texas family physician VOL. 65 NO. 2 SPRING 2014
Does Your Practice
measure
UP? In A Value-based Payment Model, Quality Improvement Isn’t Just About Checking Boxes
PLUS: How To Be Ready For The Recovery Audit Contractor
DID YOU KNOW?
Your TMLT policy includes much more than the basics.
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INSIDE
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TEXAS FAMILY PHYSICIAN VOL. 65 NO. 2 SPRING 2014
16
Does your practice measure up?
With payment reform on the horizon, continuous quality improvement in the family doctor’s office is more than just checking boxes. TFP talks with a group of Austin doctors and a Kansas physician that are rising stars in value-based medicine.
23 NUTRITION Help patients choose food instead of filler. 24 FOUNDATION FOCUS Introducing TAFP Foundation’s new student interest fund drive, Ignite2015. Recruit the family doctors of tomorrow. Build the Foundation today.
By Jonathan Nelson
6
Your TAFP President says take it slow
Embrace the concept of “slow medicine” and take your time practicing the art of family medicine. By Clare Hawkins, M.D., M.Sc.
8 MEMBER NEWS Report on TAFP’s 2014 C. Frank Webber Lectureship | Meet the TAFP Board candidates | Highlights from TAFP’s Interim Session with proposed bylaws amendments
11
Don’t be alarmed— Here comes the RAC
TAFP’s practice management guru tells you all you need to know to be ready for the Medicare Recovery Audit Contractor. By Bradley Reiner
25 RESEARCH Impact of race-specific training for health care providers on appropriate diagnosis and weight counseling for Asian patients who are overweight or obese 30 TAFP PERSPECTIVE It’s time for family doctors to be bold.
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president’s column
TEXAS FAMILY PHYSICIAN VOL. 65 NO. 2 SPRING 2014
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
Clare Hawkins, M.D., M.Sc.
president-elect vice president treasurer
Dale Ragle, M.D.
Tricia Elliott, M.D.
Ajay Gupta, M.D.
parliamentarian
Janet Hurley, M.D.
immediate past president
Troy Fiesinger, M.D.
Editorial Staff managing editor
Jonathan L. Nelson
associate editor
Samantha White
chief executive officer and executive vice president
Tom Banning chief operating officer
Kathy McCarthy, C.A.E.
advertising sales associate
Michael Conwell Contributing Editors Janet Hurley, M.D. Bradley Reiner Troy Tuttle, M.S. Deepa Vasudevan, M.D. cover photo
Samanathan Knight-Wilson
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. © 2014 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6
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Slow medicine
Taking time to practice the art of family medicine By Clare Hawkins, M.D., M.Sc. TAFP President do you ever think that your day is going slowly? Do the mundane features of patient care make you feel slow? Or perhaps, by contrast, you feel it is going too fast, like that proverbial hamster on the treadmill. My treadmill involves dealing with difficult patients, paperwork requests, and the idiosyncrasies of the electronic health record. In spite of the speed, however, I don’t always feel efficient. Even when I feel I can complete a patient encounter quickly, this does not feel like a triumph. The speed comes at the expense of a lack of connection with the patient, or less fulfilment with medicine than I had expected. Yes, I feel that it goes too fast, almost frenetic. Are there too many patient encounters? Perhaps the multiple components of the patient encounter are distracting. Rather than focusing on the patient, I am counting documentation bullets for E&M compliance, responding to care reminders, completing imaging requests, or making medication formulary substitutions. Many of these are necessary components for getting my patients the services they need, or for getting me the reimbursement I seek. However, few of these feel rewarding. What would it take to focus on the patient? What would it take to be only peripherally aware of the multiple physician agendas of quality, preventive medicine, compliance, and to be able to really listen to the patient? Research shows that we usually interrupt a patient within the first seconds
of their chief complaint. If we were to listen more carefully, then perhaps we could get to the heart of the matter at hand. The “slow medicine” I’m referring to in the title is the art of medicine, when I can slow down and listen to my patient’s story and, rather than interrupting to get to the point, gently guide the dialogue toward meaning, respect, and understanding. By delineating their needs and preferences better, more is shared. We share in making decisions, and we avoid unnecessary workups and irrelevant discussion. The slow food movement is a response to the fast food industry. Hence the name, “slow food.” Physicians have adapted the name to apply to a countercurrent in the medical world where value is placed on time spent with a patient. The first published article I can find on slow medicine appeared in the January 2002 supplement of the Italian Heart Journal, by Dr. Alberto Dolara, an Italian cardiologist, entitled “Invitation to ‘slow medicine.’” More recently, family physician Dr. Dennis McCullough, who practices mostly care of the elderly in Dartmouth, is a very articulate proponent, and has published a book entitled, “My Mother, Your Mother.” These physicians recognize the inherent value in slowing down to focus on the patient. In my previous column, I discussed the pressures of being measured. Yes, the pressures to demonstrate quality are increasing, but the obligation to hear our patients have not gone away. I want to talk about
Yes, the pressures to demonstrate quality are increasing, but the obligation to hear our patients have not gone away. I want to talk about the refuge of the doctor patient relationship and its healing opportunities.
Reiner Consulting & Associates the refuge of the doctor patient relationship and its healing opportunities. I say refuge, because often I find the interaction between a patient and physician to be insulated from the pressures of reimbursement, quality management, audits, etc. I like to block out the rest of the world and practice being 100 percent present with the patient. Yes, it takes practice. This is indeed a challenge to focus on my patient and not my computer. I like my laptop, and I try to use it within an encounter to animate our interaction by showing growth curves for children, or weight loss progress. Sometimes I enter data in front of a patient to demonstrate my attention to detail and laborious work collecting data and e-prescribing. I do this partly so the patient sees the value of my time spent on their behalf. But often I hear a voice inside my head saying it’s time to close the laptop and be fully present with my patient. There is some research to support that by being slower and more deliberate with a patient, you can prevent unnecessary workups, or even important workups that a patient doesn’t want. Defining a patient’s goals, as well as their illness, can allow us to be selective and tailor our approach to the patient. This, I believe, is the essence of being patient-centered, and perhaps the core of being a patient-centered medical home. Yes, there are all the important issues of access, preventive service reminders, and population management, but the center of the PCMH should be the patient-physician relationship. We are taught through a long process of medical education to dissect the disease into its components. In so doing, we can scientifically identify the disease process. This is very important, but the side effect can be that we continue to deal with the person in pieces rather than as a whole. Within my office or hospital, I must constantly reorient my process so the patient and the things that really matter stay at the center. It is not easy while I’m surrounded by fast medicine, but with time, I can develop skills to focus on the patient. Sometimes this means I need to slow down. I need to listen to my patient’s story, and I often need to listen to my own heart. This way, in addition to restoring health, I can focus on the things that are life-giving.
Practice ManageMent ServiceS
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Member news
Report on TAFP’s 2014 C. Frank Webber Lectureship
Family physicians congregate in Austin for annual symposium STORY AND PHOTOS BY SAMANTHA WHITE
almost 300 physicians attended the C. Frank Webber Lectureship held Friday, Feb. 28, at the Omni Austin Hotel at Southpark. Countless other family physicians, residents, and medical students also gathered at the Omni for TAFP’s Interim Session and other related events. The packed weekend included CME lectures, two ABFM SAM Group Study Workshops, TAFP business meetings, the Texas Conference of Family Medicine Residents and Students, and the Clerkship and Residency Coordinators Conference. The first SAM Group Study Workshop of the weekend was held Thursday, giving diplomates of the American Board of Family Medicine a chance to get credit for the SelfAssessment Module portion of their Maintenance of Certification. Attendees discussed depression and completed the 60-question 8
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TEXAS FAMILY PHYSICIAN
knowledge assessment portion of the module, making them eligible to complete the clinical simulation online to receive full credit. Friday’s CME lectureship featured speakers on a wide array of topics, including sinusitis, women’s health, PTSD, and more. For the first time, attendees were able to complete their evaluation survey and CME recording form not only on paper, but also within the new TAFP mobile app. The second SAM Group Study Workshop was held Saturday and covered care of the vulnerable elderly. TAFP also hosted the Texas Conference of Family Medicine Residents and Students on Saturday, giving medical school students and residents a chance to learn about the specialty. Lesa Moller with the Higher Education Coordinating Board kicked off the conference by presenting infor-
mation about the loan repayment program. The attendees were then able to interact with a panel of three TAFP members in different areas of primary care practice: Mark Chassay, M.D. (sports medicine); Emily Briggs, M.D. (OB); and Jake Margo, M.D. (rural). New to the conference this year was the Student and Resident Job Fair, giving attendees the opportunity to talk with programs hiring from around the state. As always, the student and resident conference ended with an interactive Procedures and Residency Fair where attendees could talk to representatives of residency programs from around the state and practice various procedures. TAFP commission, committee, and section meetings took place Friday and Saturday, and included discussions on multiple aspects of the family physician practice and
Meet the TAFP Board candidates Two TAFP members are running for one available at-large position on the TAFP Board of Directors, to be voted on at TAFP’s first Member Assembly, taking place Friday, July 25 in San Antonio at Annual Session and Scientific Assembly. Adrian Billings, M.D., is a full spectrum family medicine physician with Presidio County Health Services, a federally qualified health center, in rural Marfa and Presidio. He also serves as an Adrian Billings, M.D. associate professor of family and community medicine at Texas Tech University Health Sciences Center-Permian Basin and a clinical assistant professor with the Department of Family Medicine at the University of Texas Medical Branch in Galveston. Billings is a graduate of Texas A&M University and the University of Texas Medical Branch, holding a Doctor of Philosophy in Experimental Pathology in addition to his medical degree. He completed a family medicine residency at John Peter Smith Hospital in Fort Worth, where he also served as chief resident.
policy that will guide the Academy. With the changes made to the TAFP governance structure last year at Annual Session, there was no TAFP Board of Directors meeting Saturday night. Instead, board members met via conference call in April to discuss action items created by commission, committee, and section members. Read more on page 14. Mark your calendars now to join TAFP for next year’s C. Frank Webber Lectureship at the Omni Austin Hotel at Southpark on March 6. Also plan to join us for our largest symposium, Annual Session and Scientific Assembly, July 24-27, 2014, at the Grand Hyatt San Antonio Hotel in San Antonio, Texas. This fall, TAFP will host Primary Care Summit – Houston, Oct. 17-19, at the Westin Oaks, and Primary Care Summit – Dallas/ Fort Worth, Nov. 7-9, at the Westin Galleria.
After residency, Billings helped initiate and completed an obstetrics fellowship at John Peter Smith Hospital. He was awarded a National Health Service Corps Scholarship from the federal government and completed the service obligation in 2011 in Alpine, Texas while in private practice. In 2012 Secretary Kathleen Sebelius of the United States Department of Health and Human Services nominated Billings to a three-year term on the National Advisory Council of the National Health Service Corps. He has also assisted in the development of a new rural family medicine residency program with Texas Tech University Health Sciences CenterPermian Basin that will matriculate its first residents this July. A TAFP member since his first year of medical school in 1999, Billings is currently chair of the Commission on Membership and Member Services and
previously served as both chair and vicechair of the Section on Rural Physicians. He has also been a member on the Commission on Core Delegation, Executive Committee, Commission on Academic Affairs, and Commission on Legislative and Public Affairs. He has a particular interest in women’s health, surgical obstetrics, and preventive care for children. Mike McCrady, M.D., is a family practice hospitalist at Mother Frances Hospital and the Lewis and Peaches Owen Heart Hospital in Tyler, Texas. A graduMike McCrady, M.D. ate of Stephen F. Austin State University and the University of Texas Medical School at Houston, McCrady completed his family medicine training at St. Paul and Parkland hospitals in Dallas. There he was co-chief resident for the family medicine residency and president of the house staff for St. Paul Hospital. McCrady practiced as a primary care family physician for twenty-five years, first as a solo practitioner in Henderson, Texas, and then as a member of the Trinity Clinic, part of the Trinity Mother Frances Hospitals and Clinics, joining in the initial year of that organization. He went on to serve as the first president of the Trinity Clinic Board of Directors and later as Regional Medical Director and Vice-President of Clinic Operations. During that time, McCrady obtained a Master’s of Health Care Administration from the University of Texas at Dallas and also hosted a weekly radio interview program called Health Matters, which highlighted local health care professionals. A lifelong member of TAFP, McCrady has served as the board representative from East Texas, as well as on the Executive and Finance Committees. His interests include medical economics, medical education, and hospital-based family medicine. He is a frequent speaker and mentor at the University of Texas at Tyler Family Medicine Residency Program.
www.tafp.org
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9
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Medicare compliance and preparation for RAC audits By Bradley Reiner cms has taken the next steps in Medicare’s comprehensive efforts to identify improper Medicare payments and fight fraud, waste, and abuse in the Medicare program by awarding contracts to four permanent recovery audit contractors. The RACs are designed to guard the Medicare Trust Fund. The basis of these regional contractors was a successful federal demonstration project involving six states that produced significant recovery results by identifying improper payments by CMS providers. Because of this outcome, the program was implemented nationwide. The recovery audit program identifies improper payments made on claims for health care services provided to Medicare beneficiaries. Claim processing contractors are responsible for adjusting the claim, handling collections—offsets and checks—and reporting the debt on the financial statements. Believe it or not, underpayments will be identified as well as overpayments.
Underpayments occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed. Overpayments occur when health care providers submit claims that do not meet Medicare’s coding or medical necessity policies. The RACs are not allowed to review claims prior to Oct. 1, 2007 and are only able to look back three years from the date the claim was paid. A RAC is paid on a contingency fee basis for all overpayments and underpayments they find. Needless to say, the RACs have a huge incentive to find overpayments and underpayments. That percentage would allow them to generate millions and millions of dollars over the next few years. Don’t assume you don’t have to worry about RACs. If they continue to be successful, there is no doubt everyone will have a
RAC audit sooner or later. In almost every practice, a RAC can find some contestable billing, coding, or documentation issue during any given audit. It is easy to make mistakes even if you have all the right processes in place. The rules are too complex and they differ from payer to payer. Medical practices may actually benefit from an occasional RAC audit. In practices where physicians have been consistently coding at low levels for almost all services they provide, underpayments could be reimbursed. If such a practice is subject to a RAC review, they should get money back. The flip side could be much worse. If a practice is found to be consistently coding at a higher level than the documentation supports, then the RAC will require repayment to the appropriate level of service. Training providers in your practice on documenting correctly for code levels will help avoid the cost of overpayment in the future. www.tafp.org
[SPRING 2014]
11
ADDITIONAL RESOURCES What can you do to minimize the potential of an audit?
Medicare fee-for-service appeals flowchart: www.cms.hhs.gov/OrgMedFFSAppeals/ Downloads/AppealsprocessflowchartAB.pdf Providers submitting medical records to the RAC should follow the published guidelines found on the Connolly Healthcare website at: www.connollyhealthcare.com/RAC/pages/ record_submission.aspx Note: Whenever performing complex coverage or coding reviews (i.e., reviews involving the medical record), Connolly Healthcare will ensure that coverage/medical necessity determinations are made by RNs or therapists and coding determinations are made by certified coders. They want to ensure that clinical people are addressing the problem and not individuals who don’t have the clinical expertise to make medical record determinations. If an adjustment is needed based on a RAC review, the adjustment, whether overpaid or underpaid, will be indicated on the explanation of benefits called “Adjustment based on a recovery audit.” This will allow providers to know that the claim was adjusted for a particular reason. An appeal process is the same as any other appeal. If automated or complex review results in some form of adjustment needed, a provider can initiate a discussion period with the RAC or file an appeal with Novitas. The discussion period is not an appeal and does not stop the clock on the 120-day time period for asking for a redetermination, which is the first level of appeal. Providers must initiate a discussion within 15 days of the receipt of a demand letter in an automated review or a review results letter in a complex review. The discussion period does not take away a provider’s right to appeal, nor does it affect his recoupment or appeal time frames.
cms has taken the next steps in Medicare’s comprehensive efforts to identify improper Medicare payments and fight fraud, waste, and abuse in the Medicare program by awarding contracts to four permanent recovery audit contractors. The RACs are designed to guard the Medicare Trust Fund. The basis of these regional contractors was a successful federal demonstration project involving six states that produced significant recovery results by identifying improper payments by CMS providers. Because of this outcome, the program was implemented nationwide. The recovery audit program identifies 12
[SPRING 2014]
TEXAS FAMILY PHYSICIAN
•
Know if you are submitting claims with improper payments.
•
Conduct an internal assessment to identify if you are in compliance with all Medicare coding and documentation rules. Hire a consultant if you need help.
•
Identify corrective actions to promote compliance.
•
Appeal when necessary.
•
Learn from past experiences.
•
Check the RAC website weekly for new issues and what improper payments were found.
•
Identify and implement corrective actions to promote compliance (e.g., initiate awareness in the mailroom, medical records, and Medicare billing departments about RAC requests for medical records and be familiar with Connolly Healthcare’s envelope logo).
•
Conduct an audit to review medical records and codes and implement a compliance plan that can help minimize the risk of being audited.
Connolly Healthcare information www.connollyhealthcare.com www.connollyhealthcare.com/RAC/Pages/ cms_RAC_Program.aspx Phone number: (866) 360-2507
improper payments made on claims for health care services provided to Medicare beneficiaries. Claim processing contractors are responsible for adjusting the claim, handling collections—offsets and checks—and reporting the debt on the financial statements. Believe it or not, underpayments will be identified as well as overpayments. Underpayments occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed. Overpayments occur when health care providers submit claims that
It is wise to have a system in place to consistently examine your compliance and to make sure your staff is properly trained on appropriate documentation to help decrease the risk of an audit and guard against overpayments. It is not a matter of “if” but “when” medical practices will be audited, and with the recent release of Medicare payment data, overpayments are in the national spotlight.
do not meet Medicare’s coding or medical necessity policies. The RACs are not allowed to review claims prior to Oct. 1, 2007 and are only able to look back three years from the date the claim was paid. A RAC is paid on a contingency fee basis for all overpayments and underpayments they find. Needless to say, the RACs have a huge incentive to find overpayments and underpayments. That percentage would allow them to generate millions and millions of dollars over the next few years. Don’t assume you don’t have to worry
about RACs. If they continue to be successful, there is no doubt everyone will have a RAC audit sooner or later. In almost every practice, a RAC can find some contestable billing, coding, or documentation issue during any given audit. It is easy to make mistakes even if you have all the right processes in place. The rules are too complex and they differ from payer to payer. Medical practices may actually benefit from an occasional RAC audit. In practices where physicians have been consistently coding at low levels for almost all services they provide, underpayments could be reimbursed. If such a practice is subject to a RAC review, they should get money back. The flip side could be much worse. If a practice is found to be consistently coding at a higher level than the documentation supports, then the RAC will require repayment to the appropriate level of service. Training providers in your practice on documenting correctly for code levels will help avoid the cost of overpayment in the future. It is wise to have a system in place to consistently examine your compliance and to make sure your staff is properly trained on appropriate documentation to help decrease the risk of an audit and guard against overpayments. It is not a matter of “if” but “when” medical practices will be audited, and with the recent release of Medicare payment data, overpayments are in the national spotlight. Health care providers that might be reviewed include hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers, and any other provider or supplier that bills Medicare Parts A and B. The more claims billed to Medicare the greater the chance of an audit. However, don’t be fooled as even a small practice may be audited. CMS RAC regional contracts CMS awarded the contract for the south region, which includes Texas, to Connolly Consulting Associates, Inc. of Wilton, Conn. The RAC employs a staff consisting of nurses, therapists, certified coders, and a physician contractor medical director. They are obviously concerned with how much money is being paid by Medicare and are encouraged to recover as much as possible. Medicare is committed to identifying providers that have been paid more than they should and will do whatever it takes. Since the contractor is paid a percentage of money recovered, they are incentivized to find these mistakes.
SAM Workshop on Health Behavior Professional Development
July 24, 2014 Grand Hyatt San Antonio, San Antonio
To help members meet the educational requirements of licensure and obtain and maintain board certification, TAFP offers continuing medical education and Self-Assessment Modules. For more information, go to www.tafp.org.
SAM Workshop on Mental Health in the Community
65th Annual Session & Scientific Assembly
2014 Primary Care Summit – Houston
July 26, 2014 Grand Hyatt San Antonio, San Antonio
July 24-27, 2014 Grand Hyatt San Antonio, San Antonio
Oct. 17-19, 2014 Westin Oaks Hotel, Houston
SAM Workshop on Preventive Care
2014 Primary Care Summit – Dallas
July 23, 2014 Grand Hyatt San Antonio, San Antonio
Nov. 7-9, 2014 Westin Galleria Hotel, Dallas
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Highlights from TAFP’s Interim Session Feb. 27 - March 1 The committees, commissions, and sections of the Texas Academy of Family Physicians met in Austin and discussed many important items. Thanks to all members who participated. Most commissions, committees, and all section meetings are open to guests. You can also request an appointment by submitting a “Make Your Mark” involvement form. Contact Juleah Williams at jwilliams@tafp.org with any questions. Here are a few of the highlights from the recent meeting.
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Advocating for you and your patients The Commission on Health Care Services is forming a work group to discuss and consider proposing a standard definition for Texas patient-centered medical homes. Members noted that Colorado and Nebraska, among other states, have had success setting their own PCMH standards. Sue Bornstein, M.D., executive director of the Texas Medical Home Initiative, agreed to join the group as an expert consultant. The Commission on Legislative and Public Affairs discussed legislative interim studies including one regarding the expansion of transparency in the health care marketplace to facilitate informed consumer choice. Members raised concerns about unintended administrative burdens that may be placed on family physicians. The proposed Medicare SGR legislation was discussed in several different forums including the Commission on Legislative and Public Affairs. That group also discussed the time line for receiving enhanced Medicaid payments and a new prescriptive authority agreement developed by TMA and TAFP for physicians entering into a collaborative agreement with an Advanced Practice Registered Nurse or Physician Assistant. The Commission on Public Health asked the Commission on Legislative and Public Affairs to consider a recommendation to the legislature to require pharmacies to take back unused or expired medications and prescription drugs. The consensus was that current drug take back days are poorly advertised and insufficient to address the need. Member services and resources in development A new committee to design leadership development training opportunities met for the first time and began to outline a curriculum. A more formal proposal to the Board will be developed and submitted at a later date. The Commission on Continuing Professional Development discussed offering ABFM Part 4 group workshops in the future. Staff is investigating the feasibility and will report back at the next meeting.
Opportunities for members It was noted during the Commission on Core Delegation that the TMA delegation to the AMA does not have many family physicians. Members are encouraged to consider running for positions on the delegation to increase the influence of family medicine. There was also discussion of the TMA Leadership College. Those who have participated have found it quite valuable in developing their skills and gaining experience and insight. It is open to TMA members who are in their first eight years of practice or under age 40. Members interested are encouraged to apply. The Commission on Public Health, Clinical Affairs, and Research called on the Board to create a Section on Research to serve as a venue for members who are interested in research to get together and discuss opportunities. The group was approved by the Board and will meet for the first time at Annual Session in San Antonio. For several years, TAFP has provided funding for members who participate in the TMA Foundation’s Hard Hats for Little Heads. TAFP provides the matching funds for physicians to take advantage of this program to provide helmets to children in the community at bicycle safety and other community events. Contact Samantha White at swhite@ tafp.org for more information. Organizational issues The Nominating Committee had a new responsibility this year to identify candidates for positions on the new Board of Directors. They selected two candidates for one at-large position on the Board of Directors. You can read more about those two candidates on page 9. The Section on Special Constituencies and the Sections on Medical Students and Residents also have the ability to select nominees for the Board. The Member Assembly will elect members of the Board and officers at Annual Session in San Antonio. Here is the proposed slate of directors and officers for 2014-15: President-elect: Ajay Gupta, M.D. Vice President: Janet Hurley, M.D. Treasurer: Tricia Elliott, M.D. Parliamentarian: Tamra Deuser, M.D.
Delegate to AAFP: Erica Swegler, M.D.
Proposed Amendments to TAFP Bylaws
Alternate Delegate to AAFP: Troy Fiesinger, M.D. New Physician Director: Emily Briggs, M.D. At-large Director: Adrian Billings, M.D.; Mike McCrady, M.D. Special Constituencies Director: Terrance Hines, M.D. Resident Director: Kassie Johnson, M.D. Medical Student Director: Brittany Taute The Bylaws Committee reviewed recent changes to the AAFP bylaws and made recommendations to ensure alignment. They also discussed the succession of leadership and recommended changes in that area and a clarification in the section describing the Annual Business Meeting. These amendments will be voted on by the membership at the Business and Awards Lunch during the TAFP Annual Session and Scientific Assembly in San Antonio. The Finance Committee reviewed the combined 2013 audit for TAFP and NPI. There were no major findings. The committee also reviewed and made changes to TAFP’s investment allocation. Both the Commission on Academic Affairs and the Commission on Membership and Member Services discussed student enrollment in TAFP and discussed strategies to address schools with declining participation. The Commissions also reviewed and provided feedback on various member services and activities including the production of Texas Family Physician, educational programming, the Texas Conference of Family Medicine Residents and Students, the Texas State Family Medicine Preceptorship Program, and much more. The Task Force on Local Chapter Operations met for the first time and began discussing issues related to local chapters. An attorney will be consulted prior to the next meeting to provide a legal opinion of the risks and legal responsibilities. Member highlights Members from across the state were selected for scholarships to attend AAFP’s Annual Leadership Forum and National Conference of Special Constituencies. They include Domingo Caparas, M.D.; Mary Nguyen, M.D.; Farron Hunt, M.D.; Darnel Dabu, M.D.; Saleh Elsaid, M.D.; and Kristi Salinas, M.D. They join the official representatives to NCSC Adana Amechi-Obigwe, M.D.; Emily Briggs, M.D.; Lee Bar-Eli, M.D.; May Nguyen, M.D.; and Terrance Hines, M.D. The Commission on Continuing Professional Development selected program chairs for TAFP’s educational programs in the near future. Program chairs include Kristi Salinas, M.D., for the 2014 Primary Care Summit in Houston; Mark Malone, M.D., for the 2014 Primary Care Summit in Dallas; Lamia Kadir, M.D., for the 2015 C. Frank Webber Lectureship; Sarah Samreen, M.D., for the TAFP’s new summer CME conference in San Antonio; and Fozia Ali, M.D., and Tarina Desai, M.D. for the 2015 Annual Session in The Woodlands. The Section on Residents held elections for officers and delegates. Joshua Splinter, M.D.,
The proposed amendments to the TAFP Bylaws are in accordance with the TAFP Bylaws, Chapter XVII, Amendment of Bylaws. An affirmative vote of at least two-thirds of the members present and voting at the annual business meeting shall constitute adoption. If you would like to receive a complete copy of the TAFP Bylaws, contact Kathy McCarthy at the TAFP office at (512) 329-8666, ext. 14. For all of these amendments, the Bylaws Committee and the Board of Directors recommend adoption. Chapter VI. Classes of Membership and Election SECTION 10. GOOD STANDING A member in good standing shall be one whose current dues and assessments, if any, have been paid in accordance with the provision of these Bylaws, who is duly licensed to practice medicine, who is not under disciplinary action, and who has met the applicable CME requirements during the period of the preceding three (3) years as set forth in the AAFP Bylaws. SECTION 11. TRANSFERS Transfer of membership from one constituent chapter to another shall be subject to what is outlined in the AAFP Bylaws. Chapter X. Annual Business Meeting SECTION 2. Functions of the annual business meeting shall be: (1) to adopt or reject proposed changes in the Bylaws; (2) to act upon annual reports by officers and committees which are summarized and given by the President; (3) to act on business specifically referred by the Board of Directors; and (4) to make available the power of referendum the delegates to the Assembly may, by majority vote, approve a referendum for submission to the members of TAFP on questions affecting the policy or recommendations of the Academy.
from San Jacinto Methodist, was elected chair and Kassie Johnson, M.D., from UT San Antonio, was selected to be the nominee for the Resident Director on the TAFP Board of Directors. They elected Nish Shah, M.D., from San Jacinto Methodist, as vice chair and Soraira Pacheco, D.O., from UTMB Galveston, as secretary. The delegate and alternate delegate to the National Conference are Charla Allen, M.D., from Texas Tech, and Shiv Agarwal, M.D., from John Peter Smith. The delegates and alternate delegates to TAFP’s Member Assembly are Erika Spuhler, M.D., from Baylor; Benafsha Irani, D.O., from San Jacinto Methodist; Annie Jan, M.D., from UTMB Galveston; and Loren Fisher, M.D., from CHRISTUS Santa Rosa. The
Chapter XII. Board of Directors SUB-CHAPTER I. Policy and Procedure SECTION 14. Vacancies on the Board shall be filled at the next annual Member Assembly, at which time the Nominating Committee shall present a nominee for the unexpired term, if any. Board Chair. If a vacancy exists in the office of immediate past president, it shall be filled by a majority vote of the Board from among the remaining duly elected Board members. President. If a vacancy exists in the office of president due to death, resignation, or for any reason the president shall be unable or unqualified to serve, the President-Elect shall succeed to the office for the unexpired term. The duration of the term for the individual filling that position would be determined by the Board. Other Vacancies. If a vacancy exists for any officer position or elected member of the Board of Directors, unless within 90 days preceding the Annual Meeting, it may be filled with a vote by the Board of Directors. SECTION 15. If the office of the President becomes vacant, he/she shall be succeeded by the Vice President. In the event the Vice President is unable to serve, the office shall be filled by an appointment of the Executive Committee until the next Board of Directors meeting. In the event of the death, resignation, or removal from office of the President-Elect, the Executive Committee shall nominate one or more members for that office and election of the successor to the President-Elect shall take place by voting on those candidates by the Board of Directors, provided that nothing shall prevent additional nominations for this office.
resident liaison is Mary Anne Estacio, D.O., from UT San Antonio. Medical students held elections for officers and delegates for the coming year. Brittany Taute from UTMB was elected chair and nominated for the student director position on the TAFP Board of Directors, and Sharon Moore from Texas Tech was elected secretary. The delegate and alternate delegate to AAFP’s National Conference are Alyssa Shell from UTMB and Blair Cushing from UNT TCOM. The FMIG coordinator is Anna Gamwell from Texas A&M. The delegates and alternate delegates to TAFP’s Member Assembly are Glenda Linares and Cesar Cardenas from UTMB, Riesa Welch from Texas Tech, and Rodolfo Canizales from UTMB. www.tafp.org
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measuring
UP
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With valuebased payment reform on the horizon, quality improvement in the family doctor’s office is about more than checking boxes
By Jonathan Nelson
you can’t manage what you don’t measure. It’s an old business adage that has long been associated with the science of continuous quality improvement and the lean management principles made famous by manufacturing firms like Toyota and Ford, but in the era of “Big Data,” the concept has arrived at the doctor’s office. For employers, private insurers, and public purchasers of health care services, it’s an idea whose time has come. In 2004, the Rand Corporation published “The First National Report Card on Quality of Health Care in America,” which contained the troubling fact that on average, patients in the United States received the appropriate and recommended care only about 55 percent of the time. The results varied little, regardless of age, ethnic identity, socioeconomic status, gender, geography, or health insurance status. To fix the problem, the study called for system-wide investments in health information technology, performance tracking, and incentives for quality improvement. The Rand study was just one of many to point out what was becoming ever
more obvious: everyone in America was at risk for receiving poor care. Business organizations like The Leapfrog Group began calling for higher quality, increased accountability, and better value in the health care employers purchased, adding to the building pressure to transform the health care delivery system from one based on the quantity of medical services provided to one based on the overall quality of care delivered. Even in its failure, the most recent attempt by Congress to repeal Medicare’s flawed payment methodology—the sustainable growth rate—sent a powerful message to physicians and their professional organizations. The legislation would have started a clock on the implementation of value-based payment reform in Medicare over the next three to five years. The message for physicians? Payment reform is coming, and physicians will be expected to demonstrate quality or they’ll find it increasingly difficult to keep their practices viable in the current fee-for-service payment structure.
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Does your practice foster a culture of continuous quality improvement?
❑ Yes ❑ No
(check the appropriate box, please) Jen Brull, M.D., is a rising star in the AAFP membership, and as a solo family physician in rural Plainville, Kan., she presents an excellent example of how family doctors can work together to improve quality and prepare their practices to thrive in this changing health care environment. She practices with a community of like-minded family physicians who function like partners; they’re all plugged in to the same EHR and patient database, and they collaborate to conduct continuous quality improvement projects as a group. From outside, the five family physicians and five non-physician providers look like a group practice, but they’re not. They each own their own independent practice. At a TEDMED presentation she gave to an audience hosted by The Breakaway Group last spring, Brull described a realization many physicians experience once they begin to systematically assess their performance. “If you start to measure your data, you will have those ‘Aha!’ moments. You will awaken to the fact that you are not as good as you thought you were.” She told the audience about an early effort in 2004, when a state organization asked Brull’s family of practices to work on a quality improvement project for diabetic patients. At the time, the physicians had no EHR, so they set up a patient registry using some database software. It was a bit clumsy and it required entering information twice, once in the paper charts and once in the registry, but the project gave the physicians two tools that allowed them to deliver better care. “It let us do point of care management of the individual patient, and it let us do population management of our whole group of patients, so we could see who we were missing, who was falling through the cracks when it came to diabetic care,” Brull told the audience. “Many physicians assume they’re doing a fantastic job taking care of their patients, and they usually are with the people who show up in their office in front of them on a patient-to-patient basis,” Brull said in a video interview published online as part of the TEDMED series. “But oftentimes what physicians don’t realize is that they’re not necessarily taking good care of patients who are on the fringes. They don’t show up all the time. They don’t necessarily come for their chronic care appointments. And my message is that if given the opportunity and given the data—you have to have data to show you how you’re doing—physicians will desire to make that change and will use electronic health records and meaningful use to get them to that point.” Brull and her merry band of independent physicians flipped the switch on their first EHR in 2008, and she says they’ve been quite happy with it. They joined a patient-centered medical home initiative in 2011, achieving level three recognition through the National Committee for Quality Assurance in 2013. Over the years, the physicians have developed a culture of continuous quality improvement. “I found that I have a real passion for quality improvement work. It is probably one of the most exciting parts of my job for me.” As new members have joined the team along the way, the commitment to QI has only strengthened. “Now we just have people that know that every staff meeting, we’re going to be looking at a different quality improvement project. We’re going to be seeing where we came from last time and where we’re going this time and what our goals are, and what are we trying to improve, and how might we get there. Everybody knows if they have a good idea, they’re going to be listened to.” 18
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“Many physicians assume they’re doing a fantastic job taking care of their patients, and they usually are with the people who show up in their office in front of them on a patient-to-patient basis. But oftentimes what physicians don’t realize is that they’re not necessarily taking good care of patients who are on the fringes. They don’t show up all the time. They don’t necessarily come for their chronic care appointments. And my message is that if given the opportunity and given the data—you have to have data to show you how you’re doing— physicians will desire to make that change and will use electronic health records and meaningful use to get them to that point.” — Jen Brull, M.D.
Many physicians are skeptical of assessing their performance on clinical quality measures because such efforts inevitably involve increasing the amount of required documentation. In other words, they don’t want to spend time and energy checking boxes. But Brull says the benefits begin to outweigh the costs once physicians see they are delivering better care for their patients.
“You will not realize what you aren’t doing until you begin to measure it, and you can’t measure it if you don’t check the boxes.” For example, Brull had one of those “Aha!” moments when demonstrating meaningful use of her EHR to the Centers on Medicare and Medicaid Services a couple of years ago. She had to report whether she asked patients if they smoked, and if they said yes, she had to report what action she took. “The first year I did it—I wouldn’t have believed it until I ran the data—but I was not doing a good job at all about asking my patients if they smoked. Obviously if I wasn’t doing a good job of asking if they smoked, I sure wasn’t doing a good job of telling them not to, or offering support for them to stop.” She developed a workflow that allowed her to document quickly and easily, and as she completed the documentation, she found she was much more likely to discuss the dangers of smoking and the importance of cessation, regardless of the patient’s reason for the visit. “I had some great wins clinically from people who said, ‘Wow, you’ve talked to me about this three times this year. It must really be important. I guess I’ll quit,’” Brull says. “That experience of ‘I’ve got to click the box’ turned into ‘I’ve got to talk to my patients’ and in that way, it drove a change that was really good in my practice. Had I not had to click the box, I don’t think that change would have happened.”
Will checking boxes lead to checks in your box?
❑ Yes ❑ No
(you know what to do) Kurt Frederick, M.D., of Austin realized several years ago that value-based payment models for health care services were on the way, and the ability to collect, analyze, and report clinical data would be crucial to the success of his practice. His prediction is coming true, and the actions he and his partners have taken have positioned their practice to succeed in this new payment environment. “I think measurement is inevitable,” Frederick says. “I think every other industry measures quality; they measure performance, and so we’ve been sort of insulated from that for years. But I think the cat’s out of the bag now. We’re going to have to measure what we do and be able to report on it.” After years of having diminishing influence in the health plan contracts they signed, Frederick says he and his partners became convinced they had to transform their practice. “We were a group of seven family practice doctors who had a pretty good business model and a good practice, and yet still we saw every year increasing pressures on our bottom line and decreased payment for certain services, and more forms to fill out and more hurdles to jump just to get the money that we thought we had contracted for.” They needed more control in those contracts, and the only way to get it was to play the value game, he says. “Measure and report, improve quality and improve access for patients.” They began meeting with local private physicians, seeking those interested in aligning with them, and once they had identified several, they hired a CEO to provide the business expertise they needed. Now they were a group of 20 family doctors with five locations under the new name Premier Family Physicians. They bought some land in the southwest part of town, and broke ground on a state-of-the-art 80,000 square foot multi-specialty facility.
Watch Jen Brull’s presentation online. Video link: http://vimeo.com/67134970
Four pieces of advice from Jen Brull for physicians wanting to initiate a culture of continuous quality improvement in their practices First: “I always tell people to start small. It really only takes one person who wants to initiate a quality improvement project to do something. Obviously one person is not going to drive innovation across an entire company from day one, but if you are a physician or a nurse interested in quality work, you can say ‘in my own environment, I’m going to try something.’” Second: “Pick something easy. Don’t try to change the world. For instance, I always tell people colonoscopy screening is not the one to start with. It tends to be hard. It’s a complex process to get the actual measure satisfied and talking people into it is challenging. But in general, offering Pneumovax to patients over 65 in your clinic can be a very easy process to improve.” Third: “Be consistent in your commitment. So if you decide to do this, then decide how often am I going to look at this data and how often am I going to meet with my team.” Fourth: “Keep going. Even if you don’t seem to see a huge improvement initially, just pick something different to change, because what you’ve learned is by doing that thing that didn’t work, you’ve been able to cross something off your list.”
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“What it allows me to do is focus added quality on the patients who really need it. I’m able to identify my chronically ill patients, my 100 sickest and most expensive patients who have gaps in their care, or who could be getting their care in a more valuable way that’s easier on them.” — Kevin Spencer, M.D.
In January 2014, they began seeing patients in the new Southwest Medical Village. Premier Family Medicine serves as the anchor practice of the facility, its partners having vetted and invited each of the specialty practices that are now on board. All must agree with the core tenants of increased quality and access to care. “We also noticed that a number of other physicians were interested but they didn’t really want to take our tax ID and our exact business model, so we took the next step, which was to form a broader organization.” They formed a 250-physician accountable care organization, Southwest Provider Partners, LLC, and enrolled in the Medicare Shared Savings Program. Kevin Spencer, M.D., one of the original partners of Premier Family Medicine, says the group now has a number of value-based contracts in place, with several more in the works. He says these contracts are mostly examples of a blended payment model. “What that looks like is a per member per month fee up front to deliver clinical care coordination with the idea being that we would invest that as an organization into the staff and administration that it requires to manage patients in this way. Then there is a fee-for-service piece in the 20
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middle based on the volume of the care you deliver, and then a back-end piece, which is based on quality metrics or some sort of gain sharing based on your ability to deliver the care more cost-effectively.” These value-based contracts are becoming available to Premier Family Medicine and other practices that have undergone similar transformations in large part because they have learned to leverage their data—not just the ability to collect, access, and report it properly, but the sophistication to recognize trends and understand what they mean. The lessons these practices learn in blended payment and shared savings models will prepare them for what might come next, when payers begin expecting physician groups to share risk across patient populations in global payment and capitated payment models. But for Spencer, the real benefit accrues to his patients who he says are receiving better care. “What it allows me to do is focus added quality on the patients who really need it,” he says. “I’m able to identify my chronically ill patients, my 100 sickest and most expensive patients who have gaps in their care, or who could be getting their care in a more valuable way that’s easier on them.”
Texas academy of family Physicians presents: Whether it’s the ability to generate a list of diabetic patients who need a microalbumin screening and then send them a message, or the ability to quickly identify all patients taking a newly recalled drug, then notify them and issue new orders to their pharmacies, Spencer says the data allows his team to manage his patients’ health, not just treat their illnesses. “So much of medicine has become care coordination and really shepherding the patient through the health care system and not just waiting for them to choose when they think they’re sick enough, or they read an article, or their family member bothered them enough that they should come in for a physical.” Any patient of Premier Family Medicine who hasn’t had a physical exam in over 15 months gets an e-mail from the clinic complete with educational material on what a health maintenance exam is and why it’s valuable. “It’s changing what we do fundamentally, both in the exam room and in the way we touch the patients and engage them in every way as we look at strategies on our patient portal, as we look at strategies when they call and talk to our phone operators, as we look at strategies when the nurses put them in the room.” This kind of population management requires a huge investment in practice infrastructure, and today, payers are only beginning to pitch in. Spencer admits he and his partners have taken quite a risk, but they are confident their investment will pay off. “We believe it was right for our patients; we believe it was right for our office.” He advises practices looking to begin this type of transformation that the first step is to understand your current health information technology and figure out what processes you can measure. “Can you run a report on an appointment type? Can you run a report on who hasn’t had a physical in the last year?” Start small, he says, and because you probably won’t be paid for it in the beginning, focus on those clinical measures that help serve the patient while generating income. Physical exams and disease control measures for diabetic patients are good options to try. “Those are both good for patients; they improve measurements, and create income in a fee-for-service environment. So you start with those then you press the organization to be able to measure something.” Throughout the twentieth century, quality improvement philosophies and process management techniques revolutionized industries around the world, making businesses and products stronger, safer, and more efficient. In an industry as complex as health care delivery, the transition has been slow and halting. When it takes place, it happens in the exam room, practice by practice, group by group, and while a few high-performing health systems report significant success, the vast majority of the nation’s delivery system is just beginning to adapt. Spencer believes the time is right for physicians in practices small and large to step forward and lead the change. “I think sometimes we get caught up on, ‘well, they’re measuring the wrong thing,’ and that can be true.” We are measuring too many things, he says, and some of them will surely turn out to be useless. “That’s why you need physician involvement and physician leadership.” Physician leaders in practice transformation, in academia, and in physician organizations can work to identify those clinical quality measures that lead to better care outcomes for patients, improved quality in the delivery system, and lower health care costs—the triple aim. But divining which are the right quality measures to track and which should be discarded is battleground number two, Spencer says. “Battleground number one is can we measure anything.”
65th Annual Session & Scientific Assembly July 24-27, 2014
Celebrating 65 Years of learning With tafP Grand Hyatt San Antonio 65th Annual Session Antonio, Texas &San Scientific Assembly July 2014 Maximum of 20 AMA PRA11-15, Category 1 Credits™ and AAFP Prescribed Credits
San Antonio Hotel and Convention Center, San Antonio, Maximum of 23 AMA PRA Category 1 Credits™
for information contact TafP at (512) 329-8666 ext. 36 or go to www.tafp.org. www.tafp.org
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NUTRITION
The final
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Choose food over filler By Troy Tuttle, M.S.
as an exercise physiologist, I know that it can be difficult to convince people that when trying to lose weight, proper nutrition is more important than the number of hours spent working out. I observe my clients time and time again focusing on the number of miles logged or diligently scribe the sets and reps of the weight they lifted only to grab a burger or scarf down a large meat pizza that same night. My main craft is exercise science, but I know my efforts are drastically minimized if my clients opt for “filler” instead of “food.” I hear similar stories from my family physician friends. The caring, attentive physician is diligent and precise in finding the proper medication and dose for symptom relief, all the while doing their best to cure and then prevent the issue from recurring. Proper nutrition and exercise are essential in working to achieve this, especially in a number of common diseases like high cholesterol, high blood pressure, and acid reflux, and while your patients may adhere to their medication regimen for the most part, they often neglect their nutrition and exercise. Of course there are many societal and cultural obstacles to consistently eating healthy, nutritious food, but by making a few different choices and some mindset changes, your patients can see some real benefits. Recognizing the difference between food and filler, for example, is a critical component of eating right. Food – substance that has high nutritive value. It’s what the body needs. Filler – substance that has little to no nutritive value, but yet is ingested into the body and “fills” up the stomach. Food is natural, colorful, raw, and basic. Filler is often a brown or bland colored item that results when you process food so that it lasts longer, tastes sweeter, and is more profitable. Eating filler keeps you hungry – you ate something, but you didn’t eat nutrition, so you eat more filler, gain weight, get health problems, etc. When you think about it, grocery stores are usually designed and stocked so that food in its most natural and nutritious form can be found all around the perimeter, while the filler items line the shelves up and down the aisles. That’s an easy concept for a patient to remember and for you to communicate quickly. Think about that final 15 seconds of office visits with patients who are trying to shed a few pounds. With just a bit of encouragement and education, you can pass along a couple of simple, practical, and powerful ideas. Tell them to choose food over filler, and to do most of their grocery shopping along the edges of the grocery store. These two basic points can help guide your patients to proper nutrition.
Troy Tuttle, M.S., has an extensive background in exercise physiology, from research journal publications to overseeing cardiovascular clinics at the Texas Medical Center.
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Try this health check on your practice.
Foundation Focus
Can you do all of the following? Send automated campaigns that save your staff hours of phone time. Hi Sally, remember your appointment is at 10 AM CT on June 26. Please reply “YES� to confirm or “RS� to reschedule.
Send an ad-hoc message to 10’s, 100’s, or 1000’s of people simultaneously.
TAFP FOUNDATION STUDENT INTEREST ENDOWMENT
Due to inclement weather, we need to reschedule your appointment tomorrow. We apologize for any inconvenience.
TAFP Foundation Student Interest Endowment Recruit the family doctors of tomorrow. Build the Foundation today.
Send a direct message to a patient.
Recruit the family doctors of tomorrow. Build the Foundation today.
Your results are back and they are normal. Reply or call us at (469) 600-4566 with any questions.
Re-enforce desired behavior. Please remember, no food or drink after midnight and until after your appointment tomorrow.
when medical students get a chance to observe family physicians caring for their patients, they see firsthand the kind of relationships a family doctor can build in a community. These experiences can change a medical student’s life, setting that student on a path toward a career in family medicine. Preceptorships like those supported by the Texas Statewide Family Medicine Preceptorship Program offer students such opportunities, and the Texas Academy of Family Physicians Foundation has committed to ensure that medical students will continue to have that chance with the Student Interest Endowment. The preceptorship program has been in existence for many years, but lost state funding in 2011. TAFP took on the administrative work and matched students for the first time in 2012. The TAFP Foundation began raising funds and awarded 13 scholarships to students participating in the program in 2013, but the funding available was dramatically lower than before. Now, the Foundation has pledged to double the impact of donations to the Student Interest Endowment. During the Ignite2015 campaign, the Foundation will match every donation to the Student Interest Endowment. The campaign will end on Dec. 31, 2015, or when the Foundation has committed $100,000 to the endowment. What are you waiting for? Double your donation in support of the future family physicians of Texas and let’s ignite student interest in family medicine in 2015.
Keep your patients within network. Our records show it’s time for your child’s annual vaccinations. Please contact us to schedule an appointment.
Dialog Health will make sure your practice can answer "Yes" to all of these patient-centric features. Let us show you how your no-show rates will decline, patient compliance will increase, and your staff can be more efficient. For more information on this cost-effective and customized solution, please call or text DEMO to (469) 600-4566
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You can mail your donation to the TAFP Foundation at 12012 Technology Blvd., Ste. 200, Austin, TX 78727, and note that your donation is for the Student Interest Endowment. Or just call (512) 329-8666, ext. 14. Thank you for your support.
RESEARCH
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 silver level Carol and Dale Moquist, M.D. bronze level Joane Baumer, M.D. Gary Mennie, M.D. Linda Siy, 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.
Impact of race-specific training for health care providers on appropriate diagnosis and weight counseling for Asian patients who are overweight or obese By Deepa Vasudevan, M.D.; Thomas Northrup, Ph.D.; Sreedhar Mandayam, M.D., M.P.H.; Oluwatosin Bamidele, M.P.H.; and Angela Stotts, Ph.D. obesity is a global public health epidemic that affects one-third of the U.S. adult population6 and is an important risk factor for mortality, with an estimated cost of $147 billion annually.5 Obesity is a causal factor for several chronic conditions like coronary heart disease, diabetes mellitus, and cancer, with obese patients having an increased lifetime risk for cardiovascular event.9 Increasing diversity of the patient population within the United States brings forth ethnicity-related variations in disease prevalence, identification, and management. There are an estimated 18.2 million Asians in the U.S.—an increase of 46 percent from 2000 to 2010—making the group one of the fastest growing ethnic groups in the country.20 Diabetes is prevalent among Asian-Americans, with 8.4 percent of those aged 20 years and older currently having the disease.21 This number is expected to increase 54 percent by 2030.17 Heart disease is one of the major causes of death among Asians or Pacific Islanders in the United States (AHA;2009). The World Health Organization concluded that Asians generally have a higher percentage of body fat than white people of the same age, sex, and body mass index. Also, the proportion of Asian people with risk factors for type-2 diabetes and cardiovascular disease is substantial—even below the existing WHO BMI cut-off point of 25 kg/m.18 This resulted in the WHO and International Diabetes Federation proposing the use of lower BMI thresholds and waist circumference values as modified criteria for classifying overweightness and obesity among Asian population groups. Previous research has shown that WHO-modified BMI and IDF waist circumference independently identified higher number of overweight/obese South Asian Indians.16 These findings underscore that obesity is likely under-diagnosed among Asians using the standard WHO criteria for BMI and the NCEP ATPII guidelines for waist circumference. Risk prediction is not satisfactory, stressing the need to use modified overweight and obesity definitions for Asians. Primary care providers play a pivotal role in obesity identification and prevention, and it is crucial to raise health care provider awareness of appropriate criteria to increase the number of patients who receive obesityrelated care, especially within patient groups for whom the recommended modified criteria are necessary. The aim of this study was to assess the efficacy of a training to increase accurate health care provider diagnosis of
patients using modified guidelines among overweight and obese Asian patients. A secondary aim was to assess the impact of the training on physicians providing weight counseling to these patients.
Methods This research was conducted in compliance with the University of Texas Medical School at Houston Committee for the Protection of Human Subjects. Fifteen physician practices were selected in private and academic settings in and around the Houston metropolitan area, who had a high geographic representation of Asian patients. Five of those practices, with physicians ranging from solo to group practices, agreed to take part in the training. Physicians and health care providers in active practice with an adequate Asian patient representation were required to be included in the study. A face-to-face PowerPoint presentation on the current modified guidelines for diagnosing obesity among Asian patients was given to the physicians, medical assistants, nurses, and other clinic personnel from each practice. Providers were instructed to use the modified WHO criteria for Asians of > 23.0 BMI as the standard for being overweight and > 25.0 BMI as the standard for being obese. Health care providers were trained on how to conduct an appropriate waist circumference measurement and 88 and 90 centimeters were the IDF recommended abdominal-obesity criteria for women and men, respectively. During the training, health care providers were also coached on methods by which to give appropriate counseling on weight loss and weight management. Following the training, attendees were given clinic posters, laminated wallet cards with the criteria, and counseling resources. Only charts for self-reported Asian patients identified as overweight (BMI: 23.0 – 25.0) or obese (BMI >25.0) were selected and a total of 361 patient chart reviews were conducted pre- and post-training. Fifteen chart reviews occurred for up to 12 months preceding the training and 10 chart reviews occurred after the three months following the training. Data included physician and patient characteristics. Additionally, whether or not the physician diagnosed the patient as overweight or obese and whether weight management counseling was given were recorded from the charts. Physician race was coded as Asian and non-Asian. Physician setting was coded as academic or private. Patient identifiers were not abstracted in order to protect confidentiality. www.tafp.org
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TABLE 1. Physician behavior change: Diagnosis and counseling Overweight or Obesity Diagnosed Variable
OR (95% CI)
Wald Chi-squared
p
Physician Race (Ref = non-Asian)
1.90 (0.70-5.17)
1.57
0.21
Clinic Setting (Ref = Private)
0.56 (0.18-1.69)
1.08
0.30
Time Point (Ref = Pre-Training)
2.02 (1.03-3.98)
4.18
0.04
OR (95% CI)
Wald Chi-squared
p
Physician Race (Ref = non-Asian)
1.68 (0.67-4.20)
1.21
0.27
Time Point (Ref = Pre-Training)
2.16 (0.97-4.83)
3.53
0.06
Weight Counseling Provision Variable
Note: The “exchangeable” working correlation method was used for PROC GENMOD; the uncorrelated working correlation method (recommended by Allison, 2012) failed to estimate. The correlation for the diagnosis analysis was 0.22. The correlation for the counseling analysis was 0.15. “Ref” = Reference group for the odds ratio estimation.
FIGURE 1. Percentage of correctly diagnosed and weight-counseled patients at pre- and post-training
Pre-training
percentage diagnosed or counseled
p = 0.06
Post-training 60
50
p < 0.05
40
65.0%
30
45.1% 20
Generalized linear modeling, following recommendations from Allison (2012), was used for the primary outcome analysis in SAS, version 9.3 (PROC GENMOD). The model controlled for clustering of patients within physician and estimated the effect of time (pre-training vs. post-training), dichotomized physician race (Asian and non-Asian), and practice setting (private and academic) on a diagnosis of being overweight or obese. The same statistical approach was used for the model with weight counseling as the outcome. Odds ratios are given to estimate the magnitude of effects. Chi-squared tests were used to assess frequency differences. All significance tests were evaluated at the 0.05 level.
Results The 16 physicians who participated in the study were split between private and academic settings and 50 percent reported being Asian. A total of 198 pre-training chart reviews were conducted and 163 patient chart reviews were completed following the training, combining for a total of 361 chart reviews of Asian patients identified as overweight or obese. The patients selected for chart reviews were predominantly male at 63.1 percent and the mean age was 46 years. The average BMI was 28.2. No significant differences were found across the pre- and post-training chart review samples on these three variables. Physician behavior change: diagnosis The percentage of patients accurately diagnosed as overweight or obese before the training was 26.8 percent across all 16 physicians (see Figure 1). The post-training percentage of patients accurately diagnosed as overweight or obese was 45.1 percent across all physicians (p < 0.05; Figure 1). The odds of a physician correctly diagnosing an Asian patient as overweight or obese were 102 percent higher at post-training after accounting for nesting of patients, physician race, and clinic setting.
80
70
Data Analysis
43.9%
26.8% 10
0
correct diagnosis weight counseling
Physician behavior change: weight counseling Before the training, 43.9 percent of this sample was counseled on weight across physicians. Post training levels of counseling were higher, though not statistically significant (p=0.06; Figure 1). The higher rate of physician-provided weight counseling from pre- to post-training was statistically significant for non-Asian physicians and among physicians in private settings. [cont. on 29]
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[SPRING 2014]
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Physician behavior change: waist circumference measurement None of the physicians were conducting waist circumference measurements prior to the training. Post-training, only two physicians conducted a waist circumference measurement.
Discussion To better care for the health of a growing Asian population, there is an increasing need for physicians to identify Asian patients who are overweight or obese to reduce the physical, behavioral, and economic burden that accompanies obesity progression. Asians are at high risk to develop diabetes at lower BMI and WC cutoffs, and timely diagnosis may result in instituting prompt interventions to prevent morbidity. Efficacious physician training on ethnic-specific guidelines for diagnosing and managing obesity is a critical first step in this effort. This study demonstrated that training physicians on Asianspecific diagnostic guidelines for obesity and weight counseling strategies led to significant changes in physicians’ rates of diagnosis. Our work demonstrated that meaningful changes in physician-provided weight counseling were observed for some groups of physicians as well. Prior to receiving training on the WHOmodified criteria and IDF waist circumference measurement guidelines for diagnosing obesity, over 75 percent of this sample of Asian and overweight or obese patients was undiagnosed and fewer than half were receiving weight-based counseling. Following the training, accurate diagnosis and physician-provided weight counseling were approximately 20 percent higher. The significant change in physician diagnosis was strongest for non-Asian physicians and physicians in academic settings. Specifically, Asian physicians tended to accurately diagnose and counsel patients more frequently prior to receiving training, perhaps because they are more attuned to health guidelines for patients of the same race. Non-Asian physicians and physicians in academic settings tended to have the lowest levels of diagnosis and counseling before the training and could therefore make greater gains, as evidenced by the statistically significant changes. There are few studies in general that have examined the impact of medical education training on real-world physician performance, and to our knowledge no studies among Asians have been conducted. It is known that health care provider-directed weight loss counseling is beneficial1 and phy
sicians strongly agree that treating obesity is important and are moderately confident in their ability to do so.10 Physicians are willing to view obesity management as a part of their responsibility; however, interest may be mixed. Some work reports that physicians have a desire for further skills training21 while Kristeller et al reported that physicians showed variable interest in assuming roles in the management of obesity,10 with only 18.7 percent of physicians indicating it was “likely” or “very likely” that they would discuss weight problems with their non-obese but overweight patients.10 Physician motivation may be an important target for future interventions. Future work should also consider the implementation of electronic charting reminders (e.g., flags to perform BMI calculations and WC measurements as a part of the vital signs) and alerts to health care providers when these values are elevated. Also, physician awareness of other ethnicity-specific variations in obesity and weight management should be explored.
Conclusion Asians are at a high risk of developing obesity, diabetes, and cardiovascular disease at lower BMI and waist circumference cutoffs. With the rapidly growing Asian population in the western world there is a need for physicians to be educated and trained on identifying overweight and obese Asian patients appropriately and provide race-specific counseling and resources to ensure successful patient weight loss and maintenance. This seminal work demonstrated an effective approach by which to increase physician awareness and action toward meeting these goals for Asian patients.
References 1. Bleich, S. N., Bennett, W. L., Gudzune, K. A., & Cooper, L. A. (2012). National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care. BMJ Open, 2(6) 2. Bleich, S. N., Simon, A. E., & Cooper, L. A. (2012). Impact of patient-doctor race concordance on rates of weight-related counseling in visits by black and white obese individuals. Obesity, 20(3), 562-570. 3. Block, J. P., DeSalvo, K. B., & Fisher, W. P. (2003). Are physicians equipped to address the obesity epidemic? knowledge and attitudes of internal medicine residents. Preventive Medicine, 36(6), 669-675. 4. Hayden, M. J., Dixon, J. B., Piterman, L., & O’Brien, P. E. (2008). Physician attitudes, beliefs and barriers towards the management and treatment of adult obesity: A literature review. Australian Journal of Primary Health, 14(3), 9-18.
5. Jay, M., Schlair, S., Caldwell, R., Kalet, A., Sherman, S., & Gillespie, C. (2010). From the patient’s perspective: The impact of training on resident physician’s obesity counseling. Journal of General Internal Medicine, 25(5), 415-422. 6. Kristeller, J. L., & Hoerr, R. A. (1997). Physician attitudes toward managing obesity: Differences among six specialty groups. Preventive Medicine, 26(4), 542-549. 7. Lin, S. X., & Larson, E. (2005). Does provision of health counseling differ by patient race? Family Medicine, 37(9), 650-654. 8. Lytle, L. A. (2009). Examining the etiology of childhood obesity: The idea study. American Journal of Community Psychology, 44(3), 338349. 9. O’Brien, S. H., Holubkov, R., & Reis, E. C. (2004). Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics, 114(2), e154-159. 10. Polacsek, M., Orr, J., Letourneau, L., Rogers, V., Holmberg, R., O’Rourke, K., et al. (2009). Impact of a primary care intervention on physician practice and patient and family behavior: Keep ME healthy - the maine youth overweight collaborative. Pediatrics, 123(SUPPL. 5), S258-S266. 11. Powell-Wiley, T. M., Ayers, C. R., Banks-Richard, K., Berry, J. D., Khera, A., Lakoski, S. G., et al. (2012). Disparities in counseling for lifestyle modification among obese adults: Insights from the dallas heart study. Obesity, 20(4), 849-855. 12. Rurik, I., Torzsa, P., Ilyés, I., Szigethy, E., Halmy, E., Iski, G., et al. (2013). Primary care obesity management in hungary: Evaluation of the knowledge, practice and attitudes of family physicians. BMC Family Practice, 14 13. Smith Jr., S. C., & Haslam, D. (2007). Abdominal obesity, waist circumference and cardiometabolic risk: Awareness among primary care physicians, the general population and patients at risk - the shape of the nations survey. Current Medical Research and Opinion, 23(1), 29-47. 14. Stice, E., Shaw, H., & Marti, C. N. (2006). A meta-analytic review of obesity prevention programs for children and adolescents: The skinny on interventions that work. Psychological Bulletin, 132(5), 667-691. 15. Vasudevan, D. et al, (2011) Comparison of BMI and anthropometric measures among South Asian Indians using standard and modified criteria. Public Health Nutrition: 14(5), 809–816 16. Vasudevan, D. et al, (2011)Primary Care Physician’s Knowledge of Ethnicity-Specific Guidelines for Obesity Diagnosis and Readiness for Obesity Intervention Among South Asian Indians. Journal of Immigrant and Minority Health October 2012, Volume 14, Issue 5, pp 759-766 17. Wake, M., Salmon, L., Waters, E., Wright, M., & Hesketh, K. (2002). Parent-reported health status of overweight and obese australian primary school children: A cross-sectional population survey. International Journal of Obesity, 26(5), 717-724. 18. WHO Expert Consultation. (2004) Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies Lancet. 2004 Jan 10;363(9403):157-63. 19. http://ndep.nih.gov/diabetes-facts/ 20. http://www.census.gov/ 21. http://www.diabetes.org/ www.tafp.org
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perspective
Let’s be bold for family medicine By Janet Hurley, M.D.
it’s time for boldness in family medicine. As I turned to hug Jim Martin, M.D., at the last TAFP C. Frank Webber Lectureship, I was touched by his heartfelt concern. He and other dedicated leaders before me have endeavored to set the stage for family medicine to have its time in the spotlight. Yet many family physicians do not seem willing to demonstrate the leadership skills or “fire in the belly” during this pivotal time of health care change. In the past, family physicians were seen as feeder mechanisms for the procedural and hospital cash machine. We were disrespected in the academic centers and our value was minimized by payers and the Relative Value Scale Update Committee. Specialists desired our referrals for lucrative procedures that are reimbursed under an inflated fee-forservice price. The hospitals have been hiring family physicians to ensure referral sources to their admission beds, imaging centers, and operating rooms. But the day of reckoning is coming for that payment methodology. The common enemy to us all in health care is one simple concept: cost. In the next five to 10 years, we will continue to see changes in reimbursement moving away from fee-for-service toward value-based purchasing, bundled payments, and shared risk models. Payers, employers, and the public are looking for treatment methodologies that are practical, cost-effective, and evidence-based. Care coordination is needed to reduce the duplication of services, the readmission rate, and the ordering of unnecessary high-cost imaging tests and procedures. Who is the best person to coordinate that care, counsel patients about evidence-based guidelines, and steer patients toward quality specialists who do good work but don’t order unnecessary tests and procedures just because they can? The opportunity is here, and the time is now for family physicians to rise to this challenge with boldness and candor. It fills me with indignation when medical students report back to me that academic specialists still look at family physicians as just a “cheap alternative” for quality specialty
care. As a community physician and health care leader, I know community specialists, payers, employers, and, most importantly, patients appreciate the value they receive when they come to see me and my family physician colleagues. Patients want to be treated by someone who cares not only about their health but also their pocketbook. Every medication I prescribe, test I order, and referral I request takes money out of the patient’s personal budget. The copays are high enough now that patients don’t want any of this stuff if it does not really add true value to their care. That is not cheap care or poor quality care, it is compassionate and practical care, and acknowledges our responsibility to be good stewards of health care resources. The time is now, but are we ready to lead? I enjoyed hearing from Doug Curran, M.D., in Athens, Texas, whose patient fell victim to an unnecessary procedure by a nearby specialist. We need more doctors like Curran, who picked up the phone and called the specialist directly to express his dismay. This is the kind of “fire in the belly” our profession needs. I know some family physicians have learned how to be profitable in the fee-for-service world either through high volumes or smart employment contracts with hospitals. But if we are to bend the cost curve in health care, we have to change service paradigms, work toward medical home certification, invest in new technology, and transition to population management philosophies. It won’t be easy and it won’t be comfortable, but we have to hold ourselves and our colleagues accountable for duplicated services and unnecessary procedures. To be clear, I’m not asking my colleagues to have superpowers and fix all of these problems. What I’m asking is for family physicians to be engaged and to lead. Many excellent leaders have spent sweat and tears to bring our specialty to this pivotal moment. Will we lead this charge in our community hospitals and clinics, or will we permit ourselves to be marginalized again? We’ve already been down that road. Let’s get the “fire in the belly” to stand up for our patients and our specialty.
Many excellent leaders have spent sweat and tears to bring our specialty to this pivotal moment. Will we lead this charge in our community hospitals and clinics, or will we permit ourselves to be marginalized again? Let’s get the “fire in the belly” to stand up for our patients and our specialty.
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[SPRING 2014]
TEXAS FAMILY PHYSICIAN
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Kids are drinking soda and fruit drinks as early as
Kids are drinking
What?!
MONTHS
Based on NHanes Data, 2007-2010
When kids miss out on Milk, they miss out on Nutrition. Pour one more to close the nutrient gap
Dairy delivers major nutrition Calcium 59%
Potassium 25% 3.5 3
Magnesium 20%
Zinc 21%
cups
2.5 2
Vitamin D 72%
Vitamin B12 35%
1.5 1
0.5 0
Current Intake
+1 Cup Milk
Current Intake
4-8 years
+1 Cup Milk
Protein 25%
Phosphorus 37%
9-18 years Recommended Intake
Riboflavin 34%
Vitamin A 37%
Based on NHanes Data, 2007-2008
What does the American Academy of Pediatrics Recommend for kids?
Milk at meals and Water in between.
dairymax.org
Presorted Standard U.S. Postage
PAID
Austin, TX Permit No. 1450
NO.
th i ng s p hys ician s n e e d
7
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