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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Reflections of a pre-med student

As a pre-medical student and journalism/biology double major at UT, I was extremely excited when I saw TAFP’s internship posting. I thought it would be a great opportunity to learn more about what issues concern family physicians—a career I’m interested in—while applying and improving my journalistic skills. During my time at TAFP I’ve learned a lot about the issues family physicians face and that there is plenty a physician must care about outside of the exam room.

Last week I wrote a short article summarizing the results of the 2011 Main Residency Match and how family medicine fared.  I was glad to see that family medicine is on the increase, but seeing that only about half the residency spots were filled by U.S. graduates while other specialties were almost exclusively filled with these students put into perspective that family medicine isn’t an alluring future for many U.S. medical students.

Match Graph

As a pre-medical student, the Match Day data made me stop and reflect on my personal thoughts about family medicine. The first thing that came to mind is how medical debt pushes people away from the field of family medicine.

Before I was an intern at TAFP I knew about physician payment and medical school debt superficially—that family doctors aren’t the highest-paid doctors and that medical school is expensive. But, after interviewing physicians for various stories I was able to think about these issues with more depth and often draw upon a personal story they shared with me.  

One physician told me she is encouraging her daughter to look at options besides medical school because of the massive debt.  Others told me that the huge pay gap between family physicians and medical specialists plays a big factor in driving medical students away from primary care and into more lucrative fields. This certainly came through in the Match Day data as residencies in fields with the highest pay grade were the most popular.

Income Gap

I also thought about the new problems I’ve learned about, like the struggle between family docs and nurse practitioners for practice domains or how IMGs in Texas face licensing roadblocks that cause some to leave the state altogether. It worries me to see all the health professional shortage areas in Texas, then learn about IMGs leaving and U.S. medical students going to other fields. And seeing the huge pay gaps between specialties and general practice is frustrating.

Despite the problems facing family medicine, what I find more memorable are the qualities of the family physicians I have interviewed and researched for stories. Every family doc I have spoken to is a high-caliber person whose impact on their community isn’t limited to their practice. Some speak out on behalf of TAFP; others organize community events to promote wellness or lead medical trips to foreign countries to help underserved communities.

It is especially inspiring for me to talk with female family docs who are established and successful physicians and moms at the same time. When thinking about the timeline of education and residency, I’ve wondered how women find time to find a partner and start a family. It is reassuring to talk to female doctors who have done just that.

Besides talking with family docs, I’ve learned about other topics that make me feel more optimistic about the future of family medicine. I’ve learned a lot about the health care reform law and how it relates to primary care physicians, and I’m glad to see Congress includes provisions that highlight primary care physicians as an important foundation of the health care system that needs to be supported.

What makes me feel the best about family medicine are physicians deciding to turn their practices into “medical homes” where patients and doctors get to know each other and forge a trusting relationship, care is coordinated, and technology is embraced to enhance communication between patient and physician.  My grandfather, Opa as I call him, was a medical student in Italy in the 1940s; he wasn’t able to become a licensed physician because he had to escape as a political refugee. Nonetheless, the stories he tells me about practicing medicine radiate the passion he feels about caring and reaching out to the patient above all else. I believe the medical home embodies how he believes medicine ought to be practiced.

All in all, my experience at TAFP has shown me many sides to what family docs must face to care for their patients. While problems exist, I’m excited about the future of family medicine, especially with the health care reform law including provisions supporting family docs, and I hope the family residency Match Day numbers are even better next year.

 Monica Kortsha is TAFP’s spring communications intern. She is a third-year pre-med/journalism student at the University of Texas at Austin.

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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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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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Texas can improve care and cut costs with the medical home

By Greg Sheff, M.D.

I was fortunate to be one in a group of primary care physicians who met with Lt. Gov. David Dewhurst this February to discuss possibilities of payment reform in Medicaid, the Children’s Health Insurance Program, and the private insurance market.  This meeting comes on the heels of the introduction of two major pieces of legislation, Senate bills 7 and 8.  These bills would implement a host of pilot projects to test bundled payments, payments based on episodes of care, and quality incentives.  It continues the positive momentum the state needs to move us away from a fractured health care system into one that provides the right care for Texans.

The unrelenting march of increasing health care costs is unsustainable, both for Texas and for the nation. Payment reform that aligns physician and hospital incentives with our society’s goals—affordable, coordinated, evidence-based, quality-measured care—is critical to rein in health care costs.  The patient-centered medical home, driven by a strong primary care workforce, is a proven cost-effective method for delivering this coordinated and integrated care.

Earlier this year, Austin Regional Clinic (ARC) joined a multi-year medical home pilot administered by Blue Cross and Blue Shield of Texas (BCBSTX).  The pilot was initiated in large part in response to Texas legislation requiring the Employees Retirement System (ERS), the self-funded insurer for state employees, to experiment with alternate payment and delivery models in an attempt to reduce the state’s ever-increasing health care costs.  We are one of five physician groups in the state participating.  Our program serves roughly 45,000 patients, including both the ERS (whose health care benefits are administered by BCBSTX) and BCBSTX fully-insured populations.

As we have seen with our ARC Medical Home Program, there is a definite tipping-point phenomenon in getting providers to commit the resources necessary to proactively coordinate patient care.  We have been approached by a number of payers investigating our capability to transform our care delivery model.  However, not until we were approached with a payer as large as ERS were we able to make a compelling internal business case for investing the resources to transform our own workflows.

For me, this is the real pearl in the ERS Medical Home initiative: The Legislature, with control of Medicaid, CHIP, and ERS/Teacher Retirement System payments, has the opportunity to change—not by mandate but by example—the cost of care delivered across Texas.

However, a primary-care-led health care system cannot exist without actively nurturing and growing the primary care workforce.  Since its inception, ARC has emphasized the importance of long-term doctor/patient relationships, coordination of care, and a strong primary care physician base—three major tenets of the medical home model.  Drawing upon ARC’s 30 years of experience, I cannot overstate the importance of supporting initiatives to increase the number of medical school graduates choosing a career in primary care.

Payment and delivery system reform for ERS/TRS, Medicaid, and CHIP patients, coupled with an investment in growing our primary care workforce, helps not only the Texas budget in the short and long term, but provides the seeds to transform all care in Texas.

Gregory Sheff, M.D., is the medical director for the ARC Medical Home Program.

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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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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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