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THE NORTH CAROLINA

Volume 7 Issue 2 / Spring 2011

quarterly news in north carolina familiy medicine

ACOs Take Center Stage: Why Family Physicians Need to Take Notice

Inside PCMH Build It!

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Academy Busy at General Assembly

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Residency Spotlight: Southern Regional

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Spring 2011 • The NCAnnual Family Physician | 2010 NCAFP Report


2010-2011 NCAFP Board of Directors Executive Officers President Richard Lord, Jr., MD President-Elect Brian R. Forrest, MD Vice President Shannon B. Dowler, MD Secretary/Treasurer William A. Dennis, MD Board Chair R.W. Watkins, MD, MPH Past President (w/voting privileges) Robert Lee Rich, Jr., MD Executive Vice President Gregory K. Griggs, MPA, CAE District Directors District 1 - R. Kevin Talton, MD District 2 - Matthew M. Williams, MD District 3 - Scott E. Konopka, MD District 4 - Tamieka Howell, MD District 5 - Rhett L. Brown, MD District 6 - James W. McNabb, MD District 7 - Thomas R. White, MD At-Large Holly Biola, MD At-Large Charles W. Rhodes, MD

2011

MID-SUMMER FAMILY MEDICINE DIGEST

JULY 3-8, 2011

IMG Physicians Nalini S. Baijnath, MD Minority Physicians Enrico G. Jones, MD New Physicians Nadine B. Skinner, MD NC Family Medicine Departments Kenneth K. Steinweg, MD FM Residency Directors Gary I. Levine, MD

Myrtle Beach, SC

Resident Director Nicole Shields, MD (SR-AHEC) Resident Director-Elect Matthew Kanaan, DO (Duke) Student Director Amy Marietta (UNC)

Dr. Thomas R. White Program Chair

Student Director-Elect John Trimberger (WFU)

FM Department Chairs & Alternates

Fantastic Schedule for CME Lectures & Optional Seminars! 4 Half-Day CME Sessions from Sunday, July 3rd thru Wednesday, July 6th, 2011 Optional Seminars and SAMs Study Working Groups on Thursday, July 7th and Friday, July 8th, 2011

Register Online - Fast & Easy

www.ncafp.com/msfmd

Chair (ECU) Alternate (Duke) Alternate (UNC) Alternate (WFU)

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

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

Mott P. Blair, IV, MD Karen L. Smith, MD, FAAFP L. Allen Dobson, Jr., MD Michelle F. Jones, MD

The NCAFP Family Medicine Councils Advocacy Council

Robert L. Rich, Jr., MD, Chair Wiliam A. Dennis, MD, Vice-Chair

CME Council

James W. McNabb, MD, Chair

Health of the Public Council

Thomas R. White, MD, Chair

Practice Enhancement Council

Rhett L. Brown, MD, Chair

www.ncafp.com/ncfp


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.

ACOs Take Center Stage:

Vision Statement: Family physicians will be universally valued for their role in providing high quality care to the people of North Carolina. Core Beliefs: • • • • • •

Why Family Physicians Need to Take Notice

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:

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• • • • •

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 NCAFP strategic plan are located at www.ncafp.com/home/academy/mission

Inside

THE NORTH CAROLINA

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PCMH Build It….What if Patients Don’t Want to Come Home?........................................4 Academy Busy Advocating for Family Medicine at N.C. General Assembly...................6

PUBLISHED BY THE NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS, INC. R al ei gh, Nor th Ca r olina 27605 919.833.2110 • fa x 919.833.1801 http://www.nc a fp.c om M AN AG IN G EDITOR & PRODUCTION P eter T. G raber, MMC , CAE, Dir e c tor of Communic a tions

2011 Mid-Summer Meeting is A Great July 4th CME Getaway........................................8 2010 NCAFP Annual Report....................................................................................Center Residency Spotlight: Southern Regional Family Medicine Residency..............................9 Newest Family Medicine Scholars Announced............................................................12 Students and Residents: The Future of Family Medicine in North Carolina....................14

President’s Message............................................... 4

Advocacy & Policy.................................................................. 6

Residents & Students......................................................... 9

Practice Management................................................. 5

Meetings & Education........................................................... 8

Executive’s Message......................................................... 14


PRESIDENT’S MESSAGE

PCMH Build It…. What if Patients Don’t Want to Come Home? By Richard Lord, Jr., MD, NCAFP President

Since our Annual Meeting last December, the momentum behind the Patient-Centered Medical Home (PCMH) has continued to grow. In our state, Community Care of North Carolina (CCNC) networks are investing in their member practices to help them gain NCQA recognition as patient-centered medical homes. Blue Cross and Blue Shield of North Carolina has partnered with UNC Healthcare to pilot a PCMH practice for 5,000 patients covered by their plans. Active Health, Inc., is working with the State Employees Health Plan in an attempt to engage state employees in their own health and encouraging them to use practices that are PCMH-recognized. In addition, there is a multi-payer pilot involving PCMH in 7 rural counties where practices are receiving enhanced payments for Medicare, Medicaid, the State Employees Health Plan, and private BCBSNC through CCNC Networks. In N.C. we now have about 750 primary care physicians that are recognized by NCQA as patient-centered medical homes. Over the next few years it will be imperative that all family medicine practices across N.C. evaluate their ability to become patient-centered medical homes and seek recognition in order to benefit from the emerging payment models. As accountable care organizations (ACO) begin to develop, it is likely that the best operating ACOs will seek out practices that are PCMH-recognized. While obtaining recognition as a PCMH is important to us as family physicians, I believe we must also think about how we help our patients understand this model of practice and how we motivate them to want to rely on their PCMH for help in coordinating their health care needs. Not that many years ago, a new model of care was introduced called managed care. While managed care had its problems, it did slow the rise in the cost of care without compromising health outcomes, a goal many have for the PCMH model. One of the causes of the demise of managed care was patient dissatisfaction with a requirement that they first seek care through their primary care physician. Grumbach,1 et al., showed that patients want to have a family physician and they in fact valued having a family doctor, but they did not like having to obtain referrals before seeing a subspecialist. In order for the PCMH model to succeed, patients will have to value their medical home and want to utilize their medical home as their main entry point to the health system. Research in this area about the PCMH has been mixed. A study looking at the Group Health experience with PCMH found that patient experience was improved in their clinics that utilized a PCMH model.2 While data from 36 practices in the National Demonstration project did not show an improvement in patient experience.3 So what are we to do as we journey down this road of becoming PCMH recognized and trying to engage our patients with this model of care?

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Spring 2011 • The NC Family Physician

The first place we can look is to try and determine what patients’ value out of the doctor-patient relationship. A consensus report in 2004 identified 7 areas that were important to patients and physicians in the 21st century.4 These were communication, office experience, hospital experience, education, integration, decisionmaking, and outcomes. The first place to start would be for us to think about how a PCMH model will improve the areas that patients care about. For example, in a medical home model utilizing care managers, patients will have the opportunity to clarify questions about the care plan, as well as develop self-management skills. Using the technologies available in the PCMH model will improve the patients’ access to the office and to care. A main focus of the medical home is coordinating or integrating care for the patients we see. One key difference to make sure our patients understand is that in the PCMH model the payment arrangements are not based on savings, but on services provided and quality achieved. This type of payment is a distinguishing feature from managed care where the focus was on the cost-savings side of the equation. As we work at promoting the PCMH, we will need to use strategies that reach out to the community. But we will also need to understand the concerns of the individual patients we serve. The PCMH model has the ability to improve the care of the patients we serve and to improve our satisfaction in our careers as family physicians. We just need to be sure our patients -- who trust us with their care -- understand what this model is and what it is not. Having recently completed the NCQA application with colleagues in our residency practice, I can attest to the benefit of going through the application process. This process has helped us think about how we structure our care now and how we might improve upon it. We have not engaged our patients to this point and will need to think about this just as other practices around the state are doing the same thing. I encourage all of us to share ideas, successes and failures we have had in promoting this concept to our patients. References 1. Grumbach K., Selby J., Damberg C., Bindman A., Quesenberry C., Truman A., Uratsu C.; Resolving the Gatekeeper Conundrum: What Patients Value in Primary Care and Referrals to Specialists. JAMA July 21, 1999; 281(3):261-266 2. Robert J. Reid, Katie Coleman, Eric A. Johnson, Paul A. Fishman, Clarissa Hsu, Michael P. Soman, Claire E. Trescott, Michael Erikson, and Eric B. Larson. The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, and Less Burnout For Providers. Health Affairs, 29, no.5 (2010):835-843 3. Jaén, C.R., Ferrer, R.L., Miller, W.L., Palmer, R.F., Wood, R., Davila, M., Stewart, E.E., Crabtree, B.F., Nutting, P.A., Stange, K. Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project. Annals of Family Medicine, 2010;8(Suppl 1):s57-s67. 4. Johns Hopkins and American Healthways. Consensus Report Defining The PatientPhysician Relationship for the 21st Century; Disease Management, Vol. 7, no. 3, 2004.

www.ncafp.com/ncfp


P RAC T I C E MA N A G E M E N T

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ACOs Take Center Stage:

e’ve all seen and heard it before – the latest acronym that is going to bring savings Why Family Physicians Need to an ailing health care system and finally reward primary care for its role in reducing to Take Notice costs and preventing illness. So why should physicians be paying attention to the latest acronym, ACO, or Accountable Care Organizations? There are many reasons, but in short, for the first time in our country’s history, failure is not an option. The healthcare industry is on the verge of bankrupting the country. Primary care, more than any other facet of the health care industry, has been called upon to lead the charge to save it. Whether you are a solo practicing physician or employed by a hospital, educating yourself about The Family Physician’s the ins and outs of ACOs is ACO Blueprint for Success extremely important to your future, and particularly to your Preparing Family Medicine for the future earnings. The NCAFP Approaching Accountable Care Era is working hard to ensure its In Part One of the ACO Guide (full version available online), we members are educated about learned what an ACO is, that it will not be going away even if this important change. With several sessions on ACOs at part of health reform is repealed, and that most experts think our upcoming meetings, as it will be centered on a strong primary-care base, preferably well as an “ACO Boot Camp” a medical home model with financial accountability in August, we want to be infrastructure and shared savings contracts. But what, sure our members are not left specifically, will this mean for the family physician? in the cold, particularly by organizations that employ up to A. The Pros 60% of our members. Many family physicians find the biggest positives of the primary care-centered ACO The NCAFP, in a partnership with the movement to be respect and validation of the reasons they went to medical school Raleigh law firm Smith Anderson, recently and chose family medicine. There also is a sense of empowerment from being asked published a family physicians guide to to guide health care delivery and being given the tools to do so. There is a sense of ACOs, entitled, “The Family Physician’s fulfillment from leading change that will save lives and improve patient access to care. ACO Blueprint for Success.” The following is an excerpt from the document. To read There also is, of course, the potential for financial gain. Unlike other specialties, Family the entire ACO Blueprint, please visit Medicine has many opportunities in accountable care: prevention, chronic disease www.ncafp.com/aco-report. The NCAFP management, complex patient management, transitions in care, and is working with the AAFP to offer CME reduced hospitalizations, to name just a few. credits for reading the document. Educating yourself on the ACO model is B. The Cons critical and the window will not stay open Most family physicians are overworked, burned out, and do not have the time, long. It is in your best interest to be sure resources, or remaining intellectual bandwidth to get involved. You have seen this you are the most prepared and educated before, and it didn’t work out as advertised. You fear “they” will do it to you again. You person in the room when conversations have little capital and no business or legal consultants on retainer, like other health about ACOs take place.

Could an ACO Be a Good Thing for Family Physicians?

©2011 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.

care stakeholders. There is a shortage of the specialty and the ACO model is asking

See ‘ACOs Take Center Stage’ on Page 10 Spring 2011 • The NC Family Physician

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ADVOCACY & POLICY

Academy Busy Advocating for Family Medicine at N.C. General Assembly By Robert L. ‘Chuck’ Rich, Jr., MD, NCAFP Advocacy Council Chair

As we enter the New Year, we have welcomed a new legislature to Raleigh, with new majorities in the N.C. House and Senate. Regardless of your political affiliation, the economic downturn and subsequent budget shortfalls at both the federal and state level have led to significant pressures to curtail government spending. As many physician practices (especially primary care) are significantly dependent upon governmental reimbursement (Medicare and Medicaid), we are devoting significant lobbying efforts towards the preservation of provider rates and preservation of Community Care of North Carolina (CCNC). To accomplish these objectives, we have developed a working plan outlining our top concerns and our strategies to deal with them. Our first and foremost legislative priority remains the preservation and enhancement of CCNC and the protection of Medicaid provider rates to the extent possible. CCNC has been recognized by other states and the federal government as a possible model for cost effective national health care. The Academy has actively lobbied our legislators regarding the savings produced by CCNC since its inception and the potential for future savings. Since CCNC is a wholly NC-based program, we have also sought to emphasize the jobs that CCNC has brought to each county and the subsequent employment impact that would occur if the program was outsourced to The North Carolina House of Representatives. an out-of-state Medicaid HMO. With the growth of the Medicare 646-Waiver (to serve Medicare recipients in CCNC) and the start of the Multi-Payer pilot within the next few months (involving Medicaid, Medicare, The State Health Plan and Blue Cross Blue Shield of North Carolina), we have detailed to our legislators how these projects will continue to produce increased health care cost savings for N.C. These savings directly assist the state budget, with the Medicaid budget already running substantially under budgeted projections for the first half of the current fiscal year. As a provider, you may question the emphasis placed on CCNC by the Academy, particularly if you have few or no Medicaid patients. To that, we would like to emphasize the

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importance of the Medicaid Multi-Payer pilots. If they prove to be as successful as projected, they could become the care models utilized by major private insurance carriers in the state. As noted, BCBSNC is already one of the key investors in the seven county multi-payer pilot that CCNC will soon undertake. Another legislative priority focuses on the continued threat to scope-of-practice by non-physician providers. Currently, the state’s pharmacists have been granted immunization authority for adult influenza vaccines, as well as Zoster and pneumococcal vaccinations, with approval of the patient’s provider. The Academy continues to lobby against expansion of this authority, secondary to concerns about fragmentation of the Patient-Centered Medical Home. We have continued to argue that immunizing pharmacies be required to enter vaccination information into the North Carolina Immunization Registry (NCIR), similar to what our offices are being required to do. With support from local health department directors, insurance carriers, and even some members of the retail pharmacy membership itself, we are hopeful that there will be minimal movement on this issue during this legislative session. Additionally, we continue to closely monitor attempts by the nurse practitioner lobby to push for independent practice, as well as calls by other groups to expand the provider pool, including efforts by lay midwives. We have entered into dialogue with centrist members of the nursing community and emphasized our areas of commonality, as well as the importance of the nursing profession to the medical home concept, with the finding that there is less push for independent practice authority when we work together. Our next major legislative priority has been meaningful malpractice reform. As you may remember from years past, we have always lobbied for meaningful reform, but have found the legislative environment not favorable for substantial reform. With the start of this legislative session, the new leadership in both chambers have made it clear that they were receptive to liability reform, not only for medical providers, but for small business in general. In conjunction with the N.C. Medical Society, we have joined those liability reforms efforts in the legislature. There has been substantial movement on various components of the reform proposal, including caps on non-economic damages, limited liability for patient care provided in the Emergency Room, and other elements. Reform still faces significant challenges, but as of this report, most observers expect some measure of liability reform to be completed during this session. See ‘Advocacy’ on Back Cover www.ncafp.com/ncfp


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MEETINGS & EDUCATION

2011

MID-SUMMER FAMILY MEDICINE DIGEST

JULY 3-8, 2011 Myrtle Beach, SC

30+ AAFP Prescribed Credits -- Convenient Schedule -- Family Fun

2011 Mid-Summer Meeting is A Great July 4th CME Getaway Sunday, July 3rd – Friday, July 8th, 2011, in Beautiful Myrtle Beach, South Carolina

C

ome and enjoy the week of the Fourth of July with your friends and colleagues in Family Medicine while earning up to 30+ AAFP Prescribed credits. Program Chair Thomas R. White, MD, has crafted an outstanding program that will include topics such as Improving Major Depressive Disorder Treatment Outcomes, Optimizing Fracture Prevention in Primary Care, Coding, Vitamin D, Contraception Choices for Patients, Hypertension, Obesity, and more. The conference is structured around conveniently-scheduled General Sessions from Sunday through Wednesday that keep your afternoons free. The week wraps up with 2-days of optional seminars on Thursday and Friday.

The 2011 Mid-Summer Family Medicine Digest will present an excellent line-up of clinical education. General Session officially begins on Sunday at 4:00 pm and lasts until 9:30 pm that evening. Monday through Wednesday lectures are scheduled from 7:30 am to 1:15 pm. On Thursday, the meeting will shift to workshop mode and present a series of practice management seminars titled: The Patient-Centered Medical Home (PCMH), Accountable Care Organizations (ACO’s), Business Plans Matter, Taking Care of Yourself: Professional Self Care, and Risk Management. The conference wraps up on Friday with another series of seminars focused on office-based procedures. These will include Mastering Sprains, Strains & Dislocations, Cosmetic Procedures, and Skin Biopsies. Coinciding with Thursday’s and Friday’s seminars, there will also be two opportunities to participate

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in a SAMs Study Working Group. SAMs are targeted at physicians who have entered the American Board of Family Medicine’s (ABFM) Maintenance of Certification Cycle. The SAMs topics include Childhood Illnesses (Thurs.) and The Care of the Vulnerable Elderly (Fri.). All of the conference’s educational activities will be held in the Embassy Suites Hotel at The Kingston Plantation. Registering for the conference is easy and there’s multiple ways to do so. Registration can be completed online (www.ncafp.com/msfmd) or a printed registration form can be mailed or faxed to the NCAFP. Please note that a valid credit card number or a check made payable to the North Carolina Academy of Family Physicians must be included with all registrations. All AAFP members receive our Early Bird Registration Rate if registration is completed prior to June 6, 2011. If you require more information, please contact the NCAFP Meetings Department by calling (919) 833-2110 or via email at meetings@ncafp.com. Hotel accomodations can be made by calling The Kingston Plantation Embassy Suites at 800-Embassy or 800-876-0010. A block of rooms has been reserved by the NCAFP for Saturday, July 2 through Saturday July 9, 2011; rates are $235 per night plus tax. There are also a variety of condos and villas available. Prices for these range from $235 per night to $429 per night depending on size and location. The cut-off date for reserving your rooms at the NCAFP’s group rate is June 1, 2011. Make your reservations soon as rooms fill up quickly. The latest meeting and schedule information, including full seminar descriptions and social activities being held at the 2011 Mid-Summer Family Medicine Digest are available on line at www.ncafp.com/msfmd.

www.ncafp.com/ncfp


R E S I D E N T S & N E W F Ps

Southern Regional is Embracing Family Medicine’s Changing Times Fayetteville’s Southern Regional-AHEC Family Medicine Residency Program (SR-AHEC) was established in 1976 and is dually-accredited by the ACGME and the AOA. The program is affiliated with Duke University Medical Center, yet incorporates medical education from the University of North Carolina at Chapel Hill, Campbell University, and East Carolina University. The program’s clinical facility sits directly across from its primary teaching hospital, Cape Fear Valley Medical Center. Cape Fear Valley is a 765-bed hospital providing Pediatric, Cardiac, Medical and Surgical intensive care, OB/GYN, Emergency, Cancer and Cancer rehabilitation services. SR-AHEC serves a diverse patient population through an integrative, team-based approach. The program’s main ambulatory clinic, the Family Medicine Center, serves approximately 29K patients annually, the bulk of which are insured by either contracted, TriCare, Medicare, and Medicaid payors. The clinic’s on-site services include radiology, pharmacology, complete diagnostic lab services and behavioral care. The program currently utilizes GE’s Centricity electronic health record system and was just recently awarded NCQA PPC-PCMH Level I recognition. SR-AHEC is the seventh NC-based Family Medicine residency to achieve NCQA PCMH recognition. The most attractive aspect of SR-AHEC for incoming physicians is its unopposed status within Cape Fear Valley Medical Center. With no other residencies Dr. Samuel Warburton, Interim Program Director, describing based in the hospital, SR-AHEC and its team-based approach. each resident has the opportunity to work directly with attendings almost immediately upon entering. “One of our strengths is that we are an unopposed residency. So if you want to work, and get your hands wet, come here,” noted Interim Residency Director Dr. Samuel ‘Woody’ Warburton. ‘Our residents really get a deeper clinical training experience - and earlier - because of this arrangement.’ The program also supports this with a number of strong community-based rotations. Dr. Warburton also noted that because the program brings together both allopathic and osteopathic teaching faculty, residents can take

advantage of a greater degree of musculoskeletal approaches. SR-AHEC was the first osteopathic-accredited residency in the state and with Campbell University’s anticipated medical school on the horizon, it is expected to continue to add key benefits. Residency training in Family Medicine is an intense time for all new physicians. SR-AHEC emphasizes life-work balance and encourages monthly resident outings and activities. This keeps the program close-knit and family friendly. The program also pays close attention to overall resident duty hours. ‘All of our residents make their numbers and our duty hours are real. We take duty hours seriously, don’t have violations, and are proud of that,’ noted Dr. Warburton. Dr. Warburton also indicated that SR-AHEC is in a good position to adapt to the coming duty hours changes since Cape Fear Valley already operates a night-float system. SR-AHEC is coming off a strong MATCH this past March, having recruited seven new physicians. The program has instituted a couple of changes to its recruiting process that impacted its success. Residents have become more engaged in the process and are taking on a much larger role in interactions and interviews. Another improvement has been its new ‘individualized second-looks’ where applicants are invited to re-visit the program and experience a half-day of hospital and office rounds. This experience provides them with a closer glimpse of both in-patient and clinic operations. The program is also using some webbased tools to ensure that all applicants hear the same message. “I think the future for our program looks very bright,” noted Warburton. ‘We have a very strong program, strong faculty, and we embrace change as well.’ SR-AHEC is currently recruiting for a Residency Program Director, and looking to supplement its current teaching faculty. Longer term, it is anticipated that a new clinical facility will help it stay on the cutting edge, especially as it continues its patient-centered transformation. “It’s real important - and we tell our applicants - that this is the way primary care and family medicine is going to be practiced in the future. (As a resident) you want to be learning in that kind of practice model,’ commented Warburton.

Spring 2011 • The NC Family Physician

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‘ACOs Take Center Stage,’ continued from p. 5.

that you take on more responsibilities. It is hard to give up independence and rely on specialists and hospitals. A hospital-employed physician may feel powerless. As a result, your profession risks not recognizing in time the magnitude of its role, so that the opportunity for ACO success passes by and is replaced by dismal alternatives. C. Suppose I’m Employed by the Hospital? (or Foundation or Clinic) Your pathway may be different, but the same pros and cons apply generally. By being on the “inside,” and having read this ACO Blueprint, you may actually have more influence to shape a successful ACO that fairly values the prime role of primary care. However, you may have more difficulty freely associating with an ACO outside of the hospital’s ACO.

ACO Strategies for the Family Physician A. Awareness/Leadership/Urgency - Family medicine needs to know what an ACO is, how to recognize one with a likelihood of success, and the professional opportunities and risks involved. A number of leaders need to get up to speed and be catalysts for this transformative change. These champions need to act with confidence, but also a sense of urgency. This is mentioned as a strategy in and of itself because almost every properly created ACO will empower an informed family physician, but if too many primary care leaders do not recognize this, the entire ACO movement may fail. B. Readiness Assessment of Your Practice - Evaluate your practice’s readiness for accountable care. As noted, preparing to be, or participating in, a medical home is entirely consistent with this readiness effort. Remember that of the 8 Essential Elements of an ACO, culture change is the hardest. Cultivate relationships, get outside of the “silo,” have “what if” creative conversations with open-minded specialists, other primary care physicians, allied providers, and hospital administrators. Assess your HIT, data capture, care capabilities, patient education, and self-support tools and how you can increase value. C. Create or Join a Medical Home Network - The Medical Home is a precursor to the recommended primary carecentered ACO. As also noted, many high-impact, highreward opportunities accrue to family physicians through a medical home component of an ACO. Recent successes of medical homes should stimulate this movement even more. As physician-owned Medical Home networks become more common, a wise strategy may be simply to join an existing one if it has, or will have, the 8 Essential Elements for ACO success identified in Part One of the ACO Guide. This is a rare opportunity, not available to specialist physicians, to not only have such a high “target field” of high-impact ACO initiatives to choose from, but also to have friendly pre-existing vehicles becoming available. The statewide confederation of 14 Medical Home Networks under the

10 Spring 2011 • The NC Family Physician

nonprofit umbrella organization, North Carolina Community Care Networks, Inc., is a case in point. If a medical home network does not exist, creating one should be a basic strategy. D. Evolve to Medical Home-Centered ACO - The differences between an ACO and a medical home are the former’s ability to incentivize accountability for value delivery through administration of shared savings or similar financial arrangements and to reach out to include specialists and hospitals. In some areas, the medical home attracts payors interested in efficiencies and quality improvement and it becomes the contracting vehicle. Select specialists and hospitals contract with the medical home, sometimes through a sub-ACO. In other areas, a hospital or health system jointly controls the ACO and contracts with the medical homes to complete its network. If the 8 Essential Elements for ACO success are present, either option or variations thereof will all work well. If these options are not available, your strategy should be to work to make sure your ACO has the core primary care components and high-yield primary care initiatives outlined in the ACO Guide. E. Hospital-Employed Physician Strategies 1. Engage – Thoughtful leadership to help the hospital create a successful ACO is the best strategy. Get informed, get involved. Make sure the ACO’s goals are aligned with all stakeholders and are clearly articulated. Will the ACO have the 8 Essential Elements outlined in the ACO Guide? Is there a culture of partnership? Seek involvement in anything regarding best practices, incentive payments, compensation design, bundled payments, etc. Seek compensation for this administrative time. Become a champion if there is a chance for success. 2. Compensation Design – Your employment agreement should have financial incentives to reward accountability for the success of ACO initiatives over which you have control. Negotiate so that your shared savings distribution will be in addition to, and not limited by, any salary cap. Some contracts tie a percentage of compensation to the success of the entire organization. This can be rather attenuated, since you may not be able to influence this overall metric meaningfully, but it is better than having all compensation based on personal productivity. 3. Suppose Your Hospital’s ACO is Fatally and Irrevocably Flawed? Attitudes are changing rapidly regarding ACOs, so “never say never,” but if you determine that the ACO will never pass muster, this raises the question of the legality of economic credentialing and non-compete covenants that may bar you from participating in other ACOs. As of the date of this writing, these are untested legal concepts. Traditionally, freedom of contract prevails unless the restriction will limit access to needed care or offend some other public policy. Since primary care is in such short supply, if the prohibition on participating in an ACO will limit access by patients contracting through it, it might not be enforceable as against public policy. The AAFP has recommended legislation prohibiting a single ACO “lock in” for employed physicians.

www.ncafp.com/ncfp


Since the hospital employs you, it also stands to profit from your shared savings distribution in any ACO. It may view this similarly to your practice signing up with a desirable managed care company. However, the hospital might not accept your helping to make a competitive threat more successful.

What Specific ACO Initiatives Should Family Physicians Target? Other specialties around the country are scrambling to determine which ACO initiative, if any, allows them to demonstrate value, and thus gain reward. Thanks to the track record of the Medical Home, the family physician does not have this problem. As noted, a nascent ACO should involve physicians to design a deliberate targeting process. Looking first at the recommended target zones:

• prevention • chronic disease management • reduced hospitalizations • complex patient management • effective transitioning

The ACO matches its strengths against the community’s largest care deficiency. One looks also to the targets with the highest impact and those most quickly accomplished the most easily. With the success of Medical Homes around the country, family physicians have a “menu” of targets to choose from. See what is working elsewhere but do not be afraid to innovate.

Next Steps? It is ironic that the potentially career-changing opportunities for family medicine may never be realized because not enough family physicians become engaged in time. We recommend concerted strategic briefing efforts at the national and state academy levels, and increased local leadership by focused family physician champions. NCAFP will be providing several education opportunities about ACOs, including an ACO Boot Camp in August, so be sure to stay posted and get involved. This window will not stay open very long. The CMS Shared Savings Program starts in 2012 on a voluntary basis. With primary care the only required specialty, it would seem logical to get involved early to help create a standard of having a strong primary care role in ACOs.

Excerpted from ‘The Family Physician’s ACO Blueprint for Success,’ authored by Julian ‘Bo’ Bobbitt, J.D., of Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P., 2011, Part II: ACO Strategies for the Family Physician.

Practice Tracks

Sleep Medicine CAQ Pathway Expiring for Family Physicians 2011 is the final year that board-certified family physicians can qualify via either one of two practice eligibility pathways for the Sleep Medicine Certificate of Added Qualifications (CAQ) Examination. These pathways currently allow physicians to apply for this exam based on previous experience and clinical care of sleep disorders (Pathway A), or prior certification by the American Board of Sleep Medicine (Pathway B). These pathways sunset after 2011. The exam is scheduled this year for November 10, 2011. For more information about the American Board of Family Medicine’s Sleep Medicine CAQ exam, please visit https://www.theabfm.org/caq/sleep.aspx. Diplomates may contact the ABFM Support Center with further questions: help@theabfm.org or 877-223-7437.

NC Immunization Program No Longer Supplying Tripedia® Sanofi Pasteur, manufacturer of Tripedia®, will no longer be supplying this vaccine and anticipates that current supplies will last only through the end of April 2011, based on demand. Effective May 1, 2011, the NC Immunization Program (NCIP) is no longer providing this product. The NCIP will continue to offer two other DTaP vaccines, Infanrix, manufactured by GlaxoSmithKline, and DAPTACEL, manufactured by Sanofi Pasteur. The following DTaP-containing combination vaccines will also remain available through the NCIP: Pediarix (DTaPHep B-IPV), manufactured by GlaxoSmthKline; Kinrix (DTaPIPV), approved for the booster dose only, manufactured by GlaxoSmithKline; and Pentacel (DTaP-Hib-IPV) manufactured by Sanofi Pasteur. For questions regarding the use of these products, contact the Regional Nurse Consultant for your region, or the nurse on call in the central office at 919-707-5575. Questions regarding ordering vaccines should be addressed to the NCIP Help Desk, at 1-877-873-6247.

Medicaid Recovery Audit Program Postponed By CMS CMS’s much maligned Recovery Audit Contractor program (RAC) did not roll-out on April 1st as originally planned. CMS announced in late February that they were postponing implementation of the state-based RAC programs. The final RAC rules and a new implementation deadline are expected to be announced later this year. The AAFP, along with a number of national health organizations, have been critical of the program and have been hammering CMS to improve it. Last year’s health reform legislation requires that all state Medicaid programs contract with RACs to identify overpayments to physicians and other providers.

Spring 2011 • The NC Family Physician

11


STUDENT INTEREST ~ The Family Medicine Interest & Scholars Program ~

New Family Medicine Scholars Announced The NCAFP Foundation recently announced its new class of Family Medicine Scholars for the class of 2014. These (12) students are the second group to participate in the Family Medicine Interest & Scholars Program, an initiative jointly-supported by the Blue Cross and Blue Shield of North Carolina Foundation and the NCAFP Foundation. The program received increased interest this year and the selection competition was fierce. All students who applied demonstrated the potential to excel in Family Medicine. Collectively, the group offers very diverse academic, work, and volunteer experiences, and they hold a wide range of interests. Each new Scholar will begin their experience this summer with a 4-week externship with their Master Preceptor. Congratulations to the following selected participants: Brody School of Medicine at East Carolina University— Joshua Carpenter, Emily Dell, Katy Kirk, Marie Moser, and Emily Ross. University of North Carolina School of Medicine— Laura Cone, (Cameron) McLean Ellis, William McLean, Amy Nayo, and Cleveland Piggott. Wake Forest University School of Medicine— Vanessa Consuelo-Gallegos and Lindsey Wright. In related news, the 2013 Family Medicine Scholars class are quickly approaching their 3rd-year of medical school. Each of these students attended the NCAFP Winter meeting last December and had the opportunity to touch base with their Master Preceptor at that time. Currently, they are focusing on preparing for the USMLE Step I Exam, and although most will be taking this exam in June, a few students have already cleared that hurdle. After Family Medicine Day (May 21st) and their Step I exam, some will Scholars and Preceptors met in Asheville last December. Pictured is Dr. Mark Beamer be looking ahead to attend the National Conference of with Holly Love. Family Medicine Residents & Medical Students in Kansas City. Then it will be back into the clinical setting where they will begin their 3rd year rotations and have the opportunity to complete their Family Medicine rotation with their Master Preceptor again. We wish you well along the way!

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AAFP President Dr. Roland Goertz was the guest speaker at the Duke FMIG Annual Banquet in early April.

AAFP President Roland Goertz Addresses Duke FMIG AAFP President Roland Goertz, MD, was the keynote speaker at the Duke University Family Medicine Interest Group’s (FMIG) annual banquet held on April 6th. In his presentation, Dr. Goertz emphasized the current excitement and energy around Family Medicine, especially as health system reform and transformation continue. Approximately 50 people attended the banquet, including NCAFP President Richard Lord, Jr., MD; AAFP Board Director and Past President Conrad Flick, MD; NCAFP At-Large Director Holly Biola, MD; Resident Director-Elect Matt Kanaan, DO; and NCAFP Foundation Resident Trustee Mo Shahsahebi, MD. The NCAFP Foundation provides financial support for all state FMIGs to promote the specialty of Family Medicine to medical students. This support was recently increased with the launch of The Family Medicine Interest & Scholars program.

ECU #1 for Family Medicine Production According to AAFP The Brody School of Medicine at East Carolina University really knows how to produce Family Physicians. The AAFP notified leaders at Brody that for the years 1999 through 2009, the average national percentage of Family Medicine graduates (among 124 schools) was 9.59%. ECU Brody’s average percentage during this same period was 19.46%! This statistic ranks Brody the top in the nation for the percentage of medical students choosing Family Medicine residencies for the years 1999 to 2009. Congratulations on a fantastic job!

www.ncafp.com/fmd

12 Spring 2011 • The NC Family Physician

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Spring 2011 • The NC Family Physician

13


EXECUTIVE’S MESSAGE

Students and Residents: The Future of Family Medicine in North Carolina By Gregory K. Griggs, MPA, CAE, Executive Vice President

I’ve heard many of our members say, “One of my biggest concerns is who will take care of my patients when I retire.” And it’s true. We must be concerned about the pipeline of future family physicians to care for the people of North Carolina. As the large majority of internists now specialize and some estimates indicate that 50 percent of pediatricians are now specializing, primary care could become a single specialty career choice: Family Medicine. As a result, it’s crucial that we do all we can to feed the pipeline for tomorrow. And that’s exactly what we are trying to do. We’ve written a lot about our Foundation’s Family Medicine Interest and Scholars Program, jointly funded by the Blue Cross and Blue Shield of North Carolina Foundation and the NCAFP, but much more is going on to nourish and grow tomorrow’s family physicians. We’ve recently announced our second class of “Family Medicine Scholars,” as well as students selected for the NCAFP Externship Program. But let

The NCAFP is working hard to build student interest in Family Medicine. Over 50 students attended last December’s Annual Meeting in Asheville for learning, leadership, and networking.

me tell you about a few of our other efforts to help insure an adequate pipeline of future family physicians for our state. First, we have begun a concerted effort to visit every Residency Program in North Carolina, and let our residents know that the NCAFP is there for them – in the Legislature, for practice management support, for their ongoing education and more. We also want to encourage every residency program graduate – or at least as many as possible – to stay and practice

14 Spring 2011 • The NC Family Physician

right here in North Carolina. As we’ve started this process, it’s been an eye opening experience for me. We’ve already made it to Fayetteville, Wilmington, Greensboro, Charlotte and Concord, with more visits scheduled throughout the next year. Next, we have continued our efforts to get both medical students and residents involved in public policy issues. In December, I had the privilege of participating in a panel before all of the second-year medical students at Duke to discuss how physician organizations work to influence public policy. This resulted in 11 of the students spending a day at the General Assembly with me in March. What a talented group of young professionals. While not all of them are interested in family medicine, they did get to hear a lot about primary care, our perspectives, the Medicaid program and Community Care of North Carolina. The students asked great questions, had stimulating conversations with a number of Legislators and even had a spirited discussion with a group of lay midwives that were protesting for the right to do unsupervised home deliveries. Finally, in March, Tracie Hazelett, our Manager of Family Medicine Interest Initiatives, and I travelled to Charleston, S.C., for a regional meeting on how to increase student interest. Others from North Carolina at the day-long meeting included a medical student, a resident, a practicing physician, and representatives of both residency programs and medical schools. About 50 people attended the meeting from 12 different states. It was a great day with a lot of discussion and new ideas. Some of the concepts we hope to implement include: • A presentation to better prepare medical students for what they may hear about Family Medicine when they enter specialty wards at academic medical centers. • Outreach from our medical school’s Family Medicine Interest Groups to some of the STEM (Science, Technology, Engineering and Mathematics) High Schools that focus on health professions. • And outreach from our residency programs to health professional career groups at major universities around the state.

So remember, not only is the Academy supporting you as a practicing physician, we’re trying to help you have colleagues for the future and someone to ultimately care for your patients when you retire. If you’d like to help, simply e-mail me at ggriggs@ncafp.com.

www.ncafp.com/ncfp


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‘Advocacy,’ continued from p. 6 Other areas of legislative priorities for the Academy include concerns about how federal health care reform will be implemented here in our state and its effects on primary care, the development of Accountable Care Organizations, and physician involvement in those efforts. We are also monitoring the development of the Campbell University osteopathic medical school and any proposed DO residencies for the state. We are encouraging member participation in the Doctor of the Day program -- White Coat Wednesdays -- and other opportunities for physician involvement in the lobbying process during the legislative session. This is a brief outline of concerns that we have highlighted for this legislative year, some of the background behind those concerns, and some of our proposed actions. Your legislative staff, including our government affairs consultant, began planning our proposed actions for this legislative year immediately after the election of 2010, and has continued to adjust those plans since the legislature convened in January. To help accomplish those goals, the Academy has utilized every available opportunity to educate legislators about our positions and key issues. In conjunction with the NCAFP staff, we have already called upon key physician contacts in various districts to help in this process. There have been significant successes achieved by those physician contacts in educating legislators about our concerns. Finally, we continue to ask for your contributions to our political action committee, FAMPAC. Although we cannot disperse its funds while the legislature is in session, we are actively planning for the next election cycle when those funds will be put to use, helping to elect legislators, sensitive to our issues. Please consider making a contribution to FAMPAC. You can do so from the convenience of your personal computer by visiting www.ncafp.com/fampac.

AHRQ Reports Confirms that Disparities in Care Continue The Agency for Healthcare Research and Quality (AHRQ) recently released the 2010 National Healthcare Disparities Report and the National Healthcare Quality Report in collaboration with the U.S. Department of Health and Human Services. The AHRQ produces these reports annually and they measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness and the efficiency of care. The Disparities Report more specifically evaluates healthcare quality and access among racial, ethnic, and socioeconomic groups and other priority populations. Both reports found that improvements are being made in the quality of care. Quality healthcare refers to delivering services in ways that are safe, timely, patient-centered, efficient, and equitable. However, while quality continues to improve, disparities based on race/ethnicity and socioeconomic status have not changed. One reason for this is that access to care showed no improvement, and, in some measures, got worse. Other barriers for patients include access to care, provider biases, poor provider-patient communication, and low health literacy. The AHRQ’s full report is available at http:// www.ahrq.gov/qual/qrdr10.htm. The NCAFP remains committed to addressing these barriers to quality healthcare through ongoing educational efforts. Physicians and practices should be on the lookout for educational sessions at the Academy’s major meetings that address this issue.

UNC Study Shows Significant Reductions in Tooth-Decay in IMB Program Into The Mouths of Babes (IMB), a program that assesses risks for dental caries and applies fluoride varnish in Medicaid toddlers, has been shown to be effective in reducing tooth decay! The NCAFP and the NCAFP Foundation were major contributors in establishing this statewide project in 2000. The IMB model has since been duplicated by dozens of states nationwide. Findings from UNC’s study have been published in the online journal Pediatrics and show ‘that children up to age 6 who had four or more IMB visits before they turned 3-years old had, on average, 17 percent fewer treatments for dental caries than a similar group who did not.’ This is a significant reduction and great news! A press release issued by UNC announcing the findings is available at the NCAFP website.

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