Texas Family Physician, Summer 2014 by Texas Academy of Family Physicians

The Hybrid Concierge Model Explained Team-Based Care With Physician Assistants, Your Partners in Practice

texas family physician VOL. 65 NO. 3 SUMMER 2014

Join An ACO Or Take A Job With A Hospital? The

Facing Many Family Docs

PLUS: Photos And Report From TAFP’s 65th Annual Session & Scientific Assembly How To Come Out Ahead When It’s Time To Sell Your Practice

Cut And Paste Conundrum: What The OIG Doesn’t Like About Your EHRGenerated Notes

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INSIDE

TEXAS FAMILY PHYSICIAN VOL. 65 NO. 3 SUMMER 2014

Physician-led ACO or hospital employment?

Health care lawyer Bo Bobbit weighs the differences between physicians creating accountable care organizations and being employed by hospital or health systems.

By Julian D. “Bo” Bobbit, Jr., J.D.

Hybrid concierge: Best of both worlds?

The hybrid concierge model allows you to tailor services to your patients without completely eschewing insurance. By Wayne Lipton

Team-based care with PAs

Don’t sell your practice short

What you need to know when you decide to sell your practice. By Lowell Davis

EHRs: good, bad, or ugly?

Physician assistants can ease the challenges in your practice.

The OIG is cracking down on copy-and-paste notes from EHRs. Here’s what you need to look out for.

By Karrie Lynn Crosby, MPAS, PA-C

By Bradley Reiner

6 FROM YOUR PRESIDENT Get connected with TAFP’s social and education networking opportunities. 8 MEMBER NEWS Sugar Land physician selected for DSHS panel | New rural residency program in Permian Basin | Athens FP becomes TMA Board Vice Chair | Two Texas physicians elected to AAFP positions | Two TAFP resident members honored with AAFP award | North Richland Hills loses beloved physician 14 ANNUAL SESSION REPORT Physicians from across the state congregated in San Antonio for this year’s Annual Session and Scientific Assembly. Full report and photos inside. 38 TAFP PERSPECTIVE Hospice care can be rewarding.

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president’s column

TEXAS FAMILY PHYSICIAN VOL. 65 NO. 3 SUMMER 2014 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

Clare Hawkins, M.D., M.Sc.

president-elect vice president treasurer

Dale Ragle, M.D.

Tricia Elliott, M.D.

Ajay Gupta, M.D.

parliamentarian

Janet Hurley, M.D.

immediate past president

Troy Fiesinger, M.D.

Editorial Staff managing editor

Jonathan L. Nelson

associate editor

Samantha White

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, C.A.E.

advertising sales associate

Michael Conwell Contributing Editors Julian D. “Bo” Bobbitt, Jr., J.D. Wayne Lipton Karrie Lynn Crosby, MPAS, PA-C Lowell A. Davis Bradley Reiner Lloyd Van Winkle, M.D.

subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by The Whitley Company, Austin, Texas. legislative advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2014 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

[SUMMER 2014]

TEXAS FAMILY PHYSICIAN

Get connected

Take advantage of the many social and educational networking opportunities your Academy has to offer By Clare Hawkins, M.D., M.Sc. TAFP President electronic opportunities to connect with friends, family, and colleagues abound. I can communicate very quickly with people I know and people I don’t know. I can broadcast ideas by blogging and I can post photos or see others’ photos in many ways. This is both exciting and frightening. Who am I reaching? Who knows these details about me? As a family physician most of my contact is with individual patients or their families, essentially one on one. Therefore these new opportunities are not familiar to my normal social intercourse. I’m so used to confidentiality and preserving my professional image that in my middle age, I find myself uncomfortable reaching out. How should I get connected professionally or socially? Should I get “linked in” to a professional network? Perhaps, but what about privacy, being barraged by unsolicited e-mails, or being taken out of context? Considering opportunities for a virtual professional community, I realize I have a real professional community in TAFP, available to me in so many different ways. The more I think about it, the more I come to value it. The practice of medicine can be isolating, especially for the busy clinician whose treatment of his or her patients consumes so much time. It may well be true that no man is an island, but frequently we function as isolated individuals in our busy daily professional role. What’s more, the confidentiality we vow to keep with our patients compels us to carry others’ burdens in silence. With whom can we share the weight we carry?

TAFP facilitates formal and informal venues to discuss the difficulties we carry. There are opportunities to ask questions and share thoughts. These include CME sessions, committees and commissions, and the peer-to-peer networks that we create. In the literature on physician wellness, there is good evidence that we perform better as physicians if we are healthier. A healthy physician is one who is not only practicing good general health behaviors, but one who employs strategies to deal with the stress of being a physician. Sometimes we are overwhelmed as doctors and we need help. We need a new medical partner, a locum, or a new practice design. TAFP is a great resource for finding a practice partner or a place to practice, and in these days of constant change, we can open our minds to new practice arrangements. Since becoming part of the TAFP family, I’ve found that there are resources I wouldn’t have dreamed of. I’ve found them by meeting family physicians across the state, because you see, the greatest resources your Academy has to offer are you, its members. By interfacing with a network of family physicians who have adapted to diverse conditions, we don’t have to reinvent the wheel. The geographic and business challenges specific to each area of Texas are remarkable, and in this great laboratory, we can find myriad examples of best practices. One of the best opportunities to meet your colleagues and experience this network is by joining us at one or more of our statewide CME conferences. TAFP’s learning community allows for exchange of ideas,

Few people understand the life of a family physician like other family physicians, and our mutual support strengthens the individual and the Academy.

interacting with peers, sharing new ideas, and challenging old ones. For me, they offer a breath of fresh air, a reset if you will, or a recalibration. I find that attending these events stimulates my thinking, and makes me feel synchronized with my colleagues. Interactive learning through the group ABFM SelfAssessment Modules is even more stimulating as I can work through problems with colleagues and benefit from their knowledge. Next year, the Academy has big changes in store for our live CME events, as we move our Annual Session from the summer to November to pair it with one of our most popular conferences, Primary Care Summit. The other big announcement is that TAFP is launching a brand-new conference in the spring, the Texas Family Medicine Symposium, which will offer 25 credits of cuttingedge CME including your required ethics credit in only two and a half days. We believe these changes will provide the Academy new chances for growth and improvement, and we invite you to take a look at the full 2015 schedule and mark your calendars accordingly. Visit www.tafp. org/professional-development to plan your CME for next year. The more involved you become, you’ll realize as I have how our community is one of support and comradery. Peers can and have assisted each other at times of family crisis, job change, and other difficulties. Few people understand the life of a family physician like other family physicians, and our mutual support strengthens the individual and the Academy. In a real way, TAFP is a family for each of us. In various ways and at various times we support one another, encourage one another, and inspire each other. When we are feeling burned out and frustrated, interaction through the Academy refocuses us on our central mission, unites the family physicians of Texas through advocacy, education, and member services, and empowers us to provide a medical home for patients of all ages. So get closer to your family of family physicians. Continue coming to TAFP functions across the state and interacting in our virtual community through www. tafp.org and our social media accounts. Follow TAFP on Twitter at @TXFamilyDocs and like us on Facebook by searching for Texas Academy of Family Physicians. I’ll see you there.

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[SUMMER 2014]

Member news

Start Saving Money on Vaccines Now! Discounts on Vaccines • Reimbursement Support With Payers • Timely Updates About New Products, Changes & Sales • Donations to TAFP With Every Purchase! Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV. Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management. The program is free to your practice, and enrollment is completely voluntary. The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine. Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered. Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or info@atlantichealthpartners.com for more information and to register.

Sugar Land physician selected for DSHS panel TAFP member Joe Anzaldúa, M.D., recently received an invitation to be a member of the Texas Department of State Health Services Crisis Standards of Care Panel. The panel will develop a standards of care framework to address ethical issues and priorities during a crisis situation. “This is one of several benefits of being a family physician,” Anzaldúa says. “We have the unusual opportunity to use our training and experience outside of traditional family medicine, especially with respect to community health and services.” After receiving his medical degree from the University of Texas Medical School in San Antonio, Anzaldúa completed his

Joe Anzaldúa, M.D.

residency training at Memorial Hospital in Houston. He has been practicing in the Sugar Land area since 1985 and is the Medical Director of Emergency Medical Services for the cities of Sugar Land, Stafford, and Missouri City.

New rural residency program in Permian Basin A new residency program focusing on rural medicine has been established by the Texas Tech University Health Sciences Center at the Permian Basin Department of Family and Community Medicine. The Permian Basin campus will be the only one in the TTUHSC system to offer rural medicine training to residents. The first two residents of the program began their training this July at the Odessa campus. They will complete the last two years of the rural medicine residency track in either Fort Stockton or Alpine.

“Training physicians in a rural setting will better prepare them for the unique events and circumstances of patients without access to major medical centers,” said Timothy Benton, M.D., in a recent press release. Benton is the chair for the Family and Community Medicine Department at TTUHSCPB. He also thinks that this introduction to rural medicine may encourage residents to stay in the West Texas area to practice long term.

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[SUMMER 2014]

Member news

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[SUMMER 2014]

TEXAS FAMILY PHYSICIAN

Athens FP elected vice chair of the TMA Board Douglas Curran, M.D., of Athens, was recently elected as vice chair to the Texas Medical Association’s Board of Trustees. He has served on the board for the last five years and also currently serves on TAFP’s Nominating Committee and as the alternate delegate to AAFP’s Congress of Delegates. “I think it’s really good for those of us in family medicine to be involved in the house of medicine because it helps everybody understand what family doctors do,” Curran said. “An opportunity to be on the Board of Trustees is just acknowledging my commitment to patient care and the community of physicians in Texas.” “I consider it a huge privilege to represent other physicians. It’s really humbling to get to do this. I love our profession and I love what I do.”

Douglas Curran, M.D.

Through his work with both TAFP and TMA, Curran hopes to affect change. “If I’ve been able to help formulate some laws that will help people get care, that’s what it’s about.”

Two Texas physicians elected to AAFP positions Two active TAFP members were elected to AAFP positions at the Academy’s 2014 National Conference of Special Constituencies in Kansas City, Missouri in May. Emily Briggs, M.D., of New Braunfels, was elected as the new physician member for the AAFP Board of Directors, to be approved by the Congress of Delegates this fall. Briggs earned her medical degree from the University of Texas Houston Health Science Center and completed a residency at Christus Santa Rosa. She began her private practice in New Braunfels, Briggs Family Medicine, in 2009.

Christina Kelly, M.D., of Killeen, was elected as the 2015 Convener of AAFP’s National Conference of Special Constituencies. Kelly was awarded her medical degree by The Ohio State University College of Medicine and Public Health and completed a residency with Tacoma Family Medicine in Tacoma, Washington. She moved to Killeen when her husband was stationed at Fort Hood and is currently civilian faculty on base at the Family Medicine Residency at Carl R. Darnall Army Medical Center.

Two TAFP resident members honored with AAFP award Of the 12 recipients of this year’s AAFP Award for Excellence in Graduate Medical Education, two were Texas family medicine residents. William McCunniff, M.D., M.B.A., of the Waco Family Medicine Residency Program, and Zachary Taylor, M.D., of the Christus Santa Rosa Family Medicine Residency Program, were both honored with this year’s award, which is supported by a grant from Bristol-Myers Squibb.

The award recognizes the nation’s top residents for their leadership, civic involvement, exemplary patient care, and aptitude for and interest in the specialty of family medicine, according to AAFP. McCunniff and Taylor will accept their awards at AAFP’s Annual Assembly in Washington, D.C. in October.

GET READY FOR

ICD-10

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Member news

In tribute By Justin Bartos III, M.D.

David Pillow, M.D. | June 9, 1923 – May 24, 2014

North Richland Hills loses a beloved physician, TAFP Physician Emeritus tafp life member David Pillow, M.D., passed away on May 24, 2014, at age 90. A true icon in the Tarrant County community, Pillow practiced medicine in North Richland Hills, Texas for over 50 years until 2006 when his health forced him to retire at age 83. The area boasts a city parked named after Pillow, as well as a senior health clinic. Pillow was born June 9, 1923, in Austin and graduated high school in Fort Worth. He served as a pharmacist in the Navy during World War II and was honorably discharged in 1946. After graduating first in his class from George Washington University School of Medicine in Washington, D.C., Pillow started a private practice in 1955 in North Richland Hills. He then helped found Glen12

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TEXAS FAMILY PHYSICIAN

view Hospital, later known as North Hills Hospital, and served as president of its board. Pillow left private practice for a short time to serve as director of the Family Medicine Residency program at John Peter Smith Hospital from 1972 to 1978. He also served as the co-director of the nurse practitioner program at the University of Texas at Arlington and as a pharmacology instructor. From 1996 to 2000 he worked in the Senior Medical Clinic of North Hills Hospital, and in 2002 at the age of 78 opened the Pillow Medical Clinic in North Richland Hills. He is survived by his wife of 70 years, Annabel, their five children, an older sister, 11 grandchildren, 15 great-grandchildren, and one great-great-grandson.

i considered david pillow my mentor. He was a unique individual who visualized the future and made it happen. As a family physician in North Richland Hills, he introduced many physicians to the Tarrant County chapter of TAFP and served as president. After helping start a practice and a hospital, he left his practice to serve as program director for the John Peter Smith Family Medicine Residency. When he left the program, he returned to North Richland Hills to start another practice. He promoted family medicine as the solution to health care and he believed nurse practitioners could expand the number of patients served by family physicians. He included them in his practice and began teaching at the nurse practitioner program at the UT Arlington School of Nursing. During this part of his career, I had the opportunity to join him. I was familiar with his name from the residency program, and I sought him out. He was somewhat of a legend and he exceeded all my expectations. Along with his vision he possessed a practical approach to all problems. He did not accept artificial barriers created by specialties to define their turf. If he was trained to do it, he did it. His patients sought him out if their specialty providers were not successfully addressing their concerns. He frequently provided them with acceptable solutions. He had a confidence and a joyous disposition that infected all those around him. I could never tell if he was mad or disappointed with my decisions, but he often pointed out areas of caution. He loved to hunt and had a getaway in Colorado. In his western attire and with his confident wisdom, he gave you the impression that he was the personification of a character from an old western movie. He would introduce himself as “Dave Pillow; like a feather (pillow).”

He loved to teach, and we always seemed to have nurse practitioner students in the office along with a mix of pre-medical and medical students. When he wasn’t teaching students he was teaching noncredit health courses to the local population at the junior college. I wish I had written down all the sage advice and truisms passed on by David Pillow, but here are a few: • When we first met, he shared his ideas about group practice: 1. Always cover for your partner’s patients as if they were your own, 2. Always share the money as equally as possible, 3. Do not bring the spouses into the business. • When dealing with difficult patients, he would caution you to listen carefully to what they say. Even patients with mental health problems can often have serious medical illnesses. I remember a woman who complained of being tired for years with normal exams, but once she presented with a severe anemia.

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• He also reminded me that if you felt uncomfortable or uneasy evaluating a patient, the problem does not necessarily rest with you. • In a humorous but practical situation he might say that if the patient scares you, then you make sure you position yourself between the patient and the door. • I remember how adamant he was about screening for colon cancer before it was very popular. • For patients with symptoms that were vague or difficult to describe, he would diagnose autonomic nervous system dysfunction, which now has an approved Medicare test.

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Most of all David Pillow conveyed a genuine interest in improving the health and lives of the patients he served and the people around him. He had a wonderfully supportive wife, Annabel, and children who admired him and followed in his footsteps. They are his legacy along with those of us that had an opportunity to be touched by this wonderful man.

www.tafp.org

[SUMMER 2014]

Family docs meet in San Antonio for 65th Annual Session By Samantha White

family physicians and other health professionals from around the state gathered in San Antonio July 24-27 for TAFP’s 65th Annual Session and Scientific Assembly. Attendees networked, earned CME, shaped TAFP policy at committee and commission meetings, and celebrated the specialty of family medicine. As always, attendees had opportunities all weekend to learn about a variety of topics from an especially distinguished faculty during the scientific portion of the conference. Participants also had the opportunity to attend three Self-Assessment Module workshops Wednesday, Thursday, and Saturday, on preventive care, health behavior, and mental health in the community. The National Procedures Institute offered one of its most popular courses, Joint Exam and Injections with Introduction to Ultrasound 14

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TEXAS FAMILY PHYSICIAN

Guidance, on Thursday. This year’s Scientific Assembly also included a CME dinner and satellite symposium Friday evening on injectable strategies. The TAFP Foundation held a cocktail cruise on the Riverwalk Thursday evening. Members enjoyed appetizers and drinks from the Iron Cactus while cruising down the San Antonio River on a guided tour. The event benefitted the Student Interest Endowment, a fund created in 2012 by the Foundation to support stipends for students participating in the Texas Statewide Family Medicine Preceptorship program. Thank you to Blue Cross and Blue Shield of Texas for being a platinum sponsor; AbbVie, Texas Hospital Association, Texas Medical Association, Texas Medical Liability Trust, and Robert Youens, M.D., for being gold sponsors; and Lewis Foxhall, M.D., Donald

Niño, M.D., and ProAssurance for being silver sponsors. The CME general session opened Friday morning with a presentation by Bo Bobbitt, Jr., J.D., on family physicians succeeding in ACOs. The rest of the weekend’s CME included topics on patient-centered medical home, direct primary care, chronic obstructive pulmonary disease, geriatric care, and much more. AAFP President Reid Blackwelder, M.D., addressed attendees Sunday morning on advocacy, education, and family medicine for the nation’s health. Troy Fiesinger, M.D., gave a TAFP update during Friday’s Member Assembly Luncheon. There were also updates from the TAFP Foundation and TAFP Political Action Committee and a report from the Task Force on Payment Reform. Members had the opportunity to ask questions of Academy leaders and they elected members to the TAFP Board of Directors. Saturday’s Annual Business and Awards Lunch began with members present voting to adopt the TAFP bylaws changes. Next, TAFP’s top honors were announced and the 20142015 officers assumed their new positions. Russell Thomas, D.O., M.P.H., of Eagle Lake, [cont. on 16]

Clockwise from top left Russell Thomas, D.O., M.P.H., speaks to the crowd at Saturday’s Business and Awards Lunch after being named the 2014 Texas Family Physician of the Year. Drs. Shelley Kohlleppel, Jake Margo, and Linda Siy enjoy fiesta props at the President’s Party. TAFP COO Kathy McCarthy, Dr. Lloyd Van Winkle, and Dr. Mary Nguyen beat the heat with the TAFP Foundation’s cocktail cruise on the Riverwalk. TAFP members support the TAFP Foundation Student Interest Endowment by cruising down the San Antonio River. Congressman Pete P. Gallego receives the 2014 Patient Advocacy award.

www.tafp.org

[SUMMER 2014]

“I encourage you as we leave today to remember that we’re all the physician of the year in the eyes of our patients, so we must continue to work hard to make family medicine the cornerstone of medical practice.” — Russell Thomas, D.O., M.P.H. 16

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[cont.from 14]

was named Texas Family Physician of the Year, the highest honor of the Academy. After finishing a family medicine residency in 1983, Dr. Thomas went into practice with his physician father in their hometown of Eagle Lake, Texas. He took a break from practicing from 2000-2002 to be the program director at the Central Texas Medical Foundation Family Practice Residency Program in Austin, where he established a rural rotation. He is also a second generation recipient of this award as his father, Raymond Thomas, M.D., was the 1997 Texas Family Physician of the Year. After accepting the award, Dr. Thomas addressed the physicians present at the

lunch. “I encourage you as we leave today to remember that we’re all the physician of the year in the eyes of our patients, so we must continue to work hard to make family medicine the cornerstone of medical practice.” TAFP honored Dr. Seth Cowan this year with the Physician Emeritus award. He started practicing family medicine in 1953 in Colorado City, Texas, and was later a founding partner in the Family Clinic of Garland, where he practiced until his retirement. Joining TAFP when it was still the Texas Academy of General Practice, he served on numerous committees and commissions, and was TAFP president in 19791980. Dr. Cowan served as president of the [cont. on 18]

Clockwise from top left TAFP 2014-2015 officers, left to right: Vice President Janet Hurley, M.D.; Parliamentarian Tamra Deuser, M.D.; Treasurer Tricia Elliott, M.D.; President Dale Ragle, M.D.; and President-elect Ajay Gupta, M.D. (Not pictured: Immediate Past President Clare Hawkins, M.D., M.Sc.) Seth Cowan, M.D., speaks after being given the Physician Emeritus award. TAFP President Dale Ragle, M.D., presents AAFP President Reid Blackwelder, M.D., with a TAFP traditional hi-roller hat at Saturdayâ&#x20AC;&#x2122;s Business and Awards Lunch. TAFP CEO Tom Banning, President Dale Ragle, M.D., and Troy Fiesinger, M.D., answer questions at the Member Assembly. Sheri Talley, M.D., receives the TAFP Political Action Committee award. Tricia Elliott, M.D., is given the Special Constituency Leadership award.

www.tafp.org

[SUMMER 2014]

Try this health check on your practice.

[cont.from 16]

Can you do all of the following? Send automated campaigns that save your staff hours of phone time. Hi Sally, remember your appointment is at 10 AM CT on June 26. Please reply “YES” to confirm or “RS” to reschedule.

“Expanding access to family medicine provides a great opportunity for policymakers and payers to improve the health of the nation and lower health care costs. In this vein, we need to promote the expansion of our family medicine workforce. We must redouble our efforts to promote family medicine in our medical schools and encourage students to choose our specialty.”

Send an ad-hoc message to 10’s, 100’s, or 1000’s of people simultaneously. Due to inclement weather, we need to reschedule your appointment tomorrow. We apologize for any inconvenience.

Send a direct message to a patient. Your results are back and they are normal. Reply or call us at (469) 600-4566 with any questions.

Re-enforce desired behavior. Please remember, no food or drink after midnight and until after your appointment tomorrow.

Keep your patients within network. Our records show it’s time for your child’s annual vaccinations. Please contact us to schedule an appointment.

Dialog Health will make sure your practice can answer "Yes" to all of these patient-centric features. Let us show you how your no-show rates will decline, patient compliance will increase, and your staff can be more efficient. For more information on this cost-effective and customized solution, please call or text DEMO to (469) 600-4566

™

[SUMMER 2014]

Dr. Blackwelder presided over the official TAFP Foundation Board of Trustees during installation of TAFP’s new officers who will the early years of establishing and growing the lead the Academy in 2014-2015. The new very successful scholarship program. TAFP officers are: President Dale Ragle, M.D., This year’s TAFP Patient Advocacy Award of Dallas; President-elect Ajay Gupta, M.D., was given to Congressman Pete Gallego, of Austin; Vice President Janet Hurley, M.D., who represents District 23 in the U.S. House of Whitehouse; Treasurer Tricia Elliott, of Representatives and is from Alpine, Texas. M.D., of League City; He has established a and Parliamentarian solid record of advocacy Tamra Deuser, M.D., of for patients’ rights, Flower Mound. working to solve probIn his presidential lems in the health care address, Ragle encourdelivery system at both aged his peers to help the state and national expand the family levels, and to make the physician workforce in Affordable Care Act the state. function better. “Expanding access Receiving the 2014 to family medicine Presidential Award provides a great opporof Merit was Joane tunity for policymakers Baumer, M.D., for her and payers to improve commitment to solidifythe health of the nation ing the future of family and lower health care medicine. costs,” Ragle said. “In Sheri Talley, M.D., this vein, we need to received the TAFPPAC promote the expansion award for her time of our family medicine advocating for family workforce. We must medicine by testifying in redouble our efforts front of committees and to promote family regulatory agencies. medicine in our medical The TAFP Foundaschools and encourage tion presented scholstudents to choose our arships to medical specialty.” students and honored The conference’s Melissa and Cory Gerdes most anticipated event, as the Philanthropists of the President’s Party, the Year. was a fiesta in the conLisa Glenn, M.D., ference host hotel, the Clinical Innovation Grand Hyatt San AntoMedical Director for nio. Attendees listened the Texas Department — Dale Ragle, M.D. to mariachi music, ate of Aging and Disability street tacos and churros, Services, received the and danced cumbias all Public Health Award. night. The University of Mark your calendars now for upcoming North Texas Health Science Center and Texas symposia. TAFP offers two Primary Care College of Osteopathic Medicine in Fort Summit conferences this fall; Primary Care Worth was given the Medical School Award of Summit – Houston at the Westin Oaks Oct. Achievement for attaining 25 percent of gradu17-19, and Primary Care Summit – Dallas ates entering family medicine residencies. at the Westin Galleria Nov. 7-9. The 2015 Dan Sepdham, M.D., received this year’s C. Frank Webber Lectureship will be held Exemplary Teaching Award for his work at March 6-7 at the Omni Austin Hotel at the University of Texas Southwestern MediSouthpark. For the full 2015 schedule, check cal Center. out the ad on the facing page or go to www. Tricia Elliott, M.D., received the Special tafp.org/professional-development. Constituency Leadership Award.

TEXAS FAMILY PHYSICIAN

announcing

TAFP’s All-New 2015 CME Conference Schedule Next year, big changes are in store for TAFP’s CME conference schedule, as we move the state’s premier education conference for family physicians to the fall and introduce a brand new summer CME event.

C. Frank Webber Lectureship & Interim Session Omni Austin Hotel at Southpark • Austin

TAFP’s first conference of the year features a full day of engaging CME, Academy business meetings and policy discussions, networking opportunities, and more. Most committee, commission, and section meetings will be held on March 7, as will the Student and Resident Conference.

Introducing our new summer CME event:

Texas Family Medicine Symposium La Cantera Hill Country Resort and Spa San Antonio

Attendees will have the chance to earn 25 credits of cutting-edge CME including the required ethics credit in only two and a half days, or they can work toward their maintenance of certification requirement with a SAM Group Study Workshop.

Annual Session & Primary Care Summit The Woodlands Waterway Marriott • The Woodlands Annual Session is moving to November! This is TAFP’s most anticipated conference of the year, complete with more than 20 hours of CME, a bustling exhibit hall, social and networking events, SAM Group Study Workshops, procedural training, and much more. TAFP’s committees, commissions, and sections will meet to discuss policy and practice concerns, and delegates from local chapters will gather at the TAFP Member Assembly. Plus TAFP’s officers for the coming year will be installed, some of our most dedicated members will receive honors and awards, and we’ll all celebrate a great year at the President’s Party.

[SUMMER 2014]

TEXAS FAMILY PHYSICIAN

Is hospital employment or physician-led ACO the best bet for professional and economic reward? New data sheds light on the answer.

THE

BIG DECISION By Julian D. “Bo” Bobbitt, Jr., J.D.

Primary care physicians around the country are facing the largest decision of their lives: Do I stay independent and maybe form an accountable care organization with other independent physicians, or do I become an employee of a hospital or health system? As accountable care is taking hold, new data may alter historic thinking on this “bet-the-practice” question.

www.tafp.org

[SUMMER 2014]

The historic case for hospital employment

Even though the fee-forservice days are waning and strains are showing for many hospitals that are not adapting, for many employed physicians, the pace of preparedness for the accountable care era has been disappointing.

[SUMMER 2014]

TEXAS FAMILY PHYSICIAN

Tired of being overworked, under-satisfied, and overwhelmed with growing regulatory requirements, many primary care physicians have sought the security and strength of hospital employment. They say the pressures to invest in technology, billing, coding, and continued reimbursement pressures are just too great. Yet the majority of these physicians miss their days of self-employed autonomy. On average they are less productive and they worry that the clocks on their compensation guarantees are ticking down. Most of the moves by your colleagues, and perhaps you, to hospital employment have been defensive. It was just no longer feasible to stay afloat in the current fee-for-service system. You cannot work any harder, faster, or cheaper. You can no longer spend satisfactory time with your patients. On the other hand, some of you may have joined a hospital or health system to be proactive in gaining a solid platform to prepare for the new value-based payment era. You may have envisioned being integrated with a critical mass of like-minded physicians and facilities, aided by advanced population management tools, a strong balance sheet, and all linked together on the hospital’s health information technology platform. You read that primary care should be in a leadership position and financially incentivized in any ACO, including a hospital’s. Independent physicians could theoretically form ACOs, too, but lack the upfront capital, know-how, and any spare intellectual bandwidth to do so. So from a strategic perspective, becoming employed with other physicians by a health system has seemed the way to go.

New data The pace has quickened for health care’s movement away from fee-for-service or “pay-for-volume” to payment for better outcomes at lower overall costs, or “pay-for-value.” The factors that applied to the decision to become employed in the fee-for-service era may be yielding to those in the accountable care era sooner than anticipated. Independent physician-led ACOs appear to be adapting better than hospitals to this mega change. Although much better prepared fiscally, hospitals are conflicted, or at least hesitant, to make this switch because much of the savings comes from avoidable admissions and readmissions. On the other hand, emerging data and experience are showing that physician-led ACOs can be very successful. There are some very integrated and successful hospital-led integrated ACOs or other value-delivery hospital/physician models. In fact, this author believes that if the hospital is willing to right-size and truly commit to value, it can be the most successful model. However, many physicians signed volume-only physician work RVU compensation formulas in their hospital employment agreements, with no incentive payments for value. They have not been involved as partners, much less leaders, in any ACO planning. Even though the fee-for-service days are waning and strains are showing for many hospitals that are not adapting, for many employed physicians, the pace of preparedness for the accountable care era has been disappointing. New data shows that while most of the early ACOs in the Medicare Shared Savings Program were hospital-led, there are now more physician-led ACOs than any other type. At the same time, early results of some modest primary care-only ACOs have been exciting. One rural primary care physician ACO, Rio Grande Valley Health Alliance in McAllen, Texas, is preliminarily looking at 90 percentile quality results and more than $500,000 in savings (unofficial) per physician in their first year under the Medicare Shared Savings Program.

In fact, in a May 14, 2014 article in the Journal of the American Medical Association, its authors stated: “Even though most adult primary care physicians may not realize it, they each can be seen as a chief executive officer in charge of approximately $10 million in annual revenue.” They note that primary care only receives 5 percent of that spending, but can control much of the average of $5,000 in annual spending of their 2,000 or so patients. The independent physician-led Palm Beach ACO is cited as an example, with $22 million in savings their first year. They recommend physician-led ACOs as the best way to leverage that “CEO” power.1 These new success lessons are being learned and need to be shared. Primary care physicians need to understand that the risk of change is now much less than the risk of maintaining the status quo. You need transparency regarding the realities of all your choices, including hospital employment and physician ACOs. This author heartily endorses the trend recognized in the JAMA article: “[A]n increasing number of primary care physicians see physician-led ACOs as a powerful opportunity to retain their autonomy and make a positive difference for their patient—as well as their practices’ bottom lines.”2

Primary care physicians need to understand that the risk of change is now much less than the risk of maintaining the status quo.

RESOURCES FROM AAFP Contract negotiations: Five elements to consider If you’re considering a position as an employee of a hospital, health system, or physician group, it’s important to know the basics before you negotiate an employment agreement. These five elements are just the starting point; there are a number of other important contract-related considerations to take into account. A health care transactional attorney can help you review a specific employment agreement in detail to be sure it is fair and appropriate and represents your best interests.

1. Compensation: Am I being compensated fairly? Will I be able to earn incentive compensation under the terms of the agreement? Ensure that your base salary is guaranteed for as long as possible without adjustment. For physicians coming directly out of training, this period may only be one year, while physicians who are joining a health system as part of a practice sale may be able to negotiate a longer period of guaranteed base salary (three to five years). Find out whether the compensation you’re being offered is comparable to that of physicians with similar skills and experience in your region. Survey reports on physician compensation are available to help you to determine how much family physicians in your area earn. You can also ask employed colleagues who are in similar practice situations how they are compensated. If an employer offers a base salary plus incentive compensation, look closely at how you would qualify for incentive payments and how they are calculated. Many incentive models are still based on collections or work relative value units. However, these models are evolving to support higher quality, better coordination of care, and improved efficiency through clinical integration and accountable care organizations. If you will be eligible for meaningful use incentive payments and other types of bonus money that may be available, get specific information about the criteria the employer will use to disburse these payments.

F. Mostashari, MD, MPH; D. Sanghvi, MD; M. McClellan, MD, PhD; Health Reform and Physician-Led Accountable Care: The Paradox of Primary Care Physician Leadership, Journal of American Medical Association, 2014; 311(18): 1855-1856. Id.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, North Carolina. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or (919) 821-6612. This article is reprinted with permission of Family Practice News.

Specific requirements regarding all of the activities and metrics (e.g., collections, productivity, quality, meaningful use) that will affect your compensation should be included in the employment agreement or in an established written policy that is applicable to all similarly-situated physician-employees, not subject to the employer’s discretion. Consider what benchmarks you will be measured against and how data will be collected and submitted, and ensure that the benchmarks are stipulated in the agreement.

2. Benefits: What benefits does the employer offer? Should I ask for any additional benefits? Employers typically offer health insurance for the physician employee (and possibly for family members), license fees, medical staff dues, and a stipend for continuing medical education. Many employers also provide a retirement plan. In general, hospitals and health system employers offer a better range of benefits and more retirement options than private practices. www.tafp.org

[SUMMER 2014]

Practice management help from your Academy TAFP offers several payment and system reform resources at www.tafp.org/ practice-resources/payment-reform. Learn more about ACOs at www.tafp.org/practice-resources/practiceredesign. You’ll find The Family Physician’s ACO Blueprint for Success, an ACO Legal Primer, The Family Physician’s Practice Affiliation Guide, and much more. For more practice management resources from AAFP, go to www.aafp.org/ practice-management.html.

It’s not unusual for physician employees to get three to four weeks of paid vacation and CME time. It is less common for employers to offer paid sick leave. More employers are combining vacation, CME time, and sick leave into a “paid time off” concept. Be sure that your employment agreement specifies the amount of paid time off to which you’re entitled. If not, changes to your employer’s leave policy could reduce your benefits without your consent. If your compensation is based in part on productivity, you should analyze how your income may be affected when you take paid time off. Most employers pay for malpractice insurance. As an employee, it’s preferable to have occurrence-based coverage (for incidents that happen during the coverage year, regardless of when a claim is filed). If you have claims-made coverage (for claims filed during the coverage year), you will need a reporting endorsement (“tail coverage”) when your employment ends. This covers incidents that happen during employment but aren’t litigated until after employment ends. If the employer offers a claims-made policy, your employment agreement should specify whether the employer will pay for part or all of your tail coverage upon termination of employment. If you’re considering a position in a different area, ask the employer whether a moving expense allowance is available.

3. Schedule and call: What are my call and coverage obligations? Employers often leave scheduling provisions loose so that physician employees have the flexibility to deal with the needs of their patients and the practice. Be open about your schedule expectations to ensure that they align with the employer’s requirements. If the employer makes any promises about your schedule (e.g., you won’t have to work more than one night per week or one Saturday per month, you can work a flexible schedule), try to incorporate the specifics into the employment agreement. Call and coverage obligations should be spelled out in the employment agreement. Be sure that your call responsibilities are not more burdensome than other family physicians employed under similar terms. Also, find out whether the employer offers compensation for taking call, which usually only occurs for taking additional call beyond that which you are already required to provide. If you’re only working part-time, be specific about your schedule in the employment agreement, especially if you’re paid on a salary basis. This prevents the employer from taking advantage of you by requiring you to work more hours than agreed upon.

4. Terms and termination: What is the actual term of the employment agreement? What are the termination provisions? Many employers (especially physician groups) include a “without cause” termination provision in the employment agreement. This allows you or the employer to terminate your employment without cause. A notice provision that requires written notice 30 to 90 days prior to termination is typical. Almost all physician employment agreements allow the employer to terminate for cause. Be sure the agreement requires your employer to give you written notice of the cause for termination and an opportunity to “fix” alleged breaches or deficiencies within a reasonable period of time (typically, five to 30 days). Keep in mind that termination provisions set the term of the agreement, regardless of the stated term. If you or the employer can terminate the agreement without cause, the actual term of the agreement is the length of the notice period (e.g., 30 to 90 days). Some hospitals and health systems will guarantee a minimum one-year term. Be aware that if you agree to this, you’re contractually obligated to stay for the full term.

5. Restrictive covenants: If my employment ends, will I be able to practice in this area? Some states do not permit restrictive covenants, or they limit an employer’s ability to enforce them. However, many states do enforce them, even if there are limits imposed by state law. In general, these states require that restrictive covenants must be limited in duration and geographic scope to reasonably protect the employer’s interest against competition. Most restrictive covenants last for one to two years following termination of employment. A reasonable geographic radius for a restrictive covenant depends on where you practice. A restriction of 25 miles might be appropriate in a rural area, whereas a one-mile radius might be enforced in an urban setting. Ask if the employer will agree to limit the instances in which the restrictive covenant is enforced. For example, the employment agreement could specify that the restrictive covenant will not be enforced if you terminate your employment for cause. Non-solicitation provisions go hand-in-hand with restrictive covenants. States that don’t enforce restrictive covenants often allow provisions that prevent you from soliciting former patients, employees, and referral sources after your employment ends. Source: AAFP Practice Management Resources, referenced July 2014. http://www.aafp.org/practice-management/payment/contracts.html

[SUMMER 2014]

TEXAS FAMILY PHYSICIAN

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11/13/12 1:26 PM

CONCIERGE MEDICINE Which option is best for you and your patients?

By Wayne Lipton Managing Partner, Concierge Choice Physicians

ndependent and small group physicians in Texas and throughout the nation are literally at their wit’s end. They are seeing the practices they spent years to build erode as reimbursement is slashed and overhead spirals. They are becoming less the caregiver and more the administrators of care. Workdays are getting longer, worry about how to maintain the practice is increasing, and personal satisfaction is waning as physicians have less time to spend getting to know patients as people and spend more time inputting codes and impersonalized data into increasingly complex computer systems. It’s all a bit heartbreaking to many physicians. In frustration, many sell their practices, retire early, or add other incomeproducing services, from aesthetics to weight loss products. What’s more, those who have joined groups wonder if there is a way to recapture the reasons they entered medicine in the first place: a chance to have one-to-one connections with patients and to be the “quarterback” who directs and manages all care. As if these questions weren’t enough, physicians are also faced with a rash of new models and options all promising a better life, more income, less reliance on insurance, or any one of a number of other claims. So, what to do? The reality of the physician marketplace in Texas is that it is changing and there is no going back. Now is not time to take a wait-and-see position. It’s the time to study options, to ask yourself what you want, and to make the decision to embrace change. Such change doesn’t need to be foisted upon you. Texas physicians are still predominantly independent. Most are looking for ways to stay that way. The good news is there are options to maintain autonomy and remain a viable practice. Is concierge medicine the answer? One option Texas family physicians are considering is full-model concierge programs. While it’s hard to pinpoint a specific

[SUMMER 2014]

TEXAS FAMILY PHYSICIAN

number as there are many permutations, it’s estimated there are more than 100 concierge programs in Texas today. In full concierge care, the goal is to limit the number of patients – typically to around 600 – to allow for more time and personal care. Fees are usually over $1,500 per year, which helps ensure profitability and limit the patient panel. Full model concierge programs include: • The potential for a significant increase in revenue; • The opportunity to return to the style of practice most family physicians were taught in medical school; and • The chance to build an ideal practice for physicians nearing retirement or dealing with physical limitations, as well as those wanting more time with family and those wishing to pursue other interests. Concierge programs today can be flexible. Some physicians opt to continue taking insurance, including Medicare, and some decide to forgo that feature. While there are some constraints, including the fact that not every market can sustain such programs, for those physicians who enter the market judiciously and for the right reasons, it can be a life-changing move. Hybrid concierge In the early 2000s, a new practice model called hybrid concierge was introduced to physicians. In this model, physicians continue to see all their patients, even those on Medicare, giving those patients the option to participate in a concierge program. Hybrid programs specifically offer non-covered and enhanced services, typically an in-depth physical, complete with relevant tests and lab work. Patients retain and use their existing insurance and as most physicians remain on insurance panels, there is practice stability and a guaranteed source of income. The hybrid concierge program is built around a package of services tailored for the physician’s patient population. Most physicians emphasize prevention and wellness and a comprehensive approach to health. It also offers extended patient appointments and same- or next-day scheduling. Patients have direct access to their physician via a private phone line, e-mail, and text. Physicians also have the ability to provide more advocacy and care coordination services. In a hybrid practice, a few hours each day are dedicated to delivering the concierge main services and follow up care. Members can schedule appointments during non-con-

cierge time as well if needed. Since the concierge service represents from 10 percent to 25 percent of the practice time, the impact on the overall volume of the practice is minimal. If needed, overflow can be moved to other providers, like nurse practitioners. During concierge hours, physicians see one to two patients an hour with time built in to allow for patient outreach, personal follow-up, and coordination of care. The typical patient who opts to join a hybrid program is often over 45. However, many are far from the stereotypical concierge image. They run the gamut from schoolteachers to truck drivers to retirees to busy executives who want the convenience concierge care offers. They share one common trait—an interest in prevention, wellness, and a closer relationship with their chosen physician. It’s a very family-centric model as many patients join with their older parents and use the model as a way to provide the care coordination and personal advocacy that can be lacking in some practices today. Plus, in some programs, children up to age 25 are covered under their parents’ plan. Physicians note they often have up to three generations of patients, enabling them to provide true “family” medicine. Because the physicians’ primary source of future patients is existing ones, great care is taken to ensure that all patients in the practice are satisfied. The hybrid model also works well in group and even large health care system environments. Because it incorporates insurance plans and doesn’t disenfranchise patients, it can be integrated into existing programs. It also ensures that practice referrals and hospital admitting privileges can continue. Revenue generated varies significantly and depends on the number of patients who join. While one can attempt to introduce a hybrid model without assistance, using a company that can help practices avoid the marketing, regulatory, and strategic land mines is extremely valuable. In addition, external companies often cover all of the costs associated with the implementation and can ensure the overall risk to the practice is minimized. Exploring choices There remains much uncertainty for physicians today. But there are also many choices. Now is the time to fully explore available options—look at what is best for you and your patients and commit to embarking on a change that will enable you to continue to practice medicine the way you think is best for you and your patients.

One Texas FP’s experience with the hybrid concierge model Gregory Fuller, M.D., is a family physician in Keller, Texas. He has been part of a successful independent family medicine group for 24 years. In addition to Dr. Fuller, there are two other physicians and a physician assistant in the practice. Dr. Fuller has always enjoyed taking care of his patients, but over the past several years, he found it more frustrating. One of his biggest concerns was the evolution of insurance companies and Medicare becoming more involved in clinical decision making and increasing administrative burdens, thus decreasing his face-toface time with patients. Plus, as with many physicians, his reimbursement was continuously uncertain. Yes, there were payer bonuses and incentives (that typically added little real revenue when all was said and done) and there were small increases that would appear to bump up compensation. But there were also many payment reductions and often to earn incentives, considerable investment had to be made in infrastructure or administrative services, thus negating the benefit (EHR anyone?). Payers have always targeted primary care physicians first when trying to cut costs. As a result, practice revenue had gone down or stayed flat, while expenses continued to increase. He knew something had to change. “I’m first and foremost a physician,” Fuller says. “But I also have an obligation to my practice, my employees, and my community to stay viable. The only way to break even was to increase the volume of patients in my practice.” As a result, he noted that both he and his patients often felt rushed. Unless there was a problem, patient visits were scheduled in 10 to 15 minute increments. If patients did have other questions, they were told to schedule another appointment. “All these changes were necessary, but they had me missing the days when I could have a real relationship with my patients,” he says. “I like being a doctor and I want to have the time needed to communicate fully with my patients about what we can do together to improve their health. I can’t provide patients with the information they need, or answer their questions, if they don’t get that dedicated time from me.” To accommodate the demands of his practice, Dr. Fuller’s days became longer and increasingly more exasperating. He decided it was time for a change. In 2011,

he heard about the hybrid concierge model and decided to find out more. He was aware of full model programs, but with a patient panel of 4,500, he didn’t want to embrace a practice model that might disenfranchise many patients. After careful consideration, he decided the hybrid model was the right choice. With the program, patients have his direct phone line or can e-mail or text. While some of his contemGregory Fuller, M.D. poraries shared concern that such access might be abused, leading to calls late at night or weekends, Dr. Fuller notes that because he is more accessible during the day, patients don’t call off-hours unless it is a true emergency. “Patients are extremely respectful of my time,” he states. “I often have to remind them they can call any time.” Dr. Fuller reports the model has worked well for him and his patients. The launch of the program was seamless, taking minimal time from him and his staff. It has enabled him to continue to see all patients, even those on Medicare, and most importantly to practice medicine the way he and his patients prefer. His income has increased about 7 percent monthly, without adding more patients or extra services, and with no additional cost to his practice. However, he has the capacity to increase the program to generate greater income. He could also opt when needed to move to a transitional program and over time, segue to a full concierge model. Dr. Fuller notes that he has contemporaries who have opted to sell their practices to rid themselves of financial and administrative pressures, but that often they are simply changing one set of headaches for another. “I am hearing about a lot of physicians who joined large health care systems but who now want to return to private practice,” he says. He advises other physicians struggling to maintain their practice to consider all options available today and to move forward with making the decision they want quickly to avoid having that option taken away by outside forces.

www.tafp.org

[SUMMER 2014]

Karrie Lynn Crosby, MPAS, PA-C, is President of the Texas Academy of Physician Assistants. A PA at Scott & White for 16 years, Karrie is a member of its Advanced Practice Professional Council, made up of PAs, nurse practitioners and clinical nurse anesthetists. She is also the first non-physician provider to have a voting seat on the Clinic Staff Organization, which represents physicians. In her 20 year career, 18 of those years have been in family medicine.

Physician assistants can help ease the challenges in your practice By Karrie Lynn Crosby, MPAS, PA-C the shortage of primary care physicians in Texas and the increasing demands of a growing-insured population have converged to create a heavy burden for physicians, especially those in family medicine. Other issues abound: physicians are being challenged by significant changes in the profession; they are concerned about health care reform and how it will affect the way they practice and care for their patients; new processes make it hard to stay on schedule; work days are getting longer; and the reimbursement structure is changing. Rightfully so, family physicians are concerned for their quality of life and the future of their practice. Physician assistants are keenly aware of the stresses on the physicians they work with and are well equipped to be a part of the solution. Certified PAs are educated in the medical model to work alongside their physician partners. We do not seek independent practice; rather we are allies to our supervising physicians, supporting the team-based practice model that involves all providers being utilized to the full extent of their education and licensure. We want to help practices continue to deliver quality care and alleviate some of the physicians’ challenges, which ultimately benefits the patients. The PA mindset A PA’s job is to help make the team successful. We work closely with our physicians to improve the lives of our patients. It is a phenomenal partnership that my physician partners would not want to give up. They see us as a team, and they know we share their goals. 28

[SUMMER 2014]

TEXAS FAMILY PHYSICIAN

I enjoy working in family medicine, probably for the same reasons you do. It affords the opportunity to develop important relationships with patients and their families. My personal philosophy is to meet our patients at their level of concern and understanding. It is important to listen and really hear what they have to say. They come in with an agenda and don’t always spell it out; we have to investigate and get to the root of the real problem. As family medicine providers, we seek to understand the whole patient, their life stressors and their family environment. Rapport develops over time, and they become comfortable sharing the whole picture. This unique opportunity allows us to have a relationship that, in the long run, enhances their care. Patients are consumers; they have a choice of whom they want to see, and quality measures will define the care we give in new ways. Patients need to trust us and understand how we arrive at decisions, or they won’t follow our advice. PAs are trained to discuss preventive medicine, and we try to explain to patients their role in managing their own health. PAs at Scott & White provide many benefits Michael Reis, M.D., who chairs the Department of Family Medicine at Scott & White Healthcare, points out that physicians have to be willing to share responsibility with PAs. “In the past, physicians were trained to do everything, and delegation was discouraged. But the world has changed, and team-based care is the norm. [cont. on 30]

Kids are drinking soda and fruit drinks as early as

Kids are drinking

What?!

MONTHS

Based on NHanes Data, 2007-2010

When kids miss out on Milk, they miss out on Nutrition. Pour one more to close the nutrient gap

Dairy delivers major nutrition Calcium 59%

Potassium 25% 3.5 3

Magnesium 20%

Zinc 21%

cups

2.5 2

Vitamin D 72%

Vitamin B12 35%

1.5 1

0.5 0

Current Intake

+1 Cup Milk

Current Intake

4-8 years

+1 Cup Milk

Protein 25%

Phosphorus 37%

9-18 years Recommended Intake

Riboflavin 34%

Vitamin A 37%

Based on NHanes Data, 2007-2008

What does the American Academy of Pediatrics Recommend for kids?

Milk at meals and Water in between.

dairymax.org

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“PAs are a second set of eyes and ears to manage patients,” Reis says. “By being engaged in the health care team, they are valued partners who help us contribute to quality outcomes. They also allow us to expand our panel of patients, extending the physician’s reach to a growing patient population.” At Scott & White family medicine clinics, PAs see a larger load of acute care patients, but we also have pre-scheduled patient appointments and manage chronic conditions. PAs can be very helpful in the area of population management. When I came to Scott & White, there were less than 100 advanced practice professionals (including PAs, nurse anesthetists, and nurse practitioners), and that number has more than tripled in the last three years. Our physician partners have appreciated the ways we enhance their practice. In private family practices across Texas, PAs are growing in numbers as well. According to the National Commission on Certification of Physician Assistants, there are currently more than 95,000 certified PAs in the United States. NCCPA estimates:

Scott & White has always had a quality-centered approach to health care, following evidence-based medicine, so what is required to support the patient-centered medical home model and an accountable care organization is not new to us. Part of our success in these areas is the team-based model which fully utilizes PAs and other advanced practice professionals. What has changed in this age of health care reform is that we now document that care using a standardized approach through electronic health records. This will allow us to demonstrate outcomes and prove our quality assurance measures. Considerations when hiring a PA Physicians often ask how they can utilize PAs to provide access to more patients. Obviously different practice models will utilize PAs in different ways, depending on the patient population, setting and specialty. Seven things to consider are: 1.

Review state guidelines and regulatory standards. In Texas, PAs are allowed to prescribe dangerous drugs and CIII-V medications in the clinic settings, with added CII delegated prescribing in facility based practice settings and hospice; one physician can supervise up to seven PAs; and there is no distance limitation for physician supervision, making it easier to provide care in rural and underserved areas.

Talk to your physician colleagues. Ask them how they integrate PAs into their practice and how they effectively utilize PAs to increase patient access and decrease physician over-

• More than 20,000 of those work in family medicine, • There are more than 7,600 certified PAs in Texas, and • More than 2,000 of the PAs in Texas work in family medicine. At Scott & White, certified physician assistants are used in most clinical specialties. We have documented that utilizing certified PAs can help improve access, maximize same-day appointments, enhance preventative care, decrease length of hospital stay and are cost-effective, contributing positively to the bottom line.

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load. Each practice setting will utilize PAs in a different way based on the needs of the practice. 3.

Determine how you want to utilize a PA. Will the PAs see walk-in patients or those with scheduled appointments? Will they concentrate on chronic disease management or wellness exams? Will your model be dual care, where a PA sees the patient and the physician joins in at the end to answer questions? Or will PAs have their own patient panel and bring you in only for consults as needed?

Decide whether to hire experience or a new grad. This depends on the physician’s or employer’s vision for the practice. Do you want a PA who can hit the ground at full speed, or would you rather hire a new graduate that you can mold in your methodology? Cost may weigh into this decision as well.

Volunteer to be a preceptor. This has worked well at Scott & White. Yes, it takes time, but you get to train them in the way you practice. It is a way to try out a PA for a designated period of time. If the collaboration works well, you can hire them before others have a chance. Nationally, 30 percent of PA graduates find their first job with a preceptor.

Allow your PA to practice to the full extent of their license. PAs want to contribute to the practice as much as possible. Many PAs say they could do more when given the opportunity, and would appreciate being able to continue to learn from their physician partners. We want to earn their respect and trust.

Explain team-based care to your patients. Have a plan in place to introduce the PA and explain what they will do and how you will work together. Studies show that patients often choose to see a PA if they can be seen sooner.

Why you can count on PAs Certified PAs are highly educated medical providers who graduate from accredited, masters-degree level PA programs, pass a rigorous national certification exam, and maintain certification through ongoing education and recertification exams. They are also licensed by state medical boards. PAs routinely obtain medical histories; examine, diagnose, and treat patients; order and interpret diagnostic tests; and develop and implement treatment plans. They can perform minor surgery and assist in major surgery; instruct and counsel patients; order or carry out therapy; and prescribe medications. According to NCCPA, every week certified PAs work 3.8 million hours enabling them to increase health care access by seeing 7 million patients in every clinical setting across the U.S. A recent NCCPA survey shows that access to good, affordable health care now trumps virtually every other societal concern and indicates that more consumers are ready for PAs to play a greater role in their care. For physicians in family practice who are being squeezed between patient demands and hours in the day, certified physician assistants might help transform your practice into one that you envision for your future.

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The sale of any private practice offers three benefits: To the selling physician: Monetary exchange for an ongoing business. Many physicians think that because they have HMO contracts, the patient base cannot continue. This is not true. Although any patient will go first to a doctor “on my insurance plan,” after that, patients will often stay with a physician with whom they have a relationship of care. This is the goodwill of the physician with the patient. And the IRS recognizes goodwill as a value. Benefit to the buyer: An existing business and patient base does not cost as much to maintain as the cost to start from scratch. There is an often spoken assumption that patients will leave when the doctor leaves. This is not true. Patients often stay with a group when a doctor leaves. Patients will often stay and transfer to another doctor in the practice. This means that an ongoing practice that is bought, often for less than starting up a practice, has the benefit of immediate cash flow. This means that there is revenue to pay the bills, payroll, and operations. Starting up a practice costs more and it may take a year or two to generate a paying patient base to break even. Who wants that? Benefit to the patient: many physicians think that when they leave all the patients will also leave. Some will for reasons other than a change in the doctor. But most will want to come back. “I don’t have to go out and look for another doctor that I don’t know and start all over.” A patient does not want to change everything. The doctor may be new but the practice location is the same, the staff often remains, the chart of medical history is the same. The exiting doctor has recommended the new doctor, so most patients will give the new doctor taking over the benefit of a first visit. Continuity of care is important.

Don’t sell your practice short What you need to know when you decide to sell your practice By Lowell A. Davis

are private medical practices bought and sold today? This is an important question to consider on different occasions. Retirement. Do I just send my patients a letter, close my doors, and liquidate my office furniture and equipment? Illness. Is this just an earlier retirement than I had planned for? Has a group practice approached me? Has a hospital approached me? Private medical practices are sold all the time. It just takes time. The fact is that a private medical practice has a marketable value. This is because a private practice has cash flow, goodwill, and assets. And there is a whole body of professional standards and strategies that professional brokers use to assist physicians in a sale transaction. 32

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Who are the buyers? There are two kinds of buyers: those who come to you and those to whom you market. Who would come to you and offer to buy? Many hospitals want to consolidate their market share of a region. Hospitals are looking for outpatient diagnostic patients, as well as a more predictable hospital census and procedure utilization. With recent regulatory changes, hospitals have been more aggressive in buying the private medical practice. In large metropolitan areas, hospitals have set up clinics all over the area. In smaller communities the doctor referral base is vital to a hospital’s survival. The expanding private medical group may approach you. This type of practice wants to grow. The easiest way to grow is by acquisition. Larger private practices want patient “market” share and stability. They also are looking for economy of scale, hopefully providing more medical services more economically. Two cautions: Don’t wait until you are desperate due to the financial condition of your practice (you are too deep in debt, or losing too much money). Don’t wait until you are too ill and cannot practice any longer. The second caution is, don’t try to sell it yourself. Get professional help. There are two kinds. A professional appraisal that tells what your practice is worth, and professional help in negotiating the sale. Most selling efforts fail due to the physician’s erroneous value of the practice, and trying to sell the practice directly. Be patient. To negotiate a good sale to someone who approaches you will take an average of six months. To find a buyer and negotiate a sale may take as long as 12-15 months. Don’t leave a medical practice equity value for others when it is time for you to make a move. Exit with a crown and not a cane. Lowell A. Davis is a consultant with Physician Practice Advisors in Houston, Texas. Contact him at ppag81@gmail.com or (281) 855-3027.

www.tafp.org

[SUMMER 2014]

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PRACTICE MANAGEMENT

Electronic health records: Good, bad, or ugly? By Bradley Reiner

it’s not unusual for a doctor to pick up any trade journal and read about how electronic health records are the end all and be all in documenting services and maximizing reimbursement. The U.S. government has encouraged physicians around the country to transition to EHRs offering billions of dollars in incentive payments. These systems have been touted to increase efficiency, improve care, and reduce costs in the health care industry. But new information is being released by the U.S. Department of Health and Human Services warning that increased use of improper documentation standards in EHRs may lead to an increase incidence of Medicare fraud. The letter warns against cloning medical records, which could lead to up-coding claims and improperly inflating reimbursement. In January, the Office of Inspector General issued a report flagging EHR related fraud as a problem. This will almost assuredly trickle down to commercial payers who are constantly looking for reasons to request refunds for over-coded services. I provide hundreds of record reviews each year and I’m seeing a similar trend in documentation. Many of the documented visits are looking the same as the previous one. With the increased use of EHRs, the OIG is growing concerned with the increased frequency of medical records documenting the same information regardless of the nature of the presenting problem. The OIG is evaluating multiple records for the same provider to determine the extent to which doc

umentation problems exist. They are cracking down and penalizing physicians who duplicate documentation in this fashion. Physicians must be cautious when they pull information from previous visits or repeat documentation regardless of the presenting problem. Records should be specific and unique for each visit. Here are some things to watch for as they may be causing significant problems in your practice. Copy and Paste It’s so simple. Just copy and paste, right? Wrong. Doctors love this easy mechanism for repeating information—maybe too much. Many doctors feel that more information in the record means the documentation must be better, which means they should be able to bill for higher codes. This mindset creates a serious fraud risk. For example, established patient visits require only two of the following: history, examination, and medical decision making. If you copy and paste information from a previous visit and this increases the level of history and examination, the code choice could be higher. However, if the problem presented that day was something simple such as a thumb injury, it would not be appropriate to document a high level history or examination for this type of problem. This is where additional but unnecessary documentation is a mistake and can be interpreted as fraudulently attempting to increase payments. www.tafp.org

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Standardization Electronic systems have functions now that allow the user to insert standardized text into the medical note. These “macros” can make it easy for doctors to complete their records each day, but predetermined scripts can backfire and cause records to look exactly like previous documentation causing more scrutiny. I’ve seen this problem most often in the history of the present illness and review of systems where the HPI documents the presenting problem, but the ROS states that the patient does not have any of the symptoms discussed previously in the record. The record appears to have been pre-populated for all of the systems to be reviewed and no one bothered to change it to ensure it is consistent with the rest of the record or the nature of the problem. Doctors must ensure that the entire record is consistent and appropriate. Nature of the presenting problem I’ve seen many records that may meet a higher level of history or examination but the medical decision making falls short. The medical decision making is made up of the number of diagnoses and management options, the amount and complexity of data ordered or reviewed, and the risk. These elements are important in code choice regardless if the patient is new or established. I would also suggest that the risk can be considered the most critical issue in determining code level. A patient may present to the office with a minor problem that is quickly diagnosed including over the counter treatment recommended. The record can be over documented for the history and examination, but what really must drive code choice are the limited diagnoses, limited data reviewed, and straightforward risk. The code should be billed as a low level. I consistently have to train physicians to understand medical decision making and the work involved for the visit. Recognizing that this is the element that ultimately drives code choice has to be a significant factor when selecting a code.

Things you can do to prevent your EHR from exposing you to fraud and possible refunds includes following these recommendations: •

If you use an automated text function, don’t assume it will be consistent with the other information in the note. Read the note to ensure that it flows and is consistent with what you are trying to communicate. Make sure the record does not include extra or unwarranted information.

•

Ensure each record stands alone and is unique from the previous patient or visit. Don’t let records look the same.

•

Read your assessment and plan and ask yourself: “Is the information contained in the history and examination relevant for the nature of the presenting problem?” If you answer yes then you have the required information for the problem presented. If the answer is no, remove unnecessary information that doesn’t have any relevance to the current problem.

•

Consider the medical decision making (number of diagnoses, complexity of data, and risk) to be the most critical elements in code choice. Ensure these elements are met.

•

Consider an educational record review audit to determine the elements that need improvement. Help train doctors with weak documentation ways to document more effectively. This will help ensure more consistent documentation and help avoid refunds or questions of fraudulent behavior.

Compliance with medical record documentation is crucial to avoid suspicions of over documenting or up-coding. It’s not a matter of whether they review your records; it is a matter of when. Be prepared by having your records reviewed to understand areas of weakness and what needs to be improved. The government and commercial payers are relying on those inside the medical community to take a stand against abuse. It starts with you.

Bradley K. Reiner, formerly with Texas Medical Association, has been owner of Reiner Consulting and Associates for 15 years. He is TAFP’s endorsed consultant and is a billing and coding auditor for the Texas Medical Board. He can be reached at (512) 858-1570 or e-mail at breiner@austin.rr.com.

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Hospice experience can be rewarding By Lloyd Van Winkle, M.D.

it used to be that when I had a patient whose health was declining and he or she was nearing the end of life, I would direct the patient to hospice care. Hospice would take responsibility for the patient’s care, and I would receive updates by phone. I might go by and see the patient once or twice. Ultimately, I would be notified that the patient had died, and I would call the family to offer my condolences. That was my standard procedure for more than 20 years. Life goes on. Then my own mother was diagnosed with cancer. Her health declined, and she went to hospice. There, I was free to be her son and not another doctor in the room. We listened to the old 1950s music that she loved and reminisced. I will always be grateful that we had those 21 days together. My mother’s physician at the hospice was a general internist who had his own practice but who also worked at the hospice on the side. I was intrigued, and, rather than following the old routine of referring my terminal patients to someone else, I started following them through hospice care myself. It only makes sense. Family physicians help bring new lives into the world. Then we care for those patients throughout their lives and help them make that life as healthy and productive as possible. At the end of life, we can help them be as comfortable as possible. The hospice in San Antonio is near the hospital to which I refer my patients, so I make rounds at both facilities. I was at hospice often enough checking on my own patients that, after a few years, I was asked if I would take calls a few times a month. So now I work two weekdays and one weekend a month at hospice in addition to my own practice. And after I take on a hospice patient, I follow him or her through the process. Hospice can be an uncomfortable topic for physicians, but I’ve found it incredibly rewarding. The opportunity to build relationships with patients is why many of us chose family medicine in the first place. We build connections

over years with our patients. In hospice care, similar bonds can form in a much shorter time. One of the patients I met at hospice was a 42-year-old single mother. She had terminal throat cancer and could no longer talk. During rounds one day, I asked if she had any pain. She did not look up from her note pad and simply wrote, “No.” I asked if I could do anything for her. Again, she wrote, “No.” So I went on and completed my rounds. But when I was done, I went back to her room and sat down by her bed. She wrote that she did not want to talk, but I told her that we should talk anyway. Then I asked her what she was afraid of. I looked down at her note pad waiting for a response, but what I saw next were not words but tears dropping on the page. She was afraid that the cancer would eventually erode a major artery in her throat, and she would drown in her own blood. I assured her that if her condition deteriorated to that point, we would give her medication to make her sleep, and she would not suffer. She asked me to promise, which I did. She then told me about her adult daughter and her 6-year-old son and that she wanted the daughter to have custody of the boy. The paperwork had not been completed, so I arranged for a social worker to meet with them, and it got done. At one point, she took my arm and told me, in writing, that two oncologists, two surgeons, an otolaryngologist and two radiologists had seen her during her treatment, but I was the first doctor who had sat down and talked with her. Well, that’s what family physicians do, isn’t it? In 72 hours, she was gone. But after those three days, it seemed like I had known her for years. That’s what the hospice experience can be. If you think you don’t have anything to offer to hospice care, you might be wrong.

Hospice can be an uncomfortable topic for physicians, but I’ve found it incredibly rewarding. The opportunity to build relationships with patients is why many of us chose family medicine in the first place. We build connections over years with our patients. In hospice care, similar bonds can form in a much shorter time.

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Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.

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