Setting the Agenda - President-Elect Dr. William W. Hinchey Discusses TMA’S Legislative Push
• SAN ANTONIO
In medicine, the role of the medical pathologist is often a poorly understood one. Operating in labs, mostly concealed from public view, the pathologist works to determine the mechanism, structure and consequences of diseases in order to provide information for others to act on.
In a way, it’s a role that seems exceptionally compatible with the function of a physician and healthcare advocate: Determining the mechanism, structure and consequences of public health policy – except in this particular case, his role is very much in public view.
In May, San Antonio native Dr. William W. Hinchey, a graduate of and an assistant clinical professor of pathology at The University of Texas Health Science Center at San Antonio—who also served as chair of pathology and chief of anatomic pathology at The Baptist Health System as well as director of residency rotations at Baptist Medical Center for several years—became UTHSCSA’s first graduate to become the president-elect of the Texas Medical Association.
After serving one year as president-elect, Dr. Hinchey will take the reins as the association’s president in the spring of 2007, well into the next session of the Texas Legislature.
“Texas physicians have big challenges to face and solve. Declining patient access to care, threats to the viability of physicians’ practices, and the changing demographics of both Texas patients and physicians are all paramount,” Hinchey said.
“We also must work with all stakeholders to address the problem of Texas’ growing number of uninsured patients. I also look forward to working with state and federal officials to improve the health of all Texans.”
DOCTalk recently sat down with Dr. Hinchey to talk about these issues and TMA’s plans for action in the new year.
DOCTalk: Where are you originally from, doctor?
Dr. William W. Hinchey: I was born in San Antonio, and I’ve been here all my life. I went to medical school here, and I’m living in the house I grew up in.
My father was an orthopedist that came here in the late 1940s, and was in practice here until he retired. I grew up here, went to Catholic grade school. I’m a native San Antonian.
You are president-elect of the Texas Medical Association, is that correct?
That’s right. Dr. Ladon W. Homer is the current president; I take over in April.
How much importance do you place on the role of politics in the delivery of healthcare?
It’s really important. The decisions at both the state and federal level greatly affect the delivery of healthcare in getting programs adequately funded, so people can find a medical home.
For example, we need to take advantage of the federal programs, so we can draw down the federal dollars, so we can get children into the CHIP program and get people with lower incomes into the Medicaid programs, so they don’t end up in our emergency rooms to get basic medical care, or end up in the emergency room after they’ve gotten sicker than they should have been, and get more expensive care.
Access to healthcare is critical. We have fewer and fewer doctors taking new Medicare and new Medicaid patients. A number of those patients do not have a medical home. We’ve got to change the environment so that physicians will take these patients, so these people will have a medical home.
A healthy Texas workforce is the way to a healthy Texas economy.
We often talk about EMTALA. What would happen to this indigent population if we did not have EMTALA?
It’s hard to say. EMTALA is essentially an unfunded mandate. If a person goes to the emergency room, they at least have to be stabilized; the hospital has to make sure they do not have a life-threatening event before they are discharged or transferred. They have to be handled.
If we did not have EMTALA, people would still go to the emergency room; doctors would still see the patients, I have no doubt about that. An emergency room doctor, until he puts his hands on the patient, talks to the patient, does not know what the situation is. He’s going to see the patient. There’s not going to be a sign on the door that says, ‘If you don’t have money to pay, go down the street.’ The healthcare system would still take care of them.
Do you think there is a better way?
That’s what we are trying to look for.
We have a new legislative session starting in January, and obviously you are going to be very involved. What is the most pressing issue for the physician community?
I finished a term as chairman of the Board of Trustees last May, before my election, and there was no doubt that the message I heard most urgently was to do something about the Medicaid system. And that really expands into the whole uninsured problem.
Texas is the uninsured capital of the country. We like to be number one in a lot of things, but that is one thing we do not want to be number one in.
We have this large uninsured population – a large number of whom work or have a family member who is employed, but whose employer doesn’t provide insurance. So, we have the uninsured problem that expands the Medicaid problem—the pie just gets bigger and bigger. That is an issue we are going to address.
Is this issue equally important to physicians throughout the state of Texas?
Yes, I do think so. I know that in the Rio Grande Valley and in deep South Texas, the Medicaid population makes up a large proportion of those physicians’ practices, so they may be more severely hit than other areas.
But there are also people here in Bexar County who have large Medicaid practices, as well as parts of Harris County, in Dallas, and they have the same issues. And we all have the problem of the uninsured that we need to look at.
In fact, with Healthy Vision 2010, which I think Dr. Gunby talked to you about, we’ve been having a series of summits. We’ve drawn people in from business, from the government, from the insurance industry and from among physicians. What do we have in common, and what kind of program can we all support together in the legislature that will at least help to begin to solve these problems?
Has the business community been receptive?
They have so far. They’re the guys who write the checks.
You mentioned Ken Shine, and there’s no doubt that Code Red is running almost parallel with our Healthy Vision 2010. Two separate, independent projects with almost the same goals, are coming to the same conclusions: We’ve got to do something, and we’ve got to do it now.
And we have an opportunity. There are a lot of forces coming together. TMA brought business in, and so did Code Red. Everyone is starting to realize that business has been writing a lot of checks for healthcare through their employee health programs.
Who is subsidizing healthcare here in Bexar County? It’s the local citizens, and that includes the business community. According to a study by Families USA, it’s been estimated that in Texas, $1,551 annually from an employer-sponsored health insurance premium goes to cover the uninsured.
Nationally, that figure is $922, so we are paying more for the uninsured in Texas, and that is a business cost.
Have all these groups been coming to the table?
So far we have had very productive talks. Very productive. Aetnea’s been there, United has been there, Blue Cross/Blue Shield has been there. They are participating.
And when I say they have been there, I mean their senior officers. The Texas CEO of United Healthcare, Tom Quirk, was there. Martin Foster, the president of Blue Cross/Blue Shield of Texas as well as Dr. Paul Handell, his vice president and chief medical officer were also there. We had Dr. Daniel Valdez, who is the medical director for Aetna, there. They’re sending the heavyweights, so they are interested.
Over the last five years, has the access situation improved for the average patient?
That’s a good question, and a little tough to answer. Tort reform, no doubt, has resulted in more doctors coming to Texas, which increases access, and it has been all specialties. They’ve been going to areas that have been underserved—the number of doctors locating to the Rio Grande Valley has been increased. The number of doctors locating to Bexar County has been increased. So yes, there are more doctors available.
From that point, the question becomes: Are they taking new Medicare and Medicaid-eligible patients? I don’t have the answer for that, I don’t know, but the polls that TMA has done show that fewer doctors are taking new Medicaid and Medicare patients.
Because of the reduction in reimbursements?
Because of lowered reimbursements, and the higher costs of running a practice. It becomes a situation of: “I can’t do many of these, because I can’t pay my nurse or my office staff to keep my office open.”
We also have the issue of CHIP, where we have lost a substantial number in enrollments in the last couple of years. It seems that because of some political decisions, things have been going in reverse. Will this be addressed in the next session?
That’s our goal. We are going to go with a plan to address both the Medicaid and CHIP programs.
Doctors have taken cuts in their Medicaid reimbursements, and CHIP is tied to Medicaid, of course. We’ve never kept up with the rate of inflation, even at the low rate it was.
More than just getting the doctors their reimbursements, there’s the problem of just keeping the office open to see the patient, to give that person a medical home. We need to look at innovative ways. What programs can we use to draw down more federal dollars?
The Houston and Galveston area is going to do the Three-Share Insurance Program, in which the premium costs are shared between the employee, the employer and the federal government through a subsidy fund. We need to get these federal waivers to try and draw down more federal dollars.
What we are going to do at our summit with the business and insurance people on Friday, October 27 may become our legislative agenda. What we are going to be doing is mocking up a bill—we’re going to work in a senate hearing room next Friday. One of us is going to act like a legislator, laying out a bill. We’re going to have a mock committee hearing, we’re going to have testimony and then a decision on a final draft. We’re going to be doing that on the uninsured issue, and one on wellness.
Part of this is to stimulate ways of getting businesses—small employers who, because of costs, have been driven out of providing insurance—back into the market. Do we get an actuarially sound pool, so that the small employers can combine their resources and create a bigger risk-sharing pool?
There has to be some way; there are so many small employers who just cannot afford to provide insurance.
Exactly, and that’s a real problem.
But the idea—as far as Medicaid is concerned—is how we can draw down more federal dollars. Do we need to convince the state that more state resources need to be put into this program so we can care for more people?
It’s almost a trickle down effect. If the state does not kick in a larger share—not to say that it’s not a large share, because if you look at the total, it’s a lot of dollars already—where does it finally fall down to? The local level.
And what does that mean? Local businesses pay more for healthcare, the hospital districts have to charge a higher tax rate, and that affects everybody. It’s a Texas problem. It’s everybody’s issue.
If we can keep kids in school, because they are not home sick, they do better—we have good data that shows that. They get a better education, they go into better jobs, and in the long term they contribute to a better economy.
Let’s talk about another issue that’s come up. As far as scope of practice is concerned, what would count as a successful session?
No expansion. If you want to be a physician, go to medical school, bottom line. It’s that simple.
Podiatrists are trained well to do the things they do with the foot. But when a group tries to start rewriting Gray’s Anatomy—which has been the anatomy text for centuries—and tries to say the ankle is the foot, its not. It’s the bones of the lower leg. That’s just a scientific fact.
Some of these organizations, like the Texas Chiropractic Association, are pretty strong organizations, with lobbyists and money. These guys in Austin will be listening to everybody.
They do, and they should be listening to everybody. It’s their job to listen to their constituents. We just need to provide them with the truth.
But we expect this sort of thing every session; it’s just a part of life.
When you went to medical school, did you expect to come out having to fight all these political battles?
I had a little idea that I would be doing it. My father was involved in organized medicine, and one of his best friends—his roommate when he was an intern at Robert B. Greene down the street here—was a fellow named John Smith, who was very active in both the Texas Medical Association and the American Medical Association. Dr. Smith was president of TMA during my last year in medical school. So, I grew up with the understanding that part of the job was to try and give back in some way, and organized medicine was one way to do it.
The man who brought me back to San Antonio, Merle Delmer, who was the head of our group, was active with both the Texas Medical Association and the American Medical Association. After I had been working for one year, he came in and said, ‘Okay, which TMA committee do we want to get you on?’
The Bexar County Medical Society has also been a very active, very effective voice for medicine—not just in the politics, but in the public health arena, everything.
Texas spends about half of what other states spend on public health. Is that an issue we can address?
It’s one of the issues we will address. You asked me earlier what the main issue was; which ball in the air do I want to catch?
The immunization rate is improving, but we need to do better. Prevention programs, wellness programs, childhood obesity – one of the things we are going to talk about at the 2010 summit is the wellness programs, trying to get the jump though that on the school vending machines. Let’s get physical activity mandated all the way through high school. Kids’ lives and bodies are changing – we need to get them active.
How do we get legislators to understand that it’s not just about school finance and taxes, but about improving the wellness of our community?
I think both the TMA 2010 projects and the Code Red are bringing a lot of these things to the surface—the water is boiling. Two separate, independent projects posited that if you invest in the health of the population, it will pay tremendous dividends. Not only in the well-being of the people, but in the autonomy of the state. If you have a healthy economy, businesses will want to relocate, will want to come to Texas.
The governor has done a good job in bringing jobs to Texas—there’s been a lot of good job growth. Our goal is to take the next step by investing strongly in the health of Texans—with that, the economy will grow even bigger and faster, and create more jobs.
A sick employee costs a company money. There’s data that shows the return on investment for wellness programs has been tremendous for those companies that have had it for quite a while.
But you have to make an initial investment. You’re not going to see the return the first year, you may not the second year – but as you go down the way, you will. And you’re making your investment with today’s dollars rather than tomorrow’s dollars.
Shouldn’t the federal government be taking a lead role in this as well?
There’s no doubt that the government has to be involved in a lot of this too. The uninsured may be a little difficult for the federal government to deal with, because each state is different. Governor Romney put out a bold program in Massachusetts. Would that work in Texas? It would be a little tough, because his entire population equals Texas’ uninsured population.
This country is so diverse, it almost has to be taken on a state-by-state basis. But there are things the federal government can do. Can they, through the tax codes or other means, provide incentives for businesses to develop wellness programs? There are a number of things. There are smart people up there; they ought to be able to come up with a number of ways.
The Wellness Council of America estimates that the annual cost per employee of a wellness program is between $100 and $150 per year. An effective wellness program will provide a return on that investment in the area of $300 to $350. The Wisconsin Public Health Policy Institute tells us that companies are achieving a return of $3 to $6 on a well-designed worksite wellness program.
If I tell you, “If you give me a dollar, I’ll give you three-to-six back,” then how many dollars are you going to want to give me?
When we look at the proposed cuts to Medicare over the next few years, do you think that most physicians are aware of the train wreck that’s coming?
They should be. The TMA has bombarded our membership with communications on the subject.
I think the doctors must know it, because every time I have gone to a reception for a legislator over the last two or three months to talk about it, they have been aware of it.
The coming cuts are substantial.
They are big cuts. If they come, it becomes an expense for a practice to take care of a patient; their office overhead is not going to decrease by five percent come January 1st. Their employees are not going to take a five percent cut in pay. Their utilities are not going to drop.
What alternative do they have? They’re at a point where they are going to have to make hard choices about the people they are willing to take care of. Doctors got into this business to take care of people, and with these cuts, the federal government is asking them to ration care.
Looking at the overall picture of healthcare, where do we begin to address the issues that will turn things around?
Well, there is the matter of political courage, of course. It may have to take something like we did in Texas, where the doctors conducted their grassroots campaign about the liability issue, to bring that kind of mandate to the federal level.
Doctors advocate for their patients, not for themselves. It’s for their patients. Are we going to have the patients advocate for themselves? Sometimes that happens. When Dan Rostenkowski was chair of the House Ways and Means Committee in 1989, he got chased by an angry mob of senior citizens in Chicago who were upset about changes in Medicare. He got the message, and the law was repealed.
We are going to have to keep showing them the CMS data. If you look at the current data, it’s going show a large percentage of doctors seeing Medicare patients, and a federal legislator might say that he doesn’t see any access problem. Now, there are a lot of doctors who are continuing to see their established patients who become Medicare patients. The question becomes: Are they taking new ones? And the answer is, that number is dropping.
Might doctors begin sending letters to their patients who become Medicare-eligible that they can no longer see them?
I can see some doctors possibly doing that, having to tell them, “I’m sorry, I just cannot afford to see you anymore.” I don’t know how many will end up doing that.
But I do know that it can be tough to find a doctor who will accept new patients. A couple that lives near my son on the Northwest side—they moved to San Antonio just a couple of years ago, and we gave them names of doctors we knew and trusted, and they told them that they were not seeing new Medicare patients. And that was then, before the latest rounds of cuts. With the new cuts, that problem is only going to increase more and more.
I know that we were hoping that Congress would address the cuts and SGR formula before the recess, and it didn’t happen. What are the chances of it being addressed before the New Year?
I was fortunate to have lunch with Congressman Michael Burgess at the Inauguration a couple of years ago. He’s from Plano, Texas, and a physician, so he understands the problem.
I asked him, ‘Are we going to be able to get this fixed?’ And he told me that he did not see that happening at the time, which was two years ago this January, and that every year would probably be a battle to stay even.
Now, however, Congressman Burgess has introduced a bill that had gotten some support to move physicians to the Medical Economic Index rather than the Sustainable Growth Rate (SGR). Whether that will have any success in the lame duck session, I don’t know. But I think it’s telling that a couple of years ago he didn’t think that sort of thing would get any support, but now a bill he’s introduced has some support in the subcommittee he’s on.
Maybe we won’t get it this session, and get a temporary fix for this year, but in the new session maybe we’ll get a little further.
Everybody else in healthcare is on that Medical Economic Index. The hospitals get an increase, the nursing homes get an increase, and the pharmacies get an increase. Everybody but the physicians.
What would you call a successful session in the upcoming session?
Increased Medicaid rates, so that it becomes somewhat close to Medicare. Doctors want to take care of those people, give them a medical home.
We would also keep the tort reforms intact.
Are they in danger?
I think we are going to be in danger every two years. They have been in California ever since they passed theirs; I think that’s just going to be our way of life.
We should not allow the expansion of scope of practice.
Something we haven’t talked about is implementing some way of allowing patients to find out who are in there networks, who’s not in their networks and get a better idea of the people who are serving them in the hospital if they are in their network, and if they aren’t what it will mean to them financially.
When you talk to the elected officials about these issues, do they understand that it’s all about the patients, and not all about the doctors? And would it make a difference?
I think a lot of them realize it’s about the patient. No one knows healthcare better than doctors, and the goal of the TMA is to have healthy Texans. When we meet with legislators and people in the executive branch, it’s all about the patient.
You’re becoming TMA president during some challenging times. Are you excited about it?
Very excited. I’m looking forward to it.
I come to it under some unusual circumstances. I was nominated by my son, who is a medical student, and it was the first time a student every nominated someone for President- elect. I’m also the first graduate of the University of Texas Health Science Center at San Antonio to be elected president-elect, as well as the first one to be on the TMA Board of Trustees.
This medical school has a tradition of letting physician parents give their child their degree when they graduate, so on May 19, not only will my son get his degree from his father, but from the President of the Texas Medical Association, and I don’t know if that has ever happened.
Beyond that, the TMA president is the spokesperson for the organization. I like doing that. I like advocating for the patients and people of Texas. I like working on healthcare issues with whomever we need to do so - government, insurance, business – to help improve healthcare in Texas.
The one drawback to my specialty—pathology—is being back behind the scenes, not getting to interact directly with the people. This gives me the chance to get out there and interact. • DT