MSSNY eNews: September 6, 2019 – Consent of the Governed

PRESIDENT’S MESSAGE Arthur Fougner, MD MSSNY President MSSNY eNews September 6, 2019 Vol. 22  Number 33

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Colleagues:

“To secure these rights, governments are instituted among men, deriving their just powers from the consent of the governed.” Thomas Jefferson, “Declaration of Independence”

Credit my colleague from the Great White North, Dr. Shawn Whatley, for this piece. Your Medical Society is your membership organization. While those in leadership may be quite learned in many ways, we are not you. We may think we know what you need but only you truly know what you need. From time to time, we all must reflect on what matters in our day to day lives. Views from 30,000 feet are never quite the same as they are on the ground.

In 1911, Robert Michels coined the Iron Law of Oligarchy – all forms of organization, regardless of how democratic they may be at the start, will eventually and inevitably develop oligarchic tendencies. Over time, motivation shifts from that which is good for the members to that which is good for the preservation of the organization. Much of the time, motivation is in sync. However, some of the time, it is not. This is how organizations fail. Service organizations all too easily forget whom they serve. Leadership may be far more knowledgeable at the organizational level, yet deaf, dumb and blind to members’ daily lives.

Next week, we begin fashioning the MSSNY Legislative Agenda for 2020. So here is your opportunity to weigh in. What are YOUR asks – positive and negative? Please weigh in. What matters to you matters to us all. We may be your voice but we need your vibe.

So what say you?

• Surprise Billing Interview: Dr. Ira Nash recently interviewed me on the subject of surprise billing for his radio program, Well Said with Dr. Ira Nash. Tune into WRHU 88.7FM this coming Monday, September 9 at 4 pm to listen to the program. 

Comments? comments@mssny.org; @mssnytweet; @sonodoc99

Arthur Fougner, MD
MSSNY President

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eNews

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Physician Advocacy Urged on Priority Bills Awaiting Governor’s Signature
As we move into fall, bills that passed during the 2019 session will begin to make their way to the Governor’s desk for action – to either be vetoed or signed into law. Currently, a few priority items for MSSNY that passed both houses this year are awaiting delivery to the. Physicians can quickly and easily send a letter to the Governor here on these issues by using the MSSNY Grassroots Advocacy Center here (direct links to these priority items are listed below):

• Mid-year formulary changes – would prohibit a health insurer from removing a prescription drug from a formulary during the patient’s policy year. Moreover, if the plan’s drug formulary has two or more tiers of drug benefits with different deductibles, copayments or coinsurance, the plan may not move a drug to a tier with higher patient cost sharing during the policy year. It also prohibits the plan from adding new or additional formulary restrictions during the policy year. Please reach out to the governor and let him know how helpful this bill would be for patients by clicking here.

• Partial prescription fills – would allow prescribers, in consultation with their patients, to prescribe up to a 30-day supply of a controlled substance with a notation to the pharmacist that they should only dispense the amount agreed to by patient and prescriber. Each partial fill would be dispensed and recorded in the same manner as a normal refill and the aggregate quantity dispensed across partial fillings may not exceed the overall total quantity prescribed. This measure would help to reduce unnecessary accumulation of leftover medication in households, and prevent diversion. Please encourage the governor to sign this legislation by clicking here. 

• Malpractice expansion – two bills passed the legislature that will further tip the scales in lawsuits against physicians and others, adding costs and potentially increasing your liability premiums while doing nothing to reform the current broken system. One would force physician defendants into making a “blind gamble” in cases involving multiple defendants where one defendant settles prior to trial and would enable in many cases the total payout to a plaintiff to actually exceed a jury’s award. The other would allow plaintiffs to collect a judgment from a third party that is not a direct party to the lawsuit in question. The bill would permit this to occur even though the plaintiff had not sued or perhaps could not have sued the third-party defendant in the first instance. Please let the governor know how harmful these bills would be by clicking here.

• Surprise Billing Legislation Poised to Move: Physician Action Urgently Needed!

• With Congress set to return to DC, all eyes are on the competing pieces of surprise billing legislation that are up for debate. Rhetoric is heating up with insurance company hit pieces being posted in national media outlets such as the Washington Post in support of legislation to pad their bottom lines while potentially harming patient access to care through network terminations and inadequate specialty coverage in hospitals. It is imperative that physicians send a letter to Senators Schumer and Gillibrand, as well as their local Representative in Congress here. This link allows you to participate in a grassroots campaign that sends a message to your elected officials, through a letter, tweet and phone call. It only takes a few minutes and contains all of the details necessary to get our point across.

• While MSSNY is working diligently with partners 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 the effective, sensible and bipartisan bill H.R.3502, sponsored by Representatives Ruiz and Roe. Further, 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).

•         New York’s acclaimed system is clearly working, with patients being removed from the fight, while physicians and insurance companies work payment out fairly via an independent dispute resolution process. This process is closely mirrored by H.R.3502, which is why MSSNY and physician groups across the nation support this legislation. Conversely, H.R.3630 is similar to California’s disastrous benchmarking system that has resulted in significant physician network terminations and reduced on-call specialty care access in emergency departments.

• Moreover, this week a study was released attacking the Congressional Budget Office’s dubious claim about the savings that would accrue through disastrous proposals like HR 3630/S.1895

• In particular, the report notes that the savings will not be what CBO has projected due to a) increased health system costs arising from an acceleration of hospital purchase of physician practices b) decreased tax revenue from physician practices and c) the premise of savings resulting decreased corporate health insurance premiums being faulty.
• For more about the intense advocacy on this issue, please read this article in The Hill.
• Please contact your Senators and Representatives today! 

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Responding to Physician Pushback, ABIM Announces New Option for MOC
Physicians certified by the American Board of Internal Medicine (ABIM) will soon have a new option that takes some of the pain out of maintaining their certification. In a letter sent to its diplomates, the ABIM board of directors announced that it plans to add a longitudinal assessment option for Maintenance of Certification (MOC) that will allow physicians to take shorter, more frequent tests online.

“As a result, the ABIM board in August committed to providing a longitudinal assessment option that will allow physicians to take tests online to maintain their board certification.

“We recognize that some physicians may prefer a more continuous process that easily integrates into their lives and allows them to engage seamlessly at their preferred pace while being able to access the resources they use in practice,” Marianne Green, M.D., chair of the board of directors, and Richard Baron, M.D., president and CEO said.

The American Board of Medical Specialties (ABMS), made up of 24 medical specialty boards including ABIM, has faced a backlash in recent years from physicians over tougher requirements and costs of MOC. That prompted changes in the process by those certifying boards, including the ability to take the exam online as well as allowing doctors to use clinical references to answer questions as they do in practice.

The ABIM said it is developing the new option, and, in the meantime, its current MOC program with the choice of its two-year “knowledge check-in” and traditional long-form exam physicians take every 10 years will remain in effect. The board, which certifies internal medicine doctors to practice in the specialty, said more details about the new option will be revealed in the months ahead as it looks for physicians to play an active role in providing feedback.

The ABMS said other boards have developed a longitudinal assessment option including the American Board of Colon and Rectal Surgery, the American Board of Dermatology, the American Board of Medical Genetics and Genomics, the American Board of Nuclear Medicine, the American Board of Otolaryngology-Head and Neck Surgery, the American Board of Pathology and the American Board of Physical Medicine and Rehabilitation.

The longitudinal assessment option will offer “a self-paced pathway for physicians to acquire and demonstrate ongoing knowledge,” said Green and Baron. However, the traditional long-form assessment will remain an option as some physicians prefer a point-in-time exam taken less frequently.

With the new option, physicians will be able to answer a question and receive immediate feedback as to whether it was correct, along with rationale and links to educational material. “By engaging in such a pathway, physicians can assure their medical knowledge is up to date and utilize—in real time—learning activities to address gaps,” they said.

The ABIM said it developed the new option based on feedback from internal medicine physicians including focus groups and interviews as well as information from other ABMS boards.

The ABMS said its member boards are exploring and piloting longitudinal assessment as part of their continuing certification programs. Longitudinal assessment draws on the principles of adult learning combined with modern technology to promote learning, retention and transfer of information, the group said. (Fierce Healthcare)

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NY AG Leading Coalition to Allow Stays for Immigrants in Extreme Medical Need
New York Attorney General Letitia James is leading a coalition of 19 attorneys general in calling on the U.S. Citizenship and Immigration Services and U.S. Immigration and Customs Enforcement to provide answers regarding the status and oversight of the federal medical deferred action program, which has allowed immigrants to apply to remain in the United States if they are in extreme medical need. The attorneys general wrote a letter to the acting directors of the agencies that they are “deeply concerned by USCIS’s apparent decision to stop considering requests for medical deferred action.”

Garfunkel Wild Offers Discount to MSSNY Members for Nov. Symposium in NYC
Garfunkel Wild is pleased to offer a discount to members of the Medical Society of the State of New York to attend Garfunkel Wild’s 6^th Annual ASC and Healthcare Management Symposium on November 1, 2019 in NYC.  This has been a highly successful program and over the years it has grown in content, attendees and sponsors.  The agenda includes speakers from New York, Connecticut and New Jersey who will present timely and important topics that should be of great interest to your members.

For more information, please see the flyer. MSSNY members will receive a discount ($285) if you register before September 15! After September 15, the cost is $350.

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New York Law Ends Religious Exemptions to Vaccinations
Opponents challenging the constitutionality of a New York law that ends religious exemptions to school vaccination requirements hit another roadblock this week as a state appellate court rejected their request to block the repeal. A four-judge panel of the State Supreme Court Appellate Division’s Third Judicial Department on Thursday denied Attorneys Michael Sussman and Robert F. Kennedy Jr.’s motion for a preliminary injunction in the case.

The New York Times (9/3) reports that as the new school year begins this week in New York, the parents of about 26,000 children “who previously had obtained religious exemptions to vaccinations, are facing a moment of reckoning.” A state law, “enacted amid a measles outbreak…ended religious exemptions to vaccinations for children in all schools and child care centers.”

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Physicians More Likely to Prescribe Opioids Later in the Day or Running Late
A study published in JAMA Network Open on August 30 reveals that physicians were more likely to prescribe opioids later in the day and when appointments were running behind schedule.

The study utilized claims and electronic health data in 2017 for 678,319 patients with new pain who saw 5,603 physicians at health care clinics. The patients’ complaints ranged from back pain and headaches to muscle and joint aches. The researchers looked at the order of appointments and whether an appointment started at its scheduled time. Opioid prescriptions were compared to prescriptions of non-steroidal anti-inflammatory drugs and physical therapy.

Overall, physicians were 33% more likely to prescribe opioids later in the day and 17% more likely to do so if the appointment was running later than its scheduled time. NSAIDs and physical therapy prescribing did not change throughout the day.

When working with patients in pain who want opioids, offering them alternative therapies such as NSAIDs or physical therapy can require time-consuming discussions, Neprash said. “Prescribing opioids may be the quick fix when they do not have enough time to discuss non-opioid options.”

In 2017 there were six times the number of opioid related deaths compared to 1999. While much of the opioid epidemic is due to illicit drug use, prescription opioids still play a large role. The authors note that if prescribing practices remained constant throughout the day, 4,459 opioid prescriptions would not have been written in 2017.

Dr. Mark Linzer, director of the Office of Professional Worklife at Hennepin Healthcare in Minneapolis, “I suspect this is the tip of the iceberg: that time pressure has numerous adverse consequences…The conversation that avoids narcotics just takes time,” he said.

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Feds Eyeing Unauthorized Vaping Products in Outbreak of Severe Lung Disease
Health officials are warning against the use of black market or unauthorized products for vaping as they investigate at least 215 cases of pulmonary illness potentially related to e-cigarette use. The Washington Post reports that authorities are investigating whether contaminants may be involved.

Officials also caution against using e-cigarettes in ways that are not intended by the makers, like dripping or dabbing. For dripping, users drop e-cigarette solvents onto the hot coils of the e-cigarette, resulting in more concentrated compounds. For dabbing, substances containing high levels of tetrahydrocannabinol (THC) or cannabidiol (CBD) are superheated in the device. THC and CBD use has been reported in many, but not all, cases.

Some patients who have developed pulmonary disease improved with corticosteroids. Antibiotics have not demonstrated a consistent effect. Several patients were diagnosed with lipoid pneumonia.

The CDC is recommending that clinicians:

• • • Ask all patients who have used e-cigarettes in the past 90 days about whether they have had pulmonary illness.
    • Obtain a detailed history — including the substance, device, and methods used, and where products were purchased — in cases of severe pulmonary disease where e-cigarette use is suspected.
    • Coordinate testing with the appropriate health department if e-cigarette products are available for testing.

FDA MedWatch safety alert; CDC health advisory

Surgeon General Warns About Marijuana’s Effects on Young Brains
U.S. Surgeon General Jerome Adams is warning about the dangers that marijuana poses to the developing brains of youth and fetuses. In an advisory released Thursday, he writes: “No amount of marijuana use during pregnancy or adolescence is known to be safe.

Until and unless more is known about the long-term impact, the safest choice for pregnant women and adolescents is not to use marijuana. “The percentage of pregnant women who said they had used marijuana in the past month doubled between 2002 and 2017 (from 3.4% to 7%). In 2017, over 9 million young people aged 12 to 25 said they had used marijuana in the past month. The Surgeon General says that frequent marijuana use during adolescence is tied to brain changes related to memory, attention, decision-making, and motivation. Fetal exposure is linked to disruption of the endocannabinoid system and lower birth weight. Surgeon General’s advisory HHS news release; Background: NEJM Journal Watch Women’s Health coverage of marijuana use in pregnancy

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3500 Kidneys Discarded Every Year Due to Intense Regulations
There are 93,000 people in the United States waiting for a kidney transplant, and kidney disease kills about 5,000 U.S. residents on the kidney waiting list annually. Yet, a study published last week in JAMA Internal Medicine estimated the United States throws away at least 3,500 donated kidneys every year, mainly because of the “intense regulatory scrutiny of U.S. transplant programs.”

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AMA Releases 2020 CPT Code Set
Updates to medicine’s common language reflect tech-enabled patient services
The AMA announced the release of the 2020 Current Procedural Terminology (CPT^®) code set containing identifiers and descriptors assigned to each medical, surgical, and diagnostic services available to patients. There are 394 code changes in the 2020 CPT code set, including 248 new codes, 71 deletions, and 75 revisions. In making these updates, the CPT Editorial Panel considered broad input from physicians, medical specialty societies and the greater health care community.

Among this year’s important additions to CPT are new medical services sparked by novel digital communication tools, such as patient portals, that allow health care professionals to more efficiently connect with patients at home and exchange information. CPT has responded by adding six new codes to report online digital evaluation services, or e-visits. These codes describe patient-initiated digital communications provided by physician or other qualified health care professional (99421, 99422, 99423), or a non-physician health care professional (98970, 98971, 98972).

Additional CPT changes for 2020 include the new codes for health and behavior assessment and intervention services (96156, 96158, 96164, 96167, 96170 and add-on codes 96159, 96165, 96168, 96171). These codes replace six older codes to more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings.

New CPT category I codes are effective for reporting as of Jan. 1, 2020. To assist the health care system in an orderly annual transition to a new CPT code set, the AMA releases each new edition four months ahead of the Jan. 1 operational date and develops an insider’s view with detailed information on the new code changes.

The 2020 CPT codes and descriptors can be imported straight into existing claims and billing software using the downloadable CPT 2020 Data File.

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Med Students: Learn How to be a Physician Advocate at AIM Conference in NYC
The second annual Advocacy in Medicine (AIM) Conference will bring together healthcare advocates and trainees from various academic institutions interested in health advocacy for a full day of talks, interactive panels, breakout sessions and networking. The conference opens with keynote speakers addressing the role of physician advocacy followed by an interactive Q&A panel discussion with physicians on advocacy, activism, and their personal career trajectories. The afternoon will be dedicated to small workgroups with the opportunity to focus on skill-building and topic-focused content.

When:  Sunday, September 22, 2019

Where: New York Academy of Medicine, 1216 Fifth Avenue, NY, NY 10029

Time:    8:30 am-4:00 pm

For more information and a full list of speakers, click here. Admission is free for medical students and health professionals with a current ID.

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