2009 TMA Annual Report

President's Message: Let's Finish the Job

As you can see by reading the annual report, 2009 was a very successful year for the Texas Medical Association. That means we made some important strides for you and your patients at a time when we all need it the most.

Our accomplishments were considerable, yet there is still significant work that needs to be done. We cannot rest on our laurels.

Yes, we pushed through our Doctor's Orders agenda in the Texas Legislature, and, yes, we let President Obama and Congress know how we felt about the various health system reform proposals being debated in Washington.

But among the jobs we haven't finished in Washington is fixing the Medicare payment system. Once again, as they have for the past 10 years, Congress and the Centers for Medicare & Medicaid Services put physicians and patients through a gut-wrenching experience.

It's time to tell Congress to stop playing politics with the lives of our patients. Stop the partisan bickering and do what the voters sent you to Washington to do - act in the best interests of the American people. Kill the Sustainable Growth Rate (SGR) formula that cuts Medicare payments to physicians and create a rational Medicare physician payment system.

We don't care who gets the credit. Just get it done.

Please contact your local House of Representatives member and Sens. John Cornyn and Kay Bailey Hutchison and tell them we cannot be patient any longer. We've developed a five-part plan to help Texas physicians fight the Medicare meltdown. All you have to do is log on to the  Medicare Meltdown Action Center . There you'll find all the resources you need to make your voice heard.

We also launched a drive to gather signatures on a petition that asks Congress to abolish the SGR and preserve senior citizens' access to care. Fifty-one state medical associations and 14 national specialty societies promoted the petition that urges Congress to "Stop the Medicare Meltdown" and develop "a rational Medicare physician payment system that automatically keeps up with the cost of running a practice and is backed by a fair, stable funding formula."

Please add your name to the petition and encourage your friends, family, colleagues, staff, and patients to sign it, as well. Log on to  www.ipetitions.com/petition22768.html .

It was a great honor for me to serve as your president during the past year. It was a pleasure to work alongside TMA Alliance President D'Anna Wick. I know that with our new president, Susan Rudd Bailey, MD, at the helm, 2010 will be another great year for our association.

William H. Fleming III, MD
2009-10 TMA president

2009: TMA Wins Again

As January 2009 dawned, the Texas Medical Association entered the year geared to take on familiar opponents: insurance companies, politicians, and bureaucrats who forgot they didn't go to medical school, and some who remembered but didn't care.

It ended the year battling in Congress to add a dose of common sense to the debate over health system reform, and, once again, trying to stave off drastic practice-killing cuts to Medicare payments to physicians.

In 2009, TMA did what it has done since physicians founded it in 1853 - help physicians and patients through its ongoing socioeconomic, legal, public health, scientific, practice management, continuing education, and medical education advocacy efforts.

And as in past years, the association followed the TMA 2015 goals established by the TMA Board of Trustees as its roadmap to the future. TMA 2015 is the trustees' strategic plan to allow TMA to remain successful, stick to core values, and address issues affecting physicians' ability to care for patients. Its goals are Practice Viability, Healthy Environment, Trusted Leader, and One Voice.

Texas physicians responded to TMA's advocacy on their behalf. The association membership continued to increase; thus, TMA now represents almost 45,000 physicians and medical students.

Lawmakers Listen to TMA

The first fight came when the Texas Legislature convened in January. TMA met the opening of the session armed with a powerful array of legislation known as Doctor's Orders . It was an agenda for force-feeding accountability and transparency to insurance companies, expanding patients' access to care, and enhancing the quality and safety of that care.

TMA secured major wins for physicians and patients in the 2009 session, despite the depression-like economy and lawmakers' preoccupation for much of the session with a time-wasting partisan battle over a voter identification bill that killed many other pieces of legislation.

Even so, TMA prevailed and persuaded the legislature to:

  • Require insurers to use accurate data and valid, recognized standards when ranking or tiering physicians in their networks;
  • Increase funding for graduate medical education;
  • Expand the state's physician loan repayment program;
  • Fund the expansion of community-based obesity prevention programs;
  • Enhance funding for mental health crisis intervention;
  • Protect funding to enhance cancer prevention and research, and
  • Create a lifelong immunization registry.

And, while it took the governor's help to fend off trial lawyer treachery and Texas Hospital Association (THA) betrayal, TMA was able to preserve the 2003 liability reforms.

TMA 2009-10 President William H. Fleming III, MD, says lawmakers largely followed TMA's prescription for fixing the state's broken health care system.

"Thanks to patients' champions in the House and Senate, the 2009 Texas Legislature passed bills to reform health insurance, increase access to health care, preserve the patient-physician relationship, and improve the health of all Texans," he said.

A major reason for TMA's success again this year was the association's not-so-secret weapon. A record 1,117 physicians and medical students clad in their white lab coats, along with  TMA Alliance members from across Texas, descended on Austin on the first Tuesdays of February, March, April, and May. They filled the House and Senate galleries, offices, and hallways of the Capitol to lobby lawmakers to pass TMA-backed bills and to testify on legislation before House and Senate committees.

Perhaps the most important development in maintaining a healthy environment for physician practices came after legislators went home. TMA asked Gov. Rick Perry to veto a bill, House Bill 3485, that would have savaged the 2003 tort reforms that TMA fought so hard to pass.

TMA engaged in extensive and lengthy negotiations on HB 3485, a bill that would have allowed hospitals to hire physicians. Those negotiations produced a bill that said government-run hospitals in rural areas would be allowed to hire physicians but only if numerous guarantees and safeguards were included in the employment contract. At the last minute, however, the Texas Trial Lawyers Association, with the secret participation of THA and the Texas Association of Rural and Community Hospitals, and without giving notice to TMA or the Texas Alliance for Patient Access (the tort reform alliance TMA, THA, the Texas Medical Liability Trust, and others formed in 2001 to fight for the 2003 tort reforms), added language that undermined liability protections for physicians and hospitals.

Outraged, on June 8, after the legislature adjourned, Dr. Fleming asked Governor Perry to veto the bill because it would have changed the liability cap from a per-incident standard to a standard that was subject to multiple interpretations, increasing the tort liability for both physicians and rural, government hospitals beyond that of large government facilities.

The governor agreed and vetoed the bill on June 19.

He said what the trial lawyers tried to do "would undermine some of the gains in medical liability reform that have come from caps on physicians' liability," adding that the bill's provision regarding physician liability "was neither debated nor discussed, but rather amended onto this bill late in the session. It risks unraveling the progress we made in curtailing excessive liability and ensuring that patients who need physicians will be able to find them. The 2003 medical liability reform has led to thousands of new doctors coming to Texas. The changes proposed by House Bill 3485 threaten the progress that reform has made."

TMA scored other successes during the 2009 legislative session. Aiding TMA's efforts were legislative champions such as Sens. Robert Deuell, MD (R-Greenville), Jane Nelson (R-Flower Mound), Kirk Watson (D-Austin), Kip Averitt (R-Waco), and Judith Zaffirini (D-Laredo); and Reps. John Zerwas, MD (R-Richmond), Garnet Coleman (D-Houston), Trey Martinez Fisher (D-San Antonio), Todd Hunter (R-Corpus Christi), Lois Kolkhorst (R-Brenham), John Davis (R-Houston), and Craig Eiland (D-Galveston).


  • Introduced insurance companies to the concept of fairness by wining passage of a bill that requires them to make sure any physician-ranking system uses a valid methodology for measuring performance; gives physicians due process before their rankings are published; and mandates disclosure of the measurement standards to physicians before the evaluation period.
  • Blocked a bill by Sen. Rodney Ellis (D-Houston)that would have weakened the 2003 protections for emergency physicians against liability lawsuits. It would have modified the current gross negligence standard from "willful and wanton" to "willful or wanton" and limited the emergency care protections only to Good Samaritans.
  • Won approval of bills requiring health plans to cover the cost of routine care associated with clinical trials, mandating rule-making to require adequate health insurance networks in local markets, and creating a mediation process for patients to resolve disputes for out-of-network, facility-based physician claims.
  • Secured passage of an 18.1-percent, or $15.7 million, increase in state support for graduate medical education.
  • Convinced lawmakers to appropriate funds to help physicians repay their medical school loans if they agree to practice in underserved areas or treat Medicaid patients. TMA-backed legislation increases from $45,000 over five years to $160,000 over four years the amount of medical school debt the state will repay for a physician who agrees to practice in an underserved community.
  • Stopped a bill to allow plaintiffs to collect phantom damages on discounted, or forgiven, medical bills.

TMA also earned higher workers' compensation fees for physicians who treat injured workers and delayed a Texas Health and Human Services Commission attempt to prohibit out-of-network "balance billing" by physicians in Children's Health Insurance Program managed care.

TMA Backs Rational Health System Reform

Nationally in 2009, TMA developed a guiding set of principles on health system reform as it sought to convince the U.S. Senate and House of Representatives not to do anything stupid in the name of reform. TMA supports health insurance industry reforms - including stronger consumer protections and the prohibition of preexisting condition exclusions - as part of its consistent message to Congress and President Obama: Keep what's good and fix what's broken in the health care system.

TMA physicians spoke loudly in one voice in 2009 when they let Congress know through town hall meetings, e-mails, faxes, letters, and telephone calls that they did not support drastic reform of America's health care system.

Working with our medical society partners, TMA leaders fanned out across the state in the summer and fall to conduct 17 "House Calls" to learn directly from patients and physicians what they wanted in health system reform. More than 3,000 patients and their doctors shared their opinions, hopes, and fears.

Unlike the disgraceful and near-riotous spectacles in other states, TMA's meetings offered participants a chance to discuss health system reform and get their questions answered in a rational and respectful manner.

Everyone agreed on four central themes:

  • The country needs insurance reform, not health system reform;
  • National medical liability reform must be included in the health bill;
  • Health care decisions should be made by patients and their physicians, and
  • Texas patients believe the health care system will suffer if reforms are poorly done.

TMA collected and analyzed all comments recorded on video, written on note cards, and submitted in surveys, and forwarded the information to the Texas delegation to Congress. Each member received a video that highlighted the comments made at the House Calls, a report summarizing the written comments, and results of the survey [PDF]. 

Fix Medicare Now!

Health system reform wasn't TMA's only gripe with Congress in 2009. As they have for the past decade, TMA and its allies in organized medicine found themselves pressing Congress to stop yet another scheduled cut in Medicare payment to physicians. This time it was a 21-percent fee reduction set for Jan. 1, 2010.

TMA galvanized physicians to contact their senators and representatives and deliver a simple message: Quit playing useless partisan political games and fix the fatally flawed Medicare physician payment system before it's too late.

Dr. Fleming urged Congress to "to take swift action to stop the implosion of our Medicare system. Since its inception, the Sustainable Growth Rate formula has not worked. Annually, it has forced physicians to limit access for our patients, pushing patients into higher-cost areas like emergency rooms. Every year for a decade, we have faced steep cuts that jeopardize our ability to care for patients. Senators and representatives from both parties recognized this glaring problem - this gaping wound in our health care system - but have been willing to address it only with Band-Aids. We need more than Band-Aids. We need more than sutures. We need a complete transplant. Congress created this disease, and only Congress can cure it."

Congress ultimately delayed the cuts until March, then again until April. But then Congress went home for its Easter recess without doing anything, leaving the fee cut to take effect April 1. It later delayed the cut until June 1.

TMA continues to push for Medicare payment reform. Those efforts include joining county medical societies in holding news conferences across the state to emphasize what the fee cuts mean to access to care for the elderly, Texans with disabilities, and military families, and campaigning to gather 1 million signatures on a petition to urge Congress to "Stop the Medicare Meltdown." 

TMA Protects Physician Practices

TMA, the American Medical Association, with former TMA President Jim Rohack, MD, as its president, and the rest of organized medicine also spoke in one voice in 2009 to persuade Congress and the Federal Trade Commission (FTC) to delay the FTC's "red flags rule" from Nov. 1 to June 1, 2010.

The rule defines physicians who regularly bill their patients for services (including billing for copayments and coinsurance) as creditors. The FTC thus requires them to develop and implement written identity theft prevention programs for their practices. Such programs must identify and respond to patterns, practices, or specific activities known as "red flags" that could indicate identity theft.

TMA continues its efforts to exempt physicians from the rule because they are not creditors.

Physician practices must remain open or they are of no use to patients. In 2009, TMA worked to maintain the viability of medical practices by:

  • Protecting patient safety by challenging the Texas Board of Chiropractic Examiners' attempt to expand the scope of practice for chiropractors through rule-making. TMA won a state district court ruling preventing chiropractors from performing clinical needle electromyography and spinal manipulation under anesthesia.
  • Working with other plaintiffs to settle a lawsuit against Blue Cross and Blue Shield, earning $131 million in payments to physicians for past harm and forcing the company to change its business practices.
  • Joining AMA and other state medical societies in suing Aetna and CIGNA for wrongful out-of-network payments.

TMA helped physicians switch from paper to electronic medical records (EMRs) and prescribing. Some 1,535 physicians and staff members participated in 26 programs conducted by TMA's Health Information Technology Department staff.

TMA also:

Maintaining Trust

When the H1N1 influenza swept across the state in 2009, alarmed patients turned to physicians as trusted leaders and a source of treatment and information on the outbreak.

TMA and its Committee on Infectious Diseases helped physicians meet their patients' expectations by creating a subcommittee of experts known as the "Flu Fighters." These physicians, along with a vast array of resources compiled in the TMA Influenza Resource Center on the TMA website, answered colleagues' questions and kept them up to date on the latest information about H1N1 and seasonal flu from the Centers for Disease Control and Prevention and the Texas Department of State Health Services.

TMA also helped physicians remain their communities' trusted leaders on other critical public health issues in 2009 by developing educational materials on obesity, diabetes, tobacco, the human papillomavirus, and other diseases and conditions.

Thanks to the efforts of physician leaders and TMA staff, TMA remains America's largest and strongest state medical society, effectively representing member physicians in nearly all venues and providing members with quality education, information, and tools they can't find anywhere else.