Texas Family Physician Spring 2011

Lege Weighs Massive Cuts To Medicaid, GME Funding

D E D ICA T E D T O T HE D ELI V ERY O F Q U ALI T Y HEAL T H CARE

V OL . 6 2 NO . 2 s p r i n g 2 0 1 1

Lloyd Van Winkle Texas Family Physician of the Year, 2010-2011 PLUS: TAFP Bill Would Keep More Texas-trained Docs In State 10 Time Management Tips To Improve Your Practice

ARE YOU CONTRACTING AWAY YOUR RIGHT TO BE INSURED BY TMLT? If you are thinking about becoming employed in an Accountable Care Organization (ACO) or Non-Profit Health Organization (NPHO) aka 5.01(a),

DID YOU KNOW THAT: 1. You may not be able to keep or choose your medical liability insurance carrier. Consequently, you may be required to put your reputation and assets in the hands of the organization’s self-insured entity rather than with the proven insurance professionals at TMLT. 2. You may lose the right to withhold consent to settle if a claim occurs. The captive insurance carrier provided by your employer may be making the decision whether to defend or settle your case.

3. You may have to purchase tail coverage. Unless your new carrier is providing prior acts coverage, you will have to purchase tail coverage. Your new employer may not cover the cost for tail coverage. Additionally, you may lose the free tail coverage that you had earned with your current carrier as well as your accrued claim-free discounts.

4. You may lose access to a physician-focused defense. For instance, if you are insured by a hospital’s captive insurer, its attorneys will have expertise in defending hospitals, but may not have expertise in defending physicians. TMLT claim staff and defense attorneys specialize in defending physicians in lawsuits. Does the hospital’s insurance company have a claims philosophy that focuses on individual physicians’ risk exposures independent of the hospital’s organizational interests? Who will be protecting your career in the event of a claim or lawsuit?

IN ADDITION: • What if there are conflicts of interest in a lawsuit?

• What if there are disciplinary proceedings?

• Will you have enough coverage?

• What about “moonlighting” coverage?

• What happens if there is a voluntary or involuntary termination?

• Beware of any promises not made in writing.

It is important to clearly understand these questions and their answers if you are looking at signing a contract to become an employed physician. You should also seek advice from an experienced attorney before making a decision. For more information, please visit www.tmlt.org or call John Southrey at 800-580-8658 x5976. The Texas Medical Association web site has additional resources for physicians considering becoming employed by a hospital, ACO, or NPHO at www.texmed.org.

More information is available at www.tmlt.org/employedmd contact John Southrey, Business Development Coordinator john-southrey@tmlt.org l 800-580-8658 x5976

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Volume 62, No. 2

TEXA S

FAMILY PHYSICIAN spring 2011

F E A T U R E S 16 Budget cuts threaten Medicaid, GME The 82nd Texas Legislature has been marked with contentious budget battles as lawmakers weigh the state’s priorities. With less than half of the session to go, TAFP will continue advocating for funds and programs crucial to the specialty.

By Kate Alfano

20 Cover: Medina Valley’s medicine man Meet the 2010-2011 Texas Family Physician of the Year, Lloyd Van Winkle, M.D.

By Jonathan Nelson

26 License delays push doctors away Texas law prohibits international medical graduates from obtaining a medical license until after completion of three years of residency, compared with one year for U.S. medical graduates. Some say the IMG licensure delay— instituted as a safeguard—is not only unnecessary, it hurts the state in the long run.

By Monica Kortsha

30 ANNUAL SESSION PREVIEW: Get the scoop on this year’s event, July 27-31 in Dallas 34 PRACTICE MANAGEMENT: Ten tips for time management 36 NUTRITION: NFL, Dairy Council team up for childhood obesity 38 TAFP PERSPECTIVE: Work on reform has only just begun

D E P A R T M E N T S

24 JONATHAN NELSON

20

6

FROM YOUR PRESIDENT: Together, members make strides for the specialty

8

IN THE NEWS: Access toolkit on HIT incentives | Family medicine gains in the 2011 match | CMS releases guidelines for ACOs, TAFP launches resources

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MEMBER NEWS: Tarrant County AFP inducts new officers | TAFP member becomes hospital CMO | Report from Interim Session

29

INTERIM SESSION MINUTES IN BRIEF

TEXAS

FAMILY PHYSICIAN

from your pres ident

s p r i n g 2 0 1 1 V O L . 62 N O . 2

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.

Members work to advance family medicine and TAFP’s strategic initiatives

By Melissa Gerdes, M.D. TAFP President

Officers President Melissa Gerdes, M.D. President-elect I. L. Balkcom, IV, M.D. Vice President Clare Hawkins, M.D. Treasurer Troy Fiesinger, M.D. Parliamentarian Dale Ragle, M.D. Immediate Past President Kaparaboyna Ashok Kumar, M.D., F.R.C.S.

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. Publications Intern Monica Kortsha

Advertising Sales Associate Audra Conwell

Contributing Editors Roland Goertz, M.D., M.B.A. Donald E. Stillwagon, M.D. Teresa Wagner, M.S., R.D./L.D.

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. © 2011 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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s pri n g 2 0 1 1 | T e x as Family Ph y sician

I devote this column to our Academy members and friends. The Texas Academy of Family Physicians is, after all, only as good as our membership.

As you will recall, TAFP held a strategic planning retreat in August 2010. We began with the anticipation that we would design a three-year plan, but it soon became a one-year plan. The group identified so many items needing urgent attention that the timeframe necessarily shortened. A physician champion paired with a TAFP staff person to design and implement each action item. Now, seven months later at Interim Session, we are well on our way to accomplishing our goals. The entire strategic plan can be viewed at www.tafp.org/ stratplan.pdf.

Continuing medical education continues to be a major Academy focus for our members. An additional Primary Care Summit was held in Dallas this past year.

We have experienced record attendance at our consistently well-reviewed CME events. Self-Assessment Module workshops (part of the Maintenance of Certification process for board certification) have been conducted all over the state. I thank our physician champion, Clare Hawkins, M.D., for the SAMs. Members have asked for more education in the areas of practice management and the direction of health care reform in the changing marketplace. Greg Johnson, M.D., is championing a practice management curriculum which will debut at the 2011 Annual Session and Scientific Assembly. I invite you to join us for this special event in Dallas this July.

Also at Annual Session and other TAFP symposia will be TAFP’s practice management consultant, Bradley Reiner. Bradley is available year-round as a consultant with a plethora of services and advice for members. More information can be found at www.tafp.org/resources/practmanagement.

To date, Tom Banning, paired with a local family medicine leader, has traveled to half a dozen local chapters to educate members on health care reform and current political issues affecting family medicine. These visits have been very well received. TAFP appears to be one of the few groups to dialogue with physicians in a proactive way regarding politics and medicine. In addition to these outstanding efforts, I want to thank the education staff at the Academy. They consistently deliver high-quality CME offerings that are sensitive to members’ needs.

Creating frequent and useful communication with members is a key action area. Please check out our website for a large variety of resources. In addition to practice management help is a section titled “Medical Home,” which provides up-to-date information on this developing concept.

Information on accountable care org­anizations can be found there as well. I want to thank TAFP’s Communi­ ca­tions Department and the Commission on Member­ ship and Member Services for constantly improving member communications.

TAFP deeply values new member involvement. This is evidenced by the level of commitment to student and resident involvement. To date, the TAFP Foundation has awarded more than 100 student and resident scholarships. I want to thank all those recipients for their participation.

Also, our members are more active than ever, founding and raising funds for new scholarships every year. These innovative actions and commitment to fostering a bright future for our discipline are vital.

Physician champions Kaparaboyna Ashok Kumar, M.D., Tricia Elliott, M.D., and Troy Fiesinger, M.D., are leading efforts to streamline licensing for international medical graduates and fostering student interest in family medicine. I have been visiting each

Our members are more active than ever, founding and raising funds for new scholarships every year. These innovative actions and commitment to fostering a bright future for our discipline are vital.

medical school in the state as well. I am very impressed with the students and their questions regarding health care reform and how it will impact their future. I am bringing them the message about what TAFP may offer them as students.

Finally, we must not forget legislative action items. We have had a very busy year at the Capitol. Tom Banning and our excellent team of lobbyists have kept us up to date on proceedings. Our critical issues include primary care workforce preservation and development, public health and graduate medical education funding, scope of practice, and collective bargaining.

I want to thank all the members who participated in our Legislative Action Day in conjunction with Interim Session. Your voices make an impact. Keep up the good work dialoging with your legislators on our action items. The Primary Care Coalition, represented by myself; Sue Bornstein, M.D. executive director of the Texas Medical Home Initiative; Robert Jackson, M.D., of the Texas Chapter of the American College of Physicians; Greg Sheff, M.D., of Austin Regional Clinic; Tricia Elliott, M.D., from UTMB Galveston; and Jim Lukfarh, M.D., of the Texas Pediatric Society visited with Lt. Gov. David Dewhurst regarding two bills he introduced in the Senate about Medicaid ACO pilots. The meeting went well and we will continue to provide input to the governor’s office on these bills.

I want to give a special thank you to Marie-Elizabeth Ramas, M.D., a third-year family medicine resident at the Conroe Family Medicine Residency Program, who spent a semester studying health care policy as the James C. Martin, M.D. scholarship recipient. She produced a wonderful paper titled, “The Question of Independent Diagnosis and Prescriptive Authority for Advanced Practice Registered Nurses in Texas: Is the Reward Worth the Risk?” The document details training differences between physicians and nurse practitioners, physician and NP distribution in the state, and implications for Texas’ primary care workforce. We were honored to hear her presentation at the legislative affairs meeting at Interim Session. We are very proud to be able to provide our residents with such learning experiences and extremely pleased that residents are committed to helping the discipline of family medicine.

The momentum family medicine has in Texas going forward is exciting and exhilarating. Each and every member is vital in achieving our vision. I am privileged to work with such members and friends every day. Thank you all for your efforts. There are many more champions and work ongoing through the Academy. Please visit the website at www.tafp.org to view. :

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News Briefs TAFP launches HIT Toolkit for Family Physicians

2,000 1,500 1,000 500 2011

2010

2009

2008

2007

2006

2005

2004

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2,500

2003

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Family medicine positions filled by U.S. seniors

3,000

2002

The California AFP developed the resources with grant support from The Physicians Foundation, and TAFP staff tailored them to Texas. Access the HIT toolkit at www.tafp.org/ resources/technology. :

Family medicine positions filled

3,500

2001

• EHR Incentive Program Basic Facts • Five Things to Do NOW • A Physician’s Guide to Working with the HIT Regional Extension Centers in Texas • Why Implement an Electronic Health Record?

• Determinants of Successful EHR Implementation • Patient Volume Information • EHR Readiness Assessment Tool • Summary of Meaningful Use Objectives for Eligible Professionals • What Do Federal EHR Incentives and Meaningful Use Mean to You? • EHR Vendor Selection and Contracting • Vendor Selection Tools (Chart) • Available HIT Tools and Resources (Links) • Health Information Technology in Primary Care: A Bibliography

Family medicine positions offered

2000

TAFP has made available a library of tools and resources to help family physicians access health information technology incentive payments available through the American Recovery and Reinvestment Act of 2009, otherwise known as the federal stimulus bill. Physicians have the opportunity to earn up to $44,000 through Medicare or up to $63,750 through Texas Medicaid to help them at any stage in the process of “getting wired,” whether implementing HIT for the first time, upgrading an existing system, or improving an EHR to meet newly defined standards.

The Health Information Toolkit for Family Physicians starts with a primer on the electronic health record incentive program. Additional resources list benefits of implementing health information technology, help physicians determine their readiness for new technology, summarize meaningful use requirements, provide sources to help select the right EHR, and explain how the Regional Extension Centers can assist physicians in the selection and implementation process. Here is a list of the full set.

Number of Medical Students, U.S. Medical School Graduates Choosing Family Medicine Residencies

Source: 2011 National Residency Matching Program results reported by the American Academy of Family Physicians

More medical students match into family medicine residencies in 2011 Results from the 2011 residency match released by the National Resident Matching Program on March 17 show an uptick in the number of medical school graduates pursuing careers in family medicine.

Of the almost 38,000 applicants who participated in the 2011 match, 2,576 chose family medicine residencies, filling 94.4 percent of the 2,730 spots available.

One hundred additional family medicine residency spots were offered this year.

Of U.S. medical school seniors, 1,317 choose a residency in family medicine, an 11-percent increase over last year. This is the third time in over a decade that the number of U.S. seniors choosing family medicine increased compared to the previous year, according to the American Academy of Family Physicians. The other two years were 2008 and 2010.

Family medicine had the strongest growth out of the primary care residencies, but pediatrics and internal medicine also showed an increase in applicants.

Three of the categories of pediatrics and internal medicine are considered primary care; two of these filled with more U.S. seniors in 2011 than in 2010. Twenty-six more positions filled in internal medicineprimary care in 2011 when compared with 2010 and one more position was filled in pediatrics-primary in 2011 than in 2010.

The most competitive residency programs among U.S. seniors were dermatology, orthopedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery. Of these

residencies, each filled 90 percent or more with U.S. medical graduates.

The increase in the number of medical students choosing to pursue primary care may be influenced by national health care reform and family medicine interest groups, or FMIGs, said AAFP President Roland Goertz, M.D., M.B.A., of Waco, in an AAFP news article.

“Primary care has become much more visible as a result of the discussion about improving our health care system. More people understand that if we’re to have high-quality care at a controllable cost, we need to balance our system on a foundation of primary medical care.”

FMIGs, which are organized at all medical schools across the country, are also helping to foster interest in family medicine by providing information on the future of the field as well as exposure to clinical procedures.

While the increased interest in family medicine is encouraging, the numbers are not nearly enough to provide adequate health care coverage in the United States, according to a report by the Council on Graduate Medical Education. At least 40 percent of U.S. physicians need to practice primary care to ensure access and to keep costs under control, the authors stated. To do this, the workforce needs 163,000 additional primary care doctors.

The more than 2,000 medical students who chose to pursue family medicine this year is a start; however, changes are still needed to encourage more medical students to choose primary care. :

CMS releases ACO guidelines

Plus, check out new ACO resources for family physicians After months of delays, the Centers for Medicare and Medicaid Services released the draft regulations for the Medicare Shared Savings Program on Thursday, March 31. This program aims to improve the quality and reduce the cost of providing care to Medicare patients by encouraging collaboration among physicians, hospitals, and long-term facilities.

Accountable care organizations have long been popular among academic and policy groups, but ACOs began gathering steam recently when the concept appeared as part of the Patient Protection and Affordable Care Act. Described in just six pages of the health care reform bill, stakeholders have waited for the draft regulations to answer their lingering questions.

How will incentive payments work? How will quality improvement be assessed?

Will patients be assigned to an ACO or will they “pick” one in which to participate?

Where do anti-trust laws come in?

Though it will take time to sort through TxPhysAd2010.pdf 11/30/2010 4:24:13of PM the new 429-page document, some

these questions can be addressed immediately. According to a CMS fact sheet, “The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first. Patient and provider participation in an ACO is purely voluntary.”

Organizations must apply to join the program, providing information such as how they plan to deliver high-quality care at lower costs for their patients. But not all will be accepted. Those who are approved must participate for three years and, during that time, must comply with a monitoring program that includes analysis of claims, financial data, and quality data; site visits; patient surveys; and quarterly and annual reports.

Physicians who choose to join an ACO would continue to receive payments under the current fee-for-service system. The proposed rule calls for CMS to establish a benchmark for savings to be achieved by cont. on page 10 each ACO.

Download the ACO resources from TAFP’s website: www.tafp.org/resources/new.

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s p r i n g 2 0 1 1 | T e x as Family P hysician

trust laws. ACOs in rural areas may be While an ACO would receive a share of eligible for additional exemptions. the savings it generates, the organization Stakeholders have until June 6 to subcould have to repay Medicare if it does not mit comments on the draft regulations for meet the benchmarks, a key difference from CMS to consider when developing the final initial proposals. However, even the poorest regulations. Those should be published performer would repay, at most, 10 percent later this year. of what Medicare would have spent on those patients if they weren’t in the ACO. AAFP, TAFP release new ACO Additionally, “shared losses” wouldn’t resources for family physicians start immediately depending on which track the ACO chooses. One track allows To assist members in exploring pracan ACO to operate on a shared-savings-only tice style options and ACOs, AAFP and a basis for the first two years, then assume coalition of six state chapters—including the risk for shared losses in the third year.

TAFP—have developed new resources.

These ACOs would be eligible for smaller The first resource, “The Family bonuses of up to 50 percent of any savings Physician’s Practice Affiliation Guide,” it generates and would face potential penalexplores the trends ties of up to 7.5 percent in the third driving physicians year. The second toward collaboration track allows ACOs and affiliation, weighs to share in savings the advantages and and risk liability disadvantages of for losses from the various affiliation opstart, but receive a tions, and provides a higher share—up detailed analysis of to 60 percent—of the hospital employany savings it genment model, all from erates. the perspective of The rule calls a family physician. for the establishThe guide considers ment of quality legal implications of performance meavarious practice afsures and a method filiations, and how for linking quality the patient-centered and financial permedical home can formance. The ACO be incorporated into would have to estabthese models. lish procedures to According to the promote evidenceDownload the ACO resources from TAFP’s guide’s introducbased medicine and website: www.tafp.org/resources/new. tion, “There are patient engagement. compelling ‘offenUnder the rule, sive’ and ‘defensive’ reasons to consider patients are not assigned to ACOs. Rather, integration and specific guideposts to Medicare will take a retrospective look at assure a successful and sustainable partwhere a beneficiary received services to denership.” termine whether a particular ACO should be The second resource, “The Family credited for improvements in care and costs.

Physician’s ACO Blueprint for Success,” Physicians would need to notify a patient that is a two-part guide to help family physithe practice is participating in an ACO, and cians develop their strategy to evaluate whether they share the patient’s claims data and implement a successful accountable with an ACO. care organization. Part one examines these Regarding anti-trust, two sections new organizations and identifies essential give the secretary of Health and Human elements, generally addressing specialties Services the authority to waive fraud and and facilities. Part two applies the prinabuse laws to achieve the goals of ACOs. ciples and processes of the guide specifiThese include the physician self-referral cally to the family physician. law, the anti-kickback statute, and the civil Both of these documents and more are monetary penalty law. This only applies available on TAFP’s website, www.tafp.org/ to ACOs that cover less than a third of resources/new. As federal and state health the local market unless they are blatantly care reforms roll out, AAFP and TAFP will violating competition laws. Larger ACOs continue working together to provide you would be evaluated by the Federal Trade with the most up-to-date information for Commission within 90 days of application your practice. : to determine if they would violate anti-

NO.

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11

Member News

courtesy of TARRANT COUNTY AFP

Tarrant County AFP inducts new officers

Members of the Tarrant County Academy of Family Physicians installed a new slate of officers at their 60th Annual Inaugural Ball on Feb. 26, 2011. From left to right: Program Chairman Brett Cochrum, M.D., of Fort Worth; Secretary-treasurer Steve Siegler, M.D., of Southlake; President-elect Craig Freyer, M.D., of Colleyville; and President Lesca Hadley, M.D., of Cleburne.

Texas Tech faculty becomes hospital CMO TAFP member Michael Ragain, M.D., has been named chief medical officer of the University Medical Center in Lubbock. In this position, Ragain will work with UMC staff, the Texas Tech School of Medicine, and the Texas Tech Physicians Michael Ragain, M.D. group to guide physicians

through changes the hospital faces from the federal health care reform law and advances in technology, according to an article in the Lubbock Avalanche-Journal.

“I’ve always been interested in innovation and quality in health care,” Ragain said in the article. “That’s becoming more and more important as we go forward.”

Ragain has served as the chair of the Texas Tech Health Sciences Center Department of Family and Community Medicine since 2002 and as UMC chief of staff from 2008 to 2009. He received his medical degree from the University of Texas Southwestern Medical School and his Master’s of Education from the University of Southern California. :

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Member News

KATE ALFANO

At the residency and procedures fair Saturday night, Tomas Villarreal of the TTUHSC Paul L. Foster School of Medicine practices a procedure under the instruction of Kelly Gabler, M.D., faculty at San Jacinto Family Medicine Residency Program.

News from the 2011 C. Frank Webber Lectureship

Gaining clinical knowledge, advancing the specialty

M

ore than 400 physicians, residents, and medical students gathered at the Omni Austin Hotel at Southpark to attend this year’s C. Frank Webber Lec­ tureship and Interim Session, March 1112, 2011. In addition to CME lectures and TAFP business meetings, the busy weekend included an ABFM SAM Group Study Workshop, TAFP’s first-ever Legislative Action Day, and the 2011 Texas Conference of Family Medicine Residents and Students.

New this year, TAFP ramped up its communications effort through social media outlets Facebook and Twitter. View the series of tweets from the conference at www.twitter.com/txfamilydocs or enter our hashtag—cfw2011—in the search box at the top of your Twitter browser.

TAFP’s SAM Group Study Workshop was held Thursday, providing an opportunity for diplomates of the American Board of Family Medicine to get credit for the Self-Assessment Module portion of their Maintenance of Certification. Attendees dis1 4

s p r i n g 2 0 1 1 | T e x as Family Physician

cussed cerebrovascular disease and completed the 60-question knowledge assessment portion of the module. Attendees were then eligible to complete the clinical simulation online to receive full credit.

Also on Thursday, more than a dozen TAFP-member family physicians and general internal medicine physicians from the Texas Chapter of the American College of Physicians participated in TAFP’s inaugural Legislative Action Day. Physicians, representing all areas of Texas, received a legislative briefing from TAFP’s lobby team before heading to the Capitol to meet with their legislators and advance issues important to the specialty.

TAFP CEO Tom Banning and lobbyists Marshall Kenderdine, Dan Hinkle, and Jerry Philips opened the meeting, presenting the top issues for primary care and how the first 60 days of the session had been.

“I feel that now, more than ever before, family medicine is well positioned to make major gains during the legislative session,”

Banning told attendees. “This is because of the work we’ve done in past sessions to educate lawmakers on the value of primary care, and to put in place programs to build the primary care workforce.”

Armed with TAFP’s issue briefs, the physicians left the briefing ready to speak to their legislators. Access these issue briefs on the Advocacy Resources page of TAFP’s website, www.tafp.org/advocacy/resources.

The sold-out lectureship on Friday featured CME topics on a range of issues facing practicing family physicians: from diabetes and dementia to joint pain and appropriate utilization of vitamin supplements, plus an ethics lecture from Clare Hawkins, M.D. TAFP hosted the 22nd annual student and resident conference on Saturday, which combined lectures tailored to future family physicians with an interactive residentled residency and procedures fair. Morning speakers addressed TAFP member benefits, how to pay off educational debt, and ways to stay a leader. That afternoon, residency programs from around Texas set up booths to promote their programs and show students the full scope of family medicine through hands-on procedure demonstrations. Students practiced simulations of joint injections, ultrasounds, circumcisions, and more.

JONATHAN NELSON

“I feel that now, more than ever before, family medicine is well positioned to make major gains during the legislative session. This is because of the work we’ve done in past sessions to educate lawmakers on the value of primary care, and to put in place programs to build the primary care workforce.”

— TAFP CEO Tom Banning on the 82nd Texas Legislature

JONATHAN NELSON

During TAFP commission, committee, section, and task force meetings on Friday and Saturday, TAFP members discussed topics that touch every aspect of family physicians’ practices, and developed policy that will guide the Academy through the year. At the Commission on Legislative and Public Affairs meeting Friday night, TAFP members listened to a presentation on federal health care challenges from AAFP President Roland Goertz, M.D., M.B.A.; heard a presentation from Marie-Elizabeth Ramas, M.D., on her recently-published policy brief on scope of practice; discussed progress and top issues of the 82nd Texas Legislature; and developed strategies for promoting family medicine in a tough budget session.

Members of the Commission on Public Health, Clinical Affairs, and Research discussed methods to promote tobacco cessation and current recommendations for the pertussis vaccine.

Attendees of the new Section on Com­ munications and Marketing examined the Academy’s current communications plan and discussed how to expand its reach through standing publications, the new Texas Family Docs blog, and other ways. The formation of the section was one of TAFP’s strategic initiatives, created to increase

Top: TAFP Past President Doug Curran, M.D., left, of Athens, and TAFP Treasurer Troy Fiesinger, M.D., of Sugar Land, compare notes in the Capitol extension during TAFP’s Legislative Action Day. Bottom: Javier Margo, M.D., left, of Rio Grande City, meets with Rep. Dee Margo, R-El Paso.

interaction with TAFP members through different communication vehicles, and will continue its work at Annual Session.

The TAFP Board of Directors meeting concluded the weekend when board members heard all of the reports and recommendations from TAFP’s business meetings, and reports from TAFP and AAFP officers and delegates.

Mark your calendars now to join TAFP for next year’s C. Frank Webber Lectureship at the Omni Austin Hotel at Southpark on March 2, 2012. Also plan to join TAFP for its largest symposium, Annual Session and

Scientific Assembly, July 27-31, 2011, at the Sheraton Dallas in Dallas, Texas. In the fall, TAFP will host Primary Care Summit − Houston Oct. 21-23, 2011, at the Westin Oaks, and Primary Care Summit − Dallas/ Fort Worth Nov. 11-13, 2011, at the Westin Galleria Dallas.

Stay connected to TAFP year-round through our social media outlets. Find us on Facebook at www.facebook.com/txafp, follow us on Twitter at www.twitter.com/ txfamilydocs, and read and comment on our new Texas Family Docs blog at www. txfamilydocs.org. : www.ta f p.or g | spr i n g 2 0 1 1

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leg i slat i ve up date

THE BUDGET SESSION

By Kate Alfano

Having passed the halfway point in the 82nd Texas Legislature, the dominant issue of this session has been and continues to be the budget. Lawmakers came into the session aware of a multi-billiondollar shortfall for the 2012-2013 biennium, as well as a significant deficit in the current 2010-2011 biennium.

A revised revenue estimate from Texas Comptroller Susan Combs decreased the 2010-2011 deficit to $4 billion. After much wrangling, top state leaders and House budget writers agreed to use $3.1 billion of the Economic Stabilization Fund—also known as the Rainy Day Fund—to address this deficit. Agency cuts will make up the rest.

Using this portion of the Rainy Day Fund frees the same amount to be used in the 2012-2013 budget, which helps but does not come close to solving the looming shortfall—now estimated to be around $23 billion. Though a little more than $6 billion remains in the Rainy Day Fund, Gov. Rick Perry has said repeatedly that he will not sign a 2012-2013 state budget that uses any of the remaining balance.

The original versions of the House and Senate budgets released at the beginning of the session spared no area of government, especially health care and education. Both versions cut Medicaid provider rates and funding for graduate medical education. The House base budget eliminated many of the programs TAFP has advocated for years to in16

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crease Texans’ access to primary care: the Family Medicine Residency Program funding from the Texas Higher Education Coordinating Board, the Statewide Family Medicine Preceptorship Program, and the Physician Education Loan Repayment Program. The Senate didn’t eliminate these programs, but made large cuts.

After weeks of hearings, the House Appropriations Subcommittee on Article II made the restoration of most of the proposed cuts to Medicaid payments for primary care services its top priority. The subcommittee agreed that if funds become available during later stages of the budgeting process, payment for primary care services for children in Medicaid and for CHIP should be cut by only 2-3 percent rather than 10 percent.

This idea originated from Health and Human Services Commissioner Tom Suehs, who told the committee at an earlier hearing, “I’m really concerned about having to cut primary care rates for physicians treating children. We’ve already cut 2 percent this biennium from

Graduate medical education As mentioned above, graduate medical education suffered greatly in the base budgets of both bodies of the Legislature. Formula funding was cut by 32 percent in the House version and by 28 percent by the Senate. Total GME spending under the House budget was cut 44 percent; in the Senate, 26 percent.

Mike Ragain, M.D., chair of the department of family medicine at Texas Tech University Health Sciences Center testified before the Senate Committee on Finance on Feb. 15, asking the panel not to cut funding to family medicine residency programs and other primary care residencies.

Medicaid/CHIP

Third-party payment

28.0% Medicare

29.7%

18.7%

9.3%

Self pay

14.3%

Uninsured/ indigent

Source: Texas Higher Education Coordinating Board

THECB Article III funding for family medicine residency programs

$25M $20M

0

02-03 04-05 06-07 08-09 10-11

$15.1M

$5M

$21.2M

$10M

$17.5M

$15M

$17.5M

S.B. 1 H.B. 1

$18.4M

Payment reform Senate bills 7 and 8, authored by Sen. Jane Nelson, R-Flower Mound, and supported by Lt. Gov. David Dewhurst, would implement a host of pilot projects in the private insurance market, Medicaid, and CHIP to test the success of various health care payment reforms, including bundled payments, payments based on episodes of care, and quality incentives.

S.B. 7 introduces alternative payment systems for Medicaid and CHIP, while S.B. 8 provides a safe harbor from antitrust laws for hospitals, insurers, and physicians to experiment with various payment models. It also provides for so-called “health care collaboratives,” designed to align payment incentives for physicians, hospitals, and health plans.

“We don’t have health care in America—we have sick care,” Dewhurst said at a press conference on Feb. 15. “Studies by Dartmouth Institute and others indicate that we can save money and improve medical outcomes by incentivizing doctors and hospitals to use best practices and focus on wellness and prevention, rather than the number of procedures they perform.”

“These bills move us toward a payment system that rewards quality outcomes rather than quantity of services, along with reducing our costs for unnecessary tests and preventable hospital readmissions,” Nelson said at the press conference. “We need to refocus our payment system on the true goal: healthy outcomes for Texans.”

S.B. 7 and 8, as well as others in House and at the agency level, propose to change the way the state finances health care. TAFP CEO Tom Banning says these solutions hold great potential.

At a March 8 hearing of the House Committee on County Affairs, Banning spoke on health care financing, saying that reforms like these will be instrumental in “moving us away from a truly fractured delivery system of care to more of a clinically integrated delivery system where you align payments for outcomes and for quality to ultimately reduce costs.”

Patient mix at Texas FaMily medicine residency programs

$20.6M

KATE ALFANO

when y’all wrote the [2010-2011] budget. I believe that’s about as far as I can tolerate to maintain the access to primary care so I’m asking to put back not all 10 percent, but 8 percent.”

The House budget as passed in early April made few changes to the original, including retaining the 10-percent cut to Medicaid provider rates and other drastic cuts. The general revenue budget would spend $77.6 billion—$4.48 billion less than the 2010-2011 budget, and the total budget would spend $164.5 billion—$23 billion less than 2010-2011.

Though the House budget stays true to the no-new-tax, deepcut approach advocated by leaders, chief budget writer Sen. Steve Ogden, R-Bryan, has said that passing such a stark budget in the Senate is likely impossible. That means that the Senate version can be expected to be less lean and the conference committee—which will comprise legislators from the House and Senate—will have a tough job hammering out a final budget bill before sine die on May 30.

As those deliberations continue, here is a quick synopsis of a few other bills important to family physicians’ practices and their patients.

As always, TAFP will provide an in-depth report after the session.

$0

12-13 proposed

“One of the challenges is that almost every revenue stream that we see in medical education is going to get cut, and that cumulative effect is tough. We are pretty tight. You could say we’re running on fumes as far as keeping things going.”

— Mike Ragain, M.D., testifying before the Senate Committee on Finance, Feb. 15, 2011

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FAMILY MEDICINE RESIDENCY PROGRAMS TRAIN FAMILY PHYSICIANS ACROSS THE STATE 686 family medicine residents train in 28 family medicine residency programs in Texas

FAMILY MEDICINE RESIDENCIES

NUMBER OF RESIDENTS

TTUHSC – Amarillo FMRP UTSW – Austin FMRP San Jacinto Methodist FPRP Texas A&M FMRP Conroe FMRP Corpus Christi FMRP Methodist Health Systems FMRP UTSW – Dallas FMRP TTUHSC – El Paso FMRP CRDAMC FMRP John Peter Smith FMRP UTMB FMRP Baylor FMRP at Garland Valley Baptist FMRP Baylor FMRP at Houston Baylor/Kelsey-Seybold FMRP Methodist Hospital Houston FMRP UT Houston FMRP TTUHSC – Lubbock FMRP McAllen FMRP TTTUHSC Permian Basin FMRP CHRISTUS Santa Rosa FMRP UT San Antonio FMRP Memorial FMRP Scott & White/Texas A&M FMRP UT Tyler FMRP McLennan County FMRP Wichita Falls FMRP TOTAL FAMILY MEDICINE RESIDENTS

18 21 24 21 22 35 17 26 24 15 68 20 18 15 18 12 12 36 27 17 18 21 35 42 19 24 37 24

Full HPSA county (fewer than 1 physician per 3,500 people) Partial HPSA Location of a family medicine residency program

686

“One of the challenges is that almost every revenue stream that we see in medical education is going to get cut, and that cumulative effect is tough,” he said. “We are pretty tight. You could say we’re running on fumes as far as keeping things going.”

One controversial budget proposal reported in a March 10 article in the Texas Tribune would concentrate state funds for graduate medical education on the first three years of residency training regardless of how long the residency takes to complete. That means that it would fully fund three-year residencies like family medicine, but not specialty residencies that last four to seven years.

Though opposed by the Texas Medical Association and many academic health centers, the rationale is to provide an incentive to produce more primary care physicians whose services do not garner high payments. After the first three years of training, proponents argue, subspecialty residents “pay for themselves.” For more on this proposal, see the Texas Family Docs blog post on www.txfamilydocs.org, “Can the state shift the balance of power in GME?” Scope of practice House and Senate members have filed 72 bills on scope expansions for a variety of non-physicians including advanced practice nurses, chiropractors, and podiatrists, according to the Texas Medical Association. TAFP is tracking five bills in particular that would expand the scope of APNs. House Bill 708 by Rep. Kelly Hancock, R-North Richland Hills, would grant nurse practitioners, nurse anesthetists, and clinical nurse specialists complete prescriptive authority and the ability to 18

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diagnose and treat patients without physician supervision, all under the regulation of the Texas Board of Nursing.

Similar bills include H.B. 1266 by Rep. Garnet Coleman, D-Houston, and Rep. Rob Orr, R-Burleson, and its companion bill, S.B. 1260 by Sen. Rodney Ellis, D-Houston; H.B. 915 by Rep. Wayne Christian, R-Center; and S.B. 1339 by Sen. Royce West, D-Dallas.

TAFP working for you TAFP is taking a number of steps to educate lawmakers on each of these issues and provide members with the tools needed to advocate on behalf of the specialty. Visit the Advocacy Resources page of www.tafp.org to find a series of issue briefs outlining scope of practice, graduate medical education, and licensure for international medical graduates—as well as a multi-page brief on scope of practice. The policy brief—“The Question of Independent Diagnosis and Prescriptive Authority for Advanced Practice Registered Nurses in Texas: Is the Reward Worth the Risk?”—is authored by MarieElizabeth Ramas, M.D., a third-year family medicine resident at the Conroe Family Medicine Residency Program, and uses current research to dispute some of the claims made by advanced practice nurses as they work to expand their scope of practice.

The Academy will continue working hard to keep Texas family physicians informed on what’s happening under the dome. Watch your e-mail inbox for each edition of QuickInfo. During the session, each leads with the TAFP Capitol Update news report. TAFP has also released the first two Capitol Report webcasts of the session with more planned as the action heats up. Stay tuned. :

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COVER STORY

Lloyd Van Winkle, M.D. Texas Family Physician of the Year, 2010-2011 20

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Man

about

TOWN

By Jonathan Nelson

T

wenty-five miles west of San Antonio alongside the Medina River is the quaint village of Castroville, population of about 3,000, home to TAFP’s 2010-2011 Family Physician of the Year, Lloyd Van Winkle, M.D. For more than 25 years he’s practiced family medicine here, just off the old town square in a clinic he designed and built, Medina Valley Family Practice. He keeps the original floor plan, splattered with little spots of spackle and mounted on a plywood plank, leaned against the wall behind his office door.

The clinic is surrounded by the whitewashed adobe facades of provincial buildings new and old—several dating back to the mid-to-late 1800s—characterizing the community, which began as an empressario settlement in 1842, when Henri Castro brought a group of settlers from the Alsace-Lorraine region of France to populate the Medina River valley. From his clinic, Van Winkle can see the spire of the rustic and beautiful St. Louis Catholic Church, completed in 1870, dominating the great town square, enhancing “the Little Alsace of Texas,” as Castroville is called, with its old-world rural European charm.

Through his dedication and determination, Van Winkle has written himself into the distinguished history of this place. His is a household name here. Feats of selfless kindness, considerate leadership, and his continuous availability are recounted time and again by grateful patients and friends. In a letter recommending Van Winkle for the Family Physician of the Year Award, one patient wrote:

JONATHAN NELSON

“Having four very active children and living on a ranch, we have had many occasions to call his after-hours answering service. Without fail, in a matter of 10 or 15 minutes, we’ll receive a call back (even on Saturday nights), ‘Well, I am dining in San Antonio with my family. We are almost through. Can you meet me at the clinic in 25 minutes?’ To the parent of an injured child in a rural area, those are the sweetest-sounding words in the world.”

Perhaps his most conspicuous characteristic is his consistency of behavior and appearance.

His partner in practice for more than 10 years, Mary Nguyen-Poole, M.D., swears he sleeps in a suit. “Maybe if it’s a casual event, he may go without a tie, but I have never seen him disheveled,” she says. “He always looks like Dr. Van Winkle.” Whether you call him at 2 p.m. or 2 a.m., “the way he answers the phone and talks to you is exactly the same.”

In another letter of recommendation for the award, a patient commented on this same quality: “His patients can always depend on his being there for them, no matter the date or time of day or night. I do not pretend to know how he manages to be all places at all times, unless he has a closet full of clones, but he does it. Even more amazing to me is the fact that, even in the wee hours of the morning and after countless hours without sleep, hours filled with one dire emergency after the other, he will appear at the bedside of a newly admitted patient meticulously groomed, incredibly alert, and disgustingly energetic. As a matter of fact, in all the years I have known him, I have yet to see him otherwise.”

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Top: Van Winkle reviews a chart with head nurse Donna Winters.

Bottom: Leah Raye Mabry, M.D., and Van Winkle share a laugh at an AAFP event.

“He never had a hair out of place.

He always had on his suit and his tie, and you know, he was always well-shaven and taken care of. So quickly we nicknamed him Mr. Clean.”

cont. on page 24

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JONATHAN NELSON

—Leah Raye Mabry, M.D.

The head nurse at Medina Valley Family Practice finds his unflappable nature among his finest qualities. Donna Winters has practiced alongside Van Winkle since he came to town, and she remembers clearly her employment interview with him. After answering several of his questions, she was surprised when he asked if she had anything she’d like to ask of him.

“I said, ‘Do you curse?’

“He said, ‘Never.’

“I said, ‘Do you throw things?’

“He kind of sits back in his chair and gives me this look and says, ‘No.’ “So I said, ‘If we have a really stressful day and something really bad happens in the office, you’re not going to yell at me, and cuss at me, and throw things across the room at me?’

“He goes, ‘You have to be kidding me, right?’

“I says, ‘No. I’ve had all those things done to me. Are you going to do those things?’

“And he says, ‘Never.’ And I can tell you, 25 years and he’s never cursed, he’s never thrown anything, and he’s never yelled at me.

He’s a man of his word.”

There have been plenty of stressful days, rest assured, as one would expect in a practice as busy as Van Winkle’s. He regularly sees 40 or more patients a day, admits patients to three hospitals, serves as the medical director for a nursing home and for the Medina County Emergency Management Service, and is the supervising physician for a rural health clinic in Utopia, about 60 miles west of Castroville. Between Nguyen-Poole and himself, they share about 7,500 patients.

They offer full-spectrum family medicine at the clinic, complete with X-ray imaging, casting, suturing, and removal of foreign objects.

(Over a quarter of a century, they’ve racked up a long list of painfully funny tales of foreign-object removal, none of which can be safely recounted here.) They even have a crash cart, which they’ve had to use from time to time.

He sponsors little league sports teams for boys and girls, and has for years. Hanging all along the clinic walls are team pictures—girls’ softball, boys’ baseball, soccer teams, and basketball teams—all with jerseys that read “Lloyd Van Winkle, M.D.” He’s a clinical associate professor in the Department of Family Medicine at the University of Texas Health Science Center in San Antonio. He’s the health officer for Castroville and its neighboring community, LaCoste. He’s the Medina County Aviation Medical Examiner, the chair of the Department of Family Practice at San Antonio’s Methodist Hospital, and a quality reviewer for TMF Health Quality Institute.

He has served on too many committees and commissions with TAFP, the Alamo Chapter of TAFP, and the American Academy of Family Physicians to list, and he’s held every office of TAFP, serving as president in 2000 and 2001. He has just completed a 10-year commitment representing TAFP as alternate delegate and then delegate to the AAFP Congress of Delegates, an honor he holds most dear.

At age 56, with a wife of more than 30 years and four successful children, Van Winkle has accomplished a tremendous amount. But don’t think he’s about to coast into the golden years. He’s planning a major remodeling project for the practice, and he and his staff are currently in the thick of implementing an electronic health record system. “My goal is to practice into my 80s,” he says.

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cont. from page 22

V

an Winkle grew up quite close to where he practices today.

His great-grandparents settled in the area in the late 1800s, and his parents met in high school in a nearby town. His family moved to San Antonio in search of better schools for Van Winkle and his younger brother and sister, and his father went to work for IBM. Van Winkle remembers being surrounded by early computers, learning the theory behind them, their presence fueling a keen interest in science. His parents subscribed to the Time-Life Science Library, offering a new book every two months for three years, which he read from cover to cover.

In September of his freshman year in high school, 1969, his biology teacher pulled him aside. “You really have a gift for this; you ought to be a doctor,” Van Winkle remembers him saying. “He was the first person to suggest that.”

“When I went off to college, the politics of the late ’60s, early ’70s were in gear, and I decided as much as I enjoyed science, politics and changing the world was important, so I became a political science major.” After a year, he had changed his mind, switched his major to biology, and entered the pre-med program.

He would change the world another way.

After graduating from St. Mary’s University in San Antonio, he began medical school at the University of Texas Health Science Center at Houston. The first two years were tough. School had always come easy to him, but now he had to learn to study. Then came the clinical rotations.

“Every single course I took during my clinical rotations, whether it was psychiatry, or dermatology, or general surgery, or ER, everything I did, when I finished it, I said, ‘That’s what I’m going to do.’”

There wasn’t a true department of fam—Lloyd Van ily medicine at the school back then, so he didn’t have any exposure to the specialty until his mandatory primary care rotation with a family doctor in north Houston.

“I watched him making hospital rounds and seeing his patients, and I said, ‘This is the missing link.’ I saw how his patients talked with him and the relationship he had with them, and I said, ‘This is the thing I need. This is what will pull it all together and make it work for me.’”

Back at school, he got a cold reception from friends and faculty. He says not one faculty advisor, attending, or professor supported his decision. “They all said, ‘You can’t do that. You’re too smart for that.’”

Undeterred, Van Winkle became an intern at the UT Health Science Center at San Antonio Family Medicine Residency. “It was a whipping of a residency,” he says. “It was in the days when there were no hour limits on call, but man, I learned a lot. You would admit someone at 3 a.m., and you’d have an option of going to sleep until 5 or going to the library and preparing for rounds to know that patient’s disease. You’d better go to the library, because that attending in the morning is expecting you to present that case.”

Entering the internship in the same class as Van Winkle was a tall, strong-willed physician who had already had a brief career as a pharmacist and who would go on to become TAFP president, TAFP Family Physician of the Year, and Speaker of the AAFP Congress of Delegates, Leah Raye Mabry, M.D.

“Of course we were all young and innocent,” she says, “but one thing we immediately noticed about Dr. Van Winkle is that he was very professional.” She says the interns and residents would go on call, working extremely hard each night with multiple admissions, then come in the next morning hoping not to look “half dead.” Then they would see the young Van Winkle. “He never had a hair out of place. He always had on his suit and his tie, and you know, he was always well-shaven and taken care of. So quickly we nicknamed him Mr. Clean.”

She says he would say he wanted to look like the doctor that his patients expected him to be, and to this day, he abides by the same code. He runs six days a week, and pays close attention to his caloric intake. He reads voraciously from a wide variety of genres, the clinical literature for certain, but also fiction—from science fiction and mysteries to the classics—and histories, biographies, and other non-fiction.

He cultivates a grand appreciation for music of all sorts. Yes, he loves The Beatles, but his ear wanders far, and his music collection would rival that of many 20-something hipsters, including the likes of Death Cab for Cutie, Wilco, Sufjan Stevens, and Radiohead. He has attended multiple concerts by progressive metal rockers Tool, probably clad in coat and tie.

“When I have [medical] students here, I always ask them about music, and some of them have some music knowledge and some really don’t, but I tell them you know, medicine is important, but you can’t limit yourself. If you broaden your horizons, you’ll have a better ability to interact with patients.”

Van Winkle is usually in the process of tutoring medical students, and he enjoys Winkle, M.D. doing it. During his residency training, one of his clinical professors taught him that to be a physician, you must do three things.

First, you must take care of patients. Next, you have to teach, to pass on the knowledge you’ve been given, and lastly, you have to study.

“I thought it was a great philosophy, and so it’s what I’ve done from the beginning.”

Teaching is one of the many ways Van Winkle extends his benevolent influence beyond the exam room. Another is his community leadership. After completing his residency training and setting up shop in Castroville, he was asked to serve as medical director for the Medina County EMS. At that time, the unit consisted of a few volunteers and a single ambulance parked under a carport behind the volunteer fire department building. Today, the department has three stations, five ambulances, and a paid staff on duty around the clock. It is a model department, conducting training sessions for EMS units in rural communities across the country. Medina County EMS was named Texas State EMS Provider of the Year in 2009.

This transformation didn’t take place overnight, and it was successful because of the concerted effort of many members of the community. They had to establish an emergency services district that could impose a quarter-cent sales tax to pay for the service.

Van Winkle says it took several months of persuasive phone calls.

“There’s a lot of folks out here who don’t want to pay any taxes for anything, and you kind of had to get them to come around to the

“That’s really what you’re doing. You’re giving to your patients through your involvement in organized medicine.”

24

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fact that when your mom has an MI [myocardial infarction, or heart attack] in the middle of the night, if you had to pay an extra $100 a year in tax, would you be willing trade your mother for that? They came around.”

In a letter of recommendation from the Medina County EMS, business manager Sherry Trouten wrote: “Dr. Van Winkle has definitely been a very valuable key to the success of this organization and we could not recommend him higher for any recognition for his service to this community.”

It was this leadership quality that led Leah Raye Mabry to recruit Van Winkle into service for the Academy, first at the local chapter level, then at the state and national levels. “I like to think I talked him into it,” she says.

According to Van Winkle, she wouldn’t take “no” for an answer.

When Mabry had begun moving through the officer ranks at TAFP, she called Van Winkle again, saying that when she became TAFP president, she needed him to be the parliamentarian. “I told her thanks, but I really couldn’t. I was just too busy,” he says. “She goes, ‘Lloyd, I didn’t call to ask you, I called to tell you you’re going to be the parliamentarian.’”

A few years later, Van Winkle was sworn in as TAFP president.

For years, he’s served as the chair of the TAFP Political Action Committee, and he has become a respected voice for family medicine on various AAFP committees and in the Congress of Delegates.

He sees his participation in organized medicine as an extension of the care he provides in his community.

“In my office, I see patients every day and I impact health care in Texas by doing that. But medicine is practiced in an environment

and it became clear to me that the medical environment as the world became a bigger and bigger place was going to be regulated.

It also became clear to me that there were people with different motives for that environment that I might not agree with and that might be detrimental to my patients.”

He says when he saw his colleagues serving as leaders in the state and national levels, making policy and working to improve the state of family medicine, he had to be a part of that process. “That’s really what you’re doing,” he says. “You’re giving to your patients through your involvement in organized medicine.”

After all the excitement, though, it’s good to get back to Castroville, back to the practice, back to his patients. “All the other things I do are interesting, but the thing I do where I really feel like I’m where I’m supposed to be is when I’m here, seeing patients in the office.”

When he accepted the 2010-2011 Texas Family Physician of the Year Award at TAFP’s 61st Annual Session and Scientific Assembly in San Antonio last summer, he told his assembled colleagues and friends that family medicine is really about relationships. He showed a video montage of images of family medicine’s leaders in Texas over the decades set to the old Louis Armstrong standard, “What a Wonderful World.” Then he looked out over the crowd and thanked them for the honor.

“You know, a popular show on television right now is called ‘House,’ but none of my patients is looking for a house. They’re looking for a home, and that’s what we are. Friends and colleagues, I thank you all for being here. I love you all. We’re all Family Physicians of the Year every year.” :

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policy

brain drain

Licensure delay provides incentive for IMGs to leave Texas after residency training

By Monica Kortsha

Kaparaboyna Ashok Kumar, M.D., director of medical student education at the University of Texas Health Science Center at San Antonio, has long advocated for an end to licensure delays for qualified IMG physicians.

s p r i n g 2 0 1 1 | T e x as Family Physician

Troy Fiesinger, M.D., clinical associate professor of family medicine at the Memorial Family Medicine Residency Program and TAFP treasurer.

To qualify to take their board certification exam, residents must have their medical license. Because IMGs can’t receive a Texas license until after they graduate, they usually don’t have it in time to take the board certification exam in mid-June. Since board certification is usually a requirement for insurance credentialing and hospital privileges, IMGs are essentially out of the job until they can take the next board certification exam in December.

Residents who graduated from a U.S. medical school don’t face the same delays and are able to take their board exams within weeks of residency graduation, which not only increases the speed in which they’re board certified, but also their score on the exam, says Rebecca Gladu, M.D., associate program director of the San Jacinto Methodist Family Medicine Residency Program.

“The residents do the best when they come right out of residency and take that exam,” she says. “It puts [IMGs] at a further disadvantage to have to wait until December to take the exam. That’s a little bit of discrimination here.”

Not having a license until after graduation can take a toll on an IMG’s career even while he or she is still in residency. According to TAFP past president Kaparaboyna Ashok Kumar, M.D., director of medical student education at the University of Texas Health Science Center at San Antonio, hospitals, physicians groups, and other potential employers start recruiting residents at the beginning of the third year and often don’t want to take a chance on a physician who doesn’t have a license.

“You can say all you want to say to them, but they don’t want to look at you because nobody is 100-percent sure that you will get [your license],” Kumar says.

Not being able to line up a job before graduation can create a “catch-22” for IMGs staying in the U.S. with a visa, which requires them to have a job offer immediately after they finish residency to remain in the United States.

To avoid the delay, many IMGs obtain medical licenses in states like New Mexico or Oklahoma that allow them to be licensed before completing residency. Once they’ve finished their training, they have an incentive to leave the state.

Although it’s possible for IMGs to apply for a Texas and an out-of state license, and

JONATHAN NELSON

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C

ephas Mujuruki, M.D., is the chief-resident-elect at the Texas Tech University Family Medicine Residency Program in Amarillo.

He grew up and went to medical school in Zimbabwe. Although he’s only a resident, Mujuruki has an extensive medical résumé: He’s a registered family physician in Zimbabwe, which required completing five years of medical school and a two-year internship that resembled a miniresidency, with four six-month rotations in surgery, internal medicine, pediatrics, and obstetrics/gynecology. After graduation, Mujuruki worked as a family doctor in government and mission hospitals in Zimbabwe and Namibia before moving to Texas in 2008 to enter Texas Tech’s residency program.

He’s lived in Texas for only three years, but has quickly grown to love the state where his 4-month-old son was born.

However, Texas law requires international medical graduates, or IMGs, to complete three years of residency before they can receive a medical license, meaning Mujuruki won’t be able to practice in Texas immediately after graduation. This is something he says he and his family cannot afford.

The Texas Legislature is considering a measure supported by TAFP that would remove this licensure barrier for IMGs, but if it’s not passed, Mujuruki, who planned to practice medicine in rural Texas, says he will leave the state and settle somewhere where he can start practicing and earning income right away.

“The welfare of my family has to come first and I would rather take up a full-time job and settle with them than do locum tenens in another state waiting for a Texas license,” Mujuruki says.

Unlike IMGs, residents who graduated from U.S. medical schools can get their license after one year. Not having a license in hand at graduation can trigger a series of delays that prevents an IMG from practicing medicine in Texas for months after residency.

“One of the principles we’re trying to get across is it’s a ripple effect that we think a lot of people aren’t aware of,” says

24 states require fewer than 3 years of residency for IMG medical licensure

3 years required 2 years required 1 year required

then use the out- of- state license to take the board exams, many can’t afford the costs associated with two licenses, or don’t want to wait for a Texas license when they can start practicing in another state.

“When you come out of school with $100,000, $150,000 worth of debt, those payments start immediately,” Fiesinger says.

“They cannot afford to wait. We’ve had residents who lived barely above the poverty level because they had a family.”

After attending medical school in India and completing his residency in Texas, Kumar became licensed in Oklahoma and practiced there for four years because he was unable to get a Texas license right away. He later returned to Texas to take a position at the residency program where he trained. However, Kumar says that when most IMGs leave Texas, they leave for good, becoming part of their new community.

“We have a brain drain,” Gladu says.

“Our trained residents we paid for with our state funds to deliver services in the state of Texas end up leaving Texas because they don’t have their license.”

While moving to a different state may help jump-start IMGs’ careers, it adds to the severe doctor shortage that Texas faces.

Half of Texas’ 254 counties are classified as full health professional shortage areas, or HPSAs, having less than one physician per 3,500 people. The numbers are likely to get worse with fewer than 20 percent of U.S. medical school graduates planning to enter primary care, according to the Council on Graduate Medical Education.

IMGs are already an important part of the physician workforce in America; one in four physicians is an IMG. They have great potential to help fill the family doctor shortage in Texas, too, with IMGs increasingly deciding to

pursue family medicine residencies over the last decade. They currently make up 38 percent of family medicine residents in Texas.

According to the National Residency Matching Program, slightly less than half of family medicine residency spots were filled

by U.S. medical graduates in this year’s match.

The logic behind the waiting period in Texas is to give extra time to make sure that IMGs have been educated up to U.S. standards. Residency directors say that U.S. medical graduates and IMGs are held to the same high standards, complete the same rotations, perform the same tasks, and, when their respective application times come, take the same medical licensing exam. Fiesinger says that this equal evaluation should result in equal licensure opportunities.

“It blows my mind that someone comes here on a visa; trains; meets every requirewww.ta f p.or g | spr i n g 2 0 1 1

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“We have a brain drain. Our trained residents we paid for with our state funds to deliver services in the state of Texas end up leaving Texas because they don’t have their license.”

—Rebecca Gladu, M.D., San Jacinto Methodist Family Medicine Residency Program ment, every test, and every standard; and then we make them wait. We have the cream of the crop from other countries.”

In some cases, IMGs have more clinical experience than U.S. graduates because of the mandatory clinical rotations or service that many foreign medical schools require.

“These doctors are experienced and mature,” Gladu says. “It hurts me when I know that we’re holding up such great doctors that I would send my own family to.”

When IMGs decide to leave Texas they have plenty of options; 24 states allow them to obtain medical licenses during their first three years of residency training.

Legislation has been introduced in both houses of the Texas Legislature that would allow IMGs to obtain their Texas medical licenses after completing two years of residency. “For something that doesn’t cost

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very much, we can increase the supply of physicians and I think that’s key in a state that’s undergoing a severe budget deficit,” Fiesinger says.

The bill, House Bill 1380 by Rep. Vicki Truitt, R-Keller, passed out of committee in late March. The Senate Health and Human Services Committee took up its companion, S.B. 1022 by Sen. José Rodríguez, D-El Paso, in April.

According to a TAFP issue brief, found in the Advocacy Resources section of www. tafp.org, passing the legislation is a small change that would have a tremendous effect on Texas’ health care system. IMGs who are practice-ready, Texas-trained, and who would like to remain in Texas are leaving, often because of the unnecessary delays they face. Passing the legislation can help keep primary care physicians in Texas and, in effect, improve access to cost-efficient

and high-quality health care across the state, the brief says.

No matter the outcome of the legislation, Mujuruki says he’ll be saving lives as a family physician. But if he it was up to him to decide, he says he would rather be doing it in the “great state of Texas.” :

RESOURCES To access the TAFP issue brief “Keep Texas-trained International Medical Graduates Practicing in Texas,” go to www.tafp.org/advocacy/resources.

Using a few workarounds, IMGs could sit for the June board certification exam and keep their careers on track. To view one timeline to licensure, go to www. tafp.org/students/resources/timeline.asp.

TA FP Mi nutes i n B r i ef

Interim Sessio n 2011 Minutes in brief The TAFP Board of Directors met on Saturday, March 12, 2011, to hear reports and recommendations from TAFP’s committees, commissions, and sections. Below are the highlights of the meeting, which included a robust discussion of the 82nd Texas Legislature. For a complete copy of the minutes, contact Kathy McCarthy at (512) 329-8666, ext. 14, or at kmccarthy@tafp.org.

TAFP Foundation Board of Trustees The Foundation announced that fundraising for the Roland A. Goertz, M.D. Scholarship will begin in summer 2011.

Bylaws Committee The committee recommended that “family medicine” replace “family practice” throughout the bylaws.

Executive Committee AAFP President Roland Goertz, M.D., M.B.A., updated the committee on various national issues. Eduardo Sanchez, M.D., from Blue Cross and Blue Shield of Texas also addressed the committee. He spoke about a pediatric obesity toolkit that the TAFP Foundation will distribute with the help of a grant from Blue Cross.

Finance Committee The committee recommended that TAFP adopt a new investment policy statement. The policy clarifies and defines duties and responsibilities of the Finance Committee, the Executive Committee, and the investment manager.

Nominating Committee The committee proposed the following slate of officers for 2011-2012: President-elect Troy Fiesinger, M.D.; Vice President Dale Ragle, M.D.; Treasurer Clare Hawkins, M.D.; and Parliamentarian Ajay Gupta, M.D. The committee also nominated Justin Bartos, M.D., for the position of AAFP delegate, and Douglas

Curran, M.D., for the position of alternate delegate. Both terms will expire after the AAFP Congress of Delegates in 2013.

Commission on Academic Affairs The commission discussed the Texas Conference of Family Medicine Residents and Students, and the Clerkship and Residency Coordinators Conference. The commission received their first nomination for the TAFP FMIG Program of Excellence.

Commission on Annual Session and CME The commission recommended that TAFP amend the name of the commission from the Commission on Annual Session and CME to the Commission on Continuing Professional Development. The commission also approved program chairs Clare Hawkins, M.D., to assist Rebecca Gladu, M.D., with the 2011 Primary Care Summit – Dallas/Fort Worth; Oscar Garza, M.D., for the 2012 C. Frank Webber Lectureship; and Sharon Hausman-Cohen, M.D., and Ami Foster, M.D., for the 2012 Annual Session and Scientific Assembly.

Commission on Core Delegation The commission discussed the work of the various AAFP commissions. Goertz provided an update on AAFP. Michael Speer, M.D., and Lyle Thorstenson, M.D., candidates for TMA president- elect, also addressed the commission.

Commission on Health Care Services and Managed Care The commission recommended that TAFP submit Resolution A: Maintenance of Certification Program Expansion and Resolution B: Pay for Performance Programs to the AAFP Congress of Delegates.

Commission on Legislative and Public Affairs The commission heard a presentation from Tom Banning on the events so far in the 82nd Texas Legislature.

Goertz discussed the national political environment regarding health care reform, accountable care organizations, and AAFP’s priorities.

Commission on Membership and Member Services The commission recommended that TAFP staff not produce a printed membership directory in 2012. An online directory is available on the AAFP website.

Section on Maternity Care The section requested that an e-mail questionnaire be sent to members to update TAFP’s list of members who include maternity care in their scope of practice. The section also recommended that TAFP staff work on video profiles of maternity care providers with an emphasis on rural family medicine.

This information could be available to students and residents to learn about the day-to-day routine of family medicine doctors who practice maternity care.

Section on Special Constituencies The section organized a service project in conjunction with the TAFP Foundation.

During the 2011 Annual Session and Scientific

Assembly, TAFP will collect donations for North Dallas Shared Ministries. Donations can be made directly to the TAFP Foundation on the Annual Session registration form, or at the Annual Session registration desk. The section selected Kaparaboyna Ashok Kumar, M.D., as the recipient of the Special Constituency Leadership Award.

Section on the Medical Home The section recommended that TAFP offer training on how to become an NCQAcertified patient-centered medical home at the next available CME event. They also recommended that TAFP create a task force on future health care delivery models.

Section on Medical Students The section held elections for student officer positions.

The new officers are Chair Brook Huffsmith, Chair-elect Rebecca Divers, Secretary Veronica Vittone, Delegate to the TAFP Board of Directors Stephanie Eyestone, Alternate Delegate to the TAFP Board of Directors Rachel Finn, National Conference Delegate Dana Brown, and National Conference Alternate Delegate Karl Greer.

Section on Resident Physicians The section held elections for resident officer positions.

The new officers are: Chair Enjoli Benitez, M.D.; Vice Chair Justin Squyres, M.D.; Secretary Diana Mercado, M.D.; National Conference Delegate Justin Bogwu, M.D.; National Conference Alternate Delegate David Mullican, M.D.; Delegates to the TAFP Board of Directors Jamal Mohammed, M.D., and Matthew Brimberry, M.D.; and Alternate Delegates to the TAFP Board of Directors Irvin Sulapas, M.D., and Ike Okwuwa, M.D. : www.ta f p.or g | sp r i n g 2 0 1 1

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The Texas Academy of Family Physicians presents:

2 2011AnnualSession

{ &ScientificAssembly } 11 A S S A Sheraton Dallas Hotel :: Dallas, Texas Maximum of 24 AMA PRA Category 1 Credits™

For information contact TAFP at (512) 329-8666 ext. 36 or go to www.tafp.org

Join TAFP July 27 - 31 when the 2011 Annual Session and Scientific Assembly returns to one of the Academy’s favorite host cities, Dallas. All of the elements for the premier conference for primary care physicians come together at the Sheraton Dallas Hotel: informative CME events, entertaining special events, and plenty of time to get together with old friends.

CME topics that will be presented on Friday, Saturday, and Sunday include stroke, pediatric asthma, pain management, and diabetes.

Thursday afternoon seminars, free for Annual Session registrants, are Financial Realities for the Physician Manager, Pediatrics in Pictures, and Family Medicine Preceptorship and Medical Ethics.

Through seminars and lectures, attendees will be able to earn up to 24 credits of CME. Earn 16 Prescribed Credits by attending the National Procedures Institute Orthopedics for the Office workshop. In this workshop, attendees will learn specific clinical tests to evaluate each joint using evidence-based medicine guidelines;

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review imaging techniques used for evaluation; and practice exam techniques, joint aspirations, and injections. The NPI course runs all day Wednesday and Thursday. Can’t stay the rest of the weekend?

No problem. Annual Session registration is not required to attend this course.

Attendees can add the SAM Group Study Work­ shop on Health Behavior to their Annual Session education events. The SAM, or Self Assessment Module, is one requirement of the American Board of Family Medicine’s Maintenance of Certification.

At the one-day workshop on Wednesday, ABFM diplomates will discuss and complete the 60-question knowledge assessment portion of the module moderated by Clare Hawkins, M.D. To earn full credit, attendees should complete the clinical simulation online after the conference. Annual Session registration is required to attend the SAM. TAFP invites all members to attend commission, committee, and section meetings. During these meetings, family physicians come together to discuss cur-

July 27-31 Hotel Information rent issues facing their practices and patients and propose actions to the TAFP Board of Directors that then become Academy policy. Most meetings will be held on Thursday, with the board meeting on Saturday. To view descriptions of the different groups, go to the membership section of the TAFP website.

It’s not all work and no play at TAFP’s Annual Session. Each year, the family physicians of Texas enjoy spending time catching up at the many social events on the calendar. The festivities kick off in the Exhibit Hall, starting with breakfast on Friday. Hosted by the TAFP Foundation, attendees will have the opportunity to eat, drink, and socialize in the Exhibit Hall, surrounded by 70 of the leading companies in the fields of medical services, products, supplies, and information technology. Don’t forget to check out the Student, Resident, and Community Physician Research Poster Competition in the back of the hall.

These displays feature the best of family medicine research and will be available to view all day on Friday.

At Saturday’s Business and Awards Lunch, TAFP will reveal the 2011-2012 recipients of the Academy’s top honors including Family Physician of the Year, Physician Emeritus, the Exemplary Teacher Award, the Public Health Award, and more.

Plus, see the 2011-2012 installation of officers. The Members’ Reception Saturday evening honors all TAFP members, especially the 2011 award recipients, new physicians, special constituency physicians, medical students, and residents. It precedes the Academy’s premiere event of the year, the President’s Party on Saturday evening.

Try your luck at this year’s casino-nightthemed President’s Party, which will be held in the Chaparral Club on the 38th floor of the Sheraton Dallas Hotel. Enjoy a buffet dinner and musical entertainment, and congratulate outgoing President Melissa Gerdes, M.D., and welcome incoming President I. L. Balkcom, IV, M.D. So mark your calendar for TAFP’s 2011 Annual Session and Scientific Assembly as we celebrate family medicine in Dallas. :

The Sheraton Dallas Hotel is the perfect TAFP meeting destination with a $90-million renovation just completed and all meeting space and sleeping rooms under one roof. Soak up the scenery in the park-like lobby lounge, or enjoy a late-night drink in front of the fireplace. Relax at the new outdoor pool, located on the fourth floor of the center tower overlooking the city. In the evening, slip away to a rooftop cabana or patio for spectacular downtown views.

Room Rate TAFP has negotiated a special group rate at the Sheraton Dallas Hotel.

The room block is available until July 8, 2011, or until all rooms are reserved, whichever comes first. Single or double rate is $149 and is available July 23 - Aug. 3, 2011, if you’d like to extend your stay.

Remember to mention that you are with the Texas Academy of Family Physicians to receive this special group rate. For reservations, contact the hotel at (214) 922-8000 or visit www.tafp.org to book your room online. Cancellations made fewer than 30 days before the event will result in a fee of one night’s room charge plus tax.

Registration Information Visit TAFP online at www.tafp.org or call TAFP at (512) 329-8666, ext. 36.

Online you’ll find a complete CME schedule, a description of all special events, a schedule of committee and commission meetings, and a listing of Annual Session’s distinguished speakers.

If you register by June 30, this year’s rates are: • TAFP/AAFP members: ........................................................... $275 • New physician members (out of residency for 7 years or fewer): ............................. $200 • Non-member physicians, PAs, or other health professionals: ............................................. $375 • TAFP Life Members, and resident and student members: . ........................................................FREE These prices will increase by $100 after June 30. Register before the earlybird deadline to save. Space is limited and popular events fill fast, so call or visit www.tafp.org today.

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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!

TAFP Partners with Atlantic Health Partners 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.

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 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.

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.

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 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.

Taking New Steps

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

practice management

10 tips to maximize your time Editor’s note: Like many family physicians, Donald E. Stillwagon, M.D., of The Woodlands, Texas, must make the most of his time in the office so he can address patients’ needs and his administrative work, and still make it home at a reasonable hour.

Realizing that many family physician colleagues also struggle with a daily time crunch, he graciously offers his “ten commandments” for in-office time management to achieve a happier, more productive practice.

By Donald E. Stillwagon, M.D.

1 2 3

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I shall start on time. Catching up is much harder than staying ahead.

6

I shall walk into the exam room at the time of the patient’s appointment. Doing so will result in a greater likelihood of the patient requesting that the problem for which the appointment was made will be addressed and not additional items that he or she thought of while waiting.

I shall be proactive, rather than reactive, when considering the amount of time needed to complete tasks. Knowing how much time you will need to get back on schedule allows you to then block off slots ahead of time to get back on schedule (and get the work done).

7

I shall have reviewed the patient’s medical history prior to the patient’s appointment time. This will allow you to get to the point of the patient visit and not appear as if you do not recall what was done the previous visit.

I shall address the lab results on my desk at the beginning of the day before the time of my first patient appointment. Reviewing/addressing labs of patients seen the previous day takes seconds, rather than the minutes required for patients seen many days ago.

8

I shall ensure my medical record summary lines reflect what it is I need to know when addressing the patient next time. This will make No. 3 easier.

9

I shall keep the number of intra-office memos on my desktop to a single digit at any one time. Keeping tasks on the desktop that will not be addressed until some later date just creates clutter, making it difficult to locate what needs to be addressed today.

10

I shall spend more time with my family as a result of these tips. Remember that in “family practice,” “family” comes first and “practice” comes second. :

4

I shall step out of the exam room when time permits to be available to precept physician assistants and nurse practitioners. This allows you to maximize the down time while the patient is getting changed into a gown; you have the 1-2 minutes needed to precept.

5

I shall complete the prior day’s work before starting a new day and time. This may be at the end of the workday, or via a very early start on the following day.

s p r i n g 2 0 1 1 | T e x as Family P hysician

nutrition

courtesy of NATIONAL FOOTBALL LEAGUE and DAIRY MAX

Sam Bradford, NFL quarterback for the St. Louis Rams, volunteers with Fuel Up to Play 60.

Fuel Up to Play 60 and make a difference

By Teresa Wagner, M.S., R.D./L.D. Program Director, Dairy Max Incorporated

F

uel Up to Play 60 is an in-school nutrition and physical activity program launched by National Dairy Council and National Football League, in collaboration with the United States Department of Agriculture. The program encourages youth to consume nutrient-rich foods (low-fat and fat-free dairy foods, fruits, vegetables, and whole grains) and achieve at least 60 minutes of physical activity every day.

Research shows that kids who are well nourished and more physically active tend to have improved cognitive function, stronger academic achievement, increased concentration, and better test scores. The bottom line is that Fuel Up to Play 60 can help improve the health, achievement, and longterm well-being for students in schools.

Nutrition and health professional organization supporters include Action for Healthy Kids, the American Academy of Family Physicians, American Academy of Pediatrics, American Dietetic Association/Foundation, National Hispanic Medical Association, National Medical Association, and School Nutrition Association.

Fuel Up to Play 60 is designed to engage and empower youth to take action for their own health by implementing long-term, positive changes for themselves and their schools. Customizable and non-prescriptive program components are grounded in research and include tools and resources, in-school promotional materials, a website, youth challenges, and rewards.

• The ultimate goal is to ensure changes made at school are sustainable, making it possible for children to have more opportunities to be physically active and choose tasty, nutrient-rich foods throughout the school environment.

• Program advisors are a network of supportive adults in the school environment who volunteer to help guide youth involvement in the Fuel Up to Play 60 program.

Each school needs a program advisor.

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• Funding opportunities for Fuel Up to Play 60 are available to help schools and kids make healthy changes. The following are needed for physicians and schools to get involved and become childhood obesity community advocates.

1. A physician can become a program advisor for an enrolled Fuel Up to Play 60 school or work as a supporter with a school program advisor.

2. The school must complete the Fuel Up to Play 60 school wellness investigation.

3. The school must participate in the National School Lunch Program.

4. The school should have the backing and support of the school principal, school nutrition professional, and physical education department chair.

5. Students should be involved in program planning and participation.

6. Funds should be used to address both healthy eating and physical activity.

Sign up for the program by visiting www.FuelUpToPlay60. com. On the website, students can take a pledge, get involved in challenges, learn from other students, track their physical activity and healthy eating behaviors, earn rewards, and explore ways to get healthy and be active.

Adults can sign up to be program advisors or supporters. Schools can apply for competitive funding and find out which others are involved in Fuel Up To Play 60.

Remember that funding is competitive and based on the quality of the application and sustainability of the specific request. Find out more from your local Dairy Max representative at www.dairymax.org. : © 2011 NFL Properties LLC. All NFL-related trademarks are trademarks of the National Football League.

ExPAnd your MEdiCAl knowlEdgE through CoMPlEtE And innoVAtiVE CME

Pri-Med Access with ACP* June 10-11, 2011 Dallas Convention Center Dallas, TX September 16-17, 2011 George R. Brown Convention Center Houston, TX Join Pri-Med® and the American College of Physicians for an all-new CME curriculum that will explore advances in efficient, cost-effective diagnosis in primary care. It is taught by expert faculty, who are practicing clinicians as well as leading educators. The techniques, treatments, and therapies you’ll learn about at Pri-Med Access with ACP today will improve your patients’ health tomorrow.

Your medical education needs are unique.

But they reflect a common goal — to gain knowledge that helps patients.

Pri-Med® is committed to expanding your knowledge base through the most complete CME in the industry.

• Live conventions and seminars in cities across the United States.

• Continuously growing list of online CME activities addressing the latest research in multiple topic areas.

• CME Tracker to manage your learning online, easily track credits, and print a summary of credits and certificates earned.

Pri-Med is proud to Partner with Texas Academy of Family Physicians to bring quality education to family physicians.

Earn and manage your valuable CME credits through Pri-Med’s comprehensive live and online educational programs. © 2011 M/C Communications, LLC. All rights reserved. Pri-Med is a registered trademark and KnowLedge ThAT TouChes PATienTs is a trademark of M/C Communications, LLC. All other trademarks are the property of their respective owners.

For more information, visit us at Pri-Med.com/tafp or call 866-263-6998 (Mon-Fri, 9 am-8 pm et).

*These activities are sponsored by

® TM

TA FP p E R S PECTIV E

Work to support family medicine in new health care reform environment is just beginning

By Roland Goertz, M.D., M.B.A. AAFP President P assage of the P atient P rotection and A ffordable C are Act—commonly known as the Affordable Care Act, or simply PPACA—was an important step toward establishing primary care as the foundation of America’s health care system. The law will have a far-reaching impact on family medicine as the nation begins to rebalance our health care system with more appropriate emphasis on primary care.

Once fully implemented, it will focus more on health care and place a greater emphasis on prevention, primary care, and improved health outcomes instead of a predominately sickness care model which has focused on paying for procedures and volume.

The final vote and the signing of the PPACA was a first step. Now the task is implementation. And this is where the real work—and the real debate—begin.

Since its passage, the AAFP has focused on filling in the holes in the Affordable Care Act, preserving its primary care-friendly provisions, and ensuring support for primary care education that will help increase the number of future family physicians.

The effort has come on several fronts.

Your AAFP has worked aggressively with the Centers for Medicare and Medicaid Services, the new Health and Human Services Office of Consumer Information and Insurance Oversight, the Government Accountability Office, Federal Trade Commission, Food and Drug Administration, and several other federal agencies to ensure that regulations support the PPACA’s intent to rebuild our system on primary medical care and the primary care physician workforce.

We are working with Congress and the administration to preserve the modestly increased payment for evaluation and management codes that resulted from the elimination of consultation codes and are pushing for more. We successfully moved to expand the number of family physicians who qualify for Medicare’s 10 percent incentive payment for primary care services. And we continue to focus our efforts on a significant issue that the PPACA does not address—a permanent solution to the flawed Medicare physician payment formula.

Early PPACA insurance reforms concentrated on patient protections against such practices as rescinding policies when patients become ill, denying coverage to children due to pre-existing conditions, and placing caps on annual or lifetime benefits.

Now, policymakers in several federal agencies are focusing attention on accountable care organization regulations, and officials are consulting with your AAFP

leadership to develop them. For example, in a recent meeting with AAFP Board Chair Lori Heim, M.D., Presidentelect Glen Stream, M.D., and me, the recently-appointed Richard Gilfillan, MD, acting director of the CMS Center for Medicare and Medicaid Innovation—and also a family physician—turned to the AAFP for information on the cost efficiencies derived from the primary care patient-centered medical home. While Dr. Gilfillan understands the importance of PCMH as the most effective model for improving patient care and ensuring care coordination, he seeks further information on the model’s cost-effectiveness as the new CMMI develops new innovative payment programs.

Through meetings and correspondence with CMS Administrator Donald Berwick, M.D., we have made progress toward federal understanding that the AMA/Special Society Relative Value Scale Update Committee, commonly referred to as the RUC, should be augmented with an evidence review panel that includes employers and consumers who help identify whether medical services are valued appropriately.

At the same time, we have continued our strong advocacy efforts on Capitol Hill. We continue to take specific messages to key members of the U.S. House and Senate, successfully reducing the reporting requirements for primary care charges from 60 percent to 50 percent in order to qualify more family physicians for Medicare’s 10-percent primary care incentive payment. We also want Congress to maintain existing policy that eliminated consultation codes and, most importantly, permanently address the flawed Medicare physician payment system.

As a result of our meetings and communications with them, every member of Congress has been contacted about the need to stabilize Medicare physician payments and pass legislation to adequately pay for primary care services. They are turning to your AAFP for input into how we can affect these changes without increasing the federal deficit.

Our ultimate success depends on your continued participation with AAFP grassroots messages and with the 112th Congress. As members of the 112th Congress take their oath of office and settle in, we’ll continue to work proactively to ensure that family medicine is supported in all regulations. :

The final vote and the signing of the PPACA was a first step. Now the task is implementation. And this is where the real work—and the real debate—begin.

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s p r i n g 2 0 1 1 | T e x as Family P hysician

This article was first published in the winter 2011 issue of California Family Physician, a quarterly publication of the California Academy of Family Physicians.

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