new program, while being able to focus on what matters most — the needs of their patients."

The technical assistance, for example, will help clinicians choose and report on quality measures. It will include guidance with all aspects of the program, including supporting change management and strategic planning, and assessing and optimizing health information technology.

TMF will provide technical assistance and services in a region comprising Texas, Arkansas, Colorado, Kansas, Louisiana, Mississippi, Missouri, Oklahoma, and Puerto Rico. Customized assistance will include:   

  • Evaluating practice readiness for participating in a new payment model,
  • Engaging practices in continuous quality improvement,
  • Assessing and optimizing health information technology, and
  • Supporting change management and strategic planning.   

Additional federal training on the new Quality Payment Program includes:   

In addition to TMF, CMS awarded contracts to these organizations:    

  • Altarum,
  • Georgia Medical Care Foundation (GMCF),
  • HealthCentric,
  • Health Services Advisory Group (HSAG),
  • IPRO,
  • Network for Regional Healthcare Improvement (NRHI),
  • QSource,
  • QualisQuality Insights (West Virginia Medical Institute), and
  • Telligen.    

For more information on the Quality Payment Program, visit the TMA MACRA Resource Center or the CMS website.  

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Bugs Are Back, So Is Zika

As we hit the first official days of spring, anticipation builds over of the threat of Zika virus cases spread by mosquito bites in Texas, and TMA is preparing an event to help you help your patients. 

Texas' first locally-transmitted Zika case occurred in November in the Rio Grande Valley. As of March 10, the Department of State Health Services (DSHS) reported seven new Zika cases affecting Texas residents this year. Public health officials are concerned the relatively mild winter will contribute to the growth of mosquitoes spreading the virus to more people in the Lone Star State.

TMA is joining forces with DSHS to convene a second critical "tele-town hall" conference call with Texas physicians.

"Our goal is to ensure you are ready to counsel your patients and take the right actions when the inevitable happens — more cases of mosquitoes spreading Zika in Texas," TMA President Don R. Read, MD, said in announcing the event. "Physicians across the state are concerned about reporting and testing in their communities as the long, hot summertime bug season approaches."

TMA is taking to the phone — your home phone — to spread the vital information. Answer your phone at 7 pm CT, Wednesday, April 12, to take part in TMA's Tele-Town Hall Meeting on Zika. 

TMA will call you at the home phone number on file in your membership record. If you want us to call a different number — or if you do not want us to call you at all — please email the TMA Knowledge Center or call (800) 880-7955 by 5 pm CT on Friday, April 7.

Our growing list of speakers includes:  

  • John Hellerstedt, MD, DSHS executive commissioner; 
  • David Lakey, MD, former DSHS commissioner and current chair of the TMA Council on Science and Public Health;
  • Catherine Eppes, MD, MPH, co-director of the High-Risk Obstetrics Infectious Disease Clinic at Ben Taub Hospital, Houston;
  • Philip Huang, MD, MPH, medical director and health authority for Austin Public Health; and
  • Rajendra Parikh, MD, medical director, Medicaid and Chip Division, Texas Health and Human Services Commission.  

The call will include an update on the state's Zika preparedness planning, a briefing on reported Texas Zika cases, and the latest on Zika testing. And during this interactive, hour-long event, you may ask questions of Dr. Hellerstedt and the other expert Texas physicians. Dr. Lakey will serve as facilitator. 

The Texas Medical Association designates this activity for a maximum of 1 AMA PRA Category 1 Credit™. This course has been designated for 1 credit of education in medical ethics and/or professional responsibility. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who remain on the call for at least 53 minutes will automatically receive CME credit. 

TMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Learn more about Zika in the TMA Infectious Diseases Resource Center.  

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 How to Submit the Bare Minimum to Avoid 2019 MIPS Penalty

Under the new Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules, physicians submit data on their 2017 performance, and that data will affect their 2019 Medicare payment rates. TMA has compiled some easy steps you can take now to avoid the 4-percent Medicare penalty in 2019.

To implement MACRA, the Centers for Medicare & Medicaid Services (CMS) designed a new Quality Payment Program that has two paths: the Merit-Based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Although you don't submit data for the 2017 performance period until early in 2018, you may take the necessary steps now to avoid the 2019 MIPS penalty. Here's how.

For the first year, CMS offers a "pick-your-pace" approach to participation. In 2017, you may participate in an advanced APM or submit data under the MIPS program for a full year or for a partial year (90 days), or you may just test the system by submitting a minimum amount of data for any point in time to avoid a penalty. If you choose not to participate in any path in 2017, you will receive an automatic 4-percent pay cut on a per-claim basis to your Medicare Part B payments in 2019. 

CMS will exempt physicians from MIPS in 2017 if they are in their first year of Medicare Part B participation, part of an advanced APM, or are below the low-volume threshold of $30,000 or less in Medicare Part B charges or 100 or fewer Medicare Part B enrolled beneficiaries annually. CMS tells TMA it will soon add a website tool to help physicians determine if they are below the low-volume threshold and exempt from MIPS in 2017. TMA will notify physicians once the tool is made available by CMS. 

Bare Minimum Requirements

If you are not in an advanced APM and are not exempt from MIPS in 2017, you must complete at least one of the following bare minimum requirements to avoid the 2019 MIPS penalty:

Quality Category   

  • To submit the bare minimum for this category, you only need to report data on one quality measure for one patient for any point in time in 2017. TMA recommends physicians report on more than just one patient to ensure sufficient data is received by CMS.
  • Review the list of 271 MIPS quality measures and select a measure that applies to you and your patients.
  • The most affordable and easiest way to submit the bare minimum for the quality category is through claims-based reporting. The process to report data on quality measures via claims should be similar to what it was for PQRS, except you will need to refer to 2017 MIPS measure specifications to obtain the most current data codes for the quality measure you choose to report. NOTE: Make sure you use only MIPS codes and not old PQRS codes.
  • Access the TMA guide for step-by-step guidance on how to select a quality measure and review measures specifications to obtain quality data code(s) that you will use on a claim form.
  • The deadline for claims-based reporting for the quality category for the 2017 performance period is Feb. 28, 2018, but you can fulfill this bare minimum requirement now.  

Improvement Activities Category   

  • To submit the bare minimum for this category, you only need to report that you completed one improvement activity for a minimum of 90 days in 2017. 
  • Review the list of 92 improvement activities, and identify at least one improvement activity your practice already does and will continue to do or which activity your practice could implement or engage in to receive credit for the first performance period.
  • The most affordable and easiest way to submit data on improvement activities is by attesting to participation via the CMS MIPS portal. This portal is not yet ready, but will be made available by January 2018. Once available, it is expected that all you will need to do is log in and attest to one activity on the list.
  • The deadline for attestation for the Improvement Activities category for the 2017 performance period is March 31, 2018.  

Advancing Care Information Category    

  • To submit the bare minimum for this category, you only need to attest to meeting the four or five measures that are required for the base score. CMS will accept a minimum of 90 consecutive days of data in 2017. 
  • Review the list of up to 15 measures and two reporting options, and select your reporting option and number of measures required for the base score that corresponds with your electronic health record (EHR) edition.
  • For the measure requiring a yes/no response, the answer must be "yes." For numerator/denominator measures, you must report at least "one" in the numerator, meaning at least one patient per measure during the 90-day reporting period to meet the bare minimum requirements for the base score. 
  • Contact your EHR vendor to inquire about these requirements, whether you will be able to meet them through your EHR system, and to discuss fees for MIPS reporting.
  • The deadline for attestation for the Advancing Care Information category for the 2017 performance period is March 31, 2018.    

According to CMS, completing one of the above actions in 2017 will ensure you avoid the 2019 MIPS penalty. However, the more data you submit, the greater the potential for a higher performance score and bonus payment. If you decide to report more data in 2017 to shoot for a bonus payment in 2019, review the TMA MACRA Checklist to learn about requirements for full year or partial year participation. 

As always, visit the TMA MACRA Resource Center to stay up to date on the latest information.  

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Meaningful Use Hardship Exemption Application Due by July 1

Physicians who are not participating in the Medicare electronic health record (EHR) incentive program, also known as meaningful use, will be penalized by Medicare beginning Jan. 1, 2018. To prevent the penalty, physicians must have either attested to meaningful use by March 13, 2017, or applied for a hardship exemption by July 1, 2017.

Physicians who meet these criteria are automatically exempt from the program and do not need to file an exemption application: 

Specialties: If you're classified in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) as one of these five specialties, you don't need to file an exemption and will be exempt for payment year 2018:   

  • Diagnostic radiology,
  • Nuclear medicine, 
  • Interventional radiology, 
  • Anesthesiology, and 
  • Pathology.   

New to practice: If you are in your first year of practice, you do not need to claim an exemption. The Centers for Medicare & Medicaid Services (CMS) says it will know you are new to practice and will automatically exempt you. 

Hospital-based: If you perform more than 90 percent of services using place-of-service codes 21 or 23 (hospital), then you will automatically be exempt from the Medicare penalty. 

Other exemptions are available, but you must take the time to fill out the 10-page application and submit it to CMS by July 1. If more than 100 physicians are applying for the same hardship, please attach an Excel spreadsheet listing each physician’s first name, last name, and NPI.

You can apply for a hardship exemption for these circumstances:   

  • Insufficient internet connectivity: You must demonstrate that your practice is in an area without sufficient internet access to comply with meaningful use and that you face insurmountable barriers to obtain such connectivity. 
  • Extreme and uncontrollable circumstances: This exemption can be claimed in the case of a natural disaster, practice closure, or bankruptcy, or for EHR certification/vendor issues. 
  • Lack of control over the availability of certified EHR technology: You have no control over the availability of certified EHR technology in one or more practice locations where more than 50 percent of the patient encounters occurred.
  • Lack of face-to-face patient interactions: Your specialty isn't listed above as exempt and you lack face-to-face interactions with your patients.   

Exemptions must be renewed annually, and you may not claim an exemption for more than five years.

If you never successfully attested to meaningful use in the past, but plan to report for program year 2017 (which would prevent a 2019 Medicare fee-for-service penalty) under the MACRA Merit-Based Incentive Payment System (MIPS), you can submit a Transitioning to MIPS Hardship Form by Oct. 1, 2017, to avoid the penalty in 2018. 

Contact TMA's Health Information Technology Department with questions by email or by calling (800) 880-5370.  

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Medicaid Help in Five-Minute Doses

Texas Health Steps Online Provider Education (OPE) recently released two quick courses. Quick courses give you five minutes of targeted instruction on timely topics or policy updates.

The new courses are:  

Texas Health Steps OPE is a one-stop source for free, online continuing education that supports improved health and well-being for Texas infants, children, and adolescents enrolled in Medicaid. 

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 New Form Required for All Medicaid EHR Incentive Program Participants

Starting April 1, all participants of the Medicaid electronic health record (EHR) incentive program for program year 2017 or later must complete a Third Party Attestation Authorization Form indicating whether you intend to use a third party to complete your meaningful use attestation.

You can complete the form on a computer using a digital signature and upload it to the Texas Medicaid EHR Incentive Program portal. Alternatively, you may print it, sign in ink, and scan it as an electronic file for upload. Participants will be prompted during the attestation process to upload the form through the secure upload function in the portal. You must complete and submit the form before receiving an incentive payment.

To find out more about the Medicaid EHR incentive program and attestation requirements, see the Texas Medicaid website.

If you have questions about the meaningful use program, contact TMA's Health Information Technology Department by email or call (800) 880-5720. 

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 Your Video Guide to Texas' New Prescription Drug Monitoring Program

In an effort to address the very real and debilitating crisis caused by the misuse of opioid pain medicines, the Texas Sunset Advisory Commission has recommended a mandate that all prescribers and pharmacists check the state's Prescription Drug Monitoring Program (PDMP) before prescribing any controlled medication.

TMA, other prescribers, and pharmacies are fighting that proposal in the Texas Legislature and recommend instead that lawmakers turn to the new and evolving technology of the revamped PDMP and its abilities to accomplish a number of important data tasks.

In conjunction with that strategy, TMA is introducing a new tutorial video to help physicians set up accounts and use the new PDMP website, hosted by the Texas Board of Pharmacy. Allison Benz of the pharmacy board demonstrates the new site in this brief, informative TMA-produced video, showing viewers what each page looks like and how to navigate and interact with the site.

At TMA's urging, the state moved the PDMP from the Texas Department of Public Safety to a new online system the pharmacy board created in 2016. This online portal is designed to facilitate physician participation in the new program. Physicians and health care providers can set up an account to enter info or check existing prescriptions of Texas patients.  

 

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Supervise an APRN or PA? What You Need to Know

Delegating duties to an advanced practice registered nurse (APRN), physician assistant (PA), or other nonphysician can be an excellent way to enhance your practice and improve your patients' access to quality medical care. But, a newly updated TMA white paper cautions, you have to do it right. Your license to practice may be at risk.

Delegation of Duties by a Physician to a Nonphysician is available to TMA members only.

"Generally, latitude is given to a supervising physician in the physician's delegation authority, but which acts a physician may delegate greatly depends upon the education and experience of the person to whom the acts are being delegated," according to the white paper. "A physician must adequately supervise the activities of those acting under the physician's supervision, and may not delegate professional medical responsibility or acts to a person if the delegating physician knows or has reason to know the person is not qualified by training, experience, or licensure to perform the responsibility or acts."

The 18-page white paper covers the law, ethical considerations, billing, standing orders, delegating duties and prescriptive authority, supervisory requirements, administration of anesthesia, and other practical considerations. It discusses supervising and delegating duties to APRNs, PAs, physical therapists, medical assistants, pharmacists, and midwives.

TMA's Office of General Counsel reminds you, however, that the information in the white paper "is of a general nature and should not be used in place of retained legal counsel."

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