v o l u m e 9 8 • n u m b e r 7 • j u l y 2 0 1 2

I n t h i s i s s u e :

DCMS Spring Celebration Picnic - Photos from the event

Business of Medicine - Ensuring an Adequate Healthcare Workforce

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submit letters to the editor to lauren@dallas-cms.org

About the Cover PhotoAs candidate for speaker of the TMA House of Delegates, Clifford Moy, MD, speaks to physicians at TexMed 2012, held in Dallas on May 18 and 19. Drs. Carolyn Evans and Robert T. Gunby Jr. accompanied Dr. Moy on his visits with the caucuses.

123 President’s Page Ich bin ein Parklander

127 Congratulations DCMS Members Elected to TMA Leadership

129 DocBookMDTM Join the Mobile Revolution 130 DCMS Spring Celebration Picnic

133 Business of Medicine Ensuring an Adequate Healthcare Workforce

139 Texas’ Grand Medicaid 1115 Waiver What to Expect when the Medical World Shifts

Dallas County Medical SocietyPO Box 4680, Dallas, TX 75208-0680Phone: 214-948-3622, FAX: 214-946-5805www.dallas-cms.orgEmail: lauren@dallas-cms.org

DCMS Communications CommitteeRoger S. Khetan, MD ............................................. ChairRobert Beard, MD Gene Beisert, MDSuzanne Corrigan, MDSeemal R. Desai, MDDaniel Goodenberger, MD Gordon Green, MD Steven R. Hays, MDC. Turner Lewis III, MDDavid Scott Miller, MD

DCMS Board of DirectorsRichard W. Snyder II, MD ................................. PresidentCynthia Sherry, MD .................................President-ElectJeffrey E. Janis, MD .........................Secretary/TreasurerShelton G. Hopkins, MD ......... Immediate Past PresidentMark A. Casanova, MDWendy Chung, MDR. Garret Cynar, MDSarah L. Helfand, MDMichael R. Hicks, MDRainer A. Khetan, MDTodd A. Pollock, MDKim Rice, MDChristian Royer, MD

DCMS StaffMichael J. Darrouzet .................. Chief Executive OfficerLauren N. Cowling ............................... Managing EditorMary Katherine Allen ..........................Advertising Sales

Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2012 DCMS

According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish leg-islative advertising in the DMJ: Michael J. Darrouzet, Ex-ecutive Vice President/CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680.

Dallas Medical Journal(ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.

Subscription rates$12 per year for members; $36, nonmembers; $50, overseas. Periodicals postage paid at Dallas, TX 75260.

PostmasterSend address changes to:Dallas Medical Journal, PO Box 4680 Dallas, TX 75208-0680.

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v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • J u l y 2 0 1 2 • 1 2 3

President’s Page

Richard W. Snyder II, MD

Recently, I performed what I consider to be my most enjoyable duty as president of the Dallas County Medical Society. Like so many presidents of the society before me, I administered the physician’s Hippocratic Oath to the graduating class at the University of Texas Southwestern Medical School. For me it was an emotional, almost surreal, trip down memory lane as I had taken the same oath with my graduating class at UTSW almost 25 years ago to the day. However, unlike the sweltering hot environment of the outside concourse by the campus administration building, where the ceremonies had traditionally been performed (until 2009), this ceremony was held inside the beautiful and air-conditioned Meyerson Symphony Center in downtown Dallas.

Upon my arrival, I was given a packet of information and told I would be seated with eight other individuals. So far, so good. However, I was completely unprepared for what happened next. As the ceremony started, we began to march. We marched up the stairs ... and onto the stage ... and sat on the front row! At the Meyerson! It was a packed Meyerson at that! Let me tell you, those lights are bright! All right, I thought to myself, I was Parkland trained. I could handle impromptu, unexpected, pressure situations like this.

As UTSW President Dr. Daniel Podolsky, the master of ceremonies, began his comments, he informed the audience that he would like to introduce some special people in the audience, and have them stand one by one as he recited a brief biography. Yes, you got it! He was going to be talking about the eight of us in the front row! This is the moment my Parkland training failed me; I was completely unprepared. Looking down the row, I immediately knew this was not good. It looked like a murderer’s row for overachievers. I was No. 7. Numbers one through six were seated in this order: Kay Bailey Hutchison, US Senator; Dr. Johann Deisenhofer, Nobel Prize winner; Dr. Bruce Beutler, Nobel Prize winner; Greg Fitz, MD, UTSW Executive Vice President for Academic Affairs, Provost and Dean; Linda Hart, Vice Chairman and CEO of The Hart Group, and Southwestern Medical Foundation Board of Trustees; Kern Wildenthal, MD, PhD, former UTSW President and currently President and Chief Executive Officer of the Southwestern Medical Foundation; and then little ol’ yours truly. For those of you wondering, UTSW now boasts five Nobel Prize winners, more than any other medical school in the world. I am just thankful the other three weren’t up there on stage, as well. Sitting directly behind us facing the audience were numerous other legendary faculty members

and members of the National Academy of Sciences who were not individually introduced. Talk about a mismatch. Now I know what a fish out of water feels like.

However, as the ceremony progressed, my insecurity quickly dissipated and I was rapidly immersed into the excitement of this special event. As I sat there, the quiet acoustic perfection of the

Meyerson was shattered by the obligatory shouts of “way to go,” and “we love you,” from proud and ecstatic family members as each student’s name was announced. Watching from a few feet away as the graduates received their diplomas, their overflowing enthusiasm, eagerness and youthful exuberance was palpable. As they descended the stage one by one, now as doctors, their exuberant smiles were infectious and electrifying, almost like shock therapy. For me, a physician of 25 years who has been tarnished, as most of us have, by the cynicism and pessimistic harsh realities found in our profession, what I witnessed was both therapeutic and rejuvenating. Every physician should attend a med school graduation ceremony and be transported back to that moment when we were full of unlimited energy, hope and innocence, and bathe in their optimism like manna from heaven.

After each name was called, images of my own former classmates flashed through my head — guys like (Drs.) Sam Chantilis, Joey Peterman, Baron Hamman, Trey Herndon, and Drew Dossett (which reminds me ... Drew, you still owe me money for all of those Notre Dame victories over USC during med school and residency). The faces of senior resident mentors and friends under whom I served on the wards back then and who had a profound influence in shaping the course of my medical career, such as Nina Butwell-Radford and Brent Glamann, came into clear focus. Other memories of former professors and intense morning rounds at Parkland danced around in my mind. Many of these individuals are the “giants” we often speak of during lunchroom chatter. Before the ceremony began, I was reunited with several of these former giants who were then, and still are, my heroes, such as Drs. Don Seldin (affectionately, “The Don”), Dan Foster, Wes Norred, Chuck Ginsberg, and Kern Wildenthal — all icons of medical education excellence. I also was reacquainted with several former senior residents who are now anchors of the medical school and Parkland, such as Drs. Jim Wagner and Jay Shannon. (Don’t worry guys; for the right price, your secrets are safe with me!)

During the rather lengthy ceremony (227 graduates), I began to recall my own “glory days,” as Bruce Springsteen calls them. Visual echoes buzzed in and out of rounding on the wards of Parkland (affectionately referred to as “The Lands” to those who trained there) and the medicine ER (less so as “The Pit”). In a series of flashbacks, I relived a roller coaster of emotional highs and lows, those life-and- death moments that are reflected in the human condition as moments that touch one’s soul, especially in a teaching hospital, especially at Parkland. I still get chills remembering the sheer awe of the Parkland experience. Today, most of us, when asked where we did our training, will answer with pride, “at Parkland,” just as readily as we reply “Southwestern.” That is simply the prestige that both Parkland and UTSW have in the academic and medical communities worldwide. The two are so intertwined that they are almost like inseparable Siamese twins. Parkland training carries with it a brand of excellence that is the envy of the nation. The name Parkland often is received by those not fortunate enough to have trained there with a bow of acknowledgment and respect. It’s

“Ich bin ein Parklander”

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President’s Page

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almost legendary amongst academic and medical training institutions. I still remember how we would exchange our two chief residents with two from Brigham and Women’s Hospital (a teaching affiliate of Harvard University) for 2 weeks on a yearly basis, and how overwhelmed the two from Boston would seem after witnessing the depth of knowledge of our students and residents, and, of course, at the complexity of our morning report. The broad spectrum, breadth and acuity of diseases that one cares for at Parkland are difficult to rival nationwide. In very few places is one exposed to the end stage of so many disease processes, and in fewer places are those patients treated with as much expertise and compassion, as well.

It is not just North Texas patients who benefit from the depth of training that takes place at Parkland. In 1986 I treated a few Afghan refugees from the Soviet invasion. They were transferred halfway around the world to Parkland for excellence in burn management. In fact, the gold standard fluid management protocol for burns is called the “Parkland formula.” I also recall how patients requiring dialysis from Monterey, Mexico, would arrive with hand-drawn maps with directions to Parkland given to them by doctors in Mexico. The doors at Parkland were open to all those who came. It was an island of hope for those desperately seeking help — a veritable Ellis Island of health care.

To have one’s medical training pedigree include Parkland carries with it the same prestige as attending an Ivy League school. Parkland. There is certain magic in the sound of the name. It is uttered with awe, demanding respect. Those of us who served there in the trenches say it with pride.

Thus, it is with sadness that I have witnessed the negativity

in the press directed toward Parkland over the last 18 months. It is truly painful to those of us who once called Parkland home. Is Parkland a perfect institution? Well, of course not. No place is perfect. It certainly is not infallible. Are there mistakes made there? Sure, just as there are at most major hospitals. Are there systemic deficiencies that need improvement and that would benefit from a corrective action plan? Yes; however, the incessant and scathing criticism by the local newspaper toward Parkland is not the manner in which to bring positive reform and change. The execution of the well-publicized corrective action plan is underway, so the seemingly unending attacks are unnecessary. During my training days at Parkland, the No. 1 rule taken from the Hippocratic Oath that was drilled into us almost daily was, “Above all, do no harm.” It was recited regularly, almost fanatically. This is still Parkland’s No. 1 goal, but each day with very limited resources Parkland takes on a very difficult task of providing health care to the underserved and most vulnerable of our community, a progressively growing group. Almost 36 percent of Dallas County residents are currently uninsured and 100 percent bed occupancy is not unusual at Parkland. One of the major obstacles Parkland faces is that it has serious manpower issues and is chronically understaffed. For the newspaper to “serve the community” by pointing out deficiencies and systemic errors that need correction is one thing, perhaps even admirable. But, to level unending personal and institutional attacks by using vitriolic, over-the-top rhetoric is another. That does not serve the goal of correction. The bias is obvious and isn’t exactly a fair and balanced approach. It seems that Parkland has been particularly targeted, for some unclear reason. It almost

makes one question the agenda of the editors (Pulitzer Prize, headline-grabbing sensationalism, circulation enhancement, etc.).

The damage of this approach taken by the newspaper is substantial and serves as a major contributing reason I cancelled my print subscription a while ago. The brilliant careers of Drs. Ron Anderson and Kern Wildenthal, who devoted decades to the betterment of the Dallas medical community and the underserved, have been dimmed. Continually dragging the reputation of this fine institution through the mud makes the task of executing the corrective action plan even more difficult. Significant numbers of ancillary staff and medical personnel are leaving Parkland because of the incessant barrage of negative media coverage, which makes the job of alleviating the dire manpower issues that much more daunting. There are even whispers by some that Dallas would be better served if Parkland were shut down in the name of quality. The problem with that argument is if you have no access, you definitely have the worst quality of care possible. It has been suggested that the remaining major county hospitals could pick up the slack. I am here to tell you that that is just not happening. For example, last year Parkland delivered 13,000 babies while the rest of the county hospitals delivered 26,000 collectively. You do the math.

Some would say I am biased. You’re darn right I am biased — and proud of it, as are most of the other physicians who have ever trained there. My love of medicine was initially sparked at Parkland while I served my required 100 community service hours as a Jesuit High School student. As a second-year medical student at UTSW, I remember going down to the ER on Friday and Saturday nights with some classmates to volunteer, as opposed to visiting the bars on Greenville Avenue, because we were so eager to start our Parkland experience. Altogether, I spent 9 years as a medical student, resident and fellow in those hallowed Parkland corridors. I also met my wife, Dr. Shelley Hall, while she was a medical student there. She also devoted 9 years to Parkland during the course of her training. So, for me it is a very special place.

But, Parkland is not just a place, a hospital or a system. It is not merely a building, with brick and mortar. It is the spirit of the much broader Dallas medical community that is embodied in all those who have ever served under its roof, physicians and nonphysicians alike. Parkland has left an indelible mark on the medical community and patients of Dallas. According to DCMS records, 40 percent of all physicians in Dallas County trained on some level at Parkland. To a larger extent, Parkland is the medical community of Dallas, not just those physicians who serve within the Dallas County Hospital District system proper. It was at Parkland that our compassion and respect for human dignity and life was forged. It was through the Parkland experience that our sense of integrity, collaboration, leadership, and excellence were given birth. These gifts are not only taught by those mentors we call professors and attendings. They are especially demonstrated in the lab techs and orderlies, transporters and janitors, administrators and nurses. But, most of all, they were taught to us by the patients themselves. Parkland is a medical jewel for the citizens of Dallas where miracles happen every day. The patients themselves are the ultimate teachers. Within Parkland is a unique symbiotic relationship where the patients are the teachers and the caregivers are the students.

As the very last of the 227 students received his diploma and descended the stage, I began to make my way to the podium, under those bright lights, to administer the physician’s oath. I realized, at that moment, that a new generation was entering the Parkland fraternity — a fraternity you really never leave. The pride and affection that we all share for Parkland and our Parkland heritage is one that is not and cannot be diminished by the biased attacks of the media.

Forty-nine years ago, just 5 months before he died, Parkland’s most famous patient found himself in an enclave of hope and democracy surrounded by an adversarial government and a thoroughly biased propaganda media machine. That patient gave an iconic speech, in a show of solidarity with the people of an isolated city. That speech is still recited today.

Borrowing from that famous patient, President John F. Kennedy, I too would like to declare, on behalf of myself and the Dallas County Medical Society, solidarity with Parkland in its dedication to the underserved of Dallas and its pursuit of quality by proclaiming loud and proud:

“Ich bin ein Parklander.”“I am a Parklander.”

The Physician’s OathI pledge the following as an expression of the spirit in which I strive to practice medicine:

To promote health and to relieve suffering in the living and the dying.

To approach all my patients with integrity, candor, empathy, and respect.

To honor the confidences entrusted in me.

To be a student and a teacher always, and to remain conscious of my limitations.

To place the welfare of the patients above personal gain, and to protect patients from improper care.

To respond always in an emergency.

To improve health care for the underserved, and to work to change those conditions in society that threaten the health of the community.

To withdraw from active practice when I am no longer capable of fulfilling these pledges.

To keep the promise of Hippocrates: “Above all, do no harm.”

I make these pledges solemnly, freely and upon my honor.

President’s Page

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Isn't it about time you focused more on medicine,

and less on administrative hassles?

D o you enjoy reading man-

aged care contracts? How

about completing multiple

applications? Do you know if you

are being reimbursed correctly?

Could a physician-operated IPA be

the answer?

What do you get out of SPA Membership? Contracting: SPA reviews

hundreds of pages of legal terms with

the cooperation of the health plan

and presents you with an objective

summary of the terms in a format

which is standardized. Then,

"SPA Compare" allows you

to analyze the fees offered

compared to local Medicare

and to other commercial

plans in a way that is customized

to your practice.

Operations: The contract

summary and SPA Compare may

easily be used by your collections

operation to be sure that you are

being paid properly under the

SPA Contract. SPA maintains

relationships with its contracted

health plans which help you receive

what you are entitled to under the

SPA Contract.

C r e d e n t i a l i n g : All SPA Contracts include

delegated credentialing and

recredentialing. This allows you

to contract with many plans by

completing only one application and

allows you to keep your credentials

updated with many payors through

only one entity.

Ancillary Services: SPA has

group purchasing rates for medical

supplies, medical waste disposal

and other services for SPA members.

This helps you to keep your overhead

Find out more about how we can help your practice at www.spa-dallas.com or call 214.346.6623 8150 N. Central Expressway • Suite 1250 • Dallas, TX 75206

PRACTICE MANAGEMENT

FACT: Physicians earn more money per hour in the clinic and the O.R. — practicing the skill of medicine — than they can playing accountant, coder or office manager. Delegation is the key of every successful business enterprise.

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DCMS congratulates Clifford Moy, MD, on his election as the Texas Medical Association Speaker of the House of Delegates and Don R. Read, MD, on his re-election to the TMA Board of Trustees. DCMS had a full delegation of 51 physicians to help elect Drs. Moy and Read at TexMed in May in Dallas.

Clifford Moy, MDDon R. Read, MDThe Voice of Reason

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Accountant (CPA) / Tax ServicesPaula Allgood, CPA……Beaird Harris & Co, P.C.972.503.1040……PaulaA@bh-co.com

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Design / Build Medical & Dental ContractorGrady Herzog……Structures & Interiors Inc.817.329.4241……gherzog@structures-interiors.com

Electronic Medical RecordsLeslie Warren……EMR Advisory Group972.898.5671……lwarren@emradvisorygroup.com

Employee BenefitsAmy Rickman……Lockton Dunning Benefits940.380.1245……ARickman@lockton.com

Financing / BankingGary West……BB&T469.791.4502……GMWest@BBandT.com

Financial / Estate / Insurance PlanningMark A. Trewitt, CFP®, CLU, ChFC, AEPIntegrated Financial Solutions Group972.312.1337……mark@ifsgllc.com

Healthcare FurnishingsLisa Locke……bkm Total Office of Texas, LLC214.902.7215……llocke@bkmtexas.com

Healthcare Interior DesignerLaura Ginsberg……Medical Space Design, Inc.972.566.6771…….lauraginsberg@msddallas.com

Linen / Laundry ServicesGary W. McDaniel……ImageFirst214.769.6677……gmcdaniel@imagefirst.com

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W. Darrell Armer*……Looper, Reed & McGraw, PC214.922.8923……darmer@lrmlaw.com*Board Certified-Health Law by The Texas Board of Legal Specialization

Marketing / Public RelationsBarbara Steckler……Concepts in Medical Marketing972.490.7636……barbarasteckler@yahoo.com

Medical Malpractice / Commercial InsuranceJames Patterson, CIC, AAI……Agapé Healthcare PartnersMetro 817.329.4200……jim@agapeins.com

OSHA ComplianceJessica James469.360.1367……jsscjames@aol.com

Personnel RecruitmentJan Harris, CPC……J. Harris Co. Personnel Services Inc.214.369.9545……j.harrisco@verizon.net

Practice Management / Billing / ConsultingDavid Loomis……The Health Group972.792.5700……dloomis@thehealthgroup.org

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v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • J u l y 2 0 1 2 • 1 2 9

Join the mobile revolution Read how your colleagues all over Texas are taking

advantage of the latest technology by using the DocBookMD™ app to securely send HIPAA-compliant messages directly from their iPad, iPhone and Android devices.

Case study

A patient arrives in the emergency department after injuring his toe while mowing his lawn. The ED physician determines that the wound can be treated with antibiotics and local care. He calls the on-call orthopaedic surgeon.

The ED physician describes the wound and what is shown in the X-rays to the orthopaedic surgeon. The orthopaedic surgeon is unsure of the diagnosis, having just treated a patient who lost his toe due to necrosis after being lost in follow up. The orthopaedic surgeon must decide whether to accept the ED diagnosis or go to the ED and see the patient.

Due to his recent experience, the orthopaedic surgeon requests that X-rays and photos of the wound be sent to his smartphone through DocBookMD™. Within minutes, he reviews the images and agrees with the ED physician’s assessment of the wound. The patient does not need to see a specialist.

The patient is released from the ED much quicker and received more appropriate care. The orthopaedic surgeon could be sure the wound was not severe and did not require him to see the patient in the ED. He avoided an unnecessary trip to the ED.

DocBookMD™

Physicians in the Dallas area now have access to a tool that can help them communicate more efficiently and save time and money in the process. That tool is DocBookMD™, a physicians-only smartphone app that allows physicians to:

• Send HIPAA-compliant text messages and photos. Message content can include diagnosis, test results and medical history. Physicians can add a high-resolution image of an EKG, an X-ray, lab report, or anything that can be photographed with a smartphone.

• Assign an urgency setting to outgoing text messages. Physicians can assign each message a 5-minute, 15-minute or normal response time. If the physician does not answer the message within 5 minutes or if the message does not get to the physician, the sender will receive a message that the original message did not go through.

• Enable enhanced notifications. The physician can enter a cell phone number to receive text messages or an e-mail address to receive notifications that DocBookMD™ messages are waiting. The e-mail feature will send a weekly reminder to view DocBookMD™ messages.

• Search a local county medical society directory. Physicians can look up other physicians in their county by first or last name or by specialty. Physicians then can contact other physicians by messaging, office phone, cell phone, or e-mail.

• Search a local pharmacy directory. Physicians can search for a local pharmacy alphabetically or find a pharmacy by ZIP code. Users also can create a “favorites” list of physicians or pharmacies.

DocBookMD™ is offered through county and state medical societies to their members and is available in 23 states. Texas Medical Liability Trust — the state’s largest medical professional liability insurance provider — sponsors DocBookMD™ in Texas and makes it possible for physician members of participating county medical societies to use the app at no charge.

Can you text that to me?DocBookMD™ has been available since 2010 and more

than 600 Dallas-area physicians use the app. Dallas nephrologist Ruben Velez, MD, uses the DocBookMD™ texting feature frequently. “It has made communication better and faster, particularly about patients in hospitals,” he says. “I can also get a summary about discharged patients from the hospital.” Dr. Velez also uses the app to find contact information for referring physicians.

One of the most popular features of the app is texting, as DocBookMD™ offers physicians one of the few ways to text patient information securely and in a way that meets HIPAA requirements.

“As we say, a photograph is worth a thousand words, and with DocBookMD™, I can have the emergency department physicians send me all the information, with a photograph of a hand injury or a face laceration,” says Austin plastic surgeon Rocco Piazza, MD. “I can tell them right away what we need to do or where we need to go, and assess whether it’s something I need to see now, or if it can wait until morning.”

Texting features are one reason medical professional liability carriers sponsor the app and support its use among physicians. Carriers believe DocBookMD™ can improve communication and help physicians practice safe medicine.

TMLT Chairman Stuart McDonald, MD, uses DocBookMD™ and is particularly excited about the ability to contact physicians through a secure network to request consults or provide follow-up information. “This saves a significant amount of time that would previously be spent on hold or waiting for a return call,” Dr. McDonald says. “Knowing whether my message has been read in a timely manner helps prevent delays in patient care.”

Communicating across county lines

In 2012, DocBookMD™ began regionalizing the app, allowing physicians to communicate across county lines. Members of the Dallas, Tarrant, Denton, and Collin-Fannin county medical societies now can send each other text messages or search county medical society directory information.

Such regionalization breaks down the communication barriers among counties, allowing for real-time access to specialists. This is particularly important in rural areas where access to specialty care is limited.

For a geographic area to become regionalized in DocBookMD™, the county medical societies must agree to share membership data. Central Texas and several counties in California were the first areas to be regionalized. Additional counties will be regionalized during the coming weeks and months.

County Medical Society BenefitsIn addition to helping physicians communicate and

collaborate, DocBookMD™ helps county medical societies build membership. This benefits physicians by creating a stronger county medical society and a louder voice for physician advocacy. Physicians also have access to a broader referral base and more opportunities for networking and community-building.

Join DocBookMD™

DocBookMD™ is available for iPad, iPhone and Android devices, and is provided at no charge to members of the Dallas County Medical Society. To register or for more information, visit www.docbookmd.com.

DocBookMDTM

More than 480 DCMS physicians and their families gathered for the 2nd annual DCMS Spring Celebration Picnic on Saturday, May 12 at the Dallas Arboretum. Children enjoyed activities and crafts, and food was enjoyed by all. The beautiful Chihuly blown glass exhibits were a sight to see, and the professional photographer captured great pictures of physicians and their families admiring the art.

Richard Vera, MD, with Karys, Krystal, Bryson, and Kambryn

Louis Nardizzi, MD, with Ana, Fernando, Mario, and Javier Nardizzi and Laura Avila

DCMS SPRING CELEBRATION PICNIC at THE DALLAS ARBORETUM

DCMS members and guests enjoy views of White Rock Lake from the Arboretum while dining.

1 3 0 • J u l y 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

Matthew Nevitt, MD, with Christine, Grant, Dean, Audrey, and LukeRachel Quinby, MD, with Vivian and Sophie

Children enjoy crafts with help from the DCMS Alliance

Carolyn Thomas, MD, with Jake and Abigail

Regiss and Raighne Richards Randall Wooley, MD, with Nicholas

Kaki and Shelton Hopkins, MD

Hector Hidalgo, MD, with Magda, Lorenzo and Joaquin

v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • J u l y 2 0 1 2 • 1 3 1

1 3 2 • J u l y 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

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v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • J u l y 2 0 1 2 • 1 3 3

Business of Medicine

Texas has a large, growing population

that is growing sicker and needs more and

better-coordinated healthcare services.

Unfortunately, Texas — even more than

most of the rest of the country — needs more

physicians and other healthcare professionals.

Meet the growing demand for medically necessary care with clinically appropriate medical services

Texas’ population is expected to boom from 25 million to almost 45 million by 2040, creating a greater need for more healthcare services from a growing populace of increasingly obese Texans and generally sicker elderly residents. 1

Texas has long been challenged to produce or recruit enough physicians to keep up with our rapidly growing population. The sheer size of the state’s population is the biggest driver of physician demand. The state’s broad expanse and variance in geography and demographics, plus the great attraction for others to move to Texas, result in an ever-increasing demand for physicians and other healthcare professionals. Over the past two decades, Texas has led the country in population growth.

Several powerful trends are pushing Texas’ significant physician shortages to levels that will threaten the ability of Texans, regardless of where they live or whether they have insurance, to access health care. Those trends include: • More than 5.7 million Texas baby boomers will

become eligible for Medicare, 2 the age group with the highest demand for physician services;

• Our high birth rate further increases demand for physician services;

• More than 2 million additional people will be eligible for Medicaid in 2014, according to the Affordable Care Act;

• More than 2.2 million currently uninsured Texans will qualify for subsidized coverage through the ACA’s insurance exchanges; and

• A growing prevalence of chronic diseases, such as diabetes and hypertension, frequently require more healthcare services.

Ensuring an Adequate Healthcare WorkforceCompiled by DCMS and TMA Staff

1 3 4 • J u l y 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

Physicians must be the backbone of such a complex system of care if it is to be cost-effective. Otherwise, the state’s efforts to increase preventive care, improve medically necessary treatment for the chronically ill, and reduce inappropriate emergency department utilization will falter. Physicians also play an important role in helping develop and partnering with the public health system. This partnership can enhance local coordination of care, disease surveillance, access, and health promotion.

Ensure All Areas of Texas are Served by an Adequate Number of Physicians and Other Healthcare Professionals

Texas has a shortage of both primary care physicians and specialists. It ranks behind other more-populous states in the number of primary care physicians per capita. To evaluate this shortage across specialties, we devised “Texas Specialty Ratio,” a metric that compares the number of Texas physicians per 100,000 population with the US average. The closer this ratio is to 100 percent for a given specialty, the closer Texas is to the national average. • Texas has fewer physicians per capita than the

national average for 36 of 40 specialties.

• Texas needs more primary care physicians and specialists. A number of specialties have acute shortages.

• Psychiatry and child/adolescent psychiatry are among the specialties with the lowest Texas Specialty Ratios.

We must look to the Texas of tomorrow to evaluate the kinds of physicians we will need the most. Texas ranks fourth among the six most-populous states in medical students and resident physicians per capita. Texas continues to be overly dependent on other states and countries for supplying new physicians. Last year, nearly 75 percent of newly licensed physicians graduated from medical schools outside Texas.3 Thus, we are subject to the vagaries of external forces that influence the numbers of physicians we can recruit. To meet future physician demands, Texas needs a stable, high-quality medical education system to produce physicians. Similarly, we must provide a reasonable opportunity for Texas medical school graduates to obtain their residency training in the state. Multiple studies confirm that physicians who complete both medical school and residency training in the state are three times more likely to practice here.

Texas needs continued and stable state support for both critical parts of a physician’s education and training to help cultivate future generations of Texas physicians, ensuring stable access to health care for all Texans.4

In 2011, almost half (48 percent) of Texas

medical school graduates left the state for residency training. 5 Texas invests almost $200,000 in a medical student’s four years of education. Texas physicians are concerned about the state’s ability to protect that growing investment with enough graduate medical education positions to meet demand. For 2011, the annual National Resident Matching Program offered 1,476 entry-level GME positions in Texas. By comparison, 1,445 students graduated from

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Business of Medicine

v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • J u l y 2 0 1 2 • 1 3 5

Business of MedicineTexas medical schools in 2011.6 The Texas Higher Education Coordinating Board recommends a ratio of 1.1 entry-level GME positions for each Texas medical school graduate. To meet this goal, Texas would have needed 1,590 entry-level training positions in 2011, or 114 additional positions.

Texas medical school graduates are projected to peak at more than 1,700 around 2015.7 This will mean an even greater demand for residency training positions to enable graduates to remain in the state. To achieve the 1.1-ratio goal after enrollments reach the peak, Texas would need to add 400 GME positions. This growth will be even more difficult to achieve with the Legislature’s recent 41 percent reduction in state support for residency training.

Considering the significant challenges the state faces in meeting its healthcare workforce needs, state leaders must mandate a comprehensive health professions workforce analysis that includes all appropriate stakeholders and visualizes the needs of Texas for the near and long term.

Improve Rural Access to CarePhysician shortages create a special problem in rural

areas of the state. The continued urbanization of Texas exacerbates this longstanding problem. Approximately 12 percent of Texans live in rural counties, 8 yet only 10 percent of primary care physicians practice there.9 In 2011, Texas had 52 primary care physicians per 100,000 population in rural areas vs. 72 per 100,000 in urban areas.10 Physician shortages in rural areas not only hinder access to primary and other specialty care but lead to potential losses in the local economy, difficulties attracting new businesses, and diminished quality of life for residents. A number of factors hurt a physician’s ability to open and sustain a rural practice, including heavy concentration of Medicare, Medicaid and uninsured patients; professional isolation; and high debt after medical school.

Physician practices in rural Texas contribute to the local economy in three critical ways: • They employ administrative and clinical staff to

help care for patients. On average, a solo primary care physician in a rural area will employ three staff: a registered nurse, a medical technician or licensed vocational nurse, and a receptionist/billing clerk.

• They contribute revenue to and generate additional employment at local hospitals through inpatient admissions and outpatient services.

• They generate essential tax revenues for their communities.

If rural physician practices and rural economies are to thrive, physicians need incentives to practice in those areas. Medical school programs with rural-focused curricula increase the supply of primary care

physicians in underserved areas as do loan forgiveness programs such as the National Health Service Corps and the State Physician Education Loan Repayment Program.

Limit scope of practice expansions The state’s 11 health-related institutions have

experienced the growing demand for healthcare services. They have expanded clinical services and added slots in their schools of medicine, dentistry, nursing, physician assistants, and a broad array of other health professions. Although the Texas Medical Board has set a string of new records in medical license applications and newly licensed physicians since the passage of solid tort reform provisions in 2003, most other major health professions have grown at an even faster rate. • Of the major health professions, supplies of

physician assistants and advanced practice nurses grew at the highest rate, 132 percent and 1,114 percent, respectively. (In comparison, numbers of physicians grew by 32 percent.) In absolute numbers, registered nurses had the largest gain (56,000), followed by physicians, up by more than 10,000.11

• Although Texas added 56,000 RNs over the past decade, shortages persist in many parts of the state.

• Of the 10 largest health professions, podiatry had the slowest growth rate.

This increase in the number of specially trained healthcare professionals is good for Texans. TMA believes that a physician-led team approach to care, with each member of the healthcare team providing care based on his or her education and training, is key to ensuring that patients receive high-quality care. Team care requires cooperation and collaboration among all professionals, with a focus on quality, measureable outcomes and efficient utilization of

1 3 6 • J u l y 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

Business of Medicine

resources. This growth, along with the narrow political interests

of a small number of allied health professionals, has spurred their calls for Texas to grant them more independent practice. Such an expansion in their scope of practice would exacerbate Texas’ physician shortage and likely increase costs and utilization, and could endanger the safety of patients. The Texas Medical Practice Act was created more than 130 years ago to protect Texans from people who called themselves “doctor” but who did not have the skills, training or education to warrant such a title. The act, administered by TMB, clearly defines the practice of medicine and the educational qualifications necessary to diagnose, independently prescribe, and direct patient care — and to be held accountable for that care.

However, some scope expansions are consistent with team care, based on objective educational standards, and would improve patient care services. These should be carefully weighed and ultimately involve TMB supervision and regulatory oversight.

Although our 2003 liability reforms have brought an influx of new physicians, the supply won’t be able to keep up with the demand, especially if the Affordable Care Act stands. We need more physicians and other healthcare professionals working in all parts of the state. We need to invest more in our medical schools and graduate medical education training programs. We should not fool ourselves into thinking that allied health professionals — who haven’t gone to medical school — can fill the gap as independent practitioners. Instead, we need to work on building physician-led healthcare teams that can safely meet the diverse needs of the Texas population.

For more information on TMA’s state and federal advocacy initiatives, visit www.texmed.org/Verondi/Templates/TierTwo.aspx?pageid=24401&terms=health%20vision%202012.References

1 Texas State Data Center. Population Projections by Migration Scenario for Texas Counties and Regions. Available at http://idserportal.utsa.edu/sdc/projections/default.aspx. Accessed March 2012.

2 Texas State Data Center, 2010 Census Data. Available at http://txsdc.utsa.edu/Data/TPEPP/Estimates/Index.aspx. Accessed March 2012.

3 Texas Medical Board. 2011. Available at http://www.tmb.state.tx.us/. Accessed April 2012.

4 https://www.aamc.org/download/265994/data/tripp-umbach-research.pdf

5 National Resident Matching Program. Results and Data: 2011 Residency Match. April 2011. Available at http://www.nrmp.org/data/resultsanddata2011.pdf. Accessed April 2012.

6 Texas Higher Education Coordinating Board. Texas Higher Education Data. December 2011. Available at http://www.txhighereddata.org/. Accessed April 2012.

7 Texas Medical Association. Survey of Texas Medical Schools. 2011.

8 Texas State Data Center. Texas Population Estimates. Available at http://txsdc.utsa.edu. Accessed March 2012.

9 US Census Bureau, Department of State Health Services. Available at www.dshs.state.tx.us/chs/hprc/PCphys.pdf. Accessed April 2012.

10 Ibid.

11 Texas Department of State Health Services. Health Professions Resource Center. Supply and Distribution Tables for State-Licensed Health Professions in Texas. Available at http://www.dshs.state.tx.us/chs/hprc/health.shtm. Accessed February 2012.

Texas Health Professionals

2001

2011

Net Difference

Rate of Change

Physicians 32,281 42,716 +10,435 +32%

Physician Assistants 2,319 5,372 +3,053 +132%

Advanced Practice Nurses 5,145 10,995 +5,850 +114%

Dentists 7,561 11,751 +4,190 +55%

Physical Therapists 7,526 11,127 +3,601 +48%

Registered Nurses 128,514 184,467 +55,953 +44%

Pharmacists 15,559 21,306 +5,747 +37%

Chiropractors 3,676 5,020 +1,344 +37%

Optometrists 2,262 3,077* +815 +36%

Podiatrists 746 882 +136 +18%

* Comparison for optometrists is from 2001 to 2010; 2011 data not available. Prepared by Medical Education Department, Texas Medical Association, February 2012

It’s almost time for the annual DCMS Medical Student Dinner. For 36 years, DCMS physicians have hosted the freshman class of the University of Texas Southwestern Medical School at this special event to welcome them into the family of medicine. Students will have completed just one week of classes, and they’ll have many questions about their medical future. New this year, DCMS will welcome 3rd and 4th year medical students from the Baylor Dallas campus of Texas A&M Health Science Center College of Medicine. During dinner, students sit with physicians who share their experiences of surviving medical school and choosing a specialty. Who better to welcome them than you — a practicing physician?

YOU HAVE TWO WAYS TO PARTICIPATE:• Attend the dinner and sponsor students — this one is the most fun.• Sponsor students — this tax-deductible donation is greatly appreciated.

THE DETAILS:• Mark your calendars now for Sunday, Aug. 19, at 6 p.m.• Doubletree Hotel Campbell Center, 8250 N. Central Expy. (Across the highway from NorthPark Center)• All contributions for student meals are tax deductible. Your contribution will be acknowledged through various DCMS communication tools.

RESERVE YOUR SPOT BY FRIDAY, AUG. 10:Mail the form below with your check payable to DCMS Foundation, PO Box 4680, Dallas, TX, 75208, OR Call Cara Jaggers, DCMS director of membership, at 214.413.1423 or cara@dallas-cms.org ORFax credit card payments to 214.946.5805. We look forward to your participation.

2012 DCMS Medical Student Dinner RSVP Form

I will attend. My spouse/guest also will attend. Spouse/Guest name I will support 2 students or a student and spouse/significant other.

I am unable to attend; however, I will sponsor student(s). (quantity)

Payment enclosed for people @ $40 each = $

Physician Name Phone

Circle Card Type VISA MC AMEX DISC E- mail Address

Credit Card # Exp. Date Security Code

Fax credit card payments to 214.946.5805 or mail checks payable to DCMS Foundation, PO Box 4680, Dallas, TX 75208. Reservations must be received by Friday, Aug. 10.

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Texas’ Grand Medicaid 1115 Waiver: What to Expect when the Medical World Shifts

By: Katherine Lane, DCMS staff

The medical world has been rotating in the same direction, on the same axis, for years, at least in terms of Medicare and Medicaid. That world is about to be rocked. Since 1965, with the notable exception of the introduction of the Diagnosis-Related Group, there has not been such a significant change in healthcare financing. In 2014, the effects of the Affordable Care Act will come into play, unless the US Supreme Court intervenes. Texas is making massive plans for health system reform, and this time, the transformation includes physicians. Changes will be made and ways of doing things will shift, but it doesn’t have to be overwhelming. In an upcoming series of articles, we will break down what reform means to physicians, particularly with the uninsured, and what potential it brings to those in the medical field.

How does a state make changes to a plan like Medicaid? First, permission must be given by the Centers for Medicare and Medicaid Services. The long and arduous process used to obtain changes is called an 1115 Waiver. Think of it as a protracted negotiation between the state of Texas and CMS that feels like it never ends. During the 2011 legislative session, the Legislature and Health and Human Services Commission realized health system reform in 2014 was imminent. Like states all across the country, Texas rushed to submit an 1115 Waiver; some would say without understanding the consequences of its actions. This was done because the time crunch that comes between the end of the next legislative session in May 2013 and the start of the 2014 federal fiscal year in October 2013 would provide little to no time to accommodate millions of Texans who would soon be health insurance-card carrying residents. Thus the state made several major decisions to change its Medicaid model in anticipation of the change in 2014. Although the legislative leadership and the Texas Health and Human Services Commission were involved at the waiver’s inception, the process has not gone as smoothly as anyone had hoped. Helen Kent Davis, TMA director of governmental affairs, said the TMA supported the waiver so as to preserve funding for the state’s safety net. “Texas pursued the waiver in order to allow expansion of the Medicaid HMO model without jeopardizing hospital supplemental funding available through the UPL (Upper Payment Limit) program,” Davis said. “Under an HMO model, UPL payments are not available, and without the waiver, Texas hospitals stood to lose about $1.7 billion in funding.”

The federal government has long reimbursed safety-net hospitals through quarterly UPL payments for the treatment provided to the uninsured. They certainly were not made whole by these UPL payments, getting close to 50 percent of their lost costs, but the payments added up. Physicians received no such payment.

As the state considered financing models to make up for the loss of the safety-net hospital UPL payments, it also hoped to address a longstanding concern

regarding UPL payments to hospitals — oversight of how the funds were spent. Until attention was drawn to changes resulting from health system reform, no entity monitored where government tax dollars were being allocated once they reached the hospitals.The formula is complicated; even those in healthcare financing find it hard to explain. But those days are gone now that Texas has chosen to move to an HMO model for Medicaid. With the HMO in, UPL is out, and the 1115 Waiver is the plan to save the safety net.

Life after UPLSo, Texas borrowed California’s plan. Although

insiders would like to have designed a plan from the ground up, there was no time. The California Waiver was a framework that Texas could live with, but there were some serious differences. The California plan was designed with only the state’s public hospitals in mind, not private hospitals. Immediately Texas had to amend the West Coast model.

The waiver should maximize federal matching funds and provide for more accountability. Planners intend for this to allow expansion of safety-net services as the number of insured grows.

So how do legislative leaders plan to kick the healthcare world in Texas right off its axis to make this possible? They started by making the public hospitals the center of the new world order, instead of the private hospitals. Previously, the federal UPL matches, which brought new dollars totaling more than $150 million each year across all private systems, were deposited into the accounts of the private hospitals. As partners in the safety net, these hospitals provided care directly to thousands of uninsured, or rather, physicians provided the care and hospitals did what the doctors ordered. Some great accomplished resulted from the federal funds. DCMS’ own Project Access Dallas is supported through the private hospitals due to UPL funds. Yet, accountability was lacking for the vast majority of the funds sent to these systems.

The new state plan fundamentally changed this by deeming the major public hospitals across the state as “anchor” hospitals, and allowing them to receive the match directly or control any subsequent release of funds to private hospitals or physicians.

Did you catch that last phrase? It is one of the most significant changes in healthcare financing in decades, and physicians may be, should be, in the path to partake in the cash flow of this new model.

Regional Healthcare PartnershipRegional Healthcare Partnerships across Texas were

developed to organize regional approaches. Each RHP has an “anchor hospital” to facilitate the process. Each region must consist of at least two counties, and is charged with making sure the needs of the uninsured are met. The region first will conduct a needs assessment to determine which areas are most important to focus

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on, such as chronic disease or behavioral health. Then, it’s up to that region to implement the reforms over a five-year period. Hospitals still will receive funding for uncompensated care, known as a UC Pool, and then receive funds through a Delivery System Reform Incentive Payment program. By the end of the five years, funding will be a 50/50 split, funding-wise, between UC and DSRIP dollars.

The Creation of Region 9Texas is big, so the Medicaid Waiver called for a regional

approach. There are now 19 regions across Texas. After months of debate and some drama with neighboring counties, Dallas and Kaufman counties have been designated as Region 9. Parkland Health and Hospital System has been deemed the anchor and has taken its role seriously. It has facilitated and led discussions with healthcare systems and other parties, including DCMS. This process is being aided by the leadership of Dallas Medical Resource, a local non profit, with leaders from the area private hospital systems, business, Dallas Regional Chamber, Dallas Citizens Council, and DCMS.

The next article will detail the two primary funding pools and the types of structure being put into place across Texas and in North Texas to ensure that the safety net stays in place and expands in 2014.

At least 32 million U.S. households own

insurance policies that aren’t right for them.1

Make sure you have the right insurance to help you protect the life you’ve worked so hard to build.

1. Insurance Information Institute. “Changes in Your Life Can Mean Changes in Your Insurance, Says the I.I.I.,” Press Release, January 22, 2007.

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