Texas Family Physician Summer 2011

Blue Cross Launches Medical Home Pilot In Texas

DEDICATED TO THE DELIVERY OF QUALITY HEALTH CARE

V O L . 6 2 N O . 3 s u m m er 2 0 1 1

TAFP on the LEGE How Family PLUS: How To Renegotiate Your Managed Care Contracts AAFP To The RUC: We’re Watching You

Medicine Fared In The 82nd Texas Legislature

Get Ready For Change In HIPAA Electronic Transaction Standards

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Volume 62, No. 3

TEXA S

FAMILY PHYSICIAN summer 2011

F E A T U R E S 26 The economics of the medical home In this article from Texas Medicine, family physicians speak about their experiences in a pilot project by Blue Cross and Blue Shield of Texas that rewards them for improving quality and controlling health care costs.

By Ken Ortolon

20 Cover: The session of what might have been Now that the 82nd Legislature and the first called special session have concluded, we take a look back on a turn of events that delivered ideas to reform an unsustainable system while simultaneously cutting programs that nurture the physician workforce.

By Kate Alfano and Jonathan Nelson

33 RESEARCH: Characteristics of patients using extreme opioid dosages in the treatment of chronic low back pain

By Shannon Essler, Terrell Benold, M.D., and Sandra Burge, Ph.D.

30 PRACTICE MANAGEMENT: Learn to successfully renegotiate your contracts 38 TAFP PERSPECTIVE: The rise of large, integrated medical systems, and the drivers behind it

D E P A R T M E N T S

20

all photos: KATE ALFANO

24

6

FROM YOUR PRESIDENT: Family physicians must lead payment reform

8

IN THE NEWS: HIPAA 5010 switch happens in six months, are you ready? | Academy resources featured in new magazine section: “Did You Know?” | Announcing the 2011 Tar Wars poster winner | Physicians bring great economic benefit | AAFP calls for changes to the RUC

12

COMING SOON: Join TAFP for Oct. 1 payment reform summit

14

MEMBER NEWS: Harris County AFP names top honorees | San Antonio residency earns NCQA PCMH certification | Academy leader joins TMA Foundation board

18

ON TAFP.ORG: Meet June’s Member of the Month; New feature on www.tafp.org

Nothing’s as good as face-to-face.

Patients. Colleagues. Medical experts.

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

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

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

Register today at Pri-Med.com/access.

pmiCME

This program is sponsored by pmiCME.

Stay in touch!

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

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

TEXAS

FAMILY PHYSICIAN

from your president

SUMMER 2 0 1 1 V O L . 62 N O . 3

The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. Texas Family Physician is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.

Officers President 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 Erin Redwine Advertising Sales Associate Audra Conwell Contributing Editors Melissa Ayala Terrell Benold, M.D. Sandra Burge, Ph.D. Shannon Essler Anne McCrady W. Mike McCrady, M.D. Ken Ortolon Sheri Porter Bradley Reiner Subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727.

Subscriptions are $20 per year.

Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publica­tion of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by The Whitley Company, Austin, Texas.

Legislative Advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt.

Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 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 u m m e r 2 0 1 1 | T e xas Fami ly P h y si cian

Payment reform starts with family doctors

By Melissa Gerdes, M.D. TAFP President Adequate payment for primary care health services has long been an issue for family medicine. The absence of adequate payment has affected our specialty in numerous ways, including forcing physicians to see too many patients too fast, causing student interest in family medicine to decline, and leading practicing physicians into nonclinical careers. This migration of physicians away from family medicine has a negative effect on the public and our patients.

According to the Commonwealth Fund, countries that have a lower proportion of primary care physicians to patients have populations with higher morbidities and poorer health outcomes.

Our current payment system is volume-driven, where physicians are paid more for doing things to patients than for doing things for patients.

Research shows that doing more things to a patient does not automatically result in improved health outcomes.

In fact, such practice very often results in worsened health outcomes. How do we migrate away from the volume basis?

Many answers to this question are being debated at the national and local level.

Some options have been tested and have failed already. The leading ideas include pay-for-performance, comprehensive care payment, episodic payment, and shared savings. Many others abound. How does today’s family physician make an educated choice about which of these new payment systems, if any, he or she should engage? Over the next several months, your Academy will explore the various options.

Many physicians fear we are returning to a dreaded payment model: capitation.

Current thinking on payment reform, however, is vastly different from the capitation of the 1990s. Twenty years ago, capitation was a financial-risk term. Today, payment methodology ideas are based upon concepts like quality, service, efficiency, and collaboration. Emphasis is on episodes of care, diagnoses, and the degree of difficulty in caring for individual patients. Focusing

on these care aspects improves health outcomes; thus, care has higher value because better outcomes at lower costs are delivered.

Current payment reform ideas represent only partial solutions to the payment problem, however. For instance, under federal health care reform, primary care physicians get a 10-percent increase in payment. But these ideas do not address the true problem with payment, which is the fragmented and disorganized health care system. Broader concepts like clinical integration and accountable care organizations have emerged, but while they may improve care coordination and mitigate escalating hospital expenses, they will probably do little to improve payment for the average family physician.

Perhaps jumping to full system reform is just too much. Total reform of the health care delivery system represents massive cheesemoving in an industry that historically spends 17 years adopting new practices into daily usage. Are we doomed to receive only Band-Aid solutions, then?

The discipline of family medicine has actually tackled this question with its patientcentered medical home concept. While the PCMH has definitely proven to improve patient perception of health, provider job satisfaction, health care quality, safety and outcomes, and to reduce the total cost of care, the PCMH does not integrate the entire continuum of care (what the ACO structure hopes to do) very well. It is upon us, family doctors, to continue being leaders in this area. In the pursuit to improve our patients’ lives, we need to reach out to the other components of the health care delivery system (i.e. specialists, hospitals, rehab facilities, home health) and form collaborative relationships for better quality, safety, and experience. Then we will create an integrated system which provides value.

Higher value inherently includes cost efficiency, and only then will payment reform be achieved. :

This migration of physicians away from family medicine has a negative effect on the public and our patients.

Be the 1 P>otect 2 TO

Pregnant women need to know about the heightened risks the fl u poses to them and their babies. And there’s no health care provider they trust more than their OB/GYN. So it’s vital that you educate them about the risks of getting the fl u while pregnant, and tell them how safe and effective the fl u vaccine is for them and their babies.

Explain to your patients how the fl u puts them and their babies at unnecessary risk.

Offer a fl u vaccine to your pregnant patients, or refer them to a local pharmacy or health clinic.

Send your patients to Protect2.org or Protege2.org, and provide printed materials that answer questions about pregnancy, the fl u and the fl u vaccine.

Order free printed materials for your patients at Protect2.org/downloads.

new s br i efs

Prepare now for HIPAA transaction standards change Physicians need to begin preparing for the next step in the evolution of Health Insurance Portability and Accountability Act transaction standards. The compliance deadline for the HIPAA 5010 transaction standards is Jan. 1, 2012, and physicians who wait until the end of 2011 risk not being paid or having to pay a clearinghouse to convert transactions in 2012.

This change will affect family physicians and all other entities that electronically transmit health information, including claims submissions and patient eligibility inquiries. To help physicians prepare, the Centers for Medicare and Medicaid Services held a national testing day for the 5010 transaction standards on June 15. Another testing day will be available on Aug. 24.

The test day gives physicians, clearinghouses, vendors, and Medicare contractors an opportunity to identify and correct any problems they have sending or receiving 5010 transactions before the compliance

deadline. Physicians will also have realtime help desk support and immediate access to Medicare contractors.

What is 5010?

Under HIPAA, covered entities must conduct electronic transactions such as claims submission and eligibility inquiries in a standard electronic format. The current standard is 4010a. As of Jan. 1, 2012, all transactions must be transmitted using an updated standard, 5010. The 5010 transition is also an important first step to preparing your practice for the Oct. 1, 2013 change from ICD-9-CM diagnosis codes to ICD-10-CM. The 5010 format accommodates both ICD-9 and ICD-10 by including an indicator that identifies which code set is being transmitted.

Don’t count on a delay of the Jan. 1 implementation date. CMS has repeatedly stated that there will be no delay. As of May 17, 2011, CMS reports that all Medicare contractors are ready to conduct 5010 transac-

tions and have processed over 1,500 claims in that format already. CMS is also conducting periodic surveys of vendors, payers, physicians, and other providers to track transition progress. A March 2011 survey of vendors indicated that most are ready to upgrade their clients or soon will be.

What does this mean FOR ME? The system that you use to electronically submit and receive information will need to be updated and you will need to test the system’s ability to submit and receive 5010 transactions before the compliance date. This upgrade may be included in your system maintenance/support fees if your contract with the vendor includes HIPAA-mandated upgrades. If you are not using the current version of the vendor’s software, you may be required to upgrade to the newest version.

The good news is that as soon as your practice management software vendor completes the internal testing of their systems and provides your upgrade, you can begin testing with your Medicare contractor and/ or claims clearinghouse. Most private payers will not require individual practices to test since claims typically pass through a clearinghouse, but your staff should verify

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this for payers most common to your practice. Once you successfully transmit and receive test transactions, you can switch to 5010 and have no concerns about compliance on Jan. 1. Also, you do not have to wait until Jan. 1 to start conducting transactions in 5010 format.

There are a large number of changes in what data and in which order data is transmitted under 5010, and your staff will need to be trained on the information that must be entered into the practice management system. This may require changes to your practice information that goes out on claims, and also to the patient, dependant, other insurance, and encounter information. Your software vendor may provide information or training sessions on these changes. hOW should I prepare?

If you or your staff have not already begun working with your software vendor and any clearinghouses that receive your electronic transmissions, it is time to do so now. AAFP has a checklist for the associated tasks on its website, www.aafp.org.

Now may also be the time to consider adding electronic transactions that you are not currently utilizing. With the increasing number of patients who have high-deductible health plans and plans that will be required to cover preventive services under the Accountable Care Act, verification of eligibility and benefits prior to service is more important than ever. Did you know that your staff can check eligibility with the payer electronically in batches or by individual patient before the patient presents to the office?

If you are not currently taking advantage of electronic eligibility inquiry, now is a good time to consider adding this function. Other considerations are electronic remittance advice (some systems also include an automatic posting to patient accounts) and claims status inquiries.

Who can help?

Besides the support staff of your practice management system vendor, your Medicare administrative contractor and claims clearinghouse can provide you with information and assistance. Texas’ MAC is Trailblazer Health Enterprises. If your staff will be responsible for overseeing the change to 5010, please be sure they are aware of these resources.

CMS will provide information directly and through the MACs on a regular basis in 2011. CMS calls include question-andanswer time so that those unfamiliar with the topics or with specific concerns can get additional information. :

Nacogdoches, Texas – Partnership Opportunity for IM/FP

We are seeking a BC/BE internist or family medicine physician interested in joining a thriving, well-established practice, performing adult/pediatric medical care. Particular treatment areas include prevention and management of HPTN, AODM, hyperlipidemia, CAD and metabolic syndrome. Special interest in acute and chronic sinus disease, including allergy/immunology, is especially welcome, and physicians enjoy the convenience of an in-house lab.

This position offers shared call of 1:8 and partnership after one year.

Nacogdoches, the Oldest Town in Texas, is a full-service city actively stepping into the future with progressive development and an innovative attitude. Our friendly people, rich history, and comfortable lifestyle make Nacogdoches a great place to live and work.

For more information, please contact:

Ashley McNeil

800.678.7858 x64465 • amcneil@cejkasearch.com ID#137736TF

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Texas Family Physician Summer 2011 1/4 page KJS 137736 FM

The Texas Academy of Family Physicians in conjunc tion with UT M.D. Anderson Cancer Center presents:

tw o No lo w c a in ti oN O c tob e r 21 - 23 , 2011 s T he Wes tin Oak s Hous ton, Te xas and Novemb e r 11 - 13 , 2011 T he Wes tin Galle r ia Dallas, Te xas

2011 Primary Care Summit Ma x i mu m o f 2 4 . 5 A MA P R A C a te g o ry 1 Cr e dit s T M

For more information or to re gis te r go to TAFP.org

www.ta f p.or g | summ er 2 0 1 1

9

Did you know?

news briefs

Don’t have an MBA? Get business training from AAFP The three-part “AAFP Family Physician Mini MBA Resource Guide” provides quick-access resources on the business skills practicing family physicians wish they’d received in medical school or residency. The toolkit targets busy physicians who need to be better business managers but don’t have the time to pursue an advanced degree.

Section one applies to employed physicians, with topics ranging from the job hunt to employment contracts and privileging forms. Links connect readers to content on conflict resolution, teamwork, staff relationships, and how to balance work and home.

Section two focuses on basic management skills: a review of general principles of accounting; a rundown on financial statements; tips on operating a small business; and guidance on leadership principles, marketing, and negotiation.

The final section delves into advanced management skills including quantitative methods and economic principles that can affect a medical practice. Find resources on keeping a small business financially viable and improving the bottom line, and learn how to stay within the boundaries of everchanging state and federal regulations.

Download the toolkit from AAFP’s website: http://tinyurl.com/67fuw5v. :

AAFP has a new video series on the medical home AAFP’s patient-centered medical home video series gives you an insider’s look at how real family physicians are transforming their practices to meet the needs of their patients and grow with the evolving health care system.

The set of five videos covers a range of topics about the patient-centered medical home that apply to the full spectrum of family medicine practices: how to improve care with patient registries, patient self-management support, and the team-based care model; how to use data to improve your practice; and how to improve the patient experience.

All can be played on the website or downloaded to be viewed later. Next time you have 10 minutes to spare, watch one of AAFP’s latest videos at http://tinyurl.com/3orc6sq. :

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s u m m e r 2 0 1 1 | T e xas Family Physician

#1

TAR WARS:

We have a winner!

Congratulations to the 2011 Texas Tar Wars Poster Contest winner, Hady Hernandez of Houston, Texas, a fifth grader at Crockett Elementary. Hernandez’s poster, “Hang Tough, Don’t Puff,” was selected for the grand prize from many entries by a panel of TAFP members. Her message reinforces the anti-smoking mission supported by Tar Wars and the Academy.

Physicians generate trillions in economic activity

By Erin Redwine A study released in February shows the important contributions physicians make to the local, state, and national economies. “The State-Level Economic Impact of Office-Based Physicians,” published by the American Medical Association, illustrates the direct economic benefit office-based physicians provide through caring for patients and creating jobs, purchasing goods and services, and supporting state and community public programs.

Findings reveal the office-based physician industry supports $1.4 trillion in total economic output, 4 million jobs, $833 billion in wages and benefits, and $63 billion in total state and local tax revenues. Each officebased physician or physician practice generates an average $2.3 million in output, 6.2 jobs, $1.3 million in wages and benefits, and $100,000 in state and local tax revenues.

Compared to other industries, the study found office-based physicians to almost always generate a greater economic impact than the legal, college, home health, hospital, or nursing industries.

“Although physicians are primarily focused on providing excellent patient care, physician offices and the jobs and revenue they produce are significant contributors to national and state economies,” said AMA President Cecil Wilson, M.D., in an AMA

article on the study. “This study illustrates that office-based physicians contribute to both the health of their patients and also to the economic health of their communities.”

Texas has more than 42,000 practicing physicians, the second highest number in the country, making it one of the leading states supported by office-based physicians. In 2011, office-based physicians in Texas generated approximately $63.6 billion in economic output, $40 billion in wages and benefits, and $2.1 billion in state and local tax revenues. In 2008, Texas physicians provided almost $24.4 billion in charity care on a nationwide basis.

“Texans benefit directly when the state creates a positive practice environment for physicians,” according to a joint release by AMA and the Texas Medical Association. “By attracting and keeping physicians in the state, the people of Texas have better access to health care and a stronger state economy.”

Researchers analyzed more than 638,000 office-based physicians practicing in the United States as of October 2010.

Economic impact was measured across four variables: output, jobs, wages and benefits, and tax revenue. Both direct and indirect effects were included when calculating the total economic impact and data were used from three primary sources: the AMA masterfile, MGMA cost survey, and IMPLAN modeling system. :

Academy strongly urges changes in RUC structure, process AAFP task force will work on solutions for better pay for primary care

By Sheri Porter

Did you know?

AAFP took a bold step toward ensuring that the health care services provided by primary care physicians—and most importantly family physicians—are appropriately valued.

In a strongly-worded June 10 letter to Barbara Levy, M.D., chair of the AMA/ Specialty Society Relative Value Scale Update Committee, or RUC, AAFP Board Chair Lori Heim, M.D., of Vass, N.C., called on the committee to make changes in the RUC’s structure, process, and procedures.

Specifically, AAFP asked the RUC to add four additional “true” primary care seats to the committee, including one each for AAFP, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association; create three new seats to represent outside entities, such as consumers, employers, health systems, and health plans; include a seat for a representative of the specialty of geriatrics; eliminate the three current rotating subspecialty seats when the current representatives’ terms expire; and implement voting transparency among the RUC representatives.

“We request a decision from the RUC regarding the implementation of these changes

by March 1, 2012,” said Heim, adding that the RUC should have ample time to consider and make decisions regarding the requests during its next two scheduled meetings.

The RUC acts as an expert panel and makes recommendations to CMS on the relative values of CPT codes. Many family physicians and AAFP have expressed concern that the actions of the RUC are biased toward subspecialist procedures rather than preventive care and chronic disease management, leading to an undervaluation of primary care services.

“As you know, the AAFP has been concerned for some time about the composition of the RUC and the manner in which it conducts its business,” said Heim in the letter. “We continue to believe that the RUC would benefit from additional primary care expertise and the perspectives of other stakeholders in the health care system.”

Although the work of the RUC is very technical, additional representation from outside the physician realm would add a new and important perspective to discussion about the valuation of physician services, noted Heim.

In the same letter, the Academy said it intended to “create and fund a task force to review and make recommendations to the AAFP Board of Directors for an alternative methodology [or methodologies] to appropriately value evaluation and management services [provided] by family physicians and other primary care physicians.” The task force will include experts in both health policy and research and will be chosen from professionals working both within and outside of AAFP. Heim pointed to a growing body of research that “suggests the complexity of evaluation and management services provided by primary care physicians today is different and likely more ‘intense’ than the same services provided by other specialties.” The survey data that the RUC currently uses to value physician services should be complemented with other data sets so as to provide a more complete picture of how those physician services should be assessed across all physician specialties and subspecialties, said Heim.

The task force will make recommendations to the AAFP Board of Directors in the next six to nine months regarding alternative methodologies for valuing the health

AAFP HIT reviews can help you choose an EHR When considering implementing an electronic medical record, don’t you wish you could know which one will be best for your practice before making the investment? While predicting the future is impossible, AAFP has the next-best thing: a database where family physicians in a variety of practice situations share their personal experiences with purchasing an EHR. To help you find the best fit, AAFP’s physician product reviewer and EHR user direc-

tory gives you access to nearly 100 reviews searchable by regional availability, initial cost, hosting models, and operating system.

It’s easy: Go to AAFP’s Center for Health IT website, www.centerforhit.org, and select EHR reviews from the front page. It’s members-only, so you’ll need to log in with your AAFP username and password. Once on the form, check criteria that fit your practice and select “view results.” Or, choose to view all reviews and start your research.

care services provided by primary care physicians.

In an interview with AAFP News Now, Heim made it clear that the Academy was taking a proactive stance on behalf of family physicians.

“Our evaluation of the RUC puts the committee on notice that it needs to change its structure and process because, currently, neither works for family medicine,” said Heim. It isn’t enough to simply say the current system is not working. “It’s incumbent upon organizations like the AAFP to say ‘This is what we need to replace the old methodology.’”

Heim also made it clear that the Academy has worked diligently—albeit subtly—during the past several years to encourage the RUC to make changes. When it became clear that a stronger approach was needed, however, AAFP leaders changed course. “Our frustration with the RUC is not new, and family physicians know this.

What’s different now is that, for the first time, the AAFP is formally calling on the RUC to implement changes,” said Heim.

She acknowledged that some members have urged the Academy to withdraw from the RUC, but after much consideration and deliberation, the AAFP Board of Directors decided that taking such an action “would not be the best course for our members or for family medicine.”

“However, we did want to make very public some prominent changes that we think will improve the RUC’s function,” said Heim. “We’re calling on the committee to respond in a ‘time certain.’” : Source: AAFP News Now, June 10, 2011. © 2011 American Academy of Family Physicians.

The database simplifies the bulk of online information about EHR systems, and because it’s written by your peers in the Academy, it’s tailored to family medicine practices. Some reviewers even post their contact information in case you have follow-up questions or want to visit their practice.

Use this tool to find out what EHRs can offer and how they work in a real practice before taking the leap. Read Academy member reviews or submit your own at www.centerforhit.org. :

www.ta f p.or g | sum m er 2 0 1 1

11

comi ng soon

Payment reform is coming TAFP summit will help you prepare

by Kate Alfano

WHAT: Payment Reform Summit WHEN: Oct. 1, 2011, 9 a.m. – 4 p.m. where: Austin, at the Omni Austin Hotel at Southpark

A

s health insurance premiums continue to spiral upward and patients are forced to take on a larger share of their health care costs, pressure is mounting for policymakers and stakeholders to find real solutions for an unsustainable system.

“Something is going to give,” says family physician Mark Laitos, M.D., immediate past president of the Colorado Medical Society.

“According to our current payment and delivery system, the only tools that can put a lid on the inflation are either slashing fees or denying care. Doctors don’t like that and patients don’t like that either.”

He says physicians are in a unique situation to “take the lead, come up with our own proposals, and then work together constructively with the other stakeholders—the plans, the government, the employers—to figure out how to come up with something different from the old-fashioned system that we have that’s based on CPT codes and collecting RVUs.” This is exactly the type of forwardthinking action the Academy hopes to spark at TAFP’s payment reform summit, “Lead or Be Led: How to Thrive in the Evolving Health Care Delivery System.” At the one-day conference on Saturday, Oct. 1, experts from around the country—including Laitos—will share their strategy for success and vision 1 2

s u m m e r 2 0 1 1 | T e xas Family Physician

for the future, topping the event with a panel discussion to address attendees’ questions.

The topics speak to family physicians in all practice types and at any stage of practice transformation.

“When people think of payment reform, they’re thinking of something coming out of Washington associated with the Affordable Care Act,” Laitos says. “What I see is that … the commercial world, the employers in my community, the patients and the plans that they work with, they are going to demand significant change. This has nothing to do with federal legislation; this has everything to do with the business of medicine and how we are organized.”

Fellow speaker François de Brantes, M.S., M.B.A., executive director of Health Care Incentives Improvement Institute, Inc., says, “The key to success in this changing environment is the ability of the physician to manage the health of the entire patient population in the practice.” HCI3 runs the innovative Bridges To Excellence and Prometheus Payment pilots.

“That means, first and foremost, having systems in place to understand how well patients are currently doing compared to how well they could be doing. Then you need people and systems to track patients, reach out to them, and manage their health as effectively as possible.”

Also speaking are Christopher Crow, M.D., M.B.A., founder and president of Village Health Partners and founder of Legacy Medical Village in Plano; W. Mike McCrady, M.D., M.B.A., vice president of clinic operations at the Trinity Mother Frances Health System; Eduardo Sanchez, M.D., senior vice president and chief medical officer for Blue Cross and Blue Shield of Texas; AAFP President Roland A. Goertz, M.D., M.B.A.; Gregory Sheff, M.D., medical director of the Austin Regional Clinic Medical Home Program; Gary Piefer, M.D., CMO of WellMed in San Antonio; and Dan Stultz, M.D., CEO of the Texas Hospital Association.

No matter the final product, physicians will be integrally involved in the delivery and success of payment reform. Mounting evidence shows that the care primary care physicians provide—coordinated, high-quality, preventive medicine—can reduce costs and improve outcomes. Physicians must now arm themselves with the knowledge and tools to be leaders in the new system.

Make plans to join the Academy on Oct. 1 at the Omni Austin at Southpark in Austin, Texas, for “Lead or Be Led: How to Thrive in the Evolving Health Care Delivery System.” To read more about the payment reform summit and to register, go to www.tafp.org/advocacy/conference. :

NO.

th i ng s p hys ician s n e e d

7

to k n o w a b o u t i n s u r a n c e

At least 32 million U.S. households own insurance policies that aren’t right for them.

1

Make sure you have the right insurance to help you protect the life you’ve worked so hard to build.

1. Insurance Information Institute. “Changes in Your Life Can Mean Changes in Your Insurance, Says the I.I.I.,” Press Release, January 22, 2007.

Talk to a TMAIT Advisor about insurance for you, your family, and your medical practice. We can help you choose the right coverage from an array of plans, including medical, dental, vision, life, short-term disability, long-term disability, long-term care, and office-overhead expense.

Call 1.800.880.8181

contact@tmait.org

Request a quote at www.tmait.org

member ne w s

Harris County Chapter names Physicians of the Year and Physician Emeritus The Harris County Chapter of TAFP named the recipients of its top honors at their Scientific Dinner meeting in May. Physician Emeritus is Glen Johnson, M.D., and the Physicians of the Year are husband and wife John C. Rogers, M.D., M.P.H., M.Ed, and Jane E. Corboy, M.D. Physician Emeritus Johnson was named TAFP’s 2009 Physician Emeritus for his longtime service and commitment to the specialty. A former TAFP president and AAFP vice president, Johnson has over 28 years of health care experience in clinical practice, academic medicine and medical education, managed health care, and medical group management.

Johnson was awarded his medical degree

by Howard University in Washington, D.C., and completed a family medicine residency at Howard University affiliated hospitals.

Fresh out of residency in 1975, he started a family medicine practice in east Austin and began volunteering as clinical faculty at the newly opened family medicine residency pro-

gram at Brackenridge Hospital, later serving as interim residency director.

Throughout his career he has passionately advocated for vulnerable populations like Medicaid, CHIP, the uninsured, and the underinsured.

Physician of the Year Rogers currently serves as professor and executive vice chair of family and community medicine at Baylor College of Medicine where he has been on faculty since 1987. He is a pastpresident of the Society of Teachers of Family Medicine and has held faculty positions at the University of Washington School of Medicine, the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, and Rutgers.

Rogers was awarded his medical degree by the University of Iowa Medical School in Iowa City and completed a family medicine residency at the University of North Carolina School of Medicine. He completed a Robert Wood Johnson Family Medicine Fellowship, a master’s in public health at the University of

Washington, and a master’s in education at the University of Houston.

Physician of the Year Corboy is an associate professor and vice chair for education in the BCM Department of Family and Community Medicine where she has been on faculty since 1991. She also serves as director of the newly revitalized residency training track at Baylor Family Medicine, which accepted its first group of residents in July 2010. She was director of the residency program from 1997-2007.

Corboy was awarded her medical degree

by BCM and completed a family medicine residency at the University of Kansas in Kansas City. After residency, she fulfilled a National Health Service Corps scholarship, practicing full-scope family medicine at Nuestra Clinica del Valle, a community health center in the Rio Grande Valley. She served as the center medical director there in her last two years.

Rogers and Corboy both hold Certificates of Added Qualification in Sports Medicine, are certified in Advanced Wilderness Life Support, and are faculty sponsors of BCM’s Wilderness Medical Society student chapter. They have completed 27 marathons, and have backpacked, climbed, and rafted the trails, mountains, and rivers of four continents. :

Every 9-1/2 minutes someone in the US is

infected with HIV. The CDC recommends routine HIV testing in medical care settings for patients 13 to 64 years old.

Routine HIV testing is the first line of defense against HIV and AIDS. Learn more at

www.testtexashiv.org

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5/8/11 6:33:46 PM

Diabetes treatment team:

Physicians nurses Dietitians Podiatrists For Your Patients With Diabetic neuroPathY

send them to a Podiatrist

Today’s PodiaTrisT is a PodiaTric Physician, surgeon, and sPecialisT. The number of Americans diagnosed with diabetes continues to rise toward record levels: One in three adults are predicted to have the disease by the year 2050.

Up to 25 percent of people with diabetes will develop a foot ulcer, which can quickly escalate into an amputation.

Care by a podiatrist can drastically reduce the incidence of diabetes-related hospitalizations and amputations. (29 percent lower risk of lower limb amputation and 24 percent lower risk of hospitalization).

Make a podiatrist a part of the diabetes management team for your patients.

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2/25/11 1:53 PM

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San Antonio residency program receives NCQA medical home certification Million-dollar HRSA grant to aid in implementation

By Erin Redwine The Christus Santa Rosa Family Medicine Residency Program in San Antonio was certified as a level-3 patient-centered medical home by the National Committee for Quality Assurance, making it the first practice in Bexar County and the second residency program in Texas to receive this recognition.

Level-3 is the highest certification level awarded to physician practices that attain the NCQA standards of the medical home, which include evidence-based guidelines for chronic conditions, patient self-management support, performance reporting and improvement, and care coordination.

“This is the realization of a project we have been working on at our clinic for almost three years now,” says Associate Residency Program Director David Ortiz, M.D. “We set up our program and teaching clinic up to be a patient-centered medical

home so that when our residents graduate to be practicing physicians they will already understand what a patient-centered medical home is and how to carry it out.”

A report recently released by the Patient-Centered Primary Care Collaborative found that PCMH demonstrations increased the quality of care and reduced the cost of care. “With this model we can start partnering and work together to take better care of our patients, and share in the cost savings,” Ortiz says. “We can work with hospitals, health systems, and payers to bend the cost curve in health care.”

NCQA says its ultimate goal for the PCMH initiative is to improve primary care.

Christus seeks to accomplish that with quality improvement projects and surveys, teams working together to solve problems and track care over time, and by coordinating care to reduce costs.

2011 Primary Care Update Improving Patient Care

October 16-18, 2011 New Orleans Marriott New Orleans, Louisiana

October 15, 2011 SAM Study Group on Preventive Medicine

The Interstate Postgraduate Medical Association designates this live activity for a maximum 24 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For Information & Registration Visit www.ipmameded.org 1 6

s u m m e r 2 0 1 1 | T e xas Family Physician

The first residency program to receive this recognition in Texas was the Memorial Family Medicine Residency Program in Sugar Land, Texas, led by Residency Director David W. Bauer M.D., Ph.D. Ortiz says that the Memorial program’s success inspired them to seek the certification.

“Our mission is that every residency program in the state of Texas would eventually get this recognition to show that they are committed to quality improvements and to confirm the success of the practice.”

In addition to the NCQA certification, the Christus residency program was awarded a five-year, $1.6 million-dollar grant through the Health Resources and Services Administration’s Training Programs in Primary Care initiative. Christus will use the funding to develop and implement residency curriculum to teach the complex care model of treating chronic diseases, and to employ a complex care manager to reach out to at-risk patients to manage their conditions before they worsen.

“We are excited about both of these awards because they are separate but related in that they are trying to provide better care for patients,” Ortiz says. “With these tools we can really go out and improve the health care system.” :

Family physician elected TMA Foundation Board secretary T. David Greer, M.D., a family physician in private practice in Henrietta, Texas, has been elected to serve a two-year term as secretary of the board of trustees of the Texas Medical Association Foundation.

The TMA Foundation raises funds for TMA initiatives to improve the health of all Texans. The board comprises TMA physician members, TMA Alliance members (volunteers who are TMA members and members’ spouses), medical students, and community leaders from across the state.

A recipient of TAFP’s Family Physician of the Year award, Greer has a long history of leadership within the medical community. Among his many commission and committee positions in TAFP, he has served as chair of the Commission on Legislative and Public Affairs and is a member of the Academy’s Board of Directors.

He has served on TMA’s Patient-Physician Advocacy Committee as well as TMA’s Political Action Committee, and has been a donor to TMAF since 1994. :

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Academic physician’s love of fitness inspires community involvement June’s Member of the Month: Christine Criscuolo Higgins, M.D. between. I’m always learning and never stop being amazed by the breadth of family medicine, the intricacies of the human body, and the power of the human spirit.

Left: Christine Criscuolo Higgins, M.D. Right: Higgins crosses the finish line at her most recent Ironman triathlon.

C

hristine Criscuolo Higgins, M.D., is a clinical faculty member and the curriculum director for the Christus Santa Rosa Family Medicine Residency Program in San Antonio.

In addition to teaching residents, she combines her family medicine background, love of fitness, and compassion for the indigent in her service as a member of the San Antonio Active Living Council, a coalition group led by the mayor that aims to reduce the incidence of childhood obesity in the city.

Higgins received a Bachelor of Arts in Communications and Theater from the University of Notre Dame in South Bend, Ind.; she was awarded her medical degree by the University of New Mexico School of Medicine in Albuquerque, N.M.; and she completed her family medicine residency at Christus Santa Rosa where she was chief resident. She completed an Academic Medicine Fellowship at the Faculty Development Center in Waco, Texas, before joining the faculty at Christus.

Between her undergraduate and medical education, she spent a year volunteering

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with AmeriCorps VISTA—a national service program—providing community services, emotional support, and various resources to the indigent population of Delaware County. She is a member of AAFP, TAFP, the Society of Teachers of Family Medicine, and Bexar County Medical Society.

In her spare time, Higgins trains for long-distance athletic events, and has completed four Ironman triathlons—a threeleg race encompassing a 2.4-mile swim, a 112-mile bike ride, and a 26.2-mile run. She also enjoys traveling and spending time with family and friends. She is married to Russell, a hematopathologist.

Here are her responses to TAFP’s questions from the Academy’s new Member of the Month feature on www.tafp.org. ► I chose family medicine because … it never gets boring! I get to do something different every day, ranging from delivering a baby, performing sports physicals for the local high school, providing diabetic education in my clinic, treating a severely ill patient in the ICU, and everything in

► How does your experience as a family physician benefit your interaction with and contribution to the fitness council?

I practice and teach medicine at the only charity-based hospital in San Antonio, Christus Santa Rosa, in an underprivileged part of town. I’m acutely aware of the challenges that face many of San Antonio’s underserved population—lack of health insurance, lack of access to health care, lack of access to safe places to exercise, and limited knowledge about how to make healthier food choices that fit within their cultural traditions and financial constraints. As an athlete, I’m also conscious of what many San Antonio residents crave—more bike routes with bigger bike lanes; more parks with shaded trails and playgrounds; and more community-sponsored races, training groups, and fitness programs, so Bexar county residents can find the support they need to maintain their health gains. ► How has your experience been teaching residents?

I don’t know who learns more—me, or the residents I teach. They definitely keep me accountable for staying current and evidenced-based. There are many times when a resident asks me a question and we wind up looking up the answers together. And while residents might not always remember all the content of their lectures, they do recollect the tone, body language, and underlying character of their teachers. So I strive to maintain high personal standards worthy of imitation. ► What advice would you give third-year residents transitioning to become new family physicians?

Challenge yourself daily. Just because you’ve graduated from residency doesn’t mean that you won’t still have to work hard, that you won’t sometimes be nervous or scared, or that you’ve learned everything.

► How can we attract more medical students to family medicine?

Exposure, exposure, exposure! It’s difficult to put into words the relationship a family doctor has with her patients and their families, especially when she treats multiple generations within one family. It’s also hard to describe that being a good family physician is not just a job, but a way of life. But once a student has spent some time with such a physician in her clinic, watches how she interacts with her patients, and sees the satisfaction on both the physician’s and patient’s face at the end of their visit, the student knows he’s witnessed something special and often wants to be a part of it.

“I’m acutely aware of the challenges that face many of San Antonio’s underserved population—lack of health insurance, lack of access to health care, lack of access to safe places to exercise, and limited knowledge about how to make healthier food choices that fit within their cultural traditions and financial constraints.”

Member of the Month TAFP launches program to recognize outstanding family physicians TAFP is proud to present a new section of QuickInfo e-newsletter and the TAFP website dedicated to honoring outstanding Texas family physicians. Through Member of the Month, launched in February, your Academy profiles a TAFP member each month who is working above and beyond to advance family medicine in his or her community. Each article features a short biography and question-and-answer section that highlight the physician’s unique approach to medicine.

If you know an outstanding family physician colleague who you think should be featured as a Member of the Month, nominate the physician by sending his or her name, phone number, and e-mail address to kalfano@tafp.org. To view past Members of the Month, go to www.tafp.org. View excerpts below.

Meet our past Members of the Month

► How do you spend your free time?

I find exercise to be extremely therapeutic.

It clears my head and helps me feel strong and confident, both physically and mentally.

It makes me a more effective person in all the activities of my day. Subsequently, I spend a lot of time outdoors running, biking, hiking, swimming, and practicing yoga. I’ve completed four Ironman triathlons and even a 100mile ultramarathon. I love spending time with my husband and our two big dogs. Oh, and I really love eating at new restaurants or experimenting in the kitchen with new recipes. ► If you weren’t a doctor, what would you want your job to be?

That’s easy. I’d be a film editor. My college degree is in film and video production.

I’d love to edit movies and documentaries.

I find it fascinating how the same footage can tell so many different stories just by the way the frames are cut and pasted together.

Music and images have an amazing power to motivate and film editing is just one way to harness that power. Or a wedding planner—everybody loves weddings! :

February Chrisette Dharma, M.D. | Dallas, Texas Presenting our inaugural Member of the Month “I inherited my practice from an amazing woman named Dr. Fannie Clark who, back in the days of segregation, saw African-American patients.

She sold me her practice, charts, equipment, and receivables for $10.

The only thing she asked of me was that I take care of her patients.”

March Howard Brody, M.D. | Galveston, Texas Galveston physician educates patients, promotes specialty through writing “My own approach to medical ethics and humanities is always based on insights and perspectives I have gained as a result of my being a family physician, and I think it has proven to be a strong combination.”

April Loren S. Lasater, M.D. | Roanoke, Texas Physician invigorates practice through military service “My time working with our American soldiers and their families has been an incredible experience. Our American men and women in uniform are true patriots who have all volunteered to help our country during very difficult times and it is very gratifying to work in service to them.”

May Julie Graves Moy, M.D., M.P.H. | Austin, Texas Physician explores many sides of family medicine “I have had a varied and interesting, but non-traditional career. I’ve been able to practice in the academic setting as medical school and family medicine residency faculty, in private practice as a hospitalist, and do contract work in emergency medicine. Additional training in public health allowed me to work for the state health department in infectious diseases, Medicaid, and the Children with Special Health Care Needs program.”

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:

COVER STORY

Good News Bad News

TAFP’s recap of the 82nd Texas Lege

BY KATE ALFANO & JONATHAN NELSON

or health care reform advocates, the 82nd Texas Legislature will go down as the session of what might have been. More than previous sessions, lawmakers seemed to get it, and they crafted bills that could put Texas at the forefront of innovation in high-quality, cost-effective health care delivery. Yet lawmakers simultaneously adopted a budget that slashes critical funding to educate and train vital health care professionals and could debilitate the state’s primary care infrastructure.

“The good intentions of the Texas Legislature to improve the state’s health care delivery system were thwarted by their refusal to invest in the production and support of the state’s health care workforce,” says TAFP CEO Tom Banning.

Legislators entered this session with ideas to address the three most pressing problems bedeviling health care delivery across the country: cost, quality, and access. For weeks, committees held hearings at which lawmakers decried the inadequacies of Texas’ fractured health care delivery system and championed the tenets of efficient, high-quality systems. Communities with ready access to primary care physicians in a well-coordinated delivery system experience better health outcomes for less money.

They crafted a reform bill that would employ free-market principles to encourage better coordination of care between doctors, hospitals, and other caregivers, aligning financial incentives to keep patients healthy and out of the most expensive care settings. Measures in the bill held great potential to drive down the costly variations in the care patients receive across the state, reduce medical errors resulting from miscommunication, and improve outcomes, therefore increasing the value of the state’s health care resources.

After failing to pass in the regular session, the bill was resurrected in a special session, although the chances that its provisions will

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succeed in practice had already been undermined by budget-writing that neglected to include projected caseload growth in health and human services programs like Medicaid and that crippled the programs that produce our primary care physician workforce.

The Bad News

The budget was the theme of the session. Fully aware of the multibillion-dollar deficit in general revenue, state leaders made it clear from the beginning that they would not seek additional state revenue or use the estimated $9.6 billion in the state’s savings account, the Rainy Day Fund, to pay for the next biennium’s budget.

That meant enacting severe cuts across every area of state government, particularly the two biggest, as Sen. Steve Ogden, R-Bryan, warned in his speech on opening day in January.

“If you look at our budget with respect to education and health and human services—article II and article III—81 percent of all the general revenue that we appropriate is appropriated in article II and article III. It is impossible to balance this budget without making cuts in article II and article III.” Before the end of the regular session, both the House and Senate approved a budget for 2012-2013 that spends $15 billion less than the budget for the current 2010-2011 biennium, a decrease of 8.1 percent. The Health and Human Services Commission says the budget underfunds Medicaid by at least $4.8 billion and that the program will run out of money by May 2013. The budget also shorts public schools by $4 billion, according to the state’s current school finance formulas. All efforts to change the formulas failed in the final days of the session, leading to the immediate call for a special session.

all photos: KATE ALFANO

F

“Clearly, hospitals are financing a disproportionate share of the state shortfall. Unfortunately the budget situation could be even worse in 2013 because lawmakers wrote an IOU for Medicaid caseload and cost growth, and were unwilling to address the structural deficit in the business margins tax, which takes in less revenue than the state pays out for property tax relief.”

— John Hawkins, Texas Hospital Association

Overall, health and human services took the biggest hit, with almost $11.3 billion in cuts from state and federal funds. Federal funds make up the bigger loss due to the expiration of federal stimulus dollars and the associated 10-point decline in the federal Medicaid matching rate, says John Hawkins, senior vice president of advocacy and public policy for the Texas Hospital Association.

While Medicaid provider rates were not reduced for physicians, nursing homes, and mental health services, hospitals received an 8-percent Medicaid rate cut on top of the 2-percent reduction already in place for 2012-2013.

“Clearly, hospitals are financing a disproportionate share of the state shortfall,” Hawkins says. “Unfortunately the budget situation could be even worse in 2013 because lawmakers wrote an IOU for Medicaid caseload and cost growth, and were unwilling to address the structural deficit in the business margins tax, which takes in less revenue than the state pays out for property tax relief.”

“The cuts in Medicaid—coupled with a 23-percent reduction in trauma funding—will curtail growth in the health care sector, lead to more unemployment, increase costs to those with health insurance, require higher local taxes, and reduce access to health care services in communities statewide.”

With much of the attention directed toward public education, higher education sustained about $1.2 billion in cuts from general revenue.

Medical schools will receive about $280 million less in medical student formula funds, and about $25 million less in graduate medical education formula funds. Funding administered by the Texas Higher Education Coordinating Board for primary care residency programs was slashed by almost 80 percent, leaving just $2.8 million per year for the state’s 29 family medicine residencies. Altogether, the state cut its support for graduate medical education by $47.4 million, or 39 percent.

The Good News

Despite these seemingly paradoxical budget tactics, medicine did celebrate several wins in the areas of licensure reform, scope of practice, and public health.

The IMG licensure bill, House Bill 1380 by Rep. Vicki Truitt, R-Keller, and Senate Bill 1022 by Sen. José Rodríguez, D-El Paso, passed both chambers before the end of the regular session and was signed into law on Friday, June 17. The law permits international medical graduates to receive a medical license after two years of residency instead of three, removing the barriers to licensure for these physicians and allowing them to start caring for patients as quickly as graduates of U.S. medical schools.

It removes the incentive for practice-ready, Texas-trained physicians to leave the state in search of employment and it removes related credentialing delays to allow them to be paid, keeping more Texas-trained physicians in the state and thus improving Texans’ access to care.

Featured in the last issue of Texas Family Physician, Cephas Mujuruki, M.D., an international medical graduate from Zimbabwe and current chief resident at the Texas Tech University Family Medicine Residency Program in Amarillo, said he would like to stay in the state where he trained, but had to consider the well-being of his wife and young son.

“Before this bill we had to make a difficult choice between staying in the state we love and facing financial difficulties until finishing licensing, or moving to another state and starting over but having that financial security from the beginning,” Mujuruki says. “We no longer have to face that difficult choice, and we no longer have to look outside Texas. We can simply stay here.” www.ta f p.or g | summ er 2 0 1 1

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¶ Three bills aimed at granting nurse practitioners independent diagnosis and prescriptive authority failed to beat House deadlines and died in the regular session. H.B. 915 by Rep. Wayne Christian, R-Center, and H.B. 708 by Rep. Kelly Hancock, R-North Richland Hills, were never voted out of the House Public Health Committee.

H.B. 1266 by Rep. Garnet Coleman, D-Houston, and Rep. Rob Orr, R-Burleson, which would have required a legislative interim study, was not scheduled for debate by the House before the deadline for bills to be heard on first reading.

The scope of practice bills were defeated thanks in part to the hard work of several TAFP members and TAFP’s partners in organized medicine. On April 21, 2011, so-called “scope day,” the House Public Health Committee heard the three bills in a marathon committee meeting that began after 7 p.m. on Wednesday and didn’t adjourn until 5 a.m. the next morning. TAFP member Tricia Elliott, M.D., of Galveston, and Texas Pediatric Society member Gary Floyd, M.D., of Fort Worth, were at the hearing into the wee hours to provide testimony on behalf of TAFP. Elliott, director of the University of Texas Medical Branch Family Medicine Residency Program, stood before the committee just before 3 a.m. to testify against H.B. 915 and H.B. 1266.

“Twelve years ago, I completed my residency program in the Bronx in New York, in the inner-city, underserved area, and I also practiced in that community for several years,” she said, adding that during that time she worked closely with nurse practitioners.

“They are a valuable part, a critical part of our health care team, but they must work with us collaboratively.”

Nurse practitioner organizations will not give up on their pursuit of independent practice in Texas. TAFP will continue to oppose such expansion during the legislative interim and when the next round of scope bills is filed in the 83rd Legislature in 2013.

In public health, S.B. 1107 by Sen. Wendy Davis, D-Fort Worth, was signed into law on May 27. The law requires students entering Texas colleges and universities to receive a bacterial meningitis vaccination, expanding existing law that requires the vaccination of students who will live in on-campus housing. Now all students must show through vaccine certificate or immunization record that they received the vaccination dose or booster within a certain period of enrollment. It excludes students enrolled in online courses or those older than 30, and parents may apply for an exemption.

Also signed into law on May 27, H.B. 3336 by Rep. Coleman, and Sen. Robert Deuell, R-Greenville, requires staff in the hospital setting

Budget slashes 80 percent of support for programs designed As lawmakers crafted and passed innovative, market-based health delivery system reforms designed to increase clinical integration, care coordination, and disease management, all the while touting the cost-saving and quality-improving benefits of primary care, the Legislature slashed total state support for graduate medical education by almost 40 percent.

Lawmakers reserved the most drastic cuts for a set of programs administered by the Texas Higher Education Coordinating Board specifically designed to support the recruitment and residency training of family physicians and other primary care physicians, and to encourage them to practice in underserved communities throughout the state. The Legislature cut the line item supporting family medicine residency programs by 73.6 percent, going from $21.2 million in the current biennium to $5.6 million in the next. Two other line items for residency training were eliminated, as was all funding for the Statewide Primary Care Preceptorship Program.

Finally, the state’s new Physician Education Loan Repayment Program, created by the last Legislature, was cut from $23.2 million in 2010-2011 to $5.6 million in 2012-2013. According to analy-

FY 2012-2013 Texas budget overview in millions

sis by the Texas Primary Care Office at the Department of State Health Services, this reduction could affect health care access for 1.1 million Texans in underserved areas.

Altogether, the budget decisions for these programs constitute a withdrawal of $39.8 million, or 80 percent, in the state’s investment in the production of its primary care workforce.

“I think it’s tragically shortsighted,” says TAFP member Dana Sprute, M.D., M.P.H., residency program director at the University of Texas Southwestern—Austin Family Medicine Program. “At a time when we should be advocating for not just supporting what we already are doing but expanding the number of primary care GME slots, we’ve actually cut it.”

Sprute says the state already doesn’t have enough residency training positions to produce enough primary care physicians to care for Texas’ growing population. “By defunding GME slots, and primary care specifically, they’ve made this circumstance worse. We’ll have an even further brain drain out of our state where we pay to educate medical students only to send them out to other states for residency training because we haven’t been able to meet the need for expanded GME slots. In fact, this will have the effect of contracting them, I’m sure.”

Funding for primary care residency training administered by the Texas Higher Education Coordinating Board

$60M Health and human services $54,206.5 (31.0%)

Total = $172.345 billion Education $75,597.6 (43.3%)

General government $4,291.2 (2.5%) Other $4,067 (2.3%)

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Business and Public safety economic development Natural resources and criminal justice $24,368.3 (13.9%) $3,158.4 (1.8%) $11,430.8 (6.5%) s u m m e r 2 0 1 1 | T e xas Family Physician

$50M $40M

$51.7M $20.6M

$26.8M $21.2M

$30M

Total THECB GME funds for primary care residency training Family Practice Residency Program THECB budget line item

$20M $10M

$5.6M

0 FY 02-03 FY 04-05 FY 06-07 FY 08-09 FY 10-11 FY 12-13

to provide information about pertussis to all new parents, including the availability of the pertussis vaccination and the CDC recommendation that parents receive Tdap during the postpartum period to protect newborns from the transmission of pertussis.

A bill to require health care facilities to develop and implement vaccination policies for employees did not pass during the regular session, but did pass in the special session as part of a larger health reform bill.

TAFP past president Erica Swegler, M.D., of Keller, testified in support of the regular session bill, S.B. 1177 by Sen. Jane Nelson, R-Flower Mound, at a May 18 hearing of the House Public Health Committee.

Swegler said the measure prevents health care workers from unknowingly spreading flu and other preventable diseases to patients in their care. “Numerous published medical studies show that when health care workers are immunized, patient mortality is reduced by nearly 58 percent,” she said at the hearing. “Additionally, evidence shows that preventing influenza reduces patient hospitalizations and death from heart, chronic lung, and kidney disease, and diabetes, so this is really a critical patient-safety issue.”

On the defensive front, measures to repeal school-based fitness measurements and end health education were defeated in the regular session, but reappeared in the special session. Amendments

to an education bill known in the regular session as H.B. 400 by Rep. Rob Eissler, R-The Woodlands, aimed to remove or reduce Fitnessgram annual fitness testing in grades 3-12, remove coordinated school health programs, and remove or reduce physical education or health requirements as a means to cut spending in public schools. As passed in the special session, only children in PE courses must participate in the Fitnessgram assessment.

According to Carrie Kroll, chair of the Partnership for a Healthy Texas, this means that fewer Texas high school students will participate in the fitness assessment and those who do will only participate during one year. Middle school students will participate one less year than current PE requirements. “While the most devastating proposals impacting nutrition and obesity policy weren’t successful, cuts were made and the true impact of those changes may take time to feel,” Kroll says. “It is clear, however, that a good majority of the legislators in the House aren’t aware that Texas has been in the forefront among states developing nutrition and obesity public policy, to the benefit of our children and taxpayers. It’s up to the champions of these issues to provide this necessary education in the interim.”

to increase primary care physician workforce TAFP CEO Tom Banning expressed similar sentiments to the Texas Tribune in June, adding that the cuts would likely lead to the closure of some of the state’s 28 family medicine residency programs. “We’ve already seen two family medicine programs close over the last four years. We will have fewer physicians caring for Texas patients at a time we need to be growing that physician base.”

In a survey of family medicine residency programs receiving funds through the THECB, seven programs reported their existence would be threatened if the coordinating board funding were eliminated.

The severe reduction will spell the end of the Family Practice Faculty Development Center, which has been training faculty for family medicine residency programs since 1978. Located in Waco, the center receives the majority of its funds from the THECB through the Family Practice Residency Program budgetary line item.

The coordinating board uses another portion of those funds to support rural and public health rotations, through which residents experience one-month rotations in practices serving communities in need. The Legislature established the rural rotation program in

Programs designed to recruit and train primary care physicians

$60M

$51M

$11.2M

$50M $40M

$23.3M $859,000

$30M

Total state support for GME training

Physician Education Loan Repayment Program

$120M

Texas Statewide Primary Care Preceptorship Program

$100M

THECB GME funds for primary care residency training

$20M $10M 0

1989 to increase access to family medicine in underserved communities, and it has had measurable success. In the last 15 years, about 82 family medicine residents on average have participated in the program each year. Approximately 15 percent of the program’s participants since 1991 are practicing today in a rural community in Texas, with 14 percent serving in counties with less than 50,000 people.

For the next two years, there will only be enough funds for about 20 residents to participate in the rural rotations. Sprute says her program has required all residents to complete rural rotations for years and that many have gone on to practice in underserved communities. “We’re not able to send people to the rural rotation anymore because we don’t have the ability to pay for it,” she says. “So fewer residents will be exposed to rural medicine, making worse the health professional shortage areas that we have.”

The Legislature directed the THECB to conduct an interim study on the adequacy of the state’s GME capacity to produce an appropriate number of physicians of each specialty. That should be an interesting study, to say the least.

$5.6M $5.6M

FY 10-11 FY 12-13

$26.8M

$80M

GME formula funding $5.6M $5.6M

$60M $40M

$26.8M

Total THECB GME funds for primary care residency training

$79.1M $53.9M

$20M 0 FY 10-11

FY 12-13 www.ta f p.or g | summ er 2 0 1 1

23

¶ The Late Edition

Gov. Rick Perry called the special session the evening of the last day of the regular session, directing legislators to return at 8 a.m. the next morning to work on two outstanding issues: school financing and Medicaid reform. As was the case with the first called session, special sessions can last a maximum of 30 days. They can only address legislation listed on the call, though bills’ relevancy to the call is determined by each chamber, and the governor can and did add additional issues since the original proclamation, including redistricting and immigration.

The special session presented the opportunity for many bills to be brought back for consideration. This included the state’s health reform bill, which became an omnibus health and human services efficiencies bill encompassing elements of the regular session’s S.B. 23, S.B. 7, H.B. 32, H.B. 3537, and S.B. 8, plus other provisions.

Proponents believe the bill saves money in Medicaid and the Children’s Health Insurance Program by expanding Medicaid managed care into South Texas and creating incentives for doctors and hospitals to form “health care collaboratives” that provide coordinated, more efficient care. It takes steps to improve access to afterhours medical care and reduce emergency room use for non-emergent care. The Legislative Budget Board estimates that measures in the bill could save $468 million over the next biennium.

“Every day that goes by that this is not implemented, we are losing money,” bill author Sen. Nelson told fellow members of the Senate Finance Committee in a hearing on June 2. “We keep using a word that I want to remind everybody of and that is ‘unsustainable.’

Our Medicaid cost trends are unsustainable so we need this bill, but we don’t just need it for [cost savings]. It truly does improve the Sharps_TAFP Half Page Ad_06.08.11.qxd:Layout 1 6/8/11 quality of our system and creates a more efficient system.”

“It is clear that a good majority of the legislators in the House aren’t aware that Texas has been in the forefront among states developing nutrition and obesity public policy, to the benefit of our children and taxpayers. It’s up to the champions of these issues to provide this necessary education in the interim.”

— Carrie Kroll, Partnership for a Healthy Texas

On the next-to-last day of the special session, the Legislature finally passed the bill, sending it to the governor’s desk where it’s likely to receive his approval.

Moving forward, TAFP’s Banning encourages stakeholders to stay engaged to help build the case for family medicine in preparation for the 83rd Legislature. “Texas must invest in educating, training, and producing the primary care physician workforce the state so desperately needs so that the laudable goals of the reform legislation— improved quality of care at a lower cost—can be realized,” he says.

“Over the interim we will need to redouble our efforts to show the cause and effect of the Legislature’s funding decisions. We need to methodically document the downstream cost increases and 4:26 PMemergency Page 1 room utilization.” : higher

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s u m m e r 2 0 1 1 | T e xas Family Physician

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www.ta f p.or g | summ er 2 0 1 1

25

MED I C A L E C O N O MICS

P Finding a home

Blue Cross medical home pilot targets quality, costs

By Ken Ortolon Senior Editor, Texas Medicine

First published by Texas Medical Association (May 2011).

Reprinted with permission.

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lano family physician Christopher Crow, M.D., M.B.A., says Village Health Partners, the 10-physician primary care group where he practices, was built on giving patients access to care, convenience, and quality.

So he says it was only natural for him and his colleagues to get on board when Blue Cross and Blue Shield of Texas asked them to participate in a pilot program to measure how effective a patient-centered medical home could be at improving quality and controlling health care costs. The medical home model “is basically how our model has always been at Village Health Partners,” Crow says.

The pilot couples what some are calling “aggressive care coordination” by participating physicians with extensive feedback from BCBSTX on several quality and patient satisfaction measures. Practices get a per-patient-per-month care management fee and share in whatever savings are achieved if they hit the cost and quality benchmarks. The fees and shared savings are negotiated between the individual practices and BCBSTX, Crow says.

Norman Chenven, M.D., founder and CEO of Austin Regional Clinic, whose group joined the pilot program in January, says the BCBSTX medical home model is physicianled in that the carrier chose to contract directly with the physician groups to provide coordination of care rather than bringing hospitals into the program.

Just over a year into the pilot project, Crow says the preliminary results look very favorable. His practice already has seen lower hospital readmission rates, reduced inappropriate emergency department usage, and higher quality scores on chronic disease and preventive care measures.

And he is excited about the impact of the patient-centered medical home model on health care delivery in Texas.

“In fact, I can see how we could create some win-wins across the board in terms of pushing a model that provides access and quality, and potentially could bend the curve for some cost controls,” he says.

BCBSTX officials are so impressed with the early results that the insurer added three additional practices to the pilot program. The program now includes five sites in the Dallas area, Houston, Austin, and Tyler, and covers more than 100,000 patients, including more than 40,000 ben-

eficiaries within the Employee Retirement System of Texas, and 500 physicians.

Lee Spangler, J.D., vice president of medical economics for the Texas Medical Association, says TMA has not taken a position on the BCBSTX medical home pilot, but TMA generally supports attempts to find new ways to deliver care that truly improve outcomes, create value for patients, and don’t add hassles for the physicians.

Proof of Concept Eduardo Sanchez, M.D., M.P.H., senior vice president and chief medical officer for BCBSTX, says the insurer is looking at expanding the patient-centered medical home model throughout Texas, New Mexico, Oklahoma, and Illinois, the four states covered by Health Care Service Corp., BCBSTX’s parent company.

“We, just like everyone else, have heard a lot about the notion of a patient-centered medical home,” Sanchez says. “We reviewed all the existing evidence base and looked at what the potential was to getting that done in Texas. When all of those things got put together, we decided to start last year with two sites where we have now one year’s worth of experience with some pilots.”

Crow says participating practices have agreed to some “shared quality metrics” based on National Committee for Quality Assurance criteria for certification as a medical home. They cover disease management, preventive care services, and patient satisfaction, he says.

Sanchez says BCBSTX chose only a subset of the NCQA criteria because the company was “more interested in proof of concept as we got going and didn’t want to get caught up in a set of criteria that weren’t going to help us move the needle along as quickly as we would have liked.”

The program, referred to by BCBSTX as the Accountable Practice Model, began at Medical Clinics of North Dallas in January 2010 and then Village Health Partners in February 2010.

On Jan. 1, 2011, three additional practices—ARC, Kelsey-Seybold Clinic in Houston, and Trinity Clinic in Tyler—joined the program. Those pilots largely are centered on ERS health plan enrollees, but also include patients in BCBSTX fully insured products.

Houston internist Spencer Berthelsen, M.D., board chair of the Kelsey-Seybold Medical Group, says his group signed on because the medical home pilot was “a natural extension” of what it already was doing.

“We’ve been doing a form of coordinated care long before the phrase was coined,” Berthelsen says. “We can qualify

Basic elements of a medical home for medical home certification under NCQA and are in the process of doing that.”

Rob Kukla, ERS director of benefit contracts, says his agency’s interest in medical homes stemmed from legislation Lt. Gov. David Dewhurst pushed in 2009.

“The Legislature and, in particular, the lieutenant governor, really wanted us to explore new methods to compensate physicians to do two things. One is to improve quality of care in our program and then try to move away from the fee-for-service model that has existed for years,” Kukla says.

While the bill didn’t pass, ERS got the message. It approached BCBSTX, which administers the ERS plan, about pilot-testing the medical home model for its enrollees.

Berthelsen says the medical home is an important concept and “a necessary first step” toward more comprehensive care coordination.

“The patient-centered medical home really focuses on primary care, which needs more focus in American medicine and public policy today,” he says. “But it’s not, by itself, sufficient. We really need to have systems of care that incorporate all aspects—outpatient, inpatient, primary care, specialty care—all together.”

Sanchez agrees. “Physicians should be responsible and incentivized to coordinate care for their patients, not only in the primary care setting but also across any specialty referrals, hospitalizations, etc.,” he says. “The literature tells us that when one organizes care around a primary care home, you get three great outcomes. One, you get better medical care outcomes; two, you get better and higher patient satisfaction; and, three, you reduce costs.”

Proactive coordination Austin family physician Gregory Sheff, M.D., the medical director for the ARC pilot, says the program includes 21 measures that look at both processes and outcomes. For example, the measures gauge whether a hemoglobin Alc test was done for patients with diabetes and whether the Alc results were below an established level.

BCBSTX spokesperson Margaret Jarvis says the full list of measures is proprietary but is centered on chronic diseases such as diabetes, coronary artery disease, and asthma, as well as preventive screenings and patient satisfaction.

Sheff says ARC has 44,000 BCBSTX patients in its practice, including more than 25,000 ERS enrollees. He says ARC approaches the pilot in a manner that allows it to provide “more proactive and coordinated care for all of our patients.” That

The National Committee for Quality Assurance has identified nine standards required for achieving status as a medical home. Within those standards are some 30 additional elements and 183 so-called data points.

Among the NCQA’s required standards are: • Patient access and communication, including elements such as coordinating visits with multiple clinicians or diagnostic tests in one trip; providing telephone advice on clinical issues during office hours by a physician, nurse, or other clinician within a specified time; and providing secure e-mail consultations with a physician or other clinician on clinical issues, answering within a specified time.

• Use of patient tracking and registry functions, including status of age-appropriate preventive services, presence of an advance directive, age-appropriate risk factor assessment, and more.

• Care management, including conducting pre-visit planning with physician reminders of preventive or other services that need to be addressed, use of individualized care plans, and use of individualized treatment goals.

• Use of patient self-management support, including documenting communication needs; assessing patient/family preferences, readiness to change, and selfmanagement abilities; and providing a written care plan to the patient or family.

• Use of electronic prescribing.

• Use of test tracking, including use of electronic systems for managing tests, followup on abnormal test results, and notifying patients of normal test results.

• Use of referral tracking systems that include information on origination of the referral, clinical information, referral status, and other details.

• Use of performance reporting to facilitate quality improvement efforts.

• Use of advanced electronic communications, including an interactive website that allows patients to request appointments, referrals, test results, and prescription refills.

For more information on the NCQA standards, go to the NCQA website, www.ncqa.org.

“The literature tells us that when one organizes care around a primary care home, you get three great outcomes. One, you get better medical care outcomes; two, you get better and higher patient satisfaction; and, three, you reduce costs.”

— Eduardo Sanchez, M.D., M.P.H. includes creating a clinical data repository that allows them to make sure they are addressing gaps in care that are identified.

Chenven says it uses the care management stipends it gets from BCBSTX to develop that clinical data repository. ARC includes not only patient data from its own electronic medical record system, but also claims data received from BCBSTX, as well as prescription data from the ERS plan’s pharmacy benefits manager.

Chenven says the repository allows ARC physicians to print reports that can be used during office visits so they can address preventive care gaps for otherwise healthy patients, such as whether a female patient has had a mammogram in an appropriate period of time. Physicians also can use the reports to ensure that patients

with chronic illnesses are current on all needed tests or treatment, he says.

“That allows the physician at that visit … either to catch up on the issues or schedule a follow-up appointment to catch up on them,” Chenven says.

Crow says getting additional data on their patients from BCBSTX is essential to understanding where Village Health Partners stands in meeting both quality and cost measures.

“Physicians can never truly understand costs unless they’re getting them fed back to them in some type of relevant way,” he says. “And once you understand where you fall above or below the average and what the average is—whether that be ER visits or hospitalizations or hospital readmissions or specialist referral rates—then you www.ta f p.or g | sum m er 2 0 1 1

27

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s u m m e r 2 0 1 1 | T e xas Family Physician

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can know what to focus on and whether what you’re focusing on is appropriate.”

For example, data he receives from BCBSTX show his practice has a higher than usual referral rate for physical medicine and rehabilitation specialists. “But that’s because we make sure that all of our back pain patients go to a PMR physician, which is nonsurgical, and make sure they get all the things possible done for their back pain, and surgery is the last resort,” Crow says. “We’re okay with being an outlier there because it improves the total cost of care if you’re keeping people out of unnecessary back surgeries.”

On the flip side, the data showed that Village Health Partners patients use hospital emergency departments for care even when their offices are open. Crow says his practice would not even know those patients were going to the emergency department without the feedback reports it is getting from BCBSTX. That led the practice to beef up efforts—including partnering with employers—to encourage patients to call their office before going to the emergency room.

“What we found was well over half of those emergency room visits could have been handled in our office at a more appropriate place, at a more appropriate cost level,” Crow says.

Meeting the Goal Participating physicians are optimistic they will be able to meet the quality and cost measures set out in the pilot, even though there likely will be added cost early in the program as they catch up on preventive and chronic disease care their patients need.

“It’s a three-year pilot, and we’re definitely optimistic that we’ll improve quality and cost over the course of the three years,” Sheff says. “We certainly expect to see an improvement over our baseline in the first year and definitely want to be hitting all the quality goals by the second, and we think that’s realistic.”

Sanchez also is optimistic and says BCBSTX hopes to add additional selffunded employer groups as the program evolves.

And, Kukla says ERS believes so strongly in the program that it would entertain discussions with other physician groups interested in joining the program.

“Our feeling is that by coordinating care and helping ensure that members are compliant with a doctor’s regimen, we will in fact be able to control health care spending because the members will have better total outcomes and will be healthier as a result of this outreach.” :

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practice management

Patience and perseverance pay off in contract negotiation

By Bradley K. Reiner Practice Management Consultant, Reiner Consulting and Associates

H

ave you ever wondered if renegotiating contracts is really worth the time and effort? Is an increase in payment even possible? Will payers consider changing your contracted rates?

I can tell you for a fact that if you have a plan in place, it can work. You will never get an increase if you never ask, right? Insurance plans don’t send out notices asking you to renegotiate your contract because they aren’t paying appropriately. What if I told you there was a chance you could get an increase between 3 percent and 5 percent for your negotiations? It might be worth considering. Just a 3-percent increase on total annual collections of $250,000 can put an extra $7,500 in your pocket. The effort may just pay off. What do you have to lose?

A few months ago I held an initial meeting with doctors in a practice to discuss their goals in negotiating their contracts. I asked them to answer a few questions.

• Which contracts and with which payers do we want to renegotiate?

• What are the top three items you want to accomplish in the negotiations?

• What are the main factors in renegotiating your contracts?

• What do you see as the significant issues or concerns you have for accomplishing these goals?

• What are the strengths of your practice?

• What measures have you implemented to save the insurance plan money or to increase the quality of care their members receive?

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s u m m e r 2 0 1 1 | T e xas Family Physician

• Have you implemented performance measures for chronic disease management protocols?

• Do you prescribe generic over name-brand medications to reduce costs?

• Do you have an after-hours clinic to avoid costly emergency room visits?

• Do you have any billing issues with payers that cause additional cost expenditures?

We decided to negotiate with all of the major payers— Blue Cross and Blue Shield, United, Aetna, Cigna, and Humana—as they accounted for almost 90 percent of charges and revenue. Certainly any increase would generate a positive result.

Once the questions above were answered, we developed a formal proposal that identified the practice’s cost-saving measures and outlined the rationale for the requested increase. In such a negotiation, your job is to convince the payer that you offer superior service, above and beyond what other competitors offer. Here is a sample letter to start the negotiation.

AAA Family Medicine, comprised of three boardcertified family physicians with over 50 years of service to Texastown and the surrounding communities, has been analyzing our current fee arrangements and contractual obligations with insurance companies and networks. During this analysis we discovered that fees have not been reviewed or negotiated for years and, in some cases, have never been evaluated.

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After careful analysis, the current contract in place includes inadequate rates that are not consistent with the excellence, quality care, and cost effectiveness this practice has provided since its inception. This letter serves as a formal request for a more suitable fee schedule that mirrors our commitment to quality, patient satisfaction, and cost effectiveness.

The physicians at AAA Family Medicine represent some of the finest in Texas. It is our goal to provide our patients with the highest level of medical and surgical treatment in an environment that fosters a close patient-physician relationship. Our practice philosophy encourages our physicians to draw from the knowledge of our entire physician team when treating patients.

This means that when seeing one of our doctors, our patients benefit from the experience of all of our physicians. If services are needed, our physicians make sure patients are placed under the care of the one best suited for the service. By allowing physicians to focus on specific issues and encouraging referrals within the group to the most experienced doctor, each physician becomes highly experienced within their area of focus and therefore provides patients with the highestquality outcome.

This group philosophy and team approach also means that if patients have an urgent need, we find the most available doctor with the expertise to handle their medical issue. Efficiency and experience means fewer complications and quicker recovery time with less expense to the insurance company.

Through our chronic disease management program, AAA Family Medicine provides a higher level of care to the most at-risk patients. This allows the doctors to spend the majority, and in some cases all, of their time taking care of patients with similar medical needs.

While we provide services for all needs, this program was created to provide a more focused approach to patient care.

The cost of providing the highest-quality care through our disease management program has risen dramatically since the inception of our agreement with your company.

Current reimbursement rates are too low to maintain overhead and provide the level of service we expect to give each of our patients. This is unacceptable.

The team has analyzed these rates thoroughly and has determined that to continue to meet overhead demands, an increase as outlined on the attached fee schedule is necessary. The proposal is based on a three-year stair progression. This increase will allow us to continue to render quality care and provide the services our patients expect and deserve.

We are willing to meet with your representatives to negotiate our contract if the attached request is not approved. Please be aware we will be forced to make some difficult decisions about the future if we are unable to negotiate fair and reasonable fees.

Thank you for your time and attention to this important matter. We look forward to hearing from you at your earliest convenience.

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The goal is to tell a story about the practice and communicate why a raise in rates should be granted. If no increase is granted, you should consider terminating the contract. You should request a meeting with the payer so they will know how important it is that they approve the requested increase.

I submitted the proposal letter to the plans we identified. Then we waited. What do you think we heard from the plans over the next week? Crickets. Dead silence.

Absolutely nothing.

Many plans are notorious for delaying their response.

You ask for an increase and they ignore you in hopes that you will not follow up. If you don’t continue to pursue it, your effort has been for naught. For the plans in my example, we followed up every week until we got a response.

You may not hear back in two weeks. You may not hear back in a month. I’ve had negotiations with a particular plan go on for months. However, after a length of time, persistence pays off and you generally get something for your efforts.

Our first reply was typical of most plans: XYZ health plan currently participates only on our commercial products. Current reimbursement is set at a rate for your area. Your RBRVS-based fee schedule is above our market rates. A reimbursement increase is not possible at this time.

And another: Thank you for the proposal. I presented it to senior management, and unfortunately we must respectfully decline the request at this time. However, senior management is reviewing the fee schedules across the board, and 90-day fee disclosure letters are scheduled to be mailed out by the end of April in order to make an Aug. 1 effective date. I would like to point out that senior management is focusing on family practice reimbursement this year, and I am hopeful the group will find it fair and reasonable. We appreciate the services that AAA Family Medicine provides to our members and look forward to your continued participation.

Do you think we gave up? Of course not. If you recognize the strategy, then it becomes easier to deal with.

You can anticipate the reaction and settle in for the long haul. After following up with each, some multiple times, I achieved a positive result with most of their payers. In one case, the health plan did not grant an increase, but instead allowed the practice to join its new pay-for-performance program that offered them the opportunity to earn quarterly bonuses totaling up to $40,000 per year.

It takes endless patience and perseverance, but nothing a payer says should keep you from continuing to negotiate your agreements. What do they teach in Contracting 101? The squeaky wheel gets the grease. All contracts are negotiable with the right spin and gamesmanship. It is important to get every dollar you can. You deserve it. :

Bradley K. Reiner, owner of Reiner Consulting and Associates, is TAFP’s practice management consultant. He can be reached at (512) 858-1570 or by e-mail at breiner@austin.rr.com.

RESEARCH

Characteristics of patients using extreme opioid dosages in the treatment of chronic low back pain

This study was funded in part by a research grant from the TAFP Foundation. Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.

Shannon Essler Southwestern University, Georgetown Terrell Benold, M.D. University of Texas Southwestern – Austin Family Medicine Residency Program

Gold level Richard Garrison, M.D. David A. Katerndahl, M.D.

Sandra Burge, Ph.D. Department of Family and Community Medicine University of Texas Health Sciences Center, San Antonio

Bronze level Carol and Dale Moquist, M.D.

Acknowledgements: Co-investigators from the Residency Research Network of Texas (RRNeT) include: Tamara Armstrong, Psy.C.; Jose Hinojosa, M.D.; Sarah Holder, D.O.; Sunand Kallumadanda, M.D.; Jerry Kizerian, Ph.D.; Shashi Mittal, M.D.; Shannon Moss, Ph.D.; Raji Nair, M.D.; Jesus Naranjo, M.D.; Darryl White, M.D.; John Whitham, D.O.; Richard Young, M.D.; and Robert Wood, Dr.P.H.

Introduction In the United States alone, physicians see two million annual cases of back pain. Low back pain ranks second only to respiratory illness as a reason to visit primary care providers.1 Recent studies document a 423-percent increase in opioid expenditures for back pain.2 While constituting only 4.6 percent of the world’s population, Americans have been consuming 80 percent of the global opioid supply and 99 percent of the global hydrocodone supply, despite continued research that indicates the repercussions of chronic opioid treatment.3 Specific deterrents include constipation, nausea, vomiting, respiratory depression, drug abuse, drug diversion, addiction, and opioid-induced hyperalgesia (OIH).3,4 Abuse of prescription opioids among teens has increased an astounding 542 percent between 1992 and 2003. During this same period, there was a 90-percent increase (from 7.8 million to 14.8 million) in the number of Americans who admitted abusing controlled prescription drugs.5 A large study of over 14,000 patients found evidence to suggest that 20.1 percent to 53.6 percent of patients treated for chronic non-cancer pain diverted their prescribed narcotics.6 Other reports have also documented the characteristics of patients most likely to abuse or divert prescribed opioids (e.g. anxiety, depression, history of drug abuse).7,8,9 The prescribing of opioids for chronic, non-malignant pain often varies dramatically among physicians.10 This is likely due to the subjective nature of non-cancer pain complaints, as well as a historical lack of clear, concrete guidelines regarding the appropriateness of opioid prescribing. A few studies have recorded the average opioid dosage used in treating chronic low back pain (CLBP) in primary care populations. However, only one study, published in 2008, has ever provided evidence to suggest an opioid dose beyond which patients might suffer decreased functionality and quality of life. The results of this study suggest an opioid ceiling for most patients of 40 mg per day in morphine equivalence.

While functionality of patients taking greater than 40 mg per day suffered, patients taking 105 mg or more per day suffered to an even greater extent.11 In this study of patients with CLBP, we assess characteristics that may differentiate patients taking extremely high doses of opioid medication (in the top 10 percent) from those taking lower

Thank you to all who have donated to an endowment.

For information on donating or creating a new endowment, contact Kathy McCarthy at kmccarthy@tafp.org.

doses and patients taking none at all. We examine differences in demographic characteristics, treatments for pain, comorbidities, and pain and health outcomes.

METHODS Subjects. In 2008, student research assistants consented and enrolled 213 outpatients with CLBP from six family medicine residency programs in the Residency Research Network of Texas. Eligible patients had low back pain for three months or longer; investigators excluded pregnant women and patients with cancer. In 2009, student research assistants conducted one-year follow-up data collection from medical records of 204 participants (96 percent follow-up), and surveys of 137 participants (64 percent follow-up).

Procedure. In 2008, students enrolled, consented, and surveyed patients as they arrived for routine outpatient visits. Immediately following the visit, students abstracted study data from participants’ medical records. For the one-year follow-up, the medical records were revisited and data abstracted from the past 12 months.

In addition, patients were contacted again and surveyed by telephone or during return clinic visits.

Measurement. From participants’ medical records, students gathered information about causes of low back pain, medical and procedural treatments for pain, comorbidities, and BMI. The dosages of the various opioids used by the CLBP patients were converted to daily morphine equivalence using the tool shown in Table 1.

A five-page patient survey addressed demographic characteristics, pain duration, frequency and severity, physical functioning and general health (from the MOS-SF 36), screening questions for anxiety and depression (PHQ-2), substance abuse, and risk for opioid abuse (SOAPP).12,13,14 Analysis. In this analysis, participants were divided into three groups: non-users of opioid medication (N = 100); moderate users (115 mg or less per day in morphine equivalence, N = 93); and high users, the top 10 percent of users (greater than 115 mg per day, N = 11). Differences between the three groups with regard to demographic characteristics, other treatments for pain, and comorbidities were analyzed using chi-square analysis and AVOVA. The 137 surveys completed were examined to assess group differences in pain and physical function, and risk for substance abuse. www.ta f p.or g | summ er 2 0 1 1

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TABLE 1. Opioid equianalgesic dosages (Converting to morphine equivalence)

10

20

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

Oxycodone (OxyContin, Percocet)

10

10

20

30

30

40

50

50

60

70

70

80

90

90

100

110

110

120

130

130

Hydrocodone (Vicodin, Norco)

25 50 75 100 Fentanyl Patch (Duragesic Patch) mcg mcg mcg mcg patch patch patch patch

Morphine (Kadian, MS Contin)

10

20

30

40

Methadone

5

10

15

20

Codeine (Tylenol #3)

60 120 180 240

90 150 210 270

Hydromorphone (Dilaudid)

2

50

60

70

80

90

100

110

120

130

25

30

35

40

45

50

55

60

65

300 390 450 510 570 660 720 780 840 330 420 480 540 630 690 750 810 870 360

4 6 8 10 12 500

14 16 18 20

Meperidine (Demerol)

100

200

300

400

Propoxyphene Napsylate (Darvocet)

200

400

600

800 1000 1200

600

700

800

22 24 26 28 30 32

140

150

160

170

180

190

200

70

75

80

85

90

95

100

34 36 38 40 42

44 46

48

50

900 990 930 1020 960

900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000

Published data suggest that a 25 mcg patch/72° is equivalent to 45-135 mg of Morphine daily (24°). Most other sources suggest that a 25 mcg patch/72° is equivalent to 45-60 mg of morphine daily. We have selected 50 mg morphine as our marker on this table.

Figure 1. Dosage per day of moderate and high users using opioid medication for the treatment of chronic low back pain 25

Moderate users (≤ 115 mg/day ); (N = 93); Median = 30 mg/day; S.D. = 21 mg/day

Number of patients

20

15

10 High users (> 115 mg/day); Top 10% sample (N = 11); Median = 180 mg/day; S.D.= 64 mg/day

5

0

10

20

30

40

50

60

70

80

100

110

120

130

140

150

170

180

200

240

280

320

Dosage (mg/day in morphine equivalence)

RESULTS Of the 204 participants, 70 percent were women, 40 percent were Latino, 45 percent were Caucasian, and 14 percent were African-American. The mean and median age were 55 years old, and age ranged from 19 to 90. Half of the patient sample used opioid medication to control their CLBP. Among opioid users, prescriptions ranged from 10 mg per day in morphine equivalence to 320 mg per day, with 79 percent of dosages being less than 50 mg per day (Figure 1). On the other hand, 90 percent of opioid users took less than 115 mg per day. The median doses of moderate and high users were 30 mg per day and 180 mg per day, respectively.

Three groups of CLBP patients (high users, moderate users, and non-users of opioid medication) were compared across several dimensions, including health care utilization, comorbidities, use of other treatments for pain, and demographic characteristics.

Significant group differences were evident, such that high users were more likely than moderate and non-users to have hepatitis C, 34

s u m m e r 2 0 1 1 | T e xas Family Physician

to use benzodiazepines, and to be receiving treatment for depression (Table 2). The average pain scale of patients on and off medication also differed significantly between groups, and high-dose users reported the worst physical and role functioning (Figure 2).

In addition, high users were significantly more likely than moderate and non-users to seek care in pain clinics, but not to attend physical therapy (Figure 3). The three groups of CLBP patients did not differ significantly with respect to their gender, ethnicity, age, or body mass index.

DISCUSSION In this study, most opioid-using patients (90 percent) took less than 115 mg per day in morphine equivalence. The median dosage of high users, or patients taking the top 10 percent of dosages, was extraordinarily higher (500 percent) than that of the moderate users. High users were also more likely than moderate and nonusers to have Hepatitis C, to seek care in a pain clinic, to use ben-

TABLE 2. Comparing 3 groups across health care characteristics using chi-square tests Percent with treatment for depression

Percent prescribed benzodiazepines

Percent diagnosed with hepatitis C

Percent visiting pain clinic

Non-users (N = 100)

26.0%

7.0%

4.0%

3.0%

Moderate users (N = 93)

44.7%

19.1%

10.6%

14.9%

High users (N = 11)

70.0%

40.0%

30.0%

40.0%

P-value

0.002

0.003

0.010

0.0001

Figure 2: Comparing 3 groups across pain and functioning using one-way analyses of variance

Pain and functioning analog scale

10

p = 0.0001

Non-users (N = 100) Moderate users (N = 93)

8

High users (N = 11)

p = 0.001

(Scale 1-10; 10 = High)

6 4 p = 0.003

2 0

p = 0.0001

Average pain unmedicated

Average pain medicated

Physical functioning Role functioning (1-3; 3 = Best) (0-4; 4 = Best)

Measurement of health

Figure 3: Comparing 3 groups across procedural treatment using chi-square tests

Percent of patients

zodiazepines, and to be receiving treatment for depression, but less likely to pursue physical therapy as a means to gain pain relief. On the other hand, 79 percent of opioid-using participants took 50 mg or less per day. These patients reported greater physical and role functioning than high users.

Such findings are consistent with previous research, which suggests that chronic, high-dose opioid use increases a patient’s pain sensitivity (OIH) and imparts poorer functionality.3,4,11,15,16 Therefore, it may be that when patients reach extremely high dosages of prescribed opioids, it is no longer their original pain that is primarily being treated, but rather their OIH, tolerance, and/or addiction. Indeed, previous research has failed to correlate reported pain intensity with opioid use in CLBP populations and mixed chronic pain populations.17,18,19 In addition, studies show that patients tapered off of opioids in structured pain management programs experience decreased CLBP and improved mood and functional status.4,20 This study allows physicians treating CLBP to compare their opioid prescribing to that of doctors in several Texas cities. While limited by a small sample of very high-dose users, this study supports the existing literature that suggests a need for tighter restriction of opioid prescribing. A second limitation is related to the research design, a prospective cohort study. Our data are observational and descriptive, intended to follow the natural history of CLBP and its treatment over time. The design does not allow us to determine cause and effect.

Although opioids have been shown to relieve pain and improve functionality of patients over a short term, the efficacy of opioid treatment long term for chronic non-cancer pain is questionable.21,22,23,24 Many sources recommend setting stricter guidelines for prescribers and using treatments less detrimental to functional outcomes of patients.2,10,11,21 However, the use of opioids by primary care physicians continues to grow. Because opioidseeking patients often complain of CLBP in order to gain access to opioid prescriptions, clinicians should pay close attention to current guidelines, which describe the patient characteristics known to be risk factors for opioid abuse or diversion. Such factors include personal or family history of alcohol or drug abuse, history of mental health problems, history of arrest/legal problems, and relatively younger age.7,8,9 Indeed, the characteristics that distinguish high users in this study correspond to those same characteristics previously shown to be predictive of prescription abuse.

The results of this study are consistent with those of prior studies that have suggested that there is an opioid dose beyond which patients might suffer decreased functionality and quality of life. We recommend that clinicians reconsider the appropriateness of opioid prescribing above 115 mg per day and closely monitor patients identified to have risk factors for abuse. We also point out that a dosage of 50 mg or less per day in morphine equivalence represents one community standard for the treatment of chronic non-cancer pain.

40%

Non-users (N = 100)

35%

Moderate users (N = 93)

30%

High users (N = 11)

25% 20% 15% 10% 5% 0

Pain clinic (p = 0.0001)

Physical therapy (p = 0.7983)

Trigger point injections (p = 0.198)

Procedural treatment for pain

www.ta f p.or g | summ er 2 0 1 1

35

REFERENCES 1. Levy BS, Wegman DH, Baron SL, Sokas RK. Occupational and environmental health: recognizing and preventing disease and injury.

Philadelphia: Lippincott Williams & Wilkins; 2006.

2. Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22:62-8.

3. Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 2008;11:63-88.

4. Miller NS, Swiney T, Barkin RL. Effects of opioid prescription medication dependence and detoxification on pain perceptions and selfreports. Am J Ther. 2006;13:436-444.

5. Bollinger LC, Bush C, Chenault KI, et al. Under the counter: the diversion and abuse of controlled prescription drugs in the U.S. July 2005. The National Center on Addiction and Substance Abuse at Columbia University (CASA).

6. Kell M. Monitoring compliance with OxyContin prescriptions in 14,712 patients treated in 127 outpatient pain centers. Pain Med. 2005;6:186-7.

7. Manchikanti L, Giordano J, Boswell MV, Fellows B, Manchukonda R, Pampati V. Psychological factors as predictors of opioid abuse and illicit drug use in chronic pain patients. J Opioid Manag. 2007;3:89-100.

8. Chou R, Qaseem A, Snow V. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-91.

9. Low Back Pain Workgroup. HA/DOD clinical practice guideline for the management of low back pain or sciatica in the primary care setting. Washington, DC: Veterans Health Administration, Department of Defense; 1999.

10. Atluri S, Boswell MV, Hansen HC, Trescot AM, Singh V, Jordan AE. Guidelines for the use of controlled substances in the management of chronic pain. Pain Physician. 2003;6:233-57.

11. Dillie KS, Fleming MF, Mundt MP, French MT. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med. 2008;21:108-17.

12. Stewart AL, Hays RD, Ware JE. The MOS Short-Form General Health Survey: reliability and validity in a patient population. Med Care.

1988;26:724-735.

13. Whooley MA, Avins AL, Miranda J, Browner WS. Case finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12:439-45.

14. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain 2004;112:65-75.

15. Sim MG, Hulse G, Khong E. Back pain and opioid seeking behaviour.

Aust Fam Physician. 2004;33:431-5.

16. Breckenridge J, Clark JD. Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain. J Pain. 2003;4:344-50.

17. Fillingim RB, Doleys DM, Edwards RR, Lowery D. Clinical characteristics of chronic back pain as a function of gender and oral opioid use. Spine. 2003;28:143-50.

18. Mitra S. Opioid-induced hyperalgesia: pathophysiology and clinical implications. J Opioid Manag. 2008;4:123-30.

19. Angst MS, Clark JD. Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiology. 2006;104:570-87.

20. Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992;49:221-30.

21. Nicholas MK, Molloy AR, Brooker C. Using opioids with persisting noncancer pain: a biopsychosocial perspective. Clin J Pain.

2006;22:137-46.

22. Martell BA, O’Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146:116-27.

23. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349:1943-53.

24. Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996;11:203-17.

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s u m m e r 2 0 1 1 | T e xas Family Physician

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37

TA FP p E R S PECTIV E

The changing landscape of family medicine in Texas

By W. Mike McCrady, M.D., and Anne McCrady While politicians debate health care reform in Washington, here in Texas change is already affecting the practice of family medicine. In hospital board rooms and medical staff meetings, local doctors are hearing about the transformation of primary care, payments based on quality and value, and the expectation of providers to capture a larger and larger market share. There is a confounding list of issues behind these pressures: some legislative, some economic, and others technological. In response, around the state, not just doctors, but administrators, legislators, and consultants are weighing in on the critical role of primary care to manage cost, ensure continuity, and meet patients’ needs.

With so much at stake, Texas family physicians face a daunting future. How should we respond to these changes?

As with so many things, the answer seems to be to work together. For a rapidly growing proportion of us, that means joining forces with other providers, often as part of a hospital system. A report from the Texas Department of State Health Services shows a drop in the percentage of physicians who identified themselves as being in partnerships from 50 percent to 30.2 percent in the past 10 years. This decreasing number of small medical groups is also documented in national statistics.

In fact, a recent New England Journal of Medicine article predicts that by 2012, 40 percent of active primary care physicians will be employed by hospital systems.

The shift toward doctor employment isn’t just a business trend. One of the major factors driving the decrease in independent practice is the changing demographics of Texas. Over the past two decades, the population growth in our state has been in urban areas, where large hospital systems dominate the market.

Physicians are locating to follow that growth, and must either align with those systems or compete. The 2010 census shows that only 14 percent of Texans live in rural areas, and an even smaller number of doctors are choosing small towns. This is especially true of younger physicians, whose practice choices are more influenced by lifestyle issues than previous generations, and who prefer the advantages of employment.

Another feature in the growth of integrated health care systems is the Affordable Care Act. Health care reform is already altering the landscape with new processes, incentives, and requirements. A survey by Cejka Search, a leading physicians’ recruiting group, in conjunction with the American Medical Group Association, reports that 64 percent of integrated medical systems find that since the introduction of health care reform, physicians they want to recruit are more receptive to their model of care.

In light of all these developments, the future of Texas family medicine seems to depend on accessing the resources and networks of large integrated medical systems,

while maintaining our autonomy and personal commitment to patients. It will be a test for our specialty, but one for which our skills and strengths are well suited. In fact, as family physicians, we have reason to believe we will not only survive the coming changes, but thrive.

First, as family doctors, we value patient relationships; our patients know we will never compromise our personal relationship with them. Regardless of our affiliations or payment structures, our core values about patient care remain valid. Evidence from pilot programs, such as the patient-centered medical home, continues to show that in a wide range of delivery models, family doctors are essential to high-quality, cost-effective health care. As the 20102011 TAFP Texas Family Physician of the Year Lloyd Van Winkle, M.D., remarked in his acceptance speech when he referred to a popular television show, “Patients don’t want a [Dr.] House; they want a home.” Family doctors have provided the “medical home” to their patients for decades.

Secondly, family physicians are committed to quality, access, and affordability. Aligning with health care systems can enhance those commitments by providing new services, specialty interaction, information technology, measurement and reporting, evidence-based protocols, and administrative support. Roger Fowler, M.D., a long-time family physician and chairman of the board of Trinity Clinic in Tyler, recently noted that advantage, “When family doctors join groups, they don’t give up their independence as much as they gain resources.”

Finally, family physicians have a long history of providing coordinated care. Our role has always been to guide patients to seek the “right care at the right time” from a wide range of sources. Integrated care is actually an expansion of what we are already doing. Recently, Karen Kennedy, CEO of Medical Clinics of North Texas, a multispecialty group with a strong family practice base, said, “Physicians who have a well-developed sense of teamwork are looking for groups like ours to join.”

While Texas health care delivery systems will continue to expand and evolve, it seems clear that integration, or at least affiliation, will be the choice of many physicians in Texas. My hope is that we, as family physicians, will embrace these new opportunities and remain the essential health care providers and patient advocates we have always been. Using our shared values, medical expertise, and the support of TAFP, we can ensure that family physicians lead the transformation of Texas medical care far into the future. :

The future of Texas family medicine seems to depend on accessing the resources and networks of large integrated medical systems, while maintaining our autonomy and personal commitment to patients.

38

s u m m e r 2 0 1 1 | T e xas Family Physician

Dr. McCrady is a family medicine hospitalist and vice president of clinic operations at the Trinity Mother Frances Health System. Anne McCrady is a freelance writer and speaker.

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