Family medicine under the dome in the 83rd Texas Legislature

By Jonathan Nelson

After all the heated controversy and partisan polemics that characterized this summer’s special sessions of the 83rd Texas Legislature, it’s difficult to remember the comparatively calm and congenial nature of the regular session. As longtime political observer Harvey Kronberg of The Quorum Report puts it, both Gov. Rick Perry and Lt. Gov. David Dewhurst entered the session somewhat adrift, having both just lost big elections, which left Speaker Joe Straus in a strong position to set the tone for the session.

“Whereas last session was driven by the Tea Party hysteria and the anti-Obama mobocracy, this session—even with major Republican majorities—the lesson of the 2012 election was still fresh in everybody’s mind,” Kronberg says. “It was hugely anti-incumbent and adolescent behavior was generally not going to be rewarded. So you ended up with I think a far more modulated session that accomplished a few big things and didn’t embarrass itself by racial and gender poison.”

At least until the first gavel dropped in the first special session, but that’s another story.

The Legislature finished the regular session with mixed scores on health care’s most perplexing problems, but compared to last session, organized medicine and the patients of Texas have several reasons to celebrate. After the drastic budget cuts enacted across the board by the 82nd Legislature in 2011, everyone from public schools to women’s health programs were left scrambling to make ends meet.

What a difference a couple of years and several billion dollars can make. Flush with cash and a swelling Rainy Day Fund this time around, lawmakers were in much better moods as they faced teams of advocates from every sector seeking restored funding.

Graduate Medical Education

Topping TAFP’s legislative priorities for the session was restoration of graduate medical education funding, which sustained a 43 percent cut in state support in 2011. This session lawmakers were determined to address GME by partially restoring funding to existing efforts and by investing additional funding in new initiatives designed to increase the number of training positions available in the state.

As a result, total state GME funding will increase by $30 million, or about 45 percent in the upcoming biennium, and planning grants will help develop new residency programs in needed specialties.

Family medicine residency programs receive a special line of direct state funding that goes to train the bulk of Texas’ future primary care physician workforce. Those funds were slashed by almost 74 percent last session, from $21.2 million in 2010-2011 to $5.6 million in 2012-2013. In the next two years, those programs will receive $12.78 million, more than doubling their appropriation. The new funding level will relieve some of the stress residency programs have been under since the deep cuts, but it is still far less than the appropriation these programs have received in the last decade.

Strengthening Texas’ Physician Workforce

Throughout 2012, TAFP’s advocacy team and physician leaders laid the groundwork for a broad policy discussion about Texas’ primary care physician workforce, and the effort paid off. A month before the session began, the issue had gained so much momentum that the chair of the Senate Health and Human Services Committee, Sen. Jane Nelson, R-Flower Mound, pre-filed a bill to strengthen primary care in Texas.

“Primary care serves as the gateway to preventive care, specialty providers, and a wide range of services,” Nelson said at the time. “A strong primary care workforce results in higher quality, more efficient health care with better patient outcomes at a lower cost. This legislation will address Texas’ growing need for primary care, encourage physicians to accept Medicaid patients, and strengthen the provider network for women’s health.”

Her original bill went through many changes and ultimately, it died waiting to make it to the floor of the House, but Sen. Nelson succeeded in attaching its provisions to a bill that passed and was signed by the governor. The bill created a set of incentive programs to create new residency training positions and to encourage medical schools to produce more primary care physicians. The Texas Higher Education Coordinating Board has already begun proposing the administrative structure to implement these programs.

Here’s some more great news: Lawmakers appropriated $33.8 million for the Physician Education Loan Repayment Program, which is an almost 500 percent increase over the current budget. The program will cover up to $160,000 in medical education debt for physicians who agree to practice for four years in an underserved community. Enrollment in the program was closed in 2011 after the Legislature cut its funding by almost $18 million, but with the promise of reinvestment, THECB reopened the enrollment process in late May, with a deadline for the first group of enrollees set for Aug. 31, 2013. For more information and to apply, go to www.thecb.state.tx.us/lrp.

Women’s Health Care

Last session, the combination of the deficit threat and a political determination to deny state funding to Planned Parenthood had a devastating effect on women’s health care programs in Texas. Next biennium, programs that provide preventive and contraceptive care for women will be almost completely restored to their 2010-2011 levels, thanks to a dedicated group of lawmakers and advocates, like the Texas Women’s Healthcare Coalition.

The Legislature increased state funding to the DSHS Family Planning Program by $32.1 million to replace federal funding under Title X awarded to the Women’s Health and Family Planning Association of Texas, and it gave the DSHS Primary Health Care Expansion an additional $100 million for the biennium for women’s health care. About $60 million of that is expected to go for family planning services including contraceptive care. The budget also adds $71.3 million for the Texas Women’s Health Program.

Mental Health

Patients needing mental health services in Texas will be much more secure after this session, as lawmakers pledged more than $225 million in new funding to

Universal Prior Authorization

Physicians will be relieved to know that lawmakers passed a bill designed to end the hassle of dealing with hundreds of prior authorization forms from different insurance plans. The legislation directs the Texas Department of Insurance to convene workgroups that will develop standardized prior authorization forms for prescription medications and medical services for private and public payers.

Scope of practice

Knowing that nurse practitioner organizations would be back this session pushing to gain independent practice, TAFP and the Texas Medical Association worked throughout 2012 to craft a delicate compromise with nurse practitioners and physician assistants. The effort resulted in landmark legislation that streamlines the requirements for physicians delegating NPs and PAs, supports and encourages a collaborative, team-based model of care, and should increase access to care for Texans.

Importantly for physicians, the new law maintains the long-held legal definitions of “diagnosis” and “prescribing” as medical acts, which only physicians can perform under Texas law. For NPs and PAs, the law loosens and simplifies what had become a confusing tangle of regulations; it increases the number of NPs or PAs with which a physician may delegate prescriptive authority from four to seven; and it allows physicians to delegate Schedule II prescriptive authority in hospitals and in hospice care.

Medicaid expansion fails

With the backing of state leadership, this Legislature refused to expand Medicaid coverage to poor adults under the Affordable Care Act, a decision that will have lasting repercussions. For now, Texas will continue to have the highest rate of uninsured people in the nation. TAFP News will follow developments and examine the policy and political considerations surrounding Medicaid expansion in the future.

Politics, relationships, and participation

Throughout the session, family physicians and their patients were represented by a number of members and physician leaders volunteering to serve as Physician of the Day, providing testimony before legislative committees, and providing counsel to lawmakers and their staffs. TAFP’s advocacy team couldn’t have achieved these victories without the influence and the participation of those members across the state who wrote letters, made phone calls, sent e-mails, and played a part in your Academy’s efforts this session.

We’re headed into a busy election cycle and your legislative representatives are headed back to their districts. This is the most important time for you to build those relationships, introduce yourself, or thank them for their work. The time you spend between sessions advocating for your specialty is the foundation for what TAFP can achieve during the session. Check out www.tafp.org/advocacy for tools and ideas on how you can get involved.