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Volume 13 Issue 2 / Spring 2017

The North Carolina

Family Physician Quarterly News in North Carolina Family Medicine

Battling Opioids on the Frontlines See p. 24


When was the last time you wore flip flops to a conference?

2017 Mid-Summer Family Medicine Digest CONFERENCE & EXHIBITION 30+ AAFP Prescribed Credits • Program Chair: Jewell Carr, MD

Make plans now to join us for a fun, educational week of half-day, interactive sessions. Tentative topics include: Gout Diabetes Pediatrics

Direct Primary Care Models Sports Medicine Depression Hypertension

Travel Medicine Pain Management And much, much more!

Optional sessions: Hands-On Cosmetic Procedures, Nexplanon Training, and KSA Study Working Group on Hypertension

SUN, JULY 2 – THURS, JULY 6, 2017 Kingston Plantation/Embassy Suites • Myrtle Beach, SC

CME | Camaraderie | Networking | Family Fun www.ncafp.com/msfmd


Inside Spring 2017

13 The 2016 NCAFP

Annual Report

2016

Annual Report

Continued progress and change by the North Carolina Academy of Family Physicians

PRESIDENT’S MESSAGE

MEMBERSHIP & MEMBER SERVICES

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21

Painting the Mona Lisa While Sitting on a Fire Ant Hill

NCAFP Membership Surpasses 4,000!

HEALTH POLICY & ADVOCACY

STUDENT INTEREST & INITIATIVES

6

22 Another Fantastic Match Year for North Carolina

Your Academy in Action

EXECUTIVE’S MESSAGE

PRACTICE MANAGEMENT

10 Everyone Needs a Little Joe Time

28 Direct Primary Care: Myths, Misrepresentations & Hope

DEPARTMENTS

PUBLISHED BY

t 919.833.2110 •

fax

919.833.1801 • ncafp.com

Managing Editor & Production Peter Graber, NCAFP Communications

President’s Message 4 Policy & Advocacy 6 CME Meetings & Education 8 Chapter Affairs 10

Membership 21 Student Interest 22 Residents & New FPs 24 Practice Management 28

Have a news item we missed? NCAFP members may send news items to the NCAFP Communications Department for publishing consideration. Please email items to pgraber@ncafp.com


me about their loved ones and the struggles they are having. The morning became a big group hug for the community.

PRESIDENT’S MESSAGE to NCAFP Members By Dr. Charles Rhodes 2016–2017 NCAFP President

It also hit home for me personally, as Nancy and I were the caregivers for my mother, Emmi, who passed away from Alzheimer’s Disease in 2005.

- MUSINGS FROM THE MOUNT -

Painting the Mona Lisa While Sitting on a Fire Ant Hill Being a physician these days is like trying to paint the Mona Lisa while sitting on a fire ant hill. The entities in charge (EIC – there, I invented an acronym) expect perfect outcomes, superlative quality measures, 5-star ratings on Press-Ganey, and excellence in whatever other metrics they can dream up. And all of this has to be done within the context of a 20-minute visit, which is pretty well gone by the time my nurse checks the patient in, does a medication reconciliation, updates the depression screen, checks vital signs, and gets the EHR ready for me to go.

Family Physicians provide the majority of care for senior citizens in the United States. This is true not only due to our broad scope-of-practice, but also due to our geographic footprint. Quite simply, there are more of us than other specialties, particularly outside of the urban areas.1 Alzheimer’s Disease is now the 6th leading cause of death in the United States. Over 5 million Americans have the disease, and the number is climbing as our population becomes older. On top of this, more than 15 million Americans provide unpaid care for people with Alzheimer’s or other dementias. And here is the statistic that bothers me: 35% of caretakers report that their own health has gotten worse due to care responsibilities, versus 19% of caretakers of people without dementia.2

Being a caretaker can be a difficult job. From personal experience, I 2016-2017 NCAFP President know it is emotionally and physically exhausting, not to mention the financial aspects of long term care. It is 24 hours a day, There are days I feel the acronyms are winning. But seven days a week, 365 days a year. For the caretakers, every time I start to feel sorry for myself, something it can be a heavy burden, but it is a burden borne out happens to remind me why I love being a small-town of love. I have a great deal of admiration for family Family Doctor. members who give up careers, school, homes or otherwise sacrifice to help take care of a chronically ill I recently had the opportunity to speak at a demenfamily member. tia seminar sponsored by the local Methodist Church. I was told to expect 50 to 75 people. Almost 300 I have seen many examples of this in my career. Let showed up. A few patients were there, but the crowd me share a couple of stories that left an impression on was mostly caregivers of those with dementia. I was me. The names have been changed out of respect to overwhelmed as people came up afterwards to tell their families. Including Pork Chop.

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Charles W. Rhodes, MD

The North Carolina Family Physician


2016-2017

NCAFP Board of Directors Executive Officers President President-Elect Vice President Secretary/Treasurer Board Chair Past President (w/voting privileges) Executive Vice President

Charles W. Rhodes, MD Tamieka M.L. Howell, MD Alisa C. Nance, MD, RPh David R. Rinehart, MD Rhett L. Brown, MD Thomas R. White, MD Gregory K. Griggs, MPA, CAE

District Directors District 1 - Mackenzie Smith, MD District 2 - Gilbert Palmer, MD District 3 - Eugenie M. Komives, MD District 4 - Shauna L. Guthrie, MD, MPH District 5 - Dimitrios “Taki” P. Hondros, MD District 6 - Cody A. Wingler, MD District 7 - Jennifer L. Mullendore, MD At-Large Jason T. Cook, MD At-Large Benjamin F. Simmons, MD IMG Physicians Christopher Z. Rayala, MD Minority Physicians Jewell P. Carr, MD Osteopathic Family Physicians Slade A. Suchecki, DO New Physicians Jessica Triche, MD Medical School Representatives Chair Warren P. Newton, MD, MPH (UNC) Family Medicine Residency Directors Viviana Martinez-Bianchi, MD (Duke University FMR) Resident Director Alyssa M. Shell, MD, PhD (MAHEC-A) Resident Director-Elect Courtland Winborne, MD, MPH (Cabarrus)

Mr. and Mrs. Petrea were in their late 70’s. They had been married for almost 60-years, and lived in a double wide trailer along the Rocky River. Mr. Petrea had severe coronary artery disease and needed bypass surgery. But then Mrs. Petrea was diagnosed with a malignant brain tumor the size of an orange. Surgery and radiation therapy left her unable to walk, speak, or care for herself. Discharge planning recommended skilled nursing home placement. Mr. Petrea chose instead to bring her home. He took all of the furniture out of the living room, and put two queen sized mattresses on the floor. He bathed her, he fed her, he helped her with her daily chores of living. He rolled her from one mattress to the other every four hours, all day and all night, to keep her from getting a bedsore. Pork Chop, their pet pig, lived in the trailer as well, and could be found sitting on the mattress next to Mrs. Petrea whenever I visited. I was concerned when they asked me to See MONA LISA on back cover

Student Director Angie Maharaj (Campbell) Student Director-Elect Allyson Mentock (BSOM) Medical School Representatives & Alternates Chair (UNC) Warren P. Newton, MD, MPH Alternate (Campbell) Nicholas Pennings, DO Alternate (Duke) J. Lloyd Michener, MD Alternate (ECU) Chelley Kaye Alexander, MD Alternate (Wake) Richard W. Lord, Jr., MD, MA AAFP Delegates & Alternates AAFP Delegate Michelle F. Jones, MD AAFP Delegate Karen L. Smith, MD AAFP Alternate Richard W. Lord, Jr., MD, MA AAFP Alternate Robert L. Rich, Jr., MD The NCAFP Family Medicine Councils Advocacy Council Thomas R. White, MD, Chair Garrett Franklin, MD, Vice-Chair CME Council Membership & Workforce

Alisa C. Nance, MD, RPh, Chair Benjamin Simmons, MD, Chair Shauna Guthrie, MD, MPH, Vice-Chair

Practice Management Council

Spring 2017

Public Relations & Marketing

Thomas Wroth, MD, Chair Slade Suchecki, DO, Vice-Chair William A. Dennis,5MD, Chair


HEALTH POLICY & ADVOCACY By Gregory K. Griggs, MPA, CAE NCAFP Executive Vice President

The Academy in Action NCAFP’s Work on Your Behalf The 2017 legislative session, as expected, has been a busy one. Listed below are a few the bills that the NCAFP Government Affairs team has been following, and the status of these bills. Concussion and Heat Related Sports Injuries (H116): This bill seeks to provide better education on heat-related injuries and sudden cardiac arrest in athletes. As originally written, however, it would have provided parents the authority to decide on when a student athlete could return to play from a possible concussion. Status: VICTORY! The NCAFP successfully lobbied to have the provision allowing parents to make return to play decisions removed from the bill. The bill now asks the state Board of Education to develop guidelines and education to inform students and parents about the dangers of sudden cardiac arrest and heat-related injuries. The bill also requires CPR certification by the head coach or athletic director for each athletic activity and requires local boards of education to adopt mandatory heat stroke prevention protocols

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for student athletes. The bill now limits concussion return-to-play decisions to a physician, physician assistant, nurse practitioner or an athletic trainer. Finally, the bill creates a database of catastrophic illnesses, injuries and concussions that occur at athletic events. Next Steps: The bill, with appropriate changes, gained approval form the House Health Committee, but now must receive approval by the Committee on Education prior to being voted on by the full House and moving on to the Senate. Scope of Practice Bills: Several scope of practice bills are now being considered by the Legislature, including a bill that would allow Optometrists to perform surgery (Senate Bill 342), and a bill that would eliminate supervision from all Advanced Practice Registered Nurses (House Bill 88 and Senate Bill 73). Status: MIXED. The NC Optometric Society made a major push for Senate Bill 342, investing significant efforts in both PAC fundraising and lobbying. However, due to confusion over the language

in the bill, there has been some significant pushback from the Legislature. The proponents of the bill claimed that they only wanted to add four simple procedures to the scope-of-practice for Optometrists. However, the language of the bill indicates that there would be 14 procedures that an Optometrist could NOT do (only Ophthalmologists could), but other areas would be within the scope-of-practice of optometrists. The NC Society of Eye Surgeons have pushed back strongly, and the NCAFP expressed concern due to the open-ended language of the bill. Recently, the House revised their bill and adopted language to have the NC Institute of Medicine conduct a study of the issue. The revised language passed the House and is now in the Senate. The Modernize Nursing Practice Act (H88 and S73): This bill received a hearing but not a vote in the House Health Committee in March. NCAFP Past President Dr. Conrad Flick (‘03) spoke against the bill on behalf of the NCAFP, expressing concern around quality of care and the length of education that an APRN would have when being able to practice independently. We also asked members to e-mail their legislators, and hundreds of you did. We’ve also had a current firstyear resident who previously completed her NP degree and served in that capacity for two years, meet with numerous members of the Legislature about the differences in training and education. There continues to be a strong nursing lobby on this issue, and it is unclear where

The North Carolina Family Physician


the bill will ultimately land. However, your NCAFP Executive Committee and government affairs team have discussed the issue extensively to develop various options for numerous scenarios. Stay tuned. Opioids - The STOP Act (H243 / S175): The Strengthen Opioid Misuse Prevention (STOP) Act has been one of the most discussed pieces of legislation of the year. The bill proposes to strengthen numerous regulations governing the prescribing and dispensing of opioids, as well as providing greater addition treatment services. Status: MOSTLY POSITIVE. After much debate and numerous revisions, the bill has passed the House and moved onto the Senate. We successfully lobbied for several positive changes. The bill moves to require e-prescribing of opioids. We were successful in pushing this requirement date back to January 1, 2020 rather than it taking affect immediately. The legislation requires NPs and PAs to consult directly with their supervising physician if prescribing over 30-days of opioids. It also requires dispensers (pharmacists) to report to the Controlled Substances Reporting System (CSRS) by the close of the next business day after delivery. Finally, prescribers (physicians) would also be required to check the CSRS on the initial prescription and every three months. There were three significant changes that the NCAFP was successful in negotiating on this portion of the Spring 2017

bill. First, an original suggestion was to have physicians check the CSRS at every prescription. Second, the implementation date for this will be 30-days after the State Chief Information Officer has certified that certain upgrades to the CSRS have been completed to make that system work more effectively and efficiently. Third, the bill would had applied to all Controlled II through Controlled V substances. The NCAFP was able to limit this requirement to certain “targeted controlled substances” in Categories II and III. This is pretty much limited to highly addictive pain killers. The bill also requires hospice providers to educate families on proper disposal of controlled substances. The bill had originally required the prescribing physician to ensure that a hospice patient’s leftover prescriptions were returned. In addition, the bill limits a 5-day supply for the first prescription on an acute pain (injury) visit and to 7-days for the first prescription post operatively. A pain management agreement is also required when prescribing for over 60-days.

Let’s make NCAFP’s voice even in Raleigh

Contribute

Today!

This bill has now moved to the Senate for consideration. It has bi-partisan support in the House. These are just a sampling of the bills we are following this session. To date, we have evaluated or followed over 50 pieces of legislation, some that are very simple and some complex. While we won’t take positions on all 50 of those bills, we certainly are always looking for how they could impact you, our member.

FAMPAC Empowering Family Medicine

ncafp.com/fampac


EDUCATION & PROFESSIONAL DEVELOPMENT By Kathryn Atkinson Manager, Meetings & Events

Summertime Conference to Feature Timely Topics: Saltwater, Sunshine & CME Mid-Summer Family Medicine Digest July 2 – July 6, 2017

When was the last time you wore flip flops to a conference?

2017 Mid-Summer Family Medicine Digest CONFERENCE & EXHIBITION 30+ AAFP Prescribed Credits • Program Chair: Jewell Carr, MD Make plans now to join us for a fun, educational week of half-day, interactive sessions. Tentative topics include: Gout Diabetes Pediatrics Sports Medicine Direct Primary Care Models

Depression Hypertension Travel Medicine Pain Management And much, much more!

Optional sessions:

When was the last time you wore flip flops to a medical conference? Just can’t recall? Well, pretty-up those piggies, pack your favorite flip flops and plan to meet us in Myrtle Beach this July 2nd – July 6th for a fantastic week of saltwater, sunshine and CME! The plan is simple and the schedule is ideal; plan to soak up valuable CME in the mornings and relax by the sea with family and friends in the afternoons.

Hands-On Cosmetic Procedures, Nexplanon Training, & KSA Study Working Group on Hypertension

SUN, JULY 2 – THURS, JULY 6, 2017 Kingston Plantation/Embassy Suites • Myrtle Beach, SC

CME | Camaraderie | Networking | Family Fun www.ncafp.com/msfmd

Like a well-packed beach bag, our Program Chair, Dr. Jewell Carr, has made sure to include all the important topics in this year’s General Sessions. Clinical sessions slated for the week include Depression, Diabetes, Hypertension, Lipids, Bacterial Pneumonia, Pain Management, Pediatrics, and many more. The last day of the conference will feature a practice management track aimed at addressing popular topics such as Direct Primary Care models, MACRA, MIPS, New Payment Opportunities, and more. General Sessions will begin on Monday, July 3 at 7:15 am and are scheduled to adjourn each day at 1:15 pm. In other words, this means one important thing: You can be on the beach or by the pool by 1:30 pm each day!

that afternoon from a hands-on interactive cosmetics procedures CME workshop, or a Knowledge Self-Assessment Study Working Group on Hypertension. Ever considered adding cosmetic procedures to your practice? Join Dr. Amrish Patel from 1:15 pm to 4:15 pm as he explores the latest updates on botulinum toxin injections, dermal fillers, and chemical peels during the Cosmetic Procedures in Family Medicine CME Workshop. Meanwhile, KSA Study Working Group participants can fulfill their MC-FP requirements with Dr. Jonathon Firnhaber from 1:15 pm to 5:15 pm and earn 8 CME credits upon their completion of the course.

If you happen to need a little more CME than you need sunshine, Wednesday, July 5th will feature two optional afternoon CME workshop opportunities. Take your pick

But wait, like free ice cream on a hot summer day, this conference line-up just keeps getting better! Back by popular demand, we are excited to present a free

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The North Carolina Family Physician


pre-conference Sports Medicine Symposium beginning Sunday, July 2nd from 1:00 pm – 6:45 pm with two of our favorite co-chairs, Dr. Karl Fields and Dr. Kevin Burroughs. Participation in the Sports Medicine Symposium is FREE with your conference registration. Those of you arriving in Myrtle Beach early in the day on Sunday are encouraged to take advantage of this terrific opportunity to earn 5 sports-medicine-focused CME credits, all in one convenient afternoon. We think half-day sessions, along with the salty air and warm beach breezes, make this the perfect conference to include your family and friends! We’ll provide the fantastic CME (and discounted tickets to the Alabama Theatre!) while you make plans for everyone you love to join you in Myrtle Beach over the 4th of July. Accommodations at the Kingston Plantation & Embassy Suites include hotel rooms and 2 – 3 bedroom condos and villas ranging from $249 to $448 per night. While the cut-off date for reservations is June 1st, the hotel will sell out before then. Make your reservations today by calling 800-876-0010 and requesting the NCAFP room block. You can get started on making your plans to attend by visiting our conference website at www.ncafp.com/msfmd. You will find additional conference details including a tentative schedule of events, hotel reservation information, family fun activities, and convenient online registration all at your fingertips.

See You at the Beach! If you have any questions or need any assistance in planning your participation in this fantastic annual event, please contact Kathryn Atkinson, Manager of NCAFP Meetings & Events, at 919-214-9058 or via email at katkinson@ncafp.com. We look forward to seeing you there!

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Spring 2017


CHAPTER AFFAIRS Our members making news Brody SOM Honors Dr. Jessica Triche with its 2017 Community Physician Award Dr. Jessica Triche, NCAFP’s New Physicians Constituency Director, has been honored by ECU Brody’s Class of 2017 with their annual Community Physician Award. The award recognizes Dr. Triche’s excellence in teaching medical students as a non-staff, community physician. Dr. Triche received her award on May 4th, at Brody. She was also recently honored by the school’s Family Medicine Department as their Community Preceptor of the Year.

Dr. Jim Jones Honored as Wake Forest Distinguished Alumni NCAFP Past President Dr. Jim Jones (’73), was honored recently as a Wake Forest Distinguished Alumni. As a 1955 graduate of the University and a 1959 graduate of Wake Forest’s medical school, Dr. Jones was recognized for his many lifetime career achievements, including his impact on family medicine, primary care and rural healthcare delivery across North Carolina and nationally. The award is presented yearly by the Wake Forest Alumni Association to graduates whose achievements and recognitions reflect honor on the University. Congratulations!

Dr. Karen Smith Honored by Hoke County Commission 2017 National Family Physician of the Year, Dr. Karen Smith, FAAFP, of Raeford, NC, was recently recognized with an official proclamation by the Hoke County Board of Commissioners. The procla mation recognized Dr. Smith’s ongoing work and contributions to improving the health of Hoke County and serving as a professional role model within her community.

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Executive’s Message

Everyone Needs a Little Joe Time By Gregory K. Griggs, MPA, CAE NCAFP Executive Vice President

Recently, I had the pleasure of visiting with the residents at New Hanover Regional Medical Center Residency in Family Medicine in Wilmington. The NCAFP has embarked on another effort to visit all of North Carolina’s residency programs and engage with both the faculty and residents. During the visit, I was struck by the emphasis placed on resident wellness. Joe Kertesz, MA, LPC, oversees behavioral health education for the residency and has undertaken an added emphasis on faculty and resident wellness. For example, once a week during intern year, all first-year residents have lunch with Joe. It’s a chance for them to decompress, relieve stress and just help one another. Every family physician can relate to the stress of internship year. But Joe, and the entire faculty at the residency program, has made resident wellness a priority. It showed on the faces of all the residents and even in the laughter at a resident huddle I had the privilege of attending. The program also received a grant to help emphasize wellness for all the residents at New Hanover Regional Medical Center, including the OB/ Gyn residency, the Internal Medicine

The North Carolina Family Physician


You can’t imagine doing anything else…

NCAFP’s Greg Griggs speaks to residents at New Hanover Family Medicine Residency.

residency and the Surgery residency. Now, the effort is crossing medical disciplines. The Family Medicine program blocks a few hours each month for each class of residents to take part in a team-building effort. One month included a cooking class. Hearing about what goes on at the residency program in Wilmington reminded me that we all must stop, breathe a bit, and re-energize our own professional and personal lives. Whether it’s the staff here or everyone in your clinic, we’ve got to make sure we make our own “Joe Time” a priority. The residents in Wilmington certainly raved about their “Joe Time,” whether it was the weekly lunches during intern year or now the monthly team-building sessions. With all the acronyms in medicine today (ACOs, PCMH, MACRA, etc.) it can seem overwhelming at times. And of course, there’s always the WAC (Work After Clinic). But none of that is what drove each of you into medicine. You entered Family Medicine to help your patients. I get frustrated with a different set

of acronyms at times as well. They include NCGA (NC General Assembly); JLOC (Joint Legislative Oversight Committee for Health and Human Resources); LME/ MCO (Local Management Entity/ Managed Care Organization for Mental Health); PHP (Pre-Paid Health Plans for the Medicaid Managed Care Proposals); etc. But I have to step aside and remind myself at times what energizes me as well. While I can’t take care of patients directly, I get energized when I know in some small way I’m helping you take better care of your patients. Family physicians wear the white hats, and it’s easy and rewarding to represent you. Sometimes it takes a “Joe” at a family medicine residency program to remind me what’s important. Or in this case, it was a lot of residents who were happy because they had their own “Joe Time.” So remember, when the prior authorizations, acronyms, or red tape get you down, remember to take some “Joe” time for yourself and focus on what energizes you – your relationship with your patients.

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Spring 2017


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By Tamara R. Johnson, BSN, RN, CPHRM, RHIA, Senior Risk Consultant – Team Manager, Medical Mutual With the opioid prescription abuse problem at epidemic proportions, many providers face the challenge of recognizing and managing patients who fabricate symptoms to obtain certain prescribed substances, mainly controlled substances. Drug-seeking patients typically display several common behaviors. Being aware of these “red flags” can help providers identify these patients. Here are a few behaviors that fall into the “red flag” category. The patient: • • • • • •

Frequently changes providers in an attempt to find one who will prescribe the desired medication (“doctor shopping”) Exhibits a history of last-minute calls for refills to “carry him or her through the weekend” Believes only one medication—the requested drug—can relieve symptoms Makes complaints that cannot be confirmed with objective clinical findings or appear exaggerated based on objective clinical findings Repeatedly reports loss of written prescriptions Uses different pharmacies over an extended geographical area

Providers can implement the following strategies to mitigate risk exposures related to prescribing practices, particularly as it relates to drug-seeking patients: 1. Utilize the state Prescription Drug Monitoring Program (PDMP) to identify patients who are at high risk for drug diversion and/or doctor-shopping. State PDMP websites can be accessed at http://www.pdmpassist.org/content/state-pdmp-websites 2. Implement a systematic procedure for refilling prescriptions, educating appropriate staff, and enforcing strict compliance with the policy 3. Inform patients verbally and in writing about their practice’s medication refill procedure 4. Establish a treatment agreement with the patient that outlines the provider’s expectations; this agreement should address the number and frequency of prescription refills, early refills, replacement of lost or stolen medications, and specific reasons for discontinuing or changing the drug therapy (e.g., violating the treatment agreement) 5. Consider referral to or consultation with a pain management specialist for patients not responding to the treatment plan 6. Exercise the right to terminate patients who fail to follow the treatment plan or adhere with the treatment agreement 7. Maintain accurate and complete medical records In 2016, the CDC released a Checklist for Prescribing Opioids for Chronic Pain. The checklist includes information on considerations for prescribing an opioid, renewing a prescription, and reassessing the need to continue opioid therapy. This checklist can be accessed at http://www.cdc.gov/drugoverdose/pdf/PDO_Checklista.pdf. Dealing with a drug-seeking patient is inevitable at some point for most providers. However, being aware of the “red flags” and risk strategies addressed here can help them recognize and manage these patients.


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2016

Annual Report


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The State of the Academy 2016 saw significant change and continued progress for the North Carolina Academy of Family Physicians. Our Academy continued to adapt to a rapidly changing environment by transforming how and where we work, by directly engaging our members, and by continually investing in advocacy. Change and transformation were everywhere. The following pages highlight many of the Academy’s accomplishments over the past year. From a revamped NCAFP brand identity to new corporate offices, 2016 saw our Academy realign its resources and begin to direct them in new and exciting ways. The end goal is to provide more value to members through enhanced services, stronger support and the right resources at the right time. Our Academy completed other important work, too:

Rhett L. Brown, MD 2015-2016 NCAFP President

Legislative Advocacy: 2016 proved that even during the legislative ‘short’ session, constant engagement and continuous regulatory advocacy is the new normal. Medical Education: The NCAFP’s meetings and conferences continue to be the best value in professional development for family medicine and primary care. We succeeded again! Membership Service: Academy leaders connected with community practices to engage members where they serve patients, to gather actionable insight, and build relationships. Leading our Academy during such an important and memorable year was an amazing experience. Thank you for the wonderful opportunity to serve you and to help strengthen our specialty. It was an experience I will never forget.

2015-2016 NCAFP Board of Directors Executive Officers President Rhett L. Brown, MD President-Elect Charles W. Rhodes, MD Vice President Tamieka M.L. Howell, MD Secretary/Treasurer Alisa C. Nance, MD, RPh Board Chair Thomas R. White, MD Past President (w/voting privileges) William A. Dennis, MD Executive Vice President Gregory K. Griggs, MPA, CAE

District Directors District 1 - Mackenzie Smith, MD District 2 - Gilbert Palmer, MD District 3 - Eugenie M. Komives, MD District 4 - Shauna L. Guthrie, MD, MPH District 5 - Dimitrios “Taki” P. Hondros, MD District 6 - Cody A. Wingler, MD District 7 - Jennifer L. Mullendore, MD

At-Large Jason T. Cook, MD At-Large David R. Rinehart, MD IMG Physicians Joseph P. Pye, MD Minority Physicians Benjamin F. Simmons, MD Osteopathic Family Physicians Slade A. Suchecki, DO New Physicians Jessica Triche, MD Medical School Representatives Chair Warren P. Newton, MD, MPH (UNC)


3 Resident Members

Financial Summary Our Academy continues to be financially sound.

Student Members Active Members Life Members

Other Members

Net Assets:

$2,980,631

2016 Revenues and Support:

$3.200,000

2016 Direct Financial Support to Residents and Students:

$136,947.00

Political Action Committee contributions to candidates last election cycle:

$17,750.00

Our Membership

Family Medicine Residency Directors Viviana Martinez-Bianchi, MD (Duke University FMR) Resident Director Margarette Shegog, MD, MPH (MAHEC-A) Resident Director-Elect Alyssa Shell, MD, PhD (MAHEC-A) Student Director Jeffrey Pennings (Campbell) Student Director-Elect Angie Maharaj (Campbell)

Medical School Representatives & Alternates Chair (UNC) Alternate (Campbell) Alternate (Duke) Alternate (ECU) Alternate (Wake)

Warren P. Newton, MD, MPH Charlotte Paolini, DO J. Lloyd Michener, MD Chelley Kaye Alexander, MD Richard W. Lord, Jr., MD, MA

AAFP Delegates & Alternates AAFP Delegate AAFP Delegate AAFP Alternate AAFP Alternate

Michelle F. Jones, MD Karen L. Smith, MD Richard W. Lord, Jr., MD, MA Robert L. Rich, Jr., MD

The NCAFP Family Medicine Councils Advocacy Council CME Council Membership & Workforce Practice Management Council Public Relations & Marketing

Robert L. Rich, Jr., MD, Chair Alisa C. Nance, MD, RPh, Chair

Jessica Triche, MD, Chair Benjamin Simmons, MD, Vice-Chair Joseph P. Pye, MD, Chair Thomas Wroth, MD, Vice-Chair William A. Dennis, MD, Chair


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Recognitions 2017 AAFP National Family Physician of the Year Karen L. Smith, MD, FAAFP Beloved by her patients and highly respected in her community, Dr. Smith was selected as the nation’s consummate family physician for her lifelong commitment to improving patient lives and her instrumental efforts in making Hoke County a healthier place to live. This prestigious, national award was the second consecutive year a North Carolina family physician was selected for the honor.

Chapter Membership Recognitions 1st Place XL Chapters - Active Member Retention (96.7%) 1st Place XL Chapters - New Physician Retention (94.4%) 1st Place XL Chapters - Resident-to-Active Conversion (88.5%) 1st Place XL Chapters - Overall Market Share (86.9%) 1st Place XL Chapters - Highest Percentage Increase, Student Membership


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Education 2016 Winter Family Physicians Weekend 40.50 AAFP Prescribed Credits

• • • •

809 Registrations 77 Exhibitors James McNabb, MD – Program Chair Erika Steinbacher, MD – Program Vice-Chair

2016 Mid-Summer Family Medicine Digest 29.00 AAFP Prescribed Credits

• • • •

201 Registrations 20 Exhibitors Alisa Nance, MD – Program Chair Jewell Carr, MD – Program Vice-Chair

55th Annual Post-Graduate Symposium & Leadership Retreat 11.50 AAFP Prescribed Credits

• 79 Registrations • Jewell Carr, MD – Program Chair

For 2016: 81+ AAFP Prescribed Credits 1,089 Total NCAFP CME conferences attendees Secured $1M+ in grant funding, allowing NCAFP to educate over 2,000 AAFP members across the country


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NCAFP

Foundation

Engaging Medical Students: The NCAFP Foundation conti experiences resulted in nearly 3000 hours of clinical an resulting in increased student interest and attendan

Investing in Medical Students: The NCAFP Interest Group on campus through travel scholarships. This support reaches h $1,131,000.00

2016 Direct Financial Sup ments in student and r of support was prov

2016 Famil only a w

2016 NCAFP FOUNDATION BOARD OF TRUSTEES President Vice-President Secretary-Treasurer Physician Trustee Physician Trustee Physician Trustee Physician Trustee Physician Trustee Physician Trustee Academy President Academy President-Elect Corporate Trustee Corporate Trustee Resident Trustee Resident Trustee Student Trustee Student Trustee Trustee Emeritus

Robert L. Rich, Jr., MD, FAAFP L. Allen Dobson, Jr., MD, FAAFP Shannon B. Dowler, MD Tom Wroth, MD Cherrie Crowder Hart, MD Michelle F. Jones, MD, FAAFP Viviana Martinez-Bianchi, MD, FAAFP David E. Lee, MD Lisa A. Cassidy-Vu, MD Rhett L. Brown, MD Charles W. Rhodes, MD, FAAFP Steve Parker John R. Smith, MD Stephen M. Carek, MD Amy J. Nayo, MD Alyssa S. D’Addezio Franklin C. Niblock, MPH Maureen E. Murphy, MD, FAAFP


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inues to work hard to promote Family Medicine through direct student experiences. In 2016 these nd didactic education. Efforts also impacted attendance at Family Medicine meetings, with every event nce.

Foundation’s financial investment in student programs continues with support to each Family Medicine scholarships provided to students to attend Family Medicine conferences, as well as the provision of Family Medicine hundreds of students in North Carolina! The Foundation’s Medical Student Endowment now stands at just under

pport to Residents & Students: The NCAFP and NCAFP Foundation continued to make significant financial investresident programs to promote interest and leadership in the specialty. In 2016, more than $136,000 ovided directly to students and residents.

ly Medicine Gala Raised $50K: This event honored North Carolina’s Dr. Maureen Murphy of Concord and was not wonderful time but a tremendous success and represented the single biggest Foundation fundraiser in 2016!


8 Foundation Contributors NCAFP members and supporters of the Academy are encouraged to make gifts of on-going significance or annual contributions to the NCAFP Foundation. The following individuals contributed to the Foundation in 2016. Thank you for your continued support.

Dr. Robert Adams Mr. David Baker Dr. Kathleen K. Barnhouse Dr. Elizabeth G. Baxley Dr. David Becker Dr. Janalynn Beste Dr. Holly Biola Dr. & Mrs. Mott P. Blair Dr. Emily Bray Dr. Rhett L. Brown Mr. Edwin Bryan Dr. Casey Burnette Dr. William Byars Mr. Tom Campbell Mr. Richard Campbell Dr. Megan Campbell Dr. Ed Campbell Dr. Stephen Carek Dr. Lisa A. Cassidy-Vu Drs. Stephen and Kim Causey Dr. Joyce Copeland Ms. Alyssa D'Addezio Dr. Janice Rawl Dr. William Dennis Dr. Andrea DeSantis Dr. Deanna Didiano Dr. L. Allen Dobson Dr. Katrina Donahue Dr. Shannon B. Dowler Dr. Fernando Escabí-Méndez Dr. Allison Evanoff Dr. Mark Faruque Dr. Conrad L. Flick Dr. Brian Forrest Dr. Garett Franklin Dr. Jessica Friedman Dr. Kara Lee Gallagher Dr.. Herbert Garrison Mr. & Mrs. John Gehring Dr. Carl Gentry Dr. Benjamin Gersh Ms. Margaret Gibson Dr. David Gilbert Ms. Monica Gonzales

Dr. Donald Goodman, Jr. Mr. Gregory K Griggs Dr. Mary Lisa Gunning Dr. Shauna L. Guthrie Dr. Wayne A. Hale Dr. David Hall Dr. Jacqueline Halladay Dr. Vicki Hardy Dr. Revella Harmon Dr. Cherrie Crowder Hart Mr. Brent Hazelett Ms. Tracie Hazelett Dr. Lori Heim Dr. William Arthur Hensel Mr. William Herring Dr. M. Mark Hester Dr. Melissa Hicks Dr. Dimitrios P. Hondros Dr. Tamieka M L Howell Dr. Janice Elizabeth Huff Dr. Nichole Johnson Drs. James and Michelle Jones Dr. Geniene Jones Dr. Viki Kaprielian & Mr. Jon Luis Dr. Susan K. Keen Dr. William Kelly Ms. Jane Kelly Dr. Genie M. Komives Dr. Hervy B. Kornegay Ms. Kristine Lamont Dr. Kelley Lawrence Dr. Frank W. Leak Dr. David E. Lee Dr. Rich Lord, Jr. Dr. Kimberly Mallin Dr. Viviana Martinez-Bianchi Mr. Scott Maxwell Dr. A. Tom May Mr. Patrick McCarthy Dr. Geeta McGahey Dr. James McGrath Dr. William C. McLean Dr. James McNabb Dr. Darlyne Menscer Ms. Barbara Metz Dr. Paul Meyer Dr. Lloyd Michener Dr. Robert Moser Dr. Jennifer L. Mullendore & Mr. Josh Evans Dr. Maureen Murphy & Mr. Scott Maxwell Dr. Elisabeth B. Nadler Dr. Alisa Nance

Dr. Andrew Nance Dr. Liliana Nazario Mr. Whit Newton Dr. J. Thomas Newton Mr. Franklin C. Niblock Dr. Jerry Nymberg Dr. Augustine Onwukwe Dr. Gilbert F. Palmer, V. Dr. Charlotte Paolini Mr. Steve Parker Dr. Ankur Patel Dr. & Mrs. Timothy Paul Dr. Nicholas Pennings Mr. Paul Pikman Dr. Robert P. Poetta Dr. Ronald A Pollack Dr. Lara Pons Dr. Bradley W. Propst Dr. Joseph P. Pye Dr. & Mrs. Charles W. Rhodes Dr. & Mrs. Robert Chuck Rich, Jr. Dr. David Rinehart Dr. Sarah Ringel Dr. & Mrs. Mark Robinson Dr. J. Carson Rounds Dr. Devdutta G. Sangvai Dr. Charles Sawyer Dr. Gary S. Schenk Dr. Susan A. Schmidt Dr. Stephen C. Seltzer Dr. Mike Sevilla Dr. Margarette Shegog Dr. Alyssa Shell Ms. Ann Shepherd Dr. Candice Sieben Dr. Benjamin Franklyn Simmons Dr. Nadine Skinner Dr. Mackenzie Smith Dr. Tala Smith Dr. Karen L. Smith Dr. Richard A. Smits Dr. Christopher Snyder Dr. Neil Sparks Dr. Barbara Stagg Dr. Holly L. Stegall Dr. Erika Steinbacher Dr. Julian Taylor Dr. Erin J. Trantham Dr. Jessica Triche Ms. Lily Trout Dr. Donna Tuccero Dr. Ying Vang Mr. Andy Vrantsis Mr. Vincent Wade Ms. Alexa Waters Dr. Jana C. Watts Dr. Thomas R. White Dr. Tom Wroth Dr. Christopher Zagar


MEMBERSHIP By Tara Hinkle Manager, Member Services

- GROWTH MILESTONE -

NCAFP Membership Surpasses 4,000!!!

from a vast array of topics that directly impact you and of our extremely important advocacy efforts here in North Carolina. Keep reading our e-newsletter, NCAFPNotes, our magazine, and the occasional alerts we send, as there may be times when we would welcome your brief presence, your influential voice, or your many talents and gifts to help support and shape the future of family medicine and primary care. Just as many have helped you get to where you are, we hope that you will continue to help the NCAFP nurture the spectacular talent of our medical students, residents, and new physicians. Our future looks bright because of you! Get Involved!

The NCAFP Membership Department has some exciting news. As of January 31, 2017, total NCAFP membership has surpassed 4,000 members! 4,030 to be exact. This accomplishment has been years in the making and could not have happened without you, our loyal members, who strive each and every day to make family medicine all it should be.

Please visit our website at www.ncafp.com/membership for ways you can become involved, even in mi-

Whether you are a seasoned physician, a resident in training, or a new medical student, we appreciate your passion for family medicine, and the diverse communities and patients you serve. And we know that you do not take the decision to renew your membership lightly, so we are sincerely grateful that you choose to take this journey with us each year.

nor ways, or promote the great things happening in family medicine. And also be sure to post your family medicine openings on our online career center, NCAFP FMCareers, at jobs.ncafp.com. Quality candidates are looking...

As NCAFP membership grows, so do our obligations to serve you. We try hard to keep you informed of our upcoming meetings where you can earn CME credits

If you have membership questions, please contact Tara Hinkle, NCAFP Manager, Member Services, at thinkle@ncafp.com or 919-980-5381.

Spring 2017

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STUDENT INTEREST & INITIATIVES By Tracie Hazelett Manager, Medical Student & Residency Relations

Another Fantastic Match Year for North Carolina It’s a Match!

Day helped put a few of the medical school sacrifices and challenges they and their families have made the last four years a little further behind as they eagerly opened their envelope – or even their e-mail – to learn where they will spend the next phase of their training. This year, 612 North Carolina medical students participated in either the Military Match held last December, the National Matching Service’s Match for the American Osteopathic Association in February, or the National Resident Matching Program (NRMP) Match in March. Of those 612 students, 82 chose to enter Family Medicine, representing 13.4% of all graduating NC medical students. This marks the highest number and percentage of NC medical students to enter this specialty.

I know many reading this are thinking, “Of course it went up!” since we now have a 5th medical school Friday, March 17, 2017 wasn’t only about the ‘Luck (Campbell UniO’ The Irish’ or simply another rea2017 NC Student Match at a Glance versity’s Jerry M. son to celebrate or have a little fun. Wallace School of This year, it marked the day that most Family Med In-State Medical School Osteopathic Medmedical students learned where they Match % Match icine) contributing will be spending their next three to Brody SOM @ ECU 16.2% 75% to the number of seven years. Campbell Univ. School 21.2% 25.8% of Osteopathic Medicine graduating physiDuke University SOM 1.9% 50% cians. True, it cerAlthough some students 11.7% 40% tainly had a positive learned their fate back in UNC SOM Wake Forest SOM 14.8% 41.2% effect on our overall February when the Nationnumbers. However, al Matching Service’s (NMS) reeven before factoring those graduates into the numsults were announced, or perhaps as early as last bers, North Carolina’s four allopathic medical schools December when the Military Match results were still hit an all-time high in the total number students unveiled, “that” day is a day to remember! choosing Family Medicine. Although this rise is encouraging, our work is not done. For one brief moment, the excitement students Congratulations to the Class of 2017 as you embark experienced on their Match on your next great adventure!! David Baker, Brody SOM, Match: MAHEC-Asheville

Jessica Bitencourt, Campbell SOM, Match: New Hanover Regional Medical Center FMRP

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Adam Willson, UNC SOM, Match: UNC FMRP

Kate Timberlake, Wake Forest SOM, Match: Cone Health FMRP

The North Carolina Family Physician


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RESIDENTS & NEW PHYSICIANS

Battling Opioids on the Frontlines By Peter Graber NCAFP Communications

A

SHEVILLE, NC -- The Friday evening began just the way Dr. Blake Fagan of the MAHEC-Asheville Family Medicine Residency Program wanted. After a hectic week teaching, seeing patients, and attending to administrative duties every physician loves, unwinding with his family was just what he needed. He glimpsed the start of his call-free weekend as a just reward for navigating another crazy schedule. Then his cell phone rang. Recognizing the number from Mission Hospital in Asheville, he did what many family doctors do on their time off – he answered on the second ring.

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The news wasn’t good. One of Fagan’s longtime patients was in the ICU and couldn’t be stabilized. He recognized her name instantly, a remnant of having delivered two of her children and knowing her family. His heart sank as he found out more. “I was very disturbed that the patient was in the ICU, and after finding out it was from an overdose, it prompted me to ask many questions,” Dr. Fagan recalled in relating the story. Tragically, his patient died that night. The magnitude of the loss and what it represented set-in immediately. “Right there, I realized that the opioid problem was not just a little problem, but a major crisis.”

The North Carolina Family Physician


North Carolina’s opioid and prescription drugs crisis has drawn the attention of family physicians, state legislators, and has fostered new educational requirements by the NC Medical Board. Family doctors in practices large and small, urban and rural, independent and hospital-affiliated have all seen the effects of the crisis. Addiction and tragedy respect no divide.

management, brief interventions, and helping prepare them for what they may encounter in daily practice.

Fagan says the response has been extremely positive, both by trainees and patients. The program has now taught its graduating residents for two straight years and recently expanded its work to include residents of MAHEC’s Obstetrics residency program. MAHEC’s approach features didactic training on Fight Comes to Residency Programs addiction and brief interventions, appropriate opioid prescribing, and Like no other style of practice, helps prepare residents to become North Carolina’s family medicine licensed buprenorphine/Suboxone residencies have a front row seat prescribers. The program completo our opioid crisis. As teaching ments its training with multi-discenters that operate busy outpaBlake Fagan, MD ciplinary clinical teams led by phytient clinics and maintain close ties MAHEC-Asheville Family sicians and consisting of a nurse Medicine Residency with local hospitals, North Carolipractitioner, pharmacists, and bena’s residencies are witnessing the havioral health providers. Group therapy is also beepidemic firsthand. And with their responsibility ing used with growing success. of training physicians who often graduate to the frontlines of care delivery, residency programs are Although it took time to develop the necessary taking the lead on educating new physicians about policies and procedures, and to set up the group therapy addiction medicine, modern pain management, and visits, Dr. Fagan says the program’s efforts are paying interventional, in-office care. off. MAHEC has now begun to expand its training to the local provider community, as well. In Dr. Fagan’s case, as MAHEC’s then-Residency Program Director, he was in the unique position to Marina MacNamara, MD, MPH, is a 2016 graduhelp make a difference. He committed to developate of MAHEC Asheville who serves patients at Mising a solution as soon as possible. sion Community Primary Care-Haywood, in Clyde, NC. She was part of the first class of residents to go “That patient really taught me a lot. And I wanted to through MAHEC’s new program. The training was help with solutions like training the next generation instantly applicable. of family doctors to screen for, recognize addictions, provide brief intervention and treat or refer to treat“My very first continuity OB patient in residency was ment,” he said. “I also wanted to train all providon Subutex. For a mom who already has enough apers in appropriate opioid prescribing to reduce the pointments, to be able to obtain her Subutex from number of people who start in their addiction.” her prenatal provider simply makes sense on so many levels,” MacNamara shared. Dr. MacNamara sees Over the next 18-months, Dr. Fagan and his team the training as improving the kind of help patients developed and launched a teaching curriculum often need, but may not immediately recognize. At designed for that very purpose. MAHEC-Asheville her four-physician rural health center, she is the only is now training new physicians about addictions, prescribing best practices, modern pain Continues on next page

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physician licensed to be a buprenorphine/Suboxone provider.

Training by NC’s Residency Programs

“Opiates are out there even if you yourself don’t prescribe them. Instead of simply saying, ‘I don’t prescribe opiates,’ help your patients who are already on them by offering safer ways to manage these potentially harmful medications,” MacNamara noted.

Morganton / Blue Ridge - All incoming residents are oriented about controlled substance prescribing policy, UDS screening, and controlled substance agreement forms. Formal didactics feature presentations from physicians at our pain management group on opiate prescribing practices.

Outside of MAHEC, all other North Carolina family medicine residencies are working to educate their residents on opioids, too. At training centers from Wilmington to Morganton, programs are training new physicians on pain management best practices, mandating strict adherence to controlled substances care policies, and utilizing tools like the NC Controlled Substances Reporting System.

All Family Medicine residency programs across North Carolina are training new physicians on pain management, prescribing best practices, controlled substances, and addictions. Examples of some of our residency program efforts include:

Cabarrus - All new residents use the DEA registry, collaborate with pharmacy care team members on opiate policy reviews, quality improvment project was trying to increase the use of narcan rx. Another was trying to identify people taking both benzodiazepines and opiates to intervene. Carolinas HealthCare System - Several learning modules are available for residents and faculty to complete for independent learning. CHS programs also give several didactic seminars in various venues. Cone Health Medical Center - Residents attend up to 2 conferences yearly on opioids, opioid overdose deaths, and appropriate prescribing. The clinical workflow uses a custom EHR template and features routine UDS screening and review for all chronic opioid users. New Hanover Regional Medical Center - Uses standardized approach to all patients on controlled substances that includes a controlled substance agreement, a clinical workflow that checks with the NC Controlled Substances Reporting System, and the use of EHR templates. UNC - Provides multi-faceted training that includes 2-hour sessions on chronic pain and safe prescribing of controlled medications, multiple sessions on safe opioid prescribing and opioid dependence treatment with buprenorphine.

“North Carolina’s residency programs are on the frontlines and in many respects, setting the pace against the crisis,” explained NCAFP President Dr. Charles Rhodes, President of Cabarrus Family Medicine in Concord. “Their work multiplies with every physician they produce.” Practical Harm Reduction The core of MAHEC’s approach is the concept of harm reduction as a means toward overcoming addiction and dependency. Because patients often

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have significant shame and guilt associated with their addictions and will often be extremely wary of the medical community (including their own personal physicians), services that are presented in a non-judgmental manner make them respond very positively. Harm reduction exists in a growing range of today’s most effective addiction management efforts, from initiatives like needle-exchange programs and methadone clinics, and through progressive laws like North Carolina’s 911 Good Samaritan/ Access to Naloxone bill passed in 2013. When this kind of approach is combined in the exam room of a primary care physician, it often represents a practical, scalable strategy in battling a crisis like opioid abuse.

Dr. Fagan says MAHEC’s program is seeing growing success with patients and has seen a marked impact on resident and faculty prescribing patterns. Patients who have been stabilized on Suboxone have been able to keep their children, obtain jobs and make progress in their recoveries. “People with addictions make-up approximately 8% of the population, so they are already in our practices,” said Fagan. “With the opiate crisis we’re facing, if we can provide the therapy in our offices, that eliminates a major barrier to care.”

The North Carolina Family Physician


Pick Your Pace to Payment Success

Start now to avoid a negative payment adjustment in 2019.

Let the AAFP guide you through the Quality Payment Program (QPP) and MIPS.

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IMPORTANT! October 2 is the last day to begin gathering data in order to fully or partially participate in MIPS.

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i

Gottschalk A, Flocke SA. Time spent in face-to-face patient care and work outside the examination room. Ann Fam Med. 2005;3(6):

ii Solomon J. How strategies for managing patient visit time affect physician job satisfaction: a qualitative analysis. J Gen Intern Med. 2

PRACTICE MANAGEMENT

iii American Academy of Family Physicians. Teamwork within a practice can relieve patient overload. AAFP News Now. October 9, 2012

www.aafp.org/online/en/home/publications/news/news-now/practice-professional-issues/20121009teambasedcare.html. digm-changing way of practicing medicine. What follows is Davies M, Boushon B. Panel size: how many patients can one doctor manage? FPM. 2007:14(4):44-51. a few ivofMurray theM, most common comments that we hear:

v Kong MC, Camacho FT, Feldman SR, Anderson RT, Balkrishnan R. Correlates of patient satisfaction with physician visit: differences non-elderly survey respondents. Health and Quality of Life Outcomes. 2007;5(62). www.hqlo.com/content/5/1/62.

DIRECT PRIMARY CARE

Myths, Misrepresentations and Hope By Thomas Rhyne White, MD HomeTown Direct Care, Cherryville, NC trwhitemd@mac.com Amy Walsh, MD Doctor Direct, Raleigh, NC amy@doctordirectmd.com This year is shaping up to be an interesting year for health care, to say the least. The future of the Affordable Care Act is a moving target, but clearly not as easy a target as some thought. But what does seem clear is that there is a great appetite in DC and Raleigh for change from the status quo, and especially for how we pay for care. We are two family physicians who in recent years have chosen to leave traditional insurance-based practices to establish Direct Primary Care (DPC) models. Each of us felt that the “usual” led us to practice in a manner we never intended: rushed, impersonal, and beholden to someone or something other than the patient. Looking back, we are convinced we made the right decision. We are even more convinced that DPC offers the opportunity for Family Medicine to flourish: to recruit significantly more students to our specialty, to maintain the morale and financial stability of those in practice, and to make it more feasible for those contemplating retirement to “hang in there” a little longer. However, we still hear comments which lead us to believe that DPC is still misunderstood by many of our colleagues. In this brief article, we hope to dispel some myths and clarify this increasingly popular and (in our opinion) para-

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vi Dugdale DC, opened Epstein R, Pantilat SZ. Time the patient–physician relationship. J Gen Intern Med. 1999:14(S)S34-S40. “I heard you one ofandthose “concierge practices.”

vii Wasson JH, Anders SG, Moore LG, Ho L, Nelson EC, Godfrey MM, et al. Clinical microsystems, art 2. Learning from micro practice patients the care they want and need. The Joint Commission Journal on Quality and Patient Safety. 2008:34(8):445-452.

Well, not exactly. Although DPC and concierge medicine do share a few similarities, there are some pretty significant differences. Let’s start with the similarities. Both DPC and concierge have smaller panel sizes, typically under 1000 patients per physician, and commonly 400 to 600. They both involve fewer daily patient visits but with longer appointments; often hour-long visits. Now, let’s examine the differences. Concierge medicine arose

Get to Know Direct Primary The AAFP has excellent learning resources on Direct Primary Care

Visit the Direct Primary Care Resource Center at w

as an option for the wealthy. The annual membership fee can be anywhere from $2,000 to over $10,000 for some practices. Concierge doctors still accept insurance, claims are filed with third-party payors, copays are collected, and deductibles still apply. DPC practices, on the other hand, strive to be “insurance-detached.” They do not file claims or accept any third-party payments, nor do they balance bill a patient. DPC practices see patients with or without insurance under the same pricing. The monthly membership fees for DPC typically range from $40 to $100, with most charging discounted rates for children (under $20 per mo). Clearly, the DPC price tag is much lower compared to concierge care. DPC practices may charge a modest “utilization fee” for visits, or include them in the recurring fees. Labs are offered at a discounted fee, or may even be free in some DPC models. Some offer prescription medications directly to their patients at a fraction of what they would cost if billed through

PrimaryCareFAQ2014.indd 4

The North Carolina Family Physician


005;3(6):488-493.

rn Med. 2008;23(6):775-780.

er 9, 2012. l.

insurance. The emphasis is on value and affordability, while still providing enhanced access and more personalized care.

ferences between elderly and

“That won’t work in my town.” practices about providing

We beg to differ. Currently, there are over 500 DPC practices in the US, and the number is growing monthly. These practices are in large cities, in small rural communities, and in suburbs in between. Although DPC had its roots as an option for the uninsured - and still offers an incredible option for those patients and families - it is the “insured” who are driving the growth of our practices. Patients are frustrated with their current health care. They are looking for better access, more value, more time with their doctor, and the ability to get advice and an-

priority. We do, however, acknowledge the need for accountability and transparency, and that the lack of data has been a fair criticism. Patients and employers and payors expect and deserve as much. Although DPC is really in its infancy, data is now emerging. In fact, in the state of Washington, Qliance (one of the largest and oldest DPC networks in the country) has reported a 20% reduction in overall health care costs compared to a traditional cohort, with a reduction in ED visits, hospitalizations, specialty visits, and advanced radiology. In Apex NC, Dr. Brian Forrest has demonstrated in his DPC practice significantly better BP, LDL-C, and A1C control than national norms. And thanks to an innovative option for employees of Union County NC, DPC has resulted in a 38% reduction in medical expenses with an annual savings of $1,408,089. These are all impressive. However, even with such data, we believe that the doctor-patient relationship remains the most important measure of what we do. And the value of that, to a large extent, is unmeasurable. As Einstein once said, “Not everything that can be counted counts, and not everything that counts can be counted.”

ry Care

“If more doctors do this, it will just worsen access.”

at www.aafp.org/dpc

If every family doctor converted to DPC overnight, then yes, there is a chance a crisis could occur. But we think it is not that simple. It would be a stretch to say that access in our current system is optimal, or even good. 04/2014

swers to their questions as efficiently as possible, even with4/24/14 10:51 AM out an office visit if appropriate. So even when they have insurance, they are willing to pay the low monthly fee (the equivalent of basic cell phone service, or a visit to the hair salon) for a different experience. Rising deductibles have and will make DPC even more attractive. And in 2017, we expect federal legislation to make Health Savings Accounts (HSAs) a clearer option for individuals who desire care from a DPC practice. Employers are particularly interested in DPC too, as they seek to control their health insurance costs and provide benefits for their employees. Patients and employers understand the value of DPC. They “get it.” “Sounds good, but you are off the grid. You have no data.” In some ways, yes, and thank goodness! We appreciate our independence and that the patient is our customer and our

Family Physicians are over-booked, over-worked and over-extended already. By necessity, visits are short and sometimes limited to “one problem, please.” Too often, patients are unable to see their primary care physician for sick or acute visits in a timely fashion, and are choosing or being referred to urgent care centers and Emergency Departments. Even if such visits are within the same system and documented in the same electronic record, is this really desirable continuity of care? Currently, access is not nearly as good as it might appear. Our specialty is growing, but not nearly fast enough. Other specialties look more attractive. The attrition due to burnout, disillusionment, and early retirement is alarming. Put simply, we think the status quo is unsustainable and the future concerns us. Will “pay for performance” truly be our salvation? We are skeptical. Is team-based care, utilizing more extenders, a solution? Perhaps, but ask patients what they want … they want a phyContinues on next page

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sician! They want us! And clearly, there are not enough of us. Imagine not worrying about ICD10, Meaningful Use, MACRA, or MIPS! Imagine using a friendlier, more efficient EHR which is designed for patient care, not third-party billing. DPC offers hope and relief: a more attractive way of practicing, a more desirable specialty choice and a greater demand for residency slots. DPC represents an opportunity to not only maintain but dramatically grow our numbers, while improving patient access to physician care. We do agree that the less fortunate are at risk of suffering in a system which requires the patient to pay the doctor directly out of pocket. This must be addressed if DPC is to become more mainstream. But really, in our experience, most DPC practices already provide care for the working poor at a reduced or gratis fee. Several states, including Washington and Maine, have implemented a DPC model for Medicaid recipients. We think North Carolina should explore this as well. Yes, there may be a rough and rocky transition period as more doctors choose the DPC path. There are details to be worked out. But answer us this: Is the status quo really working for us, and for our patients? We think not. “There is no way I could do that.” If we can do it, anyone can! Yes, it takes a dose of courage and a leap of faith to choose the DPC path. Fortunately, there are ample resources to help. The AAFP has supported DPC as a viable model, and offers online tool kits, workshops, an online member interest group, CME events, and the increasingly-popular annual DPC Summit conference. There are franchise options which provide guidance and a more “turn key” approach. Almost weekly we are contacted or visited by fellow family physicians who want to see what we are doing and how we are doing it. The interest is tremendous, and growing. This is doable. We are proof. We are confident that all Family Physicians are committed to the best possible care for their patients. But we are concerned about our specialty. We believe DPC offers hope. We believe DPC offers a better chance of achieving the “Quadruple Aim” which we all desire - an enhanced patient experience, with improved outcomes, at a lower cost, and with greater physician satisfaction. Thank you for reading. We welcome your comments, questions, rebuttals, and criticisms.

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GET SMART

About Antibiotics Week

WWW.CDC.GOV/GETSMART

Antibiotic Stewardship

RETURN ON INVESTMENT

Antibiotic resistance is among the greatest public health threats today, leading to an estimated 2 million infections and 23,000 deaths per year in the United States. Although antibiotics are life-saving drugs that are critical to modern medicine, infections with pathogens resistant to first-line antibiotics can require treatment with alternative antibiotics that can be expensive and toxic. The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics. Approximately half of outpatient antibiotic prescribing in humans might be inappropriate, including antibiotic selection, dosing, or duration, in addition to unnecessary antibiotic prescribing. At least 30% of outpatient antibiotic prescriptions in the United States are unnecessary. The Healthcare Infection Control Practices Advisory Committee (HICPAC) was convened to provide advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (HHS) regarding the practice of infection control and strategies for surveillance, prevention, and control of healthcare-associated infections, and antimicrobial resistance. As a result, CDC has released the Core Elements of Outpatient Antibiotic Stewardship to accompany the existing recommendations for hospital and long-term care settings. The four areas of focus for outpatient settings are:

Did You Know?

1. Antibiotic resistance is one of the world’s most pressing Actionpublic for policy and practice: threats. Implement at least one policy health Commitment: Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety. or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.

2. Antibiotic overuse increases the development of drugThe North Carolina Family Physician resistant germs.


Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves. Education and expertise: Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing. Alliant GMCF received a contract from the Centers for Medicare and Medicaid Services (CMS) to support the development of outpatient antibiotic stewardship programs in physician offices, urgent care centers, emergency rooms and federally qualified healthcare centers. Our focus will be to assist clinicians in ensuring that each patient receives the right antibiotic, at the right time, at the right dose for the right duration according to current evidence based guidelines. Additional benefits to participation include:

Setting Up a Medical Practice: 4 Things to Do By Whit Newton, CFP ®, a Northwestern Mutual Financial Advisor based in Raleigh, NC

Many medical school graduates dream of starting their own practices. But starting a practice can be a difficult and expensive, so it’s critical to do it right. 1. Create an emergency fund. Since many new practices don’t make money initially because they’re building a client base and paying up-front expenses, it’s imperative to have an emergency fund to cover six months to a year of expenses.

1. Updated knowledge of appropriate antibiotic prescribing practices for common infections in seniors, thus lowering the overall cost of the care.

2. Hire a financial professional. It’s critical to have someone who can help you plan, pay student debt, grow retirement savings and get credit in shape before applying for a practice loan.

2. Available learning collaboratives, including topics, such as: appropriate antibiotic prescribing, patient engagement, antimicrobial resistance, etc.

3. Get the proper insurance. Lenders who specialize in practice loans often mandate that life and disability insurance be in place before lending. Consider disability insurance that is designed specifically for medical professionals. Look for a policy that offers the flexibility to decide whether you keep working in the event you are partially disabled but are still able to perform some of your duties or are able to work in another occupation.

3. Access to resources to educate patients about appropriate antibiotic usage. 4. Virtual technical assistance on workflow redesign and implementation of best practices to support appropriate antibiotic prescribing. 5. Overall cost of care will decrease, improving your value to insurers. 6. Completion of one Improvement Activity under the Merit Based Incentive Program (MIPS) of the Quality Payment Program (QPP)

For more information, contact: Adrienne Mims, MD MPH FAAFP, AGSF VP, Chief Medical Officer, Medicare Quality Improvement O: 678-527-3492 | Adrienne.Mims@alliantquality.org

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4. Evaluate group benefits. Considering which to provide and not provide can be valuable for an owner physician’s personal situation as well as recruiting and retaining top employees. If you do these four things, you will have a head start toward launching a successful practice, and you’ll be more likely to enjoy your business. Article prepared by Whit Newton with the cooperation of Northwestern Mutual. Whit Newton is a Financial Advisor with Northwestern Mutual based in Raleigh, NC. Newton is a licensed insurance agent of NM. Northwestern Mutual is the marketing name for The Northwestern Mutual Life Insurance Company (NM), Milwaukee, WI, and its subsidiaries. Northwestern Mutual Investment Services, LLC (NMIS), (securities) subsidiary of NM, broker-dealer, registered investment adviser, member FINRA and SIPC. Whit is a Representative of Northwestern Mutual Wealth Management Company®, Milwaukee, WI (fiduciary and fee-based financial planning services), a subsidiary of NM and federal savings bank. Please remember that all investments carry some level of risk including the potential loss of principal invested. They do not typically grow at an even rate of return and may experience negative growth. No investment strategy can guarantee a profit or protect against a loss.

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MONA LISA, continued from p. 5

Getting back to the Mona Lisa and fire ants, Leonardo Da Vinci was a perfectionistic genius. I am not. And these days I struggle to read my own signature, much less my handwriting. EIC’s aside, I am allowing myself to be less than perfect these days. I think we all need a little grace sometimes. And if anyone has a solution for the fire ants, please let me know.

REFERENCES 1. Peterson, L. et al (2009). Family Physicians’ Present and Future Role in Caring for Older Patients. Am Fam Physician. 2009 Nov 15:80(10):1072. 2. Alzheimer’s Association “Quick Facts”. Retrieved 5 April, 2017 from the World Wide Web. http://www.alz.org/facts/overview.asp

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Having been a part of Mt Pleasant for 30 years, I have had the privilege of knowing my patients both before and after they developed dementia. And it is a natural transition for me to see them in my office, and then in their home, and then sometimes in the nursing home.

2501 Blue Ridge Road, Suite 120, Raleigh, North Carolina 27607

I also remember the Barriers. Luther had been a secret agent in Peru during World War II. (It never ceases to amaze me how people from small towns can do extraordinary things.) He was a renowned local historian and orator, but as he got older he developed dementia and then lost the use of his legs due to back problems. Mrs. Barrier took care of Luther at home. In his mind, he was back in Peru fighting the Axis, and he always wore his aviator cap and had his .45 caliber pistol at his side. He refused to leave the house, so I took my medical students on home visits to see him. We managed to get him to the office one time for labs, but my staff had to draw his blood in the parking lot, with his arm extended out of the window of the car. Whenever I got ready to visit, I would call Mrs. Barrier and ask her to take the bullets out of the pistol, just in case. Mr. Barrier was a delightful man with great stories. And his wife loved him, and took great care of him as long as she could. Luther smoked a pipe. He unfortunately set the house on fire one night and passed away in the blaze.

I have said before, and I still believe it, that the solution to physician burn out is for us to get out of our offices and see our patients on their own terms. Seeing what other families deal with every day puts the small and petty things I complain about in perspective. What endures are the memories of good people doing great things for the right reasons. I encourage you to do home visits, and I encourage you to get engaged in your community. Participating in the dementia seminar was a cathartic event for me as well as for the community.

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stay for dinner one evening, and had to ask if Pork Chop was on the menu. Mrs. Petrea just smiled and nodded “no”. Mr. Petrea took care of his wife like this for about 18 months until she passed away. He had episodes of exertional angina the entire time, but refused to leave her side. He died about a year later from his heart problems.

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