NC Family Physician - Summer 2018

Volume 14 Issue 3 • Summer 2018

The North Carolina

Family Physician Quarterly News in North Carolina Family Medicine

Fighting for Family Medicine in Raleigh

Join us in Asheville for top-notch CME. We’ll save you a seat. 2018 Winter Family Physicians Weekend ANNUAL CONFERENCE & EXHIBITION 25+ AAFP Prescribed Credits Program Chair: Jewell P. Carr, MD • Program Vice-Chair: Shannon B. Dowler, MD Early Bird Discount Registration for Members Ends on Sun, Oct 7, 2018

Tentative lecture topics include: HIV Chronic Pain Irritable Bowel Syndrome ASCVD Risk Hepatitis C Multiple Sclerosis

Eating Disorders Pediatrics Reproductive Health Pelvic Pain in Women Osteoporosis Female Sexual Dysfunction

Lupus Diabetes Heart Failure Psoriasis STDs And many others

Optional Workshops & Seminars Practice Management 301 • Health Systems Panel Discussion • Medicaid Reform Town Hall Medication Assisted Therapy Training • Osteopathic Manipulative Treatment

Optional Pre-Conference Opportunities on Wed, Nov 28 KSA Study Working Group on Women’s Health • Group Medical Visits Nexplanon Training

THURS, NOVEMBER 29 – SUN, DECEMBER 2, 2018 Omni Grove Park Inn • Asheville, NC

CME | Camaraderie | Networking | Fun www.ncafp.com/wfpw

Inside Summer 2018

DREAMING BIG! UNC’S DR. BEAT STEINER LEADS STFM

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PRESIDENT’S MESSAGE

CHAPTER AFFAIRS

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18 This is What NCAFP is Doing to Fight for You

NCAFP Begins News Strategic Initiatives

HEALTH POLICY & ADVOCACY

STUDENT INTEREST

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28 NCAFP Rural Immersion Program: A Student

Keeping Half-a-Billion in Healthcare

FOUNDATION

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Thank You, 2018 Family Medicine Gala Sponsors!

Perspective

PRACTICE MANAGEMENT

30 NC MedAssist Helps The Uninsured and Low Income

PUBLISHED BY

DEPARTMENTS

t 919.833.2110 •

President’s Message 4 Health Policy & Advocacy 6 Membership 12 NCAFP Foundation 16 Chapter Affairs 18

fax

919.833.1801 • ncafp.com

Managing Editor & Production Peter Graber, NCAFP Communications

Professional Development 22 Residents & New FPs 26 Student Interest 28 Practice Management 30

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

PRESIDENT’S MESSAGE to Members By Dr. Tamieka M.L. Howell 2017–2018 NCAFP President

NCAFP Begins New Strategic Initiatives In my last article, I spoke about our strategic plan and your needs based on last year’s member needs assessment survey. The Academy has been able to move forward with implementing some of the goals outlined in this plan. One of those goals focused on the need to strengthen the influence of family physicians with payors and health systems. Along these lines, I am happy announce that you will have a chance to hear from some of our major health system leaders at our Annual Meeting. We have confirmed attendance by: • Ronald A. Paulus, MD, President and CEO, Mission Health • Terry Akin, Chief Executive Officer, Cone Health • Donald Gintzig, President and CEO, WakeMed • Carl Armato, President and CEO, Novant Health

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There will be a panel discussion of some key issues impacting family medicine. I hope this will take some of the mystery out of what happens at “the top,” and also give insight to our frontline physicians that don’t always have the opportunity to provide input. Additionally, one of the goals was to provide quality education that impacts patient care and the practice of family medicine. As many of you know, we had the final summer CME meeting in Myrtle Beach this year. Our members did not find it as valuable as a resource as other CME opportunities, and many out-ofstate physicians attended the meeting. I attended the full meeting for the first time this year and could watch as people reflected on the many years they have attended and brought their families for vacation. I could see that some were sad to see the meeting go. On the positive side, in lieu of this meeting, we intend to bring the CME directly to you. The staff and volunteers that organize NCAFP CME activities will continue to provide subjects that are most relevant to you, but now allow it to happen closer to home. We hope that having an evening or weekend event will allow you to minimize time away from the office and the cost of travel, thus making attainment of CME hours less burdensome. Keep an eye out for more information in the coming months. Finally, in an effort to rebuild the excitement about family medicine by celebrating successes and accomplishments of our members as outlined in the strategic plan, I want to highlight one of our members. Below you can read about Dr. Ronak Shah, a third-year resident at Wake Forest and current Chief Resident.

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2017-2018

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

MEMBER SPOTLIGHT Dr. Ronak Shah, Chief Resident Residency: Wake Forest Family Medicine - Class of 2019

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

District Directors District 1 - Mackenzie Smith, MD District 2 - Gilbert Palmer, MD District 3 - Garett R. Franklin, MD District 4 - Shauna L. Guthrie, MD, MPH District 5 - Dimitrios “Taki” P. Hondros, MD District 6 - Ying Vang, MD District 7 - Jennifer Mullendore, MD

Years in Practice: Starting 3rd year of residency Why Did You Choose Family Medicine: I chose family medicine because there’s something new every day. I enjoy the breadth in medical decision making, diversity of patient ages and backgrounds, and most importantly, developing long term relationships with my patients.

At-Large Jason T. Cook, MD At-Large Talia M. Aron, MD IMG Physicians Brian McCollough, MD Minority Physicians Jewell P. Carr, MD Osteopathic Family Physicians Slade A. Suchecki, DO New Physicians Elizabeth B. Baltaro, MD

Practice Setting: Academic hospital and clinic

Family Medicine Residency Directors Mark L. Higdon, MD (Novant FMR) Resident Director Courtland Winborne, MD, MPH (Cabarrus)

Favorite Thing About Being an FM Physician: I’m so thankful I chose Wake Forest for my FM residency. It has been a delight to pursue academic opportunities in teaching medical students, and the staff and co-residents have made this place home. I can’t see myself leaving!

Resident Director-Elect David S. Baker, MD (MAHEC-A) Student Director Allyson Mentock (BSOM) Student Director-Elect Cameron G. Smith (Campbell)

Hobbies: Everything beverages. I love making different types of coffee and brewing beer. I also enjoy cooking. North Carolina has also expanded my green thumb, and my wife and I have enjoyed the stunning beaches of the Outer Banks and lush mountains of Asheville.

Medical School Representatives & Alternates Chair (ECU) Chelley K. Alexander, MD Alternate (Campbell) Nicholas Pennings, DO Alternate (Duke) Anthony J. Viera, MD, MPH Alternate (UNC) Cristen P. Page, MD Alternate (Wake) Richard W. Lord, Jr., MD, MA

Interesting Fact: I will win at Monopoly.

AAFP Delegates & Alternates AAFP Delegate Michelle F. Jones, MD AAFP Delegate Karen L. Smith, MD AAFP Alternate Richard W. Lord, Jr., MD, MA AAFP Alternate Robert L. Rich, Jr., MD

What I Hope for the Future of Medicine: I hope to see technology continue to expand to standardize electronic medical records, making them easier to sift through. EMRs have been a blessing and a curse. It’s very convenient to have labs/images/history all in one place and have the ability to prescribe medicine with a few clicks, but I do believe computers draw attention away from the patient and distance us from the reasons we got into medicine in the first place—to provide humanistic, wholesome care.

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

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www.ncafp.com

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

- YOUR ACADEMY IN ACTION -

Keeping Half-A-Billion Dollars in Healthcare and More The 2018 Legislative Session has ended, at least temporarily, with a few victories for family medicine, some battle scars and some opportunities and challenges for the future.

KEEPING MEDICAID DOLLARS IN HEALTHCARE First and foremost, the NCAFP helped preserve nearly half-a-billion dollars in healthcare spending during a last-minute fight regarding how Medicaid managed care in North Carolina will ultimately be implemented. Fortunately, due to fortuitous scheduling of our White Coat Wednesday, 25 NCAFP members converged on the General Assembly the week these changes were under consideration. Planned legislation that would license and regulate Medicaid managed care plans included some last-minute surprises (House Bill 156). At the 11th hour, some senators sought to cap the required Medical Loss Ratio (the MLR) managed care plans would have to meet at 85 percent, as opposed to a minimum of 88 percent proposed by the Department of Health and Human Services. The MLR is the portion of every dollar that the plans must spend on health care. But the NCAFP and others in the healthcare community fought back, keeping over $400 million in state and federal dollars to provide healthcare as opposed to added administrative fees and profits for the managed care companies. A senator also proposed stripping out all funding for medical homes. This would have meant the loss of any care management or medical home fees that practices would receive in the new system, which would have taken at least another $30 to $40 million directly away from primary care practices.

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White Coat Wednesday at the NC General Assembly: (L to R) NCAFP President-Elect Alisa Nance, MD; President

Tamieka Howell, MD; Secretary-Treasurer Jessica Triche, MD; District 5 Director Takie Hondros, MD; and William Leatherwood

The NCAFP, NC Pediatric Society, NC Medical Society, and others fought back against the changes and prevailed on the first two points. A proposal to prohibit certain accountability measures for managed care plans using financial withholds by the Department did move forward, but with a shortened timeframe (only an 18-month prohibition). The legislation that ultimately passed also included hardfought provisions under Chapter 58 of the NC General Statutes that govern how health insurance companies operate in the state. Most provisions that apply to commercial health plans, including prompt payment requirements, will also apply to Medicaid managed care plans. Thanks to the NC Medical Society’s Chip Baggett for leading the charge on Chapter 58 protections.

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per region for six regions in the state. The Department will then select plans based on review of the RFPs and begin contract negotiations. It is estimated that managed care will be implemented in North Carolina’s Medicaid program, sometime in the last third of 2019. Stay tuned. Heroin & Opioid Prevention and Enforcement Act (SB 616) The HOPE Act, as it is referred, is touted as an additional tool for law enforcement to help control the movement of opioids into the illegal drug market. The key provision impacting healthcare allows for expanded access to the Controlled Substance Reporting System (CSRS) for certain law enforcement officials. While the NCAFP expressed early concerns about some provisions of the act particularly around how law enforcement would garner access to information in the CSRS, your voice was heard. Based on input from the NCAFP and others in the healthcare community, the bill ultimately contained these provisions: • Individuals requesting information around controlled substance prescriptions must be a “certified diversion investigator” and must be conducting a “bona fide active investigation.” In addition, they must be supervised by a “certified diversion supervisor.” • There will be an audit trail for all information released from the CSRS.

Integrated Care for Medicaid (House Bill 403) The Legislature also considered a bill that would allow integration of behavioral health care in primary care for Medicaid recipients. Individuals with mild to moderate behavioral health conditions will now receive all services through what will be called “standard Pre-Paid Health Plans (PHPs)” under Medicaid, fully integrating physical and behavioral health. Specialty or “tailored plans,” initially run by the current LME/ MCOs, will manage more severe behavioral health issues but will also be responsible for the entire healthcare spend for that small portion of the population. Implementation of these provisions will be complicated, but the NCAFP remains engaged with top officials at Medicaid on all aspects of the Medicaid Managed care transition. As of writing this article, the NC Department of Health and Human Services was still awaiting federal approval of the waiver that would ultimately move Medicaid into a managed care system in North Carolina. Approval is expected soon. Once the waiver is approved, the Department will issue Request for Proposals (RFPs) for up to four statewide managed care plans and up to two plans

• To become a certified diversion investigator, a law enforcement official will have to undergo specific training including HIPAA training, training on prover investigative techniques in drug diversion cases, training on proper handling of confidential data and records, and best practices for working with pharmacies in a manner that minimizes disruption of customer service and operations. • Investigators will have to be re-certified every three years. As an additional safeguard, any individual (including law enforcement) who knowingly and intentionally accesses prescription information in the CSRS for a purpose not specifically authorized or discloses or disseminates information from the system for a purpose not authorized is guilty of a Class I felony. If the person disseminates the information for commercial advantage or personal gain or to maliciously harm any person, then the felony is increased to a Class H felony. Beyond the provisions regarding access to the CSRS, the Act also increases penalties for anyone who sells, manufactures, delivers, transports or possesses certain controlled substances, such as opioids, heroin, fentanyl, etc. The Act also implements criminal penalties for anyone who diverts controlled substance by means of dilution or substation, including healthcare professionals who would dilute or substitute a controlled substance to divert said substance. Continues on next page

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FIGHTING FOR RURAL HEALTHCARE The NCAFP followed several bills closely that sought to increase access to care in rural areas. House Bill 998, entitled “Improving NC Rural Health” directs the NC Department of Health and Human Services (DHHS) to study incentives for medical education in rural areas and assist rural hospitals in becoming designated as teaching hospitals. The bill also directs the Office of Rural Health to ensure that state loan repayment programs are targeted to benefit health care providers in rural areas. Finally, Part V of the bill directs DHHS to conduct a study to propose two new Medicaid coordinated quality outcome programs designed to reduce unnecessary and inappropriate service utilization and generate sustainable savings to the Medicaid program. The Academy had advocated for additional provisions that would have studied how to reduce primary care provider administrative burden and improve quality of life in both Medicaid and the State Health Plans, including potential pilots of Direct Primary Care within these health plans. These provisions became tied to a potential study of Medicaid expansion and were removed in the state Senate. The Legislature approved all other provisions. The NCAFP hopes to collaborate with DHHS on the enacted provisions. House Bill 1002 would have continued the work of a legislative subcommittee studying medical education and residency expansion. An interim committee had two meetings on the issue but did not feel they were able to complete their work. As a result, the bill would have authorized ongoing study of both undergraduate and graduate medical education by a joint healthcare/education subcommittee. The bill passed the House but was never considered by the full Senate. Similarly, House Bill 967, which ultimately proposed studying a possible statewide Telemedicine Policy, passed the House unanimously but never gained traction in the Senate. An early version of the bill had some provisions the NCAFP considered troubling, including a lack of clarity on payment for telemedicine and a lack of coordination with the medical home. However, after both the NCAFP and the NC Pediatric Society expressed these concerns to the House sponsors, the bill was modified to study developing a telemedicine policy as opposed to addressing specifics at this time. While the Study Bill did not move forward, it is expected that additional telemedicine efforts will develop in the next legislative session.

BUDGET PROVISIONS Several provisions of the updated state budget for 2018-19 proved positive for healthcare, especially primary care. They include:

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Western School of Medicine, Asheville – Nearly $5 million in nonrecurring funds for the UNC School of Medicine’s Asheville Campus, a joint program between the UNC School of Medicine, other UNC System universities, and the Mountain Area Health Education Center. The revised net appropriation is $15.4 million in FY 2018-19 as opposed to the previous annual appropriation of just over $10 million. UNC Rockingham Health Care – Provides $500,000 nonrecurring to UNC Rockingham Health Care for matching grant funds for a primary care rural advancement program. Southern Regional Area Health Education Center – Provides nearly $5 million nonrecurring to the Southern Regional Area Health Education Center for surgery and family medicine residencies in the SR AHEC service areas and for facility and structural improvements associated with current residency programs. Smoking Cessation Programs – Provides $250,000 nonrecurring for QuitlineNC and You Quit Two Quit smoking cessation programs. Youth Tobacco Prevention – Provides $250,000 nonrecurring to develop strategies to prevent the use of new and emerging tobacco products, including electronic cigarettes, by youth and people of childbearing age. Newborn Screening – Budgets increased fee receipts to support the full cost of the State’s Newborn Screening Program. Receipts will be used to support direct and indirect costs (including supplies, equipment maintenance, staff, etc.) and to add three new tests to the State’s newborn screening panel to conform to federal recommendations. Physician Supplemental Payment Plan – Provides $3,200,000 recurring to expand allowable slots for the physician upper payment limit plan by 60 slots to be allocated between East Carolina University (ECU) Brody School of Medicine and University of North Carolina (UNC) Health Care. The total Upper Payment Limit slots allowed after this addition will be 1,761 slots. These slots are designed to offset the cost of clinical operations in an academic health center. Medicaid Funding – Full funding for physician and other provider payments (no additional rate cuts). In addition, the budget sets aside $60 million for a Medicaid Transformation Reserve.

NCAFP Vice President Dr. David Rinehart of Belmont, NC

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CONSTITUTIONAL AMENDMENTS While not directly related to healthcare, most of the waning days of the legislative session were spent on six proposed constitutional amendments that will appear on voter ballots this fall. The proposed Constitutional amendments are highlighted below: Senate Bill 75 – Maximum Income Tax Rate of 7.0% This would amend the state constitution to cap the Personal Income Tax Rate at 7.0% effective January 1, 2019. The cap was raised to 7.0%, from 5.5%, after lengthy caucus discussions by House Republicans. The amended proposal passed the House 73-45 largely along party lines. The Senate then concurred with the House changes and the measure will be included on the November ballot. Senate Bill 677 – Protect Right to Hunt and Fish The Senate concurred to House changes to a bill adding a proposed constitutional amendment protecting the right to hunt and fish. There was little debate and the bill passed with large bi-partisan support. This awaits final approval by the voters. Senate Bill 814 – Judicial Vacancy Sunshine Amendment If approved by voters, this proposed constitutional amendment would create a new state commission to vet judicial nominees and create a process and timeline to forward those recommendations to the General Assembly. Lawmakers would then send at least two names to the governor for him or her to select one. The proposal passed the Senate 34-13 with a single Democrat joining all Republican members. It then passed the House 73-45 with a couple of Republicans joining all Democrats against. House Bill 551 – Strengthening Victims’ Rights A proposed constitutional amendment expanding crime victims’ rights received final approval from the House. The proposed amendment passed the Senate 45-1 with a lone Democrat dissenting and 107-9 in the House with 8 Democrats and 1 Republican voting no. House Bill 913 – Bipartisan Ethics and Elections Reform The Senate gave final approval 32-14, along partisan lines, to a proposed constitutional amendment that would change the way the state elections and ethics board is appointed. Objections by Democrats centered on that fact that the new format, reducing the membership from nine to eight, will lead to deadlocks. The bill passed the House 74-44 largely along party lines. House Bill 1092 –Require Photo ID to Vote This proposed, if approved by voters, would add an amendment to the State Constitution requiring the presentation of an ID card prescribed in law to vote in person. It passed both chambers along party lines.

Summer 2018

STATE HEALTH PLAN —

NCAFP, Other Healthcare Representatives Meet with State Treasurer Folwell Regarding State Health Plan In May, North Carolina State Treasurer Dale Folwell directed Blue Cross and Blue Shield of North Carolina to begin seeking significant rate reductions in “major” provider contracts on behalf of the State Health Plan. Last month, Treasurer Folwell brought together representatives of various healthcare organizations, including the NCAFP, to discuss ways to lower costs in the State Health Plan, that represents 700,000 state and local government employees, as well as retirees. Organizations represented in addition to the NCAFP included the NC Pediatric Society, the NC Psychiatric Association, the NC Medical Society, the NC Healthcare Association (formerly NC Hospital Association), the State Employees Association, the Retired Government Employees Association, Blue Cross and Blue Shield of North Carolina and several other healthcare organizations, as well as the Treasurer and his staff. The Treasurer has a goal of saving $300 million in the next plan year and maintaining that savings over the next five years on what he characterized as unsustainable spending growth by the State Health Plan. Executive Vice President Greg Griggs and Government Affairs Consultant Stephen Kouba attended on behalf of the Academy. Griggs spoke on the value of primary care and the role family physicians play in coordinating care, improving health, and lowering costs. These points were well received in the meeting and Treasurer Folwell reiterated the importance of family physicians in any setting. The meeting included a long and detailed discussion of healthcare transparency, the need for claim and referral outcome data at the point of care, the need for a greater emphasis on value-based care, and a better examination of the key cost drives in the plan. The discussion focused on providing the right care at the right time in the right setting to eliminate unnecessary hospitalizations and over-utilization of tests and procedures. Treasurer Folwell closed the meeting by saying the dialogue was a good beginning, but that his office is looking for some immediate changes that will provide long-term cost relief. However, he did not commit to a specific rate cut. The NCAFP team will continue to follow up with the Treasurer’s staff and coordinate with other provider groups as these conversations evolve over the next several weeks and months.

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PRACTICE ADVOCACY

DMA Announces Payment Schedule for Reprocessed Vaccine Claims Victory for Family Medicine Practices After Years of Advocacy by NCAFP The Division of Medical Assistance (NC DMA) has announced the checkwrite schedule for the reprocessing of certain vaccine administration claims as part of last year’s ruling on a suit filed by the NCAFP, the NC Pediatric Society, and several pediatric practices. The adjusted payments come after more than three years of direct advocacy and litigation to correct the underpayments. According DMA, claims will be reprocessed in four batches and reflected in the checkwrites between August 28, 2018 and October 23, 2018. Certain vaccine administration claims paid by Medicaid to attested providers with dates of service January 1, 2013 through December 31, 2014, will be adjusted. The amount any individual practice is due will be based on how many vaccines were administered and paid at the lower level during the years 2013 and 2014.

For You and Your Family The award-winning, consumer website, familydoctor.org offers you physician-reviewed education materials focused on supporting the physical, mental, and emotional health of the whole family. A trusted source for medical answers and advice used by both physicians and consumers, familydoctor.org is here to help you.

Content available in English and Spanish. Connect with us. HOP17122136

A Great Resource for Patients AAFP’s award-winning, consumer website, familydoctor.org offers your patients physician-reviewed education materials focused on supporting the physical, mental, and emotional health of the whole family. FamilyDoctor.org is a trusted source for medical answers and advice used by both physicians and consumers, and here to help you help your patients. To help practices promote FamilyDoctor.org, a convenient downloadable full color flyer that can be distributed to patients can be downloaded at www.ncafp.com.

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The North Carolina Family Physician

NATIONAL

North Carolina’s David Rouzer Honored as a Primary Care Champion by AAFP North Carolina Representative David Rouzer (NC-7) was one of two Congressman recognized this May for his work in helping advance primary care across the nation. Several leaders from NC’s family medicine community were present during the official ceremony that took place in Washington, D.C., as part of the annual Family Medicine Advocacy Summit. “Our state is truly fortunate to have such a progressive and informed healthcare advocate like Rep. David Rouzer who recognizes that strong primary care is the foundation for better health for all North Carolinians,” noted NCAFP president Dr. Tamieka M.L. Howell of Greensboro. In addition to Rouzer, Rep. Joe Courtney (D-CT) was recognized, as were two key legislative staff members from their offices; Rouzer’s Jason Cooke and Courtney’s Maria Costigan. The awards are designed to honor members of Congress and congressional staff for their work as champions for primary care and their efforts in raising awareness of the value of primary care; supporting policies and programs that help enhance national primary care and its infrastructure; and working toward bipartisan solutions to improve primary care. Congressmen Rouzer and Courtney co-founded the bipartisan Primary Care Caucus in 2015 to educate and advocate on behalf of primary care physicians, providers, and patients. Together, they have brought attention to the need for increased investments in primary care and the great value it provides to the health care system— saving $13 in downstream costs with every $1 invested. I N WA S H I N G T O N , D . C .

North Carolina Lobbies for Family Medicine on Capitol Hill A delegation of six from the NCAFP attended the 2018 Family Medicine Advocacy Summit this spring and met with members of the North Carolina Congressional delegation on the importance of primary care. Pictured at immediate right, physicians representing the chapter included Past Presidents Drs. Karen Smith (05) and Conrad Flick (04), AAFP New Physician Board Member Dr. Frankie Simmons, NCAFP President Dr. Tamieka Howell, and Dr. Jeffrey Walden. The group discussed the importance of primary care, funding for rural residency programs, the opioid epidemic, administrative simplification and other issues to three members of the US House and staff members from the offices of both U.S. Senators and four other Congressional offices.

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MEMBERSHIP

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STFM

DREAM

orth Carolina has a lengthy history of leadership in the national organizations that drive and shape family medicine. For decades, NCAFP members have delivered progressive leadership in the family of organizations that form the specialty’s bedrock, including the AAFP, the ABFM, the Society of Teachers of Family Medicine, and the Association of Family Medicine Residency Directors.

Today, North Carolina is once again playing a leading role with UNC Chapel Hill’s Dr. Beat Steiner currently serving as president of the Society of Teachers of Family Medicine (STFM). Starting out, Steiner earned both his undergraduate and medical degrees from UNC Chapel Hill, and went on to join the family medicine residency at the University of Rochester in upstate New York. The

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BIG

UNC’s Beat Steiner Leads STFM By Peter Graber

NCAFP Communications

residency was anchored around an urban community health center and Dr. Steiner thrived. He served as the residency’s Chief Resident and graduated with a passion for improving the health of the underserved, and a strong interest in academic medicine. Following residency, Dr. Steiner returned to UNC where he completed a Preventive Medicine

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Remarkable people providing remarkable healthcare

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residency and earned his MPH. He was first introduced to STFM soon after joining the faculty at UNC family medicine in the late 1990s. He realized STFM’s culture fit squarely with his training and emerging clinical interests. “STFM is a very inclusive organization that encourages all of its members to pursue opportunities that their passionate about,” Steiner described in outlining his involvement. He became more actively involved in STFM leadership when he joined its education committee. In 2012, he was asked to become the chair of that committee and with that position had the opportunity to serve. This leadership experience and those that followed helped him grow as a family physician

Physician opportunities Novant Health primary care and specialty North Carolina and Virginia Novant Health is a not-for-profit integrated health system of 15 medical centers, 1,558 physicians in 539 locations, as well as numerous outpatient surgery centers, medical plazas, rehabilitation programs, diagnostic imaging centers and community health outreach programs. Our 26,000 team members care for patients in communities across North Carolina, South Carolina, Virginia and Georgia. Novant Health offers physicians a fair market value salary package, a relocation allowance, support annually for continued medical education, and a comprehensive benefits package. As a member of our medical group, you will be supported by highly-trained professionals who provide assistance at every level. We will provide you with all the assistance necessary to ensure your success. Support services include: • Managed care • Electronic health record • Human resources • Legal services • Coding and compliance • Financial services • Information systems

To learn more about the health system, visit NovantHealth.org or contact one of the recruiters below. Emily Slagle Manager, provider recruitment for Novant Health eclslagle@NovantHealth.org Physician recruitment Samantha Brown - samantha.brown@NovantHealth.org Cher Chambers - cldelaney@NovantHealth.org Stephanie Floyd - skuykendall@NovantHealth.org

“I chose family medicine as a career because I wantEOE

Summer 2018

• Self-insured malpractice coverage • Operational and practice management • Marketing and communications • Group purchasing • Centralized billing

ed to play a role in narrowing the inequities in healthcare. My leadership roles have helped me better understand how to change systems and influence people. There are essential roles of a family physician in my view,” describes Dr. Steiner in a snapshot of his professional interests on the UNC Medical School website. Battling the Physician Shortage Dr. Steiner’s leadership is happening during a transformative era for the specialty. Like no other time in recent memory has the impetus been stronger for America’s medical establishment to produce the kinds of physicians the country needs. With the primary care physician shortage now a nationwide issue, organizations like STFM are on the frontlines attacking the problem. STFM’s advocacy is driving key discussions, helping shape national policy, and equipping its members – approximately 4,500 family medicine educators, residents and students – with the tools and resources to drive even more change. Writing earlier this summer in STFM’s academic journal, Family Medicine, Dr. Steiner described the need of a multi-faceted approach in addressing the shortage, especially as it relates to creating an environment that can drive the competitive spirit of family physicians. Steiner noted (that) “…we are in a time of transformative change in health care and medical education. If we do not dream the big dreams, we will miss the opportunity to influence our future.”

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In several ways, STFM’s dreams have already begun to pay off, with 2018 already bringing major victories. This past winter, the Centers of Medicaid & Medicare Services (CMS) announced refined rules around medical student-assisted clinical documentation that a recent survey showed can save as much as 2-hours per day for physician preceptors. STFM began laying the groundwork for this effort, (formally known as the Community Preceptor Expansion Initiative) as far back as 2016 and has been shepherding ever since. Dr. Steiner and the STFM are extremely hopeful the change will encourage more high-performing practices to precept medical students. STFM also recently announced its participation in an audacious new program known as ‘25x30 for Americas Health.’ In concert with several family medicine organizations, the goal is to get 25% of the country’s medical students to choose family medicine as their career by 2030. For its part, STFM has already begun offering free memberships to medical students with the aim of showing the value and the reward of teaching. To develop leaders and advance the specialty further, Dr. Steiner also noted that STFM has a number of leadership offerings that provide to a wide range of opportunities for family physicians. The organization wants to grow the ranks of underrepresented minorities in leadership across the specialty.

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MEMBER BRIEFS NEWSMAKERS

Pardee Hospital Foundation Names Dr. Betsy Merrell as 2018 Physician of the Year Family Physician Dr. Betsy Merrell was recently awarded the Pardee Hospital Foundation’s “Physician of the Year” award. The Physician of the Year Award is given to a Pardee physician whose career has been defined by medical excellence, dedication to compassionate patient care, and a commitment to improving the lives of people throughout the community. Dr. Merrell was nominated by several of her patients for exemplifying such characteristics. She joined the Pardee medical staff in 2009, initially as a hospitalist and then as a family medicine associate since 2011. Dr. Merrell is a member of the NCAFP, the North Carolina Medical Society, and has been involved in the community and served in leadership capacities, including president of the Henderson County Medical Society for two years.

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APPOINTMENTS

Sushma Kapoor, MD, Named Chief Executive of Southern Regional AHEC Dr. Sushma Kapoor has been named CEO/President of Southern Regional Area Health Education Center, beginning July 1, 2018. Dr. Kapoor serves as Residency Director of Southern Regional’s family medicine residency program and has been SRAHEC’s Vice President of Clinical Services and Administration since 2013. In her new role as CEO, Dr. Kapoor will provide strategic leadership and overall organizational management. In the interim, she will continue to serve as program director of the residency program while it conducts a national search for a new director.

Dr. Elizabeth Baxley Named Senior Vice President of the ABFM In early May, the American Board of Family Medicine announced the selection of Elizabeth G. (Libby) Baxley, MD, as its next Senior Vice President. Baxely officially joined the organization on July 1st and was formerly Senior Associate Dean for Academic Affairs and Professor of Family Medicine at the Brody School of Medicine at East Carolina University and is a past chair of the ABFM. As Senior Vice President, Dr. Baxley’s focus will be to lead all aspects of ABFM activity that relate to the experience of Board-certified family physicians, including residency, the early clinical years, credentials, and communications. Along with Baxley, UNC’s Dr. Warren Newton joined the ABFM effective July 1st as well. Dr. Newton assumes the title of President and CEO when Dr. James Puffer retires at the end of 2018.

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919.835.0450 Owners: Tom Forsythe, Designer Elizabeth Forsythe, Writer/Consultant Summer 2018

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H O N O R I N G

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DR. KAREN L. SMITH, FAAFP 2017 AAFP National Family Physician of the Year Dr. Karen Smith lives and practices in Hoke County where she operates a solo private practice in a small town called Raeford. She has made it her life’s work to improve patient lives and make her rural, North Carolina town a healthier place to live, work and play. An inspiration to the specialty, Dr. Smith is a rural family medicine rock star who relentlessly pursues the use of technology and innovation to serve patients, families and her entire community.

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The North Carolina Family Physician

Profession

Find out

ww

Corporate Spon

FOUNDATION

The 2018 Family Medicine Gala August 25th, 2018 • Raleigh, NC

Thank You TO OUR SPONSORS

~ As of press time, the following organizations and individuals are helping sponsor the Gala ~

OLD SPONSOR

SILVER SPONSORS

BRONZE SPONSORS

Brody School of Medicine at East Carolina University, Department of Family Medicine

Accu Reference Medical Labs

FirstHealth of the Carolinas We Listen. We Respond. We Protect.

More than 220 Risk Management dical Mutual of North Carolina educational resources available!

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OLKITS

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rofessional Liability

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A.M. Best has awarded Medical Mutual’s professional liability coverage the highest rating of “A” (Excellent) for thirteen consecutive years.

Find out more by calling 800.662.7917 or visiting

www.medicalmutualgroup.com

porate Sponsor of the North Carolina Academy of Family Physicians

Rhett Brown, MD; Tamieka Howell, MD; Frankie Simmons, MD; Mackenzie Smith, MD; and Jessica Triche, MD

Aledade Alliant Health Campbell University School of Osteopathic Medicine Cape Fear Valley Health Lisa Cassidy-Vu, MD

Wake Forest Baptist Family and Community Medicine

Duke Population Health Management and the Duke Dept. of Community & Family Medicine

Wake Forest Baptist Health

Giant Genie / Randolph Medical Pharmacy Holy Trinity Greek Orthodox Foundation of Charlotte, NC Eugenie M. Komives, MD Levine Cancer Institute MAKO Medical Laboratories Julius Quintin Mallette, MD Charles W. Rhodes, MD Robert L. Rich, Jr., MD David A. Rinehart, MD UNC School of Medicine, Department of Family Medicine Thomas R. White, MD

- LISTEN AND ACT -

plan in the country, Dr. Conway still practices as a pediatric intensivist one weekend a month and hopes to increase investment in primary care while at the same time easing the administrative burdens you face in day-to-day practice. It won’t happen overnight, but he committed to your NCAFP leadership to continue to work with the Academy to assist family physicians, particularly independent family physicians in our state.

That is What the NCAFP is Doing to Fight for You

Dr. Conway will be providing a keynote presentation on the future of value-based healthcare in NC during our Annual Meeting in Asheville on Thursday, November 29 at 11:30. Immediately after that, he will be meeting with the NCAFP Board to discuss how the two organizations can work together to improve the environment for primary care in our state.

We’re listening to you, but we’re not stopping there. Most importantly, we’re taking ACTion. During our most recent Member Needs Assessment and the subsequent revision of the NCAFP Strategic Plan, your leadership decided to focus on three key areas:

But we haven’t stopped with BCBS NC. We continue to be engaged with North Carolina representatives of United Healthcare, Aetna and Humana, as well as representatives to the State Employees Health Plan. In addition, we are already engaged with many of the companies that plan to bid on the Medicaid Managed Care Contracts in the state, including Carolina Complete Health, WellCare and many others.

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

1) Payer and System Advocacy; 2) Member Satisfaction and the Practice Environment; 3) Workforce Pipeline Let me take just a few minutes to talk about some of the ACTion we are taking relevant to Payer and System Advocacy. First, we are stepping up our efforts to meet with major healthcare payers in the state. Our efforts have included a recent visit with the New President and the new Chief Medical Officer at Blue Cross and Blue Shield of North Carolina (BCBS NC), Dr. Patrick Conway (President and CEO) and Dr. Rahul Rajkumar (Chief Medical Officer). Both Dr. Conway and Dr. Rajkumar have senior management experience at the Center for Medicare and Medicaid Innovation at the federal level, serving as the brain trust behind innovative primary care payment models. As the only physician running a major health

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We are also taking ACTion to advocate on behalf of our members employed by healthcare systems. But just like continuity is the “secret sauce” to patient relationships within family medicine, it takes time to develop the relationships with healthcare systems. One of our first steps in health system engagement will bring several system Chief Executive Officers to our Annual Meeting in November. This will include a panel discussion on Friday morning, November 30 at 8:45 AM. Confirmed panelists include: Ronald A Paulus, MD, President and CEO of Mission Health. Earlier this year, Mission announced plans to merge with HCA Healthcare, a multi-state for-profit healthcare system based in Tennessee. Donald R. Gintzig, President & CEO of WakeMed in Raleigh.

The North Carolina Family Physician

Terry Akin, Chief Executive Officer of Cone Health in Greensboro. And Carl Armato, President and CEO, of Novant Health During the session, we will ask them their vision for healthcare in North Carolina and press hard on the important role that family medicine must play to improve health in our state. Without engagement, we cannot succeed in advocating on behalf of our members. These are some of the initial strategies we are using to meet the objectives of our updated strategic plan: to ACT and Advocate on behalf of you. Much like your work with the most complicated, multiple chronic disease patient, this won’t be easy. It won’t come without setbacks. And it may take time. But just as you do with your most complicated patients, we will continue to build the relationship, try different strategies, use multiple members of the team, and constantly strive to improve the health of family medicine just as you constantly strive to improve the health of your patients. We’ve listened and now we’re ACTing. We hope you will help us throughout this process. We will only succeed by working together as a team: staff, leaders and members alike. Thanks in advance for your involvement.

Summer 2018

NCAFP

Sights & Scenes

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~ ADVERTORIAL ~

BEST PRACTICES WORKING WITH SCRIBES IN HEALTH SETTINGS $17.6 MILLIONFOR VERDICT IN MISSOURI DRIVES HOMECARE MEDICAL LIABILITY IMPLICATIONS

OF OPIOID EPIDEMIC

By Janet McCrossen, Risk Consultant

By Jason Newton, Senior Vice President, Claims and Risk Management, and Associate General

One way that medical practices have chosen to deal with the increasing burden of electronic health records (EHRs) is Counsel to use medical scribes. Scribes help document patient encounters by capturing data in electronic charts, retrieving diagnostic results, and providing proper coding. This allows physicians to communicate with patients face-to-face without Missouri jury last month $17.6 to a are man who claimed hison physician overprescribed theAbarrier of a computer screen.awarded Both patients andmillion physicians able to better focus the visit, not the EHR—and opioids for him, confirming what we at Medical Mutual have been telling our members for more than a physicians can be more productive, effective, and present.

year: that in addition to its human toll, the opioid epidemic carries significant implications for physicians’ medicalthat liability. Recent studies suggest the benefits of having medical scribes go beyond enhancing patient interactions and can

include improved physician satisfaction and increased practice revenue. In fact, a recent study by the National Center the case, aInformation, 45-year-oldwhich mantook alleged that heatbecame addicted to on three different practice, opioids showed his primary for In Biotechnology a close look the impact of scribes a cardiology physicare physician (unaffiliated with Medical Mutual) prescribed to him for back pain—a total of 40,000 cians with scribes generated an additional revenue of more than $24,000 by producing clinical notes that were coded at pills over a higher level.four years, according to the plaintiff. The plaintiff alleged that the volume of painkillers

prescribed by his physician led him to become addicted to them, requiring him to enter a drug

There are, however, potentialand drawbacks to having scribes on staff. First, it can be his difficult to find and retain a good rehabilitation program damaging personal relationships, including marriage. scribe. There is often high turnover. Some scribes are medical school students, and are therefore, only available for short-term experience. canliable, be frustrating for $1.4 practices since amount of training required for aman new and scribe is The jury found theTurnover physician awarding million in the compensatory damages to the time-consuming. $1.2 million to his wife, as well as $15 million in punitive damages. Furthermore, since medical scribes aredoctors a relatively idea health care, of there minimal impact information around the Until this opioid epidemic ebbs, willnew need to in stay mindful its is potential on their legal issues that have emerged as a result of using scribes. There are currently no certification requirements, and the liability. The verdict drives home for physicians and practices the vital importance of ensuring that minimal qualification is a high school diploma. Regulatory agencies have not forbidden the use of scribes, but opioid prescribing practices are consistent with CDC and state medical board guidelines. That’sregulatory not requirements guidance around the prudent role differ.risk As management. a result of these differing guidelines and requirements, scribes just good and patient care—it’s also may have different responsibilities and restrictions in various care settings.

Medical Mutual members can visit www.medicalmutualgroup.com to view CME-eligible webinars,

Given theof lack of consistent someCarolina key considerations for practices looking to involve scribes: three which can helpguidance, doctors here meetare North pain management CME requirements. • Scribes cannot act independently. The Joint Commission, an organization that accredits and certifies thousands of health care organizations and programs in the U.S., permits scribes to document physicians’ dictations and/or activities but does not permit them to act independently, with the exception of obtaining past family social About the Author history and a review of systems.

Jason graduated from UNC Chapel Hill and obtained his law degree from Wake Forest. After a 14• career Providers are ultimately responsible for scribe documentation. The Joint Commission indicates that year in private law practice defending doctors, APPs, and hospitals, in 2013, Jason came on scribes should sign and date all entries they make in an EHR. The scribe must use his or her own identifiable logboard with Medical Mutual—a longstanding client—in an in-house capacity. At Medical Mutual, Jason in/password when documenting in the EHR. A licensed practitioner should then authenticate the entry by signing oversees the Risk Management, Healthcare Compliance, and Claims departments. and dating it, as well as adding a time stamp if applicable. It is imperative that the physician review and sign the documentation and notes from each visit to make sure they are accurately entered.

• Practices should develop and maintain a policy on scribes. It is highly recommended that any practice using the services of a scribe have a policy that defines the documentation and auditing processes for the role. It should be understood that the scribe’s role is to provide better documentation and that the scribe is not there to question the physician’s clinical judgement or to add or change documentation on their own. It is also important for practices to review state laws to ensure compliance and proper use of scribes by mid-level providers. Medical Mutual member practices can visit www.medicalmutualgroup.com/risk-management to access tools to help manage and reduce risk related to scribes (and other unlicensed assistive personnel). Members can also contact our Risk Management team for further support on this issue at 800.662.7917.

You went into healthcare to change lives. Start with your own. Join a remarkable team. It takes a remarkable team to change lives. We speak from experience. • We rank in the 90th percentile for provider engagement.* • Our physicians rate our EMR in the 95th percentile for ease and efficiency.* • Novant Health is in the top 1 percent for MyChart Enterprise Activation.** • We rank in the top 10 percent nationally for diabetes care, breast cancer screenings and colorectal cancer screenings.** This environment naturally attracts talented experts, who are driven to make a difference. We hope you’ll join us.

Discover what makes Novant Health different. NovantHealth.org/providercareers Connect with one of our recruiters to learn more: Cher Chambers, cldelaney@novanthealth.org Samantha Brown, samantha.brown@novanthealth.org

*NHMG Press Ganey 2017 survey results **In comparison with all EPIC clients across the U.S. © Novant Health, Inc. 2018 7/18 • 1709

PROFESSIONAL DEVELOPMENT By Kathryn Atkinson, CMP NCAFP Manager of Meetings & Events

- MEETINGS & CONFERENCES -

Top-Notch CME and Rocking Chairs An NCAFP “Family Tradition” in Asheville is coming soon

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elieve it or not, cooler months are coming. Yes, it’s the middle of summer, it’s hot, and it’s humid, and my hair is really frizzy right now, but cooler months are coming. The puppy calendar in my office says so. In less than three months, the holidays will be here, and for many people, that means a time for family traditions. As many of you know, the NCAFP also has a “family tradition;” the Annual Winter Family Physicians Weekend in Asheville, NC. If you’ve never attended this annual weekend in the Blue Ridge Mountains, we warmly invite you to join us this year. Mark your calendars for Thursday, November 29th through Sunday, December 2nd and begin making your plans for a top-notch CME experience that happens to include rocking chairs and incredible mountain views.

ic line-up of expert speakers with evidence-based lectures and updates on several timely topics. General session topics slated include chronic pain, irritable bowel syndrome, pediatrics, heart failure, psoriasis, lupus, hepatitis C, multiple sclerosis, HIV, eating disorders, reproductive health, osteoporosis, ASCVD risk, pelvic pain in women, and many more. Visit the conference website at www.ncafp.com/ wfpw for a full rundown of planned topics.

Like any good tradition, the Winter Weekend always includes things you can count on; rewarding CME in a relaxed and fun setting with friends and colleagues. Creative and out-of-the-box learning opportunities combined with our user-friendly mobile conference app, live audience polling, interactive learning sessions, and innovative product theaters make this weekend not only educational but exciting and rewarding for everyone.

The Winter Weekend wouldn’t be complete without fantastic optional sessions to choose from. Several workshops and seminars including practice management, Medicaid reform, medication-assisted therapy training and osteopathic manipulation treatments, to name a few, round-out the weekend’s learning opportunities. Consider making the most of your out-of-the-office time and plan to join us on Wednesday, Nov. 28th for our pre-conference KSA study working group on women’s health, or plan to attend a complimentary Nexplanon training workshop that afternoon. By combining general sessions and optional workshops

Program Chair, Jewell P. Carr, MD, and Program-Vice Chair, Shannon B. Dowler, MD, have assembled a terrif-

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The North Carolina Family Physician

Winter Family Physicians Weekend Nov. 29th through Dec. 2nd, 2018 Asheville • North Carolina

and seminars, attendees can anticipate earning 25+ AAFP prescribed credits during this terrific annual event. In addition to the CME opportunities, we are excited to announce a special presentation on Saturday afternoon. Plan to join us in the main hall as we welcome NC Governor Roy Cooper to the stage. Mr. Tom Campbell, host of NC Spin, will conduct the Governor’s live year-end interview. This session will be recorded and aired for a later segment on NC Spin, North Carolina’s only state tv show dedicated to covering politics and policy. All conference attendees are encouraged and welcome to participate in this special presentation. While the Winter Weekend includes camaraderie and fun all weekend long, the pinnacle of fun is Saturday evening’s Presidential Gala. This annual tradition has rightfully earned the title, “The Big Party”; and it is something you do not want to miss. Be a part of the celebration and merriment when we install our new board members and Dr.

Summer 2018

Alisa Nance as the 2018-2019 NCAFP President. After you enjoy a gourmet dinner prepared by the GPI chef, Diverse Groove, known nationwide for their first-class showmanship, will take the stage to perform many of your favorite songs. Plan to dance the night away to top 40 hits, beach music, Motown, R&B, and more. Slip on your dancing shoes, come dressed in your holiday-best, and make your way to dance floor on Saturday night! This year, the fun doesn’t stop when the music stops on Saturday night. Be sure to get in on the fun with our Tacky Holiday Fashion Sunday. Celebrate the end of a fantastic weekend with colleagues and friends and sport your best tacky holiday wear on Sunday morning. We know you’ve got some fantastically tacky holiday clothes tucked back in a closet somewhere, and you’ve secretly been waiting for the perfect time and place to show them off. In the words of one of my favorites, Mr. Lionel Richie, “Well, my friends, the time has come.” And, Continues on next page

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the tackier, the better! By the way, there just MAY be a prize for the best tacky holiday fashion wear spotted by NCAFP staff on Sunday morning. Lastly, be sure to include your family and friends in this year’s Winter Family Physicians Weekend. From breathtaking afternoon sunsets, stunning gingerbread houses, incredibly decorated Christmas trees, outof-this-world hot chocolate, an award-winning luxury spa, and discount tickets for a magnificent Biltmore House Candlelight Tour, there’s something for everyone in your group. With so much do to and see, your friends and family will thank you for bringing them along.

We Listen. We Respond. We Protect. More than 220 Risk Management educational resources available!

S U B O X O N E

Medication Assisted Therapy Waiver Workshop On Friday, November 30th, at the Winter Family Physicians Weekend, the NCAFP will be spon-

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soring a Medication Assisted Therapy Waiver workshop from 3:15 to 7:15 pm at the Grove Park Inn. Individuals interested in receiving training to prescribe suboxone can sign-up to attend the workshop for $30 (limited to the first 60 people).

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The workshop will complete 4 of the 8 hours required for waiver training (with the other 4 hours available online). United Healthcare is supporting this training through an unrestricted educational donation.

Professional Liability

Employee Benefits

A.M. Best has awarded Medical Mutual’s professional liability coverage the highest rating of “A” (Excellent) for thirteen consecutive years.

A full schedule of events, invited speakers, workshop and seminar descriptions, research poster information, social activities, online registration, hotel reservations information, and much more is available at www.ncafp. com/wfpw. Keep in mind, the Early Bird Rate for Members ends on Sunday, October 7th. On behalf of everyone at the Academy, we look forward to seeing you during our annual “family tradition” of top-notch CME in Asheville. We’ll save you a seat! Contact Kathryn Atkinson, CMP, Manager of NCAFP Meetings and Events at katkinson@ncafp.com or by direct dial at 919-214-9058 with questions.

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Find out more by calling 800.662.7917 or visiting

www.medicalmutualgroup.com Corporate Sponsor of the North Carolina Academy of Family Physicians

ADVERTISE! Reach many types of Family Medicine professionals in North Carolina. Contact Peter Graber with the NCAFP at pgraber@ncafp.com

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25 The North Carolina Family Physician

RESIDENTS & NEW FPs

uate who is now a resident at UNC, and UNC faculty member Dr. Catherine Coe. The Academy is free of charge for the campers and sponsored by the Department of Family Medicine and the UNC School of Medicine’s Office of Rural Initiatives. During camp,

By Tracie Hazelett Medical Student and Residency Relations Manager

- UNC FAMILY MEDICINE -

New Summer Academy Introduces Students to Primary Care A new UNC program designed to introduce promising students to careers in primary care hosted a total of 14 recent high school graduates from rural North Carolina earlier this summer, all of whom have an interest in a future career in medicine.

students received three days of hands-on workshops, shadowing, and lectures. They also learned how to take vital signs, perform basic suturing, and received tips on things like resume writing. There was also an interprofessional panel with students from across multiple health affairs schools at UNC.

The new program was developed and launched by Drs. Kyle Melvin, a recent UNC School of Medicine grad-

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NORTH CAROLINA’S RESIDENT BRIEFS

Duke’s Dr. Jessica Lapinski Named 2018 AAFP Excellence in Graduate Medical Education Award Winner Congratulations to Dr. Jessica Lapinski, a rising thirdyear resident at the Duke Family Medicine Residency Program, on recently being named an AAFP Excellence in Graduate Medical Education award winner for 2018. Dr. Lapinski earned her Doctorate of Osteopathic Medicine (w/Predoctoral Academic Fellowship in Medical Education) from A.T. Still University - Kirksville College of Osteopathic Medicine (MO) in 2016. Dr. Lapinski will be formally recognized during AAFP’s Family Medicine Experience in New Orleans this October.

NCAFP SEEKING

2018

Resident & Student Research Poster Presentation The NCAFP Foundation’s twenty-fifth annual Research Poster Presentation will be held at the Academy’s Winter Family Physicians Weekend (Nov. 29 – Dec. 2, 2018) this December. The Foundation is interested in showcasing practice-based research, but poster presentations may address any topic relevant to Family Medicine. Work-in-progress may also be submitted, but submissions must be of original work not yet published. Projects previously presented at medical schools’ or student “Research Days” are acceptable, as are concurrent submissions to other conferences such as NAPCRG and STFM.

Resident & Student

Community Teaching Innovations Given the tremendous amount of innovative work happening in family medicine practices across NC, NCAFP members are being encouraged to send descriptions of a community teaching successes to Tracie Hazelett (thazelett@ncafp.com). The Academy intends to highlight and share them in an upcoming edition of this magazine, The NC Family Physician.

Posters will be judged for awards with winners announced at the Annual Meeting in December. Resident and Student members interested in participating must submit their application and all corresponding materials (including final PDF of poster) by October 1st, 2018. Please direct questions to Tracie Hazelett at thazelett@ncafp.com or 919-980-5357.

STUDENT INTEREST & INITIATIVES

The NCAFP Rural Health Immersion Program: A Student Perspective By Katelyn Turlington (MS-2) Wake Forest School of Medicine

“What do you hear?” I listened carefully with my stethoscope, straining to hear a faint ‘whoosh’ after the second heart sound. My experience with auscultation was limited to standardized patients with healthy hearts, I had no idea how to articulate this anomaly. “The beat is regular, but there’s a strange whirling sound between beats,” I replied. Dr. Smith nodded, “That’s a murmur, aortic regurgitation.” It was an exciting moment in my medical education. “A murmur? I’ve never heard one before.” I passed my stethoscope to our patient with enthusiasm, “Here, have a listen.” My experience in the North Carolina Academy of Family Physician Foundation’s (NCAFPF) Eastern Rural Health Immersion Program was filled with similar moments. Whether it was watching a circumcision or performing a musculoskeletal exam, my days were filled with memorable experiences. This summer program offers medical students the opportunity to learn about rural family medicine in a short, but intensive two-week experience. The first week was filled with workshops and clinical experiences with a group of other rising 2nd year medical students from around the state. The second week was an immersive clinical experience with a rural family physician. On the first day, I learned how to perform a cir-

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cumcision and practiced my newfangled skills on a gloved Little Smokie sausage. The next afternoon, I witnessed an actual circumcision procedure on a baby – a real baby! Dr. Susan Keen expertly explained each step of the patient encounter, from initial contact with the infant’s parents to his return with post-operative instructions. From the Ms. Turlington is a 2nd year initial lidocaine injecmedical student at Wake tion and clamping, to Forest School of Medicine in administering the anesWinston-Salem. She currently thetic with confidence, to serves as a Family Medicine preparation of the surgical Interest Group leader on campus and volunteers at DEAC, site, my peers and I were the student-run free clinic in mesmerized. Back in the Winston Salem. In addition to classroom, our collective the NCAFP’s rural health proexcitement over the procegram, Ms. Turlington has been dure was matched by our very involved in other NCAFP activities and is interested in eagerness to learn about expanding her role by serving labor and birth with Dr. as a Student Leader with the Kelley Haven. We exAcademy. Outside of medicine, changed our Little SmokKatelyn is active with The Juie trainers for full-sized nior League of Winston-Salem as well as the National Society delivery models complete of the Daughters of the Ameriwith placentas, umbilical can Revolution. cords and neonates. We learned how to measure the dilation and effacement of the cervix, to identify a breach, and to safely maneuver a baby through a nuchal cord. The more I learned about family medicine, the more I marveled at the breadth of the specialty. If circumcisions and delivery simulations were not enough, we had the opportunity to explore cases in wilderness medicine with Dr. Johnathon Firnhaber and the family medicine residents. Whether it was anaphylaxis from IgE cross-reactivity, a bundle branch block, or a broken limb, we learned how to effectively approach emergencies in a myriad of nontraditional environments, including airplanes. I

The North Carolina Family Physician

especially enjoyed the opportunity to work through these cases with the family medicine residents. They helped us develop a list of possible diagnoses, steered us through the pathophysiology of unknown disease processes, and impressed us with their resourcefulness – who would have thought to control hypotension with seatbelts? These conversations, peppered with personal and professional advice, highlighted the diversity of experiences available to students interested in family medicine. Our experiences in hands-on workshops and case centered learning was complemented by discussions that focused on the unique needs of rural populations. The

program introduced me to the field of agromedicine, a translational research initiative devoted to promoting the health and safety of farmers, fishermen, foresters and their families. I was thrilled to learn how physicians could leverage medical and agricultural research to learn about unique agricultural health concerns, such as pesticide exposure, diagnosis and treatment. I also developed an awareness of several challenges to maintaining rural family health, such as the burden of transportation, food insecurity and – amongst agricultural workers in particular – the absence of paid time off or sick leave. Through these lessons and experiences, I gained a greater appreciation for the needs of these unique populations. During the second half of the program, I spent one week living with Dr. Colin Smith and his family, traveling with him to clinic, and working alongside him at his practice in Chocowinity, North Carolina. My experience with Dr. Smith was nothing short of extraordinary – his clinic and his family welcomed me into their world with a wonderfully authentic picture of life as a rural family physician and a working parent. On my first evening, Dr. Smith warned me about the possibility of a nighttime visitor, his five-year-old son was just learning to sleep through the night on his own. Every night, without fail, a little voice would wake the house between 1-2 am. Every morning, we’d leave for clinic clutching some form of caffeine on the commute to Chocowinity. The tiredness abated once we reached the office and reviewed our patient list for the day. “This one will be interesting,” he said, “why do you think her TSH is elevated?” One morning, Dr. Smith asked me to sit down with a copy of Pfenninger’s to study the anatomy and technique for subacromial shoulder injections. After I described the method to him in detail, he smiled and said, “Want to do one?” His patients graciously allowed me to observe and assist him in two before the end of the week. Dr. Smith also encouraged me to listen to heart and lung sound anomalies, an educational experience I will never forget. I knew where to place the diaphragm, but I had no frame of reference for sounds besides the familiar “lub-dub.” Dr. Smith asked me to describe these sounds, which fostered confidence in Continues on back cover

Summer 2018

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PRACTICE MANAGEMENT

NC MedAssist Helps The Uninsured and Low Income By Nicole Banahene Director of Partner Relations, NC MedAssist

Imagine having a chronic and debilitating disease like rheumatoid arthritis, then losing your job along with your health insurance benefits, and then barely making ends meet with the last of your savings. Every month you face a horrible choice: Should I put food on the table for my family; or should I purchase my medication to relieve my tremendous pain? Jakeita B., age 49, made this gut-wrenching decision regularly before coming to NC MedAssist. She is disabled from rheumatoid arthritis and has been unemployed since September 2014. Jakeita is prescribed methotrexate which helps relieve her ongoing chronic pain associated with this terrible disease. She had been without her medication for quite some time because she had no insurance and did not qualify for Medicaid. She was hopeless. The pain was so unbearable that Jakeita planned to end her life. She simply did not want to live anymore. She was hospitalized due to her severe depression. Thankfully, Jakeita found NC MedAssist through the help of a social worker at the Department of Social Services. Jakeita is now taking her methotrexate as prescribed. She is feeling better and stronger every day and has hope of a pain-free life living independently and now able to visit with her family and friends with hope of returning to work. 30

Physicians Can Help the Most Vulnerable Many physicians around the state see patients on a daily basis who struggle to pay their bills and purchase the medications they need to stay healthy. Often these patients present at the doctor’s office or ER as self-paying patients. Currently in North Carolina, there are over 463,000 individuals who are uninsured and approximately 50% have at least one chronic illness that requires daily medication. In a recent report, Health Status of the “Medicaid Gap” Population in North Carolina from the Gillings School of Global Public Health at UNC Chapel Hill, over 57% of the uninsured have paying jobs. However, these jobs don’t offer health insurance or it’s not affordable. NC MedAssist is open to direct referrals from physicians across North Carolina. For prescription medications, patients do have to qualify as someone who is uninsured and low-income. The patient will have to provide NC MedAssist with proof of their income, proof of being a North Carolina resident and sign the NC MedAssist application. Either the Physicians and/or someone on their staff can help their self-pay patients through this process in one of two ways: Simply provide the patient with the NC MedAssist phone number (704) 536-1790 or our website. We have social workers available to walk the patient through the eligibility process. Once all the paperwork is in, then the determination of eligibility is immediate with letters going out to the patient and the provider. Or, The physician or someone on their staff can print out the application and the list of what is considered proof of income and help the patient complete the information. Applications can be emailed or faxed into NC MedAssist. While all services to the patient are free, NC MedAssist does a limited formulary. The formulary is listed on our website at www.medassist.org and the physician can easily search for the medication their patient needs or find a similar alternative. This is very important to order medications available as sending in a prescription for a medication that is not available significantly delays the patient from getting help.

The North Carolina Family Physician

Once approved for services, the patient’s eligibility is good for one year. The patient may have any number of prescriptions as ordered by their physician as there are no artificial limits. After one year, the patient will be notified that it is time to recertify if they continue to remain uninsured. The patient must complete the eligibility process again. About NC MedAssist

who do not have access to a free clinic the ability to enroll directly. Once approved, patients receive their medications through the mail at their home address. To qualify for The Free Pharmacy Program, individuals must be uninsured and at or below 200% of the Federal Poverty Level.

NC MedAssist is a non-profit pharmacy program that provides access to lifesaving prescription medications, patient support, advocacy and related services to vulnerable and uninsured North Carolina residents. It is NC MedAssist’s goal to improve the health of North Carolina one prescription at a time. NC MedAssist was incorporated in 1997 as a 501c3 pharmacy providing free medications for seniors in Mecklenburg County. Medications were donated through the pharmaceutical companies’ individual Patient Assistance Programs (PAP). When Medicare Part D was introduced in 2006, NC MedAssist expanded to serving uninsured county residents of all ages. In 2009, NC MedAssist received a start-up grant from the North Carolina Attorney General’s Office to expand services to all counties developing contracts with the largest pharmaceutical companies. As a partner, the manufacturers donate their products in bulk without the need of additional paperwork. In 2012, NC MedAssist added the Over the Counter Medicine Program where thousands of low-income people get access to medicine like Tylenol/Motrin, cough and cold, and vitamins. The Free Pharmacy Program The pharmacy program works with over 100 non-profit partner agencies across North Carolina to efficiently and effectively deliver prescription medication to low-income, uninsured residents at no cost. By collaborating with these free clinics, health departments and other safety-net organizations, NC MedAssist is able to serve more patients and save the community money in duplicative pharmacy services. NC MedAssist’s statewide pharmacy also gives residents

Summer 2018

Impact on Healthcare NC MedAssist values the continuity of care provided and the positive health outcomes patients are able to achieve through access to medications. By working collaboratively with local agencies, NC MedAssist provides a robust continuity of care. Clinic partners receive monthly reports about their patients. By keeping people compliant, 61% of patients report improved health, 98% report taking all their medications as prescribed and 50% report no visits to the ER and 79% report fewer ER visits. NC MedAssist has an impact on healthcare cost avoidance. 52% of NC MedAssist patients have at least one of the four top chronic illnesses (i.e. diabetes, hypertension, high cholesterol, and asthma). For these disease states, research supports that by giving access to medications, NC MedAssist helps achieve $55 million dollar cost avoidance for North Carolina. For every dollar donated, NC MedAssist is able to dispense $17 worth of lifesaving prescription medication back to the community. In fiscal year 2017, NC MedAssist dispensed over $48.5 million in prescription medication and $5.4 million in over -the-counter medication. For more information on NC MedAssist, visit www. medassist.org or follow us on social media – Facebook, Twitter and Instagram.

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IMMERSION Continued from p. 29

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Pontiac, Illinois Permit No. 592

Dr. Smith was not my only mentor during the Eastern Rural Health Immersion Program. I spent a day with his wife, Dr. Mackenzie Smith, in a Federally Qualified Health Center (FQHC) where I learned about public health and the challenges of operating a large, federally-funded facility for underserved populations. Her clinic

My immersive experience with the Smith family and rural healthcare systems emphasized family medicine’s longitudinal and relationship-centered approach to healthcare. Providers like Dr. Smith embrace the social and economic challenges of treating communities characterized by poverty, low health insurance coverage, and a perceived lack of physical and social amenities. They understand that rural communities are frequently supported by strong ties among extended families and they use this resource to paint a comprehensive picture of a patient’s personal health in the context of his or her family’s health history. It was a privilege to partake in this process, to be trusted with a patient’s story and to participate in an individual’s healthcare journey. The NCAFP Eastern Rural Health Immersion Program has given me a tremendous opportunity to learn about rural family medicine in North Carolina. This experience has helped me to better understand the political, economic, and cultural forces shaping rural health and I am grateful for the opportunity to deepen my interest in a career in family medicine.

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

Dr. Smith ensured I learned more than physical exam skills, injections, and the importance of good insoles during my week in Chocowinity. His approachable bedside manner and passion for teaching showed me how to effectively converse with patients about their healthcare maintenance and medications. Statins were a topic of extensive discussion with many patients; when Dr. Smith proposed starting someone on a statin, many patients frowned and shared a story (or two) about a friend or family member with an unpleasant statin experience. Dr. Smith would smile, reach into his white coat for a tri-colored pen, and begin drawing a red blood vessel on the crinkly white paper on his exam table. “Let’s talk about statins,” he’d begin as he drew an angry-looking plaque and a clump of blue platelets; explaining the physiology of atherosclerosis as he completed his sketch with a series of black lines to secure the plaque in place. “Statins tie down the plaque, just like Gulliver and the Lilliputians, and prevent little pieces from breaking off and traveling in your bloodstream to your heart or brain.” His explanations, combined with his visual aids, were powerful educational tools that helped his patients feel comfortable discussing the risks and benefits of a new medication.

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my auscultation, before he educated me on their clinical significance. It was extremely rewarding to link a medical description to its tangible form and this early exposure to murmurs, arrhythmias, and rales prepared me to identify them with greater assurance in my onward training.

provided medical care, dental care, and social services to a diverse patient population. We saw toddlers, children, and senior patients with a range of maladies. I was particularly moved by a dialysis patient’s willingness to show me his enormous arterial venous shunt, which he hid beneath his long sleeves. He allowed me to palpate and auscultate as Dr. Mackenzie Smith explained hemodialysis and arteriovenous fistulas. Many of the patients I met during the program were equally gracious teachers. They shared their concerns with me, some of them quite personal, and allowed me to intuit their apprehensions regarding expenses, medications and health.