Texas Family Physician Fall 2010

Roland Goertz, M.D., M.B.A., Installed As AAFP President

DEDICATED TO THE DELIVERY OF QUALITY HEALTH CARE

VOL. 61 NO. 4 FALL 2010

NURSE PRACTITIONERS SEEK

INDEPENDENT PRACTICE The 82nd Legislature Will Determine Who Can Practice Medicine In Texas

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Volume 61, No. 4

TEXA S

FAMILY PHYSICIAN FALL 2010

F E A T U R E S 17 Invest in preceptorships, invest in primary care When the 82nd Texas Legislature convenes in January, every budget item will be scrutinized. One program—the Texas Statewide Preceptorship Program—is increasing student specialty choice in primary care.

By Kate McCann

20 Cover: Forces amass for looming scope fight Nurse practitioners are calling for independent, autonomous prescriptive authority and the ability to diagnose patients without physician collaboration. Family physicians say collaboration works.

By Jonathan Nelson

26 Texas’ preceptorship program needs you Want to make a real difference in the future of family medicine? Host a pre-clinical medical student through the Texas Statewide Family Medicine Preceptorship Program.

By Rachel Dorn 12 STUDENT VOICE: Presenting research at WONCA 31 CASE MANAGEMENT: Case managers can help build the medical home 33 PRACTICE MANAGEMENT: The RACs are on the prowl 36 FOUNDATION FOCUS: Building the Foundation in 2010 33 NUTRITION: A new look at lactose intolerance 38 PERSPECTIVE: ACOs on the rise, family medicine can survive

D E P A R T M E N T S

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FROM YOUR PRESIDENT: Meet Dr. Gerdes, your new TAFP president

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IN THE NEWS: AAFP to award double CME credit through new program | Register to certify deaths online

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MEMBER NEWS: Mabry elected to third term as AAFP Speaker | Laredo physician joins TMF Health Quality Institute board | Improve diabetes care through Oklahoma and Georgia AFP program | Former TAFP physician emeritus dies | Dallas-area physician launches health reform blog | Houston physician passes away | Deuser wins AAFP Public Health Award

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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.

Lessons from the past guide the future An excerpt from the inaugural address of TAFP’s new president

By Melissa Gerdes, M.D. TAFP President

Officers President Melissa Gerdes, M.D. President-elect I. L. Balkcom, IV, M.D. Vice President Clare Hawkins, M.D. Treasurer Troy Fiesinger, M.D. Parliamentarian Dale Ragle, M.D. Immediate Past President Kaparaboyna Ashok Kumar, M.D., F.R.C.S. 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. Publications Intern Melissa Ayala Advertising Sales Associate Audra Conwell Contributing Editors Tom Banning Guy L. Culpepper, M.D. Rachel Dorn Lana Frantzen, Ph.D. Kathy McCarthy, C.A.E. Allison Peddle Bradley K. Reiner Teri Treiger, RN-C, MA, CCM, CCP 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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As your president for the next year, I will live and advance our vision and mission. I will be your faithful servant, listener, and even cheerleader. Fortunately, I have some experience in each of these roles. I am sure you have heard of the book “All I Really Need to Know I Learned in Kindergarten.” I like to say much of what I really need to know to be a family physician, I learned before medical school.

My very first job at McDonald’s prepared me well for service. I was born in Chicago where the famous Hamburger University is located. Consequently, I got to work with many young recently trained managers for the company. McDonald’s is actually all about brand recognition and service, concepts I very much respect and push forward in my job today.

I earned my bachelor’s degree in communication studies, an unusual major for a pre-med student, but I found it extremely helpful in learning how to listen to people.

It also helped me to understand human behavior and group behavior, tools I still use every day. While in college, I got my practice as a cheerleader for the Northwestern Wildcats. Drawing from non-medical experiences and from those around you (sometimes those not in medicine) is a good strategy to maintain a positive attitude as we do our challenging work.

I take the Academy’s vision statement seriously. It states: “The Texas Academy of Family Physicians is dedicated to the promotion of a health care environment that values the vital role of family physicians in providing quality, comprehensive care to all Texans.” I helped rewrite it with several other members of the Academy a few years ago and our board approved the final statement. There are five major areas where we need to focus over the next year: recognition and promotion, communication, education, advocacy, and workforce development.

Our recently rewritten mission statement gives us specific guidance in how the Academy can assist our members in these areas: The Texas Academy of Family Physicians unites the family physicians of Texas through advo-

cacy, education and member services, and empowers them to provide a medical home for patients of all ages.

The promotion of a health care environment that values the vital role of family physicians starts at home. I will help the Academy work through its many arms to appreciate and publicize the caring, personal, tireless work our physicians do every day. The Academy and your fellow physicians tremendously value the work done by family physicians. We are very fortunate to have the privilege of being such an intimate part of our patients’ lives.

We get to connect with people and help them achieve their personal health goals every day.

Yet, many family physicians do this work tirelessly without sufficient reward simply because they love it. It would be nice to receive some external validation for the great work Texas’ family physicians do. Sometimes we just need to show it a little better or more often. We need to promote the wonderful work our members do each and every day. Apply for an award.

Nominate a colleague for an award. Say thank you. Let your community know what you do. Donate time or money to what you believe in. The power of positivity is a strong force that we as family physicians should harness.

TAFP will take the lead, informing its members about our rapidly changing health care environment. In the very near future, all Texas family physicians will be wrestling with the vast changes that are upon the national health care scene. The Patient Protection and Affordable Care Act is long, large, and with far-reaching implications for our future. We anticipate confusion and even fear, but also opportunities over the next five to six years in family medicine. Again, TAFP is committed to helping Texas family physicians navigate through the bill and its provisions in a real way. The medical home is a huge part of this reform.

TAFP will guide members through the vast research outcomes and help them apply lessons to their own practices. cont. on page 8

Come practice with us !

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Primary care physicians, psychiatrists, advanced practice nurses and physician assistants Texas state supported living centers are looking for full- and part-time primary care physicians and psychiatrists, advanced practice nurses and physician assistants to fill vacancies across the state. We offer challenging opportunities, competitive salaries, and excellent benefits.

For more information contact: Julie Graves Moy, MD, MPH, FAAFP Medical Director 512-810-2533 julie.moy@dads.state.tx.us or Judy Garner, recruiter judy.garner@dads.state.tx.us

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Meet TAFP’s new president, Melissa Gerdes, M.D.

cont. from page 6

Our Academy will continue to provide first-class education for our members, a tradition of which we should be very proud.

Our members’ educational needs will be broader than ever in the coming years. Not only will they need basic and clinical science, but practice management, practice transformation, electronic health record guidance, financial management, even career advice.

As physicians’ needs broaden, TAFP will be at the leading edge, providing the answers and education in these new areas.

We must focus more than ever on our advocacy efforts. The next legislative session is going to be challenging with redistricting and budgetary concerns occupying much of our legislators’ time. However, we will remain strong advocates of our discipline and patients’ needs. We have some decisions to make as an Academy.

Where do we stand on scope of practice?

The practice landscape is changing. Nurse practitioners are seeking independent practice in Texas. Many of our members work with nurse practitioners today. How about the corporate practice of medicine? Our members work in very diverse practice arrangements in this state. Independent practitioners may have very different needs and concerns than do physicians employed by larger health systems. Over this next year, through proactive, respective, honest dialogue, we need to form the answers to these questions together.

Finally, let’s talk about workforce. We face a severe shortage of family physicians today and much more in the future.

The population of Texas is exploding, and unfortunately, the population of family physicians is not. I am proud of the advocacy work our Academy has done in the past, 8

fa l l 2 0 1 0 | T e x a s Fa mily P h y sician

including the recent passage of a very robust loan repayment program, which will certainly help. We depend upon our colleagues in academic institutions and the insight of our resident and student members to guide our Academy in ways to attract new students to family medicine.

Perhaps we need to reach students earlier than medical school, maybe in junior high and high school. Payment reform would certainly be helpful, but I do not think we need to wait for this reform to act. There are other motivators for students in choosing specialties. We need to understand and employ these motivators in new ways. The tide is definitely turning in our favor nationally, and we should ride it with the natural innovation of our members.

I will meet these challenges over the next year as your president. I have the benefit of having a superb team of officers and I am confident we will achieve our goals. We count on all of you to be part of that team. As I mentioned earlier, we are, as people, composites of our experiences and relationships with others who have influenced us. Get involved: get to know your colleagues, influence people.

Those who know me well will know that Walt Disney is a hero of mine and has been from a very young age. Today I do a little more serious Disney reading. One of my favorite books, “If Disney Ran Your Hospital: 9½ Things You Would Do Differently,” discusses how using Disney’s principles of customer service can be applied in the health care industry to improve patient experiences. As I embark on this next year, I would like to live the words of Mr. Disney: “The way to get started is to quit talking and begin doing.” :

Follow TAFP President Melissa Gerdes, M.D., on Twitter: Go to www.twitter.com/TAFP_ President to sign up to follow her weekly tweets about issues important to family physicians. Also, don’t forget that TAFP has a Twitter page. Go to www.twitter.com/ txfamilydocs and click “follow” to stay up to date on all Academy activities.

photo: JONATHAN NELSON

Melissa Gerdes, M.D., of Whitehouse is sworn in as TAFP President by past AAFP President Jim Martin, M.D.

Melissa Gerdes, M.D., is the medical director of Trinity Clinic in Whitehouse, Texas, and a staff physician at Mother Frances Hospital in Tyler. She previously served as an associate professor of medicine at the University of Texas Health Science Center at Tyler, where she also completed her family medicine residency.

Gerdes received a Bachelor of Science degree in Communications from Northwestern University in Evanston, Ill., and received her medical degree from Loyola University Stritch School of Medicine in Maywood, Ill. Gerdes’ practice was one of 36 chosen for TransforMED’s National Demonstration Project, a two-year pilot to determine whether patientcentered care would improve quality of care, physician satisfaction, and practice performance in the primary care setting. Gerdes’ practice emerged as a star and, after NDP concluded in 2008, she continues to mentor other family medicine practices interested in implementing TransforMED’s practice redesign recommendations.

Gerdes has been a member of the American Academy of Family Physicians since 1992 and a member of the Texas Academy of Family Physicians since 1996. Within TAFP, she has served as Chair of the Commission on Membership, on the Executive Committee from 1998-1999 and 2004-2005, and as Chair of the Section on Resident Affairs from 1998-1999, as well as the Section on Special Constituencies.

News Briefs AAFP to replace “2-for-1” CME credit program with outcomes-based credit program AAFP will end its popular 2-for-1 Evidence-Based Continuing Medical Education credit program at the end of the 2010 calendar year after nearly a decade in practice, the Academy has announced.

The decision was adopted by the AAFP Board of Directors in April 2009 following a recommendation by the Commission on Continuing Professional Development, and will go into effect Jan. 1, 2011. The 2-for-1 EB CME program began in 2002 when the Academy created the original standards for classifying clinical content.

According to an AAFP News Now article, the EB CME program is ending because it has accomplished its operating mission— incorporating principles of evidence-based medicine and improving medical practice and patient outcomes.

In its place, AAFP will launch a new program called Transition to Practice, which

will allow participants to earn double credit for AAFP Prescribed CME credit. In the current EB CME program, physicians could simply attend education programs and receive 2-for-1 credit; in Transition to Practice, they must illustrate how they applied their knowledge to gain the additional credit. Showing outcomes data is now a regular way of practice, rather than the exception, said AAFP Commission on Continuing Professional Development Chair Mark Stephens, M.D., of Bethesda, Md., in the ANN article.

“I don’t think this will make a significant change with how physicians get the required prescribed credits,” says TAFP Director of Education Anna Jenkins. “After the program ends, in order to receive the total credit required, it may be possible that some have to attend more educational programs approved for prescribed credit.”

After this year, physicians can still receive the required single credits they need each year by attending TAFP’s CME programs, including the four annual symposia: the C. Frank Webber Lectureship, Annual Session & Scientific Assembly, Primary Care Summit – Houston, and Primary Care Summit – Dallas/Fort Worth.

“TAFP will continue to work with our faculty to provide quality CME that is evidence-based,” Jenkins says.

For more information, read the AAFP News Now article about Translation to Practice on AAFP’s website, www.aafp.org. :

By Melissa Ayala, TAFP publications intern

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A student’s perspective: The importance of family medicine research

By Allison Peddle Presenting at the 19th WONCA International Conference of Family Doctors as a second-year medical student was a unique opportunity that I will never forget. My presentation was in the afternoon of a beautiful day in Cancun, Mexico at the same time as other insightful presentations, and I still had a packed room. I was honored to have so many people interested in my work. The number of questions after my presentation led to a delay in the rest of the presentations. This showed me the importance of my project and has inspired me to continue to do community-based participatory research in the future.

The summer after my first year at University of Texas Southwestern Medical Center, I was accepted into the Community Health Fellowship Program. The CHFP is a nine-week program in which first-year medical students learn the steps of community-based participatory research from getting approval from IRB to a final presentation and paper by doing their own project under the guidance of a mentor at UTSW and a community partner.

My project was a health needs assessment of Hispanic seniors at a local community center.

In the United States, the Hispanic senior population is increasing at an alarming rate.

This population is more likely to have a lower socioeconomic status, less education, limited health literacy and higher rates of chronic disease and depression when compared to younger age groups. The purpose of my project was to assess the health needs of Hispanic seniors attending Wesley-Rankin Community Center in Dallas, Texas. The specific aims included:

had an annual household income of less than $10,000. A majority of participants (77.9 percent) reported Medicare or public health insurance whereas 8.14 percent were uninsured. Over half of participants (61.5 percent) had limited-to-marginal health literacy.

The three most prevalent diagnosed conditions were hypertension (71.15 percent), arthritis (67.31 percent), and teeth problems (51.92 percent). Health literacy level was associated with transportation to doctor (p=0.013), attendance at Wesley-Rankin Community Center (p=0.0187), health care provider (p=0.048), and income (p=0.0075). Age was also associated with attendance (p=0.0028) and suggested activities (p=0.035).

Some of our conclusions could be generalized to the U.S. Hispanic senior population. General practitioners need to be aware of the high rate of limited to marginal health literacy when seeing Hispanic seniors and take precautions to make sure their patients understand their treatment. General practitioners should be aware of an association between health literacy and sociodemographic measures including: transportation to doctor, attendance, health care, and annual income. All Hispanic seniors should be screened for chronic disease such as hypertension, arthritis, dental problems, and depression when they come to a general practitioner. And finally, there is an association between attendance at a community center and health status.

Our specific recommendation to the WesleyRankin Community Center is that future health education programs for Hispanic seniors should focus on the top three reported health problems: hypertension, arthritis, and teeth problems. Also, the activities included in their senior citizen program should be age appropriate.

The unique opportunity to present my project at the 19th WONCA International Conference of Family Doctors was an amazing climax to my first community-based participatory research project. I met many general practitioners from all over the world who were inspiring to talk to. I met residents from England, a woman who works for the World Health Organization in Switzerland, and had a conversation in Spanish with a doctor from Colombia. I also learned about some research that is going on worldwide that will influence how we practice in the future, including some amazing work on decreasing the rate of abortions in Sao Paulo, Brazil.

Given the location of the conference in Cancun, Mexico, I also took some time to experience some sights. The group from UTSW went to Chitzen-Itza together one day, where we got to experience one of the new Seven Wonders of the World. We also enjoyed the beautiful white beach and blue water. The water was warm and so clear you could see the bottom. I celebrated daily with a real margarita and wonderful local cuisine; Mexican food in Texas will never meet my new standards. :

The unique opportunity to present my project at the 19th WONCA International Conference of Family Doctors was an amazing climax to my first communitybased participatory research project.

• Determining the prevalence of chronic disease and depression; • Measuring quality of life and health literacy level; • Determining whether there is an association between attendance and quality of life or health literacy and sociodemographic characteristics; and • Determining curriculum needs for future health education programs.

We conducted a cross-sectional survey of Hispanic seniors enrolled in the senior citizen program at the Wesley-Rankin Community Center. A 25-item health needs assessment was administered to 52 Hispanic seniors through 15-minute face-to-face interviews. Frequencies and percents were used to report sociodemographic characteristics of this population. Chi square and Fischer exact tests were used to measure associations between categorical variables.

Out of 140 enrollees in the senior citizen program, we interviewed 52 seniors (40 percent response rate). Eligible participants were aged 60 years or older and enrolled in the senior citizen program. The mean age of the participants (86.54 percent female) was 75.8 years. A majority of participants (90.3 percent) had less than nine years of formal education and 42.3 percent of participants 12 Fa l l 2 0 1 0 | T e x a s Fami ly Phys ician

Allison Peddle received a special travel grant from the TAFP Foundation to help fund her trip to WONCA.

m e mbe r n e ws

photo: JONATHAN NELSON

Former TAFP physician emeritus dies at 88 TAFP life member John E. Green, Jr., M.D., died on Aug. 15, 2010, at the age of 88. He practiced family medicine for over 58 years and was named the 2008 TAFP Physician Emeritus in recognition of his longtime service to the specialty of family medicine.

Green received his undergraduate degree from Texas A&M University in 1943 and his medical degree from the University of Texas Medical Branch in Galveston in 1948. He completed a surgical internship at Pearce County Hospital in Tacoma, Wash. Green served in the U.S. Air Force from 19501952 and completed tours of duty in Tokyo, Japan, and Guam.

In addition to his practice in Ballinger, Green also practiced in Meridian, Santa Anna, Coleman, Bronte, San Angelo, and Menard. His son, John Green, III, M.D., accepted the Physician Emeritus Award on his father’s behalf and told the audience about the elder Green’s passion for medicine. “Those of you who know my dad know that he is a quiet giant and never said very much. He couldn’t change the whole world, but he attempted to change the corner he lived in. For over 50 years he offered the people of Ballinger and west Texas a medical home and a place to seek medical care. He also strived through his work with TAFP to ensure that opportunity continued to be available to the people of Texas.”

In his community, Green was a longtime member of the First United Methodist Church of Ballinger. He served for 10 years as the city health officer of Ballinger and served on the Board of Trustees of the Ballinger Independent School District from 1955-1964. He was also a member of the Runnels County Medical Society, the Texas Medical Association, the American Medical Association, the Southern Medical Association, TAFP, and AAFP, and was a diplomate of the American Board of Family Medicine.

He was a member of the Ballinger Noon Lions Club for over 50 years.

Green is survived by his wife, Mary Anne; children, John E. Green, III, M.D., and wife Mary Elizabeth Lansdell Green, Ph.D., Perry Green and wife Paula Harral Green, Jan Green Haney, Ph.D., Peggy Green Fiveash, and Julie Green Rojas and husband Peter Rojas, M.D.; and many grandchildren and great-grandchildren. :

(from left) TAFP Delegate Lloyd Van Winkle, M.D., AAFP Speaker and TAFP past president Leah Raye Mabry, M.D., TAFP immediate past president, Kaparaboyna Ashok Kumar, M.D., and Paul Davis, M.D., of Dillingham, Alaska, enjoy the festivities at the hospitality suite event during the 2010 AAFP Congress of Delegates conference.

Mabry elected to third term as AAFP Speaker Leah Raye Mabry, M.D., R.Ph., of San Antonio, was elected to a third term as Speaker of the AAFP Congress of Delegates when the Congress gathered in Denver in September. The Speaker presides over the Congress, the Academy’s policymaking body. As an AAFP board member, Mabry will advocate on behalf of family physicians and patients nationwide to inspire positive change in the U.S. health care system.

A longtime leader on the state and national levels, Mabry served as AAFP Speaker in 2008-2009 and 2009-2010, as AAFP Vice Speaker from 2005-2008, is a TAFP past president, a past recipient of the TAFP Family Physician of the Year award and the TAFP Foundation Philanthropist of the Year award, and served three consecutive two-year terms as one of TAFP’s delegates to AAFP. Mabry is immediate past chief of staff and president of the medical board at CHRISTUS Santa Rosa City Center Hospital, and a faculty member at the CHRISTUS Santa Rosa Family Medicine Residency Program, San Antonio. She also serves as a clinical professor with the University of Texas Health Science Center, Department of Family Medicine, San Antonio.

Throughout the past decade, Mabry has represented the AAFP on numerous commissions, committees, and task forces, including AAFP’s Task Force on Health Care Coverage for All; Strike Force on Liability Reform; Task Force on Governance; and the commissions on Finance, Public Health, and Clinical

Policies and Research. She also was appointed as a member consultant to the U.S. Pharmacopia.

Mabry is a member of, and has served on numerous committees for, the American Medical Association, Texas Medical Association, National Association of Parliamentarians, Texas State Association of Parliamentarians and the San Antonio Unit of the National Association of Parliamentarians. She has served on the board of directors and public relations committee of the American Institute of Parliamentarians. She is a district reviewer for the Texas State Board of Medical Examiners, appointed to this position by Texas governors George W. Bush and Rick Perry.

She previously served on the Texas Department of Health Medical Education Subcommittee and the Texas Department of Health Tobacco Advisory Committee. She was a consultant to the National Institute of Health Center for Disease Control, Federal Drug Administration Forum: Development of Public Health Plan for Antibiotic Resistance and a member of the editorial board of the Journal of Family Practice.

Mabry earned her bachelor’s degree in pharmacy at the University of Texas at Austin, and her medical degree at the University of Texas Health Science Center at San Antonio. She completed her internship and residency at the Medical Center Hospital, San Antonio, and later completed her fellowship in teaching at the Faculty Development Center in Waco, Texas. : www.ta f p.or g | fa ll 2 0 1 0

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m e mb e r n e ws

Texas' own Roland Goertz, M.D., M.B.A., addresses his colleagues at the opening ceremony of the 2010 AAFP Scientific Assembly on Sept. 29, 2010, minutes after being sworn in as AAFP's 63rd president.

TAFP member Roland Goertz installed as AAFP president TAFP member Roland A. Goertz, M.D., M.B.A., F.A.A.F.P., of Waco, was inaugurated as the 2010-2011 president of the American Academy of Family Physicians at the 2010 AAFP Congress of Delegates meeting in Denver, Colo. Previously, he served three years as a director on the AAFP Board and one year as president-elect.

In his acceptance speech, Goertz told the gathered delegates, “This is our time.” He described the efforts of earlier generations of family physicians and how they relate to the Academy’s current position of strength.

“There is a confluence of forces creating incredible opportunities,” he said. “We are dealing all at once with a new set of realities in health care, a new political reality, and a new economic reality. The new health care reality is partly the realization that modern medicine will not always ‘fix us’ and the frustration of current shortfalls.

The new political reality is that improving health care is being pitted against the need to constrain governmental costs and 14

fa l l 2 0 1 0 | Te x a s Fami ly Phys ician

to reduce the federal deficit. And the new economic reality is, well, all you have to do is have a patient tell you they lost their job or home to know what it is.”

These political and economic realities present the perfect opportunity for family physicians to show their worth and value, he said.

“We and the other major primary care physician groups are the only ones offering a significant change in the current care delivery model, the patient-centered medical home.”

Goertz concluded his acceptance speech by proclaiming his optimism and hope for the future of family medicine.

“We know that the essence of what we do cannot ever be replaced by a test or a procedure of any kind. We know that coordination of care is valuable, and that we do it best. We know there are volumes of data from excellent studies that champion our value to patients. We know the public wants and needs who we are and what we

do. And we more than anyone else know the value a personal patient relationship has; it makes all the difference in the world. What we do is not just a job, it is a commitment, a vocation that we love and want to do.”

As AAFP president, Goertz will advocate on behalf of family physicians and patients nationwide to inspire positive change in the U.S. health care system. In his 26-year medical career, he has served as a physician in rural private practice, a family medicine residency program director at two highly regarded Texas residencies, and chair of the Department of Family and Community Medicine at the University of Texas Medical School – Houston.

For the past 14 years, Goertz has served as chief executive officer of the three foundations that oversee all operations of the Waco Family Health Center, which operates one of the oldest family medicine residency programs west of the Mississippi River. It provides care to more than 50,000 patients in

photo: JONATHAN NELSON

McLennan County, Texas. Goertz also holds an appointment at the University of Texas Southwestern Medical School at Dallas.

A member of the AAFP and TAFP since 1979, Goertz has served on numerous committees and commissions at the state and national level. He actively participated in and chaired the AAFP Commission on Education and Commission on Governmental Advocacy. He was a member of the AAFP Task Force to Enhance Family Medicine Research. Goertz served as TAFP president from 1994 to 1995, and as a delegate or alternate delegate to the AAFP Congress of Delegates from 2000 to 2006. He is past president of the McLennan County Medical Society.

Goertz chairs the Texas Higher Education Coordinating Board’s advisory committee on family medicine residencies and is a past president of the Texas Association of Community Health Centers.

He represented family medicine on the Council of Academic Societies of the Association of American Medical Colleges from 2000 to 2006. He also served as a member and chair of the Texas Medical Association’s Committee on Physician Workforce and Distribution, and was a member of its Council on Medical Education.

Locally, Goertz is a member and past board chair of the Greater Waco Chamber of Commerce. He is a member of the Waco Business League, the Waco Downtown Rotary Club, and serves on the board of the Cooper Foundation, a local philanthropic organization.

Both AAFP and TAFP have recognized Goertz for his hard work and dedication to the specialty. He has received TAFP’s Presidential Award of Merit Award (1989), TAFP Political Action Committee Award (2003), TAFP Foundation Philanthropist of the Year Award (2004), and AAFP’s Robert Graham Family Physician Executive Award (2006). He also was awarded the “GoldHeaded Cane” by the McLennan County Medical Society and Alliance in 2010.

Goertz graduated from medical school at the University of Texas Health Science Center – San Antonio in 1981.

He then completed a residency in family medicine at John Peter Smith Hospital in Fort Worth. He subsequently completed a clinical teaching fellowship in family medicine in 1986 and received a master’s degree in business administration from Baylor University in 2003. Goertz has the AAFP Degree of Fellow, an earned degree awarded to family physicians for distinguished service and continuing medical education. :

TAFP member elected board president of TMF Health Quality Institute TAFP member David E. Garza, D.O., has been elected president of the TMF Health Quality Institute David Garza, D.O. Board of Trustees.

TMF Health Quality Institute is a nonprofit health care consulting company. Its 18-member board is comprised of physicians elected from the TMF membership, non-physicians, and consumer representatives. Garza has served on the TMF board since 2006 and he will serve a one-year term as president.

“Dr. Garza has strong experience as a leader and will build on the guidance provided by our recent president, Dr. Maya

Bledsoe,” Tom Manley, CEO of TMF Health Quality Institute, said in a press release.

“His active involvement in local, state, and national health care will provide valuable insight to lead TMF through its next phase of growth in the era of health care reform.”

In his community of Laredo, Garza is a solo practice family physician. He has been on active staff at Doctors Hospital of Laredo and Laredo Medical Center since 1993 where he has served in various leadership positions including chief of staff, chairman of the board of trustees (DHL), and chief of family medicine (LMC). Garza was awarded his Doctor of Osteopathic Medicine degree by the University of North Texas Health Science Center Texas College of Osteopathic Medicine. :

Blog alert: “Health Scare” online TAFP member Richard Young, M.D., of North Richland Hills, gives a family physician’s perspective on the health care reform debate on a non-partisan website and blog titled, “American Health Scare: How you are scared into buying health care you, your employer, and your country can’t afford.” Young challenges readers to consider the “appropriate role” of health care in our society, asserting that “the primary solution to expensive health care is that the relationship between doctors and patients must change.”

Access the website and blog at www.healthscareonline.com.

Improve diabetes care, patient education through GO! Diabetes The GO! Diabetes program, an initiative of the Georgia and Oklahoma chapters of the American Academy of Family Physicians, is looking to expand to Texas family medicine practices and residency programs. In its third year, the GO! Diabetes program enables family medicine residency programs and private practices to identify, initiate, and implement clinical, practice, and system-based quality improvements to enhance their education and care of patients with diabetes.

GO! Diabetes was founded in 2008 and is funded by an educational grant

by Sanofi Aventis. In 2010, the program expanded to include 48 family medicine residency programs from 15 states and a pilot program for 37 private practices in Georgia and Oklahoma. It is driven in the individual practice or residency program by self-appointed “change agents.”

The program uses METRIC, for its data-gathering and measurement ability.

METRIC is an approved, online quality improvement tool from AAFP and a requirement for ongoing board certification for

family physicians (Part IV of the American Board of Family Medicine’s Maintenance of Certification). It provides step-by-step instructions on how to review patient charts, assess performance, build and implement an action plan and reassess progress in the months following the onsite training session in the change agent’s chosen practice improvement area.

“The benefits of the GO! Diabetes program are found in its simplicity, structure and support,” said Sam Blackstock, executive vice president of the Oklahoma Academy of Family Physicians, in a press release. “With incentives and stipends for our change agents built into the program, there’s no investment except time. While improving our processes for care, we’re also chipping away at the barriers to care for patients with diabetes and that’s priceless.”

If your private practice or residency program is interested in participating in the 2011 program, please contact Susan Reichman, B.S.N., GO! Diabetes program director, at susan@godiabetes.org, or visit www.godiabetes.org. : www.ta f p.or g | fa ll 2 0 1 0

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m e mbe r n e ws

TAFP life member Joseph T. Ainsworth, M.D., of Houston, died on Aug. 31 at the age of 93. “Doctor Joe,” as he was known by friends and patients, practiced family medicine for nearly 30 years. In 1977 he joined the staff of MD Anderson Cancer Center in Houston, serving as vice president for patient care until his retirement in 1989.

Ainsworth grew up in Mississippi and attended Tulane University School of Medicine from 1938-1942, where he was awarded his medical degree. After serving an internship at Charity Hospital in New Orleans in 1943, he joined the Army Air Force as a Flight Surgeon and retired in 1946 with the rank of Major. He completed a residency in surgery and medicine at Lafayette Louisiana General Hospital and later moved to Houston.

Ainsworth was active in several medical organizations including the Texas Academy of Family Physicians, the Texas Medical Association, the Harris County Medical Society, and the American Medical Association. He received TMA’s Distinguished Service Award and AMA’s Benjamin Rush Community Service Award.

In his community, Ainsworth was active in the Houston Livestock Show and Rodeo for over 40 years as a volunteer and in various leadership positions including chairman of the Palomino Horse Committee and Health Committee and vice president of the show. He later served as president and chairman of the board of the organization and was named a lifetime member of their executive committee. He was also a member of the St. Vincent De Paul Catholic Church for 50 years.

Ainsworth is survived by his children, John and wife Sandra, and Michael and wife Karen, and grandchildren Cody and wife Mandi, Joseph, and Lindsay. He was married to the late Kathryn Gene Ainsworth for 59 years. :

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photo: JONATHAN NELSON

Career family doctor and rodeo man passes away

TAFP’s Tamra Deuser, M.D., receives the AAFP Public Health award from AAFP President Lori J. Heim, M.D., of North Carolina. After installing AAFP’s new president, Roland Goertz, M.D., Dr. Heim ascends to the position of chair of the AAFP Board of Directors.

TAFP member awarded AAFP Public Health Award Tamra Deuser, M.D., of Flower Mound, a private practice physician and owner of MaxHealth Family Medicine, was awarded the 2010 AAFP Public Health Award during the 2010 AAFP Congress of Delegates in Denver, Colo. She received TAFP’s Public Health Award in 2009. Both awards recognize individuals who are making extraordinary contributions to the American public’s health.

In a congratulatory letter, AAFP recognized her long record of service and dedication to the specialty and her patients.

“Among your many accomplishments, the board noted that you are a wonderful role model to family physicians through your professional and personal life by promoting public health and wellness. You are a proponent and participant in many important public health programs.”

In addition to her years of service on TAFP’s Commission on Public Health, Deuser represents the specialty of family medicine on the Texas Immunization Stakeholder Working Group, a coalition of public and private stakeholders that meets quarterly to discuss the current state of immunizations in Texas, identify shortages and disparities among different populations, and propose strategies to increase immunization education, awareness and implementation across the state. Through this group she facilitated TAFP’s participation in a project to educate physicians and patients on pertussis vaccinations.

Deuser has also hosted multiple Hard Hats for Little Heads events in and around her community. Hard Hats for Little Heads is a public safety initiative led by the

Texas Medical Association that provides physician volunteers with the materials to present safety courses and hand out bicycle helmets to local children to promote helmet use during biking, skating, and other wheeled activities.

She is on the Board of Directors for Christian Community Action, an organization that provides services to the poor in southern Denton County to help stabilize and transform their lives. Deuser has served as medical director and currently serves on CCA’s Adult Health Center Advisory Committee.

At the awards ceremony, Deuser said that much of her commitment to public health comes from her desire to serve others, her choice to get involved with several worthy groups, and the natural leadership of her profession. “As family physicians we are the leaders of public heath for our local communities, our state and our country,” Deuser told the audience. “We are the only doctors that take care of everyone. You’re never too old or too young, too well or too sick to be cared for by a family physician. No one else is in the position to care for everyone, so we are the leaders of public health and we are the leaders of health care change.”

Deuser received her medical degree from the University of Tennessee Health Science Center College of Medicine in Memphis, Tenn. and her undergraduate degree from the University of Texas at Austin. She completed her residency in family medicine at San Jacinto Family Practice Residency in Baytown, Texas. :

One initiative, the Texas Statewide Preceptorship Program, makes a quiet but significant impact on student specialty choice for a relatively small investment of state funds. Plus, the turnaround for a medical student from preceptorship to primary care practice can be as short as five years.

As the 82nd Texas Legislature convenes in January 2011 and the state faces a multi-billion dollar shortfall, proponents of the program encourage state leaders to take a careful look before sending the preceptorships back to the chopping block.

photo: KATE McCANN

With federal health care reform expanding insurance coverage to an estimated 4.2 million Texans over the next four years and a dwindling pipeline of primary care physicians to care for this newly insured population, increasing the number of medical students choosing careers in primary care must be one of the state’s top priorities.

Austin family physician Mark Hutchens, M.D., participates in the Texas Statewide Family Medicine Preceptorship Program.

A small investment for a large return: The Texas Statewide Preceptorship Program

By Kate McCann

T

he Texas Statewide Preceptorship Program provides funding to first- and secondyear medical students to spend up to four weeks in a primary care physician’s office experiencing the daily life and work of doctors in the specialties of family medicine, general internal medicine, or general pediatrics.

Because many of these pre-clinical students have never experienced medicine outside of the academic setting, daily tasks mostly include observation, taking patient histories, learning to formulate treatment plans, identifying early diagnoses for common disorders, and polishing presentation skills.

More than witnessing the daily routine of their volunteer physician preceptor, the students gain one-on-one mentorship and a glimpse of “realworld medicine.” Many leave their preceptorship with a very different idea of primary care.

This was the case with Travis Bias, D.O., currently a third-year family medicine resident and co-chief of his residency class at Memorial Family Medicine Residency Program in Houston. He entered medical school wanting to become an orthopedic surgeon, dismissing family medicine as monotonous and boring. He was also concerned about repaying his medical education debt once he graduated and believed,

like many others, that he had to pursue a subspecialty to make a decent salary; a career in primary care could not be lucrative.

Bias says that his family medicine precep­ torship, a requirement of his medical school curriculum, was what made him realize he could pursue this career. His preceptor earned a generous salary his first year out of residency and had a well-run, business-savvy practice.

Seeing this made it seem “easy,” Bias says. “It was the only reason I thought about family medicine.”

Now Bias looks forward to the day he has an established family medicine practice when he can volunteer to be a preceptor, passing on his positive experience for the next generation of physicians. “The preceptorship is not to teach you medicine; it’s to teach you about the real world of medicine, the business of medicine, the humanitarian side of medicine.”

Authorized through the Texas Education Code, the Texas Higher Education Coordinating Board oversees the three primary care precep­ torship programs. THECB receives an appropriation from the state to cover administrative costs and student stipends—currently $1,000 for rural preceptorships and $750 for urban— and contracts with three organizations that www.ta f p.or g | fa ll 2 0 1 0

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operate the programs for each specialty: the University of Texas Health Science Center at Houston for family medicine, the Texas Chapter of the American College of Physicians for internal medicine, and the Texas Pediatric Society for pediatrics.

The Texas Statewide Family Medicine Preceptorship Program has been in operation for the longest of the three, having accepted its inaugural class in 1980. The General Internal Medicine Statewide Preceptorship Program and the General Pediatric Preceptorship Program were both created in 1995. All together, the programs have placed nearly 9,000 students in primary care preceptorships across the state.

While impressive, funding depends on the will of the Texas Legislature, and budget reductions over the past decade have put a noticeable dent in student participation. The most damaging cut to the preceptorship programs came during the 79th Texas Legislature in 2003. This was the case for most state initiatives at the time, says Stacey Silverman, Ph.D., THECB senior director of academic research and grant programs. In her previous position at the coordinating board, Silverman oversaw the preceptorship programs, and she was on staff when funding was cut in half from $1.94 million in fiscal years 2002-2003 to $997,000 in 2004-2005.

“These outcomes show that the only way to promote family medicine is to get into the medical schools and change the curriculum so the students have more exposure to family medicine, or to keep offering these programs where they get this really early exposure. I’ve had several students who have told me their preceptorship completely changed their mind about family medicine, just having that experience they wouldn’t have otherwise had.”

— Rachel Dorn, TSFMPP coordinator This cut occurred as a result of the $10 billion state budget deficit lawmakers faced in 2003, caused mainly by the national economic recession and low sales tax revenue. “In the second year of the 2002-2003 biennium, we had to reduce funding,” Silverman says.

“For fiscal years 2004-2005, the Legislature again faced a shortfall in funding and as a result, many if not all [state] programs received funding reductions.”

Staff from the coordinating board and the primary care precep­ torship programs brainstormed ways to deal with the cut, responding with streamlined administrative tasks and reduced student stipends.

More importantly, the reduced funding meant the programs could only match a little more than half of the students previously enrolled, causing the number of students participating in the preceptorships to plummet from just over 800 in fiscal 2003 to roughly 500 in fiscal 2004. They received another 10-percent cut in 2006-2007 to $904,000 where funding has remained until the current biennium.

With no new money available, student participation has remained flat for the most part, standing at 452 in fiscal 2009.

In the face of the current budget shortfall, state leaders asked all state agencies in January 2010 to propose a 5-percent overall reduction in their general revenue spending for the 2010-2011 biennium. While some THECB programs were cut completely, the state18 Fa l l 2 0 1 0 | T e x a s Fami ly Phys ician

wide preceptorships withstood the baseline 5-percent reduction, which totaled just over $45,000 and will come out of the programs’ 2011 budgets. The effect on GIMSPP alone will mean the number of medical students able to be matched into an internal medicine preceptorship with funding will drop from 90 in 2010 to about 40 in 2011, according to staff.

Now state leaders are preparing for an even worse budget scenario for 2012-2013—a shortfall that experts predict could fall between $18 billion and $22 billion, or 10 to 12 percent of the state’s total $180 billion budget—and have asked agencies to make further reductions in their legislative appropriation requests, or LARs. As a result, THECB’s proposed 2012-2013 LAR trims a combined 10 percent from the preceptorships for the next biennium, which could cut 85 more spots from the program.

In total, if this cut goes through, funding for preceptorships will have decreased 60 percent in 10 years, not accounting for inflation, without any recovery of lost funds.

TAFP lobbyist Marshall Kenderdine stresses that the reason for the reductions is not lack of knowledge or support for the program.

In the latest budget reduction, THECB ranked the preceptorships high on their priority list of programs to spare. “It’s not that any legislator is against funding preceptorship programs, it’s just that there are a number of programs competing for a limited number of state resources,” Kenderdine says.

Fortunately, says Gene Stokes, M.D., chair of the committee that oversees the GIMSPP, the programs have the data to prove their worth. Speaking specifically about GIMSPP, “It does increase the number of applicants to primary care programs, it does increase the number of primary care doctors trained who eventually stay in Texas, and it does have an influence on the number of doctors who enter rural and underserved areas.”

Each year, students and preceptors fill out an exit survey about their experience. According to these surveys, of the more than 1,400 medical students who completed a general internal medicine preceptorship between 1999 and 2006, 40.6 percent of them enrolled in an internal medicine residency program, 26.4 percent of them said they intended to practice primary care, and 82 percent of them intended to stay in Texas.

Pediatrics report similar findings: 37 percent of the almost 1,400 medical students who completed a pediatric preceptorship between 1999 and 2009 entered a pediatric residency and 62 percent stayed in Texas. For family medicine, of the 238 medical students who completed family medicine preceptorships in 2009, 93 percent said the experience made them more receptive to primary care as a career.

A study by UT Houston published in the Journal of Academic Medicine in 2004 took a critical look at the family medicine program between 1992 and 2000. The authors concluded that “the proportion of students choosing family practice residencies was significantly greater [among participants] than among nonparticipants.”

The authors tracked more than 10,000 students who graduated from eight Texas medical schools between 1992 and 2000, finding that 52 percent of them chose family medicine, general internal medicine, or pediatrics. Of the roughly 2,500 who participated in the preceptorship program, 27 percent chose family medicine residencies compared with 15.7 percent who chose family medicine without having participated in the preceptorship program.

In terms of increasing the primary care workforce, the authors found, “If the students who participated in the [TSFMPP] had selected family practice residency at the same rate as had those who did not participate, over 300 fewer students would have chosen family practice careers.” In essence, without the influence of the preceptorship program, the state shortage of primary care physicians would be even worse.

“These outcomes show that the only way to promote family medicine is to get into the medical schools and change the curriculum so the students have more exposure to family medicine, or to keep

PARTICIPATION AND FUNDING FOR TEXAS’ PRIMARY CARE PRECEPTORSHIP PROGRAMS Since 2003, funding has been cut by 53.4%, and total participation has dropped by 44.2% $1,000,000

Annual Appropriation

400

$800,000

Family Medicine General Internal Medicine General Pediatrics

300

Projected 10% cut for 2012-2013 budget

$600,000

200

$400,000

100

$200,000

0

Annual Appropriation for Preceptorship Program

Number of Participants in Each Preceptorship Program

500

0 2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Check out the Primary Care Coalition issue brief in support of the Texas Primary Care Preceptorship Programs on the advocacy resources page of www.tafp.org. offering these programs where they get this really early exposure,” says Rachel Dorn, statewide coordinator for TSFMPP. “I’ve had several students who have told me their preceptorship completely changed their mind about family medicine, just having that experience they wouldn’t have otherwise had.”

Austin family physician Mark Hutchens, M.D., agrees, pointing out shortfalls in the nation’s medical school curriculum. “The nature of medical education in our country is that we’re more focused on specialty care and all of our training is done in care settings where they’re more focused on that,” he says. “I think most students don’t have an idea of what they want to do and they’re not exposed to primary care medicine as a whole until they finish their other specialty rotations.”

While these programs can’t solve the workforce crisis alone, they do have a significant role in correcting students’ false perceptions of primary care early in their medical careers, spurring interest in these specialties that they might not have considered previously. And these gains can be achieved with a relatively small investment by the state.

As Stokes points out, “This is incredible for $2-or-$3 million to have the kind of impact we can have on primary care in the state of Texas.” A specialist himself, he says he is “sold on the idea of primary care” and its ability to provide higher-quality, lower-cost care than can be provided by a group of specialists. “This is definitely the penny of medicine for the pound of cure. … [Legislators] have an opportunity to make an impact on the state of Texas and we can’t quite get them to hear this message.”

The Texas Primary Care Coalition, which includes TAFP, the Texas Chapter of the American College of Physicians, and the Texas Pediatric Society, asks the Texas Legislature to consider the future of the state’s primary care workforce and the economic benefit enjoyed by communities with access to high-quality primary care,

and restore funding for the Texas Statewide Preceptorship Program to 2002-2003 levels. This would require investing $1 million per year, or $2 million per biennium. Kenderdine says, “It’s a small investment for a relatively large payoff, which also coincidentally helps to meet our workforce needs going forward.”

“In my opinion, I don’t think $2 million should be a ceiling,” Stokes says. “I think they ought to look at a $5 million investment.

It’s such a small amount of the total [state] budget, but the impact can be absolutely incredible to our cause.”

While each of the three programs faces unique operation challenges to ensure an adequate volunteer corps of preceptors, student applicants, and staffing, they share a common worry: continued funding.

With further reductions, “we’d have to limit the number of preceptorships offered, limit travel money, and do less recruiting and promotion,” Dorn says. Reducing the amount of student stipends is not an option. “If we compromise the amount of stipends, we would have no student interest. Or we’d just have the students who are going to go into family medicine regardless. Our goal is to get the students who are on the fence and bring them in.”

Amy White, director of the pediatrics preceptorship, says decreased funding means the programs lose their edge. “The more students we get through the program, the more exposure students receive to the primary care field. The less money we have, the less opportunity we have to do so.”

“The physicians see it as the future of internal medicine and if this program gets cut, it would be devastating,” says Gena Girardeau, executive director of the Texas Chapter of the ACP. “A bigger concern is for the patients of Texas. If we don’t have enough internal medicine and primary care doctors, the general population won’t get the care they need or deserve.” : www.ta f p.or g | fa ll 2 0 1 0

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“Professional nursing� means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.

Texas Nursing Practice Act, Subchapter A, Sec. 301.002.

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It’s no secret that Texas suffers from a shortage of primary care physicians, and that as health reform initiatives are implemented over the coming years, the demand from newly insured patients will put even more strain on the system. Nurse practitioner organizations are seizing this opportunity to demand that their members be granted the authority to diagnose and treat patients without physician collaboration, and they are receiving significant support.

BY JONATHAN NELSON

R

ecent articles in the San Antonio Express-News and the Austin American-Statesman are just the latest of a spate of news stories touting the possible benefits of removing all requirements that nurse practitioners collaborate with physicians. This fall, AAFP had to fight openly to convince the National Board of Medical Examiners to reconsider several policy statements asserting equivalence between physicians and graduates of doctorate of nursing practice programs.

In early October, the Institute of Medicine released a controversial report, “The Future of Nursing: Leading Change, Advancing Health,” which called for states to remove scope of practice barriers on nurse practitioners. The report drew immediate criticism from AAFP, TAFP, and the American Medical Association.

“The report simply says, ‘Do away with all blocks on full scope of practice. Do away with anything that prohibits an advanced nurse practitioner from having direct patient care or direct licensing,’” said AAFP President Roland Goertz, M.D., M.B.A., in an Oct. 6, 2010, AAFP News Now story. “It doesn’t mention anything about how to maintain competencies or ensure patient safety.”

“Nursing, as a whole, is not just about advanced practice nursing,” Goertz went on to say. “In my community, the largest need from a nurse staffing standpoint is not advanced nursing degree people but bedside nursing—nursing that works side-by-side with teams of practices in the area.”

AMA board member Rebecca J. Patchin, M.D., made a similar statement on Oct. 5, 2010. “With a shortage of both physicians and nurses and millions more insured Americans, health care professionals will need to continue working together to meet the surge in demand for health care. A physician-led team approach to care— with each member of the team playing the role they are educated

and trained to play—helps ensure patients get high-quality care and value for their health care spending.”

Texas is one of 34 states that require nurse practitioners to collaborate at some level with physicians if they are to engage in diagnosis and prescribing. Earlier this year, the Associated Press reported that 28 states were considering legislation that would remove those requirements.

Texas lawmakers will almost certainly consider similar legislation when the 82nd Texas Legislature convenes in January, 2011. For physicians, the question of giving nurse practitioners the authority to diagnose and prescribe without physician collaboration is not a fight over turf; it is an issue of quality and safety.

Family physician Sandra Esparza, M.D., is in private practice with her husband, a pediatrician, in Round Rock. A young woman complaining of frequent urination recently sought treatment from Esparza after seeing three different nurse practitioners at a retail health clinic over as many weeks. The patient claimed that at each visit, the nurse practitioner on duty checked her urine, told her she had a urinary tract infection, prescribed an antibiotic, and said the infection should clear up in a few days. And each time, the symptoms persisted.

“She finally got frustrated because they weren’t really doing anything, so she came to see me,” Esparza says. “She had a very large dermoid tumor on her ovary, and she was such a thin young woman you could actually see it protruding from her abdomen. She was in surgery that night.”

The tumor was the size of a small grapefruit, Esparza says, and it had been pressing against the patient’s bladder causing her symptoms. Three nurse practitioners on separate occasions had missed the diagnosis completely. www.ta f p.or g | fa ll 2 0 1 0

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In another recent case, Esparza saw a male patient complaining of pain and swelling in his cheek. He had seen a nurse practitioner at the same retail health clinic who had diagnosed him with an enlarged lymph node and prescribed a round of antibiotics. The treatment had not affected his symptoms.

“Anyone who has studied anatomy knows there are no lymph nodes in the center of the cheek,” Esparza says. The patient had a salivary gland stone, and with the application of warm compresses, the swelling was alleviated.

“These are nurses who haven’t taken full anatomy and physiology. My husband and I like to say, ‘everybody wants to be a doctor, but nobody wants to go to medical school.’”

Barbara Pierce, M.D., a family physician in College Station, tells of a recent patient who arrived at her clinic in an ambulance. The patient was a resident in a nursing home who had been seen by a nurse practitioner because pus was seeping from her ear. The nurse practitioner diagnosed the patient with serous otitis and referred her to an ear, nose, and throat specialist.

“Somehow the nursing home sent her to me instead; a little Alzheimer’s dementia lady, wheeled in on a stretcher to my office with her contractures and frantic moans,” Pierce says. With a quick glance, Pierce confirmed the diagnosis of otitis externa and prescribed antibiotic ear drops.

“If a nurse practitioner whose primary job is in a nursing home cannot treat a simple otitis externa, and sends a weak little elderly woman on a traumatic ambulance trip across town for evaluation, how can we be confident in her care of more complex issues with these often complicated nursing home patients?”

Education and training are the difference Cases like these are why physicians question the wisdom of granting nurse practitioners the authority to diagnose and prescribe independently. Rodney B. Young, M.D., is an associate professor and the regional chair of the Department of Family and Community Medicine at Texas Tech University Health Science Center School of Medicine at Amarillo. He agrees that nurse practitioners are a valuable part of the solution to Texas’ shortage of primary care, but that the Legislature should continue to require them to practice as part of a coordinated team with appropriate physician collaboration rather than lowering the standard for the practice of primary care.

“There are many excellent clinical nurse specialists who practice surgical subspecialties such as neurosurgery and orthopedics with physicians,” he says. “Many of them are so experienced that they could practically perform some of the surgeries themselves, yet there is not a reasonable person out there who thinks that would be a good idea. Primary care is no less complicated than surgery; it’s simply different, and more cognitive than technical in most cases.”

“Pharmacy technicians can dispense most prescriptions just as well as pharmacists, but they are not the same,” Young says.

“Physical therapy techs can provide many of the same treatments and modalities as the PTs themselves, but they are not the same.

Paralegals know many of the same legal issues as lawyers, but they are not the same. Nurse practitioners can know a lot about primary care, but they are not primary care physicians.”

The difference is in the training. While nurse practitioners are trained to emphasize health promotion, patient education, and disease prevention, they lack the broader and deeper expertise needed to recognize cases in which multiple symptoms suggest more serious conditions. Family physicians are trained to provide complex differential diagnosis, develop treatment plans that address multiple organ systems, and order and interpret tests within the context of patients’ overall health conditions.

This expertise is earned through the rigorous study of medical science in the classroom and the thousands of hours of clinical study in the exam room that medical students and residents must complete before being allowed to practice medicine independently.

22 Fa l l 2 0 1 0 | T e x a s Fami ly Phys ician

As described by AAFP in policy documents addressing scope of practice issues, patients can depend on and expect a level of expertise and quality from doctors because primary care physicians throughout the United States follow the same highly structured educational path, complete the same coursework, and pass the same licensure examination.

There is no such standard to achieve nurse practitioner certification, as their educational requirements vary from program to program and from state to state. Nurse practitioners normally receive their education through a one-and-a-half year to three-year degree program. Some complete this education through online degree programs rather than attending an institution. According to research conducted by AAFP, during their education, nurse practitioners experience between 500 and 1,500 hours of clinical training. At the completion of medical school and residency training, a family physician has experienced between 15,000 and 16,000 clinical hours.

A 2007 study published in the American Journal of Nurse Practitioners reported that more than half of practicing nurse practitioners responding to a survey believed they were “only somewhat or minimally prepared to practice” after completing either a master’s or a certificate program.

Another survey of practicing nurse practitioners published in the Journal of the American Academy of Nurse Practitioners in 2004 showed that in the area of pharmacology, 46 percent reported they were not “generally or well prepared” for practice. “In no uncertain terms, respondents indicated that they desired and needed more out of their clinical education, in terms of content, clinical experience, and competency testing,” the authors wrote. “Our results indicate that formal NP education is not preparing new NPs to feel ready for practice and suggests several areas where NP educational programs need to be strengthened.”

Linda Siy, M.D., assistant professor in the Department of Community Medicine at the University of North Texas Health Science Center in Fort Worth, trains third-year medical students as they complete their family medicine clerkships. She points out that many of the nurse practitioners publicly making the case for autonomous practice are at the top of their field.

“They are the instructors; they are the ones with the most credentials; they are the ones with the most clinical experience,” she says. “I would probably feel comfortable sending any one of my family members to any one of them. But they’ve had the benefit of working in a system where there is physician supervision.”

These are not the nurse practitioners one should imagine when considering autonomous practice, she says. “You have to think about the nurse practitioners who have just graduated.” When a nurse practitioner completes education, he or she has about the same number of clinical hours as a third-year medical student.

“I wouldn’t trust a third-year medical student to do primary care without any supervision,” Siy says. “No way.”

Could autonomous practice by NPs save the state money?

As state officials contemplate a budget shortfall for the next biennium of between $18 billion and $24 billion, bending the health care cost curve will be a major goal of any change in health care policy in the next Legislature. Nurse practitioner organizations claim their members provide cheaper care than physicians, and that if given autonomous practice authority, they could cut state health care expenditures.

Pediatrician Ernest D. Buck, M.D., of Corpus Christi, disagrees. He is the medical director of the Driscoll Children’s Health Plan, which serves CHIP and Medicaid patients. He says in his experience, care provided by nurse practitioners is likely to be more expensive than care provided by physicians. “I do not find that the nurse practitioners are more frugal with their referrals, or that their total cost of care is cheaper than that as provided by a physician. In fact I find that they refer liberally to higher-cost specialists and to unfruitful therapies.”

Degrees Required and Time to Completion

Undergraduate Entrance exam degree

Post-graduate schooling

Residency and duration

TOTAL TIME FOR COMPLETION

Family physician Standard 4-year (M.D. or D.O.) BA/BS

Medical College Admissions Test (MCAT)

4 years, doctoral program (M.D. or D.O.)

REQUIRED, 3 years minimum

11 years

Nurse practitioner Standard 4-year

BA/BS*

Graduate Record Examination (GRE) & National Council Licensure Exam for Registered Nurses (NCLEX-RN) required for MSN programs

1.5 – 3 years, master’s program (MSN)

NONE

5.5 – 7 years

Medical/Professional School and Residency/Post-Graduate Hours for Completion

Lecture hours (pre-clinical years)

Study hours (pre-clinical years)

Combined hours (clinical years)

Residency hours

TOTAL HOURS

Family physician

2,700

3,000**

6,000

9,000 – 10,000

20,700 – 21,700

Doctor of Nursing Practice

800 – 1,600

1,500 – 2,250**

500 – 1,500

0

2,800 – 5,350

Difference between 1,100 – 1,900 750 – 1,500 4,500 – 5,500 9,000 – 10,000 15,350 – 18,900 FP and NP hours of more for FPs more for FPs more for FPs more for FPs more for FPs professional training

* While a standard 4-year degree, preferably a BSN, is recommended, alternate pathways exist for an RN without a bachelor’s degree to enter some master’s programs. ** Estimate based on 750 hours of study dedicated by a student per year.

Sources: Vanderbilt University Family Nurse Practitioner Program information, http://www.nursing.vanderbilt.edu/msn/fnp_plan.html, and the Vanderbilt University School of Nursing Handbook 2009-2010, http://www.nursing.vanderbilt.edu/current/handbook.pdf.

American Academy of Family Physicians, Primary Health Care Professionals: A Comparison, http://www.aafp.org/online/en/home/media/kits/fp-np.html.

Download Primary Care Coalition issue briefs that support arguments against granting nurse practitioners authority to diagnose and prescribe without physician collaboration on the advocacy resources page of www.tafp.org.

clinical training hours during A Family physician’s education

Medical school

Undergraduate degree years 1 & 2

4 years (pre-clinical years)

Year 1

2

3

4

5

Medical school years 3 & 4 (clinical years) 6,000 clinical hours

6

clinical training hours during A nurse practitioner’s education

Undergraduate degree

4 years

Master’s program or Doctor of Nursing Practice 1.5 – 3 years 500 – 1,500 clinical hours

7

Family medicine residency 3 years 9,000 – 10,000 clinical hours

8

9

10

11

“Pharmacy technicians can dispense most prescriptions just as well as pharmacists, but they are not the same,” Young says. “Physical therapy techs can provide many of the same treatments and modalities as the PTs themselves, but they are not the same. Paralegals know many of the same legal issues as lawyers, but they are not the same. Nurse practitioners can know a lot about primary care, but they are not primary care physicians.”

— Rodney B. Young, M.D. Nurse practitioners perform quite well in many instances, Buck says, like when completing a Texas Health Steps well-child examination for children’s Medicaid or CHIP. “The bigger fear is when they find something abnormal, now what do they do? That’s where the expense runs up. They’re more likely to get a scan; they’re more likely to refer to a specialist or to order too much therapy.”

The American College of Physicians published a comparison of utilization rates among physicians, residents, and nurse practitioners in the journal Effective Clinical Practice, which showed that utilization of medical services was higher for patients assigned to nurse practitioners than for patients assigned to residents in 14 of 17 utilization measures, and higher in 10 of 17 measures when compared with patients assigned to attending physicians. The patient group assigned to nurse practitioners in the study experienced 13 more hospitalizations annually for each 100 patients and 108 more specialty visits per year per 100 patients than the patient cohort receiving care from physicians.

“The higher number of inpatient and specialty care resources utilized by patients assigned to a nurse practitioner suggests that they may indeed have more difficulty with managing patients on their own (even with physician supervision) and may rely more on other services than physicians practicing in the same setting,” the authors concluded.

Kim Ross, health policy consultant and owner of Kimble Public Affairs in Austin, says allowing nurse practitioners to diagnose, treat, and prescribe without any physician collaboration will only serve to further fragment the chaotic and poorly coordinated health care delivery system Texans encounter.

“Adding another independent health care provider with a billing number compounds the economic felony of rising costs with no prospect for improved outcomes or better value. It is well established from published longitudinal studies that the most effective means of bending the medical cost curve is through better care coordination in team settings, which have over time demonstrably reduced the frequency of redundant services, unnecessary referrals, and other manifestations of both under and over treatment patterns that plague Texas’ fragmented delivery systems.”

Could autonomous practice by NPs solve the state’s physician workforce shortage?

In 2009, the Texas Department of State Health Services reported that 16,830 primary care physicians were in active practice. That’s about 68 for every 100,000 people, well below the average of 81.

DSHS states that 5,745 nurse practitioners were in active practice in Texas while the Coalition for Nurses in Advanced Practice says that number is more than 7,900.

Neither DSHS nor CNAP says what percentage of these practice primary care and what portion has chosen to work in other medical specialties. One recent study published in the journal Health Affairs estimates that fewer than half of all nurse practitioners in the United States practice in office-based primary care settings, and reports that 42 percent of patient visits to nurse practitioners and physician assistants in office-based practices are in the offices of specialists.

Just as medical students are lured away from primary care by the prospect of more lucrative careers in high-paid medical specialties, so are nurse practitioners.

Robert C. Bowman, M.D., professor of family medicine at the A.T. Still School of Osteopathic Medicine in Arizona and noted expert on the nation’s physician workforce, reports that since 2004, the 24 Fa l l 2 0 1 0 | T e x a s Fami ly Phys ician

number of nurse practitioners entering primary care has dropped by 40 percent. To measure the productivity of various health care providers over their careers, Bowman designed a formula to calculate what he calls the standard primary care year. Using this measurement, Bowman found that family physicians deliver 29.3 standard primary care years over an expected 35-year career, while nurse practitioners deliver only three standard primary care years.

According to Bowman, it would take almost 10 nurse practitioners to equal the primary care productivity of one family physician.

TAFP CEO Tom Banning says even if the Legislature decided to grant nurse practitioners autonomous practice, there aren’t enough of them to make a significant difference to Texas’ primary care workforce shortage and there’s no evidence to support the claim that they would practice in rural and underserved areas at a greater rate than they do today.

“You can look at the maps the American Medical Association published showing the geographic distribution of nurse practitioners and primary care physicians and see that for the most part, nurse practitioners practice in the metropolitan areas. The pattern is the same whether you’re in a state that allows independent practice or not.”

“Health care is best given in a medical team” John Richmond, M.D., practices at what he calls a “frontline family medicine clinic” that serves a needy population in central Dallas seven days a week. He and four other family physicians practice with two nurse practitioners, one obstetrician/gynecologist, and one pediatrician, and he believes in the team-based approach to high-quality medicine.

“The breadth of knowledge, confidence, and experience of a residency-trained board-certified physician will never be matched by a NP,” he says. “However, a physician working with an NP will improve patient care and increase availability of services while also improving the knowledge, confidence, and experience of the NP. All that would be impossible if the NP was allowed to work independently without physician supervision.”

TAFP’s position on the question of whether to give nurse practitioners the authority to diagnose and prescribe independently is clear.

Recently the Academy published a set of issue briefs on the subject and encouraged members to use the documents when discussing the topic with their legislators. The issue briefs, which can be found in the advocacy resources section of TAFP’s website, www.tafp.org, acknowledge that as a vital part of Texas’ health care workforce, nurse practitioners collaborate with physicians to increase access to wellcoordinated medical care in communities across the state.

“Nurse practitioners and physicians have the same goal: to keep Texans healthy and productive, and to ensure that when they need it, patients have access to safe, high-quality medical care,” one brief states. “Nurses and physicians provide the highest quality health care when they work together for the well-being of their patients.

They are a team, striving each day for the better health of Texans.

This team should be supported and kept together by state policies that have the best interests of the patient in mind.”

“I attest that our nurse practitioners are a strong and essential part of my clinic’s success,” Richmond says. “Health care is best given in a medical team approach that combines the skills of physicians and nurse practitioners working together. The NPs need to be supervised by interested, experience, and available physicians like myself. The current Texas medical supervision system for NPs is stable, working, and safe.” :

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With your REC’s help, you can answer these questions: j Is my practice ready for an electronic medical record (EMR)? j Which EMR should I choose? j What type of training will my staff need? j How do I install an EMR with minimal disruption to my practice? j How do I make meaningful use of an EMR so it helps my patients and earns me a Medicare or Medicaid incentive bonus? j How can I qualify for incentives with my existing EMR?

For physicians who qualify, reaching “meaningful use” can mean up to $63,750 in incentives from Medicaid or $44,000 from Medicare.

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Who is eligible for REC services?

REC services are targeted at primary care practices with 10 or fewer professionals with prescriptive privileges: internal medicine, family practice, pediatrics, and OB-Gyn.

Visit the TMA REC Resource Center at www.texmed.org/rec for more information.

giving back

photo courtesy of: RACHEL DORN

Houston preceptor Rosanne Popp, M.D., right, teaches Texas A&M Temple medical student Eva Chavez, left.

your Statewide preceptorship program needs you

By Rachel Dorn Coordinator, Texas Statewide Family Medicine Preceptorship Program

S

ince 1985, the Texas Statewide Family Medicine Preceptorship Program has been matching preclinical medical students with family physicians throughout the state of Texas. The summer preclinical program provides an opportunity for students who have completed their first year of medical school to work in the office of an established family physician in order to gain real, hands-on, clinical experience early in their medical school career. Through this summer program, over 4,000 pre-clinical students from every medical school in Texas have been exposed to the difficulties and rewards of maintaining a family medicine practice, and the relationships between family physicians and other health care providers and the community.

Many students cite their participation in the TSFMPP as a pivotal experience in their medical school career.

The continued success of the program and the increase in students ultimately choosing family medicine as a career attests to the effectiveness of the preceptorship program.

In recent years, however, the growing needs of medical schools and the increasing load of students and residents at all levels of education have resulted in a higher demand for community-based family physician educators. Many of the TSFMPP’s current preceptors also devote their time to residents and clinical students. Additionally, the transition of medical practices to electronic records and increased pressures of managed care have served as added challenges and demands on the voluntary teaching time of family medicine preceptors.

Despite these challenges, there is an ongoing need for all medical schools to recognize that more emphasis should 26 Fa l l 2 0 1 0 | T e x a s Fami ly Phys ician

be placed on promoting family medicine preceptorship experiences, particularly in rural and underserved areas.

TSFMPP takes on an even greater significance in medical schools that require little exposure to family medicine, and in which rural and underserved training opportunities are even more limited. According to a 2004 study published in Academic Medicine, the proportion of students choosing family medicine residencies among TSFMPP participants was significantly higher than among nonparticipants. In order to help meet the workforce needs in Texas, it is now more important than ever for family physicians to nurture and protect the special tradition of experienced physicians teaching future physicians and sharing the unique qualities and values that define the profession.

Though the benefits to student participants are obvious, many current preceptors have also cited their involvement as abundantly rewarding. TSFMPP preceptors are devoted mentors and teachers who are committed to ensuring the growth and success of future physicians, and many preceptors forge ongoing relationships with their students, following their development and providing support and guidance throughout the students’ transition into a career as a family physician. Pre-clinical preceptors from nearly every corner of Texas volunteer between two weeks to four months of their summer to teach and host students in their offices and clinics. Additionally, many preceptors provide lodging for students to help defray the costs of relocating to a rural site for the duration of the preceptorship.

Although preceptors serve voluntarily and are unpaid, the Texas Higher Education Coordinating Board cont. on page 28

www.ta f p.or g | fa ll 2 0 1 0

27

cont. from page 26

provides funds to support a central preceptorship office and offer stipends to participating students. Student stipends range from $375 to $1000, depending on the length of the preceptorship and whether or not the student is participating in a rural or underserved area. During the preceptorship, pre-clinical students have the opportunity to enhance their classroom instruction through hands-on learning, including history-taking, physical examination, early diagnosis, and treatment plan formulations. Students also gain insight into the lifestyle of a family physician and learn more about what goes into running a practice.

Similar preceptorship programs provide pre-clinical experiences for students interested in general internal medicine and pediatrics; however, the family medicine program has the largest membership of participating preceptors from across the state. Despite TSFMPP’s broad pool of preceptors, student applicants are often unable to be placed because of the lack of available physicians. Throughout the last few years the number of participating preceptors accepting preclinical students has consistently declined from 125 in 2006 to now approximately 100. Participating preceptors in rural communities are currently limited to just 22 locations. With more than 170 student applicants in 2009, TSFMPP is in dire need of more pre-clinical summer preceptors.

To support the family medicine preceptors and enable each physician to feel well-prepared to teach medical stu-

28 Fa l l 2 0 1 0 | T e x a s Fami ly Phys ician

dents, the preceptorship program works in collaboration with the Faculty Development Center in Waco to provide training workshops and clinical teaching resources for interested preceptors. Additionally, every preceptor receives outlined learning objectives for students, as well as an evaluation form which provides a way for both preceptors and students to give constructive feedback on the program and their experiences. TSFMPP preceptors are also eligible to submit teaching hours towards CME credit as recognized by AAFP. Some recent initiatives of the preceptorship program include providing more training materials, resources, and pertinent forms on the program website in order to be easily accessible to preceptors. The program website currently allows student applicants to browse preceptor profiles to learn more about individual practice locations and make requests for specific physicians and clinics.

The website will also feature a photo gallery, recent news articles, and links to the program’s Facebook page and LinkedIn group. Interested physicians are encouraged to visit the website to learn more about program eligibility and register as a preceptor. Students will apply for the summer 2011 program beginning in January 2011.

For program inquiries or questions on how to become a preceptor, contact Rachel Dorn at rachel.a.dorn@uth.tmc. edu or call (713) 500-7615. :

TA FP Minut e s in B rie f

Annual Session 2010 M inut e s in B ri e f The Texas Academy of Family Physicians Board of Directors met on Saturday, July 24, 2010, to hear reports and recommendations from TAFP’s committees, commissions, and sections. Below are the highlights of the meeting, which included a robust discussion of the upcoming legislative session with representatives from Texas Medical Association. for a complete copy of the minutes, contact Kathy McCarthy at (512) 329-8666, ext 14. or at kmccarthy@tafp.org.

TAFP FOUNDATION BOARD OF TRUSTEES The Foundation announced the creation of the David Katerndahl, M.D. Research Champion Fund within the Research Endowment. The Board voted to allocate $25,000 of reserves for this purpose.

Executive Committee The Executive Committee heard from Joe Cunningham, M.D., on the subject of federal health care reform. The committee also discussed strategic partnerships for TAFP and asked staff to review and evaluate proposals and provide a risk analysis for potential partners. Staff will develop a proposal of principals and guidelines for future partnerships.

Finance Committee The Board approved the proposed fiscal year 2011 operating budget and the fiscal year 2011 capital budget.

Nominating Committee The Board elected the slate of directors and alternates presented by the Nominating Committee. They also approved several AAFP commission recommendations from the committee.

Commission on Academic Affairs The Board approved a recommendation that TAFP focus advocacy efforts on modifying the timeline for

IMG licensure. Currently United States graduates can obtain a license at the end of their first year of residency while IMGs must wait until after they complete residency. This results in IMGs leaving the state to avoid a waiting period to begin practicing.

Commission on Annual Session and CME The Board approved a new CME mission statement as recommended by the commission.

Commission on Core Delegation The Board approved a recommendation that TAFP send a resolution of condolence for the late Harold High, M.D., to the AAFP Congress of Delegates.

Commission on Health Care Services and Managed Care The Board approved a recommendation that TAFP present lectures and other communications on Accountable Care Organizations and payment reform models.

Commission on Legislative and Public Affairs The commission heard from guests Harvey Kronberg of the Quorum Report and House Rep. Larry Taylor. The commission also discussed political priorities in the upcoming legislative session.

Commission on Membership and Member Services The Board approved a recommendation to initiate a dues rebate program enacted during the 2011 dues cycle for physician members who are in their first year of practice.

Section on Research The Board approved a recommendation that this section sunset after Interim Session 2011 and that its concentration be absorbed by the Commission on Public Health, Clinical Affairs, and Research.

Section on Special Constituencies The section selected Khalida Yasmin, M.D., to serve on the Executive Committee and Zafreen Siddiqui, M.D., to serve on the Board of Directors.

Call for proposal Bylaws Amendments Any TAFP member wishing to submit a proposed amendment to the TAFP bylaws must submit it to Kathy McCarthy at TAFP headquarters by Dec. 15, 2010. The TAFP bylaws can be viewed online at www.tafp. org/membership/organization/bylaws.pdf.

Amendments can be emailed to kmccarthy@tafp. org or faxed to (512) 3298237. Members submitting a proposed amendment must include a statement giving the rationale for the amendment.

The TAFP Bylaws Committee will review the amendments at the 2011 Interim Session meeting on March 12, 2011. The Chair of the Bylaws Committee will present the proposed amendments, with the recommendations of the Bylaws Committee, to the Board of Directors at Interim Session.

If the Board of Directors approves the amendment, it will go before the TAFP members in attendance at the TAFP Annual Business Meeting in July 2011. :

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30 Fa l l 2 0 1 0 | T e x a s Fami ly Phys ician

Collaboration in care: Case management can make a difference

By Teri Treiger, RN-C, MA, CCM, CCP Case Management Society of America President 2010-2011 The widely recognized Institute of Medicine’s 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” proposed a framework for improving health care quality in the United States through the pursuit of six improvement targets: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The IOM report went on to describe primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Almost 10 years later, this country’s health care system continues to transform in an effort to improve the delivery of quality care. One emerging model of care is the patient-centered medical home, or PCMH. According to the Joint Principles of the Patient-Centered Medical Home, a PCMH is “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.” This model continues to gain momentum as regulations associated with the Patient Protection and Affordable Care Act are issued and enacted.

Along with regulation comes the desire to demonstrate compliance, often in the form of accreditation and certification programs. The National Commission of Quality Assurance issued PCMH standards in 2008. Currently, the nonprofit health care accreditation organization URAC is preparing its patient-centered primary care home program. Both offerings call for medical practices that aspire to become accredited to offer care-coordination services to their patients. The concept of care coordination extends beyond current practice and moves toward cross-continuum integration with all participants of the health care system as well as within the patient’s base of support (e.g., family, community-based services).

Health care, supported by information technology, is focused upon assuring the patient obtains the right care, at the right time, in the right place, in a manner that is appropriate to their cultural and linguistic needs.

The terms care coordination, care management, and case management appear 20, 22, and 10 times respectively within the ACA. While each term has a unique definition, they have become somewhat interchangeable in general use. The Case Management Society of America defines case management as “a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes.” Not every patient will require high-intensity care coordination, but the individual with complex needs associated with chronic, co-morbid health conditions, such as congestive heart failure in combination with chronic obstructive pulmonary disease, encounters both tremendous challenge and opportunity for improvement in his or her overall health and quality of life.

In his 2008 article, Thomas Bodenheimer, M.D., M.P.H., wrote: “Care must be coordinated among primary care physicians, specialists, diagnostic centers, pharmacies, home care agencies, acute care hospitals, skilled nursing facilities, and emergency departments.” The difficulty of caring for individuals with complex health conditions cannot be understated. Left on their own, patients face seemingly insurmountable obstacles in understanding their health condition and obtaining necessary clinical care across disparate financial and delivery systems while at the same time maintaining current knowledge about their health care coverage and benefit limitations. While working through a rocky health care landscape is difficult for a lay person, it is the specialty of a skilled case manager.

Given the level of complexity of health care infrastructure, there is a tremendous opportunity for clinical practices to leverage the knowledge and experience of case managers as integral members of the patient’s health care team. Case managers come from a variety of educational backgrounds, including nursing and social work.

The professional case manager is uniquely positioned to coordinate care and services and is adept at working with patients to understand their health conditions, the importance of adhering to their prescribed plan of care, and providing vital connections to available services and resources.

Practice-based case management has been in place for many years in group practices such as Harvard Pilgrim Health Plan and the Geisinger Health System. The embedded model has case managers seated within the practice and readily available to clinicians.

When care coordination is required, the case manager takes on the responsibility of working with the patient to find an acceptable vendor or supplier, reviewing health care benefits for coverage, obtaining authorization of services, and coordinating the delivery of care or equipment in a timely manner. Case managers also monitor service and care to ensure prompt delivery, patient satisfaction, and progress toward desired health outcomes, and report their observations back to the health care team to evaluate efficacy and alter treatment plans as necessary.

It is exciting to see the prospects for case management professionals expanding into the medical home practice structure. As health care makes the transition to the patient-centered medical home model, case managers will meet the needs of both patient and practice in providing ongoing care and support with an end result focused on the improvement of patient care quality.

To learn more about the role case managers can play in improving patient care coordination, consider attending CMSA’s 21st Annual Conference and Expo in San Antonio, June 14 - 17, 2011. As the nation’s leading professional case management association with over 10,000 members, CMSA fosters cross-continuum professional collaboration focused on enhancing the role of case management in advocating for patient wellbeing and improved health outcomes. :

Given the level of complexity of health care infrastructure, there is a tremendous opportunity for clinical practices to leverage the knowledge and experience of case managers as integral members of the patient’s health care team.

www.ta f p.or g | fa ll 2 0 1 0

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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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practice management

Ready or not, Recovery Audit Contractors are coming

By Bradley K. Reiner Practice Management Consultant, Reiner Consulting and Associates

W

hy is it that every time you turn around there is another painful reminder that practicing medicine is becoming harder and harder?

Have you wondered at times if seeing patients, and dealing with overhead, collections, billing, and HR problems are worth it?

CMS has taken the next steps in Medicare’s comprehensive efforts to identify improper Medicare payments and fight fraud, waste, and abuse in the Medicare program by awarding contracts to four permanent Recovery Audit Contractors. The RACs are designed to guard the Medicare Trust Fund. (I didn’t know the Medicare Trust Fund needed that much guarding.)

The reason these regional RACs have been established is because of a successful demonstration project involving six states. That program produced significant results in identifying improper payments so they decided to implement the program nationwide. In other words, they made a ton of money.

The goal of the recovery audit program is to identify improper payments made on claims for health care services provided to Medicare beneficiaries. This is done through a post-payment review.

The claim processing contractors are the entities responsible for adjusting the claim, handling collections (offsets and checks), and reporting the debt on the financial statements. Believe it or not, underpayments are to be identified as well and additional revenue paid. I wonder what the percentages are of overpayments versus underpayments? My guess is that overpayments will win hands down.

Overpayments occur when health care providers submit claims that do not meet Medicare’s coding or medical necessity policies. Underpayments occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed.

The RACs are not allowed to review claims prior to Oct. 1, 2007, and will only be able to look back three years from the date the claim was paid.

The RAC is paid on a contingency-fee basis for both overpayments and underpayments they find. Rumor has it that this may be as much as 9 to 12 percent. Needless to say, the RACs have a huge incentive to find overpayment and underpayments. That percentage would allow them to generate millions and millions of dollars over the next few

years. Don’t make the assumption that you won’t have to worry about RACs. If they continue to be successful there is no doubt everyone will have a RAC audit sooner or later. In almost every practice a RAC can find some billing, coding, or documentation issue during any given audit. It is easy to make mistakes even if you have all of the right processes in place. The rules are too complex and differ from payer to payer.

I recently reviewed a medical practice and found the physicians were coding at low levels for almost all services they provided. Once I reviewed the documentation, I discovered the doctors should have coded the services at higher levels, which meant they were significantly underpaid. If they have a RAC review they should get money back, but the bad news is that after billing this way for years there is no way to recover all the dollars lost.

The flip side could be much worse.

I reviewed another group that consistently coded high-level visits and the documentation did not substantiate the level billed. I trained this group on documenting correctly for code levels, which will help them avoid the cost of overpayment in the future. However, the group could still be audited and may owe money back for those claims filed after October 2007. It is wise to have a system in place through a compliance plan and documentation training to help decrease the risk of an audit or overpayments. It is not a matter of if but when in regards to auditing medical practices.

Almost everyone in the health care system will be affected by an audit. This includes hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers, and any other provider or supplier that bills Medicare parts A and B. The more claims billed to Medicare, the greater the chance of an audit. However, don’t be fooled; even a small practice may be audited.

CMS awarded Connolly Healthcare the contract to provide recovery audit services in Region C, which includes Texas and 14 other southern states and two territories.

The RAC employs a staff of nurses, therapists, certified coders, and a physician contractor medical director. They are obviously concerned with how much money is being paid by Medicare and are encouraged to recover as much as possible. Medicare is committed to identifying providers who have been paid more than they should and will do whatever it takes. Again, since the contractor is paid a

Medicare is committed to identifying providers who have been paid more than they should and will do whatever it takes. since the contractor is paid a percentage of money recovered, they have an incentive to find these mistakes.

I believe these RACs will be around for a long time.

www.ta f p.or g | fa ll 2 0 1 0

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percentage of money recovered, they have an incentive to find these mistakes. I believe these RACs will be around for a long time.

The RAC will use the same Medicare policies as the carriers. Issues identified by the RAC will be approved by CMS prior to a widespread review. Once an issue receives CMS’ approval, the RAC will use its own proprietary software and systems as well as its knowledge of Medicare rules and regulations to determine what areas to review.

Connolly Healthcare uses data analysis techniques to identify those claims most likely to result in underpayments or overpayments. This process is called “targeted review.” Connolly Healthcare will target a claim because the claim contains information that leads them to believe it is likely to result in an underpayment or overpayment.

There are two types of reviews. Automated review occurs when a RAC makes a claim determination at the system level without a human review of the medical record.

Connolly Healthcare will communicate to the provider the results of each automated review that results in an overpayment determination, and inform the provider of which coverage/coding/payment policy or article was violated. If the review does not result in an overpayment, the RAC may elect to not communicate the results to the provider.

Complex review occurs when a RAC makes a claim determination utilizing human review of the medical record.

The RAC may use complex review in situations where the requirements for automated review are not met or the RAC is unsure whether the requirements for automated review are met.

The numbers of records the RAC can request are based on the size of the practice.

• Solo practitioner: 10 medical records per 45 days per NPI • Partnership (2-5 individuals): 20 medical records per 45 days per NPI • Group (6-15 individuals): 30 medical records per 45 days per NPI • Large group (16+ individuals): 50 medical records per 45 days per NPI Connolly Healthcare will complete its complex reviews within 60 days from receipt of the medical record documentation. There may be some instances where the RAC may request a waiver from CMS if more time is needed due to extenuating circumstances.

The results of the complex reviews will be communicated by letter to the provider in a detailed review, including cases where no improper payment was identified. In cases where an improper payment was identified, the RAC will inform the provider of which coverage/coding/ payment policy or article was violated.

If you agree with the RAC’s determination you may: • • • •

Pay by check, Allow recoupment from future payments, Request or apply for extended payment plan, or Request appeal time frames.

Providers submitting medical records to the RAC should follow the published guidelines found on the Connolly Healthcare website at www.connollyhealthcare. com/RAC/pages/record_submission.aspx.

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Note that whenever performing complex coverage or coding reviews (i.e., reviews involving the medical record), Connolly Healthcare will ensure that coverage/ medical necessity determinations are made by RNs or therapists, and coding determinations are made by certified coders. They want to ensure that people with clinical experience are addressing the problem, not individuals who don’t have the expertise clinically to make medical record determinations.

If an adjustment is needed based on a RAC review, the adjustment, whether overpaid or underpaid, will be indicated on the explanation of benefits called “adjustment based on a recovery audit.” This will allow providers to know that the claim was adjusted for a particular reason.

An appeal process is the same as any other appeal.

If automated or complex review results in some form of adjustment needed, a provider can initiate a discussion period with the RAC or file an appeal with Trailblazer.

The discussion period is not an appeal and does not stop the clock on the 120-day time period for asking for a redetermination, which is the first level of appeal.

Providers must initiate a discussion within 15 days of the receipt of a demand letter (in an automated review) or a review results letter (in a complex review). The discussion period does not take away a provider’s right to appeal, nor does it affect his recoupment or appeal time frames.

How can you minimize the risk of an audit?

• Know if you are submitting claims with improper payments.

• Conduct an internal assessment to identify if you are in compliance with all Medicare coding and documentation rules. Hire a consultant if you need help.

• Identify corrective actions to promote compliance.

• Appeal when necessary.

• Learn from past experiences.

• Check the RAC website weekly for new issues and what improper payments were found.

• Identify and implement corrective actions to promote compliance (e.g., initiate awareness in the mailroom, medical records, and Medicare billing departments about RAC requests for medical records and be familiar with Connolly Healthcare’s envelope logo).

• Conduct an audit to review medical records and codes and implement a compliance plan that can help minimize the risk of being audited. If you don’t have the expertise to provide a review and implement a compliance plan, your Academy retains my practice management consulting services for this reason.

• Complete a provider contact form so the RAC knows the precise address and the contact person it should use when sending medical record request letters. The form is found under the provider contact information tab on Connolly Healthcare’s website www.connollyhealthcare.com. Contact Connolly Healthcare at (866) 360-2507. :

Bradley K. Reiner, formerly with Texas Medical Association, is now owner of Reiner Consulting and Associates. He can be reached at (512) 858-1570 or e-mail at breiner@austin.rr.com.

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F OUNDATION FOCUS

“As physicians, we have so many unknowns coming our way...

Research endowment gets new champion fund; Two residents receive Martin Scholarship

By Kathy McCarthy

One thing I am certain about is my malpractice protection.”

Medicine is feeling the effects of regulatory and legislative changes, increasing risk, and profitability demands—all contributing to uncertainty and lack of control.

What we do control as physicians: our choice of a liability partner.

I selected ProAssurance because they stand behind my good medicine. In spite of the maelstrom, I am protected, respected, and heard.

I believe in fair treatment—and I get it.

Professional Liability Insurance & Risk Management Services ProAssurance Group is rated A (Excellent) by A.M. Best. www.ProAssurance.com • 800.492.7212

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Texas Academy of Fam Phys.indd 1

8/17/10 9:13:09 AM

The TAFP Foundation had another exciting year, during which the James C. Martin, M.D. Scholarship was awarded for the first time, the David Katerndahl, M.D. Research Fund was created in honor of the longtime Research Committee chair, and the Cassie Murphy-Cullen, Ph.D. Scholarship continues to make good progress toward full funding when it will be used to support resident travel to research conferences.

The first recipient of the Martin Scholarship—Marie Ramas, M.D., from the Conroe Medical Education Foundation—spent two weeks in June studying scope of practice. In August, Travis Bias, D.O., from the Memorial Family Medicine Residency Program in Houston spent two weeks studying graduate medical education funding. Their research gave them valuable experience in policy development and will help TAFP in the upcoming legislative session. The scholarship was established to honor past TAFP and AAFP President James Martin, M.D., of San Antonio.

Two years ago, the Foundation began building a research endowment to provide ongoing support to practice-based research. Within the endowment, we are developing Research Champion Funds to honor generous donors and leaders in family medicine. This summer, the Foundation Board unanimously voted to allocate $25,000 to establish a David Katerndahl, M.D. fund. Dr. Katerndahl is a member of the Board of Trustees and has served as chair of the TAFP Foundation Research Committee for many years. He has championed the cause of research within the Academy and throughout the state, pushing to not only fund research grants, but build the research infrastructure through training and by providing vehicles to share research with family physicians.

The Foundation funded four research grants this year on topics including health literacy, vitamin D deficiency, and inefficiencies in the health care system. At the medical-school level, we funded activities of the FMIGs and provided travel funding

for 51 medical students to attend TAFP and AAFP conferences. The Foundation also funded 42 resident physicians to attend TAFP conferences.

Another way the Foundation supports the specialty is through scholarships for medical students interested in family medicine. Since its creation in 1994, the scholarship program has awarded more than $165,000 to future family physicians. Congratulations to the nine future family physicians who were awarded medical student scholarships this year: • Karen Oehler, M.D. (William F. Ross, M.D. Scholarship); • Zachary Taylor (Valley Chapter Scholarship); • Heather Zidow and Patrick Allen (Harold T. Pruessner, M.D. Scholarship); • Sarah Low, M.D. (Norma Porres, M.D. and Felipe Porres, M.D. Scholarship); • Michelle Dobbs (Minnie Lee Lancaster, M.D. and Edgar Lancaster, M.D. Scholarship); • Cole Zanetti (Arnold N. Krause, M.D. Scholarship); • Erica Jarrett, M.D. (S. Perry Post, M.D. Scholarship); and • Carmella Caldwell (Glen R. Johnson, M.D. Minority Scholarship).

In addition, Sergio Alvarado, M.D., received the Jim and Karen White Leadership Scholarship to attend AAFP’s National Conference.

Thank you to all who supported the Foundation this year. Your generosity makes the good works of the Foundation possible. :

For information on donating to the TAFP Foundation, go to www.tafp.org/foundation, or call Kathy McCarthy at (512) 329-8666 ext. 14.

A new perspective on lactose intolerance nutrition

By Lana Frantzen, Ph.D. Director of Nutrition Communications at Dairy MAX, your local dairy council

L

actose intolerance is a real and important clinical syndrome, according to the National Institutes of Health. Last February, NIH convened an independent expert panel to examine the latest research. Their key findings were that the prevalence is unclear: lactose malabsorbers aren’t necessarily lactose intolerant, avoiding dairy can lead to nutrient shortfalls, and more research-based strategies are needed.

The bottom line on the scientific consensus is “in most cases lactose intolerance shouldn’t limit dairy consumption when managed appropriately.”

The National Dairy Council recently hosted a dairy science forum to bridge from the science to practical solutions for health care professionals. Dr. Janet Taylor, a private practice psychiatrist based in New York, presented a new perspective on lactose intolerance. She is a former clinical instructor of psychiatry at Harlem Hospital, affiliated with Columbia University.

She is also a frequent contributor to CBS’ “The Early Show” and NBC’s “Today.” She shared her perspective on lactose intolerance’s psychological impact.

Dr. Taylor began her presentation by explaining several factors that influence health behaviors. Here are some of her insights.

• One factor is social context; for example, what does a patient need to do to get to their doctor’s office and how does that affect their decision to seek medical treatment?

They may need to take more than one mode of transportation to arrive at their final destination.

• Secondly, don’t underestimate the influence of cultural beliefs. I couldn’t agree more with this statement because I used to work as a clinic supervisor at a Women, Infants, and Children clinic in an area of Houston, Texas, that was a cultural melting pot. I remember when postpartum Hispanic women arrived at the clinic with little cotton balls stuffed in their ears not for medical reasons, but because of their specific cultural beliefs.

• Family education is another important factor since low socioeconomic status and poverty may lead to poor health outcomes.

• Health literacy also impacts health behaviors since patients may not be able to read or English is not their first language.

Health-literate information is written at a fourth-grade level or less and may include diagrams and pictures. To change health outcomes, you need to take the time to adequately explain the necessary steps to improve one’s health.

• The food environment inevitably affects health behaviors. The term “food desert” has been used to describe a lack of accessibility to nutrient-rich foods and neighborhood bodegas may be void of fresh fruits and vegetables. These factors are like pieces of a puzzle that create and shift our health behaviors.

Dr. Taylor identified four important psychological factors related to lactose intolerance. The first factor, somatization preoccupation, is the potential culmination of a sudden onset of abdominal pain or gastro-intestinal complaints. As a psychiatrist, she asks what is going on, what the patient needs, and what is the secondary gain. There may be no relation

to lactose intolerance or another factor may be influential.

The second factor, mood dysfunction, may be reported with symptoms of depression and anxiety at home. Patients may feel different because they can’t eat what everyone else is eating. As a psychiatrist, Dr. Taylor may ask, “over the past two weeks, have you felt hopeless or lost interest in activities you usually enjoy?” The third factor, self-efficacy, is when you give clients the tools needed to increase their health knowledge and empower them to believe that they can complete, converse, or convey the necessary action to improve their health outcomes.

Lastly, quality of life may be impaired due to situations where someone is in immediate need of a restroom at inconvenient times. Over time, this may affect relationships and lead to guilt, shame, or depression that may worsen if untreated.

The good news is there are several strategies that may be beneficial for individual and community intervention. One highly effective strategy, peer support, allows peers to share information among themselves. Along that same line, strong social networks may be very helpful. Encourage a formal diagnosis and personalized nutrition counseling since there are individual variations in the amount of lactose that can be comfortably consumed. Promoting the acceptance of one’s own physical state may help to increase self-efficacy. Taking an active role in making decisions regarding one’s health is another helpful strategy as well as managing beliefs. Educating communities about the health benefits of consuming three servings of low-fat or fat-free milk, yogurt, or cheese daily for individuals 9 years and older may help those who are lactose intolerant enjoy foods they may have thought they could no longer consume.

The strategies suggested for health care providers include employing the correct testing techniques to ensure a correct diagnosis and teaching patients how to minimize their lactose intolerant symptoms. Health professionals can improve their own self-efficacy by understanding the current scientific consensus, regularly educating themselves about the latest nutrition, calcium, and lifestyle risk factors research and practicing shared decisionmaking with their patients. (Checking in with our blog, The Dairy Report, regularly can help!) Always ask your patients and clients specific questions and don’t make assumptions about lactose intolerance. Collectively, these strategies may help close the gap of understanding and improve a patient’s overall health.

Dr. Taylor’s key considerations for health professionals include doing “what you can to help your clients understand health literacy,” meaning ask, don’t assume. “Be aware of the key influences and influencers in the household” by asking questions about who makes the meal-planning decisions. Dr. Taylor also suggested health professionals be “empathetic and encourage health empowerment by increasing health efficacy and health knowledge.” In other words, do not feel sorry for your patients, but instead have an ability to understand and impart power and wisdom. Dr. Taylor suggested offering information in the waiting room; however, be mindful of your patients’ ethnicity and reflect that in your nutrition education materials.

Learn more about simple and memorable strategies to manage lactose intolerance or access our latest lactose intolerance health education toolkit at www.dairymax.org. : www.ta f p.or g | fa ll 2 0 1 0

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TA F P pER S P E C TIV E

Don’t let others define you

By Guy L. Culpepper, M.D. D uring his recent NFL H all of F ame induction speech , running back Emmitt Smith affirmed that refusing to let others define him was critical to his success. This simple, yet powerful advice has been a core value shared by champions throughout history.

Success begins with a clear vision of one’s abilities and goals.

Defining identity must not be swayed by the ever-present naysayers. This principle holds true across all spectrums of life; in faith, in business, and certainly in medicine.

Nicholas Pisacano, M.D., the founding director of the American Board of Family Practice, faced a multitude of naysayers and roadblocks when he led the efforts to have family practice recognized as the 20th medical specialty in 1969. To achieve that recognition required meticulous documentation and high standards of definition as to the training and responsibilities of the family physician. In other words, family physicians defined themselves. And Dr. Pisacano understood the importance of defining ourselves.

The clear vision provided by our specialty’s founding leadership has resulted in remarkable success. As we look back over the past 40 years, one of the greatest strengths in medicine has been the family physician. Our specialty, family medicine, is a jewel in the crown of the health care system. Multiple studies have acknowledged the critical role that the family physician offers in both the prevention and early detection of disease, consistently creating enormous impact and savings for our patients and our country. For all of the concerns regarding our country’s health care crisis, there is agreement that family medicine is part of the solution, not the problem. Family medicine remains the highest calling in health care.

It is not a surprise that every plan of action proposed to improve health care delivery and to reduce cost revolves around primary care. The family physician is the greatest value in medicine. Business leaders and politicians are anxious to develop systems that further capitalize upon the successes of primary care. But no one except the primary care physician really understands just what it is that we do to achieve that success. No one else is aware of the demands, the sacrifice, and the commitment that is required to deliver high-quality primary care. The flawed reimbursement system, which fails to adequately reward primary care, is proof of that ignorance.

The patient-centered medical home has been proposed as one system to accentuate comprehensive patient care, as well as reimburse primary care physicians for some of the myriad services provided in that pursuit. Much of the cost savings to be found in health care reform is based upon reducing the utilization of resources. There is no one in a better position to decide which resources may not be necessary to use than a personal family physician when reviewing that decision with a patient.

Additional significant savings can also be derived from cost effective referrals. The need for primary care physicians to be independent in making these cost-saving referral decisions is

obvious. In order to lower costs, the referral choice cannot be restricted to only the hospital or specialist with whom the primary care physician has a business relationship. True cost savings, and often quality enhancement, comes from the competition for those referrals. Again, this positions the family physician in a place of substantial control. Understandably, the potential empowerment of primary care physicians through a medical home model has been recognized with concern by some hospitals and specialists.

It is this concern over losing market share, referrals, or power that has led many health care corporations, hospitals, and specialty groups to quickly embrace the new buzzword in medicine, the Accountable Care Organization. Based in Washington, D.C., the Brookings Institute and researchers at the Dartmouth Institute for Health Policy developed the model of the Accountable Care Organization as a part of health care reform efforts. While this model naturally emphasizes the importance of primary care, it also facilitates and encourages the development of large hospital-based, singletax-number corporations.

The rapid popularization and political support of the Accountable Care Organization model has been propelled by those recognizing an opportunity to control a market by quickly employing that region’s primary care physicians. It is clear that whoever controls the majority of family physicians will control the area’s health care dollars.

Scare tactics are being used in many parts of our country, frightening primary care physicians into becoming employees under the guise of national policy inevitability. The message conveyed is that you have no choice.

The family physician is being told that our only future is to be an employee, one who can effectively manage a bevy of mid-level providers by using an electronic medical record. The family physician of this model may not even see the patient, but instead review each case’s management for efficiency. Instead of rewarding family physicians, the new model plans to replace us with midlevel providers and prescribing pharmacists. The Accountable Care Organization is not the patient-centered medical home. It is just a policymaker’s latest idea to define our profession.

When you hear naysayer opinions, stop and remember the clear vision of our founders. Family medicine is critical to the success of cost-effective health care. We are the key to the successful Accountable Care Organization and we can define the model of the Accountable Care Organization. Primary care and the mission enhanced by the patient-centered medical home are at the core of the Accountable Care Organization. Independent family physicians can develop the Accountable Care Organization, lead the changes, and remain true to that mission.

We must not let others define us. The vision of politicians and policymakers cannot define family medicine. We, the family physicians, just as the champions who founded our specialty, must instead define ourselves and proudly guard our future. Our country’s health care depends on it. :

For all of the concerns regarding our country’s health care crisis, there is agreement that family medicine is part of the solution, not the problem. Family medicine remains the highest calling in health care.

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