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U.S. Life Expectancy Drops Amid 'Disturbing' Rise In Overdoses And Suicides

O I OP

eroin(e)': The omen Fighting Addiction In Appalachia

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GRASSROOTS ADVOCACY: TIPS & GUIDELINES

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Patients With Chronic Pain Fe Caught In An Prescribing Deb

A C I ER Most Americans Know About Opioid Antidote And Are Willing To Use It

PRESIDENT'S MESSAGE: FAMILY MEDICINE IS STRONG

ATE D P U AN


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T N S E T A THE L INFORMATIO & Y L I NEWS A D ... KP MAGAZINE ARCHIVE VISIT THE BACK CATALOG OF KEYSTONE PHYSICIAN AND MAKE YOUR OWN HEALTH CARE NEWS AND INFORMATION REMIX

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KEYSTONE PHYSICIAN

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SPRING 2019


PENNSYLVANIA ACADEMY OF FAMILY PHYSICIANS & FOUNDATION 2704 Commerce Drive, Suite A Harrisburg, PA 17110 717-564-5365 • TOLL FREE 1-800-648-562 • FAX 717-564-4235 www.pafp.com

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Keystone Physician, member magazine of the PA Academy of Family Physicians, is digitally published four times a year. Editorial opinions and advertisements in this publication do not necessarily reflect the views of the PAFP and Foundation, unless so stated. © 2016. Unless stated otherwise, nothing may be reproduced either wholly or in part without permission from the Editor-in-Chief.

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CONTENTS

15

PRESIDENT'S MESSAGE Patientsremain, With While challenges family

U.S. Life Expectancy Drops Amid 'Disturbing' Rise In Overdoses And Suicides

oin(e)': The en Fighting diction In palachia

O

Chronic Pain Feel medicine isCaught strongIninAnPennsylvania Prescribing Debate

MEMBER NEWS

N I S D PIOI

AM

A C I ER AN U P

6

D AT E

Most Americans Know About Opioid Antidote And Are Willing To Use It

ƒƒ

Ten State Meeting brings northeast

8

region together to plan and learn ƒƒ

PAFP announces award winners

ƒƒ

PAFP releases 2018 Annual Report

8 10

FEATURES ƒƒ

Opioids in American: An update

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GOVERNMENT AFFAIRS ƒƒ

COVER STORY

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KEYSTONE PHYSICIAN

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Tips & Guidelines

As the overdose epidemic continues to effect the lives of thousands of Pennsylvanias, the PAFP is working to keep its members educated and informed on the issue. Here we take a look at some of the best news reporting to get an overview of the current state of opioid abuse.

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Grassroots Advocacy:

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SPRING 2019

ƒƒ

2019-20 state legislative priorities member survey results

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SPRING 2019 VOLUME 79 | NUMBER 1

PUBLIC HEALTH Caring for the rare

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LEGAL AND COMPLIANCE UPDATE ƒƒ

Medicare Evaluation Management

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coding and documentation amendments ƒƒ

HIPAA Privacy violation: $500,000

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fine: Failure to execute business associate agreement EDUCATION Online CME Catalog

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N LATIO O I V CY PRIVA

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PRESIDENT'S MESSAGE DAVID O'GUREK, MD, President president@pafp.com

While challenges remain, family medicine is strong in Pennsylvania t’s unbelievable how quickly a year goes by. As it sometimes seems like yesterday I was preparing for my inauguration as PAFP president, I reflect fondly on this phenomenal experience and honor to have served as the president of this outstanding organization. It’s truly surreal to be compiling my final column as your president. As I reflect on the year, I am incredibly humbled by the work we have been able to accomplish together. One of my very first meetings as president was with Attorney General Josh Shapiro where I was able to highlight the great work that our Academy is doing around the overdose crisis as well as provide insights into potential improvements in the prescription drug monitoring program. Months later, we continue to be at the forefront of this critical public health crisis with the release of our opioid resource center with information to address both chronic pain and opioid use disorder. Furthermore, our relationship with the Attorney General’s office has facilitated connections that have resulted in a presentation at our upcoming Annual Meeting on trauma-informed care with Deputy Attorney General Rob Reed. 6

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Our advocacy work in Harrisburg and beyond around critical issues such as scope of practice with nurse practitioner independence and administrative burdens, notably prior authorization reform, has created greater alignment within the house of medicine. Our efforts have created a stronger voice for primary care within the Commonwealth with development of the Primary Care Collaborative in the state with the Pennsylvania chapters of the American College of Physicians and the American Academy of Pediatrics. Months later, we recently aligned once again in Harrisburg to meet with the new chair of the House Professional Licensure Committee and have a stronger alliance to work together to meet the needs of the citizens of Pennsylvania. A unified voice is undoubtedly a stronger voice. Advancing the health of all Pennsylvanians requires the focus on social determinants that we as family physicians know are so critical to advancing individual and population health. The AAFP’s work with the EveryONE project has placed family medicine as a leader nationally and we had the opportunity to share this as well as the great work that you do on behalf


of your communities to address social determinants with Executive Deputy Secretary Leesa Allen and Deputy Secretary Sally Kozak. Advancing the medical neighborhood through value based-payments that acknowledge this work is a critical next step and the Department of Human Services knows that the PAFP stands as a leader and a friend, ready to engage in discussions to move this forward. Ensuring a strong future for family medicine in the Commonwealth requires investments in our students and our residents. Funding for residency expansion was sustained through the last session and we continue to explore opportunities to ensure this remains and hopefully expands in future years to meet the needs of the citizens of Pennsylvania. Our students and our residents continue to do exceptional things across our state as well as nationally. I am continually inspired by these students and know that the future of family medicine is a strong one.

While these represent just an overview of the great memories and the work I am most proud of over the past year, our work continues. We have an exciting year ahead, having just completed strategic planning for our Academy to move us boldly into the future and transform your Academy further into a proactive and innovative organization. We continue to host exceptional CME events across the state with a diverse array of topics and speakers that always deliver. We greatly look forward to the upcoming Annual Business Meeting where we will inaugurate Dr. Mary Stock Keister, an exceptional leader and visionary, as our next PAFP president. Philadelphia will host the AAFP’s FMX Meeting Sept. 24-28 with a lineup of activities and events that will showcase some of the great work being done by our members and in our state. Despite wonderful successes and upcoming excitement, challenges remain. As we confront these challenges, maintain your undying spirit, your inspirational service, and your infinite hope that defines family medicine and defines our Academy. I love this Academy and have truly loved serving as your president over this past year. I honestly wish I had more time to accomplish more for you and the communities you serve. Our work will continue and as I sign off my final column as president, I bid you to remember: “for all those whose cares have been our concern, the work goes on, the cause endures, the hope still lives, and the dream shall never die.� WWW.PAFP.COM

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MEMBER NEWS THE LATEST NEWS AND INFORMATION FOR PAFP MEMBERS For more, visit: www.pafp.com

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PAFP on twitter

Ten State Meeting brings northeast region together to plan and learn

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PAFP Connect

dent David O’Gurek, MD provided an update on the political goings-on in Harrisburg on the PAFP’s state legislative agenda. The PAFP extends its thanks to the state chapters that make the Ten State coalition such a strong voice for family medicine in America!

PAFP announces award winners

The 2019 Ten State Meeting of American Academy of Family Physician chapters, Feb. 1-3 in Orlando, brought 12 chapters from the northeast region together to focus on common issues affecting family physicians in the geographic region. The Connecticut, Illinois, Indiana, Kentucky, Massachusetts, Michigan, Minnesota, New Jersey, New York, Ohio, and Wisconsin chapters joined the PAFP for the weekend.

The Pennsylvania Academy of Family Physi2019 cians is pleased to PAFP announce the winners AWARDS of its 2019 awards slate! William Taddonio, MD of Douglassville has been selected as the PAFP’s Family Physician of the Year; Elizabeth George, MD of Mercersburg has been named the PAFP’s inaugural Public Health Award winner. Gordon Liu, MD of Pittsburgh and Allison Myers, MD of Philadelphia have been named the PAFP’s Exemplary Teachers of the Year.

Topics discussed at this year’s meeting included American Board of Family Medicine (ABFM) developments, rethinking chronic pain, and legislative updates from each state. PAFP Presi-

Congratulations to these excellent and deserving family physicians! For more details and to read about the individual winners, visit the awards page on pafp.com.

PAFP President, David O'Gurek, MD, provides an update on PAFP's legislative agenda at the 2019 Ten State Meeting of American Academy of Family Physicians chapters.

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MEMBER NEWS

PAFP releases 2018 Annual Report The Pennsylvania Academy of Family Physicians is pleased to announce the release of its 2018 Annual Report! This report details each area of the PAFP's mission, including updates on government affairs and practice advocacy, education, membership, residents and students and financials. In addition, this report includes a summary by PAFP President David O'Gurek, MD and PAFP Executive Vice President and CEO John Jordan, MD, detailing the successes of family medicine in Pennsylvania over the course of 2018. Click here to read the 2018 Annual Report.

Pain Management & Opioid Misuse Resource Center If you know of an additional resource that visitors to this page may find useful, please click here. 10

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3RD ANNUAL CHILI COOK-OFF Be crowned the CHILI CHAMPION for the weekend during PAFP's March CME Meeting See PAFP.com for entry form and details

Visit the beef booth for nutrition information, recipes and more. BeefItsWhatsForDinner. BeefItsWhatsForDinner.com

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Visit www.pafp.com for details and registration |

KEYSTONE PHYSICIAN

SPRING 2019


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 you’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 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!

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www.pafp.com/leadership

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The ting In a

U.S. Life Expectancy Drops Amid 'Disturbing' Rise In Overdoses And Suicides

O I P O

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A C I ER Most Americans Know About Opioid Antidote And Are Willing To Use It

ATE D P U AN

Pa Chro Ca Presc


atients With onic Pain Feel aught In An cribing Debate

FEATURE

Opioids in America: An update s the overdose epidemic wreaks havoc on Pennsylvania, opioids continue to be front-and-center of the news cycle in the Keystone State and beyond. At the beginning of January, PennLive reported an encouraging sign: efforts to combat the epidemic are leading to decreased deaths from opioids. Secretary of Health Dr. Rachel Levine says those numbers have yet to appear in figures released by the Centers for Disease Control and Prevention (CDC): But she said she’s convinced overdose rates are falling in some Pennsylvania counties. She attributed it to things including more overdose victims being saved as the result of increased access to the overdose reversal drug naloxone, and more overdose survivors and others getting treatment as a result of state-driven efforts. Still, she said the fight against the opioid addiction and overdose crisis is far from

over, and Pennsylvania has no plans to scale back on its effort. (PennLive, Jan. 7, 2019) Nevertheless, not all the news coming from the center of the epidemic is as rosy. One demographic in particular is seeing a massive increase in drug overdose deaths - women. CNN reports the rates of death from drug overdoses among women has skyrocketed in recent years, according to new data; between 1999 and 2017, the drug overdose death rate among women aged 30 to 64 climbed more than 260 percent. In that time, drug overdose deaths involving antidepressants, cocaine, heroin, prescription opioids, synthetic opioids and benzodiazepines such as such as Xanax and Valium all increased, the report said. "Overdose deaths continue to be unacceptably high, and targeted efforts are needed to reduce the number of deaths in this evolving WWW.PAFP.COM

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FEATURE epidemic among middle-aged women," the researchers wrote. (CNN, Jan. 10, 2019) And another startling statistic: deaths from opioid overdoses have now overtaken deaths on the road for the first time. For years in the United States, deaths from automobile accidents have been a key mortality statistic. For the first time, NPR reports, Americans are likelier to die from an overdose than in a vehicle. Americans now have a 1 in 96 chance of dying from an opioid overdose, according to the council's analysis of 2017 data on accidental death. The probability of dying in a motor vehicle crash is 1 in 103. (…)

You’ve spent 20 years building your career. We’ve spent 60 years protecting your investment.

Questions about responsibility for the overdose epidemic abound. A new report suggests drug companies – and their marketing for opioid painkillers in particular – is linked to more overdose deaths, according to Vox.

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Fentanyl is now the drug most often responsible for drug overdose deaths, the Centers for Disease Control and Prevention reported in December. And that may only be a partial view of the problem: Opioid-related overdoses also have been undercounted by as much as 35 percent, according to a study published last year in the journal Addiction. (NPR, Jan. 14, 2019)

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The study, by researchers from Boston University, UC Davis, New York University, and Brown University, looked at more than 430,000 marketing payments, totaling $39.7 million, to nearly 68,000 doctors across the US between August 2013 and December 2015. They then looked at county-level data to see whether the payments had an effect on painkiller overdose death rates one year later. If the marketing led to more opioid prescriptions, and more opioid prescriptions led to more misuse, addiction, and overdoses, then you could expect to see painkiller overdose deaths rise in places that got more marketing.

assembled a new tool for family physicians: the Pain Management & Opioid Misuse Resource Center. From a collection of resources from the American Academy of Family Physicians and information on the treatment of opioid use disorder (OUD), including approved CME webcasts from the PAFP, the Pain Management & Opioid Misuse Resource Center is a one-stop shop for Pennsylvania family physicians who need a leg up in the battle against opioid misuse.

46th Family Medicine Refresher Course

That’s exactly what researchers found: The counties that got more marketing the year before saw more painkiller prescriptions and more overdose deaths. (Vox, Jan. 25, 2019) Family physicians have been front and center in response to the overdose epidemic. According to the Philadelphia Dept. of Public Health, in that city – the largest in the state and sixth-largest in the U.S. – family physicians are the top prescribers of buprenorphine. In addition, the Pennsylvania Academy of Family Physicians has

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For more information please visit https://ccehs.upmc.com If you have any additional questions, please contact Naomi Ziegler at Phone: (412) 383-2366 E-mail: zieglern@upmc.edu

Online streaming of the conference is available!! WWW.PAFP.COM

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GOVERNMENT AFFAIRS BRENT ENNIS, Deputy Executive Officer / Chief Operation Officer bennis@pafp.com

Grassroots Advocacy: Tips & Guidelines FIRST Register to vote. It matters. Officials and their staff will check to see if you are registered or not. If you are not a registered voter, you risk undermining your own credibility.

KNOW YOUR CONTACT Legislators represent people based on where they live, not where they work. Use the General Assembly’s “Find Your Legislator” search to find the right contacts. If you approach the wrong official, expect them to refer you to your district’s contact. Read up on your legislators via their public profile on the Pa. General Assembly website. Connect with them via Facebook. Join their email list for constituent communications.

PA FP G R AS S ROOTS ADVO CACY

THE MEETING

BE PREPARED

Meet in person with your legislator in their district office; meeting face-to-face with legislative staff is fine as well. If you’ve no time to meet, make a call. No time to call? Email is okay, but a letter is better.

Have your policy talking points or elevator speech prepared. Be concise, focused and relatable. Don’t expect to chat for an hour about your issues. Officials deal with a wide variety of issues, from health care to criminal law to property taxes, and everything in between. Have one main issue to discuss and no more than three.

Be polite and courteous at all times. Uncivil discourse is too commonplace these days; you must take the high road. Make a new friend. Build trust and credibility. Be a resource: offer to answer any questions they have about your topic or some other matter they’re facing. Good

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relationships are a two-way, transactional affair, and as important in advocacy as in family medicine! Be honest. Don’t be afraid to answer a question with “I don’t know, but I’ll find out,” and follow up with that new information. Too many people engaged in public policy give inaccurate information; don’t risk your credibility by being one of them. The “Ask”: The ask is not “I demand you support” this, the ask is “I hope you will consider supporting” this and here’s why. Don’t expect, suggest. If you are going to discuss a bill, make sure you read the bill beforehand. Use the “find legislation” search on the General Assembly Website.

Say thank you. Public life is more challenging than most people understand. Elected officials constantly deal with complaints, problems, and adversaries while attempting to know all they can and do right by their constituents.

USE SOCIAL MEDIA FOR GOOD All of the above applies on social media, too. Be an authority; be credible, trustworthy and gracious. Avoid sensational stories and questionable sources. Choose your issues wisely. Still, face-to-face is most effective for building relationships. Follow leaders like @DrWandaFiler  for strong examples of social media use; observe how she has cultivated her presence with authority and chosen her “follows” carefully.

T h e Pe n n sylva n ia Ac a d e m y o f F a m ily P hy s i ci ans

Political Action Committee

WWW.PAFP.COM

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GOVERNMENT AFFAIRS

2019-20 state legislative priorities member survey results When the PAFP unveiled its 2019-20 State Legislative Agenda, we invited members to help us prioritize our advocacy slate. Which issues are most important to family physicians in Pennsylvania? We have the results. E N N S Y LV A N I A A C A D E M Y O F F A M I LY P H Y S I C I A N S Below are the results of ourP2019-20 State Legislative Priorities Member Survey. From prior authoriza2 0 1 9 2 0 S T A T E L E G I S L A for T I Vworking E P R I Omothers, R I T I E S these M E Mresults B E R S- U R V E Yto your input tion reform to workplace accommodations thanks R E over S U LT S legislative term. - will help determine our advocacy in Harrisburg this

O V E R A L L S U R V E Y R E S U LT S O V E R A L L S U R V E Y R E S U LT S

PRIOR AUTHORIZATION REFORM

NURSE PRACTITIONER INDEPENDENCE

HEALTH INSURER CREDENTIALING REFORM

BUPRENORPHINE MEDICALLY ASSISTED TREATMENT ACT

DIRECT PRIMARY CARE (DPC) AUTHORIZATION LEGISLATION

RESTRICTIVE COVENANTS

POLST LEGISLATION

WORKPLACE ACCOMODATIONS FOR NURSING MOTHERS LOWEST PRIORITY

0

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P E R C E N TA G E R A N K I N G S B Y I N I T I AT I V E 20

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PRIORITY RANKING

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DIRECT PRIMARY CARE (DPC) AUTHORIZATION LEGISLATION

RESTRICTIVE COVENANTS

POLST LEGISLATION

WORKPLACE ACCOMODATIONS FOR NURSING MOTHERS LOWEST PRIORITY

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P E R C E N TA G E R A N K I N G S B Y I N I T I AT I V E P E R C E N TA G E R A N K I N G S B Y I N I T I AT I V E PRIORITY RANKING

HIGHEST

LOWEST

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2

3

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8

40.30%

29.85%

13.43%

2.99%

7.46%

2.99%

1.49%

1.49%

31.82%

21.21%

9.09%

6.06%

4.55%

9.09%

7.58%

10.61%

4.62%

12.31%

21.54%

29.23%

12.31%

15.38%

3.08%

1.54%

8.96%

7.46%

11.94%

13.43%

16.42%

26.87%

11.94%

2.99%

4.55%

13.64%

16.67%

12.12%

10.61%

19.70%

7.58%

15.15%

6.15%

3.08%

13.85%

13.85%

33.85%

9.23%

10.77%

9.23%

1.49%

5.97%

7.46%

8.96%

7.46%

11.94%

44.78%

11.94%

4.41%

7.35%

8.82%

11.76%

8.82%

4.41%

11.76%

42.65%

PRIOR AUTHORIZATION REFORM:

Prior authorizations have become significantly burdensome to family physicians, and more importantly result in delays and jeopardized quality care to patients. The PAFP supports reforms that would maximize electronic communications for authorizations as well as adverse determinations, and define consistent response times for authorizations, rejections, appeals, and external utilization review. NURSE PRACTIONER INDEPENDENCE:

Nurse practitioners (NPs) are integral, valuable members of the health care team, held in the highest regard by family physicians. However, patients are best served when a physician-led, highly coordinated health care team provides care. Therefore, the PAFP opposes legislation that would expand their scope of practice and eliminate collaborative agreements. HEALTH INSURER CREDENTIALING REFORM:

Delays in credentialing of new physicians or existing physicians changing practices create undue hardships most notably on the communities they serve. The PAFP supports legislation that would standardize the credentialing form and set processing standards. BUPRENORPHINE MEDICALLY ASSISTED TREATMENT ACT:

Access to care for patients suffering from substance abuse disorder is critical, and state regulation could significantly jeopardize access to office based opioid treatment (OBOT). The PAFP opposes legislation that would require prescribers of Buprenorphine to be licensed by the state and pay any state licensing fee. DIRECT PRIMARY CARE (DPC) AUTHORIZATION LEGISLATION:

DPC is a model of care outside the bounds of health insurance and an emerging option for patients and physicians. The PAFP supports legislation that specifies direct primary care agreements are not insurance and therefore not subject to insurance laws or regulations. RESTRICTIVE COVENANTS:

In this age of health system consolidations, PAFP supports legislation limiting restrictive covenants in health care practitioner employment agreements.

POLST LEGISLATION:

Working with the Pennsylvania Medical Society, the PAFP supports updating and revising Pennsylvania law to include codification of Pennsylvania Orders for Life Sustaining Treatment (POLST) to be used by medical professionals across all health care settings for patients who voluntarily wish to execute a POLST order, WORKPLACE ACCOMODATIONS FOR NURSING MOTHERS:

The PAFP supports legislation that requires employers to provide employees time to express breast milk in a sanitary environment for her nursing child.

To view the PAFP legislative agenda (updated February 20, 2019), visit the PAFP Government and Practice Advocacy Committee page at www.pafp.com. PAFP’s State Legislative Agenda is crafted through the Government and Practice Advocacy Committee with position decisions made by the Board of Directors. WWW.PAFP.COM

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PUBLIC HEALTH STORIES ABOUT THE HEALTH OF PATIENTS AND THEIR COMMUNITIES Watch for regular public health updates in our bi-weekly newsletter - Progress Notes

Caring for the Rare ach staff member of the PAFP offers their own unique skill set to fulfill the PAFP’s mission to each of our members. But within the household of one staff member, there is a rare experience not shared by many. PAFP’s Director of Education, Lindsey Killian, and her husband have a toddler son with a rare medical condition called Phenylketonuria (PKU). The rare inherited disorder causes the amino acid known as phenylalanine (PHE) to build up in the body. The cause of PKU is the result of a gene mutation that prevents the creation of the necessary enzyme to break-down the PHE. With a buildup of PHE, the outcome includes serious health concerns, including neurological, behavioral, and emotional problems.i When their son was born, Lindsey and her husband were already familiar with PKU and the limited treatment options. Lindsey’s husband was among the first class to be diagnosed with PKU in Pennsylvania courtesy of the newborn screening process. The primary treatment option for individuals living with PKU is a strict medial diet. At nearly two years old, Lindsey’s son is restricted to nearly 6 grams of protein per day. As a result, Lindsey and her husband weigh and track everything their son eats and 22

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THE CAUSE OF PHENYLKETONURIA (PKU) IS THE RESULT OF A GENE MUTATION THAT PREVENTS THE CREATION OF THE NECESSARY ENZYME TO BREAK-DOWN THE PHE

try to account for the food that is turned down throughout the day. This requires they carry a letter of medical necessity and a cooler with them every place they go to allow their son’s special medical formula and a food scale. Lindsey’s husband is one of the fortunate PKU patients that is a responder to a medication that helps his body breakdown the PHE and covert it to tyrosine. Lindsey’s husband is still on a medically restricted diet and takes a medical formula to ensure his body has the correct amount of tyrosine. With the medication and formula, Lindsey’s husband is able to enjoy a more normal vegetarian like lifestyle.


At the age of 40 years old, Lindsey’s husband is still seen at the children’s hospital where he was originally treated for PKU. The family makes multiple trips throughout the year to the PKU clinic to meet with their PKU treatment team, including five different medical specialties. In addition to the appointments at the clinic, both Lindsey’s son and husband perform regular at-home blood tests that are mailed to the state’s lab and reported back to the clinic.

On February 28, the National Organization for Rare Disorders, which represents the more than 7,000 rare diseases, asks everyone to “show their stripes” in support of rare diseases. Similar to a zebra with its unique striped pattern, everyone has their own unique characteristics but many commonalities are shared by each of us. In honor of raising awareness and to celebrate Rare Disease Day, wear stripes and share your photos using the hashtags #showyourstripes and #rarediseaseday.ii

Mayo Clinic. Phenylketonuria (PKU). https://www.mayoclinic.org/diseases-conditions/phenylketonuria/symptoms-causes/syc-20376302

i

National Organization for Rare Disorders. NORD Issues New Rare Disease Day Rallying Cry: Show Your Stripes! https://rarediseases.org/

ii

nord-issues-new-rare-disease-day%E2%93%87-rallying-cry-show-your-stripes/

A WellSpan Physician Career: What’s your goal? Join WellSpan Medical Group, a physician-led organization providing innovative care throughout central Pennsylvania and northern Maryland. We are part of WellSpan Health, one of the region’s largest integrated health systems, with more than 1,500 providers, a network of eight community and teaching hospitals, and comprehensive specialty care services. We’re transforming the patient experience through health IT and care coordination across providers, care environments and life stages. At WellSpan, your goals are our goals. To learn more about physician and other provider opportunities, or to apply, visit WellSpan.org/Careers or send your CV to: Cris Williams, Physician Recruiter Cwilliams9@wellspan.org (717) 812-4487 6099 PR&M 1/19


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 24

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. Everyday.

ow for download on iOS azon Kindle Fire) devices!

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LEGAL AND COMPLIANCE UPDATE CHARLES I. ARTZ, Esq., General Counsel cia@artzhealthlaw.com

Medicare Evaluation/Management coding and documentation amendments ew Medicare regulations published as part of the 2019 Fee Schedule contain significant changes to the Medicare Evaluation and Management (E/M) coding and documentation requirements. 83 Federal Register 59452, 59628-59635 (Nov. 23, 2018). Some of the changes take effect Jan. 1, 2019. The remainder of the changes do not take effect until Jan. 1, 2021. Each will be addressed separately.

visit as opposed to an office visit; however, the documentation of the service itself must establish medical necessity. Only the requirement for a home visit compared to an office visit has been eliminated from the medical necessity requirements.

1. CMS will continue the current coding and payment structure for E/M office and outpatient visits. Physicians and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document their E/M services billed to Medicare.

3. For established office outpatient visits, when relevant information is already contained in the medical record, physicians may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed. Physicians need not re-record the defined list of the required elements if there is evidence that the physician reviewed the previous information and updated it as needed. Nevertheless, physicians should still review prior data, update it as necessary, and also indicate in the medical record that they have done so.

2. CMS eliminated the requirement to document the medical necessity of a home

4. CMS clarified that for E/M office outpatient visits, for new and established patients,

2019 E/M CHANGES Beginning Jan. 1, 2019 through the end of calendar year 2020, the following rules apply:

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physicians need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient. The physician may simply indicate in the medical record that he or she reviewed and verified this information. 5. CMS removed the potentially duplicative requirements for notations in the medical records that may have been previously included in the medical records by residents or other members of the medical team for E/M visits furnished by Teaching Physicians. CMS did not adopt its proposal to collapse the E/M levels 2-4 visits into a single rate as it proposed in July of 2018. In addition, CMS did not finalize its proposed regulations that would have: • Reduced payment when an E/M office visit is furnished on the same day as a procedure (which would have essentially eliminated the -25 Modifier requirement); or • Standardized the allocation of practice expense RVUs with the codes that describe these services. 2021 E/M AMENDMENTS Beginning January 1, 2021, CMS intends to “further reduce burden” on physicians by implementing payment, coding and other documentation changes. Generally, reimbursement for E/M office patient visits will be simplified and

payment will vary primarily based on the attributes that do not require separate, complex documentation.

Specifically, beginning January 1, 2021, CMS will finalize the following policies: 1. CMS will reduce payment variation for E/M office outpatient visit levels by paying a single rate for E/M outpatient visit Levels 2-4 for established and new patients, while maintaining the payment rate for Level 5 visits. 2. CMS will allow physicians to choose to document E/M Level 2-5 visits using medical decision-making or time, instead of applying the current 1995 or 1997 E/M documenWWW.PAFP.COM

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LEGAL AND COMPLIANCE UPDATE tation guidelines. In the alternative, physicians can continue using the current 1995 or 1997 documentation guidelines. 3. For E/M Level 2-5 visits, CMS will allow for flexibility in how visit levels are documented. Physicians can choose to use the current framework, medical decision-making or time.

CMS INDICATED THESE POLICIES WILL ALLOW PHYSICIANS GREATER FLEXIBILITY TO EXERCISE CLINICAL JUDGMENT IN DOCUMENTATION

4. For E/M Level 2-4 visits, when using medical decision-making or the current framework, CMS will also apply a minimum supporting documentation standard applicable with Level 2 visits. For those cases, Medicare will require information to support a Level 2 E/M visit code for history, exam and/or medical decision-making. 5. When time is used to document the service, physicians must document medical necessity of the visit and that the billing physician personally spent the required amount of time face-to-face with the patient. The 28

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current policies regarding use of time to bill the visit code will remain in effect. That is, when counseling and/or coordination of care accounts for more than 50 percent of the face-to-face physician-patient encounter, time can be utilized. 6. CMS will implement add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care. They will not be restricted by physician specialty. The add-on codes would only be reportable with Level 2-4 E/M services. Generally, CMS will not impose new per-visit documentation requirements. 7. CMS will adopt a new “extended visit” add-on code for use only with Level 2-4 E/M services to account for the additional resources required when physicians need to spend extended time with the patient. CMS indicated these policies will allow physicians greater flexibility to exercise clinical judgment in documentation, so physicians can focus on what is clinically relevant and medically necessary for the patient. More public input will be invited to further refine the policies before they take effect in 2021. Although we are unsure at this point what the “collapsed” rate for the E/M services will be, it could have a significant impact on reimbursement for not only Medicare, but all other government and commercial third party payors that follow Medicare payment rules.


PAFP Annual Business Meeting & CME Conference Joint Conference with Wellspan Health

March 7-10, 2019 • Gettysburg, PA 3rd Annual Dermatology Conference (featuring a special outdoor medicine track) August 8-10, 2019 • Lake Raystown Resort and Conference Center

Bedford CME Conference November 8-10, 2019 • Bedford, PA PAFP Annual Business Meeting & CME Conference March 5-8, 2020 • Hershey, PA

Available Now

All online sessions meet your Patient Safety requirement • Advances in the Screening, Diagnosis and Treatment of Testicular and Prostate Cancer • Advances in the Screening of Female Reproductive Cancers • Improving the Diagnosis and Management of Opioid-induced Constipation to Optimize Outcomes of Patients with Chronic Pain View the webcast catalog for all courses

www.pafp.com 29 WWW.PAFP.COM || 29 Visit www.pafp.com details on all of our CME offerings


LEGAL AND COMPLIANCE UPDATE

HIPAA Privacy violation: $500,000 fine Failure to execute business associate agreement he most recent U.S. Department of Health and Human Services Office for Civil Rights (OCR) enforcement action involving a medical group practice’s failure to sign a HIPAA-compliant Business Associate Agreement (BAA) before disclosing PHI to the Business Associate is important to consider for compliance purposes. In the case In re Advanced Care Hospitalists, the medical group practice (ACH) hired a company to perform billing data processing services on behalf of the medical group. ACH did not enter into a Business Associate Agreement with the billing company before disclosing PHI. It was later discovered that patient information was readily viewable on the billing company’s website, including names, birth dates and social security numbers of over 9,000 patients. The medical group filed a Breach Notification report and OCR conducted an investigation. At the conclusion of the investigation, the medi30

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N LATIO O I V CY PRIVA

cal group agreed to pay $500,000 and enter into a comprehensive Corrective Action Plan with OCR. OCR made the following legal findings: 1. The medical group impermissibly disclosed the PHI of over 9,000 of its patients to a third party for billing data processing services without the protections of a BAA in


place in violation of the HIPAA Privacy regulations. 2. The billing company contract to provide data processing and billing services did not satisfy the HIPAA Privacy regulations. 3. The medical group failed to conduct a valid risk analysis. This case emphasizes the need to continuously monitor potential relationships in which PHI is disclosed to third parties and execute a HIPAA-compliant BAA before any PHI is disclosed to the third party. Even though there was no evidence that any PHI was improperly accessed, used or disclosed, and no evidence of any harm to any patient existed, the health care provider had to pay a $500,000 fine. For compliance and training purposes, here is a reminder of the BAA regulatory requirements: 1. A Business Associate is a person or entity that performs functions or activities that necessarily involve the use or disclosure of PHI on your behalf, or provides services. 2. The types of functions or activities that may make a person or entity a Business Associate include payment or health care operations, activities, and several other functions, including: • Claims processing or administration; • Data analysis, processing or administration; • Utilization review;

• Quality assurance; • Billing; • Benefit management; • Practice management; • Repricing; • Legal, actuarial, accounting and consulting services; • Data aggregation; and • Management, administrative, accreditation and financial services. 3. Examples of Business Associates include language interpreters, outside compliance or other consultants and IT consultants. 4. As a reminder, Business Associates are not: • Cleaning services; • Contractors; and • Any other person or organization that has no right to access PHI. 5. Each person’s access to and use of PHI must be based on a reasonable requirement to actually use or access the PHI. The health care provider (i.e. the covered entity) was responsible to pay the full fine in this case. That emphasizes the need to include an indemnification clause in every BAA because, in this case, the Business Associate improperly, and perhaps even inadvertently, failed to implement sufficient security measures on its own website. In other words, the health care provider was still liable for the Business Associate’s security breach. WWW.PAFP.COM

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THE

PAFP FOUNDATION Your donation builds a home for future docs

“ I am so grateful for the foundation’s support when I was a medical student and resident, which allowed me to grow as a leader and advocate for family medicine.” Jason Woloski, MD Geisinger Wyoming Valley Wilkes-Barre, PA

An all new online donation form makes giving simple and fast.

DONATE TODAY CLICK HERE

Thank you for your support! FM InSpIRe (Family Medicine INfluencing SPecialty Interest REvolution) is a new PAFP initiative to create awareness | 32 | KEYSTONE | SPRINGand 2019 ofPHYSICIAN the PAFP Foundation raise funds that directly support residents andwww.pafp.com students.

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Pennsylvania Academy of Family Physicians Foundation

FREE CME WEBCASTS AT YOUR FINGERTIPS ADVANCES IN THE SCREENING, DIAGNOSIS AND TREATMENT OF TESTICULAR AND PROSTATE CANCER 0.75 CREDIT(S)

ADVANCES IN THE SCREENING OF FEMALE REPRODUCTIVE CANCERS 0.5 CREDIT(S)

IMPROVING THE DIAGNOSIS AND MANAGEMENT OF OPIODINDUCED CONSTIPATION TO OPTIMIZE OUTCOMES OF PATIENTS WITH CHRONIC PAIN 0.75 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA

A CLEAR VIEW OF COMMON PROBLEMS IN OPHTHALMOLOGY 0.75 CREDIT(S)

ADULT IMMUNIZATION UPDATE 0.75 CREDIT(S)

CDC OPIOID PRESCRIBING GUIDELINES AND PDMP RULES 1.0 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA

EARLY CKD DIAGNOSIS AND WHEN TO REFER 0.75 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA

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EVALUATION OF PATIENT WITH COMMON ELECTROLYTE ABNORMALITIES 0.75 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA

EXPLORING PROTEIN’S ROLE IN WEIGHT LOSS AND BODY COMPOSITION 1.0 CREDIT(S)

HEPATITIS C UPDATE 0.75 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA

MEDICAL GENOMICS 1.0 CREDIT(S)

OBESITY MEDICINE IN PRIMARY CARE 0.75 CREDIT(S)

QUICK HITS - NEPHROLOGY BOARD REVIEW 0.5 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA

TICK-TOCK: ARTHROPOD BORNE DISEASE ON THE RISE 1.0 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA

TOP 10 ISSUES IN WOMEN HEALTH 0.75 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA

TREATING CHRONIC PAIN IN NON-CANCER PATIENTS 0.75 CREDIT(S)

All online sessions meet your Patient Safety requirement Online CME = reward points PAFP members, collect 10 reward points and earn discounts at PAFP Foundation CME conferences or discounts off PAFP apparel. Your reward points will be added to your member record after you complete the webcast or monograph post-test and evaluation. 34

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Profile for PA Academy of Family Physicians

Keystone Physician Magazine - Spring 2019  

Keystone Physician Magazine - Spring 2019  

Profile for pafp