texas family physician VOL. 63 NO. 3 SUMMER 2012
Shared Savings And Pioneer ACOs On The Rise In Texas Texas Medical Board Rules You Should Know “Choosing Wisely” Campaign Aims To Cut Costs, Improve Quality Report From Family Medicine Chief Resident Conference
SPECIAL LEGISLATIVE EDITION
Condition Critical
The Case For Rescuing Primary Care In Texas
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INSIDE
20 TEXAS FAMILY PHYSICIAN VOL. 63 NO. 3 SUMMER 2012
6 PRESIDENT’S LETTER Enduring the frustrations of technological advancement
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8 NEWS CLIPS A look at physician compensation in 2011 | Patients use social media to access health info | HIT adoption on the rise | Physicians are going to work for hospitals in growing numbers | AAFP membership by the numbers
Two Texas ACOs to test accountable care
With the establishment of the final rule for the Medicare Shared Savings Program and 27 organizations named as its first participants, the CMS-approved accountable care organizations must now prove what many have known for decades: that preventive, coordinated care based on a foundation of primary care can save our failing health care system.
By Kate Alfano
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Primary care in Texas: Condition critical For the sake of Texas’ citizens and its economy, the 83rd Texas Legislature must renew its investment in primary care.
By Jonathan Nelson
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Three more TMB rules you should know
TMLT presents the second of a two-part series on Texas Medical Board rules physicians may unknowingly break, addressing death certificate requirements, standing delegation rules, and office-based anesthesia rules.
By TMLT Risk Management Department
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Reduce waste, save billions
Top experts say we can save hundreds of billions by targeting waste in six key categories.
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AAFP urges docs to choose wisely
Academy joins several groups in a new campaign to cut unnecessary medical services.
12 MEMBER NEWS Chief residents gather to hone skills | Family docs elected to TMA leadership | In memoriam: Mathis Blackstock, M.D. | Resident research | Tar Wars winner | TAFP revives preceptorship program 35 RESEARCH Researchers explore correlation between vitamin D deficiency and hypertension. 38 PERSPECTIVE Physicians and patients must learn to “choose wisely” to address unsustainable health costs.
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president’s column
TEXAS FAMILY PHYSICIAN VOL. 63 NO. 3 SUMMER 2012 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. Texas Family Physician is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org. Officers president
I. L. Balkcom IV, M.D.
president-elect
Troy Fiesinger, M.D.
vice president treasurer
parliamentarian
Ajay Gupta, M.D.
immediate past president
Melissa Gerdes, M.D.
Editorial Staff Jonathan L. Nelson
associate editor
Kate Alfano
chief executive officer and executive vice president
Tom Banning chief operating officer
Kathy McCarthy, C.A.E.
advertising sales associate
Audra Conwell
Contributing Editors Matt Brown Roberto Cardarelli, D.O., M.P.H. Kimberly Fulda, Dr.P.H. Tasleyma Sattar, D.O. TMLT Risk Management Department Kun Don Yi, Ph.D., Richard Young, M.D. 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. © 2012 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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By I. L. Balkcom IV, M.D. TAFP President
Dale Ragle, M.D.
Clare Hawkins, M.D.
managing editor
Defining the meaning of “meaningful use”
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serious discussion or counseling to occur. I shhhh! don’t tell anyone, but I am attemptam certain as time passes my computer skills ing to practice on my laptop so I might underwill improve so that I might have “meaningstand how to have a “meaningful” encounter ful use” by 2014. Being somewhat of a country with my patient. I have made progress in techphilosopher, I could submit the “Eulogy of nology in that I even sent our chief operating the Doctor” as evidence officer, Kathy McCarthy, of true medical use. The an e-mail this year—a following was written by proud moment in my Robert Louis Stevenson. technological infancy. “Generosity he has, “There are men and Now I find myself imsuch as is possible classes of men that mersed in a small screen only to those who stand above the comwith small print and mon herd: The soldier, myriad options for the practice an art the sailor, the shepherd EHR. As Peanuts would and never to those not infrequently; the say, “ARRRGHH!” as I who drive a trade; artist rarely; rarelier erase an entire page by still, the clergyman; the accident. discretion, tested by a physician almost as a Now for those of hundred secrets; tact, rule. He is the flower you who are fortutried in a thousand of our civilization and nate enough to know when that stage of man all things computer or embarrassments; is done with, only to young enough to have and what are more be marveled at in hisgrown up with iPhones, important, herculean tory he will be thought laptops, and MP3 players, to have shared but I heartily congratulate cheerfulness and little in the defects of you. Some of us less techcourage. So it is that the period and to have nologically gifted are still he brings air into the most notably exhibited learning how to turn on the virtues of the race. these infernal machines sick room and often Generosity he has, such and not to treat them enough, though not as is possible only to like coke machines— so often as he desires, those who practice an beat and kick the “heck” art and never to those out of them. I wish so ofbrings healing.” who drive a trade; disten they would say some— Robert Louis Stevenson cretion, tested by a thing so I could keep up hundred secrets; tact, my tirade. Oh, I forgot. tried in a thousand emThey do talk to you now. barrassments; and what are more important, I confess to still trying to get comfortable herculean cheerfulness and courage. So it visiting with patients on the computer. I do is that he brings air into the sick room and not enjoy diverting my eyes from my patient often enough, though not so often as he deto a screen since inspections and observation sires, brings healing.” are still part of a history and physical. The Now that’s meaningful use. one blink or hesitation I miss may prevent
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news clips
Getting paid in 2011 26 percent of U.S. physicians earned less this year than last year, though the top-earning specialties from 2011, radiology and orthopedic surgery, remained at the top in 2012 with average earnings of $315,000. The bottom-earning specialties in 2012’s survey were pediatrics, $156,000; family medicine, $158,000; and internal medicine, $165,000; though the each saw modest gains of 5 percent, 2 percent, and 2 percent, respectively. The largest declines were in general surgery, 12 percent; orthopedic surgery, 10 percent; radiology, 10 percent; and emergency medicine, 8 percent. Male physicians across all specialties earned about 40 percent more than female physicians, a difference of $242,000 versus $173,000. In primary care, men earned 23 percent more, a difference of $174,000 versus $141,000.
47 percent of family physicians said that they felt fairly compensated, 64 percent reported that they would choose medicine again as a career, and 32 percent said they’d choose the same specialty, bringing overall satisfaction for family physicians to 48 percent. Source: “2012 Physician Compensation Report,” Medscape, February 2012.
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of U.S. health care expenditures are related to obesity.
Source: “The medical care costs of obesity: An instrumental variables approach,” Journal of Health Economics, January 2012.
Partners in private practice earned more than physicians in any other work situation, a mean of $308,000, compared with solo practice at $222,000, independent contractors at $175,000, and employed physicians at $194,000. By work setting, physicians in single-specialty group practice earned an average of $253,000, followed by those in health care organizations at $241,000 and multispecialty group practice at $239,000.
if you ‘like’ health care
Source: “AHA Hospital Statistics, 2012 edition.”
20.6%
By geographic area, physicians in the South Central United States— Texas, Oklahoma, and Arkansas—earned an average of $228,000; physicians in the North Central region—including Iowa, Missouri, Kansas, Nebraska, and South and North Dakota—earned the most with a mean income of $234,000.
Yelp
Hospitals’ employment of physicians has risen sharply in the last decade. The latest figures reveal that 20.3 percent of all physicians are covered by a group contract, 17.3 percent are directly employed, and 7.2 percent have individual contracts; 55.1 of physicians are not employed or under contract with hospitals.
42 percent of consumers have used social media to access health-related consumer reviews, 28 percent have supported a health cause, 24 percent have posted about their health experience, and 20 percent have joined a health forum or community.
TEXAS FAMILY PHYSICIAN
HIT
adoption on the rise
Nationwide, physicians reporting use of an EHR reached 57 percent in 2011, a stark increase from 17 percent in 2002. Adoption of at least a basic system—or one that would “enable physicians to realize the potential to improve the quality and efficiency of care”—grew from 12 percent to 34 percent over the same period.
In Texas, 52.4 percent of physicians reported having an EHR in 2011, and 33.9 percent reported having at least a basic system. In 2011, 52 percent of all physicians indicated that they intended to apply for meaningful use incentives, but only 10.5 percent reported an intention to apply and an ability to meet the required functionalities. Source: “Health Information Technology in the United States: Driving Toward Delivery System Change, 2012,” Harvard School of Public Health, Mathematica Policy Research, and the Robert Wood Johnson Foundation, April 2012.
61 percent of consumers are likely to trust information posted by providers, compared to 37 percent trusting information posted by a drug company. 41 percent are likely to share with providers via social media, compared with 28 percent likely to share with a drug company.
54 percent of consumers feel comfortable or very comfortable with doctors going to online physician communities for advice related to their health situation; 23 percent feel uncomfortable or very uncomfortable. Source: “Social media ‘likes’ healthcare, from marketing to social business,” Health Research Institute, April 2012.
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news clips
AAFP BY THE NUMBERS At this year’s Annual Leadership Forum in Kansas City, representatives from AAFP’s marketing department presented the results of AAFP’s latest member survey. Here are some data points of interest.
billion
Total AAFP membership as of June 30, 2012: 96,158 59 percent of members are salaried or employed 20 percent are partial owners in their practices 17 percent are solo owners of their practices 81 percent provide chronic care management 77 percent practice geriatric medicine 57 percent provide urgent care 39 percent practice sports medicine
What are their top 3 concerns? Payment reform
Medical liability reform 42%
15 percent provide obstetrical care
Attracting medical students to family medicine 26%
Journal: Health care could save billions by reducing waste in six key areas the u.s. health care system could save hundreds of billions of dollars each year in public and private health care expenditures by adopting strategies to reduce waste in six key categories that are major drivers of health care costs. That’s the conclusion of an article by former CMS Administrator Donald Berwick, M.D., and Andrew Hackbarth, M.Phil., an assistant policy analyst at the RAND Corp., in JAMA: The Journal of the American Medical Association. “In just six categories of waste—overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse—the sum of the lowest available estimates exceeds 20 percent of total health care expenditures,” say the authors. “The actual total may be far greater. The savings potentially achievable from systematic, comprehensive, and cooperative pursuit of even a fractional reduction in waste are far higher than from more direct and blunter cuts in care and coverage.” 10
55%
30 percent practice occupational medicine
Source: AAFP Member Census, July 2011
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$1.3
The authors point out that health care costs consumed nearly 18 percent of the gross domestic product in 2011, a figure that is expected to climb to 20 percent by 2020. “No matter how polarized politics in the United States have become, nearly everyone agrees that health care costs are unsustainable.” In addition, the nation’s growing health care costs negatively affect other parts of the U.S. economy. These costs erode wages and undermine U.S. competitiveness in the global economy, and reduce resources for needed government programs, according to the article. Berwick and Hackbarth note that obtaining savings by cutting spending in health care may be seen as the most obvious remedy, but cutting waste instead of spending actually is a basic survival strategy in most industries today. The goal is to retain “processes, products, and services that actually help consumers and systematically remove the elements of work that do not,” say the two authors. In identifying the six areas for waste reduction, Berwick and Hackbarth define the waste
The amount in rebates that insurers expect to send to customers for plans that failed to meet the federal minimum medical-loss ratios set under the Patient Protection and Affordable Care Act, according to a Kaiser Family Foundation estimate. Source: “Insurers say health reform-related rebates will exceed $1 billion,” American Medical News, May 7, 2012.
associated with each category and estimate the cost savings that could occur by improving processes and care. Following are those six areas and their associated costs for 2011. • Delivery-of-care failures resulted in an estimated cost of between $102 billion and $154 billion. • Care-coordination failures accounted for $25 billion to $45 billion in wasteful spending. • Overtreatment represented between $158 billion and $226 billion. • Administrative complexity resulted in wasteful spending of between $107 billion and $339 billion. • Pricing failures cost the United States between $84 billion and $178 billion. • Fraud and abuse contributed between $82 billion and $272 billion in wasteful spending. “If the United States is to reconstruct a health care industry that is both affordable and relentlessly focused on meeting the needs of every single patient and family, waste reduction (that is, the removal of nonvalue-added practices in all their forms) is the best strategy by far,” the authors write. Source: AAFP News Now, May 16, 2012. © American Academy of Family Physicians.
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Member news
Family medicine chief residents hone leadership and management skills at Dallas conference
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TEXAS FAMILY PHYSICIAN
Top: The chief residents listen to Richard Grant Jr., Ph.D., as he presents an engaging and entertaining session on enhancing communication. Bottom: Attendees participate in a group activity to learn more about leadership, developing a strategy for their team and prioritizing items needed for success.
care as long as you have the facts,” Grant said. “That’s why being a chief resident is a tough job because you have to be both a T and F. You don’t know which type you’re dealing with.” Saturday brought a panel of experts to delve deeper into leadership and management skills when faced with real-life situations. The experts included Jackson Griggs, M.D., former
chief resident and current faculty at the Waco Family Medicine Residency Program; Jonathan MacClements, M.D., former chief resident, current chair of family medicine, and current residency program director at the University of Texas Health Science Center at Tyler; and Jim Tysinger, Ph.D., vice-chair of professional development in the Department of Family
photos: KATE ALFANO
fifty chief residents from around the state and country gathered for the 2012 Family Medicine Chief Resident Conference in Dallas, Texas, to participate in lectures, panel discussions, and hands-on activities to identify the tasks they’ll face in their upcoming year as chief resident, set goals, and hone their skills to meet the challenges ahead. It all began Friday morning with speaker Cindy Passmore, M.A., executive director of the UNTHSC Faculty Development Center, leading a discussion on the basic job description of a chief resident. The residents in attendance, in small groups, identified scheduling and conflict resolution as their top two responsibilities. They then set goals for themselves: to improve communication among all residents, organize schedules in advance, and work to improve the quality of life for residents, among others. “What I liked best about the conference was being able to bounce ideas and concerns off fellow chiefs, and learning more about myself as a leader—both strengths and weaknesses—and how to use those qualities to lead,” said Shane Stone, M.D., chief resident at the Conroe Family Medicine Residency Program. Passmore also discussed effective observation and feedback, encouraging the chiefs to gather specific information while withholding judgment, use it to pinpoint the source of a problem, and then present it to the recipient providing fair evaluation. Friday afternoon featured Richard Grant Jr., Ph.D., on enhancing communication with colleagues using the Myers-Briggs Type Indicator. Residents completed the MBTI survey and scored their results, and Grant explained how different types—extraversion vs. introversion, sensing vs. intuition, thinking vs. feeling, and judging vs. perceiving—affect an individual’s preference for communication, problem-solving, and structure, and that pairing opposites can often achieve better results. For instance, “if you put an S, sensing type, together with an N, intuition, you get faster and better problem-solving,” Grant said. He also put it in the context of recognizing personality types and using them to be an effective manager. “With an F-type, if you’re not a living, breathing example of everything that you say, you lose credibility. T-types don’t
and Community Medicine at the University of Texas Health Science Center at San Antonio. They were joined later in the day by Paty Lesczynski, M.D., former chief resident and current family physician in Allen. One focus was on conflict and how to manage a disgruntled resident. Griggs identified two types of individuals: one who is deeply conscientious and wants the program to be better and another who may have deep-seated personal issues. “The solution is to listen deeply, try to incorporate their input, and get their buy-in. That can change their attitude. Or if it’s actually malicious, sequester them.” MacClements added in the case of a troubled resident, “If they have problems with you, you’re probably not the only one. There’s probably an intervention that should be done.” When working toward a solution, Tysinger advised the residents, “If someone has an idea, respectfully listen and don’t shut the door. People should be valued as a member of the group; they deserve respect and they deserve to be heard. You want to listen respectfully even though they may seem to be the ‘squeaky wheel.’ They just may be the one with relevant experience and a great solution.” TAFP presented the 2012 Chief Resident Conference in collaboration with the UNTHSC Faculty Development Center in Fort Worth. Funding for the Faculty Development Center in Waco was zeroed out by the 82nd Texas Legislature and the center closed in August 2011. The TAFP Board of Directors, recognizing the importance of providing training for these future family medicine leaders, agreed to host the 2012 conference. Since then, the University of North Texas Health Science Center has assumed the Faculty Development Center and the UNTHSC FDC will continue to offer quality programs, including the 2013 Family Medicine Chief Resident Conference. Passmore says the conference is important to Texas family physicians, TAFP members, academic family medicine, and all Texans because of the vital role these talented young physicians hold in producing a well-trained family medicine physician workforce. “It is no surprise to me that many of the men and women who take part in the Chief Resident Conference go on to assume leadership roles in academic medicine, clinical medicine, their communities, and professional organizations such as TAFP.”
TexMed report: Foxhall re-elected to TMA Board of Trustees, Waco family physician honored for service In May, family physicians from around the state traveled to TexMed, the Texas Medical Association’s annual conference, to earn continuing medical education credit, set Lewis E. Foxhall, M.D. TMA policy on medicine’s key issues, and network with specialty colleagues and friends. TMA convened its House of Delegates, held elections for top leadership positions, and honored members with awards. Family physician Lewis E. Foxhall, M.D., of Houston, was re-elected to serve on the Texas Medical Association Board of Trustees. He was first elected to the board in 2009.
Foxhall is an active leader in organized medicine and previously served as TAFP president. He has held numerous positions at TMA, including chairing the Council on Socioeconomics and serving on the Council on Legislation, Select Committee on Health System Reform, Select Committee on Patient Safety, and Committee on Cancer. In addition, Foxhall is past president of the Harris County Medical Society and the Houston Academy of Medicine. A graduate of Baylor College of Medicine, Foxhall is professor of clinical cancer prevention and vice president for health policy at the University of Texas M.D. Anderson Cancer Center in Houston. TAFP-member Jackson Griggs, M.D., of Waco received the J. T. “Lamar” McNew, M.D. Award from the TMA Resident and Fellow Section for his outstanding service to that section.
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www.tafp.org
[SUMMER 2012]
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Member news
Farewell to a great family medicine educator, Mathis Blackstock, M.D., 1925-2012 TAFP life member and longtime residency program faculty Mathis Blackstock, M.D., passed away on Tuesday, July 3, from melanoma that had spread. He was 87. Blackstock practiced family medicine for more than 40 years and served as faculty for the University of Texas Southwestern – Austin Family Medicine Residency Program for 30 years. Until recently, he remained involved with former patients, doctors, and family medicine residents at his namesake clinic, Blackstock Family Health Center in Austin, the Austin American-Statesman reports. “He was the type of doctor that patients would gravitate to,” David Wright, M.D., TAFP member and fellow faculty member, told the Statesman. “He knew medicine very, very well, but at the same time, he was interested in what you were going through and what you needed. And it wasn’t just you
as an individual; he took care of your whole family. He, more than anybody else that has been associated with the training programs, taught all of us ... how to be doctors.” Blackstock was passionate about geriatrics, indigent health care, and access to health care. He helped create Austin Groups for the Elderly, a non-profit committed to providing resources for the area’s seniors, adults with disabilities, and their caregivers. TAFP named Blackstock Physician Emeritus in 2007, recognizing his long and meritorious service to family medicine. In nomination letters for the award, his patients described his dedication to their health, providing care after hours, on weekends, and in their own homes. They also talked about his patience and willingness to listen to all of their concerns. He was awarded a bachelor’s degree by the University of Texas at Austin in 1944, his medical degree by the University of Texas Medical Branch at Galveston in 1948, and he completed a general practice residency at the University of Colorado Medical Center in 1953. He is survived by his wife of 63 years, Mary, and three children.
Texas residents to present research at AAFP’s National Conference AAFP has selected 16 posters to be showcased in the poster competition at the 2012 National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo., and two hail from Texas. Presenting in the research category is Richel Avery, M.D., chief resident at the University of Texas Health Science Center at San Antonio with her poster, “Family Responsibilities and Thinking Abilities.” Avery participated in TAFP’s Student, Resident, and Community Physician Poster Competition held last year during the Academy’s Annual Session and Scientific Assembly, and was awarded first place in primary research, resident category for her poster “Residents’ Knowledge, Attitudes, and Behaviors in Colon Cancer Preven14
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tion: Findings from a Residency Training Project.” She was awarded a cash prize and travel funding from the TAFP Foundation to present her research at a national conference. She attended the Society of Teachers of Family Medicine’s Annual Spring Conference in Seattle in April 2012. In clinical inquiry, Saquib Ansari, M.D., presents “When Designer Drug Users Arrive at Your Clinic Front Door,” in collaboration with Myers Hurt III, M.D., and Jose PerezEnriquez, M.D. All are third-year residents at the University of Texas Medical Branch in Galveston. Posters will be displayed in the exposition hall Thursday through Saturday, July 26-28. Outstanding poster presentations will be recognized with ribbons.
New for you Learn about payment reform models with TAFP online videos Last fall, TAFP held a summit on various payment reform models physicians should consider as the country moves away from fee-forservice. The expert speakers concurred that whether the system of the future is based on the patientcentered medical home, bundled payment, accountable care, or a proposal yet to be imagined, physicians will play an integral role in its delivery and success. Now you can see and hear those experts in a series of videos produced from the conference. Hear more on the economics driving reform, the role of family physicians, the business of health care financing, and a case study on a highly successful Plano practice. View the videos on the payment reform page of TAFP’s practice resources at www.tafp.org/practice-resources/ payment-reform.
Call for nominations: Select our next Member of the Month Each month, TAFP highlights a TAFP-member family physician and his or her unique approach to family medicine with a brief biography and Q&A published in TAFP News Now and on www.tafp.org. We need your nominations! If you know an outstanding family physician colleague who should be featured as a Member of the Month – or if you want to share your own story – contact Kate Alfano at kalfano@tafp.org or (512) 329-8666. View past Members of the Month at www.tafp.org/membership/ spotlight.
TAFP launches revived family medicine preceptorship program The ability for medical students to complete a family medicine preceptorship is an important recruitment tool to demonstrate the breadth and depth of family medicine and encourage those students drawn to whole-person and community care to pursue the specialty. That’s what family physician members on the TAFP Board of Directors recognized when they voted unanimously for the Academy to carry on the Texas Statewide Family Medicine Preceptorship Program after funding was zeroed out by the 82nd Texas Legislature.
TAFP selects the 2012 Texas Tar Wars poster contest winner Academy leaders top advisors panel Congratulations to the 2012 Texas Tar Wars Poster Contest winner, Juan Elizondo of Houston, Texas, a fifth-grader at Crockett Elementary School. Elizondo’s poster, “Blow Bubbles Not Smoke,” was selected for the grand prize from many entries by a panel of TAFP members. His message reinforces the anti-smoking mission supported by Tar Wars and the Academy. Elizondo will receive travel funding to travel with a parent to the Tar Wars National Conference in Washington, D.C., in July. In addition to competing in the national poster contest, he will have the opportunity to meet with his senators and representatives and talk about the need for greater tobacco control efforts. In other Tar Wars news, two TAFP leaders have been chosen to lead the Tar Wars Program Advisors Panel. Rebecca Hart, M.D., serves as chair. She is the associate program director of the San Jacinto Methodist Family Medicine Residency Program. Kaparaboyna Ashok Kumar, M.D., F.R.C.S.,
visit the all-new
serves as vice chair. He is professor and vice chair of medical student education at the University of Texas Health Science Center at San Antonio. The advisors panel represents a mix of academic backgrounds, past experiences with the program, and diverse skill sets that contribute to the continued development, success, and growth of the Tar Wars program. Program advisors serve a two-year term beginning Jan. 1 of each year and ending Dec. 31 of the next year. Tar Wars, led in Texas by TAFP, is AAFP’s nationwide education program to prevent tobacco use among children. Tar Wars provides students with the tools to make positive health decisions and promote personal responsibility for their own well-being. Physicians volunteer to present educational curriculum to fourth- and fifthgrade students in their community, and the students compete in a poster contest demonstrating their personal tobacco-free message.
The program matches medical students with an experienced and skilled family physician for a two- to four-week period to help them gain real-life experience in a community setting. By participating in a family medicine preceptorship, students have the unique opportunity to explore what being a family physician is really about and many have decided to pursue family medicine as a result of their participation. Under TAFP’s direction, the program will be coordinated in the same manner as previous years, but without paying stipends to participants. Beginning in 2013, the TAFP Foundation will fund stipends for a limited number of pre-clinical medical students in the program. The Foundation is currently accepting donations for preceptorship funding. Visit the newly re-launched Texas Statewide Family Medicine Preceptorship Program website at www. familymedicinepreceptorship.org for more information and to apply for a preceptorship, or to become a preceptor or update your profile. Or contact Juleah Williams, program coordinator, at (512) 329-8666 or jwilliams@tafp.org.
tafp.org and connect with your academy www.tafp.org
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Discounts on Vaccines • Reimbursement Support With Payers • Timely Updates About New Products, Changes & Sales • Donations to TAFP With Every Purchase! Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV. Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management. The program is free to your practice, and enrollment is completely voluntary. The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine. Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered. Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or info@atlantichealthpartners.com for more information and to register.
KATE ALFANO
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Member news
Attendees of the Annual Leadership Forum heard from a panel of AAFP leaders—including Board Chair Roland Goertz, M.D., M.B.A., of Waco, right—who discussed current issues facing family physicians and answered questions from the audience.
TAFP members learn, network at AAFP’s NCSC, ALF “Family medicine is an unstoppable force but we have work to do. Engage your colleagues!” That was the message from AAFP President Glen Stream, M.D., M.B.I., at the opening event of AAFP’s Annual Leadership Forum, and the unofficial theme of both ALF and its sister conference, the National Conference of Special Constituencies, held in Kansas City in May. More than 20 TAFP delegates, leaders, and staff attended to represent Texas, joining nearly 400 family physicians and family medicine advocates from around the country. NCSC attendees—representing GLBT physicians, minority physicians, women, international medical graduates, and new physicians—developed recommendations for the AAFP Congress of Delegates and held elections for various national leadership positions. ALF attendees learned the latest on leadership, association management, media interaction, website optimization, and how to stay relevant in a competitive market. One Texas representative served in the AAFP leadership for the 2012 conference and
two were elected to leadership positions. Christina Kelly, M.D., of Harker Heights, served on the NCSC advisory group as a 2012 new physician co-convener. Kelly Gabler, M.D., faculty at San Jacinto Methodist Residency Program in Baytown, was elected to be new physician alternate delegate to the AAFP Congress of Delegates. Bruce Echols, M.D., of Dallas, was elected special constituency co-convener for NCSC 2013. TAFP received recognition for gains in membership during the ALF portion. Our Academy was honored for having the highest percent increase in active membership in the large-chapter category, and for achieving 100 percent resident membership, both of which speak to the caliber of our members. Next year’s NCSC and ALF will be held April 25-27, 2013. TAFP will place a call for delegates and provide more information about opportunities for travel funding in January 2013. To add your name to our NCSC/ALF contact list or for more information on these conferences, e-mail tafp@tafp.org.
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SEEKING PRIMARY CARE PHYSICIAN!!! Excellent federally-qualified primary care clinics in Galveston County seeking a primary care physician to join a clinician team of 11 providers (physicians and midlevels) serving residents of Galveston County and Cities. Family practice, pediatrics, and/or internal medicine desired. Excellent work hours and government benefits. Applications and additional information may be found at www.gchd.org/hr/Physician-131.pdf or by contacting Human Resources at apply@gchd.org or (409) 938-2230. EOE.
KATE ALFANO
Miguel Franco, M.D., medical director of Accountable Care Coalition of Texas, says that ACOs will become what physicians make them; they won’t achieve quality and cost goals without physician involvement and leadership.
Accountable care organizations take shape in Texas By Kate Alfano with cms’ announcement of the first accountable care organizations approved to participate in the Medicare Shared Savings Program and the publication of the program’s final rule last fall, what was once an amorphous concept is now a reality that more physician groups and hospitals are buying into. And as varied as the methods to medicine, each organization brings its own approach to connect a host of physicians and other providers and meet the goals of the program. The Medicare Shared Savings Program, the only ACO program enacted through the Affordable Care Act, encourages health care providers to coordinate a Medicare fee-forservice beneficiary’s care in a way that avoids duplication of
services, prevents medical errors, and averts hospitalization, thereby slowing the rate of growth in health care spending and improving quality of care. It evokes the triple aim—to improve the health of the population, enhance the patient experience of care, and reduce the per capita cost of care. And in return for demonstrating reduced costs and increased quality, the organization is eligible to receive a share in the savings it produces. Twenty-seven ACOs nationwide were approved in the first round of the Shared Savings Program this April, with five of those participating through the Advance Payment Initiative, an option providing advance payments to participants
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and operational oversight. And as each Shared Savings ACO must do, like rural and physician-based ACOs to help defray the costs of estabACC of Texas has established its method to reach out to and gather lishing IT and staff infrastructure. Two of the Shared Savings ACOs input from its network of providers. are in Texas: Accountable Care Coalition of Texas serving southeast That job falls partly to Miguel Franco, M.D., medical director of Texas, and RGV ACO Health Providers serving areas in south Texas. the ACO and of Memorial Clinical Associates in west Houston. An Thirty-two ACOs were accepted into the Pioneer ACO Model in internist and board-certified pulmonologist himself, he listens to the December 2011, a program also under CMS’ purview on a similar but physicians and makes sure their knowledge and medical experiences separate track from the Shared Savings Program. These established orinfluence the ACO’s operations and that the organization is responganizations have demonstrated their ability to coordinate care across sive to their needs. settings and will move more rapidly from the shared savings payment “Physicians treat each model to a population-based patient differently,” Franco payment model. Again, two says. “And therefore, as mediare based in Texas—Plus! in cal director of our ACO in Tarrant County and Seton Texas, I don’t assume that all Health Alliance serving Cenpractices are the same and I tral Texas. don’t assume that every phyMany groups around the sician that calls me or that state and country have alevery clinical issue should be ready employed the concepts treated the same. of coordinated care and pre“One example is that not vention built on a foundation all physicians have EMRs, of primary care to improve but if I’m interacting with a quality and control costs, and physician who is a few years some will apply for future from retiring and they’ve destart dates in the Medicare cided not to have an EMR, program while others will sometimes you have to think continue to serve their pubabout additional resources to lic and commercial markets help. So if it means sending without joining in. CMS recare coordinators or other ports in a press release that staff to their office to look at the agency is reviewing more charts and gather data, we than 150 applications from can do that. It sounds antiACOs seeking to particiquated, but EMR is a huge pate in the second round of investment and at the end Shared Savings, to start July 1, of the day, if we implement with more than 50 applicants something for the occasional for the Advance Payment Iniphysician who may not have tiative. an EMR and it helps gather Each ACO varies widely, information and it helps even among the Texas orga– Miguel Franco, M.D. them care for their patients, nizations. Take Accountable then mission accomplished.” Care Coalition of Texas, the Access to the tools and largest of the Shared Savstaff that facilitate practicing ings ACOs, expected to serve whole-person, coordinated nearly 70,000 beneficiaries. care is one big benefit of parACC of Texas is a partnership ticipating in the ACO, Franco of independent physician assays, because “in this day and sociations, medical groups, age, it takes a lot more than and health systems in the seeing patients in the examination room.” Houston and Beaumont area. It and eight others around the country “One thing that brings us together, even though there are differwere formed by Universal American health plan in partnership with ent kinds of practices, is the fact that there are resources that we can community doctors treating Medicare Advantage patients. Collaboraget through an ACO,” he says. “The resources would be the analytics, tive Health Systems, a subsidiary of Universal American, provides care information to help us identify what our patients need, and care coorcoordinators and other personnel. dinators. And that helps us take the care literally into the home where ACC of Texas is its own legal entity owned by CHS and the medical we can identify specific needs that are pertinent to the patient’s care.” group and, in accordance with CMS ACO guidelines, is governed by ACOs participating in the program must report to CMS on quality physicians, suppliers, and Medicare beneficiaries. This governing body measures relating to care coordination and patient safety, appropriis responsible for the overall management and operations of the ACO ate use of preventive health services, improved care for at-risk popuincluding compliance, quality improvement, medical management,
“At the end of the day, if physicians don’t have major input in this, it’s not going to work the way it should. Our patients want physicians to make medical decisions. They don’t want it to come primarily from another source. We all have to work together. An ACO is not just physicians and other health care providers— it’s also other health care professionals—but physician input is incredibly crucial.”
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“Our job is to ensure that we increase communication, that we inlations, and the patient experience of care. CMS monitors ACOs by tegrate our work, and that we are constantly providing the resources analyzing claims, financial and quality data, and quarterly reports, and for everybody around the patient to be able to provide the necessary by performing site visits or beneficiary surveys. information and make the patient better.” This means collecting a great amount of data, but also spreading Admittedly, the cost savings part is tricky and he couldn’t get into the process and “culture” to each physician and health care provider specifics at this early stage of the program. While they trust that the involved. process will inherently drive costs down, “we need to benchmark,” EsEdwin F. Estevez, Ph.D., chief operating officer and chief administevez says. “It’s like we want to lose weight, but we haven’t weighed trator of RGV ACO Health Providers, the other Shared Savings ACO ourselves yet.” in Texas, says their biggest challenge to date has been integrating When considering affilihealth information technolating with an ACO, he advisogy between the practices. es physicians to perform an They qualified for the Adinternal operational assessvance Payment model, which Meet the four CMS-approved Texas ACOs ment that sets up an alignhe says has been invaluable in ment process and expectahelping them create the infrations of the ACO. “That’s not structure to connect their six Accountable Care Coalition of Texas, Inc. is a partnership between to say that some doctors or physicians, 10 clinics, and 18 independent physician associations, medical groups, and health physicians are not practicing different providers to serve an systems in southeast Texas under the larger umbrella of Universal medicine correctly, but it is estimated 6,000 beneficiaries American and Collaborative Health Systems. The largest of the to say that there are going from Mission to Mercedes. 27 Shared Savings ACOs, ACC is expected to serve nearly 70,000 beneficiaries. to be some adjustments that Though they have four will have to be made.” different electronic medical Franco, of ACC of Texas records between the six phyRGV ACO Health Providers, LLC is comprised of six primary care in Houston, says that achievsicians, four were the first to group practices with 10 clinic locations serving the south Texas ing savings will depend on a adopt EMRs in the Rio Grande populations of Weslaco, Mercedes, Elsa, Donna, Mission, and surnumber of factors including Valley and two serve on narounding communities. RGV is participating as one of five Advance the data that CMS sees. “A tional boards for EMRs. “EvPayment ACOs in this group. RGV is expected to serve over 6,000 lot of us have been taking erybody is engaged. We’re albeneficiaries. care of patients with this ready gathering data in terms focus on prevention and disof hospitalization and access Plus!, formerly North Texas ACO, is a partnership of Fort Worthease management for a long for patients to the clinic, and based North Texas Specialty Physicians, an independent physitime, so we know and we see we are engaging every single cian association comprised of more than 600 family and specialty the results within our praclateral or potential partner doctors serving patients in Dallas, Johnson, Parker, and Tarrant tices. But as far as the shared who may be involved, from counties, and Arlington-based Texas Health Resources, one of the savings being realized and specialists to pharmacies,” Eslargest faith-based, nonprofit health systems in the country with CMS identifying it, that’s to tevez says. “It’s a massive mov24 acute care and short-stay hospitals. Plus! is participating as a be determined.” ing target that requires agility Pioneer ACO. The important part is and I think we have it.” that more are realizing the This agility comes from Also a Pioneer, Seton Health Alliance is a partnership of Seton benefit of prevention and their size, he says. As one of Healthcare and Austin Regional Clinic, serving 11 counties in disease management, Franthe smallest ACOs in the proCentral Texas with 13 hospitals in Austin, Round Rock, Kyle, Luling, co says, which is a good sign gram—the minimum number Burnet, and Smithville, and 21 primary and specialty care outpafor the future. “A lot of priof beneficiaries an organizatient clinics in Austin, Round Rock, Cedar Park, Hutto, Pflugerville, mary care physicians have tion can have to qualify for and Kyle. been focusing on preventhe program is 5,000—this tive care and disease manhelps them quickly apply new agement; we’ve been very guidelines among the pracproactive with that and we tices. “We’re small enough to know it works. We know it’s going to be the oxygen of health care get to everybody at the same time to see some of the implementation reform. It’s very encouraging that we see the whole system going in results.” that direction.” Physician-owned and physician-driven, RGV supports the clinical “At the end of the day, if physicians don’t have major input in this, autonomy of the practices while increasing interaction at all levels to it’s not going to work the way it should. Our patients want physicians achieve large-scale change. “We’re not going to dictate how to practice to make medical decisions. They don’t want it to come primarily from medicine, but we are going to dictate how to carry out our model,” another source. We all have to work together. An ACO is not just phyEstevez says. “What we want to do is ensure that there’s an increase in sicians and other health care providers—it’s also other health care procommunication that, bottom line, is for the patient’s benefit and also fessionals—but physician input is incredibly crucial.” the practice’s benefit. It not only facilitates good medicine, it facilitates good business and is great patient service.”
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Texas’ primary care workforce shortage threatens the health of the state’s economy and its citizens. The 83rd Texas Legislature can lay the foundation for innovation and improvement in our health care delivery system by reinvesting in our primary care workforce. By Jonathan Nelson
long before the u.s. supreme court upheld the constitutionality of President Obama’s health care law and lobbed a Medicaid grenade into the political dynamics of state legislatures across the country, Texas lawmakers were already laying the groundwork on a comprehensive strategy to increase the state’s primary care capacity and restore devastating funding cuts in programs designed to produce more primary care physicians. Notwithstanding what will likely be sharp partisan divisions in how or whether the state implements provisions of the Affordable Care Act, there is a strong consensus among legislative leaders and policy experts across the political and ideological spectrum that Texas must re-examine how the state funds medical education and residency training to ensure we can meet the health care needs of our growing population. With the ACA potentially expanding health insurance coverage to an estimated 5 million currently uninsured Texans starting in 2014, time is of the essence. 20
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“There are compelling economic and demographic realities driving the need to strengthen our primary care workforce that transcend the political volatility of health care,” says TAFP President-elect Troy Fiesinger, M.D. “The time has come to re-examine the state’s investment of taxpayer dollars in medical education and residency training, and to restructure that investment to ensure Texas recruits, educates, and trains the physician workforce Texas communities need.”
Hitting the fiscal cliff Legislative leaders from both sides of the aisle are acutely aware that we have reached the economic tipping point where health care costs have become a drag on the economy. This unabated increase in costs has forced state and federal lawmakers to spend more on programs like Medicaid and Medicare, leaving less for education, transportation, and other important expenditures.
“Data have shown year after year that Texas is faced with two clear trends: (1) the population is growing faster than almost any other state in the U.S., and (2) the number of health care providers is not keeping pace with that rate of growth. In addition, there continues to be major geographic maldistributions of health care practitioners across Texas.” — Statewide Health Coordinating Council, 2011-2016 Texas State Health Plan
The projections are bleak. In its 2011 long-term fiscal outlook, the U.S. Government Accountability Office reported that if health care cost trends continue unchecked, by 2020, 89 cents of every dollar of federal revenue will go to pay for Medicare, Medicaid, Social Security, and the net interest payments on the federal debt. With 2.8 million baby boomers becoming eligible for Medicare this year and another 75 million awaiting their turn, there is no question that the rising cost of health care is the most significant contributor to the nation’s longterm deficit. In Texas the news is similarly sobering. From 2001 to 2011, annual state Medicaid spending more than doubled, from about $6.2 billion to $16.1 billion. Health care now consumes 31 percent of the state budget and that portion is growing. Spiraling increases in insurance premiums have forced employers to divert revenues away from business expansion and wage increases for employees. From 2000 to 2010, the average premium for family
coverage in an employer-sponsored health plan in Texas jumped almost 120 percent, from $6,638 to $14,526. Faced with such unrelenting cost pressure, employers have shifted a growing share of premium costs to their employees, switched to plans offering smaller benefit packages, or have simply stopped providing coverage altogether. According to the Economic Policy Institute, only 51 percent of non-elderly Texans were covered by employersponsored plans in 2009 and 2010, down from 61 percent just a decade earlier. A 2012 Rand Corporation report found these increases have wiped out a decade of income gains for the average American family. The fiscal burdens imposed on federal and state budgets, employers, and families by rising health care costs can no longer be ignored.
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The primary care conundrum The health care cost crisis is inescapably linked to the way in which medical services are delivered and financed. Despite substantial evidence that when patients have adequate access to primary care physicians, communities enjoy improved health care outcomes, better overall health, and lower health costs, Texas suffers from a shortage of primary care physicians. Political and budgetary decisions have stalled system-wide improvements to transform our fragmented health care delivery system into one that supports high-quality, cost-efficient, and well-coordinated primary care. Nearly 20 years ago, the Council on Graduate Medical Education issued a blistering report warning policymakers that our nation had too few primary care physicians. Little has changed since. Approximately 18,000 primary care physicians practice in Texas, serving a population that will soon exceed 26 million. This ratio falls far below the national average and will worsen as Texas’ population continues to balloon at both ends of the age spectrum. Compounding the problem is the poor distribution of primary care physicians throughout the state. Three of every four Texas counties are designated as whole or partial Primary Care Health Professional Shortage Areas. Many factors contribute to Texas’ inability to produce and sustain an adequate primary care physician workforce. Long work hours, huge patient loads, and a growing income gap between primary care physicians and specialists discourage medical students from pursuing careers in primary care. Add to that the rising expense of medical education, which saddles graduates with an average of more than $150,000 in debt, and it’s perfectly rational that so few medical students choose primary care. But there are other influences at play, and to understand them, you have to know a bit about how residency training is financed. The majority of graduate medical education funding comes from the Centers for Medicare and Medicaid Services in the form of direct GME payments—intended to reimburse teaching hospitals for the direct cost of training residents including resident stipends and faculty salaries—and indirect medical education payments—intended to pay for the higher cost of patient care at teaching hospitals. Funding amounts for both methods are calculated based on the number of residents in training at a hospital.
Total net general revenue budgeted for health-related institutions, 2012-2013
“Medical school deans and university presidents have traditionally been judged on their ability to build large medical research enterprises focused on discovery and innovation. Most academic medical centers focus on technology-intensive care
Number of first-year residency positions offered in Texas, all specialties vs. family medicine
2,000
Medical Education Formula Funding
Total first-year residency positions offered
1,500
All other total net general revenue budgeted for healthrelated institutions
First-year family medicine residency positions offered
1,000
Graduate Medical Education Formula Funding
$2.236 billion
Two fundamental problems with Medicare GME funding combine to jeopardize many primary care residency programs, especially family medicine programs. First, Congress capped Medicare GME funding as part of the Balanced Budget Act of 1997. With few exceptions, a teaching hospital can only receive Medicare GME funding for the number of residents it trained in 1996, and while many teaching hospitals have exceeded that cap, they have done so at their own expense. The other problem is that Medicare only reimburses teaching hospitals for the time residents spend in the hospital, which is fine for most specialties, but detrimental to primary care. For family medicine residents, the majority of training takes place in an outpatient clinic. Increases in residency training positions since Medicare capped GME funding have occurred almost exclusively in subspecialty training. The Medicare Payment Advisory Committee, COGME, and numerous researchers have observed that teaching hospitals and academic health centers have built GME training programs that serve their institutional goals instead of serving the physician workforce needs of their communities. Left to their own devices, academic medical centers have little incentive to increase primary care residency training positions. Residents in training provide inexpensive labor for treating patients, so teaching hospitals naturally realize higher revenues when employing residents in procedural specialties compared to residents training in primary care. Robust specialty residencies also present academic medical institutions greater opportunities to receive substantial research grants. Studies have shown there is an inverse proportion between the amount of research grant funding an institution receives from the National Institutes of Health and the number of primary care physicians the institution produces. Together, these factors set the stage for what COGME calls the “hidden curriculum” medical students encounter at academic health centers. Consider this statement from COGME’s 20th Report: Advancing Primary Care, from 2010:
1,519 1,281 $71.3 million
500
$640.2 million* 0 *Includes appropriation for Paul L. Foster School of Medicine at El Paso
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247 2000
211 2012
Direct patient care physicians per 100,000 population, 2011 to pursue these institutional goals, emphasize basic science and clinical investigation, and provide relatively greater rewards to subspecialty care. In most schools, the family medicine department, dedicated to primary care, is dwarfed in size and prestige by the department of internal medicine, which is often the largest research department in the entire university. In addition, many large hospitals have developed GME programs to support their complex care programs. The GME programs of these large teaching hospitals are effective for the recruitment of physicians to the medical staff and for building subspecialty clinical care. This disconnect between meeting the needs of the population versus meeting the needs of the academic health center was the focus of an Institute of Medicine report in 1989 and has recently been an area of concern for the Medicare Payment Advisory Committee. “Although Medicare capped its funded GME slots in 1997, accredited GME positions have grown 6.3 percent from 20032006, virtually all of which are self-funded by the hospitals. Despite this increase, a rise in subspecialty rates led to fewer physicians pursuing generalist careers. Like student choices, this build-out of residency training positions is highly correlated with specialty income. Teaching hospitals invest in lucrative services in order to support their bottom line and residents and fellows are an inexpensive way to support those services. Increasing options for subspecialization has both direct and indirect effects on primary care production, first by closing primary care positions to be used for subspecialty training, and second by giving would-be primary care physicians options to subspecialize. The net effect is a substantial reduction in primary care production from GME, now at about 29 percent or less compared to 32 percent from 2003 to 2008. In bending GME to service their financial bottom line, the needs of the population are not best served.�
DPC physicians per 100,000 population (# of counties) No physicians (28) 0.1 to 72.7 (123) 72.8 to 122.8 (62) 122.9 to 197.6 (20) 197.7 to 342.3 (21)
Primary care physicians per 100,000 population, 2011
PC physicians per 100,000 population (# of counties) No physicians (29) 0.1 to 39.7 (77) 39.8 to 62.4 (80) 62.5 to 89.9 (47) 90.0 to 150.5 (21)
Source: Supply Trends Among Licensed Health Professions, Texas, 1980-2011; Texas Department of State Health Services
From 2000 to 2012, the number of first-year residency positions offered in Texas through the National Residency Matching Program and the American Osteopathic Association Intern/Resident Registration
Cuts in state support for programs designed to recruit and train primary care physicians
$60M
$51M
$11.2M
$50M $40M
$23.3M $859,000
$30M $20M
Cuts in total state support for GME training
Physician Education Loan Repayment Program
$120M
Texas Statewide Primary Care Preceptorship Program
$100M
THECB GME funds for primary care residency training
$80M
Total THECB GME funds for primary care residency training $26.8M
$60M $40M
$79.1M $53.9M
$26.8M $10M
$5.6M $5.6M
0 FY 10-11
GME formula funding $5.6M $5.6M
FY 12-13
$20M 0 FY 10-11
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Program increased by 18.6 percent, from 1,281 positions to 1,519. Over that same period, the number of first-year family medicine residency positions in Texas fell by 14.6 percent, from 247 to 211. To make matters worse, Texas will soon be graduating more medical students than the number of first-year residency training positions available in the state. A recent report by the Texas Higher Education Coordinating Board shows that from fall 2002 to fall 2011, enrollment in Texas medical schools jumped by 31 percent, from 1,342 to 1,762. Since residency positions have increased more slowly, the coordinating board predicts that without investment in new residency positions for first-year residents, by 2014 Texas medical schools will produce 63 more graduates than the number of first-year positions available. By 2016, the number rises to 180. According to the medical student funding formula used in the state’s current budget, Texas invests approximately $168,000 to educate each medical student. That’s down from about $200,000 just a couple of years ago. Even if every graduate of a Texas medical school wanted to complete residency training in this state, Texans would still be exporting those who couldn’t find a place to train, thereby subsidizing the physician workforce of other states when the need in Texas is so critical.
Aligning incentives to increase primary care production In the current fiscal biennium, Texas will spend $2.24 billion in total net general revenue on its 10 health-related institutions in large part for the recruitment, education, and training of its future physician workforce. Yet the state has no reliable way to influence what kind of physicians are produced for that investment or to hold medical schools accountable for producing an appropriate physician workforce to meet the needs of its population. As a result, Texas has developed an imbalanced workforce with too few primary care physicians. A 2010 study in the Annals of Internal Medicine confirmed as much. The study examined a cohort of graduates from the nation’s 141 allopathic and osteopathic medical schools to rank the schools on their performance in addressing three interrelated shortcomings in the U.S. physician workforce: the insufficient number of primary care physicians, the geographic maldistribution of physicians, and the lack of racial and ethnic diversity among physicians. The authors found
Although the state has increased both the number of medical schools and the size of medical school classes over the past decade, there have not been significant increases in graduate medical education positions for the training of these graduates in Texas. The lack of funded GME slots results in Texas graduates going out of state to do their residencies. Only half of those who leave Texas to train ever return; in contrast, more than 80 percent of those who graduate from a Texas medical school and complete a Texas-based GME program will stay and practice in Texas. Until Texas makes graduate medical education its priority in health education funding, the state will continue to invest in medical students who ultimately will go elsewhere for residency and long-term practice. It simply doesn’t make good economic sense for Texas to educate physicians who will serve other states when the need here is so great. — Statewide Health Coordinating Council, 2011-2016 Texas State Health Plan
Total net general revenue budgeted for Texas’ medical schools, 2012-2013 $500M $400M $300M $459.8M
$200M $100M
$269.2M
$232.6M
$249.2M
$273.9M $193.6M $103.6M
$92.4M
0 UTSW Dallas
UTMB Galveston
UT Houston
*Includes appropriation for Paul L. Foster School of Medicine at El Paso
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UT San Antonio
TAMU
UNT Fort Worth
TTUHSC*
Baylor
that no Texas medical school appeared in the top 50, four ranked in the lowest 40, and one was next to last. For the production of primary care physicians, the Texas College of Osteopathic Medicine at the University of North Texas Health Science Center ranked seventh in the nation. The next Texas school on the list came in at number 40, and three Texas schools were in the lowest quarter of the rankings. The amount of state support Texas’ health-related institutions receive will always seem small compared to the net revenues of their affiliated practice plans, research funding, and other sources of revenue. Still state support is significant, and given the state’s desperate need to gain more primary care physicians for the sake of its citizens, its economy, and for the hope of controlling escalating health care costs, medical schools should be expected to produce an appropriate mix of specialist and primary care physicians. Of course medical schools can’t force medical students to pursue primary care careers, but the state could implement incentives to encourage schools to counteract the “hidden curriculum.” In the upcoming legislative session, TAFP will propose a series of incentives and related structural reforms intended to facilitate a more rational and predictable physician workforce. Those policy reforms are common sense, straightforward, and evidence-based. They have been vetted by Texas’ top policy experts, medical educators, business leaders, and a wide range of health professionals. First, the Legislature will be urged to increase the number of primary care physicians practicing in Texas by restoring funding to family medicine and primary care residency training programs, and by creating incentives for the development of new training programs based in community clinics, such as federally qualified health centers. Next, lawmakers should target the state’s investment in medical education to get a better return by creating incentives for medical schools to produce the primary care physician workforce Texas demonstrably and urgently needs. Finally, the state can recruit primary care physicians to practice in underserved communities by recommitting to the promise of physician education loan repayment. “Together, these initiatives constitute a bold set of strategies to grow and improve Texas’ primary care physician workforce and to increase access to primary care services for Texans across the state,” Fiesinger says. “With a robust primary care physician workforce, we can ensure Texas’ patients will receive the right care at the right time for the right price.”
Fast facts Texas Health Rankings When compared with other states, Texas ranks near the bottom in many determinants of health—from behaviors and community factors to public policies and clinical care—which are reflected in poor health outcomes. Consider these 2011 rankings:
STATE RANKING
Obesity (percent of adult population).........................................................42 Lack of health insurance (percent without health insurance)................50 Early prenatal care (percent with visit during the first trimester).............. 50 Primary care physicians (per 100,000 population)...................................42 Preventable hospitalizations (number per 1,000 Medicare enrollees).......36 Diabetes (percent of adult population).......................................................34 Cardiovascular deaths.....................................................................................30 Source: America’s Health Rankings 2011, United Health Foundation
The economic impact of chronic disease Experts predict that the combined effect of treatment costs and lost productivity from chronic disease will cost the Texas economy $187 billion in 2013. This figure balloons to $332 billion by 2023. Source: An Unhealthy America: The Economic Burden of Chronic Disease, Milken Institute, October 2007
The Primary Care Solution The addition of primary care physicians in a population results in better overall health outcomes for all patients. • An increase of one primary care physician per 10,000 population (about a 20 percent increase) was associated with a 6 percent decrease in all-cause mortality and about a 3 percent decrease in infant, low-birth-weight, and stroke mortality. • For total mortality, an increase of one primary care physician per 10,000 population was associated with a reduction of 34.6 deaths per 100,000 population at the state level. • Lower primary care physician supply and higher specialty-to-population ratios were associated with higher overall age-adjusted mortality, mortality from heart disease, mortality from cancer, neonatal mortality, life span, and low-birth-weight ratios. Source: Starfield, Barbara, et al. “The Effects of Specialist Supply on Populations’ Health: Assessing the Evidence.” Health Affairs Web exclusive w5.97 (15 March 2005): 97-107.
Support for graduate medical education budgeted for Texas’ health-related institutions, 2012-2013 $20M
$15M
Special item support for GME programs GME formula funding $2.2M $805,000
$10M
$262,000 $6.4M
$13.7M
$10.9M
$5M
$7.9M $4.6M
0
$6.6M
$5.0M
$5.1M
$5.1M
$1.2M
$1.7M UTSW Dallas UTMB Galveston UT Houston
UT San Antonio
UT Tyler
TAMU
UNT Fort Worth
TTUHSC
www.tafp.org
Baylor
UT MD Anderson
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TMB rules you should know (part 2) By TMLT Risk Management Department
This is the second in a series of articles about specific Texas Medical Board (TMB) rules that seem to give physicians the most trouble. Part 1 was published in Texas Family Physician, Vol. 63 No. 2. This article will discuss these more challenging TMB rules in an effort to enhance knowledge of the TMB, reduce exposure to disciplinary actions by the board, and assist in the physician’s defense should a TMB action occur. In this article, new death certificate requirements, standing delegation rules, and officebased anesthesia rules will be reviewed.
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1. New death certificate requirements Texas physicians who are asked to sign a death certificate must now do so electronically or face fines from the TMB of up to $500 per violation. House Bill 1739—which took effect in 2007—requires a medical certifier on a death certificate to submit the medical certification and attest to its validity electronically. Physicians must register with the Texas Electronic Death Registrar (TEDR) before signing a death certificate. Any physician who signs a paper death certificate because he or she is not registered with TEDR could be fined $500 by the TMB. The Texas Department of State Health Services operates the TEDR. Physicians should also note that signing a paper death certificate—even if you are registered with the TEDR—is now considered illegal. Therefore, sign up for the electronic system so you will not have to sign a paper death certificate. It is currently taking about two weeks to process a physician’s electronic registration through the TEDR. If you wait and try to sign up after a patient dies, it will be too late and you could be fined. Though the legislation went into effect in 2007, the TMB began enforcing it in 2011. And although the Board put enforcement on hold in late 2010, they recently restarted enforcement.1
2. Supervising midlevel practitioners The rules related to the supervision of midlevel practitioners are focused primarily on requiring written delegation of responsibilities and active follow-through with supervision. The applicable rules are found mainly in Texas Medical Board Rules 185 and 193.6, and the Medical Practice Act, Section 157 (also known as the Texas Occupations Code). All of these rules can be found at the Texas Medical Board website, www.tmb.state.tx.us/ rules/rules.php.2 TMB rules require “continuous” supervision of physician assistants, but the rules make it clear that this does not require the physician’s continuous physical presence. The physician must always be available by phone.3 Note however, that rule 185.16 states that the physician must be on-site with the physician assistant at least 10 percent of the time, though there is an exception provided for medically underserved areas.4 The Medical Practice Act, Section 157.0541, further re-
quires that the supervising physician must review 10 percent of the charts of midlevel practitioners who are located at a site other than the physician’s primary practice site.5 Regarding documentation of supervision of midlevels at non-primary sites, board rule 193.6(f)(2) requires the following. “If the physician assistant or advanced practice nurse is located at a site other than the site where the physician spends the majority of the physician’s time, physician supervision shall be further documented by a permanent record showing the names or identification numbers of patients discussed during the daily status reports, the times when the physician is on-site, and a summary of what the physician did while on-site. The summary shall include a description of the quality assurance activities conducted and the names of any patients seen or whose case histories were reviewed with the physician assistant or advanced practice nurse. The supervising physician shall sign the documentation at the conclusion of each site visit.”6 Notably, this rule also specifically states that this type of documentation is not required for midlevels practicing on-site at the physician’s primary practice site. The Medical Practice Act, section 157.053 allows for delegation of prescribing authority to midlevels as long as there is a written standing order or protocol in place that defines the parameters of the prescribing authority. The act implies that the delegation of prescribing authority should be commensurate with each midlevel practitioner’s experience and expertise.7 Board rule 193.6 specifies that midlevel practitioners may neither write prescriptions for Schedule II drugs nor write a prescription for more than 90 days for any Schedule III, IV, or V drug. This same rule requires that “A physician shall document any delegation of prescriptive authority to a physician assistant or advanced practice nurse by a protocol, as defined in this section.”8 Medical board rule 185.16 limits to five the number of physician assistants or their fulltime equivalents (up to 50 hours per week) that one physician may supervise.9 Importantly however, the Medical Practice Act, section 157.053(e)(1) states that with respect to prescribing practices, the supervising physician may delegate prescription authority to only four physician assistants or advanced practice nurses or their full-time equivalents practicing at the physician’s primary practice site or at an alternate practice site.10 The Medical Practice Act, section 157.0541(e) [cont. on 28]
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[cont.from 26]
also places a limit of four on the number of midlevel practitioners who can be located at non-primary sites of practice of the supervising physician. This would include a combination of both physician assistants and advanced practice nurses.11 Any physician who practices in a hospital environment and employs physician assistants to help take care of hospitalized patients must consider whether they (the physicians) are sufficiently available to cover acute problems that may be identified by the midlevel practitioner. For example, the question needs to be asked whether it would be appropriate for a surgeon to operate on a patient and then leave town, leaving the midlevel practitioner to monitor the patient and communicate with the physician if problems arise. This arrangement generally works satisfactorily until the need for a second procedure arises. In such a situation, it is necessary to arrange surgical coverage before becoming physically unavailable. In other words, supervision by phone will not always suffice. With respect to the requirement for written protocols, medical board rule 185.14(b) states: “It is the obligation of each team of
physician(s) and physician assistant(s) to ensure that: • the physician assistant’s scope of practice is identified; • delegation of medical tasks is appropriate to the physician assistant’s level of competence; • the relationship between the members of the team is defined; • the relationship of, and access to, the supervising physician is defined; • a process for evaluation of the physician assistant’s performance is established; and • the physician assistant’s annual registration permit is current.”12 Each of these items should be covered in a written document. This same rule also states that “Physician assistants must utilize mechanisms which provide medical authority when such mechanisms are indicated, including, but not limited to, standing delegation orders, standing medical orders, protocols, or practice guidelines.” Medical board rule 193.6(f) also requires that “The physician shall also maintain a permanent record of all protocols the physi-
cian has signed, showing to whom the delegation was made and the dates of the original delegation, each annual review, and termination.” The important point to keep in mind at all times is that basically all authority of a physician assistant is obtained by specific delegation from his or her supervising physician.13 An interesting provision of the Medical Practice Act provides at least some degree of protection from liability for supervising physicians. Section 157.060 states, “Unless the physician has reason to believe the physician assistant or advanced practice nurse lacked the competency to perform the act, a physician is not liable for an act of a physician assistant or advanced practice nurse solely because the physician signed a standing medical order, a standing delegation order, or another order or protocol authorizing the physician assistant or advanced practice nurse to administer, provide, carry out, or sign a prescription drug order.” The noteworthy aspect of this section is that the legal standard it imposes is whether the physician “has reason to believe” the midlevel practitioner lacked competence, rather than imposing a “should have known” or “should have believed” standard.14
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Supported in part by a grant from the American Academy of Family Physicians Foundation. 28
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3. Office-based anesthesia This discussion applies primarily to outpatient, ambulatory, non-accredited clinic facilities that require control of pain or anxiety during treatment by some means other than using local anesthesia or a nerve block. The general purpose of the rule is to first classify procedures into four different levels depending upon the type of anxiolytic, analgesic, or anesthetic being used (either before, during, or after the procedure). The rule then sets forth standards for the level of personnel training and the availability of equipment for each level of care. The rules applicable to this discussion are found in Texas Medical Board rule 192.15 First, it may be helpful to give an example of a common situation that illustrates the very broad applicability of this rule. If you give a patient a single tablet of alprazolam to take before removing a mole or performing a cosmetic laser procedure, this rule applies. You will need to comply with the personnel training and resuscitation equipment requirements of the rule. The rules classify this as a Level I situation, which is the lowest of
the four levels. In all settings covered by the office-based anesthesia rules, the physician and at least one other person present must maintain certification in basic cardiac life support (BCLS). Medical board rule 192.2(c) provides that in a situation in which a Level I service is being provided, the following requirements must also be met: “(B) the following age-appropriate equipment must be present: • • • •
bag mask valve; oxygen; AED or other defibrillator; and epinephrine, atropine, adrenocorticoids, and antihistamines.”16
Level II services are those in which there is delivery of analgesics or anxiolytics by mouth in dosages greater than allowed at Level I or there is use of tumescent anesthesia. Provision of Level II services requires a higher level of certification of personnel and more sophisticated equipment. For example, the physician must be ACLS (advanced cardiac life support) or PALS (pediatric advanced
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life support) certified, and there must be an EKG machine and a crash cart available (among other additional requirements).16 Medical Board rule 192.4 requires that any physician providing Level II, III, or IV services must register with the board and pay a fee.17 Rule 192.2(j) also requires that written protocols must be adopted that cover at least the following subjects: • patient selection criteria; • patients/providers with latex allergy; • pediatric drug dosage calculations, where applicable; • ACLS or PALS algorithms; • infection control; • documentation and tracking use of pharmaceuticals, including controlled substances, expired drugs, and wasting of drugs; and • discharge criteria.18 At a minimum, management of emergencies must include, but not be limited to: • cardiopulmonary emergencies, • fire,
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• bomb threat, • chemical spill, and • natural disasters.18 A very important requirement provided by rule 192.4(l) is that “All equipment and anesthesia-related services must remain available at the office-based anesthesia site until the patient is discharged.” This could easily be interpreted to mean that the physician must remain on-site until the patient goes home.19 Finally, it should be noted that since Sept. 1, 2010, a clinic must be registered with the TMB if the majority of its patients are treated for pain management issues. The specific requirement under rule 195 is for registration if the “majority of patients are issued, on a monthly basis, a prescription for opioids, benzodiazepines, barbiturates, or carisoprodol, but not including suboxone.”20 Registration for OBA will be combined with the physician’s biennial registration. If you need to register to provide OBA services between registrations, please contact PreLicensure, Registration, and Consumer Services at (512) 305-7030, for the proper forms. The fee to register is $210. Editor’s note: Since the publication of this article, there was a considerable discussion about whether physicians who provide tumescent anesthesia for either liposuction or for vascular ablation procedures are covered by these rules if they are not also providing patients with other analgesics or anxiolytics. We believe that the intent of the rules is that Level II anesthesia includes tumescent anesthesia even if other analgesics or anxiolytics have not been given, otherwise there would be an unintended gap in the rules. Many physicians who use tumescent anesthesia are trying to interpret the rule to mean that if they use only tumescent anesthesia (and they do not also use an analgesic or anxiolytic), they are not covered by the rule. We suspect that the TMB will clarify the rule to say that Level II anesthesia includes delivery of analgesics or anxiolytics by mouth in dosages greater than allowed at Level I or delivery of tumescent anesthesia.
Conclusion With its mission to protect the public and ensure a sufficiently trained physician workforce, the TMB is poised to enforce all rules for which it has responsibility. The practice of medicine is highly regulated and each licensed physician needs to be aware of cur30
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rent TMB guidelines and rules.All TMLT policies that cover individual physicians include a Medefense Endorsement, which provides reimbursement for legal expenses for disciplinary proceedings and various audits. Medefense provides coverage for any action by the TMB, a hospital action regarding clinical privileges, actions by the Texas Department of State Health Services or the U.S. Department of Health and Human Services, and noncompliance with Medicare/Medicaid regulations. In addition, reimbursement for individual federal tax audits is covered. Notify your medical liability carrier as soon as you receive the initial letter from the TMB or other disciplinary authority. TMLT policies state that a policyholder has 60 days to report an insured event to receive reimbursement for covered expenses. To preserve coverage, it is extremely important to pay attention to the 60-day window in which to report knowledge of a proceeding. Retaining an attorney at the very beginning of any regulatory process will allow the attorney to guide you in providing the best response possible. The sooner you involve a representative from your medical liability carrier in any legal proceeding involving your medical practice, the better your result will be.
1. Health and Safety Code, Title 3, Chapter 193, Section 193.005. Available at http://codes.lp.findlaw.com/txstatutes/ HS/3/193/193.005. Accessed May 20, 2011. 2. Texas Medical Board. Medical Board Rules. Available at http://www.tmb.state.tx.us/ rules/rules.php. Accessed May 17, 2011. 3. Texas Medical Board. Medical Board Rule 185.14(a). Available at http://www.tmb.state. tx.us/rules/rules.php. Accessed May 12, 2011. 4. Texas Medical Board. Medical Board Rule 185.16(c). Available at http://www.tmb. state.tx.us/rules/rules.php. Accessed May 12, 2011. 5. Medical Practice Act. Section 157.0541. Available at http://www.statutes.legis.state. tx.us/?link=OC. Accessed May 16, 2011. 6. Texas Medical Board. Medical Board Rule 193.6(f)(2). Available at http://www.tmb. state.tx.us/rules/rules.php. Accessed May 16, 2011. 7. Medical Practice Act. Section 157.0. Available at http://www.statutes.legis.state. tx.us/?link=OC. Accessed May 17, 2011. 8. Texas Medical Board. Medical Board Rule 193.6. Available at http://www.tmb.state. tx.us/rules/rules.php. Accessed May 17, 2011.
9. Texas Medical Board. Medical Board Rule 185.16. Available at http://www.tmb.state. tx.us/rules/rules.php. Accessed May 17, 2011. 10. Medical Practice Act. Section 157.053(e)(1). Available at http://www.statutes.legis.state. tx.us/?link=OC. Accessed May 17, 2011. 11. Medical Practice Act. Section 157.0541(e). Available at http://www.statutes.legis.state. tx.us/?link=OC. Accessed May 17, 2011. 12. Texas Medical Board. Medical Board Rule 185.14(b). Available at http://www.tmb. state.tx.us/rules/rules.php. Accessed May 17, 2011. 13. Texas Medical Board. Medical Board Rule 193.6 (f). Available at http://www.tmb. state.tx.us/rules/rules.php. Accessed May 17, 2011. 14. Medical Practice Act. Section 157.060. Available at http://www.tmb.state.tx.us/ rules/codes/chapter157.php#157060. Accessed June 28, 2011. 15. Texas Medical Board. Medical Board Rule 192. Available at http://www.tmb. state.tx.us/rules/rules.php. Accessed May 17, 2011. 16. Texas Medical Board. Medical Board Rule 192.2(c). Available at http://www.tmb. state.tx.us/rules/rules.php. Accessed May 17, 2011. 17. Texas Medical Board. Medical Board Rule 192.4. Available at http://www.tmb.state. tx.us/rules/rules.php. Accessed May 17, 2011. 18. Texas Medical Board. Medical Board Rule 192.2(j). Available at http://www.tmb. state.tx.us/rules/rules.php. Accessed May 17, 2011. 19.Texas Medical Board. Medical Board Rule 192.4(l). Available at http://www.tmb. state.tx.us/rules/rules.php. Accessed May 17, 2011. 20. Texas Medical Board. Medical Board Rule 195.1. Available at http://www.tmb.state.tx.us/ rules/rules.php. Accessed May 17, 2011. The information and opinions in this article should not be used or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalization can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services. © Copyright 2011 TMLT.
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academy news
Choosing Wisely campaign aims to cut use of unnecessary medical interventions AAFP, other groups release lists of tests, procedures to question By Matt Brown Sometimes, less health care is the best health care. As part of an effort to help physicians curtail the practice of ordering unnecessary tests and procedures, AAFP released a list of five tests and treatments physicians should think twice about before performing, ordering, or prescribing. The list is part of a national campaign called Choosing Wisely that launched at a press event in Washington, D.C. The campaign is working to identify specific tests or procedures commonly used within various specialties that are not always necessary. The Academy’s involvement in the Choosing Wisely campaign underscores family physicians’ long-term commitment to ensuring high-quality, cost-effective care to patients, said AAFP President Glen Stream, M.D., M.B.I., of Spokane, Wash., in a prepared statement.
“Family medicine’s ‘top 5’ list encourages more in-depth conversations between patients and their doctors so they discuss all options and then ‘choose wisely’ when it comes to a treatment plan,” he said. According to the Congressional Budget Office, as much as 30 percent of care provided in the United States consists of unnecessary tests, procedures, medical appointments, hospital stays, and other services that may not improve people’s health. CMS projects that if U.S. health care spending continues at current levels, it will reach $4.3 trillion, or 19.3 percent of the nation’s gross domestic product, by 2019. In response, the Academy and eight other medical specialty societies—the American Academy of Allergy, Asthma, and Immunology; the American College of
Cardiology; the American College of Physicians; the American College of Radiology; the American Gastroenterological Association; the American Society of Clinical Oncology; the American Society of Nephrology; and the American Society of Nuclear Cardiology—joined the Choosing Wisely campaign, which originated as an initiative of the American Board of Internal Medicine Foundation last year. The nine organizations initially participating in the Choosing Wisely campaign worked individually and collaboratively to create evidence-based lists of overused tests and treatments for their individual specialties. Dubbed “Five Things Physicians and Patients Should Question,” the lists are designed to help physicians and patients think and talk about overuse or misuse of health care resources. The AAFP’s list consists of the following five recommendations. 1. Do not do imaging for low back pain within the first six weeks, unless red flags are present. (Red flags include, but are not limited to, severe or progressive
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neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.) Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs and involves unnecessary radiation exposure. Low back pain is the fifth most common reason for all physician visits. 2. Do not routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days or symptoms worsen after initial clinical improvement. (Symptoms must include discolored nasal secretions and facial or dental tenderness when pressure is applied.) Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis, resulting in risk of side effects without benefit. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs. 3. Do not use dual-energy X-ray absorptiometry (DEXA) in women younger than
age 65 or men younger than 70 with no risk factors. DEXA is not cost-effective in younger, low-risk patients but is costeffective in older patients. 4. Do not order electrocardiograms or other cardiac screening for low-risk patients without symptoms. There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit. 5. Do not perform Pap smears on women who are younger than 21 or who have had a hysterectomy for non-cancer disease. Most observed abnormalities in adolescents regress spontaneously; therefore, Pap smears for this age group can lead to unnecessary anxiety, additional testing, and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease), and there is little evidence for improved outcomes.
The lists drawn up by the campaign’s eight other medical specialty partners are available on the Choosing Wisely website, www. choosingwisely.org. In addition, eight more medical specialty organizations signed on to the campaign during the press event and are scheduled to release their lists this fall. In an interview after the press event, Stream stressed the need to develop a solid, secure physician-patient relationship so meaningful patient conversations can take place. “People really do need a doctor who knows them and can help them navigate the medical system if they have a serious medical problem,” he told AAFP News Now. “It is also important to note that it is one thing to get a ‘Choosing Wisely’ decision from a doctor who knows you, but that to do that, you have to build trust up over time. “I think that as family physicians, our role is unique, because we are not only managing the care that we give, but it is also just as critical that we coordinate care for our patients using our subspecialty colleagues.” Source: AAFP News Now, April 4, 2012. © American Academy of Family Physicians.
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RESEARCH
Vitamin D and hypertension: Racial/ethnic disparities Tasleyma Sattar, D.O., Kimberly Fulda, Dr.P.H., Kun Don Yi, Ph.D., and Roberto Cardarelli, D.O., M.P.H. Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.
Gold level Richard Garrison, M.D. David A. Katerndahl, M.D. Jim and Karen White Bronze level Joane Baumer, M.D. Carol and Dale Moquist, M.D. Lloyd Van Winkle, M.D. George Zenner, M.D. Thank you to all who have donated to an endowment.
For information on donating or creating a new endowment or applying for research grants, contact Kathy McCarthy at kmccarthy@tafp.org.
Primary Care Research Center, Department of Family Medicine University of North Texas Health Science Center
the benefits of adequate vitamin D levels are well documented including the regulation of calcium and parathyroid hormone levels (Holick, 2006) and a potential impact on cancer risk (Lieberman DA, 2003). Despite the physiological importance and efforts at food fortification, the number of persons with deficient or insufficient vitamin D serum levels is estimated at approximately one billion worldwide (Holick, 2006). There are many factors that affect vitamin D levels including age, weight, skin pigmentation, gender, sunlight exposure, inadequate dietary intake, smoking, and medications. Differences in vitamin D deficiency or insufficiency unequally impacts certain socioeconomic, age, and racial/ethnic groups (Nesby-O’Dell S, 2002 and Holick, 2006). In addition to these disparities, racial/ethnic minorities are also at increased risk of developing hypertension and subsequent comorbid consequences. The exact causes of hypertension disparities continue to be investigated as new emerging factors and theories are developed in the research community. One promising factor includes serum vitamin D and its relationship with hypertension. However, no research has assessed whether this relationship differs by race or ethnicity. We propose that due to the diverse causes of vitamin D deficiency (some of which are more prevalent in certain racial/ethnic groups), hypertension disparity observed among racial/ethnic groups can be partially explained by the presence of vitamin D deficiency.
Methods
Study design: Cross-sectional study. Subjects and setting: Existing plasma samples collected from participants of the North Texas Healthy Heart Study (NTHH) were used to retrospectively determine levels of vitamin D, specifically 25(OH)D. These levels were compared to clinical blood pressure measures. In addition, physical, demographic, and behavioral measures from the NTHH were utilized in the analyses. The NTHH includes a convenience sample of 571 Caucasians, African Americans, and Hispanics/Latinos recruited from 12 participating sites of the North Texas Primary Care Practice-Based Research Network (NorTex) from April 2006 to May 2008.
Study participants in the NTHH study were African American, Caucasian, and Hispanic men and women 45 years of age and older. Plasma samples were stored on 428 of the 571 NTHH participants. Collection of the samples was approved by the University of North Texas Health Science Center and JPS Health Network Institutional Review Boards, and participants signed a separate written informed consent to have their samples stored and used for future research studies. Informed consent and surveys were administered in Spanish for Spanish speaking individuals. Of these samples, race/ ethnicity was recorded for 424 participants. Due to costs of performing the assays, only African American and Caucasian subjects were utilized for this pilot study. The 230 samples were randomly selected from those available. Table 1 provides the racial/ethnic distribution of these samples. Table 1. Racial/ethnic distribution of samples for proposed study
African American.................................... 115
Caucasian................................................. 115
Inclusion/exclusion criteria: Participants were eligible for the study if they were over the age of 44, self-identified as non-Hispanic Caucasian, non-Hispanic African American, or Hispanic/Latino, and had no history of self-reported cardiovascular disease (coronary artery disease, peripheral arterial disease, history of myocardial infarction or stroke, or congestive heart failure), renal failure, or liver failure.
Results Blood pressure and vitamin D levels were obtained for all 230 participants and were included in the analysis. Vitamin D levels were dichotomized into ≤20.99 (deficient) and ≥21 (sufficient). Overall, 69.4 percent (160) of participants had deficient vitamin D levels, and 30.4 percent (70) had sufficient levels. Forty-three percent (99) of all participants had blood pressure readings <140/90 (no hypertension) and 57 percent (131) were ≥140/90 (hypertension). www.tafp.org
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RESEARCH African Americans had a higher percentage of vitamin D deficiency at 82.6 percent versus Caucasians at 56.5 percent. African Americans had a higher percentage of hypertension than Caucasians, 60.0 percent versus 53.9 percent, respectively. Data were analyzed using simple logistic regression to determine whether vitamin D levels were associated with hypertension. Hypertension was used as the dependent variable, and vitamin D as the independent variable. The odds ratio (OR) was found to be 1.380, but did not reach significance (p=0.264, 95 percent CI 0.785, 2.429). In addition, when analyzing for race/ethnicity, the OR was 1.761 (95 percent CI 0.836, 3.710) for Caucasians, and 0.773 (95 percent CI 0.283, 2.114) for African Americans.
Conclusion
Discussion
Holick, M. F. (2006). High Prevalence of Vitamin D Inadequacy and Implication for Health. Mayo Clinic Proceedings, 81 (3), 353-373. Nesby-Oâ&#x20AC;&#x2122;Dell S, S. K. (2002). Hypovitaminosis D prevalence and determinants among African American and white women of reproductive age: third National Health and Nutrition Examination Survey, 1988-1994. American Journal of Clinical Nutrition (76), 187-192. Lieberman DA, P. S. (2003). Risk factors for advanced colonic neoplasia and hyperplastic polyps in asymptomatic individuals. JAMA, 290, 2959-67. Li, Y. C. (2003). Vitamin D Regulation of the Renin-Angiotensin System. Journal of Cellular Biochemistry (88), 327-331. Pereira M, L. N. (2009). Differences in prevalence, awareness, treatment and control of hypertension between developing and developed countries. Journal of Hypertension (27(5)), 963-975. CDC. (2009). Health, United States, 2008. Hyattsville, MD: National Center for Health Statistics. Kramer H, H. C. (2004). Racial/Ethnic Differences in Hypertension and Hypertension Treatment and Control in the Multi-Ethnic Study of Atherosclerosis (MESA). American Journal of Hypertension (17), 963-970. Scragg R, S. M. (2007). Serum 25-hydroxyvitamin D, Ethnicity, and Blood Pressure in the Third National Health and Nutrition Examination Survey. American Journal of Hypertension (20), 713-719. Gordon CM, D. K. (2004). Prevalence of vitamin D deficiency among healthy adolescents. Archives of Pediatrics and Adolescent Medicine (158), 531-537. Lee JH, O. J. (2008). Vitamin D Deficiency: An Important, Common, and Easily Treatabel Cardiovascular Risk Factor? Journal of the American College of Cardiology (52), 1949-56. Holick, M. (1994). McCollum Award Lecture, Vitamin D: New Horizons for the 21st Century. American Journal of Clinical Nutrition (60), 619-30. Fiscella K, Franks P. (2010). Vitamin D, Race, and Cardiovascular Mortality: Findings From a National US Sample. Annals of Family Medicine (8), 11-18.
This pilot study provides preliminary data regarding the relationship between hypertension and vitamin D deficiency among Caucasians and African Americans. No association between vitamin D deficiency and hypertension was observed in the current study. There was a definite difference in hypertension among Caucasians and African Americans, as expected, and an even greater difference in vitamin D deficiency. However, the data indicate that African Americans, who have a greater incidence of vitamin D deficiency and hypertension, may actually have an inverse relationship between the two variables, although the relationship did not reach significance. The researchers believe that a greater number of participants are needed to better define this relationship. In the Caucasian population, a direct relationship was seen between hypertension and vitamin D deficiency, which is in keeping with previous studies in this group. Again, the data did not reach statistical significance, but the researchers believe this is due to the low number of participants in the study. Strengths: This study will add to the body of knowledge of the health effects of vitamin D deficiency or insufficiency and will also guide further research into eliminating these health disparities. Future treatment recommendations for hypertension could potentially be targeted to specific ethnic groups to achieve optimal blood pressure control, and vitamin D level determination in patients could become a standard of care, especially in racial/ ethnic minorities. If indeed African Americans have an inverse relationship between hypertension and vitamin D deficiency, then current clinical recommendations on vitamin D supplementation may have to be revisited. In addition, this pilot study provides valuable information to estimate the appropriate sample size for future research studies. It is seen that the sample size of 115 participants per group was not a large enough number. Limitations: The small number of samples for each racial/ethnic group severely limited the ability to determine a statistically significant relationship between the variables. Future studies will need to contain a larger sample size. 36
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Although the data obtained were not statistically significant, it was seen that a general direct relationship exists between hypertension and vitamin D deficiency in Caucasians, whereas the relationship is inverse in African Americans. Whether this was due to the small sample size of this pilot study remains to be seen in future, larger scale, studies. If this relationship is indeed true, clinical recommendations on the supplementation of vitamin D could be significantly impacted.
References
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perspective
By choosing wisely, physicians can help address the unsustainable trajectory of health care costs By Richard Young, M.D. “every admitted patient should have a chest X-ray and a VDRL,” said one of my Type A personality internal medicine attending physicians during residency. The year was 1990 and this attitude was shared by a few other knowledgeable physicians at the time, though others questioned the practice and were more flexible in their medical decisionmaking. I would venture to guess that few family physicians or internists practice this way in 2012, but the practice is not completely dead. A lot has changed since 1990. The total cost of U.S. health care was $724 billion and consumed 12.5 percent of the gross domestic product.1 In 2012, the total cost of U.S. health care is estimated to be $2.8 trillion and will consume 17.6 percent of GDP.2 This health care inflationary trend has continued unabated for the last 50 years. There are other reasons besides cost considerations to avoid unnecessary tests, such as the harms caused by further work-ups of first-test abnormalities that are later discovered to be false positives. Recently, the American Board of Internal Medicine Foundation challenged specialty societies to propose five patient care practices that should not be routine. They named this initiative “Choosing Wisely,” and nine medical societies participated. The complete lists of recommendations and their rationales are available at www.choosingwisely.org. The American Academy of Family Physicians submitted the following five recommendations: • Don’t do imaging for low back pain within the first six weeks, unless red flags are present. • Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement. • Don’t use dual-energy X-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. • Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms. • Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. Other societies wrote recommendations that impact family medicine. From the American College of Physicians (with duplicates of the AAFP recommendations removed): • In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI). • In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test. • Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. From the nephrologists: • Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms. 38
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From the cardiologists: • Don’t perform stress cardiac imaging or advanced non-invasive imaging as a preoperative assessment in patients scheduled to undergo low-risk non-cardiac surgery. • Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms. From the radiologists: • Don’t do imaging for uncomplicated headache. • Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability. • Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. • Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts. Changes in physicians’ habits are driven by many factors, including the fear of lawsuits. While these lists do not provide ironclad protection in the event of a rare patient outcome, they are clear statements from the major medical societies on tests and treatments that should be considered unnecessary by everyone. Recent projections estimate that if major changes are not implemented to reduce the growth of U.S. health care costs, then the cost of a family health insurance premium will equal household income by 2033.3 Even under optimistic assumptions of the Affordable Care Act, this crossover year is only pushed back four years to 2037. For physicians to be part of the solution to this unsustainable trajectory, they must be willing to let go of outdated practices for both cost and quality concerns. They need to move away from a general attitude of “just do it,” to “when in doubt, don’t.” The Choosing Wisely campaign is a great place to start this journey.
1. Centers for Medicare and Medicaid Services. National Health Expenditures Aggregate. https://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf. Accessed May 30, 2011. 2. Centers for Medicare and Medicaid Services. National Health Expenditures and Selected Economic Indicators, Levels and Annual Percent Change: Calendar Years 2005-2020. https://www.cms. gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/NationalHealthExpendData/downloads//proj2010.pdf. Accessed May 21, 2012. 3. Young RA, DeVoe JE. Who will have health insurance in the future? An updated projection. Ann Fam Med. Mar-Apr 2012;10(2):156-162.
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