Michigan Medicine, Volume 114, No. 6 by Michigan State Medical Society

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www.msms.org

November / December 2015 • Volume 114 • No. 6

Embracing the Health Care Team: Conversations in Staff Recruitment, Retention and Training

Mildred J. Willy, MD, (pictured), Ed Washabaugh, MD, FIPP, and Denise Heyboer share their insights.

ALSO IN THIS ISSUE

• Vaccine Management: Protect Your Patients, Protect Your Investment

• Final Rule on CMS’s EHR Incentive Program • ICD-10, the Medical Team and Gun Safety

Congrats Congrats to to ourour newest newest PCMH PCMH practices. practices.

Blue Cross Blue Shield of Michigan and Blue Care Network thank the 1,551 primary care physician practices designated as Patient-Centered Medical Homes in 2015 for their dedicated, compassionate care. PCMH-designated practices in Michigan are also recognized as part of the national Blue Cross and Blue Shield Associationâ&#x20AC;&#x2122;s high performance program, Blue Distinction Total Care. MSMS members: To learn more about joining the Physician Group Incentive Program (PGIP) and becoming PCMH designated, contact your BCBSM provider consultant or visit valuepartnerships.com.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

Chief Executive Officer JULIE L. NOVAK

Committee on Publications November / December 2015 • Volume 114 • No. 6

COVER STORY

10 Embracing the Health Care Team: Conversations in Staff Recruitment, Retention and Training by Veronica Gracia-Wing for MSMS

FEATURES

22 Employing Advanced Practice Providers: Balancing Benefits and Potential Malpractice Risks by Kathleen Moon, ARNP, LHRM, Patient Safety Risk Manager, The Doctors Company

COLUMNS

4 Ask Our Lawyer By Daniel J. Schulte, JD Offering Fairness in Key Employment Agreement Terms

6 MDHHS Update By Linda Dingerson, RN, BSN, VFC Coordinator and Kyle Wildt, BA, Special Project Coordinator, MDHHS, Division of Immunization Vaccine Management: Protect Your Patients, Protect Your Investment

LYNN S. GRAY, MD, MPH, CHAIR, BERRIEN SPRINGS THEODORE B. JONES, MD, DETROIT BASSAM NASR, MD, MBA, PORT HURON

Managing Editor KEVIN MCFATRIDGE EMAIL: KMCFATRIDGE@MSMS.ORG

Publication Office Michigan State Medical Society PO Box 950, East Lansing, MI 48826-0950 517-337-1351 www.msms.org All communications on articles, news, exchanges and classified advertising should be sent to the above address, attn: Kevin McFatridge.

Display Advertising CARL MISCHKA Email: carl@mischka.us Phone: 888-666-1491

Design / Layout STACIA LOVE, REZÜBERANT! Email: rezuberantdesign@gmail.com

Printing BRD PRINTING, LANSING, MI Email: lallen@brdprinting.com

Postmaster: Address Changes Michigan Medicine Hannah Dingwell PO Box 950, East Lansing, MI 48826-0950

HIT Corner by Dara Barrera, MSMS The Final Rule on CMS’s EHR Incentive Program (EDITOR’S NOTE: Sept/Oct HIT Corner attributed to MPro)

34 President’s Perspective By Rose Ramirez, MD Winter Refocus: ICD-10, the Medical Team and Gun Safety

DEPARTMENTS

19 Obituaries

27 MSMS Foundation Education Course Offerings

29 WealthCare Advisors

30 The Marketplace

33 New MSMS Members

The mission of the Michigan State Medical Society is to promote a health care environment which supports physicians in caring for and enhancing the health of Michigan citizens through science, quality and ethics in the practice of medicine.

Michigan Medicine, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2015 it is published in January/February, March/April, May/June, July/August, September/October and November/December. Second class postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2015 Michigan State Medical Society

A S K

O U R

L AW Y E R

Offering Fairness in Key Employment Agreement Terms BY DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL QUESTION:

ANSWER:

I am preparing for retirement and plan to hire a new physician that I hope will take over my practice in the next few years. I have heard from colleagues who have done this that negotiating an employment agreement can be a time consuming and difficult process. I would like to avoid this by offering an employment agreement that is fair and reasonable while adequately protecting my interests. What are the key employment agreement provisions and how does a prospective employer balance fairness and protection when drafting these provisions?

The employment agreement provision that typically generates the most negotiation (and the most employer overreaching and employees walking away) is the covenant not to compete. A covenant not to compete must be reasonable to be enforceable in Michigan. Reasonableness is determined by examining the identity of the activities prohibited, the geographic boundary of the prohibition and its duration. Each of these elements must be reasonable. You should be prepared to demonstrate to prospective employees that the geographic scope is no larger than what is necessary to encompass the patient population of your practice. Completing this exercise prior to presenting your employment agreement to a prospective employee will go a long way to demonstrate to that prospective employee that you are being reasonable. The duration of the covenant not to compete should not be longer than two or three years. If the employment relationship ends this should be sufficient time for you to hire a replacement and for that replacement to solidify relationships with the practice’s patients. Michigan courts typically do not enforce covenants not to compete in employment agreements that last longer than two to three years. You should also avoid including liquidated damages clauses (e.g. if the covenant not to compete is violated the employee must pay $2,000 for every patient seen) that are punitive in nature and/or outright penalties. Such liquidated damage provisions are unenforceable and will only make you look unreasonably threatening to prospective employees. Finally, you should be willingly to include an exception to the applicability of the covenant not to compete if you terminate the employee without cause in the shortly after hiring (e.g. within the

Daniel Schulte, JD, MSMS Legal Counsel, is a member of Kerr Russell Attorneys and Counselors

MICHIGAN MEDICINE

first year). It is not likely that such a short term employee will be in a position to compete with and including this exception will be seen as reasonable on your part. The employment agreement should clearly define the employee’s duties. The number of hours seeing patients, completing records, participating in practice administrative activities, etc should be itemized and listed on an exhibit. If your practice involves on call responsibilities the agreement should provide that they will be equitably divided (i.e. the hire will not be allocated more than his/ her share of call at night, on weekends and during holidays). Most employment agreements are silent on the division of on-call responsibilities and providing for equitable division upfront will demonstrate your reasonableness. Indemnity provisions in employment agreements tend to be unreasonable and overreaching. An employee should only be required to indemnify the practice in the event he/she commits malpractice or breaches of the employment agreement. No fault indemnity clauses (i.e. where the employee’s obligation to indemnify extends to any act related to his/her employment) are not reasonable. Your employment agreement should also contain an exception to the employee’s obligation to indemnify the practice for any claims that are covered by insurance (including any deductable). Drafting your covenant not to compete, duties and indemnity sections as provided above will adequately protect your practice while at the same time demonstrate your reasonableness to your prospective employee. This will also make the process of agreeing on the employment agreement terms less time consuming and difficult. November / December 2015

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M D H H S

U P D AT E

Vaccine Management: Protect Your Patients, Protect Your Investment BY LINDA DINGERSON, RN, BSN, VFC COORDINATOR AND MDHHS, DIVISION OF IMMUNIZATION AND KYLE WILDT, BA, SPECIAL PROJECT COORDINATOR, MDHHS, DIVISION OF IMMUNIZATION

ver the past few years, both the number of vaccines and doses needed to protect a child has increased. The cost of vaccinating a child has risen from approximately $370 in 2000 to nearly $2,000 in 2015.

A single vaccine storage and handling error can result in loss of vaccines worth thousands of dollars. In addition to financial losses, these errors may reduce vaccine potency causing inadequate protection against disease, the possible need to revaccinate, and a potential lack of confidence in vaccines or the provider. Maintaining appropriate vaccine storage and handling conditions protects vaccine potency and ensures adequate patient protection while also reducing the chance of a costly loss.

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November / December 2015

Temperature Monitoring When developing or updating a vaccine storage and handling plan it is prudent to first look at the area in which vaccines will be stored and how they will be received: • Post “Do Not Unplug” signs at wall outlets

Historically, out-of-range temperatures were only detected if staff were present at the time of the excursion. With the emerging prevalence of digital data loggers and continuous temperature monitoring it is now possible to know the quantity and duration of every excursion. These systems help guide responses to temperature excursions to ensure vaccine viability.

Some points to consider when developing a temperature monitoring plan are:

and circuit breakers. • Develop an emergency plan and keep a cooler

• Maintain refrigerators between 35 and 46 degrees Farenheit. Freezer temperatures must be maintained between -58 and +5 degrees F.

nearby to move vaccines, if needed. • Inspect vaccines upon delivery and notify supplier immediately if problems are

• Have a properly calibrated thermometer or temperature recording device with a buffered probe (glycol, glass beads, etc.) inside each storage compartment. Place the thermometer in the

encountered.

center of the storage unit, with the vaccines.

Storage Units The backbone of every storage and handling plan is the storage unit itself. Carefully select and use proper units to store vaccines. CDC recommends stand-alone pharmaceutical grade units designed for vaccine storage. Only about one-third of the space in a household refrigerator is appropriate for vaccine storage. Studies have shown that household combination units may be unacceptable for storing frozen vaccines. Dorm style units should never be used!

Some points to keep in mind when utilizing a storage unit are: • Use water bottles in refrigerators or ice packs in freezers to help maintain consistent temperature ranges. • Do not store food or beverages in refrigerators or freezers with vaccines. Store vaccine separately from other medications or biologics.

• Check and record temperatures twice a day, when you arrive and 30-60 minutes before leaving the clinic for the day. Check and record min/max temperatures daily in the morning. If you use data loggers, download data on a weekly basis and assess data. • Consider using a temperature monitoring alarm system that will alert staff when the temperature goes out of range. • Investigate and act on any temperature excursions immediately. Label vaccine ‘Do not use’ and determine the length of the excursion. Contact manufacturers to determine if vaccine is viable before using it on patients. A provider’s storage and handling plan is only as good as the staff that implements it. Ensure staff are well trained and motivated to properly handle vaccine storage and administration. Michigan Department of Health and Human Services provides several resources to train staff about vaccine safety and handling. Refer to the Division of Immunization website at www.michigan.gov/immunize > Health Care Professionals/Providers > Provider Education Resources > Immunization Education Opportunities for Health Care Personnel.

• Store vaccines in their original containers until ready to administer to a patient. Do not pre-fill syringes. • Store vaccines in the center of the unit in baskets that allow for good air circulation. Keep vaccines away from fans, sides and the bottom of the unit. • Prevent expiration of vaccine by rotating vaccine stock weekly so the oldest vaccines are used first. If vaccines expire, remove them from storage units so they don’t get administered. Volume 114 • No. 6

REFERENCES: Chojnacky, M. J.; Miller, W. W.; and Strouse, G. F., “Thermal Analysis of Refrigeration Systems Used for Vaccine Storage,” NISTIR 7753, 2010 U.S. Department of Health and Human Services, Centers for Disease Control, “Vaccine Storage and Handling Toolkit,” May, 2014

MICHIGAN MEDICINE

H I T

CO R N E R

The Final Rule on CMS’s EHR Incentive Program BY DARA BARRERA, MICHIGAN STATE MEDICAL SOCIETY

he wait is over. The Centers for Medicare and Medicaid

Services (CMS) has published the final rule that specifies criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The final rule’s provisions covers performance years 2015 through 2017 (Modified Stage 2) as well as Stage 3 in 2018 and beyond.

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November / December 2015

Now, the big question – what do you have to do to attest for meaningful use this year? This year will again be a 90 day reporting period with full year reporting starting back up in 2016. You can choose any 90 day period throughout the year (January 1, 2015 – December 31, 2015). The attestation system is scheduled to open after January 4, 2016 and close on February 29, 2016. Additionally, there has been a reduction and consolidation of measures, as well as some changes in the threshold requirements. And, yes, there are changes to the patient electronic access and secure messaging requirements that were so troublesome for practices to meet.

Key “need to know” changes for 2015: All providers are required to attest to a single set of objectives and measures (Modified Stage 2). This replaces the core and menu objectives structure of previous stages. For EPs, there are 10 objectives, including one consolidated public health reporting objective. In 2015, all providers must attest to objectives and measures using EHR technology certified to the 2014 Edition. To assist providers who may have already started working on meaningful use in 2015, there are alternate exclusions and specifications within individual objectives for providers who were previously scheduled to be in Stage 1 of meaningful use. These include:

These changes, while late in the year, will allow more physicians to attest to the modified version of Stage 2 this year.

— Allowing providers who were previously scheduled to be in a Stage 1 EHR reporting period for 2015 to use a lower threshold for certain measures. — Allowing providers to exclude for Stage 2 measures in 2015 for which there is no Stage 1 equivalent.

Changes to Specific Objectives/Measures Stage 2 Patient Electronic Access, Measure 2: For 2015, instead of the 5 percent threshold, this measure requires that at least 1 patient seen by the EP during the EHR reporting period (or patient authorized representative) views, downloads, or transmits to a third party his or her health information during the EHR reporting period. Stage 2 Secure Electronic Messaging: The 5 percent threshold has been changed to the 2 capability for patients to send and receive a secure electronic message with the EP was fully enabled during the EHR reporting period (yes/no). Public Health Reporting: The public health reporting objectives have been consolidated into one objective with three measure options for EPs. For more information or assistance, visit MSMS.org/CMS EHRIncentive or contact Dara Barrera at MSMS at djbarrera@msms.org or (517) 336-5770. Source: Centers for Medicare and Medicaid Services, www.cms.gov.

Volume 114 • No. 6

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Embracing

THE

TEAM

Conversations in staff recruitment, retention and training

HEALTH CARE

BY VERONICA GRACIA-WING FOR THE MICHIGAN STATE MEDICAL SOCIETY

The effectiveness of medical staff can make or break any private practice or hospital health care team. How we define effectiveness varies, with the path toward achieving effectiveness more varied still. In this issue of Michigan Medicine, weâ&#x20AC;&#x2122;ll talk to two physicians, and a medical staffing health care services company for their respective insights into staff recruitment, retention and training.

MICHIGAN MEDICINE

November / December 2015

MILDRED J. WILLY, MD Emergency Medicine Physician, St. Mary’s of Michigan Q: HOW DO YOU APPROACH STAFF RECRUITMENT, RETENTION AND TRAINING? MW: I think each group creates a culture at their institution based on what they value.

In order to understand your culture, you need to have a mission statement, recognize your strengths and weaknesses and discuss the priorities of and opportunities for growth within your group. This allows you to focus on recruiting providers who will continue to foster and strengthen the group’s ideals and practice environment. In order to recruit physicians, you need to ask each of them what is important for their practice environment and be honest with how your culture fits with their future goals. I think you need to be aware of what resources are available in your community, at your institution, and what the possibilities are for negotiation. Consider the following: • A competitive benefit and retirement package. • Financial support for CME is very important to keep your providers competent and up-to-date on the latest information in medicine as it is rapidly changing. • Look at a variety of specialty job salary surveys to know you are competitive and be familiar with salaries in your local area, which are even more predictive of how successful you will be in your recruitment and retention of providers. • One source emergency physicians look to for some of this information is the American College of Emergency Physicians, our national specialty society. Other things to consider are moving expenses, loan repayment and signing bonuses as the new graduate looks for these types of extras that may tip them toward choosing one institution over another. New grads have many expenses out of the gate, which can be overwhelming for them, and an institution willing to support them in their time of need may win their loyalty.

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Q: IN WHAT WAYS DO YOU PRACTICE

Q: WHAT ARE THE CHALLENGES OF

FLEXIBILITY AND EFFICIENCY WHEN

STAFF RECRUITMENT, RETENTION,

IT COMES TO STAFF RECRUITMENT,

AND TRAINING?

RETENTION AND TRAINING?

MW: We lose many of our new graduates in this state to other states with a more favorable malpractice environment like Texas and Indiana or those states with population growth, new industries, growing economies, or favorable winter weather.

MW: Many young physicians focus on work/life balance, which I think overall improves their general wellness and resiliency during stressful times. In order to accommodate some of their needs, you might need to consider the possibility of different contracts for different providers based on their personal needs, which may need to be flexible over time in order to keep good people. This is easier for a larger group to support, however, there are ways to do this even in smaller groups. For example, we have two physicians who do most of our night shifts during the week, which works well for them as they are home with their children after school. They have a regular block schedule with weekends off which gives them more flexibility. This allows for others in the group to work fewer night shifts overall and at times even work more total hours because they have less sleep disturbance due to night shift changes. It’s a win-win situation for both providers involved. As emergency physicians, we often have a variety of interests over the course of our career. For some it is academics, for others it’s administration or involvement in organized medicine. Again, supporting your physicians during their changing career goals benefits everyone as they bring their newly learned skills back, which only strengthens the leadership and passion within the group. The return on investment outweighs the time invested in order to promote the personal and career growth of your providers.

Specifically, I think it is more difficult to recruit and retain physicians to northern Michigan for a variety of reasons. Some geographic challenges unique to Michigan are that we have many of our large urban centers concentrated in the lower part of the state and practicing medicine in a rural or small urban center may be different than the exposure new graduates received during their residency. There may be fewer resources available, smaller groups may mean less time off and there are fewer primary care physicians to refer patients and for providers to be cared for themselves. Another difference is there is less subspecialty back up in general. There are times when there is a lack of coverage by ENT, plastics, hand, maxillofacial and vascular surgeons for example, meaning transfer of patients long distances away from their homes and concern for their safety and ability to receive follow-up. One challenge we continue to see in mid-Michigan is that it can be difficult for spouses to get a job in the area depending on what they do. I suspect some of our struggles will lessen as the Michigan economy continues to improve overtime. On the flip side, our region has affordable living and a diverse patient population, which creates a very interesting practice environment demanding we use our skill sets learned in residency.

Estimated recruitment costs and lost revenue due to physician turnover in a range from $200,000 up to $2 million. —American Journal of Medical Quality

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November / December 2015

We also recruit some great physicians to this state because we have so many excellent training programs with years of experience in education. I am personally a product of this, as I was an Indiana University School of Medicine graduate who did my residency training at St. John Hospital and Medical Center in Detroit. I’ve now been in Saginaw enjoying my career for over 16 years. This is my 20th year as a Michigander. Q: WHAT TOOLS OR RESOURCES DO YOU USE IN STAFF RECRUITMENT, RETENTION, AND TRAINING?

MW: I think that some providers may look similar on paper when reviewing CVs, however their performance may be different in clinical practice. This is why having student and resident rotators is invaluable as it allows you to see their performance and get to know them as people. Providers grow with knowledge and experience at different rates some of which depends on their own initiative, so you also have to give new people some time to adjust to their environment. We have always had an orientation month with additional provider staff so that the new recruit can be paired with a senior physician who is available to mentor them and for questions regarding system issues, which we find helps the physician feel more comfortable when they’re on their own in the future. Advanced practice providers at our institution receive a three-month orientation, which may be shortened or extended depending on their previous experience and predicted success.

care. Scribes often improve the provider’s productivity, which allows them to see even more patients. Some places have patient care navigators who assist with patient throughput, which can be helpful for physicians. Others have volunteers or pastoral care to assist with interfacing with patient’s families. Scheduling is very important for EM providers, as most of us do many different shifts. The scheduled shift start time should always rotate forward, nightshifts should be no more than four in a row with time off following, as this will allow for your providers to adjust their sleep schedule and be more productive. Ideally we try to provide people with two weekends off a month. This allows for adequate rejuvenation for the provider and improved patient safety. It may also be useful to have contact with the local chamber of commerce and small business community to provide assistance for spousal job search. Providers also need to feel safe in their environment, which means an active security department. Some providers can face a violent patient population and family members, which can lead to a considerable amount of stress, depression and potential for burnout. Q: WHAT ADVICE WOULD YOU GIVE TO COLLEAGUES/CLIENTS AS THEY NAVIGATE THE INS AND OUTS OF STAFF RECRUITMENT, RETENTION, AND TRAINING?

With EMRs now, there can be a steep learning curve as these vary from place to place and this is a source of frustration for many physicians. Having someone train them and readily available for their questions the first few shifts is definitely needed.

MW: When trying to recruit, there needs to be close follow-up and many different methods of contact with a potential employee. The recruit needs to feel special and have their concerns addressed and you want to stay on their radar. When recruiting and retaining physicians, people need to be communicated with in many different forms. Based on different generations in the workforce, some people may need to be contacted via phone, with others email is best, and texting may actually be the quickest way to communicate for some issues.

Scribes can also be useful in taking off some of the stress placed on physicians to keep up with documentation while providing patient

There should also be a focus on how to retain physicians as we put a lot of work into getting them and then often we don’t focus on how

Here are a few resources that can help you to both recruit and retain providers:

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to keep them. Leadership and mentoring programs may help retain some physicians. Having good leaders in your group who lead by example and groom future leaders is important. Getting to know your physicians and their goals may help keep them involved and if they are able to work on projects they are passionate about, you will help them achieve their personal and career goals and they will feel more satisfied. In addition, continuing education and assistance with board certification and maintenance of certification are extremely important. The department chairman can assist in monitoring the educational needs of the providers within the group. You should always be looking at what you can do better, and how you can improve the quality of life for your physicians, because most of them are feeling pretty stressed these days. Some of my friends work in places where they take a sabbatical every 18 months. We used to reward our providers who stayed with the group after 10 years with a nonmedical trip and we recognized them at an award banquet. I don’t think you can ever give too many awards and it always creates good will. There are many ways to be creative and reward physicians and overtime this helps to create loyalty. Finally, I think involvement in organized medicine assists with retention of providers. Our specialty society offers opportunities to be involved with legislative efforts, disaster committees, health finance and reimbursement committees, a democratic group section, and many others. Providers can accomplish a lot more when they pull together, away from the bedside, in order to improve their specialty and the care for their patients. I think for me personally, both the continued need to learn and my involvement in organized medicine has been extremely important for my own career satisfaction, growth and longevity. It has provided me with continued intellectual curiosity, unique opportunities, career advancement, professional fulfillment, friendships and spousal support. (Continued on page 15) 13

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November / December 2015

Q: WHAT CONCERNS DO YOU HAVE ABOUT THE CHANGES IN HEALTH CARE AS IT RELATES TO STAFF RECRUITMENT, RETENTION, AND TRAINING?

MW: As it continues to be more difficult for smaller hospitals and physician practices to stand on their own, I fear that physicians will feel a lack of control and large health care systems may lose the local community perspective including what is important to providers. This may make it more difficult to recruit and retain physicians. As we move forward, my concern is that providers may have less input into patient care, provide less volunteerism and feel less valued. This may create a situation with less loyalty to stay in one place and the provider is less likely to choose a community with strained resources. Instead, they may choose their place of employment based only on lifestyle, which may amplify difficulties recruiting to areas already experiencing provider shortages. Q: WHAT ARE SOME OF THE STAFF RECRUITMENT, RETENTION, AND TRAINING PRACTICES AND SUCCESSES OF WHICH YOU’RE MOST PROUD? WHAT ABOUT WHAT YOU’VE LEARNED FROM NOT-SO-SUCCESSFUL PRACTICES?

MW: I’ve found it helps having a variety of training programs, including residencies, medical schools, physician assistant programs and nursing schools because it creates a culture of learning and challenges the status quo. Involvement in teaching those students shows your level of commitment to them as individuals. This is the best recruitment tool because it showcases your workplace and word of mouth spread by those who have experience with a group or institution is very powerful.

I have enjoyed working with and learning from our residents and students here in Saginaw, as well as my faculty colleagues. I am always proud when one of our medical students or physician assistant student rotators joins our or other successful practices and are happy with their career choice. I have taken residency graduation day off for the past 16 years so I can witness the event. I often see students and residents who have moved on to other places at conferences and it warms my heart when they talk about their training years in Saginaw and reconfirm that it was a great place to learn about patient care and the art of medicine. Even more satisfying is when I see them as colleagues stepping up as leaders in our specialty to make the practice of medicine better and to help advocate for our patients. ‘Not-so-successful practices’ is a little more difficult…. I think you do a disservice to people by trying to recruit them to a practice that does not fit them well. Some people also need to move on to continue to grow in their careers and sometimes that does not mean you have failed, but have succeeded in helping them to rise to a different level. I do not think one-size fits all for people at all times and sometimes people need a change as life events change their individual perspective and goals. Q: HOW DOES YOUR TEAM APPROACH AND MANAGE PATIENT EXPECTATIONS AND DEMANDS?

MW: The emergency care team, which consists of techs, nurses, nurse managers, physicians and physician assistants, all strive for low wait times by trying to streamline front end processes in order to improve our door to doc time. We try to

address the concerns that brought the patient to us, realizing the difficulty patients have trying to maneuver through the complicated medical system we have today. In the emergency department we work as a physician led team, which helps us to be successful in addressing the patient’s expectations and needs in a timely fashion. Often times if a chest pain patient comes in, the triage nurse has coordinated moving the patient to a room quickly and starting the evaluation process including an initial assessment, IV and blood draw. The ED tech has obtained the EKG by the time I see the patient. We have protocols set up for certain high risk patients in order to expedite their workups and shorten their times for definitive treatments like going to the cath lab or surgery if needed. Patients come to us and are often scared and we try to alleviate their fears, showing them compassion and focus on expediting their patient care while checking on their progress, updating them as often as possible, and make arrangements for the next step in their plan for care. As emergency physicians we are masters of interfacing with the complicated health care system at multiple levels every day, however, I think our current system is being taxed and is broken in many ways. We need more providers to care for the baby boomers as they age. We need different resources to do this efficiently and protect access to care for all patients. We need to serve our patients differently than we have considered before and better by including them in more of their care discussions. It’s time to step up and be the leaders of redesigning acute care in this country with the help of our colleagues in the house of medicine.

(Continued on page 17) Volume 114 • No. 6

MICHIGAN MEDICINE

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November / December 2015

ED WASHABAUGH, MD, FIPP Interventional pain physician, Michigan Pain Specialists Q: HOW DO YOU APPROACH STAFF RECRUITMENT, RETENTION AND TRAINING?

EW: Managing human resources comes from the top of the administrative chain. We are a six-provider practice that works out of one office and three hospitals. There are three owners so a single point person is our executive director. Through her, clinical and administrative staff is hired with a shared dedication of making a patient’s visit as pleasant as possible. Our clinical nurse manager for the multiple sites is instrumental in providing the training needed to maintain a uniform experience for our patients in multiple counties with different institutional requirements. People are hired by our administrative staff with a desire to work with challenging patients and a track record of complex patient care. We often hire from within for more demanding positions, so all employees have the opportunity for job growth and added responsibility and reimbursement for their efforts. Q: IN WHAT WAYS DO YOU PRACTICE FLEXIBILITY AND EFFICIENCY WHEN IT COMES TO STAFF RECRUITMENT, RETENTION AND TRAINING?

EW: Employees want competitive compensation, good working hours and a chance for growth in their positions. Competitive compensation is pay plus benefits. Employees with variable hours are placed on a salary. This allows for the variable work schedule to match staffing needs. For hourly employees, full time and contingent part time individuals are needed to match varying physician work schedules. The contingent part time employee is an excellent administrative strategy to allow flexibility for the other employees for Volume 114 • No. 6

needed time off and vacations. Every time an employee leaves, expect a 5 percent drop in net revenue. It is expensive to hire, train and fire so the upfront process of employment is critical to the bottom line. Q: WHAT ARE THE CHALLENGES OF STAFF RECRUITMENT, RETENTION AND TRAINING?

EW: The real key is to have the right people “on the bus.” This means that the bus driver - the executive director - has to set up the mechanisms for hiring staff that want to be on the bus and go the same direction that the bus is going. Complaints have to be addressed. Problems have to be solved in a timely manner. One of our biggest hurdles is addressing our ability to maintain the proper workflow for the providers. Some clinic days are packed and others are light. To solve this problem, our clinical nurse manager has been able to open and staff extra treatment rooms so even on busy days, a patient is in and out of the clinic in a safe, seem less fashion. By flexing staff up or down on heavy clinic days, our clinical nurse manager is able to maintain a pleasant workload for our staff and a quality experience for our patients. Q: WHAT TOOLS OR RESOURCES DO YOU USE IN STAFF RECRUITMENT, RETENTION AND TRAINING?

EW: Newsletters, group CME/CEU sessions and lunches provide for a team approach to making the clinics run smoothly on a weekly basis. All clinic meetings are scheduled for training for larger needs such as BCLS, ACLS training or major clinic changes such as implementation of new record system requirements. These training sessions are paid and the clinics are closed on those days with mandatory attendance. MICHIGAN MEDICINE

Q: WHAT ADVICE WOULD YOU GIVE TO COLLEAGUES/CLIENTS AS THEY NAVIGATE THE INS AND OUTS OF STAFF RECRUITMENT, RETENTION AND TRAINING?

EW: There are State of Michigan and Federal requirements that have to be met with everyone under employment. Your accountant and lawyer are important consultants to help direct you with securing space, supplies and staff. These are the three areas that make up the majority of your expenses. The head administrator is your most important hire. Hire the right person and let that person do their job. Support their decisions and don’t undermine their authority. Judge their performance on how well they are able to meet your needs. Our practice relies very heavily on this person. One of our requirements is that our head administrator must have a backup that is trained and ready. That person is then available during down time for the head administrator. Q: WHAT CONCERNS DO YOU HAVE ABOUT THE CHANGES IN HEALTH CARE AS IT RELATES TO STAFF RECRUITMENT, RETENTION AND TRAINING?

EW: Presently costs are escalating and providers are being pressured towards being employees of institutions. Asking a new graduate to take out a business loan to start a practice on top of a mortgage and school debt is not practical. Medicine is a commodity in which systems are competing over quality and physicians are presently a small part of that equation. Health care insurers have supported institutional medicine at the cost of private practice. Private practices are being excluded from the insurers and hospital systems. (Continued on page 18) 17

Q: WHAT ARE SOME OF THE STAFF RECRUITMENT, RETENTION

It can cost anywhere from $22,000 to $64,000 to replace a registered nurse. Robert Wood Johnson Foundation

AND TRAINING PRACTICES AND SUCCESSES OF WHICH YOU’RE MOST PROUD? WHAT ABOUT WHAT YOU’VE LEARNED FROM NOT-SOSUCCESSFUL PRACTICES?

EW: Staff teamwork and commitment to patient care have been extraordinary. Our employee creed is,“ If you find a problem… fix it, if you are the problem… leave!” The people I work with are hardworking, trustworthy and good people. To name one employee of the year would require naming fifty people. As a physician, to see how hard others work inspires me to put a smile on my face and do my best. We have three meetings per month that make the staff an integral part of formation of policy and improving patient care. There has been a large shift in the ownership of medical practices. The largest mistake

that I have seen is the lack of an accurate one, three and five year business plan. It is more than an exercise to try to imagine your practice in the future. Health care is continuing to change and it takes vision to navigate future pitfalls. In yesterdays’ market, a seven-year lease was an asset. In today’s market a seven-year lease can be a death sentence. Q: HOW DOES YOUR TEAM APPROACH AND MANAGE PATIENT EXPECTATIONS AND DEMANDS?

EW: The best way remains an old school process. Identify a problem and fix it the best you can. Cater to the individual but identify system errors to make fewer problems and have a smooth running process. As an example, our major business needed to change from a private outpatient clinic to a hospital based clinic. We were in charge of managing those changes and to maintain the expectations of our past patients.

Serving healthcare providers for over 25 years

MICHIGAN MEDICINE

November / December 2015

In order to meet those needs, we began by streamlining the patient experience with the facility and the clinic by having a staffing arrangement that was financially beneficial to the institution and the clinic. From that win-win administrative framework, all entities benefitted from supplying the best product to the patient as possible. Any relationship will fail where there are winners and losers. Strive for win-win arrangements.

students. From that, the “externship” was born. Initially it was with any premedical student that was at least 18 years old with a high school education. The student would shadow a doctor for a week and then a nurse for three weeks. With the nurse they would learn how to take vital signs, transfer patients and participate like a medical assistant. They would receive a stipend and letter of recommendation for medical school. Some of the externs would apply for part time or summertime employment. The plan was to give them hands on experience and a real taste of being a physician

Q: TELL MICHIGAN MEDICINE READERS A BIT ABOUT THE EXTERNSHIP PROGRAM YOU STARTED IN WASHTENAW COUNTY.

EW: This is a personal win-win that I have had with many pre-medical students. It started in 1983 when my extent of health care involvement was boiling 72-hour urine samples for evaluation of patients with pheochromocytoma. After smelling of urine for a summer, I vowed to make a better experience for future pre-medical

Initially, we had 30 participants in three years, mostly from southeastern Michigan, but some from as far away as the Upper Peninsula! We found that all were good students but at least three quarters of them had no interest in medicine. Their parents had a huge interest in them going to medical school and they did not share the same goal. For the next seven years, we improved

our offerings by only accepting applications after at least one semester of college directed towards pre-medicine. In 2013, I was fortunate to be the Washtenaw County Medical Society President and I had the opportunity to switch the program to the society. Now I participate with the program in two ways: Assisting in obtaining funds for the extern stipends and finding clinical sponsors for the one month 80 hour rotations. Because the Washtenaw County Medical Society sponsors it, the executive director is a tremendous help in organizing and administering the program’s needs. Now we are focused on premedical students from Washtenaw County and having at least one semester of premedical studies in college. There are many bright students that will shine in our specialty when they are given the chance.

(Continued on page 20)

OBITUARIES The members of the Michigan State Medical Society remember with respect their colleagues who have died. Lee R. Pool, MD Kent County Medical Society Died August 8, 2015 Warren R. Moore, MD Wayne County Medical Society Died September 3, 2015 Dan A. Fox, MD Muskegon County Medical Society Died September 7, 2015

∫

IN MEMORY

If you would like to recognize a colleague by making a gift or bequest to the MSMS Foundation in their memory, please contact: Rebecca Blake, Director, MSMS Foundation, 120 W. Saginaw St., East Lansing, MI 48823 phone: 517-336-5729 email: rblake@msms.org

Volume 114 • No. 6

MICHIGAN MEDICINE

Q: WHAT ARE THE CHALLENGES OF

DENISE HEYBOER

STAFF RECRUITMENT, RETENTION

Senior Client Services Manager, Diversified Medical Staffing

DH: The economy plays a huge role in business and we have been challenged this year with heavy demand for nurses, medical assistants, mid-levels and CENAs – and the supply just isn’t there really for most any discipline. Employee turnover is extremely costly.

AND TRAINING?

Q: HOW DOES DIVERSIFIED MEDICAL

Q: HOW DO FLEXIBILITY AND EF-

STAFFING RECOMMEND PRACTICES

FICIENCY PLAY A ROLE IN STAFF

APPROACH STAFF RECRUITMENT,

RECRUITMENT, RETENTION AND

RETENTION AND TRAINING?

TRAINING?

DH: Practices have a variety of resourc-

DH: Staff appreciates flexibility. We often

YOU RECOMMEND IN STAFF RECRUIT-

es at their fingertips that can assist with sourcing, finding and placing quality and qualified staff for all disciplines. Diversified Medical Staffing suggests practices to invest in staff’s skills and professional development by offering training, flexibility, and solid resources available as needed. Utilizing a staffing agency is also a good resource.

hear from our team members how much they enjoy having flexibility and choices with their work schedules so they can maintain a great work/life balance. Practices will be attractive to prospective candidates when they provide flexible schedules. Flexible work schedules create less stress for employees, which, in turn, helps with retention of staff.

MENT, RETENTION AND TRAINING?

Q: WHAT TOOLS OR RESOURCES DO

DH: Tools and resources we recommend to

physician practices would be customer and employee satisfaction/engagement surveys. Gathering this data and feedback assists with determining how the practice or organization is doing overall. This helps to recognize what your organization or practice does well or what areas need improvement.

Health Professions

RECRUITMENT & RETENTION

TIPS

from the Health Workforce Information Center

Programs that support health workforce recruitment:

Possible recruitment and retention incentive programs:

Other steps employers can take to attract and keep health care workers:

• Loans.

• Enhanced total compensation including benefit packages.

• Redesigning internal processes to achieve better efficiencies.

• Mentoring by experienced health care providers.

• Focusing on ways to retain, train and promote current workers.

• Work-life balance support.

• Attracting a new generation of workers.

• Competitive salary and benefit programs.

• Providing competitive benefit packages, including non-traditional benefits – such as onsite child care, concierge services and flex scheduling – to assist employees with work/life balance. (Hospitals & Health Networks)

• Signing bonuses. • Loan repayment programs.

• Loyalty bonuses. • Support for continuing education. • Opportunities for career advancement.

MICHIGAN MEDICINE

November / December 2015

Volume 114 • No. 6

MICHIGAN MEDICINE

T H E

D O C TO R S

CO M PA N Y

Employing Advanced Practice Providers: Balancing Benefits and Potential Malpractice Risks BY KATHLEEN MOON, ARNP, LHRM, PATIENT SAFETY RISK MANAGER, THE DOCTORS COMPANY

dvanced practice providers (APPs)—mainly nurse practitioners (NPs) and physician assistants (PAs)—can be found in a wide variety of specialty areas and clinical settings, including hospitals, outpatient clinics, and rural community centers. The APP is an important and integral member of the healthcare team, assisting physicians in providing a wide range of healthcare services. Practices and hospitals that employ APPs can experience many benefits, such as lower operating overhead, increased physician time with patients, and improved patient education and satisfaction. However, employers of APPs should consider implementing effective risk management measures to help ensure that the benefits of using APPs are not at the expense of increased liability exposure.

The role of APPs has broadened substantially since the first training programs were created in response to a physician shortage approximately 40 years ago. The number of PAs in the United States has increased 36.4 percent over the last five years,1 and the number of NPs has doubled in the past 10 years.2 APPs now perform both routine and complicated medical services for hospitals and medical practices across the country. They improve patient access to healthcare, particularly with the increase in patients due to the Affordable Care Act. An APP is often covered under the physician’s or hospital’s malpractice insurance policy under vicarious liability coverage. APPs can be held directly liable for their own acts or omissions, but, in addition, under the legal theory of vicarious liability, physicians and hospitals can also be held liable for the actions of their employees, including APPs. Therefore, the physician or hospital is often named in malpractice claims involving their APPs.

According to closed claims data compiled by The Doctors Company and the PIAA, most malpractice claims attributed to APPs can be traced to clinical and administrative factors that potentially could have been identified and remedied by the employing physician or hospital, including: • Operating outside of the APP’s scope of practice. • Inadequate physician supervision of the APP. • Absence of written protocols. • Deviation from written protocols. • Failure and delay in seeking referral or physician collaboration. 22

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November / December 2015

The following is an example of a claim involving an APP: A 53-year-old female underwent a laparoscopic cholecystectomy, which was performed without incident by the insured general surgeon. The surgeon saw the patient three days post-op, noting that she was doing well and had no complaints other than the expected incisional pain.

The patient was next seen at five days post-op by the surgeon’s PA. The PA noted an obvious infection at the umbilical surgical wound. He obtained a culture (which was later proved to be Klebsiella) and started the patient on Levaquin, an antibiotic.

The patient returned four days later and was reevaluated by the surgeon, who noted that the wound still looked infected, with the presence of drainage. The surgeon felt that the patient had cellulitis, continued the antibiotic, and advised her to return if needed.

A week later the patient returned and was seen by the PA. She complained of recent onset of nausea, vomiting, and diarrhea and had a temperature of 103 degrees. Although the PA noted that the wound still appeared infected, because the patient’s abdomen was not tender and no masses were felt, he diagnosed the patient as having a “superficial wound infection” and “gastroenteritis.” The PA told the patient to continue the Levaquin and prescribed Phenergan for the nausea and vomiting.

Three days later, the patient was admitted through the ER with an acute abdomen. She underwent exploratory surgery and was diagnosed with an intrahepatic abscess. The patient then developed disseminated intravascular coagulopathy, continued to deteriorate, and expired several days later.

Suit was filed against the insured, the PA, and the insured’s medical practice. The primary issue was the failure to diagnose and treat the intrahepatic abscess. Defense experts could not support the PA’s failure to properly assess the patient when she presented with obvious clinical signs of infection. The PA was criticized for failing to consult with the surgeon. The surgeon, who signed off on the PA’s medical management of the patient, was held vicariously liable for the acts of the PA and directly negligent for his inadequate supervision of the PA.

To help decrease liability risks, the employing physician or hospital should have a written policy outlining the APP’s scope of practice. This policy should be signed by the APP and other staff members annually. In putting together this policy, it is important to know the laws in your state that govern the scope of practice of APPs. For example, supervision of an NP by a licensed physician is not required in certain practice settings in some states, which allows NPs to practice independently. Although supervision may not be required, most NPs practice under the guidance of a licensed physician. PAs, however, are only allowed to practice under a supervising physician.

Other suggestions to decrease liability risks include: • Ensure that all newly hired APPs undergo orientation with the practice or hospital. • When scheduling appointments, staff should inform patients when they are being scheduled with an APP. If that patient requests to see his or her physician, the staff should provide the patient with that option. • Make certain APPs wear identification that indicates their name and their job title. • Develop treatment guidelines and clinical triggers for physician consultation. Meet with the APPs regularly to discuss their roles and expectations within the practice, and document these meetings. • Regularly review the charts, including prescription monitoring, of patients seen by the APPs. • Make sure that all staff members, including APPs, have adequate professional liability coverage. For nonemployed APPs, liability coverage should be equal to what the physician or practice carries.

Because APPs can be full partners with physicians in malpractice litigation, it is imperative that medical practices and hospitals design purposeful measures to reduce risks. Employers of APPs should work with their APPs to initiate meaningful changes that will potentially protect the healthcare team from liability risks, reduce adverse events, and promote patient safety. To read more case studies about employing APPs and for detailed risk management checklists, download The Doctors Company’s guide to an APP preventive action and loss prevention plan at http://ow.ly/OxqBm.

REFERENCES: 2014 Statistical Profile of Certified Physician Assistants. National Commission on Certification of Physician Assistants. https://www.nccpa.net/ uploads/docs/2014StatisticalProfileofCertifiedPhy sicianAssistants-AnAnnualReportoftheNCCPA.pdf. Accessed May 18, 2015. Auebach DI. Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Med Care. 2012 Jul;50(7):606-10.

The author, Kathleen Moon, patient safety risk manager at The Doctors Company, can be contacted at kmoon@thedoctors.com. Volume 114 • No. 6

MICHIGAN MEDICINE

M S M S

A L L I A N C E

SAVE Today! (Stop America’s Violence Everywhere) BY CLARA SUMEGHY, PRESIDENT, MICHIGAN STATE MEDICAL SOCIETY ALLIANCE

ur Alliance of physician spouses and partners is dedicated to advancing the health of Michigan with the overriding

objective of benefitting our communities and families as well as the medical profession. We try to achieve our goals through advocacy and action. A key focus of our Alliance, and that of the National Alliance, is the ongoing problem of violence in the U.S. Back in 1995, the American Medical Association Alliance recognized the terrible toll that violence was taking in far too many communities across the country and introduced “SAVE Today” to “Stop America’s Violence Everywhere.” The statistics were sobering then; 20 years later, they still are, unfortunately. Violence continues to affect all age groups.

All too often it leaves permanent physical and emotional scars. And in the process, it destroys families and communities. No one, it seems, is immune. In the 20 years since the AMA Alliance membership undertook this huge health promotion initiative, more than 700 anti-violence programs were implemented by county and state Alliances nationwide. Just as relevant today, the “SAVE” message continues to focus attention on this serious, but preventable, public health issue. On October 14th, we in the Michigan State Medical Society (MSMS) Alliance, together with our national Alliance partners, commemorated the 20th Anniversary of the “SAVE” Campaign. As it happens, this date coincided with national “Health Cares About Domestic Violence Day” (HCADV Day). Then, 10 days later on October 24th, the MSMS Foundation’s campaign to help domestic violence survivors (“Doctors and Their Families Make a Difference in Michigan Day”) took center stage. Thus, October was a strategically important month in the fight against domestic violence.

MICHIGAN MEDICINE

November / December 2015

What is the Alliance doing? Here are just a few examples of how we in the Alliance are working to make a difference: Our MSMS Alliance assisted the MSMS Foundation in their effort to “Make a Difference” in the lives of domestic violence survivors. Throughout Michigan, despite limited funding, thousands of domestic violence survivors are housed in local shelters which we supplied with personal necessities as well as small comforts. All too frequently, the women and children (sometimes even men) affected by domestic violence arrive at the shelters with only the clothes on their backs. For “SAVE Today,” county Alliances across the country worked with their school districts to distribute the AMAA’s elementary-age booklets, such as “Hands Are Not For Hitting” (in the form of placemats as well as books), “I Can Choose”, and “You Can Handle Bullies.” These booklets have reached millions of children throughout the U.S. Accompanying teacher guidelines provide suggestions for using the books. Other “SAVE Today” activities, in addition to support for domestic violence shelters, included mentoring programs for the prevention of child abuse, physician education on domestic violence, distribution of teen and adult safety cards, and mental health screenings at health fairs and schools. Equally dark and evil, another form of violence is human trafficking. The Genesee County Alliance first brought attention to human trafficking in Michigan several years ago. Today, they continue to build

awareness of this increasingly severe problem, particularly with regard to slave labor and sexual exploitation. The Alliance, together with county and state medical societies, is working on educating physicians to identify and get help to victims of human trafficking. Finally, various local projects managed by Michigan county Alliance members have received recognition from the national AMA Alliance during the past couple years. Examples include: • Kent County Medical Society Alliance’s “Children’s Charity Ball” – First place, AMA Alliance Health Awareness Promotion Fundraising County Award • Genesee County Medical Society Alliance’s program to build awareness regarding human trafficking in Michigan – Honorable Mention, AMA Alliance Health Awareness Promotion (HAP) Award • Tri-County Medical Society Alliance’s “Deciphering Fact & Myths About Childhood Immunization” booklet – Honorable Mention, AMA Alliance Health Awareness Promotion New Projects Award • Kent County Medical Society Alliance’s “Immunization Conference” – First Place, AMA Alliance Legislative Education & Awareness Promotion Award The Alliance is indeed proud of the work that has been done on behalf of all victims of domestic abuse through the “SAVE Day” initiative and “Doctors and Their Families Make a Difference in Michigan Day”. Thank you for your attention and support.

MANDATORY USPS STATEMENT OF OWNERSHIP, MANAGEMENT, AND CIRUCLATION

Volume 114 • No. 6

MICHIGAN MEDICINE

Patients trust you. You can trust Kerr Russell. A successful practice requires more than talented individuals and a desire to heal. Let Kerr Russell provide the legal insight needed to manage and grow your business. ENTITY FORMATION • BUSINESS MATTERS • EMPLOYMENT CONTRACTS • PURCHASE / SALE OF OWNERSHIP INTERESTS • MALPRACTICE AND ALL OTHER COMMERCIAL LITIGATION • APPEALS • MEDICAL STAFF PRIVILEGE DISPUTES HOSPITAL RELATIONS RELATIONS MATTERS MATTERS • • HEALTHCARE HEALTHCARE FRAUD FRAUD DEFENSE DEFENSE • • LICENSING LICENSING AND AND OTHER OTHER REGULATORY REGULATORY MATTERS MATTERS HOSPITAL

T R U S T E D

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For more information, please contact: Daniel J. Schulte dschulte@kerr-russell.com Patrick J. Haddad phaddad@kerr-russell.com

500 Woodward Avenue, Suite 2500 Detroit, Michigan 48226 T: 313.961.0200 / F: 313.961.0388

Established 1874

MICHIGAN MEDICINE

W W W.KERR - RUSSE LL .COM

November / December 2015

Fall/Winter 2015 Education Course Offerings If you have questions need more information, or to register for a webinar, conference or program please CLICK www.msms.org/eo or CALL the MSMS Registrar at 517-336-7581.

Educational Conferences  Health Literacy and Its Daily Impact: Lunch-and-Learn Webinar

Date: Wednesday, November 11, 2015 Time: 12:15 pm - 1:00 pm Presenter: Nickell M. Dixon, DrPh, MPH, Health Equity Initiative Coordinator No cost, but registration is required. Registrants will be sent an email with the webinar link and call-in instructions prior to the event.

 19th Annual Conference on Bioethics: Ethical Issues in Neonatal and Pediatric Care Date: November 13-14 Time: Friday, November 13, 5:30 – 8 pm; Saturday, November 14, 8 am – 5 pm Location: The Sheraton, Ann Arbor Dinner on Friday; continental breakfast and lunch on Saturday will be provided

Intended for: Physicians, executives, office administrators and staff, and other health care professionals

Intended for: Physicians, bioethicists, residents, students, other health care professionals, and all individuals interested in bioethical issues

Contact: Trish Keast at 517-336-5734 or tkeast@msms.org.

Contact: Caryl Markzon at 517-336-5755 or cmarkzon@msms.org.

Recruiting is hard work. We can help. Medical Opportunities in Michigan connects Physicians, Physician Assistants & Nurse Practitioners with Michigan’s healthcare employers. Private practice memberships begin at $500.

MOM is a service of the Michigan Health Council

800-479-1666

miMOM.org

 Compliance Essentials for Everyday Practice Date: Wednesday, November 18 Time: 9:00 am to 4:00 pm Location: MSMS E.L. Headquarters Continental breakfast and lunch will be provided

Intended for: Physicians, executives, office administrators and staff, and other health care professionals, Contact: Caryl Markzon at 517-336-5755 or cmarkzon@msms.org.

On-Demand Webinars  Physician Executive Development • Health Care Law for Physicians in ACO’s • Medicaid Issues and Trends: Outlook for 2014 and Beyond • In Search of Joy in Practice: Innovations in Patient Centered Care • From Physician to Physician Leader • Inter-Professionalism: Cultivating Collaboration • Financial Information Analysis, Budget Development and Monitoring  Choosing Wisely  Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction  CDL-Medical Examiner Course  Legalities and Practicalities of HIT • Cyber Security: Issues & Liability Coverage • Engaging Patients on Their Own Turf: Using Websites and Social Media  Summary of the Affordable Care Act  HIPAA Security Rule  End of Life Concerns & Considerations  Labor & Employment Law: What’s New?  Preparing for the Medicare Physician Value-Based Payment Modifier  Understanding and Preventing Identity Theft in Your Practice  Stepping Up to Stage 2  Physician On-line Rating and Reviews: Do’s and Don’ts  Patient Portals as a Tool for Patient Engagement Visit www.msms.org/eo for complete listing.

Volume 114 • No. 6

MICHIGAN MEDICINE

November / December 2015

Volatility: Friend or Foe? BY NICOLE GOPOIAN, JD, CFP®

tock market volatility is a normal part of investing. But with the flood of mixed messages from the media, it can be difficult to determine if volatility is good or bad…

For example, a 10% drop in the market is generally considered a correction, which historically occurs once per year. Although this is a common occurrence, every media outlet you turn to - whether it’s TV, newspaper, or internet - creates hysteria about it and surrounding the possibility of a recession. It’s easy to be swayed by the gloom and doom outlook. Our brains sense fear and then hysteria ensues. The fact of the matter is that no one knows if the market will rebound or continue to fall. The reality is that volatility can be your friend or foe. It really depends on your circumstances. The chart below illustrates the historical frequency of declines in the market, expressed by percent drawdown. It also shows how long it typically takes for the market to recover from the drop. Volatility is part and parcel of investing in the market.

When Volatility is Your Friend In the accumulation phase of your life, you’re (hopefully) saving in a systematic fashion. Perhaps through salary reductions to a retirement plan or automatic contributions to an IRA or a taxable account, like a trust. If you’re smart, then you’re taking advantage of all options in your high income years. In volatile markets, the automated savings function increases the likelihood you will continue to make these contributions. This has advantages. It makes you buy low. When the market swoons you purchase more shares with your fixed contribution. Volume 114 • No. 6

Drawdown Threshold 20% 10% 5% 3% 2%

HIstorical Frequency Once per Market Cycle Once per Year Once per Quarter Once per Month Often

Typical # per year 0 1 4 11 18

Typical Recovery Time 20 Months 8 Months 2 to 3 Months 2 to 6 Weeks 1 to 4 Weeks

Source: Standard & Poor’s, FactSet, J.P. Morgan Asset Management. Returns are based on price index only and do not include dividends. For illustrative purposes only. *Analysis based on each type (size) of drawdown being independent. For example, the market does not typically see four 5% drawdowns and one 10% drawdown in the same year, but rather those 5% drawdowns may compound into a single 10% drawdown for the year. Data are as of 1/31/15.

When you’re in the accumulation phase of your life, you generally have employment income to support your lifestyle. You will probably not need to take distributions from your investments for awhile. You’re more likely able to tolerate the swings in the markets in anticipation of higher, longterm returns. Volatility is good. It helps fuel growth.

When Volatility is Your Foe When you’re in (or nearing) the distribution phase of your life, volatility becomes your foe. You may need to draw regular income from your investment portfolio to create a retirement “paycheck.” Volatility can harm your portfolio if you’re taking distributions and depleting capital during down markets. Your withdrawal compounds the effects of the loss and means you’ll have to achieve even higher gains to return to the original value of your investment before the loss occurred. What can you do to manage volatility in retirement? An appropriate cash distribution strategy with an adequate reserve will allow you to have a stable base of assets to draw from during volatile or bear markets. When markets are higher and outperforming, you should sell to add to your cash position. When markets are down, this strategy allows you to use your reserves instead of selling securities. MICHIGAN MEDICINE

It’s important to review your mix of stocks versus bonds to confirm they are aligned with your appetite for risk and phase of life. For example, as you near retirement your willingness to take on risk will likely decrease. No one knows which asset classes are going to perform best year to year. A globally diversified, multi-asset class portfolio that is aligned with your risk tolerance hedges volatility. You should reevaluate your risk target annually as you update your financial plan.

The Long View It’s important not to lose sight of the long view during market volatility. Investors should understand what phase of life they’re in and develop a plan to either embrace volatility or mitigate its effects. Reviewing your financial plan to make sure that your investment strategy is coordinated with your goals will provide clarity during turbulent times.

Nicole Gopoian, JD, CFP® is an advisor at WealthCare Advisors, LLC – an MSMS joint venture.

T H E

M A R K E T P L A C E

Would You Like To Place A Classified Ad? The rate for classified advertising in Michigan Medicine, including both print and online versions, is $1.60 per word, with a minimum of $65.00. All ads must be prepaid. Text for classified advertisements and advertising fee should be received no later than the first of the month proceeding the month of publication. All submitted ads must be typed. No handwritten or dictated ads will be accepted. To place an ad call Carl Mischka at 888-666-1491 or email carl@mischka.us.

Orthopedic Surgeon and/or Neuro Surgeon

January/February issue of Michigan Medicine closes December 8th! Reserve your space today.

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Recruiting Physician

Primary Care Opportunity

Private solo practice in rural Perry seeks new

TRAVERSE CITY, MI

provider to assist ill Owner/Provider. I am no longer able to continue independent full-time services to my busy family practice. Good EHR infrastructure for 15 years. Excellent, loyal, proficient support staff for 10-25 years. Good payer mix with low Medicaid and self-pay patients. Easy call and good hospitalist coverage. Large catchment area near I-69 Exit so pull from rural Owosso, Lansing and Flint. May be good opportunity for new or retiring family doc or specialist to practice centrally. Multiple business models considered. Contact: If interested contact John Behm, D.O. or Kim King, 6980 South M-52, Owosso, MI 48867. Call office 989-729-9766, cell 517-290-2248 or 989-413-0966.

week for a Pain Center in Warren. Generous compensation.

Excellent opportunity to join a busy well-established ambulatory Internal Medicine practice in beautiful Traverse City, Michigan. We are a team based practice committed to improving our patient’s healthcare experience with the patient an integral part of the process. A Patient Centered Medical Home since 2011 and recipient of numerous awards including Priority Health Quality Award multiple consecutive years and BCBS Provider Distinction Award 2013 and 2014. eClinicalWorks since 2009. Interactive website for patients to log in to their patient portal, download forms and get updated clinic information. Healow app available for iPhone and droid users. We offer an experienced team, on-site lab, flexible schedule with a competitive salary and partnership opportunity in 2 years. Contact: Beth Mutter, Practice Manager, at 231-935-0850, ext 11 or email manager@gtinternists.com

MICHIGAN MEDICINE

November / December 2015

Family Practices n Allen Park: Retired Orthopedic Surgeon offering turn key operation. Full PT Lab, receive patient files, lots of potential for a very low price asking $50,000. n East Pointe Primary Care: Near I94 and Kelly Road. 3 Exam rooms, 2 year old practice. Asking $60,000 includes equipment/goodwill and transition. Real estate available. n Farmington Hills: Long established Internal Medicine Practice, 10 Mile/Middlebelt area. Free standing building, 5 exam rooms, lab, x-ray. Very close to Botsford, St. Maryâ&#x20AC;&#x2122;s, and Providence Novi. Asking $175,000 for practice. n Garden City Internal Med Practice: Long established, majority of patients Medicare. Fully equipped, grossing in excess of $200,000 annually. Asking $70,000. n Mexican Town Detroit: 20 year old Primary Care Clinic. Staff is fluent in multiple languages. Seller financing available, priced to sell, work as you pay terms. Never in 25 years have I had the opportunity to offer more flexible terms. Price reduced to $589,000 for everything including real estate. n Lincoln Park: Walk-in clinic. Very visible, long established, seeing approximately 40 patients daily. Approx. gross income $800,000. Asking $250,000 for practice and $350,000 for real estate. n Podiatry Practices Detroit: 2 locations, very successful, grossing in excess of 600,000 annually. Fully equipped. Asking $300,000 for both locations. Real estate available. n Westside Detroit, Primary Care Practice: Established 2005, grossing in excess of $500,000 annually. Fully equipped. Asking $200,000 owner wants to retire.

Medical Buildings For Sale or Lease n Pontiac: Large professional medical building. Three story, suites 5005,000 sq. ft. Across from hospital, acres of parking. VERY REASONABLE rates/terms or buy building for $250,000. n West Side Detroit: 8,000 square feet, multi suites, fully leased. $60,000 pos. cash flow excellent. Brick, single story asking $500,000 or lease for $1.00 square foot plus utilities.

For more details contact our practice specialist at Union Reality:

Joe Zrenchik, Broker 248-240-2141 (cell) joezrenchik@yahoo.com 248-919-0037 (office) Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.

Volume 114 â&#x20AC;˘ No. 6

MICHIGAN MEDICINE

MICHIGAN • ILLINOIS • OHIO • TEXAS • LOUISIANA

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MICHIGAN MEDICINE

November / December 2015

Welcome New MSMS Members! Salisu Aikoye, MD Saginaw Mohammed Makki Aldawood, MD Saginaw Hassan Alosh, MD Kent Bishr Al-Ujayli, MD Oakland Jacqueline Appiah, MD Wayne Leonard Aronovitz, DO Oakland Berny Bastiampillai, MD Saginaw Clint Bernhard, MD Wayne Chad Bertucci, MD Muskegon Shivani Bhutani, MD Saginaw Thomas Bills, MD Saginaw Maura Bradley, MD Wayne Christine Brenner, MD Wayne Elisabeth Brodeur, MD Saginaw David Burdette, MD Wayne Helen Byrd, MD Wayne Christopher Chambers, MD, PhD Kent Yiling Chang, MD Washtenaw Jacquelyn Charbel, DO Saginaw Kathleen Chauvin, MD Calhoun Maryam Davari, MD Saginaw Peter Dews, III, MD Wayne Megan Dutcher, DO Saginaw Almohanad Eidah, MD Saginaw Ruaa Elteriefi, MD Wayne Kelly Fitzgibbons, MD Wayne Sonia Geschwindt, MD Marquette Joseph Giannola, MD Wayne Christopher Goltz, MD Genesee Paul Goyt, MD Saginaw

Volume 114 • No. 6

Smitha Gudipati, MD Saginaw Srinandan Guntupalli, MD Saginaw Mark Hake, MD Washtenaw Trina Hara, MD Saginaw Donna Harold, MD Kent Patrice Harold, MD Wayne Nina House, MD Saginaw Mihai Iliesiu, MD Macomb Michael Jacobs, MD Oakland Robert Jarve, MD Kent Christine Jones, DO Wayne Mark Karadsheh, MD Oakland Lauren Kershnar, MD Saginaw George Kikano, MD Saginaw Tina Kinsley, MD Wayne Maribeth Knight, DO Wayne Jessica Lancaster, MD Saginaw Rita Lang, DO Genesee Ashley Lopez, MD Saginaw Zachary Love, DO Kent Stephanie Mager, MD Saginaw Jamuna Manoharan, MD Saginaw Mark Mattos, MD Genesee Asad Mehboob, DO Saginaw Michael Mills, MD Ingham James Moravek, Jr, MD Washtenaw Mary Mullins, MD Saginaw Vamsee Mupparaju, MD Saginaw Iquo Nafiu, MD Washtenaw Davorka Nikolic, MD Macomb

Mark Oppenlander, MD Washtenaw Louis Ostola, MD Marquette/Alger Scott Owens, MD Washtenaw Navneet Panesar, MD Saginaw Dhara Patel, MD Saginaw Yannis Paulus, MD Genesee Elizabeth Paulus, MD Saginaw Niharika Perni, MD Saginaw Evgenia Polosina, MD Saginaw Priya Punnoose, MD Saginaw James Putnam, MD Saginaw Jan Rajlich, MD Kent Rex Roda, MD Saginaw Susan Sauber, MD Oakland Jordan Schaefer, MD Washtenaw Matthew Schram, DO Kent Daniel Schroyer, MD Kalamazoo Veronica Sesi, DO Macomb Ala Shuker, MD Wayne Smit Singla, MD Genesee Stacy Smith, MD Wayne Ronak Soni, MD Saginaw Mark Stacherski, MD Wayne Philomina Thomas, MD Wayne Byron Thompson, MD Washtenaw Jared Toupin, MD Saginaw Sarine Trochakerian, MD Saginaw Amanda Waterman, MD Saginaw Eden Wells, MD, MPH, FACPM Washtenaw Fakhar Zaidi, MD Saginaw

MICHIGAN MEDICINE

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P R E S I D E N T ’ S

P E R S P E C T I V E

Winter Refocus: ICD-10, the Medical Team and Gun Safety BY ROSE RAMIREZ, MD

s we celebrate our 150th anniversary of the Michigan State Medical Society, we reflect on our history and think about the future. Then… we refocus on the work we are about today.

In this issue of Michigan Medicine, I want to touch on three areas: ICD-10, staff recruiting and retention and gun violence. ICD-10 is now the official medical coding system of the United States. We are late to the game compared to many other countries in the world The World Health Organization, the public health sector of the United Nations, which focuses on international health and epidemics, began work on the tenth edition of the International Classification of Diseases (ICD-10) coding system nearly 30 years ago in 1983. It took almost a decade before the new classification system was complete. Some countries began adoption of ICD-10 before 2000. It was finally, in 2008, when the United States Department of Health and Human Services proposed that medical professionals use ICD-10 for reporting diagnoses and procedures on healthcare transactions. It has taken seven years for that to become a reality. Oct. 1, 2015 has come and gone. I hope your day was as uneventful as mine. The many tools, videos and educational programs available from MSMS and other organizations have helped us prepare for this change to ICD-10. In addition to the many CME offerings, I appreciate the work MSMS has done to make physician and practice education a valuable part of our organizations mission. In this issue of Michigan Medicine, we’ve highlighted two physician-led teams and the importance of developing all members of our teams to provide the highest quality and safest care for our patients. As a small practice owner, I think it requires creativity to recruit excellent new staff members. I often ask my current staff if they have a friend or acquain34

tance that is looking for a position. That being said, it is critical to hire someone who has the right skill set or education for a particular job. We have used MLive, Craigslist and other online tools to recruit for an open position. During the interview process, we have used medical knowledge tests to quantify a recruit’s fund of knowledge. Comfort using computers and keyboard agility are also important skills to assess. One other option we offer is the opportunity to come in and job shadow to see if they like our office, which gives us the option for a second look. It is essential that the potential new hire shows interest by engaging with our staff and asking a lot of questions. Once we have hired someone to join our team, we work hard to make this person feel welcome. We usually choose one of our seasoned workers to do the training and take a flexible approach to length of orientation. When our new employee demonstrates competence in a prioritized list of skills, we will continue to mentor them and encourage them to assume additional responsibility. As an integral part of our culture, we look at mistakes as an opportunity to learn. The last thing we want is for mistakes to be hidden. Sometimes, a mistake will highlight a need for more training, but more often, it reveals a broken process. Only by highlighting the process problem and looking for solutions are we able to take this learning to promote safety and higher quality. Retaining the best people requires paying them appropriately, but more importantly, we must demonstrate fair and equitable treatment of all the staff members. One way to kill morale is to show favoritism to a person or persons. As leaders in our practices, it is our role to create environments that have MICHIGAN MEDICINE

excellent communication, build camaraderie, demonstrate respect for each other and proactively nurture our staff to prevent burnout and attrition. One last topic that I want to touch on briefly is gun violence. I realize this is a very sensitive issue and has also been described as a proverbial third rail. However, we have just had another mass shooting in our country (Oregon) and it is increasingly disturbing to me that we are not doing more about addressing this problem. I have pulled our MSMS policy from our policy manual as a reminder of the position our Society has taken on gun violence.

REDUCTION OF GUN VIOLENCE MSMS supports federal and state legislation ensuring that physicians can fulfill their role in preventing firearm injuries by health screening, patient counseling on gun safety, and referral to mental health services for those with behavioral/emotional medical conditions and supports federal and state evidence-based research on firearm injury and the use of state/national firearms injury databases to inform state/federal health policy. (Res78-13) The National Physician Alliance has an excellent 20-page booklet titled “Gun Safety & Public Health, Policy Recommendations for a More Secure America:” http://bit.ly/GunSafety-PublicHealth. My intent is not to debate the Second Amendment to our U.S. Constitution, it is to highlight a real public safety issue and remind us of our unified position on the matter.

Doctor Ramirez, a Kent County family physician, is president of the Michigan State Medical Society

November / December 2015

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