Monday, August 31, 2015

Texas Must Fix Its Mental Health Hospital System

By David Lakey
Former Commissioner, Texas Department of State Health Services
Associate Vice Chancellor, Population Health, UT System

This piece originally appeared in TribTalk, a publication of The Texas Tribune.

Texas’ mental health hospital system was designed and built a century ago and is ill suited to meet the needs of our state. Although these hospitals play an essential role in the mental health delivery system, many of them are functionally obsolete.

That’s why the Texas Legislature next session must make restructuring and replacing the state’s outdated mental health hospital structure a top priority.

The system was developed when Texas and health care were significantly different, a time when Texas was very rural and good treatment options for mental illness weren’t available. Large campuses of 60 to 90 acres, often in rural areas of the state, were built to house 3,000 patients each, and they included farms, baseball parks and cemeteries. Most patients sent to these facilities weren’t expected to recover.

Today, there’s hope for recovery. Hospitalizations for civil commitments are shorter, with the goal of returning people back to their communities, families and jobs. The large facilities now house just over 300 people each. Increasingly, those who require inpatient treatment are sicker, more difficult to treat and more likely to be admitted following a crime.

Unfortunately, our state mental health hospital system never adjusted to these changes. Buildings are old — most were built between the 1930s and 1970s. Many are abandoned, decaying and, frankly, a safety hazard. Buildings used for clinical care are in reasonable condition but poorly designed for modern care, with convoluted hallways with poor visibility from nursing stations. Higher-acuity patients require more caregivers, further crowding already limited common spaces.

And instead of single- or double-occupancy rooms, up to six patients may sleep in a single room. Imagine the challenge a patient with paranoid schizophrenia faces sleeping in a room with five strangers and only being able to retreat to an overcrowded common room. I believe these factors lead to the patient-on-patient and staff violence that’s too often seen in these facilities.

A recent Department of State Health Services study determined that five state hospitals — Rusk, Austin, San Antonio, Terrell and North Texas at Wichita Falls — were beyond repair and should be replaced. Furthermore, the buildings and facilities at the Big Spring, Kerrville and North Texas at Vernon state hospitals, as well as the Rio Grande State Center, El Paso Psychiatric Center and Waco Center for Youth, should be repaired and renovated, and the unused, decaying buildings on these campuses should be torn down, the report said.

The mental health hospital system also lacks the capacity to meet today’s needs, and the demand will only increase as Texas’ population grows. The state needs an estimated 570 additional inpatient beds today and about 600 more beds by 2024.

Replacing and repairing these hospitals will not be cheap. Replacing the large hospitals is estimated to cost about $180 million each, so replacing five hospitals, repairing the remaining hospitals and adding capacity will have a price tag close to $2 billion.

So how can Texas best address this urgent but expensive public policy issue?

Next session, the Legislature should fund the replacement of two hospitals. Solving the problem in one session is not realistic, but replacing two hospitals is. The likely candidates would be the Rusk, Terrell or San Antonio state hospitals.

Replacing and building new hospital capacity will take time, but we need additional capacity now. The state should buy currently unused inpatient capacity from hospitals across Texas. This capacity can be purchased in more urban communities, where most of the patients reside, allowing them to be cared for closer to their families and support structures. Our rural facilities are appropriate for long-term and forensic commitments, but allowing other patients to receive their care closer to their communities would facilitate recovery.

As Texas repairs and restructures its mental health inpatient system, stronger partnerships between our academic medical centers should also be fostered. And there are already good models to follow. The Harris County Psychiatric Center is managed by the University of Texas Health Science Center at Houston and provides learning and training opportunities for our next generation of mental health workers. In 2013, the UT Health Science Center at Tyler partnered with the state to convert a 30-bed ward to care for mental health patients. These partnerships work, bringing in updated technology and additional primary care tools and resources to improve overall care.

Finally, Texas must continue to improve the availability and quality of outpatient community services, which are effective and relieve the pressure on our state mental health hospitals. Without these services, more severely mentally ill patients end up in our jails, emergency rooms and hospitals.

By working together, elected officials, state agencies and higher education institutions can develop a 21st century behavioral health system for Texas that will be a model for the rest of the nation.

David Lakey, MD, is associate vice chancellor for population health at the UT System.

Friday, August 28, 2015

States Looking For More Effective Ways To Encourage Vaccinations

By Michelle Andrews
Kaiser Health News

Content provided by Kaiser Health News

When kids start school this fall, it’s a sure bet that some won’t have had their recommended vaccines because their parents have claimed exemptions from school requirements for medical, religious or philosophical reasons. Following the much publicized outbreak of measles that started in Disneyland in California in December, these exemptions have drawn increased scrutiny.

That outbreak, which eventually infected 147 people in seven states, was a wake-up call for many parents, who may not have realized how contagious or serious the disease can be, and for states as well, say public health officials.

“States are beginning to realize that they have effective measures to combat these outbreaks, and philosophical exemptions are eroding these protections and resulting in significant costs to states,” says Dr. Carrie Byington, professor of pediatrics at the University of Utah and chairwoman of the American Academy of Pediatrics Committee on Infectious Diseases.

In addition, research shows that eliminating vaccine exemptions or making them harder to get can improve vaccination rates and reduce disease outbreaks.

California and Vermont passed laws this year eliminating exemptions in 2016 for philosophical reasons; California’s law eliminates religious exemptions as well.

The federal Centers for Disease Control and Prevention provides suggested vaccination schedules for children and adults, but there’s no federal requirement that parents vaccinate their children. All states, however, have laws or policies requiring that children be up-to-date on recommended vaccines in order to attend school or day care. Unvaccinated children can generally attend only if their parents have obtained a vaccination exemption approved by the states.

Every state allows medical exemptions for children whose immune systems are compromised because of congenital problems or cancer treatment, for example. Nearly all states allow exemptions from vaccinations because of religious beliefs; excluding California and Vermont, 18 permit exemptions because of parents’ personal or philosophical convictions, according to the National Conference of State Legislatures.

Just three states–West Virginia, Mississippi and now, California–allow vaccine exemptions only for medical reasons.

In recent years, exemption rates for children have soared, but they vary. On the low end, New Mexico’s rate was less than half a percent in 2012, while the top state rate was Oregon’s at 6.5 percent, according to a study this month in the journal Health Affairs.

Local rates may be much higher, though. There are pockets in California and Colorado, for example, where the exemption rates top 30 percent, says L.J Tan, chief strategy officer at the Immunization Action Coalition, an advocacy group that works to increase immunization rates.

But since in most places the percentage of children getting the recommended vaccines tops 90 percent for most diseases, many parents have never seen someone with measles, for example, or whooping cough and may not understand their dangers.

“In the absence of disease the alleged risks of the vaccine become easier to sell,” says Tan.

Those risks are real, says Barbara Loe Fisher, co-founder and president of the National Vaccine Information Center, a group that advocates that people be able to decline mandatory vaccines based on their philosophical or personal beliefs. Fisher testified before the California State Assembly against the new law, which takes effect next July.

“Some people are more susceptible than others to injury or death from vaccines,” Fisher says. “But it’s not clear who is at higher risk.”

For the vast majority of people, however, vaccines are very safe, and studies have failed to show a link to autism, a common concern of parents who don’t vaccinate their kids.  “The risk of getting the disease is higher than the risk of getting a vaccine,” says Dr. Mark H. Sawyer, a pediatric infectious disease specialist at the University of California, San Diego.

The Health Affairs study analyzed the different elements of state rules to tease out the extent to which they affected vaccine exemptions. It found, for example, that policies that required the state health department to approve nonmedical exemptions or permitted exemptions only for specific vaccines rather than all vaccines had a significant effect on reducing vaccine exemptions. So too did laws that imposed civil or criminal punishments such as expulsion from school (for the child) or criminal negligence charges (for parents) for not complying with vaccination rules.

The threat of penalties alone may be enough to deter parents from refusing vaccinations, says study co-author W. David Bradford, a professor of public policy at the University of Georgia.

The more restrictive policies were reflected in lower rates of whooping cough. States with the most effective exemption policies had an average incidence of 7.3 pertussis cases per 100,000 people from 2002 to 2012, while states with the least effective policies had an incident rate more than twice as high at 16.06 cases, the study reported.

More broadly, the study shows that there are tools that work. “There is room for lots of states to improve their policies in ways that encourage people to get their kids vaccinated,” says Bradford. “I take that as encouraging.”

Thursday, August 27, 2015

TMA Presents “Cutting Edge: A History of Surgery”

When Texas gained its independence in 1836, surgery was a medical treatment of last resort, always painful and often fatal. Now the average American can expect to undergo at least seven surgeries in a lifetime. The evolution of surgery from the earliest civilizations to modern day advances is on display in the Texas Medical Association’s (TMA’s) History of Medicine Gallery.

Anesthetic masks used to administer ether or chloroform to patients, c. 1900s.
TMA’s “Cutting Edge: A History of Surgery” presented by the association's History of Medicine Committee, honors the centennial of the Texas Surgical Society in 2015 by exploring improvements that allowed surgery to become essential to medicine. The exhibit features stories of the primitive and precarious nature of early Texas surgery from the time of the Spanish explorers to the Alamo to advances in anesthesia and safer surgery around the turn of century. “Uneven quality of surgical care leads to formation of Texas Surgical Society in 1915,” said Texas Surgical Society Archivist Mellick Sykes, MD. Meanwhile “Texas’ surgical reputation has skyrocketed from backwater to beacon” from the early years of the Texas republic to the present, Dr. Sykes said.

Steam atomizer used to sterilize incisions or wounds, c. 1890
Artifacts on display in the exhibit display like the steam atomizer, a device used to sterilize surgical incisions or wounds, illustrate both the inventiveness and limitations of the early Texas surgeons. Also on display is the Bohler Frame, an early 20th century metal device used to keep fractured bones stable during the post-surgery healing process. Cutting Edge: A History of Surgery also recognizes the role of pioneering Texas surgeons who brought international acclaim to Texas with their innovations and skill in transplant surgery.

Bohler Frame used in surgery and treatment to keep fractured bones in alignment, c. early 20th century
“The TMA commitment to the history of medicine — the successes, failures, and struggles of our doctors and our institutions — is deep and longstanding. The TMA archives preserve this story,” Dr. Sykes said. 

Visiting Austin?
“Cutting Edge — A History of Surgery” is in the History of Medicine Gallery on the ground floor of the TMA building at 401 W. 15th St. in Austin through March 2016. It is free and open to the public 9 am-5 pm Monday through Friday. For more information or to arrange a tour, call (512) 370-1552 or (800) 880-1300, ext. 1552, or email knowledge@texmed.org.

Tuesday, August 25, 2015

Pregnant Women May Be Getting Unnecessary Ultrasounds

By Kenneth Higby, MD 
Center for Maternal-Fetal Care, an affiliate of MEDNAX, San Antonio 
Consultant, TMA Committee on Maternal and Perinatal Health

Pregnant women are getting more ultrasounds today compared with years past, as The Wall Street Journal reported recently. Last year, American women received an average of 5.2 fetal ultrasounds prior to delivery, up 92 percent from 2004. For most of these women, that’s more than double the number of recommended ultrasounds. 

Two ultrasounds are sufficient for women with low-risk pregnancies: an early one to confirm the gestational age of the fetus — and possibly another scan called a “nuchal translucency evaluation” that assesses the fetus’ risk for certain genetic disorders — and a second ultrasound in the middle trimester to evaluate fetal anatomy and determine gender.

Additional scans in a low-risk patient are unnecessary, though higher-risk pregnancy situations might require more scans.

No objective evidence indicates that obstetrical ultrasound is dangerous to the fetus, but energy is dissipated from the ultrasound beams. Nearly every modern ultrasound machine has energy parameters located on its main screen. These numbers clearly increase when other applications are used, such as pulsed Doppler or color Doppler (techniques used to detect blood flow and fetal heartbeat). When used properly, these should be considered safe procedures for patients. 

It’s important to note that several credentialing organizations for obstetrical ultrasound ensure professionals meet criteria for performing adequate fetal evaluation, in addition to providing guidelines and protocols for patient safety. In the future, medical practices may be required to have certification to perform an obstetrical ultrasound. Such credentialing is important for consistency, performance standards, and patient safety.

TMA recognizes that ultrasound is an important tool for monitoring and assessing the health of the fetus and mother. Earlier this summer, TMA amended its policy to recommend increasing patient and physician awareness on the latest information from the U.S. Food and Drug Administration about the nonmedical use of fetal ultrasound imaging.

Monday, August 24, 2015

Announcing the Best in 2014 Texas Health Reporting: TMA’s Anson Jones, MD Awards

Ebola, West Nile virus, mental health care, experimental treatments, workers’ safety, cancer, child sexual abuse, and the West, Texas explosion ― these are just some of the topics covered by Texas’ leading health and medical journalists in 2014. Whether shocking, bittersweet, upsetting, or uplifting, each story drew in readers and left them more informed, aware, or motivated: They stood out. That is part of the reason the judges in TMA’s annual media competition chose to recognize them as this year’s TMA’s Anson Jones, MD, Award winners.

Since 1957, the Texas Medical Association has been recognizing excellence in health journalism annually through its Anson Jones, MD, Awards. Print, broadcast, and online journalists are recognized in 10 categories, including the Texas Health Journalist of the Year. A physician journalist also is recognized. The award is named after pioneer physician, statesman, and prolific writer Anson Jones, MD, perhaps best known as the last president of the Republic of Texas.

Members of TMA’s Council on Health Promotion judge the competition, along with respected journalists who hail from the news publishing and broadcast fields. Stories are judged on accuracy, significance, quality, public interest, and impact. This year’s awards were presented by TMA physicians at local ceremonies during the spring and summer months.

2014 Winners of TMA’s Anson Jones, MD, Awards 
(Judges awarded honorable mentions in several categories. See the entire list of honorees.):

Small-Market TV
Karin McCay, Azian Bermea, and Kasie Davis 
KCBD-TV, Lubbock 

In-Depth TV
Janet St. James
WFAA-TV, Dallas

Large-Circulation Print
Anna Kuchment
The Dallas Morning News

Small-Circulation Print
Kevin King 
Vital Signs

In-Depth Print
Emily DePrang
The Texas Observer

Radio
Lauren Silverman
KERA FM, Dallas

In-Depth Radio
Lauren Silverman
KERA FM, Dallas

Online/Mixed Media
Jay Root and The Texas Tribune staff
The Texas Tribune

Texas Health Journalist of the Year
The Dallas Morning News

Thursday, August 20, 2015

Medical Coding and Billing Overhaul Could Disrupt Patient Care, Physicians Say

TMA survey shows too few doctors prepared for ICD-10 transition; some may retire, borrow to keep practice afloat


If physicians’ predictions are accurate, patients might need to brace for disruptions in doctor visits this fall. 

Most Texas physicians say they are not confident their practices are prepared to use the new medical coding and billing system by Oct. 1, according to a new report. That is the deadline the federal government imposed for all physicians to start using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, or ICD-10, to document all patient diagnoses and treatment. The doctors’ concerns were revealed in a new Texas Medical Association (TMA) survey regarding practice readiness for the new system. Some physicians might even retire early as a result of the anticipated disruption stemming from the overhaul.

Nearly two-thirds (65 percent) of all physicians responding have little or no confidence that their practice is prepared to transition to ICD-10 by the deadline, even though the new coding system is supposed to enable doctors’ offices to collect and report more detailed patient data.

“It’s horrible,” said TMA President Tom Garcia, MD. “The United States is the only country that couples the ICD coding with payment. The implications are that the doctor-patient relationship is going to be stressed.”

Only 10 percent of physicians are “very confident” their practice is prepared to transition. More than half of the solo physicians are “not at all confident” their practice is ready for the big switch. That could spell disruptions in patient care considering solo doctors comprise close to half of the physicians in the survey (42 percent).

Physicians fear the massive switch to the new coding system will disrupt patient care, and delay payment. In fact, 83 percent of the doctors anticipate delayed or denied claims because of the transition, regardless of specialty. More than one-third of the physicians expect disruption so bad they will have to draw from personal funds to keep their practice open (36 percent), and almost one-third (30 percent) might retire early over anticipated cash-flow problems.

The federal government mandated the upgrade from the current coding system, ICD-9, which has 13,500 diagnosis and procedure codes, to ICD-10, which has 69,000 codes. 


Tuesday, August 18, 2015

HPV Is an Epidemic That We Can Prevent

By Lois M. Ramondetta, MD
Houston Gynecological Oncologist
Chair, TMA Committee on Cancer
Be Wise – Immunize Physician Advisory Panel

This article was first published in the Houston Chronicle on Aug. 17, 2015, and is reprinted here with permission from the author.

I have devoted my entire professional life to protecting the health of my patients. But when I see patients diagnosed with cervical cancer, especially in its later stages, it's heartbreaking. And far too often, it's a losing battle.

When it comes to other forms of cancer, we're all aware the risks can be reduced through simple lifestyle behaviors, such as quitting smoking, eating healthier and increased exercise. It's a no-brainer for a parent to apply sunscreen to their child to prevent skin cancer.

It should be equally as obvious to get our kids vaccinated against the human papillomavirus (HPV). Doing so can protect against seven types of cancer associated with the virus.

The time has come for Texas, and the rest of the country, to ramp up efforts to get our children vaccinated and protect the health of future generations. I don't want your children to become my patients.

HPV exposure is part of being human. Almost every sexually active person will acquire HPV as some point in their lives.

Each year in the U.S., HPV infection leads to 45,000 cancer cases and nearly 10,000 deaths.

Two virus strains – HPV 16 and 18 – are blamed for almost all cervical cancers, more than 90 percent of anal cancers and a large share of genital cancers. They may also cause cancers in the back of the throat, most commonly at the base of the tongue and in the tonsils, called oropharyngeal cancers.

More than 70 percent of oropharyngeal cancers are HPV related. These cancers disproportionately affect men, and will soon be more common than cervical cancer.

Late last year, the Food and Drug Administration (FDA) approved the latest vaccine, Gardasil 9. According to the FDA, the complete three-dose vaccine has the potential to prevent the vast majority of HPV-related cancers.

The problem is, very few of us are getting our kids vaccinated.

Just this week the Centers for Disease Control and Prevention (CDC) published the latest vaccination rates. Less than 40 percent of girls and slightly more than 20 percent of boys receive all three doses.

Communication is our major obstacle to increasing these rates. We need more open communication between pediatricians and family practitioners and the families they treat. Because HPV is a sexually transmitted infection, some doctors and parents avoid discussions as they can be an awkward subject to address.

However, that's not necessarily true.

A recent study from the CDC shows physicians overestimate parents' hesitancy about the vaccine and, as a result, become more hesitant themselves to broach the subject. Such reluctance results in missed opportunities to vaccinate kids at the recommended ages of 11 and 12.

Some parents fear saying "yes" to the vaccine may encourage their children to say "yes" to sex at an early age. However, many studies have shown that adolescent girls who are vaccinated are no more likely to show signs of sexual activity than those who aren't vaccinated, including a 2012 study in the journal Pediatrics and a 2015 study in JAMA Internal Medicine.

MD Anderson clinicians and researchers are launching increased efforts to combat HPV-related cancers. We want to increase HPV vaccination rates in Texas and across the nation, improve early screening, and rapidly develop new and better therapies.

We have a vaccine and if we use it, we believe the cancer cases linked to HPV could almost be entirely eliminated. HPV-linked cancers could become as rare as smallpox or diphtheria.

If we want to make a significant impact, we need to face facts: HPV is an epidemic – one that in many cases is preventable.

Dr. Ramondetta is a professor of Gynecologic Oncology & Reproductive Medicine at the University of Texas M.D. Anderson Cancer Center and chief of the Division of Gynecologic Oncology for Lyndon B. Johnson General Hospital.

Wednesday, August 12, 2015

Learning the Conscience of Medicine: Medical Students Explore Women’s Health Issues


By Aditi Raye Allen
Third-Year Medical Student
The University of Texas Southwestern Medical School

The first two years of medical school are a blur of PowerPoints and multiple choice questions. If it weren’t somehow done every year at hundreds of medical schools — and if I hadn’t experienced it myself — I’d say the task of crunching through that amount of information was impossible.

Between the seemingly unending streams of science, students occasionally get a glimpse of the conscience of medicine: volunteering at a clinic, patient interview training, or an exploration of clinical ethics. One set of opportunities at my medical school is “enrichment electives,” student-driven classes on a variety of topics. These give students an opportunity to explore areas that matter to them by inviting faculty to speak on the subjects.

Last year, fellow classmates and I created a course to focus entirely on the subject of women’s health. The primary objective is to prepare physicians-in-training to approach medical issues that are for the most part unique to women. These include domestic violence, eating disorders, genital mutilation, unintended pregnancy, transgender health, abortion, and menopause, among others. We chose subjects that we felt were not taught in detail in the already-packed medical school curriculum.

There is no shortage of subject matter: Women face a unique set of health challenges in today’s society. In Texas, 54 percent of pregnancies are unintended, and since 2011, funding cuts to safety-net health care services have led to fewer women receiving screenings and contraception. Rising costs of child care, combined with a gender wage gap, mean many women must often ignore their own health needs in favor of maintaining a family.

Many of our course topics speak to these challenges, and that was intentional. Social and medical issues generally go hand in hand, and women’s health is a fantastic example. The traditional arc of medicine tends to minimize women’s health issues, and our program counters that trend. We designed it to reinforce preclinical students’ knowledge of women’s health concerns, from both a scientific and a social perspective. We want to help create a generation of doctors that never forgets to ask: “What form of contraception are you using?” and “At home, do you feel safe?” and “How do you cope with stress?”

During the progression of our 13-week elective, a faculty member or other professional in the field presents the clinical and operational aspects of one health topic during a lunch-hour lecture on Wednesday. We were thrilled to regularly host more than 50 medical students for our lectures, and to later receive extremely positive feedback on the course. We had 36 students officially complete the program (attendance at 10 of the 13 lectures), and we have both a team and a plan to run the elective again this coming fall semester.

Although medical school can feel like living in a bubble, we bear the same responsibility to our future patients as any other care provider: Understand your patient. There is a lot to understand that is unique and critical to women’s health, and our curriculum connects the preclinical with the clinical years in this area. It is my hope that with more similar courses and discussions, we can build an educational experience that truly connects the science with the conscience sooner and sooner in medical education.

Tuesday, August 11, 2015

Texas Ninth-Worst State for Child Well-Being

When it comes to well-being, Texas is failing its children. The latest national KIDS COUNT® Data Book from the Annie E. Casey Foundation ranks Texas ninth worst in the United States in terms of overall child well-being. The dismal score is due in part to the state’s high percentage ― and thus low ranking ― of children without health insurance (49th), children living in high-poverty neighborhoods (46th), and teen birth rates (46th).

The results aren’t all doom and gloom, though. Texas rose two positions from last year and ranks higher than most states for eighth-grade math proficiency (15th) and at least one parent with full-time employment (17th). Still, the number of children who are not proficient in math and have no parent with a full-time job is “unacceptably high,” the foundation reports.

“The two most important things we could do to raise our child well-being rankings are to provide more children with health insurance and reduce the teen birth rate,” said Center for Public Policy Priorities Research Associate Jennifer Lee in a news release.

The release also points out the disconcertingly high number of Texas Latino and African-American children living in high-poverty neighborhoods, where their health and safety are at risk and their educational opportunities are stagnated.

“All children ― regardless of race or ethnicity ― should have the chance to compete and succeed in life,” said Ms. Lee. “It’s time to adopt comprehensive policy solutions ― like closing the health care coverage gap ― that benefit children of all backgrounds and prepare them to be healthy, well-educated, and financially secure.”

Read the full report.

Monday, August 10, 2015

College Students: Put Required Vaccination on To-Do List

As young adults make final preparations for college, the physicians of the Texas Medical Association (TMA) remind college-bound students to put an important and required vaccination on their to-do list. Texas law requires almost all new and transfer students to be vaccinated against bacterial meningitis at least 10 days before the semester begins or to show proof of having received the vaccination within the past five years.

“College students are targeted for prevention of the devastating illness of meningococcal infection because they are among those most at risk,” said Donald K. Murphey, MD, an infectious disease specialist at Dell Children's Medical Center in Austin and a consultant to TMA’s Child and Adolescent Health Committee.

Meningococcal disease affects people who live in close quarters like dormitories, such as college students and military recruits. Meningococcal disease is a potentially devastating bacterial infection that spreads through coughing and sneezing, sharing drinks or utensils, and kissing or other person-to-person contact. Preschool children also are at high risk, doctors note.

“When this disease arises, it is often very severe,” said Dr. Murphey, “taking normal, healthy young adults and in a matter of hours putting them at risk of death.” After its initial flu-like symptoms, meningococcal disease kills about 10 percent of sufferers even if they have begun to receive treatment ― often within hours of the onset of symptoms. Dozens of patients contracted bacterial meningitis last year, with adolescents and young adults being most susceptible.

Survivors can suffer severe, lifelong complications. Dr. Murphey said those can include loss of limbs, deafness, strokes, and organ failure.

The good news is that vaccination works to prevent meningococcal disease. Doctors believe that as many as four out of five of the adolescents and young adults who contract the infection could have avoided it, had they been vaccinated. The meningococcal vaccine protects against four of the five common strains of the disease.

If a college student’s vaccinations are up to date, most likely the student had a meningococcal vaccination or booster, which is recommended for adolescents at age 11 and 12. Protection from the vaccine lasts for several years but typically not through the college years, so a second vaccination is needed at age 16 to boost immunity. Students should check with their doctor to see if they are up to date. Free and low-cost vaccinations may be available for teens and young adults who don’t have health insurance.

TMA has published a fact sheet about the importance of meningococcal vaccination, in English and Spanish.

Tuesday, August 4, 2015

Texas Medicine Scores for Patients and Physicians in 2015 Legislature


A lineup that swung for the fences — combined with a solid defense and some outstanding pitching — led Texas medicine to an outstanding season at the top of the standings in the 2015 Texas Legislature.

The Texas Medical Association team hit home runs on graduate medical education funding, Medicaid fraud reform, e-cigarette regulation, tax cuts, and red tape elimination. The pitching staff threw a perfect game, keeping all inappropriate and dangerous expansions of nonphysician practitioners’ scope of practice off of the base paths.

The team did experience a few letdowns, failing to score on Medicaid payment increases, and some public health improvements and insurance reforms. But the skippers vowed to enhance their squad’s off-season training and conditioning so medicine is even more prepared for the 2017 battles.

“We asked our state government to make it easier — not more difficult — for us to care for our patients,” said TMA Immediate Past President Austin King, MD. “And for the most part, that’s exactly what our lawmakers did.”

“Our team of physician volunteers and TMA staff gave it all they had to score important runs for patients and their physicians,” said TMA President Tom Garcia, MD. “We absolutely have to build a stronger TEXPAC to give us more firepower in the next season.”

The box score below highlights the health care hits, runs, and errors of the 84th Texas Legislature.


Home Runs


Graduate Medical Education
Graduate medical education (GME) funding gets a big boost in the 2016-17 state budget. Our goal is to have 1.1 entry-level residency positions for each graduating medical student. That would ensure enough slots for the Texas students who want to stay here and to recruit from other states. To meet that goal, we need to add almost 600 GME positions by 2022. Lawmakers appropriated enough money for the next two-year budget to keep the new positions they added in 2013 and to create up to 200 new slots. The legislature also passed Senate Bill 18 to create a permanent endowment of roughly $300 million to be used solely to help expand GME starting in fiscal year 2018. Thanks goes to Sen. Jane Nelson (R-Flower Mound), the Senate Finance Committee chair, for making this one of her priorities.

Medicaid Fraud Investigation Reforms
Senate Bill 207 by Sen. Juan “Chuy” Hinojosa (D-McAllen) responded to TMA’s call for due process improvements in overzealous Medicaid fraud investigations by the Office of Inspector General (OIG). Among other reforms, the bill clarifies that “fraud” does not include unintentional technical, clerical, or administrative errors, and it requires OIG to give physicians a detailed summary of its evidence relating to the allegation.

E-Cigarette Regulation
Senate Bill 97 by Senator Hinojosa was one of the first bills to reach the governor’s desk this session. The first-time regulation of e-cigarette sales in Texas applies many existing state rules on tobacco cigarettes to vapor products, foremost barring sales of e-cigarettes to minors. It also prohibits their use on public school campuses and at school functions.

Tax Relief
TMA led a collaboration of associations representing a total of 600,000 Texas professionals to win passage of House Bill 7 by Rep. Drew Darby (R-San Angelo) and Senator Nelson, which eliminates the $200 occupation tax physicians pay each year. The tax was imposed in 1993 as a “temporary measure” and has been on the books ever since.

Red Tape Cut
Physicians won’t need a state-controlled substance permit starting Sept. 1, 2016, because we passed Senate Bill 195 by Sen. Charles Schwertner, MD (R-Georgetown), and Rep. Myra Crownover (R-Denton). The bill also moves the Prescription Drug Monitoring Program from the Texas Department of Public Safety to the Texas State Board of Pharmacy, and allows physicians to delegate access to the database to any HIPAA-trained staff member.


Perfect Game


Scope of Practice
Not a single bill passed that would expand midlevel practitioners’ scope of practice beyond what is safely within their education, skills, or training. Grassroots physicians rallied with calls to legislators to keep almost every one of these bills bottled up in committee. Many lawmakers, Republican and Democratic, in the House and Senate, stood with medicine against these bills. TMA did support a smart scope-of-practice bill, which will allow emergency medical technicians to practice in hospitals under the direct supervision of an emergency room physician.


Extra Base Hits


Mental Health Funding
The 2016-17 state budget includes an $80 million increase in funding for outpatient mental health services, autism intervention services, early intervention and treatment for pregnant women with substance use disorders, substance abuse prevention initiatives, and mental health workforce training programs in underserved areas.

Health Insurance
To help practices identify and educate patients who may fall under the 90-day grace period for subsidized plans purchased through the Affordable Care Act (ACA) marketplace exchange, House Bill 1514 will require health plans to place the letters “QHP” (for “qualified health plan”) on their ID cards. The opportunity to remind patients of the importance of continuing to pay their premiums helps both the physician and the patient. Senate Bill 760 would enhance state regulation of network adequacy in Medicaid HMO plans.

Public Health
Under House Bill 2171, ImmTrac — the state’s vaccination registry — will store childhood vaccination records until the person turns age 26. Senate Bill 66 provides liability protections to schools, pharmacists, and physicians that encourage making unassigned epinephrine autoinjectors available on school campuses for use in emergency anaphylactic reactions.

Health Information Technology
House Bill 2641 gives important new liability protections for physicians using health information exchanges (HIEs), including any inappropriate disclosure of patient information by an HIE or another physician or provider.

State Agency Contracting
In light of recent contracting scandals involving the Texas Health and Human Services Commission, Senate Bill 20 will enhance reporting requirements and increase accountability in the contracting process to boost confidence in how state government is spending tax dollars.


Solid Singles


2016-17 State Budget
  • $50 million increase for women’s health
  • $20 million investment for infectious disease prevention and response
  • $11 million for tobacco cessation programs

Health Care Delivery
  • House Bill 1945 streamlines how patients can contract directly with primary care physicians for medical services.
  • Senate Bill 239 establishes a tuition loan repayment assistance program for mental health professionals.
  • House Bill 1624 requires health plans to display accurate directories and formulary lists on the Internet.
  • House Bill 1621 requires 30 days’ notice on adverse utilization determinations for medications and infusible drugs.
  • House Bill 751 requires pharmacists to notify physicians when they substitute a biological product prescribed to a patient.
  • Senate Bill 1753 spells out how hospital ID badges must show a health care worker’s professional credentials.
  • HB 3781 creates the Texas Health Improvement Network to study ways to reduce health care costs and increase quality and patient satisfaction.
  • HB 3433 clarifies the level of care designations for hospitals that provide neonatal intensive care services.

Public Health
  • Senate Bill 202 strengthens the Texas Department of State Health Services to focus on core public health priorities.
  • Senate Bill 200 requires a strategic plan for human papillomavirus-related cancers.

Medicaid
  • House Bill 3519 allows Medicaid to pay for some home telemonitoring services.
  • Senate Bill 200 enhances the accountability of Medicaid vendors.


Saves

Bad outcomes that TMA prevented:

  • TMA stopped several bills that would have eliminated balance billing for out-of-network services. In addition, Senate Bill 481, as filed, would have allowed patients to take to mediation any bill for out-of-network services from facility-based physicians, for any balance. TMA negotiated a $500 minimum balance for mediation.
  • Several bills would have mandated that physicians provide specific, state-produced information to patients or families of patients with certain diagnoses. In Senate Bill 791 (cytomegalovirus) and House Bill 3374 (Down syndrome), TMA negotiated the elimination of the mandate and of government practice of medicine.

Wild Pitches

Bills that became law with TMA’s reservations or concerns:

  • Senate Bill 339 allows the prescription of low-THC cannabis oils for certain intractable neurological conditions.
  • House Bill 3074 removes “to prevent suffering” from the reasons physicians might be able to restrict artificial food and hydration in end-of-life care.
  • House Bill 21 provided alternative treatments to terminally ill patients who did not qualify for Food and Drug Administration free trials.

Fly Outs

Despite support in at least one chamber of the legislature, and hard work by TMA, these measures did not pass:

  • Medicare-parity payment for primary care services in the 2016-17 state budget
  • House Bill 2474: Parents’ right-to-know bill on vaccine exemptions at school campuses
  • Senate Bill 1229: Banning health plans’ use of virtual credit cards to pay physicians
  • House Bill 80: Statewide ban on texting while driving
  • House Bill 65: Establishing pilot needle exchange programs 
  • House Bill 2541: Ensuring health plans cover certain treatments for patients with terminal illnesses

Ground Outs

These TMA-supported bills just didn’t seem to get enough traction in 2015:

  • House Bill 1433: To stop efforts to reduce the penalties on health plans for prompt pay violations
  • House Bill 2348: To require health plans and Medicaid to pay local physicians for after-hours telephone and telemedical consultations
  • House Bill 661: To make it easier for qualified physicians to obtain licensure across state lines


Caught Stealing

TMA stopped these bad bills from moving:

  • House Bill 2172 would have allowed physicians to prescribe over the phone without establishing a patient-physician relationship.
  • House Bill 3095 would have imposed complicated and unworkable changes to Durable Power of Attorney forms.
  • House Bill 136 would have removed the statutory requirement that Texas Medical Liability Trust insurance is for TMA members only.


Thrown Out at the Plate


Mental Health
The day after Texas lawmakers went home, Gov. Greg Abbott vetoed a pair of TMA-supported mental health bills. Senate Bill 359 would have allowed a four-hour emergency department hold for a mentally ill patient the physician believes is a danger to self or others. “TMA is extremely disappointed in Governor Abbott for vetoing a bill that would have saved lives, provided short-term help for people with mental illness, and actually would have kept some of them out of forced imprisonment,” Dr. Garcia told the media. The governor vetoed House Bill 225 as well, which would have protected from prosecution people who seek emergency care for someone suffering a drug overdose. It also would have allowed first responders to administer an opioid antagonist to save someone from a potentially fatal overdose. Senate Bill 1462, which the governor did sign, also contained the opioid antagonist language.

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