MSSNYeNews: October 18, 2019 – Foul Turns Fair

Arthur Fougner MSSNY Presiident

Arthur Fougner, MD
MSSNY President

October 18, 2019

Vol. 22  Number 39



October marks the tenth anniversary of the establishment of FAIR Health. Among other things, FAIR Health holds the database of physicians’ charges. It wasn’t always that way. When the managed care networks were first set up, many physicians did not join the plans and were Out of Network. Were an insured to see one of these physicians, if their plan had an Out of Network provision, that physician would be paid according to the plan’s formula based on Usual and Customary Fee. The most widely consulted database for usual and customary was held and run by a company called Ingenix. Basically, all the insurers relied on Ingenix data for their payment determinations. However, it turned out there was a problem. Ingenix was a wholly owned subsidiary of United Healthcare – soon to be United Health Group.

Our Medical Society began an action that didn’t go far but attracted attention. Soon, then Attorney General Andrew Cuomo became interested and he began investigating how exactly insurers and Ingenix determined these out of network payments. Cuomo’s staff found the flies in that ointment.

A NY Times editorial from 2008 noted that the insurers’ ingenious Ingenix solution was an invitation for abuse since the insurers had a strong financial interest in keeping the payments to physicians low. Eventually, Attorney General Cuomo filed suit, thus joining Medical Societies in their actions against the insurers. When Ingenix was unable to demonstrate even that their figures were accurate, it was game over and United agreed to pay $50 Million that was used to set up a new database – FAIR Health.

Oh, but don’t shed a tear for Ingenix. It is still around – you know it as OPTUM.

And so it goes.

Comments?; @sonodoc99

Arthur Fougner, MD
MSSNY President

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Please Continue the Fight for a Fair Federal Solution to Surprise Medical Bills
Please continue to contact Senators Schumer and Gillibrand, as well as your local Representative in Congress, in support of a fair federal legislative solution to the issue of surprise medical bills.  By clicking here, you can send a letter, make a tweet and make a phone call to your elected officials. It only takes a few minutes and contains all of the details necessary to get our point across.

Recently, the NY Department of Financial Services released a report detailing the great success of New York’s surprise bill law enacted in 2014. In particular, the report found that between 2015 and 2018, consumers over $400 million and reduced out-of-network billing by 34%, in part through a reduction in costs associated with emergency services and an increased incentive for network participation.

While MSSNY together with physician groups across the country are working diligently to refute the lies and half-truths expressed by the insurance lobby, more physician advocacy is urgently needed. MSSNY leadership and physician advocates have been meeting with key members of Congress to advocate for passage of legislation that emulates New York’s successful model, such as H.R.3502, sponsored by Representatives Ruiz and Roe.   This week, the number of co-sponsors for this legislation reached 100, including 13 members of New York’s Congressional delegation (Clarke, Higgins, King, Lowey, Meng, S. Maloney, Morelle, Nadler, Rice, Rose, Stefanik Suozzi, and Velasquez).

At the same time, grave concerns have been raised about the alternative being pushed by insurance companies (H.R.3630, sponsored by Representative Pallone, and S.1895-Alexander/Murray), that would limit payment in these surprise bill situations to an insurer controlled “median contracting rate”.  When California enacted a similar law a few years ago, what followed was a 48% increase in patient access to care complaints including delays in obtaining care or securing physician appointments, inadequate selection of providers, and problems accessing facilities.   

United, Empire Aetna and many of the other market dominant companies already hold enormous power over physicians and their patients to dictate the terms of care delivery.  Please do not give them any more power.  Please contact your Senators and Representatives today!

Patient Medical Debt Protection Act Introduced
Comprehensive legislation (A.8639/S.6757 – was recently introduced in New York that would place significant new restrictions on the billing of patients for outstanding medical bills.  The legislation would also expand New York’s “surprise bill” law to address circumstances where a patient receives a bill from an out of network physician due to incorrect information regarding that physician’s participation status.

MSSNY, together with representatives for several specialty societies, have met with key legislative staff to have a further understanding of the legislation, including raising significant concerns with a component of the legislation that would require a consolidated bill for the services of hospitals and physicians for hospital-based care.  We noted that the requirement to go through the hospital would substantially increase the circumstance where a physician is unpaid or underpaid for medical care delivered, since the physician bill will very often be a fraction of the hospital bill.   The legislation is also unclear as to how such hospital based care would be billed to an insurance company when the patient has health insurance coverage.  A major source of the problem facing patients, we noted, is the increasing number of health plans offering coverage with enormous deductibles, which necessitates legislative action to increase coverage options to reduce this huge financial burden for patients.

Please remain alert for further updates on this legislation.

Contact Your Members of Congress to Prevent a Medicare Conversion Factor Freeze
As Congress works towards a year end healthcare package, we are calling on Congress to stand with America’s physicians and patients by urging Congress to implement positive payment adjustments to the grossly inadequate Medicare fee schedule.  Click here to send a letter to Senators Schumer and Gillibrand, as well as your congressional representative.

For years, physicians were faced with an uncertain environment as Medicare’s deeply flawed Sustainable Growth Rate (SGR) formula constantly threatened devastating cuts that would deeply impact the access to care for millions of patients. The Medicare Access and CHIP Reauthorization Act (MACRA) got rid of the SGR and provided modest increases for a few years, but physicians are now facing a pay freeze for the next six years.

According to the Consumer Price Index, economy-wide inflation increased 43 percent or 2.1 percent on average. However, adjusting for inflation in practice costs, Medicare physician pay has declined by 19 percent between 2001 and 2018.  Based on these statistics it is clear that American physicians cannot continue to provide quality care to Medicare patients under the current payment system therefore;

We are urging Congress to:

  • Implement positive payment adjustments for physicians to replace the payment freeze over the next six years.
  • Extend the Advanced APM bonus payments for an additional six years.
  • Implement additional technical improvements to the MACRA MIPS program to reduce the hassles inherent in complying with the program.

These improvements will have an immediate impact and help protect physician practices from accruing additional penalties as they transition over to the MIPS and APM programs.

Albany Policy Forum Examines New York’s Enormous Medicaid Budget
This week the Empire Center for Public Policy held a policy forum: ‘Medicaid Migraine: Retaking control of New York’s Surging Health-Care Costs’ on Wednesday at the Albany Institute of History and Art. The forum, which was comprised of a panel of individuals from various organization which included Rose Duhan, President and CEO of Community Health Association of New York State, James Lytle, Partner, Manatt, Phelps & Phillips, Lara Kassel, Coordinator at Medicaid Matters and Harold Iselin, Managing Shareholder at Greenberg Traurig.

Rose Duhan, President and CEO, Community Health Care Associations of New York State: highlighted the disparity between the amount that is spent on Medicaid verses the overall amount spent on public health in New York State. She spoke about the need to focus on the social determents of health and investing in existing social services infrastructure to improve patients’ outcomes. She noted that the social aspects of health which includes access to food, housing and racism all drive healthcare costs and although cannot be solved in a single budget cycle require investment over the long term.

James Lytle, Partner, Manatt, Phelps & Phillips: noted that it shouldn’t be a surprise that Medicaid continues to have a cost-discipline issue. He noted that while New York is a compassionate state that avoids having to cut spending on programs, though nearly 1/5 of spending on health-care is wasted.  With regard to the global cap, he noted the cap doesn’t cut costs; it simply counts them and is a barometer to show how much has been spent thus far.  He also noted that long term care is the biggest driver of Medicaid spending due to an aging population with less family and community-based resources being available to them.  Moreover, many stakeholders will be impacted if sudden big changes are made.

Lara Kassel, Coordinator of Medicaid Matters New York: emphasized on the need for policy makers to look at Medicaid from the perspective of the consumer; those who are directly benefitting from the program. She added that their perspective comes from the advocacy and highlighted the importance of looking at their organization as an equal partner when it comes to budget-making.

Harold Iselin, Managing Shareholder at Greenberg Traurig: noted that the global cap has been a useful tool that has added predictability to budgeting. He spoke about the three main drivers of Medicaid costs; Enrollment, Health-Care Costs and Special Programs. Regarding enrollment, he noted that it is a good sign and having an increase in enrollment is a good thing.  In relation to utilization costs, he noted that overall it has been a successful outcome, adding that it has not spiked even in terms of long-term care.  When it comes to unit costs however, he highlighted three major drivers; minimum wage, pharmacy costs and hospital costs. In terms of minimum wage he noted that it was originally supposed to be outside of the global cap but was added into it later on.  In relation to pharmacy costs, he noted that as new treatments were introduced namely the Hep-C treatment, costs went up. He added that though physician costs have stayed flat overall, there must be more investment into primary care. He concluded by mentioning that you cannot look at the global cap without looking at the general fund and state funding in general.

MSSNY, CT, and NJ Medical Societies Commend Governors’ Efforts to Address “Cross-Border” Issues Relating to Cannabis; Concerns Remain About Legalization of Marijuana Use

On October 17, MSSNY released the following joint statement to the press:

“We commend the regional approach that the Governors of Connecticut, New Jersey, and New York are seeking to take to address ‘cross-border” issues relating to cannabis purchase and use.

However, our medical societies continue to have serious concerns with proposals to legalize the purchase of recreational or so-called “adult use” marijuana given the public health challenges that have arisen in other states that have legalized the purchase of marijuana for non-medical purposes.

These concerns have grown in recent weeks given the significant number of cases of pulmonary illness relating to the use of vaping devices, which have included many instances where cannabis was being vaped.

Important steps were taken this year in New York State to greatly reduce the threat of criminal sanction based upon possession of small amounts of marijuana, including expunging previous convictions for low-level possession offenses.  We believe that similar “decriminalization” measures should be pursued in other states, and a review taken as to whether these laws are achieving their intended goals.  Most importantly, we urge Congress and the President to work together to pass legislation to re-schedule marijuana under the Controlled Substances Act. Then, necessary research as to the health benefits and health risks of marijuana could begin.”

Art Fougner, MD
President, Medical Society of the State of New York
Marc Levine, MD
President, Medical Society of New Jersey
Bollepalli Subbarao, MD
Connecticut State Medical Society

Montefiore Plans to Close Mount Vernon Hospital
Montefiore Health System plans to close its Mount Vernon hospital and invest $41 million to build an emergency department and ambulatory care center, officials said Tuesday. Upon completion of the 40,000-square-foot health care complex, the 121-bed hospital will close. Montefiore expects construction to be completed by the end of next year. It still must receive state Department of Health approval for the project. The hospital will be replaced by the emergency department and medical offices for primary and specialty care.

Montefiore Health System, which has its flagship hospital in the Bronx, has expanded rapidly in the Hudson Valley. It has taken over management of hospitals in Cornwall, New Rochelle, Nyack, Newburgh, and White Plains. It is negotiating to add St. John’s Riverside Hospital in Yonkers. Services at the new center will include primary care, mental health care, specialty care, pediatrics, chronic disease management, wound care and imaging services. Its emergency department will include equipment for cardiac diagnosis and monitoring as well as an X-ray machine and CT scanner.

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Weill Cornell Medicine Eliminates Medical Ed Debt for Qualifying Students
A transformative new scholarship program established by Weill Cornell Medicine will eliminate medical education debt for all students who qualify for financial aid, the institution announced today. A lead gift from The Starr Foundation, directed by Weill Cornell Medicine Overseer Maurice R. Greenberg, in partnership with gifts from Joan and Board of Overseers Chairman Emeritus Sanford I. Weill and the Weill Family Foundation have made this longstanding goal possible. Learn more.

HHS: Physicians Guide to be More Cautious When Tapering Patients Off Opioids
HHS “published a guide” instructing physicians to be more cautious in tapering patients off opioids in response to reports of some physicians cutting patients off from opioids too fast or “in some cases even dismissing patients from their practice.”

The new guide states that doctors “should never abandon” pain patients, and warns of risks including “acute withdrawal, pain exacerbation, anxiety, depression, suicidal ideation, self-harm, ruptured trust, and patients seeking opioids from high-risk sources.” It says that opioid doses are typically reduced by between 5 and 20 percent a week, but that slower tapers are often better tolerated, partly because they are less likely to trigger withdrawal symptoms.

The guide also lays out reasons to consider tapering patients off opioids, stressing that the benefits of staying on the drugs need to outweigh the risks. Those risks are substantial, including addiction and overdose, but many chronic pain patients and their doctors say they have been able to stay on high doses of opioids and function competently. (NY Times, 10/17)

As of October 8, the CDC confirmed 28 deaths associated with the use of e-cigarettes, or vaping, and 1,299 lung injury cases.

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Workers Comp Webinars for Medical Providers
The Board is hosting webinars to provide training on the Drug Formulary and prescription prior authorization process. These are being offered at different times so you can choose one that best fits your schedule. Visit the Board’s website to register for one of the sessions listed below.

October 22, 8:30 a.m. – 9:30 a.m.
October 24, 4:30 p.m. – 5:30 p.m.
October 29, 8:30 a.m. – 9:30 a.m.

More Information

For more information, visit
General Formulary questions:
Technical support questions:
Subscribe for email notifications

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Case Count for Vaping-Related Lung Injury Up
CDC yesterday said as of Oct. 15, the number of people sickened from a lung illness linked to vaping and e-cigarettes rose to 1,479 cases. So far, 33 people have died from the illness—which officials are now calling EVALI, short for “e-cigarette or vaping product use associated lung injury”—and additional deaths are being investigated.

Only Alaska among the 50 states and the District of Columbia has yet to see a case. Deaths confirmed as part of the outbreak total 26.Moreover, it is reported that the CDC will shortly step up its surveillance efforts on “vaping illness” in a novel way.  The agency will request that doctors seeing patients with suspected respiratory infection ask about their use of vaping products.

An updated guidance will “advise physicians on how to diagnose and manage patients who may have both a lung infection and a vaping injury,” the news service reported.

Physicians suspecting a patient has vaping-related lung damage are asked to get a detailed history of substances used and obtain the actual products for testing, if possible, as well as to report the case to local or state health departments.

The CDC said it still had no clear idea of what is causing the vaping-related illnesses. The general profile for victims has not changed either: most are young men and the majority used THC e-liquid products.

Amazon Pays for Employees to Travel to California for Cancer Care
Amazon is aiming to control healthcare spending by paying to send employees to California to receive cancer care, according to The Wall Street Journal. Seattle-based Amazon will cover travel expenses for employees diagnosed with cancer who see physicians at Duarte, Calif.-based City of Hope.

More than 380,000 of Amazon’s workers and families are eligible for the benefit, which can be used for any cancer diagnosis, according to the report. Dene Sparrman, Amazon’s director of global benefits, told The Wall Street Journal the benefit is designed to lower healthcare spending and increase employees’ choices. “Instead of waiting for patients to get the wrong care first, then reaching out to the expert, this model is designed so that the patient has access to expertise as early as possible to help ensure the correct care is delivered first,” she told The Wall Street Journal. The new benefit also enables Amazon workers to meet with City of Hope physicians by videoconference, when allowed by state regulations, according to the report. (October 15, WSJ)

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When Is the Flu Not the Flu?” CME Webinar on Nov. 20; Registration Now Open
Be sure to sign up for Medical Matters: When is the Flu not the Flu? On November 20 at 7:30am. This is a companion program to the October Medical Matters webinar: Influenza 2019-2020.  William Valenti, MD, chair of MSSNY Infectious Disease Committee and a member of the Emergency Preparedness and Disaster/Terrorism Response Committee will serve as faculty for this program. Registration is now open for this webinar here.  Please click here to view the flyer for this program.

Educational objectives are:

  • Recognize the distinction between types of influenza and other similarly presenting illnesses
  • Describe key indicators to look for when diagnosing patients presenting with flu-like symptoms

Additional information or assistance with registration may be obtained by contacting Melissa Hoffman at

The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA/PRA Category 1 credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Health Matters for Women: Symposium on Women’s Health
LIVE CME Symposium in Queens, November 2, 2019 7:30am – 12:30pm
The Medical Society of the State of New York and the Academy of Medicine of Queens County are proud to announce a live CME symposium entitled Health Matters for Women: Symposium on Women’s Health on November 2nd from 7:30am – 12:30pm at the NYC Health + Hospitals/Queens, 82-68 164th St., A-540 Conference Room, Jamaica, NY, 11432.  Please click here to register. To view the flyer, please click here.

Program schedule:

7:30—8:20 am:           Registration and Breakfast

8:20—8:30am:            Welcome and Opening Remarks

8:30—9:30am:            Health Matters for Women: Endometriosis *
 Faculty: Lisa Eng, DO

9:30—10:30am:         Ovarian Cancer and Genetic Risk **
Faculty: David Fishman, MD

10:30—11:30am:       Health Matters for Women: Fibromyalgia and Myalgic Encephalomyelitis *
Faculty: Florence Shum, MD

11:30—12:30pm:       Genetic Profiling of Breast Cancer and Its implication for Staging, Prognosis and Treatment **
Faculty: Louis Auguste, MD

* The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians

The Medical Society of the State of New York designates each of these live activities for a maximum of 1.0 AMA/PRA Category 1 credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

**The Academy of Medicine of Queens County is accredited by the Medical Society of the State of New York (MSSNY) to provide Continuing Medical Education for physicians.  

The Academy of Medicine of Queens County designates each of these live activities for a maximum of 1.0 AMA PRA Category 1 creditsä.  Physicians should only claim credit commensurate with the extent of their participation in the activity.



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Rental includes: two consultation rooms, private office, private bathroom.  Common waiting room, back office filing space and reception desks included.  Affordable rent.  Location East 60s between Park and Lexington.  Easy distance to Lenox Hill Hospital and New York Cornell.  Subway access within 1 block. Immediate occupancy available.  Call James: 917-710-7643

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Nurse, RN Utilization Review Full-Time-Westbury, NY (In-office position only)
Excellent opportunity for a RN who is seeking a position performing utilization review.  We require 1-2 years recent experience in hospital and/or insurer utilization review and experience using Interqual criteria and/or MCG Guidelines. Data entry/PC skills a plus. Benefits include 401(k), paid vacation and holidays. Send resume and salary requirements to: Empire State Medical Scientific and Educational Foundation, Inc. Human Resource Department e-mail:  Fax: (1-516) 833-4760 Equal Oppty Employer M/F