Michigan Medicine, Volume 113, No. 6

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MichiganMedicine

November/December 2014 • Volume 113 • No. 6

As Narrow Networks Make Their Way to Michigan, Physician Leaders Consider Their Impact on Health Care Spending ALSO IN THIS ISSUE

• Engaging Patients in the Age of Meaningful Use • Hospital Collaboration Boosts System Quality, Patient Outcomes • Mandatory Flu Shots for Employees – Policy Implementation & Best Practices

MichiganMedicine November/December 2014 • Volume 113 • Number 6

COVER STORY 1 0 As Narrow Networks Make Their Way to Michigan,

Physician Leaders Consider Their Impact on Health Care Spending

By Pamela Lewis Dolan No longer able to control health care costs by medical underwriting, limiting benefits or denying coverage, in this post-Affordable Care Act (ACA) market, insurers are turning to another strategy to reel in health care spending: limited network plans, also know as narrow networks.

FEATURES 13 ICD-10 Preparation Starts Now Contributed by The American Medical Association The differences between ICD-9 and ICD-10 are significant and physicians and practice management staff need to start educating themselves now about this major change so that they will be able to meet the compliance deadline of October 1, 2015.

15 Hospital Collaboration Boosts System Quality, Patient Outcomes

It All Began with a Checklist

By Stephanie VanKoevering In 2001, a Johns Hopkins physician named Peter Pronovost began studying hospital-acquired infections, and determined that a simple checklist could prevent infections when inserting a central venous catheter. His work was validated right here in Michigan through the Keystone Initiative, which saved 1,500 lives and $100 million over an 18-month period.

16 Profile – Nick Lyon, Director of the Michigan Department

of Community Health

Nick Lyon is an example of strong leadership in action. He took the helm as Director of the Michigan Department of Community Health in mid-September after Director Jim Haveman announced his plan to retire.

17 DTaP Vaccination – It Takes the Full Series to Protect Children

With Michigan’s coverage rate at only 79.6 percent and pertussis disease on the rise, ensuring your patients receive all the recommended doses of DTaP vaccine on time becomes a critical part of daily assessment.

18 Mandatory Flu Shots for Employees

By Patrick J. Haddad More and more health care employers are requiring that all employees get the influenza vaccine in order to help protect patients and coworkers during flu season.

22 Year-End Planning Can Save You Time and Money

By Nathan Mersereau, CFP®, AAMS As the end of the year approaches, make sure your financial affairs are in order.

COLUMNS 2 Ask Our Lawyer By Daniel J. Schulte, JD

Are Compliance Programs Now Required by Law?

7 HIT Corner By Sylvia D. Roemer

Engaging Patients in the Age of Meaningful Use

8 Professional Liability Update By Julie Song, MPH, CPHRM

Should Physicians Friend or Unfriend Social Media? ‘It’s Complicated’

8 Medical Family Matters By Nancy Fody Alliance Update on Immunizations

28 President’s Perspective By James D. Grant, MD Our Babies Are Growing Up to be Doctors

DEPARTMENTS 14 New MSMS Members 21 MSMS Foundation Conferences 21 Obituaries 23 The Marketplace 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.

Executive Director JULIE L. NOVAK Committee on Publications LYNN S. GRAY, MD, MPH, Chair, Berrien Springs MICHAEL J. EHLERT, MD, Livonia THEODORE B. JONES, MD, Detroit BASSAM NASR, MD, MBA, Port Huron STEVEN E. NEWMAN, MD, Southfield 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 GRETCHEN CHRISTENSEN 2779 Aero Park Drive, Traverse City, MI 49686 888-822-3102, Fax: 989-892-3525 Email: gretchen@villagepress.com Design JOSEPH MCGURN, Village Press, Inc. Printing Village Press, Inc., Traverse City, MI Postmaster: Address Changes Michigan Medicine Hannah Dingwell PO Box 950, East Lansing, MI 48826-0950 Michigan Medicine, the official magazine of the Michigan State Medical Society, 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 Michigan State Medical Society 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 2014 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. © 2014 Michigan State Medical Society

A S K

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Are Compliance Programs Now Required by Law?

By Daniel J. Schulte, JD

QUESTION: Is it true that my practice now must have a compliance program? I always thought that these were a good idea but not required.

Has the law changed

ANSWER:

Not yet. Section 6401 of the Patient Protection and Affordable Care Act (the “ACA”) requires the U.S. Department of Health and Human Services (“HHS”) and the Office of Inspector General (“OIG”) to promulgate regulations that will make a compliance program mandatory for physicians/physician practices that participate with Medicare, Medicaid and other federal health care programs.

To date, HHS/OIG has not issued these regulations nor has an effective date for the compliance program requirement been established. Once the effective date has been established having a compliance plan will be an additional condition of participation in Medicare, Medicaid and other federal healthcare programs and the failure to have the required compliance program could result in exclusion from participation in these programs.

Currently, there is no law requiring a compliance program. Those that have them have done so voluntarily or in response to requirements in a third party payer, participation or similar agreements. However, it has always been considered a best practice for physicians to have an operating compliance program in their practice that addresses both compliance with government regulations (e.g. the Stark law, the Anti-Kickback Statute and other fraud and abuse laws) and third party payer billing requirements. Having and following a compliance program is an important part of your practice’s risk management process. Not having one will only lead to a greater likelihood of reimbursement disputes, demands for repayment, and fines and penalties being imposed for billing irregularities.

Having an operational compliance program will put your practice in the best position to establish that any billing 2

from acting now. HHS has announced that ACA Section 6401 compliance programs will be required to contain the following so called “core elements”: 1. Written policies and procedures including standards of conduct.

irregularity or other misstep was an inadvertent an unintentional error instead of a deliberate act or fraud. In recent years OIG has made the existence of an operational compliance program a significant factor when determining whether and to what extent to impose fines and penalties and whether or not to exclude physicians from federal health care programs.

2. Designation of a compliance officer.

It has always been

Although there is not yet a requirement by law that you have a compliance program, it has always been a best practice to implement and follow one. There is certainly enough information to go on to create a compliance program for your practice that contains all the “core elements” which it is known will have to be included when the ACA Section 6401 compliance program requirement takes effect. MM

considered a best practice for physicians to have an operating compliance program in their practice that addresses both compliance with government and third party payer billing requirements.

Because it is known that a compliance program will be required at some point by law for physicians participating with Medicare, Medicaid and other federal health care programs and because of the risk management benefits to be realized from having a compliance program (whether or not required) it would be wise to put one in place now, in advance of the effective date of the new requirement. The failure of HHS/OIG to issue regulations with the specific ACA Section 6401 compliance program requirements should not stop you MICHIGAN MEDICINE

3. Training and education.

4. Effective lines of communication.

5. Enforcement of the program’s requirement and publicizing disciplinary guidelines.

6. Regular monitoring and auditing.

7. Procedures for responding to detected offenses and, when necessary, the adoption of corrective action plans.

Daniel J. Schulte, JD, MSMS Legal Counsel, is a member of Kerr, Russell and Weber, PLC.

ED I T O R’ S NO T E: If you have legal questions you would like answered by MSMS legal counsel in this column, send them to: Kevin McFatridge, Michigan Medicine, MSMS, 120 West Saginaw Street, East Lansing, MI 48823, or at KMcFatridge@msms.org.

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Michigan State Medical Society the Voice of Michigan Physicians OFFICERS

DIRECTORS

President JAMES D. GRANT, MD, Oakland

District 1 MOHAMMED A. ARSIWALA, MD, Wayne PETER BAUMANN, MD, MPA, Wayne T. JANN CAISON-SOREY, MD, MSA, MBA, Wayne CHERYL GIBSON FOUNTAIN, MD, Wayne THEODORE B. JONES, MD, Wayne JAMES H. SONDHEIMER, MD, Wayne J. MARK TUTHILL, MD, Wayne District 2 AMIT GHOSE, MD, Ingham DAVID T. WALSWORTH, MD, Ingham District 3 JOHN J.H. SCHWARZ, MD, Calhoun District 4 STEPHEN N. DALLAS, MD, MA, Kalamazoo LYNN S. GRAY, MD, MPH, Berrien District 5 ANITA R. AVERY, MD, Kent DAVID M. KRHOVSKY, MD, Kent TODD K. VANHEEST, MD, Ottawa District 6 S. “BOBBY” MUKKAMALA, MD, Genesee JOHN A. WATERS, MD, Genesee District 7 BASSAM NASR, MD, MBA, St. Clair District 8 DEBASISH MRIDHA, MD, Saginaw THOMAS J. VEVERKA, MD, Saginaw District 9 RICHARD C. SCHULTZ, MD, Grand Traverse

President-Elect ROSE M. RAMIREZ, MD, Kent Secretary JOHN E. BILLI, MD, Washtenaw Treasurer VENKAT K. RAO, MD, Genesee Speaker PINO D. COLONE, MD, Genesee Vice Speaker RAYMOND R. RUDONI, MD,Genesee Immediate Past President KENNETH ELMASSIAN, DO, Ingham

B OA R D OF DIRECTORS Chair DAVID A. SHARE, MD, MPH, Washtenaw Vice Chair S. “BOBBY” MUKKAMALA, MD, Genesee

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District 10 MARK C. KOMOROWSKI, MD, Bay District 11 JAMES J. RICE, MD, Muskegon District 12 CRAIG T. COCCIA, MD, Marquette District 13 JEFFREY E. JACOBS, MD, Houghton District 14 SANDRO K. CINTI, MD, Washtenaw JAMES C. MITCHINER, MD, MPH, Washtenaw DAVID A. SHARE, MD, MPH, Washtenaw District 15 ADRIAN J. CHRISTIE, MD, Macomb BETTY S. CHU, MD, MBA, Oakland SCOT F. GOLDBERG, MD, MBA, Oakland MICHAEL A. GENORD, MD, MBA, Oakland DONALD R. PEVEN, MD, Oakland DAVID P. WOOD, JR., MD, Oakland Ex-Officio EDWARD G. JANKOWSKI, MD, Wayne F. REMINGTON SPRAGUE, MD, Muskegon Young Physician PAUL D. BOZYK, MD, Wayne Resident MICHAEL J. EHLERT, MD, Wayne Student NICOLAS K. FLETCHER, Kent

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Engaging Patients in the Age of Meaningful Use

By Sylvia D. Roemer

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here is no denying that patient engagement continues to be one of the most discussed topics

in health care today. When patients establish a purposeful relationship with their medical providers and are given the tools and opportunities to manage their own care, the result most often is improved quality, safety, efficiency and most importantly, improved outcomes. All of these objectives are the key goals found within the Meaningful Use incentive program.

Many physicians who have embraced medical technology by adopting an electronic health record (EHR) and are participating in either Stage 1 or Stage 2 of Meaningful Use, have discovered that reporting requirements go beyond the documentation of clinical measures such as vital signs or problem lists within the EHR. Providers are expected to utilize their EHR technology to actively engage their patients by way of two Meaningful Use core requirements: patient portal and secure messaging.

Although for merly considered an optional Meaningful Use menu measure, patient electronic access has now shifted to a Meaningful Use core requirement for those attesting under 2014 Certified Electronic Health Record Technology (CEHRT). For 50 percent of all unique encounters during the reporting period, the goal is to “provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the eligible provider (EP).” Additionally, for providers attesting to Stage 2, there is a second part to this measure where 5

percent of those unique patients must actively utilize the portal by viewing, downloading or transmitting their health information.

However, the patient engagement requirements don’t just end there for providers. A second Meaningful Use core requirement, known as secure messaging, states that “a secure message was sent using the electronic messaging function of the CEHRT by more than 5 percent of unique patients (or their authorized representative) seen by the EP.” Simply put, a patient must send a message to their provider through one or more safeguarded modes of electronic communication which include an online patient portal.

It is easy to make the portal readily available to every patient, but the most significant obstacle facing providers in meeting these two core Meaningful Use requirements involves its actual usage, which many providers believe to be outside of their control. A recent article published by EHR Intelligence indicated that nearly 33 percent of patients were unaware that portal technology even existed. Patient education by provider and staff can help correct this problem.

Sharon K. Geimer, MD, of Riverbend Health Care in Sterling Heights has had success with implementing her portal.

“The accessibility of a portal can be a real draw with its many benefits. We encourage our patients to explore its functionality and communicate with us at their convenience,” says Doctor Geimer. A few key words from the provider to the patients or their family can have a significant impact when promoting the portal.

Contrary to the common belief that seniors dislike utilizing a patient portal, an EHR Intelligence survey found that many actually enjoy the convenience that a portal offers. When limited mobility is a concern, scheduling multiple

appointments, refilling prescriptions for multiple medications and communicating directly with their provider via a portal is a convenience they value.

Younger patients utilize portals for different reasons, such as obtaining clinical lab test results. Regardless of patient demographics, it is important for providers to clearly, consistently and enthusiastically communicate the benefits of the portal to every one of their patients.

Once portal activity has been established with patients, it is important to keep the momentum building by addressing some of the common complaints expressed by patients. A survey conducted by Software Advice found that: • 34 percent of staff were unresponsive to patient requests and inquiries • 33 percent of patients found navigating through the portal confusing • 22 percent of patients indicated automatic emails to be an annoyance • 11 percent of patients didn’t understand the notes and thought they were written in medical jargon As with any new journey, it is important to remember that successful integration of patient engagement and technology won’t happen overnight. As we all adapt to the increasing levels of patient engagement required by EHR incentive programs, it is imperative that all staff be educated about effective communication strategies and timely, helpful responses to patient inquires that arrive through the portal. It will require patience and determination from both providers and their staff coupled with cooperation from their patients to successfully achieve mutual health care goals. MM The author is Project Manager for MPRO, Michigan’s Quality Improvement Organization (QIO-QIN).

MPRO Consulting offers contract services for CMS incentive programs, such as Meaningful Use, Physician Quality Reporting System (PQRS), as well as EHR selection and optimization, medical and utilization review, health care data analysis, needs assessments and informal dispute resolution. In addition, MPRO partners with local colleges to teach quality improvement classes. For over 30 years, MPRO has served as the federally- designated quality improvement organization (QIO) for Michigan under contract with the U.S. Centers for Medicare & Medicaid Services (CMS) and is a nationally recognized leader in health care quality improvement. For more information, please contact Sylvia Roemer at sroemer@mpro.org or at 248-465-7420, or visit MPRO’s website at: http://www.mpro.org/.

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Should Physicians Friend or Unfriend Social Media?

‘It’s Complicated’

By Julie Song, MPH, CPHRM, Patient Safety Risk Manager, The Doctors Company

S

ocial media can be a tool to motivate patients to be more active participants in

their healthcare. However, because of confidentiality rules in the Health Insurance Portability and Accountability Act (HIPAA) and potential medical-legal repercussions, the medical community must be cautious when engaging with social media. Healthcare is a profession that is dependent on establishing trust and credibility – and social media has the potential to undermine a strong reputation built over years with one careless post or tweet.

With the limited time that physicians have to spend with patients in the exam room, interacting with patients through social media might be seen as a way of strengthening the physicianpatient relationship. However, liability can result from blurring professional and personal boundaries. In a profession where objectivity is paramount, having a personal relation-ship with the patient may compromise professional judgment.

Communication with patients either directly or en masse through social media may also lead to HIPAA violations if protected health information (PHI) is revealed online. PHI in electronic form must be encrypted to ensure security, but the majority of social media platforms are not capable – posting just a few distinguishing characteristics, which might enable another person to figure out the identity of the patient, could be enough to be a violation in itself.

The Federation of State Medical Boards specifically discourages physicians from “interacting with current or past patients on personal social networking sites such as Facebook.”* The American Medical Association strongly suggests that physicians distinguish their public and professional digital identities.

8

Even if the physician is aware of the privacy and security concerns with social media, staff training is important.

A physician’s staff could incur liability on behalf of the practice through unprofessional social media activities that portray patients or the practice in a poor light. Ensure that there is a social media policy that is reviewed with all staff members on an annual basis. The social media policy should discourage employees from engaging with patients on social media and also should require that employees not mention patient-related matters on their personal social media sites.

Social media can also create confusion about when the patient-physician relationship is established. Traditionally, the relationship did not begin until the patient presented for an office visit and a full-faith examination occurred. However, there are certain social media sites where patients post medical questions about the symptoms they are experiencing. If the physician responds in a manner that may be construed as providing medical advice, a patient-physician relationship may be established. To further complicate matters, if the potential patient is in a different state than the physician, the interaction could be construed as practicing medicine without a license in the state where the patient resides.

There is significant variation among state jurisdictions regarding licensing, and the standard of care/scope of practice is determined by the location of the patient, not the location of the physician.

Certain social media sites are intended to facilitate discussions between physicians to share knowledge and information.

The potential for collaboration through social media is vast, and the speed of technology is faster than the legislation that regulates it. Therefore, as a peer or colleague participating in these collaborative forums, each physician should provide a disclaimer that states that the commentary is not to be considered a consultation. HIPAA confidentiality applies when presenting a case or posting a patient scenario, so be sure to sanitize the details of the case to protect the identity of the patient.

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With the sophistication of search engines, any commentary posted online can be permanent and searchable. Online communication can be discoverable and can be used against the physician in the event of a malpractice lawsuit. Ultimately, the physician’s online presence can also be used to establish character or lack of judgment.

Some of the early adopters of social media have used it as an effective marketing tool and have taken a proactive approach by hiring marketing directors to expand their online presence. However, HIPAA rules require an individual’s written authorization before using his or her information for marketing.

Additionally, any potential conflict of interest must be fully disclosed, including whether the physician received any form of compensation for mentioning the product or services.

There is no easy answer to whether a physician should use social media, or how a physician should use social media.

The issue is complicated and should be evaluated on a regular basis. MM The Doctors Company is the exclusively endorsed medical liability carrier of the Michigan State Medical Society (MSMS).

We share a joint mission of supporting doctors and advancing the practice of good medicine. *Federation of State Medical Boards Special Committee on Ethics and Professionalism. Model policy guidelines for the appropriate use of social media and social networking in medical practice. http://www.fsmb.org/Media/Default/PDF/FSMB/ Advocacy/pub-social-media-guidelines.pdf.

Accessed October 6, 2014.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

A longer version of this article originally appeared in Contemporary Oncology, November 2014.

For More Information For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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As Narrow Networks Make Their Way to Michigan, Physician Leaders Consider Their Impact on Health Care Spending

N

By Pamela Lewis Dolan

o longer able to control health care costs by medical underwriting, limiting benefits or denying coverage, in this post-Affordable Care Act (ACA) market, insurers are turning to another strategy to reel in health care spending: limited network plans, also know as narrow networks.

Narrow networks existed before the ACA, primarily in the form of Health Maintenance Organization (HMO) plans. They dropped out of favor for several years, but are making a comeback.

They save money for consumers by offering low monthly premiums in exchange for a limited number of options in health care providers. Some insurers can save money by offering physicians more volume in exchange for discounted rates. Physicians and hospitals are selected to join based on cost and quality criteria.

Michigan-based physicians may not have seen much of an impact from narrow networks in 2014. But that’s likely to change.

There will be many physicians who are forced to pay attention to the growing trend next year, especially those who are left out, said Robert Jackson, MD, a family physician in Allen Park and a Michigan Academy of Family Physicians board member.

Early reports find patients are generally happy with narrow network plans since they offer an affordable option for insurance coverage. But that satisfaction comes with the caveat that they get accurate information on things such as in-network provider lists.

Without an absolute definition of narrow network, pinning a precise number to the share of health plans that are narrow is not an exact science. But data show consumers are more likely to choose lower-cost options when shopping on the insurance exchanges.

A June report by McKinsey and Company, a global management consulting firm, found across the country, close to 70 percent of the lowest-priced products on the 2014 exchanges were built around narrow, ultra-narrow, or tiered networks.

Rhonda Fossitt, senior deputy director of the Michigan Department of Insurance and Financial Services, said while she cannot provide specific numbers, it appears about 15 percent of the products being offered on the Michigan insurance exchange for 2015 would be considered narrow network plans. “It’s greater than in 2014,” she said.

Because of the good relationship between organized medicine – particularly the Michigan State Medical Society – and the payer community in Michigan, physicians have long been involved in activities that have the same aim as narrow networks: improving quality and lowering costs, Doctor Jackson said.

“When you have physicians that are more engaged in these things there’s less need to do something 10

like this to get their attention,” he said, explaining why narrow networks were likely slow to catch on in Michigan. But the desire to make insurance more affordable to consumers has led to more plans offering them.

Little Pushback From Consumers An analysis of narrow network plans in six states published in September by the Robert Wood Johnson Foundation (RWJF) found there wasn’t much pushback from consumers about the plans. At least not compared to the pushback employers got in the 1990s as a result of the rise in HMO plans.

One reason there may be little pushback, said Richard Gundling, FHFMA, CMA, vice president of the Healthcare Financial Management Association, is that unlike the HMO plans, which employers chose, this time the plans are being selected by the individuals themselves through the marketplace. Those decisions are financially motivated based on what the customer can afford and what they are willing to give up for the lower cost.

The McKinsey and Company report, “Hospital Networks: Updated National View of Configurations on the Exchanges,” found that compared with narrow network plans, products with broad networks had a median increase in premiums of 13 to 17 percent; the maximum increase was 53 percent.

McKinsey’s survey found 42 percent of the respondents who were aware of the type of network they would be getting with their chosen plans purchased a narrow network product. Twenty-six percent did not know the network type they chose.

Some are predicting that as consumers get a better feel for the insurance plans they bought, the backlash may increase for the same reasons some in organized medicine are concerned.

“We will see more discussions about narrow networks,” Gundling predicted. “As more and more people get into the exchanges … when it’s time for the treatments they may want, it may not be the provider that they want or something else, you’ll see much more pushback.”

Network adequacy is an issue that several state societies have focused on. It refers to a health plan’s ability to create a network that has a sufficient number of providers and will allow patients to access services within a reasonable amount of time.

States can decide how, specifically, adequacy is defined.

Fossitt said in Michigan, regulators look at factors such as whether the plan members are in rural or urban areas and what the drive time to the closest primary care physicians and specialists would be.

Greater than the issue of network adequacy, however, is the issue of

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network accuracy, said Katherine Hempstead, PhD, director of coverage for the Robert Wood Johnson Foundation.

“We know that…when people are asked what kind of tradeoffs they are willing to make, a lot of consumers indicate they are willing to trade off access to fewer providers in exchange for lower premiums. So I don’t think consumers are allergic to the idea of narrow networks,” Hempstead said.

But they have to be clear on what they are buying, she added.

“Whenever consumers are surprised after they purchase something; When they think they are going to get something and they find out they didn’t get what they thought they were going to get, that’s always bad,” Hempstead said. In 2014, many consumers based their purchasing decisions on outdated physician directories.

Because providers fall into and out of networks and contracts with payers on a continual basis, physician directories are really living documents. And keeping them updated in real-time has proven to be a challenge.

At its interim meeting in November, the American Medical Association adopted policy that calls on insurers to ensure that any provider terminations made without cause are done prior to the enrollment period so that patients will know if care provided by their existing providers will be covered by their new plans.

“Inaccurate or late revised provider directories are leaving patients stuck with plans that dropped their physicians after they enrolled,” the AMA said in a news release. And new enrollees, according to the organization, “deserve to have an honest look at their coverage options – including the physicians, hospitals and medications they will have access to as well as cost-sharing so that they can make an informed choice.”

Fossitt said her office received a number of complaints over the past year from patients confused about what they bought on the insurance exchange. She said few were aware of the term “narrow network” but called to say they thought certain doctors were part of the plan only to later find that they were not.

Unintended Consequences Regardless of whether switching physicians is a tradeoff patients are consciously making or if it’s an unintended consequence of their plan choice, some physicians are concerned about the disruption it may cause.

“As a physician, it’s hard,” said Dennis Ramus, MD, a family physician in New Baltimore who sits on the MSMS Third Party Payers Committee. “You have patients you may have had for 20 years and your name isn’t on the list [of the narrow network] and they have to leave you.”

Not only is the change hard from an emotional standpoint, but the quality of care can also suffer as a result, said Robert Wergin, MD, a family physicians in Milford, Nebraska, and president of the American Academy of Family Physicians (AAFP). Numerous studies have shown that team-based care with one team and one consistent provider leads to better care and lower costs, he said.

The potential problems came to light about a year ago when UnitedHealthcare announced it would be “optimizing” its market in Connecticut and approximately 2,200 physicians would be dropped from its Medicare Advantage program. This caused a political firestorm because the decision came after President Obama pledged that patients would be able to keep their doctors after the Affordable Care Act was implemented.

The AAFP and others sent letters asking the plan to reconsider.

Connecticut’s Fairfield County Medical Association and Hartford County Medical Association filed suit against United over the Volume 113 • Number 6

matter. The two sides later reached an agreement to end the suit.

Under the terms of their agreement, the physicians were able to challenge their removals from the network which would force the payer to cite its reasons for dropping them.

In an emailed statement to Michigan Medicine, UnitedHealthcare said: “Our Medicare Advantage members continue to have broad access to hospitals and physicians to meet their health care needs. With the many changes happening in health care, we are building a network of health care providers that we can collaborate with more closely to have the most positive impact on the quality of care for our members. This will encourage better health outcomes and ultimately lower costs.”

In California, several lawsuits have been filed against Anthem Blue Cross “We know that…when by consumers and consumer watchdog people are asked what groups over narrow networks. The lawsuits allege Anthem Blue Cross kind of trade-offs they misled consumers about the size of its are willing to make, a lot networks and it misled some consumers of consumers indicate into believing their plans were PPO plans that provide more generous networks they are willing to trade only to find they were actually exclusive off access to fewer provider organization (EPO) plans. providers in exchange Unlike PPO plans that cover out-ofnetwork doctors at a lower rate, EPOs for lower premiums. So do not offer any coverage for providers I don’t think consumers out of network with some exceptions are allergic to the idea for emergency services. The insurer was of narrow networks.” also accused of delaying updating its physician directories until it was too — Katherine Hempstead, PhD late for consumers to switch plans. The confusion led to several consumers incurring large medical bills for seeing physicians out of network, according to one lawsuit.

In an emailed statement to Michigan Medicine, Anthem Blue Cross Spokesman Darrel Ng acknowledged the plan inadvertently listed some providers while it was in the process of updating its databases. “Many of the doctors inadvertently listed decided to join Anthem’s network for individual members. Overall, Anthem has added more than 6,200 doctors to our statewide exchange network since Jan. 1, 2014,” Ng said. “Members having an issue finding a provider should call the customer service number on the back of their ID card, and our customer service team will assist in finding an available provider.”

While they may not have resulted in formal legal action, Doctor Wergin said complaints similar to those against Anthem and United have been made against plans across the country. The AAFP argues that the narrowing of networks causes fragmentation of care and introduces inefficiencies when patients are forced to change providers. Doctors must collect and review the files of new patients, in many cases, without the help of interoperable electronic health record systems, and become acquainted with the nuances of each patient’s history. And patients must become acquainted with a whole new care team. Getting up to speed takes time, and quality can suffer as a result of the delay, according to the AAFP. Hospitals in New Hampshire claimed patient care was interrupted when 12 of the 26 hospitals in the state were excluded from Anthem Blue Cross and Blue Shield’s narrow network plan in 2014.

Anthem was the only plan that participated in the 2014 exchange in New Hampshire. All 26 hospitals are expected to be included in at least one network for 2015 after Anthem added more to its network and additional plans joined the exchange.

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Some states have enacted “any willing provider” laws that require plans to accept, or at least negotiate with, any provider willing to comply with the insurers’ terms, rates and conditions.

Future of Narrow Networks The September RWJF report, “Implementation of the Affordable Care Act: Cross-Cutting Issues,” reported an expectation that existing networks will be narrowed even further in 2015. And as long as consumers continue to accept the terms of these plans in exchange for lower premiums, more plans will add narrow networks to their offerings in an attempt to stay competitive.

The RWJF study found that in Oregon, despite the fact there were 11 insurers competing for non-group marketplace business, Moda Health was able to claim 76 percent of the market. Officials there say this was because Moda was able to offer the lowest rates, at least in part, because of their narrow network offerings.

According to the report: “A state marketplace official noted, ‘if plans want to compete with Moda [in 2015], they will have to come down in price, and networks are the easiest thing to fiddle with to do this.’”

Hempstead said she expects more employers to start using narrow networks as a way of controlling costs, as well. Employers are sharing more health care costs and they want to choose lower-priced options just as consumers do.

Narrow networks were found in 23 percent of the plans offered by employers in 2012, up from 15 percent in 2007, according to a May study by the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms.

Narrow networks may very well drive lower costs for certain services, said John Billi, MD, an internist in Ann Arbor and MSMS board member. “But generally when insurers do this, they do not look at the quality of care or – more importantly – the appropriateness of care.”

“To quote an anonymous source, a health plan medical director in the state, ‘narrow network is maybe the fastest way to get the lowest cost for unnecessary care in the state,’” said Doctor Billi.

Doctor Jackson agrees: “Narrow networks are the canary in the coal mine of a dysfunctional payment system. They are trying to get at something that needs to be approached in a different way.

In other words, we need real payment reform.”

One way they can be improved, said Doctor Jackson, is to not just narrow the primary care networks, but also the specialty networks, which is where the high-dollar services are provided.

“Everybody wants to get things that are more profitable instead of doing what’s right. So if the parent system had relatively even profits for different things that I might do, or a hospital might do, or a specialist might do, then there’d be fewer bad choices.

It would come down to what’s the right choice for the patient.

I’m going to get paid the same either way,” said Doctor Jackson.

Sometimes watchful waiting is the right thing to do instead of intervention. But watchful waiting hasn’t always been rewarded, said Doctor Jackson. Now that more attention is being paid to cost and quality, which could determined whether a physician is

invited to join a narrow network, that will start to change. “I feel good about this because some doctors need to be refocussed,” he said. “But it’s not just primary care doctors. Specialty docs and hospitals need to refocus on what’s important.”

As long as narrow networks continue to grow, physicians need to decide whether to be involved. Practices that are already filled to capacity may not be eager to join, said Doctor Billi. If several new patients join that practice’s panel, wait times are going to increase for everyone, including patients with whom the practice has had a longstanding relationship. Patient satisfaction will decrease as a result.

The problem, says Doctor Ramus, is that it’s hard to predict how many new patients a practice will gain and how many will leave.

“You’re totally unsure if it’s going to be a small trickle of volume.

Is it going to be worth all of this; is it going to achieve anything.

But the converse of that is, are you going to end up having 1,400 calls to the practice and none of your [existing] patients have left and you don’t have capacity to deal with that. For most mature physicians, it’s difficult to make the decision.”

Those who consider joining should have a deep understanding of the reimbursement model, Doctor Billi advised. Some plans only offer discounts in exchange for volume while others are combining narrow networks with shared savings models, especially for those who continue to perform well in the narrow network.

If physicians are offered the chance of shared savings, they need to understand:  The attribution model: How beneficiaries are assigned to providers.  The risk adjustment model: What demographics and other information are taken into account and how are they adjusted for?  The size of the population that needs to achieve positive outcomes. An extremely small panel will not be effective.  The specific details of the budget. If it is a shared savings, what comparisons are made to determine the savings?

Even if a practice doesn’t need to expand its patient population, some physicians may feel compelled to join a narrow network anyway to stay in the good graces of the payers, said Doctor Billi. Others may feel because it’s the wave of the future, it’s best to get in now.

While there’s widespread agreement narrow networks are an effective tool to bring down health care costs, and consumers are willing to accept the trade-offs, there’s also widespread belief they are not a panacea.

“Narrow networks are a symptom of a need for payment reform,” said Doctor Jackson. “That’s the elephant in the room we have to address and we continue not to address.” MM The author is an Oak Lawn, Illinois-based freelance writer.

LINKS “Hospital networks: Updated national view of configurations on the exchanges,” McKinsey and Co., June. http://healthcare.mckinsey.com/hospital-networksupdated-national-view-configurations-exchanges “Implementation of the Affordable Care Act: Cross-Cutting Issues,” Robert Wood Johnson Foundation, September. http://www.rwjf.org/content/dam/farm/ reports/reports/2014/rwjf415649 “New American Medical Association Policy Works to Protect Patient Choice and Access to Care,” American Medical Association, Nov. 10. http://www. ama-assn.org/ama/pub/news/news/2014/2014-11-10-ama-policy-protect-patient-choice-access-care.page Summary report, “Fairfield County Medical Association and Hartford County Medical Association v. UnitedHealthcare of New England,” United States Court of Appeals for the Second Circuit, Feb. 7, 2014. ——00American Academy of Family Physicians’ letter to UnitedHealth Group, July 24. http://www.aafp.org/dam/AAFP/documents/advocacy/coverage/medicaid/ 12LetterUnitedHealthcareNarrowNetworks.pdf

MICHIGAN MEDICINE November/December 2014 “Narrow Provider Networks in New Health Plans: Balancing Affordability with Access to Quality Care,” Georgetown University Center on Health Insurance Reforms, May. http://www.statecoverage.org/files/GeorgetownUrban_Narrow_Networks.pdf

ICD-10 Preparation Starts Now

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Contributed by The American Medical Association

he differences between ICD-9 and ICD-10 are significant and physicians and practice management staff need to start educating themselves now about this major change so that they will be able to meet the compliance deadline of October 1, 2015.

ICD-10-CM codes are the ones designated for use in documenting diagnoses. They are 3-7 characters in length and total 68,000, while ICD-9-CM diagnosis codes are 3-5 digits in length and number over 14,000. The ICD10-PCS are the procedure codes and they are alphanumeric, 7 characters in length, and total approximately 87,000, while ICD-9-CM procedure codes are only 3-4 numbers in length and total approximately 4,000 codes. ICD-10-PCS is only used for coding hospital inpatient procedures. CPT remains the code set for reporting procedures and services in offices and outpatient settings.

Moving to ICD-10 is expected to impact all physicians. Due to the increased number of codes, the change in the number of characters per code, and increased code specificity, this transition will require significant planning, training, software/system upgrades/replacements, as well as other necessary investments.

The Final Rule requiring the replacement of ICD-9 with ICD10 was published in January 2009. At that time, the compliance date was set for October 1, 2013. Two delays have occurred since then which have pushed the date back to October 1, 2015.

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ICD-10 FAQs What is “ICD-10”?

“ICD-10” is the abbreviated way to refer to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS).

Explain the difference between ICD-10-CM and ICD-10-PCS. ICD-10-CM is the diagnosis code set that will be replacing ICD-9-CM Volumes 1 and 2. ICD-10-CM will be used to report diagnoses in all clinical settings. ICD-10-PCS is the procedure code set that will be replacing ICD-9-CM Volume 3. ICD-10PCS will be used to report hospital inpatient procedures only.

Will ICD-10-PCS replace CPT®?

No. ICD-10-PCS will be used to report hospital inpatient procedures only. The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) will continue to be used to report services and procedures in outpatient and office settings.

Do I have to upgrade to ICD-10?

Yes. The conversion to ICD-10 is a HIPAA code set requirement. Providers, including physicians, are HIPAA “covered entities”, which means that you must comply with the HIPAA requirements.

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Who else has to upgrade to ICD-10?

Health care clearinghouses and payers are also HIPAA covered entities, so they are required to convert to ICD-10 as well.

I thought HIPAA code set standards only applied to the HIPAA electronic transactions. What if I don’t use the HIPAA electronic transactions?

It is correct that HIPAA code set requirements apply only to the HIPAA electronic transactions. But, it would be much too burdensome on the industry to use ICD-10 in electronic transactions and ICD-9 in manual transactions. Payers are expected to require ICD-10 codes be used in other transactions, such as on paper, through a dedicated fax machine, or via the phone.

Why is ICD-9 being replaced?

The ICD-9 code set is over 30 years old and has become outdated.

It is no longer considered usable for today’s treatment, reporting, and payment processes. It does not reflect advances in medical technology and knowledge. In addition, the format limits the ability to expand the code set and add new codes.

The ICD-10 code set reflects advances in medicine and uses current medical terminology. The code format is expanded, which means that it has the ability to include greater detail within the code. The greater detail means that the code can provide more specific information about the diagnosis. The ICD-10 code set is also more flexible for expansion and including new technologies and diagnoses. The change, however, is expected to be disruptive for physicians during the transition and you are urged to begin preparing now.

When do I have to convert to ICD-10?

All services and discharges on or after the compliance date must be coded using the ICD-10 code set. The compliance date is October 1, 2015. The necessary system and workflow changes need to be in place by the compliance date in order for you to send and receive the ICD-10 codes.

What if I’m not ready by the compliance deadline?

Any ICD-9 codes used in transactions for services or discharges on or after the compliance date will be rejected as non-compliant

and the transactions will not be processed. You will have disruptions in your transactions being processed and receipt of your payments. Physicians are urged to set up a line of credit to mitigate any cash flow interruptions that may occur.

What do I need to do now to prepare for the conversion to ICD-10?

There are several steps you need to take to prepare for the conversion to ICD-10.

• Begin by talking to your practice management or software vendor. Ask if the necessary software updates will be installed with your upgrades for the Version 005010 (5010) HIPAA transactions. If you do not use the HIPAA transactions, determine when they will have your software updates available and when they will be installed in your system. Your conversion to ICD-10 will be heavily dependent on when your vendor has the upgrades completed and when they can be installed in your system.

• Talk to your clearinghouses, billing service, and payers.

Determine when they will have their ICD-10 upgrades completed and when you can begin testing with them.

• Identify the changes that you need to make in your practice to convert to the ICD-10 code set. For example, your diagnosis coding tools, “super bills”, public health reporting tools, etc.

• Identify staff training needs and complete the necessary training.

• Conduct internal testing to make sure you can generate transactions you send with the ICD-10 codes.

• Conduct external testing with your clearinghouses and payers to make sure you can send and receive transactions with the ICD-10 codes.

For questions or more information about the ICD-10 implementation, please contact Stacie Saylor, CPC, CPB at (517) 336-5722 or ssaylor@msms.org. MM

Welcome to These New MSMS Members

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Ibrahim Abou Daya, MD, Saginaw Nicole Akers, MD, Kalamazoo Ferris Alkazir, MD, Kalamazoo Annie Arrey-Mensah, MD, Oakland Jane Beimer, MD, Washtenaw Judy Borovicka, MD, Oakland Alan Braunstein, MD, Oakland Sarah Bur, MD, Washtenaw William Chavey, MD, Washtenaw Rebekah Costello, DO, Kalamazoo Adam Darnell, MD, Muskegon Wesley Eichorn, DO, Kalamazoo Ibad Farooqui, MD, Kalamazoo Silvia Galva Dugas, MD, Kalamazoo Travis Ganje, MD, Washtenaw Kym Gohn, DO, Midland Tara Golisch, MD, Kent Moises Googe, DO, Kent Kim Gygi, DO, Kalamazoo Allison Halonen, DO, Calhoun Sonia Haque, MD, Kalamazoo Benjamin Harper, MD, Kent Lindsey Henderson, MD, Kalamazoo

Marsha Henderson, MD, Washtenaw Maurilio Hernandez, MD, Macomb Derrick Holeman, MD, Kent AHM Huq, MD, Genesee Kanika Jaggi, MD, Kalamazoo Elysia James, MD, Kent Jed Jensen, DO, Kalamazoo Susan Jevert, DO, Kalamazoo Zachary Koehn, DO, Kalamazoo Lindsey Kotagal, MD, Washtenaw Kenneth Krajewski, MD, Kent Priya Krishen, MD, St Clair Anthony Livorine, MD, Washtenaw Toby Long, MD, Saginaw Marla Maikelait, MD, Washtenaw Matthew Martin, MD, Kent Shannon McKeeby, MD, Kalamazoo Dorian Moore, MD, Washtenaw Charlotte Moriarty, MD, Kalamazoo Ellen Ozolins, MD, Oakland Latifa Pacheco, DO, Kalamazoo Sneh Patel, MD, Kalamazoo JuliusMRamirez, I C H I G A N MD, M E D Kalamazoo ICINE Paul Romanoski, MD, Muskegon

Lucille Saha, MD, MPH, Genesee Imran Shafqat, MD, Kalamazoo Vick Sidhu, MD, Kalamazoo Michael Siegel, MD, Oakland Sukhpreet Singh, MD, Kalamazoo Matthew Sleziak, DO, Washtenaw Emily Smith, DO, Kalamazoo Krishna Sowjayna Pothugunta MD, Oakland Amanda Springer, MD, Kalamazoo Joshua Stewart, MD, Washtenaw Jared Sturgeon, MD, Genesee Joshua Suderman, MD, Kent Nabil Suliman, MD, Oakland John Szajenko, MD, Midland David Szaraz, MD, Wayne John Tanner, MD, Kent Randi VanOcker, DO, Kalamazoo Anish Wadhwa, MD, Jackson Raymond Weitzman, MD, Oakland Alexander Witte, MD, Kalamazoo Stephen Witzke, MD, Ingham Hugh Wong, MD, Kalamazoo Sri Yadlapalli, MD, Wayne November/December 2014

Hospital Collaboration Boosts System Quality, Patient Outcomes IT ALL BEGAN WITH A CHECKLIST

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By Stephanie VanKoevering

n 2001, a Johns Hopkins physician named Peter Pronovost began studying hospital-acquired infections, and determined that a simple checklist could prevent infections when inserting a central venous catheter. His work was validated right here in Michigan through the Keystone Initiative, which saved 1,500 lives and $100 million over an 18-month period.

The Keystone Initiative brought together the Quality and Safety Research Group of the Johns Hopkins University School of Medicine, the Michigan Health and Hospital Association, and 108 intensive care units (ICUs) from 77 hospitals. Together, they focused on improving intensive care in Michigan by creating a culture of safety, reducing central line-associated bloodstream infections (CLABSI) and ventilator associated pneumonias (VAP), and improving compliance with evidencebased ventilator care.

Today, the MHA Keystone Center, as it’s now known, is still working to deliver strong results for hospitals across Michigan.

From obstetrics and surgery to emergency room care, hospitals have begun sharing critical information about their strategies for boosting hospital and patient results.

“Through Keystone, we get to ensure that all Michigan hospitals have access to the very best physician practices available,” says Doctor Michelle Schreiber, Chief Quality Officer for the Henry Ford Health System. “Rural, community, and academic hospitals are systematically provided access to the same training and information as the state’s major systems, for the benefit of everyone. We’re all learning from each other.”

Last month, Keystone released its Patient Safety and Quality Annual Report, offering benchmarking data and insights into effective practices. Highlights include: • Unplanned hospital readmissions dropped by nearly 5 percent between 2010 and 2013, and generated over $121.5 million in cost savings during 2013 alone.

• Michigan hospitals reduced catheter use by 10 percent during 2012 and 2013, reducing Neonatal ICU admissions were reduced by nearly 60 percent between 2010 and 2013.

• Hospitals have reduced central-line-associated bloodstream infections by 66 percent between 2004 and 2013.

• Hospital-acquired pressure ulcers were reduced by 32 percent from 2011 through 2013 in participating hospitals.

• Surgical specimen defects in Michigan hospitals dropped by 84 percent between 2010 and 2013.

The report also offered suggestions for physicians and clinical teams:

• A team-oriented, patient-centered culture is essential.

“Eliminating harm cannot happen with individual healthcare providers and improvement efforts operating within silos…

Entire clinical teams must be engaged.”

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• Monitor patient care transitions carefully.

“Poor transitions in care between healthcare settings can result in medical errors, diminished health, and re-hospitalization for patients. They often occur due to lack of communication and coordination, the complexity of managing chronic disease and a lack of patient resources.”

• Use evidence-based interventions, such as those taught in the Patient Safety Immersion Initiative.

“The Patient Safety Immersion Initiative [is] aimed at building the foundational skills necessary for individual clinicians to lead change. More than 244 healthcare professionals in Michigan engaged in the initiative and 20 have been Certified Professionals in Patient Safety as a result.”

Doctor Schreiber notes that many of the proven interventions recommended through Keystone are simple and inexpensive.

“It used to be that if a person was on a ventilator, physicians would automatically assume an infection would occur,” Doctor Schreiber says. “Imagine the amazement when we learned that simply by elevating the head of the patient’s bed or providing better oral care the rate of infection would drop substantially.”

As a result of Keystone, Michigan remains a national model in terms of health care improvement.

“There are other well-funded health care collaboratives across the nation, but the state of Michigan really stands out in leading quality improvement,” Doctor Schreiber says. “Working together, physicians across Michigan have really developed a wonderful collaboration and a great model of care.”

Duke University’s Doctor J. Bryan Sexton echoes this assessment.

As a national expert in culture and resilience in the health care profession, he offers a national, objective look at Michigan’s leadership.

“Michigan is not just a little bit, but a lot ahead of the ball in so many ways,” Doctor Sexton says.

Doctor Sexton urges Michigan physicians and hospitals to ensure effective pacing and intensity in their improvement efforts. “[Well-paced] quality improvement is meaningful and fills people with a sense of purpose and accomplishment,” Doctor Sexton says.

He cautions against thinking about quality improvement as “just one more thing” for physicians and systems to consider, saying that progress needs to be evidence-based, deliberative, and of the right intensity.

“I think where this is going is that we’ll use better data and better diagnostics to know how fast we can put different levels of intervention in a given clinical area and how intense those interventions can be,” Sexton says. “Michigan is at the front lines of this, in every way.”

Full copies of Keystone’s Patient Safety and Quality Annual Report are available at MHAKeystoneCenter.org. MM The author is Michigan-based Freelance writer.

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PROFILE

Nick Lyon, Director of the Michigan Department of Community Health

O

n October 24, the New England Journal of Medicine published the results of a study hailing the rollout of the “Healthy Michigan Plan” as a model for the rest of the nation.

The program, which extends health care benefits to poor and low-income residents, surpassed its first-year enrollment goals within the first 100 days.

Even better, the study found that more than a third of those who signed up for the plan in the first two months used it to visit a physician almost immediately after their coverage began.

The glowing report was a testament to the impact physicians and health care services can have on patients, but it also spoke to the difference strong leadership can have on health policy overall.

“Physicians are Michigan’s most valuable health care providers.

They understand their patients best.

I and the entire Department are appreciative of the work of physicians and organizations like the Michigan State Medical Society. We value their partnership and their input.”

— Nick Lyon, Director, MDCH

Nick Lyon is an example of strong leadership in action.

He took the helm as Director of the Michigan Department of Community Health in mid-September after Director Jim Haveman announced his plan to retire. His work as leader of the multi-agency group responsible for the wildly successful rollout of the Healthy Michigan Plan made him an easy choice.

Now he’s hit the ground running, and the stakes have only gotten higher.

“My responsibility is to ensure the department delivers the best tools for the health and safety of Michigan residents,” Lyon says. “That means working with providers to ensure patients get access and quality care and the information they need to make the best decisions.

“It’s a unique responsibility, because it touches every Michigander.”

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And the Department’s responsibilities extend beyond health care.

Giving patients access to primary care physicians and the physician specialists they need is also a key driver, Lyon insists, for a healthier economy.

“By lowering the costs of health care by treating issues before they reach a crisis, we can lower the burden health care places on Michigan’s economy,” says Lyon. “That makes Michigan more economically competitive with other states and with Nick Lyon the rest of the world.”

With Healthy Michigan, Lyon’s off to an impressive start. With 452,000 enrollees thus far and thousands more every week, the program has already resulted in more than 200,000 primary care visits, 17,000 mammograms and 8,000 colonoscopies. Patients who were previously unable to afford preventative care have begun taking a more active role in their own health, driving down the need for the kind of high-cost care that drives up insurance rates for everyone.

As owner of a strong track record delivering results that garner national headlines, Lyon has set out a bold priority list for the Department. Key initiatives include further increasing access to physician care to drive down preventable deaths and infant mortality, decreasing the economic burden of high-cost treatments like emergency room visits by getting more residents the primary and specialty care they need first, and lowering the administrative complexity physicians and patients struggle with in today’s health care environment.

“By coordinating primary and behavioral care and rewarding outcomes in health care, we’re going to be able to make a difference for patients,” Lyon says.

That starts, he insists, by equipping and empowering physicians.

“Physicians are Michigan’s most valuable health care providers. They understand their patients best. I and the entire Department are appreciative of the work of physicians and organizations like the Michigan State Medical Society,” Lyon says. “We value their partnership and their input.”

It’s a partnership that’s already yielding incredible results for Michigan patients. MM

MICHIGAN MEDICINE

November/December 2014

DTaP Vaccination It Takes the Full Series to Protect Children

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ertussis is on the rise in Michigan and we have to make sure that we do everything we can to protect everyone in Michigan through vaccination. As of August 31, 684 cases of pertussis have been reported in Michigan for 2014.

This is 57 percent higher than were reported at this time last year. This is concerning news when we look at the number of children who are not receiving all their doses of DTaP vaccine.

In Michigan, our vaccination coverage rate with four doses of DTaP for 19 through 35 months of age is at 79.6 percent. The goal for Healthy People 2020 is to have a 90 percent coverage rate with four doses of DTaP vaccine. Immunization providers do a good job starting the DTaP series with rates as high as 95 percent for dose number one, but it drops off to 93 percent for two dose coverage and down to 90 percent for three dose coverage.

Children will not be protected if the series is not completed. The fourth and final dose is very important to assure that children are protected against these very serious diseases.

With Michigan’s coverage rate at only 79.6 percent and pertussis disease on the rise, ensuring your patients receive all the recommended doses of DTaP vaccine on time becomes a critical part of daily assessment.

A strategy to decrease pertussis disease and increase immunization rates in Michigan is to assess vaccination status at every visit

Volume 113 • Number 6

and administer all recommended vaccines. Administer a five-dose series of DTaP vaccine at ages: (1.) two months; (2.) four months; (3.) six months; (4.) 15 through 18 months, this fourth dose may be administered as early 12 months, if at least six months has elapsed since the third dose; (5.) four through six years.

When assessing vaccination status there may be times when a child arrives to your office at 12 months of age and needs a fourth DTaP dose. Remember, the fourth DTaP dose may be given at 12 months, if at least six months has elapsed since the third DTaP dose. By vaccinating at 12 months with all recommended vaccines, including the fourth DTaP dose, we can prevent a possible missed opportunity and provide protection against pertussis.

Another strategy to decrease pertussis disease and increase immunization rates is to generate reminder/recall messages through the Michigan Care Improvement Registry (MCIR). These messages inform parents/patients that recommended vaccines are due soon (reminders) or past due (recall messages). They have been found to be an effective strategy for improving vaccination rates. To learn more about generating these messages, contact MCIR at: www.mcir.org.

As patients in your practice come in for sick or well visits, school physicals and even flu shots, assess for all recommended vaccines, including the fourth DTaP dose. To find out more on pertussis disease, DTaP vaccine and recommendations visit: • Immunization Schedules at CDC • CDC Pertussis (Whooping Cough) Vaccination • MDCH Quick Look DTaP • IAC Ask the Experts – Pertussis MM

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Legal Regulation of Vaccination Policies As a condition of employment, an employer may require that all employees receive a flu shot. However, an employer’s compulsory flu shot policy must provide for exemptions in order to comply with various laws regulating the employer/ employee relationship. For example, if an employee with a physical or mental disability refuses a flu shot, the employer may have to make a reasonable accommodation in order to comply with the federal Americans with Disabilities Act (ADA) and the Michigan Persons with Disabilities Civil Rights Act, unless the accommodation would impose an undue hardship on the employer. A reasonable

By Patrick J. Haddad accommodation could take the form of exempting the employee from the requireore and more health care employers are requiring ment and instead requiring a different protective measure, such that all employees get the influenza vaccine in as wearing a surgical mask. Similarly, if an employee objects order to help protect patients and coworkers during due to a sincerely held religious belief, the employer may also have to provide a reasonable accommodation, unless doing so flu season. This trend has resulted in questions would impose an undue hardship on the employer, in order pertaining to the legality of such policies, as well as how to comply with the federal Civil Rights Act of 1964 and the to properly implement a mandatory influenza vaccination Michigan Elliot-Larsen Civil Rights Act. policy for employees. Employers may adopt mandatory flu If an employee refuses to comply with the employer’s policy shot policies which are drafted and implemented in a legally compliant manner. and/or any reasonable alternative protective measures required

Mandatory Flu Shots for Employees

Policy Implementation & Best Practices

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MICHIGAN MEDICINE

November/December 2014

by the employer if an exemption is granted, an at-will employer may pursue disciplinary action which could include termination.

An employer should understand that, as with other employment decisions, its determination to impose disciplinary action for noncompliance could be challenged by the employee and is not binding on governmental agencies or the courts. In appropriate circumstances, an employer should consult knowledgeable legal counsel before making employment based decisions.

Employers Should Adopt a Written Policy It is advisable for an employer that wishes to require flu shots to adopt a written flu shot policy so that all employees have reasonable advance notice that receiving an annual influenza vaccination is a condition of employment. The policy should set an annual compliance deadline based on the anticipated start of the flu season and outline consequences for noncompliance. For instance, the policy may list the steps triggered by noncompliance, such as a written warning, suspension, and termination if the noncompliance is not cured within a certain time frame.

The policy should also specify what written documentation the employee must furnish the employer to prove that the employee was vaccinated.

An Employer’s Policy Should Include Exemptions An employer’s influenza vaccination policy should provide a process for employees to request an exemption from the employer. Additionally, the policy should notify employees that if the employer grants an exemption, employees are required to comply, as a condition of employment, with reasonable alternative protective measures specified by the employer.

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Exemptions should be allowed for a number of reasons, including: (1) a sincerely held religious belief or creed; (2) a qualifying physical or mental disability; (3) a prior severe allergic reaction to the flu shot; (4) a history of Guillain-Barré Syndrome; or (5) some other relevant medical reason.

If an employee requests an exemption, the employer will need to determine whether an exemption should be granted and if so, the reasonable alternative protective measures that it will require the employee to comply with during flu season. An employee’s request for an exemption, as well as the employer’s decision, should be documented in writing.

Strategies for Improving Vaccination Rates Educating employees about the benefits and importance of the flu shot may help maximize employee participation. Just like frequent hand washing and wearing gloves, the flu shot is an important protective measure for employees and patients. The Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that all U.S. health care workers get vaccinated annually against influenza.1 The CDC has a variety of resources related to influenza vaccination for health care workers (http://www.cdc.gov/flu/healthcareworkers.htm), as well as general information pertaining to adult immunization (http://www. cdc.gov/vaccines/hcp/patient-ed/adults/index.html) that may helpful to employers and employees in the health care field. MM The author is a member with Kerr, Russell and Weber, PLC. 1. http://www.cdc.gov/flu/healthcareworkers.htm

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M E D I C A L

F A M I L Y

M A T T E R S

Alliance Update on Immunizations

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By Nancy Fody ccording to our bylaws the purpose of the Michigan State Medical Society Alliance

(MSMSA) is to work in partnership with the Michigan State Medical Society and the American Medical Association Alliance to develop, implement, and support educational programs that improve the public health, to educate about legislative issues that impact the practice of medicine, to provide support for the medical family, and serve as a resource for county alliances and auxiliaries.

Our current Immunization Awareness project underlines nearly every one of those goals. After receiving a grant from the Michigan State Medical Society Foundation, MSMSA has been underwriting County Alliance projects related to raising immunization awareness in our community. Our aim is to improve Michigan’s immunization rate and, consequently, public health. According to the Centers for Disease Control & Prevention, Michigan has the fourth highest vaccination exemption rate in the nation. Last year, 5.9 percent of Michigan’s kindergarteners entered school unvaccinated.

This is causing an increase in cases of measles and pertussis in Michigan.

Of those “opting out”, 0.6 percent for medical reasons and 5.3 percent were for religious or philosophical reasons.

Alliance members are concerned about the high rate of parents foregoing vaccinations for philosophical reasons. Already three projects have been completed across the state. Kent, Muskegon, and the Tri-Counties Medical Society Alliances have held public informational meetings about the need to immunize. Tri-County Medical Society Alliance produced an informative booklet “Deciphering Facts and Myths about Childhood Immunizations” as a resource for parents concerned about vaccinating their children.

Alliance members, along with many health and community organizations, 20

have been attending the Immunization St a keholder me et i n g s held i n Lansing. MSMSA added its support to the proposed amendments to the rules governing state immunization requirements. We urge the Michigan Department of Community Health to enact changes that will lower the public health risks associated with parents choosing not to immunize their children for non-medical reasons.

The change to the Public Health Code that may have the greatest impact on Michigan’s immunization rate is the addition of informed consent.

The proposed changes will allow parents to make decisions based MICHIGAN MEDICINE

on sound information and careful consideration. Families choosing not to immunize their children will still be able to do so. However, each individual requesting an exemption must receive local health education on the benefits of vaccinations and the risks of not receiving vaccines.

Currently, exemption rates are lower in counties where parents are required to speak with a health professional before opting out of immunization.

The MSMSA has been working with MSMS for 88 years. If you, your spouse or partner would like more information or would like to join MSMSA, visit our website at www.MSMSA.org. MM The author is President of the MSMS Alliance, comprised of physicians’ spouses.

November/December 2014

Educational Conferences MSMS On-Demand Webinars: Education When You Want It! • Physician Executive Development Program, featuring The Doctors Company CEO Richard E. Anderson, MD • CDL-Medical Examiner Course • Summary of the Affordable Care Act • HIPAA Security Rule • End of Life Concerns and Considerations • Understanding and Preventing Identity Theft in Your Practice • Stepping Up to Stage 2 Please visit website www.msms.org/eo for a complete listing.

FREE MSMS “Lunch and Learn” Policy Webinars • Physician On-line Ratings and Reviews: Do’s and Dont’s December 3, 2014 Visit www.msms.org/eo for complete details.

Compliance Essentials You Need to Know in 2015 Date: Wednesday, January 28, 2015 Time: 9:00 a.m. to 3:30 p.m.

Location: MSU Management Education Center, Troy Contact: Caryl Markzon, (517) 336-7575 or cmarkzon@msms.org Note: Continental breakfast and lunch will be provided Intended for: Physicians, executives, office administrators and all other health care professionals Patient Centered Medical HomeSupporting Patients through Population Health Date: Wednesday, March 4, 2015 Time: 9 a.m. to 3:30 p.m.

Location: Crown Plaza, Troy Contact: Caryl Markzon, (517) 336-7575 or cmarkzon@msms.org Note: Continental breakfast and lunch will be provided Intended for: Physicians, executives, office administrators and all other health care professionals

Physician Assistant and Nurse Practitioner Services – Incident To, Split Shared and Other Compliance Issues 6 AAPC CEU Date: Thursday, March 26, 2015 Time: 9:00 a.m. to 4:00 p.m.

Location: Crowne Plaza, Novi Date: Thursday, April 2, 2015 Time: 9:00 a.m. to 4:00 p.m.

Location: Marriot, Troy Contact: Marcie Barnum, (517) 336-5724 or mbarnum@msms.org Intended for: Physicians, billers, coders, office managers, and billing managers ICD-10-CM Boot Camp: The Clock is Ticking 12 AAPC CEU Date: Thursday, March 19 and Friday, March 20, 2015 Time: 9:00 a.m. to 4:00 p.m. each day Location: Marriot, Troy Date: Wednesday, May 13 and Thursday, May 14, 2015 Time: 9:00 a.m. to 4:00 p.m. each day

Location: The Henry, Dearborn Contact: Marcie Barnum, (517) 336-5724 or mbarnum@msms.org Intended for: Coders and billers, billing managers, and physicians Train the Trainer – An Advanced ICD-10 Course 6 AAPC CEU Date: Thursday, April 9, 2015 Time: 9:00 a.m. to 4:00 p.m.

Location: Crown Plaza, Novi Contact: Marcie Barnum, (517) 336-5724 or mbarnum@msms.org Intended for: Coders and billers, billing managers, and physicians Spring Scientific Meeting Date: Wednesday, May 13 and Thursday, May 14, 2015 Time: Morning, afternoon and evening sessions will be offered Location: The Henry in Dearborn Contact: Marianne Ben-Hamza, (517) 336-7581 or mbenhamza@msms.org Note: Continental breakfast and lunch will be provided.

Intended for: Physicians and all other health care professionals Annual Joseph S. Moore, MD, Conference on Maternal and Perinatal Health Date: Thursday, May 14, 2015 Time: 9 a.m. to 4:15 p.m.

Location: The Henry in Dearborn Contact: Marianne Ben-Hamza, (517) 336-7581 or mbenhamza@msms.org Note: Continental breakfast and lunch will be provided Intended for: Physicians, nurses, residents, students, and all other health care professionals working with women and their infants

To Register Online: www.msms.org/eo • Mail Registration Form to: MSMS Foundation, PO Box 950, East Lansing, MI 48826-0950 Fax Registration Form to: 517-336-5797 •Phone MSMS Registrar at: 517-336-7581

OBITUARIES

The members of the Michigan State Medical Society remember with respect their colleagues who have died.

James Barnett, MD

James Fenton, MD

Leroy Strong, MD

Muskegon County Medical Society Died October 25, 2014.

Ogemaw County Died November 10, 2014.

Kent County Medical Society Died September 23, 2014.

Richard Collier, MD

Heinrich Schaefer, MD

Ingham County Medical Society Died October 10, 2014.

Wayne County Medical Society Died October 6, 2014.

I N M E M O RY If you would like to recognize a colleague by making a gift or bequest in their memory to the MSMS Foundation, please contact Rebecca Blake, Director, MSMS Foundation, 120 W. Saginaw St., East Lansing, MI 48823, Volume 113 • Number 6 M I C H Ior G A e-mail N M E D I rblake@msms.org.

CINE Call 517-336-5729

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Year-End Planning Can Save You Time and Money

A

By Nathan Mersereau, CFP®, AAMS

s the end of the year approaches, make sure your financial affairs are in order. Take time to review the following financial tips to make sure you’re maximizing opportunities in 2014.

Begin Tax Planning Now – Evaluate which tax strategies are appropriate for you to implement before year-end. Project your 2014 tax liability and consider the benefits of making charitable contributions, purchasing equipment (if you have a practice and are subject to a Section 179 deduction), realizing investment capital gains or losses, making gifts subject to the $14,000 annual gift tax exclusion, or contributing to 529 education savings plans. You may need to adjust your Q4 estimated tax payment. Consult with your tax advisor before you make any year-end tax moves.

Maximize Your Retirement Plans – Physicians put most of their savings into retirement plans to build financial security and protect assets from creditors. If you have a 401k, remember to maximize your $17,500 ($23,000 for over age 50) salary deferral limit. You may have additional savings opportunities through 401(k)/Profit Sharing Plans, 403(b)’s, Cash Balance Pension Plans, and 457 deferred compensation plans, SEP-IRA’s or SIMPLE IRA’s. Make sure you have a plan that works best for you.

Consider Converting to a Roth IRA – A Roth IRA doesn’t let you deduct contributions but can deliver tax-free payments in your 60’s, 70’s and beyond. You can convert traditional IRA’s to a Roth IRA, paying tax on the converted amount now to avoid tax liability on these assets during retirement. Because the Roth IRA doesn’t require mandatory withdrawals beginning at 70 1/2, you’ll have the option of keeping money in the account to pass along tax-free income to your heirs.

Get Organized – Many physicians spend more time organizing content in their iPads than organizing their financial records. Use year-end planning as a time to identify what to keep and what to throw out.

Not only will you know where your records are located, but you can develop a system to monitor your finances in the years to come.

Spend Only What You Can Afford – It seems simplistic, but many physicians, even those with substantial incomes, ignore this basic financial principle. If you have more money going out than you have coming in, it’s a recipe for eventual disaster. To get things in balance, you may need to trim spending or look for ways to increase your income. Before year-end, it may be necessary to meet with a spouse or business partner to evaluate past spending patterns and make adjustments for the future.

Get a Second Opinion – Many physicians are caught up in a busy schedule and feel they have limited time to invest in themselves. But taking the time to review your financial affairs with your trusted advisors and even seeking second opinions is time well spent. An ounce of prevention is worth a pound of cure. MM The author is President of WealthCare Advisors, LLC – an MSMS joint venture.

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MICHIGAN MEDICINE

November/December 2014

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 advertise­m ents 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 888-822-3102 or email gretchen@villagepress.com.

RURAL OPPORTUNITIES IN SW MICHIGAN • Family Practice – outpatient • Internal Medicine (model is: 3 weeks IM outpatient, 1 week Hospitalist)

• Orthopedic Surgeon,

Employment Opportunities Due to growing demand, HURON VALLEY CONSULTATION CENTER is currently looking to affiliate adult and child psychiatrists. Huron Valley Consultation Center offers: Competitive Compensation, Billing Services and Clerical Support, Professional and Comfortable Working Environment and Proven and Well-regarded Reputation. To join our team, please submit your CV to Alex Martinez, MSW, Director, Huron Valley Consultation Center, 2750 S. State St., Ann Arbor, MI 48104 or by email at: amartinez@huronvalleyconsult.org.

Fully accredited 60 bed hospital, rehab unit, regional referral availability, wound clinic on campus. 2 hours to both Chicago and Detroit, close to Kalamazoo.

Can be employed or income guarantee, full benefits, malpractice, relocation. Check us out at www.threerivershealth.org.

Forward CV to:

Office Space GYN OFFICE IN ROCHESTER HILLS. Available on Wednesdays, Fridays, evenings, weekends, other days negotiable. Good location near Rochester Road /Tienken Road intersection. Ideal for physician/individual needing part-time or satellite office space. For further info, please call Dr. Wagner: 248-656-1300 or email: kswmd4@yahoo.com.

Volume 113 • Number 6

General Ortho but subspecialty is welcomed, employed, benefits, relocation, share call

MICHIGAN MEDICINE

Cindi Whitney-Dilley – Inhouse Recruiter WhitneyRecLLC@aol.com (269) 506-4464

Equal Opportunity Employer

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D I S C I P L I N A R Y A C T I O N S

Physicians and Practice Managers…Thinking of Adding a Nurse Practitioner or Physician Assistant?

Increase your time, revenue, patient’s access/satisfaction, hospital rounds, overall business. NP/PA providers can be incorporated into the practice in three ways: 1. Acute care with same day access/extended hours, 2. Physician partner on care team, 3. Or as a fully paneled provider in your practice.

Locum Tenens, Temp to Permanent, Direct Hire.

Call us at (734) 398-3444 regarding your NP/PA needs. We are here to help!

We are a Michigan based company…in business to provide fully credentialed and committed healthcare practitioners where and when needed.

Disciplinary actions of the Michigan Board of Medicine can be found at www.michigan.gov/lara/ 0,4601,7-15435299_63294_2752943008--,00.html

HCS Staffing staffinginfo@hcsgroup.com www.hcsstaffing.com

The Voice of Michigan Physicians 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.

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MICHIGAN MEDICINE

November/December 2014

Volume 113 • Number 6

MICHIGAN MEDICINE

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EMPLOYMENT OPPORTUNITIES

Family Practices m Dearborn Heights: Internal Medicine/Primary Care Practice.

Newly remodeled, 6 exam rooms, break room, central lab, plenty of parking, very visible potential gross income of $400,000 annually w/current patient base. Asking $127,900 for practice and $268,900 for real estate. m Keego Harbor/Orchard Lake: Urgent care center – willing to sell all or part of the practice. Asking $117,500.00 for entire practice. Excellent location, totally remodeled 4 exam rooms, x-ray, easy access. Real estate also available.

Three adjoined buildings, flexible terms. m Commerce Area: Oakland County. High traffic area, shorter hours still produces $500,000+. We offer a one year transition period, 30 years of office. Real estate also offered…priced right. m 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. m 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. m Mack Ave. Detroit: High volume primary care clinic, under served area, Medicaid and Medicare pay a bonus fee schedule, receive up to $25,000 annually for your medical school loans, gross income is approximately $880,000 annually asking $250,000 for practice and $260,000 for real estate. m Belleville-Canton: Canton Primary Care Clinic, presently resently grossing in excess of $1 million annually, price reduced $100,000, asking $800,000 for practice and real estate, seller financing available.

Open Positions: [ MD/ DO/ DPM ] Primary Care • Pain Management • Psychiatry Podiatry • Ophthalmology • Wound Care

Residential Home Care, Inc.

Corporate Office: 11477 E. 12 Mile Road, Warren, MI 48093 Telephone: (586) 751-0200 • Fax: (586) 751-0414

Dr. Metropoulos, Medical Director Multiple providers needed for our growing practice.

No Nights. No Weekends. No On-Call.

Full-time or Part-time.

Compassionate and skilled practitioners for providing quality care to elderly and disabled patients in their homes. Transportation provided for you, driven by medical assistant in company-owned vehicle.

In-home diagnostics are available to assist you with the evaluation, diagnosis, and management of our patients.

Clinic opportunities available.

If you are interested in more information, please call (586) 751-0200.

Please mail, fax, or email us your CV today.

Fax: (586) 751-0414 • Email: HealthNetWeb@aol.com

Serving Southeastern Michigan for 55 Years

Medical Buildings For Sale or Lease m Far West Side Detroit: Multi suite property fully leased, $60,000. Positive cash flow for owner. Very good condition, brick, single story. One suite opened up for your practice.

8,000 sq. ft., private parking. Asking $525,000, or lease at $1 sq. ft./mo.+utilities. m Garden City: Medical practice building, still has equipment, exam tables, EMR. About 1,200 sq. ft., three exams, basement storage, private packing. Asking $129,800 or $900/mo. lease. Seller will finance. m Pontiac: Large professional medical building. Three story, suites 500-5,000 sq. ft. Across from hospital, acres of parking. VERY REASONABLE rates/terms or buy building for $250,000.

For more details contact our practice specialist at Union Realty:

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.

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MICHIGAN MEDICINE

November/December 2014

Volume 113 • Number 6

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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

Our Babies Are Growing Up to be Doctors

By James D. Grant, MD

W

illie Nelson once warned mamas not to let their babies grow up to be

cowboys and, instead, suggested they “make them be doctors and lawyers and such.”

Depending on the time day and who you are talking to, I know a lot of physician parents who are definitely not making their babies become doctors.

The health plans. The hospitals. The government. The grind. The world of medicine is changing. More focus on cost control, increased reporting of quality metrics and patient satisfaction. These three are just examples of key changes that are driving the health care system forward and something that physicians of earlier generations could not even imagine. The lamentation that “the end is near” is heard often throughout the physician community.

But wait. Before we flush the medical profession down the drain, let’s look at that bright spot on the horizon.

Last month, the Association of American Medical Colleges announced that applications to medical schools rose 3.1 percent in 2014 while medical school enrollment increased 1.4 percent to an all-time high of 20,343. Michigan alone has developed three new medical schools in the past ten years. This is in addition to the growth and expansion at some of our legacy medical schools.

Apparently, many of our generation’s offspring do want to become doctors after all. Some currently practicing physi-

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cians will argue that “ignorance is bliss” and that these health care neophytes really don’t know what they are getting themselves into. With applicants’ grade point averages and MCAT scores reaching all time highs, these young adults are neither ignorant nor oblivious when it comes to choosing a career. Many of the next generation are choosing lifestyle when making career choices and are opting not for the world that we knew of working 36-hour shifts, seven days a week. They know there has to be more to life than that. Many in our next generation have thought it out and they want a career that is oriented to direct contact and personal interaction with fellow human beings in hope of making their lives better. Just like we did.

After spending several days at the AMA Interim Meeting in early November, the student delegates there proved to me that they are not naïve about the issues facing health care and the practice of medicine. In fact, they were almost overwhelming in their organization and energy to effect change and create policy. Their knowledge and intensity on issues, their discipline, and their use of high-tech communication created a beehive-like vibe among the student delegates.

These are not going to be physicians who will allow themselves to be beaten down by the system. They will become the masters of their universe because they will communicate and organize and lead any changes that need to be made for patients and the profession. I can’t believe that their optimism, creativity, and energy could be extinguished by anyone and anything.

MICHIGAN MEDICINE

Except this. Despite the full force of organized medicine’s ongoing lobbying efforts, three bills in Congress to increase funding for Graduate Medical Education beyond the 17-year-old cap on residency training slots are going nowhere. They come with a heavy price tag, about $10 billion for all three bills over 10 years.

That would be on top of a $150 billion fix to the Sustainable Growth Rate formula. It’s finding the “pay fors” that keeps Congress from acting.

It could be argued, however, that with the rapidly aging Baby Boomers and an estimated shortage of 130,000 physicians by 2025, investing in physicians now really is not an option but an imperative.

Our generation of physicians, as well as every generation before us, stands on the shoulders of our predecessors who worked to preserve, protect, and improve the profession.

The gift we can give to our next generation of doctors is an unrelenting effort to increase and improve the distribution of GME funding so our medical school graduates can get the rest of the education and training they need to hang their own shingles.

A parent’s job is never finished. But they’re doing their part, so let’s do our part and fix GME funding. MM Doctor Grant, a Royal Oak anesthesiologist, is President of the Michigan State Medical Society.

November/December 2014

Volume 113 • Number 6

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