Texas Family Physician Summer 2010

Report From TAFP Annual Session And Scientific Assembly

DEDICATED TO THE DELIVERY OF QUALITY HEALTH CARE

VOL. 61 NO. 3 SUMMER 2010

SPECIAL ISSUE

Grassroots Advocacy For The Family Doctor Your Guide For Success In The 82nd Legislature

PLUS: Nurse Practitioners Fire First Salvos In Campaign For Independent Practice Texas Medical Schools Rank Low On Social Mission Scale

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Volume 61, No. 3

TEXA S

FAMILY PHYSICIAN SUMMER 2010

F E A T U R E S 16 Viva San Antonio, viva family medicine!

Attendees of the 61st Annual Session and Scientific Assembly had a blast in San Antonio. Read all about the conference and see photos.

By Kate McCann

20 Cover: Your primer on grassroots advocacy Facing a tough legislative session, your patients need you to get involved in the political process now. A nationally renowned political consultant gives a step-by-step guide for those new to the Capitol scene and for seasoned veterans.

By Kim Ross

28 10 questions for TAFP’s lobby team Get an insider’s perspective into the upcoming 82nd Texas Legislative Session through a Q&A with the top experts in health care lobbying.

By Jonathan Nelson

30 How to win allies and influence legislators Six secrets to know before investing in a political issue.

(Psst—some of the most effective methods are free.)

By Joe Gagen

34 DOLLARS & CENTS: Family physicians’ pay increases in 2009 36 ACADEMY UPDATE: Realpolitik—you gotta pay to play 38 PERSPECTIVE: One student’s journey to family medicine

24

photo illustration: Jonathan nelson

D E P A R T M E N T S 6

FROM YOUR PRESIDENT: A year of challenges, victories

8

IN THE NEWS: Bay City fourth grader wins Texas Tar Wars | Nurse practitioners prepare for battle | TransforMED supports solo, small practices | Top medical schools don’t meet society’s needs | Loan repayment program to accept applications all year

12

MEMBER NEWS: San Antonio FMIG honored for excellence | TAFP leader recognized for work with young physicians | Houston physician named to national advisory board | TAFP member to be inducted into Texas Women’s Hall of Fame | TAFP members elected to TMA leadership posts

32

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

Officers President Kaparaboyna Ashok Kumar, M.D., F.R.C.S. President-elect Melissa Gerdes, M.D. Vice President Troy Fiesinger, M.D. Treasurer I. L. Balkcom, IV, M.D. Parliamentarian Clare Hawkins, M.D. Immediate Past President Robert Youens, M.D. Editorial Staff Managing Editor Jonathan L. Nelson Associate Editor Kate McCann Chief Executive Officer and Executive Vice President Tom Banning Chief Operating Officer Kathy McCarthy, C.A.E. Contributing Editors Tom Banning Joe Gagen Kim Ross Laci Waner, M.D. Advertising Sales Associate Audra Conwell Subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727.

Subscriptions are $20 per year.

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

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

Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2010 Texas Academy of Family Physicians Postmaster: Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727.

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Reflections on a year as president

By Kaparaboyna Ashok Kumar, M.D., F.R.C.S. TAFP President

I t has been truly a privilege and an honor to serve as your president. This year was fast-paced, exciting, and full of accomplishments. It was a great year and I have many wonderful people to thank for it.

First, I would like to thank my wife, Elaine, and my children, Priya and Nikhil, for their love and affection, patience and understanding, and for their support without which I would not have been able to take up the responsibilities of this office.

Next, I would like to thank Dr. Carlos Jaén, chair of the UTHSCSA Department of Family Medicine, for his constant support, guidance, and encouragement. I also want thank my colleagues, Drs. Tysinger, Gillard, Moscrip, Akram, Lantz, and Dellalo, for their help and support.

I would like to thank my clinic staff and the staff in the medical school— the best people in the world—who help me every day.

Finally, I would like to thank the Academy staff for their tremendous support. Tom Banning and Kathy McCarthy, for the times you traveled with me, and for your constant support and friendship, I thank you. To the entire academy staff, I could not have done it without you.

As I said above, this year has been very exciting. We have accomplished many victories and faced many challenges. At the beginning of my year as president I made it a priority to address the declining interest in family medicine and vowed to visit all of the Texas medical schools and as many of the family medicine residency programs as was possible. My purpose at the medical schools was to explain to students who we are and what we do as family physicians.

Academy staff members Tom and Kathy

joined me in this endeavor. At the residency programs, I was joined by fellow officers Drs. Melissa Gerdes, I. L. Balkcom, and Troy Fiesinger. We talked with residents and explained to them what we, the Academy, do for our members, our profession, and our patients.

I am delighted to tell you that both groups were extremely receptive to our message.

The medical students were very interested in what family physicians do. They loved the fact that we are patient-centered and offer continuity of care, and that our specialty is based on relationships.

The residents were astounded at the Academy’s work on their behalf advocating for graduate medical education and workforce issues, providing high-quality education, and providing practice management tools that help family physicians in the business of medicine.

Though we experienced great success during these road trips, we must continue to enlighten the next generation of physicians. We want to show students that our profession is great and it is worthwhile to be a part of, and we need to teach the residents the benefits of involvement in the Academy.

TAFP has also played a role in reaching out to students and residents and those involved in their education. TAFP facilitated two meetings of the Texas family medicine department chairs to share ideas about increasing student interest, in July 2009 during Annual Session in Arlington and in March 2010 during Interim Session in Austin. To encourage activities of the Family Medicine Interest Groups at the medical schools, TAFP increased funding for FMIG activities in each school. Effective June 2010, AAFP and TAFP agreed to cover

The bottom line is that as a member of the Texas Academy of Family Physicians, it is crucial for all of us to put forth every effort in the years to come in ensuring the growth and longevity of our specialty.

Family Practice and Internal Medicine can save on: the cost of membership dues for medical students, making it easier for them to get involved with the Academy now so they can continue in the future, and will also discount a new physician’s dues during their first year of practice.

As you may remember from my inaugural presidential address in Arlington, I challenged all TAFP members to become mentors to the next generation of physicians, beginning as early as high school and continuing through medical school and residency. I was pleased with the number of doctors who took time out of their busy schedules to invest in the longevity of our profession by teaching young students and young professionals about what we do as family doctors and why our profession is so rewarding and important.

Encouraging their involvement in the Academy must continue. The bottom line is that as a member of the Texas Academy of Family Physicians, it is crucial for all of us to put forth every effort in the years to come in ensuring the growth and longevity of our specialty. We must do this through student education, continually talking about what we do as family doctors and why we do it. We must continue to share what we are doing with residents who are preparing to enter the world of medicine, and promote membership in the Academy to keep them engaged. We must push for an increase in Academy membership particularly among new physicians.

During this year of change and debate, I learned that we may have differences of opinion, but we are not different. We are all family physicians and we are one family. We care for one another, we care for our specialty and we are all interested in the same goal of caring for our patients, our communities, and our country. We should all remember that debate is healthy in a democratic process to resolve our differences.

As immediate past president, I pledge my support to Dr. Gerdes, our new president, and I will continue to take an active role in building the primary care workforce. I encourage all of you to do the same. :

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News Briefs Patient-centered medical home resources

TAR WARS:

We have a winner!

Allison McNeil, 10, a fourth grader at McAllister Elementary School in Bay City, won the Texas Tar Wars poster contest this spring with her poster, “Brain to heart, please don’t start! Be tobacco free.”

Nurse practitioners fire first shots in latest battle to achieve independent practice Nurse practitioners say they know how to solve Texas’ shortage of primary care physicians: give advanced practice nurses the authority to diagnose and prescribe without physician supervision. And they’re telling anyone who’ll listen.

A May 21 story in the Texas Tribune, “Nurse Practitioners Want Less Doctor Oversight,” is just one of several recent articles describing the coming battle over scope of practice that is certain to occupy much of TAFP’s advocacy efforts during next year’s 82nd Texas Legislature.

The Tribune article pits several claims by nurse practitioner organizations against the position of TAFP and the Texas Medical Association that in the interest of patient safety and the delivery of high-quality medical care, state regulations should continue to foster the collaborative model of care in which physicians delegate authority to mid-level providers.

In the story, Lynda Woolbert, executive director of the Coalition for Nurses in Advanced Practice, argues that lawmakers should grant independent practice to nurse practitioners to help address the shortage of primary care physicians, particularly in rural areas.

“Patients need help managing chronic illnesses; they need well-child exams—all things that aren’t physicians’ strongest suits,” Woolbert said.

The CBS TV news affiliate in Austin ran a similar story on the evening news the following week, and an Associated Press story in April listed Texas as one of 28 8

s U M M E R 2 0 1 0 | T e xas Fami ly P h y si cian

states considering the expansion of nurse practitioners’ scope of practice.

“This is the first in what will be a long, sustained effort by the nurse practitioners to achieve the independent practice of medicine,” said TAFP CEO Tom Banning.

Marie-Elizabeth Ramas, M.D., a thirdyear resident at Lone Star Family Medicine Residency Program in Conroe, Texas, was awarded one of two James Martin, M.D. Scholarships from the TAFP Foundation.

Ramas traveled to Austin in June to research scope of practice, meet with numerous lawmakers at the Capitol, and gather materials that will help our legislative team craft a policy brief on this issue to prepare for the upcoming legislative session.

As the Academy prepares for what is sure to be a challenging session, your support and your input is needed to help explain the differences between family physicians and nurse practitioners in their medical knowledge, their qualifications to treat patients, their educational requirements, and the quality of care they deliver.

Since this story’s original publication in TAFP’s QuickInfo e-newsletter on May 27, TAFP has received many anecdotes from family physicians around the state that will help build our case for the value of family medicine. But we could always use more. TAFP encourages physicians to continue sending TAFP your thoughts and any examples from your practice that could help illustrate the differences between a family physician and a nurse practitioner. Send e-mails to Jonathan Nelson at jnelson@tafp.org. :

TransforMED rolls out new product to support solo, small practices TransforMED, a wholly owned subsidiary of the AAFP, has launched a new service that offers small primary care practices the help they need to implement the patient-centered medical home, or PCMH, model of care.

According to a May 25 news release, TransforMED’s Small Practice Package program “bundles together the necessary tools and components and streamlines the process to enable practices with four or fewer physicians to implement the components of the TransforMED PCMH model in two years.”

Elements of the new program that are available to each participating practice include: • a medical home assessment to help identify practice expectations, define processes, and understand objectives; • a gap analysis to a evaluate a practice’s current situation and PCMH opportunities; • a comprehensive transformation plan that will prioritize goals and set timelines; and • a dedicated TransforMED facilitator.

The package is available to practices for $1,250 per quarter for virtual online support or $2,500 per quarter for practices that choose TransforMED’s on-site option.

Practices must commit to a twoyear program enrollment.

Both the virtual and on-site options include unlimited access to Delta-Exchange, TransforMED’s online learning community, and enrollment in the TransforMED Institute, a soon-to-be launched educational forum.

For information, go to: www.transformed.com/smallpractice-pkg.cfm Source: AAFP News Now, May 26, 2010. © 2010 American Academy of Family Physicians.

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News Briefs SOCIAL MISSION OF MEDICAL SCHOOLS

Study: Many top-ranked medical schools fail to meet “social mission”

By Kate McCann A study released in late June takes medical schools back to the basics, judging them on a set of criteria that has placed many of the typical top dogs at the bottom of the heap. “The Social Mission of Medical Education: Ranking the Schools,” published in the Annals of Internal Medicine, ranks schools not on academic performance, but on their ability to carry out their responsibility to society.

The authors say that for medical schools to fulfill their basic purpose—to educate physicians to care for the population— they must produce an adequate number of primary care physicians, ensure adequate distribution of physicians to underserved areas, and add a sufficient number of minority physicians to the workforce. Overall performance in these three areas gave the schools their “social mission score.”

The researchers analyzed records from more than 60,000 physicians in active practice who graduated from medical school between 1999 and 2001 and completed residency training. They defined primary care as family medicine, general internal medicine, general pediatrics, and internal medicine pediatrics, and used data from the American Medical Association, the Association of American Medical Colleges, and the Association of American Colleges of Osteopathic Medicine.

With scores compiled, the authors ranked the 141 medical schools. No Texas schools made the top 20 and two fell in the lowest 20. The University of Texas Southwestern Medical Center in Dallas was the second-worst following Vanderbilt University in Nashville, Tenn., and Texas A&M Health Science Center in College Station was the 17th worst.

The Texas schools’ composite social mission scores, from best to worst: the University of North Texas College of Osteopathic Medicine in Fort Worth (55), the University of Texas Medical Branch in Galveston (56), Baylor University College of Medicine in Houston (84), the University of Texas Health Science Center at San Antonio (86), Texas Tech University Health Science Center in Lubbock (114), Texas A&M HSC (125), and UT Southwestern (140).

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Three historically black colleges had the highest social mission rankings, and public and community-based medical schools had higher scores than private and non-community-based schools. Also, the schools that received greater amounts of research grants from the National Institutes of Health tended to fare worse, with a few exceptions. Geographically, schools in the northeast and in more urban areas were less likely to produce primary care physicians and physicians who work in underserved areas.

One rationale for the study the authors stress is the rising concern about physician workforce, especially “as citizens and policymakers reconsider the U.S. health care system and seek ‘quality, affordable health care for every American.’” Primary care advocates echo this point. In a June 22 Texas Tribune article on the study, TAFP CEO Tom Banning questioned the responsibility that taxpayer-supported medical schools have to train and recruit the physicians Texas needs. He told the Tribune, “What we need to ask is, should the state be supporting those schools that receive significant outside funding the same as the schools producing doctors who are going to go in and care for Texas patients?”

Detractors were quick to criticize the study’s timeframe, definitions, and societal benefits not included in the criteria. One scathing review came in a statement released by the American Association of Medical Colleges. “Like other attempts at ranking medical schools, this study falls short. By defining ‘societal mission’ and ‘primary care’ so narrowly, it provides a very limited picture of medical education’s many contributions to society in the U.S. and around the world. And that serves no one well.”

The AAMC continued to say that medical schools are producing more primary care physicians, and that other types of physicians like general surgeons, OB-GYNs, and other specialists should have been counted as primary care physicians.

Troy Fiesinger, M.D., faculty member for the Memorial Family Medicine Residency Program in Sugar Land, disagrees. He says that the numbers used in this study are more accurate than other data often cited in the press because they include only

Out of 141 schools in the country, here’s where Texas schools rank North Texas College of Osteopathic Medicine

55

University of Texas Medical Branch

56

Baylor University

84

University of Texas at San Antonio

86

114 Texas A&M University 125 University of Texas Southwestern 140 Texas Tech

Source: Annals of Internal Medicine

“Many of our state’s medical schools clearly value biomedical research—which often generates expensive treatments—and production of specialists over production of primary care physicians and research on more clinically effective and costeffective treatments for the diseases that impact the majority of Texans.”

— Troy Fiesinger, M.D. actively practicing family physicians, internists, and pediatricians—those “trained to look at all of a patient’s health care needs and ensure they are met,” he says. “To include other specialists in the category of primary care physicians only increases the fragmentation of our health care system that negatively impacts our patients’ health and underestimates the shortage of primary care physicians.”

He continues. “Many of our state’s medical schools clearly value biomedical research—which often generates expensive treatments—and production of specialists over production of primary care physicians and research on more clinically effective and cost-effective treatments for the diseases that impact the majority of Texans.” :

Loan repayment program opens rolling enrollment • The Texas Primary Care Office of the Texas Department of State Health Services has announced a more-frequent application schedule for the state’s Physician Education Loan Repayment Program. The program assists certain qualified physicians with educational loan forgiveness of up to $160,000 over four years.

Previously, applications were accepted annually. Now, applications from primary care physicians will be accepted and processed quarterly. Applications from subspecialist physicians will be accepted and processed as they are received and completed.

The revisions were made by the Texas Higher Education Coordinating Board and TPCO after the latest annual application deadline of June 15, 2010. Applications received, approved, and finalized between June 16 and Aug. 31 will have a service start date of Aug. 31. For applications received, approved, and finalized after Sept. 1, the service start date will be the last day of the state fiscal year quarter.

To be considered for the program, primary care and subspecialty physicians

must be practicing in a designated Health Professional Shortage Area. Subspeciality physicians also must provide evidence that there is a need for their subspecialties.

As long as funds are available, the program is able to accept up to 225 new PELRP participants per year as authorized

by Texas law.

To be eligible to apply for PELRP assistance, a physician must: • Have completed residency and/or fellowship training, • Be employed by, and seeing patients at the location referenced in the application that is currently open and operational, • Be practicing in a designated Health Professional Shortage Area, and • Have a full physician license with no restrictions from the Texas Medical Board.

To receive loan repayment assistance a physician must: • Have eligible outstanding student loans,

•

•

•

•

made from an accredited U.S. lending institution, Provide four consecutive years of direct patient care service in a HPSA in Texas, Be board eligible in years 1 - 3 and board certified, as recognized by the American Board of Medical Specialties (ABMS) or Bureau of Osteopathic Specialists, as applicable, by year 4.

Provide care to Medicaid enrollees and/ or CHIP enrollees if the physician treats children, Not be fulfilling a service obligation to any other program that offers loan repayment or loan forgiveness, and Not agree to another service obligation for loan repayment or forgiveness during the four-year PELRP commitment.

DSHS and THECB are partners in administering the PELRP. DSHS is the point of contact for applications, practice opportunities, and program questions. THECB verifies all loan data and disburses the loan repayment funds on behalf of selected applicants.

For more detailed information and a link to the online application, go to www.TXLRP. org. For more information call (512) 458-7518 or e-mail TexasPCO@dshs.state.tx.us. :

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member news

San Antonio FMIG receives national award The University of Texas Health Science Center at San Antonio Family Medicine Interest Group was chosen as one of 10 recipients nationwide of the 2010 AAFP Program of Excellence Award. This award recognizes FMIGs for their efforts to stimulate interest in family medicine and family medicine programming. The award has been a cornerstone of the FMIG network, facilitating the sharing of best practices of FMIGs from across the country and recognizing the hard work of these student groups. The UTHSCSA FMIG currently boasts nearly 200 active members, and has been recognized as a Program of Excellence a total of four times.

The UTHSCSA FMIG takes extensive steps to actively recruit medical students to family medicine and retain membership by electing student liaisons from each medical school class to promote upcoming events and meetings; and using FMIG meetings to discuss relevant medical topics, sponsor hands-on workshops, and bring family physicians from the community to speak. One of their most successful recruiting events was the FMIG-sponsored residency fair, which brought 19 family medicine residency programs to interact with students.

In the community, the UTHSCSA FMIG staffs student-run free clinics weekly at two locations: Alpha Home, a transitional living home for women recovering from drug addiction, and the San Antonio Metropolitan Ministries, a transitional living home for previously homeless families.

The group is involved in Tar Wars, AAFP’s anti-tobacco initiative that brings medical professionals into fourth- and fifth-grade classrooms, and Apple Wars, an antiobesity initiative that teaches fifth-grade students the importance of proper nutrition, portion sizes, and exercise.

AAFP will honor the UTHSCSA FMIG in multiple ways. AAFP has posted a program profile in the “New & Notable” section of the Virtual FMIG website, http://fmignet. aafp.org. At National Conference in Kansas City, Mo., July 29-31, the UTHSCSA FMIG will be featured in the official conference program, members will be given a special ribbon to wear on their conference badges, and FMIG leaders will present an educational session to share their success story with other student groups. : 12

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Former TAFP president, physician emeritus wins TMA Young at Heart award Add another accolade to an already decorated star of family medicine. TAFP member Glen Royce Johnson, M.D., of Houston, received the Texas Medical Association’s Young At Heart Award during the TMA House of Delegates meeting at TexMed 2010 in Fort Worth. TMA’s Young Physician Section, who voted for Johnson to win the award, cited his continuous support and promotion of organized medicine and his drive to engage young physicians.

Gregory R. Johnson, M.D., F.H.M., F.A.A.F.P., son of Glen Johnson, nominated his father and presented him the award.

Gregory Johnson recently completed his term as chair of TMA’s Young Physician Section. In the nomination, he spoke of his father’s vast “coaching tree,” the extensive network of physicians he helped in the formative years of their careers.

“He has mentored younger physicians who are now program directors of fam-

ily medicine residencies, clinic medical directors, and executives in health care plans,” he wrote. “He has spoken at numerous engagements in support of young physicians and their causes, including contacting the Texas Medical Board to expedite new physician applications for licensure. In terms of organized medicine, he has consistently and vocally supported not just membership but involvement in TMA and TAFP.” Glen Johnson was named TAFP’s 2009 Physician Emeritus for his longtime service and commitment to the specialty. A former TAFP president and AAFP vice president, Johnson has over 28 years of health care experience in clinical practice, academic medicine and medical education, managed health care, and medical group management. :

Keep up with the news that’s important to the family physicians of Texas with TAFP’s e-newsletter, QuickInfo, and online at www.tafp.org.

TAFP member appointed to insurance CO-OP panel TAFP member David D. Buck, M.D., M.P.H., of Houston has been appointed to a new national advisory board to oversee the disbursement of grants and loans to establish non-profit, member-run health insurers for the individual and smallgroup markets. Established by the Patient Protection and Affordable Care Act, the U.S. Government Accountability Office appointed 15 members to the advisory board of the Consumer Operated and Oriented Plan Program. Buck joins two other AAFPmember family physicians on the board.

Buck is an associate professor in the Department of Family and Community Medicine at Baylor College of Medicine, and the founder and president of Healthcare for the Homeless – Houston, Texas. He is also

a member of the governing board of the Harris County Healthcare Alliance, which has partnered with other local organizations to launch the TexHealth Harris County 3-Share Plan, a program designed to make health benefits affordable for uninsured employees of small businesses.

The creation of a co-op system to bolster the individual and small-group insurance market was a compromise to the controversial public option insurance coverage originally proposed in the health care reform legislation. The advisory board will make recommendations to the Department of Health and Human Services, awarding all of the grants and loans by July 2013.

The board may continue its work until December 2015. :

member news

Dickey named to Texas Women’s Hall of Fame

TAFP members elected to TMA leadership posts

TAFP member Nancy W. Dickey, M.D., has been chosen for induction into the Texas Women’s Hall of Fame by the Governor’s Commission for Women.

Dickey is president of the Texas A&M Health Science Center and vice chancellor for health affairs for the Texas A&M System.

Previously, she served as dean of the TAMHSC College of Medicine, where she still serves as professor of family and community medicine.

Dickey is the founding program director of the Family Medicine Residency of the Brazos Valley. During her tenure as president of TAMHSC, she has chaired the state’s formula funding advisory committee, and advocated increased funding for health-related educational programs.

As a result of her leadership, she helped establish the Irma Lerma Rangel College of Pharmacy in Kingsville, the first professional school in South Texas. She also created the Rural and Community Health Institute to address issues of patient safety and quality of care in rural Texas hospitals, and, in response to Texas’ nursing shortage, she oversaw the creation of a College of Nursing in Bryan/College Station. She chairs the Texas A&M System Council on Nursing, a statewide consortium of nursing programs designed to address the shortage.

Dickey holds the distinction of being the only female president of the American Medical Association. She is also active in TAFP, the Texas Medical Association, the American Academy of Family Physicians, and the National Patient Safety Foundation.

She was appointed to chair the Texas Health Policy Council by Texas Gov. Rick Perry; chosen for membership in the Society for Executive Leadership in Academic Medicine; and selected to be a member of the Institute of Medicine, a component of the National Academy of Sciences.

The Governor’s Commission for Women established the Texas Women’s Hall of Fame in 1984 to honor the state’s most accomplished women. A permanent exhibit honoring the inductees is housed inside Hubbard Hall on the campus of Texas Woman’s University in Denton, Texas. Dickey’s biography and photograph will become part of this exhibit after her induction in September 2010. :

Family medicine fared well during the Texas Medical Association’s TexMed conference in April as several TAFP members were elected to TMA leadership positions.

TAFP Past President Douglas Curran, M.D., of Athens, was elected to the TMA Board of Trustees, and Michael Ragain, M.D., of Lubbock, was appointed alternate delegate to the American Medical Association.

Curran was elected to a three-year term on TMA’s Board of Trustees. Travis Bias, D.O., a second-year resident from Houston, was elected this past winter to the oneyear resident position on the board. They join other TAFP members: Trustee Lewis Foxhall, M.D., of Houston, and Secretary/ Treasurer Art Klawitter, M.D., of Needville.

The Board of Trustees manages business and financial affairs of the association, implements policies of the House of Delegates, establishes association policy between meetings of the House of Delegates, and monitors program activities of association councils and committees. It is comprised of nine at-large members, six TMA officers, one resident, and one medical student.

Curran practices at East Texas Medical Center and Lakeland Medical Associates, Group Practice, and has been active in TMA, TAFP, and AAFP serving on numerous committees and in various officer roles. He is a member of the TMA Council on Legislation and the Executive Committee for TEXPAC, the lobbying arm of TMA. He has served as a consultant to the TMA Committee on Professional Liability and was a member of the TMA Council on Member Services. Curran is a member of the Henderson County Medical Society and serves in the TMA House of Delegates for Henderson County. At TAFP, Curran has served as chair of the Commission on Membership and Member Services, chair of the Commission on

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Curran, Bias join board of trustees, Ragain becomes alternate delegate to AMA Legislative and Public Affairs, and as an active member of TAFPPAC. He also served on the AAFP Commission for Governmental Advocacy.

Bias is a resident at the Memorial Family Medicine Residency Program in Sugar Land, Texas. In his third year, he will be one of three chief residents. He currently serves as Texas resident delegate to the AMA House of Delegates and is a member of the AMA Legislative Advocacy Committee. As a medical student, Bias served as a regional delegate to AMA; member of the Regional Infrastructure Task Force; member of the Ad-Hoc Committee on Medical Ethics; and in leadership capacities with AMPAC, the political arm of AMA. Within TMA, Bias recently completed terms on their Executive Committee and Foundation board. He was awarded TAFP’s James C. Martin, M.D. Resident Scholarship and will travel to Austin to research health care policy affecting family medicine and develop recommendations to carry into the next legislative session.

Ragain currently serves as the Braddock Chair of the Texas Tech University Health Sciences Center Department of Family and Community Medicine in Lubbock. After completing his residency training at TTUHSC, he became associate residency director for the program, then residency director. He served various other posts before being appointed Braddock Chair in 2002. Ragain is a current member of the TAFP Commission on Academic Affairs, and also served on the Task Force on Credentialing and the TAFP Board of Directors. Within TMA, Ragain has been a delegate and alternate delegate for his county society, a member of the Continuing Medical Education Committee, and a member and chair of the Council on Medical Education. :

TAFP member elected to ABFM board TAFP member Carlos Roberto Jaén, M.D., of San Antonio, has been elected to the Board of Directors of the American Board of Family Medicine. Jaén is the chairman of the Department of Family Medicine at the University of Texas Health Science Center at San Antonio. He is also an adjunct professor at the UTHSC School of Public Health at Houston and is co-director of the Center for Research in Family Medicine and Primary Care.

ABFM is the second-largest medical specialty board in the United States and facilitates certification and recertification to thousands of family physicians around the country throughout their years of practice.

Jaén will serve on the ABFM Information and Technology Committee and the Research and Development Committee, and will serve a five-year term on the 12-member ABFM board. :

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report from tafp’s 61st annual session & scientific Assembly

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Family docs gather for great CME and family fun in San Antonio

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By Kate McCann View an Annual Session photo album at www.facebook.com/txafp.

ore than 450 physicians joined TAFP staff and leaders to celebrate the family of family medicine at the 61st Annual Session and Scientific Assembly in San Antonio.

Amid fun and fellowship, family physicians from around the state earned CME, shaped Academy policy at the TAFP committee and commission meetings, learned about all facets of the medical industry in the Exhibit Hall, and explored historic San Antonio.

The scientific portion of the conference gave attendees the opportunity to receive quality continuing medical education credits in a variety of ways: through the two-day Office and Musculoskeletal Ultrasound Workshop presented by the National Procedures Institute; the Self-Assessment Module Workshop on Asthma to aid board-certified physicians in their maintenance of certification process; and a variety of workshops and lectures spanning Thursday through Sunday.

The lectures opened with an update on the Texas Academy led by TAFP leaders Kaparaboyna Ashok Kumar, M.D., F.R.C.S.; Melissa Gerdes, M.D.; and Tom Banning.

The most popular CME lectures were Case Studies in Diabetes Management with Charles Reasner, II, M.D.; Current Recommendations for the Evaluation and Management of Hypertension with Michael Bloch, M.D.; Wound Care for the Primary Care Practitioner with Aimee Garcia, M.D.; and Managing Patients with Treatment-resistant Depression with Christopher Ticknor, M.D. The Academy supported family medicine research through the 2010 Student, Resident, and Community Physician Poster Competition held on Friday. Researchers entered in three categories: primary research, evidence-based review, and case report. First place in the primary research category for family physicians went to 16 S U M M E R 2 0 1 0 | Te xas Fa mily Physician

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photos: Jonathan nelson

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Sally Weaver, M.D., from the McLennan County Medical Education and Research Foundation for her poster, “Exponential Pharmacy Growth as a Community Health Center.”

The first place in primary research for residents went to Shilpa Miniyar Shah, M.D., who recently completed her family medicine residency at the University of Texas Southwestern Medical Center and will now move to California to start practice. Co-author on Shah’s poster, “Depo-Provera and Herpes Genitalis: Is There an Association?” was Gretchen Stuart, M.D. Finally, first place in primary research for students went to Shannon Essler, a pre-med student at Southwestern University in Georgetown. Resident poster competition winners receive cash prizes, and students and physicians receive plaques.

At the Annual Business and Awards Lunch on Saturday, the 2010 awardees for TAFP’s top honors were unveiled and the 2010-2011 officers assumed their new posts. The recipients were Lloyd Van Winkle, M.D., of Castroville, Texas Family Physician of the Year; Bruce K. Jacobson, M.D., of North Richland Hills, Physician Emeritus; Rep. Veronica Gonzales of McAllen, Patient Advocacy Award; Stephen Benold, M.D., of Georgetown, TAFPPAC Award; Carlos Roberto Jaén, M.D., Ph.D., of San Antonio, Presidential Award of Merit; James and Karen White of Austin, TAFP Foundation Philanthropists of the Year; and Ulysses Urquidi, M.D., M.S., F.A.A.F.P., of El Paso, Exemplary Teaching Award.

Presented for the first time this year was a new award, the Special Constituency Leadership Award. It was created by the Section on Special Constituencies and rec

1) Incoming president Melissa Gerdes, M.D., of Whitehouse takes her presidential oath from former AAFP and TAFP president James Martin, M.D., of San Antonio.

2) Carlos Roberto Jaén, M.D., Ph.D., of San Antonio, receives the 2010 Presidential Award of Merit from TAFP outgoing president Kaparaboyna Ashok Kumar, M.D., F.R.C.S. Jaén is chair of the department of family medicine at the University of Texas Health Science Center at San Antonio.

3) TAFP installed the 2010-2011 officers at Saturday’s ceremony. From left to right: Treasurer Troy Fiesinger, M.D., of Sugar Land; Immediate Past President Kumar; President-elect I. L. Balkcom, IV, M.D., of Sulphur Springs; President Gerdes; Vice President Clare Hawkins, M.D., of Baytown; and Parliamentarian Dale Ragle, M.D., of Dallas.

4) A TAFP tradition, Kumar receives his Hi-Roller hat from Gerdes in recognition of his service as president. www.ta f p.or g | sUMM ER 2 0 1 0

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1 ognizes an outstanding TAFP-member family physician who has been a strong advocate for a specific special constituency or, as a member of one of the five special constituencies, has served as an outstanding leader in some capacity. The 2010 recipient was Amer Shakil, M.D., F.A.A.F.P., of Carrollton.

Shakil is the residency program director in the Department of Family Medicine at the University of Texas Southwestern Medical Center in Dallas and he started a small free clinic for the underserved that has grown into one of the largest faithbased charity clinics in the Dallas Metroplex.

Physician of the Year Van Winkle told the audience at the awards ceremony of family physicians, family medicine residents, medical students, and legislators that family doctors get to be part of something wonderful. “It’s sometimes difficult, but the difficult journey is part of the gift. When you students are going through the four years of medical school and then another three years of residency and maybe a fellowship, it isn’t easy, there are tough moments, there are call nights you won’t forget, but the difficult journey is part of the gift that we give our patients.”

He continued, listing different criteria he felt a physician must have to be named Physician of the 3 Year: an excellent staff, a supportive family, great patients, and a willing physician partner.

“What else you need is grey hair. You have to do it long enough to understand what it’s really all about, and what it’s really all about is the doctor-patient relationship. The highest-paid physician in the largest hospital in this city is a pathologist. But after 25 years, would you trade your relationship with your patients to be a pathologist? No, no one in this room would. That’s who we are. That’s part of that journey I was talking about.”

Lastly, Van Winkle said you need an education built on interactions with great physicians. As a tribute to the great doctors from whom he’s learned, he showed a video featuring photos of TAFP’s past and current leaders set to the song “What a Wonderful World” by Louis Armstrong.

Attending as the AAFP invited guest, AAFP and TAFP past president James Martin, M.D., installed the new TAFP officers who will lead the Academy in 20102011. The new TAFP officers are President Gerdes of Whitehouse; President-elect I. L. Balkcom, IV, M.D., of Sulphur Springs; Vice President Clare Hawkins, M.D., of Baytown; Treasurer Troy Fiesinger, M.D., of Sugar Land; and Parliamentarian Dale Ragle, M.D., of Dallas.

In Gerdes’ presidential address, she described how events in her life, even those before medical school, prepared her to be a family physician. They also prepared her for the role as president, which she says will encompass being a “faithful servant, listener, and even cheerleader.” From her first job at McDonald’s through her undergraduate education in Communications Studies to her involvement as a cheerleader for the Northwestern Wildcats, each experience gave her knowledge and wisdom she still calls upon in her daily life.

In her year as president, she will focus on five areas, each of which presents its own challenges: recognition and promotion, communication, education, advocacy, and workforce development. She told the audience that she is confident she will be able to meet these challenges with the help of a superb team of officers and staff. She then called on the larger membership to be part of that team by getting involved, getting to know their colleagues, and influencing people.

Once again this year, TAFP combined the Town Hall meeting with the meeting of the Commission on Legislative and Public Affairs. Harvey Kronberg, writer and editor of the political newsletter the Quorum Report, led a thoughtful discussion on the upcoming November elections. Another special guest, Rep. Larry Taylor, R-Friendswood, gave an insiders’ perspective on the upcoming 82nd Legislative Session and chal18 S U M M E R 2 0 1 0 | Te xas Fa mily Physician

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lenges lawmakers and physicians will face as the state moves forward.

The featured event occurred Saturday night as guests gathered at the beautiful San Antonio Botanical Gardens for the annual President’s Party. TAFP members and their families welcomed the new TAFP president to office with a garden party celebration featuring great food, music, and garden tours.

It’s never too early to mark your calendars for other TAFP symposia where you can expect bigger and better educational programs, informative topics, and great events. The 2010 Primary Care Summit will be held in two locations this year: Primary Care Summit – Houston will be held at the Westin Oaks in Houston Oct. 29-31, and Primary Care Summit – Dallas/Fort Worth will be held at the Westin Galleria Dallas Nov. 5-7. Registration for both programs is now open. The 2011 C. Frank Webber Lectureship will be held Friday, March 11, at the Omni Austin Hotel at Southpark, and the 62nd Annual Session and Scientific Assembly will be held July 2731, 2011, at the Sheraton Dallas. :

1) Lloyd Van Winkle, M.D., of Castroville receives the 2010 Family Physician of the Year Award from Gerdes.

2) TAFP Foundation President Dale Moquist, M.D., of Sugar Land, presents the 2010 Philanthropist of the Year Award to Karen and Jim White.

3) Kumar presents the 2010 TAFP Political Action Committee award to Stephen Benold, M.D., of Georgetown for outstanding political advocacy on behalf of family medicine.

4) State Representative Veronica Gonzales accepts the 2010 Patient Advocacy Award.

Gonzales represents District 41 in the Texas House of Representatives, which includes portions of McAllen, Edinburg, and Mission.

5) Kumar and Gerdes congratulate the 2010 Physician Emeritus, Bruce K. Jacobson, M.D., of North Richland Hills.

6) Gerdes presents Amer Shakil, M.D., F.A.A.F.P., of Carrollton with the 2010 Special Constituency Leadership Award. This is a new award created by the TAFP Section on Special Constituencies.

7) T. David Greer, M.D., and his wife Lea Ann enjoy the 2010 President’s Party at the San Antonio Botanical Gardens.

KATE McCANN

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JONATHAN NELSON

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A

Getting

mad isn’t

enough The art of translating ideas into consequences: How politics drives the process that sets policy

By Kim Ross

s electoral waves of unbridled anti-government sentiment are somewhat unevenly expressed against incumbents in both primaries, many physicians are likely to wave at the parade (or angry mobs), if not grab pitchforks and torches and join the procession. Physician frustration, broadly speaking, has reached a tipping point.

The medical societies who have dared to conduct surveys of their member physicians have found unprecedented white-hot anger, cynicism, and a pessimism that runs as high as 8-to-1. But where are physicians putting all this righteous, and to some extent misdirected, anger?

The art of politics, if that’s not an oxymoron, is channeling motivated voters into constructive results rather than merely a short-run tantrum that unhorses or simply antagonizes an incumbent. The end game isn’t the political assassination of an office holder. It is winning or leveraging an election so that the survivor/winner supports your well-reasoned ideas over your adversaries’ equally reasoned ideas, out of conviction or fear. Either motivation works. After all, why engage in these often unsavory and disingenuous public affairs if your ideas don’t have consequences?

In these times of incumbent rejection and unfocused resentment of all things governmental, a story often resurfaces as told by a longtime Capitol press corps reporter.

It seems this reporter was attending a post-election interview with a newly elected governor who had just won back his former position from the same incumbent who, four years previously, had unseated him. The reporter asked the governor-elect in a post-victory press conference, “What will be your top priorities this session?” The governor-elect stared for a moment, then asked, “What?”

The consensus interpretation from the journalists in the room was that his agenda was avenging a previous defeat at the hands of the soon-to-be ex-incumbent. There was no other agenda, although there were plenty of well-heeled supporters of the challenger who had their own ideas already drafted in bill form.

Legislative ideas, after all, arrive at their destinations from a political process. They aren’t all that often born spontaneously from civic-minded public servants. They are turtles on fence posts. Someone put them there.

Legislators, especially part-time state legislators, do not have the time or capacity to grasp every nuance of the more than 6,000 bills that are filed every session, nor, realistically, the 1,000 or so that pass their desks on the House or Senate floor and that are voted for or against. Ideally and by their preference, they rely on guidance from local, credible sources who are also supporters. Lobbyists either direct that local traffic to the politician or inject their clients’ opinions in its absence.

It should thus follow that if politics drives the process that sets public policy, how do physicians master the art of politics? What follows is a brief guide to the principles of political engagement, and how medicine’s ideas can have real-world consequences. It is in three parts—the basics of electoral engagement, how to be an advocate during the legislative process, and what constitutes effective policy development within the confines of a political process.

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Part 1

Electoral engagement: The basics

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n politics, relationships are as important, if not more so, than issues, and as a corollary, elected officials can trace many of their most valuable relationships back to their earliest electoral experiences. Running for office, then hanging on to it, is not for the timid or those plagued by self-doubt. A politician rarely forgets or overlooks those who were there during that first, seminal election, or their first neardeath experience during a re-election.

Who gets to cut in line at a legislator’s office? The physicians who have stayed out of the electoral process and never contributed or worked in the incumbent’s campaign, or his local optometrist and longtime finance chair?

What does one suppose is the predisposition of that legislator on expanded scope of practice for optometrists? Since most legislators didn’t go to medical school, where do you suppose they go to get some sense on how to vote on these complex and intensely political matters?

There are three types of grassroots relationships, as opposed to the timehonored lobbyist relationships of those who regularly haunt the halls, bars, and anterooms in Austin and Washington, D.C., and direct client support to those lawmakers. All have relative value, in descending order:

Given the extent of corporate interference and government involvement in health care, physicians have a moral obligation to their patients and to their profession to be active in the political and legislative process.”

Sen. Robert Deuell, M.D. R-Greenville Vice chair, Senate Committee on Health and Human Services

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Organic: These relationships are of a more natural order, preceded their political careers, and are by definition relatively close: family members, classmates, physician-patient relationships, neighbors, or other community-based relationships involving regular interaction. When managed methodically and ethically, they are by far the most influential during legislative cycles.

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Home grown: These are relationships acquired during an election cycle.

Physicians who engaged in all the basics of volunteer political action (not just making a contribution, however important this emphatically is) during a campaign: signing letters or ads; hosting events; block walking; traveling with the candidate; and any in-kind public, sustained gesture. They are the most numerous relationships and in most cases neutralize even the largest contributors’ efforts at bullying your legislator.

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Artificial turf: These are the en masse responses rallied from your medical organization where volume, in addition to personal contact, count.

These are letters and e-mails. Some legislators are notorious for hiding behind perceived local doctor ambivalence. Lobbyists frequently hear from the uncommitted legislator, “I haven’t heard from my docs on this,” implying a lack of political interest among physicians and the politician’s proportionate disinterest in supporting the position, especially if the other side is pounding his or her office with mail and calls.

In the next part we’ll review how to apply these relationships in legislative battle.

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difference between the electoral risks of taking sides as compared to the personal or ideological beliefs of the legislator. For some issues, the legislator will bend to the ideological side, willing to take political risk because of personal conviction.

At the other end of the spectrum, the legislator may see the vote as potentially career-ending, or at a minimum calling in heavy artillery on his or her own position in the next election, by violating partisan doctrines that guarantee a primary opponent or by offending local constituencies capable of organizing a grassroots offensive.

Calling on a legislator—really just showing up—is vital, if for no other reason that if absent, you forfeit your interest and influence to the other side. But, it isn’t a social call. Longtime University of Texas football coach Darrell K. Royal famously said about his aversion to the forward pass, “three things can happen to you and two of them are bad.” It can be also said of legislator contact or public testimony: the legislator may agree, disagree, or simply not respond. Your words have consequences, but epiphanies are virtually nonexistent. I’ve never seen the Red Sea part or a blinding light hit a legislator after giving it our best shot, causing him to fall to his knees and dramatically proclaim, “I see the light! All this time you were right and we were wrong. I am born again, and this time, I’m on your side.” Physicians making those House and Senate calls will need some guidance from their lobby or their peers who enjoy an organic or home-grown relationship to assess their legislator’s disposition so as to know what to expect and how to temper their conversations. This prior assessment is crucial to assuring a productive contact and minimizing the possibility of a grenade going off in someone’s lap.

To make things more linear in this chaotic world, here’s a simple typological guide to your legislator’s possible position before the vote.

Part 2

Doctors as policy advocates: How hard could it be?

photo: JONATHAN NELSON

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o the extent physicians and their advocacy organizations have invested in the political process during successive election cycles, they will have accumulated the kind of political capital that has currency before and during a legislative session. That will be the time to expend that capital, but it should be spent judiciously, not murdering a bill that was already committing suicide or trying to persuade the unpersuadable. Whether the contact with their legislator is in their crowded Capitol office during the biennial melee or the more quiet environs in their district, there are certain rules of engagement and guiding principles to those conversations.

How legislators think This isn’t an oxymoron. Every legislator runs legislation that has local backing or political muscle behind it through a rational calculus that measures the

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Kamikazes: Whether for your issue or against, conversation is at best symbolic if not futile. Their disposition implies a risk-irrelevant stance to the point of self immolation. Though they may wrap their views in some rhetorical or partisan device, what they are really saying is they are intractable. If they are for you, one invokes the “strike oil, stop drilling” rule. Say thank you and ask what they are hearing about your issue. For those against, say thank you and offer the vague hope there may be other issues where hearts and minds might otherwise converge. No reason to share your playbook with the other team.

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Ambivalents: Here is where all legislative traction is acquired and change is realized. These are legislators, often a substantial plurality of the Legislature, who by definition are on the proverbial fence. There are two kinds of ambivalents: moral and political.

The moral ambivalents are high-centered because they have not heard a sufficiently persuasive argument from either side. This is very lucrative ground, where an evidence-based policy and well-reasoned arguments have immense consequence. It is also a rare circumstance. One can infer from the morally ambivalent that the legislator does indeed want to do the “right” thing, has disregarded ideological, political, or partisan pressures, and considers the issue sufficiently relevant to everyday life to spend precious time studying the merits of the issue.

The political ambivalents are uncommitted because they are simply indifferent to the policy consequences and more interested in the political risk of taking sides.

This is by far the largest ongoing plurality in any debate preceding legislative action. The more intense the party, local, and lobby pressure, the more a political ambivalent will be inclined to wait the issue out, hoping for a forced compromise (no one willingly gives ground—it is usually achieved at gunpoint) or for the arcane twists and turns in the legislative process to kill the bill before it reaches his or her desk. This is a trickier encounter since the legislator will be reluctant to admit having political fears without incurring certain liabilities, including an implied quid-pro-quo transaction or one that explicitly ties a vote to promised support. It regrettably happens on rare occasion in the privacy of an office or local venue, and it is also a criminal offense. Physician conversations in these circumstances are no different than the policy debate with the morally ambivalent legislator—succinct, well-reasoned, evidence-based arguments.

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advanced grassroots advocacy for family docs

ADVOCACY

Your advocacy encounter checklist

Remember, during a session, you may be talking with policy staff in lieu of your legislator.

1. Prepare. Rehearse your issue talking points with your lobbyists. They are professionals and spend a lot of time in that swamp. Get a profile of your legislator, especially if you don’t have an organic or homegrown relationship in tow.

2. Don’t cuss the alligator before you cross the swamp.

Never, ever, threaten, show anger, or imply you’d like to remove a favorite appendage without the benefit of anesthesia. The legislative process assures many opportunities for instant karma payback, with no fingerprints or smoking guns.

3. It’s not personal. The venal, mercenary, bottom-feeding, yellowpage-advertising, ambulance-chasing personal injury lawyer’s vote is as good as the white-gloved, afternoon-tea, gated-community debutante’s.

Make no assumptions about where your support may come from, or indulge in personal opinions about any legislator’s life philosophies or lifestyles. Sam Rayburn said it more succinctly, but we can’t print it.

4. No ad hominem attacks on the other side. You may reference the canine ancestry of a rival profession only to find the legislator’s spouse or family member belongs to that tribe. Besides, it is non-persuasive and bad form, especially from a respected member of your learned profession.

5. Don’t negotiate. The more clever of the ambivalents, in seeking to distract or find a way out, may ask for a trade or a downgrade of your request. Refer them back to your lobby.

6. Address legislators by the titles they’ve earned. Nicknames like bubba, big guy, or cutie, even their given names, are off-limits unless you enjoy that kind of intimate, organic relationship. Even then, it’s best in the presence of others to say “senator, representative, or mister/ madam chair.” Your lobby can help you with protocol.

7. Treat staff with the same deference. They are the filter to the boss, and have no problem filtering your points. See also point No. 1 about doing your homework—they have personal physicians, friends who are physicians, and quite possibly good friends working against you.

8. Argue from evidence, not beliefs. While avoiding jargon and acronyms, cite the scientific evidence in a cause-and-effect linkage that ties the policy to the desired or undesired consequence. Your position may involve three wise men and a virgin, and the other side may be agents of Satan, but that is in most cases an insufficient argument. Everyone likes to invoke a deity when backed into a legislative life-or-death corner. The ambivalents want probable outcomes.

9. Take the debate to the exam-room level. Tell a story using real or redacted cases of the consequences of action and inaction.

10. Stay inside your knowledge. If you don’t know, just say you’ll check and get back. Don’t chase hypothetical questions.

11. Report back. It’s okay to take notes, and vital you compare what you heard, thought you heard, and didn’t hear to your advocates. Your intel will fit into a complex pattern across 181 votes, and provides valuable insights into your opponents’ strategy, progress against you, and the predisposition of your legislative contacts. And, drop a note to thank whomever you met with to memorialize the contact with them, but present that fairly. This gives you one more chance to reinforce your points.

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TO-DO LIST

Sign up to be a TAFP Key Contact.

Sign up to serve as Physician of the Day. Stay informed on the issues.

Join the TAFP Political Action Committee.

Build meaningful relationships with your representative and your senator.

Need help with these?

Contact TAFP at (512) 329-8666 or tafppac@tafp.org.

The art of politics, if that’s not an oxymoron, is channeling motivated voters into constructive results rather than merely a short-run tantrum that unhorses or simply antagonizes an incumbent.

Sign up for TAFP’s Physician of the Day and Key Contacts programs TAFP’s Physician of the Day program

TAFP is preparing for the 82nd Texas Legislative Session. Since 1971, Academy members have participated in the Physician of the Day program by donating their valuable time to provide the Capitol with an on-call physician. The Physician of the Day

works in a primary care clinic located in the Capitol extension and treats anyone sick or injured on the Capitol grounds.

Fax this form to Kate McCann at (512) 329-8237 or mail it to TAFP, 12012 Technology Blvd, Suite 200, Austin, Texas, 78727. You may also sign up on our website, www.tafppac.org.

2011 Session Dates All dates are listed as Monday through Friday,

though the Legislature usually cancels on Fridays, January through March.

January

11 17 18 24 25 31

12 19 26

13 20 27

14 21 28

April

4 5 6 7 11 12 13 14 18 19 20 21 25 26 27 28

1 8 15 22 29

F ebruary

1 7 8 14 15 21 22 28

2 9 16 23

3 10 17 24

4 11 18 25

May 2 3 4 5 9 10 11 12 16 17 18 19 23 24 25 26 30

6 13 20 27

To serve as Physician of the Day, volunteers must have a valid unrestricted Texas medical license and be a member in good standing in TAFP or TOMA. The 82nd Legislative Session will convene on Jan. 11, 2011, and the Academy needs volunteers to participate in this program. The Physician of the Day will be introduced in both the Senate and the House of Representatives each day and his or her name will become a permanent part of the official legislative record.

Volunteers are scheduled on a first-come, firstserved basis. Dates may change due to the legislative schedule and TAFP staff will try to provide as much advanced notice as possible in the case of a schedule change. Please note that the Legislature usually adjourns on Fridays, January through March.

Information (Please complete fully and legibly.)

Sign up to be a Key Contact

other legislators you know

Now more than ever, state and federal lawmakers are making decisions that directly affect your patients and your practice. The 82nd Texas Legislature will be addressing a number of issues important to family medicine including scope of practice, graduate medical education, physician workforce, and much more. As legislative battles heat up, legislators need to hear from family physicians about how medicine should be practiced, now and in the future. They certainly hear from others with far less insight than physicians.

TAFP’s Key Contact program seeks to identify family physicians willing to serve as resources to their legislators to advocate the values of family physicians and their patients.

If you would like to participate in TAFP’s Key Contact Program, please check the appropriate box on this form. If you want to serve as a Key Contact but don’t know your legislators, TAFP can help.

Check the second box.

Volunteer to serve as Physician of the Day or as a Key Contact by filling out and returning this form to Kate McCann at TAFP headquarters or go to www.tafppac.org.

Note: TAFP reserves the right to remove a physician who is scheduled to serve as Physician of the Day if there are any changes made to his or her membership status or medical license.

March

7 14 21 28

1 8 15 22 29

2 9 16 23 30

3 10 17 24 31

4 11 18 25

name address City/State/Zip Phone

Fax

E-mail address State representative (if known) state senator (if known)

❏ Yes! I want to volunteer for the Physician of the Day program.

Can you serve on short notice? ❏ Yes Please indicate the dates you would like to serve. first choice

❏ No

second choice

❏ Yes! I want to serve as a KEY CONTACT. ❏ Yes! I want to serve as a KEY CONTACT, but I don’t know my legislators. Please help arrange a meeting with my legislators so I can serve as a resource.

disclosure Have you ever had your license suspended or revoked, voluntarily surrendered your license, or been convicted of a felony or violation of any state or federal narcotics act? ❏ Yes ❏ No If yes, please explain

By signing this form, I confirm that the above information is correct and that I have a valid unrestricted Texas medical license and am a member in good standing in TAFP or TOMA. signature daTE

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advanced grassroots advocacy for family docs

Part 3

The legislative process: Insights into the flow and logic inside the skunkworks

T

he Texas Legislature is constitutionally limited to convening every two years for 140 consecutive days, part of a series of post-reconstruction reforms intended to limit the governmental excesses imposed on the locals after the Civil War by Yankees, carpetbaggers, “radical Republicans,” and ardent unionists. Modern observers wryly suggest the legislators at the 1875 constitutional convention made a transposition error and meant to limit the Legislature to meeting “every 140 years for 2 days.”

The governor can summon lawmakers to Austin for special sessions that are limited to 30 days and subject only to legislative items listed in the governor’s call. These are understandably rare and invariably unpleasant episodes since at least half of these part-time legislators, if not most of them, are being dragged back to Austin to deal with an issue that couldn’t be resolved in the first 140 days.

The input of family physicians is invaluable.

They are truly the frontline of our health care system; their voice is very important and must be heard. There are many groups that are very active in Austin and without a strong voice all sides will not be heard.”

Rep. Lois Kolkhorst R-Brenham Chair, House Committee on Public Health 26 S U M M E R 2 0 1 0 | Te xas Fa mily Physician

Physicians who wade into this swamp without an interpreter are likely to get frustrated, lost, or both. It is an arcane, insider process with elaborate rules and procedures. It is sufficiently complex that even the most skilled lobbyists often retain highly specialized wizards and gremlins, usually former staffers, who are experts in navigating the wilderness of rules and procedures. Within that context, the process of making law is quite rational and predictable, given a few hints and insights.

Every high school civics text has a flow chart entitled “how a bill becomes law.”

It is a truthful representation, but as is often the case in politics, it is not accurate.

This brief discussion should be entitled, “why most bills will never become law,” and is intended to outline the logic of the process more than its byzantine features.

Every aspect of the state constitution governing the legislative process, the enabling statutes, and the minutiae of the House and Senate rules are designed around type I error avoidance: the acceptance of a false positive—better no law than a bad law. While in the swamp, one should never assign to coincidence or stupidity, however tempting, what can be fully explained by conspiracy. There is a floating plurality of legislators who on any given politically volatile issue would prefer not to vote on it. The system favors lobbying toward that bias, and politicians use the process to hold bills hostage and hopefully inspire negotiated deals that limit their exposure to controversial votes. (See ideology vs. ambivalence above.)

Consider some of the more common choke points and impediments to billpassing. Bills go to a committee, and then in most cases to a subcommittee. The bills as filed are read aloud as a formality known as “first reading,” then are sent to a committee at the discretion of the Speaker. Since the Speaker appoints those committees, a bill referred to a committee with a majority of hostiles didn’t wind up there by accident. (See “turtles on fence posts” rule.)

photo: JONATHAN NELSON

While in the swamp, one should never assign to coincidence or stupidity, however tempting, what can be fully explained by conspiracy. There is a floating plurality of legislators who on any given politically volatile issue would prefer not to vote on it.

Each bill then requires a hearing, the scheduling of which is entirely at the discretion of the chair.

Contentious bills that rise to the level of political ambiguity are very likely to be held hostage, often at the request of the committee members, to see if a compromise can be compelled.

Each bill also requires a fiscal note. The comptroller staff guesstimates if the legislation requires state revenues. If your legislation comes back with a zilliondollar fiscal note when the more probable revenue impact is at worst neutral, one should assume the fiscal note is really a poison pill.

The House has a third gatekeeper, the Calendars Committee, which filters all bills coming from full committees (assuming they escaped their subcommittees) and schedules them for floor debate. Proceedings of the Calendars Committee are hardly transparent.

Committee members are allowed to “tag” bills they don’t like, an informal means of delaying their consideration. If pended bills were pebbles in a boat, the boat would be taking on water and nearly capsized by the end of the 140-day session.

Amendments to legislation have to be germane to the caption, or topic of the bill, unlike in the U.S. Congress, where lawmakers can pile on Medicare

reforms to Department of Defense bills. There are elaborate “layout” rules requiring several days of incubation pre-floor debate so presumably legislators can see what’s coming and prepare.

The Senate has its own version of a third gatekeeper, called euphemistically the “two-thirds rule,” which in effect means that all bills pending Senate floor debate require two-thirds of a quorum (19 to 21 out of 31). Sometimes a senator or two can be persuaded to “walk,” or “vote with their feet,” meaning they are not on the floor when the bill is recognized for a suspension vote, dropping the absolute threshold needed. But that is another story.

More on the Senate two-thirds rule: Senate rules state that all bills are brought up in their regular calendar order. As bills come of out of Senate committees, they pile up on the calendar. The presiding officer of the Senate, usually the lieutenant governor, never recognizes that batting order. The first bill is called the “blocker,” for obvious reasons. So, to take up a bill out of regular calendar order requires a suspension of that Senate rule—a motion to take up and consider the bill out of regular calendar order. Rules suspensions require a two-thirds vote. If you’re still following this, the net relevance is that any legislation in the Senate can be blocked by just one-third of its members—11 votes—with one extraordinarily rare exception we experienced last cycle. Add to this the fact that state senators serve fouryear terms, and you’ll see that since they sit for two sessions before they are up for re-election, a mid-term senator has more discretion than a two-year-term House member, and can be more aggressive in exploiting the two-thirds barrier.

Given the variety of methods with which legislators can dispose of potential legislation, it’s quite an achievement when a bill you’ve supported survives the gauntlet and lands on the governor’s desk to be signed into law. The process is designed to kill bills, not to pass them, but with the right strategy, personal relationships, and a strong, well-prepared grassroots campaign, you can win the day.

In 2003, when the Legislature was consumed by the prospect of a $10 billion budgetary shortfall and the angst of the bloodiest redistricting battle in recent memory, TAFP and the rest of organized medicine succeeded in passing landmark tort reform legislation that stabilized the medical liability marketplace and put an end to skyrocketing malpractice premiums.

This coming January, the Legislature will convene in Austin facing many of the same challenges: an $18 billion shortfall in a redistricting year, plus the sunset of some major agencies including the Texas Department of Insurance and the Texas Department of Transportation. Even so, by nurturing your relationships, building coalitions, understanding the process, and making your voice heard, you can translate great ideas into meaningful consequences for the benefit of your patients and your practices. :

Kim Ross is a public affairs consultant specializing in health care policy and political strategy. He is the former vice president for public policy of the Texas Medical Association, and he regularly advises state and national office holders, corporations in the health care industry, and physician associations across the country.

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advanced grassroots advocacy for family docs

Q1) Facing a possible $18 billion budget shortfall, how likely is it that physicians will suffer a pay cut in state health care programs and why?

10 Questions for TAFP’s lobby team

T

his session promises to be one of the toughest in years, with the state facing an enormous budget shortfall, physicians under siege by nurse practitioners seeking independent practice of medicine, the sunset of several major agencies including the Texas Department of Insurance, and—oh, by the way, it’s a redistricting year.

To get a 30,000-foot perspective on what can be expected from the 82nd Texas Legislature, we asked 10 questions of TAFP’s crack lobby team as well as the Academy’s CEO, Tom Banning.

The lineup:

Marshall Kenderdine MK Representing TAFP under the dome since 2006, Kenderdine is a former aide to two chairmen of the Texas House Appropriations Committee, including the committee’s current chair, Rep. Jim Pitts, R-Waxahachie. Kenderdine managed the initial campaign for office of Rep. Byron Cook, R-Corsicana, and served as legislative aide to former Sen. Todd Staples, the state’s current commissioner of agriculture.

Dan Hinkle DH A longtime advocate and fixture on the Texas political scene, Hinkle joined the TAFP lobby team before the 2009 legislative session. He has represented some of the state’s most powerful interests, including several companies in the oil and gas industry.

Kurt Meachum JP Jerry Philips KM After many years of working in and around the Texas House for multiple Democratic members, Kurt Meachum and Jerry Philips joined forces in 2009, hanging a shingle under the name Philips & Meachum Public Affairs. They have each served as chair of the House Democratic Campaign Committee, thereby playing an integral role in electing the vast majority of House Democrats. Last session, they took up the cause with TAFP, helping get the new physician education loan repayment program through the House.

Tom Banning TB Banning came on board as a lobbyist for the Academy in 1998, and took over the helm as CEO in late 2007. This session will be his seventh serving as an advocate for the family physicians of Texas.

KM: It is certainly a possibility. When you face a budget deficit this large, everything is on the table.

The two biggest pieces of the state budget are health and human services, and education. If you subscribe to the belief that the votes do not exist for a tax bill, then there are only two other ways to bridge the budget gap: new sources of revenue and budget cuts.

MK: Physician fees under Medicaid and CHIP will come under serious scrutiny, but since providers already received a 1-percent reduction in the current biennium, and since HHSC has testified to legislative leaders about the negative implications associated with further reductions, there is some hope.

Q2) In what other ways do you expect the state to make up the deficit that might affect Texas’ patients and family medicine practices?

JP: I think you’ll see a combination of accounting gimmicks, new and increased fees—not to be confused with taxes—new revenue sources like gaming, potentially, perhaps some privatization of state services, and a host of other budget cuts. Graduate medical education, statewide preceptorship programs, and physician education loan repayment programs are among the funds we’ll be fighting to protect.

MK: Like 2003, legislators could try to implement tactics in the public health programs like waiting lists, enrollment verification, means tests—anything to push more people off the Medicaid and CHIP rolls.

DH: My sense is everything that we are getting now will be on the table for discussion, so we really need to look at our priorities and know early on what our list is.

Q3) What is redistricting, why is it important, and how do you predict it will affect what organized medicine can achieve this session?

KM: Every 10 years states use new census information to redraw congressional and legislative boundaries to ensure equal and fair representation. Nothing is more important to elected officials than redistricting and the overall make-up of their own districts, which means redistricting sessions are extremely contentious, partisan, and unproductive.

JP: When you consider the fact that along with redistricting, this session features an $18 billion budget deficit, it’s unreasonable to expect any other major piece of legislation to make it through both chambers.

Q4) How will the new health care reform law come into play this session?

TB: Despite a lot of political rhetoric, the Health and Human Services Commission and the Texas Department of Insurance are already working on how to implement federal health care reform legislation in Texas and will make recommendations to the Legislature on needed statutory changes, which will

28 S U M M E R 2 0 1 0 | Te xas Fa mily Physician

range from building a health insurance exchange to piloting different payment models in Medicaid.

DH: We do have to keep in mind that there are a number of legislators who see the new health care reform bill as a huge drain on the budget, and there will be those who will want to postpone action on it under the belief that Republicans will take the Congress and repeal it.

Q5) Will any major managed care issues be on the docket this session?

TB: Yes and no. The Texas Department of Insurance is up for sunset, meaning every law governing the oversight of managed care operations from prompt payment to standardized credentialing will be up for review and open to hostile amendments.

Additionally, there will be a concerted effort to roll out an HMO Medicaid model in the Rio Grande Valley.

Q6) What is sunset, and what do you predict for TDI in the process?

KM: Every 12 years, state agencies go through the sunset process in which the Sunset Commission looks at whether the agency is achieving its core purpose. TDI is up for sunset again after the TDI sunset bill failed to pass last session.

JP: Democrats believe that the insurance industry is a liability for Republicans, and they will be pressing hard to ensure that this bill comes to the floor where hundreds of amendments will likely be offered to force folks to take politically difficult votes. I think the bill will come to the floor this session, and there will be fireworks.

DH: Lots of folks have real problems with the insurance industry and TDI, so when that bill is on the House and the Senate floors, we should expect a real battle and we shouldn’t be surprised that some of those amendments hurt rather than help the process.

Q7) What should TAFP members expect from the advanced practice nurses?

JP: All-out war. Unless it gets bottled up in committee, you should expect a huge fight on scope of practice. The nurse practitioners have only one request: independent practice including diagnosis and treatment. It’s tough for an elected official to say no when a constituency asks for only one thing.

DH: Right now they have no downside to their strategy, and they have not indicated that there is any middle ground.

Q8) What are the difficulties of fighting a scope of practice battle, or any other turf war in the Legislature?

against most legislators’ belief that it’s better to let these sorts of problems work themselves out in the marketplace.

DH: In this particular fight, we are somewhat the victims of our own success. We did a wonderful job of educating the Legislature on the need to address medically underserved areas. Now the nurses are using that very issue against us to argue that they should be allowed to expand their scope of practice to provide care to the underserved.

Q9) Given the chaos and complexity of a session encompassing redistricting and a massive budget shortfall, what would constitute a successful session for organized medicine—and family doctors in particular?

DH: My list is short. Defeat of the scope of practice bill and stay even in the budget process, and we’ll have achieved success.

MK: I’d add that lawmakers block any adverse changes to TDI. Q10) We’re asking members to sign up as Key Contacts, to serve as Physician of the Day, to stay informed on the issues, to become members of the TAFP Political Action Committee, and to nurture relationships with their legislators. Do these tactics work for associations in effecting positive policy changes?

MK: Absolutely they work. Look at the physician loan repayment bill passed last session. Because legislators constantly heard from their physician constituents on the need to ensure more medical students go into primary care, we were able to pass a bill that was opposed by nearly $2 million worth of big tobacco lobbyists.

DH: When a family doctor calls their legislator, that legislator listens and in most cases does everything he or she can to honor the request. Building those relationships with your representative and senator can be the difference in our efforts to pass or defeat legislation.

There is nothing magic about legislative advocacy.

Get to know your elected officials, tell them how legislation will affect your patients and make your voice heard.

We’re listening and we need your input.”

Rep. Garnet Coleman D-Houston Chair, House Committee on County Affairs

TB: The most powerful legislative advocacy begins and ends with a strong grassroots effort. The cynic will argue that politics is a fixed game and lobbyists are all-powerful. The truth is lobbyists are a dime a dozen in Austin; they’re important in that they help open the doors and explain the rules of the game, but it is the constituents back in the district to whom legislators ultimately have to answer.

When you think about how complex and far-reaching health care policy is, legislators desperately want to hear from family physicians. They are listening and they want feedback. :

MK: Legislators don’t like to get in the middle of a fight between competitors in a market. No matter who wins the fight, the legislator makes enemies of the losing side, and refereeing a scope battle goes

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advanced grassroots advocacy for family docs

6 rules for making your legislative friends champions for your cause

By Joe Gagan

A

ll of us know and appreciate the importance of a legislator who not only votes for our issues, but actively supports our efforts.

Oftentimes this person is the sponsor of our legislation or a member of a key appropriations committee. Sometimes these legislative friends align with our issue due to effective lobbying and sometimes due to personal experience. For whatever reason, we all know how critical these legislative friends are to success. They become not only our advocates, but valued consultants on legislative strategy as well.

Unfortunately, even the most well-meaning and dedicated legislator is forced to pick and choose among the issues he or she supports and select those worthy of additional time and attention. This may be due to the volume of legislation, the daily press of time, or just the politics of the process. An example of the latter occurs often in the making of an appropriations bill, when an individual committee member has the ability to influence only a limited number of funding items during a process that often takes place outside the public light. Under those circumstances, the individual legislator is forced to make a difficult choice as to which of several worthwhile projects or activities he or she believes should receive stronger support.

The Animal Farm rule Joe Gagan is CEO of Texas CASA, an organization dedicated to advocacy on behalf of abused and neglected children in the court system.

He has a long history of involvement in political and legislative affairs, serving as general counsel to a legislative committee, and chairing a major state regulatory agency in Texas. He has conducted successful strategic planning and legislative educational programs for TAFP, AAFP, and many other organizations.

Like the pigs in the George Orwell novel, some legislators are more equal than others, and given that most organizations have limited resources, it is important to focus your resources on key legislators such as those that serve on key committees or those that have personal experience with your issues. Of course, this doesn’t mean you ignore other legislators or refrain from seeking their support.

The Henry B. Gonzalez rule Henry B. Gonzalez was a longtime member of Congress from Texas. He once said that there is a world of difference between someone being against you and someone being really against you. There are many degrees of support and opposition in the legislative process. The significance for you is that moving one key legislator from hard opposition to indifference may be just as critical to success as moving a supporter from passive support to championing your cause.

The Winnie the Pooh rule Like the A. A. Milne character, legislators love honey. And what is legislative honey? It is quite simply praise and attention for doing positive things in support of your issues. Like Winnie with his honey, it’s nearly impossible for constituents to give legislators too much attention for doing good things.

30 S U M M E R 2 0 1 0 | Te xas Fa mily Physician

The Strike-While-the-Iron-Is-Hot rule Don’t wait until after the legislative session to thank those who’ve helped you, and don’t reserve praise solely for your sponsor or floor leader. Look and look hard for things for which to thank other legislators: a favorable vote in committee or on the floor, a quote in the newspaper, a comment during floor debate supportive of your position, or even taking time to meet with representatives of your organization. All of these are worthy of a thank-you letter. Don’t forget letters to the editor in the hometown papers. You may not think anyone reads those letters, but I promise you, most legislators do.

The There-Is-No-Friend-Like-aConstituent rule Letters of appreciation from the CEO of your association or from your lobbyist are nice, but they can’t compare to the impact of a letter from a constituent. If you don’t have any supporters in a key legislator’s district, then make an effort to find some.

There is no substitute for hand-written thank-you letters from constituents. Local constituent advocates can be far more effective than paid lobbyists.

The Smith Barney rule In a famous commercial for the stock brokerage company, the punch line says, “We make money the old fashioned way, we earn it.” Hometown media stories about your organization’s local members honoring a legislator after a legislative session are far more valuable to that legislator than any paid political advertising. Legislators know that. So after each legislative session, make a list of your key legislators, find something they did during the session for which you can thank them, and do it.

You can do this at a local restaurant, your offices, or even someone’s home. Order a nice plaque or frame a resolution, send out press releases before the event so local reporters know they can attend, and invite your members and supporters. TAFP staff back at the association headquarters can help you with the press release and media contacts, but it is your relationship with the legislator that will make the difference.

Take pictures of the member receiving the award, and after the event, send out a second press release with the pictures to every newspaper in the legislator’s district. Major dailies might not run the story, but the smaller weeklies and suburban papers probably will. You can also send the story to your local chapter of TAFP, county medical society, and any other organization to which you belong that has a newsletter or website. Clip any articles that appear in these publications and send them to the legislator, thanking him or her again.

A little thoughtfulness can go a long way in the legislative process. Just like the rest of us, legislators like to be recognized when their efforts make a positive difference in people’s lives. It is by this recognition that legislators will take a greater interest in your issues. :

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The Texas Academy of Family Physicians and UT MD Anderson Cancer Center present:

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Family Physician Wanted Are you ready for a change of pace? We are looking for a family physician to work a 24- or 48-hour shift 45 minutes from Laredo, Texas. This is a 24-hour primary care clinic and you don’t have to worry about billings or collections.

You will be compensated $2,000 per 24-hour shift.

This is a great opportunity to supplement your income with no added overhead expenses, or You have the opportunity to earn $200k/yr by working only two shifts per week.

That’s five days off every week to pursue your other passions!

This is a great opportunity for the right physician.

You must be board certified/eligible in Family Medicine, in good standing and comfortable seeing adults and pedi. No OB. Only serious inquiries to: 4/1/2010 Dr. M. Vazquez (956) 765-8494 Healthcare Dr. E. Garcia (210) 675-8390

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FAMILY MEDICINE AMBULATORY and HOSPITALIST PHYSICIANS Scott & White Healthcare and Texas A&M College of Medicine Scott & White Healthcare and Texas A&M University College of Medicine is seeking BC/BE Family Medicine Physicians interested in either a full-time hospitalist or ambulatory clinic position within our central Texas healthcare system.

The hospitalist physician will join an existing group of three Family Medicine Physicians in a 7-on, 7-off rotation at the new S&W Memorial Hospital in Temple, Texas. Nighttime coverage by Family Medicine Residents allows evening call from home.

Ambulatory physicians will join existing practices at one of our regional clinics in Bellmead, Cameron, Gatesville, Killeen, Temple, Georgetown or Waco. These are excellent opportunities for positive minded and motivated physicians who desire to join an outstanding group of family doctors, and who enjoy caring for patients as a member of a well functioning health care team. Additionally, an academic appointment with Texas A&M College of Medicine is available for those involved in primary-care research or medical student and resident education.

Scott & White is a fully integrated healthcare system, the largest multi-specialty practice in Texas, and the sixth largest medical group in the nation. Scott & White employs nearly 800 physicians and research scientists with a coverage area of 25,000 square miles in Central Texas. One hundred thirty family physicians enjoy friendly relationships with over six hundred Scott & White specialist physicians, facilitating a high quality and cost effective approach to patient care. A shared electronic health record allows for immediate communication within this tightly integrated system including thirty-one regional clinics and Memorial Hospital. Employed physicians enjoy a competitive salary, outstanding benefits, and the freedom to practice medicine without the hassle of the business of medicine.

If living in beautiful Central Texas and practicing medicine in a collegial environment interests you, please contact: Pat Balz, Physician Recruiter, Scott & White Clinic. (800) 725-3627 or pbalz@swmail.sw.org. For more information on Scott & White, please visit our web site at www.sw.org. Candidates under consideration must complete a formal application process.

Scott & White is an equal opportunity employer.

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s U M M E R 2 0 1 0 | Te xas Fa mily Physician

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PHYSICIAN COMPENSATION TRENDS 2002-2009, SELECTED SPECIALTIES Orthopedic Surgery

dollars & cents

$500K

Ophthalmology Gasteroenterology $400K

Dermatology Cardiology: Invasive Family practice (without OB)

$300K

All primary care median compensation $200K

$100K

2002

2003

2004

2005

2006

2007

2008

2009

Source: Medical Group Management Association Physician Compensation and Production Reports

MGMA survey: Primary care physicians report pay increase in 2009

By Kate McCann

P

rimary care physicians, nurse practitioners, and primary care physician assistants experienced an increase in their compensation in 2009 while some specialists saw flat or slightly decreased payment. This comes from the latest Physician Compensation and Production Survey from the Medical Group Management Association.

The 2010 survey uses data from 2009.

Physicians in primary care specialties earned an average of 2.8 percent more in 2009, with internal medicine physicians receiving the biggest bump in this group.

Internal medicine physicians earned an average income of $197,000, increasing 3.08 percent this year. Physicians in pediatric/adolescent medicine had the second-highest growth of primary care, earning an average $191,400 and increasing 2.55 percent. Family physicians who do not practice obstetrics earned an average income of about $184,000, an increase of 2.41 percent in 2009. This is a 14.48 percent increase from 2005. Accounting for inflation, family physicians’ incomes increased an average of 2.77 percent in 2009 and 4.21 percent from 2005.

“Despite a convergence of economic factors, employers’ and payers’ increased commitment to preserve the ability of primary care physicians to do their important work has allowed their compensation to keep pace with inflation,” said William F. Jessee, M.D., F.A.C.M.P.E., president and CEO of MGMA, in a press release. “However, the 34 S U M M E R 2 0 1 0 | Te xas Fa mily Physician

continued threat of cuts to Medicare payments and its impact on private insurance reimbursement to all physicians impedes practices’ ability to deliver quality care to an ever-expanding patient population.”

Nurse practitioners earned an average $85,700, increasing 4.87 percent in 2009 and 21.9 percent since 2005. Physician assistants in primary care earned an average $89,000, up 1.75 percent in 2009 and 17.83 percent since 2005.

Physicians in obstetrics/gynecology and invasive cardiology were among the specialists who reported flat or declining incomes. OB-GYNs earned an average $282,600, declining 1.11 percent, and invasive cardiologists earned an average $481,878, down 0.20 percent.

The largest percent growth in compensation went to dermatologists, who earned an average of $413,600, a 12.28 percent increase. Dermatologists’ incomes have increased 23.75 percent since 2005, which MGMA attributes to dermatologists’ ability to offer elective procedures not covered by insurance and collect the full fee at the time of service, as well as an increased demand for these services. Similarly, ophthalmologists experienced a 7.7 percent increase in 2009, which could be attributed to the increasing popularity of laser refractive surgery and other non-covered services.

To purchase the report or view a synopsis, go to www. mgma.com. :

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 Insulin for Type 2 Diabetes in Children

and Adults

The Texas Diabetes Council is a leading resource in Texas for up-to-date diabetes news and information.

Now that information is even more accessible. Visit TDCToolkit.org to view or download diabetes treatment algorithms and guidelines, including recently adopted A1c Goals. Look to TDC as your premiere Texas provider of free physician and patient care materials.

Many are available for download directly from our website.

Visit TDCToolkit.org today.

 IV Insulin Infusion Protocol in the

ICU Setting

 ICU Insulin Orders

Read the Texas Diabetes Newsletter online or subscribe to our printed edition.

 Orders for Adults with DKA and

Hyperglycemic Hyperosmolar State

D I A B ET E S TO O L K I T

 Transition from IV to SQ Insulin  Exercise for Diabetes Prevention and Therapy  Hypertension

W i n t e r / S P r i n G 2 010

A PRACTITIONER’S REFERENCE

i n t h i S

updated algorithms at tdctoolkit.org Texas Diabetes Institute 2 announces 2010 continuing education program schedule

Resources for Healthcare Professionals with Patient Handouts | www.texasdiabetescouncil.org

TDC-0363 Tool Kit Cover_2009.indd 1

TDC Recommends A1c Goal Based on Patient Risk Factors 7/24/09 11:18 AM

Download the Diabetes Tool Kit or order copies.

 Lipid Treatment

in Children and Adults: A Simplified Approach

In October, the TDC adopted the A1c range illustrated below to assist healthcare professionals in determining appropriate A1c goals for their patients with diabetes. This latest recommendation takes into account the importance of individualizing A1c goals based on patient characteristics and comorbidities.

w Minimum Practice Recommendations Flow Sheet The recommended A1c range is reflected in a “Glycemic Goals” box found on each algorithm:

The TDC’s Medical Professional Advisory

Glycemic Goals

Subcommittee reviewed clinical evidence from

 Medical Nutrition for Prevention and Therapy  Weight Management for Overweight Children

i S S u e

TDC publishes new 11 A1c target range and

5th Edition

intervention trials, long-term follow-up trials, and

individualize goal based on patient risk factors

epidemiological data in recommending the range now referenced in the following algorithms: w

Glycemic Control Algorithm for Type 2 Diabetes Mellitus in Children and Adults

w

Insulin Algorithm for Type 1 Diabetes Mellitus in Children and Adults

w

Insulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults/Initial Insulin Therapy for Type 2 Diabetes Mellitus

and Adolescents

A1c

≤6%

<7%

<8%

FPG

≤110

120

140 mg/dL

2h PP

≤130

180

180 mg/dL

A1c Goals

A1c < 6-7% Intensify management if: • Absent/stable cardiovascular disease

 Prevention and Delay of Type 2 Diabetes in

• Mild-moderate microvascular complications • Intact hypoglycemic awareness • Infrequent hypoglycemic episodes

Children and Adults

• Recently diagnosed diabetes

Link to the TDC with new 4 web banners for tdctoolkit.org Results from the 2008 5 National Diabetes Education Program Survey of the Public’s Knowledge, Attitudes, and Practices Related to Diabetes

Texas Diabetes, the newsletter of the Texas Diabetes Council/Program, is published by the Texas Department of State Health Services in Austin.

Publication No. 45-11004.

A1c < 7-8% Less intensive management if: • Evidence of advanced or poorly controlled cardiovascular and/or microvascular complications • Hypoglycemia unawareness • Vulnerable patient (ie, impaired cognition, dementia, fall history)

A1c is referenced to a non-diabetic range of 4-6% using a DCCT-based assay. ADA Clinical Practice Recommendations.

Diabetes Care 2009;32(suppl 1):S19-20

Continued on page 2

 Diabetic Foot Care  Neuropathy Free patient materials are also available to order.

Working for a Texas free of diabetes and its complications.

a commercial driver’s license | New faithbased education resource addresses diabetes and chronic kidney disease

As a result of these recent revisions, the Diabetes Tool Kit, Fifth Edition (Revised August 2009) includes outdated versions of the algorithms listed above. Download the latest revisions to TDC algorithms and guidelines by visiting tdctoolkit.org and selecting “Algorithms and Guidelines.” n

Individualized goal based on patient risk factors

 Weight Loss for Adults

patients who 3 Assisting use insulin in obtaining

Please send news and information to: Texas Diabetes Texas Diabetes Council/Program MC 1965 Texas Department of State Health Services PO Box 149347 Austin, TX 78714-9347 Phone: 1-888-963-7111 ext. 7490 Fax: 512-458-7408 Email: richard.kropp@dshs.state.tx.us Internet: www.texasdiabetescouncil.org Texas Diabetes Staff: Richard Kropp, Editor

aca d emy update

If a frog had a back pocket …

It’s time for a political reality check

By Tom Banning TAFP Chief Executive Officer/Executive Vice President

This issue of TEXAS FAMILY PHYSICIAN features a series of political tutorials emphasizing the importance of grassroots activism and political action in order to build the kinds of relationships with elected officials that get the interest, attention, and oftentimes support of well-reasoned policy positions. Put another way, if you want to affect health care policy, you must get involved in the political process. It is that simple and that important.

The unwritten laws of politics are as immutable as the laws of nature. As Voltaire put it perhaps more eloquently, “hawks have always eaten pigeons when they have found them.” Understanding these three, albeit cynical, rules will help you break the code to why some bills survive the legislative process and some die before ever being filed.

Politics drives process that sets policy.

You’ve heard us preach this before, but this is the holy trinity of how things really work. Who we help elect and how strong our relationship is with them determines the rules of the legislative process—whether or not a bill will get filed, set for hearing, debated on the floor, signed by the Governor, etc. In turn, this means our policy options are limited by political and legislative opportunity. In other words, policy objectives—no matter how well-meaning—may only see the light of day if our politics are in proper order.

Legislative reforms are reactive, not proactive.

Legislative policy changes occur after the proverbial train wreck, plane crash, biblical plague, financial meltdown, oil rig explosion—you get the picture.

A politician’s first duty is to get re-elected.

Every legislative idea and every vote that is cast passes through a political filter that measures the potential electoral consequences of supporting or opposing one set of constituents while antagonizing another. A legislator may not always be influenced by the politics, but they will invariably weigh the political consequences (a potential career-ending vote) against the policy implications (passing a tax bill to fund indigent health care).

36 S U M M E R 2 0 1 0 | Te xas Fa mily Physician

Most physicians are understandably frustrated by the legislative process and think it is a fixed, insider game. I’ve heard it expressed many times from many different physicians: “If only they listened to me and supported my idea on how to fix health care, all would be right with the world.”

In a perfect world, our elected officials would make decisions based solely in the best interests of patients, but we don’t live in a perfect world and you can’t pass wishes. Politics and other considerations ultimately come into play. That’s how it works in the real world of practical politics and health care policy.

A veteran legislator, who to this day is still handing out one-liners and hard-earned wisdom to his less experienced colleagues on the House floor, is fond of reminding them that “if a frog had a back pocket he’d carry a pistol and shoot snakes.”

What he means, in my words, not his, is that good ideas will be devoured by the reptiles in the legislative swamp every time unless you can defend those ideas with more than mere words and good intentions. Or as Al Capone famously said, “you get more with kind words and a gun than kind words alone.”

Consider this: If all 5,000 members of TAFP gave $100 per year, a little more than a quarter a day, to our political action committee, the PAC would match and even exceed the political muscle of other influential professions and businesses. If only one-tenth of our members developed personal relationships with their elected officials, our grassroots presence would be transcendent. A legislator couldn’t swing a dead cat without hitting an involved family physician in his or her district armed and ready to work.

In the synergistic combination of activism and money, political action puts the pistol in the frog’s back pocket. :

Consider this: If all 5,000 members of TAFP gave $100 per year, a little more than a quarter a day, to our political action committee, the PAC would match and even exceed the political muscle of other influential professions and businesses. If only one-tenth of our members developed personal relationships with their elected officials, our grassroots presence would be transcendent. A legislator couldn’t swing a dead cat without hitting an involved family physician in his or her district armed and ready to work.

Patient-Centered Medical Home One step at a time.

Get started at www.aafp.org/PCMH. Featuring: Steps, Examples, Tools, What You’ll Need, Where to Go for Help, and When to Call an Expert

Practice Organization: • Create a balance sheet.

• Write a job description.

Health Information Technology: • E-mail patients.

• Begin e-prescribing.

Quality Measures: • Install data collection system.

• Use the system to identify opportunities for improvement.

Patient Experience: • Offer same-day appointments.

• Offer after-hours care.

TA F P p E R S P E C TIV E

My journey to family medicine

By Laci Waner, M.D.

W hen I was a child , there were two physicians in my small town and both were family physicians. Thus, I based my idea of a physician on these two men: a man who treats each member of an entire family, a community leader, wears boots, has a polished log with a saddle for kids to ride in the waiting room, and has a jar full of stickers and suckers for post-visit rewards. When I asked for a doctor’s kit one Christmas and set up my first clinic for my dolls and toys in my bedroom, it was this idea of a physician that I aspired to be—minus the man part.

As I grew into an adult and started my journey in medicine, I initially strayed from my lifelong interest in primary care. I was drawn to the instant gratification of surgery and the false security in the idea of limited, specific knowledge in a specialty. After exploring my interest in research, I embarked on my time in medical school much the same as any other student. I did not bargain for the expanded education I received from life while completing my school’s pre-clinical courses. The saying “sometimes life happens whether you are a student or not and whether you have a test or not” became more than just words to me. In addition to many educational experiences in medical school, I married my husband, Chris; gained a son we named Kylen; buried my father, Dudley; and gave birth to our second child, Addyx.

My third-year rotations, especially the one in family medicine, greatly influenced my decision to pursue my desired specialty. However, they cannot compare to the influence that life imposed.

I believe wellness to be incredibly important to families and communities. I was reared with the idea that culture, education, and wealth cannot be passed on without longevity of generations, and wellness is at the heart of these things. My father taught me that one of the reasons my family and ancestors had struggled was due to the fight for wellness. With length of life in the generations of a family, the older generations can support the younger ones while passing on culture, education, wealth, and the ability to focus on wellness that they worked during

their life to attain. When the life of an elder is cut short, the family loses this part of its richness. When the life of a child is cut short, the family loses a part of its future.

When a family is disabled by disease, it weakens the foundation of the future and cripples the richness of the past.

This idea sparked a passion in me for caring for all generations of a family, especially in underserved, uninsured, and minority populations.

This passion intensified into a fire when my father died unexpectedly in November of my second year. My choice of specialty has mirrored the gauntlet of grief I endured.

I initially moved away from family medicine, feeling that it was too much responsibility, too much knowledge was needed, and I lacked the ability to cut myself off from caring. I saw family medicine as a potentially overwhelming, heartbreaking specialty. Fortunately, I had a moment I refer to as my epiphany moment during my family medicine clerkship orientation. It occurred when the speaker used the quote, “People do not care how much you know until they know how much you care.” I realized I could not only “handle” family medicine, but I could excel for my patients as a family physician because I care and am passionate about their health and future.

I will never know everything, and I will walk handin-hand with families and grieve at times, but I will continue learning and working hard for each patient because I care. When I close my eyes and picture myself and my family 10 years from now, I envision a full scope family medicine practice in a rural Texas town complete with a jar full of stickers and a log horse. I see myself coaching my kids’ soccer teams, going on health mission trips, representing my town and patients at family medicine conferences, and advocating for wellness and healthy living in men, women, children, families, and my community. :

When I close my eyes and picture myself and my family 10 years from now, I envision a full scope family medicine practice in a rural Texas town complete with a jar full of stickers and a log horse.

38 S U M M E R 2 0 1 0 | Te xas Fa mily Physician

Laci Waner, M.D., is a first-year resident at Texas A&M Family Medicine Residency in Bryan,Texas. She is a graduate of UT Health Science Center in San Antonio.

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