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Volume 62, No. 1
TEXA S
FAMILY PHYSICIAN winter 2011
F E A T U R E S 18 Texas Lege brandishes the budget axe Confronted by a $15 billion to $27 billion shortfall, lawmakers have begun their work under the dome. Some of TAFP’s greatest policy achievements hang in the balance.
By Jonathan Nelson
20 Cover: Taking a chance on accountable care Health system reformers hope the ACO is a game-changer, but where do solo and small-group family physicians fit in as large hospital systems buy up the board? By Kate Alfano
29 RESEARCH: Monitoring and management of cardiovascular risk factors by primary care physicians at an academic medical center By Cindy Ripsin, M.S., M.P.H., M.D.
25 QUALITY IMPROVEMENT: Blue Cross and Blue Shield of Texas, Bridges to Excellence team up to improve quality 31 FOUNDATION FOCUS: Thanks to the 2010 donors 33 PRACTICE MANAGEMENT: Six steps to increase your revenue 38 TAFP PERSPECTIVE: Family physicians can succeed in and alongside Accountable Care Organizations
D E P A R T M E N T S
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photo illustration: JONATHAN NELSON
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FROM YOUR PRESIDENT: Promote the value of family medicine
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IN THE NEWS: TAFP wins AAFP advocacy award | Presenting the Texas Family Docs blog | Academy political arm celebrates 20 years | Brush up on scope with new issue briefs
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MEMBER NEWS: TAFP members appointed to AAFP commissions | Texas residency program awarded HRSA grant | Texas governor appoints family physicians to state committee
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FROM AAFP: Family physicians get raise in many CPT codes
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YEAR IN REVIEW: 2010 was a year of innovation for TAFP
TEXAS
FAMILY PHYSICIAN
f ro m your president TAFP President Melissa Gerdes, M.D., of Whitehouse, served as the Physician of the Day at the Texas Capitol on the opening day of the 82nd Texas Legislature.
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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 Melissa Gerdes, M.D. President-elect I. L. Balkcom, IV, M.D. Vice President Clare Hawkins, M.D. Treasurer Troy Fiesinger, M.D.
Assessing the value of a family physician By Melissa Gerdes, M.D. TAFP President
Parliamentarian Dale Ragle, M.D. Immediate Past President Kaparaboyna Ashok Kumar, M.D., F.R.C.S. Editorial Staff Managing Editor Jonathan L. Nelson Associate Editor Kate Alfano Chief Executive Officer and Executive Vice President Tom Banning Chief Operating Officer Kathy McCarthy, C.A.E. Fall Publications Intern Melissa Ayala Spring Publications Intern Monica Kortsha Advertising Sales Associate Audra Conwell Contributing Editors John K. Frederick, M.D. Kathy McCarthy, C.A.E. Bradley K. Reiner Cindy Ripsin, M.S., M.P.H., M.D. Eduardo Sanchez, M.D. Subscriptions To subscribe to Texas Family Physician, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in Texas Family Physician represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. Texas Family Physician is printed by The Whitley Company, Austin, Texas. Legislative Advertising Articles in Texas Family Physician that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2011 Texas Academy of Family Physicians
Postmaster: Send address changes to Texas Family Physician, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6
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Our Academy’s vision statement begins: “The Texas Academy of Family Physicians is dedicated to the promotion of a health care environment that values the vital role of family physicians.” I spoke of the importance of recognizing and promoting the value of Texas family physicians in my installation speech. It will take all of us doing what family physicians do every day: taking care of ALL Texans, knowing them, and tailoring care to individuals and communities. How do we create value? How do family physicians feel valued? If we equate value to payment, I am afraid we will always be disappointed. Perhaps if our current triangular thirdparty payer system evolves, payment may provide a sense of being valued. For now, I would suggest we focus on the true ways in which family physicians are already valued. In my short four months as president, I have seen ample evidence that family physicians do play a vital role in our health care system and that people value us. The first evidence came on my way back from Annual Session in San Antonio. I have to admit I was doing a little eavesdropping sitting at a Chili’s in Hutto. What I heard made me very hopeful that our message is getting out. The three individuals who were sitting in the booth behind me were reviewing their morning. One gentleman, sporting a knee brace and walking cane, had obviously just visited with a specialist. The other two asked how his visit had
gone and how he liked the physician. The man with the knee affliction responded that he did not know why he needed to see so many different physicians. One of the others started talking about our medical system. “You start with your family doctor. He tries to figure out your problem. If he is honest, he will admit when he doesn’t know the answer and send you to another physician who does.” The woman went on to describe her foot problem. She could not decide which doctor to see about it. “I mean, you can’t just look in the phone book for a doctor anymore. Did you know there are six different types of doctors in the phone book who treat the foot? My family doctor knew who I should see, though.” The second man asked the first if he felt better about his doctors now. “You were ready to throw in the towel on the last group.” The man responded, “Yes, I really like [my family doctor]. It all comes down to bedside manner. I feel he really listens to me.” I almost turned around and asked this group to star in an ad for family medicine. With this year’s legislative agenda, one would hope family physicians have value in the eyes of Texas legislators. I can tell you we do. Recently, I spent the day as Physician of the Day at the Capitol. For those of you who have done this, you will know what I am talking about. A family physician serves in the capitol clinic alongside nurse practitioner Tim Flynn. Anyone on the capitol grounds
With this year’s legislative agenda, one would hope family physicians have value in the eyes of Texas legislators. I can tell you we do.
photo: JONATHAN NELSON
can stop in for free minor medical care. In return for volunteering, the physician is introduced and thanked on the Senate and House floors. As I was wearing my white coat, several people came up to me and thanked me for what I do. Even Gov. Rick Perry thanked me for serving. What an honor! You can find out more about the Physician of the Day program or sign up as a Key Contact for your legislator on the Academy’s website, www.tafp.org. What can you do to help recognize and promote family physicians? First of all, thank you all for being family physicians. In my installation speech, I called on each of you to do your part in promoting family medicine. I hope you are telling people what you do. Write articles in your papers; serve as a health resource for local radio or television stations. I encourage you to volunteer time, money, or advice where you see a need. Continue playing a vital role in all your communities. Recognize your colleagues for their contributions. Nominate a colleague for an award. TAFP is collecting annual award nominations now. Just contact the staff or visit the website to do so. In the end, our value comes down to how patients see us. This week, I was visited by a longtime patient of mine. She had been battling lymphoma at a regional oncology hospital. Though I was following along with her care, I had not seen her in the office in nearly two years. She was proud to be in remission for a year. The first thing she did was to give me a hug and thank me for diagnosing her and saving her life. She also thanked me for seeing her family and helping them through the past two years. As I hugged her back, just she and I in an exam room, I thought, “This is what family medicine is all about.” :
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News Briefs
:
NEW FOR YOU
TAFP launches new blog: TXFamilyDocs.org
TAFP wins AAFP advocacy award The Texas chapter collected some new hardware at AAFP’s 2010 State Legislative Conference in New Orleans, La., Nov. 12, winning the Academy’s Leadership in State Government Advocacy award. The Kansas and Indiana chapters joined Texas in receiving TAFP CEO Tom Banning (right) receives the 2010 Leadership in State Government Advocacy award from the award for successes in their AAFP President Roland Goertz, M.D., M.B.A., of Waco. respective state legislatures. TAFP won the award in recogniTAFP CEO Tom Banning accepted the tion of the chapter’s work in the award and gave a presentation to conferpassage of a new physician education loan ence attendees from all parts of the counrepayment program that could potentially try on the political efforts required to pass bring more than 200 primary care physicians the legislation. to underserved areas each year. The program This is the second time TAFP has won provides up to $160,000 in loan repayment to the state advocacy award. The chapter physicians who agree to practice in federally claimed the prize in 2007 for its news covdesignated Health Professional Shortage erage during the 80th Texas Legislature. : Areas throughout the state.
In a post-health-reform era of rapid changes to the practice of medicine, your Academy has opened a new forum to explore the topics most important to the family physicians of Texas: the Texas Family Docs blog. In this space, the TAFP community— Academy members and staff—can analyze measures of health reform, delve into Texas health policy, share practice management tips, highlight tools and resources to improve your practice experience, share media links from the most influential medical journals, and more. This is where you come in. We want this to be a space where you contribute to the discussion. Comment on our posts or ask us how to submit your own. Go to www.txfamilydocs.org. E-mail tafp@tafp.org for more information on becoming a contributing author or with general questions. :
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News Briefs TAFP’s political arm celebrates 20 years Martin, Lambert reflect on TAFPPAC’s beginning and progress As the Academy ramps up for the 82nd Texas Legislative Session, TAFP celebrates a milestone in family medicine advocacy: the 20th anniversary of the TAFP Political Action Committee. Two TAFP past presidents reflect on this important time: James Martin, M.D., 1989-1990, and C. Tim Lambert, M.D., 1990-1991. TAFPPAC was founded in 1991 in response to the growing political involvement of individual TAFP members and the realization that family medicine advocacy had a role in the effort to advance medicine on the state level. “While there had been several successful individual efforts in the past, there had been no formal strategic commitment to an overall process,” Martin says. He references action taken in 1977 when a group of family physicians succeeded in convincing the Texas Legislature to pass House Bill 282, securing state funding
for family medicine residency programs through the Texas Higher Education Coordinating Board. Those involved included TAFP greats such as Jack Haley, M.D.; Edwin Franks, M.D.; Warren Longmire, M.D.; Thomas Nicholas, M.D.; Chris Ramsey, M.D.; and Bill Ross, M.D. Fast-forward more than a decade to another group of TAFP leaders and officers, including Martin and Lambert, who would work to form the PAC as it stands today: Barker Stigler, M.D.; Kenneth Davis, M.D.; Lewis Foxhall, M.D.; Roland Goertz, M.D.; and Jim White, then-TAFP executive director. Through his involvement on the Texas Medical Association Council on Legislation, Lambert had developed a relationship with two big political personalities, Kim Ross and Alfred Gilchrist. “Alfred was really convinced that family medicine was a sleeping giant and that we had more clout than we realized,” he says. “When we started lobby-
ing and got the rider for the funding of the student clerkships, then it became pretty obvious that we needed to do something.” Sam Nixon, M.D., longtime TAFP leader and TMA president at that time, publicly opposed the formation of a family medicine PAC, saying that it would be in direct competition with TMA’s PAC and divide the house of medicine. But in private conversation, Martin says, “the TMA leadership wanted us to succeed, as they had a policy of always supporting the incumbent and felt that some incumbents were not looking at the health interests of Texas.” Martin says, “the leadership looked at developing two specific components: identify and develop relationships with existing special interest groups who shared our concerns or whose members would benefit from the success of our legislative efforts, and develop our own ties with legislators either through shared concerns or PAC influence.”
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According to Lambert, the biggest issue TAFPPAC championed was workforce, and they approached it from all angles by focusing on increasing interest in family medicine careers in high school and college students, improving the presence of family medicine role models in medical schools, maintaining and improving residency funding, and expanding the availability of doctors in underserved areas of Texas. Over the years, TAFPPAC membership grew and the group enjoyed many victories—pushing through tort reform to stifle frivolous malpractice lawsuits, advocating for Medicaid and CHIP, fighting attempts by allied health groups to expand their scope of practice, and passing one of the most generous physician education loan repayment programs in the country. Lambert says leaders and members have learned how much organizations spent in contributions to be a part of the political process, and that to have their TxPhysAd2010.pdf 11/30/2010 4:24:13 PM
voice heard, family physicians had to participate in this practice. However, that’s not why lawmakers respond to family medicine’s message. They’ve paid attention “because we were talking about doing the right thing,” Lambert says. “One thing I always remember and I hope we never forget—we need to be the guys with the white hats. We needed to be fighting the war for our patients and our constituents. That is the most important thing.” “At this anniversary, it’s a good time for us to remind all of our members that policy is made by those who are at the table. If we’re not at the table, we’re not going to have a say. That’s an important message going forward. There have been a lot of wars fought, a lot of blood and tears shed, but we’re nowhere near where we need to be. We need to keep going.” For more information on TAFPPAC’s current work, go to www.tafppac.org. :
“One thing I always remember and I hope we never forget—we need to be the guys with the white hats. We needed to be fighting the war for our patients and our constituents.” — C.Tim Lambert, M.D.
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News Briefs PCC to Legislature: Support collaborative care model, maintain scope of practice The Primary Care Coalition released its latest advocacy resource: a set of three policy briefing papers describing the rationale to support team-based care led by a primary care physician and protect against changes to scope of practice laws in Texas. TAFP encourages family physicians to use the briefs when speaking to their state senator and representative to help educate legislators on the appropriate role of nurse practitioners. The first brief, “Compare the Education Requirements of Primary Care Physicians and Nurse Practitioners,” focuses on the differences in years and intensity of training between physicians and advanced practice nurses. Standard medical training prepares doctors for complex differential diagnoses, the development of treatment plans across multiple organ systems, and the ordering and interpreting of tests within the context of the patient’s overall health condition. “Because primary care physicians throughout the United States follow the same highly structured educational path, complete the same coursework, and pass the same licensure examination, you know what you’re getting with a physician,” the authors state in the brief. “There is no such standard to achieve nurse practitioner certification, as their educational requirements vary from program to program and from state to state.” One of three charts on the brief displays the gap in clinical training hours. When a nurse practitioner finishes education, he or she has equivalent clinical experience to a third-year medical student. After this point, physicians go on to complete an additional year in medical school and a three-year residency program at minimum. The training gap is further described through studies showing deficiencies in education and preparation for practice of newly graduated nurses. The second brief, “Primary Care Physicians Are the Most Likely Health Care Professionals to Practice in Rural and Underserved Areas,” disputes the argument that nurse practitioners will fill the physician workforce shortage by opening practices in rural and undeserved areas. 1 2
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It features a large map of Texas on the front, illustrating practice-mapping data from the American Medical Association. With color-coded counties for full Health Professional Shortage Area counties and partial HPSAs, the map shows that the state of Texas relies more on primary care physicians to provide health care to patients in rural, underserved areas. This is further illustrated through four state maps on the back of the brief. The four states—Idaho, Oregon, Arizona, and Utah—each allow nurse practitioners to diagnose and prescribe without any physician collaboration, and they also feature metropolitan areas and large, rural areas like Texas. They show that even in states that allow independent practice, nurse practitioners follow the same practice patterns as their colleagues in states that require collaboration; they gather in large, metropolitan, non-border areas, not in rural, underserved communities as their professional organizations claim. An important conclusion the authors draw in the brief is that the economic environment that discourages family physicians from opening and maintaining a rural medical practice will discourage and has discouraged nurse practitioners from these areas as well. The third brief, “Collaboration Between Physicians and Nurse Practitioners Contains Health Care Costs,” explores the goal of reducing health care costs through implementation of the patient-centered medical home rather than through relaxed scope of practice laws. “Contrary to the claims of nurse practitioner organizations, independent practice by nurse practitioners would not lead to more efficient or cost-effective care; in fact, studies show the opposite would be the likely outcome,” the authors state in the brief. The brief refutes the claim by citing a study on utilization of medical services such as diagnostic tests, hospital admissions, and specialty referrals, all of which increased in the nurse practitioner group and all of which led to increased cost of care. Coordinated care provided in a patient-cen-
PCC Issue Briefs are available for download at www.tafp.org/advocacy/resources.
tered medical home, on the other hand, has proven to be better quality and lower cost, and the brief provides five practice settings where this has been the case. “Allowing nurse practitioners to diagnose, treat, and prescribe without any physician collaboration will only serve to further fragment the chaotic and poorly coordinated health care delivery system Texans encounter,” the authors state in the brief. The brief’s conclusion is that both nurse practitioners and physicians have the same goal: to keep Texans healthy and productive, and to ensure that when they need it, patients have access to safe, highquality medical care. Advanced practice nurses are a vital part of Texas’ health care workforce, and physicians and APNs provide the highest quality health care when they work together. This team should be supported and kept together by state policies that have the best interests of the patient in mind. The Primary Care Coalition is a partnership comprised of the Texas Academy of Family Physicians, the Texas Pediatric Society, and the Texas Chapter of the American College of Physicians, collectively representing more than 14,000 physicians across the state. To access these and other advocacy resources, go to www.tafp. org/advocacy/resources. :
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Two TAFP members appointed to AAFP commissions Two TAFP members were appointed to AAFP commissions this fall. Rebecca Gladu, M.D., has been appointed to the Commission on Health of the Public and Science, and Janet Hurley, M.D., has been appointed to the Commission on Membership and Member Services. Gladu is the associate residency director and director of the obstetrics and hospitalist fellowships at the San Jacinto Methodist Family Medicine Residency Program in Baytown, Texas. She currently chairs the TAFP Commission on Annual Session and CME. She has been a frequent speaker at TAFP symposia, has served as program chair for many CME programs, and chaired the TAFP Commission on Academic Affairs and Section on Maternity Care. She has also participated in the Hard Hats for Little Heads program, providing bicycle helmets to children during safety demonstrations. Gladu has served on numerous committees over the years at the residency
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program and the University of Texas Health Science Center at Houston. She has received the Dean’s Teaching Excellence Award and Best Doctors honors. She was also recognized by WIC for her support of breastfeeding. Hurley practices at Trinity Clinic in Whitehouse, Texas, one of the TransforMed demonstration sites. Since the conclusion of the National Demonstration Project, she has gone on to give lectures on the patientcentered medical home and practice transformation. She also has been part of the Texas Medical Home Initiative serving on the initial steering committee and now on the board of directors as well as chairing their Best Practices Workgroup. She has been involved with the Academy since medical school, first serving as a leader of her school’s FMIG and then as chair of the TAFP Section on Medical Students. As a resident she served on two AAFP commissions as well
as reference committees at the National Conference of Family Medicine Residents and Medical Students. Since being in active practice, she has chaired the TAFP Task Force on Chapter Revitalization and the Section on Leadership Development, and has served on the Executive Committee twice. Hurley has been a board member for the Rose Chapter of TAFP since 2004 and currently chairs the Section on the Medical Home. In addition to her work with AAFP and TAFP, Hurley has served on committees within her local health system, and on the board of the Northeast Texas Public Health District. :
San Antonio residency program receives federal grant to improve chronic care The Christus Santa Rosa Family Medicine Residency Program in San Antonio has been awarded a five-year, million-dollar grant by the Health Resources and Services Administration to implement and refine an integrated chronic care clinical model and develop residency curriculum within the context of the primary care medical home. The funding comes through HRSA’s Training Programs in Primary Care initiative, put in place to support and enhance family medicine, general internal medicine, and general pediatric programs to develop curriculum, train faculty, provide didactic and community-based education, and train residents in underserved areas. Within the U.S. Department of Health and Human Services, HRSA is the primary federal agency responsible for improving access to health care for the uninsured, isolated,
or medically vulnerable, according to an article published in the Christus Santa Rosa newsletter. “This is tremendous news for our team and provides validation that we are moving in the right direction as we strive to promote and teach the tenets of the primary care medical home,” residency program director Todd Thames, M.D., M.H.A., said in the article. The Christus residency program was one of only 23 programs nationwide to receive funding through the TPPC initiative. They are one of an even smaller number of community-based programs without the grant-writing resources of a large academic health center, Thames noted in an e-mail to TAFP. He said, “We are proud of this award and excited about the possibilities as we implement the program.” :
Family physicians join state committee Gov. Rick Perry reappointed two TAFP members to the Pharmaceutical and Therapeutics Committee: Mario R. Anzaldua, M.D., and Guadalupe Zamora, M.D. The committee makes recommendations about the contents of preferred drug lists for Medicaid and the Children’s Health Insurance Program. Anzaldua is a private-practice physician in Mission, Texas. He is a past member of the Mission Chamber of Commerce Board of Directors. Anzaldua received a bachelor’s degree from Stanford University and a medical degree from the University of Texas Health Science Center at San Antonio. He is also a member of the Texas Medical Association. Zamora is a private-practice physician in Austin, Texas. Zamora received a bachelor’s degree from St. Mary’s University and a medical degree from the University of Texas Medical Branch at Galveston. He is also a member of the Texas Medical Association and Travis County Medical Society. :
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from aafp
AAFP chart details increases in primary care CPT codes for 2011 Declining conversion factor should have little effect on family physicians By AAFP news staff CMS’s release of the final 2011 Medicare conversion factor, which decreased from 2010, has caused a lot of confusion and consternation among family physicians. To allay those concerns, the Academy has created a chart that shows why family physicians actually may see payment increases in 2011. Members should be aware, however, that payment allowances in the chart are not adjusted geographically. According to Kent Moore, AAFP’s manager of health care financing and delivery systems, actual payment rates for providing Medicare services will vary according to the Medicare locality where services are performed because geographic practice cost indices also have been updated. Moore noted that many physicians expected that their Medicare payments for 2011 would remain the same because Congress extended the payment rate that was in place for the second half of 2010 through the end of 2011. Expectations were that payments would remain the same and there would be no change in the conversion factor applied to payments, he told AAFP News Now.
However, Moore added, “CMS instituted a number of changes in the payment formula, including rebasing the Medicare economic index, increasing some of the payment codes and recalculating the figures for practice expense.” These changes would have resulted in increased costs to the Medicare program, but any changes to the program must remain budget-neutral. Thus, CMS was forced to apply a negative adjustment to the overall conversion factor. Although the actual 2011 conversion factor went down from $36.8729 to $33.9764, changes in relative value units, or RVUs, have resulted in an overall increase in the Medicare allowance for the CPT codes family physicians use the most. In fact, Medicare allowed charges for family medicine are expected to increase in 2011 by about 2 percent to 3 percent, said Moore. For example, according to the AAFP chart, the allowance for CPT code 99212 went up 4.09 percent. The allowance for CPT code 99213 went up 3.34 percent, and for CPT code 99214, it went up 2.35 percent. In addition, Moore noted, many family physicians will receive an additional 10-percent bonus because of provisions in the Patient Protection and Affordable Care Act. Many physicians look at the conversion factor to compare their potential revenue from year to year, said Moore. “They see a declining conversion factor and assume their claims will decline by the same amount. But, in fact, the payment formula is increasing payments to primary care, sometimes at the expense of services provided by other, higher-paid specialties.” : Source: AAFP News Now, Jan. 17, 2011. © 2011 American Academy of Family Physicians.
TABLE 1: AAFP Comparison of 2010 and 2011 Medicare Allowances for Services Commonly Provided by Family Physicians Medicare Conversion Factor as of December 2010: Medicare Conversion Factor as of January 2011:
$36.8729 $33.9764
Code
Descriptor
99201 99202
2010
2011
RVUs
Allowance
RVUs
Office/outpatient visit new
1.08
$39.82
Office/outpatient visit new
1.86
$68.58
99203
Office/outpatient visit new
2.71
99204
Office/outpatient visit new
99205 99211
Change in Allowance
Allowance
$$$
1.21
$41.11
$1.29
3.24%
2.09
$71.01
$2.43
3.54%
$99.93
3.03
$102.95
$3.02
3.03%
4.21
$155.23
4.66
$158.33
$3.10
1.99%
Office/outpatient visit new
5.28
$194.69
5.80
$197.06
$2.37
1.22%
Office/outpatient visit est
0.53
$19.54
0.58
$19.71
$0.16
0.84%
99212
Office/outpatient visit est
1.08
$39.82
1.22
$41.45
$1.63
4.09%
99213
Office/outpatient visit est
1.81
$66.74
2.03
$68.97
$2.23
3.34%
99214
Office/outpatient visit est
2.71
$99.93
3.01
$102.27
$2.34
2.35%
99215
Office/outpatient visit est
3.66
$134.95
4.05
$137.60
$2.65
1.96%
99221
Initial hospital care
2.64
$97.34
2.86
$97.17 $(0.17)
-0.18%
99222
Initial hospital care
3.58
$132.00
3.89
$132.17
$0.16
0.12%
99223
Initial hospital care
5.27
$194.32
5.71
$194.01 $(0.31)
-0.16%
99231
Subsequent hospital care
1.05
$38.72
1.13
$38.39 $(0.32)
-0.83%
99232
Subsequent hospital care
1.90
$70.06
2.04
$69.31 $(0.75)
-1.07%
99233
Subsequent hospital care
2.73
$100.66
2.93
$99.55 $(1.11)
-1.10%
99238
Hospital discharge day
1.87
$68.95
2.03
$68.97
0.03%
Editor’s note: Blue boxes indicate a reduction in RVUs for 2011.
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w i nt e r 2 0 1 1 | T e x as Family Physician
$0.02
%
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le g i slat i ve update
The 82nd Texas Legislature:
Game on! by jonathan Nelson
The opening bell has rung and the gavel has dropped in Austin as lawmakers grapple with a massive budget shortfall, the sunset of several important state agencies, a divisive voter identification measure, and what is certain to be a vicious backroom brawl over redistricting. Topic number one on everyone’s docket is passing a balanced budget for the 2012-2013 biennium. On opening day, the Senate’s chief budget writer, Sen. Steve Ogden, R-Bryan, delivered a stark assessment of the difficulty of that task as he was sworn in as president pro tempore of the Texas Senate. Earlier that week, Texas Comptroller Susan Combs had announced that general revenue for the 2012-2013 biennium will likely be $72.2 billion, $14.8 billion less than the general revenue budget for the current biennium. She estimated the shortfall in the current biennium would be $4.3 billion, but she did not quantify the size shortfall expected in the next biennium. Ogden told the audience in the Senate chamber that since 81 percent of general revenue appropriated by the Legislature goes to education and health and human services, it is impossible to balance the budget without cutting those two areas. “How we deal with Medicaid will determine how the rest of the budget goes,” he said. Last session, lawmakers appropriated $44 billion in all funds to the Medicaid program; 70 percent of that came from the federal government and 30 percent came from the general revenue budget. The federal match was richer than usual because it included money from the federal stimulus 1 8
w i nte r 2 0 1 1 | T e x as Family Physician
package. Ogden predicted the match in the next biennium would be closer to 60:40, a difference of approximately $4.5 billion. “Our first job, senators, is to figure out how to save Medicaid.” The exact size of the budget shortfall confronting lawmakers is a point of contention. The Center for Public Policy Priorities has calculated the cost of providing existing levels of services in the coming biennium at $99 billion, which puts the shortfall at $26.8 billion. Talmadge Heflin of the Texas Public Policy Foundation argues that figure is based on the assumption that the state should continue providing the same level of services as in the past. He says the impending shortfall is somewhere between $12 billion and $16 billion, according to a story by John Reynolds of Quorum Report. Gov. Rick Perry, Lt. Gov. David Dewhurst, and House Speaker Joe Straus have pledged to balance the budget without raising taxes and without tapping the $9.4 billion Rainy Day Fund, and the base budgets introduced in both the House and the Senate seek to do just that. The House budget would spend $156.5 billion in all funds in 2012-2013, $31.1 billion less than in the current biennium, while the Senate version would spend $158.7 billion, a reduction of $28.8 billion from current spending. Neither budget assumes
any caseload growth in Medicaid and CHIP, even though the Commission on Health and Human Services estimates Medicaid will swell by more than 200,000 by 2013. Both budgets cut Medicaid and CHIP provider rates by 10 percent. That comes on top of a 2-percent cut in the current biennium. HHSC Commissioner Tom Suehs has made it clear to lawmakers that such reductions will restrict access to patients as physicians are forced to limit their participation in the programs. He suggested that the Senate Finance Committee spare primary care physicians the full weight of the proposed cuts. “I’m really concerned about having to cut primary care rates for physicians treating children,” he told the committee on Feb. 1. “We’ve already cut 2 percent this biennium from when y’all wrote the [2010-2011] budget. I believe that’s about as far as I can tolerate to maintain the access to primary care so I’m asking to put back not all 10 percent, but 8 percent.” Both budget drafts also include significant savings from implementing bundled payments in Medicaid, rolling out Medicaid managed care in the Valley, reducing ER utilization in Medicaid and CHIP, cuts to mental health programs, and a host of other programs administered by HHSC. Several programs designed to improve the state’s primary care physician workforce would be eliminated in the House budget and would be severely reduced by the Senate. Included among them are the funding initiatives administered by the Texas Higher Education Coordinating Board for family medicine residency programs and other primary care residency programs, the State wide Primary Care Preceptorship Programs, and the state’s newly enhanced Physician Education Loan Repayment Program. The coordinating board would receive 29 percent less funding for family medicine residencies in the Senate version; the preceptorship program and the loan repayment program would both be cut by 25 percent. Graduate medical education formula funding was cut by 32 percent in the House version, and 28 percent by the Senate. Total GME spending under the House budget would fall 44 percent; in the Senate, 26 percent. These programs make up the bulk of the state’s efforts to promote primary care, and they comprise some of TAFP’s greatest legislative achievements toward the Academy’s goal of improving the quality of care patients receive while controlling the cost of that care. “The spending proposals in the base budget don’t reflect the policy goals that the state is working toward,” said TAFP CEO Tom Banning in a TAFP news story posted
from the TAFP blog: http://www.txfamilydocs.org on www.tafp.org. “There is overwhelming evidence that high-quality, cost-effective health care systems are built on a strong primary care foundation, and now is the time when we should be investing in our primary care physician workforce.” To further complicate the workforce conundrum, the Legislative Budget Board recommended that the state grant nurse practitioners the authority to diagnose and prescribe without any physician collaboration or supervision. “Allowing APRNs to diagnose and prescribe up to the limits of their education and certification would allow them to provide lower-cost primary care for patients within their professional scope,” the LBB advised in a report released with the draft budgets. Two bills filed in the House would carry out this scheme. House Bill 708 by Rep. Kelly Hancock, R-North Richland Hills, and H.B. 915 by Rep. Wayne Christian, R-Center, would allow nurse practitioners, nurse anesthetists, and clinical nurse specialists to diagnose, prescribe, and institute therapy or referrals of patients to health care agencies, health care providers, and community resources. Nurse practitioners would not be required to collaborate with physicians in any way, and all regulation of their practice would remain the purview of the Texas Board of Nursing. Rumors of more bills to expand nurse practitioners’ scope of practice abound, and there is no doubt this will be one of TAFP’s primary challenges this session. TAFP has a strong advocacy team and has nurtured beneficial relationships in both the House and the Senate over the years, but the most influential advocacy comes from the grassroots. You can help by staying alert and informed of what is happening at the Capitol. Watch for TAFP’s Capitol Update and our webcast news video, Capitol Report. You’ll see them in your e-mail inbox in every edition of the TAFP electronic newsletter, QuickInfo. You can also sign up to serve as Physician of the Day at the Capitol—a great opportunity to show lawmakers the importance and value of family medicine. And you can sign up to be a TAFP Key Contact. Just go to www.tafp.org to take part in both programs. As the session heats up, more and more contentious items are certain to arise, including the sunset of the Texas Department of Insurance, voter identification, and legislative redistricting. Stay tuned and rest assured that your Academy is fighting to protect your patients and your practice. :
Bleak House: Family medicine and the great budget debate, day one posted: Jan. 19, 2011 | author: Jonathan N Texas lawmakers got their first chance to comment on the first draft of the House budget for 2012-2013 today, when Appropriations Chair Jim Pitts took questions on the floor. The draft budget is $31.1 billion slimmer than the state’s current budget, coming in at $156.5 billion in all funds. That means general revenue plus federal matching funds. The capitol press corps was in fine form, tweeting and texting a constant stream of budget-related news, and filing stories at a fevered pace. Check out the Texas Tribune’s coverage for a healthy dose: http://www.texastribune.org/. Several lawmakers were upset over the proposed closure of four community colleges, and massive cuts to public education got a lot of play as well. Lost amid the critiques and complaints was the proposed fate of a set of programs designed to strengthen primary care. The House budget would eliminate $26.8 million that support family medicine residency programs through the Texas Higher Education Coordinating Board. A year ago, we published a story in Texas Family Physician about the closure of the Kelsey-Seybold Family Medicine Residency Program in Houston that detailed the budgetary difficulty afflicting such programs. These funds, while not a great amount, go directly to the programs, unlike federal GME funding, which the programs must cajole out of their affiliated teaching hospitals. And these funds advocated by TAFP and protected by the coordinating board specifically support the residency training of primary care physicians. GME formula funding took a hit, too. That money goes to the state’s medical schools, which in turn use it to support their residency programs. Total state spending on GME in 2010-2011 was $118.4 million, but in the draft for 20122013, it was cut down to $66.3 million. Another victim: the Statewide Primary Care Preceptorship Program, which places medical students in primary care clinics so they can experience the joy and excitement of frontline medicine. The draft budget defunded the program. And then there’s TAFP’s crowning achievement of the 81st Legislature, the Physician Education Loan Repayment Program, which provides up to $160,000 for physicians who serve in health professional shortage areas for four years. The program was zeroed out in the draft budget. For years now, we’ve been engaged in a debate about improving the quality of care patients receive while controlling the cost of that care through system reforms intended to increase access to primary medical care. These programs are some of our great achievements in pursuit of that goal. In their place, the Legislative Budget Board recommended that the state grant nurse practitioners the authority to diagnose and prescribe without any physician collaboration or supervision. “Allowing APRNs to diagnose and prescribe up to the limits of their education and certification would allow them to provide lower-cost primary care for patients within their professional scope,” the LBB advised in a report released with the draft budget. As Chairman Pitts reminded lawmakers on the floor this morning, this budget is only a draft, and there’s a long way to go before this thing’s a done deal, but it’s a stark beginning to what is certain to be a tough session. Care to comment? You can speak your mind online at TAFP’s new blog, Texas Family Docs—Blogging the state of health care in Texas.
www.ta f p.or g | wi n t er 2 0 1 1
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COVER STORY
w i nt e r 2 0 1 1 | T e x as Family Physician
Accountable Care Organizations
ACO Health system reformers hope the
is a game-changer. Are you ready to play? By Kate Alfano
Facing ballooning costs in the current fee-for-service-based health care system, payers are actively seeking different ways to pay for care. One model—the accountable care organization—is designed to bend the cost curve by encouraging physicians to coordinate their services within the continuum, and paying them based on their ability to improve the quality of care their patients receive.
photo illustration: JONATHAN NELSON
This isn’t a new concept; ACOs have been gaining traction for years in academic and policy institutions. They recently received a boost through the Patient Protection and Affordable Care Act, which aims to test the model first in Medicare, and if it works, expand it into other patient populations using additional payment models. Moving away from medicine as we know it raises a lot of questions, but one expert says it’s far from political. “The health reform we’re going through right now is not a Democratic or Republican ideology,” says James Martin, M.D., chief medical officer of the Christus Santa Rosa Health System in San Antonio. “It is based on economic realities that the country will go bankrupt if we continue to address health care and pay for health care the way we do right now. The sooner physicians can quit trying to frame it in terms of conservative or liberal viewpoints and really address the economy, the better we’ll be moving forward.” As described in the health reform law, ACOs are groups of affiliated health care professionals that agree to be accountable for the quality, cost, and overall care of patients for whom their physicians provide the bulk of primary care services. Several organizations could potentially form ACOs, including physicians in group practice, physicians in networks
of practices, hospitals and physicians in partnerships, and hospitals employing physicians. The only ACO program created in the law is the Medicare shared savings program, scheduled to launch Jan. 1, 2012. The law also provides for a Medicaid pilot and other payment and delivery models devised through the new Center for Medicare and Medicaid Innovation. Insurers and others in the private market are expected to follow with their own ACO programs. As for Medicare, qualified ACOs must coordinate care, define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and encourage investment in infrastructure and redesigned care processes. In return for meeting quality and cost targets, physicians within the group are eligible to receive “shared savings” bonuses on top of their typical fee-for-service payments. Even though the Centers for Medicare and Medicaid Services won’t release the full guidelines until late winter, and the Federal Trade Commission and U.S. Justice Department are working to clarify antitrust issues, a lack of details hasn’t stopped physician groups, hospitals, and others from positioning their organizations for what’s to come. This includes some hospitals in large urban areas of Texas that have begun aggressively campaigning to purchase medical practices, particularly in primary care. www.ta f p.or g | wi n t er 2 0 1 1
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John K. Frederick, M.D., is a private practice physician at South Austin Family Practice Clinic.
o ity t ortun p t p o s, bu an ation z en us i v n i a g d s rg m ha ip an ew o refor ese n dersh h a h t e t l l o o t “Hea show her t egral ch ot up to e int a p e m e o t h c s t i be ctors ate w if do orpor c n i only y to .D. abilit ick, M r e some d .” e ies K. Fr entit John form
w i nt e r 2 0 1 1 | T e x as Family Physician
photo: KATE ALFANO
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“It appears that the ACO structure requires that there be primary care involved, which is why there has been a sudden resurgence of interest in primary care,” says John K. Frederick, M.D., a family physician at South Austin Family Practice Clinic. “It’s because hospitals and other groups have interpreted [the law] as meaning they have to have a strong and vibrant primary care presence. These big entities are trying to find primary care wherever they can, and in Austin, they’re trying to buy practices or absorb practices very rapidly.” Facing pressure to consolidate, reorganize, and rethink the way they practice, this time of change can be unsettling for physicians— especially those in small-group, solo, or rural practice settings—but Frederick says reform will ultimately be good for family doctors and their patients. He points to data showing that communities with a large presence of primary care have cheaper and better health care, which have also piqued the interest of lawmakers. “I interpret what [health care reform] has tried to do with family practice is to be supportive of the model of having an aggressive and very active family practice base,” Frederick says. “In a sense, it’s given us an opportunity to become integral to these new organizations, but only if doctors step up to show leadership and some ability to incorporate with each other to form entities.” Some physicians are wary of ACOs and liken them to the health maintenance organizations of the 1990s, the last time physicians faced this type of integration. In some cases, Frederick says, they were very good for primary care, and for others, disastrous. “If you think of it in its largest sense, it really is reminiscent of historical managed care in the ’80s and ’90s where a group of physicians or a delivery system takes responsibility of the care of a population,” says Norman Chenven, M.D., founder and CEO of
Austin Regional Clinic, a multispecialty group with a heavy concentration of primary care. “That’s my definition of an ACO; it’s taking responsibility for both the quality of the care delivered and the cost of care delivered to a defined population of people.” Doug Ardoin, M.D., M.B.A., says this type of delivery system can be very beneficial for patients if executed correctly. He is physicianin-chief for the Memorial Hermann Healthcare System in Houston. “The ACO is about a continuum of care; it’s not about an isolated episode of care in time. It is about taking care of populations of patients and knowing who in your panel has chronic disease that needs to be better managed in an outpatient setting.” It’s about engaging your patients and walking them through all of the different care settings, he says, “so you reduce waste, reduce duplication, and you better coordinate care through the continuum.” HMOs failed because they didn’t value this type of continuity or the primary care physician’s role in addressing the health care of the individual, says Christus’ Martin. What makes this time different is the federal government’s commitment to value primary care. According to Martin, officials are committed to paying primary care physicians more than what they’ve been paid, offering them a care management fee to help them continue doing the routine preventive care, and implementing pay for performance measures. “Those are the big differences in what the HMO was and what I see the ACO becoming,” he says. “Everybody I’ve talked to nationally about ACOs says that if we do not have a strong primary care infrastructure based on the patient-centered medical home, the ACO will fail. It’s a complete turnaround from what it was when the primary care physician was simply a gatekeeper and a necessary evil; now that person will become the leader of the process.” Encouraging family physicians to step up as leaders of ACOs is the key message of the Joint Principles for Accountable Care Organizations, published by AAFP in November in collaboration with the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. They assert that ACOs must have a strong foundation of primary care using the patient-centered medical home model and must have strong physician leadership at all levels of the organization, with “significant and equitable representation from primary care and specialty physicians.” Gary Piefer, M.D., agrees. “Family physicians have to be keenly involved in the leadership and development of governance, and of the business model.” Piefer is the chief medical officer of WellMed, a group of affiliated companies founded in San Antonio that includes an employed physician group, a health plan, a transportation company, and a disease management company. He describes WellMed as a functional medical home operating as an accountable care organization that is led and governed by primary care physicians delivering high-quality, cost-effective health care. “What we’d really like to see family physicians do is to get themselves in the position that they’re organized appropriately and can help significantly impact the leadership and governance of whatever happens in an accountable care organization,” Piefer says. “They’re not very well positioned to do it because the debate tends to be on trying to improve reimbursement when the discussion should be how to improve quality. Because once you improve quality, you’ll now have money left in the pool. Then the question becomes how you distribute it.” AAFP can’t give the same advice to every physician; each market is different. However, Academy leaders say they can tell physicians the issues and options to consider, and the questions they should be asking hospitals and others involved in forming an ACO. Until
Medicare Physician Group Practice demonstration The ACO concept in the health reform law is modeled after a five-year CMS pilot project that began in April 2005, called the Medicare Physician Group Practice demonstration. As the law was being written, lawmakers had access to the second-year results. Since that time, other outcomes for years three and four have been released. For the demonstration, CMS contracted with 10 large multispecialty groups with varied organizational structures to see whether care management initiatives could produce cost savings for the system and improve quality. On top of individual physicians’ fee-for-service claims, groups were eligible for an 80-percent share of Medicare’s savings if they collectively achieved quality and cost targets for the patients loosely assigned to their group. There were no penalties for missing the targets. To qualify for these performance payments, groups had to generate savings for Medicare parts A and B of more than 2 percent of their target expenditures. CMS established the spending targets by creating a comparison group of Medicare beneficiaries in the same geographic area and comparing the organization’s per capita expenditures in its base year with those for the comparison group. Results revealed that all 10 entities achieved significant improvements in quality of care and patient satisfaction, with half receiving performance payments of $31.7 million in the fourth year of the program. The groups who earned bonuses attributed the savings to changes in their organizational structure, investments in care management programs and health information technology, and continuing education and feedback for providers. The four groups who earned performance payments by the second year were affiliated with an academic medical center or were unaffiliated physician groups. The five groups who received no performance payments in the second year were part of integrated delivery systems with hospitals or a physician network sponsored by a hospital. The majority of the savings at all sites occurred in outpatient services. The Marshfield Clinic in Marshfield, Wis., received the most over the four-year span, a total of more than $40 million. :
CMS releases the final guidelines, AAFP advises physicians to prepare for clinical and financial integration, and to consider investing in health information technology if they haven’t already done so. Continue working to implement aspects of the patient-centered medical home, communicate with other physicians in their community about organizing a virtual or actual group practice to enhance their market leverage, collect data on their practice’s quality and cost effectiveness to establish their value in the market, continue talking with and listening to commercial payers about ACOs, and follow updates on regulatory implementation and network with other members of their health care community. www.ta f p.or g | wi n t er 2 0 1 1
23
s t ACO abou y l l a n y natio rimar d to ong p e r k t l s a I’ve t ave a ient not h ybody e pat r o h e d t v E e n “ o if w fail.” ased that will ure b t O c C says u A r he st me, t infra al ho care c i D. d e , M. dm e n i r t e r t a cen C. M
-
s
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AAFP also asks members who have gone through this process to become an expert to assist others. Based on his past experience with population-based care, ARC’s Chenven says aligning necessary resources and developing infrastructure for ACOs is daunting, even to someone who has done this sort of thing before. “You don’t just grab a few doctors and decide you’re going to be an ACO,” he says. “It’s much more complicated than that.” According to Chenven, physicians must first have a very well thought-out business plan. Second, they need to have a source of capital that can be invested in the venture, or “adventure” as he says may be more appropriate. Third, they must have a real commitment to finding experienced managers, both physicians and laypersons, who have experience with this type of model. “I think it’s much harder for small practices to do, and I think the small practices will have to find ways to link arms and work together with each other to develop at least enough scale to spread the overhead on the kinds of investments you need to do this,” Chenven says. “A lot of investment is in the IT system, but it’s also dedicated staff to manage the program, dedicated case managers, outreach people, that sort of thing, who are contacting patients.” Piefer says the rise of the ACO doesn’t spell doom for the solo practitioner, “but if you generally want to be successful in the long run, you’ll need to learn how to affiliate and work in teams.” That’s why Frederick, a private-practice physician for 20 years, is exploring the idea of forming a virtual physician network of other small-group and solo primary care practices in his community rather than joining a multispecialty network or a hospital system. “Those are not bad options, but there are a lot of physicians who want to maintain their autonomy and their own self-determination. They don’t want to be owned by anyone,” he says. Still in the planning stages, his organization would give private practices a chance to stay as they are while pooling resources in health information technology and administration. “To some degree they’ll have to clinically be a part [of the larger group], but if we can do that virtually and allow them to continue to have a say in what happens to their practices professionally, to me, that’s a very good option for a lot of smaller practices.” As their ACO takes shape, Frederick and his partners must overcome several of the challenges already mentioned. They are actively seeking funding and equity partners, and seeking answers to legal questions. Of the practices that have already made the switch to electronic medical records, each has a different system that will need to be connected with the others to allow for clinical collaboration. And they must overcome physicians’ attitudes toward organizing. “There’s a big hill of pessimism, fear, and suspicion we’re trying to get over.” 24
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Regardless of how individual physicians choose to collaborate, they can no longer “hunker down” and survive, says Christus’ Martin. He points out that if ACOs don’t work, “something else must step up to the plate right after that also addresses the principles of primary care infrastructure and health outcomes.” There’s no going back to the old system, he says. To make ACOs work, “it’s going to take a change in how we [physicians] take care of business, moving away from a physician-centric model to a patient-centric model, willingness to use guidelines of best practices, and providing consistency of care. It will require physicians to report their outcomes, their successes, which are all new and different. It will also force physicians to look for partnerships in the community, whether it’s the hospitals, or a larger physician organization, or another health system,” Martin says. “Hospitals will really have to adjust because they’ve always been focused on revenue-generating into the hospital. The new ACO, as I understand it, is actually going to reward more to keep people out of the hospital. So hospitals will have to change the way they look at their health system.” Instead of asking how much money we made, the question is how well we took care of patients in this community and did our outcomes support what we’re trying to accomplish, he says. Accountable care ultimately must be about improving and maintain the health of a population of patients and not just about controlling costs, AAFP says. It must be about proactive and preventive care, not reactive care; about outcomes, not volume or processes; about leveraging the value of primary care and the patient-centered medical home. “At the end of the day, it ain’t rocket science, it’s just work,” says Memorial Hermann’s Ardoin. “It’s not like we’re building a spaceship. All these parts and pieces already exist; the work is just connecting them and making them work as a unit. That’s where I think everyone needs to take a step back and realize that ACOs and the law aren’t about creating a new map. All of these parts already exist, we just need to quit functioning in our silos, open the door to the continuum and connect the dots.” :
resources on accountable care organizations AAFP will publish a set of ACO resources this spring, but in the meantime, here are some resources you can find on www.aafp.org. > Joint Principles for Accountable Care Organizations http://tinyurl.com/29tr75k > AAFP Accountable Care Organization Principles http://tinyurl.com/4en6a4b > Family Practice Management—Opinion: The PCMH and ACO: Opposed or Mutually Supportive? www.aafp.org/fpm/2010/1100/p6.html > AAFP Accountable Care Organization Task Force Report, October 2009 http://tinyurl.com/4ftho96 > Private Sector Advocacy: ACOs http://tinyurl.com/4rgnr8v
quality improvement
BRIDGING THE QUALITY CHASM Blue Cross and Blue Shield of Texas and Bridges to Excellence collaborate to recognize and reward Texas physicians By Eduardo Sanchez, M.D. Vice President and Chief Medical Officer, Blue Cross and Blue Shield of Texas
H
ere’s a riddle many physicians have reflected on with some frequency: How do you increase the quality of patient care, enhance practice income, and, at the same time, reduce the cost of health care? For Texas physicians, Blue Cross and Blue Shield of Texas and Bridges to Excellence are beginning to crack that conundrum. How? BTE makes it their mission to help clinicians build their practices, help patients get healthier, and help insurers and employers manage costs better. In fact, BTE programs recognize and reward clinicians who deliver superior patient care and place a special emphasis on managing patients with chronic conditions, who are most at risk of incurring potentially avoidable complications. That’s why Blue Cross is a sponsor of the BTE organization and specifically supports their Diabetes Care Recognition and Cardiac Care Recognition programs. The sponsorship is a result of BCBSTX’s commitment to making health and wellness a priority for its members, and BCBSTX financially rewards physicians for their performance and their BTE recognition status in the diabetes and cardiac care programs.
The goals of BCBSTX sponsorship of BTE are to: • Improve patient outcomes and quality of life. • Financially reward physicians who provide superior care to members with diabetes and cardiac disease. • Reduce the economic burden of caring for BCBSTX members. • Link into other established Blue Care Connection medical and dental programs that interact directly with members to help improve their health and disease condition. We understand the value of BTE-recognized physicians in treating members with chronic conditions. In response, BCBSTX has developed a statewide program that provides financial incentives to physicians who seek and obtain BTE recognition and who treat members with diabetes and cardiac disease. BCBSTX offers BTE-recognized physicians the opportunity to earn $100 per selected patient, per year, per program for providing excellent care. The BCBSTX-BTE collaboration also has received high marks from the physicians who participate. “This is a significant shift for providers,” says Scott Conard, M.D., chief www.ta f p.or g | wi n t er 2 0 1 1
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TABLE 1: How to become a BTE recognized physician Pathway NCQA
Quantity of data submitted
How data is extracted/submitted
Cost to apply (individual)
Cost to apply (groups)
Sample of 25 diabetic patients.
Clinicians will abstract data from patient charts and submit to NCQA for review.
$360
$360 each with a max of $2,700 for groups of up to 100. For groups over 100, $10 surcharge for each physician.
IPRO portal
Full patient panel of diabetic patients when possible, otherwise sample of 25.
Patient data is manually or electronically extracted into a standard file format and uploaded to the web portal for assessment.
$95
$295 per practice of 3 or more clinicians.
ABIM
Sample of 25 diabetic patients.
Direct electronic submission to IPRO through ABIM PIM.
$95
No group/practice option.
EMR/Registry system
Full patient panel of diabetic patients.
EMR or registry vendor will extract patient data from clinicians’ electronic system and submit to MNCM or IPRO on their behalf.
No BTE or PAO* fee.
No BTE or PAO* fee.
*The PAO will be either IPRO or MNCM.
medical and strategy officer at Medical Edge Healthcare in Dallas. “Ensuring a patient gets appropriate, timely, comprehensive care requires the development of new systems of care. This takes capital. Before this program, it was a labor of love. This is the beginning of systematically paying for quality, which will drive higher and higher quality while reducing waste and redundancy. As the old adage says, ‘you get what you pay for,’ and finally the financial and quality will unquestionably and clearly be aligned.” Blue Cross and Blue Shield of Texas believes that the collaboration is a win-win for patients and primary care practices. We want to see more of our members and more of our providers, physicians, and non-physicians reaping the benefits of this program, which reinforces and financially rewards high-quality primary care and that also results in better outcomes and lower costs. To achieve these goals and outcomes, BTE programs are designed around three key lessons gained from research and experience. First, it’s critical to measure what matters most—the handful of indicators that have truly significant clinical and financial impact. These are the quality measures most predictive of improved patient health. These measures also form a set of indicators to help practices identify patients who are not well controlled and need more proactive management. Second, clinicians who follow those quality measures will consistently provide better care at lower costs. Typically, they outperform their peers on process measures of quality and have lower average costs per patient and per episode. In part, this is because they tend to rely more on evaluation and management and less on tests and procedures; they know costlier care is not always better care. 26
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Third, incentives only work if they are fair, so clinicians who continually improve their practices are rewarded appropriately. As physicians improve the management and treatment of chronic conditions, more patients should be encouraged to utilize them. As in any industry, the best performers should earn the most and have the biggest market share. Several studies have shown how BTE recognition leads to improved physician performance, better patient health, and reduced costs of care. Patients of BTE-recognized physicians with chronic conditions generally had fewer hospital admissions and were healthier, on average. In addition, recognized practices reported a higher level of shared accountability between patients and providers. As a result, these patients typically are better managed and incur fewer hospitalizations and emergency department visits. After BTE recognizes a physician in either its Diabetes Care Recognition program or the Cardiac Care Recognition program, BCBSTX will identify members with diabetes or cardiac disease for their respective physicians. Recognized physicians will be asked to provide biometric information and will then be eligible for the financial reward. There is no cap on the number of patients per year for which a physician may receive a financial incentive. To date, the number of BTE-recognized physicians in Texas has gone from less than 40, when the BCBSTX recognition program was initiated, to almost 400. That growth has been realized in 18 months. BCBSTX wants to double the number of BTE-recognized physicians in 2011. In fact, BCBSTX encourages all physicians in Texas treating patients with diabetes or cardiac disease to seek and obtain BTE recognition. Once recognition is achieved, all physicians are automatically eligible for participation in the BCBSTX BTE program. For more information, please visit the BCBSTX BTE website at www.bcbstx.com/provider/training/bridges_excellence.html. :
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Primary care physicians, psychiatrists, advanced practice nurses and physician assistants Texas state supported living centers are looking for full- and part-time primary care physicians and psychiatrists, advanced practice nurses and physician assistants to fill vacancies across the state. We offer challenging opportunities, competitive salaries, and excellent benefits. For more information contact: Julie Graves Moy, MD, MPH, FAAFP Medical Director 512-810-2533 julie.moy@dads.state.tx.us or Judy Garner, recruiter judy.garner@dads.state.tx.us
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The program is free to your practice, and enrollment is completely voluntary. The Texas Academy of Family Physicians is partnering with Atlantic Health Partners because Atlantic can save family physicians money, advocate for fair payment and support family medicine.
Atlantic also works as an advocate – working directly with payers on issues such as payment for vaccines and administration. They can provide a number of resources on billing, coding, pricing and inventory management.
Atlantic Health Partners will donate 10 percent of revenue from all TAFP member sales to TAFP and provide an additional $1,000 unrestricted educational grant to the TAFP Foundation for every 125 TAFP members registered.
Contact Cindy Berenson or Jeff Winokur at (800) 741-2044 or info@atlantichealthpartners.com for more information and to register.
RESEARCH
Monitoring and management of cardiovascular risk factors by primary care physicians at an academic medical center Cindy Ripsin, M.S., M.P.H., M.D. Associate Residency Director University of Texas Southwestern Austin Family Medicine Program This study was funded in part by a research grant from the TAFP Foundation. Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions. Gold level Richard Garrison, M.D. David A. Katerndahl, M.D. Bronze level Carol and Dale Moquist, M.D. Thank you to all who have donated to an endowment. For information on donating or creating a new endowment, contact Kathy McCarthy at kmccarthy@tafp.org.
One in 10 adults in the United States have diabetes and recent information suggests that will rise to one in three by 2050 if current trends continue.1 Although cardiovascular disease (CVD) is the leading cause of death for all Americans, it is accelerated in persons with diabetes.2 Targeted management of CVD risk factors—blood pressure, low-density lipoprotein cholesterol (LDL-C), and urine microalbumin in addition to hemoglobin A1C—for patients with type 2 diabetes mellitus (T2DM) has been shown to decrease total and CVD mortality,3,4 and detailed guidelines are available.5 However, published reports suggest that patients are not routinely receiving comprehensive management of these risk factors.6-9 A retrospective analysis using a system-wide electronic health record at an academic medical center was performed to determine to what extent patients with T2DM are receiving targeted management of CVD risk factors by primary care physicians (PCPs) according to the guidelines published by the American Diabetes Association.5 METHODS Study design: Retrospective cohort. Subjects and setting: Electronic health records of patients who received management of their diabetes by PCPs (family medicine, internal medicine) at an academic medical center from January 2007 through July 2008 were analyzed after obtaining approval from the human subjects committee of the local institutional review board. Inclusion/exclusion criteria: Subjects were initially included if they had any diagnosis of diabetes (ICD 250. xx), were at least 30 years old, non-pregnant, and had three or more visits to one of the primary care clinics during the study period. Once these records (n = 856) were received, patients were further excluded if at least three visits were not with the same physician during the 18-month study period (n = 217) or if diabetes care was managed at a specialty care clinic (n = 238). An additional 145 records were excluded for miscellaneous reasons that included a lack of laboratory data or a notice of death at the time of chart review; charts of deceased patients were not accessed.
RESULTS Records representing 256 unique patients met all criteria and were included in the analysis. For the 18 months of the study period, mean frequencies for monitoring CVD risk factors were: hemoglobin A1C 2.7 (STD 1.48); blood pressure 6.83 (STD 2.96), LDL-C 1.82 (STD 1.16), serum creatinine 6.2 (STD 9.12), and urine microalbumin 0.60 (STD 0.75). Average values for the study group as a whole for these same CVD risk factors were: A1C 7.6 percent (STD 1.74), blood pressure: systolic 134 mmHg (STD 22) and diastolic 76 mmHg (STD 12), and LDL-C 103 mg/dL (STD 31.3). The values were significantly modified by age for A1C (< 65 years = 7.99 percent and > 65 years = 7.19 percent; p = 0.0004), and diastolic but not systolic blood pressure (< 65 years = 77 mmHg and > 65 years = 74 mmHg; p = 0.032). Only the value for LDL-C was significantly modified by gender (females = 110 mg/dL and males = 93 mg/dL; p = 0.0007). Data were also analyzed to determine if there were significant differences in the surveillance of CVD risk factors between family medicine and internal medicine physicians. There was a significant difference in the frequency of monitoring A1C (p = 0.0001) and LDL-C (p = 0.04), but not in the actual values themselves. However, comparisons using physician type were found to be confounded by significant differences in referral patterns between family medicine and internal medicine physicians (p = 0.03). Although approximately half of the initial sample of 856 (56 percent) of patients were managed by family physicians, family medicine patients accounted for just over a third (38 percent) of excluded patients based upon this criterion. The discrepancy in referral pattern was most pronounced at the faculty level; in the final analysis, 15 of the 256 patients were managed by internal medicine faculty compared with 100 patients being managed by family medicine faculty, and 58 and 82 by family medicine and internal medicine residents, respectively. The proportion of patients prescribed statins (57 percent), aspirin (34 percent) and ace-inhibitors (61 percent) was assessed. Controlling for gender www.ta f p.or g | wi n t er 2 0 1 1
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approached but did not achieve statistical significance for statins (p = 0.069) and ace-inhibitors (p = 0.069), and adherence by age approached but did not achieve significance for statins (p = 0.068) and for ace-inhibitors (p = 0.068). DISCUSSION The frequency of monitoring CVD risk factors in this group of patients did not uniformly comply with recommended guidelines. On average, monitoring hemoglobin A1C and urine microalbumin occurred less often than recommended by the guidelines, while blood pressure and serum creatinine were monitored at least as often as the guidelines recommend. One would expect that the frequency of monitoring hemoglobin A1C should approach six (every three months for an 18-month study period) since the average A1C was less than ideal at 7.6 percent, and urine microalbumin should be measured annually. Although the frequency of monitoring for serum creatinine and blood pressure was on target with stated guidelines, this doesnâ&#x20AC;&#x2122;t necessarily reflect a conscious effort to monitor CVD risk factors since blood pressure is routinely measured at every office visit regardless of the reason for the visit, and serum creatinine is a part of virtually every chemistry panel. One of the touted benefits of an electronic health record is the ability to track and monitor health parameters in a systematic fashion. This analysis shows that simply using an electronic health record did not lead to improved monitoring of CVD risk factors. The disparity in referral patterns between family physicians and internal medicine physicians was a significant and unexpected finding. Determining the reason for this is beyond the scope of this study, but one could speculate that perhaps internists see patients with more advanced disease and therefore need to refer proportionately more patients, or that family physicians are more comfortable managing patients with more advanced disease. Perhaps some combination of the two created this discrepancy. Regardless of the reason, it seems prudent to exercise caution when interpreting these as well as other study results that compare or contrast the management of primary care patients according to medical specialty. Since statins, aspirin, and ace-inhibitors are standard medications for most patients with diabetes, it is disappointing to see the relatively low proportion of patients on these medications in this study, but these values are in line with those from the published literature.7 Aspirin use is almost certainly under-reported in this group of patients; electronically-generated prescriptions formed the data set for this part of the analysis with a secondary assessment of medication lists. Since aspirin is not a prescription medication it will not appear on an electronic medication list unless the provider enters it separately.
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STRENGTHS This study was designed to reliably represent management of diabetes and CVD risk factors by PCPs. Because of the strict inclusion criteria the final sample was quite small, and these results need to be validated with a much larger sample of patients. In addition, this study was conducted at an academic medical center so the ability to apply the results to other primary care settings is limited. SUMMARY Monitoring and management of CVD risk factors did not uniformly occur according to recommended guidelines in this sample of patients in spite of the use of an electronic health record. Comparisons between the management practices of family medicine and internal medicine physicians were confounded by significantly disparate referral patterns to subspecialty care, so comparing management practices across primary care specialties should be done cautiously if at all. : BIBLIOGRAPHY 1. Centers for Disease Control and Prevention. 1600 Clifton Road, Atlanta, GA 30333. Number of Americans with diabetes expected to double or triple by 2050. Oct. 22, 2010. 2. Rao SV and McGuire DK. Epidemiology of diabetes mellitus and cardiovascular disease. In Diabetes and Cardiovascular Disease: Integrating Science and Clinical Medicine. Editors: Steven P Marso and David M. Stern. Lippincott Williams and Wilkins, 2004. Philadelphia Penn. 3. Gaede P, Lund-Anderson H, Parving H, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Eng J Med. 2008;358:580-591. 4. Gaede P, Vedel P, Larsen N, et.al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Eng J Med. 2003;348:383-393. 5. American Diabetes Association. Clinical practice recommendations 2008. Diabetes Care. 2008;31(Supp 1). 6. Beaton S, Nag S, Gunter M, Gleeson J, Saijan S, Alexander C. Adequacy of glycemic, lipid, and blood pressure management for patients with diabetes mellitus in a managed care setting. Diabetes Care. 2004;27(3):694-698. 7. George P, Tobin K, Corpus R, Devlin W, Oâ&#x20AC;&#x2122;Neill W. Treatment of cardiac risk factors in diabetic patients. How well do we follow guidelines? Am Heart J. 2001;142(5):857-863. 8. Massing M, Henley N, Carter-Edwards L, Schenck A, Simpson Jr. R. Lipid testing among patients with diabetes who receive care from primary care physicians. Diabetes Care. 2003;26(5):1369-1373. 9. Putzer G, Roetzheim R, Rameriz A, Sneed K, Brownlee Jr. H, Campbell R. Compliance with recommendations for lipid management among patients with type 2 diabetes in an academic family medicine practice. J Am Board Fam Pract. 2004;17(2):101-107.
FOU N DAT ION FOCUS
2010 TAFP Foundation Donors Thank you to the 2010 TAFP Foundation donors whose contributions fund scholarships for Texas medical students, family medicine research grants, and travel scholarships for residents to attend continuing education activities.
Kelly Alberda, MD Kate Alfano Trisha A Allamon, MD Barbara L Allen, MD D Crawford Allison, MD Michael Alan Altman, MD Ichabod L Balkcom, IV, MD Maria Diana Ballesteros, MD Tom Banning Charles Oliver Barker, MD Lynda Jayne Barry, MD Justin V Bartos, MD Arturo Enrique Batres, MD Joane Goforth Baumer, MD Stephen Douglas Benold, MD Jahnavi Bheemreddy, MD Alex J Blanco, MD Henry Julius Boehm, Jr, MD Emily D Briggs, MD Craig D Brown, MD Dennis L Brown, MD Augusto A Castrillon, MD Chinglin Lillian Chan, MD Terence Chang, MD C Mark Chassay, MD George Wilson Childress, MD Samuel T Coleridge, DO Barbara Nell Conner, MD Seth B Cowan, MD Michael Avery Crouch, MD John Cullen Kenneth Gayle Davis, MD Tamra K Deuser, MD Joseph C De Witt, MD Jorge Duchicela, MD Roberto Duran, MD Carolyn Eaton, MD Bruce Alan Echols, MD Tricia C Elliott, MD Robert Floyd Ezell, MD Troy Treanor Fiesinger, MD Lewis Emory Foxhall, MD Edwin R Franks, MD Gregory Michael Fuller, MD Kelly A Gabler, MD Melissa Susan Gerdes, MD
Rebecca Gladu, MD Lisa Biry Glenn, MD Roland Adolph Goertz, MD Mae Pacis Gonzales, MD Wayne Gossard, MD John Edward Green, III, MD Thomas David Greer, MD Nellie Poh-kee Grose, MD Ajay Kumar Gupta, MD Natalia Gutierrez, MD Lesca C Hadley, MD Parul Harsora, MD Guoxiang He, MD James M Henderson, MD Harriet Nailor Hilliard, MD Terrance S Hines, MD Kim Hollon James G Horton, MD Charles V O Hughes, III, MD Leigh Hunter, MD Janet L Hurley, MD Walter V Hyde, Jr, MD Bruce K Jacobson, MD Melanie Lane Reed, MD John C Joe, MD, MPH, PhD David Arthur Katerndahl, MD William Frank Key, Jr, MD Art L Klawitter, MD Kaparaboyna Ashok Kumar, MD, FRCS James Lackey, MD C Tim Lambert, MD Doyle K Lansford, MD Lars Larsen, MD Pierre Lebahar, MD Kay Lynn Lee, MD Leah Raye Mabry, MD Bonny Macfarlane, MD, CM Javier D Margo, Jr, MD Elizabeth R Mattson, MD Erik William Maynard, MD Kathy McCarthy, CAE John M McCullough, MD Gary R Mennie, MD Nina Miller, MD Presley Joe Mock, Jr, MD
Dale C Moquist, MD Mary Helen Morrow, MD Lynda Mueller, MD William Mygdal, EdD Jonathan Nelson Mary S Nguyen Poole, MD Hall E Nichols, MD Donald R Nino, MD Rebecca A Olivares, MD Luis C Palacios, MD David M Palafox, MD Billy Don Pierce, MD Henry David Pope, Jr, MD Juanita Porter Clarence H Prihoda, Jr, MD Alma M Pruessner, MD Theron Dale Ragle, MD Harvey Resnick, MD Murray Charles Rice, MD John R Richmond, MD Shelley Poe Roaten, Jr, MD Leon Rochen JoAnne L Rogers, MD Fred Rohm, DO Alex Salazar, MD Ramiro Sanchez, MD Manuel Josue Sanchez, MD Lee R Schreiber, MD M Sandra Scurria, MD Duck Gi Moon Seo, MD Judge Timothy Seo Amer Shakil, MD Charles Edward Shields, MD Robert F Shields, DO Alka P Shirodkar, MD Zafreen Arfeen Siddiqui, MD Linda Marie Siy, MD David B Skelton, MD Brad Sloan, MD Beverly Smay Tobie-Lynn Smith, MD Hubert L Smith, Jr, MD Howard Smith, MD Laura Snell, MPH Mary Carmen Spalding, MD Janice Srivathanakul
Donald E Stillwagon, MD Thomas R Strawmyer, MD Irwin Streiff, MD Erica Williams Swegler, MD Sheri J Talley, MD Thomas Bruce Tennant, MD James R Terry, MD Amalia Tinoco, MD Kevin Lee Tomsic, MD, DC Ashok Tripathy, MD Thao Minh Truong, MD Sharon Elizabeth Tucker, MD Peter M Valenzuela, MD, MBA Lloyd Van Winkle, MD David B Vaughan, MD John S Volk, DO Loc Tien Vu, MD Bradley D Wasson, DO Sally Pyle Weaver, MD
Judith K Werner, DO Jim and Karen White Walter D Wilkerson, Jr, MD Hubert Neil Williston, MD Hugh H Wilson, Jr, MD Thomas Paul Winkler, MD Keith Allen Wixtrom, MD Hong Xiao, MD Khalida Yasmin, MD Robert Allen Youens, MD Richard A Young, MD Baylor Health Care System Gold Star Show Services Memorial Family Medicine Residency Faculty Pepsico Foundation Southwest Center for Reproductive Health
Thank you to these monthly donors Trisha A Allamon, MD Barbara L Allen, MD Maria Diana Ballesteros, MD Lynda Jayne Barry, MD Justin V Bartos, MD Arturo Enrique Batres, MD Joane Goforth Baumer, MD Stephen Douglas Benold, MD Alex J Blanco, MD Henry Julius Boehm, Jr, MD Emily D Briggs, MD Chinglin Lillian Chan, MD C Mark Chassay, MD Samuel T Coleridge, DO Barbara Nell Conner, MD Seth B Cowan, MD Kenneth Gayle Davis, MD Tamra K Deuser, MD Jorge Duchicela, MD Bruce Alan Echols, MD Tricia C Elliott, MD Robert Floyd Ezell, MD Troy Treanor Fiesinger, MD Lewis Emory Foxhall, MD Gregory Michael Fuller, MD Kelly A Gabler, MD Melissa Susan Gerdes, MD Lisa Biry Glenn, MD Roland Adolph Goertz, MD Ajay Kumar Gupta, MD Natalia Gutierrez, MD Lesca C Hadley, MD James M Henderson, MD Janet L Hurley, MD David Arthur Katerndahl, MD
Kaparaboyna Ashok Kumar, MD, FRCS James Lackey, MD C Tim Lambert, MD Leah Raye Mabry, MD Javier D Margo, Jr, MD Kathy McCarthy, CAE John M McCullough, MD Gary R Mennie, MD Nina Miller, MD Dale C Moquist, MD Mary Helen Morrow, MD Mary S Nguyen Poole, MD Henry David Pope, Jr, MD Theron Dale Ragle, MD John R Richmond, MD Shelley Poe Roaten, Jr, MD Lee R Schreiber, MD Amer Shakil, MD Robert F Shields, DO Zafreen Arfeen Siddiqui, MD Linda Marie Siy, MD Mary Carmen Spalding, MD Donald E Stillwagon, MD Erica Williams Swegler, MD Sheri J Talley, MD Ashok Tripathy, MD Thao Minh Truong, MD Lloyd Van Winkle, MD Sally Pyle Weaver, MD Jim and Karen White Hugh H Wilson, Jr, MD Khalida Yasmin, MD Robert Allen Youens, MD Richard A Young, MD
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MARK YOUR CALENDAR FOR THESE UPCOMING TAFP CME EVENTS C. Frank Webber and Interim Session March 11-12, 2011 Austin, Texas Annual Session and Scientific Assembly July 27-31, 2011 Dallas, Texas For more information, visit TAFP online at www.tafp.org or call (512) 329-8666.
Submit CV to: khall@gchd.org, fax to (409) 938-2243, or call (409) 938-2230.
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practice management
Six opportunities to raise your practice revenue By Bradley K. Reiner Practice Management Consultant, Reiner Consulting and Associates
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ow often do you find yourself wondering how to maximize revenue? Do you think that managing a practice is getting harder and harder? I hear these questions repeatedly from doctors I work with. When asked what struggles they have the answers are similar: volume of patients dropping, payments declining, and overhead rising. What can be done? Physicians wonder if the problems involved with running a practice are their fault or if blame can be placed on managed care plans. Is the cost of running a practice too high? The problem is complex and there are no simple answers. Unfortunately some things can’t be controlled. The good news is there are ways doctors can improve efficiencies, increase revenue, and reduce expenses in their offices. Here are some things that can be done to help maximize revenue and reduce expenses. renegotiate your contracts Have you renegotiated your contracts? When was the last time you updated your contracts and how successful were you? Do you go back every year and renegotiate? If you have never updated your contracts, how long have the contracts been in existence? Contracts that have not been renegotiated in awhile contain opportunities to increase reimbursement if the negotiation is presented to the managed care plan in a formal manner. Things to consider when renegotiating contracts: • Start with the top payers—pick the ones with the biggest impact. • Choose high-volume services representing the bulk of your revenue. Look for the codes that will have the most impact on your bottom line. • Research the total revenue for each one of the plans you want to negotiate. This can be used as comparison when you get an offer. A practice should develop a sophisticated letter that details what the practice wants to accomplish in the nego-
tiation. Several items that should be included in the letter to the payer include: • Specific strengths of the practice—toot your own horn! • Things that make the practice unique, including special services. • Conveniences and quality-improvement initiatives in place for patients. • Cost-effective measures implemented to help reduce costs for the payers. Once you have crafted this letter, submit it to the appropriate contracting managers for consideration. Develop a relationship with the payer’s contracting staff; such relationships can improve your negotiations. If the contractors know you personally, they’re much more likely to work a little harder to help you, which can be the difference between success and failure. Face-to-face meetings with the contractor can help as well. One thing to remember is to never to accept “no” as the only answer. Contractors are trained to say no at the beginning of almost every negotiation. They do this because about 50 percent of the practices will accept this answer and not bother to continue negotiating. Do not let this happen to you. “No” almost always means maybe. Tell them you will not accept no for an answer so they know you are serious and won’t go away easily. Contact the contractor to set up a formal meeting with the decision-makers to discuss the contract. Talk to them about access of care, quality, cost effectiveness, avoiding ER referrals, after-hours care, and other ways that your practice helps them. Make sure they understand that you care about the negotiation and expect success. Come to reasonable compromises. Remember it’s a negotiation, so work to get the best increase you can. Even a small percentage can have a significant effect on your bottom line. www.ta f p.or g | wi n t er 2 0 1 1
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Scrutinize your Billing processes Billing can affect your bottom line in many ways. This is a tremendously important area that is often overlooked because money coming in means everything is going well, right? Not always. You may only be generating a fraction of your potential income. Practices don’t realize that an efficient billing office can increase revenue. So, how do you ensure successful billing in your office? Monitor the staff to ensure they are doing their job. Make certain you hire the best billing staff available. Having a certified biller is not critical, but they must be knowledgeable and experienced in your specialty. Coding is another critical factor. Are you maximizing your coding in the office? Make certain you bill every appropriate code available to maximize your revenue. Be certain modifier use is maximized. Physicians should code the highest evaluation and management service based on their documentation. It might be a good idea to have an outside consultant complete a documentation audit to help you identify areas for improvement and help determine ways to maximize your revenue. This resource usually pays for itself. Meeting deadlines is also a critical factor for billing. You must ensure charges are posted within 24 hours of the day of service. Payments must be posted within the same time period. How are you handling denied claims and zero-pay explanation of benefits? You need a system for how these cases should be worked. How are statements handled and when are patients referred to a collection agency? The practice needs to establish specific policies and procedures for billing so everyone knows their responsibilities and how to achieve defined goals. Incentives—such as a percentage of collections over a certain amount—are an excellent way to motivate and get the most of your billing staff. Collect what you’re owed Is your front office doing everything they can to collect money due at the time of service? Patients have more out-of-pocket responsibilities than they’ve ever had. High deductibles and co-pays are the norm for most patients today. It is critical for medical practices to implement collection policies that require front office staff to collect all balances at the time of service. You don’t want to be chasing these dollars after the patient walks out the door; it becomes much more difficult to collect on these balances and it delays and decreases revenue if you don’t collect the money while he or she is in your office. Outstanding balances are equally as important to collect when the patient is in the office. Do not let patients leave the office without a plan in place for resolving any balance. The best way to ensure that patients are well informed about co-pays, deductibles, and outstanding balances is to improve communication. How you communicate with your patients makes a huge difference in the response you get. Appointments should be verified for every scheduled patient. This should be completed at least two days before the appointment to give patients time to reschedule if necessary. It also allows the practice to communicate specific insurance and payment information, such as the 34
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exact co-pay to be collected at the visit, deductible information to be collected, and any outstanding balances that need to be paid. By communicating information in this way, patients will be better prepared to resolve their balances before they are seen. It also helps streamline the procedure for all front office staff to follow regardless of the situation presented. Consider ancillary services Have you considered adding services to your practice? Many doctors are discovering that seeing patients in the office and hospital is just not enough to maintain viability. One way to increase potential revenue is to offer additional services. Things such as radiology, lab, DME, stress tests, echocardiograms, nerve conduction studies, and even pharmaceuticals in the office can be a revenue enhancer. Of course, before purchasing any equipment, make sure you complete a cost-benefit analysis to ensure you can increase revenue by adding these services. Review codes that will be billed for the services and the average reimbursement for providing them. Estimate the potential revenue impact of providing the service versus the estimated costs, including the cost of supplies and staff time. This cost-benefit analysis can give you a clear picture of whether adding a new service is the best option for your practice. Market yourself Is your volume dropping or do you just need to add more patients? Many offices have seen a significant decline in patients. As co-pays or deductibles go up patients have a harder time affording care. You have to work harder to attract the patients that are seeking care. Don’t assume that if you’ve been in business for 20 years patients are just going to automatically show up at your door. Competition increases choices for patients and you should position yourself to go after these patients. Clinics are popping up everywhere, even in Walmarts and grocery stores, making it more competitive than ever to attract patients. Practices should consider a user-friendly website, print media, radio ads, patient brochures, television, and other forms of marketing. These avenues can have a successful impact bringing patients into the practice. Consider utilizing a health care marketing professional to help you determine which methods will be the most helpful for your situation and goals. This is one resource that can have a real positive impact for your practice. Sublease your extra space Do you have extra space that could be generating money at times during the week? Why not investigate if someone needs a satellite office one to two days a week? Advertise in trade journals and determine the cost of the space charging in four-hour increments. You get the advantage of extra money and the satellite gets a new location. The cost of running a business is expensive and extra space may be one way to generate revenue. Do not miss opportunities to generate more revenue. Be creative or try some of the discussed ideas. This article is by no means exhaustive, but might help enhance your revenue. :
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2010: A YEAR OF INN By Melissa Ayala
L
aunching into a new decade, TAFP experienced a year full of advancements in every category, from technology to politics. 2010 was marked with hard-hitting and award-winning advocacy and communications work, high-quality CME programs, and an ever-expanding network of member resources. Advocacy In April, a group of TAFP leaders gathered in Austin for the 2010 TAFP Leadership and Legislative Conference. Through lectures and interactive demonstrations, attendees enhanced their leadership and legislative skills by receiving training on lobbying and dealing with the media. The training included information on important policy issues, how to build a strong relationship with lawmakers, and how to handle news interviews. In recognition of the Academy’s work to pass the physician education loan repayment bill during the 81st Texas Legislature in 2009, AAFP awarded TAFP the 2010 AAFP Leadership in State Government Advocacy award at the State Legislative Conference in New Orleans, La. TAFP received the award in 2007 for the Academy’s efforts during the 80th Legislative Session to deliver a comprehensive news package to family physicians that included the Capitol Report webcast and Capitol Update e-newsletter. The TAFP Political Action Committee engaged in the November election cycle, building relationships with lawmakers in preparation for the 82nd Texas Legislature. The top issues for family medicine will include maintaining budget allocations that build the primary care workforce and holding the line on nurse practitioners’ scope of practice. To further prepare members for the session, TAFP released multiple advocacy resources for physicians to use to educate their representatives and patients on the issues most important to family medicine. Use these issue briefs, found at www.tafp.org/advocacy/ resources, when meeting with representatives or just to stay engaged in the legislative process in the upcoming session. 36
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Communications Through its quarterly magazine Texas Family Physician, the Academy explored relevant issues facing family medicine in 2010. The last year of issues featured cover stories on scope of practice, a step-by-step guide to grassroots advocacy for the 82nd Legislature, the multi-billion-dollar budget shortfall, and the closing of the Baylor College of Medicine Kelsey-Seybold Family Medicine Residency Program. Other magazine content delved into news on state and federal legislative and regulatory topics affecting the practice of family medicine, news on what TAFP is doing on behalf of the family physicians of Texas, member news about notable accomplishments and activities of our members, service articles providing practice management tips, human interest stories about Texas family doctors, and opinion pieces from our officers and members. TAFP continues to upgrade its website, www.tafp.org, to host member resources and tools relevant to family physicians’ practices. QuickInfo, TAFP’s e-newsletter, acted as a springboard to publicize these virtual tools and the latest news. TAFP Communications has many more exciting projects in the works, all part of the effort to continually expand the Web and media presence for family medicine. Education This past year brought about many changes to TAFP’s CME program including the sunset of Doctors in Motion and PrimeCME, the addition of a Primary Care Summit conference in Dallas and more Self-Assessment Module Group Study Workshops. TAFP presented four annual symposia in 2010 including the C. Frank Webber Lectureship and Interim Session in Austin, TAFP’s 61st Annual Session and Scientific Assembly in San Antonio, and Primary Care Summit in both Houston and Dallas. These programs reached almost 1,400 family physicians and other health professionals. C. Frank Webber and Primary Care Summit – Houston had recordbreaking attendance and Annual Session had the best attendance since 2005. In its inaugural year, Primary Care Summit – Dallas/Fort Worth boasted over 300 attendees, well over initial expectations.
NOVATION Symposia attendees had the opportunity to earn more than 86 CME credits at these conferences on more than 76 topics. Continuing a commitment to excellence, attendees ranked the education offerings an average of 4.48 on a five-point scale. In addition, TAFP offered five SAM Group Study Workshops this year to help ABFM diplomates meet certification and recertification requirements. These workshops were held during the C. Frank Webber Lectureship, Annual Session, Primary Care Summit − Houston, Primary Care Summit − Dallas/Fort Worth, and the first of the series roadshow in Lubbock. TAFP will offer six more SAM workshops in 2011 to meet the growing needs of our members. The National Procedures Institute also had a successful year, providing procedural training to primary care physicians across the country. A joint investment of AAFP, TAFP, and the Society of Teachers of Family Medicine, NPI provides members valuable practice enhancement techniques while also providing the Academy non-dues revenue. In 2010, NPI delivered 96 procedural workshops to more than 1,000 medical professionals around the country, including a series of courses in San Antonio in November. View the 2011 event schedule and register for upcoming CME conferences on the NPI website, www.NPInstitute.com. Along with planning successful educational programs this past year, TAFP completed the year-long reaccreditation process in July. TAFP is accredited by the Accreditation Council for Continuing Medical Education to provide CME. With reaccreditation completed, TAFP will be able to offer CME for another four years. The Academy staff looks forward to working with members on the TAFP Commission on Annual Session and CME to continue to provide quality education for years to come. Members and Leaders TAFP’s new officers were inducted at this year’s Annual Session. The inductees were: President Melissa Gerdes, M.D.; President-elect I. L. Balkcom, IV, M.D.; Vice President Clare Hawkins, M.D.; Treasurer Troy Fiesinger, M.D.; and Parliamentarian Dale Ragle, M.D.
Also during Annual Session, the Academy recognized some of its revered members. Lloyd Van Winkle, M.D., of Castroville, received the Family Physician of the Year Award; Bruce Jacobson, M.D., of North Richland Hills, was recognized as the 2010 Physician Emeritus; Carlos Roberto Jaén, M.D., of San Antonio, received the Presidential Award of Merit; Jim and Karen White, of Austin, received the TAFP Foundation Philanthropist of the Year Award; James Mobley, M.D., of Portland, won the Public Health Award; Stephen Benold, M.D., of Georgetown, was awarded the TAFPPAC Award; Ulysses Urquidi, M.D., of Dallas, was awarded the Exemplary Teaching Award; State Rep. Veronica Gonzales, of McAllen, received the Patient Advocacy Award; and Amer Shakil, M.D., of Dallas, received the Special Constituency Leadership Award. Texas was well represented at AAFP’s 2010 conferences. During AAFP’s 2010 Scientific Assembly in Denver, Colo., Roland Goertz, M.D., M.B.A., was inducted as AAFP president-elect, and Leah Raye Mabry, M.D., of San Antonio was elected to a third term as Speaker of the AAFP Congress of Delegates. Representing Texas during the Congress were Delegates Van Winkle and Justin Bartos, M.D., of North Richland Hills, and Alternate Delegates Linda Siy, M.D., of Fort Worth, and Erica Swegler, M.D., of Keller. As of November 2010, membership in TAFP had increased to 6,443 total members. TAFP student and resident enrollment rose to 1,821. At TAFP’s 21st Annual Student and Resident Conference in March, TAFP leaders spoke on the business of medicine. The conference included the 6th TAFP Residency and Procedures Fair with residency programs demonstrating various procedures to students such as suturing, joint injections, ultrasounds, colposcopy, and others. TAFP Foundation The TAFP Foundation could not function without the generosity of its members. The Foundation currently has 64 monthly donors whose contributions go toward research, scholarships, and travel funding for medical students and residents. This year, the TAFP Foundation Scholarship Program awarded its first James C. Martin, M.D. Scholarship; launched the David Katerndahl, M.D. Research Fund, created to honor the longtime Research Committee chair; and continued raising money for the Cassie Murphy-Cullen, Ph.D. Scholarship. Since the TAFP scholarship program was created in 1994, it has awarded more than $165,000 to future family physicians. The Foundation continued the new Family Medicine Research Endowment Program this year. The program pools contributions into a large research fund that allows the research committee to award larger and more meaningful grants, one of which is the Katerndahl fund. Whether donors create a research fund in their name or honor a colleague, the funds will collectively support the research efforts of the Foundation. Each fund honoree will be identified as a Family Medicine Research Champion at four different levels on the website and in TAFP’s magazine. Read more about the Research Endowment Program and find more Foundation news on the Foundation website, www.tafp.org/ foundation. Back at the Office In August, a group of TAFP leaders and members representing a wide demographic range of Texas family physicians met in Austin to set priorities for the upcoming year. The group reviewed results of the 2010 member survey; integrated the findings; and set broad goals in the areas of advocacy, practice viability, membership, and education. The full 2010-2011 Strategic Plan can be found on www. tafp.org. Academy staff is working hard with project leaders on these new initiatives. Look for them as they roll out in 2011. : www.ta f p.or g | wi n t er 2 0 1 1
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Family medicine can flourish in accountable care By John K. Frederick, M.D.
I’ve been at this right at 20 years now. Some things are the still the same and will never change: the importance of a smile, a touch, a listening ear to a worried or discouraged patient, or wise counsel to a parent facing the health crisis of a child. That’s the clinical stuff, and it’s still “all good.” On the business side of my medical practice, things aren’t still the same. For all sorts of reasons the business has steadily gotten worse—lower payments, longer hours, and ever more forms to complete. Yet the same national politics which have caused an erosion of private practice over the years seems now to have turned, and may now offer us a golden opportunity. The crafters of the new federal health care law put us right back in the middle of things, requiring new vertically integrated health care ACOs to be built on a foundation of primary care! As a result this is the best, most timely opportunity for family medicine doctors since the advent of our specialty! What we do in the next 24 months may well either cement our validity with the public and general medical community, or relegate us to lapdog status. Until now we have been putting out fires, providing episodic care driven by patient demand. There are a number of lesser-trained medical folks quite capable of working at this level. Our response has been to increase visit volume, and perhaps become more accurate in our coding. But in the near future our broader skill set, our breadth of training, and our ability to see the big picture will set us apart. Chronic medical care drives most of the health care costs in our country, and we are in a perfect position to put a significant dent in those costs with the help from one of the good EHRs now on the market. The really good news is that voluminous data now exists that health systems designed and led by primary care provides for lower costs and improved patient outcomes. And the politicians now know it. There will be a price. We must get to know each other again and gather into teams. We can maintain our physically separate clinics, but only if tied together financially to maximize our negotiating and purchasing power. We will have to work collaboratively with lesser-trained providers so that the episodic care can still be delivered in a timely fashion since there are not enough hours in the day for us to physically provide for all the demand. We also must be willing to have our work measured, thus allowing us to show how we indeed are better, smarter, and cheaper. Now
we can prove what we’ve been saying all along—people need us and we are not expendable. In addition, we’ve got to be more available and accessible. In a world increasingly dominated by smart phones and iPads, it only makes sense that new methods of interaction must become part of our practices. Let’s welcome Googling, blogging, video chatting, and whatever the next communication trend is. This openness to new things makes us unique and valuable, especially as we harness and craft those technologies for the good that family medicine can do. In this new paradigm of physician payment brought by health care reform, small- and medium-sized practices have the most to gain and to lose. The economics will only work for those that cooperatively share expenses and collaborate with the data. Those that do will gain market share because insurers and employers will prefer them. Those that don’t will become gradually more irrelevant and be either absorbed by large multispecialty groups or purchased for a song by a hospital. In either case, personal and professional autonomy may be diminished or lost altogether. Now is our time. The new federal health care law has created attractive incentives for family doctors to acquire software that will make sense of it all. I suspect most of us, at least in spirit, are already collectors of “meaningful use” data. Now we may get paid just for recording it, something most top-rated EHRs can do with relative ease. Data collection is our friend, allowing us to be prompted and reminded, to be thorough and complete, and to implement best ways of doing things. New technologies can help us overcome the difficulties of data entry and even us old dogs must be willing to give it a try. Obsolescence awaits those who do not. There are some big ifs: if those provisions in the law are left intact, if the legislation is funded by the new Congress, if the political winds continue to move those in charge toward significant change. But even if the ACO clamor dies, we and the public will still be better off if we work together. All of this will require leadership, from us, now. It has been too easy for us to retreat into our silos, hoping for the best yet allowing events to dictate our futures. Are we happy where such passivity has left us? I think not. It almost feels like the survival of our specialty hangs in the balance. :
This is the best, most timely opportunity for family medicine doctors since the advent of our specialty! What we do in the next 24 months may well either cement our validity with the public and general medical community, or relegate us to lapdog status.
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Texas Academy of Family Physicians Continuing Medical Education Providing engaging, high-quality CME to primary care physicians since 1947
2011 Annual Symposia & SAM Series Mark your calendars for TAFP’s 2011 educational offerings. Each year, TAFP produces the Annual Symposia Series—four high-quality educational conferences specifically tailored to the needs of Texas family physicians. New this year, your Academy will take to the road to present six Self Assessment Module Group Study
Workshops. The SAMs aid diplomates of the American Board of Family Medicine in meeting their Maintenance of Certification requirements. Join us for our 2011 program to access the latest findings and hottest topics in primary care. For information on these programs and more, go to www.tafp.org.
SAM: Coronary Artery Disease · February 5 Omni Houston Hotel Houston, Texas
SAM: Cerebrovascular Disease · March 10 C. Frank Webber Lectureship · March 11 Omni Austin Hotel at Southpark Austin, Texas
SAM: Hypertension · April 9 Renaissance Casa de Palmas McAllen, Texas
62nd Annual Session & Scientific Assembly · July 27-31 SAM: Health Behavior · July 27 Sheraton Dallas Dallas, Texas
Primary Care Summit – Houston · October 21-23 SAM · October 22 Westin Oaks Houston, Texas
Primary Care Summit – Dallas/Fort Worth · November 11-13 SAM · November 12 Westin Galleria Dallas Dallas, Texas
NatioNal Procedures iNstitute Teaching procedural skills to enhance medical practice since 1989
Austin, TX Permit No. 1450
NPI is a joint venture of the American Academy of Family Physicians, Society of Teachers of Family Medicine, and TAFP.
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