V10n4

THE NORTH CAROLINA

Volume 10 Issue 4 / Autumn 2014

quarterly news in north carolina family medicine

Dr. Mott Blair Elected to AAFP Board Of Directors

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

MEDICAL STUDENT PROGRAMS

Building Student Interest in Family Medicine

FOUNDATION ACTIVITIES & INITIATIVES

Developing Future Leaders for Family Medicine

F OUN D AT I O N M E D I C A L S C H O O L S U P P O RT

Driving Student Engagement with Family Medicine

Invest in The NCAFP Foundation Today!

FOUNDATION

To make a tax-deductible contribution, visit www.ncafp.com/contribute

Inside Family Medicine for America’s Health Officially Launches!

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President’s Message

A Letter to Santa from a Family Physician

education

Online CME Programs are Great for Learning

healthisprimary.org

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POlicy & advocacy

2015 Medicaid Payment Reductions: Symptoms of a Broken Payment System

student interest

Campbell Students Recognize Importance of Holistic Care

#MakeHealthPrimary

chapter affairs

NCAFP Board Approves New Strategic Plan

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THE NORTH CAROLINA

residents

Transformative Training in Western North Carolina

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7 20 24

DEPARTMENTS

PUBLISHED BY THE NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS, INC. Raleig h , N o rt h C aro lin a 2 7 6 0 5

919.833.2110 • fax 919.833.1801 • http://www.ncafp.com MANAGING EDITOR & PRODUCTION

P eter T. Gr a be r, Dir e c tor of Communic a tions

President’s Message.......................... 4 CME Meetings & Education................... 7 Policy & Advocacy................................ 8 Chapter Affairs.................................... 12

Public Health & Initiatives................... 19 Student Interest.................................. 20 Residents & New Physicians............... 24 Practice Enhancement........................ 30

HAVE A NEWS ITEM WE MISSED? NCAFP members may send news items to the NCAFP Communications Department for publishing consideration. Please send via email to pgraber@ncafp.com.

2013-2014 NCAFP Board of Directors Executive Officers President William A. Dennis, MD President-Elect Thomas R. White, MD Vice President Rhett L. Brown, MD Secretary/Treasurer Charles W. Rhodes, MD Board Chair Shannon B. Dowler, MD Past President (w/voting privileges) Brian R. Forrest, MD Executive Vice President Gregory K. Griggs, MPA, CAE

President’s Message Dr. William A. Dennis 2013-2014 NCAFP President

District Directors District 1 - Jessica Triche, MD District 2 - Matthew M. Williams, MD District 3 - Eugenie M. Komives, MD District 4 - Tamieka Howell, MD District 5 - Janice E. Huff, MD District 6 - Alisa C. Nance, MD

A Letter to Santa from a Family Physician

District 7 - David A. Rinehart, MD At-Large Holly Biola, MD At-Large Jennifer L. Mullendore, MD IMG Physicians Joseph P. Pye, MD Minority Physicians Benjamin F. Simmons, MD Osteopathic Family Physicians Robert Agnello, DO New Physicians Matthew G. Kanaan, DO NC Family Medicine Departments Brian A. Kessler, DO (Campbell) Family Medicine Residency Directors Geoffrey Jones, MD (MAHEC-Hendersonville) Resident Director Aaron George, DO (Duke) Resident Director-Elect Deanna M. Didiano, DO (Cabarrus) Student Director Julie Barrett (ECU) Student Director-Elect Christian A. Jasper, MPH (WFU)

Dec. 1, 2014

— Love and respect for primary care.

Dear Santa,

— Postponement of ICD-10 until the year after I retire.

How are you doing? Good, I hope. I know you have had a busy year but I hope things have been OK. Especially with your diet, ha ha!

I have been a good doc most of the time this year, though I admit I have said a few ugly words at my computer. But I have always acted like I’m sorry afterward.

Well I guess it is that time of year again when we all write and tell you what we would like for Christmas. I have tried to be very thoughtful this year to keep my list short so there will be plenty left for all the other good little docs in the world, even the specialists.

So here goes. I would like: — A Medicaid reform plan that will make all the patients and all the doctors happy.

— If not that, then how about Expansion?

— Or both!

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

Brian A. Kessler, DO J. Lloyd Michener, MD Kenneth K. Steinweg, MD Warren P. Newton, MD, MPH Richard Lord, Jr., MD

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

Mott P. Blair, IV, MD Karen L. Smith, MD, FAAFP Michelle F. Jones, MD Robert L. ‘Chuck’ Rich, Jr., MD

The NCAFP Family Medicine Councils Advocacy Council Robert L. Rich, Jr., MD, Chair CME Council Alisa C. Nance, MD, Chair Health of the Public Council Charles W. Rhodes, MD, Chair Practice Enhancement Council Rhett L. Brown, MD, Chair 4

— Two more hours added to every day so I can do more than just work and sleep.

— An explanation of how meaningful use is either meaningful or useful.

— A scribe.

— A pill that combines Lipitor, lisinopril, glucophage, xanax, phentermine, Viagra, Ambien and Celexa and costs just $4 a month.

— A way to bend the cost curve downward while helping me practice at the upward part of my license.

— World peace.

— And, a new iPad Air. If you can’t bring all that, it’s OK. I will appreciate anything you can deliver.

As usual, I will leave you some milk (2%) and cookies (gluten-free, of course) by the fireplace.

Please fly safely, and say hello to Ms. Claus for me.

Your pal, Billy D.

|***| Dear Billy D.: We have received your letter of 12/1/14.

Your letter is very important to us, but all of our mailroom elves are busy assisting other writers at this time.

In the future you can get a more prompt reply on line. Just complete the XMS e-verification which is an E-Z 31-step process and then register for the XMS Holiday Grant Application System, which is much shorter at 28 steps.

You will need separate passwords at least 12 characters long and consisting of a mixture of letters, numbers, symbols, icons, doodles and including at least 3 non-consecutive characters from the Chinese alphabet.

On preliminary review, however, I can see we will not be able to grant any of your requests, as each line item must be accompanied by the

proper ICD code extended to the 5th digit and specifying a specific and separate demonstrably necessary purpose for each wish. Entries with more than three requests at a time require a separate letter.

Further, the initial glance at your file, via the “Sunshine Act,” shows you received two pads of sticky notes, a really nice pen, and a sausage biscuit from that very cute Pfizer rep who used to be a college cheerleader and is a third your age and you really should be ashamed.

Too, there is a report that you offended the JCAHO inspector by jokingly asking if he knew the definition of a “Code Brown.” There ARE no jokes with JCAHO, Billy D.

SOURCES 1

2

Also there is a disturbing note that you failed to give an After-Visit Summary to an obnoxious patient whom Starfield, B., L. Shi, and J. Macinko. “Contribution of Primary Care to Health Systems and Health.” The you just wanted to get out of the office after 45 minutes Milbank Quarterly. 2005. Vol. 83, No. 3. (pp. 457-502). Available at http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2690145/. of hassling you for some Cialis samples.

The Commonwealth Fund, “Health Reform & You - Primary Care: Our First Line of Defense.” 12 June 2013.

Available at http://www.commonwealthfund.org/~/media/files/publications/health-reform-and-you/healthreform_primary-care_612.pdf.

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Macinko, J., B. Starfield, and L. Shi. “Quantifying the Health Benefits of Primary Care Physicians Supply in the United States.” International Journal of Health Services Research. 2007. Vol. 37, No. 1. (pp. 111-126). Available at http://www.jhsph.edu/sebin/m/n/2007_IJHS_Macinko.pdf.

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Rosenthal, T. “The Medical Home: The Growing Evidence to Support a New Approach to Primary Care.”

Journal of the American Board of Family Medicine. September-October 2008. Vol. 21. No. 5. Available at http://www.jabfm.org/content/21/5/427.full.pdf+htm.

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In fact, Billy D., a closer look at your record shows you have been good only 77.3% of the time, and you know as well as we do that that number is EXTREMELY Kravet, SJ. A.D. Shore, R. Miller, G.B. Green, K. Kolodner, and S.M. Wright. “Health Care Utilization and the Proportionforgiving. of Primary Care Physicians.” American Journal of Medicine. 12 February 2008. Available at http://

The Future of Family Medicine 2.0:

Family Medicine for America’s Health Officially Launches 5-Year, $20M Effort will Feature National Advertising Campaign Over ten years ago the American Academy of Family Physicians and the organizations that made up the Family Medicine Working Party (FMWP) released a roadmap for the specialty, titled, ‘The Future of Family Medicine.’ The report represented the culmination of two years of study and defined an exciting ‘new model’ of practice for family medicine. It painted a picture of a specialty that was patient-centered, technology enabled, qualityfocused, and valued appropriately.

www.ncbi.nlm.nih.gov/pubmed/18261503.

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Baicker, K., and A. Chandra. “Medicare spending, the physician workforce, and beneficiaries’ quality of care.”

Health Affairs. 7 April 2004. Available at http://content.healthaffairs.org/content/early/2004/04/07/hlthaff. w4.184.full.pdf+html.

Therefore, Billy D., not only are we NOT going to be able to grant any of your requests this year, by extrapolation OECD 2010, “Health care systems: Getting more value for money”, OECD Economics Department Policy are going to have to ask that you return 22.7% of Notes, No.we 2. http://www.oecd.org/economy/growth/46508904.pdf. all the gifts you have received from us over the past 61 years. TO FAMILY MEDICINE CONTRIBUTE

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FOR AMERICA’S HEALTH

And don’t think we have forgotten about that Luis Aparicio baseball glove you got in the 3rd grade. So fork it over.

Individuals and organizations can support Family Medicine for America’s Health by making a tax-deductible donation through the AAFP Foundation. Donate online at aafpfoundation.org/donatetoday and select Family Medicine for America’s Health.

We will expect full repayment by Dec. 31 of this year.

If you disagree with any of the above, you are entitled to a peer-to-peer review if you can find a “peer” in our office who is actually down at your level. Please have your DEA, NPI, Tax-ID, Social Security, State License, Passport, ABFM and Voter ID numbers handy, along with your original birth certificate, recent urine drug screen, proof of medical school graduation, and full procedure log.

P.S. All of us here at the XMS want to wish you a VERY Merry Christmas and a Happy New Year. (Har!)

Sincerely,

Ebenezer S. Claus

Deputy Assistant Fulfillment Officer XMS

healthisprimary.org

Family medicine has remained true to this vision in many ways.

Today, thousands of family medicine practices across the country operate as patient-centered medical homes, health information technology uptake has progressed rapidly, and practice redesign advancements have resulted in family physicians leading health teams that is raising quality and lowering costs.

But a lot has changed in the past decade. New strategies that reflect today’s realities and the sweeping changes taking place in #MakeHealthPrimary healthcare are required. With this in mind, the Family Medicine Working Party (FMWP) set out last year to update the Future of Family Medicine in order to develop a revised way forward.

After formally engaging a consulting group, what followed was a 9-month strategic planning exercise that drew on the feedback from stakeholders across the specialty. Several key questions were asked along the way, including what will be the role of the family physician to help achieve the Triple Aim, and specifically what will be its key attributes, practice scope, and role within the health system?

The product of the group’s work is ‘Family Medicine for America’s Health, (FMAH)’ a comprehensive strategic advocacy effort that contains seven core strategies. Complementing FMAH is a 3-year, communications campaign known as ‘Health is Primary’ that formally launched this October at the AAFP Scientific Assembly in Contnues on next page

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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Washington, DC. A complete discussion of the design process of both efforts appears as a supplement to the November 2014 edition of the Annals of Family Medicine.

In total, more than $20 million has been pledged to carry out the 5-year initiative.

More specific information is expected to be available over the next couple of months, including how physicians can engage in the program.

2) Work to ensure every person understands the value and has the opportunity to have a relationship with a family physician in the context of the patient-centered medical home.

F O E C 3) Family medicine will be accountable for increasing the value of primary care by lowering the cost of care, improving care quality, and improving patient experiences.

7) Family medicine will commit to moving away from fee-for-service to comprehensive primary care payment models.

These seven strategies map to tactic areas that include: technology, workforce education, practice, payment, research and engagement. The FMAH board expects to name tactical teams for each of these areas with representatives that will include young physicians and physicians in solo or small practices.

N N U O O I T N N A Strategic Advocacy Goals

E EV

FMAH is designed around two pillars: a strategic advocacy effort and a communications campaign.

The advocacy portion centers on 7 core strategies that were systematically developed after months of research by the consulting group. These are:

R P

1) Show the value of primary care and demonstrate how family physicians can meet the healthcare needs of people throughout the country.

4) Family physicians will collaborate with national stakeholders to reduce health disparities.

5) Family physicians will lead the evolution of and continually improve the patient-centered medical home model.

6) Family medicine will work to ensure the country has a welltrained primary care workforce.

HEALTH IS PRIMARY - As part of the $20M effort, the campaign is utilizing a variety of paid media to raise awareness of the power of family medicine and primary care. Below are some advertisements that have been developed for use in placements. Each is available for download at www.healthisprimary.com

DOTS CONNECTED WHERE HEALTH IS PRIMARY. A growing body of evidence shows that chronic medical conditions are best managed in a primary care setting. That’s because patients with access to coordinated, comprehensive care have better outcomes.

Family doctors treat patients, not conditions. We want everyone to have a doctor who sees them as a whole person and provides them with quality, coordinated care.

Let’s make health primary in America.

Learn more at healthisprimary.org. #MakeHealthPrimary

TEAMS

WORK

WHERE HEALTH IS PRIMARY. In primary care, teams of health professionals provide patients what they need when they need it in a coordinated setting.

Family doctors work closely with team members to keep their patients healthy.

Let’s make health primary in America.

Learn more at healthisprimary.org.

EVERYBODY

KNOWS YOUR NAME

E R E WH WHERE HEALTH IS PRIMARY.

Long-term relationships between doctors and patients build trust and lead to better outcomes.

Family doctors work with their patients throughout their lives. We want to give all patients access to this kind of continuing care.

Let’s make health primary in America.

Learn more at healthisprimary.org.

#MakeHealthPrimary

INNOVATION AT YOUR SERVICE

WHERE HEALTH IS PRIMARY. Technology is transforming our lives and has the potential to improve our health.

Family doctors are integrating technology into their practices in a way that strengthens their connection to patients and enhances the quality of care.

Let’s make health primary in America.

Learn more at healthisprimary.org.

#MakeHealthPrimary

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

#MakeHealthPrimary

The second pillar of the effort represents a 3-year communications campaign. For this portion, the FMAH board engaged an international communications agency specializing in stakeholder engagement and business strategy. The agency constructed a communications plan after conducting interviews with hundreds of patients, numerous health policy makers, employers, physicians, allied health professionals, and medical students. The agency then summarized the key findings and designed the ‘Health is Primary’ campaign. The campaign will target patients, the medical community, students, payers and policy makers. Health Is Primary will also advocate for the values of family medicine, and demonstrate the benefits of primary care in a way that reflects the values of family medicine.

R P S I H T L A HE

.

Y R IMA

One important component of the campaign is its multi-city ‘roadshow’ that will raise awareness of family medicine by highlighting the individuals, ive organizations, and communities ions rece ditthat o t n y l o currently successfullike in making al c ‘health re edic has been t to mo Carolina primary.’ rNorth m e r i wan re a re thethis effort in February selected fo . We care. y ca tobekick-off r y a h t .

WHERE HEALTH IS PRIMARY. al ve NCAFP primof ly2015. heshould care o reat members ntibe em information e thetlylookout t t eve s to timon r h s t p as more e r p os acc kee regula and obecomes re c available. with ices ts to se m

AN OUNCE OF

PREVENTION

Patients with access to primary care are more likely to receive preventive services and timely care before their medical conditions become serious – and more costly to treat.

Family doctors work with their patients to keep them healthy. We want to ensure that all patients have access to and use regular preventive care.

s u en nd ient serv pati to and r i Pat ntive ous – a e th ss exciting effortathat ri ve cean is raise ithFMAH pre me se ic . will r rk w ave ac e o . the o w m h c awareness of family medicine and g e s s r A r t b tien critical importance octo y.o care by ry in ofarprimary ry a ly d t all pa i m m ima i m r r the current i Fa re tha r P p riding wave of enthusiasm p lth u lth ens Hea thispatients, and policymakers. hea from payers, Let’s make health primary in America.

Learn more at healthisprimary.org.

#MakeHealthPrimary

GET MORE FACE TIME

ke al up-to-date with developments ekeep ake t To Ma h # m a s re and activities surrounding the program, Let’ mo n r visit www.fmahealth.org.

WHERE HEALTH IS PRIMARY. Lea Health improves when doctors and patients spend time together.

Family doctors make it a priority to stay connected to their patients. We want everyone to have a trusted primary care doctor who is there when they need them.

Let’s make health primary in America.

Learn more at healthisprimary.org. #MakeHealthPrimary

CME Meetings & Education ncafp.com/education

Online CME Programs are Great for Learning The NCAFP has a number of excellent online continuing medical education programs available at www.ncafp.com/cme.

These programs are all free-of-charge and enable family physicians to capture valueable credits. Listed below are the programs currently available. To participate in any one of these, simply visit the web address associated with each program.

Creating A Medical Home For Children and Youth In Foster Care

Comprehensive Adolescent Health Screening

Online at: http://fostercare.ncafp.com

Online at: http://mociv.ncafp.com

The aim of this program is to improve the use of social emotional screening rates, referral patterns, and follow-up in the delivery of care for patients in foster care in pediatric and family practices.

This activity has been approved by both the ABFM and the ABP as a MOC Part IV Activity.

The aim of this project is to improve the delivery of care for adolescent patients in pediatric and family practices. It is critical to integrate adolescents into pediatric and family practices in order to ensure regular, annual visits and screenings for these patients. This activity has been approved by the AAFP for 20 prescribed credits.

This activity has been approved by both the ABFM and the ABP as a MOC Part IV Activity.

Promoting Dental Homes for Young Children Through Screenings, Varnishing, and Referrals Online at: http://oralhealth.ncafp.com The aim of this project is to improve the oral health screening, referral pattern, and follow up in the delivery of care for infants to children age 3 in pediatric and family practices. It is critical to integrate oral care into pediatric and family practices in order to ensure regular, annual visits.

This activity has been approved by both the ABFM and the ABP as a MOC Part IV Activity.

Comprehensive Screening for Maternal Depression & Infant Toxic Stress Online at: http://md2013.ncafp.com The aim of this project is to improve the delivery of care for the mother infant dyad in pediatric and family practices. This intervention will assess the various practices and protocols in place for working with both the mothers and the infants, including screening tools, referral and follow up patterns. This activity has been approved by both the ABFM and the ABP as a MOC Part IV Activity.

Valuable Hands-On Procedures Skin Biopsies & Joint Injections Procedures Online at: http://handsonprocedures.ncafp.com Family physicians, FNPs and PAs often see patients with conditions that require the performance of a minor office procedure.

Too often, many patients are referred out of the practice. Learn the benefits of adding these simple procedures to your practice.

This CME online program will demonstrate the indications and contraindications for joint and soft-tissue injections and aspirations. Also the program will address the common techniques used to perform skin biopsies.

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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Health Policy & Advocacy ncafp.com/advocacy

2015 Medicaid Rate Reductions -- Symptoms of a Broken Payment System By: Joanna Spruill, JD - NCAFP Director of Government Affairs & General Counsel

For family physicians, January 1, 2015 does not just mark the beginning of a new year and new resolutions, but it marks the end of the Affordable Care Act's (ACA) enhanced Medicaid rates. For the past two years, family physicians have been reimbursed for certain Medicaid services at rates equal to Medicare payments. Unfortunately, not only do these enhanced rates sunset December 31, 2014, but family physicians will also join other North Carolina physicians in receiving a 4% rate reduction in Medicaid reimbursements at the beginning of 2015.

enhanced rates were not paid until the Fall of 2013, due to the implementation of NCTracks. Because the ACA only guaranteed a two-year bump in rates, these enhanced rates are set to expire December 31, 2014.

U.S. Senator Sherrod Brown of Ohio has introduced federal legislation to extend the parity payment for an additional two years. The Ensuring Women and Children Access to Primary Care Act was introduced in July and referred to the Committee on Finance. The American Academy of Family Physicians has been lobbying Congress at the national level to extend these “As we advocate for a healthcare system enhanced rates and continues to based on value and not volume, it is work hard advocating on your essential that family physicians remain behalf as national lawmakers return for a lame duck session in engaged in the advocacy process both at November.

the state and national levels.”

North Carolina State-Imposed Reductions ACA Enhanced Payments One of the provisions in the ACA provided for an enhanced Medicaid rate equal to Medicare for certain primary care physicians. For the past two years, this boost in pay has meant higher rates for family physicians and immunity from any state-imposed rate cuts. The ACA provision went into effect January 2013, but for many family physicians the

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

Because the ACA's parity provision ensured reimbursement at Medicare rates through 2014, family physicians have avoided a 3% rate reduction that other physicians have seen this year. When lawmakers passed the 2013 budget, they included a shared savings provision that instructed the Department of Health and Human Services to withhold 3% of Medicaid reimbursements from providers

starting January 1, 2014, and develop a plan incentivizing providers to reduce health care spending and achieve quality metrics. In the Spring of 2014, the Department stated that they did not have enough time to implement such a plan and asked legislators for clarifying language in the short session.

This past summer, legislators clarified the language by eliminating the Department's requirement to develop a shared savings plan. This clarification effectively turned the provision into a 3% rate reduction.

Primary care physicians were exempted from the reduction this year because of the federal guarantee that they would earn the enhanced Medicaid rate. However, without the passage of federal legislation guaranteeing the enhanced rates for two more years, starting January 1, 2015, the 3% rate reduction will take effect.

In addition to the 3% reduction, lawmakers also passed a 1% provider rate reduction in their budget this year. In other words, effective January 1, 2015, all physicians will receive a 4% rate reduction in their Medicaid reimbursements.

Outlook for 2015 If Medicare parity does not get extended at the federal level, family physicians will face a substantial rate reduction for 2015.

Taking into account the sunset of the

NCAFP Advocacy Council Chairman’s Report ACA parity rates and the 4% state reductions, the reimbursement rates for Evaluation & Management codes and vaccine procedures will decrease to approximately 76% to 84% of Medicare. As a result, family physicians can expect to see a 16% to 24% reduction in rates for these E&M codes and vaccine procedures. These rates will be slightly less than the payment primary care physicians received prior to the 2013 parity provision.

With AAFP working hard at the national level to extend parity an additional two years, we encourage you to call your Congressman and U.S. Senator and ask them for their support of extending Medicare parity at the federal level to avoid these cuts in Medicaid rates.

Ongoing Efforts Towards Reform This constant struggle over rate reductions is an indication of the problems around how healthcare services are valued today.

Continuing to be reimbursed in a volume-driven fee-for-service delivery system does not work anymore and the impending rate cliff facing family physicians is a reminder that payment reform must remain a top priority at both national and state levels. Until family physicians can start being paid for the value they provide instead of volume of services, these reductions in rates will continue to be an issue. Now more than ever, it is essential that family physicians work towards and advocate on behalf of reforms that reward quality, improve patient and physician satisfaction, produce efficient healthcare delivery systems, and lower overall costs.

Reforming Medicaid has been a top issue for our General Assembly and Governor over the past two years and it will continue to remain a priority for lawmakers. NCAFP's position has remained constant, supporting reform that keeps the current patient-centered medical home foundation in place and continues to improve quality, reduce costs, and ultimately move to a system of healthcare built on value, not volume. NCAFP continues to spread this message during the interim and most recently did so at an interim committee meeting on Medicaid reform and reorganization. In October, the NCAFP and the NC Pediatric Society jointly testified at a hearing in front of the Joint Legislative Oversight Committee on Health and Human Services Subcommittee on Medicaid Reform and Reorganization.

Together, we represented nearly 6,000 combined members and the bulk of primary care physicians in North Carolina. Our statement urged lawmakers to build on the success of medical homes and Community Care of North Carolina, and to make the system easier for patients and providers.

As we advocate for a healthcare system based on value and not volume, it is essential that family physicians remain engaged in the advocacy process both at the state and national levels. While the impending rate reductions at the beginning of 2015 are yet another symptom of a broken healthcare payment system, the NCAFP will continue to work hard to ensure proper payment and ensure that our healthcare delivery system can reward quality, lower costs, and produce better outcomes for your patients.

Report Fall 2014

Robert L. ‘Chuck’ Rich, Jr., MD Chair, Advocacy Council NCAFP Past President

Effective Lobbying Skills Can Be Learned With the conclusion of the 2014 Legislative session, the emphasis for the legislature turned to the pending November general election. Legislators have shifted their focus from issues such as Medicaid reform, Medicaid expansion, provider pay cuts, accountable care organizations, scopeof-practice issues to the one issue that maters the most in the fall – getting elected. The interim between legislative sessions is a prime opportunity for an NCAFP member to become involved in the workings of our General Assembly.

FAMPAC Currently, the average cost of a successful North Carolina legislative campaign is over $100,000, and most candidates do not possess the personal fortune to self-finance their election. Therefore, the average legislator must raise election funds and to do so, they turn to interested citizens and various political action committees (PACs) for those funds. The amount of funds that one individual or PAC can contribute is limited by election law and a legislator will need to solicit funds from more than one source. Campaign contributions can help a person gain access to a legislator and are a great way to become involved in the political process. Without access, it is more difficult to share your perspective with a local legislator on such issues as provider reimbursement. If you find it difficult to contribute to a legislator on your own-then consider contributing to the NCAFP’s political action committee, FAMPAC. We need your contributions to replenish funds that have been depleted by the current election. If you choose to donate directly to a candidate, do not forget to identify yourself as a NC family physician and where you live in a legislator’s district.

Contact your local legislator Whether in person or on the phone with a Legislator (e-mails may be seen only by a staffer who intercepts it for the Legislator) be succinct but take the time to point out the effects of Legislative decisions on Contnues on next page

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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your practice and patients. Do not assume that an individual legislator understands every eligibility, reimbursement and coverage nuance of Medicare, Medicaid and other programs. Most legislators do not have the time, staff and other resources to understand these issues and may have rather erroneous understanding of how their decisions affect these programs. Simple but insightful stories of how legislative decisions affect the average citizens in their district are very powerful and often appreciated. In this time of Medicaid reform, stories of how your practices, your hospital, your network are producing real savings for Medicaid would capture the attention of legislators from both parties.

What do I say to a legislator?

My personal style in meeting legislators has been to be respectful, attentive and listening during the conversations with them. At the appropriate point, I have interjected suggested actions on a particular topic and then quickly outlined why it would be in the legislator’s best interest to support those actions. I typically begin those conversations by thanking them for taking the time to meet with me and then talking with them about current events in the district. Most visits and conversations with legislators are short (typically 10-15 minutes) and may occur while a legislator is going from one meeting to the next.

Be resourceful and willing to talk with a legislator in any environment from their personal home to their Raleigh office. Again, be succinct, but also be ready to interject a comment at the proper moment in a conversation.

Advocacy Briefs NC GEAR has Website to Collect Ideas to Reform State Government The NC Government Efficiency and Reform initiative, commonly known as NC GEAR, has launched a new website to collect ideas from state employees and citizens interested in reforming state government.

The website address is www.ncgear.nc.gov.

Created by the Governor and General Assembly last year, NC GEAR is currently performing an evaluation of state government that will lead to a package of reforms to be presented early next year. The legislation gave NC GEAR the authority to evaluate the entire executive branch of government. Over the past few months, NC GEAR has met with leaders across state government to identify opportunities to improve its efficiency, effectiveness, and customer service. However, the NC GEAR team realizes that good ideas come from both inside and outside government. All proposals will be reviewed by the NC GEAR analysts and consultants. The strongest concepts will be evaluated further and included in the final report to the Governor and General Assembly next February. Some proposals will be included in the Governor’s Budget. Others will be offered to the Legislature for their consideration.

AAFP Denounces Elimination of Primary Care from ‘Narrow’ Insurance Practice Networks

How do I set up a meeting?

Not sure who represents you in the Legislature- contact the NCAFP office and we can tell you. Need assistance in setting up a meeting with a Legislator- NCAFP has contact numbers for a legislator’s Raleigh office and back home in a district. While we will often ask you to set up your appointment directly with staff in the legislator’s office, we can provide you with suggestions for how to work with staffers in setting up those appointments and often may know individual staffers in various offices. Not sure about the issues- we can provide you with background information and position sheets for your use but emphasize that the information needs a local perspective to be presented successfully.

Get Involved Today!

Above all, we need your willingness to become involved in the process and to form a relationship with your local legislator.

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

The AAFP is strongly protesting the continuing practice among health insurers of limiting patient choice and access to primary care through the use of ‘narrow’ practice networks. The AAFP authored and has sent several letters to CMS, Americas Health Insurance Plans (AHIP), and to United Healthcare.

Among AAFP’s requests, it has specifically asked CMS to intervene in neighboring Tennessee where a large insurance carrier has dropped physicians from its Medicaid managed-care plan, causing many Medicaid patients in that state to lose their primary care physician. The AAFP also urged AHIP to begin dialogue with the Academy on how narrow networks are determined and forwarded it a series of questions it would like answered.

The AAFP conducted a survey of members in September on the impacts of narrow networks and presented its key findings directly to CMS Administrator Marilyn Tavenner, MA. Among its requests was urging CMS to examine the issue during the upcoming rule-making process for 2016, the earliest point at which the agency will be able to finalize adjustments.

Narrow insurance networks are a growing trend, especially in the exchange networks nationwide where they make up 48 percent. They also represent 60 percent of networks in the largest city of each state, according to the AAFP.

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Copies of FAMPAC reports are filed with the Federal Election Commission and are available for purchase from the Federal Election Commission in Washington, D.C. Voluntary political contributions are subject to the limitations of FEC regulations, Section 110.1, 110.2 and 110.5 (Federal regulations require this notice). Contributions to FAMPAC are not deductible as charitable contributions for Federal Income Tax Purposes. N.C. LAW REQUIRES POLITICAL COMMITTEES TO REPORT THE NAME, MAILING ADDRESS, JOB TITLE OR PROFESSION AND NAME OF EMPLOYER OR EMPLOYER’S SPECIFIC FIELD FOR EACH INDIVIDUAL WHOSE CONTRIBUTIONS AGGREGATE IS IN EXCESS OF $50 IN AN ELECTION CYCLE.

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Chapter News & Affairs ncafp.com/academy

NCAFP Board Approves New Strategic Plan The NCAFP Board of Directors met in Concord in early September at the headquarters of Cabarrus Family Medicine, stepping through an agenda that provided several policy, advocacy and program updates, and also featured two action items that won formal approval.

The Board approved a newly-updated strategic plan for the chapter written

by NCAFP leaders earlier this summer.

Specific components of the new plan were established based upon input gathered during the board’s Leadership Retreat held last March.

The new plan is built atop five strategic pillars: government affairs, membership and workforce, practice management, public relations and marketing, and education. The objectives within each area are listed at right, and reflect member and leader input, as well as the changing dynamics of the specialty and the overall healthcare system.

The Board also approved the creation of a physician/resident mentoring program aimed at connecting residents-in-training with community physicians for coaching, mentoring and guidance. It’s expected that core components of the program will be developed over the coming months, with formal rollout slated for early 2015.

NEW NCAFP STRATEGIC PLAN GOVERNMENT AFFAIRS: NCAFP will be the policy voice for all family physicians and their

patients in North Carolina

Objectives: • Cultivate relationships with legislators, government leaders, health systems and payers • Increase policy makers’ understanding of the value of family medicine • Advocate for improved health of the public in North Carolina Membership and Workforce: NCAFP will create a culture of engagement among family

physicians, residents and medical students

Objectives: • • • •

Maintain and grow NCAFP membership Increase and sustain NCAFP engagement and participation with residency programs and medical schools Foster a diverse leadership that represents different schools of thought, geography, and employment type Strive to ensure an adequate workforce of family physicians in North Carolina

Practice Management: NCAFP will support family physicians across practice environments Objectives: • Continue to develop resources to support success in the new value-based healthcare environment • Actively engage with other organizations to support emerging models of care such as PCMH, ACOs, Direct Pay, etc.

• Develop family physician leaders, particularly in healthcare systems • Assist in providing the tools for family physicians to thrive in all practice settings, including private practice Public Relations & Marketing: NCAFP will educate patients, payers, health systems

and others about family medicine’s value

Objectives: • Promote the value of family medicine and the medical home – including the role of family physicians in health promotion and disease prevention – to the public and key stakeholders • Undertake activities to shape the perceptions of family medicine in North Carolina • Identify opportunities to work with the media to disseminate news and information about family medicine • Develop partnerships with other organizations to promote the cause of family medicine in North Carolina Education: NCAFP will provide high-quality, innovative education Objectives: • Explore innovative methods of education delivery • Expand subject matter covered at Academy meetings, including leadership and professional development, etc.

• Continue to offer in-person educational opportunities for our members.

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

Members in the News

Dr. Richard Lord Named Chair of Wake Forest Department of Family & Community Medicine The Wake Forest Department of Family & Community Medicine has a new chair - NCAFP Past President Dr. Richard Lord, MA (2011). Dr. Lord had been serving as interim chair of the department since last fall, but his appointment was formalized by the School in late July.

Dr. Lord earned his medical degree from Wake Forest in 1988 and began his academic service with the department in 1999 as Director of Maternal & Child Health. As Department Chair, Dr. Lord will also serve as Executive Director of Wake Forest’s Primary Care Service Line, and inherits a department ranked in the top 15 of all family medicine departments for research funding from the National Institutes of Health.

East Carolina University Names New Family Medicine Department Chair The East Carolina University Department of Family Medicine has a new chair: Chelley Kaye Alexander, MD. Dr. Alexander comes to the Brody School of Medicine from the Department of Family Medicine, College of Community Health Sciences at the University of Alabama where she served as chair from 2006-2014, and as Assistant Dean for Graduate Medical Education from 2005-2014. Dr. Alexander earned her undergraduate degree in Neuroscience from Davidson College, Davidson, NC, in 1990 and completed her medical degree in 1996 at the University of Alabama-Birmingham. Her residency training was with Tuscaloosa Family Practice Residency, Tuscaloosa, Alabama.

Dr. Alexander succeeds Dr. Kenneth Steinweg, ECU Family Medicine’s department chair since 2009. Dr. Steinweg demonstrated expert leadership during his tenure, shepherding the department during the completion and transition into the university’s new Family Medicine Center. Dr. Steinweg remains with the department, serving full-time within its Division of Geriatrics.

CMC’s Dr. Mary Hall Promoted to Associate Dean of UNC Medical School’s Charlotte Campus Carolinas Medical Center’s (CMC) Chief Academic Officer, Dr. Mary Hall, was recently named the new Associate Dean for the UNC School of Medicine’s campus in Charlotte, a regional campus that hosts approximately 50 full-time medical students. As Associate Dean, Dr. Hall will be working to supervise student affairs and curriculum development at the campus while also helping to direct activities around medical student recruitment and admissions. Dr. Hall will also continue to serve as CMC’s Chief Academic Officer where she oversees all CMC medical education, including undergraduate, graduate, allied health, CME, and fellowships.

Dr. Mott Blair, IV, Elected to AAFP Board of Directors NCAFP Past President Dr. Mott P. Blair, IV, (2003) of Wallace, NC, was elected to serve a new 3-year term on the AAFP Board of Directors during AAFP’s annual Congress of Delegates in Washington, DC in October. The victory was a culmination of over a year of planning by the chapter and spearheaded by a campaign committee that included a large number of past and present NCAFP leaders. Dr. Blair’s candidacy was described in last quarter’s magazine, where he shared his insights on a number of topics related to the specialty.

Dr. Blair delivered a moving speech where he told a story of a flower seedling given to his late father, Dr. J. Seaborn Blair, as payment for care. That seedling has since grown into a thriving gardenia at the Blair family homestead in Wallace and Dr. Blair related its growth and maturation to that of the specialty.

In his acceptance speech, Dr. Blair noted, “I feel passionate about this organization and this specailty. And I could not have done this without the support of a great team!”

New AAFP Commission Chairs The AAFP also announced the chairs of its commissions for 2015. The Academy is proud to announce that Past President Dr. Robert L. ‘Chuck’ Rich, Jr., (2008) of Elizabethtown, NC, was selected to chair AAFP’s Commission on Public Health and Science. This commission works on issues that address health of the public, evidence-based clinical recommendations and care, generation of new knowledge and science with dissemination and implementation, and other related issues.

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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MEMBERSHIP 2015 Membership Dues are Due by January 1st, 2015

NCAFP Partners with Medicare QIO to Help Deliver Upcoming Improvement Projects The NCAFP is proud to announce a new partnership with Alliant-Georgia Medical Care Foundation (GMCF), the Medicare Quality Improvement Organization (QIO) for Georgia and North Carolina. The QIO program is one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries through education; outreach and collaboration with patients, families, and community partners; and peer-to-peer learning.

Over the next five years, GMCF will build on the platform of better health, better care, and lower cost to accomplish major goals through these initiatives: • Improve Cardiac Health and Reduce Cardiac Health Disparities • Improve Diabetes Management • Meaningful Use of Health Information Technology • Value-based Purchasing • Screening and Delivery of Preventive Services These initiatives will be delivered through unique Learning and Action Networks (LANs) that engage communities of local-level partners in action-oriented, real-time learning and rapid-cycle quality improvement.

All practicing family physicians and practices are invited to be a part of these important QIO improvement initiatives. There are no prerequisites: you don’t have to be a visionary to affect change. All you need to participate is the experience you already have and the passion to improve the lives of your patients that you exhibit each and every day.

If you would like more information or would like to participate, please contact Tara Hinkle, NCAFP Membership Coordinator, at thinkle@ ncafp.com or (919) 833-2110/(800) 8729482 NC toll free. Additionally, GMCF will be exhibiting at the NCAFP Winter Family Physicians Weekend meeting in Asheville, December 4-7, so please make plans to stop by their booth. In the meantime, background information may be found by visiting www.qioprogram.org and www. alliantquality.org.

The NCAFP will continue to update our members about this exciting project as it gets underway. Stay tuned!

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

It’s that time of year! 2015 membership dues payment deadline is January 1, 2015. Remember that since membership is unified according to AAFP bylaws, both AAFP and NCAFP dues must be paid in full to maintain your membership.

Recent residency graduates who have been upgraded to Active status: Remember to take advantage of your first year discount!

To pay your 2015 dues online or to print an invoice, please visit www.aafp.org/ checkmydues. Your username is your seven-digit membership ID number. If you are not able to pay the entire dues amount, you may set up an installment plan online (installments taken out through August 2015) or by calling AAFP at 1-800-274-2237. The first paper invoice has already been mailed to primary addresses but another may be requested by contacting AAFP. Should you have any questions about dues, need a receipt, or would like to sign up for the installment or auto renewal plans, please contact AAFP at 1-800-274-2237.

Please verify that we have current contact information while online or on the phone with AAFP staff. Contact information may also be viewed or changed at www.aafp.org/updatecontactinfo.

Types of Credit

Resident Dues are Now Due Residents: Since your membership calendar is July – June, your Resident dues are now due. Please remember to check with your residency program coordinator to make sure your AAFP/NCAFP Resident dues have been paid. They may request another invoice from the AAFP by calling 1-800-274-2237 or sending an email to contactcenter@aafp.org.

2014 CME Re-election CME Re-election is around the corner for 2014 candidates! To determine your re-election cycle or to view/update your transcript, please visit www.aafp.org/ mycme. Remember – only CME hours earned during your three-year cycle are applicable and consists of earning at least 150 credits with a minimum of 75 Prescribed credits and 25 credits from live learning activities.

Please keep in mind that all hours must be earned prior to the 12/31/14 deadline to maintain your membership. AAFP no longer offers earning extensions, so all online quizzes and CME hours must be completed prior to 12/31/14. If you think you will be short of the required 150 hours by the 12/31/14 deadline, please contact the AAFP immediately at 1-800-274-2237. Did you know that more than 200 free Prescribed credits may be earned by completing multiple posttests at www.aafp.org/cme!

Prescribed Credits include completing a fellowship, teaching*, participation in a research study, most life support courses, and most activities produced by the AAFP including online quizzes from American Family Physician and Family Practice Management, and CME Bulletin products.

Elective Credits include activities approved for the American Medical Association Physician’s Recognition Award Category 1 CreditTM or American Osteopathic Association credit, taking a Board certification exam, or even attending medical staff or medical society meetings.

Live Activities are held in real time, include two or more people, and are either Prescribed or Elective credit such as medical seminars or conferences including the AAFP Scientific Assembly, lecture series, or life support activities (ACLS, ATLS, BLS, NALS, PALS, etc.).

Other activities that may be eligible for CME credit include advanced training, clinical research, scholarly work, or medical writing or editing (there may be limits on the number of credits from these types of activities applied to each re-election cycle.) *A maximum of 60 Prescribed credits can be applied during a three-year re-election cycle for teaching medical students, residents, physicians, physician assistant students, physician assistants, nurse practitioner students, nurse practitioners, nursing students, or nurses in formal individual or live educational formats. Teaching is also considered a live activity.

NC Academy of Family Physicians

2015 NCAFP

winter

2 0 s e t a D 1 e v a S 5

FAMILY PHYSICIANS WEEKEND

DEC. 3-6, 2015 Asheville, NC

The Stunning Mountains

The Beautiful Coast

The

~ More at ~

www.ncafp.com/2015

Executive’s Desk

By Gregory K. Griggs, MPA, CAE, NCAFP Executive Vice President

Embracing Change, Preserving Tradition

We were thrilled that Dr. Blair won his election for the AAFP Board. In many ways, he exemplifies much of what is happening all across North Carolina and all across our country. And he also exemplified many of the changes we are going through as a chapter representing family physicians.

One of the key points of his speech was that the physician-patient relationship is sacred. He noted that this relationship is more important than anything else – more important than prior authorizations, meaningful use, or any other administrative detail that gets in the way of patient care. It’s a sacred trust.

As we’ve worked to identify areas that our chapter wants to concentrate on in the near future, preserving that tradition of the patient-physician relationship is paramount to our efforts. If someone chooses to practice in a system, we

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

cannot let the healthcare system break that sacred trust. If someone chooses to practice independently, we cannot let the paperwork and administrative headaches of small practice hurt that one-on-one relationship. And while models may change, including working with teams of providers (physicians and others alike), we still must preserve that sacred relationship between the family physician and their patient.

The practice of medicine is changing.

The rate of change is accelerating. And the bottom line is that change will come with us or without us. I believe organized family medicine can harness that change and empower you -- as physicians -- by putting that patient relationship at the center of care. Some of you may say that I’m too optimistic, but that’s OK. I believe valuebased healthcare – if it’s done right with family medicine at the helm – can lead to the renaissance of your specialty.

receiving compensation for coordinating care and keeping your patients healthy.

That’s already happening to some extent with the care coordination fees that are being developed by Medicare. Look for more on these codes in upcoming magazines and in our e-newsletter.

Like the Phoenix that once represented your profession, family physicians can rise up and take control over a fragmented and disjoined healthcare system. It’s up to us -- working together -- and it won’t be easy, but I believe it can be done. We can preserve the traditions that have made this specialty so great, while at the same time moving toward care models that improve quality, patient satisfaction, physician satisfaction and ultimately lower costs.

CHANGE & TRADITION

Embracing Change. Preserving Tradition. This was the catch phrase for Dr. Mott Blair’s recent campaign for the AAFP Board of Directors. In his case, it included the tradition of the small rural practice as exemplified by the work of both Mott and his father in the small town of Wallace, NC. The ‘Embracing Change’ included how Dr. Blair led his practice through EMR implementation, meaningful use and PCMH recognition, and now is helping lead an eastern North Carolina healthcare system through the process of developing an Accountable Care Organization and transforming other primary care practices into the medical home model.

Patients are changing as well, and their demands are changing.

Some folks may call it the consumerization of healthcare.

Patients are demanding to be seen quicker and at times when your office may not traditionally be open. The fact is that your patients don’t only get sick during the week from 9 to 5. And they may need you at different times. But with team-based care and new technologies, it may not always be a face-to-face visit or a visit with the physician. Your NP or PA may cover an after hours visits. Or you may complete an e-visit.

As we move toward greater population management, it may not be about getting paid for a certain visit or code, but

We know that primary care done well – with the appropriate resources and compensation – will lead to better healthcare outcomes.

We just have to harness those things that have worked in the past while at the same time embracing new technologies and new models that can move your specialty forward. I truly believe the future for family medicine – and most importantly the way your patients receive care – is bright and promising.

On a closing note, one tradition of your chapter that I definitely hope we preserve: the tradition of NCAFP leaders rising to the top at the national level. From Amos Johnson to Jim Jones to Doug Henley to Lori Heim and Conrad Flick and now Mott Blair, we have sent a continuous flow of North Carolina family physicians to help direct the national efforts of the American Academy of Family Physicians.

It’s certainly one tradition that I’m proud of and you should be as well.

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Public Health Chapter Affairs & Initiatives

Driving

Primary Care-Public Health

Integration with

The Practical Playbook

By Peter Graber NCAFP Director of Communications

N

ew and emerging payment models across family medicine have begun to place more emphasis on population health and outcomes, altering the decades-old payment mix away from traditional fee-for-service to incentive models incorporating quality and value.

As this shift begins to take root, physicians and practices are re-evaluating their care processes in new ways, especially as they relate to larger patient populations.

Developing alongside this trend is the growing recognition of the untapped potential of primary care-public health collaboration, and how it can contribute to achieving greater value. Improved integration between primary care and public health is now considered as another avenue towards better chronic disease management, improved care quality, and lower overall costs.

In North Carolina, Duke University's Department of Community and Family Medicine is playing a key role in equipping public health practitioners, family physicians, primary care groups, and key community stakeholders with resources to advance these type of integrations. The centerpiece of Duke's effort is an innovative -- and interactive -web tool known as the Practical Playbook: Public Health and Primary Care Together (www.practicalplaybook.org).

The Playbook is a first-of-its-kind effort and is a collaboration between Duke, the de Beaumont Foundation, and the Centers for Disease Control and Prevention.

Family physicians and their public health peers have historically shared the common goal of improving the health and wellness of people, even though both have attacked the issue from somewhat different viewpoints. With family doctors focused on serving individuals and families, and public health professionals targeting the community level, this difference has separated the two groups, sometimes even leading towards

competing goals and creating integration hurdles in the process.

A 2012 Institute of Medicine (IOM) report entitled, "Primary Care and Public Health: Exploring Integration to Improve Population Health," studied a number of past and current public health-primary care integration efforts. Listed among the report's key findings was '...the inability to create a common template or framework for primary care-public health integration efforts...' due to '...the vast differences among communities, both in resources and populations...' The report went on to conclude that most successful integrations were largely the result of local circumstances.

Fortunately, the report did uncover

was the most important of all, even in cases where all core principles weren't immediately identified. This is exactly what the Practical Playbook is designed to accomplish: to get family physicians and others acting and moving forward together.

To foster action, the Playbook is designed around the simple three-step metaphor of 'learn-do-share.' Users are educated on the integration cycle, receive guidance on bootstrapping integrations in the 'do' phase, and also provides access to real world examples and insights through a collection of shared success stories. One such success story features highlights of how Community Care of North Carolina has worked with the North Carolina Division of Medical Assistance, and the

The Practical Playbook (www.practicalplaybook.org) is a fully-interactive web tool designed to drive successful primary care-public health integrations.

several core principles common among successful integrations. These principles included: establishing a common goal of improving population health that engages a community; strong leadership that bridges multiple disciplines; sustainability; and the collaborative use of data.

But even in acknowledging these attributes, IOM authors stressed that taking initial action -- the first step --

North Carolina Division of Public Health to improve birth outcomes through its Pregnancy Medical Home Initiative.

Additional learning resources (there are more than 700 links to state and federal resources) are also embedded throughout the Playbook and focus on topics ranging from accountable care to workforce development. It all works to jumpstart action, whether in small steps or in See PLAYBOOK on Back Cover

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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Student Interest & Initiatives ncafp.com/students

Campbell Students Recognize the Importance of Holistic Care and Family Interaction in Volunteer Experience By: Kelly Stanley (MS2), Jerry M. Wallace School of Osteopathic Medicine at Campbell University Give Kids the World (GKTW) is a nonprofit village resort near Orlando, Florida.

Its purpose is to serve as a retreat for children diagnosed with life-threatening illnesses. By partnering closely with wish-granting organizations throughout the world, the resort allows children and their families to enjoy a fully-paid vacation at the village, including trips to Disney World and other amusement parks in the area.

Considering that the village is for very sick children, I expected volunteering there to be a fairly somber experience – I couldn’t have been more wrong. The resort village was filled with music, color and life, and every child that walked through the door had a huge smile on their face. GKTW means so much more than an all expenses paid vacation for these young children and their families; it means a safe environment to spend what could be the small amount of time they have left together. One week that would otherwise be filled by hospitals, needles, surgeries, doctors and nurses, now is spent relaxing, laughing and just being a kid.

Daniel Moses, co-president of the Campbell University School of Osteopathic Medicine (CUSOM) Family

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

Medicine Interest Group, has been volunteering with GKTW for 4 years.

He organized this particular project for himself and a few of the club members that included Mark Lorenzini, Jeffrey Pennings and myself. Our assignment was to set up and serve meals, and help carry trays for the families before they left to spend the day in the theme parks. While this seems like a small and impersonal task, I was surprised by how involved we all got with different families during the day. I walked around and talked with the visitors to make sure they had everything they needed, which actually sparked up a lot of conversation. I sat down with kids and asked them about their favorite rides and Disney characters, and they were beaming as they told me about all the fun they were having. Parents talked about how relaxing their vacation was and how much it meant to them. We were able to give these mothers and fathers, grandparents, and siblings a muchneeded break from their daily routine – making breakfast, doing dishes, cleaning etc. This allowed them to fully focus on their children and enjoy the time they had to spend together.

As unthinkable as it may be, many of these children will have their last wish

granted at GKTW, which is why this organization, and ones like it, are so important. They run on the power of donors, dedicated staff and volunteers.

As medical students pursuing family medicine, this project allowed us to take a more holistic look at patient care and family interaction – it was a truly unique experience. I was able to see the magic of the GKTW village through the eyes of the children, and see what this truly meant for their loved ones. These are things that make family medicine such a gratifying specialty, and I know this experience will stay present in our minds as we pursue our careers in primary care.

Kelly Stanley is a second year medical student at Campbell University School of Osteopathic Medicine from San Francisco, CA. She obtained her undergraduate degree in Health Sciences from University of California, Santa Cruz. Before attending medical school, Kelly spent three years doing HIV vaccine research for Beth Israel Deaconess Medical Center in Boston, Massachusetts.

Sat., May 16, 2015 in Raleigh, NC

Family Medicine Day

2015

ATTENTION RISING 3RD AND 4TH YEAR MEDICAL STUDENTS

The North Carolina Academy of Family Physicians (NCAFP) and the North Carolina AHEC Program are presenting a family medicine residency recruitment conference introducing rising M3 & M4 medical students to the state’s family medicine residency training programs. Don’t miss this great event!

•

ABSOLUTELY FREE for all rising M3 & M4 medical students - graduating in 2016 or 2017. Rising M2s welcome to attend, space-allowing. Complimentary overnight hotel accomodations available

•

BUILD YOUR SKILLS 4-Hours of clinical skills training workshops. See below for listing.

•

RESIDENCY RECRUITING FAIR Meet-and-greet faculty of NC’s family medicine residency training programs

•

NETWORKING Connect with medical students and key residency leaders from North Carolina Registration Requires a $20.00 Refundable Deposit

These Skills Workshops are Being Considered

• Basic Suturing

• Common Dermatology Procedures • Splinting/Bracing & Casting

• IUD Insertion/Endometrial Biopsy

• EKG Reading Session

• Outpatient Radiology Film Review

• Lumbar Puncture

• Knee Examinations & Injections

• OB Perineal Laceration Repair

• Ultrasound in OB & Sports Medicine

• Circumcisions

• Osteopathic Manipulation

BROUGHT TO YOU BY THE NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS AND THE NORTH CAROLINA AREA HEALTH EDUCATION CENTERS PROGRAM

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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STUDENTBriefs Five Medical Students Awarded NCAFP Foundation Scholarships The NCAFP Foundation is pleased to announce that five medical students have been selected to receive a scholarship through the Foundation for the academic year of 2014-2015. Fourthyear medical students Ian Lateef Cannon (UNC) and Scott Gremillion (ECU) have committed to family medicine and are currently applying to FM residency programs. Also receiving awards are third-year medical students Jered Cope Meyers (ECU), Jessica Friedman (Duke), and Liza Rathbun (UNC).

The NCAFP congratulates and extends best wishes to these outstanding students as they continue their training.

Family Medicine Interest Programs Available for First-Year Medical Students

The University of North Carolina Chapel Hill School of Medicine (UNC-SOM) and the Mountain Area Health Education Center’s (MAHEC) Sarah Graham Kenan Primary Care Medical Scholars Program received a big $3 million dollar boost recently from the William R. Kenan, Jr. Charitable Trust. The funding will enable each UNC medical student who commits to the 4-year longitudinal program to reduce their student debt by $30,000. The program pairs individual students with a rural preceptor and provides a unique rural healthcare mentoring experience that features a 6-week summer internship, monthly discussion groups, and required rural rotation during their 4th-year.

This past summer, five students enrolled in the program were mentored by physicians in Linville, Burnsville, Cherokee, Bryson City and Robbinsville.

According to NCAFP Residency Directors Constituency Chair Dr. Geoff Jones, Residency Director at MAHEC Hendersonville and clinical co-director of the program, ‘there is very good evidence that exposing medical students to rural health careers during their education increases the likelihood that they will choose to practice in a small community. Medical schools with rural health programs will play a key role in supplying the rural workforce of the future.’

Additional information on the program, can be found at http://mahec.net/ residency-and-student-info/som-asheville/kenan-rural-scholars-program.

Novant Rowan Medical Center Partners with Campbell University to Provide Medical Student Teaching Slots

The NCAFP Foundation offers a variety of programs and opportunities to medical students.

A few of these are clinical experience opportunities only available to 1st year medical students. These opportunities take place during the summer between your first and second year of medical school.

Two programs are available -- the NCAFP Externship Program and the NCAFP Rural Experience -that range from two-four weeks in length. To learn more about these programs and the exciting specialty of Family Medicine please visit: http://www.ncafp.com/students

Novant Health’s Rowan Medical Center and Campbell University’s Jerry M. Wallace School of Osteopathic Medicine announced a new agreement in late August establishing Rowan Medical Center as a key teaching hospital for the school’s medical students.

The clinical partnership will include training in the areas on primary care, family medicine, general surgery, OB/GYN, pediatrics, psychiatry and other critical services, all while emphasizing the unique needs of underserved communities. When fully operational in 2016, a total of 44 third- and fourth-year Campbell students will receive clinical training from physicians affiliated with Rowan. To learn more about the partnership, visit http://www.campbell.edu/news/item/campbell-announcesteaching-hospital-agreement-with-novant-health-rowan-med.

Deadline is Jan. 15, 2015

Looking to get up-to-speed on the fundamentals of the patient-centered medical home (PCMH)? Hear from AAFP President Reid Blackwelder, MD, about how physicians, patients, and everyone involved in their care can have a better experience, see improved health outcomes, and all at a lower cost to the patient and the health care system. That’s the magic of PCMH! The 16-minute video is a great introduction and knowledge builder for medical students at all levels. To view the video, visit http://www.youtube.com/watch?v=GajUQOVpMpQ .

Application deadline is January 15, 2015. For questions or more information please contact Tracie Hazelett at 919-833-2110, ext. 120 or thazelett@ncafp.com.

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Kenan Charitable Trust Endows Primary Care Medical Scholars Program with $3 Million

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

PCMH is Explained in Detail for Medical Students in Free Episode of Family Medicine on Air

P A I D

A D V E R T I S E M E N T

Medical mutual announces its 2014 RIsk management TOP OF MIND: ICD-10 webinar series The U.S. Department of Health and Human Services (HHS) has designated as a code under the Health Medical Mutual’s 2014 Risk Management Webinar Series tackles a Is There Really Any ICD-10 “Safe” Social Mediaset in Health Care? wide range of topics based on scenarios often heard from Act our pracYou’re Exposed.

Get Protection.

Insurance Portability and Accountability (HIPAA). Physicians and other health care providers will be required to use tice managers and insured members. In these six webinars, we will ICD-10from effective October 2015.to incorporating cover everything preventing “never1,events” These days, like it or not, social media is part of everyone’s lives: clinical trials into the physician practice. patients, health care providers, and the lawyers who represent

As you are undoubtedly aware, in comparison to previous HIPAA mandates, transition to ICD-10 is can expected them.

New digitalthe platforms and storage devices heightento be risk for privacy breaches and can create contemporaneous to adjust documentation and other processes.

Previous HIPAA records. These can compete with EHRs once a fact-finder tries mandates have allowed physicians to rely on billing services, vendors, and other partners; however, ICD-10 will involve a to determine “what really happened.” The webinar’s guest The CDC estimates that 150,000 Americans have been afmuch higher level of direct physician involvement. speaker is Medical Mutual’s Chief Operating Officer & General fected by unsafe injection practices in the past decade. There

A Historic “Never Event”: for How Can We Prevent Others? most disruptive physicians, as they are required

Counsel, David Sousa. David will bring you up to speed on pohave been over 50 confirmed outbreaks and countless patient tential payoffs facingtraining health care providers practic- for the notification events during thisheard time period. guest speaker, Medical Mutual has from aOur number of our insured practices that theyand arepitfalls seeking in order to prepare ing and living in today’s digital and social media worlds.

Evelyn McKnight, AuD, is a survivor of one of the largest viral transition from ICD-9 to ICD-10. have hired outside consultants that have expertise with ICD-10 training for various outbreaks in American health care history. AsSome a result, Dr. McKspecialties, while have attended seminars offered –byA the American Academy of Professional nightmedical co-founded HONOReform andothers subsequently became a educational In-Office Dispensing Primer for Physicians nationally recognized patient safety advocate.

During of thisOphthalmic weCoders (AAPC), the American Academy Executive (AAOE), and the Medical Group Management binar, Dr. McKnight shares her personal story of the Nebraska PhysiciansICD-10, in a wide training range of specialties dispense prescription Association (MGMA). on the cost and complexity to implement is imperative in order to prepare for outbreak and how it could haveBased been prevented. drugs to their patients. A typical in-office dispensing program

the changeover to code sets for new diseases and procedures.involves This conversion means that health care of providers purchasing and maintaining an inventory frequentlyand 14,000 existingprescribed codes with roughly new codes.are often implelegend drugs.68,000 Dispensing programs

Promoting Personal and Patientthe Satisfaction insurers willSafety have to replace approximately

mented as an ancillary revenue stream and a convenience to patients. These potential benefits need to be weighed against Medical practices aim to provide a positive patient/family We recognize that we are not ICD-10 experts; however, we thought it would be helpful to compile resources available to potential pitfalls, such as regulatory and logistical burdens, and health care experience, but sometimes patients’ expectations health providers on this be in atoposition address ofother yourscrutiny ICD-10 questions increasedtorisk of auditsall and from are not met, care leading to complaints and daunting disruptions.issue.

Some- While we may notexposure payers.

In this Carolina webinar “primer,” expert health(NCMS) timesand unhappy patients becomehave unruly, or even concerns, please peace ofmenacing. mind knowing that we areregulators workingand with the North Medical Society care compliance attorneys, Carrie Hanger, Esq. and Laura Evans, Being confronted with aggressive patients or family members and other organizations to identify and develop resources to support a smooth transition for our insured medical practices Esq., with Smith Moore Leatherwood LLP review restrictions on is understandably frightening and adds stress to any clinical and physician members.webinar, The NCMS website currently featuresin-office a comprehensive of ICD-10 learning dispensing andlist address registration, fraud opportunities. and abuse, situation.

During this case-based our guest speaker, controlled substance, and related compliance issues.

James W. Pichert, PhD, with the Center for Patient and Professional Advocacy at Vanderbilt Medical Mutual(CPPA) is sensitive to theUniversity impact Medical that the ICD-10 delay has had on medical practices and physicians. This is Center, weighs practical options and considerations for consisLook Before You Leap: Incorporating Clinical Trials into undoubtedly a cumbersome and costly process.

Please visit the MedNotes blog to view periodic updates on this issue. tently, professionally, and ethically addressing encounters with Your Practice dissatisfied, aggressive, or potentially violent patients.

For additional information, visit us at www.medicalmutualgroup.com or call at: 800.662.7917 Health Care Reform andus declining reimbursement have physi-

Patient Portal Tips: Weatherproof Your Door to Meaningful Use

HIPAA and state law provide patients access to copies of their health information. In order to attest to Stage 2 measures of the Meaningful Use EHR incentive programs, physicians and physician offices must both use secure electronic messaging to communicate with their patients and permit patients to view, download, and send copies of their own health information.

Patient portals not only enable these secure communications, but are emerging as an effective communication tool between physicians and their patients. Before implementing a portal, practices should carefully consider available portal functionalities, choose those meeting the practice’s needs, and assure the policies and processes surrounding use of the portal protect the practice and safeguard shared information. In this webinar our speaker, Andy Lemons, Esq. with Smith Moore Leatherwood LLP outlines criteria to consider in selecting portal technology an offers recommendations on how practices can minimize risk in the implementation and operation of a patient portal.

TOP OF MIND: ICD-10

cians and other providers searching for alternative sources of revenue. Serving as an investigator for clinical research sponsored by pharmaceutical, biotechnology, or medical device companies offers additional revenue and other potential benefits. During this webinar, guest speaker, Trish Markus, Esq., with Smith Moore Leatherwood LLP considers the upsides of adding or growing your clinical research program. She will provide an overview of clinical trials, and address regulatory burdens, practical considerations, and obligations of an investigator.

More importantly, she will address fraud and abuse concerns and Medicare billing.

For ease and convenience, all Risk Management webinars are pre-recorded and available for viewing on the Medical Mutual website at www.medicalmutualgroup.com/rm-webinars-audioconferences. For questions about the webinars, please contact the Risk Management Department at 800.662.7917.

Webinar Attendance is an approved Premium Rewards Program (PRP) physicianlevel activity. Members can record points for up to two webinars per one-year term for a total of 10 points (or 5 points each).

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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Residents & Chapter Affairs New Physicians ncafp.com/residents-newfps

By: Dr. Aaron George NCAFP Resident Director Dr. George is a third-year resident at the Duke Family Medicine Residency Program and the resident representative on the NCAFP Board of Directors.

A Call for Leadership: A Resident’s Perspective The modern physician is called to provide twenty-first century health care upon the foundation of a twentieth-century training. Today's physician trainees enter a world of teamwork and collaboration in health care delivery. Evidence-based medicine and quality initiatives reinforce the fact that better outcomes and lower costs are driven by such a team-oriented approach. Complimenting these internal health care initiatives has been the strong response of policy reform and regulation.

Together, new models for health delivery facilitate patient care under the joint banner of teamwork and communication.

At every step of the journey, physicians accept the role of team leader, facilitator, and communicator.

The ability for future physician leaders to embrace the role of team leader can be best cultivated and enhanced through the response of medical educators. This next generation of physicians must be equipped to deal with an expanded skill set that goes beyond the approach to developing the traditional clinician. It must also relinquish the outdated belief that physician administrators are the only group in need of leadership training.

Rather, all physicians must be prepared to be active leaders. The academic medical community can go a long way to develop this sort of physician leader, one that is prepared for the challenges and successes of twenty-first century health care.

This call for a new model of leadership development in the medical academic community was recently emphasized in Academic Medicine, “The full benefits of such a model will not be apparent for years. Early benefits, however, include reduced costs of care, increased availability of health care, improved quality,

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

and a focus on wellness rather than disease management. Long-term benefits include increased involvement of physicians in all aspects of health care administration, with younger physicians leading changes in health care delivery.”1 Research suggests that there is a link between the engagement of doctors in leadership and quality improvement – with correlative improvements in patient care.2 It has become evident that trained physician leaders are better able to both initiate positive change as well as respond to negative or unexpected diversions.

This flexibility to interact with change is crucial to the maintenance of equitable and sustainable high quality patient care.

With the continued mantra of placing the patient first in health care, investment in such leadership development should be a priority.

Meanwhile, contemporary legislative and regulatory output continues to interplay with systems development to drive the evolution of patient care around the foundation of team-based approaches.

Health care systems continue to grow, and to further integrate the various levels of providers and practitioners, in an effort to find a cost-saving blend of quality care.

The constant in all of these regulatory models remains that the physician is placed at the center of delivery and as the leader of a team. If the academic community does not strive to meet the demands of these evolving health care systems, perhaps other licensed providers will be offered the chance to step into the void. Physician leaders must be prepared to both interact with, as well as facilitate and lead, these future health care teams.

Finally, perhaps the most systemic influence on leadership development will be driven by financial incentives.

Bundled reimbursements, value-based purchasing of health care resources, and pay-for-performance all indicate that providers will be rewarded in concert with team-based care. To complement this, several national societies, think-tanks and government bodies have suggested stratified incentives to academic institutions that engage medical core competencies to differing degrees. All of this is indicative of a likelihood that institutions and residency programs that address necessary competencies, such as leadership development, will likely see greater direct funding.

Some would argue that the movement towards leadership development in medicine is already upon us. To be fair, much discussion has taken place and early adoption has followed in, mostly, isolated settings. But, as a profession, we must still be doing something wrong.

Physician burnout is at an all time high, with studies demonstrating that 1 in 3 physicians is experiencing such burnout at any given time.3 Further studies show that 90% of professionals, who leave their profession, either voluntarily or involuntarily, leave not because of technical incompetence, but because of a non-technical shortcoming or difficulty.

Meanwhile, the most commonly raised issues in both medical student and physician performance continue to be within the domain of the non-technical competencies. These areas of concern include professionalism, ethics, and perhaps most important - interpersonal skills.4 The time for leadership development in medicine is at our doorstep. It is quite clear that the business community tapped into the importance of recognizing and advancing these principles over three

decades ago. In review of the literature on leadership development, it is evident that these topics have only just begun at earnest within the past five to ten years in the medical community. As a profession, physicians have likewise lagged behind – with only recent mutterings and support for the importance of structured and focused leadership in academic medicine. The necessity for developing a new generation of physician leaders is without question. The call for such leadership development is now loud and clear. However, the response of the academic community must be considered. As a profession, we cannot miss the opportunity to answer the door.

1. Snyderman, Carl. Eibling, David. (2011). The Physician as Team Leader: New Job Skills are Required”. Academic Medicine. 86(11): p 1348.

2. Ferlie, Ewan B.Shortell. Stephen M.(2001). Improving the Quality of Health Care in the United Kingdom and the United States: A Framework for Change. The Milbank Quarterly: A Journal of Public Health and Healthcare Policy. 79(2): p 281-315.

3. Shanafelt, Tait D. (2009). “Enhancing Meaning in Work: A Prescription for Preventing Physician Burnout and Promoting PatientCentered Care.” Journal of the American Medical Association. 302(12). p 1338-1340.

4. Eva KW, Rosenfeld J. (2004). “An Admissions OSCE: the MultipleMini Interview.” Medical Education. 38 p. 31-326

AAFP Stresses Accountability in its Push to Reform Graduate Medical Education The AAFP went on the offensive this fall, pushing for Graduate Medical Education (GME) payment reform that builds on its ‘four pillars’ strategy of family physician workforce development introduced early this year. The AAFP released a briefing document on GME reform titled, Aligning Resource, Increasing Accountability, and Delivering a Primary Care Physician Workforce for America.

The plan proposes to limit both direct and indirect GME payments to ‘first-certificate’ residency training programs; seeks to establish primary care thresholds and maintenance requirements for all sponsoring institutions and any existing institution seeking to expand; moves to align GME financial resources with population health needs; and promotes funding for the National Health Care Workforce Commission. The plan affirmed and even goes beyond the recommendations put forth by the Institute of Medicine this summer.

To read coverage of the effort and the proposal, see www.aafp.org/news/education-professionaldevelopment/20140917gmeproposal.html.

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The Mountain Area Health Education Centers Program Asheville Family Medicine Residency

Transformative Training in Western North Carolina

By Peter Graber NCAFP Director of Communications

O

n a beautiful Saturday evening last September, the Mountain Area Health Education Centers Program (MAHEC) celebrated its 40th anniversary with an event that brought together program leaders spanning four decades.

Attending were numerous MAHEC visionaries credited with launching the program and establishing it as one of the most successful of its kind in the nation.

Since MAHEC's earliest days, its core mission has been to strengthen the healthcare workforce that serves its 16-county coverage area in western North Carolina. The linchpin to realizing this vision has been MAHEC's family medicine residency program at Asheville (MAHEC-A), one of the state's largest and most progressive training programs.

Founded in 1976, MAHEC-A has graduated more than 280 family physicians, with more than 62% continuing to practice across the region.

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

Embracing Transformation Like many family medicine residencies today, MAHEC-A has been hard at work adapting to a steady stream of changes taking place within the specialty and in healthcare delivery. Program leaders view these changes as placing a new set of skills requirements on tomorrow's family physicians, particularly in the areas of quality, value-based care delivery, and population health.

"As a resident back in the late 1990s, 99% of what we learned was about what happened in the exam room in the one-on-one patient encounter. Now, although great clinical care continues to be our foundation and 90% of what we teach, the remainder now is chronic care management and increasingly, population management," noted Dr. Blake Fagan, MAHEC-Asheville Residency Program Director.

Dr. Fagan has been the program's director for the last six years and has seen a lot of changes since completing his residency training with MAHEC in 2001. But

to Dr. Fagan, all have been focused on improving the training experience, and preparing residents for an exciting future.

The most visible aspect of MAHEC-A's transformation is the program's new outpatient teaching center. Situated on the 14-acre Mary C. Nesbitt Biltmore Campus, MAHEC-A moved into the 40,000 square foot Family Health Center just over a year ago. The new center is 50% larger than its old facility and much better equipped to support the program's growing case management team, and its efforts in training residents on emerging new models of care delivery, like group visits.

"With the accountable care model emerging, the thought is that group visits are a great way to help achieve better population health," explained Dr. Fagan. "And for populations, it's not just the patients our residents see, it's also the ones they don't see." Dr. Fagan described how its new group visits room allows residents to see multiple patients simultaneously for issues like diabetes and prenatal care. He even noted that

residents are also receiving excellent feedback in how they're integrating other services into their care process, like pharmacy and behavioral health. The new center is making all of this easier.

Apart from its clinical operations, MAHEC-A is also using some newer teaching methods to actively engage residents. Similar to its group visits, the program's weekly didactic sessions are being delivered in small group formats using the 'flipped classroom' model.

This model works to identify the subject areas requiring the most concentrated teaching, helping to make better use to time and enhancing overall lesson quality. Residents also are pressed to apply their learning through small group casework.

Even with these improvements, the program hasn't lost sight of its ultimate goal of strengthening the health workforce. Keeping graduates in the region long term is crucial, and to help drive this, the program recently expanded its post-graduate offerings with a new sports medicine fellowship. According

to Dr. Fagan, the fellowship is helping recruiting, providing a much needed community service, and now offers another great reason to stick around Asheville after graduation. MAHEC-A also offers fellowship training in geriatrics, hospice and palliative medicine, and obstetrics.

Preparing Family Physicians to Meet the Need Since it began in 1976, MAHEC-A's mission has been to produce family physicians who are expertly trained and adaptable in serving the needs of small towns and underserved communities. MAHEC-A blends a demanding clinical curriculum with a service philosophy that trains residents to integrate a range of services into their care process to help realize this goal. The net effect of these efforts has been a steady output of extremely well-trained graduates who complete their training with strong professional ties to the region and to the overall MAHEC program. From a high level, MAHEC-A's training environments are a blend of urban, suburban, and rural facilities.

The program's in-patient training experience takes place at Mission Hospital in Asheville, an 800+ bed critical care and regional referral center that houses North Carolina's busiest emergency room, and also one of its most demanding pediatrics centers. Because the hospital offers nearly every imaginable service and serves such a large catchment area, Mission can really be considered a combination of a busy community hospital and an academic medical center.

MAHEC-A's outpatient and continuity experiences consist of residents staffing the busy Family Health Center, but also serving some rural clinics affiliated with the program. Team-based care in each of these locations is playing an increasingly larger role. Residents work closely with professionals from across MAHEC's residency programs (dental, pharmacy, and ob-gyn), to integrate those services into their care when appropriate, but also to serve patients referred from those services as well. It all works to promote synergy across MAHEC's entire service spectrum, improve quality, and reflects Continues on next page

MAHEC-Asheville’s Dr. Blake Fagan, Residency Program Director

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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MAHEC-ASHEVILLE the program's embrace of team-based care and population health.

Current MAHEC-A second-year resident Dr. Ben Aiken recognized the power of the program's progressive thinking as he investigated training programs across the country. As a UNC medical student who participated in the school's longitudinal curriculum in Asheville, Aiken was familiar with many aspects of MAHEC. While visiting residencies across the country, he was drawn back to MAHEC-A by the people and the progressiveness of the training.

"One of the things that I was drawn to in coming here and what my experience has affirmed, is that I will be very prepared to practice in a rapidly changing healthcare system," explained Dr. Aiken. He went on to share that progressive thinking and training is shared by everyone: residents, faculty, administrators and staff.

The changing healthcare system -- with its trends towards quality, value, and patientcenteredness -- are squarely on the minds of residency program leaders and across MAHEC's Division of Family Medicine.

Fortunately for residency trainees, opportunities to learn about these concepts and how they're being addressed are close Dr. Ben Aiken by. Earlier this year, MAHEC partnered with Mission Health to manage 22 Missionowned primary care clinics across the region.

This has enabled MAHEC-A residents to see firsthand the issues in delivering progressive, patient-centered care across a network that spans both urban and rural environments.

Additionally, MAHEC and its family medicine division are key players in developing the western North Carolina's first integrated clinical network that's set to launch later next year.

Dr. Fagan sees the demand for high quality primary care only increasing in the coming years. Even with Asheville and its surrounding region well-served by MAHEC's family medicine residency, much more work still needs to be done. It's estimated that there is still a demand for 140 more primary care physicians to serve the region at this time.

But MAHEC-A is committed and busy tackling the challenge through its progressive approach. With dedicated people and a clear vision, its future looks as bright as its history.

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

Into the Mouths of Babes NC Dental Screening & Varnish Project

North Carolina Academy of Family Physicians, Inc P.O. Box 10278 • Raleigh, NC 27605

F ourteen Y ears of G rowth & S uccess

Collaborations Fuel Steady Growth of NC’s Dental Varnish Program Almost 15-years ago, an innovative statewide program addressing tooth decay in young, at-risk children launched in North Carolina. Known as the Into The Mouths of Babes (IMB) Dental Fluoride Varnish Project. The aim of the program was simple: integrate an evidence-based dental preventive service into primary care targeting Medicaid children, combine it with educational counseling and fair payment, and see what happens.

North Carolina became one of the first states in the nation to provide the service when it rolled out the effort statewide in 2000. Family physicians and the North Carolina Academy both played instrumental roles in helping to establish IMB, providing strategic input, office space, technology, and communications support. At the time, dental caries in young children was already recognized as the most common chronic childhood disease, with nearly 40 percent of new kindergarteners having a history of cavities. In some NC counties, the rate was as high as two-out-of-three children.

In the 14 years since its launch, the IMB program has steadily grown and today Medicaid-insured children from tooth

eruption to age 3½ receive the service at 48% of all well-child visits. Family physicians, pediatricians, and community health clinics in all North Carolina counties participate in the program and the numbers continue to grow, effectively expanding much needed dental access to the state's most vulnerable children.

According to a July, 2013 Healthy North Carolina 2020 Update, the program has been instrumental in helping the state already exceed its goal of dental access for Medicaid children aged 1-5 years.

The program also has helped establish North Carolina as the national leader in providing non-dentist oral health services to Medicaid children aged 1-2.

Beyond these major access gains, the most impressive aspect of the IMB program have been its results. In a study conducted by the UNC Gillings School of Global Public Health and published in the journal Pediatrics in 2011, children aged 6 to 35 months who had four or more screenings and fluoride varnish treatments had 49 percent fewer dental caries at 17-months of age compared to those with no visits. Additionally, trend lines of the state's kindergarteners with

IMB program has been extraordinarily successful.

"People ask me all the time how we've done it. I always tell them it's the partnerships: family physicians,

pediatricians, dentists, Public Health, UNC, Medicaid and others. All of us working together and supporting each other has been the magic."

See IMB on Back Cover

Percentage of children, age 1-2, enrolled in Medicaid for at least 90 days who received Oral Health Services provided by a Non-Dentist Provider, FFY 2012 (12f) 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%

North Carolina Iowa Washington Maine Texas Florida Maryland Wisconsin Colorado Minnesota Wyoming Mississippi National Nevada Illinois Montana Massachusetts Vermont California Alabama North Dakota Ohio Nebraska Virginia New York Oregon Rhode Island South Carolina Pennsylvania New Mexico Connecticut* Georgia Kansas Michigan Utah Missouri South Dakota Oklahoma Kentucky West Virginia Louisiana Idaho Indiana Alaska Arizona Arkansas Delaware District of Columbia Hawaii New Hampshire New Jersey Tennessee

dental caries experiences also continues to fall, with a reduction of almost 14% from 2007-2012.

“It’s gratifying to know that ‘Into the Mouths of Babes’ works as well as we’d thought,” stated Gary Rozier, DDS, one of the study's authors in a UNC press release announcing the results.

“Children with early childhood caries often experience pain, difficulty eating and sleeping, all of which affect their quality of life. If children have caries early, they are more likely to develop caries in permanent teeth, ” Rozier noted.

Dental health programs that mirror the key aspects of the IMB program (oral evaluation and risk assessment, varnishing, education and payment) are now commonplace across the country, according to Kelly Close, Preschool Oral Health Coordinator within the Oral Health Section and the project's lead. But according to Close, few have been as successful as IMB and many continue to struggle with finding their footing in terms of provider participation and utilization. That's the area where the

Source: FFY 2012 CMS-416 reports, Line 1b, 12f Note: *FFY 2012 data for Connecticut is not yet available and was substituted with FFY 2011 data. Estimates for this state are included in the National figure for FFY 2012. Data reflects updates as of 4/03/14.

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Practice Enhancement ncafp.com/practice-mgt

Primary care physicians around the country are facing the largest decision of their lives: Do I stay independent and maybe form an accountable care organization with other independent physicians, or do I become an employee of a hospital or health system?

As accountable care is taking hold, new data may alter historic thinking on this “bet-the-practice” question.

Tired of being overworked, undersatisfied, and overwhelmed with growing regulatory requirements, many primary care physicians have sought the security and strength of hospital employment. They say the pressures to invest in technology, billing, coding, and continued reimbursement pressures are just too great.

Yet, the majority of these physicians miss their days of self-employed autonomy, are on average less productive, and worry that the clocks on their compensation guarantees are ticking down.

Most of the moves by your colleagues, and perhaps you, to hospital employment have been defensive. It was just no longer feasible to stay afloat in the current feefor-service system. You cannot work any harder, faster, or cheaper. You can no longer spend satisfactory time with your patients.

On the other hand, some of you may have joined a hospital or health system to be proactive and gain a solid platform to prepare for the new value-based payment era.

You may have envisioned being integrated with a critical mass of likeminded physicians and facilities, aided by advanced population management tools and a strong balance sheet, and all linked together on the hospital’s health information technology platform. You read that primary care should be in a leadership position and financially incentivized in any accountable care organization – including a hospital’s.

Independent physicians could theoretically form ACOs, too, but lack

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THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

Stay Independent or Join A System?

Emerging Data Shows That Physician-Led ACOs Can Be Very Successful

By Julian D. ‘Bo’ Bobbit, Jr., JD Reprinted with permission of author Bo Bobbit. This article originally appeared in Family Practice News in July, 2014

the up-front capital, know-how, and any spare intellectual bandwidth to do so.

So, from a strategic perspective, becoming employed with other physicians by a health system seemed the way to go.

The pace has quickened of health care’s movement away from fee for service or “pay for volume” to payment for better outcomes at lower overall costs, or “pay for value.” The factors that applied to the decision to become employed in the fee-for-service era may be yielding to those in the accountable care era sooner than anticipated.

Independent physician-led ACOs appear to be adapting better than hospitals to this change. Although much better prepared fiscally, hospitals are conflicted, or at least hesitant, to make this switch, because much of the savings comes from avoidable admissions and readmissions. On the other hand, emerging data and

experience are showing that physicianled ACOs can be very successful.

There are some very integrated and successful hospital-led ACOs or other value-delivery hospital physician models.

In fact, I believe that if the hospital is willing to right-size and truly commit to value, it can be the most successful model.

However, many physicians signed volume-only physician work relative value unit (RVU) compensation formulas in their hospital employment agreements, with no incentive payments for value.

They have not been involved as partners, much less leaders, in any ACO planning.

Even though the fee-for-service days are waning and strains are showing for many hospitals that are not adapting, for many employed physicians, the pace of preparedness for the accountable care era has been disappointing.

New data show that while most of the early ACOs in the Medicare Shared

Savings Program were hospital led, there are now more physician-led ACOs than any other. At the same time, early results of some modest primary care–only ACOs have been exciting. The rural primary care physician ACO previously reported on in this column, Rio Grande Valley Health Alliance in McAllen, Tex., is preliminarily looking at 90th-percentile quality results and more than $500,000 in (unofficial) savings per physician in their first year under the Medicare Shared Savings Program.

In fact, in a May 14, 2014, article in JAMA, its authors stated: “Even though most adult primary care physicians may not realize it, they each can be seen as a chief executive officer (CEO) in charge of approximately $10 million in annual revenue” (JAMA 2014;311:1855-6). They noted that primary care receives only 5% of that spending, but can control much of the average of $5,000 in annual spending of their 2,000 or so patients. The independent physician-led Palm Beach ACO is cited as an example, with $22 million in savings their first year. The authors recommend physicianled ACOs as the best way to leverage that “CEO” power.

These new success lessons are being learned and need to be shared. Primary care physicians need to understand that the risk of change is now much less than the risk of maintaining the status quo. You need transparency regarding the realities of all your choices, including hospital employment and physician ACOs. As readers of this column know, I heartily endorse the trend recognized in the JAMA article: “[A]n increasing number of primary care physicians see physician-led ACOs as a powerful opportunity to retain their autonomy and make a positive difference for their patient – as well as their practices’ bottom lines.”

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice.

For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919821-6612.

PRACTICEBRIEFS NC Division of Public Health Offers Guidance on Recommending e-Cigarettes as Cessation Aids According to the NC Division of Public Health, the use of e-cigarettes is exploding without clear documentation about their benefit in facilitating cessation. There are no clinical guidelines for recommending patients use electronic cigarettes (or other nicotine vaporizing devices) as cessation support. A recent study which surveyed North Carolina primary care providers showed that 35 percent had recommended electronic cigarettes as cessation devices to their patients. Providers were more likely to recommend electronic cigarettes if the patient introduced the topic or the provider believes electronic cigarettes are less harmful than smoking combustible cigarettes. The FDA has released proposed regulations for these currently unregulated products and much research of these devices is now underway. A complete description of the study, including methods, results and analysis, is online.

ACIP Recommends Routine PCV13 Immunization for Older Adults A new recommendation released by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) states that adults aged 65 or older should now be vaccinated with 13-valent pneumococcal conjugate vaccine (PCV13), with a follow-up dose of PPSV23 in six- to twelve-months. Approved by ACIP during a special meeting convened in mid-August, physicians are now being encouraged to integrate the new recommendation into patient visits during this fall’s influenza vaccination season. One point to note, however, is that for some patients -- particularly those who have already received PPSV23 -- the recommendation could mean an out-of-pocket expense, since Medicare only pays for one dose of pneumococcal vaccine for patients older than 65. See http://www.aafp.org/ news/health-of-the-public/20140827pcv13vote.html for complete coverage.

BCBSNC’s Blue Quality Physician Program Provides Training on Serving the Growing Veteran Population With North Carolina home to two major military installations and the United States in the midst of the largest active duty forces drawdown in decades, many veterans leaving or retiring from the service may choose to stay and settle in communities across the state. Physicians and practices should keep in mind that Blue Cross and Blue Shield of NC (BCBSNC) offers training on serving military veterans through its Blue Quality Physician Program, an incentive program offered to certain primary care physicians.

For more on this program, visit http://www.bcbsnc.com/content/providers/ bqpp/index.htm

Sunshine Act’s Payments Database Debuts, But System is Challenging CMS formally launched the Open Payments System in late September (www. cms.gov/openpayments), releasing data on more than $3.5B in payments and other financial benefits made to individual physicians during the 5-month period of August-December, 2013. Initial reaction to the system’s launch have been mixed, with many citing concern that the data lacks appropriate context for consumers, as well as the fact that of the 546,000 physicians in the system, only 26,000 registered to review the accuracy of the payments data. If you have yet to review the data, please see http://www. cms.gov/OpenPayments to begin this process.

THE NORTH CAROLINA FAMILY PHYSICIAN • Autumn 2014

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PLAYBOOK, continued from p. 19

But taking action and gathering information is only part of the journey to successful integrations. People, contacts and relationships are still the most important component. In recognizing this, the Playbook provides information that helps physicians make key connections within their communities or at existing programs that mirror their aims. For instance, each success story provides updated organizer/program contact information, as well as a description of each program's methodology, process, and its future plans. The goal is to drive idea sharing, road mapping, and relationship building, especially in larger communities where stakeholders may not know each other.

Even beyond what's found in the Playbook, however, is the overarching goal of creating a robust 'game plan' for developing crossdisciplinary family medicine leaders to spearhead tomorrow's integrations. Doing so is key, as the IOM report pointed out, and family physicians are very well-suited to the task.

The Practical Playbook will continue to evolve to meet the needs of its users and plans are underway to provide support and assistance to communities working on integrative projects.

Much akin to where value-based payment models are today, the Playbook is only beginning to establish itself. But even now, family physicians and others working together to implement tomorrow's new programs have another tool in their arsenal, and it's just a click away at www.practicalplaybook.org.

statewide. Close also noted that the NC Oral Health Section's public health dental hygienists are also being trained to provide the procedure, which should help expand IMB's range even further.

Finally, a unique program extension to IMB -the Priority Oral Health Risk Assessment and Referral Tool (PORRT) -- was developed in collaboration with the Carolina Dental Home Project. This tool standardizes the information gathering process when identifying and referring high-risk children to local safety-net dental homes. To help train providers on its use, the NCAFP, along with CCNC, the NC Pediatric Society, the NC Department of Health and Human Services/Office of Rural Health, and the NC Foundation for Advanced Health Programs, developed a web-based Maintenance of Certification Part IV educational activity titled, 'Oral Health: Promoting Dental Homes for Young Children Through Screenings, Varnishing, and Referrals.' The program is available free-ofcharge at http://oralhealth.ncafp.com To learn more about the IMB program, including how to participate and offer the service, visit www.ncdhhs.gov/dph/oralhealth/partners/IMB. htm

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IMB, continued from p. 29 The effectiveness of the IMB program and similar efforts in other states are beginning to draw increased attention. This past May, the independent US Preventive Services Task Forces (USPSTF) issued a new "B" recommendation for fluoride varnishing twice a year for children aged 6-months to age 5. This expanded upon its previous 2004 recommendation where it urged primary care providers to only prescribe oral fluoride supplementation in cases where water sources were fluoride deficient. In expanding its guidance, USPSTF noted that because nondental primary care clinicians were more likely than dentists to have contact with children aged 5 years or younger, the benefits of the flouride application outweighed any potential overexposure risks.

Close also noted that private payers have begun to recognize the benefits as well. She said that Blue Cross and Blue Shield of North Carolina will begin paying for the procedure beginning in January, 2015.

Going forward, growing IMB participation and utilization is the program's top priority. To enroll more practices, the program is expanding its outreach through some new, promising collaborations. For example, Community Care of North Carolina (CCNC) has been providing in-practice training in all of its 14 networks

North Carolina Academy of Family Physicians, Inc. 1303 Annapolis Drive Raleigh, North Carolina 27608

clearing more challenging hurdles.

For example, the Playbook includes practical information on simpler topics like locating your county health director, all the way to the most challenging, such as framing key meetings and motivating others in the community around a shared vision. Along the way, it presents success stories of existing programs that can be used as guides.