NJ Physician Magazine January 2013

JULY 2013 2012 JANUARY

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Marano Eye Care Centers Keeping the Demands of Today’s World in Sight Also In This Issue: N.J. Legislators Set Sights on Fighting Diabetes Report Finds NJ Hospitals Face Multiple Financial Pressures Christie Denies State-Run Insurance Exchange Presence of Anesthesiologists Required When Nurses Deliver Anesthesia in Hospitals

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Publisher’s Letter Dear Readers, Welcome to the January issue of New Jersey Physician, now reaching over 28,000 physicians statewide, along with most hospital executives and practice managers. If you know of any physicians not receiving the publication, please feel free to send me their personal email address and we’ll include them. Our goal is to reach every physician practicing in the state.

Diabetes, one of the biggest contributors to rising healthcare costs in New Jersey is being targeted by state lawmakers. A new legislative bill would require an action plan fo combating diabetes in the state, including a review of the financial impact of the disease and the effectiveness of existing programs. New Jersey had one million residents with diabetes in 2010 or 11.2% of the population, a number that is expected to rise to 1.5 million or 15.6% by 2025.

The N.J. Legislature has passed a bill requiring medical professionals to get flu shots, starting next autumn. Health care facilities would have to provide a vaccination program for their employees by the start of the next flu season. Employees would have to get the vaccine, show proof they got it on their own, or sign a statement that testifies to their decision not to get vaccinated, according to the bill.

The New Jersey Assembly’s Regulated Professions Committee reported favorably last month on Bill A2419. If passed, it would authorize the State Board of Psychological Examiners to issue a certificate of “ prescriptive authority” to licensed practicing psychologists. The psychologist must have a doctoral level degree and has successfully graduated with a post-doctoral master’s degree in clinical psychopharmacology. This degree must be from a regional accredited institution of higher education. Alternatively, the candidate must have completed equivalent training to the post doctoral master’s degree approved by the board. An examination must be passed that is approved by the board relevant to establishing competence for prescribing drugs.

Our cover story this month is on Marano Eye Care Centers. As technology progresses, our eyes are now focusing on an area frequently of only a few inches for many hours of the day. There is concern for the demand we are placing on our sight and how we can maintain our visual acuity. Dr. Matthew Marano of Marano Eye Care Centers is committed to providing patients with customized vision correction addressing the needs of each individual’s personal lifestyle and medical history. Using the most cutting edge technologies available, Dr. Marano can offer patients optimal vision for an entire lifetime allowing them to adapt to the variety of ways in which information is delivered.

With warm regards,

Michael Goldberg Co-Publisher

Published by Montdor Medical Media, LLC

Co-Publisher and Managing Editors Iris and Michael Goldberg Contributing Writers Iris Goldberg Michael Goldberg Andrew Kitchenman Susan K. Livio Keith J. Roberts Kevin M. Lastorino Carol Grelecki Debra C. Lienhardt John D. Fanburg Mark Manigan Joseph M. Gorrell Richard B. Robins Todd C. Brower Lani M. Dornfeld Melanie Evans Joseph Conn Andis Robeznieks Layout and Design Nick Justus

New Jersey Physician is published monthly by Montdor Medical Media, LLC., PO Box 257 Livingston NJ 07039 Tel: 973.994.0068 F ax: 973.994.2063 For Information on Advertising in New Jersey Physician, please contact Iris Goldberg at 973.994.0068 or at igoldberg@NJPhysician.org Send Press Releases and all other information related to this publication to igoldberg@NJPhysician.org Although every precaution is taken to ensure accuracy of published materials, New Jersey Physician cannot be held responsible for opinions expressed or facts supplied by its authors. All rights reserved, Reproduction in whole or in part without written permission is prohibited.

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Contents

Marano Eye Care Centers Keeping the Demands of Today’s World in Sight CONTENTS

9 15 20 21 23

2 New Jersey Physician

STATEHOUSE HEALTHLAW UPDATE PRACTICE MODELS HOSPITAL ROUNDS FOOD FOR THOUGHT

4

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Cover Story

Marano Eye Care Centers Keeping the Demands of Today’s World in Sight

By Iris Goldberg How we receive and disseminate information has changed dramatically during the course of recent decades. With the birth of the internet, came a new way of life. Looking at a computer screen for hours on end each day became a reality for many of us. As technology progressed, our devices and display screens grew smaller. Texting, the smartphone and also the explosive presence of social media, now have us repeatedly focusing on an area of only a few square inches in order to stay connected.

While this communication revolution has significantly increased our capabilities at work and within our personal lives, there have been some negative effects to our health. Sitting hunched over a computer for a prolonged time can cause neck and back problems. When young and older people, alike, devote most of their time to occupying themselves online, they don’t get enough exercise, causing an increase in obesity and other related problems. Certainly as concerning, is the demand we are placing on our eyes and whether we can have and maintain the visual acuity that is essential for taking advantage of those benefits which modern technology provides.

Marano Eye Care Centers, with locations at the Barnabas Health Ambulatory Care Center in Livingston and St. Michael’s Medical Center in Newark, are committed to providing patients customized vision correction that addresses the needs of each individual’s personal lifestyle and medical history.

By continuously pioneering the use of the most cutting-edge technologies available, the skilled surgeons at Marano Eye Care Centers can offer their patients optimal vision for an entire lifetime that allows them to adapt to the variety of ways in which information can be delivered today.

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From top left: Matthew Marano, MD, Edward Decker, MD and below, Adriana Palumbo, OD

Matthew Marano, MD is the founder of Marano Eye Care Centers. Dr. Marano, who is a board-certified ophthalmologist and ophthalmic surgeon and one of the most experienced cataract and LASIK surgeons in New Jersey, discusses how he and his colleagues ensure that patients who choose Marano Eye Care Centers have the most consistently successful surgical outcomes. “When a patient first comes in, we are very careful to take a detailed history,” Dr. Marano informs.

“Now you need to be able to look down to check your phone. And we have icons for everything today, so your mind and your eyes are moving differently than before,” Dr. Marano states. “By doing a personalized evaluation of your needs and desires and giving you a reality check as to what your eyes are capable of achieving, we can customize the right procedure for your situation,” he adds.

“It’s not just giving patients vision that’s 20/20,” states Dr. Marano.

I like to ask patients to tell me about the quality of their lives,” Dr. Marano continues. “Are you having trouble driving at night? Can you not read? Are colors minimized? Are you getting glare?” he elaborates.

“For me, it’s about knowing what they are looking for and how they live their lives.

The individuals who are my patients want to see faster, want to perceive faster and want to be able to move on. We can customize that delivery system,” he reports.

Dr. Marano goes on to explain that getting this lifestyle analysis of the patient’s hobbies, profession, likes and dislikes, etc. and what visual problems the patient reports, helps him determine whether or not that patient is ready for surgery. He remarks about how much the way in which we use our eyes has changed in the last 20 years or so.

“The store-bought reading glasses are fine if you’re going to be reading the newspaper but if you’re going to be looking at the computer, then watching TV and then looking down at your iPhone, you need something that’s going to give you a blend. Otherwise you wind up with what people think are migraines or

Dr Marano and his OR staff at St. Michael’s Medical Center

sinus headaches,” warns Dr. Marano. He knows of many cases in which individuals have consulted with neurologists or ENT specialists and undergone diagnostic testing such as CT scanning, only to discover that they’d been using the wrong eyeglasses.

Dr. Marano gives a possible profile of a patient who might be seen at Marano Eye Care Centers for cataract surgery and specifies what type of procedure he would recommend. “You’re mid-fifties to seventies. You’re active. You like to play golf or perhaps you work out. I would encourage you to consider one of the premium or high-tech intraocular (IOL) lenses,” Dr. Marano states. Unlike standard monofocal IOLs, which do not correct near and/or intermediate vision, Dr. Marano refers to multifocal IOLs, which allow the patient to see at a distance, up close and at many intermediate arm’s length distances without the need for prescription eyeglasses.

Prior to undergoing cataract surgery, all patients who are treated at Marano Eye Care Centers undergo extensive

preliminary testing. This includes a visual acuity test to measure how well the patient sees at various distances. Also the pupil is dilated to see the retina and look for other eye problems which might disqualify a patient for this procedure.

Tonometry, which measures eye pressure, is performed to determine if the patient is at risk for developing glaucoma.

“A really crucial part of the pre-operative exam is the calculation of the corneal surface and the measurements for the intraocular lens,” Dr. Marano says. For this, Dr. Marano utilizes a state-of-theart, computer-assisted ultrasound and also a special laser. He makes a point of emphasizing the importance of keeping up with technology and having all of the current instrumentation. “A lot of this has evolved,” relates Dr. Marano. “I do two different types of tests, which is why, post-operatively, my patients often see extremely well without glasses,” he offers. All of this pre-testing is quite crucial to customize an optimum result for each individual patient.

Dr. Marano performs most cataract

A crucial part of the pre-operative exam is the calculation of the corneal surface and the measurements for the IOL. For this, Marano Eye Care Centers utilizes the most current instrumentation.

January 2013

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surgery using a technique called phacoemulsification, or phaco. In this technique, a very tiny (3mm) incision is placed on the side of the cornea, which is the clear, dome-shaped surface that covers the front of the eye. Dr. Marano then inserts a microscopic probe into the eye. This probe sends out ultrasound waves that soften and break up the cloudy center of the lens so that it can be removed by gentle suction. Then a foldable IOL is injected through the small incision and properly positioned.

The ReSTOR® multifocal IOL is one of two multifocal lenses which Dr. Marano chooses to implant. It has a multi-tiered surface rising in concentric rings from the edge to the center. This design both transmits and gathers light evenly over a full range of distances. It also has a yellow tint to cut out some blue light.

“Although this lens has been around for a long time, it has been modified so that the reading correction is not as high as it was, since now, most of us do more intermediate and computer work than reading a newspaper that is 14 inches away,” Dr. Marano points out.

The TECNIS® multifocal IOL is the other option and an excellent choice for providing focused vision in all depths of field – near, intermediate and far – in all lighting conditions. It is designed to provide clear, sharp vision for every activity, from reading, to using a computer, to driving. This is a lathe-cut IOL that is not yellow-tinted.

Both lenses are foldable and acrylic and Dr. Marano explains that their optic sizes differ slightly. “So I can talk with a patient and decide what the distance requirements are, what the nighttime driving requirements are and what the near requirements are,” shares Dr. Marano. “In addition, I will look at the measurements that we calculate in the office. After looking at the corneal curvature, the ultrasound length of the eye as well as the laser length of the eye, I can then hand-select which lens is going to work best for each individual patient.

These lenses work a little bit differently for everyone so I have to be sure that I have calculated the correct power in each case,” he emphasizes.

“There are also lenses that correct astigmatism, which will give you quality of vision that you haven’t had since birth,” Dr. Marano continues. Since astigmatism

6 New Jersey Physician

Dr. Marano is one of the most experienced cataract surgeons in New Jersey.

is in one’s cornea and is present when an individual is born, he relates that after patients receive Toric IOL implants for astigmatism they have better vision than they ever had previously. Dr. Marano also shares, that while it is possible for him to further fine-tune the astigmatism correction with a subsequent laser procedure, the Toric lenses that are now implanted have been improved to such a great extent, that an additional procedure is rarely necessary.

In order to choose the correct lens for each individual, Marano Eye Care Centers have the most technologically current equipment that enables precise calculations for each individual patient.

Dr. Marano explains that this allows him to select the best multifocal IOL for each patient’s individual needs, sometimes

During cataract surgery, Dr. Marano inserts a microscopic probe that sends out ultrasound waves to soften and break up the cloudy center of the lens. It can then be removed by gentle suction. Then a foldable IOL is inserted and properly positioned.

mixing and matching implants for a totally customized and positive result.

“This is where the art of calculating and the surgical technique really enhances the ultimate result for each patient,” Dr. Marano stresses.

Dr. Marano is one of only a limited number of ophthalmic surgeons who performs laser correction along with cataract surgery for appropriate patients. “Now during cataract surgery it is possible to perform a laser correction to eliminate residual astigmatism or prescription for eyeglasses,” Dr. Marano informs. “Not every cataract surgeon does this but I have been doing it for some time now,” he adds.

For those patients who do require fine tuning of their vision, following cataract surgery with multifocal lens implants, or for patients without cataracts who no longer wish to wear eyeglasses or contact lenses, the surgeons at Marano Eye Care Centers are among the most highlyskilled LASIK surgeons in the state.

Combining their skills with the latest in laser vision correction technology (see Fig.1), enables them to provide excellent outcomes for their patients.

Using the precision of a laser to create the corneal flap enhances the surgeon’s precision significantly. The accuracy of the laser (100 times more accurate than a blade) is unparalleled by any other technology in vision correction surgery.

This allows for more control during the procedure and even make it possible to customize the corneal flap for every individual patient.

After the flap has been created the StarS4 Excimer laser is used to fine tune vision, correcting nearsightedness, farsightedness or an astigmatism. With this innovative technology, complications such as “dry eye” and glare or halos are virtually eliminated. Also, many patients who were dismissed as candidates for traditional laser vision correction due to thin corneas can now be treated. Its consistent accuracy makes this system the critical first step in a totally customized procedure. Never before has there been a combination of technologies that has allowed for such personalized vision correction.

In addition to outpatient cataract and vision correction procedures performed by the surgeons at Marano Eye Care Centers, there are a host of in-office

Marano Eye Care Technology •

Visx Star S4 Excimer Laser System

•

The Bladeless Intralase Laser

•

CustomVue WaveScan WaveFront System

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Orbscan System

•

IOLMaster

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Aviso A/B High Definition Ultrasound System

•

Axis II PR

•

Humphrey ® Field Analyzer/HFA II-i

•

Non-Mydriatic Photo Camera

•

Stratus Optical Coherence Tomography - Comprehensive Glaucoma and Retinal Imaging and Analysis Fig. 1

The Intralase laser creates a flap of corneal tissue that is folded back. The Intralase acts directly upon the stromal layer of the cornea, sparing the outer surface.

state-of-the-art medical laser capabilities for treating conditions including but not limited to: • Diabetes • Glaucoma • Inflammation in the eye that has caused scarring • Secondary cataract membranes For example, the physicians at Marano Eye Care Centers often see patients who have had cataract surgery at some point in the past and over time have noticed a gradual decrease in vision or problems with glare or haziness. The natural lens of the eye is enclosed in a clear, cellophanelike membrane called the lens capsule. Dr. Marano explains that most times during cataract surgery a portion of the original lens is left in the eye to hold the IOL that is implanted in place. Visual problems can occur when cells grow on the part of the capsule that remains after cataract surgery. This is called posterior capsule opacification or secondary cataract membrane and can occur within months or years after cataract surgery.

The YAG laser safely removes secondary cataract membrane within the office.

In order to correct the problem, the surgeons at Marano Eye Care Centers use a YAG laser to cut a hole to remove the cells that try to regrow after cataract surgery and have clouded the back lining of the lens capsule. This allows light to pass through the membrane to the retina at the back of the eye. “The YAG laser will safely remove this membrane within the office, letting more light in, providing better clarity, better color and also enable the optometrist or ophthalmologist to better evaluate the retina,” Dr. Marano states. “This procedure is totally noninvasive. Afterwards, you can go to the gym, go swimming, have dinner out,” he says, emphasizing how good patients feel following treatment.

To fulfill the mission of providing patients optimal vision for life, Marano Eye Care Centers address other evolving conditions in addition to cataracts. “As we get older, our eyes get dry,” Dr. Marano mentions as an example. “This dryness affects you – the forced air heat in your house, or office January 2013

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or car, perhaps. At some point we all need supplemental drops or treatments and by treating dry eye beforehand, we can improve the quality of your surgical result,” he adds.

“So I’ve been very careful, before surgery, to treat for this,” Dr. Marano states. He explains that drops, as well as fish oil capsules and sometimes plugs within the corners of the lids help to alleviate the dryness and the sensation it causes.

In fact, tear production is affected to a great deal by what is happening along the eyelids.

Glaucoma medication, for instance, can cause irritation. “It’s really important to monitor this for our patients,” Dr. Marano emphasizes.

Also, Dr. Marano and his colleagues at Marano Eye Care Centers know that the general health of each patient can have a tremendous effect upon the eyes.

Therefore, maintaining an up to date health history as well as communicating with other specialists who are treating the patient is a priority.

Additionally, diagnosing problems within the eye can sometimes allow Dr. Marano to alert patients about health problems they might be unaware of. Dr. Marano finds that his initial training in internal medicine helps him to treat the “whole patient” and not just the eyes. “I will ask a diabetic patient, for example, when the last time the hemoglobin A1C was tested to find out how well the blood sugar is being controlled,” he offers.

Sometimes, the condition of the eyes will reveal that a patient is not being compliant in terms of nutrition, for instance, or perhaps the patient is still smoking. Dr. Marano will definitely have a discussion with that patient, encouraging him or her to become more engaged in making better choices.

Marano Eye Care Centers employs a combination of the latest in laser vision technology to provide the most personalized and customized vision correction.

8 New Jersey Physician

Diabetics comprise a significant number of patients at Marano Eye Care Centers and for them, especially, consistent monitoring and evaluation of the eyes is a crucial part of their healthcare. “We have a vast array of mechanisms to evaluate the health of the eye,” Dr. Marano shares.

He makes a point of mentioning the priority within his practice of obtaining the most current technology to enable accurate and early diagnoses.

“Diabetics, in particular, are more prone to developing glaucoma, for example,” he adds. Glaucoma is a disease in which the optic nerve becomes damaged over time. Since there may be no symptoms in the early stages, it is crucial to check for it during an office exam. Left untreated, glaucoma can eventually lead to blindness.

“We also have ways of doing angiograms of the retina in the office,” relates Dr. Marano. High-tech cameras provide pictures of the retina that could barely be seen with the naked eye. “Another mechanism called an OCT evaluates the macula to the tiniest microns as well as the optic nerve,” he elaborates. “So I can pretty much tell you how healthy your eye is and what we expect to evolve over the next five years in your eye,” Dr. Marano states. “I can throw up caution flags to tell you what you will require going forward. I don’t have a crystal ball but I have a lot of experience and we have incredible diagnostic information.”

At Marano Eye Care Centers the diagnosis and management of patients with macular degeneration is another important service provided. Macular degeneration is the leading cause of severe vision loss in people over the age of 60. It occurs when the small central part of the retina, known as the macula, deteriorates. As Dr. Marano points out, it is important for individuals who have macular degeneration to be carefully monitored.

“We are primary care eye docs in this practice,” Dr. Marano states. “We offer the whole gamut of evaluations for everyone from young kids to seniors,” he notes. As such, Marano Eye Care physicians work with specialists such as neurologists, endocrinologists, internists, pediatricians, optometrists and other ophthalmologists who refer patients.

It is important for referring physicians

At Marano Eye Care obtaining the most current in office technology to enable accurate and early diagnoses is a priority. Above, Optos provides high tech pictures of the retina.

Below, OCT evaluates the macular as well as the optic nerve.

and/or perspective patients to note that Dr. Marano has amassed an impressive amount of experience as an ophthalmic surgeon. “I’ve been doing this for a long time and I keep myself in top shape so that I can have the longevity and the quality of life that I want. That definitely includes being able to continue to do what I love doing,” Dr. Marano candidly shares, citing the tremendous gratification that comes from helping people regain and maintain an optimal level of vision for life.

Even now, with all that has been accomplished, Dr. Marano looks to exciting new technology on the horizon and wonders what he may be capable of offering patients in the coming years.

“This is so much more than a career to me,” he says.

For more information or to schedule an appointment, please call (973) 322-0100 for the Livingston office or (973) 877-5534 for the Newark office.

www.maranoeyecare.com photography by Michael Goldberg

Statehouse

NEW JERSEY STATEHOUSE Legislature Takes Second Look at Regulating Emergency Medical Services

Opponents argue that bill would put excessive financial burden on volunteer EMT squads

By Andrew Kitchenman, Howard Meyer, president of the New Jersey State First Aid Council.

For the second time since taking office, Gov Chris Christie may have a chance to sign a bill that increases state oversight of emergency medical technicians and paramedics.

The measure (A-2463), requires that ambulance workers be licensed by the state and undergo criminal background checks.

The legislation comes at a time when the state’s longtime reliance on volunteer ambulance squads is under threat from several quarters, including increased regulation, tougher training requirements, and a general decline in volunteerism.

“EMS is in crisis in New Jersey,” said Mary Daley, president of the state EMS union. -- the Professional Emergency Medical Services Association. “A lot of the volunteers are falling by the wayside, a lot of it is going commercial and paid.”

Supporters of the bill argue it makes much-needed changes, adding that the current state of affairs -- in which volunteer squads don’t even have to register with the state -- must end. They also say the state must take action now to ensure that local departments maintain necessary standards.

Opponents maintain that the bill will force more volunteer units to shut their doors..

Christie conditionally vetoed an earlier version of the bill two years ago, saying it needed further study.

The volunteers who oppose the bill are hoping that the governor again calls for further study. Supporters contend that Christie’s staff didn’t have time to study the issue then, and that now is the time to move forward with more state oversight.

The state’s largest emergency medical volunteer organization is the chief critic of the proposal. Howard Meyer, president of the New Jersey State First Aid Council, said the increased costs from state licensing and background checks put too much financial strain on volunteer squads.

“On top of Sandy and everything else, I don’t think it’s any secret that New Jersey has financial issues,” said Meyer, a volunteer with the Berkeley Heights Volunteer Rescue Squad and Hoboken Volunteer Ambulance Corps. He has 40 years experience and has instructed volunteer EMTs for more than 20 years.

The nonpartisan Office of Legislative Services forecasts that the bill will increase costs, but didn’t put a price tag on the increase. The legislation specifies that the costs won’t be borne by the volunteers themselves, but opponents said costs could be pushed onto cash-strapped squads.

“Where’s the money coming from?” Meyer asked, adding that his organization estimates that the bill will cost $30 million to $50 million annually.

That number is disputed by bill supporters, who noted that the State Police already conduct background checks for police and firefighters, as well as for emergency squads that request them.

Meyer said Christie took the correct approach in his 2011 conditional veto, in which he called for a review by state officials of the financial impact of the measure. The Legislature did not act on the veto before the end of this past session.

“That would have been a very reasonable thing to sit down and do,” Meyer said.

Meyer said ambulance services do need changes, including adding a requirement that all ambulances receive inspections and that all patients be guaranteed that an EMT is traveling with them in an ambulance.

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“There’s ways of doing that without costing millions, that would be of little or no additional cost to volunteer squads,” Meyer said. He said private ambulance agencies and hospitals are pushing out volunteer squads.

“We believe it’s going to make it more difficult for volunteer squads be able to recruit, to be able to provide services,” Meyer said of the bill.

First-aid training programs have increased their requirements in recent years, while the state fund for this training has been exhausted. Meyer added that shifting the state from certifying to licensing EMS is a means of raising costs.

“I think the goal here is to make it more difficult and bureaucratic for volunteer squads until the people who run the squads say, ‘You know what? We’ve had enough,’” Meyer said.

Meyer noted that volunteer emergency responders have been crucial in responding to large-scale disasters.

Not all volunteers agree with the first-aid council’s position, including Michael Bascom, a volunteer captain with the Shark River Hills First Aid Squad for 20 years. Bascom is also chief financial officer for Neptune and Sea Bright and EMS coordinator for Monmouth County and Neptune.

“There’s been a lack of direction of EMS in general and there’s a need for standardization across the board, for volunteer and career [services]," Bascom said.

The Shark River captain said that the current state of affairs allows volunteer squads to function with inadequate response times and training.

“Most volunteer EMTs and career EMTs are very professional and very qualified in what they do and very dedicated, but a few bring it down,” Bascom said. He added that mandatory background checks are needed for personnel who enter residents’ houses and can be alone with patients.

“You would want to have some comfort level that that person is an upstanding individual,” Bascom said.

Bascom said one path forward for volunteer squads is to regionalize. By grouping together, volunteers will be able to share infrastructure.

“The strong squads will survive, the weaker will not,” Bascom said.

Bascom contends that the bill will not significantly raise costs for squads. Instead, there should be a focus on increasing state funding for training. “I don’t believe there will be a big cost to go along with this, I think that’s a scare tactic. “ Bascom said bill opponents are trying to link broader changes that are affecting the number of volunteers -- such as increased regulation and training requirements -- to a bill that has nothing to do with these changes.

“They point to the bill as [including] everything that’s changing EMS,” Bascom said. “This bill doesn’t talk about that at all.”

“There’s a need of a set of standards that [they] should have to follow,” he said.

Daley, another backer of the bill, said that it doesn’t go far enough in setting requirements. The head of the state EMT union, Daley said the law should specify that every life-support ambulance must have two paramedics, while every commercial ambulance should have two EMTs. Paramedics receive more training and can provide more medical services than technicians.

Daley added that Ocean County has the same number of ambulances as 20 years ago, while the population has increased sharply.

“I believe that the volunteers have a difficult road ahead of them, volunteerism is waning while the volunteer requirements” are growing, said Daley, who has served as a volunteer EMT for Pleasant Plains Volunteer First Aid Squad in Toms River, has been a statecertified paramedic for 29 years, and is a registered nurse.

The Assembly is scheduled to vote on the bill on Monday. The Senate has already passed its version.

Bill Seeks to End Government Role in Determining Brain Death Doctors look to bring state law in line with medical criteria, technology

By Andrew Kitchenman, Doctors would have more say in determining brain death, rather than having to adhere to state regulations requiring a series of outdated tests, under a bill advancing in the state Legislature.

Physicians and state officials agree that the mandated tests are not keeping up with technology. The bill would give doctors leeway to apply more up-to-date methods for determining brain death.

A few critics, however, expressed concern about patient rights, wondering if doctors might, for example, be pressured to declare brain death too hastily in order to facilitate organ transplants.

An Assembly committee recently approved the change, which would affect some of the most sensitive and difficult moments that a patient’s family can experience..

10 New Jersey Physician

The bill, A-3586, would prohibit the use of a specific criteria, test or procedure to determine “death by neurological criteria,” also known as brain death. Instead, doctors would use their best medical judgment, in accordance with current medical standards.

Defining the line between life and death has long been controversial in New Jersey, which uniquely allows an exemption from declarations of brain death for patients based on religious belief.

Groups representing neurologists, neurosurgeons and other specialists who determine brain death are promoting the change. They say that tests currently required by the state are out of step with medical standards. In addition, any new standards that are written into law could soon become obsolete, according to supporters of the change.

These possible new standards include a multipart test of reflexes, including whether a patient’s pupils respond to light, that must be repeated after six hours. Current medical standards don’t require that tests must be repeated, which can reduce the time it takes for a doctor to declare brain death.

However, a legislator and an activist raised questions about whether the change would be in the best interests of patients with minimal brain activity.

Currently, the state Department of Health and Board of Medical Examiners regulate the standards for determining brain death. The board has voted on a measure saying that it doesn’t see the need to keep its regulatory authority.

Dr. John J. Halperin, a neurologist, said medical science on brain-death standards is evolving. The medical director of neurosciences of Atlantic Health System, he said he has 30 years of experience dealing with both the technical aspects and the human tragedy surrounding declarations of brain death.

“It’s something very near and dear to my heart,” said Halperin, who also is a professor at Mount Sinai School of Medicine.

“The fundamental challenge we face has to do with the differences between medical science and the legislative process,” Halperin said.

Halperin said trying to reconcile state law with medical standards can lead to “confusion, delay and consternation” for families.

“Although medical science can help us update what we as a profession do, getting those changes through things that are carved in not quite stone but close in law, is a much more challenging and time consuming process,” Halperin said. “So that today, if I were called to see a patient with brain death, I would have to decide if I want to abide by the national professional standards of the American Academy (of Neurology) or do I want to go by New Jersey law.”

Halperin said it would greatly simplify the decision if doctors “could do what we do with everything else in medicine,” using evolving medical standards rather than an outdated legal definition.

The proposal to change the law was put forward by doctors’ groups to state officials reviewing whether state laws are up-to-date.

State legal research found that changes in technology have resulted in regulations lagging behind medical standards, according to Marna L. Brown, counsel for the New Jersey Law Revision Commission. She said the commission supports the bill’s intent.

In addition, state officials could not find any other state that sets legal criteria for determining brain death, Brown said.

Brown also informed legislators of the position of the State Board of Medical Examiners that “any established criteria must include adequate and sufficient safeguards to ensure that a declaration of brain death could not be made on a patient who is not in fact brain-dead.”

Christina Strong, counsel for the New Jersey Neurosurgical Society, said the legal standards are wrong.

“It’s possible to be deceased in New Jersey, in a hospital, and not be legally deceased,” she said, describing the viewpoint of doctors: “I have to jump through hoops while the family is waiting for closure, I have to do medically unnecessary testing.”

She said an earlier effort to change standards, beginning in 2004, took three years. Strong said the change isn’t a “lowering of the clinical standards, it’s instead making them appropriate, so that doctors can follow the latest in accepted standards.”

Strong said that as a result of federal requirements governing organ donations, New Jersey hospitals now struggle to reconcile “legal diagnostic language, which doesn’t really exist, and clinical diagnostic language, which really does.”

Assemblyman Herb Conaway Jr. (D-Burlington), the bill’s sponsor and a doctor, said state government “should not be in the business of practicing medicine. Medical care should be driven by medical science and medical standards.”

Conaway said lawsuits could change medical standards, “but the government can’t properly keep up, nor should it.”

Assemblyman Erik Peterson (R-Hunterdon, Somerset and Warren) was the only member of the Assembly Health and Senior Services Committee to vote against the bill.

Peterson expressed concern that the doctors were seeking to declare patients dead more quickly.

“If they’re saying we’re making people wait unnecessarily to have their loved one declared brain dead, I’m just curious about how long we’re talking this difference would be,” he said.

Strong said doctors are seeking clarity and closure for patients’ families, noting that a doctor who conducts the second round of January 2013

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tests a few minute earlier than required by current regulations may result in another doctor having to start the entire six-hour testing process over again.

John Tomicki, executive director of the League of American Families, expressed concern about the future direction in determining brain death, saying that he has seen standards change, “sometimes unfavorably, because there is no patient advocacy.”

Tomicki said some patients declared brain dead later had “some degree of recovery.”

“There should also be somebody who is an advocate for the patient,” Tomicki said, adding that the state “should always err on the side of life.”

He later said doctors might feel pressure to declare brain death to aid with organ donation.

“We’re fighting to see that people are not declared dead before they are in fact dead,” he said.

NJ Legislators Set Sights on Fighting Diabetes

Bill would review current programs with eye on devising more effective battle plan

By Andrew Kitchenman, Diabetes, one of the biggest contributors to rising healthcare costs in New Jersey and the nation, is the target of a new bill introduced by state lawmakers.

The bill, S-2288 and A-3432, would require the state Department of Health to produce an action plan for combating diabetes in the state, including a review of the financial impact of the disease and the effectiveness of existing programs.

Assemblyman Herb Conaway Jr. (D-Burlington), a bill sponsor and a physician, said he wants to take action both because of the impact diabetes has on patients as well as the costs of the chronic disease, which causes severe complications if left untreated.

“The state has an important interest in the programs in trying to reduce the costs of diabetes for its employees,” Conaway said, adding that state action may benefit the private sector. “The kinds of things the state may choose to do or highlight may have a good application outside of state government.”

New Jersey had 1 million residents with diabetes in 2010, or 11.2 percent of the population, a number that is expected to rise to 1.5 million, or 15.6 percent, by 2025, according to the Institute for Alternative Futures, a Virginia-based nonprofit .

Dr. Samuel Grossman, advocacy chairman for the state’s American Diabetes Association chapter, said diabetes is “like an iceberg,” with many undiagnosed cases.

“It’s an expensive disease and it’s a disease that affects many patients,” said Grossman, whose organization supports the bill.

Grossman noted that the bill would require a report every two years on the progress the state is making in deal with the disease.

“It’s like a report card and I believe that a report card would help many providers and many patients improve the quality of healthcare in New Jersey, especially for diabetes,” Grossman said, adding that programs found to be effective in the reports could be implemented across the state.

“We don’t have the data,” Grossman said. “This is why it’s so important to have this monitoring information.”

Global diabetes-focused pharmaceutical company Novo Nordisk, whose U.S. headquarters is in Plainsboro, also is advocating for the bill.

Novo Nordisk state government affairs director Tom Boyer said the most important goal of the legislation is to “break down the silos” that exist dividing state government departments. By requiring state Medicaid and public health efforts to be coordinated, new information about the disease can be analyzed, Boyer said.

“No one has conducted the kind of soup to nuts assessment as to how much we’re spending, how effective the interventions are and what kind of return we’re getting on our investment,” Boyer said, noting a recent increase in diabetes costs. “If we don’t collectively conduct an assessment of what’s working today, how can we possibly know what’s going to work tomorrow and the greatest opportunity for the state to achieve savings in its Medicaid program and improve the lives of its citizens?”

Boyer pointed to gestational diabetes – which affects some pregnant women and leads to a higher risk of delivery complications and costs – as an area with particularly high potential for effective state policies.

“In an ideal world we would have done this work 10 or 15 years ago, but we’re not in the ideal world; we have to deal with the crisis that’s at our doorstep,” Boyer said. “We really need to come up with strategies and interventions that are available today that reduce the cost of that care in an appropriate way.”

Boyer said the bill opens the possibility of the state gathering the “best and brightest minds” on diabetes policy and treatment to formulate measures that would be most effective.

The bill can put the state in a position where it “can dictate the terms by which it will engage diabetes, rather than having diabetes dictate the terms that it will engage the state. It’s that simple,” Boyer said.

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He pointed to the IAF report Diabetes 2025, which projected that the medical and indirect societal cost of diabetes to New Jersey will rise from $9.3 billion in 2010 to $14.5 billion in 2025. He noted that the most prominent state program addressing the program, which is funded by the federal Centers for Disease Control, provides $350,000 to the state.

“The state of New Jersey today is combating a $9.3 billion problem with a $350,000 grant,” Boyer said.

State Department of Health spokesman Dan Emmer said the state has additional funding streams other than the CDC grant that allow the state to leverage additional grants that allow the state “to take a global approach to combating diabetes and other chronic conditions. This strategy allows those who are impacted to live to their optimum health.”

State officials declined to comment on the bill, but said the state is already working to reduce the disease’s impact. It currently has several programs seeking to address diabetes as well as other chronic diseases, according to Melita Jordan, senior executive service director for the Department of Health’s chronic disease prevention and control unit.

The state is using evidence-based policies to promote a healthy lifestyle for residents who have diabetes or are at risk for it, including a worksite wellness program, Jordan said. This helps give people more control over their health and reduces hospitalizations, she said. She noted that the CDC grant, which funded a diabetes self-management program in southern New Jersey more than a year ago, has been expanded to northern New Jersey.

The bill is backed by other organizations that focus on the disease. Bonnie Starr, program manager for the Diabetes Foundation, said the bill could complement her organization’s focus on providing emergency medication to low-income residents with diabetes.

Conaway agreed with Boyer than gestational diabetes is a potential subject for new state policies. He added that providing comprehensive services for state employees with diabetes is another area, including the potential for providing diabetes supplies for free, in line with the federal Affordable Care Act’s focus on promoting free preventative screenings.

“How can the government as the employer help employees take better care of their health?” Conaway asked, adding that encouraging exercise or other programs could be started by the state and then expand into the private sector.

Sen. Robert Gordon (D-Bergen), the Senate sponsor, said he has been interested in reducing diabetes since he worked as a hospital consultant prior to joining the Legislature.

“I think the state needs to develop public policies that try to address the epidemic,” he said. “If you look at the major cost drivers in the public sector today it’s healthcare costs, health insurance, and the major cost driver of rising insurance rates is chronic diseases,” primarily diabetes.

If the state can drive down the cost of treating diabetes, it will ultimately reduce the burden on taxpayers who finance government health programs, Gordon said.

The last statewide report on diabetes dates back to 2005 and 2006. Novo Nordisk’s Ken Inchausti said a new look at diabetes is necessary, considering the changing demographics of the state – minority populations are more likely to have diabetes – and the importance of diabetes in healthcare spending. One quarter of Medicare spending and 10 percent of national healthcare spending is on diabetes.

“Diabetes is starting to overwhelm healthcare systems,” Inchausti said.

The Senate version of the bill is scheduled for a hearing in the Senate Health, Human Services and Senior Citizens Committee meeting on Monday. The Assembly version has been referred to the Assembly Health and Senior Services Committee.

Report Finds NJ Hospitals Face Multiple Financial Pressures Increase in 2011 operating margins offset by pension payments, stock market decline

By Andrew Kitchenman, Jersey's hospitals are still fiscally healthy, but their financial pulse isn't as strong as it was a year ago.

While state’s hospitals saw increased operating margins in 2011, those gains were offset in large part by required pension contributions and declines in the stock market, according to a recent report by the New Jersey Hospital Association.

The annual Financial Status of New Jersey Hospitals Report found that the operating margin for hospitals increased to 3 percent in 2011 from 2.3 percent in 2010.

However, non-operating expenses caused total margins to fall from 4.7 percent in 2010 to 0.3 percent in 2011, once contributions to worker pensions and a drop in investment income were factored in.

The final numbers for 2012 won’t be available until later this year.

“New Jersey hospitals continue to face a delicate balancing act between their mission and their margins,” said Elizabeth A. Ryan, association president and CEO, in a statement. “Their efforts to deliver high quality healthcare services while improving the efficiency of their operations are reflected in an improved operating margin.”

Association officials said the increased margins were also the result of aggressive efforts to reduce costs and increase collaborations January 2013

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with doctors and post-acute providers, moves prompted by reductions in Medicare, Medicaid and the state charity care program.

Hospitals face additional cuts in government payments under a law passed by Congress last week. The measure reduces reimbursements to hospitals in lieu of cuts that had been planned in Medicare payments to doctors.

The association estimated that the reduction in Medicare reimbursements would reduce payments to New Jersey hospitals by $83.2 million in the first 12 months.

In 2011, New Jersey hospitals had $50.5 million in total gains and $585.9 million in net operating income, so that $83.2 million drop in revenues represents a significant financial blow.

The report also found that different categories of hospitals are in different financial situations.

For example, operating margins were stronger at suburban hospitals, with an average 3.2-percent margin, compared with rural hospitals, at 1.7 percent, and inner-city hospitals, where the average margin was 0.8 percent.

In addition, acute-care hospitals had higher operating margins than non-acute care facilities.

While the hospitals’ total margins were barely positive, they were much improved from the recent low of 2008, when total margins were minus-14.1 percent.

The 0.3 percent total margin was lower than the operating margin for hospitals in the rest of the Northeast, where it was 2.8 percent, and the national median of 3.2 percent.

The hospitals’ financial situation worsened over the past year in other ways. The number of days of expenses that the hospitals would be able to cover with the amount of money that they have accumulated, or cash on hand, dropped from 53.8 days in 2010 to 49.2 days in 2011, while the average time it takes to be paid for services increased from 73.1 days to 78.5 days, according to the report. The annual return on hospitals’ equity dropped from 12.6 percent in 2010 to 1.4 percent in 2011.

Sean Hopkins, NJHA senior vice president of health economics, noted that these financial pressures are affecting an industry that is important to the state’s economy, adding that hospitals are usually the largest employer in their communities.

“Our hospitals will have to remain focused and creative in their efforts to continue to deliver high quality care in a cost-effective manner,” Hopkins said in a statement. “The pressure needle on hospital revenues is still pointing down for the foreseeable future.”

N.J. Legislature passes bill requiring medical professionals to get flu shots

By Susan K. Livio, The Star-Ledger Beginning in the fall, medical professionals who come into contact with patients would have to get a flu shot under a bill that won final legislative approval.

Health care facilities would have to provide a vaccination program for its employees by the start of the next flu season in the fall.

Employees would have to get the vaccine, show proof they got it on their own, or sign a statement that testifies to their decision not to get vaccinated, according to the bill.

All health care facilities would have to report its annual compliance rate to the state Department of Health and Senior Services, according to the bill, (A3920).

The bill passed, despite calls from anti-vaccine groups urging people to tell lawmakers to oppose any vaccine mandate. "This opens the door for vaccine mandates for adults. Records will be maintained regarding who has received this vaccine and who has declined it,'' according to an e-mail sent Friday by the New Jersey Coalition for Vaccine Choice to its members.

The Senate passed the bill 36-3 just before 6 p.m. The Assembly passed the bill last month.

Visit us now online at www.NJPhysician.org 14 New Jersey Physician

Health Law Update

HEALTH LAW Update Committee Reports Favorably on Bill Allowing Psychologists to Prescribe Medication The New Jersey Assembly’s Regulated Professions Committee reported favorably last month on bill A2419, which, if passed, would authorize the State Board of Psychological Examiners to issue a certificate of “prescriptive authority” to a licensed practicing psychologist with a doctoral-level degree who: (1) has successfully graduated with a postdoctoral master’s degree in clinical psychopharmacology from a regionally accredited institution of higher education or has completed equivalent training to the postdoctoral master’s degree approved by the board; and (2) has passed an examination approved by the board that is relevant to establishing competence for prescribing drugs.

For additional information, contact: Keith J. Roberts | 973.364.5201 | kroberts@bracheichler.com Kevin M. Lastorino | 973.403.3129 | klastorino@bracheichler.com Nursing Scope of Practice Bill Last month, the Consumer Access to Health Care Act bill was introduced, which seeks to eliminate the requirement of joint protocols with physicians for advance practice nurses (APN) to prescribe medications.

New Jersey laws and regulations governing the practice of APNs are set forth in the “Advanced Practice Nurse Certification Act” and Board of Nursing regulations. These laws and regulations require that an APN enter into an agreement with a collaborating physician if the APN intends to prescribe medications as part of his or her practice. A “collaborating physician” is defined as a person licensed to practice medicine and surgery who agrees to work with an APN. The proposed bill seeks to delete the reference to a “collaborating physician” and replace it with a “collaborating provider,” defined as a physician licensed to practice medicine and surgery “or an advanced practice nurse issued a certification…” The bill proposes that APNs qualified with certain minimum qualifications (including certain continuing education hours) may issue prescriptions on their own authority. To the extent an APN does not possess the required qualifications, he or she would be able to prescribe medications pursuant to a collaboration agreement with a collaborating provider.

For additional information, contact: Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com Christie Denies State-Run Insurance Exchange Governor Christie recently vetoed legislation that would have established a state-run health insurance exchange under the Affordable Care Act, making New Jersey the 19th state to decline to create its own exchange for New Jersey’s residents.

“I will not ask New Jerseyans to commit today to a state-based exchange when the federal government cannot tell us what it will cost, how that cost compares to other options, and how much control they will give the states over this option that comes at the cost of our state’s taxpayers,” Christie said in a statement.

For additional information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Mark Manigan | 973.403.3132 | mmanigan@bracheichler.com Out-of-Network Reimbursement Suit for $120 Million Aetna, Inc. recently agreed to settle a lawsuit relating to its out-of-network (OON) reimbursement practices, particularly its use of United HealthCare Corporation’s Ingenix database to determine OON services reimbursement amounts. In December 2009, United entered into a settlement agreement relating to this same issue. The use of the Ingenix database has been discontinued under settlements with the New York Attorney General.

Provider class members are those who provided covered OON services to Aetna plan members from June 3, 2003 until the preliminary settlement approval date. Subscriber class members are plan members who received covered services from OON providers from March 1, 2001 until the preliminary settlement approval date. The settlement is divided into three financial components: (1) a General Settlement Fund of $60 million against which provider class members and subscriber class members can make claims; January 2013

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(2) a Subscriber Prove-Up Fund from which Subscriber Class Members can instead seek compensation related to covered services they received from OON providers; and (3) a Provider Prove-Up Fund for which providers can instead seek compensation related to covered services they provided to plan members. Attorneys’ fees and costs, as well as the costs of administration, are to be paid from the General Settlement Fund before reimbursing settlement class members.

Payment to providers and subscribers from the General Settlement Fund will be based upon the number of years a party provided or received services from the applicable time period, and no supporting documentation will be required.

There will be an additional $40 million available from the Subscriber Prove-Up Fund and an additional $20 million from the Provider Prove-Up Fund, under which a subscriber or provider can elect to submit a claim from the applicable Prove-Up Fund instead of the General Settlement Fund. Such subscriber or provider will be required to submit a completed Proof of Claim Form and the required supporting documentation to be eligible to receive payment from the Prove-Up Funds.

The parties to the settlement have requested that the Federal District Court of New Jersey set a preliminary approval hearing as the next step in the settlement process.

For additional information, contact: Mark Manigan | 973.403.3132 | mmanigan@bracheichler.com Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com Fiscal Cliff Deal Temporarily Addresses Sustainable Growth Rate Posted on January 14, 2013 by admin Reply The deal, passed by the House and Senate on January 1, and signed by President Obama on January 3, put off for a year the 26.5% cut in physician reimbursement mandated by Medicare’s sustainable growth rate formula scheduled for January 1, and pushed back another 2% cut for an additional two months. Savings from the deal come in part from cuts to hospital reimbursement, including empowering Medicare officials with the ability to take back an estimated $500 million in payments made to hospitals and physicians since 2007. The provision, known as “Removing Obstacles to Collection of Overpayments,” provides that Medicare contractors now have five years to collect on errors in Medicare payments. Before this change, the statute of limitations on non-fraudulent Medicare overpayments was only three years. However the largest cuts occur in the five-year period from 2014 to 2018, when Medicare will reduce hospital payments by $10.5 billion. Medicare authorities will recoup what they consider overpayment to hospitals caused by a new system of diagnosing patients. The cliff deal also created a “new high-level commission ” to develop a national plan for long-term services for the elderly and disabled. Should the measure become law, the Commission on Long-Term Care will have six months to draft recommendations.

For additional information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com Presence of Anesthesiologists Required When Nurses Deliver Anesthesia in Hospitals In a case litigated by Brach Eichler on behalf of the N.J. State Society of Anesthesiologists (NJSSA), an appellate court last month upheld regulations of the Department of Health (DOH) requiring the presence of an anesthesiologist when an Advanced Practice Nurse/Anesthesia (APN/A) administers anesthesia in a hospital. The regulations provide that an APN/A, in order to administer general or major regional anesthesia, conscious sedation or minor regional blocks in a hospital, must enter into a joint protocol with a collaborating anesthesiologist that requires the anesthesiologist to be present during induction, emergence and critical change in status. The N.J. Association of Nurse Anesthetists (NJANA) claimed that the regulations were unlawful.

Brach Eichler Member Joseph M. Gorrell and Counsel Richard B. Robins succeeded in convincing the court to grant the NJSSA Amicus Curiae (“friend of the court”) status. Brach Eichler filed several briefs on behalf of the NJSSA in support of the regulations, and also participated in the oral argument.

A unanimous three-judge panel rejected the NJANA’s challenges and upheld the regulations, finding it was “fundamentally reasonable for DOH to recognize the differences in education, training and skill of APN/As and anesthesiologists in establishing hospital anesthesia staffing regulations,” and that requiring an anesthesiologist to be available to handle complications beyond the expertise of APN/As would better protect patients. The court reaffirmed that administration of anesthesia is the practice of medicine, so the rules did not improperly regulate the practice of APN/As or the nursing profession.

For additional information, contact: Joseph M. Gorrell | 973.403.3112 | jgorrell@bracheichler.com John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Richard B. Robins | 973.403.3147 | rrobins@bracheichler.com

16 New Jersey Physician

Pharmacy May Provide Certain Items to Community Homes In a recent advisory opinion (Advisory Opinion 12-19), the U.S. Department of Health and Human Services, Office of Inspector General (OIG) approved part, while declining to approve another part, of an arrangement whereby a pharmacy would provide, either free or at a nominal cost, certain services and items to community homes. The approved arrangements include the pharmacy’s provision (1) of pre-populated medication administrative records, physician order forms and treatment sheets once a month to each resident receiving his or her medications from the pharmacy; (2) of access to software that would, among other things, print pre-populated MARs, physician order forms and treatment sheets relating to the services the pharmacy provides to each resident receiving prescriptions from the pharmacy; (3) of sublicenses, at below-market price, for software that integrates pharmacies’ information and order fulfillment processes with the user’s medication administration work responsibilities (e.g., documenting medication administration, tracking vital signs and storing medical observations).

The OIG declined to approve a fourth arrangement whereby the pharmacy would provide community homes with a free sublicense to certain software (which had a significant cost) that allowed, among other things, the community home to create and store medical administrative records. The OIG stated that, because the data was not transferable to other systems, it would steer the community homes to using the pharmacy over other providers, thus creating the risk of fraud and abuse.

For additional information, contact: Todd C. Brower | 973.403.3103 | tbrower@bracheichler.com Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com Thousands of Patients Affected by Breach A Rhode Island hospital recently reported that several unencrypted back-up tapes containing ultrasound images from two of its ambulatory locations are missing. The hospital conducted an investigation but was unable to locate the tapes, which contained images from the mid-1990s up to 2007 and also included patient names, dates of birth and Social Security numbers.

This incident serves as yet another reminder of the importance of implementing adequate physical, technical and administrative safeguards and considering encryption when appropriate. Although the HIPAA Security Rule, on its own, does not mandate encryption, the HITECH Act’s breach notification rule provides a “safe harbor” for those entities that encrypt their protected health information. (Encryption is considered an “addressable” standard under the HIPAA Security Rule, which means that covered entities must determine whether encryption is feasible and cost-effective in light of its particular environment.)

For additional information, contact: Todd C. Brower | 973.403.3103 | tbrower@bracheichler.com Lani M. Dornfeld | 973.403.3136 | ldornfeld@bracheichler.com Proposed Rules for Licensed Genetic Counselors The Genetic Counseling Advisory Committee of the New Jersey State Board of Medical Examiners has proposed regulations implementing the Genetic Counselor’s Licensing Act, N.J.S.A. 45:9-37.111 et seq., which became effective in April 2010. The proposed rules address, among other things, licensing requirements for genetic counselors, scope of practice, sexual misconduct, advertising practices, recordkeeping requirements and patient confidentiality. Comments must be submitted by January 2, 2013.

For additional information, contact: Kevin M. Lastorino | 973.403.3129 | klastorino@bracheichler.com Joseph M. Gorrell | 973.403.3112 | jgorrell@bracheichler.com Proposed New Rules on Prescription Blanks The New Jersey Division of Consumer Affairs has published proposed amendments to the New Jersey Uniform Prescription Blanks Program. The proposed amendments would, among other things, require pre-printing of the licensed prescriber’s DEA registration number, or, in the alternative, permit the prescriber or health care facility to use an electronic health records system to print the prescriber’s name, address, National Provider Identifier (NPI) number or the unique provider number of the health care facility in lieu of having that information pre-printed on the blank. Comments concerning these amendments must be submitted by January 4, 2013.

For additional information, contact: Todd C. Brower | 973.403.3103 | tbrower@bracheichler.com Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com January 2013

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Corporations to Employ Physicians in Limited Circumstances The New Jersey State Board of Medical Examiners (BME) recently received a petition for rulemaking filed by the New Jersey Hospital Association, for enactment of a rule permitting licensed physicians to be employees of a corporation under limited circumstances, including if: • the corporation is a wholly-controlled subsidiary of a licensed hospital that monitors the activities of the subsidiary corporation through a quality assessment and performance improvement program and makes the structure of this program available to the BME for review, upon request • the corporation does not exercise control over employee physicians’ independent medical judgments • the corporation has, as part of its governance structure, a committee comprised solely of licensed physicians who have sole responsibility for all corporate decision-making involving the exercise of independent medical judgment.

For additional information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com Proposed Medicaid Rules Released The New Jersey Department of Human Services recently released proposed regulations to comply with various provisions of the federal Affordable Care Act. Specifically, these rules would prohibit the New Jersey Medicaid/NJ FamilyCare programs from making payments for items or services provided by entities outside the U.S. Providers, suppliers, managed care entities and others would also be subject to, unless otherwise exempted, additional program integrity requirements, such as new medical review and certification requirements, new requirements regarding overpayments and other oversight requirements. In addition, if certain individuals were prohibited from participating in other federal health programs, they would also be precluded from New Jersey Medicaid/NJ FamilyCare. Comments on the proposed regulations are due no later than January 18, 2013.

For additional information, contact: Keith J. Roberts | 973.364.5201 | kroberts@bracheichler.com Joseph M. Gorrell | 973.403.3112 | jgorrell@bracheichler.com Non-Medical Providers Must Enroll as “Non-Billing Providers Physicians who are not Medicaid participants recently received a letter from the New Jersey Medicaid program, pursuant to provisions of the federal Affordable Care Act. In short summary, providers who are involved with the care of fee-for-service Medicaid recipients (“straight Medicaid”) must enroll as either a “billing/servicing” NJ Medicaid provider (authorized to bill Medicaid) or a “non-billing” NJ Medicaid provider (authority limited to referring, prescribing, attending or operating, but not to billing Medicaid).

Beginning January 1, 2013, any claim submitted by an enrolled Medicaid provider containing the NPI number of a referring, ordering, prescribing, attending or operating medical professional who is not enrolled either as a “billing” or “non-billing” Medicaid provider will be denied. Billing providers will have access to a non-billing provider directory on the NJMMIS website.

For additional information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Carol Grelecki | 973.403.3140 | cgrelecki@bracheichler.com Governor Signs Prescription Medication Disposal Law A new law recently signed by Governor Christie, P.L. 2012, c. 62, prohibits health care institutions, including New Jersey hospitals, or any of their employees, staff or others under their supervision, from discharging, disposing of, flushing, pouring or emptying any unused prescription medication into a public wastewater collection or septic system. Health care institutions found in violation of the law could face an administrative penalty of $1,000 for the first offense and $2,500 for each subsequent offense.

In addition, each health care institution must submit to the Department of Health and the Department of Environmental Protection a plan for the proper disposal of unused prescription medications, within 90 days of enactment of the law (November 19, 2012).

Rejected plans will require amendment and re-submission, and health care facilities failing to submit a plan will be subject to financial penalty.

For additional information, contact: Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com Mark Manigan | 973.403.3132 | mmanigan@bracheichler.com Governor Signs Medical Waste Law A new law, P.L. 2012, c. 65, tightens controls on the dumping of medical waste in New Jersey. A health care professional, facility, generator or transporter found in willful violation of New Jersey’s medical waste anti-dumping laws, rules or regulations will have

18 New Jersey Physician

its license, registration or other authorization to operate or practice suspended for at least three years, with reinstatement possible only after a hearing before the applicable governmental authority. Continued operation or practice during a suspension will trigger revocation.

The law also requires the New Jersey Attorney General to notify the Attorney General or equivalent authority of another state, within 30 days of finding a health care professional, facility, generator or transporter of that state was in violation of New Jersey’s medical waste disposal law. In addition, upon receipt of information from another state that a violator was from New Jersey and violated that state’s medical waste disposal laws, the information will be forwarded to the appropriate New Jersey authority for action.

For additional information, contact: Kevin M. Lastorino | 973.403.3129 | klastorino@bracheichler.com Debra C. Lienhardt | 973.364.5203 | dlienhardt@bracheichler.com DOBI Adopts New PIP Regulations The New Jersey Department of Banking and Insurance has adopted new personal injury protection (PIP) regulations. The majority will go into effect on January 1, 2013, while those outlining internal appeals for pre-certifications went into effect on November 5, 2012.

Although proposed regulations were published twice with comment periods, in August 2011 and February 2012, the regulations were adopted, for the most part, unchanged. Some of the more salient adopted regulations include: • The PIP fee schedule provides higher reimbursement for surgical procedures performed in a hospital setting versus the same procedures performed in a freestanding ambulatory surgery center (ASC); some procedures will not be reimbursable in an ASC setting • 111 (of the proposed 117) neurosurgical and spinal surgical codes were deleted • Pre-certification is subject to an internal appeal process; if not filed, a healthcare provider is barred from initiating arbitration • Claims of less than $1,000 will be arbitrated and resolved on the papers without an in-person hearing • PIP reimbursement will be subject to the Medicare Claims Processing Manual, the National Corrective Coding Initiative and guidance from the Center for Medicare and Medicaid Services.

Given that the newly adopted regulations will have a significant negative impact across a wide spectrum of healthcare providers, these regulations are being challenged. Stay tuned.

For additional information, contact: Mark Manigan | 973.403.3132 | mmanigan@bracheichler.com Keith J. Roberts | 973.364.5201 | kroberts@bracheichler.com NJ Governor Vetoes State Implementation of Health Insurance Exchanges On December 6, New Jersey Governor Chris Christie vetoed legislation that would establish a state-run health insurance exchange under the Affordable Care Act (the “ACA”). The ACA looks to exchanges as facilitators of a health insurance marketplace. In this marketplace, individuals can apply for tax credits and other subsidies that would reduce the cost of their coverage. New Jersey is the 19th state to decline to create its own exchange. The federal government will now be tasked with creating an exchange for New Jersey’s residents. States have until December 14 to inform federal authorities of their plans for health insurance exchanges.

Seventeen states and the District of Columbia already are moving ahead with their own exchanges, five states intend to jointly operate them with the federal government, and nine haven’t made announcements.

Christie remained skeptical of the cost and flexibility. “I will not ask New Jerseyans to commit today to a state-based exchange when the federal government cannot tell us what it will cost, how that cost compares to other options, and how much control they will give the states over this option that comes at the cost of our state’s taxpayers,” Christie said in a statement.

Governor Christie has stood by his pledge before. He rejected a similar bill in May on the grounds that the ACA might be unconstitutional, a view the Supreme Court rebuffed when it ruled in favor of the law in June.

For additional information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Mark Manigan | 973.403.3132 | mmanigan@bracheichler.com

Visit us now online at www.NJPhysician.org January 2013

19

Practice Models CMS announces over 100 new ACO contracts

By Melanie Evans Posted: January 10, 2013 Medicare nearly doubled the size of one accountable care program as of Jan. 1 with 106 new ACO contracts (PDF) that offer hospitals and doctors financial incentives to improve quality and slow health spending.

The CMS announced its latest and largest round of accountable care organizations under the Medicare shared-savings program, which launched in April last year with 27 ACOs. Another 89 ACOs were named to the program last July. The Center for Medicare and Medicaid Innovation separately launched 32 Medicare ACOs known as Pioneers roughly one year ago. CMS said half of ACOs are physician-led and care for less than 10,000 Medicare enrollees.

Jonathan Blum, the CMS acting principal deputy administrator and director for the center for Medicare, said it is too soon to release results from Medicare accountable care efforts launched last year. Blum, speaking with reporters after the CMS announced the latest ACOs, said the agency was optimistic the contracts would reduce costs.

Accountable care, an experimental payment model that has also emerged among commercial insurers, was among a few policies in the health reform law that seek to more closely tie payment to performance, though critics contend that incentives in such programs are too modest.

Hospitals and doctors in Medicare's shared-savings program may select from two incentive options, including one with greater incentives but also carries the risk of potential losses. So far, eight shared savings ACO have selected his option. The other sharedsavings option offers only bonuses but no risk of losses. Pioneer accountable care contracts require all hospitals and doctors to be at risk for losses starting this year.

Medicare spending increased 6.2% in 2011, a growth rate faster than the 4.3% growth in 2010, CMS officials said this week. The program's budget is one likely target for lawmakers who are seeking a deficit reduction deal as they debate scheduled spending cuts and raising the debt ceiling in coming weeks.

The group of ACOs announced today includes 15 Advance Payment Model ACOs, physician-based or rural providers who receive upfront and monthly payments for capital investments, the CMS said.

Pharmacy chain Walgreens contracted with two medical groups and one health system to form three separate Medicare ACO. The drugstore giant, which also operates walk-in clinics, isn't the only company to see a market opportunity in Medicare's accountable care program. Universal American, a publicly traded Medicare Advantage and supplemental insurance provider, also contracted with hospital and medical groups to successfully win Medicare ACO contracts last year.

Dr. Jeffrey Kang, Walgreens' senior vice president of health and wellness services and solutions, said the company brings to the ACOs prevention, screening, health and wellness programs; medication management; walk-in clinics; and care management with physician groups.

Stephen Shortell, a professor of health policy and management for the University of California Berkeley School of Public Health, said the importance of medication management among costly, chronically ill patients makes the entry of a pharmacy chain into accountable care unsurprising.

New rule: Hospital, physician partners face penalties for privacy leaks

By Joseph Conn HHS in its long-awaited privacy rule released today expanded liability of business associates of hospitals, physicians and other HIPAA-covered entities if they release data in ways that violate patient privacy.

Called the “omnibus” privacy and security rule because of its broad reach, it updates earlier Health Insurance Portability and Accountability Act rules with more stringent privacy and security measures passed under the American Recovery and Reinvestment Act of 2009.

“Much has changed in healthcare since HIPAA was enacted over fifteen years ago,” said HHS Secretary Kathleen Sebelius said in a news release coordinated with the posting of the 563-page rule in the Federal Register. “The new rule will help protect patient privacy and safeguard patients' health information in an ever-expanding digital age.”

The rule clarifies when breaches of information must be reported to the Office for Civil Rights, sets new rules on the use of patientidentifiable information for marketing and fundraising, and expands direct liability under the law to the so-called “business associates” of hospitals and physicians and other “HIPAA-covered entities.” Those associates might include a provider's healthcare data-miners and health information technology service providers.

It also restores a limited right of consent to patients to control the release to their insurance company of records about their treatment if the pay for that treatment is out of pocket. And it spells out how the greatly increased penalties for privacy and security violations under the ARRA are to be applied.

20 New Jersey Physician

“This final omnibus rule marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented,” said Leon Rodriguez, director of the Office for Civil Rights at HHS, also in the news release. The office is the lead privacy and security enforcement agency under HIPAA. “These changes not only greatly enhance a patient's privacy rights and protections, but also strengthen the ability of my office to vigorously enforce the HIPAA privacy and security protections, regardless of whether the information is being held by a health plan, a healthcare provider or one of their business associates,” Rodriguez said.

Official publication of the new rule in the Federal Register is scheduled Jan. 25. Its effective date is March 26 with a compliance date 180 days later, or Sept. 21, 2013.

Hospital Rounds MinuteClinic, Barnabas Health team up

By Andis Robeznieks Physicians with Barnabas Health, a seven-hospital system based in West Orange, N.J., will serve as medical directors for three nurse practitioner-operated retail clinics in New Jersey operated by MinuteClinic, the Woonsocket, R.I.-based division of CVS Caremark Corp.

The clinics are located in CVS stores in Jackson, Manalapan and Marlboro. Barnabas will collaborate on patient education and disease-management initiatives and will take patients whose conditions require above the level of service MinuteClinics provide, according to a news release.

With patient permission, MinuteClinic will send medical histories and visit summaries via its electronic health-record system to Barnabas locations in Monmouth and Ocean counties. The release noted that MinuteClinic and Barnabas Health “will begin to work toward fully integrating electronic medical-record systems.”

MinuteClinic recently entered into a similar agreement with Virtua, a four-hospital system based in Marlton, N.J., covering stores in Burlington, Camden and Gloucester counties.

According to the Convenient Care Association, there are about 1,400 retail clinics operating in the U.S., compared with 1,000 in 2009.

January 2013

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A New Level of Healthcare Technology University of Medicine and Dentistry of New Jersey (UMDNJ)-The University Hospital launched Computerized Provider Order Management (CPOM) on January 27. It is a new and revolutionary part of the hospital’s electronic medical records system that will allow physicians and other providers to enter medical orders by computer rather than on paper.

“Our implementation of CPOM is a significant investment in our facility, and one that will allow us to provide patient care with greater accuracy and quality,” said James R. Gonzalez, MPH, FACHE, President and CEO (Interim), UMDNJ-The University Hospital.

“More important, CPOM is simply the right thing to do and furthers our commitment to patient safety.”

CPOM will enable UMDNJ-The University Hospital to enhance patient safety, efficiency and communications through state-of-theart electronic access, according to Suzanne H. Atkin, MD, FACEP, FACP, Chief Medical Officer for UMDNJ-The University Hospital, and Associate Dean for Clinical Affairs at UMDNJ-New Jersey Medical School.

Dr. Atkin, along with Michael A. Curi, MD, MPA, Chief, Division of Vascular Surgery, and the CPOM physician champion, led the hospital’s physician steering committee for CPOM. The committee worked tirelessly with the nurses, pharmacists and the entire hospital community over the past year to build order sets, organize training sessions and develop policies to prepare for the CPOM launch.

This preparation was tested during a dress rehearsal on January 16. During the dress rehearsal, CPOM Superusers, hospital staff members who were trained to teach others how to use CPOM, practiced a number of typical patient scenarios throughout the hospital.

The advantages of CPOM include: •

Improved patient safety, efficiency and communication

•

Elimination of the need to read difficult handwriting

•

Remote access to medical orders

•

Several providers, including nurses and therapists, can view the status of medical orders at the same time.

Visit us now online at www.NJPhysician.org

Friendly, Compassionate Staff to Serve the Urban Patient The Smith Center for Infectious Diseases and Urban Health was developed to address infectious diseases in the inner city.

This non-profit center, which is initially focusing on HIV, recognizes that inner city patients face many unique challenges in their daily lives. These challenges interfere with treatment of infectious diseases and foster an environment where infectious diseases are easily spread.

When you treat a person with HIV, you greatly reduce the chances of transmission and treat the whole community. In the past 10 years there have been incredible advances in HIV treatment. We at the Smith Center believe that by using novel approaches we can rid New Jersey of HIV. We have designed programs to incentivize patients to continue their medications. We have created a personal atmosphere, where each patient is known by her or his first name. We work with our patients to ensure that we are providing the best service possible.

Dr. Stephen Smith - named a Top Doctor of New Jersey by Castle Connolly 310 Central Avenue, Suite # 307 • East Orange, NJ 07018 Phone: 973-809-4450 Fax: 973-395-4120 • www.smithcenternj.org

22 New Jersey Physician

Food for Thought

Heating Up a Cold Super Bowl Sunday

By Iris Goldberg

Here in New Jersey we’d been getting accustomed to some exciting football. With both the Giants and Jets participating in playoff games that were real nail-biters and the Giants winning the Super Bowl in 2008 and again last year, football Sundays were enjoyed by more of us than ever before. Even those (like myself ), who usually found something else to do on Sundays while their significant others spent the entire day screaming at the TV screen, got pulled in.

With the 2013 Super Bowl right upon us, we must concede that the past season has been more than just a little disappointing for New Jerseyans. Of course diehard fans of the game like my husband will watch almost any football that’s on but I lost interest weeks ago. Still, there will be a Super Bowl party to attend for many of us, whether or not we plan to actually watch the game.

As always, the food served will provide an opportunity for even the most diet-conscious among us to totally “pig out.” Here are a couple of easy to do recipes that will add some warmth to the taste buds, the winter-chilled bones and also perhaps, to a cooled spirit. The first is probably the most traditional Super Bowl Sunday food. Here is a fool-proof and relatively simple way to prepare Buffalo chicken wings that won’t disappoint:

Ingredients: (Serves 8)

•

16 chicken wings split at both joints with wing tip discarded (will yield 32 pieces)

•

1-11/2 cups flour

•

salt

•

black pepper

•

garlic powder

•

cayenne or chipotle pepper

•

vegetable oil

•

1-11/2 cups Frank’s Hot Sauce

•

½ stick butter

Add dry seasoning to flour according to taste. Adjust cayenne or chipotle according to level of heat you desire. For medium heat ½ tsp. does the trick. Add washed and paper towel-dried wings to flour and toss to evenly cover. Fry wings on each side in about ½ in. of oil, turning and then removing when golden-brown. Drain on paper towels. Place wings in clean, large bowl. Next, heat Frank’s Hot Sauce and butter on low flame just until butter melts. Pour over wings and toss to cover. Serve with celery sticks and blue cheese dressing. (We use Marie’s ready-made dressing because it’s really good and so easy).

January 2013

23

The next dish is not as common but whenever I serve it someone asks for the recipe. It’s not hot in a spicy way but rather warm and satisfying, especially on a cold winter’s day. Here is an artichoke dip that’s as easy as can be:

Ingredients: (For a really big crowd double the recipe)

•

1 can artichoke hearts, drained and coarsely chopped

•

1 cup grated mozzarella cheese

•

1 cup mayonnaise

•

1 cup store-grated grated parmesan cheese

I use a food processor for this dish. Place drained artichokes in. Coarsely chop with a few quick on and off clicks. Remove and hold on the side. Then put a small package (8 oz.) of mozzarella into the machine and process until completely grated. This will yield a bit more than a cup but I use it all. If you like it less cheesy, measure out 1 cup and save the rest or discard. To the grated mozzarella, add the artichoke hearts, the mayo and the parmesan cheese. Process all ingredients until well-blended (ten seconds or so). Pour into an oven-safe crock or serving dish and bake at 350° until top turns golden-brown, usually for ½ hour or so. Slice fresh Italian bread or any kind of bread you prefer and place around dip. Supply a serving spoon or two to place dip on bread. Stand back and watch as your guests dig in!

Even though we won’t be able to root for our New Jersey team this year, hopefully we will all enjoy sharing a terrific Super Bowl Sunday with friends and family. After all that’s what it’s really all about anyway. That – and of course, the FOOD!

Visit us now online at www.NJPhysician.org

24 New Jersey Physician

St.Health Cloud VA Care System

St.Health Cloud V Care Sys

Brainerd | Montevideo | Alexandria

Brainerd | Montevideo | Al

is accepting applications for the following full or part-time positions:

Associate Chief, Primary

& Specialty Medicine ï Associate Chief, Primary

&Cloud, Specialty Medicine (Internist-St. MN)

(Internist-St. Cloud)

Director,ï Primary and Director, Primary

and Specialty Medicine Specialty Medicine (Internal Medicine) (Internal Medicine) (St. Cloud)

(St. Cloud, MN)

ï EN T

(St. Cloud)

ENT

(St. Cloud,ï MN)

Geriatrician

(Nursing Home-St. Cloud)

Geriatrician/Hospice/Palliative Care

ï Hematology/Oncology (Nursing Home-St. Cloud, MN) (Part Time-St. Cloud)

ï Hospice/Palliative Care Hematology/Oncology

(Part Time-St. Cloud, MN)

(St. Cloud)

Internal Medicine/

Practice ï Family Internal Medicine/ Family Practice (Alexandria, Brainerd ï Associate Chief, Primary (Alexandria, Brainerd, & Specialty Medicine St. Cloud, Montevideo, MN) St. Cloud, Montevideo) (Internist-St. Cloud)

ï Medical Medical DirectorDirectorï Extended Care & Rehab Extended Care & Rehab (IM or Geriatrics) (IM Geriatrics) (St.orCloud) (St. Cloud, MN)

Director, Primary and Specialty Medicine (Internal Medicine) (St. Cloud)

ï Pain Specialist (St. Cloud)

ï EN T (St. Cloud)

ï (St. Psychiatrist Cloud, MN) (Brainerd, St. Cloud)

ï Geriatrician (Nursing Home-St. Cloud)

Specialist ï Pain Radiologist (St. Cloud, MN) (St. Cloud)

ï Hematology/Oncology (Part Time-St. Cloud)

Pain Management

Urgent Care Provider

(MD: IM/FP/ER) US Citizenship required or candidates must have proper authorization to work in the US.

(St. Cloud, MN)

ï Interna Family (Alexand St. Clou

ï Medica Extende (IM or G (St. Clo

ï Pain Sp (St. Clo

ï Urgent Care Provider ï Hospice/Palliative Care Psychiatrist (MD: IM/FP/ER) (St. Cloud) (Brainerd, St. Cloud, MN) (St. Cloud)

is accepting applications fo following full or part-time po

ï Psychia (Brainer

ï Radiolo (St. Clo

ï Urgent (MD: IM (St. Clo

US Citizenship required or candidates mu J-1 candidates are now being accepted for the authorization to work in the U Hematology/Oncology positions.

J-1 candidates are now being accept US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Geriatrician/ applicants BC/BE. Applicant(s) Hematology/Oncology positions. PhysicianPhysician applicants should beshould BC/BE.be Applicant(s) selected forselected a position may be eligible forHematology/Oncology an award up to the positio a position may be eligible for Program. an awardPossible up to the maximum bonus. maximum limitation under the provision for of the Education Debt Reduction recruitment EEO Employer.

Physician applicants should be BC/BE. App limitation under the provision of the Education Debt Reduction for a position may be eligible for an award up Excellent benefit package including: Program. Possible relocation bonus. EEO Employer. limitation under the provision of the Educatio Favorable lifestyle Program. Possible relocation bonus. EE Excellent benefit package including: 26 days vacation Favorable lifestyle CME days 26 days vacation Competitive salary CME days 13 days sickCompetitive leave salary 13 days sick leave Liability insurance Interested applicants Liability can mailinsurance or email your CV to St. Cloud VAHCS Sharon Schmitz (Sharon.schmitz@va.gov) Interested applicants can mail or email your CV to VAHCS 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN6618 56303 Telephone: 320-252-1670, extension

Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618

Excellent benefit pa

Favorable li 26 days vac CME days Competitive 13 days sic Liability ins

Interested applicants can mai your CV to VAHCS

Sharon Schmitz (Sharon.schmitz 4801 Veterans Drive, St. Cloud, M Or fax: 320-654-7650 o Telephone: 320-252-1670, exten

Talk to Bollinger about your Professional Liability …

Before entering this room.

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