Tuscaloosa Family Medicine - Clinical Pearls

Resident match data: How the numbers add up

Resident match data: How the numbers add up

• The NRMP reports that over 35,000 applicants participated in the Match! 
• The big news this year is that 9%  more medical students are entering family medicine residencies than in 2009. Of the 2,608 family medicine slots available, U.S. seniors filled 1,169 of those positions, compared to 1,071 in 2009, according to a NRMP press release.
• Internal medicine and pediatrics also had more positions filled by U.S. medical school seniors. Three percent more U.S. seniors matched into internal medicine this year compared to 2009. The number of U.S. seniors entering pediatric programs increased by 2%.
• The number of non-U.S. citizen international medical graduates (IMG) declined this year by 238. This is the first time since 2002 that a decline occurred. However, the number of U.S. citizen IMGs increased by 305 over 2009 numbers. A total of 10,941 IMGs participated in the Match, but the percentage of  IMGs who matched declined this year. Only 47 percent of U.S. citizen IMGs and 40 percent of non-U.S. citizen IMGs matched to first-year positions, according to the NRMP.
• Neurological surgery, orthopaedic surgery, dermatology, and otolaryngology were the most competitive fields for applicants, with at least 90% of the slots filled by U.S. seniors.
• A record-breaking 808 couples participated in the Match this year. Of those, 730 both matched to their respective preferences, the NRMP reports.

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AAFP on Health Care Reform 2010

AAFP Health Care Reform Summary Page

Important Message From the President of the AAFP:

Now that the health care reform legislation has passed, we must look to the future -- for your practices, for your patients and for yourselves.  We consider this legislation a platform upon which to build other needed system changes, as called for in the Future of Family Medicine Project.  We are working on additional reforms with Congressional leaders, including increased bonuses to narrow the pay disparity between the family physicians and the sub-specialists, a permanent SGR fix, changing the mechanism for funding family medicine residencies, increased malpractice reform initiatives, and many others. 

Whether you are disappointed or overjoyed, we have heard from you and of your views about what the new law means going forward.  The AAFP has already begun to provide information for you to use in your practices and with your patients to understand what the system changes mean.  For background on the legislation and how it will impact a variety of audiences and issues, go to this new page on the AAFP web site. There you will find a timeline outlining when different aspects of the law will take effect and how you may need to prepare for or take advantage of these opportunities. We will continue to update you on specific issues via email messages, AAFP News Now articles, and other communications.

Regulatory changes will be the next phase and will likely last for two or more years.  Be assured that AAFP will continue to shape, monitor, and communicate details of these changes.  Examples include how the Innovation Center, which will house the Patient-Centered Medical Home pilots, will shape a new payment methodology for family medicine.  The Primary Care Extension Program is another instance of future programs that will be developed to help family doctors, but the current law only sets the framework not the details.  Your AAFP leadership has already been in conversations with the Administration and HHS officials about where and when the AAFP may provide the family medicine perspective to these regulations now being developed. 

As you know, the AAFP has advocated for health care reform for more than 20 years.  The AAFP Congress of Delegates has refined and reaffirmed our health care reform policy over the years and the Board of Directors has implemented that policy.  And now, the AAFP will be here to help as you incorporate and put in to practice various facets of the new legislation.

While it may seem a formidable task, we believe family physicians are perfectly poised to lead in a health care system focused on providing the best care possible for the people of the United States. And your Academy is here to help you do just that.

Regards, 
Lori Heim, MD, FAAFP 
AAFP President

Health Care Reform 2010 - the Reconciliation Bill

From the New York Times:

To avoid the threat of a filibuster by Senate Republicans, Democratic leaders are planning to pass health care overhaul in a three-step process. Under this plan, the House would pass the health bill approved in December by the Senate, and both chambers would approve a separate package of changes in a budget reconciliation measure, which could be adopted by a simple majority. A look at key provisions of the Senate bill and the changes proposed in the reconciliation bill unveiled Thursday:

Proposed Changes in the Final Health Care Bill (NYT / WaPo)

Read the Bill (153 pages)

The vote is anticipated to be this Saturday, 03/20/2010

Health Care Reform - 11/07/2009 - HR 3962

Many of you have heard that HR 3962 ("Affordable Health Care for America") passed yesterday in the House 220-215.

The summary of the bill (NYTimes) is copied/linked at length below, as is a PDF of the bill.

This is both a historic piece of legislation in and of itself... and also one that, if merged with a future Senate Bill and signed by the President, will have a significant and immediate impact on your profession and your patients fairly immediately. 

I have attempted to compile some useful articles and resources here:

Status of Health Care Legislation (NYTimes)

Interactive Timeline of Health Care Policy and Reform (New England Journal of Medicine)

Interactive PDF of HR 3962 (NYTimes)

Where Things Stand Now (NYTimes)

Frequently Asked Questions (NYTimes)

Other Recommended Resources:

• AAFP News Now (essentially mandatory for Family Docs) - http://ow.ly/Avye
• NYTimes Prescriptions Blog - http://prescriptions.blogs.nytimes.com/
• NEJM Health Care Reform - http://healthcarereform.nejm.org/
• AMA Health Care Reform - http://www.hsreform.org/

Comparison of the Various Health Care Proposals (NYTimes) - HR 3962 info is copied below...

Individual Mandates: Require nearly all Americans to have a minimum level of health insurance or pay a penalty. (http://ow.ly/Avkn)

• Would include mandate.
• Penalty: 2.5 percent of adjusted gross income over a certain level, which is $9,350 for singles and $18,700 for couples.
• Exempt those with incomes below the above-mentioned thresholds, American Indians, people with religious objections and people who can show financial hardship

Employer Contributions: Some kind of requirement for employers to contribute to the cost of coverage for some or all of their employees. (http://ow.ly/AvkS)

• Would require employers with annual payrolls of $500,000 or more to provide health insurance or pay a new federal tax.
• Employers would have to contribute at least 72.5 percent of the premium cost for individuals and 65 percent for families for the lowest cost plan that meets the minimum benefit requirements set by the government.
• Penalty: Up to 8 percent of wages in payroll taxes. Employers with payrolls of $500,000 to $750,000 would pay 2 percent to 6 percent of wages, and those with payrolls above $750,000 would pay the full 8 percent.
• Employers that offer health insurance must automatically enroll employees into the lowest cost plan available. But employees may opt out of employer coverage.

Insurance Exchange: Create a new health insurance marketplace, national or state, where people could shop for insurance and compare prices and benefits. (http://ow.ly/AvkY)

• Would create a national exchange. Allows states to opt out and operate their own exchange if they follow federal rules.
• Open to people who do not have qualifying coverage through an employer or a public program.
• Open to employers with 25 or fewer employees in the first year, 50 or fewer in the second year and 100 or fewer in the third year. The exchange could be expanded to larger employers over time, “with the goal of allowing all employers access.”
• Until the exchange is established, a temporary program would provide health coverage to “those who have been uninsured for several months or denied a policy because of pre‐existing conditions.”

Public Plan: Create a government-run insurance plan or nonprofit insurance cooperatives to compete with private insurers. (http://ow.ly/Avl3)

• Would create a new government insurance plan that would negotiate rates with doctors and hospitals, rather than using Medicare rates set by the government
• The public plan would have to offer different levels of benefits, covering between 70 to 95 percent of health care expenses.
• Like private plans, the public plan must offer the same benefits, comply with the same insurance market reforms, follow provider network requirements and other consumer protections. The plan would not provide abortion coverage.
• Health care providers would not be required to participate in the plan. But the bill assumes that providers participating in Medicare are participants of the public plan, unless they opt out.
• The government would allocate $2 billion in start-up money but the public plan must be financially self-sustaining. The bill would require premiums, paid by beneficiaries, to cover the plan’s cost. The government would also provide loans to start up non-profit insurance cooperatives to compete with private insurers and the public plan.
• The legislation would also create a public long-term-care program that would provide cash assistance — not less than an average of $50 per day — to people who become disabled. The program would be financed through premiums deducted from paychecks of people who choose to participate. Workers would have to contribute for at least five years before they can collect benefits.

Subsidies for Individuals: Provide credits to lower-income people to help them buy insurance. (http://ow.ly/Avl9)

• Would provide credits for premium costs and other health care expenses to citizens or legal immigrants who buy insurance through the exchange. Verification of legal immigration status would be required to receive subsidies.
• Households with incomes up to 400 percent of the federal poverty level ($88,200 for a family of four) would be eligible to receive premium credits, if they pay specified percentages of their income toward the premium. Premium contributions would range from 3 percent to 12 percent depending on the income. People with insurance from employers would be eligible for the credits if the cost of their premium exceeds 12 percent of their income.
• The proposal would also offer cost-sharing subsidies and reduce out-of-pocket spending limits for those under 400 percent of the poverty level.

Subsidies for Employers: Provide tax credits to help small-business owners who want to offer coverage. Subsidize employer-sponsored health plans covering early retirees. (http://ow.ly/Avlq)

• Would provide tax credits to employers with 25 or fewer workers and average wages of $40,000 or less.
• The credit would not be allowed for employees earning more than $80,000 a year. The amount, up to 50 percent of premium costs, phases out as firm size and average wages increase.
• Would spend $5 billion from 2013 to 2015 to subsidize employer-sponsored health plans covering early retirees ages 55 to 64. The federal government would cover 80 percent of the cost of a retiree’s medical claims of more than $15,000, with a cap at $90,000 — at which point the employer’s plan would pay the rest.

Expanding Medicaid: Expand Medicaid, the federal-state health program for low-income people, to cover millions of additional people. (http://ow.ly/AvlH)

• Would include all individuals with incomes up to 150 percent of the federal poverty level ($33,075 for a family of four). The program currently covers millions of low-income older Americans, people with disabilities, pregnant women, children and some parents. Childless adults are generally not eligible.
• The federal government would pay all the costs for those who are newly eligible for the first two years and 91 percent of the costs after that.
• The legislation would end the Children’s Health Insurance Program, which benefits children of the working poor. Children with family incomes up to 150 percent of the poverty level would receive coverage through Medicaid. Families with higher incomes would receive subsidies to buy coverage through the exchange.

Defining Benefits: Require insurance plans to offer a minimum package of health insurance benefits, to be defined by the federal government. (http://ow.ly/AvlO)

• Would require the basic benefits package to cover 70 percent of the health care spending covered by the plan. Consumers would pay the remainder, in deductibles, co-payments and other charges. The plan would cap out-of-pocket health care spending to $5,000 for an individual and $10,000 for a family.
• Insurers could choose to cover or not cover abortion as they see fit. But people who receive federal subsidies to buy insurance cannot choose a plan that includes abortion coverage. Federal tax dollars can only be used for abortion as allowed by current law, in case of rape or incest or if the life of a pregnant woman is in danger.
• Insurers could not deny coverage because of a person’s pre-existing conditions. Variation in premiums is limited. Maximum difference in premiums based on age is 2 to 1 (for oldest group, compared with young adults).
• The legislation would also revoke the exemption from federal antitrust law that health insurance companies have long enjoyed. It would outlaw price-fixing, bid rigging and “market allocations” by companies that sell health insurance or medical malpractice insurance.
• Insurance plans covering children and their parents would have to continue “dependent coverage” for children through age 26. Rules and age limits for dependents under employer plans currently vary by state.
• Besides the basic plan, the legislation would create three other levels of coverage to be offered through the health insurance exchange, covering up to 95 percent of costs. The Congressional Budget Office says the actuarial value of policies bought in the individual insurance market now averages 55 percent to 60 percent.

What It Will Cost: Estimated 10-year cost. (http://ow.ly/Avm7)

• About $1.05 trillion, according to the Congressional Budget Office, to provide coverage to 36 million people. The costs would be fully offset by cuts in the growth of Medicare and by new fees and taxes. The bill would reduce projected federal budget deficits by $104 billion over 10 years.
• Earlier versions of the bill in the House included provisions to avert cuts in Medicare fees to doctors, scheduled to occur under existing law. Those provisions, which would cost more than $200 billion over 10 years, were put into a separate bill.

Raising Revenue: Increase taxes for wealthier households. (http://ow.ly/AvmU)

• Would raise $460 billion over 10 years by imposing an income surtax on high-income people — couples with adjusted gross incomes over $1 million a year and individuals over $500,000 — at a rate of 5.4 percent.
• Would raise about $100 billion with various other revenue provisions, which include a 2.5 percent excise tax on the medical devices sold for use in the United States, a $2,500 cap on contributions to health care flexible spending accounts and elimination of the tax deduction for employers who receive federal subsidies for providing retiree prescription drug coverage.

Cutting Costs: Reduce health care spending, especially on Medicare. (http://ow.ly/Avn9)

• Would raise more than $400 billion over 10 years by trimming Medicare payments to hospitals and most other health care providers. Cut nearly $200 billion in subsidies for insurers that offer the elderly private plans through Medicare Advantage. (The government pays about 14 percent more for the private plans than it would pay for the same people in traditional Medicare.) Demand better prices from drug makers participating in Medicare and Medicaid.
• The Institute of Medicine at the National Academy of Sciences would conduct two studies and recommend changes to the current Medicare reimbursement system. In the first, the institute would analyze geographical disparities in Medicare rates and send recommendations to be implemented by the secretary of health and human services. The other would assess whether to tie Medicare payments to quality of care. Those recommendations would be subject to a vote in Congress.

(Again, giving credit... the above was copied from 11 different pages of the New York Times.)

Family Physician from Alabama picked to be U.S. Surgeon General

By LAURAN NEERGAARD, AP Medical Writer

WASHINGTON – The Associated Press has learned that President Barack Obama has chosen a well-known Alabama family physician, Dr. Regina Benjamin, to be the next surgeon general.

An administration official said Obama will announce the nomination later Monday. The official spoke on condition of anonymity so as not to upstage the official announcement.

Benjamin was the first black woman to head a state medical society, received the Nelson Mandela Award for Health and Human Rights and just last fall received a MacArthur Foundation "genius grant." But she made headlines in the wake of Hurricane Katrina, with her determination to rebuild her rural health clinic Bayou La Batre, Ala., which serves 4,400 patients who would be hard-pressed to find care elsewhere.

Physician Assistants and Nurse Practitioners

... from MASA / AlaPAC Rotunda on May 18th... 

---

PA’s Prescriptive Bill Becomes Law

The MASA and physician assistant-backed bill allowing physician assistants (PA’s) in Alabama to prescribe Controlled Substances Schedules III-V under the supervision and approval of a doctor was signed into law by Gov. Riley Wednesday.

“This law allows PA's to better assist physicians as we work toward improving high quality, accessible healthcare for all Alabamians,” MASA President Dr. Jorge Alsip said.

The bill was sponsored by Senate Health Committee Chairperson Senator Linda Coleman (Birmingham) in the Senate and House Health Committee Member Representative Ron Johnson (Sylacauga) in the House of Representatives. 

“This legislation will help ensure cost-effective, quality health care for Alabama residents, especially in medically underserved and rural areas,” Wendy Cornelius, President of the Alabama Society of Physician Assistants, said.

Nurse Practitioner Bill Dies in Committee

The Nurse Practitioners Alliance of Alabama bill that would have abolished the longstanding collaborative practice model in Alabama never made it out of the Senate Health Committee, and now that the 2009 Regular Session is over, the bill is dead.  The bill would have allowed nurse practitioners to prescribe controlled substances without the supervision of a physician and would have given regulation and licensing over this new expansion of authority to the Board of Nursing.

A MASA ad hoc committee formed last year to study the best practices of other states recommended that nurse practitioners be allowed prescriptive authority for controlled substances Schedules III-V only under the supervision of a collaborating physician.  The recommendations of the ad hoc committee however, were refused.

"We're disappointed The Nurse Practitioner Alliance of Alabama rejected efforts to enact legislation that would have allowed nurse practitioners expanded prescriptive authority within the collaborative practice model," MASA President Dr. Jorge Alsip said. 

Claritin and Schering-Plough: A Prescription for Profit

Classic NYT expose of the pharmaceutical industry and the FDA from 2001. If you've never read it, you really owe it to yourself to take the 10 minutes and read it.

Vitamin D restrictions on testing coming

According to AAFP Advocacy, a multiregional Medicare Contractor is proposing (ridiculous) restrictions on Vitamin D Testing. "The Academy recently called on a Medicare contractor with operations in 16 states to be more inclusive in its list of acceptable medical conditions for coverage of vitamin D assay testing."

In a Feb. 16 letter, AAFP Board Chair Jim King, M.D., of Selmer, Tenn. said, "it appears that the draft LCD (local coverage determination) is based upon sound medical practice from the 1980s, not the 21st century." 

According to the draft LCD, measurement of vitamin D levels is only indicated for patients with

• chronic kidney disease,
• osteomalacia,
• hypercalcemia or
• rickets.

Stay tuned....

 

Birmingham News 11.28.08: Carraway medical residents quickly find avenues to continue their studies

Carraway medical residents quickly find avenues to continue their studies

The medical residents at Physicians Medical Center Carraway - who had virtually no notice they would lose their jobs before the hospital filed for bankruptcy Oct. 20 - have found new training facilities, according to hospital officials.

But the process was far from painless, and at least a third of the 59 doctors in training left Alabama to continue their residencies.

The residents had to find hospitals with accredited medical-education programs that either had open spots or were able to create space on short notice. Physicians Carraway had four residency programs, in surgery, internal medicine, family medicine and transitional year.

One of Physicians Carraway's family medicine residents has to wait until May before she can resume her work because the program she is going into does not have room for her until then.

Some of the medical residents were only months away from completing their training. Others had almost five years to go. Of the 59, 26 were able to land positions in Birmingham, at Baptist Health System or UAB Hospital, according to officials at Baptist and the University of Alabama at Birmingham. Others had to leave the city or state, which meant in some cases uprooting family and selling a house.

"It was traumatic both for me and the residents," said Dr. Mary Gipson, who was associate director of the family-medicine residency at Physicians Carraway. "They were in my office every day as I made phone calls, as I pleaded."

Degrees of difficulty:

Family-medicine residents were among the most difficult to place. The program directors over surgery, internal medicine and transitional year had an easier time, but even they report spending hours on the phone for two or three weeks securing spots for their residents.

"I put my heart and soul into training residents," said Dr. Raleigh Kent III, over the surgery residency. "My one relief in all this was that we got them all placed. They all got jobs."

Physicians Carraway transferred its final patients to other hospitals by Oct. 22, and all of the hospital's 1,000 employees have lost their jobs. Employees were paid for the time they worked but not for their accrued vacation.

The closure of Physicians Carraway's medical-education program was not only a hardship on the residents, but also bad news for Alabama. Physicians Carraway had the longest-operating graduate medical education program in the state, and most of the doctors trained there remained in Alabama to practice. The state is woefully short of doctors in rural areas and in some inner cities.

With Physicians Carraway's demise, the state almost certainly will lose the hospital's federally approved and funded education slots. Getting more spots approved and paid for at other programs in the state is unlikely.

"Alabama just lost all of these slots and there's nothing we can do about it," said Dr. Elizabeth Ennis, Baptist Health System's vice president of medical education and research.

Ennis said doctors who complete their residencies here tend to come back to Alabama, even if they get further specialty training elsewhere. Baptist tried to salvage something out of Physicians Carraway's shutdown by taking as many of the residents as possible, she said.

"We realized that if we lost these residents, Birmingham and Alabama's health care would suffer and we would lose some newly trained doctors who otherwise would have practiced in the state," Ennis said.

Baptist took on the most Physicians Carraway residents, adding 18 to its existing program of 82. Baptist, which trains residents at Princeton Baptist Medical Center and Trinity Medical Center, did not have the open spots but implored supervising physicians to take on more.

"It really is a huge undertaking to be able to absorb these doctors with no fiscal planning, she said. "We've pressed people into additional service."

Dr. Hernando Carter, in his final year of an internal-medicine residency, landed at Baptist and was able to start there just two weeks after Physicians Carraway closed. He said he and others sweated those intervening weeks.

"There was a sense of urgency and panic," Carter said. "We knew we had to get on the phone immediately and find a place."

Carter's wife is a physician at Cooper Green Mercy Hospital and they're expecting their second child in January. "Being separated from family was a real concern for me."

Insurance woes:

The residents also learned that Physicians Carraway's bankruptcy meant they were on their own to find malpractice insurance to cover them for their time at the hospital. Usually, the teaching hospital provides the needed insurance after residents leave.

Ennis said Baptist worked hard to find a carrier who would provide the coverage but the residents had to pay from $1,314 to almost $11,000 out of pocket, depending on their specialties and how long they had been in the program.

UAB Hospital took eight of the displaced residents, according to UAB officials. The Tuscaloosa Family Medicine Residency at the University of Alabama, based at DCH Regional Medical Center, took five residents and wanted to take more, said Dr. John Waits, the residency director.

"We really only had room for one resident, but we created room, feeling like this was a service to the state," Waits said.

Waits said he would like to increase the program's number of slots permanently because Alabama desperately needs more primary-care physicians. But the federal freeze on residents' spots makes that unlikely. In the past several years, Waits said three of the state's family-medicine residency programs have closed - at UAB, in Anniston and now at Physicians Carraway.

"It's really a travesty," Waits said. "There has been a freeze on new training spots for over a decade despite the primary-care shortage."

Gipson, who struggled to place Physicians Carraway's family-medicine residents, said she was disappointed in the state's other family-medicine programs' efforts to help, with the exception of the Tuscaloosa program. Two other family-medicine residents got slots in Alabama, but seven of the 14 went out of state, Gipson said.

"We basically lost seven primary-care physicians who likely would have stayed in state to practice," she said.

Gipson said she was blindsided by the hospital's closure because it had survived other financial problems and because hospital leaders had told her just two weeks earlier to start recruiting next year's residents.

"I didn't see it coming," Gipson said. "I had been through so many things with Carraway over the years."

Dr. Hugh O'Shields, program director over Physicians Carraway's internal-medicine residency and one of the hospital's physician owners, said he was sorry about how the residents ended their experience at Physicians Carraway but was relieved that all found placement.

"They were justifiably angry at what had happened," O'Shields said. "Given the circumstances, though, I think everybody came out fairly well."

E-mail: avelasco@bhamnews.com

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