MDAdvisor: A Journal for the New Jersey Medical Community by MDAdvantage Insurance Company of New Jersey

ATTENTION EMPLOYED PHYSICIANS: KEYS TO PROTECT YOUR INTERESTS

Michael J. Schoppmann, Esq.

VACCINE-PREVENTABLE DISEASES STILL POSE A THREAT TO OUR COMMUNITIES

Commissioner Mary E. O’Dowd, MPH

MINIMALLY INVASIVE SURGERY: PATIENT SAFETY & INFORMED CONSENT A DISCUSSION WITH STEVEN MCCARUS, MD

James C. Whorton, PhD

DISEASE AND CIVILIZATION: CONSTIPATION & HEALTH SINCE THE INDUSTRIAL REVOLUTION

VOLUME 6 • ISSUE 3 • SUMMER 2013

PHYSICIAN EMPLOYMENT CONTRACTS: IS YOUR FUTURE ALREADY WRITTEN?

MDADVISOR: A JOURNAL FOR THE NEW JERSEY MEDICAL COMMUNITY

Did you know… MDAdvantage WE PROVIDE THE TOOLS AND RESOURCES YOU NEED TO BETTER PROTECT AND MANAGE YOUR PRACTICE. Our complimentary Supreme Advantage® coverage protects you from: • Employment practice claims such as harassment and wrongful termination • Breaches of privacy or security • RAC audit fines • HIPAA violations Our updated practice management offerings include: • Customized on-site practice assessments • Regulatory compliance evaluation • Coding and billing audits • Online and on-site training and education

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NTE A T OS A. C es

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EMERGING MEDICAL LEADER PERSPECTIVES

The 22nd of May, 2013, marked the final Commencement exercise at UMDNJ. President Denise Rodgers, MD, celebrated the final and largest graduating class in UMDNJ’s history. Keynote speaker President Robert Barchi of Rutgers, The State University of New Jersey, addressed the graduates about the forthcoming changes to New Jersey healthcare with the Rutgers/UMDNJ Integration on July 1, 2013. He challenged graduates to be the “architects of a healthier future” as part of a more sustainable healthcare system. I am a proud graduate of UMDNJ, and am ready to be embraced by the Rutgers community. I am confident that UMDNJ’s level of medical care, education, research and service will continue for our citizens as the different entities of UMDNJ become integrated with Rutgers and Rowan Universities. Both universities have strong alumni networks that will become even stronger with the addition of the outstanding past alumni of the UMDNJ schools. Now it is up to all of us–providers educators and students–to come together and to solidify New Jersey as a great state for medical care, education and research.

MDADVISOR A Journal for the New Jersey Medical Community PUBLISHER PATRICIA A. COSTANTE, FACHE Chairman & CEO MDAdvantage Insurance Company of New Jersey PUBLISHING & BUSINESS STAFF CATHERINE E. WILLIAMS Senior Vice President MDAdvantage Insurance Company of New Jersey JANET S. PURO Vice President MDAdvantage Insurance Company of New Jersey THERESA FOY DIGERONIMO Copy Editor MORBELLI RUSSO & PARTNERS ADVERTISING INC. EDITORIAL BOARD STEVE ADUBATO, PhD RAYMOND H. BATEMAN CAROL V. BROWN, PhD PETE CAMMARANO DONALD M. CHERVENAK, MD STUART D. COOK, MD VINCENT A. DEBARI, PhD

GERALD N. GROB, PhD JEREMY S. HIRSCH, MPAP PAUL J. HIRSCH, MD WILLIAM G. HYNCIK, ATC JOHN ZEN JACKSON, Esq. ALAN J. LIPPMAN, MD

EMERGING MEDICAL LEADERS ADVISORY COMMITTEE ANDREW BUTLER, MD MICHELLE DIAZ OREN JOHNSON, MD NEIL KAUSHAL, MD RAYMOND MALAPERO, MD, MPH

JACQUELINE PARK KIRSTEN TANDBERG REGINA YU

Ray Malapero, MD, MPH

PUBLISHED BY MDADVANTAGE INSURANCE COMPANY OF NEW JERSEY Two Princess Road, Suite 2 Lawrenceville, NJ 08648 www.MDAdvantageonline.com Phone: 888-355-5551 • Editor@MDAdvisorNJ.com

UMDNJ–New Jersey Medical School Class of 2013

INDEXED IN THE NATIONAL LIBRARY OF MEDICINE’S MEDLINE® DATABASE.

Sincerely,

Material published in MDAdvisor represents only the opinions of the authors and does not reflect those of the editors, MDAdvantage Holdings, Inc., MDAdvantage Insurance Company of New Jersey and any affiliated companies (all as “MDAdvantage®”), their directors, officers or employees or the institutions with which the author is affiliated. Furthermore, no express or implied warranty or any representation of suitability of this published material is made by the editors, MDAdvantage®, their directors, officers or employees or institutions affiliated with the authors. The appearance of advertising in MDAdvisor is not a guarantee or endorsement of the product or service of the advertiser by MDAdvantage®. If MDAdvantage® ever endorses a product or program, that will be expressly noted. Letters to the editor are subject to editing and abridgment. MDAdvisor (ISSN: 1947-3613 (print); ISSN: 1937-0660 (online)) is published by MDAdvantage Insurance Company of New Jersey. Printed in the USA. Subscription price: $48 per year; $14 single copy. Copyright © 2013 by MDAdvantage®. POSTMASTER: Send address changes to MDAdvantage, Two Princess Road, Suite Two, Lawrenceville, NJ 08648. For advertising opportunities, please contact MDAdvantage at 888-355-5551.

MDADVISOR | SUMMER 2013

LETTER FROM MDADVANTAGE® CHAIRMAN & CEO PATRICIA A. COSTANTE

DISEASE AND CIVILIZATION: CONSTIPATION & HEALTH SINCE THE INDUSTRIAL REVOLUTION | By James C. Whorton, PhD

HEALTH INSURANCE EXCHANGES: A HOSPITAL PERSPECTIVE | By Neil Eicher, MPP

ATTENTION EMPLOYED PHYSICIANS: KEYS TO PROTECT YOUR INTERESTS | By Michael J. Schoppmann, Esq.

IMPROVING PATIENT FLOW AND ASSET MANAGEMENT USING REAL-TIME LOCATION SYSTEMS | By Alexander Kopeykin, RN, MBA, MPM, and Alfred Campanella

VACCINE-PREVENTABLE DISEASES STILL POSE A THREAT TO OUR COMMUNITIES | By Commissioner Mary E. O’Dowd, MPH

MINIMALLY INVASIVE SURGERY: PATIENT SAFETY & INFORMED CONSENT A DISCUSSION WITH STEVEN MCCARUS, MD | Interviewed by Theresa Foy DiGeronimo

BUILDING YOUR MD BRAND | By Steve Adubato, PhD

LEGISLATIVE BRIEF: HOT TOPIC ISSUES IN TRENTON | By Pete Cammarano & Michael Schweder

MAINTENANCE OF CERTIFICATION: AN ONGOING CONTROVERSY | By Alan J. Lippman, MD

SUMMER 2013 – CONTENTS

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Disease and Civilization:

Constipation & Health

Since the Industrial Revolution By James C. Whorton, PhD

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Freedom of the bowels is the most precious, perhaps even the most essential, of all freedoms–one without which little can be accomplished….As a consequence, obstinate constipation constitutes not merely a minor and temporary unpleasantness,...but to the contrary a true infirmity, a pathological condition, that one must defend against like the plague….How could it be forgotten–before having a brain, dear reader, before having a heart, dear lady reader–you have…a digestive tube open at both ends, an obstruction of which will promptly cause a turn toward disaster? Émile Gautier, 19091 French physician Émile Gautier penned this warning at the height of a scare about the ravages of constipation that gripped both the medical profession and the public in Europe and America over the first third of the 20th century. Torpid bowels were believed by many to be the great plague of the age, not because of the immediate discomfort they produced, but because of wideranging, chronic injuries presumably inflicted through the process of “autointoxication”–the period’s term for absorption of toxic compounds produced by decomposing fecal matter in the colon. Constipation, furthermore, was interpreted as the consequence of industrialization and urbanization, as, in effect, a disease of civilization. Indeed, autointoxication was regarded as the disease of civilization.2 A HISTORY OF INTUITIVE APPEAL The suspicion that illness might result from prolonged retention of excrement in the body has a powerful intuitive appeal. Many ailments manifest themselves by the evacuation of putrid matter from the body, primarily in the form of vomit and diarrhea. Since ancient times, such evacuations have suggested that disease is a form of internal putrefaction, a process that culminates with the complete putrefaction of the body following death. It follows that putrid matter inside the body must be avoided. But there is one place in the body where putrefaction is always occurring, and the longer decomposing material is held in the intestines, the greater the danger the decomposition will spread. It was such thinking that directed the author(s) of the Ebers Papyrus, a 16thcentury BCE Egyptian pharmaceutical text, to posit that illness often results from a poisonous substance being absorbed from the intestines to initiate putrefaction in the body’s vital organs.3 Similarly, in Hippocratic medical thought, great emphasis was placed on regular evacuation as an essential of good health.4 In this respect, medical theory remained consistent through the 18th century. Joseph Lieutaud, personal physician to Louis XV, represented the thought of the 1700s in warning that “the depraved juices, putrid matter…lodged in the stomach and intestinal canal” might make their way into the circulatory system and the resulting “feculent blood” would spread havoc throughout the body.5 Such fears rose to new heights as the 19th century dawned, for the changes in lifestyle accompanying rapid urbanization seemed certain to make constipation a much more common condition. Rich food, lack of exercise and mental stress had long been linked to inactive bowels, so what else could be expected as people turned from the countryside’s quiet life of daily toil and simple diet to the sedentary luxuries of the pressured city?

“a 16th-century BCE Egyptian pharmaceutical text, to posit that illness often results from a poisonous substance being absorbed from the intestines to initiate putrefaction in the body’s vital organs.”

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Disease and Civilization Hence the despair voiced by London physician Richard Reese in the 1820s: “There is no complaint more general…than costiveness…it is often [the] cause of the diseases that terminate the lives of more than one half of the human race….Subjects whose bowels have not been regularly relieved every or every other day, very rarely attain the age 6 of forty.” THE CATCHALL DIAGNOSIS OF AUTOINTOXICATION Dire as such projections were, they paled beside the lamentations that became commonplace by the end of the century, when the dangers of constipation were dramatically magnified by the advent of the germ theory. As the microbic causes of one infection after another came to be discovered during the 1880s and 1890s, medical scientists came to think of virtually all illness as the result of germs. Studies of microorganisms included the microbes of the colon, which, it was determined by the mid-1880s, broke down protein residues in feces into a number of compounds (including the aptly named putrescine) that proved highly toxic when injected into animals. It was evident these substances were not absorbed by the human intestine in deadly amounts (people were not dropping in their tracks from putrescine poisoning), yet it was difficult to believe the compounds resisted absorption altogether. There was, indeed, no great difficulty formulating a plausible argument that people could suffer low-level poisoning from their bowels.7 The leading theorist of autointoxication, French physician Charles Bouchard, spoke confidently of the condition of “copraemia”–Lieutaud’s “feculent blood” revived but given a modern scientific rationale.8 As a process of slow undermining of health, autointoxication proved highly useful for diagnosing difficult patients who insisted they were ill but presented the physician with no clear organic pathology to prove it. Autointoxication became the profession’s catchall diagnosis, the box into which headache, indigestion, impotence, insomnia and any number of other functional disorders of indeterminate origin could be dumped. As Bouchard explained, “Man is…constantly living under the chance of being poisoned; he is always working toward his own destruction; he makes continual attempts at suicide by intoxication.”9 Inability to demonstrate the presence of products of fecal decay in the blood led to the rejection of autointoxication theory over the course of the 1920s.10 However, in its heyday from 1890 to 1930, autointoxication was widely embraced by

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the profession. Autointoxication, the physician authors of The Lazy Colon announced, “inflicts upon mankind vastly more misery, suffering and death than …cancer, tubercu11 losis, heart disease, etc.” PREVENTION AND TREATMENT So grave a threat to human existence naturally inspired all manner of preventive and remedial measures, presented to a frightened public by a host of physicians and quacks alike. Diet: On the diet front, increased fiber intake was urged by a number of health advocates, both professional and lay, but by none so energetically as breakfast cereal manufacturers. The breakfast cereal industry was launched in 1877 by John Harvey Kellogg, MD, Superintendent of The Battle Creek Sanitarium–a health recovery institution in Michigan. Kellogg was convinced that modern ways of life had weakened intestinal function (which, in a state of nature, he believed, produced five bowel movements a day), creating a near-universal condition of “civilized colon.” A vegetarian diet supplemented by colonic irrigation was his recommended restorative of natural bowel activity, with particular 12 attention paid to consumption of unrefined grains. By the 1910s, Kellogg’s All-Bran (produced by his brother Will’s company) and Post Bran Flakes were being marketed as the most reliable preventives of autointoxication (and would continue to the present as the most popular insurers of regularity). A 1928 advertisement for the Post product pictured a modern menu flanked by two burly policemen announcing the menu had been indicted for causing much ill health due to a lack of dietary bulk.13 Close behind the cereal industry came yogurt manufacturers exploiting the ideas of Élie Metchnikoff, the 1908 Nobel Prize winner (in medicine and physiology). Arguing that lactic acid-generating microbes, such as those found in yogurt, would suppress the putrefactive bacteria in the gut and extend human life to an average of 120 years, he set off a craze for consuming a variety of cultured milk preparations.14 Numerous brands of yogurt claimed to fight the autointoxication scourge, but there were also powders, tablets, extracts and at least one lactobacillusinfused chocolate cream.15 Muscle Tone and Stimulation: Others insisted regularity was best achieved by increasing abdominal muscle tone, the better to push along the bowel’s contents. This could

FIGURE 1 Kolon Motor

be achieved either actively, through a range of muscle-tightening exercises ranging from doing sit-ups to running and dancing, or passively through massage. The latter might be performed in the traditional way, by hand, or mechanically with devices invented specifically to prevent constipation–the Kolon Motor, for example, was attachable to the wall of any room and featured a round projection that vibrated against the user’s abdomen when he or she turned handles mounted on either side of the instrument (see Figure 1). Electrical stimulation of belly muscles seemed to hold even greater promise, and could be obtained through widely available machines. Some brands included electrodes to be inserted directly into the rectum to spark intestinal activity. An alternate method of elevating intestinal tone was the use of rectal dilators–three-to five-inch long, phallic-shaped devices made of metal or rubber, to be placed and held in the rectum 30 minutes or more twice a day (see Figure 2). All too often, the dilator remained inside for considerably longer, requiring the 16 assistance of a physician to remove it. Laxatives: Among the passive methods of stirring the bowels into action, by far the most popular was the use of laxatives. Cathartic drugs had a long history of use in mainstream therapy, but with the arrival of autointoxication, manufacturers of over-the-counter pharmaceuticals went all out in marketing new laxative products guaranteed specifically to save purchasers from early death. Aggressive advertising confronted the public with terrifying warnings of the wages of intestinal stasis, while simultaneously assuring that the remedy for such threats could be pleasurable. Laxative manufacturers competed to come up with the most alluring formulations: Jam-o-Lax combined its active ingredient with fruit jam, Lax-Krax sweetened senna-filled crackers with honey and Citrolax came in the form of Epsom salt lemonade. The most delicious disguise of all, though, was chocolate found in Laxybar, Chu-Lax, Tru-Lax, Tryalax and many other brands, including, of course, Chocolax. The active ingredient in most of the chocolate preparations was the newly discovered (1900) compound phenolphthalein, which would serve as the most popular aperient substance of all through most of the 20th century.17 The number of phenolphthalein products was legion, but two stood out from the throng: Ex-Lax (chocolate-based) and Feen-a-mint (gum-based). Both companies targeted adults with advertising that urged them to purchase their brand not simply to save themselves but, more importantly, to rescue their innocent children from the insatiable maw of autointoxication. The ads regularly implied that the products were health foods, even a daily nutritional requirement, and assured parents that the appealing taste made it easy to get children to take their medicine, that indeed “youngsters actually beg for Ex-Lax.”18 Colectomy: The delicious daily laxative was at one end of the anti-autoxication therapy spectrum. At the other was the approach favored by the most outspoken of all opponents of that dread condition, the renowned British orthopedic surgeon William Arbuthnot Lane. From his orthopedist’s mechanical interpretation of body functioning, Lane argued that since the human digestive system had originated in four-footed ancestors, evolution into Homo erectus subjected the intestines to new mechanical stresses that resulted in “kinks” in

Gant, S. (1909). Constipation and intestinal obstruction (p. 281). Philadelphia: Saunders.

FIGURE 2 Advertisement for Rectal Dilators

Nature’s path. (1938, December).

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Disease and Civilization the organ, strictures that hindered fecal movement. The resulting “chronic intestinal stasis” led to autointoxication: 19 “Death,” Lane announced, “implies defective drainage.” In particular, defective drainage was seen as the cause of the higher incidence of colon cancer in industrialized nations.20 Moderate autointoxication might be treated with diet and exercise, but in advanced cases, there was only one remedy: excision of the kinks that lay at the root of the problem. Lane was a surgeon, after all, and by the early 1900s, he had come to believe that total colectomy was the surest way to save the most badly affected. By the 1910s, he was performing up to 40 21 colectomies a year at London’s Guy’s Hospital. EASING THE PHOBIA OF “THE MONARCH OF ALL DISEASES” A number of other surgeons followed Lane’s lead for a few years, but beginning with a debate at the Royal Society of Medicine in 1913, the radical surgical approach was called into question and by 1920 had fallen into disuse.22 Anxiety over autointoxication in general faded away over the ensuing two decades, and while there was a revival of concern in the 1970s with epidemiological studies showing a correlation between high levels of dietary fiber and low incidence of colon and other cancers, we are still far from returning to the near-hysterical level of autointoxication phobia of the early 20th century. At that time, constipation was, in the words of one laxative manufacturer, “The Monarch of all Diseases.”23 James C. Whorton, PhD, is Professor Emeritus of the History of Medicine, University of Washington School of Medicine. 1

Gautier, É. (1909). La saignée urique (pp. 18–19) Paris: Chatelain.

Note: This theme is explored in much greater detail in: Whorton, J. (2000). Inner hygiene. Constipation and the pursuit of health in modern society. New York: Oxford University Press.

Ebbell, B. (Ed.). (1937). The papyrus ebers. Copenhagen: Levin and Munksgaard.

Hudson, R. (1989). Theory and therapy: Ptosis, stasis, and autointoxication. Bulletin of the History of Medicine, 63, 392–413.

Bouchard, C. (1906). Lectures on autointoxication in disease or self-poisoning of the individual (p. 18). Philadelphia: Davis.

Bouchard, C. (1906), 106.

Alvarez, W. (1919). Origin of the so-called autointoxication symptoms. Journal of the American Medical Association, 72, 8–13.

Campbell, C., & Detweiler, A. (1924). The lazy colon. New York: Educational Press.

Kellogg, J. (1919). Autointoxication, or, intestinal toxemia. Battle Creek, MI: Modern Medicine.

Advertisement. (1928, March 31). Literary Digest, 57.

Metchnikoff, É. (1908). The prolongation of life. New York: Putnam.

Herschell, G. (1909). Sour milk and pure cultures of lactic acid bacilli in the treatment of disease. London: Glaisher.

Whorton, J. (2000). Inner hygiene. Constipation and the pursuit of health in modern society. New York: Oxford University Press.

Whorton, J. (1993). The phenolphthalein follies: Purgation and the pleasure principle in the early twentieth century. Pharmacy in History, 35, 3–24.

Advertisement. (Box 246, Folder 4). American Medical Association Historical Health Fraud and Alternative Medicine Collection, Chicago.

Lane, W. (1926). The paramount importance of effective intestinal drainage in preventing ill health and disease. American Medicine, 21, 689–693.

Lane, W. (1924). Cancer and intestinal stasis. The Practitioner, 12, 205–210.

Hurst, A. (1922). An address on the sins and sorrows of the colon. British Medical Journal, i, 941–943.

A discussion on alimentary toxaemia. (1913). Proceedings of the Royal Society of Medicine, 6, 1–380.

Advertisement. (Box 113, Folder 5). American Medical Association Historical Health Fraud and Alternative Medicine Collection, Chicago.

Berryman, J. (1989). The tradition of the “six things non-natural.” Exercise and Sport Sciences Review, 17, 515–559. Lieutaud, J. (1816). Synopsis of the practice of medicine. Philadelphia: Parker. Reece, R. (1826). A practical dissertation on the means of obviating and treating the varieties of costiveness. London: Longman, Rees, Orme, Brown and Green.

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MDADVISOR

Health Insurance Exchanges:

A Hospital Perspective “The plans offered in the Exchange must strike a balance between offering

affordable coverage and providing essential benefits to ensure that consumers are getting

value for their purchases.”

The hospital industry has long supported the policy initiative of healthcare reform–the general concept that our healthcare system needs to be revamped to increase medical insurance coverage, reduce costs and improve quality. Although the Affordable Care Act (ACA) will institute measures to address cost and quality, many will agree that the focal point of the law is to increase coverage to nearly 32 million uninsured American citizens and legal immigrants. Recognizing the importance of this expansion of coverage, the American Hospital Association (AHA) quickly threw its support behind the initiative and agreed to systematic cuts of more than $155 billion from 2010 to 2020.1 The hope is that the reductions in funding will be more than offset by the increased number of covered individuals. However, as the creation of Health Insurance Exchanges, required under the provisions of the ACA, becomes a reality, the healthcare industry must remain vigilant to avoid implementation problems that may place undue burdens on healthcare providers and their patients. INSURING THE UNINSURED Many currently uninsured individuals with family income less than or equal to 133 percent above the federal poverty level (the poverty level is $19,530 for a family of three in 2013) 10

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By Neil Eicher, MPP

will be covered under provisions of the ACA in states that choose to expand their Medicaid program on January 1, 2014. The working poor and small businesses will be guided to online insurance marketplaces known as Health Insurance Exchanges (Exchanges) to shop for quality healthcare insurance plans at competitive prices. Individuals/families with income between 133 and 400 percent of the federal poverty will be eligible for generous subsidies on a sliding scale based on income to purchase health insurance coverage in the Exchange.2 Small businesses, in theory, will be able to select, or allow each employee to select, an affordable plan from the menu of options in the Small Business Health Options Program (SHOP). Although the intent of this extended coverage is laudable, the reality of increased insureds is problematic. Already, there are not enough physicians to cover the number of patients enrolled in Medicaid. Certainly, the New Jersey Medicaid rules are inadequate in many respects–a recent National Ambulatory Medical Care Survey determined that only about 30 percent of physicians in New Jersey indicated that they would take new Medicaid patients.3 Given this fact, the many challenges associated with finding enough providers to

cover the increased number of patients who will need care has the potential to weaken New Jersey’s ability to fully care for the newly insured. Still, the hoped-for benefits of the Exchanges propel the movement forward. The ACA gave the option for states to establish and operate their own Exchanges with the fallback that the federal government will be ready and willing to run a national Exchange in any state that refuses to create an Exchange. As of now, the federal government will run Exchanges in 26 states, while 24 states will either run their own or partner with the federal government for specific por4 tions of the entity. In New Jersey, for example, the Christie administration has decided to permit the federal government to establish and operate an Exchange in the state. The objectives of the ACA are intrinsically linked to the success or failure of these Exchanges. The plans offered in the Exchange must strike a balance between offering affordable coverage and providing essential benefits to ensure that consumers are getting value for their purchases. If this balance can be attained, the benefits for all are substantial. Insurance companies will have a new market to increase the number of enrollees in their plans, as well as a guarantee of a subsidy payment from the federal government when the plan is selected by the individual. Hospitals will receive payment for services rendered to these newly insured patients who currently are being absorbed by the hospitals as bad debt. Lastly, the healthcare system will benefit as a whole by equipping these individuals with access to preventative care that was once unavailable to them. Of course, these possible benefits do not eliminate the innumerable hurdles of establishing the logistics of the Exchange. But even putting these hurdles aside, there are still two major issues of paramount concern to hospital executives. The first is the reduced commercial reimburse-

ment rates that insurance companies have already begun negotiating with hospitals for the newly insured individuals. The second is the concern that those who purchase coverage from commercial payers will have adequate access to care for all services across the spectrum. RISK OF REDUCED COMMERCIAL REIMBURSEMENT RATES The rates negotiated between payers and providers are proprietary and vary based on geography, markets and other factors. Payers offer to “steer” a volume of patients to hospitals, physicians and other providers if these providers agree to contract with the payer and accept discounted rates. But what happens when insurance companies and providers begin to negotiate contracts for an Exchange market that does not yet exist? For providers, accepting an even lower rate for these newly insured patients could mean a loss of revenue for each patient that comes through their doors, much like treating a Medicaid patient. It is understandable that the insurance industry would seek to lock in lower rates with providers for the new Exchange market before the open enrollment date of October 1, 2013. Their argument to hospitals and physicians is that these soon-to-be insured patients were previously uninsured, and therefore, a patient with coverage at a discounted rate is better than receiving very little to no payment at all. It has also been reported that some insurance companies are looking to renegotiate their contracts in December 2013 to take advantage of “grandfathered” status, which delays the application of the new rules on 5 those plans until they are renegotiated. What further complicates the issue is the fear that many employers will choose to forgo providing coverage through their business and instead encourage employees to purchase

Did you know… MDAdvantage MDAdvantage® is an advocate for all New Jersey physicians. That’s value beyond insurance.

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insurance through the Exchange. This process, commonly referred to as “dumping,” could occur in both the large group and small group markets. Under the ACA, only employers with more than 50 employees must provide creditable coverage or face a penalty. Some employers have been vocal about the fact that they would rather take the penalty for non-compliance than offer coverage to their employees. While there is no requirement for small businesses to provide creditable coverage, some may see a benefit to providing a stipend to their employees to purchase coverage through the Exchange, even though the employee will most likely not be eligible for subsidies from the federal government. The migration of consumers from the small employer market to the individual Exchange market has the potential to devastate the hospital industry if sufficient reimbursement rates are not maintained. RISK OF INADEQUATE ACCESS TO CARE Many state laws require insurance companies to build an adequate network of providers for their plans to ensure that their patients will have sufficient access to in-network providers. The objective of network adequacy requirements is clear: Patients must have access to affordable healthcare services across the continuum of care. If a consumer purchases an insurance plan from an insurance company, it is the responsibility of that insurer to offer in-network services at a reasonable time and distance for each beneficiary. Otherwise, a patient will have an insurance card that will have little to no value. Providers must remember this when negotiating contracts with insurers for the Exchange marketplace; the onus is on the insurance company, not the provider, to meet network adequacy requirements. In New Jersey, for example, Medicaid and commercial health maintenance organizations (HMOs) are required to offer in-network services for hospitals, primary care and many 6 specialists within 45 miles, or 60 minutes of every beneficiary. Recent federal guidance for implementing federal Exchanges in states has indicated that the Centers for Medicare and Medicaid Services will utilize existing state practices when determining if an insurance company’s network is sufficient.7 Enforcing stringent network adequacy requirements is essential to ensure that patients can access primary and specialty care services when needed instead of utilizing the emergency department for all services. Health Insurance Exchanges are crucial to the successful transformation of our healthcare system. Done correctly, these virtual marketplaces will realign our priorities by granting 12

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access to primary and preventative care to those who currently use the emergency department as their only source of care. However, we must remain vigilant to ensure that the health insurance industry does not undercut provider rates or fail to contract with all types of providers if we want the true realignment of the system to be successful. Also, we must not lose sight of the fact that an insurance card means nothing if it does not grant adequate access to healthcare services across the healthcare spectrum. Neil Eicher, MPP, is Director of Policy at the New Jersey Hospital Association. 1

Galewitz, P. (2010, March 22). Doctors, hospitals, insurers, pharma come out ahead with health bill. Kaiser Health News. www.kaiserhealthnews.org/Stories/2010/March/22/ winners-losers-health-reform.aspx.

The Kaiser Family Foundation. (2011). Summary of the Affordable Care Act. Focus on Health Reform. http:// kaiserfamilyfoundation.files.wordpress.com/2011/04/ 8061-021.pdf.

Kliff, S. (2012, August 6). Study: One-third of doctors wouldn’t take new Medicaid patients last year. Washington Post. www. washingtonpost.com/blogs/ezra-klein/wp/2012/08/06/ study-one-third-of-doctors-wouldnt-take-new-medicaidpatients-last-year/.

Federal government to run 26 state health exchanges. (2013, February 20). www.insurancejournal.com/news/ national/2013/02/20/281869.htm.

Appleby, J. (2013, April 5). Insurers’ efforts to delay health law compliance could affect premiums, benefits for millions. www.kaiserhealthnews.org/Stories/2013/April/05/health-lawinsurance-deadlines.aspx.

N.J.A.C. 11:24-6.2, C:30:4D-1.

45 C.F.R. § 156.230(a)(2). Note: This regulation requires a Qualified Health Plan (QHP) issuer to maintain a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay. The Centers for Medicare and Medicaid Services (CMS) recognizes that many states conduct network adequacy reviews as part of the issuer licensure process under their existing authority. As a result, for the 2014 coverage year, when CMS is evaluating applications for QHP certification, CMS will rely on state analyses and recommendations when the state has the authority and means to assess issuer network adequacy. CMS’s approach to reviewing network adequacy will vary based on whether the state assesses network adequacy sufficiently and uses standards at least as stringent as those identified in 45 C.F.R. § 156.230(a).

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ATTENTION EMPLOYED PHYSICIANS:

s all areas of healthcare shift and change in erratic, yet seismic, ways, certain trends are already beginning to emerge:

By Michael J. Schoppmann, Esq.

■ A September 2010 survey by the Medical Group Management Association found a nearly 75 percent increase in the number of active doctors employed by hospitals since 2000. The survey further revealed that 74 percent of hospital leaders planned to increase physician employment within the next 12 to 36 months.1 ■ Whereas hospitals prioritized primary care physician (PCP) employment in the 1990s, they are now targeting both PCPs and specialists.2 ■ By the end of 2013, approximately less than onethird of physicians are expected to remain truly independent, down from 57 percent in 2000 and 43 percent in 2009.3

of a physician contract is to gain control over the physician by constraining the physician’s independence and autonomy as well as limiting his or her future activities and/or earnings. A physician contract dispute rarely involves the failure to provide salary. It is, however, common (and increasingly so) that the efforts of a physician’s employer to exercise control over the physician results in a disagreement, a dispute and a legal action. To avoid such adverse events, employed physicians need to immediately adopt new strategies and new methods for managing personal risk (which, in turn, help manage professional risk). Such new strategies and methods should initially include the following prerequisites.

Each physician who now finds him- or herself (or who is contemplating becoming) an employee of a hospital or large group must immediately understand that the matrix of achieving professional survival (if not success) has changed dramatically. Physicians are continuously and relentlessly barraged with new rules and regulations, rendering today’s practice of medicine increasingly challenging–and potentially fraught with risks. In addition to the many rules and regulations that physicians deal with daily, they must now also become aware of the potential impact of increasingly oppressive, rigid and legally unyielding physician contracts* that can directly impact their present income, their prospective rights and, ultimately, the course of their careers. The first key for an employed physician seeking to protect his or her interests is to understand that the foundational goal

IDENTIFY, READ AND UNDERSTAND YOUR EMPLOYMENT CONTRACT Many employed physicians, upon becoming embroiled in an employment dispute, are unable to produce a fully signed, current version of their employment agreement. Not knowing what rights an employed physician holds (or does not hold) under an employment agreement, especially at the initial stages of a dispute, provides the employer with a dramatic and potentially devastating advantage. Without properly understanding the rights and restrictions contained within an employment contract, a physician is unable to effectively negotiate that form of physician contract to his or her benefit. Following are common sections/terms found in most physician “contracts” that all physicians should be aware of.

* The word “contract” in this article also includes all hidden forms of employment “contracts”–legally binding agreements that govern the physician’s employment and post-employment status. For example, most employed physicians currently work under, and are governed by, “contracts” such as code(s) of conduct, employee handbooks or manuals, medical staff bylaws, department policies and/or protocols and human resources employment requirements.

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Compensation: An employment agreement should clearly spell out, in terms the physician can readily understand, such financial elements as compensation, expense reimbursements and benefits. Compensation should include salary and the method for calculating bonuses. Expense reimbursement should include practical elements such as the cost of a cell phone, travel expenses, continuing medical education (CME) reimbursement and meal/entertainment costs. Benefits should comprise health insurance, any available or applicable retirement plan, disability insurance and paid time off (vacation and personal days, holidays, illnesses, bereavement, etc.). Job Duties: Duties should also be detailed in practical terms and provide not only the expected number of hours the employed physician is required to work but also define “work” with specificity. At what location will “work” be required? How will “work” be broken down in terms of the treatment of patients and on-call obligations (including when and where) compared to billing and recordkeeping, administrative responsibilities and marketing obligations? Term: Every physician employment contract should also clearly define the contract’s term. How long is the contract designed to last? Provisions regarding term should also spell out the initial term and whether the contract provides for automatic renewals. Some of the most heavily disputed, and extensively litigated, provisions in an employed physician contract are the elements regarding termination (termination without cause, termination for cause, etc.). Employed physicians should be aware of their obligations regarding termination (notice, patient care during notice period, etc.) and the consequences

that can result from the contract’s termination (forfeiture of any pending bonus, loss of hospital privileges, application and enforcement of restrictive covenants, etc.). Termination: In dealing with the issue of post-contract termination status, every employed physician should pay special attention to the restrictive covenants spelled out in his or her employment contract. Such provisions can block many efforts by and/or goals of the departing physician to seek employment elsewhere, practice in a proximate setting and/or reopen a private practice. These restrictions typically provide confidentiality (medical records, patient lists, referral sources), non-solicitation (patients, employees, referral sources), non-competition (scope of activities and geographic limitation, i.e., how many miles and the number of offices) and duration of the restrictions (months/years). Malpractice Insurance: In any physician’s employment, the issue of malpractice insurance should be explored, understood and confirmed. What type of insurance does the employer provide (i.e., claims made versus occurrencebased)? What amounts of coverage (primary and/or excess) is the employed physician being provided? Is “tail” coverage required? Who holds payment obligations for such coverage? Partnership: In a group practice setting, a properly constructed employment contract should also clearly identify what is required of the employed physician to be eligible or considered for partnership within the group (whether in the form of partnership, shareholder status, profit sharing, etc.). Alternative Dispute Resolution (ADR): One of the more popular new aspects of physician contracts is the requirement that any disagreements be resolved through Alternative Dispute Resolution (ADR). Dispute resolution can be accomMDADVISOR

“Although the importance of obtaining and retaining a signed copy of each employment agreement may seem self-evident, the failure to do so continues to be a cause (and a frustrating one) of physician disempowerment.”

plished through arbitration or the court process. The advantages of ADR arbitration are that it can be less time-consuming and less expensive than the normal court processes. However, ADR can also be less inclined to issue definitive rulings and/or render decisions that rule exclusively in favor of the employed physician. Court can be less costly and includes the right to discovery and the right to appeal. REQUEST AND NEGOTIATE CHANGES TO YOUR EMPLOYMENT CONTRACT

Many, if not most, employed physicians enter into employment contracts, and practice thereafter, under the prevailing assumption that an employment contract is nonnegotiable and impervious to change. Nothing could be further from the truth. Even if the employed physician’s salary is preset or subject to some form of employer salary schedule, the terms of employment are readily subject to change and are certainly an appropriate arena for discussion and negotiation. Although compensation is a primary area of concern for many physicians, physicians must also be aware of the many differing forms of restrictions contained within their contracts. Physicians should pay particular attention to their rights/restrictions upon termination of employment and focus on the restrictive covenants that may well threaten their economic futures. For example, depending on the specialty of a physician and the geographic area where he or she practices (i.e., rural versus urban), a restrictive noncompete clause can be seriously harmful and isolate a physician from thousands of potential patients over a considerable geographic landscape for a long period of time. As a result, when negotiating a physician contract, every employed physician should seek professional advice to ensure that the contract is not overly broad, overreaching, unreasonable and potentially injurious to the physician once his or her association with the employer ends. Although practices have the right to protect confidential patient and proprietary information, physicians should not be hesitant to negotiate termination provisions within their contracts that provide appropriate and mutually protective restrictive covenants. Although courts are likely to enforce reasonable, narrowly tailored and specific

MDADVISOR | SUMMER 2013

restrictive covenants, courts are also just as likely to strike down unreasonable covenants. Physicians should work closely with experienced healthcare counsel to help craft and revise restrictive covenants and/or termination provisions so that they comply with state and federal laws and protect physicians’ rights. OBTAIN AND MAINTAIN A SIGNED COPY OF YOUR EMPLOYMENT CONTRACT

Although the importance of obtaining and retaining a signed copy of each employment agreement may seem self-evident, the failure to do so continues to be a cause (and a frustrating one) of physician disempowerment. Each contract should be accepted only upon receipt of a fully executed original form of contract, and that original should be maintained in a confidential, secure and safe location. CONCLUSION The varied forms of employed physician contracts are increasing, ever changing and more stringent, in both legal and practical terms, than ever before. The keys to addressing this phenomenon are for every employed physician to understand that contracts can and must be negotiated, that contracts can be managed, that employed physicians must be engaged in the contract process and that every physician must learn to adapt as healthcare stumbles and crashes through the changes yet to come. Michael J. Schoppmann, Esq., is the Managing Partner of Kern Augustine Conroy & Schoppmann, P.C., a firm that specializes in healthcare law. 1

Medical Group Management Association. (2010). Physician compensation and production survey: 2010 based on 2009 data. Englewood, CO: Author.

Kocher, R., & Sahni, N. R. (2011). Hospitals’ race to employ physicians: The logic behind a money-losing proposition. New England Journal of Medicine, 364, 1790–1793.

Accenture. (2011). Clinical transformation: Dramatic changes as physician employment grows. www.accenture.com/ SiteCollectionDocuments/PDF/Accenture_Clinical_ Transformation.pdf.

By Alexander Kopeykin, RN, MBA, MPM, and Alfred Campanella In many hospitals, patient flow is a labor-intensive, manual process that includes numerous phone calls, multiple text pages and paper logs to manage available beds and determine how patients are assigned to them. Hospitals also face challenges with primarily manual processes for managing “movable assets” such as wheelchairs, IV pumps and ventilators. These two challenges can lead to inefficient use of hospital resources and frustrated clinicians who cannot efficiently locate movable assets for patient care. An operational improvement initiative at Virtua, a comprehensive healthcare system with four hospitals in southern New Jersey,1 addresses some of these challenges. The initiative includes improved processes for patient flow, bed management and movable asset management, supported by real-time tracking technologies. THE VIRTUA PROJECT In April 2009, Virtua embarked on a project to improve patient flow, bed management and asset management processes in a more automated, efficient and metric-driven fashion. The project’s steering committee realized early on that a real-time location system (RTLS) would be a key enabler for achieving the needed efficiency improvements in these workflows. RTLS technology would enable the Virtua employee–typically nurses and bed-flow coordinators–to track bed availability and the actual location of patients. Since the location of employees who perform environmental clean-up could also be tracked, the “clean” or “dirty” status of patient rooms could be monitored by the system. For both non-therapeutic and therapeutic equipment, par levels2 could be monitored for each hospital unit, the time

RTLS Systems RTLS systems utilize radio-frequency identification (RFID) technologies to capture data to identify, locate and track objects–and sometimes people–in real time. Tags that have a unique identifier and can transmit an RF signal–and can be as small as a square inch or a small box–are attached to equipment or people. The identification data from the tags are transmitted to “readers” (electronic RF-signal receivers, mounted to the wall or ceiling that serve as the connection or access point to a Wi-Fi network). The asset or patient data are then used by software applications to map the location of the object and support searches, the sending of alarms or alerts and the analytical reporting of asset usage. The real-time tracking software selected for the Virtua project was the GE Healthcare AgileTrac Real Time Asset and Patient Flow Management System.

to respond to both stat and routine movable asset requests could be shortened and the current status of facility-owned and rental equipment could be better tracked and managed by equipment service technicians. Assisted by the consulting firm Aspen Advisors and GE Healthcare, the Virtua operational and technology leaders and staff who formed the project team reviewed and documented more than 30 current state processes across the organization. A Six Sigma approach3 was used to redesign each process into a more efficient future state process, enabled by RTLS technology, to eliminate inefficiencies, manual work and rework, and to provide much-needed transparency to the patient workflows. The goal was to develop standardized processes that could be replicated across all four of Virtua’s hospitals. Future users from the impacted departments (Nursing, Environmental Services, Escort Services, Registration and

MDADVISOR

Plant Operations) were actively involved in the future state design, thus creating buy-in and ownership of the new processes that would be supported by the new technology. The team also created par levels for all movable assets used by nurses, and a database was designed to inventory, on a real-time basis, all “clean” and “soiled” equipment. A new process for managing rental equipment was also developed to better identify rental equipment needs as well as to improve the return process. The project team also determined the best user interface and communication mechanisms for staff who are based on the nursing units throughout the hospital, as well as for the bed-flow coordinators who manage the assignment of beds to patients. A guiding principle was to provide clinical staff the tools needed to provide the best care to patients, including mobile computing support with tablets when appropriate. After many months of redesigning processes and planning infrastructure, the Asset Management software was deployed in September 2010 in a pilot phase at Virtua’s newly built Voorhees Hospital, in Voorhees, New Jersey, followed by the Patient Management software in December 2010, also in a pilot phase. Both modules were fully deployed at Voorhees by May 2011, and in August 2012, a new operational unit, the Joint Replacement Institute, was added to this RTLS platform. Learnings from these initial implementations were incorporated into the May 2012 implementation at Marlton Hospital, Marlton, New Jersey. By fall 2012, 400 patients were tracked daily, and more than 4,000 assets were managed with RFID tags. An implementation at Memorial Hospital in Mount Holly, New Jersey, is still under way at the time of this writing, and a 2014 implementation is planned for Berlin Hospital, in Berlin, New Jersey. On an ongoing basis, tags are issued to patients when they are admitted to the hospital and are attached to the patient’s identification wrist bracelet. Upon discharge, the tags are collected at a central location on each nursing unit; each day, these used tags are sterilized and become reusable for patient use. For moveable equipment, the biomedical service technicians maintain tags on each piece of equipment as part of the routine workflow. A small percentage of tags need to be replaced each year due to loss or wear-and-tear.

MDADVISOR | SUMMER 2013

MEASURING THE WORKFLOW IMPROVEMENTS In April 2010, prior to the implementation of the new system, the project team conducted several “voice-ofthe-customer” interviews with staff at the Voorhees Hospital to establish baseline perceptions of the current processes for patient and asset flow. The team members also captured anxieties about the intended future state processes so that the team could anticipate users’ concerns as part of the local implementation plans. Two years later, the team conducted a follow-up survey and compared the results with the new workflows supported by the RTLS system to the baseline data. Asset Management. One of the most striking improvements was the reduced response time for filling stat and routine requests for equipment. As shown in Figure 1, the response time for stat requests was reduced from an average of 202 minutes to 12 minutes (94 percent improvement), and for routine requests from 232 minutes to 14 minutes (92 percent improvement). These efficiency and quality-of-care improvements were a direct result of streamlining the equipment delivery process with the use of the RTLS technology. Comments from key users provided additional support for these asset management improvements (see Table 1). The new rental equipment management process also resulted in significant cost avoidance.

FIGURE 1. Delivery Time Improvements for Movable Equipment

Patient Flow. The most noticeable change for patient flow processes was in the number of phone calls that a nursing supervisor or bed-flow coordinator had to make throughout the day. Based on estimates captured from data provided by key users (nursing supervisors and nursing unit secretaries), there was a greater than 90 percent reduction in phone calls made by the nursing supervisor or bed-flow coordinator during an admission process, and a 50 percent reduction during the discharge process (see Table 2). This significant decrease in telephone calls equates to almost 1,200 labor hours saved annually, which means more time available for direct patient service. Improvements in bed utilization were also captured in staff com-

Table 1. User Comments on Movable Equipment Pre-and Post-Implementation Pre-Implementation (April 2010)

Post-Implementation (September 2012)

“Many different names for equipment. “The system gives me more knowledge, For example, Central Sterile/ Depot as we can pull up actual information refers to it as [a] heating pad, while (standard asset naming) terms of nursing refers to it as [a] K-pad.” knowing where equipment is.” Biomed Technician Nurse Director “Broken repair tags are placed on pumps. Pumps are cleaned by staff on the floors with no real system for clean or dirty.” Patient Care Technician “I get calls all the time to find specific equipment.” Nurse Supervisor

“The system helps to track pumps, and the report out is amazing. [It tells us] that the pump belongs to a particular patient.” Patient Care Technician “In a Code situation, when we are looking for a piece of equipment… the system is a great help.” Nurse Director

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Table 2. Phone Calls Related to Admission and Discharge Processes Patient Flow Process

Pre-RTLS: Calls per Day

Post RTLS: Calls per Day

Calls Saved per Day

Time Saved Annually

Admissions

162/day 59,130/yr.

16/day 5,963/yr.

146/day 53,667/yr.

894 hrs./=37 days

Discharges

100/day 36,261/yr.

50/day 18,131/yr.

302 hrs./=13 days

Note: The data exclude obstetrical admissions and discharges. Average admits/day = 36; average discharges/day (med/surg only) = 33. Average phone call estimated at 1 minute: average calls per day 4–5/admitted patient has saved 90 percent of phone calls since RTLS (nursing supervisor); 3 average phone calls per day per discharged patient has saved 50 percent with RTLS (med/surg unit secretary). Sources: Virtua Hospital Admission, Discharge and Transfer Data June to September 2011; phone call estimates were collected through interviews.

ments collected before and after the RTLS system implementation: Patients were being moved from emergency department (ED) and intensive care unit (ICU) units into empty beds more quickly. LESSONS LEARNED Some factors related to implementation success for other major workflow and system change projects were also evident. These include the following: • The right project team, program organization and governance structure • Key users on the project team to help ensure user buy-in • Using “local” champions to get the word out and drive support • A flexible training plan to meet the individual needs of different users in a given facility In addition, several lessons were important for a project that involves implementing new RFID technology to support new workflows with real-time location systems for the first time. These lessons include the following: • Focus first on the process and the workflow changes, and then on the technology that will support them • Develop an overall program road map with clearly defined metrics and capture metrics before implementation for a baseline comparison • Create a testing environment to simulate real-time patient flow and asset tracking, including how to adapt to rare occasions when the RTLS technology is undergoing maintenance and is unavailable • Pilot the technology first–and start with equipment (not people) tracking Managing movable assets as well as patient and bed flow is a behind-the-scenes operational challenge in all

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hospitals. Typically, these administrative tasks steal valuable time from patient care and can foster frustration among hospital staff. The move to real-time tracking technologies, as undertaken at the Virtua hospitals, is an example of how new information technologies can be leveraged for both clinical and administrative improvements. Alexander Kopeykin, RN, MBA, MPM, is a Project Manager within the Department of Information Services at Virtua Health, Inc. Alfred Campanella is Executive Vice President for Strategic Business Growth and Analytics at Virtua Health, Inc. 1

Virtua (www.virtua.org, www.virtuabroadcastnetwork.org) is an integrated healthcare system with more than 8,500 employees. As an early adopter of clinical and information technology, Virtua has been recognized for its innovative partnerships with GE Healthcare, Children’s Hospital of Philadelphia and the Fox Chase Cancer Center.

A “par level” is the minimum quantity of an item that needs to be available–e.g., 15 drug infusion pumps for a hospital unit.

Six Sigma is management technique for improving the quality of process outputs by identifying and removing the causes of defects (or errors) and minimizing variability in manufacturing and business processes. It uses workflow analysis and statistical methods to identify process errors and to design improved workflows with a goal of nearly error-free (or defect-free) outcomes as represented by the statistic of 99.99966 percent.

Vaccine-Preventable Diseases

Still Pose a Threat to Our Communities By Commissioner Mary E. Oâ&#x20AC;&#x2122;Dowd, MPH As healthcare and public health leaders, we routinely promote vaccination as a critical measure to protect the health of residents. Thanks to the success of immunizations, vaccine-preventable diseases are at near-record lows. Fewer people in the United State experience the devastating effects of polio, rubella and other illnesses than in the past. However, with the increase in global travel, vaccine-preventable diseases are imported into this country by people who are infected abroad and have the potential to rapidly spread infection within our schools and communities. When these diseases suddenly pose a threat, we are reminded of the importance of immunization.

Cluster of Measles Infections in Somerset County: A Local Perspective Somerset County recently experienced the impact that one unvaccinated person can have on its residents when one child exposed others who, during a potentially infectious period, frequented a hospital and its affiliated cancer center, two county government buildings, a department store, two restaurants, one bookstore and one salon. The index case was a two year-old child who had recently traveled internationally to a region where measles is still endemic. Although interruption of indigenous transmission of measles in the United States has been achieved, cases are still reported in the United States, the majority of which are imported from other countries or linked to imported cases.1 Complacency regarding vaccination still exists, along with the tendency to assume that those with whom we come into contact each day (either directly or indirectly) are adequately protected. The index case exposed both employees and visitors at Somerset Medical Center. Shortly after contact with the child, a healthcare worker at the hospital developed a fever and a rash. This individual, unaware of the cause of the symptoms, worked while infectious, potentially exposing workers and visitors at the hospital. The dilemma was that there were only two days left before hundreds of potentially exposed people transitioned from an incubation period into possible prodrome. At this point, it was too late to administer live measles vaccine as postexposure prophylaxis, and at the cusp to provide temporary protection with immune globulin (IG). Measles is highly communicable, with greater than 90 percent secondary attack rates among susceptible persons. The virus can survive on inanimate objects and remain airborne for up to two hours.2 To ensure that those who visited the hospital were aware of the potential exposure, the New Jersey Department of Health issued a public health alert informing the public of dates and times of the possible exposure. A third suspected case was also identified. In addition

to being at the hospital, this third individual also visited the hospitalâ&#x20AC;&#x2122;s cancer center and several local businesses.2 This extensive travel triggered an additional public health alert to make the public aware of potential exposure at the hospital, cancer center and local businesses. More than 400 county government employees were potentially exposed to this third suspect case of measles. First responders, including law enforcement and Emergency Medical Service (EMS) personnel, were among the potentially exposed. Without any documented evidence of immunity on file, the Somerset County Health Department closed administrative operation within one of the county government buildings to be facilitated as a clinic for serologic testing for IgG antibodies to rubeola. Testing continued for a period of four days, two of which fell on a weekend. More than a dozen county employees were self-quarantined, lasting from 11 to 14 days, depending on when the last exposure occurred. Although it is estimated that hundreds of residents were potentially exposed, thankfully, only two confirmed measles cases resulted from this experience. One of the most significant findings resulting from this experience, and what was found to be paramount, was the vulnerability of the first responder community and reciprocally the community they serve. It is imperative that first responders and support staff receive and maintain the level of protection necessary and available to eliminate and/or mitigate any threat to their health and the health of their community. For those organizations employing individuals not involved with providing emergency response services or medical treatment, where Advisory Committee on Immunization Practices (ACIP) standards might already be in place, ensuring immediate access to employee immunization records can prove to be an invaluable process should a public health emergency necessitate documented proof of immunity. Submitted by Nicole Rondon, MPH, Public Health Epidemiologist, Somerset County Department of Health. MDADVISOR

“Many believe the rise in measles cases can be attributed primarily to the proportion of unprotected 10 to 16 year olds who were not vaccinated in the late 1990s and early 2000s when concern surrounding the discredited link between autism and the vaccine was widespread.”

A RECENT OUTBREAK IN NEW JERSEY A New Jersey county recently experienced the impact that one unvaccinated person can have on its residents when an ill child’s visit to Somerset Medical Center in Somerville, New Jersey, caused a measles scare within the whole community. OTHER RECENT MEASLES OCCURRENCES New York City is currently addressing an outbreak of measles in Brooklyn that also began with an unvaccinated individual who traveled overseas. Currently, more than 56 confirmed cases of measles are associated with this outbreak. All of the Brooklyn cases are members of the Orthodox Jewish community and were unvaccinated at the time of exposure because they were either too young to be vaccinated or refused or delayed vaccination. The New York City Health Department has identified more than 2,000 people who were exposed.3 The index patient who triggered the cases in Brooklyn traveled to England where there has been an outbreak of measles. In 2013, the United Kingdom has had more than 1,200 measles cases, and last year there were 2,000 cases.4 To prevent further infection, Public Health England has launched an immunization program aimed at increasing vaccination rates in children and teens. Many believe the rise in measles cases can be attributed primarily to the proportion of unprotected 10 to 16 year olds who were not vaccinated in the late 1990s and early 2000s when concern surrounding the discredited link between autism and the vaccine was widespread. Since then, measles vaccination coverage in the UK fell nationally to less than 80 percent in 2005. After many years of low vaccination rates, measles became re-established in 2007. More recently, the measlesmumps-rubella (MMR) vaccination level rose to 95 percent of 5 year olds in England receiving one dose and 90 percent receiving two doses.5 This is similar to vaccination coverage in the United States, which was 95 percent in 2010.6

MDADVISOR | SUMMER 2013

ENSURING HIGH IMMUNIZATION RATES As healthcare providers, you are critical partners in ensuring that individuals are vaccinated to protect not only their own health but also the health of the community. The following guidelines can help ensure a high level of protection. Dosage Schedule: To protect against measles, the Advisory Committee on Immunization Practices (ACIP) recommends that all children receive two doses of measles vaccine, as combination MMR vaccine, separated by at least four weeks. The first dose of MMR should be given on or after the first birthday. A second dose of MMR should routinely be given at 4 to 6 years of age. International Travel Advisory: It is important to educate parents about the risk of measles associated with international travel. The ACIP recommends that travelers are vaccinated, particularly infants ages 6 to 11 months.7 Although measles is rare in the United States, the disease still kills nearly 200,000 people each year around the world, according to the Centers for Disease Control and Prevention.8 In 2011, there were 158,000 measles deaths worldwide–about 430 deaths every day.9 School Requirements: School immunization requirements are also an important tool in ensuring high immunization rates within our communities. In New Jersey, any child over 15 months of age entering childcare, preschool or prekindergarten needs a minimum of one dose of MMR vaccine. For entry into kindergarten, a child needs two doses.10 Students entering a higher education institution must have had two doses of a live measles-containing vaccine. Healthcare Personnel Requirements: As was found in the recent Somerset County outbreak, it is critical to ensure that healthcare personnel who work in medical facilities are protected. Healthcare workers should have presumptive evidence of immunity to measles documented and readily available at the workplace. Then, if there is an exposure in a healthcare environment, the administration of that facility will be able to quickly assess who is most at risk. Presumptive evidence of immunity to measles for persons who work in healthcare facilities

“While measles is rare in the United States, it still kills nearly 200,000 people each year around the world, according to the Centers for Disease Control and Prevention.8 In 2011, there were 158,000 measles deaths worldwide–about 430 deaths every day.9 ”

includes any of the following: written documentation of vaccination with two doses of live measles or MMR vaccine, laboratory evidence of immunity or laboratory confirmation of disease.11 YOUR ROLE IN PREVENTION Although healthcare providers and the public health community have made great strides in encouraging vaccination, diseases that could be prevented still pose a risk to our residents. As leaders of New Jersey’s medical community, please educate your patients about risks of vaccine-preventable disease. Please take time to encourage vaccination among your patients–only through increased immunization rates can we effectively protect our residents. For more information on the New Jersey Department of Health’s Vaccine Preventable Disease Program, please visit http://nj.gov/health/cd/vpdp/index.shtml. Mary E. O’Dowd, MPH, is the Commissioner of the New Jersey Department of Health. 1

Kutty, P., Rota, J., Bellini, W., & Redd, S. B. (2011). VPD surveillance manual (5th ed.). Atlanta, GA: Centers for Disease Control and Prevention.

New Jersey Department of Health. (2013, March 15). Measles exposures in New Jersey. Vaccine Preventable Disease Program Measles Public FAQs. www.nj.gov/ health/documents/measles_faq_public.pdf.

New York City Department of Health and Mental Hygiene. (2013, May 21). Alert # 15: Update on measles in New York City. www.nyc.gov/html/doh/html/diseases/ immmea.shtml.

Editorial Board. (2013, May 23). Aftermath of an unfounded vaccine scare. The New York Times. www.nytimes.com/2013/ 05/23/opinion/the-aftermath-of-measles-vaccine-scare-inbritain.html.

Public Health England. (2013, April 25). National MMR vaccination catch-up programme announced in response to increase in measles cases [Press release]. www.gov.uk/

government/news/national-mmr-vaccination-catch-up-programme-announcedin-response-to-increase-in-measles-cases. 6

Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases. (n.d.). Coverage estimates for school entry vaccinations: For school year 2009-2010. www2.cdc.gov/nip/ schoolsurv/nationalAvg.asp?SY=SY10.

Centers for Disease Control and Prevention. (2005, August 26). Preventable measles among U.S. residents, 2001–2004. Morbidity and Mortality Weekly Report. 54(33), 817– 820. [Available at www.cdc.gov/mmwr/ preview/mmwrhtml/mm5433a1.htm]

Centers for Disease Control and Prevention. (2012). Overview of measles. www.cdc.gov/measles/ about/overview.html.

World Health Organization. (2013, February). Measles. www.who.int/ mediacentre/factsheets/fs286/en/.

New Jersey Department of Health. (2012, October). Childhood and adolescent recommended vaccines. Vaccine Preventable Disease Program. www.nj.gov/health/cd/documents/ childhood_recommended_vaccines.pdf.

Immunization Action Coalition. (n.d.). Healthcare personnel vaccination recommendations.www.immunize.org/ catg.d/p2017.pdf.

MDADVISOR

MINIMALLY INVASIVE SURGERY: A Discussion with Steven McCarus, MD – Interviewed by Theresa Foy DiGeronimo

It certainly is not breaking news that patient safety is a major concern within the healthcare community. The emergent need for focused attention on this issue was highlighted in 1999 after the Institute of Medicine published a landmark report, To Err Is Human: Building a Safer Health System. This report announced that up to 98,000 Americans die each year due to medical error–more than those dying from motor vehicle accidents, breast cancer or AIDS.1 Fourteen years later, many in the medical community believe that protocols ensuring patient safety have greatly improved. However, the rapidly expanding use of minimally invasive manual laparoscopy and robotic surgical techniques–whether for outpatient or inpatient procedures–has added new factors that complicate the status quo methods designed to ensure operating room safety for both the patient and the physician. ACKNOWLEDGING THE NEED FOR BETTER TRAINING As Anthony Quartell, MD, Director of Minimally Invasive GYN Surgery at Saint Barnabas Medical Center, explained in Part 1 of this article series, minimally invasive surgery (MIS) can, in fact, decrease the risk of surgical complications. MIS is known to offer a more rapid recovery, a decrease in infection * This is the second of a two-part series on minimally invasive surgery. Part I, focusing on the learning curve and its effect on safety, appeared in the Spring 2013 issue of MDAdvisor. 24

MDADVISOR | SUMMER 2013

PAtieNt SAFety & iNFORMeD CONSeNt* rate and a decrease in post-operative pain and pain medicaIMPROVE OR READINESS TO DECREASE tion. MIS can be also be cosmetically more desirable and PATIENT RISK is often the surgery of choice in morbidly obese patients.2 Along with Paul Alan Wetter, MD, McCarus has advocated However, despite these benefits, there is no doubt through the Society of Laproendoscopic Surgeons for the that as surgeons transition from open to minimally invasive implementation of readiness guidelines in the operating surgery, there is a time period along the learning curve that room. To this end, Wetter has launched a worldwide program affects patient safety. The anatomy visible through a called ORReady. As outlined on its website: “This multi-spelaparoscope differs in perspective from that presented in cialty initiative encourages steps that are known to improve the open case, basic techniques such as suturing have to surgical outcomes and save lives. Working together, medical be relearned, and there is a decrease in tactile sense as an societies and other organizations around the world are sharinstrument is interposed between fingertip ing ideas that work to help improve outcomes 3 and tissue. These facts certainly affect outfor surgical patients. By using, analyzing and “McCarus sees a need for improved operating comes and liability. continuing to improve guidelines and proceroom (OR) readiness, Steven McCarus, MD, Founder of the dures, including check lists, time outs and warm improved standards of American Institute of MIS agrees with Quarups, we estimate that six million patients care and increased tell’s premise that the learning curve for MIS around the world could have better outcomes. transparency in informed is a key safety issue. “Increasing surgical risk That’s 2-3 percent of the approximately 250 milconsent to protect patient is directly related to inadequate training on lion surgeries that are performed worldwide safety and reduce 5 physician liability” new procedures; whether the technology is each year.” (For more information, new (as in robotic surgery) or whether the visit www.ORReady.org.) physician needs to learn a new procedure (as in laparoMcCarus emphasizes that OR readiness guidescopic surgery), there is a definite increased risk with lines for MIS support the need to respond to an issue or a doctors in training. In fact, we are seeing an inordinate misadventure in the operating room in ways that decrease number of complications associated with robotic surgery risk to the patient. For example, he notes: “If someone in the in gynecology because of the learning curve we are hospital has heart pain or chest discomfort and presents with experiencing right now.” The U.S. Food and Drug Adminacute myocardial infraction, everyone on the cardiac team istration (FDA) recently acknowledged that reports of has a pre-assigned role and works quickly and efficiently to adverse events related to the da Vinci surgical robots have save lives. We have to acquire the same mentality regarding increased, and agency officials are investigating the reasons minimally invasive surgery in the OR room to reduce risk.” behind these complaints, including causes that range from “If, for example,” continues McCarus, “I run into an equipment failure to problems associated with inadequate intraoperative bleeding complication, I have to have a team physician training.4 that is OR ready. Someone knows to call the blood bank, In addition to the recommendations intended to someone knows to notify the front desk, someone has a reduce risk during the learning curve outlined in Quartell’s runner ready. I, as the surgeon, know when to be aggressive article, McCarus sees a need for improved operating with consultation with other specialists (such as a urologist and general surgeon). And we all know what to do if the sitroom (OR) readiness, improved standards of care and uation requires that we convert to open surgery. When the increased transparency in informed consent to protect team is this ready, we can immediately reduce risk and save patient safety and reduce physician liability when lives in these procedures.” physicians perform minimally invasive surgery.

MDADVISOR

IMPROVE STANDARDS OF CARE TO PREVENT INJURY DURING MIS Certain injuries are known to occur during MIS that can increase the risk of liability. This is especially true when the injuries are not immediately recognized during the procedure–a delay in diagnosis of these injuries substantially increases liability. This is why McCarus believes it is important for surgeons to always carefully check areas that are involved peripherally during the operation. McCarus notes that 33 percent of MIS complications occur during peritoneal access. “So we have to look at surgical areas that increase our risk and create solutions that improve patient outcome and hence improve patient satisfaction. Physicians have to explore surgical strategies that will recognize early surgical complications, and they must also have techniques that will reduce litigation when treating these problems.” Using gynecological surgery as an example, McCarus explains, “There are risks in gynecological surgery that we must think about before, during and after the operation. I recommend that all gynecological surgeons practicing minimally invasive surgery look around the area under the umbilicus once they get the trocar and scope through the umbilicus. The surgeons must look for injury associated with structures such as the bowel, bladder and ureter; vascular complications should also be considered and explored.” When using MIS to conduct a hysterectomy or when facing gynecological problems such as uterine fibroids, pelvic endometriosis and pelvic adhesions, McCarus recommends that surgeons routinely check the integrity of the bladder, check ureteral patency, check the rectum/colon, drop intra-abdominal pressure and look for bleeding. He also suggests a cystoscopy after every hysterectomy and difficult surgical procedure. “Today,” says McCarus, “I spend most of my time on complicated cases, checking the integrity of the bladder, the bowel and the ureters. A best practice for MIS is to check organ systems thoroughly for injury after every surgery.” McCarus believes that this careful search for possible damage is a standard of care activity that will increase awareness of intraoperative complications and will decrease surgical litigation. INFORMED CONSENT FOR MIS Patient safety is the basis of a properly executed informed consent document. This legal doctrine is mandated before

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any intervention. In fact, without proper informed consent, the surgeon can be accused of battery if any procedure is performed. Given the role of the informed consent in securing patient safety and avoiding litigation, McCarus emphasizes that properly executed informed consent should always include the following five components: 1 – The diagnosis and indication for surgery 2 – The nature of the procedure 3 – The risk and potential complications 4 – The alternative treatments or procedures 5 – The relative probability of success These standard components of informed consent are vital whether a recommended surgery is open or minimally invasive. However, McCarus notes that emphasis on the fourth tenet often increases when MIS is an option. “I am seeing an issue,” he notes, “with patients properly understanding or properly being told about surgical options. For example, I have recently seen two patients who acquired post-operative complications from robotic hysterectomy. Both have chronic neuropathic pain, and both feel victimized–not because they are having post-operative complications, but because they feel that alternative procedures were not explained to them and felt blindsided when they found out later that they had other options. If the patient needs a hysterectomy, she must know that she can choose a vaginal hysterectomy, a laparoscopic hysterectomy, a robotic hysterectomy or an abdominal hysterectomy. She has to know all her choices–including any possible non-surgical options.” The inclusion of alternative treatments or procedures in an informed consent highlights the surgeon’s need for full transparency regarding level of experience in performing the various alternative options–especially MIS. Patients must know the physician’s level of experience and comfort. McCarus explains: “The surgeon must tell the patient, ‘I’ve been doing this procedure for x years. I’ve done x number of them, and I’m very comfortable with the procedure.’ Or, the surgeon might have to say, ‘Although I am well trained and I feel very comfortable doing this procedure, you’re my first patient.’ Then it’s up to the patient to decide what to do. Personally, I have never heard of a patient who has walked away from a trusted physician due to this kind of honest disclosure. But the bottom line is that given the many options a patient can choose from, more so today than ever, if a patient is properly informed and consented,

the outcome is more likely to be successful, and the risk of liability may decrease.” GOING FORWARD All medical professionals are living in precarious times right now due to innovations in technology and issues surrounding healthcare reform. McCarus is adamant in his belief that given this environment, all physicians need to be totally transparent and accountable for what they do. “As increased levels of liability seem to be lurking around every corner,” he cautions, “the amount of awareness, and education and involvement in the changing medical arena is more important today than ever before for every physician.” As MIS becomes more and more in demand by the general public, the medical community must rapidly evaluate its training methods, its standards of care and its inclusion of transparency in informed consent to continue to improve patient safety and reduce physician liability. Steven McCarus, MD, is Chief of the Division of Gynecologic Surgery and Director of McCarus Surgical

Specialists for Women at Florida Hospital Celebration Health in Orlando, Florida, and Founder of the American Institute of Minimally Invasive Surgery. 1

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To err is human: Building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Washington, DC: National Academy Press. [Available at: http://books.nap.edu/catalog/9728.html]

Quartell, A. (2013, Spring). Minimally invasive surgery: The learning curve for physicians. MDAdvisor, 6(2), 10–14.

Perugini, R. A., & Callery, M. P. (2001). Complications of laparoscopic surgery. In R. G. Holzheimer & J. A. Mannick (Eds.), Surgical treatment: Evidence-based and problemoriented. Munich: Zuckschwerdt. [Available from: www.ncbi.nlm.nih.gov/books/NBK6923]

Lowes, R. (2013, April 20). FDA investigates robotic surgery system after adverse event spike. Medscape Medical News. www.medscape.com/viewarticle/803339.

Wetter, P. A. (n.d.). Operating room traffic safety improves patient outcome. Society of Laparoscopic Surgeons. www.laparoscopy.blogs.com/outcome.

“But the bottom line is that given the many options a patient can choose from, more so today than ever, if a patient is properly informed and consented, the outcome is more likely to be successful, and the risk of liability may decrease.”

MDADVISOR

Building Your MD

B R AND By Steve Adubato, PhD

Building

and sustaining your professional and clinical brand is challenging regardless of the arena you are in. For physicians and medical professionals working with patients and family members, who are often dealing with complex medical issues, however, brand creation and maintenance raise a unique set of challenges. The branding game gets even more complex when we add to the equation the fact that many physicians are faced with balancing their own brand with that of the hospital at which they are employed or the brand of a partnership with an accountable care organization (ACO) or group medical practice. However, building your own brand as a physician and building one with your affiliated hospital, ACO or other medical organization are not mutually exclusive. It is virtually impossible to successfully build your own brand without considering the impact the brand of the larger organization with whom you have partnered will have on your overall success. Whether you are looking to increase your patient base, offer a new service or procedure or simply foster relationships with current patients, your overall brand is one of the largest factors in your ability to reach that goal.

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With that said, there are some very specific tips and tools to successfully build and retain your own brand as a physician while also co-branding with the goals, mission and vision of the hospital or larger organization in mind.

Embrace the Internet. The Internet has quickly become one of the first places a person goes when seeking information about a health-related issue or concern. If a patient has a particular symptom such as a rash, a growth or some sort of pain or discomfort, what does he or she do? Most people go to Google and type the symptoms into the search engine. This search often leads to the next step of looking for a physician, hospital or medical practice that specializes in the particular issue or health concern. Therefore, building an online presence both as an individual physician as well as part of a larger organization will help you to better connect with prospective patients.

“Whether you are looking to increase your patient base, offer a new service or procedure or simply foster relationships with current patients,

your overall brand is one of the largest factors in your ability to reach that goal.”

“feedback”

Maximize third-party testimonials.

When it comes to building your brand, do not underestimate the value of positive patient and family member testimonials. When searching for a physician, many rely on the affirmative experiences and stories of others when deciding to make the initial contact with one physician or practice over another. Therefore, proactively ask your patients to offer feedback, and to authorize you to publish their comments if desirable, to specific, open-ended questions about a certain service or procedure, the quality of customer service and their experience overall. Then, post these permitted testimonials on your website and share them with the hospital, ACO or organization with which you have partnered so that it can cross-promote this feedback as well.

Share information. On a regular basis, either weekly or monthly, update your website with valuable information for your patients not only about services that you provide but also cross-promote the services provided by your hospital or ACO. For example, if the hospital you have partnered with is offering a class to help patients stop smoking, post that information on your website. Better yet, send a mass e-mail to the patients in your electronic database letting them know of this opportunity, which in turn is communicating that you have partnered with an organization that cares enough about its patients to offer a free service to help them stop smoking and become healthier.

Get to know the public relations (PR) and marketing team. If you have recently partnered with a hospital or other healthcare group, quickly determine who controls the website in terms of posting updates, videos, articles and other relevant information. Schedule a meeting to determine how best to share information and be sure to ask about deadlines so that the important update you want patients to see can be received and posted in a timely manner. In return, be sure to offer the same courtesy to the PR team at the hospital, ACO or other organization on your own website. Having an open line of communication between yourself and these folks will ensure a consistent branding message is being sent to your patients and family members.

Be strategic. When promoting and building your brand, along with that of the larger organization, take the time to map out what the co-branding partnership will look like. For example, ask yourself whether your professional branding campaign is tied directly to the larger organization’s mission and values? In turn, is your professional brand being accurately represented by the hospital, ACO or other organization? The strength of your co-brand will depend on having one unifying message that truly reflects your philosophy as well as that of the larger organization. Steve Adubato, PhD, is a four-time Emmy Awardwinning anchor for Thirteen/WNET (PBS) and NJTV (PBS) and has appeared on the TODAY Show, CNN and FOX as a media and communication expert. He is a motivational speaker and Star-Ledger columnist who has written extensively on doctor-patient communication.

MDADVISOR

LEGISLATIVE BRIEF

HOT

TOPIC

ISSUES

IN TRENTON By Pete Cammarano & Michael Schweder

MDADVISOR | SUMMER 2013

Summer is officially in season for New Jersey. The Boardwalk is back, and the beaches are open. Everywhere, the temperature is on the rise outside. In Trenton, the heat has picked up inside the State House as well. The budget season ended on June 25, 2013, as New Jersey lawmakers approved Governor Christie’s $33 billion spending plan with only a few minor changes. Also, at the time of this article’s publication, the final legislative bills are being introduced before the Legislature goes on recess. Unfortunately, there was sad news for the state on June 3, 2013, when Senator Frank Lautenberg passed away at the age of 89. (In 2010, Senator Lautenberg became the oldest acting member of the U.S. Senate with the death of 1 92-year-old West Virginia Senator Robert Byrd. ) Governor Christie has called for a special election to fill the vacancy created by the loss of the Senator. The Governor has set the Democratic and Republican Special Primaries for August 13, 2013, and the special general election for October 16. Winner of the special general election will fulfill the remainder of the Senator’s term until November 2014.2 Until the special general election occurs, the Governor has appointed Attorney General Jeffrey Chiesa to fill the vacant U.S. Senate seat. Despite this upheaval in the Senate, time is running out to introduce and move bills along before the summer legislative session is completed. The following introduced health bills require immediate attention given that they are most reflective of the present issues facing New Jersey patients and citizens. ONGOING HEALTH LEGISLATION Senate Bill No. 2615: Assemblywoman and Senate Education Committee Vice Chairwoman, Shirley Turner (District 15), sponsored S-2615 to establish a prescription drug donation repository program to help provide lowincome and underinsured New Jersey citizens with access to affordable prescription medication. The Assemblywoman believes that “this type of program can be a real lifesaver to residents who cannot afford medication to treat cancer, diabetes, high blood pressure, heart disease, high

cholesterol and so many other diseases.”3 An amendment has been added to the bill that “provides immunity from civil or criminal liability to any person, health-care facility or pharmacy that dispenses donated prescription drugs or supplies that have been recalled…if the pharmacy has not been notified 4 of the recall by Central Repository.” S-2615 was reported out of the Senate Budget and Appropriations Committee on June 3, 2013, and is on its second reading in the Senate. Senate Bill No. 2810: Former Governor of New Jersey and current Senator Richard Codey proposed S-2810 to “send a message to our young adults: To smoke is no joke.”5 New Jersey would be one of the first states in the nation to raise the minimum age for buying cigarettes and other tobacco products to 21 years old; currently, the state’s legal purchasing age is 19. The persistent tobacco use by New Jersey high school students has pushed politicians to act. In 2010, the New Jersey Department of Health determined through an anonymous survey that 14.3 percent of high school students used tobacco on a regular basis.6 Out of this 14.3 percent, 67 percent of the students under 18 years old bought their own tobacco products without being asked to show identification.5 This is a very progressive bill, and it is undetermined which way the vote in the Legislature will go. Assembly Bill No. 1839: Health insurance is always at the top of the list for “hot-topic” issues in New Jersey, and A-1839 is certainly on that list. This bill “requires insurance coverage for magnetic resonance imaging for women at high risk for breast cancer.”7 The two prime sponsors of this bill, Assembly members Patrick Diegnan (D18) and Grace Spencer (D29), define high risk as one who “has a family history of breast cancer or has a background, ethnicity or coexisting medical condition, or uses a medication that the physician believes puts the woman at elevated risk for breast cancer.”7 Assembly Bill No. 561: Assembly members Connie Wagner (D38), Mary Pat Angelini (D11) and Charles Mainor (D31) have introduced A-561 that “prohibits health insurance policy exclusion of coverage for loss sustained while intoxicated or under influence of narcotics; repeals statute

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“

substance abuse and other mental disorders are illnesses just like heart disease or cancer, and yet our healthcare system tends to discriminate against mental illness when it comes to covering treatment.

”

permitting such exclusion.”8 This bill had previously been introduced in a different legislative session under the title of A-3222, with little movement. This legislation is currently referred to the Assembly Financial Institutions and Insurance Committee. Senate Bill No. 2841: Senators Joseph Vitale (D19) and Teresa Ruiz (D29) have sponsored a bill that “prohibits gender-based rating of certain long-term care insurance policies.”9 There are many reasons for this bill, and the sponsors felt compelled to act on an industry in which women are likely to receive two of every three claims dollars under long-term care policies. Opponents and proponents alike will have time to give careful deliberation on this issue because S-2841 has been referred to the Senate Commerce Committee for further debate. Some insurers have already started this practice of gender discrimination in insurance claims, and the two prime sponsors hope to stop this emerging trend. Senate Bill No. 1253: This bipartisan bill would “require public health insurance providers to cover the treatment of mental and nervous disorders, alcoholism and substance abuse under the same terms and conditions as other medical illnesses.”10 Senator Vitale is a sponsor of this mental health initiative, as well as Senators Bob Gordon and Diane Allen. Senator Allen notes that “substance abuse and other mental disorders are illnesses just like heart disease or cancer, and yet our healthcare system tends to discriminate against mental illness when it comes to covering treatment.”10 S-1253 has recently been amended to cover the state’s two largest healthcare plans: the State Health Benefits Plan and the School Employee Health Benefits Program. Senator Vitale believes this legislation will send a “statement that all insurers need to update their policies.”10

MDADVISOR | SUMMER 2013

Pete Cammarano is a partner at Cammarano, Layton & Bombardieri Partners, LLC, in Trenton, New Jersey. Michael Schweder is the Government Affairs Manager at Cammarano, Layton & Bombardieri Partners, LLC. 1

Thompson, B. (2010, June 28). With Byrd’s death, NJ’s Lautenberg becomes Senate’s oldest member. NBC Universal Media. www.nbcnewyork.com/news/local/NJs-LautenbergBecomes-Senates-Oldest-Member-with-Byrd-Death97297439.html.

Margolin, J. (2013, June 4). Gov. Christie announces special election in October for Lautenberg’s seat. ABC World News with Diane Sawyer. http://abcnews.go.com/Politics/ gov-christie-announces-special-election-sen-lautenbergsseat/story?id=19323785#.Ua6moeTD-M9.

Turner, S. (2013, February 28). Waste not, want not: Turner proposes prescription recycling program. PolitickerNJ. www.politickernj.com/63622/waste-notwant-not-turner-proposes-prescription-recycling-program? quicktabs_mostx=commented.

State of New Jersey. (2013, June 3). Senate No. 2615. www.njleg.state.nj.us/2012/Bills/S3000/2615_S2.PDF.

Friedman, M., & Livio, S. K. (2013, May 16). Codey to propose raising tobacco purchase age to 21. NJ.com. www.nj.com/politics/index.ssf/2013/05/codey_to_ propose_raising_tobac.html.

State of New Jersey Department of Health. (2013, January 15). Topic area: Tobacco use. www.state.nj.us/health/chs/ hnj2020/documents/objectives/TobaccoUse.pdf.

State of New Jersey. (2012, October 19). Assembly No. 1839. www.njleg.state.nj.us/2012/Bills/A2000/1839_I1.PDF.

State of New Jersey. (2012). Assembly No. 561. www.njleg.state.nj.us/2012/Bills/A1000/561_I1.PDF.

State of New Jersey. (2013, June 3). Senate No. 2841. www.njleg.state.nj.us/2012/Bills/S3000/2841_I1.PDF.

State of New Jersey. (2013, May 6). Senate No. 1253. www.njleg.state.nj.us/2012/Bills/S1500/1253_S3.PDF.

MAINTENANCE OF

CERTIFICATION:

An Ongoing CONTROVERSY

Controversy continues to mark the relationship between maintenance of certification (MOC), a function of the American Board of Medical Specialties (ABMS), and maintenance of licensure (MOL), a process of the Federation of State Medical Boards (FSMB) to support a physician’s commitment to continuing medical education.

Some physicians and physician groups have and to correct some of the myths that surexpressed concern that failure to comply with Alan J. Lippman, MD round the MOC process, including the beliefs MOC requirements could potentially jeopardize that MOC standards are not evidence-based their license to practice medicine, and in at least or are too costly.4 one case, has led to exclusion of a physician from Meanwhile, some in the medical profession reappointment to a hospital medical staff. continue to argue that MOC requirements fail to improve A previous article in MDAdvisor suggested that the quality of medical care and place unnecessary burdens MOC could be construed as a condition of MOL.1 on physicians. The Benjamin Rush Society, in conjunction Rather, it has been pointed out that MOL will not require with the Arthur N. Rupe Foundation, conducted a public MOC (or its osteopathic equivalent, OCC–osteopathic debate in Philadelphia in April 2013, in which both continuous certification) and that state medical boards will sides appeared to agree that whereas quality care and not require specialty certification or recertification for performance improvement remain worthy professional licensure or licensure renewal. Instead, FSMB’s proposed goals, substantial differences exist regarding the MOL system recommends that state medical boards methodology for accomplishing these goals.5 recognize physicians actively engaged in MOC or OCC as In April 2013, a lawsuit was filed in the United States being in compliance with MOL.2 In fact, many activities District Court for New Jersey by the Association of American required by specialty boards to maintain certification Physicians and Surgeons against the American Board already meet, or even exceed, requirements that state of Medical Specialties, alleging antitrust law violations and boards are seeking for MOL.3 misrepresentations by the ABMS as to its methodologies In addition, the ABMS has sought to clarify its mission for compelling physicians to comply with MOC

MDADVISOR | SUMMER 2013

“While quality of care standards are widely supported by the medical profession, substantial concerns remain, in some quarters, regarding how best to evaluate ongoing physician competency.”

requirements. Among the allegations are claims that otherwise qualified physicians may be barred from medical staff privileges because they choose not to participate in the ABMS’s MOC program and that there is no benefit in MOC programs to patient care.6 The debate about MOC and its implications for MOL will be further considered by the Policy and Strategy Panel of the Medical Society of New Jersey at its regular meeting in July 2013. While quality of care standards are widely supported by the medical profession, substantial concerns remain, in some quarters, regarding how best to evaluate ongoing physician competency. Alan J. Lippman, MD, FACP, is a hematologist/ oncologist practicing with Essex Oncology Group in Belleville, New Jersey. 1

Lippman, A. J. (2013). Maintenance of certification as a condition of medical licensure: Time for pause. MDAdvisor, 6(2), 25–28.

Carlson, D. (2013, May 22). [Personal e-mail communication]. Note: Drew Carlson is the Director of Communications, Federation of State Medical Boards.

Chaudhry, H. J., Talmage, L. A., Alguire, P. C., Cain, F. E., Waters, S., & Rhyne, J. A. (2012). Maintenance of licensure: Supporting a physician’s commitment to lifelong learning. Annals of Internal Medicine,157(4), 287–289.

American Board of Medical Specialties. (2013). ABMS maintenance of certification myths and facts. www.abms.org/ MOC_Myths_And_Facts/.

Benjamin Rush Society, & Arthur N. Rupe Foundation. (2013, April 20). Resolved that maintenance of certification requirements fail to improve the quality of medical care while placing unnecessary burdens on physicians. A public debate conducted at the Perelman School of Medicine, University of Pennsylvania.

Association of American Physicians & Surgeons, Inc. vs. American Board of Medical Specialties. (N.J. [April 23, 2013]). 3:13-cv-2609-PGS-LHG.

MDADVISOR

SAVE THE DATE! ®

UPCOMING MDADVANTAGE EDUCATIONAL PROGRAMS

Decision Making in Advanced Illness: An Introduction to NJ Guidelines for Practitioner Orders for Life-Sustaining Treatment (POLST) in December 2011, Governor Chris Christie signed New Jersey’s POLSt (Practitioner Orders for Life-Sustaining treatment) into legislation. the legislation includes a New Jersey State Board requirement for two CMe credits in programs related to end-of-life care prior to biennial registration. these three upcoming seminars will focus on end-of-life decision making. the New Jersey POLSt form will be introduced, and strategies for discussing healthcare decision-making for elderly patients and those entering the final stages of life will be presented.

Pre-registration is required for all programs. For more information or to register, contact the MDAdvantage Risk Management Department at 888-355-5551.

THURSDAY, SEPTEMBER 19, 2013 (7–9 p.m., 6:30 p.m. Dinner) L’Affaire Fine Catering 1099 U.S. 22, Mountainside, NJ THURSDAY, OCTOBER 10, 2013 (6–8 p.m., 5:30 p.m. Dinner) Sheraton eatontown 6 industrial Way e., eatontown, NJ THURSDAY, NOVEMBER 7, 2013 (6–8 p.m., 5:30 p.m. Dinner) MDAdvantage two Princess Rd., Lawrenceville, NJ

ALL NEW JERSEY PHYSICIANS ARE INVITED TO ATTEND AT NO COST. More details will be forthcoming at www.MDAdvantageonline.com.

MDAdvantage Two Princess Road, Suite 2 Lawrenceville, NJ 08648

& HONOR YOUR PROFESSION BY HONORING YOUR PEERS. ~ Nominations Now Being Accepted. ~ OUTSTANDING MEDICAL EDUCATOR AWARD OUTSTANDING MEDICAL EXECUTIVE AWARD

OUTSTANDING MEDICAL RESEARCH SCIENTIST AWARD FOR BASIC BIOMEDICAL RESEARCH

EDWARD J. ILL PHYSICIAN’S AWARD ®

OUTSTANDING MEDICAL RESEARCH SCIENTIST AWARD FOR CLINICAL RESEARCH

VERICE M. MASON COMMUNITY SERVICE LEADER AWARD

PETER W. RODINO, JR., CITIZEN’S AWARD®

A 75 YEAR TRADITION OF HONORING EXCELLENCE IN MEDICINE. Written nominations will be accepted through August 16, 2013.

Log on to www.EJIawards.org for nomination guidelines and further information about the event, or call us at 609-803-2350. Nominations are open to all New Jersey physicians, healthcare professionals and community leaders, and should be submitted to: Paul J. Hirsch, MD, Chairman, Edward J.Ill Excellence in Medicine Foundation, c/o MDAdvantage Two Princess Road, Suite 2, Lawrenceville, NJ 08648 Nominations may also be submitted electronically to Jpuro@EJ Iawards.org.