august 2012 dallas medical journal

v o l u m e 9 8 • n u m b e r 8 • a u g u s t 2 0 1 2

I n t h i s i s s u e :

1115 Waiver - Redefining the Funding

President’s Page - The Reformation

Cutting Through the Red Tape

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About the Cover PhotoStand with DCMS as we continue to advocate for you and your patients at the local, state and national levels.

143 President’s Page The Reformation

147 Community The Next Generation

150 1115 Waiver: Redefining the Funding

155 Alarming Drop in Physician Acceptance of Medicaid, Medicare Patients

157 Physician Smart Cards Reducing Disruptions, Decreasing Liability and Increasing Safety

158 Partnership Could Ease Physician Shortage

v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • A u g u s t 2 0 1 2 • 1 4 1

Dallas County Medical SocietyPO Box 4680, Dallas, TX 75208-0680Phone: 214-948-3622, FAX: 214-946-5805www.dallas-cms.orgEmail: [email protected]

DCMS Communications CommitteeRoger S. Khetan, MD ............................................. ChairRobert Beard, MD Gene Beisert, MDSuzanne Corrigan, MDSeemal R. Desai, MDDaniel Goodenberger, MD Gordon Green, MD Steven R. Hays, MDC. Turner Lewis III, MDDavid Scott Miller, MD

DCMS Board of DirectorsRichard W. Snyder II, MD ................................. PresidentCynthia Sherry, MD .................................President-ElectJeffrey E. Janis, MD .........................Secretary/TreasurerShelton G. Hopkins, MD ......... Immediate Past PresidentMark A. Casanova, MDWendy Chung, MDR. Garret Cynar, MDSarah L. Helfand, MDMichael R. Hicks, MDRainer A. Khetan, MDTodd A. Pollock, MDKim Rice, MDChristian Royer, MD

DCMS StaffMichael J. Darrouzet .................. Chief Executive OfficerLauren N. Cowling ............................... Managing EditorMary Katherine Allen ..........................Advertising Sales

Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2012 DCMS

According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish leg-islative advertising in the DMJ: Michael J. Darrouzet, Ex-ecutive Vice President/CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680.

Dallas Medical Journal(ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.

Subscription rates$12 per year for members; $36, nonmembers; $50, overseas. Periodicals postage paid at Dallas, TX 75260.

PostmasterSend address changes to:Dallas Medical Journal, PO Box 4680 Dallas, TX 75208-0680.

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President’s Page

Richard W. Snyder II, MD

When the Supreme Court ruled that the Patient Protection and Affordable Care Act was constitutional, because the penalty mandate is in reality a tax, it set off an unexpected mad scramble by yours truly to rewrite the DCMS press release concerning this verdict. It seems the three provisional versions that I wrote the night before covering the three most likely ruling scenarios under the Commerce Clause (complete affirmation, complete repeal, partial repeal) were not enough. It’s a good thing because the full office and acute MI that I was dealing with just didn’t fill the void in my morning that Thursday.

The Supremes, with their ruling, heralded the end of the beginning of the health system reform odyssey. This most anticipated of all health reform decisions will now unleash a process by which many more decisions will be made at the federal, state and local levels, both legislative and regulatory, that will start to determine how healthcare reform will manifest. In this regard, PPACA is not so much a health system reform directing clearly defined change as it is a health system reformation, triggering a process of change. The Act itself is more of a guideline that determines the general direction that health system reform should follow. I have not read anywhere near the entire 2,700-page document, so I do not pretend to be an authority on PPACA. However that puts me in same company as the vast majority of the legislators who actually voted on the bill. What I do know is that the truly clarifying “rules” will be made by nonelected regulators who will interpret how the Act should transform the daily practice of medicine. Governors must make important decisions, and state legislators must vote on a myriad of bills that will determine how the Act will apply to their states (such as regarding Medicaid expansion and Health Information Exchanges). For example, some states may decide not to participate in health exchanges or expand their Medicaid programs. PPACA will take on different flavors on a state-by-state basis depending on how these decisions are made by executive, regulatory and legislative bodies. The Patient Protection and Affordable Care Act (wait for it) is just the first act of this drama (every pun intended!). Most of the work to bring real improvement to our healthcare system lies ahead.

As physicians we must continue to play an integral role in this process. If we are to serve as true advocates for our patients, we must do more than just talk. Now that

we have certainty about the constitutionality of the Act, we must roll up our sleeves, go to work and re-elevate the patient to the pinnacle of health system reformation. We all know that the impetus for change in our healthcare system is derived from the desperate need to improve affordability and access to care. The Act aims to increase the number of Americans covered by health insurance

and decrease the cost of health care. However, it neither adequately protects patients nor sufficiently provides for affordable care. The problem with the Act is that it focuses excessively on improving the affordability and access to coverage, while doing little to improving patient access to care. Coverage is not the same as access, and access to a waiting list is not the same as access to health care. Clearly the Act has some major positives that will improve access to care for many, but it falls well short of its intended goals. In Texas, 25 percent of our population is uninsured. That represents roughly 6.3 million of our fellow Texans, a number nearly equal to the population of Massachusetts. The act would add only around 2 million of the uninsured Texas patients to Medicaid. The Texas population currently covered by Medicaid stands at about 3.4 million.

The problem with expanding Medicaid is that statewide only 31 percent of all physicians are taking new Medicaid and this number is plummeting, according to a 2012 Texas Medical Association survey. The negative trajectory of this number is just as alarming: 67 percent in 2000, 42 percent in 2010, 31 percent today. In Dallas County, the numbers are even more bleak. Only 24 percent of all physicians and just 19 percent of primary care physicians are accepting all new Medicaid patients. It makes you wonder when we will see single digits! (For disclosure purposes, myself and all physicians in my group are enrolled in and accept Medicaid.) Even if we convert all uninsured patients to a Medicaid plan, they may be covered, but that doesn’t guarantee they will have access to a physician, certainly in a timely manner. For example, everyone in the Canadian and British health systems has healthcare coverage, but wait times to see a physician are well-known and are not acceptable to patients in this country. Massachusetts has “universal” coverage for its citizens; however, the Boston municipal area has the longest wait times for new outpatient visits among the largest 15 US metropolitan areas, according to a 2009 Merritt Hawkins survey. The standard for the ongoing reformation of health care must embrace not only cost-effective, quality care but also the timeliness of care. This concept of timeliness is key: the right care at the right time. Timing for many things in life is key, frequently trumping quality. As I tell my kids, it didn’t matter how perfectly Troy Aikman spiraled the football with laser-beam precision down the field, if the timing was off, the ball got there late and was intercepted, then his effort was all for naught.

With this Supreme Court decision, we physicians must help our legislators and regulators keep what works, fix what is broken, and find what is missing in PPACA. However, before we start, let’s be clear: I don’t want to hear any clarion call for repeal of PPACA without a detailed, specific comprehensive plan to replace it. Better yet would be language crafted to improve and supplement the Act. We may not like all elements of PPACA, but at least it is an attempt at reform. We now are beyond the placebo stage of health system reform. A better medical analogy would be an access to care comparison proposed to demonstrate superiority as

The Reformation

1 4 4 • A u g u s t 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

President’s Pageopposed to noninferiority. I want to examine some requisite changes to the current healthcare system and PPACA that we have today.

What worksCoverage of pre-existing conditions and elimination of

lifetime maximum benefit limits are elements of the Act that deserve congratulations and must be preserved. The inclusion of children up to 26 years of age on their parents’ health insurance plans clearly is worthy of praise. These elements make a positive impact on access to care and generally reflect the value system of our country, regardless of one’s political ideology.

What’s brokenNow let’s focus on what is wrong with the Act. The law

introduces a Medicare cost-containment mechanism, called the IPAB (Independent Payment Advisory Board), which definitely should not be confused with an iPAD, but may become just as ubiquitous and transformative, although not for the better. This 15-member committee will be appointed by the president, and confirmed by the Senate. In this regard it is effectively a Supreme Court of Physician Reimbursement This board, affectionately called “MedPAC on steroids,” will have almost dictatorial powers to determine reimbursement cuts to service providers if costs rise beyond certain levels, with little hope for successful appeal. A form of rationing, ironically this Independent Payment Advisory Board will strip the independence from the patient-physician relationship and render this bond almost meaningless. IPAB has been condemned by all medical societies, including the AMA. A bill to repeal this component passed in the House on March 22, but stalled in the Senate.

A further problem with the Act’s cost-containment efforts is that it focuses on the wrong area: physicians. Physician compensation is not a major driver for rising healthcare costs in the United States. A recent study found that the rate of US physician compensation is among the lowest of western nations. US physicians’ salaries comprise 8.6 percent of the nation’s total healthcare costs. Among western nations with modern healthcare systems, only Sweden (at 8.5 percent) devotes less money to physician compensation than the United States. Other western nations spend more — sometimes significantly more — on physician compensation as a percentage of total healthcare expenditures: United Kingdom, 9.7 percent; France, 11 percent; Australia, 11.6 percent; and Germany, 15 percent. If the goal of healthcare reform is to take waste and excess out of the cost structure, physician compensation is not the place to start or to devote most of the efforts.

An additional element that is wrong with the Act is the prohibition on physician ownership. Physician ownership has been demonstrated by the government’s own data (www.hospitalcompare.gov), as I have detailed in previous President’s Pages, to excel from both a quality and a cost perspective. Physician-owned heart hospitals in Texas rank No. 1 in the nation in clinical outcomes for heart failure and heart attacks. If superior quality at a lower cost is a goal of health system reform, language prohibiting physician ownership must be stripped from the law.

What’s missingNow let’s turn our attention to what is missing in the

Act, where PPACA is most deficient and has the most opportunity for improvement. It is greatly inadequate in addressing physician workforce and access issues. Specifically, the Act does not effectively deal with the cancer of our medical liability environment and does not reform SGR. On the surface, these issues appear self-serving; however, both of them significantly impact cost and access to care, and determine the viability of our profession. The AMA should never have endorsed PPACA without having satisfied these two issues. By passing Texas-style liability reform that includes caps on non-economic damages, the federal government could significantly reduce cost (conservative estimates are $60 billion – $90 billion annually) without having to find additional funding sources.

The SGR fiasco is a recurring horror movie that is progressively eroding patient access to care. A 30- percent cut in physician payment rates is still looming on Dec. 31 of this year. Currently, only 58 percent of Texas physicians accept new patients who rely solely on Medicare, and that number is falling rapidly (from 66 percent in 2010). In regard to dual-eligibles (Medicare-Medicaid patients), only 40 percent of Texas physicians and 32 percent of Dallas County physicians accept them. Imagine what kind of access seniors would experience if a 30-percent reimbursement reduction materializes. All the while, the Medicare population is exploding as 10,000 patients a day age into Medicare eligibility.

Furthermore, the Act does not address the workforce bubble that soon will enter almost crisis proportions for nearly all specialties. For my specialty of cardiology, a 2009 survey revealed that 45 percent of general cardiologists were over age 55. This is a figure that I am sure is similar for most medical specialties. How can you claim you have implemented comprehensive health system reform without including language that solves these current and future access issues?

Finally, today’s healthcare system is riddled with hundreds of regulations imposed by federal health law that do little to improve care, but instead divert our attention, time and energy from our patients. We are spending less time with patients, and more with computer screens and paper. Rather than alleviate this burden, PPACA contributes to it. The evolution of health care must free doctors to focus more on patients than on paper.

We must be forceful advocates for our patients and remain determined that the patient be paramount in health system reform. Affordability and access to care, not just to coverage, should be the benchmark by which we measure success. Reformation of our healthcare system must embody the guiding principles of timely access to quality, cost-effective care for all of our citizens, and the sanctity of the independent and autonomous patient-physician relationship. Now, let’s get to work!

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Community Health - The Next Generationby Jim Walton, DO, MBA, PAD Medical Director

“We are caught in an

inescapable network of

mutuality, tied in a single

garment of destiny.

Whatever affects one directly,

affects all indirectly.”

The Rev. Dr. Martin Luther King Jr.

For the last three summers, I have had the privilege of guiding five or six pre-med students through an 8-week internship at Baylor Health Care System. As part of the internship, I simulate a “journal club” experience on Friday mornings where we discuss healthcare improvement and business-related articles. Each year, I insert one piece of “famous literature”— MLK’s “Letter from the Birmingham Jail,” introducing the concepts of healthcare equity and disparities. This summer, we covered this article the week of the US Supreme Court decision upholding the Affordable Care Act.

These future physicians of Texas were keenly interested in how the principles of societal justice relate to the larger macroeconomics of healthcare financing. This crossroads both intrigued them and challenged their thinking. Interestingly, they concluded that Dr. King’s letter from the Birmingham Jail, written in 1963 long before the outcome of the civil rights movement was clear, represented a modern-day example of informed visionary leadership. His view of how God designed people and societies shaped his actions and conviction to help change the American story for the better. As we read the letter, we relived the angst and distress of that period when the outcome and our ultimate agreement was less certain.

It was not difficult to transition the discussion to apply Dr. King’s letter to today’s political and economic healthcare situation. Many of us regularly have seen and heard political, religious and secular voices taking a position regarding the logic, thoughtfulness and threats of the Accountable Care Act. Some people resent, while others applaud, the visionary leadership of the president and Congress. The students drew a direct connection from today to 1963, as the outcome of today’s transformation in health care is not clear. They asked where they could find the healthcare leaders articulating the fundamental values and beliefs that underpin the need for these transformative political and policy steps. Finally, they wondered if anyone could rise to the heights of Dr. King in crafting an argument discussing the truths about people and society while cementing a conviction to stay the course in the midst of resistance and fear.

Walking away from the journal club, I felt a sense of relief and reassurance that these future physicians will work with us to create the necessary changes based on their passion to positively influence the American healthcare narrative.


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ReelDocs DCMS members and their families spent an afternoon at the movies on June 24 at Studio Movie Grill. Guests enjoyed conversation, food and Disney’s “Brave,” sponsored by DCMS and DCMS Circle of Friends.


Two Waiver Funding PoolsIn the past, federal matching funds for

uncompensated care went straight from the government fund to the private hospitals. The 1115 Waiver changes that. The plan creates two funding pools from which hospitals will receive funds. The State hopes that having two pools will encourage hospitals to change their delivery model from inpatient-based services to innovative and flexible outpatient service models.

The State has devised a five-year plan to bring the hospitals into a world of more value. Under the terms of the waiver, hospitals will be able to care for more patients while keeping the costs the same by shifting care to outpatient settings rather than through hospital emergency rooms, for example. Year 1 in the five-year plan, where we are now, is a transition year, meaning that funding is based on the “old model.” This means that the funding the hospitals receive through September 2012 is the same as it

was in 2011. This “old model” now is referred to as the “Uncompensated Care Pool” or “UC” funding. Year 2, which begins Oct. 1, 2012, starts reducing the amount disbursed in UC and increasing funds available in the second pool, called the “Delivery System Redesign and Innovation Pool,” or DSRIP. The transition from UC to DSRIP pools is intended to transform care from a hospital inpatient care model to a redesigned outpatient model. To force the transformation, the State created an incentive-based model: basically, inpatient-based UC funds decrease, and more funds are available for innovation and system redesign programs through DSRIP. See the table table on the next page for approximate targets.

Texas plans to incentivize hospitals to move to the DSRIP system by offering money if they adopt programs that include features such as medical homes and care coordination. If the hospitals choose not to participate, they eventually will receive half the funds they are accustomed to getting. Because

1115 Waiver: Redefining the FundingIn the July Dallas Medical Journal, we skimmed the surface of how Texas will redefine its

funding of health care to the uninsured through the 1115 Waiver. Because the waiver and the

future of medicine in Dallas County are ever-changing, DCMS will remain involved, sort out the

details, and pass these important points to you. Part 2 will explain the process by which federal

dollars are received and divvied up.

by Katherine Lane, DCMS staff


the DSRIP pool can increase, hospitals could receive more funding than they traditionally have received if they follow the State’s incentives.

Helen Kent Davis, director of government affairs with the Texas Medical Association, says that participating in DSRIP is intended to be transformative for hospitals. “For years, state and federal lawmakers have pushed hospitals — and their physician and community partners — to change how and where care is delivered,” she says. “Funding from the DSRIP pool will help hospitals implement projects many have long wanted to do but didn’t have the resources to accomplish, such as improving primary care capacity to reduce unnecessary ER usage or expanding community mental health services.” But hospitals traditionally have not shared their matching funds with the physicians who will be needed to deliver care under this new model. So, what is the private physician’s role in all this? Hold that thought while we consider both pools of funds in more detail.

The UC PoolThe Uncompensated Care Pool consists of the costs

of uncompensated care provided to Medicaid-eligible individuals or to those who have no source of third-party coverage for services provided by the hospital or other providers. It mirrors the previous model of reimbursing hospitals for their uncompensated care. It has no programs or incentives. Each hospital submits a quarterly uncompensated care cost report, figures are plugged into a formula, and the Centers for Medicare and Medicaid Services sends the amount determined to be owed to the hospital each quarter. Like its predecessor “UPL” funding, or “Upper Payment Limit,” which had no system of accountability, UC funds are pure reimbursement for care previously delivered without payment. And like with UPL, these UC funds are not expected to be shared with the physicians who provided the care.

The DSRIP PoolThe Delivery System Reform Incentive Payment

Pool consists of the incentive payments made available for projects that are preapproved (more transparent than under UPL) and have agreed-to metrics and outcomes goals (accountability). Although DSRIP sounds good in theory, it has proven to be quite complicated and confusing in practice. One key driver of confusion is that DSRIP projects are “at risk,” meaning that if the hospital or entity that operates the project fails to meet the

agreed-to metrics or outcomes, the DSRIP funding may be lost, as in the hospital would get no check in the mail. Choosing successful projects will be more difficult than one may think; innovation generates graveyards of good ideas gone bad.

Another critical factor is that the underwriter or funder of DSRIP projects usually is the public hospitals (remember that an intergovernmental transfer or IGT is needed to start the matching process). Thus, Parkland Health & Hospital System likely will put the first dollar in. Playing the role of an investor in a startup project may cause Parkland to ask that DSRIP projects relieve its burden of taking care of uninsured patients. These are two high hurdles to jump before hospitals can get a DSRIP project off the ground — be a winning idea and save Parkland money.

To ensure that there is some degree of statewide coordination and that statewide objectives are addressed, Texas has specified that projects eligible for incentive programs should come from the State’s DSRIP menu. That menu is a group of projects the State has preapproved to contribute to delivery transformation and quality improvement. The DSRIP menu has four categories— Infrastructure Development, Program Innovation and Design, Quality Improvement, and Population-focused Improvements. The menu gives samples and guidelines for the metrics the hospitals need to meet. So, choosing a project off the menu is a good idea if you can find one that works for your community.

Conducting a Needs Assessment and Public Hearings

Each region or hospital can determine what projects to propose, and what metrics and milestones need to be met by conducting a Community Needs Assessment. The State expects the Regional Health Partnerships to address real community needs. That’s where the Community Assessment Task Force comes in, led by Summer Collins, MHP, director of Population and Public Health Research at the Dallas-Fort Worth Hospital Council Foundation. DCMS was represented on this task force by James Walton, DO,

Plan Year UC Funding DSRIP Funding

1 100% 0%

2 80% 20%

3 70% 30%

4 60% 40%

5 50% 50%

Hospitals no longer solely determine how they use their UC and DSRIP funds. They must work collaboratively and submit plans regionally about how money will be used. This is done through the structure of the Regional Healthcare Partnerships.


medical director of Project Access Dallas, and Cheryl Prelow, vice president of Project Access Dallas. The assessment has been completed for our region, and soon it must be shared with the public through a public hearing. The RHP is responsible for writing the plan and for conducting a public hearing for the needs assessment and for the plan itself.

Regional Healthcare PartnershipsHospitals no longer solely determine how they

use their UC and DSRIP funds. They must work collaboratively and submit plans regionally about how money will be used. This is done through the structure of the Regional Healthcare Partnerships. Each of the 19 regions in Texas must have at least two counties and appoint an anchor hospital. An anchor hospital is responsible for facilitating the design of the plan, approving how DSRIP funds will be used, educating the public, and submitting the plan to the State. Dallas County is in Region 9 with Kaufman County, with Parkland as the anchor hospital. By Sept. 1, 2012, Parkland must finalize a plan and have it reviewed by the State and CMS.

Parkland’s PlanRegarding its role as the anchor hospital for this

region, the Parkland Board of Managers asked for help from the hospital community through the

DFW Hospital Council; Dallas Medical Resources, a nonprofit group that includes leaders from all Dallas’ major hospital systems and businesses; and the president/CEO of DCMS. The 1115 Program Work Group leads the effort, and is cochaired by interim Parkland CEO Thomas Royer, MD, and Baylor Health Care System President Joel Allison. The work group created three task forces to assist it in development of details: the Uncompensated Care Task Force, the Delivery System Redesign Incentive Task Force, and the Community Assessment Task Force.

At the end of July, these task forces were to submit their needs, plans, metrics, and outcome goals to the work group for approval. The work group will take its recommended plan to the Parkland Board of Managers, which must submit the regional plan to the Texas Health and Human Services Commission by Sept. 1, 2012. The State then will gather plans for all regions of the state and submit them to CMS by Oct. 1, 2012.

Coming NextNext month we will report on the Region 9 plan.

We will share which DSRIP projects made the cut and how physicians can expect to participate in the system redesign.

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Dallas County Medical Society36th Annual Medical Student Dinner

Sunday, Aug. 19YOU HAVE TWO WAYS TO PARTICIPATE:• Attend the dinner and sponsor students — this one is the most fun.• Sponsor students — this tax-deductible donation is greatly appreciated.

THE DETAILS:• Cocktails will be served at 6 p.m.• Doubletree Hotel Campbell Center, 8250 N. Central Expy. (Across the highway from NorthPark Center)• All contributions for student meals are tax deductible.

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PRACTICE MANAGEMENT

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SPA ad DCMS 9/11.indd 1 9/13/11 12:08:29 PM


TMA Sees Alarming Drop in Physician Acceptance of Medicaid, Medicare PatientsTexas Medical Association

(TMA) physician leaders have

long predicted government

regulatory burdens, red tape,

payment hassles, and low pay

would erode the physician

foundation of both Medicaid

and Medicare.

That day has come, according to TMA’s new biennial survey of Texas physicians. More physicians are forced to reduce the number of patients they see who depend on government health care. “All the bureaucratic red tape and administrative burdens only serve to increase the cost of running a practice while diverting a physician’s attention away from patient care,” said TMA President, Michael E. Speer, MD.

Hardest hit are low-income Texans who rely on Medicaid for their care. Texas physicians available to treat new Medicaid patients have plummeted from 42 percent in 2010 to 31 percent — an all-time low.

Medicare, a federal health program that insures seniors, people with long-term disabilities, and military families, also saw a huge decline. The number of Texas physicians accepting all new Medicare patients dropped from 66 percent in 2010 to 58

percent in 2012. That’s part of a trend that’s seen the number decline steadily from 78 percent in 2000. Meanwhile, the number of Texas physicians who limit how many new Medicare patients they accept, and the number who decline all new Medicare patients each rose by 4 percent in the past year.

Dr. Speer said these are the lowest-ever new-patient acceptance rates the association has seen. He’s saddened but not surprised. “Doctors have answered the government mandate to invest in expensive health information technology, upgraded their coding and

billing systems, implemented e-prescribing programs, withstood the threat of a new 60,000-item medical coding system (ICD-10), and for the past decade endured the payment uncertainty of Medicare,” he explained.

To make matters worse, in 2010 and 2011, the state cut physicians’ already-meager Medicaid payment rates another 2 percent. Then, at the start of this year, doctors who care for the state’s poorest elderly and disabled patients (dual-eligible patients) were cut another 20 to 100 percent. These cuts hit physician practices extremely

TEXAS MEDICALASSOCIATION

100%

80%67%

49%45%

38% 42% 42%

31%

60%

40%

20%

0%2000 2002 2004 2006 2008 2010 2012

Percent of Texas Physicians Who Will Accept All New Medicaid Patients


hard, especially because Medicaid payments cover less than half of the average cost to provide services. “Every business has a breaking point; physicians’ practices are no different,” said Dr. Speer.

Joannie Parr, a Sugar Land accountant, manages her husband’s medical practice. Thomas J. Parr, MD, is an orthopedic surgeon. “Some years ago, we looked at expenses and income, and made the difficult decision to stop accepting Medicaid patients,” she said. “Medicaid puts up so many hurdles we found it was easier to provide free care outright than hassle with Medicaid’s bureaucracy for basically no pay.” Dr. Parr now treats low-income patients referred to him by a free clinic and volunteers his surgical services at a local hospital.

Another critical issue not

addressed in the Patient Protection and Affordable Care Act (PPACA) is the faulty formula Medicare uses to pay physicians. Doctors have faced the threat of steep Medicare payment cuts every year for more than 10 years. Once again, physicians face a nearly 30-percent cut Jan. 1, 2013. Instead of addressing Medicare’s flawed payment formula, the PPACA has added even more layers of bureaucracy.

Su Zan Carpenter, MD, a family physician in Angleton, Texas, recently opted out of Medicare. “Every time you turn around someone has a new rule or a new regulation or a new audit or a new inspection or a new something,” she said. “There’s a point where enough is enough. You need to see the patient, talk to the patient, examine the patient, and actually do something with your patients for your patients. All that stuff is starting to get in the

way of practicing medicine and helping people.”

Frisco family physician Chris Noyes, MD, says he had a “straw that broke the camel’s back moment” with Medicare in 2009. “I had a patient who moved from out of state to be with his kids. He had lung cancer when he came in and ultimately died. We wrote off a fairly large balance,” Dr. Noyes said. “Two years after he died, we got a letter from Medicare saying they had overpaid for a flu shot for him by $2 and they wanted the money back with interest and a penalty, and if I didn’t pay it all within 30 days they would prosecute me.” These stories are no longer isolated incidents but stories that are becoming more common across the state.

“What’s lost in the health care debate is the simple fact that patients need a doctor when they get sick. And physicians want to take care of patients and not push endless reams of paper around our desk,” said Dr. Speer. “At some point, state and federal leaders must realize without an adequate network of physicians, no health care system can work, let alone be effective.”

TMA recently published its strategic roadmap, titled Healthy Vision 2020. The document outlines the association’s state and federal recommendations to ensure patients have the right care, at the right place, and at an affordable price.

This is article was originally released by the TMA on July 11. Reprinted with permission.

100%

80% 78% 74%67%

62% 64% 66%58%60%

40%

20%

0%2000 2002 2004 2006 2008 2010 2012

Percent of Texas Physicians Who Will Accept All New Medicare Patients

“Some years ago, we looked at expenses and income, and

made the difficult decision to stop accepting Medicaid

patients,” she said. “Medicaid puts up so many hurdles we

found it was easier to provide free care outright than hassle

with Medicaid’s bureaucracy for basically no pay.”


Physician Smart Cards Reducing Disruptions, Decreasing Liabil ity and Increasing Safety

by H.A. Tillmann Hein, MD

On average physicians carry five physical identification badges and 12 sets of usernames and passwords relating to the organizations with which they interact and conduct business. The undisputed purpose of both physical and information security in a healthcare setting is to protect patients, their family members and healthcare professionals. Unfortunately, these security tools also can be a roadblock to physicians wanting to efficiently provide patient care and conduct routine business.

As an anesthesiologist who has been in practice in DFW since 1982, I carry at least 16 identification badges on a daily basis. I also have two key fobs and use fingerprint identification at one facility for entry. For access to medication dispensing machines, I have 16 different codes. I need a different set of codes for lockers and an additional set of codes for access to medical records. One facility has an additional numeric code for access to parking.

Dealing with the multitude of badges and codes is time consuming and a regular source of aggravation. More importantly, the use of multiple badges and codes is a liability.

I keep all these badges in a compartment in my car. Occasionally, I carry a badge into my home and forget to put it on when I rush out the next morning. I keep my codes in a database in my password-protected cellphone. On rare occasions when the battery runs out, I cannot retrieve the codes. These instances cause disruptions and ultimately increase patient process times. Moreover, I often question the safety of my badges and the facilities to which the badges allow access when I hand my car over to valet parkers, car washers or repair mechanics, and I forget to remove the badges from the compartment. Also, a recent compliance check in my practice detected several smart phones that had lists of security codes but not password protection. It is clear that the proliferation of security cards, devices and codes actually has decreased security rather than increased it, and has jeopardized patient safety. It is time for an improved system.

It is time for physician smart cards. Physician smart cards can replace multiple forms of identification, and the challenges and complexities associated with multiple forms of identification required by healthcare organizations. These cards offer physicians a single identification credential to access secure resources such as electronic health records, medical devices, payor portals, building facilities, and meal plans. It provides the user or physician with an electronic signature for use on electronic documents, such as e-prescriptions. Hospitals, family and specialty

practices, imaging centers, health plans, and health information exchanges all can accept smart cards. The cards can provide access to multiple information systems and facilities for the same organization and for multiple organizations.

For at least 10 years, I have advocated for a single ID badge for all Dallas County physicians. During the past two years, the DCMS Socioeconomics Committee and I have developed traction for a Web-based portal that would enable all Dallas County physicians to remotely manage their personal information and requirements, and utilize self-service features such as password reset and temporary card issuance. Through a secure portal, physicians can register for an account, maintain their profile information, and request access to multiple accepting entities.

HITRUST ID Identity Services is one such local organization that provides unified smart cards and the aforementioned services for healthcare professionals and providers. The company has been in talks with some of the larger healthcare systems in Dallas to set up this service. For healthcare organizations, the challenge for implementation is not only to secure funding for new technology, but also to weigh the potential benefits and costs of new and emerging technology. The initial investment will allow healthcare organizations to meet increasing privacy and security concerns, improve patient identification and workflow, and increase revenue capture. The investment will improve facility and network security, and provide immediate access to vital information.

The healthcare systems should do their part in speeding smart card adoption, but we physicians also must do our part.

We must inform local healthcare system leaders and administrators of the need for this investment. We must advocate for the smart cards, stressing that they will bring a significant decrease on patient wait times, increase the efficiency of the physicians, and improve the privacy and security of data. The HITRUST badge program would be a blessing to physicians who have privileges at more than one facility. By reducing the number of badges to one, the custom of unsafely storing badges in the car would end and thus the facilities would be safer from badge abuse. Cumulatively, physicians could save thousands of hours searching for badges and codes. Medical records would be completed more promptly, and access to crucial patient information would be easier and faster. This likely would lead to a reduction in testing and reduce delays of surgery, and thus save millions of dollars in North Texas alone.

Ultimately, a smart card will free physicians to do what they are trained to do — care for patients.


Partnership Could Ease Physician ShortageBy Cristi Columbus, MD Vice Dean, Dallas Campus Texas A&M Health Science Center, College of Medicine

In light of the US Supreme Court ruling upholding the constitutionality of major elements of the Congressional Health Care and Education Reconciliation Act of 2010, the Association of American Medical Colleges has projected a nationwide shortage of at least 130,600 physicians by 2025. This projection compounds 2009 predictions of shortages attributed to the aging of the population and resultant demands on the healthcare industry.

To address this scarcity of primary care physicians in Texas and particularly in North Texas, the Baylor Health Care System partnered with the Texas A&M Health Science Center College of Medicine in December 2011 in a nonexclusive relationship to serve as a clinical training site for third- and fourth-year medical students from the Texas A&M Health Science Center College of Medicine.

Both institutions have a long and distinguished history of medical education. Baylor’s roots reach

back to the founding of the University of Dallas Medical Department in 1902, and Baylor University Medical Center and affiliated institutions have provided undergraduate and graduate medical education for more than 100 years. The Texas A&M Health Science Center College of Medicine was founded in 1977 as part of Texas A&M University, with 33 students serving the basic science years in College Station and the clinical years in Temple.

The first–year class at Texas A&M Health Science Center College of Medicine has grown to 200 students. For their first two years, they study the basic sciences at the Bryan or Temple campus. Students then receive their clinical training at one of four locations: Bryan-College Station, Round Rock, Temple, or Dallas. The medical students serve traditional mandatory third-year clerkships in internal medicine, surgery, family medicine, obstetrics/gynecology, pediatrics, and psychiatry. Inpatient training for the internal medicine,

Texas faces dire circumstances from its shortage of primary care physicians, ranking 42nd of

the 50 states and the District of Columbia in the number of physicians per 100,000 inhabitants.

A recent study commissioned by the Dallas-Fort Worth Hospital Council indicated the North

Texas area struggles with a 30 percent shortage in primary care physicians, with a projected

50 percent shortage by 2016.


surgery, and obstetrics/gynecology rotations primarily will be obtained at Baylor University Medical Center, Baylor Regional Medical Center at Garland, and other affiliated institutions. Inpatient psychiatry and pediatric experience will be gleaned at Timberlawn Mental Health System and Cook Children’s Medical Center. Ambulatory experience and fourth-year electives will be obtained in multiple subspecialties in a variety of affiliated institutions, as well as private practices throughout the North Texas area. Students from the Texas A&M Health Science Center will join a large number of fourth-year students from around the country seeking elective experiences within the Baylor Health Care System, as well as within the institutions of UT Southwestern, Children’s Medical Center, Texas Health Resources, and the Methodist Health System as they evaluate opportunities for post-graduate medical training for specialty residencies in the Dallas area.

For the first time in more than a century, Dallas-area institutions will serve as clinical training sites for two medical schools — the Texas A&M Health Science Center College of Medicine and the University of Texas Southwestern Medical School. Dallas will join luminary cities of healthcare excellence including Houston, Philadelphia, Chicago, New York, and Washington, DC, making the area ripe for interinstitutional collaboration to improve the health of the community at large.

Because many physicians establish their practices in the areas where they received their medical school or residency training, the partnership between the Baylor

Health Care System and the Texas A&M Health Science Center College of Medicine serves as an additional resource to improve the health of North Texans. However, although Texas medical schools have expanded class sizes to address growing demands for physicians, expansion of the number of internship, residency and fellowship positions has significantly lagged. Additionally, substantial federal budget cuts associated with the Affordable Care Act likely will target funding for postgraduate medical training. As the 83rd Legislature convenes in January, a pressing issue for lawmakers will be the need for additional funding for graduate medical education, as well as preservation of financial support for Texas medical schools.

To learn how you can help bring this issue to legislators’ attention, contact Tracy Casto, Dallas County Medical Society director of public affairs and advocacy, at [email protected] or 214.413.1427.

Late HIV DIAGNOSIS

contributes to increased transmission of HIV.

People who don’t know about their HIV infection are more likely to transmit it to others.

Learn more at

www.testtexashiv.org

message no 4 dcms.indd 1 8/28/11 7:02:05 AM

As the 83rd Legislature convenes in January, a pressing issue for lawmakers will be the need for

additional funding for graduate medical education, as well as

preservation of financial support for Texas medical schools.

dcms directory2012-/2013

MEMBERS RECEIVE A FREE COPY and can purchase additional copies at a discounted rate.For more information on ordering, contact Mary Katherine at [email protected] or call 214.413.1456.

has arrived.

CIRCLE

For questions about DCMS Circle of Friends, contact Mary Katherine Allen, business development manager, at [email protected] or call 214.413.1456.

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august 2012 dallas medical journal

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