Texas Family Physician, Q2 2020

TEXAS FAMILY PHYSICIAN VOL. 71 NO. 2 2020

We Need A Marshall Plan To Save Primary Care PLUS: Texas Family Physician Of The Year, Sheri Talley, MD TAFP Foundation Annual Report

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TEXAS FAMILY PHYSICIAN VOL. 71 NO. 2 2020

6 FROM YOUR PRESIDENT Summer plans?

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8 AAFP NEWS Academy warns HHS of financial threat to practices

We need a Marshall Plan to save primary care

COVID-19 has exposed gaping cracks in our siloed and fragmented health care system. As independent community-based family practices face financial devastation, it’s time for change.

By Christopher Crow, MD, MBA, and Tom Banning

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West Texas pioneer Meet the Texas Family Physician of the Year, Sheri Talley, MD.

By Kate Alfano

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Carpe diem: It’s time to fix our health care system The pandemic presents an opportunity to chart a new course.

By Shawn Martin

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Spreading knowledge with Project ECHO

The virtual clinic education model that started at the University of New Mexico brings specialized medical knowledge to underserved areas.

By Jean Klewitz 4

TEXAS FAMILY PHYSICIAN [No. 2] 2020

10 MEMBER NEWS Candidates for TAFP Board of Directors 25 TAFP FOUNDATION 2019 Annual Report 30 PERSPECTIVE What’s being heard: Methods for establishing strong patient rapport

PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 71 NO. 2 2020 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

Javier D. “Jake” Margo, Jr., MD

president-elect treasurer parliamentarian

Amer Shakil, MD, MBA

Mary Nguyen, MD Emily Briggs, MD, MPH

immediate past president

Rebecca Hart, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editor

Jean Klewitz

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Audra Conwell

CONTRIBUTING EDITORS Kate Alfano Tom Banning Antonio Barksdale, MD Christopher Crow, MD, MBA Shawn Martin

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.

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. © 2020 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727.

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TEXAS FAMILY PHYSICIAN [No. 2] 2020

The best laid plans of mice and men

By Javier “Jake” Margo Jr., MD TAFP President i don’t know about y’all, but man, I have really been looking forward to this summer because there’s been something special on my calendar — something I have always wanted to do since I attended summer Scout camp back when I was a kid. For the first time since I became a Scout, I have plans to attend Boy Scout summer camp for an entire week, this time as a counselor! It happens to be at the longest continuously operating Boy Scout camp in Texas, the same camp my grandfather and my father went to, and the same one my son attended as a Cub Scout.

And I also have on my calendar a plan to take my family for a half week of amazing fun at the Boy Scouts of America Family Adventure Camp at the world famous Philmont Scout Ranch in New Mexico. That’s right. I have a plan to introduce my family to one of the BSA’s four high adventure bases. Attending this camp is widely regarded as a pinnacle experience in scouting, particularly by those of us who were fortunate enough to have attended as Scouts.

Well, those were the plans anyway. All of that is canceled now just like the trips and conferences and family reunions we have all planned for this year and perhaps beyond.

I’m still going to be a camp counselor for a virtual Boy Scout camp, so all is not lost!

Of course, having to cancel a couple of trips is far from the worst thing in the world. Many of our colleagues across the country are fighting to keep their practices

afloat during the most devastating economic event of our lives.

The Larry A. Green Center has been tracking the response and capacity of the nation’s primary care practices in dealing with the COVID-19 pandemic with a weekly survey since the middle of March and the findings have been dramatic. The survey has revealed a “corrosive and debilitating new normal” that pervades primary care, with more than 80% of Texas respondents reporting that the strain related to the pandemic has had a severe or close to severe impact on their practices. More than three quarters say their patient volume is down more than 50% and more than half have laid off or furloughed employees.

Even in these difficult times, it is in my nature to remain optimistic. Right now the entire country is witnessing the bravery and empathy of family physicians in action. As everyone knows, the motto of the Boy Scouts is “be prepared,” and as family doctors, we are truly the most prepared physicians to fight on the front lines against this pandemic.

Family medicine is showing the world the critical role we play in screening for COVID-19 as well as providing ongoing care for acute problems, chronic disease, and mental health problems. Make no mistake; we are at war with COVID-19 and in the fog of war, it is hard to see beyond the battle you are currently fighting. But when we get to the other side of this pandemic, this crisis is going to focus political and public atten-

Family medicine is showing the world the critical role we play in screening for COVID-19 as well as providing ongoing care for acute problems, chronic disease, and mental health problems.

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tion like a laser on the role our specialty plays and the need for family physicians.

Your Academy is working hard to capitalize on that focus while also advocating for reforms that would help alleviate the financial strain and administrative burdens practices face. We have proposed a Marshall Plan for Primary Care, the central plank of which is to change payment for primary care from the transactional fee-for-service model of the status quo to prospective payment.

Such a model would mean primary care practices would receive a fixed monthly amount for each patient rather than having to bill for each service provided.

Patients would have access to a broad range of services whenever they need care without having to rack up extra out-ofpocket costs, and physicians would see a huge decrease in the amount of paperwork they have to deal with. Imagine we had that in place today. Practices would have a stable, dependable revenue stream and wouldn’t be dependent on churning as many patients through the clinic as possible to keep the lights on.

The plan has generated a lot of discussion and has garnered a good bit of attention in the press. I’m excited about the possibilities we have before us.

As summer approaches, I don’t know what challenges and surprises our “new normal” will bring. I just know there will be more challenges and surprises.

And even though I won’t get to show my family the marvels of Scout camp, I’m sure we will find some adventure of our own. As we all adjust to our new reality, I want to take a moment to say a truly heartfelt “Thank You” to all those physicians and nurses and their staff for placing themselves in harm’s way to help care for, ease, and comfort the people of Texas.

Thank you and good luck to us all.

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AAFP NEWS

COMING SOON ON TAFP’S

CME SCHEDULE Texas Family Medicine Symposium August 7-9, 2020 La Cantera Hill Country Resort & Spa San Antonio, Texas Annual Session & Primary Care Summit Nov. 6-8, 2020 Nov. 4-5: Business meetings and preconference workshops

Gaylord Texan Resort & Convention Center Grapevine, Texas C. Frank Webber Lectureship & Interim Session April 16-17, 2021 Renaissance Austin Hotel Austin, Texas 8

TEXAS FAMILY PHYSICIAN [No. 2] 2020

AAFP, others warn Azar of imminent primary care closures Letter calls on HHS to ensure COVID-19 funding reaches family physicians

By AAFP News Staff that 38% of respondents said they expected if the story of covid-19 is one of who can to see an increase in non-COVID deaths afford what — states and individuals, testbecause of delayed or forgone care. ing and unemployment, and so on — then a Thirty-five percent of respondents said dire truth about health care is at its center: they expected most independent primary Family medicine is more crucial, yet more care practices not to be in operation after threatened, than ever. this first COVID-19 wave.

“Patients and communities, especially The letter agreed that this was “increasthose that are underserved and under siege ingly a likely consequence as primary care because of COVID-19, cannot afford widepractices lose revenue and spread closures of comare not able or eligible munity-based primary to access much of the care practices,” warned federal emergency fundthe Academy and other “Patients and ing.” Practices that care health care organizations communities, for Medicaid enrollees in a May 19 letter to HHS especially those that but do not participate in Secretary Alex Azar.

Medicare, for example, “Our organizations are underserved have been excluded from strongly encourage you and under siege the Provider Relief Fund’s to provide additional because of COVIDgeneral allotment. funding to independent Available remaining and community-based 19, cannot afford funding, along with any primary care practices, widespread closures new federal support, must including Medicaid proof communitytherefore flow to indepenviders,” added the letter. dent and community-based The Academy’s six cobased primary care primary care clinicians in signatories were the Allipractices.” need, the groups said. ance to Fight for Health Primary care physiCare, the American cians continue to work on Academy of Pediatrics, the the front line of the pandemic, screening American Benefits Council, the American and treating patients and standing with College of Physicians, America’s Health surge personnel in ERs and overwhelmed Insurance Plans and the Blue Cross Blue inpatient units, the letter added. They also Shield Association. must go on providing comprehensive care “Community-based primary care is the to their existing patients, now and after the foundation for ensuring our health care emergency. system delivers accessible, high-quality, “These two roles are critically important affordable care,” the groups said. But the to individual patients, hardworking families pandemic has cracked open that founand all of our communities but, more impordation, with some 70% of primary care tant, they are essential to our national efforts practices reporting 50% or greater declines to defeat and overcome the COVID-19 crisis,” in patient volume since the public health the AAFP and its co-signatories said. “That is emergency began. why it is so important that community-based That figure, from a May 6 Primary Care primary care physicians immediately access Collaborative report, is eye-catching but emergency federal support.” well within the context of other numbers in that organization’s increasingly grim weekly surveys of primary care clinicians. The letter Source: AAFP News, May 20, 2020. ©2020 American Academy of Family Physicians. to Azar cited the same report to caution

NEW FROM CDC

HIV Nexus offers a comprehensive collection of key federal resources on COVID-19 and HIV. More than half of HIV clinicians are primary care providers. To support health care providers managing patients with HIV during the COVID-19 pandemic, the Centers for Disease Control and Prevention has compiled these resources to: • Address concerns related to COVID-19 and HIV. • Provide guidance to health care providers managing people with HIV. • Highlight how people with HIV can protect their health.

To access COVID-19 and HIV resources for your practice and patients, visit:

www.cdc.gov/HIVNexus

MEMBER NEWS PROPOSED AMENDMENT TO TAFP BYLAWS

Meet the candidates for TAFP Board of Directors At the Member Assembly on Friday, Nov. 6, during this year’s Annual Session and Primary Care Summit, members will elect officers and a number of their colleagues to the TAFP Board of Directors. Three members are running for two available at-large positions.

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.

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 is the program director in a residency program covering nine counties in the PermIke Okwuwa ian Basin. He was elected to a seat in the Congress of Delegates at the National Conference of Constituency Leaders in 2015.

He served as an alternate delegate the same year, and served as a special constituency delegate in 2016. He was elected to the Rules Committee during the 2016 Congress of Delegates. He previously served as the new physician member and currently serves as an at-large member of TAFP’s Board of Directors. He is a current member of AAFP’s Commission of Membership and Member Services. He has served as chairman of the department of family medicine at his local hospital and is the chairman of the Board of Directors of Permian Basin Health Network, a Physician-Hospital Organization. He was awarded the TAFP’s Special Constituency Leadership Award in 2019.

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TEXAS FAMILY PHYSICIAN [No. 2] 2020

Lane Aiena, MD, is originally from Beaumont and earned his undergraduate degree from Louisiana State University in Baton Rouge. He earned his medical degree from Texas Tech University Health Sciences Center School of Medicine and completed his residency training in Conroe, Texas, where he was named Employee Lane Aiena 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 has served as the New Physician Director on the TAFP Board of Directors.

He currently serves on the TAFP Commission on Legislative and Public Affairs and the Leadership Development Committee.

The proposed amendment to the bylaws is 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. For 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 this amendment.

Chapter XII. Board of Directors, Subchapter I. Policy and Procedure, Section 7 Each member of the Board of Directors shall have one vote. Action taken by a mail or electronic ballot in which a majority of Board members indicate their agreement in writing or during a virtual meeting shall constitute a valid action of the Board if reported at the next regular meeting or via meeting minutes or ballot summary.

Gerald Banks, MD, MS, FAAFP, 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 in New Jersey, where he was a Larry A. Green Scholar and studied family medicine Gerald Banks 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 the featured speaker at the AAMC Health Workforce Research Conference in Washington, D.C. Most recently he was elected 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 and is a current member of the TAFP Board of Directors.

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WEST

TEXAS

PIONEER 2019 Texas Family Physician of the Year Sheri Talley, MD

By Kate Alfano

When reflecting on rural West Texas, one might picture wide-open sky and arid, rugged land against a mountain backdrop. It’s calm but with a feeling that opportunity abounds, and it’s where the 2019 Texas Family Physician of the Year has called home for most of her life.

Sheri Talley, MD, embodies the West Texas pioneering spirit. She grew up in Midland and excelled in science and human anatomy, leading her to consider becoming a medical technician. A premed advisor plus a summer drawing blood in a blood bank with high turnover nudged her to pursue medical school without a specific specialty in mind. “I’d actually thought about being a pathologist until I realized they don’t see people, they just see specimens and tissue,” Talley says. “The minute I learned what a family physician was and what they did, that’s all I’ve ever wanted to be.”

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TEXAS FAMILY PHYSICIAN [No. 2] 2020

JIM HATCHER

Sheri Talley, MD, Texas Family Physician of the Year, poses in front of Paisano Pete, an 11-foot-tall roadrunner sculpture in the heart of Fort Stockton, Texas. Pete, the town mascot, is appropriately masked to protect visitors from COVID-19.

www.tafp.org

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“Her passion for providing outstanding care to the incarcerated population that she serves is admirable and inspiring. I am a better physician and person for having Dr. Talley’s influence and support through the years. I know that her practice has also blessed her patients, staff and, community.”

— Adrian Billings, MD, PhD

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TEXAS FAMILY PHYSICIAN [No. 2] 2020

T

alley completed her family medicine residency in San Antonio — the biggest town she had ever lived in — but felt called back to the mountain West and a rural practice. She trained hard with the expectation of practicing full-scope family medicine, including doing an obstetrics rotation in El Paso to get as much experience with Cesarean sections as possible. She hung her shingle in Fort Stockton, outfitting her own practice with two exam rooms and two employees.

At the same time, she and her husband, Jim, were starting their family.

They moved to the area when their first child, Carlos, was a baby.

There was one other doctor in town delivering babies at the time, a surgeon. Talley planned to assist with many of his Cesarean section deliveries, to build on her knowledge and experience from her training. During her OB rotation, she had performed just 15 elective C-sections and felt she needed at least 60 to be fully confident with the procedure. But being the junior physician in town meant she covered the entire community for holidays and breaks, and it was during one of these times when the surgeon was on vacation — 15 months after opening her practice — that she successfully performed a solo C-section with just a scrub nurse assisting.

But that wasn’t the most exciting delivery. Just six months after starting practice in Fort Stockton, another spring break, a woman arrived at the clinic in labor and completely dilated. Talley, who was at her home at the time, raced to town and made it just in time to catch the baby. The patient still appeared big so Talley examined her — and could feel feet. She made some quick adjustments and the second baby was quickly delivered breech. At this point, the assisting nurse told her that’s if there’s another baby in there, she’s leaving.

Talley performed another quick examination, felt a head, and asked for another umbilical clamp “just in case.” The third baby was delivered shortly after and, though estimated to be four weeks premature, all were healthy. “We ended up in the newspaper,” Talley says. The neat part of the story is that the triplets still live in town and she continues to see them and their families periodically.

“The best part to me of being a family physician is being able to take care of people from the cradle to the grave,” Talley says.

“Those who practice in a rural area know what an extraordinary choice that is, being a highly valued member of your community and knowing your patients’ neighbors and the challenges of practicing in a remote area with limited resources,” said TAFP Immediate Past President Rebecca Hart, MD, when she presented Talley with the Family Physician of the Year Award. “It takes a special person to practice on the frontier in a solo practice as she chose to do as a young, female family physician.”

After the birth of her second child, Callie, Talley decided to transition into correctional care for the Texas Department of Criminal Justice facility in Fort Stockton where she cares for the incarcerated. This allowed for a more regular schedule with no holidays or weekends and limited call but a setting where she could still serve the underserved.

“I consider myself passionate about caring for the underserved and helping to reduce health care disparities,” says Adrian Billings, MD, PhD, of nearby Alpine. “I have come to realize that Dr. Talley and I are kindred spirits. Her passion for providing outstanding care to the incarcerated population that she serves is admirable and inspiring. I am a better physician and person for having Dr. Talley’s influence and support through the years. I know that her practice has also blessed her patients, staff, and community.”

PHOTOS: JONATHAN NELSON

Talley explained that prison medicine comes with its challenges.

There is a lot of manipulative behavior; she can order things like lower bunks or job restrictions where convicts don’t have to work but she has to keenly discern the potential for abuse of her prescription pad. She determined that pain is not a vital sign in prison long before that was widespread in private practice. There is a lot of chronic care — diabetes, asthma, and high blood pressure — and her patients’ chronological ages tend to be about 10 years less than their physiological age due to life choices before prison. Some of the men can be crude or aggressive and officers have had to intervene.

“But an awful lot of these guys, once they have their substance abuse and mental health issues taken care of, they’re pretty nice, rational people. You have to learn how to say no and be firm and fair, and most of the guys handle that pretty well.” Talley added, “I’m a pretty nice person but I have had to develop that toughness and the ability to say no.”

An important part of Talley’s life is her commitment to organized medicine. Most notably, she holds the distinction of being the first female and youngest TAFP president at age 36, and she drove often between Fort Stockton and Austin during a busy legislative year when her children were ages 2 and 7. She started attending TAFP meetings as a medical student at the encouragement of a faculty member, and former TAFP Executive Director Jim White guided her in how to be involved and stay engaged. She was TAFP’s Student Affairs Committee chair and then resident chair. When she was a resident, the Academy launched constituency group meetings and she served as the first delegate, representing women, and convener of what is now the AAFP National Conference of Constituency Leaders.

“Sheri brought passion and hard work to her efforts at TAFP,” says Nancy Dickey, MD, who was the first female president of the American Medical Association and is the current executive director of the Texas A&M Rural and Community Health Institute. “I particularly appreciated that she, like me, made it a family affair, often bringing her husband and children to meetings. Physicians are busy and adding additional demands on their time — like serving a professional organization — can be more than the calendar can tolerate. But finding ways to weave two or more of these together, like having your family time overlap your professional organization time, helps the busy schedule. Sheri is a quiet leader, a good recruiter, a committed family physician and a steady hand at the helm.”

Billings, her nominator for the award, credits her for his leadership success. As she did with many, she reached out to him at one of his first meetings to encourage him to get involved, telling him “we need more West Texas physicians like you to be involved in the leadership.”

“This was a huge surprise to me as a junior physician that a former TAFP president would see potential in me,” Billings says. “This singular event gave me confidence to get more involved in the community.

I wonder how many other current leaders received similar votes of confidence from her. I think that a true leader looks for future leaders so as to hand off leadership and make things better than they were during their own leadership.”

It is true that she continually encourages the next TAFP leaders, even calling for involvement from physicians when she accepted her award and deferring attention to her peers — another attribute

Top, from left: Sheri Talley, MD, receives the 2019 Texas Family Physician of the Year Award from then TAFP President Rebecca Hart, MD, at the TAFP Annual Session and Primary Care Summit in The Woodlands, at the Annual Business and Awards Lunch on November 9, 2019.

Bottom: Sheri Talley, MD, poses by the entrance sign of the Fort Stockton Unit Transfer Facility, one of two Texas Department of Criminal Justice facilities at which she cared for incarcerated patients for many years. She has since retired.

of a great leader. “I think that one of the reasons I was nominated was at the time, especially when I had a lot more energy, I was working on inclusion, trying to get our physicians to look like our communities and our leadership to look like our physicians,” Talley says at the awards ceremony. “And if you look across this room … now there are a lot more women and people of color. Looking at all of these people with these wonderful awards, I think the specialty is in very good hands.”

www.tafp.org

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TEXAS FAMILY PHYSICIAN [No. 2] 2020

We need a “Marshall Plan” to save primary care

By Christopher Crow, MD, MBA, President of Catalyst Health Network and Tom Banning, TAFP CEO

F

ollowing the devastation of World War II, the United States enacted the Marshall Plan to rebuild a heavily damaged Europe. Our war against this novel coronavirus is far from over, but it is already wreaking havoc on the nation’s primary care workforce. Our frontline health care providers are putting themselves at risk every day without proper personal protective equipment while community-based primary care clinics are facing economic disaster.

We need a Marshall Plan for our primary care and public health infrastructure.

For years health care experts have been warning of the dire consequences of persistently underfunding primary care and public health at the federal, state, and local levels.

COVID-19 has vividly exposed gaping cracks in our siloed, fractured, and disconnected health care system. While it might be easy to point fingers and assign blame, this crisis is the result of system design failure.

Our medical supply chain has failed us. Our medical supply delivery distribution system has failed us. Our fee-forservice payment system has failed us, and our finance model — health insurance, which leaves millions without cover-

age — has failed us. The consolidation that has occurred in various segments of our health care market has only compounded the felony and exacerbated these system failures.

Our independent, community-based primary care physicians constitute the foundation of our health care system, a foundation that has been neglected and deteriorating for years. We now depend on them to serve on the front lines of the battle against COVID-19. But these practices are no different from other small businesses, and they are not immune to this sudden economic downturn. Many practices report visits are down 50% to 75% as patients stay at home, paralyzing revenue streams and hampering practices’ ability to make payroll, pay bills, and keep the lights on.

These practices operate on a tight margin and often have only two to four weeks of cash reserves on hand.

Unlike other small employers, though, these independent practices can’t simply close up shop. People will continue to get sick. Patients with chronic disease still need ongoing care, and many more will seek mental health counseling as a result of isolation, job loss, and financial insecurities than ever before. We cannot afford to lose our primary care workforce.

www.tafp.org

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We have an unprecedented opportunity to redesign our health care system so that it truly serves Americans and the professionals who care for them.

We must save our frontline primary care and public health professionals and in so doing, set the foundation for a better way of delivering and paying for care.

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TEXAS FAMILY PHYSICIAN [No. 2] 2020

We need action now. The first and most critical step in our Marshall Plan is to immediately change the way we pay for primary care, from transactional fee-for-service to prospective payment.

This means health insurance companies, Medicare, Medicaid, and all other payers would pay primary care providers a fixed monthly fee for a broad range of services rather than paying a claim for each service. To determine the amount of the monthly fee, payers could examine what they paid for primary care in the last year and then pay their primary care providers at a commensurate monthly rate for the coming year. Or it could be based on a percent of the premium cost.

It’s not a crazy idea. This is exactly how we pay providers in Medicare Advantage today and The Centers for Medicare and Medicaid Services has been testing this through other pilot projects. Under this payment model, patients could access primary care whenever they need it without racking up extra out-of-pocket costs. Primary care physicians would be released from the burden of mountains of paperwork and administrative hassles that keep them from spending more time with their patients. And in times of crisis like this, it would provide a predictable and manageable expense item for payers and a dependable income for primary care practices. Prospective payment is the future for primary care. Why not move forward with it now?

Next we need to implement regulatory and payment changes to accelerate the adoption and use of telemedicine. Patients want the convenience of telemedicine and when used appropriately, it boosts efficiency and productivity for medical clinics.

All public and private health insurance benefit packages should incorporate and financially facilitate innovative strategies that promote greater use of primary care physicians and their care teams in an effort to promote high-quality, efficient care and to assist patients in navigating an increasingly complex health care system. This approach to benefit design will not only enhance the patient-physician relationship, but it will achieve better health and lower costs.

Our plan also includes a robust a national effort to procure and stockpile necessary items like personal protective equipment to prepare for future public health crises. If we’ve learned anything from COVID-19, it’s that our public health system was woefully unprepared for a pandemic of this magnitude. We can’t let that happen again.

Finally, we need to expand and tailor our primary care workforce by producing more primary care and public health workers, and by implementing strategies to encourage their appropriate geographic distribution. We could forgive medical school tuition for graduates who choose primary care specialties and provide further loan forgiveness for those who practice in underserved communities. We can also increase graduate medical education funding for primary care residency positions to incentivize academic institutions to invest more in those programs.

The Marshall Plan was initiated three years after the end of World War II. With the current crisis threatening our frontline primary care physicians, we don’t have the luxury of waiting that long. We need our federal, state and local elected officials, as well as business leaders and insurance company executives, working on this now, even as we continue the fight to contain this pandemic.

We have an unprecedented opportunity to redesign our health care system so that it truly serves Americans and the professionals who care for them. We must save our frontline primary care and public health professionals and in so doing, set the foundation for a better way of delivering and paying for care.

If we ignore the primary care workforce crisis unfolding before us, the long-term consequences to our health care system will be dire.

AAFP IN THE TRENCHES

Carpe diem: It’s time to fix our broken health care system

By Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy

“Never let a good crisis go to waste.”

— Sir Winston Churchill

A

s the COVID-19 pandemic continues to spread across the country, family physicians continue to step forward to meet the needs of their patients and communities. Many are expanding and modifying their practices to ensure that their patients and communities have access to health care in a setting that protects them from exposure to SARS-CoV-2. Others are moving into full-time inpatient roles as part of workforce surges.

To each of you, thank you for your service to your patients, your community and the country. The AAFP is proud to work on your behalf and advocate for the amazing work that family physicians are doing.

Despite the robust response of the physician and health care community, thousands of families are mourning the loss of their loved ones — family physicians and the family of AAFP staff among them. Others in the family medicine community continue to fight for their lives and defeat the virus, often in isolation. Our thoughts are with the families who have lost loved ones and those who are battling the virus.

I recently tweeted that COVID-19 has changed health care and primary care. Although this may be well understood at this point in time, the direction our health care system is heading post-pandemic isn’t as clear. “Let’s chart a new future,” I said in that tweet.

The COVID-19 pandemic will have a devastating impact on our country.

Tens of thousands have died, and according to recent projections, thousands more will die during the next several weeks. The pandemic has placed a tremendous strain on our economy and our health care system.

It also has provided a clear line of sight into disparities, shortcomings and failures of our current health care system. Issues and policies that were once considered long-term goals are now urgent priorities.

In the coming months, the country will engage in an important discussion about what happened and how the health care system performed in advance of and during the pandemic. There will be a significant amount of handwringing, finger-pointing and posturing. However, there will also be a window of opportunity to determine how to move forward and what kind of health care system we want and need.

I have spent much of my professional career envisioning the future of family medicine and primary care and promoting incremental changes

aimed at achieving those larger goals. In recent days, I have set aside my focus on incremental achievements toward a better future for family medicine in favor of implementing big, substantive, consequential and disruptive changes.

There have been moments in history when crisis and tragedy gave way to innovation and investment. In a speech delivered at Harvard University on June 5, 1947, Secretary of State George Marshall laid out a vision for rebuilding post-war Europe. This comprehensive plan would ultimately become the Economic Cooperation Act and, in 1948, would be approved by Congress. Over the course of the next several years, the United States invested more than $13 billion in the rebuilding of the Western European economy. The commitment to something new outlined in the Marshall Plan and the investment by the United States led to a new vision for Europe and contributed to the continent’s revitalization.

We can and should do the same for the United States health care system now. I did not originate the term, but I have been echoing it loudly: We need a Primary Care Marshall Plan — a plan bold enough to fundamentally change our health care system and consequential enough that the lives of future generations will be impacted by its scope.

Here is where we should start.

A BETTER HEALTH CARE SYSTEM Our health care system is largely a top-down model in which the vast majority of spending is allocated to the least-used services. According to Health Affairs, health care spending in 2018 was $3.6 trillion, or $11,172 per person. Now let’s look at how that money was distributed on a per capita basis. According to the same article, physician and clinical services represented about 20% of overall health care spending, or $2,234 per person. Hospital spending represented 33% of overall spending, or $3,687 per person. By my (generous) estimation, primary care represents about 5% of overall spending, or $559 per person.

Now, let’s look at utilization. According to statistics from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care for 2018, a little less than 22 million people — about 7% of the population — www.tafp.org

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I am going to state clearly and loudly that fee-for-service is incapable of supporting the primary care system that our health care system needs and that patients deserve. The whole construct of FFS, and especially the resource-based relative value system, has failed primary care.

received care in a hospital compared to the more than 190 million people — roughly 60% of the population — who received care from a family physician. I am not suggesting that family physicians need to be paid on par with hospitals and I am not necessarily saying that hospitals need to be paid less. What I am stating is that an overwhelming majority of people rely on their family physicians and other primary care clinicians, yet we invest only pennies on the dollar in our primary care system.

This, my friends, is an opportunity for change. Here is how we are going to capitalize on the opportunity.

PROSPECTIVE POPULATION-BASED PAYMENTS FOR PRIMARY CARE I am going to state clearly and loudly that fee-for-service is incapable of supporting the primary care system that our health care system needs and that patients deserve. The whole construct of FFS, and especially the resource-based relative value system, has failed primary care. Primary care is comprehensive, continuous, holistic, portable, and patient-centered. The RBRVS is, by design, the complete opposite. It is focused on units of care, units of time, and sites of service. Family medicine has politely whispered for years that FFS was an illogical payment construct for primary care, and the COVID-19 pandemic simply put a giant spotlight on this issue.

The concept of prospective payments is not new. The AAFP has advocated adopting this type of payment model for years and, in 2018, we developed the Advanced Primary Care Alternative Payment Model.

Our model is the foundation of the Primary Care First model that CMS will implement in 2021. We also have advocated for other global/ prospective value-based payment models, such as direct contracting, physician-led accountable care organizations and direct primary care arrangements. Although it is easy to focus on what makes these models different, it is more important to focus on what makes them similar: They all depend on population-based, advance payment for primary care.

In response to the COVID-19 crisis, public and private payers alike have altered benefit design and begun making advance payments to family physicians. We should build on this momentum and once and for all make a complete break from the legacy fee-for-service system.

The pandemic has brought to light how inflexible and unresponsive our health care system has become. It took us three weeks to create a pathway for family physicians to provide and be compensated for virtual care visits via telemedicine or the telephone. This is because we currently pay for units of care and units of time, and our regulatory structure is designed accordingly. Imagine if every family physician had had an attributed panel of patients and an associated prospective payment for each when the crisis hit. Transformation from officebased to virtual workflows would have been easier and quicker. Home visits? Fine. Telephone visits? Fine. A game of virtual checkers with Ms. Smith because she is isolated and gets lonely? Fine. When units of care and units of time no longer get measured, providing care to patients becomes the focal point. And, when providing care to patients is the focal point, family medicine wins.

The Primary Care Marshall Plan is underway. There are countless other aspects of health care that should and will be included — the family medicine workforce, comprehensiveness, continuity, public health training, and infrastructure and analytics — all in time. Today, the two items I outlined deserve our full attention and support. They are the foundation.

Again, let’s chart a new future. Our future.

Source: In the Trenches, April 14, 2020. ©2020 American Academy of Family Physicians.

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COURTESY OF PROJECT ECHO/ECHO INSTITUTE

PROJECT ECHO PROGRAMS IN TEXAS: TELECONFERENCING FOR SPECIALIZED CARE ECHO model brings specialized medical knowledge to rural and underserved areas through virtual clinics

By Jean Klewitz

P

roject ECHO, or Extension for Community Healthcare Outcomes, is a collaborative model of medical education and care management that seeks to empower you to provide better care to more people. It has an exciting and engaging goal of “changing the world fast.” They intend to do this through moving knowledge, not patients. Partnerships formed through Project ECHO bring specialty knowledge to rural and medically underserved areas.

“To change the way the world works for underserved patients, one has to change the way it is distributed,” said Sanjeev Arora, MD, a liver disease specialist doctor in Albuquerque in a 2017 interview on the Healthcare Innovators Podcast. “When you move knowledge instead of patients, knowledge moves so much more smoothly.”

It’s not typical telemedicine where a specialist assumes the care of your patient. Project ECHO is different. Instead, you receive telementoring, where all teach and all learn. You’ll retain the responsibility of managing the care for your patient, and you’ll engage in real-time collaborative sessions with a community of providers to 22

TEXAS FAMILY PHYSICIAN [No. 2] 2020

gain expertise. Project ECHO creates self-supporting networks so you can help your patients get the care they need from you, wherever you are. It is a different way to approach health care, providing you with peer-to-peer online learning and no-cost CME. What is it like to be a part of a teleECHO program?

You’ll join with your webcam and see the faces of the other participants to engage in peer-to-peer learning. A facilitator might put a scenario up on the screen and give you several multiple-choice answers. All on the call will hold up their fingers of the number they believe it is, and then the facilitator and specialist will share the correct answer and the reasoning behind it. Then you’ll engage in casebased learning, where you and other participants present your deidentified real-life cases to the network. After the case is presented, the program team facilitates a discussion around the case, provides evidence-based recommendations, and solicits additional feedback from the network. [cont. on 24]

“It’s a wonderful thing to practice family medicine in the state of Texas, to have the opportunity y 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 22]

PROJECT ECHO PROGRAMS YOU CAN JOIN CHI St. Luke’s Health www.chistlukeshealth.org/services-specialties/telehealth/ project-echo/become-our-partner UT Health San Antonio wp.uthscsa.edu/echo/echo-programs/ UT MD Anderson Cancer Center www.mdanderson.org/education-training/global-outreach/ project-echo/programs.html The University of New Mexico School of Medicine echo.unm.edu/institute-programs

ILLUSTRATIONS COURTESY OF PROJECT ECHO/ECHO INSTITUTE

What is the impact?

Over 17 years ago, Sanjeev Arora, MD, started the first program out of the University of New Mexico Health Sciences Center. He started it because he was frustrated by the severe lack of access to specialists in New Mexico. Being a very rural state, it had only two clinics that treated more than 30,000 hepatitis C patients. Arora wanted all patients in need of treatment to get it, so he created Project ECHO for primary care clinicians to treat hepatitis C in their communities.

It worked. He saw the benefit to his patients quickly. His wait time went down from eight months to two weeks because through Project ECHO knowledge-sharing, they were able to create 21 primary care centers of excellence for treating hepatitis C. At that time, he must have known he was onto something big. Still, he likely had no idea of the global reach this model would have.

Now more than 800 teleECHO programs share knowledge across the globe. Academic hospitals, medical schools, and other organizations have become training centers, also known as “hubs,” to build these broad physician networks. And in Texas, we have four institutions that serve as hubs and organize regular Project ECHO programs.

For more information on Project ECHO and the ECHO model, watch this short video: youtu.be/VAMaHP-tEwk, and read this onepager: echo.unm.edu/data/one-pager.

If you’re interested in starting your own hub, read more about becoming a replication partner to amplify the impact at echo.unm. edu/join-echo#start. If you have questions or need more information, you can email the Replication Team at echoreplication@salud. unm.edu.

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TEXAS FAMILY PHYSICIAN [No. 2] 2020

TEXAS ACADEMY of FAMILY PHYSICIANS FOUNDATION ANNUAL REPORT 2019

Mission: The Texas Academy of Family Physicians Foundation is the philanthropic arm of the Texas Academy of Family Physicians and is organized for scientific and educational purposes in support of the medical specialty of family medicine and for the advancement of the health and well-being of patients.

www.tafp.org

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The TAFP Foundation focuses its work on two strategic areas — practice-based primary care research and supporting the next generation of family physicians.

Through the generous support of individual donors and TAFP, we are able to provide scholarships, travel funding, research grants, funding for family medicine interest groups, and research poster competition prizes. If you are a donor, thank you for being part of our success.

Practice-based primary care research

Medical students: The core of our work

The research grant program through the TAFP Foundation began in 1988 and continues to grow. Twice a year, proposals for research grants are accepted and many are funded. More than $550,000 has been awarded in small grants and many of the projects go on to be published or expanded into larger studies. In 2019, research on intimate partner violence, obesity management, the efficacy of targeted home visits for the management of chronic conditions, HPV vaccine utilization in young adults, and long acting reversible contraceptive utilization and attitudinal beliefs were approved for funding. Grant recipients are encouraged to share their research at TAFP CME events in didactic lectures and poster presentations.

The TAFP Foundation also supports the prizes for the annual research poster competition held at TAFP’s Annual Session and Primary Care Summit.

The majority of funds expended each year are devoted to medical students. Supporting and encouraging their interest in family medicine has always been a fundamental part of the TAFP Foundation’s work. As the state’s population swells at both ends of the age spectrum, the need for primary care physicians has never been greater.

Family medicine residents The Foundation recognizes residents as the future leaders in family medicine and provides funding to help them attend family medicine meetings. There are also scholarships for residents to present research at national meetings, an advocacy scholarship, and a few that recognize excellence at individual residency programs.

In 2020, the TAFP Foundation is launching a new program for residents – Texas Family Medicine Scholars. The multi-year scholarship program will provide generous financial support and leadership development to one resident each year to build the next generation of leaders for family medicine.

The TAFP Foundation provides funding for family medicine interest group activities at each medical school in the state. FMIGs can be the first exposure medical students have to family medicine. They develop programming, usually over lunch, and coordinate activities throughout the year. FMIGs provide an important infrastructure to engage in outreach to students and encourage participation in TAFP and AAFP meetings.

Once the students are interested, we provide travel funding to attend TAFP and AAFP meetings. We broke our record and funded more students to AAFP’s National Conference than ever before in 2019. We also have funding for TAFP’s two big meetings with programming specifically for medical students and residents. In fiscal year 2019, the TAFP Foundation spent more than $35,000 on medical student travel to meetings.

In the early 1990s, the TAFP Foundation embarked on a quest to build scholarships for medical students interested in family medicine. Since then, student debt levels have dramatically increased, and our total scholarship dollars awarded is now more than $350,000. The scholarships are all fully endowed so that they will continue in perpetuity to be a method of supporting future family physicians.

These fantastic programs are only possible through the support of members like you.

As the TAFP Foundation continues to support and encourage the next generation of family physicians, we remain clear and focused on why we do what we do.

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TEXAS FAMILY PHYSICIAN [No. 2] 2020

When I was a resident, the TAFP Foundation enabled me to attend National Conference and to run for leadership positions, which has made me into the leader I am today.

Highlights from 2019 • More than $36,000 in scholarships were awarded to students and residents across the state.

• Research grant funding was awarded to a variety of projects on timely topics such as LARC utilization, intimate partner violence, and obesity management.

• The TAFP Foundation collected over $30,000 in monthly donations from TAFP members, staff, and friends in 2019.

• The TAFP Foundation funded almost 50% more medical students to attend AAFP’s National Conference in Kansas City than the previous year. A total of 47 students were funded from across the state compared to 32 in 2018.

FINANCES

It’s one thing when you’re telling your friends, “Hey you really need to get involved.

You really need to go to this meeting.” It’s another thing when you can say, “The TAFP Foundation has scholarships for you to attend these meetings.” And it really makes a difference in convincing someone who’s not sure if they want to play a bigger role to put their foot out and try something new.

— Lindsay Botsford, MD

Statement of financial Position (as of 8/31/2019)

CURRENT ASSETS Cash $138,388 Investments $3,032,311 Other receivables

revenues

$3,335

Total assets

$3,174,034

LIABILITIES AND NET ASSETS Accounts payable

$1,981

Donations TAFP Grant

$150,000

Investment Return

$120,000

Miscellaneous Income

$90,000

Net assets

Without donor restrictions

With donor restrictions

$870,831 $2,301,222

Total liabilities and net assets STATEMENT OF ACTIVITIES

$3,174,034

$60,000 $30,000 $0

Revenues Donations

$123,164

TAFP grant

$62,010

Investment return

$98,555

Miscellaneous income

Total revenues

$7,832 $291,561

expenses $60,000 $50,000 $40,000

Expenses $29,729

$53,736

$20,000

Scholarships

$36,571

$10,000

$37,562

Fundraising, management and general

Total expenses

Travel, Student Interest Groups Scholarships Management, General Expenses

$30,000

Research Travel and student interest groups

Research

$0

$157,598 www.tafp.org

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THE AAFP POWERS ME, SO I CAN POWER MY PATIENTS. LaTasha Seliby Perkins, MD AAFP New Physician Board Member Washington, DC

Discover how membership can power you.

aafp.org/powering-you

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PERSPECTIVE

What’s being heard: Methods for establishing strong patient rapport

By Antonio Barksdale, MD

as providers, particularly primary care providers, it is becoming more and more vital to establish a positive and strong rapport with every patient. This rapport fosters trust, openness, and ultimately yields better compliance along with improved outcomes. How is this rapport established? How do we get patients to trust us? How do we get patients to listen? How do we improve compliance? And how do we improve patient satisfaction scores?

There is a slew of research on these topics and we have an entire team in our organization to address the last question. The one thing I’d like to highlight in this article is being mindful of how we are communicating and what messages we are sending beyond the surface of our words. We’re communicating all day. We greet, we ask, we explain, we plan, we disclose, we lecture, we theorize, we talk about numerous things with our patients. Patients however only hear a portion of what is being said. To some providers, this can be disconcerting and frustrating. After all, we’ve invested our time, expertise, energy in order to tell the patient something beneficial, so they should readily scoop it all up ... right?

Research shows that patients only grasp 20-60% of the information spouted at them, depending on the type and complexity of the information.

Therefore, it is imperative to become increasingly aware of what the patient “hears” beyond our words.

Patients “hear” your tone, they “hear” your posture, they “hear” your facial expressions, and most importantly they “hear” your care and concern. In essence, the patient hears your heart. They might not ingest the physiology of their diabetes, or the details of how their beta blocker works; however, they feel your concern and they will inwardly assess your genuine desire to help them at every encounter. From the patient perspective, I believe your concern and your intent speaks volumes above your actual words.

Below are a few pointers at sending the intended message to our patients.

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• Fostering a mindset of gratefulness for the opportunity to participate in patient care.

• Taking inventory to assess our posture, tone, and facial expressions.

• Being mindful of our own emotions.

• Be on guard for empathy burnout. (Look into physician well-being resources or burnout prevention tools) • Always smile when appropriate.

• Take a moment of silence when critical/crucial items are being discussed.

• Don’t be afraid to respectfully verbalize your care and concern for your patient.

• Most importantly, make sure you’ve listened to the patient. When patients feel like they were able to share their story and make their voice heard, they will instantly gravitate to your advice and trust you as their physician.

It is very true that physicians must be sharp, knowledgeable, adaptable, and confident in our ability to administer care. These are great qualities that are imperative for good care and they are certainly expected of us. We must know the science of medicine and yet balance this with the “art” of medicine. Patients feel your care and concern beyond what you are saying.

Once they know you care, they will trust you and this establishes strong rapport. One of the most potent ways to demonstrate this care is by taking a moment to listen.

We live in a culture that often breeds distrust, disunion, and apathy. However, when it comes to being a qualified and well-rounded physician, we must not allow the noise of the culture to overwhelm our desire to uphold the totality of the Hippocratic Oath.

“I will remember that there is an art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife of the chemist’s drug.”

FAMILY MEDICINE CLINICAL FACULTY OPPORTUNITIES

Baylor College of Medicine has opportunities for clinical faculty who are board certified/eligible in Family Medicine and/or interested

Houston, Texas

in providing non-operative obstetrics.

In addition to joining an outstanding group of faculty dedicated to the care of a diverse patient population, our faculty have the opportunity to participate in academic activities including medical student and resident education.

APPLY ONLINE: jobs.bcm.edu

This position includes a faculty

FOR FURTHER INFORMATION CONTACT

appointment at a competitive salary with excellent benefits and the opportunity to join a distinguished institution.

ROGER J. ZOOROB, MD, MPH, FAAFP Richard M. Kleberg Sr. Professor and Chair DEPARTMENT OF FAMILY & COMMUNITY MEDICINE 3701 Kirby Drive, Suite 600 • Houston, TX 77098 Roger.Zoorob@bcm.edu • 713.798.2555 bcm.edu/departments/family-and-community-medicine

Interested candidates should apply at

jobs.bcm.edu

Baylor College of Medicine is an Equal Opportunity/ Affirmative Action/Equal Access Employer