E-DMN - November 2, 2009

November 2, 2009

Editor's Column: String Theory And Health Care Reform
Physician Tax Defeated In State Senate
Red Flags Rule Enactment Delayed Until June
Blue Cross Blue Shield Association Data Breach Alert
Henry Ford Hospital CEO Steps Down
Domestic Violence Conference Shines Light In Dark Corners
Blues' 'Afterhours' Codes Benefit Physicians
Children's Holiday Party Contributors 2009

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Editor's Column: String Theory And Health Care Reform

By JOSEPH WEISS, MD
Most of us have heard of String Theory – the idea that basic particles of matter vibrate in at least 11 dimensions. Scientists in the field of theoretical physics are at work to derive a mathematical model to bring these 11 dimensions into the world of practical and experimental physics. To date, no formulas have met the mark.

Physicians have no problem understanding the difficulties facing our colleagues in theoretical physics. We are wrestling with our own 11 dimensions, or possibly more, trying to reconcile them into one coherent plan that could direct us. So far, no health economist, medical care theoretician or interested politician has found a satisfactory scheme.

We have our own cost, quality and care incompatibilities. We face increasing expense in our offices and equipment; the bill for an updated medical record system alone likely will cost $50,000 per doctor, with upkeep of $2,000 or more a year. At the same time, we have little certainty that we will see the Sustainable Growth Rate (SGR) Formula replaced. Chances are Congress will set the SGR aside and give us another ½ percent increase for our claims. For us, choice means specialty of our choice and at least for students and residents that decision will rest on what insurers will pay.

In Michigan, our strings must tie together the threats of scope-of-practice expansion by chiropractors campaigning endlessly to do more and the restrictive influence of the medical liability climate, which pushes us to circumscribe our own scope of practice. Furthermore, we have not integrated other health personnel such as nurses, physician assistants, technicians and other health care workers into the medical community as much as observed them enter and take up squatter’s rights.

We are admonished by critics for our failure to practice evidence-based medicine. Yet much of our practice must remain a response to the unique character of the individual patient rather than seeing that individual as another pixel on the health calculation’s bell-shaped curve.

The most difficult of the vibrating strings is our business model. Our future business model likely will include the necessity for the medical community to group in a regional way with a central authority. Will solo practices remain, or will physicians work in small groups or twos, threes or fives? Will the business unit be the size of Henry Ford or Beaumont Hospital? Will the scattered physician offices that represent us now be merged into an IPA (Independent Physician Association) model? Or is there some form of business we turn to that is not yet understood, like a health cooperative?

So far, String Theory has physicists tied up in knots. Physicians should not also become so strung out over requiring symmetry in every aspect of medical life. In my opinion, the most important area on which to reach a consensus is our future business model; the one I favor is the IPA. It is the one most likely to provide the organization that insurers will demand and the independence that individual physicians will need.

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Physician Tax Defeated In State Senate

The Michigan State Medical Society Oct. 28 thanked Senate Majority Leader Mike Bishop for his leadership and the full Senate for its overwhelming, bipartisan vote against an ill-conceived tax on Michigan's health care system.

"During the past two weeks the Michigan Senate heard significant input regarding this legislation and today wisely voted 32-4 to reject a tax on Michigan's health care system that would have led to serious, unintended consequences including reduced access to health care for all Michigan citizens," said MSMS president Richard E. Smith, MD, a Detroit obstetrician/gynecologist. "We thank the Democratic and Republican senators who voted against this bill for their political courage in a difficult time to take a bad idea off the table."

"Even though Michigan's Medicaid program has been under-funded for decades and we've had to fight nearly every year to avoid further cuts, members of the Michigan State Medical Society have continued to treat Michigan's most vulnerable patients," Doctor Smith said. "We are physicians who care. We will continue to work with legislative leaders and the governor to develop a sustainable Medicaid program in Michigan."

The 3 percent tax on physicians' gross receipts would have resulted in physicians retiring earlier, moving to other states or dropping out of the Medicaid program entirely, according to a recent email survey of MSMS members. Young physicians-in-training said it would have been one more reason along with Michigan's poor economy to leave the state once their training was completed. Others pointed out the tax would have made it nearly impossible to recruit new physicians to the state.

An MSMS coalition of more than 50 specialty societies, county medical societies, Michigan Medical Group Management Association, MSMS Alliance and a number of national specialty societies opposed the tax.

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Red Flags Rule Enactment Delayed Until June

On Oct. 30 the Federal Trade Commission announced that the Red Flags rule is delayed until June 1, 2010, reported the American Medical Association. The AMA has been urging the FTC and Congress that physicians are not "creditors" and should not be subject to the rule. The AMA reports it is pleased that the FTC has granted another delay. For more information on the FTC's decision: http://www2.ftc.gov/opa/2009/10/redflags.shtm

According to an FTC press release from July, “The Red Flags Rule is an anti-fraud regulation, requiring “creditors” and “financial institutions” with covered accounts to implement programs to identify, detect, and respond to the warning signs, or “red flags,” that could indicate identity theft. The financial regulatory agencies, including the FTC, developed the Rule, which was mandated by the Fair and Accurate Credit Transactions Act of 2003 (FACTA). FACTA’s definition of “creditor” includes any entity that regularly extends or renews credit – or arranges for others to do so – and includes all entities that regularly permit deferred payments for goods or services. Accepting credit cards as a form of payment does not, by itself, make an entity a creditor. “Financial institutions” include entities that offer accounts that enable consumers to write checks or make payments to third parties through other means, such as other negotiable instruments or telephone transfers.”

In Nov. 2007, the Federal Trade Commission (FTC) issued a set of regulations, known as the “Red Flags Rule,” requiring that certain entities develop and implement written identity theft prevention and detection programs to protect consumers from identity theft. Originally scheduled for a Nov. 1, 2008 compliance date, the FTC has now delayed the enforcement date of the Red Flags Rule until Nov. 1, 2009. The now-extended compliance date of Nov. 1, 2009 followed two earlier extensions to May 1 and then later to Aug. 1. The AMA reports the extensions are a result of continued advocacy by the AMA and others who continue to object to the applicability of this Rule to health care providers and other professionals.

Since the Rule was issued, the AMA has objected to the FTC's interpretation that physician practices are "creditors" when they accept insurance and bill patients after services are provided or if they allow patients to set up payment plans after services have been provided. The FTC states that this delay is intended to "give creditors and financial institutions more time to review this guidance and develop and implement written Identity Theft Prevention Programs."

While the AMA intends to continue to make the case to Congress and the agency that the FTC should republish the rule so that there is sufficient opportunity to formally comment and state the AMA's objections to physician inclusion in the program, the AMA has prepared a guidance document, along with sample policies, so that members can incorporate a simple identity theft prevention and detection program into their existing compliance and HIPAA security and privacy policies.

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Blue Cross Blue Shield Data Breach Alert

Editor’s Note: The following is a message from AMA President J. James Rohack, MD.

You may have heard reports about a data breach at the Blue Cross and Blue Shield Association (BCBSA) involving provider identifiers. We are working with BCBSA to recommend steps that it can take to help mitigate the risk of identify theft resulting from this data breach.

The breach involved a data set containing names, addresses, taxpayer ID numbers, and NPI numbers of physicians and other health care professionals. The data is used in performing internal matching analyses to compare BCBS provider networks to the networks of other health plans for employer groups. Since some practitioners use their Social Security number as their taxpayer ID number, BCBSA is taking steps to protect these physicians.

It is important to understand that the identifying information was not the intended target of the theft. The data set was stored on a laptop that was stolen from a car, which was one of several cars in the immediate vicinity that were vandalized. There is no reason to believe that the thief intends to use the data to commit identity theft. However, as a precaution, BCBSA is offering credit monitoring services to those providers whose Social Security number was exposed.

Local BCBS Plans in each area are in the process of sending out notifications to affected physicians . If you receive a letter from your local BCBS Plan offering credit monitoring services, we encourage you to take advantage of those services that BCBSA is providing through Experian. Utilizing these services will help BCBSA monitor trends to see if identity theft may be occurring as a result of the breach and could help locate the source of any such identity theft. If you have not been notified directly or if the letter you receive does not include the offer of such services, then it was determined that your Social Security number was not exposed.

We also encourage all physicians to be vigilant in protecting themselves from those who may try to use their identity as a physician to submit fraudulent prescriptions or fraudulent claims. If you receive any suspicious calls or reports erroneously suggesting that you have ordered or prescribed certain goods or services, you should follow up promptly, and notify your local BCBS plan immediately if you confirm that your identity has indeed been stolen.

If you have questions about the data breach, please contact your local BCBS Plan at their regular customer service number. AMA staff will continue to be in contact with BCBSA and will provide further information as it becomes available.

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Henry Ford Hospital CEO Steps Down

Tony Armada, president and CEO of Henry Ford Hospital and Health Network, Detroit, is resigning next month to become president of Advocate Lutheran General Hospital, Park Ridge, Ill., reported Modern Healthcare citing an internal memo from Henry Ford Health System.

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Domestic Violence Conference Shines Light In Dark Corners

By PAUL NATINSKY
Numbers regarding domestic violence are startling and appropriate diagnosis and intervention continue to present a challenge to health care providers and others who attempt to help victims.

Domestic Violence: What Every Health Care Provider Needs To Know, packed the auditorium at the Kresge Eye Institute in Detroit Oct. 29. Attendees heard from seven speakers and a panel during the full-day program.

That women are far more likely than men to be victims of domestic assaults likely is common knowledge; but the fact, reported by the US Department of Justice, that nearly 25 percent of women and 7.6 percent of men surveyed for a study published in July of 2000 said “they were raped and/or physically assaulted by a current or former spouse, cohabitating partner or date at some time in their lifetime.” Based on these statistics, approximately 1.5 million women annually are raped and/or physically assaulted by an intimate partner.

“I had hoped I would see dramatic changes in 50 or 60 years. I’ve seen changes and hope, but not the dramatic changes I’d like to see,” said Judith Barr of First Step, a group dedicated to preventing domestic and sexual violence.

Barr said domestic violence knows no boundaries. She said one-in-three women worldwide are victims, and that abuse affects people from all races, cultures, religions, income and educational levels. It’s a myth that the wealthy and educated see a lower incidence of abuse, it’s just less likely to be reported, said Barr.

She related the story of a woman who, literally, spent the night in a doghouse in the November chill at the behest of her abusive husband. She called First Step and Barr, who was new to her job at the time, tried to keep the woman on the phone and pass her along to a senior counselor. The woman said she did not want to file a report but just tell someone about it and hung up before Barr could get further involved. Before the woman hung up Barr learned that she had two adult sons from whom she was keeping this abusive treatment a secret.

Physicians and health care professionals, much like social workers, are faced with ferreting out cases of abuse, often with frightened and reticent victims as their only resource. The consequences can be devastating. Barr said 80 percent of physical assaults against women are reported during pregnancy. She said many victims demonstrate symptoms of post-traumatic stress disorder, a debilitating mental condition similar to that suffered by soldiers returning from combat.

Many women are reluctant to leave abusive relationships, and with good reason. Women who leave batterers are 75 percent more likely to be killed by the offender than those who stay, a statistic quoted by several speakers.

The American Bar Association states other reasons women stay in abusive relationships. In some cases it’s an economic issue; the abusive spouse controls the finances and in some cases prohibits the victim from working or handling money. Other reasons include pressure to stay in the relationship from other family members, including children, religious issues and sometimes love for the abuser.

Despite the challenges, health care professionals can help victims. According to First Step, “Even if a victim is not ready to leave the relationship or identify the batterer, physicians can recognize and confirm to him or her that this is a serious problem that must be solved. Emergency physicians can let victims know they are not alone, they don’t deserve to be beaten and help is available.”

The American College of Emergency Physicians (ACEP) recommends directly questioning patients about domestic violence if the following medical findings appear:

Central pattern of injuries
Contusions or injuries to the head, neck or chest
Injuries that suggest a defensive posture
Types or extent of injury that are inconsistent with the patient’s explanation
Substantial delay between when the injury occurred and when the patient sought treatment
Injuries during pregnancy
Pattern of repeated visits to the emergency department
Evidence of alcohol or drug abuse
Arriving in the emergency department as a result of a suicide attempt

Other clues to abuse include a “secretive, fearful or even hostile” patient demeanor or a partner to the patient who answers questions for the patient or refuses to leave during the patient interview or exam, said Crystal Arthur, MD, Medical Director of the Department of Emergency Medicine at Detroit Receiving Hospital.

When there are indications of abuse present, physicians can ask several SAFE questions. SAFE is an acronym for Stress/Safety, Afraid/Abused, Friends/Family, and Emergency Plan. Specific questions include: Do you feel safe in your relationship? Have you ever been in a relationship where you were threatened or afraid? Are your friends or family aware that you have been hurt? Are they able to give you support? Do you feel you have a safe place to go and the resources you need in an emergency?

While there is a requirement in most states, including Michigan, that health care professionals report injuries suspected to have resulted from violence of any kind, there are questions about how safe it is for victims if health care professionals automatically and immediately report suspected cases directly to law enforcement agencies.

The American College of Emergency Physicians’ position: “ACEP opposes mandatory reporting of domestic violence to the criminal justice system. Instead, ACEP encourages reporting of domestic violence to local social services, victims’ services, the criminal justice system, or any other appropriate resource agency to provide confidential counseling and assistance, in accordance with the patient’s wishes. In jurisdictions that have mandatory reporting requirements, persons reporting in good faith should be immune from liability for compliance.”

The National Domestic Violence Hotline: 1 (800) 799-SAFE
First Step 24-Hour Helpline: 1 (888) 453-5900

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Blues' 'Afterhours' Codes Benefit Physicians

In the Medicine section of the CPT book, there are codes for Special Services, Procedures and Reports. These codes can be reported in addition to an associated basic service (i.e., evaluation and management code).

There are three codes that Blue Cross Blue Shield (BCBSM) will reimburse for services rendered outside the normal business hours.

· 99050 – Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturdays or Sunday), in addition to the basic service.

(BCBSM defines regular office hours as 8:00 a.m. – 5:00 p.m.)

· 99051 – Services(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

· 99053 – Services(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

These bullet points are the exact nomenclature from the CPT book.

The key point is that these services are paid in addition to the basic service as an incentive for physicians to be available for patients in the “off” hours, so to speak. The idea is that it might keep patients out of the ER for non-emergency services because their physicians are not available for them after work or on weekends.

-- Stacie Saylor, MSMS

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Children's Holiday Party Contributors 2009

The following is a list of contributors to the WCMS Foundation’s 24^th Annual Holiday Party for underprivileged children. This year’s event is Dec. 5 at the New Detroit Science Center. For more information, or to contribute, call (313) 874-1360 or visit www.wcmssm.org

Barbara & Adrian Sheremeta

Fred R. Nelson, MD

Ronald E. Trunsky, M.D. & Judy Jenkins Trunsky

Michael R. Harbut, MD

Dorothy M. Kahkonen

Dr. and Mrs. H. Michael Marsh

Lisa T. Cooper, MD

Volna Clermont, MD

Robert Brent, MD

William Knapp, MD

Nancy Goll

Elizabeth Edmond, MD

Martin Daitch, MD

Benjamin Ramos, MD

Peter Cracchiolo

Robert Borchak, MD

Julian Alvarez, MD

Beth Ann Brooks, MD

Dr. & Mrs. Sajal Choudhury

William L. and Betty G. Knapp

Drs. Safwan Halabi & Razan Asbahi

Joe Weiss & Marilyn Shapiro

Dr. & Mrs. George C. Hill

Neela Sripathi

Homer M. Smathers, MD

Sidney Baskin, MD

John C. Somogyi, MD

Charla Blacker, MD

Todd R. Williams, MD

Iris and Fred Whitehouse

Joseph M. Beals, MD

Stephanie Flom, MD

Dr. & Mrs. Mark F. Pezda

Eudoro Coello, MD

Christopher W. Hughes, MD & Debra J. Hughes

Claus Petermann, MD

Richard D. Cieslak, MD

Daniel S. Moore

Drs. Peter & Alice Watson

Drs. Rachel and Brian Silver

Kathleen Yaremchuk, MD

Anne-Mare' Ice, MD

John M. Malone, MD

Anne Nachazel, MD

Eastside Surgical Specialists

Paul Mazzara, MD

Dr. Richard Pollard

Michael G. Taylor, MD, FACS

Drs. Kenneth & Deborah Granke

Aaron Lupovitch, MD

Keith P. Bartold, MD

Rev. William and Dr. Mary Logan

Scott Monson, MD

Arthur J. Frazier, MD

M. Natacha Umlauf, MD

Phyllis A. Vallee, MD

Michael Schaldenbrand, MD

Heidi R. Gunderson, DO

Paul J. Sullivan, MD

S.V. Mahadevan, MD

Indu & Bala Pai

Chris and Janet Bush

Eve M. VanEgmond, MD

Taufiek Alhadi, DO

Gwendolyn H. Parker, MD

Dr. Ray and Mrs. Marcia Littleton

Drs. Daniel & Margarita Morris

Dr. & Mrs. Laurence E. Stawick

Dr. & Mrs. John Calwell

S. Rao Talla, MD

Ghaus M. Malik, MD

Eastlake Pediatrics PC

Vernon F. Strand, MD and Jane P. Strand

Martin H. Daitch, MD

John Kurtz, MD

Dr. & Mrs. Dan Michael

Mohammed Arsiwala, MD - Livonia Urgent Care

Margaret Dowling, MD

Dr. S. Maitra

George Mogill, MD

Dr. MaryJean Schenk & David Fry

Dr. Grace Engler & Ms. Anna Fedor

Dr. & Mrs. Donald M. Ditmars Jr.

James A. Rowley, MD

Sion Soleymani, MD

Madjid Mesgarzadeh, MD

Dr. & Mrs. Allan Dobzyniak

Helene C. Dombrowski, MD

Drs. Lalitha and Babu R. Vemuri

Robert G. Borchak, M.D.

Patricia A. Kolowich, MD

Joan & Bob Allaben

Advanced Family Health Care

Marcie Treadwell & Gregory Goyert

Dr. Michael Sandler

Tom & Nancy Coles

William G. Nutting, MD

Dr. & Mrs. Edmund M. Barbour

Dr. Philip C. Hessburg

Ron & Diane Strickler

Joseph Mark Tuthill, MD

Deloris Ann Berrien-Jones, MD

Vincent C. Yu, M.D.

Andrew J. Mitchell, MD

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