First Quarter 2013 The Scope of Family Medicine A Publication of the Academy of Family Physicians • www.alabamafamilyphysicians.org

Medicaid Advisory Commission Submits Report to Gov. Bentley PG 10 2 The Scope of Family Medicine The Scope of Family Medicine Spring 2013

Officers Contents *Allen Perkins, MD, President *Tom Kincer, MD, President-Elect From the President...... 5 Drake Lavender, MD, VP Northwest (’14) Pamela Tuck, MD, VP Southeast (’15) Alabama’s Rural Health Plan...... 6 Jarod Spear, MD, VP Northeast (’16) Boyd Bailey, MD, VP Southwest (’13) 2013 Alabama Legislative *Mike McBrearty, MD, Treasurer Jeffrey E. Arrington, Executive Vice President Regular Session Snapshot...... 8 (*indicates member of the Executive Committee) Medicaid Advisory Commission Submits Board of Directors *Tonya Bradley, MD, Chair Report to Gov. Bentley...... 10 Jerry Harrison, MD, At Large (’13) Julia Boothe, MD, At Large (’15) Provider Payment Accuracy Is Focus of State- Pamela Tuck, MD, At Large (’14) Nelson Cook, MD, Calhoun County Branch Based RAC Program...... 10 Michael McBrearty, MD, Gulf Coast Branch Lisa Columbia, MD, Jefferson County Branch Project Designed to Prevent Preterm Births Tracy Jacobs, MD, Resident Chapter President Fuller McCabe, Student Representative in at-Risk Recipients...... 11

Congressional District Reps Medicaid, ADPH Collaborate to Build Vacant – District 1 Beverly Jordan, MD – District 2 New Enrollment System...... 11 Michael Goodlett, MD – District 3 Laura Lee Adams, MD – District 4 HHS Revises HIPAA Privacy Rule...... 12 Kristy Crandell, MD – District 5 Albert Smith, MD – District 6 Save the Date!...... 16 Bob Grubbs, MD – District 7

AAFP Delegates Advertisers Melissa Behringer, MD (’14) Alabama Department of Public Health, Epidemiology Division...... 14 Steve Furr, MD, (’13) Alabama Department of Public Health, Immunization Division...... 4

AAFP Alternate Delegates Alabama Disability Determination Service...... 13 Tonya Bradley, MD (’14) Belk & Associates, Inc...... 14 Jerry Harrison, MD (’13) Children’s of Alabama...... 16 Coastal Insurance Risk Retention Group, Inc...... 15 Scope Managing Editor Jeffrey E. Arrington Healthcare Workers’ Compensation Self-Insurance Fund...... 14 Alabama Academy of Family Physicians MagMutual...... 7 19 South Jackson Street Montgomery, Alabama 36104 MediSYS...... 7 334-954-2570 ProAssurance Group...... 2 Toll-free: 877-343-2237 Fax: 334-954-2573 [email protected] www.alabamafamilyphysicians.org Like us on Facebook!

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Published March 2013 • 2013/1 2013 Published March necessarily reflect the policy of the Alabama Acad- emyAlabama of Family Academy Physicians. of Family Physicians 3 The Stethoscope of 2020 FROM THE PRESIDENT

The Stethoscope of 2020 by Allen Perkins, MD

When Laennec invented the stethoscope entists were trained in laboratory investiga- patient safety and the quality of care pro- in 1816 and physicians no longer had to tion as a prelude and foundation for clinical vided, as well as participate in lifelong put their ear to the patient’s breast, health training and investigation in university hos- practice improvement. care delivery changed. Asepsis, effective pitals. All physicians had a responsibility to • Physicians are generally not prepared to be treatments for syphilis and other break- generate new information and create prog- advocates for patients on issues related to throughs soon followed. By 1910, everyone ress in medical science, with assignment of social justice (for example, elimination of was aware that medical training and prac- this task to both laboratory and clinical sci- health care disparities and access to care) tice needed updating. “Heroic” treatments entists.”1 This system was created and was and to be citizen-leaders inside and outside (such as blistering, bleeding and purging) dominant for almost 100 years. of the medical profession. were known to cause harm to patients and • Physicians often lose altruism and qualities were avoided. Patients had been exposed In 2007, the American Medical Asso- of caring as they proceed through training to newfangled technology such as antisep- ciation offered a critique of the care we and enter the practice environment. tic surgery, vaccinations and public sani- Flexnerian physicians deliver.2 The good • Because of their training, physicians find tation. Most of the public understood the news: Doctors who train and practice in it difficult to deal with the inevitable un- advantages of scientific medicine, though the Flexnerian model are knowledgeable certainty arising from incomplete or con- they didn’t know quite what it was. Almost and technically proficient in providing care flicting information. Additionally, they all physicians now wanted to say they were for acute disease; they wish to do what is are not typically prepared to convey their practicing in a scientific manner, though, best for their patients; and patients respect uncertainty when interacting with patients in truth, many were not. them as credible sources of information. and colleagues. • Many physicians are not prepared to utilize Abe Flexner was hired to assess the state of The bad news? To paraphrase from the re- information technology to assist in infor- medical education in 1910 and determine port, though many of us do try very hard, mation acquisition and management. if the schools were up to providing practi- all of us are deficient to some degree in the • Physicians are trained to be autonomous. tioners for the scientific age. As a result of following areas: This can be a barrier to providing patient- his report, the ideal of medical education • Physicians are not prepared to evaluate centered care, where patient values and and practice changed. The new leaders en- the care they provide in their own prac- desires are an integral part of shared deci- visioned a system “in which physician sci- tices and to use the results to improve sion-making. The expectation of autonomy diminishes the ability of physicians to act as team players with other physicians and other health professionals. • Physicians are not prepared to participate in ethical and political discussions about the allocation of health care resources, which are not limitless. • Graduates do not acquire skills in cul- tural competence/awareness and to recog- nize that some patients may have health literacy issues.

In the future, we must perform consistently better. Partly as a response to the findings in this report, our Academy and others signed on to the joint principles that now form the basis for the patient-centered medical home (PCMH) model of primary care de- Continued on page 13

Alabama Academy of Family Physicians 5 Alabama’s Rural Health Plan An Analysis of Access to Primary Care in Rural Alabama Published by The Office for Family Health, Education and Research, UAB School of Medicine, Huntsville Regional Medical Campus

Executive Summary Findings Conclusions A comparison of the health status of Ala- An extensive review of the health outcomes Community-oriented access to primary bama’s citizens to nationally recognized literature relative to primary care services, care through a relationship with a family health status indicators show that rural primary care access and primary care provid- physician is the most functional and practi- Alabamians do not compare well with ers finds that patients of primary care physi- cal way to improve the health status of Ala- the United States as a whole or even with cians had better health outcomes regardless of bama’s rural population. The communities Alabama’s urban population. Alabama’s the geographic area, year or outcome measured. in which Alabama’s rural hospitals are rural residents have significantly poorer Traditionally derived physician/population ra- located are spatially distributed through- outcomes than urban residents. While there tios using the 2012 medical licensure database out rural Alabama in a manner that allows are multiple and diverse barriers to improv- and the 2010 Alabama census data finds that Alabama’s rural residents physical access ing the health status of Alabama’s rural the supply of primary care physicians in ru- to a family physician. residents, the most significant and univer- ral Alabama is inadequate to meet the cur- sal is their inability to access a primary rent rural population demand, thus making Rural hospitals are the most essential re- care physician — and, more specifically, a access to a primary care physician a major source for recruiting, retaining and support- family physician. Removing this barrier is barrier to improving the health status of Ala- ing the rural family physician. In this model, dependent on having sufficient family phy- bama’s rural citizens. Literature review also rural hospitals are the geographic locations sicians (availability) at appropriate locations finds that the primary care physician with the for primary care access, and family physi- throughout the state (accessibility) to meet most extensive impact on population health cians managing 2,650-person panels are the the primary care demands of Alabama’s outcomes is the family physician. availability assets at each of these sites. A ru- rural population. Global observation of ral health plan based on a family physician/ the geographic location of Alabama’s rural A geographical survey of medical facilities rural hospital model for access to primary hospitals and their associated communities and primary care providers in rural Alabama care as described in this presentation is re- indicates that they are spatially positioned found that the most appropriate medical facil- alistic and achievable. It directs Alabama’s in the state to serve as centers for primary ity to serve as a center for rural accessibility current rural physician pipeline activities care access. is the rural hospital. The rural hospital is also and sets the stage for the expansion and ad- the community resource that historically and dition of activities to recruit and educate a To confirm that rural hospitals are, in fact, currently is the major recruiter of family phy- cohort of rural students to be family physi- the appropriate service points for Ala- sicians to rural communities. Review of the cians while identifying and designating the bama’s rural population and to determine 2010 medical licensure database finds that the rural communities where state and federal the number of family physicians needed at most available primary care physician prac- resources can be utilized with local resourc- each of these locations, this study used geo- ticing in communities where rural hospitals es to maximize recruitment and retention of graphic information systems (GIS) technol- are located are family physicians. family physicians. ogy and spatial analysis to create a spatial accessibility model unique for each of 99 Applying spatial accessibility analysis to the lo- In short, this model provides a foundation general hospital locations in Alabama. cation of Alabama’s general admission hospitals for expanding our current primary care This model used the known health care and using the family physicians located within a coverage in general and to pursue more assets (family physicians), the population 20-minute driving time of each hospital as their in-depth analysis of workforce issues and demographics and driving-time imped- primary care assets finds that Alabama’s rural barriers to primary care access based on ance, along with the practice variables hospitals are geographically located and spatially the micropopulations at individual rural panel size and office visits to make demand distributed within the state to allow Alabama’s sites. It identifies local strengths and needs a function of local census-derived popula- rural population physical access to a family phy- and gives focus for developing public and tion data. Spatial analysis was then used to sician. To meet the population demand for family private partnerships, rural public policy, create area/provider ratios, which, in turn, physicians, this study shows that Alabama cur- legislative support, pilot projects and rural were used to create bands of accessible rently needs an additional 76 family physicians outcomes research. It gives direction to ru- populations at these locations. GIS soft- in 25 locations throughout the state. Of the 25 ral educational programs. ware was then used to analyze the bands of locations where family physicians are needed, influence and characteristics that fall with- 23 are in rural Alabama. Mapping of coverage For more information and to read the entire re- port, please visit: www.uab.edu/medicine/home/ in and outside of those bands to determine bands for metropolitan hospitals shows that met- rural-medicine. the family physician need at each of these ropolitan coverage bands have no significant ef- 99 locations. fect on rural populations.

6 The Scope of Family Medicine alabama providers using medisys collect over $3 million in incentives

Alabama Academy of Family Physicians 7 2013 Alabama Legislative Regular Session Snapshot

During the first month of the 2013 Alabama HB 151 (“pain management bill”), by Rep. thing that has been outlawed in this state for Legislative Regular Session, two bills in the Weaver, would: nearly 40 years for safety reasons. organized-medicine-backed “drug-diversion • Define “pain management” and allow the package” passed the House Health Commit- Board of Medical Examiners (BME) to The AAFP has opposed lay midwifery in tee. Those bills, HB 150 and HB 152, refine promulgate rules Alabama in the past and has been successful and update the PDMP database (prescription- • Would require annual registration with in preventing its legalization here. The prac- drug monitoring program) for controlled the BME tice puts unnecessary risk of injury or death substances and combat “doctor-shopping” by • Would allow unannounced inspections on the infant and mother and gives location patients seeking controlled-drug prescriptions • Would allow for license suspension in the of birth supremacy over safe delivery at a from multiple providers within a concurrent case of a public health danger and allow for time when maternity care is widely available, period of time. disciplinary actions even to poor Alabamians through Medicaid. Additionally, there is an increased risk of ex- HB 150 (“PDMP bill”) would: Together, the three bills comprehensively posure to liability for physicians inheriting a • Allow physicians needed access to the tackle the complex issue of drug diversion in mother or infant in distress who was attend- database for better monitoring their own Alabama. The AAFP appreciates the spon- ed by a lay midwife assisted planned home prescriptions and the prescriptions of those sors of the three bills; Rep. Jim McClendon births gone wrong. authorized to do so under their supervision of Springville, chairman of the House Health • Allow physicians to designate two employ- Committee; and Rep. April Weaver of Ala- In 2012, organized medicine supported ees under their supervision to access the baster for their diligence on the issue and their amendments by Sens. Gerald Dial, Jabo Wag- database on the physicians’ behalf, saving leadership during the committee hearing in goner and that absolve phy- physicians valuable time which the bills were voted upon favorably. sicians and hospitals of liability for treating • Allow the Medicaid Agency to access the mothers and infants suffering injury or death database for inquiries concerning prescrip- While some objections to the bill to license from lay-midwife-assisted planned births, tion abuse by Medicaid patients and regulate pain clinics in Alabama have set minimum limits of insurance for lay mid- • Allow interoperability between Alabama’s been voiced by some nonphysicians and enti- wives to carry that are consistent with other database, the Department of Justice and ties that may own or manage pain clinics, the womens’ health care providers and require other states and allow law-enforcement of- legislation is designed to help solve the drug- lay midwives to pass the same examination ficials access to the database in certain cir- diversion epidemic in Alabama. The AAFP required of certified nurse midwives for licen- cumstances in order to help them combat is working with Rep. Weaver, who sponsors sure. These good amendments were added to prescription-drug abuse the pain management bill, to move it through the bill on a near-unanimous vote, and the bill the committee process with a favorable vote. passed out of committee with the same level of HB 152 (“doctor-shopping bill”) would: Once this bill is approved by the House Health support. However, these critical amendments • Allow law enforcement to effectively prose- Committee, the three-bill package can move turned the lay midwives against their own bill, cute “doctor-shoppers,” those patients going to the floor as a group, where the full House of and in the end, the bill died in the Senate. from one physician to another obtaining the Representatives can approve it, which will be same or similar controlled drug prescrip- a significant step toward combating prescrip- “Ban the Tan” Bill Would Keep tions at the same time tion-drug abuse in Alabama. Minors Out of Tanning Salons • Protect the physician-patient relationship by House Bill 179 by Rep. Ron Johnson of clarifying that an individual would have to The three-bill package in the House has a Sylacauga would regulate tanning facili- attempt to “deceptively” obtain the multiple companion package in the Senate, where Sen. ties and prohibit minors from patronizing controlled-drug prescriptions during the Cam Ward of Alabaster is the sponsor. The these businesses. Figures indicate that up “concurrent time period” to violate the act bills are assigned to the Judiciary Committee, to one-third of U.S. teenagers use tanning • Provide that initial convictions for “doctor- which Sen. Ward chairs, but have not yet been beds, with 40 percent of those doing so reg- shoppers” would be Class-A misdemeanors scheduled for a hearing. ularly. Shockingly, Birmingham has one of with a fourth conviction in a five-year pe- the highest rates of per capita tanning bed riod constituting a Class-C felony Lay Midwives Introduce use in the country. While Alabama has no Legislation Again state law preventing children from using HB 150 and HB 152 work in concert with the A bill sponsored by Rep. of Hunts- tanning devices, similar legislation has al- third piece of legislation in the “drug-diver- ville, HB 178, would legalize the dangerous ready passed in surrounding states to pro- sion” package: HB 151, a bill regulating pain practice of lay midwifery in Alabama, some tect children and provide oversight of the management in the state. indoor tanning industry.

8 The Scope of Family Medicine 2013 Alabama Legislative Regular Session Snapshot

For more information on the “Ban the Tan” Members, our best offense and defense The Academy will continue to keep you legislation, visit the UAB Department when lobbying our Legislature are mak- apprised of legislative developments as of Dermatology website, www.uab.edu/ ing personal constituent contact with they occur, but we need your help get- medicine/dermatology. your legislators when a piece of leg- ting our message to these legislators. islation is in the Senate and/or House Together, we can continue to protect the health committees. Below you will find practice of family medicine. contact information for both chambers.

Senate Health Committee Sen. Jabo Waggoner Sen. , Chair 1829 Mission Road 1065 Magnolia Ridge Drive Birmingham, AL 35216 Jasper, AL 35504 205-822-7443 334-242-7894 Sen. Tom Whatley Sen. , Vice Chair 337 East Magnolia Drive 1625 Main Avenue SW Auburn,, AL 36831 Cullman, AL 35055 334-242-7895 256-734-1700 Sen. Jerry Fielding Sen. 1300-B Talladega Highway PO Box 606 Sylacauga, AL 35150 Clayton, AL 36016 256-249-2199 334-775-3291 House Health Committee Rep. Rep. John Knight Sen. Slade Blackwell Rep. Jim McClendon, Chair 620 Davis Lane P.O. Box 6300 2501 Watkins Road 361 Jones Road Eufaula, AL 36027 Montgomery, AL 36106 Birmingham, AL 35223 Springville, AL 35146 334-616-1272 334-834-7445 205-396-1144 205-467-7768 Rep. Rep. Becky Nordgren Sen. Linda Coleman Rep. , Vice Chair P.O. Box 3367 101 Cook Street 926 Chinchona Drive 995 Country Estates Drive Huntsville, AL 35810 Gadsden, AL 35904 Birmingham, AL 35214 Hamilton, AL 35570 251-859-2234 256-546-1378 205-798-1045 205-921-3214 Rep. Ed Henry Rep. James Patterson Sen. Gerald Dial Rep. 1002 Beech Street P.O. Box 286 P.O. Box 248 P.O. Box 781 Hartselle, AL 35640 Meridianville, AL 35759 Lineville, AL 36266 Montgomery, AL 36101 256-260-2146 256-985-7990 256-396-5626 334-263-2420 Rep. Ron Johnson Rep. Sen. Harri Anne Smith Rep. 3770 Sylacauga-Fayetteville P.O. Box 126 P.O. Box 483 P.O. Box 1256 Highway Morris, AL 35116 Slocomb, AL 36375 Chatom, AL 36518 Sylacauga, AL 35151 205-566-6835 334-699-3208 251-847-2604 256-249-9489 Rep. April Weaver Sen. Cam Ward Rep. Donnie Chesteen Rep. P.O. Box 1349 124 Newgate Road 306 Goose Hollow Road 2319 Eddins Road Alabaster, AL 35007 Alabaster, AL 35007 Geneva, AL 36340 Dothan, AL 36301 334-242-7731 205-664-1066 334-449-1040 334-792-9682

Alabama Academy of Family Physicians 9 Medicaid

Medicaid Advisory Commission Submits Report to Gov. Bentley

he Alabama Medicaid Agency should end its current fee-for- agement or other services in the region; (5) The Legislature, where T service model in favor of locally led managed-care networks appropriate, and Medicaid, where administratively possible, shall that eventually can assume the responsibility and the risk for im- authorize regional care networks throughout the state and establish proving patients’ health outcomes, according to a report submitted an implementation timeline. Specific benchmarks shall be set that to Gov. Robert Bentley on January 31 by the Alabama Medicaid must be met by the networks. Failure to meet the benchmarks shall Advisory Commission. Gov. Bentley created the 33-member com- authorize state intervention. (6) The Alabama Medicaid Agency mission by executive order in October, tasking the group with eval- should seek an 1115 waiver from CMS to implement the transforma- uating the financial structure of the Alabama Medicaid Agency and tion to managed care. And (7) Legislation should be developed to identifying ways to increase efficiency while also helping ensure create a Medicaid cap, provided that the legislation ensures adequate the long-term sustainability of the agency. flexibility for the Alabama Medicaid Agency to address federal mandates, rules and regulations; economic uncertainty; catastrophic State Health Officer Dr. Don Williamson, who served as commission health events; and provider rates. chair, emphasized that both patients and taxpayers will benefit from such a change. “For the patient, it could mean they are going to have Since the commission’s first meeting on November 1, 2012, members more encompassing care. For the agency, this will be the biggest fun- met several times to hear presentations from other state Medicaid pro- damental change in Medicaid since its inception,” he said. grams, commercial managed-care organizations and Alabama Medic- aid’s Patient Care Networks and to review cost and other data. The commission’s recommendations included: (1) Alabama should be divided into regions, and a community-led network in each region Commission members include health care providers, legislative should coordinate the health care services of the Medicaid patients leaders, state health and human service agency officials, consum- in that region. (2) Regional care networks should formally engage ers and insurers appointed by the governor. Information on the consumer input and oversight at all levels of governance and opera- Commission, including the final report, meeting minutes, presen- tion. (3) The expanded regional patient care networks should become tations and membership, is available on the Medicaid website at risk-bearing organizations. (4) Regions may choose to contract with www.medicaid.alabama.gov/CONTENT/2.0_newsroom/2.2.1_ a commercial managed-care organization to provide care, risk man- Med_Adv_Commission.aspx.

Provider Payment Accuracy Is Focus of State-Based RAC Program

andatory provisions of the Affordable Care Act require and experienced clinicians. Audits will be conducted by GHS M the Alabama Medicaid Agency to select and provide using a “top-down” approach where data analysis, through data oversight for a Medicaid Recovery Audit Contractor (RAC) mining, is applied against the universe of paid claims to iden- to perform provider audits. Goold Health Systems (GHS), a tify patterns of utilization or billing that look atypical based Maine-based firm, has been selected to be Alabama Medicaid’s on Alabama Medicaid and/or national standards. Following the contractor for a two-year period that began January 1, 2013. high-level claims analysis, GHS may expand its review by re- questing clinical records and/or other documents in accordance The RAC program is designed to improve payment accuracy by with state and federal regulations. identifying underpayments and overpayments in Medicaid. The Medicaid RAC program is a separate program from the Medi- “Our goal throughout this process is to ensure that providers care RAC, which is overseen by the Centers for Medicare and are paid accurately and that taxpayer dollars are spent as in- Medicaid Services. tended based on state and federal rules and regulations,” Pro- gram Integrity Director Jacqueline Thomas said. Reviews will be conducted by the GHS staff to include full-time medical directors, pharmacists, certified professional coders

10 The Scope of Family Medicine Project Designed to Prevent Preterm Births in at-Risk Recipients

hen babies are born too early, they are more likely to have se- intensive care unit at a cost of $57.8 million, or an average cost of W rious health problems or to die. To combat this problem, the $16,345 per baby. Alabama Medicaid Agency is teaming up with the state’s maternity care providers to reduce the number of premature, or preterm, births According to Dr. Moon, the project has two goals. One is to help among Medicaid-eligible women. identify and refer maternity patients at risk for preterm births, and the second is to determine the use of 17P and the pregnancy out- The two-year project, which began February 1, is based on the Ameri- comes in this population. can College of Obstetricians and Gynecologists’ recommendation that all pregnant women with a prior history of a spontaneous preterm birth The first phase of the project will take place between February 1, at 37 or fewer weeks’ gestation be counseled on the benefits of taking 2013, and September 30, 2013. During this phase, maternity care 17-alpha hydroxyprogesterone caproate, or 17P, to prevent a second coordinators will be trained to screen, educate and refer maternity preterm birth. patients at risk of having a preterm birth. If a patient is at risk of a preterm birth, a copy of the screening tool used will be provided “Preterm birth is associated with long-term problems such as neu- to the patient’s medical provider for follow-up. After the screen- rologic handicaps, blindness, deafness and chronic respiratory dis- ing and education process, data will be collected to determine how ease, among others, especially in births before 30 weeks’ gesta- many patients were screened, how many recipients received edu- tion,” Medicaid Medical Director Dr. Robert Moon said. He noted cational materials and how many were referred to their delivering that conditions related to short gestation and low birth weight are health care provider. the leading cause of infant death, based on a 2009 study conducted by the Alabama Perinatal Program. In the second phase of the project, the Agency will determine how many recipients who were referred actually received the medication In fiscal year 2011, the Alabama Medicaid Agency financed more and if the number of preterm births among at-risk patients improved than 50 percent of all deliveries in the state. Of the 31,028 Medicaid while receiving the drug. This phase is scheduled to begin December deliveries, 3,538 babies — 11 percent — received care in a neonatal 1, 2013, and continue through July 13, 2014.

Medicaid, ADPH Collaborate to Build New Enrollment System uilding on the past successes between the two agencies’ pro- “By using an agile development process and user-centered de- B grams, the Alabama Medicaid Agency and the Alabama Depart- sign principles, we will move the state through the design and ment of Public Health are collaborating to build a new eligibility and implementation phases quickly to create a system that not only enrollment system using current technology while saving millions of meets federal requirements but also the needs of the end-user,” dollars for the state. Rawlinson said.

The new system will replace the existing architecture and structure Once the first phase is completed, the next step will be to add the of the current Medicaid system, which is more than 30 years old state’s elderly and disabled programs to the system by the end of and suffers from inefficiencies common to older, outdated systems. 2015. The state also plans to investigate the feasibility of adding By using departmental employees, the two expect to save $20 mil- Department of Human Resources programs such as TANF, SNAP lion in state and federal funds by building the system in-house. and Child Care. If approved by the Centers for Medicare and Med- icaid Services, these programs could be integrated into the new During the project’s development, design and implementation system by December 2015. phases, Medicaid and CHIP will complete the requirements for the Affordable Care Act (ACA) by January 2014 while creating a sys- A recent study by the Kaiser Commission on Medicaid and the tem that automates application processing. According to Lee Rawl- Uninsured found that nearly all states are making changes to de- inson, Medicaid deputy commissioner for beneficiary services, this velop faster, streamlined Medicaid enrollment systems as required will result in quicker and more accurate eligibility determinations under the Affordable Care Act, whether or not they intend to ex- for pregnant women, parents, ALL Kids and Medicaid children, pand Medicaid coverage under the law. and Plan First women.

Alabama Academy of Family Physicians 11 HHS Revises HIPAA Privacy Rule by Rich Sanders

The U.S. Department of Health and Hu- ZIP codes and dates of birth. Under the the Final Rule), and by providing a copy of man Services published in the Federal revised definition, an impermissible use the revised notice in its next annual mailing. Registrar on January 25, 2013, the HIPAA/ or disclosure of such limited data sets is HITECH Act Omnibus Final Rule. The Fi- presumed to constitute a breach unless the IV. Penalties nal Rule, effective March 26, 2013, modi- covered entity or business associate is able The Final Rule increases the maximum fies the requirements of the HITECH Act to demonstrate there is a low probability penalty for a violation up to $1.5 million Breach Notification Rule and the HIPAA that PHI has been compromised. per violation. Privacy, Security and Enforcement Rules. Covered entities will be required to com- II. Business Associates V. Sale of PHI ply with most provisions by September 23, and Contractors Also included within the Final Rule is a 2013. For covered entities and business Under the Final Rule, business associates prohibition on the sale of private health associates, they will have an additional and contractors are now required to com- information without prior patient consent. year to restructure their business associ- ply with the HIPAA Security Rule. The ate agreements to comply with the Final Final Rule provides a transition period of VI. Marketing Rule. Below, we have summarized the an additional year for business associate key provisions of the Final Rule. The Final Rule has created dramatic agreements that are currently in existence changes to the marketing and fundrais- to come into compliance with the Rule. For I. Breach Notification Rule ing requirements. The rule requires that example, business associate agreements covered entities must obtain authorization The Final Rule revises the definition of a that existed prior to January 25, 2013, and before sending patients treatment or health “breach” and the standard for determin- that are not renewed or modified during the care operations communications related to ing whether patient notification is required. period from March 26, 2013, to Septem- a company or product that the covered en- Previously, a covered entity or business as- ber 23, 2013, should be revised to comply tity receives compensation. sociate was not required to notify patients with the Final Rule by the earlier of two of a breach of unsecured protected health dates: (1) the date on which the agreement VII. Disclosures to Health Plans information (PHI) if it determined, in good is renewed or modified; or (2) September The Final Rule modifies the previous Ge- faith, that the breach would not result in a 22, 2014. Business associate agreements netic Information Nondiscrimination Act, significant risk of harm to the patient. The that contain automatic renewal provisions which prohibits health plans from disclos- Final Rule replaces the “harm” threshold without any additional change in terms do ing genetic information for underwriting with a “probability of PHI being compro- not trigger the earlier deadline. mised” threshold. The Final Rule states that purposes. It allows patients to pay cash for any use or disclosure of unsecured PHI not a visit, for treatment or for a procedure. If III. Revised Privacy Notices the patient does this, he or she may instruct permitted under the HIPAA Privacy Rule is HHS has revised the Privacy Notices sec- presumed to be a breach requiring patient the covered entity not to share the informa- tion of the Privacy Rule to require pro- tion with the patient’s health plan. notification unless the covered entity or viders to include additional information. business associate demonstrates that there is The Privacy Notices must now grant the VIII. Conclusion “a low probability that the protected health recipient the right to receive the breach This new rule issued by HHS will work to information has been compromised.” notification. The revised notices must also strengthen the privacy and security protec- restrict health plans from using genetic in- tion for health information. It also has sig- When determining whether there is a low formation for underwriting purposes. In nificant revisions to forms that health care probability that the PHI has been com- addition, covered entities must also obtain providers use on a daily basis, however, and promised, covered entities must take into patient authorization before using PHI for should be addressed very soon in order to account the following four factors: (a) the marketing purposes and before selling PHI. nature and extent of the PHI involved; meet the deadline of September 23, 2013. (b) the unauthorized person who used the The revised privacy notices instituted under Rich Sanders is president of the Sanders Law PHI or to whom the PHI was disclosed; (c) the Final Rule are considered to be material Firm, P.C. with offices in Atlanta, Birmingham, whether the PHI was actually acquired or changes by OCR. Thus, covered entities will Montgomery and Jacksonville. The firm provides viewed; and (d) the extent to which the risk need to provide a revised Notice of Privacy high-quality, affordable legal services to health to the PHI has been mitigated. Practices to individuals. Health plans may care providers and can assist with compliance provide the revised Notice of Privacy Prac- under the Final Rule. Rich can be reached at In addition, the Final Rule revises the defi- tices by prominently posting the revised [email protected]. nition of a “breach” to remove the excep- notice in its office or on its website prior to tion for limited data sets that do not contain September 23, 2013 (compliance deadline for

12 The Scope of Family Medicine “From the President,” continued from page 5 livery.3 Medicare, Medicaid and now private insurers such as Blue Cross of Alabama are rapidly moving to reward this type Congratulations! of care.

Medical schools have been forced to respond to the challenges outlined in this report. Both of the allopathic schools in Ala- bama have retooled their entire curriculum as a result, reduc- ing the hours dedicated to “basic science” instruction. They introduced team-based learning, early patient experiences and lifelong learning techniques. The emphasis of the curriculum at both schools is on developing the skills necessary to practice medicine in the future.

Family medicine residencies have been at the forefront of pro- viding instruction in the skills necessary to practice in the PCMH. Our Alabama residencies are leaders in the introduc- tion of information technology into their setting, providing training in a team-based environment and in implementing practice-improvement initiatives. Our training programs are Congratulations to Matthew Caldwell, MD, for being rapidly moving toward becoming PCMH-certified. the 2012 Stan Brasfield, MD, Scholarship recipient for resident members. Dr. Caldwell is a past president of the It is now time for our Academy to step up to the plate. Physi- ALAFP Student Chapter and is currently a first-year resi- cians currently in practice, who perhaps trained in the previous, dent at the UAB Huntsville Family Medicine Residency dated system but intend to be in practice through 2020, will Program in Huntsville, Alabama. need skills in practice-based improvement. She or he will need to leverage technology to provide the best patient care possible. He or she will need to practice in an environment where the culture of the patient is honored. All will need to deal with un- certainty and constraints on resource utilization. In short, we will need to be able to lead the PCMH. Change will not be easy, but it is inevitable.4

To offer support to this young physician group, the Academy is going to offer learning opportunities to develop skills to lead the PCMH. Beginning in June in conjunction with the summer meeting, we are going to provide a vehicle for ongo- ing instruction to those who feel that they want to practice using the precepts of the patient-centered medical home but who are lacking the training or experience to do so. Whether you are young or merely young at heart, I encourage you to take advantage of these opportunities. Once you use a CLASSIFIED stethoscope, there is no going back.

References BIRMINGHAM: 1. Duffy, T. The Flexner Report – 100 years later. The Yale Journal of Biol- The Alabama Disability Determination Service (DDS) ogy and Medicine, 84(3), 269-276. 2011. 2. American Medical Association. Initiative to Transform Medical Educa- invites letters of interest from family physicians wanting tion: Recommendations for Change in the System of Medical Education. to work part-time as a medical consultant. The work is re- Chicago, Ill: American Medical Association; 2007. 3. Patient-Centered Primary Care Collaborative (PCPCC). Joint Prin- viewing disability claims. An Alabama Medical License is ciples of the Patient Centered Medical Home. www.pcpcc.net/node/14. required. The DDS is committed to maintaining a diverse Accessed Feb 16, 2013. 4. Nutting P, Miller W, Crabtree B, Jaén C, Stewart E, Stange K. Ini- workforce; and therefore, we encourage minority ap- tial lessons from the first national demonstration project on practice plications. If interested, please contact the Medical Staff transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3):254–260. Supervisor, DDS, Post Office Box 830300, Birmingham, Alabama 35283-0300.

Alabama Academy of Family Physicians 13 Locum Tenens and Permanent Jobs for Physicians 1.888.892.4DRS

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14 The Scope of Family Medicine Alabama Academy of Family Physicians 15 Alabama Academy of Family Physicians 19 South Jackson Street Montgomery, AL 36104

Save the Date! Annual Meeting and Scientific Symposium June 20-23, 2013

Sandestin Golf and Beach Resort, Destin, Florida

To register, please visit www.alabamafamilyphysicians.org.