2002 TMA Annual Report: Taking the Bull by the Horns

President's Message

While we savored our share of victories on behalf of physicians and patients, the Texas Medical Association spent much of 2002 preparing for the health care tempests we saw swirling on the horizon.

The storm clouds, it seemed, were everywhere. Workers' compensation and Medicare rates fell. Liability insurance rates shot upward. HIPAA regulations loomed, our vaccination rates were lousy, and "prompt" just didn't seem to be a word in the health plans' vocabulary.

But, just as you would expect, we rustled up the resources to fight back. We stopped the workers' comp disaster dead in its tracks. We delivered always pertinent -- and often personalized -- practice management advice. We won several important skirmishes in our class action lawsuit against the for-profit HMOs. We educated every physician in Texas with our 16-page bioterrorism toolkit.

And we prepared, like never before, for the legislative brawls we knew were coming this year. TMA founded the Texas Alliance for Patient Access, a broad-based coalition to help win meaningful health care lawsuit reform. We researched the real costs of running a physician's practice so we would have irrefutable numbers to back our payment advocacy efforts. Our councils, committees, and House of Delegates developed strong, scientifically sound policy on immunizations, Medicaid, black mold, and genetically modified foods.

There's strength in numbers, so we're happier than ever that a record number of physicians and medical students have come inside the TMA corral. We spent your dues dollars wisely, marshaling our resources for the tough days to come.

I am proud to be the leader of America's best medical society this year. I know that what we accomplish together makes us all better doctors. And isn't that what we all really want?

Thank you for your support, and congratulations on a job well done.


Fred L. Merian, MD

Wranglin' for Your Rights

In 2002, physician advocates found their efforts to shape the state's health policy and regulations more often akin to herding cats than cattle. But TMA advocates began to whip legislative, legal, and regulatory programs into shape that would address the looming crises in medical liability, workers' compensation, and Medicaid. Those crises threatened to drive doctors out of some programs and specialties.

The first priority for TMA physicians was rounding up a health care lawsuit reform package to solve a growing crisis of rising medical liability premiums. With premiums sky-high for doctors engaged in obstetrics, neurosurgery, and other high-risk specialties, Texas physicians were beginning to question whether they could afford to stay in business. TMA physician advocates quickly homed in on a series of reforms first enacted in California in 1975: The Medical Injury Compensation Reform Act (MICRA) has kept California premiums far more stable than those of other states for the past 25 years.

TMA looked into the effectiveness of MICRA and prepared TMA physicians to go after four key reforms in the 2003 legislative session: a cap of $250,000 on noneconomic damages such as those awarded for pain and suffering, a legal change that stops patients from double-dipping by recovering damages for medical and other expenses already paid for by the patients' health insurance, a limit on excessive contingency fees paid to lawyers for the patients, and the periodic payment of damages to successful plaintiffs.

Steered by the standing Committee on Professional Liability and the Council on Legislation's Subcommittee on Professional Liability and Workers' Compensation, TMA also took on the laws governing the qualifications of expert witnesses and the effectiveness of the Texas State Board of Medical Examiners in dealing with patient safety.

TMA pursued additional legal advocacy through its General Counsel's Office and Board of Councilors. The association continued to shore up class action litigation that requires managed care organizations (MCOs) and other health insurers to fix their prompt pay problems. TMA remains an active party in a federal lawsuit pending in Florida that alleges that major health insurers broke antiracketeering laws in their efforts to delay payments to physicians. When health insurer CIGNA attempted to undercut the suit by reaching a settlement in Illinois with other doctors, TMA helped to block this by taking information to the Florida federal district court judge. As a result, the Florida judge ordered an injunction against CIGNA until a panel of federal judges decides whether the Illinois CIGNA settlement was valid.

Concerning the right to have independent physicians review MCO decisions, TMA hit pay dirt in December 2002, when the U.S. 5th Circuit Court of Appeals applied the U.S. Supreme Court's June decision in Rush Prudential HMO Inc. v. Moran to the Texas statute that allows independent review. The panel reversed an earlier decision that the Texas review process violated the Employee Retirement Income and Security Act (ERISA). TMA filed friend of the court briefs in both cases in support of the winning patients.

The General Counsel's Office also championed litigation in state courts, pursuing a class action suit against CIGNA for depriving physicians of payment through suspect reimbursement policies such as bundling and downcoding. When CIGNA argued that most of the plaintiff physicians were subject to arbitration clauses in their contracts, TMA supported the fight, as yet unresolved, for consolidated arbitration.

TMA bristled at the adoption of workers' compensation fee guidelines that lowered the pay for most specialists and threatened the availability of doctors for injured workers. Although the association could not thwart the Texas Workers' Compensation Commission (TWCC) passage of the guidelines, it maneuvered quickly for a joint effort with labor to challenge the guidelines as arbitrary and for being illegally based on federal Medicare fees. TMA persuaded a judge that TWCC had failed to follow its mandated process in enacting and justifying the guidelines, winning a temporary restraining order to ground the new guidelines. A full trial on the challenge was set for April.

Other advocacy efforts centered on preserving as many Medicare and Medicaid programs and as much funding as can be salvaged in the state's budget crisis, and keeping an eye on the status of clean claims and other pay disputes through TMA's Hassle Factor Log program and carrier meetings with health insurers.

TMA cochaired a task force on Medicaid pharmaceutical cost-saving options, whose recommendations saved physicians more than $50 million. Partnering with the state specialty societies, TMA developed drug management protocols for the Medicaid Vendor Drug Program that the Health and Human Services Commission will use to educate physicians and other prescribers about appropriate utilization and costs of commonly prescribed drugs.

TMA also charged an Ad Hoc Committee on Medicaid to work out legislative recommendations for 2003. The committee, comprising 10 physicians from a range of primary and specialty care backgrounds, crafted 24 proposals to help reform the Texas Medicaid program. Among the recommendations are the immediate appointment of a Select Committee on Medicaid to advise state leaders on cost-saving options; implementation of an evidence-based, physician-recommended preferred drug list within the Medicaid Vendor Drug Program; expansion of the primary care case management model to border and rural counties to ensure better care coordination and cost-effectiveness within the program; and continued support for the moratorium on Medicaid HMO expansions, except at local option.

Circlin' the Wagons

The threat of bioterrorism, the reemergence of some vaccine-preventable diseases, and increasing rates of heart disease all challenged medicine in 2002. But TMA worked hard to give physicians the tools to lasso these public health threats.

With the hazard of bioterrorism magnified by the Sept. 11, 2001, attacks, TMA worked to make sure that Texas physicians are prepared to respond, providing ongoing education and information on bioterrorism issues. A TMA bioterrorism task force developed a Texas Medicine supplement of physician protocols on four biological weapons: smallpox, botulism, anthrax, and plague. TMA also e-mailed public health alerts and provided continuing medical education (CME) opportunities for physician members. Association representatives testified to the state's Homeland Security Task Force and several legislative committees and participated in disaster response projects through the Texas Institute for Health Policy Research and the Texas Department of Health.

Childhood diseases that were prevalent on the frontier, such as whooping cough, were on the rampage in Texas again in 2002, and TMA rode in to head them off. The Council on Public Health developed a policy paper on improving immunization rates in Texas and worked with the interim Senate Health and Human Services Committee to make sure the council's eight-point plan was included in the committee's report to the legislature. TMA educated legislative staffers on the importance of immunizations and vaccine administration issues. The association also trained physicians on vaccine safety, smallpox, and vaccine shortages through Texas Medicine and formal CME.

Facing rising consumer and legislative concerns over quality of care, TMA created an Ad Hoc Committee on Patient Safety, an intercouncil physician team to develop TMA's legislative platform on reforming the Texas State Board of Medical Examiners and to powwow with the Texas Business Group on Health on private sector quality initiatives.

TMA also joined with Blue Cross and Blue Shield of Texas, Inc., (BCBS) to kick off a disease management pilot project, whose members included physician representatives from the councils on Scientific Affairs, Legislation, and Socioeconomics, and representatives from BCBS, HEB, and The University of Texas System. Members selected congestive heart failure as the medical condition of the project, Austin and San Antonio as the sites, and Inpatient Medical Services as the vendor to work with TMA physicians to implement the pilot in 2003.

Ready for a showdown with heart disease, TMA's HeartCare Partnership (HCP) made available its chart audit software program to all Texas physicians. The software program can be downloaded free of charge on the TMA Web site. With 2,797 patient charts in its aggregate database, HCP is seeing improved documentation of smoking cessation, regular diet and exercise counseling, and an increased percentage of statins and beta-blockers being prescribed.

As a result of Senate Bill 19 passing in 2001, TMA took part in the Texas Education Agency Coalition Team to establish criteria for evaluating and selecting a list of viable, high - quality coordinated school health programs for school districts to put into practice.

May 2002 witnessed the culmination of the TMA president's Task Force on Genetically Modified Foods when the House of Delegates adopted the task force's recommendations. The task force concluded that there is no evidence that genetically modified foods are unsafe for human consumption, but the panel recommended that the safety of such foods continue to be monitored. TMA members gobbled up a CME session on genetically modified foods at TexMed 2002.

TMA also gunned down myths about the connection between black mold and health problems in a much-publicized position paper the TMA Council on Scientific Affairs prepared and the House of Delegates adopted. The paper documented the lack of scientific evidence regarding sickness caused by black mold.

With input from the TMA Board of Trustees and other physicians, TMA rallied with the Texas Department of Insurance and others to write a mandated credentialing/re-credentialing application that would reduce the "hassle factor" for physicians.

TMA continued to monitor public funding for graduate medical education and advocated the restoration of Medicare cuts that funded the indirect medical education costs of teaching hospitals and residency programs.

The association also established a process for reviewing requests for TMA's support of individual medical school expansion or new campus proposals, and informed members of national efforts to implement a clinical skills assessment exam for U.S. medical graduates and a state proposal to require competency testing as a condition for relicensure of Texas physicians.

Keepin' the Home Fires Burning

The TMA homestead is bursting at the seams with new members and new programs to serve Texas physicians. TMA closed its 2002 books with a record 38,215 physicians and medical students on the membership rolls -- that's up 3 percent from the year before. All major membership categories showed improvements, particularly the critical-for-the-future resident physicians (up 7 percent) and first-year-in-practice physicians (up 16 percent).

Medical student membership also jumped, by 4 percent, and Natacha Torres of the University of North Texas Health Science Center at Fort Worth is one of our newest additions. The sixth winner of TMA's Minority Scholarship Award, Ms. Torres began her medical career with volunteer stints in medical missions in Mexico and Arizona, serving as translator, nurse, publicist, secretary, and fundraiser.

Resolving the most pressing issues for both today's and tomorrow's physicians was the goal of the Texas physicians in our American Medical Association House of Delegates. These included opposing the national clinical skills examination for medical students, actively backing the house decision to make professional liability reform the AMA's highest legislative priority, and voting to "condemn any physician who would harm a colleague with false testimony." John Armstrong, MD, a military trauma surgeon from San Antonio, won election to the young physician slot on the AMA Board of Trustees, and San Antonio pediatric neurologist Sheldon Gross, MD, was appointed to the AMA Political Action Committee (AMPAC) Board of Directors.

A cooperative effort with AMA is one of the new member services TMA began offering in 2002. Online Consultation allows physicians to communicate securely with patients online and deliver convenient, quality care, and receive direct payment through the Medem network.

Finally, TMA physicians and senior staff turned out in their Sunday best to honor Louis J. Goodman, PhD, the TMA executive vice president and chief executive officer who was elected president of the American Association of Medical Society Executives (AAMSE). From this post, Dr. Goodman is sharing his energy, ideas, and leadership skills with other leaders in this rapidly changing industry.

Steerin' You in the Right Direction

In 2002, TMA rounded up a wide variety of services for its members, from consulting to continuing medical education to online learning.

TMA Physician Services, spurred by the association's goal of helping physicians start and maintain healthy medical practices, provided consulting services to 165 members and reached 150 resident physicians across the state through seminars on starting a medical practice.

When physicians needed help with the rules and regulations of the Health Insurance Portability and Accountability Act (HIPAA), they turned to TMA for a full continuum of services. The TMA legal team wrote multiple in-depth articles and galloped around the state giving talks on HIPAA. The association's medicolegal experts developed "HIPAA: All Systems Go," a seminar offered throughout Texas that helped physicians put privacy practices in place. The association overhauled its renowned Medical Office Policy and Procedure Manual to reflect the new compliance requirements. And TMA's practice management services posse distributed "HIPAA: Take the Bull by the Horns," a home study course on the complex HIPAA regulations, in the September issue of Texas Medicine . The course, along with other HIPAA help, is in the "HIPAA Resource Center" on the TMA Web site. To round out our support to TMA members, the practice management team consulted with numerous individual physicians to make sure their practices complied.

TMA's Council on Annual Session staged TexMed 2002 in Dallas, offering more than 150 hours of free CME to TMA members. More than 3,000 physicians stampeded to Dallas for three days of thought-provoking discussions, policymaking, exhibits, and social events. The conference management office presented more than 175 seminars on 20 topics -- including regulatory compliance, legal issues, and reimbursement -- throughout the state, and developed risk and practice management publications to help members deal with the business side of medicine. Many of the publications offered AMA PRA Category 1 CME credit (including ethics) and allowed members insured by the Texas Medical Liability Trust to earn discounts on their professional liability premiums.

Other CME-related activities during 2002 included implementing an interactive online ethics CME course that permitted learners to pay by credit card and receive immediate documentation of completion; maintaining an intrastate accreditation program of 50 CME programs in Texas that enabled nearly 17,000 physicians to participate in CME at the local level; and presenting 218 CME activities offering 778 hours of formal CME credit. Two hundred and ninety-one of those hours also were designated as ethics and/or professional responsibility education to meet the Texas State Board of Medical Examiners' annual requirement for ethics education.

Nearly 9,000 physicians took advantage of the CME opportunities offered by TMA in 2002. Another 1,700 physicians attended the 46 CME activities that the association jointly sponsored with county medical societies and state specialty societies.

In 2002, the TMA Library began offering online resources to members for free. Frequently used databases the library licensed included MD Consult and Ebsco Publishing's biomedical reference and health business collections.

The library also got together with TexShare, the Texas State Library and Archives Commission's statewide online resource-sharing program. Funded by the Telecommunications Infrastructure Fund Board, this program offers online resources on a wide range of topics, including science and technology, business information, general reference, history and genealogy, newspapers and magazines, and Spanish language resources.

Grabbin' the Brass Ring

The Texas Medical Association Political Action Committee (TEXPAC) candidates won big in the November elections for U.S. Senate, attorney general, and key congressional and state house seats. And medicine continued a dominance of the state supreme and appellate courts to keep those benches fair and void of trial lawyer control.

With TEXPAC's backing, Greg Abbott (R) handily defeated trial lawyer Kirk Watson (D) for attorney general. Mr. Abbott made medical liability a focal point of his campaign. Comptroller Carole Keeton Rylander (R) crushed Marty Akins (D) in her bid for reelection. She will be a major factor in all budgetary issues, such as Medicaid.

While medicine was divided on the races for governor and lieutenant governor, Gov. Rick Perry and Lt. Gov. David Dewhurst both have made strong statements of support for Texas physicians' No. 1 agenda item: medical liability reform.

At the federal level, longtime TEXPAC friend John Cornyn became U.S. senator, and TEXPAC remained flawless in congressional races for 2002. Michael Burgess, MD, easily won election to Congress with more than 75 percent of the vote. TEXPAC-supported candidates Chris Bell (D-Houston) and Jeb Hensarling (R-Dallas) also won key open seats, while incumbent friends Reps. Charlie Stenholm (D) and Chet Edwards (D) won reelection.

Two physicians now serve in the Texas Senate for the first time in history. Kyle Janek, MD, (R-Houston) easily won in District 17, and Bob Deuell, MD, (R-Greenville) beat incumbent Sen. David Cain (D-Mesquite) in District 2.

TEXPAC won a number of key Texas House victories, including several open races and the defeat of incumbent Ann Kitchen (D-Austin) by Todd Baxter (R-Austin). TEXPAC also helped retain friendly incumbent Reps. Gene Seaman (R-Corpus Christi), Dan Ellis (D-Livingston), Robby Cook (D-Eagle Lake), Sid Miller (R-Stephenville), and Rick Hardcastle (R-Vernon).

After the Dust Settles

TMA ended a highly successful programmatic year with income of $17.6 million and expenses of $17.8 million.

The association's primary source of operating income was dues (55 percent). Additional income was derived from nondues, income-producing programs approved by the Board of Trustees, such as educational workshops, advertising, and member services. An average of $700 per active member was expended on TMA programs and activities in 2002.

2002 Expense by Focus Area

2002 Operating Income

2002 expense
2002 income

April 2003 Texas Medicine Contents
Texas Medicine Main Page