Texas Family Physician, Winter 2015

texas family physician VOL. 66 NO. 1 2015

AAFP Touts Family Medicine For America’s Health The Big Picture: Health Reform In 2015

Texas Family Physician Of The Year 2014-15 Russell Thomas, Jr.

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Current AAFP MIGs include: • Direct Primary Care • Emergency Medicine/Urgent Care • Global Health • Hospital Medicine • Independent Solo/Small Group Practice • Oral Health • Reproductive Health Care • Rural Health • Single Payer Health Care • Telehealth

Visit aafp.org/mig to learn more, join a MIG, or start your own.

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INSIDE

samantha white

TEXAS FAMILY PHYSICIAN VOL. 66 NO. 1 2015

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Texas Family Physician of the Year 2014-15: Russell Thomas, Jr., DO, MPH

This year’s Physician of the Year award recipient is the epitome of a country doc. Hailing from Eagle Lake, Texas, Thomas returned to his hometown after residency to practice full-scope, rural medicine alongside his physician father. It’s now 31 years later and Thomas wouldn’t change a thing.

By Samantha White

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Which way from here? Health reform in 2015 An expert health care industry strategist surveys the big picture.

By Kim D. Slocum

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Health is primary

Joined by seven other national family medicine organizations, AAFP and Family Medicine for America’s Health launched Health is Primary last year. The campaign aims to help patients and physicians find a home in primary care.

By Kate Alfano

6 FROM YOUR PRESIDENT An overview of AAFP’s and TAFP’s advocacy efforts for this year’s legislative sessions and how you can help 8 MEDICARE NEWS HHS announces a major shift toward value-based payment reform.

10 MEMBER NEWS You’re invited to AAFP’s National Conference of Constituency Leaders. | TAFP members appointed to AAFP commissions 26 FOUNDATION FOCUS Double your impact by donating to the Student Interest Endowment in 2015.

27 PRACTICE MANAGEMENT Bradley Reiner gives you the latest coding tips 30 TAFP PERSPECTIVE Affect the next generation of family docs by mentoring students in the preceptorship program.

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president’s column

TEXAS FAMILY PHYSICIAN VOL. 66 NO. 1 2015 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

Dale Ragle, MD

president-elect vice president treasurer

Ajay Gupta, MD

Janet Hurley, MD

Tricia Elliott, MD

parliamentarian

Tamra Deuser, MD

immediate past president

Clare Hawkins, MD, MSc

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, CAE

advertising sales associate

Michael Conwell Contributing Editors Kate Alfano Travis Bias, DO, DTM&H Christina Kelly, MD Bradley Reiner Kim D. Slocum cover photo

Samantha White

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 AIM Printing and Marketing, 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. © 2015 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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All hands on deck

By Dale Ragle, MD TAFP President welcome colleagues to a new year, a new Congress, and a new Texas Legislature. On all fronts, health care is evolving. These changes present family physicians tremendous opportunities to shape our future health care system. It’s up to all of us as family physicians to advocate for our specialty in the halls where decisions are made that affect our patients and our practices.

In Washington, D.C., the 114th Congress is well under way and is busy on a number of health care issues. AAFP’s advocacy work is focused on fixing Medicare’s broken payment model, changing Meaningful Use requirements, delaying ICD-10, and reforming graduate medical education funding. Another area in which AAFP is concentrating efforts is in making payment for direct primary care services a qualified health benefit under IRS rules. This would enable patients to pay for direct primary care with pre-tax HSA and FLEX account dollars, a move that would aid the expansion of this emerging and promising model of practice.

Back here at home, state lawmakers are at work in the 84th Texas Legislature.

According to the state constitution, the Legislature must be in session for 140 consecutive days every two years. Of course the old joke is that the framers actually intended the Legislature to be in session two days every 140 years, but someone got confused along the way.

As in all sessions of the Legislature, health care will compete with public education, tax cuts, roads, water, and energy on the state’s list of priorities, but rest assured there will be plenty of work for the TAFP advocacy team. Let’s take a look at some of the health care issues we’re likely to face.

Graduate medical education: Last session, led by state Sen. Jane Nelson, R-Flower Mound, the Legislature made significant strides in restoring funding cuts to the state’s family medicine residency programs and laid the groundwork to create new and expanded graduate medical education positions. As Texas continues to boom in population, ensuring an adequate supply of primary care physicians has been a major concern for the state. How we recruit, educate, and train our future physician workforce and how we pay for that effort is on the agenda yet again.

As Texas continues to boom in population, ensuring an adequate supply of primary care physicians has been a major concern for the state. How we recruit, educate, and train our future physician workforce and how we pay for that effort is on the agenda yet again in the 84th Texas Legislature.

Direct primary care: The concept is simple: a physician and a patient enter into a contract for care that they are willing to provide and receive for an agreed upon price without the interference of a third party. However, state insurance laws and regulations are opaque when it comes to whether DPC models should be construed as insurance products. TAFP will be pursuing legislation to clarify that practices engaged in the DPC model are not treated as insurance and thus are not held to that statutory and regulatory standard.

Transparency: As your Academy has been saying for some time, value-based payment— or rewarding physicians for quality of care over volume—has arrived in the health care marketplace and it will only become more ubiquitous among payers and across contracts in the coming years. To counter the indefensible variation in price and outcomes patients experience, health plans are turning to narrow physician and hospital networks, and angry employers, patients, and politicians are calling for greater transparency in health care cost and quality.

Texas Academy of Family Physicians presents: No market, especially in health care, can function properly without complete information on price, cost, and quality of the goods and services being purchased. TAFP will advocate for true transparency in costs while protecting network adequacy.

Public health: Remember last year’s Ebola scare? State lawmakers in Austin do, too.

As a result of systematic underfunding over the last decade, Texas’ public health infrastructure is frighteningly understaffed and fragmented. On this topic there seems to be bipartisan support: we must correct the lack of a coherent set of state and local guidelines for dealing with public health emergencies.

Medicaid: Some are calling for Texas to expand Medicaid coverage to poor uninsured Texans under Obamacare, but such a move is not likely in this Legislature. Few if any state lawmakers won elections on the promise to expand Medicaid, so the politics—especially in a much more conservative Texas Senate—should quash any expectation that they would contemplate a Medicaid expansion deal. Under the circumstances, this likely includes other red-statestyle private-market Medicaid solutions.

To be sure, your Academy will work diligently to serve as family medicine’s voice in this legislative session, but as always, we need your help. If you have a relationship with your state representatives, please join our Key Contacts program so we can coordinate with you and strengthen our advocacy efforts.

Consider serving as Physician of the Day at the State Capitol during the session. It’s an excellent opportunity to meet your representatives and see the legislative machinery at work, all while providing an important service.

Finally, make a donation to TAFPPAC. By giving to our political action committee, you are helping to support candidates who demonstrate support for issues important to family physicians and our patients. Visit www.tafp.org/tafppac for more information.

There you have it—three things you can do during this legislative session to help your Academy and strengthen our specialty so we can all get back to caring for our patients.

We need all hands on deck for this difficult legislative session. To learn more about these three actions and to participate, go to www.tafp.org/advocacy/get-involved.

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HHS: 85% of Medicare payments to be based on value by 2018

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Announcement signals accelerated shift toward value-based payment reform the hospital, and improve management of the department of Health and Human chronic diseases.

Services has signaled its intention to Even before this announcement, HHS has embrace value-based payment reform with seen promising results on cost savings in many the announcement that by the end of 2018, of these models. At the end of last year, the it plans to tie half of all fee-for-service MediCenters for Medicare and Medicaid Services care payments to quality or value through reported Medicare ACOs in the Shared Savalternative payment models like accountable ings Program and the Pioneer ACO program care organizations, or ACOs. HHS also set combined to save $417 million in 2013. a goal of tying 85 percent of all traditional The first of the new deadlines comes at Medicare payments to quality or value by the end of 2016, when 30 percent of Medicare 2016 and 90 percent by 2018 through propayments should be made grams such as the Hospital to physicians in alternaValue Based Purchasing and “Many practicing tive payment models. In the Hospital Readmissions 2011, that kind of payment Reduction Programs. physicians have was almost nonexistent, By setting these goals, been sitting on the but in 2014, 20 percent of HHS Secretary Sylvia M. sideline waiting for Medicare’s $362 billion in Burwell has added the weight of Medicare behind a sign that payment fee-for-service payments went to alternative paythe building momentum reform was really ment models. toward a system-wide transigoing to happen. ...

With this latest tion from volume to value.

“We believe these goals For family physicians announcement by HHS, it is likely that the introduccan drive transformative the time to embrace tion of value-based plans change, help us manage and change and lead that in the private market will track progress, and create accelerate as well, raising accountability for measurchange is now.” the question: are frontline able improvement,” Burwell said in an HHS release.

— Tom Banning physicians prepared to care AAFP CEO and ExecuCEO and executive vice for their patients suctive Vice President Douglas president of TAFP cessfully in an alternative payment model or under Henley, MD, voiced support value-based contracts? for the move in the release.

TAFP CEO Tom Banning believes family “We’re all partners in this effort focused on a physicians face a critical decision during shared goal. Ultimately, this is about improvthis time of transition. They can be passive ing the health of each person by making the victims of changes shaped by others or they best use of our resources for patient good.

11:57 AM can be active agents shaping a better future We’re on board, and we’re committed to for their patients and their colleagues. changing how we pay for and deliver care to “Many practicing physicians have been achieve better health.” sitting on the sideline waiting for a sign that Payment models like ACOs, primary care payment reform was really going to happen. medical homes, bundled payments for epiThis announcement puts the full force of sodes of care, and others were proposed in the federal government and the Medicare the Affordable Care Act as ways to increase program behind the shift to value-based payquality and efficiency across the health care ment,” Banning says.

“Commercial insurers delivery system. By aligning incentives to have already shown they’ll follow Medicare’s reward physicians for coordinating care, lead and embrace value-based payment. proponents hoped to reduce duplicative or For family physicians the time to embrace unnecessary tests and procedures, provide change and lead that change is now.” better care to patients transitioning out of

TEXAS FAMILY PHYSICIAN

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You’re invited! Join your colleagues from every state at AAFP’s NCCL April 30 – May 2, 2015 • Kansas City, Missouri

By Christina Kelly, MD The American Academy of Family Physicians National Conference of Constituency Leaders will be held April 30 - May 2, 2015 (with a preconference on April 29) in Kansas City, Missouri. This is the AAFP’s premier leadership and policy development event for underrepresented constituencies, which includes new physicians (physicians in their first seven years of practice), women, international medical graduates, GLBT, and minority constituencies.

At this leadership meeting, we gather every year for a purpose. We gather to: learn about how we can make a difference for our patients and our specialty, inspire each other to advocate, lead the way to action, and challenge our colleagues to join us in our efforts. A variety of issues are discussed at this meeting, such as patient barriers to quality health care that you want the AAFP to address, challenges within a variety of practice settings that you want fixed, or changes that need to occur to continually improve family medicine.

This leadership meeting ensures that underrepresented constituencies have a voice within the AAFP. I don’t know of any other organization that has a meeting like this. Each year I attend this conference is more exciting to me than the last, and I have attended nine times so far! It has been my breath of fresh air, where I can be reminded through the amazing family physicians attending the meeting why I went into family medicine, and why I do what I do at work every day. This meeting has

given me so much over the years in terms of inspiration and leadership development.

Each year I attend, I take the leadership skills I learned back to my state chapter meetings and my community. I am now more effective at running meetings. I feel more confident to raise my voice and speak up for my patients when they can’t do it themselves. I am able to develop a plan to advocate for various issues, execute that plan, and succeed in overcoming obstacles to providing my patients the best care possible. At NCCL, I learned how I can make a difference.

For those who haven’t attended before, you are missing out! This meeting is an opportunity to meet colleagues from all over the country who share the same passion you do and to learn how to advocate for change to make things better for our patients and family medicine. At this three-day conference, attendees participate in group discussions to identify issues of importance to them. Resolutions are written and presented at five reference committees. Chapter delegates for each of the member constituencies listed above then debate and vote on the resolutions and new leaders for the conference. Check out more info about the meeting at www.aafp.org/ events/aclf-nccl/nccl.html.

For those who have attended: 25 years of leadership development will be celebrated at NCCL in 2015. Those of you who previously attended—when it was known as NCSC or NCWMNP—built the legacy this conference has become. Please attend the first NCCL so

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we can celebrate and honor you for what you built. Inspire a new group of leaders to be heard and advocate for change, just like you did. It will be a wonderful reunion of all of the inspirational past attendees who have helped this conference bring change throughout the years.

So come one, come all to NCCL this year. Texas always brings a strong group of members, but with you, we can grow even stronger. CME credit is available for attending any of the breakout sessions on an hour-for-hour basis. I look forward to gathering for a purpose with you at NCCL in Kansas City!

TAFP members appointed to AAFP commissions Three active TAFP members were appointed to AAFP commissions in December.

Amer Shakil, MD, FAAFP, of Carrollton, was appointed to AAFP’s Commission on Education. Shakil is currently the interim chair and a professor for UT Southwestern’s Department of Family and Community Medicine. He is a member of TAFP’s Nominating Committee and Commission on Academic Affairs and has previously served on the Commission on Core Delegation, the Executive Committee, and the Board of Directors. He is also a member of TAFP’s Dallas chapter.

Troy Fiesinger, MD, FAAFP, of Sugar Land, was appointed to AAFP’s Commission on Governmental Advocacy. Fiesinger is on faculty at the Memorial Family Medicine Residency Program and a clinical assistant professor for the Texas A&M Health Sciences Center. He is one of Texas’ alternate delegates in AAFP’s Congress of Delegates, and he serves on TAFP’s Commissions on Academic Affairs and Membership and Member Services. He is a past president of TAFP and has served on TAFP’s Executive, Finance, and Nominating Committees.

Clare Hawkins, MD, MSC, FAAFP, of Baytown, was appointed to AAFP’s Commission on Health of the Public and Science. Hawkins is currently faculty at the San Jacinto Methodist Family Medicine Residency Program and is the TAFP Immediate Past President. He is a member of TAFP’s Executive Committee, and the Commissions on Academic Affairs, Continuing Professional Development, and Health Care Services and Managed Care.

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Which way from here?

Health care reform in the United States

By Kim D. Slocum President, KDS Consulting, LLC three years ago, I was interviewed for an article in Texas Family Physician entitled “Payment reform—The next step toward an efficient high-quality health care system.” At that time, I said that the United States would see one of three futures for health care: one based on rapidly escalating consumer cost shifting, one making significant use of price controls, or one focused on measuring and rewarding “value.”

So, where do we stand in early 2015 and what can we expect next?

At the moment, the concept of shifting costs to consumers is in high gear. The passage of the Medicare Modernization Act of 2003 created an opportunity for employers to move to high deductible health plans, which it was presumed would turn consumers into “happy economists” who would diligently study cost and quality ratings for various medical services, come to medical encounters fully prepared to argue the merits of each recommendation with their physicians, and only receive care that would optimize their clinical outcome.

As of 2014, the Kaiser Family Foundation/Health Education Research Trust annual survey of employer health care coverage shows that roughly 20 percent of all employees receiving health insurance

coverage now are enrolled in such plans. That’s not the end of the story though. Even for employees enrolled in more traditional PPO or POS plans, deductibles even for in-network services routinely exceed $1,000 so the percentage of potential patients facing significant cost sharing burdens is considerably higher than the headline number.

For physicians, these plans represent a double whammy. Thirty years of health policy research has shown that patients exposed to high deductibles will cut back on their use of care. Indeed roughly two-thirds of the savings these plans produce come from care avoidance behavior. The problem is that consumers are relatively poor judges of what care is necessary and what is not. They are about as likely to stop taking medications to manage diabetes as they are to forego a non-sedating antihistamine.

The second problem is financial. Since these policies require patients to spend a considerable amount out of their own pockets before traditional insurance coverage kicks in, it is incumbent upon physicians to collect payment at the time of service or risk an explosion of bad debt. www.tafp.org

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For physicians, highdeductible health plans represent a double whammy. Thirty years of health policy research has shown that patients exposed to high deductibles will cut back on their use of care. Indeed roughly two-thirds of the savings these plans produce come from care avoidance behavior.

Unfortunately, when physicians and hospitals are aggressive about collections from high-deductible-plan patients, it creates another problem—medical debt. Many consumers don’t have sufficient liquid assets to pay for medical services in cash and often resort to credit cards. As we all know, there is a short grace period in which to pay such obligations before high-interest rates are applied to outstanding balances. This happens with considerable regularity in the United States today and roughly 20 to 25 percent of all U.S. households are facing challenges of some sort in paying for health care.

In a worst case scenario, this can lead to medical bankruptcy.

Roughly 40 to 60 percent of all 1 to 1.2 million personal bankruptcies in the U.S. each year are directly caused by medical debt or heavily affected by such obligations. This is not just a problem for indigent patients—most of those medical debtors filing for bankruptcy actually have insurance and are well-educated and middle class. Surprisingly, the average amount of money required to put a medical debtor into bankruptcy court is only $17,000-$18,000.

Not surprisingly, consumers are not feeling empowered by all these changes. A spring 2014 survey by Nielsen Consumer Insights North America showed that while most consumers were more or less resigned to escalating costs, those who faced significant medical expenses due to illness were depressed or even angry about the economic burdens they faced.

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Disturbingly, this same survey showed an upswing in support for price caps or controls on prices charged by drug companies, hospitals and even physicians. While this finding does not suggest consumers will be going to the barricades in search of such price controls any time soon, it does represent a potential vein of populism that might be tapped at some future date. In other words, there is at least a chance that a consumer backlash against punitive cost shifting might provoke its ideological opposite—some sort of centralized price controls on the costs of medical goods and services.

The nation is also pursuing what some in the health policy community refer to as the “Berwickian nirvana” of accountable care organizations. This is a strategy with considerable support from public sector programs such as Medicare and Medicaid where the ability to shift cost to consumers is limited. Even some of the largest and most sophisticated employers have come to conclude that efforts to reform health care’s supply side must be viewed as the biggest part of reform strategy that will be viable in the long term. This approach involves an entire constellation of activities that will be at least somewhat familiar to practicing physicians most notably focused on health care information technology, so as to better understand care delivery patterns, and payment reform designed to elicit the desired behaviors from physicians and hospitals.

According to another Nielsen survey of hospitals and health systems conducted during the summer of 2014, 74 percent of all U.S. hospitals now own one or more medical groups. This buying spree has largely been tied to an organizational desire to move to accountable care. While primary care and hospital-based specialties like surgery have been the primary targets, the shopping list for these institutions now extends well down the roster of medical sub-specialties. At the same time, the federal program supporting the Meaningful Use of health care information technology has helped to drive adoption of electronic medical records and we now see the majority of U.S. physicians reporting that they have installed some form of this software in their offices. Finally, the same Nielsen survey of hospital executives shows that these institutions expect to see the source of their revenue change significantly over the next five years from predominately feefor-service to various forms of bundled, prospective, or even capitated payments.

To be sure, the transition from traditional physician and hospital business models has not been smooth. As one health system executive put it, “It’s true that when one door closes, another one opens, but it can be hell in the hallway.” The hundreds of newly minted ACOs that have sprung up across the country since 2011 have focused most of their attention on legal and business structures—the anatomy of accountable care. In some cases they have struggled to develop the sort of integrated and aligned organizational culture where the true physiology of accountable care can be delivered. While these organizations have invested significant dollars in creating information technology platforms to measure population-level health, this still remains for most a work in progress.

What is most important for physicians to bear in mind is that while the road to accountable care has not been smooth, it represents the least worse alternative to consumer cost shifting and potential backlash this seems to be producing. Ultimately, the future of U.S. health care will not be an either/or choice between consumer cost shifting, price controls, or value-based care, but some blend of the three. It is important that physicians give some consideration to the relative weight of each alternative they believe would best serve their patients and their profession, and work to make that choice a reality.

Confidential and experienCed LegaL RepResentation

foR

texas physicians

Representation before the Texas Medical Board, The Texas Medical Foundation and Medical Staff Peer Review.

Medical Practice Act and Medical Board Actions (hearings, settlement conferences and licensure) • Personal Counsel in Medical Liability Cases • Probation Modification / Termination • Managed Care Exclusions • Licensure • Reinstatement • Medico-legal Issues • Expert Review • Telemedicine • Medicare/Medicaid Appeals • Medical Ethics Opinions • Physician Assistants. tony cobos*

MichaeL shaRp*

couRtney newton

chRis shaRp Of Counsel

shaRp & cobos, LLP, Attorneys At LAw 4705 spicewood spRings Road • suite 100• austin, texas 78759 • 512 473 2265 • fax: 512 473 8525 • www.sharpcobos.com * Board Certified in Administrative Law by the Texas Board of Legal Specialization.

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thank god i’m a

country

Doc Texas Family Physician of the Year 2014-15

Russell Thomas, Jr., DO, MPH PHOTOS AND STORY BY SAMANTHA WHITE

“this is where i’m from.”

The simplest of answers. When asked why he returned to his hometown of Eagle Lake, Texas, to practice medicine, Russell Thomas, Jr., DO, MPH, only needs those few words. It’s as simple as that. It made no sense to practice anywhere else but in the place he grew up, surrounded by the family and friends he knew so well, giving back to the community that helped raise him.

Thomas, the 2014-2015 Texas Family Physician of the Year, practices at Rice Medical Associates, caring for the very people he grew up with. In a quaint town 60 miles west of Houston with a population of 3,700, Thomas not only knows most of the Eagle Lake residents, but he knows their life histories. What house they were raised in. What position they played on the high school football team. Where they work. Who they married. He knows their parents, too. And what careers they had or have. He knows their children. And maybe their grandchildren. In fact, he probably delivered many of their children and grandchildren.

If Thomas himself didn’t deliver them, there’s a good chance his father did. The late Raymond Thomas, MD, was also a family physician in Eagle Lake and was also awarded the Texas Family Physician of the Year title in 1997. Thomas is the only second generation Physician of the Year award recipient in TAFP’s history.

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G

rowing up in Eagle Lake with one of the town’s few physicians as a father meant assisting him at the age of 16, cutting high school class to scrub in for surgery, and joining him on emergency visits just to spend some time together as father and son.

These experiences combined with seeing his dad serve their community led Thomas to family medicine.

“I didn’t appreciate that there was anything else,” Thomas says. “I never imagined doing anything else.”

His mind was so set on being a physician and returning to Eagle Lake to practice alongside his father that when he failed to get into medical school, it was “like a slap in the face.” When by April he had not heard from the medical schools he had applied to, Thomas decided to pursue his master’s degree in public health.

Two weeks after finishing his degree at the University of Texas School of Public Health at Houston in 1976, Thomas married his longtime sweetheart, Robin. He went through the medical school application process again and was accepted to the Texas College of Osteopathic Medicine. He received his DO in 1980 and completed a residency at Southwest Memorial in Houston, now known as Memorial Hermann Southwest Hospital. He and Robin moved back to Eagle Lake and Thomas joined his father’s practice, an experience he calls a “17 year fellowship.”

of the vaccine home for his wife and a newborn Thomas. Before he could administer the vaccines, his conscience got the best of him and he returned the doses to the hospital. Two years later, Thomas was diagnosed with polio.

As ironic as it is, Thomas says if he could have a “do over” in life, he would not change his polio diagnosis.

“Polio has never been a cause for me,” Thomas says. “I chose for it not to be the focus of my life. It’s never really even been much of an elephant in the room. It didn’t stop me from going to medical school or doing my residency. It didn’t stop me from doing any of the important things.”

Thomas’ childhood friend, Russ Krienke, MD, nominated Thomas for the award. He says that Thomas “chose to let his childhood polio become a motivation for success rather than an excuse for failure.”

Krienke would know, as he was the friend who stayed by Thomas’ side when he was unable to participate in summer activities because of the latest cast or surgery. Instead of self-pity stories about missing out on childhood events, Thomas tells stories about Russ skipping a season of little league to instead sneak into his hospital room so the two friends could hang out.

Polio probably has something to do with Thomas’ ability to talk to patients so personally. As a child he was in and out of hospitals almost constantly.

“I’ve had surgeries so I know what being operated on is all about,” Thomas says. “Hopefully it has made me —having been on both sides of the patient fence—I’ve been more understanding and compassionate.”

According to patients, “understanding and compassionate” understate Thomas’ bedside manner. Ask patients, family, or colleagues, what makes Thomas Physician of the Year material and you’ll get the same answer: He truly cares. About his patients, his colleagues, his community, the practice of family medicine, the durability of rural medicine. He often acts as emcee at local events because he’s a great public speaker. He is an advocate for rural medicine because he cares about small communities and seeing that there are enough physicians to go around. He covers for colleagues when their children have activities because he reveres family values. He is a senior warden at his church because he holds faith dearly. He is also known for his tender bedside manner and the personal touch he brings to the exam room.

“For me, he’s so personable,” says longtime patient Susan Hadley.

Thomas and Hadley grew up together in Eagle Lake and raised children there simultaneously. “I can call him or text him and he is right there to talk to me on the spot. He’s always there when I need him.”

Hadley has multiple stories of Thomas coming to her family’s rescue. He handled her mother’s admission into hospice care on the same day Hadley had back surgery. He answers her phone calls and texts always, even on his days off. He diagnosed her lupus in 1991. His father delivered both of her sons. The Thomas family is an extension of her family.

“To do family medicine you have to do family… And in the case of a country or rural physician, you really have to be willing to say, ‘I’m going to commit to not just this practice and not just these patients but to this community.’ You’ve got to be willing to be available and to serve on things and do that kind of stuff.”

“Dad and I had a great relationship,” Thomas says. “I think we were complementary in that he had a lot of surgical skills and 30 years of experience when I came in. I had some of the newer medicine techniques. We really had a good synergy. We were just a good team.”

Having previously nominated his father and a few other colleagues for this award, Thomas knows he is in good company as Physician of the Year.

“To be held to the same standard of esteem as he was really does mean a lot to me. I knew a lot of these older docs, they were guys my dad hung out with growing up. They were kind of that same country doctor mold, and to be included with those guys…I can’t think of a higher honor.”

Thomas’ work ethic and loyalty to the integrity of medicine was passed down from his physician father. When Thomas was born in 1953, the Salk polio vaccines were going through the final stages of human trials and physicians were excited about it. While interning at Fort Worth’s City-County Hospital, Thomas’ father took two doses 18

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Thomas’ son Barrett attended West Point and is a major and a battalion operations officer at Fort Bliss. His daughter Jacqueline is a nurse in North Carolina. Both of Thomas’ children got their desire to serve the public from their father, who got the same desire from his own father.

Left: Thomas embraces patient and childhood friend, Susan Hadley following a clinical appointment.

Right: Thomas sits with his wife Robin on their lakefront back porch.

Jacqueline says she has worked with physicians who are not as personal with their patients and calls her dad’s bedside manner a “true gift.” Not to mention the strong connection he shares with his patents.

“I’ve worked at Duke Hospital and I would see physicians come in, see patients for three minutes, leave, and never see them again,” she says. “Dad spends time with his patients. I don’t know if he even has the time, but he makes time to get to know them. He would go to a football game so he could see them play and talk about other things that go on in their lives. In a big city you just don’t have that opportunity. Everywhere you go in Eagle Lake, everyone knows him.”

Jacqueline also recalls doing hospital rounds as a child with her dad, much like he did with her grandfather, as a way to spend time together. They were going to the hospital to check in on a patient who had recently given birth. She was craving a Dairy Queen Blizzard so Thomas and Jacqueline stopped on their way to pick one up for her.

“Typical dad, just doing a little extra. He didn’t think it was a big deal though.”

Another friend and patient of Thomas’ describes him as a physician who can handle the “extraordinary.”

“I know his ability to immediately understand and act upon something entirely out of the norm of family practice saved my life,” the patient says.

One day, the patient stopped by the Thomas household, something not at all uncommon, to show Thomas a serious redness on his leg. He was told to go home, rest, and call Thomas if he developed a fever. A few hours later when his fever spiked, Thomas met him at the hospital and began treatment immediately. It was vibrio vulnificus, a flesh-eating bacterium the patient contracted after wade fishing in the Gulf. After a few days of being treated by Thomas in the hospital, the infection stopped spreading.

What’s interesting is that whether you talk to a colleague, a patient, or even an acquaintance, everyone adds that they would consider Thomas a friend. It’s easy to spot if you spend even the smallest amount of time in Eagle Lake. Join him at Subway for lunch and he’ll

know the employees as well as the other patrons. Stop in the town’s small supermarket and the cashier undoubtedly has stories about him.

He’s the peoples’ physician.

Yet another patient mentions in his award nomination letter that he continues to see Thomas for routine exams and non-emergency care, despite living 114 miles from Eagle Lake in Taylor, Texas.

“In this time and age of specialties and specialists,” this patient writes, “it is a blessing to have someone like Dr. Russell who is always willing to put others first, investing his time and resources to help others.”

He goes on to say that Thomas also delivered two of his daughters, one of whom currently studies medicine at TCOM in the rural track and is mentored by Thomas. That is what Thomas hopes for the future of medicine – that rural rotations and educational tracks become more common and popular and would include things like obstetrics and inpatient care.

Medicine for Thomas was never about a paycheck or any kind of ego-boosting recognition. It has always been about the patients and the integrity of rural family medicine. The Thomas family did leave Eagle Lake for a short time. He took a position in Austin from 2000 to 2002 as the program director at the Central Texas Medicine Foundation Family Practice Residency Program, where he helped establish a rural rotation. Knowing the importance of a rural physician, or “country doc” as Thomas calls it, this rotation was an important accomplishment to Thomas.

“To do family medicine you have to do family,” says Thomas. You have to know what’s going on in a patient’s life outside of the exam room to fully take care of them, he explains. You have to know about their job, their family, their home life.

“And in the case of a country or rural physician, you really have to be willing to say, ‘I’m going to commit to not just this practice and not just these patients but to this community.’ You’ve got to be willing to be available and to serve on things and do that kind of stuff.” www.tafp.org

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In Eagle Lake, Thomas is the Practicing in Eagle Lake is, of epitome of a country doc. Many course, not the only thing Thomas of his patients were schoolmates does in the medical realm. He is growing up. Many are his closest a preceptor for medical students friends and relatives. His clinic interested in family medicine and manager is the sister of one of his has clinical appointments with the childhood friends. Many members UT Houston School of Medicine of his office staff and nursing staff and Texas College of Osteopathic come from a single family.

Medicine. He was appointed to Being a country doc in the the Board of Medical Examiners time of his father’s early practicing and served for eight years, five of years was similar to what it is now, which were spent as the vice presibut on a grander scale. Thomas’ dent. He was elected to the Board mother, Elfe, talks about her late of Directors for the Federation husband making multiple house of State Medical Boards. He was calls a day, something Thomas still appointed to the Board of DirecThomas accepts the Texas Family Physician of the Year award does but mostly on an as-needed tors for the Accreditation Council at TAFP’s Annual Session and Scientific Assembly in July 2014. basis. She remembers before EMS for Continuing Medical Education existed in Eagle Lake her husband and to the Maintenance of Licenbeing called away from the house sure Committee for the Ameriat all hours of the night to tend can Board of Medical Specialties. to accident victims. He once took Suffice it to say, he’s just as busy care of a pet monkey who had a outside of the clinic as he is inside broken leg. It was typical of him with his patients. to call the telephone company and These experiences outside of have them contact the nurses or the exam room are part of what lab technicians he needed to meet Thomas’ wife, Robin, thinks makes him at the clinic. him a great doctor and worthy of Thomas has comparable stories the Physician of the Year award. of picking up nurses in his own “Russell is a great, wonderful truck and heading to accidents he doctor,” says Robin. “He works heard about via small-town chatter. hard and has been involved in “I think that you have to have many aspects of medicine. I think a certain mindset,” says Thomas, it’s a combination of that and “and you have to be of a certain that he’s very dedicated. He’s very nature to do rural medicine.” caring.”

TAFP CEO Tom Banning has Thomas swears there hasn’t known Thomas for the duration been a day since he returned to of his career with the Academy.

Eagle Lake that he was unhappy The two consider each other more to go to work in the morning, than colleagues now, playing golf which is clear after seeing him in when they can. action with patients.

“Dr. Thomas embodies the role of a physician leader and advocate.

“For most of the last 31 years I’ve had the privilege of taking care of He’s the real deal.” Banning says. “Throughout his career he has made people in my hometown,” he says. his voice heard on issues affecting patients and the practice of mediAs a typical country doc, Thomas practices cradle-to-grave medicine. He’s developed and cultivated relationships with those in posicine. When a close family friend was diagnosed with cancer, Thomas tions of power who have a great deal of influence on medicine. He is was part of the team of physicians who treated her. He delivered her an unwavering advocate for his patients and his specialty.” children and had been their family physician for decades. The night Other physician educators see his dedication to the specialty too. she passed away, Thomas sat with her, the two reminiscing to 25 years In one nomination letter, a colleague says that medical students being earlier when he delivered her first child. mentored by Thomas are all inspired by his service to his community “That’s the length and breadth in family medicine in one patient,” and have the upmost respect for him. says Thomas. “I consider it sort of a privilege to be there for these people “He has been highly rated as an educator,” she says, “and has provided when they die. They allow me into their lives to deliver them and bring all of the necessary time and effort on a volunteer basis, believing in his life in, and they allow me to be there at the end. That’s a big deal.” responsibility to give back to the profession as his trainers gave of their Thomas captivated the audience with his speech when he accepted time and effort in his training.” the award in July 2014, proudly recounting his history as a country doc.

A physician colleague calls Thomas an “exemplary role model for He ended by telling his fellow physicians, “I encourage you as we leave young physicians-in-training” in her nomination letter. “Dr. Russell’s today to remember that we’re all the Physician of the Year in the eyes efforts on behalf of his students and patients is indefatigable,” she says. of our patients.”

“To be held to the same standard of esteem as he was really does mean a lot to me. I knew a lot of these older docs, they were guys my dad hung out with growing up. They were kind of that same country doctor mold, and to be included with those guys…I can’t think of a higher honor.”

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Trust TMAIT to Help You Navigate the Marketplace

We are reaching out to TMA members who need help with the Health Insurance Marketplace.

You have better things to do with your time than research insurance options … like taking care of patients.

We’re here to help you explore the ACA and its impact on health insurance coverage options so you don’t have to go it alone. No matter your current insurance set-up, we’ll help you identify the appropriate plan for you and your practice so you’re spending your money wisely.

• If you have no group insurance, we will help you and your staff find individual or group insurance either inside or outside the marketplace.

• If you do provide group insurance for you and your staff, we’ll help you find a plan that fits your budget.

• Our advisors also can mix and match plans and features to create “hybrids” that help fill in the coverage gaps.

Give us a call today at 1-800-880-8181. Or visit www.tmait.org.

Created in 1955 and exclusively endorsed by the Texas Medical Association, TMAIT is committed to serving Texas physicians.

A campaign to help patients and physicians find a home in primary care

By Kate Alfano

healthisprimary.org #MakeHealthPrimary

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Lloyd Van Winkle, MD, has practiced in Castroville, a small town outside of San Antonio, for 29 years. Day in and day out, same place, same office, same staff. Having cared for some of his patients for nearly three decades, he says his practice’s top priority is doing what’s best for them.

So when Van Winkle, also a board member for the American Academy of Family Physicians, heard about a new multi-year campaign launching at the 2014 AAFP Assembly in October, he did his research to make sure it would be beneficial to his patients and practice. The campaign – Health Is Primary – aims to rally patients, employers, policymakers, and other stakeholders across the country to recognize and support the value of family medicine and primary care in delivering on the Triple Aim of better health, better care, and lower costs, particularly through the patient-centered medical home.

His verdict? A thumbs-up.

“I’m a family doctor with real families, people I’ve taken care of forever, and if I can see value in this transition for my patients who I personally care about because they’re like my extended family, I think anyone else can see that that’s important.”

health is primary is the communications program for Family Medicine for America’s Health, or FMAH—a coalition of eight national family medicine organizations including AAFP—that will drive a five-year strategic initiative to transform family medicine to meet the needs of a growing population of patients with increasing complexity of health issues. Seven of the eight organizations came together a decade ago for the Future of Family Medicine project, which launched a series of strategic efforts to renew the specialty.

Former AAFP President Glen Stream, MD, MBI, serves as FMAH board chair. He says physicians made significant progress to modernize and transform the specialty following the publication of the Future of Family Medicine report in 2004 “but there’s still much work to be done, particularly around people understanding the role of family medicine and primary care and changing the payment model to support that.

That’s the alignment between the communications strategy and the strategic plan.”

After nearly a year of planning, FMAH identified its core strategies: • Working to ensure broad access to sustained, primary care relationships; • Accountability for increasing primary care value in terms of cost and quality; • A commitment to helping reduce health care disparities; • Moving to comprehensive payment and away from fee-for-service; • Transformation of training; • Technology to support effective care; • Improving research underpinning primary care; and • Actively engaging patients, policymakers, and payers to develop an understanding of the value of primary care.

“What we’re looking to do is to have patients and other stakeholders understand that foundational role of primary care and create a movement that moves our health care system to have that strong primary care

foundation,” Stream says. “We think that a critical mission of our strategic effort is to improve health care, both the quality, patient safety and patient-centeredness of the care; improve health; and address the unsustainable, growing cost of health care in our country. We are just absolutely convinced that the Triple Aim cannot be accomplished without the strong primary care foundation that we’re advocating for.”

“The Future of Family Medicine was not quite as innovative in terms of being patientcentered the way the current system is,” Van Winkle says. “It was the first steps. We were learning as we went along. But the new system is a lot more focused on the patient being the center of the medical home.”

The FMAH board guides the strategic effort for the project. It comprises one representative from each partner organization plus at-large members representing four stakeholder categories: family physician in fulltime practice, new physician leader, patient advocate, and AAFP state chapter executive. www.tafp.org

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“What we need the other stakeholders to understand– people in government, employers, health plans–is that our current system is broken in how it pays for primary care. We’ll be engaging those groups around how to retool our health care system to be based on a stronger primary care foundation; changing the payment model is a linchpin piece of that project.”

Glen Stream, MD

Driving the work of FMAH are six tactic teams—payment, practice management, workforce, education, technology, and engagement—with broad representation from the primary care community. The core members of FMAH’s tactic teams met for the first time in December at the Society of Teachers of Family Medicine’s Conference on Practice Improvement in Tampa, Florida, to develop a five-year work plan for their strategy focus. Moving forward, each team will engage a broader group of up to 60 volunteers to help with various aspects of their plan.

TAFP member Christina Kelly, MD, leads the Workforce Core Team and says the kickoff meeting was productive and engaging.

“The FMAH Board has put a great deal of work into the strategic plan over the last several months, and it was exciting to see it be put into action,” Kelly says. “All of the tactic teams worked well within the team and in between tactic teams. The potential for collaboration is immense.”

“With the current state of our health care system, we have an opportunity to transform America’s health for the better,” she continues.

“This is what is best for our patients. Advocating for our patients is something we do every day, and the core values of our specialty can be the catalyst for this transformation.”

Health Is Primary is designed to connect people to primary care and help them understand that 90 percent of health needs can be met in the primary care patient-centered medical home. The campaign will employ national advertising, workplace programs, and stakeholder outreach to raise awareness, and will travel to five cities in 2015—Raleigh, Seattle, Chicago, Denver, and Detroit—to engage local stakeholders and showcase community-level interventions that are work24

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ing to enhance and expand primary care and improve health.

The campaign will reach out to employers, disease groups, and health advocates to activate patients around major health issues to demonstrate how primary care can support them in preventing disease and promoting health. Health Is Primary launched the first quarterly consumer campaign in January, with a focus on nutrition and fitness, with chronic disease management, immunization, and smoking cessation following later in 2015.

Also in January, the campaign hosted a panel discussion at the Consumer Electronics Show in Las Vegas to share the family medicine perspective on consumer health technology, the start of the effort to engage with the technology community to help drive innovation and technologies that foster the connection between physicians and patients and improve patient care and patient health.

Stream says the biggest challenge to the campaign is the sheer size of the audience and the broad scope of the message. “We recognize that we can’t make this type of a change in the health care system on our own and are very much looking for partners to collaborate around areas of shared interests.”

“What we need the other stakeholders to understand – people in government, employers, health plans – is that our current system is broken in how it pays for primary care,” Stream says. “We’ll be engaging those groups around how to retool our health care system to be based on a stronger primary care foundation; changing the payment model is a linchpin piece of that project. … If the payment model changes to pay the medical home rather than just pay the doctor, then it will cover those services that we know can

improve people’s prevention and wellness status, chronic illness, and care coordination.”

Jen Brull, MD, FMAH board member representing practicing physicians, often fields the question from colleagues about what this campaign will “do” to them. She says she hopes it won’t do anything to them but rather that it will do a lot “for” them.

“We want people to practice in a way that brings them joy and lets them do things the way they want to do things, and accomplish objectives that are important. I think the idea is we’re not looking to massively change or reform the way physicians practice. It’s all about how can we shape technology, legislation, payment, and pipeline to make your job easier so you can do a better job of taking care of patients.”

“I hope it means that whether I choose to be an independent, solo, primary care provider with a full-scope practice or a hospitalist in a huge urban center, if I’m a family physician I have a home for that style of practice and a way to be financially viable to do what I love,” Brull says. “That’s what I want it to be.”

Van Winkle agrees. “If a young person out there is looking for a personally fulfilling career decision in health care, I think that Health Is Primary will allow them to see what a family doctor’s life is like and what it’s like to develop a really incredibly fulfilling doctor-patient relationship experience. I think this project is going to create a healthier family medicine environment that will make it possible for young doctors-intraining to have a home for themselves.”

Kate Alfano is the former associate director of communications for the Texas Academy of Family Physicians. She now lives in Fort Collins, Colorado, and works as a freelance reporter.

Ways to get involved Download and display these posters: Get these campaign ads and more resources on FMAH’s website, FMAHealth.org.

Talk to your patients: Tell your patients about Health Is Primary and how important primary care is to their health, and encourage them to spread the word. If you’re active on Twitter or Facebook, use the Twitter hashtag #MakeHealthPrimary and “like” the Health Is Primary Facebook page.

WHERE HEALTH IS PRIMARY. Increased collaboration between primary care and public health is key to addressing the biggest health challenges facing our country today.

Family doctors are working to bridge the gap between personal and public health.

Let’s make health primary in America.

Learn more at healthisprimary.org. #MakeHealthPrimary

AN OUNCE OF

PREVENTION

WHERE HEALTH IS PRIMARY. Patients with access to primary care are more likely to receive preventive services and timely care before their medical conditions become serious – and more costly to treat.

Family doctors work with their patients to keep them healthy. We want to ensure that all patients have access to and use regular preventive care.

Let’s make health primary in America.

Learn more at healthisprimary.org. #MakeHealthPrimary

INNOVATION AT YOUR SERVICE

WHERE HEALTH IS PRIMARY. Technology is transforming our lives and has the potential to improve our health.

Family doctors are integrating technology into their practices in a way that strengthens their connection to patients and enhances the quality of care.

Let’s make health primary in America.

Learn more at healthisprimary.org.

Attend a Health Is Primary event: The campaign will visit Raleigh, Seattle, Chicago, Denver, and Detroit in 2015. These visits will bring together national and local leaders to showcase community-level innovations in primary care that are leading to better health, better quality, and lower costs.

Share your story: The campaign is looking for examples of change that are underway around the country. Email your story to info@fmahealth.org.

Stay informed: The campaign sends out regular communications through Health is Primary and Family Medicine for America’s Health and they want to reach and hear from the family medicine community. If you haven’t done so already, sign up at HealthisPrimary.org to receive updates on the communications campaign, and at FMAHealth.org to receive updates and information on the strategic implementation effort.

Volunteer to be a support network member: The tactic teams are developing support networks of people with skill sets and experience specific to each of the six tactic areas to help accomplish the work that needs to be done. Anyone can express interest by sending an email to info@fmahealth.org. Be sure to include your background and interest areas.

Watch an FMAH webinar: Family Medicine for America’s Health sponsored its first webinar in early November to update the family medicine community on their work and progress. Go to FMAHealth.org/articlesupdates to watch the one-hour recorded presentation and others as they are available.

Donate: The eight family medicine organizations contributed significant financial resources to the project but continued funding is needed. Individuals and organizations can support the initiative by making a tax-deductible donation through the AAFP Foundation. Donate online at www. aafpfoundation.org/donatetoday and select “Family Medicine for America’s Health.”

Learn more: Read more on FMAH’s website, FMAHealth.org, and on the campaign website, HealthisPrimary.org.

DOTS CONNECTED WHERE HEALTH IS PRIMARY. A growing body of evidence shows that chronic medical conditions are best managed in a primary care setting. That’s because patients with access to coordinated, comprehensive care have better outcomes.

Family doctors treat patients, not conditions. We want everyone to have a doctor who sees them as a whole person and provides them with quality, coordinated care.

Let’s make health primary in America.

Learn more at healthisprimary.org. #MakeHealthPrimary

EVERYONE

WINS

WHERE HEALTH IS PRIMARY. Primary care improves health care quality and patient outcomes while reducing health disparities and costs.

Family doctors want to build a health care system in America where everyone wins.

Let’s make health primary in America.

Learn more at healthisprimary.org. #MakeHealthPrimary

TEAMS

WORK

WHERE HEALTH IS PRIMARY. In primary care, teams of health professionals provide patients what they need when they need it in a coordinated setting.

Family doctors work closely with team members to keep their patients healthy.

Let’s make health primary in America.

Learn more at healthisprimary.org. #MakeHealthPrimary

#MakeHealthPrimary

www.tafp.org

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The Woodlands Waterway Marriott • The Woodlands

Annual Session & Primary Care Summit

Annual Session is moving to November!

Foundation Focus

TAFP FOUNDATION STUDENT INTEREST ENDOWMENT

TAFP Foundation Student Interest Endowment Recruit the family doctors of tomorrow. Build the Foundation today.

Double your impact when you donate to the Student Interest Endowment in 2015 a major focus of the TAFP Foundation the past few years has been building the Student Interest Endowment to fund scholarships for pre-clinical medical students who participate in the Texas Statewide Family Medicine Preceptorship Program. In 2014, the Foundation Board initiated a matching campaign to grow the endowment faster. Every dollar donated to the Student Interest Endowment through Dec. 31, 2015, will be matched with unrestricted funds until $100,000 has been matched.

The endowment was formed in 2012 with an audacious goal of raising $4 million, but the Foundation leadership knew they had to start awarding scholarships as soon as possible. Using unrestricted donations and scholarship endowments already established, 13 scholarships were awarded in 2013 to first-year medical students who spent two to four weeks of their summer with a family physician and another 19 were awarded in 2014. The Foundation plans to award 25 scholarships this year. Your help is needed to continue supporting the future of the specialty through this successful program. Donate today by mailing a check to the TAFP Foundation or call Kathy McCarthy at (512) 329-8666, ext. 114.

You can mail your donation to the TAFP Foundation at 12012 Technology Blvd., Ste. 200, Austin, TX 78727, and note that your donation is for the Student Interest Endowment.

Or just call (512) 329-8666, ext. 114.

Thank you for your support.

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practice management

2015 coding changes and beyond

By Bradley Reiner in case you have been wondering if coding and billing will get easier this year, I hate to break the bad news to you that it is only getting more complex. In 2015, some interesting changes in coding have taken place that will be challenging for family physicians to learn and implement. A summary of these new guidelines is outlined below.

New Modifiers Just when you thought there were enough modifiers, CMS has developed four additional modifiers that will ultimately replace modifier 59. These new modifiers became eligible for use beginning Jan. 1, 2015. They are described below: • XE – Separate Encounter-Distinct because it occurred during a separate encounter, • XS – Separate Structure-Distinct because it was performed on a separate organ/structure, • XP – Separate Practitioner-Distinct because it was performed by a different practitioner, and • XU – Unusual Non-Overlapping Service-Distinct because it does not overlap main service.

Why was there a need to add more modifiers to an existing modifier? According to CMS, the 59 modifier is the most widely used modifier. Some providers incorrectly consider it to be the “modifier to use to bypass NCCI.” There has been considerable abuse and high levels of audit activity which has lead to reviews, appeals, and even civil fraud and abuse cases. CMS believes that more precise coding options with better education will reduce the errors. CMS will continue to recognize the 59 modifier but it should not be used when a more descriptive modifier is available. With certain code pairs, only one of the new modifiers will be appropriate and the 59 will not be allowed to bypass the edit. CMS is encouraging everyone to begin using the correct modifiers to avoid denials in the future.

CMS has not yet released any examples to help illustrate how to use the new modifiers correctly. In my research I was able to find some possible scenarios on how these four might be used. For example: • XE – Separate surgical operative session on the same date of service (8 a.m. and 4 p.m.); • XS – Injection into tendon sheath, right ankle and injection into tendon sheath, left ankle; • XP – Patient seen in the office by FP who encounters a problem and has to call in a specialist to provide a service on the claim; and • XU – Diagnostic cardiac angiography leads to therapeutic angioplasty.

Although these are not official examples from CMS, these samples should give you a better idea of how to use the modifiers more accurately. It is important to begin using them now in your daily billing and coding. Even though modifier 59 will still be recognized by CMS, they expect to terminate its use and require one of the four new modifiers in the future. Don’t delay. Begin using them now to avoid problems later.

Chronic Care Management CMS is recognizing the importance of chronic care management among primary care physicians and the need to be paid for monthly management of these conditions. Because of this CMS is now reimbursing physicians for the management of chronic care conditions. A new CPT code was developed with the following definition: CPT 99490: Chronic care management services, at least 20 minutes (non-face-to-face) of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: • Multiple (two or more) chronic conditions expected to last at least 12 months or until death; • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and • Comprehensive care plan must be established, implemented, revised, or monitored.

• Gives providers and clinical staff an opportunity to be paid for non-face to face services.

The national average reimbursement is $40.39 and is payable by Medicare Advantage plans as well. All practitioners will be allowed to bill this code, including extenders, while no more than one provider can bill for CCM. No prior services are required to bill CCM, but the provider must obtain a beneficiary’s consent. The services covered in CCM include: • Access to care management for chronic treatment, • Continuity of care, • Care management for chronic conditions, • Creation of a care plan, • Management of care transitions, • Coordination of home or other facilities, • Communication with caregivers, and • Electronic capture and sharing of information.

The big point to be made above involves the creation of a care plan.

A care plan is essentially a questionnaire about the problems experienced by the patient and the goals they have for treatment. These include: • Top concerns or barriers, • Symptom management, • Other health care providers, • Resources and support, • Medications, • Treatment goals and targets, and • A summary of things the patient needs to do. www.tafp.org

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As stated earlier, a beneficiary must give consent to have non-faceto-face chronic care management services provided. CMS has not created a form, but has given information on what is required by the beneficiary for approval.

Time spent providing services on different days or by different clinical staff in the same month may be aggregated to a total of 20 minutes. If two staff members are providing services at the same time, only the time spent by one individual may be counted. Less than 20 minutes cannot be rounded up. In addition, only general supervision is required. It is not required for a provider to be on site. Telephone availability is all that is needed.

Finally, Family Practice Management in its January/February magazine published a very thorough article on CCM. In it, they developed a sample care plan document for physicians to use as well as a sample beneficiary acknowledgment letter. The article also has a CCM services log so staff managing conditions through the month can log their time to meet the 20 minute threshold. All of these forms can be found in this article located at www.aafp.org/fpm/2015/0100/p7.html.

Advanced Care Planning Payers are recognizing the importance of advanced care planning and end of life directives. These require a substantial amount of time and effort to complete. Two new codes were developed this year to address these issues in more detail. The codes are CPT 99497 and 99498.

Face-to-face encounter not requiring the patient. The codes are time based with the first 30 minutes required to bill 99497 and each additional 30 minutes bill 99498. No active medical management is required and it includes the explanation and discussion of advanced

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directives. Although this is still not paid by Medicare, a recent article discussing these codes suggests that it is a matter of time before Medicare reimburses them. Although Medicare doesn’t pay them yet, it is possible that other payers will recognize them. Begin researching with your payers now to determine if these are payable codes or when they will be added.

Value Based Modifier Payment methodologies surrounding quality of care are becoming a standard for CMS as well as other payers. It is only a matter of time before providers will be paid based on quality of care and outcomes.

CMS’s Physician Quality Reporting System is one standard that is being required and payment will be reduced if physicians are not participating. A payment differential will be implemented among all eligible providers receiving reimbursement under the Medicare Physician Fee Schedule. The breakout is as follows: • In 2015, physicians in groups of 100 or more are required to participate. If they do not participate, a 1 percent reduction will be implemented.

• In 2016, physicians in groups of 10 or more are required to participate. A 2 percent reduction will be applied for non-participators.

• In 2017, all eligible providers will be required to participate.

How do you begin the process? Start by reviewing this link from CMS: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html. This will give you direction on how to begin participating in PQRS.

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OIG Work Plan The congressional watchdog ensures payments made by the federal government are appropriate as well as enforces a variety of measures to ensure that systems and polices are enforced. The U.S. Department of Health and Human Services Office of Inspector General Work Plan for fiscal year 2015 summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond. For FY 2014, OIG reported expected recoveries of over $4.9 billion, consisting of nearly $834.7 million in audit receivables and about $4.1 billion in investigative receivables. This includes about $1.1 billion in non-HHS investigative receivables resulting from their work in areas such as the States’ shares of Medicaid restitution. They reported in FY 2014 exclusions of 4,017 individuals and entities from participation in Federal health care programs; 971 criminal actions against individuals or entities that engaged in crimes; and 533 civil actions, which include false claims and unjustenrichment lawsuits. Needless to say, this is big business and a significant amount of revenue can be generated from these investigations.

There are a few areas that are being reviewed carefully in 2015 and beyond. Outpatient services billed as new patients when the physician or a physician of the same group of the same specialty saw the patient within the last three years. Overpayments have occurred when billing new patient visits when the patient is established.

TIP—Ensure all outpatient and office visit services are billed based on the three year rule.

Coding errors have occurred when the place of service has not been appended correctly. Payment is higher when services are provided in

the office than hospital based facilities. Massive overpayments have been occurring because of inaccurate coding of the place of service.

TIP—Ensure all place of service coding is based on where the service was provided.

Evaluation and Management Services continue to be reviewed although it is not specifically on the list for 2015. OIG is specifically reviewing code levels and the documentation required.

There is an increased focus on records that have the same identical information across patients (cloning of records).

Tip—Ensure documentation meets code levels and document only what’s necessary based on the nature of the presenting problem.

Errors have occurred in using modifiers during the global surgery period. These include: • Modifier 24-Unrelated E/M during post-op, • Modifier 78-Return trip surgery (related), and • Modifier 79-Return trip surgery (unrelated).

Tip—Review all modifiers and ensure the correct one is appended.

Bradley 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 breiner@austin.rr.com. See more about the services Reiner provides to TAFP members at www.tafp. org/practice-resources/reiner.

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perspective

The Power of the Preceptorship Travis Bias, DO, DTM&H in middle school, I aspired to become a DJ. Because this required me to take the least amount of math. Despite this original goal, I started my time at Southwestern University as a pre-med student and headed to UNTHSC Texas College of Osteopathic Medicine to begin my medical education. A career as a physician stood perfectly at the intersection between intellectual challenge and service to others.

I was drawn into medicine to make a difference. The calling of a medical career can be heard as young as 18. It requires determination, a selfless heart, and compassion no matter the situation. Between the ages of 22 and 26, however, a young physician-in-training must decide which specialty he or she would like to be practicing from age 30 until retirement. This decision shapes career options and powerfully influences the future lifestyle, and thus capacity for relationships, growing a family, and personal balance and well-being.

This choice in path, like in other careers, also affects potential lifetime income. Thus, specialty choice is not to be taken lightly, especially given the growing burden of educational debt that young medical graduates face.

Given the great public investment in medical education and a looming shortage and worsening maldistribution of all health providers, a young medical studentâ&#x20AC;&#x2122;s choice of specialty has far bigger implications.

Like most medical schools, TCOM emphasized early clinical exposure. These brief rounds and observerships during our first couple years of basic sciences started to plant the seeds of what our future could look like. Did I want to be the pulmonologist in the well-pressed suit and tightly tied necktie, citing recent research, rounding on the most complex cases in the hospital? Did I want to be the energetic, sometimes fatigued general surgeon in scrubs, solving life-threatening problems sometimes in a matter of hours? Did I want to be the family physician or pediatrician dressed in khakis and a button-down shirt, building relationships with the entire family, managing their chronic illnesses with varying levels of success, while treating acute exacerbations and illnesses?

Enter our formal preceptorship requirement, placing first and second-year students into clinical settings to observe a primary care physician for a total of four days. I had entered medicine to make a huge difference, a significant impact, so I figured a surgical specialty would satisfy that goal. But, this was just four days in observing primary care, and it was required anyway.

I had enjoyed the teaching style of one of our former family medicine clinical faculty, Dr. Richwine, so I spent my time with him. He graciously volunteered his time to show me what true community family medicine involved. He had an electronic health record before many practices had adopted them, and his patients loved him. Dr.

Richwine and his established patients already had a relationship built on mutual respect, so they could dive right into the current issue. He knew his patients and they trusted him enough to talk of details so intimate they might not share them with their own family members or significant others. He managed hypertension and diabetes, treated acute respiratory and urinary infections, diagnosed sleep apnea, and managed depression and anxiety. In addition to his outpatient work, he had chosen to add on a diverse and bustling weekend work schedule in the nursing home, emergency department, and local hospice.

Family medicine was so much more than I had previously imagined, and I just had to see it for myself.

I am now board-certified in family medicine, after being fully educated and trained in Texas, and my career has taken me down an exciting path of work in developing areas, the study of tropical medicine, and contributions in advocacy, public health and policy. All of these possible, with my role even stronger, thanks to the broad education in family medicine.

A physician-in-training may just need a straight-shooting mentor or model to paint a real picture of the lifestyle, complete with the beautiful and the ugly of primary care. A preceptor can have the honor of passing on traditional pearls that cannot be learned in textbooks, gathered from years of experience, to secure the future generation of family docs. Finally, the policy maker may need simple anecdotes to show the complex process that underlies why medical graduates enter certain specialties or choose to practice in certain geographic regions, in addition to the encouragement to invest a relatively small amount in a preceptorship program that could bolster our primary care base in a time of family medicine residency program contraction and poor access to health care in our great state.

Our health system is in the midst of change, but one element that stays the same is this: the importance of the primary care physician. While the diverse set of payers is slow to come around to this, a strong health system relies on a foundation of primary care. And the beginnings of a primary care career start early. Sometimes it requires simply a four-day glimpse into that challenging, versatile, and rewarding everyday life to guide that vision of what an impactful life in medicine can look like.

TAFP is currently looking for physicians for the Texas Statewide Family Medicine Preceptorship Program. As a former medical student who chose family medicine after completing a preceptorship, I urge you to sign up and mentor medical students questioning specialties. To sign up, visit www.tafp.org/preceptorship or contact Juleah Williams at (512) 329-8666 or jwilliams@tafp.org.

A physician-intraining may just need a straightshooting mentor or model to paint a real picture of the lifestyle, complete with the beautiful and the ugly of primary care.

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