The Texas Medical Association’s 171-year existence is rich with milestones.
From ushering in significant legislative reforms and responding to emergencies to expanding its own operations and solving seemingly intractable problems, TMA has played an active role in Texas and national medical history.
TMA President Ray Callas, MD, is a student of this history. He first became involved in TMA in the early 2000s at the urging of his mentor, Mark Kubala, MD, a neurosurgeon in Beaumont and past TMA president. (See “Institutional Knowledge,” page 38.) While Dr. Callas was getting his start in private practice, TMA was spearheading medical liability reform and advocating for other legislation that would rank among its most significant achievements.
Since then, Dr. Callas has learned time and time again how TMA’s past determines its present and offers a roadmap for the future. For example, tort reform has had an enduring impact on Texans’ access to care; it continues to attract physicians from across the U.S. to Texas, helping to assuage workforce shortages. (See “Coming Up Short,” May 2024 Texas Medicine, pages 12-17.)
TMA also was instrumental in Congress’ 2015 repeal of the Sustainable Growth Rate (SGR) formula that Medicare had used to calculate physician payments. Although the formula was disastrous, equating to annual physician pay cuts, its replacement has proven imperfect. This experience has informed TMA’s ongoing advocacy for Medicare physician payment reform, which now centers on the need for a systemic overhaul.
“You don’t know how big of an impact these historical events will have,” he told Texas Medicine.
The Beaumont anesthesiologist also emphasizes the insights of TMA member physicians who experienced this history firsthand. He learned about challenges to physician autonomy – and the threat such challenges pose to patient access and safety – from his father, Gerald Callas, MD, a longtime anatomy professor at The University of Texas Medical Branch at Galveston. He also learned from Dr. Kubala, who supported TMA’s founding of the Texas Medical Liability Trust in 1979 as a solution to the problem of medical liability insurance providers fleeing the state.
Dr. Callas continues to lean on – and share – the wisdom of TMA’s archive and members emeriti. (See “Living Legacy,” page 18.)
“My learning didn’t stop when I graduated from medical school, graduated from residency, or started practicing,” he said. “I’m still learning.”
The following milestones make up somewhat of a core curriculum of TMA history, from the mid-1950s onward.
1979: TMLT founding
TMLT’s founding was a response to a mass exodus of insurers starting in the 1970s due to jackpot-style laws – a crisis that left physicians with sky-high medical liability rates. Since then, TMLT has steadily supported TMA member physicians through industry upheavals, including those that led to Texas’ landmark 2003 tort reforms. Today, TMLT is the largest medical liability insurance provider in Texas and operates under a physician-focused trust model set up in 1955 with the formation of TMA Insurance Trust, which provides disability, life, medical, home, and auto coverage tailored to policyholders regardless of practice setting.
1986: Texas’ first PPO rules
When PPOs emerged on the health plan market in the early 1980s, they veered sharply from traditional indemnity insurance models, sparking physician concerns. In response, TMA advocated for fair regulations and, when the Texas Department of Insurance adopted problematic PPO rules, sued. The resulting settlement led to the implementation of PPO rules that gave Texas patients freedom of choice by limiting health plan steerage. It also set the stage for decades of regulatory fights – and wins – for medicine, including strong protections against so-called silent PPOs and the corporate practice of medicine and for network adequacy.
1997-98, 2009-10, 2021-22: AMA’s Texas leadership
Nancy Dickey, MD, president emeritus of the Texas A&M Health Science Center and past president of the American Medical Association, estimates Texas is among the U.S. states with the most AMA past presidents, a clear indicator of the strength of the state’s delegation. The first woman elected AMA president, Dr. Dickey served in 1997-98. Other Texans to hold the office include James Rohack, MD, a cardiologist who formerly practiced in Texas and AMA’s 2009-10 president, and Susan Bailey, MD an allergist-immunologist in Fort Worth who was speaker of the TMA house before her 2021-22 AMA presidential term.
2003: Medical liability reform
Prior to 2003, Texas had no cap on noneconomic damages in medical negligence cases. Physicians faced a steady increase in both lawsuits – many of them meritless – and medical liability insurance rates, threatening practice viability and patient access to care. Fed up, they turned to TMA, which, along with a coalition of physician and patient advocates, mobilized to get a landmark legislative cap passed during the 2003 state legislative session and a constitutional amendment approved by voters to protect the reforms. Ultimately, the reforms ended many of the legal practices that had harassed physicians, made Texas one of the best states in which to practice, and led to enduring aspects of physician activism.
Seeking to boost TMA advocacy for medical liability reforms heading into the 2003 state legislative session, the TMA Alliance – a volunteer force of physician spouses – created First Tuesdays at the Capitol, now the association’s signature advocacy event. On the first Tuesday of every month during sessions, hundreds of physicians, medical students, and alliance members descend on Austin to share their views with their representatives and amplify medicine’s voice.
2003-05: RICO settlements
After exhausting all other options, TMA in 2001 joined two national class-action lawsuits accusing 10 of the nation’s major private health plans of racketeering under the Racketeer Influenced and Corrupt Organizations (RICO) Act. Although the health plans involved admitted to no wrongdoing, settlements from the suits between 2003 and 2005 resulted in more than 100 pages of enforcement provisions, $2 billion in relief for physicians, and wholesale changes in plans’ business practices. Settlement funds also created what is now The Physicians Foundation and the Physicians Advocacy Institute, both of which continue to support physicians with TMA’s close involvement.
2015: SGR repeal
Between 1997 and 2015, Medicare relied on the flawed Sustainable Growth Rate (SGR) formula to calculate physician payments. Designed to sustain Medicare with lower costs, the formula equated to steep physician pay cuts and costly congressional patches to avert them year after year. By 2015, lawmakers finally had seen the proverbial writing on the walls of physician practices declaring they were unable to accept new Medicare patients. The SGR repeal became a testament to TMA’s efficacy on the national stage and continues to serve as a playbook for future Medicare physician payment reforms.
TMA’s response to Hurricane Harvey, which dumped a record 60 inches of rain in four days on the Gulf Coast region in August 2017, was the culmination of years of preparation. In just two months, TMA’s Disaster Relief Fund – established by The Physicians Benevolent Fund in the wake of Hurricane Katrina in 2005 – disbursed a record-high $792,390 to 172 physicians across 18 cities. In addition to fundraising, TMA staff and county medical societies made it easier for physicians to volunteer their services and for affected practices to overcome potential insurance payment obstacles, stay up to date on news, and access discounted consulting services.
TMA’s response to the COVID-19 pandemic was many years – more than a century, really – in the making. After the Spanish flu hit in 1918, TMA’s leaders created a bylaw provision that gave the Board of Trustees emergency power to function as a Disaster Board and assume certain responsibilities of the House of Delegates. When COVID-19 hit, TMA swiftly invoked that provision amid other crucial first steps. Thus, TMA’s COVID-19 Task Force emerged. The effort to pool resources continued with the formation of the Health Care Industry COVID-19 Strike Force. The coalition of major health care organizations in the state and Texas’ university systems went on to advise state leaders and advocate for physicians, who desperately needed assistance to keep their practices afloat.
2021: State gold-card law
Physicians have long objected to onerous prior authorization requirements that often delay patient care. With medicine’s backing, Texas’ 2021 gold-card law was a legislative response to those frustrations and one of TMA’s most substantial insurance wins. The law exempts physicians who consistently meet prior authorization requirements for a particular health care service from ongoing burden, freeing up more time for patient care. It has since inspired similar legislation in other states, with major public and private payers taking notice and beginning to follow suit. The law also laid the groundwork for additional reforms and fixes, for which TMA continues to advocate.
2021-24: No Surprises Act lawsuits
When Congress passed the No Surprises Act in 2020, it was supposed to remove patients from certain out-of-network billing disputes between payers and physicians and to provide more transparency around health care costs. But, as TMA knew from the start, some of the regulatory provisions related to the dispute resolution process were flawed and could give payers an unfair advantage. Since 2021, TMA has successfully sued federal regulators four times over their implementation of the law, prompting congressional scrutiny, new rules, and proposed legislative fixes. The lawsuits also have spotlighted TMA’s advocacy leadership, whose benefits span far beyond the Lone Star State.
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