Billing practices of North Carolina family physicians

BACKGROUND. This study describes billing practices of family physicians. Significant increases in the reimbursement for family physicians are expected from implementation of the resource-based relative value scale (RBRVS). However, the real impact of the RBRVS is unknown since little is known about how family physicians use the present reimbursement system to charge their patients. METHODS. A random sample of 270 North Carolina family physicians was surveyed, using standardized progress notes of five hypothetical patients. RESULTS. One hundred thirty-eight (51%) physicians responded; 107 (77.5%) were in private practice. Family physicians in private and nonprivate practices were similar in their Current Procedural Terminology (CPT) coding and level of service for each hypothetical case. Family physicians in smaller communities showed greater variation in CPT coding of visits than did family physicians in larger communities, and they were more likely to use CPT codes that indicated a lower level of visit. Rural family physicians demonstrated a significant inverse relationship between the CPT level of visit coded (ranging from "brief," with a CPT code of 90040, to "comprehensive," coded CPT 90080) and the amount they charged established patients for a "limited" visit (CPT 90050). CONCLUSIONS. These findings suggest that the lower income of rural physicians is due, in part, to billing at a lower CPT code, and thus charging less for comparable services, than urban physicians. The findings also lend further support to contentions that federal reimbursement reforms will have less impact on the incomes of rural physicians than originally expected.     

Locational decisions of physicians in rural North Carolina.

Recent literature suggests that there is a rural-urban imbalance of doctors in the United States. In order to investigate this maldistribution, a survey was conducted of 504 physicians in eastern North Carolina. The objective was to determine the factors which most influenced doctors' decisions to locate their practice. A conceptual framework was used to highlight the influence of the community, medical schools and the physician's personal preferences. A discriminant analysis of rural and urban physicians revealed the doctor's personal characteristics to be most important, followed by community and medical school factors. In particular, physicians raised in smaller communities showed a greater preference for practicing in rural areas. Tactics for recruiting rural doctors and other policy recommendations are suggested.     

Increasing participation by private physicians in the EPSDT Program in rural North Carolina.

This study evaluated a method to increase physicians' participation in Early and Periodic Screening, Diagnosis and Treatment (EPSDT), a preventive health care program for Medicaid eligible children. Use of EPSDT can improve children's health status and reduce health care costs. Although the potential benefits of EPSDT are clear, the program is underused; low rates of participation by private physicians contribute to underuse. This study targeted a population of 73 primary care physicians in six rural counties in North Carolina where the physician supply, their participation in EPSDT, and use of EPSDT were low. A mailed intervention packet attempted to address barriers to participation perceived by private providers. The packet consisted of a carefully constructed letter, an informative journal article, and an educational pamphlet. Participation in EPSDT screening increased from 15 to 25 private physicians (67 percent), at a cost, on average, of less than $30 per recruited provider. Suggestions are presented for adapting the intervention packet to other settings.     

Alcohol screening practices of primary care physicians in eastern North Carolina

In our study, 616 primary care physicians of eastern North Carolina were surveyed for screening practices for detection of alcoholism in their patient population. We defined primary care as Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics and Psychiatry. We defined eastern North Carolina as the 29 counties that Pitt County Memorial Hospital serves. In our survey we found that eastern North Carolina is medically underserved as well as having less resources for referral and consultation. In response to the questionnaire, we found that most physicians agreed on some numerical value for drinks per day, social drinks, and drinks per week while pregnant. Values for drinks per week and weekend binges generally reflected significant tolerance for heavy drinking behavior. We also found that physicians of the same specialty commonly agreed on answers but when compared to other specialties they differed. Physicians preferred personal and clinical screening methods to questionnaires such as CAGE. Most physicians did not prescribe Antabuse but did suggest to their patients to cut down on drinking. Physicians felt that their patients needed more education and support from the community as well as intervention at an early age. We conclude that physicians should receive more education concerning alcoholism and substance abuse.     

Community medicine in the training of family physicians.

Family practice residency programs are encouraged to include community medicine training in their curriculum, but there is little agreement as to what community medicine is or what would constitute appropriate training. Community medicine is most commonly defined as a discipline concerned with the identification and solution of health care problems of communities or other defined populations. The inclusion of training experiences in the identification and solution of health care problems of communities has two basic advantages for family practice residency programs: it fosters a contextual approach in the care of individual patients and it builds knowledge and skills for those who will work with communities in future practices. An example of curricular content is included. A survey was conducted in order to determine what residency programs teach in the field of community medicine. The results show that few of the responding programs include the areas which most clearly relate to community medicine. It is hoped that the report of these results, the rationale presented for including community medicine in the training of family physicians, and the suggested outline of curricular content will further encourage and assist family practice residency programs to incorporate such training in their curricula.     

Vaccines provided by family physicians

PURPOSE This study was conducted to document current immunization practices by family physicians.METHODS In 2008 the American Academy of Family Physicians (AAFP) conducted a survey among a random sample of 2,000 of its members who reported spending 80% or more of their time in direct patient care. The survey consisted of questions regarding the demographics of the practice, vaccines that are provided at the physicians’ clinical site, whether the practice refers patients elsewhere for vaccines, and participation in the Vaccines for Children (VFC) program.RESULTS The response rate was 38.5%, 31.8% after non–office-based respondents were deleted. A high proportion of respondents (80% or more) reported providing most routinely recommended child, adolescent, and adult vaccines at their practice sites. The exceptions were rotavirus vaccine for children and herpes zoster vaccine for adults., A significant proportion, however, reported referring elsewhere for some vaccines (44.1% for children and adolescent vaccines and 53.5% for adult vaccines), with the most frequent referral location being a public health department. A higher proportion of solo and 2-physician practices than larger practices reported referring patients. A lack of adequate payment was listed as the reason for referring patients elsewhere for vaccines by one-half of those who refer patients. One-half of responders do not participate in the VFC program.CONCLUSIONS Provision of recommended vaccines by most family physicians remains an important service. Smaller practices have more difficulty offering a full array of vaccine products, and lack of adequate payment contributes to referring patients outside the medical home. The reasons behind the lack of participation in the VFC program deserve further study.     

Obstetric ultrasound by family physicians.

Obstetric ultrasound examination is a useful diagnostic procedure for family physicians who select appropriate equipment, observe indications, understand limitations, and work toward performance mastery. The knowledge obtained during an examination assists clinical decision making and reduces liability. This is particularly true for rural and underserved communities where family physicians provide the majority of prenatal and comprehensive perinatal care. Mastery of obstetric ultrasound techniques can also lead to developing amniocentesis skills and serve as an aid to external cephalic version. The equipment does not require extensive maintenance and is available at all hospitals. Many offices and group practices have found purchase of this equipment to be cost effective. Based on clinical experience in family practice and a review of the medical literature, an approach to skill acquisition and quality assurance is described.     

Promoting participatory research by family physicians

In the past, researchers have inadvertently caused stigmatization of various populations, first by not involving community members and then through publishing negative findings. In contrast, participatory research, which is based on a partnership between researchers and those affected by the issue being studied, promotes the voice of those being researched. This essay highlights key principles, processes, complexities, and challenges of participatory research and outlines when participatory research is not appropriate. It also reflects on the training and skills of family physicians that make them especially suited to participatory research. Family physicians have established clinical partnerships with their patients and sometimes entire communities, are trained in patient-centered care-a good basis for community centered research-and are accustomed to working with uncertainty. In addition, they are frequently pragmatic, interested in questions arising from their patients and communities, and likely to respond well to community requests. The main challenges to participatory research are lack of funding, expertise, and time, which may improve as more funding agencies and universities support this approach to research.     

Ethical decision making by family physicians

One hundred thirty-one Illinois family physicians, 53 general practitioners, and 65 general internists responded to a survey on medical ethics. From these data emerged a profile of the family physicians and an identification of the ethical problems they encounter most frequently in their practice: (1) issues about contraception, (2) pain control, (3) telling the patient the truth, (4) sexual issues, (5) informed consent, (6) confidentiality, (7) controlling patients' behavior with medication, (8) sterilization, (9) professional etiquette, (10) patients' rights, and (11) peer review.