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fall 2005 PUBLISHED BY THE NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS The North Carolina Family Physician is published quarterly by the NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS P.O. Box 10278 Raleigh, NC 27605 919.833.2110 • fax 919.833.1801 www.ncafp.com 2005 NCAFP Board of Directors NCAFP Executive Officers President Karen L. Smith, MD President-Elect J. Carson Rounds, MD Vice President Michelle F. Jones, MD Secretary/Treasurer Christopher S. Snyder, III, MD Board Chair Conrad L. Flick, MD Executive Vice President Sue L. Makey, CAE Past President (w/voting privileges) Mott P. Blair, IV, MD The District Directors District 1 Donald Keith Clarke, MD District 2 Robert Lee Rich, Jr., MD District 3 Kevin B. Yow, MD District 4 William A. Dennis, MD District 5 Thomas H. Woollen, Jr., MD District 6 Thomas J. Zuber, MD District 7 R.W. Watkins, MD, MPH At Large Elizabeth B. Gibbons, MD At Large Richard Lord, MD IMG Physicians Constituency Ofelia N. Melley, MD Minority Physicians Constituency Claudia E. Gonzalez, MD New Physicians Constituency Jessica J. Burkett, MD Resident Director David C. Luoma, MD Resident Director-Elect Jennifer L. Mullendore, MD Student Director Kimberly W. Bennett Student Director-Elect Aye Otubu AAFP Delegates and Alternates AAFP Delegate L. Allen Dobson, MD AAFP Delegate Conrad L. Flick, MD AAFP Alternate George H. Moore, Jr., MD AAFP Alternate Mott P. Blair, IV, MD FP Department Chairs and Alternates Chair (UNC) Warren P. Newton, MD Alternate (Duke) J. Lloyd Michener, MD Alternate (ECU) (Interim) Mark Darrow, MD Alternate (WFU) Michael L. Coates, MD NCAFP Council Chairs Child & Maternal Health Shannon B. Dowler, MD Governmental Affairs Advisory J. Carson Rounds, MD Health Promotion & Disease Prev.

Mott P. Blair, IV, MD Mental Health Robert E. Gwyther, MD Professional Services Karen L. Smith, MD NCAFP Editorial Committee William A. Dennis, MD Chair Shannon B. Dowler, MD Elizabeth B. Gibbons, MD Richard Lord, MD David C. Luoma, MD

CREATED BY: Virginia Robertson, President vrobertson@pcipublishing.com Publishing Concepts, Inc. 14109 Taylor Loop Road Little Rock, AR 72223 FOR ADVERTISING INFORMATION: Adrienne Freeman adrienne@pcipublishing.com 501.221.9986 • 800.561.4686 edition

NCFP

Ta b l e o f C o n t e n t s

Vol 1 • No 4

4

4

7

Physician Extenders : An Invitation from the Family Physician

12 Student News

Membership Investment Letter

12 Membership News

10 Welcome To New Academy Members

12 CME News

13 NCAFP Foundation News 14 Medicare Part D Enrollment Begins this Fall

10 2006 Board Slate Approved 11

Message from the Department of Health and Human Resources

NCAFP Strategic Plan Vision Statement The vision of the North Carolina Academy of Family Physicians is to be the leader in transforming healthcare in NC to achieve optimal health for all people of NC. Mission Statement The mission of the North Carolina Academy of Family Physicians is to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity.

Strategic Objectives 1. Health Promotion & Disease Prevention (Health of the Public): Assume a leadership role in improving the health of North Carolina’s citizens by becoming proactive in health promotion, disease prevention, chronic disease management and collaborating in other public health strategies.

2.Advocacy: Shape healthcare policy through interactions with government, the public, business, and the healthcare industry.

3. Workforce: Ensure a workforce of Family Physicians which is sufficient to meet the needs of patients and communities in NC. 4. Education: Assure high-quality, innovative education for family physicians, residents, and medical students that embodies the art, science, and socioeconomics of family medicine.

5. Technology & Practice Enhancement: Strengthen members’ abilities to manage their practices, maintain satisfying careers, and balance personal and professional responsibilities.

6. Research: Develop and promote new medical knowledge and innovative practice strategies through information technology, primary care research and assessment of the practice environment.

7. Communications: Promote the unique role and value of family medicine, family physicians and the NCAFP to the public, business, government, the healthcare industry and NCAFP members.

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Physician Extenders : An Invitation from the Family Physician Family physicians are quite excited and invigorated with the concept of converting our specialty to one which is responsive to the needs of patients and family doctors across the nation. We embrace the idea of being the first to transform our discipline to one which is functional and allows for high quality care in a variety of settings.

The family physician will have access to resources which permit state-of-the-art performance in the private office setting, residency training program, hospital environment, and any other arena which the family physician designates as their practice. We have long recognized that our daily work is not accomplished in a silo, but often in combination with other professionals who assist in the delivery of care. The management of the individual patient typically requires assistance from ancillary professionals such as diabetic educators, wound care specialists, physical therapists, occupational therapists, and a host of others who have the same goal to provide comprehensive medical treatment.

We recognize that these professionals are often utilized for a short period of time and when the goal is accomplished, the patient is discharged from their services, thus ending the physician communication.

This is not the case with physician extenders who practice in alliance with the physician for the long-term. Physician assistants and nurse practitioners are invited professionals in the family physician team approach to care. Family physicians have long recognized the valuable services which these two disciplines provide in our daily work. Physicians who work in the underserved areas of our state appreciate the valuable work of the physician extenders. The “Future of Family Medicine� clearly recognizes the need for family physicians to maintain the relationship with nurse practitioners as we redevelop our discipline. It is evident that Physician Assistants will also be part of the new plan. As we proceed in structuring our profession it is important for family physicians in the state of North Carolina to ana4

lyze our current relationship and define the role of the Physician Extender in the new practice of family medicine.

Family physicians are often on the frontier, establishing practices in areas where other subspecialties may not be well suited. The comprehensive approach to the care of the entire family makes the discipline well suited for these communities.

As a result, we often establish practices which are small group or solo and consist of large patient populations with numerous high co-morbidities, are remote from established healthcare systems; and possess economics which do not attract wealth. The practice business model may be fortunate to attract other family physician partners after establishing a strong financial base. This can take many years to achieve even in the busiest settings.

Family physicians invite Physician Assistants to come into the practice under the guidance and supervision of the doctor and they assist with providing care to patients after establishing a defined management plan. Nurse Practitioners are found to be quite useful with providing comprehensive education with a compassionate approach that’s well- received by most patients. The discipline somehow lost this approach and began to allow the physician extender to provide care without the close guidance of the physician. It is suspected that patient volume may have been the driving force causing this breakdown in the relationship. The family physician of a typical practice is required to spend more time with documentation including completion of patient-generated forms and reviewing payment claims while miraculously taking care of the patients who present for care. Physicians who are participating in both the inpatient and outpatient setting are called upon to perform the duties for these two arenas respectively. Some family physicians have also witnessed the establishment of Physician Extender-Only practices where the physician is not only removed from the physical location of the practice, but in

some instances, are not even practicing in the state of North Carolina! There are several problems which family physicians are now recognizing due to our absence from taking care of business in the practice of the discipline.

The erosion of the family physician relationship with the physician extender is reflected as less than optimal patient quality of care for many situations. The medical education for a family physician is not equivalent to the education for a physician assistant or nurse practitioner. The comprehensive education and training of the doctor allows medical problems to be addressed with the goal of resolution after evaluation, in-depth review of pathophysiology, and establishing a management plan with defined treatment. There are several instances of confusion noted when discussing the role of a physician and the physician extender. The most striking level of confusion is with public perception. There are medial offices which offer only the services of a physician extender and the public perceives these offices as family physician practices. Despite the North Carolina Medical Board publications encouraging physician extenders to clearly identify their title to patients, the layperson may not to comprehend the difference in care. It is recognized that these offices have a defined scope-of-practice in the communities in which they serve, but it is not equivalent to a physician-based practice. The idea of establishing physician extender offices in underserved areas does not address the problem of PHYSICIAN SHORTAGE. There are examples where hospital systems are assuming a similar position. In the event of hiring for remote practices, the physician extender is offered a salaried position with a minimal differential noted in comparison with a physician salary. Both physicians and physician extenders are often paid for their services based on production or volume with less emphasis on outcome of care. In settings of this nature, supervision is counterproductive since it requires time

North Carolina Academy of Family Physicians

taken away from direct patient care which is volume driven. Physician assistants and nurse practitioners acquire a panel of patients who only see the extender for years. If the patient’s condition changes which warrants physician consultation via direct evaluation - this may or may not occur. The only physician contact some of these patients have is when they appear in the Emergency Room for acute intervention. Ironically, the patient can only be admitted by a physician and then discharged home back into the care of the physician extender. This scenario demonstrates a negative outcome but is becoming quite prevalent as healthcare systems are changing.

Healthcare planners are attempting to solve the needs of the community by utilizing available resources. This approach has added to the deterioration of the delicate relationship between the physician and the physician extender. Unfortunately, the trial attorneys are keenly aware of the difference in care and this too will have a negative impact as the litigious environment continues to force many physicians to modify business plans in order to pay for escalating malpractice premiums.

Family physicians are actively engaged in a plan which will allow a mutually beneficial relationship to be created between the physician and the physician extender while addressing the healthcare needs of the community.

Family physicians recognize the need to establish patient-centered care. The care provided to the patient is based upon the physician-patient relationship. The physician is actually involved in the evaluation and management of the patient’s condition. The physician extender assists the doctor with this process under supervision and with guidance. It is imperative that the family physician understands the education of the nurse practitioner and the physician assistant. This requires the family doctor to review educational curriculum of the extender and to review the list of courses completed by the physician

tronic medical records allows a different extender being supervised. This informatype of supervision to take place in the tion can be obtained from www.aafp.org outpatient setting. and the academic institutions in our state.

The Family physician now has the It is also important to review the requireoption to review all encounters in an effiments as listed by the North Carolina cient manner with the use of electronic Medical Board. Physicians who accept documentation. The medication formulaassignment of a physician extender under ries and agreed upon protocols are estabyour medical license should understand lished in the system. The physician can the responsibilities associated with this modify these protocols as new evidencecommitment. The reality of this commitbased treatment plans are introduced in ment is revealed when inspecting the continuing medical education courses. physician extender license, which will list Many systems allow for the creation of your name and license number. If you Diabetic flowcharts, coumadin managewere not involved with the interview and ment, immunization and growth charts, hiring of the physician extender who is Asthma flowcharts, Congestive Heart failutilizing your license to provide care, it is ure flowcharts, and many more. The advised that you take time to review the physician can review preventive mainterequirements together. This is an excelnance schedules and quickly identify areas lent opportunity to review the nurse pracof intervention. Communication regardtitioner collaborative arrangement and foring the care of the patient can be done via mulary. The scope-of-practice should be the electronic health record and physician reviewed and a working agreement estabintervention documented at the same time. lished regarding the supervision of care.

This is quite intensive supervision, which The physician extender is a valuable requires less disruption on the office resource for our discipline but physicians workflow. Many physicians who supercan no longer accept exploitation and vise physician extenders recognize the abuse of their services. It is also important for the physician extender to recognize the THE FUTURE OF FAMILY MEDICINE importance of the physician in maintainCLEARLY RECOGNIZES THE NEED FOR ing a supervisory relaFAMILY PHYSICIANS TO MAINTAIN tionship beyond what’s written on paper.

THE RELATIONSHIP WITH NURSE Contracts which are PRACTITIONERS AS WE REDEVELOP based on productivity OUR DISCIPLINE. quotas need to be reexamined to insure the time consuming process of reviewing main goal is quality-of-care. It is imporpages of handwritten notes and, in many tant for the supervising physician to be at instances, not having the time to review the negotiation table when these items are appropriate drug doses or flow charts. discussed. The physician extender and Electronic documentation eliminates a physician can avoid being placed in comgreat deal of the time involved since chart peting situations if the supervisory audits are done with greater efficiency. arrangement is clearly outlined from the The chart is electronically submitted to beginning. Physicians who do not practice the physician mailbox for review and final in the state of North Carolina yet supersignoff. Every portion of the chart is vise physician extender offices in the state accessible via the physician password and definitely need to review this relationship. an automatic date and the computer notes It is recognized that the advent of elec-

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5

the time of review. The physician is able to send a message if a correction is warranted or conduct further patient evaluation if desired. In addition, the physician can make the correction at the time of review if indicated. The physician is aware of the patient’s medical condition and provides guidance throughout the whole process. It is imperative that both the physician and physician extender agree upon the acceptable level of documentation. Incomplete documentation or

6

delayed entry can cause disruption in the supervision. Paper-based documentation including prescriptions should be eliminated. The physician must be able to access all forms of documentation via the electronic record in order to prevent increased time for review. This level of supervision now allows the physician and physician extender time to actually participate in quality improvement activities for the practice.

With this type of process in place, the

family physician is able to regain control over the practice of the medicine. Patients are cared for by the physician extender under the direct supervision of the doctor.

The quality of care is improved since many common medical errors are eliminated. The existence of comprehensive legible documentation may even identify problems overlooked or not identified in the high- paced, volume-driven practice.

The physician can now review continuing medical education needs based upon the medical issues of the patients. The opportunity for both the physician and physician extender to pursue these learning opportunities is possible since time is now more readily available that doesn’t compromise patient flow in the office. The physician welcomes chart audits and reviews since the performance of the practice is under constant review. Physicians can now communicate effectively with insurers regarding payment for services provided.

The practice is also able to capture more charges and decrease losses. This transmits to better payment for physician extender salaries and hopefully eliminates the need for volume-driven contract arrangements. It is no longer necessary to impose these demands on the physician and the physician extender, something that creates a less stressful work environment.

The ultimate desire is to produce long lasting relationships with decreased turnover.

The Future of Family Medicine has implications far beyond the individual family physician. The transformations occurring in the discipline are expected to benefit the people we care for, as well as the communities where our practices are located. Physician assistants and nurse practitioners have made a similar commitment to assist us in providing healthcare to these areas. The Family physician must take the lead and insure that these valuable professionals receive the support necessary for them to be effective in their discipline. The relationship between the Family physician and the physician extender is one which can be revitalized to provide optimal quality of the care for the benefit of each patient.

North Carolina Academy of Family Physicians

Dr. Karen L. Smith, 2004-05 NCAFP President October, 2005 Dear Academy Members: As we near the end of another year, it's a perfect time to reflect upon the value of membership in the North Carolina Academy of Family Physicians. Whether it's CME, advocacy or day-to-day support, the Academy strives to meet the needs of its members. As the Academy struggles to keep up with the changes in healthcare and how that relates to you and your practices, it also struggles with difficult decisions. This coming year we will have a $25 a year increase in our dues in an effort to maintain the multitude of services we are able to provide to you.

This may not seem reasonable to some, but the amount of dues (or we prefer membership investment) each physician pays on an annual basis pales in comparison to the return you receive as a member of the Academy.

Let's look at just one example from the past year.

During the 2005 legislative session, members of the General Assembly suggested cutting Medicaid reimbursement from 95 to 90 percent of Medicare. However, due to the diligent support of the Academy's members and our Advocacy team, the reimbursement rate remained at 95 percent.

But what does this mean to you? In dollars and cents, if Medicaid patients make up approximately 20 percent of your patient population, then a 5 percent reduction in Medicaid reimbursement would have cost you about $3,000 in annual income. This represents a return more than 100 times greater than the small $25 increase in state dues you will be asked to pay in 2006.

Medicaid reimbursement was just one of many issues addressed by the Academy during this year's legislative session, and Advocacy is just one of numerous examples of the Academy at work. Some of the other ways the Academy is working to provide you a return on your investment include: • Numerous opportunities for Continuing Medical Education including the Annual Meeting in Asheville in December, our Spring Family Medicine Weekend (to be held in Charleston in 2006), and the Midsummer Family Medicine Digest during the week of the Fourth of July at Myrtle Beach, as well as new Front Line and online CME opportunities.

• Day-to-day support through the "Ask Us First" helpdesk to answer your questions about practice management and other issues.

• Keeping you up-to-date on issues impacting your profession through this magazine and the periodic e-mail publication NCAFPnotes.

• Promoting the profession and the health of North Carolinians through special initiatives such as the dental varnish program, Into the Mouths of Babes, or the Health and Wellness Trust Fund's Fit Together web project Adolescent Obesity Initiative.

• Positioning the Academy to undertake strong healthcare advocacy positions through possible grant opportunities in the areas of Health Disparities and Mental Health Reform.

The bottom line: a dues investment in the Academy is utilized over and over again to provide a return much greater than any financial contribution we actually make as members. Many of the issues and projects that the Academy is involved in on your behalf and on behalf of your practices and your patients may occur ‘behind the scenes,’ but we would like to assure you that all of the efforts of the Academy and its staff go toward improving your lives and the lives of your patients. This year’s small increase is only the second in the past 12 years, and we’re now taking steps to provide even greater value to your membership. At our recent Leadership Retreat, your Executive Committee and Board unanimously approved undertaking a major member needs analysis. We hope you will take time to participate in this important effort as your leadership team strives to position the Academy for the rapidly changing environment in which we practice medicine.

We're proud to represent you as leaders of the North Carolina Academy of Family Physicians. And we know you will be proud to continue to invest your membership dues in the Academy's work each year.

With best regards, Karen Smith, M.D. President

Conrad Flick, M.D. Board Chair

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ADVERTISEMENT

PERTUSSIS transmission

How do infants get

PERTUSSIS? They get it from their family.

Nearly 75% of the time, a family member is the source of pertussis disease in infants1 Nearly

50% of Pertussis Sources are Parents

1

That’s right — their

MOMS and dads, brothers and sisters, even grandma and grandpa!

References: 1. Bisgard KM, Pascual FB, Ehresmann KR, et al. Infant pertussis: who was the source? Pediatr Infect Dis J. 2004;23:985-989. 2. National Center for Health Statistics. Health, United States, 2004 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: 2004. 3. Centers for Disease Control and Prevention.

Pertussis Surveillance Report, Feb. 23, 2005. 4. Centers for Disease Control and Prevention. Pertussis Surveillance Report, Aug. 6, 2004. 5. Vitek CR, Pascual FB, Baughman AL, Murphy TV. Increase in deaths from pertussis among young infants in the United States in the 1990s. Pediatr Infect Dis J. 2003;22:628-634. 6. Centers for Disease Control and Prevention. Summary of notifiable diseases—United States, 2000. MMWR. 2000;49(53):12. 7. Centers for Disease Control and Prevention. Summary of notifiable diseases—United States, 2001. MMWR. 2001;50(53):15. 8. Centers for Disease Control and Prevention. Summary of notifiable diseases—United States, 2002. MMWR. 2002;51(53):28. 9. Scott PT, Clark JB, Miser WF. Pertussis: an update on primary prevention and outbreak control. Am Fam Physician. 1997;56:1121-1128. 10. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book. 8th Ed. Atlanta, Ga: Department of Health and Human Services, Public Health Foundation; 2004:75-88. 11. De Serres G, Shadmani R, Duval B, et al. Morbidity of pertussis in adolescents and adults. J Infect Dis. 2000;182:174-179.

According to a recent study of pertussis in 264 infants, a family member was identified as the source of the disease in three quarters of the cases.

In fact, the infant’s mother was positively identified as the source in 32% of the cases. In addition to Mom, other confirmed sources included Dad 15% of the time, Grandma/Grandpa 8% of the time, and a sibling 20% of the time. This study provides clear documentation of the threat of pertussis within the family setting and serves as a window to the growing problem of pertussis in the general population.1

begins at home The growing threat of pertussis — an often silent disease reservoir

20,000

18,957

18,957

63%

17,500

11,647

15,000 12,500 9,771

10,000

11,647

7,867

7,500

7,580

5,000

2003

2004

2,500 0 00 20

01 20

02 20

03 20

04 20

Especially troubling are two facts: first, there has been a 36% increase in reported cases among children ages 4 years or less3,4; second, over the last decade, 80% of deaths attributed to pertussis occurred in infants under 6 months of age.5 Increase in Reported Cases of Pertussis in Children <4 Years of Age3,4,6-8 5,000

4,551

36%

4,551

3,355

3,700 2,878

3,355 2,857

2,500

2003

2004

Deaths

5

Long thought to be nearly eradicated, pertussis case reports are at a 40-year high.2 Today pertussis is the only communicable disease that is on the rise in all age groups for which a routine immunization is available. In 2004 there were 18,957 cases reported to the CDC, a 63% increase over 2003 and a startling 1000% increase from 20 years ago when incidence reached its nadir.2,3 The Growing Pertussis Reservoir2,3

contagious during the Mortality is on the Rise in the first few weeks of Most Vulnerable Population 80 illness before it is rec70 9 ognizable. In both 68 60 adolescents and adults 79% 50 1980 - 1989 the disease is often 1990 - 1999 40 mild in nature, and not 38 30 associated with the 20 trademark “whooping 45% 16 10 11 cough.”9,10 However, 0 studies have reported 0-1 Mos 2-3 Mos Infants' Age significant morbidity including pneumonia, rib fractures, urinary incontinence, weight loss, otitis media, and sinusitis.11 People with pertussis are also at risk of hospitalization and other complications such as seizures and encephalopathy. Beyond the morbidity are the social, financial, and psychological costs of pertussis disease. One recent study reported that 70% of affected adolescents lost 5 to 10 days of school while 49% of afflicted adults were out of work for 5 to 10 days.11 In addition, 49% of adults reported that their sleep was disturbed for more than 21 consecutive nights with 9% reporting disturbed sleep for an astounding 60+ nights.11 It’s no wonder the ancient Chinese called pertussis “the cough of 100 days.”

Soon pertussis prevention will begin in the home too Building on the heritage of the proven pediatric acellular DTaP vaccines, acellular Tdap vaccines for adolescents and adults will soon be available.

This intervention will allow health-care providers to protect a broad spectrum of people from the morbidity of primary disease, as well as limit the morbidity and mortality in vulnerable infants by curtailing disease transmission.

0 00 20

01 20

02 20

03 20

04 20

Among the many explanations on the explosion of pertussis in the United States are better reporting, better diagnosis, and waning immunity. What they all have in common is the acknowledgment that there exists a reservoir of disease among adolescents and adults, and more importantly, from this reservoir pertussis transmission occurs. Pertussis is most

You can find out more about pertussis by visiting any one of the following Web sites: www.pertussis.com, www.cdc.gov, www.nfid.org, www.napnap.org, www.aap.org

Brought to you as a public health service by Sanofi Pasteur Inc. MKT10234

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We l c o m e To N e w A c a d e m y M e m b e r s The Academy wishes to extend a warm welcome to all new members. If you have any questions regarding membership, please contact Marlene Rosol at (919) 833-2110, (800) 872-94882 [NC only], or mrosol@ncafp.com Active Members Donald G. Adams, MD (Lexington) Martha C. Carlough, MD (Chapel Hill) Robert Glynn Day, MD (Madison) Natalie Fowler, MD (Chapel Hill) Eva Ruth Guyer, MD (Jacksonville) John Eric Harris, MD (Mocksville) Ronald Charles Huffman, MD (Mooresville) Joseph J. Hummel, MD (Wake Forest) Michael Irvin Hutchinson, MD (Carolina Beach) Jeffrey D. Martin, MD (Raleigh) Shawn Ellington McCann, MD (Wilmington)

Michael G. Meyer, MD (Asheville) Seema C. Modi, MD (Greenville) Michael J. Nienhuis, MD (Greensboro) Lillian McKay Teigland, MD (Charlotte) Nosheen Arif Tirmizi-Qureshi, MD (Charlotte) Edwina Christine Wilson, MD (Rocky Mount) Inactive Members Mishi Kavon Jackson, MD (High Point) Resident Members Chuck LeRoy Ball, MD (Fayetteville) Megan Mowery Danekas, MD (Durham) Andrea Price Davis, DO (Fayetteville)

2006 BOARD SLATE APPROVED The Board of Directors recently approved the 2006 Slate. It was mailed to the Academy membership on August 22, 2005 and accepted by a majority vote.

All elected nominees will be installed during the Winter Family Physician Weekend and Annual Meeting to be held on December 1 – 4, 2005 in Asheville at The Grove Park Inn. Service on the NCAFP Board will begin immediately following installation.

2006 Board Slate *President: J. Carson Rounds, MD *Board Chair: Karen L. Smith, MD (*These positions are by automatic ascension – no election necessary) President-Elect: Michelle F. Jones, MD Vice President: Christopher Snyder, III, MD Sec./Treasurer: Elizabeth B. Gibbons, MD District 1: Donald Keith Clarke MD (2nd term)

Julie Marie Gregory, MD (Durham) Vicki Hardy, DO (Fayetteville) Elin Curran Kondrad, MD (Chapel Hill) Jomoke Ladapo, MD (Fayetteville) Yvonne E. Lai, MD (Raleigh) Brigid E. Mack, MD (Durham) Angela Yerden McLeod, DO (Greenville) Quoc Tai Phan, MD (Fayetteville) Kenyon M. Railey, MD (Chapel Hill) Karen Angela Saroki, MD (Durham) Aparna Bhaskar Vaikunth, MD (Fayetteville) Student Members Ms. Quintina Louise Benson (Chapel Hill)

District 3: Victoria S. Kaprielian, MD District 5: Sara O. Beyer, MD District 7: Shannon B. Dowler, MD At-Large Director: R.W.Watkins, MD AAFP Delegate: L.Allen Dobson, MD AAFP Alt. Delegate: Mott P. Blair, IV, MD *President automatically moves to this position – no elections are necessary. Resident and Student Board Members and FP Department Chair will be elected by their respective peers.

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North Carolina Academy of Family Physicians

North Carolina Department of Health and Human Services Division of Medical Assistance 421 Fayetteville St. – 2501 Mail Service Center - Raleigh, N.C. 27699-2501 One Hannover Bldg.

Michael F. Easley, Governor Carmen Hooker Odom, Secretary

Courier No. 2501

L. Allen Dobson, Jr., M.D., Assistant Secretary for Health Policy and Medical Assistance

October 2005 Dear North Carolina Academy of Family Physicians Member: Here’s the good news: Thanks to the support of many medical providers across the state, the Prescription Advantage List or “PAL” initiative is headed in the right direction.

Unfortunately, here’s the not-so-good news: revenue budget shortfalls, a “jobless” economic recovery, and Medicaid enrollment rates rising at their fastest pace in 10 years, are stressing the Medicaid system.

Leaders from all levels of government and from both sides of the aisle are trying to ensure stability in a program that provides a healthcare safety net for North Carolina citizens enrolled in Medicaid. Through a collective initiative directed by physicians representing a broad cross-section of the state’s medical leadership, Community Care of North Carolina (Access II and III) introduced in late 2002 the voluntary prescription guideline program PAL. In short, PAL is a reference guide to the relative costs of certain prescription medications that helps physicians, physician assistants and family nurse practitioners care for their Medicaid patients in a manner that balances clinical outcomes with financial realities.

The first release of PAL was a success – generating awareness of critical cost savings for the Medicaid pharmacy program both inside and outside the Medicaid community. PAL was the driving force in the overall pharmacy effort that helped the state save more than $29 million in Medicaid dollars this past fiscal year. While we should all take great pride in achieving this goal, our enthusiasm must be tempered with an understanding that this year’s goal is $45 million in savings from the pharmacy program alone. Our milestone is now further away – and we need to get there faster.

With that in mind, the new, expanded version of PAL includes guidance on the relative costs of more than 150 drugs in a wider array of therapeutic categories than that featured in the first release. This broader list is designed to help the Medicaid program reach its savings goals and ensure stability in an initiative that provides a healthcare safety net for nearly one in seven North Carolinians. And while $45 million in savings appears a daunting charge, consider this: If only half of the prescriptions for proton pump inhibitors were written for Prilosec OTC, North Carolina’s Medicaid program could yield an estimated $30 million in annual savings.

Frankly, the importance of these efforts simply can’t be overstated; without them, the Medicaid program itself will be put at considerable peril and its stakeholders – especially your practice and the patients you treat – will most certainly bear the brunt of the fallout.

If you are currently using the Prescription Advantage List in your practice – THANK YOU! If you are not, please take a moment to familiarize yourself with this newest edition of PAL. I encourage you adopt the PAL and use it as a reference whenever possible and clinically appropriate. Our collective support of the PAL initiative will help ensure that the state’s Medicaid program continues to provide vital healthcare to our most vulnerable neighbors.

If you have any questions or comments about the Prescription Advantage List or to request additional copies of the list please call 919-7151453. An Adobe PDF file version of the PAL can be downloaded at http://www.dhhs.state.nc.us/dma/pal/pal.pdf.

With best regards,

L. Allen Dobson, Jr. MD Assistant Secretary for Health Policy and Medical Assistance P. O . B o x 10 278 • R a l e i g h , N o r t h C a r o l i n a 276 0 5 – 919 . 8 33 . 2110

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student news

CME MEETINGS NEWS

Seeking Submissions for Annual Research Contest

NCAFP Launches Free Online CME Program.

The North Carolina Academy of Family Physicians is currently seeking submissions for our Research Presentations Poster Contest that will be held December 1 – 4, 2005 during the Winter Family Physicians Weekend. Presentations may address any topic relevant to family medicine. Works in-progress may be submitted.

Submissions must be of original work not yet published or presented at either regional or national meetings. Projects previously presented at medical schools or student “Research Days” are acceptable as well. Concurrent submissions to other conferences such as NAPCRG and STFM, are considered legitimate and are, in fact, encouraged. Submissions can originate from current NCAFP practicing physicians, fellows, residents or students. For complete details and to download an application, visit our website at www.ncafp.com/wfpw or call Academy offices at 919-8332110/800-872-9482.

The Academy's CME/Meetings Department recently launched a free online CME program titled 'Promoting Adolescent Health Through Immunization.' The program offers 1 .0 prescribed credit and is being promoted to primary care physicians across the country. Dr. J. Carson Rounds of Wake Forest, NC leads a onehour presentation on adolescent health that focuses on recent developments in vaccination. This includes overviews of current ACIP recommendations, licensed Tdap vaccines, meningococcal disease and pertussis. The course was made possible through an unrestricted educational grant from Sanofi Pasteur. To learn more about the program, point your browser to www.ncafp.com/pahti.

NC Students and Residents Attend AAFP National Conference

Hurricane Ophelia forced the third Electronic Health Record seminar to be rescheduled for November 19, 2005 in Wilmington.

If you are interested in signing up for this rescheduled date, complete seminar information and registration is available online at http://www.ncafp.com/ehr. The NCAFP, the NC Pediatric Society and Dr. Karen L. Smith, NCAFP President & Program Chair, are committed to educating NC’s physician community about issues surrounding EHR acquisition and use. Please don't miss out on your last opportunity this year to lean more about investigating, implementing and utilizing EHR in clinical practice.

The 2005 National Conference of Family Medicine Residents and Medical Students was held July 27 - 30, in Kansas City, Missouri.

Over 40 students and residents from NC attended the conference.

The theme of the conference was “Your Voice Counts – Who Do You Speak For?” The NC residency programs exhibited as a state block in the exhibit hall. Resident Director-Elect Dr. Jennifer Mullendore and Student Director Kimberly Bennett served as the delegates for North Carolina.

MEMBERSHIP News REELECTION REMINDER! If you were last reelected in 2002, you have until the end of 2005 to report 150 hours of CME in order to maintain your Academy membership. Requirements include at least 75 AAFP prescribed credits, a minimum of 25 group learning activities, no more than 25 from enrichment activities, plus caps on other activities. Hours reported should be obtained between January 1, 2003 through December 31, 2005.

For further details, review the AAFP CME Requirements for Members reprint 101. You can also visit the NCAFP website at www.ncafp.com, the AAFP website at www.aafp.org, or call Marlene Rosol, NCAFP Membership Coordinator at 919-8332110 or 800-872-9482 [NC only].

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Final EHR Roadshow Rescheduled for November 19, 2005.

Celebration in the Mountains The 2005 Winter Family Physicians Weekend Can you believe it's that time again? Registration is now available for the 2005 NCAFP Annual Meeting - December 1- 4, 2005 in Asheville. Program Chair Robert Gwyther, MBA, has orchestrated a wonderful program. Additional CME satellite meetings are being developed for Thursday and Friday nights.

Members are encouraged to check the Academy website for an up-to-date program at http://www.ncafp.com/wfpw

2006 Spring Family Physicians Weekend - Charleston, SC here we come!

For the first time in many years, the NCAFP Spring Meeting travels to a new city- magnificent Charleston, SC! Dr. Gary Pleasants has begun to lay the groundwork for an exceptional program, while the Academy's CME committee is planning evidence-based lectures on a variety of topics. More details about the meeting will be published next issue. In the interim, the latest meeting information will be available at the NCAFP website at http://www.ncafp.com/sfpw

North Carolina Academy of Family Physicians

N C A F P Fo u n d a t i o n N e w s COME CELEBRATE WITH THE NCAFP FOUNDATION!!

The NCAFP Foundation invites you to come celebrate the 10th anniversary of our Annual Silent Auction. This fun and popular fundraiser will be held during the Winter Family Physicians, December 1 – 4, 2005 at The Grove Park Inn Resort & Spa in the beautiful mountains of Asheville. As in the past few years, the auction will be held in the Exhibit Hall over a period of a few days. This is your special invitation to be part of our 10-year anniversary. Please consider donating an item(s) to the auction. What are we looking for? Pieces of artwork (paintings, prints, pottery), sports and college memorabilia, weekend getaways, children’s toys, Christmas items and collectibles…and more! Don’t be shy – get in on the anniversary fun!

And remember – all donated auction items are tax deductible. Look for more publicity on this year’s Silent Auction in the coming months.

If you’re interested in how you can be a participant, contact Marlene Rosol, Development Coordinator, at (919) 833-2110, (800) 872-9482 [NC only], or mrosol@ncafp.com. Thank you!

FOUNDATION SCHOLARSHIP PROGRAM The NCAFP Foundation granted a student scholarship this year to Emily Thompson, a 2nd year medical student at UNC School of Medicine. Congratulations, Emily! All NC medical students are eligible to apply for one of four scholarships yearly. Applications are available through the four FMIG programs or you can download them on the NCAFP website (www.ncafp.com). The 2006 student scholarship application will be available on our website within the next few months. For more information on student scholarships, or how you can make a donation to the Scholarship Program, please contact Christy Ayscue, Programs Coordinator, at (800) 872-9482 [NC only], (919) 833-2110, or cayscue@ncafp.com.

STUDENT ACTIVITIES ENDOWMENT FUND The Student Activities Endowment Fund (SAE) was created in 1997 through member contributions and a gift from the North Carolina Academy of Family Physicians to support student activities at the four North Carolina medical schools. Using only the interest earned on the endowment’s funds, our goal is to grow the endowment to the point where the annual interest is large enough to support all of our student activities. Your gift to this fund will help provide our students with the skills and knowledge they need to pursue Family Medicine as their chosen specialty. You can make a contribution online by visiting www.ncafp.com, or you can mail it to NCAFP Foundation, P.O. Box 10278, Raleigh, NC 27605. Thank you!!

MAKE A SPECIAL GIFT You can honor or memorialize a colleague, friend or family member with a gift to the NCAFP Foundation. By making a special designation, the Foundation will send a card to the family of the deceased, individual or organization being honored. The card will show your name as the donor, but not the amount of the contribution. To make your special, tax-deductible gift, contact Marlene Rosol, Development Coordinator, NCAFP Foundation, (919) 833-2110, (800) 872-9482 [NC only], or mrosol@ncafp.com. Thank you!

YOUR CONTRIBUTION CAN CHANGE A LIFE …

By making a contribution to the NCAFP Foundation, you can help the Foundation continue its mission of providing quality healthcare to the people of North Carolina. Your contribution can change the life of a child… your contribution can encourage a medical student to choose the specialty of family medicine. Help us continue to improve the lives of our citizens. For more information on how you can make a donation to the NCAFP Foundation, contact Marlene Rosol, Development Coordinator, at (919) 833-2110, (800) 872-9482 [NC only], or mrosol@ncafp.com. Thank you for your concern and your support!

HELP THE FUTURE OF FAMILY MEDICINE – JOIN THE NCAFP LEGACY LEAGUE! The North Carolina Academy of Family Physicians Legacy League is established to recognize those who make provisions through their estate for the North Carolina Academy of Family Physicians Foundation, Inc. By making such a planned gift, members of the Legacy League help ensure that the Foundation will have the financial resources to provide vital programs and services to future generations. The NCAFP Foundation relies primarily on annual financial support to implement its programs. We also encourage consideration of gifts that can endow one of our existing programs or endow a new program. The financial needs of the Foundation increase as the need for more programs arise, and the Foundation must keep pace by continually increasing its annual program funds.

A planned gift can help the Foundation make a significant difference for the future of Family Medicine. Planned giving enables donors to create a living memorial that will continue their support, even after their lifetime.

For information on how you can become a member of the Legacy League, please contact Marlene Rosol, Development Coordinator, at (919) 833-2110, (800) 872-9482 [NC only], or mrosol@ncafp.com.

THE FOUNDATION VALUES ITS CORPORATE MEMBERS! The NCAFP Foundation’s Corporate Members are important to us!

Their participation and support are crucial to what we do, and we are proud to include them as part of our Foundation family. Thank you to our 2005 Corporate Members – we couldn’t do it without you!!

Thank you to our 2005 Corporate Members!

We couldn’t do it without you!

Grand Patrons: First Citizens Bank, Raleigh, NC* NC Academy of Family Physicians, Raleigh, NC Supporters: ECR Pharmaceuticals, Richmond, VA** MAG Mutual Insurance Company, Atlanta, GA** MedCost, LLC, Winston-Salem, NC* Moses Cone Health System, Greensboro, NC* Misys Healthcare Systems, Raleigh, NC* Rudy L. & Joyce B. Snow, Pharmaceutical & Sales Marketing Consultants, Stanfield, NC* *Corporate Members - Unrestricted

**Corporate Members - Restricted

VISIT THE FOUNDATION ON THE WEB! Pay a visit to our web site at www.ncafp.com and discover more about the NCAFP Foundation. You’ll be able to read all about our programs and projects, and how you can get involved!

P. O . B o x 10 278 • R a l e i g h , N o r t h C a r o l i n a 276 0 5 – 919 . 8 33 . 2110

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Medicare Part D Enrollment Begins This Fall • • • By Dr. Holly Biola Soon Medicare will be rolling out the details of its longanticipated prescription drug benefit program, also known as Medicare Part D. All Medicare beneficiaries are eligible to enroll, and many will find the Part D plans to be financially helpful, especially people with high annual drug costs (>$850) and also those with low incomes. Be aware that people with both Medicare and Medicaid will be automatically enrolled in a Part D plan and will begin getting most of their drugs from their new formulary in January 2006.

Patients will be coming to you and your staff with questions.

You are not expected to understand the details of Part D or discuss this during office visits, but you should know who your patients can call for help or questions.

Contacts for patient with questions about the new Medicare Prescription Drug Plan North Carolina Senior Health Insurance Information Program (NC SHIIP) http://www.ncdoi.com/Consumer/Shiip/Shiip.asp 1-800-443-9354 Local Outreach Coordinator (LOC) In patient's county of residence See www.ncmdpartd.org for list Centers for Medicare and Medicaid Services (CMS) http://www.medicare.gov/ 1-800-MEDICARE TTY 1-877-486-2048 People with low incomes should also contact Social Security Administration (SSA) http://www.ssa.gov/prescriptionhelp/ 1-800-772-1213 TTY 1-800-325-0778 (Single people w/annual income <$14,355/year, Couples w/annual income <$19,245 who meet an asset test will receive assistance on a sliding scale.)

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Timeline – Patients who need financial assistance should contact the Social Security Administration as soon as possible to apply for the federal subsidy. Plan details will be released October 13, 2005, and Medicare beneficiaries can select and enroll in a plan starting November 15, 2005. Drug coverage will begin January 1, 2006 for anyone who enrolls by December 31, 2005. To select and enroll in a plan, patients may use the Medicare Prescription Drug Plan (PDP) finder tool online at www.medicare.gov or call 1-800-MEDICARE to have a customer service representative help them through the tool over the phone. Medicare beneficiaries who already have some form of drug coverage will be receiving a notice this fall informing them whether their coverage is “creditable” (deemed by an actuary to be as good or better than what Medicare PDP plans offer). If their coverage is creditable and affordable, they should keep it. People who do not have "creditable" prescription drug coverage who sign up after May 15, 2006 will pay a 1% higher premium for every month they were eligible and did not sign up for a PDP. Coverage – Centers for Medicare and Medicaid Services (CMS) has contracted with many private companies and groups of companies to offer PDPs and managed care plans (many "Medicare Advantage" plans will soon include a PDP).

Each of these organizations was required to meet standards defined by CMS, but is allowed flexibility in terms of the drugs they offer, the pharmacies with which they partner and the co-pays they charge. Some Medicare Advantage plans will also limit a patient's choice of hospital or provider.

(Patients should be aware of this before signing up.) Monthly premiums will range from about $20-40, and most deductibles will be around $250. Insurers are not required to have a “doughnut hole” in coverage, but all plans are required start covering at the “catastrophic coverage level” (95% coverage) once the patient has reached $3,600 out of pocket spending for qualifying drugs that year.

More Info Available from the author at www.ncmdpartd.org, from CMS atwww.cms.hhs.gov/medlearn/drugcoverage.asp , and from NC SHIIP at the link above.

North Carolina Academy of Family Physicians

Teaching the nurses of tomorrow is…

Nursing education…

If you want to know more about making a difference through a career in nursing education, visit us online at: www.nursesource.org N u r s i n g .

I t ’ s

R e a l .

I t ’ s

L i f e .

pass it on.

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

3-A-DAY™ OF DAIRY MAY HELP YOU LOSE WEIGHT! * That’s healthy advice for many of your African-American patients. † • A new report by the National Medical Association recommends African Americans consume 3-4 servings of low-fat dairy foods daily to reduce the risk of chronic diseases, such as obesity and hypertension.1 1 • Nearly half of all African Americans consume less than one dairy serving daily which may lead to inadequate intake of important nutrients.

• The newly released Dietary Guidelines for Americans recommend people consume 3 servings of fat-free or low-fat milk or milk products every day as part of a healthy diet, and lactose-free milk or yogurt for individuals who are lactose intolerant.2 People who are sensitive to lactose can still enjoy dairy foods’ great taste and health benefits.

Here are a few tips to consider.

D

rink lactose-free milk, such as LACTAID® Milk, which offers all the nutrients of regular milk, but is easier to digest and tastes great.

Aged cheeses like Cheddar and Swiss are naturally low in lactose.

Introduce milk and other dairy foods into the diet slowly. Start with small portions with meals or snacks and gradually work up to 3 servings a day.

R

emember LACTAID® Fast Act Dietary Supplements with the first bite or sip of dairy to help break down lactose so patients can enjoy milk and other dairy foods.

Yogurt is good. Cultured dairy foods like yogurt

contain friendly bacteria that help digest lactose.

Visit www.nationaldairycouncil.org for more information about dairy’s role in weight loss and to download a free African-American health education kit, including patient education materials.

For information on LACTAID® Products and lactose-free recipes visit www.lactaid.com or call 1-800-LACTAID. * Research indicates that including 3 servings of dairy each day in a reduced-calorie diet may help support healthy weight loss. † The National Medical Association is the leading national organization representing African-American physicians and health professionals.

References: 1. Wooten, W.J. and Price, W. Consensus Report of the National Medical Association: The Role of Dairy and Dairy Nutrients in the Diet of African Americans. Journal of the National Medical Association. 2004;96(12):1S-31S. 2. US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC: US Government Printing Office;2005.

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