Michigan Medicine, Volume 115, No. 6 by Michigan State Medical Society

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November / December 2016 • Volume 115 • No. 6

LOOK BEYOND THE PRACTICE:

Combining Mental and Physical Health Care

ALSO IN THIS ISSUE 10 A New Tool to Help Physicians Get the Most Out of Their Health IT

18 Money Talks: Discussing Cost with Patients Before Treatment Is a Win-Win

22 2016 Presidential Election Investor Preparation Checklist

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November/December 2016 • Volume 115 • No. 6

COVER STORY

Chief Executive Officer JULIE L. NOVAK

Look Beyond the Practice: Combining Mental and Physical Health Care By Allie McLary for MSMS

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Postmaster: Address Changes Michigan Medicine Hannah Dingwell 120 West Saginaw Street, East Lansing, MI 48823 Michigan Medicine, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2016 it is published in January/February, March/April, May/June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA.

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P R E S I D E N T ’ S

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Taking On the Challenge of Integrating Physical and Mental Health Care BY DAVID KRHOVSKY, MD This issue of Michigan Medicine highlights one of the major challenges facing health care today and establishes a clear direction on what physicians and administrators can do to move toward a solution. The challenge? Providing quality health care to patients dealing with behavioral and mental health in coordination with their physical treatment.

hen addressing this issue, it’s important to be aware of how social determinants can affect the overall physical health of our patients, and how those determinants consequentially affect their mental and behavioral health. For example, how do food deserts, violent neighborhoods and lack of transportation affect our patients’ mental and physical health? And what are we, as physicians, doing to address all those challenges?

which can lead to destructive behavioral issues, has a powerful impact on our society as a whole as well as our individual patients.

When working with any mental health case that then leads to behavioral health problems, it’s important to understand the challenges in both patient care and staff safety. Patients with behavioral issues currently represent a challenge for hospitals and practices across the state. The number of these patients seems to be growing, and many physicians just don’t have the resources available to deal with them effectively.

Currently, our system of treating a patient’s mental and physical health as separate issues, feels disorganized and disjointed. It serves as a barrier to providing the high quality care we strive for and our goal in achieving the Quadruple Aim.

It is imperative to be considerate of the needs and safety of not only the patients, but the staff caring for them. Attending to those needs must be a cooperative effort involving physicians, nurses, patient families and, at times, security. It’s important to keep in mind that these patients need the care of specially-trained professionals who are experts and can best coordinate that care. While providing additional and quality health care in general isn’t the only answer, physicians must do their part to make that care available and convenient for the patients we are already treating for physical issues. The failure to treat mental health, 4

It is essential to keep this issue top of mind because of the unique challenges we face with behavioral patients. We are well aware of recent, well-publicized instances of violence where mental health has been a concern. There is widespread recognition that we, as a society, are not yet dealing with these issues effectively.

We can’t enhance the patient’s experience, improve population health, reduce costs and improve the work life of our health care providers if we aren’t treating the whole patient from the top down.

The bottom line is we can do more. Throughout the state physicians are spearheading initiatives to address this issue. From policies initiated by the Michigan Department of Health and Human Services, to grants provided by a variety of health operatives, physicians are taking action. An action that we continue to support is Patient-Centered Medical Homes, for their role in the care of patients with mental and behavioral issues. As the name implies, this delivery model places the patient squarely in the middle of a program of coordinated and comprehensive care, MICHIGAN MEDICINE

providing necessary care where and when patients need it and in a way they can understand – all through their primary care physician. PCMH enhances quality and safety, but most importantly, it provides greater access to a wide variety of services, including behavioral health professionals. These professionals can provide the kind of care that is so essential in successfully treating patients. If we can do all this while coordinating access through the patient’s own primary care provider, then we have taken a significant step forward.

To connect with those experts and move to a cooperative solution, physicians and administrators must look to their communities for support. How can we bring in those providing mental and behavioral health care outside of our practices and fuse their efforts with what we’re already doing, but in a cohesive and organized way? Our fellow physicians, health care policies and legislators are working toward this end – a cooperative and efficient process to care for our patients from the top down. I ask physicians to take stock of the resources around you, both in the practice and out in the community. How can we leverage existing resources to provide the kind of health care that treat the whole patient– body, mind and soul? Let’s continue to provide the most complete and high quality care we can possibly deliver. Doctor Krhovsky, a Grand Rapids anesthesiologist, is president of the Michigan State Medical Society

November / December 2016

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A S K

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L AW Y E R

Must I Disclose Psychotherapy Notes? BY DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL QUESTION:

ANSWER:

I am a psychiatrist and recently received a request for a copy of a patient’s medical records. The request came from a life insurance company and was accompanied by an authorization form signed by the patient directing me to send the copy to the life insurance company. It appears to me that the patient has applied for a life insurance policy and will not be able to complete the underwriting without my records. While I do not want to stand in the way of this patient obtaining insurance, I am hesitant to disclose the psychotherapy notes that are included in this patient’s medical record. Am I obligated to turn over the patient’s complete record? I thought that as a psychiatrist these notes were exempt from disclosure even under HIPAA.

Generally, under both HIPAA and Michigan law when the patient has provided a signed and valid HIPAA authorization form and pays the allowed charge for production of the copy you are required to provide a copy of the complete medical record to the party the patient has directed it be sent to. You are correct, however, that the law is different for psychotherapy notes. Unlike the other parts of the medical record, the law does not give patients a right of access to psychotherapy notes. You may decide to provide these notes to the patient or to a third party (but, in the case of third parties, only if you have received a valid authorization signed by the patient) but are not required to do so. “Psychotherapy notes are narrowly defined by HIPAA to include only: …notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and

If you decide to provide a copy of your psychotherapy notes to your patient’s insurance company (even though you are not obligated to do so) you must first make sure the authorization you have received is valid. In order for an authorization to be valid for use or disclosure of psychotherapy notes it must contain several statements required by HIPAA, including: • A specific description of the information to be disclosed; • The name or other specific identification of the person/entity the disclosure is being made to; • The name of the physician/practice making the disclosure; • The name or specific identification of the person/entity to whom the disclosure may be made; • A description of each purpose of the requested use or disclosure; • An expiration date or expiration event beyond which no further disclosures may be made; and • The signature of the patient giving the authorization. If you are going to make disclosure of psychotherapy notes the best practice is to have the authorization form reviewed by an experienced healthcare attorney to ensure that it contains all the required information.

frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis,

Daniel Schulte, JD, MSMS Legal Counsel, is a member of Kerr Russell Attorneys and Counselors

and progress to date.”

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M D H H S

U P D AT E

MDHHS Resources Can Help Ensure Your Patients are Fully Immunized BY STEFANIE COLE, RN, BSN, MPH, PEDIATRIC IMMUNIZATION NURSE EDUCATOR, MDHHS DIVISION OF IMMUNIZATION

aking sure all your patients are up-to-date on vaccines recommended by the Centers for Disease Control and Prevention (CDC) gives them the best protection available from many vaccine-preventable diseases and related complications. Patients trust their health care provider to advise them about important preventive measures. Research indicates that most patients are willing to get vaccinated if recommended by their provider1, 2. However, many patients report their healthcare providers are not talking with them about vaccines, missing critical opportunities to immunize3.

MICHIGAN MEDICINE

Understanding the complexities of the Advisory Committee on Immunization Practices (ACIP) vaccination recommendations is challenging. Routine recommendations versus recommendations for individuals at high risk, new vaccines being licensed, and frequent changes to the vaccination schedule make staying current on immunization information difficult. Luckily, the Michigan Department of Health and Human Services (MDHHS) Division of Immunization has numerous educational resources available to help vaccination providers. The Division of Immunization has two free educational programs designed specifically for health care personnel: the Physician Peer Education Project on Immunization (PPEPI) and the immunization update for office staff.

September / October 2016

Physician Peer Education Project on Immunization The Physician Peer Education Project on Immunization (PPEPI) is a program that is developed and administered jointly by the Michigan State University Extension and MDHHS. The PPEPI program travels across Michigan providing immunization education sessions to physicians and their staff at settings such as Grand Rounds, medical staff meetings, and conferences. These physician updates are presented by carefully selected physician trainers who strive to improve immunization rates in Michigan. The PPEPI program features updates on pediatric immunizations, adult immunizations, family medicine, vaccines for women’s health (OB/Gyn), influenza, vaccines for health care personnel, and human papillomavirus (HPV). Sessions include information on current vaccination recommendations, the Centers for Disease Control and Prevention (CDC) immunization schedules, burden of vaccine-preventable diseases, vaccine safety and effectiveness, and strategies to increase immunization rates. Continuing medical education credits are available for attending these sessions. For more information on PPEPI, including how to become a presenter or to schedule a session, contact MSU Extension at 517-3536674.

Immunization Update for Office Staff Immunization Nurse Educators (INE) from both MDHHS and local health departments provide this education to health care provider staff throughout Michigan. Registered nurses at the local health departments undergo training and complete requirements to get approved to teach these sessions in their counties. The education sessions are offered free to provider office staff, and continuing nursing education and continuing medical education credits are available. INE sessions cover immunizations recommended for infants and children, adolescents, and adults, influenza, vaccines across the lifespan (all ages), vaccine administration, vaccine storage and handling, Volume 115 • No. 6

and the Vaccines for Children (VFC) program. There is also a session on vaccinating women across the lifespan, which includes a focus on OB/Gyn and other issues that are specific to women. For more information on INE opportunities or to schedule a session for your staff, call Carlene Lockwood with MDHHS at 517-284-4884.

Other Resources In addition to these two educational programs for health care providers, MDHHS has educational documents and handouts available on its website at www.michigan. gov/immunize. These include Quick Looks for a number of vaccines. These one-page documents contain the key information that a vaccination provider might need to know on any given vaccine. Examples include “A Quick Look at Inactivated Influenza Vaccines” and “A Quick Look at Using Human Papillomavirus Vaccines (HPV).” MDHHS also has numerous vaccine administration and vaccine storage and handling guidance documents for health care providers. The Division of Immunization also updates its influenza vaccine educational resources annually. These can be found by going to www.michigan.gov/flu and clicking on Current Flu Season Vaccination Materials for Health Care Professionals. Another resource available to Michigan vaccination providers is the Alliance for Immunization in Michigan (AIM) coalition. Information regarding AIM can be found at www.aimtoolkit.org. AIM provides clinical and patient information regarding vaccines to promote immunizations across the lifespan. Local health departments (LHDs) are a great resource for questions and information on immunizations; be sure to use your LHD as a resource. The CDC website has an immunization section that covers information for health care personnel and parents/patients at www.cdc. gov/vaccines. Using the Michigan Care Improvement Registry (MCIR) can help ensure that providers have access to their patients’ immunization information that is upto-date and accurate. In Michigan, it is required by law that all immunizations, including flu vaccine, administered to MICHIGAN MEDICINE

children less than 20 years of age be documented in MCIR within 72 hours of vaccine administration. Documenting adults’ vaccinations in MCIR is also an immunization best practice. For more information regarding MCIR, go to www. mcir.org. Informational brochures about immunization topics are available free of charge from MDHHS, and can be ordered online at www.healthymichigan.com – click “Enter Site” and “Immunizations” to begin adding resources to your cart. In spring 2016, the AIM packets were added. AIM packets are available with focused materials for children, adolescents, and adults. The contents include the immunization schedules, brochures, posters, and other educational flyers and resources for your practice. Make it clear to your patients that vaccinations are important because it not only protects the person receiving the vaccine, but also helps prevent the spread of certain diseases, especially to those that are most vulnerable to serious complications, such as infants and young children, older adults, and those with weakened immune systems. By ensuring that all your patients are fully immunized, you will be helping to create healthier communities in Michigan. And remember, it is equally important for health care staff to be up-to-date on their own immunizations. After all, they are responsible for protecting their patients. For more information on immunization resources available in Michigan, please contact Stefanie Cole with MDHHS at coles4@michigan.gov or 517-284-4877.

REFERENCES 1 Ding H et al. Influenza Vaccination Coverage Among Pregnant Women — United States, 2014–15 Influenza Season. MMWR Morb Mortal Wkly Rep 2015; 64(36):1000-1005. 2 Malosh R et al. Factors Associated with Influenza Vaccine Receipt in Community Dwelling Adults and Their Children. Vaccine 2014; 32(16): 1841-1847. 3 Ylitalo KR et al. Health Care Provider Recommendation, Human Papillomavirus Vaccination, and Race/ Ethnicity in the US National Immunization Survey. Am J Public Health 2013; 103(1): 164-169. 9

H I T

CO R N E R

A New Tool to Help Physicians Get the Most Out of Their Health IT

n September, the Office of the National Coordinator of Health Information Technology (ONC) released an online tool to help physicians and other health care professionals maximize the value of their health information technology (health IT) investment. Recognizing the challenges that many users face getting health IT to work efficiently and effectively, the ONC’s Health IT Playbook is intended to help make using health IT easier for providers by answering many of the questions that arise during implementation and use.

The Playbook is designed to be intuitive and user-friendly so that physicians and other health care providers can easily access key information. Providing this information in a digital format allows users to easily navigate topics of interest such as: • Payment reform terms • EHR contracting • Health information exchange • Patient engagement • Privacy and security • Quality and safety

Check out the Health IT Playbook to find answers to the following questions and more:

According to the ONC, the Playbook utilizes a number of strategies, recommendations and best practices based upon implementation experience from a variety of clinical settings. Included are success stories about researching, buying, using, or switching health IT tools, including optimizing and tailoring them to specific practices or workflows.

• How can I activate and engage patients and their families?

• How do I choose, implement, or upgrade an electronic health record (EHR) system? • How do I redesign workflows to improve and optimize practice efficiency and effectiveness? • How can I connect and share information with other providers and public health officials?

• How do I learn more about improving patient outcomes and prepare for new quality payment programs? • How do I protect the confidentiality, integrity, and availability of personal health information in my EHR system?

Take Control: Password Security October’s designation as National Cyber Security Awareness Month reminded us of the need to be proactive in creating a safer online footprint. Although it seems like we have little to no control, we can all follow some basic protocols such as enabling stronger authentications for our sensitive online accounts, using due diligence before opening unfamiliar emails and clicking on links, and setting strong passwords. Below are some basic password security tips provided by various cyber security experts: • Pick strong passwords that are different for each site that stores sensitive information (e.g., banking, email, Amazon, Apple/iTunes, etc.) • Never use the same password on social media (e.g., Facebook) that you use elsewhere, especially for financial or “sensitive” sites • Try not to “reuse” passwords across sites

“Much of the design of the new Playbook is based on feedback and input gathered from practicing physicians, professional medical societies, federal partners and recommendations made by the Consumer Task Force of the Health IT Policy and Standards Committees.”

• Update your passwords regularly • Keep your passwords in a secret place that isn’t easily visible • Use a long password made up of numbers, letters and symbols • Try using a phrase that only you know • Avoid easily recognizable patterns (e.g., day/month combos)

Thomas A. Mason, MD, Chief Medical Officer, and Lauren Richie, MA, Director, Learning & Engagement Division, Office of Programs and Engagement, ONC

• Never share your passwords with anyone 10

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November / December 2016

While these tips seem straight-forward, you might be thinking—how important is it really to create strong and unique passwords?

One security expert revealed in a blog post that “a five-letter password has 10 billion possible combinations, that means it can be cracked in five seconds. Compare that to six characters (500 seconds), seven letters (13 hours), and eight characters (57 days).”

So, yes, creating a good password is very important! Following are some additional tips for creating a password that is easy to remember but difficult to guess:

• Use a combination of numbers, keyboard characters such as?!$%, and upper- and lower-case letters • Complex passphrases that string together random words are harder to crack (common phrases like “password” are NOT safe) • Longer passwords are harder to guess; use a minimum of 8 characters • Avoid using publicly available information like phone numbers or combinations like “12345678” or public details like hometown, pet or children’s names, college, employer, etc. EXAMPLE 1 – create an email password with a related phrase to help you remember it: “I like to read my emails once in the morning and once at night” becomes “Il2rme1itm&1@N”. EXAMPLE 2 – create a password using the first letters of the words in a favorite line of poetry or a verse of song: “Here comes the sun, and I say It’s all right” becomes “Hcts,&!s!ar”.

ONC Resources » Health IT Playbook https://www.healthit.gov/ playbook/

» EHR Contract Guide https://www.healthit.gov/sites/ default/files/EHR_Contracts_ Untangled.pdf

» Security Risk Assessment Tool https://www.healthit.gov/ providers-professionals/ security-risk-assessment-tool

» Patient Engagement Playbook https://www.healthit.gov/ playbook/pe/

Patients trust you. You can trust Kerr Russell. A successful practice requires more than talented individuals and a desire to heal. Let Kerr Russell provide the legal insight needed to manage and grow your business. ENTITY FORMATION • BUSINESS MATTERS • EMPLOYMENT CONTRACTS • PURCHASE / SALE OF OWNERSHIP INTERESTS • MALPRACTICE AND ALL OTHER COMMERCIAL LITIGATION • APPEALS • MEDICAL STAFF PRIVILEGE DISPUTES HOSPITAL RELATIONS RELATIONS MATTERS MATTERS •• HEALTHCARE HEALTHCARE FRAUD FRAUD DEFENSE DEFENSE •• LICENSING LICENSING AND HOSPITAL AND OTHER OTHER REGULATORY REGULATORY MATTERS MATTERS

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LOOK BEYOND THE PRACTICE:

Combining Mental and Physical Health Care In the world of health care, physicians are always striving to achieve the Institute for Healthcare Improvement’s Triple Aim – enhance patient experience, improve population health and reduce costs. But a large barrier to achieving those aims is the longstanding separation between the mental and physical health systems.

Studies show only 20 percent of adult patients with mental health disorders are seen by mental health specialists, which means a huge portion of the population isn’t getting the mental health care they need. By default, many mental health problems are managed in the primary care setting, emergency rooms, jails and prisons.

NTEGRATING PHYSICAL AND MENTAL HEALTH has long been a challenge for practices around the world, let alone across Michigan. But with both physicians and administrators coming together to share ideas, utilize community resources and introduce innovative policies, they’re facing the challenge head on.

“

…most behavioral health is actually delivered by primary care physicians,” says Doctor Monteith. “We need to figure out how to deliver behavioral health resources in the primary care setting.”

Why combine? “We’ve started the conversation to integrate physical and mental health care, but we’re still not there,” says Scott Monteith, MD, and president-elect of the Michigan Psychiatric Society. At MPS, Doctor Monteith envisions a future in which psychiatric physicians have the resources and professional support to provide Michigan patients with full access to outstanding psychiatric care. And that means working hand-in-hand with primary care physicians.

“We know, based on many sources including the study conducted by Jurgen Unutzer at the University of Washington, that most behavioral health is actually delivered by primary care physicians,” says Doctor Monteith. “We need to figure out how to deliver behavioral health resources in the primary care setting.” In fact, the study goes on to state that older adults prefer treatment of mental disorders in primary care, and when they are referred to mental health specialists, no more than

…physicians and administrators coming together to share ideas, utilize community resources and introduce innovative policies… Scott Montieth, MD President-elect, Michigan Psychiatric Society

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November / December 2016

half complete the referral to visit the specialist and seek treatment. While the study focuses on those enrolled in Medicaid, this issue of divided and unorganized care for both physical and mental health is one that spans the state. Many practices have added efforts like screening for common mental disorders and developing treatment guidelines, but these additions have yet to improve patient outcomes. According to the study, “As few as 20 percent of patients started on antidepressant medications in usual primary care, show substantial clinical improvements.” With statistics like these, it’s clear that integration is needed to treat patients and achieve better outcomes. Collaborative care – treating both the mental and physical health problems – is an evidence-based approach that requires more than what a primary care physician can offer alone.

How do we make this happen? “The key to making this collaboration of physician-led, team-based care possible, is leadership in the clinical infrastructure,” Doctor Montieth says. “But clinicians can’t do it alone. We need the support and partnership of policy makers and an administrative infrastructure.”

including psychiatry, medication management, psychotherapy, nursing services and case management. CNS assists consumers with managing their mental illness and gaining maximum independence toward self-worth and recovery. But it’s CNS’ collaboration with primary care physicians that impacts change in patients’ lives. While working in the same building as the Oakland Integrated Healthcare Network, Doctor Reid experienced the frustration of the blurred line separating physical and mental health. Among other issues, the two organizations have two separate electronic health records that do not communicate. When a patient is treated by a primary care physician and has lab work completed, CNS can’t electronically access their lab results or lists of medications and diagnoses for behavioral health services. Both organizations were hindered by a cumbersome paper-based process that did not always run smoothly.

Psychiatrists and primary care physicians work together

To address this issue, CNS pursued the Primary and Behavioral Healthcare Integration grant, provided by the Substance Abuse and Mental Health Services Administration. CNS and the Oakland Integrated Healthcare Network received support to provide communities access to coordinate and integrate primary care services into publicly funded, community-based behavioral health settings.

Enter Michele Reid, MD and chief medical officer at Community Network Services, Inc., a human services agency in Farmington Hills, Waterford, Pontiac, Southfield and Dearborn that provides comprehensive behavioral health services,

With this grant, CNS was able to create real results. The Integrated Care Team improved access to primary care services while also improving prevention, early identification and intervention to reduce the incidence of serious physical illnesses.

Michele Reid, MD Chief Medical Officer, Community Network Services, Inc.

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Debra Pinals, MD Medical Director of Behavioral Health and Forensic Programs, Michigan Department of Health and Human Services MICHIGAN MEDICINE

“

CNS and OIHN implemented a daily huddle where mental health and physical health providers meet to discuss the patients scheduled that day and the care management plans for each. “We took it back old school and actually talked to each other,” says Doctor Reid.

They were able to increase availability of integrated, holistic care for physical and behavioral disorders and improve overall health status of patients. The grant provides healthy cooking classes, exercise with a personal trainer and smoking cessation, to name a few. “CNS also worked with the Oakland Integrated Health Network to secure funding from the Oakland County Community Mental Health Authority, which allows us to place psychiatrists directly in the primary care clinics,” Doctor Reid says. “There they can train and teach residents about mental and behavioral health care management.” CNS and OIHN took this collaboration further by identifying the best way the mental health and physical health providers can work together. They implemented a daily huddle where they meet to discuss the patients scheduled that day and the care management plans for each. CONTINUED ON PAGE 14

Eden Wells, MD Chief Medical Executive Michigan Department of Health and Human Services

CONTINUED FROM PAGE 13

“We took it back old school and actually talked to each other,” says Doctor Reid. With all the resources in one room, they can address the thorny issues like access to health food, improved access to transportation, safety in neighborhoods and other social determinants that can lead to further mental and physical issues in their patients. At the same time, they are also getting the latest updates on their patient’s physical health through the primary care physician.

The State of Michigan steps in The idea of coordination of care isn’t new, and the Michigan Department of Health and Human Services (MDHHS) has been exploring ways to address this issue through various policies, particularly with Medicare and Medicaid. Debra Pinals, MD, and medical director of Behavioral Health and Forensic Programs at the MDHHS says, “In Michigan, the goal is to coordinate service delivery and leverage coverage opportunities with more focused coordination of services.” One way the state is moving in that direction is through the development of a program that addresses those dual enrolled in Medicare and Medicaid. With no central point for care coordination and a lack of an integrated individualized care plan, it was up to the practitioner and staff to coordinate with other service areas for these patients.

“

Debra Pinals, MD, and medical director of Behavioral Health and Forensic Programs at the MDHHS says, ‘In Michigan, the goal is to coordinate service delivery and leverage coverage opportunities with more focused coordination of services.”

MDHHS seized the opportunity to develop and implement an integrated care demonstration project to improve services for beneficiaries, making a person-centered model with a strong focus on care coordination, while at the same time making the system more efficient. “Our goal,” says Dick Miles, director of the Bureau of Medicaid Policy and Health System Innovation Medical Services Administration at MDHHS, “is to provide seamless access to all services and support with an efficient administrative process, eliminating barriers to home and community-based services, focusing on enrollee satisfaction and realignment of financial incentives.” One initiative MDHHS is working on is MI Health Link, a health care option for Michigan adults, ages 21 and older, who are enrolled in both Medicaid and Medicare and live in the counties of Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, Macomb, St. Joseph, Van Buren, Wayne or any county in the Upper Peninsula. The program offers a broad range of medical and behavioral health services, pharmacy, home and community-based services, all in a coordinated effort designed to meet individual needs. “The key point here is coordination and the implementation of a person-centered approach to service delivery,” Doctor Pinals says. A well-established integration concept that serves as an example is the Patient-Centered Medical Home, which we know takes the burden off the patient and provides an opportunity for care to be coordinated across specialties, helping to manage the patient as a whole person. “We are increasingly aware of how one condition impacts another,” Doctor Pinals said. “For example, a patient’s asthma or diabetes may impact mood or anxiety symptoms and vice versa. Patients experience complexities of the system and need an easier approach to care.” Through PCMH, physical and behavioral needs can be addressed together.

MICHIGAN MEDICINE

“

“Mental health is interwoven with physical health very tightly,” says Eden Wells, MD, chief medical executive of MDHHS. “One should not be addressed independent of another.”

Moving forward and making change Programs and initiatives like MI Health Link and Patient-Centered Medical Homes are geared toward one goal: Providing patients easier access to resources in simultaneous treatment of both mental and physical health. “Mental health is interwoven with physical health very tightly,” says Eden Wells, MD, chief medical executive of MDHHS. “One should not be addressed independent of another. That’s why it is essential to utilize these new resources while also identifying services in your own community that can be integrated in to what is already offered.” Primary care physicians must explore resources in their own community, identifying local mental and behavioral specialists that may be a good fit for collaborative care. Physicians must also take the time to gain an understanding of their patients’ wishes in their total care. Without full support, patients with behavioral or mental challenges may face health care needs they’re unable to overcome. It’s through utilizing community and professional partnerships that primary care physicians and mental health specialists can work to make the integration of health care a success. While there is still a long way to go in providing patients with a truly integrated care model addressing both their physical and mental needs, physicians and administrators are working toward a common goal. Treating the whole patient, from the mental to the physical needs, will help physicians down the path of achieving the Quadruple Aim.

November / December 2016

Welcome New MSMS Members! Stephanie Croy, DO Calhoun

Christopher Greve, MD Kalamazoo

Sayeeda Fatima, MD Oakland

Tareq Kamal, MD Saginaw

Laura Reese, MD Washtenaw

Peter Miller, MD Eaton

Brandon Tanner, MD Kalamazoo

Julie Ferris, MD Oakland

Ankita Kapoor, MD Saginaw

Emad Abu Sitta, MD Genesee

Daniel Bergner, MD Kent

George Miguel, DO Oakland

Sharanjit Khaira, MD Saginaw

Christopher Sanker DDS, MD Washtenaw

Ahmed Akl, MD Genesee

Katherine Burton, MD Kent

Wendy Miller , MD Oakland

Aaron Lawrence, DO Saginaw

Samer Al Hadidi, MD Genesee

Sara Herman, MD Kent

William Rhoades, MD Oakland

Gurtej Mann, MD Saginaw

Maath (Maadh) Alani, MD Wayne

Ahmed Arif, MD Genesee

Samantha Nuffer, MD Kent

Tom Rifai, MD Oakland

Mary McKuen, MD Saginaw

Dunya Atisha, MD Wayne

Arul Chandran, MD Genesee

Robin O’Meara, MD Kent

Kimberly Rockwell, MD Oakland

Phoo Pwint Nandar, MD Saginaw

Peter Barkett, MD Wayne

Sierra Cuthpert, DO Genesee

Peter Sices, MD Kent

Carl Shermetaro, DO, FAOCO Oakland

Elizabeth Pagler, MD Saginaw

Ranjith Dodla, MD Genesee

Jeffrey Stevens, DO Kent

Joshua Smith, MD Oakland

Angadbir Parmar, MD Saginaw

Pedro Bauza (Feliciano), MD Wayne

Gunjal Garg, MD Genesee

Amy Strikwerda, MD Kent

Tracy Snell, DO Oakland

Paul Pastolero, MD Saginaw

Melissa Keller, MD Genesee

Avantika Varma, MD Kent

Richard Howell, MD Ottawa

Allison Perkins, MD Saginaw

Alexey Levashkevich, MD Genesee

Mark Bergin, MD Macomb

Rita Agayby Ghobrial, MD Saginaw

Eric Pitts, DO Saginaw

Zhanna Levashkevich, MD Genesee

Kirk Cleland, MD Macomb

Mohamed Aljefri, MD Saginaw

Pallavi Rath, MD Saginaw

Corinne Brown-Robinson, MD Wayne

Han Li, MD Genesee

David Cox, MD Macomb

Saleh Alotaibi, MD Saginaw

Jennifer Romeu, MD Saginaw

Victor Coba, MD Wayne

Matthew Mead, MD Genesee

Todd Francis, MD Macomb

Gretchen E.R. Augustine, DO Triptpal Sanghera , MD Saginaw Saginaw

Abdul Mohammed, MD Genesee

Nathan Hamburger, MD Macomb

Shafia Beg, MD Saginaw

Stacey Sharp, MD Saginaw

Tahir Hasan, MD Wayne

James Raccuia, MD Genesee

Jessica Langevin, MD Macomb

Abhishek Bhandiwad, MD Saginaw

Sukhmanpreet Singh, MD Saginaw

Hazem Hawasli, MD Wayne

Gwendolyn Reyes, MD Genesee

Arifa Malik, MD Macomb

Glen Bunn, Jr., MD Saginaw

Aron Slear, MD Saginaw

David Hazel, MD Wayne

Tahereh Soleimani, MD Genesee

Nicholas Schoch, DO Macomb

Madline Chembola, MD Saginaw

Asma Taj, MD Saginaw

Haamid Syed, MD Genesee

Angela Stoian, DO Macomb

Ryan Cox, MD Saginaw

Carrie Valdez, MD Saginaw

Hussaini Hina Syeda, MD Wayne

Kristoffer Wong, DO Genesee

Faye Zuhairy, MD Macomb

Robert Dumas, MD Saginaw

Katy Van Donselaar, DO Saginaw

Gianina Cazan-London, MD Monica Dhar, MD Midland Ingham

Karensa Franklin, MD Saginaw

Kelly Tanceusz, DO St Clair

Laith Cebe, MD Jackson

Brandon King, MD Muskegon

Andrew Goodrich, DO Saginaw

Hyuk ''Brian'' Cha, MD Washtenaw

Steven Dalton, DO, MPH Jackson

Jessica Phelps, MD Muskegon

Joy Hart, MD Saginaw

Anthony Fasi DDS, MD Washtenaw

Whitney Hoffman, DO Jackson

Tyler Voss, DO Muskegon

Thomas Henry, MD Saginaw

Kara Huls, MD Washtenaw

Bradford Berndt, MD Kalamazoo

Nicole Budrys, MD Oakland

Matthew Holden, MD Saginaw

Maher Kefi, MD Washtenaw

Matthew Engel, MD Kalamazoo

Laura Corrigan, MD Oakland

Furhut Janssen, DO Saginaw

Whitney Kiebel, MD Washtenaw

Volume 115 • No. 6

Ahmad Abou Abbass, MD Wayne

Jessica Bensenhaver, MD Wayne

OBITUARIES The members of the Michigan State Medical Society remember with respect their colleague who has died.

Jason Bihn, MD Wayne Lindsay Boik-price, DO Wayne

Celestine M. Joseph, MD Genesee County Medical Society Died August 31, 2016

Denise Gray, MD, FACR Wayne

Judy Indrakumaran, MD Wayne Thomas Keimig, MD Wayne

w To make a gift or bequest to the MSMS Foundation, please contact:

Kanika Khanna, MD Wayne

Rebecca Blake, Director

Michael Lewis, MD Wayne

517-336-5729

Gary Loyd, MD Wayne

rblake@msms.org

Shari Maxwell, MD Wayne

MICHIGAN MEDICINE

2016 Education Offerings ON-DEMAND WEBINARS

Visit www.msms.org/eo for complete listing of On-Demand Webinars.  Physician Executive Development Programs: • Health Care Law for Physicians in ACOs • Medicaid Issues and Trends: Outlook for 2014 and Beyond • In Search of Joy in Practice: Innovations in Patient Centered Care • From Physician to Physician Leader • Inter-Professionalism: Cultivating Collaboration • Financial Information Analysis, Budget Development and Monitoring  Choosing Wisely  Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction  CDL-Medical Examiner Course  Legalities and Practicalities of HIT including: • Cyber Security: Issues & Liability Coverage • Engaging Patients on Their Own Turf: Using Websites and Social Media  Summary of the Affordable Care Act  HIPAA Security Rule  End of Life Concerns and Considerations  What’s New in Labor and Employment Law  Preparing for the Medicare Physician Value-Based Payment Modifier  Understanding and Preventing Identity Theft in Your Practice

EDUCATIONAL CONFERENCES

For more information or to register online please visit www.msms.org/eo or call the MSMS Registrar at 517-336-7581.

20TH CONFERENCE ON BIOETHICS

Continental breakfast & lunch provided Date: Sat., November 12 Time: 9:00 am to 4:30 pm Location: Sheraton Ann Arbor Hotel, Ann Arbor Intended for: Physicians, bioethicists, residents, students, other health care professionals, and all individuals interested in bioethical issues Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

PRACTICAL GUIDANCE FOR HEALTH CARE COMPLIANCE Lunch provided Date: Thursday, December 8 Time: 10:00 am – 3:00 pm Location: MSMS Headquarters, East Lansing Intended for: Physicians, PO Administrators, practice consultants, office administrators, students, other health care professionals. Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

ANNUAL JOSEPH S. MOORE, MD, CONFERENCE ON MATERNAL AND PERINATAL HEALTH Continental breakfast & lunch provided Date: Thursday, May 18 Time: 9:00 am - 4:15 pm Location: Somerset Inn, Troy Intended for: Physicians, nurses, residents, students, and all other health care professionals working with women and their infants. Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

 Stepping Up to Stage 2

SPRING SCIENTIFIC MEETING

 Physician On-line Rating and Reviews: Do’s and Don’ts

Continental breakfast & lunch provided Date: Thursday, May 18 and Friday, May 19 Location: Somerset Inn, Troy Intended for: Physicians and all other health care professionals Note: Morning, afternoon and evening clinical courses available Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.o

 Patient Portals as a Tool for Patient Engagement  Health Care Providers’ Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities  Opioids & Michigan Workers’ Compensation

BILLING AND CODING COURSES For all Billing and Coding courses, contact: Stacie Saylor at 517-336-5722 or ssaylor@ msms.org

CARE MANAGEMENT

Date: Thursday, December 8 Time: 9:00 am - 12:00 pm Location: MSMS Headquarters, East Lansing Intended for: Physicians, billers coders, and billing managers.

COMPLETE CODING UPDATES FOR 2016 Date: Thursday, December 8 Time: 1:00 - 4:00 pm Location: MSMS Headquarters, East Lansing Intended for: Physicians, billers coders, and billing manager.

MSMS/MMBA BILLING WEBINAR SERIES

On the third Wednesday of each month at Noon Medicare Updates 2017 - Billing and Coding Webinar Wednesday, November 30 MSMS Legal Alerts Wednesday, December 21

PAST BILLING WEBINARS AVAILABLE ON-DEMAND:

Compliance ICD-10 for 2017 & Routine Waiver of Co-pays ICD-10 Credentialing Billing 101 Managing Accounts Receivable Understanding the Remittance Advice Tips and Tricks on Working Rejections Claim Appeals

MSMS LUNCH-N-LEARN Grab a lunch, click the link, and join us! • The Importance of Medical Documentation Wednesday, November 9 • Human Trafficking Part 2: What to look for in Patients and Other Guidelines for Physicians Wednesday, December 7

For more information and to register: www.msms.org/Education/ UpcomingWebinars.aspx

MICHIGAN MICHIGAN MEDICINE MEDICINE

November / December 2016 16

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T H E

D O C TO R S

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Money Talks: Discussing Cost with Patients Before Treatment Is a Win-Win BY RALPH A. GAMBARELLA, MD CHAIRMAN AND PRESIDENT, KERLAN-JOBE ORTHOPAEDIC CLINIC

“My knee still hurts after surgery, and I’m getting all these bills to pay that I didn’t know about.” I thought it was going to be another typical day at my practice, but I found myself comforting an upset and frustrated patient who was still having a hard time returning to golf three months after having an arthroscopic medial menisectomy. “What had I done wrong?” I asked myself.

“Mr. Jones” had made an appointment to see me after twisting his knee trying to kick a soccer ball around with his grandson. He was 62 years old and already had been treated by his primary care physician with medicine and therapy but had remained symptomatic with a torn medial meniscus on MRI. He was miserable because he had not been able to play golf and couldn’t even keep up with his wife on their evening walks. He was overweight, with a varus knee and early osteoarthritis on weight-bearing x-rays and MRI. Of course, his internist and friends had told him that he needed an arthroscopic surgery and after that he would be all better. Despite counseling him that he might still have knee pain after a meniscectomy due to the underlying arthritis, we agreed that an arthroscopic surgery was in his best interest to try to improve his lifestyle. We discussed all the medical and surgical risks and postoperative rehabilitation program. I connected him to my surgery scheduling team after carefully and clearly explaining his medical diagnosis and treatment. I thought I had done a good job—but I was wrong. I had neglected to make sure he had been advised of all the growing financial obligations that our patients face today. When the pain didn’t resolve completely after surgery—and Mr. Jones was receiving bills he hadn’t expected—I had an unhappy patient.

Miscommunication Can Lead to Claims Patient-physician miscommunication issues such as this one play a large role in contributing to malpractice claims. The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, has studied thousands of closed claims in various specialties and found that poor communication between the provider and the patient or the patient’s family is one of the key factors behind lawsuits. This issue contributes to 12 percent of cases for hospitalists and orthope18

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November / December 2016

dists and 14 percent of cases for obstetricians and emergency medicine providers.

Five Steps to Ensure Financial Disclosure

A key component of good communication with patients is a discussion about financial obligations for the medical services provided. Good communication up front can help, especially if a surgical outcome or treatment does not lead to a perfect outcome.

STEP 1

Increasing numbers of physicians are joining large medical groups with a business manager or becoming hospital employees, which typically decreases their involvement with the business portion of healthcare. Most major medical insurance companies continue to sell policies with varying deductibles, co-payments, and complex rules. Unfortunately, these factors have led to an increasing disconnect between the patient and the physician when it comes to discussing financial obligations. The physician needs to be involved in making sure that the patient is informed and educated about the financial burden of surgical and medical treatments. Doing this before proceeding with treatment can help lower the risk of a malpractice claim even when the medical outcome doesn’t meet the patient’s expectations. Understanding the financial commitment up front allows patients to make a more informed decision for care. It is incumbent upon the physician to work with his or her entire office and, where applicable, the surgery center team to provide patients with both the medical and financial information they need to make an informed decision prior to an elective surgery or other medical treatment. By paying attention to both the medical and financial details, we are more likely to have happier patients, physicians, and surgery centers. Realistic medical and financial expectations discussed prior to elective surgery or other medical treatment can result in better efficiency, better outcomes, and less litigation. Volume 115 • No. 6

In our office, we have established a series of steps for our patients once the patient has decided to proceed with elective surgery. These steps can be adjusted for non-surgical specialties. At the time of the office visit, the office staff provides the patient with a surgical information packet that includes a direct telephone number to the physician’s care coordinator (PCC). The staff tells the patient to contact the PCC once he or she has decided to proceed with surgery.

STEP 2 The patient and physician also complete three forms with information that a staff member then enters into our electronic medical record: Surgery procedure form, completed by the physician with the appropriate CPT and ICD-10 codes. Anesthesia medical questionnaire form, completed by the patient. Durable medical equipment (DME) form, completed by the physician.

STEP 3 If the patient then contacts the PCC to proceed with surgery: The PCC contacts the insurance provider. If precertification is required, the office notes this and sends other data (MRIs, etc.) to the provider to authorize. The PCC then confirms the provider authorization.

STEP 4 Once the insurance provider has certified surgery, the PCC will contact the patient to schedule a surgery date and ensure that, if needed, the patient will obtain an appropriate medical clearance by their primary care physician (or a local physician to whom the patient is referred if the patient does not have a primary care physician). The physician must complete the clearance by the time of the preoperative office visit. The type of medical clearance required, if any, is determined by the criteria set by the anesthesia medical questionnaire form.

STEP 5 The PCC then sends the correct surgical date, CPT codes, and ICD-10 codes to: Office financial advisor: This advisor will discuss the patient’s insurance plan, deductible, and co-pay; establish the surgeon’s fee based on the expected procedure; and require a patient deposit at the time of the preoperative office visit. The deposit amount is designed to minimize the need for patient refunds due to overpayment post surgery. Surgery center: The surgery date will be set and the surgery center financial advisor will contact the patient and discuss the patient’s insurance plan, deductible, and co-pay; establish the facility and anesthesia fees based on the expected procedure; and require another patient deposit prior to the date of surgery. DME company: A private DME company will contact the patient and discuss payment costs and options for the DME requested by the physician. Contributed by The Doctors Company. Dr. Gambardella is a member of The Doctors Company’s Orthopedic Advisory Board. For more patient safety articles and practice tips, please visit www.thedoctors.com/patientsafety.

MICHIGAN MEDICINE

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M A R K E T P L A C E

Would You Like To Place A Classified Ad? The rate for classified advertising in Michigan Medicine, including both print and online versions, is $1.60 per word, with a minimum of $65.00. All ads must be prepaid. Text for classified advertisements and advertising fees should be received no later than the first of the month proceeding the month of publication. All submitted ads must be typed. No handwritten or dictated ads will be accepted.

To place an ad, please call Carl Mischka at 888-666-1491 or email carl@mischka.us.

Working Together With You to Maximize the Financial Health of Your Practice Services Tailored to Your Specific Needs: • Full Billing Services • Credentialing Services • Business Planning • Electronic Health Records

• Accounts Receivable Recovery Services • New Practice Start-Up • Flexible Practice Management Software Options

All Medical Specialties Welcome PH: 248-478-5234 • FAX: 248-478-5307 www.elitemedicalbill.com We Are Your Medical Reimbursement Specialists 20

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November / December 2016

Primary Care Practices n Southfield/Oak Park Area Internist

Long Established Practice sees 40 per day, 5 days (9-5) and yes it is making BIG money, GOOD insurance mix. This practice could be financed with little down due to the CASH FLOW. You are a Doctor? Have reasonable credit? This well controlled business can be yours and I can show you how! Call Joe 248-240-2141.

n Warren Area Primary Care/ Internist

Doctor office in Professional Building of Hospital. LONG term patients, lots of Medicare and Blues. Solid five days a week practice grossing over $600K, 1 MD and two MA assistants. Work in the hospital could only increase your revenue in 2 ways. Asking $219,200 and worth it.

n 30+ years Royal Oak Family Practice

Over 1.2 million gross. Five days a week, 8a to 4p, great insurance mix; great patient mix. Virtually no HMO out of 8,000+ active patients. Aprox. 10% Pediatrics. One hired Physician will stay, owner to transition. Takes 2-3 to best handle the practice. Real Estate with tenants available as well. Nice facility, parking, and neighborhood. Add evening or weekend hours, HMO insurances or Specialists to increase revenues. Call for more details.

n Internal Medicine Practice in Jackson

Long Established $ 500K gross solid Medicare practice in 2700+ sq.ft. building with large parking lot. Patients are by appointment, no opiate seekers. Room for 2 or more Physicians. Hospital follow up offers increased revenues. Asking $124,000 Real Estate offered with flexible terms including Land Contract.

n Drastic Price Reduction on Family Practice, East Side

I now have offer a Family Practice and Building for less than the Building alone may be worth if you are Primary Care, have association with St. John Hospital, want your own office, and don’t have a lot to spend!

HOT Lease Deals! n Pontiac: Large professional medical building. Three story, 500-5,000 sq. ft. suites. Across from hospital, acres of parking. VERY REASONABLE rates/terms or buy building for $250,000.

n West Side Detroit: 8,000 square feet, multi suites, fully leased. $60,000 positive cash flow excellent. Brick, single story asking $500,000 or lease for $1.00 square foot plus utilities.

For more details contact our practice specialist at Union Realty:

Joe Zrenchik, Broker 248-240-2141 (cell) • 734-808-0147 (eFax) joezrenchik@yahoo.com 248-919-0037 (office) www.michiganmedicalpractices.com Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.

Volume 115 • No. 6

MICHIGAN MEDICINE

2016 Presidential Election Investor Preparation Checklist BY JIM NIEDZINSKI, AIF®

Investors around the world are concerned about the uncertain outcome of the 2016 election— perhaps more so than ever before.

1. Confirm the risk level of your portfolio

Who will become president? What policies will be implemented?

Use this opportunity to rebalance the mix of investments back to the original targets. If you’re not certain the target mix is still appropriate, ask your advisor to review it with you.

Perhaps you inherited shares of a stock several years ago… or you have vested stock options you haven’t yet exercised…or company stock that has built up in your retirement plan. With the stock market at all-time highs, now is a good time to review these holdings and consider trimming your exposure.

4. Prepare for anticipated withdrawals

Wise cash management strategies are designed to extend the life of a portfolio by aiming to avoid selling stocks in a down market to fund withdrawals. Even if you aren’t quite ready to start taking withdrawals, we advise preparations to begin several years in advance. Contact your advisor to discuss how smart cash management strategies can help you accomplish your goals. MICHIGAN MEDICINE

Every investor should have a reserve of cash. The classic rule of thumb is to maintain a reserve of between 3-9 months of essential living expenses, though the appropriate amount depends on your situation. Now may be an opportune time to review and shore up your cash reserve to your target amount.

6. Change the channel

3. Address concentrated holdings

What CAN you control? Of course you can vote, and if you have strong convictions, you can support the campaign of your chosen candidate. You can also clarify and strengthen your financial position. We offer the following seven-point checklist to help you prepare for whatever the outcome may be of the election this November 8th...

2. Rebalance your accounts

How will the economy and markets react? The answers to these questions matter, but they aren’t issues over which you have control.

Contact your advisor to assure the risk level of your portfolio continues to fit your financial plan, objectives and tolerance for volatility.

5. Replenish your emergency cash reserve

Buy this, sell that. The market is going to crash. No, it is going to soar. The mainstream financial media makes their money by gathering an audience, not by consistently and prudently stewarding capital. For your own sanity, don’t be their audience.

7. Maintain perspective

It can be easy to lose the forest for the trees. Refresh your shortterm perspective with a long-term view and consider the chart below illustrating the U.S. stock market since 1900.

Having completed this checklist you can feel confident that you’ve addressed what is under your control and wisely prepared for the unknown.

Jim Niedzinski, AIF®, is an advisor at WealthCare Advisors, LLC – an MSMS joint venture.

November / December 2016

Volume 115 â&#x20AC;¢ No. 6

MICHIGAN MEDICINE

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MICHIGAN MEDICINE

November / December 2016