Family Medicine Career Paths by mo-afp

FP WINTER 2021

MISSOURI FAMILY PHYSICIAN VOLUME 40, ISSUE 1

Family Medicine Career Paths

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MISSOURI FAMILY PHYSICIAN January - March 2021

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FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION BOARD CHAIR Jamie Ulbrich, MD, FAAFP (Marshall) PRESIDENT John Paulson, DO, PhD, FAAFP (Joplin) PRESIDENT-ELECT John Burroughs, MD (Liberty) VICE PRESIDENT Kara Mayes, MD (St. Louis) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR Arihant Jain, MD (Cameron) ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Brooks Beal, DO (Kirksville) ALTERNATE Vacant DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis) DIRECTOR Dawn Davis, MD (St. Louis) ALTERNATE Lauren Wilfling, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald) ALTERNATE Jennifer Allen, MD (Hermann) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia) ALTERNATE Amanda Shipp, MD (Versailles) DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville) ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City) DIRECTOR Afsheen Patel, MD (Kansas City) ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Andi Selby, DO (Joplin) ALTERNATE Kurt Bravata, MD (Buffalo) DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston) ALTERNATE Vacant DISTRICT 10 DIRECTOR Vicki Roberts, MD, FAAFP (Cape Girardeau) ALTERNATE Gordon Jones, MD (Sikeston) DIRECTOR AT LARGE Jacob Shepherd, MD (Lees Summit)

CONTENTS 4 Family Medicine Career Paths 6 MAFP Participates in COVID-19 Prevention Awareness Campaign 6 MAFP Addresses Vaccine Deployment Concerns with MDHSS 8 MAFP Report on 2020 Congress of Delegates 10 MAFP Legislative Review for the 2021 Session 12 Your Voice and Your Message 13 I Love Working at A Community Health Center 14 Annual Fall Conference in a COVID Pandemic 16 Balancing the Many Hats in Academic Family Medicine 20 See the World as a Small Town Doctor 22 From Medical School to Military Physician 24 Making Cents of CPT Codes in 2021 29 Members in the News

MARK YOUR CALENDAR February 4

RESIDENT DIRECTORS

State of Missouri Healthcare (Virtual) Visit www.mo-afp.org/advocacy/advocacy-day/ for more details. February 11

STUDENT DIRECTORS

Update from Missouri Department of Health and Senior Services (Virtual) Visit www.mo-afp.org/advocacy/advocacy-day/ for more details. February 18

AAFP DELEGATES

Legislation in the House Professional Registration Committee (Virtual) Visit www.mo-afp.org/advocacy/advocacy-day/ for more details. February 25

John Heafner, MD, SLU Morgan Murray, MD, UMKC (Alternate) Noah Brown, UMKC Kelly Dougherty, UMC (Alternate) Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Sarah Cole, DO, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon. Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org

Detailed Legislative Briefing (Virtual) Visit www.mo-afp.org/advocacy/advocacy-day/ for more details. March 2 Advocacy Day (Virtual) and Speak Out Visit www.mo-afp.org/advocacy/advocacy-day/ for more details. March 2 MAFP Board of Directors Meeting (Virtual)

2021 MAFP outreach meetings TBA. Watch your email for dates and locations. The Show Me Family Medicine Conference will not be held in 2021. MO-AFP.ORG 3

Family Medicine Career Paths

W Jamie Ulbrich, MD, FAAFP Board Chair, Marshall

hen we look back on 2020, how This issue will help us make better career many of us thought our careers decisions that ultimately lead to better patient would look the way they do now? care. You’ll be able to explore fellowships, Whether you are an employed different employment types, learn more about physician, self-employed, work in academia, some of your colleagues’ unique journeys, and get work for the government, are a resident trying some valuable information on billing changes we to determine what your career will look like, or all need to know. are a student wondering what family medicine will look like “…one of the greatest five years from now, we’ve all endured monumental changes attributes of family in our careers. medicine is the breadth Looking forward to 2021 and of subspecialties we can beyond, we will continue to search for the best ways to care pursue for our patients by using the best tools in the best environment for each of us. Every career is Please remember that as we continue our fight unique and one of the greatest attributes of family against this COVID-19 pandemic, know that our medicine is the breadth of subspecialties we can hearts and prayers continue to be extended to pursue. With so many choices, it can be hard to you, your family, and patients during this most know which decision to make and where to go. trying time. The diversity of our profession also represents our diversity as individuals.

“

”

“Whatever you are, be a good one.” - Abraham Lincoln

Mission Statement:

The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education and research.

MISSOURI FAMILY PHYSICIAN January - March 2021

YOUR EXPERIENCE TRANSCENDS BORDERS.

YOUR PRACTICE CAN TOO.

We are looking for board-certified physicians to deliver primary acute, preventive, and emergency medical care to U.S. government employees and their families overseas, sometimes in remote locations and with limited access to medical resources. Consider a career where you will get paid to explore the world and immerse yourself in foreign cultures while practicing medicine. Get ready to make a lasting impact and play a vital role in supporting healthcare diplomacy.

Apply today to become a Regional Medical Officer in the Foreign Service and join more than 200 clinicians providing essential healthcare services in locations around the globe. You will receive a competitive salary, generous benefits, and the opportunity to expand your knowledge and perspective in a career unlike any other.

Apply now! Visit https://careers.state.gov/MED/ U.S. citizenship is required. An equal opportunity employer.

SPRINGFIELD MISSOURI

EXPLORE Your Possibilities Family Medicine opportunities

SPRINGFIELD | BRANSON MONETT | LAMAR

13%

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MILES OF TRAILS

NONSTOP FLIGHTS

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DAYS OF SUNSHINE

Seeking BE/BC physician ADVANTAGES • Locations include Springfield, Missouri, surrounding communities and Urgent Care • Top 100 Integrated Health System • 2018, 2019, 2020 Modern Healthcare Best Places to Work

BENEFITS • Competitive salary • Comprehensive benefits package • Sign-on bonus • Relocation allowance

1-800-869-4201 michael.mann@coxhealth.com MO-AFP.ORG 5

MAFP Participates in COVID-19 Prevention Awareness Campaign

ith Missouri’s COVID-19 positive rate skyrocketing and hospitalization rates imperiling hospitals’ ability to provide care to the state’s residents, a coalition of organizations launched a new educational effort encouraging Missourians to engage in the recommended behaviors to reduce the spread of the virus. “Family physicians are on the front lines of this pandemic and we need to protect all Missourians against this virus that is putting a huge strain on clinics, hospitals, and our personal lives.” said John Paulson, DO, PhD, FAAFP, MAFP Board President. “Our clinics are challenged with caring for those who contracted this disease, and ensuring the health and wellness of all of our patients. We must all do our part to reduce the spread of the disease and to reduce the pressure on our healthcare system.”

Together, the Coalition for Healthy Missouri Communities, is calling on all Missourians to engage in practices that can reduce the spread of the virus — wearing face coverings, maintaining social distancing and practicing good hand hygiene. The goal of the campaign is to increase protection, thereby reducing the infection rate and driving down hospitalizations. We are at a critical time with the growth of the virus in Missouri and winter is going to be one of the hardest times for the virus. With people gathering during the holiday season, many new exposures will occur if we don’t take the necessary precautions. The campaign includes a growing number of organizations with stakeholders in every community statewide. Additional resources are available at www.healthymocommunities.com.

Coalition for Healthy Missouri Communities • Missouri Chamber of Commerce and Industry • Missouri Farm Bureau • MU Extension • Missouri Hospital Association • Missouri Health Care Association • Missouri State Medical Association • Missouri Academy of Family Physicians • LeadingAge Missouri

• Missouri Association of Osteopathic Physicians and Surgeons • Missouri Bankers Association • Missouri Center for Public Health Excellence • Missouri Association of Counties • Missouri Nurses Association • Missouri Primary Care Association • Missouri Retailers Association • One for All

MAFP Addresses Vaccine Deployment Concerns with MDHSS In a letter to Randall Williams, MD, FACOG, Director, Missouri Department of Health and Senior Services, Jamie Ulbrich, MD, FAAFP, Board Chair, expressed concerns about the deployment of the COVID-19 vaccines in Missouri. Dr. Ulbrich serves on the deployment team and reiterated his concerns in this letter. “As a rural family physician, I am confronted with daily challenges in caring for my patients. My clinic is small and the deployment outlined by the committee is fraught with processes that create a burden to implement in small clinics. It is a very laborious process with too many hoops to jump through if you are in private practice,” said Ulbrich. “Our rural Missourians deserve the same access to care as citizens who live in urban areas. The plan identified will limit rural Missourians’ access to the vaccine through availability and accessibility.” As planned, the vaccine will be distributed within 75 miles of a Walgreens and CVS retail outlet. This would exclude our more rural communities. However, other grocery stores with pharmacies in rural areas are working with the MDHSS to be of service in distributing the vaccine. And, for small clinics, accessibility is at risk because it does not make sense to participate if you are not 6

MISSOURI FAMILY PHYSICIAN January - March 2021

already signed up as a Vaccines for Children program provider. The time commitment for the enrollment process, along with the required continuing education, is another administrative burden placed on small practicing physicians. Urban, underserved areas are also impacted. The patients, based on demographics, are at increased risk of contracting COVID-19 due to skepticism of the healthcare system and will be more difficult to vaccinate. With time caring for patients during this pandemic already limited, the requirement to enroll in the vaccine registration program has compounded a stressed practice. Family physicians are key to the success of the roll out of the COVID-19 vaccine. We educate our patients on the importance of and need to receive the vaccine to minimize concerns and hesitancy to getting the vaccine. Kathy Pabst, MAFP Executive Director, is meeting weekly with the Missouri Advisory Committee on Equitable COVID Vaccine Distribution. She is working to represent independent physicians and their access to the vaccine for you and your team. Share your experiences with her through email at kpabst@mo-afp.org.

Hypophosphatasia (HPP) is a metabolic disorder characterized by LOW Alkaline Phosphatase (ALP) activity1 Patients with HPP may experience unpredictable, devastating, and life-limiting consequences, including:1 SHORT STATURE AND/OR UNUSUAL GAIT

PREMATURE TOOTH LOSS

MUSCLE WEAKNESS AND/OR FATIGUE

• In adults, low ALP activity is <40 U/L2,a

CHRONIC MUSCLE/ JOINT PAIN

SKELETAL DEFORMITIES AND/ OR FRACTURES

• Age- and sex-adjusted ALP reference intervals must be used in children3.4

Patients with any of these key signs/symptoms and LOW ALP should be evaluated for HPP1 a

Example cutoff from Abbott Laboratories; adult ALP ranges are lab specific and may vary.

References: 1. Bishop N, et al. Arch Dis Child. 2016;101(6):514-515. 2. Alkaline phosphatase [package insert]. Abbott Park, IL: Abbott Laboratories; 2007. 3. Offiah AC, et al. Pediatr Radiol. 2019;49(1):3-22. 4. Colantonio DA, et al. Clin Chem. 2012;58(5):854-868.

LOW Alkaline Phosphatase (ALP) may not be flagged if your laboratory does not use age- and sex-adjusted reference intervals in children when testing ALP activity1 Age- and sex-adjusted ALP reference ranges, U/L2,3 Females 518

518

400

100

280

273

369

156 141 134

128 62

365

273

95 48

014 15 d d<1 y 1<1 0 10 y -<1 3 13 y -<1 5 15 y -<1 7 17 y -<1 9 y

460

369

300 200

517

460

Normal ALP 156 141 134 127

164 89

014 15 d d<1 y 1<1 0 10 y -<1 3 13 y -<1 5 15 y -<1 7 17 y -<1 9 y

ALP Activity, U/L

500

Males

150 40

Low ALP in pediatric females Low ALP in pediatric males Low ALP in adults

Ad ult sa

600

Age

NOTE: Graph adapted from the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) project. 2 Caliper samples from 1072 male and 1116 female participants (newborn to 18 years) were used to calculate age- and sex-specific reference intervals. No variation in ALP based on ethnic differences was observed. Reference intervals shown were established on the Abbott ARCHITECT c8000 analyzer. a

Adult interval provided by the Abbott ARCHITECT ALP product information sheet is for females >15 and males >20 years of age. For younger ages, Abbott does not provide lower limits of normal.3

LOW Alkaline Phosphatase (ALP) is hallmark of Hypophosphatasia.1 To learn more, please visit www.hypophosphatasia.com References: 1. Rockman-Greenberg C. Pediatr Endocrinol Rev. 2013;10(2 suppl):380-388. 2. Colantonio DA, et al. Clin Chem. 2012;58(5):854-868. 3. Alkaline phosphatase [package insert]. Abbott Park, IL: Abbott Laboratories; 2007.

Please contact [amy.flinn@alexion.com] to learn more information about hypophosphatasia.

MAFP Representatives: (left to right) John Paulson, DO, President; Bill Plank, Assistant Executive Director; Todd Shaffer, MD, Delegate; Peter Koopman, MD, Alternate Delegate; Keith Ratcliff, MD, Delegate; Kathy Pabst, Executive Director. Not Pictured: Kate Lichtenberg, DO, Alternate Delegate

MAFP Report on 2020 Congress of Delegates

Keith Ratcliff, MD, FAAFP Washington

his has been a challenging year for many aspects of medicine, and the 2020 AAFP Congress of Delegates (COD) proved to be no exception to this. Your MAFP delegation, appointed by the Board of Directors, included Keith Ratcliff, MD and Todd Shaffer, MD as Delegates and Kate Lichtenberg, DO and Peter Koopman, MD as Alternate Delegates. MAFP President John Paulson, DO, PhD, was available to attend COD this year and assist with deliberations of the Delegation. Faced with the COVID-19 pandemic, the AAFP wisely decided on a virtual format for the COD this year. Planning started very early with the appointment of Congress Committees that began doing their work virtually. Dr. Ratcliff was chosen to serve on the Rules Committee which was required to modify our usual processes to accommodate a virtual meeting. Chapters were asked to submit a maximum of two resolutions this year so that all would be able to have their most pressing concerns represented. With the guidance of the Speaker and Vice-Speaker,

MISSOURI FAMILY PHYSICIAN January - March 2021

new rules were promulgated and approved so that the Congress could convene in a virtual format. Plans were laid for the Reference Committees to meet virtually and hear testimony from the Members and Delegations the two weekends prior to the COD. AAFP staff had chosen Lumi as the vendor through which to conduct our business and voting. After resolutions were provided, your delegation reviewed them, and they were presented to the MAFP Board for comments and guidance. The Board participated in a detailed survey to help your delegation understand which issues were most important for our members, and for guidance on how to best represent the perspective of Missouri’s Family Physicians. To effectively discuss and vote on resolutions and election of officers for the AAFP in real time, the MAFP Delegation decided on a “hybrid” model. Kathy Pabst, MAFP Executive Director and Bill Plank, Assistant Executive Director, were able to arrange a meeting room where your Delegation

could meet in person, but still be appropriately distanced with masking and sanitation stressed. Our staff did a great job keeping us amped up on caffeine and chocolate so that we could enthusiastically contribute to the work of the Congress over the two-day marathon meeting. The connectivity and technical challenges were mastered by Bill so that the Delegation could focus on the rapidly changing discussions. Adopted resolutions included issues such as abolishing the X waiver for buprenorphine, COVID-19 vaccine distribution not being dependent on the ability to pay, mandatory notification to physicians on vaccinations administered at pharmacies, reduction of regulatory burden on physicians, comprehensive reproductive healthcare for incarcerated individuals, alternatives to detention of asylum seekers, developing a position paper on policing as it relates to public health, and developing a position paper on climate change and health. A summary of the actions on resolutions can be found at: https://www.aafp.org/dam/ AAFP/documents/about_us/congress/restricted/2020/2020%20 Summary%20of%20Actions.pdf.

“

The Congress elected three new Directors for 2020 including Dr. Jennifer Brull of Kansas, Dr. Mary Campagnolo of New Jersey, and our very own Dr. Todd Shaffer. Dr. Sterling Ransone of Virginia was chosen as the AAFP president-elect. Other leaders chosen at the COD were: Dr. Danielle Carter of Florida as the New Physician Board member; Dr. Anna Askari of California as our Resident Board member; and Cynthia Ciccotelli of Pennsylvania as the Student Board member. Dr. Ada Stewart of South Carolina was sworn in as our new AAFP President and provided a moving address to the Congress. She will represent us well in the coming year. With a great deal of work from the members involved, and despite the challenges and limitations inherent in this temporarily virtual world, your AAFP was able to conduct meaningful business at the COD and continue to promote the remarkable contribution that our dedicated Members make to the health of this nation. Your MAFP COD Delegation thanks you for the trust you have shown in us.

Despite the challenges and limitations inherent in this temporarily virtual world, your AAFP was able to conduct meaningful business.

”

MO-AFP.ORG 9

MAFP Legislative Review for the 2021 Session

he 1st Regular Session of the 101st General Assembly promises to be one that keeps everyone on their toes. It continues to amaze those of us that regularly walk the halls of the Capitol -- the things that happen from year to year that we regard as “unprecedented”. It seems like the oddities and the unusual have become the norm which makes knowing what to expect and knowing how to move legislation very tough. Brian Bernskoetter A big help and a steadying factor in dealing with Governmental Consultant every changing norm is consistent messaging with your legislators and member engagement by you on behalf of the MAFP. We are anticipating many challenges this year in communicating concerns and opportunities because of the need for social distancing, masking and remote hearings. For lobbyists and hallway regulars, the rhythm and flow of the Capitol happens with impromptu and contemporaneous hallway communications which will be challenging next session to say the least. In terms of major items for next session, there are quite a few issues on the early list. First and foremost, will be the implementation of Medicaid expansion which was passed in August by the voters and now ensconced in our state’s Constitution. The Republican majority has made it pretty plain that they didn’t agree with the voters on expanding Medicaid per the Affordable Care Act, and will be working to blunt the expected fiscal impact on the state budget. As a starting point, they are likely to propose work requirements, reductions to reimbursements, and pro-free market reforms to encourage choice and competition, in addition to other proposals. 10

MISSOURI FAMILY PHYSICIAN January - March 2021

While the Governor did call an Extra Session to attempt to address COVID Liability Protections for healthcare providers and businesses, it never really took off and will have to wait to be addressed during the regular session. The measures being considered should hopefully provide some legal protections for health care systems and providers from liability. Potential liability circumstances include elective surgeries or routine screenings that were delayed, and in instances where equipment or providers were pressed into service outside of the normal scope of their duties. The plaintiffs’ bar has expressed great concerns about this legislation and will undoubtably put up a big fight to keep it from passing. With the COVID vaccine implementation, it is likely to rekindle the debate around mandatory vaccination and other reforms that vaccine hesitant Missourians would like to see implemented. The MAFP has been on the front line of this battle and will continue to advocate for common sense measures that support the science-based use of vaccines to promote community health. Our involvement in the Missouri Immunization Coalition ensures family physicians will have a voice in these initiatives. Scope of practice legislation will be another issue that gets discussed during the upcoming legislative session. Staffing shortages are causing more and more stresses on the healthcare system. With Governor Parson’s Executive Orders creating opportunities for mid-level providers to make their case for changes to expand scope of practice, this will be a challenge for sure. The MAFP is also looking at some proactive measures for the next legislative session. Last

session, Rep. Jon Patterson, a physician from Independence, proposed legislation on our behalf that would have slightly increased medical license fees charged by the state to establish a tax credit program to incentivize preceptorships in rural and underserved areas of the state. Rep. Brenda Shields, R-St. Joseph, will sponsor the 2021 measure which is identical to the 2020 verbiage. Additionally, the MAFP is currently working to build a coalition to advance legislation to identify the amount of health care dollars spent on primary care in this state and create a task force to come up with ways to increase it in the future. The concept is modeled after legislation that was recently passed in Colorado. The concept is very simple to explain but difficult to implement. Currently, we don’t really know how much insurers are spending on primary care in the state of Missouri. Based upon national estimates, it is likely somewhere in the 5-7% range. We also know from previous studies and programs that increased investment in primary care creates downstream savings far in excess of the up-front costs. What we hope to accomplish in legislation is to conceptualize what is primary care and what amount it accounts for in the total healthcare spend. Then work with a task force to come up with options to increase the investment in primary care in the hopes of decreasing mortality rates, hospitalization, and costs overall to the healthcare system. The MAFP introduced this legislation during the 2019

legislative session. The insurance lobby put up a number of arguments against it and we weren’t successful in advancing it. We hope to work with them more in the upcoming session to advance this legislation.

2021 Important Dates to Remember Jan. 6

Session convenes

May 14

Last day for bills to be considered

May 14

Last day to pass bills

May 31

Session adjourns

July 14

Governor’s approval deadline

Aug. 28 Effective date of laws Sept. 15 Veto session Find your Legislators online: www.senate.mo.gov/LegisLookup/ Default.aspx.

ADVOCACY DAY MARCH 2, 2021 REGISTER ONLINE AT WWW.MO-AFP.ORG/ADVOCACY/ADVOCACY-DAY/ Meet virtually with your legislators individually or in a group. You can send your message through the Speak Out portal. We will craft a message for you, or you can create your own. Refer to the Mark Your Calendar section on page 3 for Advocacy Day events. Look for more information in early 2021. CALLING ALL MEDICAL SCHOOLS & RESIDENCY PROGRAMS Students and residents can attend this year’s important legislative meeting virtually. Let’s show our legislators that we are united and serious about taking care of our patients and protecting the scope of practice for family physicians. Contact Kathy Pabst at kpabst@mo-afp.org or 573.635.0830 for more information.

MO-AFP.ORG 11

Your Voice and Your Message MAFP Advocacy Survey Defines MAFP Positions

53%

57%

85%

had significant financial impact as a result of COVID-19

prohibits medical marijuana certification

do not provide immunizations

implemented telehealth

e value your time, so we would like to thank all who completed the survey which took an average of 13 minutes to complete. The MAFP Advocacy Commission provides an annual opportunity for members to voice their opinion on legislative and regulatory issues that impact family physicians and patients. The survey is administered so responses are received prior the legislative session. This year’s survey was no exception. Here are the highlights from the results: •

•

• •

•

Our members are becoming more engaged in local, state, and national advocacy efforts with increased participation in election debates, contributing to PACs, and attending candidate fundraising events. With MAFP working on the preceptor workforce program (preceptor tax credit), there was a 9% increase in the respondents who precept students, but fewer precepted nurse practitioners and physician assistants. 92% do not support APRN independent practice and most of these responses do not want to increase the current arrangement of collaborating with any combination up to 6 mid-level providers (APRN, PA, AP) and maintain the current 75 mileage limitation. 77% of the respondents utilize APRNs in their clinic while only 3.5% utilize assistant physicians – these are slight increases from last year’s survey. The majority of respondents also supported maintaining the current 30-day practice with a physician requirement; as well as maintaining the chart review (10% every 14 days). Marijuana, both medicinal and recreational, is not supported by the respondents. However, more family physicians have use of medical marijuana certification policies – 13% allow for the certification, 57% prohibit, and 30% do not have a policy. 84% of the respondents do not plan to certify patients for the use of medical marijuana. Respondents do not support pharmacists prescribing selfadministered hormonal contraceptives, and are split on whether they should be available over the counter. 8% of respondents do not provide immunizations in their clinic; but those that do, provide the full scope provide the full scope of immunizations available to all ages. Patients in the 50+ year old category receive the most immunizations. Most referrals for immunizations are to the county health department and then to the pharmacy. Patient reluctance and refusal to be immunized is increasing slightly. Over 40% of the respondents perform radiologic imaging in clinic and is mostly performed by a registered, licensed, or certified radiologic technician. MISSOURI FAMILY PHYSICIAN January - March 2021

In response to the COVID-19 pandemic, questions were added regarding the impact that the coronavirus has had on clinics: • 75% believe Governor Parson’s Executive Order to expand scope of practice of nurse practitioners should not be extended to December 2020. Since the survey was conducted, the Executive Order was extended to March 31, 2021. • 89% believe patients should take COVID-19 vaccine • 73% did not have difficulty acquiring PPE and only 4% received PPE from the Missouri Department of Health and Human Services Central PPE Request Page • 53% of the respondents had significant financial pressure as a result of COVID-19, and 9% had no financial impact • Two-thirds of the respondents saw a 20-40% reduction in patient volume • 25% applied for and received the Paycheck Protection Program federal funds while 49% did not apply • 55% did not apply for the Medicare Accelerated and Advanced Payment funding while 19% applied for and received the funds • 67% did not apply for the Economic Injury Disaster Assistance Loan Program and 17% did not qualify for this program • Unsurprisingly, 85% of the respondents implemented telehealth • To minimize the financial impact of COVID-19, 49% either furloughed or laid off staff, 46% reduced salaries, and 36% reduced hours • Other options being considered include 12% of the respondents considering closing their practice and 47% delaying purchases • In an effort to ease the impact, 57% are reminding patients to get their annual physicals and well child checkups, promoting safety through their website and social media, triaging patients in their cars and asking patients to wait in their cars. • The vaccine barrier with the most concern is getting the patients to come in the office to receive the vaccine, and also a lack of staffing since many either laid off or furloughed staff. • Areas identified that they need assistance with are improved internet access for their patients and the patients’ knowledge and technical abilities to use telehealth. Most respondents were employed and worked in a hospital outpatient setting or rural health center. Each respondent was given the opportunity to provide additional comments on each topic which we find very helpful as we set our legislative agenda, craft talking points, position statements, and testimony throughout the year. The survey is closed for 2020, but will reopen July, 2021. If you have a topic you would like to include in the next survey, please email it to Kathy Pabst, MAFP Executive Director, at kpabst@mo-afp.org.

I Love Working at a Community Health Center

Community Health Center (CHC), also known as a Federally Qualified Health Center (FQHC), is a local, non-profit, community-driven health care provider that serves low-income and medically underserved communities. We provide comprehensive primary care medical, dental, mental health/substance use, and often pharmaceutical services to persons of all ages, income levels, and insurance status regardless of ability to pay. I chose to work at a CHC because I love serving in a capacity to help others who are medically underserved and specifically in the urban community. During my residency at Saint Louis University, I learned first-hand experience of the true meaning of working in a CHC. I gained a deeper understanding of the barriers to health and its impact on health equity and social determinants of health. Another reason I chose to work at a CHC is because of my patients. I appreciate the diversity and ability to learn from my patients. Whenever there is diversity and inclusion, it always leads to equity and self-growth! Working at a CHC allows me to continue to grow not only on a personal level, but also in my career by helping other colleagues around me. I love taking care of my patients and practicing the full scope of Family Medicine. Now, with the addition of Addiction Medicine into my practice, I can continue to serve a need that was once left out of primary care. Family Medicine is a fun and exciting specialty!

My patients are among the state’s most vulnerable populations. People who, even if insured, would remain isolated and uncared for due to their higher level of complex health care needs, where they live, the language they speak, etc. One of the biggest struggles is improving access to patient care especially during a pandemic. For patients who have the technological capabilities, telemedicine is great. On one hand, introduction of telemedicine has increased access to care for some patients with transportation concerns. However, on the other hand, it also limits care due to digital literacy and language barriers. This is an evolving area of telemedicine but based on our mission and from previous history, I am confident we will overcome this obstacle as well and be able to continue to provide high quality care. Another reason I love working at a CHC is for patient and community advocacy. Due to the pandemic and recent events of killings in the Black community, FQHC’s can take the lead on reaching a community that has been devastated by poverty, crime, and substance use. CHCs understand this complexity and are in a position to significantly transform lives and communities. CHCs are at the heart of this current movement to work towards racial and health equity and I look forward to being a part of this transformation!

Kanika Turner, MD Associate Medical Director, Family Care Health Centers St. Louis

MO-AFP.ORG 13

Pictured- Top: Natalie Long, MD, University of Missouri Columbia, sharing her expertise on deprescribing for the elderly. Bottom: The conference room was full as attendees were properly socially distanced with a setting of one person per table.

Annual Fall Conference in a COVID Pandemic

o we, or don’t we? That question was on the minds of the MAFP team and board leadership for months before the Annual Fall Conference. The closer the date came, the more we thought about the risks, rewards, and impact of our decision on whether to host the Annual Fall Conference as an inperson meeting, hybrid, or virtual. COVID cases were rising across the state; however, we were confident that we could safely hold this conference in person and virtually to meet the needs of our members where they were. We had over 130 participants. Most participated in person at Big Cedar Lodge on November 13-14, some watched the live-streamed sessions from their home or clinic, and others came to Big Cedar Lodge and watched the sessions in the comfort of their room. Each session was also recorded and is available through

MISSOURI FAMILY PHYSICIAN January - March 2021

the MAFP’s new learning management system as enduring CME. Look for more information on this new initiative. For those who attended in person, MAFP ensured social distancing throughout the conference with one person per table, placed hand sanitizer throughout the meeting space, provided a safety bag (which included an N95 mask, hand sanitizer and was sponsored by Rehab Medical Specialty) to each attendee, offered a color-coded bracelet indicating your comfort level with being around others, and meals were provided in secure containers. In addition, the annual Family Health Foundation of Missouri fundraising event was not held. The 50/50 raffle was conducted and Rachel Holt, MD, Kansas City won $400. Thank you, Dr. Holt, for donating a portion of your winnings back to the foundation. Medical students and family medicine residents appreciate your support!

The conference offered 13 hours of CME through 11 speakers and 12 topics. Many thanks to the following speakers who presented during this challenging time: Patient Engagement Strategies in a Virtual Care World | David Voran, MD Unmet Needs and the Evolving Landscape in Acute Migraine Treatment | Curtis P. Schreiber, MD Is Eugenics Re-emerging in Modern Genomics? Lessons for Today From the Historical Consequences of Violating the Oath of Hippocrates | Jenny Powell, MD How to Write an Exercise Prescription | Brad Garstang, MD Critical Coding - Important Changes Ahead! | John Paulson, DO, PhD, FAAFP Introduction to Very Low Calorie Diets | Justin Puckett, DO, FAAFP, FACOFP, FOMA Care of the Masters Athlete | Christian Verry, MD Implicit Bias Workshop 1: Learning About and Experiencing Implicit Bias| Jeff Stone, Ph.D. (Virtual) Implicit Bias Workshop 2: Reducing Implicit Bias | Jeff Stone, Ph.D. (Virtual) 2021 Legislative Preview | Peter Koopman, MD, FAAFP and Keith Ratcliff, MD, FAAFP Deprescribing: Care for the Elderly | Margaret Day, MD, MSPHc and Natalie Long, MD Current and Emerging Therapies for Endometriosis and Uterine Fibroids: What Do You Need to Know? | Georgine Lamvu, MD, MPH Venous Thromboembolism in Athletes | Scott Darling, DO, RPVI, RVT The MAFP was the recipient of an AAFP grant to provide education to our members on implicit bias. We brought in a renowned expert, Jeff Stone, PhD, from Stone Behavioral Consultants, in Vail, Arizona. His three-hour session took a unique personal assessment to help each of us understand implicit bias, and how we can be a part of the solution and reduce our biases. Attendees had an opportunity to meet with our exhibitors in person at the conference, or with those who participated virtually. The exhibitors were very supportive of our conference and are an important part of the conference experience.

Thank you to all our attendees, exhibitors, and sponsors who made this conference a success!

Save the Date – Our 2021 Annual Fall Conference will be held on November 12-13 at Big Cedar Lodge. The MAFP annual meeting will be held in conjunction with this conference. MO-AFP.ORG 15

MISSOURI FAMILY PHYSICIAN January - March 2021

Balancing the Many Hats in Academic Family Medicine This week… > I taught a medical student to lower her voice an octave and speak more slowly to communicate with a hard-of-hearing patient. She countered by asking me an anatomy question that sent me off to do research > I learned hepatitis C protocols to treat my safety net patient > A senior resident and I strategized our upcoming week on call on the COVID Service > Our clerkship director, faculty, and I met with 3rd year medical students to plan 4th year and application to family medicine residency > My research colleagues and I grappled with whether we had the bandwidth to participate in a multicenter project on a tool to assess suicide risk > I worked on a plan to help fund family medicine initiatives in the community

Christine K. Jacobs MD, FAAFP Professor and Chair Department of Family and Community Medicine Saint Louis University

MO-AFP.ORG 17

Academic family medicine stands on 3 pillars; education (of medical students and residents), scholarship (in education or research) and clinical practice (in a teaching environment). Academic careers follow different paths. Some academic physicians move from faculty to program directors directors to department chair roles, while others become master teachers, channeling intellectual inquiry and talent into education. Regardless of the path, academic physicians generally spend 5-7 years at each stage from Assistant to Associate to Full Professor. Education of Medical Students and Residents Family physicians are natural educators of patients. Academic medicine takes education to the next level with medical students and residents to grow our profession and strengthen the evidencebased practice of medicine. Medical students often matriculate with a vision of medicine that looks a lot like family medicine. Students tell us that they want to form relationships with patients. They want to engage in their community. They have broad interests and they are captivated by the intellectual inquiry of diagnosis and treatment. So why do relatively few students choose family medicine? In good part, it is because of their exposure to specialists. Academic family physicians play a critical role with medical students, demonstrating the intellectual rigor and rewards of primary care. The academic physician’s toolkit includes skills in clinical teaching, small group case-based learning, and physical diagnosis teaching. Some offer elective experiences in areas such as sports medicine, preventive medicine or community health. Some

MISSOURI FAMILY PHYSICIAN January - March 2021

faculty develop expertise in classroom teaching of evidencebased medicine. For example, at Saint Louis University School of Medicine, the academic family physicians lead courses in Epidemiology and Biostatistics, Clinical Interviewing and Clinical Diagnosis. Even if medical students decide to match into other specialties, these early experiences engender respect for primary care physicians. Family Medicine Residency faculty must adapt their teaching methods for adult learners. Being residency faculty requires a strong dose of humility as residents present the newest evidence that faculty may not yet have encountered! However, residency faculty enjoy and appreciate the climate of intellectual inquiry. Faculty are most often seen precepting residents and medical students in clinic and the hospital. But behind the scenes, they are planning residency lecture series, planning and ensuring rotation curriculum, evaluating and advising residents, and producing scholarship or research. Scholarship and Research The desire for a climate of intellectual inquiry drives most faculty to academic medicine. Very few family physicians enter academic medicine with significant research expertise. However, most university departments of family medicine have research divisions and faculty often “catch the research bug.” Scholarship that informs clinical practice and medical education is critical to the future of family medicine. Research spans the breadth of our specialty. Health promotion and disease prevention, clinical best practices, social determinants of health

and health equity are common themes, as well as innovation in medical education. We are uniquely positioned to understand what knowledge is critical to primary care. Recent investigations in our department include the relationship between HbA1c and depression treatment, effectiveness of opioid treatment protocols, and relationship of socioeconomic status to pain treatment. Academic physicians frequently collaborate with researchers or faculty from other disciplines to study these questions, and seek external funding for larger research investigations. Clinical Faculty Practice Academic family medicine often allows faculty to work with patients who fall into the healthcare safety net, supported by the mission of a university or FQHC. That practice particularly appeals to physicians who enjoy patients with multiple complex medical issues and social stressors, and who are committed to making systems work better for those patients. Medical students, universally present in the academic practice, reward faculty with a multitude of enthusiastic clinical questions even as they challenge them with time management. Sometimes academic settings allow faculty to explore practice or learning in areas that are harder to find in community practice. Obstetrical practice, for example, is less limited by insurance constraints in an academic setting. Academic departments or residency programs may support faculty to train and practice in areas such as point of care ultrasound, colposcopy, or medication assisted treatment for opioid use disorders.

Rewards of Academic Medicine So why do I love academic medicine? • Intellectual stimulation in clinical practice and education • Working with faculty colleagues who have different but overlapping interests • The ability to do projects that impact the health and healthcare of our patients and community • The opportunity to contribute to the knowledge base of medicine through research and scholarship • The joy of teaching and mentoring the physicians of the future Academic medicine can be entered at any time. Strong physician educators have often spent years in practice. Those years provide a foundation for clinical teaching and can lead to an interest in a particular area of academic medicine. For family physicians considering academic medicine, the Society of Teachers of Family Medicine (STFM) is a valuable resource. The payoff of academic medicine is not financial. Academic physician salaries are usually significantly below market salaries. But there are many satisfactions: great intellectual challenge and social engagement, the knowledge that we are contributing to evidence-based clinical medicine and improving the health of communities by training a new generation of physicians. I could not imagine doing anything else.

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MISSOURI FAMILY PHYSICIAN January - March 2021

he PBS series, Doc Martin, tells the comic tale of a London surgeon finding himself in a small English village with a family practice operating from his home. As a Mizzou medical student, I found myself in a similar situation training with an Irish physician whose home practice was the beating heart of the village. He was an integral part of the community, not only as a doctor, but as friend and neighbor to all his patients. Today, I serve in that same role at the U.S. Embassy in Manila, Philippines. As a Foreign Service Regional Medical Officer, I lead a robust family practice medical team whose relationship to the Embassy community is like that of the small town doctor. Part diplomat, part family doctor, and part emergency preparedness planner, my colleagues and I provide the same standard of care our American patients are accustomed to back home. I treat common chronic and acute conditions to uncommon threats such as malaria, dengue, tuberculosis and other diseases prevalent in many countries overseas but rarer in the United States. My career path began as a Washington University undergraduate who was interested in the wider world and went on a mission trip to Liberia. It was the first time I truly became interested in medicine. I worked with a physician in a rural clinic and saw diseases such as malaria and elephantiasis I had never seen before. The need was great and I was inspired by the commitment and determination of the Liberian doctor caring for her community. While in residency in internal medicine and pediatrics at Saint Louis University, I continued to pursue my passion for life overseas through seasonal work at mission hospitals in Kenya, the Dominican Republic, and Jamaica. I considered working full-time with Doctors Without Borders and similar organizations; but, I could not see how I could balance family life and meet my financial obligations. After a rewarding career in Denver that encompassed urgent care, pediatrics, adult medicine, and a pediatric faculty appointment, wanderlust beckoned me again. My brother by now was a diplomat with the U.S. Department of State and encouraged me to apply. To me, it seemed like the perfect opportunity to mix things up in my medical career while providing extraordinary opportunities for my family. I would be able to practice overseas in an American environment still supported by a strong network of colleagues in Washington, D.C. and the medical community in the cities in which I served. My day as a Regional Medical Officer can be spent suturing a wound, evaluating ear pain,

attending a country team meeting with the Ambassador and other heads of section, visiting a patient in the hospital, organizing a blood drive, leading a mass casualty drill, or touring a new local hospital. I have had the privilege of seeing patients born in countries all over the world and followed them through their first few years of life, then meeting them in another country and becoming their doctor again. I have also had the privilege of caring for patients working abroad and then again in the United States undergoing treatment for cancer. Rarely, I have attended an autopsy when a patient dies overseas and then comfort family nearby and afar. For the past 11 years, my family and I have lived and served in Colombia, Kuwait, Bangladesh, Jordan, Washington, D.C., and the Philippines. Off duty, we have scuba-dived in the Red Sea, biked along Bangladesh’s rivers, taken boat tours in Qatar, ridden camels in Jordan’s Wadi Rum, visited coffee farms in Colombia, seen West End musicals in London, ridden the elevator to the top of Dubai’s Burj Khalifa (the world’s tallest building) and much, much more. Not only have I been enriched personally and professionally, but my husband has continued his music teaching career at local American schools as well. Our children have flourished, too, shaped by the unique experiences and people they have met. It continues to be a rewarding and challenging career. I would encourage other Missouri physicians to consider becoming that American small town doctor in a cosmopolitan world.

Chanda McDaniel, MD U.S. Department of State

“

it seemed like the perfect opportunity to mix things up in my medical career while providing extraordinary opportunities for my family.

”

Chanda McDaniel, MD, an American board certified internist and pediatrician, is a Foreign Service Regional Medical Officer at the U.S. Embassy Manila, Philippines. For more information on U.S. Department of State medical careers, visit https://careers.state.gov/MED or contact Missouri Diplomat in Residence Amanda Johnson at DIRCentral@state.gov.

MO-AFP.ORG 21

From Medical School to Military Physician My two-year active-duty commitment to the US Air Force provided many benefits worth considering Jacob Shepherd, MD Family Medicine – US Air Force

ack to my college days, I had a desire to serve in the military. My grandfather had briefly served as a physician with the Navy during World War II, and my older brother has spent nearly two decades leading soldiers in multiple roles with the US Army. I see serving in the military as a way to give back and serve this great country. During my first-year of residency at University of Missouri-Kansas City School of Medicine, I met with the recruitment coordinator for both the I see US Army and US Air Force at the AAFP National Conference for Family Medicine serving in Residents and Students. After discussion the military with my wife and family, we decided to choose the Air Force based on base as a way to locations and the contract. Initially, I had give back to pass a Medical Entrance Physical. Once I completed this at the local Kansas City and serve Office, I was sworn in as a Commissioned this great Officer in September 2016. The program I joined as part of my Air country. Force commitment is called the Financial Assistance Program. I was compensated approximately $70,000 per year during my last two years of Residency, which is two years of financial support, and I committed to serve two years active duty as an Air Force Physician. The Air Force allowed me to select up to 20 bases where I would prefer to be stationed. During my final year of residency, I did an elective at Whiteman Air Force Base (AFB) in central Missouri and put this base as my top choice. In May 2018, I found out that I was granted my first choice by the military. When I completed residency, I showed up at Whiteman AFB—newly commissioned as an Air Force captain. One of the benefits of being in the military is housing and meal allowances. It varies based on rank and location, but roughly $18-20K per year of my monthly check is a non-taxable housing allowance. This was very helpful for our young family.

“

”

MISSOURI FAMILY PHYSICIAN January - March 2021

MILITARY MEDICINE PROS AND CONS Pros: Opportunity to Start Paying Down Medical School Loans While Still in Residency Leadership Positions and Mentorship Education Benefits for Continued Medical Education Credits Opportunities to Earn Additional Degrees (i.e. Master’s) With Tuition Paid by Military Some Education Benefits May Be Granted to Immediate Family Members (Montgomery GI Bill) Excellent Health Insurance Benefits Non-Taxable Housing and Meals Allowance Per Month

Cons: Six-to-Eight-Week Officer Training School (away from family) Additional Duties Not Compensated (medical director positions, committees, etc.) (left to right) Dr. Tim Shepherd, Jacob Shepherd, MD (former Major, USAF), Virginia Shepherd and Major Tim Shepherd (US Army).

In August 2018, I arrived at Maxwell Air Force Base in Montgomery, Alabama for a six-week Officer Training School. There I learned proper military customs and courtesy and spent long days in training from 4:30 am to to 10 pm. It consisted of some physical training, such as learning how to march, but primarily it involved classroom time learning the history and roles of the US military. (Having prepared with a solid workout regimen, fortunately I passed the physical fitness exam.) I left Maxwell AFB with a much greater understanding of how the US Air Force strategically carries out its mission to protect and defend American values. After returning home, I served at Whiteman Air Force Base as a Family Medicine Physician for two years. I became the Medical Director of the Primary Care Clinic where I started a weight loss program—following a model my father, also a family physician, pioneered. In addition, I served on the Resuscitation Committee at Whiteman AFB. During this time, my wife and I had twin boys. Due to various factors including them being born slightly underweight, the boys required a week-long NICU stay. We were thankful that Tricare insurance fully covered their birth and the NICU stay.

Military Physicians Submit Preferred Bases, But First Choice Not Guaranteed Potential International Deployments

One of my highlights at Whiteman AFB was serving under strong leaders. I had four Lt. Colonels who have each served for prolonged service times. One of the most important things I learned was to become a better listener. Each mentor had a variation in leadership styles and that helped me to gain a different perspective on how to deal with high-stress environments. Some potential military physician recruits express concerns concerns about the likelihood of international deployments. I did not personally have a deployment, but my counterpart did. However, the Air Force works hard to direct deployments to safer locations. My friend was also granted permission to return home for the birth of his child. Part of my commitment is to remain in inactive ready reserve status for the next six years, which means in an extreme situation, the US Air Force could call me into service. As I understand it, such measures have not occurred since the Korean War. In spring 2020, I served on the COVID Task Force at Whiteman AFB. We set-up our own COVID-19 testing site, one of the first in the region, to ensure the readiness of our Active Duty Airmen. Related to this role, I had the opportunity months later to brief a Four-Star General. Overall, I was honored to serve Air Force personnel and their families as a Military Physician during those two years and I completed my active-duty commitment in July 2020. MO-AFP.ORG 23

Making Cents of CPT Codes in 2021

Margaret A. Day, MD University of Missouri Columbia

n the biggest change in evaluation and management (E/M) office coding since 1997, the Centers for Medicare and Medicaid Services (CMS) released the 2021 Medicare Physician Fee Schedule set to take effect January 1, 2021. As part of the “Patients over Paperwork” goal, CMS estimates these changes will save 180 hours of paperwork for physicians annually. Findings from a time study commissioned by CMS helped drive these changes. Providers (physicians or other qualified health care professionals) are spending more face-to-face time with patients during visits, more time documenting, and more non-reimbursed time required for patient care. The goals of these changes are to decrease administrative burden, decrease the need for audits, and decrease unnecessary documentation while making it easier and take less time. The change applies to CPT codes 99202-99215 in the outpatient setting only. It does not apply to any other visit types, including inpatient or emergency room visits, consults, nursing home care, or home visits.

Levels of E/M services will be based on either total time or the level of medical decision making (MDM). The nature and extent of history and exam elements are included as determined by the provider and do not impact the level of service directly, though do inform medical necessity.

TOTAL TIME

The key change here is counseling and coordination of care does NOT need to dominate the E/M service. A provider’s time spent capturing history elements and performing a physical examination can be counted toward total time. Family medicine residents can now bill by their total time spent under the primary care exception rule, without the attending documenting the time spent that day. This does not apply to residents in the first 6 months of training, or to medical students. . Documentation does not need to include each activity or minute time breakdowns. Document,

Total time spent by a physician or qualified healthcare professional on the date of service Activities to include in total time

Don’t include

Time spent caring for the patient on the SAME DAY of the encounter

Time spent on day(s) prior to or after the encounter

Preparing to see the patient by reviewing tests or previous notes, including your own

Activities usually performed by other team members

Obtaining and/or reviewing separately obtained history

Time spent doing a procedure

Face-to-face time spent seeing the patient in the office

Separately billable services with their own CPT codes like smoking cessation or advanced care planning services

Performing a medically appropriate examination and/or evaluation Counseling and educating the patient/family/caregiver Ordering medications, tests, or procedures Referring and communicating with other health care professionals Independently interpreting results Communicating results to the patient/family/caregiver Care coordination 24

MISSOURI FAMILY PHYSICIAN January - March 2021

Minimum times needed to bill each code

NEW PT CODES

TIME (min)

EST PT CODES

TIME (min)

Eliminated 99201

n/a

99211

n/a

99202

15-29

99212

10-19

99203

30-44

99213

20-29

99204

45-59

99214

30-39

99205

60-74

99215

40-54

“My total time spent caring for the patient on the day of the encounter was XX minutes.” A prolonged services code, 99417, can be billed for additional time the provider spends on the day of service above that allocated for 99205 and 99215. Do not report 99417 for any time unit less than 15 minutes. The provider must spend at least 90 minutes for 99205 and 70 minutes for 99215*. Additional 99417 codes can be billed in 15-minute increments.

*There is some discrepancy about this, about whether smaller increments of time, like 80 minutes for 99205 or 60 minutes for 99215 can be billed with 99417. Based on CMS and Wisconsin Physicians Service Insurance Corporation (WPS), the extended time procedure code requires at least 15 minutes of additional time. Rounding is not allowed. The same is true for additional 99417 codes – at least 15 more minutes must be spent for each additional code.

SERVE YOUR PATIENTS WHILE YOU SERVE YOUR COUNTRY.

That’s the Army difference. As a family medicine physician on the U.S. Army Reserve health care team, you’ll serve the needs of Soldiers and family members in your military community. For two days a month and two weeks a year you may use your medical skills and knowledge to support humanitarian missions, train and lead your own medical team at a military field hospital, or work in one of our state-of-the art medical facilities. To learn about the variety of career opportunities in Army medicine, visit www.goarmy.com/amedd.

For more information contact Capt. Raymond Olympio at 210-392-1403 or 314-738-0300 with the U.S. Army St. Louis Medical Recruiting Station.

MO-AFP.ORG 25

continued from page 25

Current HCPCS Minimum Code Minutes per Visit 992011 99202 99203 99204 99205 99205 99213 99213 99214 99215 99XXX2 GPCIX3

Current wRVU for Code

2021 Minutes per Visit

2021 wRVU for Code

Percentage Increase in wRVU Value

0.48 0.93 1.42 2.43 3.17 0.18 0.48 0.97 1.50 2.11 N/A N/A

N/A 22 40 60 85 7 18 30 49 70 15 11

N/A 0.93 1.60 2.60 3.50 0.18 0.70 1.30 1.92 2.80 0.61 0.33

N/A 0% 13% 7% 10% 0% 46% 34% 28% 33% N/A N/A

17 22 29 45 67 7 16 23 40 55 N/A N/A

This code to be eliminated in 2021. This is an add-on code for every 15 minutes of exended patient office visit time. 3 This code is an add-on code to recognize complexity for qualified chronic patient conditions. 1 2

MEDICAL DECISION MAKING (MDM)

MDM is based on 2/3 of problems, data, and risk according to the table below

NUMBER AND COMPLEXITY OF PROBLEMS •

•

A detailed explanation of the complexity of problems and the definitions from the AMA can be found here: https:// www.ama-assn.org/system/files/2019-06/cpt-officeprolonged-svs-code-changes.pdf Problems managed by specialists can be addressed and billed. Just be sure to document how it is addressed – clarification, care coordination, additional assessment, reinforce medication compliance/treatment plan, explaining test results, etc. One or more chronic illnesses with exacerbation, progression, or side effects of treatment also includes uncontrolled chronic illnesses. For example, managing a patient with diabetes with an A1C above goal, even if it is not fluctuating/changing is considered a moderate level of complexity. With documentation of either data or risk that also satisfies the moderate level of MDM, managing this problem may achieve requirements for level 4 billing codes.

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED AND ANALYZED

1. Tests, documents, orders, independent historian(s) • Medical records – can’t be from practice partner(s), can

MISSOURI FAMILY PHYSICIAN January - March 2021

be from different specialty or external provider • “I ordered and reviewed TSH, normal and CMP, normal” would be counted as two independent data elements • Independent historian refers to family member, guardian, surrogate, spouse, etc. 2. Independent interpretation of tests • EKG, x-ray 3. Discussion of management or test interpretation with external provider or appropriate source • Discussing what imaging to order or results of an image with radiology, medication management with cardiology, delivery timing with maternal fetal medicine, etc. • NOT family members or surrogate decision-makers

RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY OF PATIENT MANAGEMENT

1. Including comorbidities and differentials can increase complexity, amount of data analyzed, and risk 2. Note “decision regarding” does not mean “decision to” and documenting reasons to not hospitalize or not order additional testing can contribute to risk 3. Drug therapy requiring intensive monitoring for toxicity • Refers to assessing for adverse events, not for therapeutic efficacy • By lab test, physiologic test, or imaging. Not by history or exam • May be short-term or long-term.

•

Short term examples could include diuresis (increase Lasix dose and repeat BMP in a week), warfarin initiation, or others • Long-term is not less than quarterly 4. GPC1X is a new add on code CMS describes for use when “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex condition.” The E/M service level is chosen either by the level of MDM performed or by the total time spent performing the services on the day of the encounter, whichever is more advantageous to the provider. Though substantial changes like this can be challenging, these are anticipated to be advantageous to our specialty. AAFP estimates a 13% net increase in total allowed charges for family medicine, even when accounting for a decrease in the annual conversion factor due to Medicare budget neutrality rules proposed by CMS.

Work relative value units (wRVUs) are increasing for most codes. RVUs assigned to level have increased for our most common codes per Table y.

REFERENCES

Keith W. Millette, MD, FAAFP, RPh, Countdown to the E/M Coding Changes. Fam Pract Manag. 2020 Sep-Oct;27(5):29-36. https://www.aafp.org/fpm/2020/0900/p29.html?cmpid=em_ FPM_20200916 https://www.ama-assn.org/system/files/2019-06/cpt-officeprolonged-svs-code-changes.pdf Initial AAFP summary of the 2021 proposed Medicare Physician Fee Schedule SullivanCotter. 2021 Evaluation and Management CPT Codes: Understanding the Impact on Physician Compensation. 2020 Aug 6. https://www.physicianleaders.org/news/2021-evaluationand-management-cpt-codes-understanding-the-impact-onphysician-compensation https://www.ama-assn.org/system/files/2020-04/e-m-officevisit-changes.pdf https://www.aafp.org/journals/fpm/blogs/inpractice/entry/ em_changes_FAQ.html?cmpid=em_FPM_20201118

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MISSOURI FAMILY PHYSICIAN January - March 2021

MEMBERS IN THE NEWS

DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review. We love to hear from our members!

Donald A. Potts, MD, Named Recipient of 2020 KCMS Lifetime Achievement Award From Kansas City Medicine, Third Quarter 2020 The Kansas City Medical Society named Dr. Potts earned his medical degree Donald A. Potts, MD, the recipient of the from the University of Kansas in 1962 and 2020 Lifetime Achievement Award. This completed internship at the former Kansas award recognizes a KCMS member physician City General Hospital. For the first 20-plus for leadership, lifelong commitment to years of his career, he was in private practice health and dedication to the health of the in Independence. In 1986, he joined the fullgreater Kansas City community. time faculty of the University of Missouri“Dr. Potts is one of the most admired Kansas City. He moved his practice to physicians in Kansas City,” said Betty M. Truman Medical Center-Lakewood, where he Drees, MD, KCMS 2020 president. “He is continued until retiring from full-time practice known as an excellent academic physician in 2003. In organized medicine, he has been a for his care of patients and his teaching in KCMS delegate to the Missouri State Medical the Family Medicine Residency program at Association for over 30 years and served for 13 Truman Medical Center-Lakewood and the years on the board of directors of the Missouri University of Missouri-Kansas City School of Medical Political Action Committee. He was a Medicine.” She continued, “He has tirelessly board member of the KCMS Foundation from worked to stop tobacco use in the region to 1997-2006. improve the health of the community. He Today, now at age 90, he remains an active is one of the most committed members of member of the KCMS Retired Physicians Donald A Potts, MD, organized medicine at both the local level Organization. A charter Fellow of the Family Physician with KCMS and at the state level with the American Academy of Family Physicians, Dr. Missouri State Medical Association. He is one of my personal role Potts was 1976 president of the Kansas City Academy of Family models for making everything he touches better.” Physicians and currently serves on the local board of directors.

We are dedicated to rural and underserved areas of our great state! Recognized as Missouri’s leading nonprofit health care focused job placement program, MHPPS helps health care professionals find a community that best fits their personal and professional needs. Opportunities throughout our Rural & Urban Areas: Find Out More: Contact Us Today! Joni Adamson  Loan Repayment Options Director of Recruitment  Competitive Salary & Comprehensive Benefits jadamson@mo-pca.org / 573.636.4222  Team Based Models of Care / Care Coordination www.mhpps.org  Little or no Call / Moving Allowance / Signing Bonus Proud Partners Of:

MHPPS is non-profit and located within the MO Primary Care Association MO-AFP.ORG 29

MEMBERS IN THE NEWS OSTEOPATHIC HEALTH POLICY FELLOWSHIP The Osteopathic Health Policy Fellowship is pleased to announce the graduation of John Paulson, DO, PhD, of Joplin, MO, as a member of the 2019-2020 class. Dr. Paulson, Chair of Primary Care Medicine at the Kansas City University of Medical Biosciences at Joplin, joins the ranks of more than 260 osteopathic physicians and other health care professionals to complete the national program that prepares leaders to engage in the formulation, analysis, and advocacy of policy that seeks to improve population health. During the Fellowship year, participants typically attend an intensive five-day academic orientation before beginning a regimen of nine three-day weekend seminars. Seminars are rotated among osteopathic colleges and the Washington, D.C., area. Between monthly seminars, Fellows complete extensive reading, research and writing assignments. Due to the COVID-19 pandemic, the 2019-2020 Fellows experienced an extended year. Beginning with orientation in August of 2019, face-to-face sessions were held as scheduled through February. As the pandemic developed, and the personal risk of travel and facility closures became apparent, the remainder of the year was completed virtually, with graduation held on December 6, 2020. Although presenting more challenges than the traditional year, the experience of incorporating the fast pace of emerging policy issues provided opportunities not previously experienced in the history of the program.

Established in 1994, alumni of the program have served as policy advisers in public and private forums to the profession, legislators at the local, state, and national levels, diverse health-centered institutions, and other health leadership groups. The program has distinguished itself by creating a prepared leadership bench and network for important roles in the future of osteopathic medicine and healthcare. Graduates of the program join a cadre of health policy experts from which the profession can draw to staff committees and task forces at the federal and state levels, testify on issues relevant to osteopathic medicine and education, and develop policy positions. The AOA, AACOM, specialty colleges, and state and regional associations have supported the program continuously since its inception. The Osteopathic Health Policy Fellowship is primarily funded through the American Association of Colleges of Osteopathic Medicine, along with support from the Ohio University Heritage College of Osteopathic Medicine and CONSULTUS Health Research Group. For additional information on the Osteopathic Health Policy Fellowship, please visit https:// www.aacom.org/reports-programs-initiatives/leadershipinstitute/osteopathic-health-policy-fellowship. Questions may be directed to OHPF Co-Directors, Dr. Dan Skinner of Ohio University’s Heritage College of Osteopathic Medicine (skinnerd@ohio. edu), and Dr. Al Pheley of CONSULTUS Health Research Group (alpheley@gmail.com).

Dougherty to Serve on AAFP Commission Kelly Dougherty, a medical student at University of Missouri Columbia, was appointed to serve on AAFP Member Services Commission. This commission guides the AAFP’s membership efforts and assists the constituent chapters in their recruitment and retention efforts. Issues that may be considered by this commission include the value of membership, awards, Degree of Fellow, chapter relations, and monitor membership trends. Ms. Dougherty’s leadership term officially began December 15, 2020 and lasts through December 14, 2021.

MISSOURI FAMILY PHYSICIAN January - March 2021

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Sojourner Health Clinic Receives Emergency Relief Grant Sojourner Health Clinic is a free safety-net clinic that helps the adult homeless and medically indigent in Kansas City, Missouri maintain their health and avoid expensive emergency room visits and hospital stays. The student-run clinic provides routine safety-net medical services including health education, disease management, diagnosis, immunizations, screenings, and medications free of charge each Sunday. Healthcare services extend to point-of-care labs offered at each clinic and a Patient Assistant Program which provides free inhalers to COPD and asthma patients. Sojourners also provides food support through UMKC’s Help a Life Organization (HALO) which supplies our patients with healthy meals at no cost. In addition, the clinic has a strong partnership with the UMKC School of Social Work and ensures patients are able to access social services. Since Sojourner’s opening, its patient population has steadily grown to more than 1,000 patient charts in the filing system. The COVID-19 pandemic has greatly affected patients and the clinic. After being temporarily shut down since March 2020 for the first time in fifteen years, they have reopened their doors in August 2020 with new safety guidelines in place.

Funds supplied by the AAFP Foundation Family Medicine Cares USA Emergency Relief Grant will go towards personal protective equipment (masks, face shields, gloves) and cleaning supplies (hand sanitizer, wipes) to protect the patients and staff. Additionally, they have established new electronic medical records. Not only will this bring efficiency to the clinic as they transition away from paper charts, this new system will enable “no-touch” or contactless patient care in the face the face of COVID-19 challenges. Resources provided by AAFP will therefore be utilized for new laptops and a safe to keep them secure. Lastly, the funds will improve the state of the clinic with a new medication cart and office supplies (accordion folder, posters) to better adapt to the growing needs of the patient population as well as to aid in advertising their reopening to their patient population. Ultimately, Sojourner Health Clinic aims to better serve and respond to the dynamic needs of its patient population as a result of the AAFP Emergency Relief Grant.

Free Child Abuse & Neglect Training for Missouri Medical Professionals SAFE-CARE training teaches the basics of providing medicalforensic evaluations for alleged victims of child maltreatment. The next SAFE-CARE Training for Medical Providers will be held virtually March 9-10, 2021. For more information on SAFE-CARE, contact Missouri KidsFirst at 573-632-4600, visit www.missourikidsfirst.org/our-work/safecare/ or email contact@missourikidsfirst.org. MO-AFP.ORG 31

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