Michigan Family Physician Magazine December 2020 by M3 Group Publications

WINTER

Medical Decision-Making & Medical Necessity

Plus New FMFM President Calls Us to Advance the Specialty Amid the Pandemic

Advocacy Update A Snapshot of CME Requirements

Phy·si·cian /fə'ziSHən/ Noun 1. A selfless champion for a community. While physicians are a source of strength in our communities, ISMIE is here to help sustain that strength. Our Wellness Center – ismie.com/wellness – is continually evolving to better meet the needs of our policyholders, helping you navigate personal and professional challenges. For answers to your COVID-19-specific questions, please visit ismie.com/COVID-19.

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TABLE OF CONTENTS Chair Keerthy Krishnamani, MD, MBA President Mustafa “Mark” Hamed, MD, MBA, MPH, FAAFP President-elect Srikar Reddy, MD, FAAFP Vice President Glenn Dregansky, DO, FAAFP Speaker Beena Nagappala, MD, MPH Treasurer Rachel Klamo, DO AAFP Delegates Robert Jackson, MD, MMM, FAAFP Loretta Leja, MD AAFP Alternate Delegates Tina Tanner, MD, FAAFP Mary Marshall, MD, RN, FAAFP Members-at-Large Harshini Jayasuriya, MD, FAAFP Brandon Karmo, DO Amy Keenum, DO, PharmD, FAAFP Holli Neiman-Hart, MD, FAAFP Sadeer Peter, MD Pamela Rockwell, DO, FAAFP Kristi VanDerKolk, MD, FAAFP Bashar Yalldo, MD Resident Member Linda Stanek, MD Student Member Jaclyn Israel Ex Officio, Chief Executive Officer Karlene Ketola, MSA, CAE

Medical Decision-Making and Medical Necessity Cover Story

Moving Forward in Tumultuous Times

What’s Your Target?

President’s Message

Year-End Work Remains Hectic

FMFM BOARD OF TRUSTEES President Mary Marshall, MD, RN, FAAFP Vice President Keerthy Krishnamani, MD, MBA Secretary/Treasurer Robert Jackson, MD, MMM, FAAFP Executive Vice President Karlene Ketola, MSA, CAE Trustees-at-Large Jennifer Aloff, MD, FAAFP Christal Clemens Adam Jablonowoski, MPA David Kazanowski, MD

Amy McKenzie, MD, MBA Elizabeth Pionk, DO, FAAFP Jeanette Wilson, MD Bradford Woelke, MD

Michigan Family Physician is published quarterly by Michigan Academy of Family Physicians and provided to MAFP members. Statements of fact and opinion are the responsibility of the authors and do not imply an opinion on the part of the Board of Directors or members of MAFP. Materials may not be reproduced without written permission. For subscription information, reprints, and back issues, email info@mafp.com. ©2020 MAFP. All rights reserved.

Editor: Dana Lawrence

Michigan Academy of Family Physicians 2164 Commons Parkway, Okemos, MI 48864 517.347.0098 | mafp.com

Advocacy Update

20 Aging Physicians and Competency

Family Medicine Business Network

Recognizing the Value of a Medical Home

Meet the Legislators

CEO Insight

Advancing the Specialty Amid the Pandemic

Foundation News

Scholarship Program for Members, Their Employees, and Families

Academy News

The How and Why of Refinancing Student Loans

Business Sense

NEW FROM CDC

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

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Moving Forward in Tumultuous Times by Mark Hamed, MD, MBA, MPH, FAAFP As we all know, 2020 will likely be remembered for being a challenging year. COVID-19 affected virtually every aspect of our lives. It has affected many of us in our private lives and in our careers. We have been inundated with the infusion of politics during a worldwide pandemic. On a state level, we have had to explain to our patients and their families what the slight differences are between an executive order, an epidemiologic order, and an emergency health order. Many of us had to decide whether to send our children back to school in-person, have them attend school remotely, or opt for the “hybrid” option (both in-person and online different days of the week). Many of us had to manage our patients through a phone call or via online visits, while some of us were able to see a limited number of patients via in-person, home visits, and even curbside care. Yet, some of us had to adopt the “hybrid” option for our clinical practices–a mix of in-person and remote patient visits. 6

WINTER 2020 | MAFP.COM

There are many more “new normals” that I can mention, but the point I am trying to get across, is that we, family physicians, have been resilient. We have had no choice but to adapt and be resilient. Let us be clear, these “new normals” will be temporary and we will get through the challenges of this pandemic.

AAFP CEO Shawn Martin announced that AAFP will not refer to a family physician as a “provider” in any official communications, stating “we should restore value and respect to the healing art of medicine and the physicians who practice it.”

Moving Forward

We are reclaiming our value and leadership positions among medical societies and in healthcare teams. As a motivated fellow Michigan Academy of Family Physicians board member reminded me, we are not NPPs (non-physician providers); we are family physicians.

We will continue to move forward as a specialty for ourselves and for our patients. Yes, 2020 has been a challenging year. Years from now we will begin to fully understand and assess the long-term implications that this pandemic has had across our communities. However, we are seeing hints of brightness and renewed energy toward the end of this year. On Oct. 12, 2020, in the opening remarks to the American Academy of Family Physicians 2020 Congress of Delegates,

Value and Leadership

We are gradually returning to providing comprehensive care for our patients, whether it may be in the outpatient clinics, hospital wards, emergency departments, labor/ delivery suites, nursing homes, public health departments, or any other setting that our versatile and amazing specialty allows us to

PRESIDENT’S MESSAGE

As we all know, 2020 will likely be remembered for being a challenging year. COVID-19 affected virtually every aspect of our lives. It has affected many of us in our private lives and in our careers. care for them at. Our resiliency during this pandemic has been recognized by AAFP, and for the first time ever, all of the 136, 700 Academy’s family physicians have been awarded the prestigious “Family Physician of the Year Award.”

•

Celebrating Personal Wins

•

We must use this renewed energy to continue working hard into 2021 and beyond. •

•

We will continue to work hard to provide the resources that our MAFP physicians need to get through this pandemic. We must continue to support the ability to enable our family physicians to adapt to the digital age by supporting payment changes that ensure the appropriate use of telemedicine and alternate ways in which we manage our patients.

We must explore and better understand the issues leading to healthcare and racial inequities. As family physicians, we are the best trained specialty to assess how a person’s social situation impacts their health. We will continue to advocate for our patients and our fellow family physicians on local and national levels to ensure we will always be able to provide the safest and highest quality care to our patients.

These are just a few of the many important tasks that we have ahead of us. Please take care of yourselves and your families. Stay positive and motivated—things will get better. Hey, if the Detroit Lions can celebrate their third win in six games as if they just won the Super Bowl, then we can and should enjoy our own personal

“wins” that come our way. Soon enough, 2020 will finally be behind us, and we will move forward into 2021 with a renewed drive, focus, and resilience.

Mark Hamed, MD, MBA, MPH, FAAFP, is the president of Michigan Academy of Family Physicians. He is also medical director of the Departments of Emergency Medicine and Hospital Medicine at McKenzie Health System in Sandusky, medical director at health departments in eight rural Michigan communities, a senior staff physician and faculty at Henry Ford Health System/ Wayne State University’s residency program, and associate clinical instructor at Michigan State University College of Human Medicine and Central Michigan University College of Medicine.

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CEO INSIGHT

What’s Your Target? by Karlene Ketola, MSA, CAE Someday, you will be asked what 2020 was like for you. As family physicians, you will have extraordinary stories to tell about treating patients during a pandemic, caring for your family and staff as they experienced their own concerns, and keeping yourself centered and focused as the world went bananas around you. It’s this last point that seems particularly important as we move into a new phase of COVID-19. How can you, as a family physician with many competing priorities, continue to focus on what matters most?

The Lesson

There’s a great allegory that comes to mind. One day the Zen master wanted to show his students a new technique for shooting an arrow. He asked his students to blindfold him, then he aimed carefully and released his shot. When he opened his eyes, he saw the target empty, the arrow lying on the ground nearby. When he looked at his students, their faces showed embarrassment. Their teacher had missed. The Zen master asked them, “What lesson do you think I intend to teach you all today?” They answered, “We thought you would show us how to shoot at the target without looking.” The Zen master became quiet. “I taught you that if you want to be successful in life, you mustn’t forget the target. You have to keep your attention on the bullseye, otherwise you may miss a good opportunity,” he said. 8

WINTER 2020 | MAFP.COM

They looked at each other, impressed with the lesson. The moral of the story is we need to consistently focus on what we want to achieve.

Lessons Learned from 2020

A year ago, when you were planning for 2020, what goals did you set for yourself? For your practice? Chances are your aims had nothing to do with managing a pandemic, telemedicine visits, and sudden financial and staffing changes. Nevertheless, in the middle of the chaos that 2020 offered, many Michigan Academy of Family Physicians members still were able to make progress toward their core objectives because they never took their eyes off the targets that mattered most to them. I read somewhere that managing a family practice sometimes can feel like playing dodgeball in the dark. You never know what’s coming, and it’s necessary to be nimble and attentive as you sort through what’s coming at you at any given moment. There’s a good deal of urgency and noise to cut through every single day. How can an effective family physician cope with these strains on an ongoing basis? I’d suggest aiming for those allimportant targets in your own life—even in the midst of that whole “dodgeball in the dark” scenario—is what’s going to not only keep you growing, strong, and stable, both professionally and personally.

Remember the old Highlights for Children magazine found in many family practices during the 1970s? There used to be a feature in there about two boys, Goofus and Gallant. Goofus was always doing life rudely, badly, and wrong while Gallant was a (let’s face it) rather nerdy Boy Scout of a youth, helping everyone politely all the time.

Eyes on the Target

Decades from now, when you are asked to describe your 2020 experiences, they may look rather more like Goofus than Gallant. But as we head into 2021, let’s make a plan to keep our eyes on the target, to Gallantly serve and grow and heal in all the ways that matter most. It’s true that the things we focus on impact our feelings, our work, and our destinies. We must always keep our eyes on the target, moving steadily forward regardless of what comes at us at any given moment. Our experiences and ideas are shaping the world around us today, now more than ever. Let’s do all we can to get it right. Karlene Ketola, MSA, CAE, is Michigan Academy of Family Physicians’ chief executive officer and Family Medicine Foundation of Michigan’s executive vice president. She joined the MAFP/FMFM team in spring 2019 after serving as executive director of the Lansing-based Michigan Oral Health Coalition for 10 years.

FOUNDATION NEWS

A Snapshot of CME Requirements for Michigan Family Physicians by Denna Bunting For Michigan family physicians, tracking required continuing medical education (CME) credits may seem daunting and sometimes confusing. Michigan Academy of Family Physicians members have multiple entities to which they report credits, including American Academy of Family Physicians (AAFP). In addition, Michigan family physicians also are required to complete state-mandated CME topics to maintain licensure. As Family Medicine Foundation of Michigan (FMFM)—MAFP’s philanthropic arm— continuously seeks to provide meaningful opportunities to best accommodate members’ CME requirements, it is important for physicians to fully understand the nuances of the requirements. In 2020, FMFM was approved to offer 30 total credits that included courses on timely clinical and practice management topics and two knowledge self-assessments. Courses that fulfill statemandated professional development requirements remain available on our website until 2021. Visit mafp.com/ events for more details. In 2021, MAFP members can look forward to a robust lineup of valuable CME being planned by FMFM’s Professional Development Committee.If there is a topic you believe may benefit your colleagues, contact me at dbunting@mafp.com with your CME programming ideas. AAFP is a member organization dedicated solely to family physicians under which your state chapter, MAFP, operates to provide state-relevant information and support. Your member reelection cycle

begins Jan. 1 of the year following the activation of your membership and lasts for three full calendar years.

scholarly work such as clinical research, or medical writing or editing.

Active AAFP/MAFP members must report at least 150 credits of approved CME every three calendar years. The 150 credits must include at least 75 AAFP prescribed credits and 25 credits from live activities.

Regardless of how physicians choose to acquire their required hours, it’s crucial that all physicians must obtain and maintain appropriate documentation related to the completion of their credits. LARA will randomly audit renewal applications to ensure the licensee has met all requirements for renewal. For more information on CME, visit mafp.com/ cme-events.

Types of CME Credit Required by AAFP

AAFP prescribed credits are designated for activities that are designed primarily for physicians. Eligible content is directly related to patient care, patient care delivery, or certain nonclinical topics. AAFP elective credits include activities that are not individually approved by the AAFP as an AAFP prescribed credit that have been designated as American Medical Association (AMA) Physician’s Recognition Award (PRA) Category 1 Credit TM or have been approved by the American Osteopathic Association (AOA) are acceptable as AAFP elective credit. Live activities take place in real-time, involve two or more physicians, and provide the opportunity for real-time interaction between learners and faculty. AAFP members are required to obtain a minimum of 25 credits from live learning activities every three years. Enduring materials are activities that are based on independent learning materials designed primarily as self-study activities. Other activities that may be eligible for CME credit include advanced training,

Maintain Records

State-mandated Topics

For each cycle, Michigan mandates each medical doctor to complete 150 hours of continuing education. This mandate includes one hour on medical ethics and three hours in the area of pain and symptom management, which may include clinical physician communication related to pain, management of pain, quality pain care, or ethics and healthrelated to pain, among others. Michigan also mandates that physicians receive training on human trafficking; although this one-time requirement must be completed prior to your next licensure renewal, it does not count toward your overall 150 required CMEs. Denna Bunting is Michigan Academy of Family Physicians’ meeting planner. She joined the MAFP team in 2018 and became meeting planner in 2020. Bunting is responsible for planning and implementing all CME events for the MAFP membership. WINTER 2020 | MAFP.COM

Year-End Work Remains Hectic by Matt Black The fiscal year 2020-21 budget has been the focus of the Legislature. It was signed just hours before the Oct. 1, 2020, deadline. The budget process this year stands in stark contrast to that of last year. Last year saw a record number of line item vetoes where Gov. Gretchen Whitmerâ&#x20AC;&#x2122;s priorities were in opposition to those priorities of legislative leaders. This year, however, legislative leaders worked with the governorâ&#x20AC;&#x2122;s office to produce a budget supported by the majority of legislators, both Democrats and Republicans. After original projections of a deficit of $3 billion for fiscal year 2020-21, which began Oct. 1, final projections and budget numbers were in much better shape including only $250 million in spending reductions. The $62.8 billion state budget included $28.5 billion to Department of Health and Human Services, with $5.09 billion coming from the general fund/ 10 WINTER 2020 | MAFP.COM

general purpose. This is an increase of over 8% from the 2019-20 budget.

Budget Priorities

Supporting proper funding to the MiDocs program was at the top of the priority list for Michigan Academy of Family Physicians following a reduction in funding in the negative supplemental. MiDocs was started to create community-oriented and based residency positions in urban and rural underserved areas by offering $75,000 in student loan relief for MiDocssponsored residents who commit to working in the underserved area for two years following residency. MiDocs was funded at $5.4 million gross ($1.4 million GF/GP). Another area of interest is the Healthy Moms, Healthy Babies program, which was funded at $12.6 million. This program is designed to provide support to women

to have healthy pregnancies and expand coverage to postpartum care for both the mother and baby. The expansion offers coverage for mothers who are between 139% and 195% of the federal poverty level, and coverage will be provided for 12 months after birth.

Politics During the COVID Pandemic

Legislative activity has seen its share of struggles with both senators and representatives testing positive for COVID-19 and requiring changes in the session schedule to ensure safety of legislators and staff. Some session weeks have been canceled while other previously scheduled district breaks saw legislative activity. In early October, the Michigan Supreme Court ruled that the use of the Emergency Powers of the Governor Act of 1945

ADVOCACY UPDATE

The lame-duck session is expected to be another busy time this year in part due to the unforeseen challenges COVID-19 has brought ...

to extend the state of emergency in Michigan beyond the initial 30 days was unconstitutional. Therefore, revoking the authority of the governor to continue to issue emergency orders and invalidating any order issues after April 30. The ruling led to much uncertainty, but swift action was taken by both the administration and the Legislature. Michigan Department of Health and Human Services Director Robert Gordon issued orders through authority granted to the director within the Public Health Code allowing to protect the public during a pandemic. His orders focused on limiting gathering size and requiring face coverings while indoor, but they were not as inclusive as Gov. Whitmer’s previous orders.

to encourage and support the adoption of this legislation during the lame-duck session. SB 1036 would adopt continuing boilerplate language into statue to exempt a prescription drug that is recognized in a generally accepted standard medical reference to prevent or treat HIV or AIDS from prior authorization from Michigan Department of Health and Human Services.

are available for those who are unable to transmit prescriptions to the pharmacy electronically. Both resolutions advanced to American Academy of Family Physicians for consideration during Congress of Delegates, which was held virtually Oct. 12-13. The resolutions were amended from original language to offer more guidance and clarity, and were supported by membership.

The lame-duck session is expected to be another busy time this year in part due to the unforeseen challenges COVID-19 has brought with a negative supplemental in August, the delayed and ever-continuing work on the 2020-21 budget, and the intermittent cancelling of session days from COVID-19 exposure concerns.

New Implicit Bias Mandate

The Legislature met later in October to pass legislation codifying many of the other executive orders. Initially, it considered bills to provide extended unemployment benefits and worker protections. On the healthcare side, one bill provided civil liability immunity to healthcare professionals while working during a pandemic, and the other would require Department of Health and Human Services to create a dedicated facility to house and care for COVID-positive patients. The next week, the Legislature met again to take up additional legislation to codify property, notary, and Secretary of State driver’s license changes during the COVID-19 emergency.

We also are monitoring other legislation, like House Bills 5302 and 5303, which sets license and establish education requires for naturopaths that were introduced into the House of Representatives late last year. MAFP has stood in opposition to this legislation, which has continued to be introduced for over 12 years. Even though they have been before the House for nearly a year, the bills have not received a committee hearing at this point, and therefore are not expected to be pushed. However, the lame-duck session frequently offers surprises that require us to remain diligent in our advocacy efforts highlighting the dangers that could arise from passing this legislation.

The Senate Health Policy and Human Services Committee met to consider and adopt a substitute for prior authorization reform in Senate Bill 612. Following statements from many senators expressing the bill is not perfect but is a step in the right direction, the panel passed the bill. It now is before the full Senate for consideration before the bill moves to the House. MAFP and the Health Can’t Wait coalition are continuing advocacy work

2020 MAFP Resolutions

Resolutions offered and adopted during the Annual Meeting are setting some guiding principles for other advocacy work. As directed through Resolution 20-01, we are supporting and working to pass SB 898, which would require parity in reimbursement for in-person office visits and telehealth office visits. Resolution 20-05 requested MAFP to work to ensure sufficient exemptions

Workgroups, both larger and small sub-groups, have been actively engaged in the implicit bias training mandate. MAFP was well represented during the initial information gathering process. The Michigan Department of Licensing and Regulatory Affairs (LARA) held these workgroup meeting to get input from the healthcare community that will be required to undergo implicit bias train as a requisite for licensure or relicensure. The initial information gathering provided hundreds of pages of notes for LARA to consider when drafting the initial draft rules. Final details are still forthcoming, and MAFP remains engaged through the rulemaking process, which is required to provide a public comment period before any final rules are approved. Any rules will also have to be supported by the Joint Committee on Administrative Rules, comprised of legislators in both chambers. Matt Black serves as Michigan Academy of Family Physicians’ director of government relations. He is responsible for directing the organization’s state public policy agenda, analyzing legislation and regulatory changes for potential impact on patients and the practice of medicine in Michigan, and bridging the gap between members and elected officials. WINTER 2020 | MAFP.COM

SPONSORED

Guest Article: Poor HbA1c Control is a Medical Emergency By Israel Hodish, MD, Ph.D., Hygieia co-founder

The d-Nav program combines an FDA-cleared mobile app using patented technology and artificial intelligence, and virtual clinical support to automate insulin titration based on each patient’s unique needs. Through a user-friendly handheld device, the d-Nav program guides patients to optimize insulin doses at home based on their changing glucose levels.

The typical first-time patient in my endocrinology practice is an individual between 40 and 60 years old, has had Type 2 diabetes for more than 10 years, is being treated with four medications for diabetes (some of which belong to new classes of medications) and has had an HbA1c of 9-11% for at least two years.

Most don’t realize their situation is urgent.

Based on what we know, HbA1c is the best marker for diabetesrelated complications. The higher the HbA1c, the more likely the patient will develop diabetes-related kidney or eye disease, foot infections, other life-threatening infections, heart attacks or strokes, or experience premature death. In patients who have already developed complications, higher HbA1c increases the chance of these complications worsening. Many patients and physicians do not recognize the severity of a sustained, elevated HbA1c.

Poorly controlled diabetes is as dangerous as advanced cancer.

That’s because the chances of developing devastating complications and dying prematurely are staggering. I know this sounds dramatic, but the risk of prolonged high HbA1c levels cannot be overstated. For example, a patient with an HbA1c of 10% has an expected five-year survival rate below 50%. Conversely, a patient with diabetes who lives with an HbA1c of 6.5-7% has a survival rate similar to the population without diabetes.

Only pharmacological treatment will lower their HbA1c. Diet, weight and regular exercise are not expected to have a significant impact

on lowering the HbA1c of these severely compromised patients. Pharmacotherapy is the key and, after about 10 years with the disease, most patients become so insulin deficient that only insulin therapy can bring glucose down. Patients with advanced Type 2 diabetes don’t have enough insulin secreted from the pancreas to support non-insulin regimens. Insulin therapy has one side effect: hypoglycemia. Additionally, as a drug, it does not have an upper dosage limit and there is no glucose it cannot reduce.

The principle of individualized insulin needs is essential for managing effective and safe insulin therapy.

For each patient, the number of daily insulin units needed is individualized and changes frequently. And because the patient’s pancreas cannot properly modulate dynamic insulin levels, it should be done by adjusting doses at least weekly. But patients and physicians can’t see one another on a weekly basis to regularly titrate insulin doses. That’s why Hygieia has developed the d-Nav® insulin management program.

Within three months, 90% of Hygieia patients on our d-Nav program report significantly improved HbA1c levels. The solution to uncontrolled HbA1c is at hand and should be adopted without delay. Interested in Hygieia’s d-Nav insulin management program? Visit hygieia.com. Physicians can refer adult patients with Type 2 diabetes who are using insulin to Hygieia by faxing patient information to 734-469-5082, or by calling 734-743-2838.

About the author

Israel Hodish, M.D., Ph.D., is a co-founder of Hygieia and its lead clinical researcher. He is an endocrinologist and associate professor of internal medicine at the division of Metabolism, Endocrinology and Diabetes of the University of Michigan Medical School.

uofmhealth.org/profile/1319/israel-hodish-md

Reference Hodish I. For debate; pharmacological priorities in advanced Type 2 diabetes. J Diabetes Complications. 2020 May;34(5):107510.

COVER STORY

Medical Decision-Making and Medical Necessity Evaluation & Management Documentation Changes in 2021 by Jill M. Young, CPC, CEDC, CIMC On Jan. 1, 2021, the first significant change in the documentation requirements of Evaluation and Management Services (E&M) in 25 years will occur for Office or Other Outpatient Services. This section of codes is used to report E&M services provided in the office or in an outpatient or other ambulatory facility as defined by the American Medical Association (AMA) in the CPT coding book, 2021. The changes discussed in this article are unique to and only apply to the CPT codes 99202-99205 and 99212 -99215. No

other Evaluation and Management code families are affected. Not hospital inpatient visit codes, not hospital observation codes and not nursing home codes—just Office or Other Outpatient Services. The new description reads “Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination (i.e. high, moderate, low) and medical decision-making that

the specific code requires.” The elements of history and examination are no longer a requirement but rather are done as determined to be medically appropriate by the provider. Medical decision-making (MDM) takes on a more prominent role. In 2021, one methodology for selecting the level of E&M service for an Office or Other Outpatient Service allows for the MDM alone to be the deciding factor. The other is time, which will not be discussed in this article. WINTER 2020 | MAFP.COM

Using this new format in selecting the level of service, gone are the days of bullet counting of the elements of a history and deciding which of the examination formats, 1995 or 1997, works best for you in documenting these services. For this select group of services, the “outdated” system of selecting a level of service is changing.

Revisions for 2021

The previously familiar Table of Risk has seen some revisions and undertaken a new name and new role in 2021. It is now titled Elements of Medical Decision Making. It has the same four levels of MDM: straightforward, low, moderate, and high. We do not see the words “medical necessity” in the AMA’s descriptors because it is defined and required by CMS/Medicare. It is found in both the Social Security Act Section 1862(a)(1) (A) and defined in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.B. Medical necessity is listed as the “overarching criterion” for payment in addition to the individual requirements of a CPT code. It also is listed that treatment must be “reasonable and necessary for the diagnosis or treatment of illness or injury” and “to improve the functioning of a malformed body member, medical necessity is a prerequisite.” Most other insurance carriers have medical necessity listed in their policies but none, in my opinion, define it as well as CMS/Medicare does. MDM and medical necessity are needed to audit-proof your note.

Documentation is Key

Which is why in 2021, documentation is key. Not in volume, but rather in its unique content based on identifying today’s findings and today’s assessment of what is wrong with the patient. There is no need to cut and paste a “normal” history with a 10-point Review of Systems (ROS) or insert a “normal” physical template that has prepopulated examination elements. Rather, documentation of the clinically appropriate history and exam leads into a potential narrative of what 14 WINTER 2020 | MAFP.COM

Showing medical necessity in documentation and medical decision-making have new tools in 2021. ‘Addressing’ a problem that has been defined with the new CPT guidelines.

COVER STORY

your thought process is as you complete your assessment and document your plan for this patient and document your MDM. Putting into the chart documentation what you are thinking or even suspecting regarding this patient’s care will additionally help show why your care plan is medically necessary. Documentation in your Assessment and Plan (A&P) of a patient with a

cough that you are ordering a CT scan of the chest does not tell the whole story. Rather, documentation of a patient with a cough whose X-ray after the last appointment shows interstitial changes would connect the pieces of information to show your, the physician’s, logic in ordering a complex test. Showing medical necessity in documentation and medical decisionmaking have new tools in 2021. “Addressing” a problem has been defined with the new CPT guidelines. This will cause a change in the thought process and documentation of a patient’s problems. In looking to count the number of possible diagnoses and/or number of management options, the guidelines indicate that “a problem is addressed or managed when it is evaluated or treated at the encounter by the physician (or other QHCP) reporting the service. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed.” So, the listing of a diagnosis that is a co-morbidity is no longer sufficient. Just as placing the problem list in the assessment area without further documentation also will not count as being addressed and, therefore, will not count toward MDM. In 2021, documentation for Office and Other Outpatient Services will need to change for many physicians. It is a change I feel is for the good. Documentation will no longer be done to satisfy a specified number of bullet points of information that you, the physician, may not deem as clinically relevant. Documentation of your thought process as you work though the Number and Complexity of Problems to be Addressed, looking at the Amount and Complexity of Data to be Reviewed and the Risk of Complications and/or Mortality and Morbidity of Patient Management takes you through the process of the newly defined Elements of Medical DecisionMaking as defined by the AMA.

New Guidance for These Codes

The AMA’s new MDM guidance for these codes states, “Medical decision making includes establishing diagnoses, assessing the status of a condition, and/ or selecting a management option.” Documenting that process (establishing, assessing, managing), likely through a narrative portion of the EMR note, connects the information in a way not often seen in physician documentation because of EMR smart phrases. This connection of information and thought processes should show the severity of the presenting problem and the intensity of the management of the problem. Most likely, in a narrative portion of the note. Documenting in this manner, MDM is clearly presented and medical necessity shown. This type of documentation of the MDM portion of a patient’s office note is something that can be used under current guidelines to show MDM as one of the two or three required elements and can be used in all the other E&M code set areas requiring MDM. If you utilize this new narrative type of note for MDM today you will be more prepared for 2021 when MDM will be the all-important measure used in selecting the level of service for office and other outpatient services.

Jill M. Young, CPC, CEDC, CIMC, is the principal of Young Medical Consulting LLC, a company founded 11 years ago to meet the education and compliance needs of physicians and their staff. Young has over 30 years of medical experience working in all areas of the medical practice including clinical, billing, and rounding with physicians.

WINTER 2020 | MAFP.COM

Advancing the Specialty Amid the Pandemic With several months under her belt as president of Family Medicine Foundation of Michigan, Mary Marshall, MD, RN, FAAFP, is more committed than ever to the organization’s mission of advancing family medicine. She took over the presidential seat in August, when the Foundation’s annual signature event—the Michigan Family Medicine Conference & Expo—would have convened family physicians from across the state at the Detroit Marriott Troy were it not for the COVID-19 pandemic. Instead, colleagues have been meeting via virtual platforms to network and earn continuing medical education. With the shift from in-person to virtual gatherings and the financial and practice management challenges the pandemic has created for members, Dr. Marshall’s priority for Family Medicine Foundation of Michigan under her tenure is the health and well-being of family physicians. “This means both personally and professionally in this most difficult time of transition,” she said. “We family 16 WINTER 2020 | MAFP.COM

physicians know that we can help guide our state and our nation through the pandemic, and by the Foundation providing practical education and services to MAFP members, we in turn help the people of Michigan, our patients.”

Virtual Programming

This year has seen the greatest number of virtual events ever hosted by Family Medicine Foundation of Michigan. While members, leadership, and staff certainly miss the camaraderie and exchange of ideas over impromptu lunch discussions or between sessions, the variety of live and on-demand webinars has answered the call for timely need-to-know information and guidance. Webinar topics have ranged from telemedicine expansion, to coding updates, to preparing COVID-19 funding relief applications. Plus, clinical sessions offer continuing medical education credits, and several meet or contribute toward the state’s human trafficking, medical ethics, and pain and symptom management

professional development requirements for medical licensure. “Our instructors are the true ‘teachers of family medicine,’” said Dr. Marshall. Visit mafp.com/cme-events for a list of virtual programing.

Student and Resident Programming Like the Michigan Family Medicine Conference & Expo, the Foundation’s flagship resident and student events also were repackaged into online offerings in 2020. Sessions from what would have been the second Beyond Clinical & Curriculum Resident Conference now comprise the on-demand Business of Medicine and Leadership e-Learning Library. “The business of medicine is a difficult thing to teach residents and can end up being relatively time-consuming for faculty. Having resources available for on-demand learning for residents is invaluable for their education,” said Kristi VanDerKolk, MD, program director at

FOUNDATION NEWS

We family physicians know that we can help guide our state and our nation through the pandemic, and by the Foundation providing practical education and services to MAFP members, we in turn help the people of Michigan, our patients. - Mary Marshall, MD, RN, FAAFP

the Western Michigan University Homer Stryker M.D. School of Medicine Family Medicine Residency. In October, the seventh annual Michigan Future of Family Medicine Conference provided students the opportunity to explore the breadth and depth of the specialty. Through funding from AAFP Foundation’s Family Medicine Philanthropic Consortium and partnership with the Western Michigan University Homer Stryker M.D. School of Medicine, medical students took part in interactive online panel discussions and outpatient procedure demonstrations live-streamed from WMed’s state-of-the-art simulation lab. Plus, 15 of Michigan’s family medicine residency programs participated in the first-ever virtual Michigan Family Medicine Residency Connection to showcase their programs and answer students’ questions. “The virtual platform is helping us reach a generation of residents and medical students who grew up with technology,” acknowledged Dr. Marshall.

Leadership Opportunities Another traditional Family Medicine Foundation of Michigan investment centers on leadership development of the physicians of tomorrow, namely through delegate positions at AAFP’s National Conference of Family Medicine Residents & Medical Students. Although traditional congress sessions weren’t held during the conference this year, resident and student delegates benefited from virtual leadership discussions. “The structure of the Leadership Networking Room allowed me to reach multiple professionals at once. I was able to field questions from participants whose interests, locations, and backgrounds varied greatly, and gain insight into the current mindset of a majority of family practitioners,” said MAFP Resident Delegate Linda Stanek, MD, Beaumont Health-Grosse Pointe Family Medicine Residency.

The leadership discussion groups also were a highlight for MAFP Resident Alternate Delegate Himanshi Chopra, MD, McLaren Oakland Family Medicine Residency. “I was able to participate in the discussion groups and advocate regarding important issues of today, like the role of telemedicine in COVID-19 times, the impact of the COVID-19 pandemic on medical school and residency curriculum, health disparities based on ethnicity, and the role and need for women in medicine,” said Dr. Chopra. To kick off the conference, the Foundation hosted a virtual Michigan gathering, to replace the traditional Michigan Reception held in the iconic Power and Light District of Downtown Kansas City. “It helped me get motivated and excited about being an active participant in the conference,” said Dr. Chopra. WINTER 2020 | MAFP.COM

FOUNDATION NEWS

FMIG Transition Each year, Family Medicine Foundation of Michigan awards grant funding to family medicine interest groups at the state’s medical schools based on competitive applications. Due to the pandemic, FMIGs were forced to refocus their planned events for increasing exposure to and excitement of family medicine.

Traditional Hands-on Experience One initiative of Family Medicine Foundation of Michigan that didn’t change due to the pandemic was the summer student externship. Through matching grants from AAFP Foundation’s Family Medicine Philanthropic Consortium, the Foundation awarded externships to two students who trained in person, for four to six weeks under the family physician of their choice. Both Ameen Suhrawardy and Eli Benchell 18 WINTER 2020 | MAFP.COM

Eisman, PhD, came away excited about and committed to their futures as family physicians. “I got to see the work of family physicians in the outpatient setting on a day-to-day basis,” said Suhrawardy. “I learned from their history-taking strategies, clinical decision-making, patient relationship building, and from their own career trajectories out of medical school. I observed how family physicians manage long-term chronic conditions and integrate lifestyle and holistic solutions into their treatment. I participated in clinical management alongside physicians, reviewing patient history, medications, consult notes, lab results, and much more.” You can read more about Suhrawardy and Eisman’s externship experiences on page 24.

You Can Help Advance Family Medicine Every MAFP member has a role to play in Family Medicine Foundation of Michigan’s work of advancing family medicine. “Contributing ideas for conference sessions and bringing issues to our attention that affect your practice will help the Foundation. By identifying needs in our family medicine community, it will extend our reach to more physicians and ultimately more patients. And although we recognize that times are tough, members can help us reach more people if they can contribute even a few dollars to advance our work,” said Dr. Marshall.

To submit your ideas, email info@ mafp.com. To make a tax-deductible contribution to Family Medicine Foundation, visit mafp.com/mafpfoundation/make-a-donation.

MEMBERS IN THE NEWS

Residents and Student Recognition Resident Members Recognized for Excellence Ali Nasrallah, MD, Julie Thai, MD, MPH Of the 3,500 eligible family medicine residents from across the country, only 12 are recognized with the annual American Academy of Family Physician Award for Excellence in Graduate Medical Education. This year, two of the 12 individuals selected to receive this esteemed distinction—Ali Nasrallah, MD, and Julie Thai, MD, MPH—are resident members of Michigan Academy of Family Physicians. “The AAFP Award for Excellence in GME is one of the greatest honors of my career,” said Dr. Nasrallah, chief resident at the Beaumont Health-Wayne Family Medicine Residency.

Dr. Mogill Remembered for Mentorship and Care for All George Mogill, MD, FAAFP George Mogill, MD, FAAFP, a 1942 Wayne State University School of Medicine alum, passed away Aug. 9 at age 103. He held the longest membership in Michigan Academy of Family Physicians, having joined the Academy in 1949 after returning from World War II. That same year, the 2-year-old Academy—then the American Academy of General Practice—held its first-ever meeting, convening 3,500 of 10,000 family physician members from across the country. Upon graduating from the Wayne State University School of Medicine in 1942, Dr.

With a passion for medicine intertwined with a desire to work within communities and give back to those around him, Dr. Nasrallah said his training at the Beaumont-Wayne program has prepared him well to practice in an underserved community. He most appreciates the opportunities it has provided for strengthening his ability to recognize and address social determinants of health—the aspect of medicine that he finds to be one of the most rewarding.

“Family medicine has allowed me to integrate my public health, patient care, and clinical research skills into caring for vulnerable and underserved populations,” she said.

Dr. Nasrallah plans to focus on general medicine, preventive medicine, acute care, sports medicine, and addiction medicine. He also aspires to pursue a master’s in public health to strengthen his foundation to serve those around him and have a greater impact on communities.

As she looks to the future, Dr. Thai plans to pursue a fellowship in clinical geriatrics at a university-based medical center with the intent of becoming geriatric faculty in an urban underserved community. She also plans to continue her advocacy work in medicine.

Equally passionate about exemplary patient care, addressing social determinants of health, and service to others is Dr. Thai, academic chief resident at the McLaren Flint Family Medicine Residency.

Mogill planned to be a surgeon. However, after returning stateside from the war, he learned his surgical internship position had been given away. Instead, he found a home as a general practitioner at Grace Hospital, where he later served as chief of the Department of Family Practice from 1977 to 1984. “Becoming a family doctor turned out to be a terrific fit and was where I belonged,” he often said of the specialty that, along with his beloved family, was the center of his life. “I am a people doctor, and I found taking care of the whole patient tremendously rewarding.” Dr. Mogill practiced until he was 96, providing compassionate care to all, regardless of race, ethnicity, or income, and he will always be remembered for the mentorship he provided to hundreds of medical students and residents.

The specialty also has called her to get involved in advocacy. Believing that advocacy is an inherent part of being a family physician and recognizing that healthcare is unequivocally linked to health policy, Dr. Thai is committed to training residents to become better advocates for their patients and profession.

Student Member Appointed to Annals of Family Medicine Editorial Advisory Board Christal Clemens, a fourth-year student at the Central Michigan University College of Medicine, was appointed by the American Academy of Family Physician Board of Directors as the student member to the Annals of Family Medicine Editorial Advisory Board. She is serving a one-year term that began Oct. 1 . “I’m incredibly thrilled to join the Annals of Family Medicine Editorial Board. Research has been a longtime passion of mine because of its impact on patient care, guidelines, and outcomes. I’m excited to join the efforts of advancing primary care knowledge and understanding through research, peer review, and collaboration,” said Clemens. Clemens holds research experience through internships at Vanderbilt University Medical Center, Mayo Clinic, and Harvard T.H. Chan School of Public Health. She is also actively involved in research as a medical student, including projects in psychiatry and obstetrics/gynecology. WINTER 2020 | MAFP.COM

Aging Physicians and Competency A Look at the Current State of Age-Based Physician Aptitude Testing by Bradley Byrne, JD

In the healthcare sector, 30.9% of active physicians are 60 or older. Research shows that between ages 40 and 75 years, a person’s cognitive ability declines by more than 20%. Given the patient safety implications, identifying age-related cognitive deterioration in physicians has become a point of emphasis nationwide.

Screening and Reviews

Several healthcare institutions, including Intermountain Healthcare, Stanford Healthcare, Scripps Health, and Penn Medicine, attempted to implement agebased cognitive screening processes. However, questions regarding the effectiveness and legality of physician agebased testing remain.

prohibit full recredentialing. Additionally, several studies have demonstrated an association between increased age and adverse outcomes. One study found mortality rates of surgeons performing coronary artery bypass grafts increased with increasing years of practice. A separate study found older surgeons performing carotid endarterectomy had higher mortality rates than younger surgeons. While further research is needed, this data suggests there may be value in age-based screening.

Legalities of Age-Based Testing

Through its screening program, Stanford ultimately concluded there was no convincing evidence for using a cognitive screen in older physicians to ascertain their ability to practice medicine safely. Conversely, emerging data suggests a more distinct correlation between advanced age and increased risk.

Employer healthcare institutions must be mindful of the Age Discrimination in Employment Act (ADEA). The ADEA restricts an employer’s ability to make age-related employment decisions unless the employer can establish age is a “bona fide occupational qualification” (BFOQ). To establish a BFOQ, an employer must demonstrate the classification is reasonably necessary to normal business operation and is compelled to rely on age as a proxy for safety related job qualifications.

A report in the Journal of the American Medical Association analyzed data from Yale New Haven Hospital’s policy requiring anyone 70 and older applying for or renewing staff privileges to submit to neuropsychological examinations. The study found 12.7% of tested clinicians had cognitive difficulties severe enough to

Age will be deemed a valid proxy if: 1. The employer had reasonable cause to believe all or nearly all employees above a certain age lack the required qualifications 2. It is impossible or highly impractical to deal with older employees on an individualized basis

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No court has yet made a definitive ruling that age is a BFOQ for physicians or other clinicians. The legal uncertainty surrounding agerelated physician testing could dissipate soon. On Feb. 11, 2020, the Equal Employment Opportunity Commission (EEOC) filed suit against Yale New Haven Hospital for allegedly discriminating against older physicians through the implementation of the hospital’s previously discussed “Late Career Practitioner Policy.” The EEOC’s lawsuit claims Yale’s policy targets individuals based solely on their age without any suspicion that their neuropsychological abilities may have declined. The EEOC contends that by subjecting only older hospital applicants and employees to the policy, the hospital violates the ADEA. This case may provide much-needed guidance. However, it will have no legal effect on organizations that use privately employed physicians, since the ADEA prohibition on age discrimination only applies to “employers.” In other words, before issuing admitting privileges or making credentialing decisions, hospitals may require privately employed physicians to undergo physical and cognitive examinations. Likewise, the ADEA does not apply to insuring decisions of medical professional liability (MPL) insurers since many MPL carriers already use age-based screening procedures.

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President’s Society

Endnotes

Though compliance with antidiscrimination laws is important, failing to identify physician competency issues presents another set of legal and risk concerns. In many jurisdictions, a plaintiff can bring suit for negligent credentialing. Liability rests on the administration’s knowledge of a physician’s dyscompetence. Knowledge of dyscompetence can be established through direct observation of a physician; it can also be imputed if, in the exercise of ordinary care, the hospital knew or should have known of a physician’s dyscompetence.

signs of neurocognitive disorders is one possible solution. Phrases such as “seemed forgetful,” “seemed confused,” and “acted inappropriately” could trigger competency testing. Implementing anonymous reporting protocols is another potential oversight mechanism to consider. Age-based physician testing is a complex issue that warrants further discussion and research. As the debate around this topic matures and case law develops, physicians and their employers should prepare for the possibility of meaningful changes in the evaluation process of senior physicians.

Looking Forward

The resulting landscape seeks balance between two compelling arguments. On the one hand is the argument that doctors, like commercial airline pilots, should be subjected to age-based testing in the name of safety and liability minimization. On the flip side is the belief that such testing is discriminatory if not predicated on observable factors. While awaiting clarification from the courts, a “middle-ground” is perhaps the most appropriate, and legal, means of addressing age-based screening. Institutions interested in “getting out in front” of this issue would do well to explore age-neutral physician screening procedures. Developing systems to evaluate unsolicited patient complaints for

Bradley Byrne, Jr., JD, is a Risk Resource Advisor for ProAssurance, advising physicians, other healthcare providers, and practice administration professionals on healthcare risk management and professional liability issues.In private practice, Bradley handled a diverse range of civil cases with a focus on Title VII civil rights claims, business development, and athlete representation. He is a member of the Alabama Bar Association, the Birmingham Bar Association, the American Society for Healthcare Risk Management, and the Alabama Society for Healthcare Risk Management.

1. Data from the Census Bureau and Bureau of Labor Statistics analyzed by investment and financial planning firm United Income unitedincome. com/ library/older-americans-intheworkforce/ 2. “2017 State of Physician Workplace Data Report,” Association of American Medical Colleges. 3. Dellinger Ep, Pellegrini CA, Gallagher TH. The Aging Physician and the Medical Profession: A Review. [published October 1, 2017]. JAMA Surg. doi: 10.1001/ jamasurg.2017.2342. 4. Cooney L, Balcezak T. Cognitive testing of older clinicians prior to recredentialing [published January 14, 2020]. JAMA. doi:10.1001/ jama.2019.18665. 5. Hartz AJ, Kuhn EM, Pulido J. “Prestige of training programs and experience of bypass surgeons as factors in adjusted patient mortality rates.” Med Care. 1999;37(1):93-103. 6. O’Neill L, Lanska DJ, Hartz A. “Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy.” Neurology. 2000;55(6):773-781. 7. https://www.eeoc.gov/eeoc/ newsroom/ release/2-11-20a.cfm 8. Under the ADEA, the term “employer” is defined as “a person engaged in an industry affecting commerce who has twenty or more employees for each working day in each of twenty or more calendar weeks in the current or preceding calendar year. 29 U.S.C § 623 (2016), et seq. WINTER 2020 | MAFP.COM

Scholarship Program for Members, Their Employees, and Families New Member-exclusive Benefit Michigan Academy of Family Physicians recognizes and supports the value of continuing education. Our members are a key asset to our family medicine community and the healthcare system. MAFP is committed to your success. “With this in mind, I am pleased to announce MAFP’s new education partnership with Davenport University, which will benefit not only Academy members, but also members’ employees and families,” said MAFP Chief Executive Officer Karlene Ketola, MSA, CAE. If you aspire to enhance your medical practice with an advanced degree— or strengthen your leadership and management skills—this program can help make your vision a reality!

Scholarship Benefits •

Up to $4,500 for members and members’ employees toward tuition

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•

• •

for most undergraduate and graduate degree programs Renewable Scholarship applies toward six classes or 22 credit hours per year 20% tuition discount for spouses and dependents up to age 29 20% discount for Professional Development courses offered at DU campuses and online

What You Will Gain from the Partnership • •

• •

Grow new capabilities with immediate payoffs and long-term impact Receive individualized and flexible support geared for professionals in demanding careers Develop into a more effective healthcare leader Gain the business skills needed to transform healthcare delivery “I highly recommend MAFP members

consider this valuable opportunity in pursuit of personal and professional development,” said MAFP President Mark Hamed, MD, MBA, MPH, FAAFP. “Davenport University is a quality institution with more than 150 years of experience delivering academic excellence and applied learning techniques. I am proud that MAFP is teaming up with Davenport University to offer this new education partnership to support members of our family medicine community. I earned my master’s in business administration with a focus in healthcare management from DU in 2008, which has allowed me to better understand the overhaul of the healthcare system, while tying this into cost-effective care, patient safety, and better patient outcomes.” Visit davenport.edu/mafp for details and the Davenport University application.

ACADEMY NEWS

Call for ‘Academy’ Award Nominations Shine the Spotlight on Family Medicine Each year, Michigan Academy of Family Physicians honors outstanding individuals of the Michigan family medicine community who exemplify the mission, vision, and values of the Academy and the family doctor. Awards are presented at a special family medicine celebration held during the annual Michigan Family Medicine Conference & Expo, taking place Aug. 5-8, 2021. To nominate a deserving individual for the 2021 “Archie” Award of Excellence, Michigan Family Physician of the Year, Michigan Family Medicine Resident of the Year, or Outstanding Medical Student Award, visit mafp.com/membership/awards. Nominations are being accepted until March 1.

In Memoriam Michigan Academy of Family Physicians respectfully remembers these family physicians who passed away in 2020: Nancy Ajemian, MD (Grosse Pointe Farms) Bernard Alper, DO (West Bloomfield) James Bersalona, MD (Troy) Rebilo Diccion, MD (Morenci) Lynn S. Gray, MD, MPH (Berrien Springs) John Hoyt, MD (Traverse City) George Mogill, MD (Bloomfield Hills) Angelo Patsalis, MD (Livonia)

IF YOU WOULD LIKE TO RECOGNIZE A COLLEAGUE BY MAKING A GIFT OR BEQUEST TO FAMILY MEDICINE FOUNDATION OF MICHIGAN IN THEIR MEMORY, PLEASE CALL MAFP AT 517.347.0098.

STAY CURRENT AND CONNECTED TO YOUR ACADEMY Renew 2021 Membership at mafp.com/membership As the new year quickly approaches, it’s time to renew your Academy membership for 2021. Renewal ensures you stay connected not only to Michigan Academy of Family Physicians—which provides you with close-to-home opportunities to earn continuing medical education, local networking events, access to Michigan-specific memberonly benefit programs, and up-to-date news and information impacting the practice of family medicine in our state—but also to American Academy of Family Physicians’ expansive suite of benefits, services, and supports. As an Academy member, you are among more than 134,000 family medicine physicians, residents, and medical students across the country, including 4,200-plus right here in Michigan. WINTER 2020 | MAFP.COM

Summer Externship Provides Hands-on Family Medicine Experience Each summer, a medical student member of Michigan Academy of Family Physicians is selected to participate in an externship to gain firsthand experience of what it’s like to be a family doctor. Thanks in part to two matching grants from American Foundation, Family Medicine Foundation of Michigan (FMFM)—MAFP’s philanthropic arm dedicated to advancing family medicine—was able to grant externship awards to two students in summer 2020. Under the mentorship of seasoned family physicians, both students gained valuable insight into direct patient care amidst the COVID-19 pandemic and strengthened their commitment to family medicine. “Once again, Family Medicine Foundation of Michigan’s summer externship program proved to be highly successful in providing students with opportunities to ‘try on’ family medicine and explore its breadth, depth, and hallmark physicianpatient relationship building,” said the organization’s president, Mary Marshall, MD, RN, FAAFP. 24 WINTER 2020 | MAFP.COM

Expanding Access to Care for Uninsured Patients

Ameen Suhrawardy, now in his second year at the Oakland University William Beaumont School of Medicine, spent July working under the mentorship of Sariea Alsmoudi, MD. Dr. Alsmoudi practices family medicine at Premier Medicine, a source of primary and urgent care in Dearborn, Livonia, and Hamtramck. With the goal of expanding access to care for uninsured patients, the team at Premier Medicine launched a pilot prior to the COVID-19 pandemic, to integrate a free clinic model within its main primary care site in Hamtramck.

As the number of COVID-19 cases continued to increase in southeast Michigan in the spring, it became quickly apparent that patients in Hamtramck, as well as at the clinic’s other two sites, desperately needed support. Many have been directly impacted by the virus, lost medical insurance due to the economic fallout, are experiencing stress or trauma, or have had a disruption in their care. This was the backdrop of Suhrawardy’s externship. In addition to being involved in direct patient care and practice management responsibilities, he helped establish a network of primary care physicians and other specialists through Premier Medicine’s integrated free clinic model. He also received a federal grant for purchasing COVID-19 testing kits that benefited over 150 patients free of charge. Through establishing the infrastructure for the integrated free clinic and applying for funding, Suhrawardy feels he built a solid understanding of the inner workings of

FOUNDATION NEWS

every aspect of a private family medicine practice, from clinical decision-making, to billing, to administration. Plus, it allowed him to apply the foundational sciences he has learned thus far in his medical training. “Seeing real-life presentations of clinical diseases and conditions is the best way to fully connect and understand illnesses,” he shared.

Comprehensive Inpatient and Outpatient Experience

From evaluating suspected COVID19-positive patients, to providing prenatal care, to caring for transgender and homeless individuals and beyond, Eli Benchell Eisman, PhD, experienced the range and depth of the family

medicine specialty during his one-month externship in the heart of Detroit. This was exactly what he was looking for, he said.

College of Osteopathic Medicine—was Eisman’s choice of mentor for his externship.

“My hope was to explore the full breadth of how the specialty can be realized, while gaining a deeper appreciation of barriers to accessing and providing culturallysensitive care for historically underserved and economically disadvantaged patients,” he said.

“Eli exemplifies the virtue to assist the poor, the sick, the weak, and the downtrodden. He showed true compassion for our patients, understanding that many are facing poverty, food insecurity, violence, homelessness, and other social determinants of health,” said Dr. Bryce of Eisman’s care delivery in outpatient and inpatient settings.

Eisman’s end goal: Construct a strong foundation for future humanitarian work as a family physician in vulnerable communities domestically and abroad. Richard Bryce, DO—program director at Henry Ford Family Medicine Residency, chief medical officer at Community Health & Social Services Center (CHASS), a federally qualified health center, faculty advisor at Detroit Street Care, and clinical professor at Michigan State University

Now in his final year at Michigan State University College of Osteopathic Medicine, Eisman’s sights are more strongly set on pursuing family medicine residency than before, he said, crediting the Family Medicine Foundation of Michigan/AAFP Foundation externship with reaffirming his commitment to the specialty.

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Recognizing the Value of a Medical Home by Matt Black

Having a strong connection to medicine and primary care, Sen. Paul Wojno and Rep. Benjamin Frederick recognize the needs and concerns of family physicians. The COVID-19 pandemic has encouraged patients to embrace telemedicine and value the importance of a medical home. With the election behind us, we need leaderthip as all levels of government to help us navigate what’s next and find ways we can all come together to serve Michigan residents.

Sen. Paul Wojno Sen. Paul Wojno (D-Warren) has had a political career spanning multiple decades. He previously served as a representative in the Michigan House from 1997-2002. Having served his constituents during these two different time periods has given Wojno a different perspective on their needs. “During this legislative session there has been support for the expansion of telemedicine, especially for rural and lowincome areas,” he said. This expansion of telemedicine leads to covering the healthcare priorities for Wojno, which have adjusted due to the onset of a global pandemic. Pre-COVID, he had set his focus on ensuring proper healthcare coverage to some of Michigan’s most vulnerable citizens through expanding Medicaid. With the onset of COVID, Wojno has shifted his focus to not only Medicaid expansion, but also to provide a responsible, coordinated response to the pandemic that provides proper PPE and support for frontline workers. 26 WINTER 2020 | MAFP.COM

The current pandemic has increased healthcare concerns. High cost of prescriptions, especially insulin, remains a concern, but other concerns have increased including behavioral health concerns and potential problems with residence in care facilities. Behavioral healthcare has been a problem facing Michigan, and we are seeing an increase in the problem given the current pandemic environment. Frontline healthcare workers are at risk and seeing an increase in behavioral healthcare problems. Wojno wants to ensure the elderly population is not left out andharmed further through COVID-19. Wojno is not a newcomer to healthcare and health policy. During his tenure in the House of Representatives, he also served on the Health Policy Committee. While attending college, he worked as a pharmacy technician and as a physician therapy aide. In addition, his wife, Lisa, has a Bachelor of Science in nursing and his brother is an ophthalmologist at Emory University. Through his work experience, legislative experience, family connections, and meeting with stakeholders, Wojno is prepared to not only vote upon, but also understand health policy issues.

This crisis has illustrated how telemedicine has increased and the important role it plays in screening patients.

Understandably, the biggest surprise for the senator is the current pandemic and the challenges, especially related to healthcare, it has brought upon our state.

A quote by Kirsten Gillibrand stating, “Heath Care should be a right; It should never be a privilege. We should have Medicare for all in this country,” defines Wojno’s personal thoughts on healthcare.

“This crisis has illustrated how telemedicine has increased and the important role it plays in screening patients,” he said. “As I mentioned earlier, I have met with members of Michigan Academy of Family Physicians and have been impressed by their outreach and advocacy on behalf of their members and the quality of healthcare for the residents of our state. Their care for a patient begins at birth and continues through the course of their lifetime. I urge you to continue your efforts in the legislative process and encourage your members to get to know their state representatives and senators and advocate at the grassroots level to be engaged.”

Wojno has been married to his wife for 25 years. She is the chief operating officer of her healthcare company. They have three children: Kennedy, a recent graduate of Central Michigan University who is employed and working on her MBA; Bradley, who will graduate from Wayne State University in December with a degree in criminal justice; and Audrey, who is a pre-med sophomore at Macomb Community College. The Wojnos spend much of their time with their three dogs learning to cook new recipes and engaging with citizens for the 9th Senate District of Michigan.

MEET THE LEGISLATORS

Rep. Benjamin Frederick Rep. Benjamin Frederick (R-Owosso), sits on the House Health Policy Committee, where he serves as vice chair. He is currently serving his second term in the Michigan House of Representatives. Frederick prioritizes rural healthcare and access to healthcare for rural communities at the top of his list. He understands the struggle rural communities face with attracting physicians and understands the problems surrounding the connection between nutritional choices and general health. Medicaid reimbursement rates is an area of great concern to the representative. The struggle of maintaining a practice accepting a larger volume of Medicaid patients remains a difficulty for most practices. Other areas of concern, which Frederick is hoping to address, include substance use disorder and the need for additional behavioral healthcare services. “Substances, especially opioids have become a popular coping mechanism for individuals during this hard time,” he said. Having served as a staffer in the Legislature for over 14 years, Frederick is not a newcomer to healthcare and health policy. He previously served as chief of staff to former Sen. Roger Khan, MD, a cardiologist. During his tenure there, he was focused on providing better physician reimbursement rates, initiatives to reduce lead poisoning in children, and the expansion of Healthy Kids Dental. All of these are vital in providing a healthier population and retaining physicians. The biggest surprise to Frederick is the importance of time management and the difficulties with collaboration. During his tenure as the mayor of Owosso, collaboration with differing points of view was less highlighted, as the position is nonpartisan.

Frederick is a big proponent of direct feedback, especially as it relates to emerging and sustained trends regarding patient care. He also is particularly interested in how to incentivize and retain more physicians in rural Michigan. With that, the needs of students and what it takes for them to feel more comfortable in pursuing family practice is of high importance. Workforce and talent development are reoccurring highlights of the representative’s focus.

increasingly difficult to navigate. On behalf of the families you serve across the state, thank you.” While the representative’s family physician is not a member of MAFP, his sentiment still stands, and he inquired about joining the Academy. Unfortunately, due to upcoming retirement he declined the invitation to join, but still works hard to ensure the best healthcare to all his patients in the community.

“Every Michigander should have a medical home where they are cared for by a practitioner able to exercise their best medical judgement,” said Frederick. He understands the importance of having a true medical home. Frederick is a patient of the same family practice physician who delivered him more than 38 years ago. This relationship is of the utmost importance to lead the healthiest lifestyle possible. “This familiarity, trust and ongoing relationship has cemented in my mind the importance of preserving access to direct care as much as possible throughout our state,” he said. “I have a tremendous respect for your members choosing family practice in a legal and regulatory environment which is WINTER 2020 | MAFP.COM

The How and Why of Refinancing Student Loans by Jon Solitro, MA, CFEI “My wife and I have over $1 million combined in student loans.”

I’m not sure it landed. He still had the look of defeat in his eyes.

I wasn’t sure what to say, but I’m pretty sure my mouth was hanging open. I quickly regained my composure and smiled.

I had just finished one of my student loan lectures to a general surgery residency program in the Detroit area, and I was hanging around afterward answering questions. I had done hundreds of these lectures and had seen the average

“So, you’re like a negative millionaire,” I joked. 28 WINTER 2020 | MAFP.COM

student loan balance slowly tick up for the resident population. There was a time when $100,000 was a lot—now the average resident I see is typically between $250,000 to $300,000. And interest rates are not at a healthy level either— the average is 6.8%, which is crazy to me that the feds can charge that high of interest in today’s world.

Business Sense

Interest rates are at an all-time low, and the free market system we live in means we could take our $250,000 federal student loan and move it over to SoFi, Common Bond, Earnest, and a handful of others, and reduce that interest rate down to somewhere in the 3% range. Why would we want to do that? Let me start with the shorter list. Why would you not want to refinance. There’s basically only one reason in my mind, and that is Public Service Loan Forgiveness. PSLF is a program that, in short, forgives the remainder of your federal loans if you make a qualifying payment for 10 years, as long as you’re working for a nonprofit during that whole time or some other qualifying institution. You may want to stick with this plan if you believe the government keeps their promises and know that you’ll be working for a qualifying institution for 10 years (and residency usually counts). If you refinance your loans, you will be kicked out of this program. If you’re still reading this, and you don’t plan to take advantage of PSLF, then refinancing is for you. Why refinance? To get a lower interest rate and pay less on your student loans over the long term. I ran a quick calculation on an average resident, using Credible.com’s calculator. If you have $300,000 in student loans at 6.8% with a monthly payment of $3,722, and you want to refinance to a 10-year loan at 3.5%, your payment gets lowered

by $755 to $2,967 per month. The big deal is how much you will save in interest over those 10 years: $45,940. So how do you refinance? It’s incredibly easy and free. There’s not enough room to list them all here, but there are several good places to go. I usually recommend you pick three companies to get quotes from. They do a “soft” credit pull, so it won’t ding your credit score each time you get a quote. Then, once you have the three quotes, they will give you a grid of different options, such as five years, seven years, 10 years, 15 years, etc. And each one will have a fixed or variable interest option. Send these to your financial planner and consider a few different factors when choosing. Look at your current budget, the monthly payment they’re offering, and if you can afford it easily with your future income as an attending. Most refinancing companies these days will let you do a low, incomebased payment during residency, often around $100/month. I’ll give you a little tip: What I usually do with my clients is get a 10-year plan and put enough on it each month to pay it off in seven years. That way, if something happens, we can stretch it a little more. Once you’ve selected your payment plan, the new company essentially pays off your federal loans, and you now have one payment with this new company. Also,

there are typically no closing costs. Most companies also now have the same death and disability clauses that the federal loans have—if you die or become permanently disabled, your loans are forgiven. Hopefully, this gives you a better idea if refinancing is right for you. I even have clients who are refinancing loans they refinanced a few years ago, because interest rates have dropped so much since then. As usual, this is not to be considered financial advice and does not apply to everyone. We are here if you have specific questions or would like us to look at your refinancing quotes. Shoot me an email, or head over to FinancialMD.com.

Jon Solitro, MA, CFEI, is a financial planner, a certified financial education instructor, and the founder of FinancialMD. He has been working with physicians for the better part of a decade, and has developed a simple, yet comprehensive financial planning process utilizing technology, for residents in training all the way up to retirement. He can be reached at jsolitro@financialmd.com. WINTER 2020 | MAFP.COM

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