Nov 14, 2016

Texas Doctors See Post-Election Opportunity to Reshape Health Care

(ORLANDO) -- The 2016 elections brought physicians an excellent opportunity to rebuild America’s health care systems, Texas Medical Association officials say.

“Everything is on the table — the Affordable Care Act (ACA), Medicare, and Medicaid,” said David Henkes, MD, chair of the Texas Delegation to the American Medical Association. “Today, we are crafting plans to remake the system so it truly serves our physician members and our patients.”

Drs. Kridel (l) and Henkes prepare to lead discussion on health care reform
at meeting of Texas Delegation to the AMA.
Fortuitously, the interim meeting of the AMA House of Delegates brought dozens of TMA leaders together just four days after the Nov. 8 elections. They laid out key strategic directions that TMA staff will use to devise a detailed plan.

“We need one document for all physicians, all specialties, to take to Congress and the administration and say, ‘This is what medicine believes in,’ ” Houston facial plastic surgeon Russ Kridel, MD, a member of the AMA Board of Trustees, said at an hour-long health care reform conversation among members of the Texas Delegation to the AMA, who are in Orlando, Fla., for the interim meeting of the AMA House of Delegates. “We need to act now, and we need to do those things that will put us at the table.”

“The ACA was a first step, now we need to take another step,” said former AMA and TMA President Jim Rohack, MD.

The Texas physicians said they are looking for an approach that simplifies the health care system for physicians and patients, reduces the huge regulatory burden on physicians, and reduces the cost of U.S. health care.

“This whole system is just too complicated for most people to handle,” said Dallas psychiatrist Clifford Moy, MD.

Many of the ideas in President-Elect Donald Trump’s “Great Again” health care platform and the health care agenda in House Speaker Paul Ryan’s “Better Way” plan are consistent with TMA policy.

TMA actively opposed passage of the ACA in 2010 but has since adopted an approach to “Keep what’s good, fix what’s broken, and find what’s missing.” Speaker Ryan echoed that approach during a Nov. 13 television interview, when he said, “We can fix what is broken in health care without breaking what is working in health care."

Six years of near absolute gridlock in Washington, DC, prevented even the tiniest ACA reforms from passing. One very significant achievement – from TMA’s “Find what’s missing” category – was the repeal of Medicare’s Sustainable Growth Rate (SGR) formula via the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

“Texas Solution” Gets New Life

It’s important to remember that what happens in Washington not only affects Medicare, commercial health insurance, and coverage for uninsured patients, but also plays a big role in how states implement the Medicaid program.

“We are entering into a new time,” U.S. Rep. Michael Burgess, MD (R-Lewisville), said at a fundraising reception TMA hosted for him in Orlando. “I would love it if the governors came to Washington and said, ‘OK, guys, you deliver the mail and secure the border, we’ll take care of our sick folks.’ That would be a far, far more reasonable way to approach it.”

Representative Burgess (l) discusses opportunities for major health system
changes with Drs. Robert Gunby (c) and John Carlo (r) of Dallas.
Dr. Burgess likely will be a key player in the health care debate in the next Congress.

Both the Trump and Ryan plans call for Medicaid changes that mirror the “Texas Solution” for expanded coverage that TMA has promoted since 2013. The Texas Solution calls for a comprehensive plan that:
  • Improves patient care;
  • Draws down all available federal dollars to expand access to health care for poor Texans;
  • Gives Texas the flexibility to change the plan as our needs and circumstances change;
  • Clears away Medicaid’s financial, administrative, and regulatory hurdles that are driving up costs and driving Texas physicians away from the program;
  • Relieves local Texas taxpayers and Texans with insurance from the unfair and unnecessary burden of paying the entire cost of caring for their uninsured neighbors; and
  • Pays physicians for Medicaid services at a rate at least equal to Medicare payments.


TMA staff are preparing a white paper on “Post-Election Strategies for Health System Reform” for discussion at the TMA Advocacy Retreat, Dec. 2-3 in Austin.

Nov 9, 2016

TEXPAC and Texas Physicians Enjoy Strong Election Results

This unique presidential election brought on many predictions and projections for who would win, but even as the polls closed last night, most voters were unsure of the likely outcome and how it would affect the races across the state.

As expected, voters flocked to the polls to vote for the next president. But while Texas set a record for early voter turnout, our Election Day turnout struggled — most Texans had cast their ballot early. TEXPAC’s concern was that the high volume of voters overall would affect our friends running for reelection in swing districts in counties such as Bexar, Dallas, Harris, and Travis. However, hard work and Donald Trump’s 54-percent win in Texas helped most of our friends claim victory last night.

Wins for Medicine

The election resulted in two HUGE wins for medicine. We have two new TMA/TEXPAC physicians elected to the Texas Legislature! Sen.-Elect Dawn Buckingham, MD, won Senate District 24 with 72.4 percent of the vote, and Rep.-Elect Tom Oliverson, MD, is the newest physician in the Texas House. He won House District 130 in the primary election last March and ran unopposed in the general election. TEXPAC endorsed both candidates in the primary and general elections, and we are thrilled to work with them in the upcoming legislative session.

TEXPAC had an extremely successful night. In total, 119 endorsed candidates for the Texas House, 16 for the Texas Senate, and four endorsed judicial candidates were victorious. Despite these successes, we did lose three friendly incumbents to their challengers:
  • In House District 117, Rick Galindo (R) was defeated by former State Rep. Philip Cortez (D). A Democrat usually holds the seat, and we expected this outcome, but we are sad to lose Rick Galindo. Fortunately, Philip Cortez is also a friend of medicine. He was a champion of our issues during the 83rd legislative session, and we are excited to work with him again.
  • In Harris County, we saw a similar scenario. In House District 144, another swing district, former State Rep. Mary Ann Perez reclaimed her seat from TEXPAC-endorsed Gilbert Pena (R).
  • The most disappointing loss for medicine last night, however, was in House District 107. Our good friend Kenneth Sheets (R) was defeated by his opponent Victoria Neave (D). This is a big loss for TEXPAC; Kenneth Sheets was a wonderful state representative, as well as a champion for medicine. He had a great relationship with the TMA Advocacy team and even better relations with his local physicians. He played a big role on the House Insurance Committee, and we are sad to lose him. His race was considered to be one of the toughest this cycle, and we worked hard to help him get reelected. I know he is grateful for the support we provided him as an organization.
Fortunately, most of our friends will be back to represent medicine in the 85th legislative session. We are extremely excited for our friendly incumbents to return, and we also are looking forward to working with the new members we supported. Below are the results for our priority races.

RACE
WINNER
PERCENT OF VOTE

State Senate
SD 19 
Carlos Uresti (D) 
55.80%
SD 20
Juan “Chuy” Hinojosa (D)
61.70%
SD 24
Dawn Buckingham, MD (R)
72.4% (new member)

State House
HD 23 
Wayne Faircloth (R)
58.90%
HD 33
Justin Holland (R)
67.8% (new member)
HD 41
Bobby Guerra (D)
56.80%
HD 43
J.M. Lozano (R)
61.20%
HD 47
Paul Workman (R)
53.60%
HD 54
Scott Cosper (R)
54.8% (new member)
HD 64
Lynn Stucky (R)
61.6% (new member)
HD 65
Ron Simmons (R)
56.30%
HD 102
Linda Koop (R)
54.70%
HD 105
Rodney Anderson (R)
50.10%
HD 107
Victoria Neave (D)
50.8% (new member)
HD 112
Angie Chen Button (R)
57.20%
HD 113
Cindy Burkett (R)
55.20%
HD 114
Jason Villalba (R)
55.70%
HD 117
Philip Cortez (D)
51.4% (new member)
HD 118
Tomas Uresti (D)
55.2% (new member)
HD 134
Sarah Davis (R)
53.60%
HD 136
Tony Dale (R)
55%
HD 144
Mary Ann Perez (D)
60.2% (new member)
HD 149
Hubert Vo (D)
63.50%

Texas Supreme Court 
Place 5
Paul Green (R)
54.30%
Place 9
Eva Guzman (R)
55.80%




Texas Medical Association Political Action Committee (TEXPAC) is a bi-partisan political action committee of TMA and affiliated with the American Medical Association Political Action Committee (AMPAC) for congressional contribution purposes only. Its goal is to support and elect pro-medicine candidates on both the federal and state level. Voluntary contributions by individuals to TEXPAC should be written on personal checks. Funds attributed to individuals or professional association (PAs) that would exceed federal contribution limits will be placed in the TEXPAC statewide account to support non-federal political candidates. Contributions are not limited to the suggested amounts. TEXPAC will not favor or disadvantage anyone based on the amounts or failure to make contributions. Contributions used for federal purposes are subject to the prohibitions and limitations of the Federal Election Campaign Act.
Contributions or gifts to TEXPAC or any CMS PAC are not deductible as charitable contributions or business expenses for Federal income tax purposes.
Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation, and name of employer of individuals whose contributions exceed $200 in a calendar year. To satisfy this regulation, please include your occupation and employer information in the space provided. Contributions from a practice business account must disclose the name of the practice and the allocation of contributions for each contributing owner. Should you have any questions, please call TEXPAC at (512) 370-1361.
Paid for by the Texas Medical Association Political Action Committee
401 W. 15th St. Austin, TX 78701

Oct 14, 2016

Ready for MACRA? TMA Can Help

Earlier today, the Centers for Medicare & Medicaid Services (CMS) released its final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA). Physician practices across the country now have a busy two and a half months trying to get ready to begin collecting and reporting data on Jan. 1.

TMA will continue to work with CMS and the Texas congressional delegation to rewrite and reform many of the problems we identified in CMS’ draft regulations. Although CMS granted physicians a reprieve from 2019 Medicare payment penalties if they attempt to report some data next year, practices still face a host of decisions about what path they will take to try to comply with the biggest change in Medicare payment policies in more than a generation.

TMA is here to provide guidance:

For all the latest, visit TMA's online MACRA Resource Center regularly.

Sep 15, 2016

Does the government know what it’s doing to physicians?

By Don R. Read, MD
President, Texas Medical Association

(This article first appeared in the KevinMD.com blog. Reprinted with permission.)

Physicians spend almost twice as much time each day typing on computers and filling out paperwork as they do seeing patients. That astonishing conclusion comes from research published this week in the Annals of Internal Medicine.

Just think about that. How would you feel if you spent two hours documenting every hour of work that you do? How would your boss feel about it? You’d be depressed and frustrated; your boss would probably be angry as hell.

Patients should be up in arms over this report. Taxpayers should be up in arms. Physicians already are up in arms because we already knew this was true — and we know it’s just going to get worse.

We know it’s going to get worse because we know what’s causing it in the first place.

And that’s what’s missing in this study. Why? Why do physicians spend just 27 percent of their time “on direct clinical face time with patients” and 49.2 percent on electronic health records (EHRs) and “desk work”? From my nearly 50 years in medicine and thousands of conversations I’ve had with my colleagues, I can guarantee you it’s not a willing choice.

But again, the question is “why.” Why is this happening? Part of it has to do with EHR systems that appear to have been designed by someone who never set foot in a physician’s exam room. They’re clunky, not intuitive, and don’t fit the flow of how we examine, diagnose, and interact with our patients.

But the bigger issue is why we have to enter all of this data into a computer system in the first place. It comes back to an alphabet soup of government regulations that definitely were written by someone who’s never been in the exam room with a patient. The Physician Quality Reporting System (PQRS), Meaningful Use (MU), and the Value-Based Payment Modifier (VBM) program all aim to “capture” the quality of care we’re providing and score us on the cost of that care. MU — the worst-named government program ever — actually cuts our Medicare payments if we don’t use an EHR.

A study published in Health Affairs earlier this year estimates the cost in physician time to comply with just one of those programs, PQRS, exceeds $50,000 per primary care physician per year. That’s a lot of money; but it’s also a lot of our time. That’s time the government has stolen from our patients.

And — as I mentioned earlier — it’s only going to get worse. The Merit-Based Incentive Payment System (MIPS), part of the Medicare Access and CHIP Reauthorization Act (MACRA), begins in January. MIPS is supposed to replace PQRS, MU, and VBM. But, as I wrote in this space in June, the new program looks to be far more costly, complex, and confusing than the costly, complex, and confusing programs it is replacing.

The Centers for Medicare & Medicaid Services (CMS) estimates MACRA will add $128 million a year in compliance costs above the costs of complying with the programs it is replacing. Texas Medical Association analysis finds that “official” number woefully low.

And all of that brings us to one more, even bigger question: Does the government know what it’s doing to physicians?

We went to medical school and dedicated our lives to helping people heal and stay healthy, not to become data entry operators. But that’s what we have become, and that’s taking a toll on physicians, our patients, and the entire health care system. Physicians are burned out and unhappy, patients have less time with their doctors, and everyone has to pay more to get less care.

I’ve been a patient — a seriously ill patient — and I owe my life to the physicians who helped me recover from West Nile virus encephalitis. Like every patient, I don’t want a burned-out, unhappy doctor who’s enslaved by his computer. I want a bright-eyed, engaged, and satisfied physician who has the time and energy to put me — and my health — first.

Jul 12, 2016

"We have deliberately set the game so that you cannot win"

Shortly before a senior Medicare official came to visit his Dallas office in late June, Texas Medical Association President Don R. Read, MD, shared with Texas Medicine his thoughts on the agency's draft rules implementing the Medicare Access and CHIP Reauthorization Act (MACRA). Dr. Read compared changing complexity of Medicare rules to a progression from a simple game of checkers to a new game no one understands, whose rules are written in Mayan hieroglyph, and which "you cannot win."

Listen to the short audio clip, or read the full transcript below.

 


 

“This is how MACRA comes across to me. With original Medicare, we were playing checkers. There were some rules we didn’t agree with, some that were truly stupid, like you couldn’t pay for a TPN outside the hospital, which was much cheaper so we had to keep them in the hospital which was much more expensive, but you pretty much understand the rules. Then with PQRS and MU, we started playing chess. Kind of easy chess, but we were starting to play chess.

“And now you say, well we’re going to change the game. It’s not checkers; it’s not chess; it’s something new. The board’s got two more columns and two more rows. Some of the chess pieces are the same, but we’ve put new ones out there. And we’ve written rules. We started to write them in Mandarin Chinese, but we figured you’d be able to get an interpreter and interpret them, so we’ve written them in Mayan hieroglyphs to make sure you don’t understand.

“But you have to start playing right away, and don’t worry about the fact that you don’t understand the rules because we have deliberately set the game so that you cannot win.

“And by the way, two years from now you’re going to get penalized because you did not win.”
  

Jul 1, 2016

Medicare Man Enters the Maw of MACRA Malcontent

To hear Dallas physician leaders Don Read, MD, and Rick Snyder, MD, tell it, if they can’t make it, no one can. And right now, Drs. Read and Snyder are extremely pessimistic about their practices being able to “make it” under Medicare’s proposed new quality regulations.

A top Medicare official, who made the trek to Dallas at the invitation of the Texas Medical Association, appeared to be listening.

Dr. Read: Without big changes, small practices
"are going to fail" under MACRA
“We are light years ahead of small practices, who are in survival mode all the time, in terms of reporting quality,” Dr. Read, the current TMA president, and head of a the 14-physician Texas Colon & Rectal Specialists, told Tim Gronniger, the deputy chief of staff at the Centers for Medicare & Medicaid Services (CMS).

“We are going to fail on the quality measures, which is something this practice prides itself on,” added Nancy Bowman, executive director for the practice.

Despite the practice’s large investment in health care information technology – about $300,000 on software alone in 2015 – Ms. Bowman said neither the group nor its advanced electronic health record (EHR) system vendor will be ready when it’s time to collect the new MACRA data on Jan. 1, 2017.

Dr. Read followed up with a theme that permeated TMA’s 26-page official comment letter to CMS on the proposed rules implementing the Medicare Access and CHIP Reauthorization Act (MACRA).

“All these small practices are doomed to fail under this system,” he told Mr. Gronniger. “It's not worth their spending money to participate in a system where they're going to fail.”

Tim Gronniger, deputy chief of staff,
Centers for Medicare & Medicaid Services
Mr. Gronniger acknowledged that CMS has heard that complaint from many quarters, including TMA’s official comment letter. “I hear your concern that it's too complicated,” he said “We're getting feedback that there’s too many things to think about.” He also promised that CMS would provide physicians with “bite-sized” instructions on how to comply with the MACRA requirements.

The agency is reviewing all of the feedback it has received on the draft rule, and will issue a final regulation around Nov. 1.

An hour later, Mr. Gronniger walked down the hall to hear from Dr. Snyder, whose 70-physician practice is the state’s largest independent cardiology group and one of the largest in the nation.

“We pride ourselves on being cutting edge on regulatory compliance,” Dr. Snyder told him. “There's no way in the world we are going to be ready Jan 1. Our goal is just not to lose money.”

Dr. Snyder presses Mr. Gronniger for an "independent practice pathway."
Dr. Snyder said his big-picture concern is that the rule as written will “accelerate the consolidation” of independent physician practices into hospital systems. That, he said, would increase costs to Medicare and give patients fewer choices.

“Please come up with an independent practice pathway,” Dr. Snyder told Mr. Gronniger. “Make it friendly so we can increase quality, reduce costs and remain independent, because we think that's the best model.”

Mr. Gronniger said he liked that idea and would work to modify the rule to make that happen.

Jun 21, 2016

MACRA Rule: Not What Congress Ordered


By Don Read, MDPresident, Texas Medical Association

(This article first appeared in the KevinMD.com blog. Reprinted with permission.)

I joined physicians nationwide last year in cheering when Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Not only did it eliminate the congressional budgetary fiction known as the Sustainable Growth Rate (SGR) formula, it also promised to simplify and improve Medicare’s costly and complex programs that purport to measure the quality of care we provide to our patients.

Unfortunately, as we review the draft implementing rule, it appears that the net result will be neither simplified nor improved. Frankly, while we see the need for some legislative tweaks, this proposed rule is not what Congress ordered.

MACRA already has accomplished two of its intended goals. It reauthorized the Children’s Health Insurance Program for two years, and it removed the constant threat of SGR-driven Medicare payment cuts. The SGR’s faulty assumptions would have forced annual fee cuts for physicians for every one of the past 15 years. The obvious folly of that policy drove Congress to override each of those cuts since 2002, often in desperate, last-minute or retroactive circumstances. The associated financial threats and uncertainty about business viability created continuously hazardous conditions for physicians.

MACRA also promised to simplify the ever-tightening thicket of federal regulations that strangle physicians’ practices. The draft regulations that the Centers for Medicare & Medicaid Services (CMS) published on May 9 fall far short of that promise. If implemented as written, they would dump additional bureaucratic work on physicians and their practices, and would continue to impose onerous federal controls on physicians and their practices — with no data to show that they would improve the quality of or access-to-care for patients. The system devised by CMS is far more costly, complex, and confusing than the costly, complex, and confusing programs it is replacing. Compliance would be especially difficult for small practices who may end up with Medicare payment penalties even if they spend the time and money to jump through all the new regulatory hoops. The budget-neutral system of bonuses and penalties pits physician practices against each other, so that there will be annually anointed winners and losers regardless of how well all practices “perform” on these new quality standards.

When MACRA legislation was enacted, TMA had no reason to expect CMS would propose to continue flawed concepts from the current quality programs along with plans to diminish a physician’s worth down to a complex point system. More disappointing is to learn that CMS proposes to design a program that is stacked against solo physicians and small group practices in its first year of implementation.

CMS and proponents of the agency’s proposed plan say it will streamline the current quality reporting systems and simplify the transition to value-based care. CMS Acting Administrator Andy Slavitt says “we have to get the hearts and minds of physicians back,” and he claims MACRA will “put physicians back in control.” Our analysis of the proposed regulations reveals something much to the contrary.

We found:
  • Costly Reporting and Compliance:
    The compliance, documentation, and reporting requirements related to the new combined incentive programs are inordinately costly for many physicians. CMS’ own figures show the new programs will add additional compliance costs of $128 million above the cost of the programs it is replacing.
  • Disjointed Timelines and Perverse Incentives:
    CMS has failed to properly engage physicians and guide them to successful participation since the current program began in 2007. The replacement does little to reverse the problems in the current systems, and in fact immediately increases the requirements for “success.” The first year of implementation is not the time to raise the bar and increase the degree of difficulty in meeting quality reporting requirements.
  • Metrics Outside of Physician Control:
    Vendors and patients, not physicians, have control over meeting MACRA’s standards and requirements. Physicians should not be penalized for the failures of their electronic health record (EHR) vendors or for the demographic or socioeconomic status of their patients.
  • Two Years Too Late:
    CMS plans to use two- year-old data to determine whether physicians receive a bonus or penalty. Data from 2017 will be used in 2019, 2018 data in 2020, and so on. At no point in the process will physicians be provided feedback on their current performance data or insights within the current performance year on how to improve their status, and no objective standard will exist for physicians to target. Physicians should be given real-time and correct information on their practices.
  • Arbitrary Incentives to Create Massive Changes in Physician Practice Type:
    The need for sophisticated support systems, the inflexibility of the measurement standards, and the lack of realistic incentives to change all create pressures for physicians to abandon small practices to join large ones — or to sell out to hospitals. In fact, CMS’ published data shows that payment penalties could decimate small practices, still the majority in Texas.
  • Cost Without Benefit to Medicare:
    There is no evidence that the incentives in the draft MACRA regulations are likely to be effective in improving care quality or increasing efficiency. Requirements should include only activities proven to actually enhance care quality, or to reduce cost with no adverse impact on quality, access, or productivity.
The nearly 50,000 physician and medical student members of the Texas Medical Association urge the leadership of CMS to chart a different course of action. We call on them to take the time necessary to ensure that this new law supports and enhances the physicians who provide the medical care to our nation’s 54 million Medicare beneficiaries. We urgently request that CMS stop moving down a path that threatens to plow under tens of thousands of physician practices and needlessly create an access crisis for patients covered by Medicare.

In general we are asking for time, fairness, simplicity, and flexibility. More precisely:
  • Exempt physicians who have no possibility of earning more than it costs them to report data, and do not force physicians into unacceptably risky payment models.
  • Establish objective and timely measurement and reporting systems that are simpler and less costly than those currently required. The focus should be improving care for all Medicare patients, not creating yearly physician winners and losers with payment affected two years after care has been delivered.

  • Use quality metrics that capture those activities that are under the physician’s control and have been shown to improve quality of care, enhance access-to-care, and/or reduce the cost of care. The focus should be on metrics that are most meaningful to a practice and its patients, not on what will result in the best “score.”
  • Allow physicians who want to shift to value-based care enough time to make this transition in a way that actually benefits their patients and does not cause undue collateral damage to their practices.
  • Require EHR vendors to build and maintain products that meet federal specifications rather than forcing physicians to purchase and constantly upgrade expensive and often-balky systems.
Last week I sat in the American Medical Association audience when Acting Administrator Slavitt said, “I am convinced that adding new regulations to an already busy health care system without improving how the pieces fit together just will not work.” He also said he wants to hear what practicing physicians think about this draft rule.

This practicing physician is telling Mr. Slavitt his plan just will not work. Change it.