TMA EVPGram

TMA President Josie Williams, MD, and a bipartisan group of lawmakers carrying our health insurance reform bills held a capitol news conference to launch our Patients’ Right to Know campaign. The legislative package includes the Health Insurance Code of Conduct Act of 2009 (PDF) and the Health Insurance Product Labeling Bill. TMA created a Web site and a Facebook cause where patients can write their legislators in support of health insurance reform bills. Educational materials will be mailed to physician offices to inform and engage patients. Watch the news conference.

TMA’s Select Committee on Health System Reform has completed work on the guiding principles we will use to evaluate reform proposals coming from the Obama administration, Congress, and elsewhere. Dr. Williams has appointed a new TMA Health System Reform Task Force to use those principles to vet and examine and measure every idea that comes out of Washington. Former American Medical Association President Nancy Dickey, MD, now the vice chancellor for health affairs in the Texas A&M University System, will chair that task force. The House of Delegates will consider the principles as part of a final select committee report to the house during TexMed 2009. If you have concerns, questions, comments, or suggestions about the principles, please contact your county medical society’s delegation to the House of Delegates or drop me an e-mail.

An outpouring of opposition from TMA members, and strong testimony from Bill Peper, MD, chair of TMA’s Committee on Professional Liability, helped to keep a dangerous bill bottled up in a State Senate committee. Senate Bill 152 by Sen. Rodney Ellis (D-Houston) would weaken liability protections for physicians who see patients in emergency situations. Also in a busy week in Austin:

• The Senate unanimously passed SB 532 by Sen. Dan Patrick (R-Houston). This is TMA's bill on supervision of physician assistants and advanced practice nurses at retail health clinics.
• TMA witnesses stood strong under withering questioning at the House Insurance Committee. TMA Immediate Past President Bill Hinchey, MD; TEXPAC Chair Susan Strate, MD; and Greg Bernica, executive director of the Harris County Medical Society, testified on behalf of TMA for some good insurance reform bills and against various pieces of health-plan-backed legislation.
• Many other TMA member physicians stepped up to the plate on your behalf. Thanks to these physicians for testifying before committees at the legislature: Dawn Buckingham, MD, and Kim Edwards, MD, of Austin; and Janet Realini, MD, MPH, and Charles Leach, MD, of San Antonio.

We expect another hectic week at the capitol, with hearings on several of our health insurance reform bills, our proposal to counter the growing demands for hospitals to employ physicians directly, bills to expand the physician loan repayment program, the Sunset bill to continue and improve the Texas Department of Insurance, and ongoing debate on the state budget.

Recruiting and retaining a sufficient number of physicians to care for Texas patients is an ongoing challenge for the state. Given the size of the state and growing demographics, many urban and rural communities continue to suffer a physician shortage. The demand for physicians is particularly acute in the rural and border areas.

The Physician Education Loan Repayment Program has been one of the most successful models to address the state’s physician shortage. However, over the years, the program has become less effective in recruiting new physicians to underserved areas. Its loan repayment levels are too low. The average debt of a new physician is approximately $131,000. The amount of new physicians’ medical school debt affects where they set up practice and what specialty they choose. The state’s Physician Education Loan Repayment Program currently covers only about a third of the average debt a physician accumulates during his or her 11-plus years of education.

To improve patients’ access to primary care physicians and other needed specialties, Texas must increase the amount of the annual and total loan repayment levels. Additional funding would help to restore the program to be a valuable tool in recruiting physicians to underserved areas of Texas.

Medicine’s 2009 Agenda

• Improve funding of Texas’ loan repayment program and annual loan repayment amounts to allow more physicians to benefit from the program and to provide an effective recruitment tool for medically underserved communities.

Medicine’s Message

• In 2006, Texas ranked 43rd out of 50 states with 191 practicing physicians per 100,000 population. Texas continues to lead the nation in overall population growth. We cannot afford to let our physician workforce lag behind population growth. Our aging population will demand more services, and a large number of practicing physicians will soon reach retirement age.
  
• Rural and border communities have a better chance of recruiting a new physician when they can offer a unique benefit such as loan repayment.

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.

Whether it's health insurance, tort reform, or secondhand smoke, TMA is constantly fighting for patients and their physicians. It's no different when we're dealing with the Texas Medical Board (TMB). TMA believes a strong and fair TMB is good for your profession and good for your patients. That's why we push TMB to focus on true quality-of-care violations, and to guarantee fair treatment for physicians under investigation. I urge you to read and share a short document we put together that describes TMA's recent activities to improve TMB and outlines our 2009 legislative strategy.

Congratulations to Susan Todd of Fort Worth, the 2002-03 president of the TMA Alliance. Susan has been asked to serve as president-elect of the American Medical Association Alliance. She will be installed as president of the national alliance in June 2010. Congratulations also go to another Fort Worth alliance whiz — Pat Hyer — who will serve another term on the AMA Alliance board.

It was another busy week for medicine at the Texas capitol. John Holcomb, MD, of San Antonio told the House Human Services Committee why the Children’s Health Insurance Program (CHIP) should be simplified and allow slightly more well-off families to buy in to CHIP coverage. TMA President Josie Williams, MD, testified before a Senate committee against two bills that would allow rural hospitals to employ physicians directly. She also testified before the House Public Health Committee in support of a bill that would bring some reason to insurance companies’ physician rating systems. Gary Floyd, MD, of Fort Worth helped push a good bill through the Senate Health and Human Services Committee. The bill carefully expands how physicians supervise midlevel providers at retail health clinics. Thanks for taking time out to testify also go to Carlos Hernandez, MD, of Eagle Pass; Charletta Guillory, MD, of Austin; Sharon Raimer, MD, of Galveston.

Health care debates, of course, are raging in Washington just as much as in Austin. AMA Board Chair Joseph M. Heyman, MD, called on the House Committee on Small Business to “to seize this opportunity for permanent action to fix the [Medicare] physician payment formula.” And David Teuscher, MD, of Beaumont told the Senate Republican Caucus about how Texas’ 2003 medical liability reforms have improved Texans’ access to quality health care.

TMA can be your “friend” on Facebook, delivering videos, photos, news, and more. Take a look at our new Facebook page, and sign up as a “fan.” I remind Web 2.0 aficionados that the EVPGram has its own blog. TMA also has Blogged Arteries, and Twitter, YouTube, and LinkedIn accounts.

Retail health clinics were designed to give patients access to fast, convenient, and affordable health care. But because the clinics are staffed by advanced practice nurses (APNs) or physician assistants (PAs), they do not provide the same level of care as physicians’ offices, urgent care clinics, or minor emergency centers. Medical services are limited to preventive care, such as immunizations, cholesterol screenings, and routine ailments. The clinics are not freestanding but operate in large discount retail stores, drug stores, or supermarkets.

TMA’s primary concerns focus on patient safety. TMA supports an integrated care model where the APNs and PAs staffing the clinics are appropriately supervised by a physician, refer the patient back to his or her regular physician to ensure continuity of care, refer patients appropriately for additional or follow-up care, and practice within their scope of practice.
During the 2007 legislative session, there was movement to free clinics from such patient protections, particularly to weaken physician oversight. TMA opposed the legislation on grounds that the changes would undermine patient safety and health care quality. Nevertheless, TMA has reached out to the retail health clinics to discuss a medical model that keeps the provision of care under the appropriate delegation and supervision of a physician but also allows innovations in the delivery of a limited set of services at these clinics.

Medicine’s 2009 Agenda

• Retail health clinics — offering a limited set of services — must be subject to sufficient oversight to ensure patients receive safe, high-quality health care.
• APNs and PAs in retail clinics must provide only services that are safely within their education, training, and skills and under the supervision and delegation of a licensed physician.

Medicine’s Message

• Retail health clinics should be monitored closely to protect patient safety, ensure positive health outcomes, and make certain that patients with more serious illnesses are referred for appropriate follow-up care.
• Retail health clinics are not replacements for a medical home, where a patient develops a relationship with his or her physician.
• Retail clinics must share health records in a timely fashion with patients’ primary physicians and direct patients to their physician for follow-up care.
  Retail health clinics must adhere to state public health reporting and safety standards.

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.

The trial lawyers have begun their campaign to tear down our 2003 medical liability reforms. The first showdown is Thursday in the Senate State Affairs Committee. TMA is rallying member physicians to stop Senate Bill 152, which would lower the standard for liability in emergency cases. Our liability reforms have made a tremendous difference in Texas – especially in trauma care. All Texas physicians must act together to protect them. If your senator serves on State Affairs, use TMA’s Grassroots Action Center to send a message: Vote “NO” on SB 152.

Nominated by TMA for his leadership in tort reform, Gov. Rick Perry was one of eight to win this year’s Dr. Nathan Davis Award for Outstanding Government Service (PDF) from the American Medical Association. “Gov. Perry’s successful efforts to reform Texas’ medical liability climate exemplify his dedication to improving care for Texas patients,” said AMA President-Elect Jim Rohack, MD. “Thousands of physicians have flocked to Texas, providing Texans with increased access to health care, including much-needed specialist and emergency medicine physicians.” Governor Perry said on Twitter he was "very grateful for TMA's support and confidence" and "humbled by the award."

I was proud to be part of the 23 Texas physicians, alliance members, medical students, and TMA staff who stormed Capitol Hill as part of the AMA’s National Advocacy Conference. We met with almost every member of the Texas delegation, applauded Rep. Michael Burgess, MD (R-Lewisville), for filing a Texas-style liability reform, and shared the work of our Select Committee on Health System Reform. I urge every physician to monitor the health system reform developments from Washington and join us in fighting for patient-friendly reforms that are good for medicine as well.

TMA's health insurance reform agenda is making headway in the 2009 legislature. Your colleagues and professional staff are lobbying and testifying to make sure our "Patients' Right to Know" campaign brings real relief to patients and physicians. Watch TMA's Political Action at Work, our monthly video update of how TMA is fighting for you and your patients at the capitol. Thanks to these physicians, who testified for TMA last week: cardiologist James Willerson, MD; pediatrician John Hellerstedt, MD; anesthesiologist Jeff Jekot, MD; and neonatologist Charleta Guillory, MD.

TMA can be your “friend” on Facebook, delivering videos, photos, news, and more. Take a look at our new Facebook page, and sign up as a “fan.” I remind Web 2.0 aficionados that the EVPGram has its own blog. TMA also has Blogged Arteries, and Twitter, YouTube, and LinkedIn accounts.

When patients with a life-threatening disease or condition, such as cancer, participate in a clinical trial, health plans deny coverage for routine medical care, such as blood pressure checks or annual cholesterol and blood glucose screenings. Clinical trials are medical research conducted on patients who suffer from the illness the treatment hopes to cure. Clinical trials are the major way scientists evaluate new drugs that treat these life-threatening illnesses.

Patients who participate in a clinical trial often have other health issues. Diabetics, for example, require routine medical tests that monitor their blood sugar levels. If the patients were not participating in a clinical trial, their health plan would cover this cost. Twenty-three states have passed legislation requiring health plans to pay routine medical care costs for clinical trial participants. In 2000, Medicare also recognized the benefit and began to cover routine health care costs for Medicare patients who participate in clinical trials. However, Texas still does not require insurance companies to cover these costs. Instead, patients in clinical trials have to pay unnecessary and unwarranted out-of-pocket expenses.

What is worse is that health insurance companies pocket that portion of the premium dollar earmarked for paying routine medical care for the patient. Employers and employees pay expensive premiums to cover these costs. They should be able to use that benefit, even if the patient is participating in a clinical trial.

Medicine’s 2009 Agenda

• Support legislation that allows patients with a life-threatening disease or condition participating in clinical trials to use their insurance coverage for routine medical care.

Medicine’s Message

• Texas patients participating in a clinical trial should have the ability to use their health insurance premium dollars to pay for routine medical costs — especially when they are suffering from a life-threatening disease or condition.

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.

TMA President Josie Williams, MD, leads a group of 23 physicians, alliance members, students, and TMA staff heading to Capitol Hill this week. As part of the American Medical Association’s National Advocacy Conference, we will meet with Texas senators and representatives to press our position on health system reform. “Please keep our patients at the forefront of your minds as you work through this reform debate,” Dr. Williams wrote to our congressional delegation.

Tuesday was a huge day for medicine and Texas patients. About 250 physicians, alliance members, and medical students were on hand for First Tuesdays at the Capitol. They spent the day meeting with their representatives and senators to discuss health insurance reform and other key legislation that would improve the health of all Texans. One big highlight: On Tuesday, State Sen. Kip Averitt (R-Waco) filed Senate Bill 1257, TMA's Health Plan Code of Conduct Act of 2009.

Thanks to these Texas physicians who testified at the capitol for their colleagues this week:

• Stan Wang, MD, of Austin, and Tom Garcia, MD, of Houston, who testified before the House Insurance Committee on House bills 390 and 389 by Rep. John Zerwas, MD (R-Simonton). HB 390 would require health plans to pay patients’ routine medical costs when participating in a clinical trial. HB 389 fixes some holes in our 2007 expedited credentialing bill.
• John Holcomb, MD, of San Antonio, who testified before the Senate State Affairs Committee for SB 39, the Senate’s version of HB 390, by Sen. Judith Zaffirini (D-Laredo).
• Jason Terk, MD, a pediatrician from Keller, who testified on two bills that relate to the state's immunization registry: SB 346 and SB 347 by Sen. Jane Nelson (R-Lewisville).
• Albert Gros, MD, chair of TMA’s Council on Legislation, who testified for TMA in support of HB 1126 by Rep. Eddie Lucio III (D-Brownsville). HB 1126 would make State Office of Administrative Hearing decisions binding on both physicians and the Texas Medical Board.
• TMA Vice Speaker Clifford Moy, MD, who testified before a House Appropriations Subcommittee on the importance of funding undergraduate and graduate medical education in Texas.

The U.S. Supreme Court says TMA is right that federal law does not protect pharmaceutical giant Wyeth from lawsuits in state court. TMA filed a brief in the case (PDF) stating that if pharmaceutical companies are insulated from liability, patients would have no option but to sue their doctor.

The Texas Medical Board (TMB) is charged with licensing physicians and enforcing the Texas Medical Practices Act. TMB has been under intense legislative scrutiny for administrative, enforcement, and licensure issues.

Last session, lawmakers increased the agency’s appropriation by $3.4 million — to $18.4 million for the biennium — to better manage the backlog of license applications. The board was directed to cut the average processing time for a new license to 51 days. TMB met this goal and initiated an online application process to further speed up licensure.

TMA continues to advocate for a strong board with fair processes and actions to enforce Senate Bill 104, which was passed along with liability reforms in 2003. That law strengthened the board’s enforcement capabilities and added a surcharge to physicians’ licenses to pay for more staff and equipment. It also directed TMB to focus on quality of care and impairment issues.

Medicine’s 2009 Agenda

• Support a new program to address the needs of illness-impaired physicians and other licensed providers TMB oversees.
• The Texas Physician Health Program would be modeled on the longstanding, successful program for impaired attorneys sponsored by the State Bar of Texas.
• Support legislation to require TMB and other licensing boards to abide by the decisions of the State Office of Administrative Hearings (SOAH) in disciplinary matters.
• Support involvement of TMB and other licensing agencies in cooperation with law enforcement to address illegal drug use and illegal use of prescriptions for controlled substances.
• Oppose efforts to require licensure of pain clinics; this would be inappropriate and ineffective.

Medicine's Message

• All Texans must be confident that they are receiving the highest quality of care and that their physicians are qualified, competent, and adhere to highest ethical and professional standards.
• TMB should focus on the SB 104 charges and work to improve its administrative and disciplinary processes so they are fair and understandable for all.
• Impairment is an important issue for all, not just physicians. The Texas Physician Health Program would not replace the board’s jurisdiction but allow for confidential reporting and encourage earlier intervention, where recovery rates are higher.
• Fairness in disciplinary hearings and processes support a requirement that TMB and others be bound by SOAH rulings. Either party could still appeal SOAH findings in court.

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.

State lawmakers continue to file bills that advance Doctor’s Orders, TMA’s 2009 legislative agenda. HB 223 by Rep. Craig Eiland (D-Galveston) and SB 714 by Sen. Leticia Van de Putte (D-San Antonio) would regulate the selling, leasing, or sharing of physician discounts. HB 1748 by Rep. Todd Smith (R-Euless) prohibits insurers from arbitrarily revoking health insurance coverage. HB 1342 by Rep. Jose Menendez (D-San Antonio) and SB 863 by Sen. Chris Harris (R-Arlington) require health plans to provide pertinent patient coverage information at the time of service. Your TMA lobby team and I are visiting with legislators on TMA’s issues, in advance of tomorrow’s First Tuesdays at the Capitol, when you can make your own direct connections. Todd Thames, MD, a family physician from San Antonio, testified for increased Medicaid payments before the House Appropriations Subcommittee on Health and Human Services. And Michelle Berger, MD, an Austin ophthalmologist, outlined TMA’s priorities to the House Public Health Committee.

The latest America’s Health Rankings shows Texas has lost serious ground in the fight against obesity and tobacco use. The newest installment of Podcast TMA looks deeper at the issue, as reported in the cover story of the March issue of Texas Medicine. Kim Edwards, MD, an Austin pediatrician and chair of the Texas Pediatric Society's Obesity Committee, and Jeffrey Levin, MD, chair of TMA’s Council on Public Health and a Tyler occupational medicine physician, discuss the Rankings report findings and suggest how Texas can improve its overall public health performance.

Medicaid is the workhorse of Texas’ health care delivery system. It covers nearly 3 million poor and low-income Texans — most are children of working parents. Medicaid is the single largest source of federal funding, returning vital federal tax dollars to the state and local economies. A dollar spent by Medicaid returns $1.54 to the state; for the Children’s Health Insurance Program (CHIP), the return is $2.63.

Investing in primary and preventive care saves state dollars through reduced spending on acute illnesses and emergency room visits, and it results in a healthier population. Cost-effective health care hinges on patients’ continuous, ongoing relationship with a primary care physician or “patient-centered medical home.” For this reason, Texas needs a robust network of physicians who can take care of Medicaid patients.

The 2007 legislature made progress toward this goal by enacting the first meaningful Medicaid physician payment increase in 15 years. The payments increased 25 percent for physicians’ services for children and 10 percent for services for adults. According to TMA’s 2008 physician survey, the increase reversed a decade-long decline in physician Medicaid participation. Physicians who will accept all new Medicaid patients rose from 38 percent to 42 percent. However, Medicaid payments are still woefully inadequate and do not cover physicians’ cost to provide the care. The cost of running a practice increases about 3 percent a year. It is critical that the state continue to improve Medicaid payments so they are competitive with the rates of other payers.

Texas also must update Medicaid’s infrastructure to streamline and modernize the program’s administration and promote use of health information technology (HIT), including public health databases that can “talk” to each other easily.

Medicine’s 2009 Agenda

• Promote a patient-centered medical home for all Medicaid and CHIP patients by supporting competitive physician reimbursement rates, including rewards for physicians who provide services like after-hours care and open-access scheduling.
• Support 12-months’ continuous coverage in children’s Medicaid.
• Support equivalent Medicaid payment rates for adults’ and children’s services.
• Reduce the Medicaid “hassle factor” to entice more physicians to participate, modernize outdated information technology, and support expanded use of HIT, such as electronic medical records and e-prescribing.

Medicine's Message

• Medicaid payments still lag far behind other payment rates even after the recent increases. The costs of physicians’ practices, like other small businesses, increase each year. Physicians want to participate in Medicaid, but they simply cannot sustain the loss.

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.