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texas family physician VOL. 65 NO. 1 WINTER 2014

Meet The 2013–2014 Texas Family Physician Of The Year Jasmine Sulaiman, M.D.

PLUS: Essential Elements For High Performance Primary Care Practice Management Advice Just For You


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6 PRESIDENT’S LETTER What would your report card look like?


8 NEWS CLIPS Medicare SGR fix deadline approaches. | New family medicine residency program in Victoria. | GME to increase in Texas. | Primary care pay hikes will begin in March.

By Samantha White

13 NUTRITION How to keep dairy in the diet of lactose intolerant patients.

Meet TAFP’s Physician of the Year: Jasmine Sulaiman, M.D.

Ever since Jasmine Sulaiman, M.D., landed at the Health Center of Southeast Texas in Cleveland, Texas, where she’s served as medical director since 2006, she has been practicing her passion, taking care of those around her regardless of their situation.

It’s time to evaluate the primary care infrastructure



Despite progress made in recent years to develop the patientcentered medical home, the primary care infrastructure needs to be strengthened for clinicians to provide the best care possible.

A TAFP member recounts his experiences shadowing a physician in the British National Health Service.

By Bruce Bagley, M.D.

A Texas longhorn in the Queen’s surgery

By Richard Young, M.D.

14 MEMBER NEWS Kumar becomes medical society president. | AAFP appoints TAFP members and staff. | December Members of the Month 33 PRACTICE MANAGEMENT Bradley Reiner highlights free services for TAFP members. 36 YEAR IN REVIEW 38 TAFP PERSPECTIVE Small practices can help each other with PCMH recognition.

samantha white


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president’s column

TEXAS FAMILY PHYSICIAN VOL. 65 NO. 1 WINTER 2014 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. Texas Family Physician is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or

Officers president

Clare Hawkins, M.D., M.Sc.

president-elect vice president treasurer

Dale Ragle, M.D.

Tricia Elliott, M.D.

Ajay Gupta, M.D.


Janet Hurley, M.D.

immediate past president

Troy Fiesinger, M.D.

Editorial Staff managing editor

Jonathan L. Nelson

associate editor

Samantha White

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, C.A.E.

advertising sales associate

Michael Conwell Contributing Editors Bruce Bagley, M.D. Claire Florsheim, J.D., R.D., L.D. Bradley Reiner Lloyd Van Winkle, M.D. Richard Young, M.D. cover photo

Samantha White

subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publica­tion of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by The Whitley Company, Austin, Texas. legislative advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2014 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

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Making the grade By Clare Hawkins, M.D., M.Sc. TAFP President as i reviewed my children’s report cards recently, I found myself proud of their achievements. I also began reflecting on whether these grades were an accurate reflection of their past performance or current abilities. I know they worked very hard and deserved credit, and that being graded was a great deal of stress for them. Ultimately I found myself being thankful that I was no longer in the educational system where I was frequently under pressure to perform and be graded by teachers and professors. Then I stopped myself and considered the last report I received from a health plan which outlined my performance as a doctor. Unfair! How do they know how good I am? They don’t really know how well I perform. Increasingly we physicians find that health plans, governments, or employers are evaluating the care that we provide. Do we know what they are measuring? Will it affect my payments? Will it affect my employment? Whether we believe in certain aspects of health care reform, physician profiling is here to stay. And as I mentioned in my TAFP installation address, change is inevitable. We can take charge of the changes imposed upon us. I am struggling to embrace the ways I am being measured by distilling the performance measurements into self-directed questions, such as: Prescribing metrics • Am I really prescribing dangerous drugs? • What proportion of my patients take the drugs that I prescribe (medication regimen adherence)? • Is it my responsibility? Accessibility metrics • Can my patients get in to see me? • Do my patients have to go to the emergency department and risk an expensive admission? • What are primary-care sensitive admissions?

Patient satisfaction metrics • Do my patients like me? Outcome metrics • Do my patients feel healthier than they did the year before? • Have I kept them out of the hospital? Many of the tools used to measure physician performance come from health care research, and have an evidence basis. Take, for example, the care of geriatric patients. It has been well established that multiple medications in the elderly interact with each other, and I should prescribe the least amount necessary. I should avoid prescribing more than six if possible. I should avoid anything that could sedate them or make them a fall-risk. However, many of my elderly patients have multiple diseases; many ask for sedatives, muscle relaxants, allergy treatments, or pain medications. All of these have risks to them, and now... to me! In my well intentioned effort to prescribe for them, I can be seen as a “bad” doctor because I’ve prescribed something that I have prescribed for many years. Not only are they at risk for falling, but I’m at risk of falling out of a health plan. In this case, there is perhaps a good reason. Research has shown that by trying to help them, I am increasing their risk of falling and sustaining a femur fracture. In some cases, perhaps, the measurements can help me to practice better medicine. If I continue to make medical decisions which place patients at risk, then I may not be able to see patients with that type of insurance. I may find that as health plans build limited networks, they may choose not to invite me into those networks, and my patients will be compelled to see different innetwork physicians. Emerging accountable care groups are able to be selective about which doctors they include because they want to provide quality and efficient care. They may even cull their ranks when physicians fall out for either quality or efficiency.

But they don’t understand, “I’m actually a good doctor!” I am gentle, caring, and I carefully evaluate the individual patient in front of me. As I balance risks and benefits I may choose to take a prescribing “risk.” Now I must consider that the risk is not only to the patient but to me and my profile! What is a doctor to do? I have several choices. I could choose to fight this assault on my autonomy, or I could engage my professional association to contest a specific measurement tool. I could also review the information behind the measurements and re-evaluate my current practice and make changes. Whenever we participate in quality improvement activities, it has been shown that our real performance is often substantially less than we think it to be. Measurement is necessary to achieve better performance. Perhaps it would be better to measure my performance on certain criteria before I am measured by a health plan or by the government. Perhaps I can achieve higher numbers of eligible patients getting preventive tests such as colon cancer or breast cancer screening by measuring on an ongoing basis? Perhaps I can implement reminders, or authorize my staff to manage disease prevention activities. In a true medical home, more than just the physician is required to accomplish all of this care, but the physician should be the leader of the medical home team. Better that I should be in control of this process rather than having others force me to do it. Being a doctor is more than just checking a box. We are experts at applying clinical guidelines to doctor-patient encounters. We can explain, negotiate, motivate, and find legitimate exceptions for the patient in front of us. Checking a box, however, can help our patients when it serves as a reminder to care for more than the just the presenting problem, but rather the whole patient. When our new TAFP board met this December, we formed a subcommittee to review these issues and create programming for county academies, our regular CME sessions, and our publications to assist our members in coming to terms with the inevitability of a report card. Will you be a “straight A” student?

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news clips

1,046,430 Texans fall into the so-called coverage gap, meaning they are not eligible for Medicaid but make too little to qualify for subsidies in the new health insurance marketplace. This number doesn’t include undocumented immigrants and legal immigrants who have been in the U.S. for fewer than five years. Here are some characteristics of these Texans.

74% People of color

Medical homes show promising results in new PCPCC report A newly released analysis by the Patient-Centered Primary Care Collaborative shows the patient-centered medical home model is helping to reduce the costs of care and improving population health. The report, “The Patient-Centered Medical Home’s Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013,” analyzed quantitative outcomes across 20 medical home studies from August 2012 to 2013. It found that 60 percent of the PCMH evaluations reported decreases in cost of care or the use of unnecessary or avoidable services, and 30 percent reported improvements in population health. “The research here suggests that when fully transformed primary care practices embrace this model of care, we can expect a number of consistent, positive outcomes across a number of clinical and financial measures,” said Marci Nielsen, Ph.D., M.P.H., CEO of the PCPCC, in a press statement. “The PCMH has undergone an impressive expansion over the last several years, reaching across all corners of the health care marketplace, from health plans to federal agencies, from employers to state Medicaid programs. As a result we are seeing an increase in the frequency and rigor of PCMH evaluations that will help us not only identify where the PCMH is succeeding, but ultimately the driving factors behind that success.” Find the report at


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67% Adults without dependent children

53% Female

69% In a working family

trendS to watch IN 2000

53% of physicians practiced independently


were affiliated with a hospital

IN 2010


of physicians practiced independently

48% were affiliated with a hospital

Source: “The Anatomy of Health Care in the United States.” Journal of the American Medical Association. Nov. 13, 2013.

1 6.4 OF EVERY

2014 marks the 20th anniversary of the Texas Medical Association’s Hard Hats for Little Heads program. TAFP has been participating for 10 years now, and continues to encourage physician members to hold bike safety and helmet giveaway events in their communities. With the anniversary, TMA hopes to give out 34,000 helmets this year which will allow the organization to reach 200,000 helmets total since the program’s inception.

Who’s in the coverage gap?

Source: “Characteristics of Poor Uninsured Adults who Fall into the Coverage Gap.” The Kaiser Commission on Medicaid and the Uninsured. December 2013.

Hard Hats turns 20

U.S. JOBS is in health care

In 2011, the health care sectors of the U.S. economy employed more than 21 million people, or 15.7 percent of the U.S. workforce. Source: “The Anatomy of Health Care in the United States.” Journal of the American Medical Association. Nov. 13, 2013.


Congress has until March 31 to pass Medicare SGR fix By AAFP News Staff

as physicians rang in the new year, they had more reason than ever to hope for the repeal of the dysfunctional sustainable growth rate, or SGR, formula for Medicare payment. Congress is considering a bipartisan, bicameral solution that would avert future double digit rate cuts for Medicare fees and provide incentives for physicians to shift toward a value-based payment model. The House Committee on Ways and Means and the Senate Committee on Finance released an SGR repeal proposal in early November, and the two committees have since met to revise their respective bills. Although the original proposal called for a 10-year freeze on Medicare physician payments, the bicameral agreement currently on the table would provide a 0.5 percent increase for the next five years. Many of the other details, however, remain the same as have been reported for the past several weeks. For example, the bills, called the Medicare Patient Access and Quality Improvement Act in the House and the SGR Repeal and Medicare Beneficiary Access Improvement Act in the Senate, would:

• •

repeal the SGR; provide funding to shift emphasis toward new payment models that focus on quality of care rather than fee-for-service; provide $125 million to help small physician practices transform to payment models based on the quality of care; consolidate existing quality improvement programs, such as meaningful use, the physician quality reporting system and the value-based modifier, into a single Value-Based Performance Payment program that would reward high performing practices and that also would decrease penalties assessed on physicians who do not participate in quality programs; create a Medicare payment for complex chronic care services, which also will compensate physicians for services provided remotely; and create a process to identify misvalued services and redistribute savings on those services within the physician fee schedule.

Texas A&M, DeTar Healthcare to open family medicine residency program South Texas is set to get another family medicine residency program soon. Texas A&M Health Science Center and DeTar Healthcare System have agreed to a partnership to open a new program in Victoria. As long as the program gains approval from the Accreditation Council for Graduate Medical Education, it should accept its first six residents in 2015. DeTar is one of nine hospitals to win a $150,000 planning grant from the Texas Higher Education Coordinating Board to help plan the new program. TAFP championed the creation of the grants by the 83rd Texas Legislature as part of a package of initiatives designed to expand residency training across the state and to strengthen the primary care infrastructure.


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The bills need to be reconciled, but it is expected that they will be debated in the full House and Senate early this year. In the meantime, Congress passed a budget resolution before adjourning for the holiday season that includes the threemonth payment patch to the SGR, putting off a 20.1 percent cut and instead establishing a temporary update in payment of 0.5 percent until March 31. “The revised H.R. 2810 (SGR repeal bill) lays the groundwork for significant reforms that encourage new models of care, such as the patient-centered medical home, simplifies and reduces the administrative burden on physicians, and gives CMS additional tools to address misvalued physician services,” said AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., in a statement from the Academy. “Importantly,” he added, “the bill provides financial support to practices as they transition away from the traditional, procedures-focused model of care that responds to illness and move toward a comprehensive, coordinated and outcomes-based model that strives to prevent health problems and improve patients’ health.” Even if the SGR is repealed, however, Blackwelder points out that primary care physicians face cuts from other sources, including the proposal in the Patient Protection and Affordable Care Act that brings Medicaid payments up to at least Medicare levels in 2013 and 2014. This program is set to end in 2014, “creating significant challenges for our members who have accepted additional Med-

According to a statement by the Texas Hospital Association, the new planning grants are “much needed to address the state’s serious physician shortage that creates access difficulties for residents across the state. Texas has the fastest growing population in the nation but a lower-than-average physician to population ratio. Among the most severe shortages are those for primary care physicians, endocrinologists, psychiatrists, geriatricians, and pediatric subspecialists.” Dan Stultz, M.D., THA president and CEO, said the planning grants come at a crucial time for hospitals facing an increased financial burden from increasing numbers of uninsured patients and state and federal budget cuts. “The 83rd Texas Legislature’s investment is recognition that GME is a public good. Sustaining and building this investment will be essential to ensure that there are enough physicians to meet the health care needs of all Texans,” he said.

“The revised H.R. 2810 (SGR repeal bill) lays the groundwork for significant reforms that encourage new models of care, such as the patientcentered medical home, simplifies and reduces the administrative burden on physicians, and gives CMS additional tools to address misvalued physician services.”

$4.5 million in grants awarded to increase GME in Texas the texas higher education Coordinating Board has announced awards of more than $4.5 million over the next two years in two programs designed to expand residency training. The new grants are part of a set of initiatives TAFP championed in the 83rd Texas Legislature to increase the number of residency positions available in the state and to strengthen Texas’ primary care infrastructure. In the first announcement, nine hospitals will receive $1.3 million in planning grants to study the feasibility of creating new graduate medical education programs. These grants are for hospitals that have never drawn Medicare funding for residency training, and so would be eligible for some Medicare GME payments for newly created positions. The grants went to Baylor College of Medicine Medical Center in Houston,

Doctor’s Hospital at Renaissance in Edinburg, Hopkins County Memorial Hospital in Sulphur Springs, Knapp Medical Center in Weslaco, Memorial Health System of East Texas in Lufkin, Scenic Mountain Medical Center in Big Spring, DeTar Healthcare System in Victoria, Texoma Medical Center in Denison and Weatherford Regional Medical Center in Weatherford. The other program provides state funding for existing residency programs to fill currently approved but unfilled first-year residency positions. Over the next two years, THECB will provide $3.25 million to seven health related institutions to fill first-year positions in primary care specialties, psychiatry, and anesthesiology. In the second year, the program will support 50 new residency positions.

Reid Blackwelder, M.D. AAFP President

icaid patients into their practices,” Blackwelder said. “As Medicaid pays on average only two-thirds of Medicare, this will hit primary care physicians especially hard.” The AAFP is actively working on encouraging Congress to extend the program for at least an additional two years to truly give it a chance to work, as state-based delays in payment have led to many physicians not receiving the enhanced payment. According to Blackwelder, “Much needs to be done to continue to move payment reform to a system that values primary care and pays for value, not volume.” He noted that these are issues the AAFP will continue to work on during 2014 and beyond. In addition, the Academy will be watching as regulations promulgated by the SGR bill are implemented to ensure there are no unintended consequences for family physicians. Source: The majority of this article was written by AAFP News Staff, AAFP News Now, Dec. 18, 2013. © American Academy of Family Physicians 2013.

Professional Development To help members meet the educational requirements of licensure and obtain and maintain board certification, TAFP offers continuing medical education and Self-Assessment Modules. For more information, go to

2014 C. Frank Webber Lectureship Feb. 28, 2014 Omni Austin Hotel at Southpark, Austin

SAM Group Study Workshop on Depression Feb. 27, 2014 Omni Austin Hotel at Southpark, Austin

SAM Group Study Workshop on Care of the Vulnerable Elderly March 1, 2014 Omni Austin Hotel at Southpark, Austin

65th Annual Session & Scientific Assembly July 24-27, 2014 Grand Hyatt San Antonio, San Antonio

2014 Primary Care Summit – Houston Oct. 17-19, 2014 Westin Oaks Hotel, Houston

2014 Primary Care Summit – Dallas Nov. 7-9, 2014 Westin Galleria Hotel, Dallas

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Start Saving Money on Vaccines Now! Discounts on Vaccines • Reimbursement Support With Payers • Timely Updates About New Products, Changes & Sales • Donations to TAFP With Every Purchase! Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV. Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management. The program is free to your practice, and enrollment is completely voluntary. The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine. Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered. Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or for more information and to register.

Primary care pay hikes for Texas Medicaid to begin March 2014 Physicians must complete attestation form to be eligible the texas health and human Services Commission announced increased payments to primary care physicians for Medicaid services will begin in March of 2014 for those eligible physicians who have completed the self-attestation process. The fee increase, which comes as part of the Affordable Care Act, should increase Texas Medicaid fees for evaluation and management services and vaccine administration by about 66 percent, according to the Kaiser Family Foundation. The increase was supposed to begin in January 2013, but delays throughout the year put it off until the beginning of 2014. To be eligible for the increased fees, physicians must attest that they are board certified in a primary care specialty or that at least 60 percent of their total billings are for evaluation and management services and vaccine administration. The attestation form is available on the Texas

Medicaid Health Partnership website at To complete the form, you will need your National Provider Identifier, your Texas Provider Identifier, and a copy of your board certification if available. Primary care physicians who complete the self-attestation form between Jan. 1, 2013 and April 1, 2014 will receive retrospective payment for claims back to the beginning of 2013. Physicians who complete the form after April 1, 2014 will only get increased fees back to the date of their attestation. TMHP has a list of physicians who have successfully submitted their attestation. You can access the list to make sure they’ve received your attestation on the TMHP website. TMHP says if you have submitted your attestation but can’t find your name on the list, e-mail them at ACARateForm@


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Seeking Primary Care Physician! Excellent federally-qualified primary care clinics in Galveston County seeking a primary care physician to join a clinician team of physicians and midlevel serving residents of all ages in Galveston County. Family practice training and certification preferred. Excellent work hours and benefits. Applications and additional information may be found at or by contacting Human Resources at or 409-938-2230.


No need to ditch dairy with lactose intolerance Claire Florsheim, J.D., R.D., L.D. Health and Wellness Program Coordinator Dairy MAX, Inc.

studies show that a diet rich in dairy foods like milk, cheese, and yogurt may help reduce the risk of chronic diseases such as osteoporosis, diabetes, hypertension, cardiovascular disease, and certain cancers. Unfortunately, a common misconception is that dairy avoidance is the best prescription for lactose intolerance, but without dairy it can be difficult to meet recommended levels of many essential nutrients, including calcium, vitamin D, and potassium. This can lead to nutrient deficiencies and missed opportunities to capture the health benefits boasted by a dairy-rich diet. Many people with lactose intolerance can still comfortably enjoy dairy—typically up to 12 grams of lactose, or the amount in one 8-ounce glass of milk—at one time. Additionally, lactose-free milk, yogurt, and hard, natural cheeses contain little to no lactose and tend to be better-tolerated. Your patients can confidently add dairy foods into their diets with simple solutions: • Lactose-free milk is real cow’s milk without the lactose and is nutritionally equivalent to regular cow’s milk. Lactase enzymes added to milk pre-digest lactose so the body does not have to. • Yogurt contains live and active cultures which help break down the lactose in milk so that little remains. Many people find they can tolerate this small amount comfortably. • Hard, natural cheeses such as cheddar, colby, and swiss are also low in lactose, as most of the lactose in milk is lost and/or broken down during the cheese-making process. So what can you do to help patients manage their lactose intolerance? Follow these simple steps: Diagnose: Many people who say they are lactose intolerant have never been diagnosed by a health professional. It is difficult to confirm lactose intolerance based on digestive discomfort alone, because gastrointestinal disturbances may relate to any number of different conditions. A two-step process is recommended for diagnosing lactose intolerance: (1) the patient provides verbal or written confirmation of gastrointestinal symptoms; and (2) the patient tests positive for lactose maldigestion via lactose tolerance test, hydrogen breath test, or stool acidity test. Guide: Advise patients that they can still comfortably consume dairy and encourage them to meet the Dietary Guidelines for Americans recommendation of three servings per day. Guide patients through the process of gradually adding dairy back into the diet, recommending that they spread dairy intake throughout the day and describing how tolerance can actually be increased gradually over time. Inform patients that lactase supplements may also help improve digestion. Explain: Explain to patients why they may be able to tolerate lactose-free milk, cheese, and yogurt. Patients who have been avoiding dairy may be reluctant to add it back into their diets so it is important that they understand why these options may work better for them. Lactose intolerance is an individual condition. Help patients find their personal level of tolerance and enjoy dairy as well as the health benefits that come with it.

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Member news

Kumar installed as medical society president The Bexar County Medical Society installed TAFP member Kaparaboyna Ashok Kumar, M.D., as their new president in January. Kumar is a professor of family and community medicine at the University of Texas Health Science Center at San Kaparaboyna Ashok Antonio and Kumar, M.D. is a past president of TAFP. “I want our physicians to get involved and help the community,” Kumar says. “Just like with TAFP, I want to establish for the Bexar Medical Society a student section and a resident section and get them actively involved at the county level.” He currently serves on the AAFP Commission on Health of the Public and Science and previously chaired the AAFP Commission on Membership and Member Services.

AAFP appoints TAFP members and staff The American Academy of Family Physicians appointed two TAFP members and a staff person to serve on commissions for the next four years. Ajay Gupta, M.D., was appointed to the Commission on Finance and Insurance. He is currently a partner with the Jefferson Street Family Practice in Austin. Lindsay Botsford, M.D., was appointed to the Commission on Quality and Practice. She leads the practice transformation team at the Memorial Family Medicine Residency program in Sugar Land. Kathy McCarthy, CAE, was appointed to the Commission on Membership and Member Services. She is TAFP’s chief operating officer in Austin.

Member Month of the

TAFP’s Member of the Month web feature highlights Texas family physicians and their approach to family medicine. If you know a family physician colleague who you think should be featured as a Member of the Month or if you’d like to tell your own story, nominate yourself or your colleague by contacting TAFP by e-mail at  swhite@tafp. org or by phone at (512) 329-8666. View past Members of the Month at

December 2013 John Egerton, M.D., and Judith Egerton, M.D. Physician couple follows golden rule in practice

after meeting at The Welsh National School of Medicine in the United Kingdom in 1961, John and Judith Egerton married as medical students in 1964. John joined the Royal Air Force as a medical student, and after graduating and finishing a residency was stationed in Singapore until 1971. They felt “unsettled” after returning to the U.K., and decided to immigrate to America. In 1975, they moved with their four small children to Houston and established a joint practice in Friendswood in 1983. Now active TAFP members, the Egertons retired in 2005 and currently reside in Austin, spending their days traveling around the world and enjoying time with their children and grandchildren. TFP: Why did you choose family medicine, and what’s your favorite aspect of it? Were you inspired by anyone? Ultimately we became family physicians because we bonded intimately with patients

and we both wanted long-term relationships with families in our care. John had an internal medicine background, and I in community-based pediatrics, and also in women’s health. We had both always wanted to be family doctors since early childhood, in difficult times in post-war U.K. Our family lived in Friendswood as it grew from a population of about 4,000 to one of about 50,000. Our four children attended preschool through college with our young patients and to this day, most of them and their aging parents are still in frequent contact with us. They all are the thread of our lives. During that time we shared our life’s work with many medical students from Baylor College of Medicine, UT, Houston, and UTMB in Galveston. Our Immediate Past President, Troy Fiesinger, was one of our favorites! TFP: How would you define the mission of your practice?

samantha white

In our practice our philosophy was to treat each patient as we would treat a member of our own family, or as we wish to be treated ourselves. We witnessed the National Health Service in the U.K. from its inception in 1948, until the present. It was a shaky start, and when we left in 1975, it was still not well run and very unsettled. Patients were not always contented, yet many received health care that they could never have hoped for previously. Now we mostly admire it. Our own parents received excellent NHS care during their failing years. But for all the pitfalls of socialized care, we feel, as doctors, that we should be ever mindful that the definition of civilization is our duty as human beings to care for the young, the aged, and the infirm. We will never forget our Hippocratic Oath: First, do no harm. TFP: How do you spend your free time? We are now retired and still seem to have little spare time! We travel; we spend time

with our four children and five grandchildren who all live in Austin. John has published four novels and is working on another. TFP: It is important for us to be members of AAFP and TAFP because: Membership of the AAFP and TAFP gives us a feeling of belonging to a family. The CME it provides is a great bonus. And we love to act as Physicians of the Day at our beloved state capitol when it is in session! TFP: If you weren’t a physician, what would you be doing? We would never rethink our decisions to become family doctors, nor to spend those many years in Texas! TFP: What is the most memorable experience you have had when dealing with a patient? Among many memorable experiences John remembers delivering a baby boy at

midnight on Christmas Eve. It was a home delivery, in the vicarage next to the church. The father was taking the midnight mass and the church bells were ringing as if in celebration. Snow was just beginning to fall. Among my many memories is that of a surprise visit from a young man, a lifelong patient, until he and his mother moved out of state when he was 16. He had severe muscular dystrophy, and at age 20 he weighed just 22 pounds. He was carried into my arms just as I was attempting to console the mother of a young woman patient. She had been the same age, and she aspired to study medicine, because she was so fascinated by what I did. But depression overcame her one lonely night, and she took her own life. I gently laid him in the arms of her devastated mother, and we three women wept together. I marveled at the love, the sadness, the joy, and the pathos of my career.

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It’s time to talk about the primary care infrastructure


et’s face it, we have made tremendous progress over the past few years in defining and implementing the patientcentered medical home. Practices throughout the country have been recognized by NCQA and others for their achievement but resources and payments have been slow to change in a system that is mired in the fee-for-service mode. Even in some of our best blended payment models, the proportion of payment to support the infrastructure required is inadequate for what we are expected to accomplish for patients. In the past, we have seen integrated delivery systems or hospitals make huge capital investments in the cardiology wing or the cancer wing. They have installed all the expensive equipment required so that the cardiologists or the oncologists could offer the latest and greatest treatment to patients with those ailments. There is a required infrastructure to do this work well and the investment was well worth it to the system because it assured a revenue stream from that service line. Whether primary care practices are independent or affiliated with a larger system, they all need a level of infrastructure support that extends from facilities and equipment to care coordinators and health coaches. In the past, support for such things had to come from fee for service revenue resulting almost exclusively from face-to-face visits. It is time to rethink what it takes to support optimal primary care so that wellness, preventive services, chronic illness care, and acute patient care are optimized. What are the essential elements of the required infrastructure for primary care clinicians to do their best work? How should we pay for that infrastructure? Who will build the proverbial “primary care wing” to assure a revenue stream from that service line? These are critical questions we need to answer if we are to fulfill the promise of the patient-centered medical home to our patients and to our nation’s health system.

Electronic medical records and connectivity

By Bruce Bagley, M.D. TransforMED CEO

Although nearly 80 percent of primary care practices now have some form of EMR, many of these systems are clunky and impede rather than enhance the workflow. Information technology must support the core business, clinical, and communication functions of the primary care office. Embedded protocols and reminders, decision support functions, point of care registries, patient portals, and support for patient outreach must be part of the normal workflow and the shared responsibility of all the care team members. Efficient entry of clinical data and office notes remains a challenge for many clinicians. Primary care physicians need a system that works for them and enhances their ability to care for patients in a team environment.

illustration: MATT WHITEHEAD

Complete and timely data for improvement and to document quality All too often the conversation about quality metric is translated into the idea that it is an extra and unnecessary burden imposed on the clinicians by the payers. With systems in place such as registries for chronic illness care, all the clinical parameters that the physician would want to see to make the best decision and recommendations for a patient are collected, organized, and displayed in a way that is

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Support for patient engagement and team care

“Risk stratified care management and care coordination may be one of the highest leverage strategies for helping patients and saving money. Knowing which patients need extra time, effort, and guidance in navigating their illness and/or the complex health care system is the first step to appropriate resource allocation.” Practice transformation tools from TransforMED Medical Home Implementation Quotient TransforMED says the MHIQ makes it easy to benchmark a practice’s current performance. Answer a dozen or so short questions in each module to benchmark yourself in each of the nine PCMH areas and get actionable recommendations based on your score. Read more about the MHIQ here:

Delta-Exchange Physicians, clinicians, and thought leaders can join with nearly 10,000 primary care physicians and practice team members sharing practical resources and best practices as they transform to a PCMH. Ask questions of your peers and participate in live online seminars. New content is being developed and shared continuously. AAFP members can get started for free at

useful and efficient. Care team members all have a role and responsibility in making sure that the clinical information is complete, gaps in evidence-based care are identified, and action is taken to close those gaps. Primary care practices need to have near real-time data feedback to continually improve service, cost, and quality. Ideally this is built in to the system of care and not an additional task. 18

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In the past there have been very few resources available for patient self-management support or a team approach to helping patients do better in managing their own care and wellness. Part of the essential infrastructure is to supply sufficient time, energy, and people in roles such as health coaching, population management, social work, home care, and home monitoring. Care teams can be trained to help with informed medical decision making, motivational interviewing, shared goal setting, and between-visit follow up. It is now clear that these efforts result in better outcomes for patients and lower costs for the health care system.

Positive, efficient, and effective interactions with specialty services Primary care cannot provide value for patients without efficient access to the rest of the medical neighborhood. Comprehensive primary care should be able to provide most of the care for the common everyday needs of patients but also must take on the responsibility of helping to procure other services from the community that are timely, high quality, properly priced, and service oriented. This is clearly a two-way street with good communications in both directions. Creating a sense of shared responsibility for service, cost, and quality is everyone’s job. Referral guidelines, service agreements, and regular interchange about shared roles and responsibilities that are all focused on the best possible outcomes for patients must be the new norm.

Care management and care coordination within the neighborhood Risk stratified care management and care coordination may be one of the highest leverage strategies for helping patients and saving money. Knowing which patients need extra time, effort, and guidance in navigating their illness and/or the complex health care system is the first step to appropriate resource allocation. Proactive intervention with high-risk patients has clearly been shown to give better results for patients and reduce ER visits and hospital admissions. Patients get better care at lower cost.

How should we pay for this infrastructure? It is not realistic to expect this investment in infrastructure to come from fee revenue. That was never part of the consideration for the cardiologists or the oncologists when planning for the “new wing.” The emergence of a care management fee has provided one way to think about supporting these additional services that may or may not be associated with a visit to the office. To date, most of the care management fees have not been adequate to support the changes required or have been for only a small portion of the patients in the practice and therefore not enough total resources to support these new services. In the case of integrated or consolidated systems, they can and should direct the resources to support primary care infrastructure as part of their strategy to succeed in a value based purchasing environment. In essence, they should build the community capacity for capable primary care... “the primary care wing.” That capital investment should assure a revenue stream from that service line to the organization.

Bruce Bagley, M.D., F.A.A.F.P., is president and CEO of TransforMED, a wholly owned subsidiary of the American Academy of Family Physicians. This article appears in Texas Family Physician with permission, and was originally published as the final 2013 installment of “Report from the CEO” on the TransforMED website,

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Dr. Jasmine Sulaiman worked all week in a Cleveland, Texas clinic treating patients and teaching local women about the dangers of breast cancer. This afternoon, however, she’s being a wife, a mother, and a host, chopping a rainbow of fresh vegetables and baking salmon fillets for a delectable, four-course meal. She likes spending time in her wide-open kitchen when not tending to patients, cooking for and entertaining the ones she loves. Everything she cooks smells delicious. And the taste? Amazing. “Family, friends, food,” is the mantra that the 2013-2014 Texas Family Physician of the Year and her family live by, applying it to all aspects of their lives. Sulaiman relates TAFP to food, too. “Actually, the Academy has the cookbook to make you a better family physician or the best family physician,” she says. “I use the recipes to make the better dish.” 20

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hroughout their 26-year marriage, she and her husband, Sulaiman, voyaged around the globe, living in and visiting numerous continents. Along with their two college-age children, Alya and Adiv, the Sulaimans are a tight knit family of four that stays in touch constantly, despite the miles between them. Alya is currently a law student at Georgetown in Washington, D.C. and Adiv is studying petroleum engineering at Texas A&M. They were all in Fort Worth last August when she was given the Physician of the Year award at TAFP’s Annual Session and Scientific Assembly. “It was good to see her finally become recognized for the person she is and the way she conducts herself,” Adiv says. “It’s something I’ve known for 20 years of my life, but it’s good to see that recognized on a greater scale.” Sulaiman’s humble outlook on her career was apparent during her acceptance speech for the award at Annual Session. “Actually I don’t do anything different than any of you other family physicians do,” Sulaiman said. While growing up in Kerala, India, Sulaiman’s journalist father died from a heart attack when he was just 45 years old. “Sometimes I think that’s what made me go into medicine,” she says. Being the oldest of three girls, Sulaiman’s mother was a very modern Muslim woman, teaching her daughters the importance education could hold in their future lives, warning them that there were no guarantees in life. “She really believed in the power of education and being independent,” Sulaiman says about her mother. “She gave us the freedom to do whatever we wanted to do.” With that, she chose a life as a physician. After earning her medical degree in Kerala, and completing an internship in Saudi Arabia, Sulaiman and her family relocated to Utica, N.Y. There, at Columbia University, she completed her residency in the Bassett Elizabeth Family Medicine Program. She then took a job at one of the program’s satellite clinics during the influx of refugees from Bosnia and Kosovo. The clinic just so happened to be one of the largest refugee settlements, spiking her interest in working with underserved populations. From there she completed a faculty development fellowship in family medicine at the University of North Carolina School of Medicine and took part in a health leadership program in Duke’s Department of Community and Family Medicine. Her husband was an electrical engineer and after a work trip to Houston, they jumped at the chance to escape “six months of snow” and headed South. After searching on the AAFP job site, she interviewed with Steve Racciato, CEO of the Health Center of Southeast Texas. He was establishing a new clinic in Cleveland, Texas, and was in need of a medical director and practicing physician. Attracting interested physicians for the position had been difficult, then Sulaiman’s resume landed on Racciato’s desk. Her Ivy League education and teaching background made her stand out from the crowd of applicants. “So we were pleasantly surprised to be seeing a resume with that much information, those credentials on it,” says Racciato. Before beginning the interview, the board said a prayer with Sulaiman. She then knew that this was where she needed to be. With the clinic to have yet landed stable funding, taking the position would be a challenge, but she knew helping this community in need was the right fit for her. Cleveland is a rural town about 45 miles northeast of downtown Houston with a population of just over 7,600. Being in such a rural area, Sulaiman sees people from towns around Cleveland too – some traveling 30 and 40 miles just for basic health care. When Sulaiman joined the health center in 2006, the local hospital provided “seed money,” as Racciato calls it, to pay her salary, as 22

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well as his. The Cleveland Regional Medical Center also helped them purchase a quaint, two-room flower shop they renovated and turned into a clinic. Sulaiman saw 4,000 patients that first year, charging $5 to those who could afford it, and nothing to those who couldn’t. While gathering information on becoming a federally qualified health center, they received a grant from the state called an incubator fund, a sum of money awarded to clinics in the process of applying for a FQHC grant. The grant couldn’t have come at a better time – the Cleveland hospital stopped their funding and the Health Center of Southeast Texas was barely surviving financially. Racciato jokes about the days when they weren’t sure how they would meet payroll. Somehow, they always did. He would tell Sulaiman how many patients they needed to see to be able to pay their employees, and she would see that many, no questions asked. Racciato remembers Sulaiman seeing 36 patients in one day, working well into the evening without hesitation or complaint. The clinic finally reached FQHC status, supplying them with funds necessary to see patients “regardless of ability to pay, taking anybody that comes through the door,” says Racciato. They also get a Susan G. Komen grant for breast cancer screenings and education, as well as a state grant meant specifically for breast and cervical cancer services.

“I’ve been lonesome for you,” an elderly patient says upon Sulaiman’s arrival at her home. Because of the rural location of the clinic, Sulaiman and her team of medical assistants travel up to 25 miles away to do home visits for patients unable to make it to town. On the flip side, patient Doris Cuellar travels 30 to 40 minutes for her appointments with Sulaiman. “I’d rather have Dr. Jasmine any day,” she says. A patient of Sulaiman’s since 2009, Cuellar drives the long distance to Sulaiman’s clinic because she can’t imagine having another doctor. It’s obvious how much of a friend Sulaiman becomes to patients, both young and elderly alike. A 12-year-old patient wrote a physician of the year nomination letter on Sulaiman’s behalf describing her as “kind, caring, and loving,” adding that the doctor checks her grades and encourages the young girl to become a doctor one day. “She acts like my mother sometimes, but in the end she’s the best doctor I could have,” the little girl wrote. Caring for people feeds Sulaiman’s zest for life. Her face lights up when she tells stories about the clinic, her staff, her patients, and her experiences as a physician. From finding housing for a local homeless man to the time one of her staff adopted a dog found at the clinic, these stories keep her engaged in her daily physician tasks. “We work as a family, actually,” Sulaiman says of her clinic staff. She describes Racciato as the “pulse” of the clinic and says that the rest of the staff shares his spirit about helping out their fellow man. She thanked her staff and patients in her award acceptance speech, saying it wouldn’t be possible for her to do her job without their support. This theme of helping people out and caring for everyone around is apparent in her nomination materials for the physician of the year award. Sulaiman’s nominator, a fellow physician, explains Sulaiman’s bedside manner with patients. “Dr. Sulaiman’s patients do not sim-

Clockwise from top left: Sulaiman at the Cleveland, Texas city limits sign. Patient Doris Cuellar chats with Sulaiman during her clinic visit. Sulaiman prepares a delicious meal in her home kitchen. Maggie Estrada, Sulaiman, and Steve Racciato at the Health Center of Southeast Texas.

ply consider her a physician; she is a healer, counselor, mentor, and friend,” they wrote. One of the clinic’s current medical assistants, Lechelle Williams, also wrote a nomination letter on Sulaiman’s behalf, saying that she is always willing to both laugh and cry with patients while listening to their problems. “To me you are more. You are a friend, mother, role model, and a well experienced provider, thor

“Actually, the Academy has the cookbook to make you a better family physician or the best family physician. I use the recipes to make the better dish.” Jasmine Sulaiman, M.D.

oughly familiar with the needs and problems of others,” Williams wrote. Sulaiman is described as a friend time and time again. Racciato thinks that Sulaiman’s even taking the position in Cleveland says much about her character as a physician. “She could if she wanted to, let’s face it, with her credentials, she could have a teaching position at Baylor. She could have a teaching position at UT right here

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“We are all fortunate. The way we live. That’s one thing I tell everybody, even a smile can do it. That makes a lot of difference.” Jasmine Sulaiman, M.D.

The 2013-2014 Texas Family Physician of the Year with her husband, Sulaiman, and son, Adiv, at their home.

in town. She could’ve done a group of family physicians; she could’ve gone into a multi-specialty practice. With her credentials, I’m sure they would’ve had no problem accommodating her and getting her certainly a higher salary than what we were going to be able to pay her. She nonetheless opted to come with us.” He adds that Sulaiman, much like the rest of the staff at the clinic, gets a certain amount of personal satisfaction out of helping their patients on a daily basis. Sulaiman’s husband agrees. “Of all the job opportunities she had she went to a really small town, helping people in need,” he says. “She enjoys more giving back to the community.” Maggie Estrada started as the receptionist of the health center and is currently the office manager. With the help of Sulaiman and Racciato, she went through medical assistant training and learned about health care billing to work her way up at the clinic. The three of them have worked together since the beginning to get the health center where it is today. Sulaiman, she says, is not just about the money. “Dr. Sulaiman wants to grow our clinic but she’s not just looking 24

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for the money. She’s actually a listener. She’ll sit with any patient, she’ll care. She’ll get real personal with patients where they can talk to her; they’ll open up to her.” To Sulaiman, this is simply the definition of a family physician—diagnosing patients while delivering the best care possible. She realizes, however, that primary care and the medical field in general are not that simple. The complex and ever-changing world of medicine keeps Sulaiman on her toes and gives her a thirst for more knowledge. “From my experience the best way to keep up with these changes is to educate others,” Sulaiman says. She has high school students interested in the medical field shadow her each summer to learn about being a physician and invites residents to Cleveland to learn about the specialty of family medicine. Sulaiman follows and teaches a Sanskrit saying that means “knowledge is the everlasting wealth, perhaps the only wealth that keeps on growing by sharing or giving.” As important as teaching future physicians is, she believes educating her patients is just as important.

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Sulaiman with family and friends after receiving the Texas Family Physician of the Year award at TAFP’s 64th Annual Session and Scientific Assembly in Fort Worth, Aug. 3, 2014.

“Patient education is one of my platforms since training days,” Sulaiman says. She believes patients have the right to know what is going on with their health and that their knowledge is a big part of their health care plan. This drives her to be active in the local community – being present at local health fairs and participating in programs like Hard Hats for Little Heads and Tar Wars. In addition to the health center and treating inmates at a nearby jail on a monthly basis, Sulaiman’s work with the Health Center of Southeast Texas is expanding. They opened a satellite clinic in Shepherd, an even smaller community just 12 miles north of Cleveland. A third clinic will open in February 2014 in Liberty, just over 30 miles southeast of Cleveland. Sulaiman also passed the PCMH Content Expert Certification exam recently, allowing them to apply to become a patient centered medical home this year.

Volunteering has always been important to Sulaiman and her family. Her children were raised volunteering in their spare time—an ac26

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tivity they both still partake in regularly and a quality they will carry with them for the rest of their lives. “I think it’s really established the value and the importance of selfless service for me,” Adiv says. “She has a natural compassion,” says Alya. Alya always has volunteer opportunities waiting for her when she arrives back in Texas on vacation from law school. “No matter how busy she’s gotten, she always makes it a point to help out locally.” Sulaiman’s son Adiv shares the sentiment with his sister. “She obviously cares about everyone,” he says. “She tries to put a lot of love into everything she does.” As an international medical graduate, Sulaiman hopes her winning the physician of the year award is encouragement for other foreign graduates hoping to work in the U.S., showing them that they, too, can be recognized and that being a foreign graduate is no disqualification to being acknowledged as a great physician. The countries she studied in didn’t offer family medicine as a specialty. “I didn’t have much knowledge about what exactly family medicine is until I got into a residency,” Sulaiman says. She hopes more international medical graduates become aware of primary care and see it as a prestigious specialty. Whether tending to her patients or feeding a stampede of her son’s friends at a moment’s notice Sulaiman lives every day with a servant’s heart. If people around her learn anything from Sulaiman, she hopes it is this: “We are all fortunate. The way we live. That’s one thing I tell everybody, even a smile can do it. That makes a lot of difference.”

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foundation focus

2013 TAFP Foundation donors

Thank you to these 2013 TAFP Foundation donors, whose contributions fund scholarships for Texas medical students, family medicine research grants, and travel scholarships for residents to attend continuing professional development activities.

★ = TAFP Foundation monthly donor

Murray Charles Rice, M.D. ★ John R Richmond, M.D. ★ Shelley Poe Roaten, M.D. Douglas and Cynthia Robinson, Jr., M.D. JoAnne L. Rogers, M.D. Colleen M. Ryan, M.D.

Austin Regional Clinic

★ Kenneth Gayle Davis, M.D.

Clare Arnot Hawkins, M.D., MSC

★ Sarah Samreen, M.D.

Blue Cross and Blue Shield of Texas

Ralph A. De La Rosa, M.D.

★ James Michael Henderson, M.D.

Ramiro Sanchez, M.D.


Manuel De Los Santos, M.D.

★ Terrance S. Hines, M.D.

M. Sandra Scurria, M.D.


★ Tamra K. Deuser, M.D.

Anthony Holbert, M.D., M.B.A.

Puja Anil Sehgal, M.D.

TAFP Alamo Chapter

★ Chrisette Dharmagunaratne, M.D.

★ Janet L. Hurley, M.D.

★ Amer Shakil, M.D.

Texas Medical Association

★ Jorge Duchicela, M.D.

Lee Janson, M.D.

★ Robert F. Shields, D.O. ★ Zafreen Arfeen Siddiqui, M.D.

★ Jerry P. Abraham, M.P.H.

★ Tamarah L. Duperval-Brownlee, M.D.

George and Kathryn Kolb Johnson ★ David Arthur Katerndahl, M.D.

★ Linda Marie Siy, M.D.

Kelly Alberda, M.D.

Carolyn Eaton, M.D.

★ Christina Marie Kelly, M.D.

Hubert L. Smith, Jr., M.D.

Ruben Aleman, M.D.

★ Bruce Alan Echols, M.D.

Art L. Klawitter, M.D.

★ Mary Carmen Spalding, M.D.

★ Trisha A. Allamon, M.D.

★ Tricia C. Elliott, M.D.

★ Kaparaboyna Ashok Kumar, M.D.

Charles Herbert Stern, M.D.

Dale Crawford Allison, M.D.

Sheridan Scott Evans, M.D.

★ C. Tim Lambert, M.D.

★ Donald E. Stillwagon, M.D.

Adanna Amechi-Obigwe, M.D.

★ Robert Floyd Ezell, M.D.

★ Loren S. Lasater, M.D.

Michael and Carolyn Stone

Ichabod L. Balkcom, IV, M.D.

★ Troy Treanor Fiesinger, M.D.

Max G. Latham, M.D.

Morgan Stone

★ Maria Diana Ballesteros, M.D.

★ Aimee Lyn Flournoy, M.D.

★ Don A. Lawrence, DO

★ Tom Banning

Linda Whidden Flower, M.D.

Kay Lynn Lee, M.D.

★ Paul and Erica Williams Swegler, M.D.

Charles Oliver Barker, M.D.

Grant Carlton Fowler, M.D.

Walter and Lillian Loewenbaum

★ Sheri J. Talley, M.D.

★ Lynda Jayne Barry, M.D.

★ Lewis Emory Foxhall, M.D.

★ Leah Raye Mabry, M.D.

Hector Edwin Tamayo, M.D.

★ Justin V. Bartos, M.D.

Edwin R. Franks, M.D.

★ Javier D. Margo, M.D.,

James R. Terry, M.D.

★ Joane Goforth Baumer, M.D.

★ Kelly A. Gabler, M.D.

James Charles Martin, M.D.

Texas Medical Association

★ Stephen D. Benold, M.D.

Oscar Garza, M.D.

★ Kathy McCarthy, C.A.E.

★ Ashok Tripathy, M.D.

Adrian Billings, M.D., Ph.D.

★ Melissa Susan Gerdes, M.D.

★ William Mike McCrady, M.D.

★ Thao Minh Truong, M.D.

★ Alex J. Blanco, M.D.

James Edward Gibbs, M.D.

★ John M. McCullough, M.D.

★ Lloyd Van Winkle, M.D.

★ Teddy and Henry Julius Boehm, Jr., M.D.

★ Lisa Biry Glenn, M.D.

★ Gary R. Mennie, M.D.

Rosa Isela Vizcarra, M.D.

★ Roland Adolph Goertz, M.D.

Presley Joe Mock, M.D.

Charles W. Waldrop, Jr., M.D.

★ Lindsay Botsford, M.D., M.B.A.

★ John Edward Green, M.D.

★ Carol and Dale Moquist, M.D.

Cristen Wall, M.D.

★ Emily D. Briggs, M.D.

★ Thomas David Greer, M.D.

★ Mary Helen Morrow, M.D.

Samuel C .Wang, M.D.

Raul N. Calvo, M.D.

Nellie Poh-kee Grose, M.D.

James A. Murphy, M.D.

★ Sally Pyle Weaver, M.D.

Jack Quinten Cash, M.D.

★ Ajay Kumar Gupta, M.D.

Mark Nadeau, M.D., MBA

Judith K. Werner, DO

★ Chinglin Lillian Chan, M.D.

★ Natalia Gutierrez, M.D.

Jonathan Nelson

★ Jim and Karen White

★ C. Mark Chassay, M.D.

Harold Norman Haber, M.D.

★ Mary Suzanne Nguyen, M.D.

Walter D. Wilkerson, M.D.

Chuck Christensen

Philip Hackbarth

Donald R. Niño, M.D.

★ Hugh H. Wilson, M.D.

Dallas Eugene Coate, M.D.

★ Lesca C. Hadley, M.D.

Beverly Burnett Nuckols, M.D.

Charles V. Wright, M.D., M.M.M.

★ Samuel T. Coleridge, D.O.

★ Suhaib W. Haq, M.D.

Phil and Nancy Perry

Khalida Yasmin, M.D.

Donald Covey, C.P.A.

★ Rebecca Eileen Hart, M.D.

Didier F. Piot, M.D.

★ Robert Allen Youens, M.D.

★ Seth B. Cowan, M.D.

Bill and Gail Hartin

★ Henry David Pope, M.D.

★ Richard A. Young, M.D.

Texas Medical Liability Trust


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A Texas longhorn in Queen Elizabeth’s surgery By Richard Young, M.D. we walked down a narrow pedestrian-only street in the small town of Litchfield, England, which is a bedroom community near the second-largest city in Britain, Birmingham. I was following Dr. Helen Stokes-Lampard, an English general practitioner I had begun corresponding with over six years ago. I had read about the British National Health Service for years and had always wanted to see it firsthand. This September I finally got that chance, though I didn’t get to meet the Queen. We were making an afternoon house call after the morning surgery session. “The surgery” is what British general practitioners call their clinic. (I have no idea why. They call surgeons “surgeons,” so why call a clinic a “surgery”?) A 92-year-old patient of the practice’s patient panel reported severe hip pain and Dr. Stokes-Lampard thought it would be a good idea to walk to her residence to check on her. We walked past modern retail consumer shops that seemed patterned after some American stores: T. K. Maxx, for example. Of course one notable difference is that these shops were in Tudor-style buildings that were over 300 years old.

We arrived at the equivalent of a low-intensity assisted living center, where we found the woman sitting in a chair with another resident of the center visiting with her. Mrs. Jones said that the pain started the previous evening and was worse than when she had her daughter. But she did not call the ambulance during the night. She waited for her general practitioner to come visit her the next day. The visit was free to Mrs. Jones. One of the founding principles of the NHS is free care at the point of service. It’s not totally free, however. Patients have to pay for prescriptions and supplies, such as eyeglasses, and some durable medical goods are not covered. But doctor’s visits and hospitalizations are completely free to the patients. After Dr. Stokes-Lampard talked to Mrs. Jones for a few minutes, the doctor excused herself to wash her hands and I took the opportunity to help Mrs. Jones use her “frame,” or walker, to shuffle to her bed for the examination. It was a slow go and she could not swing her legs from a sitting position on the bed to the surface of the bed by herself because of the pain.

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“Imagine it. A patient who did not receive a CT scan, MRI, or a definitive diagnosis, but who was extremely happy with a prescription for a mild pain reliever and the fact that people cared for her. I saw it happen in Litchfield, England. Wouldn’t it be nice if it happened here?“ When Dr. Stokes-Lampard placed her hand around Mrs. Jones’ hip, she let out a loud groan, but the same response was elicited when the doctor placed her hand on the abdomen. The doctor was worried about a possible surgical abdominal process and began arrangements to have her patient seen by the local surgeons at the hospital. Dr. Stokes-Lampard would not see her patient in the hospital. This is the result of an agreement between physician factions struck in the early days of the founding of the NHS in the 1940s. General practitioners only work in the outpatient setting; internists cover the hospitals, but don’t provide primary care. This makes more sense in a country where essentially everyone is within an hour of a major hospital. There is no equivalent in Britain to Fort Stockton. Dr. Stokes-Lampard made several communications while concluding her care of Mrs. Jones. She called the surgical clinic of the hospital to let them know her patient was coming. Essentially all specialist and surgical offices are located at hospitals and these physicians and surgeons are paid a salary from the general hospital fund. She also called the ambulance service. It might take a few hours for the pick up, but this was felt to be reasonable under the circumstances. Finally, the doctor dictated a letter to the surgeon consultant. This was a notable difference between my observations of Dr. Stokes-Lampard and even American doctors in private practices I’ve observed. Both sides of the U.K. general practitioner/specialist camps spend a significant amount of time writing letters to each other. I’m sure this is no surprise, but the letters are sprinkled with polite phrases such as “would you be so kind as to …” and “Thank you ever so much.” I was in Britain after all. When all seemed to be in order, we left Mrs. Jones’ flat and walked back to the surgery. The surgery itself was in a much newer building that looked much more like what a stand-alone large American clinic building might look like. Some of the notable differences included the fact that each general practitioner worked out of one combination office and examination room. The patient waited in a small outer room and was invited into the consultation room only after the previous patient’s visit was completed. Dr. Stokes-Lampard scheduled a visit every 15 minutes, which is longer than usual. She did this to allow a little extra time to explain to the patients why a stranger was in the room and for me to ask questions. The standard consultation time is 10 minutes and they usually don’t deviate from this. The general practitioners use electronic medical 30

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records, but they are required to document much less than American family physicians, and their system is much easier to use and more helpful than the system I have to use, or any other one I’ve heard of. The surgery used to post standard-issue NHS signs that read, “A consultation should take no more than 10 minutes.” They removed them because they thought the signs were tacky. However, the culture of the 10-minute visit is understood by both doctors and patients. The visit is free to the patient, but they can only talk about one issue. Being human they often try to squeeze in another concern if the general practitioner lets them get away with it. Practice nurses help with some of the routine chronic care by phone and occasionally with home visits. Another difference is that all the routine childcare and immunizations were given by nurses in a separate area of the clinic. There are pediatricians in the U.K., but they do not provide routine primary care. They are hospital-based consultants. A common division of labor might be for the general practitioner to care for a child with mild asthma; the pediatrician a severe case. I tried to visit the NHS with an open mind, but my reaction to the trip was that my biases were confirmed. The secret to the incredible efficiency of the NHS – better health outcomes than the U.S. at half the cost – isn’t whether or not it’s socialized. As I have written in my book, American HealthScare, whether or not a government agency, a private insurance plan, or a patient paying out of pocket spends $1,500 for an MRI, the more important question is what is the effectiveness and cost-effectiveness of the MRI in the first place? Should it even be ordered? The NHS, the doctors I observed, and most importantly the British patients were much more humble about their expectations of what their health care system should provide. A few days later we found out how Mrs. Jones fared at the hospital. She got a plain x-ray and a few blood “investigations” (British for tests). They were reassuring and she was given a relatively mild pain medicine prescription and after about three hours was sent home. The surgeons’ conclusion was that the arthritis in her hip just flared up. Mrs. Jones was extremely grateful to her personal general practitioner, the hospital, and its doctors for the care she received. Imagine it. A patient who did not receive a CT scan, MRI, or a definitive diagnosis, but who was extremely happy with a prescription for a mild pain reliever and the fact that people cared for her. I saw it happen in Litchfield, England. Wouldn’t it be nice if it happened here?

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TAFP members: I’m here to help By Bradley Reiner

Did you know? • Did you know the Texas Academy of Family Physicians has a practice management consultant representing you? • Did you know the consultant is available for free e-mail and phone consultations because of your TAFP membership? • Did you know he worked for Texas Medical Association for 10 years and has owned a practice management consulting firm for the last 14 years? • Did you know he offers practice management services at a discount because of your membership with TAFP? • Did you know he is a billing and coding reviewer for the Texas Medical Board? • Did you know you have nothing to lose and you should contact him to ask any practice management question?

What are you waiting for? You may not have any practice management questions. You might feel your practice is running smoothly and think you don’t need any help. However, I would wager that at some point you will have questions you need answered. Some of these questions might include: • What are the chances of renegotiating my insurance contracts for increased reimbursement? • What can I do to avoid a payer audit? • Is my practice running as smoothly and efficiently as it should? • What things can I do to reduce my overhead? • Am I maximizing my collections in the office? • How can I ensure I’m documenting the highest code level based on the nature of the presenting problem? • What are the key elements in hiring the right staff?

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2013 TAFP PAC donors Trisha A. Allamon, M.D.

Robert L. Hogue, M.D.

Ichabod L. Balkcom IV, M.D.

Janet L. Hurley, M.D.

Maria Diana Ballesteros, M.D.

Christina Marie Kelly, M.D.

Lee Hagar Bar-Eli, M.D.

Kaparaboyna Ashok Kumar, M.D.

Justin V. Bartos, M.D.

James Lackey, M.D.

Joane Goforth Baumer, M.D.

C. Tim Lambert, M.D.

Luis Manuel Benavides, M.D.

Loren S. Lasater, M.D.

Stephen Douglas Benold, M.D.

Francis R. Lonergan, M.D.

Alex J. Blanco, M.D.

Leah Raye Mabry, M.D.

Henry Julius Boehm, Jr., M.D.

Waleed Mahmoud, D.O.

Lindsay Kathryn Botsford, M.D.

Javier D. Margo Jr., M.D.

Emily D. Briggs, M.D.

John M. McCullough, M.D.

Matthew Alan Brimberry, M.D.

Ronnie A. McMurry, M.D.

Javier Moises Campos, M.D.

Gary R. Mennie, M.D.

Juan M. Campos, M.D.

Nina Miller, M.D.

Chinglin Lillian Chan, M.D.

Dale C. Moquist, M.D.

C. Mark Chassay, M.D.

Graciela Moreno, M.D.

Victor Sostenes Chavez, M.D.

Mary Helen Morrow, M.D.

Samuel T. Coleridge, D.O.

James A. Murphy Jr., M.D.

Kenneth Gayle Davis, M.D.

Mark Nadeau, M.D., M.B.A.

Tamra K. Deuser, M.D.

Nancy Naghavi, D.O.

Jorge Duchicela, M.D.

Mary S. Nguyen, M.D.

Tamarah L. Duperval-Brownlee, M.D.

Stephanie D. Redding, M.D.

Carolyn Eaton, M.D.

Lee R. Schreiber, M.D.

Tricia C. Elliott, M.D.

Amer Shakil, M.D.

Sheridan Scott Evans, M.D.

Robert F. Shields, D.O.

Troy Treanor Fiesinger, M.D.

Linda Marie Siy, M.D.

Mitchell Frank Finnie, M.D.

Mary Carmen Spalding, M.D.

Roger Neal Fowler, M.D.

Dana Sprute, M.D., M.P.H.

Lewis Emory Foxhall, M.D.

Richard A. Stuntz, M.D.

Gregory Michael Fuller, M.D.

Erica Williams Swegler, M.D.

Kelly A. Gabler, M.D.

Sheri J. Talley, M.D.

Melissa Susan Gerdes, M.D.

James R. Terry, M.D.

Rebecca Hart, M.D.

Todd A. Thames, M.D.

Lisa Biry Glenn, M.D.

Ashok Tripathy, M.D.

Roland Adolph Goertz, M.D.

Joel Trujillo, M.D.

John Edward Green, M.D.

Thao Minh Truong, M.D.

Thomas David Greer, M.D.

Lloyd Van Winkle, M.D.

Jay L. Gruhlkey, M.D.

Rosa Isela Vizcarra, M.D.

Ajay Kumar Gupta, M.D.

Andrew H. Weary, M.D.

Natalia Gutierrez, M.D.

David Clifford White, M.D.

Lesca C. Hadley, M.D.

Walter D. Wilkerson, M.D.

Clare Arnot Hawkins, M.D., M.Sc.

Robert Allen Youens, M.D.

Hattie E. Henderson, M.D.

Richard A. Young, M.D.

Anne-Marie Herpin, M.D. 34

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The point to all of this is that I’m available to help answer any practice management questions you or your staff may have. All you have to do is call or send me an e-mail. That’s what I’m here for. This service is included in your membership, so why not use it? If you do have questions and it looks like I may need to come on site for an evaluation, you are entitled to a discount for my services. Here is a list of services I can provide. Billing and coding reviews A billing and coding review is done to determine if the billing and front office staff is efficient in maximizing the collection of revenues. It will also determine if the practice is following Medicare, Medicaid, and other payer’s guidelines for appropriate, medically necessary billing and coding. Efficiency in coding and billing improves revenue generation. Compliance and documentation audits A compliance and documentation review is provided to determine if physicians and physician extenders are coding evaluation and management services correctly. A sample of the documentation is audited and recommendations made to assist with coding at the most appropriate level. Training can be provided to aid doctors and physician extenders to code efficiently and document appropriately. Documenting at correct code levels is critical to accurate payment and compliance with all insurance payers. This avoids refunds or penalties assessed. This will also help maximize revenue if under coding exists. Practice evaluations/assessments A practice evaluation/assessment is an operational and financial study of an existing medical practice. This evaluation provides a comparative analysis to other practices of the same specialty. Encounter or case data is reviewed and compared as well as financial ratios. Staff efficiency and workflow is another major component as is review of the reimbursement area. This review gives the practice a snapshot of where it is and what needs to change to operate successfully. Managed care contract negotiation Contract review and negotiation services will help maximize revenue for the practice by identifying insurance carriers with unfavorable fees and determining opportunities for negotiation. Increasing fees helps assist the practice in generating additional revenue. Staff recruiting and human resource management I can assist practices with recruiting quality staff for their office including providers. High quality staff is vital to a practice’s success. Other practice issues General practice management resources as requested. Don’t delay—take advantage of TAFP’s partnership. Questions and e-mails cost you nothing and you might find that I can help your practice thrive. If you want to talk to someone who has used my services in the past, I’m happy to provide references as well. I look forward to speaking to you soon.

Bradley K. Reiner, formerly with Texas Medical Association, is now owner of Reiner Consulting and Associates. He can be reached at (512) 858-1570 or e-mail at

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2013 TAFP Year in Review By Samantha White


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tafp continued working diligently in 2013 to serve our members all across the state. The year including a legislative session meant staff and physicians alike advocating for the specialty on numerous occasions. The year also saw high attendance at Academy events, a large number of scholarships awarded, and numerous members winning accolades and achieving prestigious positions. advocacy: The 83rd Texas Legislature convened in 2013 and your TAFP advocacy team worked diligently all year for the specialty of family medicine. The regular session ended with mixed scores on health care’s most perplexing problems, but compared to last session, organized medicine and Texans have numerous reasons to celebrate. After a 43 percent cut to the state’s graduate medical education funding in 2011, lawmakers were determined to address GME by partially restoring funding to existing efforts and by investing additional funding in new initiatives designed to increase the number of training positions available in the state. As a result, total state GME funding will increase by $30 million, or about 45 percent in the upcoming biennium, and planning grants will help develop new residency programs in needed specialties. Family medicine residency programs receive a special line of direct state funding that goes to train the bulk of Texas’ future primary care physician workforce. Those funds were slashed by almost 74 percent last session, but in the next two years, the programs will receive $12.78 million, more than doubling their appropriation. TAFP worked with chair of the Senate Health and Human Services Committee, Sen. Jane Nelson, R-Flower Mound, to file a bill to strengthen primary care in Texas. The original bill was amended throughout the session and finally attached to another bill that passed and was signed by the governor. The bill created a set of incentive programs to create new residency training positions and to encourage medical schools to produce more primary care physicians. Lawmakers appropriated $33.8 million for the Physician Education

Loan Repayment Program, which is an almost 500 percent increase over the previous budget. The program will cover up to $160,000 in medical education debt for physicians who agree to practice for four years in an underserved community. Last session, the combination of the deficit threat and a political determination to deny state funding to Planned Parenthood had a devastating effect on women’s health care programs in Texas. Next biennium, programs that provide preventive and contraceptive care for women will be almost completely restored to their 2010-2011 levels, thanks to a dedicated group of lawmakers and advocates, like the Texas Women’s Healthcare Coalition. The Legislature increased state funding to the DSHS Family Planning Program by $32.1 million to replace federal funding under Title X awarded to the Women’s Health and Family Planning Association of Texas, and it gave the DSHS Primary Health Care Expansion an additional $100 million for the biennium for women’s health care. About $60 million of that is expected to go for family planning services including contraceptive care. The budget also adds $71.3 million for the Texas Women’s Health Program. After years of work and negotiation the Academy succeeded at securing the passage of legislation to streamline regulations for physicians delegating prescriptive authority to nurse practitioners and physician assistants, while maintaining the physician’s position as captain of the health care team. education: TAFP held four annual symposia in 2013: the C. Frank Webber Lectureship in Austin, TAFP’s 64th Annual Session and Scientific Assembly in Fort Worth, and Primary Care Summit in Houston as well as Dallas. These programs combined had nearly 1,325 attendees and offered the opportunity to earn up to 80.25 CME credits. TAFP also offered fourteen SAM Group Study Workshops during 2013 to help American Board of Family Medicine diplomates meet Maintenance of Certification requirements. Nine of the workshops were held in conjunction

with TAFP symposia and five standalone programs were held in Houston, Dallas, Corpus Christi, and San Marcos. The Academy plans to host 11 SAM workshops in 2014, nine coinciding with symposia and two by themselves. The National Procedures Institute also stayed busy in 2013, presenting procedural training workshops for primary care physicians on various topics. NPI offered 81 courses and welcomed over 1,000 medical professionals this year. NPI will host six programs in 2014, offering more courses per program and brand new courses. The six programs will be held in Fort Worth, San Diego, Las Vegas, Chicago, Orlando, and Phoenix. New course topics include ICD10, geriatrics, and laparoscopic suturing. To see the 2014 event schedule and register for upcoming programs, visit the NPI website at TAFP membership crossed big thresholds in 2013, adding over 100 active members and more than 250 medical student members, ending the year at 8,116 total members. AAFP ended 2013 with just over 110,600 total members. Many TAFP members ascended to the leadership of various organizations or received various awards. Samuel Mathis was chosen as the AAFP Student Representative to the American Medical Association’s Medical Student Section. Adrian Billings, Ph.D., M.D., was appointed to the National Advisory Council on the National Health Service Corps. Amy Mullins, M.D., was hired as the AAFP Medical Director for Quality Improvement. Carlos Jaén, Ph.D., M.D., was chosen as a new member of the Institute of Medicine. Troy Fiesinger, M.D., was given the J.T. “Lamar” McNew Award by TMA Resident and Fellow Section. Douglas Curran, M.D., was reelected to the TMA Board of Trustees, and Gregory Fuller, M.D., was elected as TMA Alternate Delegate to the American Medical Association. TAFP’s new officers were installed at the 2013 Annual Session: President Clare Hawkins, M.D., M.Sc., of Baytown; President-elect Dale Ragle, M.D., of Dallas; Vice President Tricia Elliot, M.D., of Houston; Treasurer Ajay Gupta, M.D.,

members and leaders:

of Austin; and Parliamentarian Janet Hurley, M.D., of Whitehouse. The Academy recognized its award recipients during Annual Session. Jasmine Sulaiman, M.D., was named Texas Family Physician of the Year. Both George Zenner, M.D., and David Pillow, M.D., were recognized as Physicians Emeriti. Janet Realini, M.D., received the Presidential Award of Merit. Sen. Jane Nelson was presented with the Patient Advocacy Award. Nora Gimpel, M.D., was awarded the Public Health Award. William Huang, M.D., received the Exemplary Teaching Award. Bruce Echols, M.D., received the Special Constituency Leadership Award. Tim Lambert, M.D., was named the TAFP Foundation Philanthropist of the Year, and Xavier Muñoz, D.O., was awarded the TAFP Political Action Committee Award. The Academy was well represented on multiple AAFP commissions in 2013: Justin Bartos, M.D., and Christina Kelly, M.D., Commission on Membership and Member Services; Joane Baumer, M.D., and Tricia Elliott, M.D., Commission on Education; Melissa Gerdes, M.D., chair of Commission on Quality and Practice; Rebecca Hart, M.D., and Ashok Kumar, M.D., Commission on Health of the Public and Science; Clare Hawkins, M.D., Commission on Continuing Professional Development; Erica Swegler, M.D., Commission on Government Advocacy; and Charles Willnauer, student representative to the Commission on Governmental Advocacy. At the end of 2013, TAFP saw three new appointments to AAFP commissions: Lindsay Botsford, M.D., Commission on Quality and Practice; Ajay Gupta, M.D., Commission on Finance and Insurance; and TAFP COO Kathy McCarthy, CAE, Commission on Membership and Member Services. tafp foundation: The TAFP Foundation

continued efforts to raise and distribute funds for scholarships for medical students planning to pursue careers in family medicine, office-based family medicine research, family medicine interest group activities at medical schools across the state, and family medicine resident activities. The Foundation would like to thank all donors, especially

our 75 monthly donors, for contributing to these efforts and we look forward to continue working with you to meet our goals to support the specialty. After budget cuts during the 82nd Texas Legislature, TAFP took over administration of the Texas Statewide Family Medicine Preceptorship Program. The TAFP Foundation created the Family Medicine Student Interest Endowment and awarded the first 13 scholarships in 2013. The stipends were given to medical students who spent two or four weeks with family physicians around the state getting real life experience in community health care settings. The Foundation also gave 19 scholarships during 2013, totaling over $23,000 for medical students and residents across Texas. Among the recipients was Anastasia Benson, D.O., who received the James C. Martin Scholarship and spent two weeks doing advocacy work for TAFP in Austin. TAFP is actively preparing for programs and events taking place in 2014, including preparing for the 84th Texas Legislature that will take place in 2015. Thank you to all of our members for everything you do for your patients and the state of Texas.

2013 in numbers $30 million increase in GME funding $33.8 million to the Physician Education Loan Repayment Program 1,325 attendees at TAFP symposia 8,116 TAFP members 10 TAFP members serving on AAFP commissions $23,000 in scholarships given by TAFP Foundation

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Banding together helps small practices achieve PCMH recognition By Lloyd Van Winkle, M.D. when the topic of practice transformation comes up, one of the most frequent questions we hear is, “What about the little guy?” How are small practices expected to overcome the additional work and expense needed to achieve patient-centered medical home recognition? This is a valid question, but the answer might be simpler than you think. For my small practice, the solution was to find strength in numbers. And that didn’t require anything as complex as joining an accountable care organization or an independent practice association. There’s a common belief in health care that large group practices are more viable during practice transformation. My practice, however, has just two physicians: me and my wife. We think the medical home model is the future of medicine, but we want to remain independent. So, 18 months ago, we sat in a meeting with other small practice owners from in and around San Antonio who also were interested in achieving PCMH recognition. We realized that if our small practices worked together, we would have the resources of a large group practice. For example, if one practice researched what was needed to meet a specific PCMH requirement and developed a strategy to achieve it, that practice could then share its results with the other nine practices. Economy of scale is essential. Having several small practices working together made us much more likely to succeed. Looking for community partners that support the medical home is another move that improved our chances for success. In our situation, those partners include a large health system and a local payer. With a newfound network of support, we divided the numerous challenges amongst the practices and went to work. After reviewing the PCMH checklist, my wife and I realized our practice already was meeting three-fourths of the requirements. National Committee for Quality Assurance Level 1 recognition was relatively easy for us to achieve, and all 10 practices achieved it at roughly the same time. Of course, we had room for improvement. Our practice improved access by implementing open-access scheduling and a patient portal. Building a staff where everyone buys in to the effort also is critical. Our staff performance has improved through the process. Labs are completed on schedule, we have fewer overlooked test results and we do a better job of ensuring that immunizations are up to date.

NCQA Level 2 recognition was about three times more challenging than Level 1, but within a year of starting this process, we were there. Not all 10 practices reached that milestone at the same time, but all 10 have made it. Five of the practices, including ours, are now working on reaching Level 3, which is a daunting task. Once the first five practices reach Level 3, we’ll help the other five do so as well. So what is the future for small practices? Systems will adapt to allow us to survive. We are too important not to, especially in underserved areas. Still, we have to be willing to listen to options, and sometimes you have to be creative. Local hospitals have an interest in our survival, and so do payers who want to reduce costs through better care. Our group has asked for help from both. For example, the Christus Santa Rosa Health System has been supportive of our efforts, including by providing space for our meetings. The system has bought into the importance of primary care and the vision of primary care as the foundation and future of health care. I would encourage doctors to look for organizations in their community that share common ideals. Organizations that are interested in supporting family physicians who want to improve quality by supporting local doctors in their pursuit of medical home certification. In our community, Christus Health Care has been very supportive of primary care doctors working to achieve PCMH. It helps to find support within the organization and Jim Martin, M.D., has been a great supporter in our efforts. In addition, our project has been partially funded by Blue Cross and Blue Shield, which has provided a case manager to work with our practices. The payer also has pledged to provide a 5 percent payment differential for practices in our group that achieve Level 3 recognition. That 5 percent bump will help us pay the case manager after the project is completed. Being a small practice doesn’t necessarily mean having limited resources. Sometimes you have to look for or build your own system of support. We’re a small, rural practice, but Level 3 is within our grasp. In the next few weeks, the AAFP will be introducing a new tool that provides step-by-step work plans to guide practices through PCMH transformation. Learn more about this new resource, the PCMH Planner, at initiatives/planner.html.

We realized that if our small practices worked together, we would have the resources of a large group practice. For example, if one practice researched what was needed to meet a specific PCMH requirement and developed a strategy to achieve it, that practice could then share its results with the other nine practices.


[WINTER 2014]


Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors. Source: AAFP News Now, Jan. 15, 2014. © 2014 American Academy of Family Physicians


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Texas Family Physician, Winter 2014  
Texas Family Physician, Winter 2014  

The winter 2014 edition of the quarterly magazine of the Texas Academy of Family Physicians