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texas family physician VOL. 62 NO. 4 FALL 2011

Austin Family Doc Describes Path To “Meaningful Use” CMS Primary Care Initiative Will Test Blended Payment AAFP Billing Expert On How To Prepare For ICD–10 News And Pics From TAFP’s 2011 Annual Session In Dallas

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INSIDE

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TEXAS FAMILY PHYSICIAN VOL. 62 NO. 4 FALL 2011

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Trading volume for value

Remember when health care reform was all about slowly transforming care delivery to address rising costs? Welcome to the new reality, where deficit reduction is the first order of business. Can we solve the country’s health care cost crisis by aligning payment incentives with desired outcomes in a new era of austerity? By Jonathan Nelson

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Technology: HIT incentives start paying off

Physicians who show “meaningful use” of health information technology have begun receiving federal incentive payments. And they’re reaping quality benefits for their patients.

16 MEMBER NEWS San Antonio FMIG honored for excellence | Dallas physician named top teacher | TAFP remembers three influential family physicians: Bain, Hyde, and Kleinman 30 PRACTICE MANAGEMENT AAFP’s coding expert Cindy Hughes helps you and your practice prepare for the change from ICD-9 to ICD-10. 33 ANNUAL SESSION MINUTES IN BRIEF See the latest actions taken by the TAFP Board of Directors.

By Erin Redwine

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CMS tests blended payment

Initiative offers incentive to primary care practices that coordinate care By Sheri Porter

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RUC watch

AAFP Board Chair Roland Goertz goes to Chicago to argue primary care’s case By AAFP News Now Staff 4

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TEXAS FAMILY PHYSICIAN

6 PRESIDENT’S COLUMN TAFP’s new president wants your five minutes for family medicine 8 NEWS CLIPS Obesity on the rise | AAFP joins specialty organizations to avert year-end Medicare cut | Texas Tar War winner takes third at national contest | New for You: TAFP launches free online CME activities

34 ANNUAL SESSION REVIEW Physicians gather in Dallas for a busy weekend of education, fellowship 37 FOUNDATION FOCUS TAFP Foundation flourishes, thanks to members 38 TAFP PERSPECTIVE Medical home pilots can cut health care costs


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president’s column

TEXAS FAMILY PHYSICIAN VOL. 62 NO. 4 FALL 2011 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 jnelson@tafp.org. Officers president

I. L. Balkcom, IV, M.D.

president-elect

Troy Fiesinger, M.D.

vice president treasurer

Dale Ragle, M.D.

Clare Hawkins, M.D.

parliamentarian

Dale Ragle, M.D.

immediate past president

Ajay Gupta, M.D.

Editorial Staff managing editor

Jonathan L. Nelson

associate editor

Kate Alfano

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, C.A.E.

publications intern

Erin Redwine

advertising sales associate

Audra Conwell

Contributing Editors Cindy Hughes, C.P.C., C.F.P.C., P.C.S. Kathy McCarthy Sheri Porter Erin Redwine Greg Sheff, M.D. 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. © 2011 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727.

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The chance of a lifetime

An excerpt from the inaugural speech of TAFP’s new president By I. L. Balkcom, IV, M.D. TAFP President in 1987, as I was graduating from the Columbus medical center’s residency program, I thought I was hot potatoes. We were good. The 12 of us just thought that we were it. I felt like I could do a Caesarean section with a teaspoon. There was no body cavity I couldn’t align. We felt like we could just do it all. So, armed with that knowledge, I set off in the world. I happened to be going to a meeting at the Capitol one day, and as I checked in at my hotel, I was puffed up pretty good. I signed in: “Dr. I. L. Balkcom, IV, M.D.” The clerk looked at me and she said, “Oh, you’re a doctor.” I said, “Yes, ma’am,” still puffed up. “Well, what kind of doctor are you?” “I’m a family physician,” sort of indignant. Guess what she said. “You’re just a G.P.” Whew. You could hear the air flowing out of me. Man, I was insulted. How dare she call me a G.P.? Didn’t everybody know that family physicians are the physicians? Well, I came to find out that wasn’t the case. Flash forward to 2005. I had the occasion to be on a little cruise, and while I was on this cruise, I happened to meet a lady who was quite haughty. She just rubbed everybody the wrong way. The ship was small with only about 70 passengers. I came into the room where everyone was gathered, and one of them said, “Hey doc, come over here and sit down.” So I sat down to enjoy some good conversation. This particular lady looked at me and said, “Well, you’re a doctor, too.”

I said, “Yes, ma’am, I am.” “Well, I’m a psychiatrist and my friend the pathologist is here, and so is my friend the dermatologist. Just what kind of doctor are you?” And I’m thinking, I’m not repeating my mistake from last time. I say, “Why, ma’am, I’m an R.D.” “An R.D.? What’s that?” “A real doctor.” Unfortunately I had insulted a rather prominent lady. Some of you will not remember this, but there was a science fiction writer named Isaac Asimov. He had died but his wife had not. I found out right then you had to be careful. As I assume the office of TAFP president, I want to take a moment to consider our profession, our specialty. We are family physicians, no bones about it. I’ve been through the thing where we were gatekeepers, but that sounded to me like we were protecting the city from the giant marshmallow king, like in Ghostbusters. I don’t want to be a gatekeeper. I want us to be family physicians: recognized, appreciated, and reimbursed. Come to think of it, do you know what I really want to be? I want to be a shepherd. A shepherd leads his sheep from the front. He protects them, he serves them, and he loves them. We need to do that again. I want to be a shepherd of the people. I want to take care of them from the time they’re born—and even before they’re born—to the time they leave us. That’s what we should strive for, to be good shepherds.

A shepherd leads his sheep from the front. He protects them, he serves them, and he loves them. We need to do that again. I want to be a shepherd of the people. I want to take care of them from the time they’re born—and even before they’re born—to the time they leave us.


Service to others. Work/Life balance for you.

There’s an old song by Meatloaf, “Life Is A Lemon (And I Want My Money Back).” Well, I’m a family physician and I want my steam back. I don’t work for specialists. How many times have you felt that you were the employee of the day as you did the history and physical exam for the cardiologists or neurologists? We’ve been cordial; we’ve worked closely with everyone. Now it’s time to stand up and get a little bit of our mojo back. As our president in 2009-2010, Kaparaboyna Ashok Kumar, M.D., started a great thing when he asked us to go to medical schools and tell students what a real doctor is all about. Over the next year, you may get a phone call from me asking for your help in continuing that effort. I cannot do it alone, nor do I intend to. I’m going to ask you if you can donate five minutes for family medicine, and that’s going to be my battle cry. Give five minutes for family medicine. I know I’m preaching to the choir here, but please take the message to your colleagues and friends. I want to close with one little thing that I found. Many of you will remember a great sprinter named Jesse Owens, a black athlete who competed in the 1936 Summer Olympics in Berlin. Back in those days, what do you think his role was when he wasn’t running? He got to run down the back hall and climb the back stairs rather than take the elevator with the whites. He won four gold medals. He won the 100 meters, 200 meters, the long jump, and the 4-x-100-meter relay. His feat wasn’t matched until Carl Lewis did it at the 1984 Summer Olympics in Los Angeles. Jesse Owens won all four of those gold medals only to be told, “Well, you can go ahead and sit in the kitchen in the back.” This is what Jesse Owens said, a guy who was scorned even though he represented our country well: “We all have dreams. But in order to make dreams come into reality, it takes an awful lot of determination, dedication, self-discipline, and effort.” Here’s another thing he said, which I think is the best short quote I’ve ever heard: “One chance is all you need.” I want us all to take that one chance and move our specialty forward. Let’s get back to what we do and let’s do it well.

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www.tafp.org

FALL 2011

7


news clips

>25% obesity rate in 38 states Twenty years ago, no state had an obesity rate above 15 percent. Today, more than two out of three states, 38 total, have rates over 25 percent, and just one has a rate lower than 20 percent. In Texas, 30.1 percent of adults are obese, as are 20.4 percent of kids. Adult obesity rates increased in 16 states over the last year and did not decrease in any.

DID YOU KNOW?

Source: F as in Fat: How Obesity Threatens America’s Future 2011, Trust for America’s Health and the Robert Wood Johnson Foundation.

TAFP launched a new e-newsletter, Products & Services, a monthly communication to highlight products, services, and member benefits from TAFP and AAFP, as well as other offers from TAFP’s partners that benefit family physicians. The inaugural e-mail in July highlighted opportunities at TAFP’s 2011 Annual Session and Scientific Assembly in Dallas through the Exhibit Hall and the Annual Session sponsors. Sent on the third Thursday of each month, future editions will feature other products and services important to family physicians—practice management tools and resources, educational opportunities, public health materials, and more. For more information, go to the Products & Services section of TAFP’s website, www.tafp.org/resources/products.

Products & Services 8

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AAFP, specialty orgs develop strategy to avoid Medicare cut AAFP met with representatives from seven medical societies and seven professional organizations on Sept. 7 to develop a unified strategy to approach the newly formed congressional Joint Select Committee on Deficit Reduction and urge its members to avoid making damaging cuts to Medicare and graduate medical education. The joint committee, or supercommittee, has a historic opportunity to address the structural deficit in how the country pays physicians for the services rendered to Medicare beneficiaries. The 12 committee members can identify offsets from all areas of government, rather than only finding offsets within Medicare Part B as has complicated a fix in years past. Similarly, the supercommittee could recommend federal medical liability reform and score those savings toward deficit reduction. They must finalize their plan by Thanksgiving to cut $1.2 trillion in federal spending and Congress must pass the plan by Christmas. Year after year, Congress has stepped in to avoid a steep cut, automatically calculated through the Sustainable Growth Rate formula, and provide a short-term patch. But each year Congress fails to implement a permanent fix, the cost to fix the problem grows and the cut in physician pay gets steeper. Come Jan. 1, 2012, physicians face a 29.5-percent cut. AAFP has asked for repeal of the SGR, or, barring that, the enactment of a five-year Medi-

HELP WANTED Between April 1, 2010, and March 31, 2011, 56 percent of physician job openings were in hospitals, up from 23 percent five years ago; and 2 percent of job openings were for independent, solo practitioners, down from 17 percent five years ago. For the sixth straight year family physicians were the most requested type of doctor. Source: Merritt Hawkins’ 2011 Review of Physician Recruiting Incentives; HealthLeaders Media, June 10, 2011

care payment fix that includes a 3-percent higher payment rate for primary care physicians. Among the societies in attendance were the American College of Physicians, the American College of Surgeons, the American Academy of Cardiology, and the American Society of Anesthesiologists. “There was a good open discussion about the significance of the SGR,” AAFP Board Chair Roland Goertz, M.D., M.B.A., told AAFP News Now. “We are all engaged in trying to do what is best for our respective members and the physician community at large.” There will be an ongoing need for discussion about and refinements to any SGR strategy, as well as a collective effort by the groups represented to engage physicians in contacting their legislators, he said. “This is a game in evolution, and there are going to be some twists and turns.”


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news clips

MEDICAID

Out of the woodwork Under the health reform law, federal funds will cover 100 percent of costs of individuals newly eligible for Medicaid in 2014. States receive the traditional federal contribution rate for any additional enrollment of people who are already eligible. In some states, 5 to 8 percent of the entire population under age 65 are uninsured despite being Medicaid-eligible. Some fear the law would spur the “woodwork effect,” drawing out more than 9 million uninsured adults and children nationwide, including 1.1 million in California, 1 million in Texas, and 900,000 in New York, costing states billions of dollars. Source: Why States Are So Miffed about Medicaid — Economics, Politics, and the “Woodwork Effect,” New England Journal of Medicine

Expanding low-income adults’ access to Medicaid substantially increases their health care use in appropriate settings, reduces their financial strain, and improves their self-reported health.

NEW FOR YOU

Source: The Oregon Health Insurance Experiment: Evidence from the First Year, the Robert Wood Johnson Foundation

TAFP presents new, free online CME offerings The Texas Academy of Family Physicians is proud to present Continuing Professional Development online CME activities, available to members at no cost. Each interactive CME package includes a video of the speaker timed with a PowerPoint presentation. At the end of the CME activity, the participant completes a five-question post-test and, if passed, he or she proceeds to an evaluation and receives a CME certificate. The three courses currently available were recorded at the 2011 Annual Session and Scientific Assembly in Dallas. To access these online CME activities, go to: www.tafp.org/education/ internetCME. And be sure to check back; more will be added this fall.

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Texas family medicine residency

MATCH

UP

New numbers for Texas: Family medicine residencies filled 202 of 211 positions in the 2011 Match, or 95.7 percent. Nationwide, 2,576 of 2,730 positions were filled, for a fill rate of 94.4 percent.

Houston fifth-grader places third at national Tar Wars poster contest After winning the grand prize in Texas Tar Wars poster contest, fifth-grader Hady Hernandez of Houston won third place in the 2011 Tar Wars national poster contest on July 12. The contest is held each summer during the annual Tar Wars National Conference, which represents the culmination of the AAFP’s school-based tobacco-free education program. The Crockett Elementary student drew an elaborate jungle scene featuring a large red parrot and her anti-tobacco message, “Hang Tough, Don’t Puff.” Family physicians and other health care professionals present Tar Wars—AAFP’s tobaccofree education program—every year to fourth- and fifth-graders. After physicians present the Tar Wars curriculum in school classrooms, students are encouraged to create posters conveying

the positive aspects of being tobacco-free. The program provides students with the tools to make positive health decisions and promote personal responsibility for their own well-being. More than 8 million children have seen the presentations since the program’s inception in 1988. Texas Tar Wars is the statewide education program to prevent tobacco use among children. Tar Wars is supported in part by the AAFP Foundation. For more on Tar Wars, go to www.tarwars.org.

EHR satisfaction

SURVEY SAYS: 78 percent of the 2,800 respondents to the 2011 EHR User Satisfaction Survey were satisfied or very satisfied with the ability to customize their EHR system. 39 percent were satisfied or very satisfied with vendor support and training, and 39 percent agreed or strongly agreed that they would purchase their current system a second time.

$1.5 billion

In 2010, Texas family medicine residencies filled 195 of 198 positions, 98.5 percent—a higher rate than 2011, but with fewer positions offered and fewer positions filled. Nationally family medicine programs filled 2,404 of 2,630 positions in 2010, a fill rate of 91.4 percent. Source: AAFP Annual Report on the National Resident Matching Program (2011)

TEXAS FAMILY PHYSICIAN

The Medicaid cost savings generated by the Community Care of North Carolina program from 2007 to 2009. CCNC relies on coordinated care and patient-centered medical homes to provide care to 1.1 million Medicaid beneficiaries. Source: AAFP News Now

Source: Family Practice Management July/August 2011


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news from aafp

Initiative will use blended payment model to drive health care transformation

lesterol,” said HHS Secretary Kathleen Sebelius during a Sept. 28 press call announcing the new initiative. “Under the new program, that will change.” Richard Baron, M.D., director of the seamless care models group in the CMMI, said during the call that AAFP supports increased focus CMS will request a letter of intent from insurers on Nov. 15 and will require a formal application by Jan. 17. on family physician patient care “We will then convene community-level conversations with aligned payers, representatives of practices, and By AAFP News Now staff consumer representatives to describe specifics of community strategy and alignment around quality meaaafp has long urged public and private payers to sures,” he said. CMS also will discuss implementation adopt a blended payment model that rewards primary measures and the strategy for soliciting participating care physicians for coordinating and managing patient practices during these meetings. care. Now, CMS and its Center for Medicare and MedCMS plans to launch the initiative with participaticaid Innovation, or CMMI, have joined the movement ing practices next summer. with the launch of a new initiative—the ComprehenAccording to Baron, one of the major goals of the sive Primary Care Initiative. The initiative will allow initiative is to drive practice transformation. “What we CMS to work with commercial and state health insurare hoping for in launching this initiative is for the priance plans to support primary care practices that devate sector to join CMS in designing liver coordinated and seamless care new models that are aligned in a way based on the tenets of the patientthat will accelerate and powerfully centered medical home, or PCMH. Too often today, drive practice transformation.” “The AAFP applauds the Comprewe penalize He also called for a payment model hensive Primary Care Initiative anthat supports primary care in a way nounced by the Center for Medicare primary care that promotes practice transformation. and Medicaid Innovation,” said AAFP professionals for “The way CMS does payment now, President Glen Stream, M.D., M.B.I., and the way many insurers do it in the of Spokane, Wash., in a prepared statespending time country now, is to pay for primary care ment. “This program is an important with patients .... in a fee-for-service payment system breakthrough in reforming our health Under the new where the only thing that is paid for are care policy—focusing our system on (physician) visits,” said Baron. patients’ needs, ensuring their access program, that Stream noted that the PCMH to primary care, and helping control will change. can meet practice transformation the cost of health services.” goals because it “coordinates all the The voluntary initiative will begin Kathleen Sebelius health services a patient may need— as a demonstration project in five to be it preventive care; diagnosis and seven health care markets across the treatment of acute illness; or mancountry with about 75 primary care agement of a complex, chronic condition.” However, medical home practices participating in each market. In he added, “This way of providing care requires large the selected markets, CMS and its partners will enroll investments in electronic health records; redesigned participating practices in the initiative. The agency will medical offices; and committed time for communicapay these practices based on a blended payment model tion with subspecialists, pharmacists, hospitals, home that combines fee-for-service with a per-patient, percare agencies, and therapists. month care coordination fee ranging from $8 to $40. “These services are vital to ensuring that patients Participating practices also have an opportunity to parget the right care from the right professional at the ticipate in shared savings from the project. right time,” said Stream. “But they have never been To qualify to participate, practices have to meet sevacknowledged in the way we pay for medical services. eral criteria, including the use of an electronic health The blended payment approach in this initiative will record system or an electronic registry. In addition, they correct this misaligned system.” must serve as the first point of contact for patients while Stream also said the new initiative “will further also providing ongoing care. Participating practices also demonstrate that patient outcomes improve and costs are required to have at least 60 percent of their revenues are saved when a health care system values primary care generated by payers participating in the initiative. by paying for all the services family physicians provide “Too often today, we penalize primary care profesto their patients.” sionals for spending time with patients, for going over test results on the phone, or sitting down to create a Source: AAFP News Now, Sept. 28, 2011. © 2011 American Academy of plan to help a patient lose weight or manage their choFamily Physicians. 12

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HIGHLIGHTS CMS is launching a new initiative that will support primary care practices that deliver coordinated and seamless care by enlisting public and private payers to initiate a blended payment system. AAFP, which has long called for such a blended payment model, is praising the Comprehensive Primary Care Initiative as an important breakthrough in reforming the nation’s health care policy. The new initiative “will further demonstrate that patient outcomes improve and costs are saved when the health care system values primary care,” said AAFP President Glen Stream, M.D., M.B.I. CMS has yet to select the geographic areas or communities for the demonstration project. For more info, go to innovations.cms.gov, and search for “Comprehensive Primary Care Initiative,” or enter “tinyurl. com/6hmm6ka” in your browser.


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 info@atlantichealthpartners.com for more information and to register.

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news from aafp

AAFP addresses RUC subcommittee regarding changes the Academy seeks AAFP Board Chair: ‘We’ve presented our case’ By Sheri Porter

• create three new seats to represent outside entities, such as consumers, employers, health systems, and health plans; • add an additional seat to represent the specialty of geriatrics; • eliminate the three current rotating subspecialty seats when the current representatives’ terms expire; and • implement voting transparency.

aafp board chair Roland Goertz, M.D., M.B.A., of Waco, Texas, hopped a plane to Chicago recently to take the Academy’s argument for changes to the AMA/Specialty Society Relative Value Scale Update Committee, better known as the RUC, straight to the group’s administrative subcommittee. Earlier this summer, the Academy called In addition to Goertz, three other Academy on the RUC to make some very specific members took part in the recent Chicago meetchanges to its structure, process and proceing: Walter Larimore, M.D., of Monument, dures. After receiving the AAFP’s June 10 letColo.,who currently serves as the AAFP’s ter, the RUC invited the Academy to further representative to the RUC; explain its position. Lee Mills, M.D., of Newton, Goertz spoke with AAFP who is the alternate News Now shortly after his “Without telling Kan., representative; and Thomas Sept. 22 presentation to the the RUC exactly Weida, M.D., of Hershey, RUC subcommittee. He Pa., who is the AAFP’s RUC called the meeting “a positive which path to adviser. exchange of information.” take, I think we None of the family phy“I was allowed to make sicians in attendance was a statement to clarify our have made our able to provide any detail request,” said Goertz, addcase. Now it’s about the meeting’s proing that his 10-minute preup to them.” ceedings because of the sentation was followed by RUC’s stringent confidentia 50-minute question-andRoland A. Goertz, ality agreements. answer session. However, Goertz did say “Without telling the RUC M.D., M.B.A. he was “cordially received” exactly which path to take, I by the subcommittee memthink we have made our case. bers and that each of the Academy’s five issues Now it’s up to them,” said Goertz. was addressed. “On every issue, there were The RUC acts as an expert panel and questions related to clarifications, which I did makes recommendations to CMS on the relmy best to provide,” said Goertz. ative values of CPT codes, which determine “When they excused me from the room, what physicians are paid for the services they they began the serious deliberation of deliver to patients. The Academy and other the five requests that we made of them,” primary care physician organizations have Goertz said, adding that even though he made no secret of their belief that decisions doesn’t anticipate a formal answer to the made by the RUC favor subspecialist procerequests immediately, “I do have every readures rather than preventive care and chronson to believe that they will answer our reic disease management services. quest by the March (1, 2012) date we have The AAFP’s stance was summed up in given them.” that June letter to RUC Chair Barbara Levy, Regarding the Academy’s next move, Goertz M.D., in which the Academy made five spesaid, “I don’t believe that there are any other cific requests, asking the committee to: action steps that we can take at this time. “We’ve done everything that is reasonable • add four true primary care seats—one to make our case, and, at least to this point, each for AAFP, the American Academy of we’ve been heard.” Pediatrics, the American College of Physicians, and the American Osteopathic Source: AAFP News Now, Sept. 26, 2011. © 2011 Association; American Academy of Family Physicians.


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2/25/11 1:53 PM


Member news Dallas physician receives national teaching award

San Antonio FMIG honored as “program of excellence” aafp named 16 medical school family medicine interest groups as the 2011 Program of Excellence Award winners for their outstanding activities in generating interest in family medicine. Among the 10 overall winners is the University of Texas Health Science Center at San Antonio. FMIGs are medical school-sponsored organizations that give students a chance to learn more about family medicine through regular meetings, workshops, leadership development opportunities, and community and clinical experiences. The Program of Excellence Award recognizes FMIGs for their outstanding performance in FMIG operation, community service, promoting the value of primary care, exposure to family medicine and family physicians, professional development, and measures of success. In operation since the late 1980s, the UTHSCSA FMIG has been recognized with this award a total of five times. The group currently boasts a membership of over 200 medical students with an active board of officers. Lori Fisher, a third-year medical student at UTHSCSA, served as FMIG president in the 2010-2011 year. “The enthusiasm of the students and dedication of our incredible faculty advisors has made this year [20102011] one of the best for our FMIG,” she says. “We are proud to serve the San Antonio community by providing health care services and instruction in our local schools, homeless shelters, and student-run clinics.”

In the community, the UTHSCSA FMIG staffs student-run free clinics weekly at two locations: Alpha Home, a transitional living home for women recovering from drug addiction, and the San Antonio Metropolitan Ministries, a transitional living home for previously homeless families. The group is involved in Tar Wars, AAFP’s anti-tobacco initiative that brings medical professionals into fourth- and fifth-grade classrooms, and Ready, Set, FIT!, an AAFP fitness initiative that teaches third- and fourth-grade students the importance of fitness and proper nutrition. UTHSCSA takes extensive steps to recruit medical students to family medicine. They elect student liaisons from each medical school class to promote upcoming events and meetings; use FMIG meetings to discuss relevant medical topics, sponsor hands-on workshops, and invite family physicians from the community to speak; and sponsor an annual residency fair, which brought 17 family medicine residency programs to interact with third- and fourth-year medical students. The FMIG has become more active with the Alamo Chapter of TAFP this year, nominating a student member to attend Alamo Chapter meetings and serve on their executive committee. Award winners were honored during a July 29 ceremony at the AAFP National Conference for Family Medicine Residents and Medical Students in Kansas City, Mo.

Practice available for one or more family physicians in Waxahachie, 30 minutes from Dallas. Retiring from practice of 35 years. Office has 10 exam rooms, 4 offices, X-ray, CLIA certified lab, loyal employees and patients. An ideal opportunity for new practioner(s). Contact: Richard D. Redington M.D. Family Practice Association 1410 West Jefferson Waxahachie, Texas 75165 Phone: (972) 937-1210 Fax: (972) 937-0243

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Tamika L. Perry, D.O., M.P.H., of Dallas is among a select group of physicians honored by the AAFP Foundation for her commitment to education in the field of family medicine. Perry was selected to receive a 2011 Pfizer Teacher Development Award based on her scholastic Tamika L. Perry, achievement, D.O., M.P.H. leadership qualities, and dedication to family medicine. Perry says teaching keeps her “on her toes,” as she studies the latest in clinical knowledge before she quizzes the residents. “This award solidifies my commitment to teach family medicine residents to deliver quality, medically sound care to underserved populations. I am truly honored to be this year’s recipient.” She is currently a clinical assistant professor, volunteer faculty, at the Methodist Health System Family Medicine Residency, where she will be recognized for this achievement during a ceremony held by her teaching center. She is the co-founder of Red Bird Community Clinic, a family medicine clinic in a designated health professional shortage area. Perry earned her medical degree from Philadelphia College of Osteopathic Medicine and is a graduate of the Methodist Health Systems Family Medicine Residency Program where she served as chief resident. She received her Master of Public Health degree in Health Management and Policy from the University of North Texas Health Science Center at Fort Worth. “Pfizer Teacher Development Awards spotlight the best of our profession: those in active practice who give of themselves to teach, mentor, and inspire residents and students,” said AAFP Foundation President Richard G. Roberts, M.D., J.D., in a press release. “Tomorrow’s family doctors and their patients will be better because of their efforts. My congratulations to Dr. Perry and my thanks to Pfizer for preserving the noble tradition of the clinician-teacher.” In addition to her membership in TAFP and AAFP, Perry is also a member of the American Osteopathic Association, American College of Osteopathic Physicians, Texas Osteopathic Medical Association, American Medical Association, Texas Medical Association, and Dallas County Medical Society.


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Patients. Colleagues. Medical experts. The exchange is always more meaningful when you’re there in person. This year, Pri-Med Access with ACP is offering an all-new CME curriculum created in partnership with the American College of Physicians. The highly interactive, hands-on sessions include ample time for Q&A. The live, face-to-face format lets you collaborate with clinician-educators and share ideas and discuss emerging trends with colleagues from your own community. Join us at Pri-Med Access with ACP for the full-two day program, one day, or one course. Register today at Pri-Med.com/access.

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Stay in touch! This program is designed for primary care physicians who are actively engaged full-time in managing and treating patients (at least 24 hours per week in direct patient care) and whose attendance at this program will benefit the treatment of their patients. A limited number of registration opportunities will be made available for nurse practitioners and physician assistants also engaged in active patient care. © 2011 M|C Communications LLC. All rights reserved. Pri-Med is a registered trademark of M/C Communications, LLC. All other trademarks are the property of their respective owners.

Connect with other clinicians, discuss pressing medical topics, receive CME notifications, and get the latest updates from Pri-Med. Join the conversation at Pri-Med.com/social.


Member news

Remembering a longtime Austin physician, educator Family medicine pioneer Ruth M. Bain, M.D., of Austin died June 23, 2011, at age 92. Bain was highly influential in organized medicine; she served as president of the Travis County Medical Society in 1962, and as president of the Texas Medical Association in 1982—the second female to hold the post. She also served as a TMA delegate to the American Medical Association House of Delegates and served on the Texas State Board of Medical Examiners from 1979-1982. During four decades of private practice in Austin, Bain delivered over 1,000 babies and cared for many three-or-more generation families. Her career also led her to academia where she served as co-director of the Austin Family Practice Education Program administered by the Central Texas Medical Foundation. Glen Johnson, M.D., an influential family medicine leader and past TAFP president and AAFP vice president, worked with her at the program. He remembers her as a “no-nonsense” family physician. She influenced “not only the residents that we trained but vicariously influenced my own career as a family doctor,” he says. “Ruth deserves the highest accolade available for her years as a family physician role model par excellence.” Mathis Blackstock, M.D., of Austin, traded call with Bain. “I say you could always tell

what a doctor is like if you know his patients. Ruth’s were mostly middle-aged women, very businesslike, who were very clear with me about their expectations. That was very much like Ruth.” Bain received a bachelor’s degree in chemistry from Texas State College for Women (now Texas Women’s University) in 1939, and a medical degree from the University of Texas Medical Branch at Galveston in 1942. She served on the staff of the University of Texas Health Center for three years before entering private practice. In 1987, she retired from private practice and served as medical director and then vice president of medical affairs for Texas Health Plan (later PCA Health Plans of Texas) until she retired in 1990. Bain was the first recipient of the Physician of the Year Gold-Headed Cane Award from the Travis County Medical Society in 1989, she was inducted into the Central Texas Women’s Hall of Fame in 1990, she was recognized as a Distinguished Alumnus from both Texas Women’s University and UTMB in Galveston in 1993, and she received the TMA Distinguished Service Award in 1994. Bain is survived by her sister, Louise Sinderson; sister-in-law, Jane Bain; and many nieces and nephews.

TAFP leader, Lubbock physician passes away TAFP member Walter Hyde, Jr., M.D., passed away Sept. 18, 2011, at age 59. He practiced family medicine in the communities of Lubbock and Seminole, Texas, for 25 years. During this time he also served as a leader in TAFP, fulfilling appointments to several committees and commissions including the Commission on Health Care Services and Managed Walter Hyde, Care, and the CommisJr., M.D. sion on Membership and Member Services. Hyde was born on Sept. 25, 1951, in McAllen, Texas. He graduated from Round Rock High School in 1970 and went on to receive a bachelor’s degree in microbiology from the University of Texas at Austin. He was awarded his medical degree by the University of 18

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Texas Health Science Center at San Antonio and completed a family medicine residency at Texas Tech University Health Sciences Center in Lubbock, Texas. Remembered as a dedicated father, grandfather, friend, and teacher, Hyde coached his son’s little league baseball team for years and supported his daughters in gymnastics and volleyball. He was a member of First Baptist Church of Lubbock, and previously served as an active deacon and religious education teacher at Bacon Heights Baptist Church. And he was an avid gardener of vegetable and flower gardens along with his wife. He is survived by his wife, Vanesa; their children, Kelly Hyde and wife, Summer, Melanie Forbess and husband, David, and Mary Katherine Hyde and fiancé Tyler Hogan; grandchildren, Caedan Vaughan Hyde and Jonah Forbess; and brother, James Hyde.

TAFP loses life member, physician emeritus TAFP life member Isaac Kleinman, M.D., passed away on June 28, 2011. Kleinman opened a family medicine practice in Rosenberg in 1956 and practiced full-scope medicine including obstetrics-gynecology and surgery for nearly five decades. He taught hundreds of medical students and residents at Polly Ryon Memorial Hospital as the residency program director and director of skilled nursing, and provided emergency coverage for Polly Ryon and Tri-Star MediIsaac Kleinman, M.D. cal Services. Kleinman was named the 2011 TAFP Physician Emeritus for his longtime service to the specialty. His children—Michael Kleinman, Sam Kleinman, and Eve Zehavi—accepted the award on his behalf at TAFP’s Business and Awards Lunch on July 30 in Dallas. As Michael told the audience at the ceremony, “he administered anesthesia, he removed gallbladders and appendixes, he delivered over 5,000 babies, he managed strokes and heart attacks, casted fractures, and treated myriad diseases, all for the good of mankind.” “My dad believed in lifelong learning,” he continued. “Decades before it became a political buzzword, he felt that family physicians should treat and not triage; he recertified in family medicine at least five times; and became certified in sports medicine, geriatric medicine, and emergency medicine. He felt that since 90 percent of patients present first to their family physician, the maintenance of broad competence was a first priority for all family physicians.” Kleinman was awarded his medical degree by the University of Texas Southwestern Medical School and completed his internship at Graduate Hospital University of Pennsylvania. He served in the United States Navy from 1944-1946. He is survived by his wife Sara; children, Michael and wife Ellen, Sam and wife Diane, and Eve and husband Elan; grandchildren, Alyssa, Jonathan, MacKenzie, Mallory, Bryce, and Maya; and sister, Miriam Sabel.


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Trading Volume As worry builds over the long-term prospect of escalating deficits and mounting federal debt, reforming our health care delivery system may offer the best chance of solving the nation’s health care cost crisis. Changing the way we pay for care so that physicians and other providers reap greater rewards for value than for volume could be the key to slowing inflation in health expenditures while improving the quality of care we deliver. By Jonathan Nelson this year, total health care spending in the United States will top $2.7 trillion, exceeding 17 percent of the gross domestic product. For the past 50 years, U.S. health care spending has outpaced GDP by about 2.5 percentage points on average, and the trend shows no sign of slowing. The Centers for Medicare and Medicaid Services predict national health expenditures will rise to $4.6 trillion and almost 20 percent of GDP by 2020. If health care were like other sectors of the economy, such sustained increases in spending wouldn’t necessarily be detrimental. After all, the industry employs an expanding workforce and sells new technology and services to a demanding customer base, while requiring the products and services of other industrial sectors to support its growing infrastructure. Here’s the rub: Almost half of all health expenditures are paid by government programs. Together, Medicare, Medicaid, and the State Children’s Health Insurance Program comprise about 23 percent of the entire federal budget. In its 2011 long-term fiscal outlook, the U.S. Government Accountability Office reports that while cost-containment measures in the Affordable Care Act could “markedly improve” the country’s future deficit status, if those measures don’t succeed, 89 cents of every dollar of federal revenue will go to pay for Medicare, Medicaid, Social Security, and the net interest payments on the federal debt by 2020. With 2.8 million baby boomers becoming eligible for Medicare this year and another 75 million awaiting their turn, there is no question that the rising cost of health care is the most significant contributor to the nation’s long-term deficit. Medicare alone makes up 15 percent of federal spending and is expected to cost $555 billion this year. By 2020, CMS predicts Medicare will cost $903 billion. Popular reform ideas for Medicare like increasing the age of eligibility and requiring richer beneficiaries to pay higher premiums would reduce federal expenditures in the program, but they don’t address the underlying problem of escalating costs. Instead they shift costs to individuals, hospital districts, and state, county and local tax bases, further straining the potential for economic development in those communities and ultimately constricting U.S. living standards. A new study by David Auerbach and Arthur Kellermann at the RAND Corporation shows that growing health care costs have wiped out 10 years of income gains for the average American family. The authors conclude: “Given the perilous state of the U.S. economy, the fiscal burdens imposed on all payers by steadily rising health care costs can no longer be ignored. Controlling health care spending is a defining challenge of our times.” 20

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for Value

Can we solve the country’s health care cost crisis by aligning payment incentives with desired outcomes in a new era of austerity?

www.tafp.org

FALL 2011

21


3 POSSIBLE FUTURES The 75-year predictions by the Congressional Budget Office on federal spending for Medicare and Medicaid as a percentage of GDP if health care costs rise at their historical pace are so absurd as to be impossible. By definition, an unsustainable trend cannot continue, so significant reduction in the growth of health care costs is inevitable. How and when it will be achieved are the questions of concern. Kim Slocum, board chair of the nonpartisan health policy think tank Texas Health Institute, believes transformative change will happen soon. “Looking back, 2011 will probably be seen as the year that these issues came to a head as part of the discussions about the federal budget deficit,” he says. “There is a growing consensus that our nation may not have the luxury of waiting a decade or more for the sorts of system redesign contemplated by [the American Recovery and Reinvestment Act] and ACA. It is now quite possible that something of significance will have to occur in a much shorter time period— probably within the next five years.” As president of the Pennsylvania-based health industry consulting firm KDS Consulting, Slocum sees three possible futures for the U.S. health care system. In the first, reforms in the way we pay for and deliver care work; we successfully deploy the tools and processes to bend the cost curve so that health care costs rise at the same rate as GDP.

In that possible future, we create a more integrated system that rewards good health care outcomes and efficiency, creating value for patients and health care providers alike. The second option involves a massive shift of health care costs to patients. Benefit packages would probably be gutted and outof-pocket costs would soar. “A large body of health policy research shows that patients are relatively poor decision-makers about the care they need and when faced with steep out-of-pocket costs, simply stop consuming all medical services without regard to whether those services are optional or vital,” Slocum says. “The impact on the nation’s health and physicians’ practices from such an approach would be quite negative.” In the final option, the government imposes controls on the prices of goods and services in the health care industry. “Paradoxically, this scenario is relatively popular with the general public and therefore must be considered the default future for U.S. health care if attempts to manage cost growth through the value approach were to fail.” According to a March 2011 CBS poll, 68 percent of Americans believe the deficit is a “very serious” problem, but 54 percent think the budget can be balanced without cutting Medicare spending. A recent Harris Interactive poll shows that 59 percent oppose increasing Medicare co-pays and deductibles to shore up the program, and 50 percent oppose raising the Medicare payroll tax. Two-thirds of those polled favored cutting prescription

drug prices; 44 percent favored reducing Medicare reimbursements for hospitals; 40 percent said doctors should receive lower Medicare payments. “The three choices are before us,” Slocum says. “As one of the most powerful constituencies in health care, physicians can have an important part to play in swaying the national dialogue. It is up to the medical community to decide whether it wants to lead or follow in this important decision.”

Changing the game So how do we bring about the first possible future for health care and avoid the other two? We have to understand what is driving inflation in health care costs, and we think we have a pretty good idea. The demand for new technology and treatments is broadly considered the most important inflationary factor. The aging of the population makes a contribution as well, as does the lack of responsibility patients bear in governing the quantity of services they consume and the cost of those services. Two aspects of the health care system that both contribute to rising health costs and frustrate efforts to reduce that escalation are the perverse incentives inherent in the feefor-service payment structure, and the utter lack of understanding of what it costs to provide care at the patient level. To accurately price any service, you must be able to measure

National health expenditures, aggregate and percent of GDP, 1960–2010, and projected through 2020 $5,000

$4,638.4

PROJECTED $4,000

Dollars in billions

$3,227.4

$3,000

$2,000 $1,378.0

$1,495.3

$1,637.0

$1,772.2

$1,894.7

$2,021.0

$2,152.1

$2,283.5

$2,584.2 $2,391.4 $2,486.3

$2,708.4

$2,823.9

$2,980.4

$724.0

$1,000 $27.3

$74.8

$255.7

$0 1960

1970

1980

1990

2000

2001 2002

2003

2004 2005

2006

2007

2008 2009

2010

2011

2012

2013

2014

2020

16.2% 16.6% 17.6% 17.6%

17.7%

17.6% 17.6% 18.1% 19.8%

CONSECUTIVE YEARS

NHE as a share of GDP 5.2%

7.2%

9.2%

12.5% 13.8%

14.5% 15.4% 15.9%

16%

16%

16.1%

Sources: For years 1960 through 2009, Kaiser Family Foundation. For years 2010 through 2020, Centers for Medicare and Medicaid Services

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the cost of resources required to provide that service. In today’s complex and fragmented delivery system, that ability doesn’t exist, and in the current payment system, there is little incentive to obtain it. To solve these two problems will require system-wide transformation and effective organizational structures that facilitate and reward clinical integration, like patient-centered medical homes, and possibly accountable care organizations. At the sixth National Pay for Performance Summit in San Francisco, Calif., in March of this year, Harold Miller was assigned the task of describing the necessary strategies for implementing reforms in the way care is paid for. He is the president and CEO of the Network for Regional Healthcare Improvement and the executive director of the Center for Healthcare Quality and Payment Reform. He told attendees the key to achieving savings and efficiency in the health care system without rationing care is to focus on improving patient care, and to make the first order of business keeping patients well. Next, when patients do acquire preventable conditions or chronic diseases, the priority should be proper management of those conditions in a way that reduces avoidable hospitalizations. And when patients require hospitalization or experience acute care episodes, the priority must be to ensure that they don’t get infections, complications, or readmissions, and that care is delivered in the best way possible. “The good thing is that those are all ways of saving money, but they are also ways of im-

proving quality and outcomes for patients,” Miller said, “and I think that if we were to tell the American people that what we were trying to do is to keep them well, help them avoid having to go to the hospital, and to make sure they have a good experience when

“The current payment system pays doctors and hospitals more when patients get infections and complications. It pays them more the more often they go to the hospital, and nobody makes any money at all in health care when patients stay well.” Harold Miller

they go there, most people would say, ‘These ACO things may be pretty good deals.’” The problem is fee-for-service payment discourages such a patient-centered approach. “The current payment system pays doctors and hospitals more when patients get infec-

Medicare, Medicaid, and CHIP spending as a percent of total federal spending

Health System in Pennsylvania, Advocate Physician Partners in Illinois, and Village Health Partners in Plano, Texas, are developing cultures of value in health care rather than volume, and they are finding ways to thrive financially. Through clinical integra-

Projected change in Medicare enrollment, 2000-2050 100 88.3

90

Defense discretionary

Non-defense discretionary 15%

19% 6%

12%

Medicare

8% Medicaid and CHIP

Net interest

Other

Total federal spending, FY2010 = $3.5 trillion Source: Kaiser Family Foundation, Medicare Chartbook, fourth edition, 2010

8% 63.9

7%

Medicare enrollment (in millions)

60 50

10% 9%

80.8

70

20%

Enrollment in millions

20%

92.8

80

Social Security

tions and complications. It pays them more the more often they go to the hospital, and nobody makes any money at all in health care when patients stay well.” Across the country, health systems like Intermountain Healthcare in Utah, Geisinger

6% Average annual growth in enrollment

47.5

5%

40

4%

30

3%

20

2%

10

1%

0 2000

0% 2010

2020

2030

2040

2050

Source: Kaiser Family Foundation

www.tafp.org

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tion, measuring quality, carefully examining clinical and administrative processes, and adhering to evidence-based protocols, these systems and group practices are lowering overall health costs and improving their quality of care. Eschewing fee-for-service and implementing payment strategies that support high-quality, coordinated, patientcentered care is crucial to their success. “Fee-for-service has only one baked-in incentive, and that is to encourage the production of services,” says François de Brantes, executive director of the Health Care Incentives Improvement Institute, or HC3I. “People shouldn’t be surprised that health care is rolling at two times [the U.S. Consumer Price Index] because the core incentive in health care is to produce more services. The core incentive in every other part of the industry is to produce more value.” Change that equation, de Brantes says, and you change the rate of health care cost growth. De Brantes describes all payment models arrayed on a spectrum of incentives, with

de Brantes says. “The next minute that you spend on that particular patient, you lose money. Payment reform was really born from the realization that being stuck at one pole or the other pole doesn’t make a lot of sense, and instead we ought to have these gradations, and try as much as possible to match the payment, which drives the incentive, around the services and the care for the patient that makes sense.” Episode-of-care payments and global payments sit in the middle of the spectrum, because they encourage judicious utilization of services for each condition or each patient. Take a patient with congestive heart failure, for example. Under a fee-for-service model, if that patient has multiple acute care episodes, hospitalizations, and readmissions, each physician and hospital involved in each instance of care gets paid. The sicker the patient becomes, the more care he needs, and the more money the providers make. Now suppose that patient’s care is paid through an episode-of-care model. All care

“Fee-for-service has only one baked-in incentive, and that is to encourage the production of services.” François de Brantes

fee-for-service at one pole, and capitation at its opposite pole. On the fee-for service side, the payment model encourages utilization of services, favoring those services that are the most expensive. At the other pole, capitation completely discourages utilization. Over the past 40 years, the only period when health care costs didn’t rise faster than the rest of the economy was during the managed-care capitation phase of the early 1990s. Total capitation has its problems, too. It puts physicians at risk for the level of health of their entire patient panel, so physicians in a sicker population suffer financially. “If you think about it from an economist’s perspective, capitation is a little like a retainer,” 24

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related to the treatment of his congestive heart failure is paid out of a budget intended to cover some chunk of care—all care for his CHF over a calendar year, for example. The care team now has a real incentive to integrate their clinical data, collaborate on treatment decisions, and invest in better management of his condition. The physician assumes the risk associated with the resource costs of managing the patient’s condition during that period of time, but there’s a new budget for each patient, so there’s no incentive to avoid a new patient or a new condition. Through his work at HC3I, de Brantes has led the development of an episode-of-care payment model called PROMETHEUS that

is being tested in several pilots across the country. Before working on PROMETHEUS, he led the development of Bridges to Excellence, one of the first large-scale pay-forperformance programs, and in 2000, he was instrumental in the launch of The Leapfrog Group, an organization of employers dedicated to improving transparency and value in health care. He began to focus his efforts on payment reform in 2004 and 2005. “It was really clear at that time that unless we changed the compensation system, we could throw as many bonuses as we wanted on docs; we could throw as many incentives as we wanted on the hospitals; it just wouldn’t make a difference, because the inherent force of fee-for-service was stopping anything else from penetrating.” For large health systems like Geisinger, implementing a new payment structure and improving quality and efficiency by employing system-wide clinical protocols work in part because the organizational structures to manage those strategies are in place. Clinical integration among teams of primary care physicians, specialists, care management nurses, and other providers occurs under that structure. Family physicians who don’t practice as part of a large organization will need similar tools and processes to thrive in a health care delivery system that rewards quality health outcomes and efficiency—value rather than volume. For one, they will have to be willing to collaborate with specialists and other providers to effectively manage patients’ care. They’ll need to agree among the members of the care team on some sort of organizational structure to facilitate that collaboration. And they’ll need the ability to collect, analyze, and share clinical data to properly coordinate patient care, demonstrate quality, understand the true cost of their resources, and identify opportunities to increase efficiency. “The push toward health information exchanges, the push toward adoption of electronic medical records, those are the essential tools of clinical collaboration for individual practices that want to maintain their autonomy, but are going to be encouraged to and decide to work with other physicians on a team, even if it’s a completely virtual team, paid under the auspices of a budget that doesn’t just focus on what they’re doing individually, but on what happens to the patient across different care settings,” de Brantes says. “I think it’s going to look a little daunting to folks who aren’t already organized in either virtual teams or real teams to try to figure out


how they participate in this thing, but you know what? This is the changing world.” The crisis in health care costs isn’t new. Since the development of health insurance as a means of financing care delivery, reform efforts have all been attempts at controlling escalating costs. From the creation of Medicare and Medicaid in the 1960s, to Nixon’s HMO legislation and Reagan’s Medicare payment overhaul, rising costs have driven reforms. The country’s dire fiscal outlook and the threat of long-term structural deficits will force an end to the unsustainable pace of increasing health care costs at some point and in some manner. Changing the way we pay for health care won’t solve the problem by itself, but a growing number of health policy experts believe it is a necessary step in transforming the system. If we don’t succeed in making that transformation in time, the future could be quite difficult for physicians and patients alike. “I’m concerned about the hammer that might fall in a completely arbitrary and damaging way,” de Brantes says, “but ultimately, the threat of that hammer falling might end up being the thing that wakes everybody up.”

3 Models of Payment Reform Blended payment: Fee-for-service plus Health care services are still paid individually according to the Resource-Based Relative Value Scale, but physicians and other providers would receive two additional payments. For each patient, they would get a per-member per-month care management fee adjusted for the severity of the patient. Then they would get a performance bonus based on quality, patient satisfaction, cost efficiency, etc.

Episode-of-care payment Payment is made by diagnosis for a particular episode, or over a period of time for chronic conditions. The amount of the payment is based on best practices and historical data, and is essentially a budget for the treatment of that episode or condition. The physician or provider assumes the risk of the resources necessary to provide the treatment.

Global payment, or risk-adjusted comprehensive payment Physicians and other providers receive a global payment on a monthly per-patient basis for comprehensive primary care. The payment is adjusted for the severity of each patient, and physicians receive significant bonus payments for quality, cost containment, and patient satisfaction.

www.tafp.org

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technology

Installing the future Disbursement of incentive payments for electronic health records becomes a reality for physicians By Erin Redwine

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ealth information technology plays a prominent role in the practice of family physician Kevin Spencer, M.D. He is partner at Premier Family Physicians, a nine-doctor practice in Austin, Texas, and they began implementing an electronic health record system about a year and a half ago to achieve better outcomes, measure these outcomes, and change processes to serve patients better. As an added bonus, the practice began receiving incentive payments in January 2011 for implementing their EHR and showing “meaningful use.” Though Spencer expects the incentive payments will cover an estimated 70 percent of the overall cost of implementation, the incentive was not the main reason he and his colleagues pursued an EHR. “Before meaningful use was meaningful use, we wanted to be able to offer our patients the ability to communicate with us via e-mail, to look and schedule their own appointments online, to embrace technology, to let them see their medical record and results on the webpage, and to be a kind of practice that was using technology to really take better care of people.” The incentive payments were put in place through HITECH—the Health Information Technology for Economic and Clinical Health Act. In 2009, HITECH allocated over $30 billion in financial incentives for physicians to adopt EHRs and develop a technical support infrastructure with payments to start in 2011. The goal was to encourage widespread adoption of health information technology by 2014 in the hope that the implementation of HIT would reduce overall health care expenditures by improving the quality and coordination of care and public health activities. The “meaningful use” criteria are a set of 25 objectives, and there are three stages over the next five years that set the baseline for electronic data capture and information sharing. In stage one, physicians must meet 20 of these 25 to qualify for an incentive payment by demonstrating the utilization of the system and improving the quality of patient care. As meaningful use transitions to stages two and three, it

“Before meaningful use was meaningful use, we wanted to be able to offer our patients the ability to communicate with us via e-mail, to look and schedule their own appointments online, to embrace technology, to let them see their medical record and results on the webpage, and to be a kind of practice that was using technology to really take better care of people.” Kevin Spencer, M.D.

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is likely that physicians will be required to meet all objectives and participate in a health information exchange to be eligible for incentive payments, says Tyler Patterson, HIT marketing and resource coordinator for the Texas Medical Association. Spencer is part of a group of “early adopters,” those who start in 2011 or 2012. The early adopters are eligible for the full incentive—up to $44,000 in bonus Medicare payments or $64,000 in Medicaid. Physician incentives through the Medicare program will be awarded annually from 2011-2016. The amount of the incentive is reduced when the physician starts after 2012, and the last year to begin the Medicare program and earn an incentive is 2014. The Medicaid program offers six years of incentives. Participating physicians must enter the program by 2016 and the final year of the program will be 2021. Spencer says meeting the meaningful use criteria hasn’t been difficult. “We didn’t have to do any extra work except truly utilizing the system. The EHR has a dashboard that tallies all of it for us without us doing any work except the criteria itself. So if you put all the demographics in correctly, keep your problem list correctly, e-prescribe, interface with the lab, and give out clinical summaries, then the computer actually tracks that it is happening for you.” Another concern is how implementation of the EHR will affect physicians’ day-to-day productivity and efficiency. He says all the physicians saw the same number of patients in the beginning but wouldn’t necessarily chart all of them in the EHR. “Physicians had to stay later to do their work, but by the six-month mark life was back to normal.” Off-site training of employees, building new charts on the EHR system as patients came for appointments rather than migrating all of the data at one time, and weekly increases in the number of patients physicians would chart on the EHR during business hours cut down the loss in productivity and efficiency. “There are a very large but finite number of issues that everybody has to deal with,” says David Kibbe, senior advisor for AAFP’s Center for HIT. “Some physicians are incredibly able to use information technology software, take the program, and start using it within a couple of hours, and some are incompetent with electronics. But if someone is pursuing the incentives, most likely they are going to get them.” Whether HITECH can take the credit or not, widespread adoption of health information technology is becoming a reality. According to Kibbe, an estimated 60 percent of AAFP members have implemented an EHR and 15 percent plan to implement one. Just 25 percent say they will not implement an EHR. “Electronic health records are moving us in a direction of greater productivity,” Kibbe says. “It is inevitable that we have to move in this direction so we might as well do it now.” The process of implementation can be a daunting task with over 350 EHRs to choose from. To help physicians in choosing an EHR compatible with their practice and to aid in implementation, the law put in place 50 Regional Extension Centers around the country. The four RECs in Texas staff technical consultants that help physicians through the process of converting from a paper office to a wired office. The cost for a primary care physician to receive help for an entire year is $300. Family physicians can also find assistance through AAFP’s Center for HIT website. The site houses resources on the four stages of EHR adoption—preparation, selection, implementation, and maintenance—as well as articles on meaningful use and best practices, CME opportunities, and access to the Physician Product Reviewer and EHR User Directory—a database of reviews searchable by regional availability, initial cost, hosting models, and operating system. 28

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RESOURCES ON THE WEB AAFP Center for Health Information Technology www.centerforhit.org TMA Medicare and Medicaid EHR Incentive Instruction Guides www.texmed.org/MedicareEHR, www.texmed.org/MedicaidEHR TMA Regional Extension Center Resource Center www.texmed.org/REC TMA Meaningful Use Webinar www.texmed.org/MUWebinar CMS EHR Incentive Program Overview www.cms.gov/EHRIncentivePrograms CMS EHR Incentive Registration and Attestation System http://go.cms.gov/dXtA5d Texas Medicaid EHR Incentive Program Site www.tmhp.com/Pages/HealthIT/HIT_Home.aspx

Texas Regional Extension Centers Gulf Coast Regional Extension Center (GCREC) University of Texas Health Science Center at Houston (713) 500-3479 or www.uthouston.edu/gcrec North Texas Regional Extension Center (NTREC) Dallas-Fort Worth Hospital Council (469) 648-5140 or www.ntrec.org CentrEast Regional Extension Center (CentrEast REC) Texas A&M Health Science Center (979) 862-5001 or www.centreastrec.org West Texas Regional Extension Center (WTxHITREC) Texas Tech Health Sciences Center (806) 743-7960 or www.wtxhitrec.org

Kibbe says those who plan are the ones who do well with EHRs. “Spend a lot of time in the planning stage and have a game plan for implementation and selection.” Spencer says his practice “did a very extensive search.” They considered 30 products initially, taking four months to make their final decision. They considered EHRs based on usability and general business parameters like the companies’ financial standings. They made trips to other physicians’ offices where the systems were in place and to the final company’s headquarters. The vendors traveled to Spencer’s practice to demonstrate templates and compatibility within the office. Though the incentives are available now, penalties will kick in starting in 2015 for non-hospital-based physicians who haven’t adopted and begun using an EHR. In 2015, physicians will be penalized 1 percent of their Medicaid and Medicare payments. The penalties escalate to 2 percent in 2016 and 3 percent in 2017, but will not increase past 5 percent. However, Kibbe says the penalties will likely change since stage two of meaningful use “will almost definitely be delayed.” Regardless of delays, Spencer says the meaningful use criteria will form the basis for how all physicians practice medicine going forward. “The days of practicing without an electronic health record and achieving meaningful use are going away rapidly and so as I watch the marketplace, I just don’t see anyone being able to survive long term [without an EHR],” Spencer says. “Once you are on the other side of it and you are able to see the quality difference and the outcome measures you can get, I think it is going to be a good thing for medicine ultimately.”


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PRACTICE MANAGEMENT

ICD-10 resources

ICD-9

ICD-10

More than changing codes By Cindy Hughes, C.P.C., C.F.P.C., P.C.S. AAFP Coding and Compliance Specialist

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opefully by now your practice has the transition to the HIPAA 5010 transaction standards completed or well underway. If not, this change in how you transmit and receive electronic transactions such as claims and eligibility verifications is coming fast with a deadline of Jan. 1, 2012. It is past time to make this transition and begin another one: the change to ICD-10 diagnosis coding. Though the Oct. 1, 2013 deadline for beginning to use ICD-10 diagnosis codes in all of the places where you currently use ICD-9 may seem far into the future, many practices, hospitals, and health plans have recognized the need to plan and begin the transition now. Why so early? Because this is not just an updating of superbills or computer databases. The initial implementation of the HIPAA standards pales in comparison to the implementation of ICD-10. Here are a few reasons why: » ICD-9 currently includes 14,432 diagnosis codes. ICD-10 currently includes 69,368 diagnosis codes. A one-to-one match of the codes is not possible in most cases. » Superbills may be unworkable. The 164 ICD-9 codes from the Family Practice Management superbill were converted to ICD10 by a health plan. The result was a change from one page to eight pages of codes. » ICD-10 codes include alphanumeric characters including capital letters “I” and “O.” These must not be confused with the numerals “1” and “0.” The addition of alphabetic characters may slow down data entry. » Diagnosis codes are used not just in the billing office but in clinical care when ordering laboratory tests, pre-authorizing services, and reporting for quality or public health purposes. Updates will be required in many areas of the practice. 30

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» Unlike the move to HIPAA 5010, the ICD10 transition has a single start date. You cannot use ICD-10 codes in relation to services provided prior to Oct. 1, 2013, and you cannot use ICD-9 codes for services provided on Oct. 1, 2013, or thereafter. » The format of the codes is longer and more complex. Staff will need training on the use of the new code set. » System upgrades, production of new reference materials, and staff training may require consideration in your budget planning. » The effect of ICD-10 transition should be considered in relation to adoption of EHRs, participation in Medicare quality reporting initiatives, and other changes that your practice may be initiating. So where do you begin and where can you learn more? You can find general information about ICD-10 and an example of a transition plan on AAFP’s website at www.aafp.org/on line/en/home/practicemgt/codingresources/ icd10cm.html. You can also find the most up-to-date release of ICD-10 from the National Center for Health Statistics at www.cdc.gov/nchs/icd/ icd10cm.htm. The 2012 version is expected to be released early next year and will be the version that is adopted on Oct. 1, 2013. Because the Centers for Medicare and Medicaid Services have enacted a freeze on the ICD-10 code sets from Oct. 1, 2011, through Oct. 1, 2014, the 2012 update is the last until October 2014, with rare exceptions for new diseases. There will also be no update to the ICD-9 diagnosis codes on Oct. 1, 2012, unless there is a new disease that needs to be included immediately such as a new strain of influenza. The intention of this freeze is to provide stability in the code sets while the entire health care system transitions [cont. on 32] from ICD-9 to ICD-10.

Find information about ICD-10 and an example of a transition plan on AAFP’s website: http://ow.ly/6K2ws.

Go to the National Center for Health Statistics to find the most up-to-date release of ICD-10: http://ow.ly/6K2xI

Access an archive of the Centers for Medicare and Medicaid Services May 18 national provider call in podcast or video slideshow form. Go to the ICD-10 teleconference webpage on the CMS website at http://ow.ly/6K0q7; the four podcasts with corresponding written transcripts are available in the “downloads” section of the page and the video slideshow presentation is available in the “related links outside CMS” section.

Cindy Hughes is AAFP’s coding and compliance specialist. Contact her at (800)274-2237, ext. 4176, or chughes@aafp.org.


Go Paperless and Get Paid Register NOW for CMS Electronic Health Record Incentives

The Centers for Medicare & Medicaid Services (CMS) is giving incentive payments to eligible professionals, hospitals, and critical access hospitals that demonstrate meaningful use of certified electronic health record (EHR) technology. Incentive payments will include: • Up to $44,000 for eligible professionals in the Medicare EHR Incentive Program • Up to $63,750 for eligible professionals in the Medicaid EHR Incentive Program • A base payment of $2 million for eligible hospitals and critical access hospitals, depending on certain factors Get started early! To maximize your Medicare EHR incentive payment you need to begin participating in 2011 or 2012; Medicaid EHR incentive payments are also highest in the first year of participation. Registration for the EHR Incentive Programs is open now, so register TODAY to receive your maximum incentive. For more information and to register, visit: www.cms.gov/EHRIncentivePrograms/ For additional resources and support in adopting certified EHR technology, visit the Office of the National Coordinator for Health Information Technology (ONC): www.HealthIT.gov

EHR_Ad_TexFamPhys_7.5x10.indd 1

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[cont. from 30]

You will find that the conventions of ICD10 are similar to ICD-9. It is still necessary to consult both an index and a tabular section to arrive at the appropriate code for a condition. There are still tables of neoplasms and of drugs and chemicals. Also carried over from ICD-9 are the sections of codes to identify external causes (ICD-9 E codes) and factors influencing health status and encounters for health services (ICD-9 V codes). Differences come not only in the volume and expandability of codes but also in their structure. ICD-10 starts with a base code that typically includes an alphabetic character followed by two numbers such as I10, which represents hypertension in ICD-10. However, the code set is not limited to this format and includes some codes that include alphabetic characters in the second or third digit such as M1A.00 for idiopathic chronic gout, unspecified site. Codes then can extend to seven digits with some including an X as a placeholder for later expansion of a code category such as S06.0x1 for reporting a concussion with loss of consciousness of 30 minutes or less. Codes for injuries and certain other conditions such as S06.0x1 also require a seventh digit that identifies specifics about a condition such as whether the encounter is the initial encoun-

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ter (A) with you for this condition, subsequent encounter (D), or sequela (S) (called late effects in ICD-9). To report a complete code for the initial encounter to treat a concussion with loss of consciousness would be S06.0x1A. These examples show some of the differences that must be accommodated in the transition to ICD-10. Though the code set is larger and more complex, the increased adoption of electronic health records, mappings from SNOMED (Systematized Nomenclature of Medicine) terminology to ICD-10, and the availability of other electronic databases may lessen the challenges. However a change this big cannot be managed at the last minute and early planning is your best defense against payment delays and information inaccuracies. So what are the first steps? Planning, familiarizing, and inventory should come first. 1. Early decisions might be whether a staff person or physician will take the lead in overseeing the transition. This person can help coordinate areas such as information technology upgrades, billing and coding workflow, and clinical documentation. 2. The leader and other key team members should become familiar with the ICD-10

code set as it pertains to your practice and use this knowledge to inform changes to tools, resources, and systems. 3. Determining where ICD-9 codes are used and by which staff will be key to preventing gaps in your transition plan. By making an inventory of who uses the codes and for what purposes, you can determine who needs training and at what level, what resources or tools must be updated or replaced, and which electronic systems may require updates. With this information, you can begin an estimated budget and timeline. Upgrades of software and hardware, if required, may be included in your maintenance contract, but it is important to verify this early and seek information on vendor plans for upgrades as soon as possible. If coding and billing are performed in-house, there may also be need to either temporarily bring in extra help at the time of the transition or plan for payment delays should they occur. AAFP did not support this change at this time, but you can count on TAFP, AAFP, and Family Practice Management to support you with information and resources to help along the way.


Highlights from the TAFP Board of Directors meeting | July 30, 2011 The Texas Academy of Family Physicians Board of Directors met on Saturday, July 30, 2011, to hear reports and recommendations from TAFP’s committees, commissions, and sections. Below are the highlights of the meeting, which included a presentation from Tom Suehs, executive commissioner of the Texas Health and Human Services Commission. ■ TAFP Foundation Board of Trustees The Foundation announced the change of the Jim and Karen White Scholarship to a research champion fund pending approval of a supermajority of donors. The Foundation also announced that they raised enough money to fully fund the Roland Goertz, M.D. Scholarship. ■ Executive Committee The Executive Committee heard from Tom Banning on TAFP’s upcoming Payment Reform Summit. The meeting will be held on Oct. 1 in Austin with nationally known experts presenting on how to prepare for the future health care system. ■ Finance Committee The Board approved the proposed fiscal year 2012 operating budget and the fiscal year 2012 capital budget. The Board directed the Finance Committee to bring a recommendation to the next meeting to establish a policy to allow capital spending up to a fixed amount without Board approval. ■ Nominating Committee The Board elected the slate of directors and alternates presented by the Nominating Committee. They also approved several AAFP Commission recommendations from the Committee.

■ Commission on Academic Affairs The Board approved a recommendation that TAFP plan the Family Medicine Residency Education Leadership Conference and the Chief Resident Conference. Both conferences were previously coordinated by the Faculty Development Center. The Board also approved a recommendation that TAFP staff work with the Texas Medical Association and other primary care organizations to develop collaborative support for the continuation of the Texas Statewide Preceptorship Program. ■ Commission on Continuing Professional Development The Board approved a proposed policy for complimentary registrations and social event tickets. The Board also approved a revised CME mission statement to reflect the broader scope of education and approved a revision to the disclosure policy to include license and criminal disclosure. ■ Commission on Core Delegation The Board endorsed Lewis Foxhall, M.D., in his bid for re-election as a member of the TMA Board of Trustees. A letter will be sent to members of the TMA House of Delegates. The Board also voted to co-sponsor a resolu-

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tion to AAFP regarding payment for weight loss counseling and voted to send a resolution regarding low-cost formularies. ■ Commission on Health Care Services and Managed Care The Board approved a recommendation that TAFP petition the American Academy of Family Physicians to withdraw from the American Medical Association Specialty Society Relative Value Scale Update Committee (RUC), and work directly with the Centers for Medicare and Medicaid Services on payment issues if the issues from AAFP Board Chair Lori Heim, M.D.’s June 2011 letter to the RUC are not resolved by April 1, 2012. ■ Commission on Legislative and Public Affairs The Commission had a discussion, led by Tom Banning, on the outcome of the 82nd Texas Legislature. The commission also discussed possible opportunities for the interim between legislative sessions, and for policy initiatives in the next Legislature. ■ Commission on Public Health, Clinical Affairs, and Research The Board approved a recommendation to submit the One Key Question Initiative resolution to the AAFP Congress of Delegates. ■ Section on Special Constituencies The section selected Amer Shakil, M.D., to serve on the Executive Committee, and Terrance Hines, M.D., to serve on the Board of Directors.

■ Section on the Medical Home The Board approved a recommendation that TAFP offer a training session at an upcoming symposia on strategies for cost-effective care, including the use of generic medications, imaging tests, and evidence-based evaluation and management of back pain.

Call for Proposed Bylaws Amendments Any TAFP member wishing to submit a proposed amendment to the TAFP bylaws must submit it to Kathy McCarthy at TAFP headquarters by Dec. 14, 2011. The TAFP bylaws can be viewed online at www.tafp.org/ membership/organization/bylaws.pdf. Amendments can be e-mailed to kmccarthy@tafp.org or faxed to (512) 329-8237. Members submitting a proposed amendment must include a statement giving the rationale for the amendment. The TAFP Bylaws Committee will review the amendments at the 2012 Interim Session meeting on March 3, 2012. The chair of the Bylaws Committee will present the proposed amendments, with the recommendations of the Bylaws Committee, to the Board of Directors at Interim Session. If the Board of Directors approves the amendment, it will go before the TAFP members in attendance at the TAFP Annual Business Meeting in July 2012.

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Left: Attendees of the casino-night-themed President’s Party enjoy a variety of games. This image: TAFP Immediate Past President Melissa Gerdes, M.D., addresses general session with an update on the Academy.

Report from TAFP’s 2011 Annual Session & Scientific Assembly

All in the

family By Kate Alfano Photos by Kate Alfano and Jonathan Nelson

M

ore than 450 physicians joined TAFP staff and leaders to celebrate the family of family medicine at the 2011 Annual Session and Scientific Assembly in Dallas. Amid fun and fellowship, family physicians from around the state earned CME, shaped Academy policy at the TAFP committee and commission meetings, and connected with medical industry leaders in the exhibit hall. The Academy ramped up its focus on social media and new technology. Whether attending in person or virtually, all were encouraged to join the conversation through the Annual Session Social Media Portal— a page within TAFP’s TXFamilyDocs.org blog—that featured TAFP’s Twitter feed, daily news recaps, and the conference photo stream. This enhanced interaction included the Academy’s first-ever live streaming video. Saturday afternoon, TAFP used web-streaming service Ustream to broadcast the TMLT lecture “Know Before You Sign! What to Look for in a Physician Employment Contract, Including Employment by Non-Profit Health Corporations.” Watch the archived video on the TAFP Ustream channel, www.ustream.tv/channel/texasacademy-of-family-physicians.

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The scientific portion of the conference gave attendees the opportunity to receive continuing medical education credits in a variety of ways: through the two-day Orthopedics for the Office Workshop presented by the National Procedures Institute; the Self-Assessment Module Workshop on Health Behavior to aid board-certified physicians in their maintenance of certification process; and a variety of workshops and lectures spanning Thursday through Sunday. The general session lectures opened Friday with an update on the Texas Academy led by TAFP leaders Melissa Gerdes, M.D., and Tom Banning. The most popular CME lectures were “Five Things I Wish I Knew Last Year” with Louis Kuritzky, M.D.; “Certify Deaths: Appropriate Processes and Common Misconceptions” with Satish Chundru, D.O.; “Demystifying Accountable Care Organizations” with Patrick Carter, M.D.; and the AAFP update “Our Time is Now” with then AAFP President Roland Goertz, M.D., M.B.A. Friday night, the TAFP Foundation hosted a reception to honor Goertz for his service as a longtime family medicine leader. Because of his involvement with the Foundation and his role as a champion for future family physicians, the Academy created a medical student scholarship in his name. Not surprisingly, his work on the state and national level has touched many and, as a result, inspired TAFP members and friends to contribute to the scholarship. As of the end of the reception, contributions boosted the scholarship to full funding. At the Annual Business and Awards Lunch on Saturday, the 2011 awardees for TAFP’s top honors were unveiled and the 2011-2012 officers assumed their new posts. The award recipients were: • Thomas Mueller, M.D., of Columbus, Texas Family Physician of the Year; • Isaac Kleinman, M.D., of Rosenberg, Physician Emeritus; • Thomas Suehs of Austin, Patient Advocacy Award; • Tricia C. Elliott, M.D., F.A.A.F.P., of Galveston, TAFPPAC Award;


Clockwise from top left: Tricia Elliott, M.D., receives the 2011 TAFPPAC award from TAFP President I. L. Balkcom, IV, M.D. Jonathan MacClements, M.D., receives the Exemplary Teaching Award. 2011 Texas Family Physician of the Year Thomas Mueller, M.D., addresses the audience. HHSC Executive Commissioner Tom Suehs receives the Patient Advocacy Award. TAFP Foundation President Dale Moquist, M.D., presents the Philanthropist of the Year award to Bruce Echols, M.D. Balkcom takes the oath of office from AAFP Past President Lanny Copeland, M.D. Doug Curran, M.D., and Moquist participate in the Foundation breakfast. Kaparaboyna Ashok Kumar, M.D., receives the Special Constituency Leadership Award.

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TAFP inducted a new slate of officers at the 2011 Annual Session and Scientific Assembly. From left, Parliamentarian Ajay Gupta, M.D., of Austin; Treasurer Clare Hawkins, M.D., of Baytown; President Balkcom of Sulphur Springs; Vice President Dale Ragle, M.D., of Dallas; Immediate Past President Gerdes of Mansfield; and Presidentelect Troy Fiesinger, M.D., of Sugar Land.

• Leah Raye Mabry, M.D., R.Ph., of San Antonio, Presidential Award of Merit; • Philip Huang, M.D., M.P.H., of Austin, Public Health Award; • Bruce Echols, M.D., of Dallas, TAFP Foundation Philanthropist of the Year; • Jonathan MacClements, M.D., F.A.A.F.P., of Tyler, Exemplary Teaching Award; and • Kaparaboyna Ashok Kumar, M.D., F.R.C.S., of San Antonio, Special Constituency Leadership Award. View more information on each awardee in the news release section of TAFP’s website, www.tafp.org/news/newsreleases. In his acceptance speech for the award, Physician of the Year Mueller likened the specialty of family medicine to the sale of a new car. He told the audience that when buying a new car or truck, consumers know they can get a better value by getting a package deal rather than ordering options piecemeal, as well as getting other perks in the process. They also know the deal is sealed with TTL—tax, title, and license. “We in family medicine have survived and are successful because we are somewhat like that new car sale. Instead of our patients having to go piecemeal from one specialist to another to get all the components of their needed health care, we provide a package deal with value-added services and inform our patients of recommended services specifically tailored to them. And we seal the deal with our own form of TTL—touch, talk, and listen.” Mueller also advised his fellow family physicians to not let health information technology like electronic medical records compromise the superior care they provide. “As we get further get into patient interaction with an EMR, I implore you to not discard that healing touch, talking to your patients, and truly listening to them because those are the things that have truly made family medicine special.” Attending as AAFP invited guests, Goertz and AAFP Past President Lanny Copeland, M.D., installed the new TAFP officers who will lead the Academy in 2011-2012. The new TAFP officers are: President I. L. Balkcom, IV, M.D., of Sulphur Springs; President-elect Troy Fiesinger, 36

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M.D., of Sugar Land; Vice President Dale Ragle, M.D., of Dallas; Treasurer Clare Hawkins, M.D., of Baytown; and Parliamentarian Ajay Gupta, M.D., of Austin. In Balkcom’s presidential address, he listed some of the terms used for family physicians and described his frustrations with being called “just a general practitioner.” Instead of being called a GP or a gatekeeper, he told the audience he wants to be a “shepherd” of the people. “I want to lead them, I want to love them, and I want to take care of them from the time they’re born—and even before they’re born—to the time they leave us. That’s what we should strive for, to be a good shepherd.” He spoke directly to TAFP members when he asked for their help to reinvigorate the specialty, to achieve the recognition and appreciation deserved for family physicians’ full breadth of practice. “I cannot do it alone, nor do I intend to. I’m going to ask you if you can donate five minutes for family medicine. That’s going to be my battle cry: Give five minutes for family medicine. Take the message to your colleagues and friends. It’s time for us to do that.” The signature event occurred Saturday night as guests gathered in the Chaparral Club of the Sheraton Dallas for the annual President’s Party. The casino-night theme came to life on the 38th floor, and TAFP members and their families enjoyed great food, music, and a variety of games. It’s never too early to mark your calendars for other TAFP symposia and programs where you can expect more high-quality education and informative topics. TAFP will host six more Self-Assessment Module workshops across the state to help ABFM diplomates make progress toward maintenance of certification. See dates and details on the SAM page of TAFP’s website, www.tafp.org/education/sam. Primary Care Summit will again be held in two locations in 2011: Primary Care Summit – Houston will be held at the Westin Oaks in Houston Oct. 21-23, and Primary Care Summit – Dallas/Fort Worth will be held at the Westin Galleria Dallas Nov. 11-13. Registration for both programs is now open. The 2012 C. Frank Webber Lectureship will be held Friday, March 2, at the Omni Austin Hotel at Southpark, and the 63rd Annual Session and Scientific Assembly will be held July 11-15, 2012, at the Hilton Austin Hotel and Austin Convention Center.


foundation focus

Goertz scholarship fully endowed Foundation flourishes at Annual Session By Kathy McCarthy the tafp foundation had a strong presence at the recent TAFP Annual Session and Scientific Assembly in Dallas. The Foundation Board of Trustees served breakfast to the attendees in the exhibit hall on Friday, July 29, and held a special reception to honor AAFP leader Roland Goertz, M.D., M.B.A. At the Business and Awards Lunch on Saturday, July 30, the Foundation presented medical student scholarships, honored cumulative donors, and named the 2011 Philanthropist of the Year, Bruce Echols, M.D. Echols is a longtime contributor to the TAFP Foundation and champion of the scholarship fund set up to honor his former UT Southwestern colleague, the late Cassie Murphy-Cullen, Ph.D. “When I think of philanthropists I think of someone being wealthy, and that really doesn’t describe me,” he told the audience. “But I can say that I feel very rich in friends and family and colleagues. One the greatest riches I’ve had in my life was getting to work with and getting to become friends with Dr. Cassie Murphy-Cullen.” “Cassie spent almost her entire career working with family practice residents, and she served several residency programs as director of behavioral medicine and research. She had too many accomplishments to list here, but one of her greatest contributions and successes was in mentoring research.” He recognized the Cullen family, who attended on Cassie’s behalf. The scholarship will provide funding to one resident each year to attend a national conference to present his or her research; the first award will be presented in 2012.

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From left, Roland Goertz, M.D., M.B.A., was joined by many colleagues and friends at the TAFP Foundation reception in his honor, including James Martin, M.D., and Lloyd Van Winkle, M.D.

Colleagues and friends from across the state gathered to toast Dr. Goertz and thank him for his years of service on the state and national levels during the Friday night reception in his honor. He concluded his term as AAFP president at the AAFP Congress of Delegates in September and will serve a one-year term as AAFP board chair. Through sponsorship of the event, donations from individuals, and proceeds from a silent auction, the Foundation raised over $32,000 for the Roland A. Goertz, M.D. Scholarship. It will be used to send student leaders to the AAFP’s National Conference in Kansas City. Platinum-level sponsors included TAFP, the McLennan County Medical Society, Pfizer, Inc., and the Travis County Chapter of TAFP. Silver-level sponsors were Endo Pharmaceuticals, Providence Health Network, the Texas Medical Association, and Texas Medical Liability Trust. The Texas Association of Community Health Centers donated at the Bronze level. Thank you to all for your generosity. And thank you to all who supported the Foundation this year. Your generosity makes the good works of the Foundation possible.

Congratulations to the future family physicians who were awarded TAFP Foundation scholarships. David Aldrete — Valley Chapter Scholarship Richel Avery, M.D. — Jim and Karen White Leadership Scholarship Santiago Ayala, M.D. — Glen R. Johnson, M.D. Minority Scholarship Adrian Dirk — Harold T. Pruessner, M.D. Scholarship Jonathan Lazarini, M.D. — William F. Ross, M.D. Scholarship Judy Lu — Harold T. Pruessner, M.D. Scholarship William McCunniff — Norma Porres, M.D. and Felipe Porres, M.D. Scholarship Monte Swanson, M.D. — Norma Porres, M.D. and Felipe Porres, M.D. Scholarship

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perspective

Texas can improve care and cut costs with medical home, shared savings initiatives By Greg Sheff, M.D.

i am fortunate to be a part of a multi-year patientcentered medical home and shared savings pilot at Austin Regional Clinic. ARC is an approximately 300 physician multi-specialty group delivering care at 18 clinics and seven hospitals throughout the Austin area. Earlier this year, ARC joined a multi-year medical home pilot administered by Blue Cross and Blue Shield of Texas. The pilot was initiated in large part in response to Texas legislation requiring the Employees Retirement System, the self-funded insurer for state employees, to experiment with alternate payment and delivery models in an attempt to reduce the state’s ever-increasing health care costs. We are one of five physician groups in the state participating. Our program serves roughly 45,000 patients, including both the ERS (whose health care benefits are administered by BCBSTX) and BCBSTX fully-insured populations. In addition to the traditional PCMH goal of comprehensive, coordinated, accessible, patientcentered care for all, ARC is also implementing processes to proactively identify high-risk patients and then deploy intensive, focused, physician-led care management interventions to these high-risk patients. At ARC, we have discovered a definite tipping-point phenomenon in committing the resources necessary to develop adequate infrastructure to effectively and comprehensively manage patients’ well-being across the care spectrum. We have been approached by a number of payers investigating our capability to transform our care delivery model. However, not until we were approached with a payer as large as ERS were we able to make a compelling internal business case for investing the resources to transform our own workflows in what is currently still

an overwhelmingly fee-for-service market. Now that we have had an opportunity to begin to transform our delivery system, we are much more able to explore opportunities to efficiently extend the benefits of a medical home to all of our patients. For me, this is the real pearl in the ERS medical home initiative: Large payers, be they employer-driven (as with ERS), or public (as with Medicare shared savings initiatives), or commercial (for fully-insured beneficiaries), have the opportunity to change the cost of care delivered across Texas, not by mandate but by example. However, a primary-care-led health care system cannot exist without actively nurturing and growing the primary care workforce. Since its inception, ARC has emphasized the importance of long-term doctor-patient relationships, coordination of care, and a strong primary care physician base—three major tenets of the medical home model. Drawing upon ARC’s 30 years of experience, I cannot overstate the importance of supporting initiatives to increase the number of medical school graduates choosing a career in primary care. Unfortunately, our state’s ability to train this primary care workforce has been diminished in this last legislative session. Payment and delivery system reform, such as that being driven by the ERS medical home and shared savings pilots, coupled with an investment in growing our primary care workforce, helps not only the Texas budget in the short and long term, but provides the seeds to transform all care in Texas.

For me, this is the real pearl in the ERS Medical Home initiative: Large payers, be they employer-driven (as with ERS), or public (as with Medicare Shared Savings initiatives), or commercial (for fully-insured beneficiaries), have the opportunity to change the cost of care delivered across Texas, not by mandate but by example.

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Greg Sheff, M.D., is the medical director for the Austin Regional Clinic Medical Home Program.


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Texas Family Physician Fall 2011  

The fall 2011 edition of the quarterly magazine of the Texas Academy of Family Physicians

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