March 2016 | www.cmsdocs.org
THE
HMO
COMEBACK
As Costs Rise,
Networks Narrow
on the Exchange
Success Factors
for Physician
Leaders
2016 Hot
Compliance Areas
Zika Pandemic
Update
Pu b
of th lication
Medi e Chicag
cal S
o
ociet
y
TH E
M
SOC EDICAL
COO IET Y OF
K CO
U NT Y
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Volume 119 Issue 3 March 2016
16
FEATURES
16 The HMO Comeback
PRESIDENT’S MESSAGE
2 The Times, They Are a-Changin’!
By Kathy M. Tynus, MD
MEMBER BENEFITS
24 Working for You: 2016
Legislative Agenda
Physicians and other providers of
medical care are bracing for the return
of restrictive health insurance plans led
by health maintenance organizations.
By Bruce Japsen
OPINION
20 Success Factors for Physician
Leaders
By Anna Zelivianskaia
30 Calendar of Events
PRACTICE MANAGEMENT
31 Classifieds
Succeeding in today’s practice
environment calls for new knowledge,
skills and strategy.
By Susan F. Reynolds, MD, PhD
3 Employed Physicians’ Bill of
Rights
By Jerrold B. Leikin, MD
4 Physician Wellness Heals Patients
6 2016 Hot Compliance Areas;
Dealing with Disruptive Behavior;
New Transport Options for Patients;
Honoring a Patient’s Advance
Directives
PUBLIC HEALTH
10 An Update on the Zika Pandemic;
Snuffing Out Smoking; The Opioid
Controversy; Dry Needling Expands
PTs Scope of Practice; Curbing
Firearm Violence
28 Midwest Clinical Conference:
Thrive in a Dynamic Health Care
Environment
29 New Members
WHO’S WHO
32 Medical Examiner Scores High
Under the direction of Stephen
Cina, MD, the Cook County Medical
Examiner’s Office investigates more
than 5,000 cases yearly, performing
nearly 3,000 autopsies in 2015. Dr. Cina
personally does about 150 autopsies,
and says the most emotionally difficult
ones for him are those involving rape or
child abuse.
March 2016 | www.cmsdocs.org | 1
MESSAGE FROM THE PRESIDENT
The Times, They Are
a-Changin’!
A
S YO U M AY be aware, there was a major
change in the health insurance market recently,
when Blue Cross Blue Shield of Illinois (BCBSIL) announced the withdrawal of its broad network PPO from the Obamacare exchange for the
individual market. With some referral exceptions, the remaining PPO excluded coverage at Rush, Northwestern, Lurie Children’s and University of Chicago hospitals. The broad PPO was
unsustainable in this market, due in part to the risk corridor
adjustment payments promised in the Affordable Care Act that
Congress removed in the 2014 Omnibus Budget Act. We learned
this after meeting with Dr. Steve Ondra, chief medical officer of Healthcare Services Corp.,
the operating company of BCBSIL. To find out more about what’s happening to patients in Illinois, we met with Dr.
Opella Ernest, the CMO of BCBSIL. We learned about their efforts to identify and
provide transition of care services to vulnerable patients affected by this change. They
worked very closely with the staff at all these academic tertiary centers, identifying
patients within five high-risk categories: transplant patients, cancer patients undergoing
chemotherapy and/or radiation, hemodialysis recipients, third trimester and high-risk
obstetric patients, and hospice patients. Their case managers reached out to these
patients first by letter, then by phone, offering them waivers that would allow them
to continue care at these institutions for no additional cost (in comparison to using a
different network or having a different set of benefits). The initial deadline of January
31 was extended another two weeks to allow as many patients as possible to respond. At
this point, any additional patients wishing to continue care at these tertiary hospitals
can still apply through their standard appeals process. This answered many of our
questions and was reassuring that Blue Cross was doing the right thing to take care of
these patients. What became clear in our meeting was the existing disconnect between what the
insurance company was doing and the knowledge of these activities within the medical
community. While leaders within these hospitals know what efforts are being made
to take care of affected patients, this is not common knowledge among the rest of us.
There is a need for more and better communication—for doctors and insurance companies to work together to care for patients in an uncertain and changing environment. The leadership at BCBSIL expressed a desire to close this communication gap, and
we developed several ideas to accomplish this. First, they will conduct semiannual
meetings with leaders of all the major specialty organizations in the Chicago area,
to inform doctors of upcoming changes in insurance products. As we draw closer to
enacting MACRA and its alternative payment models in 2019, this information will be
crucial to physicians and patients alike. Second, Dr. Ernest would like to address our
membership in person, allowing us to connect a face with a name, and opening the door
for further communication. Third, BCBSIL leadership promised to inform us as soon
as possible in advance of any major network changes in the future. This would allow
us the opportunity to help them anticipate unforeseen consequences, spread the word
within the medical community, and allow us to gather feedback for them. Imagine
an insurance company and organized medicine coming together for the good of our
patients. Revolutionary times, indeed!
Kathy M. Tynus, MD
President, Chicago Medical Society
2 | Chicago Medicine | March 2016
EDITORIAL & ART
E XECUTIVE DIREC TOR
Theodore D. Kanellakes
ART DIREC TO R
Thomas Miller | @thruform
CO - EDITOR /EDITORIAL
Elizabeth C. Sidney
CO - EDITOR /PRODUC TION
Scott Warner
E D I T O R I A L C O N S U LTA N T
Cheryl England
CONTRIB UTORS
Clay J. Countryman, Esq.; Bruce
Japsen; Jerrold B. Leikin, MD; Susan
F. Reynolds, MD, PhD; Kathy M. Tynus,
MD; Jim Watson; Kimberly Young;
Anna Zelivianskaia
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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
312-670-2550
www.cmsdocs.org
Chicago Medicine (ISSN 0009 -3637 is
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Copyright 2016, Chicago Medicine. All rights
reserved.
S O U N D I N G O F F | OP I N ION
Employed Physicians’ Bill of Rights
Physician employees and executives should follow basic principles By Jerrold B. Leikin, MD
O
V E R T H E PA S T several years,
we have witnessed a gradual evolution of the physician’s scope of
practice. Physicians have been transformed from decision-makers to salaried technicians with a job description that includes
data entry, coding/billing, transcribing, medical
guideline implementation, and patient care coordination with the overall goal of revenue enhancement.
In short, physicians have become mid-level employees (revenue generators) under the direction of corporate executives (expense and revenue managers).
This evolving relationship is modeled on the hotel/
hospitality management industry from which the
fundamental principles of hospital administration
originate (short-term occupancy rates, centralized
decision-making, customer relations, and structured
pricing system). With over a 3000% rise in the number
of hospital executives since 1970, corresponding to a
2300% increase in health care spending per capita (as
opposed to doubling of the physician workforce over
this period), perhaps this shift was inevitable.
Further, with ongoing consolidation in health care,
which already has led to a majority of physicians
becoming employees, practice management uncertainty and disputes are likely to grow while physician
career options narrow. As a result, individual
contract negotiations have become quite one-sided
and problematic. The framework of community-level
patient care integration requires a degree of physician independence not usually encountered in the
traditional employer-employee relationship.
It is clear that if an employed physician must
adapt to the corporate mentality, then the corporate
mentality must have to adapt to a career physician’s
scope of work. Towards this end, the relationship
of the executive to the employed physician clinician would benefit from specific fundamental
guidelines. The adoption of basic principles form a
basis of mutual professional respect and continued
quality of patient care. These principles can serve
as a “Bill of Rights” for employed physicians.
Rights and Responsibilities
• Physicians’ compensation should be based on
the totality of their activities for the organization. This should include educational endeavors
(including preparation), committee participation,
student/resident activities, and administrative
responsibilities. Physician compensation should
not be tied directly to outcomes of strategic
revenue initiatives by the corporation.
• Physicians should have academic freedom, an
essential foundation for clinical research. There
must be no censorship by any organization.
• Physicians should not be solely responsible for
•
•
•
•
•
•
•
data entry and management (including coding)
within complex EMR systems. If the term “user
error” is constantly used, it is an organizational
issue, not a medical issue.
Evaluation of clinical activity requires the peer
review process and should be judged only by clinicians, not corporate executives. Only clinicians
in a peer-review context can judge a colleague’s
decision-making and documentation approach.
Physician activities performed outside of defined
employment boundaries are the sole prerogative
of the individual physician and are not to be
interfered with unless they directly conflict with
or increase the risk of the organization.
Physician conflict of interest disclosures should
be limited to physician activities that directly
affect the organization and should be disclosed
only to entities that directly reimburse physicians during their time of employment.
Restrictive covenants should be limited to only physicians with partnership stakes in the organization
and should not apply to salary-based physicians.
Resources should be appropriately allocated by
the organization for CME, as defined by state
licensure guidelines.
Employed physicians have the right to collective
bargaining as outlined in the National Labor Relations Act of 1935 (also known as the Wagner Act).
Acknowledgement that the patient-physician
relationship is a sacred trust that cannot be quantified through nebulous metrics such as time, relative value units and simple quality measures. It
is the physician who takes the Hippocratic Oath,
and no employment scenario should conflict with
that oath. The AMA’s Fundamental Elements of
the Patient Physician Relationship should guide
all organizations.
“The patientphysician
relationship is
a sacred trust
that cannot
be quantified
through nebulous metrics
such as time,
relative value
units and
simple quality
measures.”
Good Medicine is Good Business
An environment of mutual respect must exist
among all physicians and executives. Currently,
the physician as employee model contradicts the
accepted doctrine in the business setting: higher
degrees of education are commensurate with
greater responsibilities. Physician employee rights
are limited in an industry when employment decisions are often made for seemingly non-medical
reasons. Local, state, and national medical societies
should take the lead by adopting these principles.
Dr. Leikin is a clinical professor at the University
of Chicago Pritzker School of Medicine. He can be
reached at [email protected]. This opinion piece
is based on a resolution slated for the Illinois State
Medical Society House of Delegates, April 15-17. For
a list of references, contact [email protected].
March 2016 | www.cmsdocs.org | 3
S T U D E N T OP I N ION | S O U N D I N G O F F
Physician Wellness Heals Patients
Studies show mindfulness practice leads to better patient care By Anna Zelivianskaia
I
“Another
component
of physician
well-being
and mental
health—one
that can benefit the greatest number of
physicians—is
mindfulness.”
T I S N OW well known that physicians
and physicians-in-training are at higher risk
for mental health issues and are less likely to
seek help. Among all physicians, men are 1.41
times more likely and women are 2.27 times
more likely to die by suicide compared to their
counterparts in the general population. The statistics on depression are even more drastic. A 2010
prospective cohort study of 740 interns across 13
U.S. hospitals found that the incidence of depression increased from 3.9% at the start of residency to
27.1% after the first three months of the intern year.
While there is little data available on the use of
mental health services by physicians, we know that
only 42% of medical students with suicidal ideation
receive treatment, and 33% of those who do not
seek help cite lack of confidentiality and stigma as
barriers to seeking care.
Fortunately, the last decade has brought greater
recognition and institutional change. Many
hospitals and programs now offer mental health
resources for residents and physicians. This is a
step in the right direction, even though much work
remains to be done in changing the culture or
mindset around seeking help.
Mindfulness is Key to Well-being
Another component of physician well-being and
mental health—one that can benefit the greatest
number of physicians—is “mindfulness.” The state of
mindfulness refers to a person’s tendency to remain
“purposefully and nonjudgmentally attentive to
their own experience, thoughts and feelings.” There
are various methods to increase mindfulness.
New research into mindfulness practice shows a
positive impact on physician well-being and mental
health. For example, several studies have shown
that mindfulness-based stress reduction (MBSR)
reduces psychological distress and improves the
well-being of physicians in training. One recent
investigation found that a program teaching
mindful communication reduces burnout, improves
self-reported well-being, psychosocial orientation,
and empathy among practicing physicians.
In another study, published in 2013 in the
Annals of Family Medicine 45 clinicians participated in a quantitative mindfulness survey. Each
clinician taking the survey received a mindfulness
“score” and were then assessed during 437 patient
visits. The assessments looked at communication
behaviors, such as rapport building questions and
psychosocial discussions. Clinicians with a high
level of mindfulness made significantly more statements about psychosocial issues and rapport building compared to clinicians with low mindfulness
levels. Furthermore, patients of clinicians with
4 | Chicago Medicine | March 2016
high-mindfulness compared to low-mindfulness
had greater odds of reporting high-quality communication and high overall satisfaction with
care. This demonstrates that physician well-being,
particularly in the area of mindfulness and stress
reduction, correlates with patient care.
Many institutions have begun recognizing
the advantages of mindfulness. For example, the
University of Illinois at Chicago offers an elective
mindfulness course, seminars on stress reduction,
and meditation sessions. A wellness committee
plans these and other initiatives. However, many
physicians and residents cannot fit these programs
into their schedules. And not everyone can connect
through meditation or seminars. An important
factor to acknowledge as we encourage physician
well-being is that “mindfulness” and greater balance can be found through a variety of methods.
Hot Yoga and Mindfulness
I improved my own practice of medicine through
hot yoga. While I had been a runner for years and
used exercise as my main outlet for stress reduction, when I started my surgery clerkship, I wanted
a more low-key channel. After entering the heated
studio for the first time, I quickly forgot the frustrations of the day as I struggled to breathe. I kept
coming back because I enjoyed the external trigger
of heat for release of my emotions and anxiety.
During this adjustment period, I also began
to reflect on the quotes and poetic expressions
instructors made at the start of class. Soon I was
practicing with phrases—known as setting an
“intention”—by concentrating on words, goals, or
even people, while gliding through the poses.
As my ability to focus during yoga improved,
I was also able to better concentrate on patient
stories in the hospital. I began to feel less overwhelmed by the countless tasks to be performed
daily, because of my ability to focus on the task at
hand and be more present in each moment. This
led me to become more grateful—for what I could
accomplish, for being allowed to help patients each
day, and for taking time to reflect regularly.
Terms like “mindfulness,” or “well-being,” and
“balance” are vague. We can clarify them for ourselves. Likewise, there are many paths to achieving
mindfulness. As we continue to expand physician
wellness initiatives, we must relish their contributions to patient care and be patient with ourselves
as we seek the moving target of a balanced life.
Anna Zelivianskaia is fourth-year medical student
at the University of Illinois at Chicago. She can be
reached at [email protected]. For a list of references,
please contact [email protected].
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PRACTICE MANAGEMENT
2016 Hot Compliance Areas
Recent reports detail priorities By Clay J. Countryman, Esq.
P
H YS I C I A N S should pay attention to
recent reports released by the Department of Justice (DOJ), Office of Inspector General (OIG), and other agencies
concerning enforcement actions in 2015
and priorities in 2016. These reports and recent
settlements reveal compliance areas that physician
practices should focus on in 2016. The recent DOJ
Health Care Fraud and Abuse Control Program
Annual Report for 2015 concerns settlements and
other actions involving physicians. Here is a recap.
Insufficient Documentation
The last couple of years has seen an increase
in civil False Claims Act cases and settlements
involving allegations of physicians’ upcoding E&M
services, or of providing medically unnecessary
services. A surprising trend is of physicians not
completing and closing their EMR of services to
a patient before their practice submits a claim to
Medicare and other payers. Sometimes, physicians
may take several weeks or months before completing the EMR for services they have been paid
for. This scenario, which is based on insufficient
documentation, raises several potential regulatory
issues under the civil FCA and other civil fraud
and abuse laws, possibly for both physicians and
their practices.
“A surprising
trend is of
physicians not
completing
and closing
their EMR of
services to a
patient before
their practice
submits a claim
Enforcement Actions
to Medicare
In 2015, the DOJ announced that one of its prioriand other
ties is the enfo rcement of federal fraud and abuse
payers.”
laws against individuals, and not just corporate
entities. In September 2015, the DOJ released
the “Yates memo” outlining the importance of
individual accountability in DOJ prosecutions. For
many physicians, the Yates memo is thought to
indicate an increased focus on physicians and other
health care providers in matters involving payment
of illegal remuneration, violations of the AntiKickback Statute and the Stark Law. An example
in 2015 was a settlement in which the Columbus
Regional Healthcare System and a physician both
agreed to pay more than $25 million to settle allegations of civil FCA violations related to the Stark
Law, and the submission of claims at a higher level
of service than provided. The physician agreed to
pay $425,000 toward this settlement.
To address this hot compliance issue, physicians
should review all of their arrangements that may
be subject to scrutiny under the Anti-Kickback
Statute and Stark Law. Such arrangements include
medical directorships, professional service and
employment agreements, consulting agreements,
office lease agreements with hospitals, and other
compensation agreements.
6 | Chicago Medicine | March 2016
Physician Compensation
The government’s radar remains on physician
compensation arrangements with hospitals, health
systems, and their own practices. In 2015, several
settlements were made based on compensation paid
by hospitals and health systems to employed and
contracted physicians. In those settlements, the
government alleged that compensation exceeded the
fair market value of services in violation of the Stark
Law. The government also alleged in several cases
that Stark Law violations involving physician compensation arrangements were the basis for violations
of the civil FCA when hospitals and health systems
submitted claims to Medicare and Medicaid.
For example, in September 2015, Adventist
Health Care System agreed to pay $115 million
to settle civil FCA allegations involving bonus
payments. These payments were made to employee
physicians based on the number of tests and
procedures they ordered. Adventist billed Medicare
for the employed physicians’ professional services
using improper coding modifiers.
Medical Distributorships
Physician ownership in companies that distribute
implantable medical devices continues to be a
focus of the OIG and other governmental agencies. In September 2015, the U.S. Senate Finance
Committee held a hearing on physician-owned
distributorships (PODs) of medical devices. One
consensus from this Senate hearing seemed to be
that POD arrangements create a financial incentive
for physician-investors to recommend and perform
unnecessary surgeries. The OIG also concluded in a
study that there was limited information to identify
physicians who had an ownership interest in a POD
and in a physician-owned hospital. Physicians who
are involved in a POD can probably bank on having
their ownership interest scrutinized.
Laboratory Arrangements
The OIG released a special fraud alert in 2014
about laboratory payments to referring physicians
and has issued several advisory opinions addressing remuneration offered and paid by laboratories
to referring physicians. For example, in August
2015, three New Jersey physicians pleaded guilty to
charges related to a test-referral kickback scheme
for allegedly entering into sham consulting agreements, sham rental and service agreements, and
cash and other inducements for referring patient
blood specimens to a laboratory.
Clay J. Countryman, Esq., is a partner with
Breazeale, Sachse & Wilson, LLP, in Baton Rouge,
Louisiana. [email protected].
PRACTICE MANAGEMENT
Dealing with Disruptive Behavior
Find and fix the triggers that set off the untoward behavior and then set expectations By
Susan Reynolds, MD, PhD
W
H E N E V E R I ask my health
care audiences if they can
think of anyone with “disruptive behavior,” all of the hands
go up. If I ask them if they
can think of two people, most hands stay up. And
if I ask if they are losing sleep over these people,
again most hands stay up. Disruptive behavior can
be seen in non-physicians as well as physicians,
but my coaching work focuses on difficult physician behaviors, so that will be the focus of this
month’s column.
It appears that disruptive behavior among our
physician colleagues is on the rise. However, it
may be that the 2008 “Zero Tolerance” policy from
The Joint Commission focused more attention on
undesirable behavior and caused more reporting of
what has been a long-standing issue.
Code of Conduct Policies
According to the Joint Commission, disruptive
behavior is behavior that interferes with quality
patient care. Hospitals and medical staffs now
must have Code of Conduct policies that include a
definition of disruptive behavior and a process to
deal with it. These policies often include most, if
not all, of the following in the definition:
• Conduct that interferes with quality patient care
• Sexual harassment.
• Personal attacks on medical staff members or
hospital employees.
• Vulgar, profane, abusive language.
• Physical assault.
• Harsh criticism that belittles, or implies stupidity or incompetence.
• Threats of reprisal for reporting disruptive
behavior.
• Refusal to accept medical staff assignments.
• Inappropriate medical record entries concerning
quality of care.
• Imposing onerous requirements on the nursing
staff.
• Public criticism or defamation.
There are two key strategies I use in dealing
effectively with disruptive behavior. These strategies include: 1) finding and fixing the triggers that
set off the untoward behavior; and 2) teaching
behavior expectations. When asked to coach a
disruptive physician, I always go onsite first to do
a 360-degree assessment of the situation. I look for
triggers that cause the undesirable behavior.
Several excellent anger management programs
are available for physicians around the country, but
if the triggers are not dealt with and fixed while
new behaviors are being learned, the bad behavior
will reappear before long.
Also I often find that the bad behavior has
been tolerated for a very long time, perhaps even
dating back to when the physician was a resident.
It is very important to set expectations for what
is acceptable behavior and what is definitely not.
Many of these physicians know that they are
disruptive, but they have gotten away with it in the
past because no one set limits for them.
Carrots and Sticks as Motivators
After setting a clear expectation, I typically ask for
a 30-day time-out or truce in which the physician
I am coaching refrains from bad behavior. Most
physicians can control themselves for 30 days
while the triggers are being addressed. I also use
“carrots and sticks” as motivators for change:
rewards for good behavior and potential financial
penalties or punitive action if the bad behavior
persists or recurs.
It is important to remember that it takes six
months for a new behavior to become a habit.
Therefore any coaching done in-house or by a
professional coach should be done on a weekly
or bi-weekly basis for the first six to eight weeks,
and then use brief check-ups at three months, six
months, nine months, and even 12 months, to make
sure no back-sliding has occurred. A sample coaching protocol could look like this:
• Six to 12 months of coaching.
• Get buy-in from disruptive physician for the
coaching process—set expectations.
• Weekly or biweekly meetings for first six to
eight weeks.
• Call a truce for 30 days (ask for no flare ups)—
begin to address triggers.
• Quarterly checkups at three, six, nine, and 12
months.
• Some telephone coaching possible in between
in-person coaching.
• If no sustained improvement at six, nine, or 12
month checkup, refer for formal peer review
action.
The goal of coaching disruptive physicians should
always be to rehabilitate them so they become
respected members of the medical staff who demonstrate professional conduct to their colleagues
and co-workers on a sustained basis.
Susan Reynolds, MD, PhD, is President and CEO,
The Institute for Medical Leadership.
March 2016 | www.cmsdocs.org | 7
PRACTICE MANAGEMENT
New Transport Options for Patients
Ride-booking apps increasingly used to get patients to and from health care appointments
By Jim Watson and Kimberly Young
D
U E TO T H E rising cost of health
care and with the majority of payers
moving away from fee-for-service to
pay-for-performance (P4P) contracts,
it is becoming a world of accountable
care organizations (ACOs) and clinical integration
organizations—both of which are at the very heart
of fee-for-value. The guidelines are clear: “Provide
a better quality service at a lower cost.” Physicians
and hospitals must optimize their operations and
align cost with positive clinical outcomes. As such,
it is increasingly important to partner with outside
sources that can help you achieve your goals for
improving quality and cutting cost.
MedStar Health, the largest not-for-profit health
care system in Maryland and the Washington,
DC, area, has partnered with Uber Technologies
Inc., an international transportation network
based in San Francisco. In January 2016, MedStar
Health gave its patients the option of using Uber in
order to travel to their health care appointments.
MedStar had noted that when patients missed
appointments or had to reschedule at the last
minute, they often cited transportation as a factor.
“MedStar Health, the largest not-for-profit health
care system in Maryland and the Washington, DC,
area, has partnered with Uber Technologies Inc.,
an international transportation network based in
San Francisco.”
ACOs and clinical integration organizations are
tasked with getting all their patients evaluated
and treated for everything from a routine checkup
to treatment and cure of a disease. When patients
are seen on a regular basis for preventative care
and follow-up visits, conditions can be caught
early and treated before they become acute and
drive up costs for both patients and the organizations. Uber provides a way for patients without
transportation to get to their physician or hospital
appointment.
Tap the App, Get a Ride
MedStar patients can now select the “Ride with
Uber” button displayed on the MedStar Health
website. Patients not only can request a ride but
they can also find out the cost of the ride and
the approximate wait time for the ride. Although
patients currently have to pay for rides, which
may be cost-prohibitive for some, MedStar will
soon have the technical capability to provide rides
covered by Medicare and Medicaid.
8 | Chicago Medicine | March 2016
Uber is available throughout the MedStar
service area and offers patients another convenient
way to get to and from home or to the office or to
any of the MedStar facilities. “Uber is a reliable
option—day or night—regardless of where you need
to go in the Washington, DC, area,” said Zuhairah
Washington, general manager of Uber’s Metro DC
business. “Our collaboration with MedStar can help
patients better plan their transportation to and
from appointments, and ensure they never miss an
appointment because they don’t have a ride.”
In the Chicago market, many payers already
provide transportation benefits to enrollees, especially in government plans such as Medicaid HMOs
and Medicare Advantage plans. Historically, these
transportation benefits have been in the form of
bus or subway tokens, or contracted taxi services.
Several plans in Chicago have indicated that they
are seeking ways to use Uber as a transportation
benefit. Look for Uber to play a bigger role in that
space in the coming months.
Applying Concepts to Wait Times,
Pricing, Payment
Robert Zisman, vice president of GE Healthcare
Camden Group, recently wrote about the potential
to apply Uber concepts to other parts of health
care. For example, if you take an app like NoWait,
and apply it to health care, consumers could check
online to find out wait times for physician visits,
ancillary services and emergency room visits (a
service that is already happening in many other
formats). Another idea would be to apply Uber’s
pricing concepts to health care by, for example,
creating surge pricing for physician visits or urgent
care facility visits depending upon availability.
And what physician practice wouldn’t appreciate
being paid as quickly and easily as payment made
via the Uber app? Physicians would be paid within
minutes of the patient leaving the office.
Uber is a transformative technology that has
turned the taxi industry upside down, and its
applications are being applied conceptually to
countless other industries, including health care.
However you look at this technology, Uber is
another example of disruptive innovation, which
has a way of transforming industries. And health
care is ripe for innovation.
Jim Watson is a partner with PBC Advisors, LLC, in
Oak Brook. Kimberly Young is a senior health care
consultant with PBC Advisors. The company provides
business and management consulting and accounting
services to physician practices and hospital systems.
Visit their website at www.pbcgroup.com.
Honoring a Patient’s
Advance Directives
In the perioperative period, many hospitals
automatically suspend DNR orders
A S U R G E O N ’ S resuscitating a patient against the person’s
will is like operating without consent, according to a resolution
winning approval from the Chicago Medical Society. The
measure seeks to end a practice nationwide in which a patient
has an existing Do Not Resuscitate (DNR) order, but the operating room automatically suspends those DNR orders during the
perioperative period, thereby undermining patients’ rights and
the ethical principle of autonomy. In 2014, the American College
of Surgeons (ACS) published a statement on the issue stating:
Policies that lead either to the automatic enforcement of all
DNR orders or to disregarding or automatically cancelling
such orders do not sufficiently support a patient’s right to
self-determination. An institutional policy of automatic cancellation of DNR status in cases where a surgical procedure
is to be carried out removes the patient or the patient’s duly
authorized representative from appropriate participation in
decision making.
In 2013 the American Society of Anesthesiologists similarly
published ethical guidelines for the anesthesia care of patients
with DNR orders, echoing the ACS’ statement. One of the guidelines stated that policies that automatically suspend DNR orders
for procedures involving anesthetic care may not sufficiently
address a patient’s rights to self-determination in a responsible
and ethical manner.
With this in mind, anesthesiologist Barbara Jericho, MD,
brought forth a resolution requesting that the Illinois State
Medical Society (ISMS) support and institute guidelines on
the “required reconsideration” of patients’ existing advance
directives in the perioperative period to support the review
of patients’ advance directives prior to the performance of a
procedure or surgery and the administration of anesthesia. The
resolution also requested that ISMS forward the resolution to
the American Medical Association (AMA) House of Delegates
for support and institution of guidelines.
In bringing forth the resolution, Dr. Jericho noted that the
American Society of Anesthesiologists, the American College
of Surgeons, and the Association of Operating Room Nurses
already support “required reconsideration” of patients’ existing
advance directives in the perioperative period. She also noted
that the Joint Commission requires that policies be present
to uphold the decision of patients who refuse resuscitation.
Strengthening her position, Dr. Jericho also noted that the
Patient Self-Determination Act of 1990 requires health care
institutions to provide patients with information about advance
directives and patients’ rights to accept or refuse medical
treatment so that they can make informed decisions about their
health care—decisions that they don’t expect to be overturned by
hospital policies.
In February 2016, the Chicago Medical Society voted to support the policy of “required reconsideration” of patients’ existing
advance directives in the perioperative period.
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March 2016 | www.cmsdocs.org | 9
PUBLIC HEALTH
An Update on the Zika Pandemic
A
“Health authorities advise
pregnant
women to
avoid travel
to areas of
ongoing
transmission,
as opposed to
all countries
that have experienced Zika
outbreaks.”
N I N F L U X of new clinical and epidemiological research has strengthened the association between Zika
infection and fetal malformations and
neurological disorders, the World
Health Organization (WHO) announced. On Feb. 1,
the United Nations health body declared an international public health emergency based on Zika
outbreaks and suspected association between the
virus and microcephaly. The emergency declaration
remains in effect.
At a March 8 conference, Director General Dr.
Margaret Chan said the growing body of evidence
from several countries points to Zika as the likely
cause for an unprecedented number of babies born
with microcephaly and other grave birth abnormalities. But until there is more definitive evidence
to confirm a causative relationship between Zika
virus in-utero exposure during pregnancy and
microcephaly, WHO is making recommendations to
prevent pregnant women from becoming infected.
Precautionary measures are posted on the WHO
website.
Microcephaly: The Latest
The MMWR report for March 11 noted the birth
prevalence of microcephaly in Brazil rose sharply
from 2015-2016. The largest increase occurred in
the Northeast region, where Zika virus transmission was first reported in Brazil. About 4,000 cases
of microcephaly were reported in Brazil between
mid-2015 and January 2016, compared with an
average of 163 cases of microcephaly annually
between 2010-2014, according to JAMA Pediatrics.
An analysis of 574 cases of microcephaly,
detected through a newly established ad hoc surveillance system, identified temporal and geospatial evidence linking the occurrence of febrile rash
illness consistent with Zika virus disease during
the first trimester of pregnancy with the increased
birth prevalence of microcephaly.
As of February 2016, the United States had
reported 52 travel-associated Zika virus disease
cases. Active Zika virus transmission was occurring in 26 countries in the Americas and the
Caribbean, as well as in American Samoa, Samoa
and Tonga in the South Pacific, and Cape Verde
off the west coast of Africa. Brazil was the most
affected country, with estimates between 440,000
and 1.3 million cases of Zika virus disease through
December 2015, according to JAMA Pediatrics.
Local transmission of Zika virus has been
reported in 31 countries and territories in Latin
America and the Caribbean. In this region, where
the rainy seasons last from January to May, cases
of dengue, which is carried by the same mosquito
species as Zika, typically increase. “We can expect
to see more cases and further geographical spread.
10 | Chicago Medicine | March 2016
Imported cases of Zika have been reported from
every region in the world,” Dr. Chan said.
The virus has been detected in amniotic fluid.
Evidence shows it can cross the placental barrier
and infect the fetus. The Zika virus is neurotropic,
preferentially affecting tissues in the brain and
brain stem of the developing fetus.
Experts say they cannot give an exact time
frame for when more definitive answers will be
provided. WHO is working on a collaborative
method, sharing information, but awaits further
scientific data.
Preventive Measures WHO
Health authorities advise pregnant women to avoid
travel to areas of ongoing transmission, as opposed
to all countries that have experienced Zika
outbreaks. Pregnant women whose sexual partners
live in or travel to areas with Zika virus outbreaks
should use safe sex practices or abstain from sex
while pregnant. The Centers for Disease Control
recommends that pregnant women consider not
traveling to the 2016 Summer Olympic Games in
Rio de Janeiro from Aug. 5-21.
Though there is much to learn about the Zika
virus, Dr. Chan notes, one key factor is becoming
clear in Brazil. People who live in underserved
communities experience outbreaks at much higher
rates compared to those who reside in affluent
areas. Residents of poor communities often lack
screens on doors and windows, air conditioning,
and access to insect repellent. These factors, along
with poor sanitation, create perfect conditions for
the virus’ transmission.
All people, and pregnant women in particular,
traveling to high-risk areas, are advised to use
repellent, wear light-colored clothing, with long
sleeves and long pants, and hats. All rooms should
be fitted with screens or mosquito nets.
Each country is responsible for informing the
public about areas actively experiencing outbreaks.
At that point, it is up to pregnant women to make
their own decision.
From the Forest of Uganda
The Zika virus is a flavivirus related to yellow fever,
dengue, West Nile, and Japanese encephalitis. It
originated in the Zika forest in Uganda and was
discovered in a rhesus monkey in 1947, according to
JAMA Network. Outbreaks have occurred in Africa,
Southeast Asia, the Pacific Islands, and the Americas.
Since Brazil reported Zika virus in May
2015, at least 20 countries in the Americas have
reported infections. Zika is likely to spread to the
United States. The Aedes species of mosquito (an
aggressive daytime biter) transmits Zika virus,
and is found worldwide, posing a high risk for
global transmission. PUBLIC HEALTH
Snuffing Out Smoking
City ban hits chaw at sports sites
T
O B ACCO TO O K a hit on March 16
when the Chicago City Council upped
the city’s smoking age to 21, tacked a
$6 million tax on cigars, roll-your own
tobacco and smokeless tobacco, and
placed a ban on “chewing tobacco” at sports stadiums. The sweeping anti-smoking ordinance is key
to Mayor Rahm Emanuel’s agenda to drive the teen
smoking rate down to 10.7%, and achieving what
he calls the “attainable goal” of creating a “tobaccofree generation.” “Chicago has one of the lowest
teen smoking rates—not only in history, but in the
country. This is an important step,” the mayor said.
On March 11, in a prelude to passing the wide
ranging smoking ordinance, the City Council
Finance Committee unanimously endorsed the
prohibition of the use of chewing tobacco at
baseball games and other sporting events. The
unanimous vote came after U.S. Sen. Dick Durbin
pressed aldermen to “finally knock tobacco out
of the ballpark”—a take on a phrase used by the
Campaign for Tobacco-Free Kids. Adding testimony for snuffing out smokeless tobacco was CMS
President, Kathy M. Tynus, MD, who provided
details to the committee.
“It’s not just smoking that poses a serious
threat,” Dr. Tynus said. “Make no mistake:
Smokeless tobacco is a dangerous, addictive
product that causes cancer, heart disease and other
serious illnesses.” The CMS president further
pointed out that smokeless tobacco has nearly 30
cancer-causing chemicals that cause various types
of cancer and other health hazards—and can lead
to nicotine addiction.
Dr. Tynus, who is also an outpatient-based
primary care internist at Northwestern Medicine,
provided additional “red flags” about smokeless
tobacco:
• The International Agency for Research on Cancer (IARC) and the Department of Health and
Human Services National Toxicology Program
have concluded that smokeless tobacco is a
known human carcinogen. IARC has concluded
that smokeless tobacco causes oral cancer,
which can require disfiguring surgery, and
pancreatic cancer, which is an especially deadly
form of cancer. • Smokeless tobacco use also has significant
cardiovascular effects, and has been linked to
fatal heart attacks. Some studies have also linked
smokeless tobacco use to adverse reproductive
outcomes during pregnancy, including preeclampsia, premature birth, and low birth-weight.
• Smokeless tobacco use is associated with precancerous lesions in the mouth or leukoplakia,
gum recession and disease of the gums, and
tooth decay.
The plan to ban smokeless tobacco at all
professional and amateur sporting events
was proposed by Ald.
Edward Burke, 14th,
and Ald. Patrick Daley
Thompson, whose
11th ward is the site
of U.S. Cellular Field,
and whose father also
died of lung cancer.
Alderman Thompson
said White Sox owner
Jerry Reinsdorf supports their effort.
Dr. Tynus emphasized there is reason to worry that
smokeless tobacco use by young persons may serve
as a gateway to cigarette smoking, this nation’s
leading preventable cause of premature death and
disease. “We are not just talking about a harmless
habit or something that all ballplayers do. We’re
talking about the use of a deadly and destructive
product that has no place in kids’ lives and no place
in baseball.”
March 2016 | www.cmsdocs.org | 11
PUBLIC HEALTH
The Opioid Controversy
Reaction to CDC prescribing guidelines: a good first step?
A
“In 2012, health
care providers
wrote 259
million
prescriptions
for opioid
pain relievers,
enough for
every American
adult to have a
bottle of pills.”
S S TAT E S combat a raging opioid
epidemic, the Centers for Disease
Control recently came out with its
revised clinical guidelines aimed at
slowing a public health crisis. Though
voluntary, experts believe they’ll have a ripple
impact nationally. The guidelines are meant for primary care physicians who treat adults for chronic
pain in outpatient settings. Among the 12 recommendations: practitioners should opt for shorteracting, lower dosages, and limit opioid use to acute
pain episodes. Opioids should not be a first-line
therapy outside of major surgery. Cancer, palliative
and end-of-life care are exempt, however. CDC also
recommends that doctors conduct urine drug tests
before prescribing.
The reaction from medical organizations
reflects the complexity of the problem. While
praising efforts to curb opioid abuse, many raise
concerns. The American Medical Association,
for instance, points to scant scientific evidence
supporting strict limits on dosage and duration.
Conflicts with state laws, gaps in reimbursement
and insurance coverage for alternative treatments
all create hurdles to the guidelines’ successful
implementation, the AMA said.
Physicians also report feeling under intense
pressure to treat pain. The Hospital Consumer
Assessment of Healthcare Providers and Systems
(HCAHPS) survey encourages overly aggressive
prescribing of opioids because survey data is used
to rate providers and set reimbursement.
While the guidelines do not address physician
education, greater knowledge of pain management,
including effective alternatives to opioids, must be
part of any comprehensive solution, the AMA said.
Pendulum Swings Back
The guidelines are meant to be a “flexible tool”
that can be adjusted as needed, the CDC said.
But some groups caution about unintended
consequences. “The CDC imprimatur makes it
more likely that these guidelines become de facto
requirements through adoption by state health
departments, professional licensing bodies, or
insurers,” the American Cancer Society stated in
response. Facing regulatory risks, few primary care
physicians might want to prescribe opioids. Yet
many see that as a positive step.
In 2014 alone, opioids contributed to 28,648
deaths, a record year, with 18,893 lethal overdoses
related to prescription pain relievers, and 10,574
deaths related to heroin. Primary care clinicians
wrote nearly half of all dispensed opioid prescriptions, and the growth in prescribing rates among
these clinicians has been above average, according
12 | Chicago Medicine | March 2016
to the CDC. Put more dramatically, in 2012 health
care providers wrote 259 million prescriptions for
opioid pain relievers, enough for every American
adult to have a bottle of pills.
The guidelines, while not meeting rigorous
standards of evidence, would begin to turn the
tide, saving lives by reducing the flow of opioids.
Hailing the guidelines, the group Physicians
for Responsible Opioid Prescribing said this is
the “first time the federal government is communicating clearly to the medical community that
long-term use of opioids for common conditions is
inappropriate.” Until more data becomes available,
the recommendations serve to reinforce existing
medical principles of drug prescribing.
More Federal Efforts
Coinciding with the CDC guidelines, the
Obama administration plans to invest over $1
billion on improving access to medications like
buprenorphine. A bill in Congress—the Recovery
Enhancement for Addiction Treatment Act, or
TREAT, would raise the current cap on the number
of patients prescribers of buprenorphine can see.
But without more physicians stepping up to
prescribe the drug, greater access could prove difficult. Only 32,000 doctors nationwide have taken
the eight-hour course and applied for the special
license they need to prescribe buprenorphine.
Patients are not clamoring for such treatment
either. Addiction recovery groups say the real
problem is lack of insurance coverage.
Fewer than half of the 2.2 million people
who need treatment for opioid addiction get it,
the Department of Health and Human Services
estimates. The agency recently announced an
evidence-based HHS-wide initiative that targets
three top areas. HHS wants to expand access
to medication-assisted treatment for opioid use
disorder, increase the use of naloxone, and inform
opioid prescribing practices.
National Pain Strategy
The Institute of Medicine has called chronic pain
a “significant public health problem” in the U.S. In
2011, the organization cited the need for a “cultural
transformation in the approach to pain.” The IOM
said physicians need more education, starting in
medical school, about pain care.
Spurred on by these recommendations, the
National Institutes of Health came out recently
with a National Pain Strategy. The plan moves
away from an opioid-centric treatment paradigm.
Along with increased provider and patient education, the strategy calls for more realistic expectations for pain relief.
PUBLIC HEALTH
Dry Needling Expands PTs Scope
of Practice
Resolution calls for stringent standards
T
H E P R O C E D U R E of dry needling
has become a hot issue among health
care professionals. Specifically, objections are being raised over the increasing practice of dry needling by physical
therapists (PTs), and the Chicago Medical Society
(CMS) is pushing for action to resolve this issue.
First, though, what is dry needling? This
invasive procedure involves the insertion of
acupuncture needles into the body to treat muscle
pain by stimulating and breaking muscular knots
and bands. Unlike trigger point injections used
by physicians and licensed acupuncturists for the
same purpose, no anesthetics are used in dry needling, and it is indistinguishable from acupuncture
in definition, and therefore in the regulatory arena.
The problems, according to critics, is that dry
needling represents a considerable scope expansion
for physical therapists, whose training to perform
this procedure is being questioned.
Currently, 300 hours of training is the industry
minimum standard for medical doctors to practice
acupuncture; in most states, non-physicians, such
as acupuncturists, must have in excess of 2,000
hours of clinical and didactic education and
training before they can become certified to treat
patients. Yet there are no independently vetted
training programs for dry needling, no established
and validated dry needling curriculum, and PTs
are beginning to practice this invasive procedure
with as little as 12 hours of classroom time.
Acupuncturists, too, have opposed the use of dry
needling by PTs, claiming that PTs are practicing
acupuncture, are unqualified to do so, and are a
risk to public safety. “An ill-trained practitioner,
could, as a result of lack of education or ignorance,
cause substantial medical injury,” states the
American Academy of Medical Acupuncture
(AAMA), which is among the harshest critics of
physical therapists performing this procedure
Countering these charges, PTs are claiming
that physicians and acupuncturists are thrusting
themselves into a turf war with their profession.
CMS has gotten into the fray by pointing out that
lax regulation and lack of training standards for dry
needling are leading groups such as athletic trainers
and massage therapists to seek incorporating dry needling into practice. CMS further points out that this
trend is evolving rapidly nationwide, because medical
doctors are not involved in the regulatory and legislative management of this issue. Building on the Illinois
State Medical Society’s existing policy opposing the
practice of dry needling by physical therapists, CMS
has passed a resolution with a two-fold resolve:
• That the ISMS delegation draft a resolution
directing the American Medical Association
(AMA) to develop policy on the issue of dry
needling practice by non-physician groups,
including physical therapists in order to guide
this conversation at the national level.
• That the Illinois delegation direct the AMA to
strongly consider stringent standards for the
practice of dry needling by physical therapists
and other non-physician groups, including the
benchmarking of training standards to already
existing standards of training, certification, and
continuing education that exist for the practice
of acupuncture.
The issue will be deliberated at the upcoming
ISMS House of Delegates April 15-17.
Dry needling is an
invasive procedure
involving the insertion
of acupunture needles
into the body to
treat muscle pain by
stimulating and breaking muscular knots and
bands.
“PTs are
beginning
to practice
dry needling
with as litle
as 12 hours
of classroom
time.”
March 2016 | www.cmsdocs.org | 13
PUBLIC HEALTH
Curbing Firearm Violence
A growing trend of shootings rocks Chicago, but despite the publicity the city isn’t the
worst offender by far By Cheryl England
I
T ’ S N O S E C R E T that gun violence is a
growing problem in Chicago. By mid-February,
more than 370 people had been the victims of
firearm violence, whether homicide or suicide,
in the city. Seventy of shootings ended in fatalities, which means that fatal shootings are up 130%
over last year. At this rate, 2016 is on pace to have
more than double the number of shootings as last
year, according to the Chicago Tribune.
The website HeyJackass! tracks a multitude of
statistics on firearm violence in Chicago including
daily statistics, monthly totals, yearly totals, locations and more. For example, the site shows that
from Jan. 1 through March 27 a person in Chicago
“In Illinois, three dealers-along with a fourth
dealer in Indiana-account for 20% of the
firearms used in shootings in Chicago. One
store alone had 1600 guns traced back to it. An
average store accounts for three guns.”
On Jan. 1, 2015, a one-of-a-kind law, the Gun
Violence Restraining Order, went into effect in
California. The law allows family members to petition a judge to temporarily remove a close relative’s
firearms if they fear that their family member will
commit gun violence, whether suicide or homicide.
“The law is designed to prevent firearm violence
under conditions that only a family could know,”
says Daley. “Perhaps a family member is undergoing a divorce or has lost his or her job and is having
suicidal or revengeful thoughts.”
Under the law, the court order is good for only
one year and the person can appeal once during
the year if, for example, he or she has undergone
therapy or their situation has improved. The law
also extends to people who share a dwelling, for
example, in roommate situations. “Even better,”
says Daley, “the law empowers local law enforcement personnel to intercede.”
Curbing Illegal Access and Illegal
Trafficking
is shot every two hours and 41 minutes and a
person is murdered every 14 hours and 42 minutes.
During that same time frame, the site also shows
that the city has had 23 homicide-free days so far
this year but it hasn’t had a single shooting-free
day in nearly 13 months.
But while the statistics are grim, Chicago is, at
least, not the worst place in the country for gun
violence. Colleen Daley, executive director of the
Illinois Council Against Handgun Violence (ICHV),
the oldest and largest statewide organization in the
U.S. working to prevent the devastation caused by
firearms, says, “To say that Chicago is the worst
place for firearm violence is a lie. The numbers
being reported are not per capita. When you look
at firearm violence statistics per capita, Chicago is
not even in the top twenty.” Cities such as Detroit,
Milwaukee, St. Louis and New Orleans have much
higher rates of firearm violence per capita than
does Chicago, says Daley.
On a national level, laws requiring comprehensive background checks for gun purchasers can
help curb firearm violence. “In Chicago,” says
Daley, “half of the guns on the streets come
from Mississippi and Indiana where it is easy to
get firearms without comprehensive background
checks.”
Similarly, laws to curb illegal gun trafficking
could help curb firearm violence. “In Illinois,” says
Daley, “three dealers—along with a fourth dealer
in Indiana—account for 20% of the firearms used
in shootings in Chicago. One store alone had 1600
guns traced back to it. An average store accounts
for three guns.”
Despite clear guidelines on how firearms should
be sold and accounted for by dealers, national
laws require that local law enforcement agents
announce in advance if they are going to inspect
a firearm dealer’s shop. “That gives a dealer who
is involved in illegal trafficking a wide margin to
clean up their books,” says Daley.
A One-of-a-Kind Law Targets
Mental Health Issues
Addressing the Issues: What Can
Be Done
Many experts contend that there are three main
areas that need to be addressed in order to start
seeing a decline in firearm violence. These three
areas are: background checks for gun purchasers,
illegal firearm trafficking, and, of key interest
for the medical community, new laws that allow
for the intersection of mental health and gun
violence.
14 | Chicago Medicine | March 2016
If mental health issues, illegal trafficking and
background checks could all be addressed, the rate
of injury and death from firearm violence could
be decreased, although certainly not eliminated.
“Decreasing firearm violence is not as simple as
just passing legislation,” says Daley. “But the more
barriers we can put up, the better chance we have
of decreasing the violence.”
March 2016 | www.cmsdocs.org | 15
THE
HMO
COMEBACK
As Costs Rise,
Networks Narrow
on the Exchange
By Bruce Japsen
16 | Chicago Medicine | March 2016
THE HMO COMEBACK
D
O C TO R S A N D OT H E R providers of medical care are bracing
for the return of restrictive health
insurance companies led by health
maintenance organizations, according to industry reports and health insurance
company business plans. “It’s a return to the
1990s,” Dr. Patrick Carroll, chief medical officer
of Walgreens Healthcare Clinics, warned more
than 100 doctors, urgent care center operators
and medical practices at an ambulatory care
conference in January. “You’re going to see more
HMOs. Networks are narrowing and it’s going to
have wide impact.”
To be sure, more than half of the insurance
products offered this year on public exchanges
under the Affordable Care Act are health maintenance organizations (HMOs) or plans that limit
health care providers “within a predetermined
network,” a report by the Chicago-based Blue Cross
and Blue Shield Association released in January
shows. Employers, too, are adding narrow network
products including more HMOs than they have in
the past, though not quite at the pace of insurers
on the public exchanges, the National Business
Group on Health says.
Some of these moves by insurers are because
they aren’t making money on the individual plans
they sell on public exchanges and they admit that
limiting choice allows them to better control costs.
UnitedHealth Group, parent of United Healthcare
of Illinois, lost more than $700 million last year
providing care to Americans who purchased their
products on the public exchange. Blue Cross and
Blue Shield of Illinois has also lost money on its
public exchange business but hasn’t disclosed
publicly how much for 2015.
In Illinois, all of the exchange products offered
by Blue Cross and Blue Shield of Illinois for this
year are narrow networks or HMOs, the insurance
company said. Given the dominance of Blue Cross
and Blue Shield of Illinois in the Chicago market,
this means more than 80% of all Illinois residents
who bought coverage on the public exchange are
in a narrow network plan or HMO, state insurance
data shows.
Chicago Closely Reflects the
National Trend
Across the country, HMOs and what Blue Cross
and Blue Shield Association called “exclusive
provider organization products” increased to 52%
of the health plan offerings on public exchanges for
this year compared to 41% in 2015. Because HMOs
generally limit choices to the doctors and hospitals
in their networks and exclusive provider organizations work in a similar way to keep costs low,
consumers are picking these plans to save money.
“Across all market segments, we are seeing more
interest in network solutions that better balance
affordability, access and quality,” said Maureen
Sullivan, senior vice president and chief strategy
officer for BCBSA, in a statement to Chicago
Medicine. “In the individual market, which is less
than five percent of all insured, there are more
HMO product options and consumers are trading
access for lower costs.” The analysis drew from a “county-level database of every individual market health insurance
carrier and product sold across the country,” the
study said. This would include health plans sold
not only by Blue Cross and Blue Shield like those
offered by Chicago-based Health Care Service
Corp. but also other plans that operate in Illinois
including Aetna and its Coventry unit, Humana
and UnitedHealth Group.
“More than half of the insurance products
offered this year on public exchanges under the
Affordable Care Act are health maintenance
organizations (HMOs) or plans that limit the
choice of health care providers.”
One such narrow network plan that has emerged
in the Chicago market is known as BlueCare Direct,
which is sold by Blue Cross and Blue Shield of
Illinois and features doctors and other medical care
providers from Advocate Health Care, the Chicago
area’s largest operator of hospitals and doctor
practices. It is the lowest-cost health plan offering
by the state’s largest health insurer on the exchange
and is a replacement of sorts for a PPO that Illinois
Blue Cross sold on the exchange last year.
Dr. Lee Sacks, chief medical officer at Advocate,
said BlueCare Direct, “unlike traditional HMO
plans, doesn’t require referrals and is not limited
to a single hospital or physician group.” But doctors say physicians and their patients should be
concerned because consumers often don’t realize
the size and scope of the network. They tend to
be choosing plans based largely on cost of the
premium or the size of the deductible.
Medical Societies Push Back Against
the Lack of Transparency
The lack of transparency is triggering the
American Medical Association and other medical
groups, including state regulators across the country, into making health plans more transparent
about the size and scope of their networks.
“Insurance companies should not be allowed
to sell plans with insufficient networks,” Dr.
Steven Stack, president of the American Medical
Association said in an interview with Chicago
Medicine. “We have some significant concerns with
these narrow networks. Patients are not being fully
informed when they make their choices.”
Some medical groups, including the AMA, say
insurance regulators in each state should more
closely monitor narrow network plans and HMOs.
March 2016 | www.cmsdocs.org | 17
THE HMO COMEBACK
“Some medical groups, including the AMA, say insurance regulators should more
closely monitor narrow network plans and HMOs. These groups want insurance
regulators to look at how far patients have to travel for treatment if a plan doesn’t
have adequate coverage.”
These groups are advocating that insurance regula- it needs to be monitored.”
In Illinois, thus far there haven’t been any bills
tors look to see how far patients have to travel
that have addressed adequacy or transparency of
for treatment if an HMO or narrow network plan
provider networks. Illinois hasn’t enacted a “netdoesn’t have adequate coverage. Some states are
work adequacy” statute since 2001, and it primarily
advocating for a minimum ratio of network providaddressed pediatric care and availability of health
ers to patients to make sure there is a reasonable
care for children.
supply of doctors while other states are asking
A new Avalere analysis
finds fewer insurers are offering
preferred provider organization (PPO
For their part, the insurance companies say
insurance regulators to monitor patient wait times
choices among
plans
to see a primary
care provider.
networks on exchanges
in 2016.
Specifically, from 2014thetoexchanges
2016, offer
the ample
percentage
of plans
offering
even though some carriers admittedly have pulled
“Insurance companies should be required to
PPO networks dropped
fromnetworks,”
39 percent
to Stack
27 percent.
This represents
a 31
decline ove
products
off the exchanges.
“Onpercent
average, consumhave standard
AMA’s Dr.
said.
ers
in
urban
markets
have
44
product
choices
“They
need
to
monitor
how
far
a
patient
has
to
the three year period.
Meanwhile, use of health maintenance
organization (HMO) and exclusive
in 2016, down slightly from 50 choices in 2015,”
travel and whether there are physicians nearby,
the general,
Blue Cross Association’s
study, called
“The
provider organization
(EPO)
has
In
PPOs include
a wider
network
especially
if theynetworks
are introducing
moreincreased.
HMOs and
Marketplace,” said.
smaller network plans. This is all happening so fast Evolving Affordable Care Act
1
Fewer PPOs Offered on Exchanges in 2016
of providers and cover more out-of-network care than HMOs and EPOs.
“The shift away from PPOs underscores the evolution of network design in exchange plans,” said
Elizabeth Carpenter, vice president at Avalere. “While network type is not a perfect way to predic
network breadth,
it is Exchanges
an indicator that exchange plans are moving toward networks with fewe
PPOs
Exiting
providers.”
The percentage of PPO products sold on exchanges declined from 2014-2016. At the same time, more restrictive HMO and EPO
(exclusive provider organization) networks increased.
Exchange Plan Networks by Type, 2014 - 2016
100%
90%
80%
7%
7%
13%
11%
70%
60%
39%
12%
12%
35%
27%
47%
50%
2015
2016
50%
40%
30%
20%
41%
10%
0%
2014
Source: Avalere Health
18 | Chicago Medicine | March 2016
HMO
PPO
POS
EPO
Importantly, care provided by out-of-network providers does not count toward consume
THE HMO COMEBACK
“Rural markets saw a somewhat smaller decline;
consumers in those markets have 32 products to
choose from, on average–four fewer than they saw
in 2015.”
And the size of the HMO’s list of providers
as well as the narrow network also matters.
Illinois Blue Cross’ BlueCare Direct plan includes
Advocate’s network of hospitals and more than
250 sites of care throughout the Chicago area.
“The plan offers outstanding access to Advocate
Physician Partners’ 5,000 doctors in all specialties
across the entire metro area,” Dr. Sacks said. “As
the lowest price Blue Cross Blue Shield plan on the
exchange, BlueCare Direct offers consumers choice
and easy access to high-quality care.”
Employers are Slow to Follow
the Trend
Among employers, they see the trend as evolving
but see more movement to HMOs and narrow
networks if they are basing their in-network
doctors and hospitals on quality measures. The
National Business Group on Health, which represents hundreds of national employers including
Chicago-based Boeing, United Airlines and Abbott
Laboratories, said they need to better understand
these new models of insurance and medical care
that are being more selective about providers.
“There has been a proliferation of new
delivery models such as accountable care organizations, Centers of Excellence, patient centered
medical homes and narrow or performance
networks,” said Brian Marcotte, president and
chief executive of the National Business Group
on Health. “While employers are interested in
these new delivery models, they have been slow
to move because they have many questions about
their design, finance and administration, and the
inconsistency of their deployment and maturity.”
But insurers say a narrower network allows a
health plan to more closely monitor quality.
Poorly performing providers who don’t have
health outcomes that meet certain targets aren’t
included in the narrow network.
The Blue Cross and Blue Shield Association’s
Sullivan said insurers need to share data to help
physicians and patients “maximize health benefits
based on the coverage they’ve chosen.” Also, “as
this happens, doctors are able to use these new
resources when referring patients to other medical
professions,” Sullivan said. “Some states are advocating for a minimum ratio
of network providers to patients to make sure
there is a reasonable supply of doctors while
other states are asking insurance regulators to
monitor patient wait times to see a PCP.”
Still, doctors say there needs to be more
scrutiny. “Patients are strongly attracted to
lower premiums and they are relying on regulators that say the product they are buying is a
reasonable insurance product with a reasonable
network,” the AMA’s Dr. Stack said. “This is
a fast-evolving issue and there needs to be
transparency. It is not sufficient to merely say:
‘Let the buyer beware.’”
Bruce Japsen is a health care journalist, speaker,
author and regular contributor to Chicago Medicine
who also writes for Forbes and The Motley Fool. 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 brucejapsen@
gmail.com.
Illinois’ Pediatric Care Standards
N E T WO R K A D E Q UAC Y statutes of various potency exist in 28 states and the District of Columbia. At least 17 states,
including Illinois, enacted laws prior to the 2010 Affordable Care Act. It has been 15 years since Illinois enacted any statute
related to network adequacy. In 2001, Illinois set standards specific to pediatric care.
Illinois statute allows managed care plans to specify that children be treated by providers within the plan’s network, so
long as certain conditions are met, including:
• The network provider is immediately available to receive the referral and to begin providing services to the child.
• The network provider is enrolled as a provider in Illinois’ early intervention system and fully credentialed under the current
policy or rule of the lead agency.
• The network provider can provide the services to the child in the manner required in the individualized service plan.
• The family would not have to travel more than an additional 15 miles or an additional 30 minutes to the network provider than
it would have to travel to a non-network provider who is available to provide the same service.
• The family’s managed care plan does not allow for billing (even at a reduced rate or reduced percentage of the claim) for
early intervention services provided by non-network providers.
March 2016 | www.cmsdocs.org | 19
PHYSICIAN LEADERS
Success Factors
for Physician Leaders
Thriving in today’s practice environment part of Midwest Clinical Conference program
By Susan Reynolds, MD, PhD
P
AY M E N T R E FO R M is well underway, causing a major upheaval in the
health care industry. The new paradigm
bases payment on clinical outcomes and
accountability rather than the traditional
fee-for-service model.
Physicians must continually adjust to new rules
and regulations in order to maintain their previous
compensation levels. They have to learn about
value-based purchasing, readmission non-payment,
bundled payment, accountable care organizations,
population health management, meaningful use,
and more. Today’s payment mechanisms require
sophisticated IT systems to collect outcomes data
that demonstrate quality care. Many physicians
are struggling to become IT savvy, so they can use
these computer systems efficiently.
Quite a few medical practices have been forced
to merge in order to acquire computer systems. And
many physicians have decided not to go it alone
anymore, instead preferring to become employees of
a hospital, health system, or large medical group so
they can survive the tsunami of change.
Physicians and Hospitals Need Each
Other
In this challenging environment, how can physicians succeed, and how can physicians and hospitals
collaborate for mutual success? What new knowledge, skills, and strategies are needed to survive?
“The type of leadership in which the leader
gives an order and the follower obeys is called
‘transactional leadership.’ It is fine to use this
style in key medical situations such as when
running a Code Blue, while in the operating room
and in need of an instrument or a sponge, or
when writing medical orders.”
Today we see hospitals developing a regional
approach to care delivery wherever possible in
order to maximize reimbursement. The more lives
they cover, the more outcomes they can report.
And by collaborating with physicians, many hope
that clinical outcomes will show excellent results,
which in turn will generate better reimbursement.
Hospitals must work with physicians to develop
20 | Chicago Medicine | March 2016
financial and clinical integration models using
complex computer systems. Physicians can help
them by developing disease management systems
that ensure consistent care delivery, utilize best
practices and evidence-based medicine, and maximize clinical outcomes. They can also participate
in IT system design and help analyze the outcomes
data collected through those IT systems.
Physicians need to align with hospitals in some
way so they have access to reportable outcomes data
they can use to maximize their own reimbursement.
Physicians, also, need sophisticated IT systems, and
must learn how to use them effectively. They also
need education about care management, best practices and protocols, and evidence-based medicine in
order to demonstrate excellent outcomes.
With the new payment model focused on quality
reporting, physician oversight is needed now
more than ever. Hospital boards today have more
practicing physicians on them so that all board
members can understand the latest treatments
available for hospitalized patients and ensure that
they are being used. ACO models also need physicians in management and governance.
How Physicians View Themselves
Physician leadership is now an imperative if the
new payment system is to work. And so the next
question becomes, “What is effective physician
leadership?” A corollary is, “What are the success
factors for effective physician leadership?”
We often ask physician audiences, “Why do
people follow you?” Here are some unusual
responses:
• “We all got 800s on our College Boards.”
(Medical Society President)
• “Because they have to.” (Orthopedic Surgeon)
• “Most billable hours.” (Medical Malpractice
Defense Attorney)
• “Nobody else wanted the job.” (Chief of Staff)
Better answers have included:
• Task competence
•Knowledge
•Experience
• Work hard
•Trustworthy
• Good communicator/listener
PHYSICIAN LEADERS
•Courage
•Vision
And sometimes we hear:
• Get the job done/get results
•Approachable
•Charismatic
• … and even instill fear (not usually a longterm motivator)
Vision is frequently not at the top of the list. In fact
it was listed as the #10 success factor in a UCLA
Anderson School of Management study. Motivating
others was listed as #9. “Trust” came in at #1 and
“Communicating one-on-one” and “Teamwork”
came in at #2 and #3, respectively. Physician CEOs
did rank “Vision” as their #1 success factor, followed by “Communication,” then “Teamwork and
Creativity,” and “Management Experience.”
In the same study, Senior VPs said “Clinical
Background” was most important, followed by
“Communication,” “Teamwork,” and “Information
Management.” In other words, these physician
leaders had to be excellent clinicians, up-to-date
on clinical care guidelines, able to collaborate, and
know how to use IT systems to handle clinical
outcomes data.
For Chiefs of Staff and Department Chiefs,
“Trust” was the #1 success factor, followed by
“Communication Skills,” “Vision,” and “Creating
Buy-in” [for the vision]. Their top functional skills
mirrored those in the overall study and included
knowledge of “Health Policy,” “Health Economics,”
“Information Management,” and “Data Analysis.”
Building trust is key for any physician leader
since they must meet with administrators on a
regular basis to collaborate. However, in doing so,
they may be viewed by their clinical colleagues as
“going over to the dark side.” Administrators need
physician input as they build quality and patient
safety programs, but they may have different goals
and objectives and even different communication
styles, so the doctor may not fit in easily.
Qualities of Successful Leaders
The most successful physician leaders, according
to the UCLA study, maintain strong relationships
with their clinical colleagues while building strong
new relationships with administrators. Ideally,
physician leaders have conflict resolution skills
to bring both sides closer together. The most successful ones can create and communicate a vision.
Along with these qualities, leaders must inspire a
team to make the vision a reality. Successful leaders help others to learn and grow.
In the new health care paradigm, physicians
need to rely on tools like motivation and communication as they collaborate on teams. Many
individuals they work with are not under their
direct authority, and so physicians must be able to
build rapport, listen to others, delegate effectively,
understand millennials, and give timely and
appropriate rewards. It is difficult to motivate others when people have been assigned to a team they
have no interest in. Team members function best
when their roles match their individual strengths,
and others on the team cover their weaknesses.
Allowing others to participate in solving
problems rather than just assigning specific tasks
to be accomplished is also helpful. Team members
function better when they have ownership in the
project. Recognition, even as simple as a “Thank
You,” can be very important. People may give their
all once, but if unrecognized, they may not put in
as much effort in future projects.
Successful leaders help
others to learn and
grow, allowing them to
participate in solving
problems rather than
just assigning specific
tasks.
Obstacles to Good Leadership
When a leader seems too demanding, micromanages, or seems to criticize unfairly, team members
will become far less motivated and perform less
well. Leaders must avoid seeming autocratic. No
one wakes up in the morning and says, “I think
I’ll be arrogant today.” That just doesn’t happen.
However, white coats, clipboards, and the overusage of “medicalese,” can distance physicians
from others, making them seem arrogant even
though it was not intended. It is important that
physicians get feedback from a close colleague or
staff person about whether anyone perceives them
to be arrogant or condescending.
In our medical training, we physicians learned
to be autocratic when giving orders. We write an
order for 10 units of regular insulin and do not
want the nurse to give 25 units. We write an order
for a PA and lateral chest x-ray and do not expect
that we will get three views of the ankle instead.
Sometimes physician leaders are perceived as
too autocratic in management settings. They arrive
at a management meeting and give orders just
as they would on the clinical floor or in the OR.
Managers do not take kindly to this approach, and
there can be “tissue rejection.” In other words,
March 2016 | www.cmsdocs.org | 21
PHYSICIAN LEADERS
leaders who communicate this way do not fit in.
This type of leadership in which the leader gives
an order and the follower obeys is called “transactional leadership.” It is fine to use this style in key
medical situations such as when running a Code
Blue, while in the operating room when in need
of an instrument or a sponge, or when writing
medical orders. However, management schools
now teach “transformational leadership,” which is
more participative and inclusive. Transformational
leadership invites team members to give input
before the leader makes the final decision.
Being a poor listener is another obstacle.
Physicians are trained to ask a litany of questions
when doing the history and physical. We usually
hope the patient doesn’t give long answers, since
we have so many questions to get through in an
ever-shorter timeframe. We may talk 90% of the
time with our patients, and listen 10% of the time.
A study at LDS Hospital (Salt Lake City, Utah) of
family practice residents revealed that male residents
interrupted their patients every 18 seconds; female
residents interrupted every 23 seconds. That study
found that if residents were quiet, patients would tell
them why they were really there, beyond their chief
complaint, within two minutes. But what doctor has
two minutes per question? Becoming an effective
leader requires talking less than 40% of the time and
listening at least 60% of the time. It’s important to
listen first. We are more persuasive if we have first
heard what the other person is thinking and adjust
our comments and questions accordingly.
Having poor rapport or no rapport with one’s
followers is a recipe for disaster. To motivate followers, leaders must be able to connect with them
and understand them, which means they must build
rapport and also listen to them. Strong rapport helps
in many situations. Studies show that physicians
who have good rapport with their patients are much
less likely to be sued and patients are much more
likely to follow their instructions.
Physicians also need good rapport with their
colleagues, with administrators, with legislators
when urging that a bill be voted for or against,
and when recruiting a potential new member to
their medical group. They must be able to connect
with their audience when giving a presentation,
and with the jury, if they have been sued, or are
appearing as an expert witness.
Rapport Building
Almost all physicians know and utilize basic
rapport building skills, such as having a pleasant
facial expression and warmly greeting someone,
focusing their attention, being enthusiastic, and
giving an early honest compliment. If the physician does not know the person, the physician can
say something like, “Thank you for meeting with
me today,” so the other person feels welcome. If
it is a patient, the physician can start with, “What
can I do for you today?” or “What seems to be the
problem?” The goal is to set the patient at ease as
much as possible.
NLP (Neurolinguistic Programming) identifies
three basic communication modes: visual, auditory,
and kinesthetic. The most effective leaders use all
three in appropriate settings. More than 80% of
Americans are visual learners and communicators.
Yet over 50% of physicians are kinesthetic learners and communicators, preferentially learning
through tactile function.
We doctors palpate, percuss, lay on hands, and
even put our hands inside other people’s bodies.
These kinesthetic activities are not the norm for
most Americans, putting physicians at a disadvantage when trying to build rapport with people who
use different communication modes. To maximize
rapport, physicians must mirror back the communication mode of others.
Managing Stress, Preventing
Burnout
In today’s health care environment, team collaboration requires knowledge and mastery of leadership
skills. Developing methods to reduce stress is essential for physicians who lead these teams toward
a shared goal. Burnout is the enemy of effective
leadership. It is a tall order to fill, and that is why
we are working with the Chicago Medical Society to
offer physician leadership programs.
Susan Reynolds, MD, PhD, is President and CEO,
The Institute for Medical Leadership. The Institute
for Medical Leadership has conducted 32 Chief
of Staff Boot Camps, teaching skills to over 2,500
physician leaders since 2003, conducting hundreds of
onsite leadership programs for hospitals and health
systems as well as medical societies. For a list of
references, please contact [email protected].
Rapport Building at MCC
A DVA N C E D R A P P O R T building skills are part of what Susan Reynolds, MD, PhD, will be
teaching at the Chicago Medical Society’s Midwest Clinical Conference on May 20-21. Participants will learn about body language, matching and mirroring, and neurolinguistic programming as methods to build rapport quickly in various situations and have the opportunity to
practice with a colleague. Register online at www.cmsdocs.org/events/69thMCC; or contact
Rachel at [email protected]; or call 312-670-2550, ext. 338.
22 | Chicago Medicine | March 2016
Westin ChiCago RiveR noRth, ChiCago
May 20–21 n 2016
CHICago mEDICaL soCIEty’s
69 tH annuaL
midwest Clinical Conference
Thrive
in a Dynamic HealtH
care environment
partICIpatIng organIzatIons:
Illinois Psychiatric Society
n Chicago Dermatological Society
n Chicago Gynecological Society
n Genetics Task Force of Illinois
n Ukrainian Medical Association of North
America—Illinois Branch
n Chicago Neurological Society
n Illinois Association of Orthopedic Surgeons
n Illinois Academy of Family Physicians
n American Academy of Pediatrics—Illinois Chapter
n Chicago Ophthalmological Society
n Argentine American Medical Society
n American Heart Association
n Chicago Pathology Society
n Polish American Medical Society
n Philippine Medical Association of Chicago
n Reproductive Medical Institute
n Metropolitan Chapter of the Chicago College
of Surgeons
n Illinois College of Emergency Physicians
n The Institute for Medical Leadership
n American Bar Association—Health Law Section
n
EvEnt fEaturEs:
n
KEynotE spEaKEr: Kenneth m. Ludmerer, mD
Distinguished Professor in the History of Medicine
at Washington University
n
n
n
n
n
A Two Day educational conference providing
5 concurrent Tracks, over 30 sessions and up to
56 different topics including clinical sessions planned
in conjunction with our specialty society co-hosts
Physician Leadership Session presented by former
White House Advisor Susan Reynolds, MD, PhD
from The Institute for Medical Leadership
MCC will incorporate tracks on medical-legal
strategies, cybercrimes and hands-on workshops
highlighting cutting edge technology
Designated Exhibitor Space and Excellent
Sponsorship Opportunities
Poster Board Competition Reception
I n f o r m at I o n
Haydee nascimento
312.670.2550
[email protected]
MEMBER BENEFITS
Working for You
CMS measures lead ISMS’ 2016 legislative agenda
The Illinois State
Medical Society’s
annual House of
Delegates meeting
shapes legislative
priorities for the
coming year. CMS is a
prominent part of the
process.
E
V E RY Y E A R the Chicago Medical
Society submits a bounty of proposals to
the annual House of Delegates. In 20142015 alone, eight key CMS measures to
come before the Illinois State Medical
Society won adoption, and as a progress report
shows, they are now shaping ISMS’ legislative
action plan. (Transforming resolutions into bills for
submission to the General Assembly is a multi-stage
complex process. It requires review by governmental affairs experts and various committees. The end
result—carefully crafted proposals with the best
possible chance of becoming law.)
Here are details on the eight resolutions adopted
last year, all of which showcase just how your
Society is working for you.
Medical Necessity
At some point in any physician’s career, he or she
will receive a denial from a health insurance plan
claiming that a particular service wasn’t “medically necessary.” This is most frustrating because,
after all, the physician is in the position to know
their patients’ medical needs. Even worse, the term
“medically necessary” is vague and can even be
defined differently by different parties.
The resolution as written directs ISMS to
support or cause to be introduced legislation
amending the Illinois Insurance Code to ensure it
is consistent with CMS and ISMS policy stipulating
that only the treating physician may determine
24 | Chicago Medicine | March 2016
what is medically necessary, and not a health
insurance company. ISMS agreed with the CMS
resolution, authored by Jonathan Gamze, MD,
and even made it more rigorous in its amendment.
The final recommendation directs ISMS to cause
to be introduced legislation amending the Illinois
Insurance Code and the Managed Care Reform and
Patient Rights Act to define “medical necessity” as
any health care treatment, device, drugs or supplies
recommended, ordered or provided by a health
care professional in the evaluation and treatment
of disease, condition, or injury consistent with
the applicable standard of care, and to deem it an
unfair and deceptive practice for health insurance
plans to refer to any policy, contract, agreement
or explanation of benefits to designate services as
medically necessary or unnecessary.
Provider Shield Act of Georgia
The State of Georgia took the lead in signing into
law a provision in the U.S. House version of the
Patient Protection and Affordable Care Act that
was left out of the Senate version. Signed by Gov.
Nathan Deal on May 6, 2015, Georgia’s Provider
Shield Act prevents administrative payment
guidelines from being introduced as the standard
of care in malpractice suits. The issue came about
because payment guidelines that had nothing to do
with standard of care were being introduced into
legal arguments in medical liability suits.
Several substitute resolutions were proposed to
MEMBER BENEFITS
improve Illinois’ medical liability climate, including
by implementing legislation similar to the Provider
Shield Act of Georgia. The CMS resolution,
authored by Kathy M. Tynus, MD, directs ISMS
to support or cause to introduced legislation to
improve Illinois’ medical liability climate. It also
directs ISMS to support or cause to be introduced
legislation that would mirror the Provider Shield
Act of Georgia, which prohibits payer policies
and criteria under federal law from being used
to establish a legal basis for negligence or breach
of standard of care in medical liability cases or
product liability lawsuits.
A substitute resolution calls on ISMS to support
or cause to be introduced legislation requiring
that in medical liability cases, plaintiff attorneys
submit actual payments of medical bills, not the
amount charged to the patient. Similar language
was introduced by in the General Assembly as part
of Gov. Bruce Rauner’s larger tort reform package,
which did not advance in either chamber.
Still another substitute resolution directs ISMS to
support or cause to be introduced legislation that prohibits the practice of allowing medical professional
liability cases to be filed without a signed affidavit of
merit. Any legislation should include language restoring the right to a 12-member jury in civil cases.
In the end, ISMS combined elements of all three
resolutions to recommend the introduction of
comprehensive legislation reforming Illinois’ medical liability climate. The legislation will prevent
administrative payment guidelines from being
introduced as the standard of care in malpractice
suits; ensure that the actual payment amounts of
medical bills are presented in medical liability
cases, not the amount charged; remove the ability
to file a medical liability case without a certificate
of merit; and restore the right to a 12-member jury
in civil cases.
Medicaid Reimbursement
This resolution, submitted by the CMS Advocacy
Committee, directs ISMS to support or cause to
be introduced legislation to ensure that the higher
Medicaid reimbursement rate for primary care physicians that was established under the Affordable Care
Act is restored. Section 1202 of the ACA required
states to raise Medicaid primary care payment rates
to Medicare levels in 2013 and 2014, with the federal
government paying 100% of the increase. However,
federal lawmakers failed to reauthorize the increase
during the 113th Congress, ending in December 2014.
As a result, states had to decide whether to revert to
previous primary care payment levels or continue at a
higher level but without the benefit of the enhanced
federal match. Illinois was one of 34 states to revert
to the lower reimbursement.
Illinois law previously defined who was eligible
for the rate increases. This included: Physicians
holding board-certification from the American
Board of Medical Specialties, American Board of
Physician Specialties, or American Osteopathic
Association in pediatric medicine, internal
medicine and family medicine and associated
subspecialties, or physicians who furnished 60% of
primary care to their entire Medicaid patient load.
ISMS, while agreeing with the resolution, also
agreed that advocacy efforts for increased reimbursement should include an expanded definition
of “primary care” that covers all physicians who
provide primary care, such as ob-gyns, who may
not be included in the current definition.
In the end, ISMS recommended that as part of
Illinois’ ongoing budget negotiations, ISMS advocate that the higher Medicaid reimbursement rate
for primary care physicians established under the
ACA be restored, and that it include all physicians
who provide primary care.
Protect Physician Certification and
Licensure
Maintenance of Certification (MOC) is an extremely
contentious subject. Many physicians say that MOC
is not only time-consuming and expensive but also
that its impact on patient outcomes is debatable.
CMS’ resolution, authored by Makis Limperis,
MD, directs ISMS to seek legislation in Illinois
that would prohibit hospitals, all employers, the
Illinois Department of Financial and Professional
Regulation, all third-party payers, and other entities from requiring physicians to participate in prescribed corporate programs including Maintenance
of Certification and would prohibit expiration of
time-limited Maintenance of Certification. The
resolution also requests that ISMS work with the
AMA to introduce national legislation that would
accomplish these goals at the federal level.
In reviewing the resolution, ISMS noted that
the AMA did not adopt this resolution at its
interim meeting. Instead, AMA delegates decided
against mandating MOC. AMA voted to advocate
for an impact study on MOC requirements,
assessing entry into the profession, retirement or
recertification lapses, practice costs, outcomes and
patient safety. As such, ISMS decided to defer state
legislative implementation of this resolution until
another appropriate council or committee conducts
an in-depth study, since this complex issue affects
a wide variety of medical specialties.
ISMS Support for Physician-Owned
Labs to Be Exempted from AntiMarkup Legislation
The State of Illinois amended the Medical Practice
Act in 2014 to prohibit a markup on anatomic
pathology services. Under Public Act 98-1127,
physicians are now required to disclose the amount
paid to the anatomic pathology lab for services. In
addition, the Act prohibits physicians from marking up or directly or indirectly increasing charges
for anatomic pathology services.
The resolution, authored by Maura Quinlan,
March 2016 | www.cmsdocs.org | 25
MEMBER BENEFITS
MD, proposes to exempt anatomic pathology
services ordered or provided by physician-owned
laboratories from the prohibitions in Public Act
98-1127. The resolution sponsor and all interested
specialty societies, including pathologists, agreed
that introducing legislation should be deferred.
The parties agreed all interested specialties should
work through ISMS.
Marijuana Dispensing Organization
Responsibilities
This resolution, authored by Jerrold B. Leikin, MD,
directs ISMS to support or cause to be introduced
legislation amending the Compassionate Use of
Medical Cannabis Pilot Program Act to require that
marijuana dispensing entities provide educational
materials to each individual at the time of dispensing.
These materials should include updated information
about the effectiveness of various forms and methods
of medical cannabis administration; the purported
effectiveness of different strains of cannabis on
specific conditions; information on the health risks
and adverse effects associated with the use or abuse
of cannabis; and any other information relevant to
medical cannabis. In addition, the materials would
address whether cannabis possession is illegal under
federal law and provide information about prohibition of smoking medical cannabis in public places.
ISMS agreed that legislation should require that
dispensaries report to the Illinois Prescription Drug
Monitoring Program whenever they dispense medical cannabis to a patient, along with information
about the strain and dosage. The final recommendation directs ISMS to cause to be introduced legislation that requires marijuana-dispensing entities to
give individuals a detailed explanation of adverse
effects and risks associated with cannabis use.
Food Allergy Notification by
Restaurants
This resolution, authored by Howard Axe, MD,
directs ISMS to support or cause to be introduced
legislation modeled after the Massachusetts Food
Allergy Awareness Act, which was designed to
minimize the risk of illness and death due to
accidental ingestion of an allergen while dining
in a restaurant. Key parts of the Act include
requiring the restaurant to display a food allergen
awareness poster, provide menu notices advising
customers to inform their server before placing an
order about any food allergies they may have, and
to implement food allergen awareness training for
restaurant personnel.
ISMS noted that the AMA did not adopt this
resolution at its 2015 interim meeting. The Council
also agreed that most restaurants have already
taken steps to protect employees and customers
from exposure to food allergies. Therefore, the
Council recommended that ISMS seek the introduction of a resolution to the General Assembly
urging study and consideration of legislation
26 | Chicago Medicine | March 2016
that would achieve the purpose and goals of the
Massachusetts Food Allergy Awareness Act.
FOID Mental Health Reporting
Requirements
In 2013, Illinois passed the Firearm Concealed and
Carry Act, which expanded the reporting requirements for health care facilities and physicians,
clinical psychologists, and qualified examiners to
include any person who is adjudicated mentally
disabled; voluntarily admitted to a psychiatric unit;
determined to be a “clear and present danger”;
or determined to be “developmentally disabled or
intellectually disabled.” The Illinois Department of
Human Services (DHS) is responsible for comparing the data reported against the State Police FOID
files to identify possible matches.
Originally authored by Christine Bishof, MD, the
amended resolution directs ISMS to work with the
Illinois Psychiatric Society to cause the introduction
of legislation that would clarify state reporting
requirements for all physicians and others with
appropriate training and experience when they identify patients who pose a clear and present danger to
themselves or others. As such, ISMS will work with
the Illinois Psychiatric Society to develop a definition
of “clear and present danger” to better define state
reporting requirements in relation to FOID cards.
Headphone Public Awareness
Campaign
In January 2012, the journal Injury Prevention
published a study showing that 116 pedestrians
wearing headphones died or were injured in the
U.S. between 2004 and 2011 in accidents involving
cars or trains they didn’t hear or see coming.
Although the link between headphone use and
injuries in situations requiring auditory awareness
has not been definitively proven, common sense
suggests that the study was on the mark.
This resolution, authored by Kamala Ghaey, MD,
MPH, directs ISMS to work with the Illinois General
Assembly to develop a statewide public awareness
campaign to educate individuals about the dangers of
using earbuds or headphones during outdoor activities that require auditory attention. The resolution
also directs ISMS to support or introduce legislation
requiring that packaging for smart phones and
similar devices include warning labels indicating the
dangers of using earbuds during these activities.
ISMS agreed that educating the public about
the dangers of using headphones during certain
activities is appropriate, but noted that the Illinois
cannot regulate interstate commerce. The final
recommendation directs ISMS to work with the
General Assembly to develop a statewide public
awareness campaign to educate citizens about the
dangers of using headphones during outdoor activities and while driving, and to support legislation,
should it be introduced, requiring warning labels
on headphone packaging.
Westin RiveR noRth, ChiCago
May 20–21, 2016
The Chicago Medical Society
Presents The 69th Annual
MiDWest CliniCal
ConfeRenCe
See The U.S. ArMy exhibiT AT The ConferenCe
Register today! http://www.cmsdocs.org/events/69thMCC
Questions? Contact haydee nascimento: 312-670-2550 or [email protected]
MEMBER BENEFITS
Thrive in a Dynamic Health Care
Environment
Sign up now for CMS’ Midwest Clinical Conference
Y
O U WO N ’ T want to miss out on this year’s Midwest Clinical Conference. Hosted by the Chicago
Medical Society, the educational program explores
timely topics in medicine with presentations from
experts in a range of specialties. You’ll learn about
integrating genetics into your practice, advances in telemedicine,
innovations in pediatrics, opioid prescribing, and more.
The two-day conference runs May 20-21 at the Westin River
North, overlooking the Chicago River. Five concurrent course
tracks, featuring a total of 20 educational sessions and 60
speakers, will share cutting-edge clinical advances, medical-legal
updates, physician leadership developments, and technology tips.
And, you’ll have the opportunity to earn up to 14.5 CME credits.
MCC engages physicians at every career stage. Students,
residents and fellows will be competing in the Research Poster
Symposium. This year’s categories are Basic Clinical Science;
Clinical Vignettes; Health Policy; and Clinical Research. Authors
also display and present their work to MCC participants.
Included in your registration—breakfast, one general luncheon
session; keynote address by a prominent speaker; exhibits;
networking; and the Research Poster Symposium. To register,
visit www.cmsdocs.org/events/69thMCC. For more information,
contact: Haydee Nascimento, 312-670 2550, or hnascimento@
cmsdocs.org.
Conference Highlights
Success Factors for Physician Leaders
Friday, May 20, 8:00 a.m.-11:30 a.m.
DESCRIPTION: This program will discuss key leadership
skills physicians need to succeed and prosper in a rapidly
changing health care environment. Emerging roles for physician
leaders, strategies to motivate others, effective meeting management techniques, and building a diverse organization will be
covered.
FACULTY: Susan F. Reynolds, MD, PhD, President and CEO,
The Institute for Medical Leadership. Dr. Reynolds has disclosed
that she does not have relevant financial relationships with any
commercial interests.
DESIRED LEARNING OUTCOMES: At the conclusion of this
session, participants should be able to: discuss new roles for
physician leaders and new leadership skills that will help them
to succeed.
CO-SPONSORED BY THE INSTITUTE FOR MEDICAL
LEADERSHIP
Luncheon Keynote Session—Residency Training in the
United States: Past, Present, and Future
Friday, May 20, 12:00 noon-1:00 p.m.
DESCRIPTION: This presentation will discuss the evolution
and current status of the residency system for training doctors
in the United States. Emphasis will be placed on the underlying
28 | Chicago Medicine | March 2016
educational principles, moral values, cultural context, and
internal and external tensions within the system. There will
be an opportunity for the audience to engage in questions and
commentaries.
DESIRED LEARNING OUTCOMES: At the conclusion of
this session, participants should be able to: understand the
evolution of the U.S. residency training system as well as current
challenges and opportunities, potential solutions and future
directions.
KEYNOTE SPEAKER: Kenneth Ludmerer, MD, Professor,
Washington University Department of Medicine, St. Louis, Mo.,
and author of the bestselling book, Let Me Heal. Dr. Ludmerer
has disclosed that he does not have relevant financial relationships with any commercial interests.
Cardiovascular Health
Friday, May 20, 1:00 p.m.–5:00 p.m.
DESCRIPTION: This conference track sponsored by the
American Heart Association/American Stroke Association will
highlight current guideline recommendations, population health
strategies and innovative programs and services in cardiology.
Learn about programs and resources impacting patient satisfaction and outcomes.
Chronic Care Management & Population Health
FACULTY: Vince Bufalino, MD, Advocate Heart Institute
Get Pumped: An Overview of AHA/ASA Innovations in
Practice, Locally & Nationally
FACULTY: Marc Silver, MD, Advocate Christ Medical Center,
Clinical Professor, University of Illinois College of Medicine
Programs That Work: Controlling High Blood Pressure
FACULTY: Sarah Song, MD, Assistant Professor, Department
of Neurology, Rush University Medical Center
Patient Support Network
FACULTY: Kathleen L. Grady, PhD, RN, MS, Professor
of Surgery and Medicine, Feinberg School of Medicine,
Northwestern University, Administrative Director, Center for
Heart Failure, Bluhm Cardiovascular Institute, Division of
Cardiac Surgery
DESIRED LEARNING OUTCOMES: At the conclusion of this
session, participants should be able to: identify gaps in chronic
care by using data from ambulatory EHRs for population health;
gain knowledge of innovative AHA national programs and
local initiatives promoting the development and integration of
technologies into patient care; review the AHA HBP guideline
recommendations & algorithm and identify opportunities to
implement them into practice to impact behavioral change and
patient outcomes; gain knowledge of AHA/ASA online resources
for patients and caregivers and identify opportunities to incorporate them into practice.
MEMBER BENEFITS
Welcome, New Members!
The Chicago Medical Society greets its newest members. We are now 64 voices stronger!
Student District
Zarna Patel
Mark M. Abellera
Harrison Pidgeon
Tamathor Abughnaim
Lindsay N. Poston
Neelima Agrawal
James M. Rosati
Khalif Ball
Sanam Salimi
Jacob M. Begres
Sarah F. Schmidt
Shannon K. Bellinger
Alicia Seggelink
Michael A. Belmonte
Shivani Sockanathan
Yasin Bhanji
Hayley T. Sparks
Adrian Boscolo-Hightower
Kelsi Swanson
Jacqueline Boyle
Justin R. Sysol
Sarah A. Brownlee
Sean Till
Chelsie Carlton
Kishan Ughreja
Talia Cola
Joseph R. Weber
Krishna Constantino
Joseph A. Westrich
Kristen M. Corrao
Aaron L. Wiegmann
Ellen Daily
Erica Yothment
Vincent P. DeMarco
Peter L. Zhan
Frank DiSilvio
Nadeem T. El-Kouri
Resident District
Tara C. Funk
Gray Akoegbe, MD
Scott Goldberg
Nahiris M. Bahamon, MD
Amanda M. Goslawski
Laura S. McGuire, MD
Robert Hernandez
Andrew Wuenstel, MD
Kenneth A. Joseph
Jacob Kanter
District 2
Dipan N. Karmali
Bruce Himelstein, MD
Abdul S. Khan
Christopher B. Klein
District 3
Lawal A. Labaran
A. Pat Basu, MD
Nicholas Leader
Patricia P. Vidal, MD
Emily Li
Katie Lichter
District 5
Nelly Gonzalez Montes
Kenneth L. Schiffman, MD
Kristy Nguyen
Jennifer Novak
Anna Otieno
District 6
Joerg Albrecht, MD
Akash Patel
March 2016 | www.cmsdocs.org | 29
MEMBER BENEFITS
Calendar of Events
APRIL
12 CMS Medical Student Section Meet
CMS President Kathy Tynus, MD, who
will discuss with students the importance
of organized medicine, and how it impacts
students and physicians. Complimentary
dinner is included. 6:00 p.m. Location,
CMS Building, 33 W. Grand Ave., Chicago.
Online RSVP: http://goo.gl/forms/
J5QX2MU0qw. For information, contact
CMS Medical Student Trustee, Christiana
Shoushtari [email protected].
15-17 ISMS House of Delegates The
policymaking body of the Illinois
State Medical Society meets this year
in Springfield to deliberate and set
policy and legislative agendas. Wyndham
Springfield City Centre; 700 E Adams St.,
Springfield, Ill. Or call 217-789-1530. Also,
please contact [email protected] or call
312-853-4745 or 800-782-4767, ext. 4745.
More than 60 speakers and over 50 topics to choose from will offer participants
up to 14.5 CME credits at the Chicago Medical Society-hosted Midwest Clinical
Conference, May 20-21, at the Westin Chicago-River North. See listing on this page
and article on page 28.
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.
25 Resolutions Reference Committee
15-17 Illinois Medical Directors
Association The IMDA is hosting a
bi-state conference on long-term care in
St. Louis. Nationally known speakers will
address attendees for a total of 11.25 CME,
CMD and CEU credits over two days.
Come join us for live lectures, group workshops and a baseball game. Contact Abbey
at 312-670-2550, ext. 326; or agalvin@
cmsdocs.org for information and RSVP.
Open to all members, this committee
shapes CMS, ISMS, and AMA policy by
reviewing 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 312-6702550, ext. 338, or [email protected].
30 Midwestern Association of Plastic
Surgeons The MAPS is hosting its Annual
The CGS presents a dinner and CMEaccredited lecture by Jacques Abramowicz,
MD, titled “3D–4D Ultrasound in
OB-GYN Not Reimbursed. Should We Do
It Anyway?” 6:00-9:00 p.m., Maggiano’s
Banquets Chicago, 111 W. Grand Ave. To
RSVP, please contact Abbey 312-670-2550,
ext. 326; or [email protected]. CGS
Members and affiliates–one dinner credit.
All guests and non-members $75.00.
20 Chicago Gynecological Society
Scientific Meeting, where participants
may earn up to 8.5 CME credit hours.
Following the conference, MAPS will host
a social event and award ceremony at the
University of Chicago’s Gleacher Center.
Live entertainment will be provided by
renowned cabaret singer Nan Mason.
Contact Abbey at 312-670-2550, ext. 326; or
[email protected] for information and
RSVP. Or visit our Eventbrite registration
site: http://maps2016.eventbrite.com.
20 CMS Executive Committee Meeting
MAY
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 Board of Trustees Meets every
30 | Chicago Medicine | March 2016
18 CMS Executive Committee Meeting
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].
18 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.
6:00-7:00 p.m. Teleconference. For information, contact Rachel 312-670-2550, ext. 338,
or [email protected].
20-21 Midwest Clinical Conference
The Chicago Medical Society’s 69th
Annual MCC offers cutting-edge content
for physicians in primary care and in
the specialties. Sessions will review
the medical-legal landscape, physician
leadership issues, and technology.
Highlights include a nationally recognized keynote speaker; resident-student
poster competition; networking; and
exhibits. For details, see page 20 of this
issue. Location: Westin River North Hotel,
320 N. Dearborn St., Chicago. Up to 14.5
CME credits; $325 for CMS members;
$425 for CMS members on-site; $525 for
non-members; $620 for non-members on
site; free for CMS Students; $25 for CMS
residents/fellows; $30 for non-member
students; $50 for non-member resident/
fellows. Register online at: http://www.
cmsdocs.org/events/69thMCC; or contact
Rachel at [email protected]; or call
312-670-2550, ext. 338.
23 Resolutions Reference Committee
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].
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 (not semi-retired). Please
send resumes by fax to 847-398-4585 or to kimberleeo@officegci.
com and [email protected].
month, heating included. Building possibly for sale if interested
in income apartments upstairs. Call 708-594-1988, leave message.
For sale: Single specialty surgical center near Glen Ellyn, Ill.,
This free-standing state licensed Ambulatory Surgical Center
has 3,780 sq. ft. with two ORs, two labs, and one exam room
with lots of parking. Could easily be converted to a multispecialty center. Asking $2.3 million, not including real estate.
Sale can include business or business with building. Please
email [email protected] and [email protected] for more
information.
Office/Building for Sale/Rent/Lease
Business Services
For sale: Freestanding multi-specialty surgery center in Wood
Dale, Ill., with ample parking. State-licensed ASC with one larger
and one smaller operating room, 3,800-4,000 sq. ft. Asking
$4.75 million, not including real estate. Email Administration@
officegci.com and [email protected] with serious inquiries.
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.
For sale: medical office at 6151 W. Belmont Ave., Chicago;
four exam rooms and three administrative rooms on ground
floor; three rental apartments, garage in back. Doctor retiring.
$339,000. Call Janina 773-909-0890.
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.
Medical office space in Justice, Ill., on busy 79th Street location;
three exam rooms, reception office, reception area and storage
building shared with dentist on the other side. $1600.00 per
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March 2016 | www.cmsdocs.org | 31
WHO’S WHO
Medical Examiner Scores High
Chicago’s top forensic pathologist overcomes hurdles By Scott Warner
Under the direction
of Stephen Cina, MD,
the Cook County
Medical Examiner’s
Office investigates
more than 5,000 cases
yearly, performing
nearly 3,000 autopsies
in 2015. Dr. Cina
personally does about
150 autopsies, and says
the most emotionally
difficult ones for him
are those involving
rape or child abuse.
W
H E N H E took over as Chicago’s chief medical examiner in
September 2012, Stephen Cina,
MD, faced, shall we say, a grave
situation. He was hired by Cook
County Board President Toni Preckwinkle following
a scandal in which photos emerged showing dozens
of cadavers stacked in the facility’s overcrowded
cooler. The department was heavily criticized for
major backlogs, as well as being mired in the past,
with employees still using paper ledger books. The
County Medical Examiner’s office lost its national
accreditation. President Preckwinkle hired Dr. Cina
with this mandate: “Fix it.”
Fast forward to today. On March 1, Dr. Cina’s
office celebrated full accreditation by the National
Association of Medical Examiners after rigorous
scrutiny. It is now the only medical examiner’s or
coroner’s office in Illinois to have full accreditation, and is the third busiest medical examiner’s
office in the nation.
To say that his job is challenging is quite an
understatement. But Dr. Cina felt he was up to
the challenge. Trained as a forensic pathologist,
Dr. Cina is one of only approximately 500 forensic
pathologists in the nation. He was working as chief
administrative officer at the University of Miami
Tissue Bank, when he learned about the medical
examiner crisis in Chicago. “I contacted human
resources, and told them that I could help.” He also
said that he had grown to love Chicago through his
visits here for conferences held by the College of
American Pathologists.
President Preckwinkle was convinced. She
hired Dr. Cina and helped support his office by
guiding the County to invest in additional staffing
and equipment; forensic pathologists and trainees
went from six to a projected 18 by this July; a $1.4
million state-of-the-art cooler was installed, and
the office now uses a cloud-based management
system that tracks each case from the moment it is
called in until the decedent is released to a funeral
home. Dr. Cina also uses social media to track
down families of victims and post facial pictures of
unidentified deceased. “Most important, we want
to assure those whose loved ones pass through our
office that the deceased are treated with dignity
and respect,” Dr. Cina says.
Dr. Cina also wants health care professionals
to know that his office is freestanding, and not
influenced by politics or the police. ”Foremost,
we are physicians. It’s our job to learn as much as
we can to help the living, like examining sudden
unexpected death in young people; compiling data
of how many people die from gunshots, where they
died, what drugs they might have been using, data
that can help police.”
He also wants to clarify a misconception, held
by many, that the medical examiner’s office is
the county morgue, a place to store bodies, or a
repository for autopsies. He encourages physicians
to embrace the role of signing death certificates
for their older patients who die what appears to
be a natural death. ”Not every death needs an
autopsy nor will most natural deaths in older
people get one,” he says. “Physicians can always
call our office to discuss their cases. We want to
be a resource for them.”
Career Highlights
A N AT I V E O F B R O O K LY N , New York, Dr. Cina received his BA from Johns Hopkins University in Baltimore and his MD
from Vanderbilt University School of Medicine in Nashville. He completed a fellowship in forensic pathology in Maryland,
and served as a major in the United States Air Force Medical Corps. He then served in various medical examiner positions
in Texas, Colorado, and Florida before coming to Chicago. He is a diplomate of both the American Board of Pathology, and
the American Board of Medicolegal Death Investigators, and currently serves as vice president of the National Association
of Medical Examiners. Dr. Cina also serves as professor in the Department of Pathology at Rush Medical College, and is an
adjunct professor of pathology at Northwestern University Feinberg School of Medicine.
32 | Chicago Medicine | March 2016
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