January-March 2015 by Missouri Academy of Family Physicians

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician

January-March 2015 Volume 34, Issue 1

Advocacy Day

Be the voice of Missouri family physicians page 20 Family Physician of the Year Nominate your favorite physician today page 2 Annual Scientific Assembly Register now and save page 7 Annual Fall Conference Recap of events page 16

Connect with MAFP on Twitter and Facebook Visit us online at www.mo-afp.org

is there a physician in your community that deserves the title,

"missouri family physician of the year?"

nominate the

2015 MAFP

family physician of the year

Nominations may be made by any member of the MAFP or the public. Winner will be honored at the MAFP annual meeting in June.

2 Missouri Family Physician January-March 2015

Visit www.mo-afp.org to submit your nomination or email smengwasser@mo-afp.org for more information.

MAFP

MARK YOUR CALENDAR executive commission Board Chair - Bill Fish, MD, FAAFP (Lake Ozark) President - Daniel Purdom, MD, FAAFP (Independence) President-elect - Peter J. Koopman, MD, FAAFP (Columbia) Vice President - Kathleen Eubanks-Meng, DO (Blue Springs) Secretary/Treasurer - James Stevermer, MD, FAAFP (Fulton) board of directors District 1 District 2 District 3 District 4 District 5 District 6 District 7 District 8 District 9 District 10

Director: Dana Granberg, MD, FAAFP (Kansas City) Alternate: Jared Dirks, MD (Kansas City) Director: Lisa Mayes, DO (Macon) Alternate: Carrie Peecher, DO (Unionville) Director: David Schneider, MD, FAAFP (St. Louis) Director: Caroline Rudnick, MD (St. Louis) Alternate: Sarah Cole, DO, FAAFP (St. Louis) Director: Jennifer Scheer, MD, FAAFP (Gerald) Alternate: Kristin Weidle, MD (Washington) Director: Lucas Buffaloe, MD (Columbia) Alternate: Afsheen Patel, MD (Jefferson City) Director: Jamie Ulbrich, MD, FAAFP (Marshall) Alternate: Vacant Director: Sudeep Ross, MD (Kansas City) Director: Wael Mourad, MD (Kansas City) Alternate: Vacant Director: Mark Woods, MD (Ozark) Director: John Paulson, DO, PhD, FAAFP (Webb City) Alternate: Charlie Rasmussen, DO, FAAFP (Branson) Director: Patricia Benoist, MD (Houston) Alternate: Vacant Director: Mark Schabbing, MD (Perryville) Alternate: Steven Douglas, MD (East Prarie)

resident directors Betsy Wan, MD (SLU) Kevin Gray, MD (Alternate) (UMKC) student directors Sarah Williams (MU) Jenny Eichhorn (Alternate) (UMKC) aafp delegates Larry Rues, MD, FAAFP (Kansas City) Bruce Preston, MD, FAAFP (West Plains) Darryl Nelson, MD, FAAFP (Alternate) (Lees Summit) Keith Ratcliff, MD, FAAFP (Alternate) (Washington) mafp staff Executive Director - Kathy Pabst, MBA Education & Finance Director - Nancy Griffin Member Services/Managing Editor - Sarah Mengwasser Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p (573) 635-0830 f (573) 635-0148 www.mo-afp.org office@mo-afp.org

MAFP Advocacy Day & Board Meeting February 24, 2015 Capital Plaza Hotel & State Capitol Jefferson City, MO

AAFP Congress of Delegates September 28-October 3, 2015 Hyatt Regency Denver, CO

Multi-State Forum February 28-March 1, 2015 Grand Hyatt DFW Dallas, TX

AAFP Annual Assembly September 29-October 3, 2015 Hyatt Regency Denver, CO

AAFP Annual Chapter Leadership Forum/ National Conference of Constituencies Leaders (formerly ALF/NCSC) April 30-May 2, 2015 Sheraton Kansas City Hotel at Crown Center Kansas City, MO

MAFP 23rd Annual Fall Conference & SAM Working Group November 6-8, 2015 Big Cedar Lodge Ridgedale, MO (Board Meeting)

AAFP Family Medicine Congressional Conference May 12-13, 2015 Renaissance Downtown Hotel Washington, D.C. MAFP 67th Annual Scientific Assembly June 5-6, 2015 The Lodge at Old Kinderhook Camdenton, MO (Board Meeting) AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 30-August 1, 2015 Kansas City Convention Center Kansas City, MO

INSIDE THIS ISSUE 4

Preparing For Change

Help Desk Answers

You Are The Voice We Need

Resident Grand Rounds

Bill Fish, MD, FAAFP

Resident Case Studies

Dan Purdom, MD, FAAFP

11 Health Is Primary

29 Volunteer On A Commission 30 For Your Information 31 Donate to MAFP PAC

Advertisements 5 FPIN

12 Change Is All Around Us

6 ProAssurance

13 Capitol Commentary

13 Results Billing

Jamie Ulbrich, MD

Pat Strader, Strader & Associates, MAFP Legislative consultant

14 Members In The News 16 Annual Fall Conference Recap 20 2015 Advocacy Day 22 Why Do I Do This

Kathleen Eubanks-Meng, DO

23 Congress of Delegates Report 26 PDW RPS Education Symposium 27 Tar Wars Program

10 Community Health Center 25 MPM-PPIA 28 Children's Mercy - Kansas City 32 MHPPS

MAFP Board Chair Report

preparing for change

I Bill Fish, MD, FAAFP MAFP Board chair

hope your holidays and the close of 2014 brought good times and happiness to you and your families. The next few years look to continue the trend of rapid change in health care delivery. Nationally, change continues with further implementation of health care law, ICD-10 looming and the development of new practice models like Direct Primary Care. In our state, we will see a new class of provider in “Assistant Physicians” and we’ll see how a Republican supermajority affects our prospects of meaningful tort reform. Your state academy has been busy in 2014 and will continue in 2015 to help our membership succeed in the new health care landscape. The MAFP board is also beginning the process to develop a new strategic plan to address expected change. While preparing for change, MAFP honored our history by sending a resolution to the AAFP Congress of Delegates to preserve historic artifacts from the former AAFP headquarters in Kansas City which is scheduled for demolition. The resolution was passed and items like the large “AAGP” seal will be preserved. These will serve as a reminder that our specialty organization is still relatively young, having been established as the American Academy of General Practice in 1947. Thank you to our president, Dr. Dan Purdom, for recognizing the significance of these items and spearheading the preservation effort. Physician workforce will continue as a problem in our state without loan repayment support for new family physicians. MAFP met with retiring UMKC School of Medicine Dean, Betty Drees, MD, to brainstorm ways to increase Family Medicine as a residency choice for their graduates. The Family Medicine Interest Groups at the state medical schools continue to grow and their representatives are active participants at MAFP board meetings.

4 Missouri Family Physician January-March 2015

The next few years look to continue the trend of rapid change in health care delivery.”

Doctors Jamie Ulbrich and Keith Ratcliff lead our advocacy commission and will return to Jefferson City to meet with our legislators on Tuesday, February 24, in conjunction with the Missouri State Medical Association's "White Coat Day." We continue to advocate with legislators on behalf of our specialty and our patients. We’ve communicated with Governor Nixon about the insurance industry trend to narrow their primary care networks with “network optimization." Governor Nixon spoke with our leadership and those who attended Advocacy Day in February. While we’ve had successes on the legislative front in limiting independent practice of nonphysician providers, we failed to stop passage of legislation favoring tobacco companies and the very low state taxes on tobacco products. We continue advocating for a state drug registry for controlled substances. We brought on Kathy Pabst as our new executive director in early 2014 and she is meeting with other state execs to learn best practices to bring to our state. We remain optimistic for our specialty and our state organization and we’ll advocate for support of the practice of Family Medicine so we can all maintain that optimism.

HDAs HelpDesk Answers

is problem-solving therapy effective for managing obesity? Kathryn Watson, MD Sarah Swofford, MD, MSPH University of Missouri FP Columbia, Missouri Evidence-Based Answer Problem-solving therapy (PST) is a useful strategy in both short- and long-term management of obesity (SOR: A, meta-analysis and consistent RCTs).

ST is a five-step approach that includes having the individual identify the problem, formulate alternative solutions, make decisions, and test and evaluate those decisions until the problem is resolved.1 A meta-analysis and systematic review of 11 RCTs (N=1,591) investigated the effect of PST extended care on long-term maintenance of weight loss.2 Selected RCTs included an initial weight loss intervention based on PST, as well as PST extended care delivered in at least two sessions by trained interventionalists, either in person or by telephone. Using the pooled means from the included studies, extended care led to maintenance of an additional 3.2 kg of weight loss over 17 months compared with educational or no-contact controls (P<.0001). A nonblinded RCT of 80 otherwise healthy women with a body mass index (BMI) of 27–40 kg/m2

studied the effect of PST on weight loss versus standard behavioral treatment (BT).1 All participants completed a 20-week BT weight loss intervention, after which they were randomized to BT alone, BT and relapse prevention therapy (RPT), or BT and PST. The BT group received no additional therapy, but did have follow-up at six and 12 months. The BT/RPT and the BT/PST groups, however, had biweekly sessions aimed at weight loss maintenance for an additional 12 months. After the initial treatment period, the BT and the BT/PST groups lost on average 9.5 and 9.3 kg, respectively. At the end of the study, however, the BT/PST group had lost an average of 11 kg from baseline, which was significantly more than the 4.1 kg lost by the BT group (P=.019). In addition, 35% of the PST participants achieved a clinically significant weight loss (defined as a 10% reduction in body weight) compared with 6% in the BT group (P=.025).1 A prospective cohort trial of 272 healthy but sedentary women aged 50–79 years, with BMI >30 kg/m2 but weight <350 lb, examined whether improvements in problem-solving abilities were associated with treatment adherence and weight loss.3 Patients underwent a six-month, group-based, lifestyle intervention program for obesity utilizing PST. Problem-solving abilities were assessed preand posttreatment with the Social Problem Solving Inventory-Revised (SPSI-R) questionnaire, a 52-item report based on PST components. One hundred fourteen women (42%) had ≥10% drop in body weight at the conclusion of six months of follow-up. After controlling for adherence, the association between problem solving and weight change was significant, with a 10% increase in problem-solving ability related to an absolute 0.32 reduction in BMI (P=.008).3

About HDAs -

Resident authors work directly with a physician faculty mentor as "author teams." Residencies meet RRC requirements, and many programs have developed their faculty into local evidencebased medicine experts!

Missouri Family Physician January-March 2015

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President's Perspective MAFP

you are the voice we need

Our staff and our lobbyist will be watching the activity at the capitol closely, but, we need YOU to be engaged in the political process as well."

Our staff and our lobbyist will be watching the activity at the capitol closely, but, we need YOU to be engaged in the political process as well. First, know your state senator and representative. Contact them before the session and get to

know them. Let them know you would be happy to be a resource for them if they have questions about medicine in the state. Second, join us for Family Medicine Advocacy Day in Jefferson City on Tuesday, February 24th. It’s a great day and a wonderful chance to get to know your colleagues from all across the state. You can register now on our web page, www.mo-afp.org. Third, if you are available to testify at the capitol, do it. Our stories can change the outcome in the legislature. Our staff are great at helping you prepare for what our members describe as a great experience. Finally, put some cash where your principals are. Give to the MAFP PAC. This allows us to support candidates who support Family Medicine. You can donate through the Missouri Academy’s web page under the Advocacy tab. Thankfully, winter (and the legislative session) always comes to an end, and this year, we have even more to look forward to. This summer, we will be having our 67th Scientific Assembly at a new venue, The Lodge at Old Kinderhook at the Lake of the Ozarks. It’s beautiful, fun for the whole family and we have a great educational program lined up. Save the date for June 5th and 6th, or even better, register today through our website. Don’t miss it, it will be great. As always, thank you for all you do for your patients and our communities. Hope to see you soon.

Dan Purdom, MD FAAFP 2014-2015 MAFP President

annual scientific assembly

June 5-6, 2015

The Lodge at Old Kinderhook • 20 Eagle Ridge Road Camdenton, Missouri 65020 • P: (888) 346-4949 or (573) 317-3570

Visit www.mo-afp.org to register today

irst, holiday greetings to you and your family. I think we all have a little more appreciation for our family, friends, colleagues and our patients this time of year. I also notice the sky getting darker and I begin to feel a cold chill. Winter??? No, actually I was talking about how I feel when the Missouri General Assembly comes into session the first week of January. It seems that every year, we have to be vigilant for bills that would harm our patients or our profession. I can say that we will be proactive this year in supporting safer prescribing practices through a controlled substance registry and through our support of increased financial access for some of the most underserved in our state.

Missouri Family Physician January-March 2015

MAFP Resident Grand Rounds

unintentional amitriptyline toxicity with therapeutic doses in an adult female Dawn M. Davis MD1, Nicholas W. Van Hise PharmD 2, Amy M. Drew PharmD1,3, 1 Mercy Family Medicine Residency, Mercy Hospital, St. Louis, MO, 2 Indiana University Health Methodist Hospital, Indianapolis, IN, 3 St. Louis College of Pharmacy, St. Louis, MO Introduction: Tricyclic antidepressants (TCA) are efficacious for the treatment of depression. Serious drug interactions and side effect profiles have led to other antidepressant classes, such as selective serotonin reuptake inhibitors (SSRI) to be used preferentially in the treatment of depressive illnesses. While the overall usage of TCAs has decreased in the US, these agents continue to be utilized for the treatment of neuropathic pain, for migraine prophylaxis, and as secondary treatment for depression.1 Despite known drug interactions, SSRIs and TCAs may be prescribed concomitantly for different indications. We present a case of amitriptyline toxicity in a patient using a low dose of this medication for migraine prophylaxis while taking fluoxetine for depression. Case Report: A 37-year-old black female presented for outpatient evaluation with complaints of weight gain, increased abdominal girth, and constipation of two weeks duration. The patient’s past medical history was significant for depression with anxiety, migraine with aura, and menorrhagia. She had no pertinent surgical history. Her medications included trazodone 50mg PO QHS PRN sleep, amitriptyline 50mg PO QHS, fluoxetine 60mg PO QDay, and sumatriptan 100mg PO PRN migraines. She denied tobacco, alcohol, or illicit drug use. The patient’s vital signs were notable for HR of 110 BPM and a weight gain of 4 kg in past 20 days. Urine pregnancy test was negative. Abdominal distension was noted on the physical exam and KUB demonstrated retained stool throughout the colon. The patient was diagnosed with constipation and weight gain of unclear etiology. She was prescribed polyethylene glycol (PEG). The patient presented to the Emergency Department (ED) five days later with complaints of constipation, shortness of breath, abdominal discomfort, and abdominal distension. The patient’s vital signs were as noted: HR of 120 BPM, BP of 147/92, weight of 68kg, and an SPO2 of 100% on RA. PE was notable for tachycardia without murmur and a non-tender, distended abdomen. EKG, CBC, CMP, TSH, D-Dimer, computed tomography angiography (CTA) of the chest, CT of the abdomen, 8 Missouri Family Physician January-March 2015

and quantative beta HCG were ordered. All tests were negative or had values WNL except alkaline phosphatase, AST and ALT. Their levels were117 U/L, 37 U/L, and 99 U/L respectively. The CT of the abdomen demonstrated a large amount of stool within the colon, a fatty liver, bilateral ovarian cysts, subcutaneous edema of the buttocks, and an incidental appendicolith. The patient was discharged home with the following diagnoses: constipation for unclear reason, resting tachycardia with normal CTA, and appendicolith without symptoms of appendicitis. She was directed to follow up with her primary care provider (PCP). The patient was seen in her PCP’s office two days later for constipation and weight gain. She reported several bowel movements daily with PEG use as prescribed. Her abdominal discomfort improved, but she complained of continued abdominal distension and additional weight gain of 2.8 kg since her ER visit. Vital signs included a HR of 100 BPM. Her exam noted a soft, distended abdomen without tenderness, rebound, or guarding to palpation. She was instructed to continue the PEG and follow up in one month. The patient presented to the ED three days later with complaints of constipation, abdominal pain and distension, light-headedness, dizziness, shortness of breath, blurred vision and swelling of arms, ankles, and face. The patient’s vitals were notable for HR of 116 BPM, BP 139/84, RR 18 and weight now 71.6 kg (additional 0.8 kg from PCP visit). CBC, BMP, BNP, HCG, and ESR were normal. The ED consulted inpatient family medicine to admit the patient for further work up. While being interviewed by the FM resident the patient noted additional complaints of severe xerostomia and urinary retention. Due to the anticholinergic nature of her symptoms the patient was questioned more carefully about her amitriptyline use. The patient relayed that she had started amitriptyline for migraine prophylaxis approximately two weeks prior to the onset of her symptoms at a dose of 25mg PO QHS with instructions to increase the dose by 25 mg weekly until she reached a nightly dose of 100mg. She had taken her first 100mg dose of amitriptyline the night prior to this ED visit. She noted the amitriptyline was reducing the frequency

MAFP of her migraines. The patient reported her other daily medications as PEG and fluoxetine. She had self-discontinued sumatriptan and trazodone several weeks prior. An adverse reaction to amitriptyline was strongly suspected, and the patient was instructed to discontinue amitriptyline immediately and to follow up in the clinic. On clinic follow up two days later the patient had experienced no improvement in her anticholinergic symptoms, but did have recurrence of her migraine headaches. Her vital signs were notable for a HR of 127 BPM, BP of 138/90 and weight of 71.6 kg. The patient was reassured that her symptoms would slowly improve, however, due to the half-life of amitriptyline this could take a week or longer. An amitriptyline level was ordered and was drawn 12 days after the patient’s initial presentation to the office. It was elevated to toxic levels. (See Figure 1). Nineteen days after the patient’s initial presentation (ten days after her last amitriptyline dose) she reported continued blurry vision, dry mouth, and urinary retention. Her vital signs included a HR of 120 BPM and weight of 72.6kg. An EKG demonstrated sinus tachycardia, without other signs of cardiac toxicity. The patient was instructed to abstain from amitriptyline permanently and follow up in a week. Twenty-three days after her initial presentation, the patient reported resolution of blurry vision, xerostomia, and constipation but had continued shortness of breath. Her vital signs were normal and her weight was 71.2kg. Amitriptyline levels remained elevated. One month after her initial visit for constipation and weight gain the patient had no complaints with the exception of mild shortness of breath. An EKG demonstrated sinus tachycardia with a HR of 112 BPM, and a chest X-ray was normal. A final amitriptyline level was ordered but unfortunately, the quantity of blood collected was not sufficient for analysis. As the patient was no longer symptomatic, this lab matter was not pursued. Eight weeks after her final visit, the patient reported taking only fluoxetine 40 mg daily as she had self-discontinued PEG and propranolol, her weight had decreased to 63.5 kg. We have discussed genetic testing for CYP2D6 and CYP2C19 polymorphisms with the patient to assist in future medication selection, and are awaiting insurance approval at time of publication.

overdose. We found just one similar case describing a 36 year old male taking both amitriptyline 150mg and fluoxetine 40mg daily for treatment of major depression. This individual died after six weeks of concomitant therapy and toxicological testing revealed only amitriptyline, fluoxetine and their metabolites in his body. Fluoxetine can inhibit CYP 450 2D6 thereby decreasing the elimination of amitriptyline. Investigators hypothesized the given dose of fluoxetine essentially increased the individual’s daily amitriptyline dose to 600-1050mg/day.3 TCAs are highly protein bound, have a large volume of distribution, and a high bioavailability. TCAs can have long elimination half-lives of 8-24 hours depending on level of tissue binding and rate of hepatic metabolism. Amitriptyline is a substrate for P-glycoprotein and is metabolized by CYP2D6 to an active metabolite, nortriptyline, which extends the activity of the medication as well as increases the risk for toxicity. These pharmacokinetic parameters substantially increase the number of medications that may interact with amitriptyline.4-6,8 Two common genetic polymorphisms involving CYP2D6 and CYP2C19 affect the safety and the efficacy of TCAs. These enzymes have a significant role in the metabolism of antidepressants, antipsychotics, betaadrenergic blockers and anti-arrhythmic drugs. These polymorphisms can lead to decreased elimination of the drug or alterations in the parent drug – to-active-metabolite ratio. Those that are known poor CYP2D6 metabolizers should consider alternate therapy to amitriptyline or a significant dose reduction to reduce possible toxicity.4,5 continued on page 10> FIGURE 1

Discussion: On review of the literature, we found numerous cases of amitriptyline toxicity through intentional overdose or toxicity following larger doses than therapeutically necessary. We were unable to find a report that paralleled the characteristics of our patient: a black adult female with unintentional Missouri Family Physician January-March 2015

MAFP Resident Grand Rounds continued from page 9>

There is no well-defined breakpoint for TCA toxicity in patients. A single article published in 2007 defined supra-therapeutic levels for amitriptyline as >250 mcg/ mL. 9 Based on this threshold, our patient had toxic levels of amitriptyline 108 hours after her last dose of the medication. Our patient experienced constipation, blurry vision, urinary retention, and tachycardia with low initial doses of amitriptyline and these symptoms worsened in temporal relation to increasing doses of the amitriptyline, all within accepted therapeutic dosing levels. In retrospect, it is clear her symptoms were consistent with amitriptyline toxicity. In this case, identification of this adverse drug event (ADE) was complicated by frequent patient visits to the emergency department, the introduction of multiple providers, polypharmacy, and the relatively young age of the patient. It is not current standard of practice to measure amitriptyline levels when anticholinergic symptoms appear during treatment with TCAs. In this case, the patient’s symptoms were most consistent with amitriptyline toxicity and therefore the medication was discontinued prior to the patient having drug levels drawn. The association of the patient’s symptoms and amitriptyline as a root cause was strengthened when toxic blood levels of the drug were found 5 days after its discontinuation. In fact, the patient was still having symptoms nearly two weeks after stopping the medication, and her amitriptyline levels were still elevated, though no longer toxic. The patient’s tachycardia and blurry vision finally resolved 19 days after stopping the medication, unfortunately, the amitriptyline level we drew at that time was inconclusive due to lab error. A rechallenge with amitriptyline did not seem necessary and also seemed imprudent in this scenario. Using the Naranjo adverse drug reaction probability scale, this adverse drug reaction to amitriptyline was assigned a definite classification (see Table 1). Conclusion: Amitriptyline adverse reactions are common but documentation of toxicity while using standard dosing patterns in adults are exceedingly rare in the current literature. Toxic levels of amitriptyline can be life threatening and therefore recognition of the symptoms of TCA toxicity and prompt response is vital. Primary care clinicians should be aware of the side effects, drug interactions, and potential pharmacogenetic implications of amitriptyline and exercise extreme caution with its use.

References:

1. Mowry J, Spyker D, Cantilena L, et al. 2012 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 30th Annual Report. Clinical Toxicology. 2013;51: 949–1229. 2. Kerr GW, McGuffie AC, and Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J. 2001;18:23641. 3. Preskorn S and Baker B. Fatality associated with combined fluoxetine-amitriptyline therapy. JAMA. 1997;277(21):1682. 4. Hicks J, Swen J, Thorn C, et al. Clinical pharmacogenetics implementation consortium guideline for CYP2D6 and CYP2C19 genotypes and dosing of tricyclic antidepressants. Clin Phamacol Ther. 2013;93(5):402-8. 5. Poolsup N, Li Wan Po A, Knight T. Pharmacogenetics and psychopharmacotherapy. J Clin Pharm Ther. 2000;25(3):197200. 6. Uhr M, et al. Blood-brain barrier penetration and pharmacokinetics of amitriptyline and its metabolites in p-glycoprotein knock-out mice and controls. Journal of Psychiatric Research. 2007; 179-188. 7. Amsterdam J, et al. The Clinical Application of Tricyclic Antidepressant Pharmacokinetics and Plasma Levels. Am. J. Psychiatry. 1980; 137: 6. 8. Bae S.K, et al. Pharmacokinetics of Amitriptyline and One of Its Metabolites, Nortriptyline, in Rats: Little Contribution of Considerable Hepatic First-Pass Effect to Low Bioavailability of Amitriptyline Due to Great Intestinal First-Pass Effect. J. Pharmaceutical Sciences. 2009 (98): 1587-1601. 9. Melanson S.E.F, et al. Interpreting Tricylic Antidepressant Measurements in Urine in an Emergency Department Setting: Comparison of Two Qualitative Point of Care Urine Tricyclic Antidepressant Drug Immunoassays with Quantitative Serum Chromatographic Analysis. J. Analytical Toxicology. 2007(31).

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10 Missouri Family Physician January-March 2015

recognizing the value of family medicine

uring the 2014 AAFP Assembly in Washington, AAFP President Robert Wergin, M.D., gave assembly-goers their first glimpse of a three-year communications campaign being launched by the AAFP and its seven family medicine sister organizations. "Health Is Primary" will use advertising, news media, online communications, partnerships and other outreach efforts to rally patients, employers, policymakers and other local stakeholders across the country to recognize and support the value of family medicine and primary care. In conjunction with the communications campaign, the eight groups -- which together have formed a new organization known as Family Medicine for America's Health, will also execute a five-year strategic implementation plan that seeks to do no less than transform the U.S. health care system -- a goal that will require family physicians to work alongside their primary care colleagues, patients, policymakers and other key players in the health care arena. Former AAFP President Glen Stream, MD, MBI, is board chair of Family Medicine for America's Health.

GET MORE FACE TIME WHERE HEALTH IS PRIMARY. Health improves when doctors and patients spend time together. Family doctors make it a priority to stay connected to their patients. We want everyone to have a trusted primary care physician who is there when they need them.

Let’s make health primary in America. Learn more at healthisprimary.org. Brought to you by America’s Family Physicians

#MakeHealthPrimary

HIGHLIGHTS

"It's time to put the health back in health care." -Glen Stream, MD, MBI Former AAFP President

•AAFP and its sister family medicine organizations have launched a threeyear communications campaign known as Health Is Primary.

•Together, the eight groups have formed a new organization called Family Medicine for America's Health.

•Health Is Primary and Family Medicine for America's Health will engage in a five-year strategic implementation plan to tackle issues such as payment reform to workforce development.

Missouri Family Physician January-March 2015

MAFP Advocacy Commission Report

change is all around us

Jamie Ulbrich, MD District 6 Director

ow! What an exciting time it is to be a family physician in the state of Missouri. As a first time attendee to the AAFP State Legislative Conference held November 14-15, 2014 in New Orleans, Louisiana, I can tell you there are a lot of things happening in advocacy at both the state and federal levels - but the recurring theme is CHANGE! Topics included discussions regarding retail clinic challenges, combating prescription drug abuse with prescription drug monitoring programs, and collaborating with community and law enforcement agencies. Tara Koslov, Deputy Director, Office of Policy Planning, from the Federal Trade Commission (FTC) spoke about scope of practice issues and restricting competition from the perspective of the FTC. A political analyst from Cook Political Report dissected the 2014 mid-term election results and gave us a unique perspective on how these results could impact us both at the state and national levels in the upcoming months.

From left: Keith Ratcliff, MD; Pat Strader; Jamie Ulbrich, MD; and Kathy Pabst.

One of the “hot button” topics emerging is the Direct Primary Care (DPC) model. This alternative to fee-for-service model differs by charging a monthly fee that covers most of the primary care services. Talk about an exciting option for family physicians. A way to care for patients without the burdens and inefficiencies inherent in our current system, I believe this will continue to gain momentum in the coming years.

12 Missouri Family Physician January-March 2015

Ask not what your Advocacy Commission can do for you, but what you can do to advocate for your patients and profession in Jefferson City.” Lastly, how to succeed as a state chapter in advocacy was discussed. We are very blessed to have a great team of professionals at the MAFP working tirelessly to make our voices heard and stay on top of various issues that come our way during the year, not just during the legislative session. We are currently building on our past successes and learning how the Advocacy Commission can do a better job representing and serving the members of the MAFP. Conferences such as this allow us to understand where we are compared to other states and help give us direction on how to approach various legislative issues. When we talk to various legislators in Jefferson City, the recurring theme is how rare it is to hear from their physician constituents. I can tell you that the greatest asset we have as an Academy is you, the practicing doctor in the “trenches” taking care of patients on a daily basis. I would ask if I can borrow and paraphrase one of President John F. Kennedy’s famous quotes, “Ask not what your Advocacy Commission can do for you, but what you can do to advocate for your patients and profession in Jefferson City.” Please join us on February 24, 2015 in Jefferson City for Advocacy Day. We will have Advocacy 101 and a legislative briefing presented the evening before by our MAFP Lobbyist, Pat Strader, as well as a morning primer. This will be a great time to hear what we will be working on this legislative session, visit with your legislators if you have not already done so, and have a chance to hang out with physicians who share the same passion - to take great care of patients; and see how we can help to achieve this through the legislative process.

Legislation MAFP

capitol commentary

he 2015 Missouri legislative session opens Wednesday, January 7th. The Missouri General Assembly will swear in a large number of newly-elected legislators. This means we have to work harder to connect our physicians with their respective senator and state representative so they may introduce themselves as an important resource on health care policy and issues. Freshmen legislators may be new to the process and unfamiliar with our issues. We want to make them welcome and offer our support. Each year at MAFP’s Fall Conference, the Advocacy Commission and Board set legislative priorities for the upcoming session. Unfortunately, at that time we do not know the subjects of all bills that will be filed in the next session. This means the Advocacy Commission and Board must be flexible and ready to address issues and deal with them when a position has not yet been developed. Most importantly, they want to hear from you – the members – as positions are developed. I encourage you to read my Friday legislative reports that are made available through the “Show Me State Updates” and email me with your thoughts and comments. On average about 2,000 bills will be filed this session. As your legislative consultant, I thoroughly review all measures, track a large number of bills on MAFP’s behalf and regularly update the priority bills filed in a format we call “Tier I” and “Tier II” bills for publication on the MAFP website. My goal is to make this process as easy as I can for physicians with limited time to review bills of importance and provide us with feedback on measures we need to support, oppose or amend. Educating your lobbyist and staff on the issues is extremely important. Please share when you have expertise or an interest in a particular area. MAFP continues to work collaboratively with other coalitions and organizations. We encourage you to volunteer to testify on MAFP’s behalf at hearings before the House and Senate, to serve on statewide boards and commissions, or on specific advisory councils as they become available.

For 2015, here are some of the issues MAFP will be addressing on behalf of physicians and their patients:

Pat Strader Strader & Associates, MAFP Legislative consultant

• Tort Reform Repair – Reinstating a reasonable cap on non-economic damages in medical malpractice cases; • Direct Primary Care – Including provisions in Missouri statutes to encourage and not inhibit this health care delivery model; • Promoting the importance of primary care; stressing the concept that a true medical home is best met by a relationship between the patient and their family physician and medical team; • Adopt legislation to create a prescription drug monitoring program for Missouri (PDMP); • Medicaid Transformation/Expansion – Encourage legislators and leaders to have a thorough, thoughtful discussion about addressing the coverage for working, low-income Missourians; • Monitor all scope of practice legislation; • Support measures that encourage healthy behaviors; • Promote state funding for “Enhanced Primary Care Reimbursement” as Congress failed to address the continuation of this funding beyond December 14, 2014, and left it to the states. • Promote funding for loan repayment programs for family physicians and funding for the PRIMO Program.

Missouri Family Physician January-March 2015

MEMBERS IN THE NEWS

meet the potts: a true love story Dr. Don Potts and his wife Barbara, of Independence, Missouri, were featured in the Kansas City Star which highlighted how their college friendship turned into 61 years of marriage. In September of 1949, Don met Barbara Elledge while working for their college newspaper. After graduating, Don moved back to his home in New York, working as a bricklayer while trying to save money for medical school. Barbara moved back to her home in Independence and became an x-ray technician. When the New York brick layers went on strike, Don and a friend moved to Kansas City. In the winter of 1951, Don and Barbara were reunited when they met at a local church while singing in choir. Realizing they were in love, Don borrowed money from his sister and bought a ring. On

News to share?

FRED BLOCHER THE KANSAS CITY STAR

December 31, 1952, Don proposed. Six months later he was drafted. In December 1953, while Don was home on leave, the two were married. To read the full story of Don and Barbara visit: www.kansascity.com/living/star-magazine/lovestory.

meet your new mafp board members

The Missouri Family Physician magazine welcomes your input. Send us your "Members in the News" information you would like to share. Please submit newsworthy items for review to: office@mo-afp.org

missouri

chapter

necrology

report

Patricia Benoist, MD District 9 Director Houston Mercy Clinics

Kevin Gray, MD Alternate Resident Director UMKC

Sudeep Ross, MD District 7 Director Kansas City Samuel U. Rodgers Health Center

Lucas Buffaloe, MD District 5 Director Columbia University of Missouri

Wael Mourad, MD District 7 Director Lees Summit Truman Medical Center

Jennifer Scheer, MD District 4 Director Gerald Mercy Clinics

Jared Dirks, MD District 1 Alternate Director Concentra (KC Market)

Afsheen Patel, MD District 5 Alternate Director Jefferson City JCMG

Kristin Weidle, MD District 4 Alternate Director Washington Mercy Clinics

Jenny Eichhorn, MD Alternate Student Director UMKC

Carrie Peecher, DO District 2 Alternate Director Unionville Putnam County Memorial Hospital

IN MEMORIUM James D. Humphrey Harold D. Lankford

14 Missouri Family Physician January-March 2015

Luis A. Reyes Terrance E. Van Buskirk

"dr. tommy" takes a jouney back to normandy

I'm going home to attend medical school. I've done all the killing I'm going to do. I want to start saving lives."

-Tommy Macdonnell , MD

NBC NEWS

r. Macdonnell, 91 years old, and a faithful MAFP member since 1957, was recently featured on NBC News with Brian Williams. On the 70th anniversary of D-Day, Macdonnell, accompanied by two generations of family members by his side and four other veterans, made their way back to Normandy. For Macdonnell, the reason for the visit was simple, "I want my boys to see where it all happened," he said. Macdonnell attended Drury College and Southwest Missouri State University before earning his Bachelor of Science degree in Medicine from the University of Missouri-Columbia and his Doctor of Medicine from Indiana University. In 1942, Macdonnell enlisted in the Army Reserve and served until 1945. He was a sharpshooter with the 1st Infantry Division and was a part of the initial assault force of the Division on Omaha Beach in Normandy, France on D-Day, June 6, 1944. He was awarded the silver star, two purple heart awards, and five bronze battle stars. After receiving these awards, Macdonnell stated, "I'm going home to attend medical school. I've done all the killing I'm going to do. I want to start saving lives." In 1950, Macdonnell received his medical degree and began his residency in obstetrics and pediatrics at Kansas City General Hospital. Dr. Macdonnell returned to Marshfield with his wife, Ann, to practice medicine with his father. He also served in the state legislature representing his constituents and the interests of the Academy. Tommy and Ann have eight children together - Sally Ann, Patty Jane, Thomas, Carey, Jenalee, Nancy, John, Jeremy, and many grandchildren. Bruce Preston, MD, fellow member of the Missouri Academy of Family Physicians, shared the following: "Tommy Macdonnell is one of the

Tommy is a true example of a real hero." -Bruce Preston, MD

finest examples of The Greatest Generation you could ever hope to meet. His mind is still sharp as a tack and he has no trouble recalling his heroic past and exploits. I always thoroughly enjoy spending time with Tommy and listening to his stories. Tommy is a true example of a real hero. After risking his life in WWII, including landing in Normandy at Omaha Beach on D-Day and being wounded on more than one occasion, he decided heâ&#x20AC;&#x2122;d seen enough killing and wanted to save lives for a change. So he went to medical school and became a doctor. But even that wasnâ&#x20AC;&#x2122;t enough for Tommy. He later served in the state legislature. Tommy is a true man for the ages. Anyone lucky enough to meet Tommy will never forget him."

Watch the Journey Back to Normandy www.nbcnews.com/watch/dateline/ journey-to-normandy

Missouri Family Physician January-March 2015

mafp hosts successful conference at big cedar

M 22ndannual fall conference

AFP's Annual Fall Conference, held November 7-8 at Big Cedar Lodge in Ridgedale, Missouri was a success this year with more than 170 registered guests. The Annual Fall Conference is the largest Missouri Academy gathering of primary care physicians and exhibitors. Over 14 CME credits were offered, AAFP Chapter Lecture Series were presented, the Board of Directors and other commissions met, and a SAM Working Group was held. The exhibit area featured companies offering pharmaceutical and non-pharmaceutical products and services for the medical community.

save the date

annual fall conference big cedar lodge november 6-7, 2015

4 2

1. Emily Mebruer, MD, Allison Heider, MD and Lori MacPherson, MD take time to pose while visiting the exhibit hall; 2. William Rosen, MD talks to Deatrice Kellogg, MD; 3. Michael LeFevre, MD visits with a registrant; 4. Kerry Vance, MD, David Afshar, MD and Rodger Campbell, MD take a break between speakers; 5. Don Wagman, U.S. Army Healthcare Recruiting poses with Flora Kayakone, left, and Janine Smith with Docs Who Care; 6. Robert Shaw, MD and Curtis Dyer, MD.

16 Missouri Family Physician January-March 2015

I could listen to Dr. Weismiller all day. He is awesome.â&#x20AC;?

-Allison Heider, MD

I enjoy meeting physicians whose offices I've called on but never met.â&#x20AC;?

-Ramona Lindsey, RN

7. Mark Woods, MD donates to the FHFM raffle at the MAFP booth with Pat Strader, Governmental Consultant and Kathy Pabst, MAFP Executive Director; 8. Steve Ruzic from Eli Lilly visits with a registrant; 9. Don Wagman, U.S. Army Healthcare Recruiting and Jeff Owens, Missouri Army National Guard; 10. Ramona Lindsey, Children's Mercy - Kansas City, talks with Charles Rasmussen, MD; 11. Tom McNeill and John Kortum, Keane Insurance Group, Inc. visit with James Hawk, MD; 12. Scott Moore, ThermoFisher talks with Traci French; 13. Peter Koopman, MD talks with Donna Shelby of Citizens Memorial Hospital. Missouri Family Physician January-March 2015

MAFP

dr. jonathan privett gives back

22ndannual fall conference

onathan Privett, MD, was the winner of the Family Health Foundation of Missouri (FHFM) 50/50 raffle held at Big Cedar during the 2014 Annual Fall Conference. Dr. Privett purchased $150 in tickets. Privett won $790 from the raffle and chose to donate it back to FHFM for a total of $940. When asked about his donation, Dr. Privett replied, "I have always enjoyed the conference at Big Cedar. I donated the money to the FHFM because I remember being a poor resident with a wife, small children and having little money. We appreciated all the help we could get. I'm passing on the aid we received to others who need it." Thank you Dr. Privett. Your commitment to family medicine through your donation and participation helps FHFM reach more students and residents through the many outreach programs.

Dr. Jonathan Privett practices in Piedmont, Missouri

I donated the money to the FHFM because I remember being a poor resident with a wife, small children and having little money. We appreciated all the help we could get. I'm passing on the aid we received to others who need it.”

-Jonathan Privett, MD

improving the health of missouri families

What is Family Health Foundation of Missouri?

Founded in 1988 by the Missouri Academy of Family Physicians as its philanthropic arm, the Family Health Foundation of Missouri, (FHFM) is dedicated to improving the health of Missouri families by supporting scientific, educational, and charitable activities through the field of Family Medicine.

18 Missouri Family Physician January-March 2015

Visit www.mo-afp.org/foundation

Your generous donation supports the following: •Sponsor students to attend the MAFP Annual Scientific Assembly (ASA) each June. •Scholarship to NCFMRS each year (1 Resident and 1 Student) rotating schedule. •Scholarship for Top Student from Medical School entering Family Medicine. •Summer Externship Scholarship(s). •Tar Wars ® Program.

MAFP

thank you to our supporters The Missouri Academy wishes to recognize the following exhibitors and speakers who supported the MAFP at the 22nd Annual Fall Conference:

EXHIBITORS

SPEAKERS

Anthem Blue Cross Blue Shield Lucas Buffaloe, MD, Columbia, MO Astellas Pharma, U.S. Urology Division Roger Cady, MD, Kansas City, MO Citizens Memorial Hospital Kathryn Diemer, MD, St. Louis, MO Children's Mercy-Kansas City Katherine Galluzzi, DO, CMD, FACOFP, Docs Who Care Philadelphia, PA Eli Lilly Silvio Inzucchi, MD, New Haven, CT Freeman Health System Michael LeFevre, MD, Columbia, MO Fresenius Medical Care North America Kenneth Lichtenstein, MD, Denver, CO Genzyme a Company of Sanofi Charles Sincox, MD, Washington, MO Healthlink Jim Stevermer, MD, Columbia, MO Home State Health Mark Suenram, MD, Kansas City, MO MSMA Insurance Agency, Inc. Belinda Vail, MD, FAAFP, Kansas City, KS Medtronic: Deep Brain Stimulation David Weismiller, ScM, MD, FAAFP, Greenville, NC Merck & Co, Inc. Mercy Clinic Missouri Army National Guard Missouri Care Missouri Health Professional Placement Services Missouri Professionals Mutual MoDocs Novo Nordisk St. Anthony's Medical Center St. Jude Children's Research Hospital Salem District Memorial Hospital Silver Creek Medical Takeda Pharmaceuticals The Keane Insurance Group ThermoFisher Scientific U.S. Army Healthcare Recruiting U.S. Navy Officer Medical Programs Missouri Family Physician January-March 2015

MAFP 2015 Advocacy Day

advocacy day february 24, 2015 state capitol jefferson city

be the voice of missouri family physicians

This year’s Advocacy Day will be held in conjunction with the White Coat Day at the Capitol.

Monday, February 23, 2015 • 6:30 – 8:30 pm Detailed legislative briefing • Capital Plaza Hotel Tuesday, February 24, 2015 • 8:00 am – 2 pm Legislative briefing and breakfast • Capital Plaza Hotel Visit legislators’ offices (appointments to be scheduled for you by MAFP staff) Board of Directors Meeting (with working lunch/dinner) • 2:30 – 5 pm *Limited complimentary lodging available on a first-come, first-served basis for those attending the Monday evening briefing.

www.mo-afp.org • email: office@mo-afp.org • 573.635.0830

Master ICD-10 with AAFP’s Coding Toolkit Your practice depends on accurate coding to get paid for the services it provides. Enter AAFP’s “Coding Toolkit.” Designed to make precision part of your process, the toolkit combines the AAFP’s ICD-10 Educational Series with the popular ICD-10 Flashcards to help you maintain, or even improve, coding accuracy amidst the impending ICD-10 transition

ICD-10 Educational Series AAFP Member: $249

ICD-10

Non-member: $349

The AAFP’s family medicine-specific on-demand ICD-10 Educational Series uses 11 voice-guided PowerPoint modules to walk you through the impending ICD-10 transition and help you make sure your practice is properly compensated.

Educational Series

Attorney and professional coder Richelle Beckman guides you through this online ISBN 978-1-940373-04-1 coding resource, which focuses on the top 50 diagnosis codes in primary care to help you gain an in-depth understanding of how ICD-9 differs from ICD-10. Each 10- to 20-minute module can be viewed individually or with your practice team, on-demand as your schedule allows. You’ll learn the financial impact of the changes called for in ICD-10, as well as the specifics behind coding issues such as hypertension, routine visits, respiratory conditions, mental disorders, and more.

ICD-10 ICD-10 ICD-9 Region ICD-9DESCRIPTION K59.00 ICD-9 A60.04 DESCRIPTION UNSPECIFIED LEFT 278.00 Obesity,K59.01 ICD- RIGHT ICD-9 DESCRIPTION 843.9 Unspecified A63.0 sprains of unspecified DESCRIPTION9 unspeci314.0 hip 0 Attent S73.109– vulvovaginitis fied 681. S73.101– S73.102– ICD ionB37.3 054.11 Herpetic Strain of muscle, Other K59.02 deficit disord 00 acuminatum) DESCRIPTI -9 fascia,obesity and tendon 314.0 the hip due S76.019– toof1excess ified Anogenital warts (condyloma 278.01 Morbid erS76.011– Attent without S76.012– DESCRIP 493ON 078.11 calories ICD-10 Strain of quadriceps , unspec A56.2 K59.09 muscle, .00 (severe) fascia,obesity Cellulitis and tendon ion deficit TION S76.119– on of vulva and vagina disorder S76.111– menti Constipation ICD hyperactivit due excess Attent ation Candidiasis of andExtrinsi 564.00 -9 with hyper S76.112– unspecified 112.1 Drug-ind Strain 493 tract,adductor A53.9 muscle, uced constip fascia,obesity and tendon toion-de c asthE66.9 26 y ess ficitcalories activity Acute.10lympIntri absc infection of genitourinaryof thigh hyper Use 278.03 Morbid ation Slow transit ICD-10 ma, of 9.9 Attention-deS76.219– constipChlamydial addS76.211– finge E66.09 099.55 493 hang nsic 564.01 uns A59.03 activit y disord S76.212– ction r 28 asth pecified Nu DESRIGH Drugsobesity ficit er, predo .90 Uns itis of(severe) 681. activititional cod ofma, hyper Outlet dysfun 097.9 Syphilis, Unspecified Strain278.02 finge with tritF90.0 of Table muscle, fascia,ghtand tendon of Attent T unsr pec 0.0 ionalCRIPTI e (B9minantly inatte pecified E66.01 the alveolar TIP 564.02 A60.9 10 Cellu y disord ion-deficithypoven ation n of the Overwei Iron 5-B Mild tilation litis and 28ified posterior defi ON er, predo S76.319– ntiveasth muscle hyperactivit group at thigh R19.7 S76.311– Other constip 131.02 Trichomonal urethritisse effects colum level Attent S76.312– type Other defi L03.011ciency LEFT UNS minan97) TIP 0.8 E66.1 tointe ma, obesity (endocr 564.09 y disord iden ion-deficit N34.1 ciency te lymper, abscess tly hyper 682.3 Acu uncomp Oth rmittify L03 PEC the adver 28 StrainV77.8 ,L03 unspecified of otherScreenin 799.51fascia, uns ine, endogen specified muscles, ofMild active herpes, see hyper comb tentinfe 1.0 er spe hang toe n, Genital and Cellulitis type pec L03 DESC activit F90.0 .021anemiaL03 .012 054.10 K52.9Attention ous) asth ctious lica itisined type persiste E66.2 yS76.811– tendons ifie of toe S76.819– disordofer,axillS76.812– cified constipatio 26ma, agePerted level g for obesity and conce al urethritis, unspecified 783.1at thigh sec.022 d .019 RIPTIO nt asth induced 099.40 Other nongonococc E66.3 6.2 unc nt nic iron a type Moderat ntratioAcu iouF90.1 ond L03.029 te lymp other omp al weight gainA09 whe N TIP Abnormsprain 843.0 Iliofemoral n deficit For drug- icals. ma, s rep defi ary e pers 281.9unc Deficilica 783.21 ligament of hip iveness of a condition hangitis ICD-10 Code Cuta tedn ane S73.119– to Sev Loss mia ortin ciency Chem S73.111– E66.8 omp iste s within neous 493S73.112– and weight andofnonrespons 843.1 Ischiocapsular when lica encyF90.2 (Vigtam codes ane blood los resistance (ligament) L03 categories abscess.02of axilla ere persiste nt28asth of oth 783.22 Underw sprain ofK59.1 drug Cellu S73.121– hip resistance 2.5 ma, Unspeted .031 S73.129– Diarrhea mia for any associated Z13.89 s (ch does not identify K52.2 S73.122– axillExtr F90 throulitis TIP code 493.12 uncompcifiedL03 787.91 843.8 Other sprain of uppe a additional code F90.8 er spe L03in B12 L00-L0s8. a insic asth nt asth Use of hip eight 282.6ma, Sic ronic) diarrhe (Z16.–) if the infection gh F98 cifi .032 due kle lica defi.041 r limb S73.199–Acute lymp drugs l Chronic S73.191– Intr R63.5 ma cie 1 unc S73.192– cell R41.8 ted ncy L03ed B L03to.039 493may to antimicrobia insic 844.9 B99.9. 558.9 with Unspecified intrins 282.6(acu Sicomp Cutaneou hang traL03 .92 be used diarrhea 40 Code firstsprain of knee asth licated ane .042group 682 it .111 S83.90X– codes A00.0 through J45.90 S83.91X– itis of uppe R63.4 Unspec regar . Infectious reporting madless .4 2 te) kle cel obesity L03.049 ic fac mia ICD L03 lvovaginitis 517 with Sprain complicating of knee 682 TIP Cutaneou s abscess S83.92X– 9 of unspecified 009.2 l disL03.121 r limb (O99.2 .112(nu vita tor defi J45 min Vaginitis-Vu of the Sicexa -10 ified .3 diarrhea (acu 1-) when collateral ligament kle cerbatio codes is andatcolitis S83.409– eas of .6 s age S83.401– trit pregna asth s R63.6 uppe Mild S83.402– enterit te) (fo Functional See additional reporti absc cel L02 L03 e of 282.6 ional) N30.00 cie .20 ncy, childbi 844.1 Sprain Cellu E63.9 n .411wit gastro exacerb al cris r limb ma late ng codes of medial patie inte Use additio ess of 564.5 collateral ligament TIP 02). ofK52.89 knee nt. houtL02 .122 rth of , Vit J45ncy) 2 S83.419– litis from catego and and dietetic is wit hand rmittent 289.5with 1-Z91.nal S83.411– ationL03 the S83.412– lowe code Mild amin .30 AcuN30.01 cris.412 595.0 Acute cystitis puerpe Allergic Sicte) 844.0 (Z91.0 or D50.0 (includes asth 2 (acu ry .113h y Sprain r limb sixth of charac E66. lateral collateralfor te lymp adversofeknee rium, pers kleexa is hematuria ligament 558.3 B12 effect, S83.429– A08.4 if applica isteifntapplica ter 5) when cellcerb L03.123 acuteL03 food allerg S83.421– hangitis Mod J45.40 282.6 ma finge Acute cystitis ofwithout ) S83.422– Cuta with ble, che .114 844.2 Use type D50.8 crisation ed additio Sprain asth rs) 682 reportiofng neousto fy of unspecified cruciate ligament ble, st syn is wit with hematuria loweerat knee nal code identifyofdrug e pers 28 ma2withSic (acute) exa L02 code.7 S83.509– to identi absc other specifi L03.124 S83.501– Cutaneou Acute cystitiscolitis, J45.50 r limb to identify ess SevS83.502– h spl N30.10493 drome 844.8 categoryanterior 682.0 E66.1. iste 4.19 kle D51.0 onal code cerb .413 (acu is and ere(T36-T E66. ligament of cystitis Sprain of knee body mass s absc cell with ation enicL02.414 te) asthmaOth .01 of lowe pers 5028nt S83.519– Use additi CellulitisN30.11 S83.511– r limb gastroenterit Chronic interstitial criscerbL02.511 S83.512– ess K58.0 index ed 844.2 V85.21 istent 5.1 fifth seq 595.1 (BMI),493 E53.8 er pan exa Sprain ofhematuria ofExtr is, uns without posterior BMI ues cruciate ligament of knee Noninfective footinsi ise specifi (chronic) if known 25.0-25 asth Ac with L02.512 atio Acute of face (acucyt L03 S83.529– c asth .11 (incl tration .9, adult 558.9 .115 S83.521– (Z68.-) n Interstitial cystitis 844.3 V85.22hematuria 285.2 ma with S83.522– pec is, not otherw te)ope udes K58.9 lymphang ute when D53.9 matoes Sprain exa with ofBMI ifie L03 L02.519 superior tibiofibular joint and ligament reporti 493.91 Intrinsic L03 niacerb pos Viral enterit with 26.0-26 Cuta cystitis (chronic) me ) 1statAnng (acu S83.60X– .125 .116 itis of .9, adult S83.61X– asth 285.2 Interstitial themo 682 neous 008.8 ation d S83.62X– te) J45.90 V85.23 TIP a 844.8 em K57.30 .1 Ast ma D5 exa face us Sprain bowel syndro of from other e L02 absc L03 BMI 27.0-27.9 specified parts of knee reporting diarrhe ia in asth codes Cellu 7.3 cerb with2 1 Irritabl .126 ess of hmaS83.8X2– S83.8X9– me with agi.415 litis of matchr rrh S83.8X1– , adult atio g when 564.1 J45.21 a V85.24 c ane (B95-B97) 845.09 face , unspec285.29 statAn n L02 em bleedin us Strain Mild D57.1 K57.32 onicL02.611 neck agent ofBMI Achilles bowel syndro diarrhe s, ortendon AcuS86.019– Z68.25 asth ia in icus ified infectious 28.0-28 te lymp Irritable without to identify kidney mia (ac .416 .9, adult S86.011–inteS86.012– tion, absces typeAnem mat rmittent neo g V85.25 J45.31 icuspla syndrome code N34.1 Strain , with ofBMI Cutaneou hang Use muscle(s) ute and tendon(s) of anterior boweladditional Z68.26 ia of diseasL02.612 itis ofMild pers s, or bleedin without perfora D57.0 29.0-29 682.2 K57.10 stic bloL02 Irritable category N30. .9, adult g neck istentCodeasthma with stat intestine s abscN34.2 other tion, absces dis V85.30 muscle us od los S86.219– e 1 group at lower J45.41 Cellulitis .619 leg level of large Mod bleedin essS86.211– BMI t perfora K57.12 Z68.27 asth asth firs s, or chroni ease 30.0-30 of neck erate S86.212– e withou V85.31 of trun .9, adult g L03.211s) absces Diverticulosis t ne status asth mat Urethritis, icus Straintion, intestinunspecified of sal) other persCode ma with 597.80 c J45.51 muscle(s) D57.0 and tendon(s) at Cuta 562.10 Severe op neous493 k N34.3 of large t perfora BMI Z68.28 K57.50 31.0-31. or bleedin maticus diseas (eg, postmenopau L03.212 e withou Coistent first un statuslasasth urethritis 2 absc lowertion, leg absces Other intestin .81essN39.0 level s,9, adult pers S86.812– Diverticulitis e m mat bleeding Cellu S86.819– S86.811– V85.32 597.89of small (C00 istentde firsasthma deZ68.29 562.11 litis of BMI 32.0-32 tion, abscess, or of abdo unspecified t perfora K57.52 icus-D D57.0 493abdo Exe rlying L02.01 rciseminasyphil syndrome, 845.00 asth t un with withou Strain of unspecified status Diverticulosis muscle and t perfora.9, adult V85.33 indul wall is 597.81 Urethral ma with bleedingatAcute lymp .82 mina 49 0 intestine specified withou de Z68.30 s, ortendon chasth BMI enot site 562.00 ced (A5 L03.221 wall of small tract infection, D61.8 hangitis CoulS86.911– ronmat ) when lower intestin leg 33.0-33.9, gh CutaneouS86.919– tion, absces stating 5.3bronch 2.7 rly TIP vari 28S86.912– and largeV85.34 BMI level 599.0 Urinary Diverticulitis us dis 18 t perforaTIPadult icus ofN39.0. 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MAFP Member Services Commission Report

why do i do this?

ave you ever had one of “those” days? The kind of day where you want to throw your hands up in the air and walk away, leave, scream or just quit. This is the section of the magazine where we like to keep you up to date with the latest and greatest in family medicine or give helpful hints of how to use MAFP resources or announce upcoming events. However, sometimes we need the reminder of why we do what we do.

Kathleen EubanksMeng, DO MAFP Vice President and Member Services Commission cochair

We take care of the whole person, mind, body, and spirit. We take care of grandma, grandpa, mom, dad, brother, sister, daughter, aunt, uncle, cousins, the family.”

I have had several of “those” days described above where it did not seem that what I was doing was going to be the right thing for me or for the patient I was seeing. “Those” days where everyone needed a piece of me and I did not know how many pieces of me were left to give. I have had the opportunity to be a clinical preceptor for students in the Kansas City area over the last several years. They come to me at some point in the traditional third year of medical school to see what “private” practice in family medicine is like. I assure you, it is nothing like the former TV show. They come naïve to what family medicine is, the amount of knowledge we use on a daily basis, the variety of diseases and people that are seen on a daily basis, and the unique opportunity we have to care for the complete person. After working for what seemed to be 24 hours, in reality it was likely 10, the “last” patient of the day was ready to be seen. We will call her “Jane.” After viewing Jane with a fresh set of eyes and

22 Missouri Family Physician January-March 2015

reviewing the medical part of the visit with my student, I was presented with a small gift of thanks from Jane. It was a small necklace she had made similar to one that I had commented on months before. I graciously thanked her and we “wrapped” up the day. The student, much to my surprise, was tearful and surprised by the interactions of the day, but most distinctly by Jane. She had never seen a physician be thanked for what they do. Often, in the setting where she trained, there had been very little thank yous and not many kind words. My student had witnessed not only the medicine side of what we do, but also the relationship side of what we do. “People just don’t do that anymore.” Yet, in family medicine, not in my every day, but many days, they do. It may be a smile, asking for a hug, or just a quick glance and a smirk. It was an intangible, “non-book” lesson of why I went into family medicine. It challenges my brain and my heart. It is a balancing act of my family, their families, the business of medicine, the keeping up with the constantly evolving science of what we do. We take care of the whole person, mind, body, and spirit. We take care of grandma, grandpa, mom, dad, brother, sister, daughter, aunt, uncle, cousins, the family. It was a small necklace, but one that had been 10 years, cancer diagnoses, deaths, remarriages, births, and many other life happenings in the making. It was in that moment that reminded me what I do is an honor and a privilege. We take care of “the” family. Patients come to me humble, angry, proud, ready and unready to take care of themselves. While everyone may need a piece of me, the necklace and the medical student’s reaction was a unique opportunity that I needed to be reminded of the “why.” For those of you that like to read the beginning and the end and leave out the middle of the story, it is not about the necklace. The “why” of what we do is different for every physician, but I hope you are able to find your “why.” Please think about the gift of presence and of the unique opportunities you have each day to be the piece that someone needed.

congress of delegates meets in d.c. Summary: AAFP Congress of Delegates, Washington, D.C., October 2014 Larry A Rues, MD Delegate, AAFP Congress of Delegates Election Results unning for AAFP office at the national level is a major happening and the contestants and Academy spend considerable time and effort to helping us get to know and select our best leaders. There are complete bios of each candidate online, “meet the candidates” sessions at Congress as well as Competitive Q&A and the usual campaign speeches. This year we had six people running for three three-year slots on the Board of Directors, with a one-year remaining-term slot to be filled by the person in fourth place.

The Director winners: Mott Blair, MD of Wallace, North Carolina John Cullen, MD of Valdez, Alaska Lynne Lillie, MD of Woodbury, Minnesota Carl Olden, MD of Yakima, Washington (1 yr. term) Re-elected as Speaker: John Meigs Jr., MD of Centreville, Alabama Re-elected as Vice Speaker (contested this year): Javette Orgain, MD MPH of Chicago President Elect: Wanda Filer MD, MBA of York, Pennsylvania President: Robert Wergin, MD of Milford, Nebraska Chairman of the Board: Reid Blackwelder, MD of Kingsport, Tennessee Leader’s Comments and Direction of AAFP Our incoming president, aka “release the Bob” Wergin, is an outspoken advocate for the value of family medicine. Dr. Wergin’s message is that “the time is now for family physicians to take a leadership role in healthcare reform." We must practice evidence based medicine, and work with health insurance plans and government to assure fair financial incentives for high quality, costefficient care given by care teams led by family physicians. In exactly that spirit, the Future of Family Medicine 2.0 project began work last year. As a result, the Academy has launched a five-year strategy called “Health is Primary” which is led by the immediate past Board Chair, Glen Stream, MD, MBI, and an impressive work group for the “Family Medicine for America’s Health Campaign."

The Academy is putting a lot of eggs in this basket - $12 million to be exact, and that is supplemented by another $8 million combined from American Osteopathic Association, ABFP and the AAFP sister societies (STFM, AFMRD, etc). At the Health is Primary inaugural press conference, Don Berwick, MD past director of CMS, delineated the reasons that "someone" will step up to reign in healthcare costs. His fear is that, if it doesn’t happen from the inside (by physicians), it will be done by the government, insurance and the business sectors using blunt instruments like price controls, additional regulations and policies that will not be physician-friendly. Dr. Berwick notes that America cannot compete globally nor can we properly fund other societal needs when health care expenses are rising at three times the rate of inflation and eat up 60 percent of state budgets. It is not sustainable on any level. Therefore, we need to make genuine progress toward the “triple aim” of Better Health, Better Care and Lower Cost, the guideposts by which we will be judged.

Larry Rues, MD (left) and Bruce Preston, MD at Congress of Delegates.

Miss Priority ouri Resolut ions and Ou tcomes Page 2 5

Another speaker at the press conference, T.R. Reid referred to a remarkable statistic derived from the work of The Commonwealth Fund: If the USA traded places with the #2 most expensive country for health care (Sweden), over the last 10 years we would have $5.5 TRILLION in savings to fund other public needs, AND we would have had better health outcomes. We are 42nd in life expectancy and 11th in overall health care performance as compared to 11 other industrialized countries. Mr. Reid (a journalist) noted that in most other continued on page 24> countries, two out of three physicians are in Missouri Family Physician January-March 2015

continued from page 23>

primary care which is valued much more than in the USA. In England, generalists represent 64 percent of all physicians, and the average “GP” makes twice that of a CV surgeon! Like Barbara Starfield, MD of NIH, Mr. Reid’s study of healthcare systems worldwide showed that they MUST be based on good primary care if they hope to achieve the triple aim. Mr. Reid, too, applauded the Academy’s efforts and the Health is Primary campaign, but likewise warned that the physicians must personally be engaged and must also engage our patients toward better health in order to reform health care from the inside. If we want to be captains of the ship of Healthcare, we must lead like captains.

Models of delivery reform such as (true) ACO’s and other integrated care systems are starting to make headway in this respect. Yet the data shows that meaningful improvement occurs ONLY if Physicians are engaged in the decision-making at the highest levels of the system’s governance. And, there will not be single a nation-wide “solution” (thankfully perhaps). Rather, local health care delivery “experiments” will evolve and spread if successful. So, we must be involved in identifying our likeminded partners (and we will need help) and then lead the changes in both the health care delivery and the reimbursement models. Otherwise, the health care treadmill will run us faster and faster and with even less say in our future. So, what I learned from our leaders at the Congress of Delegates and at the ASA is that we are facing a monumental, but hopeful challenge: the time for primary care and especially family medicine MUST BE NOW, or perhaps never. I know you are all busy, but this is about the very reason that you are busy-- providing the bestpossible care to your patients. Individual physicians may wonder, "what can I do?" I suggest you start by looking at this website: www.healthisprimary.org and view the opening press conference and webinars there. Do so now, and sign up for future activities. The Family Medicine for America’s Health campaign (www.FMAhealth.org) is the best hope family medicine has to control the change that is here now - and that which will come. Every individual physician involvement is important because it is only we that actually deliver the healthcare people need. And so it follows that we must be involved in changing health care to be a better value for ALL in today’s America. Like all meaningful change, even well-planned Healthcare Reforms will be resisted by many; just let it not be resisted by us in primary care. We must strive not to be our own recalcitrant enemy. Family Medicine for America’s Health will help us LEAD the changes toward Better Health and Better Care at lower cost. And in so doing, I predict family medicine will achieve yet a fourth worthy aim- because Physician Practice Satisfaction will likely follow. Front Row (l to r): Larry Rues, MD; Bruce Preston, MD; Thank you for the honor of Kathy Pabst, MBA; Back Row: (l to r): Todd Shaffer, MD; Patrick representing Missouri Family Harr, MD; Julie Wood, MD; Keith Ratcliff, MD; Daniel Purdom, Physicians at the Congress of MD; David Barbe, MD. Delegates.

The time for primary care and especially family medicine MUST BE NOW, or perhaps never. I know you all are busy, but this is about the very reason that you are busy - providing the best-possible care to your patients.”

Daniel Purdom, MD, speaks to attendees during Congress of Delegates.

24 Missouri Family Physician January-March 2015

Congress of Delegates MAFP

congress of delegates - missouri priority resolutions For complete listings of all resolutions and summary of actions: http://www.aafp.org/about/governance/congress-delegates.html

Resolution Number Subject Action of Congress 203 AAFP History Preservation Adopted 206 Family Medicine â&#x20AC;&#x153;Physicianâ&#x20AC;? Not Adopted 305 Request the AAFP to Work with Insurers to Reduce the Administrative Burden for Medication Prior Authorization Adopted 403 Support of Ending Tobacco Sales in Pharmacies Adopted 406 End-of-Life Care Planning Substitute Adopted 408 Banning Non-therapeutic Antibiotic Use in Farm Animals Referred to Board of Directors 502 Promoting Nutritious Food Purchases in the Federal Supplemental Nutrition Assistance Program Referred to Board of Directors 506 E-Cigarettes to be Treated the Same as Tobacco Products Substitute Adopted as amended on the floor 509 Directing the AAFP to Include in its Advocacy Efforts the Development and Dissemination of Model State Legislation Substitute Adopted as amended on the floor 512 Rapid Diagnostic Testing (RDT) in the Community Pharmacy Referred to Board of Directors 609 Federal Insurance Mandate for Easily Accessible and Searchable Insurance Medication Formularies Referred to Board of Directors 610 Improving Use and Access to Managed Care Medication Formularies Referred to Board of Directors 611 Increasing the Number of Family Medicine Residency Positions Not Adopted

Missouri Family Physician January-March 2015

MAFP AAFP Residency Education Symposium

pdw and rps residency education symposium

Friday, March 27 - Tuesday, March 31, 2015

he AAFP’s Residency Education Symposium brings together the Program Directors Workshop (PDW) and Residency Program Solutions Conference (RPS) to offer members information, solutions, and inspiration for their entire residency program team. “PDW and RPS Residency Education Symposium." Connect with family medicine residency program professionals at the PDW and RPS Residency Education Symposium, March 28 through April 1 in Kansas City, Missouri. Please note that Residency Program Solutions (RPS) is before Program Directors Workshop (PDW) this year.

RPS: 1 pm Friday - 11:30 am Monday

•Program Leadership: Come a day before RPS to engage in programming designed for both you and your team.

PDW: 1:30 pm Saturday - 12 pm Tuesday

•Residency Team Members: Come a day before RPS to take advantage of special programs for administrators and nurses.

PDW and RPS Residency Education Symposium Sheraton Kansas City Hotel at Crown Center, Kansas City, MO

•Everyone: No matter which residency program role you represent, all are welcome to attend both PDW and RPS. Save $100 when you register for both PDW and RPS. Simply make your additional conference selection during the registration process. If you can’t join us for both events, register separately for RPS (Friday, March 27 through Monday, 30) or PDW (Saturday, March 28 through Tuesday, March 31). Take advantage of the opportunity to gain information, solutions, and inspiration for the whole team.

26 Missouri Family Physician January-March 2015

Tar Wars® MAFP

Today

more than 3,500 children will try their first cigarette. Stop kids from starting. Volunteer to be a Tar Wars presenter.

tar wars: help us win the war

he most visible Family Health Foundation of Missouri project is the Missouri Tar Wars program with a tobaccofree message for fourth and fifth-grade students. Tar Wars® is the only youth tobacco education program offered at this time by a medical specialty organization in the United States and reaches approximately 500,000 students annually. The program is implemented in classrooms across the U.S. and abroad by committed volunteer presenters such as family physicians, residents, medical students, school nurses, other health care professionals, educators, and community members. The mission of Tar Wars® is to educate students about being tobacco-free, provide them with the tools to make positive decisions regarding their health, and promote personal responsibility for their well being. By utilizing a communitybased approach to mobilize family physicians, educators, and other health care professionals, Tar Wars can accomplish its mission. Goals of the program: •Educate and motivate students to be tobacco-free. •Mobilize health care professionals to become proactive in their community’s health education. •Encourage community involvement in support of the Tar Wars program.

www.tarwars.org

A poster contest is encouraged following the presentation. Schools will have the opportunity to submit the top three posters to MAFP before April 24, 2015. The top five posters are chosen by a panel of judges and awarded prizes. The winner will be recognized at the MAFP Awards and Installation dinner at the Annual Scientific Assembly, June 5-6, 2015 at The Lodge at Old Kinderhook in Camdenton, Missouri.

Supported in part by a grant from the American Academy of Family Physicians Foundation.

Missouri Family Physician January-March 2015

Pediatric Genomic Medicine Conference April 8-10, 2015 Kansas City, MO ChildrensMercy.org/ newborngenomics

A FASTER, MORE PRECISE PATH TO DIAGNOSIS AND TREATMENT. As many as one in three newborns admitted to a NICU suffers from a genetic disease. The difference between life and death is often a quick diagnosis that expedites treatment. At Children’s Mercy Kansas City, our Center for Pediatric Genomic Medicine is developing genetic testing that’s helping transform the lives of patients around the world. We’ve developed the world’s fastest genome sequencing test, so that you can diagnose patients in as few as 50 hours. We’ve also developed a single test to detect more than 750 diseases that are the result of a single mutation. Beyond the NICU, we’re collaborating with pediatric subspecialists throughout Children’s Mercy in many of our clinics, including Nephrology, Endocrinology, Gastroenterology and Oncology. This allows us to better understand the genetic causes of diseases and minimizes unnecessary testing while delivering faster and more accurate diagnoses—improving outcomes for children everywhere.

Volunteer MAFP

attention residents

fp a m

what's your new year's resolution? help your academy by volunteering today

he Missouri Academy needs you. Volunteers are the support which guides the future success of the MAFP. Serving on commissions is an excellent way to help the Academy.

Volunteer today! Visit: www.mo-afp.org/about-us/committees •Advocacy Commission: Investigates and/or initiates methods of improving the health and well-being of the citizens of Missouri, representing the interests of family physicians and strengthening the specialty of family medicine, including encouraging the passage of laws to that end. This commission will also have the responsibility for evaluating and initiating changes in the by-laws. •Education Commission: Responsible for conducting all educational and research programs of the MAFP, as well as encouraging and assisting in all resident and student affairs in Missouri.

Do you need to be published? Are you interested in submitting your report to be published as a Resident Grand Rounds article in our quarterly Missouri Family Physician magazine? Contact MAFP staff at (573) 635-0830 or email office@mo-afp.org for more information.

•Member Services Commission: Responsible for any publications, public relations efforts, and communications with the news media regarding public relations efforts. The commission does not speak for the organization or represent the Board to the media. Shall be charged with the recruitment and retention of qualified members of this Academy. Time Commitment: Face-to-face meetings are held two times per year in conjunction with each CME conference and conference calls on an as needed basis.

Missouri Family Physician January-March 2015

MAFP For Your Information

Choosing Wisely®

FREE WEBINAR Getting Paid for Chronic Care Management Under Medicare in 2015 Presented by Kent Moore

When

January 27, 2015 12:30 - 1:30 pm central time. A portion of the time will be allotted for questions and answers. Space is limited. Reserve your seat now.

Two Professional Liability Insurance Mutuals Merge as MPM-PPIA Missouri’s two oldest mutual associations providing professional liability insurance for physicians have merged into one company, MPM-PPIA. Under an agreement approved November 20, the merger between Missouri Professionals Mutual and Physicians Professional Indemnity Association makes the new MPM-PPIA the largest mutual association in Missouri and the only one that is governed by a Board of Directors consisting predominantly of practicing physicians. Both member-owned companies have been providing professional liability insurance to Missouri physicians for 11 years. By offering alternatives to for-profit companies, they have stabilized medical malpractice insurance costs for Missouri physicians. Now as a combined company, MPM-PPIA will have greater financial strength, while offering additional benefits to members. MPM-PPIA covers nearly 1,800 physicians and other caregivers. As client-members, they have a voice in the governance of the association.

Visit AAFP.org for more information.

30 Missouri Family Physician January-March 2015

The Choosing Wisely® (www.choosingwisely.org) campaign was created as an initiative of the American Board of Internal Medicine (ABIM) Foundation (www. abimfoundation.org) to improve health care quality. More than 50 specialty societies have identified commonly used tests or procedures within their specialties that are possibly overused. The American Academy of Family Physicians (AAFP) remains committed to supporting the Choosing Wisely® campaign with the goal of ensuring high-quality, costeffective care to patients. The AAFP has identified 15 tests and procedures (5 page PDF) that both doctors and patients should carefully consider and openly discuss before incorporating them into a treatment plan. Antibiotics for Otitis Media Don't prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable. •The “observation option” refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. •The decision to observe or treat is based on the child’s age, diagnostic certainty, and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child. Sources AAP/AAFP 2005 "Diagnosis and Management of Acute Otitis Media." Accessible at: http://www.aafp.org/dam/AAFP/ documents/patient_care/clinical_recommendations/final_aom. pdf. Venekamp RP, Sanders S, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000219. DOI: 10.1002/14651858.CD000219.pub3. Accessible at: http:// onlinelibrary.wiley.com/doi/10.1002/14651858.CD000219. pub3/pdf(onlinelibrary.wiley.com). This recommendation is provided solely for informational purposes and is not intended as a substitute for consultation with a medical professional. Patients with any specific questions about this recommendation or their individual situation should consult their physician.

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Jefferson T MAFP Political Action Committee 722 West High Street Jefferson City, MO 65101 ake an active step Phone: (573) 635‐0830 by joining Club Tax ID 90‐0162481 Jefferson. By pledging just www.mo‐afp.org

$2 a week ($104 annually), you can help shape the AFP PAC is the state Political Action Committee of the future of patient care and Missouri Academy of Family Physicians. MAFP PAC is a special What is the MAFP PAC? MAFP PAC is the state political action committee of the Missouri Academy of Family Physicians. MAFP PAC is a family medicine in Missouri. organization set up to collect contributions from a large number special organization set up to collect contributions from a large number of people, pool those funds and make contributions to state of people, pool those funds and make contributions to state election Our goal is to involve as election campaigns. campaigns. The MAFP PAC is a bipartisan group dedicated to helping many members as possible. Where does my donation go? MAFP PAC will make direct contributions to candidates for the Missouri General Assembly (either State pro-family medicine candidates win election to public office and educating We begin by seeking that House of Representatives or State Senate), and statewide offices. Contribution decisions are made in a nonpartisan way based on current legislators on the importance of family medicine. The Missouri candidates’ positions, policies and voting records as they relate to family physicians and our patients. Direct contribution decisions are one voice in one hundred – Academy of Family Physicians also contracts a lobbyist to help ensure that made by the PAC Committee. yours. our members’ positions are supported throughout the state legislative

I already pay my dues? Isn’t that enough? Election laws prohibit the use of membership dues for donations to political candidates. process. Funds to be used for donations to candidates must be raised separately from membership dues. Voluntary MAFP PAC donations are what will enhance MAFP’s clout in the elections and with elected members of the Legislature.

“Your voice in the political process.” MAFP PAC DONATION FORM

YES! I believe in Family Medicine and I’m interested in investing in our future. Please accept my ___ personal or ___ corporate contribution:

** I would like to Join Club Jefferson ($104 annually) Other $__________________

The Missouri Ethics Commission requires the following information for all contributions of $25.00 or more: Name: ___________________________________________________________________________________________________ Employer:_________________________________________________________________________________________________ Address: __________________________________________________________________________________________________ City/State/Zip: _____________________________________________________________________________________________ E‐mail Address: _____________________________________________________ Phone:__________________________________ I am aware of the political purposes of the MAFP PAC. I understand that contributions to the MAFP PAC are purely voluntary and that these suggested contribution amounts are only guidelines. I further understand that I will not be favored or disadvantaged by reason of the amount of my contribution or a decision not to contribute. Contributions to the MAFP PAC are not tax‐deductible for federal or state income tax purposes. Payment is being made by: Check (payable to MAFP PAC) Credit card: VISA MasterCard Discover Today’s Date: ____________

Name on Card: ________________________________________________________________

Card # _________ ‐ _________ ‐ _________ ‐ _________ Expiration Date: _______________

Signature _______________________________________ Billing Zip Code: ________________

Donate online at: www.mo-afp.org or mail the form below to: 722 West High Street, Jefferson City, MO 65101

Missouri Health Professional Placement Services (MHPPS) is dedicated to rural and underserved areas of our great state! We partner with safety-net providers and health care systems throughout Missouri to help health care professionals, like yourself, find a community that best fits your personal and professional needs. Whether it's a scenic rural setting, dynamic urban location, or somewhere in between, we are committed to focusing on your interests and careers that count! Find Out More: Contact Us Today! Joni Adamson Manager of Recruitment 573.636.4222 jadamson@mo-pca.org www.3rnet.org/locations/missouri

Opportunities throughout our Rural & Urban Areas: • Loan Repayment Options • Competitive Salary & Comprehensive Benefits • Team Based Models of Care / Care Coordination • Little or no Call / Moving Allowance / Signing Bonus

Pride, Passion, Purpose: Careers That Count! Proud Partners Of:

MHPPS is non-profit and located within the MO Primary Care Association