Spring 2015

California

FAMILY PHYSICIAN Vol . 66 No. 2 Sp ring 2015

CAFP President-elect, Jay W. Lee, Md, MPH, with his family near their home in Long beach, CA.

Meet Your INCoMINg PreSIdeNt: JAY W. Lee, Md, MPH

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ALL MeMber AdvoCACY MeetINg ANd LobbY dAY A SMASHINg SuCCeSS!

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uCr PAtIeNt PortAL SYSteM CoNNeCtS to eHr, eMPoWerS PAtIeNtS

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ALWAYS LeArNINg: WHY I buILd SMArtPHoNe APPS

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Photo credit to Laura rauch

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Officers and Board President Del Morris, MD President-Elect Jay Lee, MD, MPH Immediate Past President Mark Dressner, MD Speaker Lee Ralph, MD Vice-Speaker Michelle Quiogue, MD Secretary/Treasurer Lisa Ward, MD Executive Vice President Susan Hogeland, CAE

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The California Family Physician is published quarterly by the California Academy of Family Physicians. Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year.

Call 415-345-8667 to subscribe.

AAFP Alternates Carol Havens, MD Jay Lee, MD, MPH CMA Delegation Ashby Wolfe, MD, MPP, MPH Nathan Hitzeman, MD Michelle Quiogue, MD Suman Reddy, MD Kevin Rossi, MD Patricia Samuleson, MD

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California Family Physician Spring 2015

12 Meet your Incoming President: Jay W. Lee, MD, MPH Adam Francis

18 All Member Advocacy Meeting and Lobby Day a Smashing Success!

20 Nearly Half a Million People Enrolled in Covered California during Second Open Enrollment Period

Catherine Direen

22 UCR Patient Portal System Connects to EHR, Empowers Patients

Tae K. Kim, MD

24 Always Learning: Why I Build Smartphone Apps

Steven Lin, MD

28 Point of Care Ultrasound Training Provides a “Focused View”

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Editorial

Family Docs Can Be High Tech Too

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President’s Message

Defining the Family Physician and Health Care Reform

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PCMH Corner

Technology Offers Opportunities and Challenges for PCMH

10 Political Pulse

Legislative Affairs Sees New Beginnings

16 Foundation

CAFP Foundation Focuses on Workforce Development and Primary Care Physician Shortage

30 EVP’s Forum

Future of the ACA Hangs in the Balance

Lauren M. Simon, MD, MPH

Nathan Hitzeman, MD Del Morris, MD Leah Newkirk Ashby Wolfe, MD, MPP, MPH Cody Mitcheltree Susan Hogeland, CAE

Many All Member Advocacy Meeting attendees sported pink hair on Sunday, March 9, in support of breastCalifornia cancer survivors.

Family Physician Fall 2014

5

editorial

Nathan Hitzeman, MD

Family Docs Can Be High Tech Too I just set my house alarm through my cell phone because I forgot to do it in my rush to deposit the kids in school (late again). They were playing Candy Crush on their tablets in the back seat and when they walk, the backs of their shoes light up. My car navigator says I am two miles from my destination, and it tempts me with a little Starbucks icon on the screen as I’ve been known to stop there. A card swipe gets me into the parking lot and into the clinic. The glow of my computer beckons like a mistress waiting, lonely, in my office all night. I am not in the mood just yet to refill meds.

Driverless cars, drones, QR codes, GPS, genomic medicine, Bluetooth ear buds. We are imbedded in a sea of technology and it remains to be seen whether we will sink or swim in it. The pitfalls are probably obvious – losing practical skills such as how to think for oneself, less physical activity, odd human interaction (Who’s poking me on Facebook?), constant checking, trivial conveniences (electric corkscrew), more complexity to one’s day (Did I charge my six devices?).

pacemaker interrogated over the phone). The rub is to figure out which technology is helpful and which is for the birds.

Electronic records, online calculators and all things computer have permanently nested in our areas of healing. Residents precepting a case might show me a skin lesion on their smartphone, tempting me to do armchair medicine instead of walking down the hall to see the patient.

Technology I have enjoyed over the past few years includes a lighted ear curette by Bionix to remove wax (gets the wax out every time!), a portable ultrasound machine (for OB-GYN, MSK, abdominal imaging, determining masses vs. cysts), and dermoscopy (using polarized light under magnification for pigmented skin lesions). Of course, accessing and sharing information such as growth charts and labs on the Electronic Medical Record is illustrative for patients and docs. Abundant patient education is a click away.

This stuff makes me happy.

“We live in a society exquisitely dependent on science and technology, in which hardly anyone knows anything about science and technology.”

Not to be a stick in the mud, but we at CAFP have devoted this issue to celebrate how physicians can incorporate technology into their practices to help themselves and their patients. Think of all the fun your family has with technology.

My wife wears a Fitbit to count her steps, monitor her sleep and see caller ID when her phone is all the way across the room. Over the holidays, someone got me an iPosture device that vibrates if I slouch, and now I’m the master of the “strong stance” in meetings. My sister-in-law, who works for the state, tried out an idle keyboard app which mimics the sound of work at your cubicle if you are MIA – throat clearing, crumpled paper, keyboard clicks – and you can adjust the frequency and composition of the sounds.

In medicine, we practice both low tech medicine (talking, smiling, palpating a prostate gland) and high tech medicine (using Google translate, Dragon, or seeing a patient’s

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California Family Physician Spring 2015

On the flip side, my medical assistant interrupts my patient and me just as she was telling me about her depression – Carl Sagan because an immunization didn’t get associated with the right diagnosis with the last patient.

Sometimes the computer doesn’t print. My patient’s cell phone might belt out a country song or rap number right when I am working for that Oprah “ah-ha moment.” (By the way, don’t text and drive.) Also, medico-legal issues abound with smartphone use. Texts are not encrypted. Clouds may not be secure. Smartphones can be lost/stolen, so one shouldn’t leave images or information on them. Also, they can be fomites as we take them from room to room.

But alas, we can’t resist looking behind Door #3, so open this issue, and take a look at what might be of interest to technologically boost you to a higher plane. Step into the Matrix, Mr. Anderson – oh sorry, I mean Neo! Disclaimer: Dr. Hitzeman owns vast stock in the greatest technological device ever: “The Clapper.”

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California Family Physician Spring 2015

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president’s message

Del Morris, MD

Defining the Family Physician and Health Care Reform Health is Primary is a three-year communications initiative started last October to transform family medicine to meet the challenges of our changing heallth care system. It is a vision of family medicine (representing true primary care) that re-balances our health care system. It promotes value over volume, improved health outcomes for our population and lowers cost per capita.

This is a big order and a big deal with high stakes for our specialty and our nation. Can we meet the challenge?

For the last few decades, the forces within the current medical system have been leading us to a diminished role in health care. Some believe the role of the family physician will eventually be to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician will ultimately surrender care coordination to care management functions divorced from their practices, and will work in small, ill-defined teams whose members will have little training and few in-depth relationships with the physician and patients. The family physician will serve as an agent of a larger system whose role is to feed patients to subspecialty services and hospital beds.

The family physician would not be responsible for patient panel management, community health, or collaboration with public health. SOME OF US FEEL WE ARE ALMOST THERE ALREADY.

This is a big order and a big deal with high stakes for our specialty and our nation. Can we meet the challenge?

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California Family Physician Spring 2015

Recognizing that our health care system is not sustainable, the Institute for Healthcare Improvement (IHI) developed a framework in 2007 that describes an approach to optimizing health system performance called the Triple Aim. The Triple Aim is the achievement target to improve population health, experience of care and lower costs.

The goals of this framework are interactive. For example, new effective technologies or drugs may improve care for individuals but increase cost per capita. On the other hand, eliminating overuse or misuse of therapies or diagnostic tests may both reduce cost and improve outcomes.

The dilemma is shown in “The Tragedy of the Commons.”

Imagine a group of herders whose cows shared a common pasture. When one of them realizes he can make more money by adding 10 more cows to his herd, another herder sees that and does the same. Eventually, the pasture is overgrazed and the whole community of herders suffers.

Potential “Tragedies” in health reform: • Hospital Dilemma: Filling beds and expanding services (higher costs without higher quality is the result)—rational for hospitals.

• Physician-Centric Care: Not appreciating system knowledge, sub-optimizing components of the system, repeating recent tests, elective inductions, insisting on non-standardized medical devices to be purchased by hospitals, etc.

• New Technology with Increased Cost, Limited Influence on Outcomes: New cancer therapies increasing average life expectancies weeks costing $50-100,000—rational to individual patient and oncologist.

• Direct Primary Care: Increase availability and amount of attention to a small number of patients that can afford it is rational to a physician practice and to a patient who can find the practice and afford it.

There is a tremendous opportunity for family medicine. We are being swept along by the currents of a reform that is larger than our discipline. Now, we must take advantage of this tide and promote the role of family medicine that is not subservient to others.

Leah Newkirk

pCmH Corner

Technology Offers Opportunities and Challenges for PCMH The Patient Centered Medical Home (PCMH) is inextricably tied to health information technology (HIT). HIT is essential to quality improvement: it can capture a variety of demographic and clinical information as structured data and make it possible for family physicians and practice teams to measure and systematically improve quality. Some of the challenges practices encounter in transforming to PCMH, however, can be tied to technology. Both the advantages and the challenges are worth examining.

Our guiding principles for PCMH tie the model to the use of HIT. The Joint Principles of the PCMH capture a connection between PCMH and HIT in three categories: (1) care coordination through the larger health care system; (2) continuous quality improvement; and (3) enhanced access or communication between the patient and practice team. The Joint Principles also emphasize the need for technology to improve quality through performance measurement, patient education and enhanced communication and to use technology in support of enhanced access.

Dr. Thomas Bodenheimer and Rachel Willard at the University of California, San Francisco Center for Excellence in Primary Care identified 10 building blocks of transformation to PCMH and one of the four, fundamental building blocks is data-driven improvement.

As a starting point to PCMH transformation practices must use their data to get an accurate picture of where they are and where they can improve performance.

CAFP saw data-driven improvement as a cornerstone to a successful PCMH pilot in Fresno, California, developed in collaboration with a self-insured employer and a Fresno primary care medical group. At the start of the pilot, the employer hired a consultant to assess practice status and, in negotiations with the practices, identified quality metrics to focus change processes.

A second, early change for the practices was to implement and maximize use of a patient registry. The practices began using data for population management; identifying high-risk patients for care management and populations facing certain illnesses, such as diabetes, for education. This pilot concluded with cost savings of about $2.5 million and improvements on every quality metric.

In the growing body of research on PCMH, use of HIT serves as a measure of advancement toward the ideal. In a recent study evaluating the management of chronic illness by thousands of U.S. practices, for example, the use of EHRs and registries in care coordination, use of clinical decision support tools, communication with patients via e-mail and patients’ ability to view online medical

While HIT adoption can offer many advantages, it is important to acknowledge the challenges, challenges that affect a practice’s ability to operate as a true medical home. records were among the “Medical Home Processes” that the researchers were evaluating. The processes that increased the most by both large and small practices were related to the use of HIT. While HIT adoption can offer many advantages, it is important to acknowledge the challenges, challenges that affect a practice’s ability to operate as a true medical home. Many physicians describe their EHR as a barrier to connecting to the patient and addressing the patient’s concerns. Meaningful Use poses challenges, too. Significant effort has been made to align PCMH with the Meaningful Use program created by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. NCQA, for example, tried to align its PCMH recognition requirements with Stage 2 Meaningful Use requirements. The NCQA recognition process and Meaningful Use program both are subject to the criticism that they encourage a “checklist mentality” when more fundamental change is necessary. Certainly, family physicians report to CAFP their frustration with the focus of both programs, the “make work” of both programs and their failure to guide them toward real change.

Technology brings much to the PCMH model, but how to navigate the challenges? Perhaps it needs to be paired with cultural change in the practice. Perhaps it is worth noting the three other foundational building blocks described by Bodenheimer and Willard that are more tied to practice culture: Engaged leadership, empanelment and team-based care. A data-driven quality improvement program must be led by a physician champion and be organized around a physician-patient relationship in a wellfunctioning team.

Leah Newkirk is CAFP’s Vice President of Health Policy.

California Family Physician Spring 2015

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politiCal pUlse

Ashby Wolfe, MD, MPP, MPH

Legislative Affairs Sees New Beginnings

Just as the new 2015-16 Legislative Session is about to launch into full swing, I, too, am about to launch into a new adventure. It has been a privilege and an honor to serve you and CAFP as Chair of the Legislative Affairs Committee (LAC) for the past three years. It is with pride but also bittersweet sentiments that I move into a new phase in my professional career, as Chief Medical Officer of the Centers for Medicare and Medicaid Services Region IX. This role, with its varied responsibilities, precludes me from continuing in my role as chair of the LAC. I am truly proud of what we have been able to accomplish together in such a short time. CAFP and family medicine advocates throughout the state have scored major legislative victories, including securing more than $12 million in funding for the Song-Brown Physician Training Program last year.

We’ve helped pass laws to reduce gun violence and improve public health. We’ve defeated inappropriate scope of practice expansion efforts while moving our health care system to a more patient-centered, team-based care model. We’ve also worked to support the extension of health insurance coverage to millions of newly-insured Californians. Your dedication to your patients and your family physician colleagues has been inspiring.

As I wrap up my last few days as Chair, I want to assure you that I leave you in the very capable hands of your new LAC Chair, Carla Kakutani. Those of us on the Board who have worked with Dr. Kakutani for many years know her as a tireless legislative and media activist. She has been willing to testify in legislative committees on our priority issues at the Capitol on a moment’s notice; she has been instrumental in making known CAFP’s position on health care reform. She is the current President of the Family Physicians Political Action Committee (FP-PAC) and has also serves on the board of family medicine’s national PAC, FamMedPAC. She served as chair of AAFP’s Commission on Governmental Advocacy, visits with Congressional representatives at AAFP’s Family Medicine Congressional Conference almost annually and has been generous in her time in reaching out to CAFP county chapters to keep them apprised of legislative happenings. In

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California Family Physician Spring 2015

I am truly proud of what we have been able to accomplish together in such a short time. Your dedication to your patients and your family physician colleagues has been inspiring. addition, she chaired CAFP’s delegation to the CMA House of Delegates for many years, ensuring that family medicine was well represented.

Dr. Kakutani is an extremely effective advocate for family medicine because she speaks from her heart – weaving her gentle but firm approach with legislators and the media together with her experience as a mom, an advocate for her patients and as a family physician from a small, rural community who has worked to change large health systems.

I will remain deeply involved with CAFP, continuing to chair our delegation to the CMA and providing guidance as a LAC member, as I accept a new position and the challenge of working to improve the health care system at the federal level. I look forward to accomplishing more great things together.

Dr. Wolfe has chaired CAFP’s of the Legislative Affairs Committee for the past three years. She is stepping down from this role to accept her new position as Chief Medical Officer Region IX for the Centers of Medicare and Medicaid Services.

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California Family Physician Spring 2015

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Meet your Incoming President: Jay W. Lee, MD, MPH Born in New York to Korean immigrants, Dr. Lee moved to California in the late 1970s by way of Florida. He grew up in the San Fernando Valley, attending Balboa Magnet School before matriculating at the Harvard School for grades 7-12. He later moved to the Bay Area to attend Stanford University, where he majored in Human Biology.

After college, Dr. Lee worked for a nongovernmental organization in rural postwar El Salvador providing clinical support for local physicians, facilitating a potable water project and growing his hair long.

He returned stateside to apply to medical school while doing health services research with Zynx Health in Los Angeles.

Dr. Lee speaking about the “FMRevolution” at the 2015 All Member Advocacy Meeting in Sacramento, CA.

Attending the Keck School of Medicine at the University of Southern California, he began his leadership career after deciding he had chewed on enough free pizza and was elected as Chair of the American Medical Student Association’s Global Health Action Committee. Newly-minted Dr. Lee matched at Long Beach Memorial Family Medicine Residency Program, where he was co-chief resident and a recipient of the AAFP Award for Excellence in Graduate Medical Education. After residency, he worked in community health centers in Los Angeles and Boston, where he earned his Master’s in Public Health with an emphasis in health policy and management at the Harvard School of Public Health. Dr. Lee returned to Memorial Care Health System in 2008 to serve as faculty at the residency program and, more recently, as Associate Medical Director of Practice Transformation at the medical foundation.

CFP interviewed Dr. Lee recently: You are the Family Medicine Revolution (#FMRevolution) guy. Where did that come from and how do you keep it going?

Family Medicine Revolution was inspired by resident physician members from the Santa Rosa program who were sufficiently annoyed by people telling them “You’re too smart to go into family medicine” to print t-shirts with phrases like “Use your whole brain; become a family 12

California Family Physician Spring 2015

physician.” The t-shirts resonated with CAFP members and with colleagues from other states who wondered aloud how they could get their hands on one. Around the same time, social media was beginning to be used to amplify sociopolitical movements, most notably during the so-called “Arab Spring.” I wondered if the family medicine community would benefit from having a hashtag that captured the spirit of our counterculture origins and could organize us in this virtual setting. That was how the #FMRevolution hashtag was born.

Fast-forward to today, the Family Medicine Revolution is a growing virtual community of family docs, residents and medical students from around the world who leverage social media to share our stories. If we want to move the vector away from fragmented, volume-based care toward coordinated, value-based care, we must generate the force necessary. According to Newton, force is a function of mass and acceleration. For the Family Medicine Revolution, accelerating our cause is enhanced by amplification.

The next opportunity for the Family Medicine Revolution community is how to leverage our virtual connections into real-life collaboration to achieve the Triple Aim of better care, better health and reasonable cost. We must not abdicate our responsibility to our patients, our communities or ourselves for leading health care transformation. This is the future of our specialty.

Dr. Lee, his wife Sumina (also a physician) and their children play at the beach.

Photo credit to Laura Rauch

What’s the most fun you have had so far as a CAFP representative?

When you look back on your presidency, of what do you want to be most proud?

Family Medicine is all about the relationships. Growing friendships with other family docs has been the most fun and fulfilling aspect of becoming a CAFP leader. There is never a dull moment when family docs get together and I love being infused with the joie de vivre that comes from the fellowship we share.

Looking back on 2015 years from now, I want to be most proud of the fact that we became the leaders our health care system needs us to be: that we started to assert ourselves on behalf of our patients and ourselves to more fully realize our potential as physician leaders. We’ve been too passive as a family medicine community. The fragmentation of our health care system has isolated us from one another. We must break that mental model. We have an opportunity to re-invent ourselves. I want to ignite that in us.

Married with three kids under the age of eight – how do you approach work-life balance?

The short answer is that I married well. The long answer is that my wife and I are intentional about our time. That means sharing a Google calendar to keep us on track, overcommunicating (including letting her know when I say ‘no’ to requests for my time), carving out time to spend time together as a couple and as a family, and putting mobile devices down when we do. We aren’t perfect but we keep practicing to achieve a better equilibrium.

Social media savvy, Dr. Lee is actively engaged on Twitter using the handle @familydocwonk.

The other factor is learning how to compartmentalize. When I’m doing clinical work, my focus is on my patient/population.

Continued on next page > California Family Physician Spring 2015

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When I’m doing leadership work, my focus is on practice transformation. When I’m with my family, my focus is on my wife and kids. I’m not perfect but I keep practicing.

What’s the most practical thing you think you and CAFP can do for family medicine in the next two years?

Continue to build partnerships and alliances with other organizations to help advance our strategic vision. Alone, we will not be able to build a primary care workforce that meets the health needs of every Californian or a practice environment that rewards high value and high performing primary care. I believe continuing to build the necessary political and social capital to pursue larger system goals is as important as maintaining the gains we have made over the past decade. As the great Wayne Gretzky once said, “Skate to where the puck is going to be, not where it has been.” Family Medicine must do the same and we need effective teamwork to get there.

CAFP’s dynamic duo at the AAFP Multi-State meeting in Dallas, TX: AAFP board member Jack Chou, MD (left) and Dr. Lee (right).

MED7 has been providing urgent care services in the Greater Sacramento area since 1987 Urgent care clinics are located in Roseville, Carmichael, Folsom & North Sacramento. Board Certified or Board Eligible in family practice or emergency medicine.

All shifts 9am to 9pm. Full time is 13 shifts per month. We offer our full time physicians the following: full malpractice coverage, medical & dental coverage at no cost for the physician & any dependents, disability policy & we have a simple IRA you can contribute to with 3% matching. Part time is 6 to 8 shifts per month. There is no call. There is no tail coverage that needs to be purchased should you leave our employment. We have a single policy that continues on after you leave.

If something were to arise here after you left our employment, you would be covered.

For more information about MED7 and our clinics please visit our website: www.med7.com We offer an attractive compensation package.

Contact Merl O’Brien,MD, at: (916) 791-1300, ext.111; or email CV to: sherry@med7atwork.com.

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California Family Physician Spring 2015

To read Dr. Lee’s full interview and learn more about your incoming president, please visit www.family.docs. org.

The Petaluma Health Center (PHC) has opportunities for experienced, innovative physicians to join a dynamic team of twenty nine providers in Southern Sonoma County.

PHC is a Federally Qualified Health Center (FQHC) located in Petaluma, CA and provides full spectrum comprehensive primary care including obstetrical care and mental health services to over 20,000 patients. Our health center is a leading innovator in integrative medicine, team based care, and technology. We are seeking bilingual English/Spanish physicians with a minimum of three years’ experience to provide care to a panel of patients. These positions allow for ample growth and leadership in a multitude of areas related to improvement of the patient care experience. Options for combined hospital medicine and obstetric call are available, as is the option of outpatient call (telephone call) only.

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Known nationwide as the premier provider of CME procedures training, over 50,000 clinicians have trained with NPI. This year, NPI is offering more than 50 CME seminars at many locations, covering a full range of office procedures, hospital procedures, and emergency room procedures.

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FoUndation

Cody Mitcheltree

CAFP Foundation Focuses on Workforce Development and Primary Care Physician Shortage Match Day constitutes one of, if not the, most important days in a medical student’s life. It is the day graduating medical students eagerly look forward to throughout their fourth year. With each opening of their match letters, students learn what the next step in their careers and lives will be and where it will take place. The match is also an indicator of students’ interest in family medicine and/or primary care, which has consequences both in California and nationally.

While the number of students matching into family medicine has increased over the past few years and the number of California family medicine residency programs has grown to 51, a pervasive attitude still exists on school campuses that family medicine is a “lesser” specialty and students should place their focus on other specialties.

The CAFP Foundation has been at the forefront of giving students the opportunity to learn about family medicine and see firsthand what it means to serve as a family physician.

California’s Projected Primary Care Physician Need

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California Family Physician Spring 2015

UNITED INDIAN HEALTH SERVICES, INC. (UIHS) Our Vision: Healthy mind, body and spirit for generations of our American Indian Community.

The CAFP Foundation has been at the forefront of giving students the opportunity to learn about family medicine and see firsthand what it means to serve as a family physician. The award-winning Future Faces of Family Medicine program engages ambitious and motivated high school students and excites them about careers in primary care. The CAFP Foundation Scholars Program is a three-year, longitudinal program that gives students the opportunity to be engaged with the Academy and family physician mentors throughout their medical school careers. Scholars have the opportunity to build relationships with other medical students interested in family medicine, receive financial support to attend select Academy events and develop close relationships with practicing Californian family physicians.

While there has been significant progress in expanding the primary care workforce, California still faces the reality of a primary care physician shortage. Many residency programs’ funding ends this year, which exacerbates California’s longstanding shortage of primary care physicians and burgeoning demand for primary care services. The state must appropriate funding for more primary care training positions to meet the increased demand of 8,243 more primary care physicians than we are producing now by 2030. For more information and data sources, please review our Primary Care Physician Shortage Fact Sheet on www.familydocs.org.

This match season, let’s celebrate the achievements of hard-working medical students, but also remember much work must be done to make sure California enjoys the benefits of an adequate primary care physician workforce.

Cody Mitcheltree is CAFP’s Information, Technology and Foundation Programs Manager.

United Indian Health Services, Inc. is a non - profit Tribal Organization comprised of a consortium of nine local Tribes/Rancherias.

Come join us in the natural beauty that only the North Coast has to offer.

UIHS is a tribal health program which was organized in 1970 by Indians of the local community to deliver health care services within our region.

Employment Opportunities: Medical Provider (3 positions)

Minimum Qualifications:  Must possess a valid Physician’s License  Must have passed the Family Practice Physician Certification  Must be Board Certified, preferred

We commit ourselves to creating healthy working conditions that support a sense of family within the organization and allow our staff to provide quality care.

 Competitive Salaries  Benefit Packages  For more information or to obtain an application packet, please contact UIHS at 1600 Weeot Way, Arcata, Ca 95521 or by calling (707) 825-5000 or by visiting our website at www.uihs.org.

BEST KEPT SECRET IN ALASKA! Maniilaq Health Center in Kotzebue, Alaska is looking for BC/BE Family Medicine Physicians who have a sense of adventure and a desire to practice primary care medicine. We are a tribally-owned, JC-accredited, Critical Access Hospital, with 12 inpatient beds, a 5-bed ER, two L&D rooms, and an Outpatient Clinic. J-1s welcome.

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California Family Physician Spring 2015

17

Adam Francis

All Member Advocacy Meeting and Lobby Day a Smashing Success!

In early March, more than 120 family physicians, residents and medical students from across the state converged on the Capitol for the CAFP All Member Advocacy Meeting (AMAM) to discuss hot topics in health care and advocate for family medicine and patients. This year’s AMAM focused on physician leadership. From my point of view, it is hard to think of anything that would be more effective in changing our health care system than for family physicians to take up leadership roles in their practices, medical groups, regional health systems or even at the state level. Few other specialties fight for primary care and patients the way family physicians do, and if you are not in leadership roles making decisions and guiding organizations…well, we’ve seen how that has worked out over the past few decades.

Day One The 2015 meeting gave attendees the tools they need to become leaders and effective advocates for themselves and their patients. The conference started with an update on California’s health insurance exchange and a keynote address on physician leadership from the Executive Director of the UCSF Center for the Health Professions, Sunita Mutha, MD. Attendees learned about CAFP priority legislation and then heard from four graduates of the California HealthCare Foundation Fellows program, which is a terrific fellowship that gives physicians advanced leadership training. Attendees also participated in a town hall-style gathering discussing the Affordable Care Act implementation, payment reform, Accountable Care Organizations, practice transformation and primary care physician workforce.

Other highlights included several special legislative guests: State Senator Richard Pan, MD, who spoke about his leadership path including his recent election win, as well as State Senators Bill Monning and Lois Wolk, who discussed their bill to legalize physician aid-in-dying. In addition, testimony was given on seven resolutions on which the CAFP Board of Directors will consider action and report back to the 2016 AMAM. Day two also featured special trainings for attendees about the California HealthCare Foundation’s leadership program, as well as a session on how to meet with your legislator and other ways to advocate for family medicine and patients.

Throughout the weekend, AMAM attendees broke all previous fundraising records, contributing more to FPPAC than at any other CAFP meeting ever! More than 80 contributors raised more than $20,000 for FP-PAC, the only political action committee in California that makes direct contributions to pro-family medicine, pro-patient state legislative candidates and select statewide offices.

FP-PAC thanked its donors during the third Annual FP-PAC Donor Reception that featured special legislative guests, Assemblymembers Jim Cooper and Frank Bigelow. If you have not yet contributed to FP-PAC for 2015, please go to our Rally page (rally.org/fp-pac) to ensure that family physicians can continue our important electoral advocacy.

Day Two The second day of the conference featured two award presentations: one for the 2015 Hero of Family Medicine and one for the 2015 Patient Centered Medical Home (PCMH) Practice of the Year. The Hero of Family Medicine award went to Ashby Wolfe, MD, MPP, MPH for her unyielding advocacy on behalf of family medicine, and also for her work in reaching out to medical students and residents, testifying on CAFP’s sponsored legislation, meeting with legislators and crisscrossing the state and nation to advance family medicine in California. The PCMH Practice of the Year award was given to the Harbor UCLA Family Medicine Residency Program to recognize their innovative approach to advancing the PCMH model in California.

Dr. Ashby Wolfe (right) receives the Hero of Family Medicine Award from CAFP President Dr. Del Morris (left) at the 2015 AMAM. 18

California Family Physician Spring 2015

Family Medicine Lobby Day Family Medicine Lobby Day took place on Monday, March 9 and a record turnout of more than 60 family physicians, students and residents met in more than 60 legislators’ offices to urge their support for an increase in Medi-Cal payment, investment in primary care physician training and measures to protect public health.

It was an inspiring and exciting weekend. We invite any and all CAFP members interested in advancing family medicine and fighting for patients to join us at next year’s All Member Advocacy Meeting and Family Medicine Lobby Day. Adam Francis is CAFP’s Deputy Director of Government Relations.

On behalf of Harbor UCLA, Drs. Dan Castro (right) and Luz Felix Marquez (middle) accept the 2015 Patient Centered Medical Home Practice of the Year award from CAFP staffer Leah Newkirk (left).

New Leaders Elected at AMAM Delegates to the All Member Advocacy Meeting elected the slate of 2015-16 CAFP officers and others: Presidentelect Lee Ralph, MD, San Diego; Speaker Michelle Quiogue, MD, Bakersfield; Vice Speaker Lisa Ward, MD, Santa Rosa and Secretary-Treasurer (and Rural Director) Walter Mills, MD, Monterey; Jeffrey Luther, MD, Long

Beach, AAFP Delegate 2015-16, Jay Lee, MD, MPH, Orange County, AAFP Alternate Delegate; and Maria Greaves, MD, Santa Cruz, Nominating Committee member from the AMAM for 2015-2016. All assume office on April 26, the first day of the Family Medicine Clinical Forum in San Francisco, where AAFP Board member Jack Chou, MD, will swear them in.

More than 60 physicians from across California stormed the Capitol during CAFP’s Lobby Day on Monday, March 9.

California Family Physician Spring 2015

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CoVered CaliFornia

Catherine Direen

Nearly Half a Million People Enrolled in Covered California during Second Open Enrollment Period Covered California announced in mid-March that 495,073 people selected health plans during this year’s open-enrollment period, which ended February 22. The mix of enrollees is more diverse and younger, which was a goal of Covered California’s targeted outreach.

learned they may face a penalty for 2015. Enrolling now won’t prevent them from incurring tax penalties for 2014, but since some consumers just learned that they faced these penalties as they filed 2014 taxes, Covered California extended 2015 open enrollment so they could avoid 2015 penalties.

Consumers Chose Coverage by Price and Plan

Until April 30, consumers who attest they didn’t know they would incur a tax penalty are still eligible to apply for coverage.

To attest, they can select “Informed of Tax Penalty Risk” when filling out an application at CoveredCA.com.

Consumers made some different choices in plans this year: enrollment in Blue Shield dropped by eight percent while enrollment in Kaiser Permanente jumped by eleven percent.

Enrollment in other plans held fairly steady.

Price was also a key consideration. More than 85 percent of enrollees selected lower-priced plans (Bronze and Silver Tiers) while just nine percent chose Gold or Platinum Tier plans. Health plans approved by Covered California for participation in the state’s health benefits exchange are required to cover at least a set of minimum benefits. Each health plan then offers coverage products that vary by price, co-pays, deductibles and other pricing; each level is named after a metal.

Some Patients Have until April 30 to Enroll

Although open enrollment has officially closed, Covered California is offering a special enrollment opportunity through April 30 for consumers who didn’t know or understand that they would face a tax penalty for being uninsured in 2014, or who

Life events will qualify some patients for “special enrollment periods” in 2015 and Medi-Cal enrollment is available yearround.

Californians who have a life-changing event such as having a baby, getting married, losing their health care coverage because they have changed jobs or moving to another area can qualify for a “special enrollment period,” which means they can sign up for coverage as long as they do so within 60 days of the qualifying life event.

For more information on Covered California plan options, enrollment information and resources visit www.coveredca.com.

Catherine Direen is CAFP’s media consultant.

Enrollment Statistics Covered California plan selections and Medi-Cal* enrollments

1,274,073

Enrollments in a Covered California health plan

495,073

Subsidized enrollments (those eligible for federal premium assistance, cost-sharing reduction) in a Covered California health plan

436,970

Non-subsidized enrollments in a Covered California health plan

58,103

*Medi-Cal information is through Jan. 31, 2015

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Nov. 15 - Feb. 22

California Family Physician Spring 2015

2015 Family Medicine Summit Saturday, September 12 Los Angeles, CA www.cafpfoundation.org

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21

Tae K. Kim, MD

UCR Patient Portal System Connects to EHR, Empowers Patients In an era in which health care needs are continuously changing and access to health care seems increasingly more difficult, the University of California, Riverside (UCR) Health Medical Group made the decision to implement a Patient Portal system. This system empowers patients by giving them the information they want, when they want it. Our patient portal is a fully integrated system connected to our Electronic Health Records (EHR) that provides patients with access to their personal records, online scheduling tools and a range of self-serve functions. Registered users can access the Patient Portal and their personal health records any time from any computer browser, tablet, or smart phone. The Patient Portal is also available in different languages, including Spanish. Additional benefits include having direct communication with clinic staff and physicians through a secure messaging system, facilitating prescription refill requests, sending health alerts immediately and e-mailing reminders for health maintenance examinations and recommended vaccinations. Integrating a Patient Portal system promotes patient engagement with the practice, facilitates clinical data collection, improves patient satisfaction, simplifies communication and, most importantly, allows patients to be active participants in the delivery of their health care.

documentation. From the patients’ perspective, they appreciate the ability to directly communicate with their providers and support staff and to ask questions between visits. They also enjoy the convenience of requesting medication refills and obtaining referrals online. Many of our younger patients have selected our facilities because of this technology and the ability to access their information conveniently from their home computer, tablet or smart phone.

Initially, one of the reasons to implement the Patient Portal was to meet Meaningful Use requirements, such as sending secured messages to the providers, allowing patients to have access to their health records, modifying personal information and sending reminders to patients for preventative and follow up care appointments. After implementation, however, we have found far more benefits than we anticipated. Our call volume and workload have decreased, thereby decreasing the clinic’s need to request overtime from the staff. In addition, the feedback from our patients who use the portal is more positive compared with our telephone encounters. Overall, both our patients and providers have welcomed the Patient To: Michelle Gilbert Portal and feel that it has not only increased access for our mgilbert@pcipublishing.com patients but also improved the quality of care we provide.

Re: Sea Courses ad for Winter Issue of California Family P Dr. Kim is Regional Medical Director for the UC Riverside School of Medicine and oversees the clinical development and operations for the UCR Health Medical Group.

We have had a very positive response from both our providers and the patients at our clinics.

We have had a very positive response from both our providers and the patients at our clinics. Providers and staff report that it takes less time to respond to secured e-mails versus processing incoming calls and routing them back and forth between the provider and staff member. The system allows for more efficient means of communication and reduction of “phone tags” that occur too often and result in delays and further miscommunications. In addition, patients’ messages are in their own words and are not subject to others’ interpretation or biases. Our providers many times find themselves wishing more patients utilized the Patient Portal as it allows for a smoother means of communication and uncomplicated approach to medication refill requests. In addition, all communications are saved to the EHR, which ensures more accurate and complete 22

California Family Physician Spring 2015

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California Family Physician Spring 2015

23

Steven Lin, MD

Always Learning: Why I Build Smartphone Apps When I graduated from medical school, I was the only person in my class to choose family medicine as my life’s work. Despite being pressured by my peers and mentors to reconsider, I chose family medicine because as a specialty, it offers the broadest scope of practice in all of medicine and is thus the most intellectually stimulating. I wanted a challenge, and, boy, did I get that during residency. Although I had aced my medical school classes and breezed through my clerkships, I quickly discovered that my fund of knowledge was woefully inadequate in the real world. My $270,000 Ivy League medical education did not prepare me at all for the beast that is primary care.

During internship, I realized that I did not know anything about how to provide prenatal care to pregnant women. To avoid embarrassing myself, I did a comprehensive literature review of all the evidence-based practice guidelines for prenatal care. I learned a lot, but I also knew that there was no way I could remember everything, and that I needed some way to look up information on the fly. That was when I first got the idea to create a smartphone app. Wouldn’t it be great if you could just enter a woman’s gestational age and see a list of every counseling topic, every test that is recommended, and everything you need to do or ask during the visit, immediately at the point of care? So I reached out to a colleague, Colin, who was working as a webmaster at a non-profit with which

L’Allegro is the first ever point-of-care, evidencebased antidepressant chooser. It has since been downloaded thousands of times in the United States and a dozen other countries.

I used to volunteer, and pitched the idea. He knew nothing about medicine, but had some experience making smartphone apps. I would develop the blueprint and provide the content, and he would program it.

A few months later, Ilithyia was born. We named the app after the Greek goddess of childbirth (because, well, why not?). I gave the app to my fellow residents and attendings and released it online on Apple’s iTunes Store for free. The reception was overwhelmingly positive. My friends and mentors in the residency program loved it. The app was downloaded thousands of times by medical students, residents and practicing physicians from all over the country. I received many emails from other family medicine residency programs that have adopted Ilithyia and were using it for teaching and patient care. Encouraged by the response, I became convinced that there was a need for more mobile technology that could empower primary care physicians to make smarter decisions at the bedside, especially in a world bursting with new medical knowledge.

In my second year of residency, I founded an educational non-profit organization called Linvivo (http://www. linvivo.com/) and set out to make another smartphone app. This time, I wanted to tackle depression. Working in a safety net health system meant that there was a minimum six-month waiting list for my patients to see a psychiatrist. Many of them couldn’t wait that long. Here again, my fund of knowledge failed me. I realized Continued on page 26 >

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California Family Physician Spring 2015

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California Family Physician Spring 2015

25

that I knew very little about how to pick the right antidepressant for the right patient.

Like many of my fellow residents, I had been prescribing antidepressants by trial and error, like choosing Skittles blindfolded. So I dived into the medical literature and did an exhaustive review of all the comparative effectiveness studies of antidepressants that are out there. With the help of a faculty mentor, I developed a new evidencebased algorithm for choosing antidepressants and published it in the Journal of the American Board of Family Medicine. Then, Colin and I took those algorithms and created an app, which we named L’Allegro (after a 1645 John Milton poem about “the happy man”). L’Allegro is the first ever point-of-care, evidence-based antidepressant chooser. It has since been downloaded thousands of times in the United States and a dozen other countries.

Although I am no longer a resident, I’m still a student of medicine. I doubt that a day will come when I consider my knowledge adequate. That is why, until that day arrives, I will keep building apps.

Steven Lin, MD is a clinician-educator on faculty at Stanford University School of Medicine. He is also the founding CEO of Linvivo, a nonprofit educational organization dedicated to building mobile apps that empower primary care physicians to make evidence-based decisions at the point of care.

For Sale: Established private practice since 1991 in beautiful Bakersfield, CA with gross collections of 1MM. This is a boutique type practice catering to private insurers with majority of the patients being female. Seller works part time with highly trained staff in place. This practice has great potential for a full time physician working full time and easily doubling your income. For information call (877)955-4447 or email: info@DoctorsBroker.com

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West County Health Centers seeks a mission driven, clinically excellent licensed Family Practice Physician, passionate about working with a diverse underserved population in scenic, rural western Sonoma County. Our organization is recognized nationally as an exemplary leader in: • Comprehensive relational care in a team-based environment • Integrated behavioral health and primary care • Innovative use of technology • Wellness focused, integrative medicine Boa certified MD or DO Board Contact: Phyllis Early 707-869-5977 ext. 3304 pearly@wchealth.org For more information please visit our employment page at www.wchealth.org.

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California Family Physician Spring 2015

California Family Physician Spring 2015

27

Lauren M. Simon, MD, MPH

Point of Care Ultrasound Training Provides a “Focused View” The rapid evolution of portable ultrasound technology has provided additional tools to train residents and medical students to provide optimal care for patients. In the past decade, numerous medical schools and residency programs have added ultrasound training as part of the required curriculum of clinical practice.

At University of California Irvine School of Medicine and Loma Linda University School of Medicine (LLUSOM), pointof-care ultrasound training (POCUS) is incorporated into medical school training beginning in the first year and continued throughout medical school. Ultrasounds are used to complement history and physical examination skills (not to replace them). One of the educational approaches used integrates the ultrasound training into the curriculum with focused ultrasound pertaining to the body system the medical students are studying. For example, when studying the cardiac system, the ultrasound lessons focus on evaluation of normal cardiac structures/functions compared to cardiac pathology, such as bicuspid aortic valve, cardiomyopathy or cardiac tamponade. Some of the programs have incorporated ultrasound skills into their Objective Structured Clinical Examinations (OSCEs) in which paid actors serve as simulated patients, and students are videotaped and assessed on their history taking and physical examination

Medical students and residents attend an ultrasound workshop at the 2014 Family Medicine Summit in Los Angeles, CA. 28

California Family Physician Spring 2015

Looking ahead, expanded use of point-of-care ultrasound will become more common in family medicine training, providing additional methods to optimize care to our patients. skills (and now focused ultrasound skills to answer specific clinical questions).

The standard obstetrical ultrasound skills that have been taught for decades in family medicine residency programs have expanded ultrasound training to include other body systems and outpatient and inpatient procedural skills.

Ultrasound guidance has become standard for central line placement visualization (such as internal jugular access), paracentesis, thoracentesis and arterial access. It is used to determine volume status utilizing inferior vena cava and to augment physical exams for musculoskeletal evaluations and provide direct visualization of needle placement for joint injections. These programs often include online simulations and training to review ultrasound basics, “knobology” and additional case practice. Residency programs use a variety of ultrasound machines and brands for patient care and resident training ranging from larger cart-based machines to the newer laptop and hand-held sized devices.

Teaching ultrasound to students and residents provides opportunities for multidisciplinary collaboration. In November 2014, at the California Academy Family Physicians’ Family Medicine Summit in Los Angeles, Family Medicine and Emergency Medicine physicians from the Contra Costa Family Medicine Residency program hosted a very popular ultrasound workshop for the residents and students in attendance. In February 2015, LLUSOM medical students

who were in the Ultrasound Interest Group hosted the second annual “UltraFest” in which hundreds of Southern California medical students, from numerous medical schools, enjoyed “hands on” training for cardiac, FAST (focused abdominal ultrasound for trauma) and musculoskeletal ultrasound exams, plus opportunities to perform ultrasound guided procedures on medical simulation models, taught by physicians from Family Medicine, Emergency Medicine, Orthopedics, Radiology and Rheumatology.

Looking ahead, expanded use of point-of-care ultrasound will become more common in family medicine training, providing additional methods to optimize care to our patients.

Dr. Simon is the Associate Professor of Family Medicine and Director of Primary Care Sports Medicine at Loma Linda University.

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CALIFORNIA PRIMARY CARE OPPORTUNITIES Coalinga & Atascadero MHM Services is proud to announce a new partnership with the California Department of State Hospitals. As we work together to provide exceptional health care to patients who truly need it, we are also growing a medical staff of exceptional Primary Care Physicians.

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29

Susan Hogeland, CAE

exeCUtiVe ViCe president’s ForUm

Future of the ACA Hangs in the Balance It is a crucial time in Academy-supported efforts to make certain that every American has access to affordable health insurance and a personal family physician to provide essential primary care services. The U. S. Supreme Court is expected to decide by the end of June in King v. Burwell whether those who signed up for health coverage through the Federal Exchange (because they live in the 34 states that opted not to develop their own exchanges) should continue to have plan premium subsidies in the form of tax credits. The Court is being asked to parse four words (“established by the state”) in the massive Affordable Care Act (ACA) that opponents think make clear it was NOT Congress’s intention to provide subsidies in non-exchange states. At issue is whether around 7.5 million of the 11 million now covered under the ACA would lose the subsidies that likely make coverage affordable for them.

One news report stated that no prior social safety net was ever extended to millions of people and then withdrawn; the case has the potential to reduce the number of Americans with health insurance by millions by next year – or, as the article said, the equivalent of the entire population of Virginia.

You likely are familiar with the potential impact of such a decision on insurance plans. It is referred to as a “death spiral”: the young and relatively healthy decide insurance costs too much (and without the subsidies that were given to 80 percent of consumers, many will) and only the more gravely ill who must have insurance retain it; the plans must charge increasingly more because utilization and costs go up. The point comes at which no one, not even the seriously ill, can afford coverage any longer.

Thus, the “death” part of the spiral.

Meantime, more is being written about the benefits of the ACA. AAFP’s daily Smart Brief recently carried a blurb from HealthDay News that said the number of Americans under 65 in families with medical bill burdens declined from 56.5 million in 2011 to 48 million in the first six months of 2014, according to data from the National Center for Health Statistics. Three possibilities were cited as the cause: the Affordable Care Act, a recovering economy or families with high deductibles putting off medical care. What if we took a leap of faith and said the ACA was primarily the reason? Ending the tax credit now will have a devastating impact on real people and real patients, perhaps not so much in California right away. But, if insurance plans get spooked and decide to get out of markets in the states where the tax credits go away, a ripple effect could negatively affect ALL policy holders.

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The point comes at which no one, not even the seriously ill, can afford coverage any longer. Thus, the “death” part of the spiral.

The ACA also appears to have had a dampening effect on both increases in health care costs and insurance plan premium costs the last two years. Over my time here at the Academy, our employee health plan has seen annual premium increases as high as 18 percent, but generally, they have risen around eight percent per year. This year, the increase was four percent. An “n” of one does not a study make, of course. I’m just saying…

At the same time, the Congressional Budget Office (CBO) has again lowered its estimate of the Affordable Care Act costs, according to a recent New York Times article. The CBO cited slow growth in health plan premiums as the primary reason.

The 10-year cost of federal insurance subsidies declined by 20 percent and new Medicaid costs have come down eight percent.

The benefits of these reduced costs accrue to consumers and businesses and lower the federal budget deficit, according to the article written by Robert Pear on March 5, 2015.

The other good news in this article was the “cautionary note” sounded by the CBO about why premiums for exchange health plans were priced more reasonably than was initially anticipated.

This will come as no surprise to CAFP members – it’s because they are paying physicians and hospitals less than other private insurance plans and limiting consumer choice of physician and hospital through narrow networks. The nugget, buried in the second to last paragraph in this lengthy article was: “Many plans will not be able to sustain such low provider payment rates or such narrow networks over the next few years…”

Darned right – it’s time for the plans to pay fairly for the services rendered. While they might be forgiven for anxiety about what the first years of ACA coverage would bring in terms of their medical loss ratio (of all the euphemisms….), it should be clear soon that patient choice and access will only be possible with decent payment for the hard working physicians and other clinicians caring for beneficiaries.

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Keeping true to our mission MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For 40 years, MIEC has been steadfast in our protection of California physicians with conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services; we’ve partnered with policyholders to keep premiums low.

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