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Focusing on Improving Primary Care

From the Texas Capitol to the United States Capitol, Texas ACP Services has been very active working to improve primary care. On the state level, the Texas chapter worked diligently to increase funding for the Texas Statewide Primary Care Preceptorship Program, which provides funding for our GIMSPP, so that more medical students would be encouraged to pursue primary care careers. Nationally, the Texas ACP participated in the ACP Leadership Day on Capitol Hill and sent a 13-member delegation to Washington, DC on May 20, 2009 and lobbied our Texas Congressional delegation to promote the ACP’s top priorities on health care reform, concentrating on strengthening primary care. Texas ACP Services knows the need to confront the challenges facing primary care could not be more critical.

The 81st Texas Legislature convened in Austin on January 13, 2009 amid grim budget news from State Comptroller Susan Combs that the national recession had indeed come to Texas.The state would have about $9.1 million less to spend in the current biennium than in the last. Making things even more bleak, the Legislative Budget Board filed its proposed budget for 2010-2011, which revealed that the state would need $3.7 billion more than Comb’s projections just to maintain state services at the current level. Even with an infusion of approximately $16 billion of federal stimulus dollars into the Texas state budget, increasing funding for the Primary Care Preceptorship Program would be an uphill climb.

Texas ACP leaders contacted their state representatives and senators by phone, email and personal visits to educate them about GIMSPP and the need to restore funding to $2 million for the Preceptorship Program. The Texas ACP Services also participated as a group during the first TMA First Tuesday physician lobby event on February 3, 2009 to ask their legislators to support increased funding in Senate Bill 1, the state budget. Scott Yates, MD, FACP, MBA, President of Texas ACP, testified in March before the House Appropriations workgroup deliberating GIMSPP funding.

The Preceptorship Program received significant support from leaders in the Texas House of Representatives such as Rep. Richard Raymond of Laredo, Rep. Mike Villarreal of San Antonio, and Rep. Susan King of Abilene. It was the House that decided to bring Preceptorship funding up to $2 million for the 2010-2011 biennium, and those leaders consistently voiced their support throughout the budget process. The story was different in the Texas Senate, which did not recommended additional funding. Eventually, the Primary Care Preceptorship Program received $904,289 for the next biennium.

Nationally, Texas ACP Services will work with our Texas Congressional representatives throughout the remainder of 2009 to promote ACP’s top priorities on health care reform.
The key issues are:

1. Ensure that all Americans will have access to affordable coverage;
2. Pilot test new Medicare payment models that realign incentives to support effective, efficient, patient-centered, coordinated care;
3. Improve Medicare fee-for-service system payments to make primary care competitive with other specialties; and
4. Establish a national workforce policy to ensure sufficient numbers of primary care and other physicians.

The Texas chapter will do its part to encourage its Congressional leaders to support comprehensive federal legislation to tackle the primary care crisis.

Please contact the chapter if you would like more detailed information on the 81st Texas Legislature or on Texas ACP Services participation on national health care reform.

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Texas ACP Services working for funding for GIMSPP

With every legislative session the key issue is always the state budget. And that truism is especially pertinent in 2009. Even though legislators coming to Austin were expected to be greeted with news of a revenue surplus, competing interests ranging from transportation infrastructure to higher education to health and human services have submitted funding requests that taken together would eat up all of that new money and any more than might materialize before the legislative session adjourns in May.

For the Texas Chapter of the ACP the request for funding is almost miniscule. In a two year state budget that is expected to top $168 billion, our priority funding request is only $2 million for the Statewide Primary Care Preceptorship Program. With a portion of that relatively modest sum, our General Internal Medicine Statewide Preceptorship Program will benefit and be able to place up to 200 medical students into an internal medicine practice per year. A recent Texas ACP study of former GIMSPP students revealed that participation had a positive influence on their decision to pursue an internal medicine residency.

One challenge, however, to advocating for such a low-dollar request (at least by state budget standards) is making sure it does not get lost in the rough and tumble of the appropriations process. Be assured that Texas ACP Services is working diligently to ensure that the Chapter’s needs from lawmakers are addressed. But nothing is more effective in getting the attention of elected officials than the voices of their Texas ACP key contacts and physician constituents from around the state and their districts.

That’s why it is so important to reach out to your local state representatives and senators by phone, email or personal visit to educate them about GIMSPP and the need to restore funding to $2 million. The Texas ACP Services has decided to participate as a group during the first TMA First Tuesday physician lobby event on February 3, 2009. During First Tuesday, physicians from across Texas will descend on the Texas Capitol in their white coats to lobby the Texas Legislature on issues critical to medicine.

The “White Coat Invasion” was key to physicians’ successes in the Texas Legislature in 2003, and 2005, and again in 2007. Physicians make a big impression when they show up en masse at the Capitol. Our senators and representatives listen when their hometown doctors show up in their offices. It’s the perfect time to be a part of the action to lobby for GIMSPP.

Please contact me if you are interested in participating in a future First Tuesday so I can get you more detailed information or if you would like to hear more on legislative issues affecting Texas ACP during the 81st Texas legislature. I can be reached at (800) 880-1300, ext. 1367, or (512) 370-1367, or at gena.girardeau@texmed.org.

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previous features

Advocacy: 80th Texas Legislature

80th Legislative Session Update, July 2007

Michelle Romero, MPA, TAIMS Legislative Affairs Manager

The 80th Texas Legislature gaveled into session amidst an acrimonious House speakers race, which Speaker Tom Craddick won. After five grueling months, the legislative session ended with the same rancor. At the end, Speaker Craddick was able to keep his leadership position. Events in the Senate were significantly much more composed. Through it all the Texas Academy of Internal Medicine Services came through the legislative storm with some real victories and achieving many of its legislative priorities.

None of these victories could have been achieved without the involvement of so many of our members. TAIMS would like to thank everyone who participated in the monthly First Tuesdays, responded to our VoterVoice Calls to Action, and called or met with their legislators during the session. Your advocacy on behalf of internal medicine and primary care worked! TAIMS will build on this success and looks forward to your continued participation in the legislative process.

I. Improve Primary Care Delivery

TAIMS supported initiatives aimed at reducing the ranks of the uninsured and promoted public-private partnerships increase the number of insured workers. TAIMS also supported using Medicaid dollars as a financing tool to provide insurance to working people.

Senate Bill 10 (TAIMS supported/ passed) by Sen. Nelson and Rep. Delisi is the omnibus Medicaid reform bill for 2007. The bill contains numerous provisions to test promising new approaches in the financing and delivery of Medicaid services, including promoting prevention and wellness initiatives to improve patients’ health status and lower costs. Most significantly, the bill outlines a new “health opportunity pool” that uses Medicaid dollars as a financing tool to expand private health insurance to low-income Texans.

TAIMS also supported legislation to eliminate problematic administrative burdens on primary care physicians that included the establishment of standardized contracts to reduce the administrative costs for physicians and health plans. TAIMS fought for the development of “smart cards” so health plan information, such as deductibles and co-pays, is readily available. This form of “transparency” will reduce administrative burdens and help prevent fraud and abuse.

House Bill 2016 (TAIMS supported/ failed) by Rep. John Smithee was this session’s standardized contracts bill. Referred to as the “Fair Contracting Bill,” HB 2016 would have limited the ability of health care contractors to give access to physician discounts unless proper notice to the physician had been given. Contracts issued after the bill’s effective date would have been required to include a summary disclosure of selected important contract terms. Although HB 2016 was strongly supported by TAIMS, TMA, the Texas Academy of Family Physicians and other physician groups, the bill was left pending after receiving a hearing in the House Insurance Committee.

House Bill 522 (TAIMS supported/ passed) by Rep. Beverly Wooley provides for an identification card pilot program which must begin no later than May 1, 2008. The pilot will examine the information to be included on identification cards, technology used to implement the pilot, and the confidentiality and accuracy of the required identification card information. The location of the pilot and the health plans that will participate will be determined by TDI. As with the advisory committee recommendations, the results of the pilot will be provided to the legislature. The bill became effective immediately.

HB 522 also builds upon current law to encourage the completion of the financial transaction concurrently with the provision of medical services by supporting the inclusion of real-time benefits and coverage inquiries, real time claim adjudication, and payment of deductibles at point-of-service.

HB 1594 (TAIMS supported/ passed) By Rep. John Zerwas, will expedite the health plan credentialing process for those physicians entering a groups practice in the plan’s network. Plans are required to recognize those physicians as in network at the moment they begin treating patients. The bill is aimed to protect physicians and patients and prevent patients from needlessly being balanced billed. TAIMS supported this bill to improve the delivery of primary care.

II. Graduate Medical Education

A significant priority for TAIMS is increased Graduate Medical Education (GME) funding aimed at increasing Texas’ primary care physician workforce. TAIMS supported each of the following (GME) initiatives.

Preceptorship Program -TAIMS worked to ensure increased funding for the Primary Care Preceptorship Programs, including general internal medicine, family medicine and general pediatrics. Funding for the Preceptorship programs remained unchanged at $904,289 for the biennium. The programs seek to increase interest in primary care careers among medical students by offering a one-month voluntary preceptorship with primary care physicians in community practice. While the Texas Higher Education Coordinating Board, which funds the program, sought $1,941,437 in total funding for the 2008/2009 biennium, all other funding proposals called for retention of current funding levels, including those by the Legislative Budget Board, House, and Senate.

GIMSPP is an effective means of increasing medical student interest in internal medicine residency training and TAIMS will continue to work throughout the interim to educate the Texas Legislature on the value of this highly effective preceptorship program

GME funding formulas - TAIMS supported increased GME funding formula dollars so that they have a positive impact on primary care. The Legislature appropriated record-high funding levels to train more physicians at Texas graduate medical education (GME) programs. The funding increase reflects a greater awareness among legislators of a growing physician shortage and need for enhanced GME capacity in the state to educate and retain more physicians. Texas medical schools received $63 million, up from $25 million last biennium, to cover faculty costs and create new GME slots. The Texas Higher Education Coordinating Board received $23 million as continued support for primary care GME programs. The Legislature appropriated another $13 million in special item requests to medical schools for GME programs.

State Physician Education Loan Repayment Program - TAIMS supported measures to encourage more physicians to practice in underserved areas. The State Physician Education Loan Repayment Program received approximately $3.8 million. This program is highly effective for recruiting and retaining primary care physicians in underserved areas. Interest in the program has exceeded available resources in recent years. A portion of this funding is state appropriated ($2.1 million) and from medical school tuition ($1.7 million). The current totals are approximately $1.3 million more than last session.

Restore Medicaid GME funding - TAIMS supported Medicaid GME funding so that the state can draw down significant federal matching funds, which other states successfully leverage. While the Health and Human Services Commission recommended restoration of the program and requested $207 million for the 2008-09 biennium. Legislators did not approve the request, though hospital districts may use local dollars for the state match.

III. Scope of Practice (Nurse Practioners, PAs, other allied health)

TAIMS took a keen interest in scope of practice issues that arise at the Texas Legislature. As a founding member of PatientsFirst, TAIMS believes that scope of practice issues could arise that threaten overall patient care. Patient safety is at the heart of TAIMS’ opposition to the expansion of scope by non-physician practitioners.

TAIMS opposed any efforts by allied health practitioners to expand their scope of practice beyond that permitted by training and education, in order to protect patient safety. TAIMS also defended a physician’s ability to delegate the delivery of health care while maintaining responsibility for patient care.

This session almost 90 bills were filed that dealt with scope of practice in one form or another. Not a single one passed. TAIMS, however, expects the flood gates to open in 2009 as the moratorium between medicine and advance practice nurses will expire other practitioners will push vigorously to do more.

Scope of Practice Legislation

HB 1117 (TAIMS opposed/ failed) by Rep. Betty Brown would have changed the language regarding who may file a birth certificate from "physician, midwife, or person acting as midwife" to "physician or other health care practitioner."

HB 3115 (TAIMS supported/ failed) by Rep. John Zerwas would have put in place requirements to better inform patients and the public about the distinction between a physician and others in health care who use the title “doctor.” The bill would have required practitioners, excluding physicians, who use the title of doctor to communicate to a patient orally or in writing, including on a name tag, the type of license, permit, registration or certificate under which the person is practicing. Similar legislation was passed in at least one other state. A violation of this requirement would have made the practitioner subject to action by the appropriate oversight board as grounds for revocation or denial of license, permit, registration, or certification. The bill was heard in committee in House Public Health Committee, but didn’t have sufficient votes to advance further.

Retail Health Clinic Legislation

TAIMS continued to keep a cautious eye on retail health clinic legislation as an expansion of scope of practice. These clinics have multiplied across the country since last session. They tend to be based in chain pharmacy and grocery stores and staffed by Advanced Practice Nurses or Physician Assistants, market themselves as a place for patients to obtain quick, low-cost care for minor illnesses and injuries. The concept has proved popular with patients, though organized medicine and public health officers have raised questions about the quality and safety of care, as well as the potential to further undermine patients’ ongoing relationship with a physician through a “medical home.”

A key question is on the model and whether APNs/PAs staffing the clinics are appropriately supervised by a physician and practicing within their respective scopes of practice. Texas has strong physician oversight requirements, developed over more than a decade by medicine in collaboration with nurses and PAs, that work well across many settings.

HB 1096 (TAIMS opposed/failed) by Rep. Rob Orr and SB 800 by Sen. Dan Patrick proposed that these clinics should be freed from such patient protections. Overall these bills’ passage would weaken physician oversight. As filed, both bills would have increased from three to six the number of APNs or PAs a physician could supervise and eliminated the requirement that physicians be on the premises at least 20 percent of the time.

TAIMS strongly opposed the legislation on grounds that the changes would undermine patient safety and health care quality. SB 800 died quickly, receiving no hearing. However, HB 1096 passed the House Public Health Committee, after the author made some amendments in attempt to assuage medicine’s concerns, and made it as far as the House floor, though it was never debated.

Finally, thank you for your grassroots advocacy on behalf of internal medicine and primary care. If you are not already a Key Contact, please do so in order to stay informed on all future legislative developments (link). Also, take some time to educate and get to know your local legislator so that he or she can become an effective advocate for internal medicine in the Texas Legislature.

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Legislative Victories Point TAIMS to the Future

Michelle Romero, MPA, TAIMS Legislative Affairs Manager

The climate around the Texas Capitol is calm as legislators have packed their bags and returned to their home districts after an all-consuming, five-month legislative session. Without a pending threat of a special session from Gov. Rick Perry, legislators and their staff are settling in for their much-anticipated legislative interim. Legislators use this time to report back to their constituents through newsletters, town hall meetings, and neighborhood coffees on what they achieved for their districts and the state.

TAIMS has much to report, as well. At printing of our spring newsletter, the 80th Legislative Session was in its final stretch with several legislative outcomes yet to be determined. TAIMS is pleased to report several victories on priority issues advocated for this session.

TAIMS achieved success in graduate medical education (GME) funding, particularly the General Internal Medicine Preceptorship Program (GIMSPP), and in a series of legislation that improves overall primary care delivery in our state. Regarding scope of practice, TAIMS successfully advocated against efforts by allied health practitioners to expand their scope of practice beyond that permitted by training and education to protect patient safety.

Most notably, TAIMS worked to secure increased funding for the primary care preceptorship programs, including general internal medicine, family medicine and general pediatrics. Funding for the three preceptorship programs remained unchanged at $904,289 for the biennium. After budget cuts in two consecutives previous sessions, this puts TAIMS in a position to build support during the interim and to continue educating legislators about the need for increased preceptorship funding next session.

The Texas Legislature also restored GME funding, which was cut in 2003. Nearly $86 million was allocated to GME so more homegrown physicians can take care of Texas patients.

TAIMS worked to reduce the ranks of the uninsured and promoted public-private partnerships to insure more Texans. TAIMS also supported the omnibus Medicaid reform bill that called for Medicaid dollars as a financing tool to provide insurance to working people.

TAIMS supported passage of legislation that will require greater transparency from physicians, hospitals, and health plans in pricing of services and adequacy of health plan networks. Furthermore, TAIMS promoted legislation to eliminate problematic administrative burdens on primary care physicians and fought for the development of “smart cards” so health plan information such as deductibles and co-pays is readily available.

Another bill improving primary care requires health plans to expedite their credentialing process for those physicians entering a group’s practice in the plan’s network. Plans are required to recognize those physicians as “in network” at the moment they begin treating patients. The bill is aimed to protect physicians and patients, and to prevent patients from needlessly being balance billed.

House Speaker Craddick and Lt. Gov. Dewhurst soon will appoint interim committees to study issues in preparation for the 81st legislative session. TAIMS predicts key health care interim committee assignments could be made as early as September.

TAIMS will monitor key interim committees. Also, many legislators are gearing up for re-election, and several will face opponents in the primary and/or general election cycle. TAIMS also will actively evaluate these political races and provide updates on key candidates TAIMS supports.

With notable victories achieved, the future holds much promise for TAIMS and the patients of Texas. Visit the Advocacy page (link) for the latest news on the 80th Texas Legislature, or contact me at (512) 370-1367 or gena.girardeau@texmed.org.

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