In this conversation with the Texas Medical Association’s (TMA) new president, Dr. Rick Snyder, the cardiologist from Dallas offers his insights on the issues impacting physicians in the state and his vision for how to solve them.
TMA is spearheading national advocacy for Medicare payment reforms. The organization has successfully litigated against CMS in two lawsuits for its rules around surprise medical billing disputes. Snyder also talks about how TMA’s political advocacy resulted in a successful legislative session for physicians.
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State of Reform: As TMA’s new president, what is your vision for the organization going forward?
Rick Snyder: “The healthcare that we experience today is no longer primarily determined by science and education. More and more it’s determined by politics and advocacy.
Really the advocacy part is the most important. It’s no accident that most state medical associations and national specialty societies are located in Austin and DC, the epicenters of politics and not the epicenters of science. Because the reality is you may have a patient that has every clinical indication and no exclusion criteria. They could have the clinical confidence—intervals could be clean and the P-value has eight zeros. If that test or procedure is not covered and paid for, there is no access to care.
[Physicians] can’t be satisfied with just coverage. Coverage is not the same thing as access and access to a waiting list is not access to healthcare. And a lot of these things are not mainly on the science or education side, it’s part of advocacy. So I really want for us as an organization [to be] advocates for our patients, to be more a universal part of our culture. Because a lot of the things that we can help in terms of helping access to care and enforcing that patient-physician relationship is going to be in the realm of advocacy.
The patient-physician relationship is really under attack by third parties. And it’s again, not based on factors that are scientific in nature, but really based on politics and advocacy. One of the ways they’re trying to diminish the patient-physician relationship is [to] relabel, redefine what the physician role is in redefining us as a provider and bringing in non-physicians into that relationship. We’re also seeing a lot of rules and regulations that are politically motivated in terms of what that patient-physician relationship can look like—either from a testing standpoint, or a procedure standpoint, or even just having a conversation.
A lot of times we can’t even just have a conversation about the reality of their clinical situation. What are the clinical variables or opportunities, or even what the guidelines say?
For example, I’m a cardiologist. With the American College of Cardiology, we have guidelines for women who are pregnant. If they have a certain series of conditions—I think they’re five or six—it’s been a national guideline in my society for years that therapeutic termination of pregnancy should be considered and recommended. So even if I have that conversation clearly with this current regulatory environment in Texas, I could be sued for that.
If I don’t have that conversation with my patient, I’m not being an advocate for my patient and I could be sued for not providing the standard of care. We should be able to have open, frank, and honest conversations with our patients and not be under the scrutiny or fear about what we’re trying to do in terms of educating our patients, in terms of the science and the educational part.”
SOR: What are some of these issues facing Texas physicians and their patients, and do you feel the legislature addressed them this session? Which bills were of significance and how will they impact your members and patients?
RS: “We never got 100% [of our legislation passed], but we felt this session was a particularly successful session. I think there were more than 10,000 bills total. This is one of the highest numbers on record. On healthcare-related [legislation], we were actively tracking over 2,000 bills. Most of those we were playing defense, but some were playing offense.
Scope [of practice] clearly is a big issue for TMA. There was a lot of focus on nonphysicians having complete independence [to] practice without having physician supervision, especially on the nurse practitioner side. [Nurse practitioners] want to do what [physicians] do without having done what we’ve done. Essentially, to be an MD in the state of Texas, you have to do two years of education in the classroom, and two years of clinical training in the hospital your third and fourth year.
So just conservatively, if you’re just a third-year medical student, you’ll do over 2,000 hours, just as a third-year medical student. Then you have more hours as a fourth year and then you graduate from med school and now you’re an MD. Even with all those hours, we don’t allow them as an intern with unfettered access to supervision.
When you’re an intern, if you already have 3,000 hours accumulated in med school, you still have a resident [supervising] you, providing guidance and leadership, and then you have an attendant So you still have to do an additional year. Nurse practitioners generally average 500 to 720 hours of clinical training. [Physicians] get almost two to three times that amount, just in your third year of med school. We don’t think that’s enough to let them loose taking care of patients. It’s that experience level—over and over again seeing different types of things because you can’t learn everything from a book. We do two years in the classroom the same as nurse practitioners, but it’s that clinical experience.
There were 130 scope bills in the state of Texas and all 130 were defeated. So we are very much on guard from the state level. We’ll just have to see what happens on the federal level if any federal statute is enacted, which would contravene some of the state law.
We’re trying to protect the patient-physician relationship. It’s about access … It’s not just about coverage, it’s got to be [about] meaningful access. We had some big wins at the state level—House Bill 12, which extended insurance for pregnant moms who have just delivered from two months to 12 months.
For my specialty, that’s a big deal because there’s a condition called postpartum cardiomyopathy, which doesn’t frequently manifest until anywhere between three and six months postpartum. So that’s a very vulnerable time period where they may not have insurance. That was a win for us.
Also on the insurance side [is] HB 3359. [Texas Department of Insurance] does regulate the insurance industry, but what most people don’t know about is [that many insurers] have waivers for some of those regulations. What [HB 3359] will do is bring some transparency to the waiver process. There has to be an annual report by [the] insurance entity where those waivers have to be disclosed to the public. When there’s a public comment period, the public will then be able to have their voice heard about the appropriateness of those waivers.
Additionally, what that bill has helped to redefine is the geographic and time perspective in terms of access. If your insurance plan only enables you to access the healthcare system two counties away or two months away, that’s not meaningful access. So it helps to put some geographic and timeliness constraints around that. It’s got to be timely access to high-quality care, because timeliness is as much a quality factor as anything else.
We really need to put some guardrails about what is meaningful access or meaningful coverage in terms of the health plans that people access. Some patients can’t get in to see a [specialist] on their plan for three or four months. You’re still covered, but if you can’t see somebody for three or four months, is that really meaningful [access]?
SOR: TMA was successful in its legal challenges to federal rules around surprise medical billing arbitration. What does the current arbitration process look like? What should that process look like in order for it to be equitable? How will the association be working to make those changes?
RS: “If you looked at the federal No Surprises Act, we were actually good with the statute. The part of the rulemaking—it was going to bind the arbiter to factors that overwhelmingly favor the insurance companies, specifically the QPA, the qualified payment amount. There are different ways on a geographic area to look at what a QPA would be. In the first interim rule, which we sued [against] and won, you would take the median contract for an area and the median contract would be the QPA without consideration of these other factors. [This] is really going to handcuff the arbiter.
The problem with that is … some specialties have like 60 to 70% of the physicians. You may have 70% of physicians, but that’s just one contract. And it obviously would not be the median. It’s just one contract. So that’s what we sued over. Then HHS and CMS got creative and kind of said, ‘Alright, you can consider these other things but you’ve got to consider the median first,’ and so we sued on that.
We’re really going over how they create a QPA to use and in what order. What are the different things that can be used so it doesn’t dramatically favor the insurance company? If you come out with a methodology that establishes what that QPA is—that overwhelmingly favors insurance companies—it’s going to be a race to the bottom for physician rates, which is going to be a real problem.
The other problem is when you look at the age of the average physician. Let’s say in cardiology, 64% of cardiologists [who practice] general cardiovascular disease are 55 or older. If you look at all specialties, about 48% are 55 and older. So how do we solve that? More [grant medical education] funding, which we did get quite a bit [of] this session mainly for residency, because we want to be a net importer of medical students into the state for residency. We got quite a bit of money to use for more med school slots and more residencies to help produce more physicians to help meet the need.”
This interview was edited for clarity and length.