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Monday, November 25, 2013


A majority of the Texans in the U.S. House of Representatives joined a majority of their colleagues from around the country in calling on House leaders to repeal Medicare’s Sustainable Growth Rate (SGR) formula this year. Congress “should not pass up this chance to repeal the SGR ... and enact a permanent solution,” they said in a letter to the speaker and minority leader of the House. “Continuing to enact short-term patches is bad fiscal policy — equivalent to paying the monthly minimum on a credit card bill — and increases the cost of full repeal.” Rep. Bill Flores (R-Bryan) was one of two congressmen to take the lead on the letter. Twenty-one of the 33 other Texans, from both sides of the aisle, put their name on it as well. A delegation of Texas physicians and medical students and TMA staff enjoyed productive conversations on the issue during visits with House members and Sen. Ted Cruz after the Washington meeting of the AMA House of Delegates. The Senate Finance Committee has scheduled a Dec. 12 “open executive session” on a draft SGR repeal proposal that has support from Democrats and Republicans, and in both the House and the Senate.


In an increasingly rare show of unity on a difficult issue, the AMA House of Delegates endorsed a strong plan to repeal the SGR by the end of the year. The plan maintains support for AMA’s and TMA’s pay-for-performance principles and pushes to keep fee-for-service as an important Medicare payment model. Before approving the proposal, delegates insisted on adding language directing AMA to work for increases in the Medicare physician fee schedule. The agreement stems from what AMA President Ardis Hoven, MD, called “a new cause for optimism” on repealing the SGR in Congress and among physicians. In other action on the top issues defined by the Texas Delegation to the AMA, the House of Delegates:
  • Sent back to the AMA Board of Trustees for revision two proposed sets of policy on supervision of nonphysician practitioners. Both policies included the term “collaboration,” which caused significant consternation among the delegates. “Too many people want to do what we do without having done what we’ve done,” said Gary Floyd, MD, of Fort Worth.
  • Directed AMA to once again support delaying or canceling the implementation of ICD-10.
  • Called on the Centers for Medicare & Medicaid Services to repeal the “two-midnight rule” for hospital in-patient admissions.
  • Said health plans should be required to notify physicians that a patient is in the 90-day grace period for a subsidized Affordable Care Act exchange plan when the physician checks on the patient’s eligibility for services. 


The funeral of Betty Kubala is today in Beaumont. All of us who know them will never forget the love and devotion that Dr. Kubala, a former TMA president, has shown for Betty over her decades of poor health. Even at the end, he wrote, “God sent his angels tonight and took Betty away from us.” For me, getting to know people like Betty and Mark — an outstanding physician, a great leader, and a fine man — is the No. 1 perk of my job.


Registration is now open for our live noon-time webcast, Thursday, Dec. 5, on how the new marketplace health plans will play out in your practice. Do you know whether you’re participating in the plan(s) offered in your area? Do those plans affect your current payer contracts? Can you identify patients on the exchange plans? What happens if they don’t make their premium payments? Lee Spangler, TMA’s vice president of Medical Economics, will help you answer these questions and many more. Plus, get 1 AMA PRA Category 1 Credit™.


Health and Human Services Commissioner Kyle Janek, MD, and some of his senior staff met with me, TMA General Counsel Rocky Wilcox, Advocacy VP Darren Whitehurst, and Medical Economics VP Lee Spangler to review a number of critical issues. We discussed the concerns we’ve been hearing about certain Medicaid managed care plans eliminating referrals to specialists and hospitals. We talked about streamlining the 1,800-plus pages of Medicaid rules and regulations physicians must follow. We examined the impact of the dual-eligible cuts on patient care for seniors, particularly in the Lower Rio Grande Valley and in rural Texas. We left very optimistic that Commissioner Janek will follow through and help us solve some of these problems.


The American Academy of Ophthalmology honored San Antonio ophthalmologist — and active TMA and TEXPAC member — David Shulman, MD, as its 2013 Hall of Fame Award recipient. Dr. Shulman was recognized for his lifelong commitment to preserving and protecting quality eye care and patient safety in Texas.

Monday, November 18, 2013


TMA Board of Trustees Chair Carlos Cardenas, MD, led a group of Texas physician leaders, TMA Vice President of Advocacy Darren Whitehurst, and me — plus senior staff and key physicians from eight other state medical societies — in an intense, three-day lobby visit to Capitol Hill. We met with congressional health care leaders like Reps. Michael Burgess, MD (R-Lewisville), and Kevin Brady (R-The Woodlands) plus Republican and Democrat staff of the key committees of jurisdiction. We also enjoyed audiences with Reps. Xavier Becerra (D-Calif.), John Fleming, MD (R-La.), and Bill Cassidy, MD (R-La.). Dallas orthopedic surgeon John Gill, MD, and Rep. Pete Sessions (R-Dallas) also set up lawmaker-physician meetings that included Drs. Carolyn Evans, Asa Lockhart, Russ Kridel, and Ray Callas. The major topic of conversation was the joint proposal from the House Ways and Means Committee and Senate Finance Committee to repeal the Medicare Sustainable Growth Rate (SGR) formula that has bedeviled physicians’ Medicare payments for more than a decade. The draft plan does away with the SGR but imposes a 10-year freeze on physicians’ Medicare payments and establishes several new pay-for-performance programs. While several national specialty societies are supporting the bill as is, TMA, the American Medical Association, and the Coalition of State Medical Societies is pushing for substantial improvements and elimination of a host of onerous federal health care regulations. An influential health care blog published a commentary from the coalition that outlines our concerns. The issue has generated a lot of debate at the AMA House of Delegates meeting that convened just outside Washington on Saturday. We suspect it will take at least several months for any final product to make its way through Congress — if that happens at all. That means we’ll need another short-term congressional patch to avoid the 24-percent cut scheduled to take effect in January.


Replacing the Medicare SGR formula, protecting physician practices from the ravages of the 90-day grace period in the Affordable Care Act (ACA) marketplace plans, scope of practice, and license recertification were the hottest topics in the opening days of the AMA House of Delegates meeting. As usual, members of the Texas delegation are actively engaged both in the open debates and in the behind-the-scenes negotiations. The three days we spent on Capitol Hill before the meeting have particularly informed our perspective. Look for a more complete report in next week’s EVPGram and in January’s Texas Medicine.


On March 11, 1938, just two years after graduating from The University of Texas Medical Branch at Galveston, a young Mavis Kelsey, MD, joined the Texas Medical Association. He maintained his TMA membership over an amazing 75-year career in Houston medicine. The health care innovator, flight surgeon, and Mayo Clinic-trained internist died last week at the age of 101. In 1951, he founded the Kelsey Seybold Clinic with Bill Seybold, MD; his brother John Kelsey, MD; and others. I am pleased that the clinic continues Dr. Kelsey’s tradition in organized medicine with 100-percent membership in TMA and the Harris County Medical Society. Our deepest sympathies to his family and friends.


Two stalwart members of the Texas family of medicine were honored at the AMA House of Delegates meeting. Houston trauma surgeon Ken Mattox, MD, received the 2013 AMA Benjamin Rush Award for Citizenship and Community Service. The award is given “for outstanding contributions to the community for citizenship and public service above and beyond the call of duty as a practicing physician.” Dr. Mattox was recognized for his service in Houston’s medical response to several natural disasters, including hurricanes Katrina and Rita in 2005 and Tropical Storm Allison in 2001. Marshall Cothran, CEO of the Travis County Medical Society and the Blood and Tissue Center of Central Texas, received the Medical Executive Meritorious Achievement Award. AMA gives this award to a medical society executive who has provided exemplary and exceptional service that benefits and supports physicians in caring for their patients. This contribution “is exemplary beyond the normal scope of their duties or responsibilities.”


Congratulations to a pair of medical students who won election as new Region 3 representatives to the AMA Medical Student Section. Raghuveer Puttagunta from the Baylor College of Medicine is a new Region 3 delegate, and Ben Karfunkle from The University of Texas Medical School at Houston is an alternate delegate.


Norman Chenven, MD, founder and CEO of Austin Regional Clinic, is the new treasurer of the American Medical Group Association (AMGA). Dr. Chenven, a family physician, is a member of the steering committee of the TMA Physician Services Organization.

Monday, November 11, 2013


I spent nearly all of last week working at the meeting of The Physicians Foundation. As president of the foundation and TMA’s representative on its board, I am adamant that it produce outstanding research and fund high-quality projects so we continue to get a great return for Texas physicians. The foundation was created as part of the 2003 settlement of the class-action lawsuit that TMA and 21 other state and county medical societies brought against for-profit HMOs. The board at this meeting looked at studying quality metrics, integrated delivery systems, physician leadership, a University of North Carolina simulation model on workforce needs, and the foundation’s next nationwide survey of physicians.


I’ve really enjoyed writing the series of health care policy blogs for Forbes.com with Tim Norbeck, the CEO of The Physicians Foundation. Our most recent post, “Healthcare Is Turning Into An Industry Focused On Compliance, Regulation Rather Than Patient Care,” discusses the growth of what we call “the medical-industrial complex.” This complex is concerned, above all, with creating, enforcing, and compliance with government regulations of medical practice. A previous Physicians Foundation white paper, and the recent RAND Corporation study commissioned by the American Medical Association, focus on how this overregulation is damaging physicians’ morale and hurting health care in this country. To begin to combat this hyperregulation, which we cited extensively in TMA’s Healthy Vision 2020 document, the Texas Delegation to the AMA House of Delegates will carry an emergency resolution to the house meeting next week. Our resolution will call on AMA to convene “a multidisciplinary, multispecialty panel of practicing physicians and practice managers to scientifically assess the cost and benefit of the myriad regulations physicians face today.” The purpose of the panel will be to focus AMA advocacy to keep what’s working and fix what’s not.


I wish we could answer every question Texas physicians have right now about participating in the insurance plans offered through the Affordable Care Act marketplace. Based on our email and phone traffic — plus the meetings we had with large group leaders in Austin, Dallas, and Fort Worth — the issue is at the top of your minds. Do I have to participate? Am I already signed up? Will I get a new contract? What will they pay? What about the 90-day grace period for patients who don’t keep current on their premiums? To address as many of those questions as possible, as quickly as possible, we pushed out early an article that will appear in the December issue of Texas Medicine. I hope you’ll find “Marketplace Means Decisions for Doctors” to be helpful. We’re also planning a live webinar and other tools to help you better understand the marketplace plans and make the best decisions for your practice. Stay tuned for details. And don’t forget TMA’s “Hey, Doc” campaign — chock-full of answers to questions your patients have about the marketplace. This week, we look at the platinum, gold, silver, and bronze plans and what those categories mean for patients.


Texans approved a water plan and eight other constitutional amendments; voters in a suburban Austin House district sent two candidates to a runoff; and a splinter group of Texas trial lawyers has created a new political action committee. Read about the Texas Association of Consumer Lawyers PAC and all the rest in the new weekly newsletter from TEXPAC Director Clayton Stewart.


“For the fifth consecutive legislative session, our 2003 medical tort reforms remained unscathed.” That’s the message the leaders of the Texas Alliance for Patient Access (TAPA) shared at the organization’s annual meeting, which also commemorated the 10th anniversary of the Texas liability reforms. A report on the current battle in California to protect Medical Injury Compensation Reform Act caps gave it all a sense of urgency. The membership reelected TAPA Board Chair Howard Marcus, MD, of Austin. Among those elected to the board were TMA Advocacy Vice President Darren Whitehurst, and Jim Cox, MD, and Monte Troutman, DO, of Fort Worth. A bylaws change gives TMA, which helped found the organization, a permanent seat on the TAPA board.


A road sign I passed on the way to the office this morning read, “They cared not for themselves but for the country they served. Thank a veteran today.” I cannot say it any better.

Monday, November 4, 2013


Once again, Texans in Congress are playing key roles in fixing our broken Medicare payment system. The latest joint proposal comes from the House Ways and Means Committee and Senate Finance Committee. Rep. Kevin Brady (R-The Woodlands) chairs the Ways and Means Committee’s Subcommittee on Health, and Sen. John Cornyn sits on the Senate Finance Committee and its Subcommittee on Health Care. Another bill, sponsored by Rep. Michael Burgess, MD (R-Lewisville), has already passed the House Energy and Commerce Committee with bipartisan support. We will work with all three of them, and the rest of the Texas Delegation to Congress, to come up with the best bill we can to replace Medicare’s Sustainable Growth Rate (SGR) formula. Your TMA leaders will be “on the Hill” meeting with these Texas leaders before, during, and after the upcoming American Medical Association House of Delegates meeting.


I enjoyed an excellent visit with Sue Turney, MD, president and CEO of the Medical Group Management Association (MGMA). Dr. Turney, who is an old friend from her days at the helm of the Wisconsin Medical Society, came to Austin to discuss our plans for the TMA Physician Services Organization (PSO). We explored potential collaborations with MGMA on physician-developed quality measures, physician-directed integrated delivery systems, and how best to involve practice administrators in transforming medical practices. Set to launch early next year, the TMA PSO will offer practices the business services and information technology they need to provide demonstrably better and more efficient patient care and compete in today’s health care marketplace. Because MGMA is a national leader in group practice management, Dr. Turney and her team are natural collaborators for this new TMA business.


TMA President Steve Brotherton, MD, has become a regular source for quotes in Modern Healthcare stories about issues ranging from the Affordable Care Act to Medicare to tort reform. The editors were impressed enough to ask him to pen a commentary for the magazine. Under the headline, “Obamacare needs changes to be more physician friendly,” Dr. Brotherton outlines our “fix what’s broken, find what’s missing, keep what’s good” approach to health care reform. He writes about repealing the SGR, putting ICD-10 “on permanent hold,” and passing the Medicare Patient Empowerment Act. “If our lawmakers have the same concern for their constituents as we have for our patients, they will pass these measures,” he says. If you’re a print subscriber, you’ll see the article in the December edition. If you have online access, you can read it here. If you have neither, you’ll just have to take my word for it — he represents Texas well.


We offer some special benefits to large group practices in which every physician is a member of TMA. Every year, for example, we send our senior staff around the state for some high-level discussions with leaders of our 100-percent groups. As Dr. Brotherton says, “Because we value our relationship with you, we want to understand better the challenges your organization will face in the coming year and how TMA can best help you. Additionally, we’ll talk about our newest and most innovative products and services, including those that can help you manage in a ‘value-based’ environment.” We began our briefings for the 100-percent groups in San Antonio last week. We’ll be in Austin, Dallas, and Fort Worth this week, and Houston the beginning of December. For more information on the briefings or 100-percent membership, contact Dora Tanton.


Your EVPGRAM editor rarely admits to mistakes. When he does, we publish his corrections here and make him submit to ceaseless humiliation at the hands of his peers. Herewith:

  •  The headline on the first story from last week’s EVPGRAM should have read, “Three-Fourths of Texas Counties Have Just One or Two Insurance Companies in the Marketplace.”
  •  A statement in the final story of last week’s EVPGRAM should have read, “In 2012, the most current year for which data are available, Texas reached an all-time high of 169.2 direct patient care physicians per 100,000 population.”