2008 residency match shows slight increases for family medicine
The National Resident Matching Program unveiled the 2008 residency match results on March 20, showing increased interest in family medicine. The 2008 fill rate for the specialty rose to nearly 91 percent nationally, with 2,404 of 2,654 family medicine residency slots claimed. Thirty-three more family medicine positions were offered in 2008 than 2007 and 91 more positions were filled in the same period. Included in the “family medicine” category are family medicine-psychiatry, family medicine-emergency medicine and family medicine-internal medicine programs.
In addition, NRMP data showed that interest among U.S. medical students rose this year after several years of decreasing or stagnant numbers. In the 2008 match, 65 more U.S. medical school graduates chose family medicine than in 2007—from 1,107 in 2007 to 1,172 in 2008.
The numbers in Texas grew slightly as well, with a fill rate of 97.5 percent in 2008, up from 95.9 percent in 2007. Out of the 201 residency slots offered in Texas this year, 196 of the spots were filled, up from 197 offered in 2007 and 189 filled.
In an AAFP News Now story, AAFP President Jim King, M.D., of Selmer, Tenn., said he was “extremely pleased” with this year’s match, citing a 10-year record set for family medicine in percentage of positions filled.
Other primary care specialties did not see significant changes, but still hold strong. The fill rates for the “all types” category of pediatrics and internal medicine, and obstetrics-gynecology all remain in the 90s, though their numbers for percentages-filled dropped by one point or less in these specialties. The slight decline is due to a larger increase in the number of positions offered than the number of positions filled.
While this year’s match showed better gains than family medicine’s stagnant results last year, overall NRMP numbers show that students continue to show preference for non-primary care specialties. King says that more recruitment is needed to solve the national shortage of primary care physicians and meet projected needs for the future. “We need a major increase in both the number and distribution of family physicians if we’re to end this shortage,” he said in News Now. “Although this year’s increase in interest in family medicine is very encouraging, we have a long way to go.”
Including all of the specialties nationwide, the 1,172 newly matched family medicine residents make up 8.2 percent of all U.S. seniors matched into residency programs in 2008.
With Texas’ new franchise tax looming, is your practice prepared?
Remember the franchise tax the Texas Legislature passed in May 2006 as part of Gov. Rick Perry’s school finance reform plan? After several revisions, collection time is on the horizon—with the first returns assessed May 15, 2008—but several exemptions and deductions will lessen the financial impact on physicians.
From the beginning, the new tax plan replaced the franchise tax with a margins tax on all corporations, limited liability partnerships, professional associations and other business entities. The tax is calculated based on a business’ gross receipts minus the cost of goods sold or the cost of compensation and benefits paid to owners and employees, and minus allowable deductions. Businesses with taxable gross receipts less than $300,000 pay no tax, and those grossing less than $1 million will get discounts off of the standard tax rates, which are 0.5 or 1 percent, depending on the type of business.
Sole proprietorships and general partnerships in which all partnerships are individuals rather than business entities are exempt from the margins tax, meaning physicians in solo practice who are not organized as a PA will not be affected. Also exempt are physicians who practice in federally qualified non-profit organizations.
Practices organized as PAs, LLPs or other types of entities will be taxed, but can exclude certain revenues under rules published Dec. 28. Physician practices may exclude 100 percent of the revenues they receive for covered services they provide to beneficiaries in Medicare, Medicaid, TRICARE, the Children’s Health Insurance Program and workers’ compensation plans. Some limitations on these exclusions were included in the Dec. 28 rule but will be removed, according to a tax policy newsletter published by the comptroller in February.
Another exclusion is available for the actual costs of uncompensated care, calculated by multiplying the total uncompensated care charges by the ratio of total cost to total charges for the practice. The comptroller’s rules limit uncompensated care to exclude any services for which the physician received partial payment. Capturing and reporting this and other required information may require changes in the way information is recorded.
Deductible compensation expenses include wages, salaries and benefits with some limitations, but do not include contract-labor payments. Payments for temporary labor or to staff leasing companies and management companies get special treatment.
Because the tax is coming into effect for some but not all practices, and because the impact of the tax will be affected by various business decisions, it is important to confer with your practice’s accountant to understand the tax’s impact on your practice.
HHS gathers health care stakeholders to discuss electronic health record incentive demonstration
Two big players in the health care spending debate gathered stakeholders to promote an initiative that aims to reduce spending in Medicare by expanding the use of health information technology.
As one stop of many around the country, representatives from the U.S. Department of Health and Human Services and Centers for Medicare and Medicaid Services held a round-table discussion in Austin on March 27 to gather feedback, answer questions and encourage communities to apply for the Electronic Health Records Demonstration Project, announced in February. Kerry Weems, acting director of CMS, led the discussion.
The five-year demonstration project rewards physicians in small- and medium-sized primary care practices with incentive payments for adopting EHRs and showing continual improvement in the care of Medicare patients over specified clinical quality measures. Total payments over the period could reach $58,000 per physician or $290,000 per practice. CMS will accept applications from communities around the nation “with broad connectivity and diversity of practices” until May 13, eventually choosing 12 finalists. With each community engaging up to 100 practices, CMS estimates the project to reach 3.6 million patients.
At the round-table discussion, individuals from organizations representing health care professionals, health plans, hospitals and all levels of government asked the CMS acting administrator to describe and define terms of the project, with one even asking if CMS would consider delaying implementation until possible hurdles with recruitment, measurement, reporting and community infrastructure could be addressed.
Stephen Fitzer, CEO and executive director of the Bexar County Medical Society, expressed skepticism that CMS would be able to find 12 geographic areas with enough primary care practices eligible and willing to participate. Citing a restriction barring states from applying that are already participating in a CMS EHR project, he said that only 23 U.S. states are eligible to apply. In addition, only 91 primary care physician practices qualify to participate out of thousands of physicians in the San Antonio metro area, he said.
Fitzer also noted that while individual physicians and physician practices can expect to receive compensation, administrators of the project would not, making it less attractive for state-level organizations and government to participate. Other meeting attendees questioned the reporting procedure and how incentives would be awarded if practices already have high-performance EHRs.
Weems told the group that this project will be much different from other government-led demonstration projects in that CMS purposefully did not define many of its terms, even what qualifies as a “community.” This, Weems said, will encourage the applicants to set their own terms, gather all of the resources and stakeholders in their communities, and use that ownership to ensure the project’s success. Weems said the ideal applicant will clearly define the role of all stakeholders: physicians; insurers; the state; large, self-insured employers; and others. He expects CMS to receive up to 30 applications that will range from large, urban cities to entire states or inter-state regional partnerships, though he indicated that CMS may lower the number of practices needed to qualify to 150.
Linda Carney, M.D., a solo family physician in Buda who told the group about her experiences adopting an EHR, said that this demonstration will require the participation of all types of stakeholders at all levels. “To make this project work in Texas, TAFP, TMA and other professional medical organizations will have to bring everyone to the table and clearly define what each of their roles will be,” she said.
HHS encourages widespread implementation and adoption of EHRs and other health information technology to improve patient care, transform the way medicine is practiced and delivered, and produce significant savings to the Medicare system.
Carney told the group that her EHR helps her provide high-quality care to her patients in the town of 5,000. “As a solo family physician, some people ask me if I’m part of a dying breed, but I’m not,” she said. “I have a secret weapon—my electronic health record.”
She said her EHR allows her to access a patient’s information, make referrals to other specialists, or forward insurance information to other physicians at the click of a button.
One of her patients, David Saxon, accompanied Carney to the meeting to express his contentment with Carney’s use of an EHR and commitment to this technology. He called her a “heads-up doctor” because she is able to pull up his entire medical history on her computer in the exam room and use an extensive discussion with him and any test results taken in the office to provide a comprehensive diagnosis. He compared this informed, interactive physician with another type of doctor: a “heads-down doctor” who must keep his head in a paper chart and does not have as much freedom to discuss care options with the patient because of time wasted searching for information.
While Carney is a proponent of using this technology to reduce medical errors and give her more time with her patients, she admits that it’s not easy for physicians, especially solo physicians, to adopt EHRs. She specifically pointed out that the training process is ongoing as new staff join the practice and the patient population expands.
CMS expects to announce four of the chosen community partners in May 2008 with the remainder announced in 2009. Once chosen, participating physician practices will use their EHRs to perform tasks such as clinical documentation, ordering of lab tests, recording lab tests and ordering prescriptions.
Incentive payments will be determined based on the physician’s score on the Office Systems Survey, which will be administered annually to track the level of EHR implementation. By the end of the second year, the physician practices will be required to have an EHR certified by the Certification Commission for Healthcare Information Technology, which ensures privacy, security and interoperability, Weems said. In years three through five, physician practices must show increased performance with the EHR to receive incentive payments.
TMB executive director to step down in August
Donald Patrick, M.D., J.D., will retire from his post as executive director of the Texas Medical Board on Aug. 28, his 70th birthday, he told the board’s executive committee on April 10. Patrick has been the head of the medical board since 2001. During his tenure, he gained a reputation for strictly enforcing rules and disciplinary actions against doctors, reversing previous criticism that the TMB was too lax on sanctions. Disciplinary actions against doctors nearly tripled under his lead, from 105 in 2001 to more than 300 in 2007, according to the Texas Medical Board Statistics Fiscal Years 2001-2007.
The TMB’s executive committee has begun the search for a replacement and, in a press release, said that Director of Enforcement Mari Robinson will serve as the interim executive director if one has not been appointed by August.
Medicare payment update bill introduced on Capitol Hill
AAFP Issues Speak Out Alert
AAFP encourages members to support a Senate bill that would block steep reductions in Medicare physician payment rates for the latter half of this year and all of 2009, giving Congress enough time to devise an alternative to the sustainable growth rate, or SGR, formula.
U.S. Sen. Debbie Stabenow, D-Mich., a member of the Senate Finance Committee, recently introduced S.B. 2785, or the “Save Medicare Act of 2008,” which would provide a 0.5-percent increase in the Medicare physician payment rate for the final six months of 2008 and a 1.8-percent increase for 2009. Under the current deadline, physicians face a 10.6-percent reduction starting July 1 and an additional 5-percent cut in 2009. The bill would also continue rural extender provisions set to expire such as the Work Geographic Practice Cost Indices and the Physician Scarcity Area bonuses.
Because Stabenow’s bill does not specify budgetary offsets needed to pay for the Medicare update, she acknowledged that passage of her bill in its complete form represents a “challenge.”
“The key thing is what will the president sign,” Stabenow said in an AAFP News Now article. The Bush administration and congressional Republicans oppose cuts to Medicare Advantage, Medicare’s managed care plan, to pay for Medicare payment updates, making it more difficult to find the budget offsets needed to pay for the elimination of the SGR.
Though this bill does not permanently fix the Medicare physician payment formula, it will provide physicians a degree of stability for the next 18 months, AAFP President Jim King, M.D., of Selmer, Tenn., told News Now. “This (bill) will give us some time to work with CMS and Congress to try and replace this broken SGR payment formula and put together a payment formula that makes sense. We think anything less than 18 months is not enough time to do that.”
In addition to Stabenow’s bill, other legislators are building support for their own bills to address the Medicare physician payment formula. Reps. Tom Price, R-Ga., and David Scott, D-Ga., filed House Resolution 5445 in February to delay cuts to Medicare physician payment rates until Dec. 31, 2009, to give Congress time to find a long-term solution. Sens. Max Baucus, D-Mont., chair of the Senate Finance Committee, and Charles Grassley, R-Iowa, the senior Republican member of the committee, are expected to introduce legislation before the cut goes into effect.
At a March 30 Texas Medical Association news conference, Sen. John Cornyn, R-Texas, spoke about his new legislation, Ensuring the Future Physician Workforce, that would fix the formula by eliminating the SGR. Also at the conference, TMA released the results from their 2008 Medicare Survey, giving a bleak diagnosis: inadequate and uncertain Medicare payments to physicians has forced doctors to limit the number of Medicare patients they can afford to see. Among the findings, the TMA survey found that the percentage of physicians who accept all new Medicare patients dropped to an all-time low in 2008, to 58.1 percent.
Nearly one-third of the 749 physician respondents decided to accept fewer new Medicare patients in the past three years while only 4 percent accept more new Medicare patients in the same period. More than 45 percent of family physicians and internists say they have cut back on accepting new Medicare patients in the past three years.
Additionally, 26 percent of respondents have already cut back on the charity care they deliver and 25 percent have delayed the implementation of health information technology.
AAFP encourages physicians to continue participating in the “Medicare: Stop the Cut Campaign,” which has already generated more than 800 messages to federal lawmakers since its launch on Feb. 9.
Some reporting from AAFP News Now, March 25, 2008. © 2008 American Academy of Family Physicians.
Physician pay-for-performance concerns raised in Senate hearing
During a March 26 hearing, the Senate Health and Human Services Committee listened to testimony on outcome-based reimbursement models in Texas’ Medicaid program and other health care coverage models. Overall, the testimony largely reflected the medical community’s concerns with programs such as pay for performance.
One of the physicians testifying on behalf of the medical community was John Holcomb, M.D., San Antonio pulmonologist and chair of the Texas Medical Association’s Select Committee on Medicaid.
Holcomb told the committee there is much interest in pay for performance and health plans and federal payment plans have begun implementing these programs with “almost no evidence” of their effectiveness. He voiced physicians’ concerns with the validity and reliability of measurements, costs to physicians and the sustainability of pay-for-performance programs.
Holcomb explained that two types of measurements are used to gauge quality, process measurements and outcome measurements, using the treatment of a diabetic patient as an example. “In the management of a diabetic patient, you would like to be able to tightly control the blood sugar—which is process—so that later on, 10, 15, 20 years later you have less blindness in that population, you have less loss of extremities, and you have less myocardial and stroke events,” he said. “Because the health plans can’t think in terms except in quarterly budgets, and the legislators, bless their hearts, only think in two-year cycles, it’s very hard for us to look 10 or 15 years out to get these outcomes.”
Holcomb said most health plans instituting pay-for-performance techniques are using claims systems to collect quality data and are only collecting meager process measures. For example, ordering an annual test makes a physician look like a “really good doctor” to the health plan, but in reality, the physician may not be helping the patient effectively manage his disease, he said. Outcomes measurements are much more complicated, not to mention expensive, and involve reporting what the patient actually experienced over the course of the illness.
Other hurdles that make implementing outcome-based reimbursement models in Medicaid difficult include patient compliance, an extremely geographically and ethnically diverse Medicaid population, insufficient data-collection systems, and low physician reimbursement.
On behalf of TMA, Holcomb recommended delaying statewide implementation of pay-for-performance programs in Medicaid until the committee could further investigate value, costs, impact and potential consequences. Instead, it would be beneficial to look to better investments to improve the quality of Medicaid services, he said. Some examples include looking more to medical home initiatives to improve health outcomes, reduce health care disparities and constrain health care costs; and continuing to streamline Medicaid administrative requirements in regards to paperwork, prior authorization, and billing and coding.
In his published testimony, Holcomb gave four recommendations: closely monitor and evaluate existing pay-for-performance programs using collaboration with physicians, health plans and experts to assess their effectiveness; adopt a core set of principles to guide the design, implementation and evaluation of future proposals; continue investing in physician reimbursement rates for pediatric and adult services; and invest in medical home initiatives for Medicaid patients.
Avoid penalty, heed TMB’s advertising rules
By C. M. Schade, M.D., Ph.D.
The Texas Medical Board revised its advertising rules effective Sept. 20, 2007. The TMB has disciplined physicians for false and/or deceptive advertising. I was surprised to discover that my professional business cards and letterhead are considered a form of advertising and are covered by the new TMB rule! One of the more common problems concerns the use of the words “board certification.”
“A physician is authorized to use the term ‘board certified’ in any advertising for his or her practice only if the specialty board that conferred the certification and the certifying organization is a member of the American Board of Medical Specialties, or the Bureau of Osteopathic Specialists, or is the American Board of Oral and Maxillofacial Surgery. (Rule 164.4)”
Physicians have been disciplined by mistakenly listing that they are board-certified by an organization that is not one of the three mentioned above. The new rule allows a physician to state that he is a member, fellow, diplomat or certified by a named organization if that organization meets the requirements as listed in rule 164.4. See the TMB Web site, www.tmb.state.tx.us.
I was very surprised to find that the terms “board eligible,” “board qualified,” or any similar words or phrases calculated to convey the same meaning may not be used in physician advertising.
It is also interesting to note that each licensee is held individually responsible for the form and content of any and all advertising. In other words, if you are a member of a group and someone else ordered and printed the material, that is not an excuse and you will still be held personally responsible for violating the TMB’s advertising rule.
It has now been a year since the TMB passed the new pain-management rules. It is the physician’s responsibility to have a pain-management agreement and informed consent documented in every patient’s chart who is being treated for chronic pain with opioids (TMB Rule 170). A sample Pain Management Agreement and Informed Consent Agreement in English and Spanish can be downloaded from the Texas Pain Society Web site, www.texaspain.org.