There are only two weeks left in the 81st Texas Legislature.
Both the House and Senate are expected to work late into the night
everyday through the end of the session. However, many bills are
likely to die because of a series of deadlines that began kicking
in on May 11. For example, the last day for House committees to
approve House bills was May 11. The last day House committees can
report out Senate bills will be May 23.
While those deadlines undoubtedly will result in failure for
hundreds of bills, many of organized medicine's top priorities
seemed to be moving through the process and enjoyed good chances of
passage. Here is a brief rundown of where Texas Medical
Association's key issues stood as the session entered its final
Two of TMA's top health insurance priorities cleared the Senate in
early May and were referred to the House Insurance Committee.
Senate Bill 1257 by Sen. Kip Averitt (R-Waco), TMA's health
plan code of conduct bill, creates more transparency in how health
plans conduct business. SB 1257 would limit health plans' ability
to rescind a policy based on preexisting conditions, standardize
the reporting of the health plans' medical loss ratio, allow the
Office of Public Insurance Counsel to help small
employers with premium quotes, and address health plan
SB 815 by Sen. Kirk Watson (D-Austin) requires health plans to
develop "soup can" style labels for their products to make it
easier for consumers to compare coverage levels, premiums, and
other information on various health insurance products.
The bills are part of TMA's
Patients' Right to Know
initiative. TMA hopes both bills will make it through the House and
land on Gov. Rick Perry's desk before the end of the session.
Legislation requiring health plans to provide real-time coverage
and benefit information to physicians and other providers at the
point of service also appeared to be on its way to
passage. House Bill 1342 by Rep. Jose Menendez (D-San
Antonio) and Sen. Chris Harris (R-Arlington) passed the House in
late April and received Senate State Affairs Committee approval on
A possible vehicle for both good and bad amendments relating to
health insurance coverage is SB 1007 by Sen. Glenn Hegar (R-Katy),
the Texas Department of Insurance sunset bill. Because the
bill opens up all the statutory provisions relating to insurance in
the state of Texas, any legislation dealing with insurance coverage
is potentially germane to the bill and could be added as an
amendment. TMA will be involved directly in developing good
additions to the legislation and watching for bad amendments from
the health plans and others.
Both the House and Senate have approved a budget bill for the next
biennium that includes some good news for physicians and patients.
The measure is now in a House-Senate conference committee where
lawmakers are trying to resolve differences in spending levels.
The measure includes additional funds for Medicaid to cover both
caseload growth and increased fees for physicians. The Senate
version includes a 3-percent hike in physician fees, while the
House version includes a 1.5-percent increase as part of the
so-called "wish list" -items that would be funded if money is
available. The bill also increases state support for graduate
The bad news, however, is that lawmakers may need to find even
more money for Medicaid caseload growth. Lt. Gov. David Dewhurst
announced in early May that new caseload projections would require
an additional $1 billion over what the Senate had already approved
for caseload growth. Several lawmakers say the sudden increase in
projected Medicaid caseload is nothing more than a ruse to cut
funding for existing and new initiatives, including 12-months of
continuous coverage for children in Medicaid, since forecasting
future caseload growth is speculative to begin with.
House budget conferees suggested using a more moderate caseload
forecast, but the issue had yet to be resolved. There is
speculation that budget writers might dip into the state's
so-called "rainy day" fund for the money. Lawmakers previously were
spared from using any of the rainy day fund because of federal
money the state received as part of President Obama's stimulus
bill. Those funds totaled some $17 billion, including more than $5
billion for Medicaid.
TMA believes increasing physicians fees under Medicaid and the
Children's Health Insurance Program (CHIP) is essential,
particularly in light of efforts under the
Frew v. Hawkins
lawsuit settlements to increase access for children on
Medicaid. Fee increases also become more important if lawmakers
approve 12 months of continuous coverage under Medicaid or vote to
allow families earning up to 300 percent of the federal poverty
level to buy in to CHIP. There's little point in expanding those
programs if there are not enough physicians participating to
provide access for those children, TMA leaders say.
House and Senate budget conferees also appear to have agreed to
earmark $450 million for the new Cancer Prevention and Research
Institute of Texas. The institute was created in 2007 using some $5
billion in voter-approved bonds.
TMA's agenda on medical liability this session was to defend the
2003 tort reforms from any assaults by the trial lawyers. It
appears the association has been successful. SB 152 by Sen. Rodney
Ellis (D-Houston) was the main threat to the 2003 reforms, but it
remains stranded in the Senate State Affairs Committee. The bill
lowers the standard of proof required in medical liability lawsuits
involving emergency care.
TMA leaders, however, are monitoring the bill to make sure the
trial lawyers don't make a run at tacking similar language onto
Legislation giving virtually all rural hospitals the ability to
directly hire physicians passed the Senate and is pending in the
House County Affairs Committee. SB 1500 by Sen. Robert Duncan
(R-Lubbock) allows critical access hospitals, sole community
hospitals, and hospitals in counties of fewer than 50,000
residents to employ physicians. The Texas Organization for Rural
and Community Hospitals (TORCH) and the Texas Hospital Association
(THA) back the bill. As written, the bill applies to hospitals in
some 160 counties across the state.
TMA is working with Rep. Garnet Coleman (D-Houston), chair of
the House County Affairs Committee, to amend the bill to protect
physicians from hospital administrators interfering with their
clinical autonomy. TMA also wants to lessen the bill's reach. TMA
proposes that the measure apply only to critical access hospitals
and sole community hospitals with medical staffs of fewer than 15
TMA believes the bill currently applies to hospitals that have
adequate medical staffs and, therefore, do not need to employ
physicians. TORCH and THA, however, have fought all attempts to
amend the bill.
TMA leaders say direct employment should be a "last option" for
those hospitals that need assistance attracting doctors to their
Scope of Practice
Legislation agreed to by TMA and owners of retail clinics to expand
physicians' ability to delegate prescriptive authority to midlevel
practitioners also appeared poised for passage. SB 532 by Sen. Dan
Patrick (R-Houston) expands from three to six the number of
physician assistants or advanced practice nurses to whom a
physician can delegate prescriptive authority. The measure also
reduces from 20 percent to 10 percent the amount of time a
physician delegating such authority must spend on-site with the
The measure, however, also requires the filing of such
delegation arrangements with the Texas Medical Board and gives the
board more oversight of such arrangements. The board also could
waive the delegation and on-site practice limits on a case-by-case
SB 532 passed the Senate and was approved by the House Public
Health Committee. It is expected to be on the House Calendar in the
next to last week of the session.
Nurse practitioners sought full independent practice, but TMA
lobbyists say that legislation is all but dead in the waning days
of the session. They are, however, keeping close watch on any bill
that might provide a vehicle for the nurse practitioners to
add an independent practice amendment.
TMA's efforts to expand the state's medical education loan
forgiveness program also appear to be in good shape heading into
the last weeks of the session. SB 2243 by Sen. Judith Zaffirini
(D-Laredo) increases from $45,000 over five years to $140,000 over
four years the amount of medical school debt that the state could
repay for physicians agreeing to practice in underserved areas. The
measure passed the Senate in late April and was referred to the
House Higher Education Committee on May 4.
If approved, the terms of the loan repayment program would be
similar to a Medicaid program launched earlier this year by the
Texas Health and Human Services Commission. Supporters of SB 2243
argue that average medical school debt is so high that the $9,000
per year in debt forgiveness available under the current program is
too small to attract young physicians to practice in underserved
Best (or Worst) of the Rest
Numerous other health-related bills are working their way through
the process, and TMA is watching a few very closely.
In early May, TMA Board of Trustees Chair Michael Speer,
testified against SB 2336
by Sen. Dan Patrick (R-Houston). Dr. Speer told members of
the Senate Health and Human Services Committee that SB 2336 would
weaken the Texas Medical Board at a time when we need a strong and
fair board to protect the patients of Texas and to uphold high
ethical and professional standards for physicians. TMA believes
improvements need to be made to the board, including ensuring that
a fair and just due-process system is in place for physicians. TMA
is working to improve that system through both legislation and the
rule-making process. However, SB 2336 would diminish the agency's
ability to protect public safety.
"One of our main concerns with SB 2336 is that it would severely
weaken the board's ability to sanction physicians for
nontherapeutic treatment or prescribing," Dr. Speer said. "Medicine
must rely on rigorous, scientific investigation to determine which
therapies work, which don't, and what risks they may pose to the
patient. In fact, the original Texas Medical Practice Act was
written nearly 100 years ago to rid the profession of the snake oil
salesmen. Today's patients are indeed harmed, some fatally, when
their physicians omit proven and appropriate treatments in favor of
their own unproven regimens. This bill would allow a physician to
prescribe Laetrile or human urine for cancer treatment … or
injections of jet fuel as a cure for allergies. Removing this
ability to discipline for nontherapeutic prescribing would curtail
the board's ability to sanction a physician for illegally diverting
Dr. Speer also said the bill "would virtually prohibit the Texas
Medical Board from setting standards of care," thereby seriously
jeopardizing patient safety.
A measure creating a statewide ban on smoking in public places
is still clinging to life. The House State Affairs Committee
approved HB 5, by Rep. Myra Crownover (R-Denton) after amending it
to provide exceptions for nursing homes and long-term care
facilities, cigar bars, tobacco shops, and outdoor areas of bars
and restaurants. The amended version also exempts counties of fewer
than 115,000 residents. The Smoke-Free Texas coalition fought
to keep any exceptions out of the bill.
Meanwhile, two TMA-backed immunizations bills were sent to the
governor. The first creates a lifetime adult immunization registry.
Governor Perry has already signed that measure. The second allows
Texas health officials to share immunization records with other
states in cases where Texas citizens evacuate because of hurricanes
or other emergencies.
A third TMA-backed bill to expand the state's child booster seat
law also has been sent to the governor. SB 61 would require that
children under age 8 be strapped into booster seats while riding in
automobiles unless the child is at least 4 feet, 9 inches tall.
Finally, three bills filed late in the session were advancing.
SB 7, by Sen. Jane Nelson (R-Lewisville) passed the Senate and was
referred to the House Public Health Committee. The measure seeks to
improve quality and efficiency of care in Medicaid and CHIP by
promoting health information technology, limiting payment for
so-called "never events," promoting a medical home for children on
Medicaid and CHIP, and other measures. TMA initially had concerns
about the bill but backed an amended version that, among other
things, ensures that physicians will not have to maintain a
separate electronic medical record system for Medicaid and
TMA wants to ensure that whatever system is developed works
seamlessly with office-based systems physicians are using to
communicate with private insurers. The House Public Health
Committee heard the bill on May 5 but left it pending.
The Senate passed SB 10 by Senator Duncan on May 4, and it was
referred it to the House Public Health Committee. The measure would
create pilot programs within the state Employees Retirement System
and Teacher Retirement System to test alternative payment methods.
Those methods could include payment on a global (per-person) basis,
on an episode (per-disease or health care need) basis, on a
performance basis, or any combination of these concepts. The goal
is to find ways to align payments with quality of care rather than
quantity of care.
TMA is not opposed to the pilots, but is concerned that
patients' choice of physicians could be inappropriately limited
under the bill.
Lastly, SB 8 by Senator Nelson authorizes the Texas Health
Services Authority to develop and disseminate information about
best practices and quality of care, develop recommendations to
reduce administrative costs, study alternative payment
methodologies that will reimburse physicians and health care
providers based on quality rather than quantity, study payment
incentives to increase access to primary care, and study payment
incentives related to "clinical integration." The measure has yet
to clear the Senate.
While TMA supports giving physicians more information related to
best practices, the association is concerned about making sure
physicians with expertise in quality improvement be involved in
that effort, eliminating language promoting capitated health care
systems, and expediting efforts to promote and implement the
medical home model for patients in public and private health care
systems. TMA leaders want to make sure information is kept so that
physicians can use it to improve their practices but that it is not
Senior Editor Ken Ortolon prepared this special addition to
, May 15, 2009