Texas Family Physician, Q1 2021 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 72 NO. 1 2021

D2E

TAFP Initiative Will Help Family Doctors Establish Direct-ToEmployer Contracts

PLUS: Checking Up On The 87th Texas Legislature How To Detect Email Fraud Cyber Fraud Case Study: Failure To Recognize Phishing Email

NEW FROM CDC

HIV Nexus offers a comprehensive collection of key federal resources on COVID-19 and HIV. More than half of HIV clinicians are primary care providers. To support health care providers managing patients with HIV during the COVID-19 pandemic, the Centers for Disease Control and Prevention has compiled these resources to: • Address concerns related to COVID-19 and HIV. • Provide guidance to health care providers managing people with HIV. • Highlight how people with HIV can protect their health.

To access COVID-19 and HIV resources for your practice and patients, visit:

www.cdc.gov/HIVNexus

INSIDE

TEXAS FAMILY PHYSICIAN VOL. 72 NO. 1 2021

6 FROM YOUR PRESIDENT COVID-19: A personal and professional journey

9 MEMBER NEWS TAFP members receive AAFP appointments | Coming soon: Virtual CME conference

Cutting out the middleman

Employers are looking for ways to offer more value to their employees with fewer headaches for themselves. A direct-toemployer primary care strategy may be just what the doctor ordered. By Dr. Jed Constantz

Are you taking care of your emotional health?

TAFP now offers members access to confidential therapy sessions at a greatly reduced cost so you can unload some of your burden and be more present for your patients and family. By Anticipate Joy

Legislative check-up

At the halfway point in the 87th Texas Legislature, TFP takes a look at where the Academy’s policy priorities stand. By Jonathan Nelson

Are you at risk for cyber fraud?

The risk management experts at Texas Medical Liability Trust present a case study and some hot tips to help you avoid falling for phishing scams.

By Gracie Awalt and Sara Bergmanson

9 PRACTICE RESOURCE CPAN helps with pediatric psychiatry access 10 IN THE NEWS Coalition presents vision to rewire primary care financing 11 TAFPPAC DONORS 28 FOUNDATION DONORS 30 PERSPECTIVE Registering voters at health care centers

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PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 72 NO. 1 2021 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.

OFFICERS president

Amer Shakil, MD, MBA

president-elect treasurer

Mary Nguyen, MD

Emily Briggs, MD, MPH

parliamentarian immediate past president

Terrance Hines, MD Javier D. “Jake” Margo Jr., MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editor

Jean Klewitz

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Audra Conwell

CONTRIBUTING EDITORS Anticipate Joy Gracie Awalt Sara Bergmanson Jed Constantz Elizabeth Kravitz Larry Kravitz, MD One Voice Edith Ortiz, MBA

Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2021 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN [No. 1] 2021

COVID-19: A personal and professional journey Proper treatment and management of COVID-19 patients by primary care physicians can reduce hospitalizations and mitigate the strain on our health care delivery system By Amer Shakil, MD TAFP President and I could not do much. After four days of as a frontline, community family physiworsening symptoms, my test came back cian treating patients like my colleagues positive. I was advised to get an infusion of across the country, I became infected monoclonal antibodies at UT Southwestern with the new coronavirus and contracted Medical Center. COVID-19. Fortunately, I am recovering and I had started antibidid not need to go to otics and steroids when the ICU or be put on I initially experienced a ventilator, unlike far symptoms. I was not too many of our friends This illness is nothing getting better so I and neighbors. but a great lesson and called my infectious I was taking care blessing for me. I have disease friend who of a patient in the learned so much on doubled my dose of hospital who was steroids and added a immunocompromised, both the professional few more medications. had heart failure, renal and personal levels. I A day later I worsened, failure, and a history owe so much to the with significant difof renal transplant care, love, and support ficulty breathing and rejection. While in the my pulse oximetry hospital, he became of my colleagues at reading dropped from sick again and again, UT Southwestern 96 to 94. We both got and I tested him for and the physicians in scared and my treating COVID-19 several my community. They physician referred me times. On the third epito the emergency room sode after 10 days, his checked on me regularly to get a CT scan. The test came back positive. and took care of all the scan showed typical Although I was taking work I was unable to do. findings for COVID-19 all the precautions and viral infection but likely preventive measures, I no other complicabelieve I contracted the tions, so I returned virus from him. home. I also had a telemedicine visit with When he tested positive, I filled out an a pulmonologist who further changed my occupational health questionnaire and realmedication regimen, adding an even higher ized I had been having headaches and mild dose of steroids. body aches for a few days. I thought this was Again my condition worsened and I simply the effects of working long hours in went back to the ER. I was diagnosed with the hospital. I initially tested negative but pneumonia and sepsis, and I spent three was advised to quarantine anyway. more days in the hospital. Over the course of next three to four This illness is nothing but a great days, I started experiencing severe myallesson and blessing for me. I have learned gias, low-grade fever, and chills. Later I so much on both the professional and developed a sore throat, ear pain, and night personal levels. I owe so much to the care, sweats. I took Tylenol around-the-clock

Reiner Consulting & Associates love, and support of my colleagues at UT Southwestern and the physicians in my community. They checked on me regularly and took care of all the work I was unable to do. Similarly my family and community showed an outpouring of love and care. They have delivered food and groceries, and they have helped out with anything we needed. My mom and my family back in Pakistan showed similar support. Most importantly I am lucky to have a beautiful wife who is also physician. She not only took care of me, but she maintained our practice and our COVID testing site. This is a very isolating illness; that was probably the hardest part of getting sick for me. In general, I have no trouble being alone and working away, but to be forced to stay quarantined and not to touch or feel your loved ones can be tough. However I consider myself as one of the positive stories of this pandemic. Although I was not sick enough to be admitted to the ICU or to need a ventilator — like some of my physician friends and patients — I still struggle with daily fatigue. I have a strong faith and firmly believe that everything happens for a reason and for making you better and stronger. A few things bothered me during my fight with COVID. My elderly mother waits anxiously all year long to touch, hug, and kiss me for only a few days a year. She calls every morning to chat on FaceTime, but how would she feel if I were not there to answer? I also thought about what it would mean for the love of my life, Yasmin, to lose her husband if I were to perish. I was able to feel the pain, isolation, and suffering of so many families who are faced with the devastating outcome of this disease and the harsh reality of losing a loved one. While convalescing, I have had time to think about how we as primary care physicians can combat this pandemic. I believe we must commit to a three-step strategy: identification, isolation, and intervention. First we must identify every infected and exposed patient, regardless of age. This is very important to prevent the vicious circle of spread in outpatient settings. We must provide enough testing capacity to community physicians so they can identify

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COMING SOON ON TAFP’S

CME SCHEDULE C. Frank Webber Lectureship & Interim Session April 16-17, 2021 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 4-6, 2021 La Cantera Hill Country Resort & Spa San Antonio, Texas Annual Session & Primary Care Summit Nov. 5-7, 2021 The Woodlands Waterway Marriott Hotel & Convention Center The Woodlands, Texas 8

TEXAS FAMILY PHYSICIAN [No. 1] 2021

have helped prevent numerous hospitalthese patients as early as possible and start izations. the isolation and treatment process. At the current rate the disease is The second step is isolation. It has been spreading, we must maximize outpatient my experience that in the community management, aggressively identifying and setting, families do not quarantine in the treating patients in a timely manner so we strictest sense. Particularly children and can prevent complications and the potenyoung adults do not quarantine appropritial breakdown of our health care system. ately when someone in the home is sick. My worst nightmare is that this may be the Primary care physicians should provide assault experts have been predicting for proper education about this but this is difdecades that can cause our entire health ficult now, as many practices have had to care system to collapse. I am saddened to close or curtail their business due to a lack see that many of our outpatient physicians of PPE, rapid testing modalities, and fear of and other health care spreading the disease. providers have not been The third step considered a priority is intervention. I to receive the vaccine think this is the most We must be strong, both at this time. I strongly important step that is believe they should be missing in the current in our resilience and a very high priority. If management of the commitment to defeat they are immunized, COVID-19 pandemic this pandemic and to fix they can reopen their in our country. As the our systemic health care offices and help mitidisease burden has gate the pandemic. increased, the number delivery problems, which Immunization is key of new positive cases are the real reason we for building long-term and the number of are losing this battle. We herd immunity. Howpatients becoming must commit to building ever, immunization of moderately to critically our entire nation will ill seem to be spinning a stronger foundation of take time and will not out of control. Most primary care upon which be enough to curb the cases can be identified the edifice of our health current rate of infecin the early stages and care system can stand tion. New mutations of should be aggressively the virus and uncertreated to prevent firmly and not collapse tainty over how long further progression. under severe stress. the vaccine will convey Many countries immunity further comthat do not have adeplicate our situation. quate resources have We must be strong, adapted to the situaboth in our resilience and commitment to tion using time-tested clinical strategies defeat this pandemic and to fix our systemic to mitigate the pandemic. For example, health care delivery problems, which are many of my family members and friends the real reason we are losing this battle. We who became ill in Pakistan or India were must commit to building a stronger foundatreated. If patients there have significant tion of primary care upon which the edifice symptoms, particularly respiratory system of our health care system can stand firmly involvement, physicians will start them and not collapse under severe stress. on anti-inflammatory high-dose steroids The United States has always been at the and antibiotics like Zithromax. Patients forefront of implementing the best systems, routinely get a chest X-ray to inform their using the best technologies, and applying treatment options and if their condition the best approach to overcome any chalworsens, they will get a CT scan to make lenge. With dedication and determination, sure there are no further complications. we can build a more equitable and effecOver the last 6 to 8 months, I have treated tive health care system, better equipped to many patients on an outpatient basis not handle the next pandemic while providing only here in America, but all the way back comprehensive, continuous care to all. to my home country of Pakistan, and I

MEMBER NEWS

TAFP members receive national appointments two members received appointments to serve on AAFP commissions last December. These are two of seven commissions that direct AAFP policies and programs. Jose Hinojosa, MD, of San Antonio was appointed to serve a four-year term on the Commission on Continuing Professional Development. This commission helps guide AAFP’s credit system and its provision of continuing medical education. Anush Pillai, DO, of Pearland was appointed to fill a two-year unexpired term on the Commission on Health of the Public and Science. Members of this commission help support AAFP’s strategic objectives: payment reform, practice transformation, family medicine workforce, and clinical expertise. David Tyler King, DO, of Laredo, received an appointment to serve as the resident representative on the AAFP FamMedPAC Board of Directors. King, a first-year resident at the Laredo Medical Center Family Medicine Residency, will serve a two-year term on the board. FamMedPAC is AAFP’s federal political action committee. It advocates for family physicians and their patients by helping to elect congressional candidates who support AAFP’s legislative goals and objectives.

TAFP to offer virtual CME conference in 2021 After the success of two virtual conferences last year, the Academy has announced it will offer one totally virtual conference on Saturday, August 14, 2021. As of press time for this issue, the conference has yet to be named but the crack team of CME planners at TAFP are on the job. It will be a one-day conference offering eight CME credits. TAFP’s CME Planning Committee aims to include a one-hour presentation on opioids that will count toward the Texas Medical Board CME requirement on pain management. They also intend to offer a one-hour presentation to meet the medical ethics requirement. Save the date and watch your inbox for more information coming soon.

Let the Child Psychiatry Access Network help you help your patients By Edith Ortiz, MBA

he Child Psychiatry Access Network can assist a primary care physician during a mental-health-focused assessment in the office, providing them with education and recommendations for evidence-based interventions. Studies show that families place enormous trust in you, their family doctor, and often prefer to have mental health issues managed without a referral to a specialist. Our CPAN team is there to support that process as well as help locate mental health services when the problem is severe and warrants specialty intervention. We are happy to take a call whether the patient is in your office or not. Call us when you get that inbox message and are not sure of the next steps. Call us when an intervention you have recommended is not effective. Call us when you want help explaining a mental health challenge to a family. You will reach a team member within five minutes of your call, and if a child psychiatry team member is needed to assist, they will call you back within 30 minutes. We value your special expertise and your relationship with your families. We want to be your expert consultation team that provides access to equitable care and provides you with increased knowledge and skills to manage those mild to moderate mental health disorders. CPAN is ready to provide real-time phone consultation to all Texas primary care physicians, Monday through Friday from 8 a.m. to 5 p.m. Just call (888) 901-CPAN. You can sign up on the first call or just get your mental health question answered. CPAN is here for you and the families you serve. Here’s an example from one of our CPAN psychiatrists, Lauren K. Havel, MD.

”As a CPAN psychiatrist, I provide consultation on diagnosis, medication management, and treatment planning. One recent consultation focused on choosing a medication for anxiety in a young adolescent with a diagnosis of chronic musculoskeletal pain. The pediatrician had already prescribed the first-line treatment, having tried two different selective serotonin reuptake inhibitors without sufficient benefit to the patient’s anxiety. The pediatrician and I reviewed the presenting symptoms, which met the criteria for generalized anxiety disorder, and the typical treatment algorithm. As she had already tried two medications in the first-line class, I recommended a medication in the second-line class, serotonin-norepinephrine reuptake inhibitors, with evidence for treating chronic pain. The pediatrician and I discussed the starting dose and titration schedule, potential side effects, and the follow-up plan. “This whole process took less than 10 minutes and the pediatrician was able to provide a recommendation to the patient that same day. At CPAN our child psychiatrists are available Monday through Friday, 8 a.m. to 5 p.m. The family doesn’t need to be in the office for you to pick up the phone and ask a question. Call us as many times as you need to better support the families in your care.“ For more information about CPAN, visit https://tcmhcc.utsystem.edu/ initiatives/pediatrician-and-pcp/.

Edith Ortiz, MBA, is a project manager with the Centralized Operation Support Hub of the Texas Child Mental Health Care Consortium. She is also a Senior Business Operations Associate in the Menninger Department of Psychiatry and Behavioral Science at Baylor College of Medicine.

www.tafp.org

IN THE NEWS

ASK your patients if they use tobacco.

7 national primary care organizations launch joint vision to rewire primary care financing

ACT to help them quit.

With COVID-19 as a catalyst, the organizations developed recommendations to fundamentally change the way primary care is financed, improve health equity, and boost clinicians’ ability to offer seamlessly integrated care

Tobacco cessation resources available at www.askandact.org

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TEXAS FAMILY PHYSICIAN [No. 1] 2021

AM 9/9/10 9:18

“Primary care physicians cannot adeseven of the nation’s largest primary care quately meet the needs of their communities physician organizations have released recomif they remain shackled to payment schemes mendations on the urgent need to change the which reimburse for volume instead of way primary care is delivered and financed. value,” said John Brady, MD, Chair of the The American Academy of Family PhysiAmerican Board of Family Medicine. “Many cians, the American Academy of Pediatrics, current regulatory demands unnecessarily the American Board of Family Medicine, distract clinicians from the American Board patient care. Coming of Internal Medicine, out of the pandemic, the American Board of a return to the status Pediatrics, the American “Primary care physicians quo is not sufficient. College of Physicians, cannot adequately The American public and the Society of Genmeet the needs of their deserves better.” eral Internal Medicine These seven national represent more than communities if they organizations devel400,000 physicians and remain shackled to oped specific recomhave created a unipayment schemes which mendations to advance fied vision to change reimburse for volume primary care as a public the conversation and good, shift the model of modernize primary care instead of value. Many financing primary care as we know it. current regulatory and dismantle the reguThis collaborative demands unnecessarily latory and financing work comes at a critical distract clinicians from structures that interfere time when the health with optimal individual of the population has patient care. Coming out and population health. weakened and the of the pandemic, a return The unified vision primary care setting to the status quo is not includes a shift from has been severely sufficient. The American cost-based attributes of strained by COVIDthe current model (sick 19. Handling nearly public deserves better.” care organized around 40% of all health care episodic, transactional, visits, primary care — John Brady, MD and fragmented care clinicians have made delivery) to a model incredible adaptations grounded in health to continue to provide equity and investment, care during the panwith attributes based in health and orgademic, yet they have been largely left out of nized around longitudinal, relational, and national pandemic relief legislation. A series integrated care delivery. of clinician surveys conducted during the “Primary care provides patients of all pandemic has shown widespread closures ages with the care they need to be healthy. and layoffs among primary care practices In pediatrics, it means ensuring children despite the critical role these practices and can receive critical services, like immunizaclinicians play in pandemic recovery efforts.

tions, that promote their lifelong health and development,” said Sally Goza, MD, FAAP, President of the American Academy of Pediatrics. “We must ensure that our primary care infrastructure is strong and well supported if we are to assure the health of Americans across their lifespan.” In an open letter to policy makers, payers, purchasers, and the public, the seven organizations call on: • The federal government to increase investment in safety net programs, public health agencies, and community-based services and support so that they may partner with the medical care sector in addressing structural racism and social drivers of health. • Health care organizations to invest in existing community-based social services and ensure that the flow of dollars supports services such as food banks and other safety net programs that address social drivers of health. • Fellow physician and clinician societies to create a road map for dismantling the policies and regulatory structures that enshrine the current paradigm, and to build multi-stakeholder support for a road map. The collaboration was convened by the Larry A. Green Center and facilitated by X4 Health as part of their continuing effort to change the conversations around primary care in support of improved health for all Americans and the strengthening of primary care. “Never have these seven physician societies and their boards worked together in this way,” said Rebecca Etz, PhD, codirector of The Larry A. Green Center and associate professor, Department of Family Medicine and Population Health at VCU. “Before COVID-19, our health care system was already failing us. We have a new opportunity today to protect primary care and ensure it is there for us both now and long after COVID-19. Our team at the Larry Green Center is extremely proud to work with X4 Health in enabling this work.” More information about any of these organizations and the new vision for primary care finance can be found at www. newprimarycareparadigm.org.

2020 TAFPPAC donors Thank you to these 2020 TAFPPAC donors, whose contributions amplify the voice of family medicine, speaking on behalf of more than 9,000 TAFP members through grassroots involvement, personal relationships with elected officials, and political campaign participation and contributions. TAFPPAC is a non-partisan political action committee that supports candidates who demonstrate concern for issues important to family physicians and their patients. ★ = TAFPPAC monthly donor

★ Lane Aiena, MD

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MATERNAL SUBSTANCE USE: Quick Course

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Are you taking care of your emotional health? By Anticipate Joy

s a Texan, you may have been physically, financially, and emotionally challenged by the recent weather storm. As physicians, you likely have the added stress of the care of your patients during this challenging time. So this month we felt the need to focus on your emotional health. Are you taking care of your emotional health? Let’s take a short quiz to find out by honestly answering these five questions. 1. When someone asks you how you are doing, do you often respond by saying “I’m so tired” or “I’m so busy”? 2. Do you get less than seven hours of sleep each night or find yourself crashing in your recliner as soon as you get home from work?

3. Do you wish you could have more time to simply be present – to be a listening ear and not a fixer, a savior, a creator, or a supporter for someone else? 4. Have you become easily irritated in the last two weeks (i.e. experienced mood swings, grown angry in traffic, or allowed what should have been an anthill to turn into an avalanche)? 5. Do you keep burning the midnight oil when you should be unplugging, unwinding, relaxing, and enjoying? If you answered yes to three or more of these questions, you need to take your emotional health into serious consideration. www.tafp.org

5 EASY STEPS TO GET STARTED

1. 2. 3. 4. 5.

Get access. Use the customized scan code or bit.ly/35OQGqD to access your organization’s mental health benefits. Complete a brief intake. Answer a few questions about yourself. Purchase session(s). Take advantage of the low TAFP member rate. Purchase up to four sessions. Select a therapist. Review available therapists using filters and request a therapist that best fits your needs.

Emotional health is a journey and Mental Health America has suggested a few things you can start doing today to get going in the right direction for a healthier you: 1. Track gratitude and achievement with a journal. Include three things you were grateful for and three things you were able to accomplish each day. 2. Start your day with a cup of coffee. Coffee consumption is linked to lower rates of depression. If you can’t drink coffee because of the caffeine, try another good-for-you drink like green tea. 3. Set up a getaway. It could be camping with friends or a trip to the tropics. The act of planning a vacation and having something to look forward to can boost your overall happiness for up to eight weeks! 4. Take 30 minutes to go for a walk in nature – You could take a stroll through a park or a hike in the woods. Research shows that being in nature can increase energy levels, reduce depression, and boost well-being. 5. Boost brainpower by treating yourself to a couple pieces of dark chocolate every few days. The flavonoids, caffeine, and theobromine in chocolate are thought to work together to improve alertness and mental skills. As we continue to recover from the emotional effects of the recent winter disaster and the COVID pandemic, we want to remind you that TAFP values your emotional health and they have invested in online professional counseling with Anticipate Joy so that you can have easy access to licensed professional therapists in the convenience of your own home and on your own schedule.

Pick a time.

WHAT IS ANTICIPATE JOY?

After the therapist approves your request, select an appointment time that works for you and your therapist.

Anticipate Joy is an innovative mental health treatment and wellness company that supports healing and personal growth through a HIPAA-compliant online professional counseling platform. Anticipate Joy creates an introduction between the client and the therapist, along with the technology that enables the client to have therapy sessions with a licensed mental health provider within the convenience of their own home.

YOUR BENEFITS TAFP has purchased a bulk of sessions making online therapy available to you at a significantly reduced rate of $35 per session when you use the TAFP access. These sessions are available for active and resident members.

SCAN HERE TO BEGIN

TEXAS FAMILY PHYSICIAN [No. 1] 2021

THE REALITY OF PHYSICIAN BURNOUT Not all heroes wear capes, especially during a pandemic. Medical providers all over the state of Texas have stepped into the role of unsung hero as they have worked in the trenches. There is no doubt that you have worked long hours and have taken the brunt of the mental and physical burnout associated with COVID-19. Anticipate Joy is so excited to partner with TAFP to assist you in overcoming some of the emotional and psychological stress that you have had to endure.

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Cutting out the middleman: Direct-to-employer primary care strategy By Dr. Jed Constantz

TEXAS FAMILY PHYSICIAN [No. 1] 2021

A growing number of primary care physicians have demonstrated the ability to “negotiate” direct working relationships with self-funded employers in an effort to secure more favorable “working conditions” that facilitate their ability to understand and meet the needs of an employer’s “covered individuals.” Lessons can be taken from employer interest, adoption, and use of so-called on-site or near-site clinics designed to provide highly customized care for employees and, at times, employee family members. Probably one of the most successful efforts is the Rosen Health Clinic established by Rosen Hotels in Orlando, Florida. The Rosen Health Clinic is an example of a “ground up” primary care clinic built by Harris Rosen, CEO of Rosen Hotels. In this instance, Harris Rosen sought to address the health care cost and quality challenge by beginning at the beginning — primary care. Mr. Rosen, and his team, applied basic business principles to designing and developing a strong business model for primary care finance and delivery. After all, it was his money, his decision, and his choice. On-site and near-site clinic companies and sources of primary care have learned from the Rosen model and have developed like-minded approaches to helping employers control the total cost of care, improve the health status of covered individuals, and drive high levels of satisfaction among benefit plan participants. These basic “triple aim” efforts recognize how basic and fundamental the goals are and should be in the care and treatment of an employer’s covered individuals. As such, the focus for the direct negotiation of a working relationship need not be overly complicated or unnecessarily protracted. The steps involved in the process include the calculation of the future value of primary care and the expected deliverables driven by that calculation.

Employers — also recognized as purchasers of health care for their covered individuals — need a framework they can work from that simplifies the conversation in order to simplify the negotiation and thereby ensure a more balanced arrangement that respects their role as purchasers and respects the obligation primary care assumes in the care and treatment of patients. Sources of primary care likewise need a framework they can work from to facilitate a deeper understanding by purchasers regarding their capabilities and financial needs in meeting the terms and conditions of a directly negotiated arrangement.

The Texas Academy of Family Physicians has spawned an initiative to establish a template set of materials that supports those employers and sources of primary care, seeking to engage in the direct purchase of or the negotiation for advanced primary care. This initiative is straight forward in nature. Employers — also recognized as purchasers of health care for their covered individuals — need a framework they can work from that simplifies the conversation in order to simplify the negotiation and thereby ensure a more balanced arrangement that respects their role as purchasers and respects the obligation primary care assumes in the care and treatment of patients. Sources of primary care likewise need a framework they can work from to facilitate a deeper understanding by purchasers regarding their capabilities and financial needs in meeting the terms and conditions of a directly negotiated arrangement. Purchasers, through the National Alliance of Healthcare Purchaser Coalitions, have offered seven key attributes of advanced primary care as an invitation to all sources of primary care to present themselves for the direct purchase of care and treatment of covered individuals. These seven attributes emerged from a deep-dive assessment process where sources of primary care submitted information and data about their existing characteristics and patient-level commitments leading to high value, affordable health care for an employer’s covered individuals. These attributes include enhanced access for patients, more time with patients, realigned payment methods, organizational and infrastructure backbone, disciplined focus on health improvement, behavioral health integration, and referral management. While these attributes may appear obvious, the details behind the information and data submitted by the deep-dive participants reflect the broad characteristics of physician leadership, primary care team, practice level technology, and a commitment to ongoing staff training and development as key components of continuous quality improvement. Physician leadership speaks to the commitment of the individual doctor caring for patients, and his or her acceptance of accountability for the delivery of triple aim results for the covered individuals they accept as patients under this arrangement. The care team speaks to the talent that surrounds the physician and the alignment of that care team to the needs of the patient cohort and the skill gaps of the physician. The practice-level technology is that technology leveraged by the physician and the care team to ensure a deep understanding of patient needs, and the design, development, and execution of a balanced care plan aligned with those needs. Ongoing staff training and development recognizes the need to challenge 18

TEXAS FAMILY PHYSICIAN [No. 1] 2021

team members with ever increasing performance expectations and to support that challenge with a sophisticated curriculum that measures where each team member is and where they need to be for the benefit of patients. Compensation for primary care must equal the expectations of primary care. To that end, a comprehensive or prospective primary care payment model must be adopted to ensure both cash flow and maximum flexibility for the alignment of care delivery with the needs of patient cohorts. Calculating the future value of primary care is the first step in determining what a comprehensive compensation model could or should look like to support the purchase of high value, advanced primary care. Doing the math, in this sense from the purchaser’s perspective, is an opportunity for the purchaser to spend the same or less money more intelligently. Consolidating primary care spending with primary care practices suggests the redirection of dollars associated with preventive care, acute care, wellness services, disease management, and care management and coordination to primary care. These dollars can be reduced to a per patient per month investment in primary care. The project at hand is to develop a turnkey D2E strategy built on a standardized business agreement involving the calculation of a comprehensive payment. This comprehensive payment would be consistent with the needs of the purchaser and the capabilities of the source of primary care. This business agreement would spell out the desired, and mutually acceptable, deliverables from the source of primary care consistent with the needs of the purchaser and their covered individuals. Finally, this business agreement would speak to the methodology for value-based reporting, by the source of primary care, focused on measures that matter. These measures that matter would strive to address basic triple aim deliverables, simple improvement in the health status of covered individuals, control of the total cost of care, and high levels of satisfaction among the parties. Beyond this, it is up to purchasers and sources of primary care to step forward and leverage this effort for the benefit of their respective communities.

Dr. Jed Constantz is a primary care finance and delivery reform strategy consultant. In his more than 30 years of experience in the health care industry, he has worked with payers, employers, and physicians to implement solutions that improve efficiency and quality outcomes while reducing costs. He is now the principal strategist at Advanced Primary Care Strategies.

5 questions for TAFP CEO Tom Banning TFP: On a macro level, why do you think direct-to-employer contracting for primary care services is something the Academy should explore? TB: More and more employers are finding it increasingly challenging to offer comprehensive health insurance benefits to employees. The third-party payment system we have is inefficient, costly, and not sustainable. Employers are looking for solutions to provide care to their employees, and direct contracting is one strategy they’re utilizing. The employer bypasses the traditional relationship most have with an insurance company to negotiate directly with physicians. It cuts out the middleman in rate negotiations, aligns the interests of those paying for care and those providing care, increases transparency, leads to more efficiency (i.e., higher value at lower cost), and ideally achieves value-based care. TFP: Does this model cut insurance carriers out completely? TB: Not necessarily. Direct contract arrangements can vary. An employer may choose to directly contract for a comprehensive set primary care services or single services, like COVID testing or administering vaccines. It does not necessarily mean the end of dealing with insurance companies. An employer may use a thirdparty administrator or insurance company to cover higher cost services like specialty care, hospitalization, and pharmaceuticals or to manage claims and physician payment.

TFP: What if the employer only offers the primary care services and doesn’t provide other coverage options? TB: If the employer chooses not to provide more comprehensive coverage, then the employee would need to strongly consider buying wrap coverage or catastrophic coverage. TFP: What do you think the major obstacles might be for a practice to enter into a D2E contract? TB: Scale and geography. Multi-national companies with employees spread across the country, like IBM or Southwest Airlines, want a single health care solution that can be administered across all the geographic regions where its employees live and work. It’s simply not practical for an employer to negotiate hundreds or thousands of direct contracts across the country. That, however, is not the case for large to mid-sized employers whose employees are geographically concentrated. It can also take time to negotiate terms of the contract and an agreed-to price for services. TFP: What is TAFP hoping to offer that will help physician practices make this happen? TB: Our plan is to offer resources including case studies and recommended contract language to help physicians decide whether partnering directly with employers makes sense for their practices.

Creating a turnkey direct-to-employer primary care strategy Greater use of primary care leads to lower total health care cost, higher patient satisfaction, fewer hospitalizations and emergency department visits, and lower mortality. Access to comprehensive, continuous, and coordinated advanced primary care is imperative to achieving a more cost-effective, higher-performing health care system.

Payment reform is fundamental to reward value and performance over volume A comprehensive or prospective primary care payment model will incentivize patient activation, case and care coordination, and accountability for health and health outcomes as well as downstream referrals.

A turnkey direct-to-employer primary care strategy requires a standardized business agreement that would include: • The calculation of a comprehensive payment model for the purchase of primary care access and services driven by employer need and practice level capability. • The design and structure of a contract or contract terms that facilitates agreement between the purchaser and the designated source of primary care. • The design and development of value-based care reporting driven by an agreed upon set of “measures that matter” focused on the total cost of care, improvement of covered individual health literacy and health status, and increased patient satisfaction leading to high level patient activation.

7 KEY ATTRIBUTES OF ADVANCED PRIMARY CARE 1. ENHANCED ACCESS FOR PATIENTS Convenient access, same-day appointments, walk-ins, virtual access, no financial barriers to primary care 2. MORE TIME WITH PATIENTS Enhanced patient engagement and support, shared decisionmaking, understanding preferences, social determinants of health 3. REALIGNED PAYMENT METHODS Patient-centered experience and outcomes, quality and efficiency metrics, deemphasize visit volume 4. ORGANIZATIONAL & INFRASTRUCTURE BACKBONE Relevant analytics, reporting and communication, continuous staff training 5. DISCIPLINED FOCUS ON HEALTH IMPROVEMENT Risk stratification and population health management, systematic approach to gaps in care 6. BEHAVIORAL HEALTH INTEGRATION Screening for BH concerns (e.g., depression, anxiety, substance use disorder) and coordination of care 7. REFERRAL MANAGEMENT More limited, appropriate and high-quality referral practices, coordination and reintegration of patient care

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5/10/12 10:40 AM

LEGISLATIVE CHECK-UP: Update on TAFP’s policy priorities By Jonathan Nelson

he 87th Texas Legislature has reached its halfway point and while uncertainty around the pandemic and the great Deep Freeze Disaster of ’21 got things off to a slow start, action at the State Capitol is picking up. TAFP has joined many other organizations in efforts to reinforce our public health infrastructure, fight back against efforts to allow nurse practitioners to practice medicine independently, ensure adequate payment for COVID testing, and more. And we have provided testimony in numerous hearings, both virtually and in person. TAFP Treasurer Emily Briggs, MD, MPH, testified before the Article II Subcommittee of the House Appropriations Committee on March 1, making the case for drawing down available federal funding to extend health care coverage to uninsured Texans. “More than five million lack health care coverage — a number that undoubtedly grew last year,” she said. “Five million is a difficult number to fathom, but they are the people who make our economy hum and our lives easier, such as grocery clerks, home health aides, or even the contract utility workers who repaired downed power lines following Texas’ arctic event…. By extending health care coverage to low-wage working adults, the state will provide them the freedom to start a small business, go back to school, or move or change jobs without worrying whether they’ll have health care coverage.” She went on to articulate several of your Academy’s policy priorities. Here’s a mid-session update on TAFP’s legislative advocacy objectives.

Medicaid and CHIP Texas continues to lead the nation in the percent of its population that lacks health insurance. The pandemic has only exacerbated that problem. It’s time to tackle this problem and make reforms to provide access to high-quality, continuous, and affordable health care to all Texans.

• TAFP supports finding a Texas solution for extending comprehensive health care coverage to low-income, working-age adults. • TAFP supports removing administrative barriers that make it difficult to enroll or to stay enrolled in Medicaid and CHIP. • TAFP supports the implementation of 12-months continuous coverage for children enrolled in Medicaid. • TAFP supports securing Medicaid coverage for mental health collaborative care, allowing physicians, psychiatrists, behavioral health providers, and case managers to work together to coordinate care.

www.tafp.org

“More than five million [Texans] lack health care coverage – a number that undoubtedly grew last year. Five million is a difficult number to fathom, but they are the people who make our economy hum and our lives easier, such as grocery clerks, home health aides, or even the contract utility workers who repaired downed power lines following Texas’ arctic event.” — Emily Briggs, MD, MPH 22

TEXAS FAMILY PHYSICIAN [No. 1] 2021

Although leading up to the session, it looked like the state budget would be tight, now we know Texas is about to receive a huge influx of federal stimulus money from the COVID-19 relief package. This offers lawmakers a tremendous opportunity to make major investments in the state’s health care infrastructure, particularly in Medicaid and CHIP. Physicians in these programs haven’t seen an increase in reimbursements in almost two decades. According to a recent Health Affairs article, Medicaid in Texas pays about 58% of Medicare rates on average for primary care services. Using federal stimulus dollars, the Legislature could establish a permanent fund similar to the Graduate Medical Education Expansion Grant program or the Rural Health Facility Capital Improvement Program, which was established by Texas’ tobacco lawsuit settlement. The Legislature could use dollars generated from the fund to direct the Health and Human Services Commission to pay for targeted Medicaid physician rate increases tied to either outcomes or provider network needs.

• TAFP calls on the Legislature to increase physician payment rates in Medicaid and CHIP.

Telemedicine payment parity During the pandemic, physicians and patients have adopted telemedicine as never before. As part of COVID-19 emergency measures, telemedicine services have been paid at the same rate as in-office services. TAFP supports ensuring that covered services be paid by health plans at the contracted rate, whether the service is provided in person or via telemedicine.

• TAFP supports telemedicine payment parity.

Scope of practice It just wouldn’t feel like a legislative session without a huge scope of practice battle, and this time around is no different. The nurse practitioner organizations are back once again with a bill that would allow APRNs without any physician collaboration to prescribe pharmaceuticals up to schedule III and in some situations, schedule II; order, perform, and interpret diagnostic tests; and prescribe medical devices. According to the Texas Medical Practice Act, those actions comprise the definition of the “practice of medicine.” As always, TAFP will fight this effort vigorously.

• TAFP opposes any effort to allow APRNs to prescribe dangerous pharmaceuticals; to order, perform, and evaluate diagnostic tests; and to prescribe medical devices and durable medical equipment without physician collaboration or involvement.

Health care cost transparency An all-payer claims database is a centralized database that collects medical claims data from public and private sources. This data is used by researchers and policymakers to launch initiatives to improve

quality and health outcomes while lowering costs. Among a broader consumer audience, such a database leads to greater transparency and the ability for patients to “shop around” for health care services by providing information on how much services cost across providers, facilities, and locations. In a September 2020 letter to the House Select Committee on Statewide Health Care Cost, TAFP President Jake Margo Jr., MD, wrote: “On the path from fee-for-service medical care to value-based care, gathering data to fully understand health care spending and utilization across a state or patient population is critical.” Access to claims data enables researchers to paint a more complete picture of where health care dollars go and the types of health care visits that patients make. This information is crucial to determining where savings could be found. That is why 18 states have or are establishing all-payer claims databases to facilitate this data collection. • TAFP supports the creation of a statewide all-payer claims database using the Center for Healthcare Data at the University of Texas Health Science Center at Houston to collect, process, and analyze health care claims and encounters to improve the quality of health care in Texas.

Physician workforce Our state’s 38 family medicine residency programs are the lifeblood of our primary care physician workforce, preparing more than 300 new family physicians for practice each year. During the COVID19 pandemic, these clinics have proven their worth by providing consistent and comprehensive outpatient primary care to their communities, implementing new telemedicine and safety protocols, and working to reduce the strain on overburdened hospitals. For decades, the Legislature consistently funded our state’s family medicine residency programs through the Texas Higher Education Coordinating Board. Although many of these residency programs receive some benefit from GME formula appropriations for Texas’ health-related institutions, dedicated coordinating board funds are the only direct state support these programs receive. In recent years, this funding has been inconsistent and has varied dramatically, putting existing residency programs in jeopardy. Even as the state has increased the number of residents in training, the amount of THECB funding for family medicine residents has withered, dropping from $14,300 per resident each year in 2011 to $5,400 in 2021. According to a report from the Department of State Health Services, the state will need approximately 3,400 more primary care physicians than it is on track to produce by 2030 to meet demand. Yet the base budget being considered now cuts the Family Practice Residency Program from $5 million a year to $4.75 million. • TAFP calls on the Legislature to restore funding to the Family Practice Residency Program to $10 million each year. • TAFP supports maintaining funding for other THECB programs designed to support the recruitment and training of primary care physicians in Texas and to ensure the appropriate distribution of those physicians, including the Statewide Preceptorship Program, the Physician Education Loan Repayment Program, and the State Rural Training Track Grant Program.

Women’s health As a member of the Texas Women’s Healthcare Coalition, TAFP joins many organizations advocating for policies that increase access to high-quality care for women in all walks of life. Many of those policies focus on pregnancy, maternity, and postpartum care. Consider this information from testimony TWHC presented to the Article II Appropriations Subcommittee. “In 2018, almost one out of 10 Texas births were to a woman who received late or no prenatal care. Additionally, almost one in nine Texas births were preterm, and one in 12 infants were born at a low birthweight. Moreover, alarming racial and ethnic disparities persist, with Black infants twice as likely to die within the first year of life compared to white and Hispanic babies, and with Black mothers having a disproportionately high percentage of pre-term births and low-birth weight babies. “Not only does a woman’s access to health care impact her own health, as the [Texas Maternal Mortality and Morbidity Review Committee] highlighted, but access to health care is essential for future healthy pregnancies and births. Healthy pregnancies lower costs by reducing expensive neonatal intensive care stays for infants and prevent maternal health complications. For example, in FY2015, the average cost to cover a full-term newborn’s first year of life under Medicaid was $572, while the average cost for a pre-term, low birth weight newborn’s first year of life was $109,220.” Healthy Texas Women and the Family Planning Program are two state initiatives designed to provide access to women’s health and family planning services. According to reports from the Texas Health and Human Services Commission, HTW and FPP saved the state a combined $139.7 million in 2019 alone. • TWHC and TAFP call on the Legislature to prioritize funding for women’s health programs including the Family Planning Program, Healthy Texas Women, and the Breast and Cervical Cancer Services Program. • TWHC and TAFP support extending Medicaid postpartum coverage from 60 days to 12 months. • TWHC and TAFP support removing enrollment barriers for patients in Healthy Texas Women. For more about the Texas Women’s Healthcare Coalition and its work during the 87th Texas Legislature, go to www.texaswhc.org.

Prescription Monitoring Program TAFP joined TMA, the Texas Orthopaedic Association, and the Texas College of Emergency Physicians in asking the Legislature to appropriate funds to assist the statewide integration and maintenance of the Prescription Monitoring Program. In a letter to the Senate Finance Committee, the organizations said, “The PMP served as one of the Texas Legislature’s tools for addressing ‘doctor shopping’ by individuals who are attempting to acquire prescription drugs for inappropriate purposes.” The program allows physicians to review a patient’s prescription history through their electronic health record. • TAFP supports ongoing funding for the Prescription Monitoring Program to keep software up to date and to continue the statewide integration process. www.tafp.org

Prior authorizations

“The uninsured come from all walks of life and all parts of the state, though women, Texans of color, and low-wage rural and urban workers are more likely to lack health care coverage…. By extending health care coverage to low-wage working adults, the state will provide them the freedom to start a small business, go back to school, or move or change jobs without worrying whether they’ll have health care coverage.” — Emily Briggs, MD, MPH 24

TEXAS FAMILY PHYSICIAN [No. 1] 2021

Legislators may have heard the complaints of patients and physicians about the increasing burdens health plans inflict through the overuse of prior authorizations. Several bills have been filed addressing different aspects of the practice.

• TAFP supports requiring the Texas Department of Insurance to audit health plan compliance with statutory prior authorization timelines for approvals and denials. • TAFP supports limiting the ability of health plans to deny emergency care claims based entirely or in part on what final diagnoses are eventually recorded. • TAFP supports prohibiting prior authorization for health care services that are state-mandated benefits. • TAFP supports limiting repetitive prior authorization requirements that compromise continuity of care for medical services and prescription medications for patients on appropriate, chronic, stable therapy.

Tobacco and vaping As a member of the Texas Public Health Coalition, TAFP supports a wide range of efforts to strengthen the state’s public health infrastructure and to address public health concerns. Last session, the coalition successfully advocated for the Tobacco 21 campaign, as SB 21 increased the legal age from 18 to 21 for a person to buy cigarettes, e-cigarettes, or other tobacco products. This session, the coalition has a few more policy goals.

• TPHC and TAFP support strengthening the regulation of tobacco and e-cigarette products in Texas. • TPHC and TAFP support requiring licensure for vaping retailers. • TPHC and TAFP support the prohibition of the sale of flavored cigarettes, e-cigarettes, and tobacco products.

ImmTrac Texas’ immunization registry, ImmTrac, plays a crucial role in how physicians and health departments administer vaccines. As it exists, ImmTrac is an opt-in system, meaning once minors become adults, they have to consent to keep their records in the registry. If they don’t, their records are destroyed. This is a major objective of the Texas Public Health Coalition.

• TPHC and TAFP support reform measures that would convert the state’s immunization registry to an opt-out system and simplify consent barriers in the program.

For more about the Texas Public Health Coalition and its work during the 87th Texas Legislature, go to www.txphc.org.

RISK MANAGEMENT

Cyber fraud case study: Failure to recognize phishing email By Gracie Awalt, Marketing Associate Texas Medical Liability Trust

After the incident, the hospital began using the following fraud prevention measures. • A change in policy that requires all wire transfer procedures to have oral confirmation from vendors and contractors if there are any changes in payment instructions. • Managers are now required to send emails using two-step account verification procedures. • Employees in the IT, Finance, and Revenue Cycle Departments attend required training on cyber security and cyber fraud risks.

RISK MANAGEMENT CONSIDERATIONS Social engineering, or the “art of manipulating people in an online environment, encouraging them to divulge — in good faith — sensitive, personal information,”1 typically involves a hacker using a compromised business email account to request money, passwords, banking information, or personally identifying information from the holder of the compromised account. The victim is deceived into thinking the request is from a legitimate source, such as a friend or a financial institution with whom the victim has a business relationship. In this case, the hospital fell victim to a social engineering fraud through a phishing email. The compromised ED group email requested money through multiple wire transfers, tricking the hospital into sending $407,000.

small, rural hospital contracted with an emergency medical group for emergency department coverage. The group was paid monthly by electronic funds transfer, or EFT, from the hospital’s account to the ED group’s account.

The following practices can help combat phishing attacks. • Be suspicious of emails from unknown sources, especially those requesting sensitive information or stressing the urgency and importance of the request. • Train employees to recognize suspicious emails and forward them to someone who manages cyber security.

In June, the hospital received an email invoice from the ED group with instructions to send payment to a new account. The hospital sent the $200,500 payment to the new account on July 10.

• Establish an incident response plan to initiate in case a phishing attack is successful.

On July 12, the payment was returned because the new account was frozen. On July 16, the ED group emailed new account information and instructions to the hospital. The hospital sent the $200,500 payment to the new account.

• Use technology to detect and test emails for malicious content. • Require multifactor authentication. • Conduct regular security training for employees and provide testing to ensure understanding.

In early August, the ED group sent the next monthly invoice by email with instructions to send the funds to another new account. The hospital sent the $206,500 payment on August 13. It was later discovered that the requests to send the funds to the new accounts were fraudulent. The ED group never sent the emails requesting EFT account changes. The cyber criminals who sent the fraudulent emails and set up the accounts ended up collecting $407,000 from the hospital. When the hospital discovered that the money had been sent to an invalid account, the loss was reported to the hospital’s insurance agent and cyber liability carrier. The hospital was advised to take the following steps. • File a complaint with the local police department. • Submit a complaint to the FBI’s Internet Crime Complaint Center (IC3). Instructions are found at https://www.ic3.gov/ default.aspx.

• Follow your instincts, and always report suspicious emails.2

SOURCES 1. Definition: Social engineering. Glossary. International Risk Management Institute. Available at https://www.irmi.com/term/insurancedefinitions/social-engineering. Accessed September 16, 2019. 2. Health industry cybersecurity practices. Healthcare & Public Health Sector Coordinating Councils. Department of Health and Human Services. Available at https://www.phe.gov/Preparedness/ planning/405d/Documents/HICP-Main-508.pdf . Accessed September 16, 2019.

• Contact the bank’s fraud department to flag the transactions as fraudulent.

Gracie Awalt can be reached at gracie-awalt@tmlt.org.

• Contact the local FBI office.

Reprinted with permission from Texas Medical Liability Trust. www.tafp.org

RISK MANAGEMENT LINKS • You can preview a link in an email message, without having to click on it, by hovering your cursor over the link. Either a small text box will appear with the full web address or it will appear in the lower left corner of your browser window. • If the link appears suspicious or does not match the link in the message, do not click on it. These links can direct you to false websites or malicious software.

How to detect email fraud By Sara Bergmanson, Digital and Social Media Specialist, Texas Medical Liability Trust

ASKING FOR PERSONAL INFORMATION • If the email message is asking you to confirm or provide personal information, do not reply. Email is not a secure method for sharing sensitive information, and legitimate businesses do not ask you to send information this way.

SUSPICIOUS ATTACHMENTS • Files attached in an email could contain viruses or other malware that can weaken your computer’s security. If you think you received a phishing email do not open or download any attachments.

EXAMPLE Ref. EF54325-EE14555-0456531

EMAIL PHISHING Email fraud is also known as “phishing” or “spear phishing.” Phishing – an attempt by cyber criminals using an email message that appears to come from a trustworthy source to get a recipient to provide sensitive or private information, such as a username, password, credit card number, or other secure data.

WHAT TO LOOK FOR: SPELLING AND BAD GRAMMAR • If you notice spelling or grammar mistakes in an email, it might be a scam – especially if the email appears to come from an organization you do business with. Legitimate businesses have communication departments or staff who review and edit email before sending it to customers. • Check for proper spelling in web and email addresses. Cyber criminals use web and email domains that resemble the names of well-known companies but are slightly altered.

Dear Amazon Client, Your account will be closed because a violation of our term of use We Investigated in this issue and found a fraudulent activity from another ip addre4ss. In this activity a fraudulent transactions and more suspicious activity from an unknown computer. Please verify your identity for we can process this issue We recommend follow this steps below carefully : >identity verification This is a big risk to our customers you will take all responsibility for this issue. As well if you didn’t complete the steps with all required information we will give this issueto the US Security Department. Thanks,

THREATS • Email scams will entice you to respond to the message by threatening to close an account or by threatening another type of action. Legitimate institutions, particularly banks, do not typically communicate this way or ask you to click on a link in an email. Do not reply, click on links, or call phone numbers provided in the message.

Security Team

When you’re unsure about the legitimacy of an email either call the sender or contact your security officer, IT staff, or consultant.

• Contact the institution directly using contact information you know to be correct, if you have any doubts or questions.

Sara Bergmanson can be reached at sara-bergmanson@tmlt.org.

• This also applies to emails with requests for urgent responses.

Reprinted with permission from Texas Medical Liability Trust.

TEXAS FAMILY PHYSICIAN [No. 1] 2021

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Achieve healthier outcomes—for everyone. In its first major development for The EveryONE Project, the AAFP compiled a validated, intuitive, action-oriented, and free toolkit to help physicians recognize and respond to social factors that impact the health of their patients. Utilize The EveryONE Project toolkit to: • Raise awareness about the effects of social determinants of health. • Discover specific health risks in patients of all backgrounds. • Understand and manage potential biases that may exist. • Connect patients with essential resources in their area. Reveal and address the unseen health hurdles your patients face every day. Start using The EveryONE Project toolkit now. aafp.org/EveryONE/tools

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FOUNDATION FOCUS

James Orms, MD Derrick Owens, MD

2020 TAFP Foundation donors ★ = TAFP Foundation monthly donor

Thank you to these 2020 TAFP Foundation donors, whose contributions fund scholarships for Texas medical students, family medicine research grants, and travel scholarships for residents to attend continuing professional development activities.

Grant Pham, MD Fanny Elena Ramirez, MD Mateo Reyes, MD ★ John R. Richmond, MD ★ Shelley Roaten, MD Alejandro Rocha, DO Leon Rochen Michelle Rodriguez, MD John Cecil Rogers, MD Georgia White Roth, MD Angel Salazar, MD Kristi Salinas, MD, CPE ★ Sarah Samreen, MD Marina Sanchez-Ellig, MD Lucia D. Sandoval, MD ★ David Schneider, MD

Tarrant County Academy of Family Physicians

★ Sheridan Scott Evans, MD

Stephen G. Johnson, MD

Lee R. Schreiber, MD

Christopher S. Ewin, MD

★ Brian D. Jones, MD, CPE

★ M. Sandra Scurria, MD

Lisa Burdick Abbott, MD

★ Antonio Falcon, MD

Larry R. Karrh, MD

Puja Sehgal, MD

Clive Fields, MD

★ David Katerndahl, MD

★ Dan Sepdham, MD

★ Troy Fiesinger, MD

Victor C. Knopp, MD

★ Amer Shakil, MD, MBA

★ Triwanna Fisher-Wikoff, MD

★ Shelley Kohlleppel, MD

Victor S. Sierpina, MD

★ Aimee Flournoy, MD

★ Kaparaboyna Ashok Kumar, MD

★ Linda Marie Siy, MD

Linda Whidden Flower, MD

★ C. Timothy Lambert, MD

Derek Ian Skinner, MD

★ Lewis Foxhall, MD

W. Ross Lawler, MD

Ivy Smith Coleman, MD

Juan P. Garcia, MD

★ Don A. Lawrence, DO

Oscar Garza, MD

Sarah Lay, MD

★ Lawrence Gibbs, MD, MEd

Eric Lee, MD

Mark E. Gibbs, MD

Jose Lopez, MD

★ Lisa Biry Glenn, MD

Donald E. Lovering, MD

★ Roland Goertz, MD, MBA

Miguel A. Maldonado, MD

Nadeen Gray, MD

★ Javier D. Margo, MD

★ John Green, III, MD

Oksana Marroquin, MD

★ T. David Greer, MD

Diahann Marie Marshall, MD

★ Ajay Gupta, MD

Frank Martinez, MD

★ Natalia Gutierrez, MD

Samuel Mathis, MD

★ Lesca C. Hadley, MD

★ Kathy McCarthy, CAE

Riaz Haider, MD

Louis V. McIntire, MD

★ Suhaib W. Haq, MD

Thomas McIntosh, MD

Melchor Cardenas, MD

★ Rebecca Hart, MD

Deirdre C. McMullen, MD

★ Chinglin Lillian Chan, MD

Bill and Gail Hartin

★ Susan Clymer McMullen, MD

Tuong-An Bui Wong, DO

★ C Mark Chassay, MD, MBA, MEd

★ Clare Hawkins, MD

Marta Molina, MD

R. R. Yalamanchili, MD

Maria Colon-Gonzalez, MD

Tod Heldridge, MD

Roger Moore, MD

★ Khalida Yasmin, MD

Michael Cooper, MD

★ Terrance S. Hines, MD

★ Dale C. Moquist, MD

★ Robert Youens, MD

Baldemar Covarrubias, MD

Charles V. O. Hughes, III, MD

Audrey Carr Morrill, MD

★ Richard A. Young, MD

Oscar De Valle, MD

★ Farron Cheryl Hunt, MD

Thomas Mueller, MD

Beverly A. Zavaleta, MD

★ Chrisette M. Dharmagunaratne, MD

★ Janet L. Hurley, MD

Abilio Munoz, MD

★ Yanqiu Zhao, MD

★ Jorge Duchicela, MD

Jack Ireland, MD

★ Mary S. Nguyen, MD

Roberto A. Duran, MD

Gregory M. Jackson, MD

Donald R. Niño, MD

★ Bruce Echols, MD

Lee Janson, MD

★ Ikemefuna Okwuwa, MD

★ Tricia C. Elliott, MD

Malay Jayswal, MD

★ Paul B. Oliver, MD

Stephanie H. Elmore, MD

Joe Johnson, MD

Sherri D. Onyiego, MD, PhD

Gwendolyn Allen, MD Marian C. Allen, MD Michael Altman, MD Khin H. Aung, MD Madhumita Banga, MD John F. Bangston, MD ★ Tom Banning ★ Lynda Barry, MD ★ Justin V. Bartos, MD Joane Goforth Baumer, MD Candace F. Been, PA-C Luis Manuel Benavides, MD Melissa A. Benavides, MD ★ Stephen D. Benold, MD Adrian Billings, MD, PhD Maria Susan Blahey, MD Teddy Boehm ★ Lindsay K. Botsford, MD, MBA Jessica Bracks, MD ★ Emily D. Briggs, MD, MPH Raul Calvo, MD

TEXAS FAMILY PHYSICIAN [No. 1] 2021

★ Mary Carmen Spalding, MD ★ Joshua Nathaniel Splinter, MD ★ Charles Herbert Stern, MD ★ Sharon Stern, MD ★ Donald E. Stillwagon, MD Richard A. Stuntz, MD Irvin Sulapas, MD ★ Lloyd Van Winkle, MD ★ John R. Vanderzyl, MD David B. Vaughan, MD Nelly Velasquez, MD Vivian Viera, MD ★ Sally Pyle Weaver, MD ★ Hubert Williston, MD ★ Hugh H. Wilson, MD Keith Wixtrom, MD

Your health before

all else.

INT RODUCI NG

You work hard to take care of your patients. The AAFP works hard to take care of you. AAFP Physician Health First is the first-ever comprehensive initiative devoted to improving the well-being and professional satisfaction of family physicians, and reversing the trend toward physician burnout. So you can stay passionate about your purpose: providing quality patient care.

Discover a wealth of well-being at

aafp.org/mywellbeing The AAFP Physician Health First initiative is made possible by your generous contributions to the American Academy of Family Physicians Foundation.

aafpfoundation.org

PERSPECTIVE

Registering voters at health care centers By Elizabeth Kravitz and Larry Kravitz, MD

We are two generations of primary care providers. The father, a family physician, is in his 42nd year of medical practice. The daughter, just beginning, is a fourth-year medical student at Baylor College of Medicine pursuing obstetrics and gynecology. We are at opposite ends of our medical careers, but we collaborate on our health care perspectives more than we clash. Today, we share my daughter’s view of a physician’s role in promoting democracy.

health care makes patients accessible at their appointments, and they can register to vote at the same time. The average waiting room time for a patient is listed as 18 minutes, and many initiatives exist to make productive use of this opportune free window along with other stagnant moments in the course of a patient’s encounter with the health care system. Why not voter registration? I enlisted medical students, residents, attendings, nurses, attorneys, and other patient advocates. Together we navigated our way to the executive board of the Harris County i am a physician-in-training, and I am also a public Health System to eventually gain not only approval, but a servant. I became a Texas Volunteer Deputy Voter Registrar, small grant to pilot a program to demonand in Texas, my capacity in that role is strate the necessity of voter registration to facilitate and assist in voter registraoutreach for our patients. As patients tion in a nonpartisan manner. At first exited the clinic, they were provided the glance, these professional responsibilities The political climate opportunity to fill out a mail-in voter appear mutually exclusive: a primary care and infrastructure registration form, with a mail bin located provider and a state-deployed volunteer. of Texas are imbued nearby for easy submission — in the end However, I challenge you to reflect on with innumerable registering approximately 900 patients at how these two responsibilities are contwo clinics over the course of a month. vergent and compatible. obstacles to voting. But There is precedent for physician In medical school, we are taught in these obstacles is the involvement in voter registration, such the “social history.” We inquire of our heart of our work and as this one. The National Association of patient’s lifestyle, food security, work, passion: Advocacy is the Community Health Centers, a nonprofit housing, safety, education, and more. association of health centers, completed We address these social determinants nature of a physician. voter registration for more than 18,000 of health in the exam room. As a VDVR, Communication is the people at community health centers in I address these components with the nature of a physician. 2008. These activities must be normalcitizens of Texas. I encourage citizens Teamwork is the nature ized among physicians, as we have an to utilize their right to a voice in the expansive responsibility to facilitate these policies that affect these components of a physician. opportunities for our patients. of their daily lives, and consequently, The political climate and infrastructheir health. This year, in the setting of ture of Texas are imbued with innumera global pandemic, with hundreds of able obstacles to voting, and as physicians thousands of casualties in the United and physicians-in-training, we may feel ill-equipped to States, this necessity of civic engagement is only heightened. advance into this space. But in these obstacles is the heart of And so, I have departed from the antiquated design that our work and passion: Advocacy is the nature of a physician. separates medicine and policy — the two are inseparably Communication is the nature of a physician. Teamwork is entwined. the nature of a physician. Decision making is the nature of a Health disparities affect access to the American demophysician. We are both compassionate and objective, and we cratic process. Using information from the U.S. Census spend our lives learning to balance our warm humanity and Bureau, about one in seven of those registered to vote in ideals with the cold limits of our physical realities. At all the 2008 listed illness or disability as their main reason for not life stages of our careers, being this person is our identity. voting; the rate is even worse in lower income populations. And this training needs to also be brought to a bigger stage In the summer of 2020, I endeavored to offer voter — to the stage of politics and policy. registration forms to patients at clinic sites. The necessity of

TEXAS FAMILY PHYSICIAN [No. 1] 2021

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ture u f e h t e p help sha edicine m y il m a f of

By volunteering to precept a Texas medical student, you can open a door to a new world for the next generation of family doctors. QUESTIONS? Give us a call at (512) 329-8666 or send an email to Juleah Williams, jwilliams@tafp.org. This work was supported in whole or in part by a grant from the Texas Higher Education Coordinating Board (THECB). The opinions and conclusions expressed in this document are those of the author(s) and do not necessarily represent the opinions or policy of the THECB.

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Texas Family Physician, Q1 2021

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