NC Family Physician - Fall 2018

Volume 14 Issue 4 • Autumn 2018

The North Carolina

Family Physician Quarterly News in North Carolina Family Medicine

Medicaid Managed Care is on the Horizon What Family Physicians Need to Know

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Inside Autumn 2018

Wilmington Family Docs Leap Into Action in Hurricane Aftermath 22

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PRESIDENT’S MESSAGE

CHAPTER AFFAIRS

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The Two Key Lessons in Standing Up

for Family Medicine

HEALTH POLICY & ADVOCACY

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Medicaid Managed Care is On The Horizon

NCAFP FOUNDATION

12 Dr. Karen Smith Honored at 2018

Maintaining The Status Quo is Not an Option!

RESIDENTS & NEW PHYSICIANS

26 NC Policy on Expedited Partner Treatment PRACTICE MANAGEMENT

32 Collaborative Care Model 102: Get Paid for Integrated Care in Medicaid

Foundation Gala

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DEPARTMENTS

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President’s Message 4 Health Policy & Advocacy 6 NCAFP Foundation 12 Chapter Affairs 14 Professional Development 16

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919.833.1801 • ncafp.com

Managing Editor & Production Peter T. Graber, NCAFP Communications

Membership 20 Residents & New FPs 26 Student Interest 28 Practice Management 32

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

The Two Key Lessons in Standing Up for Family Medicine As my presidential year comes to a close, I reflect on all that I have learned. I started my year encouraging you all to be ‘upstanders’ rather than bystanders in your communities. To stand up for social injustices, to stand up for yourselves and those around you, and to stand up for Family Medicine. As I have stood up for Family Medicine these last several months, there are two things I have learned that stand out for me: the art of dealing with politics; and the need to bring joy to our profession. Realization #1- Politics are not black and white; obviously. As I have spent time at the State Legislature and visited our representatives on Capitol Hill, I have come to the realization that not all who vote against what we know is right, realize why their vote is wrong. Many of those who represent us are ignorant of the ramifications of those votes and need education on the subjects that can make a difference. For instance, some had no knowledge of the difference in training of mid-level providers versus physicians as they took a stance for independent practice for Nurse Practitioners. Or how this can affect those in health systems that chose to employ the ‘cheaper’ alternative. Or how further marginalizing the transgendered population in our state goes well-beyond losing the business of NCAA events, major companies, the hottest musicians. It leaves a group that

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many of us care for depressed, suicidal, and gives people in the community permission to hate, beat, and kill our patients with little fear of punishment. We must educate ourselves, educate our politicians and educate our patients. Sometimes they truly are just ignorant, lacking knowledge, information, or awareness about the subject at hand. We’ve had to educate them that the reason for Direct Primary Care practices is not to make more money, but to lessen physician burnout, while providing improved, comprehensive patient care experiences in a relaxed and not rushed manner that many are forced to do in employed settings if they want to keep a paycheck.

“We must educate ourselves, educate our politicians and educate our patients. Sometimes they truly are just ignorant, lacking knowledge, information, or awareness about the subject at hand.”

I also always thought that giving money to politicians seemed dirty. And while it does not feel totally wholesome to me, I have realized it’s one of those necessary evils in order to affect change in politics. It’s like giving the hotel housekeeper a tip each day in hopes that she’ll leave an extra chocolate or bottle of water for you when tidying your room. Except this is well beyond Godiva and isn’t helping someone who may be using that tip to pay for their family meal the next day. Money really does talk in politics. Not much gets done in your favor without it, and there is no guarantee that giving will help. While I don’t love or agree with the thought, it’s how we get politicians to listen. I never gave to our own political action committee until I became part of the NCAFP Executive Committee because of, well - the principle of it all. I grew to understand it’s necessity once I saw how the money was being used. It is not just given for the sake of giving, not always to a Democrat or Republican because of their party affiliation, but really to those on both sides who were thought

The North Carolina Family Physician

2017-2018

NCAFP Board of Directors to be allies or potential allies in our advocacy efforts to support you and your patients. Realization #2- Recognizing and sharing efforts of our colleagues helps to bring joy to Family Medicine and helps to bring light upon all of the darkness in our country today. I’d like to highlight one of our members who has been a bright light in his community. His colleague describes him as a ‘man of extraordinary empathy, intelligence and love.’ A refugee in his late teens, escaping political unrest in his native Ethiopia, Dr. Aregai Girmay did not let adversity block his road to becoming a community leader.

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 At-Large Jason T. Cook, MD At-Large Talia M. Aron, MD IMG Physicians Brian McCollough, MD

After spending two years in a refugee Dr. Aregai Girmay camp in southern Sudan, Dr. Girmay made his way to the United States to become a citizen and put himself through college and medical school. He then completed 3-years of an OB/ GYN residency and ultimately finished a Family Medicine residency at New York Medical College. In his community of Gaston County, one of his patients describes him as providing, ‘comprehensive, compassionate and caring medical service.’ Working at Gaston Family Health Services, an FQHC, he says he has developed ‘a passion for women’s health, and in particular cervical cancer prevention.’ He has developed a dysplasia clinic to ‘provide vital services...to women who lack consistent access to medical care.’ He provides comprehensive care to patients including HIV and Hep C care and anal health anoscopy for his HIV patients, along with family planning services. He provides Suboxone services and has served on committees with the Gaston Controlled Substances Coalition to help combat the opiod epidemic in his community. He also serves on the Highlands Community Resource Board helping its residents obtain their GED and lobbying for grocery stores in their food desert. Dr. Girmay not only leads by example in his profession, but also in his personal life. He leads a healthy lifestyle through clean eating and maintaining a lean BMI. He has run 56 marathons, including Boston, New York, Chicago, and London. He also participates in local races where he is able to see and encourage his patients towards better health. On numerous occasions, he has housed, fed and supported Ethiopian emigres as they escape political unrest like he once did. Dr. Girmay has been married to his wife Zewdie for 28 years and is the father of 4 children. Thank you Dr. Girmay for being an upstander in your community and for you patients. You are FAMILY MEDICINE!

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

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Minority Physicians Jewell P. Carr, MD Osteopathic Family Physicians Slade A. Suchecki, DO New Physicians Elizabeth B. Baltaro, MD Family Medicine Residency Directors Mark L. Higdon, MD (Novant FMR) Resident Director Courtland Winborne, MD, MPH (Cabarrus) Resident Director-Elect David S. Baker, MD (MAHEC-A) Student Director Allyson Mentock (BSOM) Student Director-Elect Cameron G. Smith (Campbell) 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 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

2501 Blue Ridge Road, Suite 120, Raleigh, North Carolina 27607 www.ncafp.com

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

Medicaid Managed Care is On the Horizon What Family Physicians Need to Know By this time next year, North Carolina will have begun implementing Medicaid Managed Care, going from a feefor-service system with one payer (the State) to a managed care system, with multiple health plans covering Medicaid recipients. This article will attempt to answer key questions family physicians should know as our state’s Medicaid program makes such a drastic change.

Question: What’s the timeframe for Medicaid Managed Care? Answer: Let’s start from now and move forward, with key dates that could impact NCAFP members. October 19, 2018: Final proposals from Managed Care Companies and Provider-Led Entities were due to the state last month. By the time you read this article, we will at least know who submitted proposals. Now until January 31, 2019: Primary care practices who wish to participate in the Advanced Medical Home (AMH) program at a higher tier must attest to their AMH status (see more below). Current Carolina Access 1 and 2 providers have already been grandfathered into the AMH program as AMH 1 and AMH 2 respectively. Up until January 31st, the State will certify a list of practices by tier. Note: There is no penalty to attest to a level and then change that decision, but you must attest to some level by January

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31st, 2019. There is no deadline for attestation to a Tier 2. PHPs will be required to honor these certifications on an ongoing basis. Early February 2019: Plans selected. Late Winter/Spring of 2019: Practices negotiate with plans to finalize contracts. November 1, 2019: A portion of the state (one or two of the six regions designated for Medicaid) will go live with managed care. February 1, 2020: The remainder of the state will go live. The State will certify a list of AMH Tier 3 practices at the start of each contracting period in subsequent plan years.

Question: What do they mean by Advanced Medical Home (AMH), and what will I be attesting to? Answer: Much of the state’s new Advanced Medical Home (AMH) Model parallels what practices have been doing with Community Care of North Carolina but offers some different reward structures. To simplify, AMH Tier 1 and 2 basically replaces Carolina Access 1 and 2. If you are a Carolina Access 1 practice, you will initially be tiered as an AMH Tier 1. You will not receive any care management fee and will receive a lower medical home fee and will be required to utilize the health plans’ care managers. This is likely not you because only 534 practices serving 36,000 patients are Carolina Access 1 practices. If you are CA1 today, you should do everything to become a Tier 2 AMH. Tier 1 practices will only receive $1 per member per month (PMPM), whereas Tier 2 and 3 practices will receive $2.5 PMPM, or $5 for the aged blind and disabled population. If you are participating in CCNC today, you are a Carolina Access 2 practice and will be considered AMH Tier 2 unless you otherwise designate. Currently, 1,714 practices serving 1.6 million Medicaid recipients qualify as a CCNC/CA 2 practice. A Tier 2 AMH will continue to receive the PMPM fee as it does today. However, each health plan will

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management, among other additional functions. The bottom line: the biggest difference between AMH Tier 2 and Tier 3 is whether the plan handles care management or you negotiate to do that yourself or as part of a CIN. Question: What does care management mean if I’m a Tier 3 practice? Answer: As stated above, a Tier 3 Advanced Medical Home will be responsible for their own care management or for contracting with someone to help do it. Care Management requires five elements: 1) being able to risk stratify the patient panel; 2) provide direct care management to high-need patients; 3) develop a care plan for high-need patients; 4) being able to provide short-term, transitional care management; and 5) being able to receive claims data feeds from health plans that meet State designated security standards for their storage and use. Plans will still help do some care needs screening, but the practice will do the comprehensive assessment, analytics, and care management for high-need enrollees. It will be difficult for a practice to do this on their own, but working with your system or a Clinically Integrated Network should make this feasible for high functioning practices. Question: Tell me more about Clinically Integrated Networks and what they can do to support a practice?

provide the care management for their recipients, meaning you may have multiple care managers working in your practice. Most practices will fall into this category. However, you may want to try to become a Tier 3 AMH. A Tier 3 AMH practice will receive the medical home PMPM but will also be able to negotiate with the health plans to provide their own care management or have it provided through a Clinically Integrated Network (CIN). Your CIN could be your health system, if you are a system-owned practice, or someone like Community Care Physicians Network if you are an independent practice. The initial rate books for companies bidding on the plans set care management as $10.86 per member per month, but how much the plan pays you will be up for negotiation. Again, a Tier 3 practice must be willing to take on care

Answer: A Clinically Integrated Network (CIN) can support the Advanced Medical Home by handling data, performing analytics and delivering advanced care coordination and care management functions. CINs can be part of a hospital or health system to which a practice already belongs or is affiliated, or may be part of a group of independent practices. CINs can also partner with other entities, such as independent non-profit organizations to help support practices. Question: How many health plans will I ultimately have to deal with? Answer: That depends, but typically up to 5 or 6. The State will award four statewide contracts to managed care plans. Then each region can have one or two Provider-Led Entities. Depending on your geographic coverage area, you may see patients from more than one of the six regions. However, you don’t have to contract with every plan. Note: Ultimately, 7 statewide plans and 1 regional plan made bids to DHHS. Continues on next page

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Question: What quality metrics will my practice have to meet? Answer: The State will judge the health plans on a whole host of measures, and therefore, the plans will look at similar measures for practices. The key priority measures for health plans include: recipients getting needed care quickly, coordination of care, customer service, rating of their personal physician, and the recipient’s overall satisfaction with the pre-paid health plans. In terms of more traditional clinical quality measures, after 18 months, the State can withhold funds from the health plans for certain quality benchmarks. As a result, it is obvious that the health plans will concentrate on these measures when contracting with practices as well. They include: asthma medication, cervical cancer screening, comprehensive diabetes care (HbA1C over 9.0), follow-up after hospitalization for mental illness, prenatal and postpartum care, initiation and engagement of alcohol and other drug dependence treatment, medical assistance with smoking and tobacco use cessation, well child visits for 3- to 6-yearolds, and live births weighing less than 2,500 grams. Some of the other priority quality measures where the plans will not be subject to withholds include: Adult BMI, childhood immunization status, controlling high blood pressure, contraceptive care postpartum, immunization for adolescents, and inpatient utilization, among others. For population health, priorities in the Department’s quality strategy include: diabetes, asthma, obesity, hypertension, tobacco cessation, infant mortality, low birth rate, and early childhood health and development. Question: Are there protections for physicians in the contracts with health plans? Answer: Yes. However, we encourage you to seek the advice of an attorney before signing any contract. The State will at least approve the contract template before it can be issued by a managed care plan. In addition, the plans cannot require you to accept other lines of their business as part of the agreement to accept the Medicaid plan. In other words, a Medicaid plan cannot demand you accept their commercial product as a condition of participating in Medicaid. There must also be provider appeals processes as outlined by the NC Department of Health and Human Services (DHHS), and there will be a uniform credentialing process for providers.

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Question: What other protections are in place for physicians in terms of payments and paperwork requirements? Answer: First and foremost, rates for primary care must be at a minimum 100 percent of current Medicaid fee for service rates, including the same PMPM you now receive for serving as a medical home. Plans must also use standardized prior authorization forms developed by DHHS, and any utilization management program must have written policies and procedures meeting minimum standards set by DHHS. For the first 90-days of managed care, the plans must honor existing and active prior authorizations on file. The plan cannot require prior authorization for preventive care for beneficiaries less than 21 years of age, and telemedicine must be paid at least at the in-person rate for the same service delivered via telemedicine unless it is a DHHS-approved pilot. Question: Moving away from the practice level, tell me more about how this impacts Medicaid beneficiaries. How will they choose a plan? Answer: First and foremost, the State has contracted with an enrollment broker, Maximus, to help Medicaid recipients pick a plan. Once the contracts are set, there will be an initial 60-day open enrollment period for recipients to select a plan. The enrollment broker will proactively reach out to recipients during that time. If a beneficiary does not select a plan (which the majority will likely not), then they will be auto assigned. Fortunately, auto assignment will consider their current medical home, as well as where others in their family currently receive care. After implementation, the beneficiary will have 90-days to change plans without cause. Each subsequent year there will be a 90-day choice period for beneficiaries to select a different plan. Question: Are there network adequacy standards? Answer: Yes. There are substantive network adequacy standards, but the standards are different for urban and rural areas. For example, there must be at least two primary care providers in network within 30-minutes or 10-miles for 95% of members in urban areas, and within 30-minutes or 30-miles for 95% of members in rural areas. The State also balances these requirements with appointment wait times to make sure there is true access in a timely manner.

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Question: Will all services be covered under Medicaid Managed Care? Answer: All services currently covered will remain covered except a few items that are carved out. Carved out services include: PACE (Program of All-Include Care for the Elderly), services in an Individualized Education Plan, services billed by a Children’s Developmental Services Agency (CDSA), dental services, and fabrication of eyeglasses for adults.

measures include numerous financial penalties where the state can seek damages for plan non-compliance. Question: What did the plans have to do to bid on the contract? Answer: The bid process is quite extensive, with the Request for Proposal (RFP) package, including appendices, covering more than 700 pages. Just as an example, here are some of the questions plans had to answer:

Question: What about behavioral health services?

Discuss outreach efforts to remind members of missed screenings and preventive services.

Answer: Integrated care should be easier under managed care. All standard health plans - which will cover most Medicaid recipients - will include inpatient behavioral health services, mobile crisis management services, outpatient behavioral health emergency services, and outpatient behavioral health services provided by direct-enrolled providers. The standard plans will enroll most individuals and will include mild to moderate behavioral health and substance abuse issues. The current LME/ MCOs will continue to cover the severe and persistently mentally ill, Intellectually and Developmentally Disabled (IDD) populations, and others until such time that specialty plans are in place to cover this population. For Behavioral Health/IDD-tailored plans, which will come a bit later, only existing LME/MCOs will be able to bid on the plans.

Describe plans to partner with advanced medical homes to provide transitional care including data sharing.

Question: Are there other populations that will not be in Managed Care? Answer: Most Medicaid patients will be enrolled in a Medicaid Managed Care plan, but a few will not be covered. For example, recipients dually-eligible for Medicare and Medicaid will, at least initially, not be enrolled in Managed Care. Question: How will the state hold plans accountable? Answer: DHHS intends to utilize a wide array of enforcement mechanisms including the ability to impose remedial actions (e.g., corrective action plans, additional training) and intermediate sanctions (e.g., suspension of marketing activities, suspension of new enrollment, including auto-assignment, civil monetary penalties) to hold plans accountable. Additionally, DHHS intends to implement a Withhold Program (as a part of the Quality Strategy) in future years in accordance with State law. Accountability

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Describe methods to identify recipients with unmet health-related resource needs. Provide background on experiences with collaborating with community stakeholders, including health care providers, particularly primary care providers. Describe your network development strategy, including strategies to recruit providers in traditionally underserved areas. Overall there were 65 questions, many with multiple parts, as part of the proposal process. Remember, the State sets the rates, so the proposal will not be evaluated based on how inexpensive the plan is. It will be based on the quality of the plan’s answers to questions like these. In addition, the RFP included seven use case scenarios, some dealing with helping primary care deal with complicated patients who have both unmet healthcare and other resource needs. One specifically asked how the plan would help a 37-year-old family physician at a mixed-specialty practice in a suburban community move from a Tier 2 Advanced Medical Home to Tier 3 status. In summary, these are just a few of the items that family physicians should begin considering now to prepare for Managed Care implementation. If you have questions, you can always contact the NCAFP. In addition, the State has numerous resources to support providers in this transition at www.ncdhhs.gov/assistance/medicaid-transformation/supporting-provider-transition-medicaid-managed-care. NOTE: The following companies/organizations ultimately submitted responses to the State’s RFP: Aetna, AmeriHealth Caritas North Carolina, BCBSNC - Healthy Blue, Carolina Complete Health, My Health By My Health Providers, Optima Health, United Health Care and WellCare Health Plans.

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PRACTICE ADVOCACY

NCAFP Submits Comments to CMS on Proposed 2019 Medicare Physician Fee Schedule The NCAFP sent CMS Administrator Seema Verma a 4-page letter this summer outlining its concerns and offering several improvements to CMS’s proposed 2019 Medicare Physician Fee Schedule. The Academy listed four high-level items for the agency to consider and offered a number of specific recommendations to Medicare Part B’s fee for service program.

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.

NCAFP’s comments mirrored many of the same concerns AAFP has with the proposal, including the financial issues practices may face due to the combination of the proposed collapsed E&M codes and a reduction in a second service on the same day. The AAFP is also hard at work advocating for changes, having submitted an 80-page response to the proposed schedule. Members wishing to learn more about the 2019 proposal should access AAFP’s Medicare Physician Fee Schedule page at aafp.org.

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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PROGRESS WITH EVERY STEP Invest In Family Medicine

FAMPAC NORTH CAROLINA

Empowering Family Medicine in North Carolina

Contribute @ www.ncafp.com/fampac

NCAFP FOUNDATION By Tracie Hazelett Manager, Medical Student & Residency Relations

- FUNDRAISING -

Dr. Karen Smith Honored in 2018 Foundation Gala Event raises funds for student programs On the last Saturday in August, more than 200 peers, friends and family members gathered at the Raleigh Convention Center to pay tribute to Dr. Karen Smith and raise critical support for the NCAFP Foundation.

lengthy record of leadership service at the state and national level, and in 2017 was named the National Family Physician of the Year. During this event, guests heard about her influence at the local level, as community members shared their stories and the impact she has had in her rural Hoke County town. Guests also heard from her now-grown children, who talked about how she inspired them as people and as professionals. However, as “kids” will do, they also seized the opportunity to take a brief break from the accolades and share a few behind-the-scenes stories about their Mom, sending ripples of laughter through the crowd. After event expenses, nearly $33,000.00 was raised for student interest initiatives. If you would like to contribute to help continue Student Programs, to Honor Dr. Smith or another mentor in your life, please visit ncafp.com/contribute.

Dr. Smith of Raeford, NC, a woman with a passion for science and a heart for service, has a

NCAFP Foundation Establishes Florence Recovery Fund It’s been a rough few months for many Family Medicine practices in eastern North Carolina. Facility damage, temporary closures, and even evacuations have impacted numerous NCAFP member practices.

as an easy way to assist in the recovery. Contributions can be completed online at NCAFP’s Hurricane Florence Relief Fund page at www.ncafp.com/donations/hurricane-florence.

To offset some of the losses faced by fellow Academy members, the NCAFP Foundation has established a recovery fund to help them return to serving their patients and communities.

All contributions will be used to provide small grants to Family Medicine practices impacted by the storm. If your practice or someone you know needs assistance, please do not hesitate to contact Greg Griggs at the NCAFP at ggriggs@ncafp.com or 919-833-2110.

Members are being encouraged to donate to this fund

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FOUNDATION

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

Thank You to this year’s Family Medicine Gala Sponsors:

Brody School of Medicine at East Carolina University, Department of Family Medicine Campbell University School of Osteopathic Medicine We Listen. We Respond. We Protect. More than 220 Risk Management Medical Mutual of North Carolina educational resources available!

medicalmutualgroup.com RM TOOLKITS

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Alliant Health Blue Cross and Blue Shield of North Carolina

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

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Wake Forest Baptist Family and Community Medicine Wake Forest Baptist Health

STUDENT SUPPORTERS

Find out more by calling 800.662.7917 or visiting

The following individuals purchased one or more tickets to specifically support a student’s attendance at this event. Thanks to our generous sponsors and supporters, nearly 50 students and residents were able to attend the event and be included in the wonderful family of family medicine on this Saturday evening in August.

Corporate Sponsor of the North Carolina Academy of Family Physicians

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Aledade

Cape Fear Valley Health System

the highest rating of “A” (Excellent) for thirteen consecutive years.

Mr. Jason Bragg Ms. Chris Collins William A. Dennis, MD Andrea DeSantis, DO Shannon B. Dowler, MD Garett R. Franklin, MD Dr. Takie & Mrs. Dena Hondros Janice E. Huff, MD

Accu Reference Medical Labs

FirstHealth of the Carolinas

A.M. Best has awarded Medical Mutual’s professional liability coverage

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BRONZE SPONSORS

SILVER SPONSORS

GOLD SPONSOR

David E. Lee, MD Amy E. Marietta, MD Mr. Scott Maxwell Maureen E. Murphy, MD Alisa C. Nance, MD Mr. Whit Newton Ms. Renda Powell David A. Rinehart, MD

Lisa Cassidy-Vu, MD; Keli Beck, MD; Kaitlyn Watson, MD Duke Population Health Management and the Duke Dept. of Community & Family Medicine Family Medical Associates of Raleigh 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

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

- EXECUTIVE’S MESSAGE -

Maintaining the Status Quo is Not an Option Medicaid managed care. Insurance company mergers. Cross-industry mergers like Aetna and CVS. Telemedicine vendors. Plus, additional companies jumping into the healthcare space, including Amazon, Berkshire Hathaway, and JP Morgan Chase. It seems like every day something is changing in healthcare or someone is trying to cause a dramatic shift. And it’s the truth. So where does that leave family physicians? First and foremost, I believe change in healthcare is inevitable. We all know healthcare cost increases are unsustainable. So, something must happen. That leaves two choices: fight for the status quo and against the likely inevitable change; OR try to shape change in a manner that builds on what we know works: primary care and Family Medicine. We can all continue to be negative about the problems in today’s healthcare system. There are certainly many of them. We can all continue to complain about change or someone else encroaching upon our space. But complaining and bickering never solves anything. Our government elected officials prove that time and time again. I believe, as a specialty, Family Medicine will be much better off if we avoid trying to stop the inevitable and instead embrace the opportunity that change can bring to improve the lives of family physicians and ultimately the 14

health of your patients. Let me give just a few examples. First, new technology designed to “improve” healthcare is not going to go away. So, do you fight it, or use it to improve care? For example, remote monitoring and telemedicine, if used correctly, can help family physicians improve the care of their patients and provide greater access. I know of at least one instance right in our state where emergency room doctors have embraced technology and are providing urgent care via e-visits. Wouldn’t the system and the patient be much better off if family physicians did that instead, incorporating e-visits right into the medical home? But if we don’t harness the use of technology ourselves, someone else is going to, in this case emergency room docs. We can be the “taxis” of the past and wait on the “Uber” of healthcare to come along, or we can be the impetus for the next Uber and embrace it and make it our own. Second, in many ways the same is true with staffing. Rather than let a retail health clinic take over the care of patients at night and weekends, aren’t we better off working on ways to keep the patients connected to the medical home? That may mean more weekend or evening hours (or telemedicine mentioned above), but it can be done by shifting staff around and embracing both technology and team-based care. As we move to value –- and Family Medicine truly will be at the center of value-based care –- there are going to be additional team members that are needed, from NPs to PAs to behavioralists to pharmacists. But you, the family physician, can be and should be the quarterback of that team. You don’t have to do it all, but you may have to coordinate and direct it all and be willing to embrace some change. Let me use my own sons as an example. They are now 19 and 23 and, quite frankly, consume everything very differently than I did or do. Look at where and how young people purchase and consume goods. My youngest son delivers food to individuals and families who are ordering dinner on an app. He’s his own boss and works when he can between a busy college class schedule. Both my sons exchange funds with their friends (paying each other back and forth) with an app called, VENMO. They don’t use cash or a credit card; they are simply paying for items and exchanging money with their smart phone. And they certainly aren’t using “checks” to pay bills. In fact, they have never had a check book. That’s blasphemy to me, but it’s the new way of the world. In this environment, if we think today’s youth and young adults are going to consume healthcare the same as we did, I think we are sadly mistaken. It’s like the furniture store

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I knew that stayed open from 9-to-5 during the week (and only noon on Wednesday), and 9-to-Noon on Saturday. Most furniture is not bought between 9-to-5 during the week. And, not surprisingly, that furniture store is no longer in business. Change is coming. Fighting it is unrealistic, and the status quo can simply no longer be an option. But I believe those who are prepared to embrace change can win, and win big in the future of healthcare. Your Academy’s new strategic plan is designed to help you prepare for and hopefully embrace change. For example, this year at our Annual Meeting, we are bringing a greater focus on education that is needed to prepare for the future. You’ll have the opportunity to hear what payers like Blue Cross feel the role of Family Medicine will be in the future. In addition, you can hear from and ask questions to a panel of healthcare system executives that are navigating the tricky dual role of simultaneously operating in a volume-based payment environment today while preparing to be paid for value in the years to come. You may have read that BCBSNC and UNC Health recently agreed to a new paradigm where they will begin taking responsibility and risk for the full cost of care. You’ll also have a chance to hear from the CEO of Aledade, one of the companies funded by venture capital, that is successfully investing in physician-driven accountable care organizations and other value-based models. We know you like strong clinical content at our Annual Meeting, and over 80 percent of our meeting will still provide just that. But we would be remiss if we didn’t help prepare you for the future of healthcare. In fact, when you told us about your pain points in our Member Needs Assessment late last year, healthcare system relations, payer relations, and working to reduce administrative burdens topped your list of issues you hoped the NCAFP would address. We’re doing exactly that, but that means change. As the NCAFP changes and healthcare changes, we hope you will work with us to help you navigate the stormy waters of the next few years. I’m confident that Family Medicine has much to offer during this transition and beyond. But we simply can’t afford to constantly fight change or simply let change happen to us. It’s time to embrace change and shape it for a better healthcare system for you and your patients.

Remarkable people providing remarkable healthcare 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

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Autumn 2018

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- HEALTH PROMOTION -

NCAFP Urges Seniors and Patients with Chronic Disease to Get Pneumococcal Vaccination Last month, the NCAFP urged North Carolina’s seniors and citizens with chronic illness to get vaccinated against pneumococcal disease this fall. According to a CDC report released earlier this year, North Carolina currently ranks 49th in the nation for deaths caused by pneumonia. “If you are over 65 or live with a chronic health condition, the flu shot isn’t the only vaccination you need this fall,” noted Academy President Dr. Tamieka M.L. Howell. Pneumococcal disease is the world’s leading cause of serious illnesses such as pneumonia and blood infections. Pneumococcal disease infects nearly 1 million Americans each year, according to the Centers for Disease Control (CDC). Caused by bacteria and spread through coughs, sneezes and close contact, pneumococcal disease can lead to pneumonia, infection of the blood, middle-ear infection, sinus infection or even bacterial meningitis. North Carolinians who are over age 65 or those who live with a chronic disease that impacts the immune system – such as asthma, diabetes, cancer, lung disease, heart disease, or kidney disease – are particularly susceptible to serious complications. The CDC’s Advisory Committee for Immunization Practices (ACIP) recommends that all adults age 65 and over be vaccinated with two separate vaccines to prevent contracting pneumococcal disease.

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PROFESSIONAL DEVELOPMENT

ABFM will Pilot New Examination Alternative Option for 2019 The American Board of Family Medicine (ABFM) has announced a new pilot program designed to assess the value and feasibility of a longitudinal assessment option to the 10-year examination. Physicians who are current with continuous certification and due to take the examination in 2019 would be eligible to participate in the pilot. This new longitudinal pathway is based on the popular Continuous Knowledge Self-Assessment (CKSA) platform and will deliver 25 questions online each quarter. Incoming ABFM President and CEO Dr. Warren Newton noted that the pilot, “… will provide questions on a regular, longitudinal basis, in a format that is much more convenient—a few questions at a time, in the place and time of your choice. You may use clinical references during the assessment, much like you do in practice. You will not need to travel to a test center, nor spend additional time and money on preparatory courses.” The AAFP has been working closely with the ABFM advocating for MOC improvements sought by its member diplomates. Last year, the AAFP assembled a task force to study several issues and to formulate action items. NCAFP’s Dr. Benjamin F. Simmons served on this task force as the New Physician board member of the AAFP. At the NCAFP Winter Meeting (ncafp.com/wfpw) in Asheville, Dr. Newton will be conducting two focus groups on Saturday (12/1) to discuss proposed changes and to receive feedback from diplomates. If you would like to attend that focus group and give feedback directly to the ABFM, you can register for the focus groups on the NCAFP’s Winter conference website at ncafp.com/wfpw.

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NCAFP

Sights & Scenes

Autumn 2018

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MEMBERSHIP

- MAKING A DIFFERENCE -

Wilmington Family Docs Leap Into Action in Hurricane Aftermath

portunity to reach Burgaw and bring medical care into the community. Through the help of our local emergency operations center and law enforcement escorts, we were both able to wind through a maze of back roads, hitting road blocks along the way, in order to make the extended journey to reach Burgaw. Prior to deployment, as the CMO of Pender Hospital, I was contacted by the medical director of Med1 to start understanding all of the facets of our community and how Med1 could provide the most benefit. I also remained in regular contact with several of our current faculty and residents of Coastal Family Medicine located in Wilmington offering to help support the needs of Pender County.

Family Medicine residents and former graduates with the New Hanover Regional Residency in Family Medicine wasted little time in extending a helping hand to those in need immediately after Hurricane Florence. This is their story. Written by Heather Davis, DO Chief Medical Officer / Chief of Staff Pender County Memorial

The last few weeks have been extremely challenging for all of us in this region, and life is just now starting to get back to normal for some, but certainly will be a long road for many others. I would like to share my experience with you as it relates to Family Medicine. Our hospital system leadership made the decision prior to storm landfall to evacuate our critical access hospital, Pender Memorial, and skilled nursing facility (SNF), located in Burgaw, NC. However, immediately after the storm we were unable to open due to lack of staffing. With major and local road closures from storm damage or flooding, neither employees that stayed in their homes nor those who evacuated to distant areas were able to return. A plan was implemented instead to bring a fully-staffed mobile hospital, Med1 from Atrium, into our community of Burgaw to meet emergency needs. Having evacuated pre-storm, I, along with the Med1 mobile hospital, was waiting deployment in Charlotte, NC. Luckily within days, we found a brief window of op-

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Credit: New Hanover Regional Medical Center

With no physicians able to reach their local practices, local residents displaced from homes to multiple shelters, and a hospital that was closed, I spent the next week collaborating with Med1 in both clinical and administrative roles to support their emergency services. Along with tremendous support of Pender Hospital leadership, I was able to connect with local community resources including family physicians by phone, dialysis centers, pharmacies, and oxygen suppliers to name a few. Through regular debriefings with Med1 leadership, and learning from their experience in disaster situations, we developed strategies aimed at minimizing the effects of limited access to care, particularly for those needing chronic disease management, which would certainly overwhelm our mobile hospital and its precious resources. Additionally, I

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developed a mobile care team to visit shelters and provide primary care, urgent care, and chronic disease management to our community that was essentially cut off from the world. One of our initial conversations centered on opportunities to safely bring physicians back to the community to help support this effort, with specific requests from Med1 for pediatricians and OB physicians, neither of which exist in this part of the county. Immediately I knew that I needed to find transportation for some of my Coastal Family Medicine Residency (CFM) colleagues to help meet both of these needs, and it only reinforced in my mind why full spectrum family physicians are so valuable, particularly in rural areas. As I put out the call for support within our system, the overwhelming response from both our current and former CFM faculty and residents was tremendous. Our faculty and residents, including those who recently worked through shelter-in-place or immediate post-storm team coverage, were quick to volunteer to come join me in Pender County at a moment’s notice and only a promise of a one way trip to Burgaw by air, water, or land. Over the next two days our folks hopped on high water army vehicles through flooded and washed out roads or drove several hours out of their way, with no guarantee of an open or safe route to Pender County. They provided tremendous support and relief for me personally, as well as meeting the clinical needs of those in shelters, coordinating transfers, and assisting in performing an urgently needed procedure, providing critical care, and ensuring follow-up care for patients seen in Med1. The team also brought additional expertise through their continued OB practice, and volunteered for 24/7 calls for any OB patients and even delivered a baby in the back of the mobile hospital! During these two weeks, I also heard and read stories of the work by many other members of our CFM team to ensure delivery of care and resources in other parts of the region, providing extended hours at the residency clinic, caring for patients in neighboring county shelters, covering schedules for each other to allow for much needed rest and recovery of colleagues on storm teams, and to cover for their colleagues who were either trapped out of town or responding to clinical needs elsewhere in the region. I am confident and proud in knowing that if available, any and all of our CFM team would have volunteered and would be the best suited to help a community in need. LESSONS LEARNED There are so many things I have learned through this experience, but first and foremost is the true testament and value of the spectrum of training and care provided by family physicians. In addition, this experience spoke volumes about the incredible culture that has developed since my graduation in 2008 under the leadership of Dr. Jan Beste, leading to high quality of both clinical skills and character of those individuals that train and work at her program, Coastal Family Medicine. I am honored to be part of such a team.

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PERSPECTIVES ON THE STORM To present additional first person accounts of Academy members both during and after the Hurricane Florence, the NC Family Physician reached out to NCAFP members in eastern North Carolina. Here are their perspectives. Toren Davis, DO New Hanover Regional Medical Center - Wilmington, NC The Eye, The Children, and Stickers - The eyewall of Florence was bearing down on New Hanover Regional Medical Center. The winds lashed the building and howled as they passed. The sound was unnerving. Next door to our rounding room was the makeshift daycare area full of 120 children of employees working during the lockdown. Knowing they were going to be set up there, and figuring our clinic would be flooded, prior to the storm lockdown I raided our sticker drawer. I figured the kids in the hospital would have more use for them than a drawer flooded by Florence. Now felt like a good time to pass them out. The water dripping through the roof and wind beating the building was making me anxious and I could not imagine how it was making the children feel. Our team grabbed the sticker rolls and opened the door into the damp hall. There were very few lights from the backup generator. We began to pass the stickers to the children. There was a line of kids in blankets that we were told had started showing signs of a stomach illness that started the night before. We were pointed to a dark room with no lighting where the youngest kids were held. Some were laughing and some were crying but the elevated mood in the room was palpable. We continued to give stickers, talking about our favorite cartoon characters and getting smiles in a time where I was scared myself. I peered into the room next door where water was pooling on the floor

from the sagging and broken roof tiles above. The winds continued to hammer the building. We continued to give stickers. My hope was that, at least for a moment, these kids could forget about the chaos that surrounded them and find some happiness. I know it helped me. Evacuating Home Base - The light trickle of water from the roof had increased. Drips could now be seen coming through cracks in the cement above us. This was our rounding room, our home base. The hole that was ripped in the roof two floors above us continued to let in gallons of water. It looked like a waterfall in the residency offices two floors up. The library in between us had begun to take on water. Just outside the stairwell that led to our room an inch of water covered the floor and was rising. The water began to come over the stairs and down to where we sat. There was no question now, we had to evacuate. Our team worked quickly to unplug our equipment and computers. We drug a table with them all through the hall as the water began to come down harder. A pool began to form on the ground and in our rounding room. We grabbed a few final pieces of residency materials and left the room for the last time. The entire basement had begun to take on water with no end in sight. As we walked down the hall carrying everything we could I wondered what was next? Home base was gone but the team was safe, and would continue to be there for our patients.

Karen Smith, MD Karen L. Smith, MD, PA - Raeford, NC The Most Valuable Lesson: The most valuable lesson learned is to feel the value of “People, places and things.� Every action before, during, and after the storm focused on these three areas so well known to many. As a Family Physician actively engaged in the treatment of Opiate Use Disorder these three words brought forth deep thought as we contemplated about the potential triggers which could set back our patients who worked so hard toward success and freedom from substances. Better yet the non-opioid use disorder patients who had very little reserve after surviving Hurricane Matthew. In an effort to be there for our patients, as well as nowhere to go with five dogs and two cats we remained available to our community even as the power was lost shutting down the electronic health records, lights, and air conditioners. Our facility did have minimal wind damage as a result of Hurricane Matthew, while the personal home suffered major roof damage. All roads exiting the neighborhood were covered due to flooding and three completely collapsed. Hurricane Florence lingered

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creating wind and rain damage. The office was spared the savage assault of Florence and served as a refuge, allowing access to electronic health records for patients who still had cellular to call in for questions or needs. We opened each day and cared for higher than usual number of patients and reassured those who came all would be well as life was spared for many. Thank goodness for the brick building and the solid practice team which continuously serve the needs of the people quite well.

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MEMBER NEWSMAKERS Dr. Viviana Martinez-Bianchi Re-Elected to WONCA Executive Committee Duke University’s Dr. Viviana Martinez-Bianchi was recently re-elected to serve a second consecutive term on the WONCA Executive Committee, the World Organization of Family Doctors. Executive committee members serve three-year terms and meet up to twice annually and act for and on behalf of the WONCA World Council. As part of her service, Dr. Martinez-Bianchi also acts as WONCA’s WHO Liaison. Learn more about WONCA at wonca.net.

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Dr. Karen Isaacs Selected for 2018 AAFP Health Equity Fellowship New Hanover Regional Medical Center’s Dr. Karen Isaacs was recently selected as one of two physicians nationally for AAFP’s 2018 Health Equity Fellowship. Dr. Isaacs’ selection was announced earlier this month at the AAFP Family Medicine Experience. Isaacs will complete a project that identifies a specific health equity issue and offers a measurable strategy for how it will be addressed upon completion of the program.

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Dr. Kathy Andolsek Appointed to ACGME Board of Directors Kathy Andolsek, MD, Professor of Community and Family Medicine at Duke University, has been appointed to a 3-year term on the ACGME Board of Directors. Dr. Andolsek holds joint appointment in the Duke School of Nursing and is also an adjunct professor at the University of North Carolina Gillings School of Global Public Health.

Autumn 2018

Find out more by calling 800.662.7917 or visiting

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ADVERTISE! Reach many types of Family Medicine professionals in North Carolina. Contact Peter Graber with the NCAFP at pgraber@ncafp.com 23

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BUILDING MAINTAINING POSITIVE ONLINE REPUTATION $17.6 MILLION VERDICT AND IN MISSOURI DRIVESAHOME MEDICAL LIABILITY IMPLICATIONS OF OPIOID EPIDEMIC According to new data from the University of Southern California (USC) Annenberg’s Digital Future Report, the average By Jason Newton, Senior Vice President, Claims and Risk Management, and Associate General American spends roughly 24 hours each week online. Given that 20 percent of a person’s waking life takes place on the Counsel internet, it’s not surprising that individuals often rely upon information available online when making important decisions – including which healthcare provider to trust.

A Missouri jury last month awarded $17.6 million to a man who claimed his physician overprescribed for him, what we at Medical Mutualpresence, have been telling ourkey members more than apoWhenopioids physicians work confirming to directly build and enhance their online there are two areas of for focus: personal year: that in addition to its human toll, the opioid epidemic carries significant implications for sitioning and reputation management. By creating and maintaining a positive online presence, providers have the ability to influence the decision-making processes of potential patients, ultimately encouraging growth and success within the physicians’ medical liability. competitive healthcare industry. That is, if they know how to do it effectively.

In the case, a 45-year-old man alleged that he became addicted to three different opioids his primary

Establishing an Online Presence with Medical Mutual) prescribed to him for back pain—a total of 40,000 care physician (unaffiliated By creating theirfour ownyears, online according presence and engaged publishing new content sharingofunique professional perpills over to staying the plaintiff. Thebyplaintiff alleged that theand volume painkillers spectives, physicians willphysician have a partled in writing own stories, making it more likely forhim potential patients to encounter this prescribed by his him totheir become addicted to them, requiring to enter a drug carefully curated information easily leverage commonincluding social media sites such as Twitter, Facebook, and rehabilitation programfirst. andPhysicians damagingcan personal relationships, his marriage. LinkedIn to build the foundation of a positive online reputation, while maintaining a high level of professionalism on all public profiles. providers should disclose protected information todamages the public,to which could and put them at TheMost juryimportantly, found the physician liable,never awarding $1.4 millionhealth in compensatory the man risk of HIPAA violation. $1.2 million to his wife, as well as $15 million in punitive damages. Responding Reviews: Proceed Withdoctors Caution! Until thistoopioid epidemic ebbs, will need to stay mindful of its potential impact on their The easiest way to get positive online reviews is to provideand patients with athe positive includes paying liability. The verdict drives home for physicians practices vital experience. importanceThat of ensuring that close attention not only to the medical services provided, but also front office interactions, billing procedures, and general opioid prescribing practices are consistent with CDC and state medical board guidelines. That’s notbedside manner. Unfortunately, physicians cannot always control how their care is perceived, and unforeseen, unavoidable circumjust good patient care—it’s also prudent risk management. stances can leave both a bad taste in a patient’s mouth and a bad review online.

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

An excellent way to combat this negative press is to appropriately respond to criticism, both publicly and privately, in a way three of which can help doctors meet North Carolina pain management CME requirements. that is noncombative and respectful. When receiving criticism, responses should be kept short and apologetic, while simultaneously thanking the reviewer for their constructive criticism. Should a physician feel that the statements warrant a lawsuit for libel or defamation and the poster can be identified within About theofAuthor the parameters HIPAA, his or her medical malpractice insurer may be able to help. At Medical Mutual, we provide memgraduated from UNC Chapel Hillasand hissecurity law degree from coverage. Wake Forest. After a 14bers Jason with broad regulatory protection coverage, wellobtained as network and privacy

year career in private law practice defending doctors, APPs, and hospitals, in 2013, Jason came on

Putting Online Reputation Management Into Action: PSMR board with Medical Mutual—a longstanding client—in an in-house capacity. At Medical Mutual, Jason The fundamental action items to keep in mind when focusing on online reputation creation and management can be summed oversees Risk Management, Healthcare and Claims departments. up with a simplethe acronym. PSMR: Post, Solicit, Monitor,Compliance, Respond. • Post: Writing, posting, and sharing relevant educational information can help establish a physician’s expertise to the online community. In addition, by regularly publishing, physicians can dilute the presence of negative comments and reviews in searches • Solicit: Physicians should actively solicit feedbacks and reviews from patients to provide positive, accurate examples of care to online researchers. To do this, the providers must be sure to give patients detailed information, including URLs for important rating sites. • Monitor: Physicians should set up Google alerts to be notified when something is posted that mentions their name. • Respond: All practices should have a designated individual who will regularly review key sites to quickly respond to negative reviews and minimize the damage they may cause. When responding to feedback online, this person should always remember to listen, be empathetic, and be respectful. Remember: the internet is forever. Anything that is written online may be repeated or reposted elsewhere. For questions on this topic, Medical Mutual members are encouraged to contact our Risk Management team at 800.662.7917.

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

RESIDENTS & NEW PHYSICIANS

- PRACTICE PEARLS -

North Carolina Policy on Expedited Partner Treatment By Colleen Harkreader, MD and Demetria Rawlinson, MD Carolinas Medical Center Family Medicine Residency of Atrium Health Charlotte, NC

orrhea recurrence, there is increasing resistance to the previously used regimen of oral cefixime. As of 2012, oral treatment for gonorrhea is not preferred. Current recommended therapy for gonorrhea is a one-time dose of intramuscular ceftriaxone 250 mg (plus a one-time dose azithromycin 1 g orally). That being said, if the provider feels that it is unlikely that the partner will seek treatment for the intramuscular dose of ceftriaxone, it is reasonable to consider expedited therapy with cefixime [5]. For homosexual males, the CDC recommends using caution when considering EPT because of the higher prevalence of comorbid HIV, however EPT can be used if the provider does not feel that the partner is likely to seek further medical care. EPT is permissible in 42 states, potentially allowable in 6 states, and prohibited in 2 states. [6] As of November 2009, the North Carolina Medical Board updated its position statement on “Contact with patients

Expedited partner treatment (EPT) is the treatment of a sexual partner of a patient who has been diagnosed with gonorrhea or chlamydia withColleen Harkreader, MD, PGY-3 out a medical examinaCarolinas Medical Center FMRP of Atrium Health tion of the partner. The Dr. Harkreader completed her undergraduate studies at the University goal of this review is to of Michigan followed by medical school at Wayne State University provide information School of Medicine in Detroit, MI. Her philosophy on being a family about the legality and physician: “I am honored to have the privilege of being a physician and I hope to be able to develop strong relationships with my patients so efficacy of EPT and to that I can provide the best possible medical care. I believe that working increase this prescribing together is the best way to optimize health.” practice among providers. Expedited partner treatment is superior to traditional partner referral in preventing recurrence of both gonorrhea and chlamydia [2]. Treatment of sexual partners is important for vector control and to decrease the risk of transmission to others.

Demetria Rawlinson, MD, PGY-3 Carolinas Medical Center FMRP of Atrium Health Dr. Rawlinson graduated from the University of North Carolina-Chapel Hill prior to completing her medical degree at the Brody School of Medicine at East Carolina University in Greenville, NC. Dr. Rawlinson’s philosophy: “As a family physician, I believe it is important to build a trusting relationship with patients by listening and taking interest in them as a whole person and not just treating their disease. I aim to provide compassionate care and advocate for each of my patients by treating them as I would want my own family to be treated.”

The CDC recommends always treating partners of heterosexual individuals with the diagnosis of chlamydia with a one-time dose of azithromycin 1 gram orally [4]. Despite evidence that EPT reduces gon-

before prescribing” stating that it may be suitable to prescribe EPT for gonorrhea and chlamydia.[7,8]. The North Carolina Division of Public Health endorses use of EPT for chlamydia only. It is not recommended for gonorrhea because the first-line treatment is intramuscular ceftriaxone which requires a trained See “Expedited” on Back Cover

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The North Carolina Family Physician

RESIDENT BRIEFS

Dr. Jessica Lapinski Receives AAFP’s Excellence in Graduate Medical Education Award Duke University Family Medicine Residency third-year Population Health Chief Resident, Jessica Lapinski, DO, was honored in October at the AAFP FMX Conference in New Orleans, LA., as one of twelve Family Medicine residents selected nationwide to receive the AAFP’s Excellence in Graduate Medical Education award for exemplary patient care, interpersonal relationships with patients, physicians and faculty, and demonstrated leadership and community involvement. Dr. Lapinski cited her most important professional accomplishment to date as co-leading an effort to expand the clinical practice at Duke Family Medicine

Center in Durham, NC, to include an LGBTQ+ patient-centered medical home (PCMH). This project allowed her to employ a variety of skill sets, grow as an individual, and make positive strides for the local LGBTQ+ community. Her other professional interests include academic pursuits, such as presenting at conferences and authoring articles. In her free time, Dr. Lapinski enjoys a variety of activities, from working on her Spanish and sign language skills to writing a novel (which she hopes to complete before graduating from residency). A former professional photographer, she still counts photography as one of her passions. Following residency, Dr. Lapinski plans to pursue a career that integrates primary care medicine, advocacy, and research. She is considering returning home to Chicago, IL, and would like to work at an institution that promotes health equity, personal development, and scholarly activity. Congratulations!

Resident Liaison Opportunity The Academy is updating its Resident Advocacy/Program Liaison Contact list. If you are interested in the opportunity to increase your involvement with the NCAFP, this is a great way to get started with a low-level time commitment. The Academy seeks at least one resident volunteer from each program to serve as the communication point person between the NCAFP and their respective program. The Liaison will not be regularly called upon; but, will be used as a point of contact to help disseminate advocacy or important legislative information on an as-needed basis. This position may also be involved in helping to coordinate Academy visits to your program. The position is flexible. How Liaisons choose to distribute the information (word of mouth, text messages, emails, calendar updates) or inspire local action will be determined by each individual / program. If you are interested in serving as the Liaison for your program, please contact Tracie Hazelett at the Academy office via email at thazelett@ncafp.com or 919-980-5357.

Autumn 2018

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

Campbell’s Erin Clark Elected as AAFP’s National FMIG Network Coordinator Erin Clark, CUSOM, OMS-IV/MPH, was elected as the AAFP’s FMIG Network National Coordinator during the AAFP National Conference for Family Medicine Residents and Medical Students held in Kansas City, MO, in August. Ms. Clark previously served as a Regional FMIG Network Coordinator and worked closely with students across the country during that time. Erin looks forward to her new role with the AAFP and has a goal to “sustain an environment where students are empowered to think creatively and improve continually. I would love for leaders to feel comfortable reaching out to me and the Regional Coordinators with new and big ideas, but even more so feel that their ideas have been heard and valued. My main goal will be to ensure that I do everything I can to help students succeed and be confident in their futures as family physicians.” Not sure if FMIG at your school can make a difference for you or for your program? Think again! It can open the door to opportunities too numerous to count! When asked how being involved in her FMIG helped her

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form connections she might not have otherwise developed, she states, “I could write 10 pages on this! Being involved with the FMIG at my school helped me find a summer internship with my state chapter, which in turn led me to my current running coach (the husband of an awesome family physician and boss-lady runner), which led me to a position on my state chapter’s foundation board, which led me to a spot in the AAFP Foundation’s Emerging Leader Institute (www.aafpfoundation.org), which led to my Regional Coordinator position, and my decision to earn my MPH, and is leading to my choice to MATCH into Family Medicine! So be careful y’all: if you get involved in your FMIG you might end up a runner with an extra degree and some life-long friends. I hope you’re ready for an awesome ride!” Particularly noteworthy about this honor is that Ms. Clark is the first osteopathic medical student to serve in a regional or national level FMIG role. In addition to being elected to her new position, Ms. Clark also presented her research during the conference. She was selected as a finalist for her project on “Program Evaluation and Design for Substance Abuse & Recovery in the Urban Underserved Population” through the Emerging Leaders Institute. Ms. Clark’s year-long project partnered her with Healing Transitions, a recovery facility for homeless individuals with substance abuse disorders in Raleigh. The nonprofit is currently using Clark’s data to assess what it’s doing well and what it could improve. Ms. Clark recently completed her third year at Campbell University School of Osteopathic Medicine in Lillington, N.C., and is taking a one-year break to earn her master’s in public health at the University of North Carolina at Chapel Hill. Congratulations Erin!

The North Carolina Family Physician

First-Year Medical Students -

STUDENT TRACKS

Four Medical Students Awarded NCAFP Foundation Family Medicine Scholarships The NCAFP is pleased to announce four medical students have been selected to receive the Family Medicine Scholarship offered by the Foundation. Each year the North Carolina Academy of Family Physicians Foundation provides scholarships to North Carolina medical students considering careers as family physicians. Medical students in their 3rd or 4th year of medical school are eligible to apply. The monetary awards students receive are scholarships, unless a recipient does not complete their family medicine residency training. In that circumstance, the awarded money is converted to a loan and is paid back to the Foundation with interest. This year, each of the recipients are fourth-year medical students, who are currently actively interviewing at Family Medicine residency programs. In addition to sincere interest in family medicine, these medical students exhibited a commitment to community and service, have demonstrated leadership skills, as well as financial need. The NCAFP would like to thank the Foundation’s Scholarship Review Committee and offer best wishes and congratulations to the following outstanding 2018 Family Medicine Scholarship recipients (pictured, from top): Ashley Blasi, Campbell; Katherine Gushanas, Campbell; Olivia Johnson, Brody; and Daniel Olson, Brody.

Blasi

2019 Summer Family Medicine Interest Programs The NCAFP Foundation offers a variety of programs and opportunities to medical students. Some are clinical experiences only available to 1st year medical students. These opportunities take place the summer between your first and second year of medical school. There are multiple programs available, ranging from two to four weeks in length. To learn more about the options and the exciting specialty of Family Medicine visit: ncafp.com/students Application deadline is January 15, 2019. Contact Tracie Hazelett at 919-980-5357 or thazelett@ ncafp.com for questions, info or help.

Gushanas

Johnson

We would like to recognize that all applicants were extremely deserving women and men Olson with impressive experiences. It is understood that every medical student has financial need, so decisions were difficult! We are grateful for each student’s dedication to family medicine and anticipate North Carolina will be the recipient of these outstanding individuals’ commitment and healthcare services to our communities in the future. Autumn 2018

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THE ROLE OF VITAMINS IN FILLING NUTRIENT GAPS As family physicians know, the best and primary source of essential nutrients is through a rich, balanced diet. However, up to 9 out of 10 Americans fall short in consuming adequate amounts of key nutrients from food alone.1 Dietary supplements, especially multivitamins, are useful to provide nutrients that otherwise are not consumed in recommended amounts. A recent study using National Health and Nutrition Examination Survey (NHANES) data investigated the effect of multivitamin/multimineral supplement (MVMS) use on nutrient intake and prevalence of inadequacies and deficiencies. The study findings showed that:2 • Compared to food alone, taking a MVMS supplement was associated with a lower prevalence of inadequate intakes for 15 of the 17 nutrients examined, including those identified by the latest Dietary Guidelines for Americans (DGA) as under-consumed nutrients (calcium, vitamin D, iron, potassium). • More frequent MVMS use was associated with lower rates of inadequate intakes compared to non-MVMS users, and significantly lower prevalence of nutrient deficiencies for the nutrients examined, except iron. According to NHANES data, most people do not meet nutrient intakes for the following: vitamins A, C, D, and E, magnesium and calcium. In addition, the latest DGA reports vitamin D, calcium, iron, potassium and fiber as nutrients of “public health concern” because they are under-consumed to the point they may lead to adverse health outcomes.3 Adverse health outcomes can include poor bone health, impaired immune function, and impaired cognitive function, as well as chronic diseases, such as age-related eye diseases, certain cancers, hypertension, and coronary heart disease and stroke.4,5 In light of these findings, it is more important than ever to talk to patients about their eating habits and daily food intake to identify nutrient gaps. Since food alone may not always meet the individual’s nutrient needs, recommending dietary supplements, such as a multivitamin, could be an option for optimizing nutrient intake.

For more than 45 years, Nature Made has been a trusted leader in the wellness industry, providing high quality vitamin, mineral and herbal supplements. Nature Made is the national supplement brand with the most products carrying the United States Pharmacopeia (USP) mark*— verification that the products meet stringent quality criteria for purity and potency. Learn more at www.NatureMade.com. *Find those Nature Made USP verified products on NatureMade.com/USP

References: 1. Wallace TC, McBurney M, Fulgoni VL 3rd. Multivitamin/mineral supplement contribution to micronutrient intakes in the United States, 2007-2010. J Am Coll Nutr. 2014;33(2):94-102. 2. Blumberg JB, Frei BB, Fulgoni III VL, Weaver CM, Zeisel SH. Impact of frequency of multi-vitamin/mult-mineral supplement intake on nutritional adequacy and nutrient deficiencies in U.S. adults. Nutrients 2017 Aug 9;9(8). 3. U.S. Department of Health and Human Services; U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans, 8th ed.; USDA: Washington, DC, USA, 2015. http:// health.gov/dietaryguidelines/2015/guidelines/. 4. U.S. Centers for Disease Control and Prevention. Second National Report on Biochemical Indicators of Diet and Nutrition in the U.S. Population 2012; National Center for Environmental Health: Atlanta, GA, USA, April 2012. Available online: https://www.cdc.gov/nutritionreport/pdf/Nutrition_Book_complete508_final.pdf (accessed on 11 June 2018). 5. Ames, BN. Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce micronutrients by triage. Proc. Natl. Acad. Sci. USA 2006, 103, 17589-17594.

2019

Family Medicine Day Saturday, March 9th, 2019

Hands-On Skills Training and Family Medicine Residency Recruitment Fair The North Carolina Academy of Family Physicians (NCAFP) and the North Carolina Area Health Education Centers (AHEC) program are excited to present North Carolina’s 12th Annual Family Medicine Residency Recruitment Conference. This fantastic one-day event is North Carolina’s premier family medicine residency recruitment conference. The day will begin with an inspirational keynote lunch speaker, followed by 4-hours of clinical skills workshops. During the afternoon workshops, students will network with North Carolina’s family medicine residency programs as they teach and refine skills and share their experiences as a family physician. During the evening Residency Recruitment Fair, participants will learn even more about North Carolina’s state-of-the-art training programs. Family Medicine Day is a tremendous professional networking opportunity with residents, faculty and other students from across the state.

! N U F . G N I Registration will open late 2018 for medical students in the classes of 2020 and 2021. Class of 2022 students can register RD A beginning February 9th, 2019. For updated information and links to the registration, please visitW www.ncafp.com/fmd. E If you have questions, please contact Tracie Hazelett at thazelett@ncafp.com L. R NA O I T A C U D E

PRACTICE MANAGEMENT

Collaborative Care Model 102 Get paid for Integrated Care in Medicaid By Dr. Jennie Byrne Community Care of North Carolina

Population-Focused: CoCM uses screening and a registry to treat a defined population within the primary care practice – often patients who screen positive for depression and/or anxiety. Measurement-Guided: similar to treatment for other chronic conditions like hypertension, standardized behavioral health rating scales (like the PHQ-9) are used as behavioral health vital signs, and repeated measurements (e.g. PHQ-9 score) targets specific measurable outcomes. Evidence-based: the CoCM literature is extensive, includes all ages, different targeted populations, with an established return on investment (ROI) (up to 6:1 ROI). How does the model work in primary care?

On October 1, North Carolina Medicaid started paying primary care for the “Collaborative Care Model.” This is a population management-based model of integrated care that has already been recognized and paid for by Medicare. With Medicaid joining the payers that will fund this model, we wanted to provide NCAFP members with an overview of how collaborative care works.

The practice hires a Behavioral Health Care Manager (BHCM), typically a master’s level or higher professional with experience in behavioral health. The practice also contracts with a psychiatrist about 2-4 hours per week and typically pays them an hourly rate (typical for NC is between $100-$175). The BHCM is embedded in the practice and a 1.0 FTE would typically handle a registry of 5090 patients depending on their complexity. Importantly, neither the PCP, BHCM, nor the psychiatrist needs to be credentialed with a Medicaid LME/MCO to provide CoCM services. The primary care physician simply must be a Medicaid provider.

COLLABORATIVE CARE MODEL

What is the Collaborative Care Model and how does it impact family physicians? The Collaborative Care Model (CoCM) is an evidence-based model of behavioral health integration that is designed for the primary care medical home. The model is currently billable to Medicare and NC Medicaid (as of October 1); CPT codes record the total monthly time per patient per month and use the NPI of the primary care physician. If done correctly, the CPT codes can financially sustain the model in most practice settings. The model has 4 essential elements: Team-Driven: the primary care physician is the leader of the Collaborative Care Model (CoCM) team, which includes two new team members – an embedded behavioral health care manager (BHCM) and a consulting psychiatrist.

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The PCP has a standardized screening protocol for BH/ MH conditions (most commonly for depression using the PHQ-9) and positive screens are offered participation in CoCM. The PCP will do a brief description of CoCM with the patient, then do a “warm hand-off” of the patient to the BHCM who describes the CoCM in more detail. If the patient accepts participation in CoCM, the BHCM will gather more information, enter the patient in the registry, and start a protocol with consultation with the psychiatrist, brief (15 minute) therapeutic interventions, and frequent telephonic follow-ups. The PCP has the option to discuss cases directly with the psychiatrist, or use the BHCM to facilitate specific treatment recommendations from the psychiatrist (related to medications, psychother-

The North Carolina Family Physician

apy, or other treatment options). It is important to note that the psychiatrist is not doing 1:1 appointments with the patients in CoCM. How is it billed? The BHCM tracks time spent on each patient in the registry on a monthly basis. The CPT code is billed to the PCP NPI once per patient per month. A full CoCM caseload should be financially self-sustaining to the practice, with the potential for a small profit. What is the evidence? CoCM has a robust evidence base with more than 80 randomized controlled trials showing CoCM to be more effective than usual care, including a 2012 Cochrane Summary including 24,308 patients worldwide. In early 2014, a study showed that patients who participated in a CoCM 8 years prior were significantly less likely to experience a serious (including fatal) cardiovascular event than patients who received care as usual. For the most up-to-date references and resources, please visit the AIMS Center website: https://aims.uw.edu/resource-library/evidence-base-collaborative-care Contact: jbyrne@communitycarenc.org or aclendenin@communitycarenc.org to learn more.

Autumn 2018

PRACTICE TRACKS

NC Treasurer Announces Move to Reference-Based Pricing for State Employees Health Plan North Carolina Treasurer Dale Folwell announced a move to reference-based pricing for the State Employees Health Plan in early October. Starting in 2020, the Plan will base all payments on a percentage of Medicare. Professional services, which includes most physician payment, will be based on 160 percent of 2018 Medicare rates for all physicians in all locations and all specialties. All participating physicians will be asked to decide whether they will continue to participate in network by July 1st, 2019. You, or someone in your practice, should have received a notice directly from the State Employees Health Plan regarding this. The notice indicated that under the existing rate structure, professional services ranged from as low as 65% of Medicare to as high as 994% of Medicare, with an average of 126% of Medicare. Again, the new plan would place all professional services at 160% of Medicare, regardless of specialty or location. The NCAFP continues to evaluate the impact of these changes on family physicians across the state and will continue to advocate for our members to ensure as much investment in primary care as absolutely possible. If you would like additional information, please contact Greg Griggs at ggriggs@ncafp.com or 919-833-2110.

AAFP VirtualCare Helping Member Practices Offer Turn Key Telemedicine Services The AAFP has rolled-out of a new, leading-edge virtual care platform exclusively for members known as AAFP VirtualCare. AAFP VirtualCare combines clinical efficiency and convenience with high-quality care through both online patient interviews and video visits. The platform is completely HIPAA-compliant and has been designed to enable practicing family physicians to do more with less effort. Participating physicians can treat more patients, retain and grow their practice, and support patients who find it challenging to access in-person care. For complete information on this exciting program -- including answers to frequently asked questions, feature lists, and complete enrollment information -- see AAFP’S VirtualCare center at AAFP.org.

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ASK THE PAYER

Understanding Risk Adjustment and HCC Scores in Medicare Advantage Ask the Payer is a new periodic column in the NC Family Physician. From time-to-time, the NCAFP will ask one of the state’s health insurance companies to answer a question to help our members understand key issues. This is the first such column.

Today, we’ve asked Humana to help family physicians better understand the importance of Medicare Risk Adjustment (MRA) and the Hierarchical Condition Category (HCC) model in Medicarea Advantage. The Balanced Budget Act of 1997 mandated that a risk adjustment payment methodology be implemented in the Medicare Advantage (MA) program, no later than January 2000. The Centers for Medicare & Medicaid Services (CMS) uses the risk adjustment methodology to evaluate the burden of illness of MA members. Medicare risk adjustment (MRA) allows CMS to better predict and budget for the costs of care. In addition to facilitating payment accuracy, risk adjustment also helps ensure that MA plan members receive the care they need for their health conditions and that they are able to take advantage of disease management and other programs available through their MA plans. Today, Under the MA program, MA plans are paid a set premium to cover the costs of health services for their

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members. CMS uses demographic and disease data for each member to determine the individual premium paid to MA plans. The amount of the premium does not vary based on actual use of health services. Diagnosis data from physicians and other health care providers is used to determine whether an individual member suffers from certain diseases that are expected to lead to higher health care costs for that member. CMS uses the hierarchical condition category (HCC) model to account for those conditions that are expected to lead to higher costs. CMS uses the model to create a risk score for each member, which reflects the relative health and projected cost of care for that unique patient. A risk score of 1.0 reflects the CMS average cost of treating a fee-for-service Medicare beneficiary. The lower the risk score, the healthier the patient and the lower the expected health care costs. The higher the risk score, the less healthy the patient, indicating higher than average expected health care costs. Good medical record documentation and coding practices by health care providers are essential to the MA program. To improve medical record documentation and coding practices, physicians and other health care providers should consider the following suggestions: • Use an electronic medical records (EMR) system. • Confirm that all diagnosis codes are included in the claim submission. For professional services, physicians and other health

care providers should have the capacity to submit 12 diagnosis codes. • Ensure procedure and diagnosis codes on the form are current when using a superbill, encounter sheet or checkout form. • Provide full and accurate documentation – ascertain that diagnoses are supported. • Purchase and use updated coding books or software each year. Make sure the practice management system is kept updated. If you are interested in learning more, Humana will be offering two webinars in December entitled: Accurate Documentation and Coding: A Physician’s Perspective. The webinar will be offered on December 11 from 12:00 to 1:00 pm and one on December 13 from 3:00 to 4:00 pm. To learn more, please contact PRCE@humana. com or go to: https://tinyurl.com/ y97uor7j for December 11th webinar or https://tinyurl.com/ya3tn75e for December 13th.

Author: Rae Godsey, DO, MBA, CPC, Associate VP/Corporate Medical Director, Healthcare Quality Reporting Improvement Submitted by: Minoti Parab, MD, FAAFP, Medical Director, Medicare Health Services Organization

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EXPEDITED Continued from p. 26

The index case has been examined, tested and treated in the facility providing the partner therapy. The sexual exposure is a heterosexual partner. The partner of the index case is unlikely to present for examination and treatment. One-dose therapy is being prescribed. The partner has no contraindication to treatment with Azithromycin. Known sex partner within the last 60days (or most recent sex partner if none in the previous 60-days). Names and demographic information are provided to comply with pharmacy regulation requiring the name on a written prescription. NCGS 106-134.� For provider documentation, it is discouraged to include the partner name in the patient chart. The provider is encouraged to keep a separate log that includes the patient name and diagnosis, partner(s) name and demographics, allergies, date, counseling/materials provided, and copy of the prescription. Although EPT is recommended, traditional medical evaluation with STD testing and treatment is still preferred. [9]

4. Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. February 2, 2006; https://www.cdc.gov/std/treatment/eptfinalreport2006.pdf. Accessed June 7, 2018. 5. Centers for Disease Control and Prevention. Guidance on the Use of Expedited Partner Therapy in the Treatment of Gonorrhea. December 9, 2016; https://www.cdc.gov/std/ept/gc-guidance.htm. Accessed June 7, 2018. 6. Legal Status of Expedited Partner Therapy. Centers for Disease Control and Prevention. https:// www.cdc.gov/std/ept/legal/default.htm. Published June 26, 2018. 7. Legal Status of EPT in North Carolina. Centers for Disease Control and Prevention. https://www. cdc.gov/std/ept/legal/northcarolina.htm. Published April 10, 2012. 8. Contact with patients before prescribing. North Carolina Medical Board. https://www.ncmedboard. org/resources-information/professional-resources/ laws-rules-position-statements/position-statements/ contact_with_patients_before_prescribing. 9. Guidance: Expedited Partner Therapy. N C Sexually Transmitted Diseases Public Health Program Manual/Treatment Guidelines and Standing Orders. September 2011. https://epi.publichealth. nc.gov/cd/lhds/manuals/std/treatment/Expedited_ Partner_Therapy.pdf.

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PAID

Pontiac, Illinois Permit No. 592

References 1. Golden MR, Kerani RP, Stenger M, et al. Uptake and Population-Level Impact of Expedited Partner Therapy (EPT) on Chlamydia trachomatis and Neisseria gonorrhoeae: The Washington

3. Expedited Partner Therapy for Adolescents Diagnosed With Chlamydia or Gonorrhea: A Position Paper of the Society for Adolescent Medicine. Journal of Adolescent Health. 2009;45:303-309. doi:10.1016/j.jadohealth.2009.05.010.

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

“The index case has a diagnosis of chlamydia.

2. Golden MR, Whittington WLH, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. The New England Journal of Medicine. 2005;352(7):676-685.

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clinical staff member to administer. The eligibility criteria includes:

State Community-Level Randomized Trial of EPT. PLOS Medicine. 2015;12(1). doi:10.1371/journal. pmed.1001777.