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Tuesday, December 18, 2012

Dual-Eligibles Cut Partially Reversed

After months of TMA-organized rallies, lobbying, and meetings, the Legislative Budget Board has directed the Texas Health and Human Services Commission (HHSC) to reverse part of the cut in payments for patients covered by both Medicare and Medicaid.
The tipping point was a meeting State Sen. Juan “Chuy” Hinojosa (D-McAllen) organized at the Capitol last week with Lt. Gov. David Dewhurst and House Speaker Joe Straus. The group included TMA Board of Trustees Vice Chair Carlos Cardenas, MD, of Edinburg, and La Joya family physician Javier Saenz, MD. Although Gov. Rick Perry did not attend the meeting, his support helped move the change over the finish line.
“It’s a great first step,” said TMA President Michael E. Speer, MD. “Physicians across the state and their patients have been reeling from the impact of these cuts for almost a year. We definitely needed a reprieve. Since January, it’s been a true medical emergency. Physicians who care for Texas’ most sick and most vulnerable patients have had to borrow money to keep their doors open, lay off staff — some dropped out of the Medicaid program, and some did close their practices.”
The 2011 Texas Legislature ordered the cut in dual-eligible payments as a budget-saving move. The way HHSC implemented it covered two pieces of the complex interaction between Medicare and Medicaid payments to physicians. The change effectively:
  1. Stopped Medicaid from covering all of the dual-eligible patients’ $140 annual Medicare deductible; and
  2. Prevented Medicaid from paying more than the Medicaid-allowable charge; this stopped Medicaid coverage of the Medicare copay.
The agreement reached would reinstate coverage of the Medicare deductible in 2013. Exact details of how HHSC would implement that change were still being worked out as this issue of EVPGram was prepared. TMA will keep you informed as we learn more.
South Texas physicians praised Senator Hinojosa, state Rep. Richard Raymond (D-Laredo), state leaders, TMA, and HHSC officials for reaching agreement on the deductibles issue.
“This was indeed a team effort from the rallies we have had here in the border and in countless meetings in Austin,” Hidalgo-Starr County Medical Society President Victor Gonzalez, MD, told the Rio Grande Guardian. “Chairman Raymond and Senator Hinojosa and all our elected officials were so helpful and supportive.”
Reversing the cut is one of the top priorities identified by TMA’s Physicians Medicaid Congress. Dr. Speer said TMA will continue to pressure lawmakers when the legislature convenes in January to reverse the remainder of the cut.
“We now urge lawmakers to eliminate the rest of this cut as soon as possible,” he said. “While this cut has disproportionately impacted dual-eligible patients with disabilities and seniors, when physicians are forced to close their doors or reduce services, it affects all of our patients.”

Monday, December 10, 2012


Aetna has agreed to pay physicians and patients nationwide up to $120 million because it used databases that deflated rates for out-of-network services. The agreement stems from settlement of a 2009 lawsuit against Aetna by TMA, the American Medical Association, and nine other state medical societies. The suit alleged Aetna used databases created by Ingenix, Inc., a subsidiary of United Healthcare, to set usual, customary, and reasonable (UCR) rates for out-of-network services. It said Ingenix databases were inherently flawed and unable to establish proper UCR rates. Physicians will be notified once the judge in the case approves the settlement and will have 90 days to file a claim.


Increasing physicians’ payments, eliminating the dual-eligible payment cut, sharply reducing red tape and administrative hassles, and curtailing fraud-and-abuse witch hunts are what Texas Medicaid needs to recruit physicians back to the program. That’s the conclusion of our Physicians Medicaid Congress, which finalized its recommendations over the weekend. The TMA Board of Trustees and Council on Legislation will consider and prioritize the list, which includes advocacy for reforms at the Texas Legislature, U.S. Congress, and Health and Human Services Commission (HHSC). Check out TMA’s newest video on why Texas physicians feel Medicaid is broken.


Nearly 100 physician, alliance, and medical student leaders from TMA and state specialty societies gathered in Austin to discuss the lay of the land and establish priorities for the 2013 Texas Legislature. Improving payment from Medicaid tops everyone’s list, followed by restoring cuts to graduate medical education and physician loan repayment programs, stopping scope-of-practice expansions, and enacting health insurance reforms. House Calendars Committee Chair Todd Hunter (R-Corpus Christi), key legislative staffers, and state agency heads — including Insurance Commissioner Eleanor Kitzman and Texas Medical Board Executive Director Mari Robinson — previewed the tough issues that lie ahead. TMA Board Chair Tom Garcia, MD, and San Antonio neonatologist Alex Kenton, MD, were our guinea pigs, bravely delivering testimony at a mock legislative hearing before State Reps. Craig Eiland (D-Galveston) and John Kuempel (R-Seguin).


TMA’s Border Health Caucus called on Lt. Gov. David Dewhurst and House Speaker Joe Straus to stop the cuts in dual-eligible payments before another disastrous January rolls around. “We have met with leaders from HHSC on many occasions and they want to help us,” Drs. Luis Calo of Harlingen and Carlos Cardenas of McAllen wrote in a letter hand-delivered to the two leaders. “They agree there is a problem, but they tell us their hands are tied until the state leadership provides direction. We are asking for that direction now. We have been told specifically that even as late as the end of this month, the deductible can be paid if there is an agreement from our state leadership. … Offices have been closed. Doctors have left our area, and bank notes and credit cards have hit their respective limits as we struggle to deal with these cuts.”


A sad follow-up to last week’s story about Dallas County Medical Society (DCMS) pulling out of the regional Medicaid 1115 waiver project: Because hospitals in the area have cut local physicians out of the plan to care for low-income residents, DCMS made the tough decision to eliminate Project Access Dallas, a nationally recognized service project that provided more than $34 million in charity care and served more than 10,000 uninsured patients during its 10-year span.


It should be either-or, not neither-nor. That’s what TMA told Texas congressional leaders in a letter backing upcoming Medicaid payment increases for primary care services. Among the “fiscal cliff” proposals on Capitol Hill is one to stop the Medicaid increase to help avoid the 27-percent Medicare payment cut set for Jan. 1. “We cannot turn Medicaid into a more effective delivery system until we shore up Medicaid patients’ eroding access to primary care physicians and key specialists,” TMA President Michael Speer wrote in a letter also signed by the presidents of the Texas Academy of Family Physicians, Texas Chapter of the American College of Physicians, and Texas Pediatric Society. “Reversing this solution for short-term savings — even if those savings might be used to fix Medicare’s glaring payment problems — will ultimately cost lives and more money.”


Congratulations to U.S. Rep. Lamar Smith (R-San Antonio), my congressman, the new chair of the House Committee on Science, Space, and Technology. “The purpose of the Science Committee is to grow research and development that leads to new innovation,” Representative Smith said in announcing his new post. He previously chaired the House Judiciary Committee. Other Texans with leadership spots in the new Congress include Reps. Jeb Hensarling (R-Dallas), Financial Services Committee; Michael McCaul (R-Austin), Homeland Security Committee; Pete Sessions (R-Dallas), Rules Committee; and RubĂ©n Hinojosa (D- Edinburg), Congressional Hispanic Caucus.


This will be your last regular EVPGram for 2012. We will return early next year and, of course, send you special editions for any important, breaking news. Happy Holidays.

Monday, December 3, 2012


Citing the more than $4 billion in federal and local money that Dallas hospitals are set to receive over the next four years to care for the county’s uninsured and Medicaid populations and the “next to nothing” they will share with physicians who provide the actual care, the Dallas County Medical Society (DCMS) has pulled out of the 1115 Medicaid waiver program. “If independent physician practices cannot maintain economic viability as a consequence of their participation in this program, they will be forced to withdraw from the Medicaid insurance program (as many have already done) or go bankrupt,” DCMS President Rick Snyder, MD, wrote. Texas’ 1115 waiver sets up regional cooperatives that are to share in a redistributed mix of the hospitals’ complex Medicaid finances and new managed care programs to coordinate coverage for Medicaid patients. TMA took part in meeting with Texas Health and Human Services Commissioner Kyle Janek, MD, and DCMS leaders to discuss the Dallas doctors’ concerns with the hospitals plans.


The Texas Department of Insurance’s (TDI’s) proposed rules governing the adequacy of physician networks in insurance plans are bizarre, misguided, “extremely poor public policy,” unacceptable, inappropriate, feeble, confounding, insurer-friendly, and unsupportable, TMA President Michael Speer, MD, writes in a formal letter to be delivered to TDI today. “If the Department’s current path is not abandoned, it will ultimately result in irreparable harm to Texas’ consumers as, inter alia, the value of the products they have purchased will be reduced; their out-of-pocket expenses will be increased; and ― unjust and ― deceptive policies will (by the Department’s own admission) be allowed in the market for purchase by unsuspecting consumers,” Dr. Speer wrote. TMA, TDI, and the health plans have been involved in lengthy negotiations over the rules since we pushed passage of network adequacy laws in the 2007 and 2009 sessions of the Texas Legislature. Shortly before they were to take effect, TDI Commissioner Eleanor Kitzman late last year suspended a solid package of rules TMA helped to put together.


We need your help to convince Congress to stop the “zombie Medicare financing” it uses to pay physicians. Please call Washington at 7 am tomorrow, and at 7 am every Tuesday thereafter, until Congress stops this year’s 27.5-percent payment cut and agrees to fix the defective Sustainable Growth Rate (SGR) formula. Get commitments from Sens. John Cornyn and Kay Bailey Hutchison and your representative to fix the 12-year-old problem. For talking points and congressional phone numbers, go the Medicare Meltdown Action Center on the TMA website.


Minnesota Medical Association CEO Bob Meiches, MD, is the latest in the long line of state association leaders to visit the TMA building. Dr. Meiches came to share his organization’s plan for a strategic revitalization and to seek our answers to the tough questions: How do we provide value in today’s changing medical marketplace? What advocacy and services do physicians employed by large systems need and expect? While Minnesota’s health care delivery systems are very different from ours, I found the conversation engaging and thought-provoking. What answers do you have?


Dr. Speer and John Holcomb, MD, chair of TMA’s Committee on Medicaid, CHIP, and the Uninsured, hosted a pair of tele-town hall meetings to seek physicians’ ideas on how to improve health care for low-income Texans. The telephone listening sessions — along with an in-person meeting in McAllen hosted by TMA Board Vice Chair Carlos Cardenas, MD — are a key component of TMA’s Physicians Medicaid Congress. Thousands of Texas physicians listened in and shared their complaints with the current system and suggestions for fixing it. The Physicians Medicaid Congress meets in Austin this week to draft its legislative and state-agency advocacy agenda.


Texas’ new Medical Privacy Law requires that all physicians and their staff receive training tailored to their scope of employment within 60 days of hire and every two years thereafter. Log on to the TMA Education Center next week for one of three, live, lunch-time webinars that deliver the necessary training on HIPAA and the new state law. Buy the three-pack bundle for the best price:
  • Dec. 11: Complying With HIPAA and Texas Privacy Laws — a must for compliance officers, physicians, and a good overview for the entire staff;
  • Dec. 12: HIPAA for Nonclinical Staff — tailored for reception and medical records personnel; and
  • Dec. 13: HIPAA for Clinical Staff — focusing on physicians, nurses, billing and coding staff, and others involved in clinical care.