Michigan Medicine, Volume 115, No. 2 by Michigan State Medical Society

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March / April 2016 • Volume 115 • No. 2

Rural Practices: Founded in Family and Community MSMS member Jennifer Dehlin, MD, explains the challenges and opportunities that come along with practicing in rural Michigan.

ALSO IN THIS ISSUE

• There’s An App for That: The Benefits and Risks of Using Mobile Apps for Health Care

• Vaccinating Against Preventable Disease • Telemedicine in Michigan: What Physicians Need to Know

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Managing Editor March / April 2016 • Volume 115 • No. 2

COVER STORY

Rural Practices: Founded in Family and Community By Kathryn Palczewski

FEATURES

There’s An App for That: The Benefits and Risks of Using Mobile Apps for Health Care by Robin Diamond, MSN, JD, RN, Senior Vice President, Patient Safety and Risk Management, The Doctors Company (Contributed by The Doctors Company)

COLUMNS

President’s Perspective By Rose M. Ramirez, MD Encouraging Physician Roots to Grow in Rural Areas of Michigan

Ask Our Lawyer By Daniel J. Schulte, JD Greater Publication of State Disciplinary Actions Makes Compliance Conference Settlements More Difficult

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.

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MDHHS Update By Cristi Bramer, MPH, MCIR Epidemiologist, MDHHS Division of Immunization Over a Third of Young Children in Michigan are Susceptible to Vaccine Preventable Diseases

HIT Corner By Patrick J. Haddad, JD, Kerr, Russell and Weber, PLC, MSMS Legal Counsel Telemedicine in Michigan: What Physicians Need to Know

MSMS Alliance By Clara Sumeghy, President, MSMS Alliance Report on the Status of MSMS Alliance Works in Progress

DEPARTMENTS

In Memoriam

MSMS Foundation Education Course Offerings

New MSMS Members

Michigan Medicine, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine are neither endorsed nor warranteed by MSMS, with the exception of a few.

Michigan Medicine (ISSN 0026-2293) is the official

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magazine of the Michigan State Medical Society, Committee. In 2016 it is published in January/February, March/April, May/June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA.

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.

P R E S I D E N T â&#x20AC;&#x2122; S

P E R S P E C T I V E

Encouraging Physician Roots to Grow in Rural Areas of Michigan BY ROSE M. RAMIREZ, MD

ichigan is a beautiful place to live and even though winter can seem long, the other seasons highlight the paradise we enjoy. We have the Great Lakes, large swatches of state and federally protected lands and numerous inland lakes and waterways. Much of our state is rural and dotted with small towns from our southern border to the tip of the Keweenaw Peninsula.

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When we look at our physician workforce in the state, we see that the densely populated areas have an abundance of physicians, both primary care and specialists, along with state-of-the-art medical facilities. However, one of the challenges, especially in the northern lower peninsula and the upper peninsula is having enough physicians to care for residents in those areas. In the rural areas, we sometimes see Federally Qualified Health Centers, staffed by Physician Assistants and Nurse Practitioners. Many of these clinicians are excellent providers and we appreciate their commitment to our rural communities. However, having more physicians in these rural areas, especially well-trained primary care providers (family medicine, internal medicine and pediatricians) will enhance our ability to improve quality and address population health. How do we get more of these doctors to settle in rural communities to practice and raise their families there?

March / April 2016

Certainly, loan forgiveness and financial incentives help to get physicians to go to rural areas to practice, but too often, after the requirements of the incentives are repaid, these physicians move on to other places. The key is to look for ways to identify those most likely to go to a rural area to practice and remain there as a part of the community. I contacted Andrea Wendling, MD, Associate Professor and Director of the Rural Medicine Curriculum at the Michigan State University College of Human Medicine (MSU-CHM). Both Doctor Wendling and her husband, Mike Harmeling, MD, completed medical school at the University of Michigan, trained at the family medicine residency in Grand Rapids and then moved to Boyne City to join a practice. Despite her practice in a rural community, she has pursued her academic interests. She has written grants to get funding for rural physician training and has published original research on training rural physicians. She shared with me that “MSU-CHM has been creating, sustaining and studying innovative approaches to rural medical education for over forty years. In 1972, MSUCHM received a Federal Bureau of Health Manpower Grant and Michigan legislative funds to develop one of the nation’s first rural training programs, the Upper Peninsula Rural Physician Program (RPP).”

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Based on the success of the program headquartered in Marquette and the ongoing need for rural physicians in our state, two campuses in rural regions of the lower peninsula were developed in 2012. The same model was used which offers earlier rural experiences and a more robust clinical curriculum. Leadership experiences were promoted by development of student-led community-based scholarly projects and partnerships with rural Public Health Departments. In addition to these training programs, MSU-CHM has developed the Rural Premedical Internship Program, an undergraduate pipeline program targeting students of rural origin interested in medical school. I recently met with State Representative, Edward J. ‘Ned’ Canfield, DO. He is from 84th District which covers Huron and Tuscola counties (the thumb area of our state). He introduced legislation in the House late in 2015 to oppose Maintenance of Certification requirements by hospitals and payers. That legislation is currently assigned to the House Health Policy committee. Representative Canfield is acutely aware of the projected shortages in the physician workforce in our state and he is working on an innovative proposal to engage medical students and provide tuition relief in return for practice in a rural or underserved area of our state. He thinks that if students

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already show a desire or interest in primary care and rural practice, and if the tuition cost can be offset, this will make it easier for these students to seriously consider rural practice. More to come on this one! I grew up in a small town about 30 miles ENE of Grand Rapids, Michigan. My doctor was a general practitioner and was a beloved member of our community. He delivered babies, made house calls and had a busy practice. One Christmas, my father had just had surgery on his back and was out of work. Doctor Louis Sanford sent gifts to our home for me and my four younger siblings. I was in third grade I believe, and he gave me a stuffed kitten made from soft white rabbit fur. It made a lasting impression! These are the stories we love to hear, and that continue to come from our small Michigan communities. Thirty Years Training Rural Physicians: Outcomes from the Michigan State University College of Human Medicine Rural Physician Program. Wendling, et al. Academic Medicine, Vol 91., No. 1/ January 2016.

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

A S K

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L AW Y E R

Greater Publication of State Disciplinary Actions Makes Compliance Conference Settlements More Difficult BY DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL QUESTION:

ANSWER:

I was investigated by the State of Michigan following a patient complaint. An Administrative Complaint was filed against me alleging that I was negligent, lacked competency, billed for services improperly and that I had violated several other provisions of Michigan’s Public Health Code. My lawyer and I met with an attorney general and a representative of the Board of Medicine at a compliance conference. We all agreed that my only failure was to fully document the reasons for my diagnosis and treatment of this patient. A sanction of probation with some medical record documentation continuing education was agreed to. Is there a way to make this settlement/sanction confidential?

Unfortunately no. MCL 333.16216(6) requires that the Michigan Department of Licensing and Regulatory Affairs (“LARA”) include on its public licensing and registration website each “final decision that imposes disciplinary action against a licensee, including the reason for and description of that disciplinary action.” This statute was amended effective January 1, 2015 expanding the information that is required to be made available to the public.

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

To comply with this requirement, LARA has been including links to copies of both the Administrative Complaint and the Consent Order and Stipulation agreed to following a settlement at a compliance conference on its website that is available to the public. Because these documents are now routinely being made available to the public in an easily accessible way it is more important than ever to insist the language of any Consent Order and Stipulation you agree to accurately reflect what was decided at the Compliance Conference. The compliance conference process is an excellent way to meet informally with the attorney general and the Board of Medicine member responsible for your case. At these conferences (which are confidential) you have the opportunity to view all the evidence the State has obtained in its investigation, hear how the Board of Medicine and any expert the State has retained views the situation, offer an explanation for your acts or inaction and to agree how the case should be resolved (i.e. what the sanction, if any, should be). Any agreement reached at a compliance conference is documented in a Consent Order and Stipulation. MICHIGAN MEDICINE

In my experience the State frequently “overcharges” physicians in Administrative Complaints. Often allegations of negligence, lack of competency and other defamatory violations of the Public Health Code are included when there is only evidence to support (which is readily admitted at the compliance conference) much more minor violations (e.g. a failure to document). The overcharging can be personal as well as professional (e.g. alleging a licensee has a substance abuse disorder which makes him/her a danger to patients based only on the only DUI conviction ever received by the licensee which occurred during nonbusiness hours). Taking advantage of the compliance conference process is wise (the only alternative is an expensive administrative hearing). However, it is more important than ever to pay attention to the wording of the Consent Order and Stipulation. The public and your patients will have access to this document. If all agree at the compliance conference that there was no negligence or incompetence and instead that you only failed to include adequate documentation in your medical records then the Consent Order and Stipulation should clearly indicate this. If the State refuses to agree to language stating that there was no finding that you were negligent or lacked competency you should seriously consider going to an administrative hearing where the State will be required to prove these allegations (and its failure to do so will be just as public as its success in doing so). March / April 2016

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M D H H S

U P D AT E Before children are two years of age, the Advisory Committee on Immunization Practices (ACIP) recommends vaccination to prevent 14 infectious diseases: measles, mumps, rubella, varicella, hepatitis A, hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzae type B (Hib), polio, influenza, rotavirus, and invasive pneumococcal disease.

Over a Third of Young Children in Michigan Are Susceptible to Vaccine Preventable Diseases CRISTI BRAMER, MPH, MCIR EPIDEMIOLOGIST, MDHHS DIVISION OF IMMUNIZATION

accines are our best defense against these infections, which may cause serious complications, even death. A Centers for Disease Control and Prevention (CDC) analysis conducted in 2014 concluded that routine childhood vaccination will prevent 322 million cases of disease and about 732,000 early deaths among children born during 1994–2013 in the United States.1 To monitor immunization coverage among children aged 19 through 35 months in the United States, the CDC conducts the National Immunization Survey (NIS). The NIS is a telephone survey of parents followed by a mailed survey to children’s immunization providers that began data collection in 1994. When the first NIS data were released, Michigan had the lowest immunization coverage in the nation. In response, we implemented several initiatives to increase immunization coverage including, but not limited to, immunization campaigns (Immunize Your Little Michigander), the Michigan Advisory Committee on Immunization (MACI), and development of the statewide immunization registry (the Michigan Childhood Immunization Registry, now the Michigan Care Improvement Registry, or MCIR). The federal Vaccines for Children (VFC) program, launched in 1994, supported our efforts to increase children’s vaccination rates. Michigan’s immunization coverage subsequently increased and in the past 20 years we have not ranked at the bottom of the NIS standings again – in fact, in 2009 and 2010 we had the 5th highest coverage in the nation. On August 28, 2015, data from the 2014 NIS survey were released and Michigan was ranked 47th in the nation with 65 percent vaccination coverage; the survey reported a 5 percent decrease in coverage from

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March / April 2016

the 2013 point estimate.2 While there are limitations to surveys, the MCIR has become a reliable tool for assessing childhood vaccination coverage and these data also show a slight decrease in 19 through 35 month vaccination coverage. Following the release of the 2014 NIS data, the MDHHS Division of Immunization has endeavored to understand why immunization coverage is dropping in Michigan’s children. An increasingly complicated vaccination schedule, increased number of vaccines recommended, alternative vaccination schedules, and a reduction of VFC providers are some of the challenges faced by today’s immunization providers and parents. MCIR data show that many children in Michigan are not receiving their vaccines on time. To help pinpoint when kids are missing their vaccines we assessed vaccination status for one month cohorts of kids at age 1, 3, 5, 7, 16, 19 and 24 months; these ages correspond to the end of a recommendation period for one or more vaccines. As of January 17, 2016, only 70.9 percent of kids 3 months

of age were up-to-date for their recommended vaccines, at 5 months only 65.6 percent kids and at 7 months just over half, 53.2 percent, are up-to-date.

National data show that there are two primary factors that contribute to children falling behind from one milestone to the next: 1. Some children DO NOT have a vaccination visit during the time period, and 2. Some children who had a vaccination visit DID NOT receive all of the vaccinations that were due, resulting in missed opportunities for simultaneous vaccination.3 You can use MCIR to assess your practice’s vaccination coverage. There are also existing educational resources available to provider offices, including free immunization nurse education sessions and the Physician Peer Education Project on Immunization, and both are approved for continuing medical education credit (visit www.aimtoolkit.org – click on “health care professionals” and “education

and trainings”). You can find your county’s immunization coverage on the county immunization report cards (available at www.michigan.gov/immunize - click on “Local Health Departments”). A variety of new strategies are being explored by MDHHS to increase vaccination coverage. We encourage you to ensure that all of your patients are protected from vaccine-preventable diseases and to implement evidence-based strategies for increasing immunization rates in your practice (see http:// www.thecommunityguide.org/vaccines/index.html). REFERENCES Whitney CG, Zhou F, Singleton J, Schuchat A. Benefits from immunization during the Vaccines for Children program era—United States, 1994–2013. MMWR Morb Mortal Wkly Rep 2014;63:352–5. 1

Hill HA, et al. National, State, and Selected Local Area Vaccination Coverage Among Children Aged 19-35 Months – United States, 2014. MMWR Morb Mortal Wkly Rep 2015; 64(33);889-896.

Luman, Elizabeth, PhD, Chu, Susan, PhD, MSPH. When and Why Children Fall Behind with Vaccinations: Missed Visits and Missed Opportunities at Milestone Ages. Am J Prev Med 2009;36(2);105–111. 3

Serving healthcare providers for over 30 years

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CO R N E R

Telemedicine in Michigan: What Physicians Need to Know BY PATRICK J. HADDAD, JD KERR, RUSSELL AND WEBER, PLC, MSMS LEGAL COUNSEL1

elemedicine continues to evolve as an innovative means of providing patients with enhanced access to quality medical care through the use of technology in medically appropriate circumstances, as an alternative to conventional in-person encounters. Although there is

no universal definition, “telemedicine” is often used to describe the furnishing of clinical health care services to patients from distant sites through the use of electronic information and telecommunications technologies. Another term, “telehealth,” is commonly used to refer to a wider range of clinical and non-clinical health services furnished by technology.

This publication is furnished for informational purposes only. It does not communicate legal advice by the Michigan State Medical Society or Kerr, Russell and Weber, PLC. Receipt of this publication does not establish an attorney/client relationship. © 2016 Kerr, Russell and Weber, PLC 1

Read a “Telemedicine in Michigan: What Physicians Need to Know’’ Legal Alert online at www.msms.org/ AboutMSMS/News/tabid/ 178/ID/3820/ Telemedicine-in-Michigan-WhatPhysicians-Need-to-Know.aspx

Limitations on Commercial Health Plan Coverage for Telemedicine Services The Michigan Insurance Code was amended in 2012 to facilitate coverage for telemedicine services. The Insurance Code prohibits health insurers and HMOs from requiring face-to-face contact between a health care professional and a patient for services appropriately provided through telemedicine, as determined by the insurer or HMO. Telemedicine services must be provided by a health care professional who is licensed, registered, or otherwise lawfully authorized to engage in his or her health care profession in the state where the patient is located. Telemedicine services are subject to all terms and conditions of the policy, certificate, or contract covering the patient including, but not limited to, required copayments, coinsurances, deductibles, and other approved amounts. MCL § 500.3476(1). MICHIGAN MEDICINE

“Telemedicine,” as defined in the Insurance Code, means “the use of an electronic media to link patients with health care professional in different locations.” To qualify as telemedicine, the health care professional must be able to examine the patient “via a real-time, interactive audio or video, or both, telecommunications system” and the patient “must be able to interact with the off-site health care professional at the time the services are provided.” MCL § 500.3476(2). Importantly, in order for telemedicine services to be covered by an insurer, HMO, or self-funded plan, the services must comply with all requirements specified by the payer, which may choose to cover telemedicine services only in limited circumstances. Physicians will need to check each payer’s coverage and reimbursement criteria, including the CPT codes and modifiers which the payer will accept, whether the payer requires prior authorization, whether physicians are prohibited from billing patients for telemedicine services if not covered by the payer, and whether the payer has established additional standards that must be satisfied as a condition of payment. March / April 2016

Priority Health’s telemedicine policy illustrates how some payers approach telemedicine. Under Priority Health’s policy, evaluation, management and consultation services using synchronous (i.e., real time) technologies may be considered medically necessary when all of the following conditions apply: • The patient must be present at the time of consultation; and • The consultation must take place via an interactive audio and/or video telecommunications system and the provider must be able to examine the patient in real-time. Interactive telecommunications systems must be multi-media communication that, at a minimum, include audio equipment permitting real-time consultation with the patient and the consulting practitioner; and • A permanent record of telemedicine communications relevant to the ongoing medical care of the patient should be maintained as part of the patient’s medical record; and

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• Services delivered through a telemedicine modality shall be provided by a health care professional who is licensed, registered, or otherwise authorized to engage in his or her health care profession in the state where the patient is located; and • Appropriate informed consent is obtained which includes all of the information that applies to routine office visits as well as a description of the potential risks, consequences and benefits of telemedicine. Priority Health specifies other criteria for evaluation and management services furnished by asynchronous technologies (which Priority defines as any type of online patient-provider consultation where electronic information is exchanged involving the transmission via secure servers). In addition, telemonitoring services (i.e., the use of information technology to monitor patients at a distance) are permitted only in specified circumstances.

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Priority Health excludes various services from its definition of “telemedicine” services including, but not limited to, the following: • Administrative services such as appointment/diagnostic test scheduling, or updating patient information; • Store and forward telecommunication; • Brief patient interactions such as requests for a referral, clarifying simple instructions, providing education materials, reporting normal test results, or refilling or renewing existing prescriptions without a substantial change in clinical situation; • Brief patient discussions to confirm the stability of a patient’s chronic condition or condition following a medical procedure without any change in current treatment or without indication of complication or new condition; • When information is exchanged and further evaluation is required such that the patient is subsequently advised to seek face-to-face care within 48 hours; and • Services that would similarly not be charged for in a regular office visit.

Blue Cross Blue Shield of Michigan and Blue Care Network have announced two initiatives for telemedicine services. Both organizations have contracted with American Well® to provide online physician visits to members using the Amwell™ online health care technology. This is available to members of self-funded groups which have opted to receive this benefit effective January 1, 2016. BCN fully insured individual and group members will also have this benefit effective January 1, 2016. Blue Cross will expand its offerings to include fully insured individual and group members effective July 1, 2016. This benefit presently is not available to Medicare or Medicaid members. The other initiative is for physicians who are not affiliated with American Well®. Blue Cross Blue Shield will provide reimbursement to providers credentialed to perform evaluation and management services for HIPAA-compliant online services for members of any self-funded group that opts in as of January, 2016. After July 1, 2016, the code will be reimbursable to Blue Cross providers for all insured individual and group members. Blue Cross will keep physicians and other providers informed in The Record.

Blue Care Network has established its own special guidelines: • Participation is limited to primary care physicians. • Online visits can be conducted with established patients only. • Special software must be used to structure an automated clinical encounter. Online visits are not covered for BCN AdvantageSM members. • For Healthy Blue LivingSM HMO members, online visits cannot be used for the initial visit required to complete the Blue Care Network Qualification Form, but can be used for other visits, as appropriate. • For online visits, all physician consultative services must be documented in the member’s medical record. BCN reserves the right to audit these records and confirm billing integrity and accuracy. Online visits are subject to retrospective review. More information and billing guidance related to BCN participating providers is available in the Claims section of the BCN Provider Manual. 12

Medicare and Medicaid Telemedicine Standards MEDICARE Medicare Part B will reimburse for qualifying telemedicine services only in limited circumstances. Telemedicine services must be furnished by a licensed physician or other practitioner (i.e., the distant site practitioner) to an eligible beneficiary via an interactive audio and video telecommunications system that permits real-time, face-to-face interactive communication between the physician and the patient. Medicare beneficiaries are eligible for telemedicine services only if they are presented from an originating site located in a rural health professional shortage area located either outside of a Metropolitan Statistical Area or in a rural census tract, or in a county outside of a Metropolitan Statistical Area. Eligible originating sites include the offices of physicians or practitioners; hospitals; critical access hospitals; rural health clinics; federally qualified health centers; hospital-based or CAH-based Renal Dialysis Centers (including satellites); skilled nursing facilities; and community mental health centers. However, independent renal dialysis facilities are not eligible originating sites. Telemedicine services must be furnished by a qualified practitioner at a qualifying originating site (e.g., physician offices, hospitals, skilled nursing facilities). 42 C.F.R. § 410.78. The Centers for Medicare & Medicaid Services annually revises Medicare’s standards for reimbursement for telemedicine services. When submitting claims to Medicare for telemedicine services, physicians and other practitioners will need to use the appropriate CPT or HCPCS code for the professional service along with the telemedicine modifier GT, “via interactive audio and video telecommunications systems.” Medicare’s list of covered telemedicine services is available on the CMS website.

MICHIGAN MEDICAID PROGRAM The Michigan Medicaid Program imposes similar limitations on telemedicine as Medicare, with some differences. While Michigan Medicaid’s list of eligible originating sites is similar to Medicare’s, Michigan Medicaid does not require an originating site to be located either outside of a Metropolitan Statistical Area or in a rural census tract, or in a county outside of a MetropolMICHIGAN MEDICINE

itan Statistical Area. Claims to Medicaid for telemedicine services also use the telemedicine modifier GT. Procedure code and modifier information is contained in the MDHHS Telemedicine Services Database available on the MDHHS website. Distant site providers (i.e., physicians or other licensed practitioners) must be enrolled in Michigan Medicaid. There are no prior authorization requirements when providing telemedicine services for Medicaid fee-for-service beneficiaries. However, authorization requirements for beneficiaries enrolled in health plans contracted to the Michigan Medicaid Program may vary. Physicians and other practitioners must check with individual Medicaid health plans for any authorization, coverage or other requirements.

RECOMMENDED PRACTICES Listed below are recommended practices and issues which Michigan physicians should be aware of when furnishing telemedicine services. Practices and issues are not presented in any order of priority.

• Use Telemedicine in Medically Appropriate Circumstances. Telemedicine should be used only in medically appropriate circumstances. To mitigate professional liability and licensing risk exposures, physicians should not use telemedicine when the prevailing medical standard of practice calls for an in-person encounter. In the event of medical emergencies, patients should be directed to hospital emergency rooms or to dial 911.

• Licensing Compliance. A physician or

other health care professional must be licensed, registered or otherwise authorized by law to engage in his or her health care profession in the state where the patient is located.

• Prescribing Medications Generally— Michigan Law. Physicians must exercise

professional judgment and discretion before deciding whether to prescribe medications on the basis of a telemedicine encounter. There must be an existing and valid physician/patient relationship. Michigan is one of a handful of states that do not, by statute or regulation, mandate an in-person examination before a physician may prescribe medications. Nevertheless, a physician March / April 2016

may have an exposure to a professional liability claim, as well as a licensing action, if the standard of medical practice would require an in-person examination before prescribing medication. In contrast to prescriptions issued pursuant to a bona fide telemedicine encounter, the Michigan Board of Pharmacy, the National Association of Boards of Pharmacy, and the Federation of State Medical Boards all consider prescriptions issued pursuant only to an internet questionnaire to be invalid, because there is no existing physician-patient relationship when the physician and patient have not interacted except on the basis of an online questionnaire.

• Prescribing Medications Generally— American Medical Association Policy Guidelines. AMA policy guidelines

provide that a patient-physician relationship generally must be established before medication can be prescribed through a telemedicine encounter. The physician must (i) obtain a reliable medical history and perform a physical examination of the patient, adequate to establish the diagnosis for which the drug is being prescribed and to identify underlying conditions and/or contraindications to the treatment recommended/provided; (ii) have sufficient dialogue with the patient on treatment options, risks and benefits; (iii) as appropriate, follow up with the patient to assess the therapeutic outcome; and (iv) maintain a contemporaneous medical record, including the prescription information. If telemedicine technology is used to establish a physician-patient relationship, a video component is needed to facilitate a face-to-face encounter which is necessary to prescribe medications; ordinary telephone calls and email communications are insufficient. Exceptions to the above requirements can arise in on-call or cross-coverage situations, emergency medical treatment, in other circumstances recognized as meeting or improving the standard of care, or when medication is prescribed in consultation with another physician who has an ongoing professional relationship with the patient and who has agreed to supervise the patient’s treatment, including use of any prescribed medications.

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• Prescribing Medications—Controlled Substances. Physicians must exercise

caution before prescribing controlled substances during a telemedicine encounter, in light of intentionally restrictive U.S. Drug Enforcement Administration compliance obligations and law enforcement risks designed to combat unlawful diversion and internet mills. A prescription for a controlled substance cannot be lawfully prescribed on the basis of a telemedicine encounter unless the prescribing physician has conducted at least one (1) in-person medical evaluation of the patient, subject to limited exceptions that will not be available to most physicians and other prescribers. An “in-person medical evaluation’’ means a medical evaluation that is conducted with the patient in the physical presence of the practitioner, without regard to whether portions of the evaluation are conducted by other health professionals. Even if the minimum one (1) in-person encounter requirement is satisfied, the prescription must be issued for a legitimate medical purpose in the usual course of prescriber’s professional practice, which are longstanding legal requirements applicable to all prescriptions for controlled substances. Federal law provides that nothing is construed to imply or suggest that a one (1) in-person medical evaluation demonstrates compliance with these standards; i.e., all of the facts and circumstances surrounding the issuance of the prescription must be evaluated. Prescribers who fail to comply with the in-person medical evaluation requirement, and any pharmacy that knowingly or intentionally fills such a prescription, violate the Controlled Substances Act.

• Professional Liability Insurance Coverage. Physicians should review their

professional liability policies to confirm coverage for telemedicine services or whether exclusions may apply. The insurer or insurance agent should be contacted as needed and to determine whether the insurer has any recommended risk management practices. • Informed Consent. As in any conventional encounter, informed consent must be obtained with respect to a telemedicine encounter. Michigan is one of several states which, by statute or regulation do not expressly require MICHIGAN MEDICINE

a patient’s informed consent in order to furnish services via telemedicine. However, physicians remain responsible to ensure that patients are aware of the potential benefits and risks associated with receiving services via telemedicine, and that the patient consents to receiving services via telemedicine. Evidence of the patient’s informed consent should be maintained in the patient’s medical record, as is the case for a conventional encounter.

• Maintain Medical Records for Telemedicine Services. Michigan licensed physi-

cians are obligated to maintain medical records for telemedicine services as they would for any conventional, face-to-face encounter. There is no exception from professional liability or licensing risks for failure to do so.

• Comply with Third Party Payer Billing Requirements. Before furnishing and

billing payers for telemedicine services, physicians need to understand and to comply with each payer’s requirements. In general, each payer has the right to establish its own terms and conditions.

• Mitigate Post Payment Audit Risks.

As in any encounter, it is critical for physicians to accurately document in the clinical record all clinical and other information required to substantiate the claim as coded and billed. Physicians furnishing services by telemedicine are exposed to post payment audit risks as they are for services furnished during conventional encounters.

• Use HIPAA Compliant Technology which is Reliable. Physicians are responsible to comply with HIPAA’s privacy and security rules when furnishing telemedicine services. Physicians should verify whether their telecommunications vendors use HIPAA compliant technology. In addition, the technology must be reliable. If the telecommunications equipment is defective or otherwise fails during a patient encounter, the patient or physician may receive inaccurate information, which could result in injury to the patient. Physicians should seek to negotiate vendor responsibility within their contracts to encourage a high level of technology performance. In addition, physicians should determine whether they have liability insurance coverage in such circumstances.

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March / April 2016

www.MSMSInsurance.org

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Eliminates the need for you or your practice to contact insurers for billing purposes; Has direct access to the insurer’s systems to add, terminate or change a subscriber’s information within 24 hours, which removes the administrative burden from you and your staff; Will research claims inquiries and benefit questions for you or the subscriber, which will eliminate the frustration of contacting a complex customer service center; and, Handles all COBRA administration for groups with more than 20 employees, free of charge, thus removing another administrative burden.

You always get more with MSMS Physicians Insurance Agency because we focus on you.

For more information or to request a quote for affordable, high-quality health insurance, please connect with Beth at 877/742-2758 or belliott@msms.org. Volume 115 • No. 2

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M S M S

A L L I A N C E

Report on the Status of the MSMS Alliance Works in Progress BY CLARA SUMEGHY, PRESIDENT, MSMS ALLIANCE

Immunization: A Major Concern

My objective today is to report on the status of the Michigan State Medical Society Alliance and our works in progress. As an Alliance of physician spouses and partners, we work for the common good of our communities, our families, and the profession of medicine. Our 16-county state Alliance is an important link in the National Federation (AMAA) with whom we share the common mission of improving the health and wellness of all our citizens. Unfortunately, we also share a common concern—that of shrinking membership. For example, Saginaw is exploring a union with Midland and Kalamazoo is merging with Calhoun, while Muskegon is on hiatus. Nevertheless, we forge ahead.

In 2013, we learned that Michigan ranked 48th among the 50 states in Childhood Immunization. Our Alliance went to work. While the dismal statistics were unacceptable, the greater shock was to learn that our “best educated” citizens were the least likely to be current on vaccinations of their own children. In fact, the state of Michigan made it all too convenient for parents to opt out of vaccinating their children—thereby putting both their children and their communities at risk. In order to have an impact, education on childhood immunization must begin at an early stage. Former MSMSA President Cindy Ackerman and MSMSA Legislative Chairman Karin Maupin continue to make advances with an Educational Initiative on Immunization. During Cindy's presidency (2013-14), the MSMS Foundation approved an education grant to Michigan counties for the purpose of dispelling the many dangerous myths surrounding childhood immunizations. Based on positive feedback to their several statewide seminars on the subject of childhood immunization, they were able to channel the remaining funds to a committee charged with finding the most effective means of educating the public.

Two ideas are currently being explored: (1) to give every new-birth mother a “growth chart” showing information on the vital need for and optimal timing of immunizations, and (2) to provide doctor’s offices with posters on childhood immunization. The MSMSA would be responsible for distributing the charts and posters to all counties. About a year ago, the Alliance joined the Immunization Stakeholders Group, recently renamed the Parent Information Network. Commonly known as PIN, this group, together with Michigan Public Health and Human Services, concluded that it is in the public interest to institute a policy change to ensure that all children are up-to-date on vaccinations before they can even attend school. As of the start of each school year, parents who want a waiver from vaccinations must now go to their local Public Health Department to get educated. If their child has not been vaccinated, he or she cannot attend school. Period. Just as in most countries in the developed world. Initial results are indeed impressive. In 2014, 4.6% of schoolchildren in the state received immunization waivers. In 2015, that rate fell to 2.8%, or nearly 8,000 fewer waivers.

“The primary tool for advancing our mission is advocacy. Thus, in partnership with you and the AMA Alliance we continually work to develop, implement and support educational programs that benefit public health. We also serve as a resource for our County Alliances. Through advocacy, we try to inform our Legislature, as well as our own Alliance Members, about issues that may have an impact on public health and/or the practice of medicine.”

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Despite the progress achieved thus far, we still have an uphill battle to counter the misinformation and ignorance regarding immunizations. For example, Lansing Representative Thomas Hooker has introduced legislation (HB 5126 and HB 5127) to prohibit the MDHHS from enforcing waiver requirements that are not mandated by state law, including the aforementioned educational discussions on immunization. His proposed legislation would also prohibit local health officials from pulling a non-immunized child out of school even under the threat of a communicable disease — unless that threat amounts to an epidemic. This is just one egregious example of why our continuing support and involvement in the PIN is vital. In response, Alliance members throughout the state participated in a letter-writing campaign to all members of the Health and Policy Committee urging lawmakers to reject the Hooker Bills. This dangerous legislation could effectively reverse the positive impact on Michigan’s improved childhood immunization rate. It must be defeated. We are now waiting to learn when the Hooker Bills will be scheduled for a public hearing by the House Health Policy Committee. Our Alliance, of course, is ready to mobilize to attend this hearing. In related news, on January 28, the DHHS released their highly-anticipated report on the effectiveness of the new rules regarding school-children-immunization waivers. That same morning, PIN coordinated four simultaneous press conferences in Lansing, Grand Rapids, Southfield, (southeast Michigan) and Traverse City. Physicians talked about the importance of immunizations, health department officials discussed the decline in waiver rates, and parents shared their family experiences. Our Alliance members were present to show our strong support to the participants. In addition to the Immunization issue, we are working closely with MSMS staff to remain current on legislation requiring our Alliance’s assistance. To further this objective, we plan to hold an “Alliance Legislative Day at the Capitol” in March. Volume 115 • No. 2

Awards & Events

Other County News

In June 2015, at the AMA Alliance (AMAA) Annual Meeting in Chicago, our Alliance won 3 out of 6 possible awards. This was the first time that any one State Alliance received three AMAA awards. Moreover, one County Alliance managed to take 2 First Place awards.

Washtenaw County collected over 100 bags of personal items for Safe House, their domestic violence shelter in Ann Arbor. They also obtained a proclamation for ‘Save Day’ from Mayor Christopher Taylor of Ann Arbor.

Kent County Medical Society Alliance received the AMAA Health Awareness Promotion Fundraising County Award. First Place: “Children’s Charity Ball” — chaired by KMSA president elect Karen Begrow Kent County Medical Society Alliance received the AMAA Legislative Education & Awareness Promotion Award. First Place: “Immunization Conference” — chaired by KMSA President Elizabeth Junewick Tri-County Medical Society Alliance received the AMAA Health Awareness Promotion New Projects Award. Honorable Mention: “Deciphering Facts and Myths About Childhood Immunizations” booklet In addition to the preceding awards, we cannot forget the groundbreaking work in 2014 by the Genesee County Alliance in bringing the problem of Human Trafficking in Michigan to public notice. They were recognized by the AMAA in Chicago with Honorable Mention by the AMA Alliance HAP (Health Promotion) Award. Through their annual seminars, they continue to advance this important work. On October 7, 2015, I attended the 150th Anniversary of the Michigan State Medical Society. Our Alliance was honored and pleased to participate in predicting the course of medicine during the next 50 years. It would be fun, though quite unlikely, to see the results of our predictions in 2065. But, with the speed of scientific advances, who knows? Governor Rick Snyder declared October 14, 2015 as “SAVE Today,” and presented the Alliance with the Certificate of Proclamation during our “SAVE” (Stop America’s Violence Everywhere) campaign’s 20th anniversary celebration in Lansing. Julie Novak has kindly framed the certificate, which is now hanging downstairs in the newly-decorated Alliance Room, alongside other Alliance accolades. MICHIGAN MEDICINE

Ingham County hosted a luncheon following a period of several years’ inactivity. For their ‘SAVE Day’ shelter, they also collected much needed over-the-counter medications. In October, Marquette Alger County held their 10th annual Shower for Harbor House, the local domestic violence shelter. In addition to household furnishings, they collected $1,700. Saginaw County held their annual ‘Jingle Mingle’ fundraising event on Dec 7. With help from the Saginaw Medical Society, they raised $3,500 which will provide scholarships of $500 each to seven nursing students. In addition, they collected bags of personal care items for their Community Center. Oakland County and Jackson County collected bags of personal care items for their Domestic Shelters. Wayne County obtained a proclamation for ‘Save Day’ from Warren C. Evans, Wayne County Executive. They also contributed $500 to WCMSSM Foundation’s Annual Children’s Holiday Party held Dec 12, 2015. The children also received a copy of each AMAA booklet: Hands Are Not For Hitting; I Can Be Healthy; I Can Choose; and, I Can Handle Bullies. Finally, Kent County just held their annual Children’s Holiday Party on Jan 30 capping a successful fundraising year with $100,000 in 2015.

In conclusion, our Medical Alliance as always will continue our work to advance the health of Michigan through advocacy and action. Together we can accomplish much.

Rural Practices: Founded in Family and Community

From Monroe to Marquette, when it comes to practicing medicine in a rural area of Michigan, our physicians see their job not as a challenge, but an opportunity to care for people who need it the most.

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MONROE Monroe Family Legacy

hen Jonathan Pasko, MD, a solo primary care Internist and Pediatrician, started with medical school then residency in Wayne State University/DMC, he set out to care for the most in need. Doctor Pasko explains, “Coming back to Monroe, my hometown, allows me to care for people who live in the community where I grew up. Living in and being a part of this culture helps me to care for people better. My care is timely, appropriate and given in the context of when, where and how my patients live” Doctor Pasko’s father, John E. Pasko, MD, a General Surgeon, practiced for over 40 years in Monroe and his mom, Rosalie Pasko, was a Medical Technologist for over 25 years at their local hospital. Doctor Pasko says, “My family, growing up, was a part of the local culture and medical community. I have heard stories from many long-time residents about how my dad cared for them when they were in need.” Doctor Pasko emphasizes the importance of having support from like-minded specialists, especially in underserved regions. “I share an office with my wife, Laura Katz, MD, a solo OB/GYN and minimally invasive Robotic Surgeon. She helps give birth to babies then I take over from there. It is a holistic and family-centered approach to care and one that I would not trade for the world.” Although Monroe is a small community, Doctor Pasko has become involved in several groups and initiatives that benefit the community and help him become a better physician. Doctor Pasko sits on the board of Monroe Alliance of Physicians (MAP). Being heavily involved in the group allows him to continue his practice as a solo physician while using the collective bargaining power of his colleagues to negotiate with insurance companies. Doctor Pasko explains, “MAP helps me stay in touch with a larger world of incentives for value-driven care.”

JONATHAN PASKO, MD SOLO PRIMARY CARE INTERNIST AND PEDIATRICIAN

LAURA KATZ, MD SOLO OB/GYN AND MINIMALLY INVASIVE ROBOTIC SURGEON

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MARQUETTE Marquette-based Dream Team

hristopher Dehlin, MD, and Jennifer Dehlin, MD, longtime Marquette residents and practicing physicians are very aware of the challenges that come along with practicing in a rural, underserved area of Michigan. Doctor Jennifer Dehlin explains, “Most specialty groups up here are small, and so provider turnover can result in significant patient access issues. For example, the wait time to see a psychiatrist in Marquette right now is one year. As a result, the primary care physicians need to work to the edge of their comfort zones to take care of people” Though the couple recognizes the challenges of practicing in Marquette, they could not imagine being anywhere else. With family in the area and several nearby towns, it is very important to them to be home. They also take advantage of the outdoor sports available in Marquette. Doctor Christopher Dehlin adds, “We have world-class Nordic and mountain bike trails, we’re seven minutes from our ski hill and five blocks from the beach.” As a team, Doctors Christopher and Jennifer Dehlin have recently filed paperwork to start their own medical practice in Marquette - Singletrack Health PC. In partnership with Stevens Hardie Family Practice they will offer the full scope of family medicine including inpatient, outpatient, nursing home and obstetrical services. Doctor Jennifer Dehlin explains what inspired them to make this move, “We think that as healthcare delivery evolves we will be better prepared for changes if we are running a small, nimble, high tech practice. We’ve been surprised by how enjoyable it’s been to work with other professionals in the community to get our business started and the support and encouragement from area physicians and the hospital.”

CHRISTOPHER DEHLIN, MD

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JENNIFER DEHLIN, MD

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State Resources for Rural Physicians

➤ Conrad State 30 Program

he federal government recognizes Health Professional Shortage Areas (HPSA) and Medically Underserved Areas and Populations (MUA/P) in Michigan, which are visualized in maps found on their website. The maps show “designated” HPSA and MUA/P areas throughout the state. These designations are used to determine eligibility for state and national programs. In addition to providing the HPSA map, the federal Health Resources and Services Administration (HRSA) provides a service allowing physicians and residents to verify whether their address is considered part of an HPSA. This tool can be accessed at http://datawarehouse. hrsa.gov/tools/analyzers/geo/ShortageArea. Along with providing resources to identify underserved areas, the state of Michigan recognizes the importance of supporting rural physicians and offering them with the programs and assistance they need to be successful and best serve their patients. The following programs are designed to support rural physicians and their practices:

Under the Conrad State 30 Program, Michigan accepts applications from physicians on J-1 Visas who want to waive the two-year home residence requirement in exchange for a commitment of three years of service in an underserved area. Michigan may sponsor up to 30 physicians each fiscal year. Priority is given to safety net providers, primary care physicians and placements in Health Professional Shortage Areas.

Go to www.michigan.gov/conrad30 for more information.

➤ MSMS Medical Opportunities

MSMS Medical Opportunities, a job search website designed to connect physicians directly with private practice and hospital employers, is a partnership with the Michigan Health Council. Physicians register for free on the site and can make themselves available to employers or just browse the job market. Posted job opportunities include detailed information on the community, practice environment, employer size and benefits offered. Recruiting resources are also available for private practices, critical access hospitals or large health systems.

Go to http://msms.medopps.org for more information.

➤ Michigan Center for Rural Health

The Michigan Center for Rural Health (MCRH) assists both Critical Access Hospitals and Rural Health Clinics. MCRH provides training of on-site recruitment coordinators, represents rural Michigan at conferences, develops site specific marketing, promotes collaboration and helps rural sites navigate state and federal loan repayment, as well as the National Health Service Corps Scholar Program and Health Professional Shortage Area status.

Go to www.mcrh.msu.edu/Default.aspx for more information.

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➤ Michigan’s Rural Recruitment and Retention Network

➤ National Health Service Corps Scholarship Program

The Rural Recruitment and Retention Network (3RNet) website lists job opportunities for physicians at Critical Access Hospitals and Rural Health Clinics in rural Michigan. Registering for an account with 3RNet is free and allows physicians to browse job postings and be contacted about opportunities. Many job opportunities posted on the website are eligible for loan repayment.

Go to www.3rnet.org/locations/michigan for more information.

The federal Health Resources and Services Administration National Health Service Corps (NHSC) Scholarship Program pays tuition, fees, other educational costs and provides a living stipend for students committed to primary care in return for a commitment to work at least 2-years in an underserved community. Service begins in a high-need area upon completion of primary care residency training. Scholarship payments, other than the living stipend, are federal income tax-free.

Go to www.nhsc.hrsa.gov/scholarships/index.html for more information.

➤ Michigan State Loan Repayment Program

Michigan administers the Michigan State Loan Repayment Program (MSLRP) to encourage qualified doctors to practice in Health Professional Shortage Areas in Michigan. MSLRP will assist those selected by providing $50,000 in tax-free funds to repay their educational debt in exchange for working in an underserved area for two years. Participants compete for the renewal of the contract of up to three more times for a total of eight years and up to $200,000 in loan repayment. 40 percent of the loan repayment is funded by the state, 40 percent by the federal Health Resources and Services Administration and 20 percent by the participant’s employer. Go to www.michigan.gov/mslrp for more information.

➤ National Interest Waiver Program

The National Interest Waiver (NIW) Program allows international medical graduates to extend their commitment to practice in underserved communities in return for expediting their status as a permanent resident or citizen in the United States. The Michigan Department of Health and Human Services provides letters of support for NIW petitions.

Go to www.michigan.gov/niw for more information.

➤ Rural Health Clinic Certification

The Centers for Medicare and Medicaid Services (CMS) provides certification letters to Medicare participating clinics located in rural areas that are designated as shortage areas. The main advantage of the certification letter is to receive enhanced Medicare and Medicaid reimbursement rates.

Go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ CertificationandComplianc/RHCs.html for more information.

➤ National Health Service Corps Loan Repayment Program

The federal Health Resources and Services Administration offers the National Health Service Corps (NHSC) Loan Repayment Program for qualified doctors to work at an approved NHSC site in an underserved area. Providers may receive up to $50,000 in tax-free funds to repay their student loans in exchange for a two-year commitment in an underserved area. Participants may apply to extend their service commitment and receive additional funds after completing the initial two-year commitment. Applicants will be more likely to be selected for loan repayment if they are employed at approved practice sites with Health Professional Shortage Area scores of 14 or higher.

Go to www.nhsc.hrsa.gov/loanrepayment for more information.

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OBITUARIES The members of the Michigan State Medical Society remember with respect their colleagues who have died. Gordon Bartek, MD Ingham County Medical Society 11/27/15

Frank Cook, MD

Genesee County Medical Society 1/11/16

Richard Crissman, MD

Kent County Medical Society 12/1/15

Martin Daitch, MD

Wayne County Medical Society 2/1/16

Allan Hoekzema, MD

J. Thomas Powaser, MD

Kent County Medical Society 1/2/16

Wayne County Medical Society 12/10/15

Edward Hollenberg, MD

Robert VanderPloeg, MD Kent County Medical Society 1/25/16

Oakland County Medical Society 1/10/16

Francis Locke, MD

Lenawee County Medical Society 1/20/16

Roger Wassink, MD

Kent County Medical Society 1/9/16

William Nettleman, MD

Branch County Medical Society 12/29/15

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

Recruiting is hard work. We can help! MSMS Medical Opportunities connects Physicians and other health providers with Michigan’s health care employers. • •

Physician profiles and job searches are free, quick and effective. Job posting memberships begin at $500.

msms.medopps.org For membership information or to schedule a demo of MSMS Medical Opportunities, contact us at 800/479-1666 or recruitment@mhc.org. 24

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T H E

D O C TO R S

CO M PA N Y

There’s an App for That: Benefits and Risks of Using Mobile Apps for Healthcare BY ROBIN DIAMOND, MSN, JD, RN, SENIOR VICE PRESIDENT, PATIENT SAFETY AND RISK MANAGEMENT, THE DOCTORS COMPANY

ith over 100,000 mobile health apps now available—in addition to many new tools that allow physicians to remotely monitor their patients’ conditions—physicians now have to handle an increasing amount of constant data and patient information that they did not have in the past. Patients are using mobile apps to monitor their activity levels, track weight loss, improve medication adherence, and even track their blood pressure or blood sugar levels. Only 16 percent of healthcare professionals currently use mobile apps with their patients, but 46 percent plan to do so in the next five years.1

Mobile apps offer many potential benefits to doctors and patients • Mobile apps can help patients self-monitor their conditions and can alert them and their physicians to problems before they become serious medical issues. • Some of these apps are regulated by the FDA. For example, patients can monitor their heart rhythms with an FDA-approved device that wraps around their iPhone. 26

Mobile apps can engage patients in their healthcare Many patients today are interested in becoming as involved in their care as possible. One patient engagement platform that connects patients and physicians, Healthloop, markets its product as a way to have very satisfied patients who will publicly share their experience. This platform monitors compliance and adherence to the treatment plan; checks in with patients, thus eliminating phone calls; collects outcome data; educates and reinforces education; and identifies at-risk patients quickly to reduce readmissions.

Mobile apps can be a tool for patient education • A better-informed patient is more likely to understand risks and, if there is an adverse event, may be less likely to file a lawsuit. • Mobile apps help patients remember important information about their healthcare. Patient pamphlets and other educational materials are often lost or forgotten. Patients forget 80 percent of the information they are told and inaccurately remember an additional 10 percent, leaving patients with just 10 percent of the information remembered correctly. MICHIGAN MEDICINE

But not all of the apps currently on the market are approved or regulated by the FDA, and the use of mobile apps does not come without liability risks. The Doctors Company has not yet seen malpractice suits that involve mobile apps because the use of these apps to monitor patients is fairly new. Malpractice lawsuits may not be filed for several years after the adverse event, so with the increased use of mobile apps for healthcare, we expect there will be lawsuits involving mobile apps in the future. Physicians could face allegations of failing to educate the patient/family about the risks and limitations of the app or failing to act appropriately if the app goes offline or malfunctions. Product liability, negligence, contract law, and even malpractice tort law could be applied to possible causes of action in lawsuits brought because of an injury connected to use of a mobile app.

March / April 2016

Injuries could occur if: • The physician receives information from a mobile app and does not act on this information. Physicians have a legal duty to review real-time data direct from the patient and respond. Mobile apps raise patient’s expectations of how a physician will act—the patient/family expect that the patient is monitored 24/7 and the physician will respond “within a moment’s notice.” When an adverse event occurs, if a patient believes the physician failed to act on information from a mobile device, the patient might sue. If physicians don’t respond to information from an app, this will be recorded in the metadata, which can be used in court. • The readings received from a mobile device are wrong and treatment is prescribed based on the wrong data.

There are a lot of untested apps on the market that may be unreliable or even dangerous. Apps are also vulnerable to being hacked, resulting not only in potential loss of personal health information but also in potential malfunctioning of the app. • Patients rely on technology alone, leading to decreased phone contact with the physician when symptoms arise or there are changes in the condition that require immediate action.

REFERENCES Easy on those mobile apps: Mobile medical apps gain support, but many lack clinical evidence. Modern Healthcare. November 28, 2015. http://www.modernhealthcare.com/ article/20151128/MAGAZINE/311289981/easy-on-those-appsmobile-medical-apps-gain-support-but-many-lack. Accessed December 16, 2015.

While apps can be useful tools to support a comprehensive care plan, physicians need to educate their patients about the apps’ limitations and potential risks. Consider limiting your patients to one mobile app that you agree to monitor. This will make it easier to control the incoming data and help make the best use of the app.

Article contributed by The Doctors Company. Visit www.thedoctors.com/ patientsafety for more patient safety articles and practice tips.

Other important considerations n

Consider whether the two-way communication between you and your patient is secure and, therefore, HIPAA/HITECH compliant. Ask the vendor for assurance that the app is HIPAA-compliant and that data is encrypted for security.

Know the app:

—Vendor information, such as updates, downtime, and critical value alerts. —How will it interface with your EHR? —Is the device regulated by the FDA as a medical device? —Will you get alerts by e-mail or a phone call from the vendor when the app isn’t working? n

Beware of the possibility of lack of security when using public Wi-Fi with the app.

Clearly communicate and educate the patient/family about the purpose of the app and how and when the data is transmitted to the clinician.

Avoid assuring the patient that the app will “take care of everything.” Educate the patient/family about the limitations of the app, with specific examples of instructions for the patient to follow. For example, can the algorithm be changed for specific patient needs?

Identify a contact person within your organization to troubleshoot and be available to address technical problems.

Have patient/family sign a consent form describing the risks, benefits, and purpose of the app.

Do not do this alone! Avoid utilizing medical apps without support from your organization.

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Winter 2016 Education Course Offerings ON-DEMAND WEBINARS: EDUCATION WHEN YOU WANT IT!  Physician Executive Development Programs: • Health Care Law for Physicians in ACOs • Medicaid Issues and Trends: Outlook for 2014 and Beyond • In Search of Joy in Practice: Innovations in Patient Centered Care • From Physician to Physician Leader • Inter-Professionalism: Cultivating Collaboration • Financial Information Analysis, Budget Development, and Monitoring  Choosing Wisely  Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction  CDL-Medical Examiner Course  Legalities and Practicalities of HIT including: • Cyber Security: Issues and Liability Coverage • Engaging Patients on Their Own Turf: Using Websites and Social Media  Summary of the Affordable Care Act  HIPAA Security Rule  End of Life Concerns and Considerations  What’s New in Labor and Employment Law  Preparing for the Medicare Physician Value-Based Payment Modifier  Understanding and Preventing Identity Theft in Your Practice  Stepping Up to Stage 2  Physician On-line Rating and Reviews: Do’s and Don’ts  Patient Portals as a Tool for Patient Engagement  Health Care Providers’ Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities  Opioids & Michigan Workers’ Compensation

Visit www.msms.org/eo for complete listing of On-Demand Webinars.

2016 BILLING AND CODING COURSES ICD-10 CLEAN-UP

Date: Thursday, April 14 Time: 9:00 am to 12:00 pm Location: MSMS Headquarters, East Lansing

BILLING FOR NON-PHYSICIAN PRACTITIONERS

Date: Wednesday, May 4 Time: 9:00 am to 4:00 pm Location: MSMS Headquarters, East Lansing

BILLING 101

Date: Thursday, May 19 Time: 9:00 am to 4:00 pm Location: MSMS Headquarters, East Lansing

MSMS/MMBA BILLING WEBINAR SERIES AT NOON ON THE THIRD WEDNESDAY OF EACH MONTH. TOPICS COMING SOON!

For ALL Billing and Coding courses… Contact: Stacie Saylor 336-5722 or ssaylor@msms.org Intended for: Physicians, billers, coders and billing managers. For more information or to register on-line: www.msms.org/eo Questions? Phone MSMS Registrar at 517-336-7581

MSMS LUNCH-N-LEARN SERIES Grab a lunch, click the link, and join us! These FREE short and interactive monthly online updates are designed to explore key policy issues impacting physicians in the state of Michigan. It’s more than a presentation… insights are solicited from participants and interaction with our experts is encouraged. For more information and to register for one of our upcoming webinars, follow this link:

www.msms.org/Education/UpcomingWebinars.aspx

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Questions? Phone MSMS Registrar at 517-336-7581

EDUCATIONAL CONFERENCES  SUPPORTING END-OF-LIFE CARE

Date: Wednesday, March 16, 2016

Location: MSMS Headquarters, East Lansing

Intended for: Physicians, nurses, residents, students, and all health care professionals.

Note: Continental breakfast and lunch will be provided.

Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

 ANNUAL JOSEPH S. MOORE, MD CONFERENCE ON MATERNAL AND PERINATAL HEALTH

Date: Thursday, May 19

Location: Somerset Inn, Troy

Note: Continental breakfast and lunch will be provided

Intended for: Physicians, nurses, residents, students, and all health care professionals working with women and their infants.

Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

 SPRING SCIENTIFIC MEETING

Morning, afternoon and evening clinical courses available

Date: Thursday, May 19 and Friday, May 20

Location: Somerset Inn, Troy

Contact: Marianne Ben-Hamza 517-336-7581or mbenhamza@msms.org

Note: Continental breakfast and lunch will be provided

Intended for: Physicians and all other health care professionals

 151ST MSMS ANNUAL SCIENTIFIC MEETING

Morning, afternoon and evening clinical courses available

Date: Tuesday, October 25 through Saturday, October 29

Location: Sheraton, Novi 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

 PRACTICE SUSTAINABLITY

Details coming soon on this June 2016 conference.

Visit www.msms.org/eo for complete listing of Educational Conferences.

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MICHIGAN MEDICINE

Welcome New MSMS Members! 10-5-2015 to 11-20-2015 Ibrahim Abou Daya, MD, Saginaw Joseph Adel, MD, Saginaw Adebayo Akindele, MD, Genesee Priya Alagappan, MD, Marquette/Alger Wajdi Al-Shweiat, MD, Genesee Cindy Anderson, MD, Marquette/Alger Richard Armstrong, MD, FACS, Luce Tadesse Beyene, MD, Oakland Shelley Binkley, MD, Wayne Eric Bryant, MD, Calhoun Bret Burlingame, DO, Oakland Susan Caldwell, MD, Clinton Raza Cheema, MD, Genesee Forrest Cote, DO, Ingham Aaron Cutlip, MD, Marquette/Alger Fanny DelaCruz, MD, Oakland Jeffrey Desmond, MD, Washtenaw Veronica Dula, MD, Hillsdale Rita Eckenrode, MD, Washtenaw Joshua Ehrlich, MD, Washtenaw Luke Elliott, MD, Wayne Sara Elsayed, MD, Genesee Stephanie Fleming, MD, Ingham Jason Frost, DO, Kent Kathleen Fulcher, DO, Marquette/Alger Julie Gleesing, DO, Macomb Sandeep Grewal, MD, Genesee Sean Growney, DO, Ottawa Akhil Gulati, MD, Oakland Magdalene Gyuricska, MD, Genesee Ryan Hadley, MD, Kent Samantha Haken, MD, Marquette/Alger Evan Halchishick, DO, Oakland Maria Han, MD, Washtenaw Ali Harb, MD, Wayne Randy Janczyk, MD, Oakland Milena Jani, MD, Kent Hugh Kerr, MD, Oakland Steven Kronick, MD, Washtenaw Geoffrey Lam, MD, Kent Brian LeCleir, MD, Kent Randall Leja, DO, Kent Adam Lenger, MD, Kent Marie Lozon, MD, Washtenaw Tyson Luoma, DO, Marquette/Alger Maggie Lyles, DO, Branch John Mackovjak, MD, Isabella/Clare Lisa MacLean, MD, Monroe Daniel McClung, MD, Washtenaw Maureen Mead, MD, Alpena/Alcona/ Presque Isle Ricky Meyer, MD, Saginaw Eric Migoya, DO, Oakland John Mills, MD, Washtenaw Geetha Mohan, MD, Alpena/Alcona/ Presque Isle Sergio Montoya, MD, Jackson Claudia Nadernejad, MD, Kent Sudha Nallani, MD, Saginaw Jinny Oh, DO, Ingham Molly O’Kane, DO, Kent Mark Pankonin, MD, Saginaw Carmen Paredes Saenz, MD, Genesee Sana Patel, MD, Ingham Amish Patel, DO, Oakland Payal Patel, DO, Washtenaw Rosalie Pilbeam, DO, Kent Jeannette Prentice, MD, Kent Michael Prysak, MD, Wayne Navneet Randhawa, MD, Genesee Sandeep Randhawa, MD, Oakland Carrie Ricci, MD, Alpena/Alcona/Presque Isle Jennifer Rimmke, MD, Macomb Liana Rinzler, MD, Kent Emma Rodgers-Biebuyck, DO, Emmet Julie Rogers, MD, Kent Aliye Runyan, MD, Wayne

Shawna Ruple, MD, Midland Robyn Sackeyfio, MD, Kent Mohammed Saleem, MD, Genesee William Shepard, DO, Genesee Daniel Shumer, MD, Washtenaw Sukhpreet Singh, MD, Jackson Robert Smith, MD, Muskegon Cheryl Sobocinski, MD, Macomb Daniel Spear, MD, Kent Nicole Sroufe, MD, Washtenaw Karen Stacey-Erwin, MD, Lenawee Michael Stargardt, DO, Oakland Michael Sterrett, MD, Calhoun Terri Stillwell, MD, Washtenaw Stephen Swetech, DO, Macomb Nithin Thummala, MD, Wayne Ivy Vachon, MD, Marquette/AlgerΩ Siddharth Vannemreddy, MD, Genesee Alice Watson, MD, Oakland Melissa Wei, MD, Washtenaw David White, MD, Oakland Charles Wilmanski, MD, Calhoun Douglas Winstanley, DO, Kent Sandra Wisebaker, MD, Kent Donza Worden, MD, Alpena/Alcona/ Presque Isle Mina Zaki, MD, Wayne 11-23 to 1-29-2016 Garth Aasen, MD, Kalamazoo Sara Ahmed, MD, Washtenaw Desiree Aird, MD, Oakland Rita Akaraz-Avedissian, MD, Washtenaw Riad Al Natour, MD, Washtenaw Ambreen Allana, MD, Washtenaw Daniel Anderson, DO, Washtenaw James Applegate, MD, Kent Alex Argyelan, MD, Washtenaw Ryan Aronberg, MD, Washtenaw Sindhu Avula, MD, Washtenaw Bathmapriya Balakrishnan, MD, Washtenaw Pamela Baron, MD, Kalamazoo Farwa Batool, MD, Washtenaw Hassan Baydoun, MD, Washtenaw Dawn Becker, MD, Washtenaw Lorenzo Berlanga, MD, Midland Seth Bernard, DO, Genesee Lindsey Bewley, DO, Ingham Priyanka Bikkina, MD, Washtenaw Katrina Blanch, MD, Washtenaw David Blumenthal, MD, Washtenaw Bobby Boyanton, Jr, MD, Oakland Joshua Bradish, MD, Kalamazoo Michael Brozik, MD, Washtenaw Eve Brusie, DO, Ingham Jade Burch, MD, Washtenaw Katherine Caretti, MD, Wayne Jennifer Castillo, MD, Washtenaw Richard Cattaneo, MD, Washtenaw Myungwon Chang, MD, Washtenaw Timothy Chaprnka, DO, Kent Alexandra Chis, MD, Washtenaw Tendai Chiware, MD, Washtenaw Dennis Choi, MD, Washtenaw Raymond Cole, DO, Washtenaw Charles Croteau, DO, Kalamazoo Benjamin Davies, MD, Washtenaw Troy Davis, DO, Hillsdale Katherine Davis, MD, Washtenaw Kathleen DeHorn, MD, Kent Jeffrey Devries, MD, MPH Oakland Carter, DOcking, MD, Washtenaw Rajiv, DOddamani, MD, Washtenaw John, DOnkersloot, MD, Washtenaw Mark Drogowski, MD, Northern Taiwo Durowade, MD, Washtenaw Moushumi Dutta, MD, Washtenaw Ariadne Ebel, MD, Washtenaw

Andrew Egger, MD, Washtenaw Shafaq Ejaz, MD, Washtenaw Daniel Felling, MD, Washtenaw Garrett Fisher, DO, Ingham Jamie Frost, DO, Kent Danielle Gagnon, MD, Washtenaw Mala Gaind, MD, Oakland Brian Gallagher, MD, Washtenaw Quyen Garcia, DO, Ingham Sohaib Gilani, MD, Washtenaw Anshum Goel, MD, Washtenaw Sirisha Gokaraju, MD, Washtenaw Andrew Gordon, DO, Ingham Elizabeth Gordon Spratt, MD, Washtenaw Karen Guy, MD, Washtenaw Kevin Hannawa, MD, Kalamazoo Abdul Hasan, MD, Oakland Andrew Heaford, MD, Kent James Hecksel, DO, Kent Jennifer Hines, MD, Washtenaw Whitney Hitchcock, MD, Washtenaw Staci Hopkins, MD, Oakland Jeffrey Howe, MD, Washtenaw Ashley Huff, MD, Saginaw Michael Huvard, MD, Washtenaw Tonya Hyde, MD, Washtenaw Edwin Itenberg, DO, Oakland Miles Jackson, MD, Washtenaw James Jeltema, DO, Ingham Noah Jentzen, MD, Washtenaw Daniel Jeung, MD, Washtenaw Theodore John, MD, Washtenaw Shepard Johnson, MD, Washtenaw Zhyldyz Kabaeva, MD, Washtenaw Jacqueline Kabongo, MD, Washtenaw Palak Kachhadia, MD, Washtenaw Crystal Kavanagh, MD, Washtenaw Jeffrey Kedrowski, DO, Ingham Melissa Kennedy, MD, Oakland Sharif Kershah, MD, Wayne Ayesha Khan, MD, Washtenaw Rhami Khorfan, MD, Washtenaw Thomas Kim, MD, Kalamazoo Jared Knol, MD, Kent Mariko Kohlmeier, MD, Washtenaw Carranda Koop, MD, Washtenaw Edward Kreimier, MD, Washtenaw Elisa Kucia, MD, Washtenaw Tony Kuzhippala, MD, Washtenaw Michael LaFata, MD, Washtenaw Keith Langlois, MD, Washtenaw Eric Lerche, DO, Grand Traverse Melani Lighter, MD, Washtenaw Amber Liles, MD, Washtenaw Nathan Liles, MD, Washtenaw Robert Lin, MD, Washtenaw Talya Lorenz, MD, Washtenaw Laura Lozier, MD, Washtenaw Catriona Macardle, MD, Washtenaw Jarrod MacFarlane, DO, Kent Mahender Macha, MD, FACS Jackson Emily Maris, MD, Washtenaw Ruby Marr, MD, Washtenaw Marko Martinovski, MD, Washtenaw Ami Mavani, MD, Oakland Carmen McIntyre, MD, Wayne Jackie Michaels, DO, Ingham Eric Mitchell, MD, Kent Hrishabh Modi, MD, Washtenaw Andrew Moriarity, MD, Kent Kathryn Moseley, MD, MPH Wayne Sara Muszynski, MD, Washtenaw Mohammed Nabhan, MD, Washtenaw Rama Nagireddi, MD, Washtenaw Andrew Nash, MD, Kent Abby Navratil, MD, Washtenaw Kevin Nguyen, DO, Ingham Victoria Nichols, DO, Washtenaw

MICHIGAN MEDICINE

Stephanie Norris, DO, Washtenaw Johnna Nynas, MD, Washtenaw Nancy Omorodion, MD, Washtenaw Jennifer O’Neill, DO, Washtenaw Jill Onesti, MD, Kent Annelie Ott, MD, Washtenaw Tolutope Oyasiji, MD, Genesee Stephanie Pannell, MD, Washtenaw Caitlin Parker, MD, Washtenaw Ankit Patel, MD, Washtenaw Devin Patel, MD, Washtenaw Sylvester Paulasir, MD, Washtenaw Luke Pesonen, MD, Washtenaw Katherine Petrin, MD, Washtenaw Steven Petrovas, MD, Kent Naudia Pickens, MD, Ingham* *chose county she lives in, not works in Robert Pinney, MD, Lapeer Cara Poland, MD, Kent Adam Powell, DO, Ingham Edward Qiao, MD, Washtenaw Joanna Quigley, MD, Washtenaw Hera Qureshi, DO, Ingham Roger Ramcharan, MD, Washtenaw Patrick Rao, MD, Kent Balaguru Ravi, MD, Washtenaw Seth Raymond, DO, Kalamazoo Katherine Riddle, MD, Washtenaw Robert Riley, MD, Kent Leslie Rocher, MD, Oakland Ronald Romero, MD, Washtenaw Benjamin Roose, MD, Washtenaw Andrew Rosko, MD, Washtenaw Hyacinth Ruiter, MD, Kalamazoo Wendy Sadoff, MD, Oakland Adam Saugen, DO, Ingham Chad Savage, MD, Livingston Joseph Seymour, MD, Washtenaw Sufiya Shaik, MD, Washtenaw Michael Sharghi, MD, Kalamazoo Mariko Shelton, MD, Washtenaw Olabisi Sheppard, MD, Washtenaw Farhaj Siddiqui, MD, Saginaw Taeyong Sim, MD, Washtenaw Manvinder Singh, MD, Oakland Stephanie Spann, MD, Washtenaw Kristen Spoor, MD, Washtenaw Zbigniew Srodulski, MD, Kalamazoo Andrea Starostanko, MD, Washtenaw Michael Stein, DO, Ingham Maria Sturla, MD, Washtenaw Melissa Sundermann, DO, Washtenaw Karine Tawagi, MD, Washtenaw Christopher Therasse, MD, Kalamazoo Christopher Thuruthumaly, MD, Washtenaw Mark Tierney, MD, PhD Kent Charles Todoroff, MD, Medical Muhammad Usman, MD, Washtenaw David Van Winkle, MD, Muskegon Amy Vandenberg, MD, Washtenaw Aela Vely, MD, Washtenaw Stuart Vollmer, MD, Kent Alan Vorst, MD, Washtenaw Abdullah Wafa, MD, Washtenaw Jeffrey Walker, MD, Washtenaw R. Corey Waller, MD, Kent Jenny Wang, DO, Kalamazoo Bradley Warlick, MD, Marquette/Alger Cory Wernimont, MD, Washtenaw Joel Wilkie, MD, Washtenaw David Wilson, MD, Muskegon Mala Young, MD, Washtenaw Dima Youssef, MD, Washtenaw

March / April 2016

T H E

M A R K E T P L A C E

Would You Like To Place A Classified Ad? The rate for classified advertising in Michigan Medicine, including both print and online versions, is $1.60 per word, with a minimum of $65.00. All ads must be prepaid. Text for classified advertisements and advertising fees should be received no later than the first of the month proceeding the month of publication. All submitted ads must be typed. No handwritten or dictated ads will be accepted.

To place an ad call Carl Mischka at 888-666-1491 or email carl@mischka.us.

The theme for the May-June 2016 issue of Michigan Medicine will be:

The advertising deadline for the May-June 2016 issue is April 8th. Reserve your space today!

Hurley Medical Center/ Michigan State University

Tri-State Occupational Medicine, Inc.

COMBINED INTERNAL MEDICINE/ PEDIATRICS OPPORTUNITY

PHYSICIANS WANTED - DETROIT AREA

As part of the Michigan State University College of Human Medicine Flint, MI Campus, Hurley Medical Center is seeking an energetic and dynamic individual to lead and/or be faculty in our Combined Internal Medicine/Pediatrics clinic. The candidate( s) must be board certified in internal medicine and pediatrics and be willing to teach medical students and residents and participate as an active faculty member in the Combined Internal Medicine/Pediatrics residency training program. Candidates must have strong interpersonal, teamwork, leadership, communication, tech savvy skills and a willingness to work with an urban population. The Combined Internal Medicine/Pediatrics clinic is located in a Federally Qualified Health Center. A faculty appointment will be available with the Michigan State University College of Human Medicine at a rank commensurate with experience.

Tri-State Occupational Medicine, Inc. (TSOM) is looking for physicians to join their group to perform disability evaluations in Detroit. Part-time opportunities available. No treatment is recommended or performed. No on-call or weekends. Physicians working for us have various backgrounds and training including General Practice, IM, FP, Pediatrics, Pain Management, Surgery, and Cardiology. Training and all administrative needs, including scheduling, transcription, assisting and billing are provided. Interested physicians must have a current MI medical license and be in good standing. TSOM has an excellent reputation for providing Consultative Evaluations for numerous state disability offices.

Send CV to: James Buterakos, Academic Officer and DIO , Hurley Medical Center, One Hurley Plaza, Flint MI 48503, Email: jbutera1@hurleymc. com or fax: 810.760.9956.

Hurley Medical Center is an equal opportunity employer Volume 115 â&#x20AC;˘ No. 2

Contact: Susan Gladys / susang@tsom.com phone 866-929-8766 / fax 866-712-5202

MICHIGAN MEDICINE

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

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

For more details contact our practice specialist at Union 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.

MICHIGAN MEDICINE

March / April 2016

Working Together With You to Maximize the Financial Health of Your Practice Services Tailored to Your Specific Needs: • Full Billing Services • Credentialing Services • Business Planning • Electronic Health Records

• Accounts Receivable Recovery Services • New Practice Start-Up • Flexible Practice Management Software Options

All Medical Specialties Welcome PH: 248-478-5234 • FAX: 248-478-5307 www.elitemedicalbill.com We Are Your Medical Reimbursement Specialists

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

T R U S T E D

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

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

Volume 115 • No. 2

Established 1874

MICHIGAN MEDICINE

W W W.KERR - RUSSELL .COM

Five Tax Planning Ideas BY JIM NIEDZINSKI, AIF®

or high income earners, taxes may be the largest expense paid each year. Tax planning strategies are an important component of a sound financial plan, especially for the affluent. Introducing effective tax planning strategies into your plan can save money, creating the opportunity for greater investing or spending. Here are five ideas to consider:

Consider converting a Traditional IRA to a Roth IRA.

Provide support to your children or grandchildren tax efficiently.

A Roth IRA is powerful because it grows tax free. Anyone can convert an IRA to a Roth, but not everyone should because of the taxes due on the conversion.

Consider tax-wise ways to support your family and pass your wealth to loved ones.

While gifts of cash can provide you with a valuable tax deduction, there are ways to save even more.

Give close consideration to a Roth conversion if: • You experience a low income year – perhaps you have recently retired or are in between jobs • You have significant losses that can offset taxable income • Your IRA contains after-tax contributions • You are subject to AMT (which has a marginal rate that tops out at 28%) • You do not plan to use the IRA dollars and want to build a tax-free nest egg for future generations

Gift securities with unrealized long-term capital gains to avoid paying the capital gain tax that you would otherwise eventually owe.

Plan for the Alternative Minimum Tax (AMT).

Maximize the tax savings of your charitable donations.

Gift cash directly from your IRA. On Friday, December 18, 2015, President Obama signed a tax bill into law that extended more than 50 expired provisions of the tax code. One of those provisions, the “Qualified Charitable Distribution” (QCD), has been made permanent by the law. A QCD allows those over age 70½ to gift up to $100,000 per year from their IRA directly to a charity and have it count as their required minimum distribution without increasing their adjusted gross income. Consider contributing to a Donor Advised Fund. A Donor Advised Fund (DAF) can be opened at many community foundations or at investment custodians such as Schwab Charitable or Fidelity Charitable. You can contribute cash or securities to your DAF and receive the full allowable tax deduction. You may then request distributions be made to the charity or charities of your choice immediately or at any time in the future. 34

The AMT is an “alternative” income tax designed to prevent wealthier tax payers from enjoying too many tax breaks and loopholes under the standard tax system. Certain factors raise the risk of falling prey to the AMT, such as: • Living in high income tax states such as New York or California • Owning a large home or multiple homes with sizeable property taxes • Claiming a large amount of miscellaneous deductions • Earning more than $158,900 – and especially earning over $492,500 Consult with your accountant if you are at risk of the AMT. It can be confusing to plan for the AMT because the ways to save tax when you are subject to the AMT are actions that would normally increase your tax bill – such as accelerating ordinary income into the current year and deferring deductions into the following year. MICHIGAN MEDICINE

Contribute to a 529 college saving plan. Some states, such as Michigan, provide an income tax deduction for contributions made to a state-sponsored plan. Furthermore, 529 savings plans grow tax free when withdrawn for qualified education expenses. Gift appreciated securities to family members in a lower tax bracket. Long-term capital gain rates range from a low of 0% (yes, zero!) to a high of 23.8%. You can gift securities with unrealized gains in lieu of cash to children who earn modest incomes. They can sell the security and pay a lower capital gain tax or potentially no tax at all. However, be careful to steer clear of the “kiddie tax” where dependent children under 19 and full-time students under 24 with unearned income over $2,100 (in 2015) are taxed at the parent’s tax rate instead of the child’s rate. Help children establish a Roth IRA. They can make a contribution up to the amount they earn or $5,500 (2015), whichever is less. Roth IRAs grow free of tax, including the “kiddie tax” trap described above. Employ children. If you own a practice you might consider hiring your child to work at your company for a summer job or during winter break. This enables you to divert income to them at their lower income tax rate vs. you earning the money, paying tax at your much higher marginal rate, and giving it to them as allowance.

Jim Niedzinski, AIF® is an advisor at WealthCare Advisors, LLC – an MSMS joint venture.

March / April 2016

helps you make the most of your practice’s revenue cycle.

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Cash Flow Optimized is a service mark of The PNC Financial Services Group, Inc. (“PNC”). Banking and lending products and services, bank deposit products, and treasury management services, including, but not limited to, services for healthcare providers and payers, are provided by PNC Bank, National Association, a wholly owned subsidiary of PNC and Member FDIC. Lending and leasing products and services, including card services and merchant services, as well as certain other banking products and services, may require credit approval. All loans and lines of credit are subject to credit approval and require automatic payment deduction from a PNC Bank business checking account. Origination and annual fees may apply. ©2015 The PNC Financial Services Group, Inc. All rights reserved. PNC Bank, National Association. Member FDIC