February 2023 – Tarrant County Physician Online

PRESIDENT’S PARAGRAPH

by Stuart Pickell, MD, TCMS President

This article was originally published in the January/February 2023 issue of the Tarrant County Physician. You can read find the full magazine here.

IT IS AN HONOR AND A PRIVILEGE TO serve as president of the Tarrant County Medical Society for 2023. I aspire to lead as ably as those who have preceded me and to move the ball forward on the many priorities we have as physicians and citizens of Tarrant County. To that end, I posed several questions at the installation event in November that I will follow up on this year, using this space as a launchpad for discussion. At the root of these questions is identity- our identity as physicians and leaders in our community.

For many physicians, and I know this is true for me, there is a sense that, like Harry Potter’s wand, we didn’t choose medicine- it chose us. We have a sense of “calling” to the profession, as if by something external to us or deep within us- either way, something so profound and unknowable that it may defy articulation.

The language of “calling” resonates with nem although for me it was problematic because I had two. When I was five years old, I told my family that when I grew up, I was going to be a minister, a doctor, and a fireman. I have done all three. Firefighting didn’t stick.

What did stick was ministry and medicine. I hoped it would be one or the other, but it never was. In college, I took classical greek and 400-level biology and chemistry courses and majored in history because I liked it. i sought advice from people I respected who were ministers and physicians and they all said the same thing: If you’ve ever thought about doing something besides ministry or medicine, do that instead. As my wife would say, “Hmmmm.”

Years later, and several years into a full-time ministry position, I told a parishioner about my dilemma. He also happened to be a therapist, which only reinforced my commitment to Calvinism. After patiently listening to me explain all the reasons why it wasn’t practical to do both, he looked at me and asked, “Why not?”

Hmmmm.

Ministry and medicine are similar. They are both vocations in the truest sense of the word, a word derived from the Latin vocare, which means “to call.” Both are professions to which the people in them tend to feel a sense of calling that compels and propels them to serve.

It makes sense that medicine, as a profession, would be hardwired toward serving others. After all, our calling first had to be validated by a medical school that saw in us what we saw in ourselves. We had to be chosen by someone else to become part of a tribe. Do you remember how you learned that you had been accepted to a medical school? I do. I got a letter. I think it’s fitting, however, that student admitted to TCU’s Anne Burnett School of Medicine literally get a call- by telephone- telling them the good news. And admissions committees seek candidates who have integrity and demonstrate empathy; people who are team players and servant leaders. This is and always has been at the core of our identity as physicians.

How we grow into that identity, and how our call to serve becomes manifest, will be as unique as each one of us. People who are called are called not just to be but to do- to apply their knowledge and expertise in a unique and meaningful way. In a way, physicians don’t have a career so much as a mission- which, at the risk of sounding pedantic, comes from the Latin word mitterre, which means “to send.” The English word is rooted in medieval Christianity, but today’s “mission” is more likely to describe the driving principles of an individual, or a business, or a non-profit group or a healthcare institution. it speaks to their identity, their raison dêtre. We are called, and we are sent, sent on a mission to serve the people in our charge- our patients- and the community in which we all live.

So, how are we doing? Are we fulfilling our mission? In many ways, we are doing quite well. We have excellent physicians in just about every specialty. We have fine institutions for adults and children and one of the best county health systems in the country. But we still have pressure points. How does the execution of our mission, individually and corporately, impact the larger community- not just us or our practices or our institutions but the people we have been called to serve?

Throughout the year I will use this space to explore this question, examining our individual and corporate roles and responsibilities as physicians in the hope that doing so will promote a constructive dialogue that furthers our mission to serve the larger community. Some of the pressure points I see and hope to explore include:

- The inadequacy of Graduate Medical Education in Fort Worth, and especially at Cook Children’s Health System. The Cook Children’s Health System and its flagship hospital are among the finest in the country. It has excellent leadership and medical and support staff. But would the community not be better served if it leveraged this prestige and became an academic center as well, training physicians and pediatric specialists who, by the way, often practice near where they train?

- Lack of access to the county healthcare system for undocumented county residents. Undocumented residents can receive emergency care at a reduced rate (which is often still too expensive for most) but are ineligible for the preventive care that might have averted the need for emergency services in the first place. Even Project Access can’t access county health facilities for use by our member physicians who are willing to donate their time and expertise to do necessary but non-emergent procedures.

- Lack of physician input in the assessment, planning and implementation of strategies to address community healthcare needs and crises. Such planning should start with physicians, the people in the community who know the patients personally and who, because of these relationships, the patients trust to act in their best interest. COVID – a crisis made worse by its politicization – quickly devolved into divisive rhetoric that led to a profound mistrust of medical authorities, especially at the national level. Our member physicians voluntarily stepped into this nightmare. We partnered with neighboring county medical societies and aided the local health authorities with its media information operations, providing an honest assessment of available information to inform and educate physicians and the public. And yet, when it came to planning and implementation, the local authorities turned to non-clinical hospital leadership for input and direction.

Working together to address challenges and overcome obstacles is the center of our mission, a mission that emanates from a calling, a calling that forges our identity as physicians. What makes our calling and its ensuing mission so important, and our profession so rewarding, is the relationship we share with each patient – one that is founded on empathy, trust, and mutual respect. It’s the one thing that remains constant in the chaos, because when our patients don’t trust anyone else, they still trust us.

Our mission is not about us – it’s about our patients and our community. And if our mission is to improve their health and safety, we must be willing to take an honest look at ourselves, to understand where we have been, assess where we are, and anticipate where we are headed. And if we discover that our mission is no longer serving our patients or our community, we must have the courage to change it.

Organized medicine helps us identify challenges, assess the adequacy of our mission, and if needed, adjust it. I am honored to be a part of that process and look forward to continuing our conversation.

TMA Pleased by U.S. District Court Ruling Granting Summary Judgment Motion

Court Agrees With Physicians’ Argument
in Federal No Surprises Act Rule Case

Statement by Gary W. Floyd, MD, Texas Medical Association (TMA) president, in response to the U.S. District Court for the Eastern District of Texas ruling on TMA’s motion for summary judgment in its lawsuit opposing certain components of federal regulatory agencies’ final rules regarding dispute resolution under the No Surprises Act. TMA argued the case in the U.S. District Court in December, addressing the second of four TMA lawsuits against federal agencies related to rulemaking under the surprise-billing arbitration law.

“TMA is pleased the court granted its motion for summary judgment in its lawsuit challenging certain components of the federal agencies’ final rules relating to the federal independent dispute resolution (IDR) process under the No Surprises Act. This is an important next step after TMA successfully challenged an interim final rule that similarly skewed the IDR process in health plans’ favor.

“This decision is a major victory for patients and physicians. It also is a reminder that federal agencies must adopt regulations in accordance with the law.

“The decision will promote patients’ access to quality care when they need it most and help guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices.”

TMA is the largest state medical society in the nation, representing more than 57,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.

Feds to End COVID-19 Public Health Emergency in Mid-May

by Emma Freer

Originally published by Texas Medical Association on February 7, 2023.

After nearly three years and 11 extensions, the Biden administration recently announced the COVID-19 public health emergency (PHE) will finally expire May 11, fulfilling its commitment to give states at least 60 days’ notice of its expiration.

“If the PHE were suddenly terminated, it would sow confusion and chaos into this critical wind-down,” the Executive Office of the President wrote in a Jan. 30 statement.

Still, the end of the PHE has significant consequences for Texas physicians and their patients.

The federal Families First Coronavirus Response Act temporarily increased federal Medicaid matching dollars by 6.2% for states that agreed to maintain Medicaid coverage for anyone enrolled in the program from March 2020 through the end of the PHE.

That included Texas, where more than 2.5 million residents, predominantly postpartum women, and children, benefited from continuous Medicaid coverage.

These matching dollars will phase out between April and December, according to a provision in the Consolidated Appropriations Act of 2023, a $1.7 trillion spending package that President Joe Biden signed into law on Dec. 29, 2022.

To continue to receive these funds through the end of the year, states must comply with certain federal requirements, including agreeing not to terminate enrollment based on returned mail due to an incorrect address.

In the meantime, state Medicaid officials have a plan for unwinding this coverage, but it requires redetermining millions of patients’ Medicaid eligibility in just eight months. The Texas Health and Human Services Commission (HHSC) will begin sending notices in March reminding patients to update their information.

The Texas Medical Association has met regularly with HHSC over the past year to provide input on the state’s plan with the goal of achieving as smooth a transition as possible. Despite progress, such as streamlining the ways in which Medicaid patients can complete their eligibility applications, TMA remains very concerned about a looming coverage cliff.

Fortunately, the end of the PHE coincides with some recent policy developments, including increased federal funding for navigators – community organizations that connect eligible consumers to federal marketplace health plans – and extended subsidies for the same plans. TMA experts say these changes could help some Texans who lose Medicaid coverage enroll in a different plan.

The Consolidated Appropriations Act also makes permanent an option for states to provide 12 months of continuous Medicaid coverage to postpartum women.

TMA would like to see the Texas Legislature take advantage of this option, one of the association’s top priorities this session.

Moreover, the law requires states to provide 12 months of continuous Medicaid coverage to children, beginning Jan. 1, 2024. TMA is urging HHSC to align this provision with its redetermination process to minimize the burden on families and to prevent gaps in care.

In addition, the Consolidated Appropriations Act extended certain pandemic-era telehealth flexibilities for Medicare patients through 2024, disentangling them from the status of the PHE. These flexibilities include:

Waiving geographic site restrictions, which allow patients to access care from their homes; and

Allowing physicians to use audio-only telehealth services.

TMA and others in organized medicine recently wrote a letter to the Centers for Medicare & Medicaid Services (CMS), requesting the agency issue an interim final rule to align its telehealth policies and timeline (to expire 151 days after the end of the PHE) with those in the Consolidated Appropriations Act. Not doing so, they wrote, could create “an unintended barrier to vital health care services, as well as potential confusion” among clinicians and patients.

Prior to the act’s passage, CMS made permanent the same telehealth flexibilities for Medicare patients accessing mental and behavioral health services as well as coverage of video-based mental health visits at federal qualified and rural health centers.

Finally, the PHE’s end means physicians not using a HIPAA-compliant platform for telehealth will need to switch to one by May 12.

Physicians can refer to CMS’ fact sheet regarding PHE waivers and flexibilities for more information.

For more detailed coverage on how the end of the PHE will affect Texas physicians and patients, check out the January/February issue of Texas Medicine magazine.

Meet Stuart Pickell, MD, Our 2023 TCMS President

By Allison Howard

This article was originally published in the January/February 2023 issue of the Tarrant County Physician.

“IN MANY WAYS, MEDICINE IS A FORM OF MINISTRY,” SAYS DR. STUART PICKELL.

HIS PERSPECTIVE ISN’T SURPRISING. When you get to know Dr. Pickell, one thing quickly becomes clear – if he is interested in a project or an organization, it is because it involves serving the community. It is his desire to help others that threads his varied passions together – including his careers as both a Presbyterian minister and a physician.

“When I was five, I told my family I was going to be a minister, a doctor, and a fireman,” says Dr. Pickell. “And I did all three.”

While his stint as a fireman was limited to volunteering during high school, the experience impacted his future. During that time, Dr. Pickell became an EMT and worked for both firefighting and ambulance services. This early introduction to medicine helped to cement an interest in patient care that would continue to influence him in the years ahead.

Still, Dr. Pickell did not take a direct route to healthcare. When he attended the College of William and Mary, he was undecided between medicine and ministry. Instead of picking a degree that would only fit one or the other career path, he decided to study history and use his elective courses to take prerequisites for both seminary and medical school.

“I was in Williamsburg going to William and Mary, which is in a town where it’s always 1773,” explains Dr. Pickell. “So I was living there, with a lot of primary sources around me, and it made researching and the study of history more interesting, and it came to life more. And I knew that for ministry or medicine, it didn’t really matter what I majored in.”

Dr. Pickell was still unsure of his future path when he graduated, so he worked at a community hospital and church for two years before he decided to pursue a career in ministry, following in his father’s footsteps.

He received his Master of Divinity at Princeton Theological Seminary, and shortly after graduating, began working as the associate minister for youth and families at First Presbyterian Church in Fort Worth.

While he was enthusiastic about the job itself, leaving the East Coast to move to Texas was not originally appealing to Dr. Pickell. His interactions with some colorful Texans he met at Princeton did not leave a favorable impression. This, combined with sports rivalries imprinted since childhood, made the move less than ideal . . . so much so that it inspired some literary liberties.

“I actually rewrote the story of Jonah in the Bible; recasting it with Jonah as me and Nineveh as Fort Worth,” he says, laughing. “It was sort of therapeutic for me.”

Looking back, though, Dr. Pickell has no regrets about making the move. Texas was his future and is a place he now is grateful to call home.

“It was the second-best decision I’ve ever made – after marrying my wife,” he says.

Dr. Pickell enjoyed serving in the Church, but he still carried the desire to heal bodies alongside souls.

“I’d sit in my office, and I’d look out the window and think, ‘I don’t know if my calling to ministry is actually inside the church,’” he remembers. “‘I think maybe my ministry should be a ministry of presence, of being in the community.’”

He was hesitant, though. At that time, Dr. Pickell was still paying off student loans from his seminary and college degrees, and, perhaps more importantly, he was raised to believe that one was supposed to pick one career and stick with it.

It was the late Gordon VanAmburgh, a beloved counselor and First Presbyterian church member, who asked Dr. Pickell an important question that set him on a new trajectory.

“It was just two words, but in many ways, they changed my life,” Dr. Pickell says. “I said to him, ‘You know, I just don’t know that it’s feasible to have two careers.’ And he looked me in the eye and said, ‘Why not?’”

Dr. Pickell didn’t have an answer to that, and it led to decisions that would completely reshape his life. He applied to medical school and was accepted to
UT Southwestern, where he pursued his medical education.

Though Dr. Pickell was grateful that his prerequisites were completed, it was challenging to jump into his classes after taking an extensive break from the hard sciences.

“I wasn’t sure I was going to stay,” he says. “I liked the idea of being a doctor, but the first year was pretty rough for me. They were talking in biochemistry about discoveries five years earlier as if they were ancient history. It had been 10 years since I had taken biochemistry, so I was like, ‘I am totally lost here.’”

Though it was challenging, Dr. Rob- ert Sloane applauds him for taking the plunge to practice medicine.

“Knowing the time commitment required, it took courage on his part to train in medicine in addition to ministry,” says Dr. Sloane, who wrote a letter recommending Dr. Pickell’s acceptance into UT Southwestern. “[H]e is always caring and compassionate in his endeavors. He is committed to his work and careful in its

performance.” During his time at UT Southwestern, Dr. Pickell met his wife, Emily, while serving as an interim pastor for two small churches in and around Clifton, Texas, during a summer break. They married in the middle of his third year. Dr. Pickell completed medical school followed by a residency in internal medicine and pediatrics (Med-Peds) at the University of Mississippi Medical

Center. After completing his residency, Dr. Pickell joined an all-Med-Peds practice in Nashville but decided to return to Texas a year later. He has worked as a Med-Peds physician in Fort Worth ever since. Currently, he is a member of Texas Health Physicians Group.

For over 20 years, Dr. Pickell has thrived in building long-term relationships with patients and guiding them through complex ailments.

“Medicine is an applied science,” he says. “I like to apply principles to people to help them, whether it’s spiritually or physically, emotionally – whatever.”

Though his patients have remained at the center of his career, Dr. Pickell has maintained active participation in professional groups and committees throughout his work as a physician – including a great deal of work in ethics.

He has served on several ethics committees, including the Tarrant County Academy of Medicine’s (TCAM) Ethics Consortium, which he has chaired
for many years. And in 2016, Dr. Stuart Flynn, dean of the Anne Burnett School of Medicine at TCU, appointed Dr. Pickell to lead in the development of the medical school’s ethics curriculum.

While Dr. Pickell continues to lead the ethics curriculum, he has also expanded the reach of TCAM’s Ethics Consortium through the development of Healthcare in a Civil Society, an annual forum that has typically featured content experts from the Tarrant County community. Dr. Kendra Belfi, Dr. Pickell’s predecessor in chairing the TCAM Ethics Consortium, is grateful for his contributions to ethics in medicine.

“Dr. Pickell is a deep thinker and an articulate leader, who brings professionalism to everything he works on,” she says. “When I was about to retire and needed to find someone willing to take over chairmanship of the Consortium, I asked him to consider it – and he did. He has now been chair of the Consortium for longer than I was and has taken us to new heights.”

Throughout his years of practice, Dr. Pickell has concluded that successful leaders inspire others more through ac- actions than words.

“The biggest part of being a leader is leading by example; being willing to do what you’re asking other people to do,” says Dr. Pickell.

He speaks from experience. In addition to his work in ethics, Dr. Pickell is Project Access Tarrant County’s medical director, has served on over a dozen TCMS and TMA committees, and has worked in executive leadership positions in organizations as diverse as a health in- formation exchange company, a pioneer ACO, and an innovative primary care practice model.

“Leadership is now more about building effective teams, which is why articulating the vision is so important,” he says. “It’s not just that you have a vision and expect everyone to follow you like the Pied Piper. You must communicate it to the team, sell it to them, invite them to own it.”

Sharing a vision is key as a doctor, and it is something that Dr. Pickell believes is fostered by organized medicine. He likes to compare the relationship that physicians have with TMA and TCMS to those he shares with his own patients, many of whom he has treated for decades.

“You develop relationships and leverage them to get things done,” says Dr. Pickell. “And I think that TMA and the county medical societies are in some ways like that. They are relational, and they provide an organizational force or impetus that amplifies the message we are trying to communicate individually within our practices, broadcasting it to a larger audience than any of us can reach individually.”

As he both leads and provides support on varied projects, Dr. Pickell does it with the vision of supporting the future of medicine. In addition to his work on the ethics curriculum at the Burnett School of Medicine, Dr. Pickell has served as a preceptor to advance medical students’ hands-on education since 2002 and as an associate professor for the Department of

Internal Medicine at the Burnett School of Medicine since its inception.

Dr. Pickell’s passion for education is no surprise to those who know him; he has long desired to foster young minds in his work for both the body and the spirit. And it is a passion that extends beyond the students under his direction to the patients he cares for.

“Perhaps the most succinct statement
I could make is that I have entrusted my three children to him twice,” says Dr. Steve Brotherton, a friend, and patient of Dr. Pickell’s. “First as the youth pastor at our church, then again as their personal physician, just as I have entrusted my own health.”

“You know, I’ve always been a generalist,” says Dr. Pickell. “I like to do a lot of different things. Some people will focus on one thing and really excel at that one thing. I’ve never been wired like that.”

In many areas – ministry to medicine, education to private practice, ethics theory to hands-on application – Dr. Pickell has spent his career striking a balance between a mixed set of interests. But this extends beyond work and professional organizations.

“Husband, father, healer of bodies and souls – most know these plain facts about Stuart Pickell,” says his longtime friend Robert Johnson, who Dr. Pickell met during his time at seminary. “But there

is so much more to him: musician, actor, closeted NASCAR fan . . . and good and generous friend. For the nearly forty years I have been friends with Stuart, I have found him to be a man of great intellect, compassion, humor, and faith.”

He enjoys playing the guitar and piano, as well as writing music and essays when

he has the chance. In one particularly rewarding venture, one of the songs he wrote for a youth event in the 90s was recorded by a friend and got air time on a Denver radio station.

Dr. Pickell grins. “Yeah, that was a pretty neat experience.”

But his favorite pastime is being with his wife and their two sons, Jonathan and Will. If the family is able to spend time
at their weekend house in Clifton, even better.

“I love going down to Clifton and just being in the country,” says Dr. Pickell. “People in small towns have a strong sense of place, of community. They are grounded. I didn’t experience that growing up; maybe that’s why I like it.”

As he begins his term as TCMS president, Dr. Pickell is looking forward to using the “President’s Paragraph” to share his top concerns about medicine, such as the need to increase GME slots and funding for Project Access.

More than anything, he wants to start conversations since they are the first
step toward making tangible changes. He wants the message from TCMS to be very clear so those we interact with, such as hospital leaders and local politicians, understand the medical society’s purpose and the perspective of physicians throughout Tarrant County.

“It’s important to stay centered on why you’re doing what you’re doing,” he says. “When it comes to a ‘mission,’ I think the ‘why’ is really important. For me, this goes back to my faith. I do what I do because I believe that a loving God – who loves everyone else as much as me – has called me to serve in this way.”

We are excited to have Dr. Pickell lead us as we move forward with TCMS’s mission of advocating for the physicians and patients of Tarrant County.

New TMA Lawsuit Challenges Big Fee Hike in “No Surprises Act” Arbitration

Fourth Lawsuit Disputes 600% Fee Hike Demanded of Doctors

The Texas Medical Association (TMA) is challenging a 600% hike in administrative fees for seeking federal dispute resolution in No Surprises Act (NSA) situations. TMA seeks relief by filing a fourth lawsuit in the U.S. District Court for the Eastern District of Texas.

This TMA lawsuit against federal agencies challenges a steep administrative fee hike that will strip many physicians and healthcare providers of the arbitration process that Congress enacted. TMA calls the fees “arbitrary and capricious,” contrary to the law, and in violation of notice and comment requirements.

The U.S. departments of Health and Human Services, Labor, and the Treasury, and the U.S. Office of Personnel Management collectively adopted interim final rules implementing the federal surprise-billing law. The rules include establishing the nonrefundable administrative fee all parties must pay to enter the federal independent dispute resolution (IDR) process in the event of a payment disagreement between an out-of-network physician or provider and a health plan in circumstances covered by the law. The situations could occur when emergency services are provided by a doctor or health care provider outside of the patient’s insurance network or when out-of-network services are provided at an in-network facility.

The federal agencies set the initial administrative fee at $50 and announced in October 2022 it would remain at $50 for 2023. Two months later the agencies announced a 600% hike in the fee to $350 beginning in January 2023, “due to supplemental data analysis and increasing expenditures in carrying out the Federal IDR process since the development of the prior 2023 guidance.”

The steep jump in fees will dramatically curtail many physicians’ ability to seek arbitration when a health plan offers insufficient payment for care.

“The problem is that many payment disputes in these cases amount to less than the fees physicians would have to pay to dispute the unfair payments,” said TMA President Gary W. Floyd, MD. “Why would doctors and providers pay the $350 nonrefundable administrative fee to arbitrate a $200 or so payment dispute with a health insurer? The fees deny physicians the ability to formally seek fair payment for taking care of our patients, and that’s just wrong.”

TMA argues the administrative fee hike is difficult for all physician specialties to bear, but especially those specialties that have more small-dollar claims, such as radiology.

The non-refundable administrative fee is in addition to the separate fee that each party must pay the IDR entity for its services, though that fee is refundable to the party that wins the arbitration dispute.

TMA also disputes the rules’ narrowing of the law’s provisions on “batching” claims for arbitration, which Congress authorized to encourage efficiency and minimize costs in the IDR process.

TMA’s first lawsuit – filed in 2021, and which TMA won at the district court level – alleged that in the interim final rules governing arbitrations between insurers and physicians, the agencies unlawfully required arbitrators to “rebuttably presume” the offer closest to the qualifying payment amount (QPA) was the appropriate out-of-network rate. TMA filed its second lawsuit in September 2022 challenging the NSA’s August 2022 final rules published by the federal agencies, alleging the final rules unfairly advantage health insurers by requiring arbitrators to give outsized weight or consideration to the QPA. The court’s ruling on that suit’s December 2022 hearing is anticipated at any time. TMA filed its third lawsuit in November 2022 challenging certain portions of the July 2021 interim final rules implementing the federal NSA. No hearing date has been set for that case, which challenges certain parts of the rules that artificially deflate the QPA.