Family Medicine Under the Dome

Every legislative session has a character of its own, a personality of sorts. As the opening of the 80th Legislature approached, the fact that this would be a particularly strange session became ever more apparent. A struggle erupted in the House as Republicans and Democrats jockeyed for position in a hotly contested race for Speaker, a rarity in state history.

Speaker Tom Craddick, R-Midland, won of course, but not without the help of a contingent of Democrats dubbed the “Craddick Ds.” The race left a band of rebel Republicans oddly empowered to challenge the leadership. Democrats who had opposed Craddick found that they now had occasional partners across the aisle, as the session became less about Rs versus Ds as it was about legislators voting in the interests of their districts. The House appeared on the verge of open rebellion.

Then Gov. Rick Perry announced an executive order mandating all 6th grade girls be immunized against human papillomavirus, which set off a firestorm of protest in the House and the Senate. This was followed shortly by a brewing scandal at the Texas Youth Commission that led to the entire TYC board stepping down, most senior administration staff leaving and ultimately the governor placing the agency in receivership. The following week, the House and Senate exploded in frustration over what they saw as a gross overreach by the Texas Department of Transportation over toll road expansion. Not to be outdone, the Health and Human Services Commission announced they would be ending a contract with Accenture that was designed to privatize parts of the state’s health and human services eligibility process after significant failures. This backdrop literally sucked all of the energy out of the session, leaving legislators and their staffs tired, disgruntled and counting down the days till the Legislature adjourns sine die on May 28.

In preparation for the session, TAFP partnered with its allies in the Primary Care Coalition to publish a ground-breaking report, “Fractured: The State of Health Care in Texas.” The report synthesized information from many recent studies illustrating the state’s dire situation as health costs climb, the population ages and swells, the ranks of the uninsured grow and the physician supply dwindles.

The Fractured document has been received with surprising accolades. Editorial boards across the state referenced our information and called on lawmakers to address the crisis. And that message was heard. At the opening of the session, Sen. Juan “Chuy” Hinojosa, D-McAllen, penned an opinion piece that ran in several Texas papers in which he quoted the Fractured document on several occasions. “Without a comprehensive initiative to solve the health care crisis, Texas will not be able to sustain a healthy economy or build a future of progress and prosperity,” Sen. Hinojosa wrote. “Other states are moving forward with bold initiatives to reduce their uninsured. If Texas wants to remain an attractive place to do business, we should, too.”

TAFP President Doug Curran, M.D., expressed his optimism early and often before every group of doctors he addressed. “I really think that this year is an exceptional year for the Texas Academy,” he said in an interview with TEXAS FAMILY PHYSICIAN in February. “We are well received at the State Capitol. We have done our homework and we have a leadership position on a number of issues.”

Recently elected AAFP Board member and TAFP Past President Roland Goertz, M.D., echoes Curran’s optimism. He says he finds that legislators are more receptive to the message of family medicine than ever before. “For the first time in the history of family medicine as a discipline, we have data, information, scientific studies that show the value of a personal medical home beyond the shadow of a doubt. We’ve never had that before. Legislators will listen to information like that and they’re listening more and more. They want us to help put the personal medical home in place for all the people of Texas.”

As the year began, Academy leaders challenged the TAFP Communications Department to do more than ever before to involve and inform the membership on what happens at the Capitol and about TAFP’s advocacy efforts. We took the opportunity to put our recently retooled Web site to the test. We began sending weekly issues of our electronic newsletter, QuickInfo. That e-mail became of table of contents for our weekly Web news postings on the news page of www.tafp.org.

Then we launched the Capitol Update, TAFP News’ home for all things legislative. We nested the Capitol Update into the QuickInfo so members would be one click away from solid news reporting on the issues that affect their practices.

In perhaps the most innovative communications advancement TAFP has ever undertaken, we seized an opportunity to create a video news show that we broadcast on the news page of www.tafp.org, the Capitol Report. If you haven’t seen it, go to the news page at www.tafp.org/news and scroll across the video window on the right, click the play button and enjoy. You can view all of the weekly episodes on the Capitol Update and Capitol Report Archive page; the link is on the left of any TAFP news page.

Now that almost three-quarters of the session is over, let’s take a look at where family medicine stands.

House Bill 1 – A record-breaking budget

The budget is the only piece of legislation Texas lawmakers have to pass, and as we go to press, that bill is headed to a conference committee where it will be reworked yet again. The House bill spends $150.1 billion in the next two years and the Senate version spends about $2 billion more. While total spending breaks the all-time record for the Texas budget, lawmakers still haven’t restored all of the cuts made in health spending in 2003.

Example: Graduate medical education, or GME. Despite a looming shortage of primary care physicians, both the House and the Senate chose to freeze spending on primary care residency programs. There’s a possibility to address that need in the conference committee, where members could raise funding for residency programs back to 2003 levels. As part of the Primary Care Coalition, TAFP submitted written testimony to conferees urging them to consider boosting funding for GME.

“We recognize there are intense, competing demands for available state funds and we understand the need to balance those funding priorities,” PCC Chair Eugene Stokes, M.D., wrote in the letter. “However, given Texas’ current and impending shortage of physicians—particularly primary care physicians—this increased funding will ensure Texas families continue to have access to timely, cost-effective primary health care.”

The PCC also released an issue brief on GME and the physician workforce. It’s available on the advocacy page of the TAFP Web site.

Neither the left nor the right is happy with the budget. The left complains that the state isn’t spending enough on health care and education while setting aside billions for future property tax reductions. The right grumbles that the state budget continues to grow faster that the economy.

While much has been made of the damaging effects of having such an enormous uninsured population, budget writers completely ignored the issue. Several other states have implemented innovations to increase access to health insurance for their citizens. Yet here we are in the Lone Star state where one in four Texans are uninsured and the state budget contains virtually no initiatives to lower that number.

CHIP – Insuring Texas children is good medicine and good business

One of TAFP’s primary efforts this session has been to strengthen the state’s Children’s Health Insurance Program and after many hours of debate, the Texas House passed a bill that would do that on April 3. The day began with a rally on the Capitol steps as medical students and physicians from across the state joined the bill’s sponsor, Speaker Pro Tempore Sylvester Turner, D-Houston, in support of H.B. 109.

“We have labeled this session as a session involving insuring and protecting our kids,” Turner said to the crowd of physicians, reporters and spectators. “At the end of 140 days, we will be evaluated in terms of how well we have insured them, and by how well we have protected them, and today, we take a major step forward in insuring our kids.”

The bill reinstates the original 12-month enrollment period, it relaxes the asset test, it removes the 90-day wait for new enrollees and it allows families to deduct their childcare expenses from their reported annual income. These changes are intended to remove barriers enacted in 2003 that make it difficult for families to enroll their children in the program. Rep. Turner expects the bill would add more than 100,000 kids to the program.

The bill now moves to the Senate where it will face an uphill battle. Lt. Gov. David Dewhurst has said throughout most of the session that he opposes changing the enrollment period from six to 12 months, although he’s recently changed his tone somewhat, stating that he wants to get away from the six-month-versus-12-month debate. Now he suggests a 12-month enrollment period with a continuous eligibility component. Details on how eligibility would be monitored have yet to be revealed. How often would families have to report their income or the value of their cars? How onerous will that process be on families as well as the state? If this is a serious initiative, all those questions and more have to be answered and precious little time remains for fleshing out new ideas.

Sen. Leticia Van de Putte, D- San Antonio, joined several legislators at the press conference, telling the crowd that she looks forward to the day they get the bill signed in the governor’s office.

“The untold story here is that Texas taxpayers have left $893 million of your hard-earned money in Texas up at the federal level because we didn’t draw that down,” she said. “And so other states and other children in this country have gotten the benefit. And not that we don’t love the little children in New York and California, Florida, Georgia, those states that tell us thank you for getting our CHIP allocations, but we just want to take care of our kids at home. We want to get back to the original design. We can no longer afford to lead this country with the highest number of uninsured children.”

Medicaid – Ensuring access to care

“Reimbursement rates for health care providers in Texas with Medicaid are way too low,” said Sen. Robert Deuell, M.D., a family physician from Greenville in an interview for the March 30th edition of TAFP’s video Web cast, Capitol Report. With that statement, the senator hit upon the most important reason why Medicaid patients across the state report difficulties in trying to find physicians to care for them. A recent and oft-cited report by the Texas Medical Association shows that only 38 percent of Texas physicians accept all new Medicaid patients. The only change physicians have seen in Medicaid reimbursement rates since 1991 is a cut. “I think if the government—the state of Texas—is going to commit to a program then I think we shouldn’t subsidize that program on the backs of the people being asked to provide the health care.”

Sen. Deuell serves as vice chair on the Senate Health and Human Services Committee and worked on the Senate subcommittee on Article II, the section of the budget that deals with health spending. “I think we need to provide fair reimbursement rates,” Deuell said. “It has a lot to do with access. Out in the rural areas, as a family physician, I cannot find pediatric subspecialties to take care of Medicaid kids. That then in turn overwhelms the children’s hospitals in Dallas, Fort Worth or Houston, because they’re getting such an influx of Medicaid patients they can’t physically see them all and that creates another access problem.”

TAFP illustrated the troubles with Medicaid reimbursement in “Fractured” and in policy briefs, newspaper columns and in written testimony provided to the House Appropriations Committee, which is charged with carrying the budget bill. The Academy called for a 22.5 percent raise in reimbursements over the next two years with the idea to bring Medicaid payment up to Medicare levels over the next five years.

Secretly many health policy analysts doubted that the Legislature would pass anything close to what TAFP called for, but a twist of fate and some good fortune allowed the stars to align. A 14-year-old federal lawsuit called Frew v. Hawkins threatened to wreak havoc on the state budget. The class action suit claimed Texas children in the Medicaid program do not have sufficient access to physician services or preventive care. Several years ago, the state entered into a consent decree in the case to which it never complied. Having run out of appeals, U.S. District Judge William Justice was set to hear the case on Monday, April 9, and all involved expected him to rule against the state. Estimates for what his ruling might cost the state ranged from $500 million to $5 billion.

But at the last minute, plaintiffs’ attorneys and key legislators reached an agreement in which the state promised to spend about $700 million more on the program, an amount that draws down an additional $1 billion in federal matching funds. As part of the agreement, Medicaid providers will get a 25-percent hike in reimbursement. Whether that amount will be enough to bring physicians back to the program is anyone’s guess, but it’s certainly something to celebrate.

The state also promises to boost outreach efforts, especially in rural, border and underserved urban areas; increase children’s access to dental care; and demand better performance from Medicaid managed care contractors. Final details in the Frew case have yet to be decided and the federal judge handling the case still has to approve the settlement after the Legislature adjourns sine die, but with the plaintiffs’ attorneys and the chief budget writers on board, it looks as though the train wreck has been averted.

Medicaid reform – Variations on a theme

Several lawmakers came into the session intent upon reforming the Medicaid program. Sen. Jane Nelson, R-Flower Mound, got the nod, so she is sponsoring S.B. 10, an omnibus bill that aims to change how the state finances the program.

“We’re creating options rather than mandates,” Nelson said on the Senate floor in early March. “We are investing in prevention and over the long term, I truly believe this bill will stabilize costs, it will increase access to health care and most importantly it will help Texans live longer and healthier lives.”

Under this legislation, Medicaid recipients would receive incentives to stop smoking, control their weight and implement other preventive health measures. The bill would increase premium assistance programs to help Medicaid-eligible workers participate in employer-sponsored plans and it would set up a pilot project for health savings accounts under Medicaid. Other reforms include a state evaluation of the merits of expanding the integrated care model to manage the care of Medicaid recipients, an effort to pool state Medicaid dollars with employer and beneficiary contributions to pay for private insurance premiums in a “three-share” or “multi-share” program, and the creation of customized Medicaid benefit packages.

TAFP has worked throughout the session with the senator and allies in the TMA and the PCC to iron out potential problems for physicians in the bill and TAFP’s director of public affairs, Tom Banning, says the bill that the Senate voted to send to the House is a good bill. “This is a very ambitious piece of legislation that goes a long way toward making Medicaid a sustainable program for the future.”

Managed care – Advocacy for the private sector

Another of TAFP’s top priorities for the session is managed care reform and although health policy analysts anticipated the climate for such matters would be hostile, initiatives to level the playing field between physicians and health plans have received a surprising amount of attention in both the House and the Senate. The centerpiece of the Academy’s managed care efforts is a fair contracting bill modeled after a Colorado measure recently signed into law by Gov. Bill Ritter.

TAFP’s fair contracting bill was filed in the House as H.B. 2016 by Rep. John Smithee, R-Amarillo, and as S.B. 1170 by Juan “Chuy” Hinojosa, D-McAllen, in the Senate. The bill would require full disclosure by health plans of payment terms, mandate that all contracts be written in plain language, prohibit the health plans from imposing new categories of coverage on doctors without their knowledge, prohibit a health plan from publishing any physician-specific information, such as ratings or comparison of performance until after the physician has been provided due process, and require managed care organizations to notify doctors before changing the terms of contracts.

TAFP has provided written testimony and invited testimony from physicians in support of these bills numerous times over the course of the session, highlighting the difficulty physicians have when negotiating with managed care plans. In March, TAFP Treasurer Robert Youens, M.D., of Weimar told the House Committee on Insurance that consolidation in the health insurance market means that a huge portion of his practice revenue is dictated by just a few companies, leaving him little opportunity to walk away from egregious contracts. “Imagine trying to run a small business when you don’t know how much you’re going to get paid for your service,” Youens said.

A closely related reform bill is H.B. 839 by Rep. Craig Eiland, D-Galveston, which would stop third-party payers from “renting out” a physician’s contracted rates to other plans without the physician’s consent. This “silent PPO/rental network” bill has passed out of committee and is awaiting a hearing by the full House.

In an interview for the April 13 TAFP News Capitol Report, Eiland warned of the consequences of unnecessarily stalling managed care legislation like his bill and the fair contracting bill by recalling medicine’s prompt pay bill a few sessions ago. At that time, a member of the House Calendars Committee blocked the bill so it wouldn’t get a hearing on the floor.

“That member was defeated by the doctors the next session,” Eiland said. “So I’m just trying to remind everybody that if they’re going to be monkeying with either one of these important bills, they need to remember that member because they may join his ranks if these bills are killed by time and the fingerprints are traceable.”

One managed care bill that has a pretty good chance of passage is the “deemed credentialing” bill, H.B. 1594 by Rep. John Zerwas, R-Fulshear. It would allow a physician to be considered in-network with a health plan when joining a physician group already in that plan’s network. The House passed the bill in April and it’s now in the Senate.

Several bills would attempt to improve the information a physician has about a patient’s health benefits, deductibles and co-pays. Topping the list of bills is H.B. 522 by Rep. Beverly Woolley, R-Houston. At first, the bill was closely associated with “smart card” technology, but as the session has progressed, this bill has become the vehicle for efforts to require plans to provide real-time eligibility and benefit information at the point of service regardless of what technology serves as the medium. Real-time claims adjudication would be the Holy Grail, but physicians will likely have to settle for a silver cup this time around.

“Physicians will have a better understanding of a patient’s health insurance coverage and patients can see a reduction in the number of unexpected medical bills,” Woolley told the House Committee on Insurance when laying out the bill.

One final piece the Legislature will likely pass is S.B. 1731 by Sen. Robert Duncan, R-Lubbock, dealing with price transparency in health care.

Retail health clinics – Concerning quality and convenience

The House Committee on Public Health took up a bill this session that would greatly relax the physician supervision requirements governing the autonomy of nurse practitioners and physician assistants. Currently, a supervising physician must be on-site with NPs and PAs 20 percent of the practice’s operating hours. H.B. 1096 by Rep. Rob Orr, R-Burleson, would strike that provision entirely. It would also double the number of NPs and PAs a physician could oversee from three to six and increase the distance of any secondary practice site from 60 to 75 miles away from the supervising physician’s primary practice.

The Convenient Care Association, a group advocating the expansion of retail health clinics, is pushing the bill. RediClinic and Minute Clinic are members of the association.

TAFP provided written testimony as part of the Primary Care Coalition. “We are gravely concerned that H.B. 1096 sacrifices patients’ safety and quality for questionable convenience,” the letter read. “Texas’ current supervision requirements ensure appropriate supervision and do not create unnecessary burdens for patients’ access to care.”

Josie Williams, M.D., a gastroenterologist from College Station, testified against the bill on behalf of the Primary Care Coalition. “When we decrease supervision, we increase unequivocally the risk for error. It is dangerous, it is not wise in our opinion, nor is convenient health worth not being good health.”

The bill is currently bottled up in committee, but Tom Banning says it’s a shot across the bow. Whether or not it gets any support, you can bet the retail health clinic folks will be back in 2009 with more of its kind.

Information technology – Bringing health care into the 21st century

Health information technology, or HIT, has become a hot topic for the House Public Health Committee as a host of bills have received attention. At a meeting of the committee in April, the committee chair, Rep. Dianne Delisi, R-Temple, said that EHR implementation could be the next great innovation in health care.

“It has the potential to save literally billions of dollars; to facilitate reductions in errors, which is a topic this committee has taken up; to improve care coordination, which we discussed in the Medicaid legislation; and to help manage chronic diseases. It will save lives.” H.B. 1066 by Delisi would create a statewide electronic health information network of public and private health care stakeholders to encourage the adoption of HIT.

Joseph Perkinson, M.D., a family physician from Victoria, testified before the committee in support of the bill. He has used an EHR in his practice for more than seven years and says the issue is about portability and improved care.

“I did this not because I love computers, I’ve grown to hate them, I did it because I believe there’s a better thing that we can give my patients and I work hard for them,” he said.

Delisi identified several other bills heard by the committee that seek to address barriers to implementation. H.B. 3886 by Rep. Dan Gattis, R-Georgetown, would provide waivers to qualifying hospitals to adopt EHRs, with a stipulation that they must allow community-based health care providers to access the system remotely. S.B. 204 by Sen. Jane Nelson would ensure interoperability with the immunization registry.

“These pieces of legislation target a fragmented, piecemeal approach to the adoption of electronic health records and the inability of state programs to communicate electronically with medical care providers,” Delisi said.

Public health – Last but certainly not least

As one of 13 member organizations of the Texas Public Health Coalition, TAFP sent a letter to important committees early in the session detailing the importance of addressing public health issues such as immunizations, health promotion, chronic disease prevention, and women and children’s health services. On the obesity front, there is a lot of energy behind Sen. Nelson’s P.E. bill, which would bring 30 minutes of “moderate or vigorous” daily physical education back for students in grades K-8 and require biannual fitness assessments for students in grades K-12. Also, Sen. Eddie Lucio, Jr., D-Brownsville, has a bill that would develop an interagency obesity council, public awareness campaigns and research to identify methods by which the state can combat obesity, especially in vulnerable segments of the population.

TAFP is supporting a booster seat bill by Sen. Judith Zaffirini, D-Laredo, that would require children to be secured in a child passenger safety seat until they are 8 years old unless they exceed 4 feet 9 inches in height. There is a bill implementing worksite wellness programs in state agencies, a bill declaring a statewide smoking ban, bills on immunizations and more.

As the days race by, the session heats up and bills begin to move or die very quickly. What’s hot today might be cold tomorrow and bills that appear to be dead could grow legs and become the next major headline. So stay on top of what your Academy is doing for you at the Capitol by visiting the “News Update” block at TAFP’s homepage, www.tafp.org. Watch your e-mail for our weekly QuickInfo and follow the links to the TAFP News video Web cast, Capitol Report.