Texas Family Physician, Q2 2017 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 68 NO. 2 2017

AAFP UNVEILS NEW TOOLS TO HELP YOU AVOID PENALTIES

PLUS: How To Say No To Opioid Rx Refills: A Case Study Personal Finance 101: Keep Your Eye On The Prize

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TEXAS FAMILY PHYSICIAN VOL. 68 NO. 2 2017

Get MACRA ready with your Academy

AAFP has a new set of resources available to members looking to prepare for Medicare’s Quality Payment Program. To avoid a penalty in 2019, you must report at least one measure or activity in 2017. In this issue of TFP, we present two AAFP QPP Now modules: “Quality and Cost,” and “Advancing Care Information and Improvement Activities.”

Member profile: Janet Realini, MD, MPH

Meet a recent TAFP Member of the Month, the chair of the Texas Women’s Healthcare Coalition, and a past recipient of the AAFP Public Health Award, Janet Realini, MD, MPH of San Antonio. By Perdita Henry

Obesity at 6 months of age predictive of obesity at 24 months of age

By Sally P. Weaver, PhD, MD; Kelly R. Ylitalo, PhD; Suzy Weems, PhD

6 FROM YOUR PRESIDENT Learning to lead 8 NEWS FROM AAFP AAFP launches Center for Diversity and Health Equality. 9 MEMBER NEWS In memoriam: Mario E. Ramirez, MD | Curran wins TMA president-elect | Texas members attend NCCL, ACLF 15 PUBLIC HEALTH How to say no to opioid Rx requests: A case study by the Texas Pain Foundation. 28 INTERIM SESSION HIGHLIGHTS Plus proposed amendments to the TAFP Bylaws 30 FINANCE Start saving today to meet your long-term goals. 38 TAFP PERSPECTIVE Advocacy in medicine

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PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 68 NO. 2 2017 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.

Learning to lead By Tricia Elliott, MD TAFP President

OFFICERS Tricia Elliott, MD

president

president-elect vice president

Janet Hurley, MD

Javier “Jake” Margo, Jr., MD

treasurer

Rebecca Hart, MD

parliamentarian

Amer Shakil, MD, MBA

immediate past president

Ajay Gupta, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editors

Perdita Henry and Jean Klewitz chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell CONTRIBUTING EDITORS Lane J. Aiena, MD Greg Gulick Michael Laff Sally P. Weaver, PhD, MD Suzy Weems, PhD Kelly R. Ylitalo, PhD

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. © 2017 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN [No. 2] 2017

Eight of our members in attendance are greetings colleagues. I recently had the graduates of the inaugural class of TAFP’s pleasure of attending AAFP’s National ConFamily Medicine Leadership Experience — a ference of Constituency Leaders and the yearlong leadership program the Academy Annual Chapter Leader Forum in Kansas City, began last year — and two more are enrolled Missouri, two conferences packed with leadin the program this year. That’s something ership training and opportunities. As I was to celebrate! returning home, I couldn’t help but reflect on Several years ago, a group of members how lucky we are to be part of such an active wanted to focus on and engaged community helping family doctors of family doctors. To succeed in leadership witness the energy and roles, not just within the enthusiasm for learning We are rigorously Academy but in their and networking, to take trained in a model communities and their part in lively debates, and to watch colleagues colthat makes us experts places of work. They formed the Leadership laborate to craft policy in our clinical skills Development Commitideas — the weekend was but does little to tee and began thinking truly a joy. big. Our Texas chapter make us successful The Family Medicine was well represented leaders. Yet once Leadership Experience, or throughout both conferwe enter practice, FMLE, is the culmination ences. We had 17 memof their work. Participants bers attending, seven of we suddenly find attend four one- to twowhom were first-time ourselves leading day sessions throughout attendees to NCCL and care teams. We are the year where they ACLF. Again this year, receive expert training in Texas sent a full delexpected to be great personality types, strateegation to NCCL, which leaders without any gic planning, persuasive means we had an official practical training in communication, negotiarepresentative for each of tion, conflict resolution, the convening member leadership skills. advocacy, media skills, constituencies: new phyand so much more. Visit sicians; women physiwww.tafp.org/membercians; international medship/FMLE to learn more. ical graduates; minority Twenty-eight members went through physicians; and lesbian, gay, bisexual, and the first year of training, and just look at transgender physicians. them now. They’re attending NCCL and Mary Nguyen, MD, of Castroville served as ACLF, serving as chairs and vice chairs of co-convener for NCCL this year and Gerald TAFP committees, and taking on new roles Banks, MD, of Corpus Christi won a coin their health systems and academic insticonvener position for the IMG constituency tutions. The 2017 class has already had their at next year’s meeting. Dr. Banks was also first session and I know they’re going to elected to represent the member constituenhave a great year. cies at the Congress of Delegates this fall.

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The skills these members are learning are so important to us as family physicians. All types of people become family doctors and sure, some are natural born leaders, but most of us are not. We are rigorously trained in a model that makes us experts in our clinical skills but does little to make us successful leaders. Yet once we enter practice, we suddenly find ourselves leading care teams. We are expected to be great leaders without any practical training in leadership skills. The good news is you can learn to be a successful leader and the opportunities to acquire those skills are all around. You just have to open yourself to those opportunities and take advantage of them. For me, taking a break from the office to attend NCCL and ACLF was refreshing and invigorating, a chance to recharge, reconnect, and focus on sharpening my own leadership skills. I encourage you to seek out similar experiences, like FMLE or the leadership training track offered during the TAFP Annual Session and Primary Care Summit this fall. Sometimes you have to treat yourself, so you can get back to treating your patients, happily and healthily.

CORRECTION In an article in our first quarter magazine titled “On the Border of Health,” we misspelled medical student Edward Strecker’s name. We apologize for the mistake.

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COMING SOON ON TAFP’S

CME SCHEDULE Annual Session & Primary Care Summit Nov. 10-12, 2017 Nov. 8-9: Business meetings and preconference workshops

Galveston Island Convention Center, The San Luis Resort, and Hilton Galveston Island C. Frank Webber Lectureship & Interim Session April 13-14, 2018 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 8-10, 2018 La Cantera Hill Country Resort & Spa San Antonio, Texas 8

TEXAS FAMILY PHYSICIAN [No. 2] 2017

AAFP takes leadership role with launch of Center for Diversity and Health Equity Initiative will use evidence-based approach to address social determinants By Michael Laff

when patients visit a family physician, there are often more than physical symptoms influencing their health. There is growing recognition that the social determinants of health also are critical factors that affect individuals and families. If expanding access to care is the first step in health reform, caring for vulnerable populations is the next one, according to physician panelists who spoke on March 28 at a forum on high-value primary care for underserved communities. Continuing a long history of tackling disparities in patient care head on, Julie Wood, MD, MPH, AAFP senior vice president of health of the public and science and interprofessional activities, announced the launch of the AAFP Center for Diversity and Health Equity, an initiative that will focus on addressing the social aspects of health care. “The AAFP has developed its Center for Diversity and Health Equity to take a leadership role in addressing social determinants of health, nurturing diversity, and promoting health equity through collaboration, policy development, advocacy, and education,” Wood told AAFP News. CALL FOR ACTION FROM FAMILY PHYSICIANS A resolution adopted during the 2016 Congress of Delegates called on the AAFP to take a stronger stance on the social determinants of health, specifically by creating a new office that would enhance cultural

proficiency among the medical team and help increase diversity in the physician workforce. “The AAFP is taking an important step with the establishment of the center to improve population and community health and achieve health equity,” said Bellinda Schoof, MHA, director of the AAFP Division of Health of the Public and Science. To improve diversity, AAFP will seek to increase the proportion of students from underrepresented minority groups who choose family medicine as a specialty. On the national level, the AAFP will look to collaborate with other organizations to actively work on these issues. The AAFP also will develop practical tools and resources to equip family physicians and their teams to help patients, families, and communities with issues related to social determinants of health. NEEDS OF VULNERABLE POPULATIONS During the forum, panelists discussed several issues related to diversity and health equity, including the primary care workforce, as well as funding for federally qualified health centers, teaching health centers, and the National Health Service Corps that would address the needs of vulnerable populations. Those needs begin in childhood. Research indicates that children who are exposed to adverse experiences — such as abuse, the death of a parent, divorce,

www.aafp.org/patient-care/ social-determinants-of-health/cdhe.html

neglect or community violence — experience high rates of disease later in life, including heart disease, cancer, obesity and STDs. Increasing access to care through Medicaid expansion helps, panelists said, but health care services and medication remain an expensive prospect for many low-income individuals. “We look at coverage as the answer, but if we don’t address cost-sharing, we’re not going to get there,” said John Rother, CEO of the National Coalition on Health Care, which co-hosted the forum. William Golden, MD, medical director of Arkansas Medicaid, said U.S. residents have the highest out-of-pocket health care costs in the world. Many patients with high-deductible insurance plans cannot afford medications or the necessary preventive interventions to change their health outcomes. Individuals in both urban and rural areas who earn $20,000 or less per year are being priced out of health care, Golden said. He noted that prices for insulin tripled during the past seven years and said statins that used to cost $5 - $10 now cost $50. “Because of the pricing structure, people who are considered at risk will be a larger share of the population,” he said. To help, community health clinics are taking advantage of initiatives such as the 340B Drug Pricing Program, which allows clinic patients to obtain medication at significantly reduced prices. Kemi Alli, MD, CEO of the Henry Austin Health Center, said that through the program, patients can obtain hypertension or diabetes medication that costs $340 per month on the retail market for as little as $20 per month. The forum was the second in a threepart series co-hosted by the AAFP, NCHC, National Association of Community Health Centers, American College of Physicians, and American Osteopathic Association. The date of the final forum, on building the primary care workforce, will be announced later. Source: AAFP News, March 31, 2017. © American Academy of Family Physicians.

In memoriam Mario E. Ramirez, MD Former TAFP President Mario E. Ramirez, MD, passed away on May 22, 2017. He was 91 years old. Ramirez was born in 1926 to Efren and Maria del Carmen Ramirez in Roma, Texas. He completed high school at the age of 16 and went on to attend college at the University of Texas at Austin. While still in pursuit of his undergraduate degree, he was accepted to medical school at the University of Tennessee. Continuing his spectacular journey, he graduated medical school at the age of 22 and began his residency in the general practice of medicine at Shreveport Charity Hospital. During his residency, he met a student nurse, Sarah Aycock, who would become the love of his life. After completing residency Ramirez and Aycock returned to Roma, married, began their family, and started a medical practice, which they ran for more than 50 years.

Ramirez spent five years practicing in Roma before enlisting in the United State Air Force, where he served two years and then returned home. Upon his return, he got down to the business of improving access to health care in the Rio Grande Valley and over the next 50 years, he established the Manuel Ramirez Memorial Hospital, served as a Starr County Judge, created the Starr County Hospital, mentored medical students and residents, and founded the Med-Ed Program, which encouraged Rio Grande Valley high school students to pursue careers in medicine. In addition to those achievements, he served as TAFP president from 1975 to 1976. He was awarded the Bicentennial Benjamin Rush Award for Citizenship and Community Service by the American Medical Association. He was named the 1978 Family Physician of the Year by AAFP, an award which was presented to him at the White House by President Jimmy Carter. He received the Distinguished Alumnus Award from the University of Texas at Austin. Ramirez left a rich legacy as one of the founders of public health care in the Valley and is revered by physicians and patients across the country. He was preceded in death by his loving wife Sarah. They are survived by their five children: Judge Mario E. Ramirez, Patricia A. Kittleman, Dr. Norman Ramirez, Dr. Jaime Ramirez, and Roberto L. Ramirez. He is also survived by two siblings, Roel and Carmensa, and was preceded in death by younger brother Efren, Jr.

CHECK OUT THE TAFP CAREER CENTER WHERE TALENT MEETS OPPORTUNITY SEARCH JOBS POST JOBS POST CV ANONYMOUSLY FIND YOUR FUTURE

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MEMBER NEWS

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Athens FP wins race for TMA president-elect

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TEXAS FAMILY PHYSICIAN [No. 2] 2017

AM 9/9/10 9:18

on may 6, Douglas W. Curran, MD, of Athens was elected president-elect of the Texas Medical Association at their annual conference, TexMed. Curran, a former president of TAFP and the 1999 Texas Family Physician of the Year Award recipient, will become the 153rd president of the organization on May 19, 2018. “I feel very humbled by this opportunity to serve the patients of Texas physicians as well as protect and preserve the integrity of our profession,” Curran said in a TMA press release. “The opportunity to serve as president-elect and ultimately president of this great organization will allow me to speak from the heart about the profession I love and the commitment to improve the health care of all Texans.” A longtime advocate for both Texas patients and physicians, Curran has had a direct hand in some of the most groundbreaking health care legislation in Texas, including the medical liability reforms in 2003, improving the Children’s Health Insurance Program and Medicaid, and stopping attempts of non-physician practitioners to expand their scope of practice. He has also served as board chair on TMA’s Board of Trustees for the past two years. Curran has given decades of service to TAFP and has served as a delegate to the AAFP Congress of Delegates. With 38 years of medical practice and a history of successful advocacy efforts, his presidency is sure to be a success.

Doug Curran, MD

“The opportunity to serve as presidentelect and ultimately president of this great organization will allow me to speak from the heart about the profession I love and the commitment to improve the health care of all Texans.”

Texas FPs attend NCCL, ACLF A total of 17 TAFP members attended AAFP’s National Conference of Constituency Leaders and the Annual Chapter Leader Forum, held together April 27-29 in Kansas City, Missouri. Seven of those were first-time attendees. Mary Nguyen, MD, of Castroville served as co-convener for NCCL, a position she was elected to at last year’s conference. She

assisted in the organization and planning of this year’s meeting. Gerald Banks, MD, of Corpus Christi was elected co-convener for the International Medical Graduates constituency. He also won the election to be an alternate delegate to the Congress of Delegates this fall. Banks is currently participating in TAFP’s Family Medicine Leadership Experience.

MEMBER NEWS The 1960s was a time of change, resistance, and demands for equality. In fact, amongst this background of change, a pill revolutionized family planning and the lives of women forever. The birth control pill provided women with more control over their reproductive choices and therefore expanded their opportunities. In 2017, the struggle continues and right here in Texas many are still fighting the good fight to make sure women maintain access to health care and education needed to make the best decisions for their futures. Janet Realini MD, MPH, a native San Franciscan, came of age in the era of women gaining reproductive rights. The women’s rights movement is a part of what inspired her career journey and led her to become something of a patron saint for women’s health care in the state. She is the president of Healthy Futures of Texas and chair of Texas Women’s Healthcare Coalition. As summer approaches and she prepares to step down from her role as president, I caught up with her to find out what she thinks about the health care challenges facing Texas and the joy she’s found in building relationships within the world of advocacy.

April 2017 Member of the Month Janet Realini, MD, MPH By Perdita Henry 12

TEXAS FAMILY PHYSICIAN [No. 2] 2017

PH: Tell me a little about yourself and your career. JR: I grew up in San Francisco and came to San Antonio for my family medicine training. I served 18 years teaching on the faculty at UT Health in San Antonio. After receiving my Masters of Public Health, I spent 10 years at San Antonio Metro Health, where I served as medical director of the family planning program and helped to start Project WORTH, the city of San Antonio’s youth development and teen pregnancy prevention program. I quit my “day job” to focus on Healthy Futures of Texas, which has grown and developed, with a great team of stars who provide and promote what works to prevent unplanned and teen pregnancy in San Antonio and across the state. I wrote “Big Decisions” to ensure that youth have access to the basic information they need to make healthy choices about sex, with their parent or guardian’s

PH: Why did you choose family medicine and what’s your favorite aspect of it? Were you inspired by anyone? JR: Family medicine has always been my idea of what a doctor should be. My favorite aspect of it is the relationships that a family doctor develops with their patients. That is the part I miss most, since I have been devoted to outside-the-exam-room work. PH: What is your favorite part of advocacy work? JR: Relationships are my favorite part of the advocacy work. Working with other advocates, with legislators, agency staff, providers, and community stakeholders is exciting when we are working for an important cause like access to preventive care and contraception. But it is the relationships that make the work a true joy. PH: You’ve been a longtime champion of women’s health. What inspired you to enter advocacy? JR: I have felt close to adolescent and women’s health issues since before I can remember. I grew up in a time when the new birth control pill changed the landscape for women, allowing them to choose when and if they become pregnant. For me, this has meant the opportunity for education and career — to fulfill more roles and contribute more to the world. For women and for our society, this has meant a transformation with women having the power to contribute in many ways. My journey has been one of exciting opportunities and many privileges. I want all adolescents to have such opportunities for their lives. I want all women and men to be able to find fulfillment as people — and as parents, when they choose to become parents.

JONATHAN NELSON

permission. “Big Decisions” is abstinenceplus and designed to be Texas friendly, i.e., comfortable for conservative communities to embrace. The Texas Women’s Healthcare Coalition is a project that Healthy Futures developed after the devastating family planning cuts of 2011. Now with 67 organizational members, TWHC has brought together health care, faith, community, and advocacy groups to speak with one powerful voice to support access to preventive care — including contraception – for all Texas women.

PH: When facing the challenges and setbacks of making sure Texas women have access to health care, what keeps you going? JR: The importance of the work keeps me going. My goals have been to safeguard contraception in the setting of conflicts over abortion and to bring together “pro-life” and “pro-choice” people to work on effective prevention methods for unplanned pregnancies. Texas has made substantial progress since the 2011 family planning cuts. I am heartened by the strong bipartisan support for contraception in the Texas Legislature, but we still have far to go. Every day I think about how I can best make a difference so that all people have access to the information and the health care they need. PH: What are the most critical public health threats Texas women face? JR: Texas women have the highest maternal mortality rate of any state — higher than many third-world countries. Preventive care and contraception are incredibly important in addressing this issue in two ways: preventing unplanned pregnancies that can stress women with health issues and serving as an entry to health care for women with health risks. Texas also needs better access to care for women — and men — with diabetes, hypertension, obesity, substance abuse, and depression. Our number and percentage of uninsured is the highest in the nation. Zika virus is another lurking threat to future pregnancies and children.

With increasing temperatures in the spring and summer, Zika could make a return to our state. Here again, preventive care and contraception are essential services. PH: What has been the proudest moment or a biggest success in your public advocacy career so far? JR: It is hard to single out any one moment as our proudest. In 2013, the restoration of women’s health funding was a great success for the TWHC, along with other advocates. In 2015, we helped to ensure that the Family Planning Program continued and would be able to increase in size and reach. In 2017, we are hoping for even stronger women’s health programs going forward. PH: What public health initiatives do you wish more family physicians would champion? JR: I would say simply, “Get involved!” TAFP and the Texas Medical Association do excellent work, and both are members of TWHC. Your perspectives and your leadership are important in the advocacy for women and all people of Texas. If you can, volunteer to serve on a committee, commission, or council. Know your representatives and your state senator, and let them know how you feel about the public health issues you see. For more information about Healthy Texas Futures visit www.hf-tx.org, and for more information about Texas Women’s Healthcare Coalition visit www.texaswhc.org.

Member Month OF THE

TAFP’s Member of the Month web feature highlights Texas family physicians and their approach to family medicine. If you know a family physician colleague who you think should be featured as a Member of the Month or if you’d like to tell your own story, nominate yourself or your colleague by contacting TAFP by email at phenry@tafp.org or by phone at (512) 329-8666. View past Members of the Month at www.tafp.org/membership/spotlight.

www.tafp.org

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How to tell a patient you will not refill an opioid prescription: A case study By the Texas Pain Foundation

Scenario:

Patient T is a 45-year-old male with a history of lower back pain who has been treated for the past three years by a pain management physician. He presents to a primary care physician for a refill of his opioid medications. For the past two years, he has been on a stable dose of hydrocodone and extended-release morphine. When asked why he is no longer receiving his opioid prescriptions from his pain management physician, the patient replies that this physician is no longer willing to prescribe opioids for him. Upon reviewing his past treatments prior to chronic opioid therapy, it is determined that he underwent physical therapy of unknown type in the remote past. However, he has not tried multidisciplinary rehabilitation, tai chi, yoga, walking programs, acupuncture, mindfulness-based stress reduction, motor control exercise, progressive relaxation, electromyography biofeedback, lowlevel laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation. As such, the primary care physician decides this is a good opportunity to discuss changes in the treatment plans for managing the patientâ&#x20AC;&#x2122;s chronic pain. The physician explains to the patient there are new treatment guidelines recently published by the American College of Physicians and the Centers for Disease Control that both recommend non-pharmaceutical and non-opioid therapy as the preferred treatment for chronic pain. The physician then asks if the patient is having any opioid withdrawal symptoms. The patient states that he is having rhinorrhea, diarrhea, piloerection, and increased pain. The physician reassures the patient that increased pain is normal when going through opioid withdrawal and that this pain will improve as his withdrawal

symptoms improve. In the meantime, the physician tells the patient that she will treat his diarrhea and other withdrawal symptoms with non-controlled medications, and she reassures the patient that withdrawal symptoms are not life-threatening. The physician then discusses the concept of opioid-induced hyperalgesia. In this condition, opioids lead to a paradoxical increase in perceived pain after prolonged exposure. In these patients, cessation of opioid therapy leads to decreased overall pain after withdrawal symptoms cease. As such, the physician informs the patient that she will not be refilling his opioid prescriptions today. The patient is upset when he learns he will not receive an opioid prescription and states that opioids are the only thing that works for his pain. When the physician asks how they work, the patient states that opioids significantly reduced his pain. The physician then asks about his physical and emotional function. The patient responds that he spends 80 percent of the day sedentary watching TV or lying in bed and that he does not work. Emotionally he denies anxiety or depression but reports very little interaction with his spouse or children and that he is becoming emotionally withdrawn because of his pain. The physician then explains to the patient that although opioids may be reducing his pain, they are not increasing his physical or psychosocial function. Improvements in both perceived pain and physical function are absolutely essential for continued opioid therapy. Pain reduction alone is not an indication to continue opioid therapy. The patient becomes increasingly agitated and the physician offers him medication to treat the withdrawal symptoms and other conservative treatments mentioned above. Realizing that the patient appears to be hyper focused on opioids and not open to alternative www.tafp.org

treatments, the physician considers whether the patient may have an undiagnosed substance use disorder and considers referring him to an addiction specialist. After the physician spends time counseling and reassuring the patient, he remains convinced that opioids are the only treatment that works for him. The physician states that she respects the patient’s point of view but that she does not agree. The physician states that if the patient wants to continue with the new treatment plan, then they can continue talking. Otherwise, the patient can consult with another physician for a second opinion.

Takeaways • New CDC and ACP guidelines recommend non-pharmaceutical and non-opioid therapy as first-line treatments for chronic pain. • Opioid withdrawal should be treated, but this does not necessarily require refilling an opioid prescription. • Opioid withdrawal is not life threatening in the absence of severe cardiovascular disease. • Patients have the choice to accept new treatment plans or to find a new physician. • Physicians should NOT feel pressured to refill opioid prescriptions. • Patients who are hyper-focused on obtaining prescriptions for opioids and are not open to new treatment plans may have a substance use disorder. This should prompt the physician to consider a referral to an addiction medicine specialist.

Reasons a pain management physician would not refill • The physician changed their treatment philosophy to be in compliance with evidence-based guidelines. • The patient displayed evidence of opioid-induced hyperalgesia. • The patient failed to demonstrate a functional improvement with opioid therapy. • The patient had a nonfatal opioid overdose. This is a contraindication to future opioid prescriptions. • The patient violated the Pain Management Agreement, which is an agreement between the doctor and patient for treatment using chronic opioid therapy as required by Texas Medical Board. Violations may include: - Utilizing the Texas Prescription Monitoring Program, PMP Aware, the patient was found to be obtaining controlled substances from multiple physicians. - Patient had self escalated the medication and ran out early. This is a risk factor for accidental overdose and substance use disorders. - Patient reported lost or stolen medication. This can be associated with a substance use disorder or criminal diversion of controlled substances. - Patient had aberrant urine drug tests results, meaning nonprescribed licit or illicit drugs were found in the urine or prescribed drugs were not in the urine. The Texas Pain Foundation was established in 2011 to advance the art and science of pain medicine. Visit www.texaspainfoundation.org.

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Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 < 200 cells/μL) with HIV infection. HIV Medicine. 2004;5:93-8.

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TEXAS FAMILY PHYSICIAN [No. 2] 2017

12/17/14 6:18 PM

www.tafp.org

Scoring Quality and Cost of Care When passed into law in April 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) established two tracks for payment: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models

(AAPMs). Under MIPS, Medicare Part B payments will be adjusted based on scores from the four performance categories below. This supplement focuses on the quality and cost categories of MIPS to help prepare your practice to enhance the value of care you provide patients. Scores are calculated to determine a final score (1-100), weighted by performance category, and then compared to a performance threshold. Physicians scoring above the threshold receive a positive payment adjustment. Those scoring below the threshold receive a negative payment adjustment. Performance determines your payment adjustment two years later. For example, the payment adjustment you receive in 2019 is based on 2017 performance. Initially, scoring in quality will be weighted to account for the majority (60 percent for 2019 payment year) of your final score. Cost will account for 0 percent in the first payment year (2019), increase to 10 percent the second year (2020), and rise to 30 percent in the third year (2021) to align with the declining weight in the quality category. The graphic below indicates the sliding weights for quality and cost for the first three payment years.

Payment Year Weights

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Quality Many features of the quality category in MACRA come from the previous Physician Quality Reporting System (PQRS). If you are reporting in MIPS, you are required to report six quality measures (out of 271 possible measures), one of which must be an outcomes measure. If you report more than six measures, CMS will use the six highest-scoring measures to calculate your quality score. In addition, CMS will calculate the all-cause hospital

readmission measure for groups of 16 or more clinicians with a minimum measure case size of 200. Find the complete list of quality measures at qpp.cms.gov/measures/quality. Once your measures are selected, begin collecting data. Submit your quality data as an individual or a group through these options.

Qualified Clinical Data Registry (QCDR) Report on 50% of ALL patients eligible for the measure, regardless of payer, when reporting through QCDR, qualified registry, or EHR. Qualified Registry

Electronic Health Record (EHR)

Qualified Survey Vendor (for CAHPS only)

CMS Web Interface

Report on all the measures in the measure set listed when reporting through the CMS Web Interface. Use the first 248 ranked Medicare beneficiaries in the order they appear.

Claims

Report on 50% of Medicare Part B patients eligible for the measure, when reporting through claims.

You may use only one method for data submission per category. For example, you cannot submit some quality data through claims and some through a registry. However, you can submit data for one MIPS category (e.g., quality) using one reporting method and data for another MIPS category using a different reporting method. Additionally, if you submit data as a group in one category, you must submit as a group in all categories. The same is true if you submit data as an individual.

CALCULATING QUALITY In order to be scored based on performance, you must submit six measures, the measures must meet the case minimum of 20 unique patients, have a benchmark, and meet data completeness criteria. If you submit a measure not meeting the case minimum or data completeness criteria, it will not be scored on performance, but receive a baseline score of three points.

Benchmarks are set from data two years prior from the performance period (2015 benchmarks determine 2017 performance period scoring), and are broken down into performance deciles for each measure. Performers in the top decile are awarded full points. Those in lower deciles receive fewer points. www.tafp.org

Quality (continued) Here are the available points in the quality performance category by group size or reporting option (i.e., CMS Web Interface).

Groups of 15 or fewer clinicians Points available (without bonus) = 60 (6 measures x 10 points each)

Submit through CMS Web Interface Points available (without bonus) = 120 (11 measures x 10 points, plus all-cause hospital readmissions x 10) Groups of 16 or more clinicians Points available (without bonus) = 70 (6 measures x 10 points, plus all-cause hospital readmissions x 10)

Bonus points are available in the quality category. You can earn two bonus points for additional outcome or patient-experience measures, and one bonus point for reporting certain high-priority measures.

COST Many features of the cost category in MACRA come from the previous Value-based Payment Modifier (VBPM) program. You will not receive a score in the cost category for the 2017 performance period (2019 payment year), but it will increase in subsequent years to 10 percent in 2018 (2020 payment year), and 30 percent in 2019 (2021 payment year).

CALCULATING COST The Centers for Medicare and Medicaid Services calculates the cost category using claims data, so no submission is required on your part. Most measures in the cost category are triggered by an inpatient evaluation and management (E/M) code or procedure code. There are 10 of these measures in the cost category. They are calculated by CMS if the measure meets the minimum case size of 20 patients. If you only practice in the ambulatory medicine setting, many of the cost category measures will not apply to the care you provide. The one episode measure that may apply for ambulatory physicians is “colonoscopy and biopsy.” CMS calculates two other measures that must meet minimum case size thresholds. The measures of Medicare spending per beneficiary (35 patients) and total cost of care (20 patients) must meet these minimum case sizes to be scored. 22

TEXAS FAMILY PHYSICIAN [No. 2] 2017

Unlike the quality category (with a two-year look—back period), the cost category will have a benchmark from the actual performance period. Each measure scored will be compared to a benchmark in that same year and potentially awarded up to 10 points each. CMS will average the score of all eligible measures in cost and there are no bonus points available. Similar to the quality category, benchmarks are broken down into performance deciles for each measure, with points awarded based on where in the decile your performance falls.

VALUING QUALITY AND COST Most family physicians will initially participate in MIPS. Therefore, it is important to focus on the quality and cost of care you provide patients now. The balance of quality and cost complement each other and help lead to highvalue care under MACRA. Reviewing quality measures (qpp.cms.gov/measures/quality) and determining those to report will help position you for success. Remember, performance in 2017 determines payments in 2019. Collecting quality measure data will help fulfill MACRA requirements now and potentially lead to positive payment adjustments in the future. © 2017 American Academy of Family Physicians. All rights reserved.

www.tafp.org

The Medicare Access and CHIP Reauthorization Act (MACRA) was passed into law in April 2015. The law established two new tracks for physician Medicare Part B payment: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). The MIPS and AAPM tracks are collectively referred to as the Quality Payment Program (QPP). Through the MIPS track, Medicare Part B payments are adjusted based on performance in four performance categories: quality, cost, advancing care information (ACI), and improvement activities. Scores in each category are weighted, added together to obtain a MIPS final score, and compared to a performance threshold. This supplement summarizes components and scoring of the ACI (aafp.org/mips-aci) and improvement activities (aafp.org/ mips-ia) categories.

ADVANCING CARE INFORMATION (ACI) The ACI performance category replaces meaningful use. Similar to meaningful use, eligible clinicians (ECs) must use certified electronic health record technology (CEHRT) to report for the ACI performance category. Physicians without an EHR are eligible to participate in MIPS, but will not be able to receive any points in the ACI category.

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Measure Set Options For 2017 reporting, there are two sets of objectives and measures within the ACI category. The measures correspond to the version of CEHRT you are using (2014, 2015, or a combination of both). However, since the 2015 edition of CEHRT is not required to be in place until 2018, early adopters of 2015 CEHRT have a choice of which set of measures to use. ACI Measures The ACI measures consist of five required base score measures and six additional performance score measures (three of the base scores can be calculated for the performance score). Due to the transition year in 2017, clinicians are only required to report four base score measures, and have the option to report additional performance score measures. ACI Scoring The ACI category accounts for 25 percent of your MIPS final score in 2017. The ACI score is achieved by combining the total of the required base score (50 percent), performance score (up to 90 percent), and bonus score (up to 15 percent). While ECs could technically earn a score up to 155 percent, scores above 100 percent will only be calculated at 100 percent.

Must Do: Base Score (50 percent of total ACI score) To receive a base score in the ACI category, ECs must attest “yes” to the security risk analysis measure, and submit a numerator and denominator (that is above zero) for the remaining required base score measures. Failure to meet requirements for even one base score measure will result in a score of zero for the entire ACI category. Optional: Performance Score (50-90 percent of total ACI score) If the base score is achieved, additional performance measures are available to enable ECs to earn a higher ACI score (based on performance rates for each individual measure reported). Three of the base measures are also considered performance measures. A clinician’s performance on these measures can also be included in the performance score. While additional points are available that would put your score above 100 percent in the ACI category, an EC’s score in the category is capped at 100 percent. Unlike scoring in the quality performance category, in which performance is compared to a threshold and broken into deciles [see The Value of Quality and Cost supplement (aafp.org/value-qualitycost)], each performance score measure in the ACI category can contribute up to 10 percent to the score. For example, if an EC submits a numerator of 82 and a denominator of 100 for the Patient-Specific Education measure, the performance rate would be 82 percent. The performance score for that individual measure would be 9 percent out of a possible 10 percent. See the table to the right for how performance rates translate to percentage points in the performance score portion of the ACI category.

Performance Rates for Performance Measures – Worth up to 10% Points per Measure 1-10% = 1%

51-60% = 6%

11-20% = 2%

61-70% = 7%

21-30% = 3%

71-80% = 8%

31-40% = 4%

81-90% = 9%

41-50% = 5%

91-100% = 10%

In contrast to meaningful use, groups are allowed to report to the ACI category. If reporting as a group, ECs in the group would combine their performance data under the tax identification number (TIN), and the performance score would be calculated as a group. Extra Credit: Bonus Score (up to 15 percent of total ACI score) A maximum 5 percent bonus can be earned by attesting that you have reported to one or more additional registries under the Public Health and Clinical Data Registry reporting objective. Additionally, up to a 10 percent bonus can be earned by using CEHRT to perform at least one of a handful of specific MIPS improvement activities. Hardship Exceptions Hardship exceptions from ACI are available (with an annual application and approval) for those who demonstrate insufficient internet connectivity or extreme and uncontrollable circumstances.

www.tafp.org

IMPROVEMENT ACTIVITIES The improvement activities performance category accounts for 15 percent of your MIPS final score in 2017. While the improvement activities category is new, the functions within it should be familiar to family physicians. Improvement activities are defined as activities that improve clinical practice or care delivery and are likely to result in improved health outcomes. Practices recognized or certified as a patient-centered medical home (PCMH) by the following entities will automatically receive full credit. • • • • •

National Committee on Quality Assurance (NCQA) The Joint Commission (TJC) URAC Accreditation Association for Ambulatory Health Care (AAAHC) Accrediting bodies that have certified 500 or more practices

Eligible clinicians not in a recognized PCMH can select from a list of 92 improvement activities within the following overarching categories: • • • • • • • •

Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Achieving Health Equity Emergency Response and Preparedness Integrated Behavioral and Mental Health

Each activity is rated as either high (20 points) or medium (10 points). With a maximum score of 40 points in this category, most ECs will need to attest that they completed two high-weighted activities, four medium-weighted activities, or a combination to equal 40 points for a minimum of 90 consecutive days during the performance period. If a group has 15 or fewer clinicians, is located in a rural, or health professional shortage area (HPSA), or is non-patient facing, they will receive double the points for each activity, and will only need to complete two medium-weighted activities or one high-weighted activity. There are 18 technology-based improvement activities that also qualify for bonus points under the ACI category. Submitting Data for ACI and Improvement Activities ACI and improvement activities cannot be submitted using claims. Reporting for both the improvement activities category and the ACI category may be submitted through: • • • • •

Qualified registry; Qualified clinical data registry (QCDR); Via attestation; Electronic health record (EHR); or CMS Web Interface (groups of 25 or more ECs only).

CMS will issue additional guidance on how data is to be submitted for the improvement activities category.

TEXAS FAMILY PHYSICIAN [No. 2] 2017

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MEMBER NEWS

Highlights from TAFP’s Interim Session • April 7-8, 2017 The committees, commissions and sections of the Texas Academy of Family Physicians met in Austin and deliberated on many important items. Thanks to all the members who participated. Most commissions, committees and all sections are open to guests. You can also request an appointment by submitting a “Make Your Mark” involvement form. Contact Juleah Williams at jwilliams@tafp.org with any questions. Here are a few of the highlights of the recent meeting. All the recommendations mentioned will be presented to the Board of Directors.

ADVOCATING FOR YOUR PRACTICE AND YOUR PATIENTS Dr. Clifford Moy from TMF Health Quality Institute spoke to the Commission on Health Care Services and Managed Care about their contract with CMS to help physician practices succeed in Medicare’s Merit-based Incentive Payment Systems. He discussed tools and projects TMF offers including Chronic Care Management assistance and Project ECHO (Extension for Community Health Care Outcomes). The Commission on Health Care Services also discussed problems with prior authorizations, communication from pharmacists when prescriptions are not covered by insurance, and health plans not being available for insurance verification after hours. Members are encouraged to submit their insurer issues to TMA’s Hassle Factor Log. TMA gathers the complaints and uses their leverage to address them with health plans. Go to www.texmed.org/ hassle. TAFP’s lobby team provided the Commission on Legislative and Public Affairs with an update on legislation being debated in the 85th Texas Legislature and led a discussion on various issues including the state budget, a telemedicine bill, scope of practice expansion efforts, and public health initiatives. WORKFORCE DEVELOPMENT The Board of Directors voted to fund an initiative to develop an e-learning practice management curriculum for use by Texas Family Medicine Resi28

dency programs to help meet their ACGME requirements and better prepare residents for practice. Initially three modules will be developed and more may be added in the future. TAFP will use an outside consultant to create the content and set up the platform. Commission on Academic Affairs recommended the creation of an FMIG Program of Excellence Award to highlight the innovative activities at Texas FMIGs. The winners would receive extra funding to send students to AAFP’s National Conference in Kansas City. The Commission also discussed efforts to increase the number of medical students choosing family medicine. TAFP administers the Texas Family Medicine Preceptorship Program to provide an opportunity for first- and second-year medical students to experience family medicine outside the academic health center. Practicing physicians are needed to volunteer to serve as preceptors and medical students are encouraged to apply for the program. They also reviewed TAFP Foundation travel funding, the Research Poster Competition held each year at Annual Session, and more. MEMBER SERVICES AND RESOURCES IN DEVELOPMENT The Leadership Development Committee met to plan the curriculum for the second class of the Family Medicine Leadership Experience. Several members of the inaugural class were present to share their experience and provide feedback and suggestions to improve the sessions.

TEXAS FAMILY PHYSICIAN [No. 2] 2017

The Commission on Membership and Member Services discussed efforts to launch informal discussion opportunities at TAFP meetings. TAFP members served as facilitators of three Member Community meetings at Interim Session – Early Career Physicians, International Medical Graduates and Solo and Small Group physicians. The Section on Maternity Care and Rural Physicians recommended the creation of a scholarship program to send students, residents and active members to the AAFP FamilyCentered Maternity Care Live Course each year as a way to increase the workforce of rural family physicians who provide obstetrical care. PUBLIC HEALTH AND RESEARCH The Section on Research decided to begin holding monthly conference calls with rotating speakers. For information about the next call, contact Perdita Henry at phenry@tafp.org. The Commission on Public Health, Clinical Affairs, and Research recommended that TAFP host a half-day educational session for residents to improve HPV immunization rates. One resident from each program would be invited and then encouraged to share what they learn with their colleagues. The Commission on Public Health also heard about the anti-vaccination movement and rise in preventable disease from the director of advocacy and public policy at the Immunization Partnership. ORGANIZATIONAL ISSUES The Nominating Committee met to identify candidates for leadership positions. In addition to nominating members for officer and delegate positions, they selected candidates for at-large and the new physician position on the board of directors. The summer issue of Texas Family Physician will include profiles of the candidates in contested races. The Section on Special Constituencies and the Sections on Medical Students and Residents also have the ability to select nominees

for the board. The Member Assembly will elect members of the board and officers at Annual Session and Primary Care Summit in Galveston, November 10-12. Here is the proposed slate of directors and officers for 2017-18: President-elect: Rebecca Hart, MD Vice President: Amer Shakil, MD, MBA Treasurer: Jake Margo, Jr., MD Parliamentarian: Adrian Billings, MD; Mary Nguyen, MD Delegate to AAFP: Linda Siy, MD Alternate Delegate to AAFP: Ashok Kumar, MD New Physician Director: Mary Anne Snyder, DO; Irvin Sulapas, MD; Lawrence Gibbs, MD At-large Director: Terrance Hines, MD; Loren Lasater, MD Special Constituency Director: Lesca Hadley, MD Resident Director: Samuel Mathis, MD Medical Student Director: Jason Johnston The Bylaws Committee made several recommendations that will eliminate the vice president position and alter the structure of the at-large director seats to allow two members to be elected each year for two year terms. The amendments will be voted on by the membership at the Annual Business Meeting during the TAFP Annual Session and Primary Care Summit in Galveston. The Finance Committee reviewed TAFP’s financial reports and investments. The committee also received an update on TAFP’s investment portfolio. MEMBER HIGHLIGHTS The Nominating Committee recommended to the board that Dr. Lindsay Botsford be nominated to serve as chair of AAFP’s Commission on Quality and Practice. She is in her fourth year of service on the commission. The Commission on Continuing Professional Development selected program chairs for TAFP’s educational programs for the near future. Program

chairs include Kristi Salinas, MD, for the 2018 C. Frank Webber Lectureship; Sarah Samreen, MD, and Fozia Ali, MD, for the 2018 Texas Family Medicine Symposium in San Antonio; and Lesca Hadley, MD and Mark Malone, MD for the 2018 Annual Session and Primary Care Summit in Arlington. The Section on Residents held elections for officers and delegates. Katelyn Davis, MD, from JPS was elected chair and Samuel Mathis, MD, from Memorial was elected to be the nominee for the Resident Director on the TAFP Board of Directors. They elected Daniel Nwachokor, MD from Memorial as chair-elect and Sophia Kim, MD, from Texas Tech El Paso as secretary. The delegate and alternate to National Conference are Vicky Bakhos Webb, MD, from Texas Tech Permian Basin and Jenny Ukwu, MD, from Memorial. The delegates and alternates to TAFP’s Member Assembly are Mercedes Giles, MD, from UTMB Galveston; Arindam Sarkar, MD, from Baylor; Stephanie Crittenden, MD, from Memorial; and Anum Maniar, MD, from Methodist Houston. The resident liaison is Eddie Seto, MD, from CHRISTUS Santa Rosa. The Section on Medical Students met and held elections for officers and delegates for the coming year. Jason Johnston from McGovern-UT Houston was elected chair and the nominee for the Student Director position on the TAFP Board of Directors. Grace Guvernator from McGovern was elected secretary and Justin Fu from Baylor was elected chair-elect. The delegate and alternate to AAFP’s National Conference are Allison Yeh from Baylor and Chi Nguyen from TCOM. The FMIG liaison is Jessica D’Souza from Baylor. The delegates and alternates to TAFP’s Member Assembly are Abby Brown from McGovern, Nelson Boland from Baylor, Justin Riojas from McGovern, and Jacob Westbrook from TCOM.

PROPOSED AMENDMENTS TO TAFP BYLAWS The proposed amendments to the TAFP Bylaws are in accordance with the TAFP Bylaws, Chapter XVII, Amendment of Bylaws. An affirmative vote of at least two-thirds of the members present and voting at the annual business meeting shall constitute adoption. If you would like a complete copy of the TAFP Bylaws, contact Kathy McCarthy at (512) 329-8666, ext. 114. The Bylaws Committee recommends adoption of these amendments. Chapter XII. Board of Directors, Subchapter 1. Policy and Procedure. SECTION 18. 2018 GOVERNANCE CHANGE IMPLEMENTATION FOR SECTION 1 As of November 9, 2018, Chapter XII. Subchapter 1. Section 1. will be replaced with the following and Section 18 will expire: The control and administration of the Academy shall be vested in a Board of Directors, hereinafter called the Board. The Board shall be composed of the Academy President, President-Elect, Treasurer, Parliamentarian, Immediate Past President, Delegates to the AAFP, four at-large directors, one new physician director, one special constituency director, one resident director, and one medical student director. Chapter XII. Board of Directors, Subchapter 1. Policy and Procedure. SECTION 19. 2018 GOVERNANCE CHANGE IMPLEMENTATION FOR SECTION 4 As of November 9, 2018, Chapter XII. Subchapter 1. Section 4. will be replaced with the following and Section 19 will expire: The four at-large directors shall serve twoyear terms with two directors elected each year. All at-large directors must be active members in good standing. The Nominating Committee shall nominate them at their Interim Session meeting and they shall be elected by the annual Member Assembly and begin serving at the conclusion of the Annual Session. They may serve up to two consecutive terms. Chapter XII. Board of Directors, Subchapter 1. Policy and Procedure. SECTION 20. 2018 GOVERNANCE CHANGE IMPLEMENTATION FOR SECTION 9 As of November 9, 2018, Chapter XII. Subchapter 1. Section 9. will be replaced with the following and Section 20 will expire: The officers of the Academy shall be President, Treasurer, President-Elect, Immediate Past President, and Parliamentarian. The Immediate Past President shall serve as Chairman of the Board and shall not be eligible to succeed himself/herself. The

powers, duties, terms of office, and method of election of officers shall be set forth in these Bylaws. Chapter XII. Board of Directors, Subchapter 2. Executive Committee Duties and Terms of Office SECTION 4. 2018 GOVERNANCE CHANGE IMPLEMENTATION FOR SECTION 1 As of November 9, 2018, Chapter XII. Subchapter 2. Section 1. will be replaced with the following and Section 4 will expire: There shall be a six-member Executive Committee of the Board composed of: the President, who also serves as Chair; President-Elect; Treasurer; Immediate Past President; the Parliamentarian; and one at-large director elected by the Board of Directors. Terms shall be in conjunction with the elected position terms for President, President-Elect, Treasurer, Immediate Past President, and the Parliamentarian. The atlarge director shall be elected by the Board at the Annual Session and shall serve until the next Annual Session. Chapter XII. Board of Directors, Subchapter 3. Elected Positions SECTION 8. 2018 GOVERNANCE CHANGE IMPLEMENTATION FOR SECTION 3 As of November 9, 2018, Chapter XII. Subchapter 3. Section 3. VICE PRESIDENT will be deleted and Section 8 will expire. Chapter XIII. Standing Committees, Section 2. Committee Descriptions. Nominating Committee a) This committee shall consist of nine members; each with terms of three years. b) One-third of the members shall be appointed annually. c) Two members will be appointed by the President-Elect and the other elected by the Board of Directors. d) The chair shall be elected by the Committee from the Committee’s membership. e) The purpose of this committee shall be to: i) Present nominations for the office of President-Elect, Vice President, Treasurer, one Delegate and one Alternate Delegate to the Congress of the AAFP. ii) Present nominations for the Board of Directors. iii) Make suggestions to the President regarding appointments to the AAFP, Texas, and American Medical Associations, other state committees and commissions, and any other appointments, which may be requested. iv) Evaluate the job performance and attendance of elected TAFP officers and delegates.

www.tafp.org

FINANCE

Best financial practices and how to implement them By Greg Gulick

Think about your retirement. When you hang up your stethoscope, will your budget allow for fine dining in Paris or will it be restricted to a burger in Paris, Texas instead? Understanding your financial priorities today and what it takes to fulfill your financial goals is an important part of the long-term health of your financial plan. Building your wealth and investment portfolio and staying financially healthy will be much easier if you can stay on track with your plan. Try some of these best financial practices to help you succeed. Take advantage of tax-advantaged accounts. Once you find yourself in your high-income-earning years, contributing to a retirement plan is an important aspect of your long-term financial goals. For 2017 you can contribute $18,000 to a 401(k) plan and if you are 50 or older, you can contribute an additional $6,000. For those with their own practice, an employer-sponsored retirement plan provides you tax-advantaged retirement savings and offers your employees an appreciated benefit. The maximum annual retirement benefit an individual may receive in a defined benefit plan in 2017 is $215,000. There are several retirement plan options to choose from if you own or are a partner in a practice. In some cases, you can have more than one retirement plan, so make sure your plan is designed to meet all your goals. Takeaway – Understand all your retirement plan options and the contribution limits. If you own your practice, review your employersponsored retirement plan or options for one.

Be wary of investment recommendations from someone on TV or a friend. Who needs professional advice or to conduct research when your golfing buddy gives you tips? If his stock suggestions are as good as his golf handicap, you can’t go wrong, right? This is usually not a good idea and can be a very risky investment choice. Everyone has differ30

TEXAS FAMILY PHYSICIAN [No. 2] 2017

ent financial goals, time horizons, risk tolerances, and portfolio sizes. Investing in stocks is a personal decision that depends on your financial situation and specific goals. Each stock needs to fit in your portfolio to maintain your temperament for risk and asset allocation, and each must be thoroughly evaluated. Takeaway – Make sure you completely understand your investment choices and resist the urge to buy based on your buddy’s tips.

Take advantage of compound interest and lifestyle choices. With a physician’s prolonged education, you may not achieve significant earnings until you’re in your 30s. Add your student debt and perhaps the cost of purchasing a practice or starting a new one. Throw in other major expenses such as your home and raising children, and you can see physicians face many obstacles to saving that delay your ability to build wealth. It is important that your lifestyle allows you to save a portion of your earnings and invest for your longer term financial goals. The longer your time horizon for investments, the more compound interest can work for you. Living beyond your means is a sure way to erode your wealth, especially if you aren’t reducing your debt — or worse — you pile on more debt. Compound interest works against us when we carry debt and works for us when we invest. The plus side is you should have

many years of consistent earnings, making those years the ideal time to set a portion away for your longer-term financial goals. Takeaway – Reduce your debt, start investing early and often — even in small amounts — and live within your means.

Have a plan. A financial plan will clearly identify your financial goals and what it takes it to reach them, putting you in a much better position to make financial decisions. A plan will help you identify your priorities and develop a clear picture of your current financial situation. The more you understand about your main financial goals — the amount of money needed for your retirement lifestyle, your children’s college expenses, or the amount needed in your emergency fund — the better informed you are to make financial decisions and understand the impact of these choices. A financial plan can be very thorough and detailed, but having a plan that at least identifies your main priorities and financial goals will help provide clarity. There are also several other important areas regarding comprehensive financial planning that include tax planning, retirement planning, investment planning, education planning, and insurance planning. Takeaway – Identify your financial goals and develop a financial plan.

Understand investment fees and expenses. Investing expenses and fees can be a key factor in your net return. That’s why it’s important to fully understand every expense associated with your investment. Think of expenses as a hole in your investment

bucket. To help minimize expenses, it is important to understand how they are charged to investments. Some investments have sales charges and annual expenses while other accounts have several layers of fees and expenses. Ask lots of questions and locate the expenses so you may better understand, evaluate, and compare investments. Though fees and expenses alone shouldn’t determine your investment decisions, understanding them fully will be advantageous for your entire portfolio. Takeaway – Clearly understand the fees and expenses of your investments.

Don’t just buy and forget. Perhaps you have an investment you purchased years ago, and you haven’t looked at it since. Or maybe like many investors, you still have an old retirement account sitting in a previous employer’s retirement plan. Or maybe you are an employer and you’re not regularly reviewing your employer-sponsored retirement plan for investment options, expenses, and plan design. You may be surprised at how inefficient those investments can become over time. It is a good idea to review your investments and accounts at least once a year to make sure they are performing well to help you meet your goals according to your time horizon within the context of your entire financial plan. It is recommended to review the performance of each of your investments while comparing the performance of similar investments comparing such factors as investment objectives, performance, and fees. Takeaway – Set some time to thoroughly review each of your investments at least on an annual basis.

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Don’t react emotionally to market volatility. A bear market, which is defined as a 20 percent sell-off from the market high, can be a very difficult time as an investor, especially since bear markets can sell off extremely quickly. Market sell-offs and bear markets can create waves of uncertainty and fear as we listen to the news and review our portfolios. This is when having a financial plan and an understanding of your financial goals can help. With a well-diversified portfolio in which your assets are properly allocated, that has the right amount of risk for you, and is designed to meet your financial goals, you’ll be in a good position to weather these financial storms. If your financial plan does not call for you to sell any of your investments and your goals have not changed, then you may not be forced to sell any of your positions in adverse market conditions, even though your emotions and your feelings may tell you otherwise. Takeaway – Keep your financial plan in focus and not your emotions, especially during volatile market conditions.

Greg Gulick is a certified financial planner located in Dallas. He specializes in providing objective, independent, unbiased, and creative solutions for medical professionals and individuals regarding their investment management and financial planning needs. He can be reached at (972) 708-1070, ggulick@investmentctr.com.

With a well-diversified portfolio in which your assets are properly allocated, that has the right amount of risk for you, and is designed to meet your financial goals, you’ll be in a good position to weather financial storms.

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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*

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“It’s a wonderful thing to practice family medicine in the state of Texas, to have the opportunity to get to know our patients and their families and to take care of them. As members of the Texas Academy of Family Physicians, we don’t just care for our patients in the exam room. We take care of them at the State Capitol, too. “I’m a monthly donor for the TAFP Political Action Committee because if we want policies that are good for our patients and our practices, we have to elect politicians who understand our issues. Support TAFPPAC and make your voice heard.” Justin Bartos, MD 2016 TAFPPAC Award recipient

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RESEARCH

Support for this project included a grant from the Texas Academy of Family Physicians Foundation.

Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.

GOLD LEVEL

Obesity at 6 months of age predictive of obesity at 24 months of age Sally P. Weaver, PhD, MD Waco Family Medicine Residency Program Kelly R. Ylitalo, PhD Baylor University Suzy Weems, PhD Baylor University

Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White SILVER LEVEL Carol and Dale Moquist, MD TAFP Red River Chapter BRONZE LEVEL Joane Baumer, MD Gary Mennie, MD Linda Siy, MD Lloyd Van Winkle, MD George Zenner, MD

Thank you to all who have donated to an endowment.

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

Introduction The first 1,000 days of life — conception through 24 months — are a critical period for the growth and development of many body systems.1 Recent evidence indicates that obesity may originate during this early life time period as well.2 Race/ethnic disparities in childhood obesity remain a major public health problem.3 Hispanic and non-Hispanic black children are more likely to be overweight and obese than their non-Hispanic white counterparts at every age.1 Obese children often become obese adolescents and adults,4-6 which predisposes them for many adverse chronic health conditions such as diabetes and cardiovascular disease.7-9 Clearly, a healthy beginning in life establishes long-term health trajectories. The purpose of this investigation was to evaluate obesity in a high-risk, ethnically diverse population of children up to 2 years of age using electronic medical records, and to determine the utility of a single obese measurement at 6 months for predicting future obesity at 24 months of age.

Methods The study population for this investigation included 10,726 patients from the ADVANCE11 (Accelerating Data Value Across a National Community Health Center Network) Early Life Obesity Cohort. The ADVANCE Early Life Obesity Cohort are patients 0 to 5 years of age with at least one valid measure of height and weight at a well-child visit between January 1, 2012 and December 31, 2014. Our inclusion criteria included a length and weight measurement prior to 6 months of age, and at least three additional height and weight measurements, two of which occurred in the 6-month and 24-month age windows. Exclusion criteria included chronic conditions identified using ICD-10 codes, corresponding to previous work on pediatric complex chronic conditions ICD-9 codes.11

Variables: Weight in kilograms and length in centimeters were converted to weight-for-length (WFL) percentiles based on the World Health Organization growth standards.12 For this investigation, the primary variable of interest was an obese event, defined as any WFL ≥ 97.7th percentile, which corresponds to +2 standard deviations on the WHO growth standard.13 Children were classified as “obese at 6 months” if there was at least one obese measurement between 4.5 and 7.5 months of age and as “obese at 24 months” if there was at least one obese measurement during the 20- to 30-month age range. If there were multiple obese measurements during the respective age ranges, the first obese measurement within the age range was used. Other individual-level variables included age (in days), race/ethnicity (Hispanic, non-Hispanic African American, non-Hispanic white, non-Hispanic other), gender (male or female), primary payer type (private insurance, Medicaid, or uninsured), gestational age (in weeks) and ZIP code. Community-level variables included the median household income of the census tract and the proportion of the census tract that was below 200 percent of the poverty level. Statistical analysis: We described the sample population using means (standard deviation) for continuous variables and proportions for categorical variables. Children with an obese event at 6 months were compared to those without an obese event at 6 months using student t-tests for continuous variables and chisquare tests for categorical variables. We also compared children with an obese event at 24 months to children without an obese event at 24 months using the same tests. Generalized linear models with binomial probability distributions and log links were used to generate risk ratios and 95 percent confidence intervals to evaluate the association between an obese event at 6 months and an obese event at 24 months for the total sample www.tafp.org

population and then stratified by race/ethnicity. We included gender, race/ethnicity, insurance status, and proportion of ZIP code below 200 percent of the poverty level as covariates in the multivariate models. SAS v9.4 (SAS Institute, Cary, North Carolina) was used for all data management and analysis. Statistical significance was defined at the Îą = 0.05 level. IRB approval was obtained from the Western IRB.

Results Ethnic distribution of the sample was 25 percent non-Hispanic white, 63.0 percent Hispanic, 9.2 percent non-Hispanic black, and < 5 percent non-Hispanic other. At 6 months of age, 8.0 percent (n = 858) of sample children were obese, and at 24 months of age, 16.5 percent (n = 1,770) of sample children were obese. Male children and Hispanic children were disproportionately more likely to be obese than female children or non-Hispanic white or black children at both 6 months and 24 months of age. Over 80 percent of the sample used Medicaid as their primary payer type, and children with Medicaid were more likely to be obese at both 6 months and 24 months than children with private insurance (p < 0.001). The median household income for ZIP codes of all sample children was $48,862.22. Children who were obese at 24 months but not at 6 months resided within ZIP codes with a slightly lower median income compared to non-obese children at 24 months of age (p = 0.03). Obese children at 6 months and at 24 months were more likely to live in ZIP codes with a higher proportion of residents below the 200 percent of the poverty level than non-obese children (p < 0.001). Among the total sample population, children with an obese measurement at 6 months were almost 4 times more likely to have an obese measurement at 24 months (95 percent CI: 3.54, 4.17; p < 0.001). The relationship between an obesity at 6 months and obesity at 24 months was robust for all race/ethnic groups, even after adjusting for child sex, insurance status, and proportion of ZIP code in poverty.

Discussion In a vulnerable, multi-ethnic cohort of children from a network of federally qualified health centers in the United States the incidence of obesity was high. At 6 months of age, 8.0 percent of children had at least one obese measurement, and at 24 months of age, 16.5 percent of children had at least one obese measurement. Almost two-thirds of the sample population was Hispanic; Hispanic children were disproportionately more likely to be obese at both 6 months and 24 months than were non-Hispanic white children. Furthermore, children with an obese measurement at 6 months had almost 4 times the risk of an obese measurement at 24 months of age. Our results, drawn from a much larger population of children and are consistent with these prevalence data from the National Health and Nutrition Examina36

TEXAS FAMILY PHYSICIAN [No. 2] 2017

tion Survey regarding early childhood obesity. Ogden et al.3 reported that approximately 10 percent of infants and toddlers (all children under 2 years of age combined) were at or above the 95th percentile of weightfor-recumbent-length CDC growth charts, and that Hispanic infants and toddlers had a higher prevalence of high weight-for-recumbent-length than non-Hispanic white infants and toddlers. Our most important findings indicate that a single obese measurement in infants at 6 months of age strongly predicts the risk of future obesity at 24 months of age. For every race/ethnic group, children with one obese measurement at 6 months of age had approximately 4 times the risk of an obese measurement at 24 months of age. These findings are consistent with a smaller case-control study of 544 children that demonstrated a strong association between obesity at age 24 months and obesity at 6 months.14 Our study expands on this work in a larger, predominantly Hispanic cohort. A growing body of evidence, including our work, demonstrates how early obesity in infancy tracks to toddlerhood.15-18 Much of the work on childhood obesity has focused on children aged 2 to 19 years, or on the prevalence of obesity using repeated cross-sectional samples of the U.S. population.19 The ability to identify excessive weight for length during the first 2 years of life is an important tool in the clinicianâ&#x20AC;&#x2122;s ability to response to childhood obesity. One obese measurement at 6 months of age increases the risk of future obese measurements, particularly in underserved, race/ethnic minority children. Our work reemphasizes the need for early assessment and intervention to prevent childhood obesity and future adverse health events, and the utility of electronic medical records for population health surveillance.

References 1. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, GranthamMcGregor S, Katz J, Martorell R, Uauy R; Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in lowincome and middle-income countries. Lancet. 2013;382(9890):427-51. 2. Woo Baidal JA, Criss S, Goldman RE, Perkins M, Cunningham C, Taveras EM. Reducing Hispanic childrenâ&#x20AC;&#x2122;s obesity risk factors in the first 1000 days of life: a qualitative analysis. J Obes. 2015;2015:945918. 3. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307(5):483-90. 4. Monteiro PO1, Victora CG. Rapid growth in infancy and childhood and obesity in later life--a systematic review. Obes Rev. 2005;6(2):143-54.

5. Nader PR, O’Brien M, Houts R, Bradley R, Belsky J, Crosnoe R, Friedman S, Mei Z, Susman EJ; National Institute of Child Health and Human Development Early Child Care Research Network. Identifying risk for obesity in early childhood. Pediatrics. 2006;118(3):e594-601. 6. Ong KK, Loos RJ. Rapid infancy weight gain and subsequent obesity: systematic reviews and hopeful suggestions. Acta Paediatr. 2006;95(8):904-8. 7. Baker JL, Olsen LW, Sørensen TI. Childhood bodymass index and the risk of coronary heart disease in adulthood. N Engl J Med. 2007;357(23):2329-37. 8. Park MH, Falconer C, Viner RM, Kinra S. The impact of childhood obesity on morbidity and mortality in adulthood: a systematic review. Obes Rev. 2012;13(11):985-1000. 9. Andersen LG, Angquist L, Eriksson JG, Forsen T, Gamborg M, Osmond C, Baker JL, Sørensen TI. Birth weight, childhood body mass index and risk of coronary heart disease in adults: combined historical cohort studies. PLoS One. 2010;5(11):e14126. 10. DeVoe JE, Gold R, Cottrell E, Bauer V, Brickman A, Puro J, Nelson C, Mayer KH, Sears A, Burdick T, Merrell J. The ADVANCE network: accelerating data value across a national community health center network. Journal of the American Medical Informatics Association. 2014;21(4):591-5. 11. Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997. Pediatrics. 2000;106(1 Pt 2):205-9. 12. WHO Child Growth Standards. Available at http:// www.who.int/childgrowth/en/. 13. Centers for Disease Control and Prevention. Use of World Health Organization and CDC Growth Charts for Children Aged 0-59 Months in the United States. MMWR 2010;59(No. RR-9):1-15. 14. McCormick DP, Sarpong K, Jordan L, Ray LA, Jain S. Infant obesity: are we ready to make this diagnosis? J Pediatr. 2010 Jul;157(1):15-9. 15. Taveras EM, Rifas-Shiman SL, Belfort MB, Kleinman KP, Oken E, Gillman MW. Weight status in the first 6 months of life and obesity at 3 years of age. Pediatrics. 2009;123(4):1177-83. 16. Moss BG, Yeaton WH. Young children’s weight trajectories and associated risk factors: results from the Early Childhood Longitudinal Study-Birth Cohort. Am J Health Promot. 2011;25(3):190-8. 17. Gibbs BG, Forste R. Socioeconomic status, infant feeding practices and early childhood obesity. Pediatr Obes. 2014;9(2):135-46. 18. Roy SM, Spivack JG, Faith MS, Chesi A, Mitchell JA, Kelly A, Grant SF, McCormack SE, Zemel BS. Infant BMI or Weight-for-Length and Obesity Risk in Early Childhood. Pediatrics. 2016;137(5). 19. Cheung PC, Cunningham SA, Naryan KV, Kramer MR. Childhood Obesity Incidence in the United States: A Systematic Review. Childhood Obesity. 2016;12(1):1-11.

Interested in participating in practice-based research? www.tafp.org/practice-resources/research TAFP’s Section on Research wants you to know that Texas is home to lots of practice-based primary care research opportunities. Check out our new research page at tafp.org to learn more and to contact like-minded colleagues and find a project to dive into.

FAMILY MEDICINE PRACTICE-BASED RESEARCH RESOURCES AHRQ PBRN website: pbrn.ahrq.gov The Agency for Healthcare Research and Quality supports practice-based research networks, or PBRNs, all over the country. AAFP NRN: www.aafp.org/patient-care/nrn/nrn.htm The AAFP National Research Network is affiliated with regional practice-based research networks throughout the country. RRNeT: familymed.uthscsa.edu/rrnet The Residency Research Network of Texas is a collaboration of family medicine residency programs dedicated to improving family physicians’ interest and skills in research and to find answers to clinical questions relevant to family medicine patient populations. SPUR Net: www.prime-net-consortium.org/spur-net.html The Southern Primary Care Urban Research Network is organized by the Family Medicine Department at Baylor College of Medicine in Houston and is a member of the Primary Care Multi Ethnic Network. STARNet: https://iims.uthscsa.edu/STARNet/home The South Texas Ambulatory Research Network is a learning community of primary care clinicians, staff, and patients in clinics across South Texas. CenTexNet http://researchers.sw.org/dorfam/informationabout-centexnet The Central Texas Primary Care Research Network is based in Temple, Texas, in the Department of Family and Community Medicine at Scott & White Memorial Hospital and the College of Medicine, Texas A&M Health Science Center. NorTex: www.unthsc.edu/research/nortex NorTex is a collaborative network of researchers and clinicians throughout North Texas. They conduct primary care and public health research that will be translated into published guidelines and policies, improve the delivery of care, and ultimately, the health of North Texas citizens.

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PERSPECTIVE

A prescription for community health: The importance of advocacy in medicine By Lane J. Aiena, MD as physicians we are tasked with the monumental privilege of helping people as our craft. We train for four years in our undergraduate education, four years in medical school, and an additional three years minimum in residency to be given this trust by our patients. From this education, we gain the ability to help the patient in front of us, but all too often we lose sight of our ability to help the community as a whole. As physicians we have the ability to treat not just the patient in front of us but the thousands of patients beyond our door that are affected every day by policy. Recently I was able to do a rotation with TAFP in Austin. This rotation was set up after several advocacy trips to Washington D.C. piqued my interest in policy. I was fortunate to match to a residency, Conroe Family Medicine Residency, that is very active both in its community and at the national level. The main takeaway from my first trip was this: everyone in politics has an ask, but stories are what stick. Simply talking about what we do on a daily basis can be a huge vehicle for change. I wanted a way to learn how to more effectively “get my story out there,” and this rotation was the perfect way to do just that. In Austin my primary goal was to become more familiar with “how things work.” I had a general idea, but still felt very naïve to the overall process. I was able to see firsthand the committee meetings where bills have their first potential life, saw lobbyists delivering messages to influence change, and met staffers, representatives, and senators. I had the privilege of speaking one on one with the representative of my future hometown of Huntsville. I had breakfast with Dr. J.D. Sheffield, representative of House District 59 who is also a family physician. I spent a day getting advice from the Capitol’s Physician of the Day and 2001 TAFP Physician of the Year, Dr. Donald Niño. I read and reviewed bills, participated in meetings, and learned how to be effective at advocacy for my patients.

Health care has become one of the biggest political topics of our time and as physicians, it is our duty to shape policy in the most appropriate way we can discern. After all, we are the experts, right? In Austin I learned just how best to turn my stories and ideas into policy. Physicians are community leaders and policy makers want to know what we think. Try to establish relationships with these representatives. It helps them just as much to know a leader in their constituents’ community as it does for you to know a policy maker. Host events in your area, give back, and always be ready for an opportunity to speak at the Capitol. Like Sam Rayburn said, “Readiness for opportunity makes for success. Opportunity often comes by accident; readiness never does.” In our offices we help around 20 to 24 people a day. Imagine being able to help thousands with a single conversation or a single story. We work countless hours; we endured a rigorous education that had little to nothing to do with politics. Keeping up with policy issues often has to take a back seat to keeping up with the latest articles and recommendations in the medical journals. That being said, it is our duty to be up to date on these policy issues, too. We owe it to our communities to be the leaders they look to us to be. Stay knowledgeable, get active, and make your opinion heard. Your stories matter and they may just be what influence policy.

Everyone in politics has an ask, but stories are what stick. Simply talking about what we do on a daily basis can be a huge vehicle for change.

TEXAS FAMILY PHYSICIAN [No. 2] 2017

icine

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By volunteering to precept a Texas medical student, you can open a door to a new world for the next generation of family doctors. QUESTIONS? Give us a call at (512) 329-8666 or send an email to Juleah Williams, jwilliams@tafp.org.

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