September 2015 | www.cmsdocs.org

Legislative Year in Review Proposed Stark Law Changes

Protecting Your Accounts Receivables Under ICD-10

FrailtyA Growing Issue in Our Aging PopulationPAGE 18

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PrESidEnt’S MESSAGE2 The EHR: Meaningless Use By kathy M. Tynus, Md

PrACtiCE MAnAGEMEnt4 Proposed Stark Law Changes; Protecting Accounts Receivables; Doctors Can Still Win: Medicare Rolls Out Bundled Payments; Telemedicine: Will Courts Collide with Regulators? Medicare’s Value Based Modifier; A New Kind of MBA

PubliC HEAltH14 Stopping Unnecessary Baby Deliveries By Bruce Japsen

lEGAl16 Interoperability: On LockdownBy ashley Thomas, Jd

MEMbEr bEnEfitS 28 A Win for GME AdvocacyBy elizabeth Sidney

29 Get Involved Today!

30 Calendar of Events

30 New Members

31 Classifieds

WHo’S WHo32 Modeling Diversityophthalmologist and medical professor Mildred M.G. olivier, Md, takes diversity—and her patients and students—seriously. in her role as director of diversity at the chicago Medical School, dr. olivier works to alleviate health care disparities for minority populations, as well as help underrepresented students enter the health care field. By Scott Warner

Volume 118 issue 9 September 2015

fEAturES18 Frailty: A Growing Issue in Our Aging Populationall physicians need to step up to the plate when it comes to diagnosing frailty in our aging population. here’s how you can help. By howard Wolinsky

24 A Year of AdvocacyThis year saw numerous wins for physicians in Springfield. here’s a recap of how your chicago Medical Society and illinois State Medical Society made it all happen.

18

September 2015 | www.cmsdocs.org | 1

the EHr: Meaningless useMeSSaGe froM The preSidenT

it’S HArd to imagine living without computers and the Internet. Many processes have become faster, more accu-rate, and even fun. So why is it that the electronic health record is such a disaster? Poll after poll demonstrates the frustration, expense and bitterness among physicians. The

reality of meaningful use is anything but meaningful. A 2013 report by the RAND Corp. and the AMA cites nine negative and only three positive outcomes: “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and deg-

radation of clinical documentation were prominent sources of professional dissatisfaction.” EHRs are creating financial burdens, causing many physicians to move from private

practice to employment. Fifty-three percent of physicians seeking employment cited mean-ingful use as one of their top reasons for leaving private practice, according to a November 2012 report by Accenture. A follow-up survey released in July 2015 shows a steady decline in physician-owned practices: currently only 33% of physicians, down from 57% in 2000.

It’s no wonder why: for a five-physician practice, implementing an EHR costs $162,000, even with incentives of up to $44,000 from Medicare and $63,750 from Medicaid. Those incentives don’t cover annual licensing fees, ongoing costs for hardware and Internet ser-vice, the unanticipated hiring of staff such as scribes and IT managers, plus lost physician productivity. EHRs can place small practices in economic jeopardy.

Concern is growing that EHRs increase physician exposure to medical malpractice litigation. Errors in EMRs are common; 84% of electronic charts in a VA study had at least one error. Lack of eye contact during the office visit diminishes the doctor’s ability to build rapport and communicate effectively. Ignoring alerts and clinical decision support tools, whether through fatigue or conscious decision, also exposes physicians to risk. The tone of email communications can be easily misinterpreted by patients. Having a scribe in the room is another potential source of patient dissatisfaction. And security breaches of sensitive health information are always a real threat.

The RAND report summarizes the state of EHRs in medicine best: “EHR usability represents a relatively new, unique, and vexing challenge to physician professional satisfac-tion. Few other service industries are exposed to universal and substantial incentives to adopt such a specific, highly regulated form of technology, which has, as our findings suggest, not yet matured.”

What can we do? There is a two-part solution. First, share with the Chicago Medical Society your real-life examples of EHRs interfering in patient care. CMS educates lawmakers about daily practice hassles. Few understand the complexities of EHRs, and so we explain the physician learning curve and the impact of proprietary enterprise software systems on patient care. EHRs actually handcuff patient data because of proprietary software and technology protections. A CMS committee is studying EHR issues with the goal of developing policy and jumpstarting legislation. Just as our advocacy eased the ICD-10 requirements, CMS can achieve more flexible EHRs.

The second step is support for a new bill (HR 3309) introduced by U.S. House Rep. Renee Ellmers (R-NC) called the “Flex-IT 2 Act.” The bill would pause meaningful use rulemaking, remove the pass-fail approach, align quality reporting, expand the hardship exception to EHR payment adjustments, and promote interoperability.

If you are fed up with your EHR, please urge your congressional representatives to support HR 3309. And be sure to work through your Chicago Medical Society.

Kathy M. tynus, MdPresident, Chicago Medical Society

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tHE CEntErS for Medicare & Med-icaid Services (CMS) recently proposed changes to the Stark Law exceptions, which included certain changes that would affect physician leases with hos-

pitals and other providers. The proposed changes were included in the proposed Physician Fee Schedule for 2016.

timeshare or Part-time occupancyIn the Proposed Rule, CMS discussed certain part-time arrangements by physicians for the use of office space owned by a hospital or other provider. CMS gave an example of the use by a specialist of space owned by a hospital on a limited- or as-needed basis to treat patients in a rural or underserved area.

CMS compared these part-time, as-needed “timeshare” medical office space use arrangements to license arrangements as opposed to a full-time exclusive use lease arrangements. These part-time lease arrangements may generally include the use of office space, equipment, personnel, items, sup-plies or services on a part-time or shared basis.

Lease arrangements typically provide a physi-cian with the exclusive use of office space during scheduled time periods. CMS also commented that this type of timeshare arrangement may be used by a relocating physician whose prior medical practice office lease has not expired or to a new physician establishing his or her practice.

CMS commented that these types of use or time-share arrangements do not fit within the rental of office space or any other exception to the Stark Law. However, CMS also commented that use or time-share arrangements may be structured in a way that do not pose a risk of fraud or abuse to the Medicare program. Accordingly, CMS proposed a new excep-tion to the Stark Law for certain timeshare arrange-ments that satisfy certain requirements.

The proposed new “timeshare” exception appears to be limited to use or license arrange-ments where the occupant is given non-exclusive use of the space. CMS noted that the rental of office space exception would continue to be the only exception that would apply to leasing arrange-ments where the occupant is given exclusive use of the premises. In addition, the exception is limited to arrangements where the licensor is a hospital or physician organization and it would not apply to arrangements where the licensor is another type of provider such as a laboratory.

Another important aspect to the proposed timeshare exception is that it would only apply to use or license arrangements where a physician uses the premises to predominantly provide evaluation and

management services to patients. CMS has requested public comments on the terms “predominantly use.”

CMS is also seeking public comments to deter-mine whether the exception is sufficiently broad to improve access to care, whether the exception should be limited to rural and underserved areas and whether the proposed in-suite equipment location requirements should be expanded. CMS is requesting comments on its proposal to prohibit per unit-of-service and percentage compensation meth-odologies for determining the fees by physicians for use of office space under timeshare arrangements.

Writing and term requirementsCMS also proposed changes to clarify the “writ-ing” requirement and one-minimum term require-ment in the rental of office space exception and other exceptions to the Stark Law. These proposed changes are in response to questions received by CMS regarding whether an arrangement must be contained in a single “formal” written contract.

CMS commented that a single written document memorializing the facts of an arrangement would provide the surest way to establish compliance with an exception. However, CMS also commented that there is no requirement under the Stark Law that an arrangement be documented in a single formal con-tract. Accordingly, CMS proposed to clarify that the “writing requirement” in these exceptions would be satisfied by a collection of documents evidencing the course of conduct between the parties.

CMS also commented that it was proposing certain terminology changes to the Stark Law regulations to clarify that a formal written contract or other document with an explicit “term” provi-sion is not necessary to satisfy the minimum one-year term requirement of the Stark Law exceptions. However, the parties must be able to demonstrate that the arrangement was terminated during the first year and that the parties did not enter into a new arrangement for the same space.

These proposed changes, if adopted, would make it easier for physician lease arrangements to satisfy applicable exceptions to the Stark Law. Physician practices should keep in mind that CMS will not announce until later this fall whether these changes will be adopted and effective for physician lease arrangements.

The information in this article is intended for informational purposes only, and should not be construed as legal advice on the topics addressed. Clay J. Countryman is a partner with Breazeale, Sachse & Wilson, LLP, in Baton Rouge, Louisiana. Clay.Countryman@bswllp.com.

Proposed Stark law Changes Physician lease arrangements could more easily satisfy applicable exceptions By Clay J. Countryman, JD

pracTice ManaGeMenT

“Physician practices should keep in mind that CMS will not announce until later this fall whether these changes will be adopted and effective for physician lease arrangements.”

4 | Chicago Medicine | September 2015

AS WE GEt closer to the Oct. 1 transition date for ICD-10, many of the implementation checklist items are being completed. But we still don’t know how long it will take to

get claims out the door and processed by payers. It is extremely important to have a plan in place to strategically monitor your account receivables (AR) to understand, in real time, how the transition is impacting your cash flow.

ICD-10 transition has a high probability of nega-tively affecting cash flow. Carefully monitoring key metrics for changes from the baseline period prior to Oct. 1 to post-implementation status is the key to controlling the degree of negative financial impact ICD-10 will have on your practice. By being able to quickly identify a downward trend of key metrics, your practice can plan how to fix root causes within the practice as well as identify, respond to and monitor issues from payers. Here are three key metrics to monitor the claims process.

Charge lagUndoubtedly, in the beginning, it will take longer for staff to get a service billed. Monitor the date when the primary claim was first sent to the payer (DOS). Keeping the charge lag between 24-48 hours supports a healthy revenue cycle. It is expected, at first, the charge lag number will rise because it may take longer for both doctors and coders to code. Understand that pushing to bring the charge lag back to baseline as quickly as possible will help reduce the slowing down of cash flow. Monitoring the charge lag by provider will help to identify providers having difficulties. Additional assistance or training for the provider may be necessary.

days in ArThis is the average number of days from the date of service to a paid claim. You can use these two formulas to calculate days in AR: Total of last six months charges/number of days in the last six months = Average Daily Charges. Total AR/Average Daily Charges = Days in AR. Again, this number is expected to rise after Oct. 1. You should break this metric down into payer groups and watch closely to determine which payer category is causing the days in AR to climb.

denial ManagementMonitoring denied claims is critical to protecting the financial health of your practice. Monitoring at the Claims Adjustment Reason Code (CARC) level as well as the Remittance Advice Remark Codes

(RARC) level is imperative. This metric should also be drilled down to the payer category level. New CARCs and RARCs have not been added to the ANSI set to identify ICD-10 errors. See the grid below for some of the CARC codes you can expect to see increase after Oct. 1. It is imperative to quickly identify any rise in denials. Identifying the root cause and implementing a correction plan will assist in strategically preventing additional denials.

Although we do not know how cash flow will be affected after Oct. 1, we do have the tools to mitigate revenue slow down by managing key indicators of AR. Once denial trends have been identified, implementing a denial management strategy, reeducation plan, and continual oversight will be necessary.

Gail Wilkening is a senior consultant specializing in revenue cycle at PBC Advisors. LLC, in Oak Brook. PBC Advisors provides business and management consulting and accounting services to physician prac-tices and hospital systems. For more information, visit www.pbcgroup.com.

Protecting Accounts receivables During the transition to IcD-10, it is imperative that you maintain a healthy revenue cycle By Gail Wilkening

pracTice ManaGeMenT

“the iCd-10 transition has a high prob-ability of nega-tively affecting cash flow.”

Charge lag in number of days

aug Sept average oct nov

provider a 1 1 1 3 3

provider B 2 2 2 4 5

provider c 1 2 1.5 5 6

days in Ar

aug Sept average oct nov

aetna 27 27 27 30 35

BcBS 32 30 31 32 33

cigna 33 33 33 34 38

denial Management by Payer Category

carc aug Sept average oct nov

co-16 2% 0.50% 0.25% 1% 1%

co-50 6% 3% 2% 2% 10%

co-11 0.50% 1% 0.75% 1% 7%

September 2015 | www.cmsdocs.org | 5

pracTice ManaGeMenT

doctors Can Still Win Medicare rolls out new bundled payments By Bruce Japsen

tHE obAMA administration is shift-ing more Medicare dollars away from fee-for-service medicine when it comes to paying for knee and hip replacements. This puts more reimbursement at risk

for doctors and hospitals.The U.S. Secretary of Health and Human

Services has proposed moving doctors and hospitals in 75 geographic areas to bundled pay-ments including parts of Illinois. Under the plan, the hospital where the surgery takes place will be “accountable for the quality and costs of care for the entire episode of care—from the time of the surgery through 90 days after discharge.”

“By focusing on episodes of care, rather than a piecemeal system, hospitals and physicians have an incentive to work together to deliver more effective and efficient care,” HHS Secretary Sylvia Burwell said in announcing the five-year Medicare payment model for knee and hip replacements. “This model will incentivize providing patients with the right care the first time and finding better ways to help them recover successfully.”

But does this mean the doctor’s reimbursement is squeezed? Not necessarily, according to early adopters of bundled payment. If physicians and hospitals, working together, can find other ways to reduce costs and improve quality, it leaves more money for the providers depending on the hospi-tal’s quality and cost during the “episode of care.” “It will reward providers and doctors for helping patients get and stay healthy,” Burwell said. 

Those who have tested similar models, including those instituted by private insurers in the Chicago area, say doctors can win more reim-bursement than in the traditional fee-for-service system. In Wisconsin, a Robert Wood Johnson Foundation-funded initiative brought costs down and left more money for surgeons essentially by going out for bid on artificial knees, making the device makers more competitive.

“Could they get all the device manufacturers together to negotiate prices?” asks

Karen Timberlake, director of Wisconsin’s Partnership for Healthcare Payment Reform and director of the Population Health Institute at the University of Wisconsin. “When you start to shift the payments, there is some money at risk and it causes different questions to be asked and causes organizations to think differently.”

The Wisconsin Partnership for Healthcare Payment worked with surgeons on ways to lower costs and improve quality for total knee replace-ments from the first day the patient enters the hospital for surgery to 90 days after the patient is discharged. In the Medicare proposal, the bundled

payment will cover similar services 90 days after the patient is discharged.

Wisconsin providers began to save money when participating surgeons and hospitals went to all their device manufacturers, telling them that bundled payment was coming. “Many didn’t bring their manufacturers together until part of their reimbursement was at risk,” she added. “Bundled payment was a new catalyst of conversation. It prepares for bigger changes that they all need to make.”

In such a shared savings arrangement, surgeons and the hospital where the procedure is located can get extra payment from Medicare if prices go down on the devices used in the pro-cedures. Private health insurance companies in Chicago and across the country are already mov-ing doctors and hospitals to bundled payments with everything from knee and hip replacement to cancer care. “While we at Blue Cross and Blue Shield of Illinois do not currently have bundled payment arrangements in place, we are actively pursuing that model as part of our push toward alternative payment models, ones that align incen-tives with improved health outcomes, lower costs and overall better patient experience,” Opella Ernest, MD, senior vice president, chief medical officer and health care delivery at BCBSIL Chicago Medicine. 

In the new Medicare model, anyone can voice support, opposition and ideas.

There is a public comment period that began July 14 and runs through mid-September. Go to: www.federalregister.gov/public-inspection.

It’s then expected that the so-called “Comprehensive Care for Joint Replacement” pay-ment model will begin in January 2016. Among the 75 markets involved are the Illinois metropolitan statistical areas of Rockford and Decatur.

But commercial insurers say it’s only a matter of time before they go statewide with bundled payments given the significant variation they see in costs and outcomes of certain episodes of care such as hip and knee replacements. “There are many drivers of that variation, one being the fragmented, multiple providers who participate in a care episode; the referring physician, radiologist, surgeon, anesthesiologist, physical therapists, and so on,” Dr. Ernest said. “Then, there’s the broad choice of device manufacturers, types of implants from which to choose, the hospital and surgical suite costs, as well as the post-acute rehab settings and the nurses. An appropriately designed bundled payment model will align those incentives and drive accountability for improved quality, greater value and patient satisfaction.”

“Wisconsin providers began to save money when participating surgeons and hospitals went to all their device manufacturers, telling them that bundled payment was coming.”

6 | Chicago Medicine | September 2015

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tHiS PASt MAy, the U.S. Dis-trict Court of the Western District of Texas, in response to a lawsuit brought by Teladoc, Inc., stopped the Texas Medical Board from enforcing

a new rule prohibiting physicians from using the telephone to diagnose and treat patients with-out first seeing patients in-person or by certain methods of video engagement. The rule in ques-tion was originally enacted by the medical board after aggressive public comment by both Teladoc and the medical board, demonstrating the signif-icant fissure between the telemedicine company and the regulator. The Texas Medical Board is one of several states that specifically excludes the telephone from its definition of telemedi-cine. Illinois does not exclude telephonic com-munication from its definition, and as of Jan. 1, 2015, the Illinois Insurance Code now prohib-its a health insurer that provides coverage for telemedicine services from requiring in-person contact between a health care provider and a patient. The Court did not block the broader Texas rules involving telemedicine via synchro-

nous video and audio. Teladoc, a national provider of telephone

health services, claimed in federal Court that the new rule violated antitrust law by thwarting competition. At that initial stage of litigation, the board argued the new rule protected patient safety. But the Court strongly disagreed, calling the board’s evidence anecdotal, which was in sharp contrast to what the Court considered to be vast evidence of anti-competitive effects, including tens of millions of dollars in potential damages to Teladoc. The Court preliminarily ruled that Teladoc was likely to succeed in the lawsuit. In June, the medical board countered by claiming immunity and asking the Court to dismiss the lawsuit. The case is set for trial in February 2016.

In April 2015 the Texas Medical Board adopted a new rule specifically requiring a face-to-face visit either in-person or by certain methods of video engagement. Before the board asserted immunity, the U.S. District Court weighed the anti-competitive and pro-competitive justifications for the amended regulation. The

telemedicine: Will Courts Collide with regulators?A recent case in texas shines a bright light on the high stakes for businesses and regulators By Julian Rivera, JD

pracTice ManaGeMenT

AS tHE lEGAl battle rages between Teladoc and the Texas Medical Board, the american Medical association (aMa) has opted for a wait-and-see approach. delegates at the June meet-ing tabled proposed ethical guidelines for telemedicine services in light of recent court action.

aMa’s council on ethical and Judicial affairs say a valid patient-physician relationship can be accomplished “in person or virtually through real-time audio and video technology.” not only is an inpatient face-to-face interaction not required, but a physician presenter also need not be physically present during a patient consultation.

The spectrum of state law ranges from requiring an in-person encounter to establish a relationship, to accept-ing relationships formed through telemedicine technology. under model

policy developed by the federation of State Medical Boards, patient-physician relationships can be formed based solely on virtual encounters, though not audio-only encounters. unlike fSMB, many states do include email and telephone communication in their definition of telemedicine. rules for the formation of patient-physician relationships are com-plicated by the fact that many states use “face-to-face” to mean an in-person encounter.

intErStAtE CoMPACt Though not aimed specifically at telemedicine, the interstate Medical licensure compact will create a compre-hensive process enabling physicians with board-certification to practice telemedi-cine across state lines. illinois became the 11th state to join the compact, an fSMB initiative, which seeks to broaden

access to care through the delivery of services via telehealth technology. participating physicians need not apply for full licensure in each state. licenses issued by a state through the compact are the same licenses as those issued through traditional licensure pathways. physicians who receive licenses via the compact from a state must adhere to that state’s existing renewal and cMe requirements.

The compact does not require physi-cians to participate in maintenance of certification or osteopathic continuous certification at any stage. Board-certification is only an eligibility factor at the initial entry point of participation in the compact process. The interstate commission plans to spell out details about renewals, fees, investigation and discipline. The compact is expected to be fully functional in 18 to 24 months.

AMA Puts telemedicine Guidelines on hold

8 | Chicago Medicine | September 2015

pracTice ManaGeMenT

Court agreed with Teladoc’s claims that the anti-competitive effect of the new rule will be “increased prices, reduced choice, reduced access, reduced innovation, and a reduced overall supply of physician services.”

Given the prohibitive effect of the new rule on providing patients with greater access to quality care, the Court concluded that the amendment would negatively impact consumers. While the medical board offered as its pro-competitive justification for the new rule that it will improve the quality of care, the Court found the board’s evidence to be anecdotal and outweighed by the evidence Teladoc put forward.

In its June motion to dismiss, the board asserted that when it adopted the new rule it was acting as sovereign with multiple layers of oversight and that sovereign oversight immunizes the board from federal antitrust law. The board’s detailed basis for its assertion of immunity has become critically important to its defense, since the district court judge made clear that without a successful claim of sovereign immunity the board is likely to lose to Teladoc.

Both the regulator and the business have a lot at stake. Despite the ongoing litigation in Texas, Teladoc’s initial public offering surged in early trading the morning of its July 1 launch, rising 60% from $19 per share to almost $31.

The market’s reaction was strong even though Teladoc has made plain that requiring in-person physical examinations as a precondition for medical services will disable the company’s business model. Teladoc has also made plain that losing the lawsuit in Texas will likely destroy its business.

The implications for physician regulators are also significant. If they are not able to success-fully assert sovereign immunity as state actors, many of their existing rules will be subject to similar challenges and the way they go about regulating medicine will need to fundamentally change. For regulators unaccustomed to anticom-petitive lawsuits, the scope of potential risk is vast. Yet the potential risk is no less jarring than the existing risk–a federal judge may soon order that their rules negatively impact competition when the board is struggling to do what it thinks is right to protect the public in the new world of ever-expanding telemedicine opportunities.

Julian Rivera is a partner in the Health, Life Sciences and Education Unit of the Husch Blackwell, LLP, law firm. His practice includes the representation of health care providers and technol-ogy companies in business, regulatory and litigation matters. He can be reached at Julian.Rivera@HuschBlackwell.com.

“the illinois insurance Code now prohibits a health insurer that provides coverage for telemedicine services from requiring in-person contact between a health care provider and a patient.”

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in 2015 the Centers for Medicare and Med-icaid Services (CMS) will begin applying a value based modifier under the Medicare Physician Fee Schedule. CMS is phasing in this payment system by year and to different size physician groups. The

value modifier adjustment depends on the size of the group, year, and the group’s performance. You may see an upward, downward or neutral payment adjustment, depending on your particular circumstance.

Highlights of the phase-in are as follows:

• In 2015 the value modifier will be applied based on performance in 2013 for groups of 100 or more eligible professionals (EPs).

• In 2016 the value modifier will be applied to groups of physicians with 10 or more EPs based on 2014 performance. 

• In 2017 the value modifier will be applied to all physicians and groups of physicians based on 2015 performance.

• In 2018 the value modifier will also apply to Medicare Physician Fee Schedule payments made to non-physician EPs.

Here’s a quick summary for EPs who did not partici-pate in PQRS. Everyone who did participate in PQRS will either get no adjustment or will get an upward adjustment based on their budget neutral percentage.

The Value Modifier Program’s quality measure-ment component is aligned with the reporting requirements under the Physician Quality Reporting System (PQRS). In addition, the quality measurement component of the value modifier includes three outcome measures that CMS calcu-lates from fee-for-service Medicare claims:

• Two composite measures of hospital admissions for both acute and chronic ambulatory care-sensitive conditions.

• One measure of 30-day all-cause hospital read-missions.

• Cost measure information from ambulatory care-sensitive condition composite measures, all-cause hospital readmissions, overall total per capita cost measures, condition-specific total per capita cost measures, and Medicare spending per beneficiary measures.

When assessing performance on several of the measures, CMS use a two-step attribution process to associate beneficiaries with TINs during the year. This process assigns a beneficiary to the TIN providing more primary care services to that beneficiary than any other TIN.

Quality and resource use reports (Qrur)QRURs provide information on the quality and cost of care provided to Medicare fee-for-service beneficiaries identified by the TIN as well as infor-mation on beneficiaries’ use of hospital services compared to the average of the provider’s peers. Some information in the QRUR is used by CMS to calculate the value-based payment modifier. The quality metrics used to calculate the value modifier are based on participation in PQRS. Any physician or group that participated in the Medicare Shared Savings Program, the Pioneer Accountable Care Organization Model or the Comprehensive Primary Care Initiative in 2013 will not have a QRUR avail-able and are an exception to the value modifier. The 2013 annual report and the 2014 mid-year report are currently available.

To obtain the reports you must use your Individual Authorized Access to CMS Computer Services (IACS) account. In July, CMS transitioned the use of the IACS account to the Enterprise Identity Management System (EIDM). If you cur-rently have an IACS account you need to convert to EIDM at https://portal.cms.gov. You will receive an email acknowledging a successful conversion.

Understanding the value based modifier program is very important for all providers moving forward. The value based modifier is a complex program and another challenging change in the future of health care. This program will begin impacting your practice based on 2015 performance.

Janet Bliss is vice president of practice manage-ment and Christine O’Malley is a health care consultant with PBC Advisors, LLC, in Oak Brook. PBC Advisors provides business and manage-ment consulting and accounting services to physician practices and hospital systems. For more informa-tion, visit www.pbcgroup.com.

Medicare’s value based Modifier here’s how your payments will be affected By Janet Bliss and Christine O’Malley

Performance year vM year Physician Group Size did not Participate in PQrS

2014 2016 100+ eps Will get downward adjustment (max -2%)

2014 2016 10+ eps no adjustment

2015 2017 10+ eps Will get downward adjustment (max -4%)

2015 2017 2-9 solo physicians Will get downward adjustment (max -2%)

2016 2018 all physicians Will get downward adjustment (% TBd)

“the value based modi-fier program is a complex program and another chal-lenging change in the future of health care.”

10 | Chicago Medicine | September 2015

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pracTice ManaGeMenT

MAny PHySiCiAnS lament the fact that medical schools offer very little, if anything, in the way of a business administration education. “Yet physi-cians who have vast clinical experi-

ence often find themselves taking on leadership roles,” says Jay Noren, MD, associate dean in the College of Medicine at the University of Illinois at Chicago. “They have the talent and personality to head up departments in larger organizations. But these ‘bridge spanners’ don’t necessarily have the formal business training they need.”

Recognizing this need in Chicago, Dr. Noren approached Dimitri Azar, dean of the College of Medicine at UIC, about starting a health care focused master’s of business administration program at the school. No stranger to the concept, Dr. Noren had actually previously started a similar program during his tenure at the University of Wisconsin’s School of Medicine and Public Health. Enthusiastic, Dr. Azar agreed to the idea.

Getting StartedThis year marks the first year of the program, called the Clinician Executive Master of Healthcare Administration (CEMHA) program. Dr. Noren serves as the program’s director. Six physicians—all department heads at the College of Medicine—signed up as the first graduating class. The program will be admitting more students for the 2015-2016 year.

Anand Kumar, MD, is one of the members of the first graduating class. “I’ve been the head of the psychiatry department here for nearly seven years,” he says. “My job increasingly requires bet-ter knowledge of health care systems and how they operate. Sure, you could argue that I could learn that on the job, but if there is a smarter way to learn what you don’t know, then what’s the point?”

Similarly, Michele Mariscalco, dean of the Urbana-Champaign campus of the College of Medicine, wants to acquire business acumen that might be difficult to get on the job. “I’m working a lot with informatics,” she says. “I want to learn how to better integrate that with health care to create a better system. I also want to explore more fully how policy will affect how we physicians care for our patients in the future.

Advantages for PhysiciansMake no mistake: the two-year, four-semester program is every bit as intense as any traditional MBA program, requiring a large time commitment from its students. The program, however, is unique

in that unlike a traditional MBA it focuses solely on business administration as it relates to health care. Five key differences between the CEMHA program and a traditional MBA include:

• All admitted students must bring extensive experience as practicing clinicians.

• The course work focuses traditional manage-ment and leadership education on the essential collaboration between clinicians and admin-istrators for effective and efficient leadership unique to the health care industry, emphasizing population health sciences principles and meth-ods as a central theme.

• The student experience occurs with a single group of colleagues and takes full benefit of the prior experience of the students and the value of interaction both during the program and in career paths following graduation.

• All students engage in a special management project directly related to the health care orga-nization in which they currently work, under the guidance of an executive mentor.

• The program schedule accommodates the con-tinuing clinical responsibilities and professional commitments of mid-career clinicians through efficient use of distance education techniques, while also maximizing opportunities for per-sonal interaction of group members and faculty through intense on-campus periods intermit-tently throughout the program.

These differences all add up to a program that makes physicians glad to make the time commit-ment. Both Dr. Kumar and Dr. Mariscalco are quick to note that the program is highly demand-ing. “There never seems to be enough time,” says Dr. Mariscalco. “But on the flip side, we all bring years of clinical experience to the table. We can build on each other’s knowledge.”

The ability to do a hands-on practical project as part of the course is also a plus for the physicians. Dr. Kumar, for example, has chosen to do a project integrating behavioral health in a large academic medical center—that is, at the UIC College of Medicine. “Running a behavioral health program would be easier if it were purely a clinical setting,” he says. “But for this project, I need to bring together trainees, research, basic science and clinical work. There are a variety of competing elements.”

Success in completing the projects, and the program, bodes well for the future of Chicago medicine.

A new Kind of MbAA unique program lets chicago-area physicians earn an advanced business degree based solely on health care concerns By Cheryl England

“Make no mistake: the two-year four-semester program is every bit as intense as any traditional MbA program.”

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unnECESSAry elective baby deliv-eries, which can arise when patients demand convenience and busy doctors agree to their demands, have plum-meted in Illinois with the help of a

unique collaborative effort. The Midwest Business Group on Health (MBGH), which represents large employers in the Chicago area, said the rate of early elective deliveries—babies delivered too early for non-medical reasons—were reduced to 2% of all births last year from 24% in 2010.

To lower the rate of unnecessary deliveries, MBGH worked with the state’s physicians and hospitals and other stakeholders such as the March of Dimes and Blue Cross and Blue Shield of Illinois on a major educational effort aimed at stopping unnecessary elective deliveries. Stakeholders involved say their efforts can be replicated and used to help improve infant health nationwide.

“We reached out to area hospital systems in 2010 to encourage implementation of hard-stop policies that require approval of a designated hospital maternity leader prior to allowing induc-tion of a pregnancy prior to 39 weeks,” Margaret Rehayem, senior director of strategic initiatives at MBGH, said. “We encouraged Illinois health plans to disseminate regular communications to educate members and physicians about the importance of full-term births and working with network provid-ers to avoid unnecessary early deliveries.”

Studies show a baby’s health can be put at risk when deliveries are induced via Cesarean section before 39 weeks. Complications can include more C-sections, infections, infant breathing and feeding problems, and possible death. Though pregnancy is generally thought of as a 9-month period, studies show a baby actually needs a gestation period of 39 weeks.

Stakeholders said some hospitals brought together physicians, nurses and health informa-tion management to make sure new policies were carried out. They also consulted with the Joint Commission and Illinois Department of Public Health to determine what data was needed to come up with measurements.

“The Illinois Perinatal Quality Collaborative and Illinois Hospital Association reached out to their physicians back in 2012 to begin educating them on the impact of unnecessary elective deliv-eries, promoting the new American Congress of Obstetricians and Gynecologists’ guidelines that defined an unnecessary early elective delivery as being prior to 39 weeks of gestation without medical approval and encouraging physicians

to promote full-term births in their practices,” MBGH’s Rehayem said.

the resultsThe effort was funded with the help of a three-year grant from the National Business Coalition on Health, which represents large employers like Boeing, Abbott Laboratories and Walgreens; United Health Foundation, a nonprofit affiliate of health insurance giant UnitedHealth Group; and the Robert Wood Johnson Foundation.

More than 70% of Illinois hospitals reduced the number of unnecessary C-sections and inductions, said MBGH executives, who used data compiled from hospitals via The Leapfrog Group, which mobilizes employer purchasing power in an effort to push providers to improve quality. “Today, there are thousands fewer babies suffering in neonatal intensive care units (NICUs) in Illinois, thanks to inspiring leadership,” Leapfrog president and chief executive officer Leah Binder said.

Those involved say the educational effort to doctors, hospitals and patients is ongoing and aggressive in its effort to reach millions of health plan enrollees across Illinois.

At Chicago-based Health Care Service Corp., parent of several health plans including Blue Cross and Blue Shield of Illinois and Blue Cross and Blue Shield of Texas, the plans launched a “Special Beginnings Program” that includes edu-cational content aimed at promoting the March of Dimes campaign, “39 Weeks—Healthy Babies Are Worth the Wait,” the insurer said in a statement to Chicago Medicine. “We have a direct link to March of Dimes video explaining the benefits of not choosing non-medically necessary induc-tions prior to 39 weeks,” said Toni Allen, senior manager of clinical operations at BCBSIL. “This information is available to not only members who have a Blue Access for Members account but also the public can assess this information. Our web-site also includes supportive written educational materials on this topic.”

Employers involved in the effort say reducing unnecessary elective deliveries likely reduced health care costs and improved the health of mothers and infants across the state. “This is the first public health problem we’ve actually been able to solve in my 40+ years in health care,” said Larry Boress, MBGH president and CEO. “We’ve shown that by coordinating efforts across all health care stakeholders, we can fill gaps in care and improve the overall health of targeted popula-tions. It’s a template for other communities and health conditions.”

Stopping unnecessary baby deliveries A unique partnership lowers the rate of elective births while improving infant health By Bruce Japsen

puBlic healTh

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14 | Chicago Medicine | September 2015

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tHE CHiCAGo Medical Society and the american Bar association have established a formal relationship to address medical-legal issues affecting cMS members and their practices. This legal section is sponsored by the health law Section of the american Bar association.

for cMS members this means that you get monthly articles from legal experts who specialize in health law. The articles will focus on subjects of current interest to the medical profes-sion as well as new laws and regulations as they are implemented. The authors will vary every month in order to bring

you the best information possible from the attorney who specializes in the subject matter.

if you have a particular question or would like more information on a sub-ject, please send us your suggestions. you can send an email to elizabeth at esidney@cmsdocs.org.

Working With the Bar

leGal

tHE EASy ExCHAnGE of elec-tronic health data between systems and devices is the goal of health informa-tion technology. And since the passage of the Health Information Technology

for Economic and Clinical Health (HITECH) Act, interoperability has become a “hot buzzword.” The HITECH Act was intended to jumpstart the adop-tion of electronic health records (EHRs) and sup-porting technology, beginning with the meaningful use program. Providers who demonstrate mean-ingful use of EHRs receive a subsidy, and after a period, are penalized for not successfully demon-strating meaningful use at each of the program’s three stages.

Stage 1, which began in 2011, set basic EHR functional goals such as capturing patient data and sharing that data between patients and health care providers. Stage 2 began in 2014, and is focused on the exchange of information between patients and providers, giving patients secure online access to their health data, among other features. Stage 3, set to rollout in 2017, has not been finalized yet. Each stage is intended to increase interoperability by promoting health information exchange and improved outcomes.

Both the Affordable Care Act and the Medicare Shared Savings Program set new finan-cial incentives for data sharing with accountable care organizations. The goal of the MSSP is to reward providers for their efforts to coordinate care, improve quality, and lower health care costs. Robust data sharing is critical to reaching that goal.

By April 2015, the federal government had invested $28 billion toward the goal of a national

health information technology system. However, some providers and health IT vendors have undermined these efforts by knowingly and unreasonably interfering with the exchange of electronic health information. This diversion has been termed “information blocking” and has raised some concern in Congress.

Speed bumps in the road An interoperable system allows patients’ electronic health data to follow them regardless of boundaries. Interoperability also can help organizations achieve meaningful use compli-ance. But when it comes to attesting to Stage 2, providers encounter difficulties. The American Medical Association reported that only 25% of eligible professionals were able to comply with the meaningful use requirements as of February 2015. Among physicians and hospitals, only 20% to 30% exchanged clinical data with other providers electronically. 

This lack of interoperability was the focus of a Senate Committee last March. Julia Adler-Milstein, a professor at the University of Michigan, testified that “EHR vendors do not have a business case for seamless, affordable interoperability across vendor platforms, and provider organizations find it an expense that they often can’t justify.” The Centers for Medicare and Medicaid Services offered some reprieve, with a proposed rule to shorten the 2015 attestation period, and reduce some provider reporting requirements.

Back in 2014, Congress urged the Office of the National Coordinator for Health IT (ONC) to use its authority to decertify EHR products that pro-actively block information sharing. Congress also asked ONC to report on the extent of the problem, and come up with a comprehensive strategy to promote interoperability.

ONC published a draft roadmap this January for physicians and patients to easily exchange and access

interoperability: on lockdownthe federal government takes steps to discourage blocking of health information By Ashley Thomas, JD

“Health care providers are partly to blame since some use blocking to control referrals and enhance their market dominance.”

16 | Chicago Medicine | September 2015

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EHRs. The 10-year plan strives for baseline interop-erability across the health IT infrastructure while allowing vendors to vary usability according to the user’s needs, instead of a one-size-fits-all approach. ONC will also ensure that safeguards are in place.

What Constitutes blocking?As described by the ONC in its report to Congress (April 2015), information blocking occurs when health care providers or vendors interfere with the access of or exchange of electronic health data by authorized individuals or entities. The conduct must be made knowingly and be considered unreasonable by objective standards in light of public policy.

The ONC’s report blames the business practices of both EHR vendors and health care providers. Also, there is little formal research in this area, making evidence mostly anecdotal, and difficult to interpret and generalize, the ONC said.

Health IT developers have made it difficult to receive or send health information. One barrier is the high fee they charge. Developers also cite secu-rity concerns or business justifications for limiting the exchange of data. Yet health care providers are partly to blame since some use blocking to control referrals and enhance their market dominance. They can achieve this control with overly broad privacy policies, citing the HIPAA Privacy Rule, as a reason not to disclose electronic health data, even in circumstances that do not impose such restrictions. ONC also found that providers shift costs to patients by charging high fees to transfer electronic information.

With five hypothetical situations based on actual complaints, the report gives insight into what ONC considers information blocking. In analyzing the scenarios, it becomes apparent that what constitutes unreasonable in light of public policy might be difficult to ascertain. For instance, a developer requires consumers to participate in a “trust community,” following certain security and business best practices. Information cannot be exchanged with anyone outside the trust commu-nity. It’s unclear whether blocking is evident in this situation because the ONC needs more information about the developer’s best practices. In some circumstances, the limit on data might be accept-able according to the developer’s best practices. But limits also may not be legally warranted and more of a business practice than a compliance or liability reducing mechanism. It’s not hard to imagine future disagreement over the interpretation of what is reasonable.

Strategies to tackle blockingThe ONC proposes actions on a number of fronts. For the EHR certification process, ONC urges “more aggressive” in-the-field surveillance by requiring developers to disclose any technol-ogy limitations on the access and exchange of

electronic health data. Another approach is greater transparency. Providing information to evaluate the technology, including costs, would help par-ties choose more interoperable EHR products. Transparency could encourage better business practices.

On the privacy side, ONC will work with the Department of Health and Human Services’ Office for Civil Rights to improve understanding of HIPAA and permitted disclosures of PHI. In situations where blocking may violate state or federal law, ONC will work with law enforcement to identify and investigate this conduct.

Competition for interoperability is another approach. The Federal Trade Commission wants the ONC to encourage developers to compete by adver-tising interoperability in their products. Also, the FTC has cautioned ONC against heavy dependence on coordinated governance by market participants because this might suppress competition.

A new system to report blocking allows health care providers to bring their complaints to an email account set up by the federal CMS agency and ONC. Reports will be investigated, according to an announcement in June.

Congress also weighed in. The 21st Century Cures Act, passed by the U.S. House this July, grants authority to the OIG to impose civil mon-etary penalties on entities deliberately engaged in such activity.   

incentivizing interoperability Vendors and providers have an incentive to horde electronic health information, thereby causing tech-nology systems to develop around this market. As the parties try to protect their economic interests, they may not agree they are blocking information. The government needs to create incentives that enable the exchange of data out-of network. Further, the government needs to better articulate legitimate privacy concerns versus privacy concerns raised as a false shield to increase profit. The focus should be on long-term incentives over short-term fixes.

Many hope the ONC report and subsequent actions against information blocking will encour-age vendors and providers to reevaluate their business practices.

Ashley Thomas, JD, is an associate in the Indianapolis office of Hall, Render, Killian, Heath & Lyman. She focuses on hospital and health system matters, regulatory and compliance issues, and corporate transactions.

“the government needs to create incentives that enable the exchange of data out-of-network as well as articulate legitimate privacy concerns versus privacy concerns raised as a false shield to increase profits.”

September 2015 | www.cmsdocs.org | 17

A Growing Issue in Our Aging PopulationCalling on all MDs to play a role in combating the condition

By Howard Wolinsky

frailty

Frailty

18 | Chicago Medicine | September 2015

When MAbel Jones (not her real name) arrived at the University of Chicago Medicine’s Senior Health Center at South Shore this

spring, she was ”in extremis.” Geriatrician Katherine Thompson, MD, co-director of the U of C’s Successful Aging and Frailty Evaluation (SAFE) Clinic, said Jones “was getting weaker, had had multiple falls, did not have good support at home and was starting to have some cognitive decline as well.”

The signs of frailty were clear: Jones, in her early ‘80s, had lost more than 10% of her weight—though she wasn’t dieting. Her grip was weak. She had to rock and use her arms to get out of a chair. Dependent on a walker, her gait was slow.

Adding to these problems, Jones’ social situation was a disaster. She had been evicted from her previous residence. She could not rely on her son to bring her food. She didn’t feel safe leaving her own home even to go for a walk for exercise in her crime-stricken neighborhood.

It Takes a Team It took a team of geriatricians, geriatric social workers and geriatric nurse-practitioners to manage Jones’ complicated issues. To improve her nutrition, a social worker scheduled Meals on Wheels. Arrangements were made for transporta-tion to get her to an exercise class, where she could start moving and have an opportunity to socialize with her peers. A homemaker service was found to help Jones manage her life and pay her bills. “It took this team approach and some follow-up in the clinic to get her back in a trajectory where she can stay out of an institution,” said Dr. Thompson.

Dr. Thompson and Megan Huisingh-Scheetz, MD, MPH, co-direct the SAFE Clinic, which launched in 2011. It is believed to be the first frailty clinic in the U.S. and only the second in the world with a goal of identifying pre-frail patients and frail patients and reversing their condition. Physical frailty is a common problem, especially in patients above age 80, though it can affect younger patients, as it did elite athlete Lance Armstrong following his chemotherapy for testicular cancer.

Dr. Huisingh-Scheetz said many doctors miss the signs of frailty because historically there has not been a generally accepted definition. That changed in 2013, when an international commit-tee reached a consensus. A group of delegates from six major international, North American and European medical groups, representing the American Medical Directors Association, American Federation for Aging Research, International Association of Gerontology and Geriatrics, Society on Sarcopenia, Cachexia and Wasting Diseases, International Academy of Nutrition and Aging and European Union Geriatric Medicine Society, along with other experts, concluded that frailty

is “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance and physiologic function that increases an individual’s vulnerability for develop-ing increased dependency and/or death.”

But even then, Dr. Huisingh-Scheetz said the consensus committee disagreed on formal diagnos-tic tools. As a result, estimates on the prevalence of frailty vary widely. “The idea is that frailty is a spec-trum. Patients may range from being very robust to very frail. The tools are probably picking up slightly different aspects of frailty or earlier or later frailty signs, depending on the tool you use. The prevalence can range between 5% and more than 40% depend-ing on which tool you’re using,” she said.

Geriatrician June M. McKoy, MD, MPH, JD, an associate professor of preventive medicine and director of geriatric oncology at Northwestern University Feinberg School of Medicine, said that by the time a person reaches age 50, he or she will observe some physiological changes. “When I tell that to my medical students—many of whom are in their late 20s, early 30s—they say, ‘Dr. McKoy, are you crazy?’ I’ll tell them that they’re aging right in their seats. Aging changes occur in small propor-tions over time.”

The Old OldDr. McKoy said the “old old” population (those 85 years and over), among other things, will have lost lean muscle, have declining kidney and liver functions, and declining hormonal levels, which in women can result in weaker bones and, ultimately, osteoporosis. In addition, people in this age bracket

frailty

Katherine Thompson, MD, of the University of Chicago Medicine, times a patient’s gait. Slow gait is a sign of the frailty syndrome.

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frailty

SeATeD In fOlDInG chairs in a circle in the Bloom township Center in Chicago Heights, a group of 19 women and one man, all aged in their 60s through 80s, raise their hands above their heads and pull taught straps or neckties for resistance. they’re performing an exercise to strengthen their upper body muscles aimed at improving their posture, balance and breathing. this exercise is the upper body portion of the yoga pose known as the warrior, or veerabhadrasana, a classic yoga pose, or asana, that typi-cally is performed standing on a mat with arms extended to the ceiling and palms facing each other.

for an hour, these senior citizens perform a chair-based yoga designed for people who want to improve and maintain their health and want to fend off frailty, but feel intimidated by getting on the floor, according to their yoga instructor Nadine Kelly. Sitting in a chair in the center of the circle, Kelly puts stu-dents through modified versions of sun salutation, tree pose and other asanas.

Before she became a full-time yoga instructor four years ago, Nadine Kelly was better known as Nadine Kelly, MD. Burned out and disillusioned by her practice as a cytopathologist in a community hospital in Northwest indiana, she decided to follow a new path—one that would allow her to combine her love of medicine with her love of yoga. and one that would allow her to spend more time with her two daughters. She calls her flossmoor-based business yogi MD; she also conducts classes throughout the south suburbs.

Rx YogaOf yoga, geriatrician Victoria Braund, MD, chairman of geriatrics at Evanston-based NorthShore University HealthSystem, said, “yoga is incredible because it works on your core, and many of these old people are slouched down and their backs hurt. they really need core strength—back and abs.”

However, yoga has an image problem among seniors. look at the cover of Yoga Journal, a popular publication, and you’ll see why. the cover shows girls in impossible pretzel-like poses, creating

the impression that yoga is only for young flexible bodies.

Dr. Kelly’s mission is to make yoga accessible to all comers, without concern for age or fitness. “yoga can be practiced by all, not just the thin, young and flexible. i believe in adapting poses for the senior population to address their health issues,” said Dr. Kelly. “Seniors benefit from yoga in very prac-tical ways—stress reduction, socialization to manage anxiety and depression, and improved physical strength and flex-ibility to perform activities of daily living to maintain independence for as long as possible.”

the logo for her business? “anyone who can draw a breath can practice yoga.”

How Yoga HelpsDr. Kelly puts her understanding of anatomy to work breaking down poses so they can be done from a chair and still provide a thorough workout. She said as a result of the chair-based yoga workout her students report they have more endurance, postural awareness,

improved breathing, reduced arthritic and back pain, and better sleep. She recommends chair-based yoga for patients with chronic pain, physical dis-abilities, weight constraints, injuries, or post-surgical recovery.

She also teaches aqua yoga to relieve stress on the joints to help patients with chronic pain, including that from hip and knee replacements, back pain, fibromyalgia, arthritis or rehabilitation from injuries. She teaches yoga for osteoporosis and gentle yoga on the mat emphasizing stretching, limbering and holding gentle poses while focusing on breathing.

taking a page from her physician days, Dr. Kelly asks her students indi-vidually what ails them on that particular day and she offers asanas designed to help relieve those aches and pains. “i am used to medical speak, so if someone tells me they have myositis, i know what that is, and i’m able to tailor the correct practice. i have a student who has myo-sitis. She does yoga in the water with me, so we’re strengthening her muscles,” Dr. Kelly said.

yoga is the Best Medicine

nadine Kelly, MD, (seated at left) leads a chair-based yoga class doing a warrior pose with outstretched arms.

20 | Chicago Medicine | September 2015

frailty

are more isolated socially and tend to be sedentary. Many do not take sufficient vitamin D supplements or get adequate sun exposure, especially in our bleak, cloud-covered climate, leading to a deficiency of vitamin D, resultant weaker bones and muscles and increased risk of falls and frailty, she said.

Dr. McKoy said staying active helps prevent or postpone frailty. She cited a British study that found that while the physiologic or normal changes of aging put stress on the body, one can actually stave off or decrease frailty risk by being active. “It’s been shown that people who are active starting in their younger years and even those who pick up activities later like yoga or tai chi, or who simply keep moving can decrease their frailty risk well into their ’90s.”

She stressed: “Frailty is not just a popular term that is being bandied around as the term of the year. Frailty is a real syndrome that has real risks,” she said, “If you want to live long and prosper, you’ve got to keep moving. That’s the Number 1 thing. Moving is the key to keeping frailty away.”

Dr. McKoy said that there is persuasive data showing that over 30% of patients in their 80s will become frail at some point. But if primary care providers and geriatricians identify frailty and intervene, the status of patients can improve dramatically.

Defining frailtyHow do geriatricians identify frailty?

Dr. Huisingh-Scheetz said the SAFE Clinic uses the widely studied Phenotypic Frailty Criteria to diagnose the syndrome. These include weakness based on a grip strength test, slow gait speed on a short walking course, feeling exhausted frequently, unintentional weight loss, and low physical activ-ity. Patients are diagnosed as “pre-frail” if they have one or two of these signs and frail if they have three or more. Other geriatricians follow similar approaches.

Dr. Huisingh-Scheetz said 80% to 90% of patients in the SAFE Clinic at South Shore are physically frail. Dr. McKoy estimated that between 5% and 7% of her geriatric population at Northwestern fit the criteria for frailty.

Dr. McKoy, who makes house calls to get a full view of high-risk patients in their own environment, said another “red flag” for frailty is co-morbidity, such as diabetes, congestive heart failure, chronic obstructive pulmonary (lung) disease, cancer, dementia, and osteoarthritis. Often patients with multiple co-morbid illnesses will also have frailty, which may be masked in an environment where the focus is on other more obvious disease conditions. “You need to really worry because these illnesses themselves are going to worsen frailty and decrease life expectancy,” she said. Physicians ought to look for signs of pre-frailty in mid-life patients and not just in patients in their ‘80s. It is well settled that frailty is a

medical syndrome and not an age, she said.

The frailty Debate Does frailty kill? This is a matter for debate. There is no agreed upon death rate for frailty.

Dr. Huisingh-Scheetz said frailty does predict mortality in epidemiologic studies. “It may not be the only factor, but it’s certainly contributing,” she said.

Dr. Thompson said: “If somebody who was frail got a urinary tract infection it could kill them. So in that sense frailty does kill. A small physiologic insult in a frail person can be all it takes.”

Still, Dr. McKoy noted that full-blown frailty is hard to stop. “If frailty continues on its trajectory without intervention, it’s almost like a runaway train. We can slow it down so people won’t die prematurely. However, if you literally allow frailty to get out of control, ultimately in almost 100% of cases, it will result in a person’s demise before their time.”

Geriatrician William Thomas, MD, an author-ity on aging and a self-described nursing home abolitionist, said if he ran a frailty clinic, he would put up a sign in front saying: “Eat. Sleep. Move.” He said those are the key ingredients to prevent and reverse frailty.

Dr. Thomas was in Chicago recently on a the-atrical tour produced in partnership with AARP’s P

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A patient undergoes the grip test. Weak grip is a sign of the frailty syndrome.

September 2015 | www.cmsdocs.org | 21

Life Reimagined. Inspiration for the project comes from Dr. Thomas’ book, Second Wind: Navigating the Passage to a Slower, Deeper and More Connected Life, which examines the baby boom generation’s reluctant second “coming of age.” He said frailty is a major public health threat to the elderly. Medically frail patients undergo an accelerated loss of their reserves. “Any person with a very limited reserve capacity is at high risk for terminal events because the body enters a situation where it can’t tolerate much stress without being overwhelmed,” he said.

One example of frailty killing a vulnerable popu-lation is the heat wave in Chicago in the summer of 1995, which caused about 750 deaths in five days, Dr. Thomas said. Many seniors who died couldn’t afford air conditioning, had no air conditioning or were afraid because of crime to open their windows. Dr. Thomas said, “Their physiology was stressed to the point where they couldn’t get back to a steady state and that was the end of life.”

But he said: “Frailty can be a reversible syndrome. You can become not frail. One of the problems is people think, ‘Oh, she’s frail. That means kid gloves go on. We’re going to wrap her in bubble wrap and that’s it.’ Ironically, that’s exactly the wrong thing to do. Instead of trying to reverse frailty, we’re just trying to protect them from the consequences of frailty.”

Dr. Thompson said many of the patients referred to the frailty clinic get there because internists and geriatricians at the University of Chicago, Mercy Hospital and in the community, know the SAFE Clinic resource exists. But she is concerned that many patients don’t get the care they need. “I feel as though a lot of the referrals to our clinic right now are for non-frailty diagnosis reasons like ‘I’m worried about my patient because they’ve been falling,’ or ‘I’m worried about my patient because I think they need some social resources,’” she said.

Shrinking numbers of GeriatriciansFrailty is coming to the forefront as an issue at a time when there are shrinking numbers of geriatric specialists; at the same time the U.S. population is rapidly aging. The American Geriatrics Society projects that 17,000 geriatricians are needed to serve 12 million older Americans. But there are only 7,500 board-certified geriatricians in the U.S. The field is losing more professionals to retirement while fewer medical graduates, carrying huge debts, opt to enter better paying specialties.

As a result, identification and treatment of

frailty

above: Katherine Thompson, MD, is co-director of the U of C’s Successful Aging and frailty evaluation (SAfe) Clinic. below: June M. McKoy, MD, MPh, JD, of northwestern University feinberg School of Medicine, and associate professor of medicine and preventive medicine and director of geriatric oncology.

22 | Chicago Medicine | September 2015

pre-frailty and frailty falls to virtually all physi-cians, said Northwestern’s Dr. McKoy. “Frailty could be and should be handled by all health care professionals, including general internists, family physicians, mid-level providers, and geriatricians. With the population aging and the fastest growing demographic of that aging population being 85 years and older, every one of us in medicine will see frail elderly,” she said. “Furthermore, general surgeons and surgical sub-specialists will see them. These might be patients who come in to the clinic and have lost weight, patients who say, ‘I’m so tired,’ or patients being prepped for a broken hip post-fall. This self-reported exhaustion or fatigue, this unintentional weight loss, this recurrent fall with fractures, this weakness that is manifested by the inability to do minimal tasks in the home is often a phenotypic presentation of frailty.”

She said primary care physicians will be the main group managing these patients given the shortage of geriatricians. “The only time I think they should be referring these patients to a geri-atrician is if frailty seems out of proportion to what is normally seen in the general internist’s office or is being manifested in a patient in their 60s or 70s, and the primary care physician wants to get a comprehensive geriatric assess-ment with the development and implementation of an interdisciplinary treatment intervention. But generally, internists should be identifying and managing frailty in all of their patients over the age of 65.”

Dr. Thompson said primary care physicians need to be better trained about frailty: “There is a huge unmet need for education about planning, not just at the end of life, but when people are getting frail and getting sick and needing to make these transitions in their living situation.”

“It is critical that older individuals be assessed for the possible presence of frailty during all encounters with the health care team. Utilization of several instruments can be useful, such as the timed-up-and-go test (TUG). “Being vigilant and proactive about frailty can not only improve quality of life but can also save lives,” said Dr. McKoy.

Howard Wolinsky is an instructor at Northwestern University’s Medill School of Journalism. He is the former medical and technology reporter for the Chicago Sun-Times and a former staff writer for American Medical News.

frailty

above: Megan huisingh-Scheetz, MD, MPh, of the University of Chicago Medicine, co-directs the Successful Aging and frailty evaluation (SAfe) Clinic. below: William Thomas, MD, a geriatrician and international authority on aging, is a self-described nursing home abolitionist. he is author of a book examining the baby boom generation’s reluctant second “coming of age.”

September 2015 | www.cmsdocs.org | 23

lEgiSlatiVE HigHligHtS

A Year of Advocacyhere are some of the ways in which your societies fought for you in springfield

leGISlATIve ADvOCACY is an increasingly large component of your Chicago Medical Society’s and Illinois State Medical Society’s missions. Health care is changing rapidly and new regulations are pouring in at an extraordinary pace. CMS and ISMS keep on top of

new developments, constantly striving to educate key decision-makers about the effects—good or bad—these legislative proposals could have on patients, physicians and health care delivery.

This year saw numerous wins for us in Springfield. In this review, we first look at the scope-of-practice bills that came before the Illinois Senate and House, showing the impact CMS and ISMS had on them. Next, we look at some key bills that were passed and how CMS and ISMS helped amend them. To download the full report, go to www.isms.org.

Scope of PracticeBoth CMS and ISMS are ever-vigilant when it comes the constant barrage of bills seeking scope-of-practice expansions. We strive to protect our patients and inform lawmakers of the differences in education and training between physicians and other health professionals. Here are the victories we scored this year.

Advanced Practice nurses House Bill 421 (Rep. Feigenholtz/Sen. Steans) as originally introduced would have removed the requirement that advanced practice nurses (APNs) practicing outside of a hospital, hospital affiliate, or ambulatory surgical center (ASTC) maintain a collaborative agreement with a collaborating physician. The bill would have also removed the requirement that certified regis-tered nurse anesthetists (CRNAs) maintain a written anesthesia plan with anesthesiologists. These changes to current law would have allowed APNs to practice independent of physician input. But ISMS strongly opposed HB 421 as introduced. At the request of legislators, ISMS agreed to meet with the Illinois Society for Advanced Practice Nursing (ISAPN) in an attempt to reach a compromise. ISMS and ISAPN met for months and agreed to language that:

• MaintainscurrentlawrequiringAPNstohaveacollaborativeagreement with a physician if they are practicing outside of a hospital, hospital affiliate, or ASTC. In hospitals, hospital affiliates, and ASTCs, APNs continue to be credentialed by the medical staff.

• Makesnochangeswhatsoevertotheprovisionofanesthesiaservices by CRNAs.

• Makesnochangestothelawrequiringdelegationofprescrip-tive authority by a physician, but allows APNs (other than CRNAs) to prescribe at a hospital affiliate such as an urgent care center if credentialed by the medical staff to do so. Under a written collaborative agreement, an APN can only prescribe medications if the collaborating physician delegates authority to do so. Additional limitations exist on an APN’s ability to prescribe Schedule II controlled substances, including specific identification of the controlled substances prescribed and a prohibition on any delivery method other than oral, topical or transdermal application. These same restrictions will apply at

the hospital affiliate. • Eliminatesspecifiedcontentinthecollaborativeagreementand

allows physicians and APNs to more broadly determine their collaborative practice within the specialty area of the APN and the physician.

• EliminatescontractualbarriersthatmightpreventAPNsfromparticipating in Medicaid.

• Allowsfora90-daytransitionperiodwhen,foranyreason,a physician discontinues a collaborative agreement with an APN, provided the APN seeks any needed collaboration at a local hospital and refers patients who require services beyond the training and experience of the APN to a physician or other health care professional.

• Deletesreferencesinapproximately28differentActswhereAPNs and physician assistants are allowed to perform various functions, only if they are specifically mentioned in the col-laborative agreement, or in the supervisory agreement with physician assistants. Most written collaborative agreements do not enumerate the particular patient services, but collaborating physicians routinely allow such services to be performed by the APN even though enumeration is required by the law. Nothing will prevent a physician from including any restrictions on practice or requirements for communication within the col-laborative agreement.

HB 421 as amended has been signed into law as Public Act 99-0173 and is effective immediately.

Direct-entry Midwife licensure House Bill 424 (Rep. Morrison) would have created the Home Birth Safety Act and provided for the licensure of “certified professional midwives” (CPMs) by IDFPR. These midwives are significantly different from certified nurse midwives. CPMs have little to no medical education, yet want to be able to provide medical treatment to pregnant women. ISMS strongly opposed this legislation, which was not called for a vote in committee.

naturopath licensure House Bill 3508 (Rep. Gabel) and Senate Bill 1601 (Sen. Martinez) would have created the Naturopathic Medical Practice Act and provided for the regulation of “naturopathic physicians” through licensure by IDFPR.

Naturopaths are neither trained for nor capable of diagnosing and treating physical ailments. In the face of very strong ISMS opposition, the bill was never called for a vote in the House Health Care Licenses Committee. Senate Bill 1601 was debated in the Licensed Activities and Pension Committee, but was never called for a vote.

Authorization to vaccinate Children 10 Years and Older House Bill 3627 (Rep. Evans) would amend the Pharmacy Practice Act to authorize pharmacists to provide any vaccine to children 10 years and older. Currently, pharmacists are limited to administering the influenza and Tdap vaccines to children ages 10 to 13. ISMS, along with the Illinois Chapter of the American Academy of Pediatrics (ICAAP), strongly opposed this bill, which

24 | Chicago Medicine | September 2015

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failed in the House Health Care Licenses Committee.

Authorization to Provide the MMR and Meningococcal vaccines to ChildrenHouse Bill 4213 (Rep. Evans) would amend the Pharmacy Practice Act to expand the vaccines that pharmacists are allowed to administer to children ages 10-13 to include the measles, mumps and rubella and meningococcal vaccines. Pharmacists would be required to notify the patient’s primary care physician and record the administration of the vaccines into the Illinois Comprehensive Automated Immunization Registry Exchange. ISMS opposed HB 4213, which was never called for a vote.

Podiatric Medical Practice Act House Bill 2925 (Rep. Golar) amends the Act. The original lan-guage, which ISMS strongly opposed, would have redefined the foot to include associated tissue that affects the foot or ankle. The Illinois Association of Orthopedic Surgeons and ISMS considered this an attempt to expand a podiatrist’s scope of practice. The bill was amended and this language removed. The bill, as amended, creates a three-year temporary license for postgraduate podia-trists. ISMS was neutral on the bill as amended. HB 2925 was signed into law as Public Act 99-0225 and is effective Jan. 1, 2016.

bills Signed Into lawNumerous bills impacting health care delivery were signed into law this year. Here we look at key bills that your Societies influenced, and in some cases, proposed.

Child Immunizations Senate Bill 1410 (Sen. Mulroe/Rep. Gabel) seeks to increase immu-nization rates among Illinois children by creating a Certificate of Religious Exemption for parents or guardians who want to exempt their child from school-required vaccines on religious grounds. The certificate will detail the grounds for objection and the specific immunizations or examinations to which they object. The signed certificate would also reflect that the parent or legal guardian understands the school’s exclusion policies in the case of a vaccine-preventable disease outbreak or exposure.

The certificate must also be signed by the health care profes-sional responsible for performing the school-required health examination, confirming that the professional has provided education to the parent on the benefits of immunization and the health risks to the student and community from the diseases for which immunization is required. The provider’s signature reflects only that education was given and does not allow a health care professional to determine a religious exemption.

ISMS supported SB 1410, which was signed into law as Public Act 99-0249, effective immediately.

Disclosure of Mental health Records Senate Bill 818 (Sen. Nybo/Rep. Guzzardi) and House Bill 2796 (Rep. Guzzardi) amends the Mental Health and Developmental Disabilities Confidentiality Act to provide that records and com-munications created in the course of providing mental health or developmental disabilities services shall be protected from disclosure.

ISMS expressed concern with the original drafting of the bills. First, the bill used the word “communications” instead of “record.” Second, there are two types of records that ISMS believes should not be confidential—evaluations completed

for purposes other than therapeutic purposes, such as for employment, and summary statements given by the patient and recorded in the health history.

These concerns were addressed in Senate Committee Amendment #1 to SB 818. ISMS was neutral on SB 818 as amended. It was signed into law as Public Act 99-0028, effective Jan. 1, 2016. HB 2796 remains in the House Rules Committee.

Mental health Reporting under the fOID Card Act Senate Bill 836 (Sen. Sullivan/Rep. Phelps) addresses issues related to the new mental health reporting requirements passed as part of the Illinois Concealed Carry Act. Current law requires medical professionals to report to the Department of Human Services individuals between the ages of 0-18 who show signs of being developmentally or intellectually disabled. There is no discretion provided to the professional, nor is there consider-ation given to the patient’s cognitive development throughout childhood. In addition, current law requires reports to be made within 24 hours of the determination by the medical professional that the person is developmentally or intellectually disabled.

SB 836 changes the requirement that the report be made for those between the ages of 0-18, and instead provides that the report be made for a person age 14 and older. The age of 14 was selected with the input of medical professionals, since it is the age at which both developmental and intellectual disability con-ditions have stabilized to a degree that they can be sufficiently evaluated by a health care professional. The current 0-18 report-ing requirement unfairly reports those with a disability that may stabilize during childhood. The bill also provides that reports be made within seven days, not 24 hours, except for those persons who have been identified as posing a clear and present danger.

SB 836 is supported by ISMS and the Illinois Psychiatric Society. The bill passed both chambers and was signed into law as Public Act 99-29, effective July 10, 2015.

Out-of-State Athletic Team Physicians Senate Bill 785 (Sen. Harris/Rep. Evans) is an initiative of the Illinois Association of Orthopedic Surgeons, supported by ISMS, which will grant temporary licensure waivers for physicians who travel with their teams to Illinois for an athletic event.

Under current Illinois statute, a team’s physicians could pro-vide medical service in Illinois only if they hold a full and active license in Illinois. SB 785 would allow athletic teams to use their team physicians while in Illinois for specific athletic events.

SB 785 was signed into law as Public Act 99-0206 and is effec-tive Sept. 1, 2016.

Technical language to the Illinois Physician Assistant and nurse Practice Acts, and the Patients’ Right to Know Act Senate Bill 1205 (Sen. Barickman), an ISMS initiative, cleans up language in the Illinois Physician Assistant Practice Act and the Illinois Nurse Practice Act. It adds the definition of “hospital affiliate” to both Acts. The bill also amends the Illinois Patients’ Right to Know Act to allow retired physicians who maintain active licenses to note on their physician profiles that they are retired and no longer see patients.

The bill has been signed into law as Public Act 99-0330. Changes to the Illinois Patients’ Right to Know Act are effective immediately; changes to the Illinois Physician Assistant Practice Act and to the Illinois Nurse Practice Act are effective Jan. 1, 2016.

September 2015 | www.cmsdocs.org | 25

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Mammography/MRI Coverage HB 3673 (Rep. Smiddy/Sen. Mulroe) expands access to appropriate breast cancer screening for all women age 35 years or older who are at risk for occult breast cancer by requiring every insurance policy to include MRI screening when medically necessary, as determined by a physician. The bill also requires the Department of Healthcare and Family Services (HFS) to ensure that on or after Jan. 1, 2016, all networks of care for adult clients include access to at least one certified Center of Imaging Excellence. The bill instructs HFS to convene a panel of experts to establish quality standards for mammography. HB 3673 requires that on or after January 2017, health care professionals participating in a breast cancer quality improvement program approved by HFS must be reimbursed for breast cancer treatment at a rate no lower than 95% of Medicare rates.

HFS must work with experts in breast cancer outreach and patient navigation to optimize mammogram reminders, establish a methodology for evaluation of their effectiveness, and modify the methodology based on the evaluation. HB 3673 requires all networks of care under the Public Aid Code to develop a means for the timely navigation of cancer patients to comprehensive care. All Medicaid-related networks of care must give patients diagnosed with cancer access to at least one program accredited by the Commission on Cancer as an in-network benefit.

ISMS supported HB 3673, which has been signed into law as Public Act 99-0433, effective immediately.

Topical eye Medication House Bill 3137 (Rep. Brady/Sen. Link) creates the Topical Eye Medication Act, and prohibits Illinois health insurers that provide coverage for prescription topical eye medication from denying coverage for prescription refills. The bill ensures that patients who have difficulty administering prescription eye drops can purchase timely refills. ISMS supported the bill, which was signed into law as Public Act 99-0226, effective Jan. 1, 2016.

Interstate Medical licensure Compact House Bill 3680 (Rep. Smiddy/Sen. Koehler) creates the Interstate Medical Licensure Compact Act, specifying that Illinois will join the Interstate Medical Licensure Compact, thus allowing Illinois physicians to access an expedited licensure process in all states joining the Compact. ISMS supported HB 3680, which was signed into law as Public Act 99-0076, effective July 20, 2015.

Power of Attorney for health Care SB 159 (Sen. Haine/Rep. Williams) changes the Power of Attorney Act and the Statutory Short Form Power of Attorney for Health Care Form by granting additional powers and authority to a named health care agent. SB 159 adds a third effective option for an agent, authorizing the agency to become effective when the principal lacks decision-making abilities based on a physician’s determination, but granting the named health care agent immediate access to the principal’s medical and mental health records, the authority to share such records with others as needed, and the complete ability to communicate with health care providers, including the ability to question the principal’s decision-making ability.

SB 159 adds a provision to the Form allowing a principal to nominate a health care agent as a legal guardian. SB 159 also replaces all references to “mental health service provider” with “psychologist.” Also, the bill requires that the Form include a notice that an “advanced practice nurse, dentist, podiatric

physician, optometrist, and psychologist” cannot sign as a witness. ISMS supported SB 159, which was signed into law as Public

Act 99-0328, effective Jan. 1, 2016.

Mandated Testing for Cytomegalovirus House Bill 184 (Rep. Nekritz/Sen. Mulroe) requires the Illinois Department of Public Health (IDPH) to establish and maintain a public education program to inform pregnant women and women who may want to become pregnant about cytomegalovi-rus (CMV). The bill would have also required physicians treating newborns to test any newborn who fails a newborn hearing screening for CMV before the newborn is 21 days old, and provide to the parents information about birth defects caused by congenital CMV and available methods of treatment.

ISMS, along with the ICAAP, supported creating a public education campaign, but opposed language mandating that phy-sicians test for the virus, since this would legislate the practice of medicine. ISMS and ICAAP were successful in removing the physician mandate from the bill. As amended, HB 184 requires hospitals to provide information to parents of a newborn who fails two initial hearing screenings about CMV and the opportu-nity to test for CMV before leaving the hospital. ISMS supported the bill as amended, which has been signed into law as Public Act 99-0424, effective Jan. 1, 2016.

health Care license Suspension House Bill 1359 (Rep. Gabel) as originally introduced, proposed to automatically suspend a professional’s license under certain circumstances related to Medicaid or Medicare fraud, regardless of whether the professional intentionally or deliberately commit-ted fraud. ISMS opposed HB 1359.

IDFPR agreed to an amendment that clarified that a health care professional’s license can only be suspended at such time as a pro-fessional has been criminally convicted or entered a plea of guilty or nolo contendere of criminal insurance fraud. The amendment also provides that if a licensee requests a hearing, then the sole purpose of the hearing shall be limited to determining the length of the suspension of the licensee’s license.

ISMS supported the bill as amended, which was signed into law as Public Act 99-0211, effective Jan. 1, 2016.

Substitution of biological Drugs Senate Bill 455 (Sen. Munoz/Rep. Acevedo) amends the Pharmacy Practice Act and creates a framework under which a pharmacist may substitute a prescription interchangeable product for a pre-scribed biological product. The bill adopts the federal definition of a “biological product” and defines an “interchangeable biologi-cal product” as a biological product that the FDA has licensed and has met the standards for interchangeability pursuant to federal statute, or is equivalent to another biological product as set forth in the latest edition of the FDA’s Orange Book. Within five business days following the dispensing of any biological product, the dispensing pharmacist shall report the substitution into an electronic record that can be accessed by the prescriber. This issue was first introduced four years ago. ISMS has argued that physicians need active notification prior to dispensing. The pharmacists successfully argued that active notification to the physician was in conflict with federal law. ISMS was successful in removing language that presumed physician notification by electronic means, which would have increased physician liability.

ISMS was supportive of SB 455, asserting that it is a step in

26 | Chicago Medicine | September 2015

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the right direction. The bill was signed into law as Public Act 99-0200 and is effective Jan. 1, 2016.

Relief for burn victims House Bill 4006 (Rep. Hoffman/Sen. Haine) creates the Burn Victims Relief Act and the George Bailey Memorial Program. The program provides financial assistance to those who have been burned through no fault of their own. Burn victims who have been told by two independent physicians that their prognosis is less than 18 months left to live shall immediately receive the five months of pay that they would have received for Social Security had there not been a mandatory five-month waiting period.

ISMS raised concerns about a provision that fraudulent diag-noses shall be a Class 3 Felony. Since this provision would add a criminal penalty to the practice of medicine, ISMS was able to get this provision removed by the sponsors. ISMS was neutral on the bill as amended, which was signed into law as Public Act 99-0455, effective Jan. 1, 2016.

Civil Code of Procedure: Physical and Mental examinations House Bill 95 (Rep. Thapedi/Sen. Connelly) clarifies that the physical and mental examinations of parties, the taking of depositions, and interrogatories will be conducted in accordance with court rules. As originally introduced, the bill would have deleted language providing that: the taking of depositions will be in accordance with rules; a party shall not be required to furnish the names or addresses of witnesses; whenever the defendant in any litigation in this State has the right to demand a physical or mental examination of the plaintiff, the plaintiff has the right to have his or her attorney, or other person, present; and no person or organization shall be required to furnish claims, loss or risk management information held or provided by an insurer.

ISMS objected to removing language regarding the plaintiff’s right to have an attorney or other person present during an exam, and language providing that persons or organizations shall not have to furnish claims, loss or risk management infor-mation. Both provisions were amended back into the bill. ISMS was neutral on the bill as amended. HB 95 was signed into law as Public Act 99-0110, effective Jan. 1, 2016.

Uniform Interstate Discovery Senate Bill 45 (Sen. Barickman/Rep. Wheeler) creates the Uniform Interstate Depositions and Discovery Act and establishes procedures for the issuance of a subpoena to require deposition testimony or discovery production in Illinois in con-nection with litigation pending in a foreign jurisdiction.

ISMS expressed concern that a foreign subpoena would require the deposition outside of the state. Senate Amendment #2 was adopted to clarify that a subpoena issued under the Act may not require compliance outside a deponent’s county of resi-dence in Illinois. ISMS was neutral on the bill as amended. SB 45 was signed into law as Public Act 99-0079, effective Jan. 1, 2016.

DnR/POlST Senate Bill 1466 (Sen. Mulroe/Rep. Moeller) is an initiative of ISMS to improve the current IDPH Do-Not-Resuscitate Advanced Directive. The bill removes “Do-Not–Resuscitate” from the name of the form and renames the form “Practitioner Order for Life Sustaining Treatment,” or “POLST,” form. The bill has been signed into law as Public Act 99-0319, effective Jan. 1, 2016.

September 2015 | www.cmsdocs.org | 27

member benefits

InchIng closer to legislation, the Chi-cago Medical Society won a commitment from U.S. Rep. Mike Quigley to support HR 2124, a CMS-backed bill that boosts graduate medical education. The Resident Physician Shortage

Reduction Act is the centerpiece of CMS’ grassroots GME campaign, and a top priority for Society lead-ers, students, and area teaching institutions.

Congressman Quigley, who came for a CMS-hosted roundtable event, heard from physicians and medical students gathered at Society headquarters on Aug. 20. He joins a growing list of lawmaker to get on board, giving new energy to CMS’ workforce advocacy.

carrying the Torch ForwardThe long march to passing a bill begins with relationships. Making wise use of members’ dues dollars, the Society continually educates Congress on matters impacting medicine. Sometimes one lawmaker at a time. This investment pays off with their support for CMS-backed bills.

Rep. Quigley is the only Illinois representative to sit on the House Appropriations Committee, making his interest in CMS initiatives all the more valuable.

His pledge adds to a groundswell of support for GME legislation. Early this year, the Society secured a commitment from U.S. Sen. Richard Durbin, who told CMS leaders he will co-sign a companion Senate bill. At last count, HR 2124 had 69 co-sponsors, and S 1148, 12 co-sponsors.

Both proposals create 15,000 Medicare-sponsored slots, which would be distributed across the U.S., with a special focus on primary care shortage areas. The bills are a big step forward for students who amass over $160,000 in loan debt without any guarantee they will land

a spot. Students Mark Looman and Christiana Shoushtari cited an IHS report that projects widespread physician shortages in the near future. Each year, a significant number of U.S. medical school graduates do not match to residencies, and the problem will only worsen as teaching institu-tions ramp up enrollment without commensurate increases in training slots.

Several converging trends—U.S. population growth, health insurance availability, and aging baby boomers—will overwhelm the current physi-cian workforce, CMS President Kathy Tynus, MD, stressed to Rep. Quigley. In states like Missouri, medical school graduates have gone to work as physician assistants, added Kenneth Busch, MD, immediate past president of CMS.

Roundtable participants also urged the congressman to support HR 3309, Flexibility in HIT Reporting and Advancing Interoperability Act, or Flex-IT Act. “The high cost of EHRs and burden of achieving meaningful use forces some physicians to give up their practices,” Dr. Tynus said. Patient care gets delayed when EHR systems don’t talk to each other because of software pro-prietary issues, Dr. Tynus noted. “HR 3309 would slow down the meaningful use requirements and facilitate data sharing.”

The roundtable also dove into violence and mental health. Dr. Tynus highlighted proposed legislation to allow the CDC to gather data on gun violence. Rep. Quigley heard from several psychia-trists who voiced their deep frustration with poor insurance parity and limits on drug prescribing. HR 2646, Helping Families in Mental Health Crises Act, is another CMS-backed bill for which panelists sought the congressman’s support.

“We’re working hard to ensure the Chicago Medical Society is your voice for change.”

During a cMs-hosted roundtable, U.s. rep. Mike Quigley (seated at the head of the table) promised to support hr 2124, the resident Physician shortage reduction Act. Participants also pressed for rep. Quigley’s support on bills to improve interoperability of ehrs, and to help families coping with mental health crises.

A Win for gMe Advocacy CMS adds momentum to physician workforce bill By Elizabeth Sidney

28 | Chicago Medicine | september 2015

member benefits

The vIcTorIes that your Chicago Medical Society and Illinois State Medical Society achieved this year in the legislature didn’t just happen by chance. Representing more than 17,000

physicians, CMS is one of the largest and most active county medical societies in the country, with more influence than many other county medical societies at the state level. Members of both CMS and ISMS form a dedicated network of physicians who work together to achieve a uni-fied health care front and fight against unfair reimbursement practices, restrictions on physi-cian autonomy and the erosion of critical legis-lation that protects physicians’ practices. Just think about it. If your Societies did not exist, then insurance companies would be the only voice leg-islators hear when it comes to health care issues—and that’s a bleak prospect indeed.

Fortunately, CMS and ISMS are here working hard to enhance your practice, improve your bottom line and protect your autonomy. But you, as a caring physician, have a role to play as well, especially when it comes to shaping legislation.

CMS provides a launching pad for physician

and patient protection initiatives; your active participation is key to our success in Cook County, Springfield, and Washington, DC. And we offer a variety of ways for you to get involved. For example, CMS and ISMS train physicians how to build relationships with their elected representa-tives through our Key Contacts program. Our websites inform members of new and pending legislation, in addition to providing links, sample letters, and guidance on communicating effectively with lawmakers.

Members can also submit their own resolutions to the CMS Governing Council. The Council will debate the resolutions, amend them as necessary and, when appropriate, forward them to ISMS for further debate during the State Society’s annual House of Delegates. Your resolu-tion could ultimately end up at the American Medical Association, or form the basis of a bill introduced in Congress. Any individual physician can make a difference.

Other opportunities abound, including a mini-internship program in which an elected official follows you throughout your busy day. So don’t delay—get involved today!

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member benefits

sePTeMBer

15 Introduction to the Basics of IcD-10-cM Diagnosis coding for ob-gyn Physician Practices Intended for all ob-gyn physicians, practice managers, physi-cian executive staff and medical office staff. A successful transition to ICD-10 CM by Oct. 1, 2015, will require careful planning and coordination of resources. Numerous provider and health plan data-bases and applications will be affected–including applications where diagnosis or procedure codes are captured, stored, analyzed or reported. In this session, par-ticipants will learn the steps to correctly select ICD-10-CM diagnosis codes for common ob-gyn diagnoses; understand the conventions and rules related to the ICD-10-CM alphabetic index and tabular list; apply the ICD-10-CM basic general coding guidelines and the chapter-specific guidelines for coding pregnancy, child-birth and the puerperium; and review ob-gyn clinical examples applying ICD-10-CM codes. Speaker: Nelly Leon-Chisen, RHIA, Director, Coding and Classification, American Hospital Association, Chicago. Registration/breakfast: 8:00-8:30 a.m.; pre-sentation: 9:00 a.m.–12:30 p.m. Location: Chicago Medical Society, 33 W. Grand Ave. Up to 3.5 CME credits; $149 per person for CMS members; $249 for non-members or staff. Price includes coding book. Register online at: www.cmsdocs.org; or contact Rachel rburns@cmsdocs.org; or call 312-670-2550, ext. 338.

16 The chicago gynecological society Annual Dinner “The Use of Medical Cannabis: What Every Practicing Gynecologist Should Know.” Speaker:

David G. Ostrow, MD, PhD. The 1200th reoccurring meeting will take place at the Willis Tower Sky Deck, Chicago. 6:00– 9:00 p.m. To RSVP, please contact Abigail at CGS@cmsdocs.org; or call 312-670-2550, ext. 326. Please also visit www.chicagogyn.org for more details.

23 cMs executive committee Meeting (online) Meets once a month to plan Council meeting agendas; conduct busi-ness between quarterly Council meetings; and coordinate Council and Board functions. 8:00-9:00 a.m. For information, contact Ruby 312-670-2550, ext. 344; or rbahena@cmsdocs.org.

25-26 Illinois Medical Directors Association IMDA will be hosting its fifth annual conference on many aspects of long-term health care. Topics range from antipsychotic use to reduction of readmissions to forming joint quality care committees between the many levels of management and health care. The two-day conference includes intensive lectures, panels and small group work. Location: Indian Lakes Resort, Bloomingdale. To RSVP, please contact Abigail at IMDA@cmsdocs.org; or call 312-670-2550, ext. 326. To register, please visit https://imda5than-nual.eventbrite.com.

30 cMs governing council Meeting The Society’s governing body meets four times a year to conduct business on behalf of the Society. The policymaking Council considers all matters brought by officers, trustees, committees, councilors, or other CMS members. 7:00-9:00 p.m., Maggiano’s Banquets Chicago, 111 W. Grand Ave. To RSVP, please contact Ruby 312-670-2550,

ext. 344; or rbahena@cmsdocs.org.

ocToBer 7 Physician leadership Development Program This half-day event is intended for all physicians, CMS District officers, councilors, Board members, executives, officers of specialty societies and hospital leadership. In the age of health care reform, physicians need new skills to lead this process. Physician leaders are in high demand today, and the evolving roles of physicians require a new approach when leading patients, peers, administrators, payers and elected officials in the right direction. In this program, attendees will become more effective, engaging, and successful lead-ers. By the end of the program, attendees will learn how to assess the overall mission of an organization and engage in strategic activity that fosters long-term success, define roles and responsibilities for team members to improve account-ability, identify team incentives to help guide change and improvement, gain knowledge on managing relationships and navigate competing interests, and enhance the attendee’s overall leadership skills through effective communication and delegation. Speaker: Susan Reynolds, MD, PhD, President and CEO of the Institute for Medical Leadership. Registration: 8:30 a.m.; lecture 9:00 a.m.–12:00 p.m. Location: Chicago Medical Society, 33 W. Grand Ave., Chicago. Up to 3.0 CME credits; $209 for CMS members; $309 for non-members. Register online at: http://www.cmsdocs.org/events; or contact Rachel at rburns@cmsdocs.org; or call 312-670-2550, ext. 338.

calendar of events

student DistrictLisa m. blankenshipsarah m. bunchAnn-Gelle s. CarterAnna GutinaJordan HoerrAlexander Hristov

Kimberly Jackson

resident DistrictVanessa Alonso, mDmargaret m. J. boyle, mDAbdallah A. bukari, mDmichael J. Leukam, mD

Jacob moore, mDGina m. Piscitello, mDsudhir Polisetty, mDGary O. rodriguez, mDKumar sukhdeo, mDDavid m. tehrani, mDLeah r. Vanenk, DO

rajiv Verma, DO

District 4matangi P. bala, mD

District 5rishi Garg, mD

Welcome, new members!The Chicago Medical Society welcomes its newest members. We are now 21 voices stronger.

30 | Chicago Medicine | september 2015

Personnel Wanted

Board-certified family practice or internal medicine physician to join a busy independent primary care practice of three in Glenview for 20-30 hours per week with flexible scheduling. Technologically advanced office with EMR. No in-patient care. A great opportunity for someone who wants to call their own shots, work with experienced private practice physicians. Please fax CV to 847-657-0640. Strictly confidential.

(Board-certified or board-eligible) anesthesiology, urology, gyne-cology, gastroenterology, ophthalmology, family medicine, pain management, ENT, urogynecology, plastic surgery, orthopedics, ENT & general surgery for multi-specialty surgical out-patient centers located in northwest and west suburban Chicagoland. Active part-time physicians wanted (not semi-retired). Please send resumes by fax to 847-398-4585 or to kimberleeo@officegci.com and vino878@aol.com.

Doctors needed to perform social security disability evalu-ations, in Chicago Loop and surrounding suburbs. For more information, email PMW1999@ATT.net or call Dr. Ahmed at 708-345-7035.

Ob-gyn physician wanted to perform surgeries, D & C, laparo-scopic tubal sterilization, hysteroscopy and other gynecological procedures part-time (25-30 hrs.) in Family Planning Surgical Centers in Chicago, northwest suburbs and west suburban Chicagoland area. Must be within 50 miles of Chicagoland area. Active part-time physicians wanted (not semi-retired). No obstetrical deliveries. Please fax CV to 847-398-4585 or administration@officegci.com and vino878@aol.com.

office/Building for sale/rent/lease

For sale: Freestanding multi-specialty surgery center in Wood Dale, Ill., with ample parking. State-licensed ASC with one larger and one smaller operating room, 3,800-4,000 sq. ft. Asking $4.75 million, not including real estate. Serious inquiries only. Email Administration@officegci.com and vg1028@aol.com or fax: 847-398-4585.

Fully equipped medical office for sale or sublease, located in northwest suburb of Chicago. The office provides services for primary care and dermatology procedures. Terms negotiable. Serious inquiries only. Email: bochilind@gmail.com.

For sale: Medical office/urgent care facility; 1650 Maple Ave., Lisle; 1,500-4,000 sq. ft. available. Single story, 20-30 car park-ing lot. Asking $799,000. Email: kimberleeo@officegci.com and/or fax: 847-398-4585.

Business services

Prompt Medical Billing. Expert revenue management service. Electronic claim submission, ICD-10 ready. Professional staff, no

set-up fees. Reduce expenses and maximize profits! Affordable rates—try us free for one month! Call 847-229-1557, or visit us online: www.promptmedicalbilling.com.

Physicians’ Attorney—experienced and affordable physicians’ legal services including practice purchases; sales and forma-tions; partnership and associate contracts; collections; licensing problems; credentialing; estate planning; and real estate. Initial consultation without charge. Representing practitioners since 1980. Steven H. Jesser 847-424-0200; 800-424-0060; or 847-212-5620 (mobile); 2700 Patriot Blvd., Suite 250, Glenview, IL 60026-8021; shj@sjesser.com; www.sjesser.com.

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september 2015 | www.cmsdocs.org | 31

When MIlDreD M.G. Oliv-ier chose to specialize in oph-thalmology, she never imagined how her background would open her eyes to a world of car-

ing. An American-born physician of Haitian descent, Dr. Olivier is a professor of surgery at the Chicago Medical School/Rosalind Franklin University of Medicine and Science, where she is director of diver-sity. She is also a past president of the Chicago Chap-ter of the Haitian Physicians Association, and the Midwest Association of Haitian American Women.

It was because of her Haitian parents’ influ-ence that Dr. Olivier went into medicine. They immigrated to Chicago, where her mother became a nurse and her father a physician, and both did considerable volunteer work. Dr. Olivier, following their example, began volunteering for medical mis-sions to Haiti beginning in 1993. Nothing prepared her for the destruction and agony she found when she arrived in that tiny nation 10 days after the cataclysmic earthquake that struck on Jan. 12, 2010. With a densely packed population of nearly 10 million people, Haiti saw a staggering 300,000 of its citizens killed, with another 300,000 injured, and an estimated one million people left homeless.

Dr. Olivier came into this catastrophe, along with two other medical workers from Chicago. They spent a total of eight harrowing days serving at the Haitian Community Hospital near Port-au-Prince and the tent hospitals at the Toussaint Louverture Airport. Dr. Olivier assumed many tasks, such as training hospital staff and creating databases and a registration system. She also spent time pleading with hospitals for supplies and orthopedic equipment while other doctors battled infections and amputated limbs.

Dr. Olivier has since returned to Haiti numerous times, training physicians, and setting up a tele-health conference earlier this year. But Dr. Olivier has done much more than make a difference in health care in Haiti. Back in Chicago, in her role as director of diversity at the Chicago Medical School,

Dr. Olivier works to alleviate health care disparities for minority populations, as well as help under-represented students enter the health care field. She wants to increase the mentoring of minority students. “It’s not about lowering standards—it’s about going to public schools in the Chicago area, interacting with the children, nurturing them, bringing them to scientific and medical confer-ences, and getting them involved and interested.” 

And Dr. Olivier doesn’t hesitate to use herself as a role model. “When I was in medical school, I was the only black student in my classes, and am now the only black glaucoma specialist in Chicago, and one of only a few African-American attending physicians. It’s been wonderful. I’ve been embraced by the entire medical community, and I want to inspire minority students to reach for the stars. We need more minor-ity specialists—it’s not often the case that minorities are brought into specialties.”

Dr. Olivier also works to expose her students to minority populations and culture. One way is by capitalizing on her position as a board member at Chicago’s DuSable Museum, one of the oldest African-American history museums in the U.S. She brings her medical students there. “I like opening people’s eyes,” she says. “Then everybody wins.”

WHO’s WHO

Modeling DiversityHaitian roots spur glaucoma specialist By Scott Warner

Dr. Olivier’s Career HighlightsMIlDreD M. g . olIvIer, MD, is president and founder of midwest Glaucoma Center, PC, in Hoffman estates. she earned her undergraduate degree at Loyola University of Chicago and her medical degree at the Chicago medical school. she interned at Loyola medical Center, and completed a residency in ophthalmology at Columbia Presbyterian medical Center and a fellowship in glaucoma at the Kresge eye institute at Wayne state University. Dr. Olivier has published widely and received numerous honors, including the American Glaucoma society Humanitarian Award. she serves as professor of surgery at the Chicago medical school and at John H. stroger, Jr., Hospital of Cook County, where she says she enjoys challenging residents and being challenged by them. “they keep you on top of your profession with their questions.”

ophthalmologist and medical professor Dr. Mildred M.g. olivier often visits public schools to mentor minority students and inspire them to go into medicine. “I tell them, ‘look at me.’ Many of them have not seen an African-American woman physician. It shows them what they can achieve.”

32 | Chicago Medicine | september 2015

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