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Dr. Mark Shelton responds to ‘stay at home’ order and concern over hospitals reaching capacity

Watch Pediatric Infectious Disease specialist Dr. Mark Shelton’s responses to WFAA, where he spoke about the importance of the recent stay at home order issued in Tarrant County. Originally aired on 3/24/20.

Tarrant County COVID-19 Activity – 3/24/20

There have been a total of 71 coronavirus cases in Tarrant County. Currently, 67 of those are still active.


COVID-19 Activity in Tarrant County – 3/23/20

Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Monday, March 23, 2020 at 11:15 a.m. Find more COVID-19 information from TCPH here.

Case Status by City

Fort Worth181800
Grand Prairie1100
Haltom City2200
N Richland Hills2200
White Settlement1001

Transmission Type by City

Fort Worth11241
Grand Prairie0010
Haltom City2000
N Richland Hills1010
White Settlement1000

TMB Updated Guidance on Requirements to Check the Prescription Monitoring Program

An update from Stephen Carlton, J.D., the executive director of the Texas Medical Board, published on 3/21/20. You can read the signed letter here.

The Texas Medical Board (TMB) issued initial guidance on February 7, 2020, regarding PMP checks after multiple inquiries. The guidance was intended to be helpful for licensees to understand the upcoming change in the law on March 1, 2020 and address their concerns. No TMB guidance is enforceable nor can they result in any enforcement or disciplinary action.

TMB held a meeting of the TMB Opioid Workgroup on February 18, 2020. One of the primarygoals was to obtain input regarding when to do mandatory PMP checks, who can do them, and how to document these checks. TMB took extensive input from the Opioid Workgroup
Stakeholders. This collaborative effort resulted in the following consensus:

  1. The mandatory PMP check is required only when a physician prescribes opioids, benzodiazepines, barbiturates, or carisoprodol to the ultimate user for take-home use upon leaving an outpatient setting, such as a doctor’s office or ambulatory surgical center, or upon discharge from an inpatient setting, such as a hospital admission, or discharge from an emergency department visit. A mandatory PMP check is not required before or during an inpatient stay, such as a hospital admission, or during an outpatient encounter setting, such as an emergency department or ambulatory surgical center visit
  2. The physician may delegate the PMP check to any legally authorized personnel the same way physicians may delegate other tasks.
  3. A copy of the PMP check may be placed in a patient’s medical records.

Staff anticipates bringing a proposed rule to the Board consistent with this updated guidance for possible publication as soon as March 5-6. TMB believes this updated guidance fulfills the intent of the law, reflects valuable stakeholder input, and enhances the protection of Texas patients.

Click here for TMB’s latest COVID-19 news and resources.

Printable COVID-19 Materials to Use in Your Medical Practice

Physicians, below are a number of printable COVID-19 materials TMA has compiled so they are easily accessible for your practice throughout the pandemic.

Customizable Signs to Hang on Your Practice Door – In Color and Black and White

Customizable Permission Letter for School or Work

Coronavirus Alert for Health Care Settings – EnglishChineseKoreanSpanishVietnamese

Symptoms of Coronavirus – EnglishSpanish

Stop the Spread of Germs – EnglishChineseSpanish

CMS Announces Relief for Clinicians, Providers, Hospitals and Facilities Participating in Quality Reporting Programs in Response to COVID-19

Today, the Centers for Medicare & Medicaid Services (CMS) announced unprecedented relief for the clinicians, providers, and facilities participating in Medicare quality reporting programs including the 1.2 million clinicians in the Quality Payment Program and on the front lines of America’s fight against the 2019 Novel Coronavirus (COVID-19).

Specifically, CMS announced it is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs with respect to upcoming measure reporting and data submission for those programs.  The action comes as part of the Trump Administration’s response to 2019 Novel Coronavirus (COVID-19).

“In granting these exceptions and extensions, CMS is supporting clinicians fighting Coronavirus on the front lines,” said CMS Administrator Seema Verma. “The Trump Administration is cutting bureaucratic red tape so the healthcare delivery system can direct its time and resources toward caring for patients.”

Specifically, CMS is implementing additional extreme and uncontrollable circumstances policy exceptions and extensions for upcoming measure reporting and data submission deadlines for the following CMS programs:

Provider Programs2019 Data Submission2020 Data Submission
·      Quality Payment Program – Merit-based Incentive Payment System (MIPS)  Deadline extended from March 31, 2020 to April 30, 2020.   MIPS eligible clinicians who have not submitted any MIPS data by April 30, 2020 will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year.CMS is evaluating options for providing relief around participation and data submission for 2020.
  ·      Medicare Shared Savings Program Accountable Care Organizations (ACOs)
Hospital Programs2019 Data Submission2020 Data Submission
·      Ambulatory Surgical Center Quality Reporting ProgramDeadlines for October 1, 2019 – December 31, 2019 (Q4) data submission optional.   If Q4 is submitted, it will be used to calculate the 2019 performance and payment (where appropriate). If data for Q4 is unable to be submitted, the 2019 performance will be calculated based on data from January 1, 2019 – September 30, 2019 (Q1-Q3) and available data.    CMS will not count data from January 1, 2020 through June 30, 2020 (Q1-Q2) for performance or payment programs. Data does not need to be submitted to CMS for this time period.   * For the Hospital-Acquired Condition Reduction Program and the Hospital Value-Based Purchasing Program, if data from January 1, 2020 – March 31, 2020 (Q1) is submitted, it will be used for scoring in the program (where appropriate).
·      CrownWeb National ESRD Patient Registry and Quality Measure Reporting System
·       End-Stage Renal Disease (ESRD) Quality Incentive Program
·       Hospital-Acquired Condition Reduction Program
·       Hospital Inpatient Quality Reporting Program
·       Hospital Outpatient Quality Reporting Program
·       Hospital Readmissions Reduction Program
·       Hospital Value-Based Purchasing Program
·       Inpatient Psychiatric Facility Quality Reporting Program
·       PPS-Exempt Cancer Hospital Quality Reporting Program
·       Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals
Post-Acute Care (PAC) Programs2019 Data Submission2020 Data Submission
  ·       Home Health Quality Reporting Program  Deadlines for October 1, 2019 – December 31, 2019 (Q4) data submission optional.   If Q4 is submitted, it will be used to calculate the 2019 performance and payment (where appropriate).    Data from January 1, 2020 through June 30, 2020 (Q1-Q2) does not need to be submitted to CMS for purposes of complying with quality reporting program requirements.   * Home Health and Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from January 1, 2020 through September 30, 2020 (Q1-Q3) does not need to be submitted to CMS.   * For the Skilled Nursing Facility (SNF) Value-Based Purchasing Program, qualifying claims will be excluded from the claims-based SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510) calculation for Q1-Q2.  
  ·       Hospice Quality Reporting Program
  ·       Inpatient Rehabilitation Facility Quality Reporting Program
  ·       Long Term Care Hospital Quality Reporting Program
  ·       Skilled Nursing Facility Quality Reporting Program
  ·       Skilled Nursing Facility Value-Based Purchasing Program

For those programs with data submission deadlines in April and May 2020, submission of those data will be optional, based on the facility’s choice to report.  In addition, no data reflecting services provided January 1, 2020 through June 30, 2020 will be used in CMS’s calculations for the Medicare quality reporting and value-based purchasing programs. This is being done to reduce the data collection and reporting burden on providers responding to the COVID-19 pandemic. 

CMS recognizes that quality measure data collection and reporting for services furnished during this time period may not be reflective of their true level of performance on measures such as cost, readmissions and patient experience during this time of emergency and seeks to hold organizations harmless for not submitting data during this period. 

CMS will continue monitoring the developing COVID-19 situation and assess options to bring additional relief to clinicians, facilities, and their staff so they can focus on caring for patients.  This action, and earlier CMS actions in response to COVID-19, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, please visit For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website

COVID-19 Activity in Tarrant County – 3/22/20

Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Sunday, March 22, 2020 at 11:15 a.m. Find more COVID-19 information from TCPH here.

Case Status by City

Fort Worth141400
Grand Prairie1100
N Richland Hills2200
White Settlement1001

Transmission Type by City

Fort Worth5126
Grand Prairie0010
N Richland Hills1010
White Settlement1000

Fort Worth Amends Disaster Declaration for COVID-19

Mayor Betsy Price signed an amended order to the emergency declaration in place within the City of Fort Worth due to a local public health emergency and in a continued effort to further mitigate the spread of COVID-19.

The following went into effect today, Saturday, March 21, 2020 at 6:00 pm:

  • All in-person worship services are no longer permitted, with the exception of worship support staff to facilitate online services.
  • All malls and non-essential retail establishments including barber shops, hair salons, nail salons, spas, massage parlors, estheticians and related personal care businesses are closed and no occupancy is permitted.
  • Also closed: bars, lounges, taverns, commercial amusement and entertainment establishments, bingo halls, theaters, gyms, fitness classes, yoga and personal training facilities, similar facilities and classes, private clubs, tattoo and piercing parlors and tanning salons, residential meeting spaces, event centers, hotel meeting spaces and ballrooms, outdoor plazas and markets Essential services such as grocery stores, pharmacies and other establishments that sell household goods will remain open but must enforce social separation. This includes:
  • Convenience and package stores, pharmacies and drug stores, day care facilities, medical facilities, veterinary facilities, non-profit service providers of essential services, homeless and emergency shelters, office buildings, jails, essential government buildings, airports and transit facilities, transportation systems, residential buildings and hotels, manufacturing and distribution facilities. In-house dining at restaurants remains closed, but drive-in, drive-through, takeout and delivery are still permitted. There is no distinction between the types of gatherings in the amended declaration. There should be no gatherings of more than 10 people.

Additionally, temperature screenings at public-facing city facilities began Wednesday, March 18. Those entering city facilities during normal business hours will have their temperature checked using a forehead thermometer, and people with a temperature of 100 degrees or more will be asked to leave, and to contact their healthcare provider. This includes city employees.

COVID-19 Activity in Tarrant County – 3/21/20

Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Saturday, March 21, 2020 at 9:30 a.m. Find more COVID-19 information from TCPH here.

Arlington11 1 
Forest Hill1   
Fort Worth11   
N Richland Hills2   
White Settlement1   

The Last Word – December 2019

By Hujefa Vora

I want to close out this year talking about change.  How much have your practices changed in the past year?  How much have your lives changed over the past year?  You’ll notice that I use the terms practice and life interchangeably.  Unbeknownst to our patients, our clients, our friends, and sometimes even our own families, these terms are equivalents.  One cannot achieve the title of physician without accepting this fact.  Our work defines us as human beings.  There is no other way to make an accounting of all the time we spend caring for others while neglecting our personal responsibilities.  This year, I missed my daughter’s first gymnastics meet because I had a patient attempting to code in the hospital.  Life changes.  Practices change.  When the government rolls out new regulations governing how we practice medicine, it changes not only our interactions with our patients and their insurance companies, but also the relationships we have nurtured over the years.

So how has my practice changed?  I recall a time just 10 years ago when I could easily see 20 patients a day in my office.  Comfortably.  I remember being able to do my documentation while I sat in front of the patient.  Prescriptions were sent off with a click or two of my mouse.  Follow ups were scheduled and the patient was satisfied. I started my practice 13 years ago with the exact same electronic medical records system that I am using today.  That has not changed, though there have been many updates to the system over the years.  What has changed quite dramatically now is how I use this system.  Practice with the same system for more than a decade, and users build a higher level of proficiency and efficiency.  It would make sense that I would be faster with the system, that my proficiency would make it easier to navigate the windows and the electronic maze of my patient’s chart.  Changes over the years in the rules behind coding and documentation have not made us more efficient though.  Let me give you my most cumbersome example of change in my practice pattern brought on by changes in rules and regulations brought about Medicare.  I am an internist by trade, but the vast majority of my patients are diabetics, so I fancy myself a closet endocrinologist most days.  When I first started practicing, I routinely ordered glycosylated hemoglobin (a1C) levels to gauge the degree of control my patients had over their diabetes.  My staff would order the test for the patient to have drawn at a local lab.  We would get the results back and I would call the patient a week later, provided the patient went to get their blood work in the first place.  Based on the results of that test and the discussion with the patient, I would call in any medication changes.  Then, we would follow up with the patient in a month or two and see if the medication adjustment worked by rechecking the levels.  This worked for a few years, until Medicare and the insurance companies decided that a1C levels would only be paid for if they were drawn three months apart.  Patients would get angry at me and my staff when they started getting bills for the a1Cs I was ordering.  We were forced to move away from this really good method of tracking diabetic

Patients would get angry at me and my staff when they started getting bills for the a1Cs I was ordering.

control.  I started bringing my diabetics into the office every three or four months.  My supply salesman introduced me to a machine that we could use in the office to check a1C levels. The catch here was that regulations dictated that because I was not

running a certified lab, the insurance companies would not always pay for the a1Cs we drew in the office.  Thus, only some of my patients got everything done at the point of care.  It was easily noticeable with my patients that those who had their a1Cs checked at the time of visit had better overall long-term outcomes in relation to their diabetic care.  Medicare eventually took notice of the importance of measuring glycosylated hemoglobin levels and started asking us to track these levels more routinely.  With the advent of Medicare’s quality initiatives several years ago, tracking a1C levels became a key quality indicator for diabetes control.  It is only recently that they started paying for this test if it was done in the office.  Reporting of quality metrics has been the ultimate gamechanger.  As every insurance company begins to incorporate the reporting of these quality metrics, the process has become even more cumbersome.  I decided that the easiest way to tackle this issue was to measure all a1Cs in-house.  If the insurance company would not pay, then my practice would eat the cost, not pass it along to the patient.  Every company we have worked with on this particular metric has a different way that they want these values reported to them.  Medicare has codes for the different ranges of the a1C that have to be coded into the note at the time of care, so whether or not they paid for the test became irrelevant.  A patient with no reported glycosylated hemoglobin level was just as bad as an uncontrolled diabetic in terms of the scoring of the quality of care being provided by the physician.  Ultimately, a lower quality score means a significant drop in revenue.  Most insurance companies would not allow us to simply document the level in the chart.  Medicare would not allow an a1C to be reported without proper documentation that the test was done in-house.  We are now required to document the value of the test, followed by phrases stating that the test was “drawn, collected, and performed in office, in-house, today <today’s date>, at <time>.”

My patient volume has not increased substantially, but the amount of time required to see each patient has made it impossible to continue to do this on my own.

Understand that Medicare has primary care physicians tracking over 30 different quality metrics for every patient we see.  Also understand that what Medicare does in terms of regulations trickles down to every commercial insurance plan eventually.  So how has my practice changed?  I am a five-star rated doctor for Medicare.  That means that because I am truly obsessive-compulsive about most of these details and metrics, my staff and I keep track of all of these metrics for all of our patients at all of their visits all of the time.  First and foremost, we do our best to provide the ultimate in good service and care to our patients.  Then, we spend the rest of our time buffing and polishing the patients’ charts so that we can stay in business and continue to serve our patients.  A typical visit of 10 minutes of face-to-face time with the patient requires about 20 minutes of documentation, insurance processing, and quality reporting.  A simple follow-up visit takes a minimum of 30 minutes.  A new patient may have taken 30 minutes when I first started my practice, but we typically give an hour of my time for these visits now.  And I had to hire a second nurse practitioner to keep up with the flow of patients.  My patient volume has not increased substantially, but the amount of time required to see each patient has made it impossible to continue to do this on my own.

And so, the practice of medicine continues to change.  Our lives continue to change.  I hate to be a pessimist, but not much of the change feels positive right now.  The optimist in me says the next year will be better.  I just hope that I don’t miss too many more gymnastics meets.  No one twirls quite so beautifully, or awkwardly, as my little girl.  That too will change.  My name is Hujefa Vora, and this is the Last Word.

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