THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 119 / NO. 2
March / April 2020
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| MARCH / APRIL 2020
FEATURES & CONTENTS March / April 2020
10
Protecting Michigan’s Infants and Young Children from Vaccine-Preventable Diseases STEFANIE COLE, BSN, RN, MPH
12
Spotlight on Senator Curt VanderWall
24
The Role of the Medical Assistant in Your Office Practice DEBBIE HILL, MBA, RN
COLUMNS 04 President's Perspective
MOHAMMED A. ARSIWALA, MD
06 Ask Our Lawyer
DANIEL J. SCHULTE, JD
08 Ask Human Resources
16
JODI SCHAFER, SPHR, SHRM-SCP
DEPARTMENTS 22 Welcome New Members 28 MSMS Educational Courses
FEATURE
Making Progress in the Fight to Reform Prior Authorization and Step Therapy BY NICK DELEEUW FOR THE MICHIGAN STATE MEDICAL SOCIETY
STAY CONNECTED!
Michigan physicians, patients and patient advocates have banded together and found a better way forward. There’s only one thing left to do: convince lawmakers they’ve got it right. Story begins on page 14.
MARCH / APRIL 2020 |
michigan MEDICINE® 3
MICHIGAN MEDICINE® VOL. 119 / NO. 2
perspective
Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Marketing & Sales Manager TRISHA KEAST TKeast@msms.org Publication Design STACIA LOVE, REZÜBERANT! INC. rezuberant.com Printing FORESIGHT GROUP staceyt@foresightgroup.net Publication Office Michigan Medicine® 120 West Saginaw Street East Lansing, MI 48823 517-337-1351 www.msms.org All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Trisha Keast. Postmaster: Address Changes Michigan Medicine® Trisha Keast 120 West Saginaw Street East Lansing, MI 48823
Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine® and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine® reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine® are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine® (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2020 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2020 Michigan State Medical Society
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“In this edition of Michigan Medicine® you’ll hear from physicians, patients, and patient advocates from across the state about the burdens and sometimes life-threatening consequences that come with prior authorization. But more hopefully, you’ll also hear about the solution that is on the horizon.
By Mohammed A. Arsiwala, MD, MSMS President
Identify problems and carry out solutions. That sentence encapsulates the work we do for our patients. Most of the time, that work is conducted on the individual level; we care for and treat the specific needs of each and every patient. But sometimes, it’s bigger than that, and the work Michigan’s physician community is doing to reform prior authorization practices is the perfect example. Insurance company prior authorization and step therapy requirements drive up costs, and much more importantly, harm our patients. It’s a problem Michigan physicians and patients have been grappling with for years. In this edition of Michigan Medicine®, you’ll hear from physicians, patients,
MOHAMMED A. ARSIWALA, MD MSMS PRESIDENT
and patient advocates from across the state about the burdens and sometimes life-threatening consequences that come with prior authorization. But more hopefully, you’ll also hear about the solution that is on the horizon. Senate Bill 612 cuts out the red tape, dramatically improving the prior authorization process for patients and physicians alike. You’ll learn more about the specific reforms the legislation would enact, and the work the Michigan State Medical Society is doing to see it through to the finish line. You’ll also hear from many of the physicians, patients, and advocates who are leading the fight for reform in Lansing, and learn about the sponsor of the legislation, Senator Curt VanderWall. Working together, we’re moving patients one step closer to the care, medicine and treatment they need. Sincerely,
Mohammed A. Arsiwala, MD MSMS President
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ASK OUR LAWYER
The Standard of Care Is Not Established by Health Plans or Insurers By Daniel J. Schulte, JD, MSMS Legal Counsel
Q:
The recent legislative hearings on bills to regulate prior authorization have me wondering whether health plans and insurers are changing the standard of practice. When a health plan or insurer requires/denies prior authorization for
a prescription or other treatment are they establishing the standard of practice (i.e. that the recommended prescription or other treatment is not necessary to comply with the standard of care)? Will the fact that prior authorization was required and denied be a defense in a malpractice case or licensing action alleging that I failed to act within the standard of care?
No. The standard of practice that must be met in all cases is established by physicians not health plans, insurers or anyone else.
I
n every patient encounter you will be held to the standard of what a physician of ordinary learning, judgment or skill would do or would not do under the circumstances. The standard of practice does not take into account or change based on the requirements and judgments of the patient’s health plan or insurer. It is based solely on the relationship between the physician and the patient and is focused exclusively on what the physician should or should not have done. In a malpractice case, whether the standard of practice was met would be decided by a judge/jury after being supported/opposed by expert witnesses for the plaintiff and the defendant (who must be physicians). In licensing actions where the State of Michigan is
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alleging negligence, expert witnesses are not legally required but most often are retained for their opinions as to whether this same standard of practice has been met. It will not be a defense in either case that the treatment you failed to recommend was not (or was no longer) covered by the patient’s health plan or insurance or that prior authorization was required and denied. Instead, a prior authorization requirement and denial will be disregarded and you will be judged solely based on whether a physician of ordinary learning, judgment and skill under the circumstances would have ordered the prescription or other treatment. It is critical that you carefully document in the medical record that all recommendations for necessary prescriptions
and other treatment have been made. Whether the patient’s health plan provided coverage, requires prior authorization and whether it has been granted or denied should also be documented. Obtaining a patient’s informed consent for refusing recommended treatment due to a prior authorization denial is just as important as obtaining a patient’s informed consent for treatment. If you recommend treatment that is not covered by the patient’s health plan and the
patient refuses to obtain the treatment because he/she cannot afford to pay for it out of pocket, this must be carefully documented in the patient record. You cannot fail to recommend treatment because you know or suspect that it will not be covered by the patient’s health plan. Instead, you should ignore the fact that the treatment is not covered and make a full explanation and recommendation to the patient. This must all be documented.
The standard of care cannot be changed by a health plan or insurer. Their decisions regarding what will be paid for and when are based on their own criteria (which are unknown to physicians and others). These criteria may or may not reflect the standard of care that you will be judged by.
DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL
“It is critical that you carefully document in the medical record that all recommendations for necessary prescriptions and other treatment have been made. Whether the patient’s health plan provided coverage, requires prior authorization and whether it has been granted or denied should also be documented.”
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ASK HUMAN RESOURCES
The 90-Day Myth with Unemployment Claims By Jodi Schafer, SPHR, SHRM-SCP, Human Resources Management Services, LLC
Q:
I have an employee who I recently hired, but after
If you terminate her, she has every right to file a claim for
two months on the job, she is still
unemployment. Whether she receives it or not, has to do
making errors. I just don't think she is
with how much money she earned in the previous year and
going to work out, so it looks like I will
the reason she is out of work rather than how long she was
be terminating her. She's trying hard but does not seem to be able to catch
employed with your practice.
right? I thought I had a 90-day window
T
to decide if I want to keep her before
UIA must determine if the individual
I had to worry about unemployment
is ‘eligible’ for benefits. To be eligible in
on to the way we do things. Since she's only been with me for such a short time, I don't have to worry about an unemployment claim against me,
compensation, but I wanted to doublecheck before I make any decisions.
he Unemployment Insurance
Or, within this same base period, the
Agency (UIA) uses a two-tiered
claimant must have:
test based on eligibility and qualification to determine if a person
will receive compensation. First, the
equal at least 20 times the state weekly average wage or $20,742. For the purposes of wage calculations,
ings threshold within an established
the UIA considers wages from ALL
period of time. The UIA establishes a
employers the claimant worked for
‘base period’ by looking backwards at
during the established base period.
the last 4-5 quarters of the current/pre-
If the claimant is determined to be
vious calendar year(s). Within this base
eligible for benefits, the UIA will
period, the claimant must have:
next decide whether or not they are
wages in the highest quarter of
earnings of at least $3,744 (as of 1/1/20), and wages in the entire base period
| MARCH / APRIL 2020
wages in the entire base period that
Michigan, a person must meet an earn-
wages in at least 2 quarters, and
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wages in at least 2 quarters, and
‘qualified’ to make a claim. To be qualified, the unemployed person must: have lost their job through no fault
of their own, and
that are at least 1.5 times the wages
be able and available for work, and
earned in the highest quarter.
be actively looking for work.
There are a number of other rules and formulas that are involved with the determination of the claim, but the UIA will send letters to you (the previous employer) along the way to inform you if a claim was filed and the information required of you in response. If you do decide to terminate her and she does apply for unemployment (assuming she was deemed eligible to do so by the UIA), you can still choose to contest the claim based on the reason she is no longer working for your practice. You will need to prove that her inability to perform the work demonstrated a willful disregard for your best interest. This will
be difficult to do since it sounds like her lack of skill was not the result of an overstatement of her abilities in her resume or an interview, nor was it the result of a conscious choice to neglect her duties. As you state, “she's trying hard but does not seem to be able to catch on to the way we do things,”. Therefore, the UIA may determine that she is out of work through no fault of her own. Remember it is called unemployment insurance rather than employer insurance and it was designed to give the unemployed individual the advantage. Let’s take a step back for a minute though. Are you really sure you want
to get rid of this employee? You may want to start the training all over again, documenting the process and giving her copies of this documentation. Remember, people learn differently. It may just take her longer to learn. Try to offer her the information in different ways. She may need another person training her. Two months is not that long of a period of time, especially if she did not come with any experience. Make sure that you give her every opportunity to succeed. The labor market is very tight right now and you may find it challenging to find someone else for the job.
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MDHHS UPDATE
Protecting Michigan’s Infants and Young Children from Vaccine-Preventable Diseases By Stefanie Cole, BSN, RN, MPH, Pediatric Immunization Nurse Educator, Michigan Department of Health and Human Services, Division of Immunization
Since 1994, the United States has recognized one week of the year as National Infant Immunization Week (NIIW) to highlight the importance of protecting infants from vaccine-preventable diseases and to celebrate achievements of immunization programs and partners in promoting healthy communities.1
W
hile it is certainly important to have a dedicated time during the year to remember how vital vaccines are to protecting young children’s health, it’s even more important that pediatric healthcare providers put that into practice throughout the entire year. Infants are especially vulnerable to vaccine-preventable diseases and their associated complications. Luckily, we have vaccines available to help keep children healthy in those first important years of life.
Vaccines protect against 14 diseases by the age of 2 years. For best protection, healthcare providers should immunize their patients according to the Advisory Committee on Immunization Practices (ACIP) immunization schedules.2 Both the child/ adolescent and adult immunization schedules are updated annually and were recently updated in February 2020. Vaccines should be administered at the recommended ages. Because so many vaccine series require multiple doses for full protection, if a child falls behind on the recommended schedule it can be difficult to get them caught back up in a timely manner. According to Michigan Care Improvement Registry (MCIR) data as of November 2019, 84.1% of Michigan infants had re-
By age 7 months, only 54.2% of Michigan children are completely up to date with all recommended vaccines.
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By age 2 years, only 52.5% of Michigan children are completely up to date with recommended vaccines. ceived their first dose of hepatitis B vaccine by 1 month of age. Hepatitis B vaccine is recommended to be given to all infants shortly after birth (within 12 or 24 hours, depending on the mother’s hepatitis B status). Not only does this mean that about 16% of 1-month-olds are left completely vulnerable to hepatitis B during their first month of life, but it becomes that much harder once beginning the hepatitis B vaccine series to receive all the doses on time according to the schedule. Furthermore, there is a concerning decline in the percentage of Michigan infants between 1 and 7 months of age who are completely vaccinated according to the recommended schedule. By age 7 months, only 54.2% of Michigan children are completely up to date with all recommended vaccines (excluding influenza). By age 2 years, only 52.5% of Michigan children are complete up to date with recommended vaccines. These data show that once children fall behind on their immunization schedule, they often do not get completely caught back up. Again, these are alarming statistics because young children, especially those less than 2 years old, are at higher risk for acquiring and becoming very ill from vaccine-preventable diseases. Many vaccine-prevent-
able diseases such as pertussis (whooping cough), varicella (chickenpox), and mumps circulate in Michigan every year.3 Although influenza affects more people than any other vaccine-preventable disease, many Michiganders go unprotected from flu. As of December 31, 2019, only 5.6% of Michigan children aged 6 months through 8 years recommended to receive two doses of flu vaccine for full protection during the 2019-20 season had received both doses.4 Other diseases we typically see less often in Michigan but are just a plane ride away. In 2019, there were 46 confirmed cases of measles in Michigan, more than the state has experienced since 1991.5 More than 1,200 cases of measles were confirmed in the U.S. in 2019, the greatest number of cases reported since 1992.6 Michigan’s large measles outbreak as well as the majority of the nation’s measles cases last year were associated with unvaccinated individuals who travel internationally and bring
measles back home where it spreads in communities with pockets of unvaccinated people. Measles is currently a global public health threat with many countries around the world experiencing outbreaks. As of November 5, 2019, there were more than 413,000 confirmed cases reported to the World Health Organization.7 In the Democratic Republic of Congo alone, about 310,000 suspected measles cases have been reported since the beginning of 2019 with over 6,000 deaths.8 Remember there are situations where children should be vaccinated earlier than the routinely recommended age. Children aged 6-11 months who travel internationally should be vaccinated against measles and hepatitis A before departure.2 Refer back to the immunization schedules to ensure you fully protect your youngest patients from vaccine-preventable diseases. Keep them healthy by keeping them on the recommended vaccine schedule.
REFERENCES 1 Centers for Disease Control and Prevention (2019). NIIW (National Infant Immunization Week). Retrieved from www.cdc.gov/vaccines/events/niiw/index.html on January 27, 2020. 2 Centers for Disease Control and Prevention (2019). Immunization Schedules. Retrieved from www.cdc.gov/ vaccines/schedules/index.html on January 27, 2020. 3 Michigan Department of Health and Human Services (2020). Vaccine Preventable Diseases in Michigan – Annual Summaries. Retrieved from www.michigan.gov/ mdh-hs/0,5885,7-339-73971_4911_4914_6385-47024--, 00.html on January 27, 2020. 4 Unpublished MDHHS data. 5 Provisional data. 6 Centers for Disease Control and Prevention (2020). Measles Cases and Outbreaks. Retrieved from www.cdc. gov/measles/cases-outbreaks.html on January 28, 2020. 7 World Health Organization. (2020). Measles – Global situation. Retrieved from www.who.int/csr/don/26-november-2019-measles-global_situation/en/ on January 28, 2020. 8 Center for Infectious Disease Research and Policy. (2020). As measles deaths top 6,000 in DRC, WHO calls for aid. Retrieved from www.cidrap.umn.edu/news-perspective/2020/01/measles-deaths-top-6000-drc-whocalls-aid on January 28, 2020.
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LEGISLATIVE
Spotlight on Senator Curt VanderWall
P
atients are nearer each day to meaningful prior authorization and step therapy reforms thanks to the work of diligent patient advocate in the state legislature, led by Senator Curtis VanderWall.
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Senator VanderWall is both the Chairman of the Senate Health Policy and Human Services Committee and the sponsor of Senate Bill 612, a reform that would shorten patients’ wait for the treatment, medicine, and testing ordered by their health care providers.
“Senate Bill 612 would reform the
“The term “prior authorization” refers to the process insurance companies use to determine whether an enrollee is eligible to have certain health care services, procedures, or prescription drugs covered by insurance,” said Senator VanderWall. “Unfortunately, the prior authorization process has created barriers and inefficiencies regarding access and quality of care in the health care system. Several of my own constituents have told me accounts of how this process has endangered their health.”
“For patients, this bill would improve
VanderWall represents a wide swath of northern lower Michigan, including Benzie, Crawford, Kalkaska, Lake, Leelanau, Manistee, Mason, Missaukee, Ogemaw, Osceola, Roscommon and Wexford counties. Before coming to Lansing, he made his living as the owner of Turf Care Mole Man of Ludington, and worked much of his life at Eberhard Foods and Prevo’s Family Market. He understands the importance of meeting the needs of everyday Michiganders – he made a career out of it. When patients reached out to his office to share difficult experiences they’d had obtaining the prescriptions and the medical treatment they needed because of onerous insurance company practices, VanderWall got to work on a solution. The result is Senate Bill 612, a reform that’s already gained bipartisan co-sponsorship, and numerous hearings in Lansing.
prior authorization process to facilitate transparency, improve access to care and eliminate some of the burdens that exist,” said VanderWall.
their ability to receive prompt access to necessary care by reducing the review timeframes permitted for insurance companies to make determinations for standard and urgent prior authorization requests. “My measure also would allow physicians the ability to waive step therapy protocols when it is found to be in the best interest of the individual patient.” Thanks to his leadership, patients, physicians, health care providers, and patient advocacy organizations have had the repeated opportunity to speak directly to lawmakers, to share their stories, and to fight for prior authorization and step therapy reforms.
VanderWall encourages everyone affected by prior authorization and step therapy delays to contact their state Senators and Representatives and ask them to support SB 612. They and others can thank Senator VanderWall for his leadership in this fight, too, by visiting his website: http://senatorcurtvanderwall.com/contact.
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FEATURE
Making Progress in the Fight to Reform Prior Authorization and Step Therapy
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Like many people, Lyndsey Crosbie would occasionally take Advil for pain relief. Unlike many people, it took two visits to the emergency room before Lyndsey and her physician realized that was a bad idea. “It turns out I was actually allergic to NSAIDs and acetaminophen, which I would occasionally take to manage discomfort brought on by endometriosis and a painful hip condition,” said Crosbie. “Taking those medicines would cause me to break out severely in hives.” The solution then was simple: Lyndsey would be prescribed a new medication as a replacement for NSAIDs, one that does not typically cause allergic reactions to those with NSAID allergies. Her insurance company denied the new prescription. “At the beginning of all this, I just had to pay out of pocket while waiting for my doctor and insurance company to clear things up. It wasn’t cheap—probably about $25 dollars for 15 pills—but I was in pain and it was all I could do.” Thankfully, Lyndsey’s physician was able to get the issue resolved in short order. But the relief was just temporary. “About a week later, I received a letter from my insurance company informing me I had to try about 10 other prescriptions for my pain relief before they would cover my prescription, and every one of them was an NSAID! I’m like, ‘Did you guys even pay attention?’” It’s a story that reads like a Joseph Heller novel—a Catch-22 that seems too ridiculous to be real. But it is.
L
yndsey’s story is all too real, and one that’s too familiar for a lot of patients here in Michigan. It’s a tale about prior authorization, step therapy and the wedge insurance company practices create between physicians and the patients they’re trying to help. It’s not all bleak though. Michigan physicians, patients and patient advocates have banded together and found a better way forward. There’s only one thing left to do: convince lawmakers they’ve got it right. Senate Bill 612, currently being considered by the Senate Health Policy and Human Services Committee, introduces new transparency and clinical validity requirements that would protect patients from costly and dangerous delays in access to health care, ensuring stories like Lydney’s become a thing of the past.
According to insurers, prior authorization and step therapy are protocols used simply to ensure patients receive the medicines, treatments and therapies that are the most safe and appropriate given an individual’s condition and circumstance. In other words, insurers say they are looking out for what’s in the best interest of patients, and prior authorization and step therapy are the mechanisms that enable that watchful and caring eye. Patients and providers alike see it differently. “It’s all about controlling costs,” said S. Bobby Mukkamala, MD, president-elect of the Michigan State Medical Society.
“With far too much regularity, insurance companies use prior authorization and step therapy to delay—and sometimes flat out deny—patients from accessing the treatments they’ve been prescribed. And the more expensive a drug or therapy is, the more likely it is to get caught up in the bureaucratic red tape.” The stalling tactic may work as a cost-saving measure for insurance companies in the short term, but not before placing unnecessary administrative and financial burdens on the health care system as a whole—something that isn’t surprising given the rigmarole involved in seeing a prior authorization request through to completion. In the end, everyone—including insurers—pays (CONTINUED ON PAGE 16)
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Up to14% of U.S. health care spending goes to administrative costs incurred by private and public insurers, compared with an average of 3 to 10 percent in other developed countries. Burdensome prior authorizations contribute to that disparity.
the price. Up to 14 percent of U.S. health care spending goes to administrative costs incurred by private and public insurers, compared with an average of 3 to 10 percent in other developed countries. Burdensome prior authorizations contribute to that unfavorable disparity. While each patient, case, and treatment plan may differ, the general process is always more or less the same. A patient with an illness or health challenge makes an appointment to see their physician. The physician examines the patient and then either diagnoses the problem and prescribes a treatment to address the issue, or orders the additional testing and screening needed to develop a diagnosis and a treatment plan. From there, things often get complicated. Insurers regularly require physicians to obtain a prior authorization for any prescribed or ordered medicines, treatments, and diagnostic procedures before agreeing to cover the costs associated with those measures, and that process is one that can be painstakingly arduous. Documentation requirements and procedures differ not only from insurer to insurer, but worse, from product and plan to product and plan, creating an unwieldy bureaucratic minefield. Successfully navigating the myriad of forms,
“Unfortunately, it’s not at all uncommon for patients to walk away from a prescribed treatment plan because of all the hoops they have to first jump through in order to actualize it.” S. BOBBY MUKKAMALA, MD MSMS PRESIDENT-ELECT
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formularies and requirements that come with a prior authorization requires a tremendous amount of patience, money, and most critically, time. On average, physicians and their staff average almost two business days each week completing prior authorizations according to a 2018 survey from the American Medical Association. The Henry Ford Health System alone has a full-time staff of 100 employees devoted solely to processing prior authorization request. That all comes at an enormous cost. Prior authorization and step therapy practices’ costs to physician practices are estimated to be around $2,160 to 3,430 per FTE physician with total interactions with insurers costing $82,975 annually per physician, resources that could all be better spent on administering patient care. And as exasperating as prior authorization can be for providers, the frustration felt by patients caught up in the process is undoubtedly amplified. They face the same struggles in trying to navigate a maze of insurance company roadblocks while also going without the medicine and treatment they need. Often, the frustration is just too much, with an overwhelming 75 percent of physicians reporting that prior authorization can lead to treatment abandonment, according to a recent report from the American Medical Association. “Unfortunately, it’s not at all uncommon for patients to walk away from a prescribed treatment plan because of all the hoops they have to first jump through in order to actualize it,” said Doctor Mukkamala. “Navigating prior authorization hurdles is often a time-consuming, confusing, and ultimately, extremely frustrating undertaking for patients. Faced with all of that, it’s not at all surprising that some just simply give up and opt to forgo the care they need.”
Any decision to abandon care costs everyone—including insurers—in the end. As patients wait for the care they need, conditions worsen, health deteriorates and the cost of care skyrockets. Doctor Mukkamala has seen it play out firsthand.
respondents reporting that prior authorization burdens have increased over the last five years. The problem has drawn attention from a wide array of patient advocacy groups around the state, with organizations like the Hemophilia Foundation of Michigan (HFM)—Michigan’s only nonprofit serving the bleeding disorders community through education, advocacy and supportive services— working to highlight and communicate the growing need for meaningful prior authorization reform.
“A few months ago, I diagnosed a patient with tonsil cancer,” he said. “Thankfully, at the time of diagnosis, he was an excellent candidate for curative treatment because his cancer was localized and easily treatable with radiation following a biopsy. The diagnosis was made, and the treatment was lined up in a matter of days. But before 94 percent of being allowed to proceed, Michigan physicians the patient needed a PET report that prior scan to look for the spread authorization red of any cancer.
“Hemophilia and other bleeding disorders are chronic and complex disorders that require lifelong treatment and specialty care to prevent and limit tape causes delays internal bleeding,” said Sarah Procario, advocacy “Getting approval for that in care for their and communications manscan took weeks, and in patients. ager for HFM. “Timely that time, the patient develaccess to appropriate therapies is a oped a lump in his neck. The cancer had necessity for patients.” spread in that three-week period. Now, instead of just radiation, my patient However, with nearly all therapies would also require chemotherapy. for bleeding disorders requiring prior “Had the requirements put in place by authorization, timely treatment and SB 612 been in place four months ago care is often out of reach for Michigan’s when I first diagnosed this patient, his roughly 4,000 families living with the current wellbeing and long-term progcondition—a serious problem given nosis would be much better today. Stothe nature of hemophilia. ries like these are not the exception. “Any delay in care can have a severe The delays brought on by prior authoimpact on their health. Even three rization have gotten out of control.” days without treatment may result in And there’s ample evidence to support additional doctors’ visits, hospitalizaDoctor Mukkamala’s claim. 94 percent tion, and permanent injury from joint of Michigan physicians report that and muscle bleeds,” said Procario. prior authorization red tape causes The regular delays are a concern for delays in care for their patients. And Procario and likely all the patients and the problem is only growing more families served by work of the Hemopervasive, according to a recent surphilia Foundation of Michigan. vey from the American Medical Association, with 88 percent of physician (CONTINUED ON PAGE 18)
88%
of physician respondents report that prior authorization burdens have increased over the last five years, according to a recent survey from the American Medical Association.
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michigan MEDICINE® 17
“The health of patients should come before cost considerations. Prior authorization and step therapy have a role in health care, but they should never put the health and lives of patients at risk.” SARAH PROCARIO, ADVOCACY AND COMMUNICATIONS MANAGER FOR HFM
“The health of patients should come before cost considerations,” said Procario. “Prior authorization and step therapy have a role in health care, but they should never put the health and lives of patients at risk.” Unfortunately, they often do. According to a recent survey by the AMA, 28 percent of physicians report that prior authorization has resulted in a serious adverse event including hospitalization, permanent disability and even death. “Susan G. Komen is the world’s largest break cancer organization, funding more break cancer research than any other nonprofit, while providing real-time help to those facing the disease,” said Sarah Hockin, Mission Director at the Susan G. Komen Foundation of Michigan. “Komen served over 65,000 women and men alone in 2019. They were among the 1.3 million people diagnosed annually with breast cancer. Timely care can be the difference between life and death for many of them.” Trudy Ender, executive director at the Susan G. Komen Foundation of Michigan, echoes the sentiment. “We need to do better for these patients,” said Ender. “I can promise you that diseases like cancer are already stressful enough on their own. Making a patient wait and jump through hoops for a treatment or medicine with the potential to save their life is just simply wrong. It should not work that way. Every day—sometimes every hour— really matters.”
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And what makes prior authorization such a difficult pill to swallow is that it’s almost always all for nothing. 97.5 percent of all first-time prior authorization requests are eventually approved. In other words, insurers are delaying critical access to care for essentially no reason. Doctor Mukkamala sums the problem up nicely: “The bottom line is that delays brought on by prior authorization are way more than just a hassle for our patients—they’re costing them their health, quality of life and sometimes even their lives. It’s a problem that needs to be fixed.”
That effort has occupied physicians, patients and patient advocate groups—a formal coalition known as Health Can’t Wait—for nearly a year now. Led by groups like the Michigan State Medical Society, Michigan Academy of Family Physicians, Michigan Society of Hematology & Oncology, Susan G. Komen Michigan, Hemophilia Foundation of Michigan and dozens of other physician and patient advocacy organizations, the coalition has spent months working to make policymakers understand the need for reform, and the introduction of Senate Bill 612 late last year is proof that their efforts are starting to bear fruit.
Introduced by Senator Curt VanderWall, Chairman of the Senate Health Policy and Human Services committee, SB 612 would do a great deal to rein in the devastating effects of prior authorization and “fail-first” procedures by empowering physicians to override step therapy protocol when appropriate and by implementing new transparency, fairness and clinical validity requirements to the prior authorization process, ensuring patients throughout the state receive timely coverage decisions, and ultimately, the care they need. The legislation requires that insurance companies publish their prior authorization requirements on their website in an easy-to-find and easy-to-understand fashion. To ensure there is clinical validity baked into the prior authorization process, the bill establishes that adverse determinations and decisions on appeals must be made by a physician in the same specialty as the service being requested, while also requiring insurance company medical directors be licensed to practice medicine.
“Delays brought on by prior authorization regularly place a tremendous amount of stress on me and my family. Senate Bill 612 would do a tremendous amount to alleviate those worries for me and for countless others around the state battling their own diseases and illnesses.” ANDREW BADE, A 20-YEAR-OLD COLLEGE STUDENT LIVING WITH TYPE 1 DIABETES
Perhaps most importantly, Senate Bill 612 would mandate that urgent and non-urgent prior authorization requests are acted upon within 24 and 48 hours respectively, which is what’s fair to Michigan’s patients in need of care. “SB 612 is just sound policy,” said Doctor Mukkamala. “The modest reforms it enacts would have an outsized impact on Michigan’s patients and their health.”
tremendous amount to alleviate those worries for me and for countless others around the state battling their own diseases and illnesses.”
Lawmakers continue debating SB 612. In the meantime, physicians, patients and patient advocates can have an impact by sharing their personal stories about Senate Bill 612 the negative effects of prior would mandate authorization and making that urgent and non-urgent prior their calls for reform heard, both of which are made authorization easy by the Health Can’t requests are acted Wait coalition.
That’s the message coalition upon within members have been work24 and 48 hours “There are two ways you ing to broadcast since the can have an immediate respectively... bill’s introduction, culmiimpact on our efforts to nating in a series of hearreform prior authorization,” said Docings on the legislation earlier this year, tor Mukkamala. “The first is to visit with physicians, patient advocacy rephttps://www.healthcantwait.org/shareresentatives and patients themselves your-story and share your personal coming to Lansing to offer testimony in story about the negative impact prior support of Senate Bill 612. authorization has had on you, your Most speaking in support of the bill focused their time on sharing personal stories about themselves or patients whose health and wellbeing has suffered as a result of delays brought on by prior authorization. Andrew Bade, a 20-year-old college student living with type 1 diabetes spoke before the committee about the consistent struggles he faces in trying to restock the equipment he regularly uses to monitor and maintain healthy glucose levels.
family members, or your patients. These stories are powerful and help us communicate to lawmakers and the general public alike just how serious this problem is. “Then contact your lawmakers and www. healthcantwait.org/take-action and click ‘Take Action’ to get started. Sending the letter only takes seconds and lawmakers really do take notice. The voice of every constituent really does matter. When enough people speak up, change can and does happen.”
“I still feel like I can live a relatively normal life when I’m relying on the monitors and delivery devices my doctors have prescribed,” said Bade. “It’s when I don’t have them that things go downhill. Delays brought on by prior authorization regularly place a tremendous amount of stress on me and my family. Senate Bill 612 would do a
MARCH / APRIL 2020 |
michigan MEDICINE® 19
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michigan MEDICINE® 21
Welcome New Members Allegan
Jackson
Lenawee
Claudia Jarrin Tejada, MD
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Raheel John, DO Jennifer Johnston, MD Kathleen Justice-Kirtek, MD Brett Kucej, MD Donald LaBarge, MD Esther Lehmann, MD David Lieuwen, MD Gary Mally, DO Nanci Mercer, MD Robert Morley, DO Keith Morrow, DO Anand Rao, MD Matthew Rose, MD Dominic Scola, MD Lucas Sheldon, MD Harkiran Singh, MD Joel Stracke, DO Nicole Van Allen Horne, MD Todd Vogel, MD Michael Votruba, MD Amanda Williams, MD Sammy Yacob, MD
Monroe Nicholas Schenk, MD
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MARCH / APRIL 2020 |
michigan MEDICINE® 23
The Role of the Medical Assistant in Your Office Practice By Debbie Hill, MBA, RN, Senior Patient Safety Risk Manager, The Doctors Company
24 michigan MEDICINE®
| MARCH / APRIL 2020
Contributed by The Doctors Company
thedoctors.com
A
medical assistant (MA) can be a versatile and valuable addition to your office practice. If used effectively, an MA can improve workflow, increase patient satisfaction, and reduce physician burnout. An MA can manage front-office functions and handle some clinical
duties. However, relying on an MA to perform tasks outside the scope of practice can place both you and your patients at risk. Over-delegation of tasks can compromise patient safety, resulting in adverse outcomes and claims.
Know Your MA’s Scope of Practice
Differentiate the MA’s Tasks
The MA’s scope of practice varies by state, and regulations
The MA cannot make independent medical assessments, tri-
may include very specific lists of approved and unapproved
age, prescribe, renew prescriptions, or give any type of med-
activities, while some states do not address scope of prac-
ical advice—even if asked.
tice at all. The MA generally works under the license of the supervising physician. Be aware that different states allow MAs to perform varying
clinical functions, so always check state regulations. Use specific protocols, orders, and directions so that the
Caution your MA about expressing opinions to patients,
even if asked during a casual conversation. The MA should refer the patient’s concerns to the physician. The MA can convey basic clinical information on behalf of
the physician and follow established clinical protocols when
MA knows how to perform approved functions and all
speaking with patients when the information conveyed
MAs in your office perform duties consistently.
does not require independent medical judgment, assess-
Consult your state licensing board or your patient safety
risk manager if you have questions about scope of practice.
Telephone Triage Only physicians or qualified licensed staff, such as registered nurses, nurse practitioners, or physician assistants, should provide telephone advice. Written protocols and standing orders must be used by the office staff and should include
ment, or advice from the MA. Do not refer to your MA as “nurse” and caution office staff
against doing so. The term nurse implies advanced education and licensure and, if used inappropriately, could result in professional board investigations and prosecution. All staff members should wear nametags that designate their professional titles, and MAs should be instructed to correct patients who refer to them as “nurse.”
instructions on standard questions to ask the caller, recommended responses for minor problems, and which calls to refer immediately to a physician.
(CONTINUED ON PAGE 26)
MARCH / APRIL 2020 |
michigan MEDICINE® 25
Contributed by The Doctors Company
thedoctors.com
Adequate MA Training and Oversight Delineate the MA’s responsibilities in a written job description and provide comprehensive onboarding for each new MA. Review each new MA’s educational curriculum and work experience carefully. Assess and document the skill level and core knowledge of each MA that you supervise, and incorporate checklists, hands-on demonstrations, and written tests as they relate to specific job duties within your medical specialty. This should be done when each MA is hired and repeated periodically as needed. Provide and document additional training for any areas of deficiency or newly acquired skills. Maintain all records in administrative files. Provide in-depth training and monitor adherence to medical record documentation protocols to ensure quality and consistency across the practice and that all medical records are complete. Provide training on patient relations and communications as the MA-patient interface significantly affects patient satisfaction within your practice. Introduce MAs to the concept of safety culture and how it is prioritized within your practice.
Make Practice Improvements Ask your MA to pursue certification (e.g., American Association of Medical Assistants), and provide access to continuing education resources. Provide periodic in-service training and ongoing skills verification. Create a culture of psychological safety in which the MA feels comfortable asking questions about job tasks or clinical duties and speaks up about patient safety concerns without fear of reprisal. Do not ask the MA to perform any duties that run counter to the scope of practice within your state or that conflict with the written job description.
Complimentary Continuing Education The Doctors Company offers complimentary on-demand courses that can help you reduce risk and improve safety. Some courses can also help office staff enhance
Incorporate team training (e.g., TeamSTEPPS®) and emphasize the important role of the MA as a member of a highly effective team.
patient relations, manage challenging patients, and
Provide direct supervision until the MA demonstrates the required level of competency.
website at www.thedoctors.com/patient-safety/
Periodically assess and provide feedback on the quality of the MA’s work.
improve teamwork communication. For a complete catalog visit the Education and CME page on our education-and-cme/.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. Reprinted with permission. ©2019 The Doctors Company (www.thedoctors.com).
26 michigan MEDICINE®
| MARCH / APRIL 2020
MSMS FOUNDATION’S 9TH ANNUAL
THURSDAY, MAY 14 – FRIDAY, MAY 15, 2020 DOUBLETREE HILTON, DEARBORN
#SSM2020
STAY CONNECTED!
MSMS.ORG
MARCH / APRIL 2020 |
michigan MEDICINE® 27
Educational Offerings MSMS On-Demand Webinars Webinars that meet Board of Medicine Requirements:
Webinars at No Cost to Members: Billing 101
Human Trafficking
Balancing Pain Treatment and Legal Responsibilities
Medical Ethics – Conscientious Objection among Physicians
Claim Appeals
Medical Ethics – Decision Making Capability Medical Ethics – Just Caring: Physicians and Non-Adherent Patients
Credentialing
Pain and Symptom Management Series
Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities
Balancing Pain Treatment and Legal Responsibilities
HEDIS Best Practices
MAPS Update and Opportunities
In Search of Joy in Practice: Innovations in Patient Centered Care
Michigan Automated Prescription System Update
Legalities and Practicalities of HIT - Cyber Security: Issues and Liability Coverage
Opioid Town Hall Pain and Opioid Management Prescribing Legislation
Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media
Tapering Off Opioids
MAPS Update and Opportunities
The CDC Guidelines
Medical Necessity Tips on Documentation to Prove it
The Current Epidemic and Standards of Care
Michigan Automated Prescription System Update
The Role of the Laboratory in Toxicology and Drug Testing
Opioid Town Hall
Treatment of Opioid Dependence
Prescribing Legislation
Update on the Opioid Crisis 2019 (Fulfills the 1-time training on opioids and other controlled substances awareness)
Reading Remittance Advice
Coding and Billing Webinars: Access to Medicare Changes to E&M Codes for 2019 and other Coding Updates Billing 101
Section 1557: Anti-Discrimination Obligations Sexual Misconduct – Prevention and Reporting Tips and Tricks on Working Rejections Update on Chronic Fatigue Syndrome Part 1: Clinical Diagnostic Criteria for Chronic Fatigue Syndrome/CFS now called Myalgic Encephalomyelitis or ME/CFS Update on Chronic Fatigue Syndrome Part 2: Uniting Compassion, Attention and Innovation to treat ME/CFS
Claim Appeals Credentialing Medical Necessity Tips on Documentation to Prove it Reading Remittance Advice Tips and Tricks on Working Rejections
Other Webinars: NEW – Michigan Medical Marihuana Law
Visit msms.org/OnDemand for complete listing of On-Demand Webinars. 28 michigan MEDICINE®
| MARCH / APRIL 2020
Visit msms.org/OnDemand for complete listing of On-Demand Webinars. Register online at msms.org/eo or call the MSMS Registrar at 517-336-7581.
SAVE THE DATE for 2020! Spring Scientific Meeting
Annual Scientific Meeting
Date: Thursday, May 14 and Friday, May 15
Date: Wednesday - Saturday, October 21 - 24
Location: DoubleTree Hilton, Dearborn
Location: The Westin, Southfield
Intended for: Physicians and all other health care professionals.
Intended for: Physicians and all other health care professionals.
Contact: Beth Elliott at 517/336-5789 or belliott@msms.org
Contact: Beth Elliott at 517/336-5789 or belliott@msms.org
Register online at msms.org/eo or call the MSMS Registrar at 517-336-7581.
MARCH / APRIL 2020 |
michigan MEDICINEÂŽ 29
ADVOCACY
Five Reasons to
BACK the PAC The Michigan Doctors’ Political Action Committee (MDPAC) builds and maintains strong relationships with lawmakers, as well as candidates running for political office. As the face of physicians, MDPAC bring medical knowledge into
Activate your political voice! The Michigan Doctors’ Political Action Committee (MDPAC) is the political arm of the Michigan State Medical Society. It is a bipartisan political action committee made up of physicians, their families, residents, medical students and others interested in making a positive contribution to the medical profession through the political process. MDPAC supports pro-medicine candidates running for political office in Michigan. Physician engagement is essential to the success of a pro-medicine legislature. Current and potential lawmakers want and need to hear from professionals in the field of medicine. Through MDPAC, you will activate your voice on the things most important to Michigan physicians.
discussions with political decision makers.
For more than three decades, MDPAC has mounted successful lobbying efforts on behalf of physicians. For example... MDPAC protects and strengthens tort reform, stopped the physician’s tax, and has
helped to stop the expansion of a non-physician’s scope of practice. MDPAC has power, prestige and respect! If you wake your sleeping giant, MDPAC could make rapid, positive change for physicians and patients. It could ease administrative pressures with the current prior authorization process, save you money
and time on your Maintenance of Certification, and advance public health issues.
Trial lawyers, insurance companies, and other political opponents raise massive sums of money. Medicine’s friends, through MDPAC, must dig deeper to raise equivalent or greater amounts of funds to advance Michigan
physician’s agenda.
Get started today at MDPAC.org
The current political landscape is uncertain. Only through a well-funded, unified voice will physicians and their patients’ interests be heard. MDPAC is that voice. Get your voice heard by contributing today at MDPAC.org
16 michigan MEDICINE
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| JULY / AUGUST 2017
| MARCH / APRIL 2020
( ) | @
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michigan MEDICINE® 31
Hindsight
2020
New Loss Prevention Seminar for Physicians
The medical professional liability industry is currently experiencing an increase in the severity of jury verdicts. While jurors are not permitted to use hindsight in arriving at their decisions, they often do.
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