Disclosure Statement

2. Policies and standards of the Texas medical Association, the Accreditation Council for Continuing Medical Education, and the American Medical Association require that speakers and planners for continuing medical education activities disclose any relevant financial relationship they may have with commercial entities whose products, devices or services may be discussed in the content of the CME activity. The content of this material does not relate to any product of a commercial interest; therefore, there are no relevant financial relationships to disclose. • Disclosure Statement

3. Identify the unique health care challenges facing Texas physicians and their patients; • Describe TMA’s recommendations to address the health care challenges facing physicians and their patients; • Discuss the advocacy actions TMA has taken to deal with the issue(s); and • Implement steps in their community to improve health care policy and legislation. • Healthy Vision 2020 Objectives

4. Improve Texas’ Physician Workforce • Protect Physician’s Independent Medical Judgment • Promote Efficient & Effective Models of Care • Repeal Harmful & Onerous Regulations • Invest in Prevention • Protect Fair Civil Justice System • Provide Appropriate Funding • Fair & Transparent Insurance Markets • Healthy Vision 2020 Issues

5. Improve Physician Workforce

6. Texas Needs More Physicians

7. Funding Cuts Crippled Physician Pipeline • Family Practice Residency Program cut by 75% • Statewide Primary Care Preceptorship Program and the Primary Care Residency Program not funded. • State GME formula funding cut 32% • Physician loan repayment programs one eliminated; the other cut by 78%

8. Expanding Scope: Not A Workforce Solution TMA strongly supports physician-led teams, with each practitioner bringing important skill sets and training to patient care. Future: Physicians will become both providers AND managers of health care.

9. Restore funding cuts and programs. • Link undergraduate expansion with GME. • Encourage Texas Higher Education Coordinating Board to evaluate workforce needs and conduct research. • Incentivize physicians to practice in rural Texas. • Reinstate physician loan repayment programs. • HV 2020 Recommendations

10. Support expansions of scope consistent with team care. • Strengthen the Texas Medical Board’s regulatory oversight of physician supervision of and delegation to nonphysicians. • HV 2020 Recommendations

11. Protect Independent Medical Judgment

12. Preserved Texas’ ban on the corporate practice of medicine. • Passed employment bills with strong protections for clinical autonomy and independent medical judgment. • First state to pass statutes specifically protecting physicians’ clinical judgment. • Hospital settings include: 501(a) corporations, rural county hospital districts, large urban hospital districts, and the newly established Texas health care collaboratives. • Physician Employment Protections

13. Nonprofit health care corporations, commonly referred to as 501(a) corporations. • Physician board of directors is responsible for all clinical matters. • Physicians now have important liability protections within a 501(a) corporation. • The employed physician, “retains independent medical judgment in providing care to patients, and the health organization may not discipline the physician for reasonably advocating for patient care.” • 501(a) Corporations: SB 1661

14. Rural hospitals in counties of <50,000 population can employ physicians. • Guarantees physicians’ independent medical judgment. • Medical staff is responsible for all clinical matters – bylaws, credentialing, peer review, etc. • Ensures employed and independent physicians have same rights. • A CMO is selected by the Medical Staff • The CMO has a duty to report instances of interference to TMB • Rural County Hospital Districts SB 894

15. Multiple laws were structured to meet the hospital districts statutory mission to provide care to the indigent. • Applies to Harris, Bexar, El Paso, and Tarrant counties, and the Scottish Rite Hospital in Dallas. • Allows for physician employment with strict protections. • Ensures Medical Executive Board establishes rules for all clinical matters: credentialing, peer review, quality assurance programs, etc. • Large Urban Hospital Districts

16. New law protects patients and their physicians in new health care collaboratives. • Ensures physicians have equal say and vote in a collaborative arrangement’s governing board • Allows physicians to have: • Equal say and vote in a collaborative arrangement's governing board, • Due process protections, and • The ability to participate in more than one collaborative arrangement in their community • Health Care Collaboratives

17. Patient-physician relationship jeopardized by new law and rules. • Department of State Health Services rules impose a “gag order” on physicians who participate in Women’s Health Program. • A physician, nor anyone else in the practice, cannot discuss elective abortion issues with patient. • Women’s Health Program

18. U.S. is spending much more for older ages • Health Care Spending at End of Life Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009. 

19. 1976 (revised 1997): 2nd state to pass a law empowering families & physicians to make medical treatment decisions near the end of life. • Remarkable success in achieving 3 major goals: • Improving communication and patient choice • Decreasing pain and suffering, and • Providing appropriate treatment without outside legal intrusion • Legal definitions of terminal and irreversible illness. • Created a process to guide resolution of both right-to-die and medical futility disputes. • Texas’ Advanced Directives Act

20. Protect the patient/physician relationship. • Protect physician’s independent medical judgment in all employment relationships. • Strengthen new employment laws.. • Respect patient’s final days (TADA, DNRs, and stop legislation to treat until transfer). • HV 2020 Recommendations

21. Right Care Right Person Right Time and Right Place... • Efficient/Effective Models of Care

22. Pilot in Colorado, New Hampshire, and New York: 18% in admission rates vs. 18% non PCMH group. • 5% drop in ER visits; 4% in non-PCMH • Oklahoma saw complaints about access to same-day or next-day care drop from 1,670 in 2007 (year before PCMH implementation) to 13 in 2009 (year after) • North Carolina saved nearly $1.5 billion in costs between 2007 and 2009 • Medical Home

23. Promote patient-centered medical home for every Texan. • A physician led team that ensures that care is: • Accessable • Coordinated • Comprehensive • Patient centered • Culturally relevant • Support PCMH model in Medicare, Medicaid, and commercial health plans. • HV 2020 Recommendations

24. Repeal Harmful & Onerous Regulations

25. “Patient” not even mentioned in PPACA. Act • Patient Protection & Affordable Care Act

26. Invest in Prevention

27. Texans Are Killing Themselves Chronic disease Obesity Epidemic

29. Encourage Texans to take personal responsibility for their own health. • Invest in a public health-prevention infrastructure. • Increase immunization by reducing barriers for all Texans. • Invest in obesity control. • Invest in tobacco cessation. • HV 2020 Recommendations

30. Protect Fair Civil Justice System

31. Reforms are Working

32. Preserve Texas’ landmark liability reforms. • Ensure a fair and strong Texas Medical Board. • Oppose federal preemption of state civil justice reforms. • HV 2020 Recommendations

33. Dual-Eligible Cuts • Provide Appropriate Funding

34. Most of PPACA ruled constitutional, including the controversial individual mandate. • Congress CANNOT require states to give up ALL of their federal Medicaid funding if they decide NOT to expand Medicaid. • States can keep federal share of Medicaid money for their existing Medicaid programs. • U.S. Supreme Court Ruling: Now What?

35. $27 billion budget deficit in 2011. • HHSC forced to trim $3 billion in Medicaid (GR) for 2012-13: • $1 billion-plus, provider/health plan cuts • Medicaid HMO statewide expansion • Benefit/service reductions • Utilization management • Fraud and abuse investigations • 1115 Waiver • State Medicaid Funding: A Look Back

36. Women’s Health/Family Planning • Lawmakers reduced family planning funding by $75 million — 66%. • Legislative Budget Board estimated: • 20,500 more Medicaid births due to limited access to birth control. • Higher cost to Medicaid, $100,000 million. • Prohibited Planned Parenthood from participating in Women’s Health Program. • State Medicaid Funding: A Look Back

37. Physicians’ payments slashed more than 20-percent for care to poor and elderly patients. • Dual-eligible patients, dependent on Medicare and Medicaid. • Cuts eliminated Medicare Part B coinsurance and deductible payments (if it exceeded the Medicaid allowable). • Before cut, Medicaid paid 20% of patient’s co-insurance. • Before cut, Medicaid paid patient’s Medicare deductible. • Medicaid payments traditionally much lower than Medicare. • Dual-Eligible Payment Cuts

40. Medicare Meltdown Redux

41. Ensure competitive Medicaid and CHIP payments for physicians. • Repeal the dual-eligible payment cut. • Stop the Medicare Meltdown – Repeal the Sustainable Growth Rate (SGR). • Repeal or modify the Independent Payment Advisory Board (IPAB). • HV 2020 Recommendations

42. What Can You Do?

43. November 2012

44. Questions For more information: Call (512) 370-1300