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How A Group Of Family Doctors In Rural North Texas Fought And Won To Regain Their Obstetric Privileges texas family physician VOL. 64 NO. 4 FALL 2013



Compliance Audits: 5 Mistakes You Should Avoid HIPAA: Do You Know Who Your Business Associates Are?


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residency program wins poster competition. | TAFP changes governance structure. | San Antonio physician joins IOM.


27 HIPAA COMPLIANCE Do you know who your business associates are?

A labor of love

In a time of narrowing scope for family medicine, four family physicians in a rural north Texas town fought to keep obstetrics in their basket of services.

By Jonathan Nelson


2013 Annual Session in review

Physicians from across the state gathered in Fort Worth for a weekend full of education, TAFP business meetings, and camaraderie. Pictures and full report inside. 6 PRESIDENT’S LETTER Meet your new president, Clare Hawkins, M.D., M.Sc. and read an excerpt from the 2013 incoming presidential address.

10 NEWS IN BRIEF Health care properties are hot commodities in real estate. | Physician group practices spend more on HIT. | Private health insurance premiums to rise for Texans. | FPs top list of most recruited doctors. | New primary care workforce numbers 16 MEMBER NEWS AAFP hires TAFP member. | Two TAFP members appointed to AAFP commissions. | Memorial

29 COMPLIANCE AUDITS 5 mistakes you should avoid to keep the auditors at bay. 31 RESEARCH Adolescent bone density, breast feeding, and birth control intent in the immediate postpartum period 36 TAFP PERSPECTIVE A better way to value family physicians’ work 38 NUTRITION Prescribe breakfast for improved health and wellness.

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president’s column

TEXAS FAMILY PHYSICIAN VOL. 64 NO. 4 FALL 2013 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. Texas Family Physician is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or Officers president

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

president-elect vice president treasurer

Dale Ragle, M.D.

Tricia Elliott, M.D.

Ajay Gupta, M.D.


Janet Hurley, M.D.

immediate past president

Jonathan L. Nelson

associate editor

Samantha White

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, C.A.E.

advertising sales associate

Michael Conwell Contributing Editors Katie Barckholtz, M.P.H., R.D., L.D. Bradley Reiner Julie Sheppard, B.S.N., J.D., C.H.C. Sally P. Weaver, Ph.D., M.D. Richard Young, M.D.

subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publica­tion of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by The Whitley Company, Austin, Texas. legislative advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2013 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

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An excerpt from the 2013 incoming presidential address By Clare Hawkins, M.D., M.Sc. TAFP President

Troy Fiesinger, M.D.

Editorial Staff managing editor

Let’s work together to keep our Academy and our specialty strong in a time of great change


Instead of lecturing you on health care change is inevitable. We can change or die. reform, I’d rather give you a snapshot of how As family physicians, we can lead the coming I parachuted into this moment of change. change in our health care delivery system. In June 2012 I became a U.S. citizen and am Charles Darwin said, “It is not the strongest proud of my adoptive of the species that surstate. As many have said vives, nor the most intelbefore me, I wasn’t born ligent that survives. It is in Texas but I got here the one that is the most as fast as I could. It has adaptable to change.” The changing face been a privilege to live All of U.S. health care of Texas needs family and work in such a welis going through promedicine. After all, we coming state. found and uncharted My biggest recent changes as we travel are the only specialty change is that the resithrough health care rethat is defined by our dency program with form. AAFP and TAFP ecology. We are not which I have been dihave been working with rector for 15 years, Legfamily physicians for a defined by a body part, acy Community Health, decade leading the way by a disease, or by a is now a federally qualito a system of primary gender. We care for all, fied health center. This care which maximizes allows us to provide a the efficiency and effecfor whoever comes greater range of servictiveness with which we to see us regardless es for our underfunded can serve our patients of what is wrong patients, but has posed to remain healthy or a lot of transitional get well. This has inwith them. challenges for our faccluded the Future of ulty and residents. Family Medicine project, As American jourTransforMED, and the nalist and writer Gail patient-centered mediSheehy said, “If we don’t change, we don’t cal home movement. grow. If we don’t grow, we aren’t really living.” Most recently it has involved advocacy with What is clear about health care reform is government and private industry to recognize that how we will all move forward from here and reward the value we provide to the health is unclear. Will the health insurance exchanges system. Our state and national academies work? Will the federal mandate for insurance continue to work with our members to better hold? Will the number of uninsured shrink? understand how to evaluate the strengths of Will Medicaid ever expand in Texas? With so independent practice or joining a large group. much unclear, we need a strong TAFP now The Academy continues producing programs more than ever, to help us not only react to to understand accountable care organizations the change, but to lead the change. and integrated clinical networks .

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TAFP’s advocacy efforts were central to regaining such important ground in the 83rd Legislature. Through the advanced strategy of our CEO Tom Banning and our strong physician leadership, your Academy drafted legislation well in advance of the session, putting us in an excellent position to make our case to legislators. In an ever-changing landscape, we succeeded in mending the women’s health care safety net; we achieved the partial restoration of graduate medical education funding for family medicine residencies; we secured funding for new residency positions; and we helped convince the Legislature to recommit to the promise of the Physician Education Loan Repayment Program. One year is not enough time to accomplish all the things I hope to do for our Academy, but with the help of our excellent physician leadership and our capable and talented staff, I am confident we will have a fantastic year. As president, I’m aware that the Academy staff is the steady feature which preserves continuity. I have been a member of the Executive Committee for nine years and am consistently impressed with the caliber of our staff. Even as our chapter changes and grows, we maintain a strong ethic of member service and are frequently polling our leaders and members to try to improve. Our board structure has just gone through a metamorphosis that will increase our efficiency and effectiveness, and within the next couple of years, we will change our major meeting schedule to make them better and more accessible to our members. To help manage political change outside of TAFP, at the state and local level,

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


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AAFP board member Daniel Spogen, M.D., leads TAFP’s newly inducted president, Clare Hawkins, M.D., M.Sc., in the presidential oath of office.


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we are fortunate to have a nimble and adroit political advocacy team. Even though this is not a year when the Texas Legislature will be in session, the interim provides an opportunity to lay the advocacy groundwork for the session in 2015. We will seek to expand our state’s primary care workforce and preserve the scope of family medicine. We will advocate for the full restoration of GME funding, including renewed state investment in family medicine preceptorships. And we will work to preserve the sanctity of the patient-physician relationship by arguing against laws which would prevent our ability to discuss gun safety, family planning, and other important public health issues. Another area of constant change for our Academy is one of our core missions, the provision of continuing medical education. For the last 15 years, I’ve been part of the team that plans educational programming for the Academy, and I have been continually impressed with the work of our Academy’s director of professional development, Jessica Miley, to deliver high-quality programming with the help of the TAFP Commission on Continuing Professional Development. Together with the AAFP

Commission on Continuing Professional Development, we want to streamline educational opportunities for our members and help them maintain board certification and state licensure. In this, we will continue to change and improve. And for our patients, it is my hope that as TAFP serves family physicians in Texas, there will be a direct benefit to the families of this great state. The changing face of Texas needs family medicine. After all, we are the only specialty that is defined by our ecology. We are not defined by a body part, by a disease, or by a gender. We care for all, for whoever comes to see us regardless of what is wrong with them. We advocate for health care for all, and we do all that we can to heal our patients. When our patients cannot get better, as often happens, we remain with them and their families. As the old medical adage goes, “To cure sometimes, to relieve often, to comfort always.” God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. I would like to ask for your assistance in working with me to make our Academy ever stronger and to help make our state a better place to live.

Clare Hawkins, M.D., M.Sc., is the program director of the Houston Methodist Family Medicine Residency Program at Legacy San Jacinto in Baytown, Texas. He is board-certified in family medicine and board-certified in palliative care, and holds a master’s degree in Community Health Science. After receiving his medical degree from the University of Manitoba, Dr. Hawkins completed residency at St. Boniface Hospital in Winnipeg, Canada, in 1986. He became a faculty member at St. Boniface shortly after residency and became program director there in 1995. In 1998 he relocated to Baytown to join the San Jacinto program. His special medical interests are palliative care, COPD, asthma, obstetrics, pediatrics, and outpatient surgical procedures.


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Growing and aging population means Texas needs more family docs Texas needs an additional 6,260 primary care physicians by 2030 just to maintain the state’s current ratio of PCPs to population, according to a 2013 report by the Robert Graham Center. That’s a 47 percent increase above the 13,139 primary care physicians practicing as of 2010. With 1,913 Texans for every PCP, Texas lags behind the national average of 1,463:1. According to the report, “Pressures from a growing, aging, increasingly insured population call on Texas to address current and growing demand for PCPs to adequately meet health care needs. Policymakers in Texas should consider strategies to bolster the primary care pipeline including reimbursement reform, dedicated funding for primary care graduate medical education, increased funding for primary care training, and medical school debt relief.

Health care property hot commodity in time of ACA uncertainty Despite Affordable Care Act confusion throughout the health care industry, real estate investors are profiting from medical office buildings. Real estate management firm Jones Lang LaSalle reports that 124 medical office properties sold during the first half of 2013, totaling more than $1.83 billion. Mindy Berman, the firm’s health care capital markets group managing director, says investors realize there is uncertainty in the world of medicine, but they “believe healthcare reform can and will be managed.” The average sale included a 74,750-square-foot property going for $14.8 million. Source: “Real Estate Investors Reaping Benefits of Healthcare Reform.” D Healthcare Daily. Sept. 11, 2013.

Source: “Texas: Projecting Primary Care Physician Workforce.” The Robert Graham Center. September 2013.


increase in family medicine group practices’ spending on information technology from 2008 to 2012, averaging to an annual increase of 4.5 percent Source: “Information Technology Costs for Physicians Top Inflation.” Medscape Medical News. Sept. 13, 2013. 10

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The predicted average increase on private health insurance premiums for Texans enrolled in the individual market by 2016 due to the state’s refusal to expand Medicaid. Because low-income people tend to have worse health than their wealthier counterparts, their enrollment in private exchanges will raise costs. Had Texas expanded Medicaid this year, the percentage of nonelderly uninsured Texans would have dropped by 2016 from 28.2 percent to 12.4 percent. Source: “The Affordable Care Act and Health Insurance Markets; Simulating the Effects of Regulation.” Rand Corporation.

Family docs are health care’s quarterbacks Family physicians once again top the list of most recruited doctors, according to a new survey from physician search firm Merritt Hawkins. This is the seventh straight year family physicians have been number one on the list and general internal medicine physicians have been ranked second. Merritt Hawkins President Mark Smith believes the demand for primary care doctors is due to a growing number of health care service sites. “The new mantra in healthcare is to be ‘everywhere, all the time,’” says Smith. “This means reaching into communities with a growing number of free-standing facilities or other sites that are convenient and accessible. These facilities have one thing in common— they all need primary care physicians.” Smith also attributes the demand for primary care doctors to their perceived role as health care’s “quarterbacks,” due to their responsibility for improving care quality and lowering costs. Source: “Family Physicians Again Top ‘Most-Recruited’ List.” D Healthcare Daily. Aug. 30, 2013.

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Clockwise from left TAFP President Troy Fiesinger, M.D., gives the presidential scroll to incoming president Clare Hawkins, M.D., M.Sc. TAFP’s incoming president Clare Hawkins, M.D., M.Sc., presents the Physician Emeritus award to Justin Bartos, M.D., on behalf of David Pillow, M.D.

Tim Lambert, M.D., is given the TAFP Foundation Philanthropist of the Year award by TAFP President Troy Fiesinger, M.D., and Foundation President Dale Moquist, M.D. Jasmine Sulaiman, M.D., poses with friends and family after being named the 2013 TAFP Family Physician of the Year. George Zenner, M.D., is given the Physician Emeritus award.

Report from TAFP’s 64th Annual Session & Scientific Assembly

Family docs gather in Fort Worth By Samantha White Photos by Jonathan Nelson and Samantha White

more than 400 family physicians and other health professionals met in Fort Worth in early August to network, learn, and celebrate the specialty of family medicine at TAFP’s 64th Annual Session and Scientific Assembly. Attendees earned CME, shaped TAFP policy at committee and commission meetings, and networked with medical industry leaders in the exhibit hall, all while visiting with old friends and making new ones from across the state. See more of our favorite photos from the weekend’s events on the TAFP Facebook page at As always, attendees had opportunities all weekend to learn about a variety of topics during the scientific portion of the conference. This year’s general assembly lectures 12

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took place Friday, Aug. 2, through Sunday, Aug. 4, and were given by a range of distinguished faculty. Participants also had the opportunity to attend three Self-Assessment Module workshops Wednesday and Thursday on diabetes, well child care, and pain management. The National Procedures Institute offered one of its most popular courses, Allergy Testing and Immunotherapy for Primary Care Physicians, on Thursday, Aug. 1. This year’s Scientific Assembly also included two other workshops—Friday afternoon’s GO! Diabetes master class and that evening’s CME dinner and satellite symposium on antiplatelet strategies. The TAFP Foundation held a reception Thursday night at Zambrano Wine Cellar and

Bistro where attendees sipped and learned about three wines with owner and master sommelier Cef Zambrano. The event benefitted the Student Interest Endowment, a fund created in 2012 by the Foundation to support stipends for students participating in the Texas Statewide Family Medicine Preceptorship program. Thank you to Blue Cross and Blue Shield of Texas and Pfizer for being Platinum sponsors; Austin Regional Clinic, CareNow, Texas Medical Association, and Texas Medical Liability Trust for being Gold sponsors; Drs. Justin Bartos, Lewis Foxhall, and Donald Nino for being Silver sponsors; and Drs. Tricia Elliott and Roland Goertz for being Bronze sponsors. The CME general session opened Friday morning with an update on the state Acad-

emy by TAFP President Troy Fiesinger, M.D., and CEO Tom Banning. The rest of the weekend’s continuing medical education included topics on medicating the elderly, overdose deaths in Texas, the implementation of ICD10, and chronic pain. AAFP board member Daniel Spogen, M.D., addressed attendees Sunday morning on the national Academy’s latest updates. Clare Hawkins, M.D., M.Sc., gave a TAFP update during Friday’s Member Assembly Luncheon. Members had the opportunity to ask questions about the Academy’s latest happenings and discuss the proposed bylaws changes that were voted on later in the weekend. Saturday’s Annual Business and Awards Lunch began with members present voting

to adopt the TAFP bylaws changes and new governance structure. You can find the final version of the newly adopted bylaws and related frequently asked questions at www. The Business and Awards Lunch also unveiled the 2013 awardees for TAFP’s top honors and the 2013-2014 officers assumed their new positions. Jasmine Sulaiman, M.D., of Cleveland, was named Texas Family Physician of the Year, the highest honor of the Academy. Dr. Sulaiman is currently the medical director of the Health Center of Southeast Texas, a federally qualified health center, and the associate medical director of Compassionate Care Hospice, both in Cleveland, Texas. Prior to these positions, she held vari-

ous practitioner positions around the state of New York. Her humility was apparent at the awards lunch, saying that she doesn’t “do anything different than any of you other family physicians,” in her acceptance speech. She follows “dharmo rakshati rakshitah” on a daily basis, explaining it to mean “you protect ethics, ethics will protect you.” TAFP honored two doctors this year with the Physician Emeritus award—George Zenner, M.D., and David Pillow, M.D. Dr. Zenner served as director of the Memorial Family Medicine Residency Program from 1978 to 1985, and again from 1996 to 2001. He was also director of the Continuing Medical Education Committee at Memorial Hermann

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Southwest Hospital. Dr. Pillow is a former director of the Family Medicine Residency Program at John Peter Smith Hospital and is an icon in the Tarrant County community. He was ranked first in his class at the George Washington University School of Medicine and is a co-founder of two of the largest family medicine groups in Northeast Tarrant County. Sen. Jane Nelson was honored with TAFP’s Patient Advocacy Award. Nelson has represented parts of Denton and Tarrant counties for more than 10 years and is currently chair of the Health and Human Services Committee. During the 83rd Texas Legislature, Nelson authored Senate Bill 143 which addressed the physician workforce shortage in the state by increasing residency slots and creating incentives for medical schools promoting primary care. The legislation was added on to another bill and passed into law. The TAFP Foundation presented scholarships to medical students and honored Tim Lambert, M.D., as the Philanthropist of the Year. Dr. Lambert’s acceptance speech included a striking statement: “If you cut me, I bleed family medicine.” Receiving the 2013 Presidential Award of Merit was Janet Realini, M.D., of San Antonio, for her work with the Texas Women’s Healthcare Coalition this year. Xavier Mu14

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ñoz, D.O., of El Paso, received the TAFPPAC award for his time spent fostering relationships with his local elected officials to advance the specialty statewide. Nora Gimpel, M.D., director of the Community Action Research Experience and chief of the Community Medicine Division in the family medicine department of UT Southwestern, received the Public Health Award. Professor William Huang, M.D., of Houston, received this year’s Exemplary Teaching Award and Bruce Echols, M.D., of Dallas, received the Special Constituency Leadership Award. Dr. Spogen presided over the official installation of TAFP’s new officers who will lead the Academy in 2013-2014. The new TAFP officers are: President Clare Hawkins, M.D., M.Sc., of Baytown; President-elect Dale Ragle, M.D., of Dallas; Vice President Tricia Elliot, M.D., of Houston; Treasurer Ajay Gupta, M.D., of Austin; and Parliamentarian Janet Hurley, M.D., of Whitehouse. In his presidential address, Hawkins spoke about change—his own personal and professional changes, changes TAFP recently made, and changes involved in the country’s recent health care reform. He also described the things he hopes to accomplish in his year as president, including working with TAFP staff to better the Academy’s annual meet-

ings, laying the groundwork for the next legislative session, and continuing to provide quality CME for TAFP members. “As for our patients, it is my hope that as TAFP serves family physicians in Texas, there will be a direct benefit to the families of this great state,” Hawkins said. In his outgoing presidential address, Fiesinger thanked his family, coworkers, fellow members, and the TAFP staff for making his year as president a successful one. The conference’s most anticipated event, the President’s Party, was a hoe-down that took place at the River Ranch Stockyards. Attendees participated in true Texas events —two stepping and armadillo racing. Be sure to see photos on the TAFP Facebook page of Drs. Hawkins, Ragle, and Fiesinger battling it out in the first heat of races. Mark your calendars now for next year’s symposia. The 2014 C. Frank Webber Lectureship will be held Friday, Feb. 28, at the Omni Austin Hotel at Southpark, and the 65th Annual Session and Scientific Assembly will be held July 24-27, 2014, in San Antonio. TAFP will also offer two Primary Care Summit conferences next fall; Primary Care Summit – Houston at the Westin Oaks Oct. 1719, and Primary Care Summit – Dallas at the Westin Galleria Nov. 7-9.

Left page, clockwise from left

Right page, clockwise from top

AAFP board member Daniel Spogen, M.D., enjoys the President’s Party at the River Ranch Stockyards.

TAFP 2013-2014 officers, left to right: Immediate Past President Troy Fiesinger, M.D.; President Clare Hawkins, M.D., M.Sc.; Vice President Tricia Elliott, M.D.; Parliamentarian Janet Hurley, M.D.; President-elect Dale Ragle, M.D.; and Treasurer Ajay Gupta, M.D.

Attendees compete in a heat of armadillo racing. Thirteen of TAFP’s past presidents were in attendence, and we were lucky enough to get a snapshot. Back row: Lloyd Van Winkle, M.D.; Troy Fiesinger, M.D.; Roland Goertz, M.D.; Justin Bartos, M.D.; Robert Youens, M.D.; I.L. Balkcom IV, M.D.; and Doug Curran, M.D. Front row: Melissa Gerdes, M.D.; Sheri Talley, M.D.; Robert Hogue, M.D.; Linda Siy, M.D.; C Tim Coleridge, D.O.; and Erica Swegler, M.D.

Lloyd Van Winkle, M.D., and Mary Nguyen, M.D., dance during the President’s Party. Winners of the armadillo races celebrate their victories with the armadillo race hosts.

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Member news

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

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

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

SAM Group Study Workshop on Care Transitions March 1, 2014 Omni Austin Hotel at Southpark, Austin

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

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

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


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Amy Mullins, M.D.

TAFP member to head AAFP quality improvement efforts aafp has hired Amy Mullins, M.D., formerly of Whitehouse, Texas, as the new Medical Director for Quality Improvement to provide insight on the patient-centered medical home and quality improvement. She will be a useful resource for state chapters looking for PCMH guidance. “While working in Whitehouse, I was part of the National Demonstration Project from 2006-2008 and medical home has been part of my life since then. I hope to demonstrate

that quality in health care and the medical home go hand in hand. With my past experience in the medical home, I hope to provide practical experience to our membership about this transformation process.” Mullins previously led the PCMH team at Trinity Mother Frances Health System in Whitehouse, Texas, where she worked in various positions since 2002. She received her medical degree from the University of Texas Medical Branch in Galveston in 1999.

Two TAFP members appointed to AAFP commissions two tafp members have recently been appointed by the AAFP. Melissa Gerdes, M.D., was appointed as chair to the AAFP Commission on Quality and Practice and Samuel Mathis was appointed as the AAFP Student Representative to the American Medical Association’s Medical Student Section. Gerdes is a TAFP past president and has previously chaired TAFP’s Commission on Membership and Member Services, the TAFP Finance Committee, and the TAFP Section on Special Constituencies. She also served as new physician delegate to the AAFP Congress of Delegates in 2005-06 and has been on the AAFP Commission on

Practice Enhancement since 2010. Gerdes is currently the AVP and CMO of Outpatient Services and Accountable Care Organization Strategy for Methodist Health System in Dallas. Mathis is a fourth-year medical student at the University of Texas Medical Branch in Galveston. His volunteer experiences include being a founding member of Students Together for Galveston, an organization that coordinates service opportunities for UTMB students, and assisting at a free community clinic run by medical students. He is also a Gold Medal of Achievement recipient and is a scout leader for a local Boy Scout troop.

Memorial Family Medicine Residency Program named a GO! Diabetes research poster competition winner the go! diabetes research poster entitled, “Effect of In-house Retinal Photography on Diabetic Retinopathy Screening Rates,” submitted by Judy Lu, M.D., Rachel Maupin, D.O., and Julie Adkison, Pharm.D., CDE, from Memorial Family Medicine Residency Program in Sugar Land, Texas, was a winning entry at the 2013 GO! Diabetes Summit Research Poster Competition. The competition, held concurrently with the American Academy of Family Physicians Scientific Assembly in San Diego, Calif., had an unprecedented number of research poster finalists representing 16 residency programs from 10 states.

“The GO! Diabetes program has been a tremendous learning experience for me,” says Dr. Lu, a second-year resident. “It’s helped me improve my care to my patients with diabetes and has strengthened my ability to improve my process flow through clinic. I also enjoyed the opportunity to work with and learn from other residents across the country.” Research poster topics were based upon the practice improvement area identified by METRIC, an online quality improvement tool of AAFP. All GO! Diabetes Change Agents who participated in both the education and METRIC data collection compo-

nents of the program were eligible to enter a diabetes research poster. Poster winners now have the opportunity to receive travel stipends if their research poster is accepted by national meetings including the AAFP Scientific Assembly and the American Diabetes Association Annual Meeting. Funded by an educational grant by Sanofi, the GO! Diabetes program enables family medicine residency programs and private practices to identify, initiate, and implement clinical, practice, and system-based quality improvements to enhance their education and care of patients with diabetes. GO! Diabetes was founded in 2008 by the Georgia and Oklahoma chapters of AAFP. If your residency program is interested in participating in a potential 2014 GO! Diabetes program, please contact Susan Reichman, B.S.N., GO! Diabetes program director, at or visit to learn more about the program.

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Member news

San Antonio physician selected to join prominent national institute carlos jaén, m.d., ph.d., was recently among 70 new members chosen to join the Institute of Medicine, a nonprofit organization of more than 1,900 members dedicated to providing impartial advice to government officials and the public. Jaén was asked to join the institute because of his research surrounding community health and patient-centered medical homes. Jaén is currently a professor at and chair of the department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio. His medical interests include improving preventive care, local wellness efforts to improve the public health of his community, and studying highperformance practices. He managed the first large-scale national PCMH demonstration and had results published in the Annals of Family Medicine in 2010. Jaén

is also a former chair of the TAFP Commission on Public Health, Research, and Clinical Affairs and has been involved in publishing national smoking cessation guidelines since 1996. “I am humbled by this election and filled with gratitude toward my mentors, colleagues, friends and family who support my passion for improving health and health care,” says Jaén. “It inspires me to continue working with the next generations of physician leaders and researchers in our journey toward building a more equitable health care system based on primary care.” New members are elected by current active members for their accomplishments in a health field relevant to IOM’s mission and typically have contributed to the progression of the medical field and public health.

TAFP adopts new board structure

good standing given permission by the presiding officer will have the privilege of addressing the assembly.

At TAFP’s 2013 Annual Session, the membership present voted to adopt proposed bylaws changes that put in place a new governance structure. After studying TAFP’s governance structure for three years, the Task Force on Governance made suggestions to improve the operations of the board of directors.

Local chapters can send delegates to the Member Assembly. The number of delegates corresponds to the total number of active members in the chapter. Given the wide variation in activity levels among chapters, the selection process will differ from chapter to chapter. Names of chosen delegates must be given to Academy leaders six weeks in advance of the Member Assembly’s meeting.

The average nonprofit board includes 19 members, a significantly smaller amount than the 53 voting members on TAFP’s old board. A group this large is not ideal for executing legal and fiscal responsibilities typically associated with a board, thus creating TAFP’s new 15 member board of directors. The new board is comprised of TAFP’s six officers and two delegates to AAFP, along with three at-large directors, one new physician, one special constituency member, one resident, and one medical student. While the student, resident, and special constituency members will be recommended by their respective sections, all members will be elected by the Member Assembly. The new TAFP Member Assembly will meet for the first time during the 2014 Annual Session. Assembly members present will receive information from TAFP leaders, hear messages from committee chairs and others who wish to address the membership, and participate in opportunities to address Academy leadership on matters important to members. The Member Assembly will have the power to review policy and act on business referred by the board of directors. While voting is restricted to delegates, any TAFP member in


Carlos Jaén, M.D., Ph.D.

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TAFP’s committees and commissions will still meet twice a year at the Interim and Annual Sessions. Their composition, purpose, and processes will remain mostly unchanged, the only difference being that there will be more time between their meetings and the board meeting to craft recommendations and to conduct additional research on proposed projects and policies. Complete the Make Your Mark form, found at, to indicate your interest in joining a committee, commission, or section. Those wanting to become a delegate to the Member Assembly should contact their local chapter’s leaders or Kathy McCarthy. See a full list of TAFP’s local chapters from across the state at get-involved/local-chapters. TAFP values the participation of all members who have sacrificed to attend meetings in the past. The desire to use volunteer leaders’ time wisely was a major factor in the decision to change the Academy’s governance structure. Since much of the work in addressing member needs is done in committees and commissions, TAFP leaders hope you will attend those meetings.

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a labor of love How four family physicians fought to keep obstetrics in their basket of services By Jonathan Nelson

Womb to tomb. That’s how Shawn White, M.D., describes the brand of family medicine he and his partners practice in the rural north Texas town of Decatur and the communities around there. Cradle to grave. Along with Jeff Alling, M.D., Brad Faglie, M.D., and Lara Pierce, M.D., White considers maternity care an essential part of their busy practice, a part they almost lost when the hospital in town denied them obstetric privileges. “If you want to be a full-service doctor and you want to take care of multiple generations of a family, then obstetrics is a way to keep your practice young and vibrant and to provide that truly full-service family medicine, and that is needed in so many Texas counties,” White says. This is a story about how these doctors fought and won back their privileges, but it’s also a story about the shrinking scope of family medicine in a time of great change. Whether by choice or by constraint, a diminishing number of family physicians deliver babies today. On the 10th anniversary of AAFP’s landmark Future of Family Medicine report, should FPs keep obstetrics in their basket of services?


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From left: Brad Faglie, M.D.; Shawn White, M.D.; Lara Pierce, M.D.; and Jeff Alling, M.D.

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“All the specialists are worried that we’re going to get ourselves in trouble by getting in over our heads, but we are really good as family doctors at knowing when to ask for help. We do it all the time.” — Lara Pierce, M.D.

in 1990, dr. alling began practicing full-scope family medicine in Wise County, 40 miles north of Fort Worth. Since then, he’s delivered more than 2,000 babies. He’s trained family medicine residents in obstetrics and built a thriving practice. Dr. White joined the practice in 1997, and for a while they delivered babies at Wise Regional Health System in Decatur, but the doctors grew to believe the hospital administration’s vision had diverged from their own. “Along about 2002, we started to anticipate the writing on the wall,” Alling says. “[The hospital in] Decatur wasn’t interested in supporting family practice at all.” Later that year, Alling, White, and several other physicians decided to build a new hospital in a town 11 miles to the west, and six years later, they moved their practice to the newly opened North Texas Community Hospital in Bridgeport. Dr. Faglie joined the practice a little later and Dr. Pierce came on in 2012 after completing her residency training. “Then we trekked along, nice and happy, until November of 2012 when the hospital got in financial difficulties,” Alling says. After bankruptcy and reorganization, Wise Regional purchased the hospital and announced they would shut down the maternity ward in Bridgeport. Pierce had delivered five or six babies there, she says, and was beginning to build her practice with about 20 expecting mothers in her care. “I was just getting going and I had to hit the brakes.” One day after the acquisition, she was called to meet with the CEO of Wise Regional to discuss her contract with the hospital. “In the process of talking to me, he said, ‘Oh by the way, I’m sorry about your OB privileges,’ and I was like, ‘What do you mean, my OB privileges?’”

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6/12/11 7:18:42 PM

Then he told her that according to hospital policy, physicians had to be board-certified in obstetrics and gynecology to obtain obstetric privileges. “That was the first any of us had heard.” The policy had been in place since 2009, and according to Wise Regional’s outside counsel, Kevin Reed, it was part of a strategy to transform the hospital from a small, rural facility into one that resembled hospitals in Dallas and Fort Worth, hospitals that focus on specialty care and where family physicians rarely apply for obstetric privileges. Reed says the change was driven by a shift in the region’s population over the last 15 years. “The town of Decatur is small, but the catchment area there is actually very large. It’s really that whole area of suburban Fort Worth just growing up into that region and as you have that growth, there’s been a demand for those increased services,” he says. The four doctors had about 75 pregnant patients when they found out about the policy. They applied for credentials and began making their case to the hospital board. At first the Medical Staff Ethics and Credentials Committee agreed the doctors should be granted privileges for labor and delivery, but when the matter went before the Medical Executive Committee, the motion died for lack of a second. At that point, they hired a lawyer and settled in for a fight. They attended board meetings and pled their case; they got help from TAFP and the Texas Medical Association; they collected more than 400 signatures on a petition to the board; they told their story to reporters and garnered media coverage in the Wise County Messenger, the Texas Tribune, and the New York Times. They even filed a Freedom of Informa-

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tion Act request to access the minutes of past hospital board meetings. To help make their case, they wrote a white paper citing several studies showing that family physicians provide excellent obstetric care. “The results are clear,” they wrote. “Trained and qualified FPs deliver outstanding OB care and now is the time to infuse that message into the medical community and encourage new and existing FPs to adopt OB care if we hope to address the staffing challenges ahead.” All the while, the doctors were concerned about their maternity patients. Wise Regional had recommended that patients affected by the closure of the Bridgeport maternity ward transfer their care to one of the three obstetricians in Decatur, and several patients did, but the doctors searched for opportunities where they could keep doing OB. White looked to Gainesville, 45 miles northeast of Decatur. “If I went months without delivering babies, there comes a point where you just stop delivering babies,” he says. “I knew if I stopped, I’d be done. So I reached out to Gainesville, to North Texas Medical Center, and just asked the question.” The last family physician delivering babies there had stopped five years earlier, but White met with the obstetricians on staff and the hospital CEO, and the medical staff voted to give him privileges. “So as soon as we stopped delivering babies here in March, I took my patients up to Gainesville and started delivering babies up there.” The doctors worked another angle, too, because they were worried about what the closure of the Bridgeport maternity department might mean for communities further west. They approached the CEO of Faith Community Hospital in Jacksboro, 40 miles west of Decatur,

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[FALL 2013]


“More and more, family physicians can fill their days completely with patients with chronic medical problems and spend their whole day in the office. And there’s pressure for them to do that. So things like procedures and maternity care and nursing home care and general hospital care sometimes tend to slip just because of that sheer volume pressure that comes with a shortage of family physicians and an aging population.” — Jerry Kruse, M.D., M.S.P.H.


[FALL 2013]


about offering maternity care there. Faith Community is a 55-year-old facility, so the infrastructure wasn’t suitable for full-service obstetrics. “They actually brought in a mobile surgical unit from Joplin, Missouri, and put it next to the hospital so we could have 21st century technology,” White says. “We started delivering babies in Jacksboro for the first time on purpose in 33 years.” In late spring, the doctors entered into legal mediation with Wise Regional, but the effort failed. “The doctors were still making a lot of noise,” Reed says, “and [the board members] were listening.” The board asked the medical staff to reexamine the existing policy and make a recommendation, and they did. On July 29, 2013, the hospital board adopted a new standard for obstetrics privileging for family physicians. To be eligible, they must have performed 100 vaginal deliveries and 50 cesarean sections. To maintain privileges, they must perform 40 deliveries and 10 C-sections every two years. Alling, Faglie, and White were awarded privileges, but Pierce didn’t have enough deliveries to be eligible. She still delivers babies in Jacksboro and plans to reapply at Wise Regional once she reaches the mark, but she’s had to rebuild her practice. “If they hadn’t shut everything down and said, ‘No, you can’t practice OB,’ I would have met my numbers already,” she says. The problem, Alling says, isn’t specific to obstetrics. “This is something we battle on all fronts.” “All the specialists are worried that we’re going to get ourselves in trouble by getting in over our heads,” Pierce says, “but we are really good as family doctors at knowing when to ask for help. We do it all the time.” As hospitals and health systems follow the trend toward more specialized care, family physicians find themselves fighting to obtain credentials for many procedures. When they require board certifications for those privileges, as Wise Regional did for obstetrics, they cut family doctors out. “The fundamental problem for family physicians is you have to meet the gastroenterology standards for doing a colonoscopy; you have to meet the OB-GYN standards for delivering a baby,” says Troy Fiesinger, M.D., immediate past president of TAFP. “If you define the ability to do procedures, surgeries, et cetera by training—meaning the type of training—you always will restrict family physicians.” Rather than requiring fellowships or board certification to gain hospital privileges, credentialing should be based on demonstrated competence, according to the Joint Statement on Cooperative Practice and Hospital Privileges agreed to by AAFP and the American Congress of Obstetricians and Gynecologists. “The assignment of hospital privileges is a local responsibility and privileges should be granted on the basis of training, experience and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to assure the provision of highquality patient care. Prearranged, collaborative relationships should be established to ensure ongoing consultations, as well as consultations needed for emergencies. “The standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the criteria for privileges in that area of practice. Provisional privileges in primary care, obstetric care and cesarean delivery should be granted regardless of specialty as long as training criteria and

experience are documented. All physicians should be subject to a proctorship period to allow demonstration of ability and current competence. These principles should apply to all health care systems.”

Family medicine’s shrinking scope Despite their success, the four FPs in Decatur are not the norm. The days when most family physicians delivered babies are long gone. A recent study in the Journal of the American Board of Family Medicine reports the proportion of family physicians practicing maternity care declined from 23.3 percent in 2000 to 9.7 percent in 2010. A study in the Annals of Family Medicine shows that from 1995 to 2004, the percentage of prenatal visits provided by family physicians dropped from 11.6 percent to 6.1 percent. In rural areas where people depend more heavily on family doctors to deliver babies, the decrease was even greater, from 38.6 percent to 12.9 percent. These results led researchers to question whether residency training programs may soon have difficulty supporting the family medicine curriculum because there simply aren’t enough family doctors practicing obstetrics to recruit as faculty, to host rotations, or even to serve as community role models for residents. About 20 percent of AAFP members report they have hospital privileges for routine deliveries, but only 10 percent say they delivered one or more babies in 2009. Whether it’s because of liability costs, lifestyle concerns, or lack of institutional support, family doctors aren’t delivering many babies. When Wise Regional representatives defended their policy requiring a residency in obstetrics and gynecology for obstetric privileges, they said they were emulating Baylor University Medical Center at Dallas and other hospitals around the Metroplex. But those hospitals don’t bar family physicians from gaining obstetric privileges. Family physicians just aren’t requesting those privileges. Ten years ago, AAFP published the Future of Family Medicine report, setting the course for the Academy and the specialty for years to come. The authors called for the adoption of a “new model” of family medicine, in which all family physicians would commit to providing a “full basket of services” that all patients could expect. That basket included maternity care, but the authors hedged somewhat on whether obstetrics was absolutely required. “The flexibility and adaptability of the New Model will accommodate variation from practice to practice in the specific services provided, depending on the geographic location of the practice, the unique needs of the community being served, the physicians’ interests and training, and the availability of staff. For example, practices will vary in the range of diagnostic and therapeutic procedures performed, in the amount and intensity of hospital care provided, and in the extent to which they provide intrapartum maternity care. All family physicians, however, will share a common commitment to provide or coordinate all care specified in the family physician’s basket of services, thereby serving as effective personal medical homes for their patients.”

of the core team members on the new project, Family Medicine for America’s Health: Future of Family Medicine 2.0. He is the Executive Associate Dean of the SIU School of Medicine and the CEO of Southern Illinois University HealthCare. He’s also the immediate past president of the Society of Teachers of Family Medicine. “There’s a significant body of literature in the world that shows that the type of prenatal care, the type of total maternity care that is delivered by family physicians is highly effective and I don’t think you can find one study that shows that maternity patients that book with a family physician have worse outcomes of any kind than those that book with anyone else, whether it be an obstetrician or a midwife or any other kind of practitioner,” Kruse says. “Speaking personally and for a large group of family physicians, I think it’s very important that maternity care remain a big part of family medicine. There is some debate among those in leadership levels in the discipline of family medicine, but that’s my thought.” Kruse traces the start of the long downward trend to the 1980’s when spiking malpractice premiums caused many family physicians to give up obstetrics. Once the family physicians in a community stop delivering babies, it’s hard to start up again. The trend toward physician employment plays a role as well. AAFP survey results show that more than 60 percent of members are employed. More than 80 percent of physicians who have practiced seven years or less are employed. Physicians in employed settings often have defined roles in a system, which means employers determine the scope of practice for their family physician employees. Rising demand for primary care services in the midst of a physician shortage causes many family physicians to narrow their own scope. “More and more, family physicians can fill their days completely with patients with chronic medical problems and spend their whole day in the office. And there’s pressure for them to do that,” Kruse says. “So things like procedures and maternity care and nursing home care and general hospital care sometimes tend to slip just because of that sheer volume pressure that comes with a shortage of family physicians and an aging population.” That problem will only get worse. The Association of American Medical Colleges predicts that by 2015, the nation will have a shortage of about 21,000 primary care physicians. The American Congress of Obstetricians and Gynecologists predicts a 25 percent shortage of OBGYNs by 2030, and 35 percent by 2050. When the Wise County physicians wrote their white paper to the Wise Regional Health System board of directors, they titled it, “Who’s Going to Catch All the Babies?” Given these predicted shortages, it appears to be a fair question. Thanks to their tenacity and determination, pregnant patients in north Texas have a few more options. White says even though the fight was difficult, the ordeal had a “strange outcome.” Before it began, family physicians were delivering babies in one hospital in the area – Bridgeport. Now family physicians are delivering babies in three hospitals – Wise Regional in Decatur, North Texas Medical Center in Gainesville, and Faith Community Hospital in Jacksboro. “I think after education and perseverance,” he says, “it’s very gratifying that even though this is a partial victory in some ways, when it’s all said and done, they voted unanimously to grant privileges. Their hospital board voted unanimously to give us privileges.”

This year AAFP announced that it will revisit the project to examine the current state of family medicine and to define the role of the family physician in the 21st century. Jerry Kruse, M.D., M.S.P.H., is one

[FALL 2013]


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HIPAA compliance: Does your family practice know who your business associates are? By Julie Sheppard, B.S.N., J.D., C.H.C.

most physician practices, including family practices, are already aware that the HIPAA Omnibus Rule (enforcement date was Sept. 23, 2013) requires them to take necessary steps for compliance. Most realize the importance of having Business Associate Agreements in place, with some practices even having an updated BAA template prepared and available. However, many practices are still finding it a challenge to determine which vendor relationships require a BAA. The definition of a business associate and other helpful information is provided in 45 CFR § 160.103, found here: A basic definition of a business associate is any entity that a covered entity (physician practice including family practices) allows to create, receive, maintain, or transmit Protected Health Information. Some common examples of business associates are a billing company, a clearinghouse, an answering service, a document shredding company, a collection agency, and an attorney. Generally, physicians and those they trust to run their practices are thorough and analytical. They prefer to leave no stone unturned. Below are a few questions I encounter frequently during my discussions with physicians and practice managers. What about the phone company or the Internet provider? They could access my patient information, so we need a BAA with them, right? Business Associate Agreements are not necessary with certain organizations considered to be mere conduits. Examples are the U.S. Postal Service, some private couriers, telephone companies, and Internet service providers. This is because a conduit transports the information, but does not access it. No disclosure is intended by the covered entity, the physician practice, and there is low likelihood of disclosure of PHI in these situations. What about the landlord or the cleaning service? They have access to the office where we keep PHI. It is unnecessary to have a BAA with the cleaning service because they are not contracted to perform services involving use or disclosure of PHI. However, you need to have reasonable safeguards in place to protect PHI. Ideally, you should store paper PHI in a locked cabinet.

Do I have to have a BAA with _______? She’s been doing our accounting for years, but she isn’t an employee. It is common to overlook a business associate who has been working in your organization for a long period of time. However, if an independent contractor is providing services such as accounting or anything that involves PHI, then you must have a BAA in place. Hopefully, your practice has BAAs at the top of your priority list this month. If you don’t have appropriate BAAs in place, your procrastination could be expensive. Every time a business associate accesses your patients’ information without the proper agreement, your practice is potentially exposed to very large fines. Julie Sheppard, B.S.N., J.D., C.H.C. is president and founder of First Healthcare Compliance. She is an adjunct professor at Widener University School of Law, where she serves as the course instructor for Healthcare Compliance & Ethics. A nurse, an attorney, certified in Healthcare Compliance by the Compliance Certification Board, and a physician’s spouse, Julie intersected her professional understanding of compliance issues with her personal motivations when establishing First Healthcare Compliance. First Healthcare Compliance (http://1sthcc. com/) addresses the challenges created by the recent compliance mandates of the Affordable Care Act for health care providers, specifically those applying to physician practices, by developing a timely, comprehensive and practical solution to meet the ongoing compliance needs of physician practices.

[FALL 2013]


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Compliance audits: Top 5 mistakes all providers should avoid By Bradley Reiner

i’ve been providing coding and documentation audits for over 10 years. I’ve audited thousands of records over that time. Over the last three to five years payer compliance audits have increased at an alarming rate and the issues have escalated. Consequently, refunds and penalties have increased as a result. I would like to share some of my experiences in completing medical record audits. I will provide some ideas to increase your documentation and coding compliance and hopefully help you avoid future refunds and penalties. Here are the top five mistakes I have identified that many providers are making when it comes to documentation:

#1 CHIEF COMPLAINT NOT DOCUMENTED APPROPRIATELY I know this may sound simple and you may be telling yourself that a chief complaint is always documented, but many of the records I review don’t have a clear and compliant chief complaint. Many physicians are documenting “Follow up” as a chief complaint. Contrary to popular belief this is NOT an appropriate chief complaint. If you further describe what the follow-up is for, such as “Follow up diabetes,” then it is a compliant chief complaint. Many auditors place a high level of importance on the documented chief complaint. This element is the first thing reviewed in the record for each visit and sets the tone for what is needed in the history, exam, and medical decision making. It literally gives the reader the information regarding the nature of the presenting problem and determines how the rest of the visit will progress. Don’t forget the importance of documenting a clear and appropriate chief complaint that includes the reason the member is being seen.

#2 CLONING OF MEDICAL RECORD DOCUMENTATION Cutting and pasting language from one visit to another or one record to another is considered cloning of the documentation. This copying of documentation is happening more and more because of the addition of electronic medical records. These systems allow providers to cut things from a previous review of systems, history of the present illness, or examination and paste it on the current record, regardless of whether the visit required this information or these items to be pro-

vided. For example, I was reading a record recently that in the history of present illness the patient complained of headaches. In fact, the main reason for the visit was to discuss recurrent headaches. However, in the review of systems the patient denied headaches. This probably happened because a portion of the review was copied from a previous visit. This cloning of information in the medical record is becoming very concerning from an auditing standpoint. Insurance payers are very aware of information that is cut and pasted into other records. Ensure you only document what is truly appropriate for the nature of the problem that day. Don’t cut and paste from a previous visit if it has no relevance to the problem. More importantly, read the record before you finalize it to ensure it reads appropriately and consistently for each visit. This careful documentation will help ensure compliance.

#3 LEVEL 3 NEW PATIENT VS LEVEL 3 ESTABLISHED PATIENT There is a misconception that the documentation required for a level 3 established patient visit is the same as what is required for a level 3 new patient visit. This is incorrect. The documentation requirements for a new patient level 3 visit are defined as a detailed history and a detailed examination. For an established patient level 3 visit an expanded problem focused history and expanded problem focused exam are required. The area where most providers lack the appropriate documentation involves the history of the present illness. For level 3 new patients, it requires an extended history of present illness, which is four or more of location, quality, severity, duration, timing, context, modifying factors, and signs and symptoms. The status of three chronic conditions will also meet this level. For level 3 established patients, it only requires a brief HPI which is only one to three elements. This may not sound like much of a difference, but ensuring you meet the requirements is critical to maintain compliance. You must ensure you meet the level of the code billed. Level 3 new patients require 12-17 bullets as defined by the 1997 Documentation Guidelines for multi-system exams. It only requires 6-11 bullets for level 3 established codes. Again, this may not sound like much but it is significant and has a direct bearing on meeting a particular level. Make sure you understand the guidelines and the elements needed for the level being billed.

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#4 MEDICAL DECISION MAKING This area of documentation is where the rubber meets the road. This is the portion that ultimately drives the code choice. However, in many records I review this area is weak and not consistent with the code chosen. More documentation, if not warranted, does not increase the level of code that can be chosen if it is not necessary. Some of this is the fault of EMRs that have a system that chooses the code automatically. This problem can be significant and I have seen many examples where the code recommended is much higher than the medical decision making that has been documented. For example, an established patient may come in for a minor problem. The provider may document a comprehensive history and examination but these were not necessary based on the nature of the presenting problem. The EMR will most likely recommend the highest level code because of the amount of information documented in the history and examination. The system does not have the ability to determine if the documentation was actually appropriate for the presenting problem. It just counts the number of elements and makes a recommendation. Because this is an established patient, only two of the three elements (history, exam, and medical decision making) have to be met. The system will recommend the highest level based on this information, but the medical decision making, which drives code choice, is straightforward to low based on the nature of the problem. The service would need to be coded at a lower level based on the medical decision making. Ensure that you use medical decision making information choosing the most appropriate code for that visit.

#5 DOCUMENTATION WHEN TIME IS A FACTOR As you may know, time is a controlling factor in code choice when over 50 percent of the visit is spent counseling or coordinating care. For example, if you see a patient for depression and spend the majority of your time counseling, then the service can be billed based on time rather than history, exam, or medical decision making. Iâ&#x20AC;&#x2122;ve seen instances where the provider wanted to bill time, but only had the total time documented. This doesnâ&#x20AC;&#x2122;t meet the requirements for billing time. Here is the correct way to bill time. A patient came in, you spent 40 minutes with them, and over 50 percent was spent counseling. In order to bill time correctly, the record must indicate that a total of 40 minutes was spent with the patient over 50 percent of which was spent counseling. List all areas of the patient counseling to substantiate what was provided. Since each CPT code has a typical time associated with it, choose the code that represents the total time spent. In this instance, CPT 99215 would be chosen for an established patient. Keep in mind that time is not used regularly and should be considered an exception to standard documentation. Following each of these tips will help you manage your medical records documentation and choose codes appropriately. These suggestions will also help decrease the possibility of a compliance audit and avoid refunds or penalties. Bradley Reiner, formally with Texas Medical Association, is now owner of Reiner Consulting and Associates. He can be reached at (512) 858-1570 or


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Adolescent bone density, breast feeding, and birth control intent in the immediate postpartum period Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.

Gold level Richard Garrison, M.D. David A. Katerndahl, M.D. Jim and Karen White silver level Carol and Dale Moquist, M.D. bronze level Joane Baumer, M.D. Linda Siy, M.D. Lloyd Van Winkle, M.D. George Zenner, M.D.

Thank you to all who have donated to an endowment.

For information on donating or creating a new endowment or applying for research grants, contact Kathy McCarthy at

Acknowledgement: The author would like to thank Cindy Passmore, M.A., for her assistance with statistical analysis.

By Sally P. Weaver, Ph.D., M.D. McLennan County Medical Education and Research Foundation Family Medicine Residency Program, Waco, Texas family medicine physicians find themselves taking care of many adolescent women who may be at risk for poor lifetime bone health. Despite a declining teen pregnancy rate, close to 400,000 adolescents ages 15-19 bear children every year in the United States.1 Unfortunately, there is little published research concerning bone health and possible risk for decreased bone mineral density, or BMD, from pregnancy for adolescents. Since the four years following menarche are a time when nearly 50 percent of adult BMD is acquired,2,3 pregnancies in adolescence may critically impact long term bone health. Adolescence is a time when young women should be experiencing skeletal growth and obtaining optimal BMD.1,3,4 Childbirth during this growth period may delay or disrupt this process and potentially decrease a womanâ&#x20AC;&#x2122;s peak BMD. Bone health is a dynamic process that continues throughout a womanâ&#x20AC;&#x2122;s lifetime and is of particular concern for health care costs because of the significant morbidity associated with osteoporotic fractures. An estimated nearly $14 billion is spent each year taking care of health issues related to osteoporosis.5 Peak BMD correlates with the risk for osteoporosis in the postmenopausal years.6,7 High peak BMD is felt to be the most important factor in preventing osteoporosis.6 Peak BMD likely occurs in early adulthood,7-12 thus late adolescence or very early adulthood are critical time periods for maximum BMD development. Postmenopausal women who had their first child during adolescence have significantly lower BMD in their postmenopausal years.13,14 Any reductions in adolescent BMD that contribute to lower peak BMD may lead to the onset of osteoporosis at a younger age and potentially increase lifetime health care costs. Teens are less likely to breastfeed when pregnant and have lower rates of using birth control than adult women.15-17 National statistics concerning teen contraceptive use from the Centers for Disease Control show that highly effective contraceptive methods, such as intrauterine devices or hormonal methods, are used in up to 60 percent of sexually experienced teens with the highest use among non-Hispanic whites at 66 percent.15 CDC data also demonstrates that about half of teens who become pregnant were not using any form of birth control when they con-

ceived and only 21 percent used highly effective contraceptive methods.16 Compared to over 80 percent of adult U.S. women initiating breastfeeding, only around half of teens start breastfeeding their infants.17,18 This is important since women who breastfed during adolescence have BMD levels higher than those who had not breastfed following an adolescent pregnancy.19 The implication is that breastfeeding following an adolescent pregnancy may be protective of BMD in the long run. This project examines changes in hip and spine BMD in adolescent women following a full term pregnancy and reports on contraceptive intent and breastfeeding initiation among postpartum teens.

Methods To explore these issues further, we measured hip and spine BMD in Caucasian adolescents aged 14-18 years old following a full term pregnancy (n=10) and compared these measurements to never-pregnant 1418 year old Caucasian adolescents (n=7) matched for age, BMI, and age at menarche. BMD was measured at the time of enrollment for never pregnant control subjects and at one to three weeks postpartum for pregnant subjects. Prior or current use of any hormonal birth control method was an exclusionary criterion. Data were collected concerning fracture history, tobacco and alcohol use, daily calcium supplementation, daily exercise, and personal or family history of osteoporosis. Post-menarchal age was classified into less than three years since menarche and more than three years since menarche as much of adult bone density is acquired by three years post-menarch.2-4 All postpartum enrollees were additionally queried concerning pre- and postpartum birth control use and breastfeeding intent. Recruiting for this grant supported project was much more difficult than anticipated and resulted in low numbers of study subjects. BMD was measured at the left femoral neck, left total hip, and lumbar spine using dual-energy X-ray absorpitometry (Prodigy DXA System, Madison, Wis.). The software for this equipment is Encore 2006. All scans were performed by the same two experienced DEXA technicians. The results of these studies are expressed as a t-score (the standard deviation from the mean value of

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RESEARCH young Caucasian adult). Institutional review board approval was granted prior to subject enrollment. For data analysis, t-tests were used to test equality of means regarding age, BMI, post-menarchal age, fracture age, and BMD t-scores. A Chi-squared test was used to test equality of proportions concerning fracture history, activity levels, and calcium use by postpartum subjects.

Results Study subjects had similar ages, BMI, and age at menarche (Table 1). Ninety percent of control and study subjects had normal for age bone density. Daily calcium supplement use was low at 10 percent among postpartum subjects and nonexistent among control subjects. There were similar rates of childhood bone fractures in both cohorts. Among the postpartum subjects, results showed a trend in lower total body bone density (combined hip and spine measurements) primarily due to lower bone density in the left hip (Table 1) Bone density in the spine did not differ significantly between the postpartum and control groups. Pre-pregnancy activity levels, BMI, fracture history, calcium use in pregnancy, and post-menarchal age were not predictors of BMD in postpartum subjects or control subjects. Thirty percent of study subjects had been using some form of birth control prior to conception, but around 90 percent planned to use birth control after pregnancy. Seventy percent of those teens were planning on using highly effective contraception methods in the form of an IUD or a hormonal method (40 percent and 30 percent, respectively). Concerning postpartum subjects, breastfeeding initiation rates were low at only 40 percent and very few of the teens had plans for how long they would breastfeed.

Discussion Adolescence is a time when young women should be experiencing maximal skeletal growth and obtaining peak BMD. Childbirth during this growth period may delay this process and potentially decrease a womanâ&#x20AC;&#x2122;s peak BMD. This study showed a trend toward lower BMD in postpartum adolescents but is limited by the small population enrolled. It is possible that this trend would reach statistical significance in a larger study population. Additionally, the population examined in this study had high BMI scores and higher than expected t-scores in most all subjects which might obscure lesser changes in bone density. Greater efforts are needed to further analyze postpartum BMD changes in adolescents and their long term impact on peak BMD and future development of osteoporosis. As for contraceptive use in the study population, there was a low use of birth control prior to pregnancy at 30 percent, but the study did exclude subjects with any history of hormonal contraceptive use to avoid confounding BMD findings. Including hormonal contraceptive use, approximately one half of teens nationwide were using birth control when they got pregnant.16 Postpartum subjects did report a high level of current or planned birth control use at 90 percent, compared to a national average of around 82 percent in teens not pregnant, postpartum, or seeking pregnancy.15 More study subjects were using or planned to use highly effective contraceptive methods such as IUDs or hormonal methods, compared to the national average for all teens of around 59 percent.15 Caucasian teens report a higher prevalence of highly effective use nationally at 65 percent which is fairly comparable to our postpartum Caucasian cohort.15 Limited evidence suggests that breastfeeding may be protective of long-term BMD in adolescents.19-20


Variable Age (mean) in years


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All subjects 17.4

Postpartum 17.3

Never pregnant 17.5

p-value 0.7325






Age at menarche (in years)





Age at time of childhood fracture


10.8 (n=6)

8.3 (n=5)


Bone density at AP spine





Bone density at left femoral neck





Bone density at right femoral neck





Bone density total left hip





Bone density total right hip





Bone density L1 vertebra





Bone density L2 vertebra





Bone density L3 vertebra





Bone density L4 vertebra





Bone density left greater trochanter





Bone density right great trochanter






Breastfeeding initiation rates in this report on postpartum adolescents were low at only 40 percent compared to a national average of around 53 percent for teens.18, 21 This may be due to lack of education on the benefits of breastfeeding, family non-support, stories of negative breastfeeding experiences from peer, and/or poor professional involvement from doctors and nurses. The long-term impact of breastfeeding on a teen’s BMD is still a matter for further research.

Conclusion Postpartum teens had lower hip BMD but this did not reach statistical significance, likely due to low numbers of subjects. Breastfeeding rates were low which may further impact long term peak BMD and future risk for osteoporosis. Many postpartum subjects were using highly effective contraceptive methods. This small study on BMD in postpartum adolescents adds to the limited body of literature concerning bone health in postpartum teens. Greater efforts are still needed to further analyze the impact of pregnancy and breastfeeding on peak BMD and long term bone health in this population.

References 1. Martin JA, Hamilton BE, Ventura SJ, et. al. Births: Final data for 2010. National Vital Statistics Reports. 2012;61(1):1-3. 2. Sabatier JP, Guaydier-Souquieres G, Benmalek A, Marcelli C. Evolution of lumbar bone mineral content during adolescence and adulthood: a longitudinal study in 395 healthy females 10-24 years of age and 206 premenopausal women. Osteoporosis International 1999; 9(6):476-482. 3. Gordon CL. The contributions of growth and puberty to peak bone mass. Growth, Development and Aging 1991; 55(4):257-262. 4. Bailey DA, McKay HA, Mirwald RL, Crocker PR, Faulkner RA. A six-year longitudinal study of the relationship of physical activity to bone mineral accrual in growing children: the university of Saskatchewan bone mineral accrual study. Journal of Bone & Mineral Research 1999; 14(10):1672-1679. 5. Ray NF, Chan JK, Thamer M, Melton LJ, III. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. Journal of Bone & Mineral Research 1997; 12(1):24-35. 6. Hui SL, Slemenda CW, Johnston CC, Jr. The contribution of bone loss to postmenopausal osteoporosis. Osteoporosis International 1990; 1(1):30-34. 7. Hansen MA OKRBCC. Role of peak bone mass and bone loss in postmenopausal osteoporosis: 12 year study. BMJ 1991; 303(6808):961-964.

8. Gilsanz V, Gibbens DT, Carlson M, Boechat MI, Cann CE, Schulz EE. Peak trabecular vertebral density: a comparison of adolescent and adult females. Calcified Tissue International 1988; 43(4):260-262. 9. Lu PW, Briody JN, Ogle GD et al. Bone mineral density of total body, spine, and femoral neck in children and young adults: a cross-sectional and longitudinal study. Journal of Bone & Mineral Research 1994; 9(9):1451-1458. 10. Matkovic V, Jelic T, Wardlaw GM et al. Timing of peak bone mass in Caucasian females and its implication for the prevention of osteoporosis. Inference from a cross-sectional model. Journal of Clinical Investigation 1994; 93(2):799-808. 11. Recker RR, Davies KM, Hinders SM, Heaney RP, Stegman MR, Kimmel DB. Bone gain in young adult women.[see comment]. Journal of the American Medical Association 1992; 268(17):2403-2408. 12. Teegarden D, Proulx WR, Martin BR et al. Peak bone mass in young women. Journal of Bone & Mineral Research 1995; 10(5):711-715. 13. Fox KM, Magaziner J, Sherwin R et al. Reproductive correlates of bone mass in elderly women. Study of Osteoporotic Fractures Research Group. Journal of Bone & Mineral Research 1993; 8(8):901-908. 14. Sowers M, Wallace RB, Lemke JH. Correlates of forearm bone mass among women during maximal bone mineralization. Preventive Medicine 1985; 14(5):585-596. 15. Sexual experience and contraceptive use among female teens. MMWR: Morbidity and Mortality Weekly Report, 61(17);297-301. Retrieved from on March 4, 2013. 16. Prepregnancy contraceptive use among teen with unintended pregnancies resulting in live birth. MMWR: Morbidity and Mortality Weekly Report, 61(02);25-29. Retrieved from mmwr on March 4, 2013. 17. Scanlon KS, Grummer-Strawn LM, Chen J, Molinari N, Perrine CG. Racial and ethnic differences in breastfeeding initiation and duration by state - National Immunization Survey, United States, 2004-2008. pp. 327–334. 18. Breastfeeding report card-United States, 2012. Centers for Disease Control, breastfeeding/data/reportcard.htm#Rates. Accessed March 4, 2013. 19. Chantry CJ, Auinger P, Byrd RS. Lactation among adolescent mothers and subsequent bone mineral density. Archives of Pediatrics & Adolescent Medicine 2004; 158(7):650-656. 20. Bezerra FF, Mendonca LM, Lobato EC, O’Brien KO, Donangelo CM. Bone mass is recovered from lactation to postweaning in adolescent mothers with low calcium intakes. American Journal of Clinical Nutrition 2004; 80(5):1322-1326. 21. Tucker CT, Wilson EK, Samandari G. Infant feeding experiences among teen mothers in North Carolina. International Breastfeeding Journal. 2011;6(14):1-11.

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A better way to value family physicians’ work By Richard Young, M.D.

ms. m was a 68-year-old hispanic female who had not seen Dr. Smith (not his real name) in nearly a year. She had run out of her diabetes, high blood pressure, and cholesterol medications months before. Ms. M had other concerns in addition to these three chronic diseases and the practical difficulties she faced filling her prescriptions. She asked Dr. Smith to help her with her foot pain and knee pain. She was told by another doctor at an ER that she had visited for a non-urgent problem a few months prior that her blood potassium level was low. She expected Dr. Smith to address her heartburn, recent weight gain, bad teeth, and an additional but distinctly different abdominal pain. She wanted a test for her kidney function, for which Dr. Smith had to spend a couple of minutes trying to figure out why she was concerned about her kidneys in the first place and the results of blood tests at other facilities such as her recent ER visit. Dr. Smith also spent several minutes explaining the need and importance of osteoporosis screening, which she ultimately declined. This was not a fictitious case. I observed this clinical encounter as part of my work for the CMS Innovation Advisor Program. I was the only person in Texas selected for this program. Twelve prescriptions later and Dr. Smith asking Ms. M to obtain the lab results and other records from the recent ER visit, so as to avoid unnecessary duplicate blood tests, the visit was finished. Dr. Smith ordered no lab work or imaging and billed a CPT code 99214 plus the injection administration fees for the flu and pneumonia vaccines. He broke even on the cost of the vaccine vials to his office. For this work, it took about 45 minutes of his time with additional time spent by his staff. CMS paid him about $153 for his work. In this amount of time, a Medicare-participating ophthalmologist could perform two cataract surgeries with lens implants and receive from CMS $1,488 for the professional fee (not including the cost of the artificial lens or operating room time). The existing payment rules are clearly broken. Cost-effectiveness of family physicians How should family physicians be paid for their services? I and my colleagues in the Residency Research Network of Texas have conducted research on issues related to this important question, which were funded in part by the TAFP Foundation. What follows are findings of two of those studies. We interviewed 38 family physicians across Texas and asked them one over-arching question: “We all know about


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the Barbara Starfield-type evidence that places with more family physicians have better health at a lower cost. Why is this? Tell us stories from your daily practice that you think explain this.” Our family physician subjects told us many great stories of exercising prudent judgment in patients who knew them well and trusted them deeply. As the research team, we organized the major themes of their stories and concluded that the family physician’s personal attitudes and characteristics, combined with their long-term relationships with their patients, were the foundations of more cost-effective care than the disjointed multi-ologist model (my term from my book, American HealthScare). These traits include a comfort with uncertainty, an ability to apply probabilities to individual patients, a mastery of complexity, and even a comfort with death. None of these important factors are mentioned in the PCMH documents. These characteristics lead to fewer tests, more targeted testing when ordered, fewer ER visits, and fewer hospitalizations, because sick patients are seen and cared for in clinics and not these more expensive facilities. Problems with the current documentation, coding, and billing rules In a separate project, we interviewed 32 family physicians across Texas and asked them what they liked and did not like about the existing evaluation and management rules. As you might imagine, they didn’t like much of it (manuscript accepted for publication, but not published yet). Other than the basic SOAP format, most family physicians wanted to scrap the existing rules and work under new guidelines that are less bureaucratic and onerous and more intuitive. They are tired of counting bullet points that add nothing to the quality of care. They are fed up with taking care of multiple issues in one clinic visit but only being paid for two of them. They feel bad when they tell a patient to come back for what is actually a needless extra visit just to be paid something for their ability to provide comprehensive patient care services. A better way to value the work of family physicians To sum up the findings of these two research projects, we found that family physicians deliver better care at a lower cost because of who they are as people: their unique perspectives on what defines high-quality health care that is different from all other doctors, delivered in the presence

Payment model goals

Sources of savings

Physicians provide comprehensive primary care cognitive services

• Decreased referrals • Decreased testing • Decreased duplication of tests and treatments

Practice provides evening and weekend hours

• Decreased charges for facility fees at more expensive sites (ER vs. clinic, e.g.) • Fewer expensive tests and treatments ordered

Physicians agree to not order tests from the excessive testing list or treatments from the excessive treatment list

• • • •

Physicians prescribe generic medications whenever possible

• Lower medication costs per prescription • Increased use of OTC medications

Practice provides comprehensive procedural services

• Decreased duplication of E/M and facility fees • Decreased duplication of work ups prior to procedure

Practice has in-house urgent care capability

• Decreased charges for facility fees at more expensive sites (ER vs. clinic, e.g.) • Fewer expensive tests and treatments ordered • Decreased duplication of E/M and facility fees • Decreased duplication of work ups prior to procedure

Physicians care for continuity patients in the hospital

• Decreased transition of care errors • Decreased duplication of tests • Decreased admissions and re-admissions

of a long-term trusting relationship with their patients. But we also found a huge mismatch between these characteristics and the aspects of medical practice that are incentivized in the existing payment rules. I had the honor of being chosen to be in the first, and probably only, class of CMS Innovation Advisors in 2012. My project was to create a brand new way for family physicians to document, code, and bill for their work. I based my proposals on the results of these two research projects and later investigations. My full proposals are over 100 pages long. I’m happy to share them with anyone who is interested. There are a lot of details in this work, but the summary is that there are three major reforms: 1.

The number of issues addressed in a primary care clinic visit are additive. A patient with one simple problem will be seen quickly and the visit will generate a smaller allowable fee than existing rules. In contrast, a patient with six problems to be addressed will have all of those issues addressed, and that visit will generate a bill which is larger than the existing rules allow.

Fewer unnecessary tests Fewer tests of questionable benefit Fewer treatments of unproven benefit Physicians practice with more comfort with uncertainty


Pay primary care providers for non-face-to-face care such as phone consultations and email-based clinical encounters.


Incentivize a series of seven physician and practice characteristics that add value to the greater health care system. These are listed in the table above.

Final thoughts There are other reasonable proposals in the public discussion for family physician payment reform, but it is beyond the scope of this article to compare and contrast those proposals to mine. Whatever position the AAFP decides to support­—and hopefully it supports several possible options—the fact is that the existing documentation, coding, and billing rules do not incentivize the strengths of family physicians to provide highquality cost-effective primary care. In fact, they financially punish family physicians for practicing like family physicians. As a result, our current economy and our children’s future are bleaker than they should be. Let’s all keep fighting to change the current realities for a better tomorrow for our patients and our country. We can start by not believing that we are stuck with the status quo.

[FALL 2013]



Make an impact Prescribe breakfast for improved health and wellness Katie Barckholtz, M.P.H., R.D., L.D. Director of Health and Wellness, Dairy MAX, Inc.

Is breakfast really the most important meal of the day? It just might be! Breakfast plays an essential role in the diet. Studies show that breakfasteaters tend to have better overall diets and that breakfast-skippers miss out on important vitamins and minerals not made up for during the rest of the day.1 Breakfasteaters generally have higher intakes of calcium and fiber, and those who eat cereal in particular have higher intakes of calcium, fiber, iron, folic acid, vitamin C, vitamin D, potassium, and zinc, as well as decreased intakes of fat and cholesterol.1,2

Breakfast may help control weight. Studies also suggest that breakfasteaters have lower body mass index scores compared to breakfast-skippers, which may reduce risk for chronic diseases associated with overweight and obesity such as diabetes and heart disease.3,4 There are several theories to explain this. One is that breakfast literally breaks the overnight fast, speeding up the metabolism and thereby increasing the rate at which calories are burned. Another theory is that breakfast-eaters make healthier food choices throughout the day, ultimately contributing to fewer calories consumed. Breakfast is brain food. From the classroom to the boardroom, breakfasteaters feel more energized and better prepared to take on the day. Breakfast has been shown to improve concentration and memory, especially during childhood and adolescence.5 Studies suggest that proper nutrition can affect the development of the prefrontal cortex of the brain, which is responsible for executive functions central to learning such as working memory, problem solving, reasoning, and planning.5 Start the day off right. A healthy breakfast can go a long way toward improving health and wellness. Experts recommend a winning combination of foods from the following food groups: whole grain, fruit or vegetable, and low-fat or fat-free dairy. Breakfast can be as quick and easy as a bowl of cereal with milk and an apple, a granola bar with yogurt and blueberries, or even crackers with string cheese and grapes. Whether sit-down or on-the-go, breakfast can fit any lifestyle.

Make breakfast your prescription today. 38

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1. Barton BA, Eldridge AL, Thompson D, et al. The relationship of breakfast and cereal consumption to nutrient intake and body mass index: The National Heart, Lung, and Blood Institute Growth and Health Study. J Am Diet Assoc. September 2005;105: 1383-1389. 2. Frantzen LB, Trevino RP, Echon RM, et al. Association between frequency of ready-to-eat cereal consumption, nutrient intakes, and body mass index in fourth-to sixth-grade low-income minority children. J Acad Nutr Diet. April 2013; 113:511-519. 3. U.S. Department of Agriculture Center for Nutrition Policy and Promotion. Breakfast Consumption, Body Weight, and Nutrient Intake: A Review of the Evidence. November 2011. Nutrition Insight 45. 4. Pereira MA, Erickson E, McKee P, et al. Breakfast frequency and quality may affect glycemia and appetite in adults and children. J Nutr. January 2011; 141: 163-168. 5. GENYOUth Foundation. The Wellness Impact: Enhancing Academic Success through Healthy School Environments. 2013. Available at: http:// Accessed September 5, 2013.

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Texas Family Physician, Fall 2013  

The fall 2013 edition of the quarterly magazine of the Texas Academy of Family Physicians