MSSNYeNews: November 8, 2019 – Stop Digging

PRESIDENT’S MESSAGE Arthur Fougner, MD MSSNY President MSSNY eNews November 8, 2019 Vol. 22  Number 42

Colleagues:

How did things ever get so far? This is the existential question confronting physicians every day. One of the key reasons why so many physicians report burnout or even depression is the feeling of a loss of professional autonomy. Sadly, the only group of professionals licensed to practice medicine have so little control in the way they actually practice. We are burdened by data entry, billing, coding, keeping up with new unfunded mandates, and all the while seeing their practices barely making payroll or even taking out second mortgages to keep their offices open. As said previously, it’s not about profitability anymore but about viability.

There’s an old saying – when you find yourself in a deep hole, stop digging. Going along to get along is no longer working. It’s time for a change – but how? Here’s one suggestion. Stop digging. It’s time to say, as Roberto Duran famously said, “No mas.” The decline in fortune did not start yesterday. This did not happen overnight. Therefore, the road back will not be a short one. But we must start. It will, for sure, be a long and arduous journey. But we must start. There will be bumps along the road but we must start. As the infamous Chairman put it, “A journey of a thousand miles begins with but a single step.”

So let’s take that single step. Get together. Get active. Support your fellow physicians. We need all the help we can get.

Stop digging.

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

Arthur Fougner, MD
MSSNY President

To all physicians who served in the United States Armed Forces,
 we salute you and thank you for your service!

Congress Finalizes 2020 Medicare Payment Rule and 2021 E&M Changes with Potentially Significant Redistributive Effects
On November 1, 2019, CMS released its 2020 Medicare Revisions to Payment Policies under Physician Fee Schedule and Other Changes to Part B Payment Policies final rule.  For a brief summary from the American Medical Association as to the highlights of the nearly 2,500 page rule, click here.

Among the highlights:

• The Medicare Physician Fee Schedule conversion factor will be $36.09 (CY 2019 conversion factor was $36.04), which reflects a budget neutrality adjustment for reductions in relative values for individual services in 2020.

• Geographic Adjustment Factor (GAF) Increases. Each of the 5 New York Medicare payment locality will receive a slight GAF bump for 2020 and 2021, as follows

• • Manhattan +1.3% for 2020; +2.6% for 2021
  • NYC Suburbs/Long Island +1.5% for 2020; +2.9% for 2021
  • Poughkeepsie/Northern NYC Suburbs +1.7% for 2020; +3.4% for 2021
  • Queens +1.6% for 2020; +3.3% for 2021
  • Upstate NY +0.2% for 2020; +0.4% for 2021.

• Effective January 1, 2021, CMS will adopt the CPT guidelines to report office visits based on either medical decision making or physician time. With CMS adopting the RUC work recommendations for the office visit codes, the work value increases represent $3 billion in redistributed spending, resulting in a 3% reduction in the conversion factor.   Moreover, CMS adopted the RUC physician time recommendations. Coupled with the work value increases and some modifications in direct practice costs, these changes lead to an additional $2 billion in redistributed spending, resulting in an additional 2% across-the-board reduction.

• CMS departed from the RUC recommendations in two ways that further intensify the specialty redistribution impact. CMS will implement an add-on payment for office visits for primary care and patients with serious or complex conditions. This proposal redistributes an additional $2.6 billion, resulting in an additional 3% reduction to the Medicare conversion factor.

CMS states that although they have no specialty restrictions on reporting new code GPC1X, they assume that the following specialties will report this add-on code with 100% of their office visits, essentially making this a bonus payment for: family medicine, general practice, internal medicine, pediatrics, geriatrics, nurse practitioner, physician assistant, endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, interventional pain management, cardiology, nephrology, infectious disease, psychiatry, and pulmonary disease.

It is estimated that the add-on payment for GPCIX will be approximately $18 per visit.  Therefore, while each of these specialties are expected to see sizable increases in 2021, those expected to see sizable decreases as a result of E&M changes include: anesthesiology (-7%); cardiac surgery (-8%); colon & rectal surgery (-4%); emergency medicine (-7%); gastroenterology (-4%); general surgery (-4%);  neurosurgery (-6%); ophthalmology (-10%); plastic surgery (-5%); radiology (-8%); thoracic surgery (-7%) and vascular surgery (-5%)

Council Notes — November 7, 2019
Nancy Nankivil, AMA Director of Practice Transformation, and Kyra Cappelucci, AMA Project Administrator, Practice Transformation, presented Practice Transformation Initiative: Solutions for Increasing Joy in Medicine. The AMA has partnered with the Physicians Foundation and several state medical societies to create a practice transformation framework to reduce physician burnout by furthering research focused on evidence-based interventions; collaborate and learn from health systems committed to assessing clinician satisfaction and its correlation to workflow design; and to foster a network or organizations implementing evidence-based solutions, sharing best practices and driving change to improve the joy in medicine.

Council approved the following:

• MSSNY will become involved in the AMA/Physician Foundation’s Practice Transformation Initiative and will seek appropriate resources for this endeavor.
• Approval of 2020 Legislative Program
• MSSNY will file a FOIL request for all documents from the New York Department of Health regarding ZocDoc’s business model exempted from application of NYS Education 6530 laws.

ZocDoc changed its business model to charge practices a per-patient booking fee effective April 1, 2019. The NY DOH indicated that ZocDoc can move forward with the model despite concerns of violations with referral fees; some NY DOH emails regarding ZocDoc have been redacted in a Freedom of Information Law (FOIL) request.

• MSSNY will seek legislation to create a physician-led healthcare cooperative in New York as one pathway for achieving legally permissible state supervised collective negotiation rights for physicians.
• Strategies to Improve NYS Immunization Rates in Children: MSSNY will urge that New York State provide incentives to parents/guardians who vaccinate their children as a strategy to improve vaccine uptake in school-aged children and advocate that New York State develop programs to pay stipends to community health workers as a strategy to improve vaccine uptake in school-aged children.
• Healthcare Cooperative Act: MSSNY will seek legislation to create a physician-led healthcare cooperative in New York as one pathway for achieving legally permissible state supervised collective negotiation rights for physicians.
• Physician Owned Distributorships: MSSNY supports the concept of Physician Owned Distributorships (PODs), provided that they are operated consistently with generally accepted principles of physician ethical conduct (such as the AMA Code of Medical Ethics), including assuring that patients and other potential contractors are sufficiently notified of the physician’s financial interest in such POD.
• Study of State and National Health Service Corps Needs: MSSNY will advocate for the expansion of the Doctors Across New York Physician Loan Repayment Program, support the development of State funded loan forgiveness and repayment programs for physicians, and advocate for scholarships/grants for medical students who plan to work in the state.
• Manpower Assistance for Medical Students: MSSNY supports the concept of continuing federal manpower financial assistance, including grants and long term, low interest loans for medical students.
• Patient-Driven Groupings Model (PDGM): MSSNY will work with the AMA to monitor implementation of the PDGM methodology to determine whether this new program will impose additional administrative burdens on physicians and/or impede patients from receiving needed home care services. Should it be determined that this new model is creating these issues, these concerns will be conveyed to CMS and Congress for remediation.

Complaints Re Pharmacies Not Honoring Scripts: WE NEED YOUR DATA
At yesterday’s MSSNY Council, Dr. Sana Block expressed concerns on behalf of physicians who are finding it difficult for patients to obtain medically needed prescriptions for pain.  He explained that pharmacies are not filling prescriptions for opioids when needed for patients with chronic pain.  Other Councilors stated that they have experienced difficulty for patients obtaining pain medications following surgery.  Anecdotal information is fine; but, to bring this to the attention of powers that might be able to address this problem, we need your data.  To help us help you, please download the MSSNY Hassle Factor Form. Complete the form, letting us know if you have experienced difficulty in obtaining medically needed pain meds for your patients.

In Section C of the form, please indicate the name of the pharmacy.  If you have experienced problems with multiple pharmacies, please use multiple forms.  In addition, please identify the nature of the problem, such as the drug is out of stock; the pharmacy recommends a different drug, etc.  The completed form can be emailed to comments@mssny.org or faxed to: 516-282-7093 or 516 282-7099 or 516-282-7098.

Gov. Signs Law: Death Certificates to Specify Opioid-Involved Overdose
Following Governor Cuomo’s press release on November 5, 2019, the EDRS Team would like to reinforce the importance of complete and accurate Cause of Death data on all death certificates, including those deaths related to opioid overdose. See the Governor’s press release here. Capturing this data assists State and federal government agencies analyze and pinpoint community impacts and work toward combatting epidemics, such as the opioid crisis.

The EDRS Team would like to take this opportunity to let you know about the recently launched self-paced online course, Mastering the Cause of Death in the 21^st Century, for physicians, medical examiners, coroners, and other medical certifiers. This course provides medical data providers with tips to get the best cause of death determination, including opioid related deaths. Participants may be eligible for AMA PRA credit for completing this course and its final assessment.

According to the state Department of Health’s Opioid Annual Data Report for 2018, the rate of opioid-overdose deaths in 2016 was 15.1 per 100,000 people, about three times higher than it was in 2010.

The new law takes effect immediately. Participants may register now by visiting  https://lms.udutu.com/LMSPortal/Account/LogOn?OrgCode=EDRS and using the organization code:  EDRS and select Create New Learner Account.  If you have additional questions related to the new drug specificity requirements or the EDRS implementation, call (518) 408-0243 or kira.cramer@health.ny.gov.  For more information on registration for the course, contact Zina Adams at zina.adams@health.ny.gov or 518-474-4317. Please see the flyer here.

MSSNY President Delivers Testimony to NY State Senate on Potential Harms of Electronic Cigarettes and Vaping
MSSNY President Dr. Arthur Fougner, MD, provided testimony to the New York State Senate public hearing held to examine the safety and potential harms of electronic cigarettes and vaping, especially among school-aged youth. (View full testimony here: 1Hr and 5 mins)

Dr. Fougner praised Governor Cuomo and the New York State Health Department for its emergency executive action to ban the sale of flavored e-cigarettes in the state (http://www.mssnyenews.org/press-releases/mssny-supports-call-to-ban-menthol-flavored-e-cigarettes/).  He also noted MSSNY’s long-standing support for legislation to ban flavored tobacco products, menthol and e-cigarettes and formally codify these provisions into law.

Specifically he noted that, “While evidence exists that adult smokers who completely substitute vaping for traditional smoking reduce their exposure to many of the toxic chemicals and carcinogens present in combustible tobacco cigarettes, e-cigarettes are not risk-free and are not approved by the Food and Drug Administration (FDA) as a quit-smoking aid. The bottom line is neither smoking nor vaping is safe, and people who do not smoke or vape should not begin to do so.” 

Dr. Fougner also urged strong caution regarding proposals to legalize the recreational use of marijuana since it appears from a number of sources that the vast majority of cases of vape-related lung illness are linked to the vaping of THC. Since the FDA has launched an ongoing investigation, he urged that “any proposed adult-use cannabis program, especially with a vaporizer product, be put on hold until completion of that investigation.”

Stolen Flash Drive: U of Rochester Med Center Pays $3M HIPAA Settlement
The University of Rochester Medical Center has agreed to pay $3 million to HHS’ Office for Civil Rights to settle potential HIPAA violations, according to a Nov. 5 news release. In 2013, URMC filed a data breach report with the OCR stating that an unencrypted flash drive had been stolen. Following the notice that patients’ protected health information could have been exposed, the OCR offered technical assistance to URMC.

Then in 2017, URMC disclosed that an unencrypted laptop had been stolen. An OCR investigation found URMC failed to conduct enterprise-wide risk analysis, implement security measures sufficient to reduce risk and vulnerabilities to a reasonable and appropriate level, utilize device and media controls, and employ a mechanism to encrypt and decrypt electronic protected health information.

“Because theft and loss are constant threats, failing to encrypt mobile devices needlessly puts patient health information at risk,” said Roger Severino, OCR director. “When covered entities are warned of their deficiencies, but fail to fix the problem, they will be held fully responsible.”

Along with paying the $3 million settlement, URMC will also undergo a corrective action plan, including two years of HIPAA-compliance monitoring.

JAMA: People Turning To Social Media Platforms for STD Diagnosis
The Reddit community r/STDs “encourages its more than 10,000 members to share stories, concerns and questions about sexually transmitted diseases – and according to a study published Tuesday, they have increasingly done so.”

The study, published in the Journal of the American Medical Association, found that “the number of posts significantly increased over time, from just eight in 2010 to 3,375 in 2018.” Investigators “focused on a random sampling of 500 posts” and found over “half – 58 percent – asked the site’s members for a diagnosis,” while “nearly a third of those included photos of the apparent STD in question.”

Medscape reports investigators conclude, “requests for crowd-diagnoses were frequent, with most receiving a reply within hours, and many of these requests were for second opinions after obtaining an original diagnosis from a health care professional.”

Workers’ Compensation Formulary
The NYS Workers Compensation Board Drug Formulary (NY WC Formulary) becomes effective in four weeks (12/5/19) for new prescriptions.

Training materials related to the NY WC Formulary, as well as an updated version of the NY WC Formulary (effective 11/5/19), can be found on our webpage:

Drug Formulary Overview

Information and resources related to the Board’s Medical Portal, which is used to access the prior authorization system, could be found on the Medical Portal Overview webpage. For more information or assistance Visit http://www.wcb.ny.gov/content/ebiz/drugformulary; General Formulary questions:

Subscribe for email notifications at http://www.wcb.ny.gov/notify

CDC: Preventing Adverse Childhood Experiences Can Reduce Chronic Disease Experiencing traumatic things as a child puts you at risk for lifelong health effects, according to a body of research. The CDC’s new report confirms this, finding that Americans who had experienced adverse childhood experiences or ACEs, were at higher risk of dying from five of the top 10 leading causes of death.

And those who’d been through more bad experiences — such as abuse or neglect, witnessing violence at home or growing up in a family with mental health or substance abuse problems — were at an even higher risk. According to the agency, women and minorities—like African Americans, American Indians, and Alaskan Natives—were more likely to experience four or more kinds of harm while they were kids. The conclusions were drawn from surveys taken by adults between 2015 and 2017.

How to Maximize Success & Maintain Full Control & Ownership of Your Practice
MSSNY invites you to tune in on Tuesday, November 12 from 7PM-8PM for a webinar featuring Roy Bejarano, Co-Founder & CEO of Scale Physician Group, and Andrew Blustein, Partner/Director and Vice Chair of Garfunkel Wild, P.C. Scale Physician Group provides expert non-clinical advisory and management services to independent and private equity owned physician groups, empowering physician leaders to build modern healthcare delivery platforms that yield better results.

Roy will share the lessons and best practices learned from his experience working with over 1,200 physicians across the country. Andrew will introduce Roy and facilitate a Q&A session following the presentation. Special thanks to Garfunkel Wild, P.C., who serves as MSSNY’s General Counsel, for bringing us this program. Access the flyer here.

“When Is the Flu Not the Flu?” CME Webinar on Nov. 20; Registration Now Open
Flu season is upon us, but there are myriad other illnesses that present similarly.  Be sure to brush up on these by signing up for Medical Matters: When is the Flu not the Flu? on November 20^th at 7:30am.

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 mhoffman@mssny.org.

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. 

MSSNY President-Elect Dr. Bonnie Litvack Delivers Testimony to NY Senate on Veterans Mental Health
President-Elect Dr. Bonnie Litvack, MD provided testimony to the New York State Senate Committee on Mental Health and Developmental Disabilities at its public hearing to examine veterans’ mental health.

Dr. Litvack spoke about MSSNY’s “Veterans Matters” educational program which is a part of the Veterans Mental Health Training Initiative (VMHTI) that is funded through an appropriation in the New York State budget.  She noted that the program seeks to insure our veterans can receive the care they need and deserve in New York State. She thanked the committee for their foresight in fighting for continued funding for the program.

Dr. Litvack highlighted that roughly 1.64 million troops were deployed in Operation Enduring Freedom and Iraqi Freedom and had prolonged exposure to combat which took a toll on veterans psychologically.  Additionally she noted that “11% of New York State veterans began serving after 9/11 and this group in New York State is expected to reach 22% by 2025”. Dr. Litvack quoted a 2010 RAND survey on NYS veterans which found that 22% of post 9/11 veterans have a probable mental health diagnosis, 16% screened positive for depression and PTSD.

Dr. Litvack spoke briefly about the VMHTI program which looks to educate the community and healthcare providers on veteran specific mental health issues which includes; PTSD, depression, suicide, traumatic brain injury. Dr. Litvack emphasized the importance of asking individuals whether or not they are veterans in order to help them connect to various organizations that can help them. Dr. Litvack concluded by stating that the program is both timely and critical, emphasizing that the healthcare community needs to be educated on the importance of mental health as it relates to veterans.

MSSNY faculty have participated in numerous presentations at institutions and county medical society meetings all across the State of New York.  Please contact Mhoffman@mssny.org if you would like to have a presentation at your hospital or next county medical Society meeting.

MSSNY President-Elect Dr. Bonnie Litvack testified this week before the Senate Mental Health Committee regarding MSSNY’s Veterans mental health training initiative