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Monday, February 23, 2009


Two state lawmakers have filed bills to advance one of TMA’s top priorities: requiring health plans to provide real-time adjudication of claims at the point of service. Plans also must provide real-time information on which physicians and providers are in the patient’s network, the amount of the patient’s deductibles, usual and customary amounts for out-of-network care, and the patient’s potential out-of-pocket expense. Senate Bill 863 by Sen. Chris Harris (R-Arlington) and House Bill 1342 by Rep. Jose Menendez (D-San Antonio) will be at the top of the list of legislation our white-coated lobbyists will push at the March 3 First Tuesdays at the Capitol. I hope you can be there.


The editorial boards at Texas’ two largest newspapers heard all about Doctor's Orders, TMA’s 2009 legislative agenda. TMA President Josie Williams, MD, and Dallas County Medical Society President Phillip Huber, MD, took our comprehensive plan to the editors of the Dallas Morning News. Dr. Williams made a presentation to the Denton County Medical Society that night and then joined Harris County Medical Society President Lewis Foxhall, MD, at the Houston Chronicle editorial board. Leaders of both papers were particularly receptive to our calls for health insurance reform.


Mark Chassay, MD, of Austin, and Leo Cigarroa, MD, of Laredo were named to the Scientific and Prevention Advisory Council of the state’s new Cancer Prevention and Research Institute. The council’s recommendations for action go to the institute’s oversight board, which is responsible for managing the $3 billion in cancer research and prevention bonds voters approved in 2007. Austin oncologist Joe Bailes, MD, is a member of the oversight board, which narrowed its search for an executive director for the institute to two finalists.


To help physicians actively participate in the federal debate on health system reform, the American Medical Association has prepared an action kit outlining the AMA perspective on many of the key issues involved. So far, the kit includes briefing papers on issues ranging from physician payment to insurance reform, to wellness and prevention. The AMA Web site also has a new summary of the health care provisions in the stimulus package President Obama signed last week.

TMA Legislative Issue Brief: Delegated Authority, Advance Practice Nurses, and Safety

Working with physicians, advance practice nurses (APNs) are integral parts of the health care team. With authority delegated by a physician under state law, APNs provide services safely permitted by their education, training, and skills. In this model, APNs serve as extensions of a physician’s practice, through the authority of the physician’s license. The delegating physician retains authority over — and ultimate responsibility for —his or her patients. Texas law wisely regulates how physicians may delegate prescriptive authority to APNs. There are standards for the number of APNs or PAs to whom a physician may delegate authority, requirements for the physician to actively supervise the APNs’ actions, and specific protections for pediatric patients.

As part of a national effort to expand their scope of practice, APNs are asking the 2009 Texas Legislature to abandon the carefully balanced delegated model and replace it with an open-ended “prescriptive authority agreement” between a physician and an APN. These “liberally construed” agreements — with few requirements for supervision or collaboration — could jeopardize the health and safety of Texans. Neither the Texas Medical Board nor the Board of Nursing Examiners would have meaningful authority to investigate complaints or take disciplinary action for poor-quality care. The proposal would eliminate necessary patient-protection standards for on-site physician supervision of APNs, physician review of patient charts, narcotics prescriptions, and pediatric care.

Medicine’s 2009 Agenda
  • Ensure the Texas Medical Board has proper oversight of physicians’ delegation of prescriptive authority and other responsibilities to allied health practitioners.
  • Prevent any efforts to expand scope of practice beyond that safely permitted by nonphysician practitioners’ education, training, and skills.
  • Protect Texas’ carefully balanced physician-delegated model of care, which serves as the foundation for ensuring the physician retains authority over — and ultimate responsibility for — his or her patients.
Medicine's Message
  • Physicians are responsible for coordinating the various components of health care as they are delivered by the health care team. We must focus on this coordination as Texas searches for safe ways to meet our shortage of health care professionals.
  • Proposed “prescriptive authority agreements” remove the safety standards inherent in the delegated authority model. They also eliminate patient protections provided by the Texas Medical Board, hospital medical directors, and the hospital medical staff.
  • Prescribing medications, including dangerous drugs and controlled substances, should be done only under the supervision of a physician who is accountable, legally and ethically, for patient care.
Check out the Doctor’s Orders video to get a more complete view of TMA’s 2009 legislative agenda. You can see all of TMA’s 2009 legislative issue briefs on the TMA Web site.

Monday, February 16, 2009


TMA joined class-action lawsuits against CIGNA and Aetna. The federal lawsuits, filed along with the American Medical Association and other state medical societies, contend that the two health insurance companies rely on a flawed system to underpay physicians for out-of-network services and forced patients to pay an excessive portion of the costs. The antiracketeering suits seek to stop the health plans from using Ingenix to set “reasonable, usual, and customary” charges for out-of-network services and to require them to repay physicians for underpayments.


The Texas House of Representatives is in full swing now that Speaker Joe Straus has announced committee assignments (PDF). The representative assigned to chair each committee greatly affects whether a bills lives or dies. Chair assignments of particular interest to medicine include Appropriations: Rep. Jim Pitts (R-Waxahachie), Human Services: Rep. Patrick Rose (D-Dripping Springs), Insurance: Rep. John Smithee (R-Amarillo), Judiciary and Civil Jurisprudence: Rep. Todd Hunter (R-Corpus Christi), Public Health: Rep. Lois Kolkhorst (R-Brenham), State Affairs: Rep. Burt Solomons (R-Carrollton), and Ways and Means: Rep. Rene Oliveira (D-Brownsville).


TMA received numerous calls and e-mails over physicians’ concerns with what they perceived to be strong new federal power over health care contained in the economic stimulus bill that Congress passed. Today’s issue of TMA’s Action and a story in today’s New York Times explain that the bill contains $1.1 billion for the government to study the comparative effectiveness of various treatments. The bill does not mandate the use of treatment protocols.


I enjoyed a visit with leaders of the El Paso County Medical Society and the new Texas Tech University Health Sciences Center School of Medicine. The school recruited 40 students for its first class (PDF), which begins studies on July 9, Founding Dean Manuel De La Rosa, MD, said. I told El Paso physicians about Doctor’s Orders, TMA’s aggressive legislative agenda, which includes a stout defense of our 2003 liability reforms and calls for state investment in graduate medical education and Medicaid rates. I expect a strong El Paso group at the March 3 First Tuesdays at the Capitol.


The Texas Medical Board (TMB) announced that Mari Robinson, JD, will become executive director of the agency, effective March 1. The board also named Austin pathologist Alan T. Moore, MD, as medical director. Both had served in interim positions since October. State law requires TMB to hire a medical director if the agency executive is a nonphysician.

TMA Legislative Issue Brief: Ownership of Health Care Facilities and Equipment

Texas’ health care delivery system has changed dramatically over the past decade. Life-saving technologies and treatments, and the types of settings in which patients receive services have proliferated. Physicians, hospitals, and other entities have invested extensively in these technologies and settings. While physician investment in the health care system is not new, health care financing and coverage have changed considerably over the past decade. These changes drive the debate over who can invest in a facility.

Texas is the uninsured capital of America, creating competition for a dwindling supply of paying patients. Rather than limiting patient choice, Texas should focus on increasing health insurance coverage and assuring high-quality care regardless of setting or ownership dynamics. The Texas Association of Business and many hospitals have been trying to restrict physician ownership of facilities and equipment.

Medicine’s 2009 Agenda
  • Ensure that responsible ownership, whether by a physician or hospital, is patient-centered and includes a commitment to appropriate peer review of utilization, quality, and safety to ensure the highest quality care.
  • Promote transparent transactions, governance, and ownership by physicians, allied health providers, and hospitals alike. Disclosure should apply to all financial relationships, such as investors, employed physicians, and paid directorships.

Medicine’s Message

  • Physician-owned hospitals are not new. Physicians founded many of the nation’s first hospitals to ensure appropriate care for their patients.
  • Physicians have an obligation to advance improvements in the diagnosis, treatment, and care of patients, including innovations in medical technology.
  • Referrals to a physician-owned entity or entity in which the physician has a financial relationship must be based on the patient’s medical needs.
  • Physician-owned entities should adhere to all state and federal regulations; provide appropriate credentialing of physicians, and clinical and support staff; monitor utilization and quality; and adhere to relevant TMA and American Medical Association ethical guidelines.

Check out the Doctor’s Orders video to get a more complete view of TMA’s 2009 legislative agenda. You can see all of TMA’s 2009 legislative issue briefs on the TMA Web site.

Monday, February 9, 2009


We set a February record when almost 200 physicians and alliance members came to lobby their legislators at 2009’s first First Tuesdays at the Capitol. TMA President Josie Williams and I personally met with Lt. Gov. David Dewhurst, Senate Health and Human Services Committee Chair Jane Nelson (R-Lewisville), and Senate State Affairs Committee Chair Robert Duncan (R-Lubbock) to discuss our Doctor’s Orders agenda. The next First Tuesdays is March 3. Never been part of the “white-coast invasion”? Check out our latest Podcast TMA: “The Magic of First Tuesdays.”


A special thanks to all the TMA members who called and wrote Congress; our message got through. President Barack Obama signed the bill reauthorizing and expanding the Children’s Health Insurance Program (CHIP), which we wanted. The bill was stripped, however, of unnecessary restrictions on physician-owned hospitals. Look for that issue to come back, again and again.


The meeting already seems like it was a long time ago, and TexMed 2009 isn’t far away, but I still have some news to report from TMA’s 2009 Winter Conference. One of the most exciting parts of the weekend was our annual convocation of county medical society presidents, presidents-elect, and staff. Leaders from 20 of our largest county societies discussed their biggest concerns — membership, collegiality, and protecting the viability of physician practices — and shared some best practices that have helped them address those challenges. I also want to thank, once again, our generous conference sponsors: TMA Insurance Trust and Texas Medical Liability Trust.


After meeting with the Austin American-Statesman editorial board, Dr. Williams joined State Sen. Troy Fraser (R-Horseshoe Bay) and the Texas College of Emergency Physicians for a Capitol news conference touting the benefits of our 2003 liability reforms. Twenty-four counties that had no emergency physician prior to 2003 have one now. Dr. Williams then took our legislative agenda to Corpus Christi and the lower Rio Grande Valley with visits to TV and radio stations, newspapers, and chambers of commerce. She met with South Texas physician leaders before heading home.

TMA Legislative Issue Brief: Graduate Medical Education

Texas has a shortage of physicians, both primary care physicians and specialists. The state currently ranks 43rd out of 50 states and the District of Columbia. Even though medical liability reforms have brought more than 14,000 new physicians to Texas, we still don’t have enough physicians to keep up with the state’s robust population growth.

Texas medical schools are doing their part to expand medical student enrollments, but unless graduate medical education (GME) programs grow in the same fashion, many of our newest physicians will move to other states. GME is a necessary part of a physician’s preparation for medical practice. Physicians who complete both medical school and GME in Texas are three times more likely to remain in the state to practice.

Medical schools and teaching hospitals have limited funding available to expand GME. The shortage of GME slots virtually guarantees some medical students will be forced to leave the state upon graduation. Those leaving likely will not return to Texas. They will take with them more than $200,000 of state investment in their medical school education.

In 2007, Texas lawmakers recognized the need to support medical school efforts to expand GME by authorizing $62.8 million in state formula funding for new GME slots and as partial payment for faculty costs. Although this funding resulted in the creation of new GME positions, it is not sufficient to pay for needed growth. The current state GME formula funding represents less than one-third of estimated faculty costs for GME in Texas. In addition, to retain our Texas medical students, we must add an estimated 250 new GME slots over the next four years — 1,000 new slots in total.

Medicine’s 2009 Agenda
  • Produce more homegrown physicians through adequate state formula funding of medical school expansions and GME slots.
  • Reinvest state funds in Medicaid GME and restore the state’s ability to draw down additional federal matching dollars.

Medicine’s Message

  • Texas needs more GME slots to train the number of physicians required to care for our rapidly growing population and reverse our overdependence on other states and countries.
  • The lack of adequate GME funding jeopardizes Texas’ economic future.
  • It is not good fiscal policy to make a state commitment of $200,000 for each Texas medical student over four years, and then force graduates to leave the state for GME. Those new physicians very likely will never return to Texas.

Check out the Doctor’s Orders video to get a more complete view of TMA’s 2009 legislative agenda. You can see all of TMA’s 2009 legislative issue briefs on the TMA Web site.

Monday, February 2, 2009


We expect a good crowd of white-coated lobbyists at our first, First Tuesdays at the Capitol for 2009. Physicians, medical students, and alliance members will educate Texas legislators on why we need health insurance reform, why we need to defend our 2003 medical liability reforms, and why graduate medical education needs a shot in the arm. Join us.


Speaking to a packed house at TMA’s 2009 Winter Conference, three key legislators said debate over the state’s tight budget will dominate this year’s session of the Texas Legislature. But all three of them expressed strong support for many pieces of Doctor’s Orders, TMA’s aggressive legislative agenda:
  • “What I’ve seen in my 25 years in practice is there are more and more people getting a piece of the health care pie who do not lay a hand on the patient,” said Sen. Bob Deuell, MD (R-Greenville).
  • “To tear that barrier down and say that patient decisions should be made by those who are not in the clinical realm is wrong,” Rep. John Zerwas, MD (R-Simonton) said, defending Texas’ prohibition on the corporate practice of medicine.
  • Rep. Garnett Coleman (D-Houston) said physicians need to get patients involved in the legislative process. “When someone says that they’ve gotten loving and competent care from a physician and they tell us that, that’s the best advocate you can have,” he said.


Cycling champ Lance Armstrong joined State Sens. Rodney Ellis (D-Houston) and Jane Nelson (R-Lewisville), and Rep. Myra Crownover (R-Denton) to push for bills banning smoking in public places. A new statewide poll shows that more than two-thirds of Texans support prohibiting smoking in all indoor work and public places, including restaurants and bars. TMA supports Representative Crownover’s House Bill 5 and Senator Ellis’ Senate Bill 544.


The TMA Board of Trustees appointed Wichita Falls pathologist Susan Strate, MD, the new chair of the TEXPAC Board of Directors. Joe Todd, MD, an orthopedic surgeon from Fort Worth, will head the Candidate Evaluation Committee for the next two years, and Corpus Christi ophthalmologist Jerry Hunsaker, MD, is TEXPAC’s new membership chair.


The Caring for Children Foundation’s CareVan Program won the 2009 TMA Foundation John P. McGovern Champion of Health Award. In the past 11 years, the van has brought 581,000 immunizations to 357,000 uninsured children across Texas.


The U.S. House of Representatives and Senate have both passed bills reauthorizing and expanding the Children’s Health Insurance Program (CHIP). But the House version puts heavy restrictions on physician ownership of hospitals. They’ll iron out their differences in a conference committee. We’re asking TMA members to use our Grassroots Action Center to tell Congress to pass the CHIP bill without the ownership limits.


Smoking and secondhand smoke costs lives and money. Approximately 24,000 Texas adults die each year of a smoking-related illness. That is more than how many die from AIDS, heroin, cocaine, alcohol, car accidents, fire, and murder — combined.

Tobacco use is the single greatest preventable cause of premature death and disease in Texas. Each year, more than 32,000 Texans under age 18 become new, daily smokers. Of all Texas youth alive now, nearly 503,000 ultimately will die from tobacco-related diseases.

Tobacco also exacts a high price from business and taxpayers. In Texas, more than $12.2 billion can be attributed to the costs associated with smoking. According to the Centers for Disease Control and Prevention, the cost per smoker is about $3,561, which includes direct medical and indirect costs.

To combat this problem, legislation was filed in 2007 that would have eliminated smoking in all Texas workplaces and public places. Even though the bill had strong and broad support, it did not pass. However, given that level of support, a statewide smoking ban is likely to reemerge in 2009.

Making Texas smoke-free is one of the easiest, simplest, and fastest public health interventions Texas could undertake. Twenty-eight states have adopted smoking bans in restaurants; 22 of these states also prohibit smoking in workplaces.

Medicine’s 2009 Agenda
  • Support a statewide ban on smoking in public places.
  • Support tax incentives for employers to reward nonsmokers and encourage smokers to participate in tobacco cessation programs.
Medicine’s Message
  • Just like asbestos in schools, lead in paint and gasoline, and salmonella in food — secondhand smoke is purely a public health issue.
  • The scientific evidence is now indisputable: Secondhand smoke is not a mere annoyance. It is a serious health hazard that can sicken and kill children and nonsmoking adults.
  • If all U.S. workplaces implemented smoke-free policies, the reduction in heart attacks due to secondhand smoke would save the country $49 million in direct medical savings within the first year.
  • Tobacco use is a major risk factor for multiple cancers, heart disease, stroke, and lung disease.

Check out the Doctor’s Orders video to get a more complete view of TMA’s 2009 legislative agenda. You can see all of TMA’s 2009 legislative issue briefs on the TMA Web site.