AAFP Award Winner
Stan Kozakowski, MD EVENT WRAP-UP Bedford CME Conference
GOVERNMENT AFFAIRS Prior authorization legislation introduced
Representing Individual Physicians & Physician Groups Charles I. Artz, Esq. Health Law
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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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BOARD OF DIRECTORS Board Member Board Member Board Member Foundation President Foundation Vice President Student Chair Resident Chair
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PRESIDENT'S MESSAGE PAFP heads into 2020 after busy months of advocacy, education
PAFP CEO, EVP Jordan retires; Ennis named new EVP Apply today for a PAFP leadership position PAFP welcomes new Chief Government Affairs Officer Reis
8 9 9
Stan Kozakowski, MD: ‘Remain deeply curious’
COVER STORY PAFP member and family medicine champion Stan Kozakowski, MD talks to Keystone Physician about education, the AAFP Award for Distinguished and Meritorious Service to Family Medicine, and why he sees a bright future for the specialty.
PAFP travels to Bedford for final 2019 CME conference Highlights of the 2019 AAFP Congress of Delegates Meeting in Philadelphia, PA
WINTER 2019 VOLUME 79 | NUMBER 4
Prior authorization legislation introduced Statewide PDL goes live Jan. 1 Are you and your patients ready? Credentialing reform within reach Proposal to limit MAT receives strong opposition from providers, government officials
22 23 23 24
LEGAL AND COMPLIANCE UPDATE
Health care employer liability Negligence/breach of confidentiality Multiple HIPAA privacy/security violations; Lost records/improper internal PHI access; Media disclosure/selling PHI
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PRESIDENT'S MESSAGE MARY STOCK KEISTER, MD, President email@example.com
PAFP heads into 2020 after busy months of advocacy, education he last few months have been very busy
was introduced to the legislature under House
for the PAFP. We were fortunate to have
Bill (HB) 1194 and Senate Bill (SB) 920. You, our
the AAFP annual Congress of Delegates and FMX
members, have told us that prior authorization
CME event in Philadelphia at the end of Septem-
reform is your number-one advocacy priority,
ber. What a great opportunity to see what the
and I’m happy to report the introduction of this
AAFP is doing. From the policy discussions to
the CME, there was something for everyone! I also had the opportunity to speak to the SenAnd since then, there’s been a lot happening
ate Health and Human Services Committee on
on the advocacy front. I’ve been to the Capitol
the introduction of a unified preferred drug list
complex in Harrisburg more in the last month
(PDL) for all Pennsylvania Medicaid and Medic-
than I have been ever before in my life. The
aid managed care patients. The PDL goes live
experience of representing the PAFP has been
on Jan 1, 2020. Although the committee did
a very rewarding part of my presidency so far.
not have the authority to change the roll out of
Public speaking and hearings are not my favor-
the PDL by the Dept. of Human Services (DHS),
ite things by nature, but I know I have our values
I was able to express concerns about the tim-
as family physicians and the good work of the
ing of the rollout, communication to frontline
PAFP staff to help me along.
physicians about affected patients, and the high compliance rate dictated by DHS. I recommend
And what specific issues brought me to Har-
that those members caring for Medicaid or MCO
risburg? Prior authorization and step therapy
patients consider contacting MCOs for a list of
reform, for one. The PAFP has been working
tirelessly with both other physician groups and patient advocate groups to offer solutions
In addition, I had the opportunity to submit writ-
to the burdensome prior authorization proce-
ten testimony and attend the House Human
dures currently used by many commercial pay-
Services Committee hearing on SB 675, a bill
ers throughout the Commonwealth. The bill
which would create additional barriers to the
prescribing of buprenorphine for opioid use dis-
the PAFP at the end of 2019 after 21 years of ser-
order. With the opioid crisis continuing through-
vice to the organization. We joke that we joined
out Pennsylvania, family physicians need all the
the PAFP right around the same time! He leaves
tools we can get to help those suffering in our
behind a stellar staff with so much passion for
the work they do in supporting family medicine in Pennsylvania. We will miss him, and we know
Finally, Nov. 7-10 saw the PAFP Bedford CME Con-
he has positioned the PAFP well with the future.
ference at the Omni Bedford Springs Resort – a
Brent Ennis, current PAFP Deputy EVP, will move
wonderful meeting in a beautiful location! While
into the Executive Vice President role in 2020.
I found it a bit too cold to sit outside roasting
I’m honored to be the PAFP president during this
marshmallows, I did enjoy the first snowflakes of
time of change.
the season. The conference focused on issues of women’s health and physician wellness. I always
And speaking of change, I can’t believe it is only
enjoy the time to learn with my colleagues.
a few months until the installation of our next PAFP President, Dr. Tracey Conti. Please plan to
The Bedford Springs conference also provided
join us in Hershey, March 5-8, 2020 for CME,
a time to celebrate the impending retirement of
the Annual Business Meeting and the installa-
longtime PAFP Executive Vice President (EVP)
tion and celebration of Dr. Conti. I hope to see
and CEO, John Jordan. John will be retiring from
Mary Stock Keister, MD speaking on the issue of prior authorization reform (See Page 22 for details)
MEMBER NEWS THE LATEST NEWS AND INFORMATION FOR PAFP MEMBERS For more, visit: www.pafp.com
PAFP on twitter
PAFP CEO, EVP Jordan retires; Ennis named new EVP The Pennsylvania Academy of Family Physicians has named Brent Ennis as its next Executive Vice President (EVP) and CEO. Ennis will begin in the role on Jan. 1, 2020. Ennis is currently the Deputy EVP and COO, and also served as Chief Government Affairs Officer for the Pennsylvania Academy of Family Physicians. Prior to joining the PAFP, Ennis served as the Director of Legislative Affairs and later District Director of Southeastern Pennsylvania for the Pennsylvania Department of Health. Ennis also worked as Director
of Government Relations for Lehigh Valley Hospital and Health Network after several years with the United Way of North Carolina prior to his appointment at the state Department of Health. Ennis assumes the role with the retirement of the PAFP’s longtime EVP and CEO years John S. Jordan, CAE. During his tenure, Jordan, who joined the PAFP in 1998, developed effective public policy, supervised multiple medical educational programs and grants, and implemented a statewide virtual association for PAFP employees. Prior to joining the PAFP, Jordan served as the Group Director of Membership, Physician Programs, and Association Management Services for the Pennsylvania Medical Society. To read staff reflections upon Jordan’s retirement, click here. 8
John Jordan, CAE
Apply today for a PAFP leadership position
PAFP welcomes new Chief Government Affairs Officer Reis
The Pennsylvania Academy
The Pennsylvania Acad-
of Family Physicians is cur-
emy of Family Physi-
rently seeking applicants to
cians is pleased to wel-
serve in various leadership
come Jennifer M. Reis
positions, but you only have
as its Chief Government
until Dec. 31, 2019. PAFP
Affairs Officer. Reis will
board and committee mem-
be the lead lobbyist
bers serve as the infrastructure of the Acad-
working closely with the
emy, developing policy and making decisions
PAFP’s current head of
that keep the organization at the forefront of
government affairs Brent Ennis while he tran-
sitions to Executive Vice President; Ennis will take over the position Jan. 1, 2020 with the
Nominations are needed for President-Elect,
retirement of the PAFP’s long-serving EVP and
Treasurer, Director At-Large, AAFP Delegate,
CEO John S. Jordan, CAE.
AAFP Alternate Delegate, and Foundation President. To apply for a leadership position,
Reis has worked nearly 15 years advocating
complete the online application. Please make
with the state legislature. Staffing the PAFP’s
sure to upload your curriculum vitae when
Government and Practice Advocacy Commit-
completing your application. Please complete
tee and working with the PAFP Political Action
the online conflict of interest statement when
Committee’s Board of Directors are included in
submitting your application.
the duties of the position.
For questions regarding nominations, contact
Reis is pleased to be back with the PAFP, where
John Jordan, CAE, PAFP Executive Vice Presi-
she worked as from 2010-12 as Manager of Prac-
dent and CEO, at 1 (800) 648-5623 or jjordan@
tice Advocacy and Government Affairs. She
pafp.com. Nominations for leadership posi-
is eager to work alongside family physicians
tions may also be received at the March 7, 2020
on issues that impact them and their patients
throughout the Commonwealth. WWW.PAFP.COM
INTERVIEW CONVERSATIONS WITH INDIVIDUALS AT THE FOREFRONT OF FAMILY MEDICINE Interested in being featured in a future issue? Email Bryan Peach at firstname.lastname@example.org
Stan Kozakowski, MD: ‘Remain deeply curious’ Late this summer, PAFP member and family medicine champion Stan Kozakowski, MD was honored with the American Academy of Family Physicians’ (AAFP) Award for Distinguished and Meritorious Service to Family Medicine. This award recognizes members, nonmembers, and chapter executives with 25-year service, and entities for long-time dedication to advancing, contributing, and supporting to the AAFP and the specialty of family medicine. It is intended to recognize long-time dedication and effective leadership within the awardee’s chapter or nationally in furthering the development of family medicine. Dr. Kozakowski sat down with Keystone Physician to discuss his career, the importance of family medicine education, and what the future holds for the specialty. Keystone Physician: What led you into the family medicine specialty? Stan Kozakowski, MD: Let me begin by saying that I am deeply honored and grateful to receive this recognition from the American Academy of Family Physicians. No one works in isolation and I am especially grateful for the patients, students, residents, teachers, and colleagues who have shared their gifts with me. The concept of trusted, caring relationships that are central to family medicine was imprinted on me as a child. My grandfather, who spoke very 10
little English, was cared for by a general practitioner who made house calls and spoke my grandfather’s native language. Although I never understood the conversations, I could tell that the physician was someone who made a difference in the lives of my grandparents. In elementary school I had an inspiring science teacher who ensured that he knew each student in the class by writing their name one hundred times and presenting them with the paper if he ever forgot your first and last name. He was a teacher who made a difference and hooked me on science. The love of science and a desire to
PAFP President Mary Stock Keister, MD presents Stan Kozakowski, MD with the American Academy of Family Physiciansâ€™ (AAFP) Award for Distinguished and Meritorious Service to Family Medicine WWW.PAFP.COM
INTERVIEW connect to people on a deep and personal level led me on the journey to become a family physician. Family physician mentors such as Dr. Neil Calman seemed to find me and take me under their wing when I most needed to see that family medicine can and does thrive, often in places where we don’t expect it, such as his office in Harlem, not far from the flagship medical school hospital.
I HAVE A SPECIAL PLACE IN MY HEART FOR THOSE PATIENTS THAT GRANTED ME THE UNIQUE PRIVILEGE OF PROVIDING CARE FOR THEM IN THEIR HOMES
You’ve worn many hats throughout your career. Which role or position has been the most meaningful to you? I cannot honestly say that one position or role has been more meaningful than any other. I have always loved the relationships with my patients, especially those that I was able to maintain despite the travel demands that I faced as I became more involved with regional and national family medicine organizations. I have a special place in my heart for those patients that granted me the unique privilege of providing 12
care for them in their homes, even inviting me to their birthday parties. While some physicians see students and/or residents in the office as burdensome, I have found them to inspire me with their curiosity. I firmly believe that their questions, such as “Why do you do this that way?” or “Help me to understand…” made me a better physician. I loved working with residents, particularly one-on-one, as a coach and mentor. I am grateful for the opportunities to work on behalf of family medicine as a discipline through a number of regional and national positions, such as the Family Medicine Education Consortium, the Association of Family Medicine Residency Directors, the Council of Academic Family Medicine, the AAFP, and others. These positions have allowed me to gain a national perspective and to work with many inspiring leaders seeking to “connect the dots” to improve family medicine and family medicine education in particular. You have helped and inspired countless medical students, residents, and educators. If you could distill that inspiration into one message, what would it be? If I was forced to offer only one piece of advice for students, residents, educators, and all those in family medicine, it would be to remain deeply curious and share your curiosity and desire to improve with everyone that you work with including patients, fellow students, residents, teachers, staff, or mentors.
I can say with a high degree of certainty that most human beings are reluctant to appear ignorant. A resident once shared during a group discussion about becoming more effective learners and teachers the following strategy: “I try to make a point of asking those that I am working with to think out loud.” She uses the following questions as tools to achieve this goal: “If we could do this [fill in the blank - case, procedure, patient interaction, run a conference, etc.] again, how might we do this differently/ better?” A variation on this is, “How might others handle this and why do you do it this way, and why might someone else think that their way is better?” This simple strategy to have others think out loud changes the dynamic and creates a safe environment for learning and improvement that we all desire. Peering into your crystal ball, what do you see in family medicine’s future? I see a bright future for family medicine if family physicians and the organizations representing them demonstrate the courage and fortitude to remain true to the principles upon which family medicine was founded and are open to change. It is easy to lose sight of the fact that we are physicians, and as professionals, have a fiduciary responsibility to the needs of our patients, their families, and our communities.
The following are reasons to be optimistic: • Anthropologists tell us that in every culture people desire a relationship with a healer who is trusted for their well-being and care. • The current expenditure for health care in our nation is unsustainable and unequitable. Primary care-oriented health care systems deliver better health outcomes, lower costs, and provide greater equity in health. • People live longer in communities with a greater supply of primary care. • We are on the cusp of a new era of disease reversal and prevention for a number of conditions with intensive lifestyle change. • Finally, new systems of health delivery focused on “whole health” or “integrative health” are at the intersection of evidencebased conventional care, complementary non-drug approaches, and self-care. The addition of HOPE notes (healing-oriented practices and environments) to the traditional SOAP note approach focuses us on what matters most to our patients. This approach is reinvigorating physicians, reducing costs, and providing greater patient satisfaction. These systems are being embraced by the military and the VA to improve the care for active military and veterans and well-articulated by Dr. Wayne Jonas and others. (Jonas, W. Healing veterans requires caring for the whole person. Health Affairs, August 2019.) Thank you, Dr. Kozakowski, for speaking to Keystone Physician, and a hearty congratulations on your earning this prestigious award! WWW.PAFP.COM
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 14
ow for download on iOS azon Kindle Fire) devices!
FEATURE IN-DEPTH COVERAGE ON TOPICS THAT MATTER MOST TO YOU Join the discussion on this topic and others at PAFP Connect
PAFP travels to Bedford for final 2019 CME conference he PAFP traveled westward to “take the waters” where Dr. John Andrews decided to build the original Bedford Springs property in 1796 to host its last CME event for 2019. Nearly 200 family physicians and guests walked the hallways of the historic property, earning over 20 CME credits.
ships and techniques on how to keep them healthy. In the evening, Dr. Kelly doubled as our resident comedian, providing laughter, the best medicine, during a brief comedy segment.
The PAFP was inspired by the eight mineral springs on-site and continued its wellness initiative with extended and focused session breaks. Doug Lentz, MS, CSCS, Director of Fitness and Wellness for Summit Health led exercise sessions throughout the program. Lentz taught attendees how to be mindful of their movements and provided teaching techniques for each member to share with their patients. Attendees also had the opportunity to learn more about Qigong and Yoga Flow.
Within its CME events, the PAFP continues its board review track, namely women’s health in Bedford. The purpose of the track is to focus on one specific area of medicine helping physicians prep for their board exam. At the conclusion of the track, a review session is held incorporating a group discussion on 10 board-exam-like questions. In addition to the women’s health knowledge self-assessment (KSA), focused sessions included women’s sexual health at midlife, treating pelvic pain, and managing difficult LARC insertions and removals.
Among the weekend guests, Dr. John Kelly – voted as one of America's Most Compassionate Doctors, Patient's Choice – joined us with a focus on mental well-being and shared strategies on how to manage the daily stressors inside and outside the physician’s office as well as the importance of personal relation-
With support from the Pennsylvania Beef Checkoff, the PAFP offered a culinary learning experience on how to meet the needs of patients’ diagnosis without sacrificing flavor. Participants felt a sense of empowerment as they learned healthy cooking techniques to share with patients on how to prepare flavorful
food at home. A registered dietician also joined in the fun to teach participants how to educate patients with evidencebased science with the use of food to provide behavior change techniques. The PAFP was honored to host U.S. Congressman John Joyce (PA-13). Congressman Joyce provided a legislative update on federal issues pertinent to family medicine and overall health care in our country. He provided words of encouragement to each family physician in attendance, stressing the value of family medicine as front-line medical professionals. As the PAFP’s 2019 CME conference schedule comes to an end, the Academy is already in full swing with 2020 efforts. Click here to register now to join the PAFP at The Hotel Hershey, March 5-8, 2020 for the Annual Business Meeting, Hershey CME Conference, and Research Day. The agenda will include a wealth of patient safety CME (including mandated Act 31 training), induction and celebration festivities for Tracey D. Conti, MD as the new PAFP president, outstanding research posters and presentations, and great networking opportunities. Additional 2020 CME events include the Adventures in Family Medicine Conference, Sept. 10-12 at Camelback Mountain Resort in the Poconos and our Pittsburgh CME Conference, Nov. 13-15 at the Westin in Pittsburgh.
Nearly 200 family physicians joined the PAFP for its Bedford CME Conference, which offered 20 credits of CME and a continued focus on wellness.
With help from the Pennsylvania Beef Checkoff, the PAFP cooked up a culinary learning experience on meeting patients’ needs without sacrificing flavor.
In the exhibitor’s hall, Last Line, the community outreach program for the Bedford CME Conference, brought a fourlegged friend for fun.
Congressman John Joyce (PA-13) provided a legislative update and words of encouragement to each family physician in attendance, stressing the value of family medicine.
Sessions at the Bedford conference focused on a variety of topics, including womenâ€™s health, physician well-being, medical malpractice and social determinants of health.
A familiar face to PAFP conference attendees, Doug Lentz, MS, CSCS, Director of Fitness and Wellness for Summit Health, once again led exercise sessions throughout the program.
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GOVERNMENT AFFAIRS JENNIFER REIS, Chief Government Affairs Officer email@example.com
Prior authorization legislation introduced n a 2019 survey of PAFP members, administrative burdens related to prior authorization requirements emerged as the number-one issue facing our members’ ability to treat patients. To that end, PAFP leadership and staff have been hard at work on legislation that would standardize the prior authorization process and provide much-needed transparency of insurers’ use of prior authorizations to delay or deny patient care. Earlier this fall, House Bill 1194 and Senate Bill 920 were introduced by Rep. Steven Mentzer (R-Lancaster) and Sen. Kristin Phillips-Hill (R-York) respectively, during a press conference that included PAFP President Mary Stock Keister, MD as well as Dr. Jonathan Garino, first vice president of the Pennsylvania Orthopaedic Society, and Pennsylvania Medical Society President Dr. Lawrence John. During the event, Dr. Stock Keister referenced a 2018 survey of PAFP members that showed that prior authorizations resulted in delays in patient care nearly 98 percent of the time. The proposed legislation would require insurance companies to use a standardized prior authorization process, lessening the time physicians and their staff spend on administrative tasks and allowing more time for patient care. 22
“ Patients deserve the right care at the right time, determined by their physicians, not insurance companies.” - PAFP President Mary Stock Keister, MD The bills would also establish a framework for exempting patients from step therapy requirements by insurance companies when it is medically appropriate. These reforms would bring long-overdue consistency and transparency to an overly burdensome process and help ensure that patients get the care they need when they need it. House Bill 1194 has been referred to the House Insurance Committee; while Senate Bill 920 is in the final drafting stage. The PAFP is advocating for swift movement of these important reforms through the legislative process.
Statewide PDL goes live Jan. 1 Are you and your patients ready? Beginning Jan. 1, 2020, the Pennsylvania Department of Human Services (DHS) will implement a statewide preferred drug list (PDL) for the state’s medical assistance fee-forservice and managed care delivery systems. Of the approximately 2,300 prescriptions covered under the medical assistance program, less than half will be listed as “preferred” on the statewide PDL, subjecting “non-preferred” drugs to prior authorization. PAFP President Mary Stock Keister, MD provided testimony at a hearing of the Senate Health and Human Services Committee in October expressing the PAFP’s concerns with the hasty implementation of the statewide PDL, noting that a 60-day notification of the change does not allow sufficient time for physicians and their patients to make necessary changes to their current prescriptions in order to avoid the hassles and delays caused by prior authorization. Despite efforts to delay
FISCAL IMPACT ANALYSIS OF STATEWIDE PREFERRED DRUG LIST MEDICAL ASSISTANCE PROGRAM (PDL) UNIFORM STATEWIDE PREFERRED (PA Department of Human Services) DRUG LIST CLICK TO READ 2019 REPORT (PA Department of Human Services) CLICK TO READ
implementation, DHS is moving forward with a Jan. 1, 2020 start date. While patients were notified by mail beginning Nov. 1, physicians should take steps to educate their patients about this change and the impact it may have on their current treatment plan.
Credentialing reform within reach House Bill 533, sponsored by Rep. Clint Owlett (R-Tioga), overwhelmingly passed the House of Representatives by a vote of 187-0. The proposal would standardize the physician credentialing process, requiring insurers
to use a common form and limiting the timeframe in which insurers must make credentialing decisions. The bill has moved to the Senate where it awaits consideration in the Senate Banking and Insurance Committee. WWW.PAFP.COM
Proposal to limit MAT receives strong opposition from providers, government officials Legislation awaiting consideration in the House Human Services Committee stirred a passionate response from the medical community and Wolf Administration during a public hearing in November. Senate Bill 675, sponsored by Sen. Michele Brooks (R-Mercer) would place limits on the prescribing of buprenorphine for opioid addiction – one of the largest health crises facing the state in decades – despite the Administration’s
efforts to expand access to life-saving treatment. PAFP President Mary Stock Keister, president of the PAFP, provided written testimony expressing the organization’s concerns with placing restrictions on prescribers in the form of additional administrative requirements and fees; providers are already held to strict federal guidelines in order to prescribe.
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 today’s environment, PACs are an important part of the political process and a necessary advocacy tool.
Make your contribution today.
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FEATURE IN-DEPTH COVERAGE ON TOPICS THAT MATTER MOST TO YOU Join the discussion on this topic and others at PAFP Connect
Highlights of the 2019 AAFP Congress of Delegates Meeting in Philadelphia, PA hapter Delegates assembled in Philadelphia for the 2019 AAFP Congress of Delegates. Five reference committees heard testimony related to continuing medical education, racism in medicine, insurance coverage, adolescent gender care, medical aid in dying, emergency medical care, collective bargaining, climate change, vaping, firearms and safety, and immigration. There were many other issues related to patient care and practice management. Gary LeRoy, MD of Ohio, was installed as the 72nd President of the American Academy of Family Physicians. The AAFP Congress of Delegates elected Ada Stewart, MD, of South Carolina as the Academy's President-Elect. Others elected or chosen by acclamation for the following positions: • Speaker of the Congress – Alan Schwartzstein, MD of Wisconsin • Vice Speaker of the Congress – Russell Kohl, MD of Kansas 26
• Board Directors – Andrew Carroll, MD of Arizona, Steven Furr, MD of Alabama, Margot Savoy, MD of Delaware • New Physician Board Director – Brent Sugimoto, MD of California • Resident Board Director – Kelly Thibert, DO of Ohio • Student Board Director – Margaret Miller of Tennessee Highlights of a few resolutions are highlighted below. You can review all resolutions by going to the AAFP website at www.aafp.org. ADVOCACY The Nevada Chapter introduced a resolution, “Interstate Medical Licensure Compact.” The resolved is for the AAFP to support the interstate medical licensure compact and encourage the AAFP Chapters to advocate for adoption by state legislatures. The reference committee heard testimony to support the resolution stating the benefits of
expedited licensure, reduced administrative burden, and potential benefits to underserved communities. The reference committee recommended to support the resolution. The Congress of Delegates approved the recommendation. The New York Chapter introduced a resolution “Streamlined It was a packed house for FMX's keynote speaker, former Chairman and CEO of the Disney Corporation, Michael Eisner. Administrative Environment in Any Health Care Reform.” The resolved is for the cent Gender-Affirming Care.” The resolution AAFP to support of a single set of administrative states the American Academy of Family Physirules and procedures in any form of health care cians support the medical appropriateness of system reform considered by policymakers or gender affirmative care for transgender chilconsidered by the AAFP. dren and adolescents and oppose legislation The reference committee heard support for the resolution. Those testifying in support spoke about the multiple administrative functions that family physicians perform while advocating to a patient’s health insurer on behalf of the patient. One member spoke for the need for a single payer to more meaningfully streamline administrative functions in the health care environment. The reference committee recommended to refer to the Board of Directors. The Congress of Delegates approved the recommendation. The Arizona Chapter introduced a resolution entitled, “Oppose Legislation of PhysicianPatient Decision Making in Child and Adoles-
limiting medical decision-making by patents their parents/guardians and their physicians to provide gender-affirming care for children and adolescents. The reference committee heard passionate testimony shared from both those in support and against the resolution. The reference committee discussed the critical difference between children and adolescents with regards to gender affirmation therapies. The committee also discussed the need for a clear definition of gender affirmation therapies. The reference committee recommends the resolution be referred to the Board of Directors. The Congress of Delegates approved the committee’s recommendation. The Kansas and Michigan Chapters introduced resolutions entitled, “Medical-Aid-inWWW.PAFP.COM
FEATURE Dying/Physician-Assisted Suicide Language of Choice” and “the AAFP should not be prohibited from using accurate terminology regarding the prescribing of lethal medication intended to end a patient’s life.” The resolution states the American Academy of Family Physicians no longer reject the use of the phrases “physicianassisted suicide” and “assisted suicide” in formal statements and documents. In addition, the AAFP avoid the use of vague and euphemistic terms when referring to lethal medications prescribed with the intention of ending a patient’s life and not prohibit use of the phrases “physician-assisted suicide” and “assisted suicide” from statements or documents. The reference committee heard significant testimony on these resolutions. Those in favor supported the resolutions for a number of reasons including; the definition of suicide, the fact that medical-aid-in-dying is not currently legal in every state, failure to acknowledge the use of PAS devalues the position of those members that feel strongly on the issue, and running counter to the Hippocratic oath. Some members that opposed pointed to language included in states where MAID/PAS is legal that it specifically clarifies that MAID/PAS should not be considered (assisted suicide), homicide, or other criminal designations. The reference committee acknowledged the difficulty of this issue and what this means for the membership. The reference committee recommend the resolutions be referred to the Board of Directors. The Congress of Delegates approved the committee’s recommendation. 28
ORGANIZATION AND FINANCE The California, Oregon and New York Chapters introduced resolutions “Requiring Gender Pronouns on Nametags at all AAFP Events.” The resolves state, the AAFP require all individuals to identify their preferred pronouns upon event registration, with the option to opt-out, to be printed on name badges at all AAFPsponsored events and conference starting in 2020 and the AAFP include gender pronouns in all AAFP-sponsored event and conference registrations starting in 2020, with an optout option for individuals who do not wish to have gender pronouns included on their name badges. In addition, AAFP allow registrants for AAFP sponsored events and conferences to determine if/how they want their gender to be identified on printed name badges and make gender pronouns and option on all AAFP electronic and written materials.
Testimony was heard in support of allowing gender pronouns on printed name badges for AAFP sponsored events and conferences. The reference committee recommends that a substitute resolution be adopted “the AAFP allow registrants for AAFP sponsored events and conferences to determine if/how they want their gender to be identified on printed name badges.”
AAFP has a similar stance on investments in tobacco companies, the resolution should be supported to divest from companies producing fossil fuels.
The Congress of Delegates discussed the reference committee recommendation and revised the language ““the AAFP ask registrants for AAFP sponsored events and conferences how they want their gender to be identified on printed name badges with the option not to include gender pronouns.” The Congress of Delegates approved the amended language.
The Colorado, Maine, and Maryland Chapter introduced a resolution “Divestment from Companies Producing Fossil Fuels”, the AAFP work in a timely, incremental, and fiscally responsible manner, to the extent allowed by their legal and fiduciary duties, to reach a de minimis level of financial investment and/or relationship (divestment) with companies that generate the majority of their income from the exploration for, production of, transportation of, or sale of fossil fuels; and encourage the AAFP Foundation, chapters, and any affiliated organizations to do the same. The reference committee heard both for and against the resolution. One member who supported the resolution, who noted the enormity of the issue to climate change. Considering the
The reference committee recommended the resolution be referred to the Board of Directors. Congress of Delegates approved the recommendation.
The Virginia Chapter introduced a resolution “Reducing the Administrative Burden and Misuse of Medication Refill Requests from Chain Pharmacies.” The resolved states the AAFP request regional and national pharmacy chains to do the following: 1. Allow local pharmacies to make permanent changes to their corporate database and not be overwritten by the main servers that continually change back to erroneous information the next day. 2. De-Program their computer systems from requesting a ninety-day supply when a new chronic medication is prescribed since frequently the dose needs to be adjusted at the next visit. 3. Make easily available the corporate phone number or allow local pharmacist to stop their computer systems from sending automatic refill messages to patients and physicians for expired medications. 4. Make easily available the corporate phone WWW.PAFP.COM
FEATURE number or allow local pharmacist to make the changes to stop receiving refill requests for doctors who are not in their practice. 5. Assist in offering alternative covered medication options with various insurance plans which are covered when a prior authorization is requested. The reference committee heard testimony in support of the resolution. Those testifying noted that the manner in which regional and national pharmacies sometimes manage prescriptions for patients is an administrative burden for family physicians and their practices, much like formularies and prior authorizations. The reference committee recommended to refer the resolution to the Board of Directors. The Congress of Delegates approved the committee’s recommendation. The New Jersey Chapter introduced a resolution entitled “Scope of Care in the Hospital Setting.” The AAFP petition the American Hospital Association to create policy stating that member hospitals remove undue barriers and restriction of admitting privileges to hospitals and intensive care units for independent qualified family physicians who practice hospital medicine. The reference committee heard testimony in support of the resolution. Those testifying pointed out issues members face that restrict hospital privileges. Other testimony offered revisions to the resolved clause to support broadening family physicians’ ability to practice in the hospital setting. 30
The reference committee recommends a substitute resolution which states “the AAFP collaborate with the Joint Commission and other appropriate entities to create policy stating that hospitals remove undue barriers and restriction of privileges to hospitals and intensive care units for qualified family physicians who practice hospital medicine.” The Congress of Delegates voted to support the substituted resolution. EDUCATION The Texas Chapter introduced a resolution entitled, “AAFP Membership CME Requirement.” Board Certification.” The resolved is that AAFP study whether the current continuing medical education requirement for active membership be maintained and report back to the 2020 AAFP COD. The reference committee heard limited testimony both in support and opposition to the resolution. Those testifying in support felt that there were inconsistencies in the process by which the ABFM and AAFP award credit. Those testified in opposition to the resolution felt the financial implications could have detrimental effects on revenue production for chapters. The reference committee feels that the current CME requirement is sufficient, effective, flexible, and meets the needs of the AAFP members. The Congress of Delegates approved the committees’ recommendation.
The Colorado Chapter introduced a resolution “Family Medicine Residency Closure.” The resolved states, the AAFP request that the ABFM expand and alter the ABFM definition of “hardship” to create a new category of program, rather than individual resident hardship, that defines a residency program hardship as that period of time prior to announced closure during which a program experiences significant decrements in financial, faculty, or educational support, requiring advanced planning for postgraduate year two and three residents, and be it further the ABFM start allowing waiver of the continuity requirement for residents under the newly created hardship category, upon request of the involved program director and/or the program designated institutional official and be it further, the
AAFP either create within the AAFP or partner with the ABFM a specific resource for assisting residents involved in program closure with support in the form of administrative expertise or a subject matter liaison that can field and answer questions related to continuity, career planning and waivers. The reference committee heard significant testimony about the effect of potential residency closure upon residents. Testimony in favor of the resolution described the emotional distress residents experience when they are uncertain that they will be able to transfer into another residency program. The reference committee identified other issues that bring complexity to this issue, such as indirect and direct medical education payments from
Callbacks to Philadelphia's revolutionary roots were on full display at this year's AAFP FMX Experience meeting.
FEATURE the Centers for Medicare and Medicaid Services. The reference committee recommended the resolution be referred to the Board of Directors. The Congress of Delegates voted to support the recommendation. HEALTH OF THE PUBLIC & SCIENCE The Minnesota Chapter introduced a resolution entitled “Health in all Policy Development”. The AAFP develop a formal policy entitled “Health in all Policies” where health in all policies is a collaborative approach to improving the health of all people by incorporating health considerations into decisionmaking across all sectors and policy areas and the AAFP to support the recommendation that health in all policies can best be accomplished by using health impact assessments in the federal review of environmental impact statements and environmental assessments. The reference committee heard testimony in favor of the resolution. Those in support of the resolution is a way to impact the upstream social determinants of health by addressing the health implications of health care and non-health care policy. The reference committee discussed the existing policies and resources as related to the resolution and thought that while this resolution was in line with current policy, it went further in its statement asking for the use of health impact assessments as related to environmental impact. 32
The reference committee recommended to adopt the resolution. The Congress of Delegates voted in support of the recommendation. The Illinois Chapter introduced a resolution “Family Medicine’s Role in Addressing and Preventing Sexual Harassment.” The AAFP develop a toolkit of resources to raise awareness of family medicine’s role in addressing and preventing sexual harassment, including resources for the AAFP members affected by sexual harassment and resources to advocate and assist our patients and the public. The reference committee heard testimony in support of the resources to raise awareness in addressing sexual harassment. The committee discussed development of a toolkit and recommend to keep the language broad to facilitate the best option in development resources. The reference committee recommends a substitute resolution, “that the AAFP develop resources to raise awareness of family medicine’s role in addressing and preventing sexual harassment including resources for the AAFP members affected by sexual harassment and resources to advocate and assist our patients and the public.” The Congress of Delegates approved the substitute resolution.
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LEGAL AND COMPLIANCE UPDATE CHARLES I. ARTZ, Esq., General Counsel firstname.lastname@example.org
Health care employer liability Negligence/breach of confidentiality A new Court of Appeals decision allowing a negligence claim against a health care employer based upon its employee’s breach of confidentiality is important to consider for compliance and risk management purposes. In Henry v. Community Healthcare System, ___ N.E.3d ___ (Ind. 2019), a health care provider’s employee was an X-ray technician. The employee sent the plaintiff/patient’s protected health information to the patient’s employer. The patient’s employer is the health care provider employee’s spouse. The employer then showed the plaintiff digital images (contained on the spouse’s cellular telephone) containing the patient’s protected health information. The patient sued the health care provider for negligence based upon the breach of confidentiality and unauthorized PHI disclosure. The trial court dismissed the claim. The Court of Appeals reversed the dismissal, allowing the litigation to proceed, and held as follows: 1. There is no private right of action in court to enforce the federal HIPAA Privacy regu34
lations. But the patient did not sue directly under the HIPAA Privacy regulations. Instead, the patient asserted a negligence claim against the health care provider employer based upon its employee’s unauthorized disclosure of protected health information. 2. Medical providers owe a duty of confidentiality to their patients. The AMA Code of Medical Ethics (specifically AMA Opinion 3.2.1) holds that physicians have an ethical obligation to preserve the confidentiality of information gathered in association with the care of the patient. 3. A medical provider employer can be held negligent if an employee improperly disseminates a patient’s confidential information. 4. The HIPAA Privacy regulations may be used to establish the standard of care in tort claims related to alleged breaches of the duty of confidentiality owed by medical providers to their patients.
5. Because the complaint alleged the duty to protect the privacy, security and confidentiality of the patient’s health records, a breach of that duty by the provider’s employee when the employee shared X-rays with the employee’s spouse states a claim in ordinary negligence against the employer, if damages can be proven. This is another published Court of Appeals decision that basically evades the prohibition against suing directly under HIPAA. Courts continue to use the HIPAA Privacy regulations as a back door to establish the basis for a common law negligence or breach of confi-
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The compliance take-home points are clear. Employees should be repeatedly trained on the critical importance of compliance with the HIPAA Privacy regulations. Failure to do so could result in negligence claims and damages against the employer. Employees who negligently or recklessly violate the HIPAA Privacy regulations should be appropriately sanctioned or terminated for cause.
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dentiality tort claim, which could expose the health care provider employer to damages based upon the employee’s failure to comply with the HIPAA Privacy and Security regulations.
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LEGAL AND COMPLIANCE UPDATE
Multiple HIPAA privacy/security violations Lost records/improper internal PHI access Media disclosure/selling PHI The U.S. Department of Health and Human Services Office for Civil Rights (OCR) has published a decision imposing a $2.154 million fine on a health care provider based upon multiple and varied violations of the HIPAA Privacy and Security regulations. The defendant was a large health care provider which has multiple primary care and specialty care centers, provides health services to approximately 650,000 patients each year, and employs about 12,000 individuals. This decision, which was not a settlement, is important for HIPAA Privacy and Security training and compliance. In OCR v. Jackson Health System, OCR found the following HIPAA Privacy and Security violations: 1. LOST RECORDS – The provider lost paper records containing PHI of 756 patients. The provider conducted an internal investigation and found an additional three boxes of patient records were also lost. In total, the provider lost paper records for 1,471 36
patients. The provider did not report the additional loss or the increased number of individuals affected until three and a half years after it occurred. 2. IMPROPER INTERNAL ACCESS TO PHI/ UNAUTHORIZED DISCLOSURE – OCR became aware of multiple media reports disclosing the PHI of a patient who was a well-known player in the National Football League. An ESPN reporter shared a photograph of electronic display board in the provider’s facility and a paper schedule containing the PHI of the same patient. A nurse who treated the NFL player and who had legitimate access to his PHI at that time impermissibly continued to access his medical records after she no longer had a job-related reason to do so. In addition, a second employee was found to be accessing the NFL player’s records. This demonstrated the users’ ability to access ePHI without authorization. Although each of the employees were properly sanctioned, their
4. FAILURE TO REPORT PRIVACY/SECURITY BREACHES TO OCR IN A TIMELY MANNER – OCR’s investigation revealed the provider failed to provide timely and accurate breach notification to the Secretary of HHS/OCR. In one case, the provider was 160 days late reporting the breach.
broad and excessive access evidenced a lack of restriction, review and/or modification of the appropriate levels of access to ePHI. Due to the leak of the NFL player’s medical condition, he suffered financial and reputational harm. He suffered an injury to his hand which threatened his reputation as a successful football player. In addition, the New York Giants rescinded a $60 million contract offer after the ESPN tweet was posted. 3. UNLAWFUL ACCESS/SELLING PHI – The provider also reported that an employee had been selling patient PHI. That employee improperly accessed over 24,000 patients’ records over a five-year period. The provider admitted that for over five years an employee had access to ePHI that she did not have proper authorization or authority to access despite having written policies and procedures in place, demonstrating the provider’s failure to implement those policies on an operational basis.
5. FAILURE TO CONDUCT ENTERPRISE-WIDE RISK ANALYSES – The HIPAA Security regulations require a detailed risk analysis to be conducted. An accurate and thorough assessment of all potential risks and vulnerabilities to the confidentiality, integrity and availability of ePHI must be conducted. Although several internal risk analyses were conducted over a period of years, the risk analyses erroneously identified several provisions of the regulations as not applicable to the provider. The provider failed to identify the totality of threats and vulnerabilities that existed in its systems. The provider failed to remediate risks, threats and vulnerabilities identified. Some of the risk analysis was compartmentalized and was not thorough. With respect to internal access analysis, the provider had the capability to create audit logs and access reports for systems that contain ePHI; however, it failed to regularly review those logs. The provider failed to identify persons or classes of persons in its workforce who needed access to PHI to carry out their duties. 6. CALCULATION OF FINE – The decision summarized the various levels of fines that can be imposed for violating the HIPAA PriWWW.PAFP.COM
LEGAL AND COMPLIANCE UPDATE vacy regulations. OCR determined that a fine of $1,000 per day applied to the failure to comply with the security management and information access regulations, totaling $654,000. With respect to the failure to report breach notifications in a timely manner, the provider was fined $50,000 per day, the highest level of fine under the regulations, resulting in an additional $1.5 million. The total fine imposed was $2,154,000. This is another decision establishing the extensive fines that can be imposed for failure to conduct a thorough risk analysis, failure to respond to identified risks, and failure to control employeesâ€™ misconduct. The compliance take-home points that emerge from this decision include the following:
1. Even though some of these violations may be extreme, additional training on the foregoing subjects will be useful. 2. Regularly conduct enterprise-wide risk analyses. Identify and resolve all vulnerabilities as soon as possible. 3. Be sure to operationalize all HIPAA policies and impose sanctions where necessary, including immediate termination of employees who commit egregious violations. This decision demonstrates that when bad things happen based upon employeesâ€™ misconduct, the employer will still be held responsible.
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Diagnostic Dilemmas and Medical Mysteries - Critical Thinking
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FREE CME WEBCASTS AT YOUR FINGERTIPS All online sessions meet your Patient Safety requirement DIAGNOSTIC DILEMMAS AND MEDICAL MYSTERIES - CRITICAL THINKING NEW!
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