TMA Takes on Budget, Medicaid, Scope, End of Life

The 2013 Texas Legislature kicked off Jan. 8 with a rosier budget picture than last session, which could be good news for TMA's goals of restoring many of the harsh cuts enacted in 2011. Fewer bills filed so far this session also could mean more air time for health care issues.

That includes Medicaid, expected to remain a focus for lawmakers. As such, making headlines was the TMA Board of Trustees' decision at TMA's Winter Conference to support a bipartisan, federal-state solution to reform the state's Medicaid program and expand coverage to poor, childless adults.

Meanwhile, just one month into session, TMA already reached landmark agreements on bills addressing certain scope-of-practice and end-of-life issues. A number of insurance-related bills have medicine on alert.

Key committee appointments of House and Senate members of the house of medicine could play a big role in moving medicine's efforts forward.   

On the Senate side: Sen. Bob Deuell, MD (R-Greenville), kept his spots as vice chair of the Senate Health and Human Services and State Affairs committees and as a member of the Senate Finance Committee; rookie Sen. Charles Schwertner, MD (R-Georgetown), won a seat on Health and Human Services; and new Sen. Donna Campbell, MD (R-New Braunfels), was appointed to the Senate Education Committee.

In the House: TMA Alliance member Rep. Susan King (R-Abilene), Rep. John Zerwas, MD (R-Simonton), and new Rep. Greg Bonnen, MD (R-Friendswood), have seats on the Appropriations Committee. Representative King and new Rep. J.D. Sheffield, DO (R-Gatesville), are on the Public Health Committee. Dr. Zerwas also is on the Human Services Committee, and Dr. Bonnen is on the Insurance Committee.

Let the Budget Battle Begin
In early February, Senate and House members began tackling their respective budgets, albeit conservatively.

Both chambers unveiled budgets of about $90 billion in state funds. That's well above last session's $80 billion budget, but still below the $101.4 billion that Comptroller Susan Combs projected was available for the 2014-15 biennium. The state's Rainy Day Fund has about $12 billion on hand that lawmakers appear reluctant to touch right away.

Both draft budgets, Senate Bill 1 and House Bill 1, take into account the $4.5 billion needed to make the Medicaid program whole from last session.

The Senate Finance Committee began hearings on SB 1, and physician leaders urged lawmakers to fund medical education and graduate medical education programs; mental and public health; and family planning and women's health services. 

TMA officials already see signs of improvement on medical education funding. The initial Senate budget puts $33.4 million into the Texas Physician Education Loan Repayment Program – way up from the $5.6 million from last session and higher than the $20 million in funding when the program first started. Lawmakers are looking to use the new money to add 200 physicians to the program over the biennium.

TMA physicians also asked senators to reverse the 20-percent payment cut for physicians who treat patients dually eligible for Medicare and Medicaid.

In a partial win, the Texas Health and Human Services Commission reinstated payment of the $147 Medicare Part B deductible for these patients in January. It's up to the legislature to restore the 20-percent Medicare copayment that Medicaid used to cover for poor patients.

Medicaid Front and Center
Medicaid already is the subject of several bills that aim to save money by expanding Medicaid managed care, adding quality-based payment initiatives, and fighting fraud.

On the latter, Senate Bill 8 would essentially codify controversial state regulations that physicians believe could allow authorities to charge them with fraud for simple billing errors. TMA officials are working to ensure due process protections are included in that bill.

Despite Gov. Rick Perry's staunch opposition to expanding the state's Medicaid program as prescribed by the Patient Protection and Affordable Care Act, some lawmakers entertain the idea of finding a state-based solution that would allow Texas to get some of the extra federal dollars available.

Nor do physicians want the state to miss out on money that could go a long way toward helping their patients – so long as it fixes the broken program to win back the doctors needed to take care of those patients.

That's the gist of a recent policy statement that seeks expansion of coverage for poor, childless adults that is not traditional Medicaid.

How far those conversations go in the legislature remains to be seen.

Landmark Agreements on Scope, End of Life
There is no question, meanwhile, that TMA and nurse practitioners broke ground on a bill that protects diagnosing and prescribing as the practice of medicine, while allowing doctors to delegate their prescribing authority to advanced practice registered nurses (APRNs) and physician assistants (PA) as part of a physician-supervised care team. TMA officials say Senate Bill 406 will help establish a more flexible and collaborative practice model that improves on current site-based restrictions and expands access to care.

Months of discussions among TMA, the Texas Academy of Family Physicians, APRNs, and PAs led to the filing of the bill by Sen. Jane Nelson (R-Flower Mound) and Rep. Lois Kolkhorst (R-Brenham). The Senate Health and Human Services Committee unanimously approved the legislation, which heads to the full Senate.

Still, TMA officials anticipate other legislation aiming to expand the scope of practice of other allied health professionals. House Bill 624, introduced by Rep. Bill Zedler (R-Arlington), for example, requires health plans to pay podiatrists, optometrists, and others the same rate as their physician counterparts.

Senate Bill 303 could be another big step forward in helping to resolve the end-of-life debates that are a regular session item of late. The legislation protects doctors' rights to do what they believe is ethically and medically best for patients in their last days, while updating the Texas Advance Directives Act to give patients and their families more time and help during such discussions. Senator Deuell worked on the bill with TMA, the Texas Hospital Association, the Texas Alliance for Life, and other health care, religious, and right-to-life groups.

On the insurance front, House Bill 620 introduced by Rep. Craig Eiland (D-Galveston) seeks to regulate the so-called "silent PPO" market and prevent health plans from subcontracting physicians' discounted rates without doctors' knowledge.

However, TMA officials have a careful eye on Senate Bill 257 (Representative Deuell), which could limit physicians' ability to challenge an incorrect payment made by health plans.

House Bill 522 by Rep. John Kuempel (R-Seguin) authorizes health plans to directly pay ambulance providers and could apply to physicians not in a patient's plan. But TMA lobbyists say it is unclear whether the bill would be more administratively burdensome for doctors than the current assignment-of-benefits process.

Cutting Red Tape
To help reduce administrative burdens for practices, TMA supports HB 1032 by Representative Zerwas. The bill requires the Texas Department of Insurance to appoint a stakeholder workgroup to design a uniform and standard prescription drug prior authorization form applicable across all payers, including Medicaid, the Children's Health Insurance Program, and workers' compensation. A similar bill in the works addresses the standardization of a prior authorization form for medical services. 

TMA also is pressing for measures to relieve doctors from Department of Public Safety backlogs by making the renewal of their license to prescribe controlled substances concurrent with the medical license renewal process.

On the other hand, House Bill 595 could create another hassle factor for physicians: The bill, sponsored by Representative Kolkhorst, requires various health care entities to report to the state on quality and costs. TMA is monitoring the bill to discern to what degree physicians would have to submit such data.

On public health, Rep. Myra Crownover (R-Denton) said she plans to reintroduce a bill supporting the TMA and Texas Public Health Coalition's goals for statewide smoke-free legislation, particularly for employees who have little option but to work in smoke-filled environments.

Several vaccination bills filed would help the coalition advance its vaccine policy: Senate Bills 62, 63, and 64 by Senator Nelson, and Senate Bill 40 by Sen. Judith Zaffirini (D-Laredo). In the House, legislation by Rep. Donna Howard (D-Austin) preserves young adult vaccination data of those whose parents consented.

TMA leaders also testified in support of half-a-dozen bills to ban texting while driving. A similar effort passed both chambers in 2011 but Governor Perry vetoed it.

Record February "First Tuesdays"
Legislators heard all about medicine's agenda through TMA's initial First Tuesdays at the Capitol lobbying event on Feb. 5 with a record turnout. Nearly 300 physicians, medical students, and TMA Alliance members knocked on the doors of their representatives and senators to discuss Medicaid, medical education funding, public health, and other critical issues.

The remaining First Tuesdays events are March 5, April 2, and May 7.

Amy Lynn Sorrel, associate editor of Texas Medicine, prepared this special supplement to Action.