California Family Physician magazine (Fall 2010) by California Academy of Family Physicians

California

FAMILY PHYSICIAN VOL. 61 NO. 4 Fall 2010

EXAMINING SONOMA’S PCMH LEARNING COLLABORATIVE

WHAT DO FEDERAL EHR INCENTIVES AND MEANINGFUL USE MEAN TO YOU?

WITH PCMH, LOMA LINDA PROGRAM 24 HELPS PHYSICIANS PREPARE FOR PRACTICE

ALL UNDER ONE ROOF

Introducing CAFP’s New PCMH Resource Center

T H E C A L I F O R N I A A C A D E M Y O F F A M I LY P H Y S I C I A N S • S T R O N G M E D I C I N E F O R C A L I F O R N I A

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THE PATIENT CENTERED MEDIC AL HOME 16 An Open Letter to CAFP Members 20 Examining Sonoma’s PCMH Learning Collaborative 22 What Do Federal EHR Incentives and Meaningful Use Mean to You? 24 With PCMH, Loma Linda Program Helps Physicians Prepare for Practice 26 A Resident’s View of the Patient Centered Medical Home

Paul Grundy, MD, MPH Bo Greaves, MD Sandra Newman, MPH Lauren M. Simon, MD, MPH Ashby Wolfe, MD

27 Implementing the Patient Centered Medical Home with CAFP Member Larry Shore, MD, Brown and Toland Medical Group Physician

6 Editorial This is Our Chance to Really Build a Home 7 President’s Message PCMH Talks Are Encouraging – But We’re Not There Yet 8 Political Pulse The State Capitol Has Become a Base Camp for Family Physician Involvement

Michelle Quiogue, MD Jack Chou, MD Tom Riley

9 News in Brief 10 Resident News Making Family Medicine Sexy

Randi Sokol, MD

11 CME Calendar 13 QI Corner Efforts in C4 Stepping Stones for What’s Ahead 14 Practice Management News You and Your Hospital — Learn the Ins and Outs of Hospital Contracting 18 PCMH Corner All Under One Roof: Introducing CAFP’s New PCMH Resource Center

Jane Cho Barbara Hensleigh

Shelly Rodrigues, CAE

19 In the Spotlight 29 California Family Physicians and Political Giving – Why Are We So Different Than Other States? 30 Executive Vice President’s Forum Together, We Are on Our Way to a Better Home

Susan Hogeland, CAE

1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org

Officers and Board President Jack Chou, MD

President-Elect Carol Havens, MD Immediate Past President Thomas Bent, MD Speaker Steven Green, MD Vice-Speaker Mark Dressner, MD Secretary/Treasurer Delbert Morris, MD Executive Vice President Susan Hogeland, CAE Foundation President Robert Bourne, MD AAFP Delegates Jack Chou, MD Carla Kakutani, MD AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD CMA Delegation Carla Kakutani, MD Jeffrey Luther, MD Steve Green, MD Patricia Samuelson, MD Taejoon Ahn, MD Catherine Forest, MD

Staff Cecilia Awayan

Sophia Henry

Chris Navalta

Receptionist and Membership Administrator

Membership Coordinator

Manager of Publications and Marketing

Susan Hogeland, CAE

Leah Newkirk

Executive Vice President

Director of Health Policy

Cynthia Kear, CCMEP

Tom Riley

Senior Vice President

Director of Government Relations

Callie Langton, MPA Associate Director of Health Care Workforce Policy

Shelly Rodrigues, CAE, CCMEP Deputy Executive Vice President CAFP Foundation Executive Director

Cody Mitcheltree

Marian Yee

Student and Resident Coordinator

Director of Continuing Medical Education

cafp@familydocs.org Karen Brent, MBA Director of Information and Technology

kbrent@familydocs.org Jane Cho Manager of Medical Practice Affairs

jcho@familydocs.org Adam Francis Legislative Assistant and FP-PAC Coordinator

afrancis@familydocs.org

shenry@familydocs.org

shogeland@familydocs.org

ckear@familydocs.org

clangton@familydocs.org

cnavalta@familydocs.org

lnewkirk@familydocs.org

triley@familydocs.org

srodrigues@familydocs.org

cmitcheltree@familydocs.org myee@familydocs.org

California FAMILY PHYSICIAN VO L . 6 1 N O . 4 • Fa l l 2 0 10

Editor: Michelle Quiogue, MD • Managing Editor: Chris Navalta Communications Committee: Michelle Quiogue, MD, Chair • Julia Blank, MD • Nathan Hitzeman, MD • Lindsay Larson, DO • Jeffrey Luther, MD • Jay Mongiardo, MD, MBA • Albert Ray, MD • Gary Seto, MD

The California Family Physician (CFP) is published quarterly by the California Academy of Family Physicians (CAFP). Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe. Advertising and publication management, Franciscan Communications. Contact CFP Associate Publisher Liana King at 510-525-3990 or e-mail lianaking@gmail.com.

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A2861_CAPhysician.indd 1

9/1/10 10:24 AM

EDITORIAL

Michelle Quiogue, MD

This is Our Chance to Really Build a Home

here are good reasons why your home looks very different from mine. If each family physician were to envision the transformation of our health care delivery system into Patient Centered Medical Homes (PCMH), we would each construct very different models. While the Patient Protection and Affordable Care Act of 2010 has transformed the rules of the game, there is no question that we, the physicians and our practice teams, must craft the strategies that

can see an opportunity of a lifetime. The opportunity to gain revenue beyond a sliding scale fee and the satisfaction of charitable giving is coming into focus. Many of the barriers to implementing electronic health records, chronic care management teams, quality improvement tools and true practice transformation have been eliminated. Optimizing the care coordinated by our practice partners and office staff is congruent with upcoming requirements for health information technologies/ meaningful use, Accountable Care Organizations (ACOs) and payment reform for high performance rather than high volume care. Financial incentives have begun to realign themselves in our favor. Combining momentum and synergy, our CAFP and AAFP leaders, along with community organizers and policy makers, have won substantial commitment of resources toward redirecting payment for a high-performing primary care-based health care system. In other words, the environment is ripe for change.

“Combining momentum and synergy, our CAFP and AAFP leaders, along with community

organizers and policy makers, have won

substantial commitment of resources toward

redirecting payment for a high-performing primary care-based health care system.” make the new rules work for us. So much time has been spent discussing the concepts and establishing the basic framework for a high-performing primary care office. Now the time has arrived to create real homes for our real patients. The time has arrived to leverage our most valuable resources. Our practice partners, staff and patients are contextual, personal and built on relationships developed over time. They are the foundation for our own versions of the PCMH that must also be contextual, personal and built on relationships developed over time. Rumors of millions of ‘new’ patients overwhelming the health care system and fears of quality oversight already leave some of us uncertain of the future. However, those who have ever wondered whether we could maximize the evidenced-based care we provide to our patients, and those of us who have long cared for the millions of uninsured Americans 6

California Family Physician Fall 2010

Hundreds of practices across the country have already tested the PCMH waters over the past few years. Perhaps you and your care team can learn from their experiences and find out how much the transformation will improve both your bottom line and your job satisfaction. The first place to start is online on the CAFP website, www.familydocs.org. To find out where your practice stands on the journey toward a PCMH, you can perform the TransforMED Medical Home IQ Assessment at www.TransforMED. com. Or if you are one of the early PCMH innovators, the CAFP invites you to share your experiences in practice improvement here with us. Show your California family physician colleagues what your home looks like.

PRESIDENT ’S MESSAGE

Jack Chou, MDL

PCMH Talks Are Encouraging – But We’re Not There Yet “We shape our dwellings, and afterwards our dwelling shapes us.” – Winston Churchill

’m reminded of this quote as we promote the future of family medicine and transform the health care delivery system under the federal health care reform framework. I am heartened by the increasing number of our colleagues who are becoming more familiar with the Patient Centered Medical Home (PCMH) concept. No longer are folks staring back at me with polite interest and reflexive nods when I highlight the benefits this new paradigm brings to primary care practices. As of this writing, the academy-sponsored bill AB 1542 (Jones) is winding its way through various senate committees en route to the senate floor. It is my genuine hope that by the time this message is published, we will have a working definition of PCMH codified in California law. Still, we are far from dotting California’s landscape with communities of medical homes. Passage of a PCMA definition bill, whether we are ultimately successful or not this year, would merely lay down the chalk lines for the PCMA model. The heavy lifting involved in placing the cornerstones of any PCMH is our job as we transform our individual practices. As physicians in the front lines of this new paradigm of care, we will be accountable to deliver on the promise of a high-quality, accessible, coordinated/integrated care delivery system by leveraging chronic disease registries and health information technologies/electronic health records (EHR). Congratulations to our fellow family physicians who have already attained National Commission for Quality Assurance (NCQA) PCMH recognition. Only 110 physician practices have earned any level of NCQA recognition in California, however, whereas Maine has more than twice our numbers and New York has nearly 10 times as many. Granted, this recognition presents the classic “chicken-or-egg” argument as outlined by Drs. Terry McGeeney and Lenny Fromer of TransforMED at our Annual Scientific Assembly in May. Many are taking

a deliberate approach to practice transformation and some are holding out for a “show-me-the-money” moment before jumping on the bandwagon. Nonetheless, this model of care has already demonstrated improvement in quality and cost reduction in various pilot sites in other states. As an academy, we must facilitate our members’ practice transformation and help their practices build additional capacity in their focused areas of need. Whether it is implementation of an EHR or improving chronic disease management metrics, starting a new practice or simply tuning up existing practice workflow for better efficiency, the Academy should act as a conduit for our members by providing trusted resources to allow each of our members to achieve his or her goals. In support of this effort, over the next several weeks, you will see changes to our Academy website, www. familydocs.org. The staff has been working hard to lay the foundation for Academy support of your transformations. In addition to these internal changes, your Academy staff has traveled to many parts of the state to promote the PCMH model of care, bringing national experts to local area meetings that some of you may have attended. We are actively seeking opportunities with public and commercial payors to create proof of concept pilots in California for the PCMH model. As Frank Lloyd Wright said, “a great architect is not made by way of a brain nearly so much as he is made by way of a cultivated, enriched heart.” So should all of us be motivated by our heartfelt desire to provide the highest quality, most affordable, easily accessible, well-coordinated/integrated care for our patients. If you have not done so already, take the online readiness selfassessment at TransferMED.com. Time to roll up your sleeves and get to work building your medical home.

California Family Physician Fall 2010

POLITICAL PULSE

Tom Riley

The State Capitol Has Become a Base Camp for Family Physician Involvement

wenty years from now, Americans will look back at the passage of federal health care reform in 2010 and shake their heads. How could we have tolerated the health care system that existed prior to it? Our children and their children will likely be appalled to hear that people once died or suffered unnecessarily from debilitating diseases because they couldn’t pay for medical care; that parents once had to explain to their kids that they couldn’t buy insurance because they had a pre-existing condition; that the efficacy of preventive care was conclusively demonstrated long before private and public health programs offered it, despite the ridiculously obvious savings and improved quality of life. One of the great differences they are likely to see is the evolution of their own physician who, in addition to co-

ordinating care in the Patient Centered Medical Home (PCMH), will directly advocate not only for his or her patients within health systems, but for system improvements in policymaking arenas. In no specialty will this evolution more profound than in family medicine. Not only will health care reform propel family medicine to maturity as a profession, family medicine will be the very foundation of a more advanced patientcentered health care delivery system. I can see the transformation already from my Sacramento office. Mine is an unremarkable space, located above Ella Restaurant at a turn in the light rail track at 12thand K streets. But these days, it’s become a “base camp” for family physician forays into committee hearings and policy meetings a block away at the Capitol. Medical students and residents who shadow CAFP lob-

byists often start their day at this office before heading over to the Capitol building. CAFP members testifying in committee chambers often retreat here for debriefing before returning to their own offices and their patients. Here are just a few policy efforts in which CAFP family physicians, residents and students have recently been involved: • A group of residents, led by Santa Rosa faculty member Panna Lossy, MD met with Assemblymember Jared Huffman’s (D-San Rafael) staff to discuss support for improved payment for immunizations and to promote the PCMH. • Eryn Xavier, MD and CAFP’s Resident of the Year, Veronica Jordan, MD, each joined me on my lobbying rounds.

CAFP WINS 2010 has been a successful year for CAFP’s Advocacy Team, lead by CAFP Legislative Affairs Committee Chair Taejoon Ahn, MD, MPH. As of this writing, CAFP’s sponsored bill to define the Patient Centered Medical Home is very much alive, and may be headed to the Governor’s desk awaiting his signature or veto. Nine other CAFPsupported bills made it to the Governor’s desk, while not a single bill opposed by CAFP made it through the legislative process.

California Family Physician Fall 2010

Governor Signs CAFP-supported SB 882 (Corbett) This new law will prohibit the sale and distribution of electronic cigarettes to those 17 years old or younger.

CAFP-sponsored AB 1542 (Jones) Still Alive If signed by the Governor, this bill would define the Patient Centered Medical Home (PCMH) consistent with the Joint Principles of the Medical Home as developed by the AAFP, American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association.

CAFP Invited to Signing Ceremony for California Health Care Reform Bills Due to CAFP’s strong support for health care reform in California, the Governor invited the Academy to attend a bill signing ceremony where a package of heath care reform bills were signed, including one to establish a health care insurance exchange in California. Kelly Jones, MD, program director of USC’s Family Medicine Residency Program attended on CAFP’s behalf.

• Sam Applebaum, MD helped conduct an FP-PAC candidate interview with Linda Halderman, MD, one of two physicians running for Assembly in November’s general election. • 2010 CAFP Family Physician of the Year, Eric Ramos, MD drove from Modesto to Sacramento to testify in support of AB 1542, CAFP’s bill to define the PCMH. • Marsha McKay, DO took valuable time from her small practice in Twain Harte to testify in support of AB 2093, CAFP’s co-sponsored bill to ensure adequate health plan payment for vaccines. • UC Davis resident Charlene Hauser, MD participated in a rally in front of the Capitol to educate the public about the dangers of alcohol abuse and to drum up support for policy measures to curb the health and financial damage alcohol abuse inflicts on the state. My office looks like a small family medicine army encampment on some days, which is terrific. Policymakers need to hear how the choices they make will affect patients and physician practices and, of course, lobbyists who work for physicians need to understand those effects too. But there is something afoot larger than that these days. The annual budget crisis, the periodic renewal of the state’s Medicaid waiver and even many of the nagging, longstanding health care policy issues are all taking on a fresh spin because of the impending insurance reforms, delivery model tweaks and the rush of newly-insured Californians. One day, when the country looks back on this time as being the moment when something wrong started going right, they will be grateful that family physicians played such a crucial role. Tom Riley is CAFP’s Director of Government Relations.

Register Today for CAFP’s Annual Student Conference CAFP’s one-day annual event for medical students will take place on October 16 at the University of California, San Francisco. The focus is on the Patient Centered Medical Home and caring for the underserved. Attendees will interact with California family medicine residency programs, gain valuable skills in hands-on procedures, learn how to become involved in their communities and have answered their most common questions on applying to and interviewing with residency programs. More information is at http://www.familydocs. org/annual-student-conference.

CAFP to Help Members Obtain Cost Savings on Vaccine Purchasing CAFP has contracted with Atlantic Health Partners to help members save money on vaccine purchases. Atlantic – a group purchasing program for physicians – is working directly with Sanofi Pasteur and Merck to obtain the most favorable pricing and purchasing terms for a wide variety of pediatric, adolescent, adult, flu and travel vaccines. Atlantic works with more than 20 other AAFP chapters and serves more than 3,000 family physicians. For more information and a free membership, please contact Jeff Winokur at Atlantic at info@atlantichealthpartners.com or 800-741-2044. You can also find information on CAFP’s “Discounts on Vaccines” page on www.familydocs.org.

CMA Foundation Provides Grant to UCLA FMIG A “shout out” goes to the California Medical Association Foundation for its $1,000 grant to the UCLA Family Medicine Interest Group (FMIG) to support its on-campus activities and assist with costs of attending the AAFP National Conference of Students and Residents at the end of this month. Executive Director Carol Lee, Esq. noted that “though we have not funded attendance at out-of-state conferences in the

past, with the severe shortage of family physicians, we hope our small grant will inspire a few medical students to stay the course and go into family medicine.” Thank you, CMA Foundation!

Congratulations Glendale Adventist Family Medicine Residency Program Please join CAFP in congratulating the entire team at Glendale Adventist Family Medicine Residency Program for receiving the 2010 AAFP Pfizer Immunization Award for Best Practices! The program’s commitment to best practices in immunizations is admirable and an inspiration to other family medicine residency programs in California. Kudos! Learn how to apply for next year’s award at http://www.aafpfoundation. org/online/foundation/home/programs/education/wyethimmunizationawardsprogram.html

CAFP Editor Michelle Quiogue, MD on The Today Show CAFP Editor Michelle Quiogue, MD and her husband Jason Sperber were featured on The Today Show on NBC on August 6 in a story about stay-at-home husbands and breadwinning moms. Dr. Quiogue, a family physician from Bakersfield, is the editor of CAFP’s quarterly magazine, California Family Physician. Their story is also featured in this month’s issue of Marie Claire magazine.

San Diego Physician Steve Green, MD is a Swimming Machine! CAFP Vice Speaker Steve Green of San Diego swam the Catalina Channel on August 5 in 11 hours and 31 minutes! Dr. Green and 183 other swimmers participated in the Catalina to Long Beach event, held by the Catalina Swim Federation. He began his swim just after midnight on August 5; kayakers provided all swimmers liquid nutrition every 30 minutes.

California Family Physician Fall 2010

NEWS IN BRIEF

• 2009 Hero of Family Medicine award recipient Carla Kakutani, MD played a crucial role in numerous Capitol meetings, guiding legislators, testifying before legislative committees and bringing stakeholders together.

RESIDENT NEWS

Randi Sokol, MD, MPH

During Medical School

Making Family Medicine Sexy

he time to market family medicine is as ripe as it ever will be. With the Obama administration’s recent commitment of $168 million to create more residency slots that would train more than 500 new primary care physicians during the next five years, and an additional $5 million for states to expand their primary care workforces by 10-25 percent during the next 10 years, the financial barriers to workforce issues are being addressed for the first time. The need is certainly great. According to the Association of American Medical Colleges (AAMC), the US is projected to have a shortage of approximately 21,000 primary care professionals in 2015. (Others have estimated shortages of 40,000 by 2025, given overall population growth and a growing elderly population.) The shortage is most likely to disproportionately affect vulnerable populations such as the elderly, those who rely on community health centers and people in rural or poor urban communities who have traditionally been underserved. While the funding, the number of residency positions and the lingo shockingly appear to be heading in the right direction for primary care for the first time, will all of this change the number of students choosing careers in primary care? There are numerous ways medical students, residents, and practicing physicians can affect the pipeline and steer future physicians into a primary care career:

Before Medical School This is a perfect opportunity to get the most bang for our buck – those who enter medical school expressing an interest in primary care are highly likely to continue with this pursuit. And, those who come from rural or underserved backgrounds are most likely to practice in rural or underserved areas where primary care physicians are needed the most. Those with strong community service backgrounds and low income expectations are also likely to choose careers in primary care. So how can primary care and family physicians aid in bringing these types of students into medical school? With early exposure – get involved in mentoring pre-med students and even high school and middle school students. Those civic minded individuals from rural or underserved backgrounds might not have considered the possibility of a career in medicine, but with the right mentor, they just might. 10

California Family Physician Fall 2010

Studies show the first two years of medical school before students start rotations on the wards are critical to deciding on a specialty. While many students consider family medicine as a career choice early in their undergraduate experience, the number drops significantly during the second year of their curriculum. The most frequently cited reasons for students not choosing careers in family medicine include prestige, income and breadth of knowledge required. This is where exposure becomes critical and where we, as FPs, have the opportunity to make family medicine truly sexy and sell it. Exposure, exposure, exposure: Exposure to underserved populations, community health centers, families and communities and faculty involved in family and community medicine are key. Medical schools that champion primary care have taken proactive measures to increase their students’ exposure, such as setting up students up ‘continuity’ primary care mentors, giving students the opportunity to do home visits and exposing students to a team-based approach. Even if students do not choose to go into primary care after these experiences, they at least develop an appreciation for the breadth of primary care. Thus, it is crucial that more medical schools jump on this bandwagon and show they value primary care by giving students such fulfilling opportunities. Other innovations in care delivery: The Patient Centered Medical Home (PCMH) is perhaps one of the most brilliant marketing tools at our fingertips. With its implications for improved quality and access to care and for restructuring physician payment, it is the ”buzz word” we now hear even politicians and mainstream media use in the ongoing health care debate. And family medicine is at the forefront of this conversation. It’s time we use the PCMH to our advantage and sell it to medical students who are excited to be involved in this cutting-edge model of care delivery.

After Medical School We must be advocates for policies that forgive student loans, offer scholarships to students and reduce the salary gap between primary care doctors and specialty care doctors. Such methods include expanding the National Health Services Corps (NHSC) and advocating for public and private payors to develop enhanced funding and related incentives that allow physicians to practice in rural and other underserved areas. While the projected shortage of primary care physicians appears quite daunting, we are at a unique crossroads in health care reform history where the financial, political and cultural winds of change favor primary care. We must help fuel the future direction of our physician workforce by working with high school students, giving students the opportunities to experience longitudinal care of families in a team-based community setting, exposing them to policy and advocacy and being in the forefront of innovative models of care delivery. Family Medicine is indeed a sexy field – we have to sell it that way! Randi Sokol, MD, MPH is a second year Resident at UC Davis Family and Community Medicine Program.

CME

Looking for a Quality 10/1/10 – 10/5/10 American Academy of Pediatrics 2010 National Conference San Francisco and Exhibition 35.25 P American Academy of Pediatrics (847) 434-7890 Resource for twoike@aap.org www.aapexperience.org 10/9/10 – 10/9/10 Neurology for the Non-Neurologist 7.00 P your Patients’ La Jolla Scripps Health (858) 652-5400 med.edu@scrippshealth.org Weight Loss www.scripps.org/conferenceservices 10/11/10 – 10/13/10 Update on the Management of Thromboembolic Disorders 17.25 P Napa Unversity of California, Davis (916) 734-2283 Dietary Needs?

2010 CALENDAR

cheryl.nelson@ucdmc.ucdavis.edu www.ucdmc.ucdavis.edu/cme/

10/11/10 – 10/13/10 Hospitalist Mini College 18.25 P San Francisco University of California, San Francisco (415) 476-6127

october – november

bohlmannd@ocme.ucsf.edu http://www.cme.ucsf.edu

10/14/10 – 10/16/10 Management of the Hospitalized Patient 18.75 P San Francisco University of California, San Francisco (415) 476-6127

bohlmannd@ocme.ucsf.edu http://www.cme.ucsf.edu 10/21/10 – 10/23/10 Acute Care Psychiatry Clinical Review 23.25 P San Francisco Mayo Clinic (507) 284-4370 www.mayo.edu/cme

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The Solution

10/21/10 – 10/23/10 American Academy of Environmental Medicine Annual Meeting 16.0 P CarbEssentials.net has more La Jolla American Academy of Environmental Medicine (316) 684-5500

than 1,000 products that have been carefully selected by Perspectives in Rheumatic Diseases 2010 11.75 P University of Louisville (973) 290-8214 Dr. Ray Powell, MD for their dietary value based on 32 years s.reitman@globalacademycme.com www.chse.louisville.edu of Diabetes Day for Primary Care Physicians 4.50 P experience in weight loss American Association of Clinical Endocrinologists (904) 353-7878 medicine. All products have mburdette@aace.com http://aes.aace.com been taste-tested by thousands of American Osteopathic Academy of Addiction Medicine 12.0 P weight loss patients.

defox@aaemonline.org www.aaemonline.org/annualmeeting.htm 10/22/10 – 10/23/10 Santa Monica

10/23/10 – 10/23/10 Riverside

10/24/10 – 10/28/10 San Francisco Annual Convention American Osteopathic Academy of Addiction Medicine

(708) 338-0760 nvidmer@aoaam.org www.aoaam.org 10/27/10 – 10/29/10 Obstetrics and Gynecology Update 22.75 P San Francisco University of California, San Francisco

(415) 476-8475 kirklens@ocme.ucsf.edu www.cme.ucsf.edu 10/27/10 – 10/30/10 Academy of Breastfeeding Medicine’s 15th Annual Meeting 24.50 P San Francisco Academy of Breastfeeding Medicine www.bfmed.org 10/29/10 – 11/1/10 Women’s Health Update 20.75 P Half Moon Bay Unversity of California, Davis (916) 734-2283

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december

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12/1/10 – 12/4/10 Annual Medical Fitness and Healthcare Conference 17.75 P San Diego Creighton University School of Medicine, CME Division

(402) 280-1830 kawise@creighton.edu http://cme.creighton.edu 12/2/10 – 12/4/10 The Medical Management of HIV/AIDS 20.25 P San Francisco University of California, San Francisco

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California Family Physician Fall 2010

CHIEF MEDICAL OFFICER

Get in gear.

The Fresno-Kings-Madera Regional Health Authority is recruiting a full time Chief Medical Officer. Qualified candidates will have:

Southern California Physician Opportunities Join our dynamic and compassionate teaching physicians at Loma Linda University Family Medical Group. Our growing, highly regarded family medicine faculty practice is offering positions that cover a variety of combinations between OB, inpatient, outpatient and resident and student teaching. Additionally, we have outpatient opportunities at our new facility in Beaumont, CA. Our residency is a fully accredited, rapidly growing and innovative P4 program seeking full-time academic family medicine faculty. Entry level positions available as well as positions for experienced faculty who have interest in advancement. Must have personal and professional goals that are consistent with the institutional mission of whole person care. Current board certification with full scope practice required. We offer a competitive academic practice salary based on both clinical and academic productivity, retirement plan and great health benefits. Starting bonus and relocation stipend available. Send CV with letter of intent and three references to Michelle Sharrow at msharrow@llu.edu. If you have questions or need any additional information call 909-558-6505. “Anyone can change the world, everyone should try!”

• Current California medical license • Satisfactory completion of an accredited residency program • Board Certification preferably in Family Practice, Pediatrics or Internal Medicine • Medicaid/MediCal Health Plan experience (preferred) • Strong skills in identifying, planning, leading and executing appropriate and successful health care business strategies to meet changing organizational and community needs and regulatory requirements • 2 or more years of medical administrative experience Excellent salary and benefits including health, life and disability insurance – vacation leave - sick leave – automobile allowance and generous pension plan.

For consideration please email a cover letter and resume to creiter@calvivahealth.org addressed to: Gregory Hund, CEO CalViva Health.

Kaiser Permanente Southern California: We take care of your administrative concerns and offer you a balanced call and work schedule. We give you the support, resources and autonomy you need to give your patients the exceptional care they deserve.

Family Medicine Opportunities: Lancaster, Fontana, Riverside, San Diego, Palm Springs, Los Angeles County and Panorama City (Urgent Care) • Cross-specialty collaboration • Comprehensive support network • Highly competitive compensation and benefits • A location known world over for its great climate and natural attractions.

You’re a creative, innovative professional who’s already mastered some of your field’s most challenging terrain. Now you’re ready to shift into a whole new gear. So make tracks for Mercy Merced Medical Group in Merced, a service of CHW Medical Foundation. Located in picturesque Central California, our growing community offers more than 12 miles of class-one, grade-separated bike paths. Join us and discover a working environment, career opportunities and recreational amenities that are more than worth the ride.

FAMILY PRACTICE PHYSICIANS Merced, California

This is your opportunity to develop a full scope, outpatient-focused family medicine practice with a newly formed and growing multi-specialty group. You'll see a wide variety of patients. All inpatient care is done at Mercy Merced Hospital (www.mercymercedcares.org), a new 190-bed hospital with a soon-to-launch Hospitalist program. Located in the San Joaquin Valley near the foothills of the Sierras, Merced prides itself on being "The Gateway to Yosemite". You’ll practice medicine in a cutting-edge medical community amid a rich, culturally diverse area. Merced offers an assortment of shopping, museums, art galleries, live entertainment, great restaurants and much more for all ages to enjoy. The city also boasts its own symphony and theater company and is host to a variety of festivals throughout the year. Our physicians utilize leading edge technology, including EMR and enjoy a comprehensive and excellent compensation and benefits package in a collegial and supportive environment. For more information, please contact and/or send CV to: Arlene Wong, Sr. Physician Recruiter arlene.wong@chw.edu P: (916) 733-5774. F: (916) 859-1612. Not a J1 opportunity.

Send CV to: Kaiser Permanente, Prof. Recruitment 393 East Walnut Street, Pasadena, CA 91188-8013 Family Medical Group

California Family Physician Fall 2010

Phone 800-541-7946 • E-mail: Martin.Chao@kp.org. We are an AAP/EEP employer.

Mercy Merced Medical Group

Efforts in C4 Stepping Stones for What’s Ahead

QI CORNER

Jane Cho

ctober 16 (check the date) is graduation day for the nine practices participating in CAFP’s Capacity-Building Collaborative (C4. The practice teams will meet at The California Endowment’s headquarters in Los Angeles to celebrate their progress and share their accomplishments. Pre-work began summer 2009, and since then the teams have participated in 15 learning sessions in the following educational modules: revenue cycle management, operational efficiency, care coordination, and access and communication. The curriculum and tool set were designed and developed to lower practice overhead and create breathing room for small practices through a tour of the four modules. C4has been a substantial Academy investment in quality improvement and has served as a stepping stone for much of the work we’ve been doing with our Patient Centered Medical Home-oriented (PCMH) strategic plan. While much of the focus of C4 has been on the collaborative itself, the learnings, curricula and identified resources will be applied throughout various departments to help family physicians adopt PCMH. The most significant way we will share the new tools and resources from the C4 curriculum is by implementing our PCMH Resource Center. The previous New Directions in Diabetes Care (NDDC) resource center (http://www. familydocs.org/new-directions-diabetes-care/tools-andresources.php) was built to organize and make available a wide range of tools, templates, research and data regarding chronic care management and diabetes. Today, it is among the most-visited pages on CAFP’s website. Most of the resources are more broadly applicable to quality improvement, and with C4 we’ve identified more than 50 new tools in addition to those currently available. (Please see page 18.) Another Academy accomplishment is the publication of the NDDC Promising Practices monograph, a two-year project memorializing site visits staff made with high-performing teams participating in our diabetes collaborative. CAFP staff completed narratives from seven site visits with teams practicing throughout California. The goal of the visits was to understand, from both the physicians’ and the team members’ perspectives, what led to successful innovations in workflow, patient self-management and team-based care, and how each practice sustained these efforts. We have worked closely with our consultant and, as of August

2010, are happy to announce the production of both a print and electronic compilation of the promising practices. We will distribute the publication to the primary care community, hopeful that it will enhance the quality of patient care and systems redesign of medical practices. The monograph was supported by a grant from The Physicians’ Foundation for Health Systems Excellence. Your Academy has invested a significant amount of time and energy to help members transform their practices to a medical home; our departments are working on all levels to assist you in the process. Within the realm of quality improvement and patient-centeredness, we are searching for ways to offer userfriendly and time-efficient ways to address clinical excellence and practice redesign. We hope our efforts in the C4 collaborative, lessons from our NDDC promising practices monograph and the launch of our PCMH Resource Center will help you move forward. If you have any questions about any of CAFP’s quality improvement efforts or would like more information, please contact me at jcho@familydocs.org. Jane Cho is CAFP’s Manager of Medical Practice Affairs. California Family Physician Fall 2010

PRAC TICE MANAGEMENT NEWS

Barbara Hensleigh

You and Your Hospital — Learn the Ins and Outs of Hospital Contracting

alifornia and a minority of other states bar hospitals from directly employing physicians unless the employment relationship fits into one of a few legal exceptions. Faced with economic stressors, however, hospitals are attempting to increase revenue by offering services rendered by physicians. In some cases, hospitals have created ways to circumvent the prohibition against the corporate practice of medicine while, at the same time, using it as an excuse to pass on expenses and potential liabilities to the physicians with whom they contract. This article provides guidance in reviewing hospital/physician contracts for physician-led services and in limiting expenses and liabilities.

The Physician as an Independent Contractor There are exceptions to the prohibition against the corporate practice of medicine. Certain hospitals in rural areas can employ physicians, for example. If a physician were employed by a hospital, the hospital must pay withholding taxes, malpractice insurance, benefits, vacation pay and the like. Some physicians may prefer to be employees of a hospital because of such benefits. The hospital’s evaluation of the relationship may differ from that of the physician. Regardless of whether or not the hospital can legally employ physicians, it may desire to contract with a physician as an independent contractor to save money. The hospital is not required to offer benefits to independent contractors as it would to employees, including vacation pay, medical insurance and retirement programs. Furthermore, as an independent contractor, the physician will likely be required to pay his or her own medical malpractice insurance. Finally, physicians are liable for any professional negligence because they are not hospital employees and the hospital may rely on the general prohibition against the corporate practice of medicine to avoid entering into an employment relationship with physicians. Independent contracts between physicians and hospitals are not particularly physician-friendly for more reasons than the fact that physicians do not receive the same benefits as hospital employees. These contracts are typically written by hospital legal counsel and have become more advantageous to hospitals in recent years. It seems as though each hospital attorney is trying to outdo the other in transferring costs and liabilities to the physician. At the tipping point, it is inadvisable for a physician to enter into such a one-sided agreement. This is particularly true for contracts with large hospital chains, both for- and not-for-profit. Occasionally, a hospital chain will refuse to negotiate a decidedly inequitable 14

California Family Physician Fall 2010

arrangement citing the need for uniformity of contracting. A take-it-or-leave-it agreement probably should be left. At a minimum, before entering into a hospital contract, physicians should review the proposed agreement and assess the following: • Is the relationship truly that of an independent contractor, or does it seek to circumvent the prohibition against the corporate practice of medicine or pass on certain operating costs of an employer onto the physician? If the hospital is controlling the physician’s work hours, providing equipment and supplies, prohibiting the physician from working elsewhere and exerting general control and supervision over the physician, the agreement may be more of an employment agreement, regardless of how it is worded. • How much will an independent contracting arrangement cost the physician? The physician must pay for his or her liability and health care insurance, taxes, disability insurance and vacation, among other things. If the physician intends to enter into an independent contracting arrangement with a hospital, those costs should be recouped by the physician in the form of payment for his or her services. In other words, an independent contracting arrangement paying $140,000 per year is not the equivalent of an employment agreement for the same amount. • Is the hospital requiring the physician to create a separate corporate entity to enter into the agreement? At least one major hospital chain requires a physician be incorporated before entering into a contract to provide services on behalf of the hospital. Such a requirement is nothing more than an effort to circumvent the bar on the corporate practice of medicine by making an employment agreement appear more like an independent contracting arrangement. While protecting the hospital chain, this requirement costs the physician money. The physician is required to pay the costs of incorporation as well as the corporation’s annual taxes. These costs should be passed on to the hospital. • Is the hospital requiring the physician to carry general liability insurance? There is no reason for a physician, without an existing medical practice, to carry general liability insurance. However, one major hospital chain routinely requires its contracting physicians to purchase general liability insurance, naming the hospital as an additional insured. Before signing such an agreement, a physician should determine whether he or she can even obtain such insurance. If so, its cost should be passed on to the hospital.

• Is the hospital attempting to require the physician to indemnify the hospital? One large hospital chain in California attempts to include a contractual requirement that physicians indemnify the chain in the event it is 1) charged by the Internal Revenue Service for taxes not paid by the chain for the physician because the chain has intentionally misclassified the physician as an independent contractor rather than an employee; and 2) sued for work performed by the hospitals’ employees under supervision of the physician. As openly acknowledged by the chain’s legal counsel, a physician’s malpractice carrier typically will not provide coverage for either situation. Accordingly, the physician could be personally liable for these inequitable indemnification provisions. Indemnification and the risk of liability may be too great for a physician to enter into such an arrangement. Notably, when one physician client refused to agree to indemnify the chain under these circumstances, the chain relented and changed the provisions. But the change did not occur without the willingness of the physician, in the face of personal pleas by the hospital’s CEO, to walk away from the contract. • Does the proposed agreement provide the hospital with the right to settle a lawsuit on behalf of the physician? One hospital chain provides the contracting physician with a modicum of insurance under that system’s self-insurance policy. However, the same provision gives the system the right to settle any lawsuit brought against the physician. The provision is as unacceptable in the proposed hospital contract as it would be in an insurance policy permitting the carrier to settle an action without the physician’s consent. Any settlement may be reportable to the National Practitioner Data Bank or Medical Board. Moreover, the chain may not have the physician’s best interests at heart in settling and it would be beneficial to remove the provision from the agreement.

The Shadow Physician Practice A major hospital chain has another method of circumventing the prohibition against the corporate practice of medicine. The process involves: 1. creating a medical group; 2. locating a titular physician owner of the practice; 3. causing the group to enter into a long-term management agreement with a hospital-owned management group for significant management fees; and 4. causing the group to enter into an employment agreement with the physician providing him or her with a percentage of the revenue from the practice. Under this paradigm, the hospital controls the medical group; the group and the practice are owned in name only by the physician. If the physician terminates his or her employment agreement with the group, ownership in the group immediately terminates.

The arrangement poses significant potential liability for the physician. As the sole shareholder, the physician is subject to liability for actions by the management group or hospital of which he or she may not be aware. For example, if the hospital chain does not properly incorporate the group or does not maintain corporate formalities (e.g., maintain bylaws, annual shareholder meetings and corporate taxes), the physician may be personally liable to third parties to whom the group owes money. Since failing to maintain corporate formalities poses little or no liability to the hospital chain, there is a possibility the formalities may not be maintained. Moreover, the bylaws of the group, if there are any, or the management agreement may require the group to indemnify the management group for any actions it has taken on behalf of the group. If the group has not observed corporate formalities, then the physician may be personally liable and may be forced to indemnify the hospital chain or its management organization for acts it took on behalf of the group. Finally, even if the management group agrees to indemnify the physician for its actions, the indemnification is only as good as the financial viability of the management group. If they are insolvent, the indemnity provision may be meaningless. There are other reasons to be concerned about the de facto control by a hospital/management group of a practice legally owned by a physician. The physician is ultimately responsible for the activities of the group, regardless of whether he or she controls it. To the degree the management group engages in billing irregularities, the physician maybe legally responsible, even if he or she did not know about the irregularities. The paradigm also raises troubling kickback and fee splitting issues. California law, for example, prohibits the formation of a professional corporation for the purpose of causing a violation of the law relating to fee splitting, kickbacks or similar practices by physicians. Violation of the law may result in a referral by the Department of Managed Health Care to the Medical Board for termination of the involved physician’s license. If a court were to see through the shadow physician practice, it might find that the hospital has violated the prohibition against the practice of medicine AND that the arrangement violates the prohibition against fee splitting and kickbacks. Barbara Hensleigh, a former NICU nurse, has practiced law for more than 20 years. Her statewide practice is with the law firm of Andrews & Hensleigh, LLP, in Los Angeles, California. Ms. Hensleigh’s practice is devoted to the representation of physicians, physician groups and health care entities in litigation, arbitration and administrative proceedings. She may be reached at bhensleigh@ahlaw.us. DISCLAIMER The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney-client relationship. Consult your attorney or other professional for advice in your particular situation. Copyright © 2010 The California Academy of Family Physicians - San Francisco, CA, USA. All rights reserved.

California Family Physician Fall 2010

Paul Grundy, MD, MPH

California Family Physician Fall 2010

An Open Letter to CAFP Members

California Family Physician Fall 2010

PCMH CORNER

Shelly Rodrigues, CAE, CCMEP

All Under One Roof: Introducing CAFP’s New PCMH Resource Center

ooking for information on National Commission on Quality Assurance (NCQA) criteria? Want to know more about meaningful use and how to work with a Local Extension Center (LEC)? Need links to TransforMED for a Patient Centered Medical Home (PCMH) readiness practice assessment? Interested in continuing medical education (CME) activities that match your move toward a PCMH? Wondering what colleagues across California are experiencing? Teaching PCMH concepts to medical students or family medicine residents? Then CAFP has a great new resource for you! Using the New Directions in Diabetes Care (NDDC) Resource Center on CAFP’s website as a starting point, CAFP has gathered hundreds of PCMH resources and placed them under one roof – http://www.familydocs.org/pcmh.php – for easy access by family physicians, their practice teams, FM residents and medical students. The new PCMH Resource Center, launched with grant support from The Physicians’ Foundation for Health Systems Excellence, is open to all – no firewall, no password. The landing page offers a quick roll-over summary of the nine sections with direct links to the sections and to TransforMED, AAFP and the Patient Centered Primary Care Collaborative (PCPCC).

The nine sections at a glance are:  Getting Started: Introduction to PCMH, including definitions, videos, practice assessment tools and stories of colleagues who are in the process of transformation.  Patient Centeredness: Tools to help improve access and patient satisfaction, engaging patients, patient communication and education and multicultural issues.  Health Information Technology: Electronic health records (EHR) assessment and implementation, registries, meaningful use, working with Regional Extension Centers (RECs) and LECs and e-prescribing.  Quality and Care Management: Chronic care management and care coordination, health care improvement, group visits and team care, tools for measuring quality improvement (QI).  Advocacy and Policy: CAFP activities, national health care reform, payment reform and financial resources, workforce issues and demonstration project information.  Financial Vitality: Revenue cycle management, sound coding and billing practices, practice management and human resources, payment issues, including pay-for-reporting and pay-for-performance.  Practice Transformation and Office Efficiency: Tools to assist in increasing operational efficiency, office redesign, practice models and promising practice from colleagues who are transforming their practices.  Students, Residents and Educators: Frequently Asked Questions (FAQs) for medical students and residents, curricula resources, activities in California and other states and modules for teaching.  Continuing Medical Education: Educational activities and CME calendar, PCMH learning journal, articles, tools, videos and links.

In a recent survey, CAFP members told us they needed assistance, and asked for: • Someone to guide us through this process, with resources to assist • A checklist for the route, the difficulty of each step, and the priority

California Family Physician Fall 2010

• Development of standing order protocols • Have health care coaches trained and ready to go • Message board for answers to problematic situations • Easy to implement practices for small out-patient offices • Do it starting with solo practices

• Help line • Time for team huddles • Best practices, examples of success • Assisting is achieving NCQA status • More CME • Where to get started

The new resource center includes new tools identified as part of CAFP’s Capacity-Building Collaborative 4 (C4) and CeaseSmokingToday (CS2day) collaborative. We identified at least 50 new tools as part of the curriculum development for C4 alone. These tools are uploaded in a logically-organized and easilyaccessible fashion and range from curricula elements and templates to pre-populated spreadsheets and questionnaires. The center also features a series of video and audio pieces that will assist physicians and their teams in understanding many of the concepts of PCMH. Initial videos are already in place and others will be added in the appropriate sections with relevant tools so a selfdirected learner could essentially: 1) View a 5-10 minute clip on a topic such as process mapping; 2) See what a typical process mapping exercise looks like; 3) Download the specific tools needed to go through the process mapping exercises as a team; and 4) Access much more detailed resources on the types of process maps (i.e., where to find them in the Dartmouth Primary Care Greenbook). We’ve also planned a “subscription/feedback” mechanism to get feedback on implementation, use, barriers, successes, etc. and will offer blog/comment and RSS features in the coming months. The roof on the PCMH Resource Center is up and now we’re open for visitors. Come on in, check out the features, download the materials, use the links, and most importantly, let us know what works, what doesn’t, and what else you’d like to see in your PCMH Resource Center.

IN THE SPOTLIGHT

The PCMH Resource Center was built to meet the needs expressed by CAFP members in recent surveys (see sidebar). We have expanded NDDC resources to include essays, tools, templates, data and information on quality and performance improvement, moved the more general QI pieces (i.e., those related to motivational interviewing, workflow, patient experience, etc.) and created new sections for those resources. We’ve also added more explanatory text for each piece of content to help users understand what each section provides and improve navigation.

Medical Leadership Council Update

Medical Leadership Council on Cultural Proficiency The Medical Leadership Council

on Cultural Proficiency (MLC) met May 19 in Oakland, convened by The California Endowment. This leadership group, comprised of executive and elected leaders of the state’s medical specialty societies and county medical associations, as well as health plan and health system leaders, works to improve the provision of language services and culturally proficient care, increase the diversity of California’s health care workforce, and eliminate health care disparities. Meeting topics included ways that the new national health care reform law supports cultural proficiency; new NCQA standards on multicultural health care; new health information technology funding; and new MLC resources. In addition, the cultural proficiency educational component at this meeting was an overview of health care disparities among transgender men and women.

National Health Care Reform Law Supports Improved Care for Diverse Populations The new Patient Protection and Affordable Care Act includes several measures designed to improve the health of minority populations. Tom Riley, principal at Cal Capitol Group, outlined some of the highlights, including: • Funding is increased for data collection and research on health disparities. • Initiatives to increase the racial and ethnic diversity of health care professionals are expanded, including additional scholarship and loan repayment opportunities for disadvantaged students who commit to work in medically underserved areas. • Cultural proficiency training among health care providers will be strengthened through expanded programs to support development and use of cultural proficiency curricula in health professions schools and continuing education programs.

NCQA Establishes Multicultural Health Care Standards NCQA has released standards for a new voluntary Multicultural Distinction Program. The purpose is to evaluate race/ethnicity and language data; language services; practitioner network cultural responsiveness; incorporation of national Culturally and Linguistically Appropriate Services (CLAS) standards; and efforts to reduce health care disparities, said presenter Jessica Briefer French, MHSA, Senior Consultant, Research at NCQA. For more information, see the NCQA Standards and Guidelines for Distinction in Multicultural Health Care. In the Spotlight > 25

California Family Physician Fall 2010

THE PATIENT CENTERED MEDICAL HOME Bo Greaves, MD

Examining Sonoma’s PCMH Learning Collaborative Editor’s note: This article was first published in the Summer 2010 issue of Sonoma Medicine, the magazine of the Sonoma County Medical Association. We thank Sonoma Medicine for reprint permission. Americans have focused more on their health care system in the past year than in generations. The immediate result has been the passage of needed insurance reform that will bring coverage to nearly 38 million uninsured citizens and eliminate some egregious injustices, such as refusing coverage for pre-existing conditions. A byproduct of the debate over health reform has been a wider and deeper appreciation of the deficiencies of our current system. Many people are now aware that the United States spends more on health care than any other nation in the world, yet ranks near the bottom of developed countries in most measures of health outcomes. Adding 38 million more people to the current system without addressing these deficiencies could accelerate our problems to the point of system collapse. This possibility has increased attention on the role of primary care as the foundation of an improved health system. In particular, two propositions are emerging with more clarity than ever: The key to improving outcomes and reducing costs is for every American to have a reliable relationship with a full-service source of primary care. To maximize the benefit to the health care system and the country, we need to transform how we deliver primary care. Major efforts to transform primary care have already started. Family physicians, pediatricians and internists are modernizing primary care practice with fundamental changes in access and communication, quality improvement, care coordination, comprehensive care, team approaches and the use of health information technology. Their goal is to change their practices into Patient Centered Medical Homes (PCMH). What is a PCMH? It is a model of health care delivery that is based on patients having an ongoing personal relationship with a primary care physician or, in certain settings, a primary care nurse practitioner. This close patient/clinician relationship fosters continuous and comprehensive health care. The personal clinician leads a team of health care professionals

California Family Physician Fall 2010

who collectively take responsibility for the ongoing care of the patient. A whole person orientation is a key component of the PCMH. The personal clinician provides for all the patient’s health care needs or takes responsibility for managing care with other qualified professionals, including acute care, chronic care, preventive services and end-of-life care. The personal clinician coordinates care across all elements of the patient’s community, including consulting specialists, hospitals, home health agencies, nursing homes, and other components of the health care system. Care is facilitated through registries, information technology, health information exchanges and other means to ensure patients get the indicated care when and where they need and want it. Quality and safety are hallmarks of the PCMH. Practices that adopt the PCMH model become advocates for their patients to attain the best health outcomes. The care planning process is driven by a compassionate and robust partnership between the patient, the patient’s primary clinician, other health care providers and family members. The patient actively participates in decision making and provides feedback to ensure that expectations are being met. In a PCMH, evidence-based medicine and clinical decisionsupport tools guide decision making. Physicians and nurse practitioners in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measures. Information technology supports optimal patient care, performance measurement, patient education, and enhanced communication. The enhanced access to health care in a PCMH means the practice provides patients with options such as open scheduling, expanded hours and various arrangements for communication between patients, the clinician, the practice team and office staff. The new health reform legislation contains dozens of references to the PCMH. Both Medicare and health insurance companies are implementing demonstration projects aimed at showing that this approach can improve health care outcomes at a significantly lower overall cost. The National Committee on Quality Assurance (NCQA) has developed a system to assess and certify practices as a PCMH. One thing is clear: usual care in a primary care office today is not the same as the standards set by this new model of care. Before our practices can become certified as a PCMH, fundamental changes will need to occur in our offices and in how we provide care to our patients.

THE PATIENT CENTERED MEDICAL HOME

Financial incentives for becoming a PCMH are in the works as well. Medicare, for example, has adopted a “care management fee” above and distinct from its fee-for-service payments. Initially, the fee will be offered in Medicare’s demonstration projects. Tto receive this substantial extra revenue, a practice will need to prove (by NCQA or some other process) that it is functioning as a PCMH. Major insurers are also expected to adopt some payment methods to provide more revenue to primary care practices that are PCMHs, and less to those that are not. In March, nine family medicine practices from around Sonoma County launched a nine-month PCMH Learning Collaborative sponsored by Sonoma County Health Action with grant support from The California Endowment. In the health care setting, a collaborative is a group of different practices or hospitals that join together for a defined time period to make improvements through focused efforts. Collaboratives have been used for several decades to foster rapid improvements in hospitals and offices. The participants carry out intensive efforts, apply accepted methods of rapid improvement and share their results with each other.

“Major insurers are also

expected to adopt some payment methods to provide more revenue to primary care

practices that are PCMHs, and less to those that are not.”

Each practice in the Learning Collaborative is committed to making the transformations required to become a PCMH and hopes to make substantial strides in implementing needed changes by the end of 2010. Participating practices include health centers in Alexander Valley, Petaluma, Santa Rosa (two locations), Sonoma Valley and West County, along with Kaiser Permanente (two modules) and Sutter Pacific Medical Foundation. Each practice has completed an initial assessment of its current performance in the nine elements of PCMH certification. Most practices are focusing their efforts on those elements where they scored the lowest. In addition, each practice has formulated a statement of specific goals they

plan to accomplish by December. A special feature of the Learning Collaborative has been the inclusion of patients in the learning sessions and improvement teams at each practice. Some practices have identified an individual patient who serves as the patient voice in their efforts, while others are developing patient advisory groups. The inclusion of patients in transforming how we give care reflects the move to truly patient-centered care. At the March kick-off session for the Learning Collaborative, Dr. John Saultz, chair of family medicine at Oregon Health Sciences University, linked the efforts to transform primary care both to national health reform and to local initiatives to improve community health. His speech was followed by interactive presentations on how to approach quality improvement in a practice setting and on successful team-building. During the remainder of the session, the teams from each practice developed their PCMH quality improvement projects with goals and action plans. The second session, held in May, focused on change management. Given that change is always stressful and can lead to a variety of reactions from staff, this session helped the teams anticipate and understand the possible reactions to change. Each team then had ample time for focused work on their PCMH transformation projects. Future sessions, including both teleconferences and in-person meetings, are planned over the remainder of 2010. Topics will meet the needs identified by the participating teams. The goal is to give each practice the tools they need to become a PCMH. While these sessions are important, the most valuable work occurs as each team plans and implements the necessary changes. Learning Collaborative staff offers technical assistance between sessions to help solve problems as they arise. In December, when the Learning Collaborative concludes, each team will reassess their performance on the nine elements of PCMH certification to see how far they have progressed toward the goal of becoming a certifiable PCMH. Depending on funding and on the outcome of the Learning Collaborative, other collaboratives aimed at helping primary care practices in Sonoma County transform themselves into PCMHs may be planned for next year. This planning is in keeping with Health Action’s stated goal that every Sonoma County resident will have a Patient Centered Medical Home by the year 2020. Bo Greaves, MD is a CAFP past president.

California Family Physician Fall 2010

THE PATIENT CENTERED MEDICAL HOME Sandra Newman, MPH

What Do Federal EHR Incentives and Meaningful Use Mean to You? As many family physicians know, the federal government has invested billions of dollars in funding to create a state and federal health information technology infrastructure. One important component of this funding is the creation of financial incentives for providers and hospitals to implement and meaningfully use electronic health records (EHRs). Medicare and Medicaid both have EHR incentive programs; the initiatives are administered separately – Medicare by the Centers for Medicare and Medicaid Services (CMS), Medicaid by the states – but share many of the same criteria. A range of health care providers and hospitals are eligible to receive funding, but the eligibility criteria are very specific. For the purposes of this article, I will focus on eligible provider (EP) incentives in Medicare and Medicaid.

Table 1. Medicaid Patient Volume Thresholds

Entity

The Medicaid EHR incentive program will provide incentive payments to EPs and eligible hospitals (EHs) for efforts to adopt, implement, upgrade or meaningfully use certified EHR technology. Many different types of providers are eligible to receive the Medicaid incentives – MDs, DOs, nurse practitioners, certified nurse midwives, etc. – provided they meet patient volume threshold requirements as outlined in Table 1. In addition to these thresholds, family physicians and other EPs practicing at Federally Qualified Health Centers or Rural Health Centers (FQHCs/RHCs) must demonstrate that more than 50 percent of clinical encounters occurred at an FQHC/ RHC over a six-month period, with a minimum 30 percent patient volume from needy individuals. And finally, EPs cannot be hospital-based. Hospital-based is defined as 90 percent or more of services performed in an in-patient or emergency department setting.

Minimum 90-Day Medicaid Patient Threshold

Physicians

30%

Pediatricians

20%

Dentists

30%

Certified Nurse Midwives

30%

Physician Assistants when practicing at an FQHC or RHC led by a physician assistant

30%

Nurse Practitioners

30%

Acute Care Hospitals

10%

Children’s Hospitals

N/A

Differences between Medicare and Medicaid There are no patient volume thresholds in the Medicare EHR Incentive Program. In terms of eligibility, the rule of thumb is that if you can be paid under the Medicare physician fee schedule, then you can participate. There are a number of key differences, however. First, unlike Medicaid, payment is based on 75 percent of allowed charges, up to a maximum of $44,000. There is a 10 percent payment bonus for those located in a Health Professional Shortage Area (HPSA). In contrast, Medicaid incentives are based on a government calculation of average actual EHR purchase and maintenance costs, to a maximum of $63,750. 22

Eligibility for Medicaid Incentives

California Family Physician Fall 2010

Or the Medicaid EP practices predominantly in an FQHC or RHC – 30% “needy individual” patient volume thresholds

Since the Medicaid EHR Incentive Program is implemented at the state level, there is also flexibility for states to add requirements. States are not required to begin programs in 2011, so it will be important to check with Medi-Cal about when it plans to implement its program. There are also differences in how to qualify for incentives. While the federal meaningful use criteria apply in both programs, those in Medicaid have a special option. In their first year of participation, Medicaid EPs do not need to achieve meaningful use. Instead, they can provide documentation that they have adopted, implemented or upgraded certified EHR technology.

THE PATIENT CENTERED MEDICAL HOME

Take Home Message

Demonstrating Meaningful Use of Certified EHR Technology

There are three stages of requirements to meet meaningful use. The federal government has only finalized Stage 1; Stages 2 and 3 will be included in future rulemaking. Stage 1 meaningful use focuses on two major areas. The first is demonstrating EHR use for a number of functional criteria. These include, but are not limited to, electronic prescribing, clinical decision support, computerized physician order entry, and patient demographic information. EPs must meet 15 defined functional criteria. EPs (and EHs) must choose five from a menu of 10 additional requirements to meet in the next two years. The second meaningful use focus area is clinical quality. EPs must meet a defined set of three measures, all of which are from the National Quality Forum. These measures address hypertension, preventive care and adult weight screening. EPs must also choose an additional three from a menu of 38 measures. Many are measures family physicians already track, such as A1c, smoking use and cessation, diabetes foot exams, etc. Table 2 provides a summary of program requirements, including meaningful use.

Even if you already have an EHR, in 2011 funds will be available to help offset the costs associated with purchase, implementation and use. It is important to understand not just the meaningful use criteria outlined in this article, but also the populations to which they apply, how to report to the state and federal government and Medi-Cal rules. Many of these activities are still being developed, so monitor the Academy’s website, Medi-Cal, and CalHIPSO (the ONC-designated Regional Extension Center to help certain primary care providers implement EHRs) for news and updates. Sandra Newman, MPH was CAFP’s Director of Health Policy from 2005-2010. She is now a manager at Manatt Health Solutions in San Francisco.

Resources Medi-Cal EHR Incentive Program: http://www.dhcs.ca.gov/Pages/DHCSOHIT.aspx Centers for Medicare and Medicaid Services: https://www.cms.gov/EHRIncentivePrograms/ Federal agency charged with implementing the Medicare EHR Incentive Program. CalHIPSO: www.calhipso.org Federally-funded organization charged with helping certain primary care providers with meeting meaningful use guidelines.

Table 2. Eligible Providers: EHR Program in a Nutshell

Medicare

Medicaid

Start Date

January 1, 2011

Varies by state, but cannot begin before January 1, 2011

Payment

Based on actual charges: 75% of allowed charges (capped at $44,000)

Cost Calculation: 85% of purchase and maintenance costs (capped at $63,750)

Eligibility

Physicians

Physicians, NPs, certified nurse midwives, dentists and certain PAs 30% Medicaid volume (20% peds)

Clinical Measures 6 Total Measures:

3 core, 3 menu

15 Core Measures HIT Functionality Menu of 10 additional measures Measures Choose 5 for Stage 1 Remainder completed in Stage 2 Payment Years Payments Available Consecutive Payments

6 Total Measures:

3 core, 3 menu

Same as Medicare, except states may add 4 additional public health and reporting measures States cannot require HIE connectivity

Maximum of 5 payment years

Maximum of 6 payment years

Incentive payments available 2011 – 2014

Incentive payments available 2011 --2021.

Consecutive program years. The “clock starts running” with the 1st payment year. After receiving payment, EPs must qualify for MU each successive year.

Program years do not have to be consecutive. If an EP (or EH) does not receive an incentive payment in a given year, that year is not counted as a “payment year.”

California Family Physician Fall 2010

THE PATIENT CENTERED MEDICAL HOME Lauren M. Simon, MD, MPH

With PCMH, Loma Linda Program Helps Physicians Prepare for Practice Our residency program’s faculty coined this one-line moniker that describes our goal in training residents: “Nurturing system – savvy servant leaders in wholeperson care.” We use core family medicine values to provide continuous care within a family and community context, promote healing relationships and maintain a wholeperson care focus. Whole-person care is patient centered and considers all domains of the individual: physical, physiological, social, emotional and spiritual. Although we have been teaching whole-person care for many years, this description fits right in with the new model of care and the Patient Centered Medical Home (PCMH). Our clinic has achieved National Commission on Quality Assurance (NCQA) Level 1 PCMH designation. Our Loma Linda University Family Medicine Residency Program (LLUFMR) is a designated P4, (Preparing the Personal Physician for Practice) program. As such, it is one of 14 family medicine training programs across the country being studied for innovations in family medicine residency training to ensure that family physicians are prepared to embrace new technologies and provide superior patient care. LLUFMR has 32 residents divided into three designations. The first designation includes the traditional three-year family medicine residents. The second is the combined family medicine-preventive medicine four-year residents (who complete a Master of Public Health degree during their training and choose either Lifestyle Medicine track, which prevents illness by healthy living, or the Global Health track that teaches physicians to work with underserved populations cross-culturally). The third designation is the rural residents who begin training at Loma Linda University for six months, then complete the remaining two-and-ahalf years at our rural hospital affiliate (Hanford Hospital in Hanford, CA). Similar to findings from the AAFP- and Commonwealth Fund-supported National Demonstration Project (NDP) to test PCMH; our clinic implemented many of the technical elements of the PCMH but had more difficulty trying to implement elements that require additional resources such as group visits and population management. (More detailed findings are available in several articles on the NDP and PCMH in the Annals of Family Medicine May 2010 supplement). 24

California Family Physician Fall 2010

Implementing PCMH in our P4 program meant a lot of changes, starting with a paradigm shift navigating away from the “physician handles everything” mentality and more toward team-based care. Since the start of implementation, validated resident surveys show our family medicine residents are significantly more “engaged and satisfied” compared to their peers in other specialties. One of our chief residents in 2010, Dr. Sally Sartin, described our residents as “dynamic and innovative, unafraid of change and good problem solvers. The residents love each other and care for each other.” More specifically, when we discuss changes, we focused on training “system-savvy” residents. We redesigned the curriculum to focus around outpatient clinic rotations. The residents were divided into resident teams to promote patient access and continuity within the team so that patients have improved access to physicians familiar with them. The resident teams were then placed on broader care teams that include medical assistants and nursing staff. The residents huddle with their team members to prepare for clinic flow and work with the care team to manage electronic and paper test results, health maintenance and chronic disease management and asynchronous care. Performance evaluations come from both physician and non-physician members of the care team with the goal of continuously improving patient care and team function. To promote development of “servant leaders,” we recruit resident candidates who are mission-driven individuals willing to work with people most in need of care in the local area and around the globe. For example, four of our 2010 graduates will be working with underserved populations domestically as well as in Asia and Africa. Team-based care has provided a place for shared vision and responsibility for quality of care for our patients. The residents received experience in quality measures for health maintenance, diabetes and hypertension, and are moving toward the use of chronic disease registries. Through our combined family medicine program, preventive medicine residents get additional exposure at the Jerry L. Pettis Veterans Medical Center, an integrated system where they have increased appointment length with patients, improved access to internal specialty referrals (without the frustration of a multiple payer system) and are involved in group visits for smoking cessation and weight management. Implementation of PCMH is associated with hidden costs that are not discussed in the PCMH components. They include

THE PATIENT CENTERED MEDICAL HOME developing registries, team meeting time, leadership training and team facilitation, staffing needs (such as staff who help and maintain information technology), e-prescribing and ordering, to name a few. Thus, as we strive teach the components of the PCMH to our residents, we see the need for an improved health care delivery system and payment reform. Lauren M. Simon, MD, MPH, FAAFP is Assistant Director of the Loma Linda University Family Medicine Residency Program, Associate Professor of Family Medicine, Loma Linda University and a member of the CAFP Board of Directors.

Teams at Loma Linda such as that of (from left to right) Jamie Osborn, MD; Sara Halverson, MD and Lisa Vera, LVN start the day by getting together in preparation for clinic flow and work with the care team to manage electronic and paper test results, health maintenance and chronic disease management and asynchronous care.

In the Spotlight

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New EHR Funding Support for Primary Care Providers Will Benefit Underserved Communities The California Health Information Partnership Services Organization (CalHIPSO), one of the new California organizations called Regional Extension Centers (RECs) formed to assist providers in qualifying for federal funding to support the purchase and use of electronic health records (EHRs) and to achieve “meaningful use,” will initially focus on “priority primary care providers,” said Speranza Avram, MPA, executive director. These providers include MDs, DOs, physician assistants and nurse practitioners at small private physician practices, community health centers, primary care and rural health clinics, public hospitals, and ambulatory care clinics connected to critical access and rural hospitals. Practices that purchase and implement EHRs to meet the federal “meaningful use” criteria can qualify for incentive payments to help defray the costs. For more information, visit the CalHIPSO Web site.

MLC Education: Providing Culturally Proficient Care to Transgender Men and Women When considering the need for cultural proficiency in health care, the trans-

gender community often is overlooked. Because of biases against and lack of understanding of transgender people, they find that adequate health care often is unavailable or denied them, said Jamison Green, Primary Care Protocols Manager at the University of California, San Francisco Center of Excellence for Transgender Health. Some insurance companies refuse to provide any coverage at all to transgender people, for example, and others refuse to cover surgery and hormone therapy required for transition, the process some transgender people undergo to align their outward gender expression with their gender identity. Mr. Green explained that physicians need to know how to treat transgender patients with respect; understand their health concerns, which may or may not be related to their transgender status; and learn how to provide competent medical care to this population. Many transgender people avoid seeking health care out of a fear of discrimination or rejection, yet access to appropriate health care is essential, particularly for a population that research shows is at high risk for alcohol and drug dependency, depression, and suicidal feelings, among other health threats. For more information, visit the Center’s Web site at www.transhealth.ucsf.edu.

MLC Resources Help Improve Access to Language Services and Culturally Proficient Care A major part of the MLC’s work since its founding 8-1/2 years ago has been the development and dissemination of resources addressing language access, cultural proficiency, workforce diversity in health care, and health disparities. These resources are available on the MLC Web site, www.MedicalLeadership. org, which also hosts the searchable Language Access Database offering California-county-specific resources. Deputy Executive Vice President Shelly Rodrigues, CAE, CCMEP of the California Academy of Family Physicians encouraged MLC members to make use of the many toolkits, videos, CME courses, research articles, and other materials, all designed to help improve health care.

Looking forward The California Endowment has undertaken a 10-year initiative to address health care, social services, educational, and environmental issues in 14 specific California communities. Future MLC work will be designed to overlap with that effort. This work begins at the next MLC meeting in Los Angeles on November 17, 2010.

California Family Physician Fall 2010

THE PATIENT CENTERED MEDICAL HOME Ashby Wolfe, MD

A Resident’s View of the Patient Centered Medical Home I have always been a big fan of community-based health; it is one of the primary reasons I pursued family medicine. During my first year of medical school, I came across a quote paraphrasing Dr. Rudolph Virchow: “Medicine, if it is to improve the health of the public, must attend at one and the same time to its biologic and its social underpinnings. It is paradoxical that at the very moment when the scientific progress of medicine has reached unprecedented heights, our neglect of the social roots cripples our effectiveness.” This statement really resonated with me, and as I continue my training in family medicine, I have come to believe that the Patient Centered Medical Home (PCMH) is an important concept that addresses the sentiment behind the above statement. Today many residencies are incorporating elements of the medical home into training opportunities to teach residents how to provide comprehensive care that is targeted, accessible, continuous and coordinated. Work within my own UC Davis Department of Family and Community Medicine has been influenced by the concepts fundamental to the medical home. Our clinic has based teaching on the four elements of the medical home described by the AAFP: practice organization, quality measurement, health information technology and patient experience. For example, in terms of practice organization, we have team meetings before each half-day clinic session. Residents, faculty, staff and our coding and billing staff meet at the clinic nursing stations to discuss a pertinent clinical topic of the day. Following that discussion we break off into “teamlets.” We huddle for 10 minutes to start our clinic day and help us serve our patients better by improving patient flow and team communication. This is just one of the ways our clinic strives to be more team-oriented and patient-centered. We are also using a new email interface as part of our expanded patient communication effort. What initially seemed like just another way to connect with patients outside the office has become an essential tool as I work to manage some of my more complicated patients. I can easily followup with a patient after a clinic appointment, avoiding multiple return visits or the challenge of patient transportation to and from our office. I have found this additional method of communication helps my patients manage their own health goals and adhere to plans of care. As the medical community continues to develop treatments for chronic diseases such as diabetes and heart disease, I am finding that improved communication and non-traditional access to the health care team are necessary complements to the clinical care I give my patients in the office. In a very real sense, the PCMH aims to become that place that addresses the whole person, not just the diagnoses with which a patient presents. In such a medical practice, patients could truly improve their health, and not just their hemoglobin A1c, by making the best use of a place they can call home. One of the challenges we face as a specialty is how to integrate the medical home concepts into training environments in a practical way. As the model evolves, who is ultimately responsible for care, and how do we teach these concepts and learn in a way that reinforces, rather than fragments? The team? How do we best use data we generate to change our patients’ lives and within the clinic system? We as family physicians are uniquely positioned to address both individual and community health. Exposure to the PCMH in a training environment has helped me learn how to manage even my most complicated patients and has enhanced my growth as a leader of a health care team. I feel more prepared to face the challenges inherent in our current health system having trained in an environment that familiarizes me with the practical aspects of the PCMH. Ashby Wolfe, MD is a third-year resident at UC Davis Family and Community Medicine Program.

California Family Physician Fall 2010

THE PATIENT CENTERED MEDICAL HOME

Implementing the Patient Centered Medical Home

with CAFP Member Larry Shore, MD, Brown and Toland Medical Group Physician Larry Shore, MD is a member of the Brown and Toland Medical Group (BTMG) in San Francisco. In June, Dr. Shore advocated for adoption of the Patient Centered Medical Home (PCMH) model at the medical group’s board meeting and recounted the experience of his own practice in doing so. California Family Physician magazine caught up with Dr. Shore and asked him to share that experience: California Family Physician: What piqued your interest in PCMH initially? Larry Shore, MD: I read some articles in Family Practice Management that described some “do it yourself” approaches to various aspects of PCMH transformation. On April 1, we went live on the Allscripts Electronic Health Record (EHR), and I was getting familiar with how it works. As I read more about basic changes, I also read some more recent articles describing the current PCMH concept. My initial exposures at some conferences in 2003 made it sound a little fuzzy and very expensive to implement. The emphasis on group visits held no attraction for me, and we were just being introduced to Allscripts, which represented a profound and non-intuitive change in workflow for my practice. My associate joined me in 2005, and that was my primary concentration. CFP: Why do you think there is a need for a new model of delivering health care? LS: The current model is no model, really. Physicians and other providers focus on whatever is hot at the moment. We need a much more organized approach to groups of patients whose overall care can be coordinated and comprehensive, driven by evidence-based preventive strategies and a technology-supported personal connection to the primary care physician (PCP). The PCP, in turn, has to be connected to specialists, hospitalists, emergency room physicians, visiting nurses and all of the other health care providers in a technology-supported way that takes advantage of our training. The problem in private practice is there is little or no compensation associated with this vital activity, particularly with complex, chronically ill patients. Kaiser has a big advantage in this respect. CFP: How will the PCMH improve the delivery of health care in your medical group? LS: For Brown and Toland, a change of thinking that recognizes the value of the advanced primary care model in which the PCP has the tools to manage a population of both well and chronically ill patients needs to take place. PCMH offers a well thought out framework for this, although it will challenge both PCP and specialist to alter their usual patterns of care. I think BTMG, as a mature and innovative Independent Practice Association, is the

type of organization that could embrace this change well. CFP: Using your own practice and patients as a reference, what problems in the delivery of health care would the PCMH model address? LS: For my partner and me, if we get the patient registries going along with Computerized Physician Order Entry (CPOE) and results tracking, we will be much better at not having things fall through the cracks. We have been developing Medical Assistant/Physician teamlets since January 1 of this year, and they have freed up the physicians from a lot of clerical tasks. We also have modified our scheduling to increase same day access. In my presentation to the BTMG board, I noted that new residency grads are looking for practice models different from the current PCP model of practice (often referred to as the hamster wheel syndrome: faster and faster and going nowhere); many PCPs are leaving office-based practice; educational debt restricts medical graduates’ choice of specialty; and compensation, lifestyle and status are lower for PCPs. Those are the macro-level problems. At the practice level itself, only some large group practices are offering integrated care with the PCP as the care coordinator. At the micro level, timely access to care isn’t guaranteed; we are generally unresponsive to health care questions that are outside of the exam room – and sometimes not so good at questions inside the exam room. Personalized care and attention are variable, even within the same group practice. It seems to me our options are to do the same work harder and faster (again, the hamster wheel syndrome), hope we can afford to retire or perhaps seek an employed position (often with hospital foundations). A more attractive approach from my perspective is for PCPs to learn about the PCMH concept, identify the essential elements that sound doable to them and start transforming their practices! Physicians may have to go on faith that the payment system will begin to incentivize PCPs correctly to maintain the health of their population of patients, funded through reductions in costly and preventable admissions and emergency room visits. CFP: Do you think the model will have an impact on the payment of primary care physicians? LS: So far, improved compensation is missing. In my own practice, there has been an unfortunate coincidence of several recent factors: the recession of 2008-09 caused a 20 percent Continued

> 28

California Family Physician Fall 2010

THE PATIENT CENTERED MEDICAL HOME Continued < 27

reduction in our capitation check from Brown and Toland in 2010 compared to 2009, through loss of HMO patients to other plans. Expiration of COBRA benefits for some of our patients and new PPO plans with high co-payments and deductibles resulted in overall decreased demand. The New York Times recently wrote about this as a national phenomenon. There have been many benefits to transforming to the PCMH model: patients love email access to the practice; we’re offering sameday access; our physicians and our medical assistants (MAs) really like the expanded role of the office MAs along the lines of the “teamlet;” physician administrative workload has been reduced substantially; and we’ve experienced a slight increase in physician capacity to see more patients per day. Additionally, our chronic disease management monitoring is improving; immunization compliance is better; medication prescribing is safer and more convenient; and our sense of care coordination is growing as more physicians are added to Allscripts in the BTMG network. Ultimately, the EHR aligned with the principles of PCMH will help us qualify for stimulus dollars, too. CFP: What obstacles do you see to implementation in your own practice? LS: Unfortunately, neither a registry function nor “best practices” for chronic disease care are part of Allscripts at this time, although a newer version coming later this year promises

to have these features. Hospitalists, visiting nurses and hospice, emergency room physicians and other key components aren’t included in the system, which impairs coordination of care. Online test ordering and tracking aren’t available yet. We need more assistance in the roll-out of Allscripts (although recently, Sutter/CPMC and BTMG have reached an agreement in which the hospital will be providing substantial assistance to physicians at California Pacific Medical Center to implement the EHR). We aren’t able to measure outcomes currently. It’s not clear whether insurance companies will pay for innovative services such as “e-visits,” group visits and health coaching. We need a more robust plan for PCP recruitment and retention and, perhaps most importantly, it’s hard to make such big changes in a short time. CFP: How do you think CAFP might help you? LS: Well, I like what TransforMED has to offer but can’t afford it just yet. I am hoping that some of that expertise flows downhill as a result of a potential BTMG/CAFP joint project, perhaps combining with experts at UCSF as well as health plans and others. It would be nice to see the EHR industry and large employers embrace the medical home and push for the development of fully capable (and meaningful use-eligible) EHRs that make the PCMH easier to implement in its entirety.

TransforMED’s collaborative network for practice transformation

Delta-Exchange is TransforMED’s exclusive online practice transformation learning network dedicated to physicians, clinical staff, office staff and primary care-focused residency programs. Join the collaborative PCMH network exclusively for primary care! Connect with practices much like yours who are also endeavoring to make PCMH changes. Keep up your spirits and your momentum. Access immediately useful PCMH resources: “best practices,” forms and templates, practical how-to-articles, online seminars and more. Learn from experts and each other. Share documents. Collaborate on solutions. Discuss issues and make your voice heard. Ask questions and get useful answers from TransforMED's highly experienced Practice Facilitators as well as other PCMH innovators via the “Ask the Expert” zone. Participate in optional, private work zones based on your role: physicians, clinical staff, office staff and residency programs. Easily set up watchlists so you can track discussions, topics, or the site activities of colleagues, experts and innovators whose perspective and experience you value. No vendors. No drug reps. No nonsense. For just $30 a month, per user, join your colleagues in an active community of primary care leaders committed to PCMH practice transformation.

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California Family Physician Fall 2010 CalFamPhy_ASA_ad_06.06.indd 1

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⇨Page 28

California Family Physicians and Political Giving – Why Are We So Different from Other States? By Susan Hogeland, CAE

nquiring minds would like to know why California family physicians lag behind other states’ family physicians in political giving. While CAFP’s own political action committee, FP-PAC, has generally increased its number of contributors over time, it’s still the case that only a small percentage of all members give on a regular basis. In 2010 to date, 95 members have given (less than two percent of all active members), for total contributions of $19,326. This compares to an all-time high of 115 (2.3 percent) in a general election year, 2008. CAFP has more than 5,000 active members. A big shout-out to those who’ve given and will give this year, but everyone else, que pasa?

Let’s try another tack: Is it lack of being asked or is it lack of leadership? I think not. Carla Kakutani, CAFP past president, chairs the FP-PAC board of directors and is a member of the FamMedPAC Board of Directors. Jack Chou, CAFP President, is FamMedPAC’s champion in our state. Nearly the entire CAFP Board of Directors has contributed to both organizations. Shelly Rodrigues, CAE and I have given; Director of Government Relations Tom Riley has given to FamMedPAC (he’s not allowed to contribute to our own state PAC); CAFP staffers Leah Newkirk, Callie Langton MPA and Cody Mitcheltree also have given to FP-PAC.

At the national level, California has 91 FamMedPAC contributors for a total of $19,805 in contributions – the ninth lowest total among the 10 largest states. We are beaten also by states such as Tennessee, where 61 contributors, or 4.5 percent of the active membership, gave $45,319, an average of $759 per contributor (California averages $212 per contributor). North Carolina has nearly as many contributors as California – 89 – and contributed a total of $28,055 year-to-date, or $315 per contributor.

So, ask yourself: why don’t YOU give to the political action committees that support elected officials who support the issues of importance to family physicians and their patients? Do you give to other political organizations? Good for you! Are ANY of them as important to your practice as FP-PAC and FamMedPAC? I think not. … Personally, I give to a lot of political organizations and directly to a lot of political candidates, from local races all the way up to presidential candidates. I HOPE you do, too. If you don’t, rest assured that trial attorneys, naturopaths, chiropractors and others who’d like to eat your lunch are giving early and often. This is not the time to sit things out – excuses such as “I can’t afford to give,” “My contribution doesn’t make any difference,” “I don’t like politics,” etc., just don’t cut it anymore (just like not voting doesn’t cut it) because as former chair of FamMedPAC Mike Fleming pointed out, “If you’re not at the table, you’re on the menu.”

Is it the case that the further from the locus of political activity (Washington, DC) a state’s FPs are, the less interest they have in political giving? Well, let’s look at Alaska – seven percent of its members – 22 – gave a total of $11,155 for an average donation of $507. Oregon outstrips California with 2.77 percent of members contributing, Washington State with 3.26 percent (they also beat us in total contributed – $26,211 for an average donation of $409) and Colorado with 3.44 percent. Texas, the nearest competitor to California in membership size, has a lower number of contributors as a percentage of membership, but outpaces us in total contributed and average donation size: $41,377 and $583, respectively.

Really, it’s time for California’s family physicians to step up. Go to http://www.familydocs.org/fppac AND www. fammedpac.org today and contribute. Election Day is November 2; make your contribution count NOW.

California Family Physician Fall 2010

EXECUTIVE VICE PRESIDENT’S FORUM

Susan Hogeland, CAE

Together, We Are on Our Way to a Better Home

have written in my weekly update and in Academy in Action about the two visits to California made by IBM’s Global Director of Health Care Transformation, Paul Grundy, MD, but because this issue of California Family Physician is devoted to the Patient Centered Medical Home (PCMH), Dr. Grundy bears further mention. Dr. Grundy has visited CAFP and California three times since last December – his first trip took place after he contacted me about my video blog on the Academy’s Here2010-12 is page 8Strategic Plan, which puts PCMH at its core. He met with then-President Tom Bent, MD; President-elect Jack Chou, MD; past president Carla Kakutani, MD and members of the staff to discuss his mandate from IBM – to transform care for IBM employees; make it patientcentered; make it primary and preventive care-focused; and improve the value of health care. He brought the same mandate to the Patient Centered Primary Care Consortium, a Washington, DC-based organization he helped found and for which he is president. He brought businesses, insurers, pharmaceutical companies, primary care medical organizations and consumers to the table and has produced outstanding results. His second visit in June featured a whirlwind of meetings and presentations – most particularly one in a hearing room at the State Capitol organized by CAFP and the Assembly and Senate Health Committees to talk about PCMH before more than 40 legislative staff and lobbyists. It’s hard to describe what happens to a room when Dr. Grundy gets going. He talks about the current “insanity” in health care of paying 10 times more in one region of the country than in another for care during the last three months of life, and about IBM’s decision to move thousands of jobs to regions where care is not only delivered at a lower cost, but also at better quality. His latest trip – the week of July 12 – was a marathon. For CAFP, it began on the afternoon of the 12th with a roundtable discussion on the workforce policy implications of PCMH organized by family physician and Director of the Department of Community and Family Medicine at UCSF Kevin Grumbach, MD. At the table with CAFP were representatives of the California Association of Physician Groups, Kaiser Permanente, Pacific Business Group on Health, the UC Davis Family Medicine Residency Program and others. The upshot was agreement to take steps to develop a California-based organization similar to the Patient Centered Primary Care Collaborative with a goal of moving the PCMH ball forward here, since, shamefully, California is well behind many other states in promotion and adoption of the model. 30

California Family Physician Fall 2010

The week also included a meeting with physicians in the Sutter Health system who are interested in the PCMH model, a meeting with Brown and Toland Medical Group and a meeting with Blue Shield of California. The pièce de résistance was a meeting in Fresno on July 14 with representatives of the Fresno Unified School District’s (FUSD) Joint Health Management Board (JHMB) along with CAFP District XI Board member Adriana Padilla, MD, member Kathy Flores, MD, representatives of Kaiser Permanente, Blue Shield, California Health Care Coalition and others. JHMB consultants contacted CAFP months before to seek advice on how a PCMH demonstration project might be developed for FUSD employees. The meeting was an excellent first effort at organizing better, more coordinated care for JHMB’s self-insured members. What was most exciting about participating in the meetings with Dr. Grundy was discovering so much interest in the PCMH model among family physicians. The Sutter physicians were especially interested in Dr. Grundy’s analogy comparing presentday physician-office-based care to banking 20 years ago – customers stood in line waiting for the teller; all interaction was face-to-face; there was no electronic banking, no communication with the bank after hours, no phone, no email. We learned that Brown and Toland physician and CAFP member Larry Shore, MD is a major advocate for PCMH and is implementing transformation in his own practice. In Fresno, 25 physicians responded to a CAFP survey to determine the level of interest in participating in a PCMH demonstration model – all 25 responded positively that they were interested. In short, California family physicians are beginning to develop a critical mass for PCMH – champions are self-identifying. Bo Greaves, MD and Walt Mills, MD in Sonoma are instrumental in a PCMH collaborative in the county; Kaiser Permanente offers a large majority of the features of a PCMH, and the National Commission on Quality Assurance (NCQA) has given recognition to many of its practices; the Loma Linda Family Medicine Residency has NCQA recognition as a PCMH; the UC Davis Family Medicine Residency Program is applying for recognition. We are on our way, and CAFP hopes to serve as the midwife for many of these projects – through our website’s new PCMH Resource Center, our affiliation with TransforMED, our past work in quality improvement, our legislative efforts to define PCMH in statute, our continuing work with Dr. Grundy (he’ll be back in November!) and more. How can we help you?

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