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Texas Medical Board

The travel ban and the rural doctor shortage

Just another unintended consequence.

In Texas and across the country, foreign-trained doctors like the Iranian-born [Dr. Hossein] Yazdani fill a critical need in rural communities, which often struggle to attract physicians born and trained in the U.S. That reality has been highlighted in the weeks since President Donald Trump signed an executive order temporarily banning travel from several predominantly Muslim countries.

A revised version of the order issued Monday was intended to keep terrorists from entering the country, but it also threatens to block international medical graduates, who help fill a growing physician shortage.

Yazdani is a classic example. He came to Houston for a prestigious fellowship at Texas Heart Institute. When he completed the training in 1997, he was given two choices: Return to Iran, or apply for a J-1 visa waiver, which allows international doctors to stay in the U.S. in exchange for working as primary care physicians in medically underserved areas.

Yazdani went to work in Anahuac.

“I had to stay three years to meet my requirement,” he said during a recent interview at his clinic. “But after that, I was interested to stay here in the community. A lot of doctors are in the big city. But there are poor people here who I like to help.”

In Chambers County, where he practices, nearly 80 percent of residents voted for Trump. A few blocks from his tiny clinic, a huge “Trump-Pence” campaign sign is painted on the side of a barn.

But inside his office, he said, politics rarely comes up.

“Patients come to see me, and I help them. That is all,” he said. “Patients don’t ask where I come from.”

Physicians who attended medical school in the six countries affected by Trump’s new order – Iran, Syria, Libya, Yemen, Sudan and Somalia – provide 14 million appointments to American patients each year, according to an analysis by Harvard and Massachusetts Institute of Technology economists. That includes more than 2.3 million office visits in areas with doctor shortages.

[…]

The problem is bigger in Texas, [Travis Singleton, senior vice president of Merritt Hawkins, a Dallas-based medical recruiting firm] said, where an additional 13,000 doctors are needed just to bring the state in line with the national average of physicians-per-resident. Thirty-five of Texas’ 254 counties have no doctors at all. About 150 counties have no general surgeons, psychiatrists or gynecologists.

International doctors are helping fill the gap: A third of Texas’ doctors were born abroad, including more than 1,000 from one of the six countries named in Trump’s order, according to a Houston Chronicle analysis of Texas Medical Board licensing data.

The rural doctor shortage, in Texas and elsewhere, is nothing new. It was cited as a reason for passing the 2003 tort “reform” proposition, which doesn’t make any more sense now than it did then and which obviously hasn’t had much effect. My guess is that if it was pointed out to the Trump-voting people of Anahuac who have been patients of Dr. Yazani that they might never have had his services had a travel ban like Trump’s been in existence before, that they’d react the same was as those people in Illinois who didn’t understand why one of their longtime and well-liked local residents had been targeted for deportation. But he’s one of the good ones! That’s not what I voted for! Well, it is what you voted for, and the Trump administration doesn’t distinguish between “good” immigrants and “bad hombres”. Maybe check the fine print next time. In the meantime, will any Republican elected official who represents a rural county that may never have a doctor again speak up about this?

More on the Texas telemedicine lawsuit

Texas Monthly has a nice overview.

Imagine you’re sick, or you think you might be sick, and you want to talk to a doctor. Instead of waiting a week or two to see your primary care physician, you just open an app on your phone or computer and within minutes you’re video-chatting with a doctor or nurse. Maybe you even have a medical device, like a blood pressure monitor, that connects your computer and transmits images and data to your doctor in real time while you’re talking.

That’s not science fiction. It’s called telemedicine, an $18 billion worldwide industry and one of the fastest-growing sectors in health care. In many ways, telemedicine represents the future of health care, promising to do for medicine what Uber and Lyft have done for transportation. Across the country, the use of telemedicine is expanding as consumers realize how much more convenient it is to talk to a doctor when and where they choose. It’s also a lot cheaper. The average telemedicine visit costs between $40 and $50, compared to the average in-person doctor’s visit, which is about $100 more—not counting the cost of the time and effort it takes to travel to and from a brick-and-mortar doctor’s office.

But here in Texas, where we have an infamous shortage of doctors and nurses, telemedicine has hit a snag. New rules promulgated by the Texas Medical Board last year prompted Dallas-based Teladoc, the largest telemedicine firm in the country, to file a federal antitrust lawsuit against the board. Specifically, the medical board’s new rules (PDF), approved in April 2015 but blocked by a federal judge’s preliminary injunction just days before they were set to take effect, stipulate how physicians in Texas can establish a “doctor-patient relationship” with new patients before engaging in telemedicine. A patient must either visit the doctor in person or meet “face-to-face” over video conference. But the video conference must be at an approved medical site like a hospital, clinic, or a fire station, and there must be a “patient site presenter” on hand, like a nurse or a physician’s assistant. In other words, you can’t just turn on your computer at home, login to a telemedicine app and be connected with a doctor. Put another way, in Texas you have to go to a medical clinic to be seen by a doctor, even if the doctor isn’t there.

This presents a substantial obstacle for Texans who are interested in using telemedicine. Many people, especially younger folks, simply won’t go to a doctor’s office, either because they don’t have what doctors and policymakers call “a medical home,” or because they don’t have health insurance.

So in Texas, which has the highest uninsured rate in the nation, on-demand telemedicine could be a game-changer. It holds the promise that, instead of forgoing medical care, more people might actually seek out a doctor when they’re sick.

All of this is why the antitrust lawsuit Teledoc filed has sparked so much debate—and confusion. Teladoc, which says Texas was already among the most restrictive states in the country for telemedicine, claims the new rules will hamstring telemedicine firms and limit patients’ access to healthcare. The medical board claims just the opposite. It views its new regulations as an expansion of telemedicine, not a restriction of it. Meanwhile, as the case wends its way through federal courts, a consortium of health care and tech groups is calling on the Texas Legislature to step in and settle the matter when lawmakers convene in Austin early next year.

[…]

The Legislature seems at least somewhat aware that it needs to step in. Last session, both the Senate and House issued interim charges to study telemedicine and give recommendations about how to improve it. To date, most of these hearings have steered clear of the lawsuit and spent considerable time hearing testimony about how great telemedicine is in Texas. To be fair, Texas was one of the first states to invest in telemedicine technology in the 1990s, and since then has tried to encourage its use in rural areas where medical specialists are scarce. One pilot program, supported by state funds and run by the Texas Tech University Health Sciences Center in Lubbock, will equip ambulances in rural West Texas with technology that allows first responders to communicate with physicians at regional trauma centers on a secure internet connection and transmit patient data in real-time while en route to a trauma center or an emergency room.

Those are real advances, and will likely save some lives in rural communities. But the big gains from telemedicine will come from hundreds of thousands of consumers using the services for routine care—and doing so on their own initiative from their homes and offices. To make that possible in Texas, lawmakers might need to act. During the 2015 session, Representative Jodie Laubenberg filed several telemedicine bills, including one that would have prevented the medical board from issuing the rule requiring a face-to-face consultation if the physician had never seen the patient. The bill was introduced and referred to the House Public Health Committee, but after the board published its new rules in April and Teladoc sued, Laubenberg, pulled it. “If something’s going to court, we stand back,” she said—a line that’s since been repeated in interim hearings on telemedicine.

But Laubenberg, along with Teladoc and many other Texas-based healthcare firms, thinks the legislature should step in once the court case is settled. They think this is about something much larger than a single antitrust suit. “Over the last five to ten years, telemedicine changed from a promise to a reality,” says Gorevic. “Now we’re starting to see the benefits. Today it’s becoming part of the fabric of the healthcare delivery system.” Just how much a part of the fabric it becomes in Texas depends not only on the Fifth Circuit Court, but how well lawmakers can work with regulators once the dust settles. Right now, the tide seems to be turning in telemedicine’s favor. In September, Robinson, the medical board’s executive director since 2001, announced she’s leaving the board to direct the telemedicine program at University of Texas Medical Branch in Galveston.

For lawmakers like Laubenberg, the issue is about something yet greater than healthcare: the degree to which regulatory boards should make up rules for their industries. “I’ve never been a big fan of agency rulemaking. They tend to go rogue,” she said. “I think the medical board thought they could get ahead of it, but the issue’s too big, and they couldn’t do it.”

See here for the background, and be sure to read the whole thing. It seems likely that Teladoc will prevail in court, though one never knows for sure, and it won’t surprise me if the Lege decides to step in and attempt to settle the matter themselves. There is of course an irony in Jodie Laubenberg being so involved with this, since the omnibus anti-abortion HB2 from 2013 prohibits dispensing abortion-inducing drugs (mifepristone-misoprostol regimen) by anyone other than a physician and requires that the physician dispensing the drug first examine the pregnant woman, which is interpreted to mean “in person”, thus making HB2 itself a telemedicine ban. That provision wasn’t part of the lawsuit that led to much (but not all!) of HB2 being struck down, though it may well come later. Point being, Laubenberg considers regulating doctors to be her job, not the Medical Board’s. We’ll see who gets to make the next move, the Fifth Circuit or the Lege. Texas Association of Business President Bill Hammond, opining in the Chron, has more.

Texas v. the Feds: Telemedicine edition

Here’s a new one.

Teladoc, the Dallas-based company that sued Texas over its telemedicine regulations, has a new ally in the Federal Trade Commission.

In a letter sent to the U.S. 5th Circuit Court late Friday, the federal antitrust agency sided with Teladoc in the company’s legal battle, criticizing the Texas Medical Board for allegedly misinterpreting case law.

The telehealth company sued last year to block board rules that in most cases require face-to-face contact between a patient and a physician before a physician can issue a prescription.

That threatened Teladoc’s business model, which virtually connects Texas patients to remote, Texas-licensed doctors, some of whom are based out-of-state. The company says its physicians consult patients over the phone for routine medical issues, and patients can upload photos or other information describing their symptoms and medical history.

Teladoc filed an antitrust lawsuit against the regulatory Texas Medical Board in federal court last year, alleging that the 19-member board made up mostly of doctors had behaved like a cartel by passing rules intended to limit competition.

The state has asked the appeals court to throw out Teladoc’s lawsuit, and federal regulators on Friday urged the court not to.

The Texas Medical Board failed to show that “any disinterested state official ever substantively reviewed” the telemedicine rules “to determine whether the rules promote a clearly articulated state policy to displace competition rather than the private interests of active market participants,” federal regulators wrote.

I hadn’t noticed this before now, and I don’t know much about this, though on the surface it sounds like Teladoc has a good argument. I was hoping to find an analysis of this via Google, but the best I could do was this by the hacks at the TPPF that was just boilerplate business/free market rah-rah. Here’s an interview with Teladoc’s CEO from January about the lawsuit, if you’re interested. The suit was filed by Teladoc, the AG’s office is defending the Texas Medical Board, and the feds have only just gotten involved, so this isn’t a typical Texas-versus-feds situation. It is a reminder that not all such cases fall into the usual narrative.

Abbott sides with medical malpractice

Awesome.

Dr. Christopher Duntsch

The Baylor Regional Medical Center at Plano, accused of protecting a neurosurgeon who allegedly killed and maimed patients, gained an ally this week in Texas Attorney General Greg Abbott.

Abbott filed motions to intervene in three separate federal court suits brought against Baylor Plano by former patients of Dr. Christopher Duntsch. They have alleged that Baylor knew Duntsch was a dangerous physician but did not stop him from performing back surgery.

The suits challenge the constitutionality of a state law that requires the plaintiffs to prove that Baylor acted with actual intent to harm patients. Abbott seeks court permission to defend the statute.

If Abbott’s position is upheld, the patients would have a much harder time winning a suit against Baylor. One of the plaintiffs’ attorneys, James Girards of Dallas, criticized the attorney general’s motion.

“I think it’s absolutely insane that he has chosen to defend the hospital that enabled this … sociopathic neurosurgeon to wreak havoc on its patients,” Girards said. “I hate to think he’s doing it to pander to the medical lobby.”

Kay Van Wey, a Dallas lawyer who filed two of the suits, also attacked the attorney general. “Mr. Abbott is making it clear that his priority is to protect hospitals, not the patients they harm,” she said.

Wondering where you’ve heard the name Christopher Duntsch before? Let me quote from this Observer story, which I blogged about last October.

In late 2010, Dr. Christopher Duntsch came to Dallas to start a neurosurgery practice. By the time the Texas Medical Board revoked his license in June 2013, Duntsch had left two patients dead and four paralyzed in a series of botched surgeries.

Physicians who complained about Duntsch to the Texas Medical Board and to the hospitals he worked at described his practice in superlative terms. They used phrases like “the worst surgeon I’ve ever seen.” One doctor I spoke with, brought in to repair one of Duntsch’s spinal fusion cases, remarked that it seemed Duntsch had learned everything perfectly just so he could do the opposite. Another doctor compared Duntsch to Hannibal Lecter three times in eight minutes.

When the Medical Board suspended Duntsch’s license, the agency’s spokespeople too seemed shocked.

“It’s a completely egregious case,” Leigh Hopper, then head of communications for the Texas Medical Board, told The Dallas Morning News in June. “We’ve seen neurosurgeons get in trouble but not one such as this, in terms of the number of medical errors in such a short time.”

But the real tragedy of the Christopher Duntsch story is how preventable it was. Over the course of 2012 and 2013, even as the Texas Medical Board and the hospitals he worked with received repeated complaints from a half-dozen doctors and lawyers begging them to take action, Duntsch continued to practice medicine. Doctors brought in to clean up his surgeries decried his “surgical misadventures,” according to hospital records. His mistakes were obvious and well-documented. And still it took the Texas Medical Board more than a year to stop Duntsch—a year in which he kept bringing into the operating room patients who ended up seriously injured or dead.

In Duntsch’s case, we see the weakness of Texas’ unregulated system of health care, a system built to protect doctors and hospitals. And a system in which there’s no way to know for sure if your doctor is dangerous.

I’d call this a case of putting politics above people, and it’s completely in character for Greg Abbott. I think he just doesn’t believe anyone should be able to sue for medical malpractice. You can call it what you want – Texas Watch calls it “defending the indefensible” – I’m sure the Wendy Davis campaign will have a name for it as well.

Another poster child for tort “reform”

The Observer asks how well you know your doctor.

In late 2010, Dr. Christopher Duntsch came to Dallas to start a neurosurgery practice. By the time the Texas Medical Board revoked his license in June 2013, Duntsch had left two patients dead and four paralyzed in a series of botched surgeries.

Physicians who complained about Duntsch to the Texas Medical Board and to the hospitals he worked at described his practice in superlative terms. They used phrases like “the worst surgeon I’ve ever seen.” One doctor I spoke with, brought in to repair one of Duntsch’s spinal fusion cases, remarked that it seemed Duntsch had learned everything perfectly just so he could do the opposite. Another doctor compared Duntsch to Hannibal Lecter three times in eight minutes.

When the Medical Board suspended Duntsch’s license, the agency’s spokespeople too seemed shocked.

“It’s a completely egregious case,” Leigh Hopper, then head of communications for the Texas Medical Board, told The Dallas Morning News in June. “We’ve seen neurosurgeons get in trouble but not one such as this, in terms of the number of medical errors in such a short time.”

But the real tragedy of the Christopher Duntsch story is how preventable it was. Over the course of 2012 and 2013, even as the Texas Medical Board and the hospitals he worked with received repeated complaints from a half-dozen doctors and lawyers begging them to take action, Duntsch continued to practice medicine. Doctors brought in to clean up his surgeries decried his “surgical misadventures,” according to hospital records. His mistakes were obvious and well-documented. And still it took the Texas Medical Board more than a year to stop Duntsch—a year in which he kept bringing into the operating room patients who ended up seriously injured or dead.

In Duntsch’s case, we see the weakness of Texas’ unregulated system of health care, a system built to protect doctors and hospitals. And a system in which there’s no way to know for sure if your doctor is dangerous.

Reading this reminded me of another poster boy for tort “reform”, Doctor Eric Scheffey, who plowed a path of death and mayhem a few years ago before finally being stopped. These guys are obviously atypical, but as the Observer story points out, the system we have today has almost no power to do anything about them. The Texas Medical Board’s authority is very limited. Hospitals are not required to disclose the reasons why a particular doctor is no longer employed there, so bad doctors’ bad acts don’t follow them from one place to another. And of course, thanks to our draconian medical malpractice lawsuit limits, the courts no longer serve as a way to get the bad apples out of the barrel. The vast majority of doctors are competent and conscientious, so for most of us it’s not a problem. But for a non-trivial number of unfortunate people – the Observer story documents a few of them – it’s a matter of life and death. And our famously “pro-life” legislature could not care less.

Restricting abortion has always been about restricting abortion

Claims that it’s about “protecting women” have always been baloney.

In their successful push this summer for strict new regulations on abortion facilities and the doctors performing them, proponents of the legislation said it was needed because conditions at existing facilities made it unsafe for women seeking to terminate pregnancies.

But a Texas Tribune review of state inspection records for 36 abortion clinics from the year preceding the lawmakers’ vote turned up little evidence to suggest the facilities were putting patients in imminent danger. State auditors identified 19 regulatory violations that they said presented a risk to patient safety at six abortion clinics that are not ambulatory surgical centers in Texas. None was severe enough to warrant financial penalties, according to the Department of State Health Services, which deemed the facilities’ corrective action plans sufficient to protect patients.

And between 2008 and 2013, the Texas Medical Board, which regulates the state’s physicians, took action against just three doctors who performed abortions — all of them for administrative infractions that did not involve criminal practices or late-term abortions.

“The point of this legislation was to make abortion inaccessible. It wasn’t about safety,” said Amy Hagstrom Miller, chief executive officer of Whole Woman’s Health, which operates four abortion clinics and an ambulatory surgical center in Texas. “Because there is no safety problem around abortion in Texas.”

[…]

During his research on the impact of Texas’ 2011 family planning financing cuts, Dr. Daniel Grossman, a principal investigator on the University of Texas at Austin’s Texas Public Policy Evaluation Project, said he found no evidence that Texas’ licensed abortion facilities had unsafe conditions. The one safety issue he has identified is the practice of abortion self-induction — where women without easy access to abortion clinics try to terminate the pregnancy themselves.

“This additional burden is just going to be too much for some women,” Grossman said. “I think it’s very, very likely that abortion self-induction is going to go up and that’s definitely going to be bad for women’s health.”

Seven percent of women whom the researchers surveyed at abortion facilities in Texas attempted self-induction before going to the abortion facility. That rate was higher, 12 percent, in cities along the Texas-Mexico border. In comparison, a 2010 research article published in the American Journal of Obstetrics & Gynecology found 1.2 percent of women surveyed at abortion clinics nationally tried to self-induce an abortion.

The researchers identified 76 family planning clinics that closed since 2011 because of lost state financing, and 45 percent of women surveyed at abortion facilities said they were unable to access their contraception of choice in the three months before becoming pregnant.

“These abortion restrictions are going into place at a time when the whole family planning safety net really has been completely dismantled,” said Grossman. “In the middle of that, now women are going to find it harder and harder to access abortion.”

The only surprise in this to me is that the anti-abortion zealots feel the need to disguise their intentions by making phony claims about being concerned about women’s health. It’s only a mild surprise, since that does poll better, but still. It’s a fundamentally dishonest argument, and in a state that’s been busy forcing women’s health clinics out of business, it’s a deeply cynical one, too. BOR has more, and Nonsequiteuse has something you can do to help fight back.