ustxtxb_obs_1974_07_05_50_00008-00000_000.pdf

The sickness biz Look who’s minding the s By Jackee Cox Austin In 1972 the federal government decided it was time to put the lid on the abuses which were skyrocketing Medicare-Medicaid bills. The rising costs, the government concluded, were due in part to unnecessary medical services performed for recipients of Medicare-Medicaid funds. Congress passed Public Law 92-603, which contained two safeguards designed to establish “quality control” over services rendered. The first provision required that all in-patient services paid for by Medicaid be monitored by a “utilization review” program to be established by June 30, 1973. These programs are supposed to be integrated with controls over all physicians’ actions under federally-funded programs, to be implemented by 1976 through regional Professional Review Standards intent to keep PSRO’s outside the monolithic control of state medical societies by requiring that no PSRO region include more than 3,500 physicians. The Texas Medical Association has not taken kindly to the idea of having medical procedures monitored. At its annual convention in Houston, in May, the TMA House of Delegates voted to collect $100 from every doctor in the state as lobbying money for a campaign to kill the PSRO law. With 12,000 doctors to call on, the TMA is shooting for a war chest of $1.2 million. During the first week in May, the TMA filed suit against the regional office of the Department of Health, Education and Welfare. The suit claims that HEW’s division of the state into nine PSRO regions constitutes arbitrary administrative action, and demands that the entire state be designated one PSRO region. If Texas is to have a PSRO, the TMA wants to control it. THEIR STRATEGY for maintaining that control is on its way with the cementing of Medicaid utilization review Jackee Cox is a free lance researcher writer specializing in the field of ;A…Texas Observer procedures into. a statewide block. The acronym for this first step is TARP the Texas Admissions Review Program. It will be financed by funds from the federal government and the Texas Department of Public Welfare. The DPW recently approved TARP. The vehicle is a contract between Blue Cross and the Texas Medical Foundation, because the Medicaid program in Texas is handled by Blue Cross \(federal funds are paid to Blue Cross, which acts as two years, TMF personnel may he employed in more than 90 percent of the state’s hospitals, carrying out the terms of the contract. They will have authority to approve or disapprove payment for all Medicaid hospital claims and will exercise authority over actions of every doctor who treats Medicaid in-patients. The TMS will have the power to invoke sanctions against any doctor whose actions do not meet with its approval. The TMF was incorporated in 1971 by the TMA. The TMA’s legal staff includes Philip Overton, Ace Pickens and Sam Stone. Overton and Pickens are listed as legal counsel to Blue Cross-Blue Shield in those corporations’ 1973 reports to the State Board of Insurance. \(In their 1972 reports, Overton and Stone were listed as Stone is employed as legal counsel to the State Board of Medical Examiners. One of his duties for the agency is to prepare actions to suspend or revoke physicians’ licenses. Under TARP, the TMF will identify physicians who do not q .omply with the foundation’s policies. Doctors so identified could :ultimately . lose’ .their licenses to practice medicine. The TMA’s possible influence over TARP raises the possibility that the independence of Texas physicians may be threatened. In April, I interviewed several San Antonio doctors in an effort to gather testimony on the influence of the TMA. Three are on the teaching staff of the University of Texas Medical School. All three expressed outrage at the reactionary philosophy they saw governing the practice of medicine in Texas. All three seemed fearful, as well. At one time or another they each had mounted a campaign for change from inside the TMA and had suffered reprisals. These three physicians are now so intimidated that they will not even point out the sources of public records which would document their efforts. The reactions of two private physicians in San Antonio were the same. TMF board member Dr. John Smith runs. the Bexar County Medical Society with an iron hand, and no one intending to maintain a practice in the county invokes his wrath. There were, however, two doctors presently employed by the military who were willing to speak up. One was Dr. Ruth Bellinger, who for several years ran her own practice in San Antonio. During that time she was a member of the Texas Medical Association and of the Bexar County Medical Society. Before she could get her Texas license, Dr. Bellinger was required to attend a Texas Medical Association “orientation seminar.” At the time of her “orientation,” President Johnson was pressing for the legislation which produced . Medicare-Medi