Texas Family Physician, Summer 2015 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 66 NO. 3 2015

INSIDE THE COVERAGE GAP Texas’ Refusal To Expand Medicaid Leaves 1.5 Million Poor WorkingAge Adults Without Access To Affordable Health Coverage

PLUS: Women’s Health And Public Health Coalitions Tally Wins From The 84th Texas Legislature ICD-10: The Final Countdown Preview Of TAFP’s Annual Session And Primary Care Summit

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STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. CMS can help you prepare. Visit www.cms.gov/ICD10 to find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

•

Train Your Staff—Find options and resources to help your staff get ready for the transition

•

Update Your Processes—Review your policies, procedures, forms, and templates

•

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

•

Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

INSIDE

TEXAS FAMILY PHYSICIAN VOL. 66 NO. 3 2015

Inside the coverage gap

Texas is the only state left with at least 20 percent of its population uninsured, yet state leaders continue to refuse to expand Medicaid. TAFP joined forces with the Texas Association of Community Health Centers to publish two reports exploring the ramifications of that refusal. In this issue of TFP, we present them to you.

How will Texas’ Affordable Care Act implementation decisions affect the population? A closer look

By Sara Rosenbaum, JD; Sara Rothenberg; and Sara Ely

Uncompensated care and the coverage gap: The role of the 1115 Transformation Waiver in Texas

By the Texas Association of Community Health Centers and TAFP

Public health report from the Lege

The 84th Texas Legislature addressed priorities of the Texas Public Health Coalition including tobacco and electronic cigarette use. By Joey Berlin

Wins for women’s health at the Capitol

The Texas Women’s Healthcare Coalition fought all session and came out on top, winning funds for preventive health care.

By Anna Chatillon

6 FROM YOUR PRESIDENT The SGR repeal will change the face of health care. It’s time for family docs to embrace change and lead the way. 8 MEMBER NEWS In memoriam: Tamra Kay Deuser, MD | Meet the candidates for TAFP’s new physician director and at-large directors. | Proposed TAFP bylaws amendments | TAFP launches new video series. 10 ANNUAL SESSION & PRIMARY CARE SUMMIT PREVIEW Everything you need to know to have a great meeting in The Woodlands this November 27 PRACTICE MANAGEMENT Bradley Reiner asks if your practice is ready for ICD-10. 30 TAFP PERSPECTIVE What is “harm” when managing pain at the end of life?

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PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 66 NO. 3 2015

The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.

The brave new world of the SGR repeal By Dale Ragle, MD TAFP President

OFFICERS president

Dale Ragle, MD

president-elect vice president treasurer

Ajay Gupta, MD

Janet Hurley, MD

Tricia Elliott, MD

immediate past president

Clare Hawkins, MD, MSc

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editor

Samantha White

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell CONTRIBUTING EDITORS Joey Berlin Anna Chatillon Vincent Mandola Bradley Reiner Sara Rosenbaum, JD Sara Rothenberg Sara Ely

SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. TEXAS FAMILY PHYSICIAN is printed by AIM Printing and Marketing, Austin, Texas. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2015 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN SUMMER 2015

ize the way Medicare, and ultimately comon april 16, 2015, President Obama signed mercial payers, will reimburse physicians. the Medicare Access and CHIP ReauthorizaMACRA creates two new payment tion Act of 2015, which phases out Medicare’s models for physicians, both flawed sustainable growth of which will incentivize rate payment formula over quality, cost containment, the next 10 years. The soand value. One creates a called “doc fix” enjoyed We must continue pay-for-performance model, bipartisan and bicameral in which fee schedules and support in Congress, a rare to push for bonus payments will be tied phenomenon these days, payment models to a physician’s performance as well as support from that reward on predetermined quality most major medical orgameasures. A physician may nizations, including AAFP those of us who also participate in alternaand the American Medideliver quality, tive payment models, which cal Association. In spite of evidence-based involve various levels of broad support, the bill took more than a year of tweakcare and advocate risk contracting. These may include capitation, bundled ing and survived innumerfor rewarding payments, and shared savable negotiations between quality and cost ings arrangements. both political parties and Some of this may seem the White House, a testaeffectiveness. like history repeating itself. ment to the adage that “the Repeal of the Capitation and bundled devil is in the details.” SGR must not payments were tried in the The SGR formula tied 80s and early 90s and they Medicare expenditures to simply be a costfailed, largely due to flawed the gross domestic prodsaving measure. payment formulas and poor uct. Since demand and It must also be a quality measures. The hope utilization of health care services do not rise and fall quality-enhancing is, with advancement of better technology, better directly with the ebbs and measure. data, and better outcome flows of the general econmeasures, the new payomy, the SGR often threatment models will work. This ened to cut physician fees remains to be seen. year after year. Perennially, Most of us will agree Congress passed special that the old payment system needed to be legislation to delay the fee cuts, often only improved. The SGR repeal, while doing away finding they have to repeat the action in the with the old system, does not clearly define following year. the new one. The idea is to progress toward MACRA did a lot more than just repeal value-based payment systems. This is a step the SGR. It put into action a series of new in the right direction, but it is really only a quality measures following the lead of the small first step. We must continue to push Affordable Care Act in rewarding quality care for payment models that reward those of us over quantity. The new law will revolution-

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https://jobshrportal.cpa.texas.gov/ENG/ Hepatitis C, and more are unaware of their infection. careerportal/default.cfm? who deliver quality, evidence-based care and advocate for rewarding quality and cost effectiveness. Repeal of the SGR must not simply be a cost-saving measure. It must also be a quality-enhancing measure. The new payment systems will not occur suddenly, but will be phased in over the next 10 years. This was done to prevent a 21 percent cut in the Medicare fee schedule. You have a little time to respond to the changes, but one thing is certain: you must begin to plan your strategy. The SGR repeal will indeed usher in a brave new world. As family physicians, now is the time to seize the moment and show policy makers we are up to the task of delivering better outcomes at a reasonable cost. You must stay involved and educate yourself about the changing landscape. There are links on the home page of www.tafp.org to help you get started. For those of you who wish to remain independent, I would encourage you to read the article in the spring 2015 issue of Texas Family Physician, “Back to the future with Direct Primary Care,” which you can find at www.tafp.org/news/tfp/spring-2015/ cover. There are other links on our home page to help you with the changes to come. I encourage you to explore them and talk with others in your community. Together we can make these changes work for our patients and for us.

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In memoriam Tamra Kay Deuser, MD

October 3, 1961 – July 7, 2015 Donations can be made to Christian Community Action at http://ccahelps.org.

TEXAS FAMILY PHYSICIAN SUMMER 2015

TAFP leader Tamra Deuser, MD, passed away quietly at the age of 53 on July 7, 2015, at her home in Flower Mound, Texas. A celebration of her life was held in Lewisville, Texas on Monday, July 13. Deuser was born in Indianapolis, grew up in Austin, and received her bachelor’s degree from the University of Texas at Austin. She left a successful career in consumer products manufacturing to become a physician, received her medical degree from the University of Tennessee Health Science Center College of Medicine, and completed her residency with the San Jacinto Methodist Hospital Family Medicine Residency Program. She began practicing in the Flower Mound area in 2002. Active in TAFP since joining in 2002, Deuser most recently served as the Academy’s parliamentarian. Having gone through cancer treatment herself, she knew the importance of palliative care and wanted to share her experiences from the patient viewpoint. She joined Clare Hawkins, MD, at TAFP’s C. Frank Webber Lectureship this year in a discussion on palliative care. She previously received both the TAFP and AAFP Public Health Awards for her dedication to caring for all patients. Deuser also previously represented the Dallas chapter on the TAFP Board for 10 years, was a member of the Commission on Public Health, Clinical Affairs, and Research, and served as chair of the Commission on Health Care Services and Managed Care. After being diagnosed with metastatic breast cancer, she continued her life as normal, traveling to Europe, Mexico, Colorado, Washington, and Oregon to spend time with family and friends. Deuser even continued treating patients until April 2014, proving her commitment to the specialty of family medicine and providing her community of patients with the treatment and education necessary. Deuser is survived by her daughter, Krista; parents, Larry and Carole; sisters, Sheryl Clark and Karen Mechura; and grandmother, Louise Reinken.

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G U CI N W. . . D O INTR ALL N E ’S TA F P

2015 annual session & Primary Care Summit

MEMBER NEWS

Celebrate the specialty of family medicine at TAFP’s 2015 Annual Session and Primary Care Summit this November. Join your colleagues from across Texas to learn, network, and explore the latest in techniques, products, and services. Here’s a quick look at what’s in store for this year’s conference. 3 must-see CME topics at ASPCS, according to Jessica Miley, TAFP’s CME expert • Five Things I Wish I Knew Last Year Louis Kuritzky, MD • Cancer Survivorship Lewis Foxhall, MD

Nov. 13 - 15, 2015

• Appropriate COPD Management Clare Hawkins, MD

TAFP mobile app ASPCS is even easier to navigate now with the help of TAFP’s mobile app. In it you’ll find the full schedule, all CME slides and handouts, conference maps, meeting materials, and more. Download it now by searching TAFP in your app store or going to https://events.crowdcompass.com/tafp.

Annual Session business: Nov. 11 - 14 Preconference workshops: Nov. 11 - 12

Where? The Woodlands Waterway Marriott

The Woodlands Waterway Marriott

Includes full-service spa, fitness center, Starbucks, and Ristorante Tuscany Italian food.

Houston, Texas

1601 Lake Robbins Drive | The Woodlands, Texas 77380

Go to www.tafp.org for more information and to register.

PROPOSED AMENDMENTS TO TAFP BYLAWS The proposed amendments to the TAFP Bylaws are in accordance with the TAFP Bylaws, Chapter XVII, Amendment of Bylaws. An affirmative vote of at least two-thirds of the members present and voting at the annual business meeting shall constitute adoption. If you would like a complete copy of the TAFP Bylaws, contact Kathy McCarthy at (512) 3298666, ext. 114. The Bylaws Committee and the Board of Directors recommend adoption of these amendments.

CHAPTER VIII. Component Chapters SECTION 3. Petitions for a component chapter shall be accompanied by the proposed bylaws for the chapter. No charter shall be issued until bylaws are approved by the Board of Directors of the Academy. The members of the component chapter shall be those to whom

TEXAS FAMILY PHYSICIAN SUMMER 2015

a charter is issued and such additional people who are elected to membership thereafter. A member may join or transfer his or her membership to another component chapter that offers a closer community of interest. Chapter IX. Dues and Admission Fees SECTION 1. Dues of the TAFP will be set and can be changed by a two thirds (2/3) vote of by the Board of Directors with the approval of the members present and voting at the annual business meeting. The dues may be changed by a two thirds (2/3) vote of the Board of Directors and a majority vote of the membership present and voting at the next annual business meeting. The Board of Directors is empowered to levy an admission fee that shall accompany any new applications for membership.

Chapter XII. Board of Directors SUB-CHAPTER I. Policy and Procedure SECTION 2. The student, resident and special constituency directors shall be nominated from among the student, resident and special constituency membership of the Academy, respectively. The Section on Medical Students, Section on Resident Physicians and Section on Special Constituencies shall select members in good standing at their Interim Session meeting to recommend for those director positions. They shall be elected by the annual Member Assembly and begin serving at the conclusion of the Annual Session. The term of office shall be one year and they may succeed themselves. There shall be a limit of three consecutive terms for the special constituency position on the TAFP Board of Directors. Members would be allowed to serve on the Board in another capacity. Members would be eligible to serve as special constituency director after a minimum of a 1 year hiatus.

Things to do near the hotel 20th Annual Children’s Festival Nov. 14 – 15, 10 a.m. – 5 p.m. Cynthia Woods Mitchell Pavilion (located one block from summit hotel) Tickets $8 in advance, $10 at the door www.woodlandscenter.org/ tourarchive.html The Woodlands Mall (located across the street from the hotel) Includes shopping and restaurants like BRIO Tuscan Grille, Cheesecake Factory, Fleming’s Steakhouse, and Mi Cocina. www.thewoodlandsmall.com Market Street shopping center (located across the street from the hotel) Includes open-air shopping and dining. www.marketstreet-thewoodlands.com

TAFP member events TAFP business meetings will take place Wednesday – Saturday, Nov. 11 – 14. Other TAFP member events include: FRIDAY, NOVEMBER 13 Breakfast with exhibitors and TAFP Foundation Board members | 7 – 8 a.m. Research Poster Competition 8 a.m. – 5 p.m. Member Assembly Luncheon 11:45 a.m. – 1 p.m. SATURDAY, NOVEMBER 14 Business and Awards Luncheon | 12:15 – 2 p.m. Members’ Reception | 5:30 – 6:45 p.m. President’s Party Casino Night | 7 – 10 p.m.

SAM Group Study Workshops Workshop on Childhood Illnesses Wednesday, Nov. 11, 1 – 6 p.m. Moderated by Rebecca Hart, MD Workshop on Care of the Vulnerable Elderly Thursday, Nov. 11, 10 a.m. – 3 p.m. Moderated by Dale Moquist, MD Workshop on Heart Failure Friday, Nov. 13, 1 – 6 p.m. Moderated by Sharon Hausman-Cohen, MD

Meet the TAFP Board candidates At the Member Assembly on Friday, Nov. 13 during this year’s TAFP Annual Session and Primary Care Summit, members will elect three of their colleagues to the TAFP Board of Directors. Two members are running for two available at-large positions and two members are running to hold the new physician position. According to the TAFP Bylaws, a slate of candidates are proposed by the Nominating Committee. Candidates may also be nominated by local chapters provided the nominations are made at least 90 days prior to the election, and candidates may be nominated from the floor at the Member Assembly. If you have any questions about the nomination or election process, please contact Kathy McCarthy at kmccarthy@tafp.org.

AT-LARGE DIRECTOR Christina Kelly, MD, was awarded her medical degree by The Ohio State University College of Medicine, then completed her residency in 2006 and OB fellowship in 2007, both with the Tacoma Family Medicine Residency Program. Kelly now serves as civilian faculty for the Christina Kelly, MD Family Medicine Residency Program and Director for the Family Medicine OB Fellowship at the Carl R. Darnall Army Medical Center at Fort Hood. She has previously been active in both the Ohio and Washington chapters of AAFP, as well as currently being an active member of TAFP. She was the convener at AAFP’s National Conference of

NEW PHYSICIAN DIRECTOR After graduating from the University of Texas Medical School at Houston and completing a residency with CHRISTUS, Emily Briggs, MD, MPH, opened her private practice in New Braunfels, where she has practiced since 2009. Briggs Family Medicine is a full scope practice Emily Briggs, MD, which highlights MPH full scope obstetrics. Briggs has served in many capacities with both TAFP and AAFP, most recently as a new physician representative for the National Conference of Constituency Leaders and the new physician member of AAFP’s Board of Directors. She also previously served as resident chair of

Constituency Leaders earlier this year, and previously served on AAFP’s Commission on Membership and Member Services, as a new physician delegate to AAFP’s Congress of Delegates, and as the resident member of the AAFP Board of Directors. Upon graduating from the University at Buffalo School of Medicine and Biomedical Sciences, Brett Johnson, MD, completed a residency with the Hamot Family Practice Residency in Erie, Pennsylvania. He has been the program director of the Methodist Health System Family Brett Johnson, MD Practice Residency Program in Dallas since 2001. Johnson previously served on TAFP’s Committee on Academic Affairs.

AAFP’s Commission on Education and as a resident delegate to AAFP’s Congress of Delegates. A graduate of the University of Texas Medical Branch, Alyssa Molina, MD, MPH, completed her residency with the Conroe Family Medicine Residency Program in 2010. She then moved to Eagle Lake, where she currently practices full scope family medicine at Rice Medical Alyssa Molina, MD Associates, including inpatient medicine and obstetrics at a critical access hospital. Molina also provides rural emergency room coverage at Southwest Medical Associates. She is currently a member of TAFP’s Committee on Academic Affairs. www.tafp.org

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TEXAS FAMILY PHYSICIAN SUMMER 2015

Family physicians embracing change

with the passage of the Medicare Access and CHIP Reauthorization Act repealing the SGR, Congress and the president accelerated the transition for the payment of Medicare services away from pure fee-for-service. In the coming months and years, we will see more and more payers both public and private paying for health care services based on value. TAFP is compiling resources and information to help you evaluate the current payment environment, prepare for the coming changes, and transition your practice to a model that will help you succeed. Visit the Embracing Change section of TAFP’s Practice Resources site at www.tafp.org/practice-resources/change to watch videos and discover resources on various payment models like accountable care organizations, the patient-centered medical home, direct primary care, and more. The latest videos posted highlight various TAFP members who practice in these newer payment models. We will continue to update the site frequently with resources that will help members succeed in this evolving health care environment.

Watch all of TAFP’s EMBRACING CHANGE videos at www.tafp.org/ practice-resources/ change/video1.

Public health efforts pay off with legislative wins in the 84th Texas Legislature

By Joey Berlin Texas Medicine

the texas public health coalition and diligent physicians earned significant victories during the 84th Texas Legislature in their drive to reduce tobacco and electronic cigarette use. Lawmakers also provided the Texas Department of State Health Services with a likely bump in chronic disease prevention funding, and an effort to keep children’s immunization records in the state registry through their early adult years made its way into law. TPHC entered the session with five categories of priorities: • Get Texas moving and eating healthy; • Vaccinations are important for all Texans; • Texas must be a leader in cancer prevention and research; • Reduce the toll of tobacco in Texas; and • Reduce preventable injuries. House Bill 1, the budget bill for the 2016-17 biennium, addressed several items on TPHC’s agenda, including the coalition’s pledge to preserve and support expanded funding for chronic disease prevention. A rider to the budget ties potential funds for that aim to federal funding in response to last year’s Ebola scare. If DSHS receives more than $20.27 million in federal funding related to Ebola prevention, planning, and treatment during 2016-17, the department will transfer an equal amount of general revenue toward strategies for public health preparedness, chronic disease prevention, and tobacco cessation. DSHS will allocate those funds as it sees fit toward pediatric asthma management, potentially preventable adult hospitalizations, expanded tobacco prevention services, diabetes prevention, and funding for the Texas Emergency Medical Task Force. Also on the tobacco front, TPHC scored another win with Sen. Juan “Chuy” Hinojosa’s Senate Bill 97. The coalition emphasized supporting the prevention of youth access to e-cigarettes, and S.B. 97 makes it a crime to sell e-cigarettes to someone younger than 18 or to someone who intends to give e-cigarettes to a minor, just as it’s illegal to

do so with regular tobacco products. Gov. Greg Abbott signed the measure into law on May 28. Sen. Hinojosa, D-McAllen, says e-cigarettes are “a training device” for minors to become adult cigarette users. “I was somewhat surprised when I was sitting in a non-smoking area in a restaurant, and I saw young people pull out these devices and start blowing vapor, which seemed like smoke,” he said. “And as I did more research, started seeing more minors using these cigarettes, I started inquiring as to the content of the cigarettes. And the contents are very damaging and harmful to the health of minors.” The Legislature and Gov. Abbott also addressed one of TPHC’s vaccination priorities with the approval of House Bill 2171. The measure by Rep. J.D. Sheffield, R-Gainesville, allows a person’s childhood immunization records to stay in the ImmTrac database until they reach age 26 if the person’s parents consented before they turned 18. ImmTrac currently keeps childhood immunization records until a person turns 18. Measures addressing TPHC priorities that didn’t make it to Gov. Abbott’s desk included House Bills 2474 and 80. Rep. Sheffield introduced H.B. 2474, which would have required school districts and campuses to provide de-identified information to requesting parents about immunization exemptions in the school or district. Parents would have been able to obtain such information as the number of students in their child’s school whose vaccinations aren’t current, the number claiming vaccination exemptions for religious reasons, and the number claiming exemptions for medical reasons. The bill passed the House by a 98-40 vote but died in the Senate Health and Human Services Committee. Rep. Tom Craddick, R-Midland, filed H.B. 80 to implement a statewide ban on texting while driving. TPHC threw its support behind H.B. 80, which contained language exempting drivers who text in stopped vehicles and those who do so for emergency purposes or to report illegal activity. The bill stalled in the Senate State Affairs Committee after the House passed it by a 104-39 vote. Texas is one of just four states that don’t have a complete prohibition on texting and driving, according to the Insurance Institute for Highway Safety. www.tafp.org

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TWHC wins funding for preventive health care in the 84th Texas Legislature

By Anna Chatillon Director of Policy and Advocacy for the Texas Women’s Healthcare Coalition

in the midst of the chaos and inevitable drama of the 84th Texas Legislature, we risk overlooking one piece of news with the potential to change thousands of lives for the better. Funding for women’s preventive health care services, such as annual checkups and contraceptive care, was increased by nearly $50 million in the state budget for the coming biennium. In 2011, draconian budget cuts to Texas’ Family Planning program devastated the women’s health care safety net. When the Texas Women’s Healthcare Coalition, a collaboration of 60 member organizations led by TAFP and others, was formed in 2012, its aim was to restore that funding. The Coalition’s successful advocacy restored the funding in 2013 through the Texas Women’s Health Program and the Expanded Primary Health Care program, in addition to the Family Planning program. In 2013, the state’s exclusion of affiliates of abortion providers meant that fewer physicians were available to care for patients in the TWHP; it also meant loss of the nine-to-one federal Medicaid match for TWHP funding. The state stepped up to provide that funding, but it was clear that the Coalition’s mission of ensuring access to preventive care for all Texas women was far from accomplished. Even the most optimistic calculations suggest that fewer than three in 10 income-eligible Texas women receive the publicly funded preventive care they so desperately need—even with the funding restored in 2013. This year, TWHC spearheaded the push to increase funding for the three programs that provide these services. Thanks to the impressive leadership of allied legislators such as Sen. Jane Nelson, R-Flower Mound; Rep. Sarah Davis, R-West University Place; and Rep. Donna Howard, D-Austin; the Coalition’s advocacy to increase the funding was successful. “The injection of $50 million in new funding into these preventive care programs is an outstanding investment in the health of Texan women, families, and communities,” said Dr. Janet Realini, TWHC chair. “Moving forward, the key in living up to the promise of the new funding will be in using

the dollars wisely and developing the programs to be as effective as possible.” To this end, the Legislature has directed the programs’ administering agency, the Health and Human Services Commission, to form an advisory committee of women’s health care providers. This direction was issued via an amendment to Senate Bill 200, recommended by TWHC and secured by Rep. Howard, and is intended to guide the state’s use of these dollars and any potential consolidation of these programs. Such a consolidation, as originally proposed in the Sunset review of HHSC, was not formally decided upon by the Legislature before the end of the session. The provider work group may take up such topics as eligibility requirements, delivery of same-day services to clients, and the appropriate method of granting funding to providers. One focus of the committee will likely be long-acting reversible contraceptives, such as intrauterine devices and sub-dermal implants. As recommended by TWHC, the final state budget issued this session includes a rider requiring that state agencies increase access to LARCs and develop provider education and training to improve that access. The coalition looks forward to the agency’s continued effort to make LARCs as accessible as possible, continuing in the vein of their prior impressive efforts to ensure such access. As TWHC marks the end of the 84th legislative session, we will take a moment to celebrate the increase in funding for women’s preventive health care programs, the new voice for providers enrolled in those programs, and the potential for increased access to the most effective forms of birth control. And as we look to the future and to our continued advocacy for women’s health care, we will in turn celebrate TAFP and our other member organizations. Through their leadership, countless Texan women will have access to better preventive health care in the next two years. From the Coalition’s perspective, that is one session outcome that truly is priceless.

www.tafp.org

TEXAS FAMILY PHYSICIAN SUMMER 2015

INSIDE THE COVERAGE GAP

Two new reports explore the ramifications of Texas’ refusal to expand Medicaid

almost two years after the Affordable Care Act took effect in October 2013, only one state still has a rate of uninsured greater than 20 percent: Texas. A recent Gallup survey shows that while the rate of uninsured in Texas dropped from 27 percent in 2013 to 21 percent in the first half of 2015, the rates in Arkansas and Kentucky have gone from above 20 percent down to 9 percent. What’s the difference? Arkansas and Kentucky are among the 30 states that have expanded Medicaid to cover poor, working-age adults. Texas is not. As the U.S. Supreme Court considered the question of whether the federal government could subsidize premiums offered by the federally-run health insurance exchange in states like Texas that refused to establish their own exchanges in the case King v Burwell, TAFP joined the Texas Association of Community Health Centers in commissioning a report to examine the existing effects and the potential future effects of these choices. A team of researchers at George Washington University wrote the report, entitled “How will Texas’ Affordable Care Act Implementation Decisions Affect the Population? A Closer Look,” which included a county-by-county breakdown of how many Texans can’t access affordable health care coverage today and how many would probably lose their coverage if the promise of federal premium subsidies had been struck down by the court. Health policy advocates across the country breathed a sigh of relief when the court ruled in favor of the government, securing subsidies for plans in the federal exchange, as did the 1 million Texans who would have lost those subsidies had the decision been different. Still by exploring the effects of refusing Medicaid expansion, the report articulates the consequences to local communities, their citizens, and the 1.5 million working-age Texans “who but for the stubborn resistance of Texas’ political leadership could be covered by Medicaid.” Consider these facts from the report’s executive summary: “The Affordable Care Act gives states two key choices: Whether to expand Medicaid to cover poor uninsured adults; and whether to establish a state exchange. No population stands to gain more from these choices than residents of Texas, who experience the nation’s highest uninsured rate. National estimates show that by not expanding Medicaid, the state has foregone coverage for 1.5 million people. County-level estimates show that in 249 out of 254 counties, the proportion of uninsured adults exceeds 20 percent of the total adult county population. In 31 counties, the proportion of low income uninsured adults exceeds 60 percent of all low income adult county residents. … “County-level estimates show that prior to implementation of the ACA, 38 counties experienced hospital annual uncompensated care levels of $50 million or greater, and four counties showed losses greater than $200 million.” You can read the full report including the appendices of countyspecific data on the TACHC website, www.tachc.org, or at this link: http://bit.ly/1IIfKve. Here at Texas Family Physician, we’ve chosen to present a redacted version of the report, including only the portion dealing with the decision to refuse Medicaid expansion.

www.tafp.org

How will Texas’ Affordable Care Act implementation decisions affect the population? A closer look Redacted to include the ramifications of refusing to expand Medicaid By Sara Rosenbaum, JD; Sara Rothenberg; Sara Ely Geiger Gibson Program in Community Health Policy Milken Institute School of Public Health at the George Washington University

the affordable care act has the potential to cut the number of uninsured Americans by more than half, as a result of two basic reforms: (1) reforms that ensure access to private health insurance for all Americans coupled with tax subsidies to make coverage affordable; and (2) an expansion of Medicaid to cover poor nonelderly adults, including adults without minor dependent children who historically have been excluded as well as parents of minor children, whose incomes, although well below poverty, exceed Texas’ eligibility standards. According to the Kaiser Family Foundation, in 2015 the income limit for parents in Texas equals 18 percent of the federal poverty level, virtually eliminating access to coverage for parents who work.1 Health insurance market reforms, insurance subsidies, and the exchange The ACA restructured the health insurance market in order to ensure that no person will be turned away or charged more because of a preexisting condition, or have a policy cancelled because of illness. The ACA also improved insurance by limiting out-of-pocket payments for covered services, guaranteeing coverage of preventive benefits with zero cost-sharing, and guaranteeing that all health insurance policies sold in the individual and small group markets cover certain “essential health benefits” covering both physical and mental health conditions. To make coverage more affordable, the ACA offers premium tax subsidies and cost sharing assistance. People who buy private insurance through an exchange qualify for premium subsidies if their household incomes are between 139 percent and 400 percent of the federal poverty level. (In states that do not expand Medicaid, subsidy eligibility begins at 100 percent of poverty). Cost sharing assistance is available to people who receive premium tax subsidies and have incomes up to 250 percent of poverty. Subsidies are available through health insurance exchanges, online marketplaces in which people without public or 18

TEXAS FAMILY PHYSICIAN SUMMER 2015

employer-sponsored health insurance can purchase affordable health plans. Together these reforms have significantly expanded coverage. As of March 2015, 10.2 million Americans had obtained exchange coverage.2 Exchange enrollment alone has had a major impact on access to affordable coverage; subsidized coverage alone has reduced the uninsured by 37 percent nationwide.3 Nationally 86 percent of all persons with exchange coverage receive premium subsidies. Expanding Medicaid The Medicaid expansion is designed to cover nonelderly low income adults with household incomes at or below 138 percent of the federal poverty level.4 In National Federation of Independent Businesses v Sebelius,5 the United States Supreme Court ruled that states could opt out of the adult expansion. As of June 2015, 29 states and the District of Columbia have implemented the expansion; Texas is not one of those states. Coupled with streamlined enrollment procedures—required of all states including those that do not expand coverage for adults—the ACA’s Medicaid reforms have increased adult coverage by 4.8 million Medicaid beneficiaries.6 The picture in Texas Had Texas’ leaders chosen to expand Medicaid, approximately 1.5 million additional working-age adults—about one-quarter of the state’s uninsured population—would have qualified for coverage.7 Furthermore, over the 2015-2024 time period, the state would have realized an estimated $128 billion in additional federal funding (a 42 percent increase in federal Medicaid financing). In order to qualify for this additional federal funding, the state would have had to increase its own Medicaid outlays by only 6 percent over the same time period ($13.5 billion). This additional outlay would be partially offset by reduced uncompensated care costs borne by state and local funds.8

Texas and the Affordable Care Act: Key facts ■ 1.5 million people would qualify for Medicaid were Texas to expand coverage to working-age low income adults. With the Medicaid expansion, the uninsured rate in Texas would be cut by half. ■ Texas would realize an additional $128.1 billion in federal funding over the 20152024 time period (a 42 percent growth) were it to expand Medicaid, with additional state outlays of only $13.5 billion (a 6 percent growth) over the same time period. ■ 1.2 million people selected an Exchange plan by February 2015, nearly 40 percent of those who are eligible. ■ The vast majority (86 percent) of Exchange plan enrollees qualify for premium tax subsidies. ■ Texas relies completely on the federal Exchange and has established neither a partnership arrangement nor a plan management arrangement with the federal government.

Figure 1. Uninsured Texas adults as a percent of total population ages 18-64 by county

Percent of population lacking insurance 16 – 19 percent 20 – 29.9 percent 30 – 39.9 percent Above 40 percent

Note: No Texas county shows less than 16.9 percent uninsured adults as a percentage of the total adult population. Source: 1. U.S. Census Bureau. (2015, March). Small Area Health Insurance Estimates (SAHIE): 2013 estimates. Retrieved May 8, 2015 from http://www.census.gov/did/www/sahie/data/20082013/index.html; 2. U.S. Department of Housing and Urban Development. (2015). HUD USPS ZIP Code Crosswalk. Retrieved on April 20 from http://www.huduser.org/portal/datasets/usps_crosswalk.html

Figure 2. Uninsured Texas adults ages 18-64 with incomes below 138 percent of the Federal Poverty Level as a percent of all uninsured adults by county

Percent uninsured 24 – 29.9 percent 30 – 39.9 percent 40 – 49.9 percent Above 50 percent

Note: When considering Texans eligible for Medicaid expansion coverage, in no county is less than 24 percent of the adult population eligible. Source: 1. U.S. Census Bureau. (2015, March). Small Area Health Insurance Estimates (SAHIE): 2013 estimates. Retrieved May 8, 2015 from http://www.census.gov/did/www/sahie/data/20082013/index.html 2. U.S. Department of Housing and Urban Development. (2015). HUD USPS ZIP Code Crosswalk. Retrieved on April 20 from http://www.huduser.org/portal/datasets/usps_crosswalk.html

UNINSURED TEXANS WHO ARE POOR

69 90

percent live in working families. percent have no access to employer health coverage.

In Figure 1 we present countylevel data which show the percent of uninsured adult residents. Figure 1 shows that in 131 counties, the proportion of uninsured adults stands at 30 percent of the total adult population or higher; in 249 counties, the number of uninsured Texans as a proportion of all adults stands at 20 percent or higher. Figure 2 shows the proportion of uninsured adults by county who have family incomes at or below 138 percent of the federal poverty level. In no county is less than 24 percent of the uninsured adult population Medicaid-eligible. In 150 counties, 40 percent or more of the uninsured adult population are Medicaid-eligible. Because Texas is a non-Medicaidexpansion state, those with family incomes between 100 percent and 138 percent of poverty can qualify for premium subsidies through the Exchange. But Medicaid coverage would offer even greater financial protection for the state’s poorest residents, because cost sharing is more modest and premiums would not be imposed. To be sure, some number of uninsured poor adults would not qualify for Medicaid under an expansion because they would not satisfy Medicaid’s legal residency requirements; at the same time, the statewide Medicaid impact estimate of 1.5 million eligible adults underscores that expanding Medicaid would aid the vast majority of poor uninsured adults.

www.tafp.org

Because Texas has opted not to expand Medicaid, its estimated uninsured population continues to exceed 4 million. With the expansion, its uninsured rate would have dipped below 3 million.9 In addition, Texas elected, along with 33 other states,10 not to establish a state exchange. Instead the state chose to rely on the federal exchange, an option afforded states under the ACA.11 Furthermore, unlike seven other states using the federal exchange, Texas has not entered into a state partnership relationship with the federal exchange, in order to carry out consumer assistance and/or plan management activities. In short, Texas has chosen to maintain no formal relationship with the exchange, either by establishing its own exchange or by partnering with the federal government. As of February 2015, over 1.2 million Texas residents had selected an exchange plan, with a selection rate of nearly 40 percent of the qualified population, placing the state close to the U.S. average of 42 percent.12 The vast majority of enrollees (86 percent) receive financial assistance in the form of premium subsidies.13

Most of Texas’ uninsured residents are uninsured on a long term basis. In a survey of state residents, conducted as part of a nationwide survey of the uninsured, 53 percent reported going without health insurance for five years or longer.16 Thirty-one percent reported never having had insurance in their lives. For a variety of reasons, the overwhelming majority of uninsured Texans (84 percent) have no access to employer-sponsored coverage. When only poor Texans are considered, this figure rises to 90 percent.17 Forty-four percent of poor uninsured Texans without access to employer coverage report that their employers offer no coverage. Eighty percent of poor Texans whose employers do offer coverage report that they are unable to afford premiums.18 Certain important conclusions can be drawn from these estimates. First, the great majority of poor uninsured adults who would be helped by a Medicaid expansion live in working families. Second, poor workers are almost never likely to have access to employer-sponsored coverage; even when it is offered poor workers are overwhelmingly unable to afford it.

The size and characteristics of Texas’ uninsured population underscores the significance of the state’s decisions on its residents The characteristics of Texas’ uninsured population underscore why the ACA reforms have such a great potential to change the lives of its residents, while infusing enormous resources into the state’s economy. Compared to residents with insurance, uninsured residents are much more likely to have low incomes. Two in five uninsured Texans (40 percent) have incomes below the federal poverty level.14 Because such a high proportion of the uninsured Texas population has poverty-level income, they fall into the coverage gap created by the state’s decision not to expand Medicaid because their household incomes are below the 100 percent threshold ($24,250 for a family of four) needed to qualify for premium subsidies. Most uninsured Texans live in working families. Nearly seven in 10 (69 percent) is a member of a family in which they or a spouse work full time or part time.15 Many are parents whose income from work would disqualify them from Texas’ extremely low eligibility standard for parents (18 percent of the federal poverty level). And yet their poverty-level wages are too low to enable them to qualify for premium tax subsidies in the Exchange.

The human impact of Texas’ high uninsured rate The impact of Texas’ decision not to expand Medicaid can be measured not only in health care access and cost terms, but in population health terms as well. In an amicus brief to the court in King, deans of schools of public health as well as the American Public Health Association presented evidence regarding the impact of being uninsured on mortality among adults.19 Because having health insurance is so closely associated with access to health care, gains in coverage reduce preventable adult deaths, with one death prevented for every 830 adults insured. The Affordable Care Act gives Texas basic choices about how to help its uninsured residents. First, the state can expand Medicaid for poor uninsured working-age adults, with costs almost entirely borne by the federal government and with a return of nearly $10 for every $1 the state lays out in new expenditures over the 2015-2024 time period. By factoring in the savings the state could realize from reduced uncompensated care costs, the savings grow still further. One-and-a-half million Texans, most residing in working families, and nearly all without access to employer coverage for one reason or another, would benefit, bringing enormous additional resources to the state’s health care system. Texas can implement the Medicaid expansion at any time.

1 http://kff.org/health-reform/state-indicator/medicaid-income-eligibilitylimits-for-adults-as-a-percent-of-thefederal-poverty-level/ 2 Robert Pear, 13 percent Left Health Care Rolls, U.S. Finds, New York Times (June 2, 2015) http://www.nytimes.com/2015/06/03/us/13-left-health-care-rollsus-finds.html?_r=3 3 Matthew Buettgens, John Holahan, and Hannah Recht, Medicaid Expansion, Health Coverage, and Spending: An Update for the 21 States that have not Expanded Eligibility (Kaiser Family Foundation, April 2015) http://kff.org/ medicaid/issue-brief/medicaid-expansion-health-coverage-and-spending-anupdate-for-the-21-states-that-have-not-expanded-eligibility/ 4 Medicaid figures include data for all individuals at or below 138 percent of the Federal Poverty Level, not all of whom may meet eligibility requirements. 5 132 S. Ct. 2566 (2012) 6 Vikki Wachino, Samantha Artiga, and Robin Rudowitz, How is the ACA Impacting Medicaid Enrollment? (Kaiser Family Foundation, May 2015) http://kff. org/medicaid/issue-brief/how-is-the-aca-impacting-medicaid-enrollment/ 7 Matthew Buettgens, John Holahan, and Hannah Recht, Medicaid Expansion, Health Coverage, and Spending: An Update for the 21 States that have not Expanded Eligibility; Table 3 (Kaiser Family Foundation, April 2015) http://kff. org/medicaid/issue-brief/medicaid-expansion-health-coverage-and-spendingan-update-for-the-21-states-that-have-not-expanded-eligibility/ Note: A 2013 presentation by the Texas Health and Human Services Commission estimated the same number of newly eligible Medicaid beneficiaries, approximately 23 percent of the state’s uninsured. Kyle Janek, Presentation to the House Appropriations Committee (March 2013)

8 Id. 9 Id. 10 http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/ 11 Patient Protection and Affordable Care Act, §1321 12 Kaiser State Health Facts Online http://kff.org/health-reform/state-indicator/ current-marketplace-enrollment/ 13 Kaiser State Health Facts Online http://kff.org/other/state-indicator/marketplace-enrollees-by-financialassistance- status-2015/ 14 Katherine Young and Rachel Garfield, The Uninsured Population in Texas: Understanding Coverage Needs and the Potential Impact of the Affordable Care Act (Kaiser Family Foundation, July 2014) (Figure 1) http://kff.org/uninsured/ report/the-uninsured-population-in-texas-understanding-coverage-needsand-thepotential-impact-of-the-affordable-care-act/ 15 Id. Figure 2. 16 Id. Figure 3 17 Id. Table 2 18 Id. 19 Amicus Brief of Deans of Schools of Public Health and the American Public Health Association to the United States Supreme Court, King v Burwell. The brief reviews a landmark study by Benjamin Sommers and colleagues on the impact of Massachusetts’ Medicaid expansion under its health reform law on mortality among low income working-age adults. Benjamin D. Sommers, Katherine Baicker, and Arnold Epstein, Mortality and Access to Care Among Adults after State Medicaid Expansion, New Eng. Jour. Med. 367: 1025-1034 (2012)

TEXAS FAMILY PHYSICIAN SUMMER 2015

INSIDE T HE COV ERAGE G AP

In advance of a series of hearings about the renewal of Texas’ Section 1115 Transformation Waiver, which provides billions of dollars to help cover uncompensated care throughout the state, TAFP joined forces again with the Texas Association of Community Health Centers to publish a report linking this funding to the larger issue of addressing the state’s high rate of uninsured citizens. In the report, the two organizations argue that renewal of the waiver should complement coverage for low-income Texans rather than fill the gap left by the state’s inaction to provide access to sustainable health coverage to poor working-age adults. Here is that report in full.

Uncompensated care and the coverage gap: The role of the 1115 Transformation Waiver in Texas By the Texas Association of Community Health Centers and the Texas Academy of Family Physicians

EXECUTIVE SUMMARY texas and the federal government are far apart on the terms of renewal for a five-year Medicaid 1115 waiver that provides funding for hospital uncompensated care costs and health care delivery system reforms. One goal of the waiver was to build health care infrastructure to support increased demand for services from a newly insured population under Affordable Care Act reforms, including Medicaid expansion. However, Texas leaders have declined to adopt Medicaid expansion, foregoing billions in federal funds and leaving more than a million low-income Texans in a coverage gap without access to affordable health insurance coverage. This report examines the relationship between Texas’ 1115 waiver and state leaders’ decisions related to ensuring access to health coverage for low-income, uninsured Texans. A large portion of the population served under the 1115 waiver would be eligible for Medicaid if Texas leaders agreed to expand coverage. The 1115 waiver was never envisioned as a substitute for coverage, and was designed to complement, not replace, expanded access to health coverage under ACA reforms. Texas leaders’ decision not to expand coverage puts federal funding through the 1115 waiver at risk. A similar situation in Florida serves as a cautionary tale for CMS’ approach to renewing the Texas waiver. Florida leaders have refused to expand Medicaid while at the same time requesting that CMS renew their 1115 waiver. CMS responded by proposing to greatly reduce

the amount of uncompensated care funds going to Florida under their waiver, and have indicated they will treat other states, including Texas, using a similar logic--no federal funds should be used to pay for services for people who could be covered under Medicaid expansion. While the 1115 waiver serves an important role in the health care delivery system, state leaders have systematically declined to address the lack of coverage options for Texans with below-poverty wages, ignoring a key opportunity to provide economic stability and additional resources to Texans living in poverty. Texas would receive vastly more federal dollars under Medicaid expansion than under the waiver, with Texas taxpayers contributing a smaller share. Pushing forward with the waiver renewal while refusing to accept federal dollars for expanded Medicaid serves as the latest example in a series of decisions made by state leaders to deny coverage for the state’s uninsured population. State leaders must adopt, embrace, and execute a coherent strategy for the 1115 waiver renewal that includes drawing down all available federal funds to expand access to health coverage for lowincome Texans. SECTION 1115 DEMONSTRATION WAIVERS Section 1115 of the Social Security Act grants the Secretary of Health and Human Services the authority to approve state demonstration projects aimed at furthering the objectives of the Medicaid program. Referred to as 1115 waivers, these projects provide states flexibility to test new approaches to delivering health care services in Medicaid. Through 1115 waivers, states can design new benefit packages, expand services to new populations and implement a broad range of Medicaid reforms. 1115 waivers are typically pilot or experimental in nature, and provide an opportunity for states to utilize federal Medicaid funds in ways not typically allowed under the program.1 1115 waivers must be designed to be budget neutral to the federal government. In other words, the federal government will not approve waivers that are projected to require more federal Medicaid funding than the state would otherwise receive without the waiver. Under www.tafp.org

The 1115 waiver was never envisioned as a substitute for coverage, and was designed to complement, not replace, expanded access to health coverage under ACA reforms. Texas leaders’ decision not to expand coverage puts federal funding through the 1115 waiver at risk.

TEXAS FAMILY PHYSICIAN SUMMER 2015

1115 waivers, states receive the same federal matching rates as their traditional Medicaid programs. This means that in Texas, the federal government provides about $0.60 for every $0.40 spent by the state.2 States submit requests for 1115 waivers to the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, the federal entity that oversees the Medicaid program. 1115 waivers are approved by CMS for a period of five years, with the opportunity to extend for an additional period, typically three years. However, CMS has the ability to grant multiple extensions and some states have had 1115 waivers in place for many years.3 Over the last several decades, states have used 1115 waivers to expand Medicaid benefits to populations not otherwise eligible for Medicaid coverage, to expand the managed care model to new populations, to support safety net delivery system improvements, and to lay the groundwork for health system reforms occurring under the Affordable Care Act.4 TEXAS HEALTH CARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM MEDICAID 1115 WAIVER In December 2011, the Texas Health and Human Services Commission received CMS approval for an 1115 demonstration waiver through Sept. 30, 2016. The Texas waiver has two main components: the expansion of the Medicaid managed care model statewide, and the creation of funding mechanisms to reimburse providers for uncompensated care costs and incentivize health care delivery system transformation.5 The waiver uses savings from the managed care expansion to achieve budget neutrality and finance the new funding pools. This paper focuses on the uncompensated care and delivery system reform elements of the waiver, rather than the managed care statewide expansion. Apart from the managed care expansion, Texas’ 1115 waiver had several broad goals, including preserving federal uncompensated care funds for hospitals, supporting a coordinated care delivery system through regional partnerships, and boosting health care infrastructure to prepare for the newly insured under Affordable Care Act reforms beginning in 2014.6 To achieve these goals, the waiver created two new funding pools for hospitals and other eligible providers caring for Medicaid recipients and the uninsured. First, the Uncompensated Care (UC) pool provides funding to hospitals for uncompensated care costs associated with providing care to uninsured Texans and shortfalls in reimbursement rates for providing care to Medicaid recipients. The UC pool replaces supplement payments received by hospitals under the pre-waiver Medicaid finance system. Hospitals are eligible for UC funding according to historical levels of supplemental funding provided by the state. The second pool, called the Delivery System Reform Incentive Program (DSRIP), is intended to incentivize regional health system reform by funding projects that work to improve quality of care, increase access to services, and lower costs. DSRIP projects must fall into one of several broad categories, including infrastructure development, program innovation, and redesign and quality improvements.7 The state is divided into 20 regions, called Regional Healthcare Partnerships, which submit DSRIP projects for approval by HHSC and CMS. Each DSRIP project must have public monies, usually local tax dollars, to draw down federal matching funds. Projects must meet certain metrics prior to receiving DSRIP funding. Public and private hospitals, local mental health authorities, academic physician groups, and local health departments are eligible to receive funding as performing providers in DSRIP projects. Other providers historically serving the waiver’s target populations, such as federally qualified health centers,

are allowed to subcontract with performing providers in order to participate in DSRIP projects. Throughout the course of the waiver, funding to the UC pool gradually decreases while funding to the DSRIP pool increases. The waiver pools are valued at $17.6 and $11.4 billion, respectively, bringing the total value of the waiver to $29 billion over five years.8 Following the standard Medicaid federal matching rate for Texas, the federal government pays about $17 billion under the waiver and the remaining $12 billion is funded primarily by local tax dollars used to draw down the federal match. As of May 2015, the waiver supported 1,458 active DSRIP projects conducted by 298 providers across the state. Over one-quarter of the projects were related to behavioral health services, 20 percent were aimed at increasing access to primary care, and 18 percent were related to chronic care management and support for health system navigation. Because DSRIP projects were approved one-and-a-half to two-and-a-half years into the five-year waiver, concrete data on most project outcomes is still being collected.9 Whether or not DSRIP funds and projects have collectively achieved health system transformation, and if these achievements are replicable, remains to be seen. However, what is clear is that no DSRIP project resembles or replaces health insurance coverage. DSRIP projects were not envisioned by CMS or the state as a substitute for health coverage, but were intended to build infrastructure to support increased demand for health care services from populations newly insured under ACA reforms and improve health outcomes while containing costs. TEXAS WAIVER RENEWAL In order to renew or extend the waiver, which expires on Sept. 30, 2016, Texas must submit an extension request to CMS no later than Sept. 30, 2015. As mentioned, one objective of the waiver was to prepare health care infrastructure in Texas for increases in demand due to newly insured populations under the ACA beginning in 2014. State leaders failed to fully implement ACA reforms, which impacts Texas’ ability to negotiate the waiver extension with CMS. These ACA coverage reforms provide context on the health care environment at the time the Texas waiver was developed, which informs the discussion around waiver renewal. In order to increase access to health insurance, the ACA created two new mechanisms for low-income Americans to obtain affordable coverage. One was the creation of health insurance marketplaces with tax credits for enrollees between 100 and 400 percent of the federal poverty level. The health insurance marketplace began offering subsidized coverage in Texas in January 2014, and by February 2015 more than a million Texans had enrolled in marketplace coverage. 10 The other was the expansion of Medicaid coverage to Americans earning up to 138 percent of the poverty level. However, Texas policymakers failed to expand Medicaid as envisioned under the ACA, when in June 2012 a U.S. Supreme Court ruling made Medicaid expansion optional for states. Up to this point, Texas has declined to participate in the ACA expansion of Medicaid, leaving approximately 1.5 million Texans in a coverage gap without access to affordable health coverage.11 The current 1115 transformation waiver was developed by HHSC and approved by CMS prior to the Supreme Court decision that made Medicaid expansion a state option. Therefore, the underlying assumption in the waiver design was that beginning in 2014, Texans with poverty-level wages would have access to health coverage under Medicaid expansion, and hospitals and other providers would experience an increase in revenues through a newly insured Medicaid population and a subsequent decrease in uncompensated care costs through a

reduction in the uninsured. Because Texas leaders declined to expand Medicaid, this shift has not fully occurred. A similar situation has developed in Florida where state leaders have refused to participate in the expansion of Medicaid and at the same time requested an 1115 waiver renewal from CMS. Florida’s waiver includes a Low Income Pool (LIP) which is similar to the UC pool in the Texas waiver in that it provides uncompensated care funds to Florida’s hospitals that care for Medicaid recipients and the uninsured. In 2014, CMS granted a three-year extension of Florida’s waiver, but only a one-year extension of the LIP portion of the waiver.12 As the LIP approached expiration in June 2015, CMS indicated that the fund would not be renewed, in large part due to Florida’s refusal to expand Medicaid under the ACA.13 CMS has indicated it views Medicaid expansion as a more comprehensive approach to providing access to health care to low-income populations than patchwork financing mechanisms that ultimately fail to provide the benefits of coverage to vulnerable Americans. At the time this paper was written, Florida reached a preliminary agreement with CMS to extend the LIP for an additional two years though at a substantially reduced amount with the state forced to increase expenditures to make up the difference. Under the compromise, CMS also indicated that LIP funds could not be used to cover populations that would be covered under a Medicaid expansion or to make up shortfalls in Medicaid reimbursement rates set by the state if CMS considers rates to be too low.14 While details differ between the Florida example and Texas’ reality, CMS has indicated to state leaders that they intend to use the same approach utilized in Florida when determining the parameters for the Texas waiver renewal. On its face, one can assume the potential for reductions, perhaps drastic, in Texas’ UC pool and possible prohibitions from using UC funds to cover the costs of providing care that would be paid for under a Medicaid expansion or to make up shortfalls in Texas’ notoriously low Medicaid reimbursement rates. TEXAS’ COVERAGE GAP Texas’ refusal to expand Medicaid coverage under the ACA not only impacts the future of the 1115 waiver, it leaves 1.5 million lowincome Texans without access to affordable health coverage. Texans earning too little to receive subsidies in the marketplace and too much to qualify for the existing Medicaid program fall in to this coverage gap. The majority of Texans in the coverage gap live in working families and overwhelmingly lack access to affordable employer-sponsored coverage.15 Numerous studies have demonstrated the health, economic, and social benefits if Texas were to agree to draw down federal funds under the ACA to expand coverage to Texans earning belowpoverty wages.16 However, Texas leaders failed to discuss the merits of coverage expansion during the 84th legislative session that ended on June 1, 2015 and adjourned until 2017 without solving the coverage gap problem. A dozen bills were filed that addressed the coverage gap, but not a single one received a hearing in either the Texas House or Senate. One Senator attempted to add a Medicaid expansion provision to another piece of legislation, but the amendment failed along party lines. This was the only vote the Texas Legislature took related to closing the coverage gap. Not only would an estimated 1.5 million Texans have access to health coverage under a Medicaid expansion, but the state would receive an additional $128 billion in federal funds over 10 years and only spend $13.5 billion in state funds over the same period. Under Medicaid expansion, the federal government never pays less than 90 percent of the costs of coverage, compared with the 60/40 match www.tafp.org

under the waiver. Additionally, these state expenditures would be partially offset by reductions in uncompensated care costs.17 In addition to the benefits of insuring a larger percent of Texans, Medicaid expansion would serve as an economic driver in communities across the state. Coverage expansion would create an estimated 300,000 new jobs in Texas18 and bring vast amounts of Texas taxpayer dollars back to the state to invest in community infrastructure and

workforce. Numerous studies demonstrate that expanding Medicaid has had a positive impact on states’ economies. Texas would experience an estimated $270 billion economic impact over ten years if state leaders were to adopt expansion.19 Medicaid coverage also brings financial stability to low-income enrollees and research shows reductions in bankruptcy rates and catastrophic out-of-pocket costs for populations gaining Medicaid coverage.20

As long as Texas has an uninsured population, there will be a continued need for federal funding for uncompensated care. It is imperative that Texas leaders take a realistic approach to negotiating with CMS for a renewal of the waiver to ensure the continued viability of community and safety-net hospitals that would otherwise have to drastically scale down services or shutter facilities.

CONCLUSION Texas’ 1115 transformation waiver serves a critical function in preserving uncompensated care funding for hospitals providing services to uninsured, low-income Texans not eligible for Medicaid coverage. As long as Texas has an uninsured population, there will be a continued need for federal funding for uncompensated care. It is imperative that Texas leaders take a realistic approach to negotiating with CMS for a renewal of the waiver to ensure the continued viability of community and safety-net hospitals that would otherwise have to drastically scale down services or shutter facilities. Additionally, the DSRIP pool has the potential to generate innovative projects that improve health care quality and lower costs, and ideally identify best practices that can be replicated on a larger scale. However, the waiver does not address the problem facing Texas’ health care system at its core: the lack of access to affordable health coverage for Texans living in poverty. The waiver was designed under the assumption that more than a million low-income Texans would gain access to Medicaid coverage starting in 2014. The waiver’s purpose was, in part, to help lay the groundwork for the increase in demand for services from this newly insured population. Texas leaders have chosen to keep Medicaid coverage from these Texans, forcing their continued reliance on safety-net clinics and hospital emergency rooms for access to care. This is one example in a series of decisions state leaders have made that deny access to health care for low-income Texans, including refusing to create a state-based health insurance marketplace and maintaining lower-than-cost Medicaid reimbursement rates. Instead of utilizing the 1115 waiver as a vehicle to prepare Texas’ health care infrastructure for a greater insured population, Texas leaders are pressing forward with a questionable waiver renewal strategy while failing to address the coverage gap. This decision not only puts a portion of the waiver itself at risk, it foregoes billions in federal Medicaid funding that could be invested in local communities statewide and reduce the burden of uncompensated care costs that falls on local governments and Texas taxpayers.

1 Robin Rudowitz, Samantha Artiga, and Rachel Arguello, A Look at Section 1115 Medicaid Demonstration Waivers Under the ACA: A Focus on Childless Adults (Kaiser Family Foundation, October 2013) (Appendix A) 2 http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/ Texas’ Federal Medical Assistance Percentage (FMAP) is $58.05 in federal fiscal year 2015. Texas’ FMAP has seen slight reductions over the last several years, and will be $57.13 in federal fiscal year 2016. 3 Rudowitz, et al. 4 Kaiser Commission on Medicaid and the Uninsured, An Overview of Recent Section 1115 Medicaid Demonstration Waiver Activity (May 2012) 5 CMS Approval Letter to Texas Health and Human Services Commission for 1115 Transformation Waiver (December 2011) 6 Texas Healthcare Transformation and Quality Improvement Program Medicaid 1115 Waiver Proposal, Texas Health and Human Services Commission (July 2011 7 CMS Approval Letter to Texas Health and Human Services Commission for 1115 Transformation Waiver (December 2011) 8 Ibid. 9 Presentation to Texas House Appropriations Committee on the Section 1115 Demonstration Waiver: Texas Healthcare Transformation and Quality Improvement Program, Texas Health and Human Services Commission (May 2015) 10 Sara Rosenbaum, Sara Rothenberg, and Sara Ely, How Will Texas’ Affordable

Care Act Implementation Decisions Affect the Population? A Closer Look (The George Washington University, June 2015) 11 Ibid. 12 CMS letter from Director Cindy Mann to Florida Medicaid Director Justin Senior (July 2014) 13 CMS letter from Acting Director Vikki Wachino to Florida Medicaid Director Justin Senior (April 2015) 14 CMS letter from Director Vikki Wachino to Florida Medicaid Director Justin Senior (June 2015) 15 Rosenbaum, et al. 16 Perryman Group, Only One Rational Choice: Texas Should Participate in Medicaid Expansion Under the Affordable Care Act (February 2013); Billy Hamilton Consulting, Expanding Medicaid in Texas: Smart, Affordable and Fair (January 2013); Families USA, Texas’s Economy Will Benefit from Expanding Medicaid (February 2013) 17 Rosenbaum, et al. 18 Perryman Group, Only One Rational Choice: Texas Should Participate in Medicaid Expansion Under the Affordable Care Act 19 Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Economic Impact of the Medicaid Expansion (March 2015) 20 Ibid.

TEXAS FAMILY PHYSICIAN SUMMER 2015

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Are you ready for ICD-10? By Bradley Reiner

i thought that icd-10 might never happen. They have been talking about it for years. We have heard other countries are using it and how much better it is for the patients and the doctors. It sounds good, but how much work is involved in implementing a system like ICD-10? Considering we’ve been using ICD-9 for as long as we can remember, we find ourselves wondering if a huge transition like this is even possible. They were on the cusp of implementation in October 2014 and at the last moment decided to postpone for another year. Oct. 1, 2015 is fast approaching and everyone is scrambling, making sure they’re prepared. I was still thinking this implementation would get delayed again. Then something happened. Last year a delay to ICD-10 came on the heels of a delay in the SGR that thwarted a reduction in Medicare payments to doctors. This year the SGR was fixed and under new legislation there was no delay in ICD-10, thus ending any speculation that the new system would be postponed further. While there was no delay, The Centers for Medicare and Medicaid Services and the American Medical Association announced a grace period in early July that will ease the transition this fall. Essentially, for the first year that ICD-10 is in place, Medicare claims coded incorrectly will still be accepted, as long as the code used is from the appropriate family of ICD-10 codes. To understand more about this grace period, go to http://blogs.aafp.org/fpm/gettingpaid/entry/cms_ama_ offer_additional_guidance. Note that all claims dated Oct. 1, 2015 or later must still be submitted with valid ICD-10 codes; ICD-9 codes will no longer be accepted. A LITTLE EDUCATION ON ICD-10 The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced with ICD-10 code sets on Oct. 1, 2015. ICD-10 consists of two parts: • ICD-10-CM, diagnosis coding for use in all U.S. health care settings. • ICD-10-PCS, inpatient procedure coding for use in U.S. hospital settings. ICD-10 will affect everyone, not just Medicare and Medicaid. The addition of ICD-10 includes over 68,000 codes as opposed to the 13,000 in ICD-9. This is a significant change for coding services. Choosing an ICD-9 code for abdominal pain, 789.0, is fairly simple. With ICD-10 there may be 11 or more codes to choose from for abdominal pain. It will be your job to decide which one is the most appropriate choice. Claims for services provided on or after the compliance date should be submitted with ICD-10 diagnosis codes. Claims for services provided prior to the compliance date should be submitted with ICD9 diagnosis codes. This will be confusing for the months surrounding the transition, even with the year grace period.

The code set has been expanded from five positions (first one alphanumeric, others numeric) to seven positions. The codes use alphanumeric characters in all positions, not just the first position as in ICD-9. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of any or all of the fourth, fifth, and sixth characters. Digits four through six provide greater detail of etiology, anatomical site, and severity. A code using only the first three digits is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required. This does not mean that all ICD-10 codes must have seven characters. The seventh character is only used in certain chapters to provide data about the characteristic of the encounter. Examples of where the seventh character may be used include injuries and fractures. The new code set provides a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code. The terminology has been modernized and has been made consistent throughout the code set. There are codes that are a combination of diagnoses and symptoms, so that fewer codes need to be reported to fully describe a condition. The ICD-10-CM code set enables reporting of laterality (right vs. left designations), reflecting the importance of which side of the body or limb (e.g., left arm, left kidney, left eye) is the subject of the evaluation. It also restructures reporting of obstetric diagnoses. In ICD-9CM, the patient is classified by diagnosis in relation to the episode of care. In ICD-10-CM, the patient is classified by diagnosis in relation to the patient’s trimester of pregnancy. OTHER IMPORTANT CHANGES TO NOTE IN ICD-10-CM: • Importance of anatomy: Injuries are grouped by anatomical site rather than by type of injury. • Incorporation of E and V codes: The codes corresponding to ICD9-CM V codes (Factors Influencing Health Status and Contact with Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main classification rather than separated into supplementary classifications as they were in ICD-9-CM. • New definitions: In some instances, new code definitions are provided reflecting modern medical practice (e.g., definition of acute myocardial infarction is now four weeks rather than eight weeks). • Restructuring and reorganization: Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM. • Reclassification: Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge. www.tafp.org

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Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 < 200 cells/μL) with HIV infection. HIV Medicine. 2004;5:93-8.

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ICD-10 Ad_5.14_CMYK.indd 1

TEXAS FAMILY PHYSICIAN SUMMER 2015

6/10/14 11:48 AM

Chapters and organization of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision Chapter

Blocks No. of codes

Title

Chapter

Blocks No. of codes

Title

1 A00-B99 1,056 Certain infectious and parasitic diseases

13 M00-M99 6,339

14 N00-N99 591 Diseases of the genitourinary system

C00-D49 1,620 Neoplasms

3 D50-D89 238 Diseases of the blood and blood forming organs and certain disorders involving the immune mechanism 4 E00-E89 675 Endocrine, nutritional and metabolic diseases 5 F01-F99 724

Mental, behavioral, and neurodevelop- mental disorders

G00-G99

591

Diseases of the nervous system

H00-H59

2,452

Diseases of the musculoskeletal system and connective tissue

15 O00-O9A 2,155 Pregnancy, childbirth, and puerperium 16 P00-P96 417

Certain conditions originating in the perinatal period

17 Q00-Q99 790 Congenital malformations, deformations, and chromosomal abnormalities

Diseases of the eye and adnexa

18 R00-R99 639

Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified

8 H60-H95 642 Diseases of the ear and mastoid process

19 S00-T88 39,869

Injury, poisoning, and certain other consequences of external causes

I00-I99

External causes of morbidity

10 11

1,254

Diseases of the circulatory system

J00-J99

336

Diseases of the respiratory system

K00-K95

706

Diseases of the digestive system

21 Z00-Z99 1,178

V00-Y99

6,812

Factors influencing health status and contact with health services

12 L00-L99 769 Diseases of the skin and subcutaneous tissue

By now you’re probably wondering how you can get ready for this transition. • It is important to ensure that all payer and all technology systems are prepared for the transition. Contact your top payers and ask them how they are preparing for ICD-10. Some payers, like Medicare, are doing testing with practices to ensure that claims go through cleanly. This is something every practice should complete to ensure everything works on the day of implementation. Contact Medicare to participate. • Start transitioning your ICD-9 codes into ICD-10 codes. You can do this by determining the top diagnosis codes that you utilize. Remember, there will likely be a number of ICD-10 codes for each ICD-9 code billed. The ICD-10 codes can be found at www.cms.gov. • After you have determined the ICD-10 codes you plan on utilizing most frequently, contact your vendor and ensure these codes are in their data base and available to use on Oct. 1. This is a critical step so there will be no delay in claim billing or payment. It would also be wise to ensure the payers will be accepting the codes you have identified.

• Train your physicians and staff on the new code sets and how everyone will be impacted by the use of these diagnoses. Retrain monthly to ensure everyone is up to speed on how they will be utilized by October. • CMS has an excellent site for planning and meeting the goals for ICD-10. Review the site they created at www.roadto10.org. They include a step-by-step action plan for implementing ICD-10 into your practice. This is an excellent way to establish your systems and develop guidelines for success. It is important to remember that the new ICD-10 code sets are not to be feared. With some preparation and education, your practice can be prepared for this landmark change to medical coding and billing.

Bradley Reiner, formerly with Texas Medical Association, has been owner of Reiner Consulting and Associates for 15 years. He is TAFP’s endorsed consultant and is a billing and coding auditor for the Texas Medical Board. He can be reached at (512) 858-1570 or breiner@austin.rr.com. See more about the services Reiner provides to TAFP members at www.tafp.org/practice-resources/reiner. www.tafp.org

PERSPECTIVE

First do no harm? A reflection on pain and intervention at the end of life By Vincent J. Mandola, MD march 25, 2015 was a day I will never forget. It was the day I watched my mother take her last breath. She was 56 years old and had battled cancer for two years. It was a surreal time stepping into the unknown for my close family, but it’s not the moment of her passing I want to write about here. It is the days leading up to that moment, as this experience has given me a new outlook on end-of-life care. After surgery and nearly a year and a half of chemotherapy, mom was determined to have a couple of decent weeks before what she knew was inevitable. She had just been discharged from the hospital for uncontrolled pain and sent home under hospice care. Her biggest fear during this time was pain, and she made her wishes known to her family and her medical team; she wanted to avoid as much pain as possible. Doctors, nurses, and hospice representatives assured her she would be kept comfortable. On the day we arrived home, a hospice nurse met us at the house and we began reviewing medications. Although we had some sublingual pain medications, many were to be taken orally. I asked, “What can we do once she cannot tolerate swallowing pills for her pain?” I was frustrated that a specialized group such as hospice did not have a satisfactory answer. They had a few alternatives, such as a patch, but nothing ready to go and it was obvious that when this happened, mom’s pain would be out of control for several hours. This precise event happened to her two times, creating two hospital admissions for IV pain medication, each time taking days to achieve adequate control. This process dragged on for months and was excruciating for my family, most of all for mom. No matter what she or my family said, the hospice team implemented their standard of care, which was first and foremost to not overdose. Mom begged during these times to be “knocked out,” and although I did not want her medically sedated so that I couldn’t speak to her, it is truly what she wanted. She made this known even before these episodes occurred. Therefore, this is what the family wanted for her as well. Through this process, I learned that medical sedation is not an option. The limited options opened my eyes to what people are forced to endure at the end of life. As physicians, we took an oath to first do no harm. In my opinion, this is harm—harm for the patient and harm for the family. During these times, medicine should be, more than ever, patient driven. It should be up to the patient and not us to define “harm.”

Two days before mom’s passing we were still struggling to control her pain. Encephalopathy had likely settled in, so the physician wanted to decrease the pain medication to determine the cause. Knowing mom’s wishes, the thought of her waking up in pain was not an option for the family. She seemed somewhat comfortable for the first time in a long time. The hospice physician refused to grant the patient and family’s wishes because she feared the medication might cause death, which was going to happen in days regardless. We ended up compromising, but why? With all of the capabilities of modern medicine, why do patients still have to suffer at the end of life? To me, this current practice is not only wrong, but inhumane. At the end of life, a patient’s wishes should simply be well understood, documented, and fulfilled. This will also help decrease hospital admissions. I believe home subcutaneous drips should be readily available with a well-educated family or caretaker and should be able to be started when necessary. IV medications should be easily available for home use by a well-educated medical provider. When in an inpatient unit, sedation for a previously understood and agreed reason should be available if the patient wishes. Anesthesiologists should be available and utilized for palliative care. The fear of lawsuit should be limited, as this time of a patient’s life should be treated differently. During the last days, breaths get further apart as the family sits and listens, waiting to see if there is a next one. Adrenaline is pumping and sleep is nearly impossible. You are concerned for your loved one and for your other family members gathered together. You all witness the mottling, continued apnea and gasping, and your loved one’s blood pressure falling. With our current practice, those at the end of life and the family are forced to go through this horrendous process. I do not expect everyone to want these same things and I don’t expect those who have not had to watch a loved one go through this to understand. I believe no one standard practice fits, but rather that physicians should adopt the practice of allowing those suffering to drive the care. After this life experience, I now know how I wish to pass when my time comes. And I will say that if our practices in Texas do not change, I already know my wishes will not be fulfilled.

With all of the capabilities of modern medicine, why do patients still have to suffer at the end of life? To me, this current practice is not only wrong, but inhumane. At the end of life, a patient’s wishes should simply be well understood, documented, and fulfilled.

TEXAS FAMILY PHYSICIAN SUMMER 2015

Vincent Mandola, MD, is the family medicine chief resident at Houston Methodist Hospital.

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