Mafp magazine jul sep 2012 final for web

MISSOURI

Official Publication of the Missouri Academy of Family Physicians

Family Physician

JUL − SEP 2012 Volume 31, Issue 3

Rottnek Installs Lichtenberg as 64th MAFP President pg. 14

Medicaid payment rate increases for primary care services pg. 17 Resident Grand Rounds Tony Pallan, MD Kavitha Arabindoo, MD pg. 18

contents MAFP

Executive Commission Board Chair - Todd Shaffer, MD, MBA (Lee’s Summit) President - Kate Lichtenberg, DO, MPH (Kirkwood) President-elect - Bill Fish, MD (Liberty) Vice President - Daniel Purdom, MD (Independence) Secretary/Treasurer - Tracy Godfrey, MD (Joplin) Board of Directors District 1 Director: Dana Granberg, MD

Alternate: Jennifer Moretina, MD District 2 Director: Lisa Mayes, DO

Alternate: Vacant District 3 Director: Jeff Suzewits, DO

Director: F. David Schneider, MD

Alternate: Caroline Rudnick, MD District 4 Director: Kelly Bain, MD

Alternate: Jennifer Stearnes-Rosas, MD District 5 Director: Peter Koopman, MD

Director: Katherine Friedebach, MD

Alternate: James Stevermer, MD, MSPH District 6 Director: Jamie Ulbrich, MD

Alternate: Vacant District 7 Director: Kathleen Eubanks-Meng, DO

Director: George Harris, MD, MS

Alternate: Vacant District 8 Director: Mark Woods, MD

Director: John Paulson, DO, PhD

Alternate: Vacant District 9 Director: Charlie Rasmussen, DO

Alternate: Vacant District 10 Director: Mark Schabbing, MD

Alternate: Steven Douglas, MD At-large Director: Robert Schneider, DO Resident Directors Suzan "Annie" Lewis, DO Imani Anwisye, MD (Alternate) Student Directors David Kramer Amanda Williams (Alternate)

Mark your

Calendar

AAFP Congress of Delegates Philadelphia Marriott Downtown, Philadelphia, PA October 15-17, 2012

3rd Annual Advocacy Day State Capitol, Jefferson City, MO February 26, 2013

20th Annual Fall Conference & SAM Working Group Big Cedar Lodge, Ridgedale, MO November 9-11, 2012

65th Annual Scientific Assembly The Lodge of Four Seasons, Lake Ozark, MO June 7-9, 2013

Register online now!

Do you need

CME?

Join us for the 20th Annual Fall Conference and SAM Study Group to be held at Big Cedar Lodge, Ridgedale, Missouri

November 9-11, 2012

www.bigcedar.com

Early bird discount and Room Reservation deadline end 10/08/12

Visit www.mo-afp.org • Registration Form • Room Reservation Form

• Schedule of Events

Inside this issue 4

Officer Reports & Annual Reports

10 Family Health Foundation of Missouri

26

ASA Sponsors & Exhibitors

27

2012 Tar Wars Winner

Advertisements 2

Cox Health

7

Physicians Professional Indemnity Association

9

CMS - EHR Campaign

11

Professional Solutions

13

United Allergy Services

17 Medicaid Payment Rate Increases for Primary Care Services

21

Core Content

25

Bristol Manor

Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101

18 Resident Grandrounds

26

Delta Exchange/TransforMED

27

HEALTHeCAREERS

p (573) 635-0830 f (573) 635-0148 www.mo-afp.org office@mo-afp.org

22 Legislative Update

28

Missouri Professionals Mutual

AAFP Delegates Bruce Preston, MD Larry Rues, MD Darryl Nelson, MD (Alternate) Vacant (Alternate) MAFP staff Executive Director - Jennifer Bauer Education & Finance Director - Nancy Griffin Managing Editor/Member Services - Laurie Bernskoetter

12 Members in the News 13 ALF/NCSC & FMCC 14 Welcome New President Kate Lichtenberg, DO, MPH, FAAFP

16 Help Desk Answers Resident Case Studies

Tony Pallan, MD Kavitha Arabindoo, MD

Missouri Family Physician July - September 2012 3

MAFP officer reports

Keith Ratcliff, MD, FAAFP 2011-2012 Board Chair

O

ur MAFP has been blessed with a productive and purposeful year.

We have a great group of officers that have dedicated themselves to further the mission of our organization. Our president, Dr. Todd Shaffer, continues to lead by example and will be a great Board Chair next year as we continue to try and refine a methodology for measuring the Primary Care Workforce in our state. We all look forward to the inauguration of Dr. Kate Lichtenberg as our next President at the ASA this weekend. Kate is very media savvy and will become the face of our organization this year. We are fortunate to have Dr. Bill Fish advancing to the role of President-Elect; he has been very effective in providing testimony at the Capital when needed and continues to be actively involved in our Advocacy Commission.

Dr. Dave Kapp has decided to focus on family issues for a while and will be stepping down as the Secretary/Treasurer.

When you have a chance at the ASA, please thank Dave for his years of service as an officer to our Academy. He has provided your Executive Committee with invaluable guidance on the budget and other issues.

With the advancement of Dr. Fish, our Advocacy Commission was in need of a new chairman and Dr. Arthur Freeland graciously rose to the occasion and accepted the challenge. Each year Advocacy seems to become more important to our membership. Thanks to the hard work of our staff and Dr. Freeland, we had an excellent second annual Family Medicine Advocacy Day at the Capitol in February. With the current state of our legislature, very few bills were passed this year. Working with our lobbyist, Pat Strader, we were able to help defeat a number of bills that would have adversely affected our patients including the licensing of clinical laboratory personnel, 4

Missouri Family Physician July - September 2012

independent practice of APRNs, Medicaid reimbursement for chiropractic services, and the attempted repeal of the motorcycle helmet statute. We were not successful in advancing other issues such as the clean indoor air act, a prescription drug monitoring program, prompt credentialing for physicians with insurers, the prohibition of economic credentialing of physicians by hospitals, and a more substantial tobacco tax in Missouri. Much work remains to be done for next year and we will continue to be the voice of Family Medicine and a resource for our legislators.

The Missouri Academy was honored this year to campaign successfully for the election of Dr. Julie Wood, one of our Soaring Eagles, to the Board of the American Academy of Family Physicians.

Many hours of hard work by our staff were spent in achieving this goal, and Julie has

made us all proud through her continued dedication to Family Medicine. She is the most recent of many physicians that have come from the MAFP to assume leadership roles in our national Academy.

I have been amazed at the great work that our Board has done this year. We are fortunate to have such an engaged and diverse Board to help guide this Academy in these times that are difficult to understand and impossible to anticipate.

Every Board member has given selflessly of their talent and time to help advance the mission to which we are committed.

Challenges will continue to present themselves and I am certain that, with the creativity and insight of this Board, our MAFP is poised to resolve any issues with which we are confronted. It has been my honor and privilege to serve as Chairman of this Board

What is the MAFP PAC? MAFP PAC is the state political action committee of the Missouri Academy of Family Physicians. MAFP PAC is a special organization set up to collect contributions from a large number of people, pool those funds and make contributions to state election campaigns.

Where does my contribution go?

MAFP PAC will make direct contributions to candidates for the Missouri General Assembly (either State House of Representatives or State Senate) and statewide offices.

Contribution decisions are made in a nonpartisan way based on candidates' positions, policies and voting records as they relate to family physicians and our patients. Direct contribution decisions are made by the PAC Committee.

I already pay my dues - isn't that enough?

Election laws prohibit the use of membership dues for donations to political candidates.

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.

Get Involved!

Make your 2012 contribution online at www.mo-afp.org

officer reports MAFP

Todd D. Shaffer, MD, MBA, FAAFP 2011-2012 MAFP President

A

s we are gathering for scientific assembly and celebrate our 64th year of meeting with family physicians across the state of Missouri, I want to thank all the MAFP staff that work so hard to put our fine meetings together.

Jennifer Bauer, Nancy Griffin and Laurie Bernskoetter provide year-round access for our members’ needs and access to building a better academy. Thank you for all you do.

I encourage all members to thank them when they see them at the meeting.

For my last president’s column, I wanted to touch on a few things I discussed last year and some of our accomplishments as an academy over the past year. Many of these items we have been building on for years and we continue to work and excel even though, at times, it may seem like they are ongoing projects as some continue to be. Last year I mentioned our three rocks in our strategic plan: Advocacy, Workforce and Communication. We have been driven by our aggressive strategic plan and aspiring to be the “go- to” organization for primary care knowledge in the state of Missouri as we proceed from a reactive organization to a planning organization.

Advocacy is always a hot topic, and although this year was a year where many proposals did not make it far in Jefferson City, there were very few notables that will directly affect family physicians. Please refer to the legislative report from Pat Strader for specific examples. We do know that many of these same items will be back next year and with potentially fewer budget woes and in a non-election year, many more of these will get a lot of face time that leads us to be in Jefferson City with our voice for our organization and for the primary care needs of Missourians.

One of the big news items this year was when Julie Wood, MD, was elected to the board of the AAFP at the national

meeting in Orlando in September 2011.

This gives great presence of the Missouri chapter on the national stage. Congrats Julie!

Workforce: This area is an area where we continue to excel in some areas and struggle in others. We continue to have strong membership (and after two previous years in a row of national awards for increases in membership, we are now continuing to hold steady!) We have had a meeting with the governor and other representatives about getting a statewide primary care workforce study completed.

As we discovered at our Advocacy Day in February, apparently the governor’s office is also interested in the same data. This workforce study must be a multifaceted effort involving our organization, other primary care organizations, the state licensing board and the governor’s office to truly look at what Missouri’s needs are now and in the future. Other states around us have already completed this task and are working on things that will address their workforce issues. We need to continue to work with the state and our own AHEC to devise strategies to educate and retain our most precious resource, those students and residents interested in primary care.

We did have an award for 100% resident membership to the AAFP again this year, great job!

Communication: Emails, website traffic, facebook site and quarterly magazine have been great ways to get more in touch with our membership and let them request, comment and get closer to our academy with more involvement. These are all great places for ideas and clinical information that can be shared. Drs. Harris and Lichtenberg and the Member Services Commission have been working hard as our magazine now includes more shared clinical information which is very useful

to our membership. While meeting at Multi State Forum in Dallas this year, the Missouri contingent got to hear some great ideas from other chapters about wins and challenges so that we can learn what others are doing and working toward as well.

The Annual Leadership Forum (ALF) and National Conference of Special Constituencies (NSCS), in early May this year, had a full delegation from Missouri representing us, and many things were learned for our new leaders to our present staff.

The other areas we need to focus on in the next year for our membership are PCMH transformation, Meaningful Use, ACOs, continue to work closer with AHEC and other primary care organizations for better patient care and access and be ready for a full legislative year to advocate for great quality of care being addressed on the front line in appropriate professional relationships with midlevel providers.

This has been a successful year for the academy, and we are stronger than ever financially and membership wise with great wins in advocacy. I know we are becoming the “go to” organization for premium primary care issues in the state of Missouri.

I know that as I turn the presidency over to Kate Lichtenberg, DO, I am leaving the organization stronger than when I came to it and have confidence it will continue to get stronger in Kate’s hands

Send us your news!

The Missouri Family Physician magazine welcomes your input. If you have "Members in the news" information you would like to share and include in the next issue, please submit newsworthy items for review to: lbernskoetter@mo-afp.org. See page 12 for current news about your colleagues.

Missouri Family Physician July - September 2012 5

MAFP officer reports

Member Services Commission Report Membership (June 21, 2012): As an organization, the Missouri Academy of Family Physicians strives to offer members benefits which are current, relevant and of importance to you. To do so, we rely on input from you – our members. Please contact your district leaders or MAFP staff with any suggestions and/or comments regarding ways in which we can improve our service to you.

During the 2012 AAFP ALF/NCSC, MAFP was presented the AAFP 2011 Full Delegation to NCSC and the AAFP 2011 Award for 100% Resident Membership.

As of June 2012, Membership Statistics include (See graph below right): In 2012, we join our MAFP members celebrating AAFP and/or MAFP membership anniversaries. Those who were present at the Annual Scientific Assembly were recognized at the Awards and Installation Luncheon.

Necrology Report (April 2011 to July 2012) †William D. Bradshaw, MD (Village of Loch Lloyd, MO)

Vice President Report

Sec/Treasurer Report

I have enjoyed my first year serving as an officer in our organization. I am learning a great deal having attended the AAFP State Legislative Conference in November 2011 Bill Fish, MD, FAAFP and the Multi State Meeting in February 2012 prior to participating in our own Advocacy Day at the Capitol this year. I was able to share ideas from Missouri with other chapters and hear from them, and from the AAFP, related to issues around the country. The problems we face are very similar to those elsewhere with ‘Scope of Practice’ issues being high on the list.

Many states have been experiencing these issues for a little longer and we learn from their successes and failures on how best to combat intrusion by less qualified practitioners in our area of practice.

MAFP continues to work diligently to provide service and value to Missouri Family Physicians and their patients.

The Board and staff continually strive to better serve our David Kapp, MD, FAAFP members while remaining fiscally responsible with the resources provided.

The academy has improved efficiency and has remained in solid financial shape despite uncertain economic times.

MAFP Membership Dashboard as of June 2012 Active

1161

†Monaford D. Durnell, MD (Lee’s Summit, MO)

Inactive

13

Life

123

†R. Raymond Lyle, MD (Versailles, MO)

Resident

117

†Keith D. Morris, MD (Washington, MO)

Student

358

Supporting 4

†Gordon W. Riffel, MD (Spokane, WA) †Walter Jack Stelmach, MD (Kansas City, MO) †Thomas L. Stern, MD (Sun Lakes, AZ) †John W. Ubben, MD (Osage Beach, MO)

6

Missouri Family Physician July - September 2012

Total

Through the efforts of our staff and board leadership, we have maintained a balanced budget again this year while actually adding to long-term reserves. I feel we are in an excellent position to continue to provide the needed support to our organization, weather any unexpected financial downturns and provide needed funding necessary for special projects deemed worthy by the board to advance the organization.

Inactive

With the ending this summer of my term as Secretary/Treasurer, I will be leaving the board after almost 10 years. It has truly been a pleasure to serve the MAFP and represent the best, hardest working doctors in Missouri. I have been continually impressed with the dedication of the board members and staff and I am confident the organization and Family Medicine in general has a bright future. I encourage all members to support and become involved in the MAFP as there is much to do to help shape the ever-changing landscape of medicine. I have truly seen first-hand what a difference we all can make. There is Active plenty to do, so get involved!

Inactive

Life

Life

1776

Active

Resident Resident Student Student Supporting Supporting

annual reports MAFP

Resident Report year’s figure, and there were 34 additional positions in this year’s match. Overall, the percentage of US medical school seniors who chose family medicine rose from 8.4% in 2011 to 8.5% this year. (Statistics from the AAFP)

Conference Attendance: At this conference, there are five residents and two students registered. Last year there were seven residents registered, and three residents showed posters.

Match 2012 – where they came from: Research Family Medicine Residency – 12 residents • KCUMB – 6 • KU – 2 • University of Indiana – 1 • Ross University – 1 • University of Belgrade – 1 • Southern Illinois University – 1

Match Results: At the match this year in March, family medicine residency programs filled 2,611 positions of the 2,764 offered, for a fill rate of 94.5%. This is 0.1% higher than last

University of Missouri-Kansas City – 14 residents • KCUMB – 8 • University of Kansas – 3 • UMKC – 1

S. Annie Lewis, DO

Mimi Propst, MD

• University of Oklahoma – 1 • Des Moines – 1 Cox Family Medicine Residency – 9 residents • KCUMB – 1 • University of Arkansas – 3 • St. Louis University – 1 • UMKC – 1 • Kirksville – 2 • Western University of the Pacific – 1 University of Missouri-Columbia – 14 residents • MU – 11 • University of Florida – 1 • Kirksville – 1 • University of Illinois – 1 St. Louis University – 4 residents • University of Kansas – 1 • Harvard University – 1 • Tulane University – 1 • Ross University – 1

Missouri Family Physician July - September 2012 7

MAFP annual reports

Family Medicine Interest Groups Report Mizzou’s FMIG continues to be one of the most active student interest groups at University of Missouri – Columbia School of Medicine. MU FMIG continues to provide numerous opportunities for students to be involved in community service, fundraising, and professional development. The group continues to provide health screening services for Harbor House (a local homeless shelter), meals for families staying at the Ronald McDonald house and continues to take the Tar Wars program to local elementary schools. MU FMIG also had numerous workshops this year including an IUD lab, practicing the geriatric interview, and a musculoskeletal workshop. We also partnered with the MU Family Medicine, Pediatrics, and Obstetrics/Gynecology departments during Primary Care Week to put on a Well Child Exam workshop and a pelvic exam simulation. MU FMIG is looking forward to the next year to continue serving their community, members, and Family Medicine in Missouri.

UMKC’s FMIG had a very active year, holding a variety of workshops (EKG, casting, and suturing). They held a successful Residency Fair, including organized talks such as “Choosing a specialty,” “Strolling through the Match,” and “Young and in debt: Managing your medical school debt.” They recently transitioned leadership and are excited about their incoming crew.

Saint Louis University’s FMIG has had a great year. They started it off with their annual Residency Fair with 11 regional residencies and over 150 students in attendance. Then they ushered in the MS1’s with a first-year only procedure night with the help of their faculty advisor, Dr. Bill Manard and the SLU Family Medicine Residency. Next up, National Primary Care Week! SLU’s FMIG coordinated Primary Care Week, collaborating with the Pediatric Interest Group and Student National Medical Association (SNMA) to put on a 8

Missouri Family Physician July - September 2012

week of activities and talks. Other events included another procedure night held by the Belleville Family Medicine Residency and participating in the YMCA’s Healthy Kids Day, an annual health fair designed to provide resources for parents and kids to stay active over the summer. What they are most proud of, however, is the creation of two new community service initiatives: the Community Health Coalition (CHC) and Timeslips. The CHC is a joint project with SNMA and Greatest Gift that checks blood pressure, gives nutritional counseling and promotes organ donation one Saturday per month at the City Plaza Schnucks in North City. The new Timeslips program is an interactive storytelling project, where medical students help groups of assistedliving residents create stories from simple photographs. And last but not least, Saint Louis University’s FMIG is proud to congratulate the 13 members of the class of 2012 who have gone on to family medicine residencies this year: Jessica Anewalt, Michael Barker, Brooke Benson, Nicholas D’Angelo, Gabriel Dunn, Sarah Gebauer, Jessica Grass, Elizabeth Harleston, Daniel Jones, Emily King, Ryan McDowell, Nicholas Moore, and Tina Toosky.

Congratulations and good luck!

Washington University’s FMIG are happy to share that for next year, they expanded the leadership positions to a 4-person board of students. Perhaps most importantly they will have a president dedicated to involvement in the local/ regional/national groups to help expand their resources and get more connected to FMIG groups in the area. They are excited to report that they hosted a dinner with Family Medicine residents as well as a talk on family medicine careers. For the next year, they hope to have a talk on family medicine residency specifics and a procedural workshop.

Kirksville’s Family Medicine Student Group had an active year as well. In January, six members of SACOFP from KCOM attended the annual Winter

David Kramer, Student

Aaron Meyer, Student

Scientific convention for MSACFP (Missouri Society of ACOFP) in Kansas City, Missouri. In February they held a “Health Fair” at Wal-Mart in Kirksville.

They were able to perform over 100 blood pressure checks throughout the day with over 50 students participating. In April they held a luncheon while students listened to Christa M. Hojlo, PhD, RN, NHA while she discussed “Caring for the Aging: Options, Opportunities, and Outcomes.” In May, they hosted a luncheon where Erica Waddington DO spoke about combined OMM/FP residencies! She discussed the “How To’s” and benefits or difficulties encountered in the many programs.

KCUMB ACOFP club has been very busy this semester. In January, they held a member meeting with Dr. Elaine Joslyn, D.O., FACOFP who came to speak on serving the under-served. They also held an annual EKG clinic where 240 students attended. In March, they organized an Obstetrics Ultrasound Clinic where 30 first and second year students were able to practice on pregnant volunteers. In April, Bruce Williams, D.O., FACOFP, the current president of Missouri State ACOFP (MSACOFP), presented a meeting titled “MSACOFP President’s Take on Healthcare Challenges in Family Practice.”

They organized Chalk Walk Health Screenings where 25 Members of the club conducted health screenings at an annual community event in the neighborhood surrounding our University. In May, 5 students went with Elaine Joslyn, D.O., FACOFP to the Capitol in Jefferson City to spend the morning meeting some senators and advocating for Osteopathic Medicine.

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MAFP family health foundation

Show your support Purchase your license plate frames today “Improving the health of families in Missouri” The mission of the FHFM is to support scientific, educational and charitable initiatives for the specialty of family medicine, and to improve the health of families in Missouri. In partnership with the AAFP Foundation, some of the ways the FHFM serve that mission are: offering summer externships that give students the opportunity to work with practicing family physicians; awarding student scholarships for outstanding graduates who have matched with a family medicine residency program; supporting the Tar Wars program; and funding scholarships for residents and students to attend national family medicine conferences. FHFM is a 501 (c) (3) charitable corporation and contributions are tax deductible.

Fundraisers FHFM still has EVERYONE DESERVES A FAMILY PHYSICIAN license plate frames available for purchase for $10. FHFM is seeking input and ideas for future fundraisers.

ASA Student/Resident Sponsorships FHFM would like to thank the following individuals for their contributions to offset costs for students/residents attending this year’s Annual Scientific Assembly.

• David Barbe, MD • Arthur Freeland, MD • David Kapp, MD • Peter Koopman, MD • Keith Ratcliff, MD • James Stevermer, MD Scholarships Six top graduating medical students who are entering family medicine residencies were awarded certificates and scholarships of $500 each. The family medicine scholarships were awarded to:, Laura Michelle Covert, A.T. Still; Katie Yi Hu, Washington University; Natalie Abert Long, UMC; Christopher Aaron Paynter, KCUMB; Gabriel Aloysius Dunn, SLU; and, Dylan Werth, UMKC. Summer Externships With AAFP Foundation matching funds, the FHFM sponsors four-week summer externships. This year, UMC Student Ontario Lacey (UMC FMR) and SLU Student William K. Otto (Mercy 10 Missouri Family Physician July - September 2012

$10 each FREE S&H

Proceeds benefit the FHFM and all purchases are tax deductible. Call (573) 635-0830 to place an order.

FMR) participated.

Tar Wars Tar Wars continues to be a very successful program. This year’s poster contest had over 25 submissions and the Missouri Tar Wars poster winners were: 1st Place: Jamison Liles, Craig R-3, Craig, MO 2nd Place (tie): Desiree Hufford, Mound City R-2, Mound City, MO 2nd Place (tie): Brandi Berkstresser, Greenwood Elementary, Lake Winnebago, MO 4th Place: Timothy Schweizer, Sunny Point Elementary, Blue Springs, MO 5th Place: Sophie Richards, South Holt R-1, Oregon, MO The first place winner traveled to Washington, DC in July and participated in the Tar Wars National Poster Contest. Jamison also received a check in the amount of $100. Checks in the amount of $50 each were awarded to both second place poster winners.

Fourth and fifth place winners each received a gift card in the amount of $25 donated by Central Bank. Next year’s goal is to have at least 30 entries.

Pictured left are Robert Schneider, DO, Assistant Professor, Department of Osteopathic Manipulative Medicine, at A.T. Still University - Kirksville College of Osteopathic Medicine who presented Laura Covert with the Family Health Foundation of Missouri award at the ATSU Class 2012 Senior Awards Banquet on May 11, 2012

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MAFP MEMBERs in the news

Members in the news

Nina Kiekhaefer, MD

Charlie Rasmussen, DO

In May 2012, the Zonta Club of Jefferson City hosted the 13th Annual Women of Achievment Yellow Rose Luncheon which honors local women for their achievements in the community and raises support to help other local women advance their education. Zonta is a worldwide organization working to improve the legal, political, economic, educational and professional status of women. MAFP member and former board member, Nina Kiekhaefer, MD, was one of fifteen nominees for the 2012 Women of Achievement Award. Dr. Kiekhaefer practices at JCMG in Jefferson City, is board certified in Family Medicine, and has held leadership positions in the MAFP. Charlie Rasmussen, DO, Houston, MO, was recently elected to the MAFP Board of Directors as a director representing District 9.

On July 27, the Students and Residents elected two alternates to the MAFP Board at the Missouri Reception in Kansas City which is held in conjunction with NCFMRS. Amanda Williams (UMKC) was elected as the new Alternate Student Director and Imani Anwisye, MD (SLU FMR) was elected as the new Alternate Resident Director. They will serve their first year as Alternate and the second year as Director for a total of two years.

On July 28, Aaron Meyer of St. Louis, former MAFP Student Director, was selected by the Student Congress to 12 Missouri Family Physician July - September 2012

Imani Anwisye, MD

Aaron Meyer, Student

Amanda Williams, Student

represent medical students on the AAFP Board of Directors. Meyer was an alternate student delegate to the Congress of Delegates last year.

MAFP Members Jack Dodson, MD, William Kimlinger, MD, James Weiss, MD, and Thomas Robbins, MD, were all recognized as Jefferson City News and Tribune 2012 Reader's Choice Award Winners under the category of "Best Family Doctor."

Jack Dodson, MD

William Kimlinger, MD

James Weiss, MD

Thomas Robbins, MD

AAFP presented students from the Saint Louis University Family Medicine Interest Group (FMIG) Class of 2014 the AAFP FMIG Program of Excellence Award for "Excellence in Community Service" on July 27 at an award breakfast. The AAFP’s FMIG Program of Excellence (PoE) Award recognizes Family Medicine Interest Groups for their efforts to stimulate interest in family medicine and family medicine programming on medical school campuses across the nation.

SLU FMIG - Pictured left to right (front row): Amy Hurt, Co-Chair, Stefanie Rademacher, Communications Chair, and Kimberly Lincenberg Membership Chair; (back row): Meghan Tierney, Co-Chair, Zachary Kaufman, Treasurer, and William Manard, MD, Faculty Advisor.

Not pictured: Jessica Sturgess, Community Outreach Chair.

ALF/NCSC and FMCC MAFP

ALF/NCSC The AAFP Annual Leadership Forum and National Conference of Special Constituencies (ALF/NCSC) was held May 2-5, 2012 at Sheraton Crown Center in Kansas City. MAFP was awarded a full delegation award with five NCSC representatives including Randi Hasselfeld, MD (IMG), Tess Garcia, MD (Minority), Susan Pereira, MD (GLBT), Chris Blanner, MD (New Physician), and Kathleen Eubanks-Meng, DO (Women). Kate Lichtenberg, DO, Dan Purdom, MD, Nancy Griffin and Jennifer Bauer attended the Annual Leadership Forum (ALF) portion of this conference.

Pictured below is Kate Lichtenberg, DO, networking with other physician leaders.

Family Medicine Congressional Conference Family Medicine Congressional Conference (FMCC) – Missouri had five representatives, including two residents and one student at FMCC held May 14-15, 2012 at Grand Hyatt Washington, DC. Some of the AAFP staff that resides in Missouri attended the congressional meetings with our delegation.

Pictured left (right to left) are Kevin Helm, Executive Vice President of the Association of Family Medicine Residency Directors, Aaron Meyer (Student), Peter Koopman, MD, Julie K. Wood, MD, Amy Sue Williams, MD, and Jonathan Wada, MD.

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Missouri Family Physician July - September 2012 13

MAFP welcome dr. lichtenberg

Meet New 2012-2013 MAFP President Kate Lichtenberg, DO, MPH, FAAFP

Kate Lichtenberg, DO, MPH, FAAFP, of Kirkwood, Missouri, was installed as the 64th President of the Missouri Academy of Family Physicians (MAFP) during its annual meeting in Lake Ozark, Missouri, on June 23. Serving as President last year, Todd Shaffer, MD, MBA, FAAFP, Lee’s Summit, Missouri, subsequently became Board Chair of the family medicine group. Other officers elected were President-elect Bill Fish, MD, FAAFP, of Liberty; Vice President Daniel Purdom, MD, FAAFP, of Independence; and Secretary-Treasurer Tracy Godfrey, MD, of Joplin.

Dr. Lichtenberg earned her undergraduate degree from Truman State University. She attended medical school at A.T. Still University – Kirksville College of Osteopathic Medicine, and earned her MPH and public health/general preventive medical board certification from Saint Louis University.

She currently practices in southwest St. Louis County and resides in Kirkwood with her husband, Mike and their two children. Dr. Lichtenberg has been a member of the MAFP since 1997. Below are remarks from the Installation and Awards Luncheon held June 23, 2012.

I

t is amazing how fast the past couple of years have gone. We have seen so many changes in medicine and we are awaiting so many more. As I write this just a week before the Annual Scientific Assembly begins, we are still waiting on the Supreme Court’s Decision regarding the Affordable Care Act (and I’m really hoping they don’t make the ruling before I give this speech!).

So many plans have been made and new policies and procedures put in place by so many physicians to meet the requirements of a law that may not even stand.

How much will this impact our day to day practice if the entire law is thrown out? We’ll certainly be back to square one. Millions of Americans will remain uninsured. If we have a new to Medicare recipient coming in, will we still perform the Welcome to Medicare Physical knowing we may not get paid? How many other changes have we already incorporated in to our practices that may no longer make any sense to continue? Will we undo everything we have worked on to prepare for implementation? I suspect not, but it will certainly be interesting to see how many smaller practices continue to spend money to implement EHRs. Trying to explain the ramifications to patients will also be time consuming if not outright overwhelming.

What if just the mandate is ruled 14 Missouri Family Physician July - September 2012

unconstitutional? The rest of the law will likely be very difficult to administer.

People without insurance will likely remain without insurance and continue to go to the ER for care. Or, people may opt to wait until they have a problem and then purchase insurance knowing they cannot be refused. This could drive up premiums for everyone which could in turn cause more people to drop their coverage resulting in even more people being left uninsured. If there aren’t healthy people buying coverage, insurance companies could face financial collapse.

It is possible the Supreme Court will not do anything and punt this back to the states where the Commerce Clause that is in question doesn’t apply. That could mean interesting things here in Missouri.

Voters approved Proposition C in August 2010 with 70% of the vote making it clear the citizens of Missouri didn’t want to be told they had to purchase insurance and that those who chose not to purchase insurance wouldn’t be subject to fines or other forms of punishment. During the 2012 Legislative Session, Senate Bill 464 was passed specifying that no state-based health benefit exchange may be established, created, or operated within this state unless the authority is enacted by legislation, initiative petition, or referendum. A statebased health insurance exchange cannot be

established by an executive order issued by the Governor. It doesn’t appear Missouri will do much if the law is sent back to the states.

And if the Affordable Care Act is found constitutional and left intact?

Twenty to sixty million Americans will be newly inured. So often, primary care and preventive care are the first things to go when a patient becomes financially strapped. But just because you have coverage, it doesn’t guarantee you will be able to obtain care. If there isn’t an adequate work force, not everyone will be taken care of.

Uncertainty is the only thing that seems certain at this point. But no matter what the Supreme Court decides, I am confident that we as family physicians will push on and continue to take excellent care of our patients. The Missouri Academy and your national academy are working hard on your behalf on these issues and more.

During our advocacy day in Jefferson City in February, we were able to meet with the governor and his aides to discuss work force issues in Missouri. They are looking for the same information we have been looking for. Namely, how many primary care physicians (and more specifically, family physicians) are practicing in the state. It is important to know not only how many physicians

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welcome dr. lichtenberg MAFP

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there are, but how many actually do primary care, and do they do it full time or part time? We have found an ally in our effort to put together a comprehensive work force report and that remains a top priority for your Academy.

Our Advocacy Commission works tirelessly on your behalf. Led by Dr. Arthur Freeland of Kirksville, they monitor activity year round to make sure our patients are protected. Our lobbyist, Pat Strader is at the Capitol daily throughout the legislative sessions to make sure our voice is heard.

Our staff, Executive Director Jennifer Bauer, Education Services Coordinator Nancy Griffin, and Member Services Coordinator Laurie Berkenstotter, keep our office running smoothly and are excellent stewards for our finances. We are fortunate to have such a dedicated staff and I am so grateful to have such a wonderful group of people to work with.

I would like to take a brief moment to thank some people. First, I would like to thank Dr. Mike Wulfers for calling me 2 years ago and asking if I would be interested in a leadership position. Vivian Helm has served as the Executive Director of the St. Louis Academy for the past 12

years and I thank her for all of the support and knowledge she provided while I was president of the St. Louis Academy and helped me make the transition to the Missouri Academy.

Thanks also to Drs. Schafer, Ratcliff, and Freeland who have been wonderful mentors as I prepared for this upcoming year.

Thank you to Dr. Fred Rottnek for coming to the Lake this weekend for installation. He was my first true mentor and I continue to be inspired by him. We first met when I was a third year medical student and he was an intern while doing our OB rotation at Forest Park Hospital. For all of the students and residents here today, please remember you can be a mentor even now.

My dad John and his wife Ty are able to be here today, along with my good friend Dr. Laura Laue. My kids Will and Sarah who often ask what meeting I’m going

to now, but are always good sports. And finally, my husband Mike. Without you, I couldn’t do any of these things. Thank you for your never-ending patience and support!

Any to my fellow family physicians, I am humbled and honored to have this opportunity to lead our Academy in these uncertain times. Thank you for this opportunity to represent you across Missouri.

Pictured above, top right are Dr. Lichtenberg and her daughter, Sarah, enjoying the Family Fun Picnic at ASA. Pictured left are Mike Lichtenberg and Dr. Kate Lichtenberg with Will and Sarah.

Pictured directly above: Dr. Lichtenberg as she recites the oath of office.

Missouri Family Physician July - September 2012 15

MAFP help desk answers 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 evidence-based medicine experts!

Is there a definitive test for coronary artery spasm?

Evidence-Based Answer

Provocative testing using intracoronary acetylcholine or ergonovine causes clinically significant coronary artery spasm in susceptible individuals. (SOR: B, based on a retrospective cohort study.) Hyperventilation, coldpressor stress echocardiography compares favorably with intracoronary acetylcholine in inducing spasm.

(SOR: B, based on a prospective cohort study.) Patients with chest pain who are identified at risk for spasm should receive further evaluation by noninvasive methods, or if coronary catheterization is planned for suspected coronary artery disease (CAD), by invasive methods. (SOR: C, based on consensus guidelines.)

Studies have shown that coronary artery spasm (CAS) is a significant cause of chest pain among patients admitted with acute coronary syndrome (ACS).1 The CASPAR study looked at patients with ACS who did not have a culprit lesion on angiography. Thirty percent of these patients were identified as having CAS after intracoronary injection with acetylcholine (ACh) resulted in a >75% constriction of the diameter of the artery.

In a retrospective nonrandomized study of 1,508 patients undergoing first coronary angiography for a variety of reasons (including chest pain, positive stress test, history of CAD with increasing angina, myocardial infarction, cardiomyopathy), ACh and ergonovine were compared for their effectiveness in inducing CAS.2 Both agents were equally effective in provoking CAS in patients with preexisting CAD: 50.9% for ACh versus 43.8% for ergonovine (P=NS). However, ACh was more effective in provoking CAS in those patients without evidence of CAD (11% vs 6.4%, P<.05).

Another study compared hyperventilation, cold-pressor stress echocardiography (HVCP-Echo); hyperventilation, cold-pressor stress angiography (HVCP-CAG); and intracoronary injection of ACh for induction of spasm in patients with suspected CAS.3 Thirty patients with chest pain and positive HVCP-Echo results were initially enrolled in the study. Nine patients were excluded because of valvular heart disease, cardiomyopathy, or organic coronary stenosis of >75% on coronary angiography. Evaluators were blinded as to patient history and other findings.

16 Missouri Family Physician July - September 2012

June 2012 EBP

CAS was induced in 11 of 21 patients by HVCP-CAG and in 14 of 21 by administration of intracoronary ACh. HVCP-Echo demonstrated wall motion abnormalities in all 14 patients with spasm from ACh, and in 16 of 19 (84%) of the coronary artery regions where spasm was induced during angiography by HVCP stress or intracoronary ACh.3 An earlier study compared 389 consecutive patients with chest pain and suspected CAD who underwent both hyperventilation stress test and coronary angiography over a 12-year period.4 This group was subdivided into a vasospasm group and a nonvasospasm group based on angiography and response to ACh or ergonovine. Ischemic electrocardiogram (ECG) changes were induced by hyperventilation in the 127 of 206 patients in the vasospasm group, and in 0 of 183 patients in the nonvasospasm group (sensitivity, 62%; specificity, 100%).

The Japanese Circulation Society published guidelines in 2010 for the diagnosis of vasospastic angina.5 Evaluation options of those clinically suspected of having CAS included: • ECGs obtained during and after the attach, or after the administration of nitroglycerin • Use of Holter monitoring to capture events that occur outside of the hospital • Exercise testing in early morning, with differences observed from later testing • Hyperventilation testing in the morning, at least 48 hours after the cessation of vasoactive drugs • ACh or ergonovine provocation testing during coronary angiography Olusegun Coker, MD Peter Danis, MD St. John’s Mercy Family Medicine St. Louis, MO 1.

2.

3.

4.

5.

Ong P, et al. J Am Coll Cardiol. 2008; 52(7):523–527. [LOE 1b] Sueda S, et al. Coron Artery Dis. 2004; 15(8):491–497. [LOE 1b] Hirano Y, et al. Int J Cardiol. 2007; 116(3): 331–337. [LOE 1b] Nakao K, et al. Am J Cardiol. 1997; 80(5):545–549. [LOE 1b] JCS Joint Working Group. Circ J. 2010; 74(8):1745–1762. [LOE 5]

mo healthnet MAFP

Medicaid payment rate increases for primary care services - Calendar years 2013 and 2014 The MO HealthNet Division is preparing to implement provisions of federal law (Affordable Care Act Section 1201 Primary Care Increase) which requires Medicaid payments for primary care services furnished by a primary care practitioner with a primary specialty of family medicine, general internal medicine, or pediatric medicine be paid at parity with Medicare for services furnished in 2013 and 2014. The purpose of the provision is to encourage more physicians to participate in Medicaid, and thereby promote access to primary care services for current and new Medicaid beneficiaries.

The law defines covered services as those Evaluation and Management (E&M) codes and immunization services that are covered by Medicare, as well as primary care codes that Medicare does not currently cover but for which it publishes and sets relative value units. The law provides 100% federal funding for the incremental cost of meeting this requirement, calculated based on the Medicaid rate as of July 1, 2009. It is anticipated that approximately 700 primary care codes utilized by MO HealthNet (Missouri Medicaid) will be affected. A proposed rule will be filed by the Division to implement the payment which applies to payment within both Medicaid managed care and fee-for-service delivery systems.

Primary care services will be reimbursed at the Medicare rate for services provided by physician extenders if those services are properly billed under the provider number of an eligible physician,

regardless of whether the services were delivered by the physician or by physician assistants or advanced practice nurses under the physician’s personal supervision.

To qualify for these enhanced payments, physicians must complete the Medicaid Primary Care Physicians' Certification and Attestation for Primary Care Rate Increase form by clicking on the Primary Care Physicians' Rate Certification-Attestation tab. Physicians are encouraged to complete this form immediately.

The form may be accessed on-line at: http://mmac.mo.gov/providers/provider-enrollment/provider-enrollment-forms/

New physicians coming in will be sent the form by email.

Physicians must sign up “individually” – no clinic numbers – as board certified or saying they meet the 60% billing of E&M codes.

MO HealthNet Provider Bulletin, Vol. 35 No. 03: Physician Primary Care Rate Increase for Certain Services has been posted to the MO HealthNet website at: http://dss.mo.gov/mhd/providers/pdf/bulletin35-03_2012jul31.pdf

For additional information or questions, please contact the MAFP office at (573) 635-0830.

Attention Residents!

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) 635-0848 for more information.

Missouri Family Physician July - September 2012 17

MAFP resident grand rounds

When are Inferior Vena Cava Filters the Answer?

Tony Pallan, MD, PGY-2 Kavitha Arabindoo, MD, Faculty Research Family Medicine Residency Program Kansas City, MO

Introduction Deep Venous Thrombosis (DVT) is the third leading cardiovascular cause of death with approximately 1 million cases reported annually in the US and an estimated 300,000 deaths related to it.1 Patients with DVT are at high risk of developing pulmonary embolism (PE).

In a multicenter study, nearly 40% of patients admitted with DVT had evidence of PE on ventilation perfusion scan.2 The mainstay of therapy for this life-threatening condition is anticoagulation to prevent clot propagation and PE. However, for some patients, this treatment is insufficient or contraindicated secondary to bleeding complications. Such patients may require the placement of inferior vena cava (IVC) filters to prevent PE. While PE can occur from upper extremity DVT and the superior vena cava (SVC), the incidence is significantly less than from the IVC and complications from a filter in the SVC can be devastating. Placement of SVC filters should hence only be considered in extenuating circumstances.3 Case Presentation Mrs. AB is a 58 year old African American female with a history of breast and rectal cancers who was hospitalized for the management of incidental (asymptomatic) PE and started on continuous heparin infusion and warfarin. During the hospitalization, she developed small bowel obstruction that required surgical intervention. Preoperatively, warfarin and heparin were discontinued and a retrievable Inferior Vena Cava (IVC) filter was placed. Post-operatively, she 18 Missouri Family Physician July - September 2012

Kavitha Arabindoo, MD

was restarted on 5mg of warfarin and discharged home. She returned two weeks later with hematuria and was found to have a supratherapeutic INR of 14.8 with no identifiable etiology. Her anticoagulation was reversed with Vitamin K and she was dismissed home on a reduced daily dose of 2mg warfarin. Three months later, her primary care physician received a letter from the interventional radiologist asking that the patient be considered for removal of the IVC filter if it was no longer indicated.

This clinical scenario raises several questions regarding the use of IVC filters such as their indications, current guideline recommendations, permanent vs. retrievable filters and recent questions regarding the removal of retrievable filters.

A discussion on these topics follows.

Usage of IVC Filters The first percutaneous IVC filter, the Mobin Uddin Umbrella was introduced in 1967 and the now widely-used Greenfield filter later in 1973.4 A review of the National Hospital Discharge Survey Database for trends in IVC filter use in the U.S. found a 20-fold increase in the use of IVC filters from 1979 to 1999.5 In 2007, nearly 167,000 IVC filters were placed in the United States, and it is estimated that annual use will top 259,000 in 2012. This has largely been driven by the increasing availability of optional filters and their increased use for prophylactic, rather than treatment indications.6 Permanent and Retrievable IVC filters

Tony Pallan, MD

IVC filters are small multi-strutted filters inserted into the inferior vena cava percutaneously via the femoral or jugular approach under fluoroscopy or ultrasound guidance. They are typically placed infrarenally with the exception of renal vein thrombosis or IVC thrombus extending above the renal veins, in which case, the filter would be placed suprarenally.7 Permanent filters attach to the IVC wall with hooks, barbs or radial pressure and have been in clinical use for nearly 4 decades. Recognition of their complications and the sometimes transient nature of contradictions to anticoagulation led to the introduction of removable IVC filters. About 30% of IVC filters currently manufactured are permanent (e.g. Birdâ&#x20AC;&#x2122;s nest, Greenfield, Trap Ease) with the remaining 70% being removable/ retrievable filters (e.g. Celect, G2, Gunther Tulip, Opt Ease).8

IVC filter - Gunther Tulip http://en.wikipedia.org

Removable filters are of two kinds: temporary and retrievable filters.

Temporary filters are not attached to the IVC wall, but are attached to a catheter that exits the skin and, therefore, must be removed due to the risk of infection and/ or embolization. Retrievable filters are

resident grand rounds MAFP similar in design to permanent filters but are designed to be removed. These can be placed with or without the intent to be retrieved depending on the indications and clinical circumstances as all retrievable filters are FDA approved to be permanent devices.9 Evidence behind the Efficacy of IVC Filters To date, there has been only one randomized controlled trial (PREPIC study) that has evaluated the efficacy of IVC filters. All other studies have been retrospective or prospective case series.

The PREPIC study:10 Methods and Results Four hundred patients with proximal deep-vein thrombosis with or without pulmonary embolism were randomized either to receive or not receive a filter in addition to standard anticoagulant treatment for at least 3 months. Data on vital status, venous thromboembolism, and postthrombotic syndrome were obtained once a year for up to 8 years. Symptomatic PE occurred in 9 patients in the filter group (cumulative rate 6.2%) and 24 patients (15.1%) in the no-filter group (P=0.008). Deep-vein thrombosis occurred in 57 patients (35.7%) in the filter group and 41 (27.5%) in the no-filter group (P=0.042). At 8 years, 201 (50.3%) patients had died (103 and 98 patients in the filter and no-filter groups, respectively).

Conclusions - At 8 years, vena cava filters reduced the risk of pulmonary embolism but increased that of deep-vein thrombosis and had no effect on survival. Although their use may be beneficial in patients at high risk of pulmonary embolism, systematic use in the general population with venous thromboembolism is not recommended.

There have been no randomized studies to compare the efficacy of permanent vs. retrievable IVC filters for PE prevention. A retrospective study comparing the clinical effectiveness of the two filter types reported no difference in the rates of symptomatic PE or DVT. The frequency of symptomatic IVC thrombosis was similar.11

Indications and Contraindications for IVC Filters The main indication for IVC filter placement is the presence of deep venous thrombosis and either a contraindication and/or severe complication to anticoagulation such as high risk for bleeding, real bleeding, thrombocytopenia, immediate postoperative VTE or large central nervous system tumor.12 There are also some other ‘minor’ (no strong evidence to support usage) indications such as large, free-floating iliocaval thrombus, limited cardiopulmonary reserve, poor compliance with medication and patients at high risk of falls if placed on anticoagulation therapy. Complete IVC thrombosis is an absolute contraindication to IVC filter placement while relative contraindications include significant coagulopathy and bacteremia. The American College of Chest Physicians guidelines (listed below) also discourage the use of IVC filters in patients with trauma or acute spinal cord injury as thromboprophylaxis.13 Complications of IVC filter placement IVC filter design and deployment are continuously improving and are associated with fewer and less frequent complications than their predecessors. The filters can however be associated with complications such as device fracture, IVC perforation, duodenal perforation, filter thrombosis, recurrent pulmonary embolism, and migration.

Animal studies have shown that device endothelialization in the caval wall does not occur until about 2 weeks after placement, implying a vulnerability for the filter to migrate greater than 1 cm in either direction within the first 2 weeks of placement with reported migration rates from 0-18%.14 Asymptomatic penetration of filters through the IVC wall has been reported in 4-38% of patients and symptomatic penetration into adjacent structures such as the aorta, duodenum, ureters and the heart at a much lower rate (less than 1% of patients).8

A recent study by Nicholson noted a 16% rate of filter leg fracture for the Bard Recovery and Bard G2 filters.15 In seven patients, these fractures were associated with clinical symptoms, including one sudden death and one episode of cardiac tamponade due to a hemorrhagic pericardial effusion that required emergent cardiac surgery.

Removal of IVC Filters The decision to remove an IVC filter is a complex individualized process as the inherent risk of the filter has to be balanced against the possibility of future PE. Data on the criteria for filter removal are limited. Epithelialization of the filter struts has been observed within 12 days after filter insertion.16 The success rate for retrieving filters appears to start declining 3 months after the filters have been in place. It is hence recommended that retrievable filters be removed once the risk of thromboembolization has declined (as early as two weeks after initial placement). Recent studies however suggest that fewer than 20% of retrievable filters are removed.17 Establishing institutional protocols for filter retrieval has been shown to increase the rate of filter retrieval when indicated.18 American College of Chest Physicians (ACCP) Guidelines for IVC Filters The 2008 ACCP guidelines on VTE management follow a grading system that classifies recommendations as Grade 1 (strong) or Grade 2 (weak), and the quality of evidence as A (high), B (moderate), or C (low).19 Using this classification system, the following are the ACCP’s current recommended guidelines: • First line treatment for a confirmed DVT or PE is anticoagulation with subcutaneous low-molecular-weight heparin, intravenous unfractionated heparin, monitored subcutaneous heparin, fixed-dose subcutaneous unfractionated heparin, or subcutaneous fondaparinux (all Grade 1A recommendations).

• For most patients with PE and/or continued on page 20 Missouri Family Physician July - September 2012 19

MAFP resident grand rounds

Resident Grand Rounds continued from page 19

DVT, the ACCP recommends against the routine use of IVC filter in addition to anticoagulants (Grade 1A).

• For patients with acute proximal DVT, if anticoagulant therapy is not possible because of the risk of bleeding, IVC filter placement is recommended (changed from Grade 2C in the 2004 guidelines to Grade 1C).

• If a patient requires an IVC filter for treatment of an acute DVT or PE as an alternative to anticoagulation, it is recommended to start anticoagulant therapy once the risk of bleeding resolves (Grade 1C).

• For patients with chronic thromboembolic pulmonary hypertension (CTPH) undergoing pulmonary thromboendarterectomy, ACCP suggests the placement of a permanent IVC filter before or at the time of the procedure (Grade 2C).

Recurrent VTE Guidelines The 2008 ACCP guidelines13 omitted the early recommendation of IVC filter use for recurrent VTE, despite adequate anticoagulation (Grade 2C). Instead, it is recommended to look for other causes of recurrent VTE such as heparin induced thrombocytopenia, antiphospholipid syndrome, Trousseau syndrome, vascular compression, etc. in conjunction with a hematologist.

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Case Discussion Revisited As the IVC filter was placed during an acute episode of bleeding and peri-operative period, and Mrs. AB now tolerates oral anticoagulation for her pulmonary embolism, she should be referred back to the interventional radiologist for filter removal.

On August 9, 2010, FDA issued a recommendation that implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVC filters consider removing the filter as soon as protection from PE is no longer needed.20 References 1.

2.

3.

4.

5.

U.S. Department of Health & Human Services. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. www. surgeongeneral.gov/topics/deepvein. Published 2008. Accessed January 18, 2012.

Moser KM, Fedullo PR, Littlejohn KL, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis. JAMA. 1994;271(3):223-225.

Owens CA, James TB, Knuttinen MG. Pulmonary Embolism from Upper Extremity Deep Venous Thrombosis and the Role of Superior Vena Cava Filters: A Review of the Literature. Journal of Vascular and Interventional Radiology. Volume 21. Issue 6.Pages 779-787. June 2010.

Clinical Practice Guidelines (8th edition). Chest. 2008;133(6Suppl):454S-545S. Stein PD, Kayali F, Olson RE. Twenty-one-year trends in the use of inferior vena cava filters. Arch Intern Med. 2004;164(14):1541-1545.

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13.

14.

15.

16.

17.

18.

19.

20.

Smouse B, Johar A. Is market growth of vena cava filters justified? Endovascular Today.

2010:74-77.

Becker DM, Philbrick JT, Selby, JB. Inferior vena cava filters.

Indications, safety, effectiveness.

Arch Intern Med. 1992; 152(10):1985-1994.

Streiff MB. Vena cava filters: a comprehensive review. Blood.

2000;95(12):3669-3677.

Ku G, Billett H. Long lives, short indications: the case for removable inferior cava filters.

Thromb Haemost. 2005;93(1):17IVC filter expandable wire mesh basket 22. http://www.abhamed.nte PREPIC Study Group. Eight year follow up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC randomized study. Circulation. 2005; 112(3): 416-422.

Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338(7):409-415.

Abdel-Razeq H, Mansour A, Ismael Y, et al. Inferior vena cava filters in cancer patients: to filter or not to filter. Ther Clin Risk Manag. 2011;7:99-102.

American College of Chest Physicians: Chest Journal Antithrombotic & Thrombolytic therapy, 8th Ed: ACCP Guidelines. www.chestnet.org/accp/ guidelines. Published June 2008. Accessed January 12, 2012.

Burbridge BE, Walker DR, Millward SF. Incorporation of the Gunther temporary inferior vena cava filter into the caval wall. J Vasc Interv Radiol. 1996; 7: 289-290.

Nicholson W, Nicholson WJ, Tolerico P. Prevalence of Fracture and Fragment Embolization of Bard Retrievable Vena Cava Filters and Clinical Implications Including Cardiac Perforation and Tamponade. Arch Intern Med. 2010;170(20):1827-1831.

Anderson RC, Bussey HI. Retrievable and permanent inferior vena cava filters: selected considerations. Pharmacotherapy 2006: 26: 1595-1600.

Charles HW, Black M, Kovacs S, et al. G2 inferior vena cava filter: retrievability and safety. J Vasc Interv Radiol. 2009;20(8): 1046-1051.

Ko SH, Reynolds BR, Nicholas DH, et al. Institutional protocol improves retrievable inferior vena cava filter recovery rate. Surgery. 2009;146(4):809-814.

Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines; report from an American College of Chest Physicians task force. Chest. 2006;129(1):174-181.

US Department of Health and Human Services. FDA protecting and promoting your health. Inferior vena cava (IVC) filters: initial communication: risk of adverse events with long term use. www.fda.gov/Safety/MedWatch/ SafetyInformation/SafetyAlerts for HumanMedicalProducts. Updated August 9, 2010. Accessed February 16, 2012.

Missouri Family Physician July - September 2012 21

MAFP legislative update

Health Care Legislation 2012 Session of the Missouri General Assembly

by Pat Strader, MAFP Governmental Consultant It was a rather long, contentious session which ended on Friday, May 18. The session has been described by the media as “short of substance, long on symbolism.”

While not a lot of the issues we would have liked to see pass actually did, defense cannot be taken lightly when you consider what could have passed into law. MAFP took positions on a large number of legislative measures – testifying in support and opposition as the issue required. I want to thank the physicians who came to Jefferson City to testify before committees, to the many physicians who contacted their elected officials when a “call to action” was issued, and to those who attended the Advocacy Day in February and engaged their legislators in discussions about issues important to you and your patients.

LEGISLATION ENACTED Health Insurance Exchange (SB 464) Prohibits the establishment and operation of a health insurance exchange in Missouri unless authorized by a state law or a subsequent vote of the people.

Missouri No-Call List (HB 1549) Allows cell phone numbers to be added to Missouri’s no-call list for telemarketers, which currently applies only to residential land-line phones.

Workers Compensation (HB 1540) Prevents employees from being sued by co-workers for work-related injuries unless the employee was engaged in an affirmative negligent act that purposefully and dangerously caused or increased the risk of injury.

Collaborative Agreements – APRN Chart Review (HB 1563) A physician other than the supervising physician is authorized to review the records of an advanced practice registered nurse if the reviewing physician 22 Missouri Family Physician July - September 2012

is designated in the collaborative practice agreement.

Physician Assistants (HB 1563) Under current law, physician assistants who are authorized to prescribe controlled substances must register with the federal Drug Enforcement Administration and the State Bureau of Narcotics and Dangerous Drugs and shall include such registration numbers on prescriptions for controlled substances. This amendment requires the physician assistants to only include the registration number from the Drug Enforcement Administration on the prescriptions.

Behavior Analysts (HB 1563) The categories of provisionally licensed behavior analyst, provisionally licensed assistant behavior analyst, temporary licensed behavior analyst, and temporary licensed assistant behavior analyst are added to the current professions that can be licensed.

Pain Management (SB 682) Mandates that only licensed physicians may use certain techniques in diagnosing or treating chronic pain or pain occurring outside of a surgical, obstetrical, or post-operative course of care. Such techniques limited to licensed physicians are ablation of nerves, placement of drugs in the spinal column under fluoroscopic guidance, discectomy, and placement intrathecal infusion pumps or spinal cord stimulators. The act does not apply to inter-laminar lumbar epidural injections performed at a hospital or ambulatory surgery center if the standard of care for medicare reimbursement is changed to allow reimbursement only with use of image guidance after the effective date of the act. This act does not apply to certified registered nurse anesthetists or anesthesiologist assistants providing surgical, obstetrical, or post-operative

pain control. The bill has a sunset date of August 28, 2016, and will have to be revisited at that time.

Protection for the Religious Beliefs as to the Imposition of Certain Health Care Services (SB 749) Provides that anyone providing or participating in a medical service cannot be required to participate in a service if it violates his or her conscience or principles.

Administration of Asthma Medication (HB 1188) Allows a school nurse or other trained employee to administer asthmarelated rescue medication to a student experiencing an asthma attack.

Child Care (HB 1323) Establishes a new child care subsidy program and tightens restrictions on unlicensed child care facilities.

Missouri Electronic Prior Authorization Committee and Pilot Program (HB 1827/ HB 1563) A committee is established to facilitate and monitor Missouri-based efforts to contribute to the establishment of national electronic prior authorization standards. The efforts must include the establishment of a pilot program and the study and dissemination of information from the National Council on Prescription Drug Programs. In consultation with the Department of Insurance, Financial Institutions and Professional Registration and the committee, a Missouri-based pharmacy benefits manager doing business nationally must conduct a pilot program if there are adequate Missouri licensed physicians and a vendor capable and willing to participate in the program, which must be operational by January 1, 2014.

The bill creates an 18-member committee which must give their first report to the General Assembly

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legislative update MAFP

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by January 1, 2013. Upon the adoption of national standards, the committee must prepare a final report to the General Assembly and the Governor that identifies the appropriate Missouri administrative regulations that will be needed and if there are any necessary legislative actions.

Cardiopulmonary Resuscitation Instruction (SB 599) Public and charter schools serving grades nine through twelve may provide their students instruction in cardiopulmonary resuscitation, as described in the act. Students with disabilities may participate to the extent appropriate as determined by the provisions of the Individuals with Disabilities Education Act or Section 504 of the Rehabilitation Act. A teacher of the cardiopulmonary resuscitation course does not need be a certified trainer if the instruction is not designed to result in certification of students. Instruction that is designed to result in certification must be taught by an authorized cardiopulmonary instructor. This was originally HB 1337 but was passed in SB 599.

Administrative Rules (SB 469/HB 1135) This act provides that every state administrative rule shall be subject to a periodic review by the appropriate state agency every five years and creates a schedule for the periodic review of rules by their title in the Code of State Regulations.

The Secretary of State is given the authority to make non-substantive changes to the Code of State Regulations to update state agency information, such as name or address changes.

LEGISLATION NOT ENACTED Clinical Lab Technician Licensing (SB 544) Would have created certification for laboratory technicians (basically required to perform any testing that is not CLIA waived) and phlebotomists (required training and certification just to draw blood). MAFP strongly opposed this legislation.

Nurse Independent Practice (HB 1371/ SB 679/HB1996) Would have completely removed the current requirement that

APRNs have collaborative agreements with physicians. APRNs would have no longer been limited to practicing in the speciality in which they were trained.

Would have removed the 50-mile distance rule and current chart review procedures.

Would have added a new definition of “advanced practice registered nursing” which definition, among other things, included “serving as primary care providers of record.”

Children’s Vision Commission/Mandated Eye Exams (HB 1339/SB 641) Would have removed the sunset on the current statute, continuing mandated eye exams for all students entering kindergarten or first grade, discontinued required enhanced eye screenings by school nurses, and did not reauthorize or continue the Children’s Vision Commission. This program will expire June 30, 2012 and will likely be revisited next session.

Electronic Cigarettes and Preemption (HB 2103) Would have specified that a local political subdivision could not restrict the use of an electronic cigarette in a public place and exempted any public place that derives at least 60% of its retail sales from alcohol, tobacco, or entertainment from any local ordinance or rule relating to smoking in public places.

Prompt Credentialing (SB 742/HB 1490/ SB 526) Would have established a process for health insurance carriers to credential health care practitioners within 90 days (original language specified 60 days).

Tobacco Taxes (HB 1673/HB 1478/ HB 1976) Various bills filed would have increased cigarette taxes in different amounts and used the revenue in a variety of ways.

Clean Indoor Air (HB 1352/SB 664) These bills would have revised Missouri’s laws on smoking in public places.

Unfortunately, the bills were never scheduled for hearings.

Physician Assistants (HB 2094/SB830) Several bills were filed changing the statutes regarding physician assistant supervision. PAs are looking to be “on par” with APRNs. Physician Queryable Prescription Database (HB 1193/SB 710) Would have created a prescription monitoring program for Missouri, which is only one of two states (NH) that does not have a program in place. A small number of legislators opposed the legislation citing intrusion on privacy of individuals’ prescription information. The program is aimed at stopping “doctor shopping” and provide a database for physicians to use as a tool to check to see if patients are receiving prescriptions for controlled substances from multiple providers.

Chiropractors MO HealthNet Reimbursement (HB 1533) Would have required licensed chiropractors to be reimbursed under the MO HealthNet Program for providing services currently covered and within the scope of chiropractic practice – further stressing already limited program funds.

Tanning Beds (HB 1475) Would have required in-person parental consent for a minor younger than 17 to use a tanning device in a tanning facility.

Midwives • Would have created a midwifery board under the Division of Professional Registration to oversee certified professional midwives who are certified by the North American Registry of Midwives (NARM).(HB 1678); • Would have required lay midwives to present each client proof of malpractice insurance coverage in an amount of at least $1 million prior to providing services.(HB 1840) Healthcare Advertisements (HB 1622/ SB 750) Would have required any advertisements for health care services to include specified information (board certification, etc.) and prohibited it from containing any misleading or false statements. continued on page 25 Missouri Family Physician July - September 2012 23

MAFP asa photos 2012

Donald Potts, MD, receives his 45-year MAFP Member certificate from George Harris, MD, Member Services Commission Co-Chair.

MAFP Board Member, Jamie Ulbrich, MD, and his family pose for a photo during the annual Family Fun Picnic held June 22.

Todd Shaffer, MD, presents Fred Rottnek, MD, with the AAFP Fellow certificate during the Awards and Installation Luncheon on June 23.

Keith Ratcliff, MD, and Todd Shaffer, MD, are pictured above with the Soaring Eagle Award. MAFP presents the award to the outgoing board chair annually.

Jackie Newton aka Sparkie Da' Clown is pictured with a "disguised" attendee at the Family Fun picnic.

Dana Galbraith, MD, is pictured with her sons at the Family Fun Picnic on Friday evening.

Resident Poster Winners Thirteen poster presentations were presented in the 2012 poster contest which is held annually at the Annual Scientific Assembly. Residents from Research Family Medicine Residency and faculty are pictured (right) with the winning poster by Travis Charles, DO. First Place – Travis Charles, DO Research Family Medicine Residency Post-treatment Chest X-rays for Community-Acquired Pneumonia Second Place –Catherine Tung, MD Research Family Medicine Residency Inactivity in the Acute Management of DVT Third Place (tie) – Michael Zybko, DO Research Family Medicine Residency Initial Treatment of Venous Thromboembolism, Heparin Infusion vs. LMWH Third Place (tie) – Sara Bradshaw, MD, MPH, and Alberto Del Pilar, MD UMKC Family Medicine Residency An Intervention to Improve Physician Comfort Levels in Domestic Violence Screening and Intervention 24 Missouri Family Physician July - September 2012

Pictured above (left to right): Uyiosa Aimiuwu, MD, Tony Pallan, MD, Kavitha Arabindoo, MD, Michael Zybko, DO, and Travis Charles, DO. Pictured left: Michael Zybko, DO, explains his poster presentation to Donald Potts, MD, during the Student and Resident Mixer.

legislative update MAFP

Legislative Update continued from page 23

Co-Pays for Certain Therapists (HB 1134/SB 687) Would have limited the copayment, coinsurance, or deductible imposed by a health insurer for licensed occupational, speech, or physical therapist services to that for services provided by a primary care physician or osteopath.

Economic Credentialing (SB 529) Would have prohibited hospitals from requiring physicians to agree to make patient referrals as a condition of receiving medical staff privileges.

Texting While Driving (Numerous Bills) Would have expanded the ban on texting while driving for all Missourians (now only applies to 21 years and younger); included an exemption for use of “hands free” device.

Covenants Not to Compete (SB 512) Would have provided that any employment contract restricting the right of a physician to practice medicine in any geographic area for any period of time after the termination of a partnership, employment or professional relationship as described in the act, would be void and unenforceable with respect to such restriction.

Diagnostic Imaging (SB 534) Would have prohibited insurers from denying reimbursement for providing diagnostic imaging services based solely on the speciality or professional board certification of a licensed physician.

Radiology Benefits Managers (SB 707/ HB 1529) Would have restricted the authority of radiology benefit managers to deny diagnostic testing ordered and recommended by a physician.

Immunizations – Notification of Vaccine Ingredients (HB 1990) Would have required health providers that give vaccinations to children under the age of seven to provide an information sheet identifying the ingredients contained in that vaccination.

Motorcycle Helmet Repeal (SB 743/HB 1670) Would have exempted motorcyclists age 21 and older from wearing a helmet when operating a motorcycle or motor tricycle.

Any Willing Provider (SB 519/HB 1816) Would have required health carriers to provide internet access to its standard fee schedules and prohibit carriers from refusing to contract with providers willing to meet certain provider participation terms and conditions. HB 1816 included additional language regarding provider referrals.

Volunteer Health Services (HB 1072) Would have established the Volunteer Health Services Act to allow certain licensed health professionals to provide services without additional licensure

requirements. These changes stem from the recent Missouri disasters such as the tornado in Joplin.

Mental Health Facility Restraint (HB 1663) Would have authorized an advanced practice registered nurse in a collaborative practice arrangement with a licensed physician to determine whether the restraint of a patient in a mental health facility was necessary.

State –Regulated Health Insurance Mandates (HB 1890) Would have required the State to conduct an actuarial analysis of the cost impact of two health insurance mandates – (1) Orally administered anticancer medication as intravenously administered or injected cancer medication and (2) Diagnosis and treatment of infertility

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MAFP 2012 Asa sponsors & exhibitors

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2012 ASA Sponsors & Exhibitors

The MAFP would like to recognize and thank the organizations who supported and participated in the 64th Annual Scientific Assembly in June. Join us in expressing our appreciation to the following: Sponsors Midwest Dairy Council Missouri Professionals Mutual (MPM) MMIC Group Exhibitors AAFP AIM-HI/Tobacco Cessation Abbott Children's Mercy Hospitals & Clinics Corizon Health Cox Health Department of Veterans Affairs Fresenius Medical Care Genzyme Health Diagnostic Laboratory

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2012 tar wars winner MAFP

Missouri Tar Wars Winner Attends National Conference

Jamison Liles, Craig R-3 School, Craig, Missouri, is pictured above with his first place poster at the annual National Conference in Washington, DC. Jamison and his family visited congressional offices on Capitol Hill July 16-17, 2012.

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