TEXAS FAMILY PHYSICIAN VOL. 71 NO. 3 2020
Priorities For The 87th Texas Legislature
The Primary Care Marshall Plan A Five-Point Plan To Transform Health Care In Texas
NEW FROM CDC
HIV Nexus offers a comprehensive collection of key federal resources on COVID-19 and HIV. More than half of HIV clinicians are primary care providers. To support health care providers managing patients with HIV during the COVID-19 pandemic, the Centers for Disease Control and Prevention has compiled these resources to: • Address concerns related to COVID-19 and HIV. • Provide guidance to health care providers managing people with HIV. • Highlight how people with HIV can protect their health.
To access COVID-19 and HIV resources for your practice and patients, visit:
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INSIDE
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TEXAS FAMILY PHYSICIAN VOL. 71 NO. 3 2020
6 FROM YOUR PRESIDENT The resilient nature of family physicians
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8 PATIENT CARE Family physicians’ role in lung cancer care
The Primary Care Marshall Plan: A five-point plan to transform health care in Texas
With the 87th Texas Legislature due to convene in January, TAFP lays out its legislative priorities in a new report that details proposals designed to repair and rebuild a stronger, more resilient health care system prepared for future public health crises. By FTI Consulting and the Texas Academy of Family Physicians
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AI in the exam room
AAFP Innovation Lab pilot tests a digital assistant that promises major reductions in clerical work, better doctor-patient relationships, and improved practice profits. By Brian Justice
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Why EHR integration can no longer be your only marketing investment
Tips to make your integrated EHR platform work for you. By Sandra Scott 4
TEXAS FAMILY PHYSICIAN [No. 3] 2020
10 MEMBER NEWS Thompson wins top AAFP education award | Two TAFP members selected for AAFP emerging leader institute | FMIG Programs of Excellence announced 30 PERSPECTIVE Direct primary care: A light in the darkness
PRESIDENT’S COLUMN
TEXAS FAMILY PHYSICIAN VOL. 71 NO. 3 2020
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
Javier D. “Jake” Margo, Jr., MD
president-elect treasurer parliamentarian
Amer Shakil, MD, MBA
Mary Nguyen, MD Emily Briggs, MD, MPH
immediate past president
Rebecca Hart, MD
EDITORIAL STAFF managing editor
Jonathan L. Nelson
associate editor
Jean Klewitz
chief executive officer and executive vice president
Tom Banning chief operating officer
Kathy McCarthy, CAE
advertising sales associate
Audra Conwell
CONTRIBUTING EDITORS Kissi Blackwell, MD FTI Consulting, LLC Brian Justice LuCa National Training Network Sandra Scott
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. 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. © 2020 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6
TEXAS FAMILY PHYSICIAN [No. 3] 2020
The resilient nature of family physicians By Javier “Jake” Margo Jr., MD TAFP President 1. Be kind to yourself. greetings colleagues! Even though it 2. We should measure happiness in hugs, is pretty much a cliché at this point, I just handshakes, and smiles. have to say: Wow, what a crazy year. As the 3. Show yourself some compassion. summer has both flown by and simultaneously seemed to last an eternity, I have We all need more of this in our lives, found myself thinking a lot about resilience. so please find some time to focus on your Even in the constant tumult of 2020, our health and well-being. Seek out the joy in members across the state and all over the everyday life. Go for a walk at sunrise or country have adapted, learned new techsunset. Listen to the birds and watch the nologies, and implemented new processes rabbits play. We often get to try to keep their clinics so locked into the next open for their patients. thing, the next task, the Certainly for some, next chart to complete, that proved impossible, Amid all this next bill to pay that we and it may be months upheaval, one thing the forget to take a moment before we know the true I’ve realized is that I and enjoy just being alive. damage done to our On another note, we primary care infrastrucam enjoying having have some exciting events ture by COVID-19. Yet we more time to spend and projects on the horiknow so many family phywith my family, zon at the Academy. As sicians are finding ways you know, the 87th Texas to make it through and while spending less Legislature will convene to continue to take care time out on the in January. In preparation, of their communities. We road. We’ve taken TAFP commissioned a have circled the wagons and battened down the more walks together report from FTI Consulting, an independent global proverbial hatches. We and had more time business advisory firm, are cautiously exploring to talk. I hope that to study the impact the what actions and activities COVID-19 pandemic has are safe in our schools is true for all of you had on Texas’ health care and our communities. We as well. system. We recently pubare moving forward with lished the report, and you hope and optimism. can read it in this issue of Amid all this upheaval, Texas Family Physician. one thing I’ve realized is that I am enjoying The report, “The Primary Care Marshall having more time to spend with my family, Plan: A Five-Point Plan to Transform Health while spending less time out on the road. Care in Texas,” lays out specific actions that We’ve taken more walks together and had policymakers should take to reimagine and more time to talk. I hope that is true for all transform how primary care is funded and of you as well. delivered to improve the health and ecoIn July I had the pleasure of attending — nomic productivity of Texans, reduce overall virtually, of course — the Wilderness Medihealth care spending, and prepare us for cal Society’s summer conference. One of the future public health emergencies. Early this association’s founders, Paul Auerbach, MD, year, Speaker of the House of Representaof Stanford University School of Medicine tives Dennis Bonnen appointed a select comgave the keynote address, and in the spirit mittee to study health care costs during the of resilience, I want to share three bits of legislative interim. The recommendations in wisdom I took away from his presentation.
this new report should inform the work of the interim select committee. The fivepoint plan recommends the state should: • Lead the way for primary care payment reform by changing the existing transactional RVU-based, fee-for-service model to a prospective payment model that supports continuous, comprehensive and coordinated care; • Decrease the rate of uninsured Texans through innovative market-based solutions; • Enable physicians and other health care providers to continue adapting to the digital age by supporting regulatory and payment changes that ensure appropriate use of telemedicine; • Ensure that all Texans have access to primary care by aligning state appropriations with Texans’ current and future health care needs; and • Develop effective public health workforce and surveillance capacity through a new kind of community health worker and full integration and interoperability of health care data across all levels of government. There’s no question that this pandemic has shown us in stark relief the fissures and cracks in our broken health care system. It has also crystalized our need to transform the way we pay for and deliver care. For months we have written about the need for a Marshall Plan for our primary care and public health infrastructure. COVID-19 has given us a roadmap to repair and rebuild a stronger, more resilient system so we can be prepared for future health crises. We believe our elected leaders have an unprecedented opportunity to redesign our health care system so it truly serves Texans and the professionals who care for them, and we hope this report will help guide them. Finally, as I’m sure you’ve heard, we’re taking this year’s Annual Session and Primary Care Summit virtual. We’ll be offering up to 13.75 CME credits for your streaming enjoyment on November 6 and 7, so go to www.tafp.org for more information and to register. Our Annual Business Meeting and Member Assembly will take place on October 24 at 9 a.m. Central Time on Zoom. All members are welcome and you can register for that on TAFP’s website as well. I hope to see you online!
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PATIENT CARE
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TEXAS FAMILY PHYSICIAN [No. 3] 2020
lung cancer is the leading cause of cancer deaths in Texas — more than breast, prostate, and colorectal cancers combined. The good news is that annual lung cancer screening with low-dose computed tomography, or LCS with LDCT, allows for lung cancer to be diagnosed at earlier stages than in the past. Most importantly, up to 80% of people with screen-detected lung cancer can be cured. Despite United States Preventive Services Task Force recommendations for LCS with LDCT in high-risk individuals and CMS coverage since 2015, Texas ranks below average for LCS among high risk individuals, with only 1.7% of those eligible receiving screening with LDCT, according to the American Lung Association. Provider discussion and referral can have a tremendous impact on screening participation. “In one study, 82% of patients reported that they would undergo LDCT lung screening if recommended by their physician. Another study found that approximately 85% of LCS-adherent patients reported ‘trust in their provider’ as a reason for undergoing screening,” according to a 2019 study in the Journal of the National Comprehensive Cancer Network. Studies have shown that lung cancer patients receive treatments at lower rates than other cancer patients, regardless of stage of diagnosis. And despite decades of research into tobacco use treatment, many providers still lack the knowledge of best approaches to assist patients in their attempts to quit smoking. As a family physician, your involvement in risk reduction, screening, and treatment is critical for reducing the burden of lung cancer. Training, resources, and tools can help you address the needs of your patients who are at risk for or living with lung cancer. The LuCa National Training Network at the University of Louisville provides free lung cancer training and materials for family physicians and other healthcare professionals. LuCa’s online course, “Lung Cancer and the Primary Care Provider” is the first of its kind to educate providers
on lung cancer care across the continuum, including lung cancer screening, tobacco cessation, shared decision making, treatment advances, patient follow-up, and survivorship care. The comprehensive and innovative online course is video-based, features animated demonstrations, includes three separate lessons, and offers participants up to 2.5 Prescribed continuing medical education credits by the American Academy of Family Physicians. The course was developed with input from family physicians across the United States, as well as lung cancer screening and treatment specialists to help you: • Have more success with patients’ tobacco cessation in less time; • Follow the latest recommendations for lung cancer screening; • Receive appropriate reimbursement for shared decision-making discussions; • Know how to follow-up on screening results; • Be aware of treatment options to answer patients’ initial questions if diagnosed; • Collaborate more effectively with treatment specialists; and • Provide optimal care to your patients during and following cancer treatment. Enroll in the free online course today at www.lucatraining.org/course. LuCa’s website also provides an expansive resource library with more than 300 articles and tools for physicians and their patients; information on upcoming training opportunities, as well as recordings of recent webinars; and technical assistance for health systems, state cancer coalitions, provider organizations, and others interested in engaging physicians and other health care providers around lung cancer topics. For more information about LuCa’s online training course, tools, or other services, visit www.lucatraining.org, email lucatraining@louisville.edu, or call (844) LUCA-NTN.
MEMBER NEWS
TAFP student and resident members selected as scholars for the AAFP Family Medicine Leads Emerging Leader Institute Luci Li, MD, and Jessica Williams were selected as 2020 scholars for AAFP’s Family Medicine Leads Emerging Leader institute. Li is in her second year of training at the John Peter Smith Hospital Family Medicine Residency Program in Fort Worth. Williams is a third-year medical student at UT Health McGovern in Houston. The Family Medicine Leads Emerging Leader Institute is a project of the AAFP Foundation. It aims to increase the number of well-trained future family medicine leaders by offering a yearlong leadership development training opportunity to family medicine residents and medical students.
TAFP, AAFP name FMIG Program of Excellence Award recipients The family medicine interest group at the University of Texas Medical Branch was recently recognized by AAFP and TAFP for their exemplary efforts to grow and support interest in family medicine. They were one of 18 medical school family medicine interest groups to win the 2020 AAFP Program of Excellence Award and received the second place 2020 Texas FMIG Program of Excellence Award. TAFP’s subcommittee from the Commission on Academic Affairs also selected the University of Texas Southwestern Medical School’s family medicine interest group as the first-place recipient of the Texas FMIG Program of Excellence Awards. The University of the Incarnate Word School of Osteopathic Medicine’s family medicine interest group won the third-place award.
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TEXAS FAMILY PHYSICIAN [No. 3] 2020
TAFP member awarded with AAFP’s highest honor, the Thomas W. Johnson Award for Career Contributions to Family Medicine Education By Jean Klewitz clerkship for all medical students at UTMB barbara l. thompson, md, of Galveston, a and helped to create UTMB’s rural training professor and family medicine department track in Weimar, Texas, providing residents chair at the University of Texas Medical with first-rate integrated rural training. Branch at Galveston, was awarded the 2020 She is known for her boundless energy, AAFP Thomas W. Johnson Award for Career her organization and collaboration skills, Contributions to Family Medicine Educaand her willingness to take on the difficult tion. The award recognizes individuals who challenges in family make extraordinary medicine education. contributions to She has also been family medicine praised for being education in undera servant leader. A graduate, graduate, great example of and continuing her leadership is education spheres. when Galveston was In a congratuladevastated by Hurtory letter, AAFP ricane Ike in 2008. recognized her long, Thompson remained distinguished career, in the hospital with a where she has small group of health inspired countless care professionals family physicians to care for those in and made valuable need throughout the contributions to storm. A colleague family medicine’s notes that Thompacademic mission. son was “a rock when “You were a family Barbara Thompson, MD a rock was needed.” medicine pioneer While traditionin Texas, helping to ally she would have establish the state’s been presented with her award during the first department of family medicine as a in-person Congress of Delegates, this year medical student at UTMB and eventually Thompson’s remarks will be posted on the becoming the chair of that very departAAFP website and referenced during the ment. Having devoted years to curriculum virtual meeting. development and educational administra“I am overwhelmed and so honored tion, you have left an indelible mark on to be among the company of wonderful UTMB,” the letter said. family medicine teachers who have won this In addition to her years of service within award. Teaching has been integral to my TAFP, Thompson has served on commitentire career and I thank all those teachers tees for the Texas Medical Association, the who were my role models and challenged National Board of Medical Examiners, and me to keep trying to improve. I am so forthe American Board of Family Medicine. tunate to be able to continue working with In 2017 she received the TAFP Presidential medical students and residents who inspire Award of Merit for her individual contribume every day,” Thompson says. tions to health care in Texas and she was Thompson received her medical degree recognized by the UTMB School of Medifrom the University of Texas Medical cine Alumni Association with the Ashbel Branch at Galveston, and her undergraduSmith Distinguished Alumnus Award for ate degree from the University of Texas at her outstanding service to the medical proAustin. She also completed her residency in fession and humanity. family medicine at the University of Texas Thompson designed and implemented Medical Branch at Galveston. a required third-year family medicine
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CAN ARTIFICIAL INTELLIGENCE HELP REDUCE ADMINISTRATIVE HASSLES IN THE DOCTOR’S OFFICE? AAFP Innovation Lab pilot tests a digital assistant that promises major reductions in clerical work, better doctor-patient relationships, and improved practice profits By Brian Justice
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aptops are not known for their bedside manner. According to the AAFP’s annual member satisfaction survey, the administrative burdens posed by EHRs make them more of an impediment to patient care than a useful tool. A machine stands between — or interferes with, rather — patients and their doctors, who are facing enough troubles these days. This clerical burden takes up more than half of physicians’ time while, simultaneously, practices are being forced to adapt to population-based care and alternative payment models. Enthusiasm for one’s chosen profession falls as financial risk to the practice rises. Artificial intelligence that does not optimize the character of family medicine impedes the physician and degrades the patient experience. Andrew Carroll, MD, a family physician in Phoenix, Arizona, voiced a common complaint. “We were looking for a solution to help us get data into the notes. We tried various voice-recognition software options, including Dragon Medical, obviously, and some of the built in Apple tools to dictate directly into a laptop, but they just became untenable,” he said. “So, we were still doing a lot of work after clinic because we were trying to recall the histories and physicals of patients we saw up to 10 hours prior.”
“Today’s EHRs have eroded the experience rather than enhancing it,” said Steve Waldron, MD, MS, AAFP vice president and chief medical informatics officer. “Our vision is to help family physicians care for patients while using health IT that works for them, not against them.” Ideally, family medicine is based, and thrives, on profound patientphysician interactions. But technology isn’t going anywhere, and neither is the long-standing and ever-growing need for technology developed and implemented specifically for the family medicine environment. Pilot program development for dramatic change In October 2018 the Academy board authorized a 42-month special project to address issues around EHRs. Designed to drive innovation in family medicine, address administrative burden, improve value-based care delivery, and start a long-term conversation with AI and machine learning communities, the goal was to make family medicine a true partner in driving the agenda in that space, especially when it comes to clinical notes. Clinical notes are now being used in billing, coding, reporting, legal uses, and more, and to address this cumbersome fact of life for the family physician, the Academy partnered with Suki AI for a pilot program. www.tafp.org
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“I can say that I have literally reduced my work after clinic by about 90%. I used to spend three or four hours after work, just finishing notes and stuff. Now, I’m doing it for 15 minutes to 30 minutes and I’m done. It’s really wonderful.” — Andrew Carroll, MD
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TEXAS FAMILY PHYSICIAN [No. 3] 2020
“We scoured Silicon Valley and other places looking for solutions that had demonstrable improvements; not in the 5% to 15% range… we wanted improvements of up to 70%,” Waldron said. “Suki was chosen for several reasons. The company was founded with the goal of helping physicians spend more time caring for patients and less time on administrative tasks.” The goal, according to Nathan Gunn, MD, and chief operating officer of Suki, is “to develop a virtual physician’s assistant that can take care of the scut work, and help doctors focus on what they went to medical school to do: take care of patients.” Creating a solution from the physician perspective Finding the right IT partner was as crucial to this endeavor as finding the right group of physician partners. Punit Soni, Suki’s founder and CEO, spent seven years with Google before serving as VP of product management for the company’s Motorola division, but he wanted to build something of his own. He decided to develop a digital assistant for physicians that combines artificial intelligence and voice-enabled technology. “I was shadowing a family physician in a hospital,” Soni said. “I was amazed to see all the clicking of boxes and how feverishly they were putting everything together.” It seemed to him that a sophisticated group of professionals had been reduced to data clerks. To ensure that the next generation of health care technology was truly relevant, he determined that the product must be developed not only with the end users in mind, but with physicians actively participating in its creation. “A key aspect of a product like Suki digital assistant is having a keen understanding of doctor workflows,” he said. “How does the doctor practice medicine?” Digital assistants fall into a new category of products designed to reduce the burden of documentation. They are somewhat akin to Alexa or Siri, using voice recognition, natural language processing and AI that listens, learns, and adapts to a practice. And in practices unable to afford additional human resources, the relief offered by eased clerical and documentation burdens can be immeasurable. Suki was chosen for several reasons. Its nature aligned with the goals of the initiative and was already being actively and successfully marketed to primary care and family physicians. It is easily adaptable and does not require new hardware; it is an app that can be downloaded and used on an iPhone or, for Android users, the Chrome browser. The pilot program was conducted on the athenaOne EHR because it was already in use by physicians currently using Suki, which made its adoption and implementation quick and easy, and it came at a reasonable price. To sum it up, it was already integrated, readily adaptable, rapidly implemented, and affordable. “Athena’s model involves real partnership with the practice to generate revenue,” Waldron said. “They are open to innovation that will help decrease administrative burden while increasing the quality and services that physicians provide in their practices.” More time with patients, less screen time Suki does not replace the laptop, but it does end the non-stop typing. The physician tells the Suki digital assistant what to document in the note, and Suki includes the ability to pull information from the patient’s record. Not every bit of data will be available, so the physician will still need to look things up. But the constant typing while trying to record every note during a patient visit will be reduced, if not eliminated. “While I’m in the room with the patient I can do a prescription or make a referral, then step outside the room and dictate for maybe
a minute, getting everything down on Suki’s built-in templates, so I don’t have to dictate the entire exam,” Carroll said. “So, I can go to my next patient right away and my relationship with both patients has been enhanced. I can spend the time with them that I would have spent worrying about the administrivia that I would normally have had to do afterwards.” Suki also utilizes machine learning, meaning that it is not simply listening to a sound and trying to convert it to a word. Its intuitive capabilities include understanding words and placing them within context. It also understands and incorporates punctuation. “In the beginning it was a little slow, then it pretty quickly learned how we spoke and how we dictated,” Carroll said, speaking for his three-person office. “Also, two of us have distinct accents, but within a few days Suki was able to recognize that and quickly became pretty much error-free.” The software is updated in all but real-time. Humans monitor flagged notes, correcting them if necessary and ‘teaching’ Suki in the process. “So, the model is continually being retrained, which they have to be because we are continually learning new things,” Waldron said. “If you had said ‘COVID-19’ in early 2019, it may not have known what that was. Now, because it’s in common use, it knows exactly what it is and how to incorporate it into the EHR.” Dramatic improvements in both efficiency and quality The results of the pilot program have aligned perfectly with the goals set by the Academy. Participating physicians recorded a 62% decrease in documentation time per patient, a 51% decrease in documentation time during clinic, and a 70% decrease in after-hours charting. “I can say that I have literally reduced my work after clinic by about 90%,” Carroll said. “I used to spend three or four hours after work, just finishing notes and stuff. Now, I’m doing it for 15 minutes to 30 minutes and I’m done. It’s really wonderful.” Every participant noted a dramatic increase in their satisfaction with notes completion, time savings, and EHR use for other administrative tasks, and across the board they found it most useful with notes that required anecdotal or complex history and assessments. “In medicine, we talk about being able to follow someone’s thought process from reading their notes, especially early on when you’re a resident,” said John Abraham, MD, of Tulsa, Oklahoma.
“With Suki I can actually document my thought process, and when I go back to my notes I can see why I changed the medicine, or didn’t start one just yet. I feel that if someone had to take care of my patients when I wasn’t around, there would be good explanations and directions for them to follow.” The platform is available on a subscription basis, with no upfront setup fees or long-term contracts, and users have automatic access to updates and improvements. In fact, early on in the pilot program, user feedback could be incorporated within 15 minutes to an hour. By the end of the program, those changes were made in nearly realtime. “That’s one of the nice things about the subscription model,” Waldron said. Technology so good, you don’t even notice it “We were thrilled with the pilot results and excited to roll out Suki to a larger cohort of doctors,” Gunn said, and a Phase 2 study has begun with the participation of 100 physicians. “Our view is that AI does not have to ‘replace’ or take over key diagnosis and treatment decisions from providers to transform health care delivery. Ultimately, the goal is for Suki to function like an outstanding resident, following you on rounds without needing any commands to be issued by the physician. Our mission here is to develop technology so good you don’t even notice it.” The cohort of doctors in the Phase 1 study was small, but they are extremely pleased across the board. “I’ve been using Suki for just over a year and it has become indispensable to me,” Abraham said. “I’ve become very accustomed to the flow I’m able to maintain, which helps me prioritize things that I like to get done in a certain order and not take too much work home with me.” More will be known after the completion of Phase 2, but the Academy’s assumption is that AI-based digital assistants are going to become an essential technology. “I anticipate big things and more growth, and I hope that other providers have a similar experience,” Abraham said. And whether the ultimate solution comes from Suki or another tech firm, the pilot programs are providing dynamic and robust solutions for family physicians. More importantly, they are driving the development of other product innovations that meet the unique needs of family medicine.
www.tafp.org
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Preparing for the 87th Texas Legislature
The Primary Care Marshall Plan A five-point plan to transform health care in Texas Report by FTI Consulting and the Texas Academy of Family Physicians
About FTI Consulting | www.fticonsulting.com FTI Consulting is an independent global business advisory firm dedicated to helping organizations manage change, mitigate risk, and resolve disputes: financial, legal, operational, political and regulatory, reputational and transactional.
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T
he COVID-19 pandemic exposed critical weaknesses in our fragmented health care system. Years of underfunding primary care and public health at the federal, state, and local levels left Texas’ health care system ill prepared to handle the ongoing national health crisis. The pandemic also laid bare health disparities among low-income Texans, particularly Texans of color, who prior to the arrival of COVID19 experienced higher rates of maternal mortality, chronic disease, and mental illness. COVID-19 made explicit how our public health system fails to overcome social determinants of health. Inconsistent access and quality, high costs, and inequities have long plagued our health care system. Yet decades of research makes clear that a strong primary care system gives patients continuous access to a primary care physician, and in result, helps them stay healthy, identify and manage chronic conditions and avoid expensive emergency settings and other costly downstream medical interventions. As we continue fighting the first wave of COVID-19, reimagining how primary care is funded and delivered can improve the health and economic productivity of our citizens, reduce overall health care spending, and prepare us for future public health emergencies. Just as the aftermath of war offers an opportunity to rebuild, the devastation COVID-19 wrought on our health care system and our economy gives us the opportunity to rebuild a better, more cost-effective system of care. And just as the historic investments made under the Marshall Plan after World War II enabled European countries to rise from the ashes of war, today we need a Primary Care “Marshall Plan” to tackle the state’s most pressing health care problems. The entire nation must learn lessons from COVID-19 and rebuild our health care system based on those. Yet, as often is the case, Texas holds unique advantages, challenges, and opportunities for immediate action. State policymakers should seize the chance to fix shortcomings, build a more effective, equitable health care system, and prepare the state for future public health crises. This five-point plan lays out the specific actions that policymakers should take to transform the Texas health care system through improved access to primary care.
I. PROMOTE COMPREHENSIVE PAYMENT REFORM AND TRANSITION AWAY FROM FEE-FOR-SERVICE When COVID-19 first emerged in the U.S., local stay-at-home orders and widespread fear kept patients at home, and revenues from in-person visits to physician practices shrank. Most practices embraced telemedicine, but virtual visits did not generate enough revenue to cover operating expenses. Because most primary care practices keep less than two months of cash on hand, the pandemic financially devastated these small businesses. With the pandemic far from over, primary care practices remain economically tenuous. Among practices that have fared better, many had previously moved away from a fee-forservice payment model — where physicians are paid based on the number of services provided, or the number of procedures ordered — to a prospective payment system. Health care spending trends are linked to the way we pay for care and incentivize health care providers. Fee-for-service payment systems reward physicians who deliver high volume, high-cost services while undervaluing comprehensive, continuous, and coordinated primary care services. That payment structure has for decades contributed to the rising cost of health care in Texas and across the country. A report by the Texas Comptroller’s Office found that health care spending rose by an average of 19.7% annually from 2011 to 2015, comprising 43.1% of Texas’ state budget in fiscal year 2015. At the same time, reimbursement for high value, cost-effective primary care services has significantly declined relative to high-cost imaging and surgical procedures. Care coordination and patient navigation has been reimbursed inadequately, if at all. Today experts across the political spectrum agree that reforming the way we pay for care to incentivize quality over quantity could contain ballooning health care costs and improve patient outcomes. During the first wave of COVID-19, practices that depended on patient volume suffered financially. By contrast, physicians operating under prospective payment systems remained viable businesses and nimble in the care they provided their patients during this unprecedented challenge. The difference offers a stark contrast and present-day case study for some of the pitfalls of fee-for-service care and the advantages of alternative payment models.
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IMPACT OF COVID-19 ON PRIMARY CARE PRACTICES A June survey of about 500 clinicians by the Larry A. Green Center and the Primary Care Collaborative found 63% of primary care practices were experiencing severe or near severe stress, 5% were either temporarily or permanently closed, and 39% needed to layoff or furlough clinicians or staff. This marks an improvement from the end of May, when 14% of practices were temporarily closed, 1% were permanently closed, and 56% had a significant decrease in patient volume. Over a quarter of practices received financial support from the federal government, yet the stress factors persist.
Physicians operating under prospective payment systems are generally paid a set amount per patient rather than per service. The payment covers a defined set of services and is issued at regular intervals, typically monthly. This approach is not new; in fact, the Centers for Medicare and Medicaid Services already uses a prospective payment model in the Medicare program for acute care hospital inpatient stays. The payment model is one of the hallmarks of success for Medicare Advantage plans. State Medicaid programs, including a handful of managed care organizations in Texas Medicaid, also use prospective capitated payments in managed care. Similar to products like Netflix, prospective payment models offer consumers subscriptions to different platforms, with different content and price structures. While there are numerous prospective payment models, partial capitation — in which physicians are paid a set payment amount for a fixed set of services and take on some risk to keep their patients healthy — is where primary care physicians can thrive. Prospective payments reward strong care management and better continuity of care for patients, incentivize physicians to keep patients healthy, and are proven to improve quality while reducing spending. If the state embraced prospective payment, the health care system’s foundation, primary care, would be on better financial footing, able to address everyday needs of patients and respond to public health emergencies. To encourage adoption of prospective payment systems in Texas, lawmakers should: 1. Engage private employers and local governments. In Texas, 47% of individuals receive health insurance through their employer. Over the last decade, employers’ insurance costs rose almost 51%. In 2018, employers paid $15,159 on average in premiums for a family of four. Moving to prospective payments would reduce costs for companies across the state by improving care coordination and patient outcomes. The same applies to local and municipal governments insuring their employees. Texas legislators should create a multi-stakeholder working group to implement a voluntary prospective payment model for primary care physicians. The group should include representatives from business groups, state health agencies, private insurers, primary care physicians, and consumers. COVID-19 has taught us lessons and created momentum for reform. While individual insurers and employers can adopt this model on their own, the ability to design and scale a cohesive prospective payment strategy without fear of anti-trust violations is critical. The Legislature should protect this group’s freedom to collaborate without fear of antitrust violation by including antitrust protections in statute. 18
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Such collaboration and protection are not unprecedented; a number of other states are already tackling cost, quality and payment reform. In 2011, the Washington State Legislature established the Dr. Robert Bree Collaborative, which created a mechanism in statute for both public and private stakeholders to work together on health care quality, outcomes, and cost effectiveness. Each year, the governor of Washington appoints members to a workgroup representing public and private health care purchasers as well as plans, physicians, and quality improvement organizations. The group identifies areas of high variation in care delivery and cost, and then makes recommendations to the Washington State Health Care Authority to inform the state’s purchasing decisions for Medicaid and the Public Employees Benefits Board Program. While the recommendations are nonbinding, the Bree Collaborative is an example of successful collaboration to represent diverse interests. This working group also benefits from antitrust protection and immunity from federal antitrust laws through the state action doctrine, as granted by the state legislature. Governors across the country are exercising their executive authority to lower health care costs while promoting high-value care. As of February 2020, 21 governors outlined plans to improve health care affordability and quality in their state. In addition to working with the Legislature, Gov. Abbott should establish a workgroup or collaborative to prioritize these issues. 2. Encourage state-funded health plans and Medicaid to implement prospective payment. Texas should institute a legislative or budgetary directive requiring Texas’ Employees’ Retirement System and Teachers’ Retirement System to offer prospective payment and other alternative payment options to interested primary care physicians and clinics. Collectively, these plans cover more than five million Texans. Additionally, ERS and TRS should be encouraged to offer some form of direct contracting for primary care services as a benefit option. New Jersey and Nebraska recently implemented direct primary care in their state health plans. While the programs are relatively new, both states expect savings and improvements in health outcomes as a result. Texas Medicaid already requires Medicaid managed care plans to promote value-based payment arrangements, including prospective payments, among network physicians. Small physician practices often struggle to implement such systems because they lack the technical expertise and financial resources. Texas could facilitate broader adoption of alternative payment models among primary care physicians by implementing a monthly per-member, per-month payment to offset upfront costs of practice transformation, better aligning Medicaid performance and outcome measurers with other payers, paying for care coordination and chronic care management, and promoting physicianled accountable care organizations to help organize and support independent physician practices with data analytics, care coordination and other key elements of value-based payment arrangements.
II. MARKET-BASED APPROACHES TO DECREASING THE UNINSURED Relative to the federal government, states have wide latitude to individually test and implement new health care coverage initiatives for their populations, which may in turn demonstrate national applicability. As the second most populous state in the country, Texas has that power in higher measure.
Experts across the political spectrum agree that reforming the way we pay for care to incentivize quality over quantity could contain ballooning health care costs and improve patient outcomes. During the first wave of COVID-19, practices that depended on patient volume suffered financially. By contrast, physicians operating under prospective payment systems remained viable businesses and nimble in the care they provided their patients during this unprecedented challenge. Prior to the pandemic, 18% of Texans lacked health care coverage — twice the national average. However, since February that number has grown significantly, with an estimated 660,000 more Texans losing employer-sponsored coverage. Insurance coverage helps individuals mitigate financial hardship caused by medical needs and expands their access to physicians. Without coverage, many individuals end up in emergency departments for preventable conditions because they avoid or are unable to access routine medical care. Moreover, this population often faces food insecurity and lack of transportation, examples of what are known as social determinants of health — non-medical factors that contribute to poorer health outcomes and higher costs. Many Texans with health insurance coverage are underinsured — their out-of-pocket health care costs (excluding premiums) are more than 10% of their income, or 5% for those who are below 200% of the federal poverty level. As such, underinsured individuals often avoid or delay care due to costs. Finally, Texas is geographically diverse with a significant number of rural communities. For rural Texans, long distances to urban health care centers limit residents’ access to both primary care and specialists. Similarly, Texans living in urban areas may struggle to obtain primary care when it is not conveniently located close to home or work. Ensuring access to primary care and the coordination of medical care for all these vulnerable populations can help save Texas valuable health care dollars while also improving health outcomes. With the anticipated renewal of its Medicaid 1115 Transformation waiver, as well as other federal flexibilities to make health care coverage more affordable, opportunities abound to put forward a proposal to the Centers for Medicare and Medicaid Services to test innovative delivery system and payment models to improve access to care for all Texans. Legislators should consider market-based solutions available to support care for these groups including: 1. Creating a tailored solution to expand Medicaid. The Medicaid program is an important safety net for low-income adults in Texas. Legislators should reconsider expanding Medicaid under the Affordable Care Act to take advantage of federal incentives and curb the state’s climbing uninsured rate due to the COVID-19 pandemic. Expanding Medicaid in Texas would provide 1.5 million lowincome working Texans access to health care coverage. At the same time, Texas has considerable flexibility to design a program best suited for its population, including designing the benefit package and establishing patient cost-sharing. Increasingly, policymakers on both sides of the aisle recognize the pressing need to expand health care coverage and support access to care among vulnerable, low-income populations.
2. Pursuing innovative, market-based approaches to reduce the ranks of the uninsured. Apart from Medicaid, a handful of innovative and market-based approaches could decrease Texans’ uninsured rate. Legislators should examine existing programs and consider how the state’s 1115 Medicaid Transformation waiver could be used to support vulnerable populations lacking insurance. Community Accountable Care Organizations As Texas seeks to renew and reimagine its Medicaid waiver, set to expire in 2022, the state should aim for a community-centric model focused on an inclusive delivery system that fosters participation by physicians, hospitals, and other health care providers interested in serving the population. Consider the Community Accountable Care Organization model, which organizes a varied network of health care providers under a single, community-based board. The model, employed in Washington, Oregon, Colorado, and North Carolina, uses value-based payment approaches to improve population health, a holistic model to address social determinants of health alongside medical issues. Ideally, Texas would implement the model statewide, but a preliminary step could be to pilot select Community ACOs in cities and towns across the state. The Dallas County Medical Society has proposed one city-specific example of a community ACO, the Dallas Choice Plan, which would establish a partnership with the local Parkland Health and Hospital System as a starting point. Legislators could consider this plan as a model to build upon. Charity Care Programs Charity-based programs like Project Access coordinate care for at-risk individuals. Similar programs are proven to improve care and lower spending. Under the Project Access program, a group of physicians and other health care workers joined forces with program coordinators and community clinics to provide charity care for a set number of vulnerable and low-income patients each year. Patients gained access to a care team who ensured they received follow-up care and assistance with transportation and translation services. These care coordination services lowered hospital costs by 60% compared to similar patients outside the program. Unfortunately, Dallas Medical Society discontinued Project Access in 2013 due to funding constraints. Legislators should consider reestablishing this program statewide. Rural Community Health System In 1997 Texas legislators authorized the Rural Community Health System, establishing a nonprofit insurance entity governed by a community board of rural physicians, hospital administrators, employers www.tafp.org
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and community leaders. By banding together as one insurance entity, these networks could compete against bigger, urban networks, or Medicaid managed care, thus keeping dollars spent on health care within their communities. Legislators should consider this existing framework to support Texans in rural communities. 3. Fostering direct contracting for primary care services. Texas should foster direct contracting for primary care services through direct primary care. In the DPC model, a physician is paid monthly, quarterly, or annually by an individual or employer to treat all or most of a patient’s primary care needs. DPC is growing in popularity because it prevents unnecessary interventions, promotes transparent pricing, and helps patients better manage their conditions and prevent complications, especially the chronically ill. After implementing DPC through Iora Health, workers in the Las Vegas Culinary Union experienced lower inpatient admissions by 37% and lower health care spending by 12%, compared to control groups outside the practice. Through DPC, Atlantic City hotel workers reduced their total health care spending by 12.3%. In both Las Vegas and Atlantic City, fewer hospital admissions, emergency room visits, and outpatient procedures explained the considerable savings. DPC is not considered health insurance and therefore does not enjoy the federal tax advantages of traditional health plans, so costeffective implementation remains challenging. Because individuals still require emergency or specialty care not offered by a primary care practice, as well as protection from catastrophic health care costs, employers often offer DPC to supplement other insurance plans. A model including DPC must be paired with more affordable coverage options for purchasers to recognize substantial savings. To increase access, Texas should create an avenue to allow for the sale of catastrophic insurance coverage when offered in combination with DPC. Generally available only to those under 30, Texas could develop a pilot program through a 1332 State Relief and Empowerment Waiver to classify catastrophic coverage purchased in conjunction with DPC as qualifying health coverage for individuals of all ages. The pilot could determine whether this combination structure leads to improved access to care, improved health outcomes, and lower overall costs. 4. Greater regulatory power and data collection to promote a competitive, transparent, consumer-friendly health insurance market. Texans deserve a competitive health insurance marketplace, and this is possible when the market is transparent and consumer friendly. As consolidation means health care markets become concentrated, research suggests that prices rise and health outcomes suffer. To protect competition, Texas might look to California where legislation gives the state Attorney General the authority to regulate mergers among nonprofit health care systems. Furthermore, the California AG is also seeking greater authority to regulate for-profit health care systems. Texas legislators should empower the state AG with both of these authorities to ensure a competitive marketplace and protect consumers. Consumers can also enable a more competitive marketplace when they are equipped to shop for care based on price and quality. That is why Texas should work toward a statewide all-payer claims database, or APCD, a centralized database that collects medical, pharmacy, and dental claims data from public and private sources. This data is used by researchers and policymakers to identify and launch initiatives 20
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to improve quality and health outcomes, while also lowering costs. Among a broader consumer audience, patients can use the APCD to discover how much services cost across physicians, providers, facilities, and locations while shopping for health care. The largest claims database in Texas is currently the Center for Health Care Data housed at the University of Texas School of Public Health in Houston, which collects health care utilization data for almost 80% of Texas’ population. Today, the data center’s capabilities are limited by the volume and type of data that they receive; private insurers are not required to provide the center claims data. To implement a robust APCD, Texas should leverage the existing infrastructure at UT Health and designate the Center for Health Care Data as the state’s official APCD and require all payers to report claims data. By doing so, the state would empower consumers to actively shop for care in a competitive, transparent marketplace.
III. ACCELERATE THE TRANSITION TO TELEMEDICINE Once considered a tool to connect rural patients and small physician practices and community clinics with specialists, COVID-19 has demonstrated the broad applicability of telemedicine for both patients and physicians. Texas distinguishes between telemedicine and telehealth. Videoconferences, telephone calls, and remote monitoring programs connecting patients and physicians are all considered telehealth. Telemedicine refers to a subset of telehealth that specifically addresses medical care, diagnostic, and prescription writing services. Primary care practices that adeptly integrated telemedicine services during the pandemic fared better than those that didn’t. Despite arguments that promoting virtual care could lead to increases in health care use, telemedicine has been shown to save as much as $1,500 per visit by keeping patients out of the emergency department. In certain specialties like primary care, increased telemedicine use is associated with decreases in overall health care spending and hospitalizations. Historically, virtual care models for payment and use vary widely across the country, and even within state lines. The COVID-19 pandemic transformed the telemedicine landscape, with public payers and private health plans expanding covered services and allowing for payment parity between in-person and virtual visits. The market research firm Arizton projects that the telehealth market will experience 80% year-over-year growth due to COVID-19. A survey by FTI consulting finds that this trend is unlikely to reverse, with 51% of Americans reporting they are more likely to use telemedicine options, even after the pandemic subsides. COVID-19 led to the adoption of telemedicine at an incredible pace, but it also exposed shortfalls of its predominantly fee-forservice payment system and demonstrated that telemedicine works best when provided in the context of an existing patient-physician relationship. Under these circumstances, physicians and patients were able to transition seamlessly into a new care modality, in many cases made possible by the flexibility provided under a prospective payment model. Many recent reforms to telemedicine payment and coverage remain temporary. Lawmakers must take steps to ensure ongoing telemedicine access in Texas after the present public health emergency subsides. As noted above, prospective payments give physicians the flexibility to transition to new care modalities like telemedicine without upending their business operations. Physicians engaged
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Prior to the pandemic, 18% of Texans lacked health care coverage — twice the national average. Since February that number has grown significantly, with an estimated 660,000 more Texans losing employer-sponsored coverage. Many of these individuals end up in emergency departments for preventable conditions because they avoid or are unable to access routine medical care. Moreover, this population often faces food insecurity and lack of transportation, examples of social determinants of health. in alternative payment models prior to the public health emergency were able to overcome initial financial stresses caused by the pandemic. According to a Premier Inc. survey, 82% of alternative payment model participants were able to leverage care management supports to manage their COVID-19 patients while only 51% of those in fee for service were able to do the same. Payment policies, like prospective payments for primary care, help physicians focus on caring for their patients without anxiety over reimbursement for a particular modality. Texas legislators should act to implement and push for prospective payments for interested primary care physicians and practices. Legislators should: 1. Adopt Medicare’s telehealth flexibilities for consistency and alignment to ease administrative burden for practices. Many physicians treat patients covered by various insurance plans, and do not differentiate between sources of coverage when working to care for their patients. When ERISA, commercial or state-based plans do not align with the nation’s largest payer, Medicare, physicians spend precious hours pursuing reimbursement from different payers. During COVID-19, many payers aligned their policies with Medicare, which helped ease administrative burdens on physicians. Current policies should be made permanent, like the allowance for patients to receive telehealth services in their home; coverage and payment parity for telephone evaluation and management services; coverage of e-visits and virtual check-ins; and documentation flexibilities that mirror the 2021 Medicare changes, which allow physicians to classify visits based on total time or medical decision-making. 2. Adopt telehealth policies that are integrated into a patient’s usual source of primary care, rather than restricting telehealth access to designated telehealth partners. Research shows that patients with regular access to their primary care physician have lower overall health care costs and improved health outcomes. Telehealth can enhance the doctorpatient relationship and improve patient and physician satisfaction. Physicians can grow familiar with patients when seeing them in a home setting, learning information unavailable during an inperson visit. When telehealth services are provided by physicians lacking a relationship with a patient, such as through a third-party platform, those benefits are lost. Texas should encourage payers to adopt telehealth policies that support established relationships between a patient and their primary care physician, ensuring continuity of care. 22
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3. Recognize that telehealth is a part of many methods to deliver care, not a standalone modality. Telemedicine is not just a point of care solution; it is one tool in a toolbox available to providers to help patients maintain and improve their health. It is an excellent option to deliver care, but it should not be the only source of communication between patients and physicians with an existing relationship. The success of virtual care can vary based on a patient’s personal needs, something their primary care physician is best fit to assess. Texas should discourage telehealth-only benefit plans, which eliminate a crucial component of care. Instead, payers should alter payment structures to incentivize continuous coordinated care.
IV. RECALIBRATE AND OPTIMIZE TEXAS’ PHYSICIAN WORKFORCE When the ranks of primary care physicians increase, mortality rates from heart disease and cancer fall, along with overall health care costs. Additionally, primary-care-based coordination of care keeps patients out of costlier settings, like the emergency room. Unfortunately, the U.S. suffers from a shortage of primary care physicians, and demand outpaces supply. Texas is on track to experience a shortage of 7,442 primary care physicians (family medicine, general internal medicine, OB-GYN, and pediatrics) by 2032, with 128 counties designated as full Primary Care Health Professional Shortage Areas, and 14 as partial HPSAs. The solution lies in vital programs encouraging medical school graduates and other health care professionals to work in primary care and underserved areas. To strengthen the primary care workforce in Texas, legislators should: 1. Increase opportunities for participation in the Physician Education Loan Repayment Program. In 2009, the Texas Legislature enhanced the state’s Physician Education Loan Repayment Program by changing the way smokeless tobacco is taxed. Legislators dedicated a portion of that tax revenue toward paying off the debt of new medical school graduates who went to work in underserved Texas communities. According to the Association of American Medical Colleges, 76% of medical students graduate with debt. In the U.S., the average cost for four years at a public medical school is $243,902. For private medical schools, the cost is $322,767. According to an AAMC 2019 survey, of the medical school graduates who borrowed money to fund their education, 53.5% borrowed between $150,000 - $299,000, a level of debt that preempts many graduates from working in the communities where they are needed most.
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Many states and localities, including Texas, still lack the resources necessary to successfully contact trace and track the disease as the economy reopens, which heightens the risk and potential severity of future outbreaks. Chronic underfunding of public health across the U.S. led to this outcome. Over the last 10 years, 56,000 public health positions were cut from state budgets and spending for state public health departments has declined by 16% per capita.
Under the PELRP plan, in exchange for a commitment to practice for four years in a HPSA and to participate in Medicaid and the Children’s Health Insurance Program, physicians are eligible to receive up to $180,000 to pay off their educational debt. In the past five years, 775 physicians have enrolled in the program and today care for patients in rural and urban communities, federally qualified health centers and other health care deserts. And yet, despite the PERLP program’s success, the Legislature has diverted funding from the program and limited participation. Instead, the Legislature should increase funding, maximize participation in the program, and renew its commitment to increase access to care for Texans in rural and underserved communities. 2. Support recent expansion in family medicine residency training by appropriately funding the Family Practice Residency Program. Texas operates 36 nationally accredited family medicine residency programs, which train the next generation of family physicians. A combination of federal and state monies sustains these programs, which have been funded for decades through the Texas Higher Education Coordinating Board. Although many of these programs receive some benefit from federal Direct Graduate Medical Education and through their sponsoring institutions, dedicated Coordinating Board funds are the only direct state support they receive. In 2017, the Texas State Legislature cut the Family Practice Residency Program, or FPRP, by 40%, reducing its annual budget to just $5 million. With the passage of Senate Bill 18 in 2015, the Legislature expanded residency training capacity, including five new family medicine residency programs. While commendable, the expansion, coupled with funding cuts in 2017, thinned FPRP per-resident funding even more. In 2017, the FPRP provided residency programs with $10,728 for each of the 761 family medicine residents in training. In 2021, it will provide only $5,485 per resident for 874 family medicine residents. This program works. The most recent Texas Higher Education Coordinating Board Budget Strategy notes that 70% of family physicians who complete their residency in Texas practice in the state. The Legislature should increase funding to the Family Practice Residency Program to the annual level of at least $10,000 per resident. 3. Support physician-led, advanced care team models The COVID-19 pandemic has demonstrated the success of multidisciplinary, integrated and team-based care. Advanced care team models improve patient care and population health by redis24
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tributing clinical and administrative functions, enhancing patient engagement, improving collaboration, and streamlining processes. The model reinforces an interdependent, team-based approach, and empowers non-physician staff to use their skills, training, and abilities. The evidence is compelling. Practices report benefits including increased productivity and capacity to accept new patients, improved performance on quality measures and increased patient and staff satisfaction. When Texas emerges from COVID-19, the state’s policymakers should support team-based care and a prospective payment model to foster more advanced team-based care models to increase access to high quality, efficient care.
V. SPOT THE NEXT PANDEMIC: LEVERAGE PRIMARY CARE FOR FRONT-LINE SURVEILLANCE When the pandemic hit the U.S., public health officials recommended officials deploy surveillance to identify when COVID-19 arrived in the country, contact trace the disease to try to contain its spread, and identify the start of community spread of the virus once containment was no longer an option. Unfortunately, surveillance was slow in the U.S. Many states and localities, including Texas, still lack the resources necessary to successfully contact trace and track the disease as the economy reopens, which heightens the risk and potential severity of future outbreaks. Chronic underfunding of public health across the U.S. led to this outcome. Over the last 10 years, 56,000 public health positions were cut from state budgets and spending for state public health departments has declined by 16% per capita. Kaiser Health News and the Associated Press investigations found that budget cuts loom for public departments across the country, despite the pandemic. For example, in Brazos County, Texas, funding constraints may force health officials to restrict the county’s mosquito surveillance program, and to cut as many as one-fifth of the health department’s staff. Along with public health funding, the national community health care workforce is also diminishing. Before the onset of COVID-19, almost half of public health workers in the country had planned to retire or leave their organizations over the course of the next five years. Texas urgently needs to replenish its public health care workforce, and creative solutions are in sight. Capitalizing on the unique position of primary care physicians and their staff, who already help public health officials track both emerging and existent diseases, can help public health officials
mount an effective response to COVID-19. Under normal circumstances, primary care practices should operate as the first line of defense against preventable health conditions. Many of these physicians already partner with federal and local public health systems to monitor the prevalence and spread of infections and chronic illnesses such as influenza or diabetes. Yet, challenges and silos persist regionally and technologically. Better integration is critical. To promote public health monitoring, Texas lawmakers should: 1. Leverage clinical and administrative staff for case investigation and contact tracing to support larger population health. During the COVID-19 pandemic, states are in dire need of case investigators and contact tracers. Public health workers remain crucial to federal and state re-opening efforts and will be needed for months to stop the spread of the virus. Texas actively seeks individuals to work as case investigators and contact tracers and both local and state health departments have identified public health students, medical students, retired physicians, and others to fill these roles. Contact tracers have always been an integral part of public health. They can be trained to connect with community members, assess their medical needs and provide solutions. This role is very similar to population health management programs staffed by community health workers who, instead of identifying individuals with COVID-19, look for individuals who may have undiagnosed, chronic conditions such as heart disease, diabetes or asthma in members of the public. Given the crossover between community health workers and contact tracers, Texas could pilot a hybrid approach where workers are recruited and trained simultaneously to do both jobs. Administrative and other ancillary health care staff are well-qualified candidates. During the pandemic, many physicians’ offices were forced to furlough staff due to reductions in in-person visits of as much as 60%. These health care workers are still essential to the health system, and those working in primary care practices already interact with individuals in the community daily. Texas could train furloughed medical workers to be contact tracers during a pandemic, and also to be population health surveillance workers under normal circumstances, operating out of their primary care offices of employment. Payment for these services could be included in a care management fee, like CMS Chronic Care Management Services codes, or included in a global prospective payment. Managing chronic conditions successfully is in the best interest of all payers to prevent higher costs should conditions be left to go undiagnosed or untreated for a long period of time. Outside of Medicare, private payers could consider integrating chronic care or population health surveillance into the services requested under a prospective payment agreement.
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2. Consolidate Texas’ IT infrastructure into one public interoperable health information exchange. Texas’ network of five regional health information exchanges, or HIEs, were designed to help providers securely share and exchange clinical health information and enable patients to access their health data electronically. HIEs help improve the quality and efficiency of health care services by reducing errors and unnecessary services while enhancing coordination among health care providers and the government. For example, Healthcare Access San Antonio became a MACRA Qualified Registry in 2017, allowing providers to more easily report and fulfill Medicare reporting requirements for certain incentive programs. Much of the momentum behind the regional
Supported in part by a grant from the American Academy of Family Physicians Foundation.
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exchanges was spurred by the federal HITECH program, which promoted the adoption of health information technology. As this program evolved over time, and incentives changed, most of these exchanges became privately operated at the expense of statewide coordination and interoperability. Today, of the original 18 HIEs funded by the HITECH program, only five are still functional. The Texas Health Services Authority operates a public HIE as a publicprivate partnership and oversees the work of the remaining five HIEs. Texas should establish one statewide, interoperable, and centralized HIE to connect every component of the health care delivery system from physicians and hospitals, to social service organizations, to public health tracking programs. The HIE would aggregate information from all the existing systems to decrease administrative burdens across providers, streamline public health reporting, and ensure that all patients have one, complete medical record. In addition, a key function of the HIE would be bidirectional information exchange. ImmTrac2, a Texas program, is one example of an exchange that allows patient records to be shared seamlessly between an electronic health record and state HIE and vice versa. Legislators should incentivize payer and provider participation in this centralized public HIE with the understanding that payers could use it alongside the state. Ultimately, the HIE could deliver a higher level of care and more streamlined information sharing to millions of Texans. This HIE should include a centralized disease reporting system. Currently, state and local health departments are responsible for collecting communicable disease data to conduct public health surveillance and lead responses. However, health departments in Texas face data sharing obstacles, which restrict their ability to coordinate. In its 2019 annual report, the Texas Health and Human Services Public Health Funding and Policy Committee called for a targeted disease reporting system to help local health departments, or LHDs, and the Texas Department of State Health Services collaborate on disease surveillance. A centralized statewide electronic disease reporting system could streamline reporting by providers to LHDs and between LHDs and the state. Texas already reports to the CDC’s National Electronic Disease Surveillance System; yet, when physicians and other providers need to report communicable diseases, they are responsible for filling out separate reporting forms and sending them to the LHD, often via antiquated systems such as the fax machine. For ease of transfer and usability, the shared data’s format should be interoperable with DSHS systems. Such a system could prepare Texas for the next public health emergency. 3. Restore funding to the state’s Office of Minority Health Statistics and Engagement. People of color experience higher rates of COVID-19 due in part to higher incidence of underlying health conditions, including asthma, heart disease, and diabetes. To understand how certain medical conditions disproportionately affect minority populations, Texas needs more robust data to give lawmakers a fuller picture. To the detriment of all Texans, statistics about health disparities are routinely underreported or under-investigated, including those related to COVID-19. Data has shown that COVID-19 hospitalization rates are higher among Native American, Hispanic, and Black individuals when compared to their white counterparts. Health care advocates and legislators in Texas have raised alarms that while Black Americans have been disproportionately impacted by COVID-19, the state has not explored why or to what extent. 26
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Texas once had an office devoted to that work – the Office of Minority Health Statistics and Engagement, which sought to study and address racial inequities in health care. When the office was still active, its staff used community-based research to identify disparities and fix them. For example, data showed higher rates of encounters with Child Protective Services over medical neglect issues in communities of color. The office engaged local community members and found that transportation and scheduling issues caused the disparity. The problem was addressed and the number of Texas mothers who forwent medical care for their children decreased. The Texas Legislature should re-establish this office to improve access to care for minority populations, provide greater insight into the racial inequities they experience, and promote health equity.
CONCLUSION COVID-19 exposed the ways that our health system fails patients. The pandemic revealed flaws in our payment systems, demonstrated how our rules and regulations inhibit technological progress in health care, and highlighted how our public health surveillance system is inadequate to contain the spread of disease. But COVID19 has also given us a roadmap to repair and rebuild a stronger, more resilient system prepared for future public health crises. The pandemic proves that under the right conditions, high-value care and technological innovation can flourish. We see now how a strong public health and primary care workforce is the linchpin to meeting Americans’ health care needs. Texas should not waste this opportunity. This five-point plan paves the way for Texas to reform and improve our health care system. Texas should: • Lead the way for primary care payment reform by changing the existing transactional fee-for-service model to a prospective payment model that supports continuous, comprehensive, and coordinated care; • Decrease the rate of uninsured Texans through innovative market-based solutions; • Enable physicians and other health care providers to continue adapting to the digital age by supporting regulatory and payment changes that ensure appropriate use of telemedicine; • Ensure that all Texans have access to primary care by aligning state appropriations with Texans’ current and future health care needs; and • Develop effective public health workforce and surveillance capacity through a new kind of community health worker and full integration and interoperability of health care data across all levels of government. While Texas remains focused on containing the spread of COVID19, the Legislature and the state executive branch can take bold steps to not only improve our costly, fractured health care system, but also ensure the state emerges from this pandemic stronger and better equipped to fend off the next public health crisis. Texas has the resources and leadership to build a better future for its citizens. It is time to lay the foundation. The views and opinions presented are solely those of the authors and the Texas Academy of Family Physicians and do not necessarily reflect the views of FTI Consulting, Inc., or other organizations with which the authors are or have been affiliated.
PRACTICE MANAGEMENT
Why EHR integration can no longer be your only marketing investment By Sandra Scott
T
he implementation of electronic medical records and electronic health records ushered in a new era of digital communication between physician and patient. Although we can reflect upon the merits as well as the disadvantages of these systems, the fact remains that the most recent data from the CDC shows that almost 86% of office-based physicians use them. Given the adaptation of this technology, how can it best serve your practice goals, and should it be your only investment in marketing your practice? DO MORE WITH YOUR INTEGRATED SYSTEM The adoption of EMRs and EHRs not only provided a valuable opportunity for practice physicians to securely share electronic information with patients and other clinicians, it also provided an opportunity for innovation – integrated systems. Integrated systems offer scheduling, billing, practice management software, referral management, patient portals, and so much more. Given increasing demands on physicians, these integrations have proven to increase practice efficiencies as well as reduce costs overall. However, more is required of your integrated system if your practice is going to survive and thrive in the next normal. In the fall of 2019, I spoke with a highly successful and well-regarded physician who wanted to expand the practice and increase patient census. However, this physician also did not want to invest in any additional marketing efforts for fear of “negatively affecting patient volume,” given the investment in the practice’s existing integrated system. The idea that additional marketing efforts would thwart an existing integrated platform is errant. Your integrated platform can do more to advance your patient census than push notifications to confirm or cancel an appointment. Examine the capabilities of your existing platform. Are you using it to its fullest beyond appointment reminders and billing? Do you have an integrated plan which supplements your EHR integration and effectively markets your practice both online and off to your current and future patient population? Does your integration provide you with tools that aid you in making informed decisions about next steps in your practice’s growth? As regulatory changes brought about EHRs, thus affecting practice management, so too did the pandemic. Before COVID-19, practices relying solely on integrated platforms to deliver a better patient
experience or increase census were leaving opportunities for growth in both areas on the table. The sole reliance on an integrated platform will serve no purpose to increase patient volume unless you make the system work for you. One way to maximize your integrated EHR platform is by optimizing your patient portal. In 2019 CMS approved five new reimbursement codes, which allow physicians to be paid for remote patient monitoring including e-visits. Depending upon your platform, you can offer e-visits through your patient portal for established patients. It’s important to ensure your patients are aware of and have access to the patient portal for your practice. Not only does this feature allow for a better physician to patient relationship, it places your patients in control of their treatments, provides them with access to their health information, and is one way you can increase patient engagement, compliance, and satisfaction. PRO TIP #1: Make your integrated platform work for you to increase patient census by investing in your website. Ask your agency to analyze your site’s performance pertaining to page views, sessions, users, acquisition, and bounce rates, and to provide suggestions for month-overmonth improvement. Pay special attention to keyword performance and how your practice ranks among your competitors. If your integrated system is tied to your website, you can review click-to-call rates and new patient conversions. Install a heat map on your website to learn more about your user experience and whether your website provides answers to the questions patients and caregivers are looking for. EMBRACE TECHNOLOGY Telehealth has been around for decades with claims growing more and more in recent years. However, COVID-19 brought it to the forefront making it the primary source of delivering care for millions of people. Practices that relied exclusively on in-person office visits found themselves unable to meet the needs of their patients with the government-mandated quarantine while others struggled to keep their doors open, working as quickly as possible to overhaul practices to provide virtual visits. Practices with a telemedicine program, however, easily adapted, increasing existing infrastructure to meet the needs of their patients and the demand within the general population. “Telemedicine, pre-COVID, was packaged as just another way to deliver care in the modern age. Telemedicine in the day of COVID is now a necessary www.tafp.org
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Telemedicine is now the norm and your competition isn’t just physicians or specialists in a primary market area, it’s the entire nation in a physician’s field of practice. Physicians can learn from the pandemic by adapting to the next normal while delivering a better patient experience and growing practice census.
way to deliver care,” says Mike Martinez, PA, telemedicine expert for WellMed/OptumCare, Gonzaba Urgent Care, and FetchMD in San Antonio, Texas. According to Mr. Martinez, his practices “adapted so very quickly to the rapid incoming information to be able to stay open and fulfill their number one mission: To take care of patients.” Pre-COVID, Mr. Martinez describes his efforts to help patients via telemedicine as “painfully slow” as he would “cold call patients off PMLs (patient member lists).” During this time, Mr. Martinez found a “70% acceptance rate among patients to enroll in his practices’ telemedicine programs among patients age 18-65. Among patients 65-75 there was a 45% acceptance rate and only 25% among patients 75 or older due to lack of interest, ability to afford, or knowledge to use the technology. Enter March 2020 with COVID and the program took off. I went from calling patients one by one to training our Wellmed providers on our telemedicine platform.” One of the practices Mr. Martinez works with served four patients via telemedicine in January of this year and just three months later, that number grew to more than 20,000. Practices today have a profound opportunity to adopt a telehealth program that meets the needs of their existing and future patient population. Mr. Martinez agrees, encouraging practices to “adopt an affordable and HIPAA compliant telehealth platform [that has] a user friendly and intuitive interface, no matter the age of the intended population.” Telemedicine is now the norm and your competition isn’t just physicians or specialists in a primary market area, it’s the entire nation in a physician’s field of practice. Physicians can learn from the pandemic by adapting to the next normal while delivering a better patient experience and growing practice census. When asked about his patients’ feedback, Mr. Martinez says “it’s beyond satisfying and heartwarming to see an elderly patient feel really good about the experience they had from a telehealth encounter. By the end of the visit, many of our elderly patients are quite excited about the experience and seem rightfully proud of themselves.” Practices that proactively embrace technology and adapt to their patients’ needs will find their practice thriving with satisfied customers who will tell others about their experiences. PRO TIP #2: Focus on your message. Who is your primary and secondary target audience and what do they need to know about your practice and your care? When is it appropriate to have an in-person visit versus a telehealth visit and how can you make the customer experience not just pleasant, but great? Is helpful, key information like your procedures exhibited on your website or in your marketing collateral? Is it clear and concise? In today’s environment, it is important to market convenience and safety. Help your patients see the value of being in the comfort of their own home without the need to spend several hours of their day dedicated to a medical appointment. Patients can also feel secure knowing they reduce their risk and exposure to illnesses as they do not need to sit in a waiting room with other patients who may be ill. Ensure your website and marketing collateral speak to the benefits as well as the features your practice provides. CONCLUSION
Scott Marketing and Consulting Group located in San Antonio, Texas, provides marketing consulting services to the health care and senior living industries. For more information or to schedule a complimentary consultation visit www.scottgroup.consulting. 28
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Philosopher Heraclitus of Ephesus is attributed to having said “life is flux” or as you may also have heard, “the only constant is change.” Medical care and how it is delivered will continue to evolve. To meet the needs of your patients, your practice will need to evolve with it, understanding that advancements are only as good as our ability to embrace and use them.
“It’s a wonderful thing to practice family medicine in the state of Texas, to have the opportunity y to get to know our patients and their families and to take care of them. As members of the Texas Academy of Family Physicians, we don’t just care for our patients in the exam room. We take care of them at the State Capitol, too. “I’m a monthly donor for the TAFP Political Action Committee because if we want policies that are good for our patients and our practices, we have to elect politicians who understand our issues. Support TAFPPAC and make your voice heard.” Justin Bartos, MD 2016 TAFPPAC Award recipient
www.TAFPPAC.org
PERSPECTIVE
Direct primary care: A light in the darkness By Kissi Blackwell, MD
recent events have shed light on the existing difficulties facing family physicians and have revealed the fragility of the current healthcare system. The SARS-CoV-2 pandemic has devastated our health care delivery process, and many family physicians are facing the difficult decision to close their doors or contend with salary reductions due to sharply decreased face-to-face visits. Now, more than ever, patients are valuing visits that can take place outside of the exam room, and, unfortunately, reimbursement has been severely lacking for virtual visits for traditional fee-for-service practices. In the midst of all this uncertainty, there has been an inherent need to shift the way we approach primary care delivery and payment. In a time where we stand to lose thousands of primary care physicians to financial difficulties or retirement forced upon them by the current situation, we owe it to our profession to find a better way. I transitioned into direct primary care, or DPC, from an employed position in July of 2017. Despite being a lot of hard work and keeping hours not much different from my employed position, it has been extremely gratifying, both professionally and personally, and exponentially so during recent events. As a DPC practice, our day-to-day schedule has not changed much during the shutdown, save for seeing a few less patients for in-office visits. Fortunately, none of our patients have left the practice, meaning our revenue has stayed stable. Even before the pandemic, many of our visits were conducted virtually through phone, text, email, or video chat at no extra cost. As a result, patients were already well-acclimated to this type of care and did not find it difficult to transition to mostly virtual visits during stay-at-home orders. Many patients expressed their gratitude and relief to be a part of this practice model where they were not worried about how they would get care nor about being exposed in a busy office. As you might imagine, my experience is not at all unique. During the course of the pandemic, DPC practices have found themselves minimally impacted in a situation where fee-for-service practices have struggled. Fortunately, transition into DPC can be a feasible option to help practices restore viability and break free from restrictions and regulations. DPC simplifies health care delivery, taking the focus away from visit volume and reimbursement, and allowing practices to focus on patients and their needs. When reimbursement is not
tied to individual visits, patients and physicians are free to have as much contact as required, whether in-person or virtual. Problems can be followed and resolved in real time instead of fragmented into spaced-out visits. Physicians become invested in people, and patients learn to trust their physician again. This translates into significantly decreased ER and urgent care visits, decreased hospitalizations, increased patient satisfaction, and increased physician well-being, as found in a recent study done through Milliman by the Society of Actuaries and attested to by the hundreds of physicians already in DPC practice. Four years ago, I knew I had to make a change. Seeing patients every 10 minutes, working long hours to get documentation done, dealing with denials and insurance requirements, and all the while being pushed to do more and more left me exhausted and mentally drained. That year, I decided I needed to explore the option of direct primary care and attended the DPC Summit in Kansas City. I had never been more blown away by the genuine compassion, encouragement, and alacrity of the physicians making up the DPC movement. Could this be real? Physicians cheering each other on and helping each other thrive? Over the past four years, I have come to find it is absolutely true, and I am now proud to count myself among those physicians, paying it forward to many others as a member of the Advisory Board of the Direct Primary Care Alliance. Direct primary care has restored my love of the medical profession and has given me the professional satisfaction that is so lacking in the current health care climate. My sincere hope is that those physicians looking for a lifeline know that there is support and boundless resources to aid practices in their transition among the DPC community and specifically through the DPC Alliance, graciously supported by TAFP. These resources include our recent statement regarding the restoration of primary care, a comprehensive startup checklist, Mastermind events that offer participants one-on-one time with DPC mentors, live learning events and group chats through social media, a directory of DPC practices with job listings available, and DPC University where readers can find everything there is to know about starting and running a DPC practice. All of these resources have been created by DPC physicians for DPC physicians. There is another way. The time to change is now. Let us help you find the light in the darkness.
Four years ago, I knew I had to make a change. Seeing patients every 10 minutes, working long hours to get documentation done, dealing with denials and insurance requirements, and all the while being pushed to do more and more left me exhausted and mentally drained.
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FAMILY MEDICINE CLINICAL FACULTY OPPORTUNITIES
Baylor College of Medicine has opportunities for clinical faculty who are board certified/eligible in Family Medicine and/or interested
Houston, Texas
in providing non-operative obstetrics. In addition to joining an outstanding group of faculty dedicated to the care of a diverse patient population, our faculty have the opportunity to participate in academic activities including medical student and resident education.
APPLY ONLINE: jobs.bcm.edu
This position includes a faculty
FOR FURTHER INFORMATION CONTACT
appointment at a competitive salary with excellent benefits and the opportunity to join a distinguished institution.
ROGER J. ZOOROB, MD, MPH, FAAFP Richard M. Kleberg Sr. 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-and-community-medicine
Interested candidates should apply at
jobs.bcm.edu
Baylor College of Medicine is an Equal Opportunity/ Affirmative Action/Equal Access Employer
Presorted Standard U.S. Postage
PAID
Austin, TX Permit No. 1450
ture u f e h t e p help sha edicine m y il m a f of
By volunteering to precept a Texas medical student, you can open a door to a new world for the next generation of family doctors. QUESTIONS? Give us a call at (512) 329-8666 or send an email to Juleah Williams, jwilliams@tafp.org.
! r o t p e c e r be a p