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Special Report On The 83rd Texas Legislature texas family physician VOL. 64 NO. 3 SUMMER 2013

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TEXAS FAMILY PHYSICIAN VOL. 64 NO. 3 SUMMER 2013

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Family medicine under the dome

The 83rd Texas Legislature strengthened the state’s physician workforce, improved access to women’s health care, and reduced administrative hassles for physicians. Not too shabby. – By Jonathan Nelson

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Texas doctors, uninsured patients, and the ACA: What’s next?

Patients seeking coverage have more options than the insurance marketplaces. Here’s how you can be ready to help. By Ankeny Minoux 6 PRESIDENT’S LETTER What is a “good doctor”? 8 NEWS IN BRIEF AIM-HI program improves patient outcomes. | Begin meaningful use reporting to avoid penalty. | HIPAA compliance date nears. | Complete Medicaid attestation to receive enhanced fees.

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Opening soon: The health insurance marketplace

With open enrollment in the health insurance marketplaces beginning Oct. 1, patients are turning to their family physicians with questions about purchasing private insurance. Familiarize yourself with the exchanges and be a resource for your patients and employees. – By Samantha White

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The shape of things to come

In a quickly changing medical economic environment, physicians’ practices need to prepare for the coming health care marketplace. By Brian Klepper, Ph.D.

10 MEMBER NEWS TAFP President wins TMA award. | UTHSCSA FMIG wins AAFP Program of Excellence award.

28 Foundation Focus TAFP Foundation selects the first round of preceptorship scholarship recipients.

28 technology Stage 2 of EHR incentive programs | What to do about preand post-payment EHR audits

38 TAFP PERSPECTIVE The chair of the Texas Women’s Healthcare Coalition on the outcome of the 83rd Texas Lege


president’s column

TEXAS FAMILY PHYSICIAN VOL. 64 NO. 3 SUMMER 2013 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. Texas Family Physician is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org. Officers president

Troy Fiesinger, M.D.

president-elect

Clare Hawkins, M.D.

vice president treasurer

Ajay Gupta, M.D.

Dale Ragle, M.D.

parliamentarian

Tricia Elliott, M.D.

immediate past president

I.L. Balkcom IV, M.D.

Editorial Staff managing editor

Jonathan L. Nelson

associate editor

Samantha White

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, C.A.E.

advertising sales associate

Michael Conwell Contributing Editors Matt Brown Brian Klepper, Ph.D. Ankeny Minoux David Nilasena, M.D. Janet Realini, M.D., M.P.H.

subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publica­tion of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by The Whitley Company, Austin, Texas. legislative advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2013 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

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What is a good doctor? By Troy Fiesinger, M.D. TAFP President diabetic patients’ average hemoglobin A1C is Although I missed the blockbuster 2011 better than 75 percent of the doctors in the Brad Pitt movie Moneyball, I recently read the country, but fewer than half of my patients get book by Michael Lewis. Oakland A’s general their diabetic eye exams. How much of that is manager Billy Beane, a promising high school my fault and how much occurs because their prospect out of California, was drafted by the eye doctors do not send a report back to me? I New York Mets the same year as Darryl Strawam still looking for the answer to that one. berry and Lenny Dykstra. Despite looking like You could ask the insurance companies, a top prospect to the scouts, Beane’s major but their first priority is whether I take care league career ended early while Strawberry of their customers—my patients—in a costand Dykstra won the 1986 World Series with effective manner. If I hit their HEDIS quality the Mets. As the general manager of the Athtargets, they are even letics, Beane struggled happier, mainly because to define more accuratethey get a higher star ly what makes a baseball Whether we love or rating to put in their player good. This got marketing material to me thinking: How do I hate the amount of attract more customers. know I’m a good doctor? information different They value keeping their I can point to the entities collect about members out of the diplomas on my wall hospital and emergency and tell you I went to us, we have to gain room, and discharging good schools, but the control of this data them quickly because U.S. News and World so we can articulate that lowers their costs, Report rankings are not because the quality little more than opinion our own definitions of care is better. surveys with minimal of quality and defend You could ask the hard data to back up them with numbers. hospital where I am on their lists. I can show staff. They can tell you you a copy of my Texas if they have achieved medical license, but their Joint Commission Core Measures, but that just means I haven’t broken any laws nor not what role I play in meeting their targets. received any complaints to the Texas Medical They can’t tell you if I have run afoul of Board. You could look at my American Board their complaint driven quality review proof Family Medicine diploma, know that I have cess, because that information is privileged. passed a national exam and do annual online They will maintain that they have only the education modules, and consequently assume I best doctors on staff, but you have to decide know something. You do not know, however, if if you believe them. I am better than the doctors across the street. The answer to the question of whether You could ask my patients. They would I am a good doctor depends on who is tell you I often run behind but they would asking the question. Whether we love or recommend me to their friends over 90 hate the amount of information different percent of the time. They might say I am entities collect about us, we have to gain a good listener or helped them through a control of this data so we can articulate difficult time, but they will not know what our own definitions of quality and defend my diabetic patients’ average hemoglobin them with numbers. We do not have time A1C is. When the Kaiser Family Foundato react indignantly as though our honor tion asked people how they chose a doctor has been grievously insulted when someone or hospital, the majority said they relied on questions the quality of our care. We must the advice of friends and neighbors, not on analyze our own data so we can answer published mortality and quality data. affirmatively: Yes, I am a good doctor, and You could ask Medicare. My Physician here is the data to back that up. Quality Reporting System data says my


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NEWS CLIPS

Study shows AIM-HI program works to improve patient outcomes By Matt Brown A recent study on the AAFP’s Americans in Motion-Healthy Interventions program showed clinically significant before and after improvements in outcomes for patients in 21 U.S. family medicine practices using the AIM-HI program. The study’s original intent was to compare two methods of implementing AIM-HI tools to see if practices using an “enhanced” AIMHI program were more successful than practices using a traditional AIM-HI program. In the enhanced program, physicians and office staff used AIM-HI tools to make personal changes and create a healthy environment. In the traditional practice approach, physicians and staff members were trained and asked to use the tools with patients. Although the study, which appears in the July/August Annals of Family Medicine, was unable to demonstrate that clinician and practice behavior changes translate to changes in patient behavior, the study did show that the AIM-HI program generated clinically significant changes in body mass index and fitness level across the entire study population.

“In our direct measurement of BMI and fitness level, 16.2 percent of patients who completed a 10-month visit and 10 percent of all patients enrolled lost 5 percent or more of their body weight,” the study authors wrote. “Similarly, 16.7 percent of patients who completed a 10-month visit and 10.3 percent of all patients enrolled had a two-point or greater increase in their fitness level. One hundred ten patients (29.2 percent of those who completed the 10-month visit, 18 percent of all enrollees) had either lost 5 percent or more of their body weight and/or increased their fitness level by two or more points.” Investigators provided all practices with AIM-HI tools, including a fitness inventory, fitness prescription, and a food and activity journal as part of the fitness intervention. All staff members and clinicians in enhanced practices were trained and encouraged to become familiar with the tools, to use the tools to make their own personal lifestyle changes, and to create a fitness culture within their own practices.

Do EHR mandates exist? It depends. What is your definition of a mandate? You do not have to use an electronic health record in your practice, but if you don’t, Medicare penalties will be incurred beginning in 2015. Currently, Medicare is the only payer planning to penalize physicians who are not “meaningfully using” their EHR system. That’s right, meaningful use is required to prevent the penalty. The penalties begin at 1 percent in 2015 and will cap at 3 percent in 2017. If at least 75 percent of office-based physicians are not meaningfully using an EHR by 2017, the U.S. Department of Health and Human Services secretary has the authority to ratchet the penalty by two more percentage points, capping the penalty at 5 percent in 2019. To prevent the penalty, you must start your meaningful use reporting period by July 1, 2014. The federally established regional extension centers are ready to help you with EHR selection, adoption, and meaningful use. For more information, visit the Texas Regional Extension Center Resource Center on the TMA website at www.texmed.org/rec.

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Traditional practices also were trained in the use of the AIM-HI tools and encouraged to use them with patients, but clinicians and staff members were not instructed to initiate practice-level interventions. Investigators said the one significant difference between the two groups was a decrease in the systolic blood pressure numbers for enhanced-practice patients. “Both groups showed greater changes at four months than 10 months, though statistically significant improvements were seen in multiple measures at 10 months in each group. Self-reported eating behaviors scores improved consistently from baseline to four months to 10 months in both groups,” the authors wrote. “As a whole, enrolled patients showed significant, albeit small, changes in most areas.” Principal investigator, Wilson Pace, M.D., a professor in the family medicine department at the University of Colorado-Denver, said the study indicates that the AIM-HI tools can be successfully integrated into family practices in various ways. “Offering help for behavioral change using the AIM-HI tools to interested patients can result in worthwhile improvements in weight and physical fitness,” he said. Source: AAFP News Now, July 26, 2013. © 2013 American Academy of Family Physicians

New HIPAA compliance date approaches Covered entities that have signed new business associate agreements since Jan. 25—when the HIPAA Omnibus Final Rule was published— have until Sept. 23 to amend the agreements so they comply with the new regulations. The final rule broadens the definition of a business associate to include all entities that routinely require access to protected health information, or PHI. It also dictates that any entity that contracts with one of your business associates and regularly deals with PHI on their behalf also will be regulated as a business associate.

For TAFP’s health information technology resources, go to www.tafp.org/practice-resources/technology.


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under the patient protection and Affordable Care Act, primary care physicians are supposed to be receiving Medicaid fees for evaluation and management services and vaccinations at Medicare payment rates as of Jan. 1, 2013. The state’s Medicaid contractor, Texas Medicaid Healthcare Partnership, hopes to implement the rate increases in early fall, but is waiting on the Centers for Medicare and Medicaid Services to approve the proposed payment methodology. Once that approval is given, qualified physicians should receive a lump-sum payment to cover the fee adjustment for eligible claims already made in 2013. According to the Kaiser Family Foundation, Texas Medicaid fees for E/M services and vaccine administration should increase by approximately 66 percent because of the change. To be eligible for the increased fees, physicians must attest that they are board certified in a primary care specialty or that at least 60 percent of their total billings are for evaluation and management services and vaccine administration. The attestation form has been available since March 8 on the TMHP website. To complete the form, you will need your National Provider Identifier, your Texas Provider Identifier, and a copy of your board certification if available. Texas Medicaid hasn’t set a deadline yet on the attestation process, but it will before the rate increases are implemented. Physicians who do not complete the attestation will not receive the higher payments, so if you haven’t done it yet, now is the time.

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Troy Fiesinger, TAFP’s 2012-2013 president, was selected by members of the Texas Medical Association Resident and Fellow Section as this year’s recipient of the J.T. “Lamar” McNew Award. Fiesinger received the award during the opening session of the TMA House of Delegates meeting at the TexMed conference, May Troy Fiesinger, M.D. 17, 2013, in San Antonio. Winners of the J.T. “Lamar” McNew Award must be TMA members who have provided outstanding service to TMA’s Resident and Fellow Section. The award was created in 2002 to honor Dr. McNew for his work with medical students, residents, and young physicians and for his “guiding influence in developing the internal moral core essential for the practice of medicine,” according to TMA.

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The family medicine interest group at the University of Texas Health Science Center School of Medicine at San Antonio has won the 2013 Program of Excellence award for “excellence in exposure to family medicine and family physicians.” The group is one of 17 medical school FMIGs across the country receiving the honor from the American Academy of Family Physicians for “their outstanding activities in generating interest in family medicine.” To win the award, an FMIG must demonstrate that it is well-rounded with competency in a number of key areas,

including FMIG structure and operation, community service, exposing students to family medicine and family physicians, promoting the value of family medicine as primary care, professional development, and measures of success. The FMIG must also illustrate significant changes or enhancements — what was learned from the previous years’ activities, what new innovations have been or will be developed, and what elements of programming were modified to meet the needs of members, according to AAFP.


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SAMANTHA WHITE

FAMILY MEDICINE

UNDER THE DOME IN THE 83RD TEXAS LEGISLATURE BY JONATHAN NELSON

after all the heated controversy and partisan polemics that characterized this summer’s special sessions of the 83rd Texas Legislature, it’s difficult to remember the comparatively calm and congenial nature of the regular session. As longtime political observer Harvey Kronberg of The Quorum Report puts it, both Gov. Rick Perry and Lt. Gov. David Dewhurst entered the session somewhat adrift, having both just lost big elections, which left Speaker Joe Straus in a strong position to set the tone for the session. “Whereas last session was driven by the Tea Party hysteria and the anti-Obama mobocracy, this session—even with major Republican majorities—the lesson of the 2012 election was still fresh in everybody’s mind,” Kronberg says. “It was hugely anti-incumbent and adolescent behavior was generally not going to be rewarded. So you ended up

with I think a far more modulated session that accomplished a few big things and didn’t embarrass itself by racial and gender poison.” At least until the first gavel dropped in the first special session, but that’s another story. The Legislature finished the regular session with mixed scores on health care’s most perplexing problems, but compared to last session, organized medicine and the patients of Texas have several reasons to celebrate. After the drastic budget cuts enacted across the board by the 82nd Legislature in 2011, everyone from public schools to women’s health programs were left scrambling to make ends meet. What a difference a couple of years and several billion dollars can make. Flush with cash and a swelling Rainy Day Fund this time around, lawmakers were in much better moods as they faced teams of advocates from every sector seeking restored funding.

Graduate Medical Education Topping TAFP’s legislative priorities for the session was restoration of graduate medical education funding, which sustained a 43 percent cut in state support in 2011. This session lawmakers were determined to address GME by partially restoring funding to existing efforts and by investing additional funding in new initiatives designed to increase the number of training positions available in the state. As a result, total state GME funding will increase by $30 million, or about 45 percent in the upcoming biennium, and planning grants will help develop new residency programs in needed specialties. Family medicine residency programs receive a special line of direct state funding that goes to train the bulk of Texas’ future primary care physician workforce. Those funds were slashed by almost 74 percent www.tafp.org

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last session, from $21.2 million in 2010-2011 to $5.6 million in 2012-2013. In the next two years, those programs will receive $12.78 million, more than doubling their appropriation. The new funding level will relieve some of the stress residency programs have been under since the deep cuts, but it is still far less than the appropriation these programs have received in the last decade. Strengthening Texas’ Physician Workforce Throughout 2012, TAFP’s advocacy team and physician leaders laid the groundwork for a broad policy discussion about Texas’ primary care physician workforce, and the effort paid off. A month before the session began, the issue had gained so much momentum that the chair of the Senate Health and Human Services Committee, Sen. Jane Nelson, R-Flower Mound, pre-filed a bill to strengthen primary care in Texas. “Primary care serves as the gateway to preventive care, specialty providers, and a wide range of services,” Nelson said at the time. “A strong primary care workforce results in higher quality, more efficient health care with better patient outcomes at a lower cost.

This legislation will address Texas’ growing need for primary care, encourage physicians to accept Medicaid patients, and strengthen the provider network for women’s health.” Her original bill went through many changes and ultimately, it died waiting to make it to the floor of the House, but Sen. Nelson succeeded in attaching its provisions to a bill that passed and was signed by the governor. The bill created a set of incentive programs to create new residency training positions and to encourage medical schools to produce more primary care physicians. The Texas Higher Education Coordinating Board has already begun proposing the administrative structure to implement these programs. Here’s some more great news: Lawmakers appropriated $33.8 million for the Physician Education Loan Repayment Program, which is an almost 500 percent increase over the current budget. The program will cover up to $160,000 in medical education debt for physicians who agree to practice for four years in an underserved community. Enrollment in the program was closed in 2011 after the Legislature cut its funding by almost $18 million, but with the promise of reinvestment, THECB reopened the enrollment process in late May,

with a deadline for the first group of enrollees set for Aug. 31, 2013. For more information and to apply, go to www.thecb.state.tx.us/lrp. Women’s Health Care Last session, the combination of the deficit threat and a political determination to deny state funding to Planned Parenthood had a devastating effect on women’s health care programs in Texas. Next biennium, programs that provide preventive and contraceptive care for women will be almost completely restored to their 2010-2011 levels, thanks to a dedicated group of lawmakers and advocates, like the Texas Women’s Healthcare Coalition. The Legislature increased state funding to the DSHS Family Planning Program by $32.1 million to replace federal funding under Title X awarded to the Women’s Health and Family Planning Association of Texas, and it gave the DSHS Primary Health Care Expansion an additional $100 million for the biennium for women’s health care. About $60 million of that is expected to go for family planning services including contraceptive care. The budget also adds $71.3 million for the Texas Women’s Health Program.

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Mental Health Patients needing mental health services in Texas will be much more secure after this session, as lawmakers pledged more than $225 million in new funding to a number of initiatives targeting prevention, early detection, community-based programs, and inpatient care. Universal Prior Authorization Physicians will be relieved to know that lawmakers passed a bill designed to end the hassle of dealing with hundreds of prior authorization forms from different insurance plans. The legislation directs the Texas Department of Insurance to convene workgroups that will develop standardized prior authorization forms for prescription medications and medical services for private and public payers. Scope of practice Knowing that nurse practitioner organizations would be back this session pushing to gain independent practice, TAFP and the Texas Medical Association worked throughout 2012 to craft a delicate compromise with nurse practitioners and physician assistants.

The effort resulted in landmark legislation that streamlines the requirements for physicians delegating NPs and PAs, supports and encourages a collaborative, team-based model of care, and should increase access to care for Texans. Importantly for physicians, the new law maintains the long-held legal definitions of “diagnosis” and “prescribing” as medical acts, which only physicians can perform under Texas law. For NPs and PAs, the law loosens and simplifies what had become a confusing tangle of regulations; it increases the number of NPs or PAs with which a physician may delegate prescriptive authority from four to seven; and it allows physicians to delegate Schedule II prescriptive authority in hospitals and in hospice care. Medicaid expansion fails With the backing of state leadership, this Legislature refused to expand Medicaid coverage to poor adults under the Affordable Care Act, a decision that will have lasting repercussions. For now, Texas will continue to have the highest rate of uninsured people in the nation. TAFP News will follow developments and examine the policy and political

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considerations surrounding Medicaid expansion in the future. Politics, relationships, and participation Throughout the session, family physicians and their patients were represented by a number of members and physician leaders volunteering to serve as Physician of the Day, providing testimony before legislative committees, and providing counsel to lawmakers and their staffs. TAFP’s advocacy team couldn’t have achieved these victories without the influence and the participation of those members across the state who wrote letters, made phone calls, sent e-mails, and played a part in your Academy’s efforts this session. We’re headed into a busy election cycle and your legislative representatives are headed back to their districts. This is the most important time for you to build those relationships, introduce yourself, or thank them for their work. The time you spend between sessions advocating for your specialty is the foundation for what TAFP can achieve during the session. Check out TAFP’s advocacy department at www.tafp.org for tools and ideas on how you can get involved.

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Since the signing of the affordable care act in 2010, you’ve probably had many patients come to you for answers to a host of questions, but you can expect an increase in their queries in the next couple of months. Among other health insurance reforms already put into place by ACA, the health insurance exchanges are scheduled to open for enrollment on Oct. 1, 2013. While pricing and specific details aren’t expected to be released until then, you can begin helping your patients prepare for this new way of purchasing coverage now.

Opening soon: The health insurance

MARKETPLACE BY SAMANTHA WHITE

one of the most important things you can tell them about the marketplace is that it is a legitimate and safe place to shop for coverage, as all plans will meet the minimum requirements set by ACA. It will allow them to shop and compare plans in a familiar and easy way, and premium assistance will be available for those who need it. In Texas, this includes individuals and families falling between 100 and 400 percent above the federal poverty line—$11,490 to $45,960 a year for an individual, and $23,550 to $94,200 for a family of four. States were given the option to create and run their own marketplace, but Texas chose to forego this opportunity and instead use the federallyfacilitated marketplace currently being created by the Centers for Medicare and Medicaid Services. Whether run by states or by the federal government, all exchanges must allow for open enrollment from Oct. 1, 2013 to March 31, 2014, with coverage beginning as soon as Jan. 1, 2014. Patients will be able to enroll in the exchange and purchase coverage in person, by telephone, fax, or mail, or online at www.healthcare.gov.

www.tafp.org

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What do the marketplace’s insurance plans look like? According to healthcare.gov, benefits include: • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services

Actuarial values for qualified health plans Bronze: covers 60% of all health care costs for an average person Silver: covers 70% of all health care costs for an average person Gold: covers 80% of all health care costs for an average person Platinum: covers 90% of all health care costs for an average person

Health insurance marketplace proposed timeline March 23, 2010

Obama signed Patient Protection and Affordable Care Act into law

April 30, 2013

Qualified health plan applications and rate and benefit information due (insurance companies wishing to be a part of the exchange)

June 2013

New healthcare.gov launched

July 2013

Consumers can create a user account on healthcare.gov

August 2013

Grants awarded to organizations to become navigators

August 2013

Exchange mockup will allow insurance companies to see what consumers will see and make changes to wording on coverage plans and pricing

September 2013

Consumers will be able to access list of local navigators

October 1, 2013

Open enrollment begins, consumers are able to compare plans and rates and choose one to purchase

January 1, 2014

Coverage begins

March 31, 2014

Open enrollment ends

AAFP resources on aafp.org Health insurance marketplace FAQ for patients http://bit.ly/13nO1B6 Health insurance marketplace brief http://bit.ly/1cQp84d

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These competitive marketplaces will deliver one-stop shopping for affordable health care coverage to thousands of Texans looking for private insurance. All plans offered through the exchange must comply with the minimum requirements set in the ACA, ensuring that all coverage purchased is adequate and affordable. Required minimum benefits include emergency services, prescriptions, hospitalization, and more. The law also set into place four levels of coverage: bronze, silver, gold, and platinum. The premiums won’t be known until the plans in the marketplace have been announced, but the actuarial values of each level have been set. Bronze plans, for example, will require insurers to pay 60 percent of all costs for an average, healthy person. On the opposite end, platinum plans will cover 90 percent of those costs. While insurance companies do not have to offer all four levels of coverage, they do have to give consumers at least one silver and one gold option. Insurance companies wishing to offer plans through the exchange submitted applications in April 2013 to become certified as qualified health plan providers. Stacey Pogue, senior policy analyst for the Center for Public Policy Priorities, compares the online exchanges to two current and wellknown websites—Orbitz, a travel-booking company, and TurboTax, which helps customers file their taxes online. Both sites focus on walking the customer through the process to the point of purchase. “TurboTax holds your hand,” Pogue says, directing consumers to enter information in the right blanks. At some point in the process, consumers will find out if they are eligible for subsidized coverage offered only in the exchange, Pogue explained. The federal exchange will also work similarly to Orbitz by allowing users to compare prices before purchasing a plan. “We’ve never been able to compare plans, at all, in any reasonable way,” says Pogue. “What the exchange will do, I think, is somewhat revolutionary in that you’ll be able to see plan A, plan B, plan C, a price for you or your group and pick them based on price.” There will be two different exchanges in the federal marketplace: one for individuals to purchase coverage and one where small businesses can buy plans to offer employees. They will look similar and will most likely offer comparable plans. SHOPPING AS AN INDIVIDUAL While enrollment does not open until Oct. 1, you can currently visit www.healthcare.gov for information on the functionality of the exchange for individuals. The open enrollment period, beginning Oct. 1, 2013, will end March 31, 2014 for the first operational year, but in subsequent years will not be as long. This is to encourage purchasing coverage now rather than waiting until health insurance is necessary because of a sickness or accident. After open enrollment ends, only those with a qualifying life event—job loss, giving birth, moving to a new state, or divorce—can obtain coverage. Any citizen except those who are incarcerated can purchase health insurance coverage in the marketplace, but to be eligible for federal subsidies to cover part of the premium cost, patients must not have access to qualified and affordable health insurance through an employer. This is an important point for many middle-class families in which at least one member can receive coverage through an employer. Family coverage through an employer is often very expensive, so will such families qualify for subsidies through the marketplace? Most likely the answer is no.


To be eligible for federal subsidies to cover part of the premium cost, patients must not have access to qualified and affordable health insurance through an employer. This is an important point for many middle-class families in which at least one member can receive coverage through an employer. Family coverage through an employer is often very expensive, so will such families qualify for subsidies through the marketplace? Most likely the answer is no.

As long as the employer-sponsored plan in question is considered qualified and affordable by the IRS, a family would not be eligible for premium subsidies. To be “qualified,” a plan must have an actuarial value of at least 60 percent, meaning it would pay for 60 percent of an average family’s annual health care expenses. To be “affordable,” the employee’s share of the premium for individual coverage cannot exceed 9.5 percent of the total household’s income. For instance, suppose a single mother of two has coverage through her employer that costs 8 percent of her income. To include her children on the plan would increase her total premium to 12 percent of her income. She could not get premium subsidies for policies covering her children through the exchange. Since Texas declined to expand Medicaid coverage to poor adults, the state is left in an odd situation. Households earning between 100 percent and 400 percent of the federal poverty level will be eligible for government subsidies in the marketplace, but families earning less will not. An estimated 1.3 million Texans are likely to be left without any options to help them obtain insurance.

People with questions about the marketplace now can sign up for e-mail and text message updates at www.healthcare.gov, or call the toll-free hotline at (800) 318-2596. Once the marketplace is open, individuals will be able to get assistance from community navigators. NAVIGATORS All health insurance exchanges are also required to create a navigator program to provide free assistance for patients wishing to enroll and establish eligibility in the marketplace. These programs will be funded through federal and state grants and will typically be well-

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Premium and out-of-pocket costs savings Individuals and families falling under the following incomes (based on 2013 numbers, will likely be higher in 2014) might be eligible for savings on monthly premiums. Up to $45,960 for individuals Up to $62,040 for a family of 2 Up to $78,120 for a family of 3 Up to $94,200 for a family of 4

Up to $110,280 for a family of 5 Up to $126,360 for a family of 6 Up to $142,440 for a family of 7 Up to $158,520 for a family of 8

Individuals and families falling under the following incomes will receive lower out-of-pocket costs when purchasing an insurance plan through the exchange (based on 2013 numbers, will likely be higher in 2014). Up to $28,725 for individuals Up to $38,775 for a family of 2 Up to $48,825 for a family of 3 Up to $58,875 for a family of 4

Up to $68,925 for a family of 5 Up to $78,975 for a family of 6 Up to $89,025 for a family of 7 Up to $99,075 for a family of 8

How the Small Business Health Care Tax Credit works For a company with 10 full-time employees making a total of $250,000 a year ($25,000 on average) that pays $70,000 to employee premiums, the maximum amount for a tax credit is $35,000.

What your patients can do now Since Texas will use the federally-facilitated health insurance marketplace, Texans seeking coverage will go to www.healthcare.gov starting on Oct. 1, 2013 to shop for qualified plans and apply for savings on premiums and out-of-pocket costs. They can go there now to set up a personal account and start learning about the process. At www.healthcare.gov, your patients can: • Sign up for e-mail or text updates. • Learn about different types of coverage and how coverage works, including information on premiums, deductibles, out-of-pocket maximums, copayments, and coinsurance. • Get a checklist of household income information they’ll need during enrollment. • Explore current options for coverage.

known community organizations. They must be impartial to all individuals and employers looking to utilize the exchange. “It’s their job to, at no cost to you, provide services to help you go step by step and get enrolled,” Pogue says. Organizations receiving grants to become qualified navigators will complete ample training and be announced before open enrollment begins to assist with determining eligibility. Once open enrollment begins, they will walk consumers through enrollment and help them choose a plan. Consumers with a more complicated family or income—step children or freelance income for example—will have a more lengthy and complex process. They will be perfect candidates to use navigators. 20

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According to CMS, navigators will also “provide outreach and education to raise awareness about the marketplace.” Organizations serving as navigators were announced in August. You can find out which organizations they are in your community at www.cms.gov and offer them as resources to those patients with complicated questions. SHOPPING AS A SMALL BUSINESS OWNER Linda Carter, benefits consultant with Texas Benefit Solutions, says that while there is plenty of information on the individual marketplaces, not much has been revealed about the Small Business Health Options Program, or SHOP. The basics we do know might be helpful to physicians running small businesses, but we will find out more as the Oct. 1 deadline nears. For businesses with 50 or fewer full-time-equivalent employees, SHOP will streamline the insurance purchasing process and, like the individual exchange, will allow you to compare plans and pricing for your employees. CMS says that by 2016, employers with up to 100 fulltime employees will also be able to use the small business marketplace. When the exchange opens in October, employers will have to choose a single plan to offer employees. However, CMS plans on changing the dynamics of SHOP to allow employers the opportunity to offer multiple plans to employees. According to what Carter has heard, by 2015 the SHOP exchange will function closer to the individual marketplace, allowing employees to pick and choose from a number of plans offered by their employer. While you do not have to offer coverage to part-timers, they do count toward your total number of employees in determining your eligibility. Some states will require that at least 70 percent of full-time employees must enroll in the SHOP plan, excluding those with coverage through another employer plan, Medicare, Medicaid, or a military program. Carter said that it is still unclear if Texas will be one of those states. Self-employed individuals with no employees can use the individual marketplace to purchase coverage for themselves. Small business owners can also currently visit www.healthcare.gov to learn more about the small business exchange. Contrary to the individual market, SHOP will not have an initial open enrollment period. Employers can enroll beginning Oct. 1, 2013 with coverage beginning as soon as Jan. 1, 2014, but will also be able to enroll at any point in 2014. Businesses with fewer than 25 full-time employees making $50,000 a year or less on average may be eligible for a Small Business Health Care Tax Credit. To qualify, you must offer coverage through SHOP and pay at least half of your employees’ premium costs. If you qualify, the tax credit can be worth up to 50 percent of your payment toward premiums, or 35 percent if you are a tax-exempt employer. For businesses smaller than 10 full-time employees, the tax credit can be even larger. If you currently get a tax credit by offering health care to your employees, know that starting in 2014 these tax credits will be available only to those offering a plan through SHOP. Employers not using SHOP to offer coverage will still be able to deduct health insurance costs, but will no longer be eligible for the health care tax credit subsidies. To find out now if your small business qualifies for a health care tax credit, go to www.irs.gov/uac/Small-Business-Health-Care-TaxCredit-for-Small-Employers. As trusted members of your communities, know that patients will come to you with questions regarding the marketplace and the mandate in general. As Oct. 1 nears and more information is released, TAFP will update you on the latest news regarding the individual exchanges, the SHOP marketplace, and navigators across the state.


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Texas doctors, uninsured patients, and the ACA: What’s next?

By Ankeny Minoux

Ankeny Minoux is COO of PointCare, developer of the cloudbased health coverage screening software, PointCarePA, and educational trainings for hospitals, community clinics, providers, and third-party vendors. More information is at www.pointcare. com or call for a free demo at (650) 762-1928.

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W

onder just what the Affordable Care Act will mean in practical terms for your office and your patients? Join the club; thousands of Texas physicians are beginning to realize that within the next few months, it will no longer be practice as usual. While there is much to consider in the coming months, one growing area of realization is that physician offices will be one of the first places patients turn to for information and advice. Eventually, patients will be directed on how to access additional state, federal, and private resources, but in reality, it’s you—the trusted physician—who is going to get a lot of questions. Patients will ask: What do you think about all of this? What does the ACA mean for my family? Will my health care be free? What options do I qualify to receive? What am I supposed to do? Becoming an insurance resource is a tall order for physician practices that are already burdened with new regulations and concerns over how to care for an ever-increasing patient base and the ongoing challenges of EMR integration. Just how exactly are MDs supposed to add insurance advisor to their list of responsibilities? While Texas is not creating its own health insurance marketplace, the state is actively seeking ways to reach out to patients and ensure those that need health care can access it. One program is even becoming a model for others nationwide. In March, Blue Cross Blue Shield of Texas launched Be Covered Texas, a grassroots campaign designed to work with community-based organizations, such as schools, religious institutions, and doctors to introduce uninsured Texans to the new health insurance options available under the ACA.  While valuable, efforts like this will take time to roll out. Some industry analysts are predicting that because initial penalties for non-enrollment are so low during the first year, it may be another three to five years before most patients are screened, enrolled, and have coverage in place. This means you and your staff will continue to be viewed as a resource by patients while you continue to struggle with securing payments. The good news is that solutions and strategies are entering the marketplace for you and your patients that can provide assistance today – not in October when open enrollment begins and not on Jan. 1, 2014 when ACA will formally launch.

Look beyond Medicaid  Solutions begin with knowing about coverage options and getting that information to patients–this includes options that go well beyond Medicaid and private coverage. In Texas, public programs, such as the Texas Health Insurance Pool that provides access to health insurance for HIPAA-eligible patients who have pre-existing conditions, CHIP, Indian Health Services, and the Breast and Cervical Cancer Services Program, are often overlooked when screening patients for coverage.


The challenge is that hospital and office staff may not be aware of these other programs without having the appropriate resources and training. Fortunately, there are organizations that are using experience and technology to resolve this issue—creating manageable screening software and trainings that do not take time away from other staff duties and provide information about all coverage options. Develop an outreach and enrollment strategy To help their busy practice prepare for the ACA, a California-based community clinic, ChapCare, began using a cloud-based, health coverage screening tool that enabled staff to screen patients in minutes and more easily assist with enrollment. The developers of the tool also educated all staff members on available coverage options in their community and explained what to expect with ACA implementation. Clinic workers take the tool into the community using tablets and laptops to screen and begin enrolling people on the street, at health fairs, and at other community events. The clinic’s strategy is simple: the more patients that can be screened and enrolled before presenting into the clinic, the more time staff can spend focusing on the patient’s immediate health care needs. The clinic is successfully screening patients; enrolling about 100 to 200 people each month. Plus their staff now is confident that they are well prepared to handle the ACA provisions and coverage options as they come into play. Realize that enrollment is a three-step process Unfortunately, there is no magic button that will simplify the enrollment process under ACA, but breaking down the different parts of the process can assist with developing strategies to help your office and your patients:

While there is much to consider in the coming months, one growing area of realization is that physician offices will be one of the first places patients turn to for information and advice. Eventually, patients will be directed on how to access additional state, federal, and private resources, but in reality, it’s you—the trusted physician—who is going to get a lot of questions.

Screening: Patients are going to have questions and need assistance with identifying their coverage options, and they will look to you for answers. Develop a consistent screening procedure—utilizing available technology and resources—to help your staff identify coverage options. Verifications and applications: Train your staff to be knowledgeable about health insurance—giving them the ability to confidently help patients gather eligibility verifications (i.e. proof of residency, income, citizenship) and to complete applications. Consider working with local licensed brokers in your area for additional help. Enrollment: Following the first two steps should lead to successful enrollment—however, snags happen. It’s important to have a process in place for follow-up to ensure patients are getting covered and claims are being compensated by the liable third-party payer. What you can do now Texas physicians have a great opportunity to lead and develop working strategies and solutions, as the ACA marketplace in the state is still being hammered out. Start preparing now by reviewing successful enrollment strategies, such as ChapCare’s, asking important ques

tions about your current setup, and taking the appropriate steps to put an enrollment process in place. Talk to your staff about the issue of uninsured and private pay patients. What impact do they have on your practice? Are you already getting questions from patients? Are they turning to you for information and advice? What is your local community, including hospitals, health plans, and businesses, doing to get the word out? Look for ways to participate in and support community-based enrollment events, such as health fairs, booths at local events, coordination with local employers, etc. Implement technologies and available programs that will give your staff the ability to screen patients for coverage quickly. The screening tool and educational trainings used by ChapCare were both provided by software developer, PointCare. The tool’s database contains every U.S. private and public option and will have ACA health insurance marketplace options available as more information comes out.

Train staff and develop a consistent process to assist patients with gathering verifications, completing applications, and following up on enrollment. Be a pioneer Whether you are a large facility in an urban area, a small group of physicians in the suburbs, or are part of a rural-based community clinic, your patients will depend on you and your staff as ACA implementation moves forward. It’s up to you how prepared your facility will be. You don’t need to wait for others to step in and help patients. Start today by asking yourself the questions above and reaching out to appropriate resources and technology providers. If you haven’t already, begin the conversation about your outreach and enrollment efforts with hospitals and other health care leaders in your community. If you work together to create coordinated and focused efforts, private pay and uninsured patients in your community will not only receive quality health care services, but will also receive information and coverage that will benefit their health and financial future. www.tafp.org

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How physician practices can prepare for a health care marketplace By Brian Klepper, Ph.D.

what is the path forward for physicians who want to remain in private practice, outside the constraints of health system employment? How will the environment change and what new demands will that place on practices and physicians? What follows are the observations of one industrywatcher who has worked on all sides of health care, but who now spends most his time focused on the interests of those who pay for it. No crystal ball, but several trends are clear. There are now concrete signs that health care’s purchasers are exhausted and seeking new solutions, that a competitive marketplace is emerging and getting increasing traction. As they abandon ineffective approaches, the paradigm that has dominated the industry for the past 50 years will be upended. The financial pressure felt by buyers will transfer to the supply side health industry that has come to take ever more money for granted. For decades, fee-for-service payment, inclusive health plan networks, and a lack of quality, safety, and cost transparency have been enforced by health industry influence over policy, effectively neutralizing the power of market forces. Without market pressure, physicians have felt little need to understand their own performance relative to that of their peers. The variation of physician practice patterns within specialties has been high, with some physicians optimizing their revenue opportunities by veering wildly away

from evidence-based practice. Even so, until recently in this dysfunctional environment, it has been nearly impossible to identify high and low performers. The impacts of this variation on cost have been staggering. Health care premiums—where costs throughout the system converge—have grown 4.5 times as fast as general inflation for more than a decade. Over the same period, personal health care expenditures—contributions to premium and out-of-pocket payments—have consumed four of every five dollars of the growth in household income, and the percentage of working age Americans (and their children) with private coverage fell by 14 percent. While implementation of the health reform law dominates the health care news, there is little in it that will substantially drive down cost or improve quality, at least in the near term. The much-heralded Accountable Care Organization program is still mostly based on fee-for-service reimbursement, allowing the rank and file of health systems to cruise without really changing care and cost patterns. At the same time, though, a mushrooming cottage industry is dedicated to disrupting the many ways that health care organizations profiteer. Most are within niches—e.g., primary care, evidence-based formularies, chronic disease management, oncology benefits management—but a few have taken a more multi-vectored approach. www.tafp.org

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A rapidly growing cadre of sophisticated purchasers now realizes that buying value requires scrutinizing physicians and other providers. Narrow networks built on this approach are exploding around the country. The early adopters are in large corporations but benefits managers in smaller self-insured firms are catching on as well. One of the most powerful of these mechanisms is the narrow, high-performing network. A core tenet here is that “choice” in health care, particularly in the absence of performance information, is a false value. Giving patients access to doctors who consistently produce poorer outcomes at higher episodic cost does nobody any favors. The logical solution is to identify physicians who produce better care at lower episodic cost, then contract with and steer to them. The smart money will also pay them higher rates for excellence. Evaluating physicians is not difficult. It requires medical and surgical, full-continuum regional claims data sets large enough to yield credible patient sample sizes for specific conditions. Snapshots in time or more longitudinal data will do. Analytics can help purchasers zero in on high versus low performers, so they can steer to the high performers and, just as importantly, avoid the low ones. My firm develops and operates worksite primary care medical home clinics that become aggressive medical management platforms for mid-sized and large employers. We directly contract significant cost reductions for a range of services, including drugs, advanced images, ambulatory surgeries, and pain management. In the process, we focus on identifying the subset of physicians who are most likely to produce better health at lower episodic cost for our patients. The point here is that a rapidly growing cadre of sophisticated purchasers now realizes that buying value requires scrutinizing physicians and other providers. Narrow networks built on this approach are exploding around the country. The early adopters are in large corporations but benefits managers in smaller self-insured firms are catching on as well. One firm I recently encountered has developed narrow regional provider networks in 138 markets around the coun26

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try. The premium costs of members of Savannah Business Group, a small regional business health coalition that uses data to identify high performing providers and then contracts directly with them, are significantly below those of non-members in the same metroplex. Last year Walmart contracted with six centers of excellence—Mayo, Cleveland, Geisinger, Scott and White, Mercy Springfield, and Virginia Mason—for costly heart, spine, and transplant procedures. Not only did Walmart get very favorable pricing, but each system agreed to share its protocols, share data associated with the procedures, and work collaboratively on transitions with each patient’s local physicians. Think through the economic impact this one maneuver has had for Walmart, as well as for local health systems, and the power of the approach becomes evident. Obviously, if purchasers are intent on understanding physician performance, it makes sense for physicians to understand their own as well. Oncology Metrics is a firm that aggregates, analyzes, and benchmarks clinical, resource, productivity, and financial data from oncology practices around the country. Practices and physicians receive detailed information about how they compare to their colleagues, which provides a basis for understanding what needs improvement. Physicians without access to this kind of information are flying blind in terms of market capability. The business requirements of becoming market competitive are enormous. Practice efficiencies become critical, so it may make sense to participate in groups and management services organizations that offer shared arrangements on practice management, billing and collections, human resources, health information technologies, group purchasing, and other mission-critical functions. At the same time, better real-time sharing of patient information with other physicians becomes essential to care coordination, which in turn can positively impact quality and cost outcomes. And, in an environment that must ultimately move away from fee-for-service to some form of risk, an ability to confidently manage a population of patients within parameters is paramount. Larger practices with more resources are necessary to finance the infrastructure required for this level of management, as well as to facilitate the team-based care that is needed to optimally manage clinical and financial risk. When markets work, they lavish rewards for excellence and are unforgiving of mediocrity. Look at Toyota and Chevrolet, Google and Hewlett Packard, Costco and JCPenney. Health care has largely evaded the disciplines of the marketplace for decades, at immense cost to American patients and purchasers. Enough financial pressure has now built that time appears to be fading. Physicians will succeed who understand that the challenge is as much in business as clinical processes. Those who simply hope for the best probably will not.

Republished with the author’s permission. The article was originally posted on April 21, 2013 on Medscape Connect’s Care and Cost Blog.


Tech Incentive News from David Nilasena, M.D. Chief Medical Officer for the Centers for Medicare and Medicaid Services’ Southwest Region

Stage 2 of the electronic health record incentive programs: Building from Stage 1 The Centers for Medicare and Medicaid Services recently published the final rule for Stage 2 of the Medicare and Medicaid electronic health record incentive programs. The rule provides new criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet to participate successfully in the incentive programs. Stage 2 core and menu objectives Stage 1 established a core and menu structure for objectives that providers had to achieve in order to demonstrate meaningful use. Stage 2 retains that core and menu structure for meaningful use objectives. In Stage 2: • Eligible professionals will be required to meet 17 core objectives, as well as three menu objectives (which they select from a list of six), for a total of 20 objectives. • Eligible hospitals and critical access hospitals must meet 16 core objectives, as well as three menu objectives (which they select from a list of six), for a total of 19 objectives.

Changes to Stage 2 meaningful use objectives Most of the Stage 1 objectives are now core objectives under the Stage 2 criteria. For many of those Stage 2 objectives, the threshold that providers must meet to achieve them has been raised. CMS expects that providers who reach Stage 2 in the incentive programs will be able to demonstrate meaningful use of their certified electronic health record technology for an even larger portion of their patient populations. Some new objectives were also introduced for Stage 2, and most of those were introduced as menu objectives. As with Stage 1, many of the Stage 2 objectives have exclusions that allow providers to achieve meaningful use without having to meet objectives outside their normal scope of clinical practice. Providers can visit the CMS website and download comparison tables for the Stage 1 and Stage 2 core and menu objectives and measures: www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/Stage_2.html. For more information on the CMS EHR incentive programs, please visit www.cms.gov/EHRIncentivePrograms/.

What you need to know about pre- and post-payment EHR audits An eligible professional, eligible hospital, or critical access hospital that attests to receive an incentive payment for either the Medicare or Medicaid electronic health record incentive program may be subject to an audit. CMS and its contractor, Figliozzi and Co., will conduct audits on Medicare and dually-eligible (Medicare and Medicaid) providers who are participating in the EHR incentive programs. Medicaid providers participating in the Medicaid EHR incentive program will be subject to audits by the states and their contractors. Pre- and post-payment audits CMS began pre-payment audits this year, starting with attestations submitted during and after January 2013. The pre-payment audits don’t replace pre-payment edit checks that have already been built into the EHR incentive programs’ systems to detect inaccuracies in eligibility, reporting, and payment. Pre-payment audits are random and may target suspicious or anomalous data. Providers selected for pre-payment audits will have to present supporting documentation to validate their attestation data before CMS releases their incentive payment. CMS, through its contractor, will also conduct post-payment audits during the course of the EHR incentive programs. Providers selected for post-payment audits will be required to show supporting documentation to validate their submitted attestation data.

Preparing for an audit To be prepared for a potential audit, providers should have on hand electronic or paper documentation that supports their attestation. If they are selected for an audit, providers will also need to produce documentation that supports the values they entered in the attestation module for clinical quality measures. Hospitals should also maintain documentation that supports their payment calculations. For more guidance on what documentation to retain for audits, see the “Supporting Document for Audits” fact sheet: www.cms. gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ Downloads/EHR_SupportingDocumentation_Audits.pdf. Audit results Providers found ineligible for an EHR incentive payment based on their pre-payment audit will not receive payment. In the case of postpayment audits, the payment will be recouped when a provider isn’t found to be eligible. CMS may also pursue additional measures against providers who attest fraudulently to receive an EHR incentive payment. Providers found ineligible for their incentive payment will also face a payment adjustment beginning in 2015. Providers should always accurately report and properly document to avoid payment penalties. Audit materials Additional audit materials can be found on the educational resources page of the CMS EHR incentive programs website under the title “Audit Information and Guidance”: www.cms.gov/Regulationsand-Guidance/Legislation/EHRIncentivePrograms/ EducationalMaterials.html. www.tafp.org

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Start Saving Money on Vaccines Now! Discounts on Vaccines • Reimbursement Support With Payers • Timely Updates About New Products, Changes & Sales • Donations to TAFP With Every Purchase! Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV. Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management. The program is free to your practice, and enrollment is completely voluntary. The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine. Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered. Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or info@atlantichealthpartners.com for more information and to register.

Foundation Focus TAFP Foundation selects first preceptorship scholarship recipients The program matches interested students the texas academy of Family Physicians and volunteer family physician preceptors. Foundation is proud to announce that the The students spend a few weeks in the sumfirst 13 recipients have been named for the mer immersed in a family medicine clinic Preceptorship Scholarships funded through learning what it truly means to be a family the organization’s new Family Medicine physician. The program used to receive Student Interest Endowment. The students state funding for its administrative support submitted applications and were selected and to provide students with stipends to based on interest in family medicine and help cover their expenses, the quality of their perbut in 2011, the Texas sonal statement. All the “We are delighted Legislature cut all funding students were matched for the program. with family physicians to to be able to TAFP leadership imcomplete a two- or foursupport these mediately decided that week preceptorship this enthusiastic the program had to be summer. The applications medical students rescued and the Academy took over the program’s reveal interest in miswho we hope administration. Enrollsion work, practicing ment opened again in in underserved areas, will be our next 2012, but the program no patient advocacy, and generation longer provided financial much more. The 2013 of family support to the students. recipients are: Anna Believing in the imporGamwell from Texas physicians.” tance of that support, A&M University Health the TAFP Foundation Science Center; Michael Dale Moquist, M.D. Board of Trustees voted Jauregui, Marco Ruiz, and TAFP Foundation to create the Student Amna Ahmed from Texas President Interest Endowment to Tech University Health be used primarily to fund Science Center; Anthony scholarships for the preceptorship program. Ng, John Tohlen, Marlene S. Garcia, Anuron Through generous donations, the endowMandal, Mark Garcia, and Petra Kelsey from ment grew to over $11,000 in the first year. UTMB Galveston; Kellie Hainline from UT That endowment, along with general funds Southwestern Medical Center; and Lauren of the TAFP Foundation, provided the supJames and Meagan Sims from the University port for the scholarships. of North Texas Health Science Center. The Texas Academy of Family Physi“We are delighted to be able to support cians Foundation supports educational and these enthusiastic medical students who we scientific initiatives of family medicine to hope will be our next generation of family improve the health of all Texans. Through physicians,” said TAFP Foundation Presithe generous contributions of members, dent Dale Moquist, M.D. “Our goal is far corporations, and friends, the Foundation is beyond what we were able to do this year­— able to raise and distribute funds for medithe program funded almost 200 pre-clinical cal student scholarships to future family students at one point. Thirteen students is physicians, for office-based family media good start but we need additional support cine research, for family medicine student to expand our efforts.” interest group activities at medical schools The family medicine preceptorship in Texas, and for family medicine resident program began in 1980 and has given thouactivities. Visit www.tafp.org/foundation sands of medical students real-life experifor more information. ence in community health care settings.


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perspective

Legislature restores women’s preventive care funding By Janet Realini, M.D., M.P.H., chair of the Texas Women’s Healthcare Coalition in a bipartisan effort, the 83rd Texas Legislature increased funding for preventive care for low-income women, making an important first step toward restored access for over 140,000 low-income women. Senate Bill 1, now signed into law by Gov. Rick Perry, invests in family planning in three key funding streams. • It adds $32.1 million in state funding to the Department of State Health Services Family Planning Program, replacing federal dollars awarded to the private Women’s Health and Family Planning Association of Texas network through Title X;  • It adds $100 million for a DSHS Primary Health Care Expansion for women’s health care, 60 percent of which will provide contraceptive care; and • It adds $71.3 million in state funding to maintain the Texas Women’s Health Program, which lost its federal funding due to the “Affiliate Ban Rule” that excluded Planned Parenthood from the program.

With more than 56 percent of Texas births paid for by Medicaid, preventing unplanned pregnancy also reduces tax costs. If they were not reversed, the family planning budget cuts were estimated to cost the state at least $136 million for Medicaid births in three years. Of course, even with restored funding, there are important concerns. Repairing the women’s health care safety net will take time, and new programs will have administrative challenges. Many experienced family planning providers, like Planned Parenthood clinics, are excluded from funding, which means that other providers will need to be found to absorb the patient volume. Multiple legislators deserve thanks for their efforts on behalf of women’s health. Rep. Sarah Davis, RWest University Place, led the bipartisan effort for women’s health funding in the House. Her efforts helped to avoid floor battles in the House and made the restoration of lost funds possible. Rep. John Zerwas, R-Simonton, showed outstanding leadership in the appropriations process, as well as during the conference committee. As a physician, his influence on women’s health issues has been critical to the restoration of funding achieved during the legislative session.  Rep. Donna Howard, D-Austin, proposed House Rider 90, which will replace the $32.1 million the state lost in Title X funds this year. It is estimated that this additional funding will provide access to preventive care for an additional 48,000 low-income women across the state.  As chair of the Senate Health and Human Services Article II Workgroup, Sen. Jane Nelson, R-Flower Mound, strongly supported funding for family planning, including contraception. Rep. Jessica Farrar, D-Houston, Rep. Dawnna Dukes, D-Austin, and Sen. Bob Deuell, R-Greenville, also helped support preventive care in the appropriations process. As chair of the Texas Women’s Healthcare Coalition, I would like to thank TAFP for your extraordinary support of the coalition’s work. As a member of the coalition’s steering committee, the Academy helped to guide our efforts in the Legislature. TAFP CEO Tom Banning was truly a fountain of wisdom throughout the process. TAFP Director of Communications Jonathan Nelson and Communications Specialist Samantha White provided expert help to make our press conferences, press releases, and photographs highly successful. On behalf of the coalition, thank you!

Members of the Texas Women’s Healthcare Coalition are passionate about this cause because prevention of unplanned pregnancy means healthier women and babies and reduced tax costs. Nearly half of Texas births result from unplanned pregnancies, with higher risks of low birth weight, prematurity, late prenatal care, poor child health, and abuse or neglect.

This legislation will mean that subsidized family planning in Texas can offer access to approximately the same number of women in 2014-15 as in 2010-11, before the deep cuts of 2011. Texas’ safety net for women’s health care was reeling after the severe cuts to family planning instituted in 2011 by the 82nd Legislature. The $73 million cut to the DSHS Family Planning Program resulted in closure of more than 53 clinics and the loss of access to preventive care for an estimated 147,000 low-income Texas women. In response to these drastic cuts, the Texas Women’s Healthcare Coalition was formed, with a mission to restore funding and ensure access to preventive care—including family planning and contraception—for all Texas women. The coalition is comprised of 39 health care, public policy, and faith-based organizations working together on prevention. Coalition members are passionate about this cause because prevention of unplanned pregnancy means healthier women and babies and reduced tax costs. Nearly half of Texas births result from unplanned pregnancies, with higher risks of low birth weight, prematurity, late prenatal care, poor child health, and abuse or neglect. Planned pregnancies have a healthier start, with earlier prenatal care, less alcohol and tobacco exposure, more folic acid to prevent birth defects, more breast-feeding, and many positive outcomes for children. The ability to plan pregnancies also allows women and families to achieve their educational goals and improve their financial situation. 30

[SUMMER 2013]

TEXAS FAMILY PHYSICIAN


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Make sure you have the right insurance to help you protect the life you’ve worked so hard to build. 1. Insurance Information Institute. “Changes in Your Life Can Mean Changes in Your Insurance, Says the I.I.I.,” Press Release, January 22, 2007.

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Texas Family Physician, Summer 2013