July 2016 | www.cmsdocs.org
Physician
Compensation
Taking Action
Against Opioid
Abuse
Value-Based Pay
Gains a Foothold
New Antitrust
Scrutiny: State
Regulatory Boards
Combatting
Superbugs
P
of t ublicat
Med he Ch ion
ical icag
So c o
TH E
iety
SO M ED
COO CIET Y ICAL
O
KC
OU F
NT Y
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Volume 119 Issue 7
July 2016
18
FEATURES
18 Physician Compensation: ValueBased Pay Gaining a Foothold
Physician compensation continues to
rise but even as more reimbursement
becomes available to physicians, the
compensation gap between specialists
and primary care doctors continues to
widen, with primary care coming out
ahead. By Bruce Japsen
22 Taking Action Against
Opioid Abuse
As the opioid epidemic continues
unabated, lawmakers are scrambling for
solutions. And your CMS is working with
U.S. Senator Richard Durbin to protect
patients and prevent unneccessary
burdens on physicians.
By Elizabeth Sidney
PRESIDENT’S MESSAGE
16 Good FCA News on the Horizon?
By Kathy M. Tynus, MD
17 Selling Your Medical Practice
OPINION
MEMBER BENEFITS
2 Curing U.S. Healthcare
3 A Call for Policy Education
By Christiana Shoushtari, MPH, MS
PRACTICE MANAGEMENT
4 Corporate Integrity Agreements;
Physician Well-Being Committees;
Analyzing the Data; Burnout: A Lot
More Than Exhaustion
PUBLIC HEALTH
10 Preserve Safe Care for
Veterans; Medical Marijuana
Program Expands; Flu Vaccine
Recommendations; Superbugs
LEGAL
14 New Antitrust Scrutiny: State
Regulatory Boards
26 Resolutions March On
28 MCC Exhibits Thrive
30 Calendar of Events
31 New Members
31 Classifieds
WHO’S WHO
32 Eclectic Background Pays Off
Nirav Shah, MD, JD, has pursued a
“non-linear career trajectory” that has
brought him to direct the complex
Illinois Department of Public Health,
overseeing 2,000 employees.
July 2016 | www.cmsdocs.org | 1
MESSAGE FROM THE PRESIDENT
Curing U.S. Healthcare
W
E H AV E S E E N a resurgence of
interest in a single payer system. But
why? We’re in the midst of a presidential campaign where one of the
candidates has strongly advocated for
it. We’re several years into the Obamacare rollout, and the
results are not pretty. While more people now have coverage, they’re seeing increasing rates, limitations on access to
hospitals and physicians, and a shrinking pool of insurers in
the exchange marketplaces. Even with full implementation,
our uninsured rate would go down from 50 to 30 million
Americans. Meanwhile, the costs of healthcare continue to
climb. As physicians, the Affordable Care Act has added complexity to our billing and
reimbursement, driving up overhead costs and further catalyzing the mass exodus out
of independent practice into employment with large hospital-based practices.
There has to be a better way. Our fragmented system serves some very well,
some not so well and others not at all. The U.S. healthcare system has elements of
every major financing model throughout the world: employer-based premiums with
subsidies for the poor, that is, our old system plus the ACA (similar to Germany);
government-run health insurance, for example, Medicare (Canada); a wholly staterun system, such as the VA (England); and the out-of-pocket model (most third world
countries). For the amount we pay, you’d think we’d be able to provide universal
coverage and be at the top of world health statistics. Sadly, neither is true.
How did we arrive at this hodgepodge system? For me, it boils down to whether
we believe that healthcare is a right or a privilege as a member of our society. When
we get sick, is it reasonable to expect to be taken care of, regardless of our income
or ability to pay? Not just for emergency care, but for ongoing potentially lethal
but treatable illnesses like diabetes, cancer and lupus? How is this different from
expecting the fire department to put out the fire in your home or expecting access
to a school for your children? As a society, we’ve been able to accept the idea that it
is more effective and efficient to pool our resources through taxes to pay for many
essential services. With healthcare, there’s a reluctance to do the same. If we could
accept this idea, we could take a proactive, comprehensive approach to financing
healthcare for everyone, with lower costs and better results.
There’s hope for the future. Polls show more Americans are supporting a single
payer model, aka “Medicare for all.” A Gallup poll, conducted in early May, showed
that 58% of Americans favor replacing the ACA with a federally funded healthcare
system. The most recent large scale poll of American physicians, conducted in 2008
and published in the Annals of Internal Medicine, showed that 59% of U.S. doctors
supported legislation to establish national health insurance. The Chicago Medical
Society recently conducted its own small poll of area physicians with similar findings:
55% support national health insurance. Our Council has passed a resolution calling
for study at the local, state and national levels into the feasibility and costs of implementing a single payer system. In addition, we plan to replicate our recent poll on a
much larger scale and publish the results. Our healthcare system is evolving rapidly
and we will remain in the vanguard of positive change for our members and patients.
Kathy M. Tynus, MD
President, Chicago Medical Society
2 | Chicago Medicine | July 2016
EDITORIAL & ART
E XECUTIVE DIREC TOR
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ART DIREC TO R
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E D I T O R I A L C O N S U LTA N T
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Burnette, Esq.; Emma R. Cecil, Esq.;
Clay J. Countryman, Esq.; Ryan A.
Haas, Esq.; Bruce Japsen; Michael P.
Leiter, PhD; Brian F. McEvoy, Esq.;
Susan Reynolds, MD, PhD; Julian
Rivera, Esq.; Christiana Shoushtari,
MPH, MS; David Solberg, Esq.; Kathy
M. Tynus, MD; Jim Watson; Sidney
Welch, Esq.; Feifei Zhang
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CHICAGO MEDICAL SOCIETY
OFFICERS OF THE SOCIETY
PRESIDENT
Kathy M. Tynus, MD
P R E S I D E N T- E L E C T
Adrienne L. Fregia, MD
S E C R E TA R Y
Clarence W. Brown, Jr., MD
TREASURER
Dimitri T. Azar, MD
CHAIR OF THE COUNCIL
Vemuri S. Murthy, MD
VICE CHAIR OF THE COUNCIL
Tina Shah, MD
I M M E D I AT E PA S T P R E S I D E N T
Kenneth G. Busch, MD
CHICAGO MEDICINE
515 N. Dearborn St.
Chicago IL 60654
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Copyright 2016, Chicago Medicine. All rights
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STUDENT OPINION
A Call for Policy Education
Medical students learn the art and science of legislative advocacy through CMS
By Christiana Shoushtari, MPH, MS
P
O L I C Y I S the arena that dictates
how medicine operates, how it treats
the sick, how it prevents illness, how it
reimburses providers, and how it covers
consumers. During my time as a legislative staffer in the U.S. Senate, one thing stuck out
for me: some health professionals did not seem to
have a good enough grasp of the political process
in order to hold purpose-driven conversations with
Capitol Hill staffers. They certainly understood the
data well and gave very passionate, moving clinical anecdotes. However, when it came to helping
Capitol Hill staffers move an issue forward or work
through potential political blockades, they were,
unfortunately, unable to provide much support.
They came to us with their concerns and demands,
yet often were speechless or uncertain when asked
for possible solutions, especially those with political, economic or social constraints.
When I decided to pursue medicine, I also had
a secret personal mission: to expose the younger
generation of medical students to the legislative,
economic and political processes of the healthcare
system, before the long hours of medical training,
the pressure of the profession and the emotional toll
of caring for patients could make them bitter, biased
or broken down. And what better way to educate
the young generation of rising physician leaders
than through organized medical societies (Chicago
Medical Society, Illinois State Medical Society, and
American Medical Association). Organized medicine
has the infrastructure and well-established
relationships within the community, profession
and legislators. While every organization certainly
does have its biases, organized medicine is unique
in that it represents a broad swath of medicine with
representation from different sectors, specialties,
and regions.
It is no secret that membership is declining in
organized medical societies. I believe part of the
reason has to do with the inherent difficulties of
revamping an established institution to accommodate rapid changes in technology, thinking and
communication among younger generations. For
instance, I personally can attest to how difficult it
is to adjust to social media. As a thirty-somethingyear-old, I’m often lumped with the millennial
generation; however, I opened my first email
account in college and first Facebook account in
graduate school. While it can be difficult, timeconsuming and humbling to have to learn new
ways of communicating and expressing oneself, it
is part of evolution and growth.
Organized medicine can add value to medical
education by offering support, guidance and
instruction in areas of medical practice that are
not emphasized in medical school. We are trained
to be excellent scientists, clinicians and healers,
yet we have not been offered much training
in how to actually navigate the professional
work environment or healthcare system. Other
physician duties may include balancing a budget,
developing policies, negotiating expectations, and
advocating for our patients. Certainly there are
medical schools that do provide such training,
as well as graduate school training to learn such
practical skills, but I wonder what the impact on
healthcare would be in 20, 30, or 50 years down
the line if we were taught to understand this complex system from the very start of our training.
“We are trained to be excellent scientists,
clinicians and healers, yet we have not been
offered much training in how to actually navigate
the professional work environment.”
With the support and guidance of the Chicago
Medical Society, we medical students have tapped
into something new, promising and worth the
investment. CMS created an educational policy
series. And through this series, we educated more
than 100 students from all seven medical schools in
Cook County on various topics (graduate medical
education, value-based care, public health policy)
and introduced them to prominent health policy
leaders in our community. While there are always
ways to improve upon initiatives, these efforts were
very well received. Not only was the attendance
at the educational policy series program greater
than expected, we obtained funding support to fly
students from each medical school to Washington,
DC, where they met with congressional staffers
and lawmakers on issues of importance to them.
Strong interest among medical students for
policy lectures and legislative advocacy creates a
unique opportunity for organized medicine. We
students come from different backgrounds, with
diverse interests and goals. Organized medicine
can bridge that diversity and fill in the educational
gaps when it comes to real-world practice. There
is no better time to bring professionals together on
their paths towards becoming passionate leaders.
Christiana Shoushtari, MPH, MS, is a third-year
medical student at the University of Illinois at
Chicago. She may be reached at: christiana.
[email protected].
July 2016 | www.cmsdocs.org | 3
PRACTICE MANAGEMENT
OIG Corporate Integrity Agreements
One approach to compliance for physician practices following a settlement for billing issues
By Clay J. Countryman, Esq.
I
“A recent False
Claims Act
settlement
requires
a Georgia
dermatology
practice to
establish a
compliance
program
that includes
an internal
auditing and
monitoring
process,
among other
requirements.”
N S E T T L I N G allegations of violating the
False Claims Act (FCA), healthcare providers
often enter into a Corporate Integrity Agreement
(CIA) with the Office of the Inspector General in
exchange for the OIG’s agreement not to exclude
the provider from participation in Medicare or other
federal healthcare programs. CIAs generally require a
provider to establish or supplement an existing compliance program, with detailed requirements described
in the CIA. Many providers, including physician practices, consider these CIAs to set the standard for what
the OIG would include in a comprehensive and effective compliance program. Generally, a CIA will impose
certain requirements on a provider related to the FCA
settlement such as specific policies and procedures
related to billing or Stark Law compliance.
Georgia Case of Compliance
A recent FCA settlement requires a Georgia dermatology practice to establish a compliance program that
includes an internal auditing and monitoring process,
among other requirements. This settlement by two
physicians and their practice, Toccoa Clinic Medical
Associates, in April 2016, with the U.S. Attorney’s
Office for the Northern District of Georgia, resolved
allegations that the practice had improperly billed for
evaluation and management services on the same day
as a procedure and had upcoded claims for evaluation
and management services to higher levels than were
appropriate.
The CIA requires the Georgia practice to
develop and implement a centralized annual risk
assessment and internal review process to identity
and address risks associated with the submission
of claims to Medicare and Medicaid. As part of the
risk assessment and internal review process, the
practice is required to:
• Identify and prioritize risks.
• Develop internal audit work plans related to the
identified risk areas.
• Implement the internal audit work plans.
• Develop corrective action plans in response to
the results of any internal audits performed.
• Track the implementation of correction plans in
order to assess their effectiveness.
The practice is also required to develop and
implement written policies and procedures for the
identification, quantification and repayment of
overpayments from federal healthcare programs.
Under the CIA, the practice must repay overpayments within 60 days after identification of the
overpayment, take remedial steps within 90 days
after identification, and take corrective action steps
4 | Chicago Medicine | July 2016
to prevent the underlying problem and overpayment
from reoccurring. Generally, physician practices
should have an internal process of notification and
repayment of any overpayment amount that is routinely reconciled or adjusted pursuant to the policies
and procedures established by each payer.
The CIA also requires the dermatology practice
to engage an accounting, auditing, or consulting firm
(Independent Review Organization or IRO) to review
coding, billing and claims submission to Medicare
and Medicaid, and related paid claims. The CIA
also included detailed requirements imposed on the
practice to conduct an annual claims review by the
IRO during the five-year period of the CIA.
The annual claims review by the IRO engaged
by the dermatology practice must include a review
of a discovery sample of 75 randomly selected paid
claims. If the error rate of the discovery sample is
5% or greater, then the IRO will review a larger or
full sample of paid claims. The IRO will use the
findings of the full claims sample to estimate an
actual overpayment amount owed by the practice to
the appropriate federal healthcare program payer.
In addition, if there is an error rate of 5% or
greater in the initial discovery sample, then the
IRO is also required to review the practice’s billing
and coding systems involving claims submitted to
federal healthcare programs. This review includes
the operation of the practice’s billing system, the
process by which claims are coded, safeguards to
ensure proper coding, claims submission and billing;
and procedures to identify and correct inaccurate
coding and billing. The IRO is required to provide
an annual report of the claims review, and any
review of the practice’s billing and coding process.
The CIA also provides that any paid claim
for which the practice cannot produce sufficient
documentation will be considered an error and the
total reimbursement received by the practice considered an overpayment. As part of its compliance,
the practice is required to provide the OIG with
an annual report on its compliance activities with
certain information detailed in its CIA. Specifically,
this annual report must include a summary of all
internal audits and corrective action plans developed in response to those internal audits.
Physician practices should consider the risk
assessment and internal review process in this
settlement and other CIAs between the OIG and
physician practices as guides for their own compliance programs and efforts.
Clay J. Countryman, Esq., is a partner with
Breazeale, Sachse & Wilson, LLP, in Baton Rouge, La.
Contact him at: [email protected].
PRACTICE MANAGEMENT
Physician Well-Being Committees
Hospital wellness must evolve to proactively address overall health
By Susan Reynolds, MD, PhD
A
S I ’ V E T R AV E L E D the country
talking about managing stress and
preventing burnout, I have asked the
physicians in my audiences if they
have a physician well-being committee at their hospital, and if so, if they think it is
effective. I’ve learned that in many hospitals these
committees are barely functional, perhaps existing
in name only, barely satisfying the Joint Commission standard 11.01.01.
Some committees never meet unless a case
arises. And then it is often seen as just an alternative to peer review and corrective action for
doctors demonstrating difficult behavior or signs of
addiction. Rarely is the committee thought to have
the function of reducing stress among the medical
staff, helping them prevent burnout and feel passion once again for their profession.
The role of well-being committees should be
regarded as more than a punishment alternative.
These committees should be considered as valuable
resources that can address issues such as stress and
burnout as well as a physician’s overall health and
happiness. The committees can provide educational
programs for the medical staff that aim to reinvigorate a passion for the profession of medicine,
something many physicians have begun to lose.
How do you maximize the effectiveness of
your physician well-being committee? First, it is
important to look at who serves on the committee
and for what period of time. This should be clearly
stated in your medical staff bylaws. I like to see
an odd number of physicians on the well-being
committee, preferably between three and seven. No
one on the committee should be a current member
of the medical executive committee. Past chiefs
of staff can make excellent committee members.
One member of the committee, but not all, should
be a psychiatrist, since there are often emotional
issues overlying a physician’s sense of well-being. If
committee members serve staggered terms of two
or three years, there is more continuity in the work
the committee does.
The committee should meet at least quarterly, if
not monthly, even if there are no referred cases to
discuss. In those meetings, medical staff education
can be planned. There can also be small roundtable
discussions with six to ten members of the medical
staff so that they understand the functions of the
committee.
There needs to be clear communication to the
medical staff about how the committee can be
accessed. There should be in place an easy-to-use
self-referral system in addition to a referral
mechanism from the medical executive committee,
medical staff department, or committee.
When physician well-being committees start to
address physician health issues, and stop being just
vehicles for doctors to avoid corrective action, they
can contribute significantly to physician satisfaction and the overall health of the organization.
“Some
committees
never meet
unless a case
arises. And
then it is often
seen as just
an alternative
to peer review
and corrective
action for
doctors
demonstrating
difficult
behavior
or signs of
addiction.”
Susan Reynolds, MD, PhD, is president and CEO,
The Institute for Medical Leadership.
Immunization Awareness
T H E M O N T H of August is national
immunization awareness month. As
such, it’s a great time for physicians
to offer education on the importance
of vaccinations to their patients,
especially as both the flu season and
the new school season approach. You
can find a variety of resources at www.
healthfinder.gov including sample
tweets, website badges and e-cards
designed specifically for various types
of vaccines such as those for children
and teens, those for pregnant women
and those for seniors.
The Centers for Disease Control and
Prevention (CDC) also has a wide
variety of resources that you can have
your patients view. They offer information on different types of vaccinations
written in plain English, making it easy
for your patients to have their questions answered by a reliable Internet
source. They also offer resources for
physicians such as vaccine recommendations, vaccine schedules and
safe practices for storing and handling
vaccines.
The HPV vaccine is one that is of particular concern. As of mid-2015 the CDC
reported that only 40% of teen girls and
22% of teen boys across the nation have
finished the three-dose course of shots.
Fortunately, Chicago is doing better
than most of the nation. In 2014, the city
received an $800,000 CDC grant to test
new vaccine strategies such as creating
public service announcements on radio
and TV. As a result, the city’s three-dose
coverage level for teen girls rose to 53%
in 2015, which was up from 37% in 2014
when the grant was received.
In next month’s edition of Chicago
Medicine, we’ll provide thorough coverage of tools you can use for vaccine
compliance.
July 2016 | www.cmsdocs.org | 5
PRACTICE MANAGEMENT
Analyzing the Data
Real-life examples show the growing importance of data analytics in healthcare
management By Feifei Zhang and Jim Watson
H
E A LT H C A R E organizations large and small are using
data analytics as part of their
strategy to improve quality and
lower the costs of care. In this
age of value-based contracting, data analytics are driven both by payer reimbursement
methodologies and managed care contract
requirements. Providers armed with insurer
claims data are using data analytics to
enhance their ability to manage their operations, improve care coordination, and provide better service with lower cost.
Here we give two examples of the use
of data analytics for a physician group
practice that participated in the Bundled
Payments for Care Initiative (BPCI).
One example is a retrospective analysis,
which monitors patients’ use of different
post-acute care facilities after the initial
hospital discharge. The other example
is a prospective analysis, which predicts
patients’ costs based on historical data
and a pre-operative scoring system.
Performing a Retrospective
Analysis
A key factor for success under the bundled
payment program is to understand
patients’ use of post-acute facilities. For
example, there are regions where the
standard of care typically includes a 21-day
stay in skilled nursing facilities, and other
regions where there is almost no use of
inpatient rehab or skilled nursing facilities,
with a cost savings of about $10,000 per
patient. Figure 1 illustrates the number
of patients who went to different postacute facilities after their initial hospital
discharge by each physician.
Figure 2 shows the usage percentage of
each post-acute facility type by each physician. It gives a good visualization of how
many surgeries each physician did during
the month (Dr. B did the most surgeries). If
the facility would like to manage the use or
overuse of inpatient rehab and skilled nursing facilities, then Figure 2 is a good place to
start (Dr. C had the highest usage percentage of inpatient rehab, at 31%, and Dr. D had
the highest usage percentage of a skilled
nursing facility, at 63%). If Dr. C and Dr. D
can help reduce their usage percentage of
inpatient rehab and skilled nursing facilities,
respectively, to the average percentage level,
then significant savings result.
Performing a Prospective
Analysis
It is always beneficial to have a good
estimate of the costs of an upcoming
surgery, both for patients and healthcare
providers. The physician practice
developed a pre-operative scoring system,
which generates a single score based on
questionnaires that are clinically proven
to be related to the length and costs of
the post-operational recovery. Combining
the pre-operational scores and the actual
costs using historical data, it is possible
to build predictive models to give a
good estimate of the costs (mainly the
Number of Patients of Post-Acute Facilities
Figure
1: Number
Patients Facilities
in Post-Acute Facilities
Number
of Patients of
of Post-Acute
Dr. A
4
33
22
3
Dr.
Dr. A
B
45
33 42
22
3
Dr. C
B
Dr.
45 6 21
Dr. D
C
Dr.
34 6 2124
Dr.
Dr. D
E
23
13
Dr. E 02
13
0
42
10
24
20
82
8
82
8
1
23 10
14
23
40
4
60
80
100
120
140
160
40
60
80
100
120
140
160
20
Inpatient Rehab
Skilled Nursing Facility
Home Health Agent
Home
6 | Chicago
Medicine
| July 2016
Inpatient
Rehab
Skilled Nursing Facility
Home Health Agent
Home
post-acute costs) of each patient. Figure
3 is a predictive regression analysis that
shows the correlation between Episode
Total Cost and Evaluation Score.
The R Squared is the coefficient of
determination. It tells you how many points
fall on the regression line. For example, 13%
means that 13% of the variation of episode
total costs is explained by the evaluation
score. In other words, 13% of the values fit
the model (which is pretty low). The linear
regression equation is Episode Total Cost =
$30,060 - 260 * Evaluation Score. If a patient
gets an Evaluation Score of, say 85, before the
surgery, by plugging the evaluation score into
the equation, we can obtain the estimated
episode total cost: $7,960. However, the standard error is big ($6,088), which represents
the average difference between the estimated
cost and the real cost. This indicates that our
pre-operational score system and regression
model need to be more precise, but we are on
the right track.
Implications of Data Analysis
and Next Steps
Payers are increasingly doing a variety of
cost and quality analytics across provider
types and networks and drilling down
into physician-specific and hospitalspecific performance measures. These
metrics lend to product and network
development strategies that payers are
increasingly using in commercial and governmental health insurance markets. And
increasingly, these trends link directly to
provider reimbursement via incentives
and penalties. The PQRS and MU are
two examples that have greatly impacted
physicians, and MACRA will increase that
potential exponentially. Providers should
be aware of these trends, recognize the
importance of data analytics at the center
of this movement, and position themselves
accordingly. Here are three helpful tips:
• Understand reports that you receive
about your performance. While you
don’t necessarily need a full-time data
guru, it will be important for you and
your office staff to understand your
performance as defined by payers
(both commercial and governmental)
based on their data analytics. These
models and this kind of data reporting
PRACTICE MANAGEMENT
will continue to drive provider reimbursement, health insurance product
offerings, and the provider networks
that serve these health insurance
products.
• Be proactive in understanding “network” and “product” offerings you are
being offered or excluded from. Health
insurance marketplace products, narrow
network products, tiered network
products, and Medicare Advantage
products continue to evolve. Inclusion
or exclusion from these networks or
products can be a double-edged sword.
Exclusion can have a negative impact on
referral patterns and public perception.
Conversely, inclusion in these networks
or products can require you to accept
lower reimbursement, accept risk on a
population of people, and take on additional administrative work in exchange
for being in a network.
• Be open to innovation: it is important.
Across the healthcare system we
have seen an explosion of new
reimbursement and incentive models
from Medicare, state Medicaid
programs and commercial insurers.
Driven by the mantra of “innovation,” beginning with the Medicare
Modernization Act of 2003 (which
Number
of
Patients Percentage
of Post-Acute
Facilities
Figure
Usage
of Post-Acute
Usage2:
Percentage
of Post-Acute
Facilities Facilities
Dr. A
A 46%
Dr.
33
Dr. B 5
Dr. B 4%
Dr. C
Dr. C
2253%
35%
42
31%
82
5%
8
60%
6%
4 6 21
31%
Dr. D 3
Dr. D
46%
24
10
Dr. E 2
63%
13
5%
0
0%
15%
23
20
10%
8%
1
8%
Dr. E
3
26%
3%
4
31%
20%
Inpatient Rehab
Inpatient Rehab
40
60
30%
40%
80
50%
Skilled Nursing Facility
Skilled Nursing Facility
introduced Medicare Advantage and
now represents roughly 20% of all
Medicare enrollees) to the Affordable
Care Act (which now cover 25 million
previously uninsured Americans),
payers will continue to try different
flavors of innovation. Some will work
well; some won’t work at all. But
recognize the source of this mantra:
payers, employers and consumers
demanding improved quality and cost
55%
100
60%
120
70%
140
80%
Home Health Agent
Home Health Agent
10%
90%
160
100%
Home
Home
management in the U.S. healthcare
system.
Feifei Zhang is a health data analyst with
PBC Advisors, LLC, in Oak Brook. Jim
Watson is a partner with PBC Advisors.
The company provides business and
management consulting and accounting
services to physician practices and hospital
systems. For more information, visit www.
pbcgroup.com.
Figure 3: Episode Total Cost by Evaluation Score
July 2016 | www.cmsdocs.org | 7
PRACTICE MANAGEMENT
Burnout: A Lot More Than Exhaustion
There’s a critical distinction between the two By Michael P. Leiter, PhD
E
“Cynicism is
what gives
burnout its
punch…. More
fundamentally,
cynicism breaks
the emotional
connection of
physicians with
their work.”
X H AU S T I O N gets all the press.
But the view that exhaustion defines
burnout misses the point. People can
be exhausted without being burned out.
Exhaustion reflects inadequate recovery.
One example is when overwhelming work demands
cause a physician to end one shift wound up and
exhausted and then only have a few hours until
the next shift. Unsustainable lifestyles also lead to
inadequate recovery. Some of these lifestyles are
noble (attending to your children in the night) while
others may be less so (partying to the wee hours).
A lot of physicians identified as burned out are
just tired. They are working more hours than they
can physically or psychologically sustain within
their larger lifestyle. The fact that they continue
to believe in the value of their work, to experience meaningful fulfillment in providing care to
patients, and to feel confident in the value of their
contribution means that they have not experienced
the full syndrome of burnout. In our research, we
find more instances of physicians who are simply
exhausted than those who are experiencing the full
syndrome of burnout. Most research on physician
burnout overlooks this critical distinction.
Eroding Impact of Cynicism
Cynicism is what gives burnout its punch. In
medicine, cynicism may occur as depersonalization,
an impersonal quality in physicians’ contact with
patients. More fundamentally, cynicism breaks the
emotional connection of physicians with their work.
Cynicism depletes what was previously a source of
joy, accomplishment, and fulfillment. Some have
described cynicism as a means of coping with
exhaustion, but evidence shows cynicism to be a poor
coping strategy that usually makes things worse.
Cynicism presents a much greater challenge
to recovery than exhaustion. Not that addressing
exhaustion is easy, but fundamentally recovery
requires a period of rest leading to a realignment
of life patterns to assure sufficient sleep, personal
social contact, health behaviors, and fulfilling
activities. Everyone faces the challenge of establishing such a lifestyle. For exhausted people the
gap between the current and desired state looms
larger with a greater urgency for action.
Recovery from cynicism presents greater challenges. Alleviating cynicism requires reviving an
emotional, values-based connection with work.
Recovery requires overcoming barriers to fulfilling
core motives that people bring to work. The lack
of recognition and intrinsic satisfaction frustrates
physicians’ efforts to confirm mastery of their
craft. Boring, tedious bureaucracy, paperwork, and
pointless meetings constrain their aspirations to
8 | Chicago Medicine | July 2016
exercise initiative through their practice. Social
discord frustrates their reasonable expectations
to work as part of a team of mutually supportive
people. Overcoming these obstacles presents a
more profound task than overcoming fatigue.
Sweating the Small Stuff
Far-reaching solutions to burnout require revamping the nature of the profession, including the
selection, instruction, and mentoring of medical
students, payment schemes for physicians, government health policies, and institutional frameworks
for delivering healthcare. Unfortunately, largescale systems change slowly. But while awaiting
system-wide improvements, individuals, groups,
and organizations can take action.
Our research has confirmed that better working
relationships reduce the propensity towards burnout. This finding has a straightforward rationale.
• Energy. Any form of social discord (disrespect,
antagonistic conflict, incivility, bullying, or
abuse) has an emotional impact that drains
energy. Beyond the exhausting emotions of the
immediate encounter, we replay incidents of
social discord, distracting our focus from work or
relaxation, interrupting our sleep, and interfering
with our capacity to connect constructively with
others. To the extent that we replace incivility
with civility, we prevent that emotional drain.
• Cynicism. Social discord encourages people
to withdraw their emotional connection with
the workplace and the work. In contrast, civil,
respectful encounters connect us more closely
with the people and activities of work.
• Efficacy. Social discord inhibits opportunities
to experience autonomy and mastery that
support a sense of efficacy. The prerogative to
take the initiative in healthcare requires trust
from colleagues. Opportunities for challenging
and meaningful work go to people in whom
colleagues have confidence. Trust and mutual
support reflect civil workgroups.
Reducing social discord has the distinct advantage
of providing a total net gain. Although reducing
work hours or shift length may represent a net
loss of capacity for a health organization, reducing
disrespect has no downside. Everyone wins.
Michael Leiter, PhD, is a psychologist and
founder of Michel Leiter & Associates. Dr.
Leiter was a featured speaker at the CMS-ISMS
sponsored Annual Residency Program Directors
Meeting last December in Chicago. He may be
reached at www.workengagement.com.
PUBLIC HEALTH
Preserve Safe Care for Veterans
Strike Anesthesia Provisions from VHA Nursing Handbook
By the Illinois Society of Anesthesiologists
T
H E D E PA R T M E N T of Veterans
Affairs’ (VA) Office of Nursing Services (ONS) has proposed a new policy
document known as the “VHA Nursing Handbook.” The document seeks
to change how care is delivered to our nation’s
Veterans receiving care in Veterans Health Administration (VHA) healthcare facilities. Currently, the
document is at the Office of Management and Budget (OMB) under the title “Advance Practice Registered Nurses” for review before it is released to the
Federal Register for public comments.
The document’s most contentious provision
seeks to abandon physician-led, team-based surgical anesthesia care, the current consensus model
of care in VA, and replace it with a nurse-only
model of care. The Handbook would mandate
that every VA facility operate with “independent”
nurse practice of anesthesia, regardless of state
law, putting veterans health at risk. The VA’s
own surgical anesthesia experts, the VA chiefs of
anesthesiology, have informed VA leadership that
the new policy “would directly compromise patient
safety and limit our ability to provide quality care
to veterans.” While VA’s rationale for moving
toward nurse-only models of care is to expand the
number of providers available to provide primary
care for veterans, there is no shortage of physician
anesthesiologists or nurse anesthetists in VA.
A bipartisan group of more than 90 congressional representatives and senators contacted VA
to express concerns about the negative impact of
the proposed VHA Nursing Handbook on patient
safety. Unfortunately, recently introduced legislation includes troubling provisions that seek to
codify the VHA’s efforts.
E. Anophelis Outbreak
T H E I L L I N O I S Department of Public Health (IDPH) and the CDC are
investigating a cluster of infections caused by Elizabethkingia anophelis
in 10 Illinois residents who have been diagnosed since Jan. 1, 2014. Six
of the 10 patients have died. However, IDPH is unable to determine if
Elizabethkingia was the cause of death because many of those individuals had underlying health conditions. The cases were identified after
IDPH sent alerts to Illinois hospitals and laboratories in early February and
again in March requesting that they report all cases of Elizabethkingia
going back to the beginning of 2014. Illinois health officials continue to
collect case histories and other information to try to find a connection
among these patients. Healthcare providers in Illinois should be aware
of the recently identified cluster and consider Elizabethkingia as a
potential cause of bloodstream infections among patients.
10 | Chicago Medicine | July 2016
Similarly, prominent national Veterans Service
Organizations (VSOs) have expressed concerns to
VA leadership about the implications of the Nursing
Handbook for care to veterans. In a letter to the
VA, AMVETS noted that the policy change “would
fundamentally, and we feel adversely, impact the
delivery of care to veterans.” The Association of
the U.S. Navy (AUSN) wrote that “We find this
proposed shift from the current guidelines unnecessary and worrisome for our nation’s veteran
community.” The National Guard Association of
the United States (NGAUS) wrote in regards to the
proposal to express their “strong concern about
the possible reduction in standards of anesthesia
delivery in surgery at Veterans Administration
medical facilities.”
The Illinois Society of Anesthesiologists has
prepared a list of key points on the proposed VHA
Nursing Handbook. These include:
• The ONS is advancing a new policy that, among
other changes, would abandon the VA’s proven
model of physician-led, team-based surgical
anesthesia care with a nurse-only model of care.
• VA patients have complex medical conditions
that pose a heightened risk of complications
during surgery. The team-based model of care
ensures that they will have access to a physician
anesthesiologist if an emergency or complication
occurs.
• Independent studies inform policy makers of
better outcomes when physicians are involved in
anesthesia.
• There is no shortage of physician anesthesiologists or nurse anesthetists in VA, according to
the 2015 Mission Critical Occupations Report
and the September 2015 VA OIG Staffing
Shortage report.
• Internal and external veteran’s health stakeholders, including VA’s own anesthesia experts, the
VA chiefs of anesthesiology, and VSOs, have
expressed concerns to the highest leadership
levels of VA about the proposed policy change.
A bipartisan group of more than 90 lawmakers
contacted VA with concerns about how the proposed VHA Nursing Handbook could negatively
impact patient safety.
To ensure that the health and lives of veterans
are not put at risk, submit your comments online
at www.SafeVACare.org urging the VA to preserve
physician-led, team-based surgical anesthesia care
in VA medical facilities.
PUBLIC HEALTH
Medical Marijuana Program Expands
Illinois legislative leaders reach agreement
A CO M P R O M I S E among Illinois’ legislative
leaders will extend the length and scope of Illinois
medical marijuana pilot program (SB 10). Under the
bill, the four-year pilot program slated to end Jan.
1, 2018, would be extended until July 1, 2020, and
two new medical conditions—post traumatic stress
disorder and terminal illness with which patients
have less than six months to live—would be added
to the list of conditions that can be treated with
cannabis. Gov. Bruce Rauner, who previously had
been opposed to approving additional conditions
and extending the length of the program, reached
the agreement on May 27 with the bill’s chief
House sponsor, State Rep. Lou Lang, D-Skokie,
and House Minority Leader Rep. Jim Durkin
(R-Western Springs).
Here are some of the other key changes that will
take effect when the bill is passed:
• Patient and caregiver cards will be valid for
three years, instead of one.
• Upon renewal of patient and caregiver cards, no
fingerprinting is required.
• Doctors will no longer have to recommend
cannabis, but will simply certify that there is a
bona fide doctor-patient relationship and that
the patient has a qualifying condition.
• Minors who are patients may have two
caregivers.
• The Medical Cannabis Advisory Board will be
reconstituted, and a new procedure created for
accepting patient petitions for the addition of
new conditions to the program.
Lawmakers also passed SB 2228 earlier in the
session. This bill would remove the possibility
of arrest, jail, and a harmful criminal record for
people in possession of small amounts of marijuana. These changes would revise a current law by
replacing criminal penalties with a fine of between
$100 and $200 for possession of up to 10 grams
of marijuana. The bill also revises current DUI
laws, which today can lead to unimpaired drivers
being considered under the influence weeks after
consuming cannabis. As of press time, the bills
were awaiting Gov. Rauner’s signature.
The revised Illinois
Medical Marijuana
Bill (SB 10) adds two
conditions that can be
treated with cannabis:
post traumatic stress
disorder and terminal
illness.
Source: Marijuana Policy Project
Flu Vaccine Recommendations
Get ready for the 2016-2017 season
O N M A R C H 4 , 2 01 6 , the Food and Drug
Administration’s Vaccines and Related Biologics
Advisory Committee (VRBPAC) endorsed the
World Health Organization-recommended
vaccine viruses for use in all United States
flu vaccines for the 2016-2017 flu season. The
committee recommended that trivalent vaccines
for use in the 2016-2017 influenza season (the
Northern Hemisphere winter) contain the
following:
• an A/California/7/2009 (H1N1) pdm09-like
virus.
• an A/Hong Kong/4801/2014 (H3N2)-like virus.
• a B/Brisbane/60/2008-like virus (B/Victoria
lineage).
The committee also recommended that quadrivalent
vaccines containing two influenza B viruses contain
the above three viruses and a B/Phuket/3073/2013like virus (B/Yamagata lineage). The vaccine
viruses recommended for inclusion in the 2016-2017
Northern Hemisphere influenza vaccines are the
same vaccine viruses that were chosen for inclusion
in 2016 Southern Hemisphere seasonal flu vaccines.
Source: Centers for Disease Control and
Prevention
July 2016 | www.cmsdocs.org | 11
PUBLIC HEALTH
Is the U.S. on the Brink
of a Superbug Outbreak?
Chicago works to cope with deadly bacteria By Scott Warner
U
. S . H E A LT H C A R E officials were
jolted in mid-May when a microbiologist at the Walter Reed Army Institute
of Research in Silver Spring, Maryland,
helped identify a strain of E. coli bacteria from a 49-year-old Pennsylvania woman that
tested positive for resistance to the drug colistin;
that’s the antibiotic physicians use when all others
fail. The resistant gene was mcr-1, the first mcr-1
gene found in bacteria from a human in the United
States. The Centers for Disease Control and Prevention (CDC) then joined in a coordinated public
health response.
This was a moment U.S. health officials and
experts had been bracing for since the gene’s
discovery late last year in China. While the U.S.
patient is reported to be fine, public health officials
have said they expect to find more cases.
Infectious disease experts are most worried
about the colistin-resistant gene spreading to a
family of superbugs known as CRE (carbapenemresistant Enterobacteriaceae), which the CDC
has called one of the country’s most urgent
public health threats. In some cases, colistin
is increasingly the last-resort antibiotic used
against multidrug-resistant pathogens. If the
gene spreads to CRE that means it couldn’t be
stopped by any antibiotic.
While the resistant gene found in
Pennsylvania has not appeared in the Chicago
area, our region has had its own brushes with
superbugs. In 2013, one of the largest U.S. outbreaks on record of CRE occurred at Advocate
Lutheran General Hospital in Suburban Park
Ridge, where 39 patients were infected and two
died, according to the Illinois Department of
Public Health. The patients were infected by
contaminated duodenoscopes.
In some hospitals, antibiotic-resistant bacteria
cause one in four catheter- and surgery-related
infections. If this trend of antibiotic resistance
continues, it could make many common surgeries
and cancer treatments too risky.
Rush, Cook County Win Grants
To increase resources to combat this threat, the
CDC has awarded $26 million to five academic
medical center-based efforts to research new
ways to control drug-resistant organisms and
prevent healthcare-associated infections. The
CDC announced the awards at a June 27 press
conference at Rush University Medical Center.
The five grant recipients include the Chicago
Prevention and Intervention Epicenter at Rush
University and Cook County Health and Hospitals
System, which will receive $9.45 million: $5 million
from the national award plus $4.45 million from
the CDC’s Safety and Healthcare Evaluation and
A National Model in Chicago
T H E C H I C AG O - B A S E D Prevention
and Intervention Epicenter at Rush
University and Cook County Health
and Hospitals System just received
$9.45 million in funding from the CDC.
The Epicenter is considered a national
model for developing a prevention
package that reduces bloodstream
infections due to the deadly carbapenem-resistant Enterobacteriaceae
(CRE) by 56%. According to Rush and
Cook County investigators, the additional funding will allow them to:
• Identify markers in the microbiome
of patients that would identify
them as high risk for infection
and develop the right interventions
12 | Chicago Medicine | July 2016
•
•
•
•
to protect those patients from
deadly bacteria.
Study the effectiveness of chlorhexidine gluconate (CHG) bathing in the
fight against MDROs.
Track the transmission of antibioticresistant germs, including CRE and
alerting healthcare facilities when
patients are admitted with CRE so
that a proper course of action can
be taken immediately.
Use advanced molecular diagnostics
such as whole genomic sequencing
to study transmission of CRE within
and between healthcare facilities in
a region.
Develop social network analysis
methods to identify where bugs are
and see where they are going as
patients move from one healthcare
facility to another.
• Evaluate the behavior of physicians
around prescribing antibiotics and
supporting them in making judicious
decisions on the appropriate use of
antibiotics.
Other epicenters that received CDC
funding are Duke University and the
University of North Carolina; Harvard
Pilgrim Health Care and the University of California, Irvine; University
of Pennsylvania, and Washington
University School of Medicine in St.
Louis and BJC Healthcare Prevention
Epicenter.
PUBLIC HEALTH
Research Development contract to develop and test
regional approaches for preventing transmission
of antibiotic-resistant germs between healthcare
facilities. The CDC stated that the protocols Rush
and Cook County implemented have reduced CRE
infections by 56%.
Also heavily involved in the campaign against
superbugs are the Chicago Department of Public
Health (CDPH), and the Illinois Department of
Public Health (IDPH). Stephanie Black, MD, medical director for CDPH, says that both organizations
are working together on an ongoing “Detect and
Protect Campaign,” which includes an Extensively
Drug Resistant Organism (XDRO) registry to share
patient information across facilities and report
CRE isolates.
In addition, Dr. Black says that CDPH assists
health facilities in appropriate testing for
laboratory identification of superbugs, and provides technical assistance on infection control
practices. “Patients with complex medical issues
often require medical devices and antibiotics,
which place them at risk of infections with
more drug-resistant bacteria,” she says. Dr.
Black urges physicians to minimize use of
medical devices and to prescribe antibiotics
judiciously for the correct diagnosis, with the
correct drug, dose and duration. Her concern
is affirmed by a recent study from CDC that
reported an estimated 154 million primary-care
physician and emergency department visits each
year resulted in the writing of an antibiotic
prescription. Nearly half were for respiratory
conditions for which antibiotics prove largely
ineffective.
“Antibiotics are lifesaving drugs, and if we
continue down the road of inappropriate use,
we’ll lose the most powerful tool we have to fight
life-threatening infections,” said CDC Director
Tom Frieden, MD, in a written statement.
“Losing these antibiotics would undermine our
ability to treat patients with deadly infections,
provide organ transplants, and save victims of
burns and trauma.”
This 2006 image,
made available by
the CDC, shows the
0157-H7 strain of the E.
coli bacteria. On May
26, 2016, U.S. miltary
officals reported the
first U.S. human case
of antibiotic-resistant
bacteria used as a lastresort drug.
THRIVE AS A
U.S. ARMY
EMERGENCY
MEDICINE
PHYSICIAN.
Make a real difference treating the immediate medical
needs of Soldiers and their families while growing in
your career. You’ll work with advanced technology,
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and receive excellent financial benefits.
To learn more about joining the U.S. Army health
care team, visit healthcare.goarmy.com/em57 or call
708-492-0450.
©2014. Paid for by the United States Army. All rights reserved.
July 2016 | www.cmsdocs.org | 13
LEGAL
New Antitrust Scrutiny: State
Regulatory Boards
N.C. State Board of Dental Examiners v. FTC has implications for other professions
By Julian Rivera, Esq., and David Solberg, Esq.
N
OTA B L E antitrust litigation has
arisen over the past year challenging
actions by state licensing boards comprised of members of the respective
professions that the boards regulate. In
February 2015, the U.S. Supreme Court ruled that a
dental state licensing board consisting of a majority
of practicing dentists may not prohibit nondentists
from selling teeth whitening services or products.
In the case, N.C. State Board of Dental Examiners v.
FTC, the state board sought to invoke a “state action
defense,” an argument that governmental agencies
acting as sovereign entities should be exempt from
antitrust scrutiny. The Supreme Court rejected the board’s argument, determining instead that “a state board on
which a controlling number of decision-makers are
active market participants in the occupation the
board regulates” may enjoy the state action defense
only if the board action is expressed as clearly
articulated state policy and is actively supervised
by a state official or agency that does not participate in the regulated market.
Given the multitude of state regulatory boards
which have a majority of board members who
practice the same profession the boards regulate,
the Supreme Court’s decision drew considerable
attention. In response to numerous questions
posed by state officials, in October 2015 the
Federal Trade Commission (FTC) published
guidance on how it determines whether active
supervision of state regulatory boards controlled
by market participants exists for purposes of
antitrust scrutiny. While the FTC explained that it will evaluate
instances of active supervision in a flexible and
contextdependent fashion, it stated that “the
purpose of the active supervision inquiry…is to
determine whether the State has exercised sufficient independent judgment and control’ such
that the details of the regulatory scheme ‘have
been established as a product of deliberate state
intervention’ and not simply by agreement among
the members of the state board” (“FTC Staff
Guidance” quoting FTC v. Ticor Title Ins. Co.). The factors considered by the FTC in determining whether the active supervision requirement
has been satisfied include: (1) ensuring that the
supervisor properly assesses the recommended
board action; (2) adequately evaluating the
substantive reasons for the proposed action;
and (3) issuing a written decision explaining the
14 | Chicago Medicine | July 2016
supervisor’s rationale for approving, modifying, or
disapproving the action.
Teladoc, Inc. et al. v. Texas Medical
Board, et al.
Shortly after the Supreme Court’s ruling in N.C.
State Board of Dental Examiners, yet another
antitrust challenge arose in response to state
regulatory board rulemaking. In May 2015, a U.S.
district court granted Teladoc, Inc., a temporary
restraining order and preliminary injunction on the
Texas Medical Board’s (TMB) new rule prohibiting
physicians from using telemedicine to diagnose
and treat patients without first seeing patients
in-person for an initial consultation. How the
physician-patient relationship can be appropriately
established has been a significantly debated policy
issue addressed by many states recently, including
Alaska, where FTC Staff sent a comment to the
state legislature in March 2016. Teladoc, a national provider of telehealth
services, claimed that the new rule violated the
Sherman Act by stifling competition. TMB did not
assert a state action defense at this stage of the
litigation but instead offered as its sole justification for the new rule that the rule was designed
to protect patient safety. The court rejected
TMB’s claims, and instead agreed with what it
regarded as considerable evidence of anticompetitive effects of the novel regulation, including
increased prices, reduced choice, reduced access,
reduced innovation, and a reduced overall supply
of physician services.
In June, TMB countered by filing a motion to
dismiss, asserting that in adopting the challenged
rule it “was acting as the sovereign with multiple
layers of oversight” and thus “active oversight
immunizes the TMB from federal antitrust
law.” In its motion, TMB sought to distinguish
itself from the facts that generated the Supreme
Court’s ruling in N.C. State Board of Dental
Examiners. TMB argued that while its board too
is made up of a majority of market participants,
the state actively supervises TMB through its
review of proposed rules. TMB also argued that
the practices of TMB physician board members,
who are all specialists, have no direct competition
with the Teladoc physicians who limit their
telemedicine consultations to general and family
medicine services.
In December 2015, the district court denied
TMB’s amended motion to dismiss. In response,
LEGAL
on Jan. 8, 2016, TMB appealed that order to the
Fifth Circuit Court of Appeals, and on Jan. 14 the
court ordered all proceedings to be stayed while
TMB’s appeal is pending. Final adjudication of the
Teladoc case will have weighty implications on
antitrust scrutiny of regulatory boards since this
is the first case to be considered by the appellate
courts since the North Carolina decision. It will
likely be many months before a decision is handed
down by the Fifth Circuit.
Other Cases Challenging
Professional Regulatory Boards
Additional cases in other professions challenging the compliance of regulatory boards with
antitrust laws have followed N.C. State Board
of Dental Examiners and Teladoc. In Robb v.
Connecticut Board of Veterinary Medicine, et
al., veterinarian John Robb sued Connecticut’s
veterinary board for alleged violations stemming
from the board’s disciplinary action against him
over his vaccination procedures. Specifically,
Robb’s rabies vaccination protocol differed
from instructed protocols as prescribed by the
state board. Robb argued that no clear policy
regarding canine rabies vaccination exists, and
that the board’s disciplinary action against him
constituted a violation of the Sherman Act by
conspiring to restrain competition and monopolize the practice of veterinary medicine.
Robb also alleged that the board, which
included a majority of market participants
without any supervisory state official who could
change or reverse its decision, violates antitrust
laws. The defendant filed a motion to dismiss,
which the U.S. district court granted in January
2016 because Robb’s allegations were held to be
insufficient to state an antitrust conspiracy claim
under the Sherman Act. Specifically, the court
held that Robb failed to allege interdependent
conduct by the board sufficient to support an
inference of antitrust conspiracy.
One recent case, Axcess Medical Clinic,
Inc. et al. v. Mississippi State Board of Medical
Licensure et al., provides another example similar
to Teladoc of antitrust litigation against a medical
board seeking to prevent the “unauthorized
practice of medicine.” In this case, Axcess claimed
that the state board violated antitrust law by
promulgating and enacting regulations excluding
non-physicians from owning a pain management
medical practice. Further, Axcess alleged that
the board suppressed competition by enforcing
non-existent rules before granting certification
to practice pain management and promulgating
regulations that create special education and
certification requirements for a pain management
medical practice as arbitrarily defined by the
board. Axcess submitted, without further explanation, a voluntary stipulation of dismissal of all
claims asserted against the Board in August 2015.
Yet another case challenging state regulatory
action was brought by a group of licensed physical
therapists and patients against the North Carolina
Acupuncture Licensing Board after receiving
cease-and-desist orders for offering dry needling
services (Henry et al. v. North Carolina Acupuncture
Licensing Board et al.). The complaint argued that
dry needling, an established physical therapy practice, differs from acupuncture, a claim supported
by the North Carolina Attorney General’s Office in
2011. While the plaintiffs alleged that the board’s
efforts violate federal antitrust law, it did not
address state action immunity. In December 2015,
the Acupuncture Licensing Board filed a motion to
dismiss for the alleged failure to sufficiently state
a plausible claim for Sherman Act violations. The
court has yet to rule on the motion.
Antitrust scrutiny of state regulatory boards
has not been confined solely to the medical field.
In 2015, LegalZoom.com Inc. filed a $14 million
federal lawsuit against the North Carolina State
Bar for allegedly violating the Sherman Act by
illegally and unreasonably prohibiting LegalZoom
from offering its prepaid legal services in North
Carolina. LegalZoom’s complaint relied on the N.C.
State Board of Dental Examiners case, claiming that
the Supreme Court’s decision allows state agencies
to make decisions regarding who can practice
regulated professions free from potential antitrust
liability only if a clearly articulated state policy
regulating the activity has been established and a
state official maintains oversight. In October 2015,
the two parties reached an agreement to settle the
dispute, allowing LegalZoom to operate in North
Carolina for the next two years.
The Beginning of a Trend?
All these cases provide notable examples of
heightened antitrust scrutiny facing state regulatory boards nationwide that have arisen in the
wake of N.C. State Board of Dental Examiners.
Considering the marked rise in such litigation,
state boards (and their legislatures) seeking
immunity from antitrust suits using a state action
defense must ensure that they meet the required
standards for invoking the defense. Failure to take
appropriate measures may lead to costly litigation
and overturned state action.
“The Texas
Medical Board
also argued that
the practices
of its physician
board members,
who are all
specialists,
have no direct
competition
with the Teladoc
physicians
who limit their
telemedicine
consultations
to general and
family medicine
services.”
Julian Rivera, Esq., is a partner with Husch
Blackwell in Austin, Tex. He represents healthcare
providers in business and litigation matters,
including telemedicine, telehealth and other
technology issues. He may be reached at Julian.
[email protected]. David Solberg, Esq.,
is an associate in the firm’s Kansas City, Mo.,
office. He focuses on transactional and operations
matters. Mr. Solberg may be reached at David.
[email protected]. Husch Blackwell
has a Chicago office and lawyers who practice
throughout the Great Lakes region.
July 2016 | www.cmsdocs.org | 15
LEGAL
Good FCA News on the Horizon?
FCA reform could signal relief for healthcare providers By Brian F. McEvoy, Esq.,
Sidney Welch, Esq., Jeremy Burnette, Esq., and Emma R. Cecil, Esq.
G
O O D N E WS may be in sight for
businesses and healthcare providers.
On April 28, 2016, the House Judiciary
Committee’s Subcommittee on the
Constitution and Civil Justice once
again considered potential updates to the federal False
Claims Act. Those in favor of reform touted the hearing as a first step toward commonsense improvements
targeted at promoting compliance and rooting out and
preventing fraud in the first instance.
The Subcommittee heard testimony from healthcare lawyers, a healthcare system CEO, and former
deputy U.S. Attorney General, Larry Thompson.
The testimony focused on two proposed reforms:
reduced awards for corporations that adopt gold
standard compliance programs; the requirement
that corporate whistleblowers report fraud internally before filing qui tams. Both proposals drew
sharp criticism from opponents of FCA reform.
Testimony
“….while the
FCA remains
a critical tool
in combating
fraud, it has
become unduly
adversarial,
giving the government enormous leverage
against private
companies and
individuals.”
Mr. Thompson observed that while the FCA
remains a critical tool in combating fraud, it has
become unduly adversarial, giving the government
enormous leverage against private companies and
individuals. The government’s reliance on post-hoc
enforcement, he testified, results in significant,
often unfair and arbitrary, penalties, even when a
company has invested considerable resources in
compliance and prevention on the front-end.
Citing a 2013 report by the U.S. Chamber
Institute for Legal Reform, Mr. Thompson
suggested that a better approach would be to
incentivize compliance in a real and meaningful
way by allowing companies that achieve and
maintain superior compliance programs to obtain
reductions in penalties or other consequences
“when inevitable wrongdoing does occur.”
Yet any reform would have to include a requirement that relators demonstrate they have brought
their concerns to the attention of the target organization before filing a qui tam complaint, said Dennis
Burke, president and CEO of a not-for profit-hospital
system. This requirement would prevent organizations from being subjected to costly and protracted
investigations, not to mention unquantifiable and
often irreparable reputational harm, as a result of
relators being allowed to “throw everything on the
wall to see if anything might stick.” If nothing does,
he said, relators can simply “walk away and say ‘oops,
I guess we were (I was) wrong.’”
Echoing Mr. Burke’s sentiments, Jonathan
Diesenhaus, healthcare attorney and former senior
trial counsel in DOJ’s Civil Fraud Section, noted
that FCA defendants are left without a remedy
16 | Chicago Medicine | July 2016
when investigations, or more often declined qui
tam litigation, come up empty. He pointed out that
the FCA’s bounty and attorneys’ fees provisions
shield whistleblowers and their attorneys from the
risk-reward proposition that governs other litigation in federal courts.
The normal rules of litigation, Mr. Diesenhaus
said, do not constrain whistleblowers and their
attorneys in the same way as other plaintiffs and
their attorneys. He suggested that Congress can
“reset [the] balance” by creating greater incentives
for compliance and self-disclosure, subjecting
frivolous whistleblower claims to the same scrutiny
as other plaintiffs under the federal rules of civil
procedure, and requiring DOJ to evaluate declined
qui tams for merit and exercise its authority to
dismiss cases that would unjustifiably burden the
courts, federal agencies, and healthcare providers.
Opponents warned that requiring corporate
whistleblowers to make internal reports to their
employers before filing qui tams would result
in widespread retaliation against whistleblowers, making them reluctant to come forward, and
rejected the idea that a so-called gold standard
corporate compliance program was a silver bullet
against fraud. Relator’s attorney Neil Getnick
argued that permitting companies to escape or face
reduced liability because they have “checked the
boxes” on how to establish a compliance program
would encourage companies to game the new
compliance regime, thus enabling fraud.
Relief Could Be in Sight
Whatever the consequences of these congressional hearings, the proposed updates to the FCA
underscore the significant leverage wielded by
the DOJ against healthcare providers under the
current FCA. That leverage has only grown in
recent years, partly as a result of the frequent and
aggressive use of the “implied certification” doctrine, which allows relators to bring suits based on
technical regulatory violations and without proof
of actual false claims submission. Until reforms are
legislatively enacted, the FCA’s treble damages and
civil penalty provisions remain the most potent and
prolific means of obtaining mammoth settlements
against healthcare providers and others that do
business with the government.
Brian F. McEvoy, Esq., Sidney Welch, Esq., Jeremy
Burnette, Esq., and Emma R. Cecil, Esq. practice
healthcare law in the Atlanta office of Polsinelli,
a firm with offices in major cities across the
United States. For information, contact swelch@
polsinelli.com.
LEGAL
Selling Your Medical Practice
Planning ahead can lead to a smoother and possibly more profitable outcome
By Kimberly T. Boike, Esq., and Ryan A. Haas, Esq.
A
S CO N S O L I DAT I O N in healthcare continues to make headlines, it
is an appropriate time for physicians
contemplating a sale of their practice
to think about whether selling their
practice aligns with their overall professional goals
and what the best practices are in pursuing such a
sale. Selling a medical practice is often something
physicians will do only once in their career, so planning ahead is critical to making an informed decision and implementing a plan to make the transition
as smooth as possible.
In thinking about a possible sale, physicians should
consider their end goal: is it to maximize value for
shareholders or is to provide stability and relief from
administrative headaches? The answer to this question
will have an impact on categories of buyers a physician
will wish to pursue in a sale. For example, if maximizing shareholder value is critical, then a physician may
elect to pursue private equity firms as potential buyers.
If, however, physicians looking for clinical integration
and less administrative burden, may instead choose to
sell their practice to a hospital or healthcare system.
Due Diligence
Often in transactions it appears that due diligence
is very one-sided, with all the effort focused on
the potential purchaser’s evaluation of the seller
and seller’s medical practice. However, it is also
a best practice for the seller to do some due diligence regarding the buyer. Such due diligence may
include: (1) identifying how many practices similar
to the seller’s practice the potential purchaser has
acquired; (2) discovering the financial viability of
the potential purchaser; (3) having a discussion
with other physician-employees who have sold
their practices to the potential purchaser about
the transaction and the post-transaction transition; (4) discussion with other employees of the
potential purchaser about their satisfaction with
that employer; and (5) reviewing other transactions the potential purchaser has been a part of
that did not close successfully and the reasons for
such failure to close.
In addition to identifying a group of ideal
purchasers, physicians will likely want to engage
their own appraiser to do an appraisal of their
practice. Often, physicians will rely on the potential
purchaser to do an appraisal. However, a potential
purchaser’s interests are not aligned with the
physician’s interests in determining an appropriate
price for the physician’s practice. Accordingly, it is
prudent for the physician to have an appraiser either
conduct its own appraisal of the medical practice
on behalf of the physician or to review the appraisal
conducted by the potential purchaser. This is needed
to confirm that both parties are in agreement with
the assessment of the value of the practice.
Once a potential value is determined for the
medical practice, it is critical to review the options
for structuring the purchase price with an accounting or legal professional who can advise on how
to best structure the transaction to minimize the
tax implications to the physicians. There may be
opportunities for portions of the purchase price to
be allocated to goodwill, which will minimize the
tax implications. However, it is essential to work
with an accounting or legal professional who has
structured these types of transactions in the past
to confirm that any allocation of the purchase price
to goodwill is compliant with applicable laws.
Letter of Intent
Letters of intent are an important aspect of having
a transaction move quickly with as few issues as
possible. The letter of intent allows the seller and
the potential purchaser to agree on key provisions of
the transaction at the outset, as opposed to having
a surprise disagreement on a key issue after the
parties have already invested time and money into a
potential transaction. The letter of intent allows the
parties at the outset of negotiations to work through
key deal terms and to identify any potential problems. If any identified problems cannot be resolved,
then the seller and potential purchaser can part
ways without having expended significant resources
on a transaction that will not come to fruition.
Transaction Timeline
Once a letter of intent is signed, all key decisionmakers and their respective legal counsel should agree
on a timeline by which various milestones will be met
in closing the transaction. The parties should agree on
the number of drafts of the key purchase documents
and agree that there will be a fixed number of meetings in which any open business items will be resolved.
By setting expectations at the outset and having both
sides agree to a timeline on the purchase documents,
the parties will be able to more effectively control their
legal fees and make the best use of their legal counsel.
Selling your medical practice may sound like
a daunting task, but with appropriate foresight
and planning, the process can move smoothly and
achieve long-term success.
“Often, physicians will
rely on the
potential purchaser to do
an appraisal.
However,
a potential
purchaser’s
interests are
not aligned
with the physician’s interests
in determining
an appropriate
price for the
physician’s
practice.”
Kimberly T. Boike, Esq., practices healthcare law
at Chuhak & Tecson, PC, and can be reached at
[email protected]. Ryan A. Haas, Esq., practices
employment law affecting healthcare providers and
can be reached at [email protected].
July 2016 | www.cmsdocs.org | 17
PHYSICIAN
COMPENSATION:
18 | Chicago Medicine | July 2016
PHYSICIAN COMPENSATION
Value-Based Pay Gaining
a Foothold
Changing reimbursement models fuel strong demand for primary care physicians
By Bruce Japsen
P
H YS I C I A N CO M P E N S AT I O N continues to
rise amid a doctor shortage and increasing numbers
of Americans gaining health coverage under the
Affordable Care Act. But even as more reimbursement
is available to physicians, a divide is widening between
specialist compensation and pay to primary care doctors.
The move to value-based care promises to transform healthcare. Value-based care puts a greater emphasis on financial
rewards to internists, pediatricians and family doctors, in
particular, since they are charged with keeping patients well
and out of hospitals and away from expensive specialized
care, unnecessary tests and procedures. “Practices are giving
primary care physicians significant new responsibility for
coordinating care among specialists, managing patient medications, and helping patients and caregivers manage chronic
conditions,” said Dr. Halee Fischer-Wright, president and CEO
of the Medical Group Management Association, which analyzes
compensation data drawn from more than 80,000 providers. “As we shift toward value-based payment, practices will
continue to look to primary care and non-physician providers
to lead efforts to improve patient experiences and the quality of
care they provide.”
Robust Demand for Primary Care Physicians
Drives Salaries
The new 2016 Medical Group Management Association annual
compensation and production survey shows median primary
care doctor compensation rose 4.3% to $251,578 in 2015 from
a year earlier. Primary care doctors in the MGMA survey
include family medicine, pediatrics, internal medicine and
obstetrics-gynecology.
But the growth in specialist compensation is moving at a
slower pace than that of primary care physicians and just ahead
of general inflation. Compensation of specialists was up 2.3% to
$425,509 in 2015, MGMA said.
There were some specialties in the MGMA tally that
actually had slightly lower compensation on average for this
year than in the prior year. Total median compensation for
noninvasive cardiologists was down 5% to $452,000 while
compensation of radiologists was down slightly, continuing a
path of flat to falling pay in the field of diagnostic radiology,
MGMA figures show.
It’s a pay increase gap that has only widened over time. Since
2011, for example, primary care compensation increased by 18%
while specialty care compensation grew by about 11% during the
same timeframe, MGMA said. The payment spread is directly
related to changing reimbursement models pushed by private
insurers, employers and the federal government, notably the
Centers for Medicare and Medicaid Services (CMS), which all
want to reward health outcomes and institute more pay-forperformance initiatives. The rewards and bonuses favor primary
care in these value-based models over specialists, compensation
analysts say.
“The focus is on primary care,” Travis Singleton, senior vice
president of Merritt Hawkins, a physician staffing firm that
also tracks doctor compensation, said in an interview. Other
analyses like Merritt Hawkins’ also showed primary care doctor
pay rising faster than for specialists. Merritt Hawkins said the
starting salaries it tracks were up in 19 of 20 specialties due to
unprecedented demand for physicians, and primary care pay was
particularly robust in its survey.
“Geographically, starting salaries went up in every region of
the country,” Singleton said. “Supply and demand is a big part
of that and it has been good for physicians. It clearly shows the
health care system is at capacity and busting at the seams.”
Starting pay for family physicians was up 13% this year to
$225,000, Merritt Hawkins said. Meanwhile, median compensation for all family doctors was up nearly 5% to more than
$230,000 in the MGMA analysis.
The Biggest Winner? Family Medicine
Physicians
Family physicians had the biggest five–year jump in compensation among all doctors in the MGMA report and for all
primary care providers, at 15%. It was in 2011 that these medical professionals first reported median compensation above
$200,000. Across the country, the emphasis on primary care
is fueling the need for physicians, especially as the Affordable
Care Act expands health coverage to millions of Americans.
These newly insured Americans are in desperate need of a
doctor, analysts say.
“The expansion of health insurance
coverage, population growth, population
aging, expanded care sites such as
urgent care centers and other factors
are driving demand for doctors through
the roof, and salaries are spiking as a
consequence.”
In particular, more states like Illinois have gone along with
the law’s expansion of Medicaid benefits. There are now 31 states
plus the District of Columbia that have expanded Medicaid
under the ACA compared to just 20 three years ago. “Demand
for physicians is as intense as we have seen it in our 29-year
history,” Singleton said. “The expansion of health insurance
coverage, population growth, population aging, expanded care
sites such as urgent care centers and other factors are driving
demand for doctors through the roof, and salaries are spiking as
a consequence.”
July 2016 | www.cmsdocs.org | 19
PHYSICIAN COMPENSATION
“Geographically, starting salaries went up
in every region of the country….Supply
and demand is a big part of that and it
has been good for physicians.”
Insurance companies including Blue Cross and Blue Shield
of Illinois, UnitedHealth Group, Aetna and the Medicare
program are shifting tens of billions of dollars in payments away
from fee-for-service medicine that emphasizes volume. Next
year Medicare will move toward payment changes under the
Medicare Access and CHIP Reauthorization Act, better known
as MACRA, which begins to tie doctor pay to outcomes and
measures. Many view the move to MACRA as the precursor to
tying even more physician payment to value rather than fee-forservice medicine.
But the more significant shift is already underway after last
year’s announcement by the federal CMS that Medicare is shifting half of its dollars to alternative reimbursement models by
2018. Though the vehicle that will be paid by insurers may vary
from an accountable care organization (ACO) to a medical home
20 | Chicago Medicine | July 2016
that includes doctors, health plans are working with the government to shift to these new models that emphasize population
health and care coordination.
Meanwhile, private insurers are becoming more aggressive.
Aetna, for example, which is working to complete its acquisition of Humana by the end of the year, said it plans to move
three-quarters of its contracts to value-based models within
the next five years. “Our strategy to achieve this mission in
part involves working to transform the healthcare system
model to one in which hospitals and doctors are rewarded
for delivering real value to patients and consumers,” Aetna
Chairman and CEO Mark Bertolini told analysts and investors
on the company’s first quarter earnings call this spring. “Our
differentiated approach focuses on meeting providers where
they are in terms of their readiness for varying levels of coordinated care and risk.”
Aetna, like other insurers, is looking at “simple pay-forperformance models to ACOs and even joint ventures,” Bertolini
said. “We’ve made good progress in the first quarter and now
have 77 ACO agreements and approximately 40% of our claims
payments running through some form of value-based care
model,” the Aetna CEO said. “Based on our progress to date,
we believe we remain on track to achieve our 2020 goal of 75%
of claims in value-based care models and our broad mission of
creating a healthier world.”
While contracts between insurers and providers vary widely
on what model or vehicle is used to pay them, compensation
analysts say doctors are taking on more financial risk in some
way or another. Merritt Hawkins, the national physician staffing
firm, said 32% of physicians for this contract year were offered
a production bonus “in whole or in part” tied to “value based”
metrics. That compares to 23% of physicians in the prior year,
Merritt Hawkins said.
Volume Still Predominant
But Merritt Hawkins takes a more contrarian tone when it comes
to just how much overall physician compensation is based on one
value-based measure or another. Just 6% of total compensation
for physicians is tied to quality or value-based metrics, compared
to less than 5% in 2015. Thus, doctor compensation at this period
of time still includes rewards based on productivity, Merritt
Hawkins analysts say.
“While contracts between insurers
and providers vary widely on what
model or vehicle is used to pay them,
compensation analysts say doctors are
taking on more financial risk in some
way or another.”
“We know it’s coming but we’re just not there yet,”
Singleton said. “We are moving in the direction of valuebased compensation, but the reality just doesn’t match that
aspiration yet. If you have seen significant changes in quality
measures or outcome measures, you more than likely [saw
them] through cultural changes or managerial changes, but
not compensation changes.”
Health insurance companies are pushing for more patient satisfaction metrics, adopting the “triple aim” framework developed
by the Institute for Healthcare Improvement. The triple aim
methodology works to improve a patient’s experience and medical care through quality and satisfaction, improve the health of
populations, and reduce the per capita cost of healthcare.
MGMA says nearly 11% of primary care doctor compensation
was tied to quality in 2014 compared to less than 7% in 2013.
MGMA’s 2015 percentages weren’t available at press time but
executives say the trend toward doctor compensation being tied
to value-based metrics continues. “New care delivery models for
primary care are shaping the landscape of healthcare delivery,
and in turn shaping patient experiences in doctors’ offices
around the country,” said Dr. Fischer-Wright said.
Bruce Japsen is a health care journalist, speaker, author and
regular contributor to Chicago Medicine who also writes for
Forbes. He is the author of the book, “Inside Obamacare: The
Fix For America’s Ailing Health Care System” and is a regular
analyst on health, business and political topics to WBBM
Newsradio and WTTW television’s Chicago Tonight program
and Fox News Channel’s Forbes on Fox. He can be reached at
[email protected].
Online CME Now
Available 24/7
• Medical Cannabis in Illinois: Legal Impact
on Physicians
• Dealing with Difficult Patients
• Vendor Relationships: What Physicians Need
to Know
• And many others
Whatever your health care practice, or even
if you are a young professional entering the
field, you need ongoing education to gain
valuable insight and strategies. These CME
and CLE webinars are held in conjunction
with the American Bar Association. So, they
are also invaluable for health care attorneys,
whether new to the legal field or longtime
practitioners. Offered exclusively by The
Chicago Medical Society. Your resource f
or high-quality education.
Bundle options available at a discount
for a limited time
For more information or to register please visit:
http://cmsdocs.inreachce.com
For registration questions and online assistance, call the
customer support line 877-880-1335. For other questions,
contact the Chicago Medical Society’s Education
Department 312-670-2550 ext. 338, or email:
[email protected] or fax to: 312-670-3646.
July 2016 | www.cmsdocs.org | 21
OPIOID ABUSE
Taking Action Against Opioid Abuse
CMS works with top lawmaker to achieve balanced solutions By Elizabeth Sidney
Dr. Kathy Tynus,
president of CMS, led
several candid and
productive meetings
with U.S. Senator
Richard Durbin. CMS
is collaborating with
the Illinois lawmaker
to address the opioid
epidemic.
A
R E P H YS I C I A N S getting a bad
rap? Certainly there’s blame to go
around inside and outside the medical profession. We’ ve learned a lot
since the widespread introduction of
powerful addictive painkillers like OxyContin in
the late 1990s. These drugs were marketed aggressively to physicians, with many misleading claims.
One of the consequences of painkiller abuse has
been the spread of heroin across all socioeconomic
groups. Heroin addiction had long been a reality
in low-income, urban minority communities on
Chicago’s West and South Sides. But it wasn’t
until opioids caused devastation in mostly white
middle- and upper class—populations with far
greater access to medical care—that the problem
garnered national attention.
While we can point fingers and recite a litany
of factors that converged to form the worst drug
epidemic in the nation’s history, at some point
what’s past becomes prologue. The question is
where do we go from here to address the medical
and social consequences?
Lawmakers are scrambling toward solutions,
22 | Chicago Medicine | July 2016
resulting in a slew of both state-specific and
national opioid-related bills. Eighteen states, not
including Illinois, have passed additional CME
credit hour requirements for physicians who
prescribe controlled substances (see sidebar).
The Chicago Medical Society is not standing by
idly. Leading efforts regionally, CMS has joined
with major organizations, making its voice heard
so that physicians can treat patients using their
clinical judgment and best clinical practices
such as those described by the CDC in its opioid
prescribing guidelines.
Collaboration and Outreach
Society leaders have met several times with U.S.
Senator Richard “Dick” Durbin, who has been highly
visible in the fight against the opioid epidemic.
Throughout these meetings, CMS has listened
to Senator Durbin’s concerns about physician
prescribing practices and has successfully educated
him on those same issues from a physician’s
perspective, thereby achieving compromise on items
such as mandatory CME and the use of prescription
drug monitoring programs (PDMPs).
OPIOID ABUSE
It is clear from these meetings that both CMS
and Senator Durbin have found common ground
in the desire to achieve workable solutions and
the relationship grows more positive over time.
For example, in the most recent meeting between
Senator Durbin and CMS President Kathy Tynus,
MD, and CMS Secretary Clarence Brown, Jr., MD,
your CMS leadership explained the negative impact
of added bureaucracy on already overburdened
physicians. Doctors working long hours, undergoing significant change within their own profession,
and fighting burnout don’t need one-size-fits-all
opioid education mandates.
As a result, the group agreed to legislation that
ties opioid education to DEA Schedule II licensure
and only for those physicians who write more
than 100 opioid prescriptions per year. The group
also agreed that this education should be based
on the recently released CDC opioid prescribing
guidelines for chronic pain, since they are up to
date and evidence-based.
Your CMS stressed that any legislation should
balance the needs of patients with a legitimate
need for opioid treatment with those who would
benefit most from other treatment options. A
comprehensive solution must include insurance
coverage for alternative treatment modalities
including substance abuse and mental health, and
of course, prescription drug monitoring.
The CDC recently published guidelines for
prescribing opioids to adults with chronic pain
who are seen in primary care settings. The
guidelines utilize evidence-based medicine as
well as input from subject matter experts and key
stakeholders. Meanwhile, the U.S. Senate passed
the Comprehensive Addiction and Recovery Act
in March, and the U.S. House of Representatives
passed a bipartisan package of 18 bills in May.
The Senate bill authorizes the U.S. attorney general to provide grants to states, local governments
and non-profit groups for programs to strengthen
prescription drug monitoring, improve treatment
for addicts and expand prevention, education and
law enforcement activities. The legislation authorizes $725 million for federal grants but does not
allocate any actual funds, which would have to be
approved as part of legislation to fund federal agencies for the 2017 fiscal year. Similarly, the package of
House bills require Congress to provide more than
$1 billion in funding in order to be effective.
Letter Lauds Leadership
Pleased to collaborate with CMS, Senator Durbin
wrote the following letter on June 13 that outlines
the common ground he and the Society share. Here
is the full text:
CME Requirements State by State
E I G H T E E N S TAT E S now require
pain management education for physicians who prescribe opioids. Three
of those states—Florida, Ohio and
Texas—limit the mandate to physicians
who practice in registered pain management clinics. Illinois currently does
not require CME on opioid prescribing
but the tide is turning in favor of more
regulation.
Here’s a state-by-state run down.
California: 12 credit hours in pain management and care of the terminally ill
except for pathologists and radiologists.
Physicians must complete the mandated
hours by their second license renewal
date or within four years, whichever
comes first.
Iowa: For primary care physicians
who treat chronic pain, two credit hours
of chronic pain management and two
hours of end-of-life care every five years.
Kentucky: four and one half credit
hours every three-year licensing cycle.
Maryland: one credit within the current renewal cycle.
Massachusetts: three credit hours of
pain management and opioid education
every two-year licensing cycle.
Nevada: two credit hours every other
two-year licensing cycle.
New Hampshire: three hours in the
area of pain management and addiction
disorder or a combination, as a condition
for initial licensure and license renewal
every two years.
New Mexico: All medical board
licensees who hold a federal drug
enforcement administration registration
and licensure to prescribe opioids must
complete at least five credit hours during their first year of licensure.
North Carolina: one credit hour every
three-year licensing cycle.
Oklahoma: one credit hour every
other year on prescribing, dispensing, and administering of controlled
substances.
Rhode Island: two hours on universal
precautions, infection control, modes of
transmission, bioterrorism, end-of-life
education, palliative care, OHSA, ethics,
or pain management every two-year
licensing cycle.
South Carolina: At least two credit
hours related to approved procedures
for prescribing and monitoring Schedules II, III, and IV controlled substances
every two-year licensing cycle.
Tennessee: At least one credit hour
on prescribing controlled substances
every two-year licensing cycle. Providers
of intractable pain treatment must have
specialized CME in pain management.
Vermont: one credit hour on hospice,
palliative care, and/or pain management
services each two-year licensing cycle.
For each licensee who holds or has
applied for a DEA number, at least one
CME hour must be on prescribing of
controlled substances.
West Virginia: Unless a physician certifies that he or she has not prescribed,
administered, or dispensed a controlled
substance during the previous reporting
period, the physician must complete at
least three credit hours of drug diversion
training and best practices training on
the prescribing of controlled substances
every two-year licensing cycle.
July 2016 | www.cmsdocs.org | 23
OPIOID ABUSE
Dr. Tynus and Members
of CMS:
The Chicago Medical
Society achieved a
compromise with U.S.
Senator Richard Durbin
so that physicians are
not subject to blanket
mandates on education
and use of Prescription
Drug Monitoring
Programs.
Thank you for meeting
with me in Chicago
last month and for
your leadership in the
health community
across a number of
important issues to
physicians, medical
students, and patients.
The Chicago Medical
Society is one of the
oldest and largest
professional medical
societies, and the
organization has had
a prominent impact
on public health and
health care.
I appreciated
our recent candid
conversation regarding
the ongoing opioid epidemic, which has impacted
too many families and claimed too many lives
in Cook County and across the nation. Each
stakeholder has a role to play in helping to address
this complex problem. I have engaged with law
enforcement officials, called upon pharmaceutical
manufacturers, and worked with treatment providers, asking everyone to step up and do their part.
The Chicago Medical Society, as the leading voice
of the medical community in the region, can be a
leader in driving its members to take responsibility
by working toward a solution.
Over the past 25 years, the number of opioid
pain relievers prescribed in the United States has
skyrocketed—from 76 million in 1991 to more than
245 million in 2014. The United States is by far the
largest global consumer of these drugs, accounting
for almost 100 percent of the world total consumption of hydrocodone and 81 percent of oxycodone.
Indeed, there are a number of reasons why we
have seen such a dramatic rise in the number
of opioids being prescribed: the introduction of
addictive painkillers like OxyContin, mass marketing and production, misleading claims by drug
companies, increased attention on identifying and
treating pain, perceived financial incentives to overtreat pain, and the lack of insurance coverage for
alternative pain treatment modalities. Regardless of
these myriad factors, we are committed to working together to take proactive steps to improve
health outcomes and reduce opioid dependency,
overdose, and death.
We agree that continuing medical education for
physicians who prescribe opioids is an important
part of the solution and a logical and important
measure for those who seek a controlled substance
24 | Chicago Medicine | July 2016
license. I applaud your organization and its commitment on identifying the best way to promote and
implement such a learning initiative for physicians.
Prescription drug monitoring programs are a vital
tool to prevent over-prescribing, misuse, abuse, and
diversion. I am pleased that you have urged your
members to increase utilization of these programs. I
believe that The Heroin Crisis Act, which is now law
in Illinois, includes many provisions to make it easier
to use this system in Illinois, such as auto-enrollment
for physicians upon controlled substance licensure
and allowing them to authorize a designee to check
the system. I urge you to work with your members
to increase uptake, with physicians checking these
systems before prescribing powerful opioids.
Research shows that universal use of these systems
reduces unnecessary prescribing, alerts physicians
to other active prescriptions, including for benzodiazepines, and can help identify signs of substance
use disorder so that patients can be provided
linkages with addiction treatment services. I look
forward to working with your organization and its
members to increase use of these lifesaving tools
and enhance information sharing and ease of use so
data can be integrated within existing technologies
and medical records.
In 2014, more than 28,000 people nationwide—1,652 in Illinois—died from prescription opioid and heroin overdoses. Efforts to expand access
to lifesaving overdose-reversal drugs and facilitate
more people receiving evidence-based substance
use disorder treatment will be critical. But it is just
as important, if not more so, to prevent addiction
in the first place by addressing the upstream
drivers of this epidemic. This is where physicians
can have the most impact and I applaud you for
your leadership and commitment to addressing
this problem. I look forward to continuing to work
together on this important topic.
Sincerely,
Richard J. Durbin
United States Senator
Survey Points to Solutions
In its push to work with stakeholders to ensure
that possible solutions to the opioid epidemic are
effective in patients and viable for physicians, the
American Medical Association (AMA) Task Force
to Reduce Opioid Abuse launched a national survey
of practicing physicians about prescription drug
monitoring programs, education, naloxone and
related issues. The survey was conducted by TNS
Global Research in November of 2015. Based on
survey results, the task force has come up with a
list of ideas that they believe will fill the bill aside
from additional CME courses. These include:
• Non-mandated access to PDMPs for physicians.
PDMPs should be integrated with EHRs, provide
real-time data and provide interstate information.
OPIOID ABUSE
• Non-mandated physician education that is
practice-specific and specialty-specific.
• Eliminating barriers to non-pharmacologic and
non-opioid treatment of patient pain, which
includes the lack of insurance coverage.
• Co-prescribing of naloxone to patients at risk of
overdose.
• Reducing the stigma of substance use disorders as
well as getting physicians trained to provide inoffice buprenorphine for substance use disorders.
• Reducing the stigma of pain.
The AMA is quick to note that based on a survey
it performed, Illinois has one of the lowest per
capita prescribing rates in the nation, even though
the state does not have mandates on PDMP use
or extra CME courses. In fact, AMA research
shows that in general, there is no correlation
between mandatory education and PDMP use and
opioid prescribing rates and mortality (see table).
And, when it comes to PDMPs, physician use in
Illinois is increasing despite the lack of a mandate.
Physician registration for PDMP increased 13%
from 2014 to 2015 and queries increased 33% in
that same timeframe.
Be Part of a Compromise
The opioid epidemic is years in the making.
Stakeholders have different ideas for addressing
the crisis based on their individual mission,
orientation, and what they desire for the future.
That’s why it is so important for physicians to have
a seat at the table, presenting their perspective in a
rational clear-cut way. True, physicians might not
achieve all their goals on behalf of patients or their
profession. But without representation from CMS,
ISMS and the AMA they might find themselves
facing greater interference with their ability to
practice medicine. It’s much better to be part of a
compromise than to have no say at all.
Correlation Between PDMP Mandates and Mortality
2013 Mortality
Rate
2013 Number
of Deaths
2014 Mortality
Rate
2014 Number
of Deaths
Percent
Change
NY
11.3
2,309
11.3
2,300
0
KY
23.7
1,019
24.7
1,077
4.2
OH
20.8
2,347
24.6
2,744
18.3
TN
18.1
1,187
19.5
1,269
7.7
AL
12.7
598
15.2
723
19.7
FL
12.6
2,474
13.2
2,634
4.8
GA
10.8
1,098
11.9
1,206
10.2
VT
15.1
93
13.9
83
-7.9
OR
11.3
455
12.8
522
13.3
DC
15
102
14.2
96
-5.3
MO
17.5
1,025
18.2
1,067
4
PA
19.4
2,426
21.9
2,732
12.9
PDMP Mandate
No PDMP Mandate
No PDMP
Source: American Medical Association
July 2016 | www.cmsdocs.org | 25
MEMBER BENEFITS
Resolutions March On
Advancing new public health protections locally and nationally By Elizabeth Sidney
A
T T H E P O L I C Y grassroots, the
Chicago Medical Society (CMS)
contributes mightily to the work of
the American Medical Association’s
House of Delegates, through its individual members and as part of the Illinois team.
That proud tradition continued June 11-15, with
several local measures advancing to this year’s
annual AMA meeting. Prior to their culmination
at the AMA House, the Chicago-based resolutions
won support at the state level. The Illinois State
Medical Society (ISMS), which met in April, submits the measures en masse to the AMA under the
Illinois banner.
Participation on the state delegation isn’t the
only way CMS physicians make their presence
known in the national arena. Their voices are
also reinforced indirectly by their colleagues who
represent their specialty societies as delegates to
the AMA. Notably, CMS’ William A. McDade, MD,
PhD, was elected in June to the AMA Board of
Trustees as a representative from the American
Society of Anesthesiology. Dr. McDade is both a
CMS and ISMS past president.
Also in the spotlight, student Christiana
Shoushtari, MPH, MS, was among the select 15
recipients of the AMA Foundation’s Leadership
Award. A student at the University of Illinois at
Chicago, Shoushtari will use the award to further
26 | Chicago Medicine | July 2016
develop her skills as a future leader in medicine
and community affairs.
Here are the resolution highlights.
Study on Health Care Payment Models
Formerly titled “Single Payer Health Care Study,”
this Illinois measure came originally from CMS
member Peter Orris, MD, MPH. Dr. Orris asked
the AMA to research and analyze the benefits and
difficulties of a single-payer healthcare system in
the United States with consideration of the impact
on economic and health outcomes and on health
disparities. However, in light of the passionate
and mixed testimony on both sides, the AMA
opted for a global study into a variety of healthcare financing models. As such, the study will
also include lessons learned from other countries
with various payment models.
Testimony reflected the desire to act on behalf
of patients, to improve access to care and cover
the uninsured. At the same time, testimony in
opposition noted that the AMA has a long history
of commitment to pluralism and freedom of
choice. Several existing policies expressly oppose
a single-payer system and support a marketbased approach.
CMS launched its resolution in early 2016.
With significant support from medical student
members, the Council voted to research the
PHOTO BY TED GRUDZINSKI, AMA
In the national
spotlight, Chicago
Medical Society
physicians participate
in the AMA House
of Delegates annual
meeting June 11-15.
Several CMS measures
are now on their way
toward introduction in
the U.S. Congress.
MEMBER BENEFITS
impact of a single-payer system. The resurgence
of interest in single payer speaks to the disappointment with Obamacare, difficulties in transitioning from fee-for-service to “value-based”
payment, rising physician burnout, among other
trends.
Gun Violence and Public Health Research
In line with CMS policy, the AMA called gun
violence in the United States “a public health
crisis” that requires a comprehensive public health
response and solution. Also in line with CMS, the
AMA voted to support congressional passage of
legislation requiring criminal background checks
for all gun sales, public and private.
The decisions come after CMS leaders Kathy
M. Tynus, MD, and Adrienne L. Fregia, MD,
authored measures to fund research into gun
violence and expand criminal background checks.
CMS believes an epidemiological approach and
analysis of problems associated with gun violence
is the first step toward addressing the crisis.
Early this year, CMS voted to join major
national medical societies in seeking increased
public and private funding for the development,
evaluation, and implementation of evidence-based
programs and policies.
Pain as the Fifth Vital Sign
An Illinois resolution made the case that treating
pain as the “fifth vital sign” has not improved
treatment outcomes and has contributed to
prescription drug abuse. The resolution sought
the elimination of pain as the fifth vital sign from
professional standards and usage.
The AMA now will work with the Joint
Commission to promote evidence-based, functional and effective pain assessment and treatment measures; support timely and appropriate
access to non-opioid and non-pharmacologic pain
treatments, including removing barriers to such
treatments when they inhibit a patient’s access to
care; and urge the removal of the pain management component of patient satisfaction surveys
as it pertains to payment and quality metrics.
Problematic pain survey questions was one of
many issues CMS raised in meetings with Senator
Richard Durbin. President Kathy M. Tynus, MD,
continues to work with Durbin’s office on comprehensive solutions to the opioid epidemic. CMS
supports education, policy change, and payment
reform.
Dry Needling Is an Invasive Procedure
New AMA policy championed by CMS recognizes
dry needling as an invasive procedure that should
only be performed by practitioners with standard
training and familiarity with routine use of needles
in their practice, such as licensed medical physicians and licensed acupuncturists.
A CMS measure originally from David W.
Miller, MD, pointed out that physical therapists
are increasingly incorporating dry needling into
their practice. Yet physical therapists are using
this invasive procedure with as little as 12 hours
of training, while the minimum industry standard
for physicians to practice acupuncture is 300 hours
of training. Dry needling is indistinguishable from
acupuncture, and is actually considered a Western
style acupuncture or Trigger Point acupuncture.
Medical risks include hematoma, pneumothorax,
nerve injury, vascular injury and infection.
Transparency in TV Ads of Unregulated
Medications and Medical Devices
A resolution originally from CMS member B.H.
Gerald Rogers, MD, will refine existing AMA
efforts to increase transparency in the advertisement of unregulated medications and medical
devices on TV. To help laypeople determine
whether advertised products are proven to be safe
or effective, new policy says that product labeling
of dietary supplements and herbal remedies that
bear structure/function claims should include
disclaimer language that does not make prohibited
disease claims. Additionally, AMA will support the
FDA’s regulation and enforcement of labeling violations and the FTC’s regulation and enforcement
of advertisement violations of prohibited disease
claims made on dietary supplements and herbal
remedies.
Preventing Hearing Loss in Children Caused
by Noisy Toys
A CMS initiative, originally from Ajay Chauhan,
DO, sets new safety standards for children’s
toys that produce dangerously high levels of
sound. Parents need to know that talking dolls
and musical instruments can seriously impair
hearing. Under new AMA policy, first adopted
by CMS, children should avoid toys that produce
more than 85 dB of SPL, or greater than 90 dB
SPL, for longer than one hour. As per the CMS
resolution, AMA will work with stakeholders
to encourage toy manufacturers to adhere to
these pediatric noise exposure standards. AMA
will also advocate for the labeling of toys with
the sound level produced and, when needed, a
warning label that sound production exceeds
safety standards (85 dB of SPL) and may result
in long-term hearing loss.
Primary Care Interventions to Support
Breastfeeding
Formerly titled “Baby-Friendly Health Care
Delivery and Breastfeeding Rights,” this measure
came from medical student James Curry. It
resulted in new AMA policy that supports the
evaluation and grading of primary care interventions to support breastfeeding as developed by
the United States Preventive Services Task Force
(USPSTF).
July 2016 | www.cmsdocs.org | 27
MEMBER BENEFITS
MCC Exhibits Thrive
Highlights from a dynamic educational clinical conference By Elizabeth Sidney
T
“As a bedside
exam tool,
point-of-care
tool or focused
care tool,
ultrasound is
often called the
stethoscope
of the 21st
century.”
H E C H I C AG O Medical Society’s
Midwest Clinical Conference (MCC),
which was held May 20-21 at the Westin
Hotel River North, featured not only
sessions and workshops led by medical
experts but also exhibits that impressed attendees.
Among the exhibitors were companies that offered
a wearable bionic suit for rehabilitation, new ultrasound technologies and help with transitional care
navigation. Here are highlights.
A Wearable Bionic Suit for Rehab
Visitors to the MCC got a close look at advanced
exoskeleton technology that brings robots into
rehabilitation—and even saw live demonstrations.
Physicians in all specialties, whether attending
primary care updates, or learning about advanced
care for neurological disorders, watched as a volunteer with paraplegia used a high-tech device from
Ekso Bionics called the Ekso GT to take weightbearing steps around the exhibitor booth. The Ekso
GT is strapped on to a patient’s upper and lower
extremities to form a full-body walking suit. It
is designed to speed the recovery of people with
stroke and severe spinal cord injuries, the device
helps patients to regain mobility and function.
Use of the Ekso GT is strictly for rehabilitation
purposes.
Achieving a milestone of sorts, the Federal Drug
Administration (FDA) on April 4, 2016, granted
clearance to the Ekso GT for the treatment of stroke
patients. Ekso Bionics reports that their device is
the first and only exoskeleton product to receive
FDA approval. The Ekso GT was cleared for use in
assisting victims of hemiplegia (a paralysis on one
side of the body resulting from stroke), as well as for
people sustaining a range of spinal cord injuries.
FDA approval paves the way for the Ekso GT
to become the standard of care in rehabilitation
clinics, according to the company. Until recently, its
use has been limited to hospitals. Ekso Bionics first
introduced its exoskeleton in 2012, partnering with
the Rehabilitation Institute of Chicago (RIC). RIC
also received the first Ekso GT exoskeleton. Several
conference sessions were led by faculty from RIC.
Exoskeletons continue to improve with
each generation, according Arun Jayaraman,
PhD, PT, who heads the RIC Max Näder Lab
for Rehabilitation Technologies and Outcomes
Research. Dr. Jayaraman says the Esko GT offers
more benefit than traditional therapy because of its
ability to mobilize patients early in their recovery,
frequently, and with a significant number of highintensity steps.
His colleague, William Zev Rymer, MD, PhD,
who is the director of research planning and
28 | Chicago Medicine | July 2016
sensory motor performance at RIC, believes there
is clinical value in bringing the technology to a
broader patient population. Ekoskeleton technology
can augment a specific joint or provide full-fledged
mobility to people who can’t walk or need to learn
how to walk again.
Physicians on break between sessions reported
being startled to see a live demonstration in the
exhibit area. “It was truly amazing,” said Anne
Szpindor, MD, a conference attendee. Adds
Clarence W. Brown, MD, “This is marvelous. I
was shocked when I saw the gentleman in the
wheelchair actually enter this apparatus and begin
to be able to walk around.” The Ekso GT is paired with Variable Assist
software so that patients can control the amount
of power to either side of the body. Individuals can
stand up and walk over ground with a full-weight
bearing, reciprocal gait. The Ekso unit is approved
for use in the treatment of people with hemiplegia
as a result of stroke; for spinal cord injuries at
levels T4 to L5; and for spinal cord injuries at levels
T3 to C7 (ASIA D). The company reports that the
technology has been used in 115 rehabilitation
institutions around the world.
Making Waves with Ultrasound
The past two decades have seen huge growth in
the use of ultrasound as a diagnostic tool in the
specialties. Traditionally used in radiology, ob-gyn,
and cardiology, the technology has moved into
clinical practice, and is now common in primary
care, anesthesiology, pain medicine, and emergency
medicine.
Highlighting these advances, two local physicians gave demonstrations of GE Healthcare
ultrasound products. Carlos Fernandez, MD,
director of gynecological ultrasound at Advocate
Illinois Masonic Medical Center, and Michael
Woo, MD, assistant professor of emergency
medicine at the University of Chicago Medicine,
showed how ultrasound is being used in their
respective specialties.
As a bedside exam tool, point-of-care tool or
focused care tool, ultrasound is often called the
stethoscope of the 21st century. The technology
allows physicians to visualize structures and
archive them as part of the patient’s medical
record. Point-of-care ultrasound provides rapid and
accurate diagnosis at lower cost and also improves
clinical management and procedural performance.
The technology can decrease the length of a hospital stay when used appropriately in the emergency
department setting. It also facilitates radiation-free
needle placement procedures.
Portable and hand-held ultrasound machines can
MEMBER BENEFITS
range from small pocket-sized scanners to a large
movable machine with many features. Cart-based
units have advanced features, such as 3-D and 4-D
ultrasound, and the ability to fuse images from
other modalities, such as MRIs. Emergency physicians like Dr. Woo use critical
care ultrasound to better triage and diagnose
patients at the point of care. A study in the New
England Journal of Medicine reported that emergency physicians increasingly use the technology
for less complex abdominal and retroperitoneal
studies.
Older clinicians who completed their training
long before ultrasound was standard practice for
their specialty. Before ultrasound, imaging was
done by an outside consultant. Now, ultrasound is
part of the medical school curriculum, allowing
anatomy students to see how everything in the
body interrelates in multi-dimensions. Ultrasound
is now threaded through the curriculum, with each
rotation incorporating ultrasound.
Ultrasound imaging uses high-frequency sound
waves to view inside the body. Because images are
captured in real-time, they can also show movement of the body’s internal organs as well as blood
flowing through the blood vessels.
The image is produced based on the reflection of
sound waves off the body structures. The strength
(amplitude) of the sound signal and the time it takes
for the wave to travel through the body provide the
information necessary to produce an image.
Transitional Care Navigation Now that Medicare pays physicians for postdischarge transitional care and for actively
managing the care of patients with chronic
conditions, more practitioners may want to tap
into this reimbursement stream. Providers have
several options, according MCC exhibitor NavCare.
Physicians can launch a chronic care management
program within their practice and hire additional
nurses and administrators who are trained to use
special software. Or, providers can contract with
an outside case management company to deliver
patient services.
NavCare representatives were on hand to
describe how their company provides outside case
management services to patients as an extension
of their physicians’ practices. NavCare is a U.S.
CareNet Company that for over 30 years has
provided seamless care transition from acute- to
post-acute care settings.
Chronic care management pays for itself in
reduced emergency room visits, reduced complications and reduced re-hospitalizations. In an effort to
improve quality and lower costs, Medicare began in
2013 to pay physicians and other qualified professionals for post-discharge transitional care management
services under CPT codes 99495 and 99496.
Beginning in 2015, physicians who actively manage
care delivery for Medicare patients with two or more
chronic conditions became eligible for reimbursement
under CPT code 99490.
According to the Medicare website, a billing
physician (or other practitioner) may arrange for
clinical staff external to the practice to provide
case management services if all the “incident to”
and other rules for billing for chronic care management are met. The billing physician must initiate
care during a “comprehensive” E&M visit, annual
wellness visit, or preventive physical exam.
This face-to-face visit is not part of the chronic
care management service and can be billed
separately, but is required before chronic care
management services can be provided directly. The
billing practitioner also must discuss chronic care
management with the patient at this visit. This
comprehensive face-to-face visit, which is part of
transitional care management, is reimbursed under
CPT 99495 and 99496.
At the Midwest Clincial
Conference, attendees
were treated to a
live demonstration
of a volunteer with
paraplegia using a
high-tech device from
Ekso Bionics called
the Ekso GT to take
weight-bearing steps
around the exhibitor
booth.
July 2016 | www.cmsdocs.org | 29
MEMBER BENEFITS
Calendar of Events
JULY
20 CMS Executive Committee Meets
once a month to plan Council meeting
agendas; conduct business between
quarterly Council meetings; and coordinate Council and Board functions.
8:00-9:00 a.m. Location: CMS Building,
33 W. Grand Ave., Chicago. For information, contact Ruby 312-670-2550, ext.
344; or [email protected].
20 CMS Public Health Committee
Open to all members, this committee
studies and responds to local public health
concerns, developing policy and working
with outside public health agencies. 6:007:00 p.m. In-person & teleconference. For
information, contact Rachel 312-670-2550,
ext. 338, or [email protected].
AUGUST
17 CMS Executive Committee Meets
once a month to plan Council meeting
agendas; conduct business between quarterly Council meetings; and coordinate
Council and Board functions. 8:00-9:00
a.m. Location: CMS Building, 33 W. Grand
Ave., Chicago. For information, contact
Ruby 312-670-2550, ext. 344; or rbahena@
cmsdocs.org.
17 CMS Board of Trustees Meets every
other month to make financial decisions
on behalf of the Society. 9:00-10:00 p.m.
Location: CMS Building, 33 W. Grand
Ave., Chicago. For information, contact
Ruby 312-670-2550, ext. 344; or rbahena@
cmsdocs.org.
20 CMS Leadership Meeting
9:00 a.m.-12:00 noon. Location TBA. For
information, contact Ruby 312-670-2550,
ext. 344; or [email protected].
22 Resolutions Reference Committee
(Tentative) Open to all members, this committee shapes CMS, ISMS, and AMA policy
by studying member resolutions, hearing
testimony, and making recommendations to
the Council. 7:00-8:30 p.m. Location: CMS
Building, 33 W. Grand Ave., Chicago. For
information, contact Rachel 312-670-2550,
ext. 338, or [email protected].
27 Illinois State Neurosurgical Society
Downstate Meeting in Springfield.
30 | Chicago Medicine | July 2016
For information, please go to: www.ilneuro.
org.
SEPTEMBER
6 CMS Governing Council The Society’s
governing body meets four times a year to
conduct business on behalf of the Society.
The policymaking Council considers all
matters brought by officers, trustees,
committees, councilors, or other CMS
members. 6:00-9:00 p.m., Maggiano’s
Banquets Chicago, 111 W. Grand Ave. To
RSVP, please contact Ruby 312-670-2550,
ext. 344; or [email protected].
10 Philippine Medical Association in
Chicago 56th Anniversary Inaugural Ball
and Induction Dinner Dance 6:00 p.m.;
Hyatt Regency O’Hare; 9300 W. Bryn
Mawr Ave., Rosemont, Ill. For information,
call 847-780-7617.
14 Chicago Gynecological Society
Annual Dinner The CGS will hold its
first meeting of the program year at
the International Museum of Surgical
Sciences. Join your colleagues for an
enlightening talk on what health professionals can do in response to human trafficking. 6:00 p.m. Space is limited. RSVPs
open in July. For information, please go to:
www.chicagogyn.org. 14 OSHA Training Workshop:
Bloodborne Pathogens & Beyond
Intended for physicians, nurses, dentists,
dental hygienists, and physician/dental
assistants. OSHA requires all healthcare
employers to maintain a written Exposure
Control Plan. This plan must include a
risk analysis, Hepatitis B vaccinations,
follow-up procedures, and an evaluation
of safer sharps and training. Participants
will learn how to identify appropriate
personal protective equipment (PPE),
implement a training program for employees who may be exposed to bloodborne
pathogens, identify frequently violated
OSHA regulations in the medical field,
create a written Exposure Control Plan
for the assigned first-aid responders, and
understand and explain the latest hazard
communication requirements. Speaker:
Sukhvir Kaur, Compliance Assistance
Specialist, OSHA Chicago North Office.
Registration: 9:30 a.m.; lecture: 10:00 a.m.
– 12:00 p.m. Hilton Oak Lawn Hotel, 9333
S. Cicero Ave., Oak Lawn. Up to 2.0 CME
credits. $99 per person for CMS members;
$109 for CDS members; $129 for nonmembers or staff. Register online at: www.
cmsdocs.org or contact Rachel at rburns@
cmsdocs.org or call 312-670-2550, ext. 338.
21 CMS Executive Committee Meets
once a month to plan Council meeting
agendas; conduct business between quarterly Council meetings; and coordinate
Council and Board functions. 8:00-9:00
a.m. Location: CMS Building, 33 W. Grand
Ave., Chicago. For information, contact
Ruby 312-670-2550, ext. 344; or rbahena@
cmsdocs.org.
21 CMS Public Health Committee Open
to all members, this committee studies
and responds to local public health
concerns, developing policy and working
with outside public health organizations
and agencies. 6:00-7:00 p.m. In-person and
teleconference. For information, contact
Rachel 312-670-2550, ext. 338, or rburns@
cmsdocs.org.
OCTOBER
12 OSHA Training Workshop:
Bloodborne Pathogens & Beyond See
the event on September 14 for a description. Registration: 9:30 a.m.; lecture: 10:00
a.m. – 12:00 p.m. Chicago Medical Society,
33 W. Grand Ave., Chicago, IL. Up to 2.0
CME credits. $99 per person for CMS
members; $109 for CDS members; $129 for
non-members or staff. Register online at:
www.cmsdocs.org or contact Rachel Burns
at [email protected] or call 312-6702550, ext. 338.
15 Indian American Medical Association
of Illinois Annual Gala & Banquet Dinner.
Begins at 6:00 p.m.; Rolling Meadows
Country Club, 2950 W. Golf Rd., Rolling
Meadows. For information, please call 630522-3990 or go to www.iamaill.org.
19 CMS Executive Committee Meets
once a month to plan Council meeting
agendas; conduct business between quarterly Council meetings; and coordinate
Council and Board functions. 8:00-9:00
a.m. Location: CMS Building, 33 W. Grand
Ave., Chicago. For information, contact
Ruby 312-670-2550, ext. 344; or rbahena@
cmsdocs.org.
Personnel Wanted
classifieds
Board-certified or board-eligible anesthesiology, urology,
gynecology, gastroenterology, ophthalmology, family medicine,
pain management, ENT, urogynecology, plastic surgery,
orthopedics, ENT & general surgery for multi-specialty surgical
out-patient centers located in northwest and west suburban
Chicagoland. Active part-time physicians wanted. Please send
resumes by fax to 847-398-4585 or to [email protected]
and [email protected].
Office/Building for Sale/Rent/Lease
Active solo family medicine practice located 90 miles southwest
of Chicago available. Please call 815-672-2417.
Class A medical office space available; 3,046 sq. ft. Rare, move-in
ready space with six exam rooms and two surgery rooms.
Potentially divisible. Excellent visibility and modern finishes. For
more information, please contact Joe Gatto at 847-518-3285.
Advertiser Index
For sale: medical office at 6151 W. Belmont Ave., Chicago; five
exam rooms and two administrative rooms on ground floor;
three rental apartments, garage in back. Doctor retiring.
$339,000. Call Janina 773-909-0890.
Business Services
Prompt Medical Billing. Expert revenue management service.
Electronic claim submission, ICD-10 ready. Professional staff, no
set-up fees. Reduce expenses and maximize profits! Affordable
rates—try us free for one month! Call 847-229-1557, or visit us
online: www.promptmedicalbilling.com.
Physicians’ Attorney—experienced and affordable physicians’
legal services including practice purchases; sales and formations;
partnership and associate contracts; collections; licensing
problems; credentialing; estate planning; and real estate. Initial
consultation without charge. Representing practitioners since
1980. Steven H. Jesser 847-424-0200; 800-424-0060; or 847212-5620 (mobile); 2700 Patriot Blvd., Suite 250, Glenview, IL
60026-8021; [email protected]; www.sjesser.com.
Welcome, New Members!
American Bar Association . . . . . . . . . . . . . . . . . . . . . 25
The Chicago Medical Society greets its
newest members. We are now
13 voices stronger!
Chicago Medical Society CME . . . . . . . . . . . . . . . . . . . 21
Lara T. Dakhoul, MD
Resident District
Zubair Ilyas, MD
Fahad Jamil, MD
CMS Insurance Agency . . . . . . . . . . . . . . . . Back Cover
Ghulam Muklaza, MD
Samantha J. Tan, MD
Mohammad Z. Taugir, MD
Jalal F. Vargha, DO
DocbookMD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Jennifer R. Velasco, DO
Daniel Wozniczka, MD
Student District
ISMIE . . . . . . . . . . . . . . . . . . . . . . . Inside Front Cover, 3
David Nai
District 2
Takijah T Heard, MD
ProAssurance . . . . . . . . . . . . . . . . . . Inside Back Cover
District 3
David K. Edelberg, MD
United States Army . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
District 8
David S. Chiang, MD
July 2016 | www.cmsdocs.org | 31
WHO’S WHO
Eclectic Background Pays Off
Physician-attorney leads IPDH By Scott Warner
“I was the
guy who was
interested
not in having
one patient in
front of me,
but in helping
thousands of
patients who
never got a
chance.”
S
O M E P E O P L E think I have been
confused, or that a lot of things I’ve done
have been unconnected,” says Nirav
Shah, MD, JD. But despite his causing
raised eyebrows among his friends, family and peers, Dr. Shah has pursued a “non-linear
career trajectory” that has brought him to direct
the complex Illinois Department of Public Health
(IDPH), overseeing 2,000 employees.
A native Chicagoan, Dr. Shah has served as
IDPH director since January 2015. That’s when a
search team from Governor Bruce Rauner’s office
wooed this multi-faceted physician from the law
firm of Sidley Austin, where he had worked on the
legal and administrative aspects of public health.
Dr. Shah earned both his medical and law degrees
from the University of Chicago and was yearning
to work more in public service, when the governor
made him the offer that he couldn’t refuse. Dr.
Shah also wanted to put into practice much of what
he had learned when he worked in Phnom Penh,
Cambodia, as both epidemiologist and chief economist for the Cambodian Ministry of Health. In that
role, he focused on gathering data and applying it
to public health policy to manage disease outbreaks
across the country. And he was deeply touched by
the Cambodian people who had suffered under a
30-year civil war.
With such formidable experience, Dr. Shah finds
his role as IDPH director his most stimulating to
date, requiring “40 to 50 skill sets” to serve the
people of Illinois. “I don’t have every skill set,”
he said, “and it’s not clear that any one person
has all the skill sets needed for this job.” What
he prides himself on is being “the glue that holds
the team together,” and in hiring people “who are
strong in areas where I’m weak.” He praises “the
IDPH’s world-class experts” who work in such
areas as mosquito control, women’s health, and
epidemiology, to name a few. “We are all keen on
the IDPH’s mission, which is to promote the health
of the people of Illinois through the prevention and
control of disease and injury.”
Dr. Shah says he wanted to go into medicine
simply to help people in need. But soon after
entering medical school, he realized, ”I was the
guy who was interested not in having one patient
Dr. Nirav Shah, director of the Illinois Department
of Public Health, is bringing his experience as
physician, attorney, and epidemiologist (for the
Cambodian Ministry of Health) to his work here.
“My goal is to improve and protect the health of
all our citizens,” he says.
in front of me, but in helping thousands of patients
who never got a chance.” He shifted from clinical
medicine to population health. But he also yearned
to help people through the legal system, and once
he received his medical degree, he enrolled in law
school, earned his JD degree, and went to work in
health law.
“I think of my career as a clock face. I’ve swept
a lot of my clock, getting more and more experience.” He’s now putting that experience to good
use. As IDPH director, he says, “Ninety percent
of my job involves public policy, analytics and
economics.”
Dr. Shah is also involved with food. An avid
home cook with his wife, Kara Palamountain,
MBA, Dr. Shah is developing a program at IDPH to
provide cooking programs for the public. ”People
have poor diets, not entirely because of food
deserts, but because they simply don’t know how to
prepare food at home—and that would be so much
healthier than eating fast food and junk food.”
Career Highlights
N I R AV S H A H , M D , J D , is currently a global public health lecturer at the University of Chicago Pritzker School of
Medicine. He teaches courses on public health policy and epidemiology. Dr. Shah also sits on the board of the Women’s
Global Education project. He was recently recognized as an “Emerging Leader” by the Chicago Council on Global Affairs.
32 | Chicago Medicine | July 2016
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