MDAdvisor Winter 2017 Issue by MDAdvantage Insurance Company of New Jersey

NEW JERSEY COMBATS RISE IN SEXUALLY TRANSMITTED DISEASE

Commissioner Cathleen D. Bennett

ANNOUNCING THE 2017 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS®

Janet S. Puro, MPH, MBA

ADVOCATING FOR CULTURAL COMPETENCY IN THE MEDICAL PROFESSION

Ronak Mistry

TOP TIPS FOR PHYSICIANS: UNDERSTAND THE IMPORTANCE OF CODING AND BILLING ACCURACY

Nancy Clark, CPC, COC, CPB, CPMA, CPC-I

VOLUME 10 • ISSUE 1 • WINTER 2017

Celebrating 10 Years of Publishing Excellence

OPIOID MISUSE, ABUSE & ADDICTION: A Two-Part Series that Sheds Some Light on a PRESSING Issue

MDADVISOR: A JOURNAL FOR THE HEALTHCARE COMMUNITY.

SAVETHEDATE 2017 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS In support of the Edward J. Ill Excellence in Medicine Scholarship Fund May 3, 2017 | 6:00 p.m. Park Château Estate & Gardens, East Brunswick, NJ

JOHN W. SENSAKOVIC, MD, PhD Outstanding Medical Educator Award ALEXANDER J. HATALA, FACHE Outstanding Healthcare Executive Award MARIA SOTO-GREENE, MD, MS-HPEd Edward J. Ill Physician’s Award® CHANTAL BRAZEAU, MD On behalf of the Rutgers New Jersey Medical School Student Family Health Care Center Verice M. Mason Community Service Leader Award NANCY D. CONNELL, PhD Outstanding Scientist Award LARRY HIRSCH, MD Outstanding Scientist Award ALFRED F. TALLIA, MD, MPH ® Peter W. Rodino, Jr., Citizen’s Award To participate in this year’s event by purchasing tickets, an Honor Roll sponsorship or an ad in the awards journal, call 609-803-2350 or visit www.EJIawards.org.

TE N A OST C . A

e of th g n i n l’s egin urna b o j e the for d th pics 7 an ys since o 1 t 0 of 2 ng wa tant i sue por s h i s m i i t nal n rs ditio asto ver the ur fi d o n a i – g r n co ed is o lus a includin p Adv s chang ged to , s D , d. fM ile rticle d topics iseases ha yon priv 98 a ue o thcare e d e 2 s r b d s e i g d n v d n’s l n r e a y an publish have co emergi f wome inte Hea ed r e . l W s o r a n e Je ve the ho urn lth, rsey cs o New ), we ha ticles. W lic hea e to f the jo een topi New Je n b m i e r o e b s h e r c o er on of hav ue a , pu es on t atto Wel olume lead ing this we oice istants, d-iss y issues u e i v r v s d s a m i h n d e c th tal clu lth ed 10t tor ass n, a als. hea date (in plemen gula ix them hearing ysician sion ptio e d s r e n e c f a p d h s in su d an ns s to es, pro s, p line lishe diabet sicia 37 issue d 11 t, legal alth urse b n e n u a h , r on s p , phy s n c r i u n e l e e u e l a o n i b c i o sic pu In arti gem ced cy. W medic phy and ana ging onic odu poli s m n r m r i t e t o c r c v i e n f mer i l i e t c m l i E b d s u t e i e r u c c e n xe 20 th .W hea pra nd nd p , huma ital e s made ced ical al a ry a have p u y d c s i o d e e g t o d s o o a i m h ol s, h y. W lh me intr r ical chn afet ator urna g. We from in thei o j r med care, te atient s s, legisl a r n e u i g h x o e r b lth nd p gulato inde g us to ress hea they ns a rog e NE n r I s a i p i , L a c w s i e r D o s face phy esso ud of th for ME tee, all e. le prof hey it o t d , r issu ssib s e m s p y t o h e c m p c e ne e g o r a a sel ry C challen in e ould be and We ere cle viso w i t d e r d h A a ts w t rtise E e an eaders men and xpe CM h e s s i a issu t l by L e n g ical omp and th ers, led ude erin c d t f f c s e a o f M se are taf mb an lthc beg e of the shing s ard me rward e hea i W l o n fo o pub torial B ers. ook e, n l d s I r e i t . u care d o dica er E sch, MD akes Of c r de olunte u o v . Hir hcare m w out ul J our a f alt ne P o with , ef t he ce ng i i a n h t h a e t C me will ess guid itor-inho rogr ars, to d w p E s r e t ou er hts g th 0 ye exp insig r eein next 1 e r r s i a e o c t h h e you ith t ealt r th ng i ip w d h r h n ove a s a r cate he ade ors edu re. to o d auth e our re t an ue futu ag ntin the rtise o eng e n c i p y ex we unit and ack as mm o c b re feed althca e h the

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MDADVISOR

The Editorial Board would like to acknowledge the following individuals who served as peer reviewers of manuscripts submitted for consideration of publication in MDAdvisor in the past year, as well as those reviewers who prefer to remain anonymous. Our reviewers are an important part of the selection process and provide our authors with valuable insights. We gratefully acknowledge the reviewers’ comments and contributions.

A Journal for the Healthcare Community

Hon. Paul W. Armstrong, JSC (Ret.) Omar Baker, MD Margaret A. Chipowsky, Esq. Jeremy P. Cooley, Esq. Daniel G. Giaquinto, Esq. Sanford Gips, MD George F. Heinrich, MD Paul J. Hirsch, MD Aline M. Holmes, DNP, MSN, RN Basil Hubbi, MD Christopher O. Kosseff Alan J. Lippman, MD Michael Nevins, MD Angelo J. Onofri, Esq. Ronald Powlick Theresa A. Soroko, MD Lee Ann Trulio, RN To find out how to volunteer to review content for MDAdvisor in your area of expertise, contact us at Editor@MDAdvisorNJ.com.

LETTER TO THE EDITOR I wanted to take a moment to congratulate you (and all who contributed) on the Fall issue of MDAdvisor. I literally could not put it down. Great articles and content from front to back! Thank you for putting this together as it really helps me better understand the current healthcare landscape.

Dan Koshiol President & CEO StoneHill Reinsurance Partners, LLC

NEWS & ACKNOWLEDGMENTS

PEER REVIEWER ACKNOWLEDGMENTS

PUBLISHER PATRICIA A. COSTANTE, FACHE Chairman & CEO MDAdvantage Insurance Company PUBLISHING & BUSINESS STAFF CATHERINE E. WILLIAMS Senior Vice President MDAdvantage Insurance Company JANET S. PURO Vice President MDAdvantage Insurance Company THERESA FOY DIGERONIMO Copy Editor MORBELLI RUSSO & PARTNERS ADVERTISING INC. EDITORIAL BOARD PAUL J. HIRSCH, MD, Editor-in-Chief HON. PAUL W. ARMSTRONG, JSC (Ret.) STEVE ADUBATO, PHD PETE CAMMARANO DONALD M. CHERVENAK, MD STUART D. COOK, MD VINCENT A. DEBARI, PHD JEREMY S. HIRSCH, MPAP WILLIAM G. HYNCIK, ATC JOHN ZEN JACKSON, ESQ. ALAN J. LIPPMAN, MD JUDITH M. PERSICHILLI, RN, BSN, MA EMERGING MEDICAL LEADERS ADVISORY COMMITTEE NATALYA ANDRIYANYCHEVA RYAN MILLER RONAK MISTRY RACHEL MORALES FAN, MD

RICHARD STEINWANDTNER MELISSA VILLARS, MD NICOLE VIOLA

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MDADVISOR | WINTER 2017

WINTER 2017 – CONTENTS

LETTER FROM MDADVANTAGE® CHAIRMAN & CEO PATRICIA A. COSTANTE

CME

OPIOID MISUSE, ABUSE AND ADDICTION PART 2: OPIOID PRESCRIBER RESPONSIBILITIES AND RESOURCES* | By Sindy M. Paul, MD, MPH & Virginia Allread, MPH

ANNOUNCING THE 2017 EDWARD J. ILL EXCELLENCE IN MEDICINE AWARDS® | By Janet S. Puro, MPH, MBA

LEGISLATIVE UPDATE | By Michael C. Schweder

NEW JERSEY COMBATS RISE IN SEXUALLY TRANSMITTED DISEASE | By Commissioner Cathleen D. Bennett

INFANTILE PARALYSIS: THE NEWARK POLIO EPIDEMIC OF 1916 | By Sandra Moss, MD

THE DANGERS OF CONCUSSIONS IN YOUNG ATHLETES: AN INTERVIEW WITH JOHN SHUMKO, MD | By Steve Adubato, PhD

TOP TIPS FOR PHYSICIANS: UNDERSTAND THE IMPORTANCE OF CODING AND BILLING ACCURACY | By Nancy Clark, CPC, COC, CPB, CPMA, CPC-I

ADVOCATING FOR CULTURAL COMPETENCY IN THE MEDICAL PROFESSION | By Ronak Mistry, Emerging Medical Leaders Advisory Committee Member ONLINE ARTICLES – VISIT OUR WEBSITE FOR FULL ARTICLES AT: WWW.MDADVANTAGEONLINE.COM/MDADVISOR

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POINT OF VIEW: THE EFFECT OF HOSPITAL MERGERS ON HEALTHCARE | By R. Bruce Crelin, Esq.

Supplemental OPIOID MISUSE, ABUSE AND ADDICTION PART 1: CHANGING TRENDS Article | By Sindy M. Paul, MD, MPH & Virginia Allread, MPH

MDADVISOR

In order to obtain AMA PRA Category 1 credit™, participants are required to: 1) Review the CME information along with the learning objectives at the beginning of the CME article. Determine if these objectives match your individual learning needs. If so, read the article carefully. 2) The post-test questions have been designed to provide a useful link between the CME article and your everyday practice. Read each question, choose the correct answer and record your answers on the registration form. 3) Complete the evaluation portion of the Registration and Evaluation Form. Forms and tests cannot be processed if the evaluation section is incomplete. 4) Send the Registration and Evaluation Form to: MDAdvisor CME Dept c/o MDAdvantage Insurance Company 100 Franklin Corner Rd Lawrenceville, NJ 08648 Or Fax to: 978-367-8545 5) Retain a copy of your test answers. Your answer sheet will be graded, and if a passing score of 70% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ and the test answer key will be mailed to you within 4 weeks. Individuals who fail to attain a passing score will be notified and offered the opportunity to reread the article and take the test again.

OPIOID MISUSE, ABUSE AND ADDICTION Part 2: Opioid Prescriber Responsibilities and Resources*

6) Mail the Registration and Evaluation Form on or before the deadline, which is February 1, 2018. Forms received after that date will not be processed. Authors: Sindy M. Paul, MD, MPH (Medical Director of the New Jersey Board of Medical Examiners); Virginia Allread, MPH (freelance public health consultant)

By Sindy M. Paul, MD, MPH & Virginia Allread, MPH

Joint Providership Accreditation: This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Medical Society of The State of New York (MSSNY) through the joint providership of Kern Augustine, P.C. and MDAdvantage Insurance Company. KA is accredited by The Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians. Kern Augustine, P.C. designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure: Kern Augustine, P.C. relies upon planners, moderators, reviewers, authors and faculty participants in its CME activities to provide educational information that is objective and free of bias. In this spirit and in accordance with MSSNY and ACCME guidelines, all planners, moderators, reviewers, authors and faculty participants must disclose relevant financial relationships with commercial interests whose products, devices or services may be discussed in the CME content or may be perceived as a real or apparent conflict of interest. Any discussion of investigational or unlabeled use of a product will be identified. The planners, moderators, reviewers, authors and faculty participants do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials. No commercial funding has been accepted for the activity. 4

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* This is the second article in a two-part series on opioid misuse, abuse and addiction. Part 1 “Changing Trends” was published in February 2017 as a supplemental online article, available at www.MDAdvantageonline.com/MDAdvisor.

LEARNING OBJECTIVES At the conclusion of this activity, participants will be able to:

Provide an overview of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

Describe the New Jersey Board of Medical Examiners prescribing requirements.

Discuss the features of the New Jersey Prescription Monitoring Program.

Opioid misuse, abuse and addiction are major public health issues. As described in Part 1 in this series “Opioid Misuse, Abuse and Addiction: Changing Trends,” the number and rate of drug overdose deaths in the United States have increased unabated since 2000. In 2015 alone, there were 33,091 drug overdose deaths in the United States. The death rate due to opioid overdoses increased sharply across the country in 2015 (in comparison to 2014) and even more alarmingly in New Jersey where the increase was 16.4 percent 1 within a single year. The number of overdose deaths in 2016 is expected to continue the upward trend due to an increase in deaths from the opioid drug fentanyl.2 One facet contributing to this epidemic is opioid prescribing. An estimated 20 percent of patients who present at physicians’ offices with non-cancer-related pain or pain-related diagnoses are prescribed opioids. Opioid prescriptions increased by 7.3 percent from 2007 to 2012, with 259 million opioid prescriptions written in 2012.3 This article describes new opioid prescribing guidelines and regulations, as well as treatment options for patients with substance abuse disorders. CENTERS FOR DISEASE CONTROL AND PREVENTION GUIDELINES The Centers for Disease Control and Prevention (CDC) monitors the prescription and illicit opioid epidemic and keeps the public and professionals informed. In mid-March 2016, the CDC published “CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016” in an attempt to bring clarity in a context of multiple competing recommendations. A summary of the new guidelines (which was written for primary care physicians, nurse practitioners and physician assistants) follows.3

Understand other initiatives in New Jersey that aim to prevent or treat substance abuse disorders or decrease the risk of overdose-related mortality.

GUIDELINES FOR DETERMINING WHEN TO INITIATE OR CONTINUE OPIOIDS FOR CHRONIC PAIN:

1 Note: At the time of publication, the NJ Attorney General has notified the BME of upcoming changes that will impose tough restrictions on the prescription of painkillers.

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Preferred for chronic pain are nonpharmacologic therapy (e.g., physical therapy), weight loss for knee osteoarthritis, psychological therapies (such as cognitive behavioral therapy) and nonopioid pharmacologic therapy (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs and selected

MDADVISOR

antidepressants and anticonvulsants; or pregabalin, gabapentin or carbamazepine). Consider opioid therapy only if the expected benefits for pain and function are anticipated to outweigh the risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. Although opioids can reduce pain during short-term use, there is insufficient evidence to determine whether pain relief is sustained and whether function or quality of life improves with long-term use. Thus, opioids should not be considered first-line or routine therapy for chronic, non-cancerous pain. Before starting opioid therapy for chronic pain, establish treatment goals (e.g., improvement in pain relief and function (function is patient-defined and might be something like walking around the block or returning to work), including realistic goals for pain and function, and consider how opioid therapy will be discontinued if the benefits do not outweigh the risks. Continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs the risks to patient safety. Before starting and periodically during opioid therapy, discuss with patients the known risks and realistic benefits of opioid therapy, as well as patient and clinician responsibilities for managing therapy. Involve patients in decisions to start or continue opioid therapy. Ensure patients are aware of the potential benefits of, harms of and alternatives to opioids before starting or continuing opioid therapy.

GUIDELINES FOR OPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP AND DISCONTINUATION:

GUIDELINES FOR ASSESSING RISK AND ADDRESSING HARMS OF OPIOID USE:

When starting opioid therapy for chronic pain, prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. Clinical evidence indicates a higher risk for overdose (without evidence of greater effectiveness) among patients initiating treatment with ER/LA opioids than among those initiating treatment with immediaterelease opioids.

MDADVISOR | WINTER 2017

When opioids are started, prescribe the lowest effective dosage. Carefully reassess the evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day and avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day. Although there is no dosage threshold below which overdose risk is eliminated, holding dosages <50 MME/day will likely reduce risk among a large proportion of patients who would experience a fatal overdose at higher prescribed dosages. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, prescribe the lowest effective dose of immediate-release opioids and prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less is sufficient; more than seven days is rarely needed. Evaluate the benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or dose escalation. Evaluate the benefits and harms of continued therapy with patients every three months or more frequently. If the benefits do not outweigh the harm of continued opioid therapy, optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

CME

Before starting and periodically during continuation of opioid therapy, evaluate risk factors for opioid-related harm. Incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose (such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day) or concurrent benzodiazepine use) are present. See guidelines for specific recommendations for people with sleep-disordered breathing,

pregnant women, patients with renal or hepatic insufficiency, older patients (≥65 years), patients with mental health conditions and those with substance use disorders. Review patient history of controlled substance prescriptions using prescription monitoring program (PMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Review PMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months. If a patient is found to have high opioid dosages, dangerous combinations of medications or multiple controlled substance prescriptions written by different clinicians, discuss this safety concern with the patient, consider tapering to a safer dosage and consider offering naloxone. If selling of opioids is suspected, consider urine drug testing to assist in determining whether opioids can be discontinued without causing withdrawal. When prescribing opioids for chronic pain, use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications, as well as other controlled prescription drugs and illicit drugs. Avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible as both cause central nervous system depression and can decrease respiratory drive. Offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder. NJ STATE BOARD OF MEDICAL EXAMINERS PRESCRIBING REQUIREMENTS

The New Jersey State Board of Medical Examiners (BME) requires practitioners to have a controlled dangerous substance (CDS) registration in addition to their U.S. Drug Enforcement Administration (DEA) registration to prescribe CDSs, including opioids.4 The BME also requires practitioners

to have a bona fide provider–patient relationship with persons to whom a CDS is prescribed. The BME holds practitioners accountable for their quality of care, including CDS prescribing. These regulations (13:35-7.6 Limitations on Prescribing, Administering, or Dispensing of Controlled Substances; Special Exceptions for Management of Pain) are summarized here. Before prescribing a CDS, practitioners need to ensure that the patient records are accurate and include the 4 following information : A recognized medical indication for the use of the CDS: patient’s medical history, physical examination and any other evaluations and consultations, including an assessment of physical and psychological function, underlying or coexisting diseases or conditions, any history of substance abuse and the nature, frequency and severity of pain Treatment plan objectives Evidence of informed consent Treatments and drugs prescribed or provided; if a CDS is prescribed, then the name of that drug, dosage, strength, quantity and instructions on frequency of use Any agreements with the patient Periodic reviews conducted In reference to Schedule II prescriptions (i.e., drugs with a high potential for abuse that may lead to severe psychological or physical dependence), which include opioids, the BME requirements set prescription limitations. The BME requirements state that the practitioner is limited to prescriptions that are no more than 120 dosage units or a 30-day supply in the treatment of non-cancer chronic pain (the pending change limits this supply to five days). The regulations state that a practitioner may give the patient multiple prescriptions authorizing up to a 90-day supply, as long as the following conditions are met4: The practitioner includes written instructions on each prescription (other than the first prescription if it is to be filled immediately) indicating the earliest date on which a pharmacy may fill each prescription. The practitioner determines that providing the patient with multiple prescriptions in this manner does not create an undue risk of diversion or abuse. Patients who require more than three months of medication must consult with the practitioner to review: 1) the course of treatment, any new information about the etiology of the pain

CME

MDADVISOR

FIGURE 1.

PRESCRIPTION BLANK SECURITY CHANGES

Security Features Incorporated in NJ Prescription Blanks

In February 2014, the New Jersey Division of Consumer Affairs (DCA), Department of Law and Public Safety, announced new regulations that determine the look and security features of prescription blanks. The old prescription blanks were phased out as of November 2014. The purpose of this new regulation is to make it more difficult to sell prescriptions for cash and to prevent forgery and counterfeiting. The new security measures are illustrated in Figure 1. PRESCRIBER EDUCATION Prescriber education continues to be an important component of the New Jersey response to the opioid epidemic. This includes New Jersey DCA provision of medical student education and enduring articles, such as this one and others that have appeared in NJ AIDSLine/HIVLinks, MDAdvisor and the Journal of Medical Regulation. A short tutorial is part of the required New Jersey Prescription Monitoring Program registration for all New Jersey practitioners holding a CDS registration and for the Do No Harm symposium series. PRESCRIPTION MONITORING PROGRAMS Reprinted with permission from the New Jersey Division of Consumer Affairs.

and the patientâ&#x20AC;&#x2122;s progress toward the treatment objectives, 2) possible problems associated with physical and psychological dependence, and 3) efforts to reduce potential for abuse or dependence, such as decreased dosage, alternative drugs, such as nonsteroidal anti-inflammatories, or other treatment modalities (unless clinically contraindicated). If the treatment objectives are not being met, the practitioner is expected to assess the appropriateness of continued CDS treatment or undertake a trial of other drugs or treatment modalities. The practitioner should also consider referring the patient for independent evaluation or treatment to achieve the treatment objectives.

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Nationally, prescription monitoring programs (PMPs) were created through funding from Congress in 2002. The purpose of PMPs is to help prevent and detect the diversion and abuse of pharmaceutical CDSs by enhancing the ability of state-level regulatory and law enforcement agencies to collect and analyze CDS prescription data through a centralized, state-administered database. PMPs focus on the retail level where prescribed medications are purchased. As of June 2016, 49 states, the District of Columbia and one U.S. territory (Guam) had legislation authorizing the creation and operation of a PMP. The NJPMP was established in 2011 and is maintained by the NJ DCA; it includes prescription data on human growth hormone, as well as CDSs dispensed in outpatient settings in New Jersey and by out-of-state pharmacies

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dispensing into New Jersey. As of April 2016, the NJPMP contained nearly 59 million records of prescription drug prescribing and dispensing. Each record contains the names of the patient, doctor and pharmacy; purchase date; type, dosage and amount of medication; and method of payment. Pharmacies are required to report 5 information to the NJPMP on a daily basis. Since 2015, CDS prescribers and pharmacists have been required to register for NJPMP access. Practitioners who renewed their NJ CDS registration last year had an NJPMP account automatically created. As of April 2016, more than 96 percent of all licensed physicians were registered.6 In a letter from Steve C. Lee, Director of New Jersey Consumer Affairs, and from the New Jersey Office of the Attorney General in September 2015, prescribers were informed that they are required to review PMP information when they prescribe a Schedule II medication to a new or current patient for acute or chronic pain, the first time they prescribe and quarterly thereafter. Patient information in the NJPMP is intended to supplement the evaluation of a patient, confirm a patient’s drug history or document compliance with a therapeutic regimen. When a practitioner or pharmacist identifies a patient as potentially having an issue of concern regarding drug use, they are encouraged to help the patient locate assistance and take any other action deemed appropriate. In response to a statutory change, regulations were published in the New Jersey Register on November 7, 2016, expanding NJPMP access to practitioners’ delegates.7 The new regulations define a “delegate” as a registered nurse, licensed practical nurse, advanced practice nurse (APN), physician assistant (PA), dental hygienist, registered dental assistant or certified medical assistant who is a licensed healthcare professional within the State of New Jersey and has completed the requirements under N.J.S.A. 45:1-44. Delegates may also be a medical or dental resident authorized by a practitioner or faculty member from a medical or dental teaching facility. APNs and PAs cannot be prescribers and delegates in the NJPMP system. If they are registered as prescribers, they will need to look up information as a prescriber and will be unable to be registered as a delegate.

Before being able to request information from the database, delegates need to be linked to a practitioner registered with the NJPMP who will be responsible for supervising the delegate’s activities. Practitioners should review the regulations before delegation. Physician responsibilities related to the delegate include the following: Before delegate designation, confirm the education, training and license or certification requirement of each delegate. Ensure that the delegate understands the limitations on disclosure of PMP information and federal and state laws, rules and regulations concerning patient information confidentiality. Ensure delegate compliance with the recordkeeping requirements. At least every six months, monitor the delegate’s PMP use for potential misuse. Report unauthorized access to the NJ DCA within five business days of discovery. Terminate the delegate’s PMP access when a delegate, for any reason, is no longer authorized to be a delegate. THE DELEGATE HAS SOME RESPONSIBILITIES, INCLUDING BUT NOT LIMITED TO THE FOLLOWING:

CME

All persons granted access to the PMP shall access the PMP using their own unique user login ID and password, which shall not be shared with any other person or entity. A delegate shall share PMP information with only his or her delegating practitioner. The delegate shall not share access to the PMP with any other person or entity. All delegates shall identify the practitioner on whose behalf they are accessing the prescription monitoring information. A delegate may be an authorized delegate for more than one practitioner. An individual who is no longer employed at the practice setting at which the practitioner practices is no longer authorized to be a delegate or to access the PMP on behalf of that practitioner.

MDADVISOR

The NJPMP information can be used by individual registrants to do a self-lookup to assess their prescribing practices and to determine if prescriptions have been filled that have not been written by themâ&#x20AC;&#x201C;through prescription blank theft, for example. Prescription blank theft needs to be reported to the police, the DEA and the New Jersey Drug Control Unit. There are anecdotal instances in which a practitioner, through self-lookup, has identified prescription blank theft through this mechanism, reported it and the NJPMP was able to alert pharmacies about the theft.

FIGURE 2. DCA Consumer Notice, Project Medicine Drop

The NJ DCA keeps NJPMP patient information strictly confidential, in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. Authorized individuals can access the NJPMP at NJRxReport.com. TARGETING CONSUMERS: PROJECT MEDICINE DROP Project Medicine Drop allows members of the public to dispose of unused and expired medications anonymously, 365 days a year, at prescription drug drop boxes located within the headquarters of participating police departments, sheriff offices and New Jersey State Police barracks. As of January 1, 2016, practitioners and pharmacies are required to provide notice about drug take-back programs upon dispensing a CDS (see Figure 2). As of October 2016, there were 213 Project Medicine Drop boxes across New Jersey.8 For information about drop box locations, visit the DCA website (www.njconsumeraffairs.gov/meddrop/Pages/Locations.aspx), contact a local police department or call the NJ DCA at 800-242-5846. The American Medicine Chest Challenge and the National Prescription Drug Take-Back are statewide, one-day events to dispose of unused medications. Both are sponsored in New Jersey by the DEA, Partnership for a Drug Free New Jersey and the Sheriffsâ&#x20AC;&#x2122; Association of New Jersey. OVERDOSE PROTECTION ACT AND NALOXONE In May 2013, the New Jersey Overdose Protection Act was signed into law. This legislation takes the following two-prong approach to prevent drug overdose deaths in New Jersey: Provision of legal protection to people who are in violation of the law while they are attempting to help a drug overdose victim. This provision encourages witnesses and victims of drug overdoses to seek medical assistance without fear of criminal or civil liability. Elimination of negative legal action against healthcare professionals, bystanders or family

Reprinted with permission from the New Jersey Division of Consumer Affairs.

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members who administer overdose antidotes in life-threatening situations. In April 2014, the BME approved a Certificate of Waiver to ensure that physicians understand that they are relieved of certain obligations when prescribing naloxone to first responders or to family and friends of a person at risk. Under the Act, the prescription may be issued in the name of a person who is not the intended end user of the medication. There is no need for an examination before or follow-up afterward of the person to whom naloxone is administered after the issuance of the prescription, as required by existing BME rules, N.J.A.C. 13:35-7.1A and 7.2. In February 2015, the Overdose Prevention Act was expanded, giving immunity to first responders, including police and EMTs, who 9 administer and dispense naloxone. Although pharmacies in New Jersey order and dispense naloxone when a prescription is presented, CVS and Walgreens, as well as other independent pharmacies, are making naloxone available for purchase without a prescription.10

rescue kits. The program targets those at risk for an opioid overdose, their families and friends who are taught to recognize an opioid overdose and to provide life-saving rescue measures to reverse the overdose.

NALOXONE Naloxone is an opioid antagonist that can be used to counter the effects of an opioid analgesic or other opioid (including heroin) overdose. Administration of naloxone counteracts life-threatening depression of the central nervous system and respiratory system. It may be injected in the muscle or vein, under the skin or sprayed into the nose. It is a temporary drug that wears off within 20 to 90 minutes. Although naloxone is a prescription drug, it is not a controlled substance and has no abuse potential. It can be administered by minimally trained laypeople.

TARGETING USERS AND THOSE AT RISK: OORP AND OOPP The Department of Human Services Division of Mental Health and Addiction Services (DMHAS) recognized early that the naloxone program is a Band-Aid approach. Naloxone saves lives but does not address the underlying substance abuse or mental health issues. To address this issue, the DMHAS created the Opioid Overdose Recovery Program (OORP) that puts recovery specialists and patient navigators in hospitals to respond to individuals reversed from opioid overdoses and treated at hospital emergency departments as a result of the reversal. The OORP provides support and treatment for long-term recovery. In 2016, DMHAS funded the OORP project in six New Jersey counties; based on the success of these initial projects, it is being expanded to other counties. The Opioid Overdose Prevention Program (OOPP) is a similar, statewide program, started in 2014 and expanded in 2015, that includes an educational component, outreach to at-risk individuals, collaboration with interested stakeholders and distribution of naloxone

Levi, J., Segal, L. M., & Martin, A. (2015). The facts hurt: A state-by-state injury prevention policy report. Trust for America’s Health and Robert Wood Johnson Foundation.

TARGETING USERS: SYRINGE ACCESS PROGRAMS In 2006, the State of New Jersey–by passing Public Law 2006, c. 99, the Blood-borne Disease Harm Reduction Act–created up to six demonstration Syringe Access Programs (SAPs) across the state. Between November 2007 and July 2009, five SAPs were established in areas with a high prevalence of HIV attributable to injection drug use. The SAPs provide patients with clean needles and syringes in exchange for used needles and provide access to a range of healthcare services. The Access to Reproductive Care and HIV Services (ARCH) nursing program is co-located with all of the SAPs, supporting

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the provision of services required by the 2006 legislation. ARCH nurses provide harm-reduction counseling and referral for care, including pregnancy testing. The SAPs are located in Atlantic City, Camden, Jersey City, Newark and Paterson, New Jersey. Despite positive results over 11 the past 10 years, the syringe exchange program has yet to be expanded beyond the original five sites. However, New Jersey state lawmakers are now pushing to expand the programs’ reach to communities around the state. TARGETING USERS: TREATMENT Although nearly two decades of treatment research have shown that proper treatment is effective and results in a clinically significant reduction in or abstinence from alcohol and drug use and accompanying criminal activity,12 a treatment gap remains in New Jersey. The number of treatment slots–both inpatient and outpatient–are still insufficient to meet demand.13 Addiction affects one in 10 Americans, yet 90 percent of those affected do not receive effective treatment.12 An analysis by NJ Advance Media shows that there are only 2,375 licensed residential treatment beds in New Jersey.14 In 2015, DMHAS estimated the size of New Jersey’s 2014 resident adult population in need of treatment for drug abuse or dependence at 349,996 persons. Of these 349,996 people, only 78,942 wanted substance abuse treatment. Of those who wanted treatment, 47,664 received it, resulting in an unmet demand of 31,278–a gap of 39.6 percent.15 The National Council on Alcoholism and Drug Dependence (NCADD) claims that each year, more than 50,000 New Jersey residents have sought treatment and were denied because 1) their insurance plan did not cover it, or 2) they could not afford it or 3) there was a lack of treatment capacity.16 NEW SOURCES OF FUNDING FOR DRUG TREATMENT With more than 1.7 million New Jersey residents enrolled in state Medicaid (as part of the Affordable Care Act) or the Children’s Health Insurance Program as of December 201517 (a 33 percent increase in two years), one could expect an increase in the number of people in need of drug treatment who now have insurance. This

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Medicaid expansion was expected to provide additional access to substance abuse treatment and services. According to personal communication with Ellen Lovejoy, spokeswoman for the state Department of Human Services, “Medicaid expansion is providing coverage for more people in addiction treatment, but the DHS data system does not automatically capture the total number of treatment beds filled by Medicaid recipients” (October 9, 2015). Advocates have criticized Medicaid by stating that treatment funded by this mechanism is often insufficient in length and quality. Additionally, the historical “Institutions for Mental Diseases (IMD) exclusion” limits Medicaid from paying for residential treatment in facilities with 16 or more beds; as a result, many facilities have to deny service access to their Medicaid clients. In 2015, there were other state-funded initiatives to 18 expand drug treatment : The New Jersey 2017 fiscal year budget included nearly $64 million to support the expansion of the Drug Court program from nine vicinages (Ocean, Hudson, Somerset/Hunterdon/Warren, Passaic, Mercer, Atlantic/Cape May, Bergen, Burlington and Monmouth) to the final three (Essex, Cumberland/Salem/Gloucester and Middlesex). The 2017 budget also included a $127 million investment in substance use and mental health treatment to raise reimbursement rates and expand access to high-quality healthcare providers for individuals with substance abuse and behavioral health needs. Another $2 million will be invested in re-opening the Mid-State Correctional Facility in 2017 as the state’s first fully dedicated drug treatment center for inmates. In August 2015, legislation was signed requiring four-year public colleges and universities–at which at least a quarter of undergraduate students live on-campus–to establish a supportive substance abuse recovery housing program within four years. MEDICATION-ASSISTED TREATMENT Patients on medication-assisted treatment (MAT) have been consistently shown to use fewer illicit opiates, commit fewer crimes and reduce their odds of contracting

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infections, such as hepatitis C virus (HCV) and HIV, 19 compared with those not taking substitution. MAT, which combines behavioral therapy and medications to treat substance use disorders, can be prescribed by physicians who are registered with the DEA to dispense controlled substances. MAT can include methadone, buprenorphine (a combination opiate mimic and blocker that can be taken as a sublingual tablet), Suboxone (buprenorphine combined with naloxone to discourage abuse as it does not produce a “high” if injected or snorted) or Vivitrol (an extended-release formulation of 20 naltrexone, an opioid receptor antagonist). Organizations in New Jersey, such as the Drug Policy Alliance, advocate for “making both methadone

IMPORTANT NJ SUBSTANCE ABUSE RESOURCES NJ ADDICTIONS HOTLINE is staffed by credentialed personnel who are available 24 hours a day to assess need, chart a plan for treatment and provide referrals. Language translation and TTY services are available. Dial 211 or 1-844-276-2777. DMHAS SUBSTANCE ABUSE TREATMENT DIRECTORY (which includes methadone maintenance programs) can be found at: https://njsams.rutgers.edu/dastxdirectory/txdi rmain.htm.

and buprenorphine more accessible through changing attitudes, laws, regulations and health insurance policies. Funding must be increased for access to methadone and buprenorphine through the public health system 21 for those who cannot afford it otherwise.” Issues limiting use of MAT include prevailing attitudes and specific state laws.

CONCLUSION New Jersey has shown laudable commitment to addressing the opioid epidemic in this state. The BME prescribing requirements are clear and thorough and complement the CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain. Prescription blanks have undergone security changes to make them more difficult to sell for cash or counterfeit, the NJPMP is up and running and all CDS prescribers are required to register. Project Medicine Drop has expanded across the state, and practitioners and pharmacies are required to provide notice about drug take-back programs upon dispensing a CDS to a patient. New Jersey has expanded or created a number of effective programs that target the drug user, including the Overdose Protection Act, which legalizes the prescription of naloxone to individuals who are not the intended end user, as well as the OOPP, the OORP and other initiatives. However, New Jersey still does not have sufficient drug and alcohol treatment slots to meet the need nor has it expanded the syringe exchange program despite a decades-old pilot scheme that has yielded positive results. There is also much untapped potential in expanding MAT, which, when prescribed and monitored properly, is effective, safe and cost-effective and reduces the risk of overdose. Sindy M. Paul, MD, MPH, FACPM, is Medical Director of the New Jersey Board of Medical Examiners. Virginia Allread, MPH, works for Rutgers School of Nursing and is a freelance public health consultant. 1

Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016, December 16). Increases in drug and opioid-involved overdose deaths–United States, 2010–2015. Morbidity & Mortality Weekly Report, 65(50–51), 1445–1452. [Available at www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm]; CDC. (2016, December 16 [updated]). Drug overdose death data. www.cdc.gov/drugoverdose/data/statedeaths.html.

Davis, T. (2016, June 16). New Jersey deaths from ultra-potent fentanyl drug are skyrocketing. Point Pleasant Patch. http://patch.com/new-jersey/pointpleasant/new-jerseydeaths-ultra-potent-fentanyl-drug-are-skyrocketing-officials.

Dowell, D., Haegerich, T. M., & Chou, R. (2016, March 18). CDC guideline for prescribing opioids for chronic pain–United States, 2016. Morbidity & Mortality Weekly Report, 65(1), 1–49. [Avail-

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able at www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm] 4

New Jersey Board of Medical Examiners. (2015, September 8). New Jersey Administrative Code Title 13 Law and Public Safety Chapter 35 Board of Medical Examiners. www.njconsumeraffairs.gov/regulations/Chapter-35-Board-ofMedical-Examiners.pdf. New Jersey Division of Consumer Affairs. (n.d.). New Jersey prescription monitoring program: Frequently asked questions. www.nj.gov/lps/ca2/pmp/FAQ.htm.

New Jersey Division of Consumer Affairs. (2016, April 27). Governor Christie announces bi-state collaboration with State of New York in fight against drug addiction neighboring states sharing prescription monitoring program data on opioid sales [Press release]. www.njconsumeraffairs.gov/News/Pages/04272016c.aspx.

New Jersey Division of Consumer Affairs. (n.d.). On Monday, November 7, 2016, the Division of Consumer Affairs, Office of Director, adopted the attached Prescription Monitoring Program Rules at N.J.A.C. 13:45A-35. www.nj.gov/lps/ca2/pmp/.

New Jersey Division of Consumer Affairs. (2016, December 6 [updated]). Project Medicine Drop Box locations. www.njconsumeraffairs.gov/meddrop/Pages/Locations.aspx. State of New Jersey, Office of the Governor. (2015, September 22). Facing Addiction Task Force one year later [Press release]. www.nj.gov/governor/news/news/552015/approved/2015092 2c.html.

Preusz, J. (2016, February 25). Opioid antidote, naloxone, now available without prescription. The Addiction Advisor. www.theaddictionadvisor.com/naloxone-opioid-antidoteavailable-without-prescription.

Wejnert, C., Hess, K. L., Hall, H. I., Van Handel, M., Hayes, D., Fulton, P., . . . Valleroy, L. A. (2016, December 2). Vital signs: Trends in HIV diagnoses, risk behaviors, and prevention among persons who inject drugs–United States. Morbidity & Mortality Weekly Report, 65(47), 1336–1342. [Available at www.cdc.gov/mmwr/volumes/65/wr/mm6547e1.htm?s_cid=m m6547e1_w]

National Council on Alcoholism and Drug Dependence – New Jersey. (n.d.). The addiction treatment gap. www.ncaddnj.org/file.axd?file=2010 percent2F3 percent2FTreatmentGapWeb.pdf.

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Stainton, L. H. (2016, February 5). Finding ways to tame epidemic of opioid addiction plaguing New Jersey. NJSpotlight. www.njspotlight.com/stories/16/02/04/findingways-to-tame-epidemic-of-opioid-addiction-plaguing-newjersey.

Peskoe, A., & Stirling, S. (2015, January 18). Want heroin treatment in NJ? Get arrested. NJ.com. www.nj.com/healthfit/index.ssf/2015/01/want_heroin_treatment_in_nj_get_arrested.html.

Center for Substance Abuse Prevention Division of State Programs, Center for Substance Abuse Treatment Division of State and Community Assistance, & Center for Mental Health Services Division of State and Community Systems Development. (2015, November 10). New Jersey uniform application FY 2016/2017 – State behavioral health assessment and plan substance abuse prevention and treatment and community mental health services block grant. www.nj.gov/humanservices/dmhas/publications/federal/SA_ Prev_Tx_and_CMHS_Combined_Blk_Grant_App_FY16_17.pdf.

National Council on Alcoholism and Drug Dependence – New Jersey. (n.d.). The future of addiction care in NJ. www.ncaddnj.org/page/the-future-of-addiction-care-in-nj.aspx.

Centers for Medicare & Medicaid Services. (n.d.). Medicaid & CHIP in New Jersey. www.medicaid.gov/medicaid-chipprogram-information/by-state/new-jersey.html.

State of New Jersey, Office of the Governor. (2016, June 30). Governor Christie signs 7th consecutive budget without raising taxes on New Jersey families. http://nj.gov/governor/news/news/552016/approved/20160630d.html.

Drug Policy Alliance. (2015, August 10). NJ Governor Chris Christie signs bill expanding access to evidence-based drug treatment for participants in drug courts. www.drugpolicy.org/news/2015/08/nj-governor-chris-christie-signsbill-expanding-access-evidence-based-drug-treatment-pa; Kastelic, A., Pont, J., & Stöver, H. (2008). Opioid substitution treatment in custodial settings: A practical guide. www.unodc.org/documents/hiv-aids/OST_in_Custodial_Settings.pdf.

Balhara, Y. P. S. (2016). What is the difference between buprenorphine, Subutex and Suboxone? http://luxury.rehabs.com/suboxone-addiction/vs-subutexbuprenorphine.

Drug Policy Alliance. (2016). Drug replacement and maintenance therapy. www.drugpolicy.org/drug-replacement-and-maintenance-therapy.

CME

OPIOID MISUSE, ABUSE AND ADDICTION Part 2: Opioid Prescriber Responsibilities and Resources*

CME EXAMINATION (Deadline February 1, 2018) According to the “CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016”: a) Opioids may be considered a first-line therapy for chronic, non-cancerous pain in patients who are also diagnosed with depression. b) Opioids may be considered a first-line therapy for chronic, non-cancerous pain if the prescription is limited to fewer than four days. c) Opioids should not be considered first-line or routine therapy for chronic, non-cancerous pain. d) Opioids may be considered a first-line therapy for all acute, non-cancerous pain.

When prescribing opioids for chronic pain, the 2016 CDC Guidelines recommend prescribing the lowest effective dosage. Holding dosages below what morphine milligram equivalent (MME)/day will likely reduce risk among a large proportion of patients who would experience a fatal overdose at higher prescribed dosages? a) 60 MME. b) 50 MME. c) 40 MME. d) 20 MME.

When are prescribers required, at a minimum, to review the New Jersey Prescription Monitoring Program (NJPMP) information when prescribing a Schedule II medication? a) The first time the Schedule II medication is prescribed. b) Quarterly while continuing to prescribe the Schedule II medication. c) Reviewing the NJPMP is not required when prescribing a Schedule II medication. d) A and B.

Which of the following healthcare professionals licensed in New Jersey can be a delegate for the NJPMP? a) Advanced practice nurse. b) Licensed practical nurse. c) Registered nurse. d) All of the above.

Physician responsibilities related to the NJPMP delegate include which of the following? a) Before designation, confirm the education, training and license or certification requirement of each delegate. b) Ensure the delegate understands limitations on disclosure of PMP information and federal and state laws, rules and regulations concerning patient information confidentiality. c) At least every six months, monitor the delegate’s PMP use for potential misuse and report unauthorized access to the NJ DCA within five business days of discovery. d) Terminate the delegate’s PMP access when a delegate, for any reason, is no longer authorized to be a delegate. e) All of the above.

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a) The physician can write the prescription only in the name/address of the person to whom the opioid antidote will be administered. b) The physician is required to write the prescription in the name/address of the person to whom the prescription is issued, rather than the person to whom the opioid antidote will be administered. c) The physician is required to document opioid abuse in someone known to the prescribee before a prescription can be written. d) The physician is required to follow up with the person to whom the prescription was issued to document naloxone use.

According to the BME prescribing regulations, before prescribing a CDS, practitioners need to ensure that patient records are accurate and include which of the following? a) A recognized medical indication for the use of the CDS. b) The patient’s medical history, physical examination and any other evaluations and consultations, including underlying or coexisting diseases or conditions, any history of substance abuse and the nature, frequency and severity of pain. c) Any agreements with the patient. d) All of the above.

As of January 1, 2016, practitioners and pharmacies are required to provide notice about which of the following programs upon dispensing a CDS? a) The availability of naloxone under the Good Samaritan Law. b) The drug take-back programs, namely, Project Medicine Drop. c) The phone number for the New Jersey Addictions Hotline. d) A and C.

Which of the following best explains syringe access programs (SAP) in New Jersey? a) Eligible providers are allowed to register with the state Department of Health to sell, furnish or accept for disposal hypodermic needles and syringes. b) Most pharmacies in New Jersey are allowed to provide clients with clean hypodermic needles and syringes in exchange for used ones. c) The SAP includes a total of six independently managed projects in which clients are provided with clean hypodermic needles/syringes in exchange for used ones and can access a range of healthcare services. d) B and C.

According to the article, patients on what treatment or therapy “have been consistently shown to use fewer illicit opiates, commit fewer crimes and reduce their odds of contracting infections, such as hepatitis C virus (HCV) and HIV”? a) Medication-assisted treatment, such as methadone, buprenorphine or Suboxone. b) Outpatient counseling followed by 12-step programs. c) Detox followed by cognitive behavioral therapy with motivational interviewing. d) Detox followed by inpatient/residential treatment.

According to the Overdose Prevention Act, a physician can prescribe naloxone (Narcan) to family members and peers of a person at risk. To do so, which of the following is/are required by the BME?

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OPIOID MISUSE, ABUSE AND ADDICTION Part 2: Opioid Prescriber Responsibilities and Resources*

REGISTRATION AND EVALUATION FORM

(Must be completed in order for your CME Quiz to be scored – Deadline for Response: February 1, 2018) REGISTRATION FORM First Name

Middle Initial

Last Name

City

State

ZIP

Phone

E-mail Address

Specialty

Degree

Address

ANSWER SHEET Circle the correct answer. 1) A B C D

2) A B C D

3) A B C D

4) A B C D

5) A B C D E

6) A B C D

7) A B C D

8) A B C D

9) A B C D

10) A B C D

Number of hours spent on this activity _______ (reading article and completing quiz) I attest that I have read the article “Opioid Abuse, Misuse and Addiction – Part 2: Opioid Prescriber Responsibilities and Resources” and am claiming 1.0 AMA PRA Category 1 Credit.™ Signature EVALUATION 1. 2. 3. 4.

The The The The

Date Completed by

content of the article was: authors’ writing style was: graphics included in the article were: stated objectives of this program were:

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Physician

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Non-Physician

Excellent___ Good___ Fair___ Poor___ Excellent___ Good___ Fair___ Poor___ Excellent___ Good___ Fair___ Poor___ Exceeded____ Met____ Not met_____

Was this article free of commercial bias? Yes _________ No _________ If not, why not __________________________________________________________________________ Please share your name and contact information so that we may investigate further. Participant Name __________________________________ Telephone/E-mail: _____________________ 5. Will the knowledge learned today affect your practice? Very Much____ Moderately____ Minimally____ None____

7. Did this CME activity change what you know about: • The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain. Yes ❑ No ❑ • The New Jersey Board of Medical Examiners prescribing requirements. Yes ❑ No ❑ • The features of the New Jersey Prescription Monitoring Program. Yes ❑ No ❑ • The initiatives in New Jersey that aim to prevent or treat substance abuse disorders or decrease the risk of overdose-related mortality. Yes ❑ No ❑ 8. Based on your participation today, what barriers to the implementation of the strategies or skills taught today have you identified?

Suggested topics for future programs:_________________________________________________________________________________

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6. Based on your participation in the CME activity, describe ways in which you will change the way you practice medicine. __Yes Describe ___________________________________________________________________________________ __No Why not ___________________________________________________________________________________ __N/A Were you the wrong audience for this activity? _________________________________________________

Announcing the 2017 EDWARD J. ILL

Excellence in Medicine Awards

By Janet S. Puro, MPH, MBA

The Edward J. Ill Excellence in Medicine Awards® are awarded annually to honor those exemplary physicians and leaders whose dedication to patient care, education, research and public service has significantly impacted the delivery of healthcare in New Jersey and around the world. The awards are named after Edward J. Ill, MD, a New Jersey physician who was a pioneer in promoting continuing education in ways that set the national standard. The event debuted in 1939 and has been sponsored by MDAdvantage Insurance Company since 2003. All profits from this annual event are dedicated to the Edward J. Ill Excellence in Medicine Scholarship Fund, which was formed in recognition of a strong need to support healthcare education in New Jersey–a need that continues to grow year over year as tuitions rise and pressures continue to mount for aspiring healthcare professionals. New Jersey lags far behind surrounding states in its ability to attract and retain talent. The goal of the Scholarship Fund is to support young healthcare providers so they can afford to remain in our state and go on to have successful, productive careers for the benefit of all the citizens of New Jersey. The scholarship recipients are composed of extraordinary New Jersey residents who demonstrate excellence in academics and a commitment to the community and the state of New Jersey. This year’s awards dinner will be held on Wednesday, May 3, 2017, at Park Château Estate and Gardens in East Brunswick, New Jersey. To order tickets, participate as a Scholarship Honor Roll member, place an ad in this year’s awards journal or make a direct contribution, please contact the Edward J. Ill Excellence in Medicine Foundation at 609-803-2350 or visit www.EJIawards.org.

OUTSTANDING MEDICAL EDUCATOR AWARD Presented to a medical educator who has made an outstanding contribution to graduate or undergraduate medical education in New Jersey. John W. Sensakovic, MD, PhD, is an infectious disease specialist and the Director of Infection Control and Continuing Medical Education at JFK Medical Center. Additionally, he is Associate Dean for Residencies and Fellowships at Seton Hall University School of Health and Medical Sciences/Seton Hall University-Hackensack Meridian School of Medicine. Dr. Sensakovic previously served for many years as Director of Medical Education at Saint Michael’s Medical Center, where he was responsible for all graduate and continuing education. Dr. Sensakovic is a past member of the New Jersey Lyme Advisory Panel and the Governor’s Advisory Council on HIV/AIDS, the Governor’s Medical Emergency Preparedness and Response Expert Panel and the Governor’s Pandemic Advisory Group, and is a past President of the Infectious Disease Society of New Jersey. Dr. Sensakovic is the author of numerous journal articles, textbook chapters on infectious diseases and articles on physicians’ training and the educational process. Dr. Sensakovic is recognized as an expert in infectious diseases and medical education and has received numerous awards and honors for his work throughout his career, including the Governor’s Clara Barton Medical Service Award. MDADVISOR

Excellence OUTSTANDING HEALTHCARE EXECUTIVE AWARD Presented to an executive in a healthcare-related organization or field who has demonstrated exceptional leadership in the enhancement of patient care and medical practice in New Jersey. Alexander J. Hatala, FACHE, is the President and Chief Executive Officer of Lourdes Health System. He is responsible for the overall strategy and operations of the healthcare system and its affiliates. In his 30 years with Lourdes, Mr. Hatala has maintained a steadfast commitment to providing high-quality patient care and upholding Lourdes Health System’s values-based mission. Under his leadership, Lourdes has become well-known for its culture of innovation. Lourdes acquired the former Rancocas Hospital (now Lourdes Medical Center of Burlington County) and since then has transformed the system into one of the leading providers in the Southern New Jersey and Philadelphia region, with an extensive physician network of 290 physicians representing nearly 100,000 lives, an accountable care organization and a growing community-based network of ambulatory care centers. In 2016, Mr. Hatala was named one of the 50 most influential leaders by South Jersey magazine. Lourdes has received several awards from Healthgrades, including America’s Best 100 hospitals for cardiac care and top 50 in the nation for cardiac surgery. In 2014, Lourdes was recognized by Truven Analytics as one of America’s 50 best hospitals for cardiac surgery and by Becker’s Hospital Review as among “100 Hospitals and Health Systems with Great Heart Programs.” Our Lady of Lourdes remains the only New Jersey hospital to have received the American Hospital Association’s Foster McGaw award. Mr. Hatala is a member of the Board of the New Jersey Hospital Association, the Chamber of Commerce of Southern New Jersey and Samaritan Hospice. He is a member of the American Hospital Association, the New Jersey Conference of Catholic Health Care Facilities and the Greater Camden Partnership and is a Fellow in the American College of Healthcare Executives.

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EDWARD J. ILL PHYSICIAN’S AWARD® Presented to a New Jersey physician for dedication and extraordinary service to the profession and to the citizens of the state. Maria Soto-Greene, MD, MS-HPEd, is Professor and Vice Dean at Rutgers New Jersey Medical School (NJMS). She has amassed more than 30 years of experience in all aspects of medical education. Initially, Dr. Soto-Greene focused on the care of the critically ill patient, honing in on the significance of physician/patient communication and its impact on vulnerable patients and their loved ones. These experiences, combined with her own life in a family that was uninsured and economically disadvantaged, influenced her to champion initiatives for individuals from similar backgrounds. Dr. Soto-Greene is committed to advancing the school’s cultural competency education with the goal of attaining health equity. She has been continuously funded by federal and private agencies since the early 1990s and has passionately worked to create unequaled opportunity for thousands of Hispanic and other individuals under-represented in medicine and science. These programs support individuals beginning at the pre-college level through medical school faculty, contributing to career advancement and cultivating the next generation of champions for social justice. Equally important, she has been a leader in disseminating best practices to other medical schools. Dr. Soto-Greene earned her medical degree from New Jersey Medical School, completed her internal medicine training at University Hospital and earned her master’s degree in Health Professions Education at the MGH Institute of Health Professions. She is a board-certified internist.

in Medicine VERICE M. MASON COMMUNITY SERVICE LEADER AWARD Presented to an individual who has personified, led and provided the vision for an organization, and to the organization served, for extraordinary commitment to improving the health and welfare of the citizens of New Jersey. Chantal Brazeau, MD, will accept the Verice M. Mason Community Service Leader Award on behalf of the Rutgers New Jersey Medical School Student Family Health Care Center. Dr. Brazeau is Professor of Family Medicine and Psychiatry at Rutgers New Jersey Medical School and maintains board certification in both specialties. Dr. Brazeau has been a faculty member at Rutgers NJMS since 1995, Director of Medical Student Education in the Department of Family Medicine since 2001 and Interim Chair of the Department since 2012. She has been actively engaged in medical student education and curriculum development while leading several federal grants related to training medical students in primary care medicine and in treating underserved patient populations. The grants include a five-year-long Health Resources and Services Administration grant in 2011 to expand the community services and clinical care provided by the NJMS student-run free clinic–the Student Family Health Care Center. Through this grant, students carry out innovative models of primary healthcare delivery and reflect on the needs of underserved patients. Dr. Brazeau has also taught students about professional self-care, the doctor–patient relationship, mental health in primary care, as well as ethics, humanism and professionalism. Her clinical practice is embedded within the Department of Family Medicine’s faculty practice, where she addresses mental health problems in primary care. She has a special interest in medical student and physician well-being.

OUTSTANDING SCIENTIST AWARD Presented to an individual or individuals who have made important contributions leading to advances in treatment. Nancy D. Connell, PhD, is Professor and Vice Chair for Research in the Division of Infectious Disease in the Department of Medicine at Rutgers New Jersey Medical School and the Rutgers Biomedical Health Sciences. Dr. Connell’s major research focus is antibacterial drug discovery in respiratory pathogens, such as M. tuberculosis and B. anthracis. Her recent work also focuses on the use of predatory bacteria as novel therapeutics for bacterial infections. Dr. Connell has been continuously funded by the National Institutes of Health (NIH), the Department of Defense, industry and other agencies since 1993 and serves on or has chaired several NIH review panels. Dr. Connell has served on a number of committees of the National Academy of Sciences, including the Advances in Technology and the Prevention of their Application to Next Generation Biowarfare Agents (2004), Trends in Science and Technology Relevant to the Biological Weapons Convention (2010) and Review of the Scientific Approaches used in the FBI’s Investigation of the 2001 B. anthracis Mailings (2011). Dr. Connell has considerable experience and interest in pedagogy, with a focus on ethics education and the responsible conduct of research. She is currently chairing the National Research Council’s (NRC) Standing Committee for Faculty Development for Education about Research with Dual Use Issues in the Context of Responsible Science and Research Integrity, which has directed a series of workshops throughout the Middle East and North Africa. Dr. Connell was recently appointed a member of the Board on Life Sciences and is a National Associate of the National Academies of Sciences.

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Excellence OUTSTANDING SCIENTIST AWARD Presented to an individual or individuals who have made important contributions leading to advances in treatment. Larry Hirsch, MD, is the Worldwide Vice President of Medical Affairs, Diabetes Care, at BD, and is board-certified in internal medicine and endocrinology and metabolism. He is an industry leader in high-quality clinical research studies resulting in evidence-based guidelines and recommendations to improve the care of patients with diabetes using insulin. His original study of skin and subcutaneous adipose tissue dimensions at insulin injection sites provided the first-of-its-kind data that gave the medical rationale to introduce the novel 4 mm insulin pen needle and 6 mm insulin syringe needle. These findings have been confirmed globally, followed by comparative trials consistently showing that such small needles provide equal glycemic control, less pain and anxiety and no greater insulin leakage vs. longer, traditional needles. These studies have helped millions of patients lessen the burden of insulin therapy. He has provided strong service to the citizens of New Jersey through several non-profit healthcare organizations, personal leadership and unusual fundraising efforts to better the lives of patients with diabetes. Living with type 1 diabetes for more than 59 years, Dr. Hirsch serves on the Community Leadership Board of the American Diabetes Association and the Board of Trustees of the Paramus-based Diabetes Foundation of NJ, Inc. (DFI). He is a founding member and the third President of the International Society for Medical Publication Professionals, an organization devoted to upholding ethical and responsible policies and practices for pharmaceutical and medical device personnel working on medical publications of industry-sponsored clinical research. Before joining BD, he spent more than 17 years at Merck in various roles in clinical drug development, including oversight of the practice-changing 4S trial with simvastatin (Zocor). He also led the development of alendronate (Fosamax) and presented the original clinical evidence at the FDA Advisory Committee in 1995, leading to its approval by the FDA as the first non-hormonal treatment for postmenopausal osteoporosis. 20

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PETER W. RODINO, JR., CITIZEN’S AWARD® Presented to a citizen or group of citizens of New Jersey who merits recognition for distinguished service in advancing and promoting the health and well-being of the people of our state. Alfred F. Tallia, MD, MPH, is Professor and Chair of Family Medicine and Community Health at Rutgers Robert Wood Johnson Medical School. Under his leadership, the department has emerged as a national center for health system change and innovation, ranking ninth in NIH funding. Dr. Tallia developed Robert Wood Johnson Partners, LLC, the integrated delivery system of Rutgers University and the RWJBarnabas Health System, designed to improve healthcare for patients across the socioeconomic spectrum. During his two years as Founding Executive Director, he grew RWJ Partners to serve more than 35,000 patients in seven New Jersey counties, with a network of 900 physicians, five hospitals and multiple post-acute facilities, while meeting quality metrics at the Centers for Medicare & Medicaid Services (CMS) 94th percentile and financial targets to achieve $3.6M in savings. RWJ Partners was recognized in 2015 and 2016 by Becker’s Hospital Review as one of “100 ACOs to Know” out of more than 1,500 operational in the United States. Nationally, Dr. Tallia is an executive member of the National Board of Medical Examiners, and he chairs the United States Medical Licensing Examination program–the common licensure assessment pathway for all foreign and domestic medical school graduates. He has served on the Patient Centered Primary Care Collaborative; the Washington-based coalition of Fortune 500 payers, providers and consumers advancing healthcare reform; and on the boards of Horizon Health Innovations and the Robert Wood Johnson University Hospital and Health System. He continues to serve numerous public and private health-related organizations in New Jersey and around the country.

in Medicine MDADVANTAGE

congratulates 2017

Michael Cacoilo Rutgers New Jersey Medical School – Class of 2017

the EDWARD J. ILL EXCELLENCE IN MEDICINE SCHOLARSHIP RECIPIENTS

Timothy Lopez Seton Hall University School of Health and Medical Sciences – Class of 2018

Kathryn Eckert Rowan University School of Osteopathic Medicine – Class of 2018

Mark McShane Cooper Medical School of Rowan University – Class of 2019

Sydney Hyder Rutgers Robert Wood Johnson Medical School – Class of 2017

Mary Thompson Rutgers School of Dental Medicine – Class of 2017 Devin Walford Godwin Rutgers School of Health Professions – Class of 2017

Janet S. Puro, MPH, MBA, is Vice President of Business Development and Corporate Communications at MDAdvantage Insurance Company of New Jersey.

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LEGISLATIVE

UPDATE By Michael C. Schweder

On January 20, 2017, Donald Trump joined the likes of John Quincy Adams (1824), Rutherford B. Hayes (1876), Benjamin Harrison (1888) and George W. Bush (2000) as one of only five presidents to be elected to office without securing the national popular vote.1 The political choices made by Trump thus far leave the medical community wondering what changes are ahead for healthcare and for the Affordable Care Act (ACA). Thus far, Republicans have not coalesced around a plan to replace the ACA. The struggles and false starts have rattled consumers and injected much uncertainty into insurance markets that thrive on stability. Insurers are threatening to exit the ACA market unless the Trump administration and Congress can quickly clarify their intentions. The deadline to file rates for 2018 is this spring, and insurers say they need time to decide what kinds of plans to offer and to set prices. MEMORIAL SLOAN KETTERING MOVES TO NJ The Manhattan-based cancer center Memorial Sloan Kettering recently opened its new outpatient facility in Middletown, New Jersey, at the site of the former Lucent Technologies. The new facility will provide more convenient access to cancer treatment for New Jersey’s residents in Monmouth and Ocean counties. The Middletown site features a 120,000-square-foot clinical program space and a 50,000-square-foot data center.2 Memorial Sloan Kettering is estimating this location will have nearly 45,000 patient visits, combined with more than 600 outpatient procedures,

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in its first year in New Jersey.3 Memorial Sloan Kettering also has an outpatient facility in Basking Ridge and is expanding into northern New Jersey with the center’s newest location in Montvale, which is expected to be fully operational in mid-2017. CANCER CARE PARTNERSHIP: MEMORIAL SLOAN KETTERING AND HACKENSACK MERIDIAN HEALTH In another attempt to stay up-to-date with the evolving healthcare system, Memorial Sloan Kettering Cancer Center (MSKCC) signed a 10-year deal with Hackensack Meridian Health to form one of the nation’s largest cancer care partnerships.4 This partnership will allow the sharing of doctors, information and best practices, as well as participation in clinical trials.5 U.S. Senator Bob Menendez called this cooperation the “singular most important moment in healthcare in our state in the last 25 years.”4 According to the MSKCC website, Memorial Sloan Kettering and Hackensack Meridian Health will “treat one in five New Jersey residents who are diagnosed with cancer. Combined, the two organizations annually will serve the most patients with cancer in the region.”6 BETTER CHOICES, BETTER CARE NJ In an attempt to improve healthcare in this new landscape, the state’s largest health insurer, Horizon Blue Cross Blue Shield of NJ (HBCBCNJ), has agreed to fund

an advocacy organization “comprised largely of business and labor groups in an effort to educate consumers … 7 and seek public input.” This advocacy group–Better Choices, Better Care NJ–will spread its message “through opinion-editorials, policy meetings, public forums, online posts and social media”8 to educate consumers on the move to “patient-centered care that pays doctors and hospitals that prevent disease and 8 promote healthy living.” The group has received some criticism for not including hospitals and other insurers that have their hand on the pulse of healthcare in the state. The group was initiated after the controversial OMNIA plan provided by HBCBSNJ. The OMNIA plan “offers patients steep premium discounts in exchange for visiting providers in a select group, or tier … [and] has drawn fire from hospitals not included in the preferred tier.”7 Better Choices, Better Care NJ Board member Lizette Delgado-Polanco stated, “fee-forservice has to go … what replaces it has to be something that is affordable, while also providing high quality coverage for hard-working New Jerseyans and their families.”9 LEGISLATIVE BILLS TARGETING HEALTHCARE Assembly Bill No. 4394: This Assembly bill, introduced by Assemblyman Gary Schaer (D-36), establishes the New Jersey Commission on Health Insurance Network Adequacy.10 This new commission will help to ensure NJ’s health insurance networks are meeting the changing needs of healthcare, and it will review the appropriateness and effectiveness of the state’s network adequacy regulations. Assemblyman Schaer remarked, “My hope is that the commission will develop a blueprint for needed changes that will provide quicker, more reliable, and more accessible care for every resident seeking in-network treatment.”11 This commission will be made up of 13 members who are healthcare industry professionals and politicians. Findings will be addressed in a full report to “the Governor and Legislature no later than 12 months after its organization…the commission would expire upon the issuance of its report.”11 A-4394 has been introduced and referred to the Assembly Financial Institutions and Insurance Committee. Assembly Bill No. 2140: Sponsors of A-2140 include Assemblyman Daniel Benson (D-14), Assemblywoman Shavonda Sumter (D-35) and Assemblyman Raj Mukherji

(D-33). This bill requires that health insurance carriers use a 12 standard explanation of benefits form. A-2140 will create a standard written explanation of benefits form that will make it easier for insured people to better understand their benefits and know exactly what services are covered. Assemblyman Benson explains that “many of these forms, with their convoluted industry terms, can be hard for the average person to decipher. Having one standard form that is simple and straightforward is not only practical, but it makes for a more knowledgeable health consumer.”13 This bill advanced out of the Assembly Financial Institutions and Insurance Committee. The bill now goes to Assembly Speaker Vincent Prieto’s desk for further consideration. Assembly Bill No. 3620: Assemblywoman Pinkin (D-18) is the prime sponsor of this legislation that “revises affidavit of merit requirement in professional malpractice cases.”14 A-3620 would require a person to “submit an affidavit of

“A-3620 … This bill is designed to limit meritless claims and to make certain that doctors are not being unjustly accused of wrongdoing.” merit from a board-certified medical professional with expertise in the medical procedure at issue attesting that the care provided by the defendant fell outside acceptable professional standards.”15 This bill is designed to limit meritless claims and to make certain that doctors are not being unjustly accused of wrongdoing. A-3620 was scheduled to be heard for discussion only in the Assembly Financial Institutions and Insurance Committee, but the bill was held and has not been rescheduled. Assembly Bill No. 3404: This legislation is sponsored by Assemblyman John Burzichelli (D-3) and Assemblyman Craig Coughlin (D-19). “[It] permits hospitals to establish [a]

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system for making performance-based incentive payments 16 to physicians.” Assemblyman Burzichelli stated that this bill will essentially “allow hospitals and physicians to enter into arrangements to improve the overall health of an individual patient by tracking him or her through the healthcare delivery system. This is a win for everyone.”17 This bill would allow payments to physicians for the outcomes of patient treatments and will not be tied to the volume of patients that physicians see. The Health and Senior Services Committee approved A-3404, and it now moves to the second reading in the Assembly. Michael C. Schweder is the Director of Government Affairs at CLB Partners, LLC, in Trenton, New Jersey. 1

Gore, D. (2008). Presidents winning without popular vote. FactCheck.org. www.factcheck.org/2008/03/presidents-winningwithout-popular-vote.

Spahr, R. (2016, November 29). New cancer center brings Sloan Kettering care closer to home for N.J. patients. NJ.com. www.nj.com/monmouth/index.ssf/2016/11/ribbon_cut_for_new_ memorial_sloan_kettering_cancer.html.

Memorial Sloan Kettering Cancer Center opens in Middletown. (2016, November 28). News12 New Jersey. http://newjersey.news12.com/news/memorial-sloan-ketteringcancer-center-opens-in-middletown-1.12680408.

Heyboer, K., & O’Brien, K. (2016, December 14). ‘Historic’ deal gives N.J. cancer patients more experimental treatment options. NJ.com. www.nj.com/healthfit/index.ssf/2016/12/seton_hall_sloan_kettering.html. Khemlani, A. (2016, December 14). Update: MSK, Hackensack Meridian to partner on cancer care, research. NJBiz.com. www.njbiz.com/article/20161214/NJBIZ01/161219931/update -msk-hackensack-meridian-to-partner-on-cancer-care-research.

Memorial Sloan Kettering and Hackensack Meridian Health announce cancer care partnership [Press release]. (2016, December 14). Memorial Sloan Kettering Cancer Center. www.mskcc.org/press-releases/msk-and-hackensack-meridianhealth-announce-cancer-care-partnership.

Stainton, L. H. (2016, November 22). Horizon to fund new NJ healthcare advocacy organization. NJSpotlight. www.njspotlight.com/stories/16/11/21/horizon-to-fund-new-nj-healthcareadvocacy-organization.

Livio, S. K. (2016, November 21). Worried about health care costs? This N.J. group is listening. NJ.com. www.nj.com/healthfit/index.ssf/2016/11/got_a_gripe_with_yo ur_health_care_costs_talk_to_th.html.

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Delgado-Polanco, L. (2016, December 15). Op-Ed: In healthcare, more tests and procedures do not ensure better outcomes. NJSpotlight. www.njspotlight.com/stories/16/12/14/op-ed-in-healthcare-more-tests-and-procedures-do-not-ensure-better-outcomes/#.

Schaer, G. S. (2016, December 12). Assembly No. 4394; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A4500/4394_I1.PDF.

Assembly Democrats. (2016, December 7). Schaer introduces legislation to make sure New Jersey’s health insurance networks meet consumers’ needs [Press release]. www.assemblydems.com/Article.asp?ArticleID=11860.

Diegnan, P., Egan, J. V., Benson, D. R., & Sumter, S. E. (Pre-filed for introduction in the 2016 Session). Assembly no. 2140; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A2500/2140_I1.PDF.

Assembly Democrats. (2016, December 5). Assembly panel ok’s Egan, Benson & Sumter bill requiring health insurers to use standard explanation of health benefits forms [Press release]. www.assemblydems.com/Article.asp?ArticleID=11835.

Pinkin, N. J. (2016, April 14). Assembly no. 3620; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A4000/3620_I1.HTM.

Pinkin introduces important medical liability legislation. (2016, April 28). New Jersey Civil Justice Institute. www.civiljusticenj.org/tag/medical-liability.

Burzichelli, J. J., & Coughlin, C. J. (2016, March 3). Assembly no. 3404; State of New Jersey 217th Legislature. www.njleg.state.nj.us/2016/Bills/A3500/3404_R1.HTM.

Assembly Democrats. (2016, December 5). Burzichelli & Coughlin bill providing incentives to improve hospital care gains Assembly panel approval [Press release]. www.assemblydems.com/Article.asp?ArticleID=11831.

NEW JERSEY COMBATS RISE IN By Commissioner Cathleen D. Bennett The damaging effects of sexually transmitted diseases (STDs) have been known for decades, but despite that knowledge, the United States is seeing a startling rise among Americans. Cases in 2015 reached their highest in the United States since the late 1980s, prompting the Centers for Disease Control and Prevention (CDC) to warn of a looming epidemic. Despite recent declines, 2015 was the second year in a row in which increases were seen in all three nationally reported STDs: chlamydia, gonorrhea and syphilis. The approximately 1.5 million cases of chlamydia represent the highest number of annual cases of any condition ever reported to the CDC.1 During 2014–2015, the rate of reported gonorrhea increased 18.3 percent among men and 6.8 percent among women. Trend data also show rates of syphilis are increasing at an alarming rate (19 percent in 2015).2 Young people and gay and bisexual men are at greatest risk for STDs. Data suggest that young people aged 15–24 years acquire half of all new STDs, and one in four sexually active adolescent females has an STD, such as chlamydia or human papillomavirus (HPV).2 Although primary and secondary syphilis rates have increased among men and women, men account for more than 90 percent of these cases. Men who have sex with men account for 82 percent of male cases where the gender of the sex partner is known.1 New Jersey STD rates have been mirroring national trends and steadily rising for several years. In 2015, there were nearly 40,000 cases of chlamydia, gonorrhea and syphilis in the state–a 16 percent increase since 2011. Nine counties, including Atlantic, Camden, Cumberland, Essex, Hudson, Mercer, Passaic, Union and Salem, have STD incidence rates that exceed the statewide rate, and Jersey City and Newark have reached outbreak status. The New Jersey Department of Health is focused on reversing this trend by increasing awareness, enhancing outreach to potentially exposed partners and working

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with providers to ensure young adults are aware of risks. Left untreated, STDs can lead to devastating and costly conditions, such as infertility in women, life-threatening congenital defects in infants, certain STD-related cancers and a higher risk of acquiring HIV. The CDC estimates the cost of treating an early case of chlamydia and/or gonorrhea is approximately $73, whereas the cost of treating secondary conditions related to these diseases, such as pelvic inflammatory disease and epididymitis, is as high as $684. This estimate does not include even higher costs of possible longer-term conditions, such as infertility treatment. The CDC estimates STD cases cost the U.S. healthcare system nearly $16 billion each year.1 Thus, providing timely treatment and reducing the number of newly diagnosed cases saves the state millions of dollars in treating these longterm conditions and preventing outbreaks and epidemics. To fight the rise in STDs, the Department launched a social media awareness campaign earlier this year about this urgent public health issue with a focus on alerting the public that one in two sexually active young people will get an STD by age 25. Our hope is that this startling fact will encourage healthcare providers, parents and educators to talk frankly and openly to adolescents about how they can get STDs and how to prevent them. Decreasing STDs relies on timely diagnosis of new cases so any sexual and/or needle-sharing partners can be traced, tested and treated to stop further spread. Targeting

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Reprinted with permission from the New Jersey Department of Health

high-incidence and at-risk populations for intense STD screening, treatment and sexual partner tracing is an evidence-based method of intervention that has been shown to reduce STDs and STD-related illnesses. To boost early identification of cases, the Department has been improving our partner-tracing efforts to ensure we are more effectively reaching those who might have been exposed to an STD. We recently combined our partner services offices for HIV and STDs to maximize outreach efforts and share successful strategies. This merging of offices will also lead to less intrusion in clientsâ&#x20AC;&#x2122; lives. The Department is also modernizing our outreach to partners to reflect the communications methods most used today, recognizing that partners are now connecting online and may use only an email address or username as their

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public identity. Our Internet Partner Services effort now allows the Department to access commonly used mobile applications to reach past sexual contacts of someone who has been diagnosed with an STD. As trends in communication have advanced, the use of current and emerging technologies to reach at-risk individuals has become essential. Individuals for whom there are only virtual identifiers, such as an email address or username, are unreachable without online search engines, email, access to online communities and other electronic tools. The Department is asking our public health and healthcare partners to join us in our effort to stem the increasing rates of STDs. The Department asks that you talk with patients about the alarming rise of STDs and make STD screening a standard part of medical care. Healthcare providers can help patients understand the health consequences of these diseases and how to protect themselves. Physicians and nurses are trusted resources and can offer a place where young people, in particular, can receive factual and reliable information. Providers can help dispel myths, such as the misconception that contraceptive pills protect against STDs. The CDC offers a resource, A Guide to Taking a Sexual History, available at www.cdc.gov/std/treatment/sexualhistory.pdf, which can aid physicians in discussing sexual history with patients. The Department also features our STD awareness campaign posters in English and Spanish, which are downloadable at www.nj.gov/health/hivstdtb/. Healthcare providers are critical in educating our residents and offering tools they need to protect themselves. As a state and nation, we have made great strides in reducing cases of HIV, and I am confident we can replicate that success with STDs. Working together, we can fight this dangerous trend and protect the health of our residents. Cathleen D. Bennett is the Commissioner of the New Jersey Department of Health.

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Centers for Disease Control and Prevention. (2016, October). Fact sheet: Reported STDs in the United States. www.cdc.gov/nchhstp/newsroom/docs/factsheets/stdtrends-508.pdf.

Centers for Disease Control and Prevention. (2016). Sexually transmitted disease surveillance 2015. Atlanta, GA: U.S. Department of Health and Human Services.

INFANTILE PARALYSIS: The Newark Polio Epidemic of 1916 By Sandra Moss, MD In the summer of 1916, Newark was gripped by a devastating waiting rooms and enclosed spaces, Craster ordered the poliomyelitis epidemic. Local newspapers favored “infantile closure of children’s clinics, day nurseries, dispensaries paralysis,” “scourge” and “plague”–words that spoke to a and mothers’ consultation stations. Charity organizations terrified public. For many survivors, poliomyelitis reverberated charged that these measures caused hardship and through wounded lives. With an incidence of 3.3 per “near-destitution.” Pediatrician Henry Leber Coit was 1,000, Newark was the nation’s hardest-hit city per capita. publicly critical of Craster’s order: “To close prophylactic Total cases for July through September numbered 1,360 with centers that are under close medical supervision…is an 5 363 deaths (26.7 percent). The worst day was August 4, with official act based on faulty judgment.” 45 new cases and 13 deaths.1 On July 1, New York Health Commissioner Haven SCHOOL CLOSINGS AND RESTRICTIONS ON CHILDREN Emerson alerted Newark officials about a poliomyelitis Libraries, playgrounds, parks, movie houses, vaudeville outbreak in Brooklyn. Newark’s first death occurred on July theaters, baseball games–and even the circus–were 4. On July 14, with 64 reported cases closed to children. 6 Craster FIGURE 1 and 17 deaths, Newark officials favored the suspension of all sumdeclared an epidemic. Most victims, mer school classes. Education almost all infants and toddlers, had officials argued that monitoring by 2 no known exposure to an active case. school personnel provided a measure of safety. The President of DEMOGRAPHICS AND PUBLIC HEALTH the Board of Health reflected: Newark’s vigilant Health Officer, “While we may be foolish if we Charles V. Craster (see Figure 1), close all the schools, we may be ordered a six-week quarantine for criminal if we don’t.” Health and affected households. Failure or inability education officials agreed to close the lower grades.7 to comply with the quarantine protocol led to forced removal of the patient to Some New Jersey towns an isolation hospital. Most families adopted a siege mentality toward acquiesced, although some defied Newarkers. In July, Newark authorities. Placards with red lettering began issuing health certificates warned, “Keep Out–This house to children under age 16 in anticcontains a case of infantile paralysis.”3 ipation of travel, although such The heaviest tolls occurred in certificates could not identify crowded wards with large immigrant healthy carriers or pre-clinical populations. However, the middle infection. Some localities arbitrarily and upper classes were not spared. banned Newarkers altogether.8 Among the victims were the daughter Charles V. Craster, MD, Newark Health of a member of the Newark Board of DIAGNOSIS Officer. From New Jersey and Its Builders, ca. 1925, NJ: New Jersey Biographical Health and the young adult son of a Thomas N. Gray, official City Association. Rutgers University Special physician in neighboring Bloomfield.4 Diagnostician, assisted family Collections and University Archives. To limit exposure in crowded physicians in diagnosing uncertain

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FIGURE 2

erected 18- by 100-foot shacks housed an additional 100 11 cases. When the Newark quota was filled, officials scrambled to open an isolation ward at Newark City Hospital. An unoccupied wing was quickly furnished with cots and staffed with nurses. In August, with scores of new cases daily, an additional 300 cribs were shoehorned into existing wards and the solarium. Recruiting nurses proved difficult, 12 despite Craster’s appeal to women’s courage and patriotism. Parental presence on isolation wards was forbidden. On August 14, 3,500 family members crowded onto the City Hospital lawn to wave to children held up to windows by nurses (see Figure 2). “As the children feebly waved, great tears, emotion that had long been pent up, broke forth,” reported the Evening News.13

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Newark Evening News headline: “When Anxious Parents are Permitted a Glimpse of their Afflicted Babies at City Hospital.” August 14, 1916. Photographic Collection, Newark Public Library.

cases.9 Cloudy spinal fluid with white cells and elevated protein was supportive but not diagnostic. Physicians recognized a spectrum of clinical syndromes, including “abortive” meningitis-like illness without paralysis, spinal paralytic poliomyelitis and bulbar poliomyelitis with its “ghastly respirations.” Newark City Hospital pathologist Harrison Martland performed more than 30 autopsies in rapidly fatal bulbar cases. A lengthy carrier state of six to eight weeks, often with negligible symptoms, stymied public health efforts.10

ISOLATION HOSPITALS Essex County Isolation Hospital in bordering Belleville admitted affected patients from across the county. (Newark’s private hospitals did not accept “contagious” cases.) When wards overflowed, two hastily

City Hospital physician Daniel Elliott and his staff treated 580 inpatients. He tartly summarized his opinion of available therapies: urotropin (urinary antiseptic: “worthless”), quinine (“no apparent effect”), salvarsan and neosalvarsan (antisyphilitic arsenicals: “all… died”), intraspinal adrenalin (“distinct harm in many”), sodium salicylate and iodine preparations (“no apparent benefit”), diphtheria antitoxin (“no apparent result”) and intraspinal immune or healthy blood serum (“no apparent result”). Rest was paramount in the acute stage. Morphine and bromides calmed some patients. Lumbar puncture seemed to relieve irritability and headaches.14 Understandably, people turned to folk remedies. Some Newark children wore bags of gum camphor around their necks.15 The occasional huckster appeared to fill the therapeutic vacuum. Homeopath Eugene Witte of Trenton arrived in Newark promoting his secret nostrum that “regenerates the blood…giving it power of resistance to combat disease.” Witte claimed success treating a number of Newark children.16

AFTER-CARE: THE CITIZENS’ HEALTH COMMITTEE A lasting legacy of the 1916 epidemic was the extragovernmental Citizens’ Health Committee, formed to “take up the work at the point where quarantine was lifted.” Pediatrician Coit, who foresaw “a multitude of paralyzed children… an appalling mass of helpless cripples,” became the tireless guiding force behind the rehabilitation program. The project was funded by a $25,000 public subscription campaign managed through the Evening News17 (see Figure 3).

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FIGURE 3

During post-quarantine home visits, THE PRESS AND THE PUBLIC The Evening News, Sunday Call nurses assessed indigent cases in and the German-language Freie need of after-care and made referrals Zeitung reported public health to reopened public and private orthoactivities and the grim daily or pedic clinics. The clinics functioned as weekly statistics. Their reportage clearinghouses for parent education, conveyed a sense of bustling in-hospital rehabilitation, home-care competence by health officials. nursing and donations of braces, all Working together and sometimes at coordinated by Coit’s committee. odds, multiple Newark constituenOver several months, the committee cies interacted with public health investigated some 1,000 cases–a “small 18 officials throughout the epidemic lame army” in newspaper parlance. Rehabilitative modalities included (see Figure 4). As health officials massage, strengthening exercises, invoked extra-judicial powers, a free the use of splints and casts, press and a vocal citizenry kept hydrotherapy and electrical stimulathe abridgement of citizens’ rights tion of paralyzed muscles. A minority under constant scrutiny. Editorial cartoon appeal for donations of children underwent orthopedic to fund braces. From Newark Evening surgery to improve function, stabilize CONCLUSION News, August 16, 1916. Microfilm joints or reduce deformity. The Newark poliomyelitis epicollection, Newark Public Library. Coit, not in robust health, toiled demic of a century ago has faded through the summer, attending to every detail of the after-care from memory. Although the American physicians who work. Perhaps overtaxed, he died in March 1917 at age 62.19 fought through the polio summers of the 1940s and 1950s have passed on, many who are now in practice remember FIGURE 4 friends and siblings who fell victim to the virus–and the pervasive fears of their own parents. Older readers will also recall the introduction of the seemingly miraculous Salk vaccine, which gave back the stolen summers of childhood. With few exceptions, today’s young physicians have never seen a case of polio; they know the disease only through the threat posed by incomplete vaccination rates in the United States, initiatives for global eradication stymied by terrorist attacks on vaccinators and the cruel ravages of post-polio syndrome in older patients. Newark’s visceral and public health responses to the 1916 epidemic provide insight into our remarkably similar responses to new threats such as SARS and Ebola. Diseases like diphtheria and scarlet fever–and now Zika–that cruelly affect children have a unique ability to terrify. As in 1916, public health officials are forced to make urgent and critical decisions with limited information. Like Craster in Newark, they hope for the best and prepare for the worst. Editorial cartoon depicting joint public and private fight Sandra Moss, MD, a retired general internist, against poliomyelitis. From Newark Evening News, August practiced in New Brunswick, served on the teaching 16, 1916. Microfilm collection, Newark Public Library. faculty at St. Peter's Medical Center, and is past

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President of the Medical History Society of New Jersey and the American Osler Society. 1

Craster, C. V. (1917, May 26). Poliomyelitis: Some features in city prevalence. Journal of the American Medical Association, 68, 1535–1540. Note: In 95 endemic cases reported from Newark between 1910 and 1915, mortality was 4 percent. Sends warning of children’s danger. (1916, July 1). Newark Evening News, p. 6; Deadly paralysis kills child here. (1916, July 5). Newark Evening News, p. 1; Diagram showing chart of local paralysis outbreak. (1916, August 12). Newark Evening News, p. 1; Paralysis gains eight new cases, three more die. (1916, July 14). Newark Evening News, pp. 1, 5; Craster, C. V. (1917, May 26). Craster, C. V. (1917). Administrative control of poliomyelitis in Newark 1916. Transactions of the Seventh Annual Meeting of the American Association for the Study and Prevention of Infant Mortality: Milwaukee, October 19–21, 1916. 8, 187–191; Drastic course by health department ends in fiasco. (1916, September 1). Newark Evening News, pp. 1, 8; Deadly paralysis kills child here. (1916, July 5). Craster, C. V. (1917, May 26); Health board member’s child among new paralysis cases. (1916, September 25). Newark Evening News, p. 20; Overbrook physician’s son dies of paralysis scourge. (1916, August 25). Newark Evening News, p. 4. Craster, C. V. (1917); Think force of epidemic is on wane. (1916, August 20). Newark Sunday Call, p. 6; Dr. Coit would combat paralysis by keeping children under experts’ eyes. (1916, July 27). Newark Evening News, p. 2.

Precautions give hope of no epidemic. (1916, July 9). Newark Sunday Call, pp. 1, 4; New city cases 31; death list is 10. (1916, August 28). Newark Evening News, p. 5; Troubled job has rival in circus. (1916, July 14). Evening News, p. 5; Ban is taken off playgrounds here. (1916, September 13). Newark Evening News, p. 3.

Cool spell hits spread of disease. (1916, July 16). Newark Sunday Call, pp. 1, 10; Health and school boards to act at special meetings. (1916, July 14). Newark Evening News, p. 5; Close all grades under the fifth in public schools. (1916, July 19). Newark Evening News, pp. 1, 9.

Craster, C. V. (1917); Bowen, D. C. (1917). Report of the Bureau of Local Health Administration: Poliomyelitis. In Fortieth annual report of the Department of Health of the State of New Jersey, 1916 (pp. 43–61). Trenton, NJ: State Gazette; Think force of epidemic is on wane. (1916, August 10).

Hunt, A. C. (1917). Report of the Bureau of Medical Supervision, 1916. In: Fortieth annual report of the Department of Health of the State of New Jersey, 1916 (pp. 39–41). Trenton, NJ: State Gazette; Gray, T. N. (1916, August). Anterior poliomyelitis. Journal of the Medical Society of New Jersey, 13, 430–431.

Osler, W. (posthumous), & McCrae, T. (1920). The principles and practice of medicine (9th rev. ed.; pp. 940–941). New York, NY: Appleton; Elliott, D. (1917, January). Poliomyelitis. Journal of the Medical Society of New Jersey, 14, 5–8; Infantile paralysis (acute anterior poliomyelitis, atrophic spinal paralysis). (1916, July). Public Health News (New Jersey),1, 271–277. Note: The first iron lung was more than a decade away, so there was no means of respiratory support.

Cool spell hits spread of disease. (1916, July 16); Craster, C.V. (1917); Asks volunteers to nurse victims of child scourge. (1916, August 5). Newark Evening News, p. 5.

Craster, C. V. (1917); Asks volunteers to nurse victims of child scourge. (1916, August 5).

Crowd hospital lawn for look at their loved ones: Joy and grief as parents get glimpse of afflicted tots at windows; some too ill to leave beds. (1916, August 14). Newark Evening News, p. 8.

Elliott, D. (1917, January).

Precautions give hope of no epidemic. (1916, July 9).

Paralysis gains eight new cases: Three more die. (1916, July 14); Credits Dr. Witte with child’s cure. (1916, September 6). Newark Evening News, p. 10.

Coit, H. L. (1917). The Newark plan for the after-care of victims of infantile paralysis: Its organization and practical working. Transactions of the Seventh Annual Meeting of the American Association for the Study and Prevention of Infant Mortality: Milwaukee, October 19–21, 1916, 8, 192–196; Ready response to citizens’ plan in paralysis war. (1916, August 8). Newark Evening News, p. 1; Paralysis relief arousing citizens. (1916, August 9). Newark Evening News, pp. 1, 8.

Small lame army now under care. (1916, October 10). Newark Evening News, p. 9; Believe 500 may need after-care. (1916, September 6). Newark Evening News, p. 1.

Dr. Henry L. Coit dead; ill one day. (1917, March 13). Newark Evening News, p. 1.

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THE DANGERS OF CONCUSSIONS IN YOUNG ATHLETES: An Interview with John Shumko, MD By Steve Adubato, PhD Steve Adubato, PhD, Emmy Award-winning anchor on Thirteen/WNET (PBS) and NJTV (PBS), interviewed John Shumko, MD, Medical Director of Sports Injury and Assessment at the Matthew J. Morahan III Health Assessment Center for Athletes at RWJBarnabas Health in Livingston, New Jersey. Dr. Shumko talked about the dangers of concussions in young athletes and about legislation that would require students who have suffered concussions to follow certain health protocols before returning to school or active play. Adubato: It’s challenging to protect young athletes, particularly when it comes to concussions. What efforts are currently under way in the State Legislature in this regard? Shumko: There are two. One is a mandate and law for Return to Play under which an athlete who is suspected of having a concussion is removed from play and further assessed. The athlete goes through a process to make sure that the concussion recovers properly and that the athlete can then safely return to play. The second one is Return to Learn, which actually takes place before an athlete returns to full play and any activities. Return to Learn is important because we have to remember that a concussion is a pathophysiological condition; there’s nothing structural that we can see, but the chemical changes that occur in concussions cause cognitive deficits. It’s more of a functional than a structural type of problem. There can be functional deficits in cognition, difficulties in concentration, headaches and sensitivity to light and noise–all of which interfere with the athlete’s participation in school. It’s important to consider that, too, and return the athlete not only to play but also to school with accommodations and restrictions so that he or she is able to return safely and participate in school and not drop back and lose time. Adubato: Tell me about the Matthew J. Morahan Center at RWJBarnabas Health and explain why its concussion assessment process is so important for young athletes. Shumko: When my colleagues and I look at schools, we find that they meet state mandates, but only in the most

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minimal way possible. That’s why education of the parents, as well as education and yearly training of the athletic trainers, is important. They are the ones who identify the concussion and remove that athlete from play. At the Matthew J. Morahan Center, we go further. We can do the maximum of what can be done. For example, let’s say an athlete comes to the emergency room with a suspected concussion. The athletic trainer, the emergency room physician or the pediatrician may then send the child over to the Center. At that point, the athlete is assessed, knowing there’s no one test that can really detect a concussion; no MRIs, no scans, no blood work, as of yet, can do that because the injury is not structural–it is a chemical physiological imbalance in the brain so it needs a recovery period. The Center will apply certain tests, including cognitive tests, balance testing, number sequencing, cognitive computer testing, as well as vestibular or visual testing. Adubato: Can you see the effects of a concussion right away? Shumko: You can. The effects can be immediate, or they can occur minutes or even hours later. Usually, a concussion doesn’t have to include a loss of consciousness. Concussed athletes could be confused, they could have a headache, they could be sensitive to light, they could have a little bit of drowsiness or they could just not feel right. Not feeling right and not being aware of exactly what is going on means that there could be some retrograde or anterior-grade amnesia involved. Adubato: If a student-athlete comes back from a concussion too quickly, what can happen? Shumko: Returning to activity too soon is very dangerous. Up to the age of 23, we have developing brains, and so there doesn’t need to be a very serious head injury or hit

to the head after the first concussion (since the child would still be symptomatic from the first one) to cause a devastating type of condition known as second impact syndrome. In this case, there is increased blood volume into the brain. The brainstem will herniate, and this can incur death within minutes. It is very important to identify the concussion, treat it appropriately and give it the time that is necessary so these kinds of things don’t happen. Even though these conditions are rare, they still can happen. Adubato: Do concussions occur more often in some sports than in others? Shumko: In girls’ sports, we see more concussions in soccer, mainly because of the way the player is going for the ball, looking down at the ball and colliding. In boys, the most concussions occur in wrestling because of impact into the ground, the contusion and the way the bodies move. Remember that you do not have to get hit in the head to get a concussion. The skull, which is created to protect the brain because it has a gelatin-like structure, encases the brain with a bony structure. When a body gets hit (that could be a very forceful hit to the face or the upper body) or the body goes down and hits almost like a whiplash, the brain gets jolted inside that case and bounces off the skull,

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becoming concussed. At that point, chemical imbalance and physiological change occur, and the changes in function that are a consequence of that become apparent. So, you don’t have to be playing a sport in which you get hit in the head, necessarily, to suffer a concussion. Adubato: What is your advice to parents who want to protect their children? Shumko: If you want to protect your kids, get educated. Listen to your kid; you know your kids the best, so watch what they’re doing and how they’re behaving after a game. The incidents and rates of concussion are going up because it seems that athletic trainers are getting better educated and are more aware of the signs of concussions. I think it’s important not to take a risk. If there is any suspicion of a concussion, get that child out of the game and get a further assessment. In addition, parents can call the Matthew J. Morahan III Health Assessment Center for Athletes at RWJBarnabas Health and ask about concussion screenings that are periodically available. 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.

MDADVANTAGE MOCK TRIAL: A CONTINUING EDUCATION PROGRAM FOR MDADVANTAGE PHYSICIANS, PRACTICE MANAGERS & TRIAL ATTORNEYS Join us for a unique, firsthand glimpse inside the courtroom as we present our annual mock trial. Friday, March 17, 2017 The Crowne Plaza, Plainsboro Twp, NJ Register online at www.MDAdvantageonline.com or call us at 888-355-5551.

Scan the QR code to view a short video clip from the 2016 MDAdvantage Mock Trial.

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TOP TIPS FOR PHYSICIANS:

Understand the Importance of Coding and Billing Accuracy By Nancy Clark, CPC, COC, CPB, CPMA, CPC-I The healthcare environment continues to challenge and even confuse practitioners. One of the most complicated areas causing this confusion is coding and billing. Although physicians know that it is important to document correctly for the services billed, they may not have an understanding of the areas that are currently being reviewed. In this article, we look at the priorities going into 2017.

USE PROACTIVE REVIEWS AND EDUCATION TO ENSURE COMPLIANT DOCUMENTATION.

Carriers are becoming increasingly aggressive in auditing medical claims. Their initial request for one chart quickly becomes 20 charts and then can escalate into hundreds of charts if they believe there are inaccuracies. Now is the time to protect your documentation from extended audits and your practice from losing previously earned revenue. Select random medical charts for review and then ensure that documentation follows national and any carrier-specific guidelines. Review Current Procedural Terminology (CPT) codes billed against the descriptors in the current CPT manual, as well as any applicable local or national coverage determinations (LCDs or NCDs). Medicare administrative contractors (MACs) offer insight into what the Comprehensive Error Rate Testing Program (CERT) is reviewing and where most discrepancies occur. Currently, most MACs are reviewing evaluation and management (E&M) coding in the office and hospital, prolonged services and critical care. In addition, be wary of appropriately coding minor procedures, such as injections, on the same day as an E&M service. The Centers for Medicare and Medicaid Services (CMS)1 list the most frequent areas of missed compliance and subsequent denied claims as insufficient documentation, medical necessity for the service, incorrect coding and no documentation submitted. If inaccuracies are found upon review, the provider and staff should be educated on the correct way to document. Often, simply a lack of knowing what is required causes insufficient documentation.

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UPDATE YOUR DIAGNOSIS CODING.

The ICD-10-CM diagnosis coding system was implemented in October 2015. In 2016, almost two thousand new codes were added. Most practices may believe they have gone through the initial change unscathed. With the exception of perhaps software and clearinghouse issues, many consider that the ICD-10 implementation was a success. However, CMS and many commercial carriers had a “transition flexibility” in place that has just ended. For the first year of claims, CMS did not allow their MACs to recoup payment on claims with certain errors when these claims were reviewed in retrospective audits. If the diagnosis code billed was in the same “family” of codes as the diagnosis supported in the medical record, then the claim could not be overturned upon review. For example, if a provider billed a diagnosis of “unspecified abdominal pain,” but the corresponding medical record indicated that the patient had “upper left quadrant abdominal pain,” then an audit would fail to reverse the claim payment. However, as of November 1, 2016, if this discrepancy is found in an audit, the payment can be taken back. The same principle applies if a specified code–such as upper left quadrant abdominal pain–is billed, and an unspecified code–unspecified abdominal pain–is supported in the documentation. Providers are responsible for ensuring that the codes billed are represented in the medical record. According to the CMS General Principles of Medical Record Documentation, 2 CPT and ICD-CM codes reported on the health insurance claim form should be supported by documentation in the medical record. Expect carriers to review medical records for CPT and ICD codes for many years to come.

“Carriers are becoming increasingly aggressive in auditing medical claims.”

KNOW WHAT TO DO IF YOU ARE AUDITED.

Before submitting any medical records, review the documentation to ensure that it reflects the correct date and place of service and is signed by the provider who billed the service. Review the coding to ensure that the documentation supports the codes billed. Ensure that all orders are documented in the medical record. The claim form should represent the information in the medical record. Remember: if it is not documented, it wasn’t done. Additionally, practices should contact their carrier to ensure appropriate understanding of the request and to indicate that they are responding. Providers should also review their liability coverage and reach out to their carrier to determine if any assistance with the audit is available. In some cases, especially those in which reimbursement is requested, practices should consider consulting a healthcare attorney. If there is not a certified professional coder on staff, consider consulting one to assist with understanding coding regulations and guidelines. Most importantly, make sure that the employee submitting the medical records reads and understands the documentation. It would not be in the practice’s best interest to allow someone with no clinical or coding background to perform this function.

PREPARE FOR MACRA.

Quality payment programs continue to be the source of additional revenue and negative penalties for providers. The Medicare Access and CHIP Reauthorization Act (MACRA) final rule was issued in October 2016 and identified two tracks of reporting: 1) Merit-based Incentive Payment System (MIPS) and 2) advanced payment models (APMs). Most practices will initially report with MIPS, which earns adjustments based on performance and affects physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse

anesthetists. In 2017, providers can choose to submit a minimum amount of data and receive a zero percent reduction in their 2019 reimbursement. This may be as simple as submitting one quality measure or otherwise testing the system. Failure to submit even this amount of data will result in a four percent negative adjustment to the 2019 reimbursement. Submitting a full year of data could result in a positive payment adjustment, and submitting even 90 days of data may result in a small reward. Very few providers will be exempt from reporting, limited to those who treat fewer than 100 patients or bill under $30,000 per year. APMs may allow for greater reimbursement than MIPS but also offer increased risk. Available models include Comprehensive Primary Care Plus, Next Generation ACO Model, Medicare Shared Savings Program tracks two and three and Comprehensive End-Stage Renal Disease Care.

UNDERSTAND THE IMPORTANCE OF PATIENT COLLECTIONS.

As healthcare changes, compared with previous years, a higher percentage of revenue is due from patients. Ensure that the patient’s insurance coverage is verified before each visit and that the copay is collected up front. While your patient is in the office, explain what his or her liability may be from the visit, such as deductibles or coinsurance. Send out statements promptly and correctly and follow up when needed. Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, is a healthcare consultant focusing on coding and documentation audits, as well as physician and staff education. 1

Centers for Medicare and Medicaid Services. (2016). Medicare fee-for-service 2015: Improper payments report. www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Medicare-FFS-Compliance-Programs/CERT/Downloads/MedicareFeeforService2015ImproperPaymentsReport.pdf.

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services. (2003). Change Request 2520 (CMS Pub. 60AB). www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/ab03037.pdf.

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ADVOCATING FOR CULTURAL COMPETENCY IN THE MEDICAL PROFESSION BUT TO ME, DIVERSITY EXTENDS FAR BEYOND THAT TO INCLUDE ASPECTS SUCH AS UPBRINGING, GEOGRAPHY, CAREER,

SEXUAL ORIENTATION , GENDER , SOCIOECONOMIC BACKGROUND,

EDUCATION AND SO MUCH MORE.

By Ronak Mistry, Emerging Medical Leaders Advisory Committee Member

As I reflect on my voyage through medical school thus far, I am amazed at how far I have come. With graduation on the horizon, the butterflies in my stomach are, to put it in scientific terms, too numerous to count. I have learned a lot and grown a lot as a medical student, and I am excited for what residency and my career may bring. Aside from the medical knowledge that I have acquired, particularly on my clinical rotations, what I have learned most about my profession is how to interact with my patients. I have developed the ability to sense cues, notice demeanor and identify tones in their voices. I have found ways to ensure that my patients feel comfortable around me. I had thought this would be easy, but I’ve learned that it is actually quite difficult. Our patients come from all walks of life, having had different upbringings and experiences up until the day they show up at the hospital or in my office. And each of these experiences contributes to who they are as a person. It is our job, as the physician, to connect with that individual. But how do we do that? One of the many projects that I have been involved in during my medical schooling has been to create awareness about “diversity.” We often limit our definition of this term to mean simply racial or ethnic diversity, namely, how people look or the languages they speak, the traditions they celebrate or the religions they practice. However, to me, diversity extends far beyond that to include aspects such as upbringing, geography, career, sexual orientation, gender, socioeconomic background, education and so much more. All of these factors play into one’s personal formation. There is no “one-size-fits-all” in our trade. Everyone is unique, and it is up to me, as a physician, to ensure that I am cognizant of these factors as I meet my patients and develop a rapport with them.

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In other words, I am advocating for a greater push towards cultural competency in the medical profession–a state in which we accept and understand another’s traditions without assuming that one’s ways of doing something are better than another’s. Now this sounds like a pretty hefty task. We are belabored by things like determining ICD-10 codes, reading journal articles regarding innovations in our fields and completing hours of administrative work. How on earth are we to have time to study culture in this way? Before you go online to order a program on cultural competency, I encourage you to open your eyes and look around at your colleagues. As medical professionals, we are surrounded by such a heterogeneous mix of physicians, nurses, therapists, ancillary staff and administrators. Medicine is rooted in science, which is rooted in human curiosity. Let us embrace this human curiosity to take time to ask questions, to listen and to learn. We will walk away feeling accomplished, and the effort will enhance our abilities to care for and understand our patients. As a student, I have been fortunate to receive an education at an institution that shares these values and fosters them in our community. I have also had the privilege of sharing my viewpoints and encouraging my peers across the country to think about their steps towards cultural competency. Now, as I take the next steps in my career, I look forward to bringing my experiences with me and to guiding others on their journey. Ronak Mistry is a medical student at Rowan University School of Osteopathic Medicine, Class of 2017, and a 2016 Edward J. Ill Excellence in Medicine Scholarship Recipient.

POV Point Of View

By R. Bruce Crelin, Esq.

The Effect of Hospital Mergers on Healthcare

Despite some opposition from the Federal Trade Commission (FTC) on antitrust grounds, two recent court cases indicate that the trend toward creating mega-hospitals may be changing direction. In the first case, the United States Court of Appeals for the Third Circuit reversed a decision of the United States District Court for the Middle District of Pennsylvania and blocked a proposed merger between the two largest hospitals in the Harrisburg, Pennsylvania areaâ&#x20AC;&#x201C;Penn State Hershey Medical Center and PinnacleHealth System.1 In the second case, in Federal Trade Commission v. Advocate Health Care Network, the United States Court of

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Appeals for the Seventh Circuit reversed an Order of the that market concentration and decreased competition have the potential to have a negative impact on treatment United States District Court for the Northern District of Illinois and patient care, as well as on physicians. The authors of that had denied the FTC’s injunction to block a merger between Chicago-area health systems Advocate Health Care Network the 2015 JAMA viewpoint point out that “[a]n important and NorthShore University HealthSystem, believing the Disaspect of competition is that hospitals compete to win trict Court’s geographic market finding to have been “clearly the favor of the public by marketing new models of 2 erroneous.” The merger had been stayed pending the appeal, health care. This marketplace facilitates innovation in 7 and the Seventh Circuit, leaving the stay of the merger in medicine that would be diminished without competition.” place, remanded the case to the District Court to reconsider The authors cite a systematic review of eight studies the injunction in light of the appellate court’s opinion. that concluded competition was associated with It is perhaps too early to make a prediction, but it is improved quality, particularly lower patient mortality.5 possible that these cases signal a new trend of greater The conclusion to be drawn from these studies is that scrutiny of hospital mergers and more active efforts by a lack of competition also means a decline in the the government to promote competition and to reduce quality of care. market concentrations in the hosAnother study found decreased pital arena. competition can also lead to However, the “bigger is better” increased utilization. In this 2012 It is believed that view of hospital reorganization in study, a survey of California hospimarket concentration New Jersey these days, unfortunately, tals over a 17-year period found indicates otherwise. For example, a 3.7 percent increase in bypass and decreased on June 21, 2016, a new entity surgeries and angioplasties and named Hackensack Meridian Health a 1.7 to 3.9 percent increase in competition have the was formed when the merger of patient mortality associated with potential to have a Hackensack University Health hospital mergers and the treatment Network and Meridian Health was of patients with heart disease.8 negative impact on finalized, creating the secondWith respect to effects upon treatment and patient care, largest hospital system in New Jersey, physicians, the authors of the “uniting 11 hospitals in seven 2015 JAMA viewpoint opined as well as counties from the New York border that concentrating market 3 to the Jersey shore.” In March power in large hospital systems on physicians. 2016, Barnabas Health and Robert could affect the care rendered Wood Johnson Health System by physicians, noting such manfinalized a merger creating RWJBarnabas Health, a system dates that physicians could use only hospital-approved that includes 11 hospitals, three children’s hospitals and a medications or surgical procedures to treat a given 4 behavioral health network. It is yet to be seen whether condition on a system-wide basis or must steer patients to these mergers will benefit healthcare in New Jersey. higher-profit services or procedures, without giving There are ample indications that they will not. patients full information regarding available alternatives.5

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POTENTIAL HAZARDS OF HOSPITAL CONSOLIDATION A viewpoint in the October 6, 2015, issue of the Journal of the American Medical Association (JAMA) points out some of the potential hazards of hospital consolidation.5 In a 2013 analysis of competition in 306 relevant geographic healthcare markets in the United States, based upon hospital referral regions, no market was found to be “highly competitive," and nearly half were “highly concentrated.”6 It is believed

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THE ECONOMIC IMPACT Hospital mergers also lead to hospital purchase of physician practices and the employment of physicians. In an article in Medical Economics, Scott Baltic discusses the effects of decreased competition on healthcare delivery.9 The author quotes Paul Ginsburg, PhD, President of the Center for Studying Health System Change (a non-partisan think tank that studies the healthcare industry) who

opined that “[h]ospital acquisition of physician practices leads to higher prices.” The author refers to an article in the Denver Post from May 2013 that reported on a patient who had two cardiac stress tests performed by the same cardiologist. The first test, performed in the physician’s office, cost approximately $2,100, while the second test, performed at a hospital, cost more than $8,000, largely due to the hospital’s facility fee. The author also cites a March 2013 report by the Medicare Payment Advisory Commission, an independent congressional panel that oversees Medicare, which found that reimbursement to a hospital’s outpatient department is typically at rates 80 percent higher than reimbursement rates for the same procedure performed in a physician’s office. Looking at only two services, echocardiograms and evaluation and management, the report found that Medicare paid hospitals $1.3 billion more in 2010 than they would have paid had those procedures been performed in physicians’ offices, and in 2011, that number rose to $1.5 billion. A June 2012 report by the Robert Wood Johnson Foundation’s Synthesis Project notes that the theory that economies of scale reduce healthcare costs has not been borne out, and in fact, procedures performed in hospitals are actually far more expensive than those performed in 10 physicians’ offices. This report, written by Martin Gaynor, PhD, of Carnegie Mellon University, and Robert Town, PhD, of the Wharton School at the University of Pennsylvania, found that hospital consolidation generally results in higher prices across geographic markets, often exceeding 20 percent when the merging hospitals are already in concentrated markets. IN CONCLUSION Studies attest that neither hospital mergers nor hospital acquisition of physician groups and employment of individual physicians are beneficial to physicians or to patient care and that these mergers result in an increase, rather than a decrease, in the cost of healthcare. These developments threaten physician autonomy and could potentially lead to the erosion of the physician–patient relationship. Unfortunately, the recent trend is to allow hospital mergers to go forward, resulting in greater concentrations of economic power and less competition, along with the negative consequences that flow from these conditions. Time will tell whether the Penn State Hershey Medical Center decision represents a departure from the pattern

of approval of hospital mergers or is simply a minor setback with no lasting effects. The outlook for the future is uncertain, but present indications and trends appear to be negative rather than positive. R. Bruce Crelin is a Partner in the healthcare law firm of Kern Augustine, P.C. in Bridgewater, New Jersey, focusing his practice on litigation. 1

Federal Trade Commission v. Penn State Hershey Medical Center, 838F.3d 327(3rd Cir. 2016). Note: The hospital systems have abandoned their integration efforts as a result of this decision. See Ellison, A. (2016, October 17). PinnacleHealth, Penn State Hershey call off merger: 6 things to know. Becker’s Healthcare. www.beckershospitalreview.com/hospital-transactions-and-valuation/pinnaclehealth-penn-state-hershey-call-off-merger-6things-to-know.html.

Federal Trade Commission v. Advocate Health Care Network, 841 F.3d 460 (7th Cir. 2016).

Livio, S. K. (2016, June 21). Latest NJ hospital mega-merger unites Hackensack, Meridian. NJ.com. www.nj.com/healthfit/index.ssf/2016/06/latest_hospital_megamerger_is_done.html.

Washburn, L. (2016, April 1). Barnabas Health, Robert Wood Johnson finalize merger. http://archive.northjersey.com/news/barnabas-health-robert-wood-johnsonfinalize-merger-1.1536186.

Xu, T., Wu, A. W., & Makary, M. A. (2015, October 6). The potential hazards of hospital consolidation: Implications for quality, access and price. Journal of American Medical Association, 314(13), 1337–1338. [Available at http://jamanetwork.com/journals/jama/article-abstract/2429159]

Cutler, D. M., & Morton, S. F. (2013, November 13). Hospitals, market share, and consolidation. Journal of the American Medical Association, 310(18), 1964–1970.

Xu, T., Wu, A. W., & Makary, M. A. (2015). 1337.

Hayford, T. B. (2012, June). The impact of hospital mergers on treatment intensity and health outcomes. Health Services Research Journal, 47(3,pt 1), 1008–1029.

Baltic, S. (2014, February 24). Monopolizing medicine: Why hospital consolidation may increase healthcare costs. Medical Economics. http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/hospital-employment/monopolizingmedicine-why-hospital-consolidation-?page=full.

Gaynor, M., & Town, R. (2012, June). The impact of hospital consolidation–Update. The Synthesis Project. www.rwjf.org/content/dam/farm/reports/issue_briefs/2012 /rwjf73261.

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