Texas Family Physician, Fall 2012

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An F n & ull ua In Pic Re l S sid tu po es e re rt sio n s texas family physician VOL. 63 NO. 4 FALL 2012

preparing for the 83rd legislature

The Right Doctors For Texas

Then &Now For 20 Years, Experts Have Sounded Alarms About Texas’ Primary Care Physician Shortage. It’s Time To Do Something About It.

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INSIDE

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TEXAS FAMILY PHYSICIAN VOL. 63 NO. 4 FALL 2012

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A workforce imperative: Change med ed

Twenty years ago, TAFP called for changes in medical education to ensure Texas would have the primary care physician workforce needed to care for a rapidly growing population. Now, the state is in a perilous position as academic institutions have no financial incentive to train new primary care physicians and medical students are actively discouraged from these disciplines. In a frustratingly obstinate system, stakeholders must now race to craft policies to reverse the damage of inaction.

16 MEMBER NEWS New physician honored for teaching excellence. | TMA names new class to leadership college. | UTHSCSA’s FMIG wins national award (again). | San Antonio medical student wins national video contest. 17 ON TAFP.ORG Meet a TAFP Member of the Month: Tamarah DupervalBrownlee, M.D., M.P.H.

By Kate Alfano

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Annual Session 2012: A capital event

Family docs gathered in TAFP’s hometown of Austin for a busy weekend of education and fellowship. Pictures and highlights from the board of directors meeting included. By Kate Alfano and Jonathan Nelson

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6 PRESIDENT’S LETTER Meet your new president, Troy Fiesinger, and read an excerpt from his incoming presidential address.

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10 NEWS IN BRIEF How influential is the RUC? | Medicaid acceptance drops among docs. | Texas ranks 4th in number of medical homes. | AAMC graduation study reveals a surprise.

Tar Wars champ

Houston fifth-grader wins top prize in national poster competition.

RACs target E/M claims

CMS’ RAC program will focus on claims for E/M services using CPT codes 99214 and 99215.

32 FOUNDATION FOCUS TAFP Foundation rescues preceptorship program, creates fund for stipends. 33 PUBLIC HEALTH Family physicians must use judgment and caution to protect young athletes from brain injury. 35 PRACTICE MANAGEMENT Check out the top eight investments to make when forming your compliance plan. 38 TAFP PERSPECTIVE AAFP came under fire from its report defending the scope of practice of physicians. AAFP Board Chair Goertz responds.


Prescribe more than just medicine.

c managase ement

When he needs special help at school, refer him for case management services, a Medicaid benefit for children birth through age 20 and high-risk pregnant women. Case managers help patients navigate the health system by providing access to medical, dental, behavioral health, educational, and social services related to their health conditions. To make a referral, call 1-877-THSTEPS or download a referral form at www.dshs.state.tx.us/caseman.


president’s column

TEXAS FAMILY PHYSICIAN VOL. 63 NO. 4 fall 2012 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.

Time to swing for the fences An excerpt from the 2012 incoming presidential address By Troy Fiesinger, M.D. TAFP President

Officers president

Troy Fiesinger, M.D.

president-elect

Clare Hawkins, M.D.

vice president treasurer

Ajay Gupta, M.D.

Dale Ragle, M.D.

parliamentarian

Tricia Elliott, M.D.

immediate past president

I.L. Balkcom IV, M.D.

Editorial Staff managing editor

Jonathan L. Nelson

associate editor associate editor

Kate Alfano

Samantha White

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, C.A.E.

advertising sales associate

Audra Conwell

Contributing Editors AAFP News Staff Walter L. Calmbach, M.D., M.P.H. Roland Goertz, M.D., M.B.A. Mark Hutchens, M.D. Kathy McCarthy, C.A.E. Bradley Reiner

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. © 2012 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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whether we practice in houston or Henderson, Wichita Falls or Weimar, El Paso or Del Rio, Alpine or Austin; we are all Texas family physicians. We bring different perspectives to the Academy based on where we live and where we’re from. I know what it’s like to work in a large integrated health care system, run a community health center, and teach our future family physicians, but I don’t know how to run your practice. I want to hear from each of you about how we can strengthen family medicine and take care of our patients. Our health care system is in the midst of a painful rebirth. The insurers, the government, and the hospitals are pulling us in different directions. We stand with our patients at the middle of this storm of abbreviations and acronyms: ACA, ACO, PCMH, EHR, and the Medicaid 1115 waiver. Now, we can ride off into the sunset like the cowboy in an old Western, resigned to obsolescence as the specialists, large hospital systems, and insurers take over health care. Or we can choose to pull up our britches and get to work. “If you don’t like change, you’re going to like irrelevance even less.” President Lyndon B. Johnson said there are two kinds of people in the world: “can-do people” and “can’t-do people.” I think family doctors are can-do people. When Bobby Youens and Jorge Duchicela of Weimar grew frustrated at the lack of family physicians in rural Texas, they got together with Tricia Elliott of UTMB to organize a rural residency track. Instead of resigning himself to complaining about changes in health care, Lloyd Van Winkle of Castroville organized primary care docs into an IPA— and is running for the board of the American Academy of Family Physicians. When Melissa Gerdes and Mike McCrady grew concerned about how family docs would fit into large health care systems, they became physician leaders who could advocate for their patients from the inside. Instead of getting

mad, Roland Goertz got even and headed off to Washington, D.C., as our AAFP president to bend the ear of every congressperson and senator he could find about the value of family physicians. While other specialties complain about “the government doing this” or “insurers doing that,” family doctors come up with a plan and get to work. It is easy to get frustrated by the changes hitting us daily, but I urge you to channel your anger into action. We understand better than most the reality on the ground—and what our patients need. When patients ask me if I think all the frustrations are worth it, I think of a 1991 CNN interview with an old redneck from the Boots and Coots well control company. Boots and Coots is who they send in when the world is going to hell and someone needs to put the fire out. Behind him, the burning Kuwaiti oil wells spewed smoke and flames into the sky. When the reporter asked him why someone would do something so dangerous, he answered in his best Texas drawl: “Hell, there’s nothin’ I’d rather be doin’ than fightin’ oil fires.” I don’t push each day to get my patients the health care they deserve to quit now. They deserve my best. And there’s “nothin’ I’d rather be doin’.” Let’s be honest, though. We took some lumps in the 2011 legislative session: the primary care preceptorship was eliminated, state GME funding for residencies like mine was cut to within an inch of its life, and the loan repayment program which placed family docs in needy communities was slashed so badly it’s on life support. Medicaid rates weren’t cut, but in typical legislative fashion, Medicaid will run out of money on Dec. 31. Your physician leaders and Academy staff have drafted a policy manifesto for the 2013 legislative session: the Primary Care Rescue Act. This plan shows our legislators how they can improve the health of their constituents—our patients—by investing in training new family doctors and getting those


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

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AAFP President Glen Stream, M.D., M.B.I., leads TAFP’s newly inducted president, Troy Fiesinger, M.D., in the presidential oath of office.

doctors to where our patients need them. To improve health care in Texas, we need to: • Train more primary care doctors by restoring funding to our residency programs, • Push our taxpayer-funded medical schools to train more residents and make sure the medical students they educate go where the taxpayers need them, • Encourage medical students to pursue primary care by funding the primary care preceptorship program, • Consolidate Texas’ two loan repayment programs and restore their funding, • Encourage doctors to adopt health information technology by offering loan programs and business tax credits, and • Reward quality improvement by requiring health plans that receive state general funds to increase the fees paid to physicians who achieve national quality certifications from the NCQA and others. These areas will be the focus of our legislative efforts for the next session. Now we could trot off to Austin in January with this list in hand to ask for more money—just like

the school teachers, the universities, and everyone else whose programs were cut last time around. Too often, doctors approach politics like a disease to be cured. We come up with a sound policy, then we wait for our leaders to respond to the rightness of our cause. But being right doesn’t get us votes. Politicians follow a different logic. Our most important issue may not be theirs. We must get to know them, learn what motivates them, and understand what issues matter to their constituents. Next year, the legislature will make decisions that will have a major impact on health care in this state. Now is the time to lay the groundwork for 2013. Every TAFP member can contribute. You each have a state representative and a senator. Call them. Remind them you are a constituent—and so are your patients. “My patients have trouble getting the health care they need, they live in your district, and they vote.” I am honored and humbled to be chosen as your president. It is time to swing for the fences. As I look forward to the next 12 months, I think of the motto: “Lead, follow, or get out of the way.” I am proud to be president of an Academy which chooses to lead.

Troy Fiesinger, M.D., currently serves on the faculty of the Memorial Family Medicine Residency Program where he practices full-spectrum family medicine including obstetrics and office procedures. He earned his medical degree at Baylor College of Medicine in 1996 and completed his family medicine residency at the East Carolina University School of Medicine/Pitt County Memorial Hospital in 1999. Before joining the residency program, Dr. Fiesinger practiced family medicine at the Scott and White Clinic in Waco and served as the regional clinic director for quality and safety at the Scott and White Memorial Hospital and Clinic in Temple. From 2006 to 2009, he served as the clinic medical director of the Lone Star Family Health Center in Conroe, a federally qualified health center.


110,000 Texans will be told

“You have cancer.” In 2012, it is estimated … • 39,000 Texans will lose their lives to cancer. • The annual cost associated with cancer will be $28 billion.

In 2012, it is estimated … • 14,500 Texans will be diagnosed with lung cancer. • 16,000 women in Texas will be diagnosed with breast cancer. • 1,200 women in Texas will be diagnosed with cervical cancer. • 10,600 Texans will be diagnosed with colorectal cancer.

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news clips

96% of physicians accepted new patients in 2011, but 31 percent did not accept new Medicaid patients and 17 percent did not accept new Medicare patients. Physicians in smaller practices and those in metropolitan areas were less likely to accept new Medicaid patients. Acceptance rates were higher in states with higher fee-forservice Medicaid rates.

Houston fifth-grader wins national Tar Wars poster contest After winning the grand prize in the Texas Tar Wars poster contest, fifth-grader Juan Elizondo of Houston won first place in the 2012 Tar Wars national poster contest in July with his poster, “Blow Bubbles Not Smoke.” The contest is held each summer during the annual Tar Wars National Conference and represents the culmination of the AAFP’s school-based tobacco-free education program. Students from around the country illustrate their tobacco-free message and compete in the poster contest. Family physicians and other health care professionals present Tar Wars—AAFP’s tobacco-free education program—every year to fourthand 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.

HOW INFLUENTIAL IS THE

RUC?

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.

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Between 1994 and 2010, CMS agreed with 87.4 percent of recommendations from the American Medical Association’s Specialty Society Relative Value Update Committee, an advisory panel representing national physician organizations. Though the RUC downplays its influence, the group has come under fire for contributing to the pay gap between specialist physicians and primary care physicians. Source: “In setting doctors’ Medicare fees, CMS almost always accepts the relative value update panel’s advice on work values.” Health Affairs. May 2012.

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TEXAS FAMILY PHYSICIAN

Source: “In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help.” Health Affairs. August 2012.

Medical home on the range With 206, Texas has the fourth-highest number of recognized medical homes in the country. As of June 30, the National Committee for Quality Assurance has recognized more than 4,400 patient-centered medical homes nationwide for coordinating patient care and meeting specific quality standards. Coming in at No. 1 is New York (1,028), followed by Pennsylvania (418), and North Carolina (386). Source: “20 states with the most medical homes.” Becker’s Hospital Review. July 12, 2012.

Role models, work/life balance rank as top factors in medical students’ specialty choice Chief among the reasons why experts say medical students are shying away from primary care specialties in favor of subspecialties is their high amount of educational debt. But results from the 2012 AAMC Medical School Graduation Questionnaire show that role models and work/life balance most influence this choice. Even so, 84.1 percent of students, or 10,270 of 12,212, report having medical school debt, while 15.9 percent, or 1,942, do not. • Average medical school debt of all respondents: $130,032 • Average medical school debt of those with debt: $157,473 • Average total education debt of all respondents: $142,906 • Average total educational debt of those with debt: $167,053

50.2%

Level of educational debt

22.7% 18.3% 8.7% 8.6%

Role model influence

11.8% 29.2% 50.5% 22.5% 30.0%

Expected income

33.3% 14.2% 7.1%

Work/life balance

15.6% 33.9% 43.4% 0 20% 40% 60%

No influence Minor influence Moderate influence Strong influence

Source: “Medical School Graduation Questionnaire: 2012 All Schools Summary Report.” Association of American Medical Colleges.” July 2012.


NO.

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Make sure you have the right insurance to help you protect the life you’ve worked so hard to build. 1. Insurance Information Institute. “Changes in Your Life Can Mean Changes in Your Insurance, Says the I.I.I.,” Press Release, January 22, 2007.

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Sign up for TAFP’s Physician of the Day and Key Contact programs TAFP’s Physician of the Day program

TAFP is preparing for the 83rd Texas Legislative Session. Since 1971, Academy members have participated in the Physician of the Day program by donating their valuable time to provide the Capitol with an on-call physician. The Physician of the Day

works in a primary care clinic located in the Capitol extension and treats anyone sick or injured on the Capitol grounds.

To serve as Physician of the Day, volunteers must have a valid unrestricted Texas medical license and be a member in good standing in TAFP or TOMA. The 83rd Legislative Session will convene on Jan. 8, 2013, and the Academy needs volunteers to participate in this program. The Physician of the Day will be introduced in both the Senate and the House of Representatives each day and his or her name will become a permanent part of the official legislative record. Volunteers are scheduled on a first-come, firstserved basis. Dates may change due to the legislative schedule and TAFP staff will try to provide as much advance notice as possible in the case of a schedule change. Please note that the Legislature usually adjourns on Fridays, January through March.

Sign up to be a Key Contact

Now more than ever, state and federal lawmakers are making decisions that directly affect your patients and your practice. The 83rd Texas Legislature will be addressing a number of issues important to family medicine including scope of practice, graduate medical education, physician workforce, and much more. As legislative battles heat up, legislators need to hear from family physicians about how medicine should be practiced, now and in the future. They certainly hear from others with far less insight than physicians. TAFP’s Key Contact program seeks to identify family physicians willing to serve as resources to their legislators to advocate the values of family physicians and their patients. If you would like to participate in TAFP’s Key Contact program, please check the appropriate box on this form. If you want to serve as a Key Contact but don’t know your legislators, TAFP can help. Check the second box. Volunteer to serve as Physician of the Day or as a Key Contact by filling out and returning this form to Juleah Williams at TAFP headquarters or go to www.tafp.org/advocacy.

Note: TAFP reserves the right to remove a physician who is scheduled to serve as Physician of the Day if there are any changes made to his or her membership status or medical license. 12

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Fax this form to TAFP at (512) 329-8237 or mail it to TAFP, 12012 Technology Blvd, Suite 200, Austin, Texas, 78727. You may also sign up on our website, www.tafp.org.

2013 Session Dates All dates are listed as Monday through Friday,

though the Legislature usually cancels on Fridays, January through March. January February March 1 1 8 9 10 11 4 5 6 7 8 4 5 6 7 8 14 15 16 17 18 11 12 13 14 15 11 12 13 14 15 17 18 19 20 21 18 19 20 21 22 18 19 20 21 22 21 22 23 24 25 25 26 27 28 25 26 27 28 29 28 29 30 31 April May 1 2 3 4 5 1 2 3 8 9 10 11 12 6 7 8 9 10 15 16 17 18 19 13 14 15 16 17 22 23 24 25 26 20 21 22 23 24 29 30 27

Information (Please complete fully and legibly.) name home address City/State/Zip Phone E-mail address State representative (if known) state senator (if known) other legislators you know (if applicable)

❏ Yes! I want to volunteer for the Physician of the Day program. Can you serve on short notice? ❏ Yes Please indicate the dates you would like to serve. first choice

❏ No

second choice

❏ Yes! I want to serve as a KEY CONTACT. ❏ Yes! I want to serve as a KEY CONTACT, but I don’t know my legislators. Please help arrange a meeting with my legislators so I can serve as a resource.

disclosure Have you ever had your license suspended or revoked, voluntarily surrendered your license, or been convicted of a felony or violation of any state or federal narcotics act? ❏ Yes ❏ No If yes, please explain

By signing this form, I confirm that the above information is correct and that I have a valid unrestricted Texas medical license and am a member in good standing in TAFP or TOMA.

signature

daTE


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news from aafp

RAC audits of E/M services set to begin in 15 states Auditors to target CPT codes 99214, 99215 By AAFP News Staff according to cms, its recovery audit contractors, or RACs, are scheduled to begin auditing claims that contain higher-level CPT codes for evaluation and management (E/M) services based on recommendations from the HHS Office of Inspector General (OIG). Physicians who practice in region C of CMS’ RAC program will be the first to undergo the latest in a series of RAC audits that will, in this instance, focus on claims using higher-level E/M codes—specifically, CPT codes 99214 and 99215—which frequently are billed by family physicians. Region C is made up of 15 states, Puerto Rico, and the U.S. Virgin Islands. Specifically, the states immediately affected are Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

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The new audits are the result of a report the HHS OIG issued in May titled Coding Trends of Medicare Evaluation and Management Services. Authors of that report encouraged CMS to audit E/M codes because, they noted, “E/M services have been vulnerable to fraud and abuse.” In a summary of that same report, the OIG noted that between 2001 and 2010, payments for Medicare Part B goods and services increased by 43 percent, from $77 billion to $110 billion. However, during the same time, Medicare payments for E/M services increased by 48 percent, from more than $22 billion to more than $33 billion. According to the OIG, it was able to look at Part B claims data and then identify individual physicians who frequently billed the more expensive and complex E/M codes, in-

cluding 99214 and 99215, in 2010. However, the OIG did not make any determination as to whether the claims were appropriate. The OIG said it identified 1,700 physicians who “consistently billed higher E/M codes in 2010.” Physicians billing higher E/M codes were not grouped in any particular state or region and treated Medicare patients of similar ages and with similar diagnoses as physicians who coded claims with lower-level E/M codes. “Overall, physicians who billed for E/M services represented 66 specialties, with most specializing in internal medicine, family practice, and emergency medicine,” said the OIG report. “Physicians who consistently billed the two highest-level E/M codes collectively represented 80 percent (53 of 66) of those specialties. Of these physicians, the majority also specialized in internal medicine, family practice, and emergency medicine.” The OIG found that among physicians who consistently billed higher-level E/M codes, 19.8 percent were internists, 12.2 percent were family physicians, and 9.9 percent were in emergency medicine. There has been speculation on some fronts that the government’s push for more robust health information technology—and a resulting physician reliance on electronic health records, or EHRs—has contributed to an increase in higher-level E/M codes because physicians are better able to document the time they spend with patients. However, a separate OIG study does not support that argument. On June 21, the OIG released results of a study that looked at the use of EHRs in 2011 by 2,000 randomly selected Medicare participating physicians who provided at least 100 E/M services in 2010. Physicians were asked if they used an EHR to document services, and, if so, they were asked to provide the name of the system and to state whether their EHR was certified. According to a study summary, the OIG found that 57 percent of the physicians surveyed used an EHR at their primary practice location in 2011, and that three of every four physicians with an EHR used a certified system to document E/M services. However, wrote the authors, “Although many EHR systems can assist physicians in assigning codes for E/M services, we found that most Medicare physicians manually assigned E/M codes.” Source: AAFP News Now, Sept. 18, 2012. © American Academy of Family Physicians.


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• When to Refer to a Geneticist • Children with Diabetes • Children with Asthma • Newborn Screening • Developmental Screening • Many others Referral Guidelines • Pediatric Depression • High Blood Pressures in the Office • Atopic Dermatitis • Gastroesophageal Reflux in Infants • Exercise-Induced Dyspnea • Referral Guidelines Overview


Member news

Harlingen physician wins national teaching award dora martinez, m.d., a TAFP member from Harlingen, was selected to receive a 2012 Pfizer Teacher Development Award for her scholastic achievement, leadership qualities, and dedication to family medicine. The awards program recognizes outstanding community-based family physicians from around the country who have practiced fewer than seven years and combine clinical practice with part-time teaching of family medicine as a preceptor or teacher of family medicine residents or medical students. Martinez is a part-time clinical professor for the University of Texas Health Science Center at San Antonio, Department of Family and Community Medicine, through the regional academic health center in Harlingen. She works in a small clinic in Santa Rosa, Texas, that is part of Su Clinica, a larger group of community health centers based out of Harlingen. Medical students from the RAHC spend three weeks under her direction learning “real-world family medicine” through their experiences in the clinic, and applying their book learning. The students participate in patient history-taking, physical exams, and formulating assessments and plans, and assist with any procedures performed in the clinic. “I teach because I love sharing knowledge and helping others,” Martinez says. “I enjoy simplifying complex concepts and helping students ‘get it.’ I think I also offer the students a different approach to medicine as I emphasize the importance of the patientdoctor relationship. I am open to integrative medicine practices and emphasize preventive medicine through nutrition and lifestyle changes—subjects that are barely touched on in medical school.”

If you know a family physician colleague who you think should be featured as a Member of the Month or if you’d like to tell your own story, nominate yourself or your colleague by contacting TAFP by e-mail at tafp@tafp.org or by phone at (512) 329-8666. View past Members of the Month at www.tafp.org/membership/ spotlight, and check out the shining example of our August Member of the Month, Tamarah Duperval-Brownlee, M.D., M.P.H.

Dora Martinez, M.D.

“I’m honored to receive the Pfizer teaching award and was grateful just to be nominated,” she continues. “Receiving this award means that I’m doing something right and it encourages me to keep bettering myself, both as a physician and a teacher.” Martinez is one of 13 physicians honored by the American Academy of Family Physicians Foundation for her commitment to education in family medicine. Each nomination is reviewed and scored by a panel appointed by the AAFP Foundation. The award provides funding for each recipient to attend an activity of choice to further her professional development and teaching skills. This program is supported by a grant from Pfizer, Inc.

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The City of San Antonio seeks a Medical Director/Family & Community Medicine Liaison to provide medical oversight to the health department as well as leadership, training and education to prevent disease and promote public health. The position also plans and sets policy with area health systems, community providers, residents and other stakeholders, and provides medical guidance to prevent injuries, control disease outbreaks, and address public health emergencies. Through a joint appointment as adjunct faculty to the University of Texas Health Science Center’s Department of Medicine, this position serves as public health liaison to family and community medicine. Apply online: www.sanantonio.gov/hr/.

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TAFP’s Member of the Month web feature highlights Texas family physicians and their approach to family medicine.

Family physician members named to physician leadership program The Texas Medical Association has selected the incoming scholars of the TMA Leadership College and the Class of 2013 includes four TAFP-member family physicians: Christopher Berry, M.D., of Dallas; Lindsay Botsford, M.D., M.B.A., of Houston; Chad White, M.D., of Hamlin; and Travis Bias, D.O., of Pflugerville. The TMA Leadership College was established in 2010 as part of TMA’s effort to ensure strong and sustainable physician leadership within organized medicine. TMALC graduates serve as thought leaders who can bridge the divide between clinicians and health care policymakers, and serve as leaders within their local communities. Scholars receive more than 40 hours of classroom instruction in topics including team building, communication skills, conflict management, legislative advocacy, and media training. The TMA Leadership College was designed for active TMA members under the age of 40 or who are in their first eight years of practice. Gregory Johnson, M.D., a family physician in Pearland and TMALC class of 2011, said in a TMALC brochure, “TMA Leadership College has been one of my most exciting experiences: to interact with so many energetic, talented, and thoughtful individuals who are really interested in not only promoting the profession of medicine, but also promoting the overall care of their patients.”


FP: Why did you choose family medicine? Were you inspired by anyone?

Member of the Month: Tamarah Duperval-Brownlee, M.D., M.P.H. Lone Star Circle of Care executive strives to help the underserved

A family physician for nearly 15 years, Tamarah Duperval-Brownlee, M.D., M.P.H., enjoys helping families attain good health through preventive and proactive care, and she believes in listening to her patients and providing respectful, compassionate care. She is the chief executive and chief medical officer for clinical systems of Lone Star Circle of Care, a federally qualified health center with 26 locations across four counties in Central Texas. She oversees clinical quality and clinical operations and administration, oversees the medical executive team, and coordinates a system for patient care review and clinical practice activities that promote efficiency and quality in patient care processes. Dr. Duperval-Brownlee takes a strong patient-centered approach to medicine with a special interest in women, children, and underserved populations.

FP: Tell us about yourself and your career. I’m a wife, sister, aunt, and family physician of 13 years who’s passionate about ensuring high quality of care, preventive services, and health care access and equity for everyone, especially underserved populations. I’m a first generation Haitian-American born and raised in Chicago, Ill., and was raised with a high sense of appreciating faith, culture, family, and giving.

KATE ALFANO

I did my training and education in medicine in Chicago, which was followed by a year at the Harvard School of Public Health where I completed a Master of Public Health and fellowship in health policy. I practiced full scope family medicine for my first 11 years in Chicago, from ambulatory medicine to obstetrics, and served as a medical director for a federally qualified health center and assistant professor of family medicine for the University of Illinois.

I chose family medicine because it was the discipline that most embodied the mission of holistic, comprehensive care that resonated with my own personal mission in medicine. I realized early in my education the tremendous privilege that physicians have in impacting lives for the good and I wanted to be able to use the skills I honed to make the greatest impact possible, being not only a provider of care, but an advocate for patients in arenas where decisions about health policy were being made. I was imprinted from my first year of medical school when I participated in what was then a new program of exposing medical students to primary care from the beginning of their education. Dr. Gary Reichard was my preceptor for the Longitudinal Primary Care program and in addition to appearing to know everything about medicine, he was kind, compassionate, and practiced patientcentered care. I knew then that’s what I wanted to do. FP: What role does HIT play in your practice? It’s crucial for the coordination of care for our patients. With 26 locations across four counties, we would be unable to provide the scope of care for our patients (including primary care, integrated behavioral health, and specialty care access) with the ability for on-time communication and access to information throughout all their touch points in the health care continuum. FP: What is the biggest opportunity or challenge you see in the specialty in the next five years? Retaining and building capacity of physicians to meet primary health care needs of our communities and even more critically, development of primary care leadership that can help direct and inform policy and population management. FP: How do you spend your free time? I find balance in being an avid reader (I participated in my first book club this year), amateur runner (I completed three marathons for charity and still do half marathons and 5Ks for fun), and spending time with my husband. Golf is my next developing passion—I’m looking to take lessons soon.

I came to Texas in March 2011 to serve in a great opportunity with Lone Star Circle of Care, which provides clinical and operational oversight for the care of nearly 95,000 people.

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Member news

San Antonio FMIG honored as “program of excellence” aafp named 16 medical school family medicine interest groups as the 2012 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 six times. The group currently boasts an active membership of 50 medical students with a board of officers who participate in state and

national family medicine leadership positions. In their application for the award, FMIG leaders described their success in collaborating with other groups to address health-related needs in their community and to promote the specialty and primary care. “This year, in particular, we took the lead in becoming a part of a great effort to educate our peers about the value of a health care system rooted in all the principles for which the specialty of family medicine stands. We encourage our FMIG colleagues in other schools to engage with other student, professional, and community groups to advance primary care because it is so greatly needed in our country.” As part of their mission to recruit medical students to family medicine, they utilize FMIG meetings to discuss relevant medical topics and sponsor hands-on workshops, and sponsor an annual residency fair, which brought 15 family medicine residency programs to interact with third- and fourth-year medical students. Most notably, they led the way in forming a Primary Care Progress chapter and sponsored the first-

ever UTHSCSA Primary Care Week with daily events highlighting primary care and the benefits and opportunities available through family medicine, general internal medicine, nursing, pharmacy, and public health. In the community, the UTHSCSA FMIG is involved in Tar Wars, AAFP’s anti-tobacco initiative that brings medical professionals into fourth- and fifth-grade classrooms, Ready, Set, FIT!, an AAFP fitness initiative that teaches third- and fourth-grade students the importance of fitness and proper nutrition, and Hard Hats for Little Heads, a bicycle helmet giveaway program. This year FMIG members also conducted health screenings at local schools and gave influenza immunizations to the homeless at the Haven for Hope Homeless Shelter. They held a toy drive benefiting children at seven university hospital-associated clinics. Award winners were honored during a ceremony at the AAFP National Conference for Family Medicine Residents and Medical Students in Kansas City, Mo.

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12/21/09 2:52:24 PM


UTHSCSA student wins AAFP video contest troy russell, a fourth-year medical student at the University of Texas Health Science Center at San Antonio, won best overall video during the first-ever National Conference Family Medicine Video Contest. Video entries promoting the specialty of family medicine, created by and for family medicine residents and medical students, were judged by a panel of AAFP members and deTroy Russell buted during AAFP’s National Conference of Family Medicine Residents and Medical Students in July. In just 30 seconds, the winning video, “Remember,” provides a poignant reminder of why many physicians chose family medicine. “Every day of our training we are confronted with the question: Do we remember why we took this path? Was it to treat the less fortunate, to provide for the underserved, or was it to be on the front lines and advocate for our community’s health? No, we have not forgotten. We chose to become

leaders. We chose to become healers. We chose to become family physicians.” An interest in film led Russell to begin pursuing a double major in film and mechanical engineering at Brigham Young University, but a mission trip to Honduras after his freshman year changed his perspective. He switched to neuroscience with the intention to pursue medicine and public health. He decided on family medicine during his family medicine clerkship, appreciating the breadth of the specialty, continuity of care, and the ample opportunity for research. “My favorite part of medicine has been my interaction with patients and helping them understand their condition,” he told TAFP in a Member of the Month profile in July. “I love when the figurative light bulb turns on and my patient decides to take a more active role in her health. This is common among the family medicine physicians I have met and I feel fortunate to have worked with so many who share the same zeal for primary care.” To view the video, go to www.aafp.org/ nc/videos. To read Troy Russell’s Member of the Month profile, go to www.tafp.org/ membership/spotlight.

“My favorite part of medicine has been my interaction with patients and helping them understand their condition. I love when the figurative light bulb turns on and my patient decides to take a more active role in her health.” Troy Russell

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The right kind of doctors for Texas Revisiting barriers to building the primary care workforce, 20 years later By Kate Alfano

For 20 years, health care stakeholders have urged academic institutions to change how they educate medical students and how they distribute funding within their graduate medical education programs in order to advance the training of more primary care physicians. Despite compelling and conclusive evidence that shows patients with ready access to primary care receive higher quality care with better health outcomes for less cost, the players best able to turn the downward trend in the primary care physician workforce have failed to enact meaningful reforms. In the early 1990s, when the current class of firstyear medical students were babies and toddlers, the Texas Academy of Family Physicians released two reports—“Training Family Physicians: A Vital Element in Solving Texas’ Access to Health Care Crisis”1 and “The Right Kind of Doctors for Texas: A Strategy for Meeting Physician Workforce Needs of Texas”2—that warned of an impending primary care physician shortage and outlined recommendations to correct the disparities in specialty mix and geographic distribution. Similarly, the Council on Graduate Medical Education published its Third Report3 in October 1992 that described the crisis in health care delivery on the national level. The authors called on educational institutions to be more responsive to the public need for more practicing primary care physicians, underrepresented minority physicians, and physicians more likely to practice in underserved rural and inner-city areas. They called for the development of a national workforce plan and strategy in medical education financing and health

care payment systems that would remove barriers to training and improve access to primary care. COGME revisited these issues in its Twentieth Report,4 published in December 2010, more directly calling on institutions to produce more primary care physicians, deconstruct the barriers to a primary care-based workforce, and address a number of issues: decreased interest in primary care professions, the mechanisms of physician payment and need for practice transformation in primary care, the biased premedical and medical school environment, issues in the graduate medical education environment, and the geographic and socioeconomic maldistribution of physicians. Yet, even with reams of studies from respected organizations and policy experts calling for a health care system grounded in primary care, academic institutions today still lag far behind in producing enough primary care physicians to care for a population that is rapidly growing, aging, and presenting worse and more complex health conditions.

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pediatrics—to resemble the 50-50 ratio seen in other developed countries that demonstrate better health outcomes than the United States.6 The authors of COGME’s Twentieth Report wrote, “There is significant evidence that optimal health care outcomes and optimal health system efficiency are demonstrated when at least 40-50 percent of the physician workforce is composed of primary care physicians.” In 2010, the most recent data available, only 36 percent of U.S. doctors were classified as active patient care primary care physicians—or physicians in adolescent medicine, family medicine, general practice, geriatric medicine, internal medicine, internal medicine/pediatrics, or pediatrics. Approximately 35 percent of Texas doctors practiced primary care in 2010.7 Already exceeding 26 million, the Texas population is projected to grow steadily to well over 30 million by 2020 and between 35 million and 40 million by 2030. And the number of Texans between age 65 and 74—a segment that demands more complex and coor“A rational health care system must be based dinated care—is expected to double between 2012 and 2030, from about 1.5 million to 3 million.8 upon an infrastructure consisting of a majority Texans already experience lack of access to of generalist physicians trained to provide quality health care in both rural and urban underserved areas. Nationwide, there were 79.4 primary care phyprimary care and an appropriate mix of other sicians in active practice per 100,000 population specialists to meet health care needs. … Physicians in 2010, but Texas averaged 62 per 100,000 popuwho are trained, practice, and receive continuing lation.7 Data from the Texas Department of State Health Services show that 29 Texas counties do education in the generalist disciplines provide not have any primary care physicians, 77 counties more comprehensive and cost-effective care than have fewer than 39.7 primary care physicians per 3 100,000 population, and 80 counties have fewer nonprimary care specialists and subspecialists.” than 62.4 primary care physicians per 100,000 population.9 Three out of every four Texas counties are designated as whole or partial primary care health professional shortage areas, or HPSAs.9 in cogme’s third report and TAFP’s “The Right Kind of Doctors for Additionally, there are a considerable number of primary care phyTexas,” the authors challenged institutions to correct the lopsided sicians currently practicing who may leave the field as they retire, reratio of specialists to primary care physicians—defined as physicians locate, enter another specialty, or take an administrative position. Of who practice family medicine, general internal medicine, and general the 242,500 primary care physicians in the U.S., COGME’s Twentieth Considering that graduate medical education is not a single entity, but rather the sum of the accreditation and certification organizations, regulatory bodies, sponsoring institutions, individual programs, faculty, and academic leaders that together prepare physicians to practice,5 this issue is much larger than line items in state and federal budgets. However, because of the state’s significant investment in healthrelated institutions, Texas lawmakers and taxpayers can demand a better return to achieve gains in physician recruitment, education, and training that will benefit the state now and in the future. Twenty years ago, these issues were pressing. Now, the need for reform is critical as more realize the urgency of the primary care physician workforce shortage and the role academic institutions play in reversing a troubling trend.

The number of Texas medical school graduates versus first-year entering residency positions 2,000

Number of first-year GME filled positions 1,674

MD/DO degrees awarded 1,565 1,519 1,500

1,426 1,502

1,502

1,502

2013*

2014*

2015*

1,314

1,000 2007

2008

2009

2010

2011

2012*

* Projected Source: Texas Higher Education Coordinating Board. “Graduate Medical Education Report: 82nd Texas Legislature, Regular Session, House Bill 2908.” April 2012.

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in primary care, 75.1 percent reported that they plan to go into a subspecialty. Only 24.9 percent of the 31.9 percent said they would not subspecialize. COGME identifies several reasons for decreased medical student interest in primary care: heavy workload, insufficient reimbursement, a lack of strong primary care role models, and the “hidden curriculum” in medical school. Then, as medical students consider their future practice environment, they see declining reimbursement in primary care relative to specialties, increasing workloads, and increasing administrative burden that continue to erode their interest.4 This hidden curriculum is a strong force formerly only spoken about anecdotally as faculty members actively discouraged bright students away from primary care and toward more prestigious subspecialties. As COGME describes it, though, the structure of medical school itself pushes students away from the adult primary care specialties. “Although the current deficit in the production of “During clinical training, impressionable medical students work shoulder-to-shoulder primary care physicians is caused by many factors with residents, interns, and their supervising facnot directly related to the medical education ulty. This is their first glimpse of the ‘real world’ of medical practice and they are fed a steady diet process, medical schools must play a central role of subspecialization. This is because most mediin improving preparation and production of cal schools have, in one form or another, a faculstudents for entry into primary care specialties to ty practice plan anchored to a large hospital that 4 attracts acutely ill patients. meet the nation’s health care needs.” “Furthermore, students receive relatively less exposure to ambulatory practice compared to their inpatient experience. Ambulatory practice is tightly managed and requires a high level of productivity. Placing students in this setting disrupts this productivity and requires financial support to offset this on the 2012 association of american medical colleges Graduacost. The result is that most medical students have heavy exposure to tion Questionnaire,11 a promising 31.9 percent of U.S. medical school serious acute subspecialty inpatient care and very little exposure to graduates indicated that they would choose family medicine, internal ambulatory care, where most of American medicine is practiced. The medicine, or pediatrics. However, this number is inflated by those in opportunity for exposure to role models in primary care practice is internal medicine or pediatrics who will subspecialize after their first very limited.”4 three years of residency. Of the 31.9 percent indicating their interest Report identified 55,000, or almost one-quarter, as age 56 or older. In Texas, the Texas Higher Education Coordinating Board reports that 45 percent of all physicians are 51 years of age or older and 20 percent are 61 years of age or older. Though physicians tend to retire later than most other professionals, the potential exacerbation of the current shortage is staggering.10 At the same time, the pipeline that supplies our future primary care workforce is drying up and stakeholders must act quickly to address this. It takes 11 years to train a new doctor—four years in an undergraduate college setting, four years in medical school, and three years minimum to complete a residency program in a primary care specialty—and student interest in primary care is declining.

Ratio of specialists to primary care physicians in the U.S. 1991

34% Primary care physicians*

66% Specialists

2010

36% Primary care physicians*

64% Specialists

*Primary care physicians includes family/ general practice, general internal medicine, and general pediatrics

*Active patient care primary care physicians includes adolescent medicine, family medicine, general practice, geriatric medicine, internal medicine, internal medicine/pediatrics, or pediatrics

Source: Texas Academy of Family Physicians. “Training Family Physicians: A Vital Element in Solving Texas’ Access to Health Care Crisis.” April 1991

Source: Association of American Medical Colleges Center for Workforce Studies. "2011 State Physician Workforce Data Book." November 2011

Student specialty choice, 2012 AAMC graduation survey 2012

31.9% of respondents indicated they would choose residency training in family medicine, internal medicine, and pediatrics.

Selected specialty other than primary care

7.9%

24.0%

Indicated family medicine, internal medicine, or pediatrics but plan to subspecialize

68.1%

Indicated family medicine, internal medicine, or pediatrics and do not plan to subspecialize

Source: 2012 Association of American Medical Colleges Medical School Graduation Questionnaire – 2012 All Schools Summary Report

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Recommendations for strengthening In the 1991 document, TAFP found that the medical reimbursement system favors procedural skills over cognitive skills and, therefore, pays substantially less for the care provided by primary care training programs. As echoed by COGME’s Twentieth Report, the ambulatory settings ideal for primary care training are more costly than inpatient settings and less favorable for medical schools to use to train medical students. TAFP also found in 1991 that the limited availability of research funds to family medicine means that family medicine departments in medical schools inherently do not generate significant grant dollars; the total amount of external research dollars available for family medicine use is only a fraction of what exists for other subspecialties. The pressure on medical schools to generate revenue makes it difficult to give primary care disciplines equal status because there is not an equal ability for those areas to generate higher income. Again, COGME’s Twentieth Report demonstrates how little has changed: “Medical school deans and university presidents have traditionally been judged on their ability to build large medical research enterprises focused on discovery and innovation. Most academic medical centers focus on technology-intensive care to pursue these institutional goals, emphasize basic science and clinical investigation, and provide relatively greater rewards to subspecialty care. In most schools, the family medicine department, dedicated to primary care, is dwarfed in size and prestige by the department of internal medicine, which is often the largest research department in the entire university.” As expenses outpace state support for medical education and the state cuts funds to academic institutions, Texas medical schools have been forced to seek additional funding to supplement their revenue. And as medical schools have increased their dependence on external funding, priorities have shifted. Medical schools understandably tend to favor research and procedural inpatient care—which bring revenue—over the workforce needs of the state. In the larger sense, medical schools all share a basic purpose— to educate physicians to care for the population. But our medical schools fall short of achieving basic standards shown to improve the health of the community: whether they have produced an adequate number of primary care physicians, ensured adequate distribution of physicians to underserved areas, and added a sufficient number of minority physicians to the workforce. A national report released in 2010 ranked the schools based on these criteria.12 Out of the 141 medical schools in the ranking, no Texas schools made the top 50 overall, four ranked in the lowest 40, and one was next to last. In the category of production of primary care physicians, the Texas College of Osteopathic Medicine at the University of North Texas Health Science Center ranked seventh in the nation, but the next Texas school came in at number 40, and three Texas schools ranked in the lowest quarter.12

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In preparation for the 83rd Texas Legislature convening in January 2013, the Texas Academy of Family Physicians retained Charles Bell, M.D., former deputy executive commissioner of the Texas Health and Human Services Commission, to develop a series of recommendations to increase the training and production of primary care physicians and improve Texans’ access to primary care. TAFP members then began a legislative education campaign through TAFP’s Key Contacts program to reach out to their elected state officials and advocate for these recommendations. In the most acute sense, family physicians know the needs of their communities and their patients, and this understanding resonates with their legislators. To learn more about how to get involved as a Key Contact in the 83rd Texas Legislature and educate your elected officials on the grass-roots level, go to www.tafp.org/advocacy or contact Tom Banning at tbanning@tafp.org.

Recommendation 1: Restore funding for Family Medicine Residency Programs through the Texas Higher Education Coordinating Board to the 2010-2011 appropriation level. Texas’ 28 family medicine residency programs are the lifeblood of the state’s primary care physician workforce, and they give back to their communities by managing primary care clinics that deliver well-coordinated, cost-effective care to populations that need it most. Last session, the Legislature reduced the investment in family medicine residency programs by 73.6 percent, from $21.2 million in 2010-2011 to $5.6 million in 2012-2013. Some temporary stopgap funding has been provided through other organizations, but unless additional state funding is provided, training programs will be forced to reduce the number of residency positions they offer, reduce their training staff, or close their doors altogether.

Recommendation 2: Create new communitybased primary care residency training programs by restoring funding to the Texas Higher Education Coordinating Board’s Primary Care Residency Program and Graduate Medical Education Program. The vast majority of state and federal support for medical residency training goes directly to teaching hospitals and academic health centers, which have budgetary priorities misaligned from the needs of the state. For the most part, primary care is practiced in outpatient clinics, the setting most effective for training primary care physicians. Last session, the Legislature zeroed out funding for two budgetary line items through the Texas Higher Education Coordinating Board intended to support community-based primary care residency training. The Legislature should restore that funding and direct the coordinating board to retool these programs so that they help fund the creation of new residency training programs set in community-based clinics.


primary care in the 83rd Texas Legislature Recommendation 3: Restore graduate medical education formula funding appropriated to medical schools to 2010-2011 levels and use the restored funds to provide incentives to medical schools that increase the number of primary care physicians they train. Medical schools receive a portion of their state appropriation based on the number of medical residents training in their affiliated residency programs through a budgetary line item entitled “graduate medical education.” While this GME formula funding is a significant investment, there currently exists no method for the state to influence what type of physicians are being trained. Last session, each medical school experienced a significant reduction in GME formula funding, cut from $79 million in 2010-2011 to $57 million in 2012-2013. If the state restored funding to 2010-2011 levels, it could use the restored funds to create an incentive pool for those medical schools that increase the number of primary care residents trained in their affiliated residency programs.

Recommendation 4: Require medical schools to spend the full amount of funding appropriated through the GME formula directly in support of residency training. GME formula funding is appropriated to medical schools based on the number of residents training in residency programs affiliated with the schools. The funding is intended to support the training of residents, but medical schools are not required to show that the funds are actually spent directly on the training of residents. Requiring health-related institutions that receive GME formula funding to spend those funds directly in support of residency training would bring a measure of transparency to bear on how much institutional support residency training programs of different disciplines receive from their sponsoring institutions.

Recommendation 5: Utilize a percentage of total medical school formula funding to create an incentive pool for the development of innovative programs designed to increase the state’s primary care physician workforce. Some medical schools in Texas are developing programs designed to encourage medical students to pursue careers in primary care by making medical education less expensive, less redundant, and more effective at generating an appropriate physician workforce. Establishing an incentive pool will create competitive pressures on medical schools to develop innovative strategies to make primary care more attractive to students at the critical decision-making moment.

Recommendation 6: Establish an information tracking system at the Texas Higher Education Coordinating Board to track medical students for five years after they complete medical school. It is relatively simple to count how many medical school graduates enter primary care residencies, but after their third year of training, many residents, in particular those in internal medicine residencies, go on to subspecialty training. To measure the number of

medical school graduates who complete training and begin practicing primary care medicine, the state must track those graduates for at least five years after they complete medical school. With this data tracking system in place, the state can accurately determine how successfully state-funded institutions are producing the physician workforce Texas requires and provide incentives to influence this action.

Recommendation 7: Align the Frew Children’s Medicaid Loan Repayment Program and the Physician Education Loan Repayment Program, and restore funding to 2010-2011 levels. With the average physician graduating from medical school with $160,000 in debt, loan repayment programs provide excellent incentives to recruit those physicians to the most needed medical specialties and to the most underserved communities. In 2009, the Texas Legislature closed a tax loophole for how smokeless tobacco is taxed, generating over $100 million per biennium. Though a portion of those funds were specifically allocated to fund the Physician Education Loan Repayment Program, future funding was zeroed out by the 82nd Legislature. Restoring funding to 2010-2011 levels will again provide an incentive to recruit physicians to the specialties and geographic areas that need them the most.

Recommendation 8: Restore funding for the Texas statewide preceptorship programs through the Texas Higher Education Coordinating Board to the 2010-2011 appropriation level. Three programs are proven to encourage more medical school graduates to choose the primary care specialties: the General Internal Medicine Statewide Preceptorship Program, the Texas Statewide Family Medicine Preceptorship Program, and the General Pediatric Preceptorship Program. But a series of funding cuts and a complete loss of funds last session have eroded the programs’ capacity and therefore reduced the number of primary care physicians the state can produce. Restoring these programs to their 2010-2011 appropriation will allow them to continue providing much-needed exposure to primary care specialties to encourage bright medical students to enter these fields.

Recommendation 9: Restore funding for the Joint Admission Medical Program through the Texas Higher Education Coordinating Board to the 2010-2011 appropriation level. Minority physicians have been shown to be more likely to practice in minority or underserved areas, improving access to care and the health status of underserved populations. The Joint Admission Medical Program, or JAMP, supports and encourages highly qualified, economically disadvantaged students to pursue medical education who have not traditionally had ready access to these careers. Last session, funding for the program was cut by 34 percent, from $10.6 million to $7 million, which will reduce enrollment in the program from 150 to 96. Restoring funding to this program through the Texas Higher Education Coordinating Board will improve access to care for underserved populations in Texas.

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Program increased by 18.6 percent, from 1,281 positions to 1,519 positions. During the same period, the number of family medicine residency positions of“Ensuring that GME meets the needs of the fered through NRMP in Texas dropped 15 percent, public will require reevaluation and revision from 247 to 210. The number of family medicine residency positions available today only represents of the present physician payment and GME 13.8 percent of training slots offered in the state. reimbursement systems, which exert a The other primary care residencies have exdominant influence on specialty choices, the perienced similar declines in Texas. In internal medicine–primary care, the number of residency types and locations of institutions participating positions offered in Texas dropped from 445 to in GME, and the number and specialty mix of 300, a decrease of 33 percent, and the positions 5 offered in internal medicine–pediatrics declined GME positions.” from 392 to 344, or 12 percent. In pediatrics–primary, the number of positions offered dropped from 110 to 64, a decrease of 42 percent.13 Nationally, the Macy Foundation found that the number of residents in subspecialty training while enrollment in texas medical schools jumped 31 percent has risen five times faster than the number of residents in primary care from fall 2002 to fall 2011, increasing from 1,342 students enrolled to specialties.5 On the current course, this defies any effort to rebalance the 1,762, and with recent campaigns to open at least two new medical ratio of specialists to primary care physicians. schools in south and central Texas, the number of Texas residency Part of the decline in positions offered in family medicine residencies positions that could train these newly graduated physicians has recan be attributed to shifting priorities in institutions providing gradumained flat. This creates an economic drain as Texas taxpayers subsiate medical education, much like the medical schools. Lack of financial dize other states’ workforces. support has led to the closing of three family medicine residencies over THECB reports that in fall 2011, the ratio of first-year entering the past decade, which also results in the loss of related benefits enjoyed residency positions to graduates was close to 1-to-1, with 1,494 firstby their surrounding communities. Research has shown that the care year entering residency positions available for the 1,458 medical school delivered in primary care clinics operated by family medicine residency graduates. However, with increases in medical school enrollment and programs is better coordinated and more cost-effective. In addition, a stagnation in the number of first-year residency positions, starting in significant portion of the care these clinics provide is for Medicaid and 2014, at least 63 graduates of Texas medical schools will not have an CHIP patients, Medicare patients, and the uninsured.14 opportunity to enter a Texas residency program. By 2016, at least 180 Christus St. Elizabeth Family Practice Residency Program in Beaumedical school graduates will have to leave the state for their first year mont, of which 88 percent of its 74 program graduates practicing in of residency training due to a lack of residency positions.10 2005 practiced in health professional shortage areas, closed in 2002. Because the state invests approximately $168,000 to educate each The Texas Tech University Rural Program in Abilene, successful in medical student, failing to add Texas residency positions results in an training physicians for rural practice, closed in 2008. The Kelsey-Seyannual loss of investment in the physician workforce that will reach bold Family Medicine Residency Program in Houston, a highly com$30.2 million by 2016.10 Adding first-year residency positions will repetitive program considered a model for training new physicians in a duce the loss of medical school graduates to other states and, eventuteam-based, multispecialty environment, closed in 2010.14 ally, reduce the loss of Texas-trained physicians. Among the events leading to Kelsey-Seybold’s termination was the Data from the Association of American Medical Colleges supports decision by its main teaching hospital, St. Luke’s Episcopal Hospital, to this. Though graduates of Texas medical schools or Texas residency reduce by half the funding for stipends paid to family medicine resiprograms are not guaranteed to remain in the state once they comdents. In a January 2010 article in Texas Family Physician, Steve Spann, plete medical training, Texas has one of the highest retention rates M.D., senior vice president and dean of clinical affairs at Baylor Colof its medical school and residency program graduates in the nation. lege of Medicine, said that St. Luke’s “did that unilaterally and despite Of physicians who complete both undergraduate medical educasome pretty strong protest from us, but they felt it was more to their tion and graduate medical education in Texas, 80.2 percent stay in benefit to put those stipends into neurosurgery.” Texas, the third best in the nation. Of physicians who only complete Patrick Carter, M.D., chair of the clinic’s department of family undergraduate medical education in Texas, 59 percent stay in Texas, medicine, said in the article that the Kelsey-Seybold Clinic needed a the second highest rate in the country. And of those who only comsubsidy from Baylor College of Medicine of between $400,000 and plete graduate medical education in the state, 57.9 percent of physi$450,000 to keep the family medicine residency program viable. But cians stay in Texas, the fifth highest rate in the country.7 BCM couldn’t save the program and it closed. The state appropriated $7.6 million in state GME formula funding to BCM that year for gradTAFP asserts that the state must invest in primary care residency uate medical education.15 positions to have a direct effect on the most dire workforce shortages and counteract the historical movement away from funding primary Although funding for educating and training a resident comes care residency slots. through various federal and state funding streams and the cost of From 2000 to 2012, the number of first-year residency positions ofeducating and training a resident far exceeds the amount of funding fered in Texas through the National Residency Matching Program and received by the state10, the state’s contribution is essential to support the American Osteopathic Association Intern/Resident Registration the training of primary care physicians in Texas. 26

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References “Because GME is a public good and is significantly financed with public dollars, the GME system must be accountable to the needs of the public.”16

legislators must act to influence the trend of declining student interest and bias against primary care specialties in academic institutions to encourage them to refocus their priorities and implement changes in medical education for the good of the public. For future generations, Texas must ensure that we have an adequate supply of primary care physicians to care for our population, and that medical students and residents receive the right kind of training to provide the coordination and continuity of care needed by patients to receive the right care at the right time at the right cost. Texas needs doctors to practice in underserved areas and needs the kind of doctors that can provide cost-effective and affordable medical care. Primary care physicians—and family physicians, in particular— are the doctors best trained to provide preventive care and provide a broad range of medical and surgical care. The state has played a significant role in the education of physicians. It is vitally important that, in the 83rd Legislature and beyond, the state examines its support of medical education and holds the medical schools and teaching hospitals accountable for producing the physician workforce Texas needs. Though it’s long past time to act, stakeholders must take steps now to increase the number of primary care physicians and increase access to health care, quality of care, and the overall health of the public.

Get involved in the 83rd Texas Legislature

1.

Sign up to be a Key Contact and educate your legislators on family medicine’s issues

2. Sign up to serve as a Physician of the Day and spend a day in the Capitol health clinic

3. Stay informed on the issues with TAFP advocacy resources the TAFP Political Action Committee and contribute 4. Join to the cause Whatever your interests or time commitment, you can help advance the specialty in this legislative session. Go to www.tafp.org/advocacy for more information.

1. Hendricks, Sarah; Roland Goertz; and James White. “Training Family Physicians: A Vital Element in Solving Texas’ Access to Health Care Crisis.” Texas Academy of Family Physicians. April 1991. 2. White, James; Stacey Vernon; and Troy Alexander. “The Right Kind of Doctors for Texas: A Strategy for Meeting Physician Workforce Needs of Texas.” Texas Academy of Family Physicians. Feb. 1993. 3. Council on Graduate Medical Education. “Third Report – Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century.” U.S. Department of Health and Human Services Health Resources and Services Administration. Oct. 1992. 4. Council on Graduate Medical Education. “Twentieth Report – Advancing Primary Care.” U.S. Department of Health and Human Services Health Resources and Services Administration. Dec. 2010. 5. Weinstein, Debra, chairperson. “Conference Summary – Ensuring an Effective Physician Workforce for the United States: Recommendations for Reforming Graduate Medical Education to Meet the Needs of the Public. The Second of Two Conferences – The Content and Format of GME.” Presented by the Josiah Macy Jr. Foundation in Atlanta, Ga. May 2011. 6. Macinko, James; Barbara Starfield; and Leiyu Shi. “The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998.” HSR: Health Services Research. June 2003. 7. Association of American Medical Colleges Center for Workforce Studies. “2011 State Physician Workforce Data Book.” Nov. 2011. 8. Eschbach, Karl. “Demographic Changes in Texas and Healthcare Work Force in Texas.” Presentation. Prepared for Senate Committee on Health and Human Services. 23 Feb. 2010. 9. Texas Department of State Health Services Health Professions Resource Center. “Supply Trends Among Licensed Health Professions, Texas, 1980-2011.” Jan. 2012. 10. Texas Higher Education Coordinating Board. “Graduate Medical Education Report: 82nd Texas Legislature, Regular Session, House Bill 2908.” April 2012. 11. Association of American Medical Colleges. “Medical School Graduation Questionnaire – 2012 All Schools Summary Report.” July 2012. 12. Mullan, Fitzhugh, et al. “The Social Mission of Medical Education: Ranking the Schools.” Annals of Internal Medicine, Vol. 152, No. 12. 15 June 2010. 13. American Academy of Family Physicians. “2012 Match Summary and Analysis.” Tables 1, 4, 7, 8, and 14. May 2012. Accessed 20 Aug. 2012. <http://www.aafp.org/online/en/home/residents/match.html> 14. Texas Academy of Family Physicians. “Family Medicine Residency Programs Are Critical in Training Texas’ Physician Workforce.” Issue Brief: Improving Texas’ Primary Care Physician Workforce. April 2011. 15. Nelson, Jonathan. “On the Brink.” Texas Family Physician, Vol. 61, No. 1, Winter 2010. 21 Jan. 2010. 16. Johns, Michael M.E., chair. “Conference Summary – Ensuring an Effective Physician Workforce for America: Recommendations for an Accountable Graduate Medical Education System.” Presented by the Josiah Macy Jr. Foundation in Atlanta, Ga. Oct. 2010. www.tafp.org

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Report from TAFP’s 63rd Annual Session & Scientific Assembly

Family physicians come together in the heart of Texas Story and photos by Kate Alfano and Jonathan Nelson about 400 family physicians and other health care providers gathered in Austin this July to learn, network, see old friends, and make new ones, all while celebrating the specialty of family medicine at the 63rd Annual Session and Scientific Assembly. For your TAFP staff, this was a special Annual Session because it was held in our hometown, so we enjoyed recommending our favorite restaurants, coffee houses, and activities to any attendees who were interested. View a photo slide show on our blog at www.tafp. org/blog/12.07.25/annual-session. Again this year, attendees had ample opportunities to learn about a wide variety of topics from a distinguished faculty during 28

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the scientific portion of the conference. In addition to the general assembly lectures presented Friday, July 13, through Sunday, July 15, attendees could participate in two Self-Assessment Module workshops on Wednesday, July 11, and had their choice of three afternoon workshops on Thursday, July 12. Plus, the National Procedures Institute offered one of its most popular two-day training courses, Hospitalist Procedures, in conjunction with the conference. The general session lectures opened Friday with an update on the Texas Academy led by TAFP leaders I.L. Balkcom IV, M.D., and Tom Banning. Thus began two and a half days of excellent continuing medical education,

including topics on head injuries in young athletes, dementia, hypothyroidism, strategies for cost-effective care, proper care for hospice patients, and many more. On Sunday morning, AAFP President Glen Stream, M.D., M.B.I., addressed the general session, presenting an update on activities of AAFP. On Thursday night, members gathered at TAFP’s Town Hall Meeting to attend a panel discussion on clinical integration featuring Kevin Spencer, M.D., of Austin; Janet Hurley, M.D., of Whitehouse; and Mike McCrady, M.D., of Henderson. TAFP held its first Member Assembly at lunch on Friday, as Academy leaders described the organization’s governance structure, the purpose and general activities of the Academy’s various commissions, and opportunities for members to become more involved. Members in attendance asked questions of Academy leadership in an open forum that over the coming years should evolve into one of the organization’s most important meetings.


Clockwise from left: This year’s President’s Party was held at the Bob Bullock Texas State History Museum in Austin. TAFP President I.L. Balkcom IV, M.D., welcomes attendees to TAFP’s first Member Assembly. TAFP’s president for the coming year, Troy Fiesinger, M.D., presents the Special Constituency Leadership Award to Linda Siy, M.D., of Fort Worth. TAFP’s newly inducted parliamentarian, Tricia Elliott, M.D., belts out a jazz standard at the Foundation’s signature event of the conference, Night of Jazz and Art. Henry J. Boehm Jr., M.D., center, is named Physician Emeritus at TAFP’s annual awards luncheon. From left: TAFP Past President Kaparaboyna Ashok Kumar, M.D., thanks AAFP President Glen Stream, M.D., M.B.I., and his wife Anne Montgomery, M.D., for attending this year’s annual session.

On Friday evening, the TAFP Foundation held a gala event, a Night of Jazz and Art. TAFP’s newly installed parliamentarian, Tricia Elliott, M.D., was the star of the evening as she sang many well-loved selections from the American song book backed by an Austin-based jazz trio. Paintings for sale decorated the room, a portion of all sales going to support the Foundation. At the Annual Business and Awards Lunch on Saturday, the 2012 awardees for TAFP’s top honors were unveiled and the 2012-2013 officers assumed their new posts. Justin Bartos III, M.D., of North Richland Hills, was named Texas Family Physician of the Year, the highest honor of the Academy. Bartos currently serves as medical director of the Dr. David Pillow Senior Health Clinic in North Richland Hills, where he provides comprehensive geriatric care for Medicare patients. He previously practiced for more than 25 years at North Hills Family Medicine, providing multigenerational care in the private practice setting.

In his acceptance speech for the award, he told attendees that though he was nominated chiefly for his political advocacy and leadership in the state and national academies, it is his relationship with his patients that defines him. “Our biggest advocates, our biggest allies are our patients. And all of you who have close relationships with your patients have advocates, too, and they’re always willing to help, you just have to ask. I wouldn’t hesitate. Thank you to my patients who allow me to share their lives with them; they give me purpose and direction.” Henry Boehm Jr., M.D., who practiced family medicine in his hometown of Brenham for nearly 50 years, was honored as TAFP’s Physician Emeritus. TAFP honored Rep. Vicki Truitt of Keller with the Patient Advocacy Award. “It’s been my distinct privilege and honor to serve the people of the 98th Texas House district in northeast Tarrant County as well as all Texans,” Truitt told attendees. “I’ve known many of you in this room since you were residents, so the history goes back, the understanding

is deep, the concern is deep, and shall continue. Best wishes to you all as you face the challenges of health care before you and I look forward to continuing our friendship.” The TAFP Foundation presented scholarships to medical students and honored Edwin Franks, M.D., of Iraan, as the Philanthropist of the Year. Lewis Foxhall, M.D., received the Presidential Award of Merit for his leadership of the Texas Statewide Family Medicine Preceptorship Program. In his honor, the TAFP Foundation Board of Trustees created the Lewis Foxhall Student Interest Champion Fund to support stipends for future medical students participating in family medicine preceptorships. Receiving the 2012 TAFPPAC award was Lloyd Van Winkle, M.D., of Castroville, who has served as TAFPPAC chair for six years. David Buck, M.D., M.P.H., president and founder of Healthcare for the Homeless— Houston, received the Public Health Award. Donald Briscoe, M.D., program director of the Methodist Hospital Family Medicine www.tafp.org

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TAFP’s newly installed officers for 2012-2013 from left: President-elect Clare Hawkins, M.D.; Vice President Ajay Gupta, M.D.; Parliamentarian Tricia Elliott, M.D.; President Troy Fiesinger, M.D.; and Treasurer Dale Ragle, M.D.

Residency in Houston, received the Exemplary Teaching Award. And Linda Siy, M.D., of Fort Worth, was awarded the Special Constituency Leadership Award. Attending as the Academy’s invited guest, Stream presided over the installation of TAFP’s new officers who will lead the Academy in 2012-2013. The new TAFP officers are: President Troy Fiesinger, M.D., of Sugar Land; President-elect Clare Hawkins, M.D., of Baytown; Vice President Ajay Gupta, M.D., of Austin; Treasurer Dale Ragle, M.D., of Dallas; and Parliamentarian Tricia Elliott, M.D., of Houston. In his presidential address, Fiesinger acknowledged that the health care system is in the midst of a painful transformation. “We stand with our patients at the middle of this storm 30

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Top right: TAFP Past President Edwin Franks, M.D., is named TAFP Foundation Philanthropist of the Year. Pictured from left: Troy Fiesinger, M.D.; Edwin Franks, M.D.; I.L. Balkcom IV, M.D.; and Dale Moquist, M.D.

of abbreviations and acronyms: ACA, ACO, PCMH, EHR, and [the] Medicaid 1115 waiver.” “It is easy to get frustrated by the changes hitting us daily, but I urge you to channel your anger into action. We understand better than most the reality on the ground—and what our patients need.” Our patients deserve our best, he said, adding that there’s nothing he would rather be doing than pushing each day to get his patients the health care they need. In his outgoing presidential address, I.L. Balkcom IV, M.D., recalled a pivotal moment in his residency and advised all future physicians in training and in their careers to be the very best family physician they can be. “You don’t need to shirk a rotation because ‘I’m not going to do that.’ I’ve heard

that a little bit lately from some of the residents that rotate: ‘I’m not going to practice OB, so why should I know anything about it?’ ... So I want to encourage our students, our residents, and anyone else here in practice today: Never, ever quit being the best that you can be as a family physician.” Consistently the conference’s most anticipated event, the President’s Party took place this year at the Bob Bullock Texas State History Museum. Revelers were treated to several tastes of Texas and serenaded by Austin’s own country music singer and songwriter Kelly Willis. 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


Highlights from the TAFP Board of Directors meeting | July 14, 2012 The Texas Academy of Family Physicians Board of Directors met on Saturday, July 14, 2012, to hear reports and recommendations from TAFP’s committees, commissions, and sections. Below are the highlights of the meeting, which included greetings from AAFP President Glen Stream, M.D., M.B.I., and a presentation by TMA President Michael Speer, M.D. ■ TAFP Foundation Board of Trustees The Foundation announced a new student interest endowment to provide support for preceptorship stipends, student travel, and FMIG activities. Within the endowment there will be separate champion funds, including the Lewis Foxhall Champion Fund. ■ Executive Committee The board approved a recommendation that TAFP move the Annual Session and Scientific Assembly to late fall beginning in 2015. This change is expected to increase registration and engage more medical students and residents. The board also approved a recommendation that TAFP provide additional funding to the Texas Medical Home Initiative. ■ Finance Committee The board approved the proposed fiscal year 2013 operating budget. ■ Nominating Committee The board elected the slate of directors and alternates presented by the Nominating Committee. They also approved a recommendation to nominate four members to AAFP commissions.

Bottom right: At center, Justin Bartos, M.D., receives the Texas Family Physician of the Year Award.

state in 2012 to help ABFM diplomates make progress toward maintenance of certification. See dates and details on the Upcoming Events page of TAFP’s website, www.tafp.org/ professional-development/events. TAFP offers two Primary Care Summit conferences this fall; Primary Care Summit – Houston will be held at the Westin Oaks in Houston Oct. 26-28, and Primary Care Summit – Dallas/Fort Worth will be held at the Westin Galleria Dallas Nov. 2-4. Registration for both programs is now open. The 2013 C. Frank Webber Lectureship will be held Friday, March 1, at the Omni Austin Hotel at Southpark, and the 64th Annual Session and Scientific Assembly will be held July 31-Aug. 4, 2013, at the Omni Fort Worth Hotel and the Fort Worth Convention Center.

■ Commission on Academic Affairs The commission discussed the Section on Medical Students’ need for a forum to connect and share best practices on the state level. The idea of a statewide presence was discussed during the commission meeting, leading to the creation of the Texas FMIG Network Facebook page. ■ Commission on Continuing Professional Development Clare Hawkins, M.D., gave an update on the AAFP Commission on Continuing Professional Development. ■ Commission on Core Delegation The commission discussed the work of the various AAFP commissions. Lloyd Van Winkle, M.D., discussed his campaign for a position on the AAFP Board of Directors. The commission also discussed resolutions introduced from other state chapters. ■ Commission on Health Care Services and Managed Care The board approved a recommendation that TAFP bring forward a resolution to the AAFP Congress of Delegates entitled: “Review Payment Reform Model Generated by a Family Physician in the CMS Innovation Advisors Program.” The commission unanimously agreed that this be forwarded to AAFP for further study. ■ Commission on Legislative and Public Affairs In lieu of a commission meeting, TAFP offered the legislative and leadership training. Attendees heard renowned policy experts give an overview of the primary care workforce, and present demographic, geographic, and policy challenges under consideration by our elected

officials. They received instruction from topnotch grass-roots consultants who provided practical advice on how to advance the cause in their own district. ■ Commission on Public Health, Clinical Affairs, and Research The board approved recommendations that TAFP include pain management education in future symposia and that TAFP staff disseminate information on drug reclamation events. The board approved a recommendation that TAFP ask AAFP to provide education for physicians on pain management. The board also approved a recommendation that TAFP submit a resolution to AAFP to petition CMS and other payers to permit reimbursement of mental health disorder counseling by licensed professional counselors with family physician co-management, without psychiatrist involvement. ■ Task Force on Governance The Task Force presented the diagram of a possible governance new structure; the board discussed the structure. ■ Section on Special Constituencies The section selected Lindsay Botsford, M.D., to serve on the TAFP Executive Committee and Terrance Hines, M.D., to serve on the TAFP Board of Directors. ■ Other Board action The board elected Adrian Billings, M.D., and Jake Margo, M.D., to the TAFP Executive Committee and Jorge Duchicela, M.D., to the Nominating Committee. The board discussed resolutions that other state chapters have recommended to AAFP.

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, 2012. The TAFP bylaws can be viewed at www.tafp.org/media/default/ downloads/membership/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 2013 Interim Session meeting on March 2, 2013. 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 2013.

www.tafp.org

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Foundation Focus Be a champion for family medicine’s future

Professional Development

By Kathy McCarthy we can all agree that Texas needs more family physicians. One of the ways we get there is for more medical students to choose family medicine as their specialty. We have evidence showing that early exposure to primary care makes a huge difference in the specialty choice of medical students. The Texas Statewide Family Medicine Preceptorship Program has been a key part of that early exposure since 1980. Over 4,000 pre-clinical medical students have participated in the program. When the program lost state funding last year, a huge need was created. Texas family physicians know the value of this program. So many of you have participated as a preceptor, preceptee, or both. TAFP leadership quickly decided that they could not stand to let this program disappear. TAFP took over the administrative support for the program, but the state funding was largely used to fund stipends for first- and second-year medical students who apply to spend two weeks to a month with a family physician. TAFP staff matched interested students in 2012, but there was no funding for the stipends. We know the funding is a critical element for medical students deeply in debt so our new task is to restore the stipends in 2013. The TAFP Foundation has taken up the cause to build support for the stipends. The TAFP Foundation Board of Trustees created the student interest endowment at their

most recent meeting and provided funding for the Lewis Foxhall Student Interest Champion Fund to honor the longtime program director who helped shepherd the program to TAFP. Seeing the need, Dr. Leah Raye Mabry asked the Foundation Board to move the money she had donated to establish a scholarship to the Student Interest Endowment creating the Platinum Level Leah Raye Mabry Student Interest Champion Fund. The endowment will provide a stable source of support for the stipends as well as student travel funding to attend family medicine meetings and funding for interest groups at Texas medical schools. At its current level, it will provide enough funding for about five students in 2013. We need your help to increase that funding. You can donate to support the Foxhall or Mabry Fund, make a general donation to the endowment, or create a champion fund in your own name. Leave a legacy and show that you support the next generation of family physicians. Donate $5,000 to establish a bronze level champion fund (it can be donated over five years). Whether you can spare $5 or $5,000, donate today and show your support for this valuable program. Visit the TAFP Foundation webpage for a donor form or simply mail a check to 12012 Technology Blvd, Ste 200; Austin, TX 78727. Call me at (512) 329-8666, ext. 14 with any questions.

2012 Foundation awards scholarships Congratulations to the future family physicians who were awarded medical student scholarships this year. Allison Peddle and Kimberly Aparicio – William F. Ross, M.D. Scholarship David Aldrete, Hugo Salazar, and Matthew Mullane – Valley Chapter Scholarship Zachary Marshall and Stella L. Benavides – Harold T. Pruessner, M.D. Scholarship Clinton Borchardt and Alyssa Adkins Tochterman – Norma Porres, M.D. and Felipe Porres, M.D. Scholarship Zachary Taylor, M.D. – S. Perry Post, M.D. Scholarship 32

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Amber Higgs, M.D., and Eliezer Castaneda – Glen R. Johnson, M.D. Minority Scholarship Geoffrey Moses, Rachel Marinch, and Amber Higgs, M.D. – Weldon G. Kolb, M.D. Scholarship Amy Thorne and Kevin Sisk – Arnold N. Krause, M.D. Scholarship Francis Goldshmid – Minnie Lee Lancaster, M.D. and Edgar Lancaster, M.D. Scholarship Danish Ali and Amy Thorne – South Texas Chapter Scholarship In addition, Richel Avery, M.D., and Elilta M. Hagos, M.D., received the first Cassie Murphy Cullen, Ph.D. scholarships to present their research at national conferences.

To help members meet the educational requirements of licensure and obtain and maintain board certification, TAFP offers continuing medical education and Self-Assessment Modules. For more information, go to www.tafp.org. SAM Group Study Workshop on Care of the Vulnerable Elderly Dec. 8, 2012, 9 a.m. - 2 p.m. Westin La Cantera, San Antonio SAM Group Study Workshop on Hypertension Dec. 8, 2012, 9 a.m. - 2 p.m. Sheraton Fort Worth, Fort Worth SAM Group Study Workshop on Mental Health in the Community Feb. 28, 2013, 10 a.m. - 3 p.m. Omni Austin Hotel at Southpark, Austin 2013 C. Frank Webber Lectureship March 1, 2013 Omni Austin Hotel at Southpark, Austin SAM Group Study Workshop on Pain Management July 31, 2013 Omni Fort Worth Hotel, Fort Worth SAM Group Study Workshop on Well Child Care July 31, 2013 Omni Fort Worth Hotel, Fort Worth 64th Annual Session & Scientific Assembly July 31 - Aug. 4, 2013 Omni Fort Worth Hotel and Fort Worth Convention Center, Fort Worth 2013 Primary Care Summit – Houston Oct. 18-20, 2013 Westin Oaks Hotel, Houston 2013 Primary Care Summit – Dallas Nov. 8-10, 2013 Westin Galleria Hotel, Dallas


public health

Head Injuries in the Young Athlete Walter L. Calmbach, M.D., M.P.H. Department of Family and Community Medicine, UT Health Science Center at San Antonio Mark Hutchens, M.D. Texas Sports and Family Medicine, Austin Background—Approximately 30 million children and adolescents participate in organized sports in the U.S. each year, and between 1.6 and 3.6 million young athletes suffer a concussion each year. As many as 53 percent of high school athletes report a history of at least one concussion, and 36 percent of college athletes report a history of multiple concussions.1 Higher risk for young athletes—To make matters worse, children seem to be more vulnerable to the effects of brain injury than adults. After concussion, there are specific changes at the cellular level resulting in a “metabolic mismatch”: increased glucose utilization and reduced cerebral blood flow. A full description of the pathophysiological cascade that occurs after concussion is beyond the scope of this brief article, but an excellent summary can be found in the Jan. 15, 2012, issue of American Family Physician.2 Physicians must be aware of the athlete’s increased vulnerability to injury during the recovery period, which typically takes 7-14 days.1 Concussion as a functional disturbance—After a blow to the head or helmet, the athlete commonly experiences the rapid onset of usually short-lived neurological impairment. These include a range of clinical symptoms that may or may not involve loss of consciousness.

The symptoms could be very subtle, such as lack of focused concentration or balance disturbance. Typically, these symptoms resolve spontaneously. It is important to recognize that these acute clinical symptoms reflect a functional disturbance rather than structural injury. Because of this, neuroimaging studies are typically normal.3 Major paradigm shift—Over the past few years, concussion management has undergone a major paradigm shift. In the past there was an overreliance on published guidelines, which were not uniform, lacked prospective validation, and over-emphasized loss of consciousness as a marker of severity. However, published guidelines remain useful as a starting point when evaluating athletes. Importantly, outdated guidelines once allowed for same-day return-to-play, but the new consensus is that there is no same-day return-to-play for an athlete with a concussion. We now recognize the broad individual variation in presentation and recovery after concussion. Therefore, sports medicine physicians recommend individualized management based on the athlete’s signs and symptoms, guided by routine use of standardized assessment tools. Some of these common assessment tools include the Standardized Assessment of Concussion (SAC), the Sports Concussion Assessment Tool v2 (SCAT2), the Balance Error Scoring System (BESS), and computerized tools such as the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT).4 The SAC is a simple paper-and-pencil scoring tool that helps the physician assess orientation, immediate recall, common neurological symptoms, concentration (both numbers and months), and delayed recall. The athlete receives a total score that guides diagnosis, management, and return-to-play decisions. www.tafp.org

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ONLINE RESOURCES Centers for Disease Control www.cdc.gov/concussion/

well as a “Concussion Management Protocol Return-to-Play Form,” to be signed by a school official and the parent or guardian.

National Collegiate Athletic Association www.ncaa.org/wps/wcm/connect/public/ncaa/ health+and+safety/concussion+homepage/ concussion+landing+page American Academy of Pediatrics http://pediatrics.aappublications.org/content/126/3/597 University Interscholastic League www.uiltexas.org/health/info/concussions

Neurocognitive testing—Tools such as ImPACT measure concussion-related symptoms, verbal and visual memory, processing speed, and reaction time. They can be administered online for individuals or groups, and can store data for repeat testing. They can objectively evaluate post-injury status, and track recovery for safe return to play, especially if baseline testing is present. Neurocognitive testing is useful as one component of the evaluation, but should not be used by itself to manage or make return-to-play decisions. It can be helpful in the overall management along with past history, co-morbid states, symptoms, physical exam, and social environment. UIL changes, standardized return-to-play protocol House Bill 2038 initiated significant changes to the Texas Education Commission section 38, specifically mandating the creation of a concussion management team at each UIL-aligned school district. One of their tasks will be to create a return-to-play protocol that describes in detail the steps an athlete must follow before they are allowed to resume full athletic competition. The UIL also requires a “Concussion Acknowledgement Form” to be signed by the student and parent or guardian, as

No such thing as a “minor head injury”—Physicians should take every concussion seriously. The concussed athlete has a decreased ability to process new information, and the degree of their impairment is proportional to the severity of the injury. Moreover, symptoms worsen with repeated injury (the so-called “cumulative concussion”). Thus, no head injury is minor; all need prompt evaluation before return to play. In summary—Sports-related concussion is common, accounting for 5.5 percent of all injures. Family physicians must be aware of the special circumstances of the young athlete, who are at greater risk of injury, and tend to recover more slowly than adults. When possible, preseason baseline cognitive assessment is recommended (e.g., with the paper-and-pencil SAC or the computerized ImPACT or similar program). When managing an athlete post-concussion, the physician should follow a structured follow-up and return-to-play protocol. Finally, as primary care physicians we have a special responsibility to protect young athletes: “When in doubt, sit them out.”

References 1. Lovell MR, Fazio V. Concussion management in the child and adolescent athlete. Curr Sports Med Rep 2008; 7(1): 12-15. 2. Scorza KA, Raleigh MF, O’Connor FG. Current concepts in concussion: evaluation and management. Am Fam Phys 2012; 85(2): 123-132. 3. American College of Sports Medicine. Concussion (mild traumatic brain injury) and the team physician: a consensus statement. Med Sci Sports Exerc 2006; 38; 395-399. 4. Halstead ME, Walter KD. Clinical report – sport-related concussion in children and adolescents. Pediatrics 2010; 126(3) 597-616.

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[FALL 2012]

TEXAS FAMILY PHYSICIAN


practice management

Compliance and documentation: Lessons learned By Bradley Reiner i’ve been a practice management consultant for 13 years. I worked 10 years for the Texas Medical Association. I’ve been a contract administrator and still have that role today. I review cases for the Texas Medical Board and I’m endorsed by TAFP. Over the last 20 years, I’ve seen significant changes in health care, but the most dramatic compliance changes have occurred in the last couple of years. The auditing efforts of the state and federal government as well as managed care plans have significantly increased. RACs, ZPICs, and MICs are dominating discussion. Throw in HIPAA, OSHA, and CLIA and you have so many acronyms and issues to contend with every day. Unfortunately these things are not going away. So you find yourself asking, what can you do? I’m not one to jump on any bandwagon when it comes to these things. In fact, when HIPAA first came out in 2003, I was skeptical about implementing so many policies and procedures if they were going to sit on the shelf gathering dust with no one monitoring them. I had the same feeling initially with OSHA and CLIA. As long as you had a system that was consistent, ethical, appropriate, and legal, why

would you waste time and money to have every single policy in writing? It seemed to be nothing more than an easy way for vendors to make money. Documentation and coding was no different. I figured if physicians documented based on the services provided and ensured due diligence, they would be protected. Besides, nobody was really watching these guidelines anyway. Wow, what a big difference a few years can make. Don’t get me wrong, I believe that compliance is important and I have always counseled the practices I’ve helped to maintain excellent compliance. Realistically, how can any practice be expected to keep track of all of these things and do it correctly every single time? Whether we think it can be done or not is irrelevant. Insurance companies and regulatory agencies expect it now more than ever. With the potential opportunity to recover millions of dollars in improper payments, documentation and coding have taken center stage. All types of insurance plans—managed care, state, and federal programs—as well as patients are beginning to advocate for compliance. www.tafp.org

[FALL 2012]

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DON’T SKIMP

So when should you begin a full-scale compliance plan to ensure your practice is protected and doing all it can to reduce documentation and coding weaknesses? Can you start on it yesterday? While you are working on that, here are my “don’t skimp” items every practice should consider when establishing a compliance plan. You need clear documentation of your policies and procedures. There are a number of sources for developing compliance strategies and plans for your practice. Your Academy has policies and procedures that can be downloaded and implemented. Another source to consider reviewing is the OIG’s compliance program for individual and small group practices. This is a seven-step process for implementing compliance in your practice. These days you must ensure that you have a policy and procedure for everything you do as well as plans for how you correct problems when discovered. These processes will help protect your practice.

Don’t Skimp on compliance policies.

36

Don’t Skimp on under­ standing proper documen­ tation.

Many physicians don’t even realize there are guidelines, developed by the AMA and CMS, for proper documentation of evaluation and management services. There are two guidelines for doctors to use, 1995 and 1997. More practices use the 1997 guidelines because the information is more detailed. Including detailed information in your record is better than not having enough documentation. You must make sure it’s consistent with the nature of the presenting problem.

Don’t Skimp on under­ standing coding specifics.

One office visit level makes a huge difference in documentation and revenue. Did you know that a new patient midlevel code (99203) and an established midlevel code (99213) require a completely different amount of information documented in the medical record? New patients require a substantially larger amount of information documented because the patient has no history in the chart. Many physicians I have trained believed level three new and established codes required the same amount of information. I find many level three new patient office visits that do not meet the guidelines due to poor or limited documentation. Physicians need to understand the difference.

Don’t Skimp on external auditing.

Have you ever had an outside party review your records to determine if your documentation is in compliance? If you haven’t had this done you should consider hiring someone to complete an audit. What you find may amaze you. Documentation errors and misunderstandings about the guidelines can be corrected, but if no one is monitoring, the same errors will continue to occur. This can lead to huge overpayments which cause insurance audits that necessitate refunds. It’s not a matter of if you will be audited, it’s when.

Don’t Skimp on staff.

Make sure you have intelligent and knowledgeable staff. This cannot be emphasized enough. Staff often make or break a practice. Billing staff must have a strong billing background with coding experience. Compliance issues can cost thousands of dollars and good staff can help you avoid these problems. If you have good staff, compensate them well so they won’t leave for greener pastures.

Don’t Skimp on self-dis­ closure.

If you find something wrong, document it based on your compliance plan and refund any amounts overpaid. Don’t wait for insurance companies to find problems. If they discover problems things could end up being much worse. Be proactive while maintaining compliance. This will impact your practice in many positive ways even if you are audited.

Don’t Skimp on educa­ tion and training.

Doctors and staff need continual education and training. Once you have completed an independent audit, investigate any problems needing correction. Train doctors and staff on the concerns and steps necessary to improve. Follow up to ensure the issues have been corrected. Then train again. This training will help the practice meet its obligations of sound compliance strategies while correcting problems.

Don’t Skimp on admit­ ting when you make mistakes.

Don’t ignore problems. Take whatever actions are necessary to correct the problem. You will sleep better at night.

[FALL 2012]

Compliance and documentation go hand in hand. Implement procedures and policies to help protect your practice against insurance companies and their associated audits. A little bit of effort will be worth the trouble. Follow these few simple suggestions and I am certain you will be happy you did.

TEXAS FAMILY PHYSICIAN


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perspective

Nurse practitioners are no substitute for physician-led team By Roland Goertz, M.D., M.B.A.; Chair, AAFP Board of Directors

discerning purchasers of health care when they don’t know the facts. Many patients, however, already express a preference for physicians. According to a recent AMA patient survey, 86 percent of respondents said that they benefit when a physician leads a primary care team, and 75 percent said they prefer to be treated by a physician— even if it takes longer to get an appointment. At a time when AAFP is advocating a team-based approach to health care to improve outcomes • The nursing field faces its and lower costs, some nurse pracown deficit with a shortage of titioners are eager to go it alone. 260,000 nurses projected for Our report makes a strong state2025. You can’t fill a gap with ment that the patient-centered something else you lack. medical home model is designed • Though some have supported to be run with a physician leading the idea of independent nurse a team of health care profespractitioners because of the sionals. A recent report by the lower costs involved with Patient-Centered Primary Care training and employing nurses, Collaborative offers more than the approach fails to consider 30 examples of public and private that those savings may be offpayers finding that better care, set by decreased productivity better outcomes, and lower costs and less efficient use of staff are possible in the PCMH model. resources. Specifically, team-based care has • Granting independent practice been proven to reduce emergency to nurse practitioners would room visits, hospital admissions, create two classes of care: one Access the report online: and total inpatient stays. run by a physician-led team bit.ly/21st-century-primary-care The PCMH gives patients and one run by less-qualified access to physicians, nurse health care professionals. Phypractitioners, physician assistants, and other health care sicians are required to complete roughly 16,000 more professionals. Together, these health care professionals hours of training than nurse practitioners. can complement each other with their experience and expertise. The Academy addressed all these issues when it Finally, the report stresses that national workforce released a report—with support from the American policies are needed to ensure adequate supplies of family Academy of Pediatrics, the AMA, and the American physicians and other health care professionals to improve Osteopathic Association—that explains in detail the access to quality care and avert the anticipated shortages differences in training and clinical expertise between of primary care physicians and nurses. Wholesale substiphysicians and nurses, why a team-based approach is tution of non-physicians for physicians is not, and should preferable, and why substituting non-physicians for not be, an option. physicians just won’t work. Our report is intended, in part, to educate the public Source: AAFP News Now, Sept. 19, 2012, © American Academy of Family Physicians. about those differences in training. Consumers are not by the year 2020, our nation is expected to face a shortage of 45,000 primary care physicians. To address this shortfall, as well as rising health care costs, the nation is seeing a movement to grant independent practice to nurse practitioners. But, this flawed, stop-gap approach overlooks some obvious obstacles to replacing physicians with non-physicians. For example:

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[FALL 2012]

TEXAS FAMILY PHYSICIAN


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