V8n3

THE NORTH CAROLINA

Volume 8 Issue 3 / Summer 2012

quarterly news in north carolina family medicine

Dr. Conrad Flick Runs for AAFP President-Elect

Summer 2012 • The NC Family Physician

1

2011-2012 NCAFP Board of Directors Executive Officers

2012 Winter Family Physicians Weekend

President Brian R. Forrest, MD President-Elect Shannon B. Dowler, MD Vice President William A. Dennis, MD Secretary/Treasurer Thomas R. White, MD Board Chair Richard Lord, Jr., MD Past President (w/voting privileges) R.W. Watkins, MD, MPH Executive Vice President Gregory K. Griggs, MPA, CAE District Directors District 1 - Jessica Triche, 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 - David A. Rinehart, MD At-Large Holly Biola, MD At-Large Charles W. Rhodes, MD IMG Physicians Nalini S. Baijnath, MD

Nov. 29th to Dec. 2nd, 2012

Minority Physicians Enrico G. Jones, MD New Physicians Nadine B. Skinner, MD NC Family Medicine Departments Michael L. Coates, MD

The Grove Park Inn

Family Medicine Residency Directors William A. Hensel, MD Resident Director Matthew Kanaan, DO (Duke)

Asheville, NC

Resident Director-Elect Mo Shahsahebi, MD (Duke) Student Director John Trimberger (WFU)

Fantastic Schedule for CME Lectures Engaging Optional Seminars!

Student Director-Elect Katy Kirk (ECU)

FM Department Chairs & Alternates

See page 10

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

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

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

Additional meeting information is online at www.ncafp.com/wfpw

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 Health of the Public Council Practice Enhancement Council

Thomas R. White, MD, Chair Charles W. Rhodes, MD, Chair 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.

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:

Dr. Conrad Flick Runs for AAFP President-Elect

• • • • •

Quality, evidence-based, timely education.

Professional excellence and integrity.

Fiscal responsibility, organizational 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/academy/mission

See page 8

Inside

THE NORTH CAROLINA

..,

Family Physicians Need to Be at the Helm of Today’s Health Care Teams...................... 4

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

President’s Message............................................... 4 Executive’s Message................................................... 6 Chapter Affairs........................................................... 8

Advocating at the National Level - Help us Elect Dr. Conrad Flick................................ 6 Conrad Flick Runs for AAFP President-Elect.................................................................. 8 November’s Annual Meeting will have Something for Everyone................................. 10 NCAFP Joins NC Accountable Care Consortium......................................................... 17

Meetings & Education......................................................... 10 .

Policy & Advocacy................................................................ 12 .

Members & Membership...................................................... 14

Student Interest................................................................15 Residents & Residency.....................................................16 Practice Management............................................................ 17

PRESIDENT’S MESSAGE

Family Physicians Need to Be at the Helm of Today’s Health Care Teams

By Brian R. Forrest, MD NCAFP President

When asked about the heroics of the landing on the Hudson River, Captain Sully was very quick to point out the other members of his team and their valuable contributions to getting everyone off of that plane safely. There is no doubt that the flight attendants, the copilot, and others played important roles and all were contributors. The copilot was even trained as a pilot and was able to land a plane under normal conditions with no problem. In retrospect though, would anyone have wanted the copilot to land that plane on the Hudson that day? Would anyone have expected a flight attendant to take the wheel, control the flaps, and make that precision landing that saved all of those lives? I doubt it.

There are two professions that rely heavily on experience, training, and competence where life and death decisions are often the consequence: pilots and physicians. Yet, we are in a time when many are wanting to allow someone other than Captain Sully to land that plane. Some would say that it takes too much training to get a pilot that experienced and so we should let someone else

There are two professions that rely heavily on experience, training, and competence where life and death decisions are often the consequence: pilots and physicians. Yet, we are in a time when many are wanting to allow someone other than Captain Sully to land that plane. on the crew try it. After all, it takes years to attain those skills and judgement.

What if there is a pilot shortage and we just do not have enough to go around?

Would it be easier and quicker just to let brand new copilots move right into the pilot position? Or maybe we should fast track some other allied airline professional to do the work - like the person at the check in counter. After all, they have been around the airline industry for years and have lots of airline-

4 Summer 2012 • The NC Family Physician

related training. Just an instrument class here and there and they could replace the pilot, right? What about letting the flight attendants do a weekend class or watch the pilot land a few times and then let them just have a go at it. They could even land small less complicated planes in someone's back yard at home.

Some would argue that in the early days of flying most planes were landed in fields; so doing that more would make it safer, right? After all, some people like to have this done in a lower technology manner at their home. Wouldn't that take care of the shortage and make flying less expensive? Wouldn't that make it so that more people would have the opportunity to be pilots. Wouldn't that give the public more options of ways to travel?

What about those that work in the airline areas that are more specialized?

Some have detailed procedural training in doing things like fueling the jet. Still others make sure that the jet turbines are maintained and safe. You certainly would not be happy if you arrived at your destination safe and sound but without your baggage. There are specialists whose only job is making sure that that job is done properly. There is a need for those specialists, but there would not be a need for them without the pilot.

There needs to be facilities where the pilots do their work. Airports are a necessity. These are large and expensive buildings with highly specialized equipment, well-trained specialists in a multitude of areas. These are high technology centers where equipment exists that can put high tech planes in the sky and keep them maintained. But how many does one town need? And although they are essential to air travel, they are useless without the pilots. You can board or land a plane in a field if need be - but you have to have someone at the helm. In a similar way we need hospitals, but they are not necessarily the centers of healthcare, in fact less than 1% of patients get medical care at a hospital each year.

My point is this, I want Captain Sully flying that plane and ensuring the safety of the public. In the same way, I want a Family Physician navigating me around the twists and turns of a complicated health care system, making sure that both their expertise and greater experience and broad training give me the best opportunity to have optimum health.

I know who I want at the helm.....How about you?

Dr. Forrest completed medical school at UNC Chapel Hill and his residency in Family and Community Medicine at Wake Forest University in Winston-Salem. He is the Founder and President of Access Healthcare and the Access Hypertension Clinic in Apex, NC. His special interests include hypertension, new models of practice and prevention of cardiovascular disease. He is an amateur magician and teaches martial arts as a Black Belt in the discipline of Hap Ki Do.

www.ncafp.com/ncfp

The value of membership with Medical Mutual has never been greater!

• Additional discounts

• Enhanced coverages

• Member savings accounts

• Improved practice resources

• Cash dividends

• Timely risk management services & tools

Professional Liability

Employee Benefits

Commercial

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

Find out more by calling 800.662.7917 or visiting www.medicalmutualgroup.com Corporate Sponsor of the North Carolina Academy of Family Physicians

Exclusive endorsement of the

EXECUTIVE’S MESSAGE

Advocating at the National Level – Help Us Elect Conrad Flick, MD

By Gregory K. Griggs, MPA, CAE Executive Vice President

This quarter I’ve chosen to take a different tact in my regular column in the North Carolina Family Physician. I want to highlight a great opportunity that our state and national Academies have this October. Dr. Conrad L. Flick (Raleigh), one of our outstanding leaders and past president of the Chapter in 2004, is seeking the office of President-Elect of the American Academy of Family Physicians during October’s AAFP Congress of Delegates.

Dr. Flick faces very strong competition. All three candidates for this position have served on the AAFP Board for the last three years and all are outstanding in their own right. Dr. Reid Blackwelder is a faculty member in a residency program in Tennessee, and Dr. Laura Knobel is in solo private practice in Massachusetts. But let me take a few minutes to call you to action and tell you why I think Dr. Flick is the right person for the job. Many of you already know Dr. Flick well, but let me review a bit about his background.

First of all, Dr. Flick has boots-on-the-ground, private practice, business experience. He has worked in both employed practice and private practice situations, serving as a managing partner for Family Medical Associates of Raleigh for the last 13 years. He truly understands the difficulties you face as you balance serving your patients while dealing with the many administrative and business aspects of practicing medicine.

Dr. Flick led his practice through a transformation as an early adopter of Electronic Health Records, led the effort to achieve Level III Designation for Patient Centered Medical Home, and in achieving meaningful use certification.

At the same time, he has been one of the officers of his Independent Practice Association (Key IPA), helping lead them to the decision to become a community of medical homes with all their members achieving and maintaining level 2 or 3 PCMH recognition. He has been a true innovator at the ground level of medicine in North Carolina.

Second, Dr. Flick is a passionate advocate – for his patients, his profession and his community. He has led both our Advocacy Council at the state level and the AAFP Commission on Governmental Advocacy. At every turn he is working to ensure that his patients get the care they need and your profession gets the respect it deserves. Whether it is lobbying at the NC General Assembly or presenting on Capitol Hill about the merits of Community Care of North Carolina, Dr. Flick has what it takes to be an advocate on behalf of the AAFP and those it represents.

And finally, he is an excellent spokesperson for the profession. He is comfortable speaking with anyone. Whether counseling a patient in his office or testifying before Congress, Dr. Flick’s congenial personality puts you at ease.

Over the years, both our Chapter and the NC Medical Society have turned to him time and time again when we received a call from the media looking for someone to interview on an important healthcare topic. Whether it’s a quick newspaper interview or an on-camera discussion in his office, Dr. Flick is prepared and professional when it comes to media relations, a crucial role for the president of AAFP.

6 Summer 2012 • The NC Family Physician

When it comes to your patients, we always talk about getting them the right care at the right time in the right place. So it is also with this year’s AAFP election. I believe Dr. Flick is the right person at the right time to provide the right care for your profession as the national leader of AAFP. The next few years are going to be crucial for healthcare in America. No matter what happens during the U.S. presidential elections in November, healthcare is going to be at the forefront of our discussions. Family physicians are well positioned to help improve the quality of care for our citizens while at the same time holding down costs. We’ve proven that in North Carolina with CCNC. But who the spokesperson is for your Academy during this critical time is extraordinarily important. I believe Dr. Flick is that right spokesperson for family medicine.

The next few years are going to be crucial for healthcare in America. No matter what happens during the U.S. presidential elections in November, healthcare is going to be at the forefront of our discussions.

So what can you do? I will give you two simple answers.

First, contact your colleagues in other states. Each Chapter of the AAFP has two votes in the Congress of Delegates. While your colleague may not be the delegate for their Chapter, they may know their delegates and can pass on your endorsement. Not everyone knows Dr. Flick as well as we do, so it helps to spread the work about his qualifications.

Second, consider making a contribution to his campaign. While AAFP has certainly cut down on the cost of running for national office by restructuring how campaigns work, it is still costly for your Chapter. Consider making a contribution to the NCAFP and designate it to Dr. Flick’s campaign. Every dollar helps.

You’ll find more in this magazine about Dr. Flick’s campaign, including his answers to a series of questions about the issues of today and why he decided to seek this important office. I know you will join me in doing everything we can to help elect Dr. Flick the next president-elect of AAFP.

www.ncafp.com/ncfp

We’re with you all the way

The defendant’s table can be a lonely place

A lawsuit can make any physician feel anxious. That’s why MagMutual’s personal handling of each case is so important. And that’s also why we have started the Doctor2Doctor Peer Support program. This program connects physicians in litigation with MagMutual-insured doctors who have been there before.

Doctor2Doctor is just one of MagMutual’s physicianfocused programs. To learn more call 1-800-282-4882 or visit MagMutual.com.

Insurance products and services are issued and underwritten by MAG Mutual Insurance Company and its affiliates.

Chapter Affairs ~ national leadership ~

Dr. Conrad Flick Runs for AAFP President-Elect NCAFP Past President Dr. Conrad L. Flick (2004) of Cary is a candidate for AAFP President-Elect. The election is this coming October at the AAFP’s Congress of Delegates.

To offer members insight into Dr. Flick’s candidacy and leadership experience, the North Carolina Family Physician asked him to share his thoughts on a number of key questions. His responses follow.

NCAFP: Leading the AAFP takes a major commitment on your behalf. What’s driving you to seek this role and what would you like to accomplish?

CLF: Ensuring that ALL patients can have the right care at the right time in a cost effective manner is the driving force behind my desire to lead the AAFP. I believe we are at the most crucial time for healthcare in more than half a century.

Regardless of what the Supreme Court had said or the outcome of our national elections in November, healthcare must, AND WILL change. We must be willing to work for the right change. Employers in this country now see the value of primary care and are advocating on our behalf – IBM is just one such example. But we must stand up and advocate for two core principles we all believe in: First, Providing Quality, cost-effective care for our patients, and second, that as family physicians we are valued and appropriately compensated for the care we provide and the contributions we make.

What happens in the next 2-3 years could determine the course of our healthcare delivery and payment system for decades to come. Primary care must be the foundation of whatever system is in place. I believe our time is now, and I’m ready to work toward change that will benefit our patients, our communities and our members.

8 Summer 2012 • The NC Family Physician

NCAFP: How did you become involved in organized medicine and how does it relate to your desire to run for President-elect?

CLF: My parents taught me the importance of giving back, not just one-on-one, but to a larger community. Early in my professional career, my mentors encouraged me to become involved with service on a state level, which ultimately grew into positions with our national Academy. For me, what I love is advocacy. Being an advocate is what makes each of us good family physicians. The role of advocate might be with one patient during a hospitalization or with that patient in dealing with their local insurer. It can also encompass advocating for our entire membership with a national insurance carrier or before a Congressional committee. And once you become involved -- whether in activities within or outside of our profession – and begin to gain mentors and develop friendships, you are instilled with a desire to do even more.

I recently read a book my father gave me called, I Dare You! by William Danforth. He states early in the book that “our most valuable possessions are those which can be shared without lessening, those

which when shared, multiply.” This is something we all understand as we serve our patients. It is my goal to pass this concept – as well as the desire to serve and to be an advocate -- onto as many students, residents and young physicians as possible. What we accomplish together as an organization will help all of our patients, as well as our specialty and its members – both in small and large practices, independent or employed.

NCAFP: PCMH continues to gain momentum.

What can the AAFP do to encourage more practices to become recognized?

CLF: It’s simple. We must give our practices the encouragement and tools to help them truly transform, but that takes a commitment from all of us at the practice level as well. AAFP made a great start with TransforMed and Delta Exchange, but we must do even more. It’s not easy to transform a practice. I know firsthand.

Changes in how we operate our practices are really no different than the clinical changes we have had to make to keep up with new research, scientific discovery and new technology.

www.ncafp.com/ncfp

The business of medicine is no different. Like medical knowledge, the business of medicine and how we operate a practice is also in a constant state of flux and we cannot lose sight of that or many of us will lose our ability to remain independent.

I see the PCMH concept really as a standardized platform, a starting point to show we are committed to providing the right services at the right time and in the right place. Each member and each practice needs to find their own way, but the AAFP must encourage and support this through services and education. It is crucial that we help our members have some standardization that employers and patients can depend on when looking for health care. PCMH is fast becoming that standard and I am also committed to making sure that those standards remain relevant to the care of patients and not just another set of ever changing rules that create more administrative burden for our practices

NCAFP: Teamwork is playing an increasingly important role in patient care and practice operations.

How have you experienced this in your own practice, and how can the specialty harness its potential?

We are now adding behavioral health to meet the needs of that segment of our patient population.

Yet, teamwork goes beyond just clinical situations to pure business functions as well. Our Practice Administrator is very much a member of our team, educated and knowledgeable and whose advice and direction are very much welcome. With business it is important to look for outside help as well, utilizing peers and colleagues, our independent practice association, the state Academy and Medical Societies and resources from our national Academy as well.

Teamwork is identifying your areas of strengths and weaknesses, then playing to your strengths and finding resources or people to help overcome your weaknesses. As we have done this at our practice, we have become more interdependent and flexible, more efficient and nimble in business, evaluating and adapting as needed. Family Medicine, under the idea of PCMH and through our partnership

CLF: My practice has had the good fortune of harnessing a team concept from the beginning.

When I joined the group, I was able to bring some added business and practice management experience to them, because I had experience in multiple settings - rural practice, group practice and being hospital owned. My group came together and agreed on issues like treatment protocols and best practice guidelines to help us with the care of our patient population and divided many of the management roles. For example, with our ever increasing diabetic population, we saw the need for a team approach and sent our FNP to become a certified diabetic educator. We then started a diabetic series twice a year and incorporated a dietician, a personal trainer and other clinical staff.

‘Flick for President-Elect’ on back The upcoming AAFP Board elections present a tremendous opportunitySee for the NCAFP. Your proven support of ourcover 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 will be a powerful resource for our association as Drs. Jones and Henley have been.

The North Carolina Academy Although the benefits are clear, election campaigns are both time-consuming and costly. I am personally asking for your financial support. Your contribution will help our chapter offset campaign expenses – estimated this year at over $15,000 – and allow us to of Family Physicians proudly the candidacy of 2nd. It will insure that Dr. Koinis’s message will be heard by all wageendorses a very competitive effort leading up to balloting on October 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!

for AAFP President-Elect in 2012

Sincerely,

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.

q $50

q $100

q $250

q $500

MEETINGS & EDUCATION

November’s Annual Meeting will Have Something for Everyone NCAFP 2012 Winter Family Physicians Weekend

Thursday, Nov. 29th – Sunday, Dec. 2nd, 2012 • The Grove Park Inn – Asheville, NC

Kick-off the 2012 holiday season during the NCAFP’s Annual Winter Family Physicians Weekend this November 29 through December 2, 2012. Program Chair Dr. Christopher Snyder has planned an outstanding program on a variety of topics.

Evidence-based CME lectures on timely issues such as rheumatoid arthritis, restless leg syndrome, allergic rhinitis, chronic kidney disease, cervical cancer, and pain management are just a few of the topics on the agenda. Participants will also enjoy many more quality lecture topics, optional CME seminars, SAMs Study Working Groups and non-CME Satellite programs throughout the weekend.

Pre-Conference Sessions

Make plans to arrive a day early and take advantage of several preconference CME workshops. Learn more at www.ncafp.com/wfpw about the SAMS Working Group on Pain Management from 3pm to 9pm; the Mastering Hands on Procedures Workshop from 3pm to 9pm; the Be Our Voice Advocacy Training to Help Reduce Childhood Obesity Workshop from 5pm to 7pm; and a Non-CME Satellite Dinner (Free) from 7pm to 9pm on Wednesday the 28th, entitled ‘Re-Evaluation, Rehabilitation & Resiliency: An Alpha-1/COPD Journey.’ Pre-registration is required for each of these workshops.

We’re Going Green

Based on numerous requests to ‘Go Green,’ the NCAFP is excited

10 Summer 2012 • The NC Family Physician

to be making this happen. Not only will this environmentally-friendly initiative save on natural resources, the NCAFP will save a significant amount in printing costs. Going Green means that the NCAFP WILL NOT be providing a printed general session syllabus for the 2012 Winter Family Physicians Weekend. We will be offering our program syllabus and conference materials online.

Registered participants will receive an email with a web link approximately one week prior to the conference. If you prefer to have a printed paper copy of the general session lectures and the conference materials, you may purchase one in advance for $35.

Please be sure to purchase and reserve your paper syllabus when you register.

your registration form with your credit card number or check made payable to the North Carolina Academy of Family Physicians. Registrations can also be completed online at www. ncafp.com/wfpw. Members of the NCAFP or the AAFP may receive our Early Bird Registration Rate by completing the registration process

by October 15, 2012. Please contact the NCAFP Meetings Department for more information or to request a brochure and registration form by calling (919) 833-2110 or (800) 8729482 (Toll-free in NC only) or via

email at meetings@ncafp.com.

Education & Relaxation

The meeting will be presenting an excellent array of topics and lectures, as well as full complement of social activities, including the NCAFP Foundation’s Annual Auction and Gala hosted by Dr. Shannon & Mr. Jared Dowler.

Be sure to visit the NCAFP’s website at www.ncafp.com/wfpw for up-to-date information on the many learning, business, and social opportunities that will be offered.

ITEMS NEEDED FOR THE 2012 FOUNDATION SILENT AUCTION

Accommodations

The NCAFP has reserved a block of rooms at The Grove Park Inn. The discounted room rate is $198.00 per night. Please call the hotel directly at 800-438-5800 or 828-252-2711.

Additional rooms are available at a discounted conference rate at the Renaissance Asheville Hotel (phone 800-468-3571 or 800-252-8211) at $144.00 per night and at the Crown Plaza (phone 800-733-3211) at $129.00 per night. Be sure to mention the NCAFP Room Block to receive the discount. Book early. Rooms fill up quickly.

The official brochure will be mailed in the coming weeks. You will also find up to date conference information online as well at www.ncafp.com/ wfpw. To register, simply mail or fax

It isn’t too soon to start thinking about trinkets, treasures and great gift ideas for the NCAFP Foundation’s Silent Auction!

This is a call to all members requesting you to consider making a contribution to this important annual fund raiser. Make it easy on yourself and send a monetary donation then we’ll do the shopping for you. If you prefer to pick out your own items we will happily accept donations from your local community such as restaurant gift certificates, children’s items, weekend getaways, sports memorabilia or tickets to events. Donations of wine, artwork, jewelry, gift baskets and your handiwork are also encouraged.

Donations to the Silent Auction are eligible as a tax- deductible charitable contribution. A Donation Form for tax purposes will be sent to you for your donated item. Please contact Tracie Hazelett, NCAFP Foundation Development Coordinator with any questions you may have or to contribute to the event at thazelett@ncafp.com or 919-833-2110 / 800-872-9482 (NC Only). We appreciate your contributions & participation and we look forward to seeing you in December!

www.ncafp.com/ncfp

B e t t e r r e v e n u e f o r Yo u r P ract i c e

What if you could restore control of your practice, spend more time With your patients, and increase your profitability?

You can our simplicity™ software platform allows you to add a robust direct pay business to your existing practice and offer your services directly to patients and local employers.

To find out more or schedule a demo of our Simplicity™ software: PhysiciancareDirect.com or call 855-PcD-2300 Summer 2012 • The NC Family Physician

11

Policy & Advocacy

Legislature’s Short Session Wraps-Up Members’ swift response to advocacy call proved effective

By Robert L. Rich, Jr, MD NCAFP Advocacy Council Chair Since the last issue of the North Carolina Family Physician, the General Session has re-convened conducted business -- including passage of a budget -- and left to return home, all within a two month time frame. Since our advocacy efforts focused on several specific bills under consideration, this report will review the results of those efforts and the final outcomes.

One of the primary goals of the legislative session was passage of a budget for the next fiscal year. Our initial advocacy efforts focused on the details of the proposed budget. As passed by the legislature, the budget maintained Medicaid provider rates and directed the Department of Health and Human Services, (DHHS) not to consider any provider cuts for the budget year.

The State Budget

The budget discussions during this session were extraordinary, as this was the first time in several years that neither chamber proposed any provider rate cuts.

As passed, the budget maintains funding for most other services in Medicaid, and directs DHHS not to seek any further cuts in optional services.

On the public health side, there was some reduction in funding for preventive programs. However, funding -- while limited -- for smoking cessation and the NC Quit line was preserved. The Medicaid program and specifically, Community Care of North Carolina, remains intact with no substantial discussions at this time about bringing in an HMO to run the program. Although, that could change next year.

Scope Issues

Several scope of practice issues were debated during the session, most significant of which was a bill to expand pharmacists’ immunizing authority (Senate Bill 246). NCAFP members were called upon to contact key legislators and our members responded swiftly. As a result of our proactive advocacy, further discussion regarding the bill was dropped, and a subcommittee of the Joint Health Oversight Committee was created and tasked with studying the issue and reporting back its recommendations to the Speaker of the House by the next session. The Academy's governmental affairs team informed political leaders that existing NC statutes allow for the resolution of this issue through a joint committee of the Medical Board, Nursing Board and Pharmacy Board. The chapter will continue to advocate that as the preferred venue.

The legislature also discussed other scope of practice bills, including the licensure of naturopathic providers and certified professional midwives.

Our advocacy team provided information on patient safety to the legislative committees considering those bills. Ultimately, no further action was taken on either of these proposals. However, we do anticipate further discussions regarding expansion of the scope of practice for both groups, and we will again

The NCAFP’s legislative advocacy effort featured a a daylong visit to the NC General Assembly in late May, held in coordination with the NC Medical Society. Family Medicine leaders met with a number of key legislators and discussed important proposals being considered, including scope of practice and state budget items.

12 Summer 2012 • The NC Family Physician

www.ncafp.com/ncfp

N C F A M P A C - A dvocacy in A ction

Why You Should Support Your PAC, and Advocacy Council

By Matthew Kanaan DO, MS, NCAFP Resident Director

need assistance from the membership as these issues are debated.

In a previous report, I had noted an effort to combine the Office of Rural Health into the Department of Public Health. We were concerned that such a merger would lead to delays in the processing of applications for loan repayment for physicians agreeing to serve in rural, health manpower shortage areas. I am proud to report that the legislature approved a resolution which will disallow this merger.

National Issues

Beyond our in-state legislative activity, your Advocacy Council and leadership continue to monitor national developments and assess their impact on the state. Specifically, the NCAFP and the AAFP continue to monitor the results of the Supreme Court decision upholding the Affordable Care Act, (ACA) and its effects on North Carolina.

Our Academy already has had representation on various state committees that have been set up to study the implementation of the Accountable Care Act in North Carolina. Additionally, our chapter continues to monitor the recognition by Medicare of Accountable Care Organizations (ACOs) across the state, including those with representation by our physician members. The Academy has previously partnered with the law firm Smith Anderson in Raleigh to prepare a guideline for those members participating in the ACO process.

As I complete this report, I again ask you to consider the importance of contributing to FAMPAC, our political action committee for Family Medicine in North Carolina. With the coming general election and legislative turnover, supporting legislators sympathetic to family medicine and primary care is crucial. Unfortunately, our funds are low and the need for contributions is great. Join me in giving a least a dollar a day to FAMPAC as members of the “Family Medicine Forerunners” club and while you are doing it, ask your fellow family physician who has never contributed before, to do the same thing.

I think that the biggest leadership challenge in 21st century medicine will be the ability to foster meaningful collaboration between often competing organizations and interests. This will not be easy and will not be solved through the passing of a bill. This will take negotiation and compromise. We will need every single medical team member to be involved from the janitor to the hospital CEO. We all know healthcare is changing. Our costs are too high, and our system is far too complicated. I have watched as debates continue on in Washington D.C., and those who are not in medicine try to dictate how medicine should function. In my opinion this will never work. This is why we need more physician leaders who have the skills to lead change, and encourage collaboration. Only a skilled physician leader will be able to sit down with a large insurance agency to negotiate payment reform, or be able to get competing physician groups to realize the value of teamwork and shared benefit. All of this talk about healthcare reform is completely useless if no one buys into it or if we all try to find ways to take advantage of it. Our problem in Family Medicine is that we have had other people dictate our payment rates, and RVU structures for far too long. We need our own Family Medicine Physician Leaders to have

discussions with our legislators in order to get our very important message to them. Unfortunately that takes monetary contributions and personal time. As a resident I know very well that money is tight and that even a small amount of money seems like a lot when you don’t make a lot. However, if we as Family Physicians do not contribute our time and money to our own Political Action Committees or to our Advocacy Council, there is certainly no one else out there that is going to have our interests in mind. I have attended a lot of meetings over my short three years in residency and I always hear the same thing , that Family Physicians donate the least amount to their PAC’s out of any physician group.

While I do understand that we are on the lower end of the salary spectrum we also have some of the greatest numbers. This means our per-member donation does not need to be as large as other groups with less members. In my opinion it is time for us in primary care to take control of the power that we do have by banding together in any way that we can.

Medicine is driven by primary care, and we have the opportunity to both serve our patients and demand higher payment. To do this we need all primary care physicians to support both their PAC and Advocacy Council so that they can represent our interests at both the state and national level.

NC FAMPAC FORERUNNER Now more than ever, NC’s family medicine community must support and educate legislators on both sides of the aisle.

FAMPAC Family Medicine Forerunners help make this happen.

As a Family Medicine Forerunner, your contribution of $100 each quarter (just over a dollar a day) to NCAFP’s Political Action Committee (FAMPAC) helps family medicine keep its voice heard and our issues recognized in the NC legislature.

Signing up is easy. Do it today and help keep family medicine running strong in North Carolina.

www.ncafp.com/forerunner Summer 2012 • The NC Family Physician

13

Members & Membership ~ member news & updates ~

Past President Bill Hedrick, MD, Celebrates 50-Years of Solo Private Practice NCAFP Past President Dr. Bill Hedrick ('75), celebrated his 50th year in private practice on July 2nd. Dr. Hedrick opened his solo family practice on July 2, 1962, and continues to work full-time, conducting daily patient care, making house calls, and, most recently, implementing new practice technology like a new web-based EHR. To recognize the milestone, the Academy presented Dr. Hedrick with a special resolution during its MidSummer Family Medicine Digest. In addition to the NCAFP's recognition, WRAL TV in Raleigh interviewed Dr. Hedrick and broadcast a small feature on his long medical career. That segment is available online at http:// www.wral.com/lifestyles/ travel/video/11274401/ .

Also, the City of Raleigh

proclaimed July 2nd 2012, as 'Dr. Bill Hedrick' day and conducted a brief proclamation ceremony in City Council Chambers.

Dr. Hedrick graduated from the Bowman Gray School of Medicine in 1957 and has been a member of the American Academy of Family Physicians and North Carolina Academy of Family Physicians since 1966. Hedrick served honorably as a Captain in the US Army Medical Corp where he was Chief of Psychiatry and Commanding Officer of the 730th Medical Detachment in Orleans, France, before returning home to Raleigh. Hedrick went on to become the first doctor hired in the Emergency Room by the former Wake Memorial Hospital (now Wake Med), and severed a lengthy term as Wake County's Medical Examiner. Within the Academy, Dr. Hedrick has been active throughout his career, including serving as President of the chapter in 1975, and continuing to be an active member of the Chapter’s councils and committees. Dr. Hedrick also is an occasional lecturer on topics related to mental health.

Viki Kaprielian, MD, Appointed to Cambell University Medical School Administration Victoria S. Kaprielian, MD, has been named by Campbell University as Associate Dean of Faculty Development and Medical Education for the University’s new School of Osteopathic Medicine. Dr. Kaprielian will join the leadership team of Dean John Kauffman, DO, in creating North Carolina’s fifth medical school, which has a distinct mission of training primary care physicians for practice in rural and underserved areas. Kaprielian is currently professor and vice chairman for Education in the Department of Community and Family Medicine at Duke University, where she has served as an educational leader since 1989.

Past President Dr. Mott Blair Dedicates New Vidant Family Medicine Building Dr. Mott P. Blair (2003) and his practice at Vidant Family Medicine in Wallace recently christened their new practice center. The new 8,600 square foot facility houses a full lab, x-ray and a practice design geared towards embracing patient-centered approaches. For a video recap on the opening and several other events mentioned below, see the NCAFP website at, http://www.ncafp.com/academy/ chapter-affairs/ncafp-leaders-chapter-active . Congratulations to Dr. Blair, his practice partner Dr. Gary Crawford, and their entire team.

14 Summer 2012 • The NC Family Physician

Membership News & Updates NCAFP’s Membership Department receives many questions throughout the year regarding dues, CME, and other issues. Please review these important reminders and helpful hints. As always, we would be happy to answer any of your membership questions. Please do not hesitate to contact Tara Hinkle, NCAFP Membership Coordinator, at thinkle@ ncafp.com or via phone at (919) 833-2110 or toll free (NC only) at 1-800-872-9482.

CME Re-Election: Active members are required to report 150 hours of Continuing Medical Education (CME) every three years to maintain membership in the AAFP and the NCAFP. The deadline for earning hours is Dec. 31st of your cycle end-year. The majority of 2012 candidates are those who were last re-elected in 2009 (some in 2008). To determine if you are a candidate for re-election this year, please visit www.aafp. org/myacademy. It is important to note that all 150 hours must be earned within your three year cycle (i.e. Jan. 1, 2010 – Dec. 31, 2012). Please plan CME learning opportunities accordingly as earning extensions are no longer granted. To avoid membership cancellation, report hours as soon as they are earned and prior to deadline; you can do so online at www.aafp.org/myacademy. Hours may also be reported in any of the following ways: fax to 913-906-6075; email to contactcenter@aafp.org; or mail to: AAFP CME Records Dept., 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672.

Member Dues - Each October, AAFP mails an invoice for the upcoming year’s dues to the primary mailing address on file in your member record. Therefore, 2013 dues invoices will be mailed in October 2012 to all Active, Inactive, Life & Supporting members. Payment is due by Jan. 1, 2013. Both AAFP & NCAFP dues must be paid in full to maintain membership. Installment plans are available upon receipt of invoice if full payment cannot be submitted. For more information on installment plans or an auto renewal option, please call the AAFP at 1-800-274-2237.

Contact Information - Please verify that your contact information is accurate at www. aafp.org/myacademy or www.aafp.org/updatecontactinfo. Please make sure the email address provided is one that is checked regularly, as this is our primary method of sending important deadline notifications regarding CME re-election and dues, as well as NCAFP chapter communications.

Status Changes - Moving out of state?

Retiring? Interrupting your practice due to an extended illness or accident? Please notify the AAFP at 1-800-274-2237 so your state chapter membership may be relocated without interruption or your membership status may be changed, if eligible. www.ncafp.com/ncfp

C

north carolina tar wars program

Student Interest

Five Students Awarded NCAFP Foundation Scholarship The NCAFP Foundation is pleased to announce that five 4th year medical students have been selected to receive a scholarship through the Foundation for this academic year, 2012-2013. The NCAFP wishes each of you well as you complete your final year in medical school and begin the process of exploring residency programs. Congratulations!

• Tiffany Cagle, UNC SOM • Erin Helms, UNC SOM • Kimberly Newton, UNC SOM • John Trimberger, WF SOM • Kate Wiegert, Duke University SOM

Durham Fifth Grader Wins State Tar Wars Poster Contest Represents NC at National Contest in Washington, DC Ms. Zane Whitley, a rising 6th grader from Durham, North Carolina, was selected as this year’s state winner in the 2012 Tar Wars poster contest.

As the winner, she recently traveled to Washington, D.C. to participate in the national poster contest and awards ceremony. The Tar Wars awards ceremony was held July 16 and 17 in Washington D.C., where her original artwork was on display.

As part of the Tar Wars Program, Zane, accompanied by her Mother Sally as well as two sisters, were able to see sights in the Washington D.C., area. Although an appointment with Senator Hagan was scheduled, the Senator had to cancel due to a conflicting meeting that arose.

They were able to visit with her staff where photos were taken and a personal tour of the Capitol provided.

The AAFP has overseen Tar Wars since 1997, and the program has grown to reach thousands of fourth and fifth grade students in all 50 states, several territories and internationally each year.

Since its founding Tar Wars has reached more than 8 million children. For more information on Tar Wars and how you can get involved in this important educational initiative, please contact Tracie Hazelett at the NCAFP offices, thazelett@ncafp.com

Family Medicine Charlotte Metro Area

CAROMONT HELSTH CaroMont Health

Outstanding outpatient family medicine opportunities available in communities located minutes from Charlotte, one of the fastest growing cities in the country. These are employed opportunities and will offer competitive compensation packages including two year salary guarantee, productivity bonus potential, generous benefits and relocation expenses. CaroMont Medical Group operates under the guidance of a physician-led Governance Committee allowing for an active partnership with the Medical Staff.

Over 300 active medical staff representing all major medical specialties at Gaston Memorial Hospital, a modern and progressive 435-bed hospital which provides comprehensive care to patient base of over 300,000.

These lovely communities have easy access to the beautiful North Carolina Mountains and some of the most popular beaches on the East coast. Just minutes from an international airport and two large lakes, communities offer unlimited cultural and recreational amenities. A superb quality of life exists here with many charming neighborhoods and stellar public and private schools.

If interested in being considered for this opportunity, please send CV to: Celia G. Billings Manager, Physician Recruitment CaroMont Health 2240 Remount Road Gastonia, NC, 28054 T: 704-834-2153 | F: 704-834-4615 Email: billingc@caromonthealth.org

Gaston Memorial Hospital | CaroMont Medical Group | CaroMont Specialty Surgery | CLiC | Gaston Hospice | Courtland

Summer 2012 • The NC Family Physician

15

Our Residencies: Duke University

R e si de n t s & R e s i d e n cy

The Duke Family Medicine Residency -

A Training Ground for Tomorrow’s Physician Leaders

Duke University’s Family Medicine Residency progam is working hard to train family physician leaders who can function as adeptly as clinicians as they do as healthcare change agents. The program’s dual focus on physician leadership development and ambulatory/team-based care, make it one of the state’s most unique training programs.

Program History

Duke’s residency program began in 1972 as a joint effort between Duke University Medical Center and Durham Regional Hospital. The program initially trained 13 residents per year, but in 1991 consolidated at Duke University Hospital.

Since then, the program has continued to refine and adapt itself to the changes in the healthcare environment and the specialty. To date, the program has graduated 348 physicians, four of which are medical school department chairs.

In 2006, the program announced that it would stop accepting new residents. This decision led to considerable reaction at the state and national level. The program then began a lengthy redesign of its training curriculum, calling for input from leadership, faculty, residents, and an expert advisory

16 Summer 2012 • The NC Family Physician

panel convened by the university chancellor. The redesigned 4-4-4 program began recruiting new residents in late 2007 for its 2011 class.

Physician Leadership Training

When Duke introduced its new training curriculum, one of the program’s cornerstones was a commitment to physician leadership development.

Its vision was to develop residents’ leadership skills for driving change not only in the clinical setting, but also in the communities and professions they serve.

“We want our residents to develop skill sets to be change agents when they graduate; physicians who can work with their local community to help affect positive change on the population they work with. That requires leadership skills and training,” explained Dr. Brian Halstater, Residency Program Director. “We’re constantly evolving and trying to find better ways of doing that.”

To achieve this, Duke’s initial approach consisted of having its third-year residents participate in

departmental coursework tied to the university’s Clinical Leadership Masters program. While that led to progress, the program recently adapted its strategy and is now embedding leadership development training across its entire curriculum.

Halstater explained that although it is still relatively early to ascertain all of the impacts of this effort, he noted progress is already evident. He pointed out that at least a third of Duke’s residents are currently involved in leadership positions within the department and Duke School of Medicine’s committee structure and several are involved on state and national level leadership posts, with more in the pipeline. Duke residents are active with the AAFP/NCAFP and also within other organized medicine or community efforts. Recent graduate Dr. Matthew Kanaan serves as NCAFP Resident Director, and 2011 graduate Dr. Meshia Waleh served the NCAFP and was Resident Delegate to the AAFP Congress of Delegates.

Dr. Mo Shahsahebi, Duke’s current Chief See ‘Duke Residency’ on back cover www.ncafp.com/ncfp

The ACO Guide

Strategic Note: Some ACOs commence

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

activities through a single pilot, or demproject, care without a sustainable ~onstration health transformation ~ patient population scale. It can de-bug

the initiative and test-run the ACO early enough to fix problems before ramping

NCAFP Joins North Carolina’s “Toward Accountable Care” Consortium and Initiative up. This must succeed, however. If it does, it will be much easier for the ACO champions to gain buy-in from others.

Effort is aimed at educating and guiding physicians through transformative healthcare era With the recent Supreme Court ruling upholding the constitutionality of the Affordable Care Act, North Carolina should continue to see more activity surrounding innovation in the health care industry. Part of that innovation clearly surrounds creation and implementation of Accountable Care Organizations (ACOs) to help achieve measured quality improvements and reductions in the rate of spending growth in this country.

The Centers for Medicare and Medicaid Services (CMS) recently announced the second wave of organizations that were granted ACO agreements, which included 89 more organizations, two of which are in North Carolina (Cornerstone Health Care, PA in High Point and Triad Healthcare Network, LLC in Greensboro).

Julian “Bo” Bobbitt, J.D., of Smith Anderson, LLP, is nationally recognized as a legal expert on the ACO framework. He partnered with the NCAFP to create the “ACO Blueprint for Success,” which was ultimately distributed nationally by other states and the AAFP. He has repeatedly described ACOs as a game changer for primary care. Recently, he and his firm joined with the NC Medical Society in an attempt to bring this message to all physicians The elements do come together and mesh. Culture dominates. Each one can be built. These are not mysterious. They are doable. It will be hard. Once the ACO organizers embrace the opportunity in this change, achieving all of the elements for sustainable success is quite feasible. Conversely, if you are evaluating a previously organized ACO, there are clear indicators regarding these essential elements that will predict reliably its likelihood of success.

page 21 in the state by forming the Toward Accountable Care Consortium and Initiative (TAC). To help finance the TAC, the NC Medical Society Foundation has applied for funding from the Physician’s Foundation with letters of support from the NCAFP and other organizations.

The Initiative, led by the leadership of the NC Medical Society and NC Medical Society Foundation, currently consists of more than 25 state, specialty and county/regional medical societies. NCAFP is joined by organizations including the NC College of Emergency Physicians, NC Pediatric Society, NC Psychiatric Association, NC Obstetrical and Gynecological Society, NC Radiology Society and many others. The top priority of the TAC is to guide all physicians through history’s most transformative time in health care. In order to navigate opportunities such as ACOs, physicians must have the knowledge and tools needed to succeed in a value-driven healthcare system. Building on work already done

by Smith Anderson for the NCAFP, TAC will seek to educate physicians further by disseminating a second white paper which will apply and appeal to all physicians in all practice settings; creation of at least ten specialtyspecific toolkits; a merit-based, shared savings pool distribution guide; a multi-media educational effort to accommodate all learning needs and preferences; and a built-in feedback and evaluation mechanism to ensure the needs of practicing physicians across the state are being met.

Recognizing that even within the ACO model there are differing models

Smith,most Anderson, Dorsett, & Jernigan, L.L.P. of care that won’t fit©2011 everyone, of theBlount, resources will Mitchell be focused on general principles promoting patient-centered, value-driven health care.

However, specific programs that are gaining traction, such as shared savings and bundled payments, will also be highlighted.

The window of opportunity for physicians to have a much needed impact on transforming our health care system will not stay open for long – the longer it takes to rally our troops, the more likely others (like the government, private payers, or hospitals) will remain in control and the cycle of escalating costs and questionable overall health status of Americans will continue. Organized medicine, and particularly primary care, has the responsibility and the opportunity to lead this initiative.

The goal of the TAC is to unite the medical community for the purpose of providing physicians with the knowledge, tools and resources needed to understand, navigate, lead and succeed in the new era of health care regardless of specialty or practice setting. The NCAFP will be working closely with the NC Medical Society and Smith Anderson to ensure that our members have every opportunity to be winners in the ACO movement. Stay tuned as NCAFP begins to publicize learning opportunities in the near future via Notes and other means.

Summer 2012 • The NC Family Physician

17

A Cost Analysis of Becoming A NCQA-Recognized Patient-Centered Medical Home

By Ashley Wofford Leong

The following article was researched and drafted by Ashley Wofford Leong as part of her participation in the Academy’s 2012 Student Leadership Elective.

The Leadership Elective works to increase a medical student’s knowledge of organized medicine and its role in medical education. Participating students spend four weeks working collaboratively with the NCAFP headquarters in Raleigh and complete a special project of their own design.

For primary care, the PCMH is the cornerstone of Health Reform, and we are inundated in publications that mark the potential for better patient health outcomes and increased cost efficiency [1, 2, 3]. Its traction is great enough that a “how to” guide for transformation has been published [4].

Although the merit of transformation is well documented, missing from much of the literature is a sense of the upfront cost of transformation.

Semi-structured interviews with three triangle-area practices revealed that transformation is possible without much upfront financial investment [Table 1].

As previously mentioned in the NC Family Physician, it pays to be recognized as a PCMH – literally [5]. Demonstration projects across the state and Blue Cross and Blue Shield of North Carolina’s unique Blue Quality Physician Program (BQPP)

have enhanced payments for PCMH-accredited physicians. Please contact your BCBS of NC representative for details about BQPP; Community Care of North Carolina (CCNC) has information on participating in the demonstration projects.

Regarding upfront cost, addition of an EMR or new staff would be the most costly financial investments, followed by consultant services [Table 2]. However, there are resources to help reduce the upfront cost of the transformation.

1. Practice Fusion is a free EMR that is also highly functional for clinical use, and has an electronic billing feature (although that is $150 fee per provider per month). There are other high-quality EMRs that are free or low-cost. NCAFP Past President Chip Watkins, MD, MPH has made a tool for identifying EMRs that are high-quality but low cost.

2. In working through the accreditation, some practices may identify areas that need additional patient services. As you think about practice redesign, it may be possible to redistribute existing team members rather than hire additional staff.

3. Consulting services can be helpful, but also quite expensive. Instead of contracting with TransforMED or another private consulting group, try to arrange for a college or graduate student in public health or health management programs to help coach your practice through the process in exchange for hands-on experience. The Multi-Payer Advanced Primary Care Practice Demonstration in Western NC has already implemented student internships at local clinics with positive feedback

Now you can provide a complete allergy testing and immunotherapy service line.

Your patients no longer have to suffer from seasonal allergies and you don’t have to risk losing them by referring out to specialists. By offering this service line, physicians are able to provide a higher level of care to a large portion of their patient base, while generating a new revenue stream.

About United Allergy Services: • We hire and train a Certified Clinical Allergy Specialist to test, educate and custom build immunotherapy under the supervision of the on-site physician.

• Provide all supplies and materials related to the service line.

18 Summer 2012 • The NC Family Physician

• Focus efforts on patient safety, patient compliance and patient outcomes.

• Allow you to treat allergy patients rather than cover their symptoms with medications.

Interested in becoming a UAS Allergy Center?

Visit www.UnitedAllergyServices.com or call 888.50.ALLERGY.

www.ncafp.com/ncfp Formerly United Allergy Labs

abs

from the practices as well as the students. Additionally, webinars on PCMH transformation are available through CCNC’s website [6].

Ultimately, the time and effort dedicated by core team members driving the application process are the most important investments. This team should include clinicians and a practice manager, at the very least. There is no good way to qualify the cost of the time invested by members of the core team.

It does require sacrifice of time beyond clinic duties, but the benefits of an appropriately functioning medical home are worth it – to the practice and to the patients alike. The PCMH is here to stay, and payment models will likely continue to grow around the medical home concept. It’s time to get on board. There are ways to successfully – and inexpensively – become a PCMH. Table 1. Upfront expenditures for PCMH accreditation through NCQA from three Table 1. Upfront expenditures for PCMH accreditation through NCQA from three triangle-area practices. triangle‐area practices.

Application fees NCQA Survey Tool Fee (based on # of Providers) Subtotal Consulting/Time Lost

Small Practice (2 MD, 1 NP)

Medium Practice (5 MD, 3 NP)

Large Practice (64 MD)

$80

$80

$80

1,000 $1,080

2,500 $2,580

4,140 $4,220

Money Invested

*

Time Invested

*

Who's Involved

MD

Operating Costs (change) EMR** Electronic Billing Utilities Medical Supplies Staffing

New Personnel

$16,000

80 hours over 4 six months months

practice manager; Interns§; MDs; practice manager MD *

$0 0 0 0

$0 0 0 0

$0 0 0 0

*

*

Interns§

* Not applicable to the practice.

* Not applicable to the ** Each practice already had a functional EMR. practice. § The large practice solicited health policy & management graduate students to help the practice **gather information and submit the NCQA application as an internship experience. Collectively, the Each practice already had a functional EMR. interns spent approximately 80 hours to pull together all necessary documentation for the § The large practice solicited health policy & management graduate students to help application. Additionally, there were clinicians and management staff from the practice who met on the practice gather information and submit the NCQA application as an internship a regular basis with the interns. Throughout the four months, the amount of time the clinicians were scheduled to see patients was not reduced, so there was no lost potential revenue. experience.

Collectively, the interns spent approximately 80hours to pull together

all necessary documentation for the application.

Additionally, there were clinicians

and management staff from the practice who met on a regular basis with the interns.

Throughout the four months, the amount of time the clinicians were scheduled to see patients was not reduced, so there was no lost potential revenue.

Table 2. Minimum and maximum estimated upfront costs associated with Table 2. Minimum and maximum estimated upfront costs associated with NQCA NQCA accreditation for PCMH. accreditation for PCMH. Application fees NCQA Survey Tool

Fee per Provider Subtotal Consulting/Time Lost Money Invested Time Invested

Who's Involved Operating Costs (change) EMR Electronic Billing Utilities Medical Supplies Staffing

New Personnel¶ Practice Size N = 1 N = 2 N = 5 N = 10 N = 60

Minimum (with sponsor) § $80 400/provider first 8 0 for next 42 8/provider > 50 $80 + $400 x # providers * 6 months (80‐100h to gather documentation)

Maximum

$80 500/provider first 8 0 for next 42 10/provider > 50 $80 + $500 x # providers ≥ $10,000** 1 ‐ 2 years

MD, practice mgmt, +/‐ student intern

TransforMED (or other), clinician, practice mgmt

$0

150/mo/provider 0 0

≥ $30,000** 0 0 0

Medical Asst $45,446 Practice Mgr $143,606 no new paid staff; PA or NP $124,057 +/‐ student intern MD or DO $231,365 Minimum Est. $480 + $150/mo $880 + $300/mo $2,080 + $750/mo $3,280 + $1,500/mo $3,360 + $9,000/mo

Maximum Est. ≥ $40,580 + new staff ≥ $41,080 + new staff ≥ $42,580 + new staff ≥ $44,080 + new staff ≥ $44,180 + new staff

* Not applicable. ** $10,000 for TransforMED and $30,000 for an EMR are high‐end estimates, but not necessarily the upper threshold. § CCNC is a sponsor if participating in a demonstration project. * Not applicable. ¶ Staffing costs represent median salary and benefits for various healthcare workers in NC [7].

** $10,000 for TransforMED and $30,000 for an EMR are high-end estimates, but not necessarily the upper threshold. § CCNC is a sponsor if participating in a demonstration project. ¶ Staffing costs represent median salary and benefits for various healthcare workers in NC [7].

References: Grumbach K, Grundy P. Outcomes of implementing patient centered medical home interventions: a review of the evidence from prospective evaluation studies in the United States. Patient-Centered Primary Care Collaborative. November 16, 2010. Available at: www.pcpcc.net. Accessed June 30, 2012.

Gilfillan R.J., Tomcavage J., Rosenthal M.B., et al. (2010). Value and the medical home: effects of transformed primary care. Am J Manag Care 16. (8): 607-614. Accessed June 30, 2012 via PubMed. Reid R.J., Coleman K., Johnson E.A., et al. (2010). The Group Health medical home at year 2: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood) 29. (5): 835-843. Accessed June 30 2012 via PubMed.

Valko G, Wender RC, Zawora MQ. (2012) A “how to” guide to creating a patientcentered medical home. Prim Care. 2012 Jun;39(2):261-80. Accessed June 30, 2012 via PubMed. The Road to PCMH Recognition & Why It Pays for Family Physicians. (2011, Summer). The North Carolina Family Physician. 7(3), 18, 20.

2011 PCMH Resources. http://www.communitycarenc.org/emerging-initiatives/pcmhcentral1/2011-pcmh-resources/ Accessed Jan 31 2012.

Salary data for Medical Assistants, Practice Managers, Physician Assistants and Nurse Practitioners, and Physicians in Raleigh, NC. http://www.salary.com/category/salary/ Accessed Feb 20 2012.

Summer 2012 • The NC Family Physician

19

‘Flick for President-Elect’ from p. 9

with the Patient Centered Primary Care Collaborative (PCPCC) and others has the potential for greater teamwork as we assist our members to put the right team together for their individual practice settings.

In a well-functioning team, everyone has a sense of ownership in the outcome, each person has a role, and everyone is a part of something larger than themselves. It should be this way in our practices and it also must be this way in our own professional organization. If elected, I may hold the title of President-Elect, but it is going to take a broad team of our members and staff to help pave the way for a bright future.

NCAFP: With the Accountable Care Act ruled constitutional, what do you see as the biggest challenges facing the specialty in the next 24-months as reforms continue to role out?

CLF: I see many challenges, including educating our members on the broad implications of ACA, motivating our members to remain engaged and active in important policy discussions that will take place, as well as a number of political challenges.

Regardless of the Supreme Court decision, the next presidential election or other outside forces, we all know our healthcare system has to change. The current system is unsustainable. It’s also clear that as family physicians, we are a key part of the solution, and we must be prepared to “lead the way.”

Whether the Supreme Court ruled in favor of or against the ACA, the AAFP would have had challenges but more importantly, I believe, opportunities.

The Patient Centered Primary Care Collaborative and many other sources, including private and public payors, now see the importance of primary care

as foundational to our future health care system. Fortunately, the ACA has several key features that the AAFP believes are, and will remain, important to our organization, including health coverage for all.

While we can control our own future by truly transforming our practices, it will be crucial for the AAFP to help members understand the rules surrounding the ACA and any other new models or legislation, whether it’s Accountable Care Organizations or other payment mechanisms.

The AAFP, state chapters and individual members have to stay engaged and active wherever discussions are held and policy determined, to be voices and advocates for our members and our patients. On the state level it is going to be important to have ongoing dialogues with hospitals and other larger entities to secure primary care input and leadership on whatever ACO type structures may occur. Nationally we have to look at the positive aspects of the ACA and help to maximize their benefits and to improve on the negatives as we see them, working with all to improve the lives of our members and patients.

Politically, this will be a challenge because even among our membership there are different opinions on the ACA, from those who are opposed to it versus those who partially or fully support it. The coming 24-months will see much political discussion, based unfortunately on partisanship rather than what is in the best interest of the people, our communities and the nation.

We will continue to struggle with the finances of healthcare as well as these political battles, but we as members and an organization must stay involved to help steer decisions in the right direction. Family Physicians need to stay focused on our positive contributions to any system and to patients in providing the most cost effective, efficient, highest quality care.

‘Duke Residency’ from p. 16

Resident and the NCAFP’s Resident Director-Elect offered his perspectives on Duke’s leadership training. “With the leadership activities we do, we are taking a whole different approach to family medicine. Ultimately, when we talk about being change agents, it’s the effect on the macro of healthcare versus the micro,” explained Dr. Shahsahebi. Dr. Shahsahebi went on to explain that in order to impact communities and populations, physician leaders must understand both public health and health policy. Duke fosters residents training and experiences in both areas.

Since rolling out this new effort in 2007, Duke’s leadership development initiative has led to shifts in its recruiting approach. Many of the program’s current residents have previous leadership experiences or strong interests in population health or communitylevel engagement. And the type of physicians who are attracted to the program, as well as the ones the program ultimately identifies as strong candidates has also changed.

“We are very clear in the recruiting process as to what we are and what we are not. One of the reasons this program works is because all of us - our department and our residents - are all moving in the same direction to affect change in a similar way,” said Halstater.

Team-Based Care Central

Leadership development takes many forms at the program. The program’s strong emphasis on team-based clinical care serves as a great example. Residents are both active participants on the residency’s care teams, but also get experience in leading these teams as well. This supports the program’s mission to producing residents who are experts in ambulatory care, but who can also lead and drive clinical and community change.

“Family doctors are used to doing everything themselves. But with the complexity of health care and the need to bring in more services, bringing in the team approach has been very helpful,” noted Dr. Halstater.

Dr. Halstater explained that the entire university is committed to developing team-based care approaches. The Family Medicine Center that the residency calls home, a Level III recognized PCMH, has undergone a top-down redesign of its entire patient workflow process. The program has operationalized a host of teambased best practices, complete with re-configuring individual exam rooms and adopting a brand new EMR.

PCMH Integral

Duke embraces patient-centered approaches in all aspects of its clinical operations and embeds PCMH training across its entire curriculum. The program has already re-certified under Level III of the new 2011 PCMH standards and approaches its PCMH training in a holistic fashion.

“Our residents embrace PCMH because they live it. They’re involved in the dayto-day operations of the program, practice in care teams and really learn by doing,” explained Dr. Halstater.

To get residents started off on the right foot, all interns (4 annually) go through a comprehensive PCMH orientation that puts the program’s care processes in context, explains PCMH terminology and its key constructs. As residents progress through their individual training, each learns how it everything fits together.

Research & Quality Improvement

Duke residents conduct a significant amount of research that seeks to bridge and integrate their clinical training, leadership development and community health focus. Many resident-led research efforts analyze clinical data and/or practice pattern data in an effort to improve interventions, physician collaboration and outcomes within the community. Residents gain valuable experience in discovering issues and translating their findings into real-world solutions that are implemented in the clinic (or within Duke’s primary care network). The ultimate goal is to create impacts at the community and population level and support the program’s ‘change agent’ philosophy.

“Our program lays at the crossroads of public health and family medicine, hoping to improve population health. It is an exciting journey, as faculty are learning together with residents the concepts of population health management, and how to implement innovation, and look together at new opportunities and tools that have come our way after the passage of the Affordable Care Act,” noted Dr. Viviana Martinez-Bianchi, Associate Program Director.

As family physicians continue to embrace team-oriented approaches in the clinic, future payment models and delivery mechanisms might well rely on their ability to lead and impact a much larger population or community. That will require new and different skills, ones that Duke-trained family physicians will already know.