Texas Family Physician, Spring 2016 by Texas Academy of Family Physicians

TEXAS FAMILY PHYSICIAN VOL. 67 NO. 2 2016

PLUS: Your Academy Helps You Get MACRA Ready ICD-10 Coding Update Tips For Renewing Your Texas Medical License

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TMF Health Quality Institute: Helping you succeed in the transformation from volume to value is their job

Did you know you can get expert consultation on quality improvement and federal reporting obligations like PQRS and Meaningful Use and it won’t cost you a dime? Help is a click away. By Jonathan Nelson

The QRUR: How will your practice get paid?

Medicare’s Quality and Resource Use Report is basically a report card telling you how you’ll likely fare in the coming payment paradigm, but most family doctors have never heard of it. By TMF Health Quality Institute

Renewing your license? Here’s what not to do

An expert from Texas Medical Liability Trust dives deep into a couple of potential pitfalls physicians face when renewing their Texas medical license.

By Franklin Hopkins

6 FROM YOUR PRESIDENT Remembering why we are family doctors 8 MEMBER NEWS Sulaiman named Country Doc of the Year | Local chapters install new officers | AAFP taps TAFP Parliamentarian for national commission | Hillsboro FP wins Citizen of the Year Award | Highlights from TAFP 2016 Interim Session 13 NEWS FROM AAFP MACRA is coming: Your Academy has resources to help 22 PRATICE MANAGEMENT ICD-10 coding: Specificity is key 28 RESEARCH The urgently non-urgent: Why do family medicine residency patients choose to go to urgent care facilities as opposed to their primary care physician for non-urgent matters? 30 TAFP PERSPECTIVE Count your blessings, family docs

PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 67 NO. 2, 2016

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.

Remembering why By Ajay Gupta, MD TAFP President

OFFICERS president

Ajay Gupta, MD

president-elect vice president

Tricia Elliott, MD

Javier “Jake” Margo, MD

treasurer

Janet Hurley, MD

parliamentarian

Rebecca Hart, MD

immediate past president

Dale Ragle, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editors

Perdita Henry and J.D. Harris chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell CONTRIBUTING EDITORS Norm Clothier, MD Franklin Hopkins Shawn Martin Bradley Reiner

SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. TEXAS FAMILY PHYSICIAN is printed by AIM Printing and Marketing, Austin, Texas. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2016 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

TEXAS FAMILY PHYSICIAN [No. 2] 2016

even as family physicians, we still have these we have all been there. None of us are moments. We are human beings after all. immune. It’s a tough environment to be a Recently I had some dramatic changes in physician these days, no matter whether you my physician career. I left my practice where are in solo or small group practice, direct priI had been for 17 years. In mary care, academic mediannouncing my departure, I cine, employed by a large was reminded several times hospital practice, in admina day why I became a family istrative care or any other We really do physician. This was further setting. Your days are filled enhanced by the countwith issues of managed care, make an impact less kind letters, cards, and human resources, schedulon our patients’ emails from my patients. ing, accounts payable, paper lives. We lose We really do make an pushing, and the like. I want impact on our patients’ to reflect for a moment on sight of this at lives. We lose sight of this why we do any of this. times because we at times because we are so When we applied for are so caught up caught up in all the nonmedical school, many of physician care responsibilius were prepared for the in all the nonties our jobs require, but we inevitable interview quesphysician care provide a source of comfort, tion: “Why do you want to responsibilities a shoulder to lean on, and a be a doctor?” We all know person to talk to in time of the correct answer: “I want our jobs require, crisis. We make people feel to help my fellow human but we provide better. beings.” We went on to a source of Some of my patients elaborate how as physicians were even angry I was leavwe can have the greatest comfort, a ing them. You see, many effect on people’s lives. We shoulder to lean patients expected me to be recalled the influences in on, and a person around longer than them. our early lives that helped The process of leaving us make this decision. We to talk to in time the practice caused me to wanted to help people with of crisis. We make reflect on all of this. their problems. We paid people feel better. Being a physician allows our respects to teachers, me to teach my patients. policemen, firemen, and Usually our patients don’t the countless other practifeel well when they see us. tioners in professions who They come to us for help have done the same. and guidance. The more patients learn But let’s admit as we go further into our how to help themselves, the more power careers and as our priorities change, someand capability they have to get better. times we lose track of these reasons. I may Patients remember the doctors who sat and be biased but I really believe as a family phyexplained the issues to them. It’s something sician, those moments are fewer than some we keep in mind whenever we also refer of our specialist colleagues. But the point is

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patients to specialists since many of our patients view them as an extension of us to some degree. Being a doctor allows you to stretch your own mental capacity. As family physicians we’re expected to have a broad scope of knowledge. It’s what attracted many of us to this specialty. Yet several times a week, most of us see something we have never seen before. This is certainly the case as an MS 22 (medical student/ year, to borrow a phrase from Dr. Carlos Pestana) and most likely will be the case when I am an MS 40 and beyond. We learn from our patients. It may not always be a medical fact but many times a life fact. We learn to adjust and meet the needs of each individual patient. As a doctor we learn that we are not omnipotent. We will make mistakes and hopefully catch them before they become issues that have a negative impact. The most we can ask of ourselves is to do our best. This mantra is something we relay to our children and it’s something that we should all practice. Patients do not expect us to know everything. They know we are human and there is so much to learn out there. They expect us to care and comfort them. They don’t know our grades from medical school or our board scores. They grade us on how well we listen, educate, care, and make efforts to improve their quality of life. In the end, this is really how we help people. The next time you get bogged down by an insurance issue, a human resources issue, or a bill to pay, please remember why you do what you do. Family physicians are the best at helping people. You will feel even more satisfied at the end of the day. Finally, remember to thank each patient for allowing you to be their doctor.

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CME SCHEDULE Annual Session & Primary Care Summit Nov. 4-6, 2016 Nov. 2-3: Business meetings and preconference workshops

The Westin Galleria Dallas, Texas C. Frank Webber Lectureship & Interim Session April 7-8, 2017 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 2-4, 2017 La Cantera Hill Country Resort San Antonio, Texas

TEXAS FAMILY PHYSICIAN [No. 2] 2016

Former Texas Family Physician of the Year wins national award jasmine sulaiman, md, of Cleveland, Texas, was named the 2016 Country Doctor of the Year presented by Staff Care, an AMN Healthcare company. The award honors physicians for their commitment and service and recognizes the spirit, skill, and dedication of rural medical practitioners across the country. “Dr. Sulaiman represents a new breed of country doctor,” said Sean Ebner, President of Staff Care, in a press release. “She combines the compassion and commitment of old school physicians with the information technology and new practice paradigms of today’s doctors.” After receiving TAFP’s Texas Family Physician of the Year Award in 2013, Sulaiman humbly thanked TAFP and her colleagues for the honor. “Actually I don’t do anything different than any of you other family physicians do,” Sulaiman said in her Physician of the Year acceptance speech. Much like the TAFP award, the Country Doctor of the Year award is a great honor to Sulaiman. “Just like the Texas Family Physician of the Year Award, this recognition encourages me to excel in what I do and continue to guide others, so they too can see the neverending primary care opportunities to create meaningful, long-lasting impacts on rural health care settings.” Sulaiman practices at the Health Center of Southeast Texas, a Federally Qualified Health Center where a majority of her patient population is uninsured. She took the position at the newly established clinic when funding was not yet stable, accepting

Jasmine Sulaiman, MD

a lower salary then comparative positions would pay, all because she knew helping the heavily uninsured community was where she needed to be. Cleveland is a small, rural town about 45 miles northeast of Houston. She and her team of medical assistants travel up to 25 miles to visit patients who are homebound, and dedicated patients travel 30 or 40 minutes to see Sulaiman rather than find a closer physician. She also visits patients at a nearby jail each month and supervises three other rural clinics in nearby communities. On top of everything, Sulaiman continues to see patients for 40 hours a week and helped the health center reach Level 2 Patient-Centered Medical Home status. As a perk for being named the 2016 Country Doctor of the Year, Staff Care will provide the health center in Cleveland with a temporary physician to fill in for Sulaiman while she visits India for two weeks.

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Hart appointed by AAFP rebecca hart, md, of League City, was appointed to AAFP’s Commission on Continuing Professional Development. She will serve on the commission for a four-year term. Hart is currently TAFP’s parliamentarian and serves on TAFP’s Commission on Continuing Professional Development. She was a previous member of AAFP’s Commission on Health of the Public and Science.

Local chapters install new officers

Hillsboro member named Citizen of the Year james earhart, md, received the Citizen of the Year Award from the Hillsboro Area Chamber of Commerce. He was previously named Citizen of the Year by the Hillsboro Lions Club for his involvement in opening the Mission Hillsboro Medical Clinic. After earning his medical degree from Texas Tech University Health Sciences Center and completing a residency at Hendrick Medical Center in Abilene, Earhart moved to Hillsboro to take a position at the Family Diagnostic Medical Center, where he continues to practice today.

For Further InFormatIon ContaCt roger J. Zoorob, md, mph, FaaFp Professor and Chair Department of Family & Community Medicine Richard M. Kleberg, Sr. Chair 3701 Kirby Drive Suite 600 Houston, Texas 77098 phone 713.798.2555 email roger.zoorob@bcm.edu Website https://www.bcm.edu/departments/ family-and-community-medicine/

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https://www.bcm.edu/careers Baylor College of Medicine is an Equal Opportunity/Affirmative Action/ Equal Access Employer

The Tarrant County Chapter officers were installed at a Jan. 30 meeting held in Fort Worth by TAFP Immediate Past President Dale Ragle, MD. The new chapter president is James Morgan, MD, of Flower Mound, pictured left. Richard Young, MD, of Fort Worth, pictured right, is president-elect and secretary, and Josephine Fowler, MD, of Fort Worth, not pictured, is program chair. The Harris County Chapter officers were installed at the Jan. 13 meeting held in Houston. The new chapter officers are (pictured from left) Immediate Past President Gregory Johnson, MD; Treasurer Eric Lee, MD; Vice President Lindsay Botsford, MD; President-Elect Puja Sehgal, MD; and President Samuel Wang, MD.

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MEMBER NEWS

Highlights from TAFP’s Interim Session • April 15-16, 2016 The committees, commissions, and sections of the Texas Academy of Family Physicians met in Austin and deliberated on many important items. Thanks to all the members who participated. Most commissions, committees, and all sections are open to guests. You can also request an appointment to one of these bodies by submitting a “Make Your Mark” involvement form. Contact Juleah Williams at jwilliams@tafp.org with any questions. Here are a few of the highlights of the recent meeting. All the recommendations mentioned will be presented to the Board of Directors at their next meeting.

ADVOCATING FOR YOU AND YOUR PATIENTS There was extensive discussion during the meeting about MACRA — what it means for practices, how to prepare, alternative payment models, and more. The Commission on Health Care Services and Managed Care discussed efforts to educate members about MACRA and the upcoming payment reforms from CMS. AAFP is developing resources to help members prepare for changes. The commission heard a presentation on the importance of integrating behavioral health into primary care with strategies to implement and bill for those services. They also listened to physicians with Austin Regional Clinic discuss their efforts to roll out telemedicine services for their patient population. TAFP’s lobby team provided the Commission on Legislative and Public Affairs with their assessment of the 2016 elections and the likely make-up of the 2017 Texas Legislature. A series of budget shortfalls will likely frame the context for the 2017 session, resulting in few meaningful opportunities to shape improvements in health care policy. The commission identified the following priorities for the session: raising Medicaid payment to Medicare levels, coverage expansion for uninsured individuals falling into the Medicaid expansion coverage gap. They also prioritized protecting residency, loan repayment and preceptorship funding and defending against scope of practice expansion. 10

Members are encouraged to build and maintain relationships with their legislators so that they can be trusted sources of counsel during the session. WORKFORCE DEVELOPMENT The Commission on Academic Affairs focused on efforts to increase the number of medical students choosing family medicine. TAFP administers the Texas Family Medicine Preceptorship Program to provide an opportunity for first- and second-year medical students to experience family medicine outside the academic health center. The program needs practicing physicians to volunteer to serve as preceptors and medical students are encouraged to apply for the program. With state funding restored for 2016 and 2017, stipends are available for students. Commission members discussed ways local chapters can help encourage medical students to choose careers in family medicine and they reviewed the various funding opportunities and scholarships available through the TAFP Foundation. MEMBER SERVICES AND RESOURCES IN DEVELOPMENT The Leadership Development Committee met to continue forming the curriculum for the new year-long leadership program and for a concurrent workshop during the 2016 Annual Session and Primary Care Summit in Dallas. The inaugural class of the Family Medicine Leadership Experience had their first session in conjunction with Interim Session and there was positive

TEXAS FAMILY PHYSICIAN [No. 2] 2016

feedback on the program. The committee also worked on the agendas for the June and August programs. TAFP will be recruiting the 2017 FMLE class in the fall. Stay tuned for details on how to apply. TAFP is an ACCME-accredited provider of continuing medical education and has maintained that status since 1996. Staff and volunteers collaborate to plan and produce education for members and ensure compliance with all requirements. At Interim Session, the Commission on Continuing Professional Development and the CME planning committee considered future educational offerings and discussed the upcoming changes to ABFM’s Maintenance of Certification. TAFP owns National Procedures Institute and the committee was asked to review current courses and make suggestions for future hands-on courses. The commissions reviewed and provided feedback on various member services and activities including production of Texas Family Physician, educational programming, Texas Conference of Family Medicine Residents and Students, the Texas Family Medicine Preceptorship Program and much more.

and practicing physicians are invited to apply by Sept. 5. Go to www.tafp.org/professionaldevelopment/aspcs to apply. ORGANIZATIONAL ISSUES The Nominating Committee met to identify candidates for leadership positions. In addition to nominating members for officer and delegate positions, they selected three candidates for one at-large position and two candidates for the New Physician position on the Board of Directors. The summer issue of Texas Family Physician will include profiles of the five candidates in contested races. The Section on Special Constituencies and the Sections on Medical Students and Residents also have the ability to select nominees for the board. The Member Assembly will elect members of the board and officers at Annual Session and Primary Care Summit in Dallas, November 4-6. Here is the proposed slate of directors and officers for 2016-17: President-elect: Janet Hurley, MD Vice President: Jake Margo, Jr., MD Treasurer: Rebecca Hart, MD

PUBLIC HEALTH AND RESEARCH

Parliamentarian: Amer Shakil, MD, MBA

TAFP meetings present an opportunity to gather and participate in discussion on a variety of topics. Members can attend section meetings at TAFP’s Interim and Annual Session on maternity care, rural health and research.

Delegate to AAFP: Doug Curran, MD

The Commission on Public Health, Clinical Affairs, and Research invited guest speakers to lead discussions on Zika and an HIV Strategic Plan being developed by DSHS and HHSC. The commission also recommended a resolution be submitted to AAFP regarding breast cancer screening guidelines for women who have dense breasts.

New Physician Director: Angela Cade, MD; Ikemefuna Okwuwa, MD

The commission oversees a research poster competition at TAFP’s Annual Session and Primary Care Summit each November. Students, Residents

Alternate Delegate to AAFP: Troy Fiesinger, MD Alternate Delegate to AAFP: Ashok Kumar, MD (unexpired term)

At-large Director: Emily Briggs, MD, MPH; Grant Fowler, MD; Oscar Garza, MD Special Constituency Director: Mary Nguyen, MD Resident Director: Samuel Mathis, MD Medical Student Director: Carissa Huq The Nominating Committee will make recommendations to [cont. on 12]

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[cont. from 12] the TAFP Board for members wishing to serve on an AAFP Commission this summer. Interested members should contact Kathy McCarthy at kmccarthy@tafp.org by July 8. The Bylaws Committee made several recommendations that will clarify, correct, and bring the document into alignment with current practices. The amendments will be voted on by the membership at the Annual Business Meeting during the TAFP Annual Session and Primary Care Summit in Dallas. The proposed amendments will be printed in the summer issue of Texas Family Physician. The Finance Committee reviewed TAFP’s financial reports and investments. They recommended a budget adjustment for FY16.

MEMBER HIGHLIGHTS The Nominating committee recommended to the board that Justin Bartos, MD, be nominated to serve as Chair of AAFP Commission on Membership and Member Services. He is in his fourth year of service on the commission. The Commission on Continuing Professional Development selected program chairs for TAFP’s educational programs for the near future. Program chairs include Sharon Hausman-Cohen, M.D. and Gretchen Crook, MD, for the 2017 C. Frank Webber Lectureship; Lesca Hadley, MD and Kristi Salinas, MD for the 2017 Texas Family Medicine Symposium in San Antonio; and Rebecca Hart, MD and Ike Okwuwa, MD for the 2017 Annual Session and Scientific Assembly in Galveston.

The Section on Residents held elections for officers and delegates. Charvi Shah, MD, from UTMB Galveston was elected chair and Samuel Mathis, MD, from Memorial was elected to be the nominee for the Resident Director on the TAFP Board of Directors. They elected Katelyn Davis, MD, from JPS as chair-elect and Aryanna Amini, MD, from Memorial as secretary. The delegate and alternate delegate to National Conference are Shiv Agarwal, MD, from JPS and Brittany Taute, MD, from Texas Tech Amarillo. The delegates and alternates to TAFP’s Member Assembly are David Wilson, MD, from JPS; Mayralis De Jesus Cortes, MD, MPH, from UT San Antonio; Tracey Angadicheril, DO, from UTMB Galveston; and Carla Basadre Quiroz, MD, from UT San Antonio. The resident liaison is Jim

Carmical, MD, from JPS. The Section on Medical Students met and held elections for officers and delegates for the coming year. Carissa Huq from Texas A&M was elected chair and the nominee for the Student Director position on the TAFP Board of Directors, Matthew Dow from TCOM was elected secretary and Jason Johnston from UT Houston was elected chair-elect. The delegate and alternate to AAFP’s National Conference are Hilary Hopkins from UT San Antonio and Abigail Smith from UT Houston. The FMIG liaison is Herbert Rosenbaum from UT Southwestern. The delegates and alternates to TAFP’s Member Assembly are Miranda Wang from Baylor, Caj Johansson from UT Houston, Herman Gonzalez from TCOM and Romero Santiago from UT Southwestern.

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TEXAS FAMILY PHYSICIAN [No. 2] 2016

6/12/11 7:18:42 PM

FROM AAFP

MACRA is coming Your Academy has resources to help By Shawn Martin

little more than a year ago, Congress approved the Medicare Access and CHIP Reauthorization Act, or MACRA, by substantial bipartisan votes of 392-37 in the House and 92-8 in the Senate.

tice for MACRA?” I encourage you to visit the AAFP’s MACRA resources page. Here you will find information, tools, and resources that are designed to help you better understand the new law. There you will find:

To put these votes in context, 91 percent of Congress voted to repeal the flawed sustainable growth rate formula and put our nation’s health care system on a new trajectory. On April 16, 2015, President Obama enacted this historic legislation into law. With a single stroke of the pen, the entire construct of how physicians are paid for their services changed.

• a MACRA overview video,

During the past 11 months, AAFP has been diligently reviewing and analyzing MACRA to better understand the law so we can prepare and position you for success. In addition, we initiated programs aimed at educating family physicians about the coming changes with respect to delivery system and payment reforms.

• AAFP News resources; and

We launched a resource center and published content designed to assist you in understanding the scope and implications of the law. My colleague Amy Mullins, MD, wrote a great primer for Family Practice Management entitled “Making Sense of MACRA.” (www.aafp.org/fpm/2016/0300/p12.html) In May, we ramped up our efforts in a big, big way through the announcement of MACRA Ready — www.aafp.org/macraready — a multi-faceted, multi-year campaign aimed at preparing our members for the new delivery reforms and payment pathways created by the law. The campaign features educational content on how the law is structured and functions, timelines for implementation, and tools aimed at helping you and your practice understand and prepare for one of the two payment pathways. The most common question I am asked these days goes like this: “What should I be doing to prepare myself and my prac

• a set of frequently asked questions, • an implementation timeline, • a list of MACRA acronyms, • a practice readiness assessment,

• our four-page PDF infographic, Making Sense of MACRA.

AAFP has also produced a series of MACRA webinars you can access from the MACRA Ready homepage. Click the button labeled “Watch the Modules” in the MACRA 101 section. This four-part series provides you with: • an overview of MACRA; • an introduction to the Medicare Incentive-based Payment System, or MIPS; • an introduction to Alternative Payment Models, or APMs; and • information about your current payment track.

While you’re on the MACRA Ready homepage, I encourage you to click the button to sign up for MACRA email updates from AAFP. These periodic emails will provide you the latest details on the new payment law and access to the latest tools and resources from AAFP. www.tafp.org

I often refer to MACRA as a historic law. Besides the fact that it repealed the SGR, MACRA made a substantive and meaningful change in the ideology of the Medicare physician payment formula by shifting from payment for episodes of care to payment for the longitudinal quality of care provided to patients. Most importantly, the new law took significant steps to place an expressed emphasis on the importance of primary care.

Visit AAFP’s MACRA Ready site: www.aafp.org/MACRAready

During the past year, I have had the opportunity to discuss MACRA with thousands of family physicians across the country. It is fair to say that many are anxious about these changes and eager to learn what the new law will mean to them and their practice. This is completely understandable. I firmly believe that the SGR was one of the worst health care policies ever enacted into law and that family physicians and our health care system are far better off since it has been sent to the garbage pile of failed policies. However, I do understand that the SGR and the traditional fee-for-service system were familiar and, no matter how bad they were, you knew and understood them. I often refer to MACRA as a historic law. Besides the fact that it repealed a severely flawed payment formula, MACRA made a substantive and meaningful change in the ideology of the Medicare physician payment formula by shifting the concept of payment from payment for episodes of care to payment for the longitudinal quality of care provided to patients. Most importantly, the new law took significant steps to place an expressed emphasis on the importance of primary care. Although there has long been an academic and conceptual belief that a health care system built on a primary care foundation is beneficial to patients and payers, there had never been a policy manifestation of this ideology — until now. This law, by design and intent, places a renewed emphasis on primary care delivery models and goes so far as to protect them from financial risk in the APM pathway. This renewed approach to primary care was set in motion as part of MACRA, but it can only be achieved as a result of the regulations issued by CMS. Therefore, the approach taken by CMS to implement MACRA is key. On May 5, CMS Acting Administrator Andy Slavitt tweeted some information, and I think you will be pleasantly surprised by what he had to say.

“Must start with a core belief that MDs know best how to take care of patients and allow freedom”

“Must simplify the practice of medicine: reduce burden, add flexibility, and provide support at every turn”

“Pay more to PC [primary care] for care coordination, for dialogue, for cost of care outcomes”

I respect that some of you will disagree that MACRA holds any opportunity or value, and I look forward to hearing your thoughts, concerns, and suggestions. I can promise you this, AAFP will do everything we can to provide you information, resources, and tools that will allow you to be successful under one of the two new payment pathways.

Source: AAFP “In the Trenches” Blog, May 10, 2016. © American Academy of Family Physicians. 14

TEXAS FAMILY PHYSICIAN [No. 2] 2016

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TEXAS FAMILY PHYSICIAN [No. 2] 2016

WHAT CAN THE

TMF HEALTH QUALITY INSTITUTE

DO FOR YOU? By Jonathan Nelson

Do you remember what you were doing two years ago today? What patients did you see that day? What about the day before? How well were you coordinating care for your chronically ill patients? Here’s a scary question: how much do you know about the care your patients were receiving from physicians and other providers outside of your practice? In the steady march from “volume to value” in how we pay for health care services, what happened two years ago is increasingly important to the amount you get paid for Medicare services you provide today. Since the passage of the Affordable Care Act, the Centers for Medicare and Medicaid Services have launched a series of payment experiments using both incentives and penalties in hopes of bending the health care cost curve and improving the quality of care patients receive. Along the way, they have invented a jumble of acronyms and a maze of initiatives, each seemingly designed to be more confusing than the last. And now with the passage of MACRA — the Medicare Access and CHIP Reauthorization Act of 2015 — the stakes have been raised yet again.

www.tafp.org

Under MACRA, physicians will either choose to participate in the Merit-Based Incentive Payment System or they will practice in an Alternative Payment Model. MIPS will be a combination of the Physician Quality Reporting System, the Value-Based Payment Modifier Program, and Meaningful Use, while APMs will offer Medicare an avenue for paying physicians in advanced delivery models like accountable care organizations and patient-centered medical homes. Whichever path you take, you’ll have to be able to report your quality and resource use data effectively and efficiently, and you’ll have to understand how the services your patients receive from other providers will affect your value scores. Unfortunately you don’t have long to get good at reporting this information or to implement quality improvement initiatives. Payment bonuses and penalties under MIPS and APMs start in 2019, but they will be based on 2017 performance data. Lucky for you there’s an organization in Texas dedicated to helping physicians and other providers succeed in the various CMS measurement programs and demonstrate their level of quality. TMF Health Quality Institute is the CMS Quality Improvement Organization for Texas and in 2014, it became the Quality Innovation Network QIO for Texas, Arkansas, Missouri, Oklahoma, and Puerto Rico. They work with hundreds of practices across the region, providing technical assistance, consultation, and education on a variety of quality improvement initiatives like behavioral health, diabetes, cardiovascular health, and immunizations. “Our job is to help any practice that accepts Medicare to improve their quality,” says Russell Kohl, MD, medical director for practice

transformation at TFM Health Quality Institute. The company runs projects with hospitals, nursing homes, and other health care venues, but Kohl says physician practices are a top priority for TMF. “We try to focus as much as possible on the actual individual doctor’s office, and the great thing about it is all the stuff we provide is completely free.” That’s right. Free. TMF is a nonprofit company that receives funding directly from CMS to help physicians improve the quality of their care and properly meet federal quality reporting obligations that affect physicians’ future payments. It’s those future payments that have Kohl and his colleagues concerned. Take the Physician Quality Reporting System, or PQRS, for example. CMS initiated the program by offering positive payment adjustments for participating physicians but in 2015, CMS started issuing negative payment adjustments to physicians who didn’t satisfactorily report on services provided back in 2013. That trend is going to continue and the penalties get steeper in the new Medicare payment model. “If a practice sits back and doesn’t try to figure out how to do things really well, what they are likely to end up with is a situation where 2019 hits, they take a significant cut to their finances, and they start trying to do the work then. Well we know that to really go in and try to optimize the way a practice works, that takes time. It’s not something you just change overnight.” A family physician from Oklahoma, Kohl was the chief medical officer for AAFP’s TransforMED before joining TMF, so he’s seen practice transformation up close. “If they are not starting until 2019 or 2020,

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they are looking at not being in a position to be successful until 2022 or 2023, and they are going to be dealing with things like 10 percent penalties on their payments each year from 2020 on.” By signing up to join TMF’s Value-Based Improvement and Outcomes Network, physicians can interact with experts and peers who can help them understand and meet the CMS goals of the physician value-based payment and quality reporting programs. Recently a major focus for the network has been showing physicians how to access and interpret the quality and cost information CMS provides in the quality and resource use reports, or QRURs. Although these dense reports indicate how physicians will fare under Medicare’s value-based payment model, many physicians don’t even know they exist. “The QRURs are daunting,” says Suzie Buhr, BSN, RN, CPHQ, a quality improvement consultant with TMF. She says many large practices with ample resources are using the reports successfully but that’s not the case for everyone. “Our concern is the smaller practices that don’t necessarily have all the manpower, so this is very new to them and they don’t really have an understanding of it yet. We are available to help walk them through the report.” In the Value-Based Improvement and Outcomes Network, TMF consultants help physicians understand and analyze their QRURs, then they help put that information to good use. The consultants can work inside the practice to identify gaps in quality and reporting procedures and help implement strategies to close those gaps. Physicians and their office staff also have access to a broad spectrum of educational materials, including online information exchanges, webinars, videos, conferences, how-to instruction manuals, and more.

Keeping the game fair...

Kohl says often TMF consultants can identify process changes inside a practice’s daily workflow that improve quality and reporting with little disruption and without “killing the doctors.” “Most of the time, if more work is being piled on the doctor, it’s because they don’t really understand how the workflow of the practice should go,” he says. “So a lot of what we do is actually taking work away from the doctor that doesn’t require a medical degree to be done, building processes in the practice so the right person can do it at the right time, and freeing up some of that time for the doctor to either just stop and take a breath for a minute in the day or to have the time to do the stuff they really need to be doing.” In fact, TMF consultants often work with practice administrators rather than physicians to implement quality improvement and reporting strategies. That’s how it went for the Youens and Duchicela Clinic in Weimar. In 2011 the practice contacted TMF for help with PQRS. The consultants worked mainly with the practice IT manager, Amanda Ritzen, to identify quality measures they could report and optimize templates in the practice’s electronic health record so they could collect the right data. “It wasn’t necessarily too much of an extra step for us because we were doing these things already,” she says. “It was more or less a couple of extra clicks to make sure that those templates captured those codes so we could report on them after the first of the year.” She says the program runs smoothly with the physicians’ current workflow. “Everyone has a busy schedule with lots of things to manage, but the good thing about TMF is they assign one or two people to work with you and they work around your schedule.”

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“A lot of what we do is actually taking work away from the doctor that doesn’t require a medical degree to be done, building processes in the practice so the right person can do it at the right time, and freeing up some of that time for the doctor to either just stop and take a breath for a minute in the day or to have the time to do the stuff they really need to be doing.” — Russell Kohl, MD

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TEXAS FAMILY PHYSICIAN [No. 2] 2016

BEHAVIORAL HEALTH AND TMF The Value-Based Improvement and Outcomes Network is only one of TMF’s learning networks. Others cover EHR care management, population health management, diabetes, cardiovascular health, immunizations, Meaningful Use, and more. In April, TMF launched a new initiative to improve integration of behavioral health into primary care. The TMF QIN-QIO has engaged with more than 200 practices in each of its four states plus Puerto Rico to increase screening for depression and alcohol use disorder. A psychiatrist in Frisco, Clifford Moy, MD, leads the project as TMF’s medical director for behavioral health. “In the Medicare beneficiary population, behavioral health disorders have been identified as a significant comorbid set of conditions that adversely affect other medical conditions such as diabetes, hypertension, COPD, and generally result in poorer outcomes,” he says. “The hope is with this project, by increasing screening, identification, and treatment, we can improve the overall health outcomes for the Medicare population. We believe this needs to occur in the primary care setting where care can be better coordinated.” Moy says a number of factors have led to low screening rates for depression and alcohol use disorder in the primary care setting but that now, a number of validated screening tools are available that can be administered to patients or completed by patients outside of the clinic. “This is really going to be a game changing process if we can make this work and identify these patients so they can get treatment.” Behavioral health screening services are billable under Medicare Part B and they also serve as reportable quality measures under Medicare’s value-based care programs. Moy says putting systems in place to ensure these services are provided to Medicare patients in primary care practices is good for patients and their doctors. “We believe that improving the overall health of a physician’s panel of patients is going to improve the physician’s financial outlook as well. This is something we believe is a win-win. Patients will have better health, they’ll get treatment, and physician practices will see better patient outcomes and the health of their practices should improve, employed or not employed.” To gain access to TMF’s behavioral health tools and resources and to benefit from what they learn over the course of this project, go to www.TMFQIN.org and join the behavioral health network. Joining this network or any of their other networks is the first step to taking advantage of what TMF has to offer. As one of 14 QIN-QIOs across the country, TMF has access to a massive amount of information and case studies on how to improve quality in a multitude of practice settings, and as the CMS contractor for quality improvement, they are empowered to help physicians succeed. By joining their networks, you can engage their resources at any level you wish, using as much or as little of their services as you like. “With everything going on in health care right now, there are all sorts of people who have gone into the business of practice transformation, or practice consulting,” Kohl says. “Some of them are great organizations with long track records and know exactly what they are doing. Others are people who just spotted that this is a great time to be a consultant in health care. ‘I can make a lot of money and be gone by the time it’s over.’” He says if you consider the history of TMF, you don’t have to worry about what you’re going to get. “It was started by Texas physicians specifically to improve quality. We still have that relationship. We are working with Medicare on a daily basis to try and give practices the things they need to be successful.”

The Quality and Resource Use Report: How will your practice get paid? By TMF Health Quality Institute According to the Centers for Medicare and Medicaid Services, Quality and Resource Use Reports provide comparative information so that physicians, either in a group or individual practice setting, can view examples of the clinical care their patients receive in relation to the average care and costs of other physicians’ Medicare patients. These reports — often referred to as QRURs — are similar to a report card, with the end goal being to achieve practice improvement and bonus payments. Ultimately, the report will suggest how solo practitioners and groups will perform under the Value-Based Payment Modifier program. How a physician or physician group will fare depends on the quality of care they provided and the cost, or resource use, for those services, which will adjust a physician’s or group’s Medicare payment under the Value-Based Payment Modifier program. Reviewing and learning to understand the QRURs now will help solo practitioners and groups learn in which areas they need to improve. QRURs are generated for all solo practitioners and groups nationwide, as identified by their Taxpayer Identification Number. These reports are confidential. QRURs can be used to see how your practice compares with others caring for Medicare beneficiaries. Recently, the 2015 Mid-Year QRURs were released.

However, mid-year reports are not comprehensive and may change somewhat when the annual report is released in the fall. Be sure you have access to view the 2015 Annual QRUR when it is released in the fall of 2016. This will be used to calculate your value modifier score and effect payment for 2017. For more information on QRURs, go to www.cms.gov, click on Medicare at the top, and go to Medicare Fee-for-Service Payment section. From there you can find information on how to obtain a QRUR plus the following documents: • How to Obtain a QRUR • Quick Reference Guide for Accessing the 2015 Mid-Year QRURs and Tables • How to Understand your 2014 QRUR and Supplementary Exhibits • Sample 2014 Annual QRUR • FAQs about QRURs and the 2016 Value Modifier The TMF Quality Innovation Network is hosting upcoming events for the benefit of physicians and hospital health care professionals. You can learn more by visiting www.TMFQIN.org and clicking on the Events tab.

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PRACTICE MANAGEMENT

ICD-10 coding: Specificity is the key By Bradley Reiner Do you remember Y2K? Think back to the panic that occurred as people predicted that all computers would shut down and global electronic warfare would start. Did any of that happen? No. Nothing happened; nothing changed. Everyone just woke up to the start of another year. I think there were some similarities between Y2K and ICD-10. Everyone expected massive claim rejections, payment delays, and code denials. Did anything really happen beyond normal claims payment issues? No. Not much changed. Claims were paid or denied with ICD-10 codes just like claims were paid or denied with ICD-9 codes. The whole thing seems like a big scare tactic used by businesses to make money. Am I naïve enough to believe a new payment system is not coming? Of course I’m not. I feel certain we are headed to a different payment system for physicians and it is likely that ICD-10 is what will help get us there. The specificity has dramatically increased and practices must learn to do a better job in accurately describing the services they are providing at each visit. I recently provided an ICD-10 review for a practice predominately composed of primary care physicians. The results of the review were interesting. Check out some of what I found in the list to the right. I hope these examples will help you avoid some of the common problems I discovered. In this review, you can see these physicians need to improve the specificity of documentation and coding. It is critical to ensure that all ICD-10 codes are addressed in the record. In addition, it is important for doctors to code only the services that are actively being treated. If you review these coding issues and follow the recommendations for this practice, you will be well on your way toward taking the mystery out of ICD-10 coding. Bradley Reiner, of Reiner Consulting and Associates, is TAFP’s endorsed consultant and is a billing and coding auditor for the Texas Medical Board. He can be reached at (512) 858-1570 or breiner@austin.rr.com. Visit www.tafp.org/practice-resources/reiner. 22

TEXAS FAMILY PHYSICIAN [No. 2] 2016

From the case files of Bradley Reiner • A claim was coded R06.02 — shortness of breath. The patient was experiencing chest pain so there was an incorrect diagnosis submitted with this claim. • A claim coded with I10 — primary hypertension. Although this diagnosis may have been an underlying factor in the patient’s record, this diagnosis was not addressed or managed in the encounter and, therefore, should not have been coded on the claim. • A claim with urinary tract infection coded N39.0. According to ICD-10 rules, when coding a urinary tract infection the site must be mentioned, together with the bacterial cause (such as E. coli). • A claim was billed with an arthropathy code, M12.9, which requires the physician to document the causal condition of the arthropathy if applicable. Unspecified codes should be avoided. • A claim coded with I25.10 — arteriosclerotic heart disease. The documentation mentioned the patient had a previous MI and therefore it should have also been coded with 125.2. • A claim coded with ICD-10 code R60.9 — unspecified edema. The assessment listed the edema as secondary to vascular insufficiency and medications. This would require a more specific code to be assigned. • A claim coded with E03.9 — hypothyroidism, unspecified. When coding hypothyroidism, the provider should document the type and if the condition is with or without goiter. • A claim coded with K80.19 — calculus of the gallbladder with cholecystitis and obstruction. The record documented elevated liver enzymes which should also be coded. • A claim coded with ICD-10 M81.0 — age-related osteoporosis without current pathological fracture. The medical record must include the region as well as the laterality. • A claim billed with S20.02XA — contusion of the left breast, initial encounter. When coding injuries, the cause of the injury must also be listed. This patient had a fall resulting in the contusion. Causal code W01.190 should also have been included. • A claim billed with a primary diagnosis of L40.0 — psoriasis vulgaris. The record did not specify the type of psoriasis which is necessary to bill this code. • A claim coded with ICD-10 I12.9 — hypertension with chronic kidney disease. The record addressed hypertension, but did not indicate the patient had chronic kidney disease. In addition, there was an ICD-10 code for the stage of kidney disease, but the record didn’t give any information regarding the stage. • A claim billed with E11.22 — type 2 diabetes with chronic kidney disease. No information was documented in the record regarding this diagnosis. • A claim billed with a primary diagnosis of mood disorder due to known physiological condition. This requires the coder to bill the underlying physiological condition. There were other codes, including F43.23, which may have been more appropriate. There were other diagnosis codes listed on the claim that were not addressed in the record. Codes should not be billed if they are not addressed specifically in the medical record.

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Question 2 — Investigations and disciplinary actions

Dos and don’ts of renewing your Texas medical license By Franklin Hopkins

Every two years, physicians licensed by the Texas Medical Board are required by law to renew their medical license either online or by mail. During registration, physicians must answer questions regarding any status changes since their last renewal. However, certain answers or omissions can trigger an investigation by the Board, and physicians may find themselves explaining their answers before an Informal Settlement Conference. Two of the six questions in the “Professional History” section of the renewal application are routinely misunderstood and are often the cause of a board investigation. To illustrate the dos and don’ts of renewing your Texas Medical License, these two questions (questions 2 and 3) are presented here along with an examination of where misunderstandings may occur and a hypothetical example of how a physician may consider responding. 24

TEXAS FAMILY PHYSICIAN [No. 2] 2016

“Since your last registration or submission of your license application, not including investigations and disciplinary actions by the Texas Medical Board, are there pending investigations, pending disciplinary matters, or final disciplinary actions against you by any licensing agency or health-care entity?”

Where misunderstandings may occur To answer this question, the physician must fully understand the definitions of “licensing agency” and “health-care entity.” The meaning of “licensing agency” is pretty clear. If the physician is licensed in another state and that state’s board is investigating the physician, or has pending (or final) disciplinary action against that physician, that physician must report it. But the scope of what constitutes “health-care entity” is less clear. Section 151.002 (5) of the Medical Practice Act defines a health care entity to include a hospital, clinic, practice group, health maintenance organization, medical school, professional medical association, and the like. Such entities’ investigation and disciplinary process is ordinarily known as a “peer review.” Peer review may take many names, such as a credentialing committee, performance review committee, performance improvement committee, etc. No matter what title the hospital gives to its peer review type committee, investigations and actions taken by it are subject to TMB reporting requirements. The Medical Practice Act also defines “disciplinary action” broadly. Reportable actions may include seemingly routine actions by credentialing committees. For example, if a physician voluntarily relinquishes his or her privileges or decides not to renew privileges while an investigation is pending, that constitutes a reportable disciplinary action. Keep in mind, the Board does not automatically accept a hospital’s peer review action. The Board is required by law to independently verify any allegation found by a health care entity. Physician example In March, Physician A, an orthopedic surgeon, performed spinal stimulation surgery on a patient. Unfortunately, the patient had complications that prompted the hospital to initiate a peer review proceeding. That June, with a peer review pending, Physician A renewed his license and failed to disclose the pending peer review. What should Physician A have done? It would have been better for Physician A to report the pending peer review. Within the renewal, Physician A would have the opportunity to explain the circumstances of the review. In addition, Physician A may supply letters of support from hospital supervisors and peers and inform the Board if the review allegation is determined to be “unfounded.” Physician A could even submit an independent expert report verifying that there were no violations of the standard of care.

Where misunderstandings may occur Physicians must report these events. It doesn’t matter whether the local prosecutor has dismissed or dropped the charges. Physician example In January 2014, Physician B was arrested for DUI. The prosecutor did not pursue the case, and the charges were dismissed shortly thereafter. In February 2015, Physician B renewed her license, but did not report her arrest since the DUI was dismissed. What should Physician B have done? Reporting the arrest from January 2014, along with the dismissal in September, would have been appropriate. She may have also supplied the Board with letters of support from supervisors, family, and friends, along with a personal letter explaining what happened. Physician B would also be wise to obtain an examination by a substance abuse counselor to show the Board that she does not have an alcohol problem. The best approach to these Board questions is to disclose with explanation. The Board may be more concerned about a failure to report than the subject of the omission. Failing to report creates an impression that you have something to hide.

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“Since your last registration or submission of your license application, have you been arrested, fined, charged with or convicted of a crime, indicted, imprisoned, placed on probation, or received deferred adjudication? (Unless the offense involved alcohol or drugs, you may exclude: 1) traffic tickets; and 2) violations with fines of $250 or less).”

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Franklin Hopkins is an Austin-based attorney, Board Certified in Administrative Law, with Germer, PLLC. He can be reached at (512) 750-8020 or efhopkinsiv@gmail.com. Source: TEXAS MEDICAL BOARD RULES Chapter 190, Disciplinary Guidelines §190.8. Violation Guidelines: (4) www.tmb.state.tx.us/idl/70D324A9-A879-BF1A-FEF1FDC92D8C4FB4. All examples are hypothetical and not based upon actual physicians or cases. This article is purely informational and not intended to be legal advice and should not be construed as such. This article was reprinted with permission from Texas Medical Liability Trust.

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RESEARCH

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

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

GOLD LEVEL Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White SILVER LEVEL Carol and Dale Moquist, MD TAFP Red River Chapter

The urgently non-urgent: Why do family medicine residency program clinic patients choose to go to urgent/emergent care facilities as opposed to their primary care physician for non-urgent matters? Theresa Le, MD Christina Casey, DO Ronya Green, MD, MPH Vonda Mayfield, RN

BRONZE LEVEL Joane Baumer, MD Gary Mennie, MD Linda Siy, MD Lloyd Van Winkle, MD George Zenner, MD

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Introduction In the last few decades, the number of non-urgent visits to the emergency room has drastically increased. According to a study in the late 1980s, patients without primary care providers sought medical care at emergency rooms more often than those with primary care providers.3 Unfortunately, this remains the case today. Proposed reasons for this dilemma include: PCP inaccessibility, lack of available same day appointments, faster and more convenient service through the emergency room, and lack of financial resources.1, 2 The purpose of this study is to determine what factors influence family medicine residency program clinic patientsâ&#x20AC;&#x2122; choice to go to urgent or emergent care facilities as opposed to their primary care physician for non-urgent matters. As an intervention, increasing schedule availability of same day appointments was performed. The number of emergent and urgent care visits among the clinic patients before and after the planned intervention were compared.

Methods During the first month of the study, surveys were randomly administered to 312 patients who presented to the family practice clinic. Posters were hung around the clinic (waiting area, exam rooms, restrooms, checkout area), advertising the availability of same day appointments to encourage patients to contact the clinic for non-urgent issues. During the second month, one designated resident physician was open for same

day acute clinic visits. Throughout the third and final month, the same surveys were randomly administered to 312 patients who presented to the clinic.

Results The demographics of the patients who were surveyed reflected that of the family medicine clinic â&#x20AC;&#x201D; primarily female, ages 36-65, and government insurance payers. The percentage of patients surveyed pre and post interventions who did not call the clinic prior to going to the ER were 69 percent and 73 percent, respectively. The most common reported chief complaints by both pre and post surveyed patients who went to the urgent clinic or ER without calling the family practice clinic were cardiac (24.6 percent) and respiratory (17.7 percent) complaints. During the intervention period, over 100 patients were seen as acute, same day appointments. The most common types of complaints that were evaluated in the family medicine acute clinic visits were respiratory (24.6 percent), integumentary (19 percent), and musculoskeletal (16.2 percent).

Discussion The percentage of patients surveyed pre and post interventions who did not call the clinic prior to going to the ER were similar, 69 percent and 73 percent, respectively. There are various hypotheses as to why there was not a change in the patientsâ&#x20AC;&#x2122; reported behaviors. First, one month of advertisement for same-day [cont. on 28] www.tafp.org

[cont. from 27]

appointments may not have been a sufficient amount of time to capture a significant number of patients’ attention. Many patients often schedule their followup appointments for at least one month out. Therefore, only a finite amount of patients who happened to go to the clinic during the first two months of this study were aware that same day appointments were being offered. Another potential contribution is that the advertising posters were not attention grabbing enough. It is possible that the patients did not see them. Additionally, many of our patients are not aware that the clinic has an on-call physician who is available, via telephone, to triage patients’ medical concerns after hours. It is not common practice to inform patients that this service is available and consequently, many patients go straight to an outside facility for care rather than calling the clinic for assistance first. Lastly, patients may perceive that their problems are truly acute and warrant evaluation at an ER rather than an outpatient clinic. Survey results indicated that there were differences between the pre and post intervention groups regarding the reason why they chose to go to the ER instead of calling the clinic. Twenty-one percent of the preintervention patients reported that going to the ER was faster. This was surprising since ER wait times can potentially last all day in contrast to a theoretically shorter clinic wait time given defined open office hours. However, patients may have the opposite perception because they are triaged immediately upon arrival to the ER compared to sitting in a clinic waiting room before seeing a nurse. On the other hand, 35 percent of the post-intervention group of patients reported not calling the clinic because it was closed after hours. This may stem from the patients’ lack of awareness regarding the availability of an on-call physician via telephone after hours as discussed above. With the availability of same-day visits, more than 130 patients had their acute problems addressed within 24 hours of calling the clinic. This volume generated $10,377 in revenue in only a single month.

Conclusion In conclusion, patients surveyed at the clinic had the perception that it is difficult to obtain same-day appointments and be evaluated in a comparable time as going to the ER for non-urgent issues. However, when offered same day appointments, a significant number of patients accepted the option and as a result, more than 130 patients were seen in a month’s time span, which translated into a potential reduction in ER visits. By having a designated clinic for acute visits, patients could potentially adopt a new culture of seeking medical care from their PCP for non-urgent issues rather than going straight to the ER. Programs like these can potentially provide the necessary groundwork to stop the ER “Revolving Door,” and reduce the quantity of 28

TEXAS FAMILY PHYSICIAN [No. 2] 2016

non-urgent ER Visits. In doing so, they can lessen the burden on the ER infrastructure and allow providers to invest more time in actual emergencies. Future studies could include assessing whether acute visits are truly acute because oftentimes, patients’ and physicians’ perceptions on acuity differ. Also, there could be value in assessing whether educating patients about the availability of an on-call physician after hours would further influence their decision about where to seek medical care.

References 1. Baron, S, Gutherz C. Why Patients with Primary Care Physicians Use the Emergency Department for Non-Urgent Care. Einstein Quarterly Journal of Biology and Medicine 2001; 18:171-176. 2. Flores-Mateo G, Violan-Fors C, Carrillo-Santisteve P, Peiro S, Argimon JM. Effectiveness of Organizational Interventions to Reduce Emergency Department Utilization: A Systemic Review. Plos One. 2012; 7:1-6. 3. Haddy TI, Schmaler ME, Epting RJ. Non-emergency emergency room use in patients with and without primary care physicians. Journal of Family Practice. 1987; 24:389-392.

This project was presented at the following conferences: FMX AAFP Annual Meeting September 2015, Denver, CO TAFP Annual Session and Primary Care Summit November 2015, Woodlands, Texas received first place in the Primary Research Resident Category Texas Osteopathic Medical Association Mid-Winter Conference January 2016, Dallas, Texas

PERSPECTIVE

Family physicians: Count your blessings By Norm Clothier, MD

i have carefully observed that we as family physicians are a rather hard-working group. The demands on our expertise and time are extraordinary. It is a true calling of service to our fellow man. Many days bring joy! Alas, many days do not. Some days we wonder why we do what we do, and how much longer we can carry on. I would guess that you have felt one of these emotions in the past six months: • Overwhelmed by the number of patients, phone calls, emails, and patient portal comments. • Harassed by an insurance system requiring a prior authorization on a generic medicine or the annual change to a “formulary” product, rather than stability, for your patient. • Frustrated by your EMR (I know this is a stretch). • Pressed for time and desirous of more efficiency.

I worked primarily in the medical clinic while in Jinotega. We had a room partitioned into three small treatment areas, separated by sheets hung from the ceiling. I’m accustomed to washing my hands frequently, what seems like 400 times per day. In this clinic, there was no sink.

I was blessed with the opportunity to take about 30 high school students on a mission trip to Nicaragua last summer. We went to the town of Jinotega, where we worked from a mission compound that spreads its reach and influence over the entire region. Among the many services provided to the people was a dental and medical clinic. I worked primarily in the medical clinic while in Jinotega. We had a room partitioned into three small treatment areas, separated by sheets hung from the ceiling. I’m accustomed to washing my hands frequently, what seems like 400 times per day, and I apparently do it well, according to my patients in helping with my board certification activities. In this clinic, there was no sink. I worked with two very good translators, thankfully. We saw many people daily, mostly with acute illness, but two things seemed to always be tacked on at each visit. The first was the length of time since the last parasite treatment, due to the lack of a clean water supply. The second was essentially “I hurt all over.” Physical labor is ubiquitous to the region. The people wear themselves out, and the aging

TEXAS FAMILY PHYSICIAN [No. 2] 2016

of the body is clearly accelerated. If one sits at a computer all day here in Texas, the wear and tear just isn’t the same (although a “happy medium” would seem to be best!). About halfway through the week, I realized that most of the patients I saw had walked as far as four or five hours to come to the clinic. The reputation of the clinic was one of compassionate, free care, with no restriction on what would be evaluated. Nearly every patient asked if I was an American. I found it incredible that they trusted me so much, when they really knew nothing at all about me, and we couldn’t converse except through the interpreter. I also found Jinotega to be quite interesting. The most ornate area of the city was the cemetery. Jinotega is referred to as “The Eternal City of Men” or perhaps more interestingly, “The City of Eternal Men.” Quite a reputation! It turns out that the name “Jinotega” in the native historical tongue means “mangy tree.” There certainly were mangy dogs! I don’t know of many towns that would trade for the “mangy tree” reputation. My trip helped me realize most things I complain about are petty. I get to serve patients that drive to see me, that have a clean water supply, and that have resources for their care. And we can both wash our hands at any time we wish during the visit! I started with the list of things we often feel. Here is what I want to feel, and that I believe we all can feel, as family physicians: • Blessed by the joy of having patients who put their trust in my hands and actually want my opinion. • Blessed that I get paid for what I do. • Blessed that we have electricity, even if it means EMR, and that we have sinks and clean water. • Blessed that I have the time that I do, although it never seems to be enough. Count your blessings, colleague! And keep on serving, and serving, and serving those to whom you have been called.

ine c i d e m y l i fam f o e r u t u he f t e p a h s p hel

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

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