This feature of MM “NEWS” introduces you to Society leaders as they explain their vision of organized medicine’s activities. This month, read Society President Michael T. Goldstein’s speech from the Annual Meeting, June 7, 2016.
Welcome to the Annual Meeting of the New York County Medical Society. This evening was supposed to be my final meeting as President. However due to some very unusual circumstances that may become more commonplace in New York medicine, I will be continuing on for a second term as the President of this Society. Our president–elect Matthew Bonnano, a second generation New York plastic surgeon, will be leaving New York for better opportunities elsewhere. Our nominating committee was convened with Doctor Joel Zinberg, the Chair of our Board of Trustees, serving as its chairman, and reviewing all available options, nominated me for a second term. I accepted and for the first time since Doctor George Henry Fox served a two–year term from 1890 –1892 has a New York County Medical Society president been elected to second–year term. I am sure medicine was a much different and less complicated profession back then.
Matt Bonnano is one of many younger New York physicians who has gone elsewhere. In fact New York is number 50 in terms of practice desirability. This unacceptable. In every other profession, it is near the top. If you are a lawyer, banker, actor, singer, artist or dot–com entrepreneur, New York is a great place to be. But for healthcare, which is about 20 percent of our economy, it at the bottom. This is despite the fact that New York County has four allopathic medical schools and one osteopathic medical school, representing the greatest concentration of medical education in the country in such a small geographic space . We are one of five counties that represent New York City and together we probably encompass the majority of physicians who practice in New York State.
For all of the citizens and physicians of New York, the unfavorable practice environment that is worsening because of expensive housing, taxes, regulatory issues, and burdensome medical liability costs needs to be reversed .Yet for this to happen we need your help and broader participation from the medical community to address and develop solutions for the problems that plague our profession.
This past year has been a challenging one for health care. Untried and unproven and failed models of health care payment are being forced upon the medical profession. Yet the sense of urgency needed to deal with this onslaught has fostered a new sense of cooperation between the medical societies that represent the five boroughs of New York. The body that represents them, the First District Branch of the Medical Society of the State of New York (MSSNY), has a new president Doctor . Zebulon Tainter of New York County, who is working to expand its role as a force for change. The presidents of the five New York City medical societies work together, exchange e–mails and meet to discuss common issues. We are bringing in the presidents–elects from the boroughs to create continuity in this process.
When Emblem Health wanted to remove approximately 800 doctors from the HIP–participating physician roster because they did not belong to an IPA, it was the presidents of the five boroughs who galvanized medicine to protest and bring the issue to the forefront. We became the tail that wagged the dog, and as we protested, MSSNY joined in with greater energy to help solve this problem. The New York State Senate got involved and legislation was proposed.
Since that time the cooperation between the five boroughs of New York has expanded and will continue to do so. We now notify each other regarding CME events, and members of all the counties are welcome under the same terms as apply to the members of the sponsoring counties. The Queens IPA has invited physicians from the other counties to join. Unity works.
At the last meeting of the MSSNY House of Delegates, four resolutions that I proposed passed. One dealt with helping employed physicians to form collective bargaining units to ensure fair treatment of employed physicians. A second involved working with other partners to form collective bargaining units for independent physicians. This is much more difficult but necessary task.
My third resolution proposed that the state medical societies, national specialty societies and the American Medical Association (AMA) work together to create an appeals process within the Centers for Medicare/Medicaid Services (CMS) when they arbitrarily change rules and reduce fees. This issue came to the forefront when CMS, against the advice of the Relative Value Committee, decided to reduce the fees for glaucoma lasers and surgery. It became obvious that there was no appeals process within CMS or the courts to alter this decision. What was most disturbing was that these fee reductions were designed to reduce the volume of vision–saving procedures in the glaucoma population which is disproportionately African American and Hispanic. CMS should not have the right to ration care by economic means to the Medicare populations, without oversight and appeals process.
The fourth resolution, and a similar one from another county, opposed linking Maintenance of Certification with licensure and hospital credentialing. There has been a huge controversy regarding Maintenance of Certification being tied to Maintenance of Licensure. Here too many considered it a done deal. New York County proposed a resolution to the House of Delegates that addressed this issue. That resolution passed. More importantly, the State of Oklahoma unanimously passed a law that would prohibit Maintenance of Certification to affect hospital privileges or be linked to Maintenance of Licensure. We need to follow the lead of Oklahoma and pass similar legislation.
Physicians have the capacity to make the practice environment better for both our patients and ourselves by working together and supporting our Medical Society. Sadly many people have given up and accepted the fact that things will only get worse. That is unacceptable. Six months ago many people believed that a change in the statute of limitations from date of treatment to date of discovery was inevitable. A strong coalition has been fighting the bill, which would produce a 15 percent increase in medical liability premiums, has again stopped this bill from passing.
Things are changing, but doctors need to wake up. There are too many freeloaders who want the benefits of the work of the Medical Society without contributing through dues and supporting the MSSNYPAC. This group is the first to complain and the last to act.
In fact less than five percent of all New York physicians fund the MSSNY PAC. That is pathetic. Last year I mentioned that my wife, Doctor Belle Goldstein, had proposed that every doctor give one co–pay to fund the MSSNY PAC, but that did not happen. This year MSSNY President and former New York County President Doctor Malcolm Reid is taking up the torch and pushing this agenda. In all political arenas it takes money to lobby, place advertisements, and fight for our issues. Everyone needs to step up to the plate.
Healthcare delivery in New York is changing in a negative way. As physicians leave private practice to become employees of large institutional healthcare systems, physician and consumer choice is disappearing. There is no question that large institutions need to play major roles in healthcare but not the only role. Competition and choice means higher quality and lower prices. Yet the driving force putting independent physicians is the government. Independent doctors do not compete on a level playing field and this must change. We have lobbied unsuccessfully for years for a physician collective bargaining bill. We must explore other options. Physicians must play a major role in shaping health care. We need use our intelligence, experience, work ethic and desire to make things better to develop innovative solutions that will improve quality and control costs.
Young physicians with huge debt are seeking employment, not independent practice. The problem is that as independent practice disappears, employers will lower salaries. Young physicians do not realize the important role medical societies play regarding their future. Every new CME or other requirement requires time and money to comply. Time that could be spent generating income is spent on regulatory compliance. Medical liability costs are a wage substitute and physician income in a large part is related to the income the physician generates minus the costs. These costs include employees, space, medical liability, and equipment. As liability costs go up there, is less money in the pot for physicians.
Physicians are managed by non–physician managers using spreadsheets to determine their economic value that is unrelated to the benefits that they provide for their patients. I can only imagine the scenario when the 30–ish MBA comes to discuss the economic productivity of a physician. The manager comes to see the doctor at the end of a long day, carrying a laptop and a latte grande. If you are lucky, the manager has brought one for you (with soy milk of course). What follows is a review of the numbers, patients per hour, and weekly income. This of course would be compared to your colleagues and to geographic norms so that you understand where you fit in on the Bell Curve. Your quality metrics will also be discussed and compared against your colleagues. The benefits you provide for your patients are irrelevant to this analysis.unless they write favorable reviews. The downstream revenue you generate for the hospital, admissions and procedures, lab testing, radiology and referrals does not count because of the Stark and Antikickback laws. In the end you will get a raise, reduced salary, warning to do better, or be terminated. This should be an unacceptable scenario.
Quality metrics are not new, but they are not necessarily an indicator of quality as we understand it. When I was a medical student at Downstate on one of my medicine rotations, one of the senior residents relayed a story about someone who was a lousy intern, but who had the highest autopsy rate. Since autopsy rate was a metric used to judge hospitals, this intern was highly regarded by the administration despite his mediocre performance as a physician. We need to make the process by which physicians are judged actually relate to the quality of care they provide for their patients rather than a contrived and irrelevant metric methodology derived by non–physicians.
The Medical Society is your voice and your advocate. The more you participate and communicate your needs, the greater our ability to advocate. Without mutual support physicians become individuals fighting against each other for an ever dwindling piece of the healthcare pie. Physicians who lack control of their own destiny become the equivalent of economic serfs in the healthcare delivery system, fighting to survive and always in fear of termination.
That scenario reminds me of an experience I had traveling through the river in Bangkok. The boat would stop in front of a museum and you were supposed to throw pieces of bread into the water. As you did so, carp would appear from nowhere and fight each other for the little scraps of bread.
This is what government policy is doing to medicine. Under MACRA, physicians will compete against each other to meet quality metrics. Since the policy is budget neutral, for every winner there will be a loser. How many metrics will you get and how many bonuses will you receive or lose. Other governmental policy regarding physician collaborative joint venturing have had the anti–competitive effect of health care consolidation. That is because individuals cannot collaborate while large groups and hospital systems can. The system is protecting the strong against the weak. This is counterintuitive, but not surprising.
Physicians have to look at history and how others in similar circumstances have either succeeded or failed. Employed physicians who are vulnerable to strong economic pressure should seriously consider forming collective bargaining units. Something has to be done to level the playing field.. Recently Verizon workers went on strike; their average benefit package is over $130,000 for someone who requires at most a high school diploma. These numbers are not far behind physicians in some specialties and some geographic regions in our State. If their salaries continue to rise and ours remain flat, it won’t be long before the person who fixes your phone gets paid more than the physician who fixes your hernia. If collective bargaining has done so well for them, why shouldn’t it work for us?
Physicians selling their services to a handful of insurance companies is remarkably similar to farmers selling their goods to a very few large agricultural conglomerates. Yet for over 200 years farmers have collaborated through cooperatives to level the playing field and earn a fair return for their labor. These agricultural cooperatives control one–third of the agricultural economy and co–exist and successfully compete with large agribusiness. Physicians should learn about economic survival from the farmers. Physicians can collaborate through Independent Practice Associations (IPAs) to varying degrees depending on whether or not they are clinically integrated. They can form quasi–groups. They can also adopt with modifications a cooperative model. The Medical Society is exploring ways to help level the playing field for small practitioners, but we need your support.
When the Affordable Care Act left many small practices without the option to purchase health insurance, except through the exchanges, we sought a solution. We partnered with Idilus, a Professional Employer Organization or PEO, to enable our members to aggregate with others so that they could obtain business services and benefits with the economy of scale of a larger business. Physicians who belong to our Society or other county societies can take advantage of that service. Even solo practitioners can get access to group benefits otherwise unavailable to them.
We are expanding the services we offer our members, but for this to succeed, we need your support and for you to take advantage of the services that we have negotiated on your behalf.
Medicine is at a crossroads. Things can either get better or get worse. The future is our hands but not for much longer. We can and want to work with you, our colleagues, to ensure that the time, effort, and money that you have invested in becoming a practicing physician is both professionally and economically rewarding. We can only succeed with your support both financially and physically.
The officers, Board of Directors and Board of Trustees are physicians who volunteer their time and hearts to the advancement of medicine in New York. We represent physicians in every practice setting from solo practitioners, members of large groups, employed physicians. and those who work in industry.
These are challenging times and we all need to work together to enable us to meet the demands of the new healthcare system while preserving our role as advocates for our patients’ health. Time is running out and the future of medicine depends on what we do today. Let us not waste the opportunity.
I appreciate the honor you have given me to serve as your president for a second term. I will do my best to ensure that the New York County Medical Society continues to be your advocate and your resource.
These members were elected at the Society’s Annual Meeting on June 7, 2016.
Scot B. Glasberg, MD, President–Elect
Naheed Van de Walle, MD, Vice President
Jessica J. Krant, MD, MPH, Secretary
Wen Dombrowski, MD, Assistant Secretary
Ami Shah, MD, Treasurer
Jill Baron, MD, Assistant Treasurer
Michael Borecky, MD, Board of Medical Ethics (Two–year term)
Henry Magliato, MD, Board of Medical Ethics (Two–year term)
Marlin Mattson, MD, Board of Medical Ethics (Two–year term)
Edward W. Powers, III, MD, Trustee
Board Members At Large
Conrad Cean, MD
Arthur Cooper, MD
Keyvan Jahanbakhsh, MD
Anuhadra Khilnani, MD
Keith LaScalea, MD
Mark Milstein, MD
Gabrielle Shapiro, MD
Bijan Safai, MD
Niket Sonpal, MD
Delegates to the Medical Society of the State of New York (MSSNY)
Scot B. Glasberg, MD
Michael Goldstein, MD,JD
Eli Einbinder, MD
Peter Lombardo, MD
Marlin Mattson, MD
Edward Powers, III, MD
Gabrielle Shapiro, MD
Zebulon Taintor, MD
Alternate Delegates to MSSNY
Jill Baron, MD
Michael Borecky, MD
Andrew Cheng, MD
Daniel Green, MD
Clarita Herrera, MD
Keyvan Jahanbakhsh, MD
Anuhadra Khilnani, MD
Jessica J. Krant, MD, MPH
Henry Magliato, MD
Mark Milstein, MD
Eugene E. Weise, MD
Joel M. Zinberg, MD, JD
On June 7, 2016, Michael T. Goldstein, MD, JD began a second term serving as the Society’s 178th President.
One of the unique services offered to you as a Society member is access to the Society̓s parking review program. The Parking Ticket Review Panel review members̓ New York City parking tickets to recommend dismissal to the New York City Parking Violations Bureau. In order to take advantage of this valuable membership benefit, you must renew your “Doctor On Medical Call” card. Display the card in the windshield of your car with MD plates in order to be eligible. The card is renewed at a reasonable price of $25.00; the new card is valid from July 1, 2016 – June 30, 2017. . Some restrictions do apply; you will receive with your new card a sheet describing these as well as the procedure to follow to request that a parking ticket be dismissed.
To order your “Doctor on Medical Call” card, send your request including mailing information and your phone number, with your check for $25.00, made payable to the New York County Medical Society to: Parking Renewal Program, New York County Medical Society, 31 West 34th Street, Suite 7053, New York, NY 10001. If you have questions, call (212) 684-4698.
If you wonder whether all the doctors who do make those phone calls, send those emails, come to Albany Legislative Day, or Society legislative events really make any difference . . .. now you know. They DO. Thanks to our members who joined with those around the State to reach out to their elected representatives. In 2016, these are the results secured by the Medical Society of the State of New York and the county medical societies, in some cases working with coalition partners including MLMIC, the Greater New York Hospital Association, the Hospital Association of New York State, and medical specialty societies.
- We won the continuation of a fully–funded Excess Medical Liability program while deflecting efforts to severely limit eligibility to the Excess coverage.
- We convinced the Legislature to not take up the date–of–discovery statute–of–limitations bill which would have measurably increased physician–liability premium rates.
- We succeeded in convincing the Legislature to reject a proposal which would have expanded the list of providers eligible to deliver (and receive payment directly from the Workers’ Compensation program) to include acupuncturists, nurse practitioners, physician assistants, and social workers. Significantly, the Legislature also rejected the proposal MSSNY strongly opposed to eliminate county medical society review and assistance for physicians looking to be authorized to deliver care.
- Working with our specialty society partners, we succeeded in defeating EVERY broad scope–of–practice expansion bill, including the naturopath, podiatrist, psychologist, nurse–anesthetist, and dental scope–of–practice bills. These victories come about because all of medicine works together, beyond narrow specialty interest.
- We twice defeated CVS Health’s retail–clinic proposal, a direct victory for our primary care providers.
- We secured an exemption from the e–prescribing mandate for physicians who certify that they prescribe less than 25 prescriptions a year. We also secured the passage of legislation that would address concerns raised by physicians and their patients protecting timely patient access to medications and eliminating burdensome reporting requirements on physicians who invoke one of three legitimate exceptions and issue paper/fax/oral scripts.We secured the passage of legislation that would allow physicians to override step therapy protocols and legislation that simplifies the administrative practices of health insurers by allowing for the development of a standard prior authorization form for medications and reducing the time for credentialing new physicians from ninety to sixty days.
The Joint Commission has updated its policy on texting orders, and New York County Medical Society’s free member benefit, DocBookMD remains the best way to ensure your practice’s compliance.
The new Joint Commission policy reads:
“Licensed independent practitioners or other practitioners in accordance with professional standards of practice, law and regulation, and policies and procedures may text orders as long as a secure text messaging platform is used and the required components of an order are included.”
So what does this mean for you and your practice? It means that you can finally take advantage of the ease and efficiency of communication that mobile text messaging brings, but you need a secure platform on which to do so — the built–in messaging app on your phone just won’t cut it.
A secure texting platform must include the following:
— Secure sign–on process
— Encrypted messaging
— Delivery and read receipts
— Date and time stamp
— Customized message retention time frames
— Specified contact list for individuals authorized to receive and record orders
DocbookMD meets and exceeds all of these requirements and is free to all New York County Medical Society members. Learn more at https://www.docbookmd.com/about-us/ and download for free in the Apple App Store or Google Play.
Need help using the DocbookMD app? The user manual and tutorial videos will walk you through everything you need to know from beginning to end:
· DocbookMD User Manual
· DocbookMD Tutorial Videos
At its meeting on April 11, 2016, and May 9, 2016, the Board of Directors of the Society did the following:
- reviewed and discussed strategy for discussing resolutions at the 2016 meeting of the House of Delegates of MSSNY;
- discussed strategy to work with MSSNYPAC and the series of upcoming issues that would arise before end of the legislative session;
- agreed to open negotiations on several new membership benefits offerings, including HIPAA Secure Now! and a medical billing service; and
- unanimously voted appreciation to Doctor Michael Goldstein as he completed this presidential term.
The next meeting of the Board will be held on September 12, 2016.
HIPAA issues are in the news every day. Data breaches occur all the time. HIPAA audits are starting. HIPAA compliance is part of Meaningful Use and MACRA. There are so many issues related to HIPAA these days.
It was not like that even five years ago. Why is that? Because most of your patient information is going online in one form or another. HIPAA requires you to protect that information, and has specific guidance on how this must be accomplished. Health and Human Services is emphasizing HIPAA much more than it used to as the healthcare system transforms from paper to digital.
How can practices become HIPAA compliant? The same complex HIPAA regulations apply equally to the largest hospitals and the smallest practices. Hospitals have dedicated staff to deal with HIPAA, but clearly, a small practice cannot afford this luxury. What can practices do to maintain HIPAA compliance without having a HIPAA expert on staff?
The New York County Medical Society has partnered with HIPAA Secure Now! (HSN) to help our members with all these issues. Since 2011, HIPAA Secure Now! has helped over 3,500 clients with their HIPAA compliance needs. They cater to smaller healthcare organizations and have clients in all 50 states. HSN provides a comprehensive, yet affordable, HIPAA compliance service. Everything you need is included:
— Risk Assessments
— Documentation Portal
— HIPAA support and consulting
On April 27, CMS came out with a proposed rule on how physicians will get paid under MACRA (the Medicare Access and CHIP Reauthorization Act). If you want to read the whole 962 page snoozefest, you can find it here (PDF). But sleep or not, this regulation changes the fundamental Fee–For–Service (FFS) system that CMS has used since Medicare’s enactment in 1966. The new system is premised on tying physician payments to quality and value, and is directly related to the Triple Aim of providing better care, lower costs, and improved health.
The final rule will be imperfect and controversial. It will be despised by many. But don’t expect MACRA to be repealed. According to Anne Phelps of Deloitte & Touche,
MACRA is the rare health care law that was passed with overwhelming bipartisan support and continues to enjoy strong support from Republicans and Democrats in Congress. This all but ensures its continued implementation, regardless of theoutcome of the November elections.
HIPAA Is Not Optional in MACRA
We are not here to give you the complete lowdown on MACRA. However, we do want to emphasize one very important point: The Role of HIPAA Compliance. As indicated above, MACRA changes the way physicians will be paid. No longer will they be paid for just providing services (FFS). Rather, there is a very complicated formula called the MIPS Composite Performance Score (CPS) that will be used to determine adjustments to a physician’s Medicare payment. These adjustments can be as high as +-9% by 2022 (By the way, in order to amplify the effect of MACRA, CMS is explicitly encouraging private payers (PDF) to implement similar programs). In order to receive a substantial portion of the MIPS CPS and maximize revenue opportunity, each provider will have to have performed a HIPAA Security Risk Analysis (SRA) within their practice. It is important to understand that since the SRA is for the practice, it can be used for all physicians within the practice. Here is a quote from the MACRA Rule:
We would require the MIPS eligible clinician to meet the requirement to protect patient health information created or maintained by certified EHR technology to earn any score within the advancing care information performance category; failure to do so would result in a base score of zero, a performance score of zero, and an advancing care information performance category score of zero.
Furthermore, the document also states:
As privacy and security is of paramount importance and applicable across all objectives, the Protect Patient Health Information objective and measure would be an overarching requirement for the base score.
Clearly there is some MACRA/MIPS specific language in those quotes. Don’t get hung up on these terms. What is important is the role of HIPAA compliance: perform a HIPAA Security Risk Analysis and you are in position to maximize your MIPS CPS and your revenue. Don’t perform the Risk Analysis, and be prepared to take a hit on your payments.
The New York County Medical Society brought a number of important resolutions to the 2016 House of Delegates of the Medical Society of the State of New York (MSSNY).
Among actions taken on Society concerns:
- That MSSNY urge the New York State Health Department’s Bureau of Narcotic Enforcement (BNE) to issue rules permitting physicians to prescribe via paper/fax/phone in situations where the patient needs to comparison shop among pharmacies or where access to the EMR(s) or electronic prescribing software is not readily available, such as off hours or cross coverage situations, and that these situations be exempted from the e–prescribing requirement; and also urge the BNE to make regulatory changes to enable pharmacies that do not have a particular medication in stock the ability to transmit the prescription to another pharmacy that has the needed medication in stock; urge the AMA to work with the DEA and other appropriate federal agencies to enable the use of tokens in multiple care settings; and support legislation 1) removing the requirement that all paper/fax/phone prescriptions be reported to the Bureau of Narcotic Enforcement, allowing instead that the prescription be recorded in the patient’s medical records; and 2) ensuring that a physician not be subjected to civil or criminal charges or other ramifications from the Department of Health and Department of Education for having written a medically appropriate paper/phone/fax/verbal prescription.
- That MSSNY ask the Centers for Medicare and Medicaid Services (CMS) to enforce Unknown Diagnosis Coding and ICD-10 Policy with private insurers and managed care organizations, in that such policy is mandatory for all entities that are covered by the Health Insurance Portability and Accountability (HIPAA) law, but is being ignored by private insurers and managed care organizations; and to require all private and managed care insurers to formally adopt CMS’s longstanding policy (reflected in ICD–10), that if a physician (1) does not know the diagnosis at the start of an encounter; (2) has not established a definitive diagnosis by the end of the encounter; and (3) is facing a “probable,” “suspected,” “questionable,” “rule–out,” or “working diagnosis” scenario, then it is acceptable for him or her to report codes for signs, symptoms, abnormal test results, exposure to communicable disease, or other reason for the visit. The resolution also urges CMS to require private and managed care insurers to adopt CMS’s policy (reflected in ICD–10) that when the physician does not have enough clinical information about a particular health condition to assign a more specific code (e.g. if he or she suspects a diagnosis of pneumonia but by the end of the encounter has not determined the underlying cause of the pneumonia — bacterial, etc.), it is acceptable to report the appropriate “unspecified” code.
— Requiring insurance companies to provide clear instructions in a timely manner on the procedure for obtaining a prior authorization.
— Requiring that for each plan or product, the insurer post on its website a complete list of services requiring pre–certification/pre–authorization;
— Requiring that after a physician has telephoned a customer service representative (CSR) to determine whether a service requires pre–certification/pre–authorization, the insurer send the physician, by fax or e-mail, a written confirmation of the CSR’s verbal statement;
— Forbidding the insurer to deny a claim solely for lack of an electronic pre– authorization/ pre–certification request, if (a) if the CSR has stated verbally that the service does not require pre–authorization/pre–certification but that statement was inaccurate, and (b) the physician, relying on the CSR’s verbal statement, has failed to submit an electronic pre–authorization/ pre–certification request; and
— If pre–authorization is not required, a physician can request from the insurance company a pre–determination about whether a particular procedure will be covered for a particular patient, and the pre–determination, in writing, is binding.
- That MSSNY continue to advocate to prohibit health insurer “all product” clauses asking that any such legislation (1) require that the insurer must set forth separate terms (including compensation terms) for each of the insurer’s products that exist when the contract is signed; (2) require that if an insurer introduces a new product after the contract is signed, the insurer will not be permitted to unilaterally designate the physician as a participant in that product; (3) enable that the physician be allowed to choose either to participate or not participate in that new product; and (4) ensure that if the physician chooses to participate, the insurer must reach an agreement with the physician on business terms for that new product.
- That MSSNY continue to advocate for legislation to regulate the practices of Pharmaceutical Benefits Managers and legislation to ensure that physicians have the final say in choosing which medications their patients should receive, and limit the ability of PBMs to interfere with the treatment recommendations of a physician prescribing medications for his/her patient.
- That MSSNY continue to support background checks for firearm purchases and advocate for firearm safety education in all settings as a component of firearm licensing; and advocate for expansion and implementation of technologies to improve gun safety.
- That MSSNY work with state agencies to educate physicians about the effective use of pre–exposure prophylaxis for HIV and the US PrEP Clinical Practice Guidelines; and continue its advocacy work to require that all insurers cover the costs associated with the administration of PrEP including studying the feasibility of providing PrEP free of charge to high–risk individuals.
- That MSSNY ask the American Medical Association (AMA) to reaffirm the AMA’s policy regarding Maintenance of Certification and Maintenance of Licensure programs.
- That MSSNY work with the American Medical Association (AMA) and other state medical and specialty societies and the national specialty societies, to change federal law by creating new checks and balances on the Centers for Medicare and Medicaid Services (CMS) regarding the Relative Value scale and other fee determination methodologies; and, provide an appeal process both within CMS and the courts regarding fee and Relative Value determinations for specific procedures.
- That MSSNY urge the Centers for Medicare and Medicaid Services (CMS) to create specific, concrete guidelines applicable to any Medicare Advantage Plan (MAP) whose “transition” of its system, or update of its claims processing system, could harm physician practices financially; and that any such guidelines from CMS impose punitive penalties (including payment of interest on delayed claim payments, and additional corrective actions), when an insurer’s “transition” of its system, and/or update of its claims–processing system, has led to (A) significantly delayed claim payments beyond the 30 days required by most contracts with Medicare Advantage Plans (MAPs); (B) improper adjudication of previously paid claims; and/or (C) improper denials followed by overpayment recoveries.
- A resolution asking that MSSNY seek acceptable union partners and publicize union membership as an option worth considering for its employed members was referred to MSSNY Council for additional investigation.
The New York County Medical Society congratulates Malcolm D. Reid, MD, MPP, its past president, for his election as President of the Medical Society of the State of New York (MSSNY) during the April 2016 meeting of the House of Delegates of the Medical Society of the State of New York. Doctor Reid was also elected as a delegate to the American Medical Association, as was past president of the Society and MSSNY, Robert B. Goldberg, DO.
Doctor Reid is chairman of the department of Physical Medicine & Rehabilitation and has served as an Associate Medical Director at Mount Sinai St. Luke’s and Mount Sinai West.
A 1982 cum laude graduate of Fordham University, he simultaneously earned his medical degree and master’s degree in public policy from Harvard University in 1987. He received his internship training at Winthrop University Hospital on Long Island and did his residency training in rehabilitation medicine at Columbia–Presbyterian Medical Center, where he served as Chief Resident. He also received his board certification from the American Board of Physical Medicine and Rehabilitation.
Doctor Reid is particularly dedicated to medical education. He is a member of his hospital’s continuing medical education committee and is Assistant Professor of Rehabilitation Medicine, Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai. Additionally, he served as a Governor’s appointee to the New York State Hospital Review and Planning Council.
The members of New York County Medical Society are particularly pleased to have one of “our own” serve as MSSNY’s new president. Since his term began, Doctor Reid has spent much of his time in Albany fighting for doctors’ issues as the legislative session ended. He also spent some time back with New York County members at the Society’s Annual Meeting on June 7.
Members of the Society’s delegation work hard before and during the House of Delegates to craft policy and bring the problems of our members to the forefront so they can be addressed by orgnaized medicine. It’s a lot of work on top of a normal practice day, and it’s time away from work and home. What is there to say except “thanks” to these New York County members who gave their all to the House:
William B. Rosenblatt, MD, Chair
Anthony A. Clemendor, MD, Vice Chair
Michael Goldstein, MD, JD, Presidential Chair
Stuart Orsher, MD, JD, Chair Emeritus
Robert B. Goldberg, DO, MSSNY Past President
Malcolm D, Reid, MD, MPP, MSSNY President–Elect
Joshua Cohen, MD, MSSNY Council, Manhattan and The Bronx
Kseinja Belsley, MD
Matthew Bonanno, MD
Michael Borecky, MD
Eli Einbinder, MD
Milton Haynes, MD
Peter Lombardo, MD
Paul N. Orloff, MD
Edward W. Powers, III, MD
Zebulon Taintor, MD
Naheed Van de Walle, MD
Eugene Weise, MD
Mimi Buchness, MD, NYS Society of Dermatology and Dermatologic Surgery
Lana Kang, MD, New York State Society for Surgery of the Hand
Patricia A. McLaughlin, MD, NYS Ophthalmological Society
Thomas Sterry, MD, New York State Society of Plastic Surgeons
Monica Pozzuoli, MD, Weill–Cornell Medical College
Harold Sirota, DO, Touro College of Osteopathic Medicine
Karin Warltier, MD, New York University School of Medicine
Gayle Rudofsky Salama, MD, Resident/Fellow Section
Robert Viviano, DO, Resident/Fellow Section
Steven Lee, MD, Resident/Fellow Section
As part of the American Medical Association’s (AMA’s) ongoing work with the Centers for Medicare & Medicaid Services (CMS) on issues affecting Medicare providers and beneficiaries, the AMA would like to remind physicians that balance billing is prohibited for Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program. CMS has conveyed concern that some physicians are still billing QMB beneficiaries, despite the existing prohibition.
The QMB program is a Medicaid program that helps very low–income dual eligible beneficiaries — e.g., individuals who are enrolled in both Medicare and Medicaid — with Medicare cost–sharing. Beneficiaries in the QMB program have annual incomes of less than $12,000. Federal law protects QMBs from any cost–sharing liability and prohibits all original Medicare and Medicare Advantage providers — even those who do not accept Medicaid — from billing QMB individuals for Medicare deductibles, coinsurance, or co–payments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full.
It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost–sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost–sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice.
The following article is provided by Ivy Kramer, MSW, CSW, at Winston Medical Staffing, the New York County Medical Society’s endorsed medical staffing partner.
One of today's greatest challenges facing medical practices is retaining qualified, valuable employees or staff members. Because of the high costs, increased time and stress of training new employees resulting from high turnover, savvy business operators are always looking to improve their relationship skills and business practices in order to retain their valuable employees and maintain a long–term satisfied and dedicated staff. The following tips will help you, the practitioner have a "Staff that Lasts.”
- Give quality time to your valued employees: The more quality time you dedicate to your employees, the more valued your employees will feel. Increase the quality of this time by making eye contact with them during your interactions, and always remember to take time out of your busy day to stop and communicate with your employees.
- Really LISTEN to your staff members: Pay close attention to what your staff members are saying. Repeat back to your staff members what you heard them say to make sure that you heard them correctly, and also to show your staff members that you've been listening. Empathize with your staff members experiencing difficulty, and empower them to take actions to consistently produce positive results.
- Verbally acknowledge your employees regularly: Let your employees know that you appreciate their hard work and dedication. Verbally acknowledge them for their contribution and celebrate their successes. This will motivate your employees to continue maintaining an optimal level of performance.
- Motivate your staff to take risks and try new things: A staff that is motivated and allowed to take risks will be more creatively engaged and satisfied with their duties, and their innovative creativeness will produce profitable results. They will never be bored, and they will be looking forward to working on Monday.
- Recognize your valuable employees with Employee Recognition Programs: Implement an "Employee of the Month" program or you can choose an award title that will be more applicable to your practices. Award recipients love to see their name on a plaque hanging on the wall and see an article of appreciation written about them posted for all to see. They feel successful and appreciated.
- Be honest with your employees: Always be straight up and honest with your employees. No one wants to walk on pins and needles worrying about what the boss is really thinking. Your employees will respect you and be more likely to stay with you forever if they know that they can always count on you to tell the truth.
- Train your staff members to be able to handle emergency situations: Your staff members will rise to the standards you set for them. The best staff members are the ones who care about the practice as much as you do, and can jump in and do whatever it takes to have the practice run smoothly. Train them to be good enough to handle hiccups as they arise. They will feel great about themselves and your business will run effortlessly.
- Teach your staff members to communicate positively and effectively: Most people really have never learned how to communicate their feelings, perceptions, needs, and goals. They just automatically assume everyone is supposed to read their minds. Give your employees a safe space to learn how to say whatever is going on in their minds. This will facilitate clearing up any miscommunication or misperception in the workplace. Open lines of communication also leads to a fun, productive and committed environment.
- Spread the wealth: Implement employee incentive programs, wherein your valuable employees earn some sort of bonus or share of the increased sales or profits. This will result in your employees staying motivated and dedicated to the business' success, and they will also feel that their contributions are rewarded and appreciated.
- Create and motivate a continued positive, energetic workplace environment: Your employees will take your lead. They will learn their accepted behavior patterns from how you are being. Maintain a positive, high–energy frame of mind and expect the same from your employees. Teach all of your employees to support each other in staying in the positive zone. As a result, you will all consistently experience a fun, successful, and committed work life.
Congratulations! The Society introduces your access to JPMorgan's NY 529 Advisor–Guided College Savings Program. Society members can utilize this benefit in one of two ways: You can sign up for the program directly as a member using the New York County Medical Society Group ID, OR you can offer the program to employees of your practice using your own Group ID number.
Delay in Diagnosis of a Nasal Cavity Chondrosarcoma: A Case Study from MLMIC Case Review, Summer 2016, by Janna Nazarowitz, Senior Claims Examiner, Medical Liability Mutual Insurance Company. MLMIC is the Society’s endorsed medical liability insurer, and THE doctor–owned liability insurer in New York State. To learn more about how MLMIC can help you, contact (800) 275–6564.
Treating friends and relatives as patients can lead to malpractice litigation. Unfortunately, sometimes such relationships result in poor or inadequate medical documentation and disastrous results for the patient. To the shock of many physicians, friends and relatives do not hesitate to sue, despite what previously was a close relationship. The potential ramifications of treating family members and close friends are demonstrated in the following case from MLMIC Files.
In October 2005, a 19-year-old college student presented to the insured, an ear, nose and throat (ENT) physician, with complaints of sinus congestion, nasal blockage, and epistaxis for 3 days. The physician knew the patient’s family because they both attended the same religious services. The insured ENT considered this to be an informal visit and did not submit a bill to the patient’s insurer.
He examined the patient’s ears and found the examination to be within normal limits. However, the left nasal septum was deviated on the right and the anterior turbinate was hypertrophic. He gave the patient a prescription for a CT scan of the sinuses. He also recommended that the patient be seen promptly by a neurology consultant, but neither referred the patient to a specific consultant nor made an appointment with a neurologist.
The CT scan was apparently performed in November 2005. However, the insured ENT never
received an official reading or written report from the radiologist. Further, he failed to contact the radiologist to obtain a copy of the report. Rather, the patient gave the insured ENT a disc which contained the images of the CT scan. The ENT reviewed the CD and advised the patient that he had chronic sinusitis. He then mailed the CD directly back to the patient. He did not document his diagnosis of chronic sinusitis in the medical record, nor did he document that he sent the CD back to the plaintiff after reviewing it. His record contained only the brief note from the initial patient visit.
In January 2007, the insured ENT received a written request for the CT report from a subsequent treating ENT physician. The subsequent treating ENT included with his request a copy of his own consultation and follow up notes regarding this patient. The insured ENT responded that he had never received a final report of the CT scan and that the patient had the CD of the CT scan.
In May 2007, a third ENT physician saw the patient. He ordered a new CT scan which revealed a very large expansile lesion in the midline, pushing into the anterior cranial fossa as well as pushing into both orbits and anteriorly toward the ethmoid sinuses. There was a significant amount of expansion and erosion of the base of the skull. The lesion did not appear to be wildly invasive, but rather expansive in nature. This physician reviewed the 2005 CT scan and confirmed that this lesion was in fact present on that first scan but at that time was not yet near the orbits. The patient was advised to promptly undergo a cranial facial resection and did so. An endoscopic resection of a sinonasal and skull base neoplasm was performed, using intraoperative image guidance. The probe confirmed that the tumor had been removed at the level of the anterior cranial fossa dura, the clivus and the cavernous sinus laterally. The patient’s visual acuity improved to 20/40.
Although an MRA of his brain was normal, an MRI revealed residual disease. In October 2007, the patient was admitted for treatment of what was initially believed to be a recurrent chordoma. He again underwent an endoscopic resection with image guidance. He was discharged the same day and had an uncomplicated postoperative course.
In May 2008, the patient commenced a lawsuit against only the insured ENT physician. He claimed that the insured was responsible for a 19–month delay in diagnosis. He claimed damages for pain and suffering arising from three transnasal surgeries and a bilateral craniotomy to remove the tumor.
However, after he commenced the lawsuit, the patient’s condition continued to deteriorate. Later in May 2008, the patient experienced headaches and visual disturbances. He underwent surgery for recurrence of the tumor. An endoscopic resection of a tumor involving the paranasal sinuses and skull base was performed without complication using image guidance. The pathologist made a diagnosis of a chondrosarcoma. In August 2008, the patient was diagnosed with bilateral optic neuropathy. His correctible vision was 20/30 in the right eye and 20/40 in the left eye.
In May 2010, the patient was re–evaluated by a neuro–ophthalmologist due to double vision. The patient was hospitalized from February 2011 through March 2011 for a cerebrospinal fluid leak and secondary meningitis. By May 2011, the double vision had subsided without additional therapy because it apparently was due to an inflammatory process. The patient’s mental status, cranial nerve, and motor coordination testing remained normal. However, the patient was orthophoric. His vision was 20/100 in the right eye and 10/400 in the left eye. He had temporal loss in his right eye and poor fixation. The patient had a worsening of his bilateral optic neuropathy.
The insured ENT was shocked that the son of his acquaintances would sue him for only one appointment for which the patient was not even billed. However, the expert ENT reviewers for MLMIC were very critical of his treatment of this patient. They focused their criticism on his failure not only to document his review of the results of the November 2005 CT scan but also his failure to pursue a copy of the final CT report from the radiologist. By failing to do so, he completely missed the sphenoid lesion causing the patient’s symptoms.
The experts also criticized his failure to confirm that the patient promptly underwent the recommended CT scan and evaluation by a neurologist. Finally, the lack of documentation
in the medical record of his alleged communication with the patient after the initial visit also
weakened the defense of this lawsuit.
As a result of these serious deficiencies, the case was settled on behalf of the insured ENT for $1,250,000.
Idilus is a Professional Employer Organization (PEO) and physician and hospital consulting company, which can provide physician practices with tax, payroll and other human resources services — plus, for many practices, health insurance using a "name brand" national PPO network. You must sign up for the basic human resources services, and the health insurance is underwritten, but Idilus's offerings are worth your consideration. The Society has entered into an exclusive contract with Idilus that allows members to receive services at pre–negotiated discounts. Please contact Matt Peterson at (877) 545–5666 for more information about Idilus benefits or visit http://nycmsbenefits.com/ The prices listed are as discounted for Society members.
>The endorsement by NYCMS of selected vendors is not intended nor should it be construed as personalized legal or financial advice. Each physician in conjunction with his/her own advisors must determine what is appropriate for his/her particular circumstances.
Q: We would like to start offering extended hours of operation for our patients on certain days. Our lease says that the landlord will provide heating and air conditioning after hours if we make a request early enough in the day, on the days we’ll need it. Are we sufficiently protected from paying extra for the required services?
A: From Marisa Manley, President, Commercial Tenant Real Estate Representation, LTD, and the Society’s Commercial Tenant Concierge Program: The need for overtime HVAC is often substantial for many medical facilities, and paying for services that you require but that others do not is appropriate. However, if your landlord’s lease is too general and nowhere specifies what building services will be provided — for example, HVAC services at what temperature and with what volume of air flow — you are not fully protected. In addition, if your lease does not specify how overtime charges will be computed, you may be subject to arbitrary charges.
The best plan is to determine how often you’ll need overtime HVAC, determine the level of service required, and negotiate for a package.
Commercial Tenant Concierge can help you analyze your needs, develop a plan and negotiate with your landlord for reasonable pricing. Call (212) 684–4400, and say you are a Society member.
The following is courtesy of James McNally, and the Society’s Third–Party Insurance Help Program.
• 2017 ICD–10 Codes & Updates Released: As with past updates to the old ICD–9 coding manual, ICD–10 codes will be updated every October. To that end, the Centers for Medicare and Medicaid Services (CMS) has released the ICD–10 codes that will be effective the last quarter of 2016 and into 2017. Physicians may wish to familiarize themselves with these new and updated codes prior to their effective date of October 1, 2016. To review and download a copy, click on the link here and then click on “2017 Code Descriptions in Tabular Order.” This is a zipped file. https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html
• Update on United Healthcare Medicare Solutions Medical Record Requests.: As reported previously, members have reported receiving multiple computer–generated requests for the medical records of their United Healthcare (UHC) Medicare Solutions patients. These requests state that payment is being withheld pending review of these records. In essence, it's a pre–payment review! Interestingly enough, these requests have been received by multiple specialties. So, it appears that no one group of physicians is being targeted. Calls to the UHC Customer Service Representatives have been met with vague answers as to why these letters are being generated and sent. However, the letters have been going out in such a large volume, and to so many different types of practices, that a contact with UHC senior staff has been needed to determine exactly what had prompted this activity. A contact/complaint was then made with the Centers for Medicare and Medicaid Services (CMS) by the Society.
As a result of this contact, UHC, at the prompting of CMS, has provided the following contact person to work with you to resolve these issues. Send an e–mail to the following individual:
Phone: (212) 912–4022
Please include physician name, contact name and number, tracking number if available, TIN, NPI and brief description of the issue. Ask the following questions when you submit your case.
— Why weren't you notified that you were allegedly exceeding any in–house parameters as to the appropriate utilization of a given service(s) and then were placed in prepayment status without even a warning?
— Why were you not given any detailed explanation as to who this universe of physicians were that you are being compared to and by what percentage they allege you exceeded these proprietary parameters? (Most likely, you were probably well within the preferred practice patterns set by your national specialty societies.)
— What mechanisms will be used and how can you reasonably be expected to be removed from this prepayment status — what percentage of claims are needed to pass the review process as sufficiently documented — what criteria are they using vis a vis the utilization parameters they were applying, etc.?
• 2016 NYS Legislative Session Closes! ERx E–mail Notification Process Removed!
The 2016 New York Legislative Session closed on June 18, 2016, with some significant issues being resolved or, at least, tabled for the next session. Chief among them are the following.
NYS E–Prescribing: Eliminates requirement that prescriber notify DOH any time one of the three allowable exceptions is invoked.* Prescribers can instead make a chart note that they invoked one of the recognized exceptions. (*The three statutory exceptions involved situations where a physician writes/faxes or calls in a paper script because their technology or power has failed; the prescription will be filled outside of New York; or it would be impractical for the patient to obtain medications in a timely manner.). To send a letter to the Governor to urge him to sign this provision, click on the link here. Send a Letter!
Allows a pharmacy which is out of a particular medication to transfer the prescription to another pharmacy.
Allows for prescriptions to be sent to a secure site and then downloaded by the pharmacy of the patient's choice.
• United Healthcare Releases June 2016 Network Bulletin: The June 2016 United Healthcare (UHC) Network Bulletin has been released and is available at the link below. Major changes involve the After Hours, Maximum Frequency Per Day policy, New Patient Visits and others.
• Important Update on Medicare Advantage Appeals and Grievances Released by CMS: The Centers for Medicare & Medicaid Services (CMS) has posted a number of important updates to the Appeals and Grievances process used by Medicare Advantage plans. A Web–Based Training (WBT) module is available at the link here.
In addition, these changes are also noted in the Medicare Managed Care Manual, Chapter 13, on Appeals and Grievances at the link here.
These changes will impact what you need to do when treating a Medicare Advantage patient and a service you will render is or likely to be denied as non–covered by a Medicare Advantage plan.
This is due to the fact that a Medicare Advantage patient has the right to an advance determination of whether services are covered prior to receiving such services. They are called pre–service organizational determinations. Failure to ask for this pre–service determination could result in any funds collected to be refunded, so physicians should touch base with the Medicare Advantage plans they participate with. Ask them what forms are necessary and what process they are using for these advance determinations. Please note that an Advance Beneficiary Notice cannot be used for Part C beneficiaries.
For guidance on all these issues, contact us through the Society’s Third–Party Insurance Help Program at (212) 684–4681.
Written by Ariel Jacoby on February 12, 2016. Originally published at www.medelita.com Medelita is the Society’s endorsed provider of quality lab coats and scrubs. Check out the Society discount at https://www.medelita.com/nycms-members.html
Here are eight easy ways that you can effectively improve communication between you and your patients:
- Listen first and don't interrupt. Let the patient tell his or her story and allow them time to find the right words to explain their symptoms or recall medical history. Studies have shown that on average, physicians will interrupt their patients within 23 seconds of the beginning of the discourse. Listen carefully and pay attention to non–verbal cues as well.
- The average comprehension level of the U.S. population is between that of a sixth grader and an eighth grader. A good rule of thumb is that when explaining medical knowledge to a patient, avoid using medical jargon and anatomical terms and speak in such a language that a sixth grader would be able to understand. Think about what you want to communicate and translate it in your mind to use simple English instead of complication medical terms.
- Humans are highly visual learners; in many cases having a medical diagram on hand to supplement your verbal communication will give your patient a more comprehensive grasp of the knowledge you are trying to explain.
- Don't talk too fast. This may sound like a no brainer, but it is important for you to take the time to explain important information very slowly and don't rush through negative information just because it is unpleasant. If you are running short on time and have to rush to your next appointment, schedule a follow–up appointment with them for you to thoroughly go over important information together.
- Be wary of your body language. Small details as simple as not making eye contact with your patient can damage the rapport between you and your patient. This can harm the trust that your patient has in you, or cause them to subconsciously shut down and lose interest in paying attention, or both.
- Make sure the patient is engaged. This is the best way to make sure that your patient not only understands the information you are telling them, but that they remember it for a longer period of time. Have your patients parrot back to you the things that they understand, and ask questions about what they don't.
- When it comes to ensuring that your patient is communicating effectively with you regarding medical history and health habits outside of visits to the doctor, ask a variety of open–ended questions. Asking patients questions such as "how do you spend a normal day?" or "what are your biggest priorities in your life?" engages your patients and gives them a reason to be more forthcoming with you about health–related information.
- Follow through with your patients' education. Before they leave the appointment, give them one last opportunity to ask you any remaining questions. Let your staff know what you have ordered for the patient and inform them of what needs to be done on their end.
The following nine candidates for membership are presented to the Board of Directors of the Society. Anyone with information reflecting against election of a new member is requested to notify the secretary of the Society as soon as possible
Michael C. Alpert, MD
Imran Ashraf, MD
Arvind R. Davanabanda, MD
Ruby Harmon, MD
Chad Kaplan, MD
Emerald Lin, MD
Ositadinma L. Mbadugha, MD
Samantha Xavier, MD
Fang Zhou, MD
Thomas A. Doyle, MD, died February 10, 2016. Doctor Doyle received his medical degree from Weill Cornell Medical College in 1949.
Alfred D. Grant, MD, died May 20, 2016. Doctor Grant received his medical degree from Chicago Medical School in 1957.
Jack Rudick, MD, died March 20, 2016. Doctor Rudick received his medical degree from University of Witwatersrand Medical School in 1957.