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PRESIDENT'S MESSAGE What is the future of family medicine?
Join the PAFP on an Alaska adventure: Cruise sets sail July 2021 Prepare your office for coronavirus PAFP EVP, CEO joins Gov. Wolf for budget address PAFP announces 2020 award winners Pennsylvania launches mental health initiative
10 10 11 11 11
COVER STORY At the Hub of Hope, some of Philadelphia’s most vulnerable residents receive health care in the tunnels of the city’s subway system. Left to right: Ivel Morales, MD, Hub of Hope medical director; Nayeli Spahr, MD, clinic physician.
Can Physicians with Careers in Family Medicine Build Walkaway Wealth? (Sponsored) Hub of Hope: Family medicine goes underground in Philadelphia
SPRING 2020 VOLUME 80 | NUMBER 1
PAFP 2019-2020 Legislative Agenda: mid-session report Pennsylvania House Speaker and former “Friend of Family Medicine” award winner to retire PAFP’s top legislative priorities: prior authorization reform; CRNP independent practice; physician credentialing reform; buprenorphine medically assisted treatment
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Mandatory opioid treatment agreements Failure to credential physician before submitting claims: Provider misidentification/locum tenens documentation fraud
23 28 34
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PRESIDENT'S MESSAGE MARY STOCK KEISTER, MD, President firstname.lastname@example.org
What is the future of family medicine? ast week, I went to a national meeting of the Health Care Advisory Board. One of the subjects was â€œThe Future of Primary Care.â€? I was interested to see what they would say as I had never been to a meeting of this organization before. And while I was pleased to hear them bring up the issue of the primary care spend, and how the state of Rhode Island is using increased money going to primary care to improve outcomes and decrease total cost of care, I must say I was disappointed in the observed trends for how to meet the demands of the population with an insufficient PCP workforce. Specifically, at no point was there any discussion
goal of 30% of medical school graduates going
of creating more primary care physicians. Their
into Family Medicine by 2030 was not anywhere
options mostly revolved around segmenting
in the presentation.
the patient population (creating some smaller panels for those patients who might best
While I could appreciate that as an organization
benefit), utilizing technology around virtual care
which focused on what is currently out there
(asynchronous and synchronous contact), and
in the market, I thought it was a real cop-out
extending clinician capacity (which specifically
to not address whether the U.S. currently has
the right breakdown of primary care physicians
and specialist physicians, And if not, what can
models). In other words, the family physician
we do about it? I was also worried because
I was sitting in a room with a bunch of health systems administrators, workers in healthcare technology, realtors, bankers, and others, and all of them are hearing the same thing: the only way to solve the problem of ensuring access to the entire population is to make sure that nurse practitioners and physician assistants work in
... negotiating for time within my job to work on projects for which I am passionate and which improve the working of my office definitely helps mitigating my feelings of burnout.
an autonomous fashion. At no point did they say without any type of physician supervision, but it was made very clear that the industry expects that these health professionals have that capacity, and that further it would be in the best interest of existing business models for the most autonomy legally available. At the same meeting, it was mentioned that primary care physicians who are employed have less likelihood to change their referral patterns based on cost and outcome data as compared to independent physicians. I found it fascinating that while many family physicians feel driven into an employed model for financial reasons, it does not seem to improve quality of care or total cost of care to the overall system.
They identify that as compared with other graduate level professionals such as lawyers and professors who have time build into their schedules for reflection and strategy, primary care physicians generally have to “bill” for quite a high percentage of their working hours and their small amount of “non-billable” time is spent completing InBasket tasks and clinical paperwork. They suggest that allowing for more diversity of the work may help mitigate burn out in family physicians. I can state for myself that negotiating for time within my job to work on projects for which I am passionate and which improve the working of my office definitely helps mitigating my feelings of burnout. The other thing that also helps me is
After getting back from the Health Care
putting things into a wider perspective. My work
Advisory Board meeting, I picked up my latest
with the PAFP has allowed has allowed me to
copy of Family Practice Management. I was
engage family physicians in a different way, and
drawn to an opinion piece in the January/
work on the issues which affect us at a different
February 2020 issue. Drs Christine Hancock
level. I found the perspective to be incredibly
and colleagues wrote an opinion piece titled
“Why Family Physicians Should Not ‘Just’ Be Family Physicians: Rethinking Physician Roles
So as I put both my experience at the Health
in Community Health Centers and Beyond1.”
Care Advisory Board meeting and my readWWW.PAFP.COM
PRESIDENT'S MESSAGE ing of the recent Family Practice Management opinion article together, here are my thoughts: Family physicians are seen as valuable; however, we don’t typically do what health care systems need us to do. We don’t like keeping our referrals “internal” when we suspect it is more expensive for the patient or the total cost of care. Our goal is to keep patients out of the hospital and health care systems still tend to make more money on inpatient billing. We need autonomy, no mat-
high school students, college students, and medical students who are showing interest and aptitude for primary care. The upcoming generation is looking for mission in their work. We have that mission. Our patients and our communities are our mission. We can keep our ideals close to us, and fight for what is right and possible. This is my last column as president, but the fight is ongoing, and worth it.
ter how we get paid, to be able to devote some working time to projects which inspire us.
1. Hancock C, Garrison-Jakel J, Jordan V, Scott T, Les J. Why Family Physicians Should Not ‘Just’ Be Family Physicians: Rethinking Physician Roles in
If we want to keep family medicine vital in our
Community Health Centers and Beyond. Family
communities, we need to do more to mentor
Practice Management. 2020: 27(1):5-7)
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Join the PAFP on an Alaska adventure: Cruise sets sail July 2021 sets sail on the Celebrity Millennium, taking in the wonders of Alaska, you can earn at least 20 hours of patient safety credit while enjoying the trip of a lifetime with family and friends. There are two options â€” a three-day pre-cruise land tour and cruise starting from Anchorage, AK, on July 13 or a seven-day cruise only which departs from Seward, AK, on July 16. With help from our cruise agent, Harry Morris from Cruises by Mark your calendar and join the PAFP along with
Lori, you can reserve your cabin today and set
the Pa. Optometric Association as we travel to
your out-of-office now! CME registration will be
Alaska for a CME Cruise in July 2021! As the PAFP
opening online mid-March.
Prepare your office for coronavirus According to the Centers for Disease Control and Prevention (CDC), the 2019 novel coronavirus, which is responsible for thousands of deaths worldwide, hit the U.S. in early February. The CDC says it's unclear how the virus is spreading. The American Academy of Family Physicians is urging doctors to prepare for this virus and follow the CDC's guidance for health care professionals. 10
PAFP EVP, CEO joins Gov. Wolf for budget address PAFP Executive Vice President and CEO Brent Ennis was invited to join Gov. Tom Wolf for his address on the 2020-21 budget on Feb. 4. This was Governor Wolf’s fifth budget proposal and officially kicks off budget season
hearings in both the House and Senate scheduled following the proposal’s release.
PAFP announces 2020 award winners
Pennsylvania launches mental health initiative
The Pennsylvania Acad-
emy of Family Physicians
Wolf announced in January
would like to congratu-
a focused multi-agency
late the winners of its
2020 awards slate! Delana (Philadel-
campaign, ‘Reach Out PA: Your Mental Health Mat-
phia) and Ed Zurad, MD (Tunkhannock) have
ters,’ aimed at expanding resources and the
been named 2020 Family Physicians of the
state’s comprehensive support of mental health
Year; Jeffrey Martin, MD (Lancaster) is the win-
and related health care priorities in Pennsylva-
ner of the PARP 2020 Public Health Award,
nia. According to the Wolf administration, the
and Abdul Waheed, MD (Hummelstown) is the
initiative is "aimed at expanding resources and
PAFP 2020 Exemplary Teacher of the Year. Stay
the state’s comprehensive support of mental
tuned for interviews with each in the next issue
health and related health care priorities in Penn-
of Keystone Physician!
sylvania." Link - PAFP press release.
Can Physicians with Careers in Family Medicine Build Walkaway Wealth? The typical physician with a career in family medicine earns an income in the top 3% of all working Americans, yet these doctors often doubt their ability to build walkaway wealth. This is especially true for younger practitioners with large student loan debts. Can family medicine physicians become financially independent, and if so, how? The keys to financial security are getting your mind right and implementing best-practice strategies. Having worked with physicians since 1979, we’ve identified five elements of success: 1) Selecting the right definition of “rich” 2) Balancing consumption and saving from the beginning of your career 3) Optimizing the effectiveness of every savings, investment, and debt paydown dollar 4) Leveraging the power of transitions between life and career stages 5) Following sensible investment practice What is walkaway wealth? We use a simple and practical definition of wealth with our physician clients: You are rich when you can maintain your chosen lifestyle, for as long as you live, without being required to work. Note two aspects of this definition. First, your chosen lifestyle determines the capital you’ll need to sustain that lifestyle without working. 12
Second, you’re not required to stop working once you attain walkaway wealth. In our experience, many physicians choose to keep practicing medicine even though they’ve accumulated enough to retire, and they do so with increased options regarding how, where, and with whom they practice. Balance lifestyle and financial security We live in a consumer society. Others measure your socioeconomic status based on where you live, what you drive, and how much you spend. Your car salesman and real estate agent don’t care if you’ll be able to retire with security. Be aware of society’s pro-spending cues and be prepared to push back. Value reputation over stuff Doctors and nurses enjoy the highest reputational status of any careers in the United States. Your work is more valued and you are more trusted than anyone in our culture. Focus on that well-deserved admiration and ignore the fact that some hedge-fund manager chooses to
drive a Mercedes. Keep in mind that spending on possessions tends to have a transient effect on happiness, while spending on relationships and experiences promotes durable emotional benefits. Commit to saving Understand that debt paydown is absolutely a form of saving and can be the most powerful form. Effective saving at the beginning of your career will have greater impact than saving nearer the end. Your minimum savings goal should be 15% of gross compensation, though 20% or 25% savings will strengthen your position. Optimize your savings sequence Savings opportunities are not created equal. Almost always, pre-tax savings are the most powerful option you’ll have. Fully fund your 401(k) or 403(b) employee savings plans if at all possible. Be ruthless in maximizing the after-tax riskadjusted return of every savings dollar. Wherever you can, automate your process of saving. In conclusion Your financial outcomes are affected by a host of large and small choices made over decades. But it will likely be the decisions you make at a limited number of significant inflection points that largely determine the financial arc of your entire life.
early-career physicians, with special attention on student loans and buying your first house. By James S. Hemphill, CFP®, CIMA®, CPWA® Jim presents financial workshops for physicians and speaks at physician conferences. He is the co-author of two books: Pay Yourself First: A Financial Guide for Doctors Entering Practice and Changing Outcomes: A Financial Recovery Strategy for Peak-Career Physicians. Jim is a CERTIFIED FINANCIAL PLANNER™. He received his Certified Investment Management Analyst designation from the Wharton School of Business and his Certified Private Wealth Analyst designation from the University of Chicago Booth School of Business. He is co-founder of TGS Financial Advisors. TriageMD by TGS Financial Advisors offers programs designed to improve the financial trajectories of physicians and their families. To learn more, click here. Your first conversation with a TriageMD advisor is complimentary.
There are well-understood financial best practices you can implement at every stage of your career. In this series of articles, we look forward to sharing those best practices. Our next installment will focus on strategies and tactics for WWW.PAFP.COM
Family medicine goes underground in Philadelphia Since 2014, the Pennsylvania Academy of Family Physicians has administered a grant from the Pennsylvania Department of Health’s Bureau of Health Planning. That grant, part of the bureau’s Primary Health Practitioner Program, led to new investment in primary care workforce development supporting family medicine residency expansion. The objective of the grant is to increase the number of family physicians who train in and remain in Pennsylvania communities experiencing a critical shortage of primary care physicians. In the following feature, we take a look at the practice of one of the participating residency programs’ graduates. elow Two Penn Center in Philadelphia, family physician Nayeli Spahr, MD, MPH is listening to her patient’s heartbeat as the sound of trains passing fills the room. A former police substation is home to a primary care clinic for homeless and underserved patients. More than 300 people a day pass through the Hub of Hope. Thanks to Project HOME – an organization that provides meals, coffee, showers, laundry, recovery groups, social services, veterinary care, and much more – family medicine is everywhere in the City of Brotherly Love, including underground.
FEATURE According to Project HOME, its mission is
“Sometimes people come in and we just have
to empower adults, children, and families to
them sleep as their medical care, because they
break the cycle of homelessness and poverty,
literally haven’t slept in days because they've
to alleviate the underlying causes of poverty,
been wandering the streets looking for a safe
and to enable everyone to attain their fullest
place to lay down.,” said Spahr. “They’ll come
potential as individuals and as members of the
in with flu-like symptoms, but not where you’re
broader society. A part of that vision is medi-
going to send them to the ED; they just feel
cal care across four different facilities in Philly,
crummy. So we turn the lights off to give them
including one at the Hub of Hope.
respite for an hour, some Tylenol, hydration, and then see how they are after that.”
“I remember when I was looking for jobs in medicine, I came down here to see what this
Spahr and the others who work with the Hub
place looks like and immediately thought, this
of Hope recognize that they aren’t just treat-
place is awesome!” said Spahr. “It just keeps
ing patients. They feel a responsibility not just
you on your toes. I do full-spectrum care; I like
to address the direct need – something to eat,
having the Steven Kline office [another Project
a place to sleep, a doctor visit – but the social
HOME location] where I can see kids and do
determinants of health that manifest in these
prenatal care, but the acuity of need here, you
more urgent matters.
just feel that you’re helping on a different level. “Everything that I do as a physician has to do “I’d prefer not having to see kids here, because
with social justice,” said Spahr. “My role as a
you would hope that children aren’t in the
physician, it’s part of my responsibility to help
social circumstances that bring most patients
decrease whatever barriers people might have
down here. But we meet their immediate needs
to being the best versions of themselves that
when we do - finding shelter, medical evals,
they can be.
dental care. I’ve even seen a newborn here before,” said Spahr. “We’ll do the best kind of
“I also feel that because of Project HOME’s
prenatal care that we can when people come
presence in the city, and the opportunities for
in who are pregnant - meeting people where
advocacy that Project HOME does do, if you
they are. So, in reality, I do see full-spectrum
see injustice, you feel empowered to do some-
here as well.”
thing about it because there’s already a precedent,” Spahr said. “There’s quick phone calls
Many chronic needs are addressed in this
that I can make that I’ve learned since starting.
subway tunnel, from controlling diabetes
[For example], if this happens again, call this
to treating hepatitis C. Often, the needs are
person and they can try to see if they can get
this person respite care somewhere else. Or,
" Sometimes people come in and we just have them sleep as their medical care, because they literally havenâ€™t slept in days because they've been wandering the streets looking for a safe place to lay down " - Nayeli Spahr, MD, MPH
Dr. Spahr puts a smile on patient Tracey Vensonâ€™s face. Venson is one of the approximately 300 people who pass through Hub of Hope every day for services including medical care, laundry, and hot meals.
FEATURE we can’t find this one person who we’re con-
Baylson said that this approach is unique to
cerned about because of a new diagnosis of
cancer, or has acute hep A – we have an outreach team that can go out and look for them.”
“Patients come to us first, so we just sort of know everything that’s going on elsewhere in
Spahr’s care for vulnerable populations is
the health system, and like all the places where
echoed in the mission of Penn Medicine’s Fam-
it’s failing people,” said Baylson. “I think you
ily Medicine Residency Program, where she
just can’t see all that and not be compelled by
completed her residency. At Penn, the impor-
tance of social determinants and health outcomes is front and center.
“It’s easier when you’re in a specialty where you don’t have continuity with someone, or
“We interview 100, 110 medical students each
you have not nearly enough continuity, to be
year who are part of the match process for
able to see a snapshot in time instead of really
residency placement the following summer,”
understanding how this depression is influ-
said Penn Family Medicine Residency Pro-
encing someone’s ability to take their insulin,”
gram Director Meg Baylson, MD, MPH. “Last
she said. “Or you have patients who confide
year, and again this year, we started including
that ‘I really just can’t go to physical therapy
a question, a standardized question for each
because I can’t afford the copays because I
applicant, that surrounds health equity. We’re
need to pay my rent.’ Well, that makes total
a mission-driven group. We wanted to include
sense. I’d like you to have a place to live more
social justice and health equity as factors in
than physical therapy.”
choosing who would join our residency program.
The transient nature of the population that the Hub of Hope largely treats means the team
“I think you really just want to make sure that
often has to think quickly and creatively.
everyone who matches into our program has some awareness of how social determinants
“There are things you don’t think of that you
of health impact health and how patients who
need to consider. Like, I’m not going to order
are discriminated against in a variety of dif-
this medication because it’s really heavy, or
ferent ways – by race, or by economics, or by
I’m not going to order this many pills because
education, or other social capital elements –
they’re not going to be able to carry it with
have worse health outcomes,” said Baylson.
them. What is the pill burden?” said Spahr. “If
“We as physicians first have to be aware of it,
you think of polypharmacy and people who
but should ideally be a part of the solution in
are carrying all their meds, it’s a huge bag for
reducing some of those health inequities.”
someone who’s carrying all their belongings
with them. You need to think, what are the
have an amazing medical team that is invested
essential medications that this person needs
in meeting patients where they are, because
to make it to the next appointment?”
this work cannot be done in isolation.
Meeting the patients’ need for care is one
“Sometimes people will come in, and initially
thing; Spahr recognizes meeting their need
they don’t want to talk and we’ll simply do
for genuine human care and connection is
wound care, for example,” said Spahr. “But
also a must.
more often, they actually want to talk about all the things, because they’ll go to the ED like
“Usually, in family medicine, continuity is super
3 times in the span of two weeks but no one’s
important, so how much do I need to invest
actually listening to that part of their story,
in getting to know the story of this patient at
because the ED is not designed to give that
this new patient visit?” said Spahr. “Because
kind of care.”
that’s time consuming, but also very important to me and integral to
Spahr – who was born in Mexico
the care they need. We
and grew up in various locations
The transient nature of the population that the Hub of Hope largely treats means the team often has to think quickly and creatively.
FEATURE across the United States – knows a bit about
her at our program. And she absolutely made
the struggles her patients face every single
our program better by inspiring some of this
day, from finances to immigration to being
health equity work and advocacy work.
evicted from her home at age 6. She hopes that her background and her eagerness to
“I think Nayeli had all this passion for caring for
confront social injustice shows in the way that
vulnerable populations and an MPH before she
she treats her patients.
came, and I think what we gave her is the confidence of how taking all of that and applying
LEARN MORE ABOUT THE HUB OF HOPE DONATE
it as a physician, in addition to teaching her medical stuff,” Baylson said. “I feel just lucky to have had the opportunity to be her program director.”
For Spahr’s part, everything centers around
“I think one of the things you see down here
“Our goal is to make access easier and reduce
a lot is that homelessness and poverty affects
the obstacles - you still care about your diabe-
everyone – and it can affect anyone at any age,”
tes, blood pressure, mental health, abnormal
she said. “I come from a background where
pap - that doesn’t stop just because you are
my mom raised me working two full-time jobs.
homeless. The priorities might change order,
her patients. They are her singular focus.
but it still matters. We’re trying to figure out “I’ve been fortunate to build relationships with
how to best meet the needs of patients.
people across the world that have helped me along my journey and taught me about the
“For people who are at the fringe of where
resilience of the human spirit, but it’s really
they can find help, or who don’t access help,
hard to go it alone.” Spahr said. “We’re all sup-
that’s where we are present in the care that
posed to take care of each other, and as a phy-
we’re providing,” she said. “It’s thinking a lot
sician, that’s my role.”
about harm reduction, point of care - what’s gonna get you to tomorrow or next week. It’s
Baylson has nothing but praise for the physi-
about connection and building trust and to
cian she mentored.
ultimately find home again.
“I won’t take any credit for how awesome
To learn more about the Hub of Hope, please
Nayeli is,” said Baylson. “She was awesome
visit www.projecthome.com/hubofhope. You
before she came, we were so excited to have
can also donate and volunteer.
, G N I T E E M M S I S H S T E & N I E S C U N B E R Y L E A F U N ANN CME CO RCH DAEY, PA H S A R E E RESERSHEY â€¢ H H C R A
EL T O H
20 0 2 , 5-8
Join us for the installation of PAFP's next President - Tracey Conti, MD
GOVERNMENT AFFAIRS JENNIFER REIS, Chief Government Affairs Officer email@example.com
PAFP 2019-2020 Legislative Agenda: mid-session report he New Year marks the halfway point of the Pennsylvania General Assembly’s 2019-2020 legislative session, and already the PAFP has several high-priority items primed to see action in the first half of this year. On Tuesday, Feb. 4, Governor Tom Wolf presented his FY 2020-21 State Budget to the Pennsylvania General Assembly. Among increases for basic and special education, the Governor’s proposed budget includes an increase in the Primary Health Care Practitioner line item within the Department of Health’s (DOH) budget. In addition to our 2019-2020 Legislative Agenda items (use same link), the PAFP will be advocating to maintain this increase as the legislature negotiates the details of the budget over the next several months. Part of this line item is allocated to the PAFP through a grant by DOH to provide financial assistance to create new residency slots at family medicine programs throughout the Commonwealth. This program is consistent with the PAFP’s commitment to expanding the family physician workforce in Pennsylvania. To further build on this effort, the PAFP has worked with Rep. Paul Schemel (R-Franklin) to 22
introduce House Resolution 625, which would direct the Joint State Government Commission to conduct a study and issue a report on the efforts of medical schools to promote primary care and include primary care experiences as part of the curriculum. Politically, 2020 is expected to be a highly anticipated election year at both the federal and state levels, with the presidential election taking center stage. In Pennsylvania, all 18 Congressional districts are up for grabs, in addition to the three statewide row offices – Attorney General, Auditor General and Treasurer.
With all 203 state House seats and half (25) of the state Senate seats on the ballot, there are sure to be significant changes in the Pennsylvania General Assembly come 2021. To date, more than 15 House members have announced they will not seek reelection (with more expected), including Speaker of the House Mike Turzai (R-Allegheny) and Senate President Pro Tempore Joseph Scarnati (R-Jefferson). In addition to high-ranking leadership positions, these retirements will leave several chairmanships of legislative standing committees open – most notably on the House Professional Licensure Committee. The long-standing Democratic Chair Rep. Harry Readshaw (D-Allegheny), who will not seek reelection, has been a strong ally of family medicine on that committee. The Majority Chair position of the House Human Services Committee will also be left vacant with the retirement of Rep. Thomas Murt (R-Montgomery) at the end of this legislative session.
PENNSYLVANIA HOUSE SPEAKER AND FORMER “FRIEND OF FAMILY MEDICINE” AWARD WINNER TO RETIRE Speaker of the Pennsylvania House of Representatives Mike Turzai (R-Allegheny) has announced he will not seek reelection at the end of his current term. Turzai, who has served in the state Mike Turzai (R-Allegheny) (left) recieves House for nearly 20 the "Friend of Family Medicine" honor in 2016 from PAFP Past President, Nicole years, was awarded the Davis, MD (right) PAFP’s “Friend of Family Medicine” honor in 2016 for his support of the family physician community throughout his tenure in the Pennsylvania General Assembly. In addition to championing medical liability reforms, Turzai has also been a strong line of defense against nurse practitioner independent practice – one of the PAFP’s top legislative issues. Elected in 2001 to serve the state’s 28th Legislative District, Turzai quickly rose through the ranks, eventually becoming the House Majority Leader from 2011 to 2014. He was elected Speaker of the House by his peers in 2015 and is currently serving his third term in that role. The PAFP congratulates Speaker Turzai on his retirement and wishes him success in his future endeavors. He will be sorely missed as an advocate for family medicine in the halls of the state Capitol.
PAFPâ€™s top legislative priorities: prior authorization reform; CRNP independent practice; physician credentialing reform; buprenorphine medically assisted treatment 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. Rep. Steve Mentzer (R-Lancaster) has introduced House Bill 1194, which has strong bipartisan support. The legislation has been referred to the House Insurance Committee. In the Senate, Sen. Kristin Phillips-Hill (R-York) has introduced Senate Bill 920, which has been referred to the Senate Banking and Insurance Committee. NURSE PRACTITIONER INDEPENDENCE Nurse practitioners (NPs) are integral, valuable members of the health care team, held in the highest regard by family physicians. However, 24
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. The Senate passed Senate Bill 25, sponsored by Sen. Camera Bartolotta (R-Washington) in June 2019. Rep. Jesse Topper (R-Bedford) has introduced House Bill 100. Both bills await consideration in the House Professional Licensure Committee. 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. Rep. Clint Owlett (R-Tioga) has introduced House Bill 533 seeking to codify significant reforms. The bill passed the House of Representatives in November 2019 and awaits consideration in the Senate Banking and Insurance Committee.
BUPRENORPHINE MEDICALLY ASSISTED TREATMENT (MAT) 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. Sen. Michele Brooks (R-Mercer)
has introduced Senate Bill 675, which passed the Senate in June 2019. The bill awaits consideration in the House Human Services Committee, which held a public hearing on the issue last fall. The PAFP is working with the Committee and stakeholders to find a compromise that will address the concerns of bill proponents without creating additional barriers to MAT prescribing.
THE PENNSYLVANIA ACADEMY OF FAMILY PHYSICIANS
Together we can do more.
PAFP-PAC is the official political action committee of Family Medicine in Pennsylvania. Through individual contributions, PAFP-PAC supports candidates for the state legislature who demonstrate an interest in issues impacting family physicians. By contributing to PAFP-PAC, you join your colleagues in creating a stronger voice for Family Physicians in Harrisburg. In todayâ€™s environment, PACs are an important part of the political process and a necessary advocacy tool.
Make your contribution today. WWW.PAFP.COM
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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 26
ow for download on iOS azon Kindle Fire) devices!
LEGAL AND COMPLIANCE UPDATE CHARLES I. ARTZ, Esq., General Counsel firstname.lastname@example.org
Mandatory opioid treatment agreements new law signed by the Pennsylvania Governor on November 27, 2019 mandates physicians who prescribe opioids to patients to enter into an Opioid Treatment Agreement with each patient. Senate Bill 572, Printer’s Number 1400 was signed into law as Act 112 of 2019. The Opioid Treatment Agreement Act was effective immediately upon the Governor’s approval on November 27, 2019. The important elements of Act 112 – 2019 are summarized below. PRESCRIBER REQUIREMENTS Before issuing an individual the first prescription in a single course of treatment for chronic pain with a controlled substance containing an opioid, regardless of whether the dosage is modified during that course of treatment, the prescriber must conduct an assessment, discussion, review and sign a Treatment Agreement, obtain consent, record the consent, and conduct urine drug testing. A “prescriber” is a physician, physician assistant or nurse practitioner who is registered with DEA and lawfully authorized to distribute, dispense or administer a controlled substance during the course of professional practice. 28
ASSESSMENT The prescriber must assess whether the individual has taken or is currently taking a prescription drug for treatment of a substance use disorder before issuing the first opioid prescription. The term “opioid” includes any of the following: • A preparation or derivative of opium; • A synthetic narcotic that has opiate-like effects but is not derived from opium; or • A group of naturally occurring peptides that bind at or otherwise influence opiate receptors, including an opioid agonist.
The term “chronic pain” is defined as “pain that persists or progresses over a period of time that may be related to another medical condition and is resistant to medical treatment.” It does not include “acute pain.” The term “acute pain” is defines as “pain that comes on quickly, may be severe, but lasts a relatively short time and is provoked by a specific condition or injury.” DISCUSSION The prescriber must have a discussion with the patient before issuing the first opioid prescription for chronic pain that includes all of the following:
OPIOID TREATMENT AGREEMENT REQUIREMENTS Before issuing the first opioid prescription for chronic pain, the prescriber must review and sign a Treatment Agreement that includes all of the following: 1. The goals of the treatment. 2. The consent of the individual to a targeted test in a circumstance where the physician determines that a targeted test is medically necessary. 3. The treatment of chronic pain shall be consistent with the Pennsylvania Opioid Prescribing Guidelines. 4.
• The risks of addiction and overdose associated with the controlled substance containing an opioid; • The increased risk of addiction to a controlled substance if the individual suffers from a mental disorder or substance abuse disorder; • The dangers of taking a controlled substance containing an opioid with benzodiazepines, alcohol or other central nervous system depressants; • Any information the physician deems relevant from the product label; and • The non-opioid treatment options available for treating chronic non-cancer pain if applicable, that are consistent with the best practices pursuant to the Pennsylvania Opioid Prescribing Guidelines.
The prescriber’s policies which include: • A requirement that the individual take the medication as prescribed; and • A prohibition on sharing the prescribed medication with other individuals.
A requirement that the patient inform the physician about any other controlled substances prescribed or taken by the patient.
Any reason why the opioid therapy may be changed or discontinued by the prescriber.
7. Appropriate disposal methods for opioids that are no longer being used by WWW.PAFP.COM
LEGAL AND COMPLIANCE UPDATE the patient as specified in consultation with the prescriber. 8. Obtain written consent for the prescription from the patient, which may be accomplished utilizing electronic methods. The consent must be recorded in the agreement itself. 9. The brand name or generic name, quantity and initial dose of the controlled substance containing an opioid being prescribed. 10. A statement indicating that a controlled substance is a drug or other substance that the United States Drug Enforcement Administration has identified as having a potential for abuse.
A statement certifying that the prescriber engaged in the discussion summarized above.
12. The signature of the patient and the date of signing. 13. The signature of the prescriber. The stated goal of the Treatment Agreement is to make sure the patient understands: 1.
The conditions of medication use.
3. The conditions under which the treatment of the individual may be terminated.
ON INSTAGRAM #pafpcme
The responsibilities of the prescriber.
URINE DRUG TESTING Physicians and extenders who prescribe opioids for chronic non-cancer pain are now statutorily required to conduct urine drug testing on patients. The following rules apply: 1. A baseline test is required prior to the issuance of the initial prescription for chronic pain. The baseline test must include confirmatory or quantitative testing of presumptive positive drug test results. 2. A baseline test, periodic test or targeted test must be used to establish a general assessment for an individual new to treatment for chronic pain and a monitoring adherence to an existing individual treatment plan, as well as to detect the use of a non-prescribed drug. 3.
An individual who is treated for addiction or an individual who is considered moderate or high risk by the prescriber must be tested at least once annually or as frequently as necessary to ensure therapeutic adherence.
The term “baseline test” is defined as the initial assessment through a urine drug test to: • Identify the presence of an illegal substance prior to prescribing a controlled substance; or
• Assess the presence or absence of a prescribed drug or drug class. The term “periodic test” is defined as a “urine drug test that screens for a selection of drugs.” Notably, the term “random” was removed from prior versions of the legislation. The term “targeted test” is defined as “a urine drug test ordered at the discretion of the prescriber, based on the observation of the prescriber and related circumstances that enhanced clinical decision making.” The term “presumptive positive drug test” is defined as follows: A urine drug test that is used to identify suspected possible use or non-use of drugs or a drug class that may be followed by a definitive test to specifically identify drugs or metabolites. The term “definitive drug test” is defined as follows: A qualitative or a quantitative urine drug test used to identify specific drugs, specific drug concentrations and associated metabolites. STATUTORY ADOPTION OF PENNSYLVANIA OPIOID PRESCRIBING GUIDELINES As noted above, Act 112 refers to the Pennsylvania Opioid Prescribing Guidelines twice. The Guidelines are not specifically defined; however, it is reasonable to conclude that the Opioid Prescribing Guidelines refer to WWW.PAFP.COM
LEGAL AND COMPLIANCE UPDATE the eight guidelines currently published and posted on the Pennsylvania State Board of Medicine’s website.1
4. The professional judgment of the prescriber with respect to assessments and discussions summarized above.
We have previously recommended compliance with each of these Guidelines because expert testimony could establish those guidelines as the applicable standard of care. The provision in 35 Pa.C.S. §52B02(a)(3)(ii) stating that “the treatment of chronic pain shall be consistent with the Pennsylvania Opioid Prescribing Guidelines” and the requirement that physicians must discuss non-opioid treatment options available for treating chronic non-cancer pain consistent with the guidelines pursuant to 35 Pa.C.S. §52B02(a)(2)(v) demonstrate that the Medical Board’s Opioid Prescribing Guidelines are now the law of the Commonwealth of Pennsylvania. Whether those guidelines can be modified without following regulatory review statutory procedures remains an open question. For now, it is legally prudent to adhere to every element of every Guideline that is applicable to any treatment circumstance.
The prescriber is required to document in the patient’s medical record which of the four factors summarized above the prescriber believes applies to the individual in order to justify an exception.
EXCEPTIONS The Urine Drug Testing Requirements do not apply if the treatment of an individual with a controlled substance containing an opioid is associated with or incident to: 1. A medical emergency documented in the medical record of the patient. 2. The management of pain associated with cancer. 3. The use of controlled substances in palliative or hospice care. 32
SANCTIONS AND PENALTIES A physician or extender who violates Act 112 is automatically subject to sanctions under the prescriber’s Professional Practice Act and by the appropriate licensing board. In other words, any violation of Act 112 constitutes an automatic violation of the Medical Practice Act or the Osteopathic Medical Practice Act, subjecting the physician to sanctions against the physician’s license. EFFECTIVE DATE As indicated above, Act 112 took effect immediately upon the Governor’s signature on November 27, 2019. OPEN LEGAL QUESTIONS Careful analysis of Act 112 raises questions that have not been answered. First, the Opioid Treatment Agreement is referred to as a “form” several times. Act 112 does not include a specific form (as some other statutes have done). Although the Department of Health is required to publish temporary regulations before the end of February 2020, Act 112 does not require DOH to prepare the form. Even if it did, the Act is already in effect.
must be included in the prescribing policies contained in the Opioid Treatment Agreement. That suggests the physician has a fair amount of discretion to change or discontinue opioid therapy, but there are no specific parameters contained in Act 112.
Second, 35 Pa.C.S. §52B02(a) imposes the Prescriber Requirements “before issuing an individual the first prescription in a single course of treatment for chronic pain with a controlled substance containing an opioid.” What about existing patients “being treated with opioids for chronic pain?” Act 112 is completely silent as to whether existing patients receiving opioid prescriptions for chronic pain are subject to the extensive requirements of Act 112. Act 112 does not contain any “grandfather clause” or any other specific exception for existing patients. Third, physicians and extenders must think critically about the reasons why opioid therapy may be changed or discontinued, which
Fourth, the urine drug testing requirements apply to individuals new to treatment for chronic pain and monitoring adherence to an existing individual treatment plan. With respect to existing patients, the Medical Board’s Opioid Guidelines give physicians some discretion about how to advise patients on the necessity of periodic compliance checks that include urine or saliva drug testing as well as pill counts. Because the Guidelines are now the law, does that mean existing patients receiving opioid prescriptions are subject to mandatory urine drug testing? Do saliva drug testing and pill counts remain optional? Perhaps the Department of Health’s temporary regulations will address these and other issues that arise; however, those regulations are not required to be published until the end of February 2020. In the meantime, PAFP members who prescribe opioids to patients with chronic pain as defined in Act 112 must move quickly to develop and implement Opioid Treatment Agreements and procedures consistent with Act 112.
1 These include the Safe Prescribing of Opioids in Orthopedics and Sports Medicine; Emergency Department Pain Treatment Guidelines; Opioids to Treat Non-Cancer Pain Guidelines; Geriatric Pain Treatment Guidelines; Obstetrics & Gynecology Pain Treatment Guidelines; Use of Addiction Treatment Medications in the Treatment of Pregnant Patients with Opioid Use Disorder Guidelines; Safe Prescribing for Workers’ Compensation Guidelines; and Pediatric and Adolescent Populations Guidelines. WWW.PAFP.COM
LEGAL AND COMPLIANCE UPDATE
Failure to credential physician before submitting claims: Provider misidentification/locum tenens documentation fraud The federal government has recovered almost $1 million from a medium-sized medical group practice based upon billing government and commercial third-party payors for services performed by a physician who was not credentialed with the payer, where the services were billed under the name and NPI of a different credentialed physician. In U.S. ex rel. Jain v. Smith, No. 18-cv-1213 (S.D. Cal. 2020), the whistleblower was another physician in the group practice. The whistleblower alleged that the medical group perpetrated a fraud by falsifying medical records on its EMR system in order to bill for treatment performed by a non-credentialed physician. A new physician employee was hired, but was not credentialed to bill services to Medicare, Medicaid and private insurance companies at the time of his employment. The group billed over 4,000 encounters under the names and 34
NPI of the other credentialed physicians in the practice. They changed the EMR field for â€œencounter providerâ€? to indicate the patient was instead examined and treated by a credentialed physician. The patient encounters were billed under the provider number of the credentialed physician who did not examine, evaluate or treat the patient rather than the
non-credentialed physician who provided all
apply to physicians who are retaining
of the services.
a substitute physician to take over at a practice when the original physician
is absent or has left the practice. The
leadership that his electronic signature had
substitute physician is usually paid by
been affixed to the records of a patient that the
the original physician on a fee-for-time
whistleblower did not treat. The reimbursement
compensation basis. It does not apply
received was not refunded. The medical
to billing for services provided by non-
group tried to “fix” the problem by adding an
credentialed employed physicians.
amendment to the medical records stating: The important compliance points that emerge “ On this date of service, Dr. X was the
from this decision include the following:
examining and treating physician. The chart was then reviewed and signed by Dr. Y.”
1. The most cost-effective approach is to delay a newly recruited physician
The amendment was not inserted in the actual
medical record; was not date or time-stamped;
credentialing has been successfully
and was not validated by a physician’s
signature. In addition, the practice contended
commercial third-party payors.
the services could be billed under the Locum Tenens rule. The Locum Tenens rules do not apply under these circumstances.
2. Do not bill the services of a noncredentialed
name and NPI of a physician who is The government recovered $950,000 to settle
credentialed if the billing physician did
the whistleblower’s billing fraud allegations
not participate in the examination and
under the False Claims Act and asserted the
treatment of the patient.
following: 3. Do not use the Locum Tenens billing 1. Failure to credential a physician then bill the physician’s services under a
rules and Q6 modifier to bill under these circumstances.
credentialed physician’s name and NPI constitutes provider misidentification and results in false claims.
4. Avoid creating amendments that do not accurately reflect the examining and
2. The Locum Tenens rules are inapplicable to these circumstances. Those rules
participation or the patient’s care and treatment. WWW.PAFP.COM
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T HE P E NNSY LVA NI A ACA DEM Y OF FA M ILY PHYS ICIA N S PR ES EN TS
ADVENTURES CONFERENCE IN FAMILY MEDICINE
September 10-12, 2020 • Camelback Mountain Resort - Tannersville, PA THE PENNSYLVANIA ACADEMY OF FAMILY PHYSICIANS FOUNDATION PRESENTS
CME CONFERENCE NOVEMBER I3-I5, 2020 THE WESTIN • PITTSBURGH, PA
Annual Business Meeting, CME Conference & Research Day March 5-8, 2020 • Hershey, PA Adventures in Family Medicine Conference September 10-12, 2020 • Tannersville, PA Pittsburgh CME Conference November 13-15, 2020 • Pittsburgh, PA 2021 CME Alaska Cruise July 13-22, 2021 • Alaska, PA
Pittsburgh CME Conference Date: TBD Topic: TBD
Available Now All online sessions meet your Patient Safety requirement •
Diagnostic Dilemmas and Medical Mysteries - Critical Thinking
Myths, Lies and Rhetoric: Deconstructing the Anti-Vax Movement
Physician Health First! - Physician Well-Being
Quick Hits – Women’s Health Board Review Q & A
View the webcast catalog for all courses
www.pafp.com 37 WWW.PAFP.COM || 37 Visit www.pafp.com details on all of our CME offerings
Pennsylvania Academy of Family Physicians Foundation
FREE CME WEBCASTS AT YOUR FINGERTIPS All online sessions meet your Patient Safety requirement DIAGNOSTIC DILEMMAS AND MEDICAL MYSTERIES - CRITICAL THINKING 1.00 CREDIT(S)
DODGING PITFALLS WITH PATIENT DISMISSALS 1.00 CREDIT(S)
ENHANCING THE PATIENT-PROVIDER CONNECTION: PRACTICAL STRATEGIES FOR IMPROVING OUTCOMES IN OBESITY MANAGEMENT 1.00 CREDIT(S)
MYTHS, LIES AND RHETORIC: DECONSTRUCTING THE ANTI-VAX MOVEMENT 0.75 CREDIT(S)
PHYSICIAN HEALTH FIRST! - PHYSICIAN WELL-BEING 2.00 CREDIT(S)
QUICK HITS - WOMENâ€™S HEALTH BOARD REVIEW Q & A 0.50 CREDIT(S)
WHEN IT ISN'T SIMPLE: MANAGING DIFFICULT LARC INSERTION AND REMOVALS 0.50 CREDIT(S)
A MULTIDISCIPLINARY APPROACH TO THE TREATMENT OF AUTISM AND INTELLECTUAL DISABILITY 0.75 CREDIT(S)
CARE OF THE PATIENT IN CRISIS: TRAUMA INFORMED DE-ESCALATION STRATEGIES FOR THE OFFICE 2.25 CREDIT(S)
CDL UPDATE 0.25 CREDIT(S)
DEPRESCRIBING AND POLYPHARMACY IN THE GERIATRIC POPULATION 0.75 CREDIT(S)
FECAL INCONTINENCE AND CONSTIPATION IN THE ELDERLY 0.25 CREDIT(S)
MEDICAL MALARKEY: MEDICAL MISINFORMATION IN THE DIGITAL AGE AND HOW TO CORRECT IT 0.75 CREDIT(S)
NARRATIVE MEDICINE 0.75 CREDIT(S)
ORAL HEALTH IN THE ELDERLY 0.75 CREDIT(S)
PAIN MANAGEMENT AND BEST PRACTICES 1.0 CREDIT(S) • MEETS MANDATED OPIOID EDUCATION CRITERIA
PRE-OPERATIVE EVALUATION 0.75 CREDIT(S)
WHEN TO STOP SCREENING AND TESTING – MAMMOGRAMS, PAPS, COLONOSCOPY 0.75 CREDIT(S)
All online sessions meet your Patient Safety requirement