FAMILY PHYSICIAN VOL. 62 NO. 2 Spring 2011
HEALTH CARE OUTSIDE THE US WHAT HAPPENS BETWEEN A PHYSICIAN AND A PATIENT WILL, IDEAS AND EXECUTION SWISS HEALTH CARE FEATURES NO HOLES
LOOKING AT ISRAEL'S SYSTEM
TAKING THE CONTROLS: PRESIDENT-ELECT CAROL HAVENS, MD READY TO STEP IN PRSRT STD US POSTAGE PAID 85719 PERMIT # 271
T H E C A L I F O R N I A A C A D E M Y O F F A M I LY P H Y S I C I A N S • S T R O N G M E D I C I N E F O R C A L I F O R N I A
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Officers and Board
President Jack Chou, MD President-Elect Carol Havens, MD Immediate Past President Thomas Bent, MD Speaker Steven Green, MD Vice-Speaker Mark Dressner, MD Secretary/Treasurer Delbert Morris, MD Executive Vice President Susan Hogeland, CAE Foundation President Robert Bourne, MD AAFP Delegates Jack Chou, MD Carla Kakutani, MD AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD CMA Delegation Taejoon Ahn, MD Sam Applebaum, MD Steve Green, MD Carla Kakutani, MD Jeffrey Luther, MD Patricia Samuelson, MD
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California FAMILY PHYSICIAN VO L . 6 2 N O . 2 • S p r i n g 2 0 11
Editor: Michelle Quiogue, MD • Managing Editor: Chris Navalta Communications Committee: Michelle Quiogue, MD, Chair • Julia Blank, MD • Nathan Hitzeman, MD • Lindsay Larson, DO • Jeffrey Luther, MD • Jay Mongiardo, MD, MBA • Albert Ray, MD • Gary Seto, MD
The California Family Physician (CFP) is published quarterly by the California Academy of Family Physicians (CAFP). 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. Advertising and publication management, Franciscan Communications. Contact CFP Associate Publisher Liana King at 510-525-3990 or by email at CalFamPhys@gmail.com. Cover Photo by Chris Navalta
Taking the Controls: President Elect Carol Havens, MD Ready to Step In
HEALTH C ARE OUTSIDE THE US 18 It’s Always What Happens Between a Physician and a Patient Interview with Richard Roberts, MD, JD, President, World Organization of Family Doctors (WONCA)
Shelly B. Rodrigues, CAE, CCMEP
20 All Can Be Achieved with Will, Ideas and Execution
Alan Glaseroff, MD
22 Unlike Its Cheese, Swiss Health Care Features No Holes
Irina deFischer, MD
24 Looking at Israel’s System – As a Student … and Patient
Mark Dressner, MD
25 Graduate Medical Education: Lessons Learned from
Callie Langton, MPA
Our Neighbors in the Great White North
Health Care Reform Should be Considered Civilized . . . Not Socialized
Albert Ray, MD
7 President’s Message
Our System Can Be Fixed – Just Look Around the World
Jack Chou, MD
8 Political Pulse
Health Care Lessons Can Be Learned From Tucson
10 Student News
It’s Never too Early to Plan for the Annual Student Conference
11 Resident News
Diversity Plays a Large Role in Developing a PCMH
Joan Bianca Roberts, MD
12 News In Brief 13 In the Spotlight
One Year Later, Help is Still Needed in Haiti
Paul Grossman, MD
15 Spring CMA Calendar 26 Practice Management News The Timely Access Regulation – What It Means to You
27 Classifieds 28 PCMH Corner NCQA Releases 2011 PCMH Standards: The Good, the Bad and the Ugly 30 Executive Vice President’s Forum Commonalities Between PCMH and Your Mom
Leah Newkirk Susan Hogeland, CAE
Albert Ray, MD
Health Care Reform Should be Considered Civilized . . . Not Socialized
s our country undergoes implementation of the Patient Protection and Affordable Care Act (PPACA), it is timely to review how other countries have instituted medical care for their populations. I had the unique opportunity as an American to experience how medicine is delivered in Belgium, having attended medical school there from 1969 to 1976 and obtaining my medical degree from the Faculty of Medicine of the University of Louvain, founded in 1425. The school takes great pride in having had such illustrious members of its faculty as the great anatomist of the 1500s Andreas Vesalius, 1974 Nobel Prize winner Christian de Duve, who discovered the lysosome, and Henri Hers, who in 1959 described the type VI glycogen storage disease which bears his name.
are open to all, but for historical reasons some funds are restricted to various religious, political or professional organizations. Funds charge the same basic contribution and pay similar benefits. Health insurance contributions are made by the employer, the self-employed or the benefit authority directly to the chosen fund. This amounts to 7.35 percent of one’s gross salary, of which 3.55 percent is withheld from one’s pay and the remaining 3.8 percent is contributed by the employer or the benefit authority. For the self-employed, the contribution is 7.35 percent made through quarterly social security payments. Coverage is automatically provided for dependent family members, spouses and partners (without coverage) and children up to age 18.
"Coverage is universal and there are no discussions about the propriety of individual mandates, as the culture supports appropriate taxes to afford the population what they regard as humane care."
My experience with Belgian health care was excellent from the point of view of quality and access; if you were to ask their inhabitants, I believe they would respond in a similar affirmative fashion. Health insurance in Belgium is mandatory; we as Americans would call it “socialized,” but Belgians would refer to it as “civilized.” Coverage is universal and there are no discussions about the propriety of individual mandates, as the culture supports appropriate taxes to afford the population what they regard as humane care. Basic coverage is provided by the national social security system. One can always supplement this basic coverage by purchasing private supplemental insurance.
Contributions are paid by both employers and employees. For those receiving public assistance (unemployment, old age pensions, sickness and maternity), the benefit authority pays the employer contribution portion. All employees and those self-employed must contribute to a health insurance fund, known as a mutuality (French) or sickfund (Flemish) as part of the social security enrollment process. Most funds 6 California Family Physician Spring 2011
For medical services, one pays the bill and submits a receipt for payment. Payments are usually less than the incurred fees, and consequently most inhabitants take out supplementary health insurance to cover the unpaid portion. Many employers provide supplementary health insurance as a benefit of employment, or one can purchase a supplemental policy. This supplementary insurance is also available to those who are self-employed through various professional associations or private insurance companies. There are different categories for medical procedures and services, each with a payment level varying from 0-100 percent, much like our coding system. There are certain preferred categories (widows, orphans and disabled such as the blind) which are entitled to a higher level of payment for many charges. On average, a standard doctor’s appointment is normally paid at 75 percent and those in a preferred category at 85-90 percent. Editorial > 14
Jack Chou, MD
Our System Can Be Fixed – Just Look Around the World
y parents just visited us from Taiwan for Chinese New Year. Among the many dinner topics was the recent passage of the Patient Protection and Affordable Care Act (PPACA) in the United States. My father, who is a semi-retired surgeonturned-family physician, still works in Taiwan, caring primarily for his loyal patients of more than 35 years and any urgent care/walk-in patients in a suburb of Taipei. I recall growing up in my dad’s clinic, with his office on the first floor of our four-story house and a surgical suite on the second floor. I saw him treat simple colds and complex lacerations as well as perform emergency appendectomies and scheduled hysterectomies. During the golden era of medicine in Taiwan, similar to that in the US, patients mainly paid cash with a few having basic fee-for-service worker’s comp and farmers’ insurance. Even though most visits cost from $5-15 in local clinics, most complex and catastrophic care was referred to large hospital systems predominately operated by academic, military and city/county institutions, with few private foundation hospitals. The tertiary care system, unfortunately, was much more costly and patients risked bankrupting a family at their neediest time. My wife reminded me that 25 years ago, her own family had to take her grandfather home to die of a brain hemorrhage because they could not afford the cost of hospital care.
and most providers were satisfied with their payment. Over time, however, the cost of the system continued to climb amid an increasing number of services and procedures performed by physicians and by advances in health care technology. By 2002, the government switched to a global budget, prospective payment system for better cost control. Private offices and clinics were barred from submitting payment requests on four days each month, and different providers could not submit the same diagnosis code on the same patient within a specified time frame, even though patients were free to choose from any specialist they wished to see. More billing submissions were denied, even up to one-third of the charges, leading to a two-tiered health delivery system – NHI and cash payment. Even at the university hospital where my brotherin-law was treated for aplastic anemia a few years ago, we paid a cash differential to get him a semi-private room – one apart from the regular NHI-paid ward – so he might receive more attentive care. He still had to line up at 7 am to see his hematologist by noon for routine visits, due to the large volume of patients and a decreasing number of physicians.
"The NHI experience is working for the 23 million people in Taiwan. As with any health care delivery model around the world, there are pros and cons. Many have referred to the PPACA as the beginning of the beginning in reforming our inefficient and costly health delivery system."
In 1995, a universal coverage single payer system called the National Health Insurance (NHI) Act was instituted. The system mandated that all citizens pay into nationalized insurance, and in turn, the government ushered in a universal electronic payment submission system for all clinics and hospitals. It further pushed the development of a rudimentary electronic health system to be used in large hospitals. Co-payment for patients remained low, and most catastrophic coverage kicked in after a relatively low deductible was met. Most patients were highly satisfied with this new system. For physicians, at the outset of NHI, the system continued to pay fee-for-service charges,
Despite these challenges, according to the Bureau of NHI, the average cost of annual premiums per citizen is nearly $650, with about $250 outof-pocket costs, and a medical loss ratio of about two percent in administrative costs. It is a much less costly system compared to the one in the US. Yet, to make up for a growing deficit in the NHI budget, there is talk of capping pharmaceutical payments, further tightening co-insurance payments and more aggressive recapturing of premiums from overseas Taiwanese citizens. Many are predicting unpopular NHI premium increases to prevent the demise of nationalized health care in Taiwan. “One good thing that came out of these changes …,” my father remarked, “ … is that big hospitals are asking for records and studies done on patients without duplicating these tests, which ultimately saves on health care expenses and decreases patient risk.” President's Message > 14 California Family Physician Spring 2011 7
Health Care Lessons Can Be Learned From Tucson
f the many lessons to be learned from the January shooting in Tucson, AZ, one is very simple: when people with severe mental health conditions fall through the cracks or do not have ready access to treatment, there can be dire consequences for themselves and others. The tragedy also showed us how interconnected we all are. President Obama spoke eloquently of the “300 million strong” American family and his hope that this painful loss, though not necessarily caused by overheated and violent rhetoric, might bring about a more civil and honest public discourse; a discourse that would help us “face up to our challenges as a nation.” In other words, we’re all in this together. This sense of connection and shared obligation will be tested in California this year, as a more than $25 billion budget gap will likely mean cuts to lifesaving health care services unless voters agree to an extension of current state tax rates. It will also be tested by how vigorously health care reform is implemented, as recent court rulings have shown a deep divide in how certain judges view some of the law’s provisions.
Governor Jerry Brown has proposed the following drastic health care cuts, coupled with a plan to realign mental health and other services between state and county government, in the hope of solving part of the budget gap:
Medi-Cal • Cut provider payments in both fee-forservice and managed care by 10 percent. This is currently prohibited by a successful CMA-spearheaded lawsuit in which CAFP participated, but the US Supreme Court will hear related cases this year which will affect our case. • Limit the number of doctor visits to 10 per year. • Impose a maximum annual benefit dollar cap on hearing aids ($1,510), durable medical equipment ($1,604), incontinence supplies ($1,659), urological supplies ($6,435) and wound care ($391). • Limit prescriptions (except life-saving drugs) to six per month. • Require a $5 co-pay on physician, clinic, dental and pharmacy services ($3 on lower-cost preferred drugs)
CAFP Medical Home Bill to Be Authored by Senate Health Committee Chair
Senator Ed Hernandez (D – West Covina), Chair of the Senate Health Committee, has agreed to author CAFP’s bill to define the patient centered medical home. If you live in Senator Hernandez’s district (Monterey Park, El Monte, Covina) please write him a thank you note for supporting the medical home and primary care (100 S. Vincent, Ste. 401, West Covina, CA 91970).
Congress of Delegates Pushes FP-PAC to New Heights
Attendees at CAFP’s Congress of Delegates in March showed overwhelming support for the bipartisan Family Physicians Political Action Committee (FP-PAC). Breaking all previous records for number of contributors and amount contributed, they raised more than $11,500 from 46 contributors to go directly to candidates for statewide office that support family medicine and our patients. To learn more or contribute, please go to http://www.familydocs.org/fppac.
8 California Family Physician Spring 2011
and a $50 co-pay on emergency room services and a $100/day ($200 maximum) co-pay for hospital stays. These changes require federal approval. Federal law (Deficit Reduction Act) allows providers to deny service if the beneficiary does not provide required co-payments, as long as they give a referral to a county indigent health program. • Eliminate Adult Day Health Care.
Healthy Families • More than double the premiums for every income level of Healthy Family enrollees. • Increase copayments for emergency room visits from $15 to $50 and inpatient stays from $0 to $100/day ($200 maximum). • Eliminate optional vision coverage (including eyeglasses and other specialized services) for all children. Governor Brown’s budget proposal calls for restructuring or “realignment” of mental health funding and services between state government and California’s 58 counties. The realignment would occur in two phases: • Phase One: Give counties full responsibility for the administration and funding of three mental health programs: the Early and Period Screening, Diagnosis and Treatment (EPSDT) program, Medi-Cal Mental Health Managed Care and AB 3632 Special Education (Serious Emotional Disorder) services. Counties would additionally acquire responsibility for Adult Protective Services, Foster Care and Child Welfare Services, and jail and probation services for children and non-serious adult offenders. Phase One would run from 2011-2012 through 2014-2015.
• Phase Two: The state would bear full cost and responsibility for the California Children’s Services program and In-Home Supportive Services while the counties would assume full charge of CalWORKs, food stamp administration and child support. • Governor Brown has proposed avoiding cuts to K-12 education funding (in addition to backing Phase One of realignment) with a five-year extension of the current personal income tax, sales tax and Vehicle License Fee, all of which are set to expire this June. The Governor also hopes to shift revenue through two fund transfers:
implementation of PPACA, but it does cloud its prospects as the matter will now head to higher courts for review.
At what point do all these conflicting trends reconcile themselves, and when they do, will we like the result?
Between the dire fiscal condition of the state and the uncertainty of health care reform, many tough questions face us all: Do we further shred the safety net due to poor funding, or do we expand it as proposed under PPACA? Do we promote better coordination of care via the medical home, or do we rely more and more on the stopgap of ER-based care?
At best, these conflicts can provide our evolving health care system the battle testing it needs to achieve the best health care reform has to offer. At worst, the result will look ugly, random and useless – as irresolvable tension often does. Either way, we will all be in it together. Tom Riley is CAFP’s Director of Government Relations.
• A one-time $861 million transfer from the Mental Health Services Act (Proposition 63) to fund the first year of realignment and the three programs mentioned above. • A $1 billion transfer of Proposition 10 (the First 5 program) funds to finance Medi-Cal services for children through age five. The Governor asked legislators to approve much of his budget proposal, including the realignment provisions, by March so ballot measures can be prepared in time for a June election. As of this writing, little has been approved.
Federal Health Care Reform The next test of our ability to face challenges together will be health care reform implementation. In January, a federal court judge in Florida deemed the Patient Protection and Affordable Care Act (PPACA) unconstitutional, arguing that the federal government cannot require individuals to buy health insurance, also known as the “individual mandate.” Also significant was his ruling that the individual mandate cannot be separated from the rest of PPACA; therefore, the entire reform package is unconstitutional. The ruling does not prevent current
California Family Physician Spring 2011 9
It’s Never too Early to Plan for the Annual Student Conference
hen it comes to fostering and nurturing interest in primary care, medical schools often fall short. Many students enter medical school interested in family medicine or other primary care fields, only to be dissuaded by the specialty-centric nature of academic institutions. Our medical school experiences teach us that primary care physicians are overworked, underpaid and unhappy. But I’m a medical student who plans to enter family medicine, thanks in part to CAFP’s Annual Student Conference. This annual conference has served as an inspiration and reminder of the many reasons why I love family medicine. I have attended this conference twice and have been refreshed with new energy and excitement after each experience. Last year’s conference theme was “Practice Your Passion” and featured, among others, my personal hero, Kevin Grumbach, MD. Dr. Grumbach talked about the impact of health care reform on primary care and the future of the Patient Centered Medical Home. In addition to this engaging keynote address, there was a panel of speakers and many breakout sessions with family physicians who have followed their passion: health policy, global health advocacy or working with the underserved locally — each story was more encouraging than the last. Not only was the conference packed with inspirational speakers, it was also an opportunity to learn about the many 10 California Family Physician Spring 2011
California family medicine residency programs and network with future colleagues. It was empowering to talk to residents who were interested in learning about my own background and interests. And at the end of the conference, the students played a challenging game of medicine-themed Taboo. I was pleased to win flash cards courtesy of Kaplan at the game this past conference as well as a very valuable USMLE QBank two years ago.
Need to get a head start on your 2011 CME? Want to hear the latest clinical information for family physicians?
It is refreshing to attend a student conference that is focused not only on making students better applicants for residency, but also on making them better family physicians to their future patients. Please keep an eye out for the annual student conference later this year. Erica Brode is a third-year medical student at UCSF. She serves as Event Coordinator/FMIG Liaison Committee Chair for CAFP’s California Student Association of Family Medicine (CSAFM).
CAFP’s 63rd Annual Scientific Assembly May 14-15, 2011 Grand Hyatt Union Square San Francisco
Completed your SAMs? Ready to tackle HIT and Meaningful Use? Register today for CAFP’s 63rd Annual Scientiﬁc Assembly. $10 for students.
Joan Bianca Roberts, MD
Diversity Plays a Large Role in Developing a PCMH
ith all the talk about Patient Centered Medical Homes (PCMHs), less attention seems to be given to the actual doctors who open the doors to allow patients inside. Glossy advertisements by health care organizations in magazines and on billboards invariably display health providers with a rich mix of ethnicities, but the unbalanced demographics of the physicians practicing nationwide show we have a long way to go in achieving this kind of diversity. Two populations are grossly underrepresented in medicine: the Latino and black communities. According to US Census data, these groups make up 16 and 13 percent of the population, respectively. Among physicians, however, they represent only about three percent each, according to 2006 data from the American Medical Association. One can speculate on the reasons for this – deficiencies in our education system, varying priorities and cultural values among ethnic groups, persistent discrimination and biases inside and outside one’s ethnic group that discourage young people from pursuing their dreams – but, to me, poverty and socioeconomic injustice clearly continue to play a role. And with the average debt coming out of medical school ranging from $145,000 for public schools to $180,000 for private schools, achieving higher professional education will remain elusive for underrepresented populations. I think about why diversity is important in medicine every day. I decided to go into medicine when I learned there were stark differences in health outcomes between populations. Institute of Medicine and Centers for Disease Control reports consistently show that the black community tends to have the worst outcomes and the lowest life expectancy, even when adjusted for socioeconomic and insurance status. Compounding the diversity problem, our country is seeing a drop in the number of US medical graduates going into primary care. Just half of family medicine residency slots are now filled by US medical graduates. With ubiquitous budgetary crises occurring in this country, universities will continue to look toward their National Institutes of Health (NIH) funding, which traditionally favors high-cost, high-technology specialty care rather than low-cost, public health-oriented primary and preventative care. Leaders within the medical community and government must recognize this is not where money is best spent if we are to improve population health.
But while there is plenty to be discouraged about, I have seen some significant progress. Having seen some high-profile racial tensions during my lifetime (think Rodney King in 1992 and Oscar Grant in 2009), I would not have thought we would have a black President by 2010. Also, there are many heroes in the black community who give me hope – Oprah Winfrey, Sydney Poitier, Eric H. Holder Jr., Regina Benjamin, MD (US Surgeon General and AAFP member), Congresswoman Barbara Lee, Geoffrey Canada, Kamala Harris, and my local mayor, Kevin Johnson. Even within my own residency program at Sutter Health Sacramento, I am proud to have attending Dineen Greer, MD, who specializes in HIV and obstetrical care and senior resident Alisha Dyer, DO who serves as President-elect for the Residents of CAFP (R-CAFP). I am encouraged by the recent attention given to the social mission of medical schools as exemplified by the June 15, 2010 Annals of Internal Medicine study, which ranked medical schools by “social mission.” “Percentage of graduates from underrepresented minorities” was used as one of the three ranking criteria. On a similar note, I benefitted greatly through the PRIME Urban Underserved program while at UCSF medical school and was inspired to provide primary care to urban underserved populations. More medical schools need to incorporate these types of programs.
"Two populations are grossly underrepresented in medicine: the Latino and black communities. According to US Census data, these groups make up 16 and 13 percent of the population, respectively. Among physicians, however, they represent only about three percent each."
Finally, within my own sphere of influence, I strive to make a difference one patient at a time both in my continuity clinic and while on my hospital rotations. There are many wonderful, albeit unquantifiable, advantages to being a minority physician. I am able to connect with many of my patients who might have otherwise become labeled as non-compliant. I can recall a conversation with a black couple fearful of vaccinations for their child, a black man who previously refused a colonoscopy and appeared to be not fully informed of what it involved, a
Resident News > 14 California Family Physician Spring 2011 11
NEWS IN BRIEF New CAFP Officers Elected and Sworn In
Your 2011 Congress of Delegates was held March 5-7 in Sacramento. New CAFP officers were elected and sworn in by AAFP President Roland Goertz, MD. All assume office May 14, following the Board of Directors meeting. The Annual Scientific Assembly will be held May 1415 in San Francisco. Please welcome the following: Carol Havens, MD President Steve Green, MD President-elect Mark Dressner, MD Speaker Del Morris, MD Vice Speaker Jay Lee, MD Secretary-Treasurer Alan Glaseroff, MD Rural Director Jack Chou, MD AAFP Delegate Jeff Luther, MD AAFP Alternate Delegate Maria Greaves, MD Nominating Committee member for 2011-12 Congratulations to all!
Keynote Speaker Announced for 2011 ASA CAFP is pleased to announce that Abraham Verghese, MD, MACP, Professor for the Theory and Practice of Medicine at the Stanford University School of Medicine and Senior Associate Chair of the Department of Internal Medicine, will give the keynote address at the 63rd Annual Scientific Assembly (ASA). Dr. Verghese will talk about taking back the art of medicine, the physical exam and the humanity of medicine. 12 California Family Physician Spring 2011
Dr. Verghese is also the author of the New York Times bestseller, Cutting for Stone. The 63rd ASA will be held May 14-15 at the Grand Hyatt Union Square in San Francisco. Register today; don't forget to make your reservations at the Grand Hyatt Union Square for the special ASA discount rate ($169). Reservations can be made online or by phone at 415-3981234 by referring to the group (California Academy of Family Physicians) and meeting name (Annual Scientific Assembly). The last day to reserve a guest room at the special rate is April 28.
NCQA Released New PCMH Standards The National Committee for Quality Assurance (NCQA) released its 2011 Standards and Guidelines for the PatientCentered Medical Home (PCMH) in late January. In many ways, these revised standards represent an improvement: they are better organized, easier to understand and more streamlined. The NCQA, responding to the comments of stakeholders such as the AAFP, with the support and input of CAFP, has placed greater emphasis on the patient experience and quality improvement and measurement. Perhaps most significantly, there is a new alignment with the concept of “Meaningful Use.” NCQA has recognized the indissoluble connection between PCMH and Health Information Technology (HIT). The NCQA’s PCMH standards are available at www.ncqa.org/tabid/631/ Default.aspx and at no cost and practices can call NCQA at 888-275-7585 for more information.
CAFP Has First Ever Chief Financial Officer We are happy to announce that CAFP’s bookkeeper, Karisa Juachon, became our first ever Chief Financial Officer on April 1. Karisa is a Certified Public Accountant and has worked with CAFP for the past three years.
AAFP National Conference for Family Medicine Residents and Medical Students Every year, the CAFP-Foundation (CAFPF) sponsors California medical students' attendance at AAFP's National Conference for Medical Students and Family Medicine Residents. Eight students are selected to receive $800 scholarships to cover their airfare and lodging expenses. The scholarship application, along with additional details, can be found at www.familydocs. org/students/scholarships/foundation scholarships.php. This year's National Conference will take place July 28-30 in Kansas City, MO. To learn more about the 2011 event, visit AAFP's website. AAFP also offers scholarships to medical students. The deadline to apply is May 1. Please note that you cannot receive scholarships from both CAFP and AAFP. For questions about the conference, email CAFP Student and Resident Affairs Coordinator Cody Mitcheltree at cmitcheltree@ familydocs.org.
Online HIT Toolkit Available on CAFP Website Get ready to implement an Electronic Health Record (EHR)! For physicians who qualify, implementing an EHR and achieving "meaningful use" can mean between $44,000 and $63,750 in incentive payments. Today, CAFP launches an online toolkit to help you select and implement an EHR and obtain incentive payments. The toolkit includes a Qualification and Assessment Wizard to help you determine which incentive program (Medicare or Medi-Cal) to register for, a guide to working with the Regional Extension Center program, tips on vendor selection and contracting, a practice readiness assessment tool, advice from physician champions who have implemented an EHR and more. Visit our Toolkit today at www.familydocs.org/ pcmh/health-information-technology.php. Email HIT@familydocs.org with questions.
Paul Grossman, MD
IN THE SPOTLIGHT
One Year Later, Help is Still Needed in Haiti Editor’s Note: Physicians in the US continue to offer assistance to those affected by the January 12, 2010 earthquake in Haiti. Many doctors (including CAFP members) have travelled in teams to provide care for victims. The following is a first-hand account through the eyes of CAFP member Paul Grossman, MD: In the year since the earthquake that devastated Port-au-Prince, Haiti has endured a seemingly endless sequence of new misfortunes. The first cholera outbreak in more than a century has spread throughout the country, and local authorities are struggling to limit its impact within the crime-ridden tent cities that continue to house more than 800,000 people left homeless by the quake. Following a primary election tainted by widespread reports of disorganization and ballot stuffing, the unpopular lame duck president’s handpicked successor emerged as an unlikely contender to compete in a run-off election. Occasionally violent protests and pressure from abroad are currently shaping the final determination of the election’s outcome. More recently, Jean-Claude “Baby Doc” Duvalier, the notorious ex-dictator, returned to Haiti with unclear intent after decades of self-exile. Haiti was the poorest country in the western hemisphere prior to the earthquake, and the quake took a heavy toll on the country’s meager physical infrastructure. The quake and the ensuing setbacks also killed more than a quarter million Haitians and wrought havoc with the prevailing Haitian social, economic and political structures. Last November, I participated in a medical mission to Haiti sponsored by a small non-governmental organization. Like most Americans, I followed the earthquake and its aftermath in the news and was shocked by the descriptions of the destruction. I felt excited by the opportunity to help, but I was simultaneously apprehensive about practicing medicine in such an utterly unfamiliar setting. I also harbored some doubt that funding short term medical missions such as ours represented the best use of relief dollars. My team arrived in Port-au-Prince a few weeks after the first reports of cholera and just ahead of Hurricane Tomas. A long-term volunteer from the United States met us at the airport with a group of young Haitian interpreters and shepherded us throughout our stay. The hurricane weakened into a tropical storm just before hitting Haiti and the day after our arrival we went to the first of several orphanages and schools that served as our makeshift clinics. In the Spolight > 14
California Family Physician Spring 2011 13
Editorial < 6
For hospitalizations, one pays a fixed daily accommodation fee either in advance or upon discharge, but the hospital sends all other bills directly to the health insurance fund. Prescriptions are taken to one’s choice of pharmacy, which bills the health insurance fund directly, with the patient responsible only for the unpaid portion. Charges vary according to whether the medication is available off the shelf in relation to its generic or brand cost, or has to be compounded by the pharmacist. I am honored to have been educated in such a welcoming environment where excellent, affordable and comprehensive medical care is available to every inhabitant. Indeed, their medical outcomes are better than ours in the US, and they have far less budget available with which to work. I do not propose this as a delivery system to be replicated here, but I do feel we as a nation have a lot to learn from the medical care system not only in Belgium, but in other countries as well, as you will read in this edition of California Family Physician magazine. Albert Ray, MD, FAAFP, is a family physician at Kaiser Permanente, Southern California. He is a member of CAFP’s Communications Committee. President's Message < 7
So far, one thing is certain: the NHI experience is working for the 23 million people in Taiwan. As with any health care delivery model around the world, there are pros and cons. Many have referred to the PPACA as the beginning of the beginning in reforming our inefficient and costly health delivery system. We should continue to examine various health care systems around the world. We should glean the best practices and avoid costly mistakes made by some of these systems while we continue moving ahead with further health care reform efforts in the US. We should bring these potential solutions to the attention of our legislators in an effort to perfect a system that is uniquely American. Would it be too much to expect our legislators to understand that an evidenced-based approach to crafting legislation should not be an oxymoron? Resident's News < 11
black elderly woman in the hospital who was being deemed non-compliant and was refusing care, and an uncontrolled diabetic patient. I was able to intervene in these cases, establish rapport, get to the root of these patients’ fears and forge a new partnership with the patient that led to better care and trust for the medical team. The modern day PCMH – with its emphasis on teamwork and the assumption of tasks by diverse care team members – seems to be building momentum. It’s branding an idea that many of us already strive for in our daily family medicine lives. Ultimately, the amount of money and human capital invested will determine whether the idea sinks or swims. For now, I am happy to 14 California Family Physician Spring 2011
say that I am one of the faces patients will see when opening the door of their medical home! Joan Bianca Roberts, MD is a first year Resident at Sutter Health Family Medicine Residency Program in Sacramento. In the Spotlight < 13
Although I had seen video of Port-au-Prince after the earthquake, it was something else entirely to experience its sights, sounds and smells first hand. I had previously travelled a fair amount in developing countries, but Port-au-Prince provided scenes of abject poverty and urban squalor on a different order of magnitude than anything I’d witnessed before. We were largely kept under lock and key when not in clinic or on the road, so I had limited opportunity to interact with Haitians other than the interpreters and the people I met in clinic. Everyone I encountered was profoundly grateful for our presence and the interpreters’ personal stories from the earthquake provided a human scale to the disaster that the news accounts couldn’t approach. As expected, the clinics were quite different from anywhere I’d worked previously. At some of the orphanages, we treated only the orphans and staff members. Other times, our visits were publicized by word of mouth and there were long lines of patients extending far outside of the clinic. The volume was quite high; I counted 66 chits in my pocket following the one clinic (lasting about 6 hours) during which we used paper markers to keep track of the patients. Most patients had familiar complaints like heartburn or nasal discharge, but the presenting symptoms were almost uniformly superimposed on a backdrop of malnutrition and extremely limited access to clinical resources. Several patients also presented acutely with more severe illness including a girl with a deep tissue infection and a tachycardic, tachypnic pregnant woman with clinically diagnosed pneumonia. I ultimately found the trip to be very rewarding. Many of our patients likely derived modest but non-trivial benefit from the care we provided. For a handful of patients, our efforts may have been life changing. In addition, I believe our actions conferred a small sense of structure and normalcy to patients living in an extremely chaotic environment with an unimaginable allostatic load. Lastly, in an attempt to create positive financial ripple effects since my return, I have shamelessly steered family and friends toward resources describing opportunities to donate professional services or money. Toward that end, I’ve included links to these resources below along with my email address. Please consider making a donation, and don’t hesitate to contact me with questions or comments. – Paul D. Grossman, MD, MSHS
RESOURCES • Pan-American Health Organization Recommendations for Humanitarian Aid – http://bit.ly/PAHOAidRecs • Doctors Without Borders – http://www.doctorswithoutborders.org • Partners In Health – http://www.pih.org/ • Clinton Foundation – http://haiti.clintonfoundation.org/
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4/15 – 17 Neurology for the Non-Neurologist 11.0 P Rancho Palos Verdes (720) 473-6112 email@example.com www.mer.org Medical Education Resources 4/21 – 22 Internal Medicine in the Primary Care Setting Anaheim 12.0 P firstname.lastname@example.org (888) 533-9031 www.mceconferences.com MCE - Meridian Conferences
2011 CME CALENDAR
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6/24 – 27 Intensive Medical Spanish and Cultural 45.0 P Competency Workshop (520) 907-3318 San Diego firstname.lastname@example.org www.medspanish.org Rios Associates
5/14 –15 CAFP’s 63rd Annual Scientific Assembly San Francisco email@example.com (415) 345-8667 www.familydocs.org/ professional-development/ASA.php California Academy of Family Physicians
6/25 – 29 PREP® the Course 42.0 P Costa Mesa (847) 434-4725 firstname.lastname@example.org www.pedialink.org/cmefinder American Academy of Pediatrics
5/20 – 22 Comprehensive Medical Officer Training 21.75 P Los Angeles (919) 489-9588 email@example.com www.aamro.com MRO Alert
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Office Orthopedics for Primary 10.75 P Care Physicians (720) 473-6112 San Diego firstname.lastname@example.org www.mer.org Medical Education Resources
7/15 – 18 Intensive Medical Spanish and Cultural 45.0 P Competency Workshop (520) 907-3318 Glendale email@example.com www.medspanish.org Rios Associates 7/16 – 17 Exercise Stress Testing 12.0 P San Francisco (866) 674-2631 firstname.lastname@example.org www.npinstitute,com National Procedures Institute 7/16 – 17 Hospitalist Procedures 16.0 P San Francisco (866) 674-2631 email@example.com www.npinstitute,com National Procedures Institute Executive Health Resources (EHR), a leading provider of expert Physician Advisor solutions, is in search of qualiﬁed family physicians who are interested in the ﬁeld of medical management. EHR currently has full-time and part-time opportunities available in its Pleasanton, CA, oﬃce, as well as some part-time, remote opportunities. EHR oﬀers a positive work/life balance, no call hours, extensive training, competitive compensation, and professional growth opportunities. Requirements: MD or DO with 3+ years of postresidency, inpatient or outpatient care experience, strong clinical skills, computer-proﬁcient, organized, team player. Contact EHR’s recruiting team today at (484) 362-1996 or firstname.lastname@example.org. Reference job # CFP10. EHR is an EOE.
7/16 – 17 Orthopedics for the Office: Part I 16.0 P San Francisco (866) 674-2631 email@example.com www.npinstitute,com National Procedures Institute 7/16 – 17 Suturing Basics 15.0 P San Francisco (866) 674-2631 firstname.lastname@example.org www.npinstitute,com National Procedures Institute 7/21 – 23 Geriatrics: A Primary Care Approach 12.0 P to the Aging Population (858) 518-6656 Carlsbad email@example.com www.mceconferences.com MCE - Meridian Conferences California Family Physician Spring 2011 15
Taking the Controls: President-Elec Article and photos by Chris Navalta
LAST YEAR, Jack Chou, MD became the first Permanente Medical Group physician to become CAFP President. This year, Carol Havens, MD will be the second PMG president in as many years. A CAFP member since 1982 (the same year she completed her residency), Dr. Havens is an educationoriented physician with a hunger to teach others. She has worn many hats for CAFP over the years and is looking forward to adding a “presidential hat” to her stack. Dr. Havens sat down with CAFP Manager of Publications and Marketing Chris Navalta and talked about her road to becoming president. We always have to ask: what drew you to family medicine? I loved everything I did in medical school. So it really wasn’t a difficult decision to make. I grew up in a small town in Missouri, where family physicians were all I ever knew. In fact, they were the only kind of physicians I thought existed except for surgeons. In my first week of medical school, when everyone talked about what they were going to specialize in, someone said internal medicine. And I was thinking,
16 California Family Physician Spring 2011
“What’s that?” To me, family medicine was what you did. So I went to medical school with the idea of specializing in family medicine. I really like getting to know people and I really like the opportunity to see them over time. You also specialize in addiction medicine – what attracted you to that field? Frankly, what got me into addiction medicine was a lifestyle choice. I started my job in the CME office in Oakland and was trying to run a fullpanel family practice two-three days a week and was out of the office during the other days. I just couldn’t keep up. I was spending 12-13 hours a day on the days I was in clinic just trying to catch up on all of my patients. It finally got to a point where something had to change. I either had to give up my education job (which I really didn’t want to do), or I had to do something different clinically. An opportunity came up within our chemicaldependency program. They had just received a grant to study whether or not patients in treatment for addiction issues did better if they also got their primary care within the clinic. They
were looking for a part-time family physician. They called me and asked if I was interested. I said “sure,” even though it was never a passion of mine to serve people with chemical dependencies. I did it because it was a more circumscribed practice than doing full family medicine. I made a deal with my new chief to bring several of my patients with me. I just couldn’t give them up. What I found out, once I got there, was that addiction medicine was incredibly rewarding to deal with people who are struggling so hard to overcome their addictions. They work so hard at it and you can’t help but be amazed and humbled by the struggles they go through and what they are willing to do to overcome them. It’s a real privilege to be part of that process and work with people working hard at getting better. It’s really amazing. You are very involved in continuing professional development as well. How do you balance that work and patient care? I’m always asked how I maintain balance. I think of balance, not so much as a single-point along the continuum, but as a pendulum.
ct Carol Havens, md Ready to Step In Some days, you spend more time doing CME and other days you spend time doing patient care. How I do it, I’m not sure. Why I do it is because I love both. I’m renewed and refreshed by doing both. So for me, it’s worth trying to find that balance because I get so much more out of it. You are the second Permanente Group Physician to become CAFP president. What might you do to encourage more Permanente physicians to become involved in the Academy? I don’t think this is unique to Permanente physicians. I think a lot of associations are finding that members are being much more selective about how they use their resources. That includes money as well as their own time. I think it is really important that CAFP find a way to describe the value of being a member participating in your specialty. We have to show why the Academy matters to them and why they matter to the Academy. That’s certainly true for Permanente physicians, but it’s true for any physician, who has gotten a lot of things from CAFP such as CME credit. If we can show why CAFP matters to
them, it won’t be a problem attracting physicians – including Permanente physicians. But we have to be able to describe that value. What are some of the biggest challenges you see in health care within the next year? Where do I start? Health care reform is huge. And even though the law has a million moving parts, the argument is always like “the chicken or the egg.” Payment reform has to happen for meaningful health care reform to happen. But the argument is always what needs to happen first. I don’t know the answer to that. I know that we have to somehow start making that change. And I’m very hopeful that if we can break in somewhere, others will follow. But I think figuring out a way to provide care to our members, to our patients, to our society is going to be the major question in health care over the next decade or so. It’s not just how do we provide care to those who have insurance. It’s how do we provide care to everyone. Whether it’s universal health care, other payment plans or increased reimbursement, we have to find a way to take those steps. Part of that also has to do with how
many doctors we have. We need more primary care physicians, particularly family physicians. We all know that the cost goes down, the quality goes up the more family doctors you have. Both of those things need to happen to provide health care in a meaningful way to people. If we attract more family physicians, more medical students to go into family medicine, that will be followed by payment reform and health care reform. What about you would surprise our members? My friends tell me that I have no secrets and that I am an open book. To some extent, that’s probably true. But it would probably surprise our members that I’m currently learning to play the ukulele. You probably saw it in my office. That’s the latest thing I’ve taken up as a form of meditation and wellness activity. It’s easy to learn. A ukulele only has four strings (as opposed to a guitar, which as six). More importantly, you can’t say the word ukulele without smiling. And you can’t think about a ukulele without smiling. There’s no way you can’t have a good time when you’re playing it.
California Family Physician Spring 2011 17
HEALTH CARE OUTSIDE THE US
It’s Always What Happens Between a Physician and a Patient Interview with Richard Roberts, MD, JD, President, World Organization of Family Doctors (WONCA) – Shelly B. Rodrigues, CAE, CCMEP IT STARTED EASILY ENOUGH – inviting Dr. Roberts to write the opening article for this issue of California Family Physician. He’s written for us before and has spoken at our meetings many times. He even did his family medicine training in Santa Monica, so we lay some claim to him. He emailed that he’d love to write, but given his schedule, he might not be able to meet the deadlines. Our solution – I was lucky enough to grab an hour of phone time with him – made easier by a blizzard in Wisconsin, where he happened to be spending some “home time” that shut down his clinic and opened his schedule.
fied 145 clinical measures for improvement, tying them to increased payment. “Physicians, being genetically-bred and sociologically-trained to ace the curve, met 90 percent of the targets in year one, nearly doubling their payments.” The flip side, though, according to Dr. Roberts, is that they met asthma goals by hiring “respiratory nurses,” and now find themselves less able to manage total asthma care, resulting in decreased patient satisfaction. A significant problem with many performance metrics is that they may not measure or predict accurately what we intend. For example, several recent large studies on diabetes
Dr. Roberts spends approximately 200 days each year on the road, about half outside of the US; he travels annually to more than 40 countries; gives about 100 presentations each year; and visits with government officials, the media, and medical students and trainees around the world. He says, however, that the best time – the time he learns and values the most – is the time he spends with physicians in their practices observing patient visits. In general, Dr. Roberts said Left to right, Doctors Vibhakar, Roberts and Harendra. to improve population health, the two things the had to be stopped early because those US needs that many other countries with hemoglobin A1c less than 7 percent already enjoy are universal access had higher mortality rates – yet many US and a health care system centered in pay for performance systems try to push primary care. The work being done to doctors to get patient hemoglobin A1c improve quality and measure outlevels below seven percent. comes in our system, as well as in other systems worldwide, is also important. Beyond the meetings with health minisHe offered a word of caution, warning ters and members of parliament, tours that in driving for quality improveof major medical centers and technology ment, pay for performance, and value demonstrations, Dr. Roberts has been measurement, we do not run over particularly touched by visits to Tajikistan the patient relationship. He cited and India – health care systems with programs in England that have identivastly different resources. These are the 18 California Family Physician Spring 2011
two stories I think should be shared. In India, Chennai (Madras), population seven million, and Mumbai (Bombay) with 20 million people, illustrate the extremes of incredible wealth and abject poverty. The medical system is a complicated mosaic of high-priced technology existing beside “mom and pop GP offices” with sheets for doors and few, if any, patient records. For the affluent few, India has some of the best technology and sub-specialty experts anywhere, with $2500 one-day bariatric surgeries touted by Bollywood actresses as a means to decrease obesity and improve diabetes problems. At the same time, India is a place where millions lack access to basic health care, where 75 percent of care is private pay, where $1 office consultations consist of a brief history and no physical exam. Many hospitals have MRIs, CT scanners, endoscopy and laparoscopy services, but also 60-bed open wards in which family members sleep beneath the beds to assist in care. The Indian medical system has not built a broad foundation of postgraduate training in family medicine, favoring specialty training instead. Primary care physician morale is low, and students are not selecting it as a specialty. Nevertheless, Dr. Roberts said the family physicians he has met in India are well-trained, highly-motivated, and have done their best in a challenging system. To illustrate the point, he described his visit with two brothers who have been practicing together for 40 years in the same site as their father and grandfather before them. Their business card lists
HEALTH CARE OUTSIDE THE US
Dr. Abdujabor Kurbonov.
Dr. Vibhakar (all allopathic family physician) on one side and Dr. Harendra (an Ayurvedic physician) on the other side. They consult each other depending on the patient’s problems – and with their blend of Occident and Orient, they teach one another and better serve their patients. Dr. Roberts also told the story of his visit to a rural village in Tajikistan and his mountain hike with Dr. Abdujabor Kurbonov, who has been the only doctor in this rural region for more than 20 years. The average income in Tajikistan is 85 percent of what it was 10 years, ago, and according to Dr. Roberts more than one-third of the economy reflects remittances from Tajikistani workers in other countries, mostly Russia. Many Tajik villages consist of women with young children and the elderly; the husbands return for one month each year for “family visits.” These visits result in three to five deliveries per month for Dr. Kurbonov and his midwife. In addition to the health center, Dr. Kurbonov also serves two rural “health houses,” six and nine kilometers away, which he visits once a week. He lives 40 meters from the health center making it easy for patients to knock on his door at any hour. He earns $35-50 US per month, buys his own equipment and often must pay for the medication for his patients. Yet he is encouraging two of his children who are in medical school now to join him in his primary care practice. What was it about Dr. Kurbonov that was so compelling? Dr. Roberts reflected on that question during the rest of his week
in Tajikistan as he observed young family doctors in training, lectured at the medical symposium, met health ministry officials, visited an orphanage for the deaf, and enjoyed the culture and hospitality of the Tajikistanis. One visit in particular stood out— a young mother who had walked nine kilometers with her 14-month-old baby to see Dr. Kurbonov. The baby was one of the more than 150 Tajikistanis who had recently contracted polio. (He had been immunized, but the oral vaccine was likely ineffective because it required refrigeration, and electricity is quite unreliable.)
children with any neurological problem in Tajikistan. Dr. Kurbonov explained firmly and compassionately that she could not afford the medications, which, in any case, would not cure her son and that the best medicine was the one she was already providing – massage, muscle work, and improved nutrition. “I felt like I was watching an artist at work – seeing this skilled family doctor pull together everything he knew about her, her family, and her community into practical and relevant advice, while giving hope to a woman in desperate need of some,” said Dr. Roberts.
The baby’s left arm and bilateral leg, weakened from the disease, were slowly improving with the physical therapy exercises and improved nutrition Dr. Kurbonov had taught the mother to provide. Out of a young mother’s understandable desire to do everything possible for her baby, she had recently traveled to Dushanbe to see a pediatric neurologist, who prescribed the standard three medications given to all
To put the hour’s conversation into 1,000 words is nearly impossible, but to put it into one sentence is really quite easy. What Dr. Roberts taught me is that no matter the continent, setting, language or culture, health care is always what happens between a physician and a patient. Simple as that.
SCI_CA Family Phys
For more information on WONCA, or to read Dr. Roberts’ monthly columns, go to www.globalfamilydoctor.com. Ad_12.18.10.qxd:Layout 1 12/20/10 1:03 PM Page
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California Family Physician Spring 2011 19
HEALTH CARE OUTSIDE THE US
All Can Be Achieved with Will, Ideas and Execution – Alan Glaseroff, MD
I RECENTLY FINISHED reading New York Times reporter T.R. Reid’s book, The Healing of America. I had listened to his insightful and interesting commentary from overseas assignments during his periodic commentaries on National Public Radio for many years. Hence, I approached his most recent bestseller on health care in other countries with some excitement. I was not disappointed. Utilizing a novel approach to exploring how health care is delivered in most of the countries of the developed world, Mr. Reid takes his ailing shoulder to both primary care physicians and subspecialists all over the world to personally experience seeking treatment and the financial ramifications of such treatment in each country. He concludes that the US would do well to look beyond superficial labels (e.g., socialized medicine, government takeover) and into how health care is actually delivered and paid for in Canada, several countries in Europe (the U.K., France, Germany), and Asia (India, Taiwan). Mr. Reid briefly discusses the Cuban health care system, describing it as sharing many similarities with our own Veterans Affairs and Indian Health Service systems. He briefly mentions that Cuba achieves results roughly equivalent to the US – life expectancy, childhood mortality, etc. Cuba’s infant mortality statistics actually surpass those in the US. They have the highest PCP-to-patient ratio in the world and even export doctors to third-world countries in exchange for needed commodities (e.g., oil from Venezuela). Comparing Cuba to the US is one thing (according to the World Health Organization’s 2009 rankings, the US ranks 37th and Cuba 39th), but comparing Cuba to a country in the Caribbean with a similar per capita wealth but a vastly different system of government (Haiti) and a much lower average life expectancy, due to abject poverty and the absence of a government safety net beyond a scattered series of charity hospitals, is perhaps a fairer assessment of their achievements. Cuba achieves its results at one-tenth the cost of the US system and is the lone global exception to lower average life expectancies in the underdeveloped world according to Mr. Reid. You also may remember Michael Moore’s controversial 2007 movie “Sicko,” which heaped praise on the Cuban system, but didn’t go much beyond saying “It’s free!” in terms of describing how the Cuban Ministry of Health achieves its results. Why my interest in a system ranked below the US? I studied the Cuban health system in 2003 as a member of a delegation of physicians and nurses who spent a week visiting Havana 20 California Family Physician Spring 2011
and several rural clinics and hospitals under the auspices of the Center for the Health Professions at UCSF. My interests in health care (as a rural family physician in practice with my wife, Ann Lindsay, MD, and as the Chief Medical Officer for the Humboldt Del Norte Independent Practice Association) have focused on the redesign of primary care, especially in regard to chronic disease, and on systems of care that are truly patient-centered and proactively provide patients the care they want and need. I’m especially interested in how the Patient Centered Medical Home movement will work to risk stratify populations of patients and provide intensive care management for those at highest risk. Success in doing this will provide funding for increasing payments to primary care – it all comes down to keeping high risk patients out of the hospital and ER. It was viewing through this double lens that allowed me to appreciate the Cuban approach to health care. Cuba is a primary care-driven system. It has 58 MDs per 10,000 in population vs. the US’s 28 per 10K (and vs. Haiti’s 2.5 per 10K). Practices generally consist of one doctor-nurse team per 150 families and are located in the very neighborhoods of the families they serve; given the Cuban birth rate, this equates to an average practice size of 500 patients per physician-nurse team. Both doctor and nurse “live in the neighborhood” as well. Charting is via 3x5 cards and there is no billing. Physicians spend half their workday seeing patients individually and the other half doing the type of work done by public health officers in the US – worksite evaluation, community outreach, school and workplace-based services and the like. Reporting is simple: preventive and chronic care services such as immunizations and screening are tabulated at a regional level, and used for outreach by community health workers. Each block also has a community health outreach worker, based in a storefront, who knocks on doors to notify patients of needed individual medical services and recruits patients to work on community projects such as building youth centers or adult day care
HEALTH CARE OUTSIDE THE US
centers. We refer to such peer health workers as promotores in California. These outreach workers are collectively known as Committees to Defend the Revolution, but their primary role is overseeing the health of individuals within the neighborhoods they serve, as well as spreading information, preparing for natural disasters and serving as a community crime watch program. Privacy is less of an issue in Cuba than in the US – it appeared that everyone was involved in everyone else’s business in a way that reminded me of a small-town grapevine. This has its obvious plusses and minuses. Fifty such practices aggregate around a polyclinic, which has rudimentary laboratory, diagnostic imaging and treatment capabilities, and also serves as the educational center for the 50 practices. Specialists work either in the polyclinic or in hospital settings. The polyclinic also has a single computer with largely pirated and out-dated Microsoft Office software, and is used to manage populations of patients and profile physiciannurse teams. One half-day per week is spent meeting at the polyclinic to hold case conferences and morbidity and mortality reviews and to access mandatory CME. Each physician-nurse panel of 500 patients is divided and managed (dispensarization) into four groups according to risk: • Class I – Healthy: one office visit, one home visit • Class II – At risk: visits every six months office and home visits • Class III – Chronic condition: visits every three months office and home visits • Class IIII – Disabled: monthly office and home visits As the US approaches meaningful use, we can only aspire to manage the patients on our panels as comprehensively as do the Cuban physicians. The Cuban approach and results are made more impressive by the fact that when the USSR finally collapsed in 1993, cutting the Cuban Gross Domestic Product by 37 percent, there was no loss of quality in their health measures. Can you imagine what effect such a cut in the US economy would have on community clinics and poor people’s access to health care? The loss of Soviet support, coupled with the US
embargo, cut off access to most medications. The outpatient pharmacies have mostly empty shelves. Nevertheless, their chronic disease results match ours and their public health system is far more successful at reducing communicable disease than is ours. There are no cholera outbreaks in Cuba; HIV infection is exceedingly rare as well. How do they do so much with so little? The answers were right in front of us – lots of exercise simply getting around, no junk food and nobody homeless or starving or falling through the cracks of a system more interested in making money than in keeping the population healthy. Even medical students have a physical education requirement! No one is homeless, though housing is very crowded. No prescription drugs? Start producing herbal medicines as an alternative. No antiretrovirals for HIV/AIDS? Break the patent owned by the pharmaceutical industry and give out the life-saving drugs for free. In terms of the design of the medical system itself, they also employ a methodology well known to those who have participated in quality improvement efforts. The principal approach is as follows: • Build it from the bottom up • Register problem • Intervene • Evaluate • Follow-up We often refer to this approach as the “Model for Improvement,” and use “small tests of change” (or PlanDo-Study-Act cycles) as the basic methodology to find out what works on a small scale before spreading successful approaches widely. They use their weekly meetings to spread these ideas. The 17 years it takes a new evidence-based approach to become widely disseminated here US Hospice care is rare there. The government prides itself in doing whatever it takes to keep an individual alive, regardless of the probability of cure. There are obvious drawbacks to being a physician in Cuba, though we met a few American physicians who had moved to Cuba and were fully integrated into life there (and enjoying their professional and personal lives). There are also Cuba > 29 California Family Physician Spring 2011 21
HEALTH CARE OUTSIDE THE US
Unlike Its Cheese, Swiss Health Care Features No Holes – Irina deFischer, MD
AFTER GRADUATING from Stanford in 1976 with degrees in Biology and French, I moved to Lausanne, Switzerland to attend medical school. Since I am a Swiss citizen, I was required to pass an exam demonstrating my proficiency in two Swiss languages (I chose French and German) and a basic knowledge of Swiss history and geography. After completing the pre-med curriculum, I was admitted into the second year of the six-and-ahalf-year program – the second and third years were pre-clinical, followed by three-and-a-half years of clinical rotations. Exams were given after each of the first three years and again at the end of the sixth year, and consisted of both written and oral portions. We could choose among French, German or Italian for the oral exams. These were nervewracking to say the least! One of my favorite clinical rotations was the two months I spent with Urs and Mali Wiget, a two-physician couple with four young children, who had a family practice downstairs from their home in a small alpine valley west of Zermatt. The valley had a half-dozen small villages and in the summer also hosted a Club Med resort. In addition to seeing patients in the office, they also made house calls and responded to emergencies, such as auto accidents. The nearest hospital was nearly 15 miles down a steep winding
22 California Family Physician Spring 2011
road. Mali had instituted group visits in which she would take several sedentary women on a 60-90-minute hike in the hills once a week, billing each woman’s insurance for a 15-minute office visit. The office had an X-Ray machine, lab and a dispensing pharmacy which, in addition to traditional medications, also sold a variety of therapeutic herbal teas. During my studies, I also got first-hand experience as a patient. I had low-cost insurance offered to students, which came in handy as I came down first with rubella, followed by chicken pox. In my fourth year, I developed a herniated disk and after a week of bed rest in the district hospital, the sciatica pain had resolved but a foot drop had appeared. I was then transferred to the university hospital in Lausanne for a discectomy. There, I was given a private room and treated quite well by the neurosurgery professor and the nurses, who turned me from side to side every four hours for several days, even moving my things from one bedside table to the other each time. The Swiss health care system is often held up as a model for health care reform in the US. It is one of the best in the world – there is an extensive network of doctors and state-of-the art hospitals, waiting lists for treatment are short; patients are free to choose their
own doctor and have unlimited access to specialists. The system is private, not government-run, though there are public (university) hospitals and clinics. The emergency rooms aren’t nearly as busy as ours. The Swiss are healthier than their American counterparts and, by and large, are happy with their care. How does this work? First, there is universal coverage in the form of an individual mandate and guaranteed issue – The Health Insurance Act of 1994 requires all residents of Switzerland to purchase a basic health insurance policy. The monthly premium typically costs around $300 for adults ages 26 and older (slightly less for young adults) and $80 for children younger than 18. Insurers are required to offer this basic insurance to everyone regardless of age or medical history. They are not allowed
to make a profit on the basic insurance, but can make a profit on supplemental plans, for which premiums are actuarially adjusted. There are no entitlement programs such as Medicare or Medicaid in Switzerland – only subsidies to cover the portion of the insurance premium that exceeds eight percent of individual or family income (35-40 percent of households get some form of subsidy). Insurance costs are generally borne by the individual – not the employer – and they are not tax-deductible. Individuals must also pay copays and deductibles, which vary depending on the supplemental plan chosen. Prescription copays are 10 percent for generics and 20 percent for brand name drugs. Pregnancy-related care is exempt from copays. Physicians in Switzerland typically earn less than their counterparts in the US. Swiss specialists typically earn three times more than the national average wage, compared to 5.6 times in the US,
and primary care physicians earn 2.7 times more than average, compared with 3.7 in the US. Physicians’ fees as well as laboratory, prescription and medical device costs are regulated to keep costs down, and physician billings are subject to utilization review. On the other hand, medical education is much less expensive than in the US – annual tuition costs only a little more than $1,000/year, so the average physician has little or no debt upon graduation. In the nearly 30 years since I graduated from medical school in Lausanne, the Swiss have achieved universal coverage and maintained a private health care system with excellent outcomes at 10 percent of the Gross Domestic Product – less than the US and Great Britain. It’s a model we would have a tough time implementing in the US, but definitely worth looking at! Irina deFischer, MD is a family physician from Petaluma, CA. She represents District 9 (Marin, Solano, Napa, Sonoma, Humboldt-Del Norte, Mendocino-Lake, San Francisco) on CAFP’s Board of Directors.
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California Family Physician Spring 2011 23
HEALTH CARE OUTSIDE THE US
Looking at Israel’s System – As a Student … and Patient – Mark Dressner, MD
UNIVERSAL HEALTH CARE is provided for all citizens and permanent residents. Everyone pays so everyone can benefit. Coverage includes both clinic and hospital care. These are three of the elements of the Israeli health care system. I had the good fortune to live in Israel from 1984-1988 where I attended medical school at the Sackler School of Medicine in Tel Aviv, one of Israel’s four medical schools. My American colleagues and I were taught in English, while the Israelis were taught in Hebrew by most of the same professors. I was
able to observe the medical system in the 1980s from the inside as a medical student and also as a patient. I had to use the system twice – and I was just there as a student. I was directed to go to the emergency room for a bad paronychia. I was seen promptly and courteously. My infection was treated by a bilingual physician. I showed the card I had received during my med school orientation and was never charged – nor did I ever receive a bill. During my fourth year, I was suffering from a terrible sinusitis that really needed antibiotics. I went to the local clinic on my own and was worried I would have to have my encounter in Hebrew. After a short wait, I was seen again by a bilingual doctor. I was treated with antibiotics. I again received consultation and treatment without paying at the time of the visit or receiving a bill (and all in English no less).
From a medical student’s point of view, I always saw residents and attendings ordering and treating as they felt was appropriate. I did not see denial of services or even the thought of not being allowed to order or treat in a certain way enter the decision-making process. I did see long waits for procedures sometimes. I also saw a lot of discontinuity between physicians and patients. What else did I see? When various parts of the big system went on strike, patient families came to help. The hospital maintenance staff that cleaned and picked up trash went on strike. Families came to clean rooms and make beds. When food services personnel went on strike, food was served by families. The value of jumping in to help and care for the sick was ever present. A report in Health Systems in Transition, Vol. 11 No. 2 2009, entitled, “Israel Health System,” by the European Observatory on Health Systems and Policies, brought me up-to-date with the present day health system. Universal coverage is provided for all citizens and permanent residents. It is guaranteed through the National Health Insurance law of 1995. Health care is provided mainly by four non-profit health plans. Health care is financed through taxation based on income. Physician services, hospitalization and medications are provided. Long-term care, mental health services, and dental care are not provided. The bottom line for Israel is a general consensus that society as a whole is responsible for the health of its citizens. Everything follows from that philosophy. We can learn much from their model. Mark Dressner, MD is a family physician in Long Beach. He serves on CAFP’s Board of Directors as Vice Speaker.
24 California Family Physician Spring 2011
HEALTH CARE OUTSIDE THE US
Graduate Medical Education: Lessons Learned from Our Neighbors in the Great White North – Callie Langton, MPA
IT IS NO SURPRISE that graduate medical education (GME) is undergoing scrutiny in the United States. With a looming primary care physician shortage, experts are seeking creative solutions to manage increasing demand for, and decreasing access to, primary care physicians. The Council on Graduate Medical Education (COGME), a commission appointed by Congress to examine medical education and training policy, published its 20th report, “Advancing Primary Care,” in December 2010 to provide recommendations to Congress on how to solve the physician shortage. (www.cogme. gov/20thReport/cogme20threport.pdf) COGME developed specific recommendations to address workforce challenges in five areas: • the number of primary care physicians; • mechanisms of primary care physician payment and practice transformation; • the premedical and medical school environment; • the GME environment; and • the geographic and socioeconomic maldistribution of physicians. According to the report, policy changes should be dramatic and implemented widely, with significant focus on new policies and programs to support primary care training. The report also strongly supports GME reform by increasing primary care GME positions, providing GME funding directly to residency programs and encouraging communitybased residency programs. So the big question is, if these recommendations are heeded, would GME funding reform help alleviate the physician shortage? We have only to look to our Canadian neighbors to see a system that produces 50 percent primary care physicians, 10 percent higher than the COGME report suggests, using some of the funding mechanisms the report recommends.
While Canada has not completely solved its physician supply problem, its medical training system generally produces an equal mix of generalists and specialists: 30 percent of medical students chose family medicine in 2010 alone (Canadian Medical Association). Medical education in Canada focuses on primary care, not subspecialty care. In sharp contrast to the United States, where some medical schools have no family medicine department, each Canadian medical school has a prominent department of family medicine. More faculty respect for the specialty and more equitable incomes for subspecialty and primary care physicians have resulted in a higher percentage of students choosing primary care training upon graduation from medical school. In the United States, hospital administrators generally choose the specialty mix of their coveted GME-funded residency slots. To a hospital administrator, subspecialty residency programs, particularly those that bring in research or surgery dollars, are more valuable than primary care programs, which can be viewed as a “cost center.” As a result, hospitalbased residency slots, which are the vast majority of GME slots in the United States, are disproportionately in highrevenue specialties. In Canada, provincial governments have a large influence over the specialty mix in GME training. Furthermore, GME financing in Canada is through explicit provincial budget lines and not comingled with clinical services and clinical research, as it is in the United States. This allows for more direct funding to ambulatory-based training programs, most of which train primary care professionals. Health is a provincial jurisdiction; provinces have an incentive to utilize GME funds to train the mix of physicians they need in the community, rather than the mix that will increase revenues for hospitals. This mirrors recommendations
in the COGME report to change GME funding regulations and expand Title VII funding for communitybased residency programs. In Canada another noteworthy difference lies in combining training program accreditation and specialist certification into just two bodies: the College of Family Physicians of Canada for family physicians and the Royal College of Physicians and Surgeons of Canada for all other specialties. This is in great contrast to the United States where 24 specialty boards each set their own certification requirements and hold seats on the Residency Review Committee of the Accreditation Council on Graduate Medical Education (ACGME). These specialty boards also hold seats on the American Medical Association/Specialty Society Relative Value System Update Committee (RUC) that makes recommendations on physician payment changes to the Centers for Medicare & Medicaid Services. Thus, in Canada, family physicians hold one of two seats at the table, whereas in the United States, primary care physician specialties represent the minority in any discussion regarding GME funding or government payment issues. This puts primary care physicians, including family physicians, at a significant disadvantage when it comes to negotiating payment or training reforms for primary care. Payment reform, medical school debt and innovative practice models such as the Patient Centered Medical Home all influence medical students’ choice of specialty. If the Canadian model is any indication, however, GME reform, as recommended by the COGME report among others, may go a long way toward strengthening the primary care workforce in the United States. Callie Langton, MPA is CAFP’s Associate Director of Health Care Workforce Policy. California Family Physician Spring 2011 25
PRACTICE MANAGEMENT NEWS
The Timely Access Regulation – What It Means to You
n January 17, 2011, California health plans adopted policies that implemented the 2002 Timely Access Law (TAL). The purpose of the TAL is to ensure that health plans deliver health care in a timely manner, through contracting with the appropriate number of primary care and specialty physicians. The TAL requires health plans to provide the following: SERVICE
24 Hours, Seven Days a Week
Wait Time for Phone Triage
Within 48 Hours
Non-Urgent Appointment with Primary Care Providers
Within 10 Business Days
Urgent Appointment Requiring Authorization
Within 96 Hours
Non-Urgent Appointment with Specialists
Within 15 Business Days
Non-Urgent Appointments with Mental Health Provider
Within 10 Business Days
Non-Urgent Appointments with Ancillary Providers
Within 15 Business Days
Under the regulation, appointments that are rescheduled must be done in a manner that is appropriate for the patient’s health care needs. Likewise, a physician can exceed the wait times by documenting that a longer time would not be detrimental to the patient. The regulation permits a health plan to delegate screening or triage services to providers. Triage or screening services must be available 24 hours a day, seven days a week by a telephone answering machine, answering service, office staff or a combination of these. Callers must be informed of the length of wait for a return call from a provider (a maximum of 30 minutes) and how the caller may obtain urgent or emergency care, including how to contact an on-call provider. Unlicensed staff may answer or respond to calls and gather information for licensed staff, but cannot advise on or make any decision regarding a patient. What does this regulation mean for family physicians? The impact of this regulation on family physicians is mitigated by 26 California Family Physician Spring 2011
several factors: 1. The regulation expressly provides that duties imposed by the regulation are required of managed care plans. The burden to meet these requirements is not on providers. 2. Most plans already have in place policies requiring primary care physicians to meet access requirements. Health plans audit their access policies by, among other things, contacting medical groups as prospective patients seeking to set appointments. Physicians should be accustomed to plan access requirements. 3. Currently, none of the major health plans have delegated the screening/ triage requirements to providers. In all but a few situations, providers (at least for now) are not obligated to provide 24/7 triage or screening services by telephone. 4. The regulation expressly states that no new causes of action or defenses are created by the regulation and vio-
lation of the regulation, e.g., exceeding wait time for an appointment does not impose liability on family physicians. Why is the regulation important to family physicians? There are at least three important provisions of the regulation that may affect your practice now. 1) Specialists: Under the regulation, health plans have only 96 hours to authorize and ensure scheduling for urgent appointments that require authorization. Plans have 15 days from a request for appointment to confirm an appointment with a specialist. A health plan is not relieved of these obligations even if there is no available in-network specialist. Instead, the plan must arrange for the patient to be seen by a specialist outside the contracted network. The plan cannot pass on additional costs of the outside referral to patients. Family physicians play a vital role in the referral process. A request for a specialty appointment may come directly from the family physician to the health plan, with the date of request clearly documented. This documentation — unlike an undocumented call from a patient — provides a clear paper trail of the starting point for calculating the wait limitation for a request for an appointment with a specialist. On the other hand, if a family physician requests that a patient be seen by an identified specialist and that specialist does not have available appointment dates to meet the wait limitations of the regulation, the family physician can extend the wait time. It is incumbent, however, for the physician to document in the patient’s record that a longer waiting time will not have a detrimental impact on the patient’s health. 2) Delegation of Screening/Triage: Although the major health plans currently do not delegate the screening/triage requirements to physicians, some regional ones do. The delegation of screening/triage requirements imposes a potentially huge burden on family physicians. While physicians already have on-call physicians
to cover their practices, they must ensure that their practices have 24-hour, seven-days-a-week screening and triage services available, with a 30-minute response time. Any plan proposing to delegate screening or triage services to physicians must amend its contract with the physician, giving at least a 45-day notice of the amendment. If a physician does not wish to accept responsibility for the delegation, he or she should reject the amendment. If a physician accepts delegation, he or she should negotiate with the plan and require the plan to pay for the screening and triage services. Physicians should also read the fine print in contract amendments to ensure that additional liability for the delegation is not foisted on practices. If a physician accepts delegation, the regulation requires that his or her telephone number be included on the back of patients’ membership cards.
3) Compliance Burdens: The regulation requires plans to implement written quality assurance systems and adopt policies and procedures designed to ensure compliance with the regulation. The policies must include the ability to track and document network availability to meet the wait limitations in the regulation. As part of the quality assurance processes, plans are required to conduct annual provider surveys and evaluate information from, among other things, these surveys on a quarterly basis. Plans must verify certain programs are available to patients for advanced access (next-day appointments). Plans must implement prompt investigations and corrective action when monitoring discloses a failure to meet the wait limitations. The compliance monitoring and corrective action procedures impose additional burdens on physicians. At the least, family physicians will be obligated to complete annual surveys. They also may be required to assist plans in
gathering information on compliance, particularly with regard to wait limits on appointments with specialists. They may be required to assist in implementing corrective actions if the plans to do not meet the wait limitation requirements. Barbara Hensleigh, a former NICU nurse, has practiced law for more than 20 years. Her statewide practice is with the law firm of Andrews & Hensleigh, LLP, in Los Angeles, California. Ms. Hensleigh's practice is devoted to the representation of physicians, physician groups and health care entities in litigation, arbitration and administrative proceedings. She may be reached at firstname.lastname@example.org.
DISCLAIMER The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney-client relationship. Consult your attorney or other professional for advice in your particular situation.
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nestled among the famous Sequoia Redwood Forests United Indian Health Services, a non-profit consortium of eight tribes and California’s premier American Indian Health Clinic, is seeking one full-time Board Certified or Board Eligible Family Practitioner to work in the Klamath-Smith River Clinics. Hospital on-call responsibilities include medicine, pediatrics and possibly obstetrics. Competitive salary. Interested applicants please FAX CV to: UIHS (707) 825-6747 attn. Trudy N. Adams; (707)825-4036. In accordance with PL 93-638 American Indian Preference shall be given.
California Family Physician Spring 2011 27
NCQA Releases 2011 PCMH Standards: The Good, the Bad and the Ugly
he National Committee for Quality Assurance (NCQA) released its 2011 Standards and Guidelines for the Patient-Centered Medical Home (PCMH) in late January. In many ways, these revised standards represent an improvement: they are better organized, easier to understand and more streamlined. The NCQA, responding to the comments of stakeholders like the AAFP, with the support and input of CAFP, has placed greater emphasis on the patient experience and quality improvement and measurement. Perhaps most significantly, there is a new alignment with the concept of “Meaningful Use.” NCQA has recognized the indissoluble connection between PCMH and Health Information Technology (HIT).
Example Standard 1. Enhance Access and Continuity (20 Points) Element A: Access During Office Hours (4 Points)
Six main 2011 standards, compared to nine 2008 standards, demonstrate an effort to simplify the evaluation process.
There are six “must-pass” elements, considered essential to the PCMH, that are required for practices at all recognition levels. These elements are: Access During Office Hours, Use of Data for Population Management, Care Management, Support of SelfCare Process, Tracking Referrals and Follow-Up and Implementing Continuous Quality Improvement. Practices seeking accreditation complete a web-based data collection tool and provide documentation that validates responses. Three levels of NCQA recognition are still in place; each level reflects the degree to which a practice meets the requirements of the elements and factors that comprise the standards. • Level 1: 35–59 points and all six must-pass elements • Level 2: 50–84 points and all six must-pass elements • Level 3: 85–100 points and all six must-pass elements
The Standards: Now and Then
1. Enhance Access and Continuity
1. Access and Communication
2. Identify and Manage Patient Populations
2. Patient Tracking and Registry Functions
3. Plan and Manage Care
3. Care Management
4. Provide Self-Care and Community Support
4. Patient Self-Management Support
5. Track and Coordinate Care
5. Electronic Prescribing
6. Measure and Improve Performance
6. Test Tracking 7. Referral Tracking 8. Performance Reporting and Improvement 9. Advanced Electronic Communications
The 2011 standards continue to involve a complicated evaluation and scoring system – likely to be a source of frustration for many physicians. Each standard includes several elements and each element is designated a specific number of points. Every element requires the practice to perform an evaluation, in the form of “yes” or “no” questions, of what services they are offering. Practices use the answers to these questions to score themselves.
28 California Family Physician Spring 2011
Evaluation: The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for: 1. Providing same-day appointments 2. Providing timely clinical advice by telephone during office hours 3. Providing timely clinical advice by secure electronic messages during office hours 4. Documenting clinical advice in the medical record.
Practices that previously achieved NCQA accreditation, using earlier standards, were accredited for three years. That accreditation is still good for the duration of the three-year period. NCQA is also accommodating those practices that relied on earlier standards and are in the process of transformation, data collection or documentation by permitting the use of the 2008 standards throughout 2011.
Prominence of Patients
The 2011 standards direct practices to organize care according to patients’ preferences and needs. The standards emphasize collaborating with patients and their families in the delivery of care and increasing access to care during and after office hours. The standards reward practices that provide services in patients’ preferred languages, support patient self-care and integrate community resources. There is a focus on integrating behavioral health care and care management. Additionally, patients and their families are involved in quality improvement.
Beginning in January 2012, NCQA will offer additional points based on reporting results from a standardized patient experience survey. Practices will be invited to use the Medical Home version of the Consumer Assessment of Healthcare Providers and Systems Survey (currently in development and sponsored by the Agency for Healthcare Quality and Research in collaboration with NCQA). Practices can earn NCQA Distinction for collecting data using the survey and reporting the results to NCQA.
HIT: Integral to PCMH
Another highlight of the new standards is their alignment with the federal electronic health record (EHR) incentive programs. Meaningful Use language is embedded in the 2011 standards, encouraging practices to adopt EHRs. For example, in the area of enhancing access and continuity, the standards look at whether and how information and services are provided to patients and their families through secure electronic systems. The standards are used to evaluate whether patients have electronic access to their current health information (such as lab results or medication lists) and can request electronic copies of their information. For identifying and manag-
ing patient populations, the standards evaluate whether practices are using electronic systems to record areas such as allergies, blood pressure and prescription medications. While the new program aligns closely with the incentive programs, NCQA recognition and Meaningful Use are not synonymous; family physicians need not achieve Meaningful Use to be an NCQAaccredited PCMH and vice versa. Rather, there is significant overlap.
Departure from the Joint Principles
One criticism of the 2011 standards is their departure from the Joint Principles of the PCMH developed by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association. The NCQA dropped the requirement for attestation to the Joint Principles and has moved away from the principle of a physician-directed PCMH. NCQA has dropped “Physician Practice Connections” from the title of the accreditation program and refers to clinicians, rather than physicians, throughout. Non-physician "primary care clinicians" can qualify for NCQA accreditation.
PCMH CORNER Take Home Message
NCQA is perhaps the most prominent of those developing standards for PCMH. Almost 7,700 clinicians at more than 1,500 sites across the United States have used earlier NCQA standards to receive recognition as a PCMH. A search on the NCQA Web site reveals 153 California physicians and practices with NCQA PCMH recognition. The NCQA should be lauded for the dissemination of the PCMH model that will undoubtedly result in improved quality, increased access and decreased costs. NCQA did an admirable job of incorporating patient-centeredness and HIT. The NCQA made an effort to streamline its evaluation process and has certainly moved in the right direction. The organization failed, however, to preserve its connection to the Joint Principles, a regrettable departure from the perspective of family physicians. The PCMH standards are available on the NCQA Web site (http://www.ncqa.org/ tabid/631/Default.aspx) at no cost and practices can call NCQA at 888-275-7585 for more information. Leah Newkirk is CAFP’s Director of Health Policy.
Cuba < 21
Americans in medical school in Havana … the basic MD salary is $20 per month (nurses earn $18), though all education and housing are free; food is subsidized and the role of a physician is highly respected. Students must be selected by their neighbors to go to medical school. Specialists all start as FPs. If they are so inclined, they get more training after two years of mandatory service, but they don’t earn any more for doing so. Also, there is less freedom to choose where you want to work, especially during the two years of service owed to the government post-graduation. Physicians supplement their incomes in various ways, such as driving a cab for European and South American tourists. Some remain working abroad following their overseas assignments, though such a move may divide a family. In fact, family separation is the
most important behavioral health issue in Cuba, whereas in the US substance abuse and economic woes top the list. So what do we have to learn from their model? First and foremost, the Cuban system demonstrates that when there is “will + ideas + execution” amazing results can be achieved even in the absence of resources. From the perspective of population health management, the Cuban system is essentially a Caribbean version of Dr. Ed Wagner’s Chronic Care Model, but fully deployed across an entire country’s population (11 million people): neighborhood-based primary care, peer health outreach workers, risk stratification of the population with systems to prevent patients from falling through the cracks, and an emphasis on individual behavior over medications.
And, yes, all care is free. We met a man who worked at an espresso bar in Havana; he survived a car accident and had had eight surgeries to repair lacerated organs and broken bones – for free. His brother, now living in Miami, was simultaneously facing bankruptcy following multiple surgeries from yet another motor vehicle accident in the States. He had apparently emigrated, as do most who leave Cuba, in order to have more disposable income, own a fast car and a big house, and experience the consumer society in all its glory. Over an espresso laced with aged Cuban rum, the man told us that he felt lucky to have stayed home. Alan Glaseroff, MD is a rural family physician in Arcata, CA. He will join the CAFP Board of Directors as Rural Director on May 14. California Family Physician Spring 2011 29
Susan Hogeland, cae
EXECUTIVE VICE PRESIDENT’S FORUM
Commonalities Between PCMH And Your Mom
hile the political scene continues in turmoil over proposals to rescind the Patient Protection and Accountable Care Act (successful vote in the House of Representatives; unsuccessful vote in the US Senate), and the judicial count is two for unconstitutionality and two against, efforts to get to the heart of the cost and quality issue in health care continue to tap into physicians’ commitment and creativity to develop solutions.
Centers for Medicare and Medicaid Services, said only 10 percent of an individual’s health status is due to health care interventions. Dr. Gawande’s article and Dr. Brenner’s experience support that contention. In the article, Dr. Brenner says: “My philosophy about primary care is that the only person who has changed anyone’s life is their mother. The reason is that she cares about them and she says the same thing over and over and over.”
One of my favorite writers, Atul Gawande, MD had yet another winning article in The New Yorker magazine on January 24: “The Hot Spotters: Can we lower medical costs by giving the neediest patients better care?” As my Baby Boomer generation starts applying some of the greatest demand ever seen for Medicare services, I’m hoping the answer to Dr. Gawande’s question is “yes, we can.”
Remember that part about growing up? “Eat your vegetables … Wash your hands … Brush your teeth … No more candy!” It isn’t the kind of thing most physicians and other health care professionals think is their job – but it can be an effective corollary to the work they do when provided as part of the PCMH through professional health coaches.
Dr. Gawande tells the story of a family physician in Camden, New Jersey who epitomizes the best of the Patient Centered Medical Home (PCMH) concept. Dr. Jeffrey Brenner took lessons he learned about community policing and Compstat (statistics used in mapping crime and focus resources where they’re needed most) and applied them to health care. For example, he gathered data about hospitalizations for specific types of injuries and determined that residents of a single apartment build ing in central Camden accounted for 57 admissions for fall injuries – $3 million in health care expenses. He also identified some high utilizing individuals; Dr. Gawande writes: “Just one patient had 324 admissions in five years; another cost insurers $3.5 million!” When he spoke a few months ago at San Francisco’s Commonwealth Club, Don Berwick, MD, Administrator of the 30 California Family Physician Spring 2011
Dr. Brenner targeted the highest utilizers in the belief that lowering their utilization and costs would lower Camden’s costs, where one percent of the 100,000 health care facilities utilizers were responsible for 30 percent of the costs. Barriers to good health included addiction, unemployment, disability, no insurance and inadequate housing – usually “symptoms” beyond the scope of most physicians. Having a usual source of care also played a role. Care for such patients required a social worker, religious support and better housing among other services, the kind of services to which a PCMH can help patients connect even though most are entirely outside the current definition of health care. We hope articles such as Dr. Gawande’s and experiences such as Dr. Brenner’s will convince health plans and government payers that a PCMH management fee is necessary to make the greatest impact on galloping health care costs. Gain sharing as a result would also be highly
desirable. And, it seems to me, that family physicians are among the doctors who care most about their patients and are positioned perfectly to catalyze the metamorphosis of our health system beyond procedures and visits alone. Dr. Brenner obtained foundation grants to test his concept of care for these high utilizing patients, a concept he says “is about building relationships with people who are in crisis.” He’s not delusional; it only works about 50 percent of the time, but still has a huge beneficial cost impact. It’s also likely that most family physician offices would have a relatively low proportion of patients such as those Dr. Brenner is helping, but there are great lessons for everyone in his experience: caring has to go beyond the visit; patients need support to make serious behavioral changes (and usually not from disembodied consulting companies that provide case management from another state); some patients may need much more intensive assistance than others, and it’s possible special programs need to be devised just for them. We’ve seen successes in similar programs for disenfranchised patients in the past. For example, Dr. America Bracho’s promatores program has been a model for years of an on-the-ground care system to help patients do their part in ensuring their own good health. Alan Glaseroff, MD’s article in this issue about health care in Cuba is another example – health workers make visits to remind patients about care they need, such as mammograms, and address the barriers to getting such care. This is perhaps the most exciting time in family medicine and the health care system during my tenure with CAFP. There’s no one way to make these changes, but there are many proven ways. Let’s do this!
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