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Missed Opportunities In The 84th Texas Legislature Report From 2015 C. Frank Webber And Interim Session

texas family physician VOL. 66 NO. 2 2015

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Back to the future with direct primary care

Remember a time when you could treat your patients without ever having to deal with a health insurance company? Well rev up the Delorean, we’re taking a look at direct primary care. By Kate Alfano


Missed opportunities in the 84th Texas Lege

For both the House and Senate this session, health care was not a top priority. Find out what passed, what didn’t pass, and what didn’t even come close to passing in this legislative wrap up.

By Tom Banning


Research support by the TAFP Foundation

Investigators report on a study of the incidence rate, demographics, and clinical manifestations of coccidioidomycosis in a West Texas regional referral medical center. Wang Li, MD, PhD, et al.

6 FROM YOUR PRESIDENT What if you could spend more time with your patients and less time coordinating with thirdparty payers? 8 AAFP NEWS AAFP weighs in on NIH’s draft National Pain Strategy 10 MEMBER NEWS Van Winkle launches website for AAFP Pres-Elect campaign. | TAFP local chapters install new officers. | Many TAFP members represented the state well at NCCL. | TAFP members graduate from leadership program. | Report on the 2015 C. Frank Webber Lectureship | Member of the Month: Patrick Leung, MD 28 Interim Session REPORT 30 TAFP PERSPECTIVE A new way to train family docs

Find Your Kind in an AAFP Member Interest Group The AAFP is committed to giving all members a voice within our increasingly diverse organization. Member interest groups (MIGs) have been created as a way to define, recognize, and support AAFP members with shared professional interests. MIGs support members interested in professional and leadership development and provide connections to existing AAFP resources, opportunities to suggest AAFP policy, and networking events with like-minded peers. Current AAFP MIGs include: • Direct Primary Care • Emergency Medicine/Urgent Care • Global Health • Hospital Medicine • Independent Solo/Small Group Practice • Oral Health • Reproductive Health Care • Rural Health • Single Payer Health Care • Telehealth

Visit to learn more, join a MIG, or start your own.

president’s column


Cutting out the middle man By Dale Ragle, MD TAFP President

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

Dale Ragle, MD

president-elect vice president treasurer

Ajay Gupta, MD

Janet Hurley, MD

Tricia Elliott, MD


Tamra Deuser, MD

immediate past president

Clare Hawkins, MD, MSc

Editorial Staff managing editor

Jonathan L. Nelson

associate editor

Samantha White

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell Contributing Editors Kate Alfano Wang Li, MD, PhD Richard Young, MD

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 AIM Printing and Marketing, 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. © 2015 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6


and national level, your Academy is paying greetings colleagues. Do you rememattention to these developments, offering ber a time when you could take care of information and resources online, educayour patients without any of the hassle and tional presentations at CME conferences, expense associated with billing insurance and advocacy support in legislative arenas. companies? When you could spend as much Here in Texas, TAFP worked with Rep. time with your patient as needed? When you Greg Bonnen and Sen. Kelly Hancock to file simply received payment from your patients legislation that will improve access to direct instead of some third-party payer? primary care by recognizing Many physicians practhese arrangements, protectticing today have only ing them, and defining them heard stories of those days, According to the as outside the scope of state but a growing number are insurance regulation. House rediscovering them by Direct Primary Bill 1945 was approved by stepping off the insurance Care Coalition, both the House and the treadmill and contracting traditional Senate and signed into law directly with their patients. by Gov. Greg Abbott. Direct primary care is primary care As value-based payment an innovative model for practices spend models begin to replace feedelivering and purchasing nearly 65 percent for-service payment in manhealth care services that aged care, physicians are gives physicians and their of their revenue faced with tough decisions patients an alternative to on overhead. about how to change their the third party, fee-forBy removing practices to remain viable service system. For a flat and continue providing the monthly fee, patients have the insurance best care for their patients. unlimited access to their bureaucracy like Direct primary care offers doctor—in person and by billing, coding, one solution. It won’t be phone or e-mail—for a full range of comprehenclaims processing, right for every family doctor, but if you’re interested in sive primary care services and appeals, direct learning more, go to www. including acute and urgent primary care care, regular checkups, direct-primary-care. preventive care, chronic practices report The passage of H.B. 1945 disease management, and significantly is one of many successes your care coordination. reduced operating Academy claimed during the According to the Direct 84th Texas Legislature, and I Primary Care Coalition, expenses. would like to thank all those traditional primary care members who gave testimony practices spend nearly 65 and support in our advocacy percent of their revenue efforts. Thank you to those who made donaon overhead. By removing the insurance tions to the TAFP Political Action Commitbureaucracy like billing, coding, claims protee as well as to those who signed up to be cessing, and appeals, direct primary care Key Contacts. Thank you to members who practices report significantly reduced opermade phone calls and sent letters and e-mails ating expenses. to your representatives and their staffs. The It sounds almost too good to be true, but relationships you build and the conversations as you can read about in this issue of Texas you have make all the difference. And thank Family Physician, some of our colleagues you especially to those of you who served as are having success and enjoying their pracPhysician of the Day. tices in direct primary care. At both the state

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AAFP news


AAFP weighs in on NIH’s draft National Pain strategy

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Academy strongly supports more physician education on pain treatment in response to nih’s solicitation of comments on a draft National Pain Strategy document developed by the Interagency Pain Research Coordinating Committee, the AAFP sent a letter offering its feedback. The National Pain Strategy is a comprehensive, population health-oriented plan based on a 2011 report from the Institute of Medicine that offered recommendations “to increase the recognition of pain as a significant public health problem in the United States.” In the May 20 letter to Linda Porter, PhD, program director for systems and cognitive neuroscience at NIH’s National Institute of Neurological Disorders and Stroke and a co-author of the draft document, the Academy expressed its support for the draft National Pain Strategy and its strong agreement that additional education and training is needed to help physicians better treat their patients’ pain. “The AAFP agrees that provider education and instruction in the use of multimodal pain management strategies, to include safe prescribing practices for opioid analgesics as one component of a comprehensive pain management plan, is needed and urges medical schools and family medicine residency programs to integrate into curricula and provide during training (this information),” said the letter, which was signed by AAFP Board Chair Reid Blackwelder, MD, of Kingsport, Tenn. In 2008, the Academy joined the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the Society of Teachers of Family Medicine in developing recommended curriculum guidelines to teach family medicine residents how to care for patients with chronic pain. Those guidelines were revised in 2011. The letter also explained that the AAFP, along with other major professional physician organizations, continues to oppose any action that limits patients’ access to physician-prescribed pharmaceuticals. “The AAFP is committed to maintaining family physicians’ rights to treat their patients efficiently and effectively,” the letter said. Furthermore, stated the letter, the Academy is adamantly opposed to mandating CME as a condition for prescribing any type of medication. The AAFP continues to work with the FDA and other government agencies to support education and physician self-regulation regarding the FDA’s risk evaluation mitigation strategy process, said the letter. “By collaborating with stakeholders and interprofessional groups to address the pain epidemic, the AAFP remains an active partner in processes surrounding physician self-regulation.” The letter concluded by saying the AAFP plans to continue to collaborate with key organizations and government entities to improve the management of pain, as well as to combat drug addiction and opioid abuse.

READ THE STRATEGY Supported in part by a grant from the American Academy of Family Physicians Foundation. Source: AAFP News, May 22, 2015. © American Academy of Family Physicians.



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ICD-10 ICD-10 ICD-9 Region ICD-9DESCRIPTION K59.00 ICD-9 A60.04 DESCRIPTION UNSPECIFIED TION LEFT 278.00 Obesity,K59.01 ICD-9RIGHT ICD-9 DESCRIP 843.9 Unspecified A63.0 sprains of unspecified 314.00 DESCRIPTI unspecified hip Attentio S73.109– vulvovaginitis S73.101– S73.102– ICD-9 681.0ON 054.11 Herpetic nB37.3 Strain of muscle, Other K59.02 deficit disorder0 acuminatum) DESCRI fascia,obesity and tendon 314.01 the hip due S76.019– PTION warts (condyloma ed S76.011– toof excess 278.01 Morbid Attentio without S76.012– 493.0 DESCRIPTIO ICD-10 078.11 Anogenital calories Strain of quadriceps A56.2 K59.09 tion, unspecifi muscle, (severe) fascia,obesity Cellul 0 and tendon n deficit S76.119– disorder S76.111– mention Constipa of vulva and vagina ICDof N itis andExtrin hyperac due to excess Attentio with hyperacS76.112– unspecified 112.1ion Candidiasis Drug-induc Strain 9 493.1 E66.9 tract,adductor A53.9 muscle, fascia, and tivity constipat sic asthm n-deficit absce calories tivity Acute0lymph ion 269 infection of genitourinaryof thigh hyperac Use ss of a, 278.03 Morbid ed obesitytendon Slow transit ICD-10 Intrin Chlamydial Attentio S76.219– tivity S76.211– fingerunsp .9 E66.09 099.55 493.9 on constipat angiti A59.03 addit sic disorder S76.212– n-deficit ional Drugsobesity s of finger 280 ecifie Nutr DESC of(severe) 681.10 , predomi 0 Unsp asthm hyperac RIGHT Outlet dysfuncti 097.9 Syphilis, Unspecified code Strain278.02 with ofofmuscle, Table a, unspe RIPT F90.0 fascia, and tendon of Attentio ition .0 d the Overweight the alveolar TIP A60.9 tivity ion ecifie E66.01 Cellul (B95 nantly inattenti hypoventila disorder n-deficit al defic ION LEFT cified Iron 280 itis and, predomi posterior muscle group at thigh level d asthm S76.319– L03.0 hyperac tion S76.311– ve Other constipat 131.02 Trichomonal urethritis effects column S76.312–-B97Mild typeTIP Other obesity R19.7 Attentio ) tointerm 11 ienc Acute UNSP a, unco .8 Othe deficL03.0 ident E66.1 disorder abscessnantly hyperac n-deficit N34.1 682.3 tivity ienc (endocrine, y,L03.0 the adverse StrainV77.8 unspecified of otherScreening 799.51 EC ify infec 281. specified muscles, ittent seeherpes, hyperac Cellul lymph,angiti combine ofMild tive endogenou mplic fascia, toe Genital and r F90.0 y21anem unspecifi 12 type Attentio 054.10ation, K52.9 tivity disorder asthm s) tious0 Pern ated spec L03.0DESCRIP unspecified s of d type persistent E66.2 itis of S76.812– tendons S76.819– n and concent 266 level for obesity S76.811– 783.1at thigh 19 agen iciou ified iron iaL03.0 uced constip Other nongonococcal urethritis, axilla seco 22 ed , other typetoe TION Mode Acute E66.3 a,.2 unco asthm t when ration 099.40 F90.1 TIP Abnormal nda L03.029 mplic weight 843.0 Iliofemoral lymph rate For drug-ind als. s anem deficit defic gainA09ess of a condition a, unco Defi 281. sprain 783.21 ligament of hip ry to persi E66.8 ICD-1 angiti Codes S73.119– CutanS73.111– Seve Loss 9 mplic cienated repoiarting ienc stent S73.112– 0 s within eous 493.0 and Chemic weight andofnonresponsiven 843.1 Ischiocapsular when y anem blood resistance (ligament) catego S73.129– L03.0 282 asthm Uns ated cyF90.2 absce 2of axilla re persi of othe (Vitacode 783.22 Underweigh sprain ofK59.1 drug hip resistance loss min s L00Diarrhea stent Z13.89.5 a, uncopeci ries F90 Cellulitis 31r ss S73.121–493.1TIP does nott identify K52.2 code for any associated S73.122– ias axillaExtrinsic code (chr 787.91 fiedF90.8 B12 843.8 Other sprain asthm L08. 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Member news

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

Van Winkle launches website for AAFP President-Elect campaign at the close of last year’s AAFP Congress of Delegates, TAFP’s Lloyd Van Winkle, MD, announced his intention to run for AAFP President-Elect this year. Now an official candidate, he recently launched his campaign website,, complete with a blog chronicling his daily life as a rural family doc in Castroville, Texas. Van Winkle has practiced family medicine in Castroville for almost 30 years. He is the medical director and CEO of United Physicians of San Antonio ACO. He is a clinical associate professor in the Department of Family Medicine at the University of Texas Health Science Center in San Antonio and he holds the position of health officer for Castroville and La Coste. He served as medical director of the Medina Valley Emergency Medical Service for more than 25 years. He is an aviation medical examiner and a quality reviewer for Texas Medical Foundation Health Quality Institute, and he provides expert testimony for Texas Medical Liability Trust, defending family physicians in medical malpractice litigation. A member of the AAFP since 1985, Van Winkle has served as a delegate and alternate delegate to the AAFP Congress

of Delegates for 10 years. He is currently in his last year of a three-year term on the AAFP Board of Directors, and has previously served on the AAFP Commission on Membership and Member Services, and as chair of the AAFP Committee on Communications and the Subcommittee on Awards. Van Winkle served as president of TAFP in 2000 and 2001, and served on numerous committees and commissions over the years. He also served as chair of TAFP’s Political Action Committee Board of Directors for many years. An active member of his community, Van Winkle sponsors children’s baseball, soccer, and basketball teams, and he serves as a volunteer physician at the annual marathon in San Antonio. He has provided free care for many patients at VITAS Innovative Hospice Care of Texas, where he now serves as a part-time attending physician. Van Winkle also has precepted medical students in his office for more than 20 years, mentoring the next generation of family physicians. For more information about Van Winkle, visit his official AAFP biography website at html. Support Van Winkle’s campaign on social media with the hashtag #LloydForAAFP.

TAFP local chapters install new officers two local chapters of TAFP recently installed new officers. The Alamo Chapter installed Graciela Moreno, MD, as president; Marisa Emmons, MD, as presidentelect; Cecily Kelly, MD, as vice president; Leah Raye Mabry, MD, as secretary; and Mitch Finnie, MD, as treasurer.

The Tarrant County Chapter also installed a new president, C. Philip Hudson, MD, and a program chairman, James Morgan, MD. Congratulations to you all and thank you for your service to your local chapters of TAFP.


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Texas well represented at NCCL aafp held its national Conference of Constituency Leaders in Kansas City, Missouri in late April and 19 TAFP members represented Texas, including three resident members and nine first-time attendees. Christina Kelly, MD, of Harker Heights, presided over NCCL as convener of the 25th anniversary conference, which had record registration. First-time attendee Ikemefuna Okwuwa, MD, of Odessa, was elected as an international medical graduate co-convener for 2016, as well as a member constituency alternate delegate to the AAFP Congress of Delegates. MarieElizabeth Ramas, MD, of Mount Shasta, Calif. , was chosen as the AAFP Board of Directors new physician candidate, to be approved by the 2015 Congress of Delegates in Denver this fall. Ramas completed her residency in Texas and previously received the TAFP Foundation James C. Martin, MD, Scholarship which allowed her to work on TAFP’s scope of practice policy brief in 2011. Congratulations to them and thank you to all TAFP members who traveled to Kansas City to represent Texas.

TAFP members graduate from leadership program two tafp members recently completed the Texas Medical Association’s Leadership College. Ahmad Ghassan Abazid, MD, of the Wichita Falls Family Practice Residency Program, and Darnel Viray Dabu, MD, MPH, FAAFP, of the Community Health Center of Lubbock, both graduated as part of the program’s class of 2015. TMA established the Leadership College in 2010 to ensure strong and sustainable physician leadership within organized medicine. Graduates of the program serve as thought leaders who can bridge the gap between clinicians and health care policymakers and be role models for their local communities. Including more than 40 hours of classroom instruction, the program is designed for physicians under the age of 40 who have been practicing for less than eight years.

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Report on the 2015 C. Frank Webber Lectureship

April 2015 Member of the Month Patrick Leung, MD TAFP Foundation donor practices alongside wife

Family docs gather for annual symposium in Austin more than 300 physicians attended the C. Frank Webber Lectureship held Friday, March 6, at the Omni Austin Hotel at Southpark. A number of residents, medical students, and other health care professionals also gathered at the Omni for TAFP’s Interim Session and other related events, including CME lectures, two ABFM SAM Group Study Workshops, TAFP business meetings, the Texas Conference of Family Medicine Residents and Students, and the Clerkship and Residency Coordinators Conference. The first SAM Group Study Workshop of the weekend was held Thursday, giving diplomates of the American Board of Family Medicine a chance to get credit for the SelfAssessment Module portion of their Maintenance of Certification. Attendees discussed asthma and completed the 60-question knowledge assessment portion of the module, making them eligible to complete the clinical simulation online to receive full credit. Friday’s CME lectureship featured speakers on a wide array of topics, including diabetes, palliative care, prostate cancer, and more. TAFP commission, committee, and section meetings also began on Friday and included discussions on many aspects of family medicine that will guide the Academy. Action items were written into final reports which the Board of Directors will discuss and vote on at their August meeting. The second SAM Group Study Workshop was held Saturday and discussed 12


hypertension. TAFP also hosted the Texas Conference of Family Medicine Residents and Students on Saturday, teaching medical students and residents about family medicine. For the first time, this year began with a discussion on procedures with Kaparaboyna A. Kumar, MD, and a procedure workshop where attendees had the opportunity to practice a variety of procedures with TAFP members Jake Margo, MD, and Clare Hawkins, MD. Attendees then got to interact with two family physicians from different aspects of the specialty, Travis Bias, DO, and Emily Briggs, MD. Students and residents also got to visit with exhibitors at the Job Fair and the Procedures and Residency Fair. This year is TAFP’s first with the new conference schedule, including the launch of the Texas Family Medicine Symposium, held June 5-7 in San Antonio, where attendees will have the opportunity to earn up to 24 AMA PRA Category 1 Credits™. Annual Session has moved to the fall and has a new name – Annual Session and Primary Care Summit. It will take place in The Woodlands, Nov. 12-15 and will include more than 20 hours of CME and all TAFP committee, commission, and section meetings. Next year’s C. Frank Webber Lectureship and Interim Session will be held April 15, 2016, at the Omni Austin Hotel at Southpark. Mark these dates on your calendars and we will see you then!

TAFP member Patrick Leung, MD, has practiced family medicine in the booming oil town of Midland, Texas, since 1980. After moving from Hong Kong to Canada, Leung met his now wife, Nancy, while in a pre-med program at the University of Alberta. Nancy was also enrolled at the university, where she became a registered nurse. The young couple met during Leung’s first year of medical school, married during his second year, and had their first child during the third. They moved around Canada for a few years, then relocated to Midland where Leung began practicing at Alamo Medical Clinic, where Nancy is now his office manager. They raised three children in Midland, all of whom followed in their parents’ footsteps and are now in the health care field. The Leungs made a generous donation to the TAFP Foundation in January to fully endow the Patrick Leung, MD, Medical Student Scholarship. It will be used to award scholarships to pre-clinical students who participate in the Texas Family Medicine Preceptorship Program during the summer after their first or second year of medical school.

Patrick Leung, MD, and his wife, Nancy Leung. SAMANTHA WHITE

TFP: Did you expect all three of your children to go into medicine? Patrick: I didn’t. I never complained about medicine and showed them what it was like. They would do house calls with me and they fell in love with it. Nancy: The oldest one would carry daddy’s black bag and watch deliveries. In high school she knew that’s what she wanted to do. That’s why she’s an OBGYN.

TFP: What is your favorite aspect of family medicine? Patrick: The variety and helping people. Nancy: We have patients that span four generations. Great grandmother, grandmother, mother, and kids, they all come to us. Generation to generation. We are invited to their weddings, funerals, whatever it is. We went to one granddaughter’s wedding and a five-year-old came over and said, “doctor, I want to dance with you!” That feels so good, you know? They are very loyal and give all of their hearts to you.

TFP: Why family medicine? Patrick: After graduating from medical school, I was already married. I had to go to work and make a living. I was pondering, should I become a psychiatrist? OB? So I stayed in family medicine because I enjoy it.

TFP: If not practicing medicine, what would you be doing? Patrick: I would have become a technical engineer. I like chemistry and was very good at it. Nancy: My dad was a professor in Taiwan. I always wanted to follow him and be a teacher. For some reason I got into nursing. He told me to go into nursing so that when I got married and had kids I could take care of them.

TFP: What hobbies do you enjoy? Patrick: Traveling. We travel all over the world. Last year we went to the Holy Land.

Nancy: We ballroom dance probably once a month. We took ballroom dancing lessons a few years ago and are in a ballroom society. His favorite is tango. It’s a pretty dance. I like the cha cha.

Why donate to the TAFP Foundation? Patrick: Giving back. I want to attract more medical students to go into family medicine, that’s the whole point. I enjoy my work in family medicine because I can help people of all ages and races. Nancy: He enjoys his career and wants the next generation of doctors to also go into family medicine.

TAFP’s Member of the Month program highlights Texas family physicians in TAFP News Now and on the TAFP website. We feature a biography and a Q&A with a different TAFP member each month and his or her unique approach to family medicine. If you know an outstanding family physician colleague who you think should be featured as a Member of the Month or if you’d like to tell your own story, nominate yourself or your colleague by contacting TAFP by e-mail at or by phone at (512) 329-8666. View past Members of the Month at http://www.


MISSED OPPORTUNITIES in the 84th Texas Legislature By Tom Banning

Yogi Berra famously said I hate making predictions, especially about the future. It’s particularly painful when those predictions come true as was the case for many of the predictions TAFP made at the outset of the 84th Texas Legislature on how health care issues would fare this session. Playing to their primary voters, the House and Senate focused attention almost solely on tax cuts, border security, transportation, when and where you can carry a gun, and a host of other mostly inconsequential partisan ideas. With a record budget surplus and money overflowing from the state’s rainy day fund, health care funding issues in the 84th Texas Legislature can best be described as a session of missed opportunities. The Legislature largely punted on coverage expansion for the uninsured, investment in our health care infrastructure, and other market reforms that could have benefited patients and physicians alike. In a January blog post published by the Texas Tribune, I wrote that “Republican primary politics alone should quash any expectation that this Legislature would contemplate a Medicaid expansion deal or any other red-state-style private-market Medicaid solution.” True to form, the topic was not even fleetingly considered during the session. Lawmakers said as much at a March 2 press confer14


ence, when the lieutenant governor and every Republican member of the Senate delivered the message that, “any expansion of Medicaid in Texas is simply not worth discussing.” Even when federal officials warned the state’s health agency that refusing to expand Medicaid could threaten the renewal of the 1115 waiver hospitals depend on to offset the cost of providing uncompensated care to uninsured patients, legislators refused to budge. Worse, the Legislature failed to invest any additional resources in physician Medicaid rates, which currently pays approximately 61 percent of Medicare. The House, recognizing that woeful Medicaid rates paid to primary care doctors were threatening access to care, authorized an additional $460 million to bring primary care rates on par with Medicare payments. But the Senate objected and

the budget conference committee opted not to include the primary care rate increases in the final budget. It would almost be comical, if it weren’t so sobering. Physicians who provide Medicaid services probably feel a bit like Charlie Brown after Lucy pulled the football away again. For the past several sessions, one of TAFP’s main advocacy goals has been to strengthen the state’s fragile primary care infrastructure by increasing support for primary care graduate medical education. As the session began, the Legislative Budget Board released its 2015 Government Effectiveness and Efficiency Report, which shined a light on a series of problems facing GME funding that ultimately results in an imbalance in the geographic distribution and the specialty mix of our physician workforce. The report recommended the Legislature improve funding to the state’s existing family medicine residency programs and align new GME funding with the state’s health care needs and produce more primary care physicians. Senate Bill 18 by Sen. Jane Nelson, (R-Flower Mound), and Rep. John Zerwas, MD, (R-Simonton), provides the statutory framework to expand existing GME programs and create new GME positions. The bill establishes a permanent trust fund to support GME, prioritizes the creation of new GME positions for critical shortage specialties, and creates an independent physician workforce resource center to conduct research on medical specialties in Texas that are determined to be in critical shortage. The Legislature put more than $53 million in the budget to fund various strategies to foster GME expansion. $32.55 million of that is designated to fund 290 new first-year residency training positions at $75,000 per resident per year. About a third of those funds, $12 million will be targeted at new primary care positions. The budget also included a $4 million increase for the Family Medicine Residency Program, a line item in the Higher Education Coordinating Board budget that allocates direct support to existing family medicine residency training programs. Restoration of this funding has been TAFP’s top policy priority since the funds were slashed in 2011. The Senate budget originally included a $16 million increase to the program, which would have fully restored funding to the Family Medicine Residency Program to historic levels. By the end of their deliberations, the budget conference committee with the


support of the Texas Medical Association shifted $12 million from the Senate budget to fund new GME programs, leaving the FMRP appropriation with 20 percent less than it received in the 2010-2011 biennium. With the help and support of our partners in the Primary Care Coalition, the Legislature restored funding for the Texas Statewide Primary Care Preceptorship Program, which will receive $3 million in state support over the next two years. The Legislature did pass a few important bills to encourage direct contracting for primary care services, reduce administrative hassles for practices as well as restrict minor’s access to e-cigarettes. House Bill 1945 by Rep. Greg Bonnen, MD, (R-Friendswood), and Sen. Kelly Hancock, (R-North Richland Hills), will improve physician’s ability to provide and patients’ receive direct primary care services. The legislation recognizes these practice arrangements, protects them, and defines them as outside the scope of state insurance regulation. Another bill eliminates the state’s troubled Controlled Substance Registration Program. S.B. 195 by Sen. Charles Schwertner, MD, (R-Georgetown), and Rep. Myra Crownover, (R-Denton), moves the Prescription Drug Monitoring Program from the Texas Department of Public Safety to the Texas State Board of Pharmacy and broaden physicians’ authority to delegate who can access the information. Last but certainly not least, the Legislature passed a bill by Rep. Drew Darby, (R-San Angelo), that repeals more than $300 million in fees over the next two years, including the $200 a year fees charged to physicians and other professionals. This session reaffirmed the time honored doctrine that politics drives the process that sets policy. The House and Senate waved the bloody red shirt of guns, gays, tax giveaways, and anti-federalism. Highways were the only infrastructure investment of any consequence, a testament to the durability and local relevance of pothole politics. Absent an uprising by patients who are being systematically denied coverage or some crisis forcing physicians and hospitals to close their doors it will be, as Yogi said, “déjà vu all over again.” We may be approaching a tipping point where health care politics is as important as potholes, but not this legislative session. Until then, to borrow from Yogi one last time, “the future ain’t what it used to be.”

It would almost be comical, if it weren’t so sobering. Physicians who provide Medicaid services probably feel a bit like Charlie Brown after Lucy pulled the football away again.


Chris Larson, DO



BACK TO THE FUTURE Direct primary care: An alternative to fee-for-service By Kate Alfano

Unlimited time with patients, decreased practice overhead, less exposure to risk, fewer medical errors, zero insurance filing; while this sounds like a wish list for family medicine in an increasingly complex and frustrating health care system, some family physicians are embracing an expanding practice model and achieving all this and more. Direct primary care is an alternative to insurancebased fee-for-service primary care. Physicians charge a monthly or annual fee, and in return patients receive all or most primary care services including clinical, laboratory and consultative services, and care coordination and comprehensive care management. Patients enjoy visits unhampered by a prescribed time limit and they can usually reach their physician outside of normal business hours by cell phone, text message, secure e-mail, or video chat. JONATHAN NELSON

Other terms are often used synonymously with DPC, including concierge medicine, but the subtle difference is in the payment. In concierge medicine, a doctor accepts insurance for routine services but also charges a membership fee that averages $150 per month, according to a January 2013 Market Watch article. While independent DPC physicians set their own fees, the average cost to the patient is about half that, roughly $80 per month.


at a time when insurance premiums are rising and more patients are switching to high-deductible health insurance plans for catastrophic coverage, patients, physicians, employers, advocacy organizations, even Medicaid programs are taking a second look at a more affordable way to keep physicians’ doors open and patients well. Jay Keese is the executive director of the Direct Primary Care Coalition, an advocacy group representing DPC physicians, residents, and medical students. The organization seeks to empower the doctorpatient relationship to achieve better health outcomes, lower costs, and an enhanced patient experience. “It’s the medical home on steroids,” Keese says. “What the original medical home movement did that was wonderful was to create a new practice model to put the patient at the center of care. Most primary care providers have been doing this their entire careers. But direct primary care creates the ideal payment model for the medical home. It takes all of the fee-for-service out of primary care and realigns the incentives. You’re incentivized to keep the patient coming back to your practice for routine wellness to take care of as many of their needs as you can.” An August 2014 Heritage Foundation white paper cited a study that found one direct primary care group practice, Qliance in Washington State, demonstrated 35 percent fewer hospitalizations, 65 percent fewer emergency department visits, 66 percent fewer specialist visits, and 82 percent fewer surgeries in their patients than in similar populations. “What direct primary care does is takes out all the administrative costs so the cost of getting paid for primary care is gone,” Keese says. “We look at that as a 40 percent cost differential. Currently 40 percent of a practice’s expenses are spent on getting paid. Because the doctor is paid directly in direct primary care, some of that savings goes to increase payment to the physician and some of that is just savings to the system.”

Impact on physician supply In the midst of a growing primary care physician shortage, it seems counterproductive to support a model where one physician has an average patient panel of between 600 and 800 patients as opposed to the average U.S. patient panel of 2,300. According to the Heritage Foundation there were 4,400 direct primary care physicians in 2012, which places approximately 3 million Americans under the care of a DPC physician – quite a gap from the more than 10.1 million patients those 4,400 physicians could theoretically see. But Keese says DPC is the best thing that will happen to the physician shortage. “It is widely acknowledged that primary care is in crisis; the fee-for-service model is smothering it and it can’t be sustained. Everybody agrees that you have to do something.” He says medical students and residents recognize DPC as a sustainable model for primary care in the future and one that embodies why they got into medicine in the first place – quite simply to care for patients. “The other group we see – and this is anecdotal – are physicians getting toward the end of their careers who are tired of the hamster wheel and fee-for-service. Would they practice for another 10 years if they could get rid of the administrative burden? Probably. You’ll extend their careers and generate a lot of other interest among younger physicians.”

DPC in real life Chris Larson, DO, of Austin Osteopathic Family Medicine, has been in direct primary care for a little more than a year – straight out of residency – and cares for roughly 100 patients. His patients pay an initial enrollment fee and then a monthly membership fee based on their age, ranging from $39 per month for ages 0-19 to $89 for patients 60 years and older. “If you can balance your checkbook at home, you can run the financial aspect of this business,” he says. “It’s that easy.” He saves his patients the time and money of going to urgent care by fielding patient questions after hours and, many times, he saves his patients the time and expense of seeing a specialist because he performs routine procedures in the office, absorbing the cost of the supplies and not charging extra for his time. “In the fee-for-service system I only have 10 minutes to see you so if you have four problems and one of those is a skin issue and I don’t have time to do a biopsy today, I’ll refer you to a dermatologist. Here I have the time to take that on so I don’t have to count on specialists to do work that I can do.” The only additional charge his patients pay is for some labs, either $5 or $10 each. In-clinic labs like strep tests, urine analysis, and blood sugar are offered at no additional cost. Though some physicians might hesitate before giving patients their cell phone numbers, Larson says he has not had an issue with patients calling in the middle of the night. He has a conversation with patients about appropriate communication when they join and they expect that an e-mail will get a response within a day, a text message will get a response within an hour, and a phone call will be answered immediately, either by him or his medical assistant. “Certainly I get calls on the weekend or I get texts after hours but I think that’s an appropriate way and method of communicating. [Your patients] need you all the time, not just 8 to 5 Monday through Friday. If you really want to be their family physician and be there for them when they need you, you need to be available.” He says the power of direct primary care is that it can be done by a single family physician. “We’ve been employees for long enough. This model gives family physicians the power to be their own boss again and to run their practice in a way that they think it should be run in a financially sustainable and emotionally sustainable way.” “I truly believe that this is the beginning of a tidal wave in medicine,” Larson says. “I believe this is the revolution that we need to bring primary care physicians back to the position that they should be in, which is making the great majority of the treatment decisions, bringing the personal relationship back to family medicine and their patient.”

Legislative and regulatory hurdles While the DPC model is expanding to more physicians and patients, stakeholders still must work to clear a number of hurdles on the federal and state levels. Chris Ewin, MD, FAAFP, is the president and founder of 121MD, a DPC practice in Fort Worth. Early in his practice one of his patients asked him why he couldn’t use his health savings account to pay the annual fee for DPC membership. “Why not? I take care of 80-85 percent of his needs and keep him out of the hospital, treat acute illness, and help prevent complications from chronic disease. I guide him through the system. He trusts me,” Ewin says. [cont. on 20]



Learn more about the DPC model with AAFP The American Academy of Family Physicians supports the physician and patient choice to provide and receive health care in any ethical health care delivery system model, including the direct primary care practice setting. Family physicians interested in learning more about DPC or transitioning to a DPC model can attend the 2015 DPC Summit, sponsored by AAFP, the American College of Osteopathic Family Physicians, and the Family Medicine Educational Consortium, or purchase the AAFP’s DPC Toolkit.

“We’ve been employees for long enough. This model gives family physicians the power to be their own boss again and to run their practice in a way that they think it should be run in a financially sustainable and emotionally sustainable way.” — Chris Larson, DO

The summit will be held in Kansas City, Missouri, July 10-12. Attendees will learn more about the DPC model and its status in today’s health care environment, find out how physicians can help advocate for and develop DPC, and discover how to make a smooth transition from fee-to-service to DPC. The program has been approved for 11.75 AAFP Prescribed Credits. Find more information at AAFP’s DPC toolkit can help physicians: • plan their DPC practice conversion; • create a sustainable DPC business plan for ongoing practice operations; • establish the appropriate membership fee structure; • address the financial aspects of running a DPC practice; • develop an effective marketing/outreach plan to recruit patients; • understand the regulations and legal implications that apply to the DPC model; and • identify appropriate service and/or technology providers to facilitate a DPC conversion. The member price of the toolkit is $249 and the nonmember price is $399. Go to for more information and to purchase the toolkit.

DPC FAQs from AAFP What is direct primary care? Direct primary care is a subset model of the retainer-based practice framework for primary care practices. DPC practices offer patients the full range of comprehensive primary services, including routine care, regular checkups, preventive care, and care coordination in exchange for a flat, recurring retainer fee that is typically billed to patients on a monthly basis. DPC practices are distinguished from other retainer-based care models, such as concierge care, by lower retainer fees.

How does direct primary care differ from traditional primary care? DPC gives physicians the opportunity to spend more time interacting with patients and providing ongoing follow-up services. The regular and recurring revenue generated by the practice retainer fees allows physicians participating in DPC practices to overcome some of the pressures associated with the traditional fee-for-service payment system. Many DPC physicians provide a larger array of non-face-to-face services, to ensure primary care services can be accessed in a manner most convenient for patients.

Why would a physician consider practicing in a DPC practice? One of the most appealing aspects of the DPC model for family physicians is that the retainer fee payment structure can greatly simplify the business of operating a family practice. DPC practices report significantly reduced operating rates when compared with traditional primary care practices. This is primarily because DPC practices do not need to maintain staff dedicated to organizing, reviewing, filing, and managing payment claims to third-party payers.

Source: AAFP,



“Think of it. Swipe your HSA card and get unlimited access to care with your trusted DPC physician at an agreed upon price on pre-tax dollars. For certain people, they have just cut their primary care expenses by a third.” — Chris Ewin, MD Chris Ewin, MD

[cont. from 18]

Patients with high-deductible health insurance plans paired with HSAs are a natural market for DPC. A DPC physician could take care of routine medical needs and preventive care while the insurance plan would provide catastrophic protection against large or unexpected medical bills. Money saved on premiums for an HSA-qualified insurance plan could help fund an HSA account. “Think of it,” Ewin says. “Swipe your HSA card and get unlimited access to care with your trusted DPC physician at an agreed upon price on pre-tax dollars. For certain people, they have just cut their primary care expenses by a third. And the consumer of health care – the patient – determines quality, not a third party. This solves one piece of the health care maze and it would save patients billions of dollars in the future.” However, according to Keese, the IRS currently considers a DPC monthly fee arrangement to be a health plan for HSAs. Under Section 223(c) of the Internal Revenue Code, individuals with high-deductible health plans paired with HSAs are prohibited from having a second health plan. That means that, under their interpretation, individuals with HSAs are barred from having a relationship with a DPC plan and employers who cover their employees in high-deductible health plans paired with HSAs can’t offer DPC as a health benefit. This is in spite of the fact that the Affordable Care Act explicitly states that DPC medical homes are not insurance products. Additionally, since payments to physicians practicing under the DPC model are not considered a “qualified medical expense” under Section 213(d) of the Internal Revenue Code, employees cannot use their HSA funds to pay their DPC physicians. 20


Keese says DPCC’s top federal priority is to make it easier for employees with HSAs to take advantage of the improved access to care DPC can bring. “In meetings with senior officials at the Department of the Treasury and IRS, they maintain that the IRC [Internal Revenue Code] is unclear regarding DPC and needs to be updated. Legislation authorizing HSAs was passed before DPC was widely known.” According to Keese, Sen. Bill Cassidy, MD, R-Louisiana, will soon introduce legislation that would clarify the tax code to make HSAs compatible with DPC and to provide a payment pathway in Medicare for DPC doctors. Senate Finance Committee Chairman Orrin Hatch, R-Utah, introduced similar language in the Family Retirement and Health Reinvestment Act in the 113th Congress and that bill will also be reintroduced soon. “We are hopeful that Congress will act this year to clarify this important provision in the IRC,” he says. Physicians and patients need to move past the status quo, Ewin says, and avoid political influences and misperceptions by health care policy analysts who have never practiced medicine nor run a physician’s office. “We have a fee-for-service systems problem in primary care. The big-picture solution is for primary care physicians to develop direct primary care practices in their own communities. All health care is local and we know our patients. I know this model will work in any county.”

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Support for this project included a grant from the Texas Academy of Family Physicians Foundation.

Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.

Investigation of incidence rate, demographics, and clinical manifestations of coccidioidomycosis in a West Texas regional referral medical center, from January 2004 to December 2012 Wang Li, MD, PhD; Charles Sponsel, DO; Timothy Benton, MD; Enrique Tobias, MD; Rosario Salarzon, MD; Alaaedin Alhomosh, MD Department of Family and Community Medicine, Texas Tech University Health Sciences Center – Permian Basin, Odessa Satish Mocherla, MD Medical Center Health Systems, Odessa

Gold level Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White silver level Carol and Dale Moquist, MD TAFP Red River Chapter bronze level Joane Baumer, MD Gary Mennie, MD Linda Siy, MD Lloyd Van Winkle, MD George Zenner, MD

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

abstract PURPOSE: Coccidioidomycosis is an endemic disease causing significant mortality and morbidity in Southwestern United States. Our group recognized recurring and increasing cases of coccidioidomycosis in a West Texas regional referral medical center between 2004 and 2012; therefore, we endeavored to identify key characteristics, including incidence rate, of this endemic West Texas disease. METHODS: This retrospective chart review contains all pertinent hospitalizations identified by searching the medical center laboratory records for the keywords “fungus” and “coccidioides” on immunoglobulin assays and fungal cultures. The positive laboratory results from January 2004 through December 2012 derive the basis for identification of the patient medical records reviewed. Data extracted from medical records, using a standardized form, includes the multivariates of age, gender, ethnicity, co-morbid illness, and body system infected (respiratory, musculoskeletal, gastrointestinal, neurological, skin, etcetera). Subsequently, data correlation analyses show the incidence trend and student t test assesses the mean of patient ages. Chi-square test reveals results for other data elements. RESULTS: During a five-year period, laboratory confirmed cases of coccidioidomycosis steadily increased by 70.3 percent from 2008 to 2012. On average, the age of male and female patients is 52.08 (± 15.81) and 55.86 (± 14.51) years old, respectively. Identifiable risk factors include male gender, African-American race, and the co-morbidity of malignancy. CONCLUSIONS: The increasing incidence of coccidioidomycosis cases at a regional referral medical center of West Texas indicates a pressing need for further epidemiological study throughout this large geographic endemic region and perhaps classification of coccidioidomycosis as “reportable” in the state of Texas.

Introduction The disease termed coccidioidomycosis results from infection by a dimorphic fungus, most commonly either coccidioides immitis or coccidioides posadasii. The coccidioides are soil-dwelling organisms and when disturbed become airborne, thereby gaining access to a host for infection. Geographic differences occur among the two most common infecting species with coccidioides immitis mainly identified in the central valley of California and coccidioides posadasii in the other endemic areas.1 The clinical manifestations, however, do not differ between the two species and overlap does exist in the general geographic distributions of the causative organisms.2 Clinical manifestations of coccidioidomycosis vary depending on both the size or burden of disease, as well as the immune status of the host. More than 60 percent of patients remain asymptomatic after infection.3 Active disease involves almost any organ system but disseminated infection occurs

in less than 1 percent of patients. As expected with an organism associated with airborne spread, pulmonary infection occurs most often followed by musculoskeletal in 10-50 percent of reported cases.2, 4 Underlying co-morbid disease, particularly immunocompromise and including prescribed immune suppressing medications, more often results in coccidioides fungemia.5 Finally, epidemiologic data from other studies identify African-American and Hispanic populations experience disproportionately higher frequency of the disease compared to other racial or ethnic groups.6, 7 Endemic coccidioidomycosis occurs in the arid Southwestern United States. More specifically a higher prevalence of disease exists in Central and Southern California, Southern Arizona, Southwestern Texas, as well as areas of Nevada, New Mexico, and Utah.8 Consequently much of the research regarding coccidioidomycosis has been performed in Arizona and California. [cont. on 24]


Figure 1. Coccidioidomycosis incidence per 10,000 inpatient admission in a regional referral medical center of West Texas, 2004-2012

Cases per 10,000 inpatient admissions


+70.3% 18.9

+62.2% 18.0

+42.3% 15.8

+31.5% 14.6

15 11.1 10

-18.0% 9.1

-18.9% 9.0

+8.1% 12.5

-23.4% 8.5


2004 2005 2006 2007 2008 2009 2010 2011 2012

Table 1. The incidence, gender, and ages of patients diagnosed with coccidioidomycosis in a regional referral medical center of West Texas from January 2004 to December 2012



Ages (years old)


Ages (years old)

2004 16 8


2005 13 7


2006 13 7


2007 13 7


2008 26 14


2009 22 16


2010 24 10


2011 18 9


2012 29 18






52.08 ± 15.81


55.86 ± 14.51










5 – 19

This retrospective chart review contains all pertinent hospitalizations identified by searching a West Texas regional referral medical center laboratory records for the keywords of “fungus” and/or “coccidioides” on immunoglobulin assays and fungal cultures. The positive laboratory results from January 2004 through December 2012 derive the basis for identification of the patient medical records reviewed. Total inpatient hospital admissions are also included for analysis. Data was extracted from medical records, using a standardized form, including the multivariates of age, gender, ethnicity, co-morbid illness, and body system infected (respiratory, musculoskeletal, gastrointestinal, neurological, skin, etcetera). Subsequently, a data correlation analysis showing the incidence trend and student t test exams the mean of patient ages were performed. Chi-square test was used to analyze results for other data elements. An independent statistician from de-identified data performed all statistical analyses. The study was approved by both hospital and Texas Tech University Health Sciences Center Internal Review Boards.


Table 2. Number of coccidioidomycosis by age and gender Area and age group (years)

Hector et al. reported a similar dramatic increase of coccidioidomycosis cases in Arizona and California from 2001 to 2006, with a 97.8 percent and 91.1 percent increase in incidence rate in the two states respectively.9, 10 Consequently, California, Arizona, and New Mexico require reporting of newly diagnosed cases of infection to their state health departments. Although Texas remains an endemic region, reporting is not mandatory in part due to the lack of a comprehensive study or epidemiologic review of cases.



[cont. from 24]

20 – 39




40 – 59




60 – 79




≥ 80




All ages




Our results confirm a suspected increasing occurrence of coccidioidomycosis at a West Texas regional referral hospital. This review indicates a 70.3 percent increase incidence rate in 2012 compared to 2008. Interestingly, a sudden jump occurred in the annual diagnoses during 2008 when trending the data over a five-year period beginning in 2004. However, there is no correlation significance of the first five-year period of 2004-2008 total cases versus the second five years, 2008-2012. (Figure 1) Although patient age does not correlate with likelihood of disease, there is a significant gender related difference. Table 1 depicts the average age of diagnosis as 52.08 (± 15.81) and 55.86 (± 14.51) years old for male and female patients, respectively (Table 1). The majority of diagnosed patient ages range between 40 to 79 years (Table 2), and no significant age difference exists among gender of the coccidioidomycosis positive patients (P=0.1059). There are more male patients than female (96 vs. 78) in our study and when compared to all hospital admissions a significant male related trend is noted (***P = 0.0011). During the nine-year [cont. on 26]



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Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 < 200 cells/ÎźL) with HIV infection. HIV Medicine. 2004;5:93-8.

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Figure 2. The percentage of male gender is significantly higher (**P= 0.0011) in coccidioidomycosis group compared to that of general admission in a regional referral medical center of West Texas from January of 2004 to December of 2012 1.0 Male



0.8 Percentage of patients

**P=0.0011 0.6



0 Coccidioido in medical center

Admission in medical center

Figure 3. The percentage of African American is significantly higher (*P= 0.03) in coccidioidomycosis group compared to that of general admission in a regional referral medical center of West Texas from January of 2004 to December of 2012


African American


Hispanic White

Percentage of patients


Others *P=0.0398



0.2 7.4% 0

4.3% Coccidioido in medical center

Admission in medical center

Table 3. The clinical presentation of coccidioidomycosis in a regional referral medical center of West Texas from January 2004 to December 2012

Clinical presentation




Mass (including lung nodules)


48.85 %

Respiratory (Pneumonia etcetera)


35.06 %


8 4.6%

Central nervous system









Disseminated (> 1 system involved)




174 100%


[cont. from 24]

study period 44 percent of all hospital admissions are male, yet 55 percent of all coccidioidomycosis positive patients are male (Figure 2). The results also demonstrate a potential higher risk among African-Americans. Our study population contains 45 percent Caucasians, 46 percent Hispanics, 7.5 percent African-Americans, and 1.7 percent other. Total hospital admissions for the same nine-year time period is 51 percent Caucasian, 41 percent Hispanic, 4.3 percent African-American, and 3.6 percent other (Figure 3). Comparison of African-Americans testing positive for coccidioidomycosis against overall AfricanAmerican hospital admission rates reveals a significant higher rate of infection among this group versus other races (*P=0.0398). The final analyses include body systems affected in this cohort and an important identification of a cancer related risk. As described by others, the majority of cases herein involves the respiratory tract and manifest as lung nodules (48.85 percent) or pneumonia (35.06 percent). Additional cases include skin lesions (4.60 percent), central nervous infection (4.02 percent), gastrointestinal with diarrhea (0.57 percent), and only 1.14 percent musculoskeletal, well below that reported by others (Table 3). Additionally, patients in certain ethnicities with a co-morbid finding of malignancy exhibit higher risk for infection overall (**P=0.01).

Discussion Centers for Disease Control reports list statespecific increased coccidioidomycosis cases in Arizona and California during 1998–2001 and 2000– 2007, respectively. The reported overall incidence increases from 5.3 per 100,000 populations in the general endemic area (Arizona, California, Nevada, New Mexico, and Utah) in 1998 to 42.6 per 100,000 in 2011.9, 11 Correspondingly, the number of West Texas cases, in this retrospective review, increases 70.3 percent from 2008 to 2012. At the time of the 2011 CDC report, more females than males have the disease in Arizona, yet the opposite is true in California with the ratio of male to female cases of 2:1.12 In our study, the upward trending overall cases starts in 2008 but analysis over nine years identifies consistently higher rate of infection in males (55 percent) compared to total general hospital admissions (44 percent). Texas’ similarities to the endemic states such as required reporting and detailed description of other epidemiological factors disappear with further literature review. The most recent CDC documents (published in March of 2013) maintain that coccidioidomycosis is endemic to Texas but not reportable to the state’s health department.12 The lack of a systematic reporting requirement of coccidioidomycosis in this endemic region may lead to an underestimation of disease burden in Texas. Furthermore, coccidioidomycosis West Texas reports date back to as early as 1967, with an outbreak among 10 children in a small community in El Paso.13 Also, in the 1970s, Karen Williams’

manuscript describes a localized outbreak in nine children in Beeville.14 Neither provides the detail documented herein, thus making our study a first relatively complete review of coccidioidomycosis in a regional referral medical center within the endemic region of West Texas. A detailed analysis of coccidioidomycosis is needed in West Texas since it provides the right environment for propagation of the disease. The relationship between climatic conditions and the outbreak of coccidioidomycosis is well documented. The characteristic favorable conditions for the growth of coccidioides include an annual rainfall of 5-20 inches, alkaline soil, and a prolonged hot, dry season of several months followed by precipitation.15 The return to dry and windy conditions after moisture brings about hyphal death of the arthrospores and spread of the spores.16 The average annual precipitation in Odessa is less than 15 inches with very hot and long summers. Also, the commonly windy conditions of West Texas may contribute to spore dissemination. Additional epidemiological studies are warranted in this region.

This study has the usual limitations of a retrospective chart review. Additional variables not addressed are the prolonged climate change of drought during the study time period, as well as marked increase of oil well drilling and the consequent rapid population growth. Additionally, focusing our research at one hospital in the endemic region limits extrapolation of our results. However, such a dramatic increase in cases may very well signal an emerging infectious disease that needs more attention. Estimates predict an annual cost of the diagnosis and management of $34,000 per person without calculating losses due to potentially months of absence from school or work.3, 17 The current study not only updates us on the status of coccidioidomycosis in West Texas, but also increases awareness of the disease in an endemic area with little previous documentation of cases. We believe this information will prime further cost improvement in diagnosis, treatment efficiency and prevention of the dissemination, as well as signal the need to consider legislation regarding mandatory reporting of coccidioidomycosis cases in the state of Texas.

References 1. Barker BM, Jewell KA, Kroken S, Orbach MJ. The population biology of coccidioides: epidemiologic implications for disease outbreaks. Ann N Y Acad Sci. 2007;1111:147-63. 2. Thompson GR, 3rd. Pulmonary coccidioidomycosis. Semin Respir Crit Care Med. 2011;32(6):754-63. 3. Stevens DA. coccidioidomycosis. N Engl J Med. 1995;332(16):1077-82. 4. Taljanovic MS, Adam RD. Musculoskeletal coccidioidomycosis. Semin Musculoskelet Radiol. 2011;15(5):511-26. 5. Keckich DW, Blair JE, Vikram HR. Coccidioides fungemia in six patients, with a review of the literature. Mycopathologia. 2010;170(2):107-15. 6. Ruddy BE, Mayer AP, Ko MG, et al. coccidioidomycosis in African Americans. Mayo Clin Proc. 2011;86(1):63-9. 7. Szeyko LA, Taljanovic MS, Dzioba RB, Rapiejko JL, Adam RD. Vertebral coccidioidomycosis: presentation and multidisciplinary management. Am J Med. 2012;125(3):304-14. 8. Fisher FS, Bultman MW, Johnson SM, Pappagianis D, Zaborsky E. Coccidioides niches and habitat parameters in the southwestern United States: a matter of scale. Ann N Y Acad Sci. 2007;1111:47-72. 9. Bissell SR, Weiss EC. Increase in coccidioidomycosis - California, 2000-2007. MMWR Morb Mortal Wkly Rep. 2009;58(5):105-9.

10. Hector RF, Rutherford GW, Tsang CA, et al. The public health impact of coccidioidomycosis in Arizona and California. Int J Environ Res Public Health. 2011;8(4):1150-73. 11. Komatsu K, Vaz V, McRill C, et al. Increase in coccidioidomycosis--Arizona, 1998-2001. MMWR Morb Mortal Wkly Rep. 2003;52(6):109-12. 12. Frieden TR, Jaffe HW, Stephens JW, Cardo DM, Zaza S. Increase in reported coccidioidomycosis-United States, 1998-2011. MMWR Morb Mortal Wkly Rep. 2013;62(12):217-21. 13. Roberts PL, Lisciandro RC. A community epidemic of coccidioidomycosis. Am Rev Respir Dis. 1967;96(4):766-72. 14. Teel KW, Yow MD, Williams TW, Jr. A localized outbreak of coccidioidomycosis in southern Texas. J Pediatr. 1970;77(1):65-73. 15. Maddy KT. The geographic distribution of coccidioides immitis and possible ecologic implications. Ariz Med. 1958;15(3):178-88. 16. Kolivras KN, Comrie AC. Modeling valley fever (coccidioidomycosis) incidence on the basis of climate conditions. Int J Biometeorol. 2003;47(2):87-101. 17. Kerrick SS, Lundergan LL, Galgiani JN. coccidioidomycosis at a university health service. Am Rev Respir Dis. 1985;131(1):100-2.


Member news

Highlights from TAFP’s Interim Session • March 5-7, 2015 The committees, commissions, and sections of the Texas Academy of Family Physicians met in Austin and deliberated on many important items. Thanks to all the members who participated. Most commissions, committees, and all sections are open to guests. You can also request an appointment to one of these bodies by submitting a “Make Your Mark” involvement form. Contact Juleah Williams at with any questions. Here are a few of the highlights of the recent meeting. All the recommendations mentioned will be presented to the Board of Directors at their next meeting.

Advocating for you and your patients With the Legislature in session, there was extensive discussion about GME funding, Medicaid, scope of practice, telemedicine, direct primary care, and a variety of public health initiatives including obesity and e-cigarettes. TAFP’s CEO, Tom Banning, discussed the status of pending legislation, answered questions and led a town hall-style discussion during the Commission on Legislative and Public Affairs. The commission recommended that TAFP investigate options for Medicaid reform and consider engaging a consultant. The members agreed that the Texas Medicaid program suffers from numerous problems and TAFP needs a better understanding of the problems and various solution options to advocate for specific Medicaid reform. The Commission on Health Care Services discussed the implications of the announcement by the U.S. Department of Health and Human Services that the Centers for Medicare and Medicaid Services will begin shifting some portion of Medicare physician payment from fee-for-service to valuebased models in the next few years. The commission also heard a presentation from the director of medical and clinical services at Wal-Mart regarding their in-store clinics and plans for expansion and discussed the Texas Patient-Centered Medical Home proposal drafted by a sub-committee. A draft set of principles and quality metrics 28

will be circulated amongst the commission and the TAFP Board of Directors for comment before the next meeting. Member services and resource in development The Leadership Development Committee met to continue forming the curriculum for a new year-long leadership program and for a concurrent workshop during the 2015 Annual Session and Primary Care Summit in The Woodlands. Stay tuned for more details on applying for the inaugural class of TAFP’s Family Medicine Leadership Experience. The first of a series of videos in the Embracing Change series was previewed at Interim Session and the board and the Commission on Membership and Member Services discussed resources in development to accompany the videos. Look for Embracing Change at TAFP is an ACCME-accredited provider of continuing medical education and has maintained that status since 1996. Staff and volunteers collaborate to plan and produce education for members and ensure compliance with all requirements. At Interim Session, the Commission on Continuing Professional Development celebrated the four-year reaccreditation that was granted by ACCME on July 31, 2014. public health and research TAFP meetings are an opportunity to gather and participate in discussion on a variety of


topics. Section meetings are held at TAFP’s Interim and Annual Session on maternity care, rural health, and research and are intended for any member to show up and participate. The Section on Research met and heard from Kim Fulda with the North Texas Primary Care Research network. They hope to have representatives from all research networks at the Annual Session meeting. The Section on Maternity Care and Rural Physicians usually meet together. At Interim Session they discussed initiatives intended to increase interest in medical students and residents in pursuing full scope family medicine in a rural setting after training. They also made a recommendation that TAFP draft a position paper to prioritize funding for family medicine residency programs that emphasize obstetric care including continuity care and operative cesarean sections. The Commission on Public Health, Clinical Affairs, and Research also has interesting discussions and guest speakers. Any member is welcome to attend as a guest. At Interim Session, the commission heard from Rachel Wiseman from DSHS on infectious diseases and Dr. James Mobley presented on Ebola. Future topics may include physician suicide prevention, burn out, and telemedicine and telepsychiatry for physicians. Organizational matters The Nominating Committee met to identify candidates for positions on the Board of Directors. They selected two candidates for one at-large position and two candidates for the new physician position on the board of directors. TFP will profile the four candidates in the Summer issue. The Section on Special Constituencies and the Sections on Medical Students and Residents also have the ability to select nominees for the board. The Member Assembly will elect members of the board and officers at Annual Session and Primary Care Summit in The Woodlands, Nov. 12-15.

Here is the proposed slate of directors and officers for 2015-16: President-Elect: Tricia Elliott, MD Vice President: Tamra Deuser, MD Treasurer: Janet Hurley, MD Parliamentarian: Rebecca Hart, MD Delegate to AAFP: Linda Siy, MD Alternate Delegate to AAFP: Doug Curran, MD New Physician Director: Emily Briggs, MD, MPH; Alyssa Molina, MD At-large Director: Brett Johnson, MD; Christina Kelly, MD Resident Director: Shiv Agarwal, MD Medical Student Director: Chris Trinh The Bylaws Committee reviewed recent changes to the AAFP bylaws and made recommendations to ensure alignment. They recommended a change to clarify that members may join the component (local) chapter that fits their needs. This amendment, along with others proposed last summer will be voted on by the membership at the Business and Awards Lunch during the TAFP Annual Session and Primary Care Summit in The Woodlands. The proposed amendments will be printed in the summer issue of Texas Family Physician. The Finance Committee reviewed the combined 2014 audit for TAFP and NPI. There were no major findings. The committee also reviewed and made changes to TAFP’s investment allocation. The Commission on Academic Affairs is recommending that the two sections that have met in conjunction with their meeting sunset and their functions be absorbed by the commission. The two sections are Section on Medical Student Education and Section on Family Medicine Resident Education.

The Nominating Committee is recommending to the board that Drs. Troy Fiesinger and Lindsay Botsford be confirmed as TAFP’s delegate and alternate delegate, respectively, to the TMA Interspecialty Society for a term of three years. Fiesinger has served as the alternate delegate from TAFP for many years and Botsford has been actively involved with both TMA and TAFP since medical school and residency and is a graduate of TMA’s Leadership College. Members from across the state were selected for scholarships to attend AAFP’s Annual Chapter Leadership Forum and National Conference of Constituency Leaders. They include Dusty Narducci, MD; Bhavana Mocherla, MBBS; Adana Amechi-Obigwe, MD; Tasaduq Mir, MD; Puja Sehgal, MD; Samuel Wang, MD; and Stephanie Roth, MD. They join the official representatives to NCCL Ann Messer, MD; Mary Nguyen, MD; Bruce Echols, MD; Ikemefuna Charles Okwuwa, MD; and Alicia Wooldridge, MD. The Commission on Continuing Professional Development selected program chairs for TAFP’s educational programs for the near future. Program chairs include Kristi Salinas, MD, and Karla Toledo-Frazzini, MD, for the 2016 Texas Family Medicine Symposium in San Antonio; Ikemefuna Charles Okwuwa, MD, for the 2016 C. Frank Webber Lectureship; and Jennifer Culver, MD, and Tasaduq Mir, MD, for the 2016 Annual Session and Primary Care Summit in Dallas.

Medical students met and held elections for officers and delegates for the coming year. Chris Trinh from TCOM was elected chair and the nominee for the student director position on the TAFP Board of Directors, Herbert Rosenbaum from UT Southwestern was elected secretary, and Carissa Huq from Texas A&M was elected chair-elect. The delegate and alternate to AAFP’s National Conference are Dan Nguyen from Texas Tech Amarillo and Blessing Amune from UT San Antonio. The FMIG liaison is Sarah Hutchison from TCOM. The delegates and alternates to TAFP’s Member Assembly are Kanza Muzaffar from Texas Tech, Tonya Sweezer from TCOM, Jean Yau from Baylor, and Sarah Abdellatif from TCOM.

The Woodlands Waterway Marriott • The Woodlands

Member highlights

was elected chair and Shiv Agarwal, MD, from JPS, was elected to be the nominee for the resident director on the TAFP Board of Directors. They elected Charvi Shah, MD, as vice chair and Soraira Pacheco, DO, as secretary. Both are from UTMB Galveston. The delegate and alternate to National Conference are David Aldrete, MD, from UT San Antonio, and Rebecca Burke, MD, from UTMB Galveston. The delegates and alternates to TAFP’s Member Assembly are Samuel Mathis, MD, from Memorial Herman; Michael Hansen, MD, from UT Houston; Tracey Angadicheril, DO, from UTMB Galveston; and Lorraine Charles, MD, from UT Tyler. The resident liaison is Heather Aquirre, DO, from Christus Spohn.

Annual Session & Primary Care Summit

The commissions reviewed and provided feedback on various member services and activities including production of Texas Family Physician, educational programming, Texas Conference of Family Medicine Residents and Students, the Texas State Family Medicine Preceptorship Program, and much more.

Annual Session is moving to November!

The Section on Residents held elections for officers and delegates. Nish Shah, MD, from San Jacinto Methodist,



A new way to train family physicians By Richard Young, MD what is the best way to train comprehensive full-service family physicians to learn how to thrive in underserved rural Texas? How have duty hour restrictions affected residents’ training with this goal in mind? JPS might have some answers. The John Peter Smith Hospital Family Medicine Residency Program was chosen to be one of 14 programs to participate in the Preparing the Personal Physician Practice (P4) experiment, which was conducted from 2007 to 2012. The leading organizations that regulate family medicine residencies allowed JPS and 13 other programs across the U.S. to blow up their curricula and start all over. JPS innovated its curriculum in two primary ways. This is a report on some of our preliminary results. First, we allowed our residents to stay for one extra year of training, but it was totally optional. This extra year could include just about anything the resident wanted to do, within reason. The most common choice was a combination of maternity care, rural, and global. Other popular options were sports medicine and geriatrics. A few residents chose hybrid years, extra ER training, extra hospital training, and other combinations. Most stayed for an entire year, but some left in the middle of the fourth academic year, which we were completely supportive of. The second layer of innovation was to take the career passions of our residents and get them involved in that experience as early as possible. If a young resident had a passion for taking care of pregnant women, why just shove that passion into a fourth year? Why not start them earlier? We thought the earlier, the better. The curriculum for the intern year was fairly fixed. We had about two weeks we could play with. But starting in the second year, the residents could receive a few extra months of training in whatever curricular area they chose. They spent extra time in this area their third year and most of their time the fourth year, though we made it clear that we expected that their comprehensive family physician brain would not atrophy during the most concentrated fourth year. Residents were still expected to be able to cover general family medicine clinics, medicine call, and ICU call. One of the central questions of the P4 experiment was “does it make a difference?” Some of the residents did extra training, but if their careers look no different, then why bother with the extra training? Why should residencies hassle with the changes? Preliminary results of the JPS graduates show that the extra training indeed makes a difference. Specifically I want to report on the results of our graduates who had extra maternity care training. Compared to all other JPS graduates, those who completed extra maternity care training were more likely to provide prenatal care (90 percent vs. 13 percent), deliver babies vaginally (80 percent vs. 7

percent), and perform primary C-sections (80 percent vs. 6 percent). They were more likely to place IUDs (100 percent vs. 47 percent) and offer vasectomies (40 percent vs. 4 percent). However these graduates were not just watered-down obstetricians. They were also more likely to work in underserved rural areas (30 percent vs. 23 percent), Health Profession Shortage Areas (25 percent versus 16 percent), and take care of hospitalized adult patients (87 percent vs. 59 percent) and newborns (93 percent vs. 19 percent). There were no differences in other outcomes such as providing elderly care (100 percent vs. 89 percent), nursing home care (30 percent vs. 24 percent), and ER coverage (33 percent vs. 51 percent). Final results on the differences in practice patterns of JPS graduates versus other residencies will be available soon. Early results were that the average JPS graduate (3- and 4-year trainees) provided a more comprehensive basket of services to their patients than the graduates of the other 13 P4 residencies. Since the completion of the P4 experiment, the JPS Family Medicine Residency has transitioned to the Accreditation Council for Graduate Medical Education Length of Training experiment. We are not changing much of what we have created, because it worked so well for us. One of our challenges has been to manage the large interest in the extra training options of our residents, especially for maternity care. In the early days, the residents had a lot of freedom to set up the extra year as they desired. The faculty has had to tighten the curriculum to try to make sure that all trainees have a meaningful experience, but we still allow as much individualization as practical. A strong positive of this whole journey for the faculty and residents has been how engaged the residents are in taking ownership of their education. The faculty’s role as mentors and coaches has grown, and it’s very rewarding. Our message to other residencies is to innovate. The future of family medicine and the health care system remains uncertain. However, the interest of our residents to serve patients and provide comprehensive patient care services remains unchanged. By forming a collaborative educational process with our residents and providing them educational opportunities that match their specific interests, we can show that this process is associated with a meaningful difference in the scope of their practices. This is exactly what the underserved citizens of Texas need.

Our message to other residencies is to innovate. The future of family medicine and the health care system remains uncertain. However, the interest of our residents to serve patients and provide comprehensive patient care services remains unchanged.



Richard Young, MD, is director of research and co-associate program director of the John Peter Smith Family Medicine Residency Program. He is a clinical associate professor of family medicine at the University of Texas Southwestern Medical School, and he blogs at

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Texas Family Physician, Spring 2015  

The spring 2015 edition of the quarterly magazine of the Texas Academy of Family Physicians.

Texas Family Physician, Spring 2015  

The spring 2015 edition of the quarterly magazine of the Texas Academy of Family Physicians.