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PRESIDENT'S MESSAGE Summers have always taken me back home
PAFP member wins award for MAT work
PAFP physicians make PAMED's 'Under 40' list
Congratulations, FMIG Program of Excellence Award winners
Now Accepting Applications for PAFP Leadership Positions
ACGME award-winners: Q-and-A
FEATURES COVER STORY Each year, the AAFP National Conference draws together young health care professionals from around the country. This year’s annual gathering resulted in the unexpected reunion of two third-year residents who forged a close friendship in U.S. Army Special Forces training and then separated by different deployments.
New CMS program capitalizes on direct primary care
National Conference ‘an incredible opportunity’ for LECOM student Hannah Smouse, fourth-year med student, LECOM Seton Hill
National Conference event coverage - photo recap
AAFP National Conference reunites long-lost ‘brothers in arms’
FALL 2018 VOLUME 78 | NUMBER 3
GOVERNMENT AFFAIRS PCMH and Pennsylvania Medicaid Value-Based Purchasing (VPB)
LEGAL AND COMPLIANCE UPDATE
Medical necessity fraud false claims case reinstated
$200 million JUA raid found unconstitutional by federal court
PRACTIVE MANAGEMENT Be aware of these most common HIPAA violations
COMMON EDUCATION Online CME Catalog
PRESIDENT'S MESSAGE DAVID O'GUREK, MD, President firstname.lastname@example.org
Summers have always taken me back home ummers have always taken me back home. For as long as I can remember, July has been about preparation for our annual church festival. For those unfamiliar with the coal regions of Northeastern Pennsylvania, weekends in the summer are planned around which festival is which weekend. As a kid, it was about the excitement of the games and rides, and then it became about hosting friends for a great weekend in our little town of Summit Hill. Over the years, it has become an experience to take time away from work, leaving Philadelphia for small town life, to give back to the roots that fostered me, setting up concession stands, running electricity, hooking up stoves, and disassembling everything in one morning that it took us a week to set up. Despite heavy rains that invaded the weekend, our community came together, worked together, and celebrated together. In essence, we showed up â€“ and that made me think of you.
tors, committed to advancing the health of their patients and their communities. When our incoming and current residents were facing struggles over the new licensure system in the state, it was quite easy to explain the significant impact it would have on patients and communities if these individuals did not get their licenses on time, and our engagement with the Department of State was a positive one.
Understanding and living the challenges of practice, I share in your woes of the everincreasing administrative burdens that hassle our practices. Spending time in Harrisburg to address our advocacy efforts, I am delighted to represent such a fantastic group of doc-
It certainly does not go unnoticed. Advocacy around the patient-centered medical home (PCMH) brought me to Harrisburg recently to meet with deputy secretaries in the Department of Human Services. Due to the impact of our PCMH legislation several years ago creating the
Our work on prior authorization reform and your willingness to engage in our survey provided a significant contribution to necessary information the state needed to move forward in this effort. While the PAFP celebrates this effort that placed us as a leader in this initiative in the state, I must acknowledge that it is because of your efforts and your participation that we were able to do so. Time and time again, for your patients, for your communities, and for your Academy, you show up.
PCMH Advisory Council in the state, the department was able to advance efforts to support primary care through value-based payments and alternative payment models with funding for these efforts increasing. Furthermore, the state is looking to advance their efforts to support the medical neighborhood and ensure that the social determinants of health are considered in advancing health through appropriate payment models. Such direction moves health care delivery closer to the model that we know is necessary for the patients we serve,
and therefore family medicine will indeed stand at the forefront of these efforts as an already established leader in this arena. The summer also brings exciting opportunities and growth for our students and residents. A new cadre of residents joins the ranks of our outstanding family medicine residency programs, taking that giant leap to the next stage of their careers in family medicine. As the new academic year starts for our medical schools, our FMIGs remain active to engage existing and brand-new students to show them the passion and commitment that is family medicine. Notably, our students and residents recently
descended upon Kansas City, Mo., for the AAFPâ€™s National Conference of Family Medicine Residents and Students. These students attended with scholarships through the generosity of many of you and your recognition of the value of this incredible experience that fosters our young leaders into the specialty and the wonderful adventures that a career in family medicine holds. I remain in awe of the phenomenal work that our students and are residents are doing in their programs, in their communities, and in the specialty. And so, I hope you will take the time to reflect on the important work that you are doing that certainly inspires me and makes me proud to stand as the president of this Academy. Our year ahead will be a busy one: continuing our advocacy efforts around administrative burden, payment reforms, nurse practitioner independence, direct primary care, and the opioid crisis, as well as key opportunities to build bridges and work together with other physician and public health organizations to advance the health of our populations. Our Academy should mirror the great work you are doing within your communities and we will be embarking on strategic planning to move us into the next few years. As I know you will continue to inspire, create, and lead, I hope to cross paths with you on my travels and at our upcoming CME opportunities. In my own reflections, it is clearly your work and consistent showing up that makes this Academy home to me: like I said, summers have always taken me back home. WWW.PAFP.COM
MEMBER NEWS THE LATEST NEWS AND INFORMATION FOR PAFP MEMBERS For more, visit: www.pafp.com
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PAFP member wins award for MAT work
PAFP physicians make PAMED's 'Under 40' list
Jonathan Han, MD of the UPMC St. Margaret Family Medicine Residency Program has received Mental Health Americaâ€™s Education Award for Innovations 2018 for his work in medication-assisted therapy (MAT) by Mental Health America of Southwestern PA. Dr. Han is pictured below (center), flanked by (left to right) Brittany Sphar, MD, who helped start the residencyâ€™s naloxone program; Sanketh Proddutur, MD; Nil Das, MD; and Jim Mercuri who all led the way initiating MAT. Congratulations, Dr. Han!
Five PAFP members have been honored on the Pennsylvania Medical Society's (PAMED) "Top Physicians Under 40" list, which celebrates young physicians and included 19 medical specialties this year. Congratulations to Todd Felix, MD; Andrew Lutzkanin, MD; Klara Roman, MD; Lydia Travnik, DO; and Valerie Vilbert, DO, representing family medicine on this list!
Congratulations, FMIG Program of Excellence Award winners Congratulations to award-winning resident and faculty PAFP members! Malina Lim and Jennifer Joyce, MD (Geisinger Commonwealth) and Elise Pearson, Sarah Minney, and Dan Lincoln, MD (University of Pittsburgh) have received FMIG Program of Excellence Awards. For more than 10 years, the AAFP Family Medicine Interest Group (FMIG) Network has recognized FMIGs with the Program of Excellence Award for their efforts to stimulate student interest in family medicine and family medicine programming. Way to go!
Primary care opportunities
Now Accepting Applications for PAFP Leadership Positions Deadline: December 31, 2018 The Pennsylvania Academy of Family Physicians is currently seeking applicants to serve in various leadership positions. PAFP board and committee members serve as the infrastructure of the Academy, developing policy and making decisions that keep the organization at the forefront of the specialty. This is an opportunity to use your individual talents and unique perspective to help guide the PAFP into the future. Nominations are needed for President-Elect, Director At-Large, AAFP Delegate, AAFP Alternate Delegate, and Foundation President. All applications are welcome but positions are open based on availability. To apply for a leadership position, complete the simple online application. For questions regarding nominations, contact John Jordan, CAE, PAFP Executive Vice President and CEO, at 1 (800) 648-5623 or email@example.com.
Geisinger is seeking experienced and newly graduated providers to join our growing primary care team throughout central, south-central and northeast Pennsylvania. Geisinger’s primary care model Access and quality care are top strategic priorities for Geisinger. Team members from all areas collaborate to continually improve and produce best-in-nation outcomes and experience for both patients and providers with a focus on: • Patient appointments: Twenty-minute appointments for routine visits and 45-minute appointments for our elderly patient population (age 65+) • Daily huddles: With all care team members to review schedules, patients, resource needs and coordination of care. • Support staff: Including nursing, clinical staff, clerical staff, pharmacists, care managers, health managers, clinic health associates and coding educators • Electronic health record: Epic, our fully integrated system • Teaching opportunities: Training the next generation of physicians, advanced practitioners, nurses and other healthcare professionals Incentives: • Competitive compensation: Base salary model • Loan repayment: Many sites qualify for the Pennsylvania State Loan Repayment Program • Visa sponsorship available: H1b and limited J1 • Benefits: Comprehensive medical/retirement benefits effective day 1 • Medical malpractice: Claims made with tail coverage • Relocation: No dollar limit to move normal household goods, paid house-hunting trip, temporary storage and more • CME: Paid CME days and funds for CME activities
Instructions: Complete the online application and submit your curriculum vitae to John Jordan at firstname.lastname@example.org. Nominations for leadership positions may also be received at the March 8, 2019 Annual Meeting.
AP P LY H E R E
For more information, visit GeisingerJobs.org/community-medicine or contact: Tammy Bonawitz: email@example.com or 570-214-4777 Miranda Grace: firstname.lastname@example.org or 717-899-0131
AAFP Award for Excellence in GME winners: Q-and-A wo PAFP resident members, Christian Bengtson, MD and Nayeli Spahr, MD have received the AAFP's Award for Excellence in Graduate Medical Education. This prestigious distinction is awarded to only 12 of 3,500 eligible family medicine residents; according to the AAFP, it recognizes â€œoutstanding family medicine residents for leadership, civic involvement, exemplary patient care, and aptitude for and interest in family medicine since 1952.â€? We talked to Dr. Bengtson and Dr. Spahr about receiving this award, how they embody the qualities the award seeks to recognize, and what they love about family medicine.
C H R I ST I A N B E N GTS O N , M D - YO R K ing residents and physicians that modeled the qualities of dedication, service, and commitment to family medicine and their communities, and they have inspired me through my journey into family medicine. I find this award to be a recognition of those individuals and of my wife, Natasha, who have all supported me through medical school and residency.
What does winning this award mean to you, and how did you feel when you were awarded this recognition? I was very humbled to hear that I had received this award. Many very impressive individuals have gained this recognition, including some of our amazing faculty, who I look up to. Since medical school and through residency, I have had the opportunity to work with outstand10
This distinction has been given to family medicine residents for 66 years, since 1952. Where would you like to see family medicine in 66 years, in the year 2084? In the year 2084, I hope to see family medicine continuing to take the lead across all fields by enacting change in medicine and advocating for those with the fewest resources. I would like to see specialists seeking out family physicians as guides to coordinate multidisciplinary care in the inpatient and outpatient setting. I am confident we will see family physicians becom-
ing even more prominent leaders in their communities, government, and in medicine.
munity. All of these driving forces circle back to refuel my desire to provide the best possible care for my patients.
The award encompasses leadership, civic involvement, exemplary patient care, and aptitude for and interest in family medicine. How do you display these qualities?
Itâ€™s the easiest question to ask and the hardest one to answer: why do you enjoy being a family physician?
I think when you are doing the things that you love, many of these qualities come naturally. My passion for my patients across all walks of life sparked my love for family medicine. My love for family medicine drove my interest in leadership positions with the PAFP and AAFP, which in turn sparked my involvement with my com-
The best part about being a family physician is that I can care for underserved populations; particularly Latino families in York, Pennsylvania. I get the opportunity to care for individuals across all stages of life â€“ from welcoming a new family member to being able to participate with families in their transition to the end of life.
N AY E L I S PA H R, M D - U N I V E RS I T Y O F P E N N SY LVA N I A work alone. I happened to have a mentor that encouraged me to apply, but truthfully, I feel that am surrounded by individuals who also exhibit the qualities that the award is meant to highlight. These individuals and relationships challenge me daily to provide excellent primary care and to be a true physician leader.
What does winning this award mean to you, and how did you feel when you were awarded this recognition? Surprised! But humbled and honored. None of the work and accomplishments are my
All in all, I am honored to receive the award more as a reflection of the exemplary mentorship, encouragement, support, and resilience of the individuals (especially my family) and the institutions that have invested in my higher education. As a Mexican immigrant who grew up with a single mother working two full time jobs, I am indebted and grateful on the one hand, but emboldened on the other hand to improve upon this current state of affairs, knowing that there has to be a better way. WWW.PAFP.COM
MEMBER NEWS This distinction has been given to family medicine residents for 66 years, since 1952. Where would you like to see family medicine in 66 years, in the year 2084? I see more and more students interested in family medicine and other primary care specialties, even coming from institutions that have been slower to acknowledge the value and clinical acumen necessary to provide great primary care. I would like to see family medicine play a larger role in shaping the future of medicine â€“ it's inherent in our practice to be a unifying force given that we are combined internal medicine, pediatrics, obstetrics and gynecology, psychiatry and geriatrics. Primary care is the cornerstone of good medicine to promote health and healing. We will move to create practice models that allow us to better take care of both the patient and the population. I also want the physician workforce as a whole to be more reflective of the demographics of the populations we serve. The award encompasses leadership, civic involvement, exemplary patient care, and aptitude for and interest in family medicine. How do you display these qualities? As physicians, whether we accept the challenge or not, we are granted the privilege of being listened to - by patients, by community leaders, by politicians. And, as family physicians, we care for individuals throughout the lifecourse. We see how structural violence brought on by racial and economic discrimi12
Building community is really important â€“ with my patients, my peers, my neighbors. We all take care of each other. And together, we figure out what we need to do to improve how we live, work and play. â€” Nayeli Spahr, MD
nation impacts our patients as children, as young adults and beyond. We also see how social isolation influences health and how human connections are vital to our ability to heal and maintain health. The work that I do outside of clinical care is just as important as what I do in an office visit. Therefore, part of being a family physician to me is attending community dinners and meetings, making signs and marching, calling government officials about unfair policies affecting patients, and coming up with creative ways to address health disparities. I am currently working with my co-residents to develop an advocacy curriculum for the residency program as well as strengthening the role of our Diversity Taskforce to increase the
presence of underrepresented minorities in medicine at Penn. I try to mentor students who reach out with interests to address health inequities, to promote interest in family medicine and primary care, and to do self-care. My co-residents and I spend spare time at Puentes de Salud providing care to a primarily Spanish-speaking immigrant population. Building community is really important – with my patients, my peers, my neighbors. We all take care of each other. And together, we figure out what we need to do to improve how we live, work and play. It’s the easiest question to ask and the hardest one to answer: why do you enjoy being a family physician? It is a privilege to be able to provide a safe space for my patients to discuss every stage of life. I get to bear witness to all of the stages as I help bring life into the world and am present for its departure. I get to discuss parenthood, health, illness, death. I love the continuous education that I receive from patients as I learn how to best care for them and their needs throughout their different stages. I love taking care of patients through pregnancies, delivering babies, taking care of children and teenagers and I love working with my adult patients all along the gender spectrum to optimize their health and quality of life. I could not imagine giving any part of that up – family medicine allows me to do it all.
We’re growing in Philadelphia
Join our winning team & unique care model. We’re excited to announce our expansion in Philadelphia with opportunities for Primary Care Physicians and Geriatricians. Over the last 25-plus years, we’ve grown exponentially, and continue to do so. Today, we operate 50-plus medical practices in seven states throughout the southeast, midwest, and in Philadelphia. We’re a family-owned, physician-led group of primary and specialty care practices providing healthcare services to the nation’s neediest, most vulnerable patients – seniors. Find out why we’re different, why our physicians are valued and highly rewarded for quality of care for their patients.
OUR PHYSICIANS ENJOY: Physician-led culture
Low patient panels
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Discover the difference a Dedicated career can offer. For more information, contact Susan Ginn (786) 753-2960 email@example.com WinningPhysicians.com
PAFP LEADERSHIP INSTITUTE Providing members with the skills to be influential community leaders and advocates of family medicine
As a family physician, you are already a leader in your office and practice - and you may also be a leader in your family, your community, the organizations youâ€™re a part of. But are you ready and willing to take your leadership skills and abilities further? The PAFP is pleased to announce the creation of the PAFP Leadership Institute: providing members with the skills to be influential community leaders and advocates of family medicine. The Institute launches this fall with a live session in tandem with the Nemacolin CME Conference. Future live and online events are scheduled through spring of 2019. You can register today for one, a few, or all of these excellent events.
UPCOMING PAFP LEADERSHIP INSTITUTE EVENTS Nemacolin Leadership Session (Live Event) - November 2, 2018 Leadership Webinar #1 (Online Event) - January 22, 2019 Gettysburg Leadership Session (Live Event) - March 9, 2019 Leadership Webinar #2 (Online Event) - May 7, 2019
Register for one or all of the events today!
learn more about the PAFP Leadership Institute at
www.pafp.com/leadership 14 | KEYSTONE PHYSICIAN | FALL 2018
Family Medicine Opportunities in Southeastern PA Tower Health Medical Group, a non-profit affiliate of Tower Health, is seeking boardcertified/board-eligible Family Medicine Primary Care physicians to join our community and provide medical services in the general care and treatment of patients in an existing outpatient practices in SE Pennsylvania.
Tower Health Medical Group is a physician network with 2,000 physicians, specialists and providers across 75 convenient locations. We offer leading-edge, compassionate healthcare and wellness services to a population of 2.5 million people.
Tower Health Medical Group Opportunity Locations: •
Berks County: • Chester County: - Birdsboro - Downingtown - Kenhorst - Exton - Kutztown - Oxford - Wyomissing - West Grove
Montgomery County: - Norristown
Tower Health is a strong, regional, integrated healthcare provider/ payer system that offers leading-edge, compassionate healthcare and wellness services to a population of 2.5 million people. With 11,000 team members, Tower Health includes six acute-care hospitals: •Reading Hospital, a teaching hospital based in West Reading •Brandywine Hospital in Coatesville •Chestnut Hill Hospital, a teaching hospital in Philadelphia •Jennersville Hospital in West Grove •Phoenixville Hospital in Phoenixville •Pottstown Hospital in Pottstown Tower Health also includes: •Reading Hospital Rehabilitation at Wyomissing •Reading Hospital School of Health Sciences •All Tower Health facilities participate in our provider-payer plan, Tower Health/UPMC Health Plan
We offer: • Competitive salary • Comprehensive benefits, including health, • • • • • • • •
professional liability and disability insurance Generous time-off allowance Educational Loan Assistance Relocation assistance CME stipend Occurrence-based malpractice insurance 403(b) and 457(b) retirement plans H1-B and Green Card support Supportive health system to advance goals For additional information contact: Tameka Pizarro, Medical Staff Recruiter 484-628-4523 Tameka.Pizarro@towerhealth.org www.towerhealth.org careers.towerhealth.org
Equal opportunity employer.
FEATURE IN-DEPTH COVERAGE ON TOPICS THAT MATTER MOST TO YOU Join the discussion on this topic and others at PAFP Connect
New CMS program capitalizes on direct primary care he Centers for Medicare & Medicaid Services (CMS) is seeking broad input on socalled direct provider contracting between payers and primary care or multi-specialty groups. In effect, this effort endeavors to include components of direct primary care, or DPC, within Medicare’s fee-for-service program. But is this true direct primary care? The DPC Alliance, an organization that provides leadership and guidance to the community of direct primary care providers, has voiced its concerns over this model in a letter to CMS. The DPC Alliance says it is already achieving the objectives of CMS’s Direct Provider Contracting model without external incentives or directives by “freeing ourselves from many of the burdens associated with the traditional complexities of third-party billing.” The group also respectfully requested that CMS rename its program, as the new terminology of “Direct Provider Contracting” mirrors the abbreviation associated with direct primary care, along with other appeals that CMS “create a program with a truly innovative approach 16
built around direct payment from beneficiaries” and address the optout status of existing DPC providers. “DPC has as its hallmark an enduring and trusting relaChris Lupold, MD tionship between a patient and a primary care physician that evades the current reactive health care system that often fails to prioritize health,” said PAFP President David O’Gurek, MD about the CMS model. “Introducing the complexity of contracting and metrics pulls attention away from the direct care that DPC physicians seek to provide and fails to acknowledge the basic tenets of this alternative payment model.” PAFP Board of Directors member Chris Lupold, MD has been practicing under a direct primary care model since October of 2017. He’s enthusiastic about the new opportunities the model has afforded him.
I think a lot of the concern, from what’s come out so far, is the potential to lose the ‘direct’ part of ‘direct primary care,’ where CMS will put themselves between the patient and the family physician — Chris Lupold, MD “This first year has gone very well,” he said. “Well-received in the community, and we continue to grow. It’s just been, personally and professionally, a joy to have made the change.” Lupold said his shift to direct primary care has helped to ease the symptoms of burnout that were, for him, a result of the insurance-based practice model. “I think burnout is so multi-factorial: everyone has different reasons why they burn out,” said Lupold. “The pressures from above, the volume of patients, an inability to affect change were really just frustrating to me. “I like that I have more time to spend with my patients,” he said. “I’ve regained control over my ability to practice medicine.” It’s still a bit early to know what CMS is actually going to do, said Lupold, and noted that no one has seen a full proposal – the agency is still in
the midst of its process of gathering ideas and requesting information. But, he said, there are considerations that worry physicians. “I think a lot of the concern, from what’s come out so far, is the potential to lose the ‘direct’ part of ‘direct primary care,’ where CMS will put themselves between the patient and the family physician,” he said. “Other pieces I’ve seen as concerning would be hurdles or requirements of reporting, measures that need to be met to get payment. “What’s made direct primary care so wellreceived is that it’s taken the middleman out and allows us to work directly with the patient: to get payment from the patient, to provide high-quality care,” said Lupold. “That allows us to have a lower overhead by not having to collect and report all that information, and it makes care more affordable for the patient.” Lupold cautioned that before CMS fully develops its program, it’s unwise to make assumptions about its impact on family medicine. He said it’s possible that CMS’ Direct Provider Contracting project makes for an attractive option for some physicians – a model that compliments traditional, insurance-based family medicine and direct primary care. The PAFP will continue to investigate the CMS Direct Provider Contracting model and keep members updated on any changes or developments. Keep an eye on www.pafp.com, Progress Notes, and PAFP Connect for the very latest! WWW.PAFP.COM
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National Conference â€˜an incredible opportunityâ€™ for LECOM student Hannah Smouse, fourth-year med student, LECOM Seton Hill
This summer, I was privileged to attend the American Academy of Family Physicians National Conference in Kansas City, Mo. As a proud future family physician, it was very encouraging to be surrounded by so many people who were so passionate about a field so close to my heart. It was an incredible opportunity that I would highly encourage any student pursuing a career in family medicine to attend in future years. I was able to participate in lectures about the different focuses you can pursue in family medicine, such as rural and underserved medicine, global health, maternal care, pediatrics, and sports medicine. I am personally interested in building a full-spectrum rural practice that has a high volume of maternal care. I also would love the opportunity to do international work, shortor long-term, and there are so many programs that has this as a focus.
An incredible opportunity... continued.
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National Conference was also an incredible opportunity to meet other students passionate about family medicine, and residency programs, as I will be applying in the fall. The expo hall had representation from over 450 family medicine residency programs countrywide, and it was so neat to get to talk to numerous programs and learn about what they focus on and how different every program really is. Again, I highly recommend that any student interested in a future career in Family Medicine attend this conference in their fourth year, or even third year. There are scholarships available for students interested in attending! Just contact Molly Talley, Director of Resident and Student Initiatives for the PAFP, at firstname.lastname@example.org.
Region 3 FMIG Table Trivia Contest W
Resident Delegation at work in the Resident Congress: Morgan Rogers, MD, Christian Bengtson, MD, Fahmida Akhter, MD, Cybill Oragwu, MD
Forbes resident, Marcus Lyon, MD, talks to students in the Expo Hall
FMIG POE Award Winners from University of Pittsburgh: Elise Hogan, Sarah Minney, and Advisor Patti Zahnhausen
Winners showing off our winner pins
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Williamsport resident Angela Genoese, DO, talks with an interested student in the Expo Hall
York resident Shu Malotra, DO, answers questions for an interested student in the Expo Hall
Forbes Program Director Amy Crawford-Faucher, MD, talks with a student in the Expo Hall
UPMC Horizon Program Director, Marty Johns, MD, chats with students in the Expo Hall
Drexel Program Director Leon McCrea, MD and resident Liz Ebueng share a laugh with an interested student
PAFP Reception selfie! Drexel Program Director Leon McCrea, MD, and PAFP staff Molly Talley
PAFP Reception reunion: UPMC St Margaret resident Jacki Gallo, MD, MBA, catches up with Penn State Hershey Program Director Dan Schlegel, MD, MPH, and itâ€™s all good!
PAFP Student Delegation with supportive mentor (from left) Jessica Magdeburger (PSU), Dennis Gingrich, MD (PSU), Kayley Swope (PSU) and Amelia Mackarey (GCMC)
Team Geisinger Wilkes Barre: APD Jason Woloski, MD, resident Darren Doran, DO, recruiter Tammy Bonawitz, student Keezia Ellison (GCMC), APD Anja Landis, MD, resident Devish Patel, MD, in the residency booth
The Pennsylvania Academy of Family Physicians Foundations presents the
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FMIG POE Award Winner from Geisinger Commonwealth, Malina Lim
Full row of UPMC Family Medicine Residencies busy talking with interested students
PAFP Reception: guests mingling â€“ residents & students
Team Lehigh Valley Health: resident Joylyn Yeazell, MD, Program Manager Crystal Walker, resident Erin Smith, DO, Program Director Drew Keister, MD.
PAFP Reception: Jefferson group: student Kyle May, resident Erica Lee, MD, APD Krys Foster, MD, MPH, fourth-year Chief Resident LJ MacIntosh, MD
Members of the York Family Medicine team engage interested students in the Expo Hall
PA Row: 25 Pa Residencies filled an entire row in the Expo Hall to facilitate student traffic. This glimpse shows a sample of the flow of interested students through the residency booths.
Andrew Warner, MD
Christian Bengtson, MD
AAFP National Conference reunites long-lost â€˜brothers in armsâ€™ written by Christian Bengtson, MD ixteen years ago, my good friend Drew and I met in Fort Benning, Georgia for basic infantry training. We had just joined the U.S. Army in 2002, motivated by the events that took place on Sept. 11, 2001. We were both passionate about our country and ready to serve.
tion and Qualification Course to both become part of the few to don a Green Beret. We were assigned to different areas: Drew was sent to Iraq, and I was sent to work in Afghanistan.
Drew left college and I passed starting college to join the military.
Fourteen years since we last saw each other, we both found ourselves at AAFP National Conference as third-year residents in family medicine: both with similar goals, both passionate about family medicine.
We became very close friends and went through the tough U.S. Army Special Forces Selec28
We lost contact.
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GOVERNMENT AFFAIRS BRENT ENNIS, Deputy Executive Officer / Chief Operation Officer email@example.com
PCMH and Pennsylvania Medicaid Value-Based Purchasing (VPB) How the PAFP’s government affairs work is influencing payments today ix years ago, Pennsylvania’s Medicaid programs were heading toward a complete managed care organization (MCO) structure. The growth of the Medicaid program, with the 2010 passage of the Affordable Care Act, would shepherd a new era of payment policies moving away from fee-for-service. At this time, the Academy’s mission statement was to ensure every Pennsylvanian would have access to a patient-centered medical home, and it attempted to aid practices in transformation while encouraging public and private insurers to examine, if not embrace the model. Some did, some did not, on both accounts. Then-PAFP Government Affairs Committee Chair Peter Cardinal, MD, and Vice Chair David O’Gurek, MD, FAAFP (current PAFP President) and I strategized on how we could drive through legislation advancement of the model with a focus on the state Medicaid program. We knew it would be a long haul, but we also knew the effort could impactful, or at the very least influential in bringing the PCMH concept 30
to public policymakers, lawmakers and administrators alike. The PAFP Board of Directors agreed. In 2012, the PAFP began the work that inspired legislation introduced in both the Pennsylvania House and Senate. House Bill 1655, sponsored by then-House Health Committee Chairman Matt Baker, was introduced in 2013. State Senator Judy Schwank introduced the identical bill in the Senate. The bill would create the Patient-Centered Medical Home Advisory Council within the Department of Public Welfare (DPW), now known as the Department of Human Services (DHS). HB 1655 became law in October of 2014 and organized by the Department in 2015; you can read about this legislative achievement by clicking here. As then-PAFP President Douglas Spotts, MD said at the time: “Advancement of the patientcentered medical home has been a part of the PAFP’s mission for years, and we are delighted to see this bi-partisan piece of legislation pass.”
Since then, Pennsylvania adopted a statewidemanaged care organization structure under Gov. Tom Corbett. Budget constraints and federal guidance were driving state Medicaid programs to find value-based purchasing alternatives. The PCMH Advisory Council met and formulated guiding valued principles for getting PCMH payment efforts off the ground within the Commonwealth. William J. Warning II, MD, FAAFP (Crozer-Keystone Health System) and Douglas Spotts, MD,
David O'Gurek, MD
Douglas Spotts, MD
FAAFP (Past-President of the PAFP, currently at Meritus Health), generously volunteered their time to serve on the council representing family medicine. Dr. Warning added his insight on the movement, commenting, “The PCMH legislation was essential to bring all the medical and mental health providers together to break down the silos of care and provide a comprehensive blueprint of care for our Commonwealth. It allowed medical providers to have some more resources to care for some of our most vulnerable patient
populations, and expand our team-based care model to address the biological, psychological and social needs of our patient population. As a PCMH practice, I feel we now have some state Medicaid support to provide the care needed and required by our patients.” As DHS was ramping up its movement, PAFP President-elect Mary Stock Keister, MD (Lehigh Valley Health Network) was involved with the Pennsylvania Insurance Department’s Primary Care Transparency Workgroup looking at qual-
William Warning, MD
Mary Stock-Keister, MD
ity measures for Medicaid initiatives as well as for private insurers providing recommendations to policy makers with the Wolf Administration. Dr. Stock Keister notes, “One of the opportunities in working in this type of workgroup is hearing the perspectives and priorities for different stakeholders. My bias as a family doc is to advocate for a small, well-defined group of quality measures which directly impact patient outcomes and for which a family doc has some ability to control the data collection and patient process. This workgroup ultimately recommended that the DHS institute a committee WWW.PAFP.COM
GOVERNMENT AFFAIRS to monitor the changing quality landscape and recommend specific measures to be instituted evenly by all insurers.” Starting in 2016, Pennsylvania’s Medicaid program adopted the use of PCMH as an alternative payment model for MCOs to utilize as part of their payment mix. What the Council provided DHS, and the General Assembly, was the organized stakeholder findings to advance PCMH on the MCOs, and guided the definition and parameters of the requirements. The PCMH/MCO payments have gone from $5 million in 2016 to $9.2 million in 2017, affecting 850 high volume practices of 460,000 patients – of which 25,000 patients are super-utilizers. We should see continued growth in lives affected and payments, with VBP mandates on the MCOs doubling from 15 percent this year to 30 percent in 2019. Not that PCMH is the only path toward alternative payment models, but it’s a slice of the $30 billion annual state Medicaid expenditure pie. Without the Council, the policy undoubtedly would be different. Recently, Dr. O’Gurek and I met with officials at DHS and discussed their thoughts on the future of the council, with their efforts moving forward to assist with whether we should pursue renewing the legislation or renovating it for a more innovative strategy. We expect the department will be looking at the concept of the medical neighborhood, advancing population health, and addressing payments for screening and addressing social determinants of health. Moreover, the need for renewal of the council appears 32
unwarranted. Nonetheless, we will continue to work toward ensuring that such changes afford adequate payment mechanisms to support family physicians and practices without cuts in other areas. PAFP President Dr. O’Gurek further explained. “Our Academy's proactive approach to incorporating principles of the PCMH into advanced payment models and our understanding of the need for the medical neighborhood to facilitate quality population health for the communities we serve has placed family medicine in a leading position within the Commonwealth. Our discussion with Deputy Secretary Allen and Deputy Secretary Kozak has paved the way for further involvement in assisting the Department develop newer models and we will ensure that these strongly support family medicine in feasibility, payment, and infrastructure.” We are fully aware this does not help all of our members and the patients enrolled in MCOs they serve. We know of the hardships our members deal with in doing their best for their patients. We know of the many challenges we face in our state legislature are hard and complicated battles. However, we also know that we can make a difference and one of our greatest strengths is our ability to inspire legislation and administrative action that can guide state health care policy. The action truly rests with the state legislatures around the nation – the “laboratories of democracy.” Moreover, PAFP leadership continuously explores where and how we can make a difference in state government.
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LEGAL AND COMPLIANCE UPDATE CHARLES I. ARTZ, Esq., General Counsel firstname.lastname@example.org
Medical necessity fraud false claims case reinstated new U.S. Court of Appeals decision holding that health care providers can be subjected to fraud claims prosecuted under the False Claims Act (FCA) for failing to follow national association guidelines (which are not the law) even in the absence of a Medicare National Coverage Determination (NCD) or Medicare Contractor’s Local Coverage Determination (LCD) is important to consider.
differences of opinion not subject to objective falsity and therefore not actionable under the FCA. The 10th Circuit U.S. Court of Appeals reversed the lower court’s dismissal, reasoning that medical judgments and opinions can be false under the FCA.
In U.S. ex rel. Polukoff v. St. Mark’s Hospital/ Sherman Sorensen, M.D. et al, ___ F.3d. ___ (10th Cir. 2018) (2018 WL 3340513), a physician filed a whistleblower complaint under the FCA against another physician and hospitals at which the defendant physician provided services. The whistleblower alleged the defendant performed thousands of unnecessary procedures and received reimbursements through the Medicare Act by fraudulently certifying that the procedures were medically necessary. The federal district court, in an extremely well-reasoned decision, dismissed the case because medical necessity fraud allegations are pure
1. The Medicare Act states that no payment may be made for any expenses incurred for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 42 U.S.C. §1395y(a)(1)(A).
The Court of Appeals important legal holdings and determinations include the following:
2. Physicians and health care providers who seek reimbursement under the Medicare Act must certify the necessity of the services under Medicare regulations, 42 C.F.R. §424.10(a), and on the reverse side of the CMS 1500 claim form.
3. CMS decides whether a particular service is medically necessary by promulgating a generally applicable rule through NCDs and LCDs or by allowing individual adjudications. NCDs announce whether a particular item or service is covered nationally. 42 U.S.C. §1395ff(f)(1)(B). In the absence of an NCD, local Medicare Contractors may issue an LCD that announces whether an item or service is covered by the contractor. 42 U.S.C. §1395ff(f)(2)(B).
standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of the malformed body member. 5. The whistleblower’s complaint relied upon national health care trade association guidelines and alleged there has long been general agreement in the medical community that the procedure performed is not medically necessary except in limited circumstances, which were not evident in the present case. 6. The Medicare Program Integrity Manual at §13.5.1 instructs Medicare Contractors to consider a service to be medically necessary if the service or procedure is:
4. Individual Medicare Contractors may also make individual claim determinations even in the absence of an NCD or LCD based upon the individual’s particular factual situation. 68 Federal Register 63692, 63693 (November 7, 2003). Medicare Contractors must consider a service to be medically necessary if the contractor determines that the service is safe and effective; not experimental or investigational; and appropriate. Medicare Program Integrity Manual, §13.5.1. One factor contractors consider when deciding whether a service is appropriate is whether it is furnished in accordance with accepted
• Safe and effective; • Not experimental or investigational; • Appropriate, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it is: • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member; • Furnished in a setting appropriate to the patient’s medical needs and conditions; • Ordered and furnished by qualified personnel; WWW.PAFP.COM
LEGAL AND COMPLIANCE UPDATE •
One that meets, but does not exceed, the patient’s medical needs; and • At least as beneficial as an existing and available medically appropriate alternative. 7. It is possible for a medical judgment to be false or fraudulent as prohibited by the FCA. The FCA was intended to reach all types of fraud, including medical necessity non-compliance. The fact that an allegedly false statement constitutes the speaker’s opinion does not disqualify it from forming the basis of FCA liability. Claims for medically unnecessary treatment are actionable under the FCA if the provider ordered or performed the services knowing they were unnecessary, or recklessly disregarded Medicare guidelines. 8. The Court of Appeals stated: “We thus hold that a doctor’s certification to the government that a procedure is reasonable and necessary is false under the FCA if the procedure was not reasonable and necessary under the government’s definition of that phrase. We understand the concerns that a broad definition of false or fraudulent might expose doctors to more liability under the FCA, but the Supreme Court has already addressed those concerns [in its materiality decisions].” 9. The whistleblower adequately alleged that the defendants performed unnecessary procedures on patients and then knowingly submitted false certifications to the fed36
eral government that the procedures were necessary, all in an effort to obtain federal reimbursement. 10. The court found several potentially aggravating factors including the following: • The provider performed an unusually large number of procedures compared to other providers; • Those procedures violated both industry guidelines and the employer’s internal guidelines; • Other providers objected to the defendant’s practice; • The provider’s employer eventually audited the practice and concluded that its guidelines had been violated in many cases reviewed. 11. The Court of Appeals further held that the amended complaint adequately states express false certification claims against the employer, and factually false claims against the provider. 12. Corporate defendants may be subject to FCA liability when the alleged misrepresentations are made while the employee is acting within the scope of his or her employment, thereby imposing equal liability exposure on the provider and the provider’s employer.
The compliance take-home points that emerge from this decision include the following:
1. Family physicians can be subjected to FCA liability based on medical necessity challenges for not only intentionally or recklessly disregarding Medicare regulations and Manual provisions (even though Manual provisions technically are not the law), but also national trade association industry guidelines for the particular service or procedure. This is astonishing because Medicare Manual provisions and industry guidelines are not the law. Nevertheless, Family physicians can be held liable for violating the FCA for recklessly disregarding industry guidelines under this decision.
2. Family physicians should be trained on all applicable Medicare regulations, Manual provisions, NCDs, LCDs, carrier medical policies and industry guidelines as it relates to medical necessity for services and procedures billed. 3. There are still defenses to medical necessity claims when a reasonable difference of opinion exists, patterns of billing are not excessively beyond statistical parameters, and there is disagreement in the industry regarding the clinical requirements for services or procedures rendered.
The Latest Health Care News...
The Pennsylvania Academy of Family Physicians’ PAFP Connect app is available no (iPhone, iPad) and Android (Samsung Galaxy, Google Nexus, Motorola Moto X, Ama
Scouring the latest headlines from reputable media sources across the globe, PAFP Connect brings you the most relevant, up-to-date news and information that affects your practice and your patients. At 1 p.m. daily, PAFP Connect posts the Afternoon Family Medicine news digest – headlines that take a deeper look at family medicine in the U.S., covering all the angles so that you can head into the rest of the day with a deeper understanding of the forces that impact you.
Available Now! Downloading the app is easy! Just search for PAFP Connect on your iPhone’s app store to get started. Alternatively, click on the icon for the app store that matches your device.
Afternoon Family Medicine puts the news into context, telling you what it means and why you should care. In addition to collaborative groups, information, a schedule of events, and links to other PAFP resources like Keystone Physician, Afternoon Family Medicine is one more reason to log on to PAFP Connect daily.
PAFP Connect was built in-house exclusively for PAFP members. To access the mobile app you will need to know your AAFP member ID number. For login assistance, email Michael Zigmund, PAFP’s Chief Communication Offic 38
ow for download on iOS azon Kindle Fire) devices!
LEGAL AND COMPLIANCE UPDATE
$200 million JUA raid found unconstitutional by federal court Chief Judge Christopher Conner of the federal court in Harrisburg issued a final decision imposing a permanent injunction and finding Act 44 of 2017 unconstitutional. Under Act 44, the Joint Underwriting Association (JUA) was forced to transfer $200 million of its surplus and excess funds into the Commonwealthâ€™s General Fund by Dec. 1, 2017. If it refused to do so, Act 44 stated that the JUA would be abolished. The JUA filed a lawsuit in federal court after Act 44 was signed into law and requested a temporary injunction and permanent injunction. In an earlier opinion, Judge Conner imposed a preliminary injunction to prevent the law from going into effect. In Pennsylvania Professional Liability Joint Underwriting Association v. Wolf, ___ F.Supp.3d ___ (M.D. Pa. 2018) (2018 WL 2263549), decided May 17, 2018, the federal court issued a lengthy opinion summarizing the implications of Act 44, addressing the state governmentâ€™s defenses, and finding the statute unconstitutional. 40
Act 44 would have forced the transfer of $200 million from the JUA into the General Fund to balance the state budget. Act 44 repealed Act 85 of 2016, which would have also effectively taken the $200 million from the JUA, but had a repayment provision. Act 85 of 2017 had no repayment provision.
The JUA sued under several U.S. Constitutional theories, including violation of the Takings Clause under the Fifth Amendment to the U.S. Constitution. The Governor and the General Assembly raised numerous defenses. In response to the government’s contention that the JUA was a public entity, the court held as follows: The [JUA’s] function is inherently private. It is, at its core, an insurance company. The [JUA] is comprised of private insurer members, governed by a private board, and supported by private employees. It is funded by privately-paid premiums and is tasked to provide medical malpractice coverage to private persons practicing medicine within the Commonwealth. It does not exist wholly to serve the state, nor is it engaged in work otherwise tasked by statute to the state’s insurance commissioner. We hold that the Joint Underwriting Association is a private entity, and its surplus funds are private property. The Commonwealth cannot take those funds without just compensation. On the ultimate constitutional issue, the federal court held as follows: The [JUA] is a private entity, and monies in its possession are private property. Act 44 endeavors to take a substantial portion of these funds – $200 million – for the public purpose of remedying longstanding imbalances in the Commonwealth’s budget. Act
44 not only fails to provide just compensation; it fails to provide any compensation whatsoever. We find Act 44 to be an unconstitutional taking of private property in contravention of the Fifth Amendment to the United States Constitution. After finding Act 44 and the raid on the JUA unconstitutional, the court addressed the JUA’s request for a permanent injunction. This required the JUA to prove it will suffer irreparable injury without an injunction; legal remedies are inadequate to compensate that injury; the hardships of the parties warrant this type of remedy; and the public interest is not disserved by an injunction. The court held as follows: We have already determined that the constitutional injury effected by Act 44 is irreparable. There is no adequate legal remedy to compensate JUA’s injury. Act 44 effects a direct loss of $200 million to the JUA as well as the indirect loss of both the interest on those funds and the cost of liquidating its investment portfolio. It inflicts a considerable and irreparable constitutional injury which far surpasses the General Assembly’s frustration in returning to the budgetary drawing board. As concerns the public interests, we do not doubt that the General Assembly’s intention was as stated – to achieve the estimable goals of balancing the state’s budget and providing for the health, welfare and safety of the WWW.PAFP.COM
LEGAL AND COMPLIANCE UPDATE residents of this Commonwealth. As we have already held, the General Assembly cannot achieve this legitimate end through illegitimate means. The public interest is furthered – not disserved – by permanently enjoining enforcement of a plainly unconstitutional statute. We will grant the Association’s request for permanent injunctive relief.
44 is plainly violative of the Takings Clause of the Fifth Amendment to the United States Constitution.
The court concluded that the General Assembly, through Act 44, attempted to take by legislative requisition the private property of a private association to remedy its perpetual budgeting inefficacies. This it cannot do. Act
This is a resounding victory for the JUA and physicians who, for whatever circumstances, are forced to participate in the JUA through payment of premiums and professional liability insurance coverage.
The court granted summary judgment, declaratory judgment and permanent injunctive relief to the JUA. Under this ruling, the government cannot use the JUA’s funds to offset any budget deficits.
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PRACTICE MANAGEMENT SUSAN ORR, Esq., Rhoads & Sinon, LLP firstname.lastname@example.org
Be aware of these most common HIPAA violations â€™m sure that by now, everyone thinks they are an expert on HIPAA and have the requisite documents, policies, and procedures to protect patient health information. However, the reason that many medical practices commonly violate HIPAA is that both staff and physicians fail to actually follow the policies and procedures. We are finding that many medical practices have become somewhat lax in dealing with all but extreme violations of HIPAA and fail to conduct annual reviews of their policies and perform annual staff training. As a result, medical practices risk potential violations that may result in damage to a practice's reputation as well as criminal and civil fines. In 2013, fines resulting from violations of HIPAA increased and now range from $100 to $1.5 million. In addition, physicians may also be at risk for sanctions or loss of license. Although there is no private right of action by a patient under HIPAA, a patient can bring a civil lawsuit for violations of their privacy. 44
Provided below are some of the more common HIPAA violations: 1. Employees disclosing information. Employees' gossiping about patients to friends or coworkers constitutes a HIPAA violation. Employees having conversations about patients need to be aware of when and where those conversations take place. Such conversations need to be restricted to private places. Staff should also not share patient information with family and friends. This is a common problem in small community practices where everyone seems to know everyone else, but it happens in practices of all sizes. 2. Failing to properly handle paper records. A physician, nurse or other staff member may accidentally leave a chart in the patient's exam room or other area, making it available for another patient to see. Think about all of the other paper documents
related to a patient that are sent to the practice, such as consultant reports, laboratory findings, or imaging reports. These must be maintained in a secure location and away from areas where unauthorized patients may view them. 3. Lost or stolen devices. Theft or loss of laptops, desktops, smartphones, and other devices that contain patient information are extremely common. These mobile devices are most vulnerable to theft because of their size; therefore, necessary safeguards should be put into place such as not leaving them unattended, using password protected authorization and encryption to access patient-specific information. 4. Texting patient information. More and more physicians and patients are texting. Whether the text consists of
transmitting patient vital signs, test results, symptoms, medications, or other data, all such information constitutes protected health information. Texting potentially places patient data in the hands of cyber criminals who could easily access this information. New encryption programs are available that allow confidential information to be safely texted, but both parties must have it installed on their wireless devices. 5. Social media. Posting patient photos on social media or talking about a patient in a social media platform constitute a very serious HIPAA violation. Both constitute a breach of the patient's privacy. Even if the patient is not named, the identity of the patient may be surmised. All employees must be trained on social media and recognize that the use of social media to share patient information is considered a HIPAA violation. 6. Employees illegally accessing patient files. Employees accessing patient information when they are not authorized or have no reason to access that information is another very common HIPAA violation. Whether it is out of curiosity, spite, or as a favor for a relative or friend, this not only subjects a practice to fines but it also can harm the practiceâ€™s reputation. 7. Social breaches. When in a social setting, how often are you asked how so-and-so is doing? An accidental breach of patient information in a social WWW.PAFP.COM
PRACTICE MANAGEMENT situation is quite common. Consider when individuals make an innocent inquiry to you at a social gathering about their friend who is a patient. Blurting out information to the patient’s friend about the patient can have serious consequences. Make sure that you have a planned response to this type of inquiry. 8. Authorization requirements. To use or disclose an individual's protected health information other than for treatment, payment, health care operations, or as permitted by the Privacy Rule requires the patient to sign an authorization. Make sure that any authorization meets the HIPAA requirements for what must be included in an authorization. If you are unsure as to whether or not an authorization is needed to make a disclosure, it’s best to obtain an authorization prior to disclosing any information. 9. Accessing patient information on home computers. Many clinicians use their home computers or laptops after hours to access patient information to record notes or review patient files when patients call after hours. Failure to turn off the computer or close the software can allow family members to access patient information. Make sure your computer and laptop and your software are password protected and keep all mobile devices out of sight to reduce the risk of patient information being accessed or stolen. 46
10. Lack of training. One of the most common HIPAA violations is lack of training of staff. HIPAA training should be part of the orientation process for new staff, physicians, volunteers, interns and medical students working out of the practice. In addition, there should be an annual training of all staff to reinforce HIPAA requirements. Documentation of such training for each individual must be maintained. 11. Failure to maintain or update policies. HIPAA requires that all health care clinicians and medical professionals maintain HIPAA Privacy and Security policies which outline how the medical practice will maintain the privacy and security of their patients protected health information. These policies must be dynamic and updated periodically and reflect the reality of how patients’ information is protected. Even if the practice does have policies, failure to actually follow them is a violation of HIPAA. Make sure your policies as well as other HIPAA documents are up to date to prevent potential violations.
Most violations can be easily prevented by implementing HIPAA regulations into practice policies and procedures and ensuring that all individuals with access to patient information receive the proper training. If you have questions regarding this article or would like to discuss HIPAA, please contact Susan Orr, Esquire, at Dilworth Paxson, LLP at sorr @dilworthlaw. com, (610) 423-4200.
Pennsylvania Academy of Family Physicians Foundation
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