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EXTRA! Patient testimonial says it all BY SHERI PORTER
Charm. Coax. Prod. Teach. And, says FP Scott Whiddon, M.D., give patients with diabetes “unconditional positive regard” in a group visit setting. Add patient-to-patient mentoring, mix in lots of laughter, then sit back and watch the magic.
Twice a month here, Whiddon gathers together some of his patients with diabetes for group visits. After a year of effort, he pronounces the concept a success.
“It’s the highlight of my week,” he says. “We have a good time.” And, adds Whiddon, group visits play an important part in providing quality care for patients with this chronic disease.
The Future of Family Medicine report encourages group visits. FP Report visited Whiddon and one of his partners to spotlight the visits in this fifth article in a series on the report’s recommendations. To read the FFM report, go to http://www.annfammed.org/cgi/content/full/2/suppl_1/s3.
The FPs’ practice, Tallahassee Memorial Family Medicine, Quincy, with three FPs and one pediatrician, serves a rural area northwest of Tallahassee. Whiddon alone has nearly 500 diabetic patients. Before he began group visits, Whiddon repeated the same medical information over and over again. “Why would I want to go through the same spiel eight times a day when I can do it once in a way that’s fun?” he asks.
 "Pedometers are free to anyone today who promises to try to exercies more," jokes Scott Whiddon, M.D., above right, during a diabetes group visit that includes seven patients, support staff and a guest speaker. |
Nuts and bolts
Whiddon is participating in a group visit pilot project sponsored by the Florida AFP Foundation with funding from Pfizer Inc. and AstraZeneca (see Group visits get boost from Florida AFP Foundation pilot project). In the past year, he’s organized six groups of patients with diabetes, each group meeting once every three months. “It’s a little like an Alcoholics Anonymous group,” says Sandy Baker, E.M.T., who assists Whiddon. “By talking, patients teach one another.”
 Exercise the upper-body muscles sitting right there in the chair, says exercise physiologist Susan Ault, left, as she encourages patient Nedia Smith, right, to give it a try. |
For each patient attending a group visit, the practice bills for a level four visit with CPT code 99214.
“We’ve not had any problem with reimbursement,” says office manager Quinton Nealy. Because the practice is designated as a rural health clinic, it receives a flat monthly fee from Medicare and Medicaid, he says. The practice’s two largest HMOs are capitated, resulting in capped checks each month. Nealy says he hasn’t seen much of a jump in revenue yet, but scheduling hassles have dwindled. “By getting a group of patients in at one time, we’re opening up slots during the day for other patients,” he says.
Whiddon measures success differently. “If I can do as well or a little better (financially), have this much fun, and make an impact on patients, how is that not successful?” he asks.
Sharing and caring
On the day of the FP Report visit, seven patients keep their group visit appointment with Whiddon. Each had received a written invitation two weeks earlier and a reminder call the day before the visit. Patients due for lab work had blood drawn ahead of time so their charts would be up-to-date.
Shortly after 2 p.m., patients filter into a meeting room set up with fresh fruit, bottled water and an array of brightly colored patient education materials. Whiddon has already spent one-on-one time with each patient, checking vital signs.
Patients greet one another like old friends. “How are you feeling?” “I hurt so bad I could hardly get out of bed.” “I gained nine pounds over the holiday!” “I cut back on my eating.” “I was walking a lot, but I got lazy.”
Eventually, Whiddon gains control of the hubbub and reminds the group why they are assembled. “You guys are pioneers in what will probably be a standard across the country in 10 years,” Whiddon says. “It’s up to you whether you continue to do group visits or schedule appointments the boring, old-fashioned way.”
Whiddon eases the discussion toward diabetes issues, going over the basic review of systems necessary every time he sees one of these patients. But the conversation is surprisingly fun. Imagine this: Four women and three men sit around a table with their physician, discussing how diabetes affects their bodies and doing so with frequent outbursts of laughter.
As Whiddon goes through his checklist, which includes topics such as pain assessment, compliance, diet and exercise, and various body parts, he keeps his audience engaged. The camaraderie and Whiddon’s unconditional positive regard for each individual in the group help draw these patients here every three months.
Group visits also provide an opportunity to include guest speakers (for diabetes, think podiatrist, ophthalmologist, nutritionist). Today, an exercise physiologist waits to take center stage (see Outside speaker spices up group session).
 Before the meeting begins, patients Nedia Smith, sitting, and James Mitchell, take a stab at a patient education game on how to stay healthy. |
 Helping patients understand the paperwork is part of every group visit for Sandy Baker, E.M.T., right, who is shown here assisting patient James Mitchell. |
Future goals
It’s 5 p.m., the patients have gone home, and Whiddon remains to answer a few last questions. “We’re the pioneers working out the bugs,” he says, acknowledging that group visits require some time-consuming preparation. “Right now, it’s front-end loaded. I spent an hour with charts this morning, and Sandy had about an hour of preparation as well,” he says. But with a computer database set up exclusively for his patients with diabetes and with constant improvement to software templates, Whiddon sees that prep time shrinking in the future.
He’d like to expand group visits to include other disease groups such as chronic obstructive pulmonary disease, congestive heart failure and coronary artery disease. “Our whole model for chronic care management is wrong,” says Whiddon. “We’re set up for acute care.”
Whiddon’s dream in five years? “Every afternoon would be a group visit about some chronic disease,” he says.
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EXTRA! Patient testimonial says it all Family physician Chuck Kent, M.D., practices at Tallahassee Memorial Family Medicine in Quincy, Fla., with his colleague Scott Whiddon, M.D. (see Group visits mix learning with laughter). A year ago, Kent and Whiddon entered a pilot project to experiment with group visits for patients with diabetes.
However, Kent has experienced some frustration. "Even though we've been doing it for a year, I've just seen a glimmer of the possible potential," says Kent. "No-shows are a big deal."
In fact, just a few weeks ago, even after handwritten personal notes from Kent and reminder phone calls, only four patients out of eight scheduled for a group visit showed up.
"I said to my nurse, 'To heck with this, just put them in rooms and I'll see them individually,'" says Kent. The patient response that followed surprised Kent.
In room number one, the elderly male patient was terribly disappointed. "This was his social outlet for the week," says Kent.
He proceeded to room number two. The female patient said that she was OK with a regular office visit today, but she wanted reassurance that her group visits would continue. "I've gotten so much out of the group," the patient told Kent. A quick review of the patient's chart revealed that her hemoglobin A1C, blood pressure, weight and LDL cholesterol level had all improved over time, improvements the patient attributed to group learning.
Patients behind doors number three and four told similar stories and, in no uncertain terms, made it clear they wanted their group visits to continue.
The positive patient feedback was just what the doctor ordered. "An hour and a half before seeing those patients, I was ready to say, 'I'm not doing group visits anymore; it's not worth it,'" says Kent. "Now I've got a little gas in my tank. I'm not throwing in the towel. I just needed to hear a little of that 'Gee, thanks, doc.'"
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EXTRA! Patient testimonial says it all The concept of group visits for diabetic patients received a big boost in Northern Florida in the past year, due in part to the efforts of FP Edward Shahady, M.D., professor, department of family medicine and rural health, Florida State University College of Medicine, Tallahassee.
Shahady coordinates the program that helped FPs Scott Whiddon, M.D., and Chuck Kent, M.D., learn how to conduct group visits (see Group visits mix learning with laughter).
"I no longer do the visits, but I teach other physicians how to do group visits," said Shahady.
Group visits are a much-needed innovation for treatment of chronic disease, in part because they help eliminate the isolation patients feel, said Shahady. "Patients learn from other patients how to live with their disease. And a two-hour session gives the patients and the physician time to discuss and better understand issues."
Grants from Pfizer Inc. and AstraZeneca allowed the Florida AFP Foundation to fund a model training program -- the Master Diabetes Clinician Program -- training that both Whiddon and Kent completed last year as part of the group visit pilot project.
According to Shahady, the pilot project includes a Web-based diabetes registry into which Whiddon, Kent and two other physician participants have entered names of 450 patients with diabetes.
Physicians participating in the pilot project have committed to a five-year stint.
Shahady said the project should help improve outcomes for patients with diabetes, as well as improve patient and physician satisfaction. He hopes to bring 24 additional practices into the pilot project.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
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EXTRA! Patient testimonial says it all Scott Whiddon, M.D., invited exercise physiologist Susan Ault to a diabetes group visit recently for some show-and-tell. Ault is certified to teach people with diabetes how to exercise. Patients with diabetes need to make a serious, full-time commitment to owning their disease, Ault tells the patients. "I'm here to help you understand how exercise, just moving, can help you control your diabetes."
In addition to demonstrating exercises, Ault shares these tips with the group:
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EXTRA!
"I didn't come to my first group visit until my eyes started going bad," said diabetic patient Dolly Holmes.
Holmes, a patient of FP Scott Whiddon, M.D., said Whiddon tried his best to get her to take her diabetes seriously, "but the information just wasn't sticking."
"He would keep at me a lot, but I just couldn't see what he was talking about," Holmes said.
When her vision began to fail, Whiddon told Holmes to get her eyes checked.
She did. Then Holmes became a regular at one of Whiddon's diabetic group visits. Now she passes advice along to other patients in her diabetes group. "Other patients listen to me when I'm talking," said Holmes. "I tell them about how Dr. Whiddon told me to get my eyes checked and how I feel when my blood sugar goes too low."
Holmes said interacting with other patients has helped her understand the seriousness of her disease and made her more compliant. "I've learned how to eat healthy, drink lots of water, take my blood sugar and take care of my feet. I've learned to go for my checkups and to keep my appointments," she said.
Group visits are special, said Holmes. "It's more personal, a circle, close like family."
BY CINDY BORGMEYER
For many Americans, April 15 isn't exactly a date to look forward to. But for FPs enrolled in the American Board of Family Medicine's Maintenance of Certification Program for Family Physicians, or MC-FP, that date might now take on a positive slant. April 15 is the new deadline for completing the required 2004 self-assessment module, or SAM, of the board's MC-FP process.
Why the extension from Dec. 31? The board had multiple reasons for allowing additional time to complete the SAM requirement this year, according to ABFM Deputy Executive Director Joseph Tollison, M.D. Perhaps foremost among them: "This is an educational initiative, not a test," Tollison stressed in an interview Jan. 4. "With all the challenges faced by family physicians and with all the start-up conditions, this was deemed appropriate by the board."
With many FPs having entered the ABFM's SAM Web site late in the year, one factor may be as simple as demand overwhelming supply.
"We had a lot of our Diplomates who were committed to doing the right thing; they were trying to get in, and the system just got really loaded," said Tollison. "And that last Christmas week, we knew our Help Desk would not be at (full) staff."
One member recounts her experience
Melissa Duxbury, M.D., of Hudson, N.H., an at-large member of the New Hampshire AFP Board of Directors, knows firsthand some of the Web-based SAM's limitations.
"During the year, I had tried several times to access the site, which was 'busy' or 'down' many times," said Duxbury in a Jan. 11 interview. "I had spent several hours trying to work on this myself when I realized there were 18 -- yes, 18 -- references that we were required to read to answer the 60 questions posed. I asked a few other physicians, some of whom told me it took over 40 hours to complete.
"I think the best idea would be to have three to four brief review articles in a POEMs (patient-oriented evidence that matters) format and be questioned on those. Or the board could request more CME credit -- maybe up to 50 CME credits -- as I would expect it to take about 50 hours to critically read 18 articles."
Based on information provided by the ABFM, the entire SAM exercise was approved for 15 Prescribed credits. And Duxbury said she hasn't even yet begun the second part of the SAM, a physician-patient clinical encounter simulation.
Throughout the process, Duxbury said she corresponded frequently with Web site support staff at the ABFM, apprising them of her progress and of problems she encountered with the system.
"After multiple complaints about the site and the enormity of the process, I was told on Dec. 23 that an extension was being made available until April 15."
What bearing Duxbury's appeal may have had on the ABFM's decision is unclear, but the ABFM board, meeting in late December, decided to cut Diplomates some slack -- this year, at least. The board remains committed, Tollison said, to requiring completion of one SAM each year of the six-year recertification cycle. So Diplomates would still need to complete a SAM during calendar year 2005 to fulfill the 2005 requirement.
"I must be honest," Duxbury said, "I have learned nothing (from this process) except how to become frustrated. I have not yet spoken to anyone who felt this was a poor idea, just that it was poorly executed. Obviously, the people who are working on this exam are trying to work with the system, but there are still a lot of issues.
User feedback drives improvements
So just how many Diplomates are likely to take the board up on its extension offer? Of 11,259 Diplomates eligible to complete this part of the recertification process, said Tollison, 4,350 had completed the diabetes module as of Jan. 4, and another 355 were in the process of doing so. For the hypertension module, 2,181 Diplomates had completed it, with another 172 in progress.
"We're delighted with this number," said Tollison. "We obviously have seen a lot of concerns, and a lot of them were appropriate concerns. We're very open about that. That's the reason we solicited user feedback."
The board has made good use of that feedback, Tollison added, instituting 16 modifications secondary to Diplomates' input.
"Technologically, we've really made some major, major improvements," Tollison noted. "So the person who took it in February or March (2004) and completed it then would have had a very different electronic experience than that person would have had in November or December. And we continue to improve it."
The end goal, according to Tollison, is to make the computer-based SAM process -- and indeed the entire MC-FP process -- as user-friendly as possible.
"Ultimately, the computer needs to be a tool, a vehicle," he said. "It should be like getting in your car. When you got in your car this morning and drove to work, you didn't worry about whether the alternator was doing its thing or whether the carburetor was doing its thing -- you were thinking about work or family or whatever. You were thinking about your life. And that's what we're working toward with this. Ultimately, the computer is just a tool -- a very good tool -- that a person can use to accomplish an educational endeavor."
Start early, document hassles
For now, Duxbury offers the following advice on tackling the SAMs: "Start sooner and e-mail about every issue -- as it happens -- to the ABFM and your local AAFP chapter, so there is strict documentation of problems with the process. This would include days the site is down, difficulty with the questions, the amount of reading required, the simulation, whether you feel the information presented is useful in everyday practice, and so forth."
To take advantage of the extension, e-mail mcfpextension@theabfm.org. Include the words extension request in the subject line and body of your e-mail.
In response to a directive from the 2004 Congress of Delegates, the AAFP last November sent a letter to the board, discussing concerns about the SAM process and offering suggestions for addressing those concerns. AAFP leaders hope the SAM process will be among topics to be discussed at a meeting of the two organizations' executive committees and asked the board to respond by March 1. For a news story linking to that letter, go to http://www.aafp.org/fpr/20050100/4.html.
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
BY LESLIE CHAMPLIN
Since 2000, the number of uninsured Americans has swelled by 5.2 million, reaching 45 million or 15.6 percent of the population. About a fourth of them lost coverage despite their good incomes because their employers either dropped health benefits or new employers never offered them.
 Michael Fine, M.C., discusses patients' access to care during a town hall meeting at the 2004 Scientific Assembly. |
Watching the trends, Michael Fine, M.D., senior managing partner of Hillside Family and Community Medicine in Pawtucket, R.I., decided to act. His solution -- the Hillside Access Alliance -- provides primary care to uninsured patients. In the two years since its inception, the alliance has worked so well that the Rhode Island AFP plans to take the concept statewide this year.
Patients who participate in Hillside Access Alliance pay a $75 enrollment fee, about $20 a month and $10 for each office visit. In return, they get preventive care, physicals, immunizations and same-date appointments when they are sick. Fine encourages patients to consider a catastrophic health insurance plan to cover serious illness or hospitalizations.
The program alleviates the fear of health care costs, according to Fine. Before establishing the alliance system, his practice had used a radical sliding scale fee, which allowed established, uninsured patients to pay what they could afford, including nothing.
"We told them we would not turn them away," said Fine. Despite that, "they'd just not appear for three years because they were afraid of the cost. People assume it's going to cost $500 to walk in the door."
Fine researched the cost of primary care and discovered it runs $130 to $140 a year per person, compared with the average annual health insurance premium of $4,000.
"Primary care is quite affordable, less than the cost of a cell phone or cable television," he said.
The program has allowed uninsured patients to maintain their medical homes, and, without the cost of a managed care middleman, Hillside Family and Community Medicine is making money, said Fine.
Fine encountered only one snag in establishing the Hillside Access Alliance: If patients paid their monthly fees in advance, the practice would be considered a health insurance plan by the Rhode Island Department of Business Regulation. As such, Fine would have been required to maintain a $3 million reserve -- something not possible for his five-physician practice. His solution: Bill for participation at the end of the month for the previous 30 days. Now, the Rhode Island AFP has sought a $5,000 grant to defray the cost of writing software that would enable other family physician offices to establish programs as part of a statewide alliance based on Fine's concept, according to Jennifer Bianco, chapter executive. In addition, the chapter hopes to market the alliance program to uninsured and low-income families throughout Rhode Island. The marketing effort would urge residents to seek primary care, either from community health clinics or private family physicians.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
BY TONI LAPP
Organizations such as the AAFP create clinical practice guidelines to assist clinicians in their decision making. The guidelines follow the best available evidence to support care practices.
But the guidelines may be used as evidence in malpractice lawsuits.
This concerns some physicians, who believe jurors may misunderstand evidence-based guidelines and how they're developed.
"Juries are ill-equipped to understand (evidence-based medicine)," says Eric Wall, M.D., of Portland, Ore., a member of the AAFP Commission on Clinical Policies and Research. "They do not have the critical appraisal skills to evaluate studies."
AAFP guidelines delve into a number of topics, including blood glucose levels in patients with type 2 diabetes mellitus, newly detected atrial fibrillation, migraine headache, minor closed head injuries in children, otitis media and trial of labor versus elective repeat Caesarean section.
In the practice of medicine, there are three types of recommendations, says Wall. In one classification, there are clinical options in which evidence is based on "expert" opinion and published evidence is of poor quality or nonexistent. Often, community standards of care are grounded in such expert opinion. On the opposite end, says Wall, are evidence-based practice standards such as immunization recommendations that are almost universally accepted. In between are clinical guidelines developed by researchers who summarize the evidence surrounding a clinical situation and propose guidelines based on studies published in the medical literature. Such guidelines do allow for flexible interpretation based on individual patient considerations.
Case in point
One family physician with firsthand knowledge of the use of guidelines in litigation is Dan Merenstein, M.D., of Washington, D.C. As a third-year resident trained in a shared decision-making model, in 1999 he discussed the risks and benefits of prostate cancer screening with a 53-year-old male patient who subsequently declined to have a prostate-specific antigen test. Merenstein didn't see the patient again until four years later, when the patient became a plaintiff in a lawsuit, seeking damages from Merenstein and his residency. The patient had been diagnosed with prostate cancer in the years following his physical exam with Merenstein.
"What I didn't anticipate was that the plaintiff's attorney was going to argue that I should have never discussed the risks and benefits and should have just ordered the PSA," says Merenstein. In June 2003, jurors exonerated Merenstein but found his residency program liable for $1 million.
AAFP policy says there is insufficient evidence to recommend for or against prostate cancer screening, in keeping with findings of the U.S. Preventive Services Task Force.
Merenstein says evidence-based medicine got a bad rap in the courtroom: "Lawyers portrayed it as a cost-saving measure used to deny tests to patients." Meanwhile, jurors had 15 separate guidelines to evaluate regarding PSA testing, further clouding the issue.
It's unfortunate the medical profession hasn't done more to regulate guidelines, says Merenstein. "In my trial, (guidelines) got thrown around. A lot of people who make guidelines have a questionable self-interest in them."
Wall notes that not all professional organizations are as rigorous as the AAFP in reviewing studies that will be included in evidence supporting clinical recommendations. The Academy is careful to use clear terminology that describes the quality of evidence supporting a recommendation, he adds.
Fodder for the defense?
Herbert Young, M.D., director of the AAFP Scientific Activities Division, says guidelines can also be used to defend a physician. "The legal system grabs everything (as evidence)," he says. "We believe that guidelines will be more beneficial than harmful because they point out that the science is not certain, while some expert witnesses state things with certainty."
A Harvard School of Public Health study in the mid-1990s showed that plaintiffs were more likely to use guidelines as evidence of a physician deviating from the standard of care than the reverse.
"That's because a lot of doctors don't follow guidelines," says Richard Roberts, M.D., J.D., of Madison, Wis., a former AAFP president.
"If you only think of guidelines as being applied defensively, you've missed the point," Roberts said. "When done well, guidelines represent an effort by a number of people to synthesize the best available evidence and weave that into a succinct set of clinical recommendations."
Once burned, twice shy
| To access guidelines the AAFP has created or helped develop, go to http://www.aafp.org/x132.xml. To see AAFP's recommendations for periodic health exams, go to http://www.aafp.org/exam.xml. To find Academy articles on liability issues, go to http://www.aafp.org and, in the search box, enter liability or malpractice. |
Practicing FPs should proceed carefully. Merenstein, now a fellow at Johns Hopkins University, Baltimore, in the Robert Wood Johnson Clinical Scholars Program, at one point questioned whether he would return to practice medicine. He currently sees only urgent-care patients and admits, "I order more tests now, am more nervous around patients; I am not the doctor I should be."
But he says he still believes in evidence-based medicine.
"I hope I'll go back to the way I should practice, but I'm not sure," he says. "I don't want to go through that again."
Avoiding the wall
Roberts, with degrees in law and medicine, has advice for physicians tempted to practice defensive medicine: "If physicians spend their time running down the hall looking over their shoulder for the lawyer they think is chasing them, they'll run into the wall. My advice is to practice the best medicine they know how."
BY LESLIE CHAMPLIN
Medicaid reform that caps federal outlays for Medicaid or imposes restrictions on eligibility will do more harm to Americans' health than good to America's budget. That's the message physicians and patient advocates are sending to Congress and President Bush as federal lawmakers convene their 109th session.
The medical community's concern stems from trial balloons floated by the Bush administration and members of Congress. One balloon -- which would have put federal Medicaid funds into block grants to states -- was defeated before it got much traction in the 108th Congress. However, the concept resurfaced when Rep. Joe Barton, R-Texas, promised hearings on the proposal early in the 109th Congress. Others have suggested capping federal Medicaid spending.
In a Dec. 16 letter to President Bush, AAFP and 15 other physician, hospital and pharmaceutical organizations urged him, "in your Fiscal Year 2006 budget, … do not include any reductions on the rate of growth or propose caps on Medicare or Medicaid spending. More than 40 million seniors and people with disabilities depend on Medicare. More than 52 million vulnerable Americans, many of whom are children and seniors, rely on Medicaid. With many states in fiscal crisis, Medicaid reductions at the federal level would drastically unravel an already frail health care safety net."
The letter is in keeping with the Medicaid Provider Coalition's core principles, which were discussed during the AAFP Commission on Legislation and Governmental Affairs January meeting in San Antonio. Composed of the organizations that represent primary care physicians, community health centers and community hospitals -- including the Academy -- the coalition developed the core principles to establish the medical community's position on Medicaid reform.
The core principles outline minimum provisions that should be in any Medicaid reform. Among them:
| Want your patients to become more informed about Medicaid reform and its potential impact on insured and uninsured people? The AAFP's newly enhanced Patient's Voice in Washington program offers an easy-to-read information sheet about Medicaid on its Web site, http://www.aafp.org/patientsvoice.xml. Read more about Patient's Voice in Washington. |
The medical community is not alone in its concern about Medicaid reform. In a Dec. 22 letter to Congress, the National Governors Association urged legislators to refrain from using the budget reduction and reconciliation process as the Medicaid reform mechanism. Though budget reduction and reconciliation might cut federal spending on Medicaid, they would do little to actually reform the program in a way that ensures greater efficiency in providing care, the letter warns.
"We agree that maintaining the status quo in Medicaid is not acceptable," the National Governors Association letter says. "However, it is equally unacceptable in any deficit reduction strategy to simply shift federal costs to states."
With Medicaid consuming 22 percent of their budgets, states already struggle to meet their Medicaid commitments. In the last four years, all states and the District of Columbia have imposed some restrictions by either cutting or freezing physician payments, according to the Kaiser Commission on Medicaid and the Uninsured. Federal caps or cuts would further stress states' Medicaid budgets, and -- according to a 2004 AAFP Practice Profile Survey -- the 77 percent of family physicians who take Medicaid patients would become less and less financially able to care for them.
"Limiting federal Medicaid resources would place additional pressures on providers, resulting in fewer providers able to serve Medicaid and uninsured patients, said a Kaiser Commission fact sheet, Medicaid: Issues in Restructuring Federal Financing.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
The struggle to resolve Medicaid's fiscal crisis came into sharp focus in Tennessee on Jan. 10, when Gov. Phil Bredesen announced he will eliminate nearly half of all adults from TennCare, the state's Medicaid program, this spring.
Bredesen's cuts mean Tennessee physicians no longer will receive reimbursement for the care they provide to 323,000 otherwise uninsured adults who had received Medicaid. Moreover, for most of the 396,000 adults who maintain Medicaid coverage, the revised program will limit doctor visits to 12 per year, prescriptions to four per month and hospitalizations to 20 days per year. Neither patients nor doctors will be able to appeal the limits.
In 1993, TennCare expanded Medicaid beyond federal standards. In addition to covering the poor and disabled, TennCare offered coverage to patients with catastrophic illnesses that would otherwise bankrupt them or who were refused private health insurance because of their chronic illnesses. It is this group who will receive letters explaining they will be dropped from TennCare rolls this spring.
Once implemented, the cuts will highlight the precarious balance family physicians and their medical peers must keep between maintaining their practices' fiscal health and ensuring their patients receive appropriate, high-quality care. Georgia's FPs faced similar challenges in 2003 when that state changed Medicaid eligibility and dropped patients from its rolls. The result: Georgia physicians who were actively treating patients lost reimbursement for ongoing care after the patients lost Medicaid coverage.
In response, the 2004 AAFP Congress of Delegates in October approved a resolution calling on CMS to require continued Medicaid coverage until soon-to-be-dropped patients complete treatment for pregnancy, inpatient care or rehabilitation.
By cutting Medicaid rolls and limiting coverage, Bredesen expects TennCare to increase spending by $75 million in the next fiscal year, rather than by $650 million without the changes. All 612,000 children in the program will still be covered. State taxpayers foot nearly a third of TennCare's bill. The federal government picks up the rest of the cost.
BY LESLIE CHAMPLIN
In effort to reduce the stress of the post-match scramble may become reality for the class of 2006 if the National Resident Matching Program Board of Directors approves a proposed second round for the process. The decision could come during the board's meeting in May.
The proposal, one of a number considered over several years by the NRMP Committee on the Unmatched Applicant, grew from concern about "the pressure to make uninformed decisions during the chaotic 24-hour period after applicants learned whether they had matched," says an NRMP proposal for a second match.
Before the second match, students who didn't place in the first match would be notified. They would apply for unfilled positions through NRMP's Electronic Residency Application Service. Students and programs would submit rankings. The NRMP would verify match results, post them to its Web site and send them via e-mail according to the current match schedule. Results of the first and second matches would be announced concurrently.
A recent NRMP survey found 70 percent of U.S. medical school seniors and 85 percent of independent applicants favored a second match.
| Jenny Butler, M.D.: "The current scramble system often forces people to make rash decisions in fear that they will miss out." |
"I think everyone's goal for a second match system would be to lessen the anxiety and stress placed on applicants, program directors and medical school officials who must participate in the current scramble," said Gretchen Dickson of Pittsburgh, student member of the AAFP Board of Directors. "A second match system could create a better fit between applicants and programs than the current scramble system."
Jenny Butler, M.D., of Ankeny, Iowa, resident representative to the AAFP Committee on Chapter Affairs, agreed. A second match "gives both residency programs and students additional time to make big decisions," she said. "I think the current scramble method is insufficient. I like the idea of having a designated period for unmatched students and unfilled programs to find each other before match day."
Moreover, a second match would give unmatched students a greater sense of control over their ultimate residency placement, said Dickson.
"A second match system with an opportunity to rank programs would lessen the panic associated with the scramble," she said.
Butler agreed. "Students who don't match will be allowed more time to explore their other options," she said. "The current scramble system often forces people to make rash decisions in fear that they will miss out."
| Peter Nalin, M.D.: "For the vast majority of applicants, the match works very well. It's difficult to address the fitness of a secont match as a 'solution' because the 'problem' hasn't been well described yet. Why complicate what works well? " |
Equally important, a second match may be of benefit to family medicine, said Michael King, M.D., of Lexington, Ky., resident member of the AAFP Board.
"I think there is some benefit of a second match for family medicine in general because of the fill rates over the last few years," he said. "Last year, family medicine filled 78.8 percent of their slots in March, but, as usual, increased it to 93.5 percent by July. By having the second match by the NRMP, applicants and programs would be bound to NRMP rules, which would provide security that people would fulfill their commitments, unlike some situations that can occur during the scramble process, where people keep fielding offers or simply do not come to the program as they said they would."
The idea does have challenges. Program directors and medical school officials aren't as keen on the idea. Only 44 percent of them favor it, according to the NRMP survey. The officials suggest the NRMP proposal is a solution searching for a problem and, if implemented, could pose more burden on the majority of matched students than it would resolve issues for unmatched students.
"Ever since the match was introduced, a few students have not matched annually," said Peter Nalin, M.D., president of the Association of Family Medicine Residency Directors. "Yet for the vast majority of applicants, the match works very well. It's difficult to address the fitness of a second match as a ‘solution' because the ‘problem' hasn't been well described yet. Why complicate what works well?"
Moreover, residency directors question the wisdom of discouraging interviews during a second match. An applicant's ability to communicate and demonstrate professionalism and preparation are important, and an interview helps identify those who offer those skills, they say.
How a second match would work
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"Selecting residents without interviews deletes those important attributes from the local selection process," said Nalin. "Why exclude onsite interviews from the unmatched group? This group deserves and requires comparable attention and scrutiny in the selection process."
Officials, students and residents all express some concern about the effect of delaying announcement of match results until the end of the second phase. Such a delay is envisioned in the NRMP proposal (see box below).
A second phase would mean applicants who matched in the first round would not know the name of their residency programs until the second phase was completed, according to King. ""Uncertainty about where you're going would be very stressful. Clearly, unmatched applicants and programs would benefit by a second match, but it would certainly be at the emotional and psychological expense of those who matched initially," he said.
The NRMP acknowledges timing issues in its proposal, noting that the schedule for ranking deadlines could pose problems for osteopathic students. If the deadline for the NRMP phase one preceded the American Osteopathic Association match results, osteopathic students couldn't participate in the NRMP. Likewise, dually accredited programs may not be able to place unfilled AOA positions in the NRMP.
Moreover, though unmatched students and unfilled programs could be "required" to participate in a second match, monitoring compliance would be difficult, according to the NRMP.
"It is likely that some participating applicants and programs would reach agreements in the period between the first and second matches or that programs would offer their unfilled positions to applicants who had not participated in the match at all," the proposal says.
Not all students would match in the second phase. Nor would all positions fill. The end of the second phase still would mark the beginning of a scramble.
Of greatest concern: Students might shorten their ranking list and wait for the second match to list their "safety" programs. That, says the NRMP, would mean "many positions may be filled in phase one by independent applicants, leaving more unmatched seniors at the conclusion of phase two."
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
BY CINDY BORGMEYER
The AAFP's 2005 Annual Clinical Focus on genomics takes a cue from the adage, "It's not what you know; it's who you know." In the case of this year's ACF, however, the saying reads more like "It's not always what you do, it's often who you're born to."
The first program in the AAFP's all-Web-based 2005 ACF, launched late last month, focuses on how family physicians can uncover, explore and use patients' family histories to help predict and manage health conditions that include a genetic component.
Seven more video programs on various genetically influenced health conditions will be released throughout the ACF year.
Getting Started
FPs begin the educational process by visiting http://www.aafp.org/acfgenomics.xml. From there, they can link to the family history program page containing links to an online CME video and other resources. RealOne Player is required to view the roughly 30-minute video program. A link provided at the site allows participants to download that software free from http://www.aafp.org/realplayer.xml.
In the video, Norman Kahn, M.D., AAFP vice president for science and education, explains why genomics was chosen for this year's ACF initiative. "First," Kahn says, "there have been rapid recent advances in genomics, centered around the mapping of the human genome. And second, we believe that this new information needs to find its way into our practices sooner rather than later."
He offers two relevant clinical scenarios participants are likely to have encountered in their practices and outlines some issues they raise. How does family history help clinicians decide what screening interventions are appropriate for their patients? What are the implications of a positive or negative screening result on preventive management? What are the relevant costs and likely benefits of such tests? These are the sorts of questions the 2005 ACF is designed to answer, says Kahn.
"Face of genomics"
Family physician Nancy Stevens, M.D., associate professor of family medicine at the University of Washington, Seattle, and medical director for the 2005 ACF, will serve as "the face of genomics" for the entire yearlong ACF video series.
"We've chosen to begin with family history because this is the foundation on which we will build our knowledge," Stevens explains. "This program will focus on three approaches to family history: tools developed for primary care practice, tools developed for patients and the pedigree genetics professionals use to record family history."
Francis Collins, M.D., Ph.D., director of NIH's National Human Genome Research Institute and keynoter at the 2004 AAFP Scientific Assembly, appears briefly in the video. Collins led the Human Genome Project that in April 2003 successfully completed mapping the entire human genome. The findings from that project, he says, will transform many aspects of how physicians practice medicine.
"We will learn the individual genetic glitches that each of us carries around," Collins says, "and that will give us a chance to make predictions about who's at risk for what."
Collins' Scientific Assembly presentation may be accessed through a link on the family history program home page. It is also included in a "Web tour" of resources that accompanies the video program. The tour may be accessed through a link on the program's home page.
Genomics toolbox
Incorporated into the family history video program are tools physicians and patients can use to provide background for discussions about family history and specific genetics concerns. Two such tools featured in the video were developed as part of Genetics in Primary Care: A Faculty Development Initiative, a multi-year project that brought together representatives from the specialties of family medicine, internal medicine, pediatrics and genetics.
Family medicine leaders were instrumental in creating the GPC initiative, with support from the Maternal and Child Health Bureau and Bureau of Health Professions of the Health Resources and Services Administration, NHGRI, and the Agency on Healthcare Resources and Quality.
"The SCREEN mnemonic developed by the GPC initiative can be administered as part of a complete history and physical examination or can be used to quickly elicit concerns and/or risk factors regarding a patient's family history," Kahn explains in the video.
The letters of the SCREEN mnemonic represent various topics -- Some Concern; Reproduction; Early disease, death or disability; Ethnicity; and Nongenetic or Not necessarily genetic -- and remind physicians of questions they can ask to identify potential genetic "red flags." In this context, red flags are clinical findings revealed by the history, physical exam or laboratory testing that suggest the presence of genetically influenced disease and require further action such as intervention, counseling, referral, screening or follow-up.
A second GPC tool, represented by the mnemonic "Family GENES," consists of a small number of red-flag categories consistent with the family medicine approach to patient care. In this context, those red flags are: Family history -- multiple affected siblings or individuals in multiple generations; Groups of congenital anomalies; Extreme or Exceptional presentation of common conditions; Extreme or Exceptional pathology; Neurodevelopmental delay or degeneration; and Surprising laboratory values.
"Although red flags clearly aren't 100 percent sensitive or specific," Kahn says, "the presence of one should raise your suspicion regarding a genetic influence."
The video also points patients to a tool they can use to record their own family health history. The tool, "My Family Health Portrait," is part of the Family Health Initiative launched last November by Surgeon General Richard Carmona, M.D., M.P.H.
Via a link from the family history program home page, participants can view a separate video of the surgeon general discussing his initiative. "Family history can save your life," Carmona says in that video. "That information is critical and we don't use it enough."
This free online tool allows patients to record their family history at home and then bring the physician a printed copy to interpret. The tool, available in both English and Spanish, enables physicians to customize patients' care by focusing preventive strategies on areas most relevant to those patients.
Rounding out the family history program is a quality improvement project clinicians can complete for 20 CME credits.
The 2005 ACF program is supported by various governmental agencies, health professional associations and consumer health groups. Numerous other organizations also are partnering with the AAFP in the educational initiative. The family history program received financial and in-kind support from HRSA's Maternal and Child Health Bureau and NHGRI. A complete list of supporters and partners may be accessed from the 2005 ACF Web page.
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
In a democracy, informed voters are the government. So the Academy is upgrading Patient's Voice in Washington, a program that distributes information about health-related issues to members and their patients.
The program provides a two-pronged approach to ensuring that patients understand the legislative issues that can affect their health care. The first comprises production of "Issues in Health Care," an ongoing series of informational materials about public policy issues of importance to family physicians and their patients. The second involves announcing call-to-action alerts on critical legislative initiatives in Academy publications. Both elements rest on helping FPs help their patients understand that government action can have direct impact on their lives and health.
"As the Academy has aggressively worked to enhance its advocacy efforts over the past three years, it's only a natural continuum that we look for ways to involve more of our members and, importantly, their patients in this effort," said Douglas Henley, M.D., AAFP executive vice president.
Family physicians can go to the Patient's Voice in Washington Web site (http://www.aafp.org/patientsvoice.xml) to download one-page information sheets that provide facts about a health care topic and explain why the issue affects everyone, regardless of current insurance, income or health status.
"The Web site will have several educational pieces about various health care topics that our members can download and place in their waiting rooms just for information to patients -- not with the intent of stimulating messages to Congress, but simply to create better understanding of these important topics by patients," said Henley. On request by FPs, the Academy can provide easels that hold the "Issues in Health Care" information sheets (see box below).
The second prong involves call-to-action alerts on critical legislative initiatives. Also available on the Patient's Voice in Washington Web site, the call-to-action materials will cover critical federal legislation and ask patients to contact their legislators about that legislation.
| Download Issues in Health Care information sheets for your patients at http://www.aafp.org/patientsvoice.xml. To obtain a free, colorful 11 x 15 cardboard easel to hold Issues in Health Care sheets, call (800) 944-0000 and ask for item #305. |
"There is nothing quite so persuasive to a member of Congress as lots of messages from constituents back home on an issue," said Henley.
Informational materials on the first three Patient's Voice in Washington topics for 2005 -- health care coverage for all, Medicaid and family medicine training issues -- went online Jan. 12. FPs can check the Web site regularly for additions to the "Issues in Health Care" series as the year progresses.
The Patient's Voice in Washington offers several benefits, said Henley. In addition to providing an avenue by which FPs and patients can express opinions to lawmakers, the program provides ongoing information about America's health care system and the role of family physicians in that system.
"This brings added value to patient-physician relationships," he said. "It brings more knowledge to our patients, including a better awareness of the Academy; a better informed and more involved member; and better debate and public discourse on important health care issues."
The Grant Generating Project Fellowship, which sponsors grantsmanship training for family medicine faculty, recently surpassed the $30 million mark in funded grants obtained by its alumni. The AAFP helps sponsor the fellowship.
Since GGP's inception in 1996, project fellows have received $30,346,383 for various research and training projects.
GGP offers a yearlong fellowship program providing advanced grantsmanship training to family medicine faculty in universities and teaching hospitals through a combination of workshops, individualized critiques and mentoring. GGP fellows also participate in national and international family medicine and research conferences.
In addition to the AAFP, current sponsors of the fellowship are the North American Primary Care Research Group, the Society of Teachers of Family Medicine and the College of Family Physicians of Canada.
WEB EXTRA!
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 If
you need help on managing your practice like a business, which it is,
consider attending AAFP's Crash Course on Cash, Codes and Computers
April 8 - 9 in New Orleans. This course reviews financial basics such
as how to interpret balance sheets and income statements. Another course
component is a review of the principles of diagnosis and procedure coding,
essential information to any practice's bottom line. Go to http://www.aafp.org/crashcourse.xml
for easy online registration. |
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| A shipping fee may apply; Kansas residents pay a 7.525 percent tax. |
WEB EXTRA!
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WEB EXTRA
You might want to put some of these deadlines on your calendar. For more information, check the Web sites.
March 15 is the deadline for proposals for workshops, seminars, lectures, papers, poster displays and special interest discussions at the 2005 Conference on Patient Education Nov. 17 - 20 in Orlando, Fla. Submit your proposals online at http://www.stfm.org/stfmpresenter/submission/index.cfm; if you have questions, call Kelly Becker at (800) 274-2237, Ext. 5415.
You have the opportunity to make a family medicine research presentation or present a scientific exhibit, resident or medical student poster, or international poster at the AAFP Scientific Assembly Sept. 28 - Oct. 2 in San Francisco. Go to http://www.aafp.org/assembly.xml for applications, and by April 1, submit the applications for research presentations, scientific exhibits, and resident or medical student posters. The deadline for the international poster application is April 15.
Two deadlines are near for Tar Wars®, AAFP's tobacco-free education effort aimed at fourth- and fifth-grade students. Nominations for the Star Award, which honors individuals or groups that have significantly contributed to the Tar Wars effort, are due by April 15. Applications for scholarships to attend the Coordinator Leadership Conference July 17 - 19 in Alexandria, Va., are due by April 8. The Star Award nomination form is at http://www.tarwars.org/x1813.xml, and the scholarship application is available from http://www.tarwars.org/x824.xml.
FP Report is published by the
AAFP News Department.
Copyright © 2005 by
American Academy of Family Physicians.
Will
your practice be compliant with the Health Insurance Portability and
Accountability Act security rule by the April 21 deadline? If you're
struggling, check out an AAFP online resource that could help you. The
HIPAA Security Rule Manual: A How-To Guide for Your Medical Practice
was developed specifically to help small medical practices complete
the compliancy task. The manual costs $50 and includes a step-by-step
security risk analysis, model policies, procedures and forms. Download
the 138-page security manual at 
If
you'd like to increase your knowledge of internal medicine topics, consider
taking this Academy CME course: Selected Internal Medicine Topics
for Family Physicians. The course will be held March 7 - 11 in St.
Kitts, West Indies. To access online course information, go to 
Two Academy
CME courses, planned back-to-back at the same location, offer busy FPs
a chance to earn CME and save on time and travel expenses. Consider
attending Women's Health in Primary Care April 6 - 9 in Savannah,
Ga. This course, designed to cover a wide spectrum of women's health
concerns, includes lectures and breakout sessions. Four hands-on optional
sessions -- available for an additional fee -- are new to this year's
program. Register separately for "Chemical Peels for Family Physicians,"
"Sclerotherapy," "Botulinum Toxin Injections" and "Procedures in Women's
Health." Hurry. Space is limited for these optional sessions. Go to
http://www.aafp.org/x14456.xml
for additional course information and to register. Stay over in Savannah
and take the Colposcopy Update and Review, offered April 9 -
10. This course targets physicians with prior experience performing
colposcopy. Enjoy hands-on practice sessions in topics such as loop
electrosurgery and cryotherapy of the cervix, as well as how to handle
office logistics for colposcopy services. Register at