Medical Association of Georgia (MAG)

Vol. 105, Issue 1, 2016

Between the mergers and narrowing networks...

It’s tIme to

Sound the ALARM!

Rep. Tom Price, M.D., weighs in on EHR CTE – Learning what we don’t know Where we practice: Augusta Legal takes on MPFS, documentation & marketing your practice

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TABLE OF CONTENTS VOLUME 105, ISSUE 1

6

16

20

35

IN EVERY ISSUE

FEATURES

3 President’s Message

6

4 Editor’s Message

10 Editorial: Keep the focus on the patient

5 Executive Director’s Message 18 Medical Ethics 24 Legal: Why documentation matters 27 Risk Management 30 L egal: Compliance issues in marketing physician practices 32 Legal: Important changes in the MPFS 36 County, Member & Specialty News 40 Member Profiles 44 Prescription for Life

It’s time to sound the alarm!

14 Market Analysis: Augusta 16 Editorial: CTE – Learning what we don’t know 20 Georgia’s new medical marijuana law 35 2016 Physicians’ Day at the Capitol

PRESIDENT’S MESSAGE

Insurers should stick to insurance John S. Harvey, M.D.

johnharveymd@gmail.com

H

The gap between the cost of delivering the care and the payments providers receive continues to grow wider, and insurers have ratcheted payments down to levels that often don’t cover the cost of providing the care. Because these companies wield such inordinate power, many physicians feel like they have to sign these contracts if they want to get paid at all.

And if the pending Aetna Inc./Humana Inc. and Anthem Inc./ Cigna Corporation mergers are allowed to go through, things will undoubtedly get worse, as the combined entities would control nearly 90 percent of the individual market in Georgia.

The insurers have also transferred costs to the individual patient in the form of higher deductibles and co-pays. It’s not unusual for a patient to have deductibles of $3,000 or more per year, which is just a more palatable way of saying they don’t have any insurance until they’ve spent $3,000.

aving posted record profits in recent years, health insurance companies now direct almost every aspect of patient care. They unilaterally set the rates that they will pay for the care our patients receive – while they sell policies that don’t have enough providers to unsuspecting patients who must bear additional out-of-network costs.

The mergers would reduce competition and place physicians and their patients at an even greater disadvantage as a shrinking number of health insurance companies seize increasingly dominant positions in the marketplace. A few insurers would have free reign to institute policies that exacerbate the physician shortage and undermine the economic viability of Georgia’s health care system – especially in rural areas where hospitals and medical practices are struggling to keep their doors open.

Our patients need to know that we, as physicians, often don’t know whether we are in or out of a given health insurance network because of the proliferation of rental networks (an issue that MAG Executive Director CEO Donald J. Palmisano Jr. addresses in his column on page 5), unilateral contract revisions, and dated and unreliable insurer databases.

Note, too, that more than 30 percent of the physicians in Georgia who participated in a survey that MAG conducted a few months ago said that they believe that the Aetna/Humana merger would threaten the long-term viability of their practice.

With all of this in mind, the physicians who discover that they were out-of-network and don’t have a contract with the insurer at the time they delivered the care are billing the patient for the difference between what the insurer is willing to pay (i.e., the in-network rate) and their normal fee. This is especially prevalent in ER and other time-sensitive health care settings.

It should come as no surprise that MAG has urged the U.S. Department of Justice to assess these mergers for antitrust violations in a full and comprehensive way.

MAG believes that there are several important steps that health insurers in the state can take to end the need for this practice.

This includes…

The Georgia Department of Insurance (DOI), meanwhile, has also expressed concerns that the Aetna/Humana merger would violate Georgia’s standards for competition. Specifically, DOI believes that the Aetna/Humana merger may violate Georgia’s competitive standard in the individual, small group, and Medicare Title XVIII markets while raising concerns of substantially reduced competition in the large group market.

Insurers claim that the efficiencies that would be created as a result of the mergers would lower premiums, but we know better based on what has transpired with deductibles and copays in recent years.

Physicians, in particular, have little leverage when it comes to negotiating the terms of their contracts with these multibillion dollar conglomerates – which are imposing take-itor-leave-it agreements and unilateral, mid-term amendments with growing impunity.

• Expanding their physician/provider networks • Being more credible and transparent about the physicians who are in their networks and updating their network directories at least once a month • Offering fair, consistent contract terms – and taking steps to ensure that every physician at a given facility is “innetwork” so patients have budget certainty and peace of mind The health care system in Georgia will be in a better place when physicians are allowed to focus on patient care while health insurers get back to the business of providing their customers with access to the health care they paid for and deserve.

Editor’s note: MAG is encouraging MAG members to contact Courtney Faust at cfaust@oci.ga.gov / 404.463.2825 or Scott Sanders at ssanders@oci.ga.gov / 404.657.7742 to urge Georgia Insurance Commissioner Ralph Hudgens to oppose the mergers. 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 Janis S. Coffin, D.O., Augusta Jay S. Coffsky, M.D., Decatur Mark C. Hanly, M.D., Brunswick Barry D. Silverman, M.D., Atlanta Joseph S. Wilson Jr., M.D., Atlanta Michael Zoller, M.D., Savannah MAG Executive Committee John S. Harvey, M.D., President Steven M. Walsh, M.D., President-elect Manoj H. Shah, M.D., Immediate Past President Madalyn N. Davidoff, M.D., First Vice President S. Mark Huffman, M.D., Second Vice President Rutledge Forney, M.D., Chair, Board of Directors Frederick C. Flandry, M.D., Vice Chair, Board of Directors Andrew B. Reisman, M.D., Secretary Thomas E. Emerson, M.D., Treasurer E. Frank McDonald Jr., M.D., Speaker of the House Edmund R. Donoghue Jr., M.D., Vice Speaker of the House Michael E. Greene, M.D., Chair, Council on Legislation S. William Clark III, M.D., Chair, Georgia AMA Delegation 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.

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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.

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4 MAG Journal

The presidential candidates and health care

Stanley W. Sherman, M.D.

I

hope that you are enjoying the presidential “reality show” as much as I am. As of press time, the Republican frontrunner is Donald Trump, followed by Ted Cruz, Marco Rubio and, finally, John Kasich. Yet by the time you read this more primaries could change these standings or perhaps more candidates will drop out of the race.

On the Democratic side, Hillary Clinton is the frontrunner, but Bernie Sanders is still a threat. Trump and Clinton won our Georgia primary. In any event, it’s likely that two of these candidates will be on the November ballot, so in case you are not clear on their health care policies, I want to share with you what I was able to find out.

If you are Republican, you want to repeal Obamacare. Trump prefers to say he will replace it with “something great.” If pressed, he touts interstate competition between insurance companies and health savings accounts. He has been in trouble with his competition in that – more like a Democrat – he is sometimes not opposed to the individual mandate, wants the government to negotiate the price of drugs, and says he may expand government coverage because he “does not want people dying on the streets.” At times, he has denied that he still feels this way about some of these positions. Cruz has been the most vocal in stating that he will repeal all of Obamacare and replace it with market-based plans. He wants patients to be able to buy coverage across state lines, expand health savings accounts (HSAs), and make insurance portable. Rubio says he wants to implement refundable tax credits for purchasing health insurance, reform insurance regulations with competition and HSAs, and fiscally stabilize and strengthen Medicare and Medicaid. Kasich is on record for opposing Obamacare but accepted the program’s Medicaid expansion in his state of Ohio, citing the need to help the poor. Ohio did cut its Medicaid growth rate. He also has favored tax-exempt medical savings accounts.

Clinton is your candidate if you want to continue Obamacare. She will add drug company price negotiations, lower copays and deductibles, and wants value-based reimbursement.

She wants to expand telemedicine and protect pro-choice and Planned Parenthood funding. Sanders simply thinks health care is everyone’s basic right and wants a “free” Medicare-for-all, single-payer system that’s funded by raising everyone’s taxes.

I hope the above is helpful in deciding who you feel is best for the future of your practice, your patients and, of course, our country.

Be sure to read about the legislation our U.S. representative and MAG member Dr. Tom Price has been leading to protect us from “meaningful use” and unfair reimbursements. Our feature article discusses the negative impact of big insurance mergers and narrowing networks with a call for action reiterated by our president, Dr. John Harvey, to block this. MAG CEO Donald J. Palmisano Jr. explains how insurers have used rental networks to lower our reimbursements.

Meanwhile, our legal contributors review changes in the Medicare fee schedules, and warn us to be careful in marketing our practices and in our patient records. The Journal’s medical ethics article warns us about the use of inappropriate “medical slang.”

Dr. Peter Buckley discusses the status of medical care in Augusta. Dr. John Antalis reviews Georgia’s new medical marijuana law. The MAG Mutual Insurance Company’s risk management article warns us of the dangers of prescribing unfamiliar drugs. Dr. Craig Kerins reviews our present knowledge of Chronic Traumatic Encephalopathy (CTE), which has been in the news lately. Finally, Dr. Coffsky’s life lessons continue to help us all as we look forward to a warm spring, and perhaps a hot political reality show.

EXECUTIVE DIRECTOR’S MESSAGE

Sound familiar?

Donald J. Palmisano Jr.

P

atient: Yes, I’d like to schedule an appointment.

Your practice staff: Good morning. Do you have your health insurance card handy?

Patient: Yes, of course – I have ABC Health Insurance Company.

Your practice staff: Unfortunately, our practice isn’t part of that insurance network – so you would have to pay the outof-network rate. (As a physician and a practice, you elected not to participate in ABC’s insurance network because of the administrative hassles and insufficient pay.)

The patient acknowledges this and schedules the appointment – knowing that they will be paying an “out-of-network” fee.

So let’s say the exam costs $100. The patient will pay the $35 they owe for an out-of-network visit (something more than they would have paid had you been “in-network”), while the practice bills the insurer for the $65 balance.

Fast forward a few months and your practice receives an ‘Explanation of Benefits’ (EOB) from ABC Insurance Company. To your surprise, they inform you that you are indeed in-network and your payment has consequently been adjusted (i.e., reduced) to $75. The patient, meanwhile, now owes just $15 (20 percent) because the plan covers $60, or 80 percent.

Your staff is scratching its collective head trying to figure how this happened when you expressly decided to remain outof-network. After multiple calls, ABC points out that your practice signed a contract with Rental Network A (RNA) – and RNA has a contract with ABC, which means that every RNA physician is now in ABC’s network.

Once (and assuming) their anger and frustration subsides, your practice staff calls RNA to get to the bottom of this.

Now because there is a good chance nobody will answer the phone, your staff might have to call RNA on more than one occasion – and your staff will undoubtedly leave messages.

Then at some point, your office will finally connect with an RNA “customer service” representative. Your staff will demand to know how your practice can possibly be innetwork when it never signed a contract with RNA. RNA assures your staff that, “Sorry, but you did indeed sign a contract.” If you’re lucky, and after a few months of backand-forth, you might actually get a copy of the contract you will no doubt request.

dpalmisano@mag.org

The bottom line here is that it turns out that you did technically sign a contract with RNA. But you did so in one of the following, less-than-transparent ways…

• You signed a patient’s HIPAA document, which included language that said by signing this document you agree to be in-network and accept a percentage of your billed charges.

• A W-9 came across your facsimile machine that stated that you need to sign the document in order to get paid.

It turns out that there was language at the end of the W-9 that said that you agreed to be in-network.

• You signed one of the many other misleading documents that contained language that bound you to in-network status.

And if things weren’t bad enough, this is when you discover that ABC Insurance Company applied some of its own unique contract terms, which will result in even lower net pay.

To put this into some perspective, let’s say you have a mortgage with ABC Bank. You have to pay them $1,000 on the first of every month. ABC Bank decides to sell your mortgage, which is a fairly common transaction in the banking world, to XYZ Bank. If you applied our health insurance rental networks example to our mortgage example, XYZ Bank would be able to change the terms of your loan (e.g., your payment or due date) without your knowledge.

This is how the rental networks – or ‘Silent PPOs’ – work in the real world. Not a real uplifting message, I know.

But the good news is that Georgia Sen. Dean Burke, M.D. (R-Bainbridge) has been working on a solution. Under S.B. 158, health insurers in Georgia would have to register their networks with the Georgia Commissioner of Insurance. Sen. Burke’s bill would also compel those insurers to be more transparent about their networks and their contract terms.

And this is something lawmakers have taken seriously. A group of legislators studied the bill for nine months in 2015. It is also worth noting that every stakeholder that participated in the process – including the lobbyists for the health insurance industry – agreed that the rental networks are flawed and need to be addressed.

This is why health insurance reform in general, and rental networks and the pending mega health insurer mergers in particular, are at the top of the Medial Association of Georgia’s advocacy objectives for 2016. www.mag.org 5

It’s time to sound the alarm!

By Tanya Albert Henry

G

eorgia physicians are loudly objecting to the pending marriage of several mega health insurers – including Aetna Inc. to Humana Inc. and Anthem Inc. to Cigna Corp. – because they know the nuptials would have disastrous results for their profession and their patients.

“These companies already control just about every aspect of our health care system,” explains Medical Association of Georgia (MAG) President John S. Harvey, M.D. “The thought of any further consolidation in the health insurance arena paints a pretty grim picture, which is why MAG has taken such an active role in opposing these deals and is taking steps to empower physicians and their individual patients.”

Dr. Harvey points out that today’s doctors struggle with a wide array of headaches associated with narrowing networks, so the mergers would undoubtedly change the atmosphere from bad to worse.

He says that, “You have to remember that physicians in Georgia already face a mountain of insurer rules and regulations and payment systems.”

The new Aetna/Humana and Anthem/Cigna companies would control nearly 90 percent of the individual health care market in the state, with the new Aetna at nearly 60 percent and the new Anthem at about 30 percent.

In the small group sector, the two new companies would control more than 80 percent of the market in Georgia – including Aetna at nearly 50 percent and Anthem at more than 30 percent. The combined entities would control more than 65 percent of the large group market in the state, with Anthem at about 55 percent and Aetna at more than 10 percent. And each of the new companies would control a little more than 25 percent of the Medicare Title XVIII marketplace in Georgia.

“If you are an insurance company executive and you control 90 percent of the population in a particular community, what incentive is there to negotiate with the physicians in that community?” asks 6 MAG Journal

Help MAG block the mergers The Medical Association of Georgia is encouraging Georgians to contact Courtney Faust at cfaust@oci.ga.gov / 404.463.2825 or Scott Sanders at ssanders@oci.ga.gov / 404.657.7742 to urge Georgia Insurance Commissioner Ralph Hudgens to oppose the Aetna/Humana and Anthem/Cigna mergers.

John J. Rogers, M.D., a co-medical director in the emergency department at Coliseum Northside Hospital in Macon.

MAG Executive Director Donald J. Palmisano Jr., warns that, “If these mergers are allowed to go through, several insurers would be able to institute policies that will intensify the physician shortage and undermine the economic viability of Georgia’s health care system – especially in rural areas where hospitals and medical practices are struggling to keep their doors open.”

He also stresses that, “Doctors won’t necessarily be able to continue to practice medicine in a way that they believe is the best way for their individual patients.”

Armed with statistics and examples of what is already taking place in a world where physicians have little-to-no negotiating power, MAG has been one of the most vocal advocates in the effort to call for state and federal policymakers to block the mergers.

For instance, Palmisano recently sent a letter to the Antitrust Division of the U.S. Department of Justice (DOJ) to call for it to scrutinize the mergers for anti-trust violations – a request that DOJ has under consideration.

He stated that, “These transactions would reduce competition and

place physicians and their patients at an even greater disadvantage as a shrinking number of health insurance companies seize increasingly dominant positions in the marketplace.”

Palmisano also pointed out that “physicians have little leverage to negotiate contract terms with these multi-billion dollar conglomerates – which are imposing take-it-or-leave it agreements and unilateral, mid-term amendments with growing impunity.”

Physicians aren’t alone The Georgia Department of Insurance is assessing the Aetna/Humana merger to determine if it would violate Georgia’s competitive standards in the individual, small group and Medicare Title XVIII markets, and it has expressed concern over the loss of competition in the large group market.

At the national level, the American Medical Association (AMA) and the American College of Physicians are among the physician advocacy organizations that have sent letters to DOJ to highlight what could happen to the nation’s health care system if the five largest insurers – the four that are involved in the pending deals plus UnitedHealth Group – become three.

AMA told DOJ that the mergers would “likely result in higher premiums for patients, a reduction in the quality of health insurance (e.g., less availability of providers, lower consumer service), and lower payment rates for physicians that lead to lower quality or quantity of the services that physicians are able to offer patients (e.g., less investment in newer technology).”

Meanwhile, AMA’s 2015 edition of its Competition in Health Insurance: A Comprehensive Study of U.S. Markets report found that the Anthem/Cigna merger would diminish competition in as many as 111 metropolitan areas within the 14 states it does business – while the Aetna/Humana deal would reduce competition in up to 58 metro areas in the 14 states.

Concern runs deep in Georgia More than 30 percent of the nearly 300 Georgia physicians who took a MAG survey in 2015 said that they believe that the Aetna/Humana merger would threaten their practice’s long-term viability – keeping in mind that some 80 percent said they participated in at least one Aetna and/or one Humana network.

MAG also discovered that more than 30 percent of the physicians who completed the survey weren’t sure if they would continue to serve as an “in-network” physician if the merger goes forward.

MAG’s research also confirmed that physicians in Georgia already are frustrated on a number of important fronts. For example…

• More than 35 percent said that they have had out-of-network billing problems with either Aetna or Humana.

• Just three percent said that either Aetna or Humana provided them with definitions for “usual, customary, reasonable” and/ or “eligible charge” and/or “maximum benefit amount” for the purpose of out-of-network billing.

• More than 60 percent said that they do not believe they have the opportunity to “materially modify” their agreement with either Aetna or Humana.

• Some 45 percent said that their “credentialing, enrollment and effective dates” experience with Aetna has either been poor (13 percent) or fair (32 percent) – numbers that were nearly identical for Humana.

AMA statement on antitrust reform The American Medical Association (AMA) believes that, “Antitrust relief remains a high priority for physicians. Legislation is needed to enable physicians and other health care professionals to effectively negotiate with health plans without fear of violating antitrust laws. Physicians should be allowed to negotiate contract terms that increase patient choice and improve quality of care. Patients and their physicians should make informed decisions about their health care needs, not insurers.”

AMA also notes that, “On November 11, 2015, the AMA urged the U.S. Department of Justice to block the proposed Anthem/Cigna and Aetna/ Humana health insurance mergers. The AMA believes that high insurance market concentration is an important issue of public policy because the anticompetitive effects of insurers’ exercise of market power pose a substantial risk of harm to patients. Our analyses of the proposed AnthemCigna and Aetna/Humana health insurance mergers reveal significant concerns with respect to the impact on patients in terms of health care access, quality, and affordability.”

Finally, AMA believes that, “Reducing five national health insurance carriers to just three should be viewed in the context of the unprecedented lack of competition that already exists in most markets. Specifically, 1) greater consolidation leads to price increases, not to greater efficiency or lower health care costs and 2) highly concentrated health insurer markets limit patient choice and 3) dominant health insurers compromise physician-patient advocacy and 4) payment to physicians below competitive levels undermines access and quality.

• More than 45 percent said that their “claims submissions, processing and timely payment” experience with Aetna has been poor or fair, a number that increased to more than 50 percent for Humana.

“The promise of consolidation is that there will be efficiencies, and insurers will pass the savings along,” Dr. Rogers says. “But the historical reality is that the premium and other costs that patients pay will go up and what the insurance companies are willing to pay physicians will go down.”

He also asserts that, “Physicians and patients are already on the losing end of this proposition because these companies have a really heavy hand and they can – and do – sway things in their favor.”

Douglas orthopaedic surgeon Jim Barber, M.D., explains that one (continued on page 8)

www.mag.org 7

(continued from page 7)

of the common tactics that insurers use to increase their profits is to change their contract terms by revising their policy and procedure manuals rather than modify the actual contract.

Resources Go to www.mag.org/advocacy/insurance-merger to obtain the following resources…

“One of the big insurers here in south Georgia changed the billing guidelines in its policy and procedures manual without notifying [our practice] and subsequently demanded a refund,” he recalls.

“There simply isn’t any reasonable excuse for that kind of behavior.”

MAG’s letter to the U.S. Department of Justice (DOJ)

In another case, Dr. Barber says that a major insurer changed its computer billing system and erroneously took back significant amounts of payments – and not by asking for refunds, but rather by withholding those funds from future payments.

AMA’s ‘Block the Mergers’ campaign

He says, “A lot of my colleagues are getting to the point where they don’t feel like they have any alternative but to become employed.”

Narrowing networks Palmisano knows first-hand that physicians have grown weary about the proliferation of increasingly narrow health insurance networks.

He declares that, “The insurance companies are using these networks to control costs. Physicians, in turn, are often unwilling to join these networks because the pay is so low – often not enough to cover the cost of providing the care…this has been a problem with Medicaid for some time, but now it’s becoming a real problem in the commercial insurance arena as well.”

Palmisano also says that because of their size and influence, insurers have assumed a more brazen, take-it-or-leave-it posture when it comes to physician contracts.

MAG’s ‘Top Docs Radio’ show on the mergers Physicians Advocacy Institute letter to DOJ

“Of course,” he adds, “some physicians don’t even get to that point… they are abruptly and often inexplicably dropped from a given network.”

The specific reason notwithstanding, patients are the ones who are ultimately left holding the bag – paying larger premiums and co-pays and deductibles for coverage that fails to provide them with enough access to the care they need and deserve.

Health insurer tactics have become such a big concern that a number of MAG member physicians have taken valuable time away from their practices to relay their experiences and perspectives to state lawmakers.

In 2015, Dr. Barber told a legislative study committee that, “One of the big insurers claimed to offer a plan with an extensive network of doctors in Coffee County, but the reality is that very few of the primary medical staff in our community were ever asked to join the network.”

And in perhaps the most jaw-dropping case that has been reported to date, Dr. Barber recalled the case of a pregnant patient whose

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8 MAG Journal

insurer had assured her that her doctor and hospital were included in her new plan – only to discover that wasn’t the case one week before her delivery; she was stunned to find out that the closest in-network hospital was two hours away.

care in an out-of-network situation.”

Dr. Barber also told lawmakers that the insurers need to be accountable for providing physicians and patients in the state with information that is both credible and up-to-date.

And Dr. Williamson emphasized that, “Insurance companies have for decades ratcheted payments down to ridiculously low levels that do not cover the costs of providing care.”

He said that, “For the sake of our patients, insurers must provide accurate lists of participating doctors, and their networks must have an adequate number of participating doctors.”

In his testimony to the legislative study group, Gwinnett County neurologist and former MAG President M. Todd Williamson, M.D., stressed that, “The insurance companies need to address the issue of out-of-pocket expenses for patients requiring medical

He pointed out that, “It is simply not practical to think that a patient will never require care from a physician outside the confines of a narrow network.”

Dr. Rogers concurs, stating that, “Until these insurance companies offer fair and adequate pay, the networks are going to remain too narrow.”

“The real long-term concern here should be the individual patient and if they will have access to the care they need, whether the filter is by specialty or geography,” Dr. Harvey concludes.¨

Georgia physicians weigh in on the Aetna/Humana & Anthem/Cigna mergers The American Medical Association (AMA) recently surveyed physicians in Georgia on the pending Aetna/Humana and Anthem/Cigna mergers. AMA will use the survey results in its advocacy efforts – as will the Medical Association of Georgia.

The following are a few of the key survey results…

Do you feel that you must contract with one or more of the following commercial insurers in order to have a financially viable practice?

[Aetna-Humana’s] Narrower physician networks would reduce patient access to care.

Aetna 72%

Somewhat likely 35%

Anthem 75% Cigna 66%

[Anthem-Cigna’s] Narrower physician networks would reduce patient access to care.

Humana 62%

Very likely 72%

For the most recent contract, did any of the following payers give you a “take-it-or-leave-it” offer versus being allowed to participate in a two-way bargaining process?

Somewhat likely 22%

Aetna 45%

Strongly oppose 74%

Anthem 57% Cigna 37% Humana 37%

Do you support or oppose regulators to allow the AnthemCigna merger to proceed?

Somewhat oppose 13% Do you support or oppose regulators to allow the AetnaHumana merger to proceed?

How would the Aetna-Humana merger impact contract negotiations?

Strongly oppose 71%

Much less favorable 66%

Do you agree or disagree that, “The mergers are necessary to gain efficiencies in areas such as innovative payment programs and care management strategies that will benefit patients.”

Somewhat less favorable 19% How would the Anthem-Cigna merger impact contract negotiations?

Much less favorable 68% Somewhat less favorable 15% What would you do if Aetna and Humana merged and you did not have a contract with the merged plan?

Cut investments (e.g., technology) 45% Cut staff 43% Spend less time with patients 40% What would you do if Anthem and Cigna merged and you did not have a contract with the merged plan?

Somewhat oppose 14%

Strongly disagree 63% Disagree 21% Do you agree or disagree that, “The mergers will give those insurers even more influence over physicians’ clinical and business practices with little or no recourse for physicians.

Physicians will be forced to cut costs so deeply that [they] will see a significant degradation of their ability to provide the care that patient’s value and need.”

Strongly agree 72% Agree 18%

Cut investments (e.g., technology) 40%

Cut staff 45%

Contact Tom Kornegay at tkornegay@mag.org for the full survey results.

Spend less time with patients 49%

Very likely 57%

www.mag.org 9

EDITORIAL

Keep the focus on the patient

By U.S. Rep. Tom Price, M.D.

A

patient-centered health care system is built upon six principles: accessibility, affordability, quality, choices, responsiveness, and innovation. Today, there are many instances where those principles are being violated – more often than not through rules and regulations handed down from bureaucratic agencies in Washington, D.C. For an example, we need only look at how physicians and hospitals have had to go about adopting electronic health records (EHR).

As part of the economic stimulus package that became law in the early days of the Obama administration, there was a concerted effort to help spur adoption of EHR among physicians and hospitals. The law states “the Secretary [of Health and Human Services] shall seek to improve the use of electronic health records and health care quality over time by requiring more stringent measures of meaningful use.”

From this text was born a complex and burdensome set of requirements known as Meaningful Use (MU) Stages 1, 2 and 3. Although well-intentioned, the MU requirements have chiefly missed the mark by focusing more on data entry and less on patients and their doctors.

Physicians face a number of impediments to meeting the MU requirements, many of which are outside of their control.

These include the lack of usability and interoperability among EHR, significant data exchange fees, interference with face-to-face patient care, time-consuming data entry, the degradation of clinical documentation, and inflexible metrics.

A total of 209,000 physicians will face penalties in 2016 for failing to meet EHR MU criteria. While 80 percent of physicians have adopted EHR in their practices, less than 10 percent of physicians have successfully participated in MU Stage 2 so far. If we want higher quality care, healthier patients, and a more efficient use of time and resources, then the MU program needs to be reevaluated so it moves in the direction of our health care principles.

This past October, the Centers for Medicare & Medicaid Services (CMS) released its modified Stage 2 rule of the MU program.

CMS issued its directive with less than the requisite 90 days remaining in the 2015 program year. That meant it was virtually impossible for doctors to meet the requirement deadlines.

Anticipating this challenge, I introduced H.R. 3940 – the Meaningful Use Hardship Relief Act – to provide physicians 10 MAG Journal

Tom Price, M.D. with much-needed relief by ensuring they would be granted a hardship exception to avoid penalties stemming from the delayed rulemaking. Working with colleagues in Congress, physicians and various stakeholders, we were able to get language based on the solutions that we introduced included in a larger package of reforms – S. 2425, the Patient Access and Medicare Protection Act – which was signed into law just prior to the new year.

On January 22, CMS released a hardship application for physicians and hospitals to use when filing an exception to the MU penalty for the 2015 program year. In the past, providers and hospitals had separate application forms. Under the new law, the application is now streamlined and can be used by both. Providers may file as individuals or in groups – while before each individual provider would have had to submit a separate application to be considered by CMS on a case-bycase basis. This new streamlined process also allows CMS to process hardship applications more efficiently in batches.

All physicians are encouraged to go to CMS.gov and apply for a hardship exception under the category “EHR Certification/Vendor Issues (CEHRT Issues),” which references “insufficient time” in accordance with CMS’ delayed rulemaking. Applications must be submitted to CMS

by March 15.

Sadly, physicians know all too well that the work of defending the principles of patient-centered care never ends. While MU penalties affect physicians and hospitals nationwide, here in Georgia our laboratories and physician groups were facing a more unique threat at the beginning of this year. Under a blatantly prejudiced reimbursement policy related to new codes for drug testing, CMS was threatening a 33 percent cut from the national payment rate for Georgia labs and doctors.

Thanks to the Medical Association of Georgia and others, we were able to get this serious discrepancy repaired and ensure that Georgia health care providers were treated fairly.

With solutions to improve our health care system that adhere to our principles, we can protect the doctor-patient relationship from undue influence and interference, and put patients, families and doctors in charge.

Dr. Price represents Georgia’s Sixth Congressional District. He is an orthopaedic surgeon who spent more than 20 years caring for his patients in the metro Atlanta area. Dr. Price is a longtime MAG member, and he serves Georgia’s AMA delegation as an alternate.

www.mag.org 11

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MARKET ANALYSIS

Where we practice: Augusta

By Peter F. Buckley, M.D., dean, Medical College of Georgia at Augusta University

A

ugusta is a terrific place to live. Few cities hold center stage for an entire week every year as Augusta is abuzz every spring for the Masters golf tournament – a remarkable global event. Yet Augusta is much more than the tournament. It is a major military city with Fort Gordon – and Dwight D. Eisenhower Medical Center employs some 2,600 people. The city is near Plant Vogtle, the first U.S. nuclear plant to be constructed in 30 years. Augusta is thriving and growing, with many points of pride in business, arts and culture, entertainment, and overall quality of life (www.augustaga.gov).

Augusta is also recognized as a ‘medical destination’ city. Citizens have access to many health care systems, including excellent physician practices and community programs. Augusta has a Veteran’s Affairs (VA) hospital (www.augusta. va.gov). In addition to its specialist spine care units, the VA provides medical and allied health training to some 700 medical students and residents at the Medical College of Georgia (MCG) at Augusta University (AU) – the state’s only public medical school.

Doctor’s Hospital (www.doctorshospital.net) is a 350-bed facility with excellent programs, including the Joseph M. Still Burn Center – the largest inpatient burn center in the U.S. Trinity Hospital (www.trinityofaugusta.com) is a 231-bed facility with comprehensive programs. It is a top performer on The Joint Commission quality measures. Quality has always been the hallmark of University Hospital (www. universityhealth.org), which was founded in 1818, with a broad range of clinical services and reputation as a ‘Top 100’ hospital.

I am also proud to know that a lot of our outstanding doctors are members of the Richmond County Medical Society (RCMS, www.richmondcountymedicalsociety.org).

14 MAG Journal

Peter F. Buckley, M.D. MCG (www.augusta.edu/mcg) is the ninth largest medical school in America. It is fortunate to have the support of the aforementioned health care systems to train our students, residents and fellows as well as the specialist care that is provided by MCG full-time and/or clinical faculty.

AU Medical Center (www.augustahealth.org) is MCG’s primary affiliate hospital, which includes 478 adult beds and a 154-bed children’s hospital (Children’s Hospital of Georgia or CHOG). With a multispecialty group practice that is comprised of 485 MCG faculty, AU Health operates 80 onsite clinics and ambulatory multispecialty facilities around Richmond County and Lake Oconee in partnership with AU Medical Associates.

MCG also supports Georgia’s health care system through its research efforts, which are directly related to the disease profiles of Georgia – including cancer, stroke, heart and vascular diseases, neurological and mental health, sickle cell disease, obesity, and childhood conditions.

Several health care innovations also include our collaborations with international health care leaders (Royal Philips and Cerner), U.S. Cybersecurity Command Center, and a Certificate of Need under review to build a state of the art new hospital in Columbia County.

MCG’s commitment to train medical students to become doctors has been further advanced with its regional network of campuses in Albany, Athens, Brunswick, Rome, and Savannah.1 We have also supported a vital initiative to establish 400 new residency positions in Georgia.2 These clinical endeavors come together in MCG’s 2015-2020 Strategic Plan (www.augusta.edu/ mcg/plan), which is designed to advance our community relationships in Augusta and across the state.

The health care needs in our region are substantial. In terms of population health, Richmond County health indices fall well below the average for the state. Columbia County performs better than Georgia averages on many

and to innovate in our practices. We are particularly proud that Augusta’s physicians provide exemplary care, are leaders in organized medicine through RCMS and the Medical Association of Georgia, and serve as outstanding role models for our trainees. We are also proud of Project Access (www. rcprojectaccess.org), the award-winning community care program for Augusta’s most economically disadvantaged people who are in need of health care. Augusta is a compassionate and caring community.

This brief account does not do justice to the commitment of so many in Augusta. While we are delighted that throngs of people visit us during Masters week, we also welcome visitors year round. Please visit our city and learn why it now thrives as a ‘medical destination’ city.¨

health indicators, while Aiken County, South Carolina performs around South Carolina’s average (which is below the average for Georgia).

As a health care community that also hosts a medical school, Augusta is taking steps to enhance health care access, to continuously improve health care quality and consumerism,

Dr. Buckley is dean of the Medical College of Georgia, interim executive VP for Health Affairs, interim CEO of the AU Medical Center & Medical Associates, and professor in the Department of Psychiatry and Health Behavior.

References 1

Buckley PF. GHSU: Addressing the state’s physician shortage. Journal of the Medical Association of Georgia. 2011; 100(3): 21-22.

2

Nuss MA, Robinson B, Buckley PF. A Statewide Strategy for Expanding Graduate Medical Education (GME) by Establishing New Teaching Hospitals and Residency Programs.

Academic Medicine 2015; 90(9):1264-1268.

www.mag.org 15

EDITORIAL

CTE – Learning what we don’t know

By Craig Kerins, M.D.

S

ports medicine has come a long way in 30 years. In its infancy, repairs of the anterior cruciate ligament didn’t work, but that seemed unimportant since the ligament was considered inconsequential. Shoulder instability was treated with huge open procedures that reinvented normal anatomy and intentionally created lots of scar tissue. Career ending injuries were common and all too often resulted in an aging athlete with devastating disabilities. Fortunately, we have come a long way. Today many (although certainly not all) of these common injuries can be corrected, and normal function and durability restored. This is absolutely one of modern medicine’s big achievements.

With this background in mind, I was alarmed when I viewed the recent movie “Concussion” and read the excellent book League of Denial (2013, Mark Fainaru-Wada and Steve Fainaru). They both deal with sports medicine’s next great challenge: closed head injuries. This is a very complicated and supremely important challenge.

The abbreviated story is that Bennet Omalu, M.D., performed an autopsy on a 50-year-old heart attack victim named Mike Webster in 2002. Dr. Omalu was a 32-yearold forensic pathologist. As the most junior pathologist on the staff, he was assigned the weekend duty. Webster was the legendary Hall of Fame player for the Pittsburgh Steelers.

He was the starting center for 150 consecutive games, which included four Super Bowl championships. He was All-Pro seven times and is widely considered the greatest center who has ever played the game. Dr. Omalu was born and educated in Nigeria. He knew nothing about American football and certainly had no clue about the celebrity of the patient. He did, however, latch on to Webster’s history of bizarre behavior as well as his meteoric mental deterioration prior to the heart attack. His autopsy included examination of the brain, which lead to the discovery of a new disease pattern…subsequently named Chronic Traumatic Encephalopathy (CTE). Since his discovery, Dr. Omalu has been portrayed as both a hero and a crackpot – with the preponderance of evidence leaning toward hero.

Many more players subsequently have been identified with this condition, which has been confirmed in multiple

16 MAG Journal

Craig Kerins, M.D. laboratories across the country, and it certainly appears to be associated with the repeated head trauma encountered in football – particularly professional football. CTE is a cruel disease that delivers a living hell to the patient, nearly always results in a broken family, financial ruin, insomnia, profound depression, debilitating headaches, and a conscious inability to process information. In some cases, athletes dealing with this tormented existence have committed suicide.

A similar disease pattern (dementia pugilistica) has long been known to affect boxers. This disease was first described in 1928, but it never gained the notoriety of football-related CTE, perhaps because the sport is not as popular as football and because the disease may not be quiet as virulent.

The pathologic changes of CTE are distinct and well described. Unfortunately, it is only possible to conduct a postmortem diagnosis today. Not every combatant is vulnerable to this disease, but there are currently no markers to identify who is at risk or who has an early stage of the disease. The role of head gear remains confusing.

Football helmets were designed to prevent skull fractures, and they do this well. But consideration was not initially given to the “soft tissue” (i.e., brain) injuries that took place in the sport.

The role of head gear in amateur boxing is currently being questioned – as the head gear may actually facilitate brain damage by padding the head and permitting more trauma before unconsciousness is finally achieved. Being “knocked out” may turn out to be the body’s protective mechanism.

No one knows if these brain injuries are caused by a relatively few devastating blows or by innumerable minor impacts. And no one knows how long a recovery period is necessary, but the conventional wisdom today is that an athlete should not return to the playing field until mental function returns to normal.

The public, as well as the medical community, need to demand answers to these questions. Changes to the rules of the game may make football somewhat safer in the near future, but this disease process needs to be fully understood and conquered. CTE is a scary disease. We are only beginning to learn what we do not know about it.

The sliver of good news is that almost all of the victims have been professionals who have competed at the highest levels of their sport. They have played on the front line for 20 or more years, and they have been subjected to forces that are virtually unimaginable to the rest of us. The risk to a high school or college athlete, although still important, cannot be compared to these pros. Clearly there has been no epidemic of dementia in old high school football players, and I certainly do not intend for this article to be an indictment of the sports of football or boxing.

The original intention of sports medicine was to return prominent, celebrity athletes to the playing field.

Innovations at the professional level gradually filtered down to the college and high school levels, and many of these treatments are now available to the legions of weekend warriors limping off tennis courts and softball fields. Comparable advances are going to happen as we learn more about CTE. Athletics, including contact sports, will remain a crucial part of education and development.

CTE is now in the spotlight, and participating in contact sports must continually become safer. Significant changes are already afoot. ImPACT testing is a computerized examination that can easily be done during a game. It

From the left are a normal PET brain scan, a brain with suspected CTE, and a brain with Alzheimer’s. More red and yellow indicates more tau and amyloid, which are abnormal brain proteins. Photo by David Geffen with the School of Medicine at UCLA.

measures cognitive function, and it is felt to be a common sense measure to determine if and when an athlete can safely return to the playing field. This is currently available on the football sidelines in Augusta, and it is an important early measure to address CTE. Football fans used to joke about the player who “got his bell rung” and would have a headache in the morning. A huge step is understanding that these head injuries are not funny.¨ Dr. Kerins is a MAG member who practices orthopedic surgery in Augusta.

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www.mag.org 17

MEDICAL ETHICS

The secret language of doctors

By Patricia Tran, fourth-year medical student, and Richard L. Elliott, M.D., PhD, professor and director of medical ethics and professionalism, Mercer University School of Medicine

O

need, only this time with an added emotional component.

Imagine that you are a new intern on your first on-call night shift. You are taking care of all of the patients that your program is seeing, not just the ones who you are familiar with. You get very little rest. Most of the pages you receive come from nurses taking care of a handful of “difficult “Argot” is defined by the Oxford Advanced Learner’s patients.” You want nothing more than to leave the hospital Dictionary as “words and phrases that are used by a and get some sleep when your shift is done in the morning particular group of people and not easily understood by hours, but before you can leave, you must “sign out” to 1 others.” Another more revealing definition of the word the day team – a process by which you turn over care of “argot” was given by Victor Hugo in Les Misérables where the patients to the incoming team. During this exchange, it is “the language of misery.” This seems particularly apt it is imperative that you give a good report of the night’s when discussing medical argot, also known as medical occurrences. With this scenario in mind, let’s revisit Hugo’s slang, terminology, lingo, or definition of the word “argot” – the the secret language that doctors  language of misery. Misery is an speak amongst themselves. apt word to describe how you, the Medicine has a rich history of fresh-out-of-medical-school intern, medical argot, the jargon that are feeling. While you could go into health care providers use to great detail on each of the patients summarize a patient’s story in you have been following, most of order to relay the most amount whom have not changed clinically of information in the shortest in quite some time, it is much easier amount of time. Much of this and quicker to call them your “rock is in the form of abbreviations. garden” (a collection of patients For example, “CAD” is used for who have been in the hospital coronary artery disease or “PE” with no change to their clinical for pulmonary embolism. It is condition for a lengthy period of easy to see why doctors would time, patients who are usually still prefer to communicate in in the hospital due to difficulties shorthand – it’s just plain faster. with discharge planning as opposed But for every above-board term to medical reasons) and move on to  there is a less politically correct other patients with more pressing one. For every “lap chole” there medical issues. Chances are your is an “FLK” (“funny looking kid,” which denotes some sort colleague will understand immediately what you mean by of congenital abnormality), for every “COPD” there is an “rock garden” and will be glad you saved a few minutes by “incarceritis” (the condition of a prisoner who fakes illness using crass terminology. In this sense, you and your comrade to go to the hospital). are bonding over a mutually frustrating experience. This is invaluable because a close bond between health care providers These terms often sound medical in nature, which allows leads to better teamwork, which in turn (theoretically) leads doctors to throw them around in areas outside of their to better patient care. But Brian Goldman, M.D., the author designated safe spaces (e.g., doctors’ lounges or private of the book, “The Secret Language of Doctors,” cautions offices). These terms can be encountered in hospital elevators, that this mindset is deleterious to doctors’ attitudes toward public dining areas, or while walking the halls of any medical their patients.2 Dr. Goldman states that: institution. The doctors who engage in the practice of using these terms in public areas might technically be HIPAA Doctors have invented hundreds – perhaps thousands compliant, as no identifying patient information is necessary – of slang terms that portray patients and their when these offensive and descriptive terms are used. attitudes, fears, hidden agendas, and even their appearance in unflattering terms. Call it the nature But if the diplomatic terms arose from a need to sum up of medical argot, but rarely if ever do doctors invent information quickly, where did the not-so-diplomatic terms words that compliment the people they care for. come from? One could argue that they stem from the same ne resident signing out to another: “Then there’s Mrs. K, last in my rock garden. She’s 62, a whale, COPD, here for a lap chole, crumped post-op, now mostly gorked out. Nobody’s gonna take this GOMER, so get to know her.”

Medicine has a rich history of medical argot, the jargon that health care providers use to summarize a patient’s story in order to relay the most amount of information in the shortest amount of time. Much of this is in the form of abbreviations.

18 MAG Journal

Recalling Hugo’s definition of argot, doctors create words to describe patients who frustrate them, anger them, or who they just simply do not like. In doing so, doctors attempt to create an emotional distance through humor that they believe will allow them to care for “difficult patients” more objectively.

Now imagine that instead of being the night-team intern who feels overwhelmed and overworked, you are the dayteam resident receiving sign out. You hear the night team refer to the patients they admitted as “whales” or someone with “status dramaticus” (a term used to describe stressed out or anxious patients who believe they are extremely sick or dying but actually aren’t). You have never seen these patients or interacted with them, but now you have a very quick, comprehensive idea of what each patient is like.

However, the night team’s sign out has now colored your opinion of the patients and you will head into encounters with those patients heavily biased by your colleague’s argotfilled description.

If it is the case that argot stems from dealing with difficult patients, then doctors must examine why these patients get under their skin. At times, doctors encounter what James Groves, M.D., has called the “hateful patient.”3 Such patients fall into four groups, which Dr. Groves referred to as “dependent clingers,” “entitled demanders,” “manipulative help-rejecters,” and “self-destructive deniers.”

Other patients are frustrating simply because of multiple comorbidities and complex presentations who present challenges to the admitting team, as they must decipher the patient’s complicated medical history and find the root of the patient’s current chief complaint. Or these patients might be so ill that doctors feel helpless.

cathartic experience for these doctors, allowing them to express frustration that they cannot express directly to their patients.

Further, some doctors find that using such argot, which is often humorous, helps them bond with other physicians. But as tempting as it is to join in such banter, mocking patients even away from patients’ hearing cannot advance the profession.

As noted earlier, behind the scenes conversations can bias the future interactions of new health care providers with these patients. Doctors also need to be aware that argot does not always remain an in-house, need-to-know communication system. In the information age, it is easy for patients who overhear such descriptions to consult Dr. Google about anything from signs and symptoms to terminology, potentially harming the doctor-patient relationship. Finally, trainees are exposed to such disparaging terms, sometimes hearing it from senior attendings – which indicates to students that ridicule has a place in medicine and suggests that one way to be accepted in the profession is to join in such behavior. What is utmost is that patient care and the doctor-patient relationship are best maintained through honest communication, and when we wonder whether a certain bit of argot is acceptable, we should ask ourselves whether we would use it in front of our patients. If not, we should not use it privately or condone its use by others.¨ Dr. Elliott welcomes your feedback on this article or other ethically challenging situations at elliott_rl@mercer.edu.

References 1

“Argot”. Oxford Advanced Learner’s Dictionary Online. Oxford University Press. 27 July 2015

2

Goldman, Brian. The Secret Language of Doctors. Chicago: Triumph Books LLC, 2014. Print

3

Groves JE. Taking care of the hateful patient. N Engl J Med. 1978 Apr 20;298(16):883-7.

Dr. Goldman describes the following scenario: a man comes in with bleeding esophageal varices, with bleeding so severe that it blocked the patient’s airway. The team taking care of the patient called in anesthesiology to provide an airway to aid the patient’s breathing. However, every time the patient’s mouth was opened, blood came pouring out, completely obscuring the anesthesiologist’s view. This patient could have been considered a “horrendoma” or a patient with an unusually bad or complicated medical condition.

It is easy to see how anyone, particularly a doctor, would be overwhelmed in this situation and feel out of control.

Doctors are trained to believe that they are the leaders of health care teams, and they are used to making decisions and taking actions to help patients. When they aren’t able to do so they find ways to express their frustration, sometimes by creating ways to describe patients and their situations in order to gain some semblance of control.

So what does this secret language mean for doctor-patient interactions and for our profession? It is probably the case that the majority of doctors who use medical argot to describe patients behind closed doors are able to interact with those patients in a pleasant and respectful manner in spite of the language used behind the scenes. Perhaps using argot is a

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Vol. 104, Issue 1, 2015

Physicians respond to MOC

Updates on Georgia’s medical schools Georgia’s residency initiative Market analysis: Thomasville Legal takes on cybersecurity, professional education and physician contracts

The Journal of the Medical Association of Georgia is a quarterly magazine that’s focused on the business and the practice of medicine. With more than 7,800 members, MAG is the leading voice for the medical profession in Georgia, which includes physicians in every specialty and every practice setting.

To find out more information about advertising please call:

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www.mag.org 19

GEORGIA COMPOSITE MEDICAL BOARD

Georgia’s new medical marijuana law

By John S. Antalis, M.D., vice chair, Georgia Composite Medical Board John S. Antalis, M.D.

I

n 2015, the Georgia General Assembly passed ‘Haleigh’s Hope Act’ (H.B. 1) by a vote of 160 to 1 to allow low tetrahydrocannabinol (THC) oil and cannabidiol use in the state. Rep. Allen Peake (R-Macon) spearheaded the bill in response to the touching stories of 17 children whose families had to leave Georgia to acquire treatment in Colorado. The new law allows qualified patients to possess up to 20 fluid ounces of “low THC oil” that contains no more than five percent THC and an equal or greater amount of cannabidiol – an active component of cannabis that does not result in the “high” that is normally associated with marijuana use.

The eight medical diagnoses that are approved for patients to obtain a physician’s “recommendation” for the oil include endstage cancer, when there is wasting and intractable nausea and vomiting; end-stage Amyotropic Lateral Sclerosis; end-stage Multiple Sclerosis; Crohn’s disease; Mitochondrial disease; endstage Parkinson’s and Sickle Cell diseases; and seizure disorders that are the result of epilepsy or trauma-related head injuries.

Under H.B. 1, the prescribing physician must have a doctorpatient relationship with the affected patient. Both a waiver form and a certification form need to be filled out and signed by the patient or their parent or legal guardian. Patients or caregivers may bring partially filled out documents to the visit or physicians may provide patients with blank forms. The physician may keep the original waiver form and a hard copy of the certification form. Either the physician or their staff can enter the information from the form into the official Georgia Low THC Oil Registry at https://dph.georgia.gov/low-thc-oil-registry.

H.B. 1 also established the Georgia Commission on Medical Cannabis (GCMC), which was tasked with preparing a report by the end of 2015. It assessed the need for additional legislation, it conducted a review of federal legislation, it looked at whether there is a need for cannabis to be cultivated in the state, and it evaluated best practices in other states.

The GCMC consisted of 17 members, which were permitted to assign a designate to serve on their behalf. This included the commissioner of the Georgia Department of Public Health (Brenda Fitzgerald, M.D.), the director of the Georgia Bureau of Investigation (Vernon Keenan), the director of the Georgia Drugs and Narcotics Agency (Rick Allen), the Commissioner of the Georgia Department of Agriculture (Gary Black), the chair of the Georgia Composite Medical Board (David Retterbush, M.D., and Alice House, M.D.), and the Governor’s executive counsel (Ryan Teague).

20 MAG Journal

Gov. Nathan Deal appointed the rest of the GCMC, which included Sens. Renee Unterman (R-Buford) and Butch Miller (R-Gainesville), Rep. Katie Dempsey (R-Rome), a hematologistoncologist (Cynthia Wetmore, M.D.), a neurologist (Yong Park, M.D.), a gastroenterologist (Mark Murphy, M.D.), a pharmacist (Sara “Mandy” Reece), an attorney from the Prosecuting Attorneys’ Council of the State of Georgia (Brian Rickman), Paulding County Sheriff Gary Gulledge, and Covington Police Chief Stacey Cotton.

The GCMC listened to pro and con perspectives from a number of stakeholders that represented government, law enforcement, and education – as well as affected patients and family members.

The GCMC submitted its final report to the Executive Counsel of the Governor, the Office of Planning and Budget, and the chairs of the House Committee on Appropriations, the Senate Appropriations Committee, the House and Senate Committees on Judiciary Non-Civil, and the House and Senate Committees on Health and Human Services.

The GCMC reached consensus on three recommendations, including…

• Urging Georgia’s Congressional delegation to change federal law to allow for the legal interstate transportation of medical cannabis oil in compliance with the laws of the cultivating state • Establishing a medical cannabis advisory board that would be responsible for any expansion of the list of medical conditions and THC formulations that are covered by Georgia’s law • Encouraging the state to consider adopting some of the provisions (i.e., “best practices”) that are included in Minnesota’s medical cannabis law.

The GCMB voted 11-to-5 to oppose a recommendation to allow marijuana to be cultivated in Georgia for the purpose of producing cannabis oil.

The GCMB will continue to monitor Georgia’s medical marijuana laws for any changes.

Finally, a special word of thanks to Drs. Retterbush and House, the former and current GCMB chairs, for their service as members of the GCMC. Dr. Antalis served as MAG’s president in 2004-2005.

High Blood Pressure Research Study

Emory University Hospital Midtown is currently enrolling in a clinical trial evaluating the potential benefits of a catheter-­‐based option to treat hypertension. Adults with high blood pressure, either on or off medication, may be eligible for enrollment in a study during which they may undergo a minimally invasive renal denervation therapy. Study participants will have outpatient follow-­‐up for 36 months after the procedure.

Primary eligibility criteria: • • •

Between 20 and 80 years old Systolic blood pressure ≥140 and <180 mmHg eGFR greater than 45 mL/min

For eligibility information, visit: CAUTION: Investigational device. Limited by Federal (or United States) law to investigational use.

www.spyralhtntrials.com call: 404-­‐686-­‐7468 or email: amanda.fiebach@emory.edu

www.mag.org 21

Years of research help create years of memories.

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LEGAL

Why documentation matters

By Daniel J. Huff, Esq., Huff, Powell & Bailey, LLC

I

was in someone’s office the other day and near the doorway was a sign that said “Keep learning.” Since seeing those words – and in preparation for writing this article – I sought out advice from several different professionals regarding continuing education.

Different physicians have different attitudes about documentation. Even if you consider it a necessary evil or the bane of your existence, documentation is critical to your practice – as well as several aspects of modern health care.

The purpose of documentation We frequently hear in lawsuits that medical records are the official and legal record of a patient’s care. While the medical record does not have the same legal ramifications as a promissory note or title to property, it is evidence for judges and juries to consider in legal proceedings. The more practical purposes of documentation are to…

• Tell a factual story about a patient’s care and treatment • Create a permanent record of what care was provided to a patient • Validate reimbursement The purposes of documentation provide guidelines for what should be contained in effective and detailed medical records.

Creating effective documentation Because documentation tells the story of a patient’s care and treatment during a particular point in time, it should be accurate and factual. Physicians and other providers should strive to avoid vague documentation. Statements attributed to the patient as opposed to information that is gathered from other sources should be clearly identified. Where appropriate, the timing of the onset of symptoms should be documented along with all positive information and pertinent negatives about the patient’s condition. Striving to be factual and accurate is the key to effective documentation.

Because documentation should be factual, careful attention should be paid to your opinions regarding the patient’s condition and plan of care. While your opinions are important be aware that others who review the medical records may rely on those opinions to formulate their own care and treatment for the same patient. If you are unsure about a diagnosis or differential diagnosis, avoid being dogmatic. If your opinions are limited to any degree, say so. Opinions about other provider’s care and treatment of a patient – particularly if you are being critical – have no place in a patient’s medical records.

Criticisms of another physician or provider do not advance the care and treatment of the patient or provide a factual story about 24 MAG Journal

the patient’s care and treatment. There are different forums for providing opinions about other physician and care providers’ treatment of the patient than in a patient’s medical records.

Myths about documentation There are several myths about documentation that are often exposed in medical malpractice cases. The first is that poor documentation suggests poor care. While this argument is frequently made in medical malpractice cases, it is simply not true – and many jurors reject this argument. Jurors understand that physicians treat patients, not charts, and they know that documentation is not patient care. Jurors understand that the principle that is taught in medical school and nursing school that “if it wasn’t charted, it didn’t happen” is not reality. In cases involving poor documentation, I always make the following point at trial: A jury would never excuse poor care with great documentation and, likewise, should not reject great care because of poor documentation.

The second myth of documentation is that if there was poor documentation there was poor continuity of care. This assumes that providers do not speak to each other except through the medical record. The reality is that a lot of treatment decisions and discussions about the patient take place independent of the medical record. The purpose of the medical record is not to serve as the sole communication device between providers. The written medical record is not the only means of communication of important information about a patient, and poor documentation does not suggest otherwise. Nevertheless, important communication that takes place between providers regarding a patient should be documented, especially for a patient who is in a high-risk situation.

The third and perhaps the biggest myth is that untimely documentation suggests guilt or a cover-up. This suggests that documentation that is not contemporaneous is inaccurate, self-serving, and part of some cover-up plan when a patient (continued on page 26)

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(continued from page 24)

has a bad outcome. Whether it is the operative note that is dictated a week later or the late entry, improper motivation is attributed to the timing of the documentation.

Operative reports, discharge summaries, and other documentation should be done immediately. Late dictation of history and physicals, operative reports, and discharge summaries should be the exception and not the rule. Likewise, documentation should be contemporaneous because that is when it is the most factual and accurate. Nevertheless, patient care takes precedence and not all documentation can be done contemporaneously.

There is nothing wrong with delayed documentation.

Documentation done around the time of the care and treatment, even if it is late and even after a bad outcome is preferable to recollection of events years later during a lawsuit. Do not forgo documentation because it is untimely and you are worried about the impact it might have down the road in a potential lawsuit.

Electronic medical records Electronic medical records (EMR) have changed documentation.

The advantage of EMR is that it provides a lot of detailed information and specifics. EMR tracks when things were done specifically. The exact time and name of the provider who utilized

26 MAG Journal

the EMR is known. We no longer have to investigate or speculate about when orders were entered or when labs were returned.

While EMR has provided us with more information about the who, what, and when of medical care, EMR is not a good vehicle for documenting the “why.”

All forms of effective documentation need to include narrative notes that are factual, specific and accurate about the patient’s complaints, conditions and the decision making that led to their care and treatment.

Conclusion Nothing makes a medical malpractice defense lawyer happier than good documentation in a patient’s chart. It provides the foundation for an effective defense of physician decisionmaking. Poor documentation is not fatal, but it makes our job much harder. Inaccurate, non-factual documentation should be eliminated from your practice.¨ Huff is a founding partner in the 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. He can be contacted at dhuff@ huffpowellbailey.com.

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RISK MANAGEMENT

Methadone for opiate-naive patient leads to deadly outcome

By Georgette Samaritan, RN, BSN, CPHRM, Ann Contrucci, M.D., director, Risk and Patient Safety, MagMutual Patient Safety Institute, and Laura Martinez, BSN, RN, MS, CPHRM, FASHRM, vice president, Risk and Patient Safety, MAG Mutual Insurance Company

T

his case arose out of the alleged negligent prescribing of methadone, which resulted in a young man’s death two days after a tonsillectomy and adenoidectomy.

Patient safety suggestions • Know what you’re prescribing. Extreme caution should be exercised when prescribing high-risk medications, particularly when one is not familiar with or does not routinely use the medication

The patient was a 25-year-old male with a history of chronic tonsillitis, two recurring episodes of strep throat, and a history of partial upper airway obstruction. He was referred by his primary care physician to an ENT specialist who recommended a tonsillectomy and adenoidectomy. The ENT specialist discussed the risk of the surgery and established a plan for pain management following the surgery – Percocet for pain and Phenergan for nausea.

• Consult with a pharmacist or another physician who specializes in pain management • Discuss your treatment plan with the patient’s primary care physician • When prescribing several high risk medications (e.g., opiates) together, written and verbal instructions should be reviewed with the patient and/or family, and copies of written instructions should be placed in the patient’s medical record

The patient underwent a successful surgery without any complications. Despite giving the patient post-surgical prescriptions prior to the surgery, the ENT surgeon and the anesthesiologist discussed the difficulties of pain management with adult patients during the procedure, and considered other pain management options. After consulting the anesthesiologist and the Physicians’ Desk Reference (PDR), the ENT decided to prescribe methadone. The ENT physician had never prescribed methadone for any of his patients.

• Be very clear about whether medications can or should be taken together • Clearly document the treatment plan in the patient’s medical record • Have the patient and their family repeat your instructions

The ENT physician verbally instructed the patient’s wife to initially give the patient Percocet and, if not effective for pain, discontinue that and give him methadone 10 mg – one to two tabs every eight hours. It was also written on the prescription “do not use Percocet, if taking methadone.” The patient was discharged home in stable condition.

Two days later, the patient was found unresponsive in bed – presumably from respiratory failure. The autopsy noted that the patient had pulmonary edema and elevated/toxic levels of methadone in his blood. The patient’s wife reported that she had given him two tablets (20 mg total) of methadone the day of the surgery, two tablets three times the day before his death, and one tablet early on the morning of his death. She denied giving him any Percocet, and methadone was the only drug in question that was found on the toxicology report at autopsy.

Allegations The patient’s estate alleged negligent prescribing of methadone with inadequate dosing instructions provided to the patient and his family.

Disposition We were unable to obtain defense support, and the case settled for a large amount of money on behalf of the ENT surgeon.

• Know your doses. In this case, an opiate-naive patient was given a starting dose of 10 mg of methadone. The literature is clear that a methadone starting dose is 2.5 mg, and increases should only be done every five to seven days due to the long half-life of the drug.1,2 This case report is a composite that was drawn from MagMutual’s case files. Any similarity to a specific case is both coincidental and unintended. The risk management advice that is presented in this article is intended to serve as general information for physicians and other health care professionals. The recommendations and advice published herein do not reflect a legal opinion, do not establish a standard of care, and do not establish rules for the practice of medicine. Successful outcomes are not guaranteed. The publication of this information is not intended as an offer to insure such conditions or exposures or to indicate that MagMutual will underwrite risks for the reader. Our liability is limited to the specific written terms and conditions of the actual insurance policies that are issued.

References 1

Prescription Painkiller Overdoses CDC Vital Signs, July 2012; www.cdc.gov/vitalsigns/ pdf/2012-07-vitalsigns.pdf

2

CDC MMWR, Vol 61, July 3, 2012 Vital Signs: Risk for Overdose from Methadone Used for Pain Relief-United States, 1999-2010;http://www.cdc.gov/mmwr/index2012.html

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Team Against Opioid Abuse

TeamAgainstOpioidAbuse.com New Resource Aimed at Educating About Opioid Analgesics with Abuse-Deterrent Properties and Team Efforts to Deter Abuse of Prescription Medicines

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The development of opioids formulated to deter abuse has been a potentially important step towards the goal of creating opioids with meaningful abuse-deterrent properties, and the FDA considers the development of these products a high public health priority.1

“Education about the proper use of opioid analgesics is a top priority at Purdue Pharma.

Everyone on the team should understand their role and responsibilities, so they can do their part in combating abuse of opioids, while ensuring their availability for appropriate purposes,”

One pharmaceutical company, privately-held Purdue Pharma L.P., is taking the lead in education on the issue with TeamAgainstOpioidAbuse.com, a new website designed to help healthcare professionals and laypeople alike learn about different abuse-deterrent technologies and how they may help in the reduction of misuse and abuse of opioids.

said J. David Haddox, DDS, MD, Vice President, Health Policy, Purdue Pharma L.P. “Opioids with Abuse-Deterrent Properties are one tool to help the team in their efforts in fighting drug abuse. We developed this website to inform everyone who influences how drugs are prescribed, taken, stored, and destroyed, when no longer needed.”

pioid abuse is a critical problem in America and one that healthcare professionals, payers, law enforcement, policymakers and drug makers are all working to combat.1,2

Abuse and Misuse of Prescription Opioids

The FDA 2015 Guidance for Industry states that prescription opioids play an important role in pain management. However, abuse and misuse of these products have created a serious and growing public health issue.1 The development of abuse-deterrent opioids is a high public health priority. Though abuse-deterrent

does not mean abuse-proof, the E development of opioids with abuse-deterrent properties is one potentially important step in helping to deter abuse.1 Fatal Overdoses Involving Opioid Analgesics 4-6 18,000 16,000 Number of Fatal Overdoses

Nonmedical use of prescription pain relievers is a serious public health issue.1,2 The 2013 National Survey on Drug Use and Health reported that, among persons age 12 or older in 2012 to 2013, approximately 68 percent of people who used prescription pain relievers for nonmedical purposes said they got the medicines from a friend or relative, for free, by purchase, or by theft.3 In 2011, the White House identified prescription drug abuse and misuse as a major public health and public safety crisis.2

14,000 12,000 10,000 8,000 6,000 4,000 2,000 0

1999

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Years

Team Against Opioid Abuse

Resources at TeamAgainstOpioidAbuse.com On TeamAgainstOpioidAbuse.com you’ll find information about: • Why abuse-deterrent properties matter • National efforts to reduce opioid abuse • FDA guidance on opioids with abuse-deterrent properties • Working together to reduce prescription opioid abuse Using clear graphics and concise language, the website features sections about why it’s critical to deter abuse and how all the members on the healthcare team can make a difference.

It also outlines the FDA’s 2015 Guidance on AbuseDeterrent Opioids — Evaluation and Labeling, which informs drug developers about FDA’s current thinking on the testing potentially abuse-deterrent opioids should undergo.

Because FDA states that having information about

an opioid’s abuse deterrence available for healthcare professionals and patients in labeling is important, the website also reviews how to identify opioid formulations with FDA-approved abuse-deterrent properties by checking Section 9.2 of a drug product’s Full Prescribing Information.1 The Team Against Opioid Abuse website can be accessed at http://www.teamagainstopioidabuse.com.

About Purdue Pharma L.P. Purdue Pharma L.P. and associated U.S. companies are privately-held pharmaceutical companies known for pioneering research in chronic pain. Purdue Pharma is engaged in the research, development, production, and

distribution of prescription and over-the-counter medicines, as well as hospital products. For more information about Purdue Pharma, please visit http://www.PurduePharma.com.

References: 1. Food and Drug Administration, Center for Drug Evaluation and Research (CDER), US Department of Health and Human Services. Abuse-Deterrent Opioids — Evaluation and Labeling: Guidance for Industry. April 2015. http://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm334743.pdf. Accessed August 25, 2015.

2. White House Office of National Drug Control Policy. Epidemic: Responding to America’s Prescription Drug Abuse Crisis. 2011. https://www.whitehouse.gov/sites/default/files/ondcp/ issues-content/prescription-drugs/rx_abuse_plan.pdf. Accessed August 25, 2015. 3. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. http:// www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. Accessed August 25, 2015. 4. Centers for Disease Control and Prevention, US Department of Health and Human Services. CDC/NCHS, National Vital Statistics System. Data Brief 81: Drug poisoning deaths in the United States, 1980-2008. December 2011. http://www.cdc.gov/nchs/data/databriefs/db81.pdf. Accessed August 25, 2015. 5. Centers for Disease Control and Prevention, US Department of Health and Human Services. NCHS Data Brief No. 190. March 2015. Drug-poisoning deaths involving heroin: United States, 2000–2013. http://www.cdc.gov/nchs/data/databriefs/db190.pdf. Data Table for Figure 1: http://www.cdc.gov/nchs/data/databriefs/db190_table.pdf#1. Accessed August 25, 2015. 6. Centers for Disease Control and Prevention, US Department of Health and Human Services.

NCHS Data Brief No. 166. September 2014. Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011. http://www.cdc.gov/nchs/data/databriefs/db166.pdf. Data Table for Figure 1: http://www.cdc.gov/nchs/data/databriefs/db166_table.pdf#1 Accessed August 25, 2015. 7. The National Academies Press. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. (2011). Institute of Medicine. http://www.nap.edu/catalog.php?record_id=13172. Accessed August 25, 2015.

LEGAL

Compliance issues in marketing physician practices

By Antonia A. Peck, Esq., Smith Moore Leatherwood LLP

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n the face of declining reimbursement and increases in overhead, many physician practices are trying to develop innovative ways to market their services and increase patient matriculation and retention. It is not unusual to look to other industries for marketing ideas. However, physician practices should be cautious when trying to mirror the marketing practices of other industries. There are a number of marketing techniques that are commonly utilized in other industries that are strictly prohibited in health care by the Anti-Kickback Statute, Stark Law, HIPAA, the Civil Monetary Penalties Law, and a handful of other laws and regulations.

Consequently, physician practices should ensure that their marketing policies and activities undergo a legal review.

An example of a common marketing technique that can pose significant risk of violation of federal and state laws in the health care industry is a free giveaway or discount for referrals. We have all seen advertisements that promise a discount or a free product if we refer a person – phone companies, daycare centers, online retailers, and other businesses use this approach. However, offering a patient a discount or a free iPad for the referral of another patient could put a provider at risk for criminal and monetary penalties for violating the Anti-Kickback Statute.

The Anti-Kickback Statute prohibits a person from knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce or in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service payable in whole or in part by a federal health care program. Remuneration is broadly defined to include anything of value, in cash or in kind, and includes discounts and free items and services. A violation of the AntiKickback Statute is a felony and is punishable by a fine of up to $25,000 per violation and imprisonment for up to five years. Rewarding a patient with a free item or a discount in services for referring a patient who is a beneficiary of a federal health care program likely would be interpreted as paying the patient to induce referrals of federal health care business in violation of the Anti-Kickback Statute.

In health care, any type of payment to a person or entity for marketing to federal health care beneficiaries implicates the Anti-Kickback Statute. Such payments can be interpreted as inducements for the recommendation of the purchase or ordering of services or items. For this reason, physician

30 MAG Journal

practices should strive to have their marketing arrangements fit into an Anti-Kickback Statute “safe harbor.”

Safe harbors are arrangements that the U.S. Department of Health and Human Services have shielded from Anti-Kickback Statue liability. Therefore, if a marketing arrangement meets the requirements of a safe harbor, it is protected from Anti-Kickback Statute liability. However, an arrangement does not automatically violate the Anti-Kickback Statue if it does not fit within a safe harbor. Before the government can conclude that an arrangement violates the Anti-Kickback Statute, it must prove that at least one purpose of the arrangement is to induce the referral of services payable by a federal health care program. Nevertheless, it is best to ensure that a marketing arrangement fits within a safe harbor so that it is protected from Anti-Kickback Statute liability.

Physician practices also should avoid these common marketing strategies that may result in violations of federal and state laws: • Basing compensation to marketing professionals on a percentage of revenue generated by their marketing efforts • Paying health care providers to refer patients or to market your practice • Offering free services or items or discounts to patients if they refer a friend to your practice • Offering employees cash incentives based on the amount of increased business they generate for your practice The stakes are high for marketing in health care, so it is imperative for a physician practice to seek legal approval of its marketing activities.

Peck is a member of Smith Moore Leatherwood LLP’s Health Care Practice Group in Raleigh, North Carolina. She assists health care providers in a variety of regulatory and corporate matters, including Stark Law, federal and state Anti-Kickback Statutes, HIPAA, the 340B Drug Pricing Program, physician recruitment, medical staff issues, antitrust, and regulatory compliance. Peck also counsels health care entities on transactional and business matters, including mergers and acquisitions, joint ventures, reorganizations, management services organizations, and hospital-physician alignment strategies.

Contact Peck at Toni.peck@smithmooreleatherwood.com.

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The Right Counsel Could Make All the Difference.

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www.mag.org 31

LEGAL

Important changes in the MPFS

By Sidney S. Welch, J.D., M.P.H., chair, Health Care Innovation, and Amy McCullough, J.D., counsel, Health Care, Polsinelli PC

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n November 16, 2015 the Centers for Medicare & Medicaid Services (CMS) published the final Medicare Physician Fee Schedule (MPFS).1 The MPFS addresses changes to the physician fee schedule and related policies, and it reflects Medicare’s ongoing shift from a fee-for-service payment model to valuebased reimbursement. Except for the changes to the Stark Law definition of “ownership or investment interest” that goes into effect on January 1, 2017, the MPFS provisions went into effect on January 1, 2016. The following is the second of the two part series on MPFS and provides a summary of non-Stark Law related highlights from the final MPFS.2

Telehealth services CMS added the following services to the list of CPT codes that are approved for reimbursement as telehealth services, subject to specific conditions: prolonged service inpatient CPT codes 99356 and 99357 and end-stage renal disease services 90963 to 90966. It did not approve proposals to include certain critical care and medication management telehealth services.3 CMS also finalized its proposal to include certified registered nurse anesthetists (CRNA) to the list of practitioners who are authorized to furnish telehealth services. Finally, CMS slightly increased the reimbursement amount for a telehealth-related originating site facility fee (Q3014) to $25.10.

“Incident to” services CMS finalized two key changes to the “incident to” billing rules. First, CMS finalized a new requirement that the billing practitioner and the supervising practitioner (not the ordering physician) be the same individual. Second, CMS finalized a provision that prohibits practitioners from utilizing “auxiliary personnel” who have: 1) been excluded from federally funded health care programs or 2) had their enrollment revoked for any reason.

‘Physician Compare’ website CMS stated the ‘Physician Compare’ website: • Will not include a value modifier that is attributed to individuals or group practices • Will include an indicator for individuals who satisfactorily report the new cardiovascular prevention measures group • Will continue to include every PQRS group practice level and ACO Shared Savings Program measures that are available for public reporting, which means that the 2016 32 MAG Journal

PQRS group practice and ACO data will be posted in 2017 • Will expand the qualified clinical data registry (QCDR) reporting to include group practices • Will include public reporting using the ABC™ methodology that is based on the PQRS performance rates that are stratified by reporting mechanisms for both group practice and individual eligible professionals (EP) level measures • Will include indicators for specialties that are represented by the American Board of Optometry and American Osteopathic Association Physician Quality Reporting System The MPFS focuses on matters that are related to the 2018 PQRS payment adjustment, which will be based on an EP or a group practice’s reporting of quality measures during the 12-month, calendar year reporting period that occurs in 2016.

CMS clarified that EP who are in a critical access hospital (CAH) under Method II (CAH-II) who are reimbursed by Medicare may now participate in the PQRS, and neither EP who practice in rural health clinics and/or federally qualified health clinics nor EP who perform services for an independent diagnostic testing facility or labs will be subject to the PQRS payment adjustment.

CMS also clarified what must be reported, as it established 12 categories of reporting information for group practices that have registered to participate in the PQRS group practice reporting option (GPRO). And CMS clarified that certain specialties – including diagnostic radiology, pathology, anesthesiology, podiatry – and hospitals are excluded from selection as a “focal provider” (i.e., specific provider who provided the most primary care to the beneficiary). Beginning in 2016, a qualified clinical data registry (QCDR) must provide substantial information to CMS to ensure that it is valid, and PQRS participants and their vendors will be subject to CMS audits.

EHR incentive reporting The Secretary for Health & Human Services selects the clinical quality measure (CQM) that EP need to report to receive the EHR meaningful use incentives program payments. Electronic reporting is conducted using certified electronic health record technology (CEHRT), and EP who use CEHRT are required to test and certify using the most recent version of CEHRT to ensure that the data is successfully transmitted. The MPFS (continued on page 34)

• • • •

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(continued from page 32)

revises the definition of CEHRT to require that certification be, at a minimum, compliant with the Quality Reporting Document Architecture Category I and Category III standards that were created by the Office of the National Coordinator for Health Information Technology.

And under the Comprehensive Primary Care (CPC) initiative, CMS pays participating primary care practices a care management fee to support enhanced, coordinated services, while CPC practice sites are required to report to CMS a subset of the CQM that were selected in the EHR Incentive Program. CMS has also expanded the requirements of one of the reporting options for practice sites that have participated in the meaningful use program for more than a year to successfully report at least nine electronically specified CQM across three domains for the relevant reporting period starting in 2016. In addition, CMS will allow practices that are in their first year of participation to use this reporting method, although the reporting period is one year rather than 90 days.

that are reimbursed under the MPFS are subject to positive, negative, or neutral payment adjustments based on the quality of care that is provided compared to the cost of care during an applicable performance period. The VM will expire at the end of CY 2018, when it will be replaced by the Merit-based Incentive Payment System (MIPS).

The MPFS includes the following changes for the VM program’s CY 2017 payment adjustment period, including revising the criteria for groups to avoid the PQRS payment adjustment for CY 2017 to provide an additional opportunity for quality data reported by individual EP in the group to be taken into account…

• Increasing the minimum number of episodes required for inclusion for the Medicare Spending Per Beneficiary measure • Applying the quality composite score of an ACO that has the highest numerical quality composite score where a group or solo practitioner is participating in multiple Shared Savings Program ACOs • Waiving the application of the VM for physicians in groups with two or more EP and physicians who are solo practitioners who are participating in the Pioneer ACO model, CPC Initiative or other similar Innovation Center model

Medicare Shared Savings Program The MPFS changes the quality measures and performance standards and provisions of the program regarding assignment of beneficiaries to an accountable care organization (ACO).

Specifically, the MPFS adds a new “Statin Therapy for the Prevention and Treatment of Cardiovascular Disease” pay-forreporting measure to the preventive health domain.

Among the various changes adopted, CMS added a right to maintain a measure as pay-for-reporting or revert a pay-forperformance measure to a pay-for-reporting measure if: 1) a measure owner determines the measure no longer meets best clinical practices due to clinical guideline updates or 2) clinical evidence suggests that continued application of the measure may result in harm to patients. CMS also requested comments to several questions related to its quality measure for PCP who successfully meet meaningful use requirements and will use the feedback received to determine whether the measure could be expanded and updated to reward providers who have achieved higher levels of health IT adoption. Finally, CMS also modified PQRS language to treat “ACO providers” the same as any other physician group electing to report via PQRS. CMS also revised the list of codes that constitute primary care services under the Shared Savings program that are related to: 1) the assignment of beneficiaries based on certain evaluation and management services in skilled nursing facilities and 2) the assignment of beneficiaries to ACOs that include Electing Teaching Assistant hospitals.

Value-Based Payment Modifier and Physician Feedback Program Under the Value-Based Payment Modifier (VM) program and Physician Feedback Program, payments for items and services 34 MAG Journal

• Applying an additional upward payment adjustment to Shared Savings Program ACO participant TIN that are classified as “high quality” under the quality-tiering methodology upon achievement of certain beneficiary risk scores.

The MPFS also sets certain standards that will go into effect in the CY 2018 payment adjustment period that are outlined in detail in the final rule. For example, the VM will be applied to non-physician EP such as physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists who are solo practitioners or are in groups that have two or more EP. ¨ Welch is the chair of Health Care Innovation at Polsinelli PC. McCullough is counsel with Polsinelli’s health care practice. They counsel physicians, physician practices, and health care technology clients in transactional, regulatory, administrative law, and litigation matters on a national basis. Go to www.polsinelli.com/ professionals/swelch for additional information. Contact Welch at 404.253.6047 or swelch@polsinelli.com.

References 1

The “Medicare Program: Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016” aka MPFS can be viewed at https://www. federalregister.gov/articles/2015/11/16/2015-28005/medicare-program-revisions-topayment-policies-under-the-physician-fee-schedule-and-other-revisions

2

The updated, comprehensive Code List effective January 1, 2016, is available on the CMS website at http://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/List_of_ Codes.html.

3

The deadline for submission of new service approval requests for the CY 2017 Physician Fee Schedule is December 31, 2015.

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ADVOCACY

2016 Physicians’ Day at the Capitol

Georgia Gov. Nathan Deal greets physicians.

The ‘Gold Dome’ was a great backdrop for this photo.

Physicians make their way to a luncheon with some 40 legislators.

Physicians have their picture taken with Gov. Deal. More than 40 physicians had a chance to discuss important issues like narrowing health insurance networks, patient billing, and the state’s prescription drug monitoring program.

www.mag.org 35

COUNTY, MEMBER & SPECIALTY NEWS

Bibb County Medical Society’s officers for 2016.

COUNTY MEDICAL SOCIETY NEWS Bibb County Medical Society

by Dale Mathews, Executive Director The Bibb County Medical Society (BCMS) installed its officers for 2016 during a ceremony that took place during its annual President’s Party at the Idle Hour Country Club in Macon in December. This includes President W. Robert Lane, M.D., President-elect J. Eric Roddenberry, M.D., Immediate Past President Maria H. Bartlett, M.D., Vice President Margaret C. Boltja, M.D., Secretary R. Jonathan Dean, M.D., and Treasurer L. Arthur Schwartz Jr., M.D. At-large directors include Robert J. Parel, M.D., I.J. Shaker, M.D., and John J. Rogers, M.D. The historian is Rana K. Munna, M.D., while Michael E. Greene, M.D., is the parliamentarian. William P. Brooks, M.D., and Robert C. Jones, M.D., will serve as the MAG director and alternate director. Mercer University School of Medicine 36 MAG Journal

Dean William F. Bina III, M.D., received the BCMS Physician of the Year award for being a “leader in educating students as well as providing care in rural areas and in underdeveloped countries around the world.” His wife, Gayle Bina, was honored with the BCMS Citizen of the Year award as she “arranged and organized medical mission trips to Asia and Central America…[and she was] an active volunteer with local charities such as Rooms from the Heart.” Finally, Lynn Denny, M.D. – who served as the medical director of the Macon Volunteer Clinic from 2003 until the end of 2015 – received the BCMS Distinguished Service Award.

Go to www.bibbphysicians. org for additional information.

Bibb County Medical Society award recipients William Bina, M.D., Gayle Bina, and Lynn Denny, M.D.

that, “A little dusting of snow wasn’t enough to damper our spirits. Decked in fine style, our members and guests had some great food and conversation, and we had a little fun playing casino games – including blackjack, poker, roulette, craps and bingo.” The prizes included a YETI cooler, Surface Pro tablet, Apple iPad Air tablet, Bose headphones, and GoPro camera. PCC Chair Gary Botstein, M.D., and PCC Executive Director Carole Fortenberry gave a PCC progress report. Michael Baron, M.D., was honored with PCC’s Volunteer of the Year award. He logged more than 270 hours at the clinic in 2015 – and he

urged his colleagues to “do the same.” Judy and Bob McMahan were honored with the DMS Community Service Award, which was previously known as the Julius McCurdy Citizenship Award.

Going forward, the award will become the Judy and Bob McMahan Citizenship Award to recognize the couple for their “exemplary service to the health care community for many years.” Event sponsors included American Health Imaging, Affinity Bank, MAG Mutual Insurance Company, Georgia Nephrology, and Radiology Associates of DeKalb. Dr. Elmore thanked Brian Levitt, M.D., and his wife, Kathy Levitt, for

DeKalb Medical Society

by Hank Holderfield, Executive Director The DeKalb Medical Society (DMS) hosted its annual ‘Casino Night’ at the Ansley Golf Club in Atlanta in January to raise funds for the Physicians’ Care Clinic (PCC). DMS President Kathy Elmore, M.D., reports

Gary Botstein, M.D., (with vase on left) honors Bob McMahan with DeKalb Medical Society’s ‘Bob and Judy McMahan Community Service Award.’

planning a “great event.” Go to www.dekmedsoc.org or contact Hank Holderfield at hholderfield@pami.org with questions.

Dougherty County Medical Society

by Susan Workman, Executive Director Sarah Codrea, D.O., will serve as the Dougherty County Medical Society (DCMS) resident representative to the Georgia Association of Family Physicians. She is in her second year at Southwest Georgia Family Medicine Residency in Albany. Go to www.dc-ms.org or contact Susan Workman at 229.436.8191 or dcms. director@gmail.com for additional information.

Georgia Medical Society

by Ca Rita Connor, Executive Director The Georgia Medical Society (GMS) honored a number of individuals and organizations with its Healthcare Heroes awards in October. The winners in the ‘Health Care Innovation’ category included Paula Hudson and Jamey Espina with Hospice Savannah/Edel Caregiver Institute; Jeremy London, M.D., Karen Boyer, Maria Theron, Anne Bennett, M.D., and Catherine Sauers with the CVICU Leadership Team at Memorial Health University Medical Center; and Linda Friedman with the Children’s Wellness Program at Memorial University Medical Center. The winners in the ‘Health Care Education’ category included St. Joseph’s/Candler Wellness Center Summer Camps;

Michael N. Leblang, M.D.; and the Hybrid OR Suite/TAVR Program at The Heart Hospital at St. Joseph’s/Candler. The recipients in the ‘Community Outreach’ category included Libby Malphus with ‘Help the Hoo-Hahs’ and the Curtis and Elizabeth Anderson Cancer Institute patient advisory council; Allen Delaney, M.D., with South University Clinical Mental Health Counseling Program and Safety Net Conference; and Rebekah Chance-Revels and Ruby Hardy with the Chatham County Health Department’s Breast and Cervical Cancer Program. The winners in the ‘Institution/Organization’ category included Frank Davis, M.D., trauma surgeon and surgical critical care at Memorial Health University; Bernie Polite with Community Help; and 100 Black Men of Savannah and the St. Joseph’s/Candler Pathways to Success Camp. The ‘Allied Health Professionals’ category recipients included Jennifer Boone with the Godley Station School; Laura Coleman with St. Joseph’s/Candler Surgical Services; and Nidsa Baker with the St. Mary’s Health Center and Good Samaritan Clinic. GMS also honored several physicians with its Physicians Lifetime Achievement Award, including Keith A. Dimond, M.D., William N. Wessinger, M.D., and Ray Rudolph, M.D. The GMS meeting in November featured a talk on ‘Sex, Hormones and Happiness’ by Murray Freedman, M.D. The January meeting featured a talk on the Ebola virus crisis

by Rick Roth, M.D. Michael J. Wilkowski, M.D., was honored as immediate past

president of GMS. The GMS officers for 2016 include President Kelly A. Erola, M.D., Vice President Luke J. Curtsinger, M.D., Presidentelect Joshua T. McKenzie, M.D., Secretary William A. Darden, M.D., and Treasurer Fred L. Daniel, M.D. Along with Drs. McKenzie and Darden, MAG delegates include Vernon T. Bryant, M.D., Thomas E. Shook, M.D., Patrick L. Blohm, M.D., David S. Oliver, M.D., Edmund R. Donoghue Jr., M.D., and Mark E. Murphy, M.D. The MAG alternate will be Carl B. Pearl, M.D. Roland S. Summers, M.D., is the parliamentarian, Leslie L. Wilkes, M.D., is the historian, and Thomas R. Freeman, M.D., is the historian emeritus. Contact Ca Rita Connor at gamedsoc@ bellsouth.net with questions related to GMS. Muscogee County Medical Society

by Dan Walton, Executive Director More than 120 members and guests attended the Muscogee County Medical Society’s (MCMS) annual ‘Wine Tasting at Epic’ event in January. The sponsors included Hudson Financial Group and MAG Mutual Insurance Company.

Physicians who are interested in joining MCMS should go to www.muscogeemedical.org or call 706.322.1254.

Ogeechee River Medical Society

by Michelle Zeanah, M.D. Rani Reddy, M.D., will serve as the president of the Ogeechee River Medical Society (ORMS) in 2016. Dr.

Reddy is a graduate of the MAG Foundation’s Georgia Physicians Leadership Academy. Aaron Davidson, M.D., will continue to serve as the society’s secretarytreasurer. Contact Dr. Zeanah at doctor@zeanah.com for additional information.

Richmond County Medical Society

by Dan Walton, Executive Secretary The Richmond County Medical Society (RCMS) held its annual holiday party at the Old Medical College in Augusta in December.

Officers for the year will include President Craig Kerins, M.D., Presidentelect Donnie Dunagan, M.D., Vice President Randy Hensley, M.D., Secretary James Rawson, M.D., and Treasurer Robert Kaminski, M.D. Dr. Kerins is stressing that, “We have a great schedule of CME programs lined up for 2016.” Go to www.rcmsga.org or call 706.733.1561 to join RCMS. Troup County Medical Society

Physicians who have questions about the Troup County Medical Society should contact Kate Boyenga at 678.303.9263 or kboyenga@mag.org.

Walker-CatoosaDade County Medical Society

Physicians who have an interest in attending a Walker-Catoosa-Dade County Medical Society (WCDCMS) meeting or who have questions related to (continued on page 38)

www.mag.org 37

(continued from page 37)

WCDCMS should contact Michael E. Wilson, M.D., at tenwilsons@gmail.com.

sessions. Monitor www. gaacp.org for details. Contact Mary Daniels at mdaniels@ gaacp.org with questions.

MEMBER NEWS

Georgia Association of Pathologists Art McCain, M.D.

Barry Silverman, M.D.

Barry Silverman, M.D., has co-authored a book – Your Doctors’ Manners Matter: Better Health Through Civility in the Doctor’s Office and in the Hospital – to help patients identify “those physicians and other medical professionals who practice medicine in a way that exhibits compassion, empathy, and respect for the dignity of their patients.” Dr. Silverman, who is a member of the Journal of the Medical Association of Georgia’s Editorial Board, is also making the book available to every first-year medical student in Georgia for free – which will include a preface that was written by MAG President John S. Harvey, M.D., and MAG Foundation President Jack M. Chapman Jr., M.D. The book is available on amazon.com.

Art McCain, M.D., who is an interventional and diagnostic radiologist with Radiology Associates of Macon, recently became just the 10th physician in the world to “simultaneously remove a patient’s spine tumors while stabilizing the spine.” He used a “cooled radiofrequency ablation technology that offers 38 MAG Journal

simultaneous, dual-probe capabilities…[the technology] uses high-frequency energy to destroy cancer cells.”

Dr. McCain performed the procedure on a patient who was under the care of Linda Hendricks, M.D., an oncologist with the Central Georgia Cancer Care practice in Macon. Dr. McCain received his medical degree from the Emory University School of Medicine, while Dr. Hendricks received her degree from the Medical College of Georgia.

by Dan Walton, Executive Director The Georgia Association of Pathologists (GAP) is encouraging every pathologist in the state to go to www. gapathology.org to join or renew their membership.

Physicians who received a renewal notice are encouraged to remit their payment as soon as possible.

Go to www.gapathology.org for membership and other information. Contact Stacie McGahee at 706.738.3119 or smcgahee@medicalbureau. net with questions.

Georgia Chapter of the American Academy of Pediatrics

Linda Hendricks, M.D.

SPECIALTY SOCIETY NEWS Georgia Chapter of the American College of Physicians

by Mary Daniels, Executive Director The Georgia Chapter of the American College of Physicians’ (GAACP) will hold its annual meeting – Fostering Excellence in Internal Medicine with Quality Based High Value Care – at the Chateau Elan Winery & Inn in Braselton on October 21-23. The event will feature a hospital medicine track and faculty development

by Kasha Askew, Director of Membership & Education The Georgia Chapter of the American Academy of Pediatrics had a busy fall, including its ‘Pediatrics on the Parkway’ event at the Cobb Galleria Centre in November – which drew nearly 150 pediatricians. Truddie Darden, M.D., with the Morehouse School of Medicine served as the program chair. The event featured seminars on nutrition, coding and practice management, adolescent medicine, and hospital medicine – as well as an advocacy summit for residents. Chapter award winners included Brad Weselman, M.D., from Decatur and Dixie Griffin, M.D., from Tifton

(Outstanding Achievement), Yameika Head, M.D., from Macon (Young Physician of the Year), and Elma Steves, M.D., from Chamblee (Leila Denmark Award for Lifetime Achievement). The Chapter’s top priority for the 2016 state legislative session is increasing pay for Medicaid physicians (i.e., Medicare parity). The Chapter will launch four quality improvement projects in 2016, including ones on ADHD, adolescent substance abuse and mental health, ‘Bright Futures,’ and HPV. Upcoming events include the Georgia Pediatric Practice Managers & Nurses Association Spring Meeting in Macon on April 22, the Jim Soapes Charity Golf Classic to benefit the Pediatric Foundation of Georgia at Cherokee Run Golf Course in Conyers on April 26, and the Chapter’s ‘Pediatrics by the Sea’ meeting on Amelia Island, Florida on June 8-11.

Go to www.gaaap.org or call 404.881.5091 for additional information.

Georgia Gastroenterologic and Endoscopic Society

by Dan Walton, Executive Director The Georgia Gastroenterologic and Endoscopic Society (GGES) will hold its annual meeting at the Atlanta Marriott Buckhead on Saturday, September 17. GGES members are encouraged to monitor www. georgiagi.org for additional information and updates.

The meeting typically offers about six CME credits. Active members can attend the meeting for free – so they should go to www.georgiagi.

org to complete a membership application for the year if they haven’t already done so.

Contact Stacie McGahee at 706.738.3119 or smcgahee@ medicalbureau.net with questions.

GSDDS’s 61st annual meeting will take place at the Ponte Vedra Inn & Club in Ponte Vedra, Florida on June 3-5.

Go to www.gaderm.org to register and for additional information.

Georgia Society of Dermatology and Dermatologic Surgery

Georgia Society of Rheumatology

by Maryann B. McGrail, Executive Director The Georgia Society of Dermatology and Dermatologic Surgery (GSDDS) and the Atlanta Association for Dermatology and Dermatologic Surgery hosted the eighth annual ‘Marilyn Fry Memorial Skin Cancer Awareness Day’ at the State Capitol on February 9. The event featured free skin screenings, while the House and Senate passed resolutions promoting skin cancer awareness day.

GSDDS will receive the American Academy of Dermatology’s (AAD) Model State Award, with honors, for the sixth straight year.

It will be recognized for the accomplishment during a ceremony that will take place at AAD’s annual meeting in Washington, D.C., in March.

by Maryann B. McGrail, Executive Director The Georgia Society of Rheumatology (GSR) will host its annual meeting at the Omni Hilton Head Resort on Hilton Head Island, South Carolina on June 3-5, 2016.

Go to www.garheumatology. org for registration and other information.

Please submit your county medical society, member or specialty society news to Tom Kornegay at tkornegay@mag. org. Also contact Kornegay with 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 to join MAG.

On January 27, the Georgia House of Representatives passed a resolution by Rep. Betty Price, M.D. (R-Marietta) to “salute” physicians in the state. Dr. Price is shown reading H.R. 1168 on the House floor.

MAG subsidiary executive installed as ACEhp president Robert L. Addleton, EdD, CHCP, FACEHP, was recently installed as the president of the Alliance for Continuing Education in the Health Professions (ACEhp), which is “a membership community of more than 2,000 health care continuing education professionals.” He will serve a one-year term. Addleton is Robert L. Addleton the executive vice president of the Physicians’ Institute for Excellence in Medicine, a subsidiary of the Medical Association of Georgia (MAG). Go to www. acehp.org for details on ACEhp or to www.mag.org/ affiliates/piem for details on the Physicians’ Institute.

MAG applauds ‘Doctor of the Day’ nurse

MAG ‘Doctor of the Day’ program nurse Ruby Butts with Gov. Nathan Deal and MAG President John S. Harvey, M.D.

Ruby Butts, the nurse who has assisted Medical Association of Georgia (MAG) ‘Doctor of the Day’ program volunteers at MAG’s Medical Aid Station at the State Capitol during the legislative session for the last three years, recently had her picture taken with Georgia Gov. Nathan Deal and MAG President John S. Harvey, M.D. “I would like to thank and applaud Miss Butts for her significant contributions and her tireless efforts,” says Dr. Harvey. “She has played an important role as we provide free minor medical care for legislators and their staff.”

Butts received her training at the Grady Memorial Hospital School of Nursing in Atlanta, where she was in charge of inpatient services for four years and the outpatient clinic for six years. She also served as a supervisor and director of a home health agency for a number of years.

Go to www.mag.org/advocacy/take-action/dod for details on MAG’s ‘Doctor of the Day’ program. www.mag.org 39

MAG MEMBER PROFILES

Sandra Adamson Fryhofer, M.D., M.A.C.P. Atlanta Internal Medicine MAG member for more than 25 years I’m a MAG member because…

Organized medicine is the best way to help make a difference for physicians and our patients. MAG has talented and devoted staff who look after our interests, and MAG’s email updates keep me informed. I also enjoy the “people” aspect of getting to know other physicians in different specialties throughout Georgia.

As a MAG member, I’m a leader…

My first introduction to organized medicine was early in my career as a member of the Medical Association of Atlanta and the Georgia Chapter of the American College of Physicians (ACP). I was the national ACP’s youngest president. I am an ACP delegate to the American Medical Association (AMA), and I served two terms on AMA’s Council on Science and Public Health. Lastly, I will be a member of the 2016-2017 class of the Georgia Physicians’ Leadership Academy.

My greatest moment as a physician…

Making a difference in the lives of my patients – helping them through an illness or a family crisis. It’s the little things that make a difference, a sweet note or an email that lets me know that I helped someone.

Biggest challenge facing physicians…

The red tape and mandates that take time away from caring for my patients and that contribute to physician burnout. Organized medicine is the only way we can effect change.

Florence R. LeCraw, M.D. Atlanta Anesthesiology (subspecialty in health economics) MAG member since 2013 I’m a MAG member because…

MAG is committed to improving the care of our patients and supporting physicians on a statewide level.

As a MAG member, I’m a leader…

As a delegate who represents the Medical Association of Atlanta at MAG’s annual House of Delegates meeting, I can influence MAG’s leaders as they take steps to help my fellow physicians and our patients.

My greatest moment as a physician…

Leading a research team that investigated the impact of a malpractice reform at a hospital.

Biggest challenge facing physicians…

Finding ways to improve care and lower costs during an increasingly stressful time for physicians and a changing health care environment.

40 MAG Journal

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PRESCRIPTION FOR LIFE

Life lessons: a continuation of lessons of 59 years in medicine Jay Coffsky, M.D. 61. The “first impressions” rule. Your first impression is usually, but not always, correct. A few years ago, worldrenowned violinist Joshua Bell gave a concert to a packed house at Carnegie Hall – where tickets were selling for $150 apiece.

The next night, dressed in a T-shirt and jeans, he gave the same concert with his Stradivarius violin in a subway entrance. Bell collected $18 in one hour – and only a few of the 5,000 people who passed him stopped to listen.

graphs or equations, I skip it. If there’s a very limited number of x-rays or scans, I read the summary and the last paragraph.

62. The “don’t emotionally assassinate yourself when it turns our bad or wrong” rule. I have interpreted more than 250,000 mammograms, more than 50,000 barium enemas, more than one million chest X-rays, and tens of thousands of scans and isotope studies. I feel like I have seen more images than 98 percent of the radiologists who have ever lived. No matter how good anyone thinks they are, there are plenty of misses and incorrect observations. I now spend all of my professional life on breast cancer detection. At present, mammography and ultrasound detections will pick up only 85 to 90 percent of the cancers. I have received many letters from patients thanking me for detecting their cancers.

When the 10 to 15 percent of non-detected cancers that are either not detectable or incorrect observations eventually show up, the patient is almost always hostile. You always beat yourself up over bad outcomes much more than your successes and you will always wonder if that density you thought was innocent was somehow suspicious.

68. The “sex, power, and money” rule. Almost all agendas, wars, quarrels, arguments, politics, and discussions are based on sex, power, or money. Of the three, money is the most important motivating factor 95 percent of the time. Be very skeptical when someone says it’s not about the money; if that is really true, then it’s about power.

63. The “greed syndrome” rule. It is human nature to want more. You see it in two to three-year-olds, so why not adults? As you gather more assets with age, you have to question how you define the concepts of greed versus financial success.

64. The “blind groundhog” rule. Every now and then a blind groundhog comes across an acorn, which means that even a dummy is occasionally right.

65. The “life is not always fair” rule. Accept it and move on because most things will come around.

66. The “how to read medical journals” rule. I am biased on this. If something is written by a PhD and not an M.D., I figure they are either too smart or I won’t be able to understand what they’re saying so I skip the article. If an article contains a lot of 44 MAG Journal

67. The “what is NOT the meaning of life” rule. I don’t know the meaning of life, but I do know that it is hard to accept that our children and grandchildren may make choices that you don’t agree with. Everyone has to lead their own life. My wife of 56 years gave her concept of life’s meaning: “Try to cope every day the best you can.”

69. The “after the fact” rule. Once an action is complete – from dropping a glass of milk to a major indiscretion – there’s no reason to belabor the point or berate that person, particularly when it involves your spouse. Just correct it as best you can and move on to the next moment in life.

70. The “investments” rule. Remember for any monetary, emotional or physical investment, getting out is usually much harder than getting in. Have an exit plan before you leap.

71. The “shazam” rule. Few of you are old enough to remember where the phrase “shazam” came from. The character Gomer Pyle said it a lot on The Andy Griffith Show. He got it from the news boy, Billy Batson, who would say shazam and turn into the Superman-like character, Captain Marvel, of DC Comics fame. If you really want to feel old, ask some young colleagues about Benny Goodman, Ella Fitzgerald, John Wayne, Sandy Koufax or Frank Sinatra.

72. The “dash” rule. The most important line in your life is the one between your date of birth and death. The essence of what you were. It is really a shame that you can’t find out how meaningful you were until your eulogy. It would be a great gift to have a loved one give you a copy of your eulogy while you are still alive.

Dr. Coffsky and his wife, Sandy, have been married for 56 years and have three children and eight grandchildren. He is in his 48th year at DeKalb Medical. His email is m3wejr@bellsouth.net.

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