Texas Family Physician, Q3 2018

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TEXAS FAMILY PHYSICIAN VOL. 69 NO. 3 2018

TEXAS FAMILY PHYSICIAN OF THE YEAR

Jorge Duchicela

PLUS: Meet The Candidates For TAFP Board Of Directors Why MIPS-eligible Docs Need An EIDM Account



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INSIDE

JONATHAN NELSON

TEXAS FAMILY PHYSICIAN VOL. 69 NO. 3 2018

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Texas Family Physician of the Year

The Texas Family Physician of the Year for 2017-2018, Jorge Duchicela, MD, FAAFP, of Weimar, is an innovator committed to the family medicine specialty. He has a talent for connecting and building the communities he belongs to and inspiring those around him to dream big, too. Congratulations, Dr. Duchicela. By Kate Alfano

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Meet the candidates

Five members placed their names in the hat for three positions on the TAFP Board of Directors.

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Learning to lead

Great leaders go far, and the Family Medicine Leadership Experience is positioning the next generation of family medicine leaders to go the distance. By Jean Klewitz

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Research: Codes for reimbursement are inadequate for reporting primary care physicians’ work

By Richard Young, MD; Sandy Burge, PhD; Kaparaboyna Ashok Kumar, MD; and Jocelyn Wilson, MD

6 FROM YOUR PRESIDENT A plea for psychiatric support 10 MEMBER NEWS FPs named TMA Health Heroes | AAFP names Award for Excellence in GME recipients | Dallas Chapter installs officers | Interim Session report 13 BYLAWS Proposed changes to the TAFP Bylaws 22 PRACTICE MANAGEMENT The benefits of having an Enterprise Identity Management account 28 PERSPECTIVE Living an intentional life


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PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 69 NO. 3 2018 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org. OFFICERS president

Janet Hurley, MD

president-elect vice president treasurer

Rebecca Hart, MD

Amer Shakil, MD, MBA

Javier “Jake” Margo, Jr., MD

parliamentarian

Mary Nguyen, MD

immediate past president

Tricia Elliott, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editors

Perdita Henry and Jean Klewitz chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell cover photo

Jonathan Nelson CONTRIBUTING EDITORS Kate Alfano Sandy Burge, PhD Tasaduq Hussain Mir, MD Kaparaboyna Ashok Kumar, MD Jocelyn Wilson, MD Richard A. 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. © 2018 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN [No. 3] 2018

An emphatic plea for psychiatry support in our communities By Janet Hurley, MD TAFP President it’s taken a while for me to be ready to write about this. It is challenging as a physician to have things go wrong with a patient—badly wrong. Such situations are a major cause of physician burnout and job dissatisfaction. Some years ago I had such an event, and the effect was harrowing. Suffice it to say we need more mental health resources in many Texas communities to provide needed services to patients and support to primary care physicians. As I speak to family physicians across the state, I learn the challenges my region experiences with insufficient mental health access are not unique. I am tired of patients being dismissed from mental health institutions back into the care of their primary care physician because there is no psychiatrist to see them for follow-up. I am tired of the insufficient payment structure that makes psychiatrists move to cash-only arrangements, limiting a patient’s ability to afford their care. I’m tired of having to treat refractory depression, advanced bipolar, and psychosis, simply because there are limited psychiatrists to do it. This simply needs to change. My patient had challenges at home, which made it difficult for them to get their mental health condition to remission. I referred this patient to psychiatry, yet there was no one who took their insurance. There was a change in the home environment that helped a great deal, yet the patient returned back to the dysfunctional situation they were in with disastrous results. When tensions arose, a family member died, and

my patient was arrested. The stress eventually killed my patient, too. I went over that case in my mind time and time again. The effect kept me up at night. There were legal issues surrounding the case and lawyers were hired. The standard legal mantra is “don’t talk to anyone about anything” and that is good legal advice. Yet this meant that I could not talk out my problems with friends or trusted colleagues, use this case to foster changes in our health system, or share details in a column like this. Yet this case clearly changed me. It was the most disparaging moment in my clinical career. There simply are not enough psychiatrists to take care of mental health needs in our communities. In my region, the local Mental Health and Mental Retardation facility usually has a three month wait, and patients in behavioral crises cannot wait three months to get help. Many of my patients cannot afford to do cash-only arrangements required by most local psychiatrists, and even the cash-only psychiatrists in my area have a several months wait. Those that take insurance sometimes have restrictive criteria about what conditions they will and will not see. And sometimes there are other barriers. Most of the time, it is not possible for patients to make long trips to the neighboring big city for psychiatric care. Thus primary care physicians are left to manage these patients themselves as best they can, even if the patient has dementia and

There simply are not enough psychiatrists to take care of mental health needs in our communities. ... Many of my patients cannot afford to do cashonly arrangements required by most local psychiatrists, and even the cashonly psychiatrists in my area have a several months wait.

[cont. on 8]


“It’s a wonderful thing to practice family medicine in the state of Texas, to have the opportunity to get to know our patients and their families and to take care of them. As members of the Texas Academy of Family Physicians, we don’t just care for our patients in the exam room. We take care of them at the State Capitol, too. “I’m a monthly donor for the TAFP Political Action Committee because if we want policies that are good for our patients and our practices, we have to elect politicians who understand our issues. Support TAFPPAC and make your voice heard.” Justin Bartos, MD 2016 TAFPPAC Award recipient

www.TAFPPAC.org


[cont. from 6]

COMING SOON ON TAFP’S

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TEXAS FAMILY PHYSICIAN [No. 3] 2018

bad mood swings with psychosis, even if they just got discharged from an inpatient behavioral health hospital with suicidal depression, and even if they have severe depression and anxiety with uncontrolled eating disorders on multiple medications. These are real patients, sent to me through the years to manage. Psychiatrists might tell me that I should not be taking care of such patients outside of my typical family medicine scope, yet I have limited other choices. Some care is better than no care. Yet as the first case in this article reminds, sometimes people do bad things or die because of their mental health condition, even with the best care I can provide. I still remember the panicked text I got from a friend of mine whose teenage son had just been discharged from an inpatient psychiatric facility, yet was still hearing voices telling him to kill himself. He had expended all his inpatient psychiatric payable days. The father was told by office staff at both pediatric psychiatry practices in town that they had a three month wait, and his son’s primary care physician would not treat him. Out of desperation he asked for my advice. Out of desperation I saw his son. That day I diagnosed his son’s bipolar disorder, stopped his antidepressant, started a mood stabilizer and an antipsychotic, and essentially begged a pediatric psychiatrist in town to see him within a few weeks. Was I practicing outside of my scope? As a family physician am I supposed to be managing psychotic, suicidal, pediatric bipolar disorder? Did I open myself up to medicolegal risk? This teenager is now a grown man in his 20s with a life full of promise. His father would say I saved his son’s life. I would say this desperate situation should have never happened in the first place and points to a pathetic decay of behavioral

health infrastructure which put this young man’s life at risk. That needs to change. Telepsychiatry is one option, yet beyond consultation, every family physician needs to have access to a psychiatrist from whom they can get advice. Larger health systems should foster such relationships and provide this support to their primary care physicians. Private physicians can get this support free of charge via the Project Echo platform. You can learn more about this at the following web address: https://echo. unm.edu. It is well known that patients with undertreated mental health disorders are costlier to insurance payers. Such patients are more likely to have frequent ER visits, be non-adherent to management for chronic conditions, and will present with more psychosomatic complaints prompting medical work-up. I implore insurance payers to be more creative with payment strategies for mental health conditions to encourage more availability of services for this critical need. Acknowledging that this is a significant source of frustration for Texas family physicians, TAFP will continue to negotiate with payers and advocate for these needs in the Texas Legislature. Yet many of these solutions will need to be found locally within our individual communities, and TAFP will continue to look for ways to provide quality education and ongoing support to our members. It’s too late for the first patient mentioned in this article. Would their outcome have been different if they had seen a psychiatrist? We’ll never know. Yet leaving primary care physicians without necessary psychiatric support is a source for physician burnout that our profession cannot shoulder. I can attest that my shoulders were heavy with that emotional burden for more than a year. Our patients deserve better, and so do we.

Primary care physicians are left to manage these patients themselves as best they can. ... These are real patients, sent to me through the years to manage. Psychiatrists might tell me that I should not be taking care of such patients outside of my typical family medicine scope, yet I have limited other choices. Some care is better than no care.


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MEMBER NEWS

FPs named Health Heroes President of the Texas Medical Association and past president of TAFP, Douglas Curran, MD, of Athens, Li-Yu Mitchell, MD, of Tyler, and Lekshmi Nair, MD, of Manvel, were named Health Heroes during TexMed. The TMA Foundation recognized the physicians for their participation in all three of TMA’s outreach programs: Be Wise — Immunize, Hard Hats for Little Heads, and Walk with a Doc Texas.

AAFP names Award for Excellence in Graduate Medical Education recipients Astrud Villareal, MD, and James Wang, MD, were both honored with AAFP’s 2018 Award for Excellence in Graduate Medical Education. The award is given to only 12 family medicine residents each year out of the 3,500 eligible for the honor. Villareal is the recipient the 2016 Minnie Lee Lancaster, MD, Scholarship Award in Family Medicine and Wang is a current TAFP National Conference Delegate.

Local TAFP chapter installs new officers The Dallas County Chapter of TAFP recently installed new officers. President, Tanya Stachiw, MD; vice president, Zaiba Jetpuri, DO; secretary, Robert Contreras, MD; treasurer, Amer Shakil, MD; member at-large, Rommana Aziz, DO; member at-large, Rathna Nuti, MD; alternate member at-large, Khalida Yasmin, MD; alternate member at-large, Minhaj Khan, MD; and immediate past president, Chrisette Dharma, MD. The chapter recently expanded its leadership roles to include a resident representative, Astrud Villareal, MD, from the UT Southwestern Family Medicine Residency Program and medical student representative, Maggie Leland, from UT Southwestern Medical School. Congratulations to all those assuming their new roles.

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TEXAS FAMILY PHYSICIAN [No. 3] 2018

Meet the candidates for TAFP Board of Directors At the Member Assembly on Friday, Nov. 9, during this year’s Annual Session and Primary Care Summit, members will elect three of their colleagues to the TAFP Board of Directors. Three members are running for two available at-large positions and two members are running to hold the new physician position. According to the TAFP Bylaws, a slate of candidates is proposed by the Nominating Committee. Candidates may also be nominated by local chapters provided the nominations are made at least 90 days prior to the election, and candidates may be nominated from the floor at the Member Assembly. The candidates profiled here are running in the contested elections but the Member Assembly will cast votes for all of TAFP’s elected positions, including officers and open board positions. If you have any questions about the nomination or election process, please contact Kathy McCarthy at kmccarthy@tafp.org.

NEW PHYSICIAN DIRECTOR Lane Aiena, MD, is originally from Beaumont and earned his undergraduate degree from Louisiana State University in Baton Rouge. He graduated from Texas Tech University Health Sciences Center School of Medicine with his medical doctorate and completed his residency training in Conroe, Texas, Lane Aiena where he was named Employee of the Quarter and Employee of the Year. He also won the Resident Teacher Award and a national Family Medicine Resident Advocacy Award for his efforts in Washington, D.C., and Austin, Texas, on behalf of the underserved. During his third year of residency, he was named chief resident. He currently serves on the TAFP Commission on Legislative and Public Affairs and the Leadership Development Committee.

Diana Mercado-Marmarosh, MD, is a family physician in Edna where she provides free diabetic group classes for the community and practices in clinical, hospital, and nursing-home settings. She earned her medical degree from the University of Texas Health Science Center in Houston and completed her Diana Mercadofamily medicine Marmarosh residency at Baylor College of Medicine in 2013, where she was chief resident. She has served as secretary and vice-chair to the Section on Resident Physicians and currently participates in the Commission on Health Care Services and Managed Care, Section on Maternity Care and Rural Physicians, and the Section on Special Constituencies. She is a 2017 graduate of the Family Medicine Leadership Experience. She was selected to be TAFP delegate to the minority constituency at the National Conference of Constituency Leaders in April 2018 and is president-elect of Victoria Goliad Jackson County Medical Society. She enjoys traveling the world and spending time with family and friends.


AT-LARGE DIRECTOR Gerald Banks, MD, MS, FAAFP, grew up in another of the panhandle states — Idaho. He received his Bachelor of Science in biology from Boise State University and his Master of Science in molecular biology from California State University — Long Beach. He completed residency at Rutgers University Gerald Banks in New Jersey, where he was a Larry A. Green Scholar and studied health policy at the Robert Graham Center in Washington, D.C. He was also elected resident delegate to AAFP’s Congress of Delegates and resident trustee to the New Jersey Academy of Family Physicians. He has a keen interest in family medicine health policy, and workforce issues. He has been published frequently and his research has appeared in American Family Physician and Annals of Family Medicine. He was recently the featured speaker at the Association of American Medical Colleges Health Workforce Research Conference in Washington, D.C. He is the current Member Constituency Delegate to the AAFP Congress of Delegates and serves on multiple committees for TAFP. He is a proud graduate of TAFP’s Family Medicine Leadership Experience.

Lesca Hadley, MD, FAAFP, is a Texas native and her rural roots run deep. She graduated from Abilene Christian University with a Bachelor of Science in biology and earned her medical doctorate at Texas Tech University Health Science Center in Lubbock. She completed her family medicine residency and Lesca Hadley geriatrics fellowship at John Peter Smith Hospital in Fort Worth. She is board certified in family medicine, geriatrics, and hospice and palliative care. She practices full-scope family medicine and teaches inpatient and maternity care to residents and students in the Family Medicine Residency Program at John Peter Smith Hospital. She also serves as the Geriatric Fellowship Program Director. She is passionate about preparing trainees to care for patients facing complex social, emotional, and medical problems. She also has a love for global health and has been grateful for the opportunity to provide medical care along with education in several countries.

Ikemefuna “Ike” Okwuwa, MD, FAAFP, graduated from the University of Benin Medical School in Benin City, Edo State, Nigeria. He completed residency training at Texas Tech University Health Sciences Center of the Permian Basin, where he’s currently the residency program director. He was Ike Okwuwa elected to be a representative at the National Conference of Constituency Leaders to the Congress of Delegates in 2015, served as an alternate delegate the same year, and as a special constituency delegate in 2016. He served on the Rules Committee during the 2016 Congress of Delegates. He’s previously served as the new physician member on TAFP’s Board of Directors and is a current member of AAFP’s Commission of Members and Member Services. He is chairman on both the Board of Directors of Permian Basin Health Network and the Physician-Hospital Organization at the Permian Basin.

www.tafp.org

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MEMBER NEWS

Highlights from TAFP’s Interim Session • April 13-14, 2018 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 by submitting a “Make Your Mark” involvement form. Contact Juleah Williams at jwilliams@tafp.org 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.

ADVOCATING FOR YOUR PRACTICE AND YOUR PATIENTS Dr. Dan Crowe of Superior Health Plan discussed the company’s recent effort to manage treatment of chronic pain and substance use disorders in Texas with the Commission on Health Care Services and Managed Care. He discussed the need to increase the use of medication-assisted treatment and the number of physicians credentialed to use it. He also discussed how Project ECHO is being used by those who prescribe MAT for opioid-dependent patients. It is a video conference system to deal with tough cases with the goal of extending training to primary care physicians. The Commission on Health Care Services and Managed Care also heard an update on the implementation of Texas’ telemedicine legislation. TAFP is monitoring the market and communicating with lawmakers and with the Texas Association of Health Plans to ensure health plans are complying with the law. The Commission on Legislative and Public Affairs discussed the results of a legislative survey of TAFP members. They also discussed a recent Florida law that would allow pharmacist prescribing under physician delegation and protocol for point-of-service, CLIA-waived testing. Dr. 12

Troy Fiesinger from the AAFP Commission on Governmental Advocacy led a discussion of federal initiatives and AAFP’s involvement. MEMBER SERVICES AND RESOURCES IN DEVELOPMENT The Section on Special Constituencies recommended that TAFP begin sending five alternate delegates to the AAFP National Conference of Constituency Leaders each year along with the five delegates. The five delegate seats are becoming more contested and the conference has proven to be a great opportunity to develop leaders for TAFP and give them opportunities for leadership at the national level. The alternate delegates would commit to attending the conference for two consecutive years and assume the role of official representative in their second year. The Commission on Membership and Member Services recommended the creation of a TAFP Humanitarian Award. The award would honor members exhibiting extraordinary humanitarian efforts in the U.S. and around the world. The award isn’t intended to be given annually but only when a deserving member is identified. If you know a colleague who should be honored, contact the staff for more information.

TEXAS FAMILY PHYSICIAN [No. 3] 2018

The Commission on Membership and Member Services also discussed ongoing efforts to facilitate informal discussion opportunities at TAFP meetings. TAFP members served as facilitators of five Member Community meetings at Interim Session — Early Career Physicians, International Medical Graduates, Hospitalist and ER Physicians, Direct Primary Care Physicians, and Solo and Small Group Physicians. The Section on Maternity Care and Rural Physicians met with two of the three recipients of the new TAFP Scholarship to attend the AAFP FamilyCentered Maternity Care Live Course. The three recipients have provided written testimonial that will be shared at the next section meeting and will be sharing what they learned in their communities. The commissions provided feedback on various member services and activities including production of Texas Family Physician, educational programming, educational programming for residents and students, the Texas Family Medicine Preceptorship Program, and much more. PUBLIC HEALTH AND RESEARCH The Section on Research has been in existence for a few years and last year began holding monthly conference calls with rotating speakers. For more information about the next call, contact Perdita Henry at phenry@tafp.org. Krista Del Gallo from the Texas Council on Family Violence shared a presentation with the Commission on Public Health, Clinical Affairs and Research on Intimate Partner Violence and the resources available to physicians who screen for it during medical visits. The Commission on Public Health, Clinical Affairs and Research also heard a presentation on transgender health

care and the challenges transgender patients face while navigating the health care system and discussed social determinants of health with Dr. Edward Dick of Integrated Health Services at Methodist Healthcare Ministries. ORGANIZATIONAL ISSUES The Nominating Committee met to identify candidates for leadership positions. In addition to nominating members for officer and delegate positions, they selected candidates for two at-large and one new physician position on the Board of Directors. You can read about the candidates in contested races in this issue of Texas Family Physician. 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 Arlington, November 9. Here is the proposed slate of directors and officers for 2018-19: President-elect: Jake Margo, Jr., MD Treasurer: Amer Shakil, MD, MBA Parliamentarian: Mary Nguyen, MD Delegate to AAFP: Doug Curran, MD Alternate Delegate to AAFP: Troy Fiesinger, MD New Physician Director: Lane Aiena, MD; Diana Mercado-Marmarosh, MD At-large Director: Gerald Banks, MD; Lesca Hadley, MD; Ike Okwuwa, MD Special Constituency Director: Stuti Nagpal, MD Resident Director: Janie Gibson, MD Medical Student Director: Justin Fu The Bylaws Committee made several recommendations that


will align TAFP’s Bylaws with AAFP’s Bylaws in the areas of ethics and dues and admission fees. The amendments will be voted on by the membership at the Annual Business Meeting during the TAFP Annual Session and Primary Care Summit in Arlington. The Finance Committee reviewed TAFP’s financial reports and investments. The committee also received an update on TAFP’s investment portfolio. MEMBER HIGHLIGHTS The Nominating Committee recommended to the board that TAFP nominate Dr. Amer Shakil for Chair of AAFP’s Commission on Education, Dr. Troy Fiesinger for Chair of AAFP’s Commission on Governmental Advocacy, and Dr. Clare Hawkins for Chair of AAFP’s Commission on Health of the Public and Science. They are all in their fourth year of service on their commission. The Nominating Committee also recommended that Dr. Troy Fiesinger be reappointed as TAFP’s Delegate to TMA’s Interspecialty Society. An Alternate Delegate will be named at the August 2018 meeting of the Board of Directors. 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 Lesca Hadley, MD, for the 2019 C. Frank Webber Lectureship and Crawford Allison, MD, and Nidhisha Anireddy, MD, for the 2019 Annual Session and Primary Care Summit in The Woodlands. The Section on Residents held elections for officers and delegates. Daniel Nwachokor, MD, MPH, from Memorial was elected chair and Janie Gibson, MD, from Scott and White was elected to be the nominee for the Resident Director on the TAFP Board of

Directors. They elected Arindam Sarkar, MD, from Baylor as chair-elect and Sophia Kim, MD, from Texas Tech El Paso as secretary. The delegate and alternate to National Conference are James Wang, MD, from Texas Tech Permian Basin and Amanda Patterson, MD, from Baylor. The delegates and alternates to TAFP’s Member Assembly are Jean Ghosn, MD, from Memorial; Dominic Maneen, DO, MBA, from Memorial; Danny Joseph, MD, from Methodist Houston; and Anum Maniar, MD, from Methodist Houston. The resident liaison is Jessica Bracks, MD, from UT Tyler and the TAFP Foundation Resident Advisor is Jasmeet Kaur, MD, from Dell. The Section on Medical Students met and held elections for officers and delegates for the coming year. Justin Fu from Baylor was elected chair and the nominee for the Student Director position on the TAFP Board of Directors. Emily Tutt from TCOM was elected chair-elect and Mac Light from Baylor was elected secretary. The delegate and alternate to AAFP’s National Conference are Jen Nordhauser from UT San Antonio and Nelson Boland from Baylor. The FMIG liaison is Ryan Trantham from Baylor. The delegates and alternates to TAFP’s Member Assembly are Alice Jean from UT Southwestern, Kendra Williams from McGovern, Marc Ghosn from UIW, and Jordan Hartman from Texas Tech. Edward Strecker from UTMB was elected to the new position of TAFP Foundation Medical Student Advisor.

PROPOSED AMENDMENTS TO TAFP BYLAWS The proposed amendments to the TAFP Bylaws are in accordance with the TAFP Bylaws, Chapter XVII, Amendment of Bylaws. An affirmative vote of at least two-thirds of the members present and voting at the annual business meeting shall constitute adoption. If you would like a complete copy of the TAFP Bylaws, contact Kathy McCarthy at (512) 329-8666, ext. 114. The Bylaws Committee and the Board of Directors recommend adoption of these amendments. Chapter VII. Ethics SECTION 2. VIOLATION OF PRINCIPLES The accused may answer in writing but failure to do so shall not be an admission of guilt or a waiver of the accused right to a hearing. The Board shall give the accuser and the accused opportunity to be heard, including oral arguments, and the filing and consideration of written briefs, conclude the hearing and within 30 days render a decision. The affirmative votes of the majority of the Board members present and voting shall constitute the verdict of the Board which by such vote may exonerate, censure, suspend, or expel the accused member. The decision of the Board shall be signed by the President Board Chair and Secretary the Parliamentarian of the Academy. No member of the Board not present for the entire time of the hearing shall be entitled to vote.

Chapter IX. Dues and Admission Fees SECTION 1. Dues of the Academy will be set and can be changed by a two-thirds vote of the Board of Directors. The Board of Directors is empowered to levy an admission fee that shall accompany any new applications for membership. SECTION 4. Any member whose dues are unpaid at the time of any annual business meeting shall be ineligible to vote or hold office. Any member who pays dues on a calendar year basis shall be considered delinquent if his/her dues are unpaid as of July 1 and shall be removed from membership 30 days after notice from the Treasurer. Any member who pays dues on an academic year basis, such as a student or resident member, shall be considered delinquent if his/her dues are unpaid as of December 31 and shall be removed from membership thirty 30 after notice from the Treasurer. Upon completion of residency or extended training, such a member may apply for active membership and may hold such membership for the remainder of the calendar year without paying the standard dues for this category. , but he/she must pay the usual and customary admission fees.

www.tafp.org

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JEAN KLEWITZ

YOUR ACADEMY

The third class of the Family Medicine Leadership Experience poses on the dais in one of many hearing rooms at the State Capitol at the end of a long day of advocacy training.

Family Medicine Leadership Experience By Jean Klewitz you’ve finished your medical school and completed your residency program and now you find yourself stripped of your white coat and standing before a group of colleagues at a meeting. You’ve gained an abundance of knowledge in your medical training, but as you look around the room you come to a startling realization. You didn’t take any leadership courses in medical school, yet you’re in a leadership role. Now what? “We go to meetings, we sign up for meetings, we sit in meetings, but you’re never taught how to lead a meeting,” says TAFP member, Mary Nguyen, MD, of Castroville. Not to worry, the Academy has what you need. TAFP has developed a leadership development program designed for new physicians, mid-career physicians, and residents. The year-long program is called the Family Medicine Leadership Experience. FMLE is intended to guide participants to become excellent leaders. The program offers four sessions throughout the year presented in interactive learning sessions, didactic lectures, case presentations, multimedia presentations, and small-group breakouts. FMLE enhances skills in strategic planning, persuasive communication, financial decision-making, negotiation, conflict resolution, and public speaking. At the 2016 Annual Session, the inaugural FMLE class presented their final projects and graduated from the FMLE program. At our 14

TEXAS FAMILY PHYSICIAN [No. 3] 2018

last annual session, the 2017 class graduated. While this free program is relatively new, it has already proven to be helpful to those who’ve attended. One of the 2016 graduates, Ikemefuna “Ike” Okwuwa, MD, says it was one of the best decisions he’s made. “You meet like-minded people interested in leadership, you build lifelong relationships, and you get one-on-one time with TAFP/AAFP leadership.” Stuti Nagpal, MD, who practices at UT Health San Antonio, says the networking training helped her connect and share in the everyday rewards and challenges of family medicine. “You realize, you’re not the only one,” she says. The program was the brainchild of the Commission on Academic Affairs and TAFP physician leader, Lindsay Botsford, MD, of Sugar Land. She heard from family medicine residents that they wanted leadership training, so she took the idea to TAFP’s Leadership Development Committee. Members spent 2014 and 2015 crafting a longitudinal curriculum designed to enhance physicians’ knowledge, develop skills, and form relationships with other up-and-coming leaders. In 2016, TAFP’s Family Medicine Leadership Experience was launched. Given the foundational role of primary care in high-functioning health care systems, TAFP believes family physicians should occupy as many leadership positions as possible. Those leaders should be capable of articulating a compelling vision for the future and be able to win the trust and support of others to carry out the vision. The FMLE program develops necessary skills that get physicians in front of the room, leading. “So much of leadership is believing you can make a difference,” Botsford says. “The FMLE will give a physician enough training to take a bigger role in their practice, step up and say ‘yes’ when asked to be a leader.” For more information and to apply for next year’s FMLE class, visit www.tafp.org/membership/FMLE.


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Jorge Duchicela Self-starter, rural role model, community benefactor, and international connector

Meet the Texas Family Physician of the Year

jorge duchicela, md, is the embodiment of a successful family physician, though it was with great humility and gratitude that he accepted the honor as the 2017-18 TAFP Family Physician of the Year at the Academy’s Annual Session and Primary Care Summit Business and Awards Lunch last November. He recognizes that many physicians around the state and country do what he does: provide high-quality, compassionate, and comprehensive medical care for generations of patients and improve their community through active involvement. Duchicela’s brand of medicine, though, extends further. He has been instrumental in leading the Youens & Duchicela Clinic, a rural private practice in Weimar, Texas, that is successful by every metric. He mentors family medicine residents and demonstrates the immense personal and professional fulfillment of rural medicine. He co-founded a nonprofit to improve education for local youth and secured sports facilities to provide safe, dedicated space for young athletes. He founded an international nonprofit to help medical students serve a community in need abroad and learn to better communicate with Latino patients at home. And he is actively involved in organized medicine to promote legislative involvement, physician autonomy, practice innovation, and wellness. 16

TEXAS FAMILY PHYSICIAN [No. 3] 2018

Born in Ecuador, Duchicela was 8 years old when his family moved to Costa Rica and later to Panama to seek new opportunities and escape tensions brewing from the Cold War. His father’s employer, an American food company, allowed their employees’ children to receive their high school education in the United States, leading Duchicela to a boarding school in Wisconsin when he was 13. Though he had an older brother with him for two years, he was on his own during his school years and after, sowing the seeds of independence, self-sufficiency, and persistence that would benefit his future career in medicine. He originally intended to return to Ecuador after high school, but he won a partial scholarship to play soccer at the University of Wisconsin-Milwaukee, a Division I program. So he stayed, supplementing his income with on-campus work while pursuing a biochemistry/premedicine degree. “I owe my decision to pursue medicine to both my mom and my dad,” Duchicela says. “My dad had very high standards for academic and intellectual development. He instilled that in all six of his children; all of us became professionals. My mom instilled in me compassion, human relations, generosity, and service to people in the community.”

JONATHAN NELSON

By Kate Alfano


www.tafp.org

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JONATHAN NELSON

Jorge Duchicela, MD, instructs Leah Mikesky, a second-year medical student at the University of Texas Southwestern Medical School, as they conduct an examination of George Berger, one of Duchicela’s longtime patients.

Though playing soccer helped fund his undergraduate education and is partly responsible for introducing him to his wife, Juanita — who saw him play and struck up a conversation in the university cafeteria — he admits it was challenging to maintain an active training and travel schedule along with a rigorous academic course load. He was also anxious about applying to medical school since he didn’t know much about the process; he says he didn’t fit the normal profile for a U.S. medical school applicant in the 1970s. Despite that anxiety, his MCAT scores, high undergraduate grades and “other qualities they must have seen in me” granted his admission to the University of Wisconsin School of Medicine in Madison. His specialty of choice was not family medicine, though, and because the medical school didn’t have a compulsory family medicine rotation he wasn’t exposed to it during these early years in his education. Instead he wanted to pursue plastic surgery, the specialty he felt would allow him to keep in touch with the culture and people of his ancestors in Ecuador — his longtime dream. At the time he was in contact with his medical school’s chief of plastic surgery who was a good friend of a plastic surgeon at Stanford who was a good friend of a plastic surgeon in Ecuador, and the three of them had created a nonprofit, Interplast, to help children with cleft lip and cleft palate in Ecuador. “I thought that was a great idea, maybe I can do that. I can spend time here in the United States and in Ecuador.” 18

TEXAS FAMILY PHYSICIAN [No. 3] 2018

So when it came time to apply to residency, Duchicela and his young family — his wife and two children who were born during his first and third years of medical school — looked around the country for a surgical program that could put him on his path to plastic surgery. They wanted a location in a warmer climate and a large urban area closer to Latin America, settling on the University of Texas Medical Branch in Galveston. During his first year in residency, though, his father became terminal with lung cancer and moved from Panama to Galveston to be closer to his son during his treatment. It was through this experience that he witnessed the comprehensive and compassionate care provided by UTMB family physicians and first learned of the value of “preventive, comprehensive care intertwined with evolving continuity” that family medicine provides. Touchingly, he describes the moment when one of the founding physicians of the UTMB Department of Family Medicine, Alice Anne O’Donell, MD, “saw my father die, and with compassion and tenderness she turned the machine off.” Later the following year, while he was still in the surgery program, O’Donell, Angela Shepherd, MD, and another family physician colleague delivered Duchicela’s third child and took care of the newborn at St. Mary’s Hospital in Galveston. “That’s how I became acquainted with family medicine, not only the specialty but actually how family physicians take care of patients


and their philosophy of care,” Duchicela says. “I learned a lot in surgery in the year and a half that I was there but in retrospect I felt that I was always a family medicine doctor at heart, I just didn’t know it. It was a great match for me for what I wanted — intellectually challenging, scientifically based, but also humanistic in its execution.” From Galveston, Duchicela spent a year with Bill Gonzaba, MD, of the Gonzaba Medical Group in San Antonio that he likens to a fellowship — long hours but invaluable experience and knowledge about how to grow his own practice. He was looking for his own place, though, and soon found himself in a Dairy Queen meeting with the longhaired, boot-wearing Robert Youens, MD, who at the time was exhausted from a period of relentless and fruitless recruiting to his rural town of roughly 2,000 located halfway between San Antonio and Houston. “Youens defined the 24/7 work of the mystical country doc of yesteryear’s lore,” Duchicela said in his acceptance speech for the award. “Running a solo practice amidst farmers, ranchers, laborers, migrants, students, business owners, the wealthy, the poor, the illiterate, the erudites; he took care of them all. He, a third-generation family physician, had inherited a wealth of medical and business knowledge, scales that I doubt he himself was aware of the magnitude of this legacy. He was a great teacher to me and I admire him most.” “He was like my soulmate,” Duchicela says. “It was a good match because we were very progressive in a lot of ways, in our thinking, socially and economically; we respected each other. The same things that I held to be valuable he also held to be valuable. … We took pride in seeing patients, in being available to our patients and in getting involved in our community. We thought it was our duty, our responsibility, as family physicians.” His sister, Olga Duchicela, MD, joined them in the year 2000. “She has always been there to help us with our patient care, has been involved with the community. She fit right in with our philosophy of patient care, bringing new skills, innovation, and a refreshing energy to the culture of our workplace.” The physicians worked hard, embodying their slogans, “if it ain’t broken, break it; be innovative, stay ahead of the game, change things; and if something is working well, see if you can make it better.” One major component of their business model was employing the use of medical scribes 25 years ago, well before it became common practice, so the physicians could keep their focus on the patient as the scribes input data to the paper medical record and eventually the electronic medical record. “That model continues to be there and is a well-oiled machine. I am the physician, I am not supposed to look at the screen,” he says. “I am listening to my patient, having significant, culturally appropriate high contact and examining my patient, not diverting my attention. When you do that, you save at least 50 percent of the time.” “For example, if a doctor is able to see 25 patients in a full day, I’m able to easily see — with better amounts of attention because it’s not diverted — 50 patients a day. The workflow is good. The patient feels they have had enough of me during the visit and I can see more patients.” As the movement toward forming groups for better coordinated care gained speed, forward-thinking Duchicela co-founded Alliance ACO, a clinically integrated network of more than 60 family physicians to manage population health for more than 17,000 Medicare beneficiaries and commercially-insured patients in value-based care contracts. The Alliance ACO providers are all independent,

“Dr. Duchicela is known by all in the Department of Family Medicine at UTMB as one of the most caring, compassionate, and committed family physicians our residents and medical students have been assigned. He is the role model that we highlight to all our learners as he continues to help us with our resident and medical student curriculum.” — Barbara L. Thompson, MD chair of the UTMB Department of Family Medicine

www.tafp.org

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JONATHAN NELSON

Leah Mikesky observes as Jorge Duchicela, MD, sutures a patient’s laceration.

community-based family medicine physicians in solo or small-group practice in Kerrville, Gonzales, LaGrange, Shiner, Victoria, Weimar, and Yoakum. “As co-founder of the Alliance ACO, Dr. Duchicela is responsible for bringing significant financial resources to these communities including several million dollars in federal funding from [the Centers for Medicare and Medicaid Services] to support the delivery of quality health care in underserved rural areas,” wrote David Spalding, chief operating officer of TMA PracticeEdge, in a nomination letter for the award. “Working with his fellow co-founders and board members, Dr. Duchicela is today ensuring the foundation being built with the support of these investment funds is based upon the best principles of family medicine: continuity of care, comprehensive attention and preventive medicine. Dr. Duchicela has been a driver of this vision, which he believes provides the best health care outcomes for rural communities and a healthier quality of life for all the citizens in rural central Texas.” In concert with maintaining a successful family medicine practice, Duchicela and Youens held their families sacrosanct and would cover for each other if one needed to be away from the practice. “That made it a very pleasant, idyllic kind of life that we lived,” Duchicela says. “Our families were not suffering at all. His kids and my kids did very well even though they were raised in a small community.” Two of Duchicela’s children are family physicians and his 20

TEXAS FAMILY PHYSICIAN [No. 3] 2018

youngest daughter is a computer scientist. One of Youens’ children is a family physician, another is a pathologist, and another is a nurse anesthetist. Despite the demands of his practice and dedication to his family, he kept the promise to his rural town and has continued to contribute significant time to community betterment and philanthropic endeavors. “The communities of Weimar and Schulenburg are wonderful to live in and I’m very humbled by the fact that I’m able to add a little bit to it because they’ve pretty much got everything they need,” Duchicela says. Duchicela started the local soccer program more than 20 years ago — a nod to the sport that allowed him to obtain his U.S. education — and along with Ken Yoder, MD, a local retired surgeon, was instrumental in acquiring 19 acres of land for the city to develop a multiuse sports complex for soccer, walking trails and other recreation. His clinic organizes an annual 5 kilometer fun run during the local Gedenke! Weimar German Festival with proceeds benefitting the sports complex. He co-founded SWIFT (Schulenburg and Weimar In Focus Together), a community-based nonprofit to support and enhance the education of local elementary school children by bringing in funding and volunteers from AmeriCorps. “Recognizing that any youth not reading at grade level by third grade has a very high probability of ending up in the welfare or judicial system, the vision was to raise


— Jorge Duchicela, MD Texas Family Physician of the Year

funds for tutoring students struggling with reading and math in the local public and parochial elementary schools,” wrote Sylvan Rossi, longtime SWIFT executive director, in a nomination letter. “Dr. Duchicela realized that to make long-term improvement in the local quality of life, the effort had to begin with our youth.” Duchicela also founded Cacha Medical Spanish Institute (Cachamsi) that brings medical students to Chimborazo, Ecuador, to help them learn or improve their medical Spanish, and improve medical care for Latino patients in the United States and the native people. This allowed him to realize his longtime dream to serve the people of his ancestors in Ecuador while also helping his larger community of Latinos in the United States. Since the organization’s founding, more than 1,000 students have participated in the immersion program. “Dr. Duchicela’s program is truly a leader in what can and should be done to improve the ability of U.S. physicians to work both more effectively in their local communities as well as gain a deeper understanding of global health,” wrote Yvonne Maldonado, MD, professor of Pediatrics and Health Research Policy and chief of the Division of Pediatric Infectious Diseases at Stanford University School of Medicine, in a nomination letter. And throughout much of his career in Weimar he has taught medical students and residents in his clinic. He and Youens hosted family medicine residents through UTMB’s Rural Training Track Family Med

JONATHAN NELSON

“I learned a lot in surgery in the year and a half that I was there but in retrospect I felt that I was always a family medicine doctor at heart, I just didn’t know it. It was a great match for me for what I wanted — intellectually challenging, scientifically based, but also humanistic in its execution.” Dr. Duchicela is proud of his team at the Youens & Duchicela Clinic in Weimar, Texas.

icine Residency Program, and later this program developed into the Integrated Rural Training Track Program, of which Duchicela served as medical director. The training track produced 17 graduates from 2000 to 2015, and more than 70 percent of these graduates selected a rural or underserved location for their first practice location. “Dr. Duchicela is known by all in the Department of Family Medicine at UTMB as one of the most caring, compassionate and committed family physicians our residents and medical students have been assigned,” wrote Barbara L. Thompson, MD, chair of the UTMB Department of Family Medicine, in a nomination letter. “He is the role model that we highlight to all our learners as he continues to help us with our resident and medical student curriculum.” On the statewide level, Duchicela is active in TAFP, the Society of Teachers of Family Medicine and the Texas Medical Association. He is the chair of TAFP’s Commission on Legislative and Public Affairs and a member of the TMA Council on Health Care Quality. “I learn from my involvement in these organizations and take it back to my practice to medical students who rotate through my clinic.” As for the future, he is recruiting younger physicians to join him but he hasn’t made plans to retire. “I really enjoy this too much and I’ve been fortunate that my health is good,” he says. “There are so many things we need to do for our patients in this country. I think family medicine is the answer to galvanize what we need to do in order to change for the better.” www.tafp.org

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PRACTICE MANAGEMENT

Why MIPS-eligible clinicians need an EIDM account By TMF Health Quality Institute

T

he Enterprise Identity Management system enables health care providers to establish a single user ID to use across multiple CMS applications. Clinicians and applicable practice staff should have an EIDM account. This article will explain why clinicians who are eligible for the Merit-based Incentive Payment System should have an account and how to open and maintain an account. What can I do with an EIDM account? Providers and their practices should have an EIDM account so they can use the CMS Enterprise Portal and the Quality Payment Program Portal and access the reports contained in both. QPP Portal — The QPP Portal (https://qpp.cms.gov/login) can be used to submit measures for MIPS. It is advised by CMS to have your EIDM account credentials ready before the QPP Portal opens for MIPS data submission. You also can sign in to the QPP Portal with your EIDM credentials to view scores from previous MIPS reporting; preliminary scores are available until final scores are determined. CMS Enterprise Portal — The reports housed in your CMS Enterprise Portal (https://portal.cms.gov/wps/portal/unauthportal/home/) may help you strategize your approach to MIPS each year. Sign in to access your most recent Quality and Resource Use Report and gain understanding of your provider’s previously attributed patients. When reviewing the QRUR report, a practice can better understand its past performance related to the MIPS Quality and Cost categories by seeing its spending and cost patterns, as well as knowing the beneficiaries attributed to each clinician.

• If you are the first person in your practice to sign up and register your practice in the EIDM, select “Create an Organization.” If your practice already exists in the EIDM system and you are signing up for a role, select “Associate to an Existing Organization” (type in minimal information to search, such as your TIN and state). • Under “Select a Group,” if you are a solo practitioner, select ”Provider Approver > Individual Practitioner.” If you have two or more providers, select “Provider Approver > Security Official.” NOTE: If you completed your registration for an EIDM account and your status is pending, this typically means that an EIDM account is already set up for your practice and is pending approval from your practice’s designated individual with an Approver Role. That individual has a pending approval for the account and you will need to notify that person to approve your role. If that person is no longer at the practice, call (888) 734-6433 or email pvhelpdesk@cms.hhs.gov to ask the CMS Help Desk to facilitate de-activating the role. To avoid this problem in the future, consider adding an additional staff member to these roles as a backup in case someone leaves the practice or is unable to log in. How do I maintain my EIDM account? Each time you log in to your EIDM account, multi-factor authentication — or MFA — is required. Additional information on the MFA may be found at Questions and Answers about Remote Identity Proofing and Multi-Factor Authentication. The password to your EIDM account must be changed every 60 days. The account will be locked if this is not completed. Placing a recurring reminder on your calendar will help you prevent lock-outs.

How do I get an EIDM account?

Free support for MIPS

Prior to beginning your EIDM account application, review the provider list and demographics in the Provider Enrollment, Chain and Ownership System (PECOS) to ensure all information is current. If updates are needed, call (866) 484-8049 or go to https://pecos.cms.hhs.gov/pecos/login. do#headingLv1. Brief tutorial videos on making updates are available.

TMF Quality Improvement Consultants are available to assist you at no cost in reviewing your reports and planning for MIPS.

When you’re ready to start, gather the following information: • All individual National Provider Identifiers; and

Contact a TMF Quality Improvement Consultant for EIDM or any MIPSrelated questions. • Call (844) 317-7609. • Email QPP-SURS@tmf.org. • Complete a Request for Support form.

• Provider Transaction Access Number — this is issued to individual providers from the Medicare Administrative Contractors upon enrollment to Medicare. The individual PTAN is required. PTANs are alphanumeric; you will enter the letters and numbers, including all leading zeros.

For more information on this topic, access the following resources:

NOTE: Group practices must enter two valid individual NPI/PTAN combinations during registration.

• Visit https://tmfqin.org/qpp and create a free QPP Learning and Action Network account. You can then access various resources and webinars.

After checking PECOS and gathering the above information, visit https://portal.cms.gov/ and select “New User Registration.” Use the EIDM User Guide for detailed instructions. Once you have opened your EIDM account, select the specific access you need for MIPS. Log in to the EIDM account and find “Physician Quality and Value Programs.” Select “Request Access.”

• Log in to your free QPP LAN account and view the recorded webinar “Do We Need an EIDM Account? Why Every Practice Needs Access to the CMS Enterprise Portal,” which was held May 9, 2018.

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TEXAS FAMILY PHYSICIAN [No. 3] 2018

• Visit https://tmf.org/qpp for an overview of available QPP support and how to contact TMF.

• Visit the CMS EIDM Overview webpage: https://www.cms.gov/ Research-Statistics-Data-and-Systems/CMS-Information-Technology/EnterpriseIdentityManagement/EIDM-Overview.html.


RESEARCH

Codes for reimbursement are inadequate for reporting primary care physicians’ work Direct observation in the Residency Research Network of Texas 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.

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 kmccarthy@tafp.org.

Richard A. Young, MD Director of Research, Department of Family Medicine JPS Health Network, Fort Worth, Texas Sandy Burge, PhD Department Family Medicine University of Texas Health Science Center at San Antonio Kaparaboyna Ashok Kumar, MD Department Family Medicine University of Texas Health Science Center at San Antonio Jocelyn Wilson, MD Baylor Family Medicine Residency, Garland, Texas

Abstract Background: The purpose of this study was to characterize the content of family physician clinic encounters, and to count the number of visits in which the family physicians addressed issues not explicitly reportable by 99211-99215 and 99354 Current Procedural Terminology or CPT codes with current reimbursement methods and based on examples provided in the CPT manual. Methods: Trained assistants directly observed every other family physician-patient encounter. A visit was deemed to include physician work that was not explicitly reportable if the number or nature of issues addressed exceeded the definitions or examples for 99205/99215 or 99214 + 99354 or a preventive service code, included the physician addressing health care system or social determinant issues, or included the care of a family member. Results: In 982 physician-patient encounters, patients raised 517 different reasons for visit (5,278 total, mean 5.4 per visit, range 1-16) and the family physicians addressed 509 different issues (3,587 total issues, mean 3.7 per visit, range 1-10). Family physicians managed 425 different medications, 18 supplements, and 11 devices. A mean of 3.9 chronic medications were continued per visit (range 0-21) and 4.6 total medications were managed (range 0-22). In 592 (60.3 percent) of the visits the family physicians did work that was not explicitly reportable with available CPT codes: 582 (59.3 percent) addressed more numerous issues than explicitly reportable, 64 (6.5 percent) addressed system barriers, and 13 (1.3 percent) addressed concerns for other family members.

Conclusions and relevance: Family physicians perform cognitive work in a majority of their patient encounters that is not explicitly reportable, either by being higher than the CPT example number of diagnoses per code or the type of problems addressed. To address these limitations, either the CPT codes and their associated rules should be updated to reflect the realities of family physicians’ practices or new billing and coding approaches should be developed.

Introduction The American Medical Association’s book Current Procedural Terminology is the only system recognized by the Center for Medicare and Medicaid Services and is used by most insurance companies for physicians to code their bills for third-party reimbursement.1 In 1995 and 1997, CMS published guidelines for documentation, coding, and billing for evaluation and management or E/M services provided to its beneficiaries that are still used today.2,3 CMS states in its E/M rules that “…in order to receive payment from Medicare for a service, the service must … be considered reasonable and necessary,”2 but there is little further explanation of what exactly defines “necessary.” This responsibility has largely been given to the eight Medicare Administrative Contractors. To define medical necessity, the website of each MAC refers to the CMS guidelines, the CPT codes, and some specifically mention Appendix C of the CPT manual that includes numerous clinical examples for each E/M code. The purpose of our study was to thoroughly describe the issues addressed in family physician office visits and to determine the number of these visits in which the physicians provided cognitive www.tafp.org

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work that was not explicitly reportable under CPT based on the E/M rules and connected examples in the CPT Coding Manual.

Table 1: Patient and visit characteristics Characteristic

Results (n = 982)

Age, mean (SD)

46.4 (22.5)

Gender, No. (%)

Female

602 (61.4)

Male

380 (38.6)

Race/ethnicity, No. (%)

White/Hispanic

532 (54.3)

White/non-Hispanic

233 (23.7)

Black

165 (16.8)

Asian

37 (3.8)

Hawaiian/Pacific Islander

6 (0.6)

American Indian

7 (0.7)

Body mass index, mean (SD)

31.3 (8.0)

Blood pressure, mean (SD)

Systolic

Diastolic

126.5 (19.8) 73.6 (11.4)

History of disease, No. (%)

Hypertension

400 (40.7)

Obesity

306 (31.2)

Diabetes

277 (28.2)

Hyperlipidemia

272 (27.7)

Depression

178 (18.1)

Arthritis

138 (14.1)

Anxiety

109 (11.1)

Headache

93 (9.5)

Asthma

92 (9.5)

COPD

56 (5.7)

Coronary artery disease

50 (5.1)

Chronic kidney disease

49 (5.0)

Primary care physician relationship, No. (%)

Patient saw personal physician

534 (54.4)

Established patient, but did not see personal physician

333 (33.9)

Neither the FP nor the practice was the patient’s primary care physician prior to the observed visit

52 (5.3)

62 (6.3)

Unknown prior practice or FP-patient relationship

Practitioner type, No. (%)

24

Faculty physician

313 (31.9)

PGY4/fellow

PGY3

372 (37.9)

PGY2

262 (26.7)

PGY1

8 (0.8)

18 (1.8)

Electronic medical record visit, No. (%)

978 (99.6)

Number of reasons for visit, mean (SD)

5.4 (2.8)

Number of issues addressed by the physician, mean (SD)

3.7 (2.1)

TEXAS FAMILY PHYSICIAN [No. 3] 2018

Methods Study population: This was a cross-sectional observational study of primary care visits in clinics of 10 family medicine residencies that are members of the Residency Research Network of Texas, or RRNeT. Observers recorded data from every other family physician-patient encounter to allow time to complete all of the study instruments for the index patient encounter and to decrease the burden of their presence on the observed physician. Observers were instructed to be a “fly on the wall” and to impact the encounter as little as possible. A crucial component of data collection was the time required for the physician to complete the encounter, both face-to-face time and non-face time. Observers were instructed to make no statements or ask any questions of the physician until he or she was finished with that encounter and was ready to see the next patient. While the physician was seeing the nonobserved patient, the observer would finish recording relevant data on paper copies of the instruments and await the next eligible patient. If the patient declined to be observed, the next eligible patient was approached. CPT reportable classifications: Briefly, the number of acute and chronic issues addressed in the visit were compared to the descriptions of medical necessity clinical examples in the Appendix C of the CPT manual for the codes 99211-99215 and 9920199205, which was also consistent with the CMS E/M guideline that uses a point counting system over multiple tables.3 The extended care code 99354 was applied if the observed face time was greater than 55 minutes per CMS guidelines (25 minutes for a 99214 plus at least 30 minutes toward the 99354 charge). 4 Complex chronic care coordination codes such as 99487 were not deemed usable because the CPT manual states “… clinical staff time [may not be counted] … on a day when the physician … reports an E/M service….”1 Preventive services such as a well woman visit were counted as being reportable using the appropriate preventive codes. This analysis did not include issues related to CMS rules of documentation elements — bullet points of physical exam elements, e.g. — also required to justify the various codes. This study was approved by the Institutional Review Board of the University of Texas Health Science Center at San Antonio and the individual residencies’ IRBs where required.

Results Researchers observed and recorded 982 physicianpatient ambulatory visits. Patient and visit char-


Table 2: Most common reasons for visit Reasons for visit

% of visits

% of RFVs

Hypertension

19.4% 3.6%

Diabetes Mellitus

14.8%

2.8%

Problem with access to medical care

11.8%

2.2%

Findings of blood tests (cholesterol, e.g.)

11.7%

2.2%

Anxiety

8.8% 1.6%

Headache

8.4% 1.5%

Back pain, ache, soreness, discomfort

8.4%

1.5%

Medical counseling, NOS

8.4%

1.5%

Cough

7.7% 1.4%

Administrative issues, paperwork

7.0%

Depression

6.8% 1.3%

Patient seeks referral to a specialist

6.6%

1.2%

Vertigo — Dizziness

6.3%

1.2%

Diet and nutritional counseling, also exercise and weight loss counseling

6.3%

1.2%

Shortness of breath

6.0%

1.1%

General medical exam

5.8%

1.1%

Insomnia

5.5% 1.0%

For results of blood glucose tests

5.4%

1.0%

For results of cholesterol and triglycerides

5.4%

1.0%

Heartburn and indigestion (GERD, dyspepsia)

5.2%

1.0%

Tiredness, exhaustion

5.1%

0.9%

Constipation

5.0% 0.9%

For radiological findings

5.0%

0.9%

Well baby examination

4.8%

0.9%

1.3%

acteristics are shown in Table 1. The patients were majority white/Hispanic (54.3 percent), female (61.4 percent), with a mean age of 46.4, ranging from newborns to elders age 90 and above. Patients brought 517 different reasons for the visit (5,278 total RFVs, mean 5.4 per visit, range 1-16) and the physicians addressed 509 different issues/ diagnoses (3,587 total issues, mean 3.7 per visit, range 1-10). Physicians managed 425 different medications, 18 supplements, and 11 devices. A mean of 3.9 chronic medications were continued per visit (range 0-21), 0.7 new medications were prescribed (range 0-11), 0.2 immunizations were administered (range 0-6), and

4.6 total medications and immunizations were managed (range 0-21). The most common issues addressed are shown in Table 2. In 592 (60.3 percent) of the visits, the physicians did work that was not explicitly reportable. In 582 (59.3 percent) of the visits, the physician addressed enough diagnoses to justify a 99214 or 99215 level code, plus additional issues in that visit that were not separately reportable, primarily traditional diagnoses. In 64 (6.5 percent) visits, the physicians addressed system barriers that are not reportable with CPT codes. Examples included calling an insurance company to see if a medication was covered and calling a referral clinic and/or physician directly after the standard referral process was unsuccessful in a previous visit. In 14 (1.4 percent) of the visits, physicians addressed social determinant barriers. An example was discussing medication options if the patient told the physician that the preferred medication was unaffordable. In 13 (1.3 percent) of the visits, the physicians addressed health concerns of other family members not present. For example, the visit was for the mother, but the physician also answered questions about a child’s medications. A clinic visit could have more than one reason that issues were addressed that were not explicitly reportable. The adequacy of reportability of diagnoses and issues did not differ by physician training level, physician clinical experience, established patient status, patient gender, or patient race/ethnicity.

Conclusions

In this study of 982 family physician ambulatory visits, patients raised 517 different reasons for the visit, the family physicians addressed 509 different issues, and the family physicians managed 425 different medications. In 60.2 percent of the visits, the primary care physicians did work that was not explicitly reportable, the majority occurring because the physician addressed a greater number of diagnoses than are explicitly reportable using the CPT codes, followed by visits where the physician addressed system barriers. Potential CPT codes 99205 and 99215 were counted even though they are rarely reported in primary care5 and when these codes are submitted, the majority are denied.6 Properly applying 99205/99215 codes are also problematic because under the management option column in the CPT guidelines, it does not define what an “extensive” number of diagnoses or management options means. Yet, the examples in the CPT coding manual for a 99215 requires exacerbations of medical illness so severe that patients often require hospitalization or major intervention, which would be unusual in a family medicine office7 and applies regardless of the social complexity or number of diagnoses handled. Of note, CMS does not pay the primary physician for both the outpatient and inpatient evaluation and management codes on the same day.3 www.tafp.org

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The hours family physicians work per week is near the median of all physicians,8 but their average personal income is about one-third that of the highest-paid physicians and is a little more than half the average of non-primary care physicians.9 An analysis of physician incomes concluded that the Medicare fee schedules that arise from CMS’s Evaluation and Management rules directly explain this income discrepancy, not inflated fees to non-primary care physicians in the private market.10 Our findings show that even before the CMS E/M rules are considered, the AMA’s CPT codes give the family physician no mechanism to fully describe and report the work performed in the majority of clinic visits. Our results help explain previous research on the problems identified by family physicians in the current CMS E/M rules and CPT codes.11 Participants believed they were not adequately paid for taking care of patients with complex needs, which could arise from factors including multiple chronic

diseases, difficult patients, family/social factors, language/cultural barriers, and financial barriers. They believed a better coding system should take into account the time required to provide care for complex patients more than the CMS E/M system allows.12 Our findings help enumerate how often this happens in an average clinic day.

References

9. Median compensation for selected specialties, 2003-2007. Medical Group Management Association.2008(Jul 14). http://www.mgma.com/ WorkArea/showcontent.aspx?id=20660. Accessed April 26, 2009. 10. Berenson RA, Zuckerman S, Stockley K. What if All Physician Services Were Paid Under the Medicare Fee Schedule? ;March 2010. www.urban. org/UploadedPDF/412051_physcian_service.pdf. Accessed Oct 9, 2012. 11. Young RA, Bayles B, Hill JH, Kumar KA, Burge S. Family physicians’ opinions on the primary care documentation, coding, and billing system: a qualitative study from the Residency Research Network of Texas. Family Medicine. 2014;46(5):378-384. 12. Young RA, Bayles B, Hill JH, Kumar KA, Burge S. Family physicians’ suggestions to improve the documentation, coding, and billing system: a study from the Residency Research Network of Texas. Family Medicine. 2014;46(6):470-472. 13. Anderson G. Chronic conditions: making the case for ongoing care. http://www.fightchronicdisease. com/news/pfcd/documents/ChronicCareChartbook_FINAL.pdf. Accessed May 2, 2009. 14. Arvantes J. Senate hearing links physician payment rates to primary care shortages. AAFP News Now. www.aafp.org/news-now/governmentmedicine/20080219helphearing.html. Accessed February 20, 2008. 15. Arvantes J. MedPAC Members Characterize RBRVS System as Subjective, ‘Deeply Flawed’. AAFP News Now.2009(Nov 3).

1. American Medical Association. CPT 2014 Standard Edition (Current Procedural Terminology). 2014. 2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. http://www.cms.hhs.gov/ MLNProducts/Downloads/MASTER1.pdf. 3. Centers for Medicare & Medicaid Services. Evaluation and Management Services Guide. https:// www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Accessed April 26, 2016. 4. Center for Medicare & Medicaid Services. Prolonged Services (Codes 99354 - 99359). MLN Matters. https:// www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/ downloads/mm5972.pdf. Accessed April 5, 2017. 5. State of Vermont Department of Banking I, Securities, and Health Care Administration,. 2009 Provider Reimbursement Report: Primary Care Services. http://www.leg.state.vt.us/reports/2010Ex ternalReports/251708.pdf. Accessed March 3, 2016. 6. NGS. NGS Focused Audit Review for CPT 99215, April-June 2015. https://www.ngsmedicare.com/ ngs/portal/ngsmedicare/newngs/home-lob/pages/ complianceandaudits/medical-review/medicalreview-focus-areas/medical-review-focus-areasdetail/. Accessed March 23, 2016. 7. Edsall RL, Moore KJ. Thinking on paper: documenting decision making. Fam Pract Manag. JulAug 2010;17(4):10-15. 8. Leigh JP, Tancredi D, Jerant A, Kravitz RL. Annual work hours across physician specialties. Arch Intern Med. Jul 11 2011;171(13):1211-1213. 26

TEXAS FAMILY PHYSICIAN [No. 3] 2018

Implications Because the highest-cost Medicare and Medicaid patients are those with multiple chronic diseases,13 creating a payment system that encourages thorough primary care for these patients would be desirable, which our study suggests is not the current situation. Our findings also show the limitations of using our current system to account for the work performed by family physicians. This concern is in addition to the observation that RVUs (based on CPT coding with examples) preferentially reward procedural work over cognitive work.14,15


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PERSPECTIVE

Life lesson: Be thankful and value the time you have By Tasaduq Hussain Mir, MD it has been almost a year now since I read the powerful book, “When Breath Becomes Air,” a neurosurgical scholar’s account of his losing battle with cancer. Dr. Paul Kalanithi died at the very young age of 36 due to lung cancer that had spread from his lungs to his brain. “When Breath Becomes Air” is about a journey toward an imminent death. This book is a doctor’s account as a patient and the reciprocal relationship between him and his doctor. It is about an uncomfortable sense of vulnerability when it comes to physicians being on the other side of the table as patients. It is also about our gratitude for what we have in our hands and how to reconcile with what is beyond our reach. It is about our appreciation for each and every blessing that comes our way without us realizing it. After finishing this book, I had more questions than answers as to why we keep on doing what we do and what we feel is important. From the day we enter medical school, we physicians spend a lot of time away from our family. There never seems to be an end, as this separation can get worse during residency than when we are full physicians. Physicians are faced with the responsibility to help patients stay healthy and alive, but that can come at the cost of neglecting our own need to truly live if we are not careful. I did my residency training in Minnesota while my wife and son were in Denton, Texas. When I was a resident, I looked to research for guidance on how to do longdistance parenting in the medical field. To my surprise, I could not find much, so I started to figure out how to survive residency while being a long-distance dad and husband. My personal research interests were influenced by this barrier, as I even started a project to study long-distance parenting and assess its effects on resident physicians. My idea was to study different aspects of long-distance parenting and come up with suggestions and recommen28

TEXAS FAMILY PHYSICIAN [No. 3] 2018

dations for resident physicians doing longdistance parenting, guidance I was unable to attain through my literature searches. I did some work on this topic and had some data to work with. Although I still think that there is a need to work on this area, I have not actively pursued this after moving back to Texas. Doing residency in itself is very challenging and when you do it without your family being around, it can be a daunting task. During my residency days, I would spend my time in the hospital and clinic seeing patients and counseling them about the benefits of a healthy lifestyle. At night I would try to figure out how to stay human in residency and remain connected with my family from afar. I have missed anniversaries with my wife and my children’s birthdays. There were days when I wanted to see them, but I could not make it happen with the demanding residency training schedule. After coming back from a long day at the hospital or clinic, I would often stick to my computer on Skype video chatting with my wife and son. Video chatting was a life saver. My weekends and vacation time were crucial to my survival. I would book airline tickets far in advance to save money. In the compressed weekend time, I would fly to my family on a Friday evening and be back in Minnesota on Sunday night, ready to see my patients early on Monday. During residency I had very little time to spend with my family and I missed key stages of my family members’ lives. I was not able to be part of parent-student meetings, I hardly made it to my son’s soccer practices and games, and I knew none of my children’s teachers. Weeks, months, and years passed, and I successfully finished residency. This would not have been possible without the support of my family, my fellow co-residents, all my faculty, especially my program director Dr. Patricia Adam, and my advisor, Dr. Timothy Ramer. Although residency was hard and challenging, every bit of it was worth doing. I

was able to learn and develop the necessary knowledge and skills I would need as a physician. Spending time with my patients was the most beautiful thing. Educating my patients about the benefits of living a healthy life gave me an opportunity to reflect on how I can improve my own life and stay connected with my family and friends despite my busy schedule at work. Going back to the book, “When Breath Becomes Air,” the questions I ask myself are these: what will we do if we are told that we have two, three or at the most five more years to live? Will we continue doing what we are doing on a routine basis or will we take a break from our crazy schedules and assess our lives? Will we continue to work like machines that start early in the morning on a set schedule and are turned off at a scheduled time? Are we still going to ignore our family and loved ones and keep thinking about how we are going to achieve more and more success no matter the cost? When death is imminent, we give more value to time, even seconds matter. We try to spend as much time as possible with our loved ones, trying to capture moments for eternity. We know that all of us are going to die one day, so why is it then that we show no urgency or respect for time? Why is it then that we continue to work like machines and ignore our loved ones? Why is it that we have no time for our kids, even for the special moments that we know are never going to return? This book has taught me so many things. It taught me that even though what happens to us sometimes can be tragic, death is a not a tragedy but a journey towards eternity. It taught me to value time and be there for loved ones while we are here, as we are not going to be here forever. This life lesson has shaped me as who I am. When I was doing long-distance parenting as a resident physician, I had no time to go with my son for his soccer practice or games. Now I make it a point that I will go to each and every soccer practice and cheer


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for him during his soccer games. During residency I did not know any of his teachers. Now I know all of them and have met most of them. Yes, being a physician with busy practice can be very hard, but if one plans things in advance (which I do now) one can enjoy all the beautiful things that this world and life has to offer. There are simple things that one can do to be able to spend time with his/her family and friends. Here are some of the things I do now. • Practice “email hygiene” by addressing urgent messages from home and leaving the rest for office hours. • Finish work — like clinic notes — in the clinic rather than bringing it home. • Plan vacations ahead of time. • Mark important dates like birthdays and anniversaries on a reliable calendar app. • While my son is at soccer practice, I take that opportunity to stay healthy by exercising. • I’m a part of a wellness initiative at my residency program that helps our residents and faculty understand that wellness can prevent burnout. • I regularly give a talk on burnout and wellness to medical students. To conclude, let us try to respect and value time, and be there for our loved ones before something tragic happens. Let us live our life the way it should be, sharing love and spreading peace. Let us live our life to its fullest and then embrace death with peace and dignity. As I continue my own journey in trying to find out more ways to live a happy and joyous life, I keep the beautiful quote by Rachel Naomi Remen in mind: Life rushes us along and few people are strong enough to stop on their own. Most often, something unforeseen stops us and it is only then we have the time to take a seat at life’s kitchen table.

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