Those efforts went nowhere, however, due to TMA’s vigi- lance at the Capitol and to a new, collaborative standard TMA and key lawmakers set for addressing scope-of-practice issues. As of Nov. 1, Senate Bill 406 replaces current site-based
restrictions for prescriptive delegation and supervision with a more flexible, collaborative model for physician-led, team- based care (See “Buried in Paperwork,” May 2013 Texas Medi- cine, pages 14–20). The legislation resulted from months of negotiations among TMA, the Texas Academy of Family Phy- sicians, advanced practice registered nurses, and physician assistants (PAs) spearheaded by Senate Health and Human Services Committee Chair Sen. Jane Nelson (R-Flower Mound) and House Public Health Committee Chair Rep. Lois Kolkhorst (R-Brenham). Council on Legislation member and Austin neurologist Sara
Austin, MD, said a shift toward team-based health care deliv- ery models means practices like hers “are using more midlevel practitioners and physician expanders.” She said the law will preserve patient safety but also “make things easier” by free- ing up physicians, nurses, and PAs for patient care rather than tying them to outdated site-based rules. TMA never deviated from the core principle that diagnosing
and prescribing remain the practice of medicine, TMA Direc- tor of Legislative Affairs Dan Finch says. However, by bringing together various parties on a pre-session compromise, “what we did was change the conversation. Now we have a process and a model for future scope-of-practice discussions.” Similarly, a compromise TMA struck last session with hospi-
tal groups over employment paid dividends this year, Mr. Finch says. Whereas last session medicine contended with more than 20 hospital employment bills, this year there were two. Both adhered to the 2011 legislation that limited direct hiring to rural areas and mandated protections for physician’ indepen- dent medical judgment in employment scenarios, among other provisions.
Using a similar strategy, TMA entered 2013 backing a com-
promise bill to help address the recurring discussions over end-of-life issues. (See “Difficult Choices,” February 2013 Texas Medicine, pages 35–38.) Dr. Austin says Senate Bill 303 aimed to address some of
patients’ and family members’ concerns by updating the Texas Advance Directives Act to give patients more time and help with these difficult decisions, while maintaining doctors’ legal rights to do what they believe is ethically and medically best for patients in their last days. Senator Deuell worked on the bill with TMA, the Texas Hospital Association, the Texas Alli- ance for Life, and other health care, religious, disability-rights, and right-to-life groups.
Although last-minute debates derailed the legislation, phy-
sicians still have access to the same protections that have worked for many years. The collective effort will aid in future legislative discussions on a topic that is equally difficult for physicians and patients’ families, Dr. Austin says. “Doctors still can do what’s right for patients. And we still have a way to resolve disagreements.”
Dan McCoy, MD Sen. Jane Nelson
August 2013 TEXAS MEDICINE 27 Sara Austin, MD
Medicaid expansion a bust; progress on reform
Meanwhile, Medicaid stole some of the spotlight this session, with the legislature ultimately declining to act on the fed- eral government’s offer of more money — as much as $100 billion over the next decade — to expand the Medicaid pro- gram. While TMA made progress on significant reforms to the program, talk of changing Medicaid coverage in any way — whether a new proposal or the one outlined by the Patient Protection and Affordable Care Act (PPACA) — went nowhere due to stiff Republican opposition. Going down in the fight was a controversial rider tacked onto a draft version of the budget that would have allowed the Texas Health and Human Services Commission (HHSC) to negotiate certain state-based reforms with the federal govern- ment to draw down extra federal dollars. Similar legislation filed by physician and House budgeter Rep. John Zerwas, MD (R-Simonton), also failed. Among other provisions, that bill, House Bill 3791, would have expanded coverage for the work- ing poor through private insurance coverage. Left standing, however, was a rider attached to a Medicaid managed care bill, Senate Bill 7, that explicitly requires legislative approval before HHSC or the governor can approve any waiver request to provide any coverage, Medicaid or otherwise, to currently noncovered populations in Texas. TMA advocated throughout the session for a Texas-specific
plan that would include significant reforms to the Medicaid program and that would allow the state to cover the working poor under Medicaid or a state-developed insurance cover- age plan using extra federal money. (See “Fix It First,” April 2013 Texas Medicine, pages 27–32.) TMA’s plan, put together by the association’s Physicians Medicaid Congress, included a fix-it list to repair the Medicaid program and boost physician participation through increased payments and reduced admin- istrative complexity, as well as suggestions similar to those proposed by Representative Zerwas and others for a state- specific solution for providing coverage to the working poor using copays and deductibles and a benefits package tailored to that population, for example. “I am saddened that Texas is throwing away $10 billion a year for 10 years because we did not address Medicaid expan- sion,” said TMA Immediate Past President Michael E. Speer, MD, a neonatologist in Houston and cochair of the Physicians Medicaid Congress. “TMA made some excellent recommendations on how to
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