Texas Family Physician, Q4 2019

TEXAS FAMILY PHYSICIAN VOL. 70 NO. 4 2019

THE GIANT STIRS As Health Costs Climb, Employers Take Charge

PLUS: Recognize Signs Of Human Trafficking Texas’ New Medical Cannabis Program: What You Need To Know

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INSIDE TEXAS FAMILY PHYSICIAN VOL. 70 NO. 4 2019

6 FROM YOUR PRESIDENT End of the road for private practice?

16

8 NEWS BRIEF Winners announced in TAFP innovators competition

The giant stirs

As the cost of health care continues to climb, employers are waking up to the might of their purchasing power. What comes next could depend largely on what they do with it.

By Todd Thames, MD, MHA

20 21

Looking ahead to 2020 Disruption is the name of the game in the health care industry.

By Tom Banning

An unspoken chief complaint: Human trafficking

Serving on the front lines of medicine, family physicians can help victims of one of society’s most terrible scourges, human trafficking.

By Victoria Udezi, MD

22

Family doctors and Texas’ new medical cannabis program

There’s a new law in the Lone Star State, and it means an estimated additional 1.8 million Texans now qualify for a medical cannabis prescription.

By Karen Keough, MD

10 MEMBER NEWS Texas FPs win national awards | Hart to chair AAFP commission | Call for NCCL reps I In memoriam: Edwin Franks, MD | Excellent honors for Texas FMIGs 15 YOUR ACADEMY Residency match results from 2016 family medicine preceptorship program participants 30 PERSPECTIVE Endangered species: Independent physicians

JONATHAN NELSON

16

PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 70 NO. 4 2019 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.

Private practice: Are we approaching the end of the road?

By Rebecca Hart, MD TAFP President

OFFICERS president president-elect treasurer

Rebecca Hart, MD

Javier D. “Jake” Margo, Jr., MD Amer Shakil, MD, MBA

parliamentarian

Mary Nguyen, MD

immediate past president

Janet Hurley, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editor

Jean Klewitz chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell

CONTRIBUTING EDITORS Christopher Crow, MD, MBA Kimberly G. Fulda, DrPH Karen Keough, MD Meng-Hua Tao, PhD, MD Todd Thames, MD, MHA Victoria Udezi, MD Long Wong, PhD, MD

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.

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. © 2019 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. 4] 2019

groups that can amass huge numbers of is private practice obsolete? Can it be doctors for payers and employers? saved, and if so, who will save it?

To find an answer—to find people and Such questions dog many of our colorganizations leveraging independent pracleagues in family medicine. We struggle tices and building networks of primary care to keep small businesses thriving amid doctors that can collectively compete for ever-increasing administrative hassles and fee-for-service and value-based contracts— expenses. All the while, disruptive new we need look no further market entrants threaten than here at home in to upend the mores and For some, Texas. norms we’ve always Over the past four known. employment offers years, Christopher Crow, Is the EHR to blame the stability and MD, MBA, has built an for the demise of private favorable workever-growing network of practice as we know it? more than 650 primary Is it burnout? Or is it a life balance they care physicians in North flawed payment system seek. But too many and East Texas through that fails to appropriof our colleagues the Catalyst Health ately value what family Network, leveraging their doctors do? have succumbed to value with insurers and We are witnessing a market pressures, employers to secure better tectonic shift in the busiand believing they contracts than they could ness of health care and have won on their own. As the changes just keep were out of options, part of a network, these coming. they’ve sold their physicians retain their In the face of such private practices independent practices upheaval, many family but they work with and physicians have chosen to large hospital through Catalyst on conto be employed by health groups or insurance tract negotiations to better systems and insurance companies that feed align payment structures companies. For some, employment offers the on a growing primary and offer more freedom of choice in how they best stability and favorable care base. care for their patients in work-life balance they their communities. seek. But too many of Catalyst also uses care teams to extend our colleagues have succumbed to market the reach of primary care physicians, putpressures, and believing they were out of ting them at the center of the care process options, they’ve sold their private pracand providing data-driven feedback so phytices to large hospital groups or insurance sicians know how their patients are doing. companies that feed on a growing primary It gives patients and physicians more choice, care base. ensuring they can access the best care a So, another question: How can small, community has to offer—not just what a independent practices compete for insurhospital system tells them to use. ance contracts with large hospital-led

Reiner Consulting & Associates Practice ManageMent ServiceS

Now employers of all sizes are approaching Catalyst to improve the care they can offer their employees — and to lower costs in the process. Everybody wins.

Physicians keep their practices and earn better reimbursement rates; employers pay lower premiums and benefit from a healthier workforce; patients get to keep their relationships with their primary care physicians without sacrificing flexibility and freedom; and insurers share risk through Catalyst’s value-based contracts that assure high quality and lower costs.

Likewise, family physicians across the state have built similar enterprises designed for doctors who want to maintain their private practices while providing excellent care to their patients. Physician leaders like Sheila Magoon, MD, at Buena Vida y Salud, an accountable care organization in Harlingen, and Clive Fields, MD, who co-founded Village MD, in Houston.

Then there is Lloyd Van Winkle, MD, with United Physicians of San Antonio ACO, and Martin Franklin, DO, with Peterson Health in Kerrville, and Norm Chenven, MD, with Austin Regional Clinic in Austin.

And the list goes on.

Can models like these work for the rest of the state? Absolutely. These kinds of solutions become more important as Texas grows and the health care market evolves.

Here is the key: Physicians who want to remain independent need to come together with like-minded colleagues to organize in a way that allows them to pool financial resources, aggregate data, and share clinical tools to provide high-quality care.

Physician leaders are already in the process of implementing these organizations around the state. They are blazing a trail that could help save private practice in Texas.

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the judges’ tallies are in and we have and the Hope Clinic of McKinney in the three winners in TAFP’s first-ever Behavsmall group and solo practice category. ioral Health Integration Innovators Compe“In our strategic planning, we discussed tition. In May, the Academy put out a call to family physicians primary care practices struggling to treat their asking them to submit patients’ behavioral their unique models health problems,” says “In our strategic of behavioral health Hurley, MD, chair planning, we discussed Janet integration for the of the TAFP Behavioral chance to win $10,000. family physicians Health Task Force.

Entries were judged by “We put together the struggling to treat their the TAFP Behavioral behavioral health task patients’ behavioral Health Task Force, force to help educate which was appointed health problems. and empower members after the Academy to act locally.”

We put together the identified the need for The Academy gathbehavioral health task greater integration ered a group of behavof behavioral health force to help educate ioral health experts services in primary care across specialties to coland empower members as a top priority in its laborate on the contest to act locally.” strategic plan. and to help develop a The judges selected — Janet Hurley, MD toolkit of resources to winners in each of help members integrate three care settings: behavioral health into academic health centheir practices. ters, integrated health “One key goal of the Behavioral Health systems, and solo and small group practices.

Integration Innovators Competition was The winners are the Memorial Family Medito prove that integrated behavioral health cine Residency Program of Sugar Land in could occur in Texas, utilizing payment the academic setting category, the Heart of mechanisms that exist in our state,” Hurley Texas Community Health Center of Waco says. “While there are many models of in the integrated health systems category, behavioral health integration found in other

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TEXAS FAMILY PHYSICIAN [No. 4] 2019

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states, we had to prove this type of model could be financially sustainable in Texas.”

The inaugural competition shed light on many successful integration models, and the task force was surprised by the number of primary care practices in Texas that are successfully doing it.

“We were both shocked and excited when we learned we’d received 30 submissions to the competition,” Hurley says. “While not all practices could win, we still plan to share some of the best practices from the topranking models. By doing this, we hope it will empower others to integrate behavioral health into their practices.”

TAFP’s new Behavioral Health Integration Toolkit aims to help members learn how to implement behavioral health resources in their practices and how to bill for those services. There are resources from the Substance Abuse and Mental Health Services Administration, examples of successful integration models, and access to a geomapped listing of local behavioral health resources.

The winners of the competition gave presentations on their successful integrated behavioral health models at the Annual Session and Primary Care Summit in The Woodlands in November, and other models will be featured soon under the “Models and mentors” section of the Behavioral Health Integration Toolkit.

They will also be featured in a future edition of Texas Family Physician.

“We are very thankful for the incredible expertise we were able to consult with the task force,” Hurley says, “and we hope that the competition and toolkit reveal resources and best practices that help members integrate behavioral health into their practices.”

Great appreciation goes out to the task force members.

• Jeff Bullard, MD, Family Physician at MaxHealth, CEO of Vault, Catalyst Health Network Board Member and Medical Director (Colleyville)

• Sandra Van Wyk, MD, Psychiatry Resident at UT Dell Medical School (Austin) • Stacy Ogbeide, PsyD, MS, ABPP, Associate Professor/Clinical and Primary Care Behavioral Health Consultant at UT Health (San Antonio) • Edward Dick, MD, Senior VP of Integrated Health Services for Methodist Healthcare Ministries (San Antonio) • Theresa Murphy, LCSW, Director of Behavioral Health Methodist Charlton Family Medicine Residency Program / Methodist Health System (Dallas) • Diane Dougherty, PhD, Clinical Psychologist (Baytown) • Richard “Garrett” Key, MD, Psychiatrist at Dell Medical School (Austin) • Deepu George, PhD, LMFT Division Chief of Behavioral Medicine and Assistant Professor of Family Medicine at UT Health Rio Grande Valley (McAllen)

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MEMBER NEWS

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TEXAS FAMILY PHYSICIAN [No. 4] 2019

DAVID MITCHELL/AAFP NEWS

COMING SOON ON TAFP’S

Ted Mettetal, MD, (pictured left) and Nancy Dickey, MD, (right) receive awards from AAFP President John Cullen, MD, at the AAFP Congress of Delegates in Philadelphia.

Two Texas physicians honored during AAFP national conference the american academy of Family Physicians announced the recipients of its most prestigious awards at its annual meeting this September and two were Texans.

C. Ted Mettetal, MD, a family physician in Athens, Texas, was awarded the AAFP’s Humanitarian Award. The Humanitarian Award honors extraordinary and enduring humanitarian efforts by an AAFP member, both within and beyond the borders of the United States.

Mettetal is a practicing family physician and the founder and executive director of Hope Springs Water. The organization was established in 2010 after Mettetal travelled to the developing world as part of a medical team and saw people suffering due to a lack of access to clean water. HSW’s mission is to bring clean water, improved sanitation, and public health and hygiene education to the people in underdeveloped parts of the world.

Mettetal led the earliest projects in Nicaragua and Belize, where HSW reclaimed 150 abandoned wells and restored access to clean water. In 2011, HSW began working in Africa—funding wells, developing rainwater collection and storage systems, and wastewater treatment facilities. Volunteer teams continue partnering with local governments, NGOs, and school systems to teach hygiene practices.

To date, the organization has brought its mission to 12 countries and has completed more than 85 water projects, bringing clean water and sanitation to more than 100,000 people.

Nancy Dickey, MD, a family physician in Bryan, Texas, was awarded the John G. Walsh Award for Lifetime Contributions to Family Medicine. This award honors those

individuals whose dedication and effective leadership has furthered the development of family medicine. It recognizes long-term dedication, rather than any single significant contribution, and effective leadership toward furthering the development of family medicine. This award is not granted on a regular basis but is awarded at the discretion of the AAFP Board of Directors.

Dickey currently serves as a professor in the Department of Primary Care Medicine and the Department of Medical Humanities in the College of Medicine and as a professor in the Department of Health Policy and Management in the School of Public Health, at Texas A&M Health Science Center. She also carries the title president emeritus of the Health Science Center, having served in the role of president for over a decade prior to stepping out of administration and into teaching and policy development.

Dickey also serves as executive director of the A&M Rural and Community Health Institute, which serves in a consultative role with hospitals and communities across the state of Texas to facilitate best practices in patient safety, enhanced quality of care, and physician excellence. The institute was created during her time of leadership at the Health Science Center and exemplifies the importance of translating sound policy into practice, not only in traditional academic health centers but across the spectrum of practice sites and care delivery.

Dickey was the first female president of the American Medical Association. She was also selected to be a member of the Institute of Medicine, a component of the National Academy of Sciences.

Dallas FP wins AAFP teaching award chrisette dharma, md, won this year’s AAFP Exemplary Teaching Award in the volunteer category. Dharma precepts medical students at her practice, Southwest Family Medicine Associates Clinic in Dallas as part of the Texas Family Medicine Preceptorship Program and as a UT Southwestern Clinical Assistant Professor.

In a letter announcChrisette Dharma, MD ing the award, the AAFP Board of Directors lauded Dr. Dharma’s commitment to education and dedication to shaping the next generation of family physicians. “You have also personally devoted countless hours to teaching and training medical students and nurse practitioner students in your practice, and you are known as a natural educator who can use almost any situation as an opportunity for instruction.”

TAFP President to chair AAFP committee rebecca hart, md, has been tapped to chair the AAFP Commission on Continuing Professional Development. She has served on the commission for the past four years. This fall, Hart is finishing her term as TAFP President and at the conclusion of this year’s Annual Session and Primary Care Summit, she will become chair of the TAFP Board of Directors.

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Spots are available for five delegates and five alternate delegates to attend in the conference in Kansas City, Mo., April 23-25, 2020. For consideration, send a CV and a statement of intent including the constituencies that suit you to Jonathan Nelson, jnelson@tafp.org.

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11

In memoriam

Edwin R. Franks, MD edwin r. franks, md, died on August 19 in Iraan, Texas at age 90.

He said you only came to Iraan for two reasons: you either intended to come or you were lost. He intended to come. Over an estimated 3,000 babies, 10,000 patients, and 59 years later, with always twinkling eyes, Dr. Franks said, “… nothing’s given me an ulcer, a heart attack, a nervous breakdown, or another wife. I wanted to be a family doctor, be my own boss and take care of people. I practiced medicine during the golden years. I love it.”

Dr. Franks often said if you take care of the people, they would take care of you. He has loved and been loved by his community, patients, friends and family. He is missing them as much as they are missing him. His energy and spirit will live on in us. We are grateful.

He is survived by his wife Chris, “the love of his life” and his daughter Suzanne Franks, “the light of his life.”

Edd Franks was born in Roby, Texas near Abilene in 1929. When he was 11 years old, his mother suffered a tragic death, which inspired him to become a doctor. After her death, he and his little brother spent their childhood with relatives in and around Brownfield.

At McMurry College, he met two women who were turning points in his life. The summer before his sophomore year, he conducted freshman biology labs as a teaching assistant for Dr. Ruth Holzapfel, professor of biology, where he met Christine Hambright who needed help dissecting her frog.

During Edd’s junior year, his mentor Dr. Holzapfel received an offer from Midwestern University in Wichita Falls to become Chairman of the Department of Life Sciences. She told Midwestern that she would accept the position if she could bring her lab TA, Eddie.

Edd graduated from Midwestern University with majors in biology and education and minors in chemistry and English, and subsequently married Christine Hambright, who was by then teaching fourth grade in Seminole.

After college during the Korean conflict, the U.S. government drafted him into the Army Medical Service Corps at Valley Forge Army Hospital in Pennsylvania, where he taught operating room and medical nurses. He and Chris were so homesick for Texas that in the evenings, they read aloud “Giant” by Edna Ferber, and Edd embroidered quilt squares with oil derricks, cotton bolls, and cowboy hats.

12

TEXAS FAMILY PHYSICIAN [No. 4] 2019

After his two-year stint in the Army, he applied to medical school but was not accepted. He and Chris moved to Irving, living in a travel trailer, where he taught high school biology and worked at Hoffbrau Trailers. That year, hocking a coffee pot over and over helped them make ends meet.

The next year, the University of Texas Medical Branch at Galveston accepted him. They traded their travel trailer for a little white house surrounded by palm trees. He worked various jobs. She taught school.

In 1959 he received his medical degree and returned to Brownfield. One day, four well-dressed men came into his office. Dr. Franks wondered, “Oh my Lord, have I killed somebody? Is my drug license up?” These men from Iraan had heard from one of Dr. Franks’ medical school classmates in Uvalde that he wanted to establish his practice in a small West Texas town.

In the summer of 1960, Dr. Franks and Chris drove into Iraan. A crowd had gathered along the road that ran by the public pool. A truck had mortally hit a little boy crossing the road. Dr. Franks pronounced him dead. Later that evening, the town welcomed Dr. Franks as their doctor at a covered dish supper in the community center.

In 2009 Dr. Franks retired from practicing medicine at the age of 80 but continued to attend TAFP conferences. In the summer of 2018, Dr. Franks last attended one of these conferences, joined by his wife, Chris, and daughter, Suzanne.

While practicing medicine “from the womb to the tomb, ” Dr. Franks loved going to his farm to take care of his sheep, goats, and cows almost every day for many years. He enjoyed hunting deer, quail, and turkey there and basking in the quiet solitude. He engaged in other hobbies at various points including ceramics, weaving, embroidery and needlepoint, sewing curtains when needed, tanning rattle snake skins and fashioning them into vests and hatbands, designing and building an adobe house from his farm’s dirt, and more.

Dr. Franks led his community in civic, professional, and charitable endeavors. During his career, he hosted a total of 28 fourth-year medical students over many years for one- to two-month preceptorships in his medical practice, usually during hunting season. He brought medical care to villages in Mexico; he served as chief of staff of Iraan General Hospital; and he was one of nine founding members of the TAFP Foundation. He served as TAFP President in 1977-78. He served as the state director of the Texas division of the American Cancer Society, was a member of the Iraan-Sheffield Independent School District Board of Trustees and the president of the Iraan Lions Club. He was also president of the Iraan Chamber of Commerce Board of Directors and a member of the Iraan Methodist Church Board of Trustees.

Obituary provided by Shaffer-Nichols Funeral Home.

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Top: UTMB students, residents, and faculty pictured from left to right are Deanne Phillips, YI “Lisa” Liang, Edward Strecker, MD, Shannon Samuelson, Jennifer Raley, MD, Alex Cantu, Tracy Hu, Jonathan Teren, and Robles Ghebrekristos.

Bottom: UTSW students and faculty pictured from left to right are Emily Gao, Amy Luu, Oliver Taylor, Tamara McGregor, MD, Brian Ostler, Zaiba Jetpuri, DO, and Anita Vasudevan.

cedures at the Primary Care Pavilion event, which has been running for nine years. At the event, students have the opportunity to practice a wide array of ambulatory clinical procedures through hands-on workshops led by faculty members and residents. They also host an annual residency fair and give back to their community by holding a flu vaccine and toiletry donation drive for the homeless population around UTMB. University of Texas Southwestern Medical School – Dallas AAFP FMIG Program of Excellence Award: FMIG Operation

Texas Family Medicine Interest Groups recognized locally and nationally

By Jean Klewitz tafp named the University of Texas Southwestern Medical School – Dallas and the University of Texas Medical Branch in Galveston as TAFP Family Medicine Interest Group Program of Excellence Award winners for their efforts in generating interest in family medicine. The Texas award winners received cash prizes from TAFP to help cover travel costs to AAFP’s National Conference of Family Medicine Residents and Students.

At AAFP’s National Conference in July in Kansas City, these two medical schools were honored nationally. The American Academy of Family Physicians Family Medicine 14

TEXAS FAMILY PHYSICIAN [No. 4] 2019

Interest Group Network recognized the two Texas medical schools as 2019 AAFP Program of Excellence Award winners.

These state and national awards celebrate and support FMIGs for inspiring medical students to consider the specialty of family medicine.

University of Texas Medical Branch at Galveston AAFP FMIG Program of Excellence Award: Professional Development UTMB FMIG members have many activities they can participate in throughout the year.

The most attended is the Primary Care Pro-

UTSW hosts events throughout the year, showcasing the family medicine specialty.

FMIG leaders started a six-session preclinical procedural skills elective course taught by resident faculty. The sessions include an educational instructional component followed by hands-on procedure training. From August through April, they host a series of lunch lectures and workshops that promote the scope and diversity of family medicine. Additionally, they hold a year-long longitudinal clinic shadowing program, where students are matched to shadow faculty advisors in the family medicine clinic.

FMIGs are sponsored by medical schools and run by students and faculty. They give medical students opportunities to learn about family medicine through meetings, workshops, leadership development opportunities, and clinical experiences.

Outstanding medical students that are leading and participating in their campus’ FMIG activities help drive the family medicine revolution in the right direction.

Are you a member of an FMIG on your campus? TAFP will begin accepting applications for the Texas FMIG Program of Excellence Award in early 2020. Please contact Juleah Williams at jwilliams@tafp. org to apply.

YOUR ACADEMY

Texas Family Medicine Preceptorship Program Residency Match Results for 2016 Participants Texas reinstated funding for the TFMPP in 2015 so in 2016, the first cohort of participants completed preceptorships between their first and second years of medical school. Now they’ve graduated so we can see what types of residency programs they chose.

63

medical students completed preceptorships in TFMPP in 2016.

FAMILY MEDICINE

34

entered primary care residencies in 2019 and 21 of those chose family medicine.

WHAT THEY SAID

WHAT THEY DID 4 OTHER

31

9 NO DATA

3 SUBSPECIALTY

SUBSPECIALTY

16

UNDECIDED

PRIMARY CARE

PRIMARY CARE

NO DATA

SUBSPECIALTY

OTHER

I was exposed to a gamut of patients: newborns and pediatrics, geriatrics, OB-GYN, intensive care, post-surgical cases, hospice patients, and admits from the emergency room. … I really don’t think I could’ve had a better experience!”

— Amanda Bell

34

29

PRIMARY CARE

WHERE THEY WENT 4 OTHER 9 NO DATA

Preferred specialty before preceptorship

10

FAMILY MED 4 OTHER PRIMARY CARE

Residency match in 2019 2 OB-GYN 4 PEDIATRICS

21 FAMILY

15 UNDECIDED

31

STAYED IN TEXAS FOR RESIDENCY

19 LEFT TEXAS

MED 7 INTERNAL MEDICINE

TFMPP matches first- or second-year students enrolled in a Texas medical school with an experienced and skilled family physician for a two- to fourweek period to help them gain real-life experience in a community setting.

By participating in our preceptorship program, students will have the unique opportunity to explore what it means to be a family physician.

Other: Two graduates entered research fellowships, one student left medical school, and one student will graduate in 2020.

Copyright ©2019 Texas Academy of Family Physicians

www.tafp.org

15

THE GIANT STIRS

By Todd Thames, MD, MHA

“Change is the law of life. And those who look only to the past or present are certain to miss the future.”

— John F. Kennedy on occasion tectonic plates shift, and when they do the result can be tremendously disruptive. But the result can also be creative. Tectonic movements are taking place in the U.S. health care economy, and while much of it may be occurring below the surface, the rippling manifestations will become clear over the next several years. One shift in particular is the more direct and aggressive engagement of employers for driving change in the way health care is paid for and delivered. Put simply, the giant is stirring.

In 2017, employers sponsored health insurance coverage for 49% of the U.S. population; 1 in 2 Americans; 152 million people. That equates to 56% percent of the insured population, compared to 19.3% on Medcaid, 17.2% on Medicare, who 16% purchase insurance directly, and 4.8% covered by the military.1 In 2017, the U.S. spent a total of $3.5 trillion on health care, amounting to 17.9% of total gross domestic product.2 Collectively, employers contributed just over $980 billion, or about 28% of this total spending.

While health insurance premiums have increased by 203% since 1999, wage growth of only 56% has been just slightly above inflation growth of 42% during this same period (Figure 1). In fact, the cumulative effects of inflation—though it remains low by historical standards—and rising employer and employee contribution to health care spending means that real wages for average Americans have actually dropped. This amount of spending and this degree of disparity has become critical, and employers are now awake and engaged to an extent they have never been engaged before. The giant is stirring.

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TEXAS FAMILY PHYSICIAN [No. 4] 2019

You have likely seen some well publicized moves in this direction, such as the formation of the health care venture known as Haven by Berkshire Hathaway, Amazon, and JP Morgan Chase. But the shifts happening below the surface involve many more large and moderate-sized employers from all across the country, all taking much more active positions such as direct purchasing of health care services in local markets; direct contracting with centers of excellence, accountable care organizations, and in some cases independent practice associations; demanding better answers and more innovation from third-party payers; and direct involvement in care delivery through on-site clinics or direct care service contracts in local markets. Employers are also demanding much more transparency on cost, utilization, quality, and outcomes, and they are either staffing themselves with the personnel and skills to vet these issues internally or employing vendors beyond insurance carriers to inform their choices and decisions.

Historically, employers have been more passive, relying on insurance carriers to serve as intermediaries focused mainly on addressing absolute costs, but the evidence over the past two decades indicates this approach has not really been effective. As such, employers have become more active, applying direct pressure on both health care systems and insurance carriers to define better value on investment, centered around quality and evidence-based utilization.

In the absence of solid or historical metrics to define “real value” in health care, employers are questioning whether this system can be saved.

“Perhaps the whole thing needs to be blown up and started over.” It’s not an uncommon refrain.

www.tafp.org

17

Employers have become more active, applying direct pressure on both health care systems and insurance carriers to define better value on investment, centered around quality and evidence-based utilization. In the absence of solid or historical metrics to define “real value” in health care, employers are questioning whether this system can be saved. “Perhaps the whole thing needs to be blown up and started over.” It’s not an uncommon refrain.

L

argely by circumstance rather than deliberate policy, America has a long tradition of employer-sponsored health insurance dating back to World War II.3 In this way, we remain isolated internationally as the only country with such an arrangement. While the 2020 election cycle promises yet again to position health care as a central point of debate, it is unlikely that any political outcome would dislodge this central tenet of the U.S. health care economy in the near future. But employers are feeling the economic pressures around health care spending like never before, and they are now awake like never before. Employers have cost shifted to the extent that the typical American household now expends an average of between 12% and 15% of their monthly income on health care.4 Employers simply cannot cost shift any more, and this approach has not been effective at holding down costs. To quote the Director of Health Benefits for one large employer with whom I spoke recently, “I am simply finding myself with no other options. I find no remedy and see limited leverage in the systems as they exist. Our employees are getting crazy expensive but often low-value care, and we have no choice but to start taking control of this ourselves. So we will. The costs are just too high not to.”

And this is where family medicine, and primary care more broadly, can capture the creative from the disruptive. The value proposition that employers are seeking—high quality care with more appropriate utilization and outcomes that match the investment, and a healthier employee population—already exist to a large degree in the practice of comprehensive primary care in the model of family medicine. We stand on an enormous body of work done by our own giants, both in the U.S. and internationally, who have uniformly defined the characteristics of high-functioning health systems constructed on the foundation of robust primary care. Whether it be higher completion of preventive services, lower ER utilization and hospitalization, greater adherence to chronic care management strategies, advocacy for healthier and safer public spaces, or aggregate cost savings across populations and communities, the evidence defines primary care in the community as the fulcrum for better outcomes.

Employers are taking notice; they are asking the right questions and taking note of the answer, and this is good!

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TEXAS FAMILY PHYSICIAN [No. 4] 2019

For family physicians, this awakening offers great opportunity.

As this giant stirs, we have the right story to tell, the data to support it, and an increasingly receptive, economically powerful and sophisticated audience. Employers are actively seeking to broaden their understanding through valid sources of information. Whether through building alliances with the employers in our local areas, aligning our policy objectives with employers at a regional, state, and national level, or perhaps considering something as practical as direct-contracted care with employers in your area—whether in a DPC model or otherwise—the time is right and the opportunities are lining up. Employers see that system level mergers have not resulted in lower costs or higher quality, and in many cases just the opposite.

They see that medicine by disconnected serial subspecialty has not served their employees or the their economic condition well. They see the value proposition of comprehensive primary care like never before as integral to the solutions they seek and want to play a role in facilitating system-level reform in this direction. The single most common question I get asked when working with employers is, “How do I get more of my folks into high quality primary care?”

We family physicians need to raise our hands boldly and say, “Here! Let me show you!”

1. U.S. Census Bureau via: https://www.census.gov/library/publications/2018/demo/p60-264.html.

2. The Henry J Kaiser Family Foundation accessed via: https://www. kff.org/health-costs/ and the Commonwealth Fund Reports accessed via: https://www.commonwealthfund.org/publications/ issue-briefs/2019/may/how-much-us-households-employer-insurance-spend-premiums-out-of-pocket.

3. For an excellent synopsis of the economic history of health care in America, and why we have employer-based health insurance, see “The Economic Evolution of American Health Care,” by David Dranove (Princeton University Press, 2000). It is a great place to start.

4. The Commonwealth Fund Report via: https://www.commonwealthfund.org/publications/issue-briefs/2019/may/how-much-ushouseholds-employer-insurance-spend-premiums-out-of-pocket.

Figure 1. Cumulative increases in health insurance premiums, workers’ contributions to premiums, inflation, and workers’ earnings, 1999-2015 250%

200%

Workers’ contribution to family premiums Health insurance premiums for family coverage Workers’ earnings Overall inflation

221%

203% 158%

150%

138% 100%

88%

75% 50%

56% 42%

20% 31%

42%

17% 0% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2015. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2015; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2015 (April to April).

LOOKING AHEAD TO 2020— SEEKING CLARITY IN A CLOUD OF CHANGE AND DISRUPTION Tom Banning TAFP CEO

momentum continues to grow for valuebased payment initiatives and other alternative payment models to fee for service.

According to a report from the Health Care Payment Learning and Action Network, 34% of all U.S. health care payments in 2017 were tied to the value of care delivered, up from 23% in 2015.

The Centers for Medicare and Medicaid Services has led the charge toward valuebased payment models, through various programs that design, pilot, and reward providers’ participation in them – pay for performance, Medicare Shared Savings ACOs, bundled payments, etc. Additionally, Medicare Advantage participation continues to grow and flourish. Commercial insurers are also beginning to aggressively drive payment models away from fee for service toward total cost of care, capitation, and value-based payments through exclusive provider or narrow networks.

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TEXAS FAMILY PHYSICIAN [No. 4] 2019

Despite an accelerating trend toward alternative payment models, many physicians are not completely on board with the shift to value-based payment models.

A recent survey of payers and providers found physicians are feeling varying levels of reluctance. Concerns include the belief that quality measures are too complex to achieve, and that physicians do not have all the information they need about their patients to improve outcomes. Some payers also believe that physicians lack tools necessary to succeed in a value-based payment model.

According to Lisa Bielamowicz, MD, of Gist Healthcare, “Physicians’ concerns are understandable; realizing clinical and financial success in a value-based payment model requires innovative business models and great skill in population health management that many providers have not yet developed. However, shrinking margins due to an older, sicker U.S. population and ever more sophisticated and costly treatments, combined with payers’ pressure to deliver a better return on the care dollars they invest may push providers toward value-based payment despite their concerns.”

The reluctance of physicians to adapt to these changes has created a void that corporate America and venture-capital-financed disruptors are exploiting by building radically different care models that depend very little on doctors. Texas has become a testing ground for disruptors looking to refine their consumer-focused care offerings.

Payers, retailers, hospitals, and thirdparty telemedicine providers are seeking to disintermediate physicians from their patients. For example: • Blue Cross Blue Shield of Texas, announced a partnership with global health care firm Sanitas to launch 10 primary care clinics in Houston and Dallas next year. They intend to expand to Austin and El Paso. The clinics will provide health and wellness services in addition to primary care, imaging, and lab services.

• Texas is also the test market for CVSAetna’s HealthHUB pilot stores, which opened in Houston in February.

• Walmart will launch a new standalone primary care clinic, offering a comprehensive array of services including behavioral health, audiology, dental, and vision care. The new clinic is branded Walmart Health, and they are differentiated from the retailer’s Care Clinics, which offer a

range of health care services inside 20 Walmart Stores in Georgia, Texas, and South Carolina.

• Amazon has agreed to acquire a new health care platform, Health Navigator, an online symptom checker and virtual triage service. The company works with a range of telemedicine, EHR, and call center companies, providing clinical content and a diagnosis engine that enables virtual triage of patients based on symptoms using a natural language processing tool to capture patient complaints and match them to clinical conditions.

TAFP physician leadership and staff have been sounding the alarms with AAFP, TMA, and our individual members on these market developments. TAFP succeeded in passing a resolution through TMA to conduct a comprehensive study of these market developments and develop a data-driven strategy to assure fair business practices and enforceable protections from predatory behavior and adverse patient consequences that empowers physicians to compete and thrive in Texas’ health care markets.

These changing market dynamics underscore the need for doctors to work together to create lower cost, consumer-friendly care models. No matter what size or type your practice may be, three questions face us all.

How shall we prepare for these changes?

How can we best compete in this new environment? And how should we rightly define patient or consumer value?

We’d like to hear from you. What are you doing to prepare for these market changes and how can TAFP assist you in those efforts? Email Jonathan Nelson at jnelson@ tafp.org and let us know.

PUBLIC HEALTH

An unspoken chief complaint The importance of recognizing signs of human trafficking among our patients

By Victoria Udezi, MD

F

amily physicians are at the forefront of our communities’ health. We rise to confront public health challenges and advocate diligently for our patients. I have known this to be true since medical school but now as a community medicine fellow, I realize there are unseen public health concerns that I am well positioned to address but not well equipped to—one being the impact of trauma on health.

Providing care in community and academic settings has increased my awareness of the value of recognizing trauma in the health care of my patients. I observe how adverse childhood experiences, exposure to crime, unsafe neighborhoods, and violence have affected a patient’s physical or mental health. I think about how these problems can be a barrier to seeking necessary care by members of my community.

Among multiple types of trauma, human trafficking has been an issue I have focused on during my fellowship. The United Nations Office of Drugs and Crime defines human trafficking as “the acquisition of people by improper means such as force, fraud, or deception, with the aim of exploiting them.” The most common forms are sex and labor trafficking. It is extremely complex and challenging to address due to its hidden and criminal nature. Human trafficking is an issue in Texas. The National Human Trafficking Hotline reports Texas is number two in the nation in number of calls received.

There are limitations that can prevent physicians from recognizing trafficked victims. These include knowledge, training, time, and resources.

Learning more about human trafficking has made me certain that I have interacted with victims in my clinic, during my OB-GYN rotations or in the emergency room. I just did not realize it then because I wasn’t looking for red flags. Multiple studies report that about 30-80% of survivors were seen by a health care provider while being trafficked.1 Health care sites thus provide an opportunity for intervention.

Conversely, there are limitations that prevent victims from seeking help when in health care settings. A few of these limitations include fear, lack of trust, threats from their trafficker, language barriers, and lack of awareness of legal protections.

I recall a 17-year-old Caucasian female during my OB-GYN rotation who presented in labor and her much older male friend was the only one who would come by the hospital, often at odd times. There was also the elderly Hispanic female who offered to help a family member with her children and ended up being held against her will to provide domestic help. Mandated reporting and legal concerns thankfully could guide our response in these situations.

However, I always think of the 20-year-old African American female who would come to the emergency room every other night during my rotation believing she had an STD. There was a certain level of discomfort in our interaction and in retrospect, asking the right questions may have helped identify if she was a possible victim.

I have learned that an important step in providing care for victims of human trafficking is that I learn the signs, respond with a multidisciplinary approach and know how to incorporate trauma-informed care into my practice, focusing on resisting re-traumatization. The Substance Abuse and Mental Health Services Administration, or SAMHSA, provides six principles of a trauma-informed approach.

• Safety • Trustworthiness and transparency • Peer support • Collaboration • Empowerment and choice • Cultural, historical and gender issues I am also fortunate to have behavioral health integrated in our teaching site, which offers expanded services to patients who have been victims.

Also social work support has helped with community resources. Some patients or their families are more willing to disclose certain issues when they know resources are available.

Some tools I have found useful—recommended by the AAFP—when addressing human trafficking include SOAR, the Stop Observe Ask Respond to Human Trafficking modules provided by a partnership with the U.S. Department of Health and Human Services. The Health, Education, Advocacy, Linkage (HEAL) trafficking network also provides tools to guide practices on training and implementing multidisciplinary procedures and protocols. Additionally, it has been helpful to know which organizations in my community are serving victims and survivors of human trafficking to ensure appropriate referrals are made.

It is probable that we will meet a victim of trafficking in our health care setting and it is critical that we can identify red flags while being aware of helpful resources. I encourage you to start the discussion on including training opportunities at your practice site. As with many public health challenges we stand up to every day, family medicine physicians are well positioned to be part of the anti-trafficking efforts in our communities.

1. Schwarz C, Unruh E, Cronin K, Evans-Simpson S, Britton H, Ramaswamy M. Human Trafficking Identification and Service Provision in the Medical and Social Service Sectors. Health Hum Rights.

2016;18(1):181–192

RESOURCES SOAR for Health Care www.acf.hhs.gov/otip/training/soar-to-health-and-wellness-training/ soar-online HEALTH, EDUCATION, ADVOCACY, LINKAGE www.healtrafficking.org SAMHSA Center for Integrated Health Solutions. Improving Health Through Trauma-Informed Care www.integration.samhsa.gov/Trauma_Informed_Care_Webinar_ Slides__072715.pdf The National Human Trafficking Hotline www.humantraffickinghotline.org (888) 373-7888 (TTY:711) I Text 233733 Victoria Udezi, MD, is a community medicine fellow and assistant instructor at the UT Southwestern Department of Family and Community Medicine. www.tafp.org

21

WHY DOCTORS ARE THE LINCHPIN FOR THE TEXAS MEDICAL CANNABIS PROGRAM

By Karen Keough, MD

A

s a child neurologist who specializes in intractable epilepsy, I have witnessed firsthand the efficacy of medical cannabis for many of my patients. And now that an estimated additional 1.8 million Texans qualify for a medical cannabis prescription, we’re moving swiftly into a new era.

The sheer volume of Texas patients newly eligible after the enactment of House Bill 3703—including those with all forms of epilepsy, seizure disorders, multiple sclerosis, spasticity, amyotrophic lateral sclerosis, autism, terminal cancer, and neurodegenerative diseases— means that their physicians are facing some urgent questions.

I’m calling on my fellow physicians to get educated now about the protocols of the state Compassionate Use Program and the ways medical cannabis applies to their field so they are fully prepared to work with patients for whom medical cannabis holds potential as a complementary treatment for their care. It’s important to note that physicians must enroll in the Compassionate Use Registry of Texas, or CURT, to issue prescriptions for low-THC medical cannabis products.

ADDRESSING SKEPTICISM HEAD ON Because medical cannabis is relatively new in Texas and research in the United States has thus far been limited, many doctors are unfamiliar with cannabinoids—the key components of the cannabis plant such as cannabidiol—and some are skeptical about this plantderived medication.

I understand this skepticism, because I myself harbored it. When my patients and their families first came to me years ago asking whether they should try CBD, my initial reaction was to say, “Don’t believe every-

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TEXAS FAMILY PHYSICIAN [No. 4] 2019

thing you’re seeing in the news.” I worried that all the media attention on “medical marijuana refugees” gave patients false hope.

But in the interests of my patients and my practice, I learned more about it. I thoroughly researched prior studies on CBD and epilepsy—clinical, laboratory-based, observational and anecdotal—to understand the potential benefits and risks.

My approach with patients included careful documentation of their progress and outcomes. As with any medication, there is no 100% success rate; however, the results have far exceeded my expectations.

Low-THC medical cannabis is one of the most impactful new therapies to come into my practice in the last decade, and I am grateful to have this option, particularly for severely ill patients who have exhausted available courses of treatment.

PHYSICIAN PARTICIPATION CRITICAL Here’s what I want Texas physicians to understand: The CUP is a legitimate medical program, one that requires our buy-in and participation to succeed. In some states, patients have a one-time consultation with a doctor to get their “card” so they can make purchases at a dispensary, no medical supervision or treatment plan required—not so in Texas.

In fact, the prescription process for rigorously regulated Texasmade medical cannabis products closely resembles the traditional process for prescribing FDA-approved drugs—which makes doctors gatekeepers for the patients who seek access to such treatment. Like any other prescription pharmaceutical, doctors must decide on a case-by-case basis whether the potential benefits would outweigh [cont. on 24] any harms.

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The sheer volume of Texas patients newly eligible after the enactment of House Bill 3703—including those with all forms of epilepsy, seizure disorders, multiple sclerosis, spasticity, amyotrophic lateral sclerosis, autism, terminal cancer, and neurodegenerative diseases—means that their physicians are facing some urgent questions.

[cont. from 22]

OTHER BENEFITS: EXPANDED KNOWLEDGE Supporting qualifying patients with a new modality will require more preparation by doctors, who typically don’t have ample spare time. But in my experience, joining the CURT registry holds other useful applications.

CURT connects physicians who are pursuing carefully monitored treatment plans. Equally important, it allows physicians to collaborate and learn from each other, expanding our collective knowledge base to determine what’s working, what’s not, and which patient populations stand to benefit most.

Informed feedback on patient outcomes with medical cannabis is invaluable. Texas physicians have a singular opportunity to contribute to the growing body of medical research on cannabis’ potential to help patients with debilitating and life-threatening conditions.

We doctors must do the work of educating ourselves and registering with the state to facilitate patient access. Our patients, particularly those with terminal conditions and others who have found no relief through traditional courses of treatment, are counting on us.

Dr. Karen Keough is a board-certified child neurologist and epileptologist with fellowship training in neurophysiology. She specializes in treating intractable epilepsy at Child Neurology Consultants of Austin, and serves as Chief Medical Officer at Compassionate Cultivation, a medical cannabis provider.

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TEXAS FAMILY PHYSICIAN [No. 4] 2019

5/10/12 10:40 AM

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 Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White

Lung cancer screening practices among primary care providers in Northern Texas Meng-Hua Tao, PhD, MD Department of Biostatistics and Epidemiology, University of North Texas Health Science Center, Fort Worth, Texas Kimberly G. Fulda, DrPH Department of Family Medicine and Osteopathic Manipulative Medicine; the North Texas Primary Care Practice-Based Research Network (NorTex), University of North Texas Health Science Center, Fort Worth, Texas Long Wong, PhD, MD Department of Family Medicine and Osteopathic Manipulative Medicine, University of North Texas Health Science Center, Fort Worth, Texas

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

Methods

As the leading cause of cancer deaths in the United States1, most lung cancers are diagnosed at a late stage when the cancer is more difficult to treat, resulting in a poor survival rate ranging from 10% to 20%.2 Because of evidence of reducing lung cancer mortality for high-risk current and former smokers,3 the U.S. Preventive Services Task Forces (USPSTF)4 and other professional organizations have recommended screening for lung cancer with low-dose computed tomography (LDCT) in high-risk persons.

Subsequently, Medicare,5 the Affordable Care Act,6 and most private insurance companies7 provided coverage for LDCT screening. However, the rate of receiving screening for lung cancer with LDCT remained low (3.9%) among eligible Americans.8 For most adult patients in the U.S., primary care providers play a critical role in offering preventive health care and screening; therefore, an understanding of PCPs’ utilization and perceptions on lung cancer screening guidelines is necessary to improve appropriate assessment and referrals for specialty care services, and overall implementation of the screening procedure.

Five years after multiple screening guidelines included LDCT for lung cancer screening, we conducted a survey to understand current implementation of lung cancer LDCT screening among primary care providers so as to examine current barriers to adherence to the lung cancer screening guidelines.

We conducted a cross-sectional survey study within the North Texas Primary Care Practice-Based Research Network (NorTex). The NorTex is a primary care practice-based network that functions as a collaborative effort to conduct research among North Texas primary care practices. Utilizing this network, we surveyed primary care providers who were active members of NorTex between July and December 2018.

Providers received up to three emails with a link to a confidential online survey. Eligible respondents were physicians, nurse practitioners, and physician assistants who provided primary care services to adult patients in NorTex within the past 12 months.

The survey was designed based on the National Cancer Institute Colorectal and Lung Cancer Screening Questionnaire9 and another prior survey of lung cancer conducted by Raz et al.10 The survey assessed PCPs’ perception of the effectiveness of LDCT as screening test, providers’ perception of benefit and harm of LDCT, lung cancer screening practices in the past 12 months, providers’ knowledge of the current guidelines for lung cancer screening, and barriers to lung cancer screening. Providers’ demographic and practice characteristics were also asked in the survey. Descriptive statistics were used to characterize provider and practice characteristics, general beliefs of effectiveness, guideline knowledge, barriers to lung cancer screening, and perception of LDCT screening compared with breast mammography. www.tafp.org

25

Table 1. Primary care providers’ lung cancer screening beliefs, self-reported practice, and patient influence Characteristics

Yes (n, %)

No/Unsure (n, %)

Missing (n, %)

Believes LDCT is somewhat or very effective in reducing lung cancer mortality for Current or former smokers Never smokers

33 (91.7) 9 (25.0)

2 (5.5) 14 (38.9)

1 (2.8) 13 (36.1)

Believes chest X-ray is somewhat or very effective in reducing lung cancer mortality for Current or former smokers Never smokers

16 (44.4) 8 (28.6)

19 (52.8) 20 (71.4)

1 (2.8) 8

5 (13.9) 1 (2.8)

29 (80.6) 21 (58.3)

2 (5.5) 14 (38.9)

-

Primary care providers’ beliefs

Believes sputum cytology is somewhat or very effective in reducing lung cancer mortality for Current or former smokers Never smokers Primary care providers’ practice in the past 12 months

Ever ordered LDCT for lung cancer screening

24 (66.7)

12 (33.3)

Ever ordered chest X-ray for lung cancer screening

10 (27.8)

26 (72.2)

-

Ever refer an asymptomatic patient for lung cancer screening

5 (13.9)

30 (83.3)

1 (2.8)

12 (33.3) 3 (8.3)

24 (66.7) 33 (91.7)

-

Referred most or almost all high-risk patients for LDCT for lung cancer screening Chest X-ray

Initiated a discussion about the benefits and risks of lung cancer screening with patients

Primary care practice has a mechanism for reminders that a patient is due for lung cancer screening

28 (77.8)

8 (22.2)

-

19 (52.8)

16 (44.4)

1 (2.8)

1 (2.8)

34 (94.4)

1 (2.8)

Patients’ influence

Patient self-referred to a lung cancer screening center

Table 2. Primary care providers’ general perception on lung cancer screening with LDCT Survey question Respondent number (n)

Yes (n, %)

Perception

Lung cancer screening is not covered by insurance

35

23 (65.7)

Lung cancer screening is too expensive

35

11 (30.6)

The benefits are not clear to me

35

8 (22.9)

I don’t have time to discuss risks and benefits

35

5 (14.3)

Results Of eligible providers within the NorTex network, 36 completed the survey with a response rate of 18%.

Majority of PCPs were female, from family medicine and reported practicing more than 10 years. 44.1% and 54.5% of PCPs reported that 26-100% of their patients were Hispanic and African American, and 58.3% reported that 26-100% of patients were insured

by Medicare. In addition, 91.7% of PCPs knew that LDCT is available in their practice area, and 55.6% of them knew the availability of lung cancer screening programs in their practice area.

PCPs’ beliefs about the effectiveness of screening tests at reducing lung cancer mortality varied by smoking status and test methods (Table 1). 91.7% of PCPs perceived LDCT as very or somewhat effective at reducing lung cancer mortality for current or former smokers, while 25% of PCPs also believed that LDCT was effective in never smokers. Meanwhile, a large proportion of PCPs thought that chest X-rays 26

TEXAS FAMILY PHYSICIAN [No. 4] 2019

were very or somewhat effective for current or former smokers (44.4%) and for never-smokers (28.6%). Twothirds of PCPs reported that they had ever ordered LDCT for lung cancer screening in an asymptomatic patient in the past 12 months, while only one-third of PCPs had referred most or almost all high risk patients for lung cancer screening with LDCT during the same time period. Meanwhile, one PCP (2.8%) reported to have asymptomatic patients self-referred to screening, and only 8.4% indicated that half or more of their high-risk patients asked whether they should be screened for lung cancer.

The most common barriers to refer patients for LDCT lung cancer screening included the perception that lung cancer screening is not covered by insurance plans (65.7%), the expensive cost of the screening for their health care system (30.6%), the perception that benefits of lung cancer screening were unclear (22.9%), and shortage of time (14.3%) (Table 2). [cont. on 28]

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[cont. from 26]

Conclusion Lung cancer screening with LDCT has been recommended by multiple organizations and covered by various insurance plans for about five years. In this cross-sectional survey study, we aimed to better understand current knowledge, beliefs, practices and barriers to lung cancer screening with LDCT among PCPs. Particularly, providers who participated this survey were from diverse medical practicing systems, and most of their patients were minorities, who are more likely to face disparities in receipt of preventive screening and in lung cancer mortality.11 In this study, we observed 66.7% of PCPs had ever ordered LDCT to screen asymptomatic patients for lung cancer in the past 12 months, suggesting the improved utilization of LDCT over time compared to previous reports. However, the referral rate for most high-risk patients was still low (33.3%). In addition, previous studies showed a lack of adequate LDCT screening awareness in high-risk patients.10, 12-14 In our study, over 80% of PCPs reported having less than 10% of high-risk patients asked about lung cancer screening in the past 12 months, which suggests that increasing awareness and knowledge on lung cancer screening among eligible patients are important to ensure successful implementation at the population

Reference

Conflict of interests: No potential conflicts of interests were disclosed.

Acknowledgement: This work was supported by the Texas Academy of Family Physicians Foundation. We thank the primary care providers who participated in this study.

We also thank the staff of NorTex, Anna Espinoza, MD, and Omair Muzaffar, MPH, for their valuable contributions.

28

1. Siegel R, Miller KD, Jemal A. Cancer statistics, 2018.

CA Cancer J Clin 2018;68: 7-30.

2. Allemani C, Matsuda T, Di Carlo V, Harewood R, Matz M, Nikšić M, Bonaventure A, Valkov M, Johnson CJ, Estève J, Ogunbiyi OJ, Azevedo E Silva G, Chen WQ, Eser S, Engholm G, Stiller CA, Monnereau A, Woods RR, Visser O, Lim GH, Aitken J, Weir HK, MP; C, Group. CW. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries.

Lancet 2018;391: 1023-1075.

3. National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM, Sicks JD. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365: 395-409.

4. Moyer VA. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160: 330-338.

5. Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N). In. 6. U.S. Department of Health and Human Services.

Patient Protection and Affordable Care Act, 2010. In. 7. Is lung cancer screening covered under your insurance? In: American Lung Association.

8. Jemal A, Fedewa SA. Lung Cancer Screening With

TEXAS FAMILY PHYSICIAN [No. 4] 2019

level. The Centers for Medicare and Medicaid Services has covered the cost of lung cancer screening counseling and shared decision-making visit from 2015.5 Therefore, PCP-based education and counseling can be an important approach to improve knowledge of LDCT screening in patients.

Insurance coverage, cost to the health care system, and unclear screening benefits were the three most commonly reported perceived barriers to LDCT in our study. These suggest that PCPs need not only to have a thorough understanding of the eligibility criteria, benefits and potential harm of LDCT screening in high-risk patients, but also to be familiar with the cost of LDCT screening, and make correct coding for the insurance.5, 7 In addition, a clear guideline or education on understanding CT screening results, documentation, and management all may be needed for PCPs to improve the utilization of LDCT. In summary, although PCPs appear to perceive USPSTF recommended guidelines and believe in the effectiveness of LDCT screening for high-risk patients, a small proportion of eligible patients are being referred for LDCT screening. This study also identified several providers’ barriers that need to be overcome to improve screening implementation, and these may include provider education and targeted interventions.

Low-Dose Computed Tomography in the United States-2010 to 2015. JAMA Oncol 2017;3: 1278-1281.

9. Klabunde CN, Marcus PM, Han PK, Richards TB, Vernon SW, Yuan G, Silvestri GA. Lung cancer screening practices of primary care physicians: results frm a national survey. Ann Fam Med 2012;10: 102-110.

10. Raz DJ, Wu GX, Consunji M, Nelson R, Sun C, Erhunmwunsee L, Ferrell B, Sun V, Kim JY. Perceptions and utilization of lung cancer screening among primary care physicians. J Thorac Oncol 2016;11: 1856-1862.

11. Hunt B, Balachandran B. Black:White disparities in lung cancer mortality in the 50 largest cities in the United States. Cancer Epidemiol 2015;39: 908-916.

12. Eberth JM, McDonnell KK, Sercy E, Khan S, Strayer SM, Dievendorf AC, Munden RF, Vernon SW. A national survey of primary care physicians: Perceptions and practices of low-dose CT lung cancer screening. Prev Med Rep 2018;11: 93-99.

13. Kanodra NM, Pope C, Halbert CH, Silvestri GA, Rice LJ, Tanner NT. Primary Care Provider and Patient Perspectives on Lung Cancer Screening.

A Qualitative Study. Ann Am Thorac Soc 2016;13: 1977-1982.

14. Mishra SI, Sussman AL, Murrietta AM, Getrich CM, Rhyne R, Crowell RE, Taylor KL, Reifler EJ, Wescott PH, Saeed AI, Hoffman RM. Patient perspectives on low-dose computed tomography for lung cancer screening, New Mexico, 2014. Prev Chronic Dis 2016;13: E108.

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PERSPECTIVE

Independent physicians are disappearing and communities suffer for it

By Christopher Crow, MD, MBA

higher costs don’t buy better care. Independent physievery six months, leaders and physicians in the Catacians scored at least as well as those in hospital-owned lyst Health Network — independent physicians all — practices on most quality measures. get together to talk over what’s going on in our network Unfortunately, consolidations are more and more and in health care generally. They’re great meetings. becoming the rule. According to the study, the share I always leave fired up about our work and I think my of hospital-owned practices more than doubled in four fellow physicians do, too. years, and other analyses put the These convenings are especially percentage of physicians employed by encouraging at this time when hospitals at 44% or even higher. there is so much pressure on physiIt can be awful Catalyst and the company that cians to join big hospital systems for patients when powers it, StratiFi Health, were built and affiliated medical groups. Such physicians have in part to help physicians remain mergers are driving health care independent.

We provide care teams, economics in Texas and across the to sacrifice their contracting arrangements, health country — and they’re creating big independence to data tracking, and back-end support problems for patients, physicians, gigantic, monolithic to help physicians keep their indeand communities. pendent practices going in the face of It can be awful for patients when health care economic winds blowing them toward physicians have to sacrifice their corporations.

New consolidations. independence to gigantic, monomanagement undercuts Six months ago, at our last bianlithic health care corporations. New nual physicians meeting, a newcomer management undercuts relationships relationships between asked a pediatrician who’d been a between patients and the doctors patients and the Catalyst member for three years how they trust, and it often pushes people doctors they trust, and things had changed since she joined into expensive tests and procedures the network.

She paused, thought that don’t always improve their it often pushes people about it and said, “It probably saved health, but do wonders for a corporainto expensive tests and our practice.”

Without Catalyst’s tion’s bottom line. The mergers can procedures that don’t support and StratiFi’s systems, she be tough on physicians, too, dictating explained, her practice probably the amount of time they can spend always improve their could not have weathered the brutal with patients and forcing them to health, but do wonders economic winds created by insuradopt business practices they don’t for a corporation’s ance companies, referral networks, like or to refer patients to specialists and others that push independent based on affiliations, not ability. bottom line. physicians into the arms of hospital But pressure on independent systems. physicians to merge with big hospital Now, she can practice medicine systems is also dangerous for society and treat her young patients, exactly how she wants and the economy. to.

It’s good for her, her young patients, and their Just this month, a study by a health economist at parents.

It means a healthier community and fewer Rice University noted that “patients in hospital-owned costs for society. physician practices pay almost $300 more per year than It’s why Catalyst and StratiFi Health exist. those in independently owned practices.” But those

30

TEXAS FAMILY PHYSICIAN [No. 4] 2019

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