Author Archive

We’ve moved! Check out the all-new TAFP.org

 

TAFP has moved our blog, txfamilydocs.org, to the all-new redesigned TAFP.org. The new site features a host of interactive opportunities with the goal of engaging our members in all facets of what the Academy has to offer, and it integrates our many communication vehicles under one roof. All of our old blog posts and several new ones can be found at www.tafp.org/blog, and as always, we encourage you to read, comment, and join the discussion.

At first you’ll notice that TAFP.org is much more graphically inviting, with lots of pictures to highlight various services, opportunities, resources, and news items of interest to family doctors. The home page is designed to introduce you to the site and welcome you to explore the various departments without overwhelming visitors with massive amounts of text and options.

Scroll a little farther down and you’ll see a substantial footer packed with links to specific high-traffic sections of the site. With this footer existing on every page of the site, a logical department structure, and a powerful search engine, navigating the new TAFP.org should be significantly easier than the previous version.

Launching the site is just the beginning. We’ve got loads of ideas under development, including a widget to call up articles and resources related to the content of any story page, a social networking “share bar” that will appear throughout the site, a survey widget so we can quickly poll the membership, and the ability to comment on news stories. In the coming months, you’ll see the site grow in content and functionality as we keep working to make it better and more interactive.

In conjunction with the redesign of the website, we are also unveiling TAFP’s new logo and identity, the Texas torch. Recognizing the value our members place in the shared membership of TAFP and AAFP, we set on a course to rebrand our chapter, joining our many sister state chapters in adopting AAFP’s torch as a symbol of the unity of family physicians across the country and our bold advocacy on behalf of the specialty. The launch of the new website seemed the perfect time to “light the torch,” in a matter of speaking.

When AAFP first announced its rebranding initiative, the Academy wrote the following sentences to describe its significance:

“Sixty years after the Academy was created, our new look signals a new approach. The torch’s guiding light embodies honor, valor, and victory. The flame begins with the representation of the serpent wrapped around the torch signifying the Aesculapius staff and the symbols of healing and the renewing power of life that go with it.”

It is in this spirit that we adopt the new TAFP logo.

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Wal-Mart: The future leader of low-cost care?

Save money. Live better. It’s Wal-Mart’s corporate motto, but put it in the context of health care and add a third line targeted at improving care for individuals and you’ve got something awfully close to Don Berwick’s triple aim for health care reform. If cost is the real cancer in the U.S. health care delivery system—and we think it is—why not look to America’s low-cost leader for the cure?

When reports started hitting the news this week about a request for information Wal-Mart sent out to its vendors in late October announcing the mega-retailer’s intent to “build a national, integrated, low-cost primary care health care platform that will provide preventative and chronic care services that are currently out of reach for millions of Americans,” alarms went off in health policy circles across the country.

The company has since backpedaled on the statement of intent. John Agwunobi, M.D., M.P.H., M.B.A., head of Wal-Mart’s health and wellness division, released a statement on Nov. 9, 2011, saying, “We are not building a national, integrated, low-cost primary care health care platform.”

Well, that’s a relief.

What struck me about the RFI wasn’t just the ambitious statement of intent, now characterized by the company as “overwritten and incorrect,” it was the list of services Wal-Mart plans to offer: chronic disease management of everything from diabetes, asthma, and hypertension to sleep apnea, osteoporosis, HIV, and clinical depression.

A few years back, Wal-Mart announced plans to open more than 400 retail health clinics in its stores from coast to coast. As of now, it operates about 140 clinics. The company exerted its massive purchasing power and brought us $4 generic pharmaceuticals. And now it wants to bring its cost-cutting strategies to the chronic disease management market.

The trouble is the price points of primary care services and chronic disease management services aren’t the cause of our health care cost crisis. The real problem is the effect on system-wide health expenditures when chronic diseases aren’t managed properly. So maybe Wal-Mart’s idea of enhanced retail clinics could improve access to those services thereby improving population health and lowering overall health care costs, but I doubt it.

I tend to agree with AAFP President Glen Stream, M.D., M.B.I., who told National Public Radio that Wal-Mart’s proposal takes health care in the wrong direction. “I would still be gravely concerned that this is going to fragment care at a time when we now clearly understand that people having a usual source of comprehensive and continuous care in a single location is one of the main features that drives high-quality care, good patient health outcomes, and drives down costs.”

Today, family physicians across the country are transforming their practices to make them more accessible to their patients, and to evolve our delivery system into one that coordinates patient care in an efficient manner to make sure patients receive the right care at the right time and in the right setting. The 2010 AAFP Practice Profile survey shows that significant percentages of our members offer many of the same conveniences that retail health clinics offer. More than 73 percent offer same-day or open-access scheduling. More than 48 percent have extended office hours, and more than 31 percent offer weekend appointments.

Wal-Mart’s interest in expanding its line of health care services is a big indication that primary care is on the rise. Here’s yet another indication. The Baltimore Sun reported this week that Maryland state officials plan “to increase the number of primary care health professionals by as much as 25 percent in the next decade through a wide range of goals that include increased educational opportunities, financial incentives, and tort reform.”

Competition for primary care services is about to get fierce, folks. Wal-Mart knows where the money is and where the demand is. Seems to me family medicine is in a great position for strong market growth.

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From the editor: Introducing a new look for Texas Family Physician

Eleven years ago, when I came on board as managing editor of Texas Family Physician, I was fresh out of journalism school with a love for design and an eye for art, photography, and typography, but no real-world experience in producing magazines. I learned much in those first few issues about the nuts and bolts of magazine production, all the while trying to appear as though I knew something about an expanding range of increasingly complex editorial topics my new magazine was required to cover.

My first cover story tackled the problems with the financing of graduate medical education – talk about jumping in at the deep end.

During those first issues, I knew the magazine needed a new look, a form and function that could achieve the news and information focus we wanted to deliver, while keeping the warmth and conversational nature we wished to convey. In 2002, we launched the first redesign of TFP under my direction, and while we’ve worked in each issue since to refine that design, I believe the artistic concept has served the Academy well.

For the past couple of years, we’ve been working on a fresh face for our magazine, a reinvention of the basic building blocks of the design, and with our Fall 2011 issue, we’re happy to unveil the new design. With a new nameplate and cover design, a fresh set of fonts, and a commitment to packaging content in smaller, more easily digestible bits, I believe this evolution of Texas Family Physician will keep our magazine at the top of its class.

Watch your mailbox and give it a read or view the virtual issue at issuu.com/txfamilydocs/docs/4mag2011. I hope you enjoy our new and improved Texas Family Physician.

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Help wanted: Send us your ideas for the Primary Care Rescue Act

As a die-hard fan of the Texas Longhorns, I have no shame in telling you that after last year’s 5-7 record, I was glad the college football season was over. Even though I’m a self-admitted policy wonk and political news junkie, I was equally relieved—even somewhat jubilant—when the 82nd Texas Legislature finally closed up shop and went home. If you followed the frustrating struggle to balance the state budget without additional revenue, and witnessed the resulting cuts to higher education, public education, and health and human services, you might have been just as ready for it to end as I was. At least when they’re not in session, they can’t do any more damage, right? Now is not the time to bury our heads in the sand. In fact, the legislative interim is perhaps our best opportunity to formulate and articulate our most effective arguments for renewed investment in Texas’ primary care infrastructure. We can document the ill effects of the drastic reduction in state support for graduate medical education, especially in family medicine residency training, and we can illustrate the broken promise of access to primary care physicians for underserved communities made manifest by the 76-percent cut to the state’s Physician Education Loan Repayment Program.

And now is the time to begin preparations for a major initiative in the next legislative session. In the late ’80s, rural medicine in Texas was in terrible need of state investment. Health care organizations and advocates rallied around a broad set of goals encompassed in what was called the Omnibus Rural Healthcare Rescue Act, which the Legislature passed in 1989. The law created the Center for Rural Health Initiatives and the Office of Rural Health Care, and it contained tort reforms, benefits for rural hospitals, several reforms to strengthen the state’s trauma care infrastructure, and new recruitment and training programs for primary care physicians. Family medicine won funding for third-year clerkships, among other valuable reforms.

As our state demographics change, and following the decision of the 82nd Legislature to withdraw almost 80 percent of its investment in programs intended to increase the state’s primary care workforce, we believe primary care in Texas is in desperate need of something like that landmark omnibus package of reforms and initiatives. Let’s call it the Primary Care Rescue Act. Obviously we would want to include the restoration of state support for GME, especially the funds that go directly to family medicine residency programs through the Texas Higher Education Coordinating Board. Also we would include full restoration of funds for the Statewide Primary Care Preceptorship Program, and the Physician Education Loan Repayment Program. But what else should we include?

We wish to engage you—the membership of TAFP—in this endeavor from the very beginning. What state reforms would make your practice easier, more efficient, and provide better care for your patients? What kind of administrative simplification requests should we make in state programs? What about managed care reforms? Would a standardized pre-authorization process help? Standardized contracts? Real-time claims adjudication? What could the state do to make primary care more attractive to medical students?

The sooner we can begin to craft a set of reforms to use during the election cycle, the more likely our success becomes. Remember, politics drives the process that sets policy. That’s why we want to hear your ideas for the Primary Care Rescue Act. Use this space, here on the blog, to comment with your ideas, and we’ll pay close attention to the discussion. If you’d rather send us your ideas individually, feel free to e-mail me, Jonathan Nelson, at jnelson@tafp.org. Or you can e-mail Tom Banning at tbanning@tafp.org, or Kate Alfano at kalfano@tafp.org. However you choose to share your ideas, we are eager to hear them. The legislative interim can be a time filled with promise and hope, and it’s the perfect time to lay the groundwork for big initiatives in the next session. Let’s take advantage of that opportunity.

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Can the state shift the balance of power in GME?

Should medical schools that receive state support for residency training be expected to produce the kinds of physicians Texas needs to ensure a cost-effective, high-quality, well-coordinated, more equitable health care delivery system? That’s the policy question posed by a Texas Tribune news article from March 10, 2011, “Budget Rider Would Emphasize Primary Care.”

The budget rider in question would concentrate state support for graduate medical education by paying for only the first three years of residency training, rather than supporting training in years four through seven, some part of which are required for subspecialties. The idea is controversial, and of course opposed by many academic health centers and by the Texas Medical Association, but it’s exactly the kind of reform to medical education that’s gathering momentum across the country.

The recently published 20th report of the Council on Graduate Medical Education proposes that a major culprit behind the declining interest in primary care among medical students is the “hidden curriculum” found in academic health centers that favors specialty care provided in the hospital setting over primary care. How did this “hidden curriculum” come to be? Because GME programs at large teaching hospitals have evolved to meet the needs of the academic health center rather than the general population.

Here’s what the COGME report has to say:

“Although Medicare capped its funded GME slots in 1997, accredited GME positions have grown 6.3 percent from 2003-2006, virtually all of which are self-funded by the hospitals. Despite this increase, a rise in subspecialty rates led to fewer physicians pursuing generalist careers. Like student choices, this build-out of residency training positions is highly correlated with specialty income. Teaching hospitals invest in lucrative services in order to support their bottom line and residents and fellows are an inexpensive way to support those services. Increasing options for subspecialization has both direct and indirect effects on primary care production, first by closing primary care positions to be used for subspecialty training, and second by giving would-be primary care physicians options to subspecialize. The net effect is a substantial reduction in primary care production from GME, now at about 29 percent or less compared to 32 percent from 2003 to 2008. In bending BME to service their financial bottom line, the needs of the population are not best served.”

Texas is spending somewhere between $75 million and $79 million on GME formula funding in the current biennium, and the proposed budgets in the House and the Senate would drop that to between $53 million and $57 million. The money is doled out based on how many residents are in training at residencies affiliated with the schools, so the amounts for each vary widely. The University of North Texas Health Science Center at Fort Worth would get around $1.6 million while the University of Texas Southwestern Medical Center at Dallas would get about $13 million.

But that’s not where the schools get most of their GME funding. The bulk of GME funding comes from Medicare in the form of Direct Medical Education payments and Indirect Medical Education funding. Both streams are calculated with methodologies based on the number of residents in training at a teaching hospital, and the payments go to those hospitals. What’s more, Medicare only reimburses teaching hospitals for the time residents spend in the hospital, which is fine for most specialties, but detrimental to primary care. For family medicine residents, the most important classroom is the outpatient clinic, and unless that clinic is attached to the teaching hospital, residency administrators have to fight tooth and nail to secure resident stipends from their training hospitals.

For a teaching hospital, having subspecialty residents is good for the bottom line for three reasons. As COGME points out, they’re cheap labor for expensive procedures, so the revenue attributed to the practice plan goes up while the costs are held in check. Secondly, the more residents you have training in the hospital, the more Medicare GME dollars you can draw down. And thirdly, having a robust subspecialty GME program makes you a prime candidate for lucrative research grants from the National Institutes for Health.

A study published in the Annals of Internal Medicine last year ranked the nation’s medical schools by the amount of primary care physicians they produced. The authors found that research funding often warps the mission of academic health centers away from primary care. 

“The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas. High levels of research funding clearly indicate an institutional commitment to research and probably indicate missions that value technical medicine and specialization rather than training in primary care and practice in underserved areas.”

In January of last year, TAFP published an article in Texas Family Physician examining the reasons behind the closure of the Baylor College of Medicine Kelsey-Seybold Clinic Family Medicine Residency Program. Among the events leading to the program’s termination was the decision by its main teaching hospital, St. Luke’s Episcopal Hospital, to reduce the stipends it paid for family medicine residents. I asked Steve Spann, M.D., senior vice president and dean of clinical affairs at Baylor College of Medicine, for his perspective on that decision by St. Luke’s. Here’s his response as quoted in the article:

“They did that unilaterally and despite some pretty strong protest from us, but they felt it was more to their benefit to put those stipends into neurosurgery.”

So here we are, after the passage of health care reform, trying to prepare at the state level for the implementation of its various components, yet still confronted by a fragmented, fractured delivery system without enough primary care physicians to make it all work. The COGME report makes a compelling argument that if we are to change the ratio of primary care physicians to specialty physicians in America, we must implement strategies to “improve GME and modify incentives so that they foster interest in primary care education and careers.” Seems to me this GME formula funding budget rider might be the right strategy at exactly the right time.

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Ethics in the era of genetic testing

While I’m at home trying desperately to figure out how to set adequate parental protections on out Internet browsers and restrict my kids’ access to any and all Showtime original series on streaming Netflix, researchers at Baylor College of Medicine are posing some challenging ethical questions physicians are ever more likely to face. What if you tested a patient’s genes and found that he or she was likely the child of an incestuous relationship? What would your ethical responsibility be?

The BCM researchers write in the Feb. 12 issue of The Lancet that they have witnessed several of these cases while performing genomic tests on children. The topic is broad, with various implications regarding the age of the parents at the time of conception, their relational status, the possibility of criminal behavior or abuse, not to mention the emotional stigma and distress involved for the patient.

With all the promise genetic testing holds for understanding, identifying, and treating various conditions and disease states, the ethical ramifications are staggering, and this is just one particularly interesting and puzzling question to explore. Check out the article: http://tinyurl.com/47k7unt. We’d be interested to know your thoughts, so use the comment feature. What are your thoughts on the ethics of finding evidence of incestuous parentage through genetic testing, or just the ethics of genetic testing in general?

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Bleak House: Family medicine and the great budget debate, day one

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.

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 2012-2013, 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.

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