Texas Family Physician, Winter 2015 by Texas Academy of Family Physicians

texas family physician VOL. 66 NO. 1 2015

AAFP Touts Family Medicine For Americaâ&#x20AC;&#x2122;s Health The Big Picture: Health Reform In 2015

Texas Family Physician Of The Year 2014-15 Russell Thomas, Jr.

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TEXAS FAMILY PHYSICIAN VOL. 66 NO. 1 2015

Texas Family Physician of the Year 2014-15: Russell Thomas, Jr., DO, MPH

This year’s Physician of the Year award recipient is the epitome of a country doc. Hailing from Eagle Lake, Texas, Thomas returned to his hometown after residency to practice full-scope, rural medicine alongside his physician father. It’s now 31 years later and Thomas wouldn’t change a thing. By Samantha White

Which way from here? Health reform in 2015 An expert health care industry strategist surveys the big picture.

By Kim D. Slocum

Health is primary

Joined by seven other national family medicine organizations, AAFP and Family Medicine for America’s Health launched Health is Primary last year. The campaign aims to help patients and physicians find a home in primary care. By Kate Alfano

6 FROM YOUR PRESIDENT An overview of AAFP’s and TAFP’s advocacy efforts for this year’s legislative sessions and how you can help 8 MEDICARE NEWS HHS announces a major shift toward value-based payment reform. 10 MEMBER NEWS You’re invited to AAFP’s National Conference of Constituency Leaders. | TAFP members appointed to AAFP commissions 26 FOUNDATION FOCUS Double your impact by donating to the Student Interest Endowment in 2015. 27 PRACTICE MANAGEMENT Bradley Reiner gives you the latest coding tips 30 TAFP PERSPECTIVE Affect the next generation of family docs by mentoring students in the preceptorship program.

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president’s column

TEXAS FAMILY PHYSICIAN VOL. 66 NO. 1 2015 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

Dale Ragle, MD

president-elect vice president treasurer

Ajay Gupta, MD

Janet Hurley, MD

Tricia Elliott, MD

parliamentarian

Tamra Deuser, MD

immediate past president

Clare Hawkins, MD, MSc

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, CAE

advertising sales associate

Michael Conwell Contributing Editors Kate Alfano Travis Bias, DO, DTM&H Christina Kelly, MD Bradley Reiner Kim D. Slocum cover photo

Samantha White

subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by AIM Printing and Marketing, Austin, Texas. legislative advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2015 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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All hands on deck By Dale Ragle, MD TAFP President welcome colleagues to a new year, a new Congress, and a new Texas Legislature. On all fronts, health care is evolving. These changes present family physicians tremendous opportunities to shape our future health care system. It’s up to all of us as family physicians to advocate for our specialty in the halls where decisions are made that affect our patients and our practices. In Washington, D.C., the 114th Congress is well under way and is busy on a number of health care issues. AAFP’s advocacy work is focused on fixing Medicare’s broken payment model, changing Meaningful Use requirements, delaying ICD-10, and reforming graduate medical education funding. Another area in which AAFP is concentrating efforts is in making payment for direct primary care services a qualified health benefit under IRS rules. This would enable patients to pay for direct primary care with pre-tax HSA and FLEX account dollars, a move that would aid the expansion of this emerging and promising model of practice. Back here at home, state lawmakers are at work in the 84th Texas Legislature. According to the state constitution, the Legislature must be in session for 140 consecutive days every two years. Of course the old joke is that the framers actually intended the Legislature to be in session two days every 140 years, but someone got confused along the way. As in all sessions of the Legislature, health care will compete with public education, tax cuts, roads, water, and energy on the state’s list of priorities, but rest assured there will be plenty of work for the TAFP advocacy team. Let’s take a look at some of the health care issues we’re likely to face.

Graduate medical education: Last session, led by state Sen. Jane Nelson, R-Flower Mound, the Legislature made significant strides in restoring funding cuts to the state’s family medicine residency programs and laid the groundwork to create new and expanded graduate medical education positions. As Texas continues to boom in population, ensuring an adequate supply of primary care physicians has been a major concern for the state. How we recruit, educate, and train our future physician workforce and how we pay for that effort is on the agenda yet again.

As Texas continues to boom in population, ensuring an adequate supply of primary care physicians has been a major concern for the state. How we recruit, educate, and train our future physician workforce and how we pay for that effort is on the agenda yet again in the 84th Texas Legislature.

Direct primary care: The concept is simple: a physician and a patient enter into a contract for care that they are willing to provide and receive for an agreed upon price without the interference of a third party. However, state insurance laws and regulations are opaque when it comes to whether DPC models should be construed as insurance products. TAFP will be pursuing legislation to clarify that practices engaged in the DPC model are not treated as insurance and thus are not held to that statutory and regulatory standard.

Transparency: As your Academy has been saying for some time, value-based payment— or rewarding physicians for quality of care over volume—has arrived in the health care marketplace and it will only become more ubiquitous among payers and across contracts in the coming years. To counter the indefensible variation in price and outcomes patients experience, health plans are turning to narrow physician and hospital networks, and angry employers, patients, and politicians are calling for greater transparency in health care cost and quality.

Texas Academy of Family Physicians presents: No market, especially in health care, can function properly without complete information on price, cost, and quality of the goods and services being purchased. TAFP will advocate for true transparency in costs while protecting network adequacy. Public health: Remember last year’s Ebola scare? State lawmakers in Austin do, too. As a result of systematic underfunding over the last decade, Texas’ public health infrastructure is frighteningly understaffed and fragmented. On this topic there seems to be bipartisan support: we must correct the lack of a coherent set of state and local guidelines for dealing with public health emergencies. Medicaid: Some are calling for Texas to expand Medicaid coverage to poor uninsured Texans under Obamacare, but such a move is not likely in this Legislature. Few if any state lawmakers won elections on the promise to expand Medicaid, so the politics—especially in a much more conservative Texas Senate—should quash any expectation that they would contemplate a Medicaid expansion deal. Under the circumstances, this likely includes other red-statestyle private-market Medicaid solutions. To be sure, your Academy will work diligently to serve as family medicine’s voice in this legislative session, but as always, we need your help. If you have a relationship with your state representatives, please join our Key Contacts program so we can coordinate with you and strengthen our advocacy efforts. Consider serving as Physician of the Day at the State Capitol during the session. It’s an excellent opportunity to meet your representatives and see the legislative machinery at work, all while providing an important service. Finally, make a donation to TAFPPAC. By giving to our political action committee, you are helping to support candidates who demonstrate support for issues important to family physicians and our patients. Visit www.tafp.org/tafppac for more information. There you have it—three things you can do during this legislative session to help your Academy and strengthen our specialty so we can all get back to caring for our patients. We need all hands on deck for this difficult legislative session. To learn more about these three actions and to participate, go to www.tafp.org/advocacy/get-involved.

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HHS: 85% of Medicare payments to be based on value by 2018

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Announcement signals accelerated shift toward value-based payment reform the hospital, and improve management of the department of Health and Human chronic diseases. Services has signaled its intention to Even before this announcement, HHS has embrace value-based payment reform with seen promising results on cost savings in many the announcement that by the end of 2018, of these models. At the end of last year, the it plans to tie half of all fee-for-service MediCenters for Medicare and Medicaid Services care payments to quality or value through reported Medicare ACOs in the Shared Savalternative payment models like accountable ings Program and the Pioneer ACO program care organizations, or ACOs. HHS also set combined to save $417 million in 2013. a goal of tying 85 percent of all traditional The first of the new deadlines comes at Medicare payments to quality or value by the end of 2016, when 30 percent of Medicare 2016 and 90 percent by 2018 through propayments should be made grams such as the Hospital to physicians in alternaValue Based Purchasing and “Many practicing tive payment models. In the Hospital Readmissions 2011, that kind of payment Reduction Programs. physicians have was almost nonexistent, By setting these goals, been sitting on the but in 2014, 20 percent of HHS Secretary Sylvia M. sideline waiting for Medicare’s $362 billion in Burwell has added the weight of Medicare behind a sign that payment fee-for-service payments went to alternative paythe building momentum reform was really ment models. toward a system-wide transigoing to happen. ... With this latest tion from volume to value. “We believe these goals For family physicians announcement by HHS, it is likely that the introduccan drive transformative the time to embrace tion of value-based plans change, help us manage and change and lead that in the private market will track progress, and create accelerate as well, raising accountability for measurchange is now.” the question: are frontline able improvement,” Burwell said in an HHS release. — Tom Banning physicians prepared to care AAFP CEO and ExecuCEO and executive vice for their patients suctive Vice President Douglas president of TAFP cessfully in an alternative payment model or under Henley, MD, voiced support value-based contracts? for the move in the release. TAFP CEO Tom Banning believes family “We’re all partners in this effort focused on a physicians face a critical decision during shared goal. Ultimately, this is about improvthis time of transition. They can be passive ing the health of each person by making the victims of changes shaped by others or they best use of our resources for patient good. 11:57 AM can be active agents shaping a better future We’re on board, and we’re committed to for their patients and their colleagues. changing how we pay for and deliver care to “Many practicing physicians have been achieve better health.” sitting on the sideline waiting for a sign that Payment models like ACOs, primary care payment reform was really going to happen. medical homes, bundled payments for epiThis announcement puts the full force of sodes of care, and others were proposed in the federal government and the Medicare the Affordable Care Act as ways to increase program behind the shift to value-based payquality and efficiency across the health care ment,” Banning says. “Commercial insurers delivery system. By aligning incentives to have already shown they’ll follow Medicare’s reward physicians for coordinating care, lead and embrace value-based payment. proponents hoped to reduce duplicative or For family physicians the time to embrace unnecessary tests and procedures, provide change and lead that change is now.” better care to patients transitioning out of

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Start Saving Money on Vaccines Now! 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.

You’re invited! Join your colleagues from every state at AAFP’s NCCL April 30 – May 2, 2015 • Kansas City, Missouri By Christina Kelly, MD The American Academy of Family Physicians National Conference of Constituency Leaders will be held April 30 - May 2, 2015 (with a preconference on April 29) in Kansas City, Missouri. This is the AAFP’s premier leadership and policy development event for underrepresented constituencies, which includes new physicians (physicians in their first seven years of practice), women, international medical graduates, GLBT, and minority constituencies. At this leadership meeting, we gather every year for a purpose. We gather to: learn about how we can make a difference for our patients and our specialty, inspire each other to advocate, lead the way to action, and challenge our colleagues to join us in our efforts. A variety of issues are discussed at this meeting, such as patient barriers to quality health care that you want the AAFP to address, challenges within a variety of practice settings that you want fixed, or changes that need to occur to continually improve family medicine. This leadership meeting ensures that underrepresented constituencies have a voice within the AAFP. I don’t know of any other organization that has a meeting like this. Each year I attend this conference is more exciting to me than the last, and I have attended nine times so far! It has been my breath of fresh air, where I can be reminded through the amazing family physicians attending the meeting why I went into family medicine, and why I do what I do at work every day. This meeting has

given me so much over the years in terms of inspiration and leadership development. Each year I attend, I take the leadership skills I learned back to my state chapter meetings and my community. I am now more effective at running meetings. I feel more confident to raise my voice and speak up for my patients when they can’t do it themselves. I am able to develop a plan to advocate for various issues, execute that plan, and succeed in overcoming obstacles to providing my patients the best care possible. At NCCL, I learned how I can make a difference. For those who haven’t attended before, you are missing out! This meeting is an opportunity to meet colleagues from all over the country who share the same passion you do and to learn how to advocate for change to make things better for our patients and family medicine. At this three-day conference, attendees participate in group discussions to identify issues of importance to them. Resolutions are written and presented at five reference committees. Chapter delegates for each of the member constituencies listed above then debate and vote on the resolutions and new leaders for the conference. Check out more info about the meeting at www.aafp.org/ events/aclf-nccl/nccl.html. For those who have attended: 25 years of leadership development will be celebrated at NCCL in 2015. Those of you who previously attended—when it was known as NCSC or NCWMNP—built the legacy this conference has become. Please attend the first NCCL so

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we can celebrate and honor you for what you built. Inspire a new group of leaders to be heard and advocate for change, just like you did. It will be a wonderful reunion of all of the inspirational past attendees who have helped this conference bring change throughout the years. So come one, come all to NCCL this year. Texas always brings a strong group of members, but with you, we can grow even stronger. CME credit is available for attending any of the breakout sessions on an hour-for-hour basis. I look forward to gathering for a purpose with you at NCCL in Kansas City!

TAFP members appointed to AAFP commissions Three active TAFP members were appointed to AAFP commissions in December. Amer Shakil, MD, FAAFP, of Carrollton, was appointed to AAFP’s Commission on Education. Shakil is currently the interim chair and a professor for UT Southwestern’s Department of Family and Community Medicine. He is a member of TAFP’s Nominating Committee and Commission on Academic Affairs and has previously served on the Commission on Core Delegation, the Executive Committee, and the Board of Directors. He is also a member of TAFP’s Dallas chapter. Troy Fiesinger, MD, FAAFP, of Sugar Land, was appointed to AAFP’s Commission on Governmental Advocacy. Fiesinger is on faculty at the Memorial Family Medicine Residency Program and a clinical assistant professor for the Texas A&M Health Sciences Center. He is one of Texas’ alternate delegates in AAFP’s Congress of Delegates, and he serves on TAFP’s Commissions on Academic Affairs and Membership and Member Services. He is a past president of TAFP and has served on TAFP’s Executive, Finance, and Nominating Committees. Clare Hawkins, MD, MSC, FAAFP, of Baytown, was appointed to AAFP’s Commission on Health of the Public and Science. Hawkins is currently faculty at the San Jacinto Methodist Family Medicine Residency Program and is the TAFP Immediate Past President. He is a member of TAFP’s Executive Committee, and the Commissions on Academic Affairs, Continuing Professional Development, and Health Care Services and Managed Care.

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Which way from here? Health care reform in the United States By Kim D. Slocum President, KDS Consulting, LLC three years ago, I was interviewed for an article in Texas Family Physician entitled “Payment reform—The next step toward an efficient high-quality health care system.” At that time, I said that the United States would see one of three futures for health care: one based on rapidly escalating consumer cost shifting, one making significant use of price controls, or one focused on measuring and rewarding “value.” So, where do we stand in early 2015 and what can we expect next? At the moment, the concept of shifting costs to consumers is in high gear. The passage of the Medicare Modernization Act of 2003 created an opportunity for employers to move to high deductible health plans, which it was presumed would turn consumers into “happy economists” who would diligently study cost and quality ratings for various medical services, come to medical encounters fully prepared to argue the merits of each recommendation with their physicians, and only receive care that would optimize their clinical outcome. As of 2014, the Kaiser Family Foundation/Health Education Research Trust annual survey of employer health care coverage shows that roughly 20 percent of all employees receiving health insurance

coverage now are enrolled in such plans. That’s not the end of the story though. Even for employees enrolled in more traditional PPO or POS plans, deductibles even for in-network services routinely exceed $1,000 so the percentage of potential patients facing significant cost sharing burdens is considerably higher than the headline number. For physicians, these plans represent a double whammy. Thirty years of health policy research has shown that patients exposed to high deductibles will cut back on their use of care. Indeed roughly two-thirds of the savings these plans produce come from care avoidance behavior. The problem is that consumers are relatively poor judges of what care is necessary and what is not. They are about as likely to stop taking medications to manage diabetes as they are to forego a non-sedating antihistamine. The second problem is financial. Since these policies require patients to spend a considerable amount out of their own pockets before traditional insurance coverage kicks in, it is incumbent upon physicians to collect payment at the time of service or risk an explosion of bad debt. www.tafp.org

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For physicians, highdeductible health plans represent a double whammy. Thirty years of health policy research has shown that patients exposed to high deductibles will cut back on their use of care. Indeed roughly two-thirds of the savings these plans produce come from care avoidance behavior.

Unfortunately, when physicians and hospitals are aggressive about collections from high-deductible-plan patients, it creates another problem—medical debt. Many consumers don’t have sufficient liquid assets to pay for medical services in cash and often resort to credit cards. As we all know, there is a short grace period in which to pay such obligations before high-interest rates are applied to outstanding balances. This happens with considerable regularity in the United States today and roughly 20 to 25 percent of all U.S. households are facing challenges of some sort in paying for health care. In a worst case scenario, this can lead to medical bankruptcy. Roughly 40 to 60 percent of all 1 to 1.2 million personal bankruptcies in the U.S. each year are directly caused by medical debt or heavily affected by such obligations. This is not just a problem for indigent patients—most of those medical debtors filing for bankruptcy actually have insurance and are well-educated and middle class. Surprisingly, the average amount of money required to put a medical debtor into bankruptcy court is only $17,000-$18,000. Not surprisingly, consumers are not feeling empowered by all these changes. A spring 2014 survey by Nielsen Consumer Insights North America showed that while most consumers were more or less resigned to escalating costs, those who faced significant medical expenses due to illness were depressed or even angry about the economic burdens they faced. 14

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Disturbingly, this same survey showed an upswing in support for price caps or controls on prices charged by drug companies, hospitals and even physicians. While this finding does not suggest consumers will be going to the barricades in search of such price controls any time soon, it does represent a potential vein of populism that might be tapped at some future date. In other words, there is at least a chance that a consumer backlash against punitive cost shifting might provoke its ideological opposite—some sort of centralized price controls on the costs of medical goods and services. The nation is also pursuing what some in the health policy community refer to as the “Berwickian nirvana” of accountable care organizations. This is a strategy with considerable support from public sector programs such as Medicare and Medicaid where the ability to shift cost to consumers is limited. Even some of the largest and most sophisticated employers have come to conclude that efforts to reform health care’s supply side must be viewed as the biggest part of reform strategy that will be viable in the long term. This approach involves an entire constellation of activities that will be at least somewhat familiar to practicing physicians most notably focused on health care information technology, so as to better understand care delivery patterns, and payment reform designed to elicit the desired behaviors from physicians and hospitals. According to another Nielsen survey of hospitals and health systems conducted during the summer of 2014, 74 percent of all U.S. hospitals now own one or more medical groups. This buying spree has largely been tied to an organizational desire to move to accountable care. While primary care and hospital-based specialties like surgery have been the primary targets, the shopping list for these institutions now extends well down the roster of medical sub-specialties. At the same time, the federal program supporting the Meaningful Use of health care information technology has helped to drive adoption of electronic medical records and we now see the majority of U.S. physicians reporting that they have installed some form of this software in their offices. Finally, the same Nielsen survey of hospital executives shows that these institutions expect to see the source of their revenue change significantly over the next five years from predominately feefor-service to various forms of bundled, prospective, or even capitated payments. To be sure, the transition from traditional physician and hospital business models has not been smooth. As one health system executive put it, “It’s true that when one door closes, another one opens, but it can be hell in the hallway.” The hundreds of newly minted ACOs that have sprung up across the country since 2011 have focused most of their attention on legal and business structures—the anatomy of accountable care. In some cases they have struggled to develop the sort of integrated and aligned organizational culture where the true physiology of accountable care can be delivered. While these organizations have invested significant dollars in creating information technology platforms to measure population-level health, this still remains for most a work in progress. What is most important for physicians to bear in mind is that while the road to accountable care has not been smooth, it represents the least worse alternative to consumer cost shifting and potential backlash this seems to be producing. Ultimately, the future of U.S. health care will not be an either/or choice between consumer cost shifting, price controls, or value-based care, but some blend of the three. It is important that physicians give some consideration to the relative weight of each alternative they believe would best serve their patients and their profession, and work to make that choice a reality.

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country

Doc Texas Family Physician of the Year 2014-15

Russell Thomas, Jr., DO, MPH PHOTOS AND STORY BY SAMANTHA WHITE

“this is where i’m from.” The simplest of answers. When asked why he returned to his hometown of Eagle Lake, Texas, to practice medicine, Russell Thomas, Jr., DO, MPH, only needs those few words. It’s as simple as that. It made no sense to practice anywhere else but in the place he grew up, surrounded by the family and friends he knew so well, giving back to the community that helped raise him. Thomas, the 2014-2015 Texas Family Physician of the Year, practices at Rice Medical Associates, caring for the very people he grew up with. In a quaint town 60 miles west of Houston with a population of 3,700, Thomas not only knows most of the Eagle Lake residents, but he knows their life histories. What house they were raised in. What position they played on the high school football team. Where they work. Who they married. He knows their parents, too. And what careers they had or have. He knows their children. And maybe their grandchildren. In fact, he probably delivered many of their children and grandchildren. If Thomas himself didn’t deliver them, there’s a good chance his father did. The late Raymond Thomas, MD, was also a family physician in Eagle Lake and was also awarded the Texas Family Physician of the Year title in 1997. Thomas is the only second generation Physician of the Year award recipient in TAFP’s history.

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rowing up in Eagle Lake with one of the town’s few physicians as a father meant assisting him at the age of 16, cutting high school class to scrub in for surgery, and joining him on emergency visits just to spend some time together as father and son. These experiences combined with seeing his dad serve their community led Thomas to family medicine. “I didn’t appreciate that there was anything else,” Thomas says. “I never imagined doing anything else.” His mind was so set on being a physician and returning to Eagle Lake to practice alongside his father that when he failed to get into medical school, it was “like a slap in the face.” When by April he had not heard from the medical schools he had applied to, Thomas decided to pursue his master’s degree in public health. Two weeks after finishing his degree at the University of Texas School of Public Health at Houston in 1976, Thomas married his longtime sweetheart, Robin. He went through the medical school application process again and was accepted to the Texas College of Osteopathic Medicine. He received his DO in 1980 and completed a residency at Southwest Memorial in Houston, now known as Memorial Hermann Southwest Hospital. He and Robin moved back to Eagle Lake and Thomas joined his father’s practice, an experience he calls a “17 year fellowship.”

of the vaccine home for his wife and a newborn Thomas. Before he could administer the vaccines, his conscience got the best of him and he returned the doses to the hospital. Two years later, Thomas was diagnosed with polio. As ironic as it is, Thomas says if he could have a “do over” in life, he would not change his polio diagnosis. “Polio has never been a cause for me,” Thomas says. “I chose for it not to be the focus of my life. It’s never really even been much of an elephant in the room. It didn’t stop me from going to medical school or doing my residency. It didn’t stop me from doing any of the important things.” Thomas’ childhood friend, Russ Krienke, MD, nominated Thomas for the award. He says that Thomas “chose to let his childhood polio become a motivation for success rather than an excuse for failure.” Krienke would know, as he was the friend who stayed by Thomas’ side when he was unable to participate in summer activities because of the latest cast or surgery. Instead of self-pity stories about missing out on childhood events, Thomas tells stories about Russ skipping a season of little league to instead sneak into his hospital room so the two friends could hang out. Polio probably has something to do with Thomas’ ability to talk to patients so personally. As a child he was in and out of hospitals almost constantly. “I’ve had surgeries so I know what being operated on is all about,” Thomas says. “Hopefully it has made me —having been on both sides of the patient fence—I’ve been more understanding and compassionate.” According to patients, “understanding and compassionate” understate Thomas’ bedside manner. Ask patients, family, or colleagues, what makes Thomas Physician of the Year material and you’ll get the same answer: He truly cares. About his patients, his colleagues, his community, the practice of family medicine, the durability of rural medicine. He often acts as emcee at local events because he’s a great public speaker. He is an advocate for rural medicine because he cares about small communities and seeing that there are enough physicians to go around. He covers for colleagues when their children have activities because he reveres family values. He is a senior warden at his church because he holds faith dearly. He is also known for his tender bedside manner and the personal touch he brings to the exam room. “For me, he’s so personable,” says longtime patient Susan Hadley. Thomas and Hadley grew up together in Eagle Lake and raised children there simultaneously. “I can call him or text him and he is right there to talk to me on the spot. He’s always there when I need him.” Hadley has multiple stories of Thomas coming to her family’s rescue. He handled her mother’s admission into hospice care on the same day Hadley had back surgery. He answers her phone calls and texts always, even on his days off. He diagnosed her lupus in 1991. His father delivered both of her sons. The Thomas family is an extension of her family.

“To do family medicine you have to do family… And in the case of a country or rural physician, you really have to be willing to say, ‘I’m going to commit to not just this practice and not just these patients but to this community.’ You’ve got to be willing to be available and to serve on things and do that kind of stuff.” “Dad and I had a great relationship,” Thomas says. “I think we were complementary in that he had a lot of surgical skills and 30 years of experience when I came in. I had some of the newer medicine techniques. We really had a good synergy. We were just a good team.” Having previously nominated his father and a few other colleagues for this award, Thomas knows he is in good company as Physician of the Year. “To be held to the same standard of esteem as he was really does mean a lot to me. I knew a lot of these older docs, they were guys my dad hung out with growing up. They were kind of that same country doctor mold, and to be included with those guys…I can’t think of a higher honor.” Thomas’ work ethic and loyalty to the integrity of medicine was passed down from his physician father. When Thomas was born in 1953, the Salk polio vaccines were going through the final stages of human trials and physicians were excited about it. While interning at Fort Worth’s City-County Hospital, Thomas’ father took two doses 18

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Thomas’ son Barrett attended West Point and is a major and a battalion operations officer at Fort Bliss. His daughter Jacqueline is a nurse in North Carolina. Both of Thomas’ children got their desire to serve the public from their father, who got the same desire from his own father.

Left: Thomas embraces patient and childhood friend, Susan Hadley following a clinical appointment. Right: Thomas sits with his wife Robin on their lakefront back porch.

Jacqueline says she has worked with physicians who are not as personal with their patients and calls her dad’s bedside manner a “true gift.” Not to mention the strong connection he shares with his patents. “I’ve worked at Duke Hospital and I would see physicians come in, see patients for three minutes, leave, and never see them again,” she says. “Dad spends time with his patients. I don’t know if he even has the time, but he makes time to get to know them. He would go to a football game so he could see them play and talk about other things that go on in their lives. In a big city you just don’t have that opportunity. Everywhere you go in Eagle Lake, everyone knows him.” Jacqueline also recalls doing hospital rounds as a child with her dad, much like he did with her grandfather, as a way to spend time together. They were going to the hospital to check in on a patient who had recently given birth. She was craving a Dairy Queen Blizzard so Thomas and Jacqueline stopped on their way to pick one up for her. “Typical dad, just doing a little extra. He didn’t think it was a big deal though.” Another friend and patient of Thomas’ describes him as a physician who can handle the “extraordinary.” “I know his ability to immediately understand and act upon something entirely out of the norm of family practice saved my life,” the patient says. One day, the patient stopped by the Thomas household, something not at all uncommon, to show Thomas a serious redness on his leg. He was told to go home, rest, and call Thomas if he developed a fever. A few hours later when his fever spiked, Thomas met him at the hospital and began treatment immediately. It was vibrio vulnificus, a flesh-eating bacterium the patient contracted after wade fishing in the Gulf. After a few days of being treated by Thomas in the hospital, the infection stopped spreading. What’s interesting is that whether you talk to a colleague, a patient, or even an acquaintance, everyone adds that they would consider Thomas a friend. It’s easy to spot if you spend even the smallest amount of time in Eagle Lake. Join him at Subway for lunch and he’ll

know the employees as well as the other patrons. Stop in the town’s small supermarket and the cashier undoubtedly has stories about him. He’s the peoples’ physician. Yet another patient mentions in his award nomination letter that he continues to see Thomas for routine exams and non-emergency care, despite living 114 miles from Eagle Lake in Taylor, Texas. “In this time and age of specialties and specialists,” this patient writes, “it is a blessing to have someone like Dr. Russell who is always willing to put others first, investing his time and resources to help others.” He goes on to say that Thomas also delivered two of his daughters, one of whom currently studies medicine at TCOM in the rural track and is mentored by Thomas. That is what Thomas hopes for the future of medicine – that rural rotations and educational tracks become more common and popular and would include things like obstetrics and inpatient care.

Medicine for Thomas was never about a paycheck or any kind of ego-boosting recognition. It has always been about the patients and the integrity of rural family medicine. The Thomas family did leave Eagle Lake for a short time. He took a position in Austin from 2000 to 2002 as the program director at the Central Texas Medicine Foundation Family Practice Residency Program, where he helped establish a rural rotation. Knowing the importance of a rural physician, or “country doc” as Thomas calls it, this rotation was an important accomplishment to Thomas. “To do family medicine you have to do family,” says Thomas. You have to know what’s going on in a patient’s life outside of the exam room to fully take care of them, he explains. You have to know about their job, their family, their home life. “And in the case of a country or rural physician, you really have to be willing to say, ‘I’m going to commit to not just this practice and not just these patients but to this community.’ You’ve got to be willing to be available and to serve on things and do that kind of stuff.” www.tafp.org

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In Eagle Lake, Thomas is the Practicing in Eagle Lake is, of epitome of a country doc. Many course, not the only thing Thomas of his patients were schoolmates does in the medical realm. He is growing up. Many are his closest a preceptor for medical students friends and relatives. His clinic interested in family medicine and manager is the sister of one of his has clinical appointments with the childhood friends. Many members UT Houston School of Medicine of his office staff and nursing staff and Texas College of Osteopathic come from a single family. Medicine. He was appointed to Being a country doc in the the Board of Medical Examiners time of his father’s early practicing and served for eight years, five of years was similar to what it is now, which were spent as the vice presibut on a grander scale. Thomas’ dent. He was elected to the Board mother, Elfe, talks about her late of Directors for the Federation husband making multiple house of State Medical Boards. He was calls a day, something Thomas still appointed to the Board of DirecThomas accepts the Texas Family Physician of the Year award does but mostly on an as-needed tors for the Accreditation Council at TAFP’s Annual Session and Scientific Assembly in July 2014. basis. She remembers before EMS for Continuing Medical Education existed in Eagle Lake her husband and to the Maintenance of Licenbeing called away from the house sure Committee for the Ameriat all hours of the night to tend can Board of Medical Specialties. to accident victims. He once took Suffice it to say, he’s just as busy care of a pet monkey who had a outside of the clinic as he is inside broken leg. It was typical of him with his patients. to call the telephone company and These experiences outside of have them contact the nurses or the exam room are part of what lab technicians he needed to meet Thomas’ wife, Robin, thinks makes him at the clinic. him a great doctor and worthy of Thomas has comparable stories the Physician of the Year award. of picking up nurses in his own “Russell is a great, wonderful truck and heading to accidents he doctor,” says Robin. “He works heard about via small-town chatter. hard and has been involved in “I think that you have to have many aspects of medicine. I think a certain mindset,” says Thomas, it’s a combination of that and “and you have to be of a certain that he’s very dedicated. He’s very nature to do rural medicine.” caring.” TAFP CEO Tom Banning has Thomas swears there hasn’t known Thomas for the duration been a day since he returned to of his career with the Academy. Eagle Lake that he was unhappy The two consider each other more to go to work in the morning, than colleagues now, playing golf which is clear after seeing him in when they can. action with patients. “Dr. Thomas embodies the role of a physician leader and advocate. “For most of the last 31 years I’ve had the privilege of taking care of He’s the real deal.” Banning says. “Throughout his career he has made people in my hometown,” he says. his voice heard on issues affecting patients and the practice of mediAs a typical country doc, Thomas practices cradle-to-grave medicine. He’s developed and cultivated relationships with those in posicine. When a close family friend was diagnosed with cancer, Thomas tions of power who have a great deal of influence on medicine. He is was part of the team of physicians who treated her. He delivered her an unwavering advocate for his patients and his specialty.” children and had been their family physician for decades. The night Other physician educators see his dedication to the specialty too. she passed away, Thomas sat with her, the two reminiscing to 25 years In one nomination letter, a colleague says that medical students being earlier when he delivered her first child. mentored by Thomas are all inspired by his service to his community “That’s the length and breadth in family medicine in one patient,” and have the upmost respect for him. says Thomas. “I consider it sort of a privilege to be there for these people “He has been highly rated as an educator,” she says, “and has provided when they die. They allow me into their lives to deliver them and bring all of the necessary time and effort on a volunteer basis, believing in his life in, and they allow me to be there at the end. That’s a big deal.” responsibility to give back to the profession as his trainers gave of their Thomas captivated the audience with his speech when he accepted time and effort in his training.” the award in July 2014, proudly recounting his history as a country doc. A physician colleague calls Thomas an “exemplary role model for He ended by telling his fellow physicians, “I encourage you as we leave young physicians-in-training” in her nomination letter. “Dr. Russell’s today to remember that we’re all the Physician of the Year in the eyes efforts on behalf of his students and patients is indefatigable,” she says. of our patients.”

“To be held to the same standard of esteem as he was really does mean a lot to me. I knew a lot of these older docs, they were guys my dad hung out with growing up. They were kind of that same country doctor mold, and to be included with those guys…I can’t think of a higher honor.”

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A campaign to help patients and physicians find a home in primary care By Kate Alfano

healthisprimary.org #MakeHealthPrimary

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Lloyd Van Winkle, MD, has practiced in Castroville, a small town outside of San Antonio, for 29 years. Day in and day out, same place, same office, same staff. Having cared for some of his patients for nearly three decades, he says his practice’s top priority is doing what’s best for them. So when Van Winkle, also a board member for the American Academy of Family Physicians, heard about a new multi-year campaign launching at the 2014 AAFP Assembly in October, he did his research to make sure it would be beneficial to his patients and practice. The campaign – Health Is Primary – aims to rally patients, employers, policymakers, and other stakeholders across the country to recognize and support the value of family medicine and primary care in delivering on the Triple Aim of better health, better care, and lower costs, particularly through the patient-centered medical home. His verdict? A thumbs-up. “I’m a family doctor with real families, people I’ve taken care of forever, and if I can see value in this transition for my patients who I personally care about because they’re like my extended family, I think anyone else can see that that’s important.”

health is primary is the communications program for Family Medicine for America’s Health, or FMAH—a coalition of eight national family medicine organizations including AAFP—that will drive a five-year strategic initiative to transform family medicine to meet the needs of a growing population of patients with increasing complexity of health issues. Seven of the eight organizations came together a decade ago for the Future of Family Medicine project, which launched a series of strategic efforts to renew the specialty. Former AAFP President Glen Stream, MD, MBI, serves as FMAH board chair. He says physicians made significant progress to modernize and transform the specialty following the publication of the Future of Family Medicine report in 2004 “but there’s still much work to be done, particularly around people understanding the role of family medicine and primary care and changing the payment model to support that. That’s the alignment between the communications strategy and the strategic plan.”

After nearly a year of planning, FMAH identified its core strategies: • Working to ensure broad access to sustained, primary care relationships; • Accountability for increasing primary care value in terms of cost and quality; • A commitment to helping reduce health care disparities; • Moving to comprehensive payment and away from fee-for-service; • Transformation of training; • Technology to support effective care; • Improving research underpinning primary care; and • Actively engaging patients, policymakers, and payers to develop an understanding of the value of primary care. “What we’re looking to do is to have patients and other stakeholders understand that foundational role of primary care and create a movement that moves our health care system to have that strong primary care

foundation,” Stream says. “We think that a critical mission of our strategic effort is to improve health care, both the quality, patient safety and patient-centeredness of the care; improve health; and address the unsustainable, growing cost of health care in our country. We are just absolutely convinced that the Triple Aim cannot be accomplished without the strong primary care foundation that we’re advocating for.” “The Future of Family Medicine was not quite as innovative in terms of being patientcentered the way the current system is,” Van Winkle says. “It was the first steps. We were learning as we went along. But the new system is a lot more focused on the patient being the center of the medical home.” The FMAH board guides the strategic effort for the project. It comprises one representative from each partner organization plus at-large members representing four stakeholder categories: family physician in fulltime practice, new physician leader, patient advocate, and AAFP state chapter executive. www.tafp.org

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“What we need the other stakeholders to understand– people in government, employers, health plans–is that our current system is broken in how it pays for primary care. We’ll be engaging those groups around how to retool our health care system to be based on a stronger primary care foundation; changing the payment model is a linchpin piece of that project.” Glen Stream, MD

Driving the work of FMAH are six tactic teams—payment, practice management, workforce, education, technology, and engagement—with broad representation from the primary care community. The core members of FMAH’s tactic teams met for the first time in December at the Society of Teachers of Family Medicine’s Conference on Practice Improvement in Tampa, Florida, to develop a five-year work plan for their strategy focus. Moving forward, each team will engage a broader group of up to 60 volunteers to help with various aspects of their plan. TAFP member Christina Kelly, MD, leads the Workforce Core Team and says the kickoff meeting was productive and engaging. “The FMAH Board has put a great deal of work into the strategic plan over the last several months, and it was exciting to see it be put into action,” Kelly says. “All of the tactic teams worked well within the team and in between tactic teams. The potential for collaboration is immense.” “With the current state of our health care system, we have an opportunity to transform America’s health for the better,” she continues. “This is what is best for our patients. Advocating for our patients is something we do every day, and the core values of our specialty can be the catalyst for this transformation.” Health Is Primary is designed to connect people to primary care and help them understand that 90 percent of health needs can be met in the primary care patient-centered medical home. The campaign will employ national advertising, workplace programs, and stakeholder outreach to raise awareness, and will travel to five cities in 2015—Raleigh, Seattle, Chicago, Denver, and Detroit—to engage local stakeholders and showcase community-level interventions that are work24

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ing to enhance and expand primary care and improve health. The campaign will reach out to employers, disease groups, and health advocates to activate patients around major health issues to demonstrate how primary care can support them in preventing disease and promoting health. Health Is Primary launched the first quarterly consumer campaign in January, with a focus on nutrition and fitness, with chronic disease management, immunization, and smoking cessation following later in 2015. Also in January, the campaign hosted a panel discussion at the Consumer Electronics Show in Las Vegas to share the family medicine perspective on consumer health technology, the start of the effort to engage with the technology community to help drive innovation and technologies that foster the connection between physicians and patients and improve patient care and patient health. Stream says the biggest challenge to the campaign is the sheer size of the audience and the broad scope of the message. “We recognize that we can’t make this type of a change in the health care system on our own and are very much looking for partners to collaborate around areas of shared interests.” “What we need the other stakeholders to understand – people in government, employers, health plans – is that our current system is broken in how it pays for primary care,” Stream says. “We’ll be engaging those groups around how to retool our health care system to be based on a stronger primary care foundation; changing the payment model is a linchpin piece of that project. … If the payment model changes to pay the medical home rather than just pay the doctor, then it will cover those services that we know can

improve people’s prevention and wellness status, chronic illness, and care coordination.” Jen Brull, MD, FMAH board member representing practicing physicians, often fields the question from colleagues about what this campaign will “do” to them. She says she hopes it won’t do anything to them but rather that it will do a lot “for” them. “We want people to practice in a way that brings them joy and lets them do things the way they want to do things, and accomplish objectives that are important. I think the idea is we’re not looking to massively change or reform the way physicians practice. It’s all about how can we shape technology, legislation, payment, and pipeline to make your job easier so you can do a better job of taking care of patients.” “I hope it means that whether I choose to be an independent, solo, primary care provider with a full-scope practice or a hospitalist in a huge urban center, if I’m a family physician I have a home for that style of practice and a way to be financially viable to do what I love,” Brull says. “That’s what I want it to be.” Van Winkle agrees. “If a young person out there is looking for a personally fulfilling career decision in health care, I think that Health Is Primary will allow them to see what a family doctor’s life is like and what it’s like to develop a really incredibly fulfilling doctor-patient relationship experience. I think this project is going to create a healthier family medicine environment that will make it possible for young doctors-intraining to have a home for themselves.”

Kate Alfano is the former associate director of communications for the Texas Academy of Family Physicians. She now lives in Fort Collins, Colorado, and works as a freelance reporter.

Ways to get involved Download and display these posters: Get these campaign ads and more resources on FMAH’s website, FMAHealth.org. Talk to your patients: Tell your patients about Health Is Primary and how important primary care is to their health, and encourage them to spread the word. If you’re active on Twitter or Facebook, use the Twitter hashtag #MakeHealthPrimary and “like” the Health Is Primary Facebook page.

WHERE HEALTH IS PRIMARY. Increased collaboration between primary care and public health is key to addressing the biggest health challenges facing our country today. Family doctors are working to bridge the gap between personal and public health.