Volume four • Number three Winter 2016

A JOURNAL OF THE STATE ACADEMY OF FAMILY PHYSICIANS

CME Famil y YES Team-based Practice: care MAY BE

FEATURE ARTICLES: SIM NO • Two Views ? • The Magic of Medicine: VBP How Magical Thinking Influences Medical DSRIP Decision-Making Patient- • Payment Reform in 2016 centered • Albany Report medical home Medical Marijuana SHIP ? Payment Reform

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REFERENCES: 1. National Health and Nutrition Examination Survey (2003-2006), Ages 2-18 years. 7. American Academy of Pediatrics, Committee on School Health. Soft drinks in schools. Pediatrics. 2005; 113: 152-154. 2. Johnson RK, Frary C, Wang MQ. The nutritional consequences of flavored milk consumption by school-aged children and 8. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2010. adolescents in the United States. J Am Diet Assoc. 2002; 102: 853-856. 7th Edition, DC: U.S. Government Printing Office, December 2010. 3. National Dairy Council and School Nutrition Association. The School Milk Pilot Test. Beverage Marketing Corporation for 9. Greer FR, Krebs NF and the Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children and National Dairy Council and School Nutrition Association. 2002. Available at: adolescents. Pediatrics. 2006; 117: 578-585. http://www.nationaldairycouncil.org/ChildNutrition/Pages/SchoolMilkPilotTest.apx. 10. Murphy MM, Douglas JS, Johnson RK, et al. Drinking flavored or plain milk is positively associated with nutrient intake and is 4. National Institute of Child Health & Human Development. For Stronger Bones…for Lifelong Health…Milk Matters! Available at: not associated with adverse effects on weight status in U.S. children and adolescents. J Am Diet Assoc. 2008; 108: 631-639. http://www.nichd.nih.gov/publications/pubs/upload/strong_bones_lifelong_health_mm1.pdf Accessed on June 21, 2011. 11. Johnson RK, Appel LJ, Brands M, et al. Dietary Sugars Intake and Cardiovascular Health. A Scientific Statement From the 5. U.S. Department of Health and Human Services. Best Bones Forever. Available at: http://www.bestbonesforever.gov/ American Heart Association. Circulation. 2009; 120: 1011-1020. Accessed June 21, 2011. 12. 2010-2011 Annual School Channel Survey, Prime Consulting Group, May 2011. 6. Frary CD, Johnson RK, Wang MQ. Children and adolescents’ choices of foods and beverages high in added sugars are associated 13. Patterson J, Saidel M. The Removal of Flavored Milk in Schools Results in a Reduction in Total Milk Purchases in All Grades, with intakes of key nutrients and food groups. J Adolesc Health. 2004; 34: 56-63. K-12. J Am Diet Assoc. 2009; 109: A97. *DAILY RECOMMENDATIONS – The 2010 Dietary Guidelines for Americans recommends 3 daily servings of low-fat or fat-free milk and milk products for those 9 years and older, 2.5 for those 4-8 years, and 2 for those 2-3 years.

4 • Family Doctor • A Journal of the New York State Academy of Family Physicians Family Doctor, A Journal of the New York Articles State Academy of Family Physicians, is published quarterly. It is free to members Transitions of the New York State Academy and is By Stephen Dahmer, MD...... 17 distributed by mail and email. Non-member subscriptions are available for $40 per year; The Magic of Medicine: How Magical Thinking Influences single issues for $20 each. Medical Decision-Making By Utsav Hanspal, MD, MPH...... 20 New York State Academy of Family Physicians The Jericho Road Model: A Strategy for Engaging the 260 Osborne Road Practice’s Most Vulnerable Albany, New York 12211 By Jordan Katz; Ju Joh, MD; Eleanor Nixon, FNP; Priscilla Lau, RN, BSN; www.nysafp.org and Myron Glick MD...... 23 Phone: 518-489-8945 Fax: 518-489-8961 Guest Medical Expert Tips for Television and Radio By Amber Robins, MD and Colleen T. Fogarty, MD, MSc...... 26 Letters to the Editor, comments or articles can be submitted by mail, fax or email to Innovation as Motivation - Making Primary Care [email protected] Attractive to Medical Students By Haran Sivakumar & Ravishankar Ramaswamy, MD, MS, FAAFP...... Editor: Penny Ruhm, MS 28 Assessing the Perceived Utility and Impact of a Continuing Editorial Board Medical Education Activity in Family Medicine Robert Bobrow, MD Richard Bonanno, MD, By Gregory W. Kirschen, BA; Dorothy S. Lane, MD, MPH and Rachelle Brilliant, DO Catherine R. Messina, PhD...... 30 Robert Ostrander, MD The Primary Care Specialist New York State Academy Officers By Sabina Rebis, MD...... 33 President: Tochi Iroku-Malize, MD President-elect: Robert Ostrander, MD Payment Reform in 2016 – A Comic Tragedy in One Act Vice President: Sarah Nosal, MD By Robert Morrow, MD ...... 34 Secretary: Barbara Keber, MD Treasurer: James Mumford, MD Changing Health Care in New York State for Medicaid Recipients By Lynda Karig Hohmann, MD, PhD, MBA, FAAFP...... 36 Staff Executive Vice President: Departments Vito Grasso, MPA, CAE...... [email protected] From the Executive Vice President: Vito Grasso...... Director of Education: 6 Kelly Madden, MS...... [email protected] President’s Post: Tochi Iroku-Malize, MD, MPH, MBA, FAAFP...... 8 Director of Finance: Upcoming Events...... Donna Denley, CAE...... [email protected] 9 Project Coordinator and Journal Editor: Advocacy: Marcy Savage...... 10 Penny Ruhm, MS...... [email protected] Two Views: Primary Care Practice Transformation...... 12 View One: The Case for Team-Based Care – Michael Mendoza, MD, MPH, MS View Two: Is it Worth the Cost? – Barbara Keber, MD, FAAFP For Advertising Information Contact Don McCormick In the Spotlight...... 38 at 518-542-3341, or fax: 321-600-4227 or [email protected] Index of Advertisers American Dairy Association...... 4 Atlantic Health Partners...... 25 Core Content Review...... 29 Fidelis Care...... IFC Glens Falls Hospital...... 7 Health Fusion Inc...... 3 Marley Drug...... 16 MLMIC...... IBC Our Lady of Lourdes Memorial Hospital...... 14 St. Joseph's Hospital Health Care...... OBC

Winter 2016 • Volume four • Number three • 5 From the Executive Vice President By Vito Grasso, MPA, CAE

Transformation

Transformation is occurring market. In fact, premiums in general have An ironic example of this is DSRIP; the throughout healthcare and in various forms increased. The default of Health Republic $8 billion Medicaid initiative to reduce with mixed reception by family physicians. in the NY exchange is just one example “avoidable” hospitalizations by 25% over Indeed, there is much confusion and often of a company created for the exchange 5 years by creating regional networks of the rhetoric and reality of the movement market that failed because of a combination providers who share risk and coordinate to incorporate change do not coincide. of factors including inability to operate care. Team care and coordination of services New York, for example, leads the nation profitably. among providers is an essential element in the number of practices that have Government has taken the lead in promoting of DSRIP, yet restrictions on business achieved PCMH recognition and New York transformation. The transformation relationships among licensed professionals policymakers are among the most vocal landscape is replete with public subsidies, has emerged as a problem in achieving the supporters of primary care and investing demonstrations, new rules and regulations kind and quality of integration contemplated in primary care. Yet, when federal funding all conceived to incent change in behavior by DSRIP. Consequently, legislation has been expired at the end of 2014 to equalize by providers and, to a more limited degree, introduced to address this issue by allowing Medicaid rates for primary care services by consumers and health insurance plans. licensed professionals to form business with those for , NY failed to partnerships. The proposal approve continuation of that endorsed by the Medicaid policy using state funds. …many of the barriers to reform are a consequence Redesign Team, however, would Much of the debate over of government rules and statutory restrictions on how permit licensed professionals to form partnerships but would healthcare reform has included health care businesses can operate and how health care prohibit anything that would the caveat that we must preserve professionals can provide services… the private market and that restrict the ability of any of the we need to encourage and partners from practicing at the accommodate competition to highest level of his/her license. In control costs and stimulate innovation. Some interesting and good ideas have effect, this would mean that the partnership The public option was eliminated from the emerged from this government-led process could not operate as an actual business earliest iteration of the but many of the barriers to reform are without a chain of command and decision because it was criticized as a threat to the a consequence of government rules and making process that vests authority in private market. It was replaced with the statutory restrictions on how health care specific individuals. The language regarding “exchange” and a plethora of rules to make businesses can operate and how health preservation of the right to practice at the the exchange mimic a viable public option care professionals can provide services. It highest level of licensure is an obvious without actually presenting an alternative is not yet evident that government actually attempt to appease non-physician providers to the private market. Although many has the will to reform itself by removing the who have lobbied incessantly for expanded people have obtained coverage through restrictions and requirements it has imposed scope of practice and independence. While the exchanges established by states and on healthcare providers and businesses the ability to practice at the highest level of the federal government, products sold in that often add costs to the system without licensure is not an unreasonable objective, the exchanges are not significantly less discernible benefits or actual protection. the practical effect of the attempt to regulate expensive than products sold in the private the internal relationships of partners in CONTINUED NEXT PAGE 6 • Family Doctor • A Journal of the New York State Academy of Family Physicians the professional corporations would impair the ability of the partnership to operate efficiently. When the various subsidy programs that fuel the current spate of transformation initiatives begin to expire it is likely that some, perhaps most, of the entities that have emerged to foster transformation will struggle to sustain themselves and the healthcare environment of the future may look very similar to that which inspired the transformation movement in the first place. I am not alone in my skepticism and remain convinced that a better way to achieve a more efficient, effective and innovative healthcare system that truly serves the needs of patients is to invest in economic development for healthcare providers. I addressed this in my column which appeared in the summer issue. If we help providers reduce their costs through waiving their tax burden in exchange for performing certain public good activities such as hiring staff and operating as a medical home, then providers Live Like You’re will be able to invest their own resources in the innovation and expansion that we are otherwise trying to cajole through mechanisms inherent in programs like DSRIP, SHIP, SIM, TCPI and on Vacation! all the others whose acronyms I cannot recall. Family Medicine Opportunities in the Glens Falls/Lake George/Saratoga Region of Upstate New York

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Winter 2016 • Volume four • Number three • 7 President’s Post By Tochi Iroku-Malize, MD, MPH, MBA, FAAFP

Alot has happened since the last We recently faced an issue in New York City patients who do not have access to family issue of our journal was released. We are with one of our family medicine residency physicians, or the impact of team based care now faced with the end of the year, trying programs facing closure. Had it not been for in teaching community health centers. At the to spread holiday cheer while preparing to the time and commitment that the residency end of the day, the question is whether we create our latest list of resolutions for 2016. program had dedicated to educating are making a difference in the lives of our students – regardless of their final choice patients – providing better quality, at lower We have had our ups and downs. Globally in specialty – there might not have been cost with improved access. we have dealt with climate change and the great groundswell of protest from the terrorists attacks in Paris. Locally we have This transformation cannot occur without student body coupled with some political dealt with the repercussions of gun violence physician satisfaction – the fourth aim in pressure, which allowed the program to at various workplaces. health care improvement. It is difficult to remain open. Our goal is to make sure that determine whether transformation is hurting As we look at transforming the way in or helping the family physician. Some which health care is provided to our say that patient perception of team based communities, we try to keep in mind the …We need to find ways to show care within the medical home is positive, importance of having a method to maintain health systems and medical schools therefore adds a level of quality which the supply of family physicians that are the value of family medicine for should reflect on the physician. However, integral to the provision of that care. We the community and their future the hoops that some physicians have to jump speak of recruiting medical students into physicians. … through in order to attain the status of a schools that place a value on primary medical home can take their toll, especially care education, elucidated by the care on a solo provider. given by family medicine specialists. We this doesn’t happen to other programs in encourage these students to apply to family our state. We need to find ways to show As the new year moves forward, I ask that medicine residency programs to learn health systems and medical schools the we all continue to do what we love and take the full scope of practice that makes our value of family medicine for the community time to renew our mind, body and spirit. specialty unique. We hope to retain these and their future physicians. We plan on Remember the reasons we became family residents upon graduation to practice within continuing to work with our programs and physicians. Recapture the joy. our communities as seasoned physicians do what is needed to help share our vision May you and your loved ones stay well. May retire or opt out of clinical practice. Most with those that are given the honor and the force be with you. See you in the new importantly, we continue to advocate for funds to train the doctors of tomorrow. year! appropriate payment models that allow This issue discusses transformation in care. family physicians to continue to practice the Whether it be the utilization of emergency specialty they love, caring for the patients departments as a primary care base for they have grown to cherish.

8 • Family Doctor • A Journal of the New York State Academy of Family Physicians Mark Your Calendars SMTWTFS Upcoming Events

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Winter 2016 • Volume four • Number three • 9 ADVOCACY

Albany Report By Marcy Savage

In the 1960s, Bob Dylan sang “The Times They Are A Delivery System Reform Incentive Payments (DSRIP) Changin’.” When it comes to New York’s healthcare system and In April of 2014, Governor Cuomo announced that $8 billion in related efforts federally, these lyrics from more than fifty years ago, federal savings generated by the MRT would be provided to NYS for still ring true and are right on point. reinvestment in further reforms to the Medicaid system as follows: New York State has embarked on a major healthcare system • $500 million for the Interim Access Assurance Fund – temporary, transformation focused on implementation of a seismic shift in how time limited funding to ensure that viable Medicaid safety net healthcare is provided and paid for through its Medicaid program, providers can fully participate in the DSRIP transformation which covers more than six million New Yorkers and is the largest in without disruption; the country in per capita spending. • $6.42 billion for Delivery System Reform Incentive Payments When Governor Cuomo first took office he hired Jason Helgerson – including planning grants, provider incentive payments, and to serve as his Medicaid Director, a role he held in Wisconsin administrative costs; immediately prior. Helgerson’s primary focus was and continues to be to reform the Medicaid program in order to achieve the Triple • $1.08 billion for other Medicaid redesign purposes – this funding Aim with emphasis on controlling the growth in Medicaid spending. will support Health Home development, and investments in long term care, workforce and enhanced behavioral health services. In the first few years, Helgerson created a Medicaid Redesign Team (MRT) which included many healthcare stakeholders and resulted To access DSRIP funding, all types of community providers were in the enactment of a series of reforms including moving a majority required to join together to form networks called Performing of Medicaid patients to managed care or a similar type of care Provider Systems (PPS’) and select from a menu of activities focused management program, as well as reimbursement cuts to hospitals, on reducing hospitalizations. Based on the location and size of the nursing homes, home care providers, pharmacies and many other PPS, patients have been attributed to them to be responsible for their providers. care and services as it relates to the DSRIP projects and deliverables. A total of twenty-five PPS’ were formed with the overwhelming As implementation of the MRT initiatives neared completion, majority having a hospital as the lead and covering nearly every Helgerson and the Cuomo team embarked on a new goal aimed at county in New York State. a systematic change in how the healthcare system operates which focused on the overall objective of reducing “avoidable” hospital use For more information on DRRIP and a list of PPS’, please visit: by 25% over a five year period. The Cuomo administration sought https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/ federal funding from the savings New York had generated from its MRT initiatives to be used for the next phase of the reform plan Value-Based Payments (VBPs) entitled the Delivery System Reform Incentive Payments or DSRIP. As the PPS networks are beginning to develop and execute their action plans around selected projects, Helgerson has now turned his attention to changing the reimbursement structure under Medicaid.

10 • Family Doctor • A Journal of the New York State Academy of Family Physicians Specifically, working with CMS to pursue the very ambitious goal o Developing a common scorecard, shared quality metrics and that by the end of the 5-year DSRIP plan, 80-90% of total MCO-PPS/ enhanced data/analytics to assure that delivery system and provider payments (in terms of total dollars) shall be value based payment models support Triple Aim objectives; (outcome-based) payments (VBP). Further, at least 35% of total o Providing state funded leading edge health information managed care payments shall be tied to VBP arrangements at Level technology, including greatly enhanced capacities to exchange 2 or higher where there are both upside and downside risks for clinical data and an all payer database; and providers in order to optimize incentives and allow providers to maximize shared savings. o Supporting an independent evaluator, data collection and performance monitoring. To implement this ambitious reform, the NYS DOH developed the “New York State Roadmap” which has been submitted and • Generating a gross savings of $4.4 billion over the grant period of approved by CMS. In addition, a VBP Workgroup has been created 2015-2018, of which half will be reinvested in the system and half with five subcommittees to advise the state on various areas of accrued as net savings. implementation. Finally, Helgerson and his consultants at KPMG For more information on the SHIP, visit: https://www.health.ny.gov/ have created Clinical Advisory Groups (CAGs) for a variety of disease technology/innovation_plan_initiative/docs/ny_sim_testing_ states/conditions to assist NYS and guide the Medicaid Managed Care application_summary health insurance plans with developing the care/payment bundles which would model how VBP care/payment would be structured. For a listing of VBP subcommittees and CAGs visit: https://www.health. NYSAFP Engagement in NY Reforms ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm As President Idi Amin of Uganda said many years ago, "If you’re not at the table, you're on the menu." As New York pursues an New York State Health Innovation Plan or SHIP ever-evolving and expanded array of health care reforms, for some providers and small/solo practitioners it may feel more like another In December 2014 while New York was focused on the series of sequel to the movie, The Hunger Games. Medicaid reforms discussed above, the NYS DOH was awarded a $99.9 million Round Two Model Test Award State Innovation Where possible we have proactively sought appointments for Models (SIM) grant by the Centers for Medicare and Medicaid Academy members on key committees/ working groups. At this point, Innovation (CMMI) to implement the State Health Innovation Plan NYSAFP is represented by more than one individual on both the SHIP (SHIP). The intent and goal of the SHIP is to identify and stimulate integrated care workgroup and the DSRIP workforce subcommittee. the spread of promising innovations in health care delivery and Additionally, the Academy sits on a SHIP workgroup for the NYC finance that result in optimal health outcomes for all New Yorkers. Department of Health including a subcommittee focused on small and solo practices. Relevant to Academy members and others in primary care, the focus of the SHIP is to enhance and bring the medical home model We will continue to closely monitor these activities and keep to scale, supported by a value-based payment system, a skilled members informed of new developments as well as identify workforce and a common set of quality measures. Specifically, the additional opportunities for the Academy to impact the processes at state funding is focused on: all levels on behalf of its membership.

• Implementing a statewide program of regionally- based primary Marcy Savage is Government Relations Counsel for NYSAFP from Reid, McNally care practice transformation, to help practices adopt and use the & Savage, LLC in Albany, NY. Reid, McNally & Savage has been working with the Advanced Primary Care (APC) model; Academy for nearly two decades providing its legislative, regulatory and budget • Changing the way primary care providers are paid expanding the representation before state government. Prior to joining Reid, McNally & Savage in 2003, Ms. Savage worked for the American Cancer Society in cancer control and use of VBP so 80% of New Yorkers receive value-based care by advocacy, focused on tobacco control and prevention. 2020; • Supporting performance improvement and capacity expansion in primary care by: o Expanding NY’s primary care workforce through innovations in professional education and training; o Integrating APC with population health through public health consultants funded to work with regional Population Health Improvement Program contractors;

Winter 2016 • Volume four • Number three • 11 PRIMARY CARE PRACTICE TRANSFORMATION

VIEW ONE: VIEW TWO: THE CASE FOR TEAM-BASED CARE IS IT WORTH THE COST? By Michael Mendoza, MD, MPH, MS By Barbara Keber, MD, FAAFP

To those who work in primary care, the thought of Although at first look, the transformation of primary care accepting one more change is all too familiar. To practices to the patient centered medical home (PCMH) physicians – and increasingly for our non-physician One model of care appears to be the solution to reducing the colleagues – change can provoke stress, discomfort, cost of health care, improving patient satisfaction and or fear that stems from our genuine concern that providing better quality of care, aka the well- known yet another barrier will detract from our time and Triple Aim, one must look at the entire picture. In attention with patients. New payment and delivery Two evaluating the true cost of the PCMH, we must evaluate models such as patient-centered medical homes not only the reduction in emergency room visits, (PCMH) and accountable care organizations (ACOs) reduction in hospital admissions, and improved quality are among the responses on the part of our health metrics which might lead to cost savings, but also the care system to well-documented disparities in costs for accomplishing those goals. Included in this health outcomes, patient experience, and cost of cost is the stress on physicians and staff as they undergo care. Common to all of these efforts is the reality change to reach the PCMH goals for certification. that our existing healthcare workforce is projected Depending on the program chosen for the certification to be inadequate to meet the healthcare needs of process, the documentation of processes within the our population, especially as needs grow due to aging, population practice is very burdensome. NCQA requires many documents growth, and expansions in insurance coverage. A recent study and significant change documentation within the practice for commissioned by the American Association of Medical Colleges certification.1 Managing the documentation is a job in itself and can found that the U.S. will face a shortage of between 46,000-90,000 be difficult depending on the resources of the practice. The Joint physicians by 2025. In primary care alone, the shortage is estimated Commission also has a PCMH certification which is less burdensome at between 12,000 and 31,000 physicians. Additional physicians in terms of document submission but which requires a site visit and and advanced-practice clinicians alone will not adequately close this all that is associated with that process. gap in primary care either.1 For this reason, many practices are left wondering how they can keep pace with demand. Some of the underlying costs that are built in to team based care which have shown benefit in decreasing utilization include care As the pressures to keep pace with demand mount, so too do the management, team members managing registries for population pressures on primary care. It is well established that our health care management, team members performing patient education, health system must rest on a solid foundation of high-performing primary coaches, staff to track referrals, test results, and hospital/emergency care, but our primary care foundation is in jeopardy. Physicians care room admissions, and those who manage and analyze data. To date for larger and larger panels, risking poor patient outcomes as well there is little information in the literature regarding these costs. One as physician burnout. Currently, we know that clinicians without pilot study performed in looked at savings for reduced teams caring for a panel of 2,500 patients would spend 21.7 hours utilization and showed significant reductions in cost, but concluded per day providing recommended acute, chronic, and preventive that the reductions seen were related to resources provided to the care.2 We also know that burnout is common among physicians practices. The cost for additional resources at the practice level was in the United States, with an estimated 30% to 40% experiencing not evaluated.3 burnout.3 In addition to its effects on clinicians, burnout impacts patient care. Physicians who have burnout are more likely to report Funding sources to create increased primary care practices with making recent medical errors, and score lower on instruments PCMH certification or at least functioning in the PCMH model of care measuring empathy. These physicians also report planning to retire with a team based structure have, thus far, been varied. They include early and have higher job dissatisfaction which has been associated enhanced fee for service, capitation payments, and external study with reduced patient satisfaction with medical care and reduced funding. Many studies have been conducted in integrated delivery patient adherence to treatment plans.4 These realities predict a grim systems rather than in independent primary care practice sites.5 prognosis for the triple aim unless we can develop better ways to Personnel costs to maintain the PCMH model in the few instances deliver care.

CONTINUED ON PAGE 13 CONTINUED ON PAGE 15

12 • Family Doctor • A Journal of the New York State Academy of Family Physicians view one, continued

Practice transformation is seen as the vehicle by which our system that physician. The new model of care reallocates responsibilities, will evolve from a fee-for-service reimbursement model to one as well as the tasks of care, among all team members so that all based on improved outcomes, and specifically those referenced members contribute meaningfully. In this way, the physician no 9 in the IHI Triple Aim which are to improve population health and longer needs to be involved in all tasks and responsibilities. patient experience of care including quality and satisfaction while Research is beginning to show support for this shift. Medical reducing per capita cost of care.5 Because practice transformation assistants who are trained in health coaching can improve care means different things to different people, however, patients and for chronic conditions when compared to care provided only by care providers alike are understandably uncertain of what to expect. clinicians, and those who take responsibility to ensure that patients Thankfully, emerging evidence from studies of high-performing have received appropriate cancer screening can improve screening practices has shown that practices that have begun evolving toward rates. 10-11 When non-clinicians serve as scribes, patients have higher new models of care share many of the same traits. These traits satisfaction, and physicians can save 75 minutes per 4-hour clinic include four foundational characteristics -- engaged leadership, session.12 A large observational study of 27 practices found that data-driven improvement, empanelment, and team-based care.1 sharing the care can enhance physician and staff satisfaction while These foundational characteristics facilitate the implementation of six lowering burnout among team members as long as teams are not additional traits -- patient-team partnership, population management, understaffed.13-14 continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future.6 These innovations, Yet, despite their best intentions, practices face many barriers however, reflect a departure from traditional primary care and may in the move toward sharing the care. First, and perhaps most be unfamiliar and unsettling to practices, clinicians, and patients. important, many practitioners in our current workforce trained in settings from the same profession, and not in the teams in which Central among these innovations – and perhaps the one representing they would eventually work. Physicians went to medical school the greatest departure from traditional care models – is the concept where their interactions with other health professionals were often of team-based care. Teams show great promise for achieving the opportunistic, not intentional. Nurses trained in nursing school, and triple aim, as well as enhancing a fourth aim, the joy of practice, rarely alongside students from medicine, dentistry, or other health which has gained prominence as part of the so-called “the quadruple professionals. Although this is changing, it will take time before aim”.7 Teams also offer relief for busy clinicians who are struggling interprofessional education becomes the dominant training modality to provide the level of care for their patients that they know they can for our health care teams. Fortunately models for this type of provide. Evolving toward an effective model of team-based care, education are becoming more common than in the . In addition, however, requires considerable effort. Among other characteristics, although there are considerable efforts afoot to transition toward effective teams require a stable team structure and, ideally, consistent value-based reimbursement, most practices remain constrained membership. Many primary care practices struggle with this. by budgets rooted in a productivity-oriented system. In this system, Colocation with staff and clinicians working side by side in the many practices do not receive payment for services unless a clinician office can facilitate effective communication, yet many practices are provides that service. It is not surprising, then, that clinicians, limited by traditional floor plans that segregate clinicians from other practices, and health systems are reluctant to embrace changes members of the team. Standing orders and protocols enable other that may jeopardize financial health. Thankfully, emerging evidence members of the care team to act independently, yet scope of practice studying patient-centered medical home models is beginning to show and other regulations can be a barrier to implementing standing financial returns. Across diverse settings and patient populations, orders.8 investments to redesign delivery systems around primary care yield Although these innovations can benefit practices and patients in a favorable return on investment, both in terms of quality of care, many ways, perhaps the most critical among them is the culture patient experience and access while also reducing cost in a relatively 16 shift toward new ways of sharing care within the care team. Sharing short time. Another barrier is that some clinicians struggle to care allows all members of the care team to work to the top of relinquish control over tasks that they can provide more quickly their ability and, frequently, relieves clinicians of tasks that can be than others, not realizing the opportunity cost of care that they completed more efficiently, and often more effectively, by others. could otherwise provide in that time. For others, the uncertainty of When clinicians are no longer burdened by these tasks, teams can reallocating tasks while retaining legal liability can be uncomfortable see more patients and ultimately expand capacity in order to narrow at first. These barriers are very real and deserve attention at multiple the gap between demand and capacity for primary care. Sharing care levels of our care delivery system. in this way is foreign to many physicians, and can represent a major With all these changes it is no surprise that all facets of our care change in how physicians and offices operate. The paradigm shift system are stressed. Our existing workforce is being stretched to do requires us to transform from a traditional care model that places the physician at the center of a team whose primary role is to help CONTINUED ON PAGE 14

Winter 2016 • Volume four • Number three • 13 view one, continued more and more during a transition toward a reimbursement system Endnotes that shows promise, but has yet to fully become reality. Thankfully 1 Estimates of supply and demand http://bhpr.hrsa.gov/healthworkforce/ there are glimmers of hope in New York State and across the nation. supplydemand/index.html. Accessed 11/23/2015, 2015. The innovations that show promise for achieving the goals of the 2 Yarnall KS, Ostbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family Triple Aim, though, will require a paradigm shift for many clinicians, physicians as team leaders: "time" to share the care. Prev Chronic Dis. 2009;6(2):A59. practices, and delivery systems. The largest shift – and the one 3 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. showing the greatest potential – is the shift toward team-based care. Lancet. 2009;374(9702):1714-1721. With team-based care comes greater potential to expand access to 4 Dyrbye LN, Shanafelt TD. Physician burnout: A potential threat to successful primary care, reduce the burden on our workforce, and meet the health care reform. JAMA. 2011;305(19):2009-2010. needs of our communities. 5 Institute for healthcare improvement: The IHI triple aim http://www.ihi.org/ engage/initiatives/tripleaim/Pages/default.aspx. Accessed 11/18/2015, 2015. 6 Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12(2):166-171. 17 Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576. 8 Ghorob A, Bodenheimer T. Building teams in primary care: A practical guide. Fam Syst Health. 2015;33(3):182-192. 9 Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med. 2012;366(21):1955-1957. 10 Willard-Grace R, Chen EH, Hessler D, et al. Health coaching by medical Family Practice (No OB) assistants toimprove control of diabetes, hypertension, and hyperlipidemia in low-income patients: A randomized controlled trial. Ann Fam Med. Physician Opportunity 2015;13(2):130-138. 11 Bodenheimer T, Willard-Grace R, Ghorob A. Expanding the roles of Our Lady of Lourdes Memorial Hospital in Binghamton, medical assistants: Who does what in primary care? JAMA Intern Med. NY, a member of Ascension Health, the largest not-for- 2014;174(7):1025-1026. profit health system in the US, is a 160-bed full service 12 Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The effect of a community hospital with a 23-practice physician physician partner program on physician efficiency and patient satisfaction. JAMA network that has served the area since 1925. The Lourdes Intern Med. 2014;174(7):1190-1193. Physician Network of over 150 employed primary care 13 O'Malley AS, Gourevitch R, Draper K, Bond A, Tirodkar MA. Overcoming and specialty providers is accepting applications for a BC/BE Family Practice physician. The opportunity is an challenges to teamwork in patient-centered medical homes: A qualitative study. J outpatient service model. Gen Intern Med. 2015;30(2):183-192. 14 Helfrich CD, Dolan ED, Simonetti J, et al. Elements of team-based care in a A strong benefits package plus a competitive base patient-centered medical home are associated with lower burnout among VA salary, which includes a two-year salary guarantee primary care employees. J Gen Intern Med. 2014;29 Suppl 2:S659-66. followed by a RVU-based compensation structure, is offered to qualified candidates. Our sites are located 15 HHS,Agency for Healthcare Research and Quality. TeamSTEPPS pocket guide: in designated HIPSA areas and H1-B candidates are Team strategies & tools to enhance performance and patient safety HHS, Agency welcome to apply. for Healthcare Research and Quality. 16 Grumbach K, Bodenheimer T, Grundy P. The outcomes of implementing patient- For more information, please contact: centered medical home interventions: A review of the evidence on quality, access Cathy Hawkes and costs from recent prospective evaluation studies. August, 2009 Director of Medical Staff Development Our Lady of Lourdes Memorial Hospital Michael Mendoza, MD, MPH, MS is Medical Director of Highland Family 169 Riverside Drive, Suite 307 Binghamton, NY 13905 Medicine, the primary residency teaching practice for the University of Rochester/ Phone: 607-798-5837 Highland Hospital Family Medicine Residency Program. Dr. Mendoza also serves Fax: 607-798-5093 as a Health Innovation Consultant for the Finger Lakes Health Systems Agency. E-mail: [email protected] Previously, Dr. Mendoza served for 4 years as a National Health Service Corps scholar A Member of Ascension Health in federally qualified health centers in the South Side of Chicago. He is a Diplomate www.LOURDES.com of the American Board of Family Medicine and a Fellow of the American Academy of Family Physicians.

14 • Family Doctor • A Journal of the New York State Academy of Family Physicians view two, continued where they have been evaluated, show increases from just over $2/ quality measures for chronic disease management, screening and per member per month to $4.68/per member per month. Much of immunization rates. In addition, care managers working with high this cost was dedicated to care management. Another study showed risk patients who generate the largest portion of the cost of care that only 21% of the cost was reimbursed in the fee-for-service within a practice are other possible outcomes of team based care. payment model.6 There are still many questions to be answered regarding the PCMH In a study of several practices in Colorado and Utah, a cost model of team based care. The sustainability of this model is assessment of PCMH functions not related to the high functioning dependent on many individual characteristics of the PCMH and the primary care practice without a PCMH model in place, the per cost for enhanced team based care has yet to be fully determined. member per month cost ran between $3.85 and $4.68. These Once it has been further studied, a better analysis of future payment costs were based on the NCQA standards for 2011 which equate to models including value based contracting and accountable care an approximate cost of $105,000 per physician FTE. The current organizations can be assessed to determine if payments from these proposed reimbursement related to additional visits generated2 by models support the enhanced staffing required to maintain the tenets enhanced access is in the range of $27,000 which would leave of PCMH. The current multitude of programs such as Delivery System a shortfall of over $76,000 per physician FTE.6 It also requires Reform Incentive Payment (DSRIP), the State Innovation Model increased visit volume to make up this cost. Of note is that the (SIM), and others only provide the funding to begin the process of current NCQA standards for 2014 include additional functions not transformation. Sustaining it will be the key to real reform and cost evaluated in this study.1 reduction. Beyond care management, other costs associated with team based Endnotes care include advanced tracking and population management 1 NCQA.org (accessed 11/30/15) which require sophisticated registry and other IT functionality. 2 Asaf Bitton, Gregory R. Schwartz, Elizabeth E. Stewart, Daniel E. Henderson, Interconnectivity of electronic systems is also crucial to the PCMH Carol A. Keohane, David W. Bates and Gordon D. Schiff, Off the Hamster model of care. This has thus far proven to be difficult in many of Wheel? Qualitative Evaluation of a Payment-Linked Patient-Centered Medical Home (PCMH) Pilot, Milbank Quarterly Volume 90, Issue 3, pages 484–515, the IT systems currently in common use. Patients who receive care September 2012. outside of a specific system may have difficulties associated with 3 Meredith B. Rosenthal, Ph.D., Shehnaz Alidina, M.P.H., S.D., Mark W. Friedberg, the inability of practitioners to access all information from previous M.D., M.P.P, Sara J. Singer,M.B.A., Ph.D., Diana Eastman, B.A., Zhonghe Li,M.S., testing, which may lead to overuse and repeat examinations. The and Eric C. Schneider,M.D., M.Sc., A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer costs associated with the lack of availability of testing results have not Patient-Centered Medical Home Pilot, J Gen Intern Med pp1-8, 2015 DOI: been studied up to this time. 10.1007/s11606-015-3521-1. 4 Kurt C. Stange, Paul A. Nutting, William L. Miller, Carlos R. Jaén, Benjamin F. New forms of payment will affect the ability of primary care practices Crabtree, Susan A. Flocke, James M. Gill, Defining and Measuring the Patient- to institute and maintain team based care as required by current Centered Medical Home, Journal of General Internal Medicine June 2010, models of the Patient Centered Medical Home. Value based payment Volume 25, Issue 6, pp 601-612. 5 George L. Jackson, PhD, MHA; Benjamin J. Powers, MD, MHS; Ranee Chatterjee, contracts which give enhanced payments for improved quality and MD, MPH; Jane Prvu Bettger, ScD; Alex R. Kemper, MD, MPH, MS; Vic lower cost care, are one way some of the costs to the practice can be Hasselblad, PhD; Rowena J. Dolor, MD, MHS; R. Julian Irvine, MCM; Brooke L. deferred. This however, fails to yield an actual decrease in the total Heidenfelder, PhD; Amy S. Kendrick, RN, MSN; Rebecca Gray, DPhil; and John W. Williams Jr., MD, MHS, The Patient-Centered Medical Home: A Systematic cost of healthcare, which is a basic principle of healthcare reform. Review, Ann Intern Med. 2013;158(3):169-178. doi:10.7326/0003-4819-158-3- Each tenet of the PCMH - every patient having a personal physician, 201302050-00579. 6 Michael K. Magill, MD, David Ehrenberger, MD, Debra L. Scammon, PhD, Julie a whole person orientation, care coordination across the spectrum, Day, MD, Tatiana Allen, CRC, Andreu J. Reall, MBA candidate, Rhonda W. Sides, quality and safety, patient engagement, enhanced access to care, CPA, Jaewhan Kim, Phd. The Cost of Sustaining a Patient-Centered Medical enhanced IT use for population management and data analysis – Home: Experience From 2 States, Annals of Family Medicine, September/October 2015 vol. 13 no. 5 429-435. have affiliated costs. Although these provide enhanced access to care for the patient, none of these increase revenue for the practice in the Barbara Keber, MD, FAAFP, has been a family physician in Long Island for the current fee for service structure, resulting in an increased burden last 30 years. She is Chair of Family Medicine at Glen Cove Hospital and Vice Chair of on the practice, especially for the physician. Although team based Family Medicine for NSLIJ-Hofstra School of Medicine. Prior to her current roles, she care can assist physicians with this burden, it also costs the practice served as the Associate Program Director for the Family Medicine Residency Program additional funds. at Glen Cove Hospital for 10 years. Her interests include clinical informatics, diabetes, the PCMH model of care, and care of uninsured populations. Added costs of team based care include the use of scribes to lighten the load and allow for improved physician–patient interaction, staff to manage registry functions for population management, enhanced patient engagement via health coaches, and improved

Winter 2016 • Volume four • Number three • 15 16 • Family Doctor • A Journal of the New York State Academy of Family Physicians I carefully thought through possible downsides: potential for patient harm, loss of my DEA license, federal imprisonment, decreased clinical acumen, career suicide, and the bias that comes when associating with an outlawed-cum-decriminalized industry. I also began to research medical cannabis, which opened up a world to me that did not exist in medical school or in any other area of my career. In society, there has been a dramatic shift in both attitudes and momentum regarding Transitions medical cannabis.14,16,17 I am specifically referring to medical cannabis – the use of cannabis, By Stephen Dahmer, MD including constituents of cannabis, THC and other cannabinoids, as a physician-recommended form of medicine. The 5,000 year history of the 36 million year old cannabis plant’s use as medicine is well documented.36-38 Attitudes toward cannabis have shifted following the discovery and growth of research exploring the endocannabinoid system and how cannabis chemical constituents influence multiple human physiological processes including appetite, regulation of mood and perception of pain.24-27,35 Any critic of medical cannabis will be quick to point out the lack of randomized controlled trials due in large part to its designation as a Schedule 1 substance.28 Despite this limitation, medical cannabis has been shown to relieve pain, muscle spasms and spasticity, as well as stimulate appetite and weight gain in patients with wasting syndromes. In addition, increasing evidence of the value of medical My dedication to family cannabis continues to build based on medium and large, double- medicine is rooted in responding to the needs blind, randomized, placebo-controlled trials.18,19,29 of others while integrating a breadth of expertise. Life experiences, as well as professional experience, offer learning opportunities that One of cannabis’ greatest potential advantages as a medicine is we can apply to the myriad of situations challenging us when we care its level of safety. There is no known case of a lethal overdose for others. My medical education has involved global travel studying and on the basis of animal models, the ratio of lethal to effective phytopharmaceuticals in Palau, population health in New Zealand, dose is estimated as 40,000 to 1 - about 5,000 times more than is and medical anthropology, ethnobotany and clinical medicine in required for any effect. By comparison, the ratio is 10 to 1 for oral 20 Brazil. These experiences always led me back to the same main dextromethorphan and between 4 and 10 to 1 for ethanol. This is focus: direct patient care. tremendously reassuring to any prescribing physician doing their best to remain true to their oath to do no harm. Nonetheless, as with Until very recently, I never thought I would do anything but direct any novel therapeutic, vigilance is necessary. Numerous reports have patient care. However, after more than a decade of growing personal suggested an association of cannabis smoking with an increased frustration with primary care, I experienced what is ubiquitous in risk of heart attack, not to mention other serious possible harm our profession – a term I coined “The Hilfiker effect”.1-5, 40 With such as addiction, adolescent cognitive dysfunction, and low birth increasing peripheral demands, the obvious question resonated weight.22,23,29 louder and louder: how much am I truly helping my patients? In addition to safety and efficacy, a top priority was direct patient Despite being open to a major change in my career, when Vireo feedback. During my interactions with patients in our Health of New York offered me the position of Chief Medical dispensaries, I spoke with the mothers of children with Dravet Officer, I struggled with making that decision. Vireo is one of five syndrome and other intractable epilepsies who had given up all registered organizations awarded a license for growing, producing hope. After initiation of cannabis therapies, I listened to stories of and dispensing medical cannabis in New York State following how their children made eye contact, wrote a note, or even played the enactment of the Compassionate Care Act. While my personal in Special Olympics games for the first time. In these interactions, I approach to medicine has always been considered integrative, have been most impressed by the subtle ability of cannabis to treat assuming a full-time role as a “weed doc” carried far more illness, rather than a disease.39 A Gulf War veteran with debilitating professional risk. CONTINUED NEXT PAGE

Winter 2016 • Volume four • Number three • 17 transitions, continued muscle spasms significantly decreased his oxycontin use.6-10 One I already miss not seeing patients on a daily basis. This void Crohn’s Disease patient had her first bowel movement in five has quickly been replaced with intensive scientific research on years without using a laxative and another was able to drive to her cannabinoids, meetings with senators and city council members parent’s house for first time without having to stop for the bathroom. and advocates, creation of standard operating procedures for And finally, there was the stage 4 breast cancer, hospice accepted dispensaries, and intense involvement in the entire process of “World’s Greatest Grandma” (written on her t-shirt) brought in via a making a medication from seed to the patient’s hands. A priceless three hour drive by her son looking for any alternative to the bottles perk is the flexibility in my schedule and a work/family balance that of pills that make her “backed up and loopy”. The most compelling has allowed me to accompany my wife during her prenatal visits stories are those that support improvement in the entire family’s and even be to glue closed my two year-old daughter’s facial quality of life. laceration when she fell down the stairs. These are experiences that I will carry with me forever. As physicians, we will all have our opinion, biases and recommendations regarding any new therapy. Before we jump to criticize any therapeutic falling outside FDA approval, we should also be honest about our current prescribing practices.33 Like many other previous therapeutics, medical cannabis defies easy dichotomies with conflicting information in both the media and the medical community. At this point, it is no longer a question of “if”, but rather “how”.31,32 A lack of FDA approval should be a red flag for further involvement, rather than an excuse to take it off our overflowing plates. Let us start the discussions on curbing adolescents’ access, developing standardized dosing levels and creating guidance for 11 novice users, as well as ways to avoid unintentional poisoning. To learn more about medical cannabis or to potentially Let us insist on child-resistant packaging, limits on THC content, recommend to qualifying patients, providers may register with food-safety requirements, and required potency and contamination the NYSDOH Medical Marijuana Program. Qualifying illness testing. Let us be the pioneers in promoting sound strategies to includes the following severe, debilitating or life threatening curb addiction, monitor potential side effects and drug interactions, conditions: cancer, HIV infection or AIDS, amyotrophic lateral and prevent falls in the elderly. And finally, let us also demand the sclerosis (ALS), Parkinson's disease, multiple sclerosis, spinal exploration of the 400+ chemical compounds specific to cannabis, cord injury with spasticity, epilepsy, inflammatory bowel novel new forms of delivery, and the science required to confirm or disease, neuropathy, and Huntington's disease. disprove cannabis’ potential as medicine. The four-hour NYSDOH approved course Practitioner Ultimately, the deciding factor in accepting the position with Vireo Education for the Medical Marijuana Program is now available was what I believed to be a unique possibility to offer our sickest online: patients a hope that did not exist before. I saw the possibility of providing a reputable and trusted medical product to replace what https://www.health.ny.gov/regulations/medical_marijuana/ many were seeking on the black market in order to provide relief, practitioner/ making purchases of varying quality and composition.15 Finally, I saw a whole class of novel therapeutics with a unique advantage: Endnotes a growing scientific evidence base of healing benefits and a 1 The Annals of Family Medicine. 2004 May; 2(3): 274–277. DOI: 10.1370/ afm.201. PMCID: PMC1466682. The Future of Family Medicine? Reflections 34 proven safety record. After years of struggling with the practice from the Front Lines Reveal Frustration and Opportunity. Kurt C. Stange, of prescribing opiates, I hoped for the possibility of promoting http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1466682/ (accessed Nov 22, alternative forms of effective pain relief.12 Despite a solid career 2015) 2 Alebra Schroll, Physicians love their work but are frustrated http://www.kevinmd. practicing what I love, I decided to take a substantial risk and com/blog/2010/09/physicians-love-work-frustrated.html (accessed accepted the position with Vireo, as I determined it offered the Nov 11, 2015) strongest potential to utilize my gifts and training to alleviate suffering 3 Sandeep Jauhare, Fed Up With the Frustrations, More Doctors Change. for the greatest number of people. Also, on a personal note, I wanted http://www.nytimes.com/2008/06/17/health/views/17essa.html (accessed Nov 11, 2015) to forestall “the Hilfiker effect” from burning me out and making me 4 Rick McGruire, The Stresses That Doctors Face: A Physician Examines the cynical about our profession. Problems of His Profession December 26, 1985, http://articles.latimes. com/1985-12-26/news/vw-21537_1_physicians (accessed Nov 11, 2015)

18 • Family Doctor • A Journal of the New York State Academy of Family Physicians 5 http://www.medscape.com/viewarticle/710904 (accessed Nov 11, 2015) 25 Endocannabinoid signaling at the periphery: 50 years after THC Mauro 6 Lynch ME. Cannabis reduces opioid dose in the treatment of chronic non-cancer Maccarrone, Itai Bab, Tamás Bíró, Guy A. Cabral, Sudhansu K. Dey, Vincenzo Di pain. J. Pain Symptom Manage., 25(6):496-498, 2003 Marzo, Justin C. Konje, George Kunos, Raphael Mechoulam, Pal Pacher, Keith A. 7 Holdcroft A, Maze M, Dore C, et al. A multicenter dose-escalation study of Sharkey, Andreas Zimmer. Trends Pharmacol Sci. Author manuscript; available the analgesic and adverse effects of an oral cannabis extract (Cannador) for in PMC 2016 May 1. postoperative pain management. Anesthesiology, 104:1040-1046, 2006 26 2004 Sep;3(9):771-84. The endocannabinoid system and its therapeutic 8 DI, Jay CA, Shade SB, et al. Cannabis in painful HIV-associated sensory exploitation. Di Marzo V, Bifulco M, De Petrocellis L. neuropathy: A randomized placebo-controlled trial. Neurology, 68:515-521, 27 Di Marzo V, Stella N, Zimmer A. Nat Rev Neurosci. 2015 Jan;16(1):30-42. DOI: 2007 10.1038/nrn3876. Review. 9 Ellis RJ, Toperoff W, Vaida F, et al. Smoked medicinal cannabis for neuropathic 28 Politicians’ Prescriptions for Marijuana Defy Doctors and Data. Page A1. June pain in HIV: a randomized, crossover clinical trial. Neuropsychopharmacology, 27, 2014. Catherine Saint Louis http://www.nytimes.com/2014/06/27/health/ 34:672-680, 2009 politicians-prescriptions-for-marijuana-defy-doctors-and-data.html (accessed 10 Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical Cannabis Laws Nov 11, 2015) and Opioid Analgesic Overdose Mortality in the United States, 1999-2010. JAMA 29 2011 Jul-Aug;24(4):452-62. DOI: 10.3122/jabfm.2011.04.100280. Cannabis Intern Med. 2014;174(10):1668-1673. DOI:10.1001/jamainternmed.2014.4005 and its derivatives: review of medical use. Leung L. http://archinte.jamanetwork.com/article.aspx?articleid=1898878 30 The endocannabinoid system, cannabinoids, and pain. Fine PG, Rosenfeld MJ. 11 The New England Journal of Medicine 2015; 372:991-993, March 12, 2015, Rambam Maimonides Medical Journal. 2013; 4(4):e0022. Epub 2013 Oct 29. DOI: 10.1056/NEJMp150004. Medical Marijuana's Public Health Lessons — 31 Doblin R, Kleiman MAR. Marijuana as anti-emetic medicine; a survey of Implications for Retail Marijuana in Colorado Tista S. Ghosh, M.D., Michael Van oncologists' attitudes and experiences. J Clin Oncol. 1991;9:1276-1290. http:// Dyke, Ph.D., Ali Maffey, M.S.W., Elizabeth Whitley, Ph.D., Dana Erpelding, M.A., www.ncbi.nlm.nih.gov/pubmed/2045870 (accessed Nov 22, 2014) and Larry Wolk, M.D. 32 Public Support for Medical Marijuana in New York State: Reading the Polls. 12 New YorkTimes Op-Ed "How Doctors Helped Drive the Addiction Crisis": http://www.compassionatecareny.org/wp-content/uploads/Public-Support-for- http://www.nytimes.com/2015/11/08/opinion/sunday/how-doctors-helped-drive- MMJ-in-NY-8.15.2014.pdf (accessed Nov 11, 2015) the-addiction-crisis.html (accessed Nov 11, 2015) 33 Gupta SK, Nayak RP. Off-label use of medicine: Perspective of physicians, 13 Sep 16, 2015. pii: S1526-5900(15)00837-8. DOI: 10.1016/j.jpain.2015.07.014. patients, pharmaceutical companies and regulatory authorities. Journal of [Epub ahead of print] Cannabis for the Management of Pain: Assessment of Pharmacology & Pharmacotherapeutics. 2014;5(2):88-92. DOI:10.4103/0976- Safety Study (COMPASS).Ware MA, Wang T, Shapiro S, Collet JP; COMPASS study 500X.130046. team. 34 Drug harms in the UK: A multicriteria decision analysis . Nutt D.J., King L.A, 14 Journal of the American Medical Association (JAMA). 2015 Jun 23- Phillips L.D. (2010) The Lancet, 376 (9752), pp. 1558-1565. 30;313(24):2456-73. DOI: 10.1001/jama.2015.6358. Cannabinoids for Medical 35 Ben Amar M (2006). "Cannabinoids in medicine: a review of their therapeutic Use: A Systematic Review and Meta-analysis. Whiting PF, Wolff RF, Deshpande potential" (PDF). Journal of Ethnopharmacology (Review) 105 (1–2): 1–25. S, Di Nisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, DOI:10.1016/j.jep.2006.02.001. PMID 16540272 Schmidlkofer S, Westwood M,Kleijnen J. 36 Abel, Ernest L. (1980). "Cannabis in the Ancient World".Marihuana: the first 15 Catherine Hiller, How I Buy Weed - The New York Times opinionator.blogs. twelve thousand years. New York City: Plenum Publishers. ISBN 978-0-306- nytimes.com/2015/03/19/how-i-buy-weed/ (accessed Nov 11, 2015) 40496-2 16 Gupta, Sanjay (August 8, 2013). "Why I changed my mind on weed". CNN. 37 Li, Hui-Lin (1974). "An Archaeological and Historical Account of Cannabis in (accessed Nov 11, 2015) China", Economic Botany 28.4:437–448, p. 444 17 By Abigail Zuger, M.D. Published: Sept. 7, 2015 In his new book, Dr. David 38 Grinspoon L, Bakalar J. Marihuana, the Forbidden Medicine. New Haven, Conn Casarett immerses himself in the culture, science and smoke of medical Yale University Press, 1993. (pp 133-136) marijuana 39 Kevin C. Shelly, Medical marijuana improves quality of life for S.J. family 18 Medical Cannabis Primer for Healthcare Professionals. Laura Bultman, Kyle http://www.phillyvoice.com/medical-marijuana-improves-quality-of-life-for-one- Kingsley. CreateSpace Independent Publishing Platform, 2014 sj-family/(accessed Nov 22, 2015) 19 Therapeutic aspects of cannabis and cannabinoids. PHILIP ROBSON The British 40 Hilfiker, David. Healing the Wounds. New York: Pantheon Books, 2013. Print. Journal of Psychiatry Feb 2001, 178 (2) 107-115; DOI: 10.1192/bjp.178.2.107 20 Calabria B; et al. (May 2010). "Does cannabis use increase the risk of Stephen M. Dahmer, MD is a board-certified family doctor whose passion for death? Systematic review of epidemiological evidence on adverse effects of health and healing has taken him around the globe. A fellow of the Arizona Center cannabis use". Drug Alcohol Review. 29 (3): 318–30. DOI:10.1111/j.1465- 3362.2009.00149.x.PMID 20565525. for Integrative Medicine, he has worked in divergent settings including Umbanda 21 Journal of the American Medical Association (JAMA). 1995 Jun terreiros in the heart of Brazil’s second largest slum, Maori clinics in New Zealand, 21;273(23):1875-6. Marihuana as medicine. A plea for reconsideration. native healers on the Palauan Islands, and as a hospitalist to the Navajo (Dine) Grinspoon L1, Bakalar JB. Tribe in Chinle, Arizona. Currently Chief Medical Officer for Vireo Health of New York, 22 International Journal of Cardiology, 2007 May 31;118(2):141-4. Epub 2006 Dr. Dahmer is also Assistant Clinical Professor of Family Medicine and Community Sep 26. Marijuana as a trigger of cardiovascular events: speculation or scientific Health at the Icahn School of Medicine at Mount Sinai and continues to practice clini- certainty? Aryana A1, Williams MA. 23 American Journal of Cardiology. 2014 Jan 1;113(1):187-90. DOI: 10.1016/j. cal medicine in New York City where he lives and resides with his family. amjcard.2013.09.042. Epub 2013 Oct 5. Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana inhalation: what cardiologists need to know. Thomas G, Kloner RA, Rezkalla S. 24 Pacher P, Bátkai S, Kunos G. The Endocannabinoid System as an Emerging Target of Pharmacotherapy. Pharmacological reviews. 2006;58(3):389-462. DOI:10.1124/pr.58.3.2.

Winter 2016 • Volume four • Number three • 19 The Magic of Medical quackery has been a pressing issue nearly from the Medicine: start of the medical profession – whether the nostrums and elixirs of the olden days or the super-foods and miracle supplements of the present (Widder & Anderson, 2014). In many cases, quackery takes the form How Magical of complementary and alternative medicine (CAM). A particular CAM therapy is considered “complementary” if it is used alongside Western Thinking Influences medicine and “alternative” if it used instead of Western medicine (National Center for Complementary & Integrative Health, 2014). Indeed, randomized controlled trials have revealed that most CAM therapies Medical Decision- are nothing more than the placebo effect (Singh & Ernst, 2008). It is disturbing, yet telling, that the global CAM industry is worth over 60 Making billion dollars and rising (The Economist, 2011). So what about CAM attracts subscribers to it? Why do millions ‘believe’ in CAM when all objective evidence points to the contrary? Are they simply uneducated or unaware? Surely millions of people cannot all be imprudent. I propose that the root cause of this propensity for CAM is magical thinking. CAM users have reported that they use their personal intuition as a source of wisdom that surpasses the knowledge of conventional medicine (Lindeman, 2010). Humans have evolved hardwired neural networks that give rise to magical thinking because it enhances survival. Evolution wired humans to recognize patterns – if a certain hunting technique worked (event ‘A’), that pattern is instinctively reinforced by the reward of food and its subsequent release of endorphins (outcome ‘B’). When ingestion of a certain food (event ‘A’) leads to nausea and vomiting (outcome ‘B’), an association is stored in the brain such that By Utsav Hanspal, MD, MPH subsequent encounters with the same entity triggers the memory. Thus, the paradigm to assume ‘A’ caused ‘B’ serves an essential biological function. A wealth of research in both psychology and neuroscience indicates that pattern processing forms the fundamental basis of all things human. Populations that more rapidly develop superior pattern processing (SPP) capabilities experience accelerated accrual of resources and prosperity. Examples of major SPP abilities include intelligence, language, imagination, invention, and the belief in imaginary entities such as ghosts and gods (Mattson, 2014). With its many advantages, SPP has also had the unfortunate consequence of biasing the human mind with the ability to make false associations and confuse correlation for causation. Magical thinking is one such by-product (Stein, 2005). However biostatistics tells us that correlation does not imply causation. A human mind that links events in this way is in danger of committing the mistake of post hoc, ergo propter hoc (“after this, therefore because of this”). An inclination to seek patterns blinds the brain’s ability to critically examine the validity of this pattern. For instance, the anti-vaccination movement is one manifestation of this human tendency; because autism is usually diagnosed around the age when children receive many vaccinations, it is misunderstood as causation. Not all patterns are true and not all correlations imply causation. The basic principle underlying all of magic is the Law of Sympathy, However, as long as this falsely patterned habitus does not impede i.e. the apparent relationships between things (Stein, 2005). These survival, it has no mechanism for negative selection. Researchers at relationships can have two different flavors –similar or contagious. Harvard University have demonstrated that when the cost of believing The Law of Similarity states that things that are alike are the same in a pattern (even a false one) is less than the cost of not recognizing (Stein, 2005). Hence, things that appear to be similar, physically a real pattern, evolution would select for such patterns (Shermer, or behaviorally, are assumed to have a causal relationship between 2008). Believing that the rustle in the grass is a dangerous predator, them. Magic stemming from such logic is known as homeopathic perhaps a snake, even when it is just the wind is low cost; a type I or imitative magic (Stein, 2005). On the other hand, contagious error or false positive. However, believing that a dangerous predator magic is based on the Law of Contagion. According to this law, things is the wind could result in death (i.e. high cost); a type II error or that were once in contact continue to be in perpetual contact even false negative. Because the owner of this latter patternicity would die, after being physically detached (Stein, 2005). It is because of this the chances of its genes passing will be reduced. Moreover, as the ‘perpetual’ contact that they can be used to influence one another at model suggests, because the cost of the type I error is far lower than a later time. the cost of the type II error, evolution selects for animals that assume Perhaps the best- most patterns are real. known example of Looked at another way, superstitions arising from magical thinking homeopathic magic is a provide an illusion of control and offer psychological comfort and voodoo doll. At its core, reassurance (Hood, 2009). It is no surprise therefore, that ritualistic the doll is an imitation behaviors increase in times of crisis (Hood, 2009). Studies of pain or representation threshold demonstrate that in contrast to humans with no control, of a living person. humans with control can tolerate much higher doses of electric Manipulation of this shock (Salomons, Johnstone, Backonja, & Davidson, 2004). The image can then be used theory of Symbolic Action states that magic is a course of action to hurt that person. undertaken when there is an emotional need for undertaking that Manifestations of this action, but no practical option exists (Evans-Pritchard, 1977). In form of thinking also other words, magic arises out of helplessness. explain many folk customs – because the outer shell of walnuts represents the skull in both shape and texture, while the nut itself The focus of medicine today is no longer eradicating infectious looks awfully like the brain, it is assumed that walnuts are good for diseases, as much of that has already been accomplished with the brain (Stein, 2005). In fact, ‘avocado’ is a fabricated word that vaccinations, public health endeavors, sanitation and hygiene. Much refers to the ahuacate fruit, as the Aztecs called it. In their language, of medicine today deals with chronic illnesses, which by definition ahuacate is a word for testicle (Yoon, 2006). The round seed in have no cure, at least not one that can be packaged into a simple pill. an oval fruit with skin that might resemble the scrotum was thus In these cases, the best medicine can do is offer symptomatic relief considered by the Aztecs to be an aphrodisiac and fertility fruit. and slow disease progression. It is therefore not surprising why many of our patients feel a sense of despair. Homeopathic medicines as well as many forms of traditional herbal medicines are also based on the Law of Similarity. The fundamental It is plausible therefore that the magical thinking of CAM offers principle of Homeopathy, similia similibus curentur, i.e. “like comfort to the sufferers of disease. Whether it is the universal energy cures like” is an explicit expression of this magical principle of Reiki, correcting imbalances of the humors, or cosmic channeling (Stevens, 2001). Herbal medical systems such as Ayurveda or of crystals, CAM therapies are inundated with the magical. And while Native American shamanism are often based on a variation of the the therapy has no biological action, it gives the illusion of control law of similarity known as the Doctrine of Signatures (Stein, 2005). and a false sense of security (which some argue has benefits of its According to this principle, a plant’s medical use is somehow own). But the danger lies in deluding oneself to think that things embedded within the structure and nature of the plant itself (Stein, are fine, when in fact the benefits are only short-term. The danger 2005). For example, because the extracts of bloodroot and red of placebo may not be so high for someone with the flu, compared clover head extract appear red, they are used to treat disorders of to someone with cancer. It is thus critical for physicians to reflect the blood. Similarly, yellow plants are associated with the yellow on the ethics of sanctioning such belief even if they believe a certain color of the bile (often vomited) and thus used to treat indigestion. CAM therapy is ‘harmless’. In reality, homeopathy should neither In modern societies, similar principles guide dietary or behavioral have efficacy nor side effects, because the process of potentization restrictions in pregnancy. For instance, many Americans believe that essentially renders the final solution free of active ingredients. if the mother is anxious during pregnancy, the baby will be nervous Zicam, a purported homeopathic cold remedy, is in fact neither and fussy (Stein, 2005). The American folk practice of rubbing a homeopathic, since it contains high amounts of zinc, nor a cold penny on a wart and then discarding it to achieve a cure is based on remedy since no cure for the common cold exists. Moreover, it has contagious magic – as if the penny expunges the wart. the grim side effect of causing anosmia (Lim, et al., 2009). CONTINUED NEXT PAGE Winter 2016 • Volume four • Number three • 21 the magic of medicine, continued Researchers have identified two distinct systems of processing in the References way the human brain works – the rational and intuitive. Hutson Evans-Pritchard, E. (1977). Theories of Primitive Religion. Oxford: Oxford University Press. describes the rational system as “slow, deliberate, abstract, and Freud, S. (1960). Totem and taboo: Resemblances between the psychic lives of logical” while the intuitive system as “quick, automatic, associative, savages and neurotics. London: Routledge Kegan Paul. and emotional.” (Hutson, 2012) Because the deliberative rational Hood, B. M. (2009). Super Sense: Why We Believe in the Unbelievable. New York: Harper Collins. system evolved much later than the ancestral intuitive system on Hutson, M. (2012). The 7 Laws of Magical Thinking: How Irrational Beliefs Keep which it is based, the former seldom overrides the latter (Hutson, Us Happy, Healthy, and Sane. New York: Penguin Publishing Group. 2012). Consequently, echoing anthropologist Richard Shweder, Keinan, G. (2002). The Effects of Stress and Desire for Control on Superstitious Behavior . Personality & Social Psychology, 28, 102 - 108. magical thinking can be defined by as “the confusion of subjectivity Lawlor, D. A., Smith, G. D., & Ebrahim, S. (2004). Commentary: The hormone and objectivity.” (Hutson, 2012) A study by Carol Nemeroff at the replacement–coronary heart disease conundrum: is this the death of observational epidemiology? International Journal of Epidemiology, 33(3), Arizona State University demonstrated that depending on its source, 464-467. people conceive of germs as differentially threatening. People Lévi-Strauss, C. (1963). Structural Anthropology: The Effectiveness of Symbols. believed that flu contracted from a stranger would be more severe New York: Basic Books. Lim, J., Davis, G., Wang, Z., Li, V., Wu, Y., Rue, T., et al. (2009, October). Zicam- than one contracted from a loved one. Because assessing severity of Induced Damage to Mouse and Human Nasal Tissue. PLoS ONE, 4(10), 7647- symptoms elicits the affective-experiential, rather than the deliberate 7657. rational cognitive processes, it is highly prone to influence by Lindeman, M. (2010). Biases in intuitive reasoning and belief in complementary and alternative medicine. Psychology and Health, 1 - 12. magical thinking (Nemeroff, 1995). Nevertheless, when asked about Mattson, M. P. (2014, August). Superior Pattern Processing is the Essence of the probability or likelihood of getting the flu, the research participants Evolved Human Brain. Evolutionary Psychology and Neuroscience , 8(265), objectively concluded the same risk, regardless of source. Because 1-17. National Center for Complementary & Integrative Health. (2014). What is there is no emotional component to calculating a probability, Complementary and Alternative Medicine? . Retrieved January 10, 2015, from Nemeroff suggests that this task uses a more logical processing style National Center for Complementary & Integrative Health: http://nccam.nih.gov/ enabling us to realize that the flu is the flu (Nemeroff, 1995). sites/nccam.nih.gov/files/D347_05-25-2012.pdf Nemeroff, C. J. (1995). Magical Thinking About Illness Virulence: Conceptions of In the context of a world that is becoming increasingly confusing, Germs From “Safe” Versus “Dangerous” Others. Health Psychology, 14(2), 147-151. impersonal, scientific and technological, social scientists and Ono, R. (2008, October 24). Higher internality of health locus of control is anthropologists explain people’s continued use of magical thinking associated with the use of complementary and alternative medicine providers by stating that such belief gives individuals power over their internal among patients seeking care for acute low-back pain. Clinical Journal of Pain, 24(8), 725-730. health locus of control (Ono, 2008). Furthermore, this general Osler, W. (1913). The Evolution of Modern Medicine A Series of Lectures rubric of imitative magic is so very successful because, at the most Delivered at Yale University on the Silliman Foundation. New Haven: Yale University Press. fundamental level, it forms the basic mechanism of human cognition. Panati, C. (1989). Extraordinary Origins of Everyday Things. New York: Harper It has long been understood that imitation lies at the basis for Collins. learning among higher primates and humans. It is no surprise then Salomons, T., Johnstone, T., Backonja, M., & Davidson, R. (2004). Perceived Controllability Modulates the Neural Response to Pain. Journal of Neuroscience, that the greatest reason for the success and persistence of magic 24, 7199 - 7203. and its rituals of medicine are because imitation lies at the core of Shermer, M. (2008, December). Patternicity. Retrieved May 05, 2015, from the human brain. It thus seems that, at the subconscious core of Scientific American: http://www.michaelshermer.com/2008/12/patternicity/ Singh, S., & Ernst, E. (2008). Trick or Treatment: Alternative Medicine on Trial. our being, the natural order of the world is based on the Law of London: Bantam Press. Sympathy. Stein, R. L. (2005). Anthropology of Religion, Magic, and Witchcraft. Boston: Pearson Publishers. In conclusion, when encountering a patient expressing interest or Stevens, P. (2001, December). Magical Thinking in Complementary and admitting use of CAM therapies, it may not simply be enough for a Alternative Medicine. Retrieved May 05, 2015, from CSI: Committee for Skeptical Inquiry: http://www.csicop.org/si/show/magical_thinking_in_ physician to ‘show evidence’. Magical thinking precludes rationality. complementary_and_alternative_medicine/ It works on the emotional-intuitive, rather than the analytical-logical The Economist. (2011, May 19). Medicine: There is No Alternative. Retrieved areas of the brain. CAM explains illnesses in a manner that appeals to February 20, 2015, from The Economist: http://www.economist.com/ node/18712290 our intuitive mind. It is rather simplistic but appealing nonetheless to Widder, R. M., & Anderson, D. C. (2014). The appeal of medical quackery: A believe that illness occurs when the system goes ‘out of balance’. It is rhetorical analysis. Research in Social and Administrative Pharmacy, 1-9. thus critical for the physician to understand the complexity and depth Yoon, H. (2006, July 19). What’s in a Name? The Avocado Story. Retrieved May 05, 2015, from NPR: http://www.npr.org/templates/story/story.php?storyId=5563805 that drives the pervasiveness of CAM. It also indicates that perhaps it is futile to intervene at an individual level. Intervention at the macro- Utsav Hanspal, MD, MPH is a first year resident at Ellis Family Medicine Resi- level may thus be imperative, i.e. regulation and control of CAM dency program in the Schenectady, NY. He received his undergraduate degree from Manchester University in Indiana, his medical degree from Ross University remedies at the level of the FDA. If saw palmetto akin to Finasteride School of Medicine and his MPH from Columbia University’s Mailman School claims to treat prostate cancer, then it is only fair that it is subject to of Public Health, where he published his thesis on the biophysical aspects that the same rigors, tests and regulations as Finasteride. predispose individuals for belief in the magical thinking of complementary and alternative medicine.

22 • Family Doctor • A Journal of the New York State Academy of Family Physicians Introduction The Jericho Road Model: Within any population there are a subset of patients for whom traditional in-office and hospital-based medical services fail to A Strategy for Engaging meet dynamic health needs. What has become increasingly evident is that this small subset accounts for a disproportionately large the Practice’s Most percentage of total health care cost.1 As costs continue to rise at an unsustainable rate there is an increased urgency to acknowledge and Vulnerable address the needs of these previously marginalized patients. In recent years progressive delivery and reimbursement models have been By Jordan Katz; Ju Joh, MD; Eleanor Nixon, FNP; Priscilla Lau, RN, proposed which are clearly reflected in state and federal programs/ BSN; and Myron Glick MD incentives as well as payer initiatives.2 However, most proposed solutions shift responsibility to a satellite agency rather than placing the primary care provider at the epicenter. Jericho Road Community Health Center (JRCHC) is a Federally Qualified Health Center located in , NY which has developed a program rooted in primary care to assist the most at-risk within an already vulnerable population. A multidisciplinary team of healthcare professionals has been assembled to engage with patients outside of the clinic and respond flexibly to complex needs. In doing so, the team can identify barriers to wellness which can only be appreciated with a person-in-environment understanding. The aim is to improve access and quality of care, increase self-sufficiency, improve quality of life, and reduce avoidable hospitalizations and emergency visits.

Physical Psychological/cognitive Multiple chronic diseases Psychiatric comorbidity Polypharmacy Substance abuse/dependence Impairment (mobility, vision, hearing, etc.) Cognitive impairment Chronic pain Trauma Hopelessness

Socioeconomic Learned Behavioral Housing challenges Mistrust of medical providers Systemic challenges (gaps in services) Underutilization of primary services (gaps in care) Transportation challenges Chronic non-adherence to medical plan Language barriers

Theory for Determining Risk The Figure above illustrates four overarching parameters Case Study contributing to a patient’s vulnerability/risk: physical, psychological Brian is a 60 y/o with a past medical history of chronic hepatitis or cognitive, socioeconomic, and learned behavioral. Traditionally, C, schizoaffective disorder, and substance abuse. He was seen in physical risk has been the easiest to identify and target but optimizing the emergency department > 10 times in 2014 with the primary physical well-being is contingent upon other factors and cannot be diagnosis of altered mental status and/or psychosis and was admitted viewed in isolation.3 Moreover, there is overwhelming evidence that on several occasions. Each time the patient was stabilized and a history of trauma and sense of hopelessness can have significant discharged only to return shortly after with a similar presentation. impact on wellness, manifesting in all of the above-mentioned areas.4 Despite good intentioned care, a malignant cycle had left both the patient and his providers frustrated; Brian was labeled “non- compliant” in several medical notes. CONTINUED NEXT PAGE Winter 2016 • Volume four • Number three • 23 the jericho road model, continued Identifying the Most Vulnerable • Dietician visits and education • Self-management education In order to address risk in a comprehensive fashion, our program • Case conferencing utilizes a multimodal approach for patient identification and • Presence at transitions in care includes metrics for addressing medical complexity, psychosocial • Linkage of services risk, socioeconomic risk and patters of inappropriate utilization • Access to clinic-employed social worker of services. The following tools are used in conjunction with one • Interpretation services, as needed another as each provides useful information: • Public transit education and clinic-employed transportation, as 1. Physician referral: providers are best positioned to recognize a needed sudden destabilizing change in a patient’s health or a transition Although not listed above, the most critical intervention offered is in care which places the patient at risk. Moreover, providers can the presence of a stable and supportive relationship with a health recognize a concerning cycle i.e. chronic inability to adhere to care representative. For lack of understanding dynamic needs, these medical plan or recurrent relapse/hospitalization with unclear patients are often neglected by the health care system at large.6 cause. 2. Custom EMR reporting: generate chronic disease scores for all patients based on the Elixhauser scoring system using Measuring Outcomes and Reflecting Value ICD-10 diagnosis codes.5 We further filter based on presence The initial assessment is not only used to acquire basic information of polypharmacy, number of emergency visits and hospital but also serves as a reference for comparison at different time admissions (via coded electronic alerts sent by the regional points. Within the assessment are modified versions of the following health information organization), and gaps in primary care questionnaires to be administered again at a later date: services. This method has the advantage of flagging patients not - Health Related Quality of Life (HRQOL) Measure7 seen regularly in clinic or unrecognized by providers as being at - Client Perceptions of Coordination Questionnaire (CPCQ)8 risk. - Caregiver Strain Index (CSI)9 3. Partnership with payers: utilize high risk and high cost reports In addition to incorporating established measures, the assessment generated by insurance companies. is also used to populate a Self-sufficiency Matrix that was developed based on a previously published material.10 Within each dynamic Interventions for Improving Outcomes (i.e. physical health, mental health, daily function, access to Once a patient is enrolled, agreeing to participate in the program, services, support system, etc.) the patient is rated on a pre-defined an extensive assessment is done in the home. This assessment helps scale ranging from ‘In Crisis’ to ‘Thriving’. Throughout a patient’s establish a baseline and includes the following: enrollment, progress is clearly shown as interventions aim to meet • Goals of care and perceived obstacles benchmarks in each dynamic. To graduate a patient from the • Patient and support strengths program the expectation is that they are ‘Stable’ in all dynamics. • Evaluation of basic needs i.e. income, food, housing • Barriers to access i.e. insurance, transportation, language Future Plans • Mental health and addiction screening To further validate a patient’s enrollment, a nurse practitioner will • Dependence of care i.e. major impairment, personal care, routine make home visits with special focus on applicable ICD-10 diagnoses needs, medical care for social circumstances and external causes of injury or disease. By • Current services doing so we intend to effect systemic change by accurately reflecting • Fall risk screening these underdiagnosed determinants of health and wellness. • Medication adherence/reconciliation In the future we hope to utilize claims data to definitively After the assessment is completed a patient-centered plan of care is demonstrate economic value. created to prioritize goals and establish milestones. The type, degree and duration of engagement are dictated by patient need. The team emphasizes utilization of interventions that are empirically supported Reimbursement Opportunity to reduce risk, improve outcomes, improve patient activation and JRCHC maintains the long-term goal of presenting this program in increase self-sufficiency: its entirety to insurance companies for value-based reimbursement. • Motivational Interviewing In the interim, JRCHC is pursuing an agreement to become a • Respecting Choices Advance Care Planning downstream care management provider for Health Home. • Home visit by nurse and blood draws, as needed • Medication checks/reconciliation with pharmacist inclusion

24 • Family Doctor • A Journal of the New York State Academy of Family Physicians Case Study: Conclusion 6 Mautner DB, Pang H, Brenner JC, et al. Generating Hypotheses About Care Needs of High Utilizers: Lessons from Patient Interviews. Popul Health Manag. 2013;16 Brian was referred to the program by his primary care physician and Suppl 1(November 2011):S26-S33. doi:10.1089/pop.2013.0033. was also identified by a case manager with his Medicaid-managed 7 U.S. Department of health and human services. (2000). CC Healthy Days. Health plan. After a comprehensive assessment, it became clear that Care. 8 McGuiness, C., & Sibthorpe, B. (2003). Development and initial validation of homelessness was a critical barrier to his compliance. Brian was a measure of coordination of health care. International Journal for Quality in subject to a shared restroom at the shelter which made it difficult to Health Care, 15(4), 309–318. take lactulose as prescribed. Eventually, Brian would stop taking the 9 Onega, B. L. L. (2013). Modified Caregiver Strain Index (MCSI), 43(14), 1–2. 10 The Snohomish county self-sufficiency taskforce (2004) lactulose and his ammonia levels would rise giving way to confusion and sleep disturbance; Brian would self-medicate and eventually stop taking the antipsychotic medications as prescribed. Jordan Katz is a fourth year medical student at University of Buffalo School of Medicine and Biomedical Sciences. He is a Primary Career Track award winner and For several months a risk reduction strategy was employed in Primary Care Research Scholarship recipient. Currently, he is partnering with JRCHC conjunction with pharmacy assistance, mental health counseling and and the School of Public Health to research and develop tools for assessment and qual- administrators at the shelter. Presence at hospital transitions allowed ity intervention targeting high-risk patient populations. for safer admission/discharge and better understanding of Brian’s challenges. With acknowledgment of these challenges, the team was Ju Joh, MD is a recent graduate from University of Buffalo School of Medicine able to advocate for an extension of an inpatient stay in order to and Biomedical Sciences. He is currently pursuing his Masters in Public Health at optimize management and discharge to stable housing. With support, University of Buffalo, and is partnering with JRCHC to help identify high-risk patient Brian has reached a level where he can consistently adhere to his populations. He plans to pursue a family medicine residency with hopes of treating medication regimen and attend outpatient psychiatric counseling. underserved populations. He is actively engaged in his own care and has begun treatment for chronic hepatitis C. Eleanor Nixon, FNP is certified in family practice and has been with JRCHC since 2003. Currently, she is team leader for the Hot Spotter program. She previously held a faculty position in the nursing program at Genesee Community College. Endnotes 1 Jiang, H. J., Weiss, A. J., Barrett, M. L., & Sheng, M. (2015). Characteristics of Priscilla Lau, RN, BSN has been with JRCHC since June 2015. Currently, she is a Hospital Stays for Super-Utilizers by Payer, 2012. Agency for Healthcare Research and Quality. care coordinator on the Hot Spotters team. She will be returning to school in 2016 for 2 Rosen, A. K., Reid, R., Broemeling, A. M., & Rakovski, C. C. Applying a risk- her master’s degree and will be pursuing a career as a family nurse practitioner. adjustment framework to primary care: can we improve on existing measures? Annals of Family Medicine, 1(1), 44–51. Myron Glick, MD is a board certified family physician and graduate of the SUNY 3 Braveman, P. A., Egerter, S. A., & Mockenhaupt, R. E. (2011). Broadening the Buffalo School of Medicine. He completed his residency training at Lancaster General Focus: The Need to Address the Social Determinants of Health. American Journal Hospital in Family Practice and was awarded a fellowship at SUNY Buffalo Depart- of Preventive Medicine, 40(1), S4–S18. 4 Druss, B. G., & Walker, E. R. (2011). Mental disorders and medical comorbidity. ment of Family Medicine and also holds a faculty appointment at SUNY Buffalo in the The Synthesis project. Research synthesis report. School of Medicine. He and his wife, Joyce, founded Jericho Road in May of 1997. 5 Quan, H., Sundararajan, V., Halfon, P., Fong, A., Burnand, B., Luthi, C., Ghali, W. (2005). Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Medical Care, 43(11), 1130–1139.

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Winter 2016 • Volume four • Number three • 25 Guest Medical Expert Tips for Television and Radio By Amber Robins, MD and Colleen T. Fogarty, MD, MSc

Imagine yourself on television or radio educating your physicians to participate in health topic segments. Since that time the community about the latest medical news. In less than 5 minutes, you Highland Hospital/University of Rochester Medical Center’s family are able to speak to thousands of people at once which could not physician faculty and residents have provided regular coverage for a occur in the traditional office setting. During your medical segment, weekly morning news health segment. Based on our experience, we an elderly man hears you speaking about a medical concern he have developed tips for family doctors interested in becoming a guest has been having for months. Because of you, he decides to go to medical expert on broadcast media. the doctor who he has not seen in years. You were able to change a patient’s life by being a guest medical expert. Choosing a Topic: Choose a subject that you are comfortable discussing. Timely topics Health communication is considered “the art and technique of in the news cycle may interest the news anchor or radio host; informing, influencing, and motivating individual, institutional conversely they may have already had adequate coverage, so explore and public audiences about health issues. The scope of medical several topics that may interest the viewing public. The interviewer communication includes disease prevention, health promotion, can guide topics. In addition, you may be approached to discuss a health care policy, and the business of health care as well as specific topic of interest. In this case, do your homework! enhancement of the quality of life and health of individuals within the community” (Parrott, 2004). Health communication spans Segments can feature seasonal topics like health effects of particular the gamut from individual communication from a nurse or other weather patterns, or topics from national health observances. These professional, to mass media campaigns. Family physicians should are special days, weeks, or months chosen to raise awareness about claim our role as general medical experts and provide information to important health topics. For a list, go to http://healthfinder.gov/NHO/ our communities outside our own practices. Being a medical expert Your own clinical practice can serve as a source of ideas. If you see can serve as a vehicle to accomplish this goal. a particular infectious disease pattern, or find patients asking similar Approximately fourteen years ago a local news station contacted questions about health topics, you might develop that into a health Highland Hospital’s Public Relations Department to identify segment.

26 • Family Doctor • A Journal of the New York State Academy of Family Physicians When narrowing down your ideas, remember to choose a topic that microphone wire from your lapel to the rear waistband more easily you can explain quickly and that will engage the audience. Be sure than some one piece outfits. Studio lighting can appear harsh when you know the expected time frame; the anchor or host determines doing a television medical segment; facial foundation and judiciously this. Most segments last two to four minutes. Good topics have a applied makeup may avoid a “washed out” appearance on camera. clear focus, can be distilled easily, and have several points which can be transmitted to viewers quickly. The anchor may work with studio During News Segment: crew to incorporate images into a TV segment; discuss this possibility After arriving to the news or radio studio, meet the journalist/ with your contact person. radio host who will be interviewing you. Review the notes that you previously submitted and discuss the plan for the segment. The host The Pitch: or other staff person will provide a microphone and orient you to Once your ideas for a medical segment on television or radio are its placement. Ask for help placing the microphone and do a sound clear, contact the anchor or host with an e-mail to “pitch” your ideas check. for the medical segment. According to Dr. Jennifer Caudle (Media When you take your seat for the recording, take a deep breath and Health Expert, Assistant Professor of Family Medicine at the Rowan allow your muscles to relax and allow your natural smile to take University School of Osteopathic Medicine in Stratford, New Jersey), over. A warm greeting and smile to the host/anchor and audience “Put it in one sentence: a one-liner describing what you want to talk sets the tone for a conversational interview style. Similar to a patient- about and then [include] three or four talking points underneath it doctor encounter, focus on making eye contact, showing empathy backing up what you’re going to tell them,” she suggested. “Really, and passion about the topic you will be discussing. this paragraph should be readable in about 30 seconds because that’s about all [the time] they’re going to take to read it. And the Follow up: subject line should be [something like] ‘Pitch, seven reasons to get Ask the host/anchor for immediate feedback on the pacing and the flu shot, medical expert.’ Something very quick.” (Raymond content of the interview. Remain open to suggestions. Importantly, 2014). view or listen to the segment after it is recorded. We are typically our own worst critics; be gentle and honest with yourself. Practice Your News Segment: After getting approval and confirmation from the media source, begin Serving as a medical expert in broadcast media can be a thrilling formulating your segment. View videos or listen to radio interviews of experience. We hope that our tips aid you in the process of medical experts to become familiar with the pace and format. beginning, preparing, and getting feedback on your media debut. By engaging our community through television or radio setting, you can After reviewing several examples, create notes for your topic to reach more people’s lives in a unique yet personal way. provide a guide for you and the interviewer. Send these notes to the news anchor or radio host several days before your segment. References: When the topic and notes are approved by the media source, begin Parrott, R. (2004), Emphasizing “Communication” in Health Communication. to practice the delivery of your segment. Consider video or audio Journal of Communication, 54: 751–787. doi: 10.1111/j.1460-2466.2004. recording yourself as you practice and ask a trusted person for tb02653.x critique, or do your own critique. Remember, your goal is to speak Raymond, R. (2014, October 29). Media tips for doctors: Position yourself as a medical expert. Retrieved November 17, 2015, from http://thedo.osteopathic clearly, concisely, and within the designated time. org/2014/10/media-101-position-medical-expert/#comments

Logistics: Amber Robins, MD is a family medicine resident and graduate of the Univer- Choose a date that works for your schedule. Plan to arrive to sity of Rochester School of Medicine and Dentistry in Rochester, NY, and earned her the local news or radio studio a few minutes early on your first undergraduate degree in Biology from Xavier University of Louisiana. Dr. Robins has appearance to become familiar with the studio location. Discuss recorded several medical segments on Rochester local news and also writes medical the segment with the journalist’s or radio host’s staff prior to articles for various blogs and magazines. arriving to determine if the medical segment will be pre-recorded Colleen T. Fogarty, MD, MSc, is the Director of the Faculty Development Fellowship or recorded live. and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine. She earned her medical degree at the University of Attire: , School of Medicine and completed residency at the University of Roches- Check with your host regarding specific wardrobe or makeup ter. Colleen has a Master of Science in Epidemiology and Biostatistics from the Boston requirements. Choose professional and stylish clothing that you University School of Public Health. She is co-editor of the journal Families, Systems, feel comfortable wearing. Large patterns and prints can appear and Health. distracting on television. Two piece outfits accommodate a

Winter 2016 • Volume four • Number three • 27 Innovation as As Dr. Josh Umbehr and I carry the catered lunch food into the lecture hall, I look over my shoulder uneasily. Nobody’s come out of the elevator yet. I’m filled with the universal dread that fills anyone Motivation - Making hosting an event. We’re a few minutes early. People always show Primary Care Attractive up late to these things. They’ll definitely show up soon...right? We go about setting up the food, unwrapping the Saran wrap, and to Medical Students fiddling with the pesky plastic utensils. By the time we’ve finished, there are already 20 students lined up. Within a few minutes, the By Haran Sivakumar & Ravishankar Ramaswamy, MD, MS, FAAFP line for food wraps around the lecture hall seating and out the auditorium door. My fears about attendance are replaced with a new worry – will we have enough food?! The average “Lunch & Learn” session at our school brings in less than 20 students. A turnout of 40 is considered a runaway success. Our family medicine event easily topped 60. To put that number in perspective, when our Family Medicine Interest Group spent over a thousand dollars to host a free open bar social, it managed to get 45 students to show up. Our turnout was the largest for a lunch event in the past two years. So what prompted students to show up? And to a family medicine event of all things?? Most first and second year students in our school react to any mention of family medicine in the same, predictable way – a polite smile, lip service to how important it is, and a quick disclaimer that “It’s just not for me.” And why is it not for them? Because they can’t stand patient interaction? Because they hate the idea of longitudinal care or diverse procedures? Because they really, really love the liver and can’t fathom pursuing a career in anything else? The truth is most students’ issues with family medicine have nothing to do with the specialty and everything to do with the career prospects. No medical student doubts the value of primary care. But almost all of us doubt whether it can actually be an enjoyable career. Within just a few months of entering medical school, we’re all too familiar with the horror stories. We’ve heard firsthand about primary care burnout. We’ve been bombarded with predictions of patient panels increasing and patient interaction decreasing. We’ve been warned that family medicine will devolve into outsourcing care to mid-level providers, serving as medical directories for specialists, and filling out never-ending, always-accelerating streams of digital paperwork. And in the face of this overwhelming bad news, what’s the response from proponents of primary care? Well-intentioned, empty-sounding platitudes. We get pedantic reassurances that primary care may change but its core will remain the same. That the fulfilling nature of the profession outweighs any of its challenges. That being a family doctor is a matter of calling, not convenience.

28 • Family Doctor • A Journal of the New York State Academy of Family Physicians Sure, all of it is true. But none of it inspires confidence. We don’t continue feeding us platitudes instead of solutions, and we will be yet want to hear why the problems facing primary care are bearable. We another generation that’s not the solution to primary care needs. want to hear how they are surmountable. Talking about innovation isn’t ultimately about making primary care We want solutions that are loud enough to silence the uncertainty. cooler or more efficient. It’s about credibly instilling a belief that We want to know how primary care can be both rewarding and primary care will continue to matter. That it will continue to be the comfortable instead of a lifelong sentence to medical martyrdom. bedrock of the doctor-patient relationship. That it will continue to We want new models, new approaches, and new paradigms that can shape and save lives. And that primary care will continue to do all realistically usher in a new future. In a word, we want innovation. this, not in spite of the future, but because of it.

Innovation is what brought out a record number of students to our Haran Sivakumar is a second-year medical student at the Icahn School of Medicine lunch event on direct primary care. It’s what prompted 15 students at Mount Sinai. He graduated with a BA in Film & Television Production from USC’s to remain after the event and have granular conversations with Dr. George Lucas School of Cinematic Arts and was accepted into medical school through Umbehr about economic models of primary care. It’s what left my Mount Sinai’s Humanities and Medicine Program. At Mount Sinai, he co-leads the inbox filled with messages asking for Dr. Umbehr to come back and Family Medicine Interest Group, produces an in-hospital children’s television show, for more speakers like him to come speak. conducts community-based Medicare research, and serves as the president of the Benjamin Rush Institute, the school’s most prominent health policy organization. As students, we know that primary care doctors are seeing more patients, more quickly, for more hours all while making less Ravishankar Ramaswamy, MD, MS, FAAFP received his medical degree from B.J. money. This makes primary care look incredibly unattractive in Medical College, Pune, India, and a Master of Science degree in Molecular Pathology terms of work-life balance, compensation, and meaningful work. from the University of Wisconsin-Madison. He completed his family medicine resi- Students need to know that it’s possible for family doctors to see dency at Underwood-Memorial Hospital, NJ, and his fellowship training in geriatrics fewer patients and work fewer hours while enjoying more patient at Icahn School of Medicine at Mount Sinai. Currently, he is an Assistant Professor interaction and earning more money. in the department of Geriatrics and Palliative Medicine, and is an ambulatory care provider at the Martha Stewart Center for Living, and spends a portion of his time And it’s not just about letting students know that there’s a light at the teaching medical students, house staff and fellows. end of the tunnel. It’s about letting them know that there are doctors who already have traveled through the tunnel and are now running in the light of that brighter future. We’re not just talking about promising ideas. We’re talking about proven solutions. The Core Content Review of Family Medicine Students need to know that they can be like Dr. Umbehr and start their own practice, or they Why Choose Core Content Review? can be like the doctors his practice has hired to cope with booming growth. Spreading the word • CD and Online Versions available for under $200! about innovation within primary care matters, • Cost Effective CME and not just for those with an entrepreneurial • For Family Physicians by Family Physicians bent. It’s for anyone who needs reassurance that • Print Subscription also available a brighter future awaits. North America’s most widely-recognized program for Contrary to conventional wisdom, talking Family Medicine CME and ABFM Board Preparation about private practice, direct payment plans, new technology, and alternative models for community health centers doesn’t bore • Visit www.CoreContent.com students or turn them away. Instead, it gets • Call 888-343-CORE (2673) them interested because it gives them a reason • Email [email protected] to believe again. The only way to overcome students’ negative ideas about family medicine is with new ideas about family medicine. Give students a reason to believe in the promise of tomorrow rather than the cynicism of PO Box 30, Bloomfield, CT 06002 today, and we will deliver on that promise. But

Winter 2016 • Volume four • Number three • 29 Assessing the Perceived Utility and Impact of a Continuing Medical Education Activity in Family Medicine By Gregory W. Kirschen, BA; Dorothy S. Lane, MD, MPH and Catherine R. Messina, PhD

Background Methodology Continuing Medical Education (CME) aims to inform practitioners We surveyed participants immediately following the March 2013 of revised guidelines, teach new clinical skills, and impart the latest and March 2014 Family Medicine Update (FMU) at Stony Brook knowledge on disease prevention and treatment. The American University (n=115 physician respondents, n=20 nurse practitioner Board of Medical Specialties Maintenance of Certification requires [NP]/physician assistant [PA] respondents in 2013; n=78 physician completion of a minimum number of CME credits to maintain board respondents, 38 NP/PA respondents in 2014). We asked whether certification, yet the relevance and effect of CME on specialty-specific the program would cause them to change their practice, would be performance in practice remains obscure. relevant to their practice, would result in better patient outcomes, and whether it satisfied expectations. Not all respondents answered Recent reports have assessed the use of evidence-based decision- every question. The program covered topics related to organ systems, making and relevance of CME, reporting positive findings in imaging techniques, and mental health, and consisted of face-to-face participant knowledge, use of evidence and improved patient lectures, two evening workshops, and a half-day simulation session. health.1-3 However, systematic reviews of CME have found mixed Five months subsequently, a medical student (GWK) attempted to outcomes in terms of learning and self-reported/observed practice contact participants who had provided contact information and changes.4-5 More follow-up data on participant recall and specific were still practicing. Eighteen (18) physicians and five (5) NPs/PAs utilization of CME content are warranted. Here we investigated completed the survey. A telephone call method was implemented self-reported perceived utility, knowledge retention, and changes in since in prior years, response rates had been poor when surveys practice resulting from a CME activity at five-month follow-up. We were mailed/emailed. Survey questions appear in Table 1. Data then looked at how content changes reflecting participant feedback were analyzed in April 2014. Evaluations of CME activities are not influenced evaluation of a subsequent CME activity. considered to be research by Stony Brook University Institutional Review Board (IRB). Therefore this project did not require IRB review.

Table 1: Questions from 5-month follow-up questionnaire

1. Do you recall any of the specific lectures or activities at the Family Medicine Update that you found to be particularly educational or helpful? 2. Any that you found to be particularly unhelpful or poorly conducted? 3. Did you learn some strategies (e.g., clinical practices) during the CME series that you can apply in your own practice? If yes, please describe the strategy or practices. 4. Did you apply these strategies or make any changes in what you do in your practice as a result of what you learned at the Update? 5. If no, were you prevented from implementing the practices or changes? If yes, please describe the difficulties that interfered with making changes. 6. Has your use of new or changed clinical practices that you learned at the CME series been reflected in the “health” of your patients? If yes, please give examples of the patient outcomes. 7. What topics that are relevant to your practice, would you like us to cover in future CME series? 8. Do you have any other comments or suggestions for the next Family Medicine Update?

30 • Family Doctor • A Journal of the New York State Academy of Family Physicians Results specifically at least one lecture/activity that they found particularly educational or useful. Accuracy of recall was assessed by reviewing Follow-up the day of the conference the 2013 FMU program content. Immediately following the 2013 FMU, 72.0% (54/75) of respondents Survey Responses intended to make changes to their practice as a result of the CME activity, while 21.3% did not (23/108). 63.0% (68/108) reported Among the survey responses, examples of the specific practice that the program would be relevant to their practice, while 0.9% changes reported were: 1) less fear of prescribing a low-dose, (1/108) reported that the program would not be relevant. 44.4% inhaled corticosteroid for children with asthma; 2) implementing a (48/108) predicted better patient outcomes. 60.2% (65/108) quick assessment for peripheral neuropathy; 3) being more careful reported that the program satisfied expectations, while 0.9% (1/108) to examine the pattern, change over time, and symmetry of nevi, reported that it did not. especially in patients with multiple nevi; 4) being more cautious about prescription and monitoring of narcotics, including imposing Immediately following the 2014 FMU, 81.8% of respondents “narcotics contracts”, conducting more urine drug screens, and intended to make practice changes as a result of the CME program, using the drug abuse screening test (DAST) for high-risk patients; 5) while 7.4% indicated that they did not. 71.3% reported that the using mini-mental status tool to assess dementia. Other insights program would be relevant to their practice, compared to 3.2% who gained included understanding the limitations of current lung cancer reported that it would not. 41.5% predicted better patient outcomes. screening, the recommendation that thyroid nodules do not require 59.6% reported that the program satisfied expectations, while 0.0% nuclear scanning if they are nonfunctional, and proper interpretation reported that it did not. In 2014, significantly fewer respondents of spirometry tests. The only barriers to implementation that reported that they would not alter their practice performance were identified were: insurance, high co-pay (e.g., for inhaled compared to 2013 (chi-square, p = 0.006), as shown in Figure 1. corticosteroid), and preauthorization requirements. The reported Follow-up at 5 months post-conference changes seen in patient health were related to: hepatitis C; diabetes and hypertension care, medication treatment of cardiovascular Five months subsequent to the 2013 FMU, 23 participants agreed disease, and quicker assessments. to a follow-up phone survey. Among these, 73.9% reported that the program had altered their practice; 56.5% reported that these changes had resulted in better patient outcomes, 26.1% reported Changes to the program that it had not resulted in better patient outcomes, and 17.4% The course’s planning committee, comprised of academic and reported that it was too soon to tell. The most commonly reported community-based family physicians and the Associate Dean for CME, changes that providers believed had resulted in improved patient considered the research findings to plan the 2014 FMU. Topics health included better management of diabetes, hypertension, and/ recommended by multiple respondents were incorporated into or heart disease (26.1%), and more appropriate use of screening the 2014 course, and included rheumatology, geriatrics, diabetes, tests (17.4%). Notably, 73.9% of respondents were able to recall heart disease, women’s health, anemia, anticoagulation, smoking cessation, tick-borne illness, adult attention deficit disorder, and palliative care. The format was not altered, as no respondent 90 requested any such change. 80 2013 Survey s t

n 70 2014 Survey e Discussion d

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P ____ based CME activity in family medicine was perceived as useful 10 and information was retained. Participants reported using revised 0 recommendations and guidelines, and recalled specific content five months subsequently. Future work should focus on larger samples, more precisely quantifying changes in practice and patient outcomes, and validating self-reports with objective medical record data.

Figure 1: 2013 and 2014 Family Medicine Update survey responses CONTINUED NEXT PAGE Figure 1: 2013 and 2014 Family Medicine Update survey responses.

Winter 2016 • Volume four • Number three • 31 cme activity, continued Endnotes 1 Andolsek K, Rosenberg MT, Abdolrasulnia M, et al. Complex cases in primary care: report of a CME-certified series addressing patients with multiple Dorothy S. Lane, MD, MPH is currently Associate Dean for CME and a SUNY comorbidities. Int J Clin Pract 2013, 67(9):911-917. Distinguished Service Professor in the Department of Family, Population and Preven- 2 Bird GC, Marian K, Bagley B. Effect of a performance improvement CME activity tive Medicine at the Stony Brook University School of Medicine. Dr. Lane is board on management of patients with diabetes. J Contin Educ Health Prof 2013, certified in Family Medicine (1977-2007) and is a longstanding member of the AAFP. 33(3):155-163. She previously developed the residency program in family medicine at Brookhaven 3 Bjerre LM, Paterson NR, McGowan J, Hogg W, Cambell CM, et al. What do Memorial Hospital in Patchogue, N.Y., where she was Director of Medical Education. primary care practitioners want to know? A content analysis of questions asked at the point of care. J Contin Educ Health Prof 2013, 33(4):224-234. She is active in CME at the local, state and national level and is dually board certified 4 Davis DA, Thomson MA, Oxman AD, Haynes B. Changing Physician Performance: in preventive medicine and family medicine. A Systematic Review of the Effect of Continuing Medical Education Strategies. JAMA 1995, 274(9): 700-705. Catherine R. Messina, PhD is Research Associate Professor in the Department of 5 Thepwongsa I, Kirby CN, Schattner P, Piterman L. Online continuing medical Family, Population and Preventive Medicine at the Stony Brook University School of education (CME) for GPs: does it work? A systematic review. Australian Family Medicine. Her research focuses on psychosocial influences on cancer screening among Physician 2014, 43(10): 717-721. asymptomatic patients and their primary care providers. She has taken part in the de- Gregory Kirschen, BA is an MD/PhD candidate at Stony Brook University. He has sign and conduct of several NIH-funded intervention studies utilizing CME activities completed the first two years of medical school, and is currently in his second year to improve breast and colorectal cancer screening among primary care physicians of graduate school, in the Molecular and Cellular Pharmacology Program. Gregory practicing in the community and in county health centers. works in the laboratory of Dr. Shaoyu Ge, studying neuronal stem cells. He also has a strong interest in undergraduate and continuing medical education.

A 5-day, retreat-like workshop designed to Mindful Practice enable clinician and medical educators deepen their skills in Mindful Practice and their ability Advanced Workshop to teach and develop programs in Mindful Practice at their home institutions. May 2-6 Designed for medical practitioners Sponsored by: The Department of Family Medicine - (physicians, NPs, PAs) and others Mindful Practice Programs involved in medical practice Hosted by: The Center for Experiential Learning and education, the program The Chapin Mill Retreat Center, Batavia, NY combines didactic presentations and experiential exercises using narratives, appreciative inquiry, and contemplative practices such as mindfulness meditation. Session themes address attention, suffering, teamwork, difficult conversations with patients/ families, uncertainty in medicine, medical education, grief and loss, resilience and compassion.

For more information contact the Center for Experiential Learning at 585-275-7666

32 • Family Doctor • A Journal of the New York State Academy of Family Physicians The era of the specialist blossomed. In 1917, Can family physicians with expertise training in the American Board of Ophthalmology led diabetes or the management of chronic heart The Primary the way. By 1964 the percentage of graduates failure in the context of all facets of a patient’s going into general practice fell from 47% in the life, act as the next era of specialists? Pipelining Care Specialist 1900’s to just 19%, with more students wanting patients to physicians with higher levels of By Sabina Rebis, MD to obtain what came to be sought as crème expertise in one population or in a type of de la crème training, in fields like radiology, chronic disease may be a way to optimize the dermatology, or ophthalmology.5 Specializing type of care provided. seemed to be the answer in decreasing the or the past twenty years the Critics believe it is important to stay true to F workload and breadth of knowledge faced by number of American medical school the traditional practice of family medicine, primary care doctors. graduates has steadily remained constant, providing continuing and comprehensive a sprout in physician supply in the 1970’s Yet training which focused on individualized medical care to all. However, the overwhelming after the passing of the Health Professions organ systems also compartmentalized explosion of knowledge and information Educational Assistance Act of 1963.1,6 At the medicine. The social climate of the 1960’s available has created new demands and time, this act forced medical schools to admit called for a more humanitarian approach that expectations for patients and doctors alike. more students to their hallowed halls, as shifted away from the focus on academia and Patients who years ago placed their trust in the need for generalists grew. However the brought medical practice closer to its house the family doctor have shed some of that trust, gap between graduates who choose to enter call roots. Family medicine was the bearer disproportionally replacing it with gigabytes specialties and those who commit to primary of the torch meant to address the need for a in their Smartphones. With this explosion of care has continued to widen. Only one-third different approach to patient care, one that faster, better, newer information patients may choose to stay in primary care, with two- would encompass comprehensive care for all be more willing to spend their time and money thirds electing to acquire further specialty ages.5 The field was to combine preventative on accessible specialists who will provide more training.2 Finding innovative ways to recruit methods such as health screens and patient effective outcomes. fresh graduates to serve as the gatekeepers to education, along with treatment of chronic The trickle of primary care specialists with the medical system has been a hot topic over conditions. the last few decades.3 solid training in family medicine has opened the Despite incentives to enter primary care, the door to new ways of providing care. The focus The opportunities to specialize and sub- desire to obtain specialized training has not on prevention and health maintenance is the specialize have carved out a tiered training abated. Currently physicians who maintain a closest we have come to the fountain of youth, system, catering to the sky-high ambitions strong interest in pursuing family medicine and one way to optimize this approach is to of medical students. The growing time include those with a particular interest in rural create a wide panel of experts in primary care constraints placed on visits, declining medicine, those with no ties to a research and prevention. reimbursements, electronic medical record career, and those who do not have great documentation requirements, and the expectations for exorbitant income.3 The Endnotes 1 The Association of Family Medicine Residency mushrooming amount of information have costs of education, years spent in training and Directors: The four pillars for primary care physician lessened the appeal of primary care fields breadth of knowledge required turns away workforce reform: a blueprint for future activity: such as family medicine and pediatrics. many tired and indebted medical students. Annals of Family Medicine. Jan/Feb 2014 vol. 12 (1) Today, even the medical students with the 83-87. Family physicians are at the forefront of change 2 Health resources and services administration. The most romanticized ideals are seeking out in healthcare and its management, but the physician workforce: projection and research into residencies that will minimize the strain. responsibility of being on the front lines of current issues affecting supply and demand. US dept medicine can lead to early burnout. of health and human services. (http://bhpr.hrsa.gov/ Despite nuances of the challenges faced by healthworkforce/reports/physwfissues.pdf) GPs, the reality is that even the most fruitful Primary care specialists are family medicine 3 Senf, J et al. Factors Related to the Choice of Family Medicine: A Reassessment and Literature Review. J Am specialties branch from the roots that residents who choose to specialize in a specific Board Fam Pract. 2003 Nov-Dec; 16(6):502-12. sprouted from seeds of primary care training. area of primary care after a year or two of 4 Geyman J. Foundation of Changing Health Care. Prior to the 1900’s doctors were apprenticed fellowship. The AAFP now lists up to three Chapter 1, Family Medicine as a Specialty. Norwalk, Conn: Appleton-Century-Crofts. 1985 into the profession as generalists, learning hundred and seventy-eight new fellowships. 5 https://www.theabfm.org/about/history.aspx to taste test urine for diabetes, deliver babies Unlike subspecialties in internal medicine, 6 Getzen, Allen. Health Care Economics. Wiley at the bedside, treat ulcers, and appease the where the focus is on addressing individual Pathways; Global Education 2007: 139-140 woes of the village census. In the 20th century, organ systems, primary care fellowships focus Sabina Rebis, MD is a first year family medicine resi- as America lagged behind its European on the patient as a whole, integrating all aspects dent at SUNY Stonybrook School of Medicine also rotating neighbors, new sets of requirements raised of patient care surrounding the needs of a at Southampton Hospital in Southampton, New York. Prior the bar for entrance into the profession. specific population. Fellowships in geriatrics, to pursuing a career in medicine she studied journalism Patient volume increased.4 Physicians at New York University and has freelanced for various adolescent and sports medicine, or women’s publications regionally and nationally. Her interests needed a funnel for the cacophony of health health are already widely available. include prevention of chronic diseases through lifestyle concerns. intervention, as well as women’s and adolescent health.

Winter 2016 • Volume four • Number three • 33 care sensitive conditions?1,2 Are the current process data generated by practices statistically predictive, considering Payment Reform their use in payments for services? Are they ethically sound, in 2016 – A Comic respecting the wishes of our patients? You reply to yourself: “I just saw Ms. Perez, and she will not take any statin, and her A1C is still 8.5%. What does this Tragedy in One Act mean for our pay--and what should I tell her? I already spent 35 minutes with her, and she might be right.” Let’s start with that evidentiary issue. Where in the world have financial incentives worked to improve patient outcomes? After a long list of trials, the answer in summary is--nowhere. According to Scott, et al. (Cochrane 2011), “We found no evidence that financial incentives can improve patient outcomes.”3,4 The most recent of these, in JAMA 11/10/15 found that giving bucks to docs and patients- both, only the docs, only the By Robert Morrow, MD patients, or neither- produced statistically significant change in LDL in high risk patients, when both patient and provider received monetary incentives, from 160 to 126, compared to 160 to 136 in the control, with broad over-lapping confidence limits. Funny-didn’t get to less than 100 in this high-risk group. Center stage: You’ve finished seeing your eighth (Framingham: +20% cv risk/10 years). But this difference is patient of the morning, chatted with a behavioral specialist and not really a clinically or statistically meaningful difference. renewed four sets of prescriptions online. It’s still early in your Wait! Don’t go home yet, evidence is of small importance (independent, small, large) health system practice day and you compared to a buffalo stampede. get a call from your (biller, manager, consultant, spouse). Small window opens for manager. Then you comment, in the spotlight: “How do you know if the results of my patients mean anything, or show I am “I don’t think we’re ready for the new models of payment, doctor, doing a good job? Can you predict that my patients will do especially after we got excluded by (pick your narrow panel payer). better because of what our practice does? My EHR seems too And we have to hire a care manager.” stupid to do that!” If desired, make your manager having recently returned from a So what’s the math? The math is too complex for me at a C-suite meeting. Close manager window. granular level, but from the exam table level, authors from the Welcome to 2016 and yet another glossary of acronyms all aimed at Centers for Medicare and Medicaid Services, Dartmouth, and making primary care survive. At least that’s how the deal is framed in Cornell [JAMA, December 9, 2009—Vol 302, No. 22] looked at 2016, and certainly 2016 has the art of the deal as the focus in health confidence intervals of measures from real life data, and found care. that a valid 10% change over a year requires a practice size of about 200 providers, not patients. Think about variability, How will new models of payment - Alternate Payment Models, Pay for funnel graphs of each payer versus practice level data and how Performance, Value Based Payment, incentive pay - shape the next few numbers bounce around from test to test for many reasons. years of our profession? Are they the answer to the health train wreck You might have 2500 patients, of whom 800 have Medicare, th rd of our country—17 out of 17 in health parameters and 43 in life of whom 400 have traditional Medicare, of whom 32 have expectancy by World Health Organization and other reports, for twice diabetes, of whom about twenty saw you twice in the time frame. the international price? Have new incentive models succeeded elsewhere in the world, with a robust evidentiary base? Do they support the way- Then think of regression to the mean, the tyranny of attribution, above-the-mean performance of most small US primary care practices in the changes seen over time for many reasons - better public outcomes, patient centeredness, and low hospitalization for ambulatory health, better food, Dr. Oz, etc. Toss in differential mortality,

34 • Family Doctor • A Journal of the New York State Academy of Family Physicians selection bias, use of multiple data points recursively over time, and better than the prior year, if the responsible organization pays out how one picks a comparison group, and you are way past my pay fairly, and if the big players don’t end up weeping about the money level. For a full discussion of the math, ask an expert. Don’t bother if they lost and layoffs which they had to make. If you already have a you work with 200 other providers and you trust the math, and the low hospital rate and short lengths of stay, you’re in trouble. If you data gatherers. don’t control the hospital stuff, then you should have known better. You, spotlight, center stage, the family doc: ”Hey author! The doctor, perplexed: “Could you and my manager stop Could we talk about my patient, Ms. Perez, who just says NO!” messing with my head and tell me what works? What is best for my patients and me?” Sorry, got distracted by bad math and inadequate data methods being used to pay us. You the family doc have the rare opportunity in our culture to do good every day, to change people’s lives. And we can do better, we all As you pointed out, your patient, who is a school principal who used agree. to teach AP calculus, and has a BMI of 21 and does sail boarding all winter and completes two ultra marathons a year, says she will not A summary would be engineering and education. Design our take meds for her lipids and type 2 diabetes. She wishes to spend electronic tools to be easy and obvious. Make data retrieval easy and the next two years solving these issues her way, and is attending a fast in the office and between all sources of care. And educate all of diabetes self-management group run by a community group near her us in their efficient use, and how to link with community and public school in Hunts Point. health efforts as they occur. Screws up the practice numbers, eh? But the bottom line is the bottom line. That requires the survival of good primary care practice that is attractive to practical medical The point is that a foundational concept in medical ethics is the students, and that requires adequate pay and support that respects voluntary quality of care. In your discussion, do you tell your patient us and our patients. Fair pay for work is the starting point, such as that you will be paid better if she takes a drug? Getting paid more is in Canada and Great Britain, and well-engineered practices with the case in VBP, P4P, APM and so on, isn’t it? Transparency is needed well trained physicians and other providers—the entire healthcare for an informed patient such as Ms. Perez, who has also already run team—make up the proper pathway to equity and improved access the numbers and finds her risk of complications does not trigger her to care, and improved health of the public. desire to take a medication—for her, 12% CV risk over 10 years, 1.2/100 annually-- doesn’t add up. And she won’t take it; she’s just You on stage: Take a bow! You need it! We can do it—we being honest, instead of ‘non adherent.’ were interns once! Consider the words ‘beta blocker.’ Do they prevent operative Endnotes cardiovascular complications like they were said to last year, in an 1 Small Primary Care Physician Practices Have Low Rates Of Preventable old guideline tied to payment? No. Do they prevent stroke, as we have Hospital Admissions Health Aff 10.1377/hlthaff.2014.0434;published ahead of thought for thirty years? Maybe no, maybe yes? Could our patients be print August 13, 2014 right when they say no? 2 http://www.aafp.org/news/practice-professional issues/20140820smallpractstudy.html Doesn’t matter! They have the ethical right and duty to choose what 3 Scott A1, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, Young D. The effect of financial incentives on the quality of health care provided by to do, and we are there to help them work through the contextual primary care physicians Cochrane Database Syst Rev. 2011 Sep 7;(9):CD008451. briar patch of interventions in health care, even when they are well. doi: 10.1002/14651858.CD008451.pub2 Especially when they are well, and we are offering prevention. 4 Flodgren Gerd, Eccles Martin P, Shepperd Sasha, Scott Anthony, Parmelli Elena, Beyer Fiona R. An overview of reviews evaluating the effectiveness of financial Do we still take these ethical positions as the foundation of our incentives in changing healthcare professional behaviours and patient outcomes. profession? Or do we insist on the statin? Perhaps we fire patients Cochrane Database of Systematic Review. 2011 who smoke or take opioids or have a high BMI. These are not trivial , received his MD from Mt. Sinai School of Medicine in issues in the age of payment for patients following the rules. Robert [Bob] Morrow, MD NYC and did his residency training at the Residency in Family Practice and Social ”People all over tell me that Accountable Care Organizations will Medicine. He has been in the independent practice of family medicine since 1980. He save my practice, reduce costs, and generally help me lose weight also works as an Associate Director for Interventional CME in the Center for CME at the and have whiter teeth. Should I believe them?” Albert Einstein College of Medicine. He is active in the Academy on state and regional levels. You don’t have to believe anyone, including me! ACO’s rely on organizations saving money by reducing care, relative to the prior year, and then paying you a piece of that at the end of the year. Think ‘hamburger today, will pay you next year,’ maybe. If each year is

Winter 2016 • Volume four • Number three • 35 Changing Health Care in New York State for Medicaid Recipients By Lynda Karig Hohmann, MD, PhD, MBA, FAAFP

These services, including certain behavioral health services such he Medicaid Redesign Team (MRT), instituted in T as rehabilitation programs, will allow better continuity of care 2011 when Governor Cuomo came to office, made numerous as recipients move through different levels of care. Additionally, recommendations for bringing the financially unsustainable NYS for recipients with complex behavioral health conditions, a new Medicaid program into alignment with the Triple Aim of better care managed care product, Health and Recovery Plan (HARP), is being for individuals, better health for the population and lower per capita developed to include the standard medical and behavioral health costs. Despite the dollars spent, New York State ranked at or near services as well as special services such as Health Home care the bottom of other states in certain health indicators including management and Home and Community Based Services, that will several measures of avoidable hospital use. The implementation provide the extra supports needed for these recipients to achieve of MRT recommendations, collected from across New York State better health and better functioning in the community. HARPs are and vetted by committees of experts, reduced the “per Medicaid being rolled out in the New York metropolitan area during the fourth recipient cost” to the level experienced in 2003, saving the federal quarter, 2015, followed by later roll out in the rest of the state. government $17+ billion dollars in Medicaid matching funds and not adversely impacting the Medicaid quality of care measures. New Health Homes: Not a physical structure as the name may imply, York State requested that the federal government reinvest a portion Health Homes is a care management program for complex super- of these savings back into New York to utilizing Medicaid recipients that was complete the redesign of the NYS Medicaid authorized through the Affordable health care delivery system, focusing on Care Act. In this model, recipients who activities recommended by the MRT but To ensure true integration of medical and have two or more chronic conditions, not implemented, as well as to stabilize a behavioral health care, traditionally “carved out” HIV/AIDS or chronic persistent mental number of “at risk” safety net providers services are being integrated into mainstream illness and who are high risk for within the state. After lengthy discussions, Medicaid managed care plans. hospitalization, placement in a nursing CMS approved the New York State Medicaid home or death (i.e., failing in their Waiver request including the Delivery ability to use health care resources System Reform Incentive Payment (DSRIP) Program with funding successfully) can enroll in a Health Home and be assigned a Health of $8 billion dollars with $6.42 billion specifically for the DSRIP Home care manager who will work with the member to organize and Program. This article for family physicians will provide an update meet his/her medical, behavioral and social determinants of health on certain MRT initiatives and DSRIP as they are relevant to primary needs. There is increased awareness in the medical literature that care. addressing the socials determinants of health, such as housing, can have significant impact in improving the health of high risk, complex Care Management for All individuals. Each New York State county has a Health Home in place. Family physicians who care for complex Medicaid recipients To meet the Triple Aim of better care for individuals, the MRT may refer these persons to the local Health Home for evaluation. adopted the concept of “care management for all”, with the goal Currently, Health Homes primarily service adults, but special of having virtually every Medicaid recipient enrolled in some Health Homes for children are currently being rolled out. Further kind of care management organization. At the highest level, this information on Health Homes and how to contact your local Health means designing managed care organizations capable of serving Home to refer a Medicaid recipient can be found at: all Medicaid recipients. To ensure true integration of medical and behavioral health care, traditionally “carved out” services are http://www.health.ny.gov/health_care/medicaid/program/medicaid_ being integrated into mainstream Medicaid managed care plans. health_homes/

36 • Family Doctor • A Journal of the New York State Academy of Family Physicians SHIP AND SIM: The state is continuing its support of primary care community needs assessment that assessed the full complement of through recognition and increased payment for family physicians physical health, behavioral health and community services available who reach certain designations as an NCQA Patient Centered within the community, the health care needs of the community, and Medical Home. Additionally, the state has recently received the State what was needed to fill the gap between the two. The projects are Innovation Models (SIM) grant, from the Centers for Medicare from a toolkit of 44 projects approved by CMS as part of DSRIP. The and Medicaid Innovation (CMMI) to implement the New York State goal is to enhance community based services, particularly increasing Health Innovation Plan (SHIP). The three core objectives of SHIP to primary care and preventive care services, allowing persons to be reached within 5 years are: receive the community based health care they need to maintain their health. Since over 50% of avoidable hospital use is for persons with 1. 80% of the state’s population will receive primary care within an mental health diagnoses who are being admitted due to a medical advanced primary care (APC) setting, with a systematic focus on condition, DSRIP emphasizes the increased integration of primary population health and integrated behavioral health care; care and behavioral health combined with care management to 2. 80% of the care will be paid for under a value-based financial provide better care for these complex Medicaid recipients. Access to arrangement; and, high quality primary care is essential to the success of DSRIP and it is expected that PPSs have already or will be reaching out to family 3. Consumers will be more engaged in, and able to make more physicians as part of the program development. Further information informed choices about their own care, supported by increased cost on this program is available at: and quality transparency. http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/ (http://www.health.ny.gov/technology/innovation_plan_initiative/ docs/sim_presentation_to_phips.pdf) In each of these programs, primary care physicians have a key role to help ensure its success. This is by design. The DOH recognizes The APC model includes behavioral and population health that improved health for the state requires increased access to integration, coupled with an appropriately trained workforce and community based, high quality primary and preventive care services engaged consumers, with supportive payment and common metrics. for all state citizens - the type of care that family physicians have been SHIP is inclusive of all providers, not just those involved with trained to provide. This is an opportunity for family physicians to Medicaid recipients. The specifics of the primary care practice in engage in and have a key role in designing a new health care delivery the APC model is under development now. SHIP will also have heavy system for New York. At the end of the five year DSRIP program, 90% emphasis on health information technology, including enhanced of health care payments will be based upon value based purchasing. capacities to exchange clinical data and an all-payer database. Primary care physicians active in the various programs noted above Further information on SHIP and the SIM grant can be found on the can ensure that family physicians and other primary care providers NYS DOH website: are appropriately valued and reimbursed for the primary and http://www.health.ny.gov/technology/innovation_plan_initiative/ preventive services that they provide. We encourage you to become involved. Delivery System Reform Incentive Payment (DSRIP) Program Lynda M. Karig Hohmann, MD, PhD, MBA, FAAFP currently works as a Medical Director for Island Peer Review Organization, embedded within the Department of As part of the Medicaid Waiver approved by CMS, $6.42 billion Health for special projects including the Delivery System Reform Incentive Payment dollars are being used to fund the DSRIP program. The stated Program. She has worked with DOH and outside organizations on development of overarching goal of DSRIP is to reduce avoidable hospital (acute the DSRIP projects and metrics after 15 years working in quality management for inpatient and emergency room) use by 25% over the five years of the two managed care organizations. She received her BS from RPI, her MD from SUNY program. This will occur by a fundamental restructure of the health Buffalo, her PhD from the University of Iowa and her MBA from SUNY Albany. She is care delivery system through the actions of local/regional Performing a board certified family physician and worked in academic medicine as well as in Provider Systems (PPSs). PPSs are groups of safety net providers addiction medicine for a number of years. (hospitals, FQHCs, practices, clinics, skilled nursing facilities [SNFs], etc.), non-safety net providers, and community based organizations that have committed to the implementation of up to 11 projects that have been identified as targeting significant health care issues within that community. Each of the PPSs was required to do a detailed

Winter 2016 • Volume four • Number three • 37 IN THE SPOTLIGHT

Adult NYSIIS By Philip Kaplan, MD, FAAFP

Pharmacists in New York State gained authority to immunize adults We have incorporated into our EMR face sheet an entry labeled ‘state against influenza and pneumococcus in 2008, shingles in 2012, mandates.’ This is where I record the offer of HIV testing, the offer meningococcus in 2013, and now Tdap in 2015. Such immunization of hepatitis C testing, and now, permission to submit vaccines to outside the medical home provides repeated opportunities for adults NYSIIS. Our data person who manages children vaccine submissions to be over-immunized. Most adults do not recall their immunization with a weekly upload, in response to this face sheet entry, clicks a history beyond this season’s flu vaccine, and there is no standard ‘permission’ box for that patient in our software, and those adult durable record of immunizations carried by most adults. Not doses go when the kids’ records go. We each have in place the only are excess doses wasteful in a country that has experienced existing software processes for submitting the kids’ mandated several vaccine shortages in recent years, but there may be harm records; the addition of adults’ doses is technically easy. from excess doses. ACIP is clear that a single dose of Pneumovax Possibly in response to our expressed concern, §2168 was again is indicated after age 65.1 ACIP is clear that a single lifetime dose amended last February. Pharmacists must now report adult doses to of Tdap is the current standard for non-pregnant adults.2 My elder NYSIIS. I have checked NYSIIS for our adult patients, and find there patient who had Pneumovax a year ago is eligible for Prevnar this is uniform pharmacist compliance in my community. We have a year. If this patient gets a second Pneumovax at the pharmacy this duty to our patients to properly immunize them. NYSIIS presents an year, I cannot give the Prevnar for another year, and it is not clear opportunity to develop a durable record so adults are neither lacking whether a third pneumococcal vaccine will be paid by Medicare. doses nor receiving excess doses. Until and unless we succeed in attaining repeal of pharmacy A mandate requiring physician submission of adult records may immunization authority, there are two options for managing the constitute ideal public health policy, but perhaps we can do the right absence of an adult vaccine durable record. First, we can simply thing without legislation. I urge my colleagues to voluntarily submit agree to provide a vaccine record onto which we all enter doses as adult doses to NYSIIS to accomplish optimal communication about we administer them. Patients in my practice often arrive without their vaccine doses. And please query NYSIIS when your patient may insurance card. Will they bring their vaccine record? have received a vaccine at the pharmacy, but cannot recall what it Second, we can agree to submit all adult vaccines to the state registry. was. Join this policy discussion by submitting your perspectives to We who immunize children were required to submit their vaccine [email protected]. records to the NYS Immunization Information System (NYSIIS) with the passage of NYS public health law §2168 beginning in July 2008. Endnotes Adult vaccines could also be submitted, but this required “specific 1 MMWR 9/19/14 /63(37);822-825 written permission,” a state mandated form. Two years ago, PBH 2 MMWR 2/22/13 /62(07);131-135 §2168 was amended with the removal of “specific written.” Now Philip Kaplan, MD, FAAFP, President 2012-2013, Chair Ad Hoc Committee on Vac- the law requires “permission” which may be verbal. There are no cine Policy, NYSAFP, President 2012-2013, Partner Fairgrounds Family Physicians, regulations specifying the content of this permission conversation. PLLC, Manlius, NY We have posted an announcement of this option in our exam rooms, and patients often ask me about this opportunity when I enter. In the past eight months we have enrolled about 1700 adult patients in NYSIIS. Only two have declined.

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