Author Archive

Med school grads bring life to workforce

Physician workforce – particularly in family medicine and primary care – has dominated TAFP’s focus during the past six months of the 82nd Texas Legislature and special session. Workforce issues emerge in all policy areas: health and human services, education, and their respective budgets – through medical school funding, graduate medical education, the Texas Statewide Preceptorship Program, and Texas Physician Education Loan Repayment program.

On June 11th, 2011, after the regular session ended and in the middle of the special session, I was very fortunate to be in the audience at the Stanford Medical School Commencement to see my sister receive her M.D./Ph.D., and to hear one of her classmates, David Austin Craig, M.D., give a thoughtful and humorous speech reflecting on his experience in med school and looking forward to the future.

Me and my sister at her medical school graduation

Seeing the class of nearly 100 brand-new doctors “preparing to go from the frying pan of medical school to the Armageddon of residency,” as Craig said, reminded me why TAFP members spent so much time at the Capitol and in district offices meeting with legislators, testifying at hearings, developing and distributing issue briefs and policy papers, and reporting back to friends and colleagues in their communities. It’s all to support and protect the noble profession of medicine.

To each physician who participated in TAFP’s advocacy effort this year, we are grateful to you and hope you are proud of the myriad accomplishments you achieved in the midst of a tough session. We’ll need your help in the interim and the 83rd Legislature to keep the momentum going.

Until then, I invite you to read an excerpt from Dr. Craig’s speech and remember how you felt when you graduated from medical school and prepared to enter residency and beyond.

“We are headed far and wide next year, the newest foot soldiers in the war against disease that leaves not one of us on this planet untouched – a true World War in a pure and timeless sense.

“And, my classmates, though your staggering debt load may prevent you from sleeping on an actual bed, you can at least sleep soundly knowing that you have chosen to fight on the right side of this war.

“We all know that there is profit to be made quickly and in abundance by spreading fear and ignorance, in promoting poor health, in disregarding or denying the sorrow of another human being. You have instead chosen to hold a candle against these things, to enter into a profession where even your daily commute is a statement against suffering and a habitual reaffirmation that good exists.

“And, believe me, this is the only way that a 1993 rusted Geo Metro driving at 6 a.m. will ever be considered a sign of good in the world.”

“In truth, after spending the last several years with you, I can say honestly that medical school has only made you doctors in the way that a microphone makes somebody a singer. The letters “M.D.” will magnify your impact and open doors for you; will let you reach into more and darker corners of the world to spread hope and comfort there. That is true.

“However, those letters work only like a microphone, only amplifying what you put into them, and a microphone will never make you a singer just as an “M.D.” will never make you a doctor. It is now, just as it has always been: You have to bring your own voice and it is, in the end, the only thing that matters.”

See the full speech on YouTube: Stanford Medical School Commencement 2011 David Craig

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Farewell to a great advocate, researcher

Last Friday, the medical community was shocked and saddened by the sudden death of pediatrician and primary care advocate Barbara Starfield, M.D., M.P.H. During her decades spent at Johns Hopkins, she authored and co-authored numerous studies on the value of primary care that provided proof that many of us believed in our hearts but couldn’t quantify—that patients are healthier and costs are lower in a system based on primary care.

However, her work provided more than just facts; it provided the footing for a movement to redesign the fragmented system to one that is better for patients. She inspired us to really take a look at family medicine’s contribution and advocate for its importance. The process has been slow, but her momentum kept it going.

 Because of her tremendous contributions to health care research and patient care, several organizations have released poignant and appropriate statements in tribute that must be shared. The first is the full statement from Roland Goertz, M.D., M.B.A., president of AAFP, and the second is an excerpt from Richard Roberts, M.D., J.D., president of the World Organization of Family Doctors.

A statement from Dr. Goertz:

“Patients throughout the world lost a dedicated advocate Friday, June 10, with the sudden death of Barbara Starfield, M.D., M.P.H. We have lost a committed scientist whose work focused the attention of policymakers and the entire health care community on meeting the needs of patients.

“As the University Distinguished Service Professor at the Johns Hopkins University Bloomberg School of Public Health and School of Medicine and as Director of its Primary Care Policy Center, Barbara was a tireless advocate for primary medical care. Her prolific research demonstrated that patients’ health, community health, and the nation’s health care system improved when people had access to primary medical care. She showed the world that family physicians’ expertise is essential to individual people, the communities where they live, and the soundness of the nation’s health care. She reminded family physicians why they chose their specialty—to help people improve the care they received and create a system that respected each person, regardless of their station in life. She painted a new vision for what family medicine could be and urged us to fulfill that vision.

“As a result, Barbara taught the nation that primary medical care is instrumental in turning the ship of health care policy toward a system that serves the needs of the people with efficiency. Her work earned her numerous awards, including the American Academy of Family Physicians’ highly prestigious John G. Walsh Award for Lifetime Contributions to Family Medicine. In giving the award, the AAFP cited Barbara’s dedicated, long-term and effective research in the advancement and development of family medicine.

“We will greatly miss Barbara Starfield’s energy, her commitment to building a system that serves patients and her leadership in teaching all of us about the value of the work we do. We have lost a good friend, an inspiring teacher and an exceptional researcher whose work helped make the world a better place for all of us.”

An excerpt from Dr. Roberts:

“She opened the eyes of family doctors to the considerable abilities we have, the weighty responsibilities we carry, and the unrealized possibilities we represent. She saw family doctors as the best hope for health care. Many times, she challenged our vision of what family medicine should look like, and nudged us to see further and clearer.

“She will be remembered for her passion for social justice, incisive intelligence, and incredible energy. Great people have an extraordinary vitality, which makes them seem immortal and lulls us into thinking we will have them forever. And then they are gone. The best tribute we can offer Barbara is to continue to work toward her vision of a world in which everyone has access to quality health care centered in a trusted relationship with a compassionate, competent, and comprehensive family doctor.”

Read the full statement from Dr. Roberts here.

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Without investing in physician training, health care bill creates aims without the means

An important piece of legislation designed to improve quality and lower costs in our fractured and inefficient health care system has received a second chance in the Special Session after dying in the House when time ran out on the 82nd Texas Legislature. However, because of other actions taken by our legislators that defund primary care residency training and other programs to bolster the physician workforce now and in the future, Senate Bill 8’s laudable goals are left without the means to achieve them.

The overarching goal of S.B. 8 is to reverse the negative trend in our health care system, to bend the cost curve by testing and implementing various performance-based payment methods that provide incentives for improved patient outcomes. It achieves this through two key mechanisms: the creation of health care collaboratives and the creation of the Texas Institute of Health Care Quality and Efficiency.

As envisioned in the bill, health care collaboratives clinically integrate physicians, hospitals, diagnostic labs, imaging centers, and other health care providers, aligning financial incentives to keep patients healthy and out of the hospital and emergency room. They are designed to move the delivery system away from a fee-for-service based system—where physicians and hospitals are paid for quantity of services over quality—to one in which doctors, hospitals, and other providers are accountable for the overall care of the patient and the total cost of the care provided.

Mounting evidence supports improved outcomes and lower costs achieved through this type of coordinated care. It works because patients receive care from a medical team, led by a primary care physician, that integrates all aspects of preventive, acute, and chronic needs using the best available evidence and appropriate technology to ensure patients receive the right care, at the right time, in the right place, at the right value.

Equally as important is the Texas Institute of Health Care Quality and Efficiency, which provides a safe harbor from antitrust laws for hospitals, insurers, and physicians to experiment with alternative payment and delivery systems.

A dedicated institute emphasizes experimentation at the state and community level, further encouraging the testing of health care provider collaboration, health care delivery models, and coordination of health care services to improve health care quality, accountability, education, and contain costs in Texas. Through regulation and rulemaking, our state and its agencies can ultimately shape how reform occurs, and this legislation provides the necessary medium for trial and error, adjustment and adaptation.

It is no secret that Texas faces a severe physician shortage, especially among the primary care physicians who are uniquely trained to address a variety of disorders and chronic diseases across multiple organ systems. By 2015, Texas will need more than 4,500 additional primary care physicians and other providers to care for the state’s underserved population.

Over the past few sessions, the Texas Legislature has put in place several provisions designed to increase the number of primary care physicians in our state and to draw those physicians to the rural and underserved areas of the state that need them most. Our elected officials expanded primary care graduate medical education and training, implemented education loan repayments for primary care physicians, and supported medical student primary care preceptorships—each proven to make a positive impact on increasing the primary care workforce.

How easily these gains can be reversed. The 82nd Legislature took a giant step backward when it chose to cut state support of medical residencies by 44 percent, from $106 million in funding for the current biennium to $59.6 million in 2012-2013; slash loan repayment programs, allocating $5.6 million to one repayment program for the first year only and zeroing out another program set up to meet the needs of Texas children; and completely eliminate the Statewide Primary Care Preceptorship Program.

Texas’ 28 family medicine residency programs prepare about 200 new family physicians each year for practice and these programs manage primary care clinics that deliver well-coordinated, cost-effective care to communities that need it. A significant portion of the care they provide is for Medicaid and CHIP patients, Medicare patients, and the uninsured. Many programs already operate at dangerously narrow margins, often teetering on the brink of closure, and proposed budget cuts could be the final nail in the coffin.

Cuts to the loan repayment programs alone could affect up to 1.1 million Texans, by the Texas Higher Education Coordinating Board’s estimate. Because of lack of funds to recruit new physicians to underserved areas, 750,000 patients could see diminished access to care, and the 426,000 currently served by 142 doctors in the program would likewise have difficulties finding a replacement physician to care for them.

Studies of the preceptorship programs in Texas indicate that exposing medical students to primary care clinical experience early in their training, like that provided by the Texas Statewide Preceptorship Program, is an effective method of increasing the number of primary care physicians and expanding access to primary care in underserved populations. Not funding this program further deteriorates our state’s ability to produce the next generation of primary care physicians.

In addition to patient care, physicians contribute to the state economy, which can be of particular benefit to rural and underserved communities. A March 2011 study by the American Medical Association revealed that through supporting jobs, purchasing goods and services, and generating tax revenue, office-based physicians contributed $1.4 trillion in economic activity and supported 4 million jobs nationwide. And the study found that office-based physicians are unique in the health care system in that they almost always contribute more to state economies than hospitals, nursing homes, and home health agencies.

Without investing in an adequate primary care base our state will not have the network of physicians it needs to care for a population ballooning at both ends of the age spectrum, and health care costs will inevitably continue their unsustainable march higher.

All is not lost. Texas has a narrow window of opportunity to identify state-based strategies that will trigger dramatic improvements in our health care delivery system, empower patients to better understand their health care choices and responsibilities, increase competition in the insurance market, and lower overall costs.

Should S.B. 8 pass during the Special Session, its goals can be achieved eventually; the bill lays the foundation to re-engineer the fractured health care system to one that serves patients and bends the cost curve to make the system sustainable long term.

The 82nd Legislature fumbled on ensuring we have an adequate workforce to make these goals a reality, but we hope that future legislatures will recommit to primary care for the sake of Texans’ future. Because without the primary care physician workforce, the potential achievements of Senate Bill 8 are just hollow promises.

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It’s time to read up on the RAC

Okay, if you haven’t started getting serious about educating yourself about the Recovery Audit Contractor program, it’s about time you should.

RACs are third parties hired by the Centers for Medicare and Medicaid Services to ensure that physicians are being paid correctly for Medicare Part A and B services. They identify all “improper payments,” whether the physician received too much or too little, and in return receive a share of the booty—I mean, spoils—I mean, identified payments. [Don’t mind me, it’s Friday.]

CMS released an update in late April that showed that in its first 18 months, the permanent RAC program had identified a total of $365.8 million in total improper payments—$312.2 million in overpayments and $52.6 million in underpayments. The agency attributed the four big reasons for improper payments to incorrect coding and billing for bundled services.

The three-year demonstration was wildly successful, too, with more than $900 million in overpayments collected from physicians and suppliers from six states (California, Florida, New York, Massachusetts, South Carolina, and Arizona) and less than $38 million in underpayments repaid.

RACs came to Texas in March 2009 and Connolly Healthcare won the contract for our region, Region C.

Bradley Reiner, TAFP’s practice management consultant, recommends that physicians be involved in the billing process, and implement a compliance plan so employees are aware of potential errors and how to fix them before they become big problems.

The compliance plan is detailed in the second part of an article Bradley wrote for Texas Family Physician in fall 2010. “Ready or not, Recovery Audit Contractors are coming” explains how the program works, how to minimize the risk of being audited, and what to do if you are. Bradley wrote another article in the winter 2009 issue, “Are you ready for the RAC?,” that details the demonstration project.

Both of these will help get you thinking about the RACs so you’ll be prepared if they knock on your door (rather, send a letter). TAFP members can also contact Bradley by phone at (512) 858-1570, or by e-mail at breiner@austin.rr.com for a consultation and discounted services.

The take-away message is that you can’t ignore them. As Bradley says, “If they continue to be successful there is no doubt everyone will have a RAC audit sooner or later. In almost every practice a RAC can find some billing, coding, or documentation issue during any given audit … . The rules are too complex and differ from payer to payer.”

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How a bill really becomes a law: A primer on the legislative process

As time winds down on the 82nd Texas Legislature, lawmakers are working extra-long hours trying to push their bills through the legislative process before a series of deadlines—intended to stretch out a few extremely stressful days to a few fairly stressful weeks—prevents the bills from becoming law. When a bill doesn’t make it to its next stage, it is considered dead, and the past two days marked two very important deadlines in the House. If your bill didn’t make it to second reading on Thursday, May 12, or to second and third reading on Friday, May 13, your bill has been killed and there is very little you can do about it.

Backing up a bit, the whole process seems designed to kill more bills than pass them. Depending on your generation, you either learned the step-by-step legislative process from your high school government class or the School House Rocks tune “I’m Just a Bill.” Away from the textbooks and animation, the real-life convolution of political forces, interest groups, and desire for re-election (of both the candidates and their supporters) means that things often run a bit differently in the Texas Legislature, and understanding how it actually works takes years of observation under the Capitol dome or a little insider’s knowledge.

Here’s the process how it stands on paper:

However, when those conflicting forces and the legislative deadlines get involved, each stage is a potential bill-killer and suddenly getting a bill passed seems impossible. For the purpose of this very simplified illustration, I’ll take fictional and non-controversial House Bill 8000 through the stages.

Stage 1 – Filed

From the time before the even session starts to 60 days in, lawmakers, legislative staff, and interest groups form legislative priorities and craft legislation. Most bills are filed with the full intention of pushing them through to law; some are filed in the full knowledge that they won’t pass, but serve the purpose to lay the foundation for future sessions or appease certain voting groups. After our fictional H.B. 8000 is filed in the House, it is assigned to a committee by the Speaker.

Stage 2 – Out of House Committee

Once a bill reaches committee, the committee chairperson wields much power on its survival. (Note that chairmanship is granted by the Speaker in the House and the lieutenant governor in the Senate.) The chair determines when the bill will be heard—day and time—or if it will be heard at all. Many times a bill will be laid out before the committee, tabled, and never called up again, sometimes because of a backroom agreement to kill a “bad bill.” The best case for H.B. 8000 is that it is laid out before committee members, advocates give moving testimony, and the bill is voted favorably out of committee. Congratulations—our bill just passed a step that a very large number of bills fail.

Stage 3 – Voted on by House

From here, H.B. 8000 must be scheduled by the Committee on Calendars to be heard on the House floor. There are four calendars and each lists bills and resolutions that are scheduled to be considered by the full House. The two most important for law-passing purposes are the Daily House Calendar (that lists new bills) and the Supplemental House Calendar (that lists bills from the Daily calendar, bills passed to third reading the previous day, bills or postponed business from the previous day, and bills that were tabled the previous day). Bills listed on the Local and Consent Calendar are local or noncontroversial bills that are typically passed very quickly without much, if any, debate.

Anyway, all of this is to say that calendar placement is very important, particularly toward the end of the session as each deadline kills scores of bills by the stroke of midnight. There are a bunch of deadlines coming up, in addition to the two mentioned above. Here’s a link to the full calendar of deadlines. Essentially, your bill has to be heard on the House floor and pass in time to go through the whole Senate process, all before sine die.

So, back to H.B. 8000, which was placed on the Local and Consent Calendar and, in a bipartisan show of goodwill, passed unanimously out of the House (hooray).

Stage 4 – Out of Senate Committee

Because our bill does not already have a companion bill in the Senate, which would shorten the process considerably, H.B. 8000 is assigned to a Senate committee by the lieutenant governor where it goes through the same committee hearings as it did in the House. This is a new ballgame with different legislators who may have different priorities. As a result, even more bills die here. Thankfully, H.B. 8000 is passed and goes onto the next stage.

Stage 5 – Voted on by Senate

The bill now goes to the Senate. With some prep work beforehand, it is placed on the Intent Calendar and brought before the full Senate by a vote of two-thirds of the senators present. Sheer paperwork kills bills here. If the Senate doesn’t bring up a bill on the day it is listed on the Intent Calendar, a senator must take action to list it on the following day’s calendar. The pesky deadlines also get in the way: If a bill is brought up for second reading, but not the third, it cannot pass. In our case, H.B. 8000 passes without amendments and goes on to the next step.

Stage 6 – Sent to Governor

Once the bill passes the Senate and has been sent back to the House, the bill is prepared for signing, signed by the Speaker and the lieutenant governor, and sent to the governor who must sign the bill, veto it, or allow it to become law without signature. The last day the governor can take action on a bill passed during the 82nd regular session is Sunday, June 19. If vetoed after sine die, the bill is dead. Our bill, however, is signed and moves on to the next and final stage.

Stage 7 – Bill Becomes Law

H.B. 8000 becomes law. Woo!

And there you go. Even in a simplified state, it still seems complicated. That’s why, once again, I’m amazed any bills are able to be passed. Because legislators are dealing with such large, polarizing issues (i.e. a tough budget and redistricting, among others), experts predict they’ll be called back in the summer for a Special Session when we’ll start all over again.

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The Twitter diagnosis: A doctor’s dilemma

Several miles into a long run last week, I started to feel a pang of pain with which I had grown familiar. I knew I would need to stop to “shake it out,” then slow my pace substantially until I could regain my stride and run through it. Because I’d had the same pang around the same mile for the past two weeks, I started thinking that I should talk to my family doctor about it. My first thought wasn’t to call her office – it was early on a Saturday morning, after all – it was to tweet it.

In addition to my personal Twitter account, I am one of the administrators for TAFP’s account and I know several of our family physician members who follow our feed. My tweet (from my personal account) would have gone like this: “Need advice: Sharp pain in the outside of my left knee near my kneecap around mile 7. Is this serious? Should I wear a brace?” With the remaining 15 characters, I would have tagged a few physician friends, none of whom is my personal family doctor.

As I kept plodding through the miles, I decided it would be unprofessional for me to use TAFP members — even those I consider to be friends — to give me a free diagnosis. However, I wondered if it would even be possible or ethical for a physician to give a diagnosis in 140 characters.

The way people communicate is obviously changing. Thanks to smart phones, we’re always plugged in checking e-mail, texts, and social media apps like Twitter and Facebook. More people post more information about themselves online, and connect with others by reading a digest of friends’ activities rather than calling, visiting, or (gasp) sending a letter.

Doctors are no exception. A growing faction of physicians supports expanding the use of social media to hash out ideas and drive reform for our health care system, market their practices, and share health information with medical students and patients. Some of these tweets are traceable through their hashtags, including #FMrevolution and #hcsm.

As explored on a recent blog post from KevinMD.com, the author writes that the application of social media to health care is “a strong candidate for bottom-up change.”

“It’s at least worth considering that, appropriately utilized, social media could do something for the doctor-patient relationship akin to what Facebook and Twitter is doing for family, friends, and business relations all over the world. … Many physicians and medical students that I know have not yet begun to wade into the Twitter waters or explore blogging. These tools must be engaged with before they are applied. I think there’s reason to believe that the very act of engagement will stimulate ideas for implementation. If big changes in health care are going to be bottom-up, and these social media tools are truly useful, then simple exposure to physicians on the ground may likely instigate much progress.”

 To satisfy my original question, I sent a tweet that tagged a few active tweeting doctors. In their experience, had they come across any barriers working with social media? Did they think these applications could only be used for social purposes, or could they be expanded for clinical purposes as well?

Respondents said that they had come across barriers, the biggest being concern for patient privacy that limits what a doctor can actually say. There are also personal-professional boundaries. However, they resoundingly supported social media being used for more than just making friends.

They said that patients seem more prepared to incorporate some social media into their medical care than doctors, and that physicians must overcome larger mental and perceived barriers for adoption. One said he faces the task of convincing skeptics that social media can be used for professional purposes, particularly when on the job. If he checks medical apps or blogs on his phone, “it’s viewed as disinterest or assumed that I am texting friends.”

There are obvious differences between having a living, breathing patient on your exam table for a 15-minute office visit and reading a string of patient-written micro-posts. Particularly for primary care, which often calls for a multi-organ-system diagnosis, Twitter consults could oversimplify a patient’s care and take the doctor out of the driver’s seat. That may be why one responder said that patients could benefit from Twitter consults with some specialists.

As a benefit, Twitter provides access to a wide database of information-sharing and knowledge that, in one source’s opinion, can be beneficial to educating medical students. To me, this is the whole point. Twitter can either mean throwing information out into a larger audience to gauge response (as I did for this post), or it can mean tagging a specific person to have a semi-private conversation (as long as both agree in its use).

In the end, I scheduled a visit to my family physician and had a conversation much longer than a 140-character tweet. She inquired about things I hadn’t considered, and I walked away with a wealth of helpful advice to keep my knees in good shape for the race and in the years to come. We can talk Twitter on my next visit.

[Special thanks to @DrJonathan, @mdstudent31, and @danamlewis for contributing to this post. To all — please comment and let me know what you think. How are you using social media in your personal and professional life?]

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The family physician’s role in smoking cessation

In testimony before the House Public Health Committee on March 2, Dallas physician John Carlo, M.D., put forth his support for a statewide smoking ban that would prohibit smoking in public places and workplaces. Advocates tried to pass similar legislation last session and failed, for various reasons. Now as it comes up again as House Bill 670 by Rep. Myra Crownover, R-Lake Dallas, and Senate Bill 355 by Sen. Rodney Ellis, D-Houston, public health groups are gearing up for another push.

Dr. Carlo said that physicians and the public at large have known conclusively since 1986 that secondhand smoke is dangerous to children and adults, and that there is no risk-free level of exposure to secondhand smoke. As medical professionals, you understand the biological explanation why secondhand smoke exposure causes damage to blood vessels and the heart. Study after epidemiological study demonstrates an increase in cardiac disease and mortality with increasing exposure to secondhand smoke.

While 33 Texas municipalities have passed some type of smoking ban in public places, including the largest cities in the state, many rural communities haven’t. Some say a smoking ban is an infringement on an individual’s right to smoke; others say it will hurt local businesses like bars and restaurants (which, by the way, isn’t true according to a January 2011 survey by Baselice and Associates, Inc.).

A March 1 press conference held by Smoke Free Texas and the Texas Public Health Coalition—of which TAFP is one of 27 members—highlighted several bills, including the smoking ban bills. Representatives spoke about the economic damages caused by tobacco use—that the annual direct medical expenses of smoking, loss of workplace productivity, and premature death cost Texas more than $20 billion. A report prepared for the American Lung Association showed while the average retail price of a pack of cigarettes in 2010 was $5.52, the actual cost to the Texas economy was $21 per pack—a heavy price. Find coverage of the press conference at http://www.tafp.org/news/stories/11.03.03.1.asp.

What do the physicians say? You know your patients better than anyone else. As a rural physician, what steps do you take to encourage patients to quit? Do you meet resistance from these patients? We’ll continue to follow this issue as it progresses. Tell us what you think.

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BCM on the closing of Kelsey-Seybold FMRP: “They just didn’t want to be in the education business”

The Senate Finance Committee has held hearings for the past two weeks on every section of the budget, and because so many primary care programs suffered cuts (as did most other programs), many interesting exchanges have come to light. In all the discussions, though, both lawmakers and those testifying agree that primary care is of the utmost importance to ensuring Texans’ access to care.

Because residency programs play such a large role in producing the primary care physician workforce, here enters Paul Klotman, M.D., president and CEO of Baylor College of Medicine. He testified during the Feb. 8 hearing of the Senate Finance Committee, and Sen. Bob Deuell of Greenville questioned him on the closing of the Baylor College of Medicine Kelsey-Seybold Family Medicine Residency Program. Here’s their exchange.

Sen. Deuell: A family medicine program closed. What’s your take on that?

Dr. Klotman: Our family medicine program is doing fine. [Person in audience speaks]. Oh, are you talking about Kelsey-Seybold?

Deuell: Yes.

Klotman: My understanding is they just didn’t want to be in the education business, that they didn’t want to continue to have residents there.

Deuell: Was that because of finances?

Klotman: They’re driven by patient care, they’re at risk now, they need efficiencies in their system. It’s hard. One of the challenges is working in the educational piece into efficient organizations, but I actually believe you can do that. It just needs to be done in an integrated way and I don’t think that’s their primary mission.

My understanding is they just didn’t want to be in the education business, that they didn’t want to continue to have residents there.

–Paul Klotman, M.D., President and CEO, Baylor College of Medicine

So why did the program close? It turns out that it was financial. As Jonathan Nelson writes in “On the Brink,” the cover story of the first-quarter 2009 issue of Texas Family Physician, it began in 2006 when the program’s primary teaching hospital, St. Luke’s Episcopal Hospital, cut support for the program in half.

That sent Baylor and Kelsey-Seybold FMRP scrambling to find new sources of funding, none of which were stable from year to year. By fall 2009, they agreed that the program was no longer financially sustainable. Kelsey-Seybold needed a subsidy from BCM of between $400,000 and $450,000 to keep the program viable. But Baylor, which has operated at a substantial deficit for the past several years, couldn’t save the program.

Baylor College of Medicine’s 2010-2011 appropriation for GME formula funding— money intended to support their affiliated residency programs—is $15.3 million. That’s $2.5 million more than they received in the previous biennium.

The program closing certainly wasn’t because of lack of interest from the faculty or the applicants. Again, from “On the Brink”: In an era when family medicine residencies only manage to fill 45 percent of available residency positions with U.S. medical school graduates, 97 percent of the recruitment classes at the Kelsey-Seybold program over the last three years graduated from U.S. medical schools. More than 600 physicians applied for the four open positions at the residency in 2009, and of the four chosen, two are from out of state. “I’m constantly bombarded with people that would just love to come to our program,” says Tricia Elliott, M.D., F.A.A.F.P., the residency’s program director.

Read the full article here.

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HHS Commissioner to Senate Finance: Spare primary care

When Tom Suehs, executive commissioner of Texas Health and Human Services, addressed the Senate Finance Committee in a hearing on Feb. 1, he told the 15 senators in no uncertain language that going through with cuts to primary care proposed in the Senate’s draft budget will damage access to care.

Suehs (pronounced “seas”) is pushing for exceptional items that would reduce the cut in payment for primary care physicians treating kids enrolled in Medicaid and CHIP from 10 percent to 2 percent. This would cost the state around $125 million in general revenue next biennium, according to a Feb. 1 article in Quorum Report.

“I’m really concerned about having to cut primary care rates for physicians treating children,” Suehs told the committee. “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. Exceptional item 1A is for Medicaid children, exceptional item 1B is for CHIP.”

Suehs emphasized his desire to make “targeted cuts to minimize hits to access to care” rather than an across-the-board cut for providers—as has happened in the past.

More than the provider pay cuts in Medicaid and CHIP, primary care took a beating in the draft budgets released by the House and Senate (read the “Bleak House” post). The House version eliminates funding for the Texas Family Practice and Primary Care Residency programs, the Physician Education Loan Repayment Program, and the Primary Care Preceptorship Programs. The Senate version cuts the residency programs by 29 and 45 percent, respectively, with other cuts to graduate medical education.

TAFP CEO/EVP Tom Banning says in a Feb. 2 article in the Texas Tribune that this isn’t the time to make cuts to primary care. Instead, lawmakers should explore ways to reduce health care costs to the state by investing in programs that reward doctors to achieve the best medical outcomes. It sounds contradictory to spend more to save, but outcomes-based initiatives that support primary care are gaining ground; pay-for-performance programs and medical home initiatives, for instance.

Banning supports Suehs’ commitment to preserving primary care and sees it as a positive indicator that primary care will survive a tough session. He wrote in an e-mail to Academy leaders, “I think this clearly points to the value and importance that HHSC and the legislative leadership is placing on primary care. This should play well into our strategy to restore higher education funding to produce the primary care workforce Texas needs to achieve their policy objectives.”

Before ending on too positive of a note, John Reynolds in the Quorum Report article foretells a battle if primary care receives special treatment and other providers receive the full cut. “What to one person is protecting a vital part of the health care system from being dismantled might sound to another like creating a set of winners and losers. And that’s a formula for conflict.”

Here’s the link to the Quorum Report article (full text for subscribers only): http://www.quorumreport.com/Subscribers/Article.cfm?IID=16647

Here’s the link to the Texas Tribune article: http://www.texastribune.org/texas-health-resources/health-reform-and-texas/are-payment-reform-texas-budget-in-conflict/.

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Is it time to declare independence from the RUC?

In a recent opinion column published in Kaiser Health news, two prominent voices in health care policy gave primary care physicians a piece of revolutionary advice: Quit the RUC.

If you don’t know what the RUC is, you aren’t alone.

RUC stands for the Relative Value Scale Update Committee, a group of 29 physicians from various medical specialties that meets three times a year to advise the Centers for Medicare and Medicaid Services on Medicare physician fee reimbursement and how certain procedures should be valued. Created by the American Medical Association in 1991, the committee has no official government standing, yet it yields great power.

CMS approves 90-94 percent of the committee’s suggestions, and because many government and commercial health plans follow Medicare’s lead to set their own fee schedules, its influence bleeds into other markets as well.

So what’s the problem? The committee is overwhelmingly dominated by specialists, outnumbering primary care physicians by a ratio of 6:1 or 13:1 depending on whether you count internal medicine, osteopathy, and pediatrics. As such, Brian Keppler, Ph.D., and David Kibbe, M.D., M.B.A., write that its payment recommendations have “consistently favored specialists at the expense of primary care physicians.” They point out that, on average, specialists out-earn primary care physicians by $135,000 a year and $3.5 million over the course of their careers.

In the $500-billion Medicare program, physician fees make up just one piece of the pie and the RUC cannot be blamed solely for the spiraling costs of health care. However, the authors assert that “the perverse incentives embedded in fee-for-service physician payments influence care decisions and are a principle driver of the health system’s immense excesses.” Further, “the system pays more for invasive approaches, so conservative treatment choices that are lower cost and lower risk to the patient may be passed over, especially near the end of life.”

They recommend that TAFP, along with other primary care medical specialty societies in the country, “loudly and visibly leave, while presenting evidence that the process has been unfair to their physicians and, worse, to American patients and purchasers.”

The AAFP Congress of Delegates has debated the question of leaving the RUC in recent years, and AAFP has been active on several fronts trying to get more primary care representation on the RUC and to get CMS to reconsider its decisions when accepting recommendations from the RUC.

There are also other ideas floating around to curb the RUC’s influence. One comes from physician-politician Jim McDermott, a U.S. representative from Washington. He wrote in an opinion column for the New England Journal of Medicine, “Congress should consider enlarging or realigning the composition of the RUC, if not demoting it to an advisory function and requiring greater transparency of its deliberations.”

Additionally, a provision in the health care reform law creates the Independent Payment Advisory Board that is tasked with capping Medicare spending beginning in 2015. Much of the momentum for creating such an entity was aimed directly at counteracting the inflationary bent of the RUC’s recommendations.

Interesting to point out is recent action from the AMA, American Hospital Association, and other specialty groups to weaken or quash the IPAB.

AAFP supported the concept, though has not been entirely happy with all aspects of the IPAB in the final legislation and continues to push for changes, such as including a primary care representative and a consumer representative to the board, including a public comment period before Congress acts on the IPAB recommendations, and including all segments of the health care industry (i.e., hospitals, nursing homes, pharmaceutical manufacturers, etc.) in the scope of the IPAB review.

Whatever happens, it certainly sounds like the RUC is in for some changes.

Read the Keppler/Kibbe article here: http://www.kaiserhealthnews.org/Columns/2011/January/012111kepplerkibbe.aspx

Read more about the IPAB here: http://www.kaiserhealthnews.org/Stories/2011/January/26/health-industry-lawmakers-medicare-spending-board-IPAB.aspx

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