Texas Family Physician, Fall 2014

texas family physician VOL. 65 NO. 4 2014

Physician, Protect Your Assets Get The 411 On Medicare Advantage Is E-prescribing Controlled Drugs Worth The Pain?

Hard Hats For Little Heads Celebrates 20 Years

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INSIDE

samantha white

TEXAS FAMILY PHYSICIAN VOL. 65 NO. 4 2014

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Embracing change in the Valley

A small group of independent primary care docs in and around McAllen built a successful ACO from scratch and just saved $6 million in Medicare spending. Here’s how they did it.

By Jonathan Nelson

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6 FROM YOUR PRESIDENT An adaptation of the 2014-2015 incoming president’s address 10 NEWS FROM AAFP Bill for chronic care management services with confidence.

12 MEMBER NEWS Annual Session highlights | Meet one of TAFP’s Members of the Month. | In memoriam: Jack Eidson, M.D.

Primary care is the real “Medicare Advantage”

24 TAFPPAC donors

Unfamiliar with Medicare Advantage? You need to read this.

30 FOUNDATION FOCUS Thanks to 2014 TAFP Foundation donors.

By Bruce Bagley, M.D.

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E-prescribing controlled drugs: No pain, no gain

With the classification of hydrocodone as a schedule II controlled substance, you should consider prescribing controlled drugs electronically.

By Kara Nuzback

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Happy birthday, Hard Hats

TMA’s helmet giveaway program turns 20, and TAFP has been helping for the past decade, so we went to San Antonio for a celebration.

By Samantha White

31 FINANCE An ounce of asset protection 34 PUBLIC HEALTH Working to improve women’s access to health care in the 84th Texas Legislature 38 TAFP PERSPECTIVE In praise of small practices

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president’s column

TEXAS FAMILY PHYSICIAN VOL. 65 NO. 4 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

Dale Ragle, M.D.

president-elect vice president treasurer

Ajay Gupta, M.D.

Janet Hurley, M.D.

Tricia Elliott, M.D.

parliamentarian

Tamra Deuser, M.D.

immediate past president

Clare Hawkins, M.D., M.Sc.

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 Bruce Bagley, M.D. Anna Chatillon Kara Nuzback Sheri Porter Lloyd Van Winkle, M.D. Brad Wiewel 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. © 2014 Texas Academy of Family Physicians postmaster Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727.

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Keep doing what you do best; change what needs to be changed An adaptation of the 2014-2015 incoming president’s address

By Dale Ragle, M.D. TAFP President it is an honor and a privilege to serve my fellow family docs as TAFP President. There is no other group of people that I would rather serve and give my time to than you. I represent all of you, whether you are a solo, rural doc in west Texas where you may be the only doctor within 70 miles, a doctor in a big multi-specialty group, a resident in training, or a medical student aspiring for a career in family medicine. You all deserve my service and attention and you all shall get it.

The last three members to serve as president of our organization have initiated their terms with inaugural speeches about change and reform of our health care system.

I too will tell you that our health care system is indeed changing and we are going to have to adapt in some way. The forces driving this change are bigger than TAFP, they are bigger than AAFP, and they are bigger than the AMA. The Medicare program is a case in point. Our population is aging and the baby boomers are entering their Medicare years.

At the same time, fewer and fewer taxpayers are paying into the Medicare system, putting the program in an untenable financial dilemma. Without some sort of change our Medicare program will go bankrupt. Now, different prognosticators give different dates on when this will occur, but, suffice it to say this is an economic reality facing our political leaders.

Something has to be done. Change and some sort of reform are coming, whether we

like it or not. It is not the role, as some would like, of our professional organizations to try to stop reform or to slow it. Rather, I believe the role of our Academy is to be a voice which will guide reform and offer constructive solutions and alternatives.

Total health care expenditures are continuing to rise. And it is very likely, in the near future, that the fee-forservice reimbursement model will fade away and will be replaced by a new payment model that emphasizes quality over quantity. Medicare is likely to move away from the widely unpopular SGR formula for reimbursement to some sort of payfor-performance model.

Private insurance is sure to follow.

In talking about all of this, it is important to point out that the amount of health care dollars spent on primary care, relative to the amount spent on hospitals, costly procedures, and specialty care is still miniscule. Exact numbers are difficult to obtain, but I saw one calculation which took the total average payments to primary care practices and divided it by the average number of total patients in a primary care practice. Using this calculation methodology, the average primary care practice gets about $144 per patient per year. When you consider that most insurance premiums are around $7,000-$10,000 per year or more, and Medicare dollar spending per beneficiary is around $10,000, that would amount to roughly 2 percent of the insurance premium going to primary care practices.

Family medicine offers a very efficient vehicle to deliver health care. Expanding access to family medicine provides a great value for policymakers and payers to improve the health of the nation and lower health care costs.

The Texas Academy of Family Physicians presents:

Even if these calculations are off by 50 or 100 percent and the real number is 3 or 4 percent, that is still a drop in the bucket of total health care costs. It is suffice to say, that primary care expenditures are not significantly contributing to Medicare’s or the private payer’s budget crises. For years now our organizations have trumpeted the many studies that clearly show that areas with higher concentrations of primary care physicians relative to specialists have lower health care costs than areas where the reverse is true. Hence, better access to primary care services lowers health care costs.

It does not take a rocket surgeon (to mix metaphors) to see that in this era of revamping payment methodology, if payers and policymakers want to reduce overall health care costs, they should invest in expanding primary care.

It’s a very simple concept. Sort of like purchasing a fuel efficient car to reduce your transportation costs. Family medicine offers a very efficient vehicle to deliver health care. Expanding access to family medicine provides a great value for policymakers and payers to improve the health of the nation and lower health care costs.

In this vein, we need to promote expansion of our family medicine workforce.

We must redouble our efforts to promote family medicine in our medical schools and encourage students to choose our specialty.

We must also advocate for robust funding and expansion of family medicine residency training slots. It’s a message that needs to be carried loud, clearly, and often. I encourage you to continue to contact your state and federal elected officials with this message.

Using the car analogy, this is sort of like promoting the manufacture of more fuel efficient cars. I give you my permission to use that analogy when talking to policymakers.

I believe that the value of family medicine lies in the fact that we know our communities and our patients better than anyone. Simply speaking, you know that lady who comes into your office complaining of headaches had a husband pass away a year ago, has a pregnant teenage daughter at home, and may not need a brain MRI. You know that 35-year-old guy coming to you with heart palpitations has a seriously ill child at home, works at a

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Discounts on Vaccines • Reimbursement Support With Payers • Timely Updates About New Products, Changes & Sales • Donations to TAFP With Every Purchase!

Atlantic Health Partners is a free vaccine purchasing program open to any physician practice. Through Atlantic, your practice orders directly from manufacturers and receives discounts on a range of vaccines – infants to adults – Tdap to HPV. Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management.

The program is free to your practice, and enrollment is completely voluntary.

The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine.

Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered.

Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or info@atlantichealthpartners.com for more information and to register.

Jonathan nelson

Start Saving Money on Vaccines Now! Dale Ragle, M.D., presents his new framed copy of the TAFP Presidential Oath of Office and gavel to the audience gathered at the Annual Business and Awards Lunch during the 2014 TAFP Annual Session and Scientific Assembly.

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local company undergoing layoffs and may not need an extensive cardiac workup. No one knows your patients and your community better than you do. Maintain that pulse that you have on your patients’ lives and let it be the beacon that guides you, whatever changes the health care system throws your way. Keep doing what you do best. Change what needs to be changed.

Those of you in solo and small group practice may ask yourself the question, “why can’t I just go on doing what I have always done?” After all, I have always done well by my patients, and I believe that you have. Unfortunately, the cold hard truth is that whenever someone else is paying for health care, whether it is the government, private payer, or an employer, we are not totally independent.

Change was and is inevitable as we cannot really expect for someone else to continually pay the bills and not eventually exercise oversight in how their money is spent.

We recognize that the current plight of the physician in solo and small group practice is difficult. I’ve been there. However, because of your value to our health care system, we also have a great opportunity to promote our profession to policymakers and payers with the goal of providing positive changes and opportunities for you.

TAFP is here to help you navigate these waters and assist you in your progress. For example, our board of directors recently commissioned a task force on payment

reform. The major charge of this task force was to provide TAFP with ideas to help you navigate these changes, whether you are in solo practice, large group practice, or are employed. AAFP is doing similar things on a national level. The task force has completed its report and I have read it. One of the ideas being bandied about is a concept known as direct primary care. This delivery model essentially eliminates the burden of public and private payer systems by targeting services directly to the patient as purchaser.

There are practices thriving today by charging small, affordable monthly fees — often $30 to $40 per month — to patients in this direct primary care model. The details of setting it up are well beyond the scope of this column, but stay tuned. Your state and national organizations will be able to help you explore this idea in the near future.

For those of you interested in navigating other models of delivery coming down the pike, such as the pay for quality model, we will be here to help you with that as well. We plan to develop toolkits to help you monitor quality in your practice. We will also promote communications and organization between colleagues in your communities and provide access to mentors who can assist you with practice and infrastructure transformation. Whatever model eventually lands in your practice, keep doing what you do best. Change what needs to be changed.

Dale Ragle, M.D., practices family medicine with the group Dallas Family Doctors in Dallas, Texas. He received his medical degree from the University of Texas Medical Branch in Galveston and completed his postgraduate training at the Baytown Family Medicine Residency Program affiliated with University of Texas Health Sciences Center at Houston. He has been a member of TAFP since 1991 and has been a member of the AAFP since 1987. During his tenure at TAFP, he has served on the TAFP Board of Directors, Executive Committee, Commission on Legislative and Public Affairs, Commission on Health Care Services and Managed Care, and TAFP Foundation Board. He is also a member of the Texas Medical Association and the Dallas County Medical Society.

I believe that the physician who took care of me when I was growing up was a doctor like you. I remember him always being there for us on a moment’s notice.

In today’s parlance, that would be known as same day appointments or acute care visits. I remember him politely chastising my mom when we showed up at his office about 30 minutes after she called with him knowing that we lived 40 miles away.

I guess he calculated that we would have had to have traveled an average of 80 mph to get to his office in that time frame. He then proceeded to tell her not to get us killed just so we could come to him and try to get well. It’s important to note, that he did this in an era before there would have been a check box in an electronic health record attesting that he had counseled the patient about automobile safety. He did this because he cared about us, wanted us to be safe and wanted us to know that he would have been available, even if we showed up to his office a few minutes late.

It just came naturally to him because he cared. I’m sure that 99 percent of you are like him.

I want you to keep being that doctor.

We will do everything in our power to enable you to do that. Caring comes natural to you. It is the essence of your value to the health care system. It is what you do best. Keep doing what you do best. Change what needs to be changed.

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AAFP news

Bill for chronic care management services with confidence Explore FPM’s tools, resources

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as of jan. 1, 2015, physicians may use Medicare’s new chronic care management (CCM) code. Check out the Family Practice Management article “Chronic Care Management and Other New CPT Codes,” which was published online at www.aafp.org/fpm and is chock-full of details FPs will want to have under their belts come the new year.

The article, authored by Kent Moore, the AAFP’s senior strategist for physician payment, covers all the important topics, such as patient eligibility, practice standards, scope of services, coding, billing and documentation, and CCM and “incident to” rules.

There’s a lot to learn about this rule, and the article details it all. For instance, the new CCM benefit • pertains only to patients with two or more chronic conditions; • comprises eight elements, including access to care, continuity of care and management of care transitions; • requires the sharing of patient information via certified electronic health record technology; and • dictates that a signed patient agreement be collected before services begin.

The article also devotes a fair chunk of space to coding, billing and documentation.

To bill Medicare for CCM services, physicians must use CPT code 99490, but the article will fill FPs in on those all-important details that mean the difference between getting a check for payment or receiving a claims rejection.

FPM also offers readers three downloadable tools designed to save physicians time as they venture into these uncharted waters.

They are:

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TEXAS FAMILY PHYSICIAN

• the Patient-Centered Care Plan, • the Agreement to Receive Medicare Chronic Care Management Services, and • the Medicare Chronic Care Management Services Log.

FPM also hammered out a list of frequently asked questions meant to assist family physicians in understanding how the new code is to be used.

Why all the extra effort devoted to this topic?

In an interview with AAFP News, Moore pointed out that payment for CCM services has been a long time coming.

“This represents a unique opportunity for our members to finally get paid for services that many of them already have been providing without payment,” said Moore.

“These codes are aimed at compensating family physicians not just for what they’re doing, but for the value they bring to their patients.” And that value goes far beyond the face-to-face interactions that happen every day in family physician practices, he added.

The tools FPM created to accompany the article should be a valuable aid to physicians, said Moore.

“These three tools are intended to give family physicians what they need — or at least a place to start — and all of them are customizable to individual practices,” he said. One in particular, the CCM services log, is designed to document the clinical staff time devoted to a patient who received CCM services during the course of a calendar year and could be particularly important.

“It’s intended to help family physicians capture the information they would need to withstand a Medicare audit,” said Moore.

READ THE ARTICLE FPM Jan./Feb. 2015 “Chronic Care Management and Other New CPT Codes” www.aafp.org/fpm

Source: AAFP News Now, Dec. 12, 2014. © American Academy of Family Physicians.

announcing

TAFP’s All-New 2015 CME Conference Schedule Next year, big changes are in store for TAFP’s CME conference schedule, as we move the state’s premier education conference for family physicians to the fall and introduce a brand new summer CME event.

C. Frank Webber Lectureship & Interim Session Omni Austin Hotel at Southpark • Austin

TAFP’s first conference of the year features a full day of engaging CME, Academy business meetings and policy discussions, networking opportunities, and more. Most committee, commission, and section meetings will be held on March 7, as will the Student and Resident Conference.

Introducing our new summer CME event:

Texas Family Medicine Symposium La Cantera Hill Country Resort and Spa San Antonio

Attendees will have the chance to earn 25 credits of cutting-edge CME including the required ethics credit in only two and a half days, or they can work toward their maintenance of certification requirement with a SAM Group Study Workshop.

Annual Session & Primary Care Summit The Woodlands Waterway Marriott • The Woodlands Annual Session is moving to November! This is TAFP’s most anticipated conference of the year, complete with more than 20 hours of CME, a bustling exhibit hall, social and networking events, SAM Group Study Workshops, procedural training, and much more. TAFP’s committees, commissions, and sections will meet to discuss policy and practice concerns, and delegates from local chapters will gather at the TAFP Member Assembly. Plus TAFP’s officers for the coming year will be installed, some of our most dedicated members will receive honors and awards, and we’ll all celebrate a great year at the President’s Party.

Member news

Highlights from TAFP’s Annual Session, July 23-27, 2014 The committees, commissions, and sections of the Texas Academy of Family Physicians met in San Antonio and deliberated on many important items. TAFP also held its first voting Member Assembly to elect new leaders. Thanks to all the members who participated. Most commissions and committees and all sections 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.

Advocating for you and your patients TAFP’s lobby team met with the Commission on Legislative and Public Affairs to provide an update on the elections and discuss the likely themes of the 2015 Texas Legislative Session including Texas’ fiscal outlook, public education and transportation funding, infrastructure development, water infrastructure, and the business tax/margins tax system. They discussed the political challenges for some of TAFP’s priorities including Medicaid expansion, increasing graduate medical education funding, and changes to Texas’ telemedicine laws.

Member services and resource in development TAFP has several sections that meet at TAFP’s Interim and Annual Sessions to discuss issues and interests common to the group. Any member is welcome to attend and participate in discussions on maternity care, rural medicine, resident education, medical student education, and now research.

The Section on Research had its first meeting at Annual Session for those interested in developing research projects, participating in research, or just learning about research going on in Texas. You are welcome to attend their meeting at Interim Session in Austin, March 6-7, 2015.

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The Leadership Development Committee moved closer to rolling out a new leadership program for TAFP members. It will include increased leadership programming at TAFP conferences and the opportunity to participate in a yearlong leadership experience with a small group of your colleagues. Watch for more details in the coming year.

Defining PCMH in Texas The Commission on Health Care Services and Managed Care received a report from the patient-centered medical home workgroup that formed after Interim Session. The report has a recommendation to develop a Texas-specific version of PCMH designation.

The goal is to compile a set of qualities, capabilities, and characteristics of a medical home in collaboration with consultants, other primary care physician associations, and the Texas Medical Home Initiative. Once the standards are developed, they should be presented to payers around the state in hopes of forging agreements to create multipayer PCMH programs. The commission recommended that TAFP develop a strategy to implement the report.

TEXAS FAMILY PHYSICIAN

Developing a strong family medicine workforce The Commission on Academic Affairs recommended, and the Board approved, a bold goal of having 50 percent of Texas medical school graduates go into family medicine.

They also recommended that TAFP facilitate a meeting of key stakeholders from Texas medical schools to discuss barriers, best practices for FMIG groups, preceptorships, and clerkship practices.

Opportunities for members TAFP has been represented

by Drs. Erica Swegler and Troy Fiesinger at the TMA Interspecialty Society since 2006 and they have done a fantastic job.

The Nominating Committee will be reviewing the responsibilities of the position and will send a “call for nominations” to identify new leadership at their next meeting. If you are interested in serving, please contact Kathy McCarthy at kmccarthy@tafp.org.

Organizational news The voting representatives on the Member Assembly reviewed recommendations from the Nominating Committee and elected these 20142015 leaders: 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. Alternate Delegate to AAFP: Troy Fiesinger, M.D. New Physician Director: Emily Briggs, M.D. At-large Director: Adrian Billings, M.D.

Special Constituencies Director: Terrance Hines, M.D. Resident Director: Kassie Johnson, M.D. Medical Student Director: Brittany Taute At the annual TAFP Business and Awards Lunch, the membership approved bylaws amendments recommended and published in Texas Family Physician earlier in 2014.

These changes were meant to ensure alignment with AAFP’s bylaws, alter the succession of leadership, and clarify the Annual Business Meeting. The Bylaws Committee met during Annual Session and discussed a few other changes that will be published in 2015 to be voted on during the next annual business meeting.

Member highlights The Nominating Committee reviewed opportunities on the national level. TAFP has a strong presence within AAFP because of the strong Texas leaders who dedicate time and energy to serving the specialty.

The committee recommended and the Board approved nominating Dr. Lloyd Van Winkle to run for AAFP President-elect in 2015. They also asked TAFP to submit a nomination for Dr. Rebecca Hart to chair the AAFP Commission on Health of the Public and Science and nominate the following members for service on AAFP Commissions – Dr. Amer Shakil, Dr. Lesca Hadley, Dr. Clare Hawkins, Dr. Troy Fiesinger, and Dr. Erica Swegler.

The Commission on Membership and Member Services recognized and applauded the election of Dr. Emily Briggs to the AAFP Board of Directors as the new physician member and Dr. Christina Kelly as the convener of the 2015 National Conference of Constituency Leaders.

Trust TMAIT to Help You Navigate the Marketplace

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Member news

After completing an undergraduate degree and a medical degree at Texas A&M and a residency at John Peter Smith, choosing family medicine was a natural decision for Terrance Hines, M.D., who knew he wanted to be a family doctor since before beginning medical school, thanks to his nurse parents and his childhood physician. Since completing his residency in 2009, Hines has been with Scott & White in Austin. He is currently the medical director for three clinics and a clinical assistant professor at Texas A&M College of Medicine.

TFP: Why did you choose family medicine, and what’s your favorite aspect of it? Were you inspired by anyone?

Both of my parents are nurses, so I grew up around health care. Even before starting medical school, I knew I wanted to be a family doctor. I had the same doctor throughout my entire childhood and his compassion and expertise defined what being a doctor meant to me.

TFP: It is important for me to be a member of AAFP and TAFP because: These organizations advocate not only for me professionally but also for my patients. CME activities, educational materials, advocacy, and outreach programs are all valuable tools to deal with the everchanging health care climate. Meetings provide opportunities to fellowship with other doctors and to learn best practices.

October 2014 Member of the Month Terrance Hines, M.D. TAFP Board member followed parents’ footsteps into health care 14

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TFP: What has your experience been like as the special constituency member on the TAFP Board of Directors?

I am completing my third and final one-year term on the Board. It has been an exceptional learning experience on how our organization governs itself as well as shapes health care policy. Particularly during our transition in governance structure, I hope I have been a strong advocate for all of the constituency groups (GLBT, women, minorities, international medical graduates, and new physicians). I have had the

TFP: What led you to be involved in TAFP business the way you are?

I became involved in the Academy as a resident and was able to attend NCSC as a delegate several years ago. This exposure to the process of resolution writing piqued my interest in health care policy and belief that our organization can be on the forefront of the evolving health care market.

TFP: What is the most interesting/ memorable experience you have had when dealing with a patient?

As physicians, we have the incredible privilege to be invited into our patients’ lives in multiple ways—celebrating the birth of a new child, dealing with the passing of a loved one, common colds, and uncommon diseases. It is hard for me to choose a favorite or most special experience because they are all, in their own way, special. I have in my file drawer a folder of cards and notes that patients have given me. On my bookshelf are a few small tokens of appreciation. On days when I’ve had about all I can take of prior authorizations, insurance company hassles, and paperwork, I can look at these things and am instantly reminded of how lucky I am to be a family doctor.

TFP: If you weren’t a doctor what would you be doing with your career?

My parents like to tell the story that as a child I wanted to either be a fireman or a garbage collector—both got to ride on the back of big trucks and I thought that sounded pretty cool. I think I would have a hard time finding anything else as special, interesting, challenging, and meaningful as being a doctor. However, I really love teaching medical students and would probably pursue a career in academics.

TFP: How do you spend your free time?

My husband and I have a very active 2-year-old who consumes most of our time—we love going to the park with our French bulldog Hugo, playing in the yard, and finding new adventures in Austin.

When I’m not busy with him, I enjoy running, grilling, going to the movies, travelling, and spending time with friends. I also love Texas A&M football.

samantha white

opportunity to interact with other national constituency leaders through National Conference on Special Constituencies.

Member Month of the

TAFP’s Member of the Month web feature highlights Texas family physicians and their approach to family medicine. If you know a family physician colleague who you think should be featured as a Member of the Month or if you’d like to tell your own story, nominate yourself or your colleague by contacting TAFP by e-mail at swhite@tafp.org or by phone at (512) 329-8666. View past Members of the Month at www.tafp.org/membership/spotlight.

Thank you to TAFP’s 2014 Members of the Month: Dan Sepdham, M.D., of Flower Mound; Ajay Gupta, M.D., of Austin; Tracey Haas, D.O., M.P.H., of Austin; Bruce Russell, M.D., of Port Aransas; Mary Nguyen, M.D., of Castroville; Linda May, M.D., of San Antonio; Joe Anzaldúa, M.D., of Sugar Land; Emily Briggs, M.D., M.P.H., of New Braunfels; Terrance Hines, M.D., of Austin; and Nish Shah, M.D., of Houston.

In memoriam Jack Eidson, M.D. TAFP member Jack Eidson, M.D., passed away at the age of 91 on June 15, 2014, in Weatherford, Texas. Eidson became a member in 1954 and was selected as the Texas Family Physician of the Year in 1993. He also helped organize the Three Rivers Chapter of TAFP. Affectionately known as “Dr. Jack,” Eidson graduated from the University of Texas at Austin in 1943, and was sent to medical school by the U.S. Army during World War II. He graduated from Baylor Medical School in 1946 and then served with the U.S. Army Air Corps

for four years in Houston, San Antonio, Indianapolis, and Denver.

Upon meeting the local pharmacist, Gerald Davis, Eidson moved to Weatherford, Texas, in January 1950, where he practiced until retirement in 2000. In those 50 years he delivered over 5,000 babies and was known for his tender bedside manner.

In addition to his busy medical practice, Eidson was active in TAFP and the Texas Medical Association; served as medical director for the American Bankers Insurance Company; was awarded the Silver Beaver by the Boy Scouts of America for 30 years of service; was president of the Weatherford Lions Club and The Cancer Society; served the local Chamber of Commerce and United Way; spent three terms as Weatherford City Commissioner and Mayor pro tem; and was active in politics, working for Dwight Eisenhower’s 1952 campaign and serving the Republican National Convention in 1972.

Eidson is survived by multiple children, including TAFP member Mark Eidson, M.D., and numerous grandchildren, nieces, and nephews worldwide. www.tafp.org

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Primary care is the real “Medicare Advantage”

By Bruce Bagley, M.D. TransforMED CEO if you are not familiar with Medicare Advantage plans and how they work, it is time to get up to speed and follow this important trend in health system change. Nearly one in three Medicare recipients is now in a Medicare Advantage plan. The Affordable Care Act, which reduced per capita global payments to Medicare Advantage health plans by more than 10 percent, was expected to cause many insurers to exit the market and stifle the growth of this option for seniors. In fact, the opposite has been the case as the total Medicare Advantage enrollment exceeds 15 million seniors, three times as many as participated in 2004. In some California cities more than half of Medicare eligible seniors are in Medicare Advantage plans.

The rapid growth in Medicare Advantage enrollment is multi-factorial. Medicare Advantage plans have discovered that even with the reductions in risk adjusted global payments required by the ACA that capable primary care practices, properly supported to do risk stratified care management and care coordination, can save enough money

on the hospital and ER side of the equation to net a fair profit for the Medicare Advantage plan. Also fueling the growth are the 10,000 individuals every day who turn 65 years old and become Medicare eligible.

This new cohort of Medicare eligible citizens has some interesting characteristics that tend to make Medicare Advantage plans a nice fit. First, they are relatively “young and healthy” compared to most current recipients; they are more likely to have been in some kind of managed care or narrow network employer sponsored plan prior to retirement and don’t have an inherent distrust of managed care; and nearly 40 percent of these new enrollees are low income individuals, making it difficult for them to purchase Medi-Gap insurance on top of a Medicare premium. Medicare Advantage plans usually offer a “package deal” including drug coverage and other benefits for premiums comparable to Medicare Part B premiums. For all these reasons, some policy folks are predicting Medicare Advantage enrollment approaching 50 percent of all eligible seniors within two or three years. www.tafp.org

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If Medicare Advantage with its risk adjusted global payment continues to grow as predicted, you can be sure the commercial markets will follow that path from volume to value. The goals and care design of an ACO and a Medicare Advantage plan are very similar. The value created by primary care is central to the success of both of these approaches.

Why is all this important to primary care practices? As our payment system moves from volume to value, primary care has an important role to play in the pro-active management of this segment of our population. The proportion of Medicare patients in a typical primary care panel can range from as low as 10 percent to 50 percent or more, and even higher for geriatric specialists. It is an important part of our work that requires special attention. We recommend that you have explicit systems and strategies in three important areas: Risk stratified care management and care coordination; coding practices that support proper reporting of the risk adjustment factor to CMS; and attention to the quality measures required for the Medicare Advantage STARs program which determines potential bonus to the plan on top of the global payment determined by the RAF score.

Proper coding practices to support determination of the risk adjustment factor The Medicare Advantage program is set up to provide a risk stratified global payment to the sponsoring health plan for each enrollee.

This score is determined once per year and calculated from the claims submitted for each encounter. CMS has specified the enrollment or health conditions that contribute to the aggregate RAF score for each patient. A computer algorithm is used to process the claims data for a calendar year to determine the RAF score for that period and estimate the composite RAF score for all Medicare Advantage patients in a given plan.

We suggest that practices use a registry for Medicare recipients so that this population can be pro-actively managed. For example, set up a workflow so that the care team does some “pre-visit planning” to determine if there are any gaps in the recommended care for the patient’s chronic conditions, preventive screenings or immunizations due and a coding review to assure that all the appropriate codes have been included in the current calendar year. This is a good time to make sure all Medicare patients, both Medicare Advantage and Feefor-Service, get an annual wellness visit.

Quality measure reporting The Medicare Advantage STARs program is designed to assure that seniors in these plans receive high quality care. It is important to set up your workflow and EMR systems to be able to report on quality results for the usual HEDIS measures. Meaningful use incentives have advanced this system capability available from vendors and caused many practices to redesign workflows to make sure the proper information is in the system to support the quality measure reporting function. Quality measure reporting will increasingly be required by all payers so it makes good sense to build these systems into regular care team work across the entire practice.

Risk stratified care management and care coordination

These recommendations are predicated on the assumption that Medicare Advantage plans will offer incentives and rewards for practices that comply with the reporting requirements of the program.

Fortunately, most plans realize that infrastructure is required for primary care to do its best work and are willing to provide additional resources for critical primary care components including registries, care managers and home visits.

If Medicare Advantage with its risk adjusted global payment continues to grow as predicted, you can be sure the commercial markets will follow that path from volume to value. ACOs have had mixed results early in their development but the goals and care design of an ACO and a Medicare Advantage plan are very similar. The value created by primary care is central to the success of both of these approaches.

Continuing to work on redesign, team-based care and building a quality improvement capacity for your practice, will pave the way for primary care practices in the new world of value based health care.

It is critical to identify those patients in the practice who need more help either in managing their own chronic conditions, navigating the fragmented system from one point of care to the next or both. Patients in the highest risk categories should be tracked on a registry, have up to date care plans in place and be contacted periodically by someone from the care team to track progress and identify deterioration early.

For a more complete discussion of RSCM, see www.aafp.org/rscm and a previous article on the TransforMED website, www.transformed.com, entitled “Why is everyone talking about population health?”

Bruce Bagley, M.D., F.A.A.F.P., is president and CEO of TransforMED, a wholly owned subsidiary of the American Academy of Family Physicians.

This article appears in Texas Family Physician with permission, and was originally published as the October 2014 installment of “Report from the CEO” on the TransforMED website, www.transformed.com.

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samantha white

Embracing change on the border RGV Health Associates ACO makes Medicare shared savings work in the Rio Grande Valley

McAllen, Texas became ground zero for the national debate about out-of-control health care costs in 2009, when Atul Gawande, M.D., published his influential article “The Cost Conundrum” in The New Yorker. In it he claimed that McAllen was the most expensive place to receive health care in the country.

The article illustrated the indefensible variation in health care costs from region to region by showing that medical services were twice as expensive in McAllen as they were 800 miles upriver in El Paso. Why such a discrepancy?

Overuse of expensive medical treatments and diagnostics are a direct result of our feefor-service environment, which has allowed an unsustainable inflationary trend in health costs.

In some regional markets like McAllen, costs have ballooned more freely than in others.

Employers, insurers, and governments federal, state, and local have been pushing hard for a transition in health care from volumebased payment to value-based payment that rewards hospitals, physicians, and other providers for keeping patients healthy rather than 20

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paying ever-increasing fees for treatment when they get sick.

The idea of transitioning health care delivery from volume to value permeated the national discussion over health care reform during the first two years of the Obama administration, often articulated as the Triple Aim: better patient care, better population health, and lower per capita health care costs.

Suddenly just about everyone in health policy could show you McAllen was on a map.

Today McAllen is home to a group of primary care physicians who took on that challenge.

Instead of holding on to the status quo as long as they could, they embraced change, and now they are providing better, more efficient care for their patients as an accountable care organization. The Rio Grande Valley Health Alliance is a physicianled ACO comprised of 14 independent physicians — mostly family doctors — in 12 practices in McAllen and surrounding communities. In their first year of participation in the Medicare Shared Savings Program, they saved more than $6 million, and $3 million of that is theirs to keep.

jonathan nelson

By Jonathan Nelson

From left: Roger Heredia, M.D., RGVHA Medical Director, and Luis Delgado, Jr., M.D., RGVHA President

www.tafp.org

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A

fter Bobbitt’s presentation at the AAFP Assembly, Delgado went home and started digging. For several weeks he studied the concept and talked with his colleagues and by early 2012, he had convinced six other independent physicians to commit to forming an ACO. Then they called Bobbitt and the real work began.

“It’s just a remarkable story,” Bobbitt says of the progress RGVHA has made. “They were a small group of people with fantastic leadership, and they let me be a cheerleader to emphasize that it’s all about culture.”

This is Bobbitt’s mantra. In a valuable how-to guide he authored for TAFP and AAFP, “The Family Physician’s ACO Blueprint for Success,” he wrote: “The most important element, yet the one most difficult to attain, is a team-oriented culture with a deeply-held shared commitment to reorganize care to achieve higher quality at lower cost.”

RGVHA had the right culture from the beginning, Bobbitt says, but that was about all they had. They had no infrastructure, no common EMR, no capital, and no idea what to do next.

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n the fall of 2011, Luis Delgado, Jr., M.D., took a trip to Orlando, Florida, to attend the Annual Assembly of the American Academy of Family Physicians. After 21 years of private practice in McAllen, Delgado felt many of the same frustrations family physicians all over the country have.

“In primary care, we’ve been taking hits left and right ever since I’ve been in practice,” he says. “What ends up happening is what everybody knows: You start seeing more volume, which is not a good way to practice medicine. I think we’re all tired of it. We miss the ideals that we were trained as we were learning to be physicians, to practice good medicine and give patients their due time.”

At the conference, Delgado attended a presentation on accountable care organizations by a North Carolina health care lawyer named Julian “Bo” Bobbitt, Jr., and even though Delgado had never heard of an ACO, he recognized the potential for his practice and his community. “I listened to his talk and the whole concept was very intriguing to me. It really gave a whole new opportunity for guys like us in primary care to get into a different model, a different system.”

ACOs were established by the Affordable Care Act to encourage physicians, hospitals, and other health care providers to work together to better coordinate care, improve patient care, and reduce costs. In return for meeting defined performance goals, an ACO’s providers receive a portion of the savings they generate.

Since ACOs are defined by function rather than by organizational structure, they can be comprised of a number of different provider configurations. An ACO could be formed by a hospital, a group of independent physicians, a multispecialty group, a clinically integrated provider system, or some combination of these. The more integrated the component groups are, the easier the ACO formation will be.

While participating physicians and practices can remain independent, the ACO must be its own legal entity with its own tax ID so it can receive payments from third parties like Medicare or private plans, and distribute payments to providers. It must have processes to measure and report quality performance data, and it must meet a minimum threshold of total patients. To be eligible for the Medicare Shared Savings Program, an ACO needs at least 5,000 patients.

Since the passage of the ACA, several hundred ACOs of various sizes and configurations have popped up. At last count, CMS reports there are 220 ACOs in the MSSP and 23 Pioneer ACOs. Together they generated more than $372 million in savings in 2013.

“It was the first time we were banding together to do something as a group with a common goal, getting patients in better health, better quality, and reduced costs.”

Luis Delgado, Jr., M.D. President, RGVHA

He helped them navigate the MSSP application process to become a network-model ACO, so the physicians could stay in their independent practices and be contracted with the ACO. He also helped them win acceptance to the CMS Advance Payment ACO Model, which gave RGVHA access to enough seed capital to build their infrastructure.

They enlisted the help of MD Online Solutions, LLC, a health IT firm out of North Carolina, to provide HIT support, data management and reporting tools, and ongoing consultation.

“During that year – 2012 – it was all preparation, communication, understanding transparency, and working together, which was something totally new to us,” Delgado says. “It was the first time when we were banding together to do something as a group with a common goal, getting patients in better health, better quality, and reduced costs.”

By the end of the year, six more physicians had signed on bringing the total membership to 13 with just over the limit of 5,000 Medicare patients among them. CMS announced RGVHA as a participating ACO in the MSSP, and in January 2013, they saw their first patients as an ACO.

ACO requirements from the Patient Protection and Affordable Care Act • That groups of providers have established structures for reporting quality and cost of health care, leadership, and management that includes clinical and administrative systems; receiving and distributing shared savings; and shared governance.

• Willing to become accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it.

• Minimum three-year contract.

• Sufficient primary care providers to have at least 5,000 patients assigned.

• Processes to promote evidence-based medicine, patient engagement, and coordination of care.

• Ability to demonstrate patient-centeredness criteria, such as individualized care plans.

Source: “The Family Physician’s ACO Blueprint for Success; Preparing Family Medicine for the Approaching Accountable Care Era.”

Announcing the new CMS ACO Investment Model

ACO resources at TAFP.org

Apart from creating the right culture and engagement from participating physicians, the second most difficult hurdle to overcome when creating a physician-led ACO is probably amassing enough capital. RGVHA got into the Advance Payment ACO model, but they were among the last to board that train. The program ended not long after they joined, but CMS is opening a new avenue to capital for some new MSSP ACOs.

The Family Physician’s ACO Blueprint for Success

In October 2014, CMS announced the ACO Investment Model, which will provide upfront investments in infrastructure for eligible Medicare ACOs. CMS intends the program to encourage new ACOs in rural areas and places with little ACO penetration.

Eligible ACOs would begin participation in MSSP in January 2016 and would need to have a prospective Medicare beneficiary assignment of 10,000 or fewer. According to CMS, applications for the new ACO Investment Model will be available in the summer of 2015.

For more information, go to http://innovation.cms.gov/initiatives/ ACO-Investment-Model/

www.tafp.org/Media/Default/Downloads/ practice-resources/aco-guide.pdf

N

ow they are completing their second year of a three year MSSP contract, and the final announcement of their year one performance is just the latest and most empirical evidence of their success. The physician members of RGVHA are thriving, energized by the confidence that they are practicing better medicine and that their patients are healthier because of it. And the ACO is growing; as of January 2015, three more physicians are coming on board.

The quality data the ACO gathers details the improvement. ACOs in the first year of MSSP only have to show the ability to report necessary quality data and in the second year, they have to meet certain quality levels to qualify for rewards. But Bobbitt says the doctors at RGVHA have been keeping track internally and they are confident that they regularly reach the 90th percentile for most of the 33 quality metrics.

By staying on top of the data and looking for risk across their total patient population, the physicians have been able to identify the small portion of their patients who account for more than half of the ACO’s patient care spending and provide those patients with additional coor

www.tafp.org/practice-resources/ practice-redesign/aco

Developed by AAFP, TAFP, and several other state chapters, this two-part guide helps family physicians develop their strategy to evaluate and implement a successful ACO. Part One examines these new organizations and identifies essential elements, transcending specialty or facility to be applicable to all ACO stakeholders. Part Two applies the principles and processes of the guide specifically for the family physician.

ACO Legal Primer Mentioned in the Blueprint for Success as available upon request, the legal primer is now available to download. The information has been updated to include the guidance submitted by the federal regulators after the CMS ACO regulations were issued.

The Family Physician’s Practice Affiliation Guide From the strategic perspective of a family physician, this guide explores the reasons driving increased collaboration and affiliation, weighs the advantages and disadvantages of various affiliation options, and provides a detailed analysis of the hospital employment model.

dination. Bobbitt says that’s why he thinks the ACO will show even better performance in cost efficiency in 2014.

“The end result is that the patients are going to be better cared for,” Delgado says, “and we’ll be alerted in a much faster way when patients need to be brought in.”

“The amazing thing is your doctors are finally getting data in their hands,” Bobbitt says. “They’re finding out the high cost hospitals; they’re finding out the runaway home health costs.” When they recognize the outliers, they gather to plan ways to address them.

According to Delgado and the ACO’s medical director, Roger Heredia, M.D., care coordinators are another critical component to quality improvement. Bobbitt calls care coordinators the “secret sauce” of ACO success.

“By going to our patients’ homes and looking not just at their medical illnesses but looking at their surroundings, the environment in which they live, the care coordinators can really give us a heads up about things,” Delgado says. This is extremely important in reducing hospital readmissions, ensuring proper care when patients transition www.tafp.org

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2014 TAFP PAC donors Trisha A. Allamon, MD

Hattie E. Henderson, MD

Ichabod L. Balkcom IV, MD

Anne-Marie Herpin, MD

Maria Diana Ballesteros, MD

Robert L. Hogue, MD

Lee Hagar Bar-Eli, MD

Janet L. Hurley, MD

Justin V. Bartos, MD

Christina Marie Kelly, MD

Luis Manuel Benavides, MD

Kaparaboyna Ashok Kumar, MD

Stephen Douglas Benold, MD

C. Tim Lambert, MD

Alex J. Blanco, MD

Loren S. Lasater, MD

Henry Julius Boehm, Jr., MD

Francis R. Lonergan, MD

Lindsay Kathryn Botsford, MD

Leah Raye Mabry, MD

Emily D. Briggs, MD

Javier D. Margo Jr., MD

Matthew Alan Brimberry, MD

John M. McCullough, MD

Javier Moises Campos, MD

Ronnie A. McMurry, MD

Juan M. Campos, MD

Gary R. Mennie, MD

Chinglin Lillian Chan, MD

Nina Miller, MD

C. Mark Chassay, MD

Dale C. Moquist, MD

Victor Sostenes Chavez, MD

Mary Helen Morrow, MD

Samuel T. Coleridge, DO

James A. Murphy Jr., MD

Douglas Curran, MD

Mark Nadeau, MD, MBA

Kenneth Gayle Davis, MD

Nancy Naghavi, DO

Tamra K. Deuser, MD

Mary S. Nguyen, MD

Jorge Duchicela, MD

Stephanie D. Redding, MD

Tamarah L. Duperval-Brownlee, MD

Lee R. Schreiber, MD

Carolyn Eaton, MD

Amer Shakil, MD

Tricia C. Elliott, MD

Robert F. Shields, DO

Sheridan Scott Evans, MD

Linda Marie Siy, MD

Troy Treanor Fiesinger, MD

Mary Carmen Spalding, MD

Mitchell Frank Finnie, MD

Dana Sprute, MD, M.P.H.

Roger Neal Fowler, MD

Richard A. Stuntz, MD

Lewis Emory Foxhall, MD

Erica Williams Swegler, MD

Gregory Michael Fuller, MD

James R. Terry, MD

Kelly A. Gabler, MD

Todd A. Thames, MD

Melissa Susan Gerdes, MD

Ashok Tripathy, MD

Rebecca Hart, MD

Joel Trujillo, MD

Lisa Biry Glenn, MD

Thao Minh Truong, MD

Roland Adolph Goertz, MD

Lloyd Van Winkle, MD

John Edward Green, MD

Rosa Isela Vizcarra, MD

Thomas David Greer, MD

Andrew H. Weary, MD

Jay L. Gruhlkey, MD

David Clifford White, MD

Ajay Kumar Gupta, MD

Walter D. Wilkerson, MD

Natalia Gutierrez, MD

Robert Allen Youens, MD

Lesca C. Hadley, MD

Richard A. Young, MD

Clare Arnot Hawkins, MD, MSc

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“Unfortunately those doctors who are sitting on the bench are making a big mistake because the future of medicine has already been told.”

Roger Heredia, M.D. Medical Director, RGVHA

back home from a hospital stay, and sorting out medication confusion for complex patients.

The care coordinators also help review charts to monitor the ACO’s performance and adherence to the MSSP quality standards.

For a small ACO like RGVHA, this kind of personal integration is synergistic. It not only puts more eyes on the strengths and weaknesses of individual providers and processes so strategic adjustments can be made in a timely manner, but it builds on the culture of teamwork shared by the group.

Bobbitt says the end result is healthier patients and happier physicians. “You talk about the shared savings payment — that really is recognition of respect. It’s the empowerment of seeing happier, healthier patients and being unhandcuffed that is really fueling this for the doctors. … I think it’s as much a professional reward as it is an economic reward.”

“I’ve been practicing 24 years,” Delgado says, “and in that time, I’ve never seen an opportunity like this. I don’t know if there will ever be another opportunity like this.”

For RGVHA, taking this path has made all the difference, but ACOs are only one way family physicians and other primary care providers can address today’s tectonic shifts in health care delivery. All indications in the health care marketplace point to the ascendancy of valuebased medicine. In coming years, payers will increase their use of value-based contracts, quality metrics, and narrow networks.

“Unfortunately those doctors who are sitting on the bench are making a big mistake because the future of medicine has already been told,” Heredia says.

He and Bobbitt agree that doing nothing is a huge decision, which will most likely lead to what Bobbitt calls the “default future.”

“Do you think we’re going to raise taxes? Not going to happen. Do you think you’re going to limit access to care or limit benefits? That’s not going to happen. So the default future is less control, drastic fee cuts, and pretty much a miserable existence. You can either drive the train or you can sit on the track and get run over. Why not fix American health care, excise the waste from it and get paid to do it?

“I don’t think I’m exaggerating; we can save American health care this way.”

practice management

A necessary pain: E-prescribing controlled substances is worth it

By Kara Nuzback getting certified to prescribe controlled substances electronically is not easy, but it’s worth the trouble, says pain medicine specialist Cheryl White, M.D. Like many physicians, White wrote controlled substance prescriptions from her prescription pad for her patients at Brazos Pain Consultants in Sugar Land, Texas. But in March, a pharmacist notified her of a patient trying to obtain a controlled substance using her name and credentials. When the pharmacist noticed the phone number and address provided by the patient did not match White’s Texas Department of Public Safety profile, he called White to confirm the prescription and faxed her a copy of the paper document.

White says the prescription was fake; someone had manufactured a prescription pad using her name and credentials, including her medical license number, her Drug Enforcement Administration certifica

tion number, and her DPS identification number, coupled with a fake address and a phone number she later discovered linked to a prepaid, disposable phone.

In October 2013, DPS officially began allowing physicians to electronically prescribe schedule II controlled substances, such as Adderall, Ritalin, morphine, methadone, Oxycontin, Percocet, and now hydrocodone. The practice of electronic prescription of controlled substances for schedule II drugs became more commonplace in March 2014, after DPS completed a small pilot program to test the accuracy of reporting schedule II drugs to the Texas Prescription Program.

Sending prescription requests to a pharmacy through an electronic vendor helps reduce the risk of prescription fraud. But doctors who are using EPCS have encountered some challenges, including pharmacies not certified to accept the electronic requests. www.tafp.org

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Prescription fraud is a type of medical identity theft in which the perpetrator lifts a physician’s credentials from a prescription pad and uses them to obtain drugs illegally. Even if a pharmacist tries to confirm the prescription, the number provided on the forged document often connects him or her with the perpetrator, who poses as the physician in question and gives the pharmacist permission to fill the prescription.

“So simple it’s elegant,” White says. “These people are hijacking my credentials, manufacturing prescription pads, and going to town. The way we currently write paper prescriptions is tantamount to leaving blank checks all over town.”

As of May 2014, White says about 75 people across Texas had filled prescriptions illegally using her name. Worst of all, White says, she can’t make it stop. If she applied for new DEA and DPS numbers, the time it would take to obtain them would interrupt patient care.

According to the DEA Office of Diversion Control, a new DEA application can take four to six weeks to process.

“I have cancer patients and cannot potentially suspend their treatment for several weeks,” she says.

Although White works to help her patients manage pain, her predicament is not unique to her specialty. She says any physician who prescribes a controlled substance, such as an obstetrician-gynecologist prescribing hydrocodone after a cesarean section, is at risk.

The solution, she says, is for doctors to embrace EPCS. “If I’m going to prescribe controlled substances, I’d rather do it through a clearinghouse,” White says.

A Growing Problem White says she reported her case of prescription fraud to local police and sheriff’s departments, DEA, the Texas Legislature, and DPS. She has also informed the Texas Medical Board and the Texas State Board of Pharmacy about her predicament to avoid being blamed for violating the law.

“I’ve had a hell of a time getting law enforcement to give me any support. I’m not sure if it’s lack of knowledge on the part of law enforcement, lack of funding, or lack of interest,” she says. “It’s been expensive, it’s been very time-consuming, and it’s been frustrating.”

White says because people are using her information to cash in faulty prescriptions all over the state, the case involves multiple police jurisdictions, and, she says, the local departments do not collaborate well.

In addition, the perpetrators are hard to pin down, she says. The fake patient could claim he or she didn’t know it wasn’t White who provided the prescription, or the perpetrator could use a fake identity at the pharmacy, she says.

“These investigations are painstakingly slow,” she says. “And the criminals are always getting smarter.”

White personally called about 20 pharmacies in the Houston area to warn them against filling a prescription with her name on it that doesn’t match her actual phone number and office address.

“Through speaking with pharmacists and various sources in law enforcement, I’ve found that at least 25 to 30 physicians in the Houston area have had the same thing happen to them. I suspect there are many more who don’t even know that it’s happened to them because they never dreamed they might be vulnerable,” she says.

1 in 8 will become disabled for 5 years* or more...

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Physicians who suspect prescription fraud should notify DPS by calling (512) 424-7293 or e-mailing RSD_CES_Criminal@dps.texas.gov.

White says if you have the credentials to write a prescription for a controlled substance, you must safeguard those credentials.

“Generally, the pharmacists try to do the right thing,” she says. “But identity theft is so easy, and I’ve seen this problem becoming bigger every week.”

An Invasive Procedure DEA legalized EPCS nationally in 2010. The process for a doctor to become certified for EPCS is arduous and intrusive, says C.M. Schade, M.D., who specializes in pain medicine in Mesquite. Schade is a member of the Texas Medical Association Interspecialty Society Committee.

As a leader in pain medicine, Schade says he is participating in EPCS to help guide fellow physicians through the process. “At this point, it [the process] doesn’t work very well.”

First, Schade says, he had to purchase e-prescribing software from an EPCS-certified vendor. Purchasing and installing the software and completing training on how to use it took about a month.

According to the U.S. Department of Health and Human Services Health Resources and Services Administration, the stand-alone cost of an e-prescribing application can cost a physician up to $2,500 a year. However, a free e-prescribing application is available through the National ePrescribing Patient Safety Initiative.

Next, Schade says his software vendor, DrFirst, had to verify his identity. Physicians’ e-prescribing vendors typically use a third-party authentication service that requires physicians to provide detailed personal information, including credit reports, to confirm the physicians are who they

say they are. Only the third-party authentication service has access to the physician’s private information; the software vendor does not.

“They know everything about your identity,” Schade says. “They have more information than the credit bureau has. It’s scary.”

It took Schade about a week to complete the authentication process, which included answering detailed questions about his credit history.

“It’s not something you can do in a day,” he says. “It’s fairly rigorous.”

Once DrFirst verified his identity, Schade had to create two identifiers to use whenever he prescribes a controlled substance electronically. An identifier can be a password, a fingerprint, a retinal scan, or a token. Schade uses a hard token and a password.

A hard token is a pocket-sized electronic device. When physicians want to verify their identity, they push a button on the token that generates a number the physician enters into an e-prescription form within a short time frame, usually 30 seconds to a minute. A soft token works similarly but takes the form of a smartphone app.

After the vendor sent him a hard token, Schade says he wanted to give the process a trial run. He called 20 pharmacies near his office to see which ones could fill an electronic prescription for a controlled substance.

He says half of the pharmacists flat-out refused his EPCS request.

Of the pharmacies with EPCS-certified software systems, only 25 percent had actually filled a prescription of this kind, Schade says.

Walgreens and H-E-B Pharmacy are two chains that accept EPCS. Schade says physicians’ best bet is to call their local pharmacies and ask whether they have EPCS-certified software.

Individual pharmacists also may decide not to fill any prescription they choose. Schade says only one pharmacist of the initial 20 was willing to fill an electronic request for a schedule II controlled substance.

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“The way we currently write paper prescriptions is tantamount to leaving blank checks all over town.”

— Cheryl White, M.D.

Pharmacy Perspective On March 1, after completing a small pilot program with a select group of physicians and pharmacists, DPS released guidelines to aid accurate reporting of EPCS to the Texas Prescription Monitoring Program, which the Texas Legislature created in 1982 to track schedule II prescriptions. The law requires pharmacists to report schedule II prescriptions to the monitoring program within seven days of filling the prescription. (See “Helpful Links.”)

According to the guides, physicians using EPCS should take the following three steps to save time and improve security and patient safety: 1. Confirm with your e-prescribing software vendor that the software application is EPCS-certified per DEA requirements. Physicians can check health information network Surescripts’ website.

2. Confirm your software vendor has notified Surescripts that both the software and the prescriber have been certified and are eligible to transmit schedule II through V electronic prescriptions. If Surescripts is not notified, the transaction will be blocked before it reaches the pharmacy.

3. Understand that not all pharmacies are certified to accept EPCS transactions. This may result in the prescription being returned when a doctor attempts to transmit it electronically.

TMA is offering a free continuing medical education course on risk evaluation and mitigation strategies specifically for physicians who prescribe schedule II controlled substances. The three-hour course is presented by the Florida Medical Association.

Many pharmacists are reasonably skeptical about filling e-prescriptions for schedule II controlled substances. In June 2013, Walgreens entered into an $80 million settlement with the DEA after the agency charged Walgreens with failing to properly account for the sale of many narcotic painkillers. Walgreens has since changed its policy to require pharmacists to take additional steps to verify the identity of the prescribing physician when many controlled substances are involved.

Though Walgreens’ case was not specific to e-prescribing, pharmacist Dennis Wiesner, senior director of government affairs, privacy, and pharmacy for H-E-B, says the DEA’s recent crackdown on pharmacies has left many pharmacists second-guessing themselves when filling narcotic prescriptions.

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“You just become a little bit more cautious,” he says.

Wiesner says H-E-B, which installed EPCS software in its 240 Texas pharmacies more than a year ago, trains its pharmacists to look for red flags. He says the red flags apply to electronic and paper prescriptions and include: • Questionable drug combinations and quantities; • The physical distance between the prescribing physician’s office and the pharmacy, distance between the prescribing physician and the patient’s home address, and distance between the patient and the pharmacy; and • Cash payment.

Wiesner says if a patient asks him to fill 200 or more tablets of hydrocodone, or a combination of a popular “drug cocktail” such as hydrocodone, carisoprodol, and alprazolam, he will take further action to confirm the prescription. And if a patient has traveled a long distance to the pharmacy, it could be a sign that other pharmacies refused to fill the prescription.

When pharmacists encounter one of these red flags, they can call the prescribing physician to confirm the medication or search the patient’s DPS profile to look for signs of drug abuse.

Wiesner says prescription fraud also is a huge problem.

“Pharmacies encounter that every single day,” he says.

In these cases, he says, someone pretending to be a physician or office staff member calls the prescription in to the pharmacy outside normal business hours, or a patient brings in a paper prescription written on a stolen or duplicated prescription pad.

Pharmacists who fill these often see a surge in similar prescription requests either the same day or in the days immediately following, Wiesner says.

He says hydrocodone is high on the list of controlled substances that people try to obtain illegally.

“We trust pharmacists to use professional judgment,” he says. “I think our folks tend to err on the side of the patient when they can.”

Wiesner says EPCS is the most efficient way for physicians and pharmacists to keep controlled substances from people who would abuse them.

“It’s the safest route, 100 percent,” he says.

Wiesner says when a physician sends an EPCS to H-E-B, the prescription must pass through Surescripts, an intermediary that looks at multiple data, including the drug in question. Surescripts also checks to see if the prescribing physician’s EPCS software is DEA-certified.

If it is, the prescription is sent to an H-E-B pharmacy for processing.

If a physician’s EPCS system is not certified, Surescripts will push the prescription request back to the physician, instead of forwarding the request to the pharmacy.

Even with EPCS, Wiesner says, physicians should continue to expect calls from pharmacists who want to clarify and authenticate prescription dosages, directions, or drug interaction details. But ultimately, EPCS will help prevent prescription abuse and protect both pharmacists and physicians, he says.

Staying Vigilant Given White’s ordeal, she says e-prescribing is the safer route for physicians who want to avoid prescription fraud.

“But it’s going to be a lot more work,” she says. “It’s just so embryonic at this point.”

White says she believes EPCS will get easier, but in the meantime, physicians must be vigilant by getting to know their local pharmacists

and checking their DPS profiles and their patients’ profiles for signs of prescription fraud.

She says physicians who refuse to participate in EPCS and continue to prescribe controlled substances using a paper system should check their DPS profiles even more frequently.

Physicians must write all schedule II prescriptions on an official DPS prescription pad. A pad of 100 forms costs $9. Physicians can obtain schedule II prescription pads from DPS by faxing (512) 424-5380.

“I have also instituted an office policy that does not allow office staff to call in any controlled substances,” White says. “I usually check my own profile on a monthly basis, but I overlooked it for one month.

During that time: BAM!” Physicians can check their patients’ and their own profiles on the DPS prescription access website.

White says while it is a necessary resource, the DPS website is difficult to use. For example, only physicians, registered nurses, physician assistants, or licensed vocational nurses have access to the site. Other office personnel, even those with access to HIPAA-sensitive information, can’t access the site.

“This translates into considerable time required to perform appropriate searches on individuals attempting to procure prescriptions for controlled substances,” White says. “In addition, the website has the ability to track physician prescribing trends, so why can it not notify a physician in the event of activity on their profile, say by e-mail?”

Schade says EPCS is still a new practice, and it will take time to get more pharmacies to install or update software to be EPCS-certified.

“This is in its infancy. We expect there will be problems. Nothing just takes off,” he says.

Helpful Links The following websites will help ease your way through the process of e-prescribing and better protect you against prescription fraud: • Texas Prescription Program www.txdps.state.tx.us/rsd/PrescriptionProgram/index.htm • Electronic prescription of controlled substance guidelines for physicians and pharmacists www.texmed.org/uploadedFiles/Current/Practice_Help/ Technology/e-Prescribing/EPCStexas.pdf • Surescripts electronic health care network http://surescripts.com/ • Drug Enforcement Administration Practitioner’s Manual for controlled substances www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html • Department of Public Safety prescription access website www.texaspatx.com

He predicts it will take two to five years for EPCS to become a convenient way for physicians to safely prescribe medications.

“The world is moving forward. The technology is moving forward,” he says. “I have faith that e-prescribing will eventually become the standard of care.”

This article was originally published in Texas Medicine [Tex Med. 2014;110(7):55-59.] It is republished here with permission.

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foundation focus

2014 TAFP Foundation donors

Thank you to these 2014 TAFP Foundation donors, whose contributions fund scholarships for Texas medical students, family medicine research grants, and travel scholarships for residents to attend continuing professional development activities.

★ = TAFP Foundation monthly donor

★ Estela Mota, MD James A. Murphy, MD Jonathan Nelson ★ Mary S. Nguyen, MD Donald R. Nino, MD Salustiano A. Pino, MD Didier F. Piot, MD ★ Henry David Pope, MD Christine Ann Powell, MD Theron Dale Ragle, MD Duren Michael Ready, MD Leonel Reyes, Jr., MD ★ John R. Richmond, MD

AbbVie

★ Seth B. Cowan, MD

★ Natalia Gutierrez, MD

★ Shelley Poe Roaten, MD

Blue Cross and Blue Shield of Texas

Michael Avery Crouch, MD

★ Lesca C. Hadley, MD

Leon Rochen

ProAssurance

Douglas W. Curran, MD

★ Suhaib W. Haq, MD

★ Sarah Samreen, MD

Tarrant County AFP

Lilette Daumas-Britsch, MD

★ Rebecca Eileen Hart, MD

Ramiro Sanchez, MD

Texas Hospital Association

★ Kenneth Gayle Davis, MD

Bill and Gail Hartin

Lee R. Schreiber, MD ★ M. Sandra Scurria, MD

Ralph A. De La Rosa, MD

Steven J. Havener, MD

Texas Medical Liability Trust

★ Tamra K. Deuser, MD

Clare Arnot Hawkins, MD, MSC

Puja Anil Sehgal, MD

★ Jerry Abraham, MD, MPH

★ Chrisette M. Dharmagunaratne, MD

★ James Michael Henderson, MD

★ Robert F. Shields, DO ★ Zafreen Arfeen Siddiqui, MD

Texas Medical Association

Maria G. Dill, MD

★ Terrance S. Hines, MD

★ Trisha A. Allamon, MD

Lawrence Raymond Doty, MD

Anthony Holbert, MD, MBA

★ Linda Marie Siy, MD

Dale Crawford Allison, MD

★ Jorge Duchicela, MD

★ Farron Cheryl Hunt, MD

Howard Smith, MD

★ Tamarah L. Duperval-Brownlee, MD

★ Janet L. Hurley, MD

★ Mary Carmen Spalding, MD

Lee Janson, MD

Sunti Srivathanakul, MD

John C. Joe, MD, MPH

★ Donald E. Stillwagon, MD

★ David Arthur Katerndahl, MD

Geetha Subramanyam, MD

★ Christina Marie Kelly, MD

★ Paul and Erica Swegler, MD

★ Shelley Kohlleppel, MD

Douglas Bryan Szeto, MD

★ Kaparaboyna Ashok Kumar, MD, FRCS

James Alan Taki, MD

Ruben Aleman, MD

★ Erick Fernando Alvarez Mosqueira, MD

Carolyn Eaton, MD

Kent E. Anthony, MD Ichabod L. Balkcom, IV, MD ★ Maria Diana Ballesteros, MD ★ Tom Banning

★ Bruce Alan Echols, MD Clare Edman, MD ★ Tricia C. Elliott, MD Sheridan Scott Evans, MD

David T. Barr, MD

★ Robert Floyd Ezell, MD

★ Lynda Jayne Barry, MD

★ Troy Treanor Fiesinger, MD

★ Justin V. Bartos, MD

★ Cyrus Timothy Lambert, MD

★ Sheri J. Talley, MD

★ Don A. Lawrence, DO

Thuy Hanh Thi Trinh, MD, MBA, FAAHPM

★ Lewis Emory Foxhall, MD

Patrick Ys Leung, MD

★ Ashok Tripathy, MD

Edwin R. Franks, MD

Kathy and Paul Locus, MD

★ Thao Minh Truong, MD

★ Kelly A. Gabler, MD

★ Leah Raye Mabry, MD

Elenita L. Usher, MD

Jessica Garcia, DO

★ Javier D. Margo, MD

★ Lloyd Van Winkle, MD

Oscar Garza, MD

Linda Seitan May, MD

David B. Vaughan, MD

★ Melissa Susan Gerdes, MD

★ Kathy McCarthy, CAE

Andrew H. Weary, MD

★ Lisa Biry Glenn, MD

★ William Mike McCrady, MD

★ Sally Pyle Weaver, MD

★ Roland Adolph Goertz, MD

★ John M. McCullough, MD

★ Jim and Karen White

★ Emily D. Briggs, MD, MPH

Geraldine Gossard, MD

★ Gary R. Mennie, MD

Walter D. Wilkerson, MD

★ Chinglin Lillian Chan, MD

★ John Edward Green, MD

Donald G. Middleton, MD

★ Hugh H. Wilson, MD

★ C. Mark Chassay, MD

★ Thomas David Greer, MD

★ Carol and Dale C. Moquist, MD

★ Robert Allen Youens, MD

★ Samuel T. Coleridge, DO

★ Ajay Kumar Gupta, MD

★ Mary Helen Morrow, MD

★ Richard A. Young, MD

★ Aimee Lyn Flournoy, MD

David W. Bauer, MD, PhD ★ Joane Goforth Baumer, MD ★ Stephen Douglas Benold, MD Adrian Billings, MD, PhD ★ Alex J. Blanco, MD ★ Teddy and Henry Julius Boehm, Jr., MD ★ Lindsay Kathryn Botsford, MD, MBA

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A Asset protection An ounce of prevention

By Brad Wiewel The Wiewel Law Firm

Brad Wiewel is a board certified Texas estate planning attorney with The Wiewel Law Firm. Based in Austin, the firm assists clients with estate planning, asset protection planning, probate and trust administration, and business succession planning, among other things. Brad is the author of the Texas Asset Protection Handbook.

© 2014 The Wiewel Law Firm.

All rights reserved.

sset protection is something that many physicians, including family physicians, don’t focus on until they have been threatened with a malpractice lawsuit. I know, because I have had more than my share of telephone calls from frightened physician clients wanting to know if it is too late to do the planning I recommended when we met at my office to discuss their estate plans.

Unfortunately, the answer is, “It’s almost always too late.” You must plan to protect your assets from being taken before a claim against you is pending, expected, or threatened.

With that warning in mind, here is a number that may keep you awake at night: There are more than 100,000 lawyers in Texas. And while you may believe that recent changes in Texas law make you immune from lawsuits, you are wrong, because plenty of those attorneys are more than ready to take advantage of the legal loopholes available to their plaintiff clients. For example, recovery of damages, especially for loss of future earning capacity and other economic damages are not capped and can easily top millions of dollars. Adding to your potential risk is the fact that if you don’t believe you are at high risk for lawsuits, you may be poorly insured.

Many Texas doctors are.

You should also be aware that in my experience doctors are even more in danger of getting sued by their own partners over practice-related issues than they are for being sued by their patients, their patients’ families, and so on, and malpractice insurance does not cover claims arising out of such lawsuits. And finally, you, like anyone else, are always at risk for being sued over such things as car wrecks, homes accidents, and even dog bites.

While there is literally nothing you can do to prevent a lawsuit, there are any number of relatively simple things you can do ahead of time, and some more complicated things too, that will go a long way toward sheltering your assets from seizure if a lawsuit results in a judgment against you.

In other words, preventive medicine is an important concept in the law too.

First, purchase an umbrella liability policy. This kind of policy is sold in units of $1 million, and every physician should have one. The policy should protect your assets from most things outside your business and practice worlds, such as car wrecks and accidents in your home.

Second, increase your malpractice coverage and make sure you are with a solid carrier. I realize that malpractice insurance is not cheap, but it does two things: It pays for a very good lawyer to defend you if you are sued, and it can pay money to compensate someone you hurt.

Third, consider investing in assets that are already protected from seizure under the law. These include your homestead, retirement accounts, life insurance, and annuities.

Fourth, consider creating a Family Limited Partnership or Limited Liability Company to own your other, more valuable assets, like your stock portfolio, rental property, and farm, ranch, or lake house.

For the most part, assets in either of these two entities cannot be seized to collect on a claim that is the result of malpractice. The same holds true if the claim is the result of an auto accident.

For those of you who want even more robust asset protection, a Nevada or Delaware “On-Shore” trust is an increasingly popular way to achieve a very high level of immunity from lawsuits. Assets in these trusts are generally safe from all claims, even those related to alimony and child support.

And finally, going off-shore remains a viable option for those of you with very sizable estates and substantially larger risks.

Of course, it goes without saying that you should only work with a lawyer who is board certified in estate planning. This is a very complex area of the law with many unforeseen pitfalls. Doing your own asset protection planning or working with an attorney who “dabbles” in it can be disastrous.

Asset protection, just like certain medical procedures and medications, can seem expensive sometimes. But like so many things in life, it should be viewed as an investment, not an expense. Furthermore, the knowledge that you have comprehensive protection in place may be the best sleeping pill you can buy. Like they say, “an ounce of prevention is worth a pound of cure.”

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PUBLIC HEALTH

Celebrating 20 years of Hard Hats for Little Heads Story and photos by Samantha White

twice a year, downtown San Antonio streets close to vehicles, allowing community members a safe place to ride bikes, run, scoot, walk, and exercise. This event, Síclovía, encourages exercise and healthy habits to battle obesity. TAFP Past President K. Ashok Kumar, M.D., is faculty at the University of Texas Health Science Center at San Antonio and attends Síclovía each year along with medical students and residents. They give away bicycle helmets to kids, fitting them with the right size helmet and teaching them the importance of protecting their heads while biking. At this biannual event and others like it, Kumar suspects he has given kids thousands of helmets.

Kumar and physicians across the state give children free helmets every year through the Texas Medical Association’s Hard Hats for Little Heads program, a public health initiative created to prevent head injuries due to bicycle accidents. In honor of the 20th anni32

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versary of the Hard Hats program, TMA started 2014 with a goal of giving out the 200,000th helmet by the end of the year.

2014 also marked the 10th anniversary of TAFP’s involvement in the program. In those 10 years, TAFP has helped sponsor hundreds of Hard Hats events and given out over 26,000 helmets through family physicians like Kumar. To celebrate the Academy’s anniversary in the program, the TAFP Board of Directors approved extra funds for this year’s budget to allow more TAFP members to hold Hard Hats events.

Here’s how the program works: physicians sign up with TMA and order up to 100 helmets to be distributed at school safety demonstrations, community fairs, wellness visits, and other events. The TMA Foundation covers the cost of up to 50 helmets and TAFP covers the cost of an additional 50 helmets for our members, thanks to the generous support of the TAFP Foundation and the AAFP Foundation.

Top: Kumar invites medical students and family medicine residents to join him at local Hard Hats for Little Heads events. Pictured from left to right: Nakiuda Hall, Chrissy Binkley, Paul Linden, Kumar, Lucas Harvey, and Emily Jacobs.

Bottom: Kumar fits children for their free helmets to take home from San Antonio’s citywide Síclovía event.

Some physicians choose to keep the helmets in their offices and give them out over time at clinical appointments, while others attend community-wide events like Síclovía to distribute their helmets.

Kumar has been holding Hard Hats for Little Heads events and giving out helmets since the beginning of TAFP’s involvement in the program. He typically collaborates with other organizations like the Bexar County Medical Alliance, the TMA Medical Student Section, and the UTHSCSA Family Medicine Interest Group.

Kumar likes to invite his medical students to attend these events with him so they see what it’s like to be a family physician who is active in the community “The most important thing is for them to get involved in the community, because doctors are an important part of community,” Kumar says.

“Meeting people on the streets is an informal way outside the clinic setting to make them feel comfortable to ask questions. We want people to know that we as physicians and medical students in the community care about what they do. It is a two-way street, that people know about us and we know about the people in more intimate surroundings.”

The process to get helmets through the Hard Hats program is simple; physicians submit a request to TMA and once approved, the helmets are sent to the physician’s office or event location. TAFP members are sent “Family docs care 4 kids” stickers to put on helmets before giving them out. If you are holding an event and have not received your stickers and would like them to put on your helmets, contact TAFP’s Samantha White at swhite@tafp.org. Physicians interested in getting involved with the Hard Hats program can contact TMA’s Tammy Wishard at tammy.wishard@texmed.org. www.tafp.org

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PUBLIC HEALTH

Working to improve Texans’ access to health care in the 84th Texas Legislature

By Anna Chatillon Policy coordinator for the Texas Women’s Healthcare Coalition

the texas women’s healthcare coalition, of which TAFP is an active steering committee member, is a coalition of 47 health care, faith, and community-based member organizations. We are dedicated to improving the health and well-being of Texas women, babies, and families by assuring access to preventive health care for all Texas women. Access to preventive and preconception care — including health screenings and contraception — means healthy, planned pregnancies, and early detection of cancers and other treatable conditions. The TWHC was formed in response to the devastating legislative budget cuts to women’s health care in 2011.

Now that the prior level of funding has been restored, it is clear the restoration was only the first step toward ensuring that all women in Texas have access to the preventive care they need. Even now, only three in 10 women who need publicly funded health care have access to it.

Texas desperately needs to appropriate more funding for women’s health care in the next legislative session. The consequences of failing to provide women access are too

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high, both in human costs and in financial implications, for Texans to accept.

Myths and political controversy abound, but the facts are clear: most Texans and most doctors agree that women need access to preventive care and contraception. That access doesn’t come easy; contraception is expensive, causing 55 percent of 18- to 34-year-olds to struggle to pay for prescription birth control. This is especially true for the most effective methods, such as long-acting reversible contraceptives, or LARCs, which have 1/20th the pregnancy rate of oral contraceptives. When cost and information barriers are removed, 75 percent of women choose to use LARCs, yet many women are forced to choose other options because LARCs are expensive up front, despite being cost-effective in the long run. This is especially concerning because contraception is a smart financial investment. According to a 2014 report by the Guttmacher Institute, for every dollar invested in contraception, the state saves seven dollars.

State agencies in Texas are periodically reviewed for efficiency and effectiveness by the Sunset Advisory Commission. The Health and Human Services Commission — the umbrella under which women’s health care is housed — is under review this year. Despite the fact that the provider network in Texas has been through multiple rounds of upheaval in the last few years, the Sunset staff recommended that the three streams of state funding for women’s preventive care — the Department of State Health Services Family Planning Program, the DSHS Expanded Primary Health Care program, and the HHSC Texas Women’s Health Program — be combined into one program. Based in part on TWHC’s words of caution, the Sunset Commission recommended continuation of the current DSHS Family Planning program and consolidation only of the EPHC and TWHP programs. This adjustment will greatly help safety-net providers remain financially viable.

This is a critical juncture for women’s health care in Texas. The Texas Women’s Healthcare Coalition believes funding for women’s preventive health care should be increased. More provider training and appropriate reimbursement are needed to increase access to LARCs. The Sunset process must proceed carefully, with sufficient provider feedback and funding.

This session, Texas needs a strong voice for prevention, including contraception. Without that voice, Texan women are in danger of losing access to the care they need.

The Texas Women’s Healthcare Coalition continues to advocate for this important care, educating legislators about preventive care. We are grateful to the membership and leadership of TAFP for your outstanding support for access to women’s health care. For more information about TWHC, or to get more involved please contact Info@ TexasWHC.org.

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perspective

More than meets the eye: Value of small practices shouldn’t be ignored

By Lloyd Van Winkle, M.D. for years, we’ve been hearing about the decline — even death — of the small primary care practice, but I’m here to say that obituary is premature, if not flat-out wrong. When a recent study published in Health Affairs touted the value of small practices, I didn’t need convincing. I’m a small practice owner and have been for nearly 30 years.

The study found that primary care practices with one or two physicians had one-third as many preventable hospital admissions compared to practices with 10 to 19 physicians. The study also reported that smaller practices achieved their impressive results despite caring for a higher percentage of patients with chronic conditions than larger practices.

So how did the small practices in the study manage to have better results regarding preventable admissions (and likely lower costs) than their larger counterparts? The authors point out patients in smaller practices may have closer relationships with their physicians, which might offer greater insight into patients’ comprehensive health needs while facilitating ready access to care.

Patient-centered care, which includes enhanced access to care along with other elements, has become a focal point of the movement to improve our health care system in the past decade and, increasingly, is being embraced by small and large practices alike. Large practices, in particular, are likely to benefit from economies of scale that enable them to readily invest in health information technology and other organized care processes recognized as components of the patient-centered medical home model. And indeed, in this study, some of the larger practices appeared to use more such processes than the smaller practices, yet didn’t fare as well in keeping patients out of the hospital.

Clearly, there’s more to the story.

An abundance of evidence tells us that the PCMH can lower costs and improve outcomes. Just think: How much more could we bolster those outcomes if we combined the efficiencies of a Level 3 PCMH with the strengths and accessibility of a small practice?

Welcome to my small rural practice, which recently achieved Level 3 recognition from the National Committee for Quality Assurance.

Regardless of a practice’s size, there are hurdles to jump through on the way to PCMH recognition. The process can be overwhelming at the outset, and the AAFP has discussed the need to simplify the process with the NCQA and other such groups.

Although the process can be especially difficult for small practices, which lack the time, capital and resources of larger practices, it can be done. My two-physician practice achieved Level 3 recognition, from start to finish, in two years. We did it by working together with other small practices in our area, combining our efforts and resources.

The key, for me, was taking the process one step at a time, which made it seem more attainable. To that end, the AAFP has created a PCMH Planner to help practices of all sizes transform to the new model; that resource offers a step-by-step guide to follow.

I’m sure many small-practice physicians look at the PCMH checklist and think, “I’m already doing this. I’m already patient-centered.”

I was one of those docs. And I was wrong. That’s a difficult thing to realize, but my practice is better now than it was two years ago.

We’ve improved vaccination rates, lowered the number of missed screenings and made care more accessible.

I realize now that it’s important to be open to change and to always be looking for opportunities to improve. For example, I initially thought a patient portal — a requirement to achieve the recognition level we did — would be money wasted, but it’s actually changed the way I practice. Giving patients access to their individual records improved the overall quality of our data.

I’ve had patients point out mistakes in their records that were quickly corrected, and I even had one patient point out something we hadn’t billed for that we should have. One benefit I had not expected is that my patients who are hearingimpaired now communicate with my office more often and with greater ease through the portal.

For our patients, the quality of care we provide has improved; so what’s the payoff for the practice? BlueCross and BlueShield has agreed to a 5 percent payment differential for small practices in the group we are working with if they achieve Level 3 recognition. Four of the practices already are there, and six have Level 2 or Level 3 paperwork pending.

Moreover, my accountable care organization, which also is made up largely of small primary care practices, is in negotiations with two other payers to increase payment for those who have achieved PCMH recognition.

For years, payers marginalized small practices, which lacked the bargaining power of our larger counterparts, leading to more and more employed physicians and fewer and fewer small practices. But if those of us in small practices continue to prove our value, our future may be a lot brighter than anyone anticipated.

As the authors of that recent Health Affairs article noted, “Small practices have many obvious disadvantages. It would be a mistake to romanticize them. But it might be an even greater mistake to ignore them, and the lessons that might be learned from them.”

I’m sure many small-practice physicians look at the PCMH checklist and think, “I’m already doing this.

I’m already patient-centered.”

I was one of those docs. And I was wrong.

38

[No. 4 - 2014]

TEXAS FAMILY PHYSICIAN

Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.

7

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

FAMILY MEDICINE

FACULTY

OPPORTUNITIES

HOUSTON, TEXAS Baylor College of Medicine has excellent opportunities for Family Medicine Faculty interested in making a difference within our Faculty Group Practice and Community Health Centers. In addition to joining an outstanding group of physicians, these positions offer opportunities to participate in academic activities such as community-oriented research, medical student education, and resident teaching.

These positions include a faculty appointment with competitive salary, excellent faculty-level benefits, and the opportunity to play a key role in planning and implementing communitybased clinical services.

Desirable, but not required, skills include: an interest in education, public health, womenâ&#x20AC;&#x2122;s health and bilingual skills.

INTERESTED? CONTACT

ROGER J. ZOOROB, MD, MPH, FAAFP Professor and Chair Department of Family & Community Medicine 3701 Kirby Drive, Suite 600, Houston, TX 77098

Roger.Zoorob@bcm.edu 713.798.2555 bcm.edu/departments/family-andcommunity-medicine

Baylor College of Medicine is an Equal Opportunity/

Please apply on line:

Affirmative Action/Equal Access Employer

https://www.medschooljobs.org