Medicaid Expansion, Scope Win Steal Legislative Limelight

While lawmakers scramble to fashion a budget at the halfway mark of the 2013 legislative session, Medicaid expansion remains a focal point. Gov. Rick Perry remains staunchly opposed as pressure mounts on state leaders to find a way to expand the program using billions of dollars available under the Patient Protection and Affordable Care Act (PPACA).

Meanwhile, TMA scored an early win on an agreed-to scope-of-practice bill aiming to improve team-based care.

Early budget drafts also appear to reflect medicine's call to restore many of last session's severe budget cuts. And while medicine makes progress on red-tape reduction, insurance regulation, and public health, TMA lobbyists remain vigilant for battles brewing in these areas and others that threaten the practice of medicine and patient safety.

A Better Budget 
As the House Appropriations Committee and Senate Finance Committee finalized their respective 2014-15 budgets in early March, both chambers added funding for graduate medical education (GME), the Texas Physician Education Loan Repayment Program, women's health care, and mental health care services.        

As this report was prepared, the Senate Finance Committee unanimously passed its version, Senate Bill 1, which would spend $195.5 billion in state and federal money, $94.1 billion of that in state funds.         

GME got a significant boost. Some of the proposed increases include $1.5 million for 10 grants of $150,000 each for hospitals that currently do not have GME; $10 million for GME expansion grants, a new program; $9.5 million in GME formula funding; and doubling of state funding to the Family Medicine Residency Program to $11.5 million.       

SB 1 also adds $230 million for mental health and substance abuse education, treatment, and housing, and community-based programs, among other things. And, an additional $100 million would go toward women's health services, in addition to the $114 million starting point.

The legislature has yet to act on restoring the payment cuts to physicians treating dual-eligible Medicare and Medicaid patients.

Meanwhile, TMA lobbyists remain wary of increased spending for additional fraud inspectors. Senate Bill 8 by Sen. Jane Nelson (R-Flower Mound) essentially codifies controversial Texas Health and Human Services Commission (HHSC) rules that allow inspectors to hold physician payments before proving fraud.

TMA officials are working with the senator to ensure the bill includes due process protections and other safeguards. Because billing varies by specialty, for example, TMA would like to see a fraud review panel that includes physicians to verify fraud allegation before HHSC holds payments.

On Medicaid, the governor has signed an emergency appropriations bill to fund Medicaid and the Children's Health Insurance Program for the remainder of the fiscal year (Aug. 31, 2013). Budget shortfalls last session forced lawmakers to underfund the program by about $4.5 billion.

Medicaid expansion continues to dominate conversations, and related bills have ensued. House Speaker Joe Straus made a recent push for Texas to consider an alternative to the PPACA-prescribed Medicaid expansion that still could bring federal dollars to the state. Meanwhile, House and Senate budget committees heard from HHS Commissioner Kyle Janek, MD, about how various Medicaid expansion scenarios would impact Medicaid caseloads and costs.

House Bill 3791 by Rep. John Zerwas, MD (R-Simonton), authorizes HHSC to strike a compromise with the federal government for a "Texas solution" that might include things like copayments and more tailored benefits, ideas TMA also has recommended.

But Lt. Gov. David Dewhurst was careful to note that because the Medicaid program is broken, the budget passed by the Senate Finance Committee includes a rider "that ensures HHSC would have to seek legislative approval before reforming our Medicaid program, and ensures any proposed changes are consistent with our conservative principles and lowering taxes."

The rider specifically states that "no amount may be expended to modify Medicaid eligibility unless the commission develops a plan to create more efficient health care coverage options for all existing and newly eligible populations."

Federal officials oppose Republican-backed ideas of giving states a block grant to do as they please, while Governor Perry faithfully refuses to fully expand the current program. "Those are the two guardrails we are operating between, and somewhere in the middle is a solution" for expansion to work in Texas, said Darren Whitehurst, TMA vice president for advocacy.

TMA continues to call on leaders to find a Texas-based solution that first fixes the current broken Medicaid system by increasing physician payments and reducing hassles like unfair fraud-and-abuse investigations, and then uses expansion money in a way that makes care available to more Texas patients.

For more on TMA's approach, see "Expand Medicaid, But Fix It First" by TMA President Michael E. Speer, MD.

Also see "Fix it First," in the April issue of Texas Medicine.

Crackdown on Silent PPOs, Red Tape
The House Insurance Committee took up a number of bills TMA hopes will crack down on insurance shenanigans and red tape.

Physicians testified in support of House Bill 620 by Rep. Craig Eiland (D-Galveston), which would for the first time regulate "silent PPOs," companies or health insurance networks that sell, lease, or share physician-negotiated discounts without doctors' knowledge or consent. The legislation has the support of TMA, the Texas Pediatric Society, the Texas Academy of Family Physicians, and Blue Cross and Blue Shield of Texas. Sen. Charles Schwertner, MD (R-Georgetown), carries the companion bill, Senate Bill 822.

House Bill 1032 by Representative Zerwas requires all insurers and health benefit managers to use a standard prior-authorization request form for prescription drug benefits. TMA lobbyists say Aetna alone has dozens of different forms. The Texas Department of Insurance would create the new standard form with stakeholder input. Sen. Joan Huffman (R-Houston) sponsors the Senate version, Senate Bill 644. The legislation also has the support of several Texas specialty societies and pharmacy associations.

Meanwhile, TMA continues to monitor a number of so-called pricing transparency bills aiming to collect data on health care pricing and quality that could create additional hassles for physicians without any clear impact on costs or quality. 

As part of TMA's red-tape reduction effort, House Bill 1803 by Rep. Bill Callegari (R-Katy) streamlines the Department of Public Safety process for renewing physicians' controlled substance permits and makes it concurrent with medical license renewals. Senator Huffman filed the companion bill, Senate Bill 1805. On March 14, the Senate passed Senate Bill 166 to allow physicians to use the electronic strip on the back of a patient's driver's license to speed up check-in time and increase medical records accuracy.

Keep Nonphysicians Out of Medicine
TMA also is working to defend against government dictates and scope-of-practice infringements on medicine and the patient-physician relationship.

The House Public Health Committee took up House Bill 446 by Rep. Dawnna Dukes (D-Austin) requiring physicians to tell pregnant patients during their first prenatal visit about the risks of drinking alcohol and fetal alcohol syndrome (FAS). Physicians must document that they counseled the patient and must provide a brochure. The patient also must indicate she received the information. TMA opposes the bill on the grounds it dictates to physicians how to practice medicine, information on the risks of FAS already is available, and research shows pre-pregnancy screening and counseling is the best prevention.

Also raising a red flag is Senate Bill 97 by Sen. Dan Patrick (R-Houston). It directs physicians to take specific action when prescribing the abortion-inducing drug Mifeprex, including having a contractual arrangement with another physician who agrees to treat any emergencies associated with the drug. TMA does not take a stance on abortion, but opposes the measure because it dictates care standards.

TMA also will battle a host of end-of-life legislation it says could interfere with physicians' ability to write do-not-resuscitate orders and create new liability risks. Instead, medicine is pushing for Senate Bill 303, which doctors say enhances patient autonomy and balances that respect for physicians' moral, ethical, and professional duties to do what's best for patients in their final days. A hearing on the bill is expected soon.      

A number of bills filed would allow nonphysician practitioners to expand their scope of practice, including a slew of chiropractic measures that made it in under the wire.

House Bill 1039 (Representative Eiland) would give physical therapists direct access to patients without first seeking a diagnosis warranting the care. TMA and specialty groups, including orthopedic surgeons, oppose the bill.

Physicians are going on offense to support House Bill 1782 to require nonphysicians to wear photo identification disclosing to patients their level of training, education, and licensing. Some practitioners with doctoral training have proclaimed themselves "doctors," which TMA says could mislead patients to think a physician is treating them.

Racing toward the finish line is Senate Bill 406 by Senator Nelson. The agreed-to legislation by TMA, the Texas Academy of Family Physicians, and nurse and physician assistant groups replaces current site-based restrictions for prescriptive delegation and supervision with a more flexible model that still preserves diagnosing and prescribing as the practice of medicine.

Senator Nelson told Texas Medicine she is confident the bill will make it through the legislative process. The bill unanimously passed the Senate this month. Read more in the May issue of Texas Medicine.

On public health, TMA and the Texas Public Health Coalition (TPHC) took steps to fight obesity by supporting a bid by Sen. Carlos Uresti (D-San Antonio) to prohibit sugary drinks in Texas schools under Senate Bill 317.      

Physicians and the coalition also told the Senate Education Committee to keep the "FitnessGram" program alive in schools so they and their communities can share best practices to address the state's obesity epidemic. Senate Bill 684 by Sen. Bob Deuell, MD (R-Greenville), would make the now-required physical fitness assessments for schoolchildren optional.

As TMA and TPHC push forward on a slew of immunization measures, House Bill 1310 offers a tax break to physicians who bear the cost of storing vaccinations. Watch for a hearing soon.

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

 Action, March 18, 2013