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Winter 2009

See Details on Page 9


Dec. 3-6, 2009

The North Carolina Family Physician

Vol. 5 - No. 3

The Grove Park Inn & Spa Asheville, North Carolina

Third Quarter, 2009

Dr. Conrad Flick Campaigns for AAFP Board of Directors

Also in This Edition The Academy is Working Aggressively to Promote the Value of PCMH ...................................4 The Happy, Well Compensated Patient-Centered Physician.................................................5 The Best of Times‌The Worst of Times........................................................................6 Phase II of Health Disparities Initiative Awarded Grant Funding.......................................... 10 Integrated Care Works for Patients, Providers in Clinton............................................... 11

30+ Credits Available

Winter 2009



D aT e


2009 NCAFP Annual Meeting Winter Family Physicians Weekend Grove Park Inn Resort & Spa • December 3 – 6, 2009


Dec. 3-6, 2009

Brian R. Forrest, MD - Program Chair

The Grove Park Inn & Spa Asheville, North Carolina

The upcoming AAFP Board elections present a tremendous opportunity for the NCAFP. Your proven support of our association gives me confidence that you’ll consider this important call to action. As you are aware, Dr. Thomas Koinis, our current NCAFP Foundation President, is a candidate for the AAFP Board of Directors. His candidacy offers the NCAFP an excellent opportunity to influence AAFP policy at the national level, and to help direct our specialty at a very critical time. Should he be elected, Dr. Koinis will be able to communicate our region’s views on topics like tort reform, medical malpractice insurance, the Future of Family Medicine Project, and our growing reimbursement crisis. If elected, he arolina cademy will be a powerful resource for our association as Drs. Jones and Henley have been.

The North C of


Although the benefits are clear, election campaigns are bothof time-consuming and costly. I am personally asking for your financial Family Physicians proudly endorses the candidacy support. Your contribution will help our chapter offset campaign expenses – estimated this year at over $15,000 – and allow us to wage a very competitive effort leading up to balloting on October 2nd. It will insure that Dr. Koinis’s message will be heard by all AAFP delegates. His election will help us secure a strong voice on the AAFP Board through 2006. Your contribution and involvement is vital.

Conrad L. Flick, MD

To make your contribution, simply fax or mail the completed form below to Academy headquarters. The fax number is (919) 833-1801 or use the enclosed business reply envelope. I always appreciate your continued commitment and look forward to success in October. Thanks!

2009 Board of Directors of American Academy of Family Physicians

for the the


Dr. Mott P. Blair, IV President

Yes, I want to help Conrad Get Elected!

North Carolina wants to continue to impact family medicine at the national level by helping to lead the AAFP. By contributing to Dr. Flick’s campaign, you help ensure that the NCAFP can conduct one of the best campaigns in the nation. To contribute, simply complete the form at right and return with your contribution to Academy offices.


THE NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS, INC Raleigh, North Carolina 27605 919.833.2110 • fax 919.833.1801 http://www.ncafp.com

2008-2009 NCAFP Board of Directors NCAFP Executive Officers President Robert Lee Rich, Jr., MD President-Elect R.W. ‘Chip’ Watkins, MD, MPH, FAAFP Vice President Richard W. Lord, Jr., MD Secretary/Treasurer Shannon B. Dowler, MD Board Chair Christopher Snyder, III, MD Executive Vice President Gregory K. Griggs, MPA, CAE Past President (w/voting privileges) Michelle F. Jones, MD The District Directors District 1 R. Kevin Talton, MD District 2 Connie Brooks-Fernandez, MD District 3 Victoria S. Kaprielian, MD District 4 Tim J. McGrath, MD District 5 Sara O. Beyer, MD District 6 James W. McNabb, MD District 7 Thomas R. White, MD At Large Brian R. Forrest, MD At Large William A. Dennis, MD Minority Physicians Constituency Enrico G. Jones, MD New Physicians Constituency Jana C. Watts, MD FM Department Constituency Warren P. Newton, MD, MPH FM Residency Director Janalynn F. Beste, MD Resident Director Alicia C. Walters, MD (WFUBMC) Resident Director-Elect Meshia Todd, MD (Duke) Student Director Lillianne M. Lewis (Duke) Student Director-Elect Kathryn Norfleet (UNC)

Volume 5

The North Carolina Family Physician

Number 3

TA B L E O F C O N T E N T S Features

The Academy is Working Aggressively to Promote the Value of PCMH ................. 4 The Happy, Well Compensated, Patient-Centered Physician.............................. 5 The Best of Times…The Worst of Times...................................................... 6 Phase II of Health Disparities Initiative Awarded Grant Funding.........................10 Integrated care works for patients, providers in Clinton...............................11 Sections

Policy & Advocacy...............................5

Health Initiatives.......................................... 10

Chapter Affairs..................................... 6

Residents & Students..................................12

Education & Development......................9

Family Medicine in Practice............................. 14

AAFP Delegates and Alternates AAFP Delegate AAFP Delegate AAFP Alternate AAFP Alternate

Mott P. Blair, IV, MD Conrad L. Flick, MD L. Allen Dobson, MD Karen L. Smith, MD

FP Department Chairs and Alternates Chair (UNC) Alternate (Duke) Alternate (ECU) Alternate (WFU)

Warren P. Newton, MD, MPH J. Lloyd Michener, MD Kenneth Steinweg, MD Michael L. Coates, MD

NCAFP Editorial Committee Chair NCAFP Council Chairs Advocacy Council Continuing Medical Education Council Health of the Public Council Practice Enhancement

William A. Dennis, MD Shannon B. Dowler, MD Elizabeth B. Gibbons, MD Richard W. Lord, Jr., MD Brian Forrest, MD R. W. Watkins, MD Richard Lord, Jr, MD James McNabb, MD Jennifer Mullendore, MD Thomas R. White, MD William A. Dennis, MD Tim J. McGrath, MD


Peter T. Graber, MMC,CAE, Director of Communications FOR ADVERTISING INFORMATION

Peter Graber, pgraber@ncafp.com 919.833.2110 • 800.872.9482 Ed i t i o n 19

The NCAFP Strategic Plan Mission Statement: to advance the specialty of Family Medicine, in order to improve the health of patients, families, and communities in North Carolina. Vision Statement: Family physicians will be universally valued for their role in providing high quality care to the people of North Carolina. Core Beliefs: • We believe that Family Medicine is essential to the well-being of the health of North Carolina, and that Family Medicine is well-suited to improve the health of the residents of our state. • We believe in a healthcare system that is primary care driven. We believe there is an inherent value in a primary care medical home—providing quality, access and affordability. • We believe in a healthcare system that is fair, equitable and accessible. We believe in the elimination of health disparities and barriers to access to healthcare for North Carolina. • We believe in a comprehensive approach to patient care, and value the health and well being of patients, families and communities. • We value collaborative communication with all parties concerned with healthcare delivery, and advocate for a positive practice environment to nourish the specialty of family medicine. • We value the professional and personal well being of our members. Core Values: • Quality, evidence-based, timely education. • Professional excellence and integrity. • Fiscal responsibility, organization integrity and viability. • Creativity and flexibility. • Member-driven involvement in leadership and decision making. Additional details on the strategic plan are located at www.ncafp.com/home/academy/mission


NCAFP President’s Message

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The Academy is Working Aggressively to Promote The Value of PCMH Medical Home Education Being Integrated Into Many NCAFP Efforts In my previous article for this magazine, I discussed the concepts of the Patient Centered Medical Home (PCMH) and implementation of those concepts in our practices. I alluded to the benefits of the PCMH and some of the justification for its use. Since the publication of that article, both on a state and national level, I have reviewed several sincere responses questioning the justification for PCMH and have decided to devote this article to answering those questions, as well as highlighting this Academy’s efforts to promote its implementation. All of the supporting information that I utilized for the production of this article is either accessible from the state and national Academy websites or has been outlined in speeches given by our national leaders, often in conjunction with discussions about the value of primary care physicians who are the core elements of the PCMH. First in any discussion of the value of the PCMH is the evidence for improved effectiveness of care. Under that heading, studies of the PCMH and the care rendered by its providers revealed the following direct patient care results: • Reduced mortality from cardiovascular and pulmonary diseases; • Improved detection of breast cancer; • Reduced incidence and mortality from colon and cervical cancer; • Improved incidence of preventive care with subsequent detection and earlier treatment of chronic diseases. Studies continue to explore the direct patient benefit of the PCMH and primary care, but as noted, the above benefits alone are substantial and have the potential to significantly improve the health of the patient receiving care from the PCMH versus the disjointed state of care currently rendered through much of the nonprimary care-based system in the United States. Next, studies of the PCMH/primary care

model reveal significant overall cost reductions through the following mechanisms: • Reduced ER utilization; • Reduced overall hospital utilization for care; • Reduced radiologic and lab testing; • Lowered medication usage; • Lowered indirect patient care costs. Underlying all those cost reductions is a shift of care away from the most expensive center of health care - the hospital - to the least expensive center, the outpatient office setting. An additional finding in studies of the PCMH/primary care model was the discovery that disadvantaged care groups, when moved into the PCMH/ primary care home, had significant reductions in health disparities such as improved rates of visual screening, better oral care, better immunization rates and improved blood pressure control compared to baseline groups. All of these achievements were directly related to these groups receiving their care in the primary care setting. Control groups not receiving their care in the primary care setting did not see those reductions. Finally, and as a result of all the above noted findings, were improved patient satisfaction scores. With the patient receiving cost effective, comprehensive care from their PCMH, the patient has a lowered sense of displacement in our often confusing healthcare system with a feeling that they are wasting less time navigating that system. This ultimately should also lead to greater patient satisfaction with the provider of their care in that system. In consideration of these benefits of the PCMH, the leadership of NCAFP has dedicated itself to the promotion and adoption of PCMH. This effort has occurred on several fronts as now described, including this magazine. Additionally, our biweekly E-notes has periodically noted updates in reference to the PCMH, such as actions regarding the recent controversary regarding the status of family nurse practitioners and their ability to be certified as a medical home in the proposed statement of policy from the AAFP. NCAFP

July - September 2009 | the North Carolina Family Physician

Robert L. Rich, Jr, MD NCAFP President is also preparing fact sheets for distribution about primary care and the PCMH to be used in discussions with groups such as legislators, insurers, and business leaders that outline the PCMH concept and how it impacts costs, access and quality of care. In addition, the NCAFP has utilized speakers such as North Carolina’s own AAFP President- Elect, Dr. Lori Heim to promote the value of the PCMH to everyone from our rising third- and fourth-year medical students to practicing physicians at our CME meetings and other NCAFP-sponsored events. By utilizing the services of speakers such as Dr. Heim, the NCAFP has been able to promote the myriad of resources that AAFP has devoted to this task of promoting the PCMH. We are also trying to bring the message directly to individual physician offices, whether it’s through quality improvement initiatives such as Improving Performance in Practice (IPIP) or the efforts of our industry partners. For example, Merck, is now utilizing its own representatives to bring the message of the Patient-Centered Medical Home directly to physicians. In this instance, they have allowed NCAFP and AAFP leaders to review and comment on their materials in hopes of making them as useful to practices as possible. After reviewing these and other discussions about the PCMH, you probably are now asking what is the value to you for making the investment in changes in your office to reach PCMH status. I propose -- that in addition See PCMH on Back Cover WWW.NCAFP.COM

Policy & Advocacy

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The Happy, Well Compensated, Patient-Centered Physician — You Can Make it Happen! By Dr. Brian Forrest, Advocacy Council Chair We are in an unprecedented time in our state in terms of budgetary shortfalls and cuts. Some of these proposed cuts could have devastating impacts on practices, especially those taking significant numbers of Medicaid patients. It has been estimated that a 6-8 percent cut in Medicaid for a moderate-sized office could easily mean $100,000 (more or less) to the bottom line of that practice. Such a financial impact would result in loss of employment for staff and possibly physicians. It definitely would have a significant impact on the ability of physicians to spend time with their patients and provide quality care. Many physicians are already maxed out from a productivity standpoint and seeing as many patients as they possibly can on the overhead treadmill. Access to quality medical care would be one of the casualties of such cuts. Already 80% of physicians in our state say that they would have to limit or stop seeing Medicaid patients with this degree of cuts. This means more overburdened and stressed Medicaid providers with even less time and longer waits for their patients. This would inevitably translate into more patients in the ER and further fragmentation of health care as people cannot gain access to a medical home. There are signs of hope that these cuts will not be as dramatic as initially anticipated, mostly due to advocacy efforts from individual physicians, groups such as our Academy, and even patients that have emailed, called, and visited with legislators in Raleigh. (As of this

writing, the reduction in Medicaid provider rates is likely to be around 3 percent). You can certainly be proud of the efforts made by your President, Robert Rich, and by EVP Greg Griggs. They have been constant watchdogs with the help of Peyton Maynard, our government affairs consultant. Their efforts and those of others will certainly pay off in that the level of cuts in our state that were anticipated may be averted despite a nearly 5 billion dollar budget deficit. Managed Care/ Insurance Contracts are finally

being addressed in NC this session. Past-President of the Academy, Christopher Snyder has worked hard to facilitate debate about contract fairness. Legislation being considered would make it a requirement that insurance company policy changes that affect primary care practices not be implemented without 60-days notice. More importantly, this legislation would also prohibit making policy changes that were in conflict with provider contracts after the fact. Recently, the Smoking Ban Bill was passed, although in a muted form. This was of particular importance to our See Happy Physician on Back Cover

Transparency In Contracting Legislation Moves Forward in NC House A bill that would bring greater transparency to health plan/provider contracts continues to move through the N.C. General Assembly. Senate Bill 877, sponsored by Sen. Daniel Clodfelter, would require that all contracts between health plans and providers contain a contact person where proposed amendments would be mailed; require that any fee schedule


changes be sent to that contact who would be given 60 days to object to the amendment; and it would prevent health plan policies and procedures from overriding or conflicting with the actual contract. The bill passed the full Senate in May – and as of this writing in mid-July – the bill had also cleared both the House Health and House

Insurance Committees. The legislation should be considered by the full House in the near future. The entire medical community has fought for this key piece of legislation, including the Academy, the NC Medical Society, the N.C. Medical Group Managers, several other specialty groups and the N.C. Hospital Association. Look for updates and alerts in NCAFPNotes.

North Carolina ACADEMY OF Family PhysicianS, INC





The Best of Times…The Worst of Times Whether it’s the words of Dickens from a “Tale of Two Cities” or the lyrics of a power ballad from the 80s rock group Styx, these truly are “The Best of Times and the Worst of Times.” Before I address why I believe our cups are half-full, let me first address the worst:

Gregory K. Griggs, MPA, CAE Executive Vice President Mr. Griggs has been on staff with the NCAFP since 2005 and is a member of the American Society of Association Executives (ASAE). He completed his undergraduate studies at UNC-Chapel Hill and his graduate training in association and non-profit management at North Carolina State University. He formerly served as CEO of the Henderson-Vance County Chamber of Commerce and as Executive Director of the Association Executives of North Carolina and the Filter Manufacturers Council. Married with two children, Greg is Past President of the Henderson Lions Club, a current active member of First United Methodist Church in Henderson, and serves the Boards of Directors of both Kerr-Vance Academy and Maria Parham Medical Center.

• Our state and nation face unprecedented financial distress with an economy at the depths of a recession that most of us have never encountered in our lifetime. In fact, some of our country’s corporate cornerstones are now mere rubble trying to survive bankruptcy. • Our state’s budget faces nearly a $5 billion short-fall; meaning per person spending levels could be rolled back as much as 20 years. • Our Chapter even represents a microcosm of the national economy with both sponsorship revenue and exhibit income dropping as past supporters of our high-quality CME have to tighten their belts. Yet, I sense a tremendous and growing amount of optimism among our members about the future of family medicine. • At the national level, the healthcare reform debate continues to bring up the need for strong primary care. • Almost every discussion of proposed federal legislation includes increased compensation for primary care, even if it’s not always as high as we would like. And when eight representatives of your Chapter visited most of the state’s Representatives and Senators in Washington in May, there was universal support for family physicians and the need to value you for what you do. And these were the opinions of both liberal and conservative members of our state’s Congressional delegation. • The concept of the Patient-Centered Medical Home is being pushed by large employer groups such as IBM, with blended payment formulas at its core. Look for IBM’s own Dr. Paul Grundy to speak at our Winter Meeting. And these new compensation formulas include per member per month payments based on the model developed by Community Care of North Carolina and many of the leaders of this very Chapter. • Once again on our smaller microcosm at the NC Academy of Family Physicians, our membership renewals continue to be strong --even better than last year, attendance at our

July - September 2009 | the North Carolina Family Physician

Continuing Medical Education Meetings is holding steady, and the sense of physician involvement is maybe higher than ever. I want to take just a few moments to address that sense of involvement. On a recent Monday evening, 21 of your colleagues attended or called into a nearly three-hour meeting of your Chapter’s Advocacy Council. Now I can surmise there are many other things these family doctors could have been doing on a Monday evening. But they each decided to give up their time to support the profession of family medicine in North Carolina. While all of us expressed frustration with proposed Medicaid cuts, we also expressed enthusiasm for potential legislation that would require basic fairness provisions in all health care contracts between insurance companies and physicians. There was also a sense of commitment from past, current and future leaders of the Academy – a commitment to stay involved and ensure family medicine’s voice is heard loud and clear. As we have embarked on the Laser-Like Focus of our new strategic plan with a significant emphasis on advocacy, I’m heartened by the number of calls and e-mails our members have made regarding the state’s budget situation. It’s almost as if our membership has heard the call to arms. But the job is yet to be finished, and your help remains crucial. In summary, let me make a few simple statements. Your specialty – family medicine – stands proud and strong in North Carolina. But we need your help. To ensure that the future truly is the best of times, it is going to take the commitment of all 2,700 members of the NCAFP. You don’t necessarily have to give us your Monday night, but I urge you to take action when you receive an advocacy alert. Those e-mails, phone calls or even personal visits with a legislator make a world of difference when we try to influence policy on the state and national level. Here’s to the best of times!


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Dr. Conrad L. Flick Campaigns for AAFP Board of Directors NCAFP Past President Dr. Conrad L. Flick of Cary recently announced his candidacy for the AAFP Board of Directors. To provide members insight into Dr. Flick’s leadership philosophy and his thoughts on what’s needed at the national level, The North Carolina Family Physician asked him to share his thoughts on a number of key questions. Health Care reform is a key topic right now. How can the specialty best take advantage of the dialogue and debate taking place to help solidify family medicine’s place in a refined system? I believe we can accomplish this by doing more of what we have already been doing. Our specialty has always put the needs of our patients and communities first, and as a result our image and reputation is in good standing with the decision makers of health care. In order to make sure our message gets heard we must continue to be at the center of discussions – both literally and figuratively. We must continue to remind decision makers of the importance of our members to any health care system through conversations, demonstrations, data and whatever other means are needed. We need to be present at as many discussions, forums, conferences as we can. If we are not, then others will claim to be able to provide similar services. Every member can play a part, either through their state chapters or by contributing to family medicine’s political action committee. This is what has gotten us to the table. How has your experience in organized medicine, especially with the state chapter and AAFP influenced your perspectives on advocacy and the best ways in achieving positive reforms and progress? I now truly understand the old adage that politics is not a spectator sport, it is truly the “political game.” As a game, you must first understand the rules of that game and participate based on its rules. To do so, you must make contacts and WWW.NCAFP.COM

get involved, stay involved, educate you contacts, and get participation on as many commissions/ committees that your organization can. This will help you get your message out and to keep it in any discussions that will occur, as well as allowing you to take an active part in that discussion. You must also make sure that you have worked on your message to make sure it is the right message and that it is refined to be concise and easily understood. As a family physician in private practice, what efforts should be made to enhance the viability of family medicine as a business – both for urban, suburban and rural practices? Is enhanced payment the only answer or can physicians pursue other means? I think that enhanced payment is a key part, both in helping current practices, but more importantly, in attracting new bright medical students into our specialty to care for future generations and to keep health care as high quality and cost efficient. However, a good business practice is also very important and even the aspects of PCMH will not keep badly run practices solvent. Each practice must know our overhead, the costs to them to provide care, how to control those costs and run efficiently, and finally be able to competitively negotiate contracts - even if it means practices collaborating with others on some degree.

As a candidate for AAFP Board, what do you consider your key strengths? What unique abilities do you offer that will make you an effective representative for the specialty? Like the majority of our members, I am a fulltime practicing physician and understand the dayto-day struggles our members experience. I have learned much of the business of medicine through good mentors who have also streessed the need for engaged and experienced leadership. I believe that through my experiences I bring my passion for family medicine to any discussion, blended with an understanding of what it takes to run a true community practice. Serving on the state and national level with regards to advocacy, I believe I also possess important strengths at this time of health care reform. Whatever comes out of Washington regarding reform, the coming months will only be the beginning and the work to make it happen will occur for some time to come. The PCMH holds great promise for the specialty and for health care. Why do you think this is different from previous efforts to communicate the value of coordination, relationships and preventative care? I believe there are two reasons. First is that the current system is not working. It is expensive and fragmented and leaves a large percentage of our population without good access to basic services. Second, while those discussing reform were looking for some solutions, there has been a coordinated effort by primary care physicians - with the help of the business community - to help define it, endorse it and to have the advocacy efforts behind it. The PCMH has the ability to improve our standing among decision makers and payors in the health care community, and, at the same time, improve our financial viability. While pcmh has many positives for practices, it alone is not the answer. What do you see as the challenges of Family Medicine in the next 24 months? Healthcare Reform - both the crafting of health care reform and implementing any reforms that may take place (and re-grouping if it does not meet what we hope for our members, patients and communities). What is going to take place in the coming months is only the beginning, the final product will take a long time to realize and tremendous energy and commitment on our part to make sure it will be as good as it can be. North Carolina ACADEMY OF Family PhysicianS, INC



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Winter 2009


2009 Annual Meeting Dec. 3-6, 2009 Asheville, NC

Dec. 3-6, 2009

The Grove Park Inn & Spa Asheville, North Carolina

NCAFP’s Annual Winter Meeting is Dec. 3-6, 2009 in Asheville Early December is always a great time to be in the North Carolina mountains!!! Each year, the NCAFP and hundreds of physicians who attend the Annual Winter Meeting look forward to returning to Asheville for the Academy’s Annual Winter Family Physicians Weekend. Over the last several years, this conference has grown in size and represents the largest educational event of the year for North Carolina’s family medicine community. Dr. Brian Forrest is planning a conference packed with engaging topics and learning activities. He anticipates that the meeting will present over thirty AAFP prescribed credits in addition to a complete line-up of Chapter business meetings, workshops, and

NCAFP Hosting Hands-On Procedures Workshop on Saturday, September 12th in Cary Family physicians, FNPs and PAs often see patients with conditions that require the performance of a minor office procedure. Too often, these patients are referred out of the practice. There are a number of benefits to adding these simple and quick procedures to your practice: Patients appreciate that their trusted family physicians provide services that traditionally require a referral to a subspecialist; Healthcare costs decrease, treatment delays are avoided and continuity-of-care improves; and WWW.NCAFP.COM

be holding a special party on Friday, December 4th called ‘Wine, Dine & Chocolate Divine’ that will combine the NCAFP Foundation Silent Auction with other fun activities. Plus tours of the Biltmore Estate, golf, Biltmore Spa packages and the President’s Gala on Saturday night will also be offered. The official brochure will be mailed in the coming weeks. For complete information, please visit the Chapter’s website at http://www.ncafp. com/wfpw. The site contains the most up-todate information and even allows you to register. If you have specific questions, please contact NCAFP’s Kathryn Atkinson at (919) 833-2110 or via email at katkinson@ncafp.com.

an array of social activities. Please don’t miss this conference - it is always a wonderful time to be in Asheville! The scientific program for the meeting continues to be refined, but will tentatively include talks on Negotiating Contracts for Employment; Overactive Bladder; Diabetes; Bipolar Disorder; Healthcare Reform; The Patient-Centered Medical Home; Acute Coronary Syndromes and more. Physicians may refer to the meeting website (http://www.ncafp.com/wfpw) for an updated listing of topics. The meeting’s social events are always lively, fun and entertaining. As a follow-up to last year’s anniversary, the NCAFP Foundation will RN E LEA TIC ES AC UR PR CED O LLS PR SKI

importantly, family physicians’ satisfaction and revenue both increase. On Saturday, Sept. 12, 2009 at the Embassy Suites Hotel in Cary, NC, the Academy will host a 1-day workshop teaching physicians, FNPs and PAs advanced techniques in Joint Injections and Skin Biopsy. Registration cost is $125 per person. For complete information on this workshop, visit http://www.ncafp.com/home/cme/handson

NCAFP to Offer Web-Based CME Program on Health Disparities Later this summer, the NCAFP expects to launch a new online CME program focusing on health disparities. The program will provide insights into the definition of health disparities, the causes and methods to address them. The speaker will define the Culturally and Linguistically Appropriate Services standards (CLAS) as outlined by the National Office of Minority Health. Also they will discuss how to use CLAS as a way to improve cultural competency and therefore reducing health disparities. Be on the lookout!

North Carolina ACADEMY OF Family PhysicianS, INC


P Phase II of Foundation Health Disparities Initiative Awarded Grant Funding By Jenni Fisher, MPH, Health Initiatives Manager The North Carolina Academy of Family Physicians Foundation is excited to announce that they have been awarded funding from the North Carolina Health and Wellness Trust Fund Commission for a Health Disparities Initiative Phase II. The grant is part of the Care to Act North Carolina Initiative with 21 grantees awarded throughout the state. The goal of the NCAFP’s Health Disparities Initiative is to educate physicians and all healthcare providers in North Carolina to increase levels of cultural competency and to better prepare them for caring for all populations in the state. The NCAFP has extensive experience and leadership in eliminating health disparities. In 2006, the Chapter was awarded a Health Disparities Initiative Phase I grant. During the last three years, the NCAFP has focused on educating their members through an online CME program offered by the Office of Minority Health, through intensive practice-site interventions and by utilizing wide reaching educational sessions at its three CME meetings held annually. Over 1,500 family physicians, residents and medical

students have participated in educational sessions to date. In December 2008, the NCAFP presented their Phase I results in a poster presentation at the NIH Summit on the Science of Eliminating Health Disparities. In Phase II of the Initiative which will begin this July, the NCAFP will extend the scope of the Initiative beyond their members and will engage other medical specialty associations in North Carolina, including the Buncombe County Medical Society, the Mecklenburg County Medical Society, the North Carolina Pediatric Society, the Old North State Medical Society and the North Carolina Academy of Physician Assistants. The NCAFP will provide educational sessions, tools related to the Culturally and Linguistically Appropriate Service Standards (CLAS) and assistance to these organizations in training their constituencies about implementing culturally appropriate services. If you would like more information about the NCAFP’s Health Disparities Initiative, please visit www.ncafp.com/home/programs/disparity.



Help Patients Revisit Their New Year’s Resolutions NC Eat Smart, Move More Offers Promotional Resources Each year thousands of North Carolinians resolve to eat smarter, move more and achieve a healthy weight. Some vow to walk five days a week, others to eat fewer snacks or drink less soda and more water. Regardless of the resolution you made in January, chances are you’ve forgotten all about it. And you aren’t the only one. Family physicians who want to encourage their patients to revisit their resolutions can take advantage of a great lineup of promotional tools. Each is designed to help communicate with their patient populations. NC Eat Smart Move More has developed ‘Revisit Your Resolutions’ as a follow-up to its annual ‘Maintain Don’t Gain Holiday Challenge.’ The program offers several 10

components including a number of articles perfect for insertion into practice newsletters, customizable advertisements for in-office handouts or other tools. Interestingly, approximately half of all people who make New Years Resolutions keep them past three months. While reasons vary, the truth of the matter is – change is hard. But, with some tips and determination you can pick your resolutions up, dust them off, try again and be successful! Take a little time to revisit your resolutions or make new mid-year resolutions. Re-commit yourself to living a healthier lifestyle. When encouraging patients to revisit their resolutions, or when making new ones, it is

July - September 2009 | the North Carolina Family Physician

sychologist Dianne Walters, MA, LPA, LPC, has worked in a variety of settings during her career, including private practice and within the North Carolina Department of Correction. The latest setting for her work, however, may be the most interesting. Since 2007, Walters has been colocated at Clinton Medical Clinic (CMC), an 11-physician practice in Sampson County. One of the first practices in the area to offer integrated care, CMC takes a holistic approach to health care, with professionals who treat body and mind in concert. “Co-location is beneficial, hands down,” said CMC’s Ted Bauman, MD, who specializes in family medicine. For those patients who already see primary care providers (PCPs) at CMC but who need additional behavioral health services, Walters’ co-location makes the referral and transition process seamless. “They come to the same office for both types of appointments and they know their primary physician, whom they trust, will be involved in their entire treatment,” said Ginger McCullen, PNP. “Patients take comfort in that kind of team approach.” Visiting a mental health care provider who practices in a primary care setting also helps reduce the stigma that often surrounds mental health treatment, said Walters. PCPs agree that in North Carolina today, there are too few behavioral health care providers to meet patient needs, and this

important to keep in mind the foundation for SMART resolutions. They should be: Specific; Measurable; Achievable; Realistic and Timely. Review their goals. Are they realistic? If there are any goals that are too lofty at this time go ahead and cross them off the list. Next, rewrite the remaining goals. Be specific. Write the details onto your paper. For example instead of, ‘walk after dinner more often’ add details such as, ‘walk after dinner four nights each week’. The more specific your goals, the easier it is to keep track of your progress. This process is just one of the many tips outlined by the resources that are now available. Practices can access these resources and a wealth of others by visiting the Eat Smart Move More website at www. eatsmartmovemorenc.com/HealthCare.html. WWW.NCAFP.COM




Integrated Care Works for Patients, Providers in Clinton is especially true in rural settings across the state. “It has been all but impossible to find mental health care providers who will accept a non-private insurance referral, and those who will accept the referrals often have a monthslong wait time,” said McCullen. “With Dianne working in our practice, we know we can make referrals as often as necessary. We have the access we need.” While Walters works with a range of patients, she specializes in children and adolescents – a certain benefit at CMC, which has four pediatric providers and a large number of young patients. As adolescent mental health services are even less accessible than adult mental health services, CMC providers appreciate having Walters as part of the team. Prior to Walters’ arrival, McCullen said she was often, out of necessity, addressing mental health issues that fell beyond her expertise. And in an emergency mental health situation, McCullen’s only option was to send the patient

to an emergency room, a solution that wasn’t ideal for providers or the patient. Now that patient can be seen the same day by Walters, who leaves room in her schedule for urgent appointments. In addition to emergency intervention, Walters provides ongoing counseling and therapy. She also conducts testing for attention deficit disorder, learning disabilities and similar concerns, providing data to support a clearer diagnostic path and freeing physicians to focus on other health concerns.. For Bauman, one of the key benefits of co-location is the opportunity to provide more effective care. “Health care often requires a two-part approach,” he said. “Patients suffering from depression, for instance, benefit most from talk therapy and coping strategies supplemented with medication. We can offer all of that in one practice, ensuring that patients receive complete treatment.” Co-location also enables simultaneous treatment, as an on-site psychologist can refer a

patient to the PCP for an immediate prescription, if needed. The patient leaves with the prescription in hand. In addition, Bauman points out that in a colocation, all patient records are kept in one place – a single file contains all primary and mental health care notes, streamlining the care process even further. While co-location has clear benefits for patients and PCPs, Walters says she appreciates the arrangement as much as anyone. “Co-location isn’t just beneficial – it’s becoming necessary,” she said. Walters notes that as insurance reimbursement rates for mental health services decrease and operating expenses rise, solo practitioners can’t afford to work alone. With co-location, Walters said, patients benefit from provider collaboration and providers are finding efficiencies in care that allow them to reduce or share cost burdens without detracting from patient care.




Eighty Students Attend NCAFP’s 3rd Annual Family Medicine Day in Durham


Briefs N C


By Peter Graber, MMC, CAE, Resident and Student Programs The NCAFP’s third-annual Family Medicine Day was a tremendous success when it was held in Durham on May 16th. Eighty (80) students from across the southeast attended the event’s activities that included a presentation by Dr. Lori Heim, AAFP President-Elect, 4-hours of skills workshops and a full recruiting fair. The Academy would like to thank the NC AHEC program for their continued support and generosity for helping to make this event a reality. Students from across the southeast participated in workshops This year’s event attracted taught by NC’s family medicine residency training programs. even more students and more family medicine program. Techniques presented included residency programs than in 2008. Family suturing, splinting and casting, shoulder and Medicine Day saw a dramatic increase in the knee exams and injections, perineal lacerations numbers of osteopathic medical students in and radiology reviews. Family Medicine Day attendance. Like the previous two years, out-ofconcluded with a two-hour recruiting fair that state students were plentiful, with some traveling gave each student the opportunity to meet with as far as southern Georgia to attend. each of the programs, make quality contacts and The theme for this year’s event was the interact with other medical students. Patient-Centered Medical Home (PCMH). Teaching faculty and Residency Coordinators AAFP President-Elect Dr. Lori Heim gave from all NC private and university-based students a comprehensive overview of the residencies attended. Residency Coordinators political environment, then went on to describe took the opportunity to meet and share ideas on how the PCMH model is so attractive. After the recruiting and program operations, as did the NC presentation and a brief Q & A period, students Residency Directors and the FMIG leadership. then proceeded to a series of four clinical skills The Academy will once again be hosting the event workshops. Each workshop was presented and in 2010. Look for additional information in the taught by physicians from each NC residency coming months.

NCAFP Co-Sponsors Student Hospitality Event at 2009 National Conference The NCAFP was a key co-sponsor at a meet-andgreet at this year’s National Conference in Kansas City. The event, the NC Hospitality Event, presented by the AAFP, offered students the opportunity to get to know residency 12

NC FMIGs to Present State Service Project This November The Family Medicine Interest Groups (FMIGs) in North Carolina are planning to present a statewide community service project highlighting family medicine. All four FMIGs have agreed to pursue a November blood drive on their respective campuses to promote the specialty and serve the community. The idea for the project originated from the NCAFP Student Section meeting in December, 2008. Leaders from each NC FMIG met in May during Family Medicine Day and agreed to pursue the project.

Six NC Students Get Travel Awards to 2009 National Conference Six NC-based medical students were awarded travel scholarships to attend the 2009 AAFP National Conference in Kansas City this year. The scholarships provide a stipend that helps offset travel costs. The students and the scholarships they received are as follows: Christina Nisonger, First-Time Student Attendee; Haley Ringwood, First-Time Student Attendee; Jewell Carr, Minority Scholarship; Jillion Harris, Minority Scholarship; Nichole Johnson, FMIG Leadership; and Jennifer Parker, FMIG Leadership.

programs and each other. North Carolina was well-represented, with members of each NC family medicine residency program in attendance. In addition to this event, North Carolina also had prime placement in the Conference’s exhibit hall. This location meant increased exposure to each program. Look for pictures and scenes from the Conference at www.ncafp.com.

July - September 2009 | the North Carolina Family Physician


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BCBSNC to Cover E-visits: Are You Eligible for Reimbursement? Blue Cross and Blue Shield of North Carolina has begun reimbursing health care providers for electronic visits with patients. Electronic visits, or “E-visits,” are online medical evaluations through a secured electronic channel similar to e-mail. It allows patients to submit information to providers at their convenience and providers to respond, usually within one to two business days. BCBSNC has developed a medical policy spelling out the terms for reimbursement for E-visits, available at www.bcbsnc.com/assets/ services/public/pdfs/medicalpolicy/evisits_ online_medical_evaluation.pdf. The policy, which took effect June 1, allows North Carolina physicians to use any technology vendor for E-visits that meets BCBSNC standards spelled out in the policy. E-visits are not intended to replace formal office visits. In its 2002 guidelines for electronic patient communication, the American Medical Association said, “New communication technologies must never replace the crucial interpersonal contacts that are the very basis of the patient-physician relations, rather, electronic mail and other forms of Internet communication should be used to enhance such contacts.” E-visits provide another way for patients to access their health care provider. To avoid long wait times for appointments, patients with less acute problems may choose to use E-visits instead

of formal office visits. Most adults – 74 percent – would like to use e-mail to communicate directly with their doctor, but few have that option, according to a 2006 survey by the Wall Street Journal Online/Harris Interactive HealthCare Poll. Lack of compensation has been cited as a main barrier preventing physicians from more widely using electronic communication for patient interaction. The BCBSNC policy describes the circumstances under which providers can be reimbursed for an E-visit: • When there is an established provider patient relationship based on a previous in-office visit. • When the services are provided by a physician, physician’s assistant or nurse practitioner. • When the extent of services provided includes at least a problem focused history and straight forward medical decision making as defined by the CPT manual. • E-visits should not be billed more than once within seven days for the same episode of care or be related to an evaluation and management service performed within seven days. E-visit should not be billed within the post-operative period of a previously completed procedure.

• When service is conducted over a secured channel with provisions meeting BCBSNC guidelines. Please refer to www.bcbsnc.com for more details on requirements. The policy also describes what’s not reimbursed: • Request for medication refills or referrals • Reporting of normal test results • Provision of educational materials • Scheduling • Registration or updating billing info • Reminders

Health Information and Privacy Toolkit for Physicians and Practices Now Available The NC Healthcare Information and Communications Alliance (NCHICA) has announced the availability of a new resource designed to help physicians and practices understand electronic health information exchange and its implications on data security and privacy. Located online at http://www. secure4health.org, the new web-based toolkit provides physician-to-physician advice, resource links, and answers to frequently asked questions

from national health care subject matter experts. This toolkit is   the result of work completed by Contact: Lorri Rishar Jandron the Health Information Security & Privacy 517.853.6787 About NCHICA lorri.edge@comcast.net Collaboration, a multi-year project launched in The North Carolina Healthcare Information January 16, 2009 and Communications Alliance, Inc. (NCHICA) 2006 by the U.S. Department of Health and is a nationally consorStates launch virtual toolkit recognized for healthnonprofit care providers, Human Services. NCAFP’s Dr. David Kibbe, tium that serves as an open, effective and encourage electronic health information exchange a nationally-recognized health IT expert, is a neutral forum for health information technolhighlighted Physician Champion that shares his ogy (HIT) initiatives that improve health and From hospital corridors care acrossin theNorth countryCarolina. to full page advertisements in USA Today, it perspectives in a short video on why all physicians appears that just about everyone is calling for the healthcare industry to go electronic. While need to be ‘connected.’ most industries have long ago updated, the medical community í entrusted with the lives of


July - September 2009 | the North Carolina Family Physician

millions of patients annually í is slower to adapt.


Numerous efforts are underway to improve a system far too reliant on paper records. One such initiative aims to provide information about privacy and security to health care providers in order to encourage their participation in electronic health information exchange



CDC Recommends HiB Booster Dose Reinstatement In late June, the US Centers for Disease Control and Prevention (CDC) recommended a return to the full Hib immunization series, including a booster dose for all children over 12 months of age. They also issued guidance on a phased approach to immunize toddlers whose booster dose was previously deferred. HiB has been in tight supply since December of 2007. Due to this, the CDC at the time recommended deferral of the booster dose to all but the highest risk children. It is expected that constrained supply of HiB vaccines will continue. All health-care providers are being advised to incorporate both ActHIB and Pentacel vaccines into their immunization schedules to ensure the latest CDC recommendations are followed and the greatest number of children are protected.

Person-Centered Plans Now Require Signature A change in state Medicaid forms that began March 1, 2009 holds important significance to physicians and providers. Family Physicians are advised that you must SIGN the signature pages of the DMA Person Centered Plans AND YOU MUST CHECK the boxes indicating if you had direct contact with the patient and if you have reviewed the clinical assessment. Failure to comply can and will result in DHHS reporting the failure to the professional’s licensing board! Physicians are directed to download Medicaid’s Person-Centered Plans Manual [http://www.dhhs.state.nc.us/mhddsas/statspublications/ manualsforms/pcp/pcp_2008_instruction_manual.pdf ] to become familiar with this requirement. Pages 32-33 describe the Signatures and the intended notification to the licensing board for non-compliance.

Recovery Audit Contracting Program Begins in Early 2010 The Medicare Recovery Audit Program (RAC) is scheduled for implementation in North Carolina in early 2010. Recovery Audit Contractors (RAC’s) are paid only if they find either overpayments that are refunded by/offset from physicians and providers or underpayments resulting in additional payment by the Medicare Administrative Contractor (MAC). North Carolina’s RAC contractor is Connelly Consulting. NC physicians and practices should review AAFP’s RAC-related information located online at [www.aafp.org/online/en/home/practicemgt/codingresources/ recoveryauditcontractors.html]. The information assembled is designed to help AAFP members understand the RAC program and proactively prepare their practices to properly handle any RAC-related activity. Much of the information was assembled during CMS’s RAC demonstration period, but is still pertinent. In addition to AAFP’s resources, CMS has also published extensive infomation at www.cms.hhs.gov/RAC

Keep YOur member info current


Members – please be sure to keep all of your contact info up to date. This includes your home and business address, phone, fax, and email address. To update, contact Tara Hinkle, NCAFP Membership Coordinator, at thinkle@ncafp.com, 919-833-2110.

July - September 2009 | the North Carolina Family Physician

Medicaid Provider Verification and Credentialing Process to Begin This Summer As part of the Division of Medical Assistance’s move to a new information systems vendor, a process to verify the credentials of all Medicaid providers will begin this summer. This process results from the NC Department of Health and Human Services contract to CSC to develop and implement a replacement Medicaid Management Information System (MMIS). Previously, EDS served as the Information system vendor, and the state handled provider credentialing. However, under the new contract, CSC will credential providers as well as administer claims. While the claims process will not change until sometime in 2011, CSC is beginning the process to verify credentials now. Some providers may have already received notification beginning as early as June, and this process will continue for the next 12 months. The notification packet will be mailed to the provider’s billing/accounting address and will include a pre-printed report of information currently on file with NC Medicaid, plus a checklist of credentialing-related documents that must be returned to CSC. Providers may verify their billing/accounting address via the DMA Provider Services NPI and address database or by calling the EVC Call Center at 866-844-1113. Providers must complete the form, attach copies of documents required for credentialing, and return the verification packet to CSC within 30 days of the date of receipt or providers may face termination of Medicaid participation. The verification process will reportedly take up to three weeks from the time CSC receives the correct and complete verification packet from the provider. CSC will be responsible for reviewing the information and conducting credentialing activities that include criminal background checks, queries of practitioner databases and verification of licensure, certification and endorsement. Finally, beginning in August, 2009, CSC will be providing a web-based enrollment application for new applicants. CSC is looking for providers to pilot the new application in the summer. If interested, please email: ommiss. providerrelations@dhhs.nc.gov. For additional information about the transition of MMIS oversight to CSC, please visit www. dhhs.state.nc.us regularly for updates. Also, please feel free to contact Brent Hazelett (bhazelett@ncafp.com) with any questions.


NC Academy of Family Physicians P.O. Box 10278 Raleigh, NC 27605

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PATIENT-CENTERED MEDICAL HOME, continued from p.4 to being the right thing to do for our healthcare system -- PCMH certification as implemented will ultimately bring increased revenue to your office. NCAFP and AAFP together are lobbying Medicare and private insurers to increase reimbursement to PCMH certified offices either through the utilization of per member per month (PMPM) payments such as currently paid by our own Medicaid program or increased E&M payments on codes submitted by PCMH offices. To that effect, AAFP’s promotion efforts in conjunction with the TransforMED project, have asked Medicare to consider significant per member per month payments to practices that meet all the requirements for PCMH certification.

To that I would propose that practices which continue to provide care for their hospitalized patients as part of the medical home, also receive improved reimbursement for hospital care codes as well as recognition of reimbursement codes for primary care physicians to act as consultants to hospitalist’s care in order to promote greater involvement of the primary care MD in the hospital environment. Please consider adopting the PCMH concept for your practice and if you need assistance, feel free to contact NCAFP headquarters for assistance. In my next article, I outline our efforts to provide legal assistance for physician contracting issues. Until then…

Happy Physician, continued from p.5 Health of the Public Council and the NCAFP showed strong support for this bill. Within the next few months, changes in national health care policy will likely have an effect on all of our practices. It will be important to continue to participate in the process and evolution of health care as these changes are implemented. Family physicians should be front and center, because we are at the center of the solution to health care costs and quality. We have to continue to emphasize the need for an adequate physician workforce to meet the demands of patients. Family physicians need to be rewarded financially and recognized for their contributions to an improved system so that medical students will choose our specialty. Your Academy is actively pursuing ideas to improve interest and retention in family medicine.

We are exploring programs to mentor students, pay off debt, and increase the esteem of our specialty choice. These efforts will be necessary to train and keep family physicians in areas where they are desperately needed. Do not sit on the sidelines. If your patients, practice, and profession are important to you then it is vital that your voice be heard. There are many ways you can contribute to being and advocate for Family Medicine. You can call or email you local legislator, sign up to be a NCAFP Key Contact, or you can send a check to NC FamPAC. You can even come to Advocacy meetings at the Academy (3rd Monday Nights) Call to verify dates. Please help us to help our patients by being a family medicine advocate. There are a number of ways you can make an impact.


& PRIMARY CARE PROFESSIONALS Advertise with the NCAFP! Magazine - Email Newsletter - Website - Meetings Visit www.ncafp.com/advertising for complete information

Charitable Giving … Helping the Future of Family Medicine As the financial needs of the NCAFP Foundation continue to grow, keeping pace financially is essential to continuing its many fine programs, such as the scholarships/loans it provides to medical students interested in family medicine, supporting our Family Medicine Interest Groups and delivering preventive health care programs like NC Tar Wars. These programs are why charitable giving to the Foundation in the form of planned giving is so important. Planned giving enables you to make a donation in a way that is tax-preferred to your individual needs and to those of your estate. By planning today and utilizing common forms of planned gifts (including charitable bequests, charitable remainder trusts and gifts of life insurance), you can make a future contribution to a very worthy cause. Often times gifts in these forms may benefit you and your estate by reducing your current and future income taxes, and in some instances, may also help reduce your final tax burden. Please be sure to visit your tax advisor or estate planner during your next annual review to learn more about your options. Once determined, you may then direct your gift to be used in any number of ways by the NCAFP/F. Please contact Kathryn Atkinson, Foundation Development Coordinator, for more information regarding charitable giving or other donations to the NCAFP Foundation. She can be reached by phone at (919) 833-2110 or 800-872-9482 (NC Only) or via email at katkinson@ncafp.com.

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