Texas Family Physician Winter 2012

texas family physician VOL. 63 NO. 1 WINTER 2012

Demystifying Clinical Integration Education Can Help You Avoid TMB Investigation TAFP In 2011: Year In Review

Meet Texas’ Family Physician of the Year

Thomas Mueller

Isn’t it time you were rewarded for your loyalty?

We think so!

Announcing TMLT’S TRUST REWARDS PROGRAM! As a new benefit for policyholders, TMLT is funding a Trust Rewards account for each physician policyholder enrolled in the program. Trust Rewards allows us to share our success! The funds that TMLT sets aside for your account on a quarterly basis will be available to you when you retire (see the complete details and restrictions in the enrollment kit recently mailed to policyholders).

TMLT’s Board of Governors has enthusiastically endorsed this program for physicians and has committed $100 million for 2012. TMLT policyholders must enroll to participate.

Contact our customer service group at 800-580-8658, ext. 5050 for more information or visit www.tmlt.org

www.tmlt.org Rated “A” (Excellent) by A.M. Best Company

901 S. MoPac Expressway, Barton Oaks Plaza V, Suite 500, Austin, TX 78746-5942 800-580-8658  512-425-5800  f: 512-328-5637  trustrewards@tmlt.org

What if your patient needs help connecting to services?

Refer your patient for case management

They also help patients and their families

services, a Texas Medicaid benefit for

find services for educational, psychological,

eligible children birth to age 20 with

financial, and transportation needs that

a health condition or health risk and

may impact the patient’s health care.

high-risk pregnant women of any age.

Learn more about case management services and

Case managers help patients access medical

get CE credit by taking the free Case Management

and dental services, specialty referrals, medical

Services in Texas course on the THSteps Online

equipment and supplies, and mental health services.

Provider Education website at txhealthsteps.com.

To make a referral, call 1-877-THSTEPS or download a referral form at www.dshs.state.tx.us/caseman/forms.shtm.

If you are an RN or licensed social worker and are interested in becoming a case manager, call 512-776-2168. Bilingual case managers are needed.

INSIDE

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TEXAS FAMILY PHYSICIAN VOL. 63 NO. 1 WINTER 2012

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Preserving a family tradition

With three decades of rural medicine under his belt and plenty more learned from a long family history in medicine, the 20112012 Texas Family Physician of the Year is the quintessential country doctor who provides the full spectrum of care and puts his family and patients first.

Meet Thomas E. Mueller, M.D.

By Kate Alfano

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16 MEMBER NEWS Goertz assumes post as AAFP board chair | Austin physician becomes HHSC exec | Mabry completes years of service to AAFP | Waco family medicine residency to develop childhood obesity program | Texas Tech medical student, UTHSCSA faculty appointed to AAFP commissions | El Paso medical school receives grant to improve border health | Moquist joins AAFP Foundation Board

Clinical integration demystified 2012 will be a year of radical transformation in many sectors of the health care industry. Here’s a concept you’ll need to know.

By Jonathan Nelson

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ACO rules are final

The final rules for establishing Medicare ACOs make the program more attractive for small- and medium-sized practices.

14

Wal-Mart care?

A request-for-information suggests that Wal-Mart is looking to build an integrated, low-cost primary care health care platform.

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TEXAS FAMILY PHYSICIAN

6 PRESIDENT’S LETTER The true treasures of medicine are the relationships you share with your patients.

8 NEWS CLIPS Texas docs get $30 million in IT incentives | U.S. scores a D on quality | IOM: Address safety risks associated with health IT | A look at the match | Just the facts: Who practices primary care?

30 PRACTICE MANAGEMENT TAFP’s practice management expert takes you through a Texas Medical Board review, providing an insider’s tips along the way.

33 Year in Review: 2011 2011 proved to be a year of great change and exceptional work that will provide the momentum for a successful 2012.

37 FOUNDATION FOCUS Thanks to the 2011 donors.

38 TAFP PERSPECTIVE The case for clinical integration.

Free CME credits are just a click away.

Now you can choose the time and place to take the courses you need and want.

We’ve made it easy to take free CME courses online. We offer 24/7 access to more than 40 courses, including when to refer to a pediatric specialist. And even when you’re not taking a course, you can access the latest references and resources you need.

The CME courses were developed by the Texas Department of State Health Services and the Texas Health and Human Services Commission. All courses are comprehensive and accredited.* *Accredited by the Texas Medical Association, American Nurses Credentialing Center, National Commission for Health Education Credentialing, Texas State Board of Social Worker Examiners, Accreditation Council of Pharmacy Education, UTHSCSA Dental

Taking New Steps

School Office of Continuing Dental Education, Texas Dietetic Association, Texas Academy of Audiology, and International Board of Lactation Consultant Examiners. Continuing Education for multiple disciplines will be provided for these events.

To view courses online, visit www.txhealthsteps.com.

CME Courses Include: • When to Refer to a Geneticist • Children with Diabetes • Children with Asthma • Newborn Screening • Case Management • Developmental Screening • Many others Referral Guidelines • Pediatric Depression • High Blood Pressures in the Office • Atopic Dermatitis • Gastroesophageal Reflux in Infants • Exercise-Induced Dyspnea • Referral Guidelines Overview

president’s column

TEXAS FAMILY PHYSICIAN VOL. 63 NO. 1 winter 2012 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. Texas Family Physician is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.

Officers president

I. L. Balkcom IV, M.D.

president-elect

Dale Ragle, M.D.

Clare Hawkins, M.D.

parliamentarian

Ajay Gupta, M.D.

immediate past president

Melissa Gerdes, M.D.

Editorial Staff managing editor

Jonathan L. Nelson

associate editor

Kate Alfano

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, C.A.E.

advertising sales associate

Audra Conwell

Contributing Editors Daniel J. Marino Bradley Reiner subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year.

Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publica­tion of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by The Whitley Company, Austin, Texas. legislative advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2012 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727.

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By I. L. Balkcom IV, M.D. TAFP President

Troy Fiesinger, M.D.

vice president treasurer

Patient relationships are the treasures of family medicine

[WINTER 2012]

TEXAS FAMILY PHYSICIAN

it’s just a small, non-descript pin. Its cash value is minimal and if found in someone’s drawer, it would be summarily thrown in the trash while other more prized items would be saved. However, this pin is a treasure to me. I will guard this pin until my time on earth has passed. While cleaning out my drawer I’m sure someone will ask why I kept this.

The middle of November found me attending a very special event for a young man of 17 years. Luke was receiving his induction as an Eagle Scout in the Boy Scouts of America.

I had been honored to be chosen to attend the service, as I had attended to Luke since he was a very young child. His mother and father are patients of mine also and I silently cheered for them, beaming with pride at their son’s accomplishment.

The service was nice and over soon, but something happened at the end that literally brought a tear to my eye, and with it, tremendous pride. Luke presented me a pin for being a mentor to him and helping him reach his goal. I walked to the front, received the pin and realized a great truth in defining our role as family physicians.

Ladies and gentlemen, we are not and cannot just be the evidence-based clinical robot, but we need to be a caring and

loving part of our community, wherever we choose to live. To be a member of the fraternity of family medicine demands involvement in the lives of our patients very often. Sure, we need time with our own families, and patients will respect that time if you invest in their lives as well.

If the expert pundits are correct, we will soon have 28 million to 40 million additional patients to care for.

This is a daunting challenge indeed and we as family physicians need to step up and fill the bill. Tirelessly, we must work with our legislators and policymakers to re-establish and sustain funding for medical education and post-graduate training.

Research should always continue but not at the expense of the education of young, new doctors. If mandates have been established to provide for increasing the supply of family physicians, then let’s enforce them and be sure monies go where we really need them … to family medicine.

I am going to put my pin with my other “buried treasures” from my 24 years in family medicine; I have a drawer at work with many letters, cards, and notes. I know many of you have similar treasures. So, come join us in family medicine. Who knows, you may have a pin waiting for you, too.

Ladies and gentlemen, we are not and cannot just be the evidence-based clinical robot, but we need to be a caring and loving part of our community, wherever we choose to live. To be a member of the fraternity of family medicine demands involvement in the lives of our patients very often.

Nothing’s as good as face-to-face.

Patients. Colleagues. Medical experts.

The exchange is always more meaningful when you’re there in person.

This year, Pri-Med Access with ACP is offering an all-new CME curriculum created in partnership with the American College of Physicians. The highly interactive, hands-on sessions include ample time for Q&A. The live, face-to-face format lets you collaborate with clinician-educators and share ideas and discuss emerging trends with colleagues from your own community.

Join us at Pri-Med Access with ACP for the full-two day program, one day, or one course.

Register today at Pri-Med.com/access.

pmiCME

This program is sponsored by pmiCME.

Stay in touch!

This program is designed for primary care physicians who are actively engaged full-time in managing and treating patients (at least 24 hours per week in direct patient care) and whose attendance at this program will benefit the treatment of their patients. A limited number of registration opportunities will be made available for nurse practitioners and physician assistants also engaged in active patient care. © 2011 M|C Communications LLC. All rights reserved. Pri-Med is a registered trademark of M/C Communications, LLC. All other trademarks are the property of their respective owners.

Connect with other clinicians, discuss pressing medical topics, receive CME notifications, and get the latest updates from Pri-Med. Join the conversation at Pri-Med.com/social.

TECHNOLOGY

news clips

Hospital systems

UPGRADE

74 percent of hospitals are planning to invest in health information exchange services. Prior to the passage of the 2009 Recovery Act, which designated $20 billion in incentives for health care providers who implement and meaningfully use certified EHRs in their offices or hospitals, only 17 percent of physicians’ offices and 12 percent of hospitals had implemented some kind of electronic health records system.

Source: Office of the National Coordinator for Health Information Technology

$30 MILLION

The amount of electronic health record incentive dollars paid to Texas physicians in 2011 by the Centers for Medicare and Medicaid Services. A total of 11,000 physicians have registered to participate in the Medicare and Medicaid EHR Incentive Programs while only 1,400 have completed the steps necessary to earn the incentive dollars.

QUALITY REPORT

Source: Texas Medicaid

The U.S. health care system’s score in a national analysis that measures 42 indicators of population health and health care quality, access, efficiency, and equity. This marks the third consecutive drop in scores on the National Scorecard on U.S. Health System Performance; the U.S. scored 65 in 2008 and 67 in 2006. In efficiency alone, which includes duplicative services, high rates of readmissions, low use of health information technology, and high administrative costs, the system scored 53 out of 100. However, the Commonwealth Fund found “rapid progress” on quality metrics that have been the focus of public reporting, collaboration initiatives, and health plans.

Source: “National Scorecard on U.S. Health System Performance, 2011,” the Commonwealth Fund Commission on a High Performance Health System

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TEXAS FAMILY PHYSICIAN

IOM report recommends steps to minimize risks to patient safety

By AAFP News Now staff A newly released report from the Institute of Medicine, or IOM, recommends that HHS take the lead on working to minimize patient safety risks associated with use of health information technology, or health IT. According to the report, “Health IT and Patient Safety: Building Safer Systems for Better Care,” the agency should publish a plan within 12 months to reduce adverse events linked to use of health IT and should report annually on the plan’s progress. HHS’ plan should set a timeframe for the private sector to assess the impact of health IT on patient safety, the report notes.

“Just as the potential benefits of health IT are great, so are the possible harms to patient safety if these technologies are not being properly designed and used,” says Gail Warden, chair of the IOM committee that developed the report, in a news release.

“To protect patients, industry and government have a shared responsibility to ensure greater transparency, accountability and reporting of health IT-related medical errors,” she adds.

If, after one year, the HHS secretary deems progress toward improving patient safety associated with the use of health IT is moving too slowly, the FDA should

step in and regulate health IT, says the report. Accordingly, the report’s authors further suggest that the FDA begin constructing a regulatory framework now in the event that FDA oversight is required in the future.

Among other recommendations included in the report: •

health IT vendors should support the free exchange of information about health IT experiences and issues;

•

the Office of the National Coordinator for Health Information Technology, or ONC, should work to make comparative user experiences across vendors publicly available;

•

HHS should fund a new Health IT Safety Council to evaluate criteria for assessing and monitoring the safe use of health IT;

•

all health IT vendors should be required to publicly register their products with ONC;

•

HHS should specify the quality and risk management process requirements that vendors will be required to adopt;

•

HHS should establish a mechanism for vendors and users to report health IT-related deaths, injuries and unsafe conditions; and

•

HHS should recommend that Congress establish an independent federal entity to investigate deaths, injuries, and unsafe conditions associated with health IT.

The report is available on the IOM website, www.iom.edu.

Source: AAFP News Now, Dec. 8, 2011. © 2011 American Academy of Family Physicians.

news clips

Match ANALYSIS After the Match, who are the first-years?

8 percent of the 17,100 graduates of U.S. medical schools between July 2009 and June 2010 were first-year family medicine residents in 2010, compared to 7.5 percent in 2009 and 8.2 percent in 2008.

Medical school graduates from publicly funded medical schools were more likely to choose family medicine residencies than residents from privately funded schools (9.6 percent versus 5.4 percent).

The Mountain and West North Central regions reported the highest percentage of medical school graduates who chose family medicine residencies (14.3 percent and 11.3 percent, respectively), while the New England and Middle Atlantic regions reported the lowest percentages (5.6 percent and 5.3 percent).

4 in 10 of the medical school graduates (40.3 percent) entering a family medicine residency program as first-year residents entered a program in the same state where they graduated from medical school.

Source: “Entry of U.S. Medical School Graduates Into Family Medicine Residencies: 2010–2011 and 3-year Summary,” Division of Medical Education, American Academy of Family Physicians

Market consolidation Four out of five metropolitan areas in the United States lack a competitive commercial health insurance market, according to an analysis from the American Medical Association.

AMA analyzed fully-insured and self-insured enrollments for health maintenance organizations and preferred provider organizations in 368 metropolitan markets and 48 states.

They also found that in about half of metropolitan markets, one health insurer had a commercial market share of 50 percent or more. And in 24 of the 48 states, the two largest health insurers had a combined commercial market share of 70 percent or more.

Source: “Competition in Health Insurance: A Comprehensive Study of U.S. Markets, 2011 edition,” American Medical Association 10

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Who’s practicing primary care?

Physicians Of the 624,000 physicians in the United States who spend the majority of their time in direct patient care, approximately one-third, or 209,000, specialized in primary care in 2010.

Of the nearly 956 million visits made to office-based physicians in 2008, 51.3 percent were to primary care physicians.

Source: “Primary Care Workforce Facts and Stats No. 1,”Agency for Healthcare Research and Quality’s Center for Primary Care, Prevention, and Clinical Partnerships

55 percent of office-based primary care physicians worked in a practice with physician assistants, nurse practitioners, or certified nurse midwives in 2009, and that number is expected to go up as the population ages and with the expansion of health insurance coverage through health care reform. Most likely to work with them are doctors age 54 and younger, those in large groups, and those serving a large Medicaid population.

Source: Data Brief, No. 69, August 2011, The Centers for Disease Control and Prevention’s National Center for Health Statistics

Of the more than 450 medical students that have participated in the University of Missouri School of Medicine’s Rural Track Pipeline, 65 percent practice in Missouri and 43 percent practice in rural areas of the state. In and outside of Missouri, more than 57 percent of participants practice in rural areas. In comparison, 9 percent of physicians practice in rural areas nationwide and 3 percent of medical school graduates plan to practice in a rural area.

Source: “Medical School Program Sparks Rural Residencies,” Health Leaders Media, Nov. 9, 2011

TEXAS FAMILY PHYSICIAN

48.7%

51.3%

Visits to primary care physicians Visits to subspecialists

teamwork works

Way to go, Mo.

Visits to officebased physicians, primary care vs. subspecialists, 2008

Estimated number of nurse practitioners and physician assistants practicing primary care, 2010

48% 52%

NPs and PAs Approximately 56,000 nurse practitioners and 30,000 physician assistants were practicing primary care in the United States in 2010, compared with 106,000 practicing nurse practitioners and 70,000 practicing physician assistants.

Source: “Primary Care Workforce Facts and Stats No. 2,”AHRQ’s Center for Primary Care, Prevention, and Clinical Partnerships

Nurse practitioners

57%

43%

Physician assistants Primary care Subspecialty care

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news briefs

CMS releases final rule for ACOs, relaxes requirements to participate

rangement for the three-year agreement. The second track allows ACOs to share in savings and losses for the agreement period in return for a higher share of any savings it generates.

Physicians’ participation in ACOs and the MediBy Kate Alfano care Shared Savings Program is voluntary. Individual ACOs must include enough primary care professionals on oct. 20, the centers for Medicare and Medicaid to care for the Medicare beneficiaries assigned to that Services released the final rule for establishing accountACO, and an ACO must have an assignment of at least able care organizations under the Medicare Shared 5,000 Medicare fee-for-service beneficiaries.

Savings Program. It represents a significant departure A prospective ACO must apply to the program and infrom initial guidelines released on March 31, 2011, clude information on how they plan to deliver high-qualwhich many commenters called “too prescriptive and ity care and lower the growth of expenditures for their burdensome.” CMS estimates that assigned beneficiaries. Once acthe final rule will help create as cepted, CMS offers two start dates: “Whether provided many as 270 Medicare ACOs—an April 1 and July 1. Under both, the through ACOs increase from the 75-150 originally first performance year ends Dec. 31, expected to participate.

2013, and the agreement period lasts or an alternative According to AAFP, “the final through Dec. 31, 2015. During this innovation rule largely recognizes that smallperiod, CMS estimates Medicare opportunity, to medium-sized physician praccould save $1.8 billion and share $1.3 tices cannot convert their adminbillion in bonuses to ACOs for hitcoordinated care istrative procedures and health ting savings targets, according to is meant to allow record systems overnight, and the the American Medical Association. providers to break final rule is designed to provide An earlier proposal would have both time and resources to make required an ACO to seek an antiaway from the the program more attractive.” trust review from the IRS, FTC, and tyranny of the The Medicare ACO model Department of Justice. CMS did 15-minute visit, encourages groups of affiliated not pursue this provision. Howhealth care professionals to coorever, the agencies have pledged to instill a renewed dinate care across care settings to the competitive impact of sense of collegiality, monitor improve the health and experience the networks and may adjust reand return to the of the patient and reduce the rate quirements in the future. of growth in health care spending.

Addressing concerns for small type of medicine These groups can include physipractices and rural community that patients and cians in group practice, networks hospitals, CMS also announced families want..” of individual practices, hospitals the advanced payment initiative, and physicians in partnerships, which will allow these groups to Donald M. Berwick, M.D. receive upfront access to capital to and hospitals employing physicians. There is no requirement cover startup costs. The program is that an ACO include a hospital. committing $170 million for ACOs that launch in 2012.

Among the changes from the proposed rule, the final In a perspective article published in the New Engrule gives primary care physicians the option to particiland Journal of Medicine, CMS Administrator Donald pate in multiple Medicare ACOs; replaces the proposed M. Berwick, M.D., said, “Whether provided through retrospective beneficiary assignment method with a ACOs or an alternative innovation opportunity, coprospective assignment method in which beneficiaries ordinated care is meant to allow providers to break are identified quarterly; reduces the number of individaway from the tyranny of the 15-minute visit, instill a ual quality measures that will decide if an ACO qualifies renewed sense of collegiality, and return to the type of for shared savings by half, from 65 to 33; shares quality medicine that patients and families want.” reporting requirements for the second and third years “For patients, coordinated care means more ‘qualof the program; allows critical-access hospitals, federity time’ with their physician and care team (a patient’s ally qualified health centers, and rural health clinics to advocate in an increasingly complex medical system) participate; and removes the use of electronic health reand more collaboration in leading a healthy life. And cords as a requirement. for Medicare, coordinated care represents the most It also eliminates financial penalties for some groups promising path toward financial sustainability and by offering two tracks for participation. The first track away from alternatives that shift costs onto patients, allows an ACO to operate on a shared-savings-only arproviders, and private purchasers.”

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TEXAS FAMILY PHYSICIAN

HIGHLIGHTS CMS released the final rule on Medicare accountable care organizations, or ACOs, on Oct. 20.

CMS estimates that, as outlined in the final rule, the program could spur the creation of as many as 270 ACOs, double the agency’s estimate in the proposed regulation.

The final rule gives primary care physicians the option to participate in multiple Medicare ACOs; replaces the proposed retrospective beneficiary assignment method with a prospective assignment method; and reduces the number of individual quality measures in half.

TAFP, working with AAFP and other state chapters, developed three resources on ACOs: “The Family Physician’s ACO Blueprint for Success,” “The Family Physician’s Practice Affiliation Guide,” and “The ACO Legal Primer.” Find these documents and more on www.tafp.org.

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Start Saving Money on Vaccines Now! Discounts on Vaccines • Reimbursement Support With Payers • Timely Updates About New Products, Changes & Sales • Donations to TAFP With Every Purchase!

Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV. Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management.

The program is free to your practice, and enrollment is completely voluntary.

The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine.

Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered.

Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or info@atlantichealthpartners.com for more information and to register.

news briefs

Wal-Mart explores expansion of health care services

By Jonathan Nelson a confidential document leaked to National Public Radio revealed that Arkansasbased Wal-Mart Stores Inc. seeks to expand its offerings in the provision of health care services. The document is a 14-page request for information sent to Wal-Mart vendors in late October announcing the mega-retailer’s intent to “build a national, integrated, lowcost primary care healthcare platform that will provide preventative and chronic care services that are currently out of reach for millions of Americans.”

The story broke on Nov. 9, 2011, and hours later, the company issued a two-line statement attributed to John Agwunobi, M.D., M.P.H., M.B.A., head of Wal-Mart’s health and wellness division, that reads, “The RFI statement of intent is overwritten and incorrect. We are not building a national, integrated, low-cost primary care health care platform.”

Despite the statement, the company appears to be proceeding with its solicitation of proposals, which were due by Nov. 22, 2011, according to the RFI. Wal-Mart has asked its vendors to demonstrate their ability to provide health care services and the “value proposition” they can offer the company. “The vendor should clearly describe how each service or product either completes or contributes to Wal-Mart’s vision of rapidly creating a nationally integrated healthcare platform.” The document then lists a set of chronic disease management services, diagnostic services, and

preventive care services Wal-Mart is seeking vendors to provide, including management of everything from diabetes, asthma, and hypertension to sleep apnea, osteoporosis, HIV, and clinical depression.

AAFP President Glen Stream, M.D., M.B.I., told NPR that Wal-Mart’s proposal takes health care in the wrong direction. “I would still be gravely concerned that this is going to fragment care at a time when we now clearly understand that people having a usual source of comprehensive and continuous care in a single location is one of the main features that drives high-quality care, good patient health outcomes, and drives down costs.”

AAFP has contacted Wal-Mart to discuss its plans, but has issued a set of talking points to its constituent chapters stating that until Wal-Mart selects vendors and releases a detailed business plan, “… we have to limit our judgment since we do not know the details.”

AAFP maintains a policy on retail health clinics that states: “The American Academy of Family Physicians (AAFP) opposes the expansion of the scope of services of Retail Health Clinics (RHC) and, in particular, the management of chronic medical conditions in this setting. The AAFP is committed to the development of a health care system based on strong, team-based patient-centered primary care defined as first contact, comprehensive, coordinated, and continuing care for all persons and believes that the RHC model of care further fragments health care.”

Practice available for one or more family physicians in Waxahachie, 30 minutes from Dallas.

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An ideal opportunity for new practioner(s).

Contact: Richard D. Redington, M.D. Family Practice Association 1410 West Jefferson Waxahachie, Texas 75165 Phone: (972) 937-1210 Fax: (972) 937-0243

TAFP offers new online courses Continue your professional development online with three free CME activities available on www.tafp.org.

The three courses currently available were recorded at the 2011 Annual Session and Scientific Assembly in Dallas in July 2011.

Guide to Maintenance of Certification: A Discussion of the ABFM MOC Speaker: Dale Moquist, M.D. 1 AMA PRA Category 1 Credit™

TAFP recognized for excellence in scope of practice advocacy Above: TAFP Director of Communications Jonathan Nelson, left, receives AAFP’s 2011 Leadership in State Government Advocacy award from AAFP President Glen Stream, M.D., M.B.I. TAFP was recognized for our effort during the 82nd Texas Legislature to preserve physicians’ scope of practice against attacks from advanced practice registered nurses. This is the third time TAFP has won this award.

ABFM eases MC-FP Part IV requirements, nixes seven-year plan the american board of family medicine has made modifications to the Part IV module that should make it easier for physicians to complete an improvement project, earn credit for that MC-FP requirement, and earn 20 CME credits. The Performance in Practice Modules are web-based, quality improvement modules in health areas that generally correspond to the Self-Assessment Modules.

Under the ABFM Part IV requirements, each physician assesses his or her care of patients using evidence-based quality indicators.

After the physician enters data from 10 patients into the ABFM website, ABFM provides feedback for each of the quality indicators. The physician then uses this performance data to choose an indicator and design a quality improvement plan using a menu of interventions available from various online sources. The physician submits the plan and implements the plan into practice.

Demystifying Accountable Care Organizations Speaker: Patrick Carter, M.D. 1 AMA PRA Category 1 Credit™ Know Before You Sign! What to Look for in a Physician Employment Contract Including Non-Profit Health Corporations Speaker: Doug Kennedy, J.D. 1 AMA PRA Category 1 Credit™ To access these online courses, go to www.tafp.org.

Previously, the physician had to wait 90 days before assessing the care provided to 10 patients in the chosen health area. This has been shortened to one week. The physician enters the data into the ABFM website, and compares his or her pre- and postintervention performance and compares results with peers. As in the original requirement, a physician must complete a Part IV module within one year, or else restart the module or select a new module.

Additionally, ABFM recently implemented “Continuous MCFP,” which removes the seven-year certification option. All family physicians who certified in 2011 or recertify in future years must follow the 10-year program. This makes the successful completion of each three-year stage essential in maintaining the 10-year plan.

For more information, go to the ABFM website at www.theabfm.org. For additional resources on fulfilling the ABFM Maintenance of Certification requirements, go to TAFP’s website, www.tafp.org.

www.tafp.org

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Member news

Goertz completes year as AAFP president, assumes role of board chair roland a. goertz, m.d., m.b.a., of Waco, Texas, completed his year as president of the American Academy of Family Physicians at the 2011 Congress of Delegates meeting in Orlando, Fla., this past September, and assumed the role of AAFP board chair. Previously, he served a one-year term as presidentelect, and three years as a member of the AAFP Board of Directors. Goertz was elected to these positions by the AAFP Congress of Roland Goertz, Delegates.

M.D., M.B.A. Reflecting on his year as president when he was called upon to be AAFP spokesperson, family medicine advocate, and voice to the media, Goertz said in his address to the AAFP Congress that his experience covered a full range of emotions—at times it was “exciting, stimulating, fast-paced, fulfilling, challenging, frustrating, and sometimes tiring.” In total over 12 months, he spent 194 days on the road, visited nine state chapters, made 15 trips to Washington, D.C., and responded to countless e-mails and phone calls.

Goertz said the majority of his time was spent in some form of advocacy, whether testifying before the U.S. Congress, briefing the Centers for Medicare and Medicaid Services, or participating in meetings with the Robert Wood Johnson Foundation.

Within the Academy, he worked to advance AAFP’s four strategic initiatives, reviewed policy statements and media releases, corresponded with members on important issues, and interacted with the media.

Goertz told the Congress that his most significant lessons were in two areas: communication and personal conduct. He encouraged all family physicians to be professional to the public; stay passionate about what you believe in; and move the needle as much as you can, but trust that those after you will continue the momentum of your work.

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He also offered thoughts on the future.

“As family physicians, we are wanted; as family physicians, we offer solutions to much of what is wrong in health care; as family physicians, we offer patient care at the highest quality; and as family physicians, we are needed,” Goertz said. “I have never been prouder to be a family physician.”

“As family physicians, we are wanted; as family physicians, we offer solutions to much of what is wrong in health care; as family physicians, we offer patient care at the highest quality; and as family physicians, we are needed. I have never been prouder to be a family physician.”

Roland A. Goertz, M.D., M.B.A. As board chair, Goertz will advocate on behalf of family physicians and patients nationwide to inspire positive change in the U.S. health care system. In his 27-year medical career, he has served as a physician in rural private practice, a family medicine residency program director at two Texas residencies, and chair of the Department of Family and Community Medicine at the University of Texas Medical School at Houston.

He has been a member of AAFP and TAFP since 1979, and served as TAFP president from 1994-1995.

Austin family physician named to new position at HHSC family medicine has a new champion among state officials. Mark Chassay, M.D., of Austin will become deputy executive commissioner for the Office of Health Policy and Clinical Services as of Jan. 1, 2012. In this newly created position at the state’s Health and Human Services Commission, Chassay will focus on coordinating health and clinical policy to ensure a coordinated approach to medical policy.

Mark Chassay, M.D.

“In his new role, Dr. Chassay will oversee the HHSC Office of the Medical Director, Office of e-Health Coordination, Office of Acquired Brain Injury, the Office of Informal Dispute Resolution, and health policy, and he will work closely with the new Texas Health Care Quality Institute,” said HHSC Commissioner Tom Suehs in a statement released in late October.

Chassay previously served as head team physician for the Department of Intercollegiate Athletics at the University of Texas at Austin, coordinating multidiscipline sports health services for over 600 student athletes. In this role, he served as medical director for the training room clinics, and supervised a team of physicians and athletic trainers. He is co-founder of Texas Sports & Family Medicine, PLLC, and has served as president of the Travis County Medical Society.

He earned his medical degree from the University of Texas Medical School at Houston in 1992, and completed a family practice residency at Memorial Hermann Hospital Southwest in Houston in 1995. Then he moved to southern California where he completed a primary care sports medicine fellowship at Kaiser Permanente.

TAFP CEO Tom Banning believes Chassay’s appointment is a welcome sign that state leaders intend to transform Texas’ fragmented health care system into one that provides higher quality, better coordinated, and more efficient care. “This is a tremendous opportunity to really drive system reform and redesign,” says Banning. “I can think of no better person than Mark to lead the charge.”

Mabry completes term as speaker of the AAFP Congress of Delegates leah raye mabry, m.d., r.ph., of San Antonio, completed her third and final term as speaker of the AAFP Congress of Delegates at the 2011 Congress of Delegates meeting in Orlando, Fla., in September. As speaker, she ensured the proper scheduling and smooth flow of business coming before the Congress, appointed members to all reference and special committees, assigned reports and resolutions to reference committees for review, and oversaw the election of AcadLeah Raye Mabry, emy officers and diM.D., R.Ph. rectors.

In her address, Mabry fittingly quoted the parliamentary authority, the Standard Code: “Parliamentary law is the procedural safeguard that protects the individual in the exercise of the rights of free speech, free assembly, and the freedom to unite in organizations for the achievement of common aims.”

With this, she stressed the importance of her office and its strong tradition. “Through the right of freedom and fair debate, the right of the majority to decide, and the right of the minority to protest and be protected, your speakers will be here to represent you and our membership.”

Mabry previously served as chief of staff and president of the medical board at the Christus Santa Rosa City Center Hospital and as a faculty member at the Christus Santa Rosa Family Medicine Residency Program in San Antonio. Semi-retired, she still provides acute care through Texas MedClinic in San Antonio and also continues to serve as a clinical professor with the University of Texas Health Science Center Department of Family Medicine in San Antonio.

Mabry has been a member of AAFP and TAFP and since 1985. She was elected vice speaker in 2005 and elected to her first term as speaker in 2008. Throughout the past decade, Mabry has represented AAFP and TAFP on numerous commissions, committees, and task forces. She served as TAFP president from 1997-1998.

“Through the right of freedom and fair debate, the right of the majority to decide, and the right of the minority to protest and be protected, your speakers will be here to represent you and our membership.”

Apply for delegate spots and scholarships for AAFP’s NCSC and ALF conferences tafp is seeking official representatives to the National Conference of Special Constituencies, and for applicants for Academy scholarships the Annual Leadership Forum and NCSC. Each year, AAFP holds these conferences in conjunction in Kansas City, Mo. The 2012 conferences will be held May 3-5.

For the Texas delegation to NCSC, five spots are available for one TAFP member to represent each of the special constituencies: new physicians, women, minorities, international medical graduates, and GLBT. TAFP reimburses up to $1,000 for expenses for each delegate. Those interested applying for one of the delegate spots should send a current curriculum vitae and/or a statement of intent to Jonathan Nelson at jnelson@tafp.org.

TAFP has two additional scholarships available for a third-year resident and a minority physician to attend NCSC, and two scholarships available for a TAFP member to attend ALF. The ALF future leader scholarships are open to first-time attendees only. All scholarships provide reimbursement of up to $1,000 for attendee travel expenses.

Those interested in applying for the NCSC or ALF scholarships should contact Kathy McCarthy at kmccarthy@tafp.org or go to www.tafp.org to download the scholarship application forms.

For information about these conferences and to register, go to www.aafp.org.

Leah Raye Mabry, M.D., R.Ph.

Waco residency program develops project to address childhood obesity the waco family medicine Residency Program has been awarded an AAFP grant to develop a family-centered, community project designed to reduce childhood obesity and promote fitness. The grant comes through AAFP’s Americans In Motion − Healthy Interventions, or AIM-HI, initiative, which positions fitness through physical activity, nutrition, and emotional well-being as the treatment of choice for the prevention and management of many chronic conditions.

AAFP awarded nine grants to residency programs across the country and encouraged them to tailor their project to the needs of

their individual community. The Academy hopes this grant program will enhance the training of family medicine residents in promoting healthy lifestyles.

The Waco Fit and Healthy Families program will encourage and enable community families to become healthier and more fit through monthly family group medical visits and healthy living workshops on nutrition, physical activity, and emotional well-being.

Program faculty saw particular need in the Waco community. A 2006 study of the program’s pediatric population found that onethird of children ages 2-18 were obese and

another 18 percent were overweight. Their project aims to target this issue through family intervention using resources already in place in the community.

AIM-HI offers physicians three primary tools to help patients follow a healthy lifestyle: a fitness inventory, which gauges a patient’s confidence about their fitness and their readiness to change; a food and activity journal, which helps patients track healthy eating, physical activity, and emotional wellbeing lifestyle behaviors; and a fitness prescription, through which the patient and the physician establish goals that are assessed periodically.

Proponents believe this approach creates physician-patient relationships that lead to behavior changes that result in better health. www.tafp.org

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Member news TAFP 2012 AWARDS

Texas Tech medical student joins AAFP commission charles “chaz” willnauer, a second-year medical student at Texas Tech University Health Sciences Center School of Medicine in Lubbock, has been appointed to the AAFP Commission on Quality and Practice. As the medical student representative, he will serve a one-year term starting Jan. 1, 2012.

As a member of the commission, Willnauer will work to Charles Willnauer fulfill its mission: to develop policy related to the practicing family physician. This includes developing recommendations, policies, and programs related to health care delivery systems, performance measurement, privileging, practice redesign and quality improvement, health information technology, practice management, physician payment, and private sector advocacy.

At Texas Tech, he is a participant in the Family Medicine Accelerated Track, which culminates in a medical degree in three years for students interested in pursuing family medi-

cine. Simultaneously, Willnauer is pursuing an MBA in Health Organization Management.

He is co-founder and vice president of finance for the Texas Tech MD/MBA Association.

His joint training in medicine and business led him to pursue the commission appointment. “My interests include providing quality health care at reasonable costs to both the individual and society. I have a special desire to develop business models that will benefit middle-class societies who can’t afford health insurance and who don’t qualify for government programs.”

Originally from Olathe, Kan., Willnauer attended Brigham Young University for his undergraduate degree and was awarded a Bachelor of Arts in Portuguese with a minor in ballroom dance. He volunteers with the Boy Scouts of America as a scout leader and young men mentor, and served a two-year mission for The Church of Jesus Christ of Latter-day Saints in Manaus, Brazil.

He was awarded the TMLT memorial scholarship in 2011, the 2011 Foster G. McGaw Scholarship from the American College of Healthcare Executives, and the 2010 Health and Social Services Scholarship from Covenant Health Systems.

El Paso medical school gets grant to increase exposure to family medicine, border health texas’ newest medical school has been awarded a grant that they’ll use to increase medical student exposure to primary care and to encourage these students to pursue practice in underserved areas.

The Department of Family and Community Medicine at the Texas Tech Paul L. Foster School of Medicine in El Paso will receive $945,000 over the next five years from the Health Resources and Services Administration for their project, “Expanding Family Medicine Training for Medical Students on the U.S./Mexico Border.”

“This award will substantially enrich and expand the family medicine-based training experiences for medical students and improve the departmental infrastructure to support delivery of the family medicine clerkship for an increasing medical student class size,” says Department Chairman 18

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Gurjeet Shokar, M.D., project director and TAFP member. Associate project director is Department Director of Medical Student Education Charmaine Martin, M.D. The project has four main objectives: First, it will enhance the family medicine clerkship with interactive web cases focused on border health and it will expand the number of longitudinal electives offered during the clerkship. Second, it will support the development of a service learning track in years one through three of the medical school curriculum. Third, it will be used to develop fourth-year electives focused on border health. And fourth, it will support the recruitment and training of community family medicine faculty to assist with the family medicine clerkship, as well as support ongoing faculty development activities.

Nominate yourself or a colleague for one of TAFP’s 2012 awards, including Physician of the Year, Physician Emeritus, the Public Health Award, the Exemplary Teaching Awards, and the Special Constituency Leadership Award.

Go to the membership section of www. tafp.org for more information and to access the nomination materials.

TAFP Foundation president appointed to AAFP Foundation board dale c. moquist, m.d., f.a.a.f.p., of Sugar Land, Texas, has been appointed to the American Academy of Family Physicians Foundation Board of Trustees. In this position, he will oversee the humanitarian, educational, and scientific initiatives of the AAFP Foundation. His four-year term begins on Jan. 1, 2012.

Moquist has served as president of the TAFP Foundation Board of Trustees since 2006, enthusiastically supporting the Foundation’s mission to encourage medical students to pursue the specialty, to support family medicine residents, and to fund practice-based primary care research. Under his leadership, the TAFP Foundation created several new medical student scholarships and began the research endowment.

He currently serves as full-time faculty and geriatric coordinator at the Memorial Family Medicine Residency Program in Sugar Land. He previously served on the faculty for two Texas residency programs and as a private-practice physician in Grand Forks, N.D. He was awarded his medical degree by the University of Texas Southwestern Medical School in Dallas and completed a family medicine residency at the University of Minnesota Family Practice Residency Program, North Memorial Medical Center.

Moquist has held numerous leadership positions in AAFP, TAFP, and the North Dakota Academy of Family Physicians including a three-year term on AAFP’s Board of Directors, from 1993-1996. Before that, he served as a delegate to the AAFP Congress of Delegates for nine years; chair of the AAFP Commission on Membership and Member Services in 1994; chair of the AAFP Commission on Quality and Scope of Practice from 1994-1995; and AAFP delegate to the American Medical Association from 1997-2010.

San Antonio educator appointed to AAFP public health commission tafp past president Kaparaboyna Ashok Kumar, M.D., F.R.C.S., has been appointed to the AAFP Commission on Health of the Public and Science. Kumar has worked in a variety of professional settings, including solo practice and as residency faculty. He currently serves as vice chair of medical student education and clerkship director at the University of Texas Health Science Center at San Antonio Department of Family and ComKaparaboyna Ashok munity Medicine.

Kumar, M.D. On the commission, Kumar will work with AAFP staff to develop and review evidence-based clinical practice guidelines; develop recommendations for clinical preventive services including immunizations; review health of the public policies including tobacco, exercise, and obesity; represent AAFP to federal, medical specialty, voluntary health, and other organizations; and serve on advisory committees to Academy programs. His four-year term began on Dec. 15, 2011.

Kumar is a longtime leader in TAFP and AAFP. He became involved as an international medical graduate of Osmania Medical College in Hyderabad, Andhra Pradesh, India, serving as one of the first IMG delegates to the AAFP Congress of Delegates and the first member elected as the special constituency member of the TAFP Board of Directors and the Executive Committee.

He previously served as chair of the AAFP Commission on Membership and Member Services, and chair of the Chapter Relations Sub-committee.

Kumar completed a surgical residency at St. James’ University Hospital, England, and a family medicine residency at the University of Texas Health Science Center at Tyler. He completed a fellowship at the Royal College of Surgeons.

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Generations of care g Thomas E. Mueller, M.D. TAFP’s 2011-2012 Texas Family Physician of the Year

BY KATE ALFANO

daybreak on the gen-vi ranch reveals hues of pale blues and greens, hazy oranges, and pinkish purples as the 200 acres of rolling hills come to life. Gazing over the land dotted with oak and cedar trees, an occasional eagle or osprey overhead, one can see for miles from the broad, open porch of Thomas E. Mueller, M.D., TAFP’s 2011-2012 Texas Family Physician of the Year.

Passed down through Mueller’s wife’s family, the Zapalacs, who first arrived in Texas in the 1840s, the ranch takes its name from their children—the sixth generation to live on the land. It’s an escape in the Colorado River Valley, separated from the bustling highway by a winding road of crushed limestone and gravel. The city of Columbus itself, where Mueller practices, is its own quiet refuge along Interstate 10 between the cities of Houston and San Antonio. The town and its surrounding communities draw much of their character from their Czech roots, and Mueller describes the people in this area as “hard working, diligent, trustworthy, and respectful of what the physician has to say.”

While country life moseys along—Mueller tells family medicine residents rotating with him from Houston that a Columbus traffic jam is five cars waiting for the train to go by—rural medicine has proved to be bustling and challenging, demanding quick thinking and a breadth of knowledge. Mueller began practice in La Grange, 30 minutes away from Columbus, first as a solo family physician and later with Fayette-Lee Family Health and Maternity Care. Now he’s with Columbus Medical Clinic, a hospital-based rural health center.

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Mueller recalls an incident during his first year in practice when he was on call for the emergency room in La Grange.

Two women were injured in a three-car accident on the highway after a drunken driver crossed the median and hit a car head on, also involving the car behind it. The two women arrived by ambulance at the emergency room with their husbands in a car close behind.

“It was a real eye-opener,” he says, to see one of his medical school professors step out of the car and another professor, the man’s wife, as one of the injured.

Mueller sprung into action, providing first aid to the female professor and treating her friend for more severe injuries—head trauma and a pulverized femur.

“Back then, when you were on ER call, you might be in your office, you might be at home, you might be at the hospital, but if anyone walked into the emergency room,” you were the one in charge, he says. Through the whole ordeal, Mueller kept his characteristic cool, treating these “VIPs” just as he would any other patient.

This inherent calm is one of the first qualities patients and colleagues identify when describing him, after his characteristic grin and easy-going attitude. “He’s obviously very caring,” says James Hrachovy, M.D., Mueller’s colleague who he’s known for more than 20 years. “He always has a smile on his face and is never too busy to listen. He’s what everyone would want in a family physician; he’s my physician. He’s old-fashioned … the epitome of what I call the old country doctor.”

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“By age 8, I knew I’d be a family physician. I used to go on rounds with my dad and papa and I liked the continuity and diversity of family medicine. If you go into rural medicine, you can still have a wide variety of practice as long as you have the training and experience. You get to do what you really want to do.”

Thomas Mueller, M.D.

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Clockwise, from left: Out on the Gen-VI Ranch, Mueller tends to nine horses. Passed down through the Zapalac family, six generations have lived on the 200 acres in the heart of the Colorado River Valley.

Mueller visits patient Eugene Schramek at the Columbus Community Hospital, just steps away from his office. Schramek began seeing Mueller in La Grange in the ’80s, and followed him to his practice in Columbus. He says the doctor makes his patients feel like “he has all the time in the world” for them.

Patient Karen Hernandez appreciates Mueller’s willingness to give freely of his time, even if it’s after traditional business hours.

She describes a visit with him in April 2010 when she was experiencing consistent pain in her joints. He tried everything to diagnose the issue, she says. Finally, while she was still in the office, he walked across the hall to talk to the orthopedist and then walked Karen over to see him. “I was diagnosed with bone cancer, multiple myeloma,” she says. “That evening I got a call from Dr. Mueller saying that he had seen my test results and was sorry for the diagnosis. He told me that if I ever had any questions, to ask him. You just don’t hear that from a doctor. He had sought out my results and took the time to reach out to me.”

Eugene Schramek began as Mueller’s patient in La Grange in the ’80s and followed him to Columbus. “He takes interest in his patients, he’s a good listener, and he doesn’t rush patients through,” Eugene says. “He

has all the time in the world.” When asked whether he would ever choose another primary care doctor, Eugene replies, “Not in this lifetime.”

Though only a patient herself for a few months, Bobbie Berger has known Mueller for 10 years. “He’s delivered all my grandbabies but two and that’s because they live out of state,” she says. “I have pictures of him with all the grandkids and there he is just”— she beams—“grinnin’.”

Mueller spent a lot of time in the obstetrics wing until last September when he scaled back on deliveries as a promise to his wife to cut down the late-night phone calls. Over 30 years, he estimates he’s delivered between 2,000 and 3,000 babies, including a record-setting 35 in one month in La Grange. The hospital presented him a cake to celebrate. Even a few thousand is a rough estimate, though. He jokes, “I’ve always thought about counting, but I would

Patient Karen Hernandez reflects on Mueller’s willingness to give freely of his time. For this visit, Mueller came into the room and asked, “So what’s going on?” She started to talk about her cough and Mueller gently interrupted her. “That’s not what I meant, what’s going on [in life]?”

Sitting around the dinner table the night before Thanksgiving, Mueller shares a laugh with his parents, Edwin Lee Muller, M.D., retired family physician and TAFP past present, and Mary Helen Mueller.

get halfway through when I was interrupted with another delivery.”

Smiling, Mueller remembers receiving one call while he and his family were riding their horses around the town square to prepare for an upcoming parade. He says the nurse sounded worried when she heard he was out riding, not realizing he was close by.

Like a scene from a movie, Mueller galloped up to the hospital, tied the horse to a shoe scraper outside the door, and arrived just in time to change into scrubs and deliver the baby. Once things calmed down, he told the family of his exciting entrance and they were so amused that they took a photo of him on his horse in his scrubs, an 8-by-10 that he still has framed at his home.

Mueller’s commitment to providing the full spectrum of care from obstetrics to endof-life comes from a long family history in medicine. Starting with his grandfather, Edwin Leo Mueller, M.D., and spanning four

generations to his own children, there are 13 doctors in the family, including one currently in medical school; five nurses, including two currently in nursing school; three technicians; and two office managers. “We all knew medicine,” says his father, Edwin Lee Mueller, M.D. His grandfather, a general practitioner, and his father, a family physician, practiced together in San Antonio. His uncle, John “Jack” Mueller, practiced family medicine in nearby Seguin. As young as 8 years old, Mueller would go on rounds with “dad and papa,” experiencing the continuity and diversity of family medicine. “We did it all,” Edwin Lee says. “OB/GYN, peds, internal medicine, cardiology, surgery, and we made house calls.”

Mueller’s brother, Frank, also a family physician, says the way their dad practiced was “by making lots of time for people.”

Even though a busy practice with obstetrics meant long hours, Edwin Lee was a de-

voted family man to wife, Nellie, a registered nurse, and their eight children—another trait passed on to later generations. “When I was growing up, my dad frequently didn’t get home until late so we made time for vacations and together time,” Mueller says.

Sitting around the dinner table the night before Thanksgiving, trading stories with friends and family, Edwin Lee recalls their first big camping trip as a family to Inks Lake State Park in central Texas. They arrived in the station wagon on a hot summer day and he began setting up an oldfashioned wall tent before an audience of impatient kids, a task made more difficult using wooden stakes in granite-riddled ground. With help from a neighboring camper who brought over two metal stakes and a beer, the tent was ready. And because they’d heard there might be some rain, they dug a trench around it to prevent water from coming in. www.tafp.org

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M.D. Over many years, he served as member While in La Grange, Mueller was actively That night, the wind began to blow and or chair of numerous TAFP committees and involved with the area chamber of comthe rain began to fall. Water started coming commissions, as a delegate for the Colorado merce, serving as president and board memin on the kids’ side of the tent, so Edwin went Valley Chapter, and as TAFP president. ber; the Lion’s Club, serving on their board outside to put their window flaps down. As Though Mueller’s organized medicine acof directors; and the Knights of Columbus, soon as he got settled again, it started comtivity has slowed, TAFP past president Robert Holy Name Society, and Sacred Heart School ing in on the other side. “Then everything Youens, M.D., of Weimar, wrote in a nominaBoard. “I was set to be president of the Lion’s broke loose,” Mueller says, joining in. “The tion letter that his influence in the specialty Club the same year as the Chamber of Comwind was blowing like crazy and we had hasn’t waned. “He is one two kids on each pole tryof those in-the-trenches ing to hold the tent down. physicians who has quietly Water started rushing in brought a positive impresthe front door, filling the sion of our specialty to his tent. Finally it started setpatients and community tling down a bit and we over many years.” went outside. There was a He has been “fightpicnic table covered with a ing the good fight for our peaked roof; the Coleman specialty simply by being lantern sitting up in the there for our patients day peak of the roof had water after day, year after year.” in it. We started looking In present day, Muelaround thinking maybe we ler’s community involveshould go home after all of ment largely centers on this, and saw downed trees patient education through everywhere where a tornathe hospital’s Do Well, Be do had come through.”

Well diabetes education Despite this initial enprogram. He also voluncounter with Mother Nateers with the SHUMLA ture—and perhaps because School, an organization of it—Mueller’s passion for in deep west Texas that travel and adventure grew. strives to preserve existing Along with wife Donna, son Native American rock art Seth, and daughters Stephand educate all ages on its anie and Leslie, the Mueller historical significance. And family motto while the kids he continues to teach rotatwere growing up was “have ing residents and students time, will travel,” whether about the variety and chalout to their hunting lease Mueller and wife Donna stand in front of a staircase Mueller fashioned from recovered cedar logs from their land. Their home’s warm décor reveals this lenges of rural medicine, in Comstock, Texas, the beautiful woodwork, stone from their hunting lease in Comstock, intricate passing on the wisdom mountains of Colorado, or pieces of ironwork designed by Donna and created by local artisans, and plenty gained over his own three between TAFP meetings. of room for their large family and many friends to stop by and visit. decades in medicine and Seth, now 31, has been from those before him. to 28 of the 50 states with Back on his own ranch, Mueller talks carmerce, but I chose the Chamber because it his dad. “Anytime there was a medical meetingly about the land and their effort to prehad a secretary,” Mueller says. He served as ing he always made time for family. It wasn’t serve it; he and his wife were awarded their the medical director of the Fayette County leisurely time; it was more like ‘we need to be district’s Resident Conservation Rancher of EMS for 15 years and volunteered for more here and there tomorrow.’” the Year Award in 2006 for their efforts and than 10 years with the MS-150, a charity biFamily is paramount for Mueller, and the have held many conservation and wildlife cycle ride between Houston and Austin benteamwork of his tight-knit clan allowed him to management seminars on Gen-VI. “It’s about efiting the National Multiple Sclerosis Socimasterfully interweave his medical practice, adbeing a good steward of the land,” Donna ety, which earned him a spot in the Lone Star vocacy for family medicine and rural medicine, says. “We believe that conserving our natural Chapter’s Hall of Fame for Best Doctor. love of traveling, and community involvement. resources is essential to the future of generaMueller’s involvement in TAFP started On nights when Mueller was working late tions to come. Our ancestors have been good in medical school at the encouragement of at the hospital in La Grange, Donna would role models for us, enabling us to enjoy the TAFP past president James R. Winn, M.D., pack up dinner and take the kids to him so beauty of nature and our ranch.” of Uvalde, with whom Mueller was doing a they could eat as a family. And though their “We continue to strive to be good role fourth-year rural medicine rotation, and conkids were involved in many extracurricular models … and strive to educate others to tinued when he was a resident through UTactivities, “he came to every event—even if secure a quality environment for future genHouston mentors and TAFP leaders C. Frank he couldn’t stay the whole time,” she says. He erations.”

Webber, M.D., and Harold T. Pruessner, even coached Leslie in soccer.

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The key to improving quality and reducing cost in health care

CLINICAL INTEGRATION

The American health care industry is under tremendous pressure to lower medical costs, and as long as the economy continues to sputter, that pressure will increase rapidly. Shortly after stepping down as head of the Centers for Medicare and Medicaid Services, Don Berwick, M.D., delivered a visionary speech at an Institute for Healthcare Improvement conference in which he said our nation is at a crossroad.

“The care we have simply cannot be sustained. It will not work for health care to chew ever more deeply into our common purse. If it does, our schools will fail, our roads will fail, our competitiveness will fail. Wages will continue to lag, and, paradoxically, so will our health. The choice is stark: chop or improve.” by “chop,” berwick meant arbitrary reductions in fees for medical services, the threat of which seems nearer with every Congressional deadline to avert drastic Medicare cuts.

And by “improve,” he alluded to the idea that by focusing on quality improvement, care delivery would have to become more efficient and costs would necessarily decline. He and his colleagues have estimated that each year, more than $1 trillion—about a third of our total cost of production in the health care industry—is waste attributable to the inefficiencies of our fragmented and antiquated delivery system.

The concept of reducing cost by improving quality is at the heart of the lean production principles that have revolutionized many other industries, and by standardizing processes and establishing shared baselines to reduce variation in care delivery, Intermountain Healthcare in Utah and Idaho has become one of the most successful systems in the country at improving quality and reducing costs. For example, by implementing a protocol designed to reduce elective labor inductions, the system significantly reduced unplanned surgical deliveries and neonatal intensive care admissions. System administrators estimate this one protocol reduces health care costs in Utah by $50 million a year. Today, Intermountain manages 60 clinical processes in this manner, making up almost 80 percent of the system’s clinical activities.

There are several model systems around the country exhibiting positive results in quality improvement and cost reduction, but

most have been pursuing these goals for several years. A health system needs a solid infrastructure of information technology, physician leadership, administrative governance, and quality measurement to support such coordination across inpatient and outpatient care delivery. To even begin establishing protocols to achieve best practices, measuring results, making improvements to the protocols, and reducing process variation, participating physicians must be clinically integrated with their regional health system.

It’s not that difficult to imagine implementing a clinical integration program in a health system where all the physicians are employed, but the vast majority of family physicians in Texas practice independently.

Even so, the movement toward clinical integration is gaining momentum, and groups of independent physicians in several Texas communities are joining in.

clinical integration has been around much longer than this latest round of health system reform, but because of its relation to accountable care organizations, the concept has become newly fashionable among health policy wonks. To understand what’s meant by the phrase these days, you have to distinguish between clinical integration as a legal construct and clinical integration as a practical concept to improve the quality of patient care.

Under most circumstances, a group of independent physicians can’t band together

and negotiate jointly with health plans to set rates for services without violating antitrust law, but the Department of Justice and the Federal Trade Commission have held that a group of independent physicians that are either clinically or financially integrated can negotiate contracts as an organization in a so-called antitrust safety zone. Neither the DOJ nor the FTC wish to dictate how to achieve clinical integration, but a number of statements, rulings, and speeches serve to define the necessary components. Here’s what the agencies published in the most recent Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program: “Clinical integration can be evidenced by the joint venture implementing an active and ongoing program to evaluate and modify practice patterns by the venture’s providers and to create a high degree of interdependence and cooperation among the providers to control costs and ensure quality.”

In a speech delivered at a health care antitrust conference in May 2010, Assistant Attorney General Christine Varney elaborated on the agencies’ position on clinical integration and accountable care: “The U.S. population is aging, with the baby boomers once again transforming the demographic landscape as they reach 65. These changing demographics demand that we devise ways to treat even greater numbers of increasingly sick patients more efficiently and affordably. Unquestionably, that will lead to additional interest in integrating what most observers say is now a fragmented health care delivery system.

“There does not seem to be serious dispute that clinical integration and coordinated care have the potential to decrease costs and improve quality.

The key is whether we can gain those benefits without sacrificing meaningful competition.

“The answer to that question is undoubtedly ‘yes.’”

In a fee-for-service payment environment, this legal safety zone for clinical integration programs is a powerful tool for independent

physician associations, physician-hospital organizations, and accountable care organizations to negotiate contracts. Apart from the legal considerations however, the practical application of clinical integration is a key component of improved efficiency and measurable quality improvement in care delivery.

of Texas’ most advanced integrated health care systems, Memorial Hermann. Christopher Lloyd is CEO of the Memorial Hermann Physician Network, MHMD, a 3,900-physician IPA affiliated with Memorial Hermann. He says the network launched its clinical integration— or CI—program about five years ago, and since then, the clinically integrated subset of MHMD has grown to about 2,600 physicians across a broad spectrum of specialties.

Physicians in the CI program sign an agreement to practice evidence-based medicine as defined by standards set by their peers, to share their clinical data transparently, and to use standardized clinical protocols, order sets, and processes. “When they sign that agreement with us, they’ve agreed

houston is home to one

curring as a result of inpatient hospitalization for the CI group are 15 percent lower than their peers, their 30-day readmission rates are 4 percent lower, and the average charges for their patients are 33 percent lower.

The physicians establish and adjust the protocols and order sets themselves by participating in specialty-specific clinical program councils. “Really, what’s interesting about this model is that it is primarily comprised of independent physicians, and these independent physicians are functioning in leadership levels collaborating around care management principles when otherwise, they wouldn’t have to.

“What we have found is that when we arm them with data and arm them with information, and provide them a forum to then focus and start managing across the clinical enterprise, the standards and protocols and order sets then become best practice, because they’re doing research about best practices across the country.”

About two years ago, Lloyd says leadership at MHMD realized that while they had become quite good at measuring and improving inpatient care delivery, they knew little about how care was delivered in the outpatient clin-

“Physicians really don’t have to do anything, but if they don’t do anything, they have to know that there’s going to be continued pressure to reduce their fee schedules, lower reimbursement from the payers, and most likely reduced compensation.

If they want to position themselves for continued growth, position themselves to try to create value so they can negotiate higher rates, then they have to begin to make some change.”

Daniel Marino, CEO, Health Directions

to participate in the processes and mechanisms that allow them to have an impact on those processes, and on the standardization of treatment and the management of costs and quality,” Lloyd says.

When compared to their peers and to national benchmarks adjusted for severity, Lloyd says the CI doctors at MHMD perform remarkably well. The average length of stay for their hospital patients is 30 percent lower than their peers. He says complications oc-

ics of their primary care member physicians.

So they held a summit and asked their independent primary care physician members if they thought clinical integration within primary care was important, what quality measures and performance standards they would suggest implementing, and what tools and resources they would need to participate.

“The physicians very clearly signaled to us, ‘We know it’s important, but we just have no idea how to get there.’” They said www.tafp.org

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they needed new processes in their clinics to manage populations with chronic diseases, people to help implement those processes, and technology.

With that discussion, MHMD began creating a new program, Advanced Primary Care Practices, which announced its launch in July 2011. Advanced PCPs is a patient-centered medical home initiative designed to deliver comprehensive care by a team of physicians, nurses, and other caregivers working together to treat acute and chronic medical conditions and manage wellness programs.

Lloyd says 220 physicians signed an extension to their CI agreement with MHMD to participate in the program, agreeing to use a standardized set of clinical protocols and measurements set by their peers and to employ information technology that will allow MHMD to mine a series of outpatient indices. The IPA uses the data to compare Advanced PCPs to each other and to national benchmarks, then engages those practices that are falling short with additional support to help them achieve the group’s goals.

“One of the most basic things is that you have to be able to report your quality mea-

sures as determined by your peers, which means you by and large have to be on an electronic medical record.” Lloyd says MHMD has been subsidizing the deployment of EMRs in their clinically integrated practices for the past four years.

Over the last two years, the physicians in the Advanced PCP initiative have set their own performance standards, designed their incentive program, upgraded and coordinated their information technology tools, and six of the practices are working with AAFP’s TransforMed to achieve NCQA certification as medical homes. “In this kind of structure, there is a tremendous amount of empowerment where they can say, ‘This is what my practice of medicine will look like, and this is the partner I want to be involved with to help me get there, and now I’ve got some clarity around how I’m going to get there,’” Lloyd says.

“I would suggest that the most important component of a program like this is allowing the physicians to sit in roles of leadership across their specialty, to have access to data and to be able to drive transformational change, and have the tools to impact the enterprise.”

in december, cms announced that a partnership between Austin Regional Clinic and Seton Healthcare Family has been selected as one of 32 provider groups to participate in the Pioneer ACO program. A partnership between Tarrant County’s North Texas Specialty Physicians and Texas Health Resources was the only other Texas group to win selection for the pilot project. The new central Texas ACO will be called Seton Health Alliance.

“We’re building an entity that will have the infrastructure to excel at coordinated, high-quality, low-cost care while accepting multiple forms of value-based payments,” says Greg Sheff, M.D., president and chief medical officer of Seton Health Alliance. A family physician and TAFP member, Sheff also serves as medical director of care management and clinical integration for ARC, a multispecialty group of about 300 physicians.

“Obviously acute care and hospital care are incredibly important parts of the health care experience, so the more we integrate with that, the better for our patients,” Sheff

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12/21/09 2:52:24 PM

says. “And it also brings capital and resources that allow us to build the IT and care management infrastructure to really look at populations in addition to individuals.”

To help create the new ACO, the alliance has enlisted the services of Health Directions, a Chicago-based health system consulting firm. Daniel Marino, president and CEO of Health Directions, says his favorite definition of clinical integration comes from the American Hospital Association: “Clinical integration facilitates the coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused.”

Marino says to successfully implement a clinical integration program, the physicians involved have to lead the transition. “The cultural change is probably one of the biggest obstacles. You’ve got to get community physicians aligned with the hospital, and historically the interests and the objectives have always been a little bit different.” Collaboration and shared accountability across the entire organization is critical, as is the ability to collect, measure, and analyze clinical data.

“At the end of the day, you’re doing this to create some value collectively for physicians and the hospital.”

Creating a clinically-integrated IPA, physician-hospital organization, or ACO are just a few ways communities can organize care to be more efficient and improve quality, and the rate of transition to value-based care as well as the various forms that may take will be different in each community. Clinical integration, as Sheff puts it, is one of the levers you can pull when you want to manage health. He says the imperative for family physicians today is not how to prepare for clinical integration, but rather how to get ready for change.

Whatever form this transition takes in communities across Texas, payers, employers, and patients are likely to demand to know that they’re getting the level of care they are paying for. The old business adage goes: “You can’t manage what you don’t measure,” so creating a culture of data collection, measurement, evaluation, and improvement is the logical first step. Programs like Bridges to Excellence and the various NCQA certifications present opportunities to prepare for tomorrow’s delivery system.

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For physicians considering clinical integration for contracting purposes, Sheff says they can expect a positive return on their investment if done properly. “Especially for a small group, if they have the opportunity to join a clinically-integrated entity, they could see improvement in their reimbursement rates while having access to resources that help them improve the quality and efficiency of their patients’ care.”

When Marino speaks to physician groups, he tells them a storm is coming. Many metropolitan communities feel the pressure now, while in other regions, major changes to the way care is delivered and paid for may be years away.

“Physicians really don’t have to do anything,” he says, “but if they don’t do anything, they have to know that there’s going to be continued pressure to reduce their fee schedules, lower reimbursement from the payers, and most likely reduced compensation. If they want to position themselves for continued growth, position themselves to try to create value so they can negotiate higher rates, then they have to begin to make some change.”

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practice management

Educate yourself to avoid a board review Lack of understanding, not fraud, triggers most TMB action

By Bradley Reiner

I have been fortunate to have the opportunity to be one of the Texas Medical Board’s consultant reviewers along with my other responsibilities. I started reviewing cases for the board in 2008 and it is a job that I take very seriously. You may be wondering why a 20-year physician advocate would work for the medical board. How could I agree to find fault with doctors and have a hand in their discipline by the board? I worried about that myself in the beginning, but it has not turned out that way at all.

I review cases for two main reasons. I feel that I can help make a difference in how the board reviews and disciplines its physicians. I believe we should educate doctors when mistakes are made, particularly when involving business or billing issues that fluctuate constantly and can be difficult for the physician and his or her staff to understand. I also review cases because I feel I can educate physicians on the types of complaints I see as well as how to avoid these issues. Part of staying out of trouble is doing it correctly the first time, right? So if physicians understand which problems are typically investigated by the board, they can take steps to prevent mistakes.

I’m generally asked to review complaints submitted by patients or insurance plans, with the majority coming from the latter.

Why? It is my opinion that some carriers spend little time doing their own internal reviews or educating their physicians and 30

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instead send complaints to the board with expectations that TMB staff will perform an investigation. I feel that some of these issues are not board-related and could have been managed by the insurance plan through compliance and education.

In the billing or coding cases I have reviewed, the problems have involved the physician’s lack of understanding regarding the rules, not fraudulent behavior. Many physicians have a poor understanding of specific rules regarding billing, modifiers, and coding—understandable because of the varying rules applied by each insurance plan and the ongoing effort required to identify and correct errors.

Unfortunately, anything filed to insurance plans will be scrutinized and accuracy is the responsibility of the physician, not the staff. Physicians are the ones who have to answer questions and may be subjected to TMB investigations, OIG reviews, attorney general inquiries, whistle-blower suits, and potential corrective action including fines or even incarceration. While insurance companies are in business to make money, government payers are there to protect our tax dollars and correct or discipline inappropriate behavior.

We have reached the age of auditing for compliance, and this is likely to get worse. Physicians need to prepare themselves for this level of scrutiny.

So, it seems obvious when a complaint comes in from a major insurance payer stating that a doctor has inappropriately billed for services for a number of years that TMB would be interested. They want to know if the doctor is a threat to the health care system and if he or she is receiving payments from the insurance company for care that was not provided or for claims billed incorrectly. The board has an obligation to ensure all physicians are licensed properly and that they render an appropriate standard of care as well as provide appropriate billing and documentation.

I will present an example of a case I reviewed along with my recommendations to the board to give you an idea of what a potential case looks like and how the system works. Recently, I received an e-mail from a representative of the board asking me to review a case regarding a complaint filed by a major insurer. I noted that I had reviewed three similar complaints from the same insurer and this struck me as suspicious. [cont. on 32]

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[cont. from 30]

The complaint read as follows: “At issue in this investigation are allegations regarding the respondent’s fraudulent billing practices. Specifically, it was alleged that the respondent submitted falsified insurance claims for services which were misrepresented, unbundled, or contained codes previously billed by Dr. X for the following patients … .”

It was clear this complaint was drafted by the insurance company and sent to the board to investigate to determine if the above actions were true. As stated above, it seemed as if the complaint could have been handled by the insurer as an educational opportunity instead of bringing it to the attention of the board. Some cases I review involve different complaints for the same physician while others, like this one, involve multiple patients with a similar issue.

This involved a billing problem and the board asked me for recommendations on

whether the doctor inappropriately billed.

Each of the patient records I reviewed included multiple claims regarding evaluation and management services and other procedures provided over a select period of time. The board wanted to know if the documentation presented for each patient met the codes the doctor had chosen that day.

To begin the review, the board provided me with a password and a case number to access the case through their secure website.

Once in the system I found the case number where everything had been scanned and was ready to review. Each file was divided into several categories, one of which was the doctor’s response to the allegations. This is always an important section for me to read to understand the physician’s perspective regarding the complaint as well as what he or she believes to be true.

As a tangent, the more information physicians provide in this section, the more a reviewer can understand their perspective and what they knew to be the issue. In the case that you’re responding to a complaint,

don’t write a small paragraph simply stating that the allegations are false. Defend the allegations with credible, timely, complete, and accurate information to back up your claim.

Specific details always help me understand the situation.

Back to the case, I reviewed the complaint letter from the insurance company, which gave valuable insight into why they sent the complaint.

In every complaint I agree to review, I am required to give the facts of the case. I provide the facts as I understand them after reviewing all of the issues involved.

The next item the board requests is the standard of care in billing. What are the general principles involved in billing for the facts of the case? If a doctor billed several codes on the same day, what are the documentation requirements to ensure the record supports the billed codes? The board also wants to know if the application to the standard of care of billing was met. This is where the rubber meets the road. Did the doctor use appropriate billing protocols to bill and document his ser-

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foundation focus

2011 Monthly Donors vices correctly and according to generally accepted billing and coding rules?

In this case, the physician did not document clearly and completely for the code levels he billed. This is a very common problem I identify in many of my reviews; it’s a matter of not knowing the guidelines. Most physicians don’t even know documentation guidelines exist much less what they say or how to apply them. Others know about them, but don’t understand all of the specific rules. Unfortunately, it gets interpreted by some as fraudulent, which I believe is unfair to physicians.

Finally, I am asked to give my opinion on whether there was a violation. In this case, I felt the doctor just didn’t understand the rules for documenting correctly. And as is my common practice when I determine the case is not fraud but involves a lack of understanding of proper billing rules, I recommended the board take action to educate and train the physician on billing protocols so that he can correct the behavior going forward.

Some doctors commit violations and need to be reprimanded for the behavior.

Other physicians have no idea that they were making these mistakes and simply need direction and education. This education can help protect physicians and ensure they understand billing and coding compliance. We all have a responsibility to report fraud and abuse, and if a case truly appears to involve fraud I’ll be the first to call it that way.

However, in my years of completing reviews, I have not personally found a case that I felt was one of true fraud.

2011 TAFP Foundation Donors Thank you to the 2011 TAFP Foundation donors whose contributions fund scholarships for Texas medical students, family medicine research grants, and travel scholarships for residents to attend continuing professional development activities.

Kelly Alberda, M.D. Dale Crawford Allison, M.D. Antony D. Anderson, M.D. Kent E. Anthony, M.D. James L. Atteberry, M.D. Sergio Antonio Avalos, M.D. Ichabod L. Balkcom IV, M.D. Tom Banning Charles Oliver Barker, M.D. Arturo Enrique Batres, M.D. Michael Thomas Beets, M.D. Adrian Billings, M.D., Ph.D. Lindsay Kathryn Botsford, M.D. Kevin Burke Walter L. Calmbach, M.D., M.P.H. Joseph Ward Cappel, M.D. Elizabeth Wagner Carter, M.D. Jack Quinten Cash, M.D. Augusto A. Castrillon, M.D. Walter T. Caven, M.D. Martha Jean Chapman, M.D. Robert E. Chapman, M.D. Jennifer L. Culver, M.D. Manuel De Los Santos, M.D. Carolyn Eaton, M.D. Mark C. Eidson, M.D. Christopher S. Ewin, M.D. Mitchell Frank Finnie, M.D. Linda Whidden Flower, M.D. Edwin R. Franks, M.D. Jose A. Fuentes, M.D. Myra Merchent Gillean, M.D. Brian Joseph Goerig, M.D. James T. Graham Jr., M.D. Thomas David Greer, M.D. Tanya R. Grun, M.D. Mina Haidarian John Harlan Haynes, M.D. Tod C. Heldridge, M.D. Kimberly Koester Heller, M.D. Terrance S. Hines, M.D. Robert L. Hogue, M.D. Todd R. Howell, M.D. Bruce K. Jacobson, M.D. Larry R. Karrh, M.D. Sharon D. Kirven, M.D. Alicia Ann Kowalchuk, D.O. Stella Kwong, M.D. James Lackey, M.D. Doyle K. Lansford, M.D. W. Ross Lawler, M.D. Don A. Lawrence, D.O. Pierre Lebahar

Paul and Kathy Locus Donald E. Lovering, M.D. Erin Luna, D.O. Robert Lawrence Magruder, M.D. Michelle L. Markley, M.D. Ryan Edward Morris, D.O. Edwin L. Mueller Jr., M.D. Thomas Edwin Mueller, M.D. Bonnie Eugenia Muncy, M.D. W. Darell Murphy, M.D. Jonathan Nelson Donald R. Niño, M.D. Beverly Burnett Nuckols, M.D. Solomon I. J. Paley, M.D. Max Peralta, M.D. Victor H. Peralta, M.D. Ronald J. Peron, M.D. Charles M. Perricone, M.D. Prathivadi Ramamani, M.D. Murray Charles Rice, M.D. Alex Salazar, M.D. Ernie L. Sandidge, M.D. Brad Sloan, M.D. John Stanley Smale, M.D. Ronald D. Stephens, M.D. Richard A. Stuntz, M.D. Tehmina Tasneem, M.D. James R. Terry, M.D. R. Chase Thebault, M.D. Henry W. Thomas, M.D. Elizabeth B. Turnage, M.D. Ricardo Vela, M.D. Charles W. Waldrop Jr., M.D. Andrew H. Weary, M.D. Bernard Karl Weiner, M.D. Walter D. Wilkerson, M.D. Hubert Neil Williston, M.D. Center for Family Medicine, Webster Endo Pharmaceutical Harris County Academy of Family Physicians Maclin Family Medicine McLennan County Medical Society North Hills Family Medicine Pepsico Foundation Pfizer, Inc. Providence Health Network South Alamo Medical Group, PA Texas Association of Community Health Centers Texas Medical Association Texas Medical Liability Trust Travis County Chapter

Trisha A. Allamon, M.D. Barbara L. Allen, M.D. Maria Diana Ballesteros, M.D. Lynda Jayne Barry, M.D. Justin V. Bartos, M.D. Joane Goforth Baumer, M.D. Stephen D. Benold, M.D. Alex J. Blanco, M.D. Henry Julius Boehm Jr., M.D. Emily D. Briggs, M.D. Chinglin Lillian Chan, M.D. C. Mark Chassay, M.D. Samuel T. Coleridge, D.O. Seth B. Cowan, M.D. Kenneth Gayle Davis, M.D. Tamra K. Deuser, M.D. Jorge Duchicela, M.D. Bruce Alan Echols, M.D. Tricia C. Elliott, M.D. Robert Floyd Ezell, M.D. Troy Treanor Fiesinger, M.D. Lewis Emory Foxhall, M.D. Gregory Michael Fuller, M.D. Kelly A. Gabler, M.D. Melissa Susan Gerdes, M.D. Lisa Biry Glenn, M.D. Roland Adolph Goertz, M.D., M.B.A. Ajay Kumar Gupta, M.D. Natalia Gutierrez, M.D. Lesca C. Hadley, M.D. James Michael Henderson, M.D. Janet L. Hurley, M.D. David A. Katerndahl, M.D. Kaparaboyna Ashok Kumar, M.D. C. Tim Lambert, M.D. Loren S. Lasater, M.D. Leah Raye Mabry, M.D., R.Ph. Javier D. Margo Jr., M.D. Kathy McCarthy, C.A.E. W. Mike McCrady, M.D. John M. McCullough, M.D. Gary R. Mennie, M.D. Nina Miller, M.D. Dale C. Moquist, M.D. Mary Helen Morrow, M.D. Mary S. Nguyen Poole, M.D. Henry David Pope, M.D. Dale Ragle, M.D. John R. Richmond, M.D. Shelley Poe Roaten, M.D. Lee R. Schreiber, M.D. Amer Shakil, M.D. Robert F. Shields, D.O. Zafreen Arfeen Siddiqui, M.D. Linda Marie Siy, M.D. Mary Carmen Spalding, M.D. Donald E. Stillwagon, M.D. Erica Williams Swegler, M.D. Sheri J. Talley, M.D. Ashok Tripathy, M.D. Thao Minh Truong, M.D. Lloyd Van Winkle, M.D. Sally P. Weaver, M.D. Jim White Hugh H. Wilson, M.D. Khalida Yasmin, M.D. Robert Youens, M.D. Richard A. Young, M.D. www.tafp.org

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2011 was a year of new ideas, initiatives, and projects, and your Academy approached all with the same goal: to unite the family physicians of Texas, equip them with the tools to navigate a changing practice environment, and proactively advance the specialty of family medicine.

YEAR IN REVIEW

By KATE ALFANO

From the start of the legislative session in January to the 10th ABFM SAM Group Study Workshop in December (and all events in between), TAFP members and staff stayed engaged in their mission. Read on for a review of happenings over the past year.

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Advocacy: Just two weeks after the start of the new year, the 82nd Texas Legislature convened, sending TAFP’s leaders, lobby team, and staff into high gear to advocate on behalf of family medicine’s top concerns: graduate medical education, scope of practice, and physician workforce. Compounding the session was a $4 billion deficit in the 2010-2011 biennium and a $23 billion shortfall for 2012-2013, which threatened all statefunded programs and any proposal containing a fiscal note.

Throughout the regular session and special session, the Academy kept members updated on the legislative twists and turns through weekly Capitol Update news articles and monthly Capitol Report news webcasts, and empowered members with various advocacy tools such as a series of issue briefs outlining scope of practice, graduate medical education, and licensure for international medical graduates, and a substantive policy brief on scope of practice.

TAFP’s advocacy effort was also boosted through the TAFP Political Action Committee and the contributions of its 77 monthly donors. Through TAFPPAC, members got involved at the grassroots level, built personal relationships with elected officials, and enabled political campaign participation and contributions to candidates who support family medicine.

Heralding the message that investing in family medicine will help contain spiraling health care costs while improving patient care, TAFP supported and lawmakers passed a comprehensive state health care reform bill. By encouraging better coordination of care between doctors, hospitals, and others, and aligning financial incentives to keep patients healthy and out of the most expensive care settings, the bill could save $468 million over the next biennium.

Despite some significant gains this session, many state programs were slashed under the 2012-2013 budget, including those under the Texas Higher Education Coordinating Board—primary care residency programs, the Texas Statewide Preceptorship Program, and the Faculty Development Center. The budget also underfunds Medicaid by at least $4.8 billion and underfunds public schools by $4 billion, setting the stage for another difficult budget session when the 83rd Legislature convenes in 2013.

TAFP has begun forming a strategy for the 2012 legislative interim and election cycle.

The Academy is working to advance an omnibus package of state reforms—tentatively called the Primary Care Rescue Act—to repair, rebuild, and restore Texas’ primary care infrastructure to improve quality of care and bend the cost curve through workforce development, delivery system and care coordination improvements, administrative simplification, and investment in health information technology. The Academy has called for member input and there’s still time to provide yours. E-mail suggestions to TAFP Director of Communications Jonathan Nelson at jnelson@tafp.org.

In recognition of TAFP’s advocacy effort to preserve physicians’ scope of practice against attacks by advanced practice registered nurses, AAFP again named TAFP a recipient of the AAFP Leadership in State Government Advocacy award, which Nelson accepted at AAFP’s State Legislative Conference Nov. 4-5, in Salt Lake City, Utah.

On the national advocacy front, AAFP and several other specialty organizations developed a unified strategy and grassroots campaign to urge members of the congressional Joint Select Committee on Deficit Reduction, or “supercommittee,” to avoid making damaging cuts to Medicare and graduate medical education, and to include a permanent fix to the broken sustainable growth rate formula that will enact a 27.4 percent cut in Medicare physician pay unless Congress acts.

Unfortunately the supercommittee failed to reach a budget compromise by the November deadline and AAFP quickly responded with a statement from AAFP President Glen R. Stream, M.D., M.B.I., advocating for swift action to prevent the pending cut.

Another national issue that gained momentum this year was the call to replace the AMA/Specialty Society Relative Value Scale Update Committee. The RUC makes annual recommendations to the Centers for Medicare and Medicaid Services on Medicare physician fee reimbursement and how certain procedures should be valued. Detractors say that its recommendations have devalued primary care in favor of specialty societies.

AAFP sent a letter to the RUC in June with a list of demands: more primary care voting positions; new seats representing consumers, employers, health systems, and health plans; the elimination of three rotating subspecialty seats; and voting transparency. AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, addressed the RUC in September to clarify the Academy’s request. AAFP has asked for a response to its demands by March 1, 2012.

Practice transformation: With 2011 came ideas and strategies for reforming the practice of medicine and payment for care delivery. Recognizing the complex and changing practice environment, TAFP and AAFP provided resources and news reporting to keep members informed of the initiatives to discern their readiness or ability to participate.

Chief among the reforms was the push toward coordinated care, particularly through accountable care organizations. The ACO concept is not new, though it received fresh attention in the Patient Protection and Affordable Care Act through the Medicare Shared Savings Program set to roll out Jan. 1, 2012. The Centers for Medicare and Medicaid Services released the final ACO rule on Oct. 20, which included many of the revisions suggested by AAFP including the ability for primary care physicians to participate in multiple ACOs and reducing by half the number of individual quality measures for an ACO to qualify for shared savings.

CMS’ electronic health record incentive program began on Jan. 1, 2011, and by October had distributed $30 million in payments to Texas physicians. Also by that point, 11,000 Texas physicians had registered to participate in the program while 1,400 had completed stage 1 of the program, meeting 20 of 25 meaningful use criteria.

Texas family physicians also began preparing for the switch to HIPAA 5010 transaction standards, which will affect how they transmit and receive electronic transactions such as claims and eligibility verifications.

The compliance date for use of the new standards is Jan. 1, 2012, but penalties won’t kick in until March 31, 2012.

And, though seemingly far off with a compliance deadline of Oct. 1, 2013, physicians began educating themselves and their staffs on the process to switch from ICD-9 diagnosis codes to ICD-10—an addition of nearly 55,000 codes.

Considering all of these deadlines, penalties, and new programs, TAFP organized the 2011 Payment Reform Summit on Oct. 1, “Lead or Be Led: How to Thrive in the Evolving Health Care Delivery System.” More than 50 physicians joined the expert speakers who reiterated how physicians must lead reform as the system moves from a volume-based model to a valuebased model. Video recordings of most sessions will be available online in early 2012.

Communications: Through quarterly magazine Texas Family Physician, TAFP Communications presented features and news on

legislative and regulatory topics, practice tips, member happenings, and more. Communications staff was particularly proud to present the fourth-quarter issue, which sported a new nameplate and cover design, a fresh set of fonts, and a commitment to packaging content in smaller, more easily digestible bites that we hope will make your reading experience even better.

In addition to regular news reporting through the QuickInfo e-newsletter, TAFP launched the new Products & Services e-newsletter in July to highlight products and services important to family physicians. This monthly e-mail contains the latest practice management tools and resources, educational opportunities, public health materials, and more from TAFP, AAFP, and Academy partners.

This year brought a tremendous expansion of TAFP’s social media effort through Facebook, Twitter, LinkedIn, and TAFP’s blog. These platforms provide an opportunity for members to connect with the Academy, share feedback, and connect with other colleagues.

TAFP Communications has several exciting developments in the works. Be sure to watch as we move forward with a new logo and website in early 2012.

Education: TAFP presented four annual symposia in 2011: the C. Frank Webber Lectureship and Interim Session in Austin, TAFP’s 2011 Annual Session and Scientific Assembly in Dallas, and Primary Care Summit in both Houston and Dallas. These programs reached more than 1,400 family physicians and other health professionals. Attendees of TAFP symposia had the opportunity to earn more than 84 CME credits at these conferences on more than 82 topics.

Expanding the reach of high-quality TAFP CME, the Academy released three online CME activities in the fall through which viewers can earn one CME credit each. Originally recorded during Annual Session, videos of lectures on maintenance of certification, accountable care organizations, and physician employment contracts are available for free on TAFP’s website.

To help ABFM diplomates meet certification and recertification requirements, TAFP offered 10 SAM Group Study Workshops in 2011. Six workshops were held in conjunction with TAFP symposia, and four standalone programs were held in Houston, Lubbock, McAllen, and San Antonio. TAFP will offer at least 10 more SAM workshops in 2012 to meet the growing needs of our members. www.tafp.org

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The National Procedures Institute also had a successful year, providing procedural training to primary care physicians across the country. A joint investment of AAFP, TAFP, and the Society of Teachers of Family Medicine, NPI provides members valuable practice enhancement techniques while also providing the Academy non-dues revenue.

In 2011, NPI delivered 103 procedural workshops to more than 1,000 medical professionals around the country. View the 2012 event schedule and register for upcoming CME conferences on the NPI website at www.NPInstitute.com.

Members and Leaders: Both TAFP and AAFP reached membership milestones this year: TAFP exceeded 7,000 total members and AAFP exceeded 100,000 members. TAFP remains the largest subspecialty physician membership organization in the state; AAFP is the second largest subspecialty physician membership organization in the country after the American College of Physicians.

TAFP student and resident enrollment rose to more than 2,300, reflecting the con-

tinued effort of TAFP leaders and staff to reach out to these future family physicians through the Texas Conference of Family Medicine Residents and Students in March, through support for the medical schools’ family medicine interest groups, through visits to the medical schools and residency programs, and by presenting leadership training and developing tools to help supplement medical education and training.

The Academy is proud to recognize the outstanding work of the University of Texas Health Science Center at San Antonio FMIG, which received AAFP’s 2011 Program of Excellence Award, and two Texas family medicine residency programs that were certified as level-3 patient-centered medical homes by the National Committee for Quality Assurance: Christus Santa Rosa FMRP in San Antonio and Memorial FMRP in Sugar Land.

TAFP’s support of young family physicians does not stop at the completion of residency. TAFP and AAFP continue to reach out to new physician members—those who have been in practice for seven years or fewer— through practice support resources, board

review courses, coding resources, and discount registration fees to Academy events.

To highlight active Texas family physicians and their unique approach to medicine, TAFP launched a new, online member feature in February called Member of the Month. Each article features a short biography of the physician followed by a question-and-answer section. Nominate one of your family physician colleagues by sending his or her name, phone number, and e-mail address to kalfano@tafp.org.

TAFP’s new officers were installed at the 2011 Annual Session: President I. L. Balkcom IV, M.D.; President-elect Troy Fiesinger, M.D.; Vice President Dale Ragle, M.D.; Treasurer Clare Hawkins, M.D.; and Parliamentarian Ajay Gupta, M.D. Also during Annual Session, the Academy recognized its award recipients. Thomas Mueller, M.D., was named Family Physician of the Year; the late Isaac Kleinman, M.D., was recognized as Physician Emeritus; HHSC Executive Commissioner Tom Suehs received the Patient Advocacy Award; Leah Raye Mabry, M.D., R.Ph., received the Presidential Award of Merit; Bruce Echols, M.D.,

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received the TAFP Foundation Philanthropist of the Year Award; Philip Huang, M.D., M.P.H., won the Public Health Award; Tricia C. Elliott, M.D., F.A.A.F.P., was awarded the TAFPPAC Award; Jonathan MacClements, M.D., F.A.A.F.P., was awarded the Exemplary Teaching Award; and Kaparaboyna Ashok Kumar, M.D., F.R.C.S., received the Special Constituency Leadership Award.

Texas was well represented at AAFP’s 2011 conferences, including the National Conference of Special Constituencies and Annual Leadership Forum in Kansas City, Mo., the 2011 Family Medicine Congressional Conference in Washington, D.C., and AAFP’s 2011 Congress of Delegates and Scientific Assembly in Orlando, Fla. Roland Goertz, M.D., M.B.A., completed his term as AAFP president and assumed his new post as AAFP board chair. Mabry completed her third term as speaker of the AAFP Congress of Delegates. Representing Texas during the Congress were Delegates Justin Bartos, M.D., and Erica Swegler, M.D.; and Alternate Delegates Linda Siy, M.D., and Douglas Curran, M.D.

Several TAFP leaders served on AAFP committees in 2011: Melissa Gerdes, M.D., Commission on Quality and Practice; Swegler and TAFP CEO/EVP Tom Banning, Commission on Governmental Advocacy; Hawkins, Commission on Continuing Professional Development; Joane Baumer, M.D., Commission on Education; Janet Hurley, M.D., Commission on Membership and Member Services; and Rebecca Gladu, M.D., Commission on Health of the Public and Science.

TAFP Foundation: The TAFP Foundation continues actively working to fulfill its goals: to raise and distribute funds for medical student scholarships for students planning to pursue a career in family medicine, family medicine office-based research, family medicine interest group activities at medical schools in Texas, and family medicine resident activities.

The Foundation could not meet these goals without the generosity of our donors, especially the 66 monthly donors. The philanthropic arm of the Academy and those who support us shined at Annual Session through the many activities held to benefit

the Foundation. The signature event was a special reception to honor AAFP Board Chair Goertz, where colleagues and friends from around the state gathered to toast him for his years of service to family medicine on the state and national level.

Through sponsorship of the event, donations from individuals, and proceeds from a silent auction, the Foundation fully funded a new Roland A. Goertz, M.D. Scholarship that will be used to send student leaders to AAFP’s National Conference in Kansas City, Mo. The first award will be presented in 2012.

Back at the Office: The direction provided by the 2010-2011 Strategic Plan proved invaluable as TAFP members and staff worked to fulfill action initiatives in the areas of advocacy, practice viability, membership, and education. By the end of the year, many had been completed and progress had been made on all, evidenced by the many new projects detailed in this report.

TAFP looks forward to another banner year in 2012 serving the family physicians of Texas.

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perspective

Clinical integration: The case for getting involved now

By Daniel J. Marino

what is your reaction to the concept of clinical integration? If you are like most physicians I talk to, you are interested in the idea but wary of the many uncertainties that surround it. You may also have some reservations about getting involved with the local hospital. If you become clinically integrated, will you be able to maintain control of your own practice?

One thing is clear: Doing nothing is not an option.

Unsustainable health care cost trends are creating pressure that is simply not going away. All payers are pushing to reduce costs, and there is broad and deep agreement that greater coordination of care is the solution. Physicians who stick to the clinical models developed under fee-for-service reimbursement are going to suffer from steady fee schedule reductions.

The good news is that family physicians who are interested in exploring collaborative care models have several options. One possibility is the patientcentered medical home. Developing a medical home model in your practice will allow you to put greater focus on coordinating patient care. Improving patient management will enable you to negotiate value-based reimbursement with payers.

One disadvantage of the medical home model is that it limits the scope of care coordination to the factors that are under your control as a primary care provider.

The other option is clinical integration with a hospital.

On the patient care side, clinical integration offers unprecedented opportunities to coordinate care as patients move between primary care, specialty medicine, hospital, and long-term care settings. On the contracting side, clinical integration opens up new possibilities for securing better reimbursement for better patient quality outcomes. Given the cost control pressures that are driving the industry today, clinical integration may offer family physicians the best chance of surviving financially in the years ahead.

Of course, the big question for physicians is where does this leave practice autonomy? One answer is to look at clinical integration from the point of view of leadership.

Who will be in charge of hospital-physician clinical collaborations? Based on discussions with hospital CEOs from across the country, I can tell you that without exception hospitals are looking to physicians for strong leadership on clinical integration programs. There is widespread recogni-

tion that the only stakeholders who can effectively guide coordinated care are physicians. Physicians are being asked to take part in decision-making at every level, lead on the development of quality metrics, and help guide implementation at the unit level.

And practice autonomy can remain strong. Hospitals are acquiring physician practices in many markets as part of their integration strategy, but clinical integration can develop outside of hospital employment. Information technology and shared governance structures are carving out a viable niche for physicians who want to collaborate with hospitals while still remaining independent.

What many physicians find most exciting is that they see clinical integration as an opportunity to practice medicine as they were trained to. Under fee-forservice reimbursement, physicians are underpaid for the cognitive work that defines the best medical practice—the time- and cost-intensive work required to diagnose and manage difficult cases and maintain patient wellness. Clinical integration gives physicians the opportunity to focus their skills on outcomes.

Physicians will be able to work at both the population level and the patient level to prevent the complications of chronic disease, keep patients out of the hospital, and optimize patient health.

Interested in moving forward? To prepare your practice for clinical integration, the key is to focus on technology. If you have not already done so, make the transition to an electronic medical record and work to meet the government’s meaningful use requirements. Then begin tracking clinical outcomes on chronic diseases within your practice. Diabetes and coronary artery disease are common starting points.

As you begin to get technology and quality tracking in order, you can also explore opportunities to collaborate. In most communities, clinical integration initiatives are still in the early planning phase. Structures, goals, and incentives are still uncertain—but that’s good. Family physicians who get involved now have a real opportunity to shape how clinical integration will develop in their community for years to come.

Unsustainable health care cost trends are creating pressure that is simply not going away. All payers are pushing to reduce costs, and there is broad and deep agreement that greater coordination of care is the solution.

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Daniel J. Marino is the president and CEO of Health Directions, a national health care consulting firm with offices in Chicago, Ill., and Austin, Texas.

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