California Family Physicians magazine (Winter 2011)

California

FAMILY PHYSICIAN VOL. 62 NO. 1 Winter 2011

OVERVIEW OF HEALTH CARE REFORM WORK TO SUPPORT FAMILY MEDICINE 22 IN NEW HEALTH CARE REFORM ENVIRONMENT IS JUST BEGINNING MYTHBUSTERS…THE PPACA EDITION 23 WHAT HEALTH CARE REFORM MEANS TO FAMILY PHYSICIANS AND THEIR PRACTICES

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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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tion istra e 15 g e R g , pa Info

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1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org

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

Staff Cecilia Awayan

Sophia Henry

Chris Navalta

Receptionist and Membership Administrator

Membership Manager

Manager of Publications and Marketing

Susan Hogeland, CAE

Leah Newkirk

Executive Vice President

Director of Health Policy

Cynthia Kear, CCMEP

Tom Riley

Senior Vice President

Director of Government Relations

Callie Langton, MPA Associate Director of Health Care Workforce Policy

Shelly Rodrigues, CAE, CCMEP Deputy Executive Vice President CAFP Foundation Executive Director

Cody Mitcheltree

Marian Yee

Student and Resident Coordinator

Director of Continuing Medical Education

cafp@familydocs.org Karen Brent, MBA Director of Information and Technology

kbrent@familydocs.org Jane Cho Manager of Medical Practice Affairs

jcho@familydocs.org Adam Francis Assistant Director of Government Relations

afrancis@familydocs.org

shenry@familydocs.org

shogeland@familydocs.org

ckear@familydocs.org

clangton@familydocs.org

cnavalta@familydocs.org

lnewkirk@familydocs.org

triley@familydocs.org

srodrigues@familydocs.org

cmitcheltree@familydocs.org myee@familydocs.org

California FAMILY PHYSICIAN VO L . 6 2 N O . 1 • W i n te r 2011

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 e-mail lianaking@gmail.com.

Refer a Colleague Get a Bobble Head!

See pg. 17

O VERVIEW OF HEALTH C ARE REFORM 22 Work to Support Family Medicine in New Health

Care Reform Environment Is Just Beginning

AAFP President Roland Goertz, MD, MBA

23 Mythbusters … The PPACA Edition

Carla Kakutani, MD

24 Roll Call: What Health Care Reform Means to Family Physicians and Their Practices 26 An Explanation of How PPACA Affects Funding for Medical Education Callie Langton, MPA

Physicians Prepare for Practice

6 Editorial Health Care Reform Has Given Family Physicians a New and Level Playing Field 7 President’s Message With New Year, Health Care Reform’s Next Phases Begin 8 Guest Editorial Setting the Record Straight on Primary Care

Michelle Quiogue, MD

Jack Chou, MD Nathan Hitzeman, MD

10 Political Pulse 2011Kicks Off With Some Game Changers

Tom Riley

11 QI Corner C4 Graduation: Another Step Toward Improving Office Practices

Jane Cho

12 Resident News How to Use EBM in a Clinical Setting

Tipu Khan, MD

13 Student News Preceptorship Program Reinforced My Love for Family Medicine

Jennifer Farah

14 News in Brief

15 CME Calendar 16 In the Spotlight CAFP Members Continue to Have Their Voices Heard

Chris Navalta

17 Membership Refer a Colleague – Get a Bobble Head!

Sophia Henry

18 PCMH Corner Accountable Care Organizations: Are They Family Medicine’s Friends – or Foes? Leah Newkirk 20 Practice Management News Responding to a Medical Records Audit Program 30 Executive Vice President’s Forum Let’s Make the Most out of Health Care Reform Law

Mary Jean Sage Susan Hogeland, CAE

California Family Physician Winter 2011

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EDITORIAL

Michelle Quiogue, MD

Health Care Reform Has Given Family Physicians a New and Level Playing Field

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his fall marked a historic milestone for America’s new patient-centered health care system, a system founded on the principles of primary care. The rules of the game changed to allow more American citizens access to achieve their full potential with minimal disability and loss of productivity from preventable diseases. This fall, the doors opened onto a level playing field where we must maximize delivery of our current medical knowledge and resources to all of our patients, not just those who can afford it.

Do we know the new rules of the game? Can we coach our patients and help them to understand their newly-won rights? Will we reach for every new opportunity to capitalize on the transformation of our practices into Patient Centered Medical Homes?

rules but exempt from others. Beginning on September 23, 2010, grandfathered employer plans will be required to eliminate any lifetime limits on coverage and restrict any annual limits on coverage, eliminate pre-existing condition exclusions for children, and if the plan provides dependent coverage, extend that coverage to adult children up to age 26. Beginning in 2014, grandfathered employer plans will be required to eliminate any annual limits on coverage, eliminate preexisting condition exclusions for adults and limit waiting periods for coverage to no more than 90 days. Grandfathered employer plans will not, however, be required to alter their benefits to meet the new minimum benefit standards nor will they have to limit enrollee cost sharing or provide coverage for preventive services with no cost-sharing. In order to maintain its grandfathered status, a plan cannot reduce nor eliminate benefits to treat particular conditions, increase employee cost-sharing (including deductibles, co-insurance and co-payments) above certain thresholds, reduce the employer share of the premium cost, or change insurers. Once a plan loses its grandfathered status, it will have to comply with all the new rules [which] requires new health plans to provide at a minimum coverage without cost-sharing for preventive services rated A or B by the US Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women.” (emphasis added)

Our patients will While we remain deeply divided on issues naturally turn to us such as taxes and socialized medicine, we are united by our commitment to help our for advice and patients achieve optimal health. While the CAFP and AAFP continue to promote guidance regarding health our professional interests and seek a permanent fix for the Medicare payment insurance changes, and formula, we would never sacrifice our patients’ interests to win self-serving we want you to turn to gains. Besides, when patients find it is easier and more affordable to see their your Academy for the family doctor, we all win. Family doctors understand their patients and know where information you need they are coming from. Family doctors know best how to tailor clinical guidelines to fit each to help them. patient. Family doctors know best how to give rational – not rationed – care.

Because the 2010 Patient Protection and Affordable Care Act (PPACA) makes it easier for patients to access primary care services, I take a minute at the end of each visit to empower the patients I know will benefit the most. To the 50-year-old woman who refused to have her colon cancer screening test done last week because the $200 co-pay was prohibitive, I urged her to let her employer know that her current health plan obstructs her path to health and that changes in the law now prevent such obstacles in new health plans. I believe my patient would benefit from the elimination of co-pays for preventive services if her plan lost its “grandfathered status.” According to the Health Reform Source page on the Kaiser Family Foundation’s website: “Employer plans that were in place on March 23, 2010, the date the new health reform law was enacted, are referred to as “grandfathered plans” and are subject to some of the new

As of January 1, our Medicare patients now have increased access to preventive services as well. We are not the only ones who will benefit from the 10 percent Medicare bonus payment for primary care services. The PPACA also eliminates cost-sharing for Medicare-covered preventive services that are recommended (rated A or B) by the U.S. Preventive Services Task Force and waives the Medicare deductible for colorectal cancer screening tests.

Our patients will naturally turn to us for advice and guidance regarding health insurance changes, and we want you to turn to your Academy for the information you need to help them.

To that end, there are easy-to-read FAQs and implementation timelines in this issue of California Family Physician. To find additional links to national resources about the Patient Protections and Affordable Care Act, visit CAFP’s Health Care Reform page Editorial > 28

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California Family Physician Winter 2011

Jack Chou, MD

PRESIDENT'S MESSAGE

With New Year, Health Care Reform’s Next Phases Begin

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n the last day of the 2009-10 legislative session at 5:45 am, Assemblyman Dave Jones (pictured) stood ready, holding a bill he authored on behalf of family physicians. The bill had survived the grueling legislative process and the year’s historic budget impasse, after having made its way through the Assembly and then the Senate earlier, and had become an urgency measure. It was up for reconsideration at the Assembly after the crucible of the Senate’s various committees. It had taken a village of lobbyists, a surprising coalition of unusual suspects, to get the bill that far.

Assemblyman Jones had been waiting patiently for an entire, sleepless night as the Assembly wrapped up its final budget approval process. He was assured by his staff and colleagues on his side of the aisle that he had enough votes. He was poised to launch his arguments for why it was important for California to have a definition of the Patient Centered Medical Home codified as state law. At last, it was his turn.

Then … the loud, cracking sound of the gavel as the Speaker signaled the closing of the legislative session for good. The Assembly chamber echoed with noise of papers rustling and briefcases snapping, interrupted by chairs squeaking as legislators got up to leave. Perhaps the prolonged session tired the Speaker and took the spirit out of the Assembly. Perhaps some members were focused on the upcoming election, after which some would not return. Perhaps there had been silent consent by the usual suspects for this item to die an unnatural death. All that remains was a bill, orphaned by the legislative process, looking for a new sponsor in the next legislative session. And it must be reintroduced.

The bill defines what the basic primary care framework for any meaningful health care reform effort must contain. It sets a foundation of sustainable primary care practices dotted among disparate communities across diverse populations in California. It creates the expectation that all Californians deserve a primary care physician who will provide care in a quality, comprehensive and coordinated manner. And it will be reintroduced at the next legislative session.

Results of the recent mid-term election had many Federal Congressional districts changing colors. It sent the political

establishment a message: to react with sound bites of collaboration or else, gridlock. The rhetoric of repealing the Affordable Care Act began as soon as Tea Party freshmen claimed early victories. But the political reality is that the nation is evenly divided about its feelings toward health care reform, with the majority in favor of many specific provisions in the law. With Democrats still in control of the White House and Senate, it is extremely unlikely that the entire law will be repealed, since many of the popular provisions had been implemented or funding appropriated.

We must continue to be vigilant about the unintended consequences of regulations or amendments associated with this law. The law in its existing form is far from perfect. To quote AAFP past president Rich Roberts, “This is the beginning of the beginning.” We will be tempted by people who offer the sustainable growth rate fix as an alternative to permanent and substantive enhancements to primary care payment reform. We will be enticed by promises of national tort reform that bring benefits to states currently without such reform, but we must defend the stringent protection that the Medical Injury Compensation Reform Act (MICRA) has afforded California physicians since 1975. We will be pressured by our nursing colleagues, who gained a second wind with the recent release of the Institute of Medicine’s Future of Nursing report opening the door to equating nurse practitioners with family physicians. Under the threat of a nurse who obtained a PhD in nursing calling himor herself a doctor nurse, we should continue to assert the fact that nurse practitioners are an integral part of our health care delivery landscape. However, they will never substitute for the primary care physician’s depth and length of training, or expertise at diagnosing and treating the undifferentiated patient.

As we move closer to many of the implementation milestones of the health care reform law, we will be forced to step out of the comfort zones of our existing medical practices. Many of us were not trained as savvy information technologists, nor were we trained as entrepreneurs with advanced business management degrees. We will have to deal with an unfamiliar lexicon of three-letter acronyms, from decisions about HIT (Health Information Technology)implementation and participation with RECs and LECs (Regional and Local Extension President's Message > 28

California Family Physician Winter 2011

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GUEST EDITORIAL

Setting the Record Straight on Primary Care Editor’s Note: This article was first published in the May/June 2010 issue of Sierra Sacramento Valley Medicine magazine.

We thank SSV Medicine for reprint permission.

However, here is the silver lining. I know my patients like no one else, and they confide in me like they would no one else. I see children, adults and advanced elderly patients.

ecently, I was dismayed to read a commentary on primary care by a UC Irvine second year medical student in my local medical society journal.� The author makes blanket assumptions and generalizations about primary care that I do not think are accurate. The comments reflect continued disparagement of primary care in multispecialty, heavily NIH-funded universities.

I am often the first person patients tell about marital problems, erectile dysfunction, depression, abuse and “this thing that has been growing on my side.” I get to do the detective sleuth work to uncover cancers and other diseases. I get the satisfaction of knowing I have done preventive care that will keep Mr. Jones from dying of colon cancer or pneumonia.

As a family physician, I have seen a number of highly intelligent and motivated students go into primary care. However, interest in primary care among US medical students has waned over recent years. This phenomenon has many of us fearing an impending primary care shortage and health care crisis. It also leads us to wonder why so many students enter medical school with primary care aspirations – but exit with intentions otherwise.

I smile inside and out when I pat my kiddos on the head as they get their stickers after their shots and I feel like a faith healer after resetting a nursemaid’s elbow. Like the very first health providers in history, I enjoy the time-honored acts of lancing boils, splinting limbs, removing ingrown toenails and cutting out skin growths.

R

I fear that in many areas of the country there are missed opportunities for supporting quality teaching venues for family medicine. That is unfortunate as family doctors account for more than 95,000 of the 788,000 active doctors in the US (second only to IM docs) and family physicians field 22 percent of all ambulatory patient visits – more than any other specialty.�,�,� Generalist IM docs field 17 percent of all ambulatory visits, but it is a field in unfortunate decline. Only 10 percent of first year IM residents end up choosing primary care and that number is probably dropping as we speak.� So why does family medicine get badmouthed at many universities? Is it because we couldn’t possibly have a grasp on the whole human body (“jack of all trades, master of none” theory).

Is it because others think that we only treat colds and fill out forms (“monotony” theory)? Or is because we do not make as much money as specialists (“prestige” theory)?

I say it’s time we set the record straight on family medicine’s place in the medical community. Every specialty has its dirty laundry. GI docs loath the poor bowel prep. Emergency medicine docs deal with a disproportionate number of psychiatric and substance abuse patients whom they lack the tools to cure.

Surgeons grimace at the repeat small bowel obstruction, and, furthermore, they don’t get to sit down very often. Dermatologists see more neurodermatoses than they would like. And ENT docs probably see even more snotty noses than we do!

As for my dirty laundry in family medicine, I see more chronic pain patients and fill out more disability paperwork than I would like. During the winters, yes, there are a lot of coughs and colds. I am also losing the war on obesity which seems to pervade most medical issues I encounter.

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California Family Physician Winter 2011

I enjoy other office procedures like joint injections, vasectomies, circumcision, colposcopy and some limited endoscopy procedures. I also do home visits, inpatient care, nursing home care and urgent care clinic shifts to keep those skills up.

Furthermore, many specialists know family doctors as the hub of their patients’ care and often consult us on a course of action.

My Latino patients often bring me homemade treats like crispy tacos and an elderly patient knits mittens for my daughters. I attended a patient’s 100th birthday party this past September. I enjoy seeing my patients at the local grocery store or in the park.

I do not live in a gated community nor do I drive a pretentious car, but I make a comfortable living.

No one day is ever the same. I have removed a spider from a kid’s itchy ear, looked at a urinary stone stuck just inside the opening of a man’s urethra, and had to perform CPR on a man who dropped dead in our waiting room. Using counseling and medication, I have helped some folks keep their jobs and their sanity.

My medical instruments are often my head and my hands when I volunteer abroad – where antibiotics, sanitation education and oral rehydration fluids go much farther in helping people than high tech approaches.

In my medical group, I am proud to say that I have family medicine colleagues who are experts in HIV care, alternative and complementary medicine, women’s health, hospital care, sports medicine, occupational health, travel medicine, health care policy, and electronic medical records.

On medical missions, I have seen many volunteers from family medicine. The field lends itself well to humanitarian efforts.

And yes, here at home we work long days and have busy clinics.

However, with the growing need for primary care docs, more of my colleagues are able to negotiate job sharing or working part time to balance their work with family.

It is true that primary care docs do not earn as much as other specialists. (Salary breakdowns among specialties can be found online.�) This pay differential between primary care physicians and specialists has been cited by doctors from the RAND Corporation as one of the biggest factors dissuading US medical students from going into primary care.� These physicians have stated in no uncertain terms that any viable health care reform that is economical and sustainable must lessen this disparity.

I also find it interesting that whenever health care reform talk comes around, my family medicine colleagues are often the first to embrace change that would ensure more access to health care even if it threatens their personal payment.

To students out there, take heed, if your goal is the pursuit of ghastly amounts of money (which I’m sure you did not mention on your personal statement), then family medicine may not be for you. But if you want to make a comfortable living, help a lot of people and have lifelong job security and practice versatility, then family medicine may be for you!

Still the larger disparity in pay between primary care docs and specialists in this country as compared to other countries does give the perception that primary care must not be as valued. Let’s look at why this disparity exists.

To students: here is the wizard behind the curtain. The Centers for Medicaid and Medicare Services (CMS) assigns values to everything in medicine from talking with patients for 15 minutes to removing their spleen. The value is called a relative value unit (RVU) and it is the form of currency, so to speak, used in health care. When the CMS assigns or revises the number of RVUs for a procedure or office visit, health insurance companies follow suit.� So who assigns the RVUs? A little known panel called the Resource-based relative value scale Update Committee (RUC) meets regularly to revise the RVUs and

Nathan Hitzeman, MD

CMS, in turn, often rubber stamps their recommendations.

Who sits on the committee? Of the 30 members, 23 are appointed by “national medical specialty societies.”� Meetings are not open to the public and only three seats rotate on a two-year basis. Not surprisingly, specialty procedures are weighted with many more RVUs than visits spent talking with patients and managing medication.

Is it any wonder that some doctors are happy to stent, inject, scope, biopsy and serially image a condition? They can make numerous times the income doing several procedures in an hour at hundreds of dollars a pop rather than talking to one patient at length about his or her symptoms?

This is not to say that these docs are not good people; it’s just that the action will follow the payment. And it will continue to do so as long as the RUC is biased toward specialty groups or until quality evidencebased medicine debunks some of these practices – as it has for elective heart caths, renal artery stenting, arthroscopy for knee arthritis, vertebroplasty and various other expensive back pain interventions.

It concerns me that the medical student’s article that irked me came from a publically- funded school. I have worked closely with students from various medical schools around the country. Disparaging comments about primary care seem pervasive in medical school training. Every school wants to portray itself to the public as “primary care friendly.” It’s much sexier to say they care about the whole patient than to say they are a “liver-friendly” school or a “prostate-friendly” school.

But in many parts of the country, students inside the school walls are somehow getting a different message – a message that primary care is not stimulating or rewarding. Comments such as these are neither fair nor constructive in improving our nation’s health care.

Shouldn’t we be nurturing primary care at our medical schools rather than just giving it lip service to the public? More than 30 million Americans will soon receive health insurance under President Obama’s health care reform law, and they will now be seeking primary care at a doctor’s office rather than at an emergency department.

Furthermore, epidemiological research

by John Wennberg out of Dartmouth and others shows that populations are healthier in parts of the US where there is lower cost health care and a high ratio of primary care physicians to specialists.�,� Therefore, medical schools should build more bridges with the community to develop innovative ways to promote primary care – in addition to fostering mutual respect among the medical fields. Students need to get a more consistent and honest message.

For all you students who read this journal, don’t be jaded by others who disparage primary care. Dare to be different. Dare to treat the whole patient.

You are not too smart for primary care.

Primary care is a lifelong learning experience. You can never be too smart for it. It is a great, challenging, and rewarding way to help people – many people – and isn’t that what we all said in our personal statements?

Nathan Hitzeman, MD is a faculty physician from Sutter Health Family Medicine Residency Program in Sacramento and a member of CAFP’s Communications Committee.

REFERENCES

� Marshall, Janelle. A new approach to primary care shortages. Sierra Sacramento Valley Medicine. March April 2010. [www.ssvms.org] � American Board of Medical Specialties (ABMS).

Certification history: ABMS Member Board general certificates issued by decade, 1930-2007. In: ABMS Annual Report and Reference Handbook. Evanston, IL: American Board of Medical Specialties Foundation; 2008:1, 8.

� Staiger DO, Auerbach DI, Buerhaus PI. Comparison of Physician Workforce Estimates and Supply Projections.

JAMA. 2009; 302(15):1674-1680.

� Cherry DK, Woodwell DA, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2005 Summary.

Advance Data. 2007; 387. http://www.cdc.gov/nchs/ data/ad/ad387.pdf

� Goodson JD. Unintended Consequences of ResourceBased Relative Value Scale Reimbursement. JAMA. 2007;298(19):2308-2310.

� http://www.cejkasearch.com/compensation/amga_ physician_compensation_survey.htm

� Brook RH, Young RT. The primary care physician and health care reform. JAMA. 2010; 303(15):1535-1536.

� www.dartmouthatlas.org � Starfield, B et al. The effects of specialist supply on populations’ health: assessing the evidence Health Aff (Millwood). 2005 Jan-Jun; Suppl Web Exclusives:W597-W5-107.

California Family Physician Winter 2011

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POLITICAL PULSE

Tom Riley

2011 Kicks Off With Some Game Changers

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hange is afoot. This month, majority control of the US House of Representatives will switch. California will have a new governor, lieutenant governor, insurance commissioner, attorney general and state superintendent of public instruction. More than a quarter of the seats in the 120-member California State Legislature will be filled by new lawmakers.

New leaders in Sacramento will be eager to break from the last four years of political rancor fueled by our state’s budget crisis and shrinking economy. Can they succeed? In November, voters approved several measures which could make profound differences in the way state health care spending is negotiated. Although Proposition 25 removed the two-thirds majority requirement to approve a budget, Prop. 26 institutes that very requirement to pass fees. The effects of Prop. 26 will be felt most by counties that rely on such fees

to fund important programs – including fees that may directly or indirectly offset health care costs.

One might think the end of the two-thirds requirement, coupled with a Democratic governor, would mean California is returning to an era of increased spending on public programs via the state’s General Fund. This seems unlikely. Instead, Governor Jerry Brown will face increased pressure to exercise fiscal discipline. Like Governor Arnold Schwarzenegger before him, Governor Brown may straddle the thankless abyss between the expectations of his own party and the political threats of his adversaries.

The Centers for Medicare and Medicaid Services’ (CMS) recent approval of California’s Section 1115 Medicaid Waiver will also affect the 2010-11 political landscape.

Just as Prop. 26 will make it more difficult for county governments to generate

CAFP Wins Friend to Family Medicine Becomes New CA Insurance Commissioner Assembly member Dave Jones (D - Sacramento), who authored

CAFP’s bill to define the Patient Centered Medical Home, was elected last November in the race for Insurance Commissioner. Mr. Jones has shown a strong commitment to primary care and will play an instrumental role in how the new federal health care reform law is implemented in California.

Two Physicians Elected to the State Assembly

Last November, for the first time in recent history, a primary care physician won an Assembly seat. Pediatrician Richard Pan, MD will be the new Assembly member in Assembly District 5 (D - Sacramento). General surgeon Linda Halderman, MD (R Fresno) is also headed to Assembly. Both physicians were elected for the 2011-12 legislative session. Family physicians met with these candidates throughout the election cycle to express their support for their campaigns and CAFP looks forward to having a stronger voice of medicine at the capitol.

CAFP Member Appointed to National Healthcare Workforce Commission CAFP member Kathy Flores, MD of Fresno has been appointed to

the National Healthcare Workforce Commission (CAFP was one of the organizations that nominated Dr. Flores to the commission through the Office of Statewide Health Planning and Development). The commissioners were selected by the US Government Accountability Office and will serve as advisers to Congress, the White House, and state and local governments on expanding, preparing, and sustaining the nation’s health care workforce.

needed revenue, the Waiver will make it easier for some counties to care for their patients. Historically, counties have been the payers of last resort for many patients, including indigent populations or those without coverage for mental health services. The new Section 1115 Waiver, a five-year agreement between state and federal government to care for the sickest Medi-Cal patients under a $10-billion federal block grant, will allow counties to draw down federal dollars to pay for mental health services, care for chronic conditions and other community health care needs. New county-organized entities and global payment models may emerge for treating the Medi-Cal SPD (Seniors and People with Disabilities) populations and Medi-Cal/Medicare dual-eligibles.

These new models may or may not fit well with federal reform constructs such as Accountable Care Organizations and medical homes, and more importantly, they may or may not result in better care. All the key operational details remain to be worked out, either in regulation or follow-up legislation; CAFP will be engaged in the process every step of the way.

Implementation of the federal Patient Protection and Affordable Care Act (PPACA) looms large. Will the Congressional Republicans succeed in repealing large or small provisions? Or does the fact that nearly 75 percent of the funding for the Act has been appropriated mean that it will proceed more or less intact? Certainly, reform will be under debate in all statehouses, including Sacramento’s, which will, unlike elsewhere, be under solid Democratic control. Will California be among the first to launch its individual insurance exchange?

Or will insurers’ willingness to participate be affected by the reluctance of other states to launch their own? And even if the Democratic governor and legislative majority pursue the more costly parts of the reform, such as expanding the Medi-Cal roll by another 1.8 million people, will the numbers pencil out for the period just a Political Pulse > 28

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California Family Physician Winter 2011

QI CORNER

Jane Cho

C4 Graduation: Another Step toward Improving Office Practices

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AFP finished its Capacity-Building Collaborative (C4) with a final learning session in October. Six family physician practices gathered at The California Endowment Los Angeles office to celebrate their 18-month commitment to collaboratory work to improve quality of care, reduce cost and improve patient, physician and staff satisfaction. The C4 initiative engaged graduates from our chronic care collaboratory, New Directions in Diabetes Care, in a curriculum designed to introduce the elements of the Patient Centered Medical Home (PCMH). The curriculum was composed of modules that included revenue cycle management, operational efficiency, care coordination and access and communication. Some of the topics covered during the monthly learning sessions included process mapping, accounts receivable (A/R) analysis, automation, improving referral relationships and streamlining workflow.

Catherine Tantau led the C4 graduation with a presentation on PCMH. She emphasized how the C4 Collaboratory prepared practices to become a medical home and adopt health information technology. The table at right shows how the C4 curriculum lined up with the National Committee for Quality Assurance’s (NCQA) standards for PCMH. Every learning session topic matched a PCMH standard. During team discussion, one of our teams, led by Shel-

don Zitman, MD of Cupertino, shared how it worked toward and achieved NCQA Level 1 recognition as a medical home.

The second half of graduation was dedicated to Health Information Technology (HIT) and its effect on family medicine.

Ms. Tantau focused on the specific applications of HIT such as patient portals, e-prescribing and online appointment requests. The agenda provided additional time for team discussion on the most efficient way to use technology. One practice team, North Coast Family Medical Group (NCFMG) led by Richard Payne, MD, implemented a virtual office system in January 2010. Thousands of patients have since signed up for the free patient portal, and the technology has proven to be a major time saver for the office staff. Office manager Charlotte SeaborC4 Match CAFP Capacity Building to PCMH Collaborative: Covered Topic Standard Access Process Improvement, Flow Mapping Financials Automation Care Coordination, Care Management Improving Referrals Patient Risk Stratification Streamlining Patient Flow Optimizing Care Team Provider, Team, Patient Satisfaction

1, 8 8, 8, 2, 5, 6, 9 3 7 2, 4 8 3 8

ough attended graduation and shared NCFMG’s experience in “going live” with the other practices eager to learn about the process. All team members contributed during the discussion and offered each other feedback on their experiences with e-prescribing, fax-prescribing, virtual office visits and more.

CAFP is proud of its graduates. We hope that by participating in the C4 Collaboratory, teams have improved their ability to implement systematic improvements in their office practices. One Collaboratory team received recognition as a medical home during the year, and we know it will only be a matter of time before the other teams are recognized as well.

Jane Cho is CAFP’s Manager of Medical Practice Affairs.

NCQA PCMH Standards 1: Access and Communication 2: Patient Tracking and Registry Functions 3: Care Management 4: Patient Self-Management Support 5: Electronic Prescribing 6: Test Tracking 7: Referral Tracking 8: Performance Reporting and Improvement 9: Advanced Electronic Communications

From left to right: Mina Olivares, Elizabeth Serrano, Craig Endo, MD, Cecile Dahlquist, FNP, Kim Lowrey, Linda Perry, Sheldon Zitman, MD, Gloria Avila, Monika Galluccio, Fred Galluccio, MD, Charlotte Seaborough, Josephine Soliz, MD, Linda Lundeen, MD, Donna Davis and Catherine Tantau.

California Family Physician Winter 2011

11

RESIDENT NEWS

Tipu Khan, MD

How to Use EBM in a Clinical Setting

Since then, theoretical EBM has become a key part of medical school curricula across the nation. Enacting EBM in a clinical practice is not practically taught in most medical schools, leaving it for individuals to learn during residency and practice. Thus, we will briefly delve into how properly to use EBM in clinical practice – for both the resident and practicing clinician.

EBM sources should come from reputable journals. That said, it is virtually impossible for a full spectrum family physician to keep up-to-date on all of the appropriate journals. One way to

Processing EBM Data Outcome

Outcome

–

Risk of Outcome

A

B

Y=A /(A+B)

+

Treatment Group (Y)

Above: the Positive Predictive Value

Identify your question

12

C

D

Y=A /(A+B)

Critically evaluate

stay up to date is by subscribing to services such as Journal Watch, POEMs and DynaMed, which summarize the most relevant/significant articles from the different sub-specialties. Another option is to use search engines such as PubMed, Google Scholar, Scopus, or Web of Science to track down the primary source.

The importance of EBM is multifold: to provide up-to-date care to patients and education for the provider and to lower the cost of deliver-

Modern medicine is a dynamic amalgam of clinical experience coupled with up-to-date knowledge of the medical literature. It combines anecdotal experience with lessons obtained from the scientific method to ensure the utmost quality in patient care. With a few simple steps, we can all ensure we are providing high quality evidenced based care to our patients in a systematic fashion – from the resident to the seasoned clinician alike.

Tipu Khan, MD is a resident at the HarborUCLA Family Medicine residency Program.

He is also the Vice President of External Affairs of the Resident Leaders of CAFP (R-CAFP).

RESOURCES FOR EBM 1. Centre for EBM: EBM worksheets and calculators including CATmaker.

This nifty program allows one to create "Critically Appraised Topics" for key topics one encounters for later distribution, review, or teaching. • http://www.cebm.net/index.aspx?o=1157 2. University of Alberta, EBM Toolkit: Worksheets for analyzing articles • http://www.ebm.med.ualberta.ca/EvidencePractice.html 3. JAMA EBM Toolkit: Worksheets for analyzing articles • http://www.jamaevidence.com/

Question

Is it specific?

Is there a known consensus on the answer?

Study Design

Is this study well formulated?

Is it randomized, concealed, blinded, or masked?

Patients

Are the subgroups analyzed?

Are confounders identified and stratified?

Do the subgroups have similar prognostic factors?

Results

Are the results clinically significant or relevant?

What percentage completed?

Have all statistically significant outcomes been addressed?

Clinical Application

Can the results be applied to my patients?

How will they affect my patients?

What is the harm/benefit profile?

Below: the Negative Predictive Value Control Group (X)

Does this apply to my patient

�

� Identify your resource

ing care by maximizing efficacy and universalizing standards of care.

Apply solution clinically

EBM Flow

�

he term Evidence-Based Medicine (EBM) was coined in the early 1990s by Dr. David Sackett and his colleagues at McMaster University in Ontario, Canada. Dr. Sackett described EBM as “The conscientious, explicit and judicious use of current evidence in making decisions about the care of the patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

�

T

How large is the final result pool?

Name

Likelihood ratio (LR)

Number needed to treat (NNT)

Relative risk (RR)

RR Reduction

Absolute RR

Sensitivity

Specificity

Equation

Pre-test probability x LR = post-test probability

1/(X-Y) OR 1/absolute RR

Y/X

1-Y(X x 100%)

X-Y

A/(A+C)

D/(B+D)

Application

How likely a person with a disorder is to have a given test result?

How many people must be treated to prevent 1 outcome? Up to 20-40=clinically effective

Pick of outcome in Y compared to X

Percent risk reduction in Y compared to X

Difference is risk between X and Y

Percentage of sick people identified as having the condition

Percentage of healthy people identified as NOT having the condition

California Family Physician Winter 2011

Jennifer Farah

STUDENT NEWS

Preceptorship Program Reinforced My Love for Family Medicine

W

hen I entered medical school, family medicine was at the top of my list of specialty choices. I was intrigued by the idea of working with a variety of health issues and age groups, as well as providing continuous care. But as the year went on, I began to doubt if being a family physician would be as fulfilling longterm or could provide the necessary income to pay back my student loans. Nevertheless, I decided to pursue a CAFP-F preceptorship to gain first-hand perspectives on the specialty. Fortunately, I received a stipend to participate in such a program.

I chose Ventura Community Memorial Hospital in Ventura, CA because their family physicians are trained in an array of skills, including surgical techniques, in addition to clinical practice. I was expecting this experience to dissuade me from exploring family medicine further, perhaps making my decision a bit easier. To my surprise, however, the summer I spent in Ventura piqued my interest tenfold.

Ventura, a small beach town, lies nearly an hour north of Los Angeles, nestled right off Highway 101. It was a welcome retreat from the bustling metropolis of downtown LA and a perfect place to witness family physicians at their best. What struck me the most wasn’t their medical prowess (although impressive), but how close they were with their patients. Many of their visits started with a firm handshake or warm hug and ended with a message to pass on to a mutual friend.

Before entering the examination room, my preceptors would usually brief me on the patient’s history. I was always impressed with how much they knew not only about their current medical condition, but also about their life stories – their hobbies, other family members and their usual response to doctor visits. I witnessed the care of everyday matters such as colds and upset stomachs, as well as difficult discussions on how to lose weight and the importance of adhering to a medication regimen. I was also surprised to have the opportunity to assist in deliveries and scrub in for surgeries – activities in which I never realized family physicians could regularly participate.

The most inspiring experience was seeing routine visits evolve into much more. A basic medical ailment would be met with a long discussion, sometimes on a completely unrelated matter, to ensure the patient’s peace of mind. And that’s when I realized the inherent art of family medicine – the balance of emotional healing and physical care. Rightly so, it’s the only specialty that’s named not after a body system or age group but a relationship – family. And that’s precisely what I experienced every day during my preceptorship, relationships forming and expanding through the medium of medicine.

Before the days when loan debt loomed and the threat of decreasing salaries became all the more real, I wanted to be the kind of doctor people counted on for more than a prescription. And thanks to my time in Ventura, I remembered why I initially fell in love with family medicine.

A basic medical

ailment would be met with a long

discussion, sometimes on a completely

unrelated matter, to ensure the patient’s peace of mind. And

that’s when I realized the inherent art of

family medicine – the balance of emotional healing and physical care.

Jennifer Farah is a second-year medical student at USC, Keck School of Medicine.

California Family Physician Winter 2011

13

NEWS IN BRIEF CAFP Loses a Past President CAFP is sad to announce the recent death of Hubert (Hugh) M. Upton, in Grass Valley, CA. Dr. Upton is a past president of the California Academy of Family Physicians (1980-81) and a past board member of the American Academy of Family Physicians.

Dr. Upton was a member of CAFP for more than 50 years. Our thoughts and condolences are with Dr. Upton’s wife Jean, his family and friends.

Looking for Vaccine Discounts?

Don’t Forget about CAFP’s Partnership with Atlantic Health Partners With the Pertussis epidemic still active in California, CAFP wants to remind you about its partnership with Atlantic Health Partners.

As the nation’s leading physician vaccine buying group, Atlantic Health Partners works directly with Sanofi Pasteur and Merck to obtain the most favorable vac-

Coming Soon: CAFP’s HIT Toolkit Get ready to implement an Electronic Health Record! For physicians who qualify, implementing an EHR and achieving “meaningful use” can mean between $44,000 and $63,750 in incentive payments.

CAFP will launch an online toolkit on February 1, 2011 to help you. The toolkit will include a Qualification and Assessment Wizard, a guide to working with RECs, tips on vendor selection and contracting, a practice readiness assessment and advice from physician champions who have implemented. Visit www.familydocs. org and link to the HIT Toolkit on February 1st!

14

California Family Physician Winter 2011

cine pricing and payment terms for its members, including Sanofi’s Pertussiscontaining Adacel vaccine (Tdap) for adolescents and adults.

Benefits of the program include: • The lowest overall prices for Sanofi and Merck vaccines • Payment support and advocacy • Medical supply discounts • Purchases are made directly from Sanofi and Merck For more details about how your practice can receive these benefits, contact Cindy Berenson and Jeff Winokur at 800-7412044 (6 am-3 pm) or at info@atlantichealthpartners.com.

Los Altos Family Physician Receives 2010 Pfizer Teacher Development Award CAFP member Rika U. Bajra, MD, Los Altos, is among a select group of physicians honored by the American Academy of Family Physicians Foundation for her commitment to education in the field of family medicine. Dr. Bajra received the 2010 Pfizer Teacher Development Award based on her scholastic achievement, leadership qualities and dedication to family medicine.

Dr. Bajra is a part-time instructor at the Stanford School of Medicine Center for Education in Family and Community Medicine, where she will be recognized for this achievement during a ceremony held by her teaching center. Congratulations, Dr. Bajra!

CAFP’s Congress of Delegates Will Be Held March 5-7, 2011 in Sacramento CAFP’s Congress of Delegates will be held March 5-7, 2011 at the stylish Citizen Hotel in the heart of Sacramento, only a few blocks from the Capitol.

CAFP will hold its annual legislative visits on March 7 after a briefing by legislative staff and leaders. If you’re interested in serving as a Delegate or Alternate for your chapter, or if you’re interested in attending the Congress or legislative

day in Sacramento (all members are invited), please contact your chapter president.

A list of chapter presidents is available on CAFP’s website, www.familydocs.org.

WIC Reforms – Good News for Physicians Donald T. Miller, MD, MPH, a Pediatrician from North County Health Services in Oceanside, CA, recently contributed an article on CAFP’s website about some changes in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC’s) food packages.

“The Institute of Medicine (IOM) undertook a lengthy and effective advocacy campaign that resulted in new WIC food recommendations and modifications in the WIC program,” Dr, Miller wrote.

“These changes were not accepted without some resistance from the food industry and their representatives. In testimony, government officials were told, for example, that "more scientific evidence was needed to make such modifications." However, the IOM recommendations were eventually adopted, bringing important changes to WIC nationally and to California statewide.”

To read about some of the changes with the WIC food packages, go to www. familydocs.org/wic-reforms-good-newscalifornia-physicians.php.

CAFP’s 2011 ASA Just Around the Corner CAFP continues its work putting together the agenda and faculty for the 63rd Annual Scientific Assembly, to be held May 14-15 at San Francisco’s Grand Hyatt Union Square. Topics include: MRSA, LGBT health disparities, primary prevention of dementia, traumatic brain injuries, Top 10 clinical highlights, plus the ever popular “Two Cases, Two Slides, Two Questions.”

If you have suggestions for a keynote speaker, email Deputy Executive Vice President Shelly Rodrigues at cafp@familydocs.org. Register today by contacting CAFP at 415-345-8667.

We give you the support, resources and autonomy you need to give your patients the exceptional care they deserve.

Family Medicine Opportunities: Lancaster, Fontana, Riverside, San Diego, Palm Springs, Los Angeles County and Panorama City (Urgent Care) • Cross-specialty collaboration • Comprehensive support network • Highly competitive compensation and benefits • A location known world over for its great climate and natural attractions Send CV to: Kaiser Permanente, Prof. Recruitment 393 East Walnut Street, Pasadena, CA 91188-8013 Phone 800-541-7946 • E-mail: Martin.Chao@kp.org

january

Kaise Permanente Southern California: We take care of your administrative concerns and offer you a balanced call and work schedule.

1/13 – 1/16 San Diego

8th Annual Natural Supplements Conference: An Evidenced-Based Update (858) 652-5400 med.edu@scrippshealth.org www.scrippshealth.org/convferenceservices

1/22 – 28/20 San Diego

25th Annual San Diego International Conference 43.25 P on Child and Family Maltreatment Rady Childrens Hospital, San Diego (858) 966-4940 ahobson@rchsd.org http://www.chadwickcenter.com/conference.htm

february

2011 CME CALENDAR

2/4 – 7/20

Glendale (520) 907-3318

Intensive Medical Spanish and Cultural Competency Workshop convesp@aol.com http://www.medspanish.org

march

3/9 – 3/12 San Francisco

We are an AAP/EEP employer.

17.0 P Scripps Health

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2/9 – 2/13 Team Physician Course Part II 27.25 P San Diego (317) 637-9200 ext. 141 American College of dhamilton@acsm.org http://www.acsm.org Sports Medicine Contraceptive Technology (925) 828-7100 ext. 5149 gblake@cforums.com http://www.contemporaryforums.com

24.50 P Contemporary Forums

For more CME listings go to: www.familydocs.org/professional-development/cme-calendar.php

San Francisco Department of Public Health

Need to get a head start on your 2011 CME? Want to hear the latest clinical information for family physicians?

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. $189 for members.

www.familydocs.org/professional-development/asa.php

Seeks Medical Directors for two community health clinics: Silver Avenue Family Health Center, and Potrero Hill Health Center These community health clinics serve San Francisco’s underserved by providing a full spectrum of primary care, from prenatal and pediatrics, to adult and geriatric care. Silver Avenue has large Spanish and Cantonese speaking populations. Looking to fill each Medical Director position with an enthusiastic and innovative administrator/clinician. Responsibilities include administration, supervision, QI, and patient care.

Minimum requirements include two years of management and administrative experience, and knowledge of QI, panel management, team building, and working with multidisciplinary teams.

Inquiries: Lisa Johnson, MD 1380 Howard St., 4th floor San Francisco, CA 94103 Phone: 415-255-3516

California Family Physician Winter 2011

15

IN THE SPOTLIGHT

Chris Navalta

CAFP Members Continue to Have Their Voices Heard

2

010 was not only a year of historic proportions for health care – it was also the year family medicine voices were heard. This edition of California Family Physician magazine is dedicated to the Health Care Reform law. But just as important, this edition is dedicated to you – the members.

CAFP commends those who have made the media rounds, taking advantage of our media training, becoming key contacts and getting out there to speak to reporters about the important topics, many of which will carry over to 2011. From the Health Care Reform law to the Patient Centered Medical Home, from the pertussis epidemic to the primary care shortage, and from CAFP-supported legislation to those helping earthquake victims in Haiti, our members have made a difference, bringing family medicine to the forefront. As of this writing, CAFP members have been mentioned in news outlets at least 128 times (nearly a 50-percent increase over the 86 times in 2009). CAFP isn’t always mentioned in the articles for which we identify family physician interviewees (some members even have their own respective health columns in various newspapers), but it’s nice to know we have members willing to stand behind a microphone and make their voices heard.

If you think there are enough members speaking on behalf of your Academy, think again. We are always looking for those passionate about family medicine to step into the media limelight. Just two years ago, in March 2009, Bakersfield family physician Michelle Quiogue, MD, who rarely spoke on behalf of CAFP, attended her first Congress of Delegates.

“I wasn’t sure what to expect, but I participated in the media and legislative trainings on the second day of the Congress,” Dr. Quiogue said. “It was a huge learning experience to be interviewed in front of a room full of your peers on video by the media consultant. I had never done anything so hands-on and practical before. Soon after that, the summer of health care reform debates heated up. The legislative committee staff made sure to have all the resources in my hands in time for each interview scheduled by our media guru, Catherine Direen. I have never had to call reporters. Through Catherine, opportunities to promote our specialty and to advocate for our patients kept pouring in. It has been such a rewarding experience to add to the ever-

16

California Family Physician Winter 2011

growing voice of family medicine in the health care reform process. I can never thank the staff of the CAFP enough for contributing so much to my personal, professional and political development.”

Just two years after her first Congress of Delegates, Dr. Quiogue has made the media rounds. She has been quoted in several newspapers in southern California, has spoken on radio programs and town hall meetings, and she has even appeared on The Today Show. She also is the editor of this magazine!

This year, we’re looking forward to hearing from more physicians interested in championing family medicine in the media. If you are interested in becoming more involved, but aren’t sure how, please contact our media consultant, Catherine Direen, at cdireen@direen.com.

CAFP thanks its members for championing family medicine. Here’s to another great year in 2011.

Chris Navalta is CAFP’s Manager of Publications and Marketing.

Sophia Henry

MEMBERSHIP

Refer a Colleague – Get a Bobble Head!

M

any organizations spend significant time and energy trying to capture the attention of prospective members.

In the digital age, with seemingly endless hightech Search Engine Optimization (SEO) and Web 2.0 tools at our disposal, CAFP is taking a different tack: we’re going back to good old word-of-mouth and asking members to spread the word and share the wealth.

That’s how we came up with the FP bobble head – those little figurines with an oversized head that bobbles when you shake them (usually distributed to the first 10,000 fans at your nearby baseball game). It sounded like fun and elicited a lot of chuckles. It caused some buzz throughout the office; various bobble heads started appearing on CAFP desks.

Bobble heads can be customized to resemble anyone; that’s why you’ll soon see a bobble head version of our very own CAFP President, Jack Chou, MD, FAAFP. It will be used in a membership recruitment campaign in 2011 to highlight the idea that, as a family physician, you deal with a unique set of wideranging issues that can make your head spin – which is why you need CAFP. The Academy guides you to resources that help meet your practice management, clinical and policy challenges while ensuring your voice is heard through the cacophony of special interests in Sacramento and Washington, DC.

How does this involve you?

You will receive a complimentary CAFP bobble head when you recommend a colleague who enrolls in the Academy and pays his or her membership dues in full. We know membership in a professional medical organization isn’t something that pops up in everyday conversation. You can use the offer of

the bobble head of Dr. Chou to strike up a conversation with a non-member colleague. Later, you can place this cool gift on your desk and when a coworker notices it, tell him or her why you are a member of the Academy. Or, use the bobble head to break the ice with patients. It can enhance your patientphysician relationship and help patients understand you are their advocate both inside and outside the exam room.

Why should you recruit members for the Academy?

Academy leaders and staff are dedicated to promoting membership day-in and day-out. But the most effective membership recruitment is peer-to-peer – when members tell non-member colleagues why it’s important and valuable to belong.

Here are four reasons to invite others to be members: 1. A bigger and better Academy benefits everyone. It provides the funding and development of more services and resources for all members — including you.

receiving a neat gift and potentially winning the top recruiting prize, you get the pay-off of networking with colleagues. Ultimately you will learn and grow from the interaction.

Please let us know if you would like to share your ideas about this program and find out how to participate. Information is available on the CAFP website at www. familydocs.org/membership.

Sophia Henry is CAFP’s Membership Manager.

Log on to www.familydocs.org to view Dr. Chou's bobble head.

2. A bigger and better organization improves the image and heightens awareness of the specialty. The power of your specialty organization has grown significantly over the years, but it never hurts to have more FPs in your ranks.

3. A potential member’s access to information about membership benefits and services is only a click away by computer, but FPs are timepressed. It’s more helpful to hear it from a trusted colleague.

4. Helping a colleague or coworker means rewards for you and for family medicine. In addition to

California Family Physician Winter 2011

17

PCMH CORNER

Leah Newkirk

Accountable Care Organizations: Are They Family Medicine’s Friends – or Foes?

T

he architects of the Patient Protection and Affordable Care Act (PPACA) and the academics who publish widely on the subject of Accountable Care Organizations (ACOs) provide us with a very loose definition of ACOs: they are entities that bring together groups of providers to coordinate care for defined populations of patients, are rewarded for their efficient use of resources and can report meaningful data on their clinical, financial and quality performance. The vague definition is frustrating; it fails to convey, even to those who work in health care, just what an ACO is and how it will operate. What has become clear is that the vague definition is deliberate. There is an emerging consensus that ACOs should be founded in pre-existing organizations with different capabilities, culture and infrastructure. ACOs will therefore vary considerably in form. We will most likely see fully integrated delivery systems, independent practice associations (IPAs), multispecialty group practices, physicianhospital organizations and, possibly, “virtual physician networks” develop into ACOs. PPACA contains several provisions that are now referred to as the “sharedsavings program” for ACOs. Under these provisions, the Centers for Medicare and Medicaid Services (CMS) are required by January 2012 to allow groups of physicians who report on quality and coordinate care to share in the savings achieved in their region. CMS is expected to issue the regulations that will govern the program in December 2010. PPACA also requires the establishment of the CMS Innovation Center by January 2011 and the Innovation Center may do more to motivate ACO development. PPACA appropriated $10 billion to the Innovation Center to test new ways to pay for and deliver care. Pilots that succeed with the Innovation Center can be implemented 18

California Family Physician Winter 2011

throughout Medicare without legislative approval.

Experts urge CMS to permit, through regulations and in pilots, different organizational structures and payment mechanisms. For example, CMS regulations governing the shared-savings program might have “tiers” of ACOs. More loosely affiliated ACOs (e.g., virtual physician networks and IPAs) would bear little financial risk, but would be eligible to receive shared savings and bonuses

ACOs may, in reality or in public opinion, be equated with rationing, and primary care providers will once again be perceived as “gatekeepers,” not “gateways” by frustrated patients who want a choice. if they meet quality benchmarks and reduce costs. More tightly integrated ACOs (e.g., integrated delivery systems) would be reimbursed through full capitation or extensive partial capitation. They would be eligible for the highest reward, but would assume the greatest risk.

The passage of PPACA has resulted in a flurry of ACO interest and activity, even before the PPACA programs are fully in place. In California, development is occurring among IPAs in collaboration with health plans. Monarch HealthCare in Irvine, and HealthCare Partners in Torrance, are collaborating with Anthem

Blue Cross in two separate ACO pilots.

Blue Shield of California, Catholic Healthcare West and Hill Physicians launched what they describe as an ACO to manage the care of more than 40,000 members of CalPERS. Blue Shield has indicated that it is considering expanding the program statewide. Multispecialty Group Practices such as Sharp Rees-Stealy are another site of ACO development. Sharp has indicated it is currently developing an ACO, as well as medical homes to support the ACO. Integrated delivery systems, such as Kaiser, are also well-positioned to develop into ACOs. What are the consequences of ACO development for family physicians? ACOs should strengthen the position of primary care. Proponents of ACOs describe the necessity, in this model, of bolstering primary care with higher pay and remodeling the delivery of care with primary care providers at the center, offering comprehensive, coordinated care. Many describe the Patient Centered Medical Home (PCMH) as the model for the delivery of care, the component of the ACO organization that will drive outcome improvements and lower cost.

ACO development poses risks, however.

Interest in forming ACOs will likely motivate a continuous and powerful drive toward integration over the next few years.

One justification is that the new model requires greater role differentiation. Another justification is that size is important to measuring and reporting on outcomes.

Sufficient numbers of patients in an ACO are necessary to determine statistically if the reported outcomes resulted from the care provided, and not from mere chance. A final justification is financial.

ACOs must have the ability to buy the necessary information technology and the ability to bear risk under payment reform. PPACA permits ACOs as small as 5,000 patients, but some doubt whether

an organization of that size can develop the infrastructure and bear the risk.

trative burden or worse, unfairly damage physicians’ reputations.

There are concerns related to consolidation. Small and solo physician practices are at risk. Consolidation could drive up costs, rather than “bending the cost curve” as these reforms are intended to do. And, consolidation increases the risk of antitrust and fraud and abuse violations.

CAFP will pursue all available strategies to ensure that ACO development strengthens family medicine and improves the lives of their patients. One important strategy is to deliver a voice and leadership role in ACO development to family physicians. Another strategy is promoting the development of PCMH within ACOs. CAFP will raise awareness about the importance of PCMH with IPAs, multispecialty groups and integrated delivery systems and pursue pilot opportunities in collaboration with these groups. CAFP must also find ways to protect small and solo practices and safety-net providers in this environment.

Finally, CAFP must fight for physician measurement that is accurate and reporting that is fair.

ACOs may create other troubles for family physicians. ACOs may, in reality or in public opinion, be equated with rationing, and primary care providers will once again be perceived as “gatekeepers,” not “gateways” by frustrated patients who want a choice. ACOs may exclude the Medi-Cal population and physicians who work as safety-net providers. ACOs will increase measurement and reporting. This could improve Leah Newkirk is CAFP’s Director of Health quality if done carefully, but it also has Policy. the potential to involve a heavy adminisSCI_CA Family Phys Ad_12.18.10.qxd:Layout 1 12/20/10 1:03 PM Page 1

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19

PRACTICE MANAGEMENT NEWS

Responding to a Medical Records Audit Program

By Mary Jean Sage

I

t is no secret that payers – including Medicare, private insurance companies and HMOs – have significantly increased their oversight of physician practices’ medical records in an effort to identify improper payment and fight fraud and abuse. The Centers for Medicare and Medicaid Services (CMS) have used Recovery Audit Contractors (RACs) since 2005 to look at services performed by the provider and determine if any over- or under-payment has occurred. RACs are now a permanent, nationwide program. While the chances of a practice undergoing an audit were once slim, it is now a virtual certainty that every practice will undergo an audit at some point. How well you and your practice fare during an audit depends on your readiness to respond to a request from one of the RACs. This article will help you to manage the audit process and decide what to do in the event that over- or under-payments are found.

Audits generally begin with a request for medical records. It may be a random sample of patient records or a sample of specific procedural or diagnostic codes. The request may be for patients’ complete medical files or for specific dates of service. Responding to the precise request of the auditing agency can help you avoid significant hassles down the line.

While some audits truly are random, most are planned in advance. The prudent family physician should assume that there is some common denominator (i.e. billing pattern) among the records requested that the auditors consider suspect.

Not responding to an audit is not an option. Failure to respond will lead to a withholding of future payments, disenrollment/debarment from the provider network, or, in the case of Medicare, a subpoena for the requested records (and possibly for additional records, as well).

The following tips can help minimize the disruption to your practice when you undergo an audit: 1) Communicate with the auditor and record all correspondence: If you receive a request for medical records, cooperate fully with the auditor. Designate someone in your practice to be the contact person with the auditor. That person should be responsible for maintaining a log of all telephone conversations with the auditor, including the date, time and subject matter of the call and maintaining a file of all written correspondence with the auditor.

20

California Family Physician Winter 2011

2) Completeness is crucial: Before responding to an audit, ensure that your medical records are complete. Each medical record should be compared to its corresponding billing record. Consider using the following questions as a checklist in reviewing your medical records: • Is there a note for each visit?

• Is each note dated and signed by the provider?

• If a lab test, EKG or X-ray was ordered, is the report in the chart?

• If a consult was billed, is there a report to the referring physician?

• If a referral was made, is there documentation for it?

Do not fabricate or alter a missing or incomplete entry or document in a medical record. Nothing will lead more quickly to a fraud prosecution than producing records that have been tampered. Instead, if records are incomplete, include a cover letter that provides the missing information. If such an addendum is necessary, consider seeking the advice and/or assistance of legal counsel in drafting that letter.

The current trend is to audit records for particular dates of service rather than complete medical files. Such requests can be traps for the unwary. Here is why: Medical records are cumulative by nature and are essentially a summary of the physicians’ knowledge of the patient.

When an auditor requests an isolated date-of-service entry, a record may inadequately reflect the complexity of both the patient’s medical history and the physician’s medical decisions. Those two factors are key components in determining the appropriate evaluation and management (E/M) service level to be billed. Therefore, if you do not provide sufficient documentation to support those decisions at each date of service, the auditors may down-code or disallow the level of service billed.

In addition, isolated services may not include related test results, X-ray reports or consultations (each of which often contributes to the E/M coding decision). Be prepared to include collateral information with your response to the request when this type of audit is performed. Although most insurers have post-audit appeals procedures, the after-thefact submission of additional material may be viewed with a jaundiced eye.

3) Respond in a timely manner: The auditor will provide an expected date of receipt with all requests for medical records. Ensure the records are submitted in ample time to

PRACTICE MANAGEMENT NEWS reach the carrier or insurer by the requested date. Should it be impossible to meet the expected date, communicate with the auditor and ask for additional time to submit the requested records. Most auditors are reasonable and will accept a legitimate request for an extension to submit records, but be prudent about the request and offer a realistic timeframe.

Unless the auditor specifically requests original records, submit copies of records. Be sure to number the pages and make at least one complete copy of the records you submit for your files.

When you send the records, include a cover letter describing the contents and send them by registered mail with a return receipt. You can also use any other secure delivery service with a tracking mechanism (i.e., FedEx or UPS) but remember, those services often cannot deliver to a postal box number, so you should have a physical address (street address) for delivery.

4) Hosting a visit: It is unlikely an auditor will visit your practice, but if it does occur, designate a staff member to oversee the visit and respond to the auditor’s requests. Do not leave the auditor unattended to converse with other staff members. While you cannot forbid staff from speaking with the investigator, be certain they know their rights. Your staff members do not have to speak to the investigator, and, if they do, they have the right to have an attorney present.

5) Assessing your options: If the auditor determines there was an overpayment, the carrier will try to recoup the money and demand a repayment. At this point your options are either to pay the amount requested or appeal. In cases of financial hardship, you may be granted a payment extension ranging from six months to three years. CMS can extend repayment up to five years in cases of extreme hardship.

Carriers must inform providers of their right to appeal an audit decision. If you do appeal, the carrier or intermediary cannot recoup overpayment until the initial determination of overpayment has been upheld at the first level of appeal, known as reconsideration appeal.

Mistakes in audits are common, so appealing may be a good idea. Information on the appeals process for Medicare is available on CMS’s website at http://www.cms.gov/MLNProducts/downloads/MedicareAppealsProcess.pdf.

Other Considerations Protect Yourself: There are a number of steps you can take to reduce the likelihood of being audited or, if you are audited, avoid a determination of overpayment.

• Know the rules governing family medicine payment and comply with them. School yourself in both national policies and local coverage decisions. Please contact CAFP (cafp@familydocs.org) for more information.

• Be knowledgeable about the CPT codes that describe the services you provide. CAFP has resources on all of your coding and payment needs (available at http://www. familydocs.org/practice-resources/coding-and-billingstrategies.php).

• In billing, use the code that most appropriately describes the service.

• Use the diagnosis code (ICD-9) specific to your patients’ conditions and need for service. Codes should be consistent with the services provided and billed.

• Make your notes clear and legible.

• Ensure that your documentation clearly shows that you provided a skilled service that was medically necessary.

• Establish a compliance plan for billing. The Health and Human Services Office of Inspector General offers guidance on establishing voluntary compliance program at http://oig.hhs.gov/fraud/complianceguidance.asp.

• As part of your compliance program, conduct periodic self-audits.

Contacting an Attorney: If you receive a letter requesting medical records, you may want to consider contacting your attorney for legal advice. Your attorney may recommend that you hire – preferably before submitting anything to the carrier – a coding expert who is familiar with the payment rules for the payer and can review your charts. If the expert identifies a problem area, you will have an opportunity to gather evidence to justify your claim prior to the auditor’s review. For example, if you are billing for a time-based service and your chart does not document that interval, you may be able to gather other evidence to support the fact that you spent that amount of time with the patient. Naturally, it is better to be prepared for an audit by identifying the problems with your medical records in advance.

Being audited by Medicare or any other insurer can be a stressful experience for any practice. But if your practice prepares itself, you can significantly reduce the risk of owing a large overpayment – or owing any payment at all.

Mary Jean Sage has extensive experience in the health care field spanning a period of more than 20 years during which time she has managed diverse groups of professionals in delivering patient care.

A founding Principal and Senior Consultant with The Sage Associates, Mary Jean is a nationally-known speaker, consultant and educator.

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.

Copyright © 2010 The California Academy of Family Physicians, San Francisco, CA, USA. All rights reserved.

California Family Physician Winter 2011

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OVERVIEW OF HEALTH CARE REFORM

Work to Support Family Medicine in New Health Care Reform Environment Is Just Beginning

By AAFP President Roland Goertz, MD, MBA

Passage of the Patient Protection and Affordable Care Act — commonly known as the Affordable Care Act, or simply PPACA — was an important step toward establishing primary care as the foundation of America’s health care system. The law will have a far-reaching impact on family medicine as the nation begins to rebalance our health care system with more appropriate emphasis on primary care. Once fully implemented, it will focus more on health care and place a greater emphasis on prevention, primary care and improved health outcomes instead of a predominately sickness care model which has focused on paying for procedures and volume.

The final vote and the signing of the PPACA was a first step.

Now the task is implementation. And this is where the real work — and the real debate — begin.

Since its passage, the AAFP has focused on filling in the holes in the Affordable Care Act, preserving its primary care-friendly provisions and ensuring support for primary care education that will help increase the number of future family physicians.

The effort has come on several fronts. Your AAFP has worked aggressively with the Centers for Medicare and Medicaid Services, the new Health and Human Services Office of Consumer Information and Insurance Oversight, the Government Accountability Office, Federal Trade Commission, Food and Drug Administration and several other federal agencies to ensure that regulations support the PPACA’s intent to rebuild our system on primary medical care and the primary care physician workforce.

We are working with Congress and the Administration to preserve the modestly increased payment for evaluation and management codes that resulted from the elimination of consultation codes and are pushing for more. We successfully moved to expand the number of family physicians who qualify for Medicare’s 10 percent incentive payment for primary care services. And we continue to focus our efforts on a significant issue that the PPACA does not address — a permanent solution to the flawed Medicare physician payment formula.

Early PPACA insurance reforms concentrated on patient protections against such practices as rescinding policies when patients become ill, denying coverage to children due to pre-existing conditions and placing caps on annual or lifetime benefits.

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Now, policy makers in several federal agencies are focusing attention on accountable care organization regulations, and officials are consulting with your AAFP leadership to develop them. For example, in a recent meeting with AAFP Board Chair Lori Heim, MD, President-elect Glen Stream, MD and me, the recently-appointed Richard Gilfillan, MD, acting director of the CMS Center for Medicare and Medicaid Innovation (CMMI) – and also a family physician – turned to the AAFP for information on the cost efficiencies derived from the primary care Patient Centered Medical Home. While Dr. Gilfillan understands the importance of PCMH as the most effective model for improving patient care and ensuring care coordination, he seeks further information on the model’s cost-effectiveness as the new CMMI develops new innovative payment programs.

Through meetings and correspondence with CMS Administrator Donald Berwick, MD, we have made progress toward federal understanding that the AMA/Special Society Relative Value Scale Update Committee, commonly referred to as the RUC, should be augmented with an evidence review panel that includes employers and consumers who help identify whether medical services are valued appropriately.

At the same time, we have continued our strong advocacy efforts on Capitol Hill. We continue to take specific messages to key members of the House and Senate, successfully reducing the reporting requirements for primary care charges from 60 percent to 50 percent in order to qualify more family physicians for Medicare’s 10 percent primary care incentive payment. We also want Congress to maintain existing policy that eliminated consultation codes and, most importantly, permanently address the flawed Medicare physician payment system.

As a result of our meetings and communications with them, every member of Congress has been contacted about the need to stabilize Medicare physician payments and pass legislation to adequately pay for primary care services. They are turning to your AAFP for input into how we can affect effect these changes without increasing the federal deficit.

Our ultimate success depends on your continued participation with AAFP grassroots messages and with the 112th Congress.

As members of the 112th Congress take their Oath of Office and settle in, we’ll continue to work proactively to ensure that family medicine is supported in all regulations.

AAFP President Roland Goertz, MD, MBA has been Chief Executive Officer of the three foundations that oversee all operations of the Waco Family Health Center in Waco, TX since 1997.

OVERVIEW OF HEALTH CARE REFORM

Mythbusters … The PPACA Edition

By Carla Kakutani, MD

Precisely because it is long and complicated, the new health care reform law has been saddled with many misconceptions that confuse both physicians and patients. Some stem from simple misunderstandings, while others were started – on purpose – to generate opposition to the law. Here are a few Patient Protection and Affordable Care Act (PPACA) myths that your patients may ask you about, and here is your chance to be a mythbuster.

MYTH: Once the individual mandate kicks in, you can go to jail if you don’t purchase health insurance.

FACT: The law specifically states that there are no criminal penalties for failing to obtain health insurance. The IRS can levy a fine, but no one will be arrested.

MYTH: Death panels!

FACT: This catchy phrase was popularized by Sarah Palin in 2009. Apparently she concluded that Medicare paying for patients to have a visit with their personal physician to discuss living will and end-of-life concerns would lead to seniors being denied health care. The AARP and many fact check websites have debunked this one.

MYTH: PPACA requires that patients be implanted with microchips.

FACT: There is a provision in the law that allows the Department of Health and Human Services to create a database of implanted medical devices to allow for better effectiveness research and to facilitate notifying patients in the event of a recall. This somehow got twisted into the microchip story by some very imaginative and paranoid people, who then spread the rumor on the Internet.

MYTH: You have to start paying taxes on your health insurance benefits starting in 2011.

FACT: In 2011, W-2 forms will show how much your employer contributed for your health insurance premium (therefore, leaving less available for wages), but that will not count toward your taxable income. The hope is that having that information will make people more aware of the full cost of their health care and inspire them to make more cost effective choices over time.

MYTH: PPACA is causing companies to stop offering health insurance to employees.

FACT: The kinds of “mini-med” plans, with annual benefit caps as low as $2,000, that are offered to hourly workers at McDonald’s and other companies can barely be considered true insurance and do not meet PPACA’s requirement of a minimum 80 percent medical loss ratio. These kinds of insurance products are being purposely phased out. In 2014, these employees will be able to get much more comprehensive insurance for the same or a better price on the new state exchanges.

Thanks to special new tax credits for small businesses that provide health insurance, the percentage of businesses with fewer than 10 employees offering insurance actually rose by 13 percent this year.

These myths are just a small sample of confusion and outright lies circulating around PPACA. We can help reassure patients and educate them about their new consumer protections, but only if we get educated ourselves. Check out the many links on CAFP’s Health Care Reform page on its website and become a PPACA mythbuster!

Carla Kakutani, MD is the Chair of the Family Physicians Political Action Committee (FP-PAC) and a CAFP past president.

California Family Physician Winter 2011

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OVERVIEW OF HEALTH CARE REFORM

What Health Care Reform Means to History was made on March 23, 2010 when President Obama signed into law the Patient Protection and Affordable Care Act (PPACA).

The Health Care Reform law means many different things to our members; when asked the question, they responded:

“For me personally, it means that my son has health insurance! For my practice, it means most people have not felt any impact. A few have insurance who wouldn’t otherwise, and many worry that they will lose something they will not.” – Bob Bourne, MD, Colton

“I’m excited that those previously uninsured now can get care, but am worried that without payment reform, we’ll have more of the same: more care since RVUs drive compensation – not necessarily better care. Accountable Care Organizations provide better care, outcomes-oriented rather than piecemeal solutions that aren’t necessarily in the patients’ best interest.” – Enoch Choi, MD, Palo Alto

“Our practice is anticipating an influx of newly-insured patients. As an integrated system, we are well-positioned to function as an ACO.” – Irina de Fischer, MD, Petaluma

“It’s a mixed bag – the devil is in the details. The support for meaningful use is a great incentive. I hope family medicine will be paid what it’s worth.” – Julian Delgado, MD, Colusa

“(Health Care Reform means) access to primary preventive care! (And) not having to say to a patient: ‘Your mom or dad may not be covered – and it costs X amount of dollars.”

– Adriana Padilla, MD, Fresno

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California Family Physician Winter 2011

OVERVIEW OF HEALTH CARE REFORM

Family Physicians and Their Practices Among other provisions, this law is expected to: expand health insurance coverage to 32 million uninsured, increase primary care physician payment, improve access to preventive care and implement patient protections against insurance company policy cancellations.

“Health care reform means great hope and support for what we’re already doing very well at Kaiser Permanente, where I see patients, and at the residency where we train our future physicians.

There are going to be wonderful pieces implemented in terms of developing real robust advanced Patient Centered Medical Homes. Patients, families, residents, physicians and staff are all going to be happier over time. I’m really excited about it.” – Walt Mills, MD, Santa Rosa

“There are a lot of measures in the law that will provide more support for primary care and family medicine. Clearly, we still have a long way to go, but we’re moving in the right direction. So, I’m optimistic about family medicine’s future.” – Kevin Grumbach, MD, San Francisco

“I expect that PPACA will have many subtle and indirect effects on my practice. I work in a rural health clinic so I don’t know whether the 10 percent primary care bonus will apply to me. That would be nice.

I expect that it will become more difficult to get appropriate care for patients with private insurance as insurance companies increase copayments and deductibles after they are no longer able to increase premiums so wildly. We were already transitioning toward thinking about getting EMR before the pre-PPACA incentives came out. My hope is that PPACA will push the system to total collapse faster than the previous trajectory and we can start over without private insurance.”

– Hal Grotke, MD, Eureka

“I work for the Children’s Clinic in Long Beach, caring for primarily uninsured adults. Health care reform means many of my patients can get full – rather than partial – care. I will actually be able to order tests for diagnostic work, expand my medical treatment options and provide recommended health maintenance and screening – just like all human beings deserve, not just the ‘haves.’” – Mark Dressner, MD, Long Beach

“We are still trying to ascertain the full impact on our practice. Hopefully, it will enable more patients to have access to our physicians.” – Lee Ralph, MD, San Diego

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OVERVIEW OF HEALTH CARE REFORM

An Explanation of How PPACA Affects Funding for Medical Education

By Callie Langton, MPA

The burden of student loans is overwhelming for many medical students and new family physicians.

Recent legislative changes, including those in the Patient Protection and Affordable Care Act (PPACA), have made small, but significant, steps toward alleviating the burden of student loans. Below is an outline of the most significant changes for borrowers and an explanation of how these changes may assist family physicians in meeting student loan obligations. It is important to note that at this time these programs only apply to federally-funded student loans, not to private student loans.

For more information on which loans are considered federal loans, visit: www.direct.ed.gov.

count the couple’s total federal student loan debt, as well as their total income, to calculate payments. This should significantly reduce monthly payments for couples with high educational debts and low income—such as medical residents!

Additionally, IBR eligibility will now be based on either the balance when the loan first entered repayment or on the current loan amount, whichever is greater, for all borrowers. This will allow borrowers whose loan balances have increased (often due to accrued interest) to qualify based on what they actually owe. This is an important change for new physicians who place loans in deferment or forbearance while in residency, as interest accrues on the loan balance during the deferment or forbearance period.

If you are currently enrolled in the IBR program, check with your lender to determine if these new changes may affect your loan repayment terms.

1. Income-Based Repayment (IBR) Program Changes: The IBR program makes repaying educational loans easier for 2. Tax Relief for Students in State Loan Repayment Prothose who have high debt and relatively low income. IBR grams: The Health Professions State Loan Repayment Tax caps your maximum monthly Relief Act, effective retroactively payment at 15 percent of to 2009, expands a tax exclusion household discretionary for doctors participating in loan Borrowers who do not complete income. The maximum forgiveness programs. Prior to the their commitment will now be repayment term is 25 years change, only students participatand only 10 years if you work ing in the National Health Service charged an interest rate two at a non-profit or in another Corps Loan Repayment Program public service job. After or certain state loan programs percentage points higher than those terms, any remaining qualified for the tax exclusion. the rate the borrower would pay Now participants in all state loan loan amount is forgiven. IBR is also a great short-term oprepayment or loan forgiveness if he or she were compliant. In tion for many physicians durprograms are eligible for this tax ing residency, offering lower exclusion. If you currently receive previous years, borrowers were monthly payments while loan forgiveness as a part of your penalized by having their avoiding loan deferment or compensation package, or plan to forbearance. in the future, your taxable income interest rate set at 18 percent.

Prior to July 1, 2010, marmay be reduced by thousands of ried couples who each had dollars. substantial student loan debt were penalized when This exclusion is retroactive to the 2009 tax year, so if you applying for the IBR program. Now, if married couples are a physician currently enrolled in a state loan repayeach have federal student loans, they will no longer face ment program, you may be eligible for a refund. CAFP higher IBR payments than their unmarried peers. For suggests checking with your loan program office to determarried borrowers who file taxes jointly, lenders will mine whether the new law covers your program.

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OVERVIEW OF HEALTH CARE REFORM 3. Public Service Loan Forgiveness (PSLF) Program: The PSLF program was created to give individuals the flexibility to work fulltime in low-paying public service jobs.

After making 120 payments (10 years) under a standard repayment plan, IBR, or Income Contingent Plan, any remaining direct federal loan balance will be forgiven.

To be eligible, you must be employed in a non-profit or public service job for the entire payment period and when the loan is forgiven. Many clinics, hospitals and public university jobs qualify, creating many opportunities for family medicine physicians to work in public service and still ensure personal financial stability.

4. Expansion of National Health Service Corps (NHSC): PPACA provides a significant funding increase for the NHSC program as well as more flexibility for NHSC participants as to what time may be counted toward their service commitment. Up to 50 percent of time spent teaching by an NHSC member may now be counted toward the service obligation—20 percent for those in general practice and 50 percent for those in teaching health centers. This change is a positive one, especially for rural programs that rely on NHSC participants to spend some of their time teaching students and residents. Finally, the NHSC now allows part-time work to count toward fulfillment

of NHSC obligations and increases the annual maximum NHSC loan repayment amount from $35,000 to $50,000.

5. Reduced Penalties for Non-Compliance with Primary Care Loan (PCL) Program: The PCL program provides lowinterest loans to financially needy students wishing to pursue careers in primary care. For new loans made after March 23, 2010, PPACA requires borrowers to complete residency training in primary care and subsequently practice in primary care for either 10 years or until the loan is paid in full, whichever occurs first. Previously, borrowers were required to practice in primary care until the loan was paid in full.

Borrowers who do not complete their commitment will now be charged an interest rate two percentage points higher than the rate the borrower would pay if he or she were compliant.

In previous years, borrowers were penalized by having their interest rate set at 18 percent.

For more information on how PPACA affects student loans, please see the Health Care Reform section of CAFP’s website at: http://www.familydocs.org/advocacy/health-care-reform. php.

Callie Langton, MPA is CAFP’s Associate Director of Health Care Workforce Policy.

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Editorial < 6

President's Message < 7

Political Pulse < 10

at http://www.familydocs.org/advocacy/ health-care-reform.php.

Centers), to contending with folks who want to coax practices to join an ACO (Accountable Care Organization).

few years away when the state must start paying for its share of the expansion?

At the opening ceremony of the 2010 AAFP Annual Scientific Assembly in Denver, our Surgeon General – and AAFP member – Regina Benjamin, MD called for family physicians to support the PPACA. She pointed out that we family physicians are acutely aware that many of our patients’ health problems will neither be fixed by a prescription pad alone nor by a new insurance card. To make an impact on our patients’ health comprehensively, physicians must advocate for our patients beyond the exam room. We can advocate for communities and economic environments where the healthy choices are the most affordable and the easiest choices.

We can take the lead and call the plays on this new playing field. This is our time.

The course of medicine has shifted toward prevention and primary care. Turn to CAFP to stay informed, to stay involved and to stay in, and ahead of, the game.

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California Family Physician Winter 2011

The Academy must be our indispensable reference source during these changing times. We will continue to bring you trusted information on each of these seemingly challenging topic areas. We have revamped the Health Care Reform pages on CAFP’s website to reflect the need to expand our members’ knowledge about this changing landscape. We have prepared tools and documents to help familiarize you with the Patient Centered Medical Home and the adoption and meaningful use of health information technologies.

Finally, I have frequently heard the analogy of comparing an ACO to a unicorn many can describe one but no one has seen one. If we begin to hear hoof beats, we will bring you a detailed analysis of the unicorn.

In November, CAFP’s Board of Directors voted that CAFP should reintroduce its Patient Centered Medical Home legislation, as well as legislation to better ensure fair payment for immunizations performed in physician offices. In 2011, CAFP has also been asked by two legislative offices to consider sponsoring mental health legislation and the CAFP Board has approved the concept of working on this effort with our “Cognitive Coalition” colleagues, who include internal medicine, psychiatry and pediatrics as well as family medicine.

All considered, 2011-12 will be a busy, unpredictable session with huge policies in flux and much politics in play. The game has changed. Even so, the goals of family medicine remain clear and strong.

Despite any political haze, CAFP knows where to head.

Tom Riley is CAFP’s Director of Government Relations.

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Let’s Make the Most out of Health Care Reform Law

I

n August 2009, CAFP responded to members who were angry, confused or both about health care reform legislation then pending in the Congress. Stunningly inaccurate information about the legislation was circulating on the Internet. Rumors flew about death panels for Medicare patients: a US SENATOR who should have known better helped fuel that inaccurate claim, based on a statement by a famous former vice presidential candidate who twisted a proposal to pay for end-of-life counseling for those Medicare patients who CHOSE to ask their personal physicians for that kind of assistance. Town Hall meetings devolved into shouting matches as angry seniors screamed: “Keep the government out of my Medicare,” with no sense of the irony of that statement.

The six-month anniversary of reform legislation passed in the fall. Reform was named by 17 percent of voters as a major issue in the election just passed, and a battle is being waged in the courts to find the legislation unconstitutional. States, including California, however, have begun enacting enabling legislation to implement reform. The federal government issues frequent regulations to do the same, including a draft proposal to address an issue that, in the past, has been of considerable concern to physicians: the medical loss ratio, i.e., how much health plans spend on care for patients vs. administrative, marketing and other costs, and profit. It’s been the position of most medical organizations that health plans should spend more on health care and less on other costs/profits – that seems reasonable to me. A study group composed of states’ insurance commissioners agrees and says the ratio should be 85:15, but some on Wall Street say the world will collapse.

One relatively minor player in the health plan world (Principal Financial Group) declared it will withdraw from the health insurance business and The Wall Street Journal decried the possibility, floated by McDonald’s fast food chain, that McDonald’s would discontinue health insurance for its 30,000 employees because it could not meet the new medical loss ratio standard.

New York Times Economic Scene writer David Leonhardt examined the issue in an October 6, 2010 article, and I think he got to the heart of the matter. Currently, McDonald’s employees have what could be termed “pseudo-insurance” (that they pay for themselves); it caps at either $2,000 or $10,000 per year, depending on which policy they purchase. The average salary at McDonald’s is about $20,000 a year; apparently McDonald’s can’t afford to give us cheap hamburgers and sugarsweetened beverages by the gallon if it offers decent coverage to its employees.

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California Family Physician Winter 2011

As Mr. Leonhardt describes it, America’s health insurance executives are claiming “that the health care overhaul is damaging American health care,” when, as he carefully goes on to explain, “the real problem (is) the status quo.” Seriously, what good IS a $2,000 plan or a $10,000 plan, for which employees pay about $730 or $1,660 a year (a significant portion of their total income)? Is it better than nothing and, as Mr. Leonhardt asks “… should the litmus test for American health care really be better than nothing?” Would you or I feel secure if we were covered at a maximum of $2,000 a year, after a contribution of $730, an actual “benefit” of only $1,270 IF plan requirements are met, and not including co-pays or deductibles? The same US Senator who fed the “death panel” rumor to a gullible public took issue with plans such as the ones McDonald’s offers. According to Mr. Leonhardt, Senator Charles Grassley, R-Iowa, chastised the AARP for “marketing similarly limited plans to its members,” saying “It’s not better than nothing to encourage people to buy something described as ‘health security’ when there’s no basic protection against high medical costs.” Mr. Leonhardt comes to the conclusion that McDonald’s employees will do better under health care reform than they do currently because of the legislation’s “three-legged stool”: 1) the requirement that all people buy insurance to spread risk; 2) the requirement that insurers take all comers regardless of pre-existing conditions to spread the costs; and 3) the provision that the government offer subsidies to those who can’t afford insurance. Several European nations have used this model successfully, he says, at lower per-person cost than we experience now in this country.

As have CAFP, AAFP and other medical organizations that supported it, Mr. Leonhardt acknowledges imperfections in the reform legislation. But really, who can say that what we have had before reform was so good it ought to be preserved at all costs, no matter who isn’t covered and no matter what we have to pay? CAFP is also an employer – we don’t offer “Cadillac plans” but we pay “Cadillac” prices. Those prices have increased at rates between 7 and 18 percent a year for as long as I can remember, despite our relatively young average age per employee. (I am definitely the exception here!)

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