Medical Association of Georgia Journal - March2018 by PubMan, Inc.

Vol. 107, Issue 1, 2018

Reinventing MOC – from the grassroots up GCMB’s take on medical ethics Rep. Carson makes a case for his ‘hands-free’ bill An update on the PDMP The changing tide in practice management Preventing workplace misconduct

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TABLE OF CONTENTS VOLUME 107, ISSUE 1

IN EVERY ISSUE

31 Perspective

3 President’s Message

32 Prescription for Life

4 Editor’s Message 6 Executive Director’s Message 12 Medical Ethics

FEATURES 8

Reinventing MOC – from the grassroots up

14 Georgia Composite Medical Board: One’s ethical obligations 11 Georgia PDMP update 16 Legal: Preventing workplace 21 Nearly 100 physicians, 40 misconduct lawmakers attend 2018 ‘Physicians’ Day at Capitol’ 20 Practice Models – Private Practice 24 Rep. John Carson’s ‘hands-free’ bill 22 Patient Safety: Prescribing for the elderly 26 Practice Management: The tide will change in 2018 28 County, Member & Specialty News

PRESIDENT’S MESSAGE

Being a good doctor isn’t good enough Frank McDonald, M.D., M.B.A.

fmcdonald@icloud.com

he U.S. health care system is in the midst of one of its most disruptive periods in history. And I wish the outlook included greener pastures, but we all know that we are on a path that is both rocky and steep. Making a good living as a physician has become increasingly difficult, but it’s certainly not an impossible task.

A few years ago, I read an article about a neurologist who was leaving his practice to become a school teacher because he could no longer make a living practicing medicine. Here was someone who was among the best and brightest of his generation and who had spent years learning his art but could not make a living at it. How could this be? The truth of the matter is that practicing good medicine simply isn’t enough in 2018. Providing the best possible patient care is our calling, and it will always be our priority. But we also have to remember that even though patients come before profits, we won’t have the resources to care for our patients if we don’t have profits. Moreover, it is important to remember that we also are not entitled to any financial rewards just because we have medical degrees. We live in a competitive and free society, so – like any profession – there is a correlation between our performance and our financial success. It is also true that one can be the most talented physician in the world and still go bankrupt if they do not embrace sound business principles. When I was in business school, I was constantly trying to think about ways I could apply the sound business principles that I was learning to improve my practice. Five key concepts emerged in nearly every class I took, including… Batching is bad Batching is the accumulation of something for future action. It can be the accumulation of patients waiting for appointments for months because you have a faulty scheduling system. It can be an overflowing waiting room because your patient flow process is flawed. If you have a large sum in accounts receivable, your collection processes are poor. If your storage rooms are full and you have accumulated several months’ worth of supplies and drugs, you are batching inventory. If you are accumulating anything for extended periods, take steps to reduce that inventory.

Measure everything You cannot improve what you do not measure. However, remember that data is expensive – so don’t collect data for the sake of it. Collect data to facilitate change. You have to know how long new patients have to wait to schedule an appointment. You have to know your actual no-show rate – and not just the average. You have to know the no-show rate for Monday mornings versus Friday afternoons and for different age groups and payers. You have to understand how much you get paid for every patient encounter, by every payer, and how much each encounter costs you to provide. If you don’t measure data in relevant ways and understand the data you collect, you can’t effect change. If it ain’t broke… The Toyota Production System showed the manufacturing world how to build faster, better, and cheaper automobiles. While building cars and practicing medicine is apples and oranges, we can take advantage of Toyota’s continuous process improvement to make our practices more profitable. Don’t wait until a process fails to improve it. Study every practice process and look for ways to improve them. It might not be broken, but in a lot of cases we can make it better. Less is more One of the giants of 20th century architecture, Ludwig Mies Van der Rohe, coined the phrase “less is more” to describe his minimalist style. The more common term that’s used in the business world is “lean manufacturing.” Either way, you should look for ways to get the same or better results with less stuff. The Pareto principle The Pareto principle states that 80 percent of the results can be attributed to 20 percent of the effort. There are hundreds of processes your practice employs – ranging from making appointments to putting stamps on envelopes. With this equation in mind, you should concentrate on the top 20 percent – the proverbial low hanging fruit. The future is daunting, but we can eliminate a lot of the uncertainty and increase our practice revenue if we adopt a few sound business principles. www.mag.org 3

EDITOR’S MESSAGE

The Medical Association of Georgia 1849 The Exchange, Suite 200 Atlanta, Georgia 30339 800.282.0224 www.mag.org MAG’s Mission To enhance patient care and the health of the public by advancing the art and science of medicine and by representing physicians and patients in the policy-making process. Editor Stanley W. Sherman, M.D. Executive Director Donald J. Palmisano Jr. Publisher PubMan, Inc. Richard Goldman, rgoldman@pubman.net 404.255.5603, ext. 1 Editorial Board Jay S. Coffsky, M.D., Decatur Mark C. Hanly, M.D., Brunswick Mark Murphy, M.D., Savannah Barry D. Silverman, M.D., Atlanta Joseph S. Wilson Jr., M.D., Atlanta Michael Zoller, M.D., Savannah MAG Executive Committee Frank McDonald, M.D., President Rutledge Forney, M.D., President-elect Steven M. Walsh, M.D., Immediate Past President Lisa Perry-Gilkes, M.D., First Vice President Despina D. Dalton, M.D., Second Vice President Frederick C. Flandry, M.D., Chair, Board of Directors Steven M. Huffman, M.D., Vice Chair, Board of Directors Edmund R. Donoghue Jr., M.D., Speaker James Barber, M.D., Vice Speaker Andrew B. Reisman, M.D., Secretary Thomas E. Emerson, M.D., Treasurer S. William Clark III, M.D., Chair, AMA Delegation W. Scott Bohlke, M.D., Chair, Council on Legislation Advertising PubMan, Inc. 404.255.5603 or 800.875.0778 Fax 404.255.0212 Brian Botkin, bbotkin@pubman.net Subscriptions Members $40 per year or non-members $60 per year. Foreign $120 per year (U.S. currency only). The Journal of the Medical Association of Georgia (ISSN 0025-7028) is the quarterly journal of the Medical Association of Georgia, 1849 The Exchange, Suite 200, Atlanta, Georgia 30339. Periodicals postage paid at Atlanta, Georgia, and additional mailing offices. The articles published in the Journal of the Medical Association of Georgia represent the opinions of the authors and do not necessarily reflect the official policy of the Medical Association of Georgia (MAG). Publication of an advertisement is not to be considered an endorsement or approval by MAG of the product or service involved. Postmaster Send address changes to the Journal of the Medical Association of Georgia,1849 The Exchange, Suite 200, Atlanta, Georgia 30339. Established in 1911, the Journal of the Medical Association of Georgia is owned and published by the Medical Association of Georgia. © 2017.

4 MAG Journal

MOC - A wakeup call Stanley W. Sherman, M.D.

t is perhaps ironic that Dr. Paul Tierstein, the chief of cardiology and the director of interventional cardiology at Scripps Clinic in San Diego – and a researcher and the head of its Fellowship training program – became the leader of the movement against MOC and the founding president of the National Board of Physicians and Surgeons (NBPAS). His organization recognizes CME rather than testing as the key to certification after his frustration with trying to comply with the American Board of Internal Medicine’s (ABIM) complicated, costly and, as he has stated in interviews, nearly worthless and time-wasting demands. He was taken aback by the charges ABIM had for approving MOC activities at national meetings, the charges for its computer modules, and the compensation of its administrators. Dr. Tierstein found no evidence that the public was demanding more oversight leading to their MOC demands on physicians. The NBPAS was started when a group of nearly 120 of his program director colleagues, also upset, asked him, “What are you going to do about it (MOC)?” Dr. Tierstein has maintained that exam questions are often not relevant to physician practices and can be outdated, while closed book tests are irrelevant given online resources and colleagues. Studies have shown no association between recertification and performance on quality measures. Therefore, it’s an activity with no proven efficacy but with high cost. He feels CME offerings provide choice, and if we do not perceive value, we can choose other offerings – in contrast to the ABIM monopoly on MOC. In his 2015 article in the New England Journal of Medicine, Dr. Tierstein wrote that “many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care, who have lost contact with realities of day-to-day clinical practice. Perhaps it is time for practicing physicians to take back the leadership of medicine.” Perhaps this is now happening. In a December 2017 letter to members of the NBPAS, Dr. Tierstein noted that 6,000 physicians are certified by the NBPAS. Five state laws, including Georgia’s, limit the requirement of MOC. There are 15 other states that have pending anti-MOC bills in process. NBPAS has charged $84.50/ year regardless of the number of certifications, and Dr. Tierstein states he is not getting paid. I am proud of the Medical Association of Georgia (MAG) and its American Medical Association (AMA) Georgia delegation’s approach to dealing with MOC. The AMA has, thus far, chosen to study the data from various alternatives and proposals from specialty organizations, and it has called for improved cost effectiveness. MAG CEO Donald J. Palmisano Jr. has sought our input in working for change in the American Board of Medical Specialties (ABMS). Personally, when lawyers and dentists need only continuing education – and no other country retests physicians like our country does – the time has come to rethink the need for the ABMS and its ABIM component after initial certification. We should leave necessary CME requirements to our specialty societies to make sure we are aware of new studies and new guidelines, or we should join the NBPAS. If you need to ask us

a question about the CME and we give the wrong answer, you must give us the correct answer immediately, so we can learn from this effort. This is professional education, not a game to see if we can answer questions purposely written in such a way that no one can answer them all correctly, and grades must be curved to pass or fail. We all need to be 100 percent correct about well delivered information that improves our patient care. And guess what…if ABIM thinks our patients are going to its website to see if we are doing its MOC, in this era where patients are being told that seeing a lesser-trained and lesser-experienced, and if they have their way, less supervised, “health care professional” is best, then the ABIM needs the wakeup call, not us. Very little of what I do now was what I did when I was trained, and the ABIM was not and will not be responsible for giving our patients the best care. We are, and we always have been and always will be. Our feature article takes an in-depth look at the MOC changes that have been proposed by ABMS. I still vividly remember the November 1, 2013 ABIM letter telling me to enroll in MOC by March 31, 2014 or be reported as “certified, not meeting MOC.” It mandated that by December 31, 2015, and every two years thereafter, one must complete at least one ABIM APPROVED MOC activity to earn points. It also mandated that by December 31, 2018, and every five years thereafter, one must earn 100 points distributed across two key areas: practice knowledge and practice assessment. In addition, one would need to fulfill a patient safety and patient survey requirement – then pass the exam for your certification. Who did they think they were to make these demands on us? Our MAG members were quick to respond to this, but it took until February 3, 2015 to get the ABIM letter saying, “WE GOT IT WRONG AND SINCERELY APOLOGIZE.” The only changes they made at that time was to suspend the practice assessment, patient voice, and patient safety requirements for at least two years. ABIM also changed “meeting MOC requirements” to “participating in MOC.” It planned to

“update the MOC exam, keep enrollment fees at 2014 levels and, by the end of 2015, recognize approved CME.” This letter did not strike me as admitting to getting any demands wrong. The fact that in March 2018 we are still trying to change ABIM MOC verifies they do not really think we know how to ensure good patient care – THEY do. In this edition of the Journal, Don Palmisano writes about MAG’s efforts and accomplishments to reform MOC, including his work with the Vision Commission. He uses the analogy of the alligators and the swamp in dealing with MOC. While I applaud these efforts, I prefer to interpret his analogy more in line with President Trump. I think it is time, at least in the case of the ABIM component, to “clear the swamp” of all the predatory, power and money-seeking administrative “alligators” who made these demands on us to begin with. I prefer to remove, not negotiate with, the people who came up with the initial MOC demands. MAG President Dr. Frank McDonald, Elizabeth Woodcock, a practice management expert, and Dr. Mark Murphy all contributed articles helping us deal with the business side of the practice of medicine. Dr. Barry Silverman’s latest practice model example is Dr. Joe Stubbs’ private group practice. We have an update on the Georgia Prescription Drug Monitoring Program requirements from MAG Legal Counsel Bethany Sherrer, J.D., MBA, MHA, as well as timely advice to ensure a proper work environment from Dan Huff with Huff, Powell & Bailey. Our patient safety article from MagMutual deals with elderly medication prescribing. Dr. David Baxter discusses the goals of his new column on medical ethics. Dr. John Antalis discusses our need to follow the AMA code of medical ethics and our obligations to report those who break it to the Georgia Composite Medical Board. Rep. John Carson discusses his MAG-supported distracted driving bill, while Molly Welch recounts the pain and suffering she experienced as a result of distracted driving. Finally, Dr. Jay Coffsky kindly “beeps” us to the conclusion of our first Journal of 2018.

Physicians Foundation encouraging MAG members to complete biennial survey The Physicians Foundation is encouraging physicians in Georgia to complete its sixth biennial “state of the union of the medical profession” survey, which is designed to “examine the morale, career plans, and practice metrics of today’s physicians.” Physicians Foundation President Walker Ray, M.D., explains that, “This is the one national survey that allows physicians to share their perspective on the state of the medical profession. We’d like to hear from as many physicians as possible so we can accurately understand – and share with the public – physicians’ perspectives on the most significant issues in medicine and health care today.” More than 17,000 U.S. physicians completed the survey in 2016.

A final summary report will be emailed to every physician who completes the survey – and participants will be entered in a drawing to win one of five $500 Amazon. com gift cards or one $5,000 Amazon.com gift card. In addition, the Medical Association of Georgia will receive the aggregated Georgia survey results to use in its advocacy efforts. The deadline to complete the survey is Tuesday, June 5. The Physicians Foundation says the survey takes about 10 minutes to complete. The survey is being conducted by Merritt Hawkins. Go to https://www.mag.org/PF2018Survey to complete the survey. www.mag.org 5

EXECUTIVE DIRECTOR’S MESSAGE

Gators, swamps & MOC Donald J. Palmisano Jr.

dpalmisano@mag.org

here might not be an obvious relationship between the problems that physicians are having with maintenance of certification (MOC) and alligators and swamps – but bear with me for a few moments.

It is a given that the Medical Association of Georgia (MAG) needs to respond to its members’ needs. What’s also clear is that physicians in every specialty in the state have reached a near-boiling point when it comes to MOC. In 2014, MAG’s House of Delegates (HOD) passed several resolutions calling for MAG to promote legislation that would limit how MOC can be applied in the context of one’s licensure, health insurance panels, professional liability insurance, and medical staff bylaws. Then in 2017, Georgia became just the second state to pass a law restricting the use of MOC in the aforementioned context when Gov. Nathan Deal signed H.B. 165 into law. We thought that was the end of that, and we moved on to other issues. But during the American Medical Association’s Annual Meeting in the middle of last year, Hal Lawrence, M.D., with the American College of Obstetricians and Gynecologists, and Cathy Rydell with the American Academy of Neurology, called for a meeting of the national specialty societies and the state medical societies to discuss the MOC laws that were being passed around the country – and the need for a more comprehensive, nationwide solution. I participated in this meeting in my role as the chair of the state medical societies for the American Association of Medical Society Executives (AAMSE) and as a member of AAMSE’s board of directors. Over the next few months, Dr. Lawrence and I orchestrated a meeting of the state medical associations, the national specialty societies, and the American Board of Medical Specialties (ABMS) and its 24-member boards. We also submitted a letter to ABMS detailing the concerns that physicians have with board certification. The American Society of Anesthesiologists hosted that meeting, which took place in December. MAG President Frank McDonald, M.D., M.B.A., and I hosted the meeting on behalf of the state medical societies, and trust me when I tell you that ABMS and its respective boards got some honest feedback on a wide array of “diplomate” (i.e., physician) concerns – from the high-stakes, 10-year exam to ensuring that board certification be removed from health insurance panels and medical staff privileges and the high cost associated with MOC. 6 MAG Journal

In my estimation, the meeting was a huge success, as ABMS subsequently announced the creation of the ‘Continuing Board Certification – Vision for the Future’ initiative. Moreover, I was named to the 27-member ‘Vision Initiative Commission’ – keeping in mind that there were 176 nominations submitted from across the U.S., which was obviously good news for MAG members. The Commission’s charter is to “assess the status of continuing board certification and making recommendations to help enable the current process to become a system that demonstrates the profession’s commitment to professional self-regulation, offers a consistent and clear understanding of what continuing certification means, and establishes a meaningful, relevant and valuable program that meets the highest standard of quality patient care.” Along with MAG, some of the most vocal and effective advocates for MOC reform have included… • Charles Cutler, M.D., a past president of the Pennsylvania Medical Society • Paul Johnson, M.D., a past president of the Wyoming Medical Society • Nitika Gupta, M.D., with the Emory University School of Medicine • Catherine Rydell, the executive director and CEO of the American Academy of Neurology I am convinced that ABMS is genuinely interested in addressing the concerns that have been expressed by its diplomates. In fact, ABMS has been more than willing to convene multiple meetings with various stakeholders to listen to physicians. I also believe that we have a real opportunity to ensure that board certification fulfills its real potential, which is driving excellence in patient care. Rest assured that the Vision Commission will be hard at work. In the meantime, I encourage you to go to www. surveymonkey.com/r/S5YLCN7 to complete a survey that the Vision Commission is conducting to solicit physician feedback on MOC reform. I also encourage you to send me an email at dpalmisano@mag.org with any comments or questions. Let’s be open-minded, let’s participate in the process, and let’s take full advantage of this great opportunity. As an old friend of mine in Louisiana used to say, “Let’s not cuss out the alligator before we attempt to cross the swamp.”

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Reinventing MOC – from the grassroots up By Tanya Albert Henry

t’s no secret that physician angst over the profession’s maintenance of certification (MOC) programs has grown more vociferous with each passing day. The list of complaints includes a high-stakes exam, high costs, poor communications, and an inconsistent approach across two dozen American Board of Medical Specialties’ (ABMS) “Member Boards.” A lot of physicians believe that MOC has evolved into a de facto requirement for licensure, credentialing, and reimbursement – yet they also know that if the profession doesn’t come up with acceptable way to regulate itself, state legislators will. The good news is that, sparked by a grassroots groundswell of frustration, an ember of optimism and change may have been ignited when the Medical Association of Georgia (MAG) and a host of other state medical and specialty organizations met with ABMS leadership late last year. It was a candid, two-way conversation. Physicians had a chance to discuss their concerns about MOC, while the Boards outlined their efforts to improve their programs. This included the “Continuing Board Certification: Vision for the Future” initiative, an effort that is designed to identify a reform path for MOC programs using a process that will give practicing physicians the opportunity to “provide their perspectives on continuing board certification as well as offer input, suggestions and feedback regarding future program improvements.” What’s more, MAG Executive Director Donald J. Palmisano Jr. was selected to be one of 27 ‘Vision Initiative Commission’ members – keeping in mind that there were 176 nominations submitted from across the U.S. The Vision Commission members represent a broad crosssection of physicians from a wide variety of specialties and practice settings and a diverse group of stakeholder communities, including national specialty and state medical societies, 8 MAG Journal

hospitals and health systems, health care organizations, and the general public. This Vision Commission has been tasked with “assessing the status of continuing board certification and making recommendations to help enable the current process to become a system that demonstrates the profession’s commitment to professional self-regulation, offers a consistent and clear understanding of what continuing certification means, and establishes a meaningful, relevant and valuable program that meets the highest standard of quality patient care.” MAG President Frank McDonald, M.D., M.B.A., a boardcertified neurologist who cares for patients at the Longstreet Clinic in Gainesville, believes that, “This is a great development for physicians in Georgia, and I can assure you that MAG will continue to take the feedback that it receives from its member physicians to help fix a flawed MOC system.” Palmisano stresses that, “The house of medicine really needs to figure this out, or physicians could be looking at some big and ominous repercussions down the road. We also can’t lose sight of the fact that the individual physician is ultimately responsible for the quality of the care they provide.” It is worth noting that MAG was one of 40 other state medical and 33 national medical specialty societies that sent an August 2017 letter to ABMS that outlined physicians’ frustrations and concerns over MOC – a correspondence that served as the impetus for the December meeting and subsequent action. Dr. McDonald asserts that, “Our complaints no longer seem to be falling on deaf ears. In fact, I have already seen tangible evidence that real change is coming – as the American Board of Psychiatry and Neurology is piloting an article-based assessment program that will ultimately take the place of the high-stakes exam.” Hal C. Lawrence III, M.D., the American College of Obstetricians and Gynecologists’ executive vice president and

CEO who represented national medical specialty societies at the December meeting, agrees that changes are afoot. He notes that several boards have already been improving the recertification process over the past couple of years, including the American Board of Obstetrics and Gynecology (ABOG). He is optimistic that the Vision Initiative will continue to bring about the right changes, stating that, “If they decrease the burden and give physicians options that allow them to opt out of the secure exam, it would take away a lot of the pressure physicians are feeling and alleviate the stress.” ABMS’ response to physicians’ concerns ABMS leadership has heard the chorus of objections from physicians, and it acknowledges that MOC needs to change. In fact, the Boards Community issued a statement to the state medical and professional specialty societies in January that details the changes that are underway – as well as their commitment to continue to improve the process. “We are listening to physicians, and we are responding,” says ABMS President and CEO Richard E. Hawkins, M.D. “For example, in 2015 ABMS standards were updated to encourage Member Boards to be more flexible in how physicians fulfill the MOC process.” He adds that, “Some boards have already made changes that moved MOC away from a single, high-stakes exam and to align some of their MOC requirements with other continuing medical education and quality reporting requirements.” And Dr. Hawkins assures that every ABMS-member board is changing the process it employs. For example… •

ABOG is working with the American College of Obstetricians and Gynecologists to provide diplomates CME credit for the article-based Part II MOC program. ABOG also has developed modular exams that allow diplomates to select content that is relevant in terms of their practice focus. And ABOG is conducting a pilot to evaluate an alternative to the high-stakes exam.

• The American Board of Ophthalmology replaced its high-stakes ‘DOCK’ exam with ‘Quarterly Questions,’ a convenient on-line assessment program that has clearer ties to patient care and can be completed at home or in the office. • The American Board of Family Medicine has launched a ‘Continuous Knowledge and Self-Assessment’ program that facilitates learning and feedback and also satisfies Part II MOC requirements. It is also collaborating with the American Academy of Family Physicians to award MOC credit for Performance Improvement CME. • The American Board of Internal Medicine (ABIM) is expanding the CME activities that it accepts for MOC credit and reducing the administrative burden of reporting completed activities via automatic reporting through a partnership with the Accreditation Council for Continuing Medical Education. In 2018, ABIM also plans to introduce a more frequent, less-burdensome alternative to the highstakes exam that can be completed on a remote basis – and physicians who choose this option will have access to an “open book” resource.

“The goal, here, is flexibility and ease of use,” Dr. Hawkins says. “When we get the word out about what the Boards are doing, physicians have generally been pleased.” ABMS is also trying to streamline MOC processes so they are better aligned with hospital practice evaluations and quality improvement activities, as well as federal quality reporting requirements For example, the ABMS Multi-Specialty Portfolio Program allows doctors to receive Improvement in Medical Practice (Part IV) MOC credit for participating in activities they are already engaged in at their hospital or through their organization including some specialty societies. Plus, Dr. Hawkins adds, ABMS is striving to improve its communications with physicians – something physicians have flagged as a problem – and it is working to gather input from multiple stakeholders, including practicing physicians at different stages of their careers and in rural and urban settings to determine how the Boards can continue to make MOC more valuable and relevant for patients and physicians. When it comes to the Vision Initiative, Dr. Hawkins emphasizes that, “We need to get this right for the sake of our profession and our patients, so we will continue to listen, we will continue to engage the profession, and we will continue to communicate with the state and specialty societies.” Dr. Lawrence says that, “Alleviating the stress that recertification has created for physicians in recent years is all the more important as medicine has become an increasingly demanding environment for physicians.” He adds that, “There is more physician stress and burnout – which is fueled by electronic medical records, increasing regulations, changes in reimbursement and, yes, MOC.” High stakes moving forward In recent years, some physicians have turned to alternative credentialing processes, such as the National Board of Physicians and Surgeons, that offer a less-strenuous path for physicians to show that they have remained up-to-date in their specialty by attesting to their CME. Meanwhile, other physicians have bypassed any kind of formal process altogether – pointing out that the data shows that, initial certification notwithstanding, there is no correlation between MOC and the quality of care a physician delivers. Of course, going this route can create problems for physicians (e.g., credentials, insurance). There does appear to be a consensus that the physician community needs to develop an acceptable form of selfregulation, be it MOC or some other mechanism. And Dr. McDonald insists that, “If we don’t figure this out on our own, the government will most certainly step in to fill that void – and that’s not something anyone in the profession welcomes.” Dr. Lawrence agrees, and says, “It’s a slippery slope to go to the state legislatures. They may begin by regulating MOC, but regulations may seep into other areas of the practice of medicine. And lawmakers don’t know what an OB-GYN, or another doctor, should do when it comes to the best way to care for their patients.” www.mag.org 9

Dr. Hawkins echoes those sentiments, stating that “This is something we need to solve within medicine, and we don’t need to give professional regulation away to the state legislatures.” He emphasizes that, “It was never our intention for MOC to be required for licensure – as evidenced by our policy, which is to maintain a distinction between licensure, for general practice of medicine, and certification, which denotes competence in specialty medicine. “We do, however, believe that it is an important credential and should be used by all stakeholders in the health system who value specialty expertise. We do not believe it should be the sole criterion for credentialing decisions.” While things get sorted out at the national level, physicians in Georgia have received some relief and peace of mind as a result of MAG’s efforts. Palmisano explains that, “Because MOC had become so onerous and physicians did not feel like the boards were changing to meet their needs, MAG lobbied state lawmakers to pass a bill that stipulates that MOC cannot be required as a condition of licensure to practice medicine, employment in certain facilities, reimbursement or malpractice insurance coverage.” And since Georgia Gov. Nathan Deal signed H.B. 165 into law in 2017, six states have passed similar laws – while another six states have comparable bills pending. Moving forward When it comes to MOC, there does seem to be a genuine sense of optimism.

“I have taken an active role in this process from the beginning, and I believe that we have a real opportunity to make some real strides in the MOC arena,” says Dr. McDonald. “I have a hope and expectation that we will see a closer working relationship between physicians and ABMS and its boards, and I also believe that we will see better lines of communications.” Dr. Lawrence sees the recent developments as both significant and historical. He explains that, “This is the first time that I can recall leaders from certifying boards, national specialty societies, and state medical societies coming together to tackle a single issue – and I’m hopeful that we can use this kind of collegial approach to address issues in the future.” Dr. McDonald concludes that physicians need to continue to speak their mind: “Physicians can’t passively accept what the boards require. Physicians inherently want to stay on the cutting edge of their given specialty, but we need to develop a better and less-burdensome way to demonstrate that we have the requisite knowledge and skill set.” MAG is encouraging its members to go to visioninitiative.org to complete a survey that the new ‘Vision Initiative Commission’ is conducting to solicit physician feedback to reform MOC programs. Contact Donald Palmisano at dpalmisano@mag.org with any questions related to the Vision Commission or MAG’s MOC advocacy efforts.

Resources ABMS ‘Vision for the Future’ initiative visioninitiative.org ABMS ‘Multi-Specialty Portfolio Program’ mocportfolioprogram.org

MAG executive director named to Vision for the Future Commission MAG will play a key leadership role in reforming MOC programs for physicians – as its executive director and CEO, Donald J. Palmisano Jr., has been selected to serve on the new ‘Continuing Board Certification – Vision for the Future” Commission.

stakeholders through multiple methods including a survey that is now open for input.

“This is a great development for physicians in Georgia,” says MAG President Frank McDonald, M.D., M.B.A. “MAG is going to have a seat at the table, which means that we will be able to take an active role in fixing the flawed MOC system.”

The Vision Commission’s final recommendations will be submitted to the ABMS and its Member Boards on February 1, 2019.

Palmisano is one of just 27 Vision Commission members who were selected from 176 nominations from across the U.S. The Vision Commission will begin [its work] by conducting a comprehensive assessment of the current continuing board certification system. Feedback will be obtained from various

10 MAG Journal

The Commission will hold hearings and seek feedback on concepts and ideas during the process and will periodically release public reports about their findings.

The Vision Initiative website – visioninitiative. org – allows physicians to “actively engage in the process through a dedicated section for feedback and input.” In a related development, ABMS recently released a summary of a ‘National Medical Specialty Societies and State Medical Societies Summit on Maintenance of Certification’ that took place in December.

PDMP UPDATE

The latest on Georgia’s PDMP requirements By Bethany Sherrer, J.D., MBA, MHA, legal counsel, Medical Association of Georgia Bethany Sherrer

eorgia’s Prescription Drug Monitoring Program (PDMP) was created by statute in 2013. The Medical Association of Georgia (MAG) continues to be an advocate for PDMP registration and use because it can become an important tool in the effort to reduce prescription drug abuse and misuse.

Georgia’s PDMP laws have been amended several times since 2013. The most recent changes took place in 2017, when Gov. Nathan Deal signed H.B. 249 into law. Every physician who has a Drug Enforcement Administration (DEA) license was consequently required to register as a PDMP user by January 1, 2018 – and by February 1, close to 80 percent of the affected physicians had in fact registered with the PDMP. (If you have not, you can do so by visiting dph.georgia.gov/ pdmp.) Physicians who have failed to register with the PDMP are subject to Georgia Composite Medical Board (GCMB) disciplinary action. Beginning on July 1, 2018, every prescriber or a delegate will be required to review the information that is in the PDMP before they prescribe a benzodiazepine or a controlled substance that is listed in paragraph 1 or 2 of the Schedule II drug listing in Georgia law. This requirement applies to the first time a prescriber checks the PDMP and every 90 days thereafter. Exemptions for this requirement include… • Prescriptions for three or less days or no more than 26 pills •

Instances whereby the patient is in a hospital or a health care facility and the prescription will be administered and used by a patient on the premises

• Instances whereby the patient has had outpatient surgery at a hospital or an ambulatory surgery center and the prescription is for no more than a 10-day supply of a covered substance and no more than 40 pills • Instances whereby the patient is terminally ill or under the supervised care of an outpatient hospice program • Instances whereby the patient is receiving treatment for cancer If a prescriber fails to check the PDMP, they will be subject to GCMB disciplinary action – though the Board is still in the process of determining what action it will take. Also keep in mind that physicians can be held liable if they misuse PDMP information, but they will not be held criminally or civilly responsible for failing to check the PDMP.

Prescribers or their delegates must make a notation in the patient’s medical record that they consulted the PDMP. If the prescriber/delegate can’t access the patient’s information in the PDMP for any reason, they should note the time and date and the prescriber/delegate’s name in the patient’s medical record. H.B. 249 also expanded the number of authorized staff that a physician can use to check the PDMP on their behalf. These delegates can include both unlicensed and unregistered staff (e.g., an office manager or medical assistant), but they must register for this role on an annual basis – though the 2018 General Assembly is considering legislation that would do away with this annual registration requirement. Meanwhile, a health care facility (e.g., hospital or ambulatory surgery center) may select two employees per shift or rotation to serve in this delegate role. And at hospitals that provide emergency services, each prescriber can designate two individuals who are employed by that hospital per shift or rotation. It is also worth noting that GCMB has “adopted Rule 36015-.01(3), which requires physicians (not resident physicians) who maintain an active DEA license and prescribe controlled substances to complete at least three hours of AMA/AOA PRA Category 1 CME that is designed specifically to address controlled substance prescribing practices by your next renewal date. The completion of this requirement may count as three hours toward the physician’s CME license renewal requirement. Note, too, that any controlled substances prescribing guidelines coursework that has been taken since a physician’s license ‘last expired’ will count toward this requirement.” As a related aside, the Georgia Chapter of the American College of Physicians is offering a free online ‘Safe RX Opioid’ course for physicians (including non-members) that offers “3.5 CME credits and 3.5 MOC points” that is available at www.acponline.org. Looking forward, the Georgia Department of Public Health (DPH) has indicated that it hopes to increase funding for the state’s PDMP. DPH also says that it would like to see Georgia’s PDMP be able to share data with PDMPs in other states – as well as allowing it to be integrated with electronic health records systems. MAG members can contact Sherrer at bsherrer@mag.org or 678.303.9273 with questions related to the Georgia PDMP. www.mag.org 11

MEDICAL ETHICS 2/26/18, 9)28 PM Page 1 of 1

Let’s all learn – together By J. David Baxter, M.D., FACP, associate professor and Year 3 program director, Mercer University School of Medicine, and Brian Childs, Ph.D., professor, bioethics, Mercer University

t is an honor to have the opportunity to contribute to the ethics column of the Journal of the Medical Association of Georgia.

Because I have no formal training in ethics per se, I have asked Brian Childs, Ph.D. to assist me. He is the real thing, a fine scholar and a good friend. His lifetime of work is profound, thought provoking, and practical. He takes ethics out of the ivory tower and brings it to the bedside. He has been involved in medical ethics since the late 1970s and remains active as a professor of bioethics at Mercer University. On a national level, he is also renowned in the field of transplant ethics. Several years ago, Brian wrote a book, Caring for our Generations. While the book concerned itself with the care of generations within families, its basic premise holds true for medical practice as well: We can only care for (as opposed to the more abstract care about) three generations – the one before us, our own, and the one that will succeed us. We hope that this column will serve the following three functions… • To honor our past and the ethical foundations upon which we have built our practices and lives • To allow our colleagues the freedom and opportunity to express their opinions, while they respectfully consider ours

J. David Baxter, M.D. Now, as a clinical educator, I reflect on the past and harbor hope for the future. Medicine is a wonderful profession that requires we learn a skill, but it is also one that requires us to pass a torch. Many of us live in the past and opine that we long for the “good old days of medicine.” Really? Do we really long for the days of no antibiotics? For the sole choice of digoxin and diuretics to treat heart failure? No intensive care units for the critically ill? Chemotherapy consisting of only a few drugs, and some of those of questionable effectiveness and many extraordinarily toxic? With progress has come complexity and conundrums. I know the next generation has the intellectual capacity to deal with complicated issues, but do they have the moral will to lay aside the political pressures to cut costs at the expense of human life?



The toxicities and torments of modern medical practice are part of a reality we cannot escape, yet we seem afraid to talk about them in any meaningful way.

• Reinforcing the primacy of patients and their needs as the primary motivation in our lives.



In order to welcome and care for the next generation of medical practitioners, this column will invite medical students, residents, and practicing physicians to write as much of the column as possible. We wish to give all a place to share their concerns and conundrums – in hopes of promoting reflection and facilitating a shared wisdom.

The next generation is encountering greater complexity in clinical care, along with a wider choice of therapies. The real challenging questions of medical practice are often not which therapy or disease treatment should be initiated (online, peerreviewed, continuously updated information has helped in that area), but the vexing questions of whether we should apply the treatment in a frail and debilitated patient or whether we should screen young and vibrant individuals for asymptomatic diseases. The toxicities and torments of modern medical practice are part of a reality we cannot escape, yet we seem afraid to talk about them in any meaningful way.

As a practitioner of medicine since the 1980s, I am humbled daily by the opportunities that I have been given. To come alongside and guide, encourage, and help fellow human beings face the arduous walk through the reality of the issues of life and death is truly an honor for which I will be forever grateful. As a fallible human, I have done my best. The generation before me guided me, including the physicians who spent their entire lives focused on their patients. 12 MAG Journal

In addition, future physicians will face the reality of greater costs, universal access, and the further “commodification”1 of medicine. As physicians, we have an ethical obligation to our

patients, but we also have the obvious obligation to care for our families and the staff we employ. We also have a legal and ethical obligation to pay our debts. Many questions come to mind. Do our medical students pay too much for the education they receive? Is it a good value? If you just want to make money, might you do that in another, less-risky way? Is medicine a calling or is it a career? When I was coming along, we never worried about finding a residency position or a job after we graduated. We knew that there were plenty of residencies and plenty of good jobs. We might not completely fulfill our dreams, but we would find satisfaction and happiness. The competition for residency slots has increased in dramatic ways. It is not unusual for today’s medical school graduate to go through 20 residency interviews – compared to six for me. This challenge is compounded by the burden of graduating with a large debt load.

More so than more information, what we now need in medicine is greater wisdom. Learning is easy, but applying learning requires wisdom. We gain wisdom through hearing, seeing, experiencing, and reflecting. By reflecting on our combined successes and failures, we learn together. These valuable lessons allow us to gain wisdom with which we hope to improve our lives in the future – as well as improve our clinical care.



More so than more information, what we now need in medicine is greater wisdom. Learning is easy, but applying learning requires wisdom.

Our medical world is rife with burnout and career change, bankruptcy, and the underserved becoming more underserved. In rural America,2 and most assuredly and sadly in Georgia, this crisis is particularly profound.3 Insurer and government agency documentation requirements complicate the problem. When I began my practice, I would review a patient’s chart and see my predecessors’ notes – which might simply state that a patient had sinusitis for which they prescribed amoxicillin. Clear, concise, and to the point. Now you have to dictate or document in some format a novel (much of which is not read) to describe a sinus infection. Maybe we should not treat most sinus infections at all? A few years ago, a colleague explained the ins and outs associated with a practice becoming a Patient Centered Medical Home (PCMH). I had never heard of a PCMH, but it sounded a lot like my practice: We were not checking boxes to be paid or because we sought designation as a PCMH, but we were a team and we were doing what was best for our patients and their families. Today’s physicians are often forced to spend more time on administrative tasks than they do actually caring for patients. The primacy of the patient’s desire has become a clear and noble foundation of modern medical ethics. This flows from the longstanding notion of free will that our Western culture has embraced for centuries. In addition, we must balance the longstanding basic tenets of beneficence and nonmaleficence with the reality of social justice. We hope to hear from “the next generation” and learn from them. We hope to encourage them to accept the primacy of patient care that we are passing to them. We hope that they will let the torch burn brightly, to illuminate their futures and improve patient care. Health care has been and always should remain “patient centered.” That is the only way.

 We must continually stoke the ethical flame of the moral principles undergirding the practice of medicine. We must continue to improve our health care system. In order to promote human flourishing, medicine is a human achievement that we must preserve. We are encouraging MAG members – including residents and students – to submit articles, questions, and musings. Brian and I will add comments and commentary as we seek answers together. Disagree with our conclusions, and let us all learn together. True leadership is seeing what is actually happening and knowing what to do. Do not avoid the hard or complex issues. The issues that we all face today were unthinkable just a few years ago. Let us lead by example, tell our stories, and listen to the stories of others. Maintaining the practice of medicine focused primarily on the patient is what we must pursue.¨ MAG members are encouraged to submit their articles and questions and musings to Dr. Baxter at baxter_jd@mercer.edu.

References 1

Pellegrino ED. The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic. J Med Philos. 1999; 24(3):243-66.

Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015; 129(6):611-20.

Nelson G. The two Georgias: Disparities in rural health and healthcare. Journal of the Georgia Public Health Association. 2016; 5(4):294-297.

www.mag.org 13

GEORGIA COMPOSITE MEDICAL BOARD

Our profession’s ethical obligations By John S. Antalis, M.D., immediate past chair, Georgia Composite Medical Board John S. Antalis, M.D.

ver years of practice, physicians learn to develop their own style to treat their patients – hopefully in a caring and competent manner. For me, and probably for most of you, there was very little formal training on ethics. The Federation of State Medical Boards (FSMB), with input from the American Medical Association (AMA), established an ethics policy in 1994 – after the AMA’s House of Delegates adopted the Council Ethical and Judicial Affairs (CEJA)-Enforcement of the Code of Ethics in 1991. This calls for 1) physicians to demonstrate that they understand their unique ethical responsibilities by addressing the issue in their licensure exams and 2) medical societies to expand their programs to examine and report quality of care complaints to the applicable state medical boards. The Georgia Composite Medical Board (GCMB) is responsible for ensuring that physicians in Georgia adhere to the quality standards that are outlined in the state’s Medical Practice Act. The GCMB is accountable to the public. It has full-time staff to investigate quality issues, although it does not have the financial wherewithal to investigate every complaint – keeping in mind that the Georgia legislature funds GCMB’s operations. GCMB relies on practicing physicians to notify it if certain physicians are not meeting the profession’s requisite standards. The GCMB also uses practicing physicians as expert consultants in its evaluations. These are especially important roles and responsibilities, as physicians in Georgia have a duty of self-regulation to safeguard the welfare and trust of the public they serve because they possess the expertise to evaluate their colleagues’ clinical performance. Simply put, we as physicians have an ethical duty to protect the public. GCMB is not a part of the normal peer review process that takes place at hospitals and integrated health care systems. But when it is warranted, these entities should work with the state medical board to review cases that are deemed egregious and which could harm patients. It is also important for practicing physicians and GCMB to cooperate when they address issues like CME requirements, impaired physicians (through the Georgia PHP), physician burnout, and physician suicide. 14 MAG Journal

One of the most common misunderstandings that I hear surrounding the GCMB is the appropriateness of reporting. According to CEJA, “Physicians who receive reports of incompetence or unprofessional conduct have an ethical duty to critically and objectively evaluate the reported information and to assure identified deficiencies are remedied or reported to the State licensing board.” Note, too, that the Georgia Medical Practice Act defines unprofessional conduct as “any departure from or failure to conform to the minimal standards of acceptable and prevailing medical practice and shall also include, but not limited to the prescribing or use of drugs, treatment or diagnostic procedures which are detrimental to the patient as determined by the minimal standards of acceptable medical care.” While rare, the reports of physician incompetence that the GCMB receives are generally reliable. In appropriate circumstances, it is also reasonable to employ peer review and hospital remedial plans to correct physician incompetence. With the proliferation of outpatient care, it has become increasingly important for state medical societies to take a more active role to help physicians achieve a successful medical remediation. If the remediation fails, the sponsoring entity has an ethical obligation to report the physician to the GCMB. It is also worth stressing that there is no liability associated with reporting physicians or institutions to GCMB as long as it is done on a good faith basis. I believe that today’s medical students must be educated on ethics in the context of patient care – as well as the ethical treatment of the patient’s caregivers and family members. The medical profession has an obligation to make sure that every medical student in Georgia has read and understands the AMA Code of Ethics. I further believe that the United States Medical Licensing Examination should be amended to include a section on medical ethics. In light of the level of scrutiny that our profession is subjected to in 2018, it is imperative for physicians in Georgia to maintain their knowledge of medical ethics and to do a better job of educating future physicians on the subject. Dr. Antalis is a member of the Whitfield-Murray County Medical Society, and he was MAG’s president in 2004-2005. He expressed his sincere thanks to AMA, FSMB, and GCMB staff for helping him write this article.

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LEGAL

Recognizing & minimizing lurking sexual harassment vulnerabilities By Daniel J. Huff, Esq., partner, and Christian P. Dennis, Esq., associate, Huff, Powell & Bailey, LLC

isconduct in the workplace does not always result in $100 million verdicts, as in Chopourian v. Catholic Healthcare W.1 Nevertheless, workplace misconduct, including sexual harassment, can be detrimental to all parties involved. Although sexual harassment is a common topic, health care providers (“Providers”) and their staff often overlook inconspicuous sexual harassment vulnerabilities. Like most legal matters, sexual harassment claims are highly fact dependent and must be addressed individually. Legal counsel is recommended. Providers, however, should proactively recognize and minimize the vulnerabilities for sexual harassment in their practice to prevent misconduct.

Sexual harassment: Application Title VII of the Civil Rights Act of 1964 (amended by the Civil Rights Act of 1991), in conjunction with court interpretations (“Title VII”), governs discrimination based on race, color, religion, sex, or national origin.2 Title VII applies to public employers and private employers with 15 or more employees affecting commerce. Notably, statute interpretations result in most businesses “affecting commerce” and Title VII may apply to public employers with fewer than 15 employees. Full-time and part-time employees are included in the 15-employee calculation. Whether temporary employees and independent contractors are included depends largely on the factual scenario. Importantly, an employer needs only 15 employees for 20 weeks of the current or prior year to be subject to Title VII.3 Sexual harassment: The requisites Sexual harassment is conduct against another that is “sufficiently severe or pervasive to alter the terms and conditions of [his/ her] employment and create an abusive working environment (“Severe or Pervasive”).”4 It presents a quid pro quo or hostile work environment. Under quid pro quo, misconduct is offered or requested in exchange for something or is a condition of employment. Hostile work environment is based on an objective analysis of whether misconduct altered the work enviornment. Hostile work environment claims typically require a pattern of offensive conduct, but individual incidents may establish a hostile work environment as well. Not all misconduct constitutes sexual harassment. Courts have acknowledged that horseplay, rude conduct, and misinterpretations exist.5 In determining whether an act is severe or pervasisve, courts consider “(1) the frequency of the conduct; (2) the severity of the conduct; (3) whether the conduct

16 MAG Journal

is physically threatening or humiliating, or a mere offensive utterance; and (4) whether the conduct unreasonably interferes with the employee’s job performance.”6 Courts and the U.S. Equal Employment Opportunity Commission (EEOC)7 often consider other factors, such as the bad actor’s role, employer’s knowledge, and the employer’s response. Actions that may constitute harassment include unwanted hugging, propositions, text messages, obscene gifts, demands, jokes, kissing, sexual gestures, blocking walkways, etc. Sexual harassment: Vulnerabilities The nature of health care presents risks uncommon in other industries. These risks arise from the breadth of potential bad actors, the personal nature of providing care, and lack of formal reporting. Potential bad actors include coworkers, subordinates, supervisors, and managers. Less frequently considered, but possing equal risks, are third parties. Third party bad actors include customers, patients, and authorized visitors (consulting providers, sales representatives, patient visitors, etc.). Regardless of the bad actor, the duty to maintain a Title VII compliant environment endures. EEOC Regional Attorney Lynette A. Barnes has warned that, “Employers have a responsibility to prevent sexual harassment not only by co-workers, but also by third parties, including patients and customers. Employers need to adopt measures to end sexual harassment that has been reported to the appropriate supervisor regardless of who is perpetrating the misconduct.”8 While a patient’s condition and treatment may be considered, it does not necessarily resolve the employer of liability. A patient’s close proximity and freqent interaction with Providers presents a continuous volunerability. In August 2017, the journal Physical Therapy published a study about the prevalence of inappropriate patient sexual behavior (IPSB).9 The IPSB study surveyed physical therapists and physical therapy students, of which 892 responded. Eight-four percent of the respondents experienced inappropriate sexual behavior by patients during their careers. Bad conduct by patients is often documented – possibly establishing knowledge – but often not formally reported. This too is a vulnerability. One reason Providers may refrain from properly reporting misconduct is because they view it as an accepted occupational hazard. One IPSB study respondent noted that, “I was told that when patients were inappropriate with me, it was ‘part of the job.’”10 Other Providers may not report misconduct because they lack an avenue to communicate grievances – especially when the alleged bad actor is influential. Despite underreporting, Providers must recognize situations and opportunities for misconduct. (continued on page 18)

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www.mag.org 17

(continued from page 16)

Consider three actual occurences where misconduct occurred: • Occurence 1: A male patient invited the receptionist at non-profit community health center to run away with him, commented that he was visualizing her naked, and made other inappropriate comments. This case resulted in the health center settling with the EEOC for $30,000 and being required to perform training.11 • Occurence 2: A female nurse documented in the nurses’ notes that an elderly female nursing home resident asked a CNA to expose her breasts so the patient could masturbate. This occurrence was revealed during discovery in unrelated litigation. • Occurence 3: A physician blocked a nurse’s attempt to leave a room. He followed her out of the room and grabbed her buttucks. He made numerous sexual advances and there was an alleged tolerated atmosphere of dirty jokes. The nurse sued the physician and hospital. She was awarded $15 million, with the physician and hospital sharing liability equally.12 Sexual harassment: Minimizing vulnerabilities Developing a plan to address Title VII vulnerabilities should be a well-thought-out process that includes input from all departments and stakeholders. A plan should include at least five activities… 1. Developing policies & procedures: This should be implemented and communicated. 2. Establishing multiple reporting paths: There should be multiple people trained and authorized to receive misconduct reports, and there should be multiple reporting methods in place. 3. Recurring training and notification: Employees should receive recurring training on the policy and procedures, reporting misconduct, and the expectations of the practice. Patients and other third parties should receive notice of policies that are directed at third parties. 4. Developing an investigation procedure: An investigation procedure should be in place to address triggering events, how an investigation is performed, investigator determination, conflicts within the investigation, and investigation confidentiality (i.e., whether attorney-related privileges are necessary). 5. Responding genuinely and consistently: Investigations should be immediate but careful and fair for all parties involved. Investigations should be consistent regardless of the bad

actor or reporter. The response should attempt to stop and prevent misconduct. Corrective actions include write-ups, termination, schedule changes, assignment changes, working in teams, flagging problematic third parties, alerting bad actors and their authorized responsible parties, etc. Employers and individuals should proactively attempt to reduce misconduct, especially given the recent sexual harassment reports. Proactiveness and viligence is crucial to maintaining a proper work environment.¨ Huff and Dennis are with Atlanta law firm of Huff, Powell & Bailey, LLC. Huff and the members of his firm defend civil lawsuits on behalf of hospitals, physicians, product manufacturers, businesses, corporations, and other professionals. Huff and his firm try several jury trials each year. Contact Huff at dhuff@huffpowellbailey.com. Paid editorial submission.

References 1

Chopourian v. Catholic Healthcare W., No. CIV. S-09-2972 KJM, 2011 WL 6396500, (E.D. Cal. Dec. 20, 2011). The plaintiff alleged nine different causes of action and testified about physical violence, working conditions, breaks, and privacy concerns in addition to sexual harassment. The verdict included $125 million for punitive damages. The Judge reduced the verdict to just over $80 million and later vacated the award because of a negotiated settlement.

42 U.S.C.A. § 2000e-2(a) (West). Additionally, many states and local governments have statues modeled after Title VII, providing more or less of the same protections. These local statutes may have different requirements and potential damages award. These laws work in addition to Title VII.

42 U.S.C.A § 2000e(b) (West).

Liebno v. Drexel Chem. Co., 262 Ga. App. 517 (2003) (citing Mendoza v. Borden, Inc., 195 F.3d 1238, 1245 (11th Cir. 1999)).

Barker v. Missouri Dep’t of Corr., 513 F.3d 831, 835 (8th Cir. 2008).

Mendoza v. Borden, Inc., 195 F.3d 1238, 1246 (11th Cir. 1999).

The U.S. Equal Employment Opportunity Commission (EEOC) is the federal agency that administers and enforces civil rights laws against workplace discrimination.

Press Release, Southwest Virginia Community Health System to Pay $30,000 to Settle EEOC Sexual Harassment Suit (Oct. 23, 2013), https://www.eeoc.gov/eeoc/newsroom/release/10-2313b.cfm (last visited Jan 19, 2018).

Jill S. Boissonnault et al., Prevalence and Risk of Inappropriate Patient Sexual Behavior Directed Towards United States Physical Therapy Clinicians and Students, Physical Therapy 1084–1093 (2017), https://doi.org/10.1093/ptj/pzx086. Jill S. Boissonnault et al., Prevalence and Risk of Inappropriate Patient Sexual Behavior Directed Towards United States Physical Therapy Clinicians and Students, Physical Therapy 1084–1093 (2017), https://doi.org/10.1093/ptj/pzx086.

See Press Release, EEOC, Southwest Virginia Community Health System Sued for Sexual Harassment, (Sept. 6, 2012), https://www.eeoc.gov/eeoc/newsroom/release/9-6-12b.cfm (last visited Jan 19, 2018); see also Press Release, EEOC, Southwest Virginia Community Health System to Pay $30,000 to Settle EEOC Sexual Harassment Suit (Oct. 23, 2013), https://www. eeoc.gov/eeoc/newsroom/release/10-23-13b.cfm (last visited Jan 19, 2018).

Janet Bianco v. Flushing Hospital Medical Center et al., 2009 WL 839234.

Don’t forget to register for MAG’s summer legislative seminar The Medical Association of Georgia (MAG) is encouraging its members to register for MAG’s 2018 ‘Legislative Education Seminar’, which will take place at the Brasstown Valley Resort in Young Harris on June 1-3. More than 50 physicians and 22 state leaders attended the meeting in 2017. Contact Anita Amin at anita@associationstrategygroup.us 18 MAG Journal

with questions related to lodging. Monitor MAG’s communications and www.mag.org for additional details. Contact Derek Norton at dnorton@mag.org or 678.303.9280 with any other questions related to the seminar. Visit the ‘Events’ section of the www.mag.org website to register for this event.

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PRACTICE MODELS

How one group has remained in private practice in Albany By Barry Silverman, M.D.

here has been tremendous growth in the variety of practice models that physicians employ. This has been driven by factors like economics, insurance and managed care, EMR and other government regulations, student debt, and generational changes.

Until recently, we employed a fee-for-service business model. We provided ancillary services, such as noninvasive cardiac and lab tests and radiology. Because of the demand for our services and the patient’s desire for “one-stop” health care, our model was quite successful.

The Journal asked some physicians in the state who use different practice models to write about their experiences. They were asked to consider…

But in the recent past, we have moved towards a value-based care model – becoming certified as a patient-centered medical home and a participant in the Medicare Shared Savings Program. In addition, we are now using a team-based model of care that includes mid-levels, nurse coordinators, and a dietician/diabetic educator.

•

If they chose their practice model based on financial considerations.

•

If the number of patients they see is reasonable.

•

Whether they feel truly responsible for their patients’ care.

•

How much time they spend managing their practice.

•

If they generate enough income to cover their overhead expense.

•

Whether their income is commensurate with their skill set and experience.

•

If they have experienced any burnout.

The following is the fourth in a series of perspectives that will appear in the Journal. It was written by Joseph W. Stubbs, M.D., MACP, an internist in Albany. Private practice in a mid-sized town I am a practicing internist and partner at Albany Internal Medicine, an independent outpatient primary care practice that consists of nine internists and family practitioners. When I finished medical school, I saw my calling as a physician who cares for the “whole patient.” I saw the long-term relationships as enriching and the management of complex illnesses as intellectually stimulating. I joined the National Health Service. In 1982, I began practicing as an internist in the Albany area – which is a relatively rural area. Until 2008, Albany Internal Medicine cared for patients in both the hospital and office setting. It was arduous, and we typically worked more than 80 hours a week. However, the primary focus was on patient care – as opposed to the array of documentation, coding, and regulatory requirements we have to contend with today. Today, we are exclusively an outpatient practice. We work 50 to 70 hours per week. But despite the reduced hours, I often feel more exhausted because so much of the work is tied to the aforementioned administrative, regulatory and documentation tasks – and not patient care.

20 MAG Journal

The challenge with this approach is “overhead creep.” When I joined the practice, our overhead was around 45 percent to 50 percent of revenue. But that number recently topped 75 percent, and revenue has failed to increase by a commensurate amount. Patient-centered care and population health do require more ancillary personnel than the traditional health care model. Moreover, the added documentation requirements and administrative hassles have limited the number of services we can offer. And the “value-based” contracts have not increased our compensation nearly enough to offset the rise in overhead and the reduction of services we can offer. Being caught in the vice of higher overhead, lower revenue, and more regulatory hassle is the primary reason so many primary care physicians are experiencing “burnout” and pursuing employment opportunities with hospitals and health care systems. Because of our desire to control our own destiny and continue the strong tradition of excellence in the delivery of high quality care at Albany Internal Medicine, we chose not to pursue the employed practice model. But we also recognized that the course we were on was untenable, so we recently elected to join a network of independent physicians called Privia Georgia. This network will hopefully enable us to be more efficient with coding and billing, provide us with more leverage in contracting with commercial payers, and enable us to be more effective and efficient with resource delegation for providing value-based care. If successful, Privia Georgia will enable us to continue to be an independent primary care practice, untethered to the needs of a hospital or health system and focused on patient care. In addition to MAG, Dr. Stubbs is a member of the Dougherty County Medical Society. MAG members who would like to share their practice model experience should contact Dr. Silverman at mssbds@gmail.com.

ADVOCACY

Nearly 100 physicians, 40 lawmakers attend ‘Physicians’ Day at Capitol’

Georgia Gov. Nathan Deal, center, with the physicians who attended the 2018 ‘Physicians’ Day at the Capitol’ event at the State Capitol on January 31.

early 100 physicians attended the ‘Physicians’ Day at the Capitol’ event that took place at the state Capitol in Atlanta on January 31. In addition, more than 40 legislators attended a luncheon in conjunction with the event. “This was easily the best turnout that I can recall for this event, and it continues to be a great way for physicians across specialties and practice settings to establish personal relationships with state lawmakers,” says Medical Association of Georgia (MAG) President Frank McDonald, M.D., M.B.A. “We addressed some important issues, including the surprise insurance coverage gap, insurance reform, scope of practice, and patient safety.” MAG Government Relations Director Derek Norton stressed that, “There simply isn’t a better or more effective way to influence the legislative process than to have a lawmaker hear a practicing physician’s first-hand, real-world account about the steps we should be taking to improve patient care and the health care system in Georgia.”

From the left are Georgia Lt. Gov. Casey Cagle, MAG President Frank McDonald, M.D., M.B.A., and Georgia Sen. Butch Miller.

And on January 24, the Georgia Senate passed a resolution – S.R. 600 – to honor Dr. McDonald. He was introduced in both the House and the Senate. MAG’s priorities for this year’s legislative session include health insurance, Medicaid, patient safety, and scope of practice. Contact Norton at dnorton@mag.org or go to www.mag.org/governmentrelations for additional information. Also follow MAG on Twitter @MAG1849.

John S. Harvey, M.D., far left, with the Gwinnett Medical Center residents who attended the 2018 ‘Physicians’ Day at the Capitol’ event.

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PATIENT SAFETY

Prescribing for the elderly By William Kanich, M.D., J.D., chief medical officer, MagMutual

mong the advances that have been made in medical treatment over the past 100 years, the progress that has been made in the development of pharmaceuticals has been especially remarkable. We can avail ourselves of an armamentarium of analgesics, antibiotics, anticoagulants and multiple other classifications of seemingly innumerable formulations that were not available to our medical forefathers. However, we all know that a medication that is safe and efficacious in one cohort of patients may not be appropriate in a different demographic group. Especially vulnerable are the elderly, who have physiologic and cognitive differences from younger patients and who are more likely to already be taking at least one medication. One survey found that nearly 90 percent of elderly patients were on at least one prescription medication, while 36 percent were on five or more medications.1 Another study found that Medicare beneficiaries discharged from an acute care setting to a skilled nursing home were on an average of 14 medications.2 At MagMutual, we continue to see allegations of malpractice against physicians that involve the effects of medications in the elderly. Consider the following scenarios: Case 1 An 88-year-old male who recently moved in with his daughter sees you for an initial visit. He lives in a rural area, and although he has a pharmacy nearby, the nearest 24-hour emergency department is a one-hour drive from his house. He is relatively healthy and his only medication is warfarin, which he has taken “for a long time” for his chronic atrial fibrillation. His daughter reports that he has occasional falls, but otherwise he is in good health and good spirits. After an uneventful history and physical, you arrange to see him again in three months. A week later the daughter calls to report that the patient fell at home and when the first responders arrived he was declared dead. His autopsy showed evidence of an epidural bleed. Case 2 Mrs. Smith is a longtime patient of yours who sees you for a routine visit. She is 79 years old and has numerous medical conditions, including low back pain, depression, chronic urinary infections – and she has started demonstrating memory loss, according to her family members. Her medications include Norco, Elavil and Tylenol. Her only complaint today is worsening depression over the recent death of her husband of 52 years. Her family asks if you can prescribe medication to “calm her down” when she gets upset about her late husband. You prescribe a low dose of Xanax and ask the family to schedule an appointment with a grief 22 MAG Journal

counselor. Two days later you receive a call from the ED and the attending physician asks you to admit Mrs. Smith overnight because “she took too many pills.” Discussion Prescribing medication in the elderly population has always presented unique challenges. As patients age, the absorption, metabolism, excretion and effects of drugs change, which must be taken into consideration. Elderly patients may have cognitive changes or comorbidities that must be taken into account when a medication is prescribed. The ultimate goal is to achieve a desired therapeutic endpoint while minimizing the chances of an adverse drug event (ADE). This is, of course, difficult. Studies that evaluate medication efficacy and safety frequently exclude the elderly, making appropriate dosing difficult. Several dosing guidelines have been developed in an effort to aid the practitioner in both choosing and dosing appropriate medications. A well-known example of such a guideline is the ‘Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.’3 The Beers Criteria attempts to reduce the rate of prescribing to the elderly those medications that are unnecessary, have little or no efficacy, or have potentially dangerous interactions with other medications. The goal of the Beers Criteria is to reduce polypharmacy, reduce the risk of ADEs, and improve the use of medications in the elderly population. It is a guideline that contains good information, but it does not replace the clinician’s judgment. Despite a physician’s best efforts, ADEs may still occur. Given the complexity of patients and the medications prescribed, this is perhaps inevitable. However, the duty we owe our patients is not to be perfect or to be able to predict the future, but to be reasonable in our decisions and recommend courses of therapy for our patients that are more likely to benefit than harm them. With that standard in mind, let’s re-visit the two cases above. Case 1 Anticoagulants have their own set of perils, particularly in the elderly; however, the elderly may benefit the most from these medications given their increased risk of stroke and cardiac disease. The fact that a patient has a history of falls may not be a contraindication to starting or continuing anticoagulation, but it should be taken into account. The risks of the medication should be explained to the patient and/ or caregivers in a manner that will impart the seriousness of the medication. This should be done in the context of a broader discussion of what the medication is treating, the expected outcomes, and possible other therapies – including no therapy at all. Given the risks inherent in prescribing an anticoagulant, the physician could consider a more

formal informed consent process. This should document the education the prescriber provided, the discussion that ensued, and any questions or concerns that were raised by the patient or caregiver. While a signed form in the record will exhibit that such a discussion occurred, a brief description of the discussion in the chart will further demonstrate that the prescriber had the patient’s well-being as the primary driver in the decision making process. Case 2 Mrs. Smith’s condition is likely related to her medications. Prior to the prescription for Xanax, she was already on two potentially sedating medications – hydrocodone and amitriptyline. Adding the benzodiazepine increased her risk of respiratory and cognitive depression. Is the Xanax still a reasonable choice? Perhaps. The ultimate expert on what is (or is not) appropriate for Mrs. Smith is her physician, who has taken into account her complete medical condition and the goals and risks of therapy. A careful reflection on her condition and a reasoned choice of medication may well be in Mrs. Smith’s best interest, but it does not guarantee an ADE-free outcome, as in this case. However, meticulous documentation of the thought process behind the medication recommendation will help protect the physician should the family allege that the prescription for Xanax fell below the standard of care. Conclusion

• Review the medication list and consider potential adverse drug-drug interactions • Communicate your risk/benefit analysis with the patient and their caregivers • Review potential ADEs with the patient and their caregivers Using these strategies will help maximize the environment of patient safety in your practice, particularly for your geriatric population. Taking the time to note that you have carefully considered both the benefits and risks of these medications in this patient’s chart will demonstrate your commitment to patient safety – particularly if your patient suffers an adverse event.¨ The information that is presented in this article is intended to serve as general information of interest for physicians and other health care professionals. The recommendations and advice that is published herein do not reflect or establish a standard of care and do not establish rules for the practice of medicine. The publication of this information is not intended as an offer to insure such conditions or exposures or to indicate that MagMutual Insurance Company will underwrite such risks for the reader. Our liability is limited to the specific written terms and conditions of actual insurance policies issued.

References 1

Prescribing for the elderly will always present its own set of risks and challenges. In an effort to keep your patients safe, consider using the following strategies:

Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016 Apr;176(4):473-82

• Look over a guideline, such as the Beers Criteria, to help choose or avoid medications

Saraf AA, Petersen AW, Simmons SF, Schnelle JF, Bell SP, Kripalani S, Myers AP, Mixon AS, Long EA, Jacobsen JM, Vasilevskis EE. Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities. J Hosp Med. 2016;11(10):694. Epub 2016 Jun 3.

American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015 Nov;63(11):2227-46

How distracted driving changed my life forever By Molly Welch It was a cold Sunday in early February. I was returning to Auburn University after a weekend at home. I was a junior – majoring in journalism. Excitement flourished through my body because I had just started a job on the school newspaper. And I had just completed a few interviews on a handheld recorder and was playing them back (while driving back to Auburn). Just two exits from Auburn, my car left the interstate, crossed the median, and into on-coming traffic. I went head-on with a pick-up truck. I suffered traumatic brain injury in the accident. I was in a coma and minimally-conscious for an extended period. I was transferred from East Alabama Medical Center to the Shepherd Center in Atlanta. I stayed at the Shepherd Center for about a month. The doctors said that they had “tried everything and she is not emerging.” They suggested I be sent home, stating that comatose patients occasionally react to familiar scents and sounds. Shortly after returning home, I did wake up. Before I could be readmitted to Shepherd Center, I had to achieve specific milestones. I started to mouth words and perform simple tasks. I returned to Shepherd Center for more intense therapy, including physical, occupational and speech therapy. It was difficult, but I worked hard – though I lost the use of my right arm. I was eventually able to move from the bed to a wheelchair to a walker and, finally, a cane. I also had to learn to talk again. My speech is quiet, but fluent. While I was going through my therapy, I set a goal to complete my degree. I was able to complete some of the courses online, but I needed to commute to Auburn to complete some of my core

classes. The professors were understanding, and they consolidated my classes to one or two days per week. While it took me an extra three years, I finally walked across the stage to receive my Auburn diploma. Due to the slow economy, it took me three years to find a part-time job. While I was working part-time, I sought opportunities to speak to students about the dangers of distracted driving. After I made several presentations, my friends and family members suggested that I dedicate my time to this effort – so I became a passionate advocate for safe, distraction-free driving. Many people have had a hand in my success. A couple of local professionals helped me create a public service announcement for TV that is running in several major markets around the country. These videos are available on Facebook and Twitter at facebook.com/asecondlater and @asecondlater. I have spoken to school groups, legislators, and the Medical Association of Atlanta and the Medical Association of Georgia – basically anyone who will listen. It is difficult to learn from others’ mistakes, but I want to get the message across about how dangerous and deadly distracted driving can be. It’s not worth it, and the faster we get people to realize that, the better off we will be. The Medical Association of Atlanta, the MAG Foundation, and the MAG Alliance are funding a ‘Make Georgia Hands-Free’ campaign to highlight the dangers associated with distracted driving. Go to www.mag.org/makegahandsfree for additional information or contact Lori Cassity Murphy at lmurphy@mag. org or 678.303.9282 to support the campaign with a tax-free donation.

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GENERAL ASSEMBLY

It’s time to be ‘hands-free’ in Georgia By Rep. John Carson (R-Marietta) Rep. John Carson

t’s not unusual to see drivers in our state holding their mobile phones and texting, using social media, or browsing the Internet. For a long time, I didn’t give that a second thought. But in January 2017, I heard a presentation on Georgia’s increasing auto insurance premiums – which are growing significantly at the expense of taxpayers and families. In fact, Georgia led the nation in auto insurance premium increases (12.2%). After further research, I discovered there were more costs involved – traffic crashes, traumatic injuries and most unfortunately, the loss of life. The crash data and the testimony of public safety personnel all pointed to one reason why crashes and fatalities are up by one-third in the last two years – distracted driving. I understand why distracted driving is one of the Medical Association of Georgia’s (MAG) patient safety priorities for 2018. It is an epidemic that affects patients across the state. As a state representative in the General Assembly, I am proud to partner with MAG and other medical associations on this issue. Last year, I chaired a study committee that traveled across Georgia and listened to local law enforcement, transportation officials, insurance industry representatives, public safety advocates, health care professionals and most importantly, the families of victims of distracted driving. The information we learned was startling. Since 2014, there has been a 36 percent increase in traffic crashes and a 34 percent increase in traffic fatalities in Georgia. The increase in fatalities has been significant among some especially-vulnerable populations, including pedestrians, motorcyclists, and bicyclists. While Georgia does have a “no-texting” law for drivers, it is mostly unenforceable, as law enforcement cannot determine whether a driver is texting or simply dialing a phone number. In fact, there were more traffic fatalities in Georgia per million vehicle miles traveled in 2016 than there were before the state’s “no-texting” law passed in 2010. Our committee looked for any possible solutions – but everything we explored kept coming back to a “hands-free” law. Fifteen states and Washington, D.C have enacted a similar law, and it’s been successful – as 13 of these states saw an average 16 percent decrease in traffic fatalities 24 MAG Journal

within two years of passage. Several cities in our state are considering adopting similar ordinances. Smyrna just recently passed one, and Marietta may follow suit soon. If multiple municipalities pass different laws, Georgia drivers won’t know what each law allows as they drive through a patchwork of various ordinances. There needs to be one clear, consistent law that promotes the safety of Georgia’s citizens. That is why I’m recommending H.B. 673. My legislation, H.B. 673, would require drivers to operate their phone on a “hands-free” basis – with no Internet streaming. Drivers would still be able to use a GPS navigation function. My bill would also increase fines and DMV penalty points for distracted driving. After a press conference that generated a lot of media coverage in January, H.B. 673 is working its way through the legislative process. I have been encouraged with the bi-partisan support that we have received in the General Assembly. I am also optimistic about the support that we have received from leading advocacy organizations – including MAG, the MAG Foundation, the MAG Alliance, the Medical Association of Atlanta, WellStar Health System, Navicent Health, the Georgia Trauma Foundation, the Georgia Association of Emergency Medical Services, the Governor’s Office of Highway Safety, the Georgia Department of Public Safety, numerous local police departments and sheriffs’ offices, AT&T and other wireless communications providers, insurance carriers, and non-profit advocates for bicyclists and motorcyclists. What started out as inquiry on rising auto insurance premiums has since become a major public safety initiative to reduce automobile crashes and injuries and save lives in Georgia. During the mentioned press conference, I said that distracted driving is the DUI issue of our generation. With that in mind, I hope that my bill will promote real societal change – making distracted driving as culturally unacceptable as DUI. I welcome your support. It’s time to be “hands-free” in Georgia. Rep. Carson has served in the Georgia House of Representatives since 2011. He represents the 46th District, which includes parts of northeast Cobb and southeast Cherokee counties. Rep. Carson is a CPA.

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PRACTICE MANAGEMENT

The tide will change in 2018 By Elizabeth Woodcock, Woodcock & Associates

he shift in the federal administration is finally being felt by physicians and patients. As the impacts of new policies play out and the implementation of information technologies advance – or, in some cases, retrench – Georgia physicians must be prepared for another challenging and potentially volatile year. Federal programs, Part A: EHR incentives The Medicare/Medicaid Electronic Health Record (EHR) Incentive Program was introduced in 2011 with a goal of bringing the benefits of information automation to the operations of the health care industry. Propelled by a promise of bonus payments and compelled by the threat of penalties, physicians spent years implementing government-certified EHR systems and reporting their progress on the federal government’s “meaningful use” measures. The program was challenging from the get-go, and the changes outlined in annual 1,000-page-plus rulings made it difficult to enjoy the journey. For far too many, the incentive program felt more like being strong armed into jumping through hoops – some of them flaming. In addition to its well-reported implementation challenges, the legacy of the EHR Incentive Program seems to be that of an inadequate framework of automation clumsily grafted onto medical practice workflow, leaving practices to endure slow speeds in an environment that demands a fast pace. What physicians acquired in electronic storage was more than offset by the lack of promised new efficiencies. Instead of gaining new and better ways of managing information, physicians have spent additional time and money to keep their practices afloat. Despite these setbacks, automation is slowly but surely improving – and physicians are adapting, determined to continue serving their communities. As we enter 2018, the industry as a whole is suffering the fallout of the EHR drive in an unexpected way: the business side of medicine seems even further behind the times. For many years, vendors have devoted time and effort into keeping their clinical products on pace with the government’s EHR Incentive Program while neglecting their practice management systems. If that sounds too judgmental, consider that physicians still cannot confirm they are getting paid what they are supposed to and that paper continues to be the prevailing mode of collections from the fastest growing category of payers: patients. The penalties of failing to participate in the government’s program aren’t insubstantial, but allowing the business of one’s medical practice to fall even farther behind today’s needs could be a fatal financial blow. A practical theme for 2018 is to pay attention to business automation, reviewing every opportunity for improvement – whether in adapting to new technologies or implementing smarter internal protocols.

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

As we enter 2018, the industry as a whole is suffering the fallout of the EHR drive in an unexpected way: the business side of medicine seems even further behind the times.  Federal programs, Part B: QPP Many physicians were surprised to learn about the 2017 implementation of the Quality Payment Program (QPP), which was formulated by the Medicare Access to Care and CHIP Reauthorization Act (MACRA) that passed in 2015. The QPP corrected the flawed payment formula that threatened to drive down Medicare rates for many years, and it required frequent Congressional intervention. Ditching the old formula and replacing it with a new payment program was passed with bipartisan support in Congress and heralded by associations representing physicians’ interests, so consider the prospects of repealing the QPP to be most unlikely. There are, however, signs of relief. Before President Trump was elected, the acting administrator of the Centers for Medicare & Medicaid Services (CMS) offered a “flexible” approach to the program’s first performance year – 2017. In November, the Trump administration issued a ruling to exempt physicians and advanced practice providers in Georgia on the basis of the overriding need to deal with the aftermath of Hurricane Irma. This exclusion extends to 2018, although there was notice that a yet-to-be-determined application process would be initiated. Georgia physicians who geared up for the program – and still wish to participate – are certainly welcome to do so; CMS will issue a performance score. Medicare is the most prominent payer for most physicians in Georgia. Therefore, it is business critical to keep tabs on the future of the QPP as well as take steps to ensure compliance to avoid the program’s panoply of penalties. For the present, however, enduring the hurricane in 2017 equates to a temporary respite.

Federal programs, Part C: The future On the same day the QPP exemption for Georgia’s physicians was announced, CMS proclaimed a rollback of the government’s

bundled payment initiative. Expected to be mandated as of 2018, the initiative was partially eliminated instead, with the remainder moved into voluntary participation status. Although the program was initially focused on joint replacements and cardiac rehabilitation, it is expected to expand into other specialty areas in the near future. Perhaps even more telling was the administration’s issuance of a “request for information” (RFI) on the future of the CMS Innovation Center. This governmental entity emerged from the Affordable Care Act, and it serves as the birthplace of recent “value-based” models – including accountable care organizations (ACOs) and alternative payment models (APMs). The RFI announced the intention of moving the Innovation Center into a “new direction.” Although the new course won’t be announced for some time, if the Innovation Center is scaled back, or ceases to exist, this may create a domino effect related to deconstructing the novel payment models formulated by the entity. Given the hope that new models will improve quality and reduce costs, the potential change in direction for the CMS Innovation Center, which is expected to be determined by mid-2018, may cause a shift of power from federal regulators to commercial payers.



With the possible vacuum of federal influence and payers gaining more power in the market via growth, it’s never been more important for physicians to understand the networks with which they participate and advocate for steps to prevent patient care disruption – namely press policymakers and payers for more inclusive networks of participating providers, eliminating or reducing the ability of payers to impose restrictive narrow networks.

What is required for success is understanding each payer’s protocols, what services need to be approved, and the process to do so. It is wise to check payers’ websites – at least once per quarter. Furthermore, be sure to identify the most efficient manner of achieving the approval – as practices often use manual systems even when electronic ones are available. Review every denial that is related to a lack of referral or certification or notification, whatever term the payer uses. Finally, work with medical societies like the Medical Association of Georgia to assist you with your advocacy efforts.

The permission scheme

Conclusion

Improvements may not come easy when physicians are yoked under an imposed “permission” scheme for many of the services they normally provide to patients. For years, physicians have had to seek approval in the form of referrals, pre-certifications, preauthorizations and, in the newest permutation, notifications. Failure to secure required permission results in non-payment accompanied by a contractual prohibition from transferring the financial responsibility to the patient.

While the trends that are related to technology and reimbursement from payers pose a significant opportunity for Georgia physicians, perhaps the single greatest challenge will emanate from a movement that has been developing for many years. Indeed, the rise of the new payer – your patients – will require the greatest attention in 2018. Spanning all specialties, the rising tide of patient financial accountability is sending unprepared medical practices into a tailspin.

The philosophy behind requiring approvals is certainly debatable, but the greater challenge comes in navigating the approval process itself. First, the rules for what requires an outside party’s consent vary not only by service but by payer. The mode for communicating approval requests differs, but it is almost always mired in paperwork. Despite the many obstacles that are placed in the physician’s pathway, it is rare for an approval to be denied, which makes one wonder why such a byzantine process is required. There appears to be no good answer. Payers must use their own administrative resources to manage approvals, yet they honor most requests. One wonders if the payoff from these efforts comes from the small percentage of approvals – often just one to two percent – that are never properly requested. Although only a handful may end up in this category, even this small percentage can equate to a high dollar amount of adjustments that the practice must accept as bad debt.

Particularly with today’s high patient deductibles, it is vital for practices to implement policies and procedures to collect from patients at the time of service while seeking any residual amounts remaining after services are rendered as effectively as possible. While 2018 stacks up as yet another challenging year to engage in the practice of medicine, those who take the time to seek out and gather knowledge about programs and payers – including patients – are the ones who will be best positioned to use the many available opportunities for success.¨ Woodcock is an Atlanta-based, nationally recognized practice management expert, specializing in practice operations and revenue cycle management. She is also a speaker, trainer and author. Contact her at contact@elizabethwoodcock.com or 404.373.6195. Go to www.elizabethwoodcock.com for additional information. Paid editorial submission.

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COUNTY, MEMBER & SPECIALTY NEWS

COUNTY MEDICAL SOCIETY NEWS Bibb County Medical Society

by Dale Mathews, Executive Director The Bibb County Medical Society (BCMS) held its 2017 ‘President’s Party’ at the Idle Hour Country Club in Macon in December. The BCMS 2018 Board of Directors includes President R. Jonathan Dean, M.D., President-elect Christopher E. Minette, M.D., Immediate Past President J. Eric Roddenberry, M.D., Vice President Zachary Lopater, M.D., Secretary/Editor Charles C. Snow, M.D., and Treasurer L. Arthur Schwartz Jr., M.D. At-large directors include I. J. Shaker, M.D., John J. Rogers, M.D., Rana K. Munna, M.D., Harold P. Katner, M.D., and Cameka N. Scarborough, M.D. Maria H. Bartlett, M.D., will serve as historian. The 2018 MAG delegation includes directors William P. Brooks, M.D., and Robert C. Jones, M.D., and alternate directors Malcolm S. Moore Jr., M.D., and Allen Garrison, M.D. John A. Hudson, M.D., was honored with the 2017 BCMS Physician of the Year award. He was the chief of medicine, the director of medical education, and an

The 2018 Bibb County Medical Society’s Board of Directors.

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associate director of critical care services at the Medical Center, Navicent Health. Dr. Hudson also served as a professor and the chair of internal medicine at the Mercer University School of Medicine. Meanwhile, Carl E. Lane, M.D. – a past chair of the Department of Surgery and a past chief of staff at the Medical Center, Navicent Health – received the society’s Distinguished Service Award for his efforts at the Macon Volunteer Clinic. Finally, Beverly Knight Olson was honored with the BCMS Citizen of the Year award. Go to www.bibbphysicians.org or contact Dale Mathews at bibbphysicians@gmail.com for information on BCMS. DeKalb Medical Society

by Melissa Connor, Executive Director The DeKalb Medical Society (DMS) recently announced that Melissa Connor will be its new executive director. DMS President Don Siegel, M.D., says that, “[former DMS executive director] Hank Holderfield and Melissa have worked together for over 25 years, and Melissa has supported DMS in a number of important ways – including managing our website, publishing our ‘Pulse’ newsletter, and planning our events. We are excited to welcome Melissa.” Connor says her short term goal is to increase membership. Contact Connor at mconnor@pami. org or 770.271.0453, and go to www.dekmedsoc.org for information on DMS.

Georgia Medical Society

by Ca Rita Connor, Executive Director Hal C. Scherz, M.D. – the chief of urology at Scottish Rite Children’s Hospital and an associate clinical professor of urology at Emory University Hospital in Atlanta – gave a ‘Doctors Drowning in the Credentialing Process’ talk at a Georgia Medical Society (GMS) meeting in Savannah on November 14. Later that month, GMS and the Medical Association of Georgia (MAG) hosted a CME program in Savannah that featured a presentation by Laura McCrary, the senior vice president or KaMMCO Health Solutions and the executive director of the Kansas Health Information Network (KHIN). She addressed HealtheParadigm, which enables physicians to generate sophisticated patient data reports they can use to improve outcomes and fulfill the new quality-based payer metrics. The society’s January 9 meeting focused on electronic medical records, including a ‘Does your practice want to win or are you willing to lose dollars?’ talk by Jody Denson, KHIN’s vice president of provider solutions. MAG Director of Strategic Programs and Initiatives Susan Moore was also on hand for the event. GMS officers for 2018 include President Luke J. Curtsinger, M.D., Vice President Roland S. Summers, M.D., Secretary William A. Darden Jr., M.D., Treasurer Fred L. Daniel, M.D., President-elect William H. Moretz III, M.D., and Carl B. Pearl, M.D. – an

at-large member of the GMS Board of Trustees. Dr. Daniel will serve as the society’s MAG delegate in 2018, while the MAG alternates include Dr. Summers, Dr. Moretz, and Buffi G. Boyd, M.D. Leslie L. Wilkes, M.D., is the historian for the year, while Dr. Summers will serve as parliamentarian. Outgoing GMS President Joshua T. McKenzie, M.D., was thanked and applauded for his efforts. Contact Ca Rita Connor at gamedsoc@bellsouth. net with questions related to GMS. Muscogee County Medical Society

by Dan Walton, Executive Director The Muscogee County Medical Society (MCMS) hosted its annual wine tasting event at Epic restaurant in Columbus in January. Over 100 members and guests enjoyed a variety of wines and food that were prepared by chef Jamie Keating. The guests included MAG President Frank McDonald, M.D, M.B.A. The event was sponsored by SunTrust Bank and MagMutual. February’s meeting featured a ‘Quality Matters: The New Data Dilemma’ CME lecture that was sponsored by MAG and HealtheParadigm. Go to www. muscogeemedical.org or call 706.322.1254 for additional information or to join MCMS. Richmond County Medical Society

by Dan Walton, Executive Secretary The Richmond County Medical Society’s (RCMS) hosted its

Joseph P. Bailey Jr. M.D., installing the RCMS officers for 2018, including (from the left) Jonathan Krauss, M.D., Bashir Chaudhary, M.D., and James Rawson, M.D.

annual ‘Family Holiday Party’ at the Old Medical College in Augusta in December. Its 2018 officers include President James Rawson, M.D., Vice President Kailash Sharma, M.D., Secretary/Treasurer Jonathan Krauss, M.D., and President-elect Bashir Chaudhary, M.D. RCMS also concluded its 2017 food drive in concert with this meeting. The society collected more than 90 pounds of goods for the Golden Harvest Food Bank in Augusta. The January meeting featured a presentation on ‘Population Health, System Dynamics and Opioids’ by Dr. Rawson. Go to www.rcmsga.org or call 706.733.1561 for additional information or to join RCMS.

MEMBER NEWS Ben H. Cheek, M.D., was recently nominated to serve as the presidentelect of the American College of Obstetricians and Gynecologists (ACOG) in 2018-2019. Dr. Cheek is an OB-GYN in Columbus. If he is elected during ACOG’s Annual Clinical and Scientific Meeting in April, Dr. Cheek would serve as ACOG’s president in 20192020. Dr. Cheek is a long-time member of both MAG and the Muscogee County Medical Society.

Resurgens Orthopaedics Co-President Douglas W. Lundy, M.D., M.B.A., was recently elected to serve as the president-elect of the American Board of Orthopaedic Surgery. He will begin his one-year term as the organization’s president in October. Dr. Lundy is a longtime member of MAG and the Cobb County Medical Society.

SPECIALTY SOCIETY NEWS Augusta Otolaryngology Education Foundation

The Augusta Otolaryngology Education Foundation is promoting the 16th Annual ‘Porubsky Symposium & Alumni Event,’ which will take place at the Medical College of Georgia at Augusta University on June 8-9. Go to www. aoefdtn.org for details. Contact Alyson Conley at alyson@ theassociationcompany. com with questions. Georgia Academy of Family Physicians

By Tenesha Wallace, Manager of Communications and Public Health The Georgia Academy of Family Physicians (GAFP) is encouraging physicians to register for its ‘Summer Family Medicine Weekend,’ which will take place at the Omni Amelia Island Resort on Amelia Island, Florida on June 14-17. Attendees can earn up to 36 AAFPprescribed credits. Note that an application for CME credit has been filed with the American Academy of Family Physicians. Determination of

credit is pending. AMA: The Georgia Academy of Family Physicians is accredited by the Medical Association of Georgia to provide continuing medical education for physicians. The Georgia Academy of Family Physicians designates this live activity for a maximum of 18 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The meeting will focus on providing family physicians and other primary care clinicians with information that will strengthen their knowledge base and introduce them to new concepts and clinical practice skills through a cost-effective, evidencebased, and diverse educational program. Go to www.gafp.org for additional information and to register. Call 800.392.3841, extension 106, with questions. Georgia Chapter of the American Academy of Pediatrics

by Kasha Askew, Director of Membership & Education The Georgia Chapter of the American Academy of Pediatrics (Georgia AAP) recently held several events, including a ‘Legislative Day at the Capitol’ on February 15 – which was a joint effort with the Patient-Centered Physicians Coalition (PCPC). The PCPC is comprised of societies that represent family medicine, internal medicine, OB-GYN, and osteopathic medicine. Of the event, Georgia AAP President Ben Spitalnick, M.D., said that, “This was an excellent opportunity for physicians

to meet their legislators and advocate at the state Capitol. Our number one priority for the year is to continue making progress on the MedicareMedicaid physician payment parity front. Georgia AAP also held a ‘Pediatric Infectious Disease & Immunization Conference’ in March. David Freeman, M.D., served as the event moderator, while Harry Keyserling, M.D., Larry Pickering, M.D., Walter Orenstein, M.D., Amanda Cohn, M.D., Inci Yildirim, M.D., and acting Georgia Department of Public Health Director J. Patrick O’Neal, M.D., gave presentations. The Chapter is encouraging physicians to make plans to attend its ‘Pediatrics by the Sea’ summer CME meeting, which will take place at The Ritz-Carlton Amelia Island (Florida) on June 13-16. In addition to the daily general sessions, the event will feature preconference seminars on developmental pediatrics, adolescent medicine, and coding/ practice management. Other noteworthy upcoming events include the Georgia ‘Pediatric Practice Mangers & Nurses Association Spring Meeting’ at the Macon Marriott City Center Hotel on April 20, the ‘Jim Soapes Charity Golf Classic’ to benefit the Pediatric Foundation of Georgia at the Cherokee Run Golf Club in Conyers on April 25, and the ‘Transitioning Youth with Special Needs from Pediatric to Adult Care Meeting’ that will take place at the Georgia AAP office in Atlanta on May 19. Go to www.gaaap. org or call 404.881.5091 for additional information.

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Georgia Chapter of the American College of Physicians

by Mary Daniels, Executive Director The Georgia Chapter of the American College of Physicians (GAACP) recently elected Waldon Garriss, M.D., MACP, as its governorelect. GAACP will hold its annual meeting at Callaway Gardens in Pine Mountain on October 12-14. The Chapter is working on a physician wellness initiative that is being led by Amy Eubanks, M.D., FACP. The Chapter is also promoting a free ACP online ‘Safe RX Opioid’ course for physicians (including nonmembers) that offers “3.5 CME credits and 3.5 MOC points” that is available at www.gaacp.org – keeping in mind that the Georgia Composite Medical Board has “adopted Rule 360-15-.01(3), which requires physicians (not resident physicians) who maintain an active DEA license and prescribe controlled substances to complete at least three hours of AMA/ AOA PRA Category 1 CME that is designed specifically to address controlled substance prescribing practices by [their] next renewal date.” Go to www.gaacp.org or contact Mary Daniels at mdaniels@ gaacp.org for additional information. Georgia Chapter of the American College of Cardiology

by Melissa Connor, Executive Director More than 150 cardiologists attended the Georgia Chapter of the American College of 30 MAG Journal

Cardiology’s (GAACC) 2017 annual meeting and scientific program at The Ritz-Carlton Reynolds/Lake Oconee in Greensboro in November. The event drew nearly 50 exhibitors and sponsors. The program addressed a number of important topics, including coronary heart disease, heart failure, valvular heart disease, and the athlete’s heart. GAACC President Charles Brown III, M.D., reported that, “Our program featured an opening keynote presentation by ACC President Dr. Mary Walsh, which was followed by a moderated panel discussion that included audience participation.” Jerre Lutz, M.D., was honored with GAACC’s Lifetime Achievement Award. GAACC’s annual meeting will take place at The Ritz-Carlton Reynolds/ Lake Oconee on November 16-18. Contact Melissa Connor at mconnor@pami. org with questions or go to www.accga.org for additional information. Georgia College of Emergency Physicians

The Georgia College of Emergency Physicians is promoting the 2018 Coastal Emergency Medicine Conference, which will take place at the Kiawah Island Golf Resort in South Carolina on June 8-10. Go to www.coastalemergency medicineconference.org for details. Contact Karrie Kirwan at karrie@ theassociationcompany.com with questions.

Georgia Gastroenterologic and Endoscopic Society

The Georgia Gastroenterologic and Endoscopic Society will hold its annual meeting at the Atlanta Marriott Buckhead on September 15. Monitor www.georgiagi.org for details. Contact Stacie McGahee at smcgahee@medicalbureau. net or 706.738.3119 with questions. Georgia Neurosurgical Society

The Georgia Neurosurgical Society will hold its annual meeting at The Cloister at Sea Island on May 25-28. Go to www.ganeurosurgical. org for details. Contact Karrie Kirwan at karrie@ theassociationcompany. com with questions. Georgia Society of Dermatology and Dermatologic Surgery

The Georgia Society of Dermatology and Dermatologic Surgery is promoting the 2018 Congress of Clinical Dermatology, which will take place at the Hilton Sandestin Beach Golf Resort & Spa in Sandestin, Florida on May 2528. Go to www.gaderm.org for details. Contact Maryann McGrail at maryann@ theassociationcompany. com with questions. Georgia Society of Interventional Pain Physicians

The Georgia Society of Interventional Pain Physicians will hold its annual meeting at The Ritz-Carlton Reynolds, Lake Oconee

in Greensboro on April 20-22. Go to www.gsipp. com for details. Contact Karrie Kirwan at karrie@ theassociationcompany. com with questions. Georgia Society of Otolaryngology/Head & Neck Surgery

The Georgia Society of Otolaryngology/Head & Neck Surgery is promoting its ‘Annual Summer Meeting,’ which will take place at the Royal Pacific Resort at Universal Studios in Orlando on July 19-22. Go to www. gsohns.org for details. Georgia Society of Rheumatology

The Georgia Society of Rheumatology will hold its annual meeting at The RitzCarlton on Amelia Island, Florida on June 1-3. Go to www.garheumatology. org for details. Contact Alyson Conley at alyson@ theassociationcompany. com with questions. Please submit Georgia county medical society, member or specialty society news to Tom Kornegay at tkornegay@mag. org. Also contact Kornegay with any corrections, which will run in the next edition of the Journal. The Journal reserves the right to edit submissions for length and clarity. Bolding recognizes the physicians who are active MAG members at the time the Journal was prepared. Go to www.mag.org/membership to join MAG.

PERSPECTIVE

The practice of management By Mark Murphy, M.D. Mark Murphy, M.D.

was a young man, all of 31 years of age, when I first put pen to paper and signed a contract that would allow me to open my medical practice for the first time. As an undergraduate zoology major with an abiding interest in history and English literature, I had taken classes such as “The 20th Century British Novel” as part of my non-majorrelated premed training. But I had never taken a business course. Not a single one. I met with my future practice manager shortly before our office was to open. They were still framing in the back doors. Dorothy Stevens, our receptionist, was making our initial patient appointments from a desk situated in a nearby trailer. “So we expect your AR to be this much after one year,” my practice manager said. “What’s AR?” I asked. She looked at me with a puzzled expression. “Accounts receivable,” she said. “Oh,” I replied. “Well, what’s that?” My crash course in running a medical practice began at that precise moment. A quarter century later, our practice had grown from two doctors and four staffers to 10 physicians, five midlevels and 85 employees practicing in three locations. I’ve learned an awful lot about the business of running a medical practice – from dealing with the veritable “La Brea Tar Pit” of government regulations to things as mundane as gossiping employees whose feelings were hurt by co-workers. And while it has certainly been an education, it’s not all been fun. From integrating an EMR to becoming compliant with HIPAA and Meaningful Use, I’ve had to deal with a plethora of issues of which I otherwise would have had zero interest in. I’ve learned more about politics and Excel spreadsheets than I ever wanted to. We built an office and an endoscopy unit, and I began to comprehend the inherent subtleties of leak-proof floors and backup generators. We bought real estate for a future office and subsequently had a local tire store utilize our wooded property to dump their retreads, prompting the need for an extensive tire cleanup and disposal (and the subsequent installation of motionactivated cameras on the lot so that it would not happen again). Ah, the practice of medicine in the 21st Century! I’ve been fortunate enough in the last 25 years to surround

myself with good business people, folks who understand all of the angles and nuances of running a physician practice. They have been a big part of my medical business education – but in learning these things, I’ve also learned a bigger lesson about what makes a medical practice successful. A good administrative team can make certain a medical practice will not fail from a business standpoint, but they likewise cannot make you succeed if you do not have the essential ingredients for success ingrained in you as a doctor. I used to follow my father, Dr. H. J. Murphy, while he made rounds. My dad was an old-school solo practice surgeon who practiced in Savannah for decades. I watched the way he interacted with patients. He’d plop down on their hospital beds and crack a few jokes. He’d talk about their families, Georgia football, and other things – until finally getting around to the nuts and bolts of their hospital stay. “So, can I get out tomorrow, doc?” a patient would ask. “If you do what you’re supposed to and have a bowel movement,” he’d say, patting the patient on the shoulder. “Is that too much to ask?” “Naw, doc. I think I can swing that,” the patient would say, beaming. And my dad would leave the room with a grin and a wink, promising to see them in the morning for that anticipated discharge, having earned the patient’s trust and their understanding about the shared responsibilities of the doctorpatient relationship. “Always remember the Three A’s,” Daddy said once when I was in medical school. “Ability, affability and availability. That’s what will bring referrals to your office.” I’ve learned a lot from my various business associates over the years. I’m fully conversant in all of the regulatory mumbo-jumbo that goes along with health care these days. But I still practice medicine like my father did – remembering the three A’s, and making certain that each and every patient knows, beyond a shadow of a doubt, that I care about them as a human being. For the practice of medical business management is one thing – but the practice of medicine is entirely something else. Dr. Murphy, a Savannah gastroenterologist and longtime MAG member, is the former President of the Georgia Medical Society. www.mag.org 31

PRESCRIPTION FOR LIFE

Beeps here, there & everywhere Jay Coffsky, M.D.

“beep” generally serves as a notification, although it’s not always clear why you’re hearing them. And beeps are a relatively new phenomenon – something that didn’t even exist when I started medical school. Early on, beeps were a “cool” novelty. But before we knew it, beeps morphed into an important and routine part of our everyday life. Beeps can represent good or bad news. And when it comes to beeps, you can’t bury your head in the sand – because beeps control just about everything we do, both personally and professionally. I love the beep that tells me that my wife Sandy’s chemotherapy treatment is finished, and we can go home. On the other hand, I hate that obnoxious beep that reminds me that there is something wrong with my computer or that I have, once again, forgotten one of my one million online passwords. When I wake up in the morning, the first beep I hear is the one that is made after I disarm our home security system, which – and assuming I enter the right code – is an exercise that also serves as my first mental wellness check of the day. Of course, I get more than my share of this particular beep because it’s one I hear every time I leave the house or come home and just before we retire for the evening. (This is also contingent on successfully getting in or out of the house in 20 seconds or less or risk having that innocent beep turning into an all-hell-hasbroken-loose, wake-up-the-entire-neighborhood siren). Of course, let’s not forget the more benign beeps I get every time I get an incoming phone call, text, or email. When I am driving, my car lets out a good, stiff series of beeps to let me know I’m drifting into another lane. And when I am at the hospital, I hear a beep every time I log into a multitude of devices – again, and God willing, I remember my username and password. This includes my workstation computer, a computer that allows me to access the report line, a computer that allows me to dictate my notes, and one more that generates patient

32 MAG Journal

reports. Before we get too comfortable, let’s not forget about the passcode I need to enter the radiology office. On a normal day, I’ve heard 10 beeps by 7:30 a.m. Other beeps that I hear on a regular basis include the one that reminds me to use my seatbelt, one that lets me know I need to change our smoke detector batteries (which is, needless to say, my least favorite), one that lets me know that my transaction at the drive-thru ATM is complete, and one the lets me know that the picture I’m about to take is – finally – in focus. You know that you’ve done something wrong if that congenial beep picks up its pace or you try and walk out of a retail store after the clerk forgot to remove the anti-theft device from the slacks you just bought, or you are about to back into a concrete pillar with your rear bumper. The hospital is full of beeps, too. Like when you take a patient’s temperature, when it’s time for their medication, when their IV is finished, or when a monitor is (or isn’t) working. I’m not aware of another profession that is so wellconnected to the beep. Have you ever heard a beep after the dentist fills a cavity or your accountant finishes your taxes or a lawyer signs a contract? I rest my case. I like some beeps more than others, but the beeps I absolutely hate the most are the ones I hear after I’m in bed. I can live with those creepy house noises – but I draw the line at beeps that take place after midnight. Did I leave a door open? Is an appliance or device malfunctioning? Making matters worse is that in my household I’m the one who has to get out of bed to investigate these perplexing noises. Medical science is great. But when it comes to getting a fancy neurological test to make sure I still have my wits, I think I’ll pass. You see, the day that I can’t successfully navigate the minefield of beeps is the day I will have my answer. Dr. Coffsky and his wife, Sandy, have been married for 58 years and have three children, eight grandchildren, and a greatgrandchild. He is in his 50th year at DeKalb Medical. You can email Dr. Coffsky at jaycoffsky@gmail.com.

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