Rural Texas Physician

Summer 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[at]texmed[dot]org.


TMA, THA Leaders Push Senator Cornyn on Proposed Medicaid Changes

Leaders of TMA and the Texas Hospital Association (THA) met with U.S. Sen. John Cornyn on July 3 to work out a better solution for the Medicaid provisions in the Better Care Reconciliation Act (BCRA), the Senate’s failed bill to repeal and replace the Affordable Care Act.

Senator Cornyn, the Senate majority whip, didn’t return to Texas for the July 4 recess. He instead stayed in Washington to work on the bill after a planned June 27 vote was canceled. He met with the physician and hospital leaders via teleconference.

San Antonio pediatrician Ryan Van Ramshorst, MD, chair of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured, and other members of the committee, participated in the meeting along with TMA Board of Trustees member David Fleeger, MD, of Austin. They explained to the senator how the BCRA’s Medicaid provisions would affect their practices and their patients.

In a joint letter to Senator Cornyn signed June 28, both organizations offered help in rewriting the bill.

“If enacted as drafted, the Medicaid provisions of the BCRA will have significant negative consequences for Texas, for Texans, and for the Texas state budget,” the joint letter said. “We welcome the opportunity to work with you to devise improvements that keep Medicaid costs low, reduce Medicaid’s administrative challenges, and preserve Medicaid’s important role in the health care delivery for all Texans.”

Compared to other states, the letter said, the proposed changes would punish Texas’ lean, efficient Medicaid system, which already underpays physicians and hospitals by as much as 60 percent and requires that enrollees must join a managed care organization. TMA and THA pointed out that:  

  • Medicaid funding is the financial lifeline for rural, border, and urban safety-net hospitals and physician practices;
  • Four million, or 15 percent, of Texans benefit from Medicaid directly;
  • Texas Medicaid is the cord that binds the state’s health care safety net, covering 40 percent of low-income children and 50 percent of births; and
  • If the federal government shifts costs to the states, Texas will be forced to shift costs to counties, which in turn will increase property taxes and/or services to compensate.  

“Undoubtedly, Medicaid is imperfect. We agree reforms are necessary,” the letter said. “However, in lieu of the BCRA’s Medicaid proposals, we strongly encourage you to examine other sensible and fiscally sound options.”

TMA also signed on to a separate letter on the same issue, sent to Senate leaders from the Coalition of State Medical Societies. That letter offers the assistance of the coalition’s 10 member societies to “craft a better bill that will engender broader support from your colleagues and the American public.”

“We are concerned that the Medicaid per-capita cap and block grant growth index will not keep pace with rising costs beyond our control,” the coalition’s letter said. “The proposal places an untenable burden on state budgets and an uncompensated care burden on physicians who are on the front lines caring for these patients every day. We need Congress’ help to better care for our patients.”

Per policy the TMA House of Delegates adopted earlier this year, TMA is committed to preserve guaranteed, uncapped federal Medicaid funding for at least all Texas Medicaid populations covered by the program as of Jan. 1, 2017.

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Oct. 1 Deadline Looming to Comply with Medicaid Enrollment Requirement

If you or your practice order or refer for Medicaid patients – even if you do not otherwise participate in Medicaid – you must enroll in Medicaid before Oct. 1.

Enrollment applies to physicians, advanced practice registered nurses, physician assistants and other health professionals and providers – anybody in your practice who orders or refers for Medicaid patients.

It also applies to physicians who only care for dual-eligible patients — those who are eligible for Medicare and Medicaid — and order Medicaid-only services for these patients (the requirement does not apply to crossover claims). If that’s you, you must enroll as an ordering and referring physician.

After Oct. 1, Medicaid patients who attempt to fill a prescription will be unable to do so if the ordering and referring physician or provider is not enrolled. 

Other examples of services that require an order or referral include:

  • Clinical, radiological, or laboratory services;
  • Home health agency services;
  • Durable medical equipment (DME);
  • Eyeglasses; and 
  • Hearing aids 

The requirement applies to whether a patient is enrolled in Medicaid managed care or fee-for-service. 

More information, including how to enroll and a section on frequently asked questions, can be found on the Texas Medicaid and Healthcare Partnership (TMHP) website.

TMHP has developed an abbreviated enrollment application for physicians whose only relationship with Texas Medicaid is to order or refer services to Medicaid clients.

If you’re submitting a claim for services that require an order or a referral, you must include the National Provider Identifier (NPI) of the ordering, prescribing, or referring (OPR) provider on the claim.

Furthermore, residents and interns at your practice will be able to order and refer using the supervising physician’s NPI, or they can use their own if they have one. 

If you have questions about any of this, call the TMHP at (800) 925-9126.

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What's Next for Rural Communities Facing a Hospital Closure?

A report on rural hospital closures in Texas proposes considering new solutions based on geography, technology, and exiting resources.

The report, by the Texas A&M Rural & Community Health Institute in partnership with the Episcopal Health Foundation, features interviews with former leaders of shuttered hospitals. 

The report found that although most rural hospitals in Texas closed due to financial difficulties and lack of patient volume, there are often available health care delivery resources within a radius of 20 to 30 miles from the closed facility.

“Rather than focusing almost exclusively on ‘to close or not to close,’ the questions should be: What geography is being discussed — a county or some other defined community?” the report said. “Which perceived needs could be reasonably met with alternative health care delivery processes? Which needs require sophisticated health care delivery even if it is a greater than ideal distance?”

Researchers suggest communities facing a hospital closure first ask community members where they currently go for health care services. Leaders can use that information to create a tool to help at-risk hospitals search for alternatives and develop area partnerships.

“Might the smaller facility become a 24-hour emergency department that feeds the larger facility?” the report asks. “Might the providers cross-cover, thus minimizing the likelihood of losing one or more providers? Might the use of non-physician providers or a pharmacy delivery service help to assuage any loss secondary to converting on the facilities?”

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New Law Shapes the Future of Telemedicine in Texas

Texas physicians and telehealth providers are one step closer to playing by the same rules to treat patients by phone, computer, and other new technologies — as when physicians see patients face-to-face in a traditional doctor’s office visit. Senate Bill 1107, passed this session by the Texas Legislature and signed into law by Gov. Greg Abbott in late May, clarifies the framework to evaluate, diagnose, and treat patients remotely via telecommunication technology. Telemedicine can be a helpful tool for physicians to see some patients who cannot travel hundreds of miles — or even one mile — to the doctor’s office.

The bill-signing by the governor ends months of debate in the Texas legislature and caps more than a year’s worth of collaborative input by TMA, the Texas e-Health Alliance (TEHA), the Texas Academy of Family Physicians (TAFP), and numerous telemedicine stakeholders. 

“I am happy and ecstatic for the patients of Texas,” said Ray Callas, MD, a TMA Board trustee and immediate past-chair of TMA’s Council on Legislation. “As technology advances, patients will have more access to physicians, resulting in fewer ER visits for minor ailments; and more patients, especially in rural areas, will have access to primary care at home via telemedicine technology.” 

Sen. Charles Schwertner, MD (R-Georgetown), chair of the Senate Health and Human Services Committee, authored the bill. Rep. Four Price (R-Amarillo) sponsored the companion bill, House Bill 2697, and also played a key role in crafting language to require health insurance plans to cover telemedicine as a service provided by the physicians they have under contract. 

The months of negotiation by TMA, TEHA, and TAFP to expand the use of technology in Texas medicine resulted in the core language of SB 1107, including: 

  • The standard of care for a telemedicine visit is the same as a patient/ physician in-person visit;
  • The definition of a true patient-physician relationship to conduct telemedicine;
  • A physician must be able to access — and must use — clinically relevant data in rendering a diagnosis in accordance with the standard of care; and
  • Health plans must cover telemedicine as a means of providing services to their insureds when a contracted physician performs the care. 

“We are now seeing opportunities to access physicians and providers from anywhere at anytime for most any reason, thanks to technology. But technology by itself is not the solution to our health care challenges," said Austin-based telemedicine internist and psychiatrist Thomas Kim, MD, who testified for TMA in support of the bill, and helped craft its language. “At the end of the day, telemedicine care is medical care and should be held to the same standards and guidelines.”

The bottom line, doctors say, is telemedicine is a means of providing care to a patient; it is not a service in and of itself. It is a tool in the physician’s toolbox.

The new law is expected to expand the use of technology in health care. “Is this the end all, be all? No,” said Dr. Callas, “but it is the start of something that will allow patients to get the best care, and for physicians to be the captain of the ship to delegate and supervise the care of all Texans.”

Some of the law’s elements took effect when the governor signed it, while the insurance related provisions go into effect on Jan. 1, 2018.

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Website Provides Help for Palliative Care-Givers, Patients

The state of Texas has a new online resource that might help you the next time you have one of those most-difficult conversations with a patient.

The Texas Health and Human Services Commission (HHS) has launched a comprehensive online resource for palliative care patients and the people who care for them.

“In instances where a serious illness may alter your life, access to reliable information and resources can make all the difference,” HHS said in announcing the website, which “includes information on the benefits of palliative care and toolkits for patients and families seeking an additional layer support.”

The resource, which can be found on the HHS website, also explains the difference between the two types of palliative care — supportive and hospice — and includes information on how to pay for care, and ways to plan for serious illness. 

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Vision and Hearing for Kids and Seniors

Check out these new resources from Medicare and the Texas Health Steps Medicaid program related to vision and hearing coverage.

For Children and Adolescents

Texas Health Steps has a new, free continuing medical education course, Hearing and Vision Screening, which covers the recommended schedule and updated tools and procedures for screening children from infancy to adolescence. It also explains: 

  • How to coordinate and document the results of office-based and school-based screenings, and
  • How your practice can better integrate screenings into routine checkups and ensure that patients receive diagnostic follow-up and referrals when needed.  

This on-demand course offers 1.5 AMA PRA Category 1 Credits TM

For Seniors and Other Medicare Beneficiaries

The Centers for Medicare & Medicaid Services (CMS) has published a new fact sheet on Medicare vision services, with codes and resources. Medicare does not normally cover routine vision services, such as eyeglasses and eye exams, but may cover some vision costs if associated with eye problems that result from an illness or injury.

For information about Medicare coverage related to hearing, see the CMS Auditory Services webpage.

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Get Tech Help from TMA

Technology. It’s changed our lives in so many ways: You can now program your television with your phone, turn on the porch light when you’re at dinner, you can even have your refrigerator tell you when it’s running low on food.

But let’s face it, technology can present plenty of challenges in the practice of medicine. TMA works diligently to give you the tools to tackle these challenges. Need help selecting an electronic health record (EHR) provider or understanding the Medicare Access and CHIP Reauthorization Act (MACRA) program? Can’t figure out the EHR incentive program? Need information on e-prescribing? TMA has you covered. 

You can find links to all of these tools on the TMA website

Here’s some of the many resources TMA has to offer: 

  • EHR Product Evaluation Tool: This tool, for members only, compares the most-used EHRs in Texas by functionality and pricing.
  • MACRA Resource Center: Whether you’re just trying to meet the minimum requirements to avoid the penalty, or you’re looking to maximize your incentive payment, here’s where you’ll find the latest MACRA program information, resources, CME, and consulting options.
  • Advancing Care Information (ACI) Resource Center: Learn what you need to do to meet the ACI objectives and measures for the Merit-Based Incentive Payment System (MIPS). You can also find out about ACI scoring, reporting options, and what you need to have in case of an audit. 
  • EHR Buyer Beware: Issues to Consider When Contracting with EHR Vendors: You’re ready to buy an EHR, but do you know what you need to know before locking down the contract? This paper discusses eight important EHR contract terms you should consider before signing an EHR contract.
  • EHR Incentive Program Resource Center: The Medicaid EHR Incentive Program continues until 2021. Stay in-the-know about program updates so you don’t miss out on the incentive payments.
  • E-Prescribing Resource Center: Benefits of e-prescribing include medication reconciliation, medication history, eligibility, and formulary information. Visit the resource center for help with e-prescribing. 
  • Ransomware and Cyber Security Resource Center: Ransomware has reached Texas, and it teaches us all why it’s so important to keep our security systems up-to-date. Use this resource center to access articles and education on cyber security and ways to protect your practice. 

You can even check out this handy print-out, which lists the online TMA Technology tools and the links. 

If you have questions about these health information technology (HIT) tools and resources or if you need additional help, contact the TMA HIT Helpline at (800) 880-5720 or by email

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 Register for TMA's Fall Conference

Registration is now open for the 2017 TMA Fall Conference, which is scheduled for Sept. 15-16 at Hyatt Regency Lost Pines Resort and Spa. This free member benefit lets you reconnect with colleagues and learn more about what’s new in Texas health care.

This year’s programming will feature a recap of the 85th Legislative session. It also will include a discussion of the long- and short-term effects of abuse and neglect and other adverse childhood experiences. 

Register today and make your room reservation at the Hyatt Regency Lost Pines. For more information, please visit the TMA Fall Conference page on the TMA website. 

Questions? Email the TMA Knowledge Center or call (800) 880-7955 Monday through Friday, 8:15 a.m. to 5:15 p.m. central time. 

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Last Updated On

April 27, 2018

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