Ohio Medicine
2016 – ISSUE 1
Ohio State Medical Association
Inside This Issue
D. Brent Mulgrew - Lifetime Achievement | 13
Critical Updates to Ohio’s Prior Authorization Process are Now Before State Leaders | 19
New Solution to Simplify Independent Medicine | 22
OSMA Member Newsmakers | 24
HEALTHCARE LAW:
REQUEST FOR
RECORDS
PAGE 14
TABLE OF CONTENTS
Ohio Medicine
MESSAGE FROM THE PRESIDENT
This will be my final dispatch as president of your Ohio State
Medical Association (OSMA) as my one-year term comes to
a close. I’ll sum these past 12 months in two ways: fast and
efficient. Fast because it really does feel that it was not long
that I stood before you at our last Annual Meeting taking the
oath for this office. Efficient because we have used this past
year to make tremendous strides streamlining OSMA operations
on everything from how we manage our finances to how
we conduct our meetings in more time-saving, yet equally
productive fashion.
2016 – Issue 1
Published March 2016
04 Legislative Digest
07 Legal and Regulatory Digest
09 Partner Digest
11 Education & Services Digest
12 Medical Residents & Students Digest
13 D. Brent Mulgrew - Lifetime Achievement
14 Healthcare Law: Request for Records
19 Critical Updates to Ohio’s Prior Authorization Process are Now Before
State Leaders
22 New Solution to Simplify Independent Medicine
24 OSMA Member Newsmakers
26 Executive Director’s Closing Point
Ohio Medicine Disclaimer
This publication provides general coverage of its subject area. It is
provided to OSMA members with the understanding that the publisher is
not engaged in rendering legal, accounting, or other professional advice
or services. If legal advice or other expert assistance is required, the
services of a competent professional should be sought. The publisher
shall not be responsible for any damages resulting from any error,
inaccuracy or omission contained in this publication. Paid advertisement
may or may not imply OSMA endorsement.
Ohio Medicine Copyright Notice © 2016 by the Ohio State Medical
Association. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording or any information storage and
retrieval system, without express written permission from the publisher.
Publisher:
D. Brent Mulgrew
Editor:
Reginald Fields
Without question, the OSMA is a strong association built to provide sufficient support and
opportunities for physicians but our membership numbers have been stagnant for several
years. That has forced the OSMA to look for ways to become a more efficiently run entity
so that the future of the association remains bright. Over the past year we have laid the
foundation to do precisely that. Last fall we sold our building in Hilliard, Ohio and leased
new office space a short distance away in Dublin, Ohio. The sales transaction and move
was a financial success as we’re able to continue to accommodate staff with comfortable
work space but at a small fraction of what we previously paid.
We also used virtual meetings to meet with members of Council and the House of
Delegates at a significant reduction of time and cost but without sacrificing the quality
or depth of conversation needed to achieve our business purposes. We held two virtual
Council meetings this year. And in January we conducted our first-ever House of Delegates
(HOD) virtual meeting – a special meeting called to discuss the OSMA’s position on
medical marijuana.
After Issue 3, an OSMA-opposed state constitutional amendment that would have legalized
marijuana, was soundly defeated by Ohio voters during last November’s election, stateelected leaders signaled they were interested in exploring whether to legalize marijuana
for some medicinal purposes. These leaders specifically requested the OSMA assist them.
Because our policy prohibits the support of marijuana for any purpose, we called the
special HOD meeting to gain clearance from our leadership to work with elected leaders
on this topic. The full HOD will consider a resolution on marijuana that could alter our
position during our Annual Meeting on April 2.
As I stated, it has been fast-paced yet efficient year at the OSMA, one marked with
considerable accomplishments with Smart Rx, our online opioid abuse training and public
awareness campaign, new on-demand professional development offerings, and key
advocacy achievements.
I have thoroughly enjoyed my time as president and the wonderful opportunities I had
to represent the OSMA before audiences of state and national healthcare leaders and
peers. As I transition to immediate-past president, I am honored to support our incoming
president, Dr. Brian Bachelder, who will continue our success.
I also want to acknowledge OSMA executive director D. Brent Mulgrew who this year will
be presiding over his final Annual Meeting. Brent will retire in January 2017, concluding a
wonderful 42-year career at the OSMA. Congratulations, Brent!
Robert E. Kose, MD, JD
President
OSMA
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LEGISLATIVEDIGEST
TOP 8 HEALTHCARE ISSUES TO FOLLOW IN 2016
FOR OHIO PHYSICIANS
2016 will be a significant year for healthcare in Ohio.
Emerging developments stemming from legislation and
other major initiatives will have a huge impact on Ohio’s
physicians and their practices. The following issues will
be at the forefront of the practice of medicine and
healthcare innovation:
01 | HEALTH INSURANCE
Prior Authorization: Senate Bill 129, the Ohio State
Medical Association’s (OSMA) prior authorization reform
legislation, passed unanimously through the Ohio Senate
and is now pending in the Ohio House. This legislation
aims to simplify and expedite the process of obtaining prior
authorization, reduce much of the associated hassles and
burdens for all parties involved, and improve patient access
to critical treatments and procedures. The main provisions
of this legislation are:
• Insurers must have a web-based system to receive
prior authorization (PA) requests.
• Insurers must disclose all PA rules to providers.
• Enrollees of the health plan must receive basic
information about which drugs and services will
require prior authorization.
• Faster turnaround times for PA requests – 5 days for
non-urgent requests and 1 day for urgent situations.
• A provision allowing for “retrospective review” for
unanticipated procedures that were performed during
an authorized procedure, with some limitations.
• A provision prohibiting retroactive denials, which would
protect coverage and medical necessity “take backs,”
as long as the procedure was performed within 60
days of receiving authorization.
Mergers: Some of the largest health insurance companies
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Ohio Medicine |
in the U.S. have proposed mergers that, if approved, would
significantly impact the Ohio health insurance market. The
mergers could pose a threat to patient health care access,
quality, and affordability. The OSMA will urge state and
federal regulators to review the mergers in order to protect
consumers from potential premium increases, lower plan
quality and a reduction in the quantity and quality of
physician services.
Telemedicine: The OSMA will continue work to ensure
that health insurers can’t refuse coverage for telemedicine
services solely because the services are not provided
through a face-to-face consultation. We’re also following
rules with respect to the provision of telemedicine services
to Medicaid recipients and Medical Board of Ohio rules that
define how telemedicine establishes a legitimate physician/
patient relationship.
02 | SCOPE OF PRACTICE
APRNs: The OSMA has been strongly opposed to a bill
currently pending in the Ohio legislature, House Bill 216,
which would grant independent practice authority to
APRNs. This legislation would inhibit the concept of interprofessional teams collaborating under the oversight of a
physician to manage patient care and illnesses, and extend
the scope of practice for APRNs beyond their training and
education. In 2016, the OSMA will continue to make sure
the concerns of Ohio physicians are heard on this issue
and fight for the protection of the collaborative relationship
between nurses and physicians.
Physical Therapists: The original version of House Bill 169
granted physical therapists practicing in the state the ability
to “diagnose” medical conditions as well as order tests and
imaging. In 2016 OSMA will be working on a revised bill to
The official publication of the Ohio State Medical Association
Pharmacists: Coinciding with a growing trend of increased
pharmacist participation in helping to manage patient care,
House Bill 421 would authorize a licensed pharmacist
to administer by injection certain drugs, with the goal of
improved medication adherence. The authorized prescribed
drugs would be limited to:
• Opioid antagonists used for treatment of drug addiction
and administered in a long-acting or extendedrelease form;
• Anti-psychotic drugs administered in a long-acting or
extended-release form;
• Hydroxyprogesterone caproate; or
• Medroxyprogesterone acetate.
The OSMA has expressed initial support of the bill, but
emphasizes the importance of making sure the patient
has an ongoing relationship with the prescribing physician,
that the pharmacist is working under protocols established
by the prescribing physician and that the pharmacist has
extended training in medication administration.
03 | MEDICAL LIABILITY/TORT REFORM
While Ohio has some of the most effective tort reform laws
in the nation, the OSMA believes additional tort reforms
can provide further predictability and premium stability
in the medical liability insurance market. Legislation is
expected to be introduced soon that would help prevent
“shot gun” lawsuits, modify Ohio’s “I’m Sorry” law to
protect admissions of fault or error, and repeal the “Loss of
Chance” legal theory of liability.
04 | MEDICAL BOARD
“One-Bite Rule”: The OSMA and eight other state medical
associations continue to work together to address major
concerns over suggested regulatory changes regarding
how physicians recovering from substance abuse, and
physicians who have physical or mental impairments, are
treated by the medical board. After meeting with staff
representatives from the State Medical Board, it is apparent
that the medical board staff and primarily the consumer
members of the board still want mandatory reporting to the
Board to determine if the practitioner is eligible for the “OneBite” program. The OSMA and the other associations are
working to draft a legislative proposal that will incorporate
many of the best practices used in states that effectively
utilize the state’s physician health program, using Ohio’s
existing non-profit PHP to determine “One-Bite” eligibility.
FTC Anti-Competitive/Antitrust Conduct: The more
than two dozen state boards that license a variety of
health professionals in the state of Ohio are faced with the
possibility of a complete overhaul on the horizon due to a
2015 U.S. Supreme Court ruling. The justices found that a
state board controlled by members of the profession which
the board oversees should not be granted immunity from
any lawsuits alleging violations of antitrust laws. Antitrust
laws are in place to prohibit the restraint of trade and
competition. The Court’s decision is bringing about potential
legislation in Ohio that could make significant changes to
the final authority of state boards – including the Medical
Board of Ohio - in matters of licensing, discipline, and other
executive actions. The OSMA will be actively involved in this
issue moving forward.
LEGISLATIVEDIGEST
eliminate the provision allowing PTs to order tests and also
further limiting the “diagnosis” provision. Developments
are still underway as the OSMA continues to closely follow
the legislation in 2016, but it is expected that the bill will
clarify that the physical therapist’s “diagnosis” would not
constitute a medical diagnosis.
05 | PUBLIC HEALTH
Prescription Drug Abuse/Misuse: Building on last year’s
launch of SmartRx, OSMA’s statewide educational campaign
on how to responsibly prescribe opiate medications, the
OSMA will continue to support efforts to address the state’s
deadly prescription drug and opioid abuse problem. In
2016, we expect to see additional efforts to further reduce
the impact of the dangerous trend, including measures
establishing prescribing guidelines for acute care situations
and House Bill 248, a bill to make medications in an abusedeterrent formulation more available. For a complete list
of Ohio’s rules and regulations for opiate prescribing, visit
OSMA.org/osmaopioid.
Medical Marijuana: Following the defeat of Issue 3, a
fall 2015 ballot issue that would have legalized the use
of marijuana in Ohio for both medical and recreational
purposes through a monopoly system, the Ohio legislature
has announced its intention to review medical marijuana
in 2016. With public opinion polls in Ohio showing a large
majority of respondents in favor of legalizing marijuana
for medical use, this issue is expected to continue to
gain momentum and traction. The OSMA will monitor all
developments on the issue as it progresses.
Flu Vaccines: A bill has been introduced in the Ohio
House that would prohibit an employer from taking an
adverse employment action against a person who has
not been or will not be vaccinated against influenza. The
OSMA is opposed to this legislation, House Bill 170, as it
threatens what public health officials call “herd immunity”
and puts vulnerable Ohioans at risk. This bill deviates
from the guidelines suggested by the American Medical
Association, the Centers for Disease Control and Prevention
and many other major health organizations, advocating
for universal influenza vaccination for any individual over
the age of 6 months, except when an individual has a
medical contraindication.
2016 | ISSUE 1
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LEGISLATIVEDIGEST
06 | PRESCRIPTION DRUG COSTS
A proposed ballot measure may be brought before Ohio
voters in the fall that would establish a price ceiling on
prescription drug prices in public health programs like
Medicaid, BWC and state employee plans. A coalition
of health advocates, including the AIDS Health Care
Foundation, a Los Angeles-based organization that
operates pharmacies and testing centers in Ohio, is behind
the measure that would limit drug costs for government
sponsored health coverage to no more than what the
Veterans Administration pays for similar drugs.
choose 17 Ohio Senators, 99 members of the Ohio House
of Representatives and three justices on the Ohio Supreme
Court. Additionally, federal elections will select a new
President and 17 Ohio members of the U.S. Congress. The
OSMAPAC will be working to support candidates for office
that respect the physician-patient relationship.
For more information about the
OSMA’s advocacy efforts, visit
OSMA.org/advocacy
07 | PRICE TRANSPARENCY
As the effort to promote greater “consumerism” in health
care continues to grow, hospitals and other medical
care providers are under increasing pressure to be more
transparent about their charges for health care services. It
is expected that this issue will continue to gain momentum
in 2016 and new rules are anticipated that will promote
greater disclosure of prices for health care.
08 | ELECTION YEAR
2016 is an election year, and brings with it many electoral
decisions that could dramatically change the politics and
policy landscape in Ohio. At the state level, voters will
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TELEMEDICINE
Ohio House Bill 188 requires the State Medical Board to adopt rules
governing the requirements for a physician to prescribe or otherwise
provide a prescription drug to a person on whom the physician has
never conducted a physical examination and who is at a location
remote from the physician. This includes an initial telemedicine visit.
The rules shall authorize a physician prescribing non-controlled
substances to establish a physician-patient relationship by the use
of appropriate technology that permits, in a manner that is consistent
with the minimal standard of care for in-person care, a medical
evaluation and the collection of relevant clinical history as needed to
establish a diagnosis, identify any underlying conditions and identify
any contraindications to the treatment that is recommended or
provided. The rules must be finalized by March 2017.
On February 10, the medical board held a public comment forum where
representatives from telemedicine companies and health systems
provided information about how telemedicine rules would affect the
activities they are currently doing or seeking to do. The board will
take the comments into consideration when they start drafting the
telemedicine rules. The OSMA will be closely following the rule drafting
process and will provide updates to our members as they arise.
LEGAL&REGULATORYDIGEST
The OSMA continues to actively engage in key regulatory actions
regarding telemedicine, physician substance abuse, opioid prescribing,
and much more. Here’s an update. . .
ONE BITE
By statute, Ohio physicians are given a one time “one bite” exception,
whereby an impaired physician may escape Board intervention, and the
physician’s colleagues may be excused from reporting the physician’s
impairment, so long as the physician has completed treatment with
a Board approved treatment provider and maintained uninterrupted
sobriety, and violated no other provisions of the Ohio Medical
Practice Act.
The OSMA and numerous other state and local medical associations
continue to work together to address major concerns over recently
suggested regulatory changes regarding how physicians recovering
from substance abuse are treated by the State Medical Board of Ohio.
After numerous meetings with the medical board and legislators who
are interested in addressing this issue, the medical board has agreed
to work with the interested parties in an effort to craft a meaningful and
more effective approach to helping first-time recovering physicians
obtain the help they need.
We are hopeful that we will be able to come to collective agreement
surrounding the one-bite rule that will improve the process and
encourage physicians to seek out help under a confidential system.
We continue to believe that the best opportunity for this is to take
place through the exclusive utilization of services available through
2016 | ISSUE 1
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LEGAL&REGULATORYDIGEST
the Ohio Physicians Health Program (OPHP). OPHP was
created by the medical community to serve in this capacity
and is prepared to support the medical board by assisting
physicians utilizing the one-bite rule and seeking treatment
for substance use disorders.
OPIOID GUIDELINES
Under new state guidelines, Ohio physicians and other
prescribers will be asked to treat patients suffering from
acute pain with ice and various forms of therapy before
prescribing an opioid. The acute pain care guidelines are
the latest effort by Ohio to reduce prescription pill abuse
and opioid addiction.
The new guidelines were drafted by the Governor’s Cabinet
Opiate Action Team (GCOAT), which included staff and
physician representatives from the Ohio State Medical
Association (OSMA).
The OSMA supports the new Acute Pain Care Guidelines.
These guidelines represent a recommended standard
of care for outpatient management of acute pain. And
while these guidelines are not intended to replace the
clinical judgment of a physician, the OSMA welcomes the
guidelines as an additional and necessary tool for helping
physicians and other prescribers determine the best and
most appropriate form of treatment for a patient.
The guidelines have been included in updates to the
OSMA’s Smart Rx program, the online training and public
awareness campaign developed for Ohio physicians. The
program is accessible at www.OSMA.org/Smartrx.
The guidelines include a set of key checkpoints for
physicians that involves properly assessing the level of
pain, developing and implementing a plan of treatment, use
of non-opioid medications and then, if pain continues to
persist, an opioid can be prescribed. The patient can then
be re-evaluated after 14 days of being prescribed the opioid
as an additional checkpoint against misuse and addiction.
NALOXONE GUIDELINES
Recent changes to Ohio law (ORC 4729.44 and OAC 47295-39) authorize a pharmacist or pharmacy intern under the
direct supervision of a pharmacist to dispense naloxone
without a prescription to the following in accordance with a
physician-approved protocol:
• An individual who there is reason to believe is
experiencing or at risk of experiencing an opioidrelated overdose;
• A family member, friend, or other person in a position
to assist an individual who there is reason to believe is
at risk of experiencing an opioid-related overdose; or
• A peace officer as defined in section 2921.51 of the
Revised Code.
Additionally, Section 3707.56 of the Ohio Revised Code
permits a local board of health, through a physician serving
as the board’s health commissioner or medical director,
to authorize the protocol for pharmacists and pharmacy
interns working in that board of health’s jurisdiction.
The State of Ohio Board of Pharmacy developed a web
page, which includes prescriber resources, to assist
pharmacies in dispensing naloxone. The resources include a
guidance document, sample protocol, and a listing of all
participating pharmacies.
It was recently announced that over 200 Kroger Co.
pharmacies across Ohio and northern Kentucky have
been authorized to dispense naloxone. Similarly, naloxone
will be dispensed pursuant to these regulations at all CVS
Pharmacy locations across Ohio by the end of March 2016,
according to CVS Health’s press release.
The OSMA also worked with other healthcare associations
and state leaders to establish guidelines for treating pain in
emergency rooms and for treating chronic pain. Acute pain
is pain that lasts fewer than 12 weeks and usually goes
away within a few days or weeks. Chronic pain is long-term
pain that typically lasts longer than three months.
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Ohio Medicine |
The official publication of the Ohio State Medical Association
PARTNERDIGEST
PARTNER SPOTLIGHT
PROVISTA
Struggling to manage your practice’s expenses? The OSMA is partnered with Provista, a group purchasing organization
that helps member practices save significantly on items such as medical and surgical supplies, wireless services, and
office supplies. Additionally, OSMA members utilizing Provista can access huge savings and special offers such as free
parts, software upgrades and extended warranties.
Now through March 31, eligible members have the opportunity to take advantage of large savings across 29 categories
through the Period 1 Group Buy. The current Group Buy promotion provides members the opportunity to save in areas
including MRI and ultrasound systems, food services, defibrillators, and more.
In order to take advantage of these savings, members must enroll in Provista, which is free of charge. For more
information on Provista, please visit www.osma.org/provista. To request an enrollment kit, contact the OSMA Resource
Center at (800) 766-6762 or [email protected].
PATIENT SATISFACTION PROGRAM
There have been significant strides in tort reform in recent years, and medical liability rates continue to trend downward as the health care environment in Ohio continues to improve. However, the risk of medical liability lawsuits remains
a significant threat and top priority for all physicians. The OSMA offers members access to the Patient Satisfaction
program, which gives physician members the opportunity to manage medical liability risk through patient satisfaction.
By implementing patient satisfaction surveys, physicians are able to collect valuable insight in areas including access to
care, patient and office communications, staff responsiveness, physician interactions.
Available to OSMA members at no additional cost, program participants are also eligible for an additional 3 percent
discount on medical liability insurance through The Doctors Company. To learn more about the program and see a
demonstration, visit www.osma.org/patientsatifaction.
To learn more about Provista, the Patient Satisfaction program, or other offerings available through the OSMA Preferred
Partners Program, visit www.osma.org/partners, or contact the OSMA [email protected].
2016 | ISSUE 1
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PARTNERDIGEST
GREEN CAMPAIGNCAP
RE
Thank you to everyone who took part in the 2016 OSMA GoGreen Campaign by renewing your 2016
membership dues online or by phone. Thanks to your support and the generous donations by several OSMA
Preferred Partners, this year’s campaign was a success!
GOGREEN WINNERS
Provista
athenahealth
Complete Medical Solutions
The Doctors Company
OSMA Insurance Agency
Provista
CECity
CompManagement
OSMA Membership
AccuMedical Waste Disposal
athenahealth Credible
Healthicity
$50 Best Buy Gift Card
Jenny L. Parks, MD
$100 Sunglass Hut Gift Card
Daniel Garritano, MD
Ready-10 Software
Komal Narula, MD
$50 Amazon Gift Card
George Chen, MD
Apple iPad mini
William Kessler, MD
$50 Best Buy Gift Card
Robert Haber, MD
Apple iPad 16bit Allison Pruett, MD
$50 Amazon Gift Card
John Parker, MD
Amazon Kindle Fire
Peter Ramirez, MD
$50 Visa Gift Card
Lisa Keder, MD
$100 Sunglass Hut Gift Card
Yasser Omran, MD
Apple TVKaren Matthews, MD
$50 American Express Gift Card
Paul Laffay, DO
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Ask yourself “How am I connecting with my patients?”
Attend the Symposium for ideas!
The White House and Congressional leaders in 2015 took
two extraordinary steps to put patients at the center of how
we pay for Care and support physicians.
CHANGE:
First, the Administration set a goal that 30-percent in 2016
and 50-percent in 2018 of Medicare payments will be
linked to getting better results for patients, providing better
care, spending healthcare dollars more wisely, and keeping
people healthy.
And, second, Congress advanced this goal through the
passage of the Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), which considers quality, cost, and
clinical practice improvement activities in calculating
how Medicare physician payments are determined.
While MACRA also continues to require that physicians
be measured on their meaningful use of certified EHR
technology for purposes of determining their Medicare
payments, it provides a significant opportunity to transition
the Medicare EHR Incentive Program for physicians towards
the reality of where we want to go next.
The practice of medicine is Changing at such a rapid
pace, and there certainly won’t be any slowdown this
year. Legislation has passed to permanently eliminate the
Sustainable Growth Rate (SGR) formula. The new law, known
as the “Medicare Access and CHIP Reauthorization Act of
2015 (MACRA)” includes many policy Changes beyond
simply repealing SGR. The law makes significant Changes
to the way that Medicare pays physicians, accelerating
Medicare’s shift toward value-based payments. It introduces
two value-based payment tracks for physicians:
• Merit-Based Incentive Payment System (MIPS) and
• Alternative Payment Models (APMs).
What happens in your practice starting now through the
next two years will impact your future reimbursement, so
it is crucial that you have a good understanding of these
options.
Attend the Symposium to learn more about MACRA
and how it impacts patient care! Learn more at
www.OSMA.org/symposium.
Attend the Symposium to learn more about the
changes in reimbursement and gain new ideas and
strategies for your practice!
CONNECT:
In addition, The Doctors Company is presenting a morning
and afternoon session on “Surviving Litigation” – a must
attend for any physician/manager that is concerned with
potential litigation.
According to Dr. Kevin Pho, a physician and social media
guru who will deliver a keynote speech at this year’s
Symposium, Connect takes on two meanings:
1. Establish a relationship; develop, dig, pursue and
2. Maintain via all the tools now available: email, texting,
Facebook, blog, etc.
When you Connect, you really need to do so on many
levels. Ninety-percent of what you do as physicians is about
connecting with patients; 10% involves the science. Why
is it that most of your time focused on the 10%? If you
are unable to connect with your patients, then it will not
matter what prescriptions you write or supplements you
recommend. The future of medicine will be based upon
how well we interact and engage our patients.
EDUCATION&SERVICESDIGEST
CARE:
This once-a-year opportunity to hear the latest in
management and reform from topic experts, to network and
share ideas with your peers, meet with industry vendors
who have products and services to help you – and have
some fun! We look forward to seeing you on April 1.
For registration information, go to
www.OSMA.org/symposium.
2016 | ISSUE 4
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MEDICALRESIDENTS&STUDENTSDIGEST
MEDICAL STUDENTS DID WHAT?!
The 2016 Spring Ohio State Medical Association Medical
Student Section (OSMA-MSS) Meeting took place at the
Columbus Marriott Northwest on February 27th with
over 30 medical students from six Ohio medical schools
represented.
Diana Wieser, OSMA-MSS Chair, began the meeting with an
introduction to what organized medicine is, the importance
of organized medicine and how the OSMA advocates on
behalf of the medical profession. “Meeting with medical
students from across the state to discuss important issues
in medicine is an incredible opportunity,” Wieser said. “The
OSMA provides us with unparalleled opportunities to build
a network and have a voice for the future of healthcare
in Ohio.”
OSMAPAC Student Director, Jason Polder, then explained
the importance of the OSMA’s Political Action Committee,
or PAC, followed by the OSMA’s director of government
affairs Monica Hueckel who offered a legislative update.
State Representative Mike Duffey (R-21st District) joined
the students for lunch and made comments emphasizing
the importance of establishing and developing relationships
with elected officials. Duffey stated that in order for elected
officials to form opinions on policy that will affect medical
students and physicians the officials need to hear directly
from that constituency.
Immediately following lunch was a round table discussion
that included Drs. Anthony Armstrong, Robyn Chatman,
Louito Edje, Lisa Egbert and Charles Hickey. Each
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Ohio Medicine |
physician was placed at a table with a group of medical
students and given the opportunity to speak and answer
questions about their involvement with the OSMA.
The MSS had a busy few months leading up to the February
1 deadline for submitting resolutions for consideration
at the OSMA House of Delegates (HOD) in April, having
drafted six of the 27 resolutions.
For the final order of business the new MSS Governing
Council was elected, which will assume office at the
conclusion of the OSMA HOD. Congratulations to:
• Gabriel Pham (MS2, University of Cincinnati)
MSS Chair;
• Brittany Kasturiarachi (MS2, Ohio University) MSS
Vice-Chair;
• Katie Adib (MS1, Wright State University) MSS
Secretary-Treasurer;
• Samantha King (MS2, Ohio State University) MSS
AMA Alternate-Delegate.
Also during the meeting, OSMA President-Elect Dr.
Brian Bachelder had a little fun before he addressed
the group. Dr. Bachelder took out his cellular phone,
turned his back to the crowd and took a selfie with the
students in the background. He then tweeted the photo
to #OSMAPrez2016, his hashtag for his upcoming term
in office. Dr. Bachelder’s one-year term begins during this
year’s OSMA Annual Meeting on April 2.
The official publication of the Ohio State Medical Association
COLUMBUS CEO 2016 HEALTHCARE
LIFETIME ACHIEVEMENT AWARD
D. BRENT MULGREW
Executive Director & Co-CEO | Ohio State Medical Association
The path towards a lifelong profession often begins in the home.
Brent Mulgrew’s mother, a nurse and clinical instructor, wanted
him to be a doctor when he grew up.
“I get sick at the sight of blood,” says Mulgrew, who served at
the Air Force hospital at Lockbourne AFB (now Rickenbacker).
He joined the Air Force after earning a master’s in history from
Ohio University. He earned a JD from the Moritz College of Law
at Ohio State while in the Air Force Reserves. When he joined the
Ohio State Medical Association, his mother said, “‘That’s almost
as good,’” he recalls with a smile. Mulgrew began his career at
OSMA in 1974, first as a government affairs lobbyist, then as chief
counsel, director of government relations and managing director.
He was named executive director in 1992.
As executive director and co-CEO, Mulgrew oversees the largest
physician association in the state, with membership including
20,000 physicians, practice managers, medical students and
residents. The American Medical Association recognizes the OSMA
as one of the most impactful state organizations in the country.
“If I can reduce the hurdles, barriers or imposition of unnecessary
restrictions on physicians and the entire healthcare system, then I
will have made a difference,” says Mulgrew.
During his career, Mulgrew and OSMA staff have successfully
lobbied to reform Ohio’s medical malpractice rules and statutes.
When he was hired by OSMA, the state was in the beginning of a
professional liability crisis.
“We actually had hospitals closing because physicians, primarily
at that time anesthesiologists, couldn’t get (malpractice insurance)
coverage, not at any cost,” says Mulgrew. After several attempts
to pass bills that could withstand constitutional challenge, a 2002
OSMA-backed bill reduced malpractice-related claims significantly
for Ohio providers, reducing rates.
He and his colleagues work to stay in front of physician-patient
issues before they become professional crises. The OSMA’s
foresight and innovation in creating the SmartRX digital training
portal helped physicians review their prescribing practices just as
opioid over-prescription was mounting as a public-health threat in Ohio.
Other current OSMA priorities include maintaining physicians’ place
as the leads on healthcare teams, reforming prior-authorization
requirements and improving physician-patient communication
around difficult healthcare decisions.
“It is a continuously changing environment,” says Mulgrew of
healthcare and the surrounding politics. “There’s no ‘carved in
stone’ here, except fundamental principles about doing no harm
and protecting patients.” His mission at OSMA has always been to
provide pathways to information. That pathway’s grown muddy in
the era of WebMD, big-pharma TV ads and “death panel” politics.
Whenever the Steubenville native starts thinking his job is rough,
he looks up at the steel mill door cutter that hangs next to his desk.
During his college summers, he used the tool to pry open coke
ovens at the steel mill that employed his father, father-in-law and
grandfather before him.
“My dad once told me, ‘If you’re in a clean shirt, you’re not having a bad
day,’” says Mulgrew. He will retire from the OSMA in January 2017.
Reprinted with permission from Columbus CEO ©2016. All
rights reserved.
2016 | ISSUE 1
13
HEALTHCARE LAW:
REQUEST FOR RECORDS
WHAT THE PHYSICIAN SHOULD DO WHEN FACED WITH
A REQUEST FOR RECORDS
Physicians are frequently on the receiving end of requests for
records. The request may come from the patient, a subsequent
treating physician, an attorney, or a regulatory agency such as the
State Medical Board.
Handling the request in a proper manner will serve to reduce the
likelihood of aggravation down the road. For physicians practicing
in Ohio, the following dos and don’ts apply:
DO NOT IGNORE THE REQUEST.
A patient, a patient’s personal representative or third-party with
a properly executed authorization (or court order) is entitled to
the records in a “timely manner.” What constitutes “timely” will
depend upon the circumstances. In most practices, it would be
reasonable to expect the records to be sent within a few days, or
a few weeks at most.
DO NOT ALTER THE RECORD.
Your first instinct upon receiving a records request might be to
review your records in order to make certain that they are complete
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Ohio Medicine |
and accurate. Moreover, if you are dealing with a request which
concerns a patient who may have experienced some sort of
complication either as the result of your care, or as the result of
care by others, your defensive instinct might be to supplement
the record in some manner in an effort to demonstrate that you
provided quality care. Setting aside that it is inappropriate to
make any such changes; doing so may expose you to a claim for
“spoilation of evidence.”
Ohio in particular recognizes an independent claim by a patient
against a healthcare provider who alters his records in an effort
to avoid culpability. Moreover, successful claims arising out of
the alteration of records may require the physician to pay punitive
damages. In turn, under Ohio law, punitive damages are rarely
covered by professional liability insurance. Additionally, this
conduct may result in formal disciplinary proceedings.
DO MAKE YOUR RESPONSE TO THE REQUEST
MEANINGFUL AND COMPLETE.
Typically requests for records will contain language asking you
to produce copies of “any and all documents which refer or
relate in any manner whatsoever to the care . . .” Where the
request is broad, and arguably seeks any record which might
The official publication of the Ohio State Medical Association
FAQ
MEDICAL RECORDS
1.) What do the new guidelines for patient access to medical records mean for
providers?
According to new guidelines brought forward by the Obama administration and the U.S. Department of
Health and Human Services, providers cannot require that a patient give a reason for requesting copies
of their medical records. Doctors and hospitals also cannot require patients to retrieve their records in
person if they have asked that the records be sent to them via mail or email. A patient’s request cannot
be denied due to the patient’s failure to pay medical bills, and while providers are permitted to charge
a fee for the cost of preparing and copying the records (and for postage if sending by mail), they cannot
charge the patient for the search and retrieval of the data.
2.) Under what circumstances can a provider deny copies of the requested
information to a patient?
Under the new rules, providers may deny a patient’s request for their medical information if it is “likely
to endanger the life of physical safety” of the patient or of another individual. Providers may not,
however, refuse to disclose the information merely out of concern that the patient might be upset by it.
3.) Are doctors and hospitals required to release psychotherapy notes to patients
with the requested medical records?
Usually psychotherapy notes are kept separate from the rest of a patient’s record, and there is no
requirement to disclose these notes with the requested copies of the record.
4.) How long does a doctor or hospital have after receiving a request from a patient
for medical records to fulfill the request?
In accordance with the Health Insurance Portability and Accountability Act of 1996, in nearly all cases,
doctors and hospitals must provide copies of medical records to patients within 30 days of receiving
their request. In rare cases, this deadline can be extended by an additional 30 days, but this exception
is not frequently used.
5.) If someone has a health care power of attorney for an individual, can they obtain
access to that individual's medical record?
According to the HIPAA Privacy Rule, someone who has been given a health care power of attorney
for an individual can access the medical records of that individual. This is true for emancipated and
unemancipated minors, as well as adults.
EXCEPTION: The exception, allowing the provider to choose not to recognize that person’s power of
attorney, is when a physician or provider has a good faith concern or reasonable belief, in the exercise
of professional judgement that:
• the individual has been or may be subject to abuse, neglect, or domestic violence by the personal
representative possessing health care power of attorney,
• treating this person as the personal representative of the individual endangers the individual, or
• recognizing this person’s power of attorney relation to the individual is not in the individual’s
best interest.
2016 | ISSUE 1
15
6.) How can family members of a deceased patient
obtain protected health information/medical records
of the deceased patient that are relevant to their own
health care?
There are two ways for a surviving family member to obtain the
protected health information of a deceased relative:
• A covered entity may release the deceased patient’s health
care information to a health care provider treating the
surviving relative. Disclosures of protected health information
for treatment purposes—even the treatment of another
individual—do not require an authorization.
• It is within the scope of the law for the deceased individual’s
legally authorized executor, administrator, or someone who is
otherwise legally authorized to act on behalf of the deceased
individual or his or her estate to obtain the information or
provide the appropriate authorization for the disclosure of
the information.
7.) When a child receives emergency medical
care without parental consent, can the parent get
access to all information about the child’s treatment
and condition?
In general, even though the parent did not consent to the treatment
in this scenario, the parent would be the personal representative
for the child according to HIPAA, and would have the authority to
act for the child and to access the health information and medical
records of the child. The exception to this would be when parental
rights have been terminated, so the parent would not have the
authority to act for the child, or when expressly prohibited by State
or other applicable law.
8.) Does the HIPAA Privacy Rule guarantee a research
participant the right to access research records of results?
Generally, HIPAA gives patients the right to possess and examine a
copy of health information about themselves that is maintained in
a group of records which a covered entity uses to make decisions
about individuals, or a “designated record set.” A designated
record set includes medical records and billing records, as well
as a health plan’s enrollment, payment, claims adjudication, and
case or medical management record systems.
A notable exception would apply to health information maintained
by a research or covered health care provider in a clinical trial.
HIPAA allows the researcher to suspend the individual’s access
rights while the clinical trial is in progress, as long as the research
participant agreed to this denial of access when consenting to
participate in the clinical trial. The provider/researcher also must
tell the participant that the right to access protected health
information will be reinstated at the conclusion of the clinical trial.
Information Compiled by the OSMA.
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Ohio Medicine |
be in your possession, all such records should be produced.
It is inappropriate to interpret the request in a manner that is
inconsistent with the scope of the request.
For example, where a patient asks for “all records . . .” the
records produced should include health history forms, lab studies,
communications with other healthcare providers, billing records,
etc. In order to avoid a situation where you might be accused
by the person requesting the records of having been less than
forthright, it is typically good practice to produce your complete
chart. This would include electronic records, imaging studies, or
anything within your custody which would be in any way related
to the care which you provided to the patient.
DO NOT PRODUCE RECORDS ABSENT THE
APPROPRIATE AUTHORITY TO DO SO.
If the request is made by the patient, you can produce the chart
without any sort of written evidence concerning the request.
However, it would be good practice to require the patient to sign a
HIPAA compliant authorization. If the request is made by somebody
other than the patient or the patient’s personal representative, you
will want either a HIPAA compliant authorization signed by the
patient, or a court order signed by a judge.
In lieu of a court order you may be provided with a subpoena;
whether you are required or even authorized to produce records
in response to a subpoena will often hinge upon the particular
circumstances. Typically, state regulatory agencies have the
authority to issue subpoenas, and those subpoenas would be
deemed by most courts to impose an obligation to produce the
requested materials; however, there are circumstances where it
would be inappropriate to respond to a subpoena. Absent an
authorization signed by the patient or a court order signed by a
judge, consult with legal counsel before producing records.
Additionally, there are unique “rules” which may apply to a mental
health professional which will in some circumstances impact your
response to an authorization or a court order. When in doubt,
consult with counsel.
The official publication of the Ohio State Medical Association
DO NOT PRODUCE ORIGINAL RECORDS.
Frequently a request for records will specifically state that original
records are being sought. From a risk management standpoint it is
never appropriate to give up custody of any original records. While
there may be situations where you will need to give up custody of
an original record, those situations are few and far between, and it
is recommended that you consult with legal counsel before doing
so. If you give up an original record, and fail to preserve copies,
or preserve copies which are not identical in all respects to the
original, you may compromise your ability to defend yourself in the
event of a claim against you related to your care.
DO NOT PRODUCE ATTORNEY-CLIENT OR WORK
PRODUCT PRIVILEGED INFORMATION.
Often, when you receive a request for records, it will relate to
care which you may have discussed with your attorney and/
or professional liability insurance carrier. There may be written
communication between you and your attorney or insurance carrier,
or possibly notes relating to your discussions. Communications
between you and your attorney or insurance carrier are almost
always privileged, and should not be produced in response to a
request for records.
Similarly, if you receive a request for records, and choose to consult
with your attorney or insurance carrier concerning your response
to that request, documentation relating to those communications
should not be produced to the individual requesting records.
As a corollary to this advice, communications between you and
your attorney or insurance carrier should be placed somewhere
other than with the original patient chart. Consider creating a
separate “legal file” to store information which relates to your
communications with your attorney or professional liability
insurance carrier.
DO NOT INCLUDE ANY RECORDS WHICH RELATE TO
CARE PROVIDED TO ANOTHER PATIENT.
Frequently, billing records and scheduling records which may
make their way into a patient chart, will contain information
concerning other patients. When responding to a request for
records, it is important that you review your chart in order to make
certain that there is no information which relates to care which
may have been provided to another patient, or which identifies
other patients. Where information concerning other patients is
embedded in documents which you are going to produce, redact
that information.
DO NOT ENGAGE IN SUBSTANTIVE DISCUSSIONS WITH
THE THIRD-PARTY WHO HAS REQUESTED THE RECORDS.
If you think that you may be subject to some sort of legal claim,
it may well be tempting to contact the individual or attorney who
has requested your records in order to make certain that they
fully understand the care that you provided (and that the care
was appropriate). However, your substantive communication may
be misinterpreted, or repeated in an inaccurate manner, thereby
complicating your defense should a claim against you ensue.
In some instances, communications which go beyond the content
of the records may constitute an independent violation of HIPAA. If
you feel that some sort of substantive communication which goes
beyond the production of the records is essential, it is strongly
recommended that you consult with counsel before engaging in
those discussions.
DO NOT HOLD THE RECORDS HOSTAGE PENDING
RECEIPT OF PAYMENT FOR UNPAID INVOICES.
HIPAA and Ohio law is clear that the patient is entitled to a copy
of their records. There is also an ADA Advisory Opinion which
supports this view. (ADA Advisory Opinion 1.B.1) By extension, a
third-party is entitled to those records as well, assuming that the
appropriate authorization has been given by the patient, or a court,
or in some circumstances a licensing agency.
DO NOT OVERCHARGE FOR THE RECORDS.
You are entitled to be paid for the reasonable cost associated
with the duplication of your records. Whether you want to charge
anything for the duplication of your records may hinge in part on
2016 | ISSUE 1
17
risk management considerations. If you treated a patient who
experienced a complication arising out of your care, insisting on
payment for a copy of your chart may be deemed petty, and can
perhaps be used against you should a claim be pursued.
In addition to the foregoing, healthcare providers are required to
provide one copy of a patient’s medical record and one copy of any
records regarding treatment performed subsequent to the original
request, free of charge, to any of the following:
That said you are legally entitled to charge a fee. The fee which
you may charge is capped by Ohio law. The maximum fee depends
upon what type of records are being produced, the number of
pages of records being requested, and also on the identity of the
person making the request for your records. See Ohio Revised
Code Section 3701.741. Please note that the maximum allowable
fees are updated on an annual basis. As of the end of calendar
year 2015, the maximum fee which you could charge is set forth below:
•
•
•
•
•
If the request is made by the patient or the patient’s personal
representative, the fee may not exceed:
•
•
•
•
$3.07 per page for the first 10 pages;
64 cents per page for pages 11-50;
26 cents per page for pages 51 and higher;
$2.10 per page for any data resulting from an x-ray, MRI, or
CAT scan, recorded on paper or film.
Note that, for any request made by a patient or the patient’s
personal representative, you may not charge a records search fee.
If the request is by someone other than the patient or the patient’s
personal representative, fees may not exceed the following:
•
•
•
•
•
The Bureau of Workers Compensation
The Industrial Commission
The Department of Job and Family Services
The Attorney General
The patient or his personal representative if the medical
record is necessary to support a claim under Title II or Title
XVI of the Social Security Act
Where the healthcare provider charges fees in excess of the
amounts set forth above, there may be a complaint to state
licensing boards or the Ohio Department of Health. Clearly, the
fees to be generated by charging more than the allowable amount
would be dwarfed by the aggravation associated with dealing with
any such complaints.
Additional resources on medical records access include this
recently released HIPPA guidance from HHS http://www.hhs.gov/
hipaa/for-professionals/privacy/guidance/access/index.html.
For this article, the OSMA thanks guest author:
Richard J. Rymond
Reminger Co., LPA
An initial search fee of no more than $18.91
$1.24 per page for the first 10 pages;
64 cents per page for pages 11-50;
24 cents per page for pages 51 and higher;
$2.10 per page for any data resulting from an x-ray, MRI or
CAT scan recorded on paper or film.
Under either scenario, you may charge the actual cost of
any postage.
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Ohio Medicine |
The official publication of the Ohio State Medical Association
CRITICAL UPDATES TO OHIO’S
PRIOR AUTHORIZATION PROCESS
ARE NOW BEFORE STATE LEADERS
One of the most important pieces of healthcare legislation is now
making its way through Ohio’s legislature. Senate Bill 129 (SB
129) offers healthy and efficient modifications for how health
insurers conduct “prior authorization” (PA), a process that requires
physicians to ask permission from a patient’s insurance company
before prescribing certain medications or performing certain
medical treatments.
Ohio physicians in recent years have endured significant delays and
other problems due to cumbersome prior authorization rules when
trying to apply medical treatments or prescribe medications. Since
March of 2015, the OSMA has been negotiating this issue with the
insurance industry, seeking to give Ohioans better access to high
quality, life-saving treatments. Provisions in SB 129 will do that. The
bill has already unanimously cleared the Ohio Senate and is now
under consideration in the Ohio House.
Among the changes SB 129 proposes are:
• Ensures that PA requirements or restrictions are listed on the
health insurer’s website;
• Allows providers and patients to obtain PAs through a webbased system;
• Ensures that any new or future PA requirements are disclosed
prior to the new requirement being implemented;
• Guarantees that once a PA has been approved, the insurer
will not retroactively deny the service based upon previously
approved medical necessity or coverage criteria;
• Guarantees a faster turnaround on PA requests and
a streamlined appeals process in the event a prior authorization
is denied.
And Ohio is not alone in addressing this issue. At least fifteen other
states have already enacted legislation or have measures pending
to address prior authorization. And while the legislation varies by
state, all include measures that strengthen the communication
between patients, providers, pharmacies and insurers, ultimately
making the PA process easier for patients to be granted coverage
for the care they need.
2016 | ISSUE 1
19
The current insurance prior authorization process has real, burdensome, and sometimes dangerous consequences. The
OSMA has collected the following thoughts from healthcare providers, underscoring the need for revisions to Ohio’s prior
authorization rules:
PRIOR AUTHORIZATION HASSLE LIMITS ACCESS TO CARE:
“I had a gentleman who obviously had
a problem in his neck. It was originally
behind the muscle and I could not define
the actual size and technically call it a
mass. I wanted a CT scan to diagnose it
and could not get prior authorization. 3
weeks and several calls into fighting for
this, the patient called and said it was
much worse. We abandoned the original
request and saw the patient again. This
time he had a measurable mass that
was about 3 by 5 inches (and ultimately
more) I was able to get the CT ordered.
He ultimately went to surgery and what
should have been a simple 2-3 hour
surgery, turned into a 4 hour surgery that
taxed the surgeons’ skills. This is not an
isolated case.”
- Edward Hemeyer, MD
PATIENTS ARE MADE TO WAIT & SADDLED WITH OUTRAGEOUS COSTS:
“We in the medical community understand the necessity of prior authorization, but believe there are some
fundamental changes that can be made to the system that will enable us to provide better care for our patients
by ensuring they have access to the treatments they need. Our cancer patients struggle with understanding why
they cannot begin treatment, or why they are unable to get answers from their health insurer regarding whether
a recommended cancer treatment, diagnostic scan or medication is going to be covered by their insurance. This
uncertainty is due to the current prior authorization system. And my patients have cancer, not the common cold. Let
me assure you, there is no patient who climbs on my radiation treatment table 5 times a week for 8 weeks if they do
not have cancer. I have been faced repeatedly with the ridiculous situation in which insurance companies will pay
for radiation treatments themselves, but not for the planning or the calculations… And in the end, if the insurance
carriers do not pay for these services, I submit those bills directly to patients who can ill afford to pay for them. After
all, these patients paid their premiums but had misfortune to come down with cancer. And now they’re faced with
bills that may bankrupt them.”
– Edward Hughes, MD, PhD
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Ohio Medicine |
The official publication of the Ohio State Medical Association
CURRENT PRIOR AUTHORIZATION PROCESS BURDENS BOTH PATIENTS AND PRACTICES:
“I am the practice administrator for a free standing, independent radiation oncology center in Dayton. One aspect
of SB 129 that will help my practice significantly is a provision that will require insurance plans to respond to PA
requests within a quicker timeframe. In 2010, my cancer patients started their radiation treatment on average in 7
days. In the first half of 2015, that had risen to 23 days. There are those on Medicare and Medicaid who begin within
2 days; and there are those on commercial carriers that wait an average 45 days as we go through the steps of preauthorization and pre-determination before they can begin their treatment. My physicians used to pride themselves
on the fact that they could begin treating a patient the day after they saw them for consultation. We employ a team
of experts capable of doing this. Those days are over. Patients now have to wait. Patients who may be in pain, may
have high anxiety, may have to return to work will all now wait.
SB 129 will also prohibit insurance plans from doing a retroactive denial of payment for a drug or procedure they
already authorized. This is a very common practice that costs us thousands of dollars per year. For example, in
2014 between insurance carriers, we had approximately $250,000 in take backs or holds from 2013 claims. That
is $250,000 in claims the insurance carriers authorized before we gave the course of treatment that we then had to
fight to keep. SB 129 will make changes to the prior authorization system that will give my patients more certainty
and comfort in the fact that we will take care of their cancer. It will give this small business a stronger chance to
survive the current healthcare storm.”
- Mrs. Kathy Corbett, CMM, CMOM
PATIENTS’ CONDITIONS CAN WORSEN AS THEY WAIT:
“I recall one patient awaiting approval for cardiac stress thallium who had his heart attack and ended up in prolonged
hospitalization. Another patient anxiously awaited CT/MRI approval for thyroid cancer metastasis. There are
other horror stories, not to mention the time wasted by me on phone calls with sometimes low information
insurance personnel.”
- Richard Hoback, MD
PRIOR AUTHORIZATION WAITING PERIOD CAN EVEN RISK LIVES:
“I had a patient with a chronic diabetic ulcer and a history of multiple infections and antibiotic resistances. We
performed a culture which demonstrated only a single antibiotic would work. The patient’s insurance denied the
medication until a PA could be obtained. This delayed the patient’s initiation of antibiotic by nearly a week. This could
have been life threatening but he got lucky and recovered.”
- Sarah Abshier, DPM, CWS
It is time to make this process better for Ohio’s patients and physicians. While the OSMA has taken the lead on SB 129,
there are more than 70 state and national organizations that are supporting the bill. SB 129 is sponsored jointly by state
Sens. Randy Gardner (R-Bowling Green) and Capri Cafaro (D-Hubbard).
By: Kelsey Hardin, Research & Content Writer, OSMA
2016 | ISSUE 1
21
NEW SOLUTION TO SIMPLIFY
INDEPENDENT MEDICINE
The one constant in health care is change.
As the market increasingly shifts from a
fee-for-service to a fee-for-value model,
physicians will have limited time to position
their practice on the right side of the value
equation. Physicians have options and
those that know where to go for support
will have the advantage. In collaboration
with Medical Advantage Group, the Ohio
State Medical Association (OSMA) offers
independent physician practices a new
solution to ease the transition to valuedriven health care that offers all the benefits
of integration without consolidation.
As for value-driven health care, the potential
for improved care may be great, but many
practices nationwide are uncertain on
how to succeed with alternative payment
models from commercial and government
insurers. While many large physician
groups and health systems have started
to position themselves for the value-driven
health care market, smaller independent
22
Ohio Medicine |
practices may find themselves at a
disadvantage if they do not align with other
physicians for value-based contracting.
Transforming practices from fee-forservice to a fee-for-value model requires
a strategic roadmap and expert assistance.
OSMA Launches New Partnership to
Accelerate Value-Driven Health Care
Transformation
Last October, the OSMA established a
multi-year strategic partnership with
Medical Advantage Group, a health care
consulting company with expertise and a
proven track record in organizing providers
into physician organizations and helping
them to optimize value-based contract
incentives. This offers OSMA members
greater success in their transition to valuebased contracts.
How Does It Work?
Medical Advantage Group manages the
Consortium of Independent Physician
Associations (CIPA), a network of 40
physician organizations representing
1,500 physicians (primary care and
specialists) dedicated to the practice
of independent medicine. CIPA creates
the opportunity for smaller groups of
physicians to participate in pay-forperformance programs and value-based
contracts that are normally only available to
larger groups. Members include individual
practices, group practices, rural health
clinics, Federally Qualified Health Centers,
and physician hospital organizations. Most
CIPA physicians are independent solo
practitioners located in urban and rural
settings. CIPA “connects the unconnected”
physician and facilitates their participation
in incentive programs while providing the
vital infrastructure to maximize incentives
in value-based contracts. Under the CIPA
umbrella, Medical Advantage Group
facilitates business and clinical practice
transformation
through
technology
implementation and optimization, revenue
The official publication of the Ohio State Medical Association
cycle management, Patient-Centered
Medical Home (PCMH) education, clinical
measures performance optimization,
population health management, HIPAA
privacy and security compliance, group
purchasing, and more. Through Medical
Advantage Group, CIPA members get
personal assistance in transforming their
practice for new care delivery and payment
models. CIPA has helped more than 600
practices transform into PCMHs. Last
year, CIPA members earned $17 million in
additional revenue through fee schedule
increases and financial incentives from
participation in value-based contracts.
Medical Advantage Group is now accepting
Ohio physicians into its CIPA network. CIPA
is committed to providing practices with
vital business and clinical transformation
services that positions them effectively for
value-based contracts. This year, OSMA
members will benefit from a low introductory
membership fee of $99. CIPA members will
have access to a wide variety of services
that will ease the transition to value-based
contracting.
“The journey to success in a fee-for-value
environment is full of obstacles,” said Paul
MacLellan, CEO of MAG. “Hurdles include
training staff in new approaches, modifying
practice workflow, and updating practice
technology. Frequently, while quality work is
being done, it’s not mapping correctly to the
EHR so it doesn’t get counted by the health
plans. Optimizing both the workflows and
the technology is critical. The process of
skill building and incorporating the correct
processes takes more time than most
practices expect. Based on our experience
in helping physicians and independent
practices, our best advice is to start now
and to use a disciplined approach to build a
fee-for-value organization.”
Learn More
To learn more, visit Medical Advantage
Group’s exhibit at the OSMA Mission Possible
2016 | ISSUE 1
annual conference on April 1, 2016, or
JoinCIPAOhio.com.
About Medical Advantage Group
Medical Advantage Group (www.medical
advantagegroup.com)
simplifies
the
delivery of efficient, high-quality health care
for health care providers. Through people,
processes and technology, we deliver valuebased health care solutions that transform
practices and achieve measurable
outcomes. Medical Advantage Group has
helped build one of the largest PatientCentered Medical Home (PCMH) networks
in the U.S. and has coached more than 600
practices to achieve PCMH.
Medical Advantage Group is owned by
The Doctors Company, the nation’s largest
physician-owned medical malpractice
insurer with more than 78,000 members
and $4.3 billion in assets.
23
OSMAMEMBERNEWSMAKERS
SHARON L. HARP, MD
QUEEN CITY PHYSICIANS
Named a top physician by Aubrey Rose Foundation. Dr. Sharon Harp received the Above and Beyond Doctor of the
Year award at the Aubrey Rose Foundation’s dinner dance event in November. This award is given annually to an
exemplary doctor in the region who specializes in general pediatrics or heart or lung conditions in children. Harp is
a pediatrician and received her medical degree from the University of Cincinnati College of Medicine.
RICHARD N. NELSON, MD, FACEP
OSU DEPARTMENT OF EMERGENCY MEDICINE
Richard N. Nelson Distinguished Alumni Award established. The Ohio State University recently established the
Richard N. Nelson Distinguished Alumni Award in honor of Richard “Rick” Nelson, MD. The award will be presented
annually to a graduate of the OSU Emergency Medicine Residency or Fellowship Programs who made significant
contributions to the specialty. Dr. Rick Nelson has had a prominent career at OSU, also serving in numerous
leadership positions locally, regionally, and nationally. After 34 years of leadership in emergency medicine and
service to Ohio State, Nelson transitioned to emeritus faculty status where he continues to work in OSUMC
emergency departments and Physician Advisor program. Dr. Nelson continues to speak and publish articles about
ABEM testing innovations and serves ABEM as an examiner and oral exam writer.
ROBERT E. FALCONE, MD, FACS
COLUMBUS MEDICAL ASSOCIATION
Named CEO of Columbus Medical Association. Robert E. Falcone, MD, became the new chief executive officer of
the Columbus Medical Association (CMA). Falcone is the first physician CEO in the CMA’s 123-year history. Dr.
Falcone, who has an extensive medical career as a practicing physician and hospital administrator, will be leading
and organization of over 2,000 physicians and looks forward to seeing membership continue to grow.
STEWART D. RYCKMAN, MD
CORONER – RICHLAND COUNTY
Selected as Believe in Ohio STEM Exemplar. Stewart Ryckman, MD, was selected by the Ohio Academy of Science
to serve as a role model for students to encourage them to pursue STEM careers. Ryckman attended the Ohio
State University College of Medicine with a specialty in obstetrics & gynecology. Dr. Ryckman is retired, but
continues in his role as county coroner in Richland county.
LAURA C. LONDRA, MD, FACOG
OHIO REPRODUCTIVE MEDICINE
Named a CREST Scholar. Dr. Laura Londra has been named a CREST Scholar for 2015-2016 Clinical Reproductive
Scientist Research Training Scholars Program. Londra was one of only four Reproductive Endocrinology and
Infertility physicians in the U.S. selected for this prestigious award which consists of a clinical research scholarship
funded by the American Society of Reproductive Medicine and the National Institutes of Health. The goal of the
award is to support individuals who have shown promise in clinical research activities while practicing reproductive
medicine. Dr. Laura is a graduate of the University of Buenos Aires and completed her fellowship training in
Reproductive Endocrinology at Johns Hopkins. Dr. Londra’s research has been published in multiple journals
including the official journal of the American Society of Reproductive Medicine, Fertility and Sterility. Last year her
most recent publication had the honor of being selected for discussion by a worldwide audience of more than 500
fertility specialists during the July online live Fertility and Sterility Journal Club.
24
Ohio Medicine |
The official publication of the Ohio State Medical Association
STEPHEN W. DAILEY, MD
UC HEALTH ORTHOPAEDICS & SPORTS MEDICINE
Honored by Press Ganey. Stephen Dailey, MD, was recognized for being among the top 10 percent in his field
at a reception at the Cincinnati College of Medicine. Dr. Dailey received the Patient Experience Excellent Award
from Press Ganey Holdings. Dr. Stephen Dailey attended the Ohio State University College of Medicine and is an
orthopedic surgeon with UC Health.
ROBERT SMITH, MD
2016 Health Care Heroes Lifetime Achievement Award. Robert Smith, MD, was honored by the Business Courier
with the 2016 Health Care Heroes Lifetime Achievement Award. Dr. Smith, 94, joined the University of Cincinnati
College of Medicine in 1975 as the first director of the Department of Family Medicine. In addition to building the
department, Smith created several fellowship training programs and a residency program, which has graduated
more than 300 family physicians. Dr. Robert Smith has expertise in the diagnosis and treatment of headaches,
founding the UC Headache Center in 1981, as well as expertise on type 2 diabetes, completing research projects on
genetics and diabetes medication. As a general practitioner in England, Smith won the British Medical Association
Hawthorne Price for research on pain sensitivity in 1958.
To nominate an OSMA Member for Member Newsmakers
submit information to [email protected]
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2016 | ISSUE 1
25
EXECUTIVE DIRECTOR’S
CLOSING POINT
Advocacy at the OSMA Has Many Faces
When you’re talking healthcare, what is advocacy? It’s a
popular word at the Ohio State Medical Association (OSMA) as
advocacy is one of our core tenets. Most physicians associate
the OSMA’s efforts with legislative advocacy, and they would be
right. And a few physicians associate the OSMA’s efforts with
regulatory advocacy, and they too would be equally correct.
The medical board’s proposed changes threaten the anonymity
of the physicians and could force physicians who want help to
avoid seeking treatment for fear of being publicly exposed and
harming their careers. The OSMA and several other healthcare
associations to jointly oppose the rule change and instead work
with the State Medical Board of Ohio on reasonable alternatives.
The OSMA is currently supporting a prior authorization bill at
the Ohio Statehouse that would lessen the red tape and delay
tactics healthcare companies often employ before agreeing to
cover necessary medical services and procedures. The way we
view it, the changes to prior authorization rules can mean a
matter of life and death for some a patient awaiting clearance
for diagnosis or treatment of their medical condition.
Another regulatory issue the OSMA closely monitors is the
prescribing of opioids. A few years ago as prescription drug
abuse grew to become an epidemic for Ohio, state lawmakers
and regulators sought ways to control the problem by focusing
their attention on physician actions. To meet their concerns
the OSMA in 2015 created and launched Smart Rx, an
education program and public awareness campaign aimed
at helping physicians improve their knowledge of rules for
opioid prescribing.
Scope of practice is another important legislative advocacy
issue for the OSMA. The OSMA supports physician-led, teambased approaches to patient care. This allows a physician
with a team of nurses, therapists, and pharmacists to provide
treatment more efficiently for a greater number of people
in shorter periods of time, thus providing greater access
and hopefully improved quality of care. But every year other
healthcare professionals seek to expand their scope of duties.
This year is no exception as advanced practice nurses seek
to be able to see a patient, test and diagnose them, and offer
treatment plans without consulting a physician.
Just as important for physicians are the regulatory advocacy
efforts of the OSMA. One deeply concerning rule with pending
medical board changes opposed by the OSMA is the One-Bite
Rule. Ohio’s current One-Bite Rule allows impaired physicians
and other licensed health care professionals who complete
treatment and aftercare at a medical board approved provider
to remain in the private sector for monitoring, as long as their
acts did not result in a criminal conviction or put patients or
others at risk.
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Ohio Medicine |
In January, the Governor’s Cabinet Opiate Action Team (GCOAT)
released guidelines for treating acute pain which includes
developing non-pharmacological treatments before prescribing
an opioid. With the OSMA’s input, the guidelines remain only that
– guidelines not mandates. And they clearly state that they are
not intended to replace clinical judgment. The guidelines were
developed at the urging of the OSMA who previously worked
with GCOAT to establish treatment guidelines for chronic and
emergency room pain.
Advocacy is a powerful word at the OSMA and takes on many
forms, all of which are important for us to meet our mission of
“empowering physicians, residents and medical students.”
D. Brent Mulgrew
Executive Director
Ohio State Medical Association
The official publication of the Ohio State Medical Association
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