NORTHERN OHIO PHYSICIAN FORMERLY KNOWN AS THE CLEVELAND PHYSICIAN formerly known as AMC/NOMA March/April 2008 | Volume 93 | No. 2

THE VOICE OF PHYSICIANS IN NORTHERN OHIO www.amcnoma.org

AMCNO Reviews Doctor-Ranking Programs with Ohio Attorney General

In October of last year, New York State Attorney General Andrew Cuomo and CIGNA reached an agreement to provide CIGNA members with more information on how it ranks physicians. Cuomo said the deal could set a national standard for physician-ranking systems. Cuomo warned other insurance companies that their physician-ranking programs likely would confuse or mislead members because of problems with the information used to rank physicians. Cuomo also warned UnitedHealth Group to cancel the launch of a similar program or face possible legal action. An agreement was finally worked out that avoided potential litigation between Cuomo and the insurers. Under the agreements, the plans will divide their preferred physician list into three lists — one that ranks by cost, one that ranks Ohio Attorney General Marc Dann (left) discussed health insurance oversight issues with AMCNO by quality and one that uses a combination of both measures. The agreements also require Vice President of Legislative Affairs, John A. that the plans report to the NY Attorney General every six months and use an outside monitor. Bastulli, MD.

Late in 2007, the AMCNO wrote Ohio Attorney AMCNO Legislative Committee in April 2007 were to take place in the future about General Marc Dann and indicated that AMCNO where Dann stated that he had concerns adding additional regulations for health leadership has been reviewing this issue. In regarding health insurers and market power. insurers in Ohio our organization would our letter, we noted Dann’s comments to the The AMCNO told the AG that if discussions like to be involved in this debate. (Continued on page 2) AMCNO Meets with CMS Leadership Regarding Electronic Health Record Project

On February 20th, AMCNO staff and physician leadership joined healthcare representatives from area hospitals, health departments and businesses at a meeting with the Center for Medicare and Medicaid Services (CMS) Acting Director Kerry Weems to discuss a new CMS electronic health record (EHR) demonstration project. The meeting was held at the MetroHealth Medical Center, and was hosted by the Aligning Forces for Quality Northeast AMCNO physician members spend a moment with Ohio Collaborative. Kerry Weems, Acting Director of CMS. Left to right – George E. Kikano, MD, AMCNO past president, This CMS project is an effort to encourage clinical quality measures. The goal of this Mr. Weems, R onald A. Savrin, MD, AMCNO past president, and Lawrence E. Kent , AMCNO board physician practices to adopt and use electronic CMS demonstration project is to revolutionize member. health records (EHR) in order to improve the way health care data is managed, the quality of patient care. The project will producing better health outcomes and INSIDE THIS ISSUE provide incentives to primary-care physician greater patient satisfaction. practices that use EHRs to improve quality as measured by their performance on specific (Continued on page 2) 2008 Medical Records Fee Update Page 8

AMCNO 2008 AMCNO 6100 Oak Tree Blvd. Legislative Directory See Insert Ste. 440 Cleveland, OH 44131-0999 2008 AMCNO Legal Issues Seminar ADDRESS SERVICE REQUESTED Registration form Page 9 ADVOCACY ACTIVITIES

AMCNO Reviews Doctor-Ranking providers to the least expensive providers. of these meetings and the focus of the Programs with Ohio Attorney Mr. Dann stated that he would like to council seems to be on charitable institutions General (Continued from page 1) discuss this matter further with the Ohio generally and not hospitals specifically. Department of Insurance in an effort to There is not a physician currently on the AMCNO representatives met again with AG explore whether or not Ohio would be able Council but the Ohio AG’s office has had an Dann in 2008 to discuss the ranking issues. to incorporate similar consent agreements initial conversation with the AMCNO about Although state law in New York differs with health plans in this state, inclusive of the AMCNO serving as an Ad Hoc member from law in Ohio, the AMCNO asked for plan oversight to assure compliance and/or of the Council. The AG plans to set up a Mr. Dann’s input on these agreements — in if this matter merits the introduction of work group to specifically address the issue particular on the plan to provide reports to legislation to achieve these goal. of hospital charity care and he believes that the NY AG every six months and the use of there will also be a need for physician involve - an outside monitor to assure compliance of The Ohio AG also mentioned his current ment in these discussions. The AMCNO the plans. During this meeting, the AMCNO initiative regarding hospital charity care. The plans to follow up with the Attorney voiced our concern that doctor-ranking Ohio AG has a Charitable Advisory Council General Dann and his staff on both the programs can be confusing and have the that is set up by statute with eleven members. health plan and charitable care issues and potential to steer patients from quality AMCNO representatives have attended two remain involved in these discussions. I

AMCNO Meets with CMS Leadership in managing patient care. Total payments Eligible communities will include those that Regarding Electronic Health Record under the project may be up to $58,000 can demonstrate active community stake - Project (Continued from page 1) per physician or $290,000 per practice. holder collaboration as well as private sector support; are geographically large enough The demonstration project is designed to The meeting in Cleveland was an opportunity to have a sufficient number of primary-care show that widespread adoption and use of for physicians and community leaders to learn physician practices; and are not already EHRs will reduce medical errors and improve more about the project and to determine if the participating in a CMS demonstration that the quality of care for an estimated 3.6 million project could be applied in our community. conflicts with the EHR project. CMS expects consumers. Over a five-year period, the project The Department of Health and Human that the demonstration will start with four will provide financial incentives to as many Services will soon open an application period communities in 2008, with the remainder as 1,200 small- and medium-sized primary-care for communities interested in becoming one beginning in 2009. physician practices that use certified EHRs to of the pilot program’s 12 sites. The intent is improve quality as measured by their perform - to engage entire communities in identifying The AMCNO physician representatives present ance on specific clinical quality measures. primary-care physician practices to participate at the meeting will continue to be involved Participating practices will be required to use in the demonstration and to support the in the discussions regarding this project in electronic records to perform specific functions, efforts of these physician practices. CMS will the coming months. To learn more about such as clinical documentation and ordering focus on locations where the demonstration the new EHR demonstration project, visit: prescriptions. While the core incentive payments may enhance existing or planned private http://www.cms.hhs.gov/DemoProjectsEval to practices will be based on performance of sector projects related to health information Rpts/downloads/2008_Electronic_Health_ the quality measures, the bonus will be based technology and quality reporting initiatives. Records_Demonstration.pdf I on how well integrated the certified EHR is

The Academy of Medicine of Cleveland & Northern Ohio (AMCNO) Membership Surpasses 5,000 Physicians

The AMCNO is pleased to announce the addition of the University Hospitals Medical of working on behalf of physicians and the Group (UHMG) and the University Hospitals Medical Practices (UHMP) to our membership patients they serve for over 180 years — roster bringing our membership total to over 5,100 physicians. The physician leadership of a legacy equaled by no other physician the AMCNO welcomes both groups to the organization. The AMCNO is also pleased to organization in Ohio. once again welcome the Cleveland Clinic main campus group to our membership roster for 2008 as well as the many other individual and group members from across the The AMCNO thanks all of our members Northern Ohio region. for their support now and into the future. There is strength in numbers — if you Reaching a membership total of over 5,100 The Academy of Medicine of Cleveland & know of a colleague who is not currently physicians establishes the AMCNO as one Northern Ohio is the only regional medical a member of the AMCNO please encourage of the largest regional medical associations organization that represents the interests of their membership in the organization. in the country and strengthens our ability physicians in the Northern Ohio community. For more information on membership, to advocate on behalf of the physicians in We are the VOICE of physicians in Northern please contact Linda Hale at the AMCNO Northern Ohio. Ohio — an organization with a rich history offices at (216) 520-1000, ext. 101. I

2 NORTHERN OHIO P HYSICIAN I March/April 2008 INSURANCE ISSUES Northeast Ohio Physician’s Pay Higher Premiums Jerry M. Crawford, Director of Regional Sales, The Premium Group, Inc.

Everyone, including the Ohio Department of Insurance (ODI), agrees that medical malpractice Northeast Ohio. The average ALAE cost of insurance rates have trended downward throughout Ohio. However, there is no disputing claims within Northeast Ohio is $26,952 the fact that physicians pay a higher premium to practice in Northeast Ohio. We will look while the remainder of the state averages at key statistics included in the ODI’s January 2008 report “Ohio 2006 Medical Liability $23,862; the difference is almost 12% Closed Claim Report” and evaluate the information that pertains specifically to Northeast higher in Northeast Ohio. This is obviously Ohio, comparing that to statistics that reflect experience in the rest of the state. going to impact the cost of liability insurance premiums that physicians will A brief overview of 2006 shows: heels of a hard market and several years of experience in Northeast Ohio as carriers • Actual changes in medical professional rate increases. look to balance expenses with income. liability insurance results brought Ohio increased competition in the insurance There is, however, a difference in the overall • Average cost of claims with industry. results and experiences of physicians in ALAE in Northeast Ohio: $26,952 • Insurance carriers reported that claims Northeast Ohio. Tables 1 and 2 compare • Average cost of claims with frequency continued to trend downward. the closed claims and paid indemnities for ALAE in the rest of the state: $23,862 • The percentage of medical malpractice 2005 and 2006. • Average difference representing cases resolved without indemnity increased costs in NE Ohio: $ 3, 090 payments increased. Although the figures indicate that the per - • Percentage difference representing • The medical malpractice insurance market centage of claims with paid indemnity and increased costs in NE Ohio: 12% is financially secure in Ohio. defense costs coming from Northeast Ohio decreased from 51% (of the entire state) in Another difference to note is in the dollar Ohio, specifically, reaped the benefits of a 2005 to 46% (of the entire state) in 2006, total of ALAE claims in Northeast Ohio; this competitive market. The Ohio Department there is more to the story. First, Northeast total shows that Northeast Ohio increased of Insurance recently reported that carriers Ohio is still the unwilling recipient of almost from 47% of the state in 2005 to 48% in took an average rate decrease of 10.9% 50% of the total costs of medical liability 2006. This was despite reductions in the in 2007. The combination of insurance claim results for the entire state. Secondly, a total number of claims by 21% in all of companies’ willingness to take premium more impressive indication of the difference Ohio and 26% in Northeast Ohio. reductions as well as offer additional in Northeast Ohio is discovered when evalu - discounts and credits provided Ohio ating the $42,691,478 of loss expense To illustrate the impact of these costs on physicians with a bit of relief on the (ALAE); this is the cost to defend claims in physicians in Northeast Ohio, let us look at the costs the physician may incur.

Table 3 (see next page) depicts the difference in medical malpractice insurance premiums between Cuyahoga County and the remainder of the state. The figures used in this table show the base filed rates of a variety of carriers and do not reflect any potential discounts or credits which may be realized when working with a qualified agent. These actual rates are filed with the Ohio Department of Insurance by admitted insurance companies. For purposes of example, we have used the largest differences in a few common specialties.

As Table 3 indicates, a physician in Cuyahoga County could pay as much as 64% more for their medical malpractice insurance than their colleagues in other areas of the state. Are the rates in Cuyahoga County justified? Our brief look at the statistics in the 2005 and 2006 Ohio Medical Liability Closed Claim Reports supports the reasons that carriers submit, and the department of insurance approves, (Continued on page 4)

NORTHERN OHIO P HYSICIAN I March/April 2008 3 INSURANCE ISSUES

Northeast Ohio Physician’s Pay Higher Premiums (Continued from page 4) rates that result in Northeast Ohio physicians paying higher premiums.

On a more global scale, the American Medical Association has, for years, included Ohio on its annual list of medical liability crisis states. And even though the AMA has softened their rating of Ohio this past year, a quick study of the data above indicates that Northeast Ohio, as compared to the state as a whole, is a more expensive jurisdiction (from a medical liability cost standpoint) to practice medicine; the capability and drive to diligently pursue the this article, please contact The Premium number of claims, indemnity payouts best solutions for their insureds. Additionally, Group, Inc., (440) 542-5020. and defense costs are higher than in any these physicians should continue to vote for other area of the state. representation that will support them in Editor’s Note: This article illustrates that their quest to reduce costs and increase although tort reform does work, the The good news is that the medical reimbursements to acceptable levels. landscape for physicians practicing in malpractice insurance industry, as a whole, Northeastern Ohio has not changed. This is in excellent financial shape; this leads to The Premium Group, Inc. continuously data clearly shows that physicians in our increased capacity and an appetite for new strives to support the physicians in Northeast region are still paying some of the highest business. The caveat is that physicians in Ohio. We have been instrumental in bring - medical malpractice rates in the state and Northeast Ohio need to be much more ing two new “A” rated carriers and a new that the majority of the claims are in diligent in understanding the reasons for the program as a partner with an “A” rated Northeast Ohio. The AMCNO believes that medical malpractice insurance premiums carrier to Ohio in the last six months alone. there is still more work to be done to alter they are charged. Northeast Ohio physicians The Premium Group, Inc. continues to pursue the medical liability trends in Northeastern need to work closely with their associations, standard and alternative options for physicians Ohio. The AMCNO plans to continue to their malpractice insurance agency and, throughout Ohio. If you have any questions, work toward finding an alternative to the more specifically, their agent who has the or would like further information regarding current tort system in Ohio if possible. I

NORTHERN OHIO CLASSIFIEDS PHYSICIAN MIDWEST ME DICAL STAFFING — FT/PT/PRN THE ACADEMY OF MEDICINE OF CLEVELAND & NORTHERN OHIO Positions available in Northeast Ohio. Create your 6100 Oak Tree Blvd., Suite 440 • Cleveland, Ohio 44131-2352 own schedule, malpractice insurance paid. Ideal Phone: (216) 520-1000 • Fax: (216) 520-0999 for retired physicians or one just opening a prac - tice. Please contact Sharon at Midwest Medical STAFF Executive Editor, Elayne R. Biddlestone staffing 5273 Broadview Road Cleveland, Ohio THE NORTHERN OHIO PHYSICIAN (ISSN# 1935-6293) is published bi-monthly by the Academy of Medicine 44134 (216) 749-3455 phone (216) 749-1077 Cleveland & Northern Ohio (AMCNO), 6100 Oak Tree Blvd., Suite 440, Cleveland, Ohio 44131. Periodicals email: [email protected] postage paid at Cleveland, Ohio. POSTMASTER: Send address changes to NORTHERN OHIO PHYSICIAN, 6100 Oak Tree Blvd., Suite 440, Cleveland, Ohio 44131. Editorial Offices: AMCNO, 6100 Oak Tree Blvd., PHYSICIAN OPPORTUNITIES — NO ON-CALL. Suite 440, Cleveland, Ohio 44131, phone (216) 520-1000. $36 per year. Circulation: 2200. PAID MALPRACTICE. FLEXIBLE SCHEDULING. Full Opinions expressed by authors are their own, and not necessarily those of the Northern Ohio Physician and part-time position available in Northeast or The Academy of Medicine of Clevelan d & Northern Ohio. Northern Ohio Physician reserves the right Ohio for Medicine, Surgery and Pediatrics. Please to edit all contributions for clarity and length, as well as to reject any material submitted. contact Christy McChesney at Physician Staffing, ADVERTISING: Inc., 30680 Bainbridge Rd. Cleveland, Ohio George H. Allen, Jr., Commemorative Publishing Company 44139. (440) 542-5000, Fax: (440) 542-5005, P.O. Box 450807, Westlake, Ohio 44145 email: clmcchesney@physic ianstaffing.com P: (440) 808-0240 • F: (440) 808-0494 © 2008 The Academy of Medicine of Cleveland & Northern Ohio, all rights reserved. BEAUTIFUL, PROFESSIONALLY DECORATED HOUSE, contemporary design in one of the best location in Beechwood. By owner, $789,000. (216) 965-3986 Correction: In the January/February issue of the Northern Ohio Physician magazine in an article regarding the AMCNO mini-internship program, Dr. Shashidar Kusuma OFFICE SPACE AVAILABLE in medical building attached to Marymount Hospital, from 1/2 day was incorrectly identified in a photo caption. AMCNO regrets the error. up to 2 full days. Call (216) 475-5944.

4 NORTHERN OHIO P HYSICIAN I March/April 2008 INSURANCE ISSUES The Ohio Department of Insurance (ODI) Plans Statewide Sessions to Consider Minimum Coverage for the Uninsured ODI to Arrange Sessions Around Ohio using the CHAT model (Choosing Health Plans Altogether).

Last summer, AMCNO leadership and staff met with the Director of the Ohio Department services and cost consequences of partici - of Insurance (ODI) Mary Jo Hudson and her health care staff to begin preliminary discussions pants’ coverage decisions. Each CHAT on the issue of health care reform and the uninsured. At this meeting, the Director of ODI group had to reach consensus in designing provided detailed information on how the ODI and interested stakeholders from around a common benefits package, a process the state were to be involved in a review process of health plans for the uninsured in the requiring negotiation and compromise. state of Ohio. This “Just Coverage Leadership Session” At that time, the AMCNO queried the healthcare priorities and trade-offs and was intended to bring together leaders Director and her staff as to whether or not fostering team building and collaboration on from around the state to go through the the ODI or the Governor of Ohio planned the topic of health care for the uninsured. CHAT process and learn how the CHAT to survey the uninsured as a part of this game works. The next step planned by the study; since it would seem imperative to A key component of this session is for ODI is to obtain a license for the usage of have data from not only the key stakeholders the participants to design a basic benefits the CHAT model. Once that license is such as physicians, hospitals, and insurers, package using a computer-based game obtained the ODI plans to take the CHAT but also from the individuals who stood to program called CHAT (Choosing Health process around the state in an attempt to benefit the most from the implementation Plans Altogether) — a game about insurance. obtain broad-based input from key stake - of a statewide health plan — the uninsured. In two-hour meetings of between 10-15 holders in order to use the data to develop people, participants design healthcare a health care plan in Ohio. ODI plans to To assist in this endeavor, the AMCNO benefits packages in separate rounds: one meet with and conduct CHAT sessions in representatives pointed to a study is completed on your own based upon your specific regions of the state, including completed by the California Healthcare experiences; the second round is done in Northern Ohio, with the intention of Foundation Commission. The Commission groups with an opportunity to discuss involving healthcare leaders, legislators, conducted a survey of uninsured patients options, and the last round is conducted small businesses, and, most importantly, at the federal poverty level of one to 300 with the entire group creating a basic benefit the uninsured in the CHAT process. The percent to seek input on the health policy plan that all of the participants agree upon. information obtained from these statewide issues and coverage that would affect the For this exercise, participants were told to sessions will be utilized by the ODI as they uninsured. The data revealed that the assume that health care coverage would be continue their review of healthcare coverage uninsured placed a high priority on preven - mandated for individuals without employer- reform in Ohio. tive care and establishing continuity with based coverage, and that the plan they a small group of physicians in a medical were going to design was to be available The AMCNO is pleased to be a participant home concept in order to reduce the need only to adults without insurance and would in this process and applauds the ODI for for emergency room visits. The survey also not include the Medicare population or making the decision to obtain additional revealed the level of co-payments and children. information from key constituents, in premiums that would be acceptable to these particular the uninsured population. The individuals. ODI had not considered such a Built into CHAT’s design is the need to AMCNO is planning to work closely with survey and requested more information. As make trade-offs, reflecting the realities of the ODI to assist them in setting up CHAT a follow-up the AMCNO sent the data and today’s environment. For example, CHAT sessions in the Northern Ohio region with information to the ODI and asked that the participants had only 50 “markers” to key stakeholders from the healthcare sector. AMCNO be considered as a participant in spend among 16 categories of healthcare The AMCNO also plans to work with other future discussions on this issue. services, but there were over 80 places to groups to arrange sessions with legislators, put them. Participants had to weigh various small businesses and the uninsured. As a result of our input, the AMCNO was limitations — increased cost-sharing, invited to participate in the “Just Coverage restricted choice, less convenience and For more information on this initiative, Leadership Session” sponsored by the ODI reduced services — as they considered the please contact AMCNO staff Ms. Elayne R. in early 2008. The purpose of the session range of options. A Health Event Lottery Biddlestone at (216) 520-1000, ext. 100. I was to query the community, healthcare presented participants with medical scenarios, and policy leaders who are: considering depicting common and uncommon illnesses coverage expansion proposals, assessing and accidents. These events illustrated the

NORTHERN OHIO P HYSICIAN I March/April 2008 5 INSURANCE ISSUES AMCNO representatives meet with the Ohio Department of Insurance (ODI) to Review Health Care Models

The State of Ohio, under the auspices of Governor Strickland and the Ohio Department of Insurance is reviewing various types of health care “reforms” to further the Governor’s goal of significantly reducing the number of uninsured citizens in the state. The healthcare coverage reform goals are: 1. To provide access to affordable health insurance coverage to all uninsured Ohioans with an initial goal of providing coverage to 500,000 more Ohioans AMCNO physician leadership with ODI representative Mr. Douglas Anderson. Left to right – John A. by 2011; 2. To increase the number of small employers who are able to offer coverage to Bastulli, MD, Mr. Anderson, and James S. Taylor, their workers. MD, AMCNO president.

The Governor has engaged myriad stake - and other factors. The health care study holders in an open transparent process committee plans to review the following: to get an idea on how to best cover the • The Connector Model employed by The 5th Annual uninsured in Ohio. The AMCNO is an active Massachusetts, which is a public/private participant in the review of health care program under which the state sets rules Marissa Rose models for Ohio. Ohio has received a grant for benefits and rates while subsidizing from the Robert Woods Johnson Foundation lower-income residents. Biddlestone Memorial for a “coverage institution” — to come up • A “reinsurance” program for small with effective reforms. The Ohio team con - employers and individuals, or stop-loss Golf Outing sists of 12 representatives, including several system under which the state puts up a legislators. In addition, ODI has also hired an portion of the claims, patterned after the Monday, actuarial group to conduct an actuarial study Healthy New York initiative. August 11, 2008 to review the alternatives for coverage reform. • A system with rates and coverage set by the state that requires insurance companies Barrington Golf Club Over the last few months, the Academy of to offer basic benefit plans and includes Medicine of Cleveland & Northern Ohio mandates on workers. 1 p.m. Shotgun Start (AMCNO) has been meeting with the Ohio Department of Insurance (ODI) regarding Additionally, the health care reform 1-2-3 Best Ball Format their health care coverage reform initiative. committee is considering the state Raffle & Great Prizes We have learned that systems in use in employee system as a model for health care Massachusetts and New York are among along with a variety of other insurance law those getting a close look from the actuarial changes aimed at improving affordability. Proceeds to benefit the firm and an economist under contracts with The plan is to develop recommendations the state. The review, overseen by the that can be reviewed and then develop a Academy of Medicine Department of Insurance and funded through plan in order to prepare legislation to Education Foundation, a $500,000 budget line item, is a component accomplish the goals. There is no distinct of the Governor’s Healthcare Coverage deadline for the introduction of legislation; its local medical school Reform Initiative. however, ODI hopes to have some results scholarship programs from the actuarial firm by early 2008 as to and public health Information gleaned by the Dallas-based how the various reform scenarios could Lewis & Ellis firm and economist Ken Thorpe, impact coverage. Researchers are expected education initiatives of Emory University in Atlanta, will ultimately to report back to the state in the near in our region. be employed by the 12-member committee future. The AMCNO will continue to work to craft recommendations to the governor with the stakeholders and groups involved and General Assembly on how to best address in this initiative and report back to our the estimated total of more than 1.2 million membership. residents, or about 11% of the state’s population, who lack health insurance. Editor’s Note: Recently the ODI responded to a request from the AMCNO that the ODI ODI representatives believe that the new consider surveying the uninsured as a part AMEF data will provide policymakers with a general of their health care reform initiative in order update of Ohio’s current situation. Researchers to obtain detailed information from this Call Linda Hale are expected to report back to the state in population on their viewpoint. The ODI has (216) 520-1000 the near future. The refinement of recom - decided to proceed with this initiative. For mendations will follow, with the timetable more information go to page 5 of this to Register Today! dependent on the nature of the findings issue. I

6 NORTHERN OHIO P HYSICIAN I March/April 2008 PRACTICE MANAGEMENT

In addition, as the ODJFS begins the process Anthem Partnership Plan for Covered of permitting CFC consumers to choose a new plan, the ODJFS has implemented an Families and Children (CFC) State assignment algorithm that looks for previous Contracts Comes to an End experience with a primary care provider. In the event the CFC consumer does not make The Bureau of Managed Health Care (BMHC) has notified the AMCNO that Anthem Blue a new health plan choice and that person is Cross/Blue Shield (BC/BS) intends to end its provider agreement with the Ohio Medicaid then assigned to a new plan, the algorithm Program and will no longer serve Medicaid consumers in the Covered Families and Children will make its best attempt to assign the (CFC) managed care program effective March 31, 2008. Anthem will, however, continue consumer to health plan which includes in its to serve Aged, Blind and Disabled (ABD) Medicaid consumers without any interruption. network a primary care provider(s) with whom the member has had previous experience. This change WILL IMPACT physicians and April 1, 2008 will be the financial responsi - Another step in the ODJFS continuity of their Medicaid patients in Northeast Ohio bility of the members’ newly assigned MCP. care transfer process will occur once the region because Anthem has 87,011 Medicaid enrollment transfer is complete. The ODJFS consumers listed as members in this region. If you have Medicaid patients in your practice plans to share with Anthem information Other regions affected include the Central who are currently enrolled in Anthem you regarding those health plans to which their and Northwest regions of the state. may wish to review whether or not your CFC membership is being transferred. practice is also contracted with one of the Anthem will then be responsible for sharing Plans are underway by the Ohio Department other MCPs still operating in the Northeast with the new health plan information on of Jobs and Family Services (ODJFS) to Ohio region. outstanding scheduled treatments, prior notify Anthem members to assist them in authorizations for: a) private duty nursing; transitioning to new health plans in their Questions Raised by AMCNO b) durable medical equipment; c) home region. ODJFS plans to send a notification The AMCNO contacted ODJFS because of care services; d) pharmacy; e) vision; letter to the 87,011 Northeast Ohio Anthem our concern about continuity of care issues f) dental; and g) prenatal care services for members on February 25, 2008, with a as Anthem Blue Cross Blue Shield Partnership members in their third trimester of pregnancy, reminder letter to be sent out on March 10, Plan (Anthem) exits from the Covered and those members who were under case 2008. The anticipated enrollment transition Families and Children (CFC) Managed Care management. The ODJFS expects that date is April 1, 2008. program in the Northeast Ohio market. whenever possible, the Anthem information The AMCNO queried the ODJFS about how will identify the authorized provider for For members who do not make an affirmative they planned to assure a smooth transition prior authorized services. choice of a new managed care plan, ODJFS regarding the continuity of care for Anthem will automatically assign them to the managed members, and more specifically how the And finally, the ODJFS has informed the care plan (MCP) with the best overlap with ODJFS planned to respond when an Anthem AMCNO that as a consumer-driven fail their historic relationships with primary care member was seeing a physician(s) not safe mechanism, members will continue providers. Any member who is dissatisfied currently a part of either of the remaining to have the right to change their health with the auto-assignment to an MCP may health plan’s networks. plan selection within the first 90 days of switch within 90 days by contacting the enrollment should they wish to do so. The Ohio Medicaid Managed Care Enrollment The ODJFS responded to the AMCNO that ODJFS noted they are confident these Center at 1-800-605-3040. Currently there their department is aware of the need to activities and processes will help assure are two other MCPs operating in the assure the smooth transition of members a smooth transition for affected Anthem Northeast Ohio region that Anthem Medicaid from Anthem to the remaining CFC- members who are required to select a new consumers may choose from at this time — participating plans in the Northeast Region, health plan. Physicians should remember CareSource and WellCare. CareSource and WellCare. In terms of that Anthem will continue as a participating continuity of care, the ODJFS informed health plan in the ABD managed care Anthem has issued a news release indicating that AMCNO that a number of things are program. that continuity of care will be the responsibility happening to help with this transition. ODJFS of the receiving MCP. The new MCP and stated that both CareSource and WellCare The AMCNO will continue to monitor this providers may contact the Anthem Partnership are working to expand their healthcare situation for our members as the transition Plan for assistance with CFC Medicaid networks to increase the overlap of network process moves ahead over the coming patients who require a continuity of care plan providers. ODJFS hopes that this activity will months. If AMCNO member have questions for qualifying conditions. Contacts may be allay concerns about CFC consumers who or concerns, contact the AMCNO and we made to the Anthem Utilization Management may be seeing providers who are not currently will bring these issues to the attention of Department at 1-866-896-6580. in either of the networks. The ODJFS is the ODJFS. I hopeful that by the time the consumer is Anthem will continue to reimburse providers required to select a new plan, their provider for eligible CFC Medicaid claims with dates of choice may be participating with one or of service up to and including midnight of more of the remaining health plans. March 31, 2008. Service dates beginning

NORTHERN OHIO P HYSICIAN I March/April 2008 7 8 NORTHERN OHIO P HYSICIAN I March/April 2008 AMEF Academy of Medicine Education Foundation

NORTHERN OHIO P HYSICIAN I March/April 2008 9 LEGISLATIVE ISSUES

By Michael Wise, JD, AMCNO Lobbyist McDonald Hopkins, LLC

Ohio Politics The AMA research is supported by the above this opinion could have an impact on recent report from the Ohio Department this type of case in the future. More than a The big news in Ohio was the Governor’s of Insurance on medical malpractice claims dozen organizations filed friend of the court recent announcement that Ohio is facing (see page 3 for related story). However, briefs on behalf of plaintiffs and defendants almost a billion dollars in deficits for the Northeast Ohio continues to trend behind in the case. The AMCNO supported next fiscal year. Ohio’s fiscal year begins on the rest of Ohio. Because of this fact, the enactment of the limits and was listed July 1, 2008 and the runs through June 30, AMCNO continues to push for a pilot along with others as a member of the 2009. Cuts have already been announced mandatory arbitration program that would Ohio Alliance for Civil Justice (OACJ) on and there will likely be legislation this spring focus on Northeast Ohio. However, the fact their Amicus Brief. to finish balancing the budget. The budget that attorneys have come out in full force reduction will be realized from cost savings, against the Bill in conjunction with the Key Legislation management strategies, program cuts and current political landscape in Ohio, SB 59 House Bill 125 – operating efficiencies, Governor Strickland has stalled. This situation may put the the Healthcare Simplification Act said. The job cuts will come from not filling brakes on the Bill for this General Assembly. The intent of this bill was to implement vacant positions, early retirements and layoffs. Senator Coughlin is attempting to broker a reforms that would provide for ease in If budget conditions worsen, Strickland said compromise and we will report on those the health insurance contracting process, he would tap into the state’s $1 billion rainy results next issue. day fund to cover any budget shortfall. fairness in contracting, a standardized Among the biggest budget reduction is Judicial Branch Issues credentialing process and Web-based $67 million from the Department of Job eligibility verification. However, after many and Family Services, which administers the The Ohio Supreme Court (OSC) recently hearings and interested party meetings, the state’s Medicaid program. Of importance to upheld the constitutionality of a law that Bill has been changed radically since it was Ohio physicians, however, is the decision by limits the amount of damages that may be first introduced. Governor Strickland to increase Medicaid awarded to injured persons who win product reimbursement rates to physicians by 3% liability lawsuits. Justices said in a 5-2 opinion Interestingly, the Ohio Manufacturers beginning July 1, 2008. With the budget that caps on noneconomic and punitive Association (OMA) is now weighing in on issue looming it may be difficult to pass damages do not violate a right to jury, due HB 125. OMA believes that the Bill has the meaningful legislation from now through process, equal protection, or the single potential to cause major disruptions in the 2008. subject rule of the Ohio Constitution. Chief administration of Ohio health care plans — Justice Moyer wrote the lead opinion and including self-insured plans. OMA states SB 59 – Mandatory Arbitration concurring were Justices Evelyn Stratton, “this legislation dictates certain terms of and Medical Malpractice Rates Maureen O’Connor, Judith Lanzinger, and the contracts between all types of medical Robert Cupp. Justice Terrence O’Donnell providers (including hospitals) and contracting In February 2008, the American Medical dissented in part. Justice Paul Pfeifer entities (i.e., insurance companies, third Association (AMA) unveiled new research dissented. party administrators (TPAs), etc.). Even if that proves medical liability reforms such as they agreed to, providers and insurers caps on noneconomic damages are effective What Justice Moyer did in this case (known would not be given the leeway to voluntarily in lowering medical liability premiums, as the Arbino case) is to raise the bar for negotiate those provisions mandated by the resulting in an increased supply of physicians future courts. His opinion reviews all of the Bill. Proponents have drafted HB 125 with to care for patients. In states without reforms, previous tort reform activity in the Ohio the intent to make it apply to employer- many physicians are forced to make difficult Supreme Court, cases that made the foun - sponsored, self-insured plans typically practice decisions to limit the care they provide dation for the Arbino ruling. Moyer is trying protected from state mandates by ERISA simply because they can’t afford to pay to force future courts to either uphold preemption. If the Bill is not changed, OMA sky-high medical liability premiums driven-up Arbino or have to rule unconstitutional a indicates that self-insured employers may be by escalating jury awards. Regardless of the whole line of previous cases. Justice Moyer is forced to go to court to stop the application case’s merit, runaway jury awards for non- telling future courts that in order to invalidate of this Bill to their plans and TPAs. At press economic damages can reach millions of Arbino, they will have to also ignore stare time, the Bill was still undergoing changes dollars, driving up premiums and putting decisis. This term is Latin and means to and more information on the Bill will be access to care at risk for patients. The “stand by that which is decided.” Nothing included in the next issue. AMA supports caps on the noneconomic is foolproof or forever in the law but Justice damages of jury awards, and unlimited Moyer and the four justices do their best to House Bill 456 – Ohio C.A.R.E. payments for economic damages. While protect this opinion. A bill introduced by Representative Jim premium rates have largely stabilized, they Raussen would require the state to subsidize remain at the highest levels in history. Although this decision does not involve health insurance claims for people with medical malpractice caps or claims as noted chronic medical conditions and offer tax

10 NORTHERN OHIO P HYSICIAN I March/April 2008 LEGISLATIVE ISSUES credits for poor adults that don’t qualify for $100-150 million to implement in fiscal year OTP tax and the cigarette tax. The revenue Medicaid. In February Rep. Raussen provided 2009 and once fully implemented would generated would be used to fund youth and sponsor testimony on the legislation noting likely cost between $450-$500 million community tobacco prevention programs the key aspects of the bill, which includes annually, but the cost would be limited to around Ohio whose long-term existence is provisions that would increase eligible age the amount the state collects through the now threatened. for family policy dependents from 22 to 29; tax on insurance premiums. Under the bill, offer BWC premium discounts to small the Ohio C.A.R.E. plan would provide tax When legislators increased the cigarette tax in businesses that don’t offer insurance but credits of $2,500 per individual and $4,000 2003 and 2005, they failed to also raise the meet certain criteria; subsidize the uninsured for families living below 100% of the other tobacco products tax. The Coalition is through tax credits for individuals and families; federal poverty level that aren’t eligible asking the General Assembly to correct this and focus reinsurance for the uninsured for Medicaid, he said. About 30% of the error so that the other tobacco products tax with chronic conditions into three categories. state’s uninsured fall into that category. equals 55% of wholesale price, equivalent to the current cigarette tax. (The current OTP tax The bill would also subsidize uninsured The AMCNO plans to review the bill in rate is 17%.) The legislature should then link Ohioans below 100% of the federal poverty detail and provide input on the legislation. the other tobacco products tax to the cigarette level that don’t qualify for Medicaid; increase The inclusion of wellness discount programs tax, so that no corrections will be needed in salaries for nursing instructors at state along with the provision to adopt nutrition the future. Statistics offered by the Coalition universities; expand the 340b Federal Drug rules in schools and eliminate trans-fat are show that the correction would decrease the Pricing Program in prisons; increase the role important public health issues, however, overall consumption of other tobacco products of public dentistry and allow more flexibility other key issues in the bill that will warrant by over 13%, and cause a 25% reduction in in providing services; require the Department the attention of the AMCNO include the use of these products by youths. While Ohio of Education adopt nutrition rules and ban changes in contracting language between has seen a significant decrease in high school trans-fat from schools; increase purchasing Medicaid Managed Care companies; the students’ cigarette use from 2000 to 2006, of pharmaceutical benefits for state programs; request that nonprofit hospitals define there has been no similar reduction among and use and expand on the Governor’s charitable care/community benefits; the this population for smokeless tobacco or cigar executive order for a Health Information requirement of certain hospitals to post use, according to the Ohio Youth Tobacco Technology board. their tax liability as compared to their Survey. Studies of Appalachian Ohio show charitable care on their Web site; the that one-third of males use smokeless tobacco Also included in the bill are changes in requirement that ambulatory surgical compared to the statewide male prevalence contracting language between Medicaid facilities annually report certain data to rate of seven percent. Managed Care companies, a request that the Director of Health; as well as a need to nonprofit hospitals define charitable care/ review how the discounts on premiums will The AMCNO has endorsed this concept and community benefits; a requirement that be implemented for BWC employers who plans to participate as a member of the certain hospitals post their tax liability as offer health and wellness programs. Also Coalition steering committee — which would compared to their charitable care on their of interest to the AMCNO will be the pilot entail offering in kind services through our Web site; and a requirement for ambulatory program and advisory board that will be lobbyist and staff. In addition, the AMCNO surgical facilities to annually report certain responsible for exploring the use of health has been asked to participate in the Coalition’s data to the Director of Health. information technology in Ohio. As the planned Advocacy Day in Columbus to educate testimony on this legislation continues, legislators on the need for this type of legisla - The reinsurance plan outlined in the bill is the AMCNO will keep our members tion. For more information on this initiative based on the Healthy New York model, and apprised of its’ progress in the legislature. contact E. Biddlestone at the AMCNO offices would define participants into three high- at (216) 520-1000, ext. 100. risk categories based on the severity of their AMCNO involved in legislative preexisting conditions. The program would initiative on tobacco products tax The AMCNO has a comprehensive tracking begin by targeting individuals with lower In keeping with the AMCNO goal to advocate system of all health care related legislation levels of risk that meet certain eligibility for our members and their patients on public in the General Assembly. If you are inter - requirements. In addition, the state would health issues the AMCNO has agreed to ested in receiving a copy of this document, offer “stop-gap coverage” by subsidizing participate in a new legislative initiative please contact Elayne Biddlestone at claims between $15,000 and $50,000 known as the Investing in Tobacco-Free Youth (216) 520-1000. In addition, AMCNO annually, a measure in the bill that would Coalition. The Coalition has already begun members should note that this issue of enable people with chronic conditions to their kick-off of a campaign to reduce the use the magazine contains a copy of the most purchase private insurance. The state would of non-cigarette forms of tobacco. The group recent Legislative Directory prepared by the have authority to audit the claims. is dedicated to reducing the problem of AMCNO lobbyists. Please keep a copy in non-cigarette tobacco produced, called “other your office for quick reference in the event As far as the cost of the program goes, tobacco products” (OTP). The group is seeking you want to contact your area legislator. I reinsuring claims for those with preexisting to make these products less appealing to conditions would initially cost between youth by correcting the inequity between the

NORTHERN OHIO P HYSICIAN I March/April 2008 11 SAVE THE DATE The Academy of Medicine of Cleveland and Northern Ohio (AMCNO) invites you to attend our 2008 Annual Meeting

Friday, April 25, 2008 Ritz-Carlton Cleveland 1515 West Third Street 6 p.m. Reception • 7 p.m. Dinner Black Tie Optional

INDUCTION OF THE 2008-2009 AMCNO P RESIDENT , Raymond J. Scheetz, Jr., MD

PRESENTATION OF 50 Y EAR AWARDEES AND ACADEMY OF MEDICINE EDUCATION FOUNDATION (AMEF) SCHOLARSHIPS TO MEDICAL STUDENTS FROM CASE SCHOOL OF MEDICINE , C LEVELAND CLINIC LERNER COLLEGE OF MEDICINE AND THE NORTHEASTERN OHIO UNIVERSITIES COLLEGE OF MEDICINE .

AMCNO 2008 H ONOREES John A. Bergfeld, MD JOHN . H. B UDD MD DISTINGUISHED MEMBERSHIP AWARD George E. Kikano, MD CHARLES L. H UDSON MD DISTINGUISHED SERVICE AWARD Victor M. Bello, MD CLINICIAN OF THE YEAR Dale H. Cowan, MD SPECIAL HONORS AWARD John D. Clough, MD OUTSTANDING SERVICE Jim Mehrling SPECIAL RECOGNITION

Please join us in congratulating our medical scholarship recipients and awardees on April 25th.

12 NORTHERN OHIO P HYSICIAN I March/April 2008 NORTHERN OHIO P HYSICIAN I March/April 2008 13 HEALTH INFORMATION TECHNOLOGY Health Information Technology, Health Insurance Exchanges, and Health Policy Research in Ohio Subject of Recent Policy Conferences By Jason Sanford, Director of Communications, HPIO

Health information technology and exchange, health insurance exchanges, and the state Ohio Health Data and of research in Ohio were the focus of several recent conferences hosted by the Health Research Conference Policy Institute of Ohio (HPIO). In December HPIO, in conjunction with the Health Foundation of Greater Cincinnati, The first conference, “Health Information efforts, the health care quality and cost hosted “Bridging Policy and Practice: The Technology & Exchange in Ohio: Where are benefits of HIT/HIE, if a standard HIT/HIE 2007 Ohio Health Data and Research we? Where are we going?” was held in permission form should be used around the Conference” in Columbus. This goal of the Columbus in late October 2007. The con - state, and where HIT/HIE efforts will go in two-day conference was to enhance the ference brought together representatives the coming years. In general, participants application of Ohio-specific research and from physician groups, businesses, hospitals, agreed that while they don’t want the state policy through exposure to health data health plans, consumer groups, and more government to run Ohio’s HIT/HIE systems, sources and information contained within to both discuss and work toward common they think it is vitally important that the state Ohio. ground around health information technology government and Ohio’s different health care (HIT) and health information exchange (HIE) groups and organizations work together for Topics covered included health systems data, efforts in Ohio. system interoperability. Otherwise, Ohio could health information technology, access to end up with a number of different HIT and care, public health, mental health, health HIT and HIE are a nationwide effort to HIE systems which are unable to communicate disparities, family violence, health surveys, promote the use of technology to improve and interact with each other, thereby and Medicaid. Among the specific issues medical care, reduce costs, and provide a negating any positive benefits of using HIT discussed were policies around researching more patient-centric focus to better health. and HIE. child health issues, the use of Geographical According to reports, the adoption of Information Systems for health research, effective HIT and HIE systems in the United Let’s Talk About a Health Insurance the upcoming 2008 Ohio Family Health States could help prevent up to 98,000 Exchange: Is it Right for Ohio? Survey, accessing Medicaid information and hospital patient deaths from avoidable On January 7, 2008, HPIO held a short data, and more. medical errors each year while also saving luncheon conference to discuss the viability hundreds of billions of dollars by eliminat - of a Health Insurance Exchange in Ohio, “We were pleasantly surprised to see such ing unneeded and redundant medical tests which allows individuals, families, and a strong turnout among so many policy and reducing administrative waste. To businesses who lack access to large group leaders in the state,” said Timothy Sahr, accomplish this, HIT and HIE would use heath insurance policies to still be able to Director of Research at the Health Policy technology systems to unite health providers, purchase affordable health insurance. Institute of Ohio. “The conference was a payers, and patients to ensure that every - first for Ohio in terms of so many policy one gets the right care at the right time. An Well over 100 healthcare and policy profes - people being exposed to professionals in example of an HIT and HIE initiative would sionals from all over Ohio met in Columbus the clinical health, preventative health, and be the creation of electronic health records, to see the presentation by Stuart M. Butler, political and private health sectors.” meaning patients would have access to Ph.D., and Edmund Haislmaier from the their medical records no matter which Heritage Foundation. The two speakers dis - The conference concluded with a luncheon physicians or hospital they go to. cussed how Health Information Exchanges honoring the recipients of the 2007 Health could help substantially alleviate the num - Policy Institute of Ohio Awards for Health The conference keynote speaker was ber of Ohioans uninsured while returning Policy Research. The winners were: Governor Ted Strickland, who discussed his control of health insurance, price sensitivity, recent executive order creating an Ohio authority, and quality to the consumers. Dr. Lisa Simpson of the Cincinnati Children’s health care information advisory board. The They stated that this significant paradigm Hospital Medical Center, Dr. Jeffrey A. goal of the board is to reduce the growth shift shouldn’t increase the cost of health Bridge of the Research Institute at in health care costs by improving the insurance, but rather simply change who Nationwide Children’s Hospital, Ellen Yard exchange of health information between makes what decisions and how. of the Ohio State University College of providers and patients. The board will do Public Health and Dee Roth and the Ohio this in part by working to implement the The topic of a possible Health Insurance Department of Mental Health. Strategic Roadmap and Policy Options for Exchange in Ohio was well received by all the Effective Adoption of Health Information in attendance and will likely be considered Editor’s Note: The AMCNO is an active Technology and Exchange in Ohio (which is by state policymakers and leaders in the participant in HPIO events and meetings. available on HPIO’s Web site). foreseeable future. In addition, several The AMCNO will continue to ask the HPIO national candidates for President have to provide our members with regular The conference also focused on issues such expressed interest in the idea. updates on the HPIO activities around the as how health care consumers view HIT/HIE state of Ohio. I

14 NORTHERN OHIO P HYSICIAN I March/April 2008 QUALITY IMPROVEMENT CMS 9th Statement of Work for Quality Improvement Organizations By Ronald A. Savrin, MD, MBA

The Centers for Medicare & Medicaid Services (CMS) directs the activities of Medicare’s 53 Quality 3) Chronic Kidney Disease (CKD) – CMS will Improvement Organizations (QIOs) by defining their Statement of Work (SOW). The 9SOW fund 13 QIO organizations to improve the defines the QIO activities for the three-year period beginning August 1, 2008. In response to quality of care for patients with chronic kidney suggestions from the Institute of Medicine (IOM) and the Government Accountability Office disease. Efforts will be directed at (1) improving (GAO), new goals and operational changes will be implemented. CMS has structured the timely testing for kidney disease (e.g., microal - 9SOW as a business model, seeking both a positive return on investment (ROI) and sustainability. buminuria), (2) slowing the progression of CKD by using ACE-I or ARBs to treat hyper - The 9SOW encompasses four themes: in the 65 and older population, resulting in tension in diabetic patients with CKD, and (1) Prevention, (2) Patient Safety, (3) Care over 21,000 hospitalizations annually. Vaccination (3) promoting the use of AV fistulas as the Transitions and (4) Beneficiary Protection, with is recommended for all persons 65 years and preferred method of angioaccess for hemodialysis. a total of 10 individual components. Of equal older and for other at-risk populations. The importance are three well-defined crosscutting penetration of pneumococcal vaccination in PATIENT SAFETY (FIVE COMPONENTS) priorities that must be integrated into all aspects Ohio (1991-2005) was only 48 percent in the of the 9SOW. The first priority is to reduce age 65 and over group and was higher in 1) Surgical Care Improvement Project healthcare disparities. QIOs are required to set whites (49 percent) than in blacks (35 percent). (SCIP) – CMS has identified nine specific this priority as a defined goal, monitor the Medicare pays for a pneumococcal vaccination measures in the SCIP that will be targeted for impact of their intervention on disparities of for all beneficiaries. improvement in the 9SOW. These first seven care, and take immediate action if such dis - are perioperative measures: SCIP Inf 1 – antibiotics parities increase (unintended consequences) Mammography – The risk of breast cancer within 60 minutes before incision; SCIP Inf rather than decrease. A second priority is the increases with age, and the Surveillance, 2 – appropriate antibiotics; SCIP Inf 3 – adoption of Health Information Technology Epidemiology and End Results (SEER) Program discontinue antibiotics within 24 hours of (HIT) to yield a true healthcare “system” with estimates that 12.7 percent of women born in surgery; SCIP Inf 4 – glucose control in cardiac interoperability and universal access. The third the U.S. today will develop breast cancer. surgery; SCIP Inf 6 – appropriate hair removal; priority is the promotion of value driven Medicare pays for one baseline mammogram SCIP Inf 7 – postoperative normothermia in healthcare (VDHC), defining, measuring and for women with Medicare between age 35 colon surgery; and SCIP Card 2 – perioperative disseminating information on both quality and and 39, and for annual screening mammograms beta-blocker. The final two measures are price. The QIOs will integrate these priorities beginning at age 40. In Ohio, Medicare claims VTE 1 – recommended VTE prophylaxis, and into each of the following themes. (4/1/05 – 3/31/07, excluding HMOs) show that VTE 2 – prophylaxis within 24 hours of surgery. 52 percent of women ages 52-69 had a PREVENTION (THREE COMPONENTS) biennial mammogram. 2) MRSA – QIOs will work with hospitals to (1) reduce the Methicillin-resistant staphylo - 1) Core Prevention – The prevention theme Colorectal Cancer Screening – Colorectal cancer coccus aureus (MRSA) infection rate and emphasizes evidence-based care and best- (CRC) is the second most common cause of (2) reduce the MRSA transmission rate. practices to prevent illness or detect disease in cancer death in the U.S. About six percent of early, more effectively treatable, stages. This the population will develop CRC with 91 percent 3) Drug Safety – Emphasis will be placed on initiative has three distinct but related of cases first diagnosed after age 50. Medicare instituting system changes (e.g., policies, components. covers the cost of CRC screening for all bene - procedures, and guidelines) that reduce the ficiaries over the age of 50: fecal occult blood incidence of drug-drug interactions and Influenza Immunization – According to the test (FOBT) every year, flexible sigmoidoscopy prevent the administration of inappropriate Centers for Disease Control and Prevention every four years, barium enema every four medications. (CDC), each year 5-20 percent of the population years (two years if high risk), or colonoscopy get the flu, over 200,000 hospitalizations are every 10 years (two years if high risk). In Ohio, 4) Pressure Ulcers – QIOs will work with required for flu complications, and about only 51 percent of Medicare patients had any hospitals and nursing homes to reduce the 36,000 die from the disease ( http://www.cdc. ONE such test over a seven-year period. incidence and prevalence of pressure ulcers. gov/flu/keyfacts.htm [accessed 1/29/2007]). Annual vaccination is effective in reducing 2) Diabetes Focused Disparities – Ohio is 5) Physical Restraints – This initiative will the incidence of influenza and reduces both one of 33 states selected for this initiative, endeavor to reduce the daily use of restraints. hospitalization and mortality. In 2005 only based on the number of diabetic medically 48 percent of Ohioans 65 and older received underserved beneficiaries. Three specific Under the 9SOW, QIOs will concentrate their influenza vaccination, and the rate was signifi - measures will be targeted: (1) HbA1c determi - efforts on facilities with the greatest opportunity cantly lower (30 percent) in black than in nation annually, (2) diabetic eye exam annually, for improvement in each individual measure. white (50 percent) residents. Medicare covers and (3) lipid testing annually. QIOs will work CMS has identified these hospitals, and QIOs annual flu vaccination for all Medicare with physician practices meeting two criteria: will help specific facilities — nursing homes beneficiaries. Medicare-underserved diabetics represent ≥ 25 and hospitals — in need of improvement on percent of the diabetics cared for by the practice, specific quality measures posted at Nursing Pneumococcal Pneumonia Immunization – The and the practice performs in the lower 50 Home Compare and Hospital Compare incidence of invasive pneumococcal pneumonia percentile for the state on the above three Web sites. as reported by the CDC is over 50 per 100,000 measures. (Continued on page 16)

NORTHERN OHIO P HYSICIAN I March/April 2008 15 HEALTH INFORMATION TECHNOLOGY

efforts and do not plan to develop a single NEO RHIO – Bringing Connected state-wide system. Representatives of NEO Healthcare to Northeast Ohio Update RHIO are actively engaged in this process. to AMCNO Members In November 2007, the Federal Communications Commission (FCC) announced the grant recip - By: Brian F. Keaton, MD, FACEP – Acting CEO, NEO RHIO ients for its $417 million Rural Healthcare Pilot Program. This program focuses primarily on The Northeast Ohio Regional Health Information Organization (NEO RHIO) is an inclusive, multi- developing the infrastructure necessary to stakeholder collaborative dedicated to improving the quality, safety, and efficiency of healthcare foster connectivity between rural healthcare in Northeast Ohio through the use of information technology and the secure exchange of health providers and their urban partners. NEO RHIO information. NEO RHIO is grounded in the need to make all necessary healthcare information and OneCommunity were awarded $11.3 available to patients and providers where and when it is needed. Its first project will make million for a project called HealthNet which patient data in all participating hospitals available to emergency physicians caring for a patient will provide high capacity fiber optic broad - in any NEO RHIO emergency department. As it grows, NEO RHIO will expand the sources of band connectivity to nineteen rural hospitals data, the users of data, and the services provided to participants and the community. When in the 22 counties of Northeast Ohio. In reality , mature, NEO RHIO will enable patients to have more control over their health and healthcare. it will provide a resource that will significantly It will lessen administrative burdens, improve efficiencies, enable important public health enhance connectivity and decrease cost for all functions, facilitate research, and enhance the economic viability of our region. healthcare providers across the region. Because of the way the project is designed, it will not This has been a somewhat quiet period as we Our meetings with hospital CEOs and senior only benefit our region’s medical community are engaged in the hard work of taking NEO management teams have been productive. but will also have huge impact on education, RHIO from being a good idea to a functioning There are no longer questions about why a government operations, and economic devel - health information exchange (HIE). Many NEO hospital or doctor should participate in HIE. opment efforts. RHIO participants have expressed interest in The conversations now focus much more on partnering with an established HIE. Our CEOs how, how much, what are the liability risks, NEO RHIO is well on its way to transitioning have almost uniformly made it clear that they and how do I protect or expand my competitive from being a good idea to a functional entity. would be much more comfortable with a advantage in the market. There is also much We have formally incorporated in the state of staged regional implementation of a proven more discussion about how the RHIO can be Ohio, ratified our first code of Regulations, HIE solution rather than pilots of homegrown used to facilitate integration both inside and and installed our first Board of Directors. We development efforts. Because of this input, we’ve outside an enterprises firewalls. We have been are actively engaging potential vendor partners, paid special attention to existing exchanges. actively exploring the role of RHIOs in connecting meeting with potential grant funders, and The Technical Selection Committee spent office EHRs to the outside world. Potential participating in state and national HIE forums. several months defining our technical needs, services include clinical messaging, electronic Several hospitals have committed funding to researching potential vendor partners and prescribing, medication reconciliation, eligibility the project and are prepared to be the first products, narrowing the choices to three testing, etc. sites for the ER linking project. finalists, and selecting our preferred vendor partner. We are now in contract negotiations In September, 2007, Gov. Strickland issued This promises to be an exciting year as NEO with the Indiana Health Information Exchange an Executive Order which created the Ohio RHIO brings connected healthcare to our (IHIE). IHIE, which is one of the nations oldest Health Information Partnership Advisory region. We look forward to AMCNO’s and most successful HIE efforts, functions in a Board. This board will provide for statewide partnership in the process. I region that is very similar to ours using technolo - coordination and facilitation of HIE efforts gies and business processes very closely aligned such as ours. The state has made it clear that with those identified in our business plan. they plan to enable and support existing

CMS 9th Statement of Work for discharge, (2) physician visit within 30 days of Ohio KePRO, the QIO for Ohio, understands Quality Improvement Organizations hospital discharge, and (3) global re-hospital - that physicians, nurses, and all healthcare per - (Continued from page 15) ization rate. sonnel strive to practice the highest quality of medicine and provide the right care for every CARE TRANSITIONS (ONE COMPONENT) BENEFICIARY PROTECTION patient every time. In the 9SOW, Ohio KePRO (ONE COMPONENT) will continue to work collaboratively with The QIO work under this theme aims to physicians, hospitals, nursing homes, and other improve the quality of care for Medicare ben - In a continuing effort, QIOs will maintain their providers to assist them with attaining this eficiaries transitioning from one care setting role in protecting Medicare beneficiaries and professional goal. If you have any questions to another. Transitions are fraught with risks the Medicare Trust Fund. Increasing emphasis regarding these quality care initiatives or if we of miscommunication, omission, and error. A will be placed on coordinating case review can assist you in meeting the objectives discussed variety of provider and community based systems with quality of care efforts. QIOs will continue above, please contact me at Ohio KePRO will be engaged to improve patient care at to administer the complaint process and will [(216) 447-9604] at your convenience. I this critical juncture as measured by three spe - be responsible for beneficiary satisfaction. cific criteria: (1) patient assessment of hospital

16 NORTHERN OHIO P HYSICIAN I March/April 2008 HEALTH INFORMATION TECHNOLOGY

To recap, specific aims of this concept Northeast Ohio Regional Health Information will include:

Organization – HealthNet Project • Connecting rural and urban hospitals The Federal Communications Commission located in the Northeast Ohio over a Rural Health Pilot Program dedicated broadband network: – 19 rural hospitals throughout the 22 In 2006, the Federal Communications Commission (FCC) adopted the Rural Health Care counties of Northeast Ohio, Pilot Program Order (RHCPP), which established a rural health care pilot program to – Clinics and remote healthcare facilities, encourage the provision of telehealth and telemedicine services throughout the nation. and Under the pilot program, selected applicants will receive up to 85 percent of the costs associated with: – Leverage the FCC RHCP $11 MM investment with local investment to 1. Building state and regional high-speed will be able to prioritize the deployment by maximize the development of the broadband networks; stages, and will bring up critical network regional HealthNet; segments earlier than the complete network • Extending the OneCommunity/NEO RHIO 2. Connecting those networks to Internet2 build-out. or National LambdaRail, Inc. (dedicated broadband services to rural providers; nationwide backbone providers); and The benefits for the participating hospitals • Creating a regional repository that employs are that they will have greater access to 3. Providing advanced telecommunications secure telehealth applications for chronic network tools and telemedicine applications. and information services to the network. disease monitoring and continuing Rural hospitals will have the ability to lever - education services; and age telemetry, improved diagnostics, health In November 2007, the FCC dedicated over monitoring, distance learning, clinical data, • Implementing sustainable enterprise $417 million for the construction of 69 and complete patient records. In addition solutions using HIT for eligible providers statewide or regional broadband telehealth the network will enable real-time physician, in rural and underserved counties. This networks in 42 states and three U.S. territories hospital-to-hospital, patient-to-hospital, and network is expected to improve the under the RHCPP. Northeast Ohio was patient-to-physician connectivity. quality of health care and to reduce the awarded $11,286,200 of that funding. The cost of health care. award was granted to the Northeast Ohio The objectives of the NEO RHIO HealthNet Regional Health Information Organization are to connect rural hospitals located in NE Next Steps (NEO RHIO) and OneCommunity. The Ohio over a dedicated fiber network and OneCommunity/NEO RHIO will hold a series anticipated total cost of this project is extend rural healthcare providers access to of workshops to create the final regional $16,123,143.00 and the NEORHIO and urban and national providers via the region’s fiber network design and establish the OneCommunity are currently coordinating existing fiber network. This will also enable Regional Health Information Security and fundraising efforts for the remaining project the secure and confidential exchange of Privacy Committee (RHISPC) underneath balance with key civic, government, medical health information between providers and NEO RHIO that will be comprised of repre - and private sector stakeholders across the provide a framework to enable secure and sentatives from the healthcare community, impacted 22-county region. The 22 counties confidential exchange of health information OneCommunity and NEO RHIO. The FCC are: Ashland, Ashtabula, Carroll, Columbiana, between providers. Another objective is to RHCP grant represents an initial investment Cuyahoga, Erie, Geauga, Guernsey, Holmes, provide a framework to enable secure that can be leveraged to create a superior Huron, Jefferson, Lake, Lorain, Mahoning, telemedicine applications such as chronic nationally recognized regional health Medina, Portage, Richland, Stark, Summit, disease management, continuing education network. Trumbull, Tuscarawas, and Wayne. and remote consultation. If interested in learning more or participating The funds will be used to expand All healthcare facilities in the 22 counties of in HealthNet of RHISPC, please contact: OneCommunity’s existing high-speed NE Ohio, both urban and rural, will have an Mark T. Ansboury, Chief Technology network to initially connect 19 additional opportunity to participate in NEO RHIO Officer – OneCommunity/NEO RHIO medical facilities. Planned network expansion HealthNet. Those not covered by the FCC Email: [email protected] will provide coverage to include a 10,000 grant will be expected to pay for the square mile area spanning 22 counties, expense of connecting them to the network, Editor’s Note: The Academy of Medicine of with an impacted population of about and for network services provided. The 19 Cleveland & Northern Ohio (AMCNO) is one 4.6 million. rural facilities included in the award will be of the organizations contributing to the expected to pay for subsequent services they development of the NEO RHIO. I Actual construction of the basic network use on the network, although it is anticipated itself will be incremental, with a current that fees will be at a discounted rate. The estimate of approximately 12 months to fee structure is still being finalized. complete (August 2009). OneCommunity

NORTHERN OHIO P HYSICIAN I March/April 2008 17 PUBLIC HEALTH Medical Home: Renewed Interest Lynda Montgomery, MD, MEd; George E. Kikano, MD,CPE, FAAFP

Background individuals at the practice level who They can see their physician in a timely The term “medical home” was coined in 1967 collectively take responsibility for the manner, pay attention to preventive services, by the American Academy of Pediatrics ongoing care of patients. simplify the care of chronic illnesses and (AAP), to describe the coordination of care 3) Whole person orientation – the maximize the use of information technology. for children with chronic medical conditions. personal physician is responsible for Outcomes will be measured, reported and Over 20 years passed without much attention providing for all the patient’s health benchmarked against best practices. The by physicians or policymakers. In 1992, the care needs or taking responsibility for Medical Home is different from a “gatekeeper” AAP formally defined the meaning of medical appropriately arranging care with other model that was promoted by managed care home as care provided by trained primary qualified professionals. This includes organizations in the early nineties. It is a care physicians and care that is “accessible, care for all stages of life; acute care; more sophisticated entry system where the continuous, coordinated, compassionate, and chronic care; preventive services; end personal physician (specialist or generalist) culturally effective.” To address increasing of life care. is a guide for the patient so that the best difficulties and frustration by family physicians 4) Care is coordinated and/or care is delivered in a timely and efficient to deliver compassionate care to communities integrated across all elements of the manner. they serve, the American Academy of Family complex health Physicians (AAFP) embarked in a project, The 5) Quality and safety are hallmarks of Though patient-centered and physician- Future of Family Medicine, in 2000. The the medical home directed, the hallmark of the medical home final report on a new model of care published 6) Enhanced access – including manage - is a partnership and a team approach to in the Annals of Family Medicine in 2004 ment of health issues through phone, care employing all parts of the health system included emphasis on the importance of a email, and effectively. Payment structures in the medical “Personal Medical Home.” In 2006, the 7) Payment appropriately recognizes the home model need to reflect how resources American College of Physicians (ACP) intro - added value provided to patients who are actually used. Examples include enhanced duced the term “Advanced Medical Home.” have a patient-centered medical home. support for use of health information tech - In March 2007, the AAP, AAFP, ACP and the nology, secure use of email and telephone American Osteopathic Association (AOA) It is important to note that a medical home communication about health, and payment authored a consensus statement entitled is distinct from chronic disease management for quality initiatives. Face- to- face encounters Joint Principles of the Patient-Centered program. While both elements are patient- must still be reimbursed in a way that Medical Home — describing an approach centered, chronic disease management accounts for the time and resources they to providing comprehensive primary care programs use case managers to improve require, but insurers will recognize the for children, youth and adults. care through coordination in the current, value-added services provided by the disjointed system. It is an attempt to add medical home, and will reimburse physician Key Elements of the Medical Home value to the current system. Chronic disease teams accordingly. The Medical Home does not refer to a management programs are geared to location where patients seek medical advice manage one condition at a time or multiple Ongoing projects and care; rather the place that a patient co morbid conditions in a parallel way. Based on the Future of Family Medicine turns to first with concerns about illness The personal medical home redesigns the project, the AAFP funded a 2-year project and health (wellness) both biomedical and patient’s portal to the medical system in a called TransforMED to assist in redesigning emotional. The home includes, of course way that meets directly his/her needs. physician practices to implement the basic the physical space where physicians and concept of the New Medical Home. The patients interact (be it in the office, long- The Need for a Medical Home TransforMED team has been working with term care facility or home), but also the With escalating health care costs, dissatis - identified practices of different sizes and in virtual portals for communication and the faction by patients and providers and an multiple settings to develop and implement team members who help patients and increasing number of uninsured in the models of care to improve access, efficiency, families with health needs. With each United States, the concept of medical cost and quality. Objective outcomes and iteration, the term has been refined. In the home is an old idea whose time has come. lessons learned will be published at the end March 2007 joint statement by the different Stakeholders are increasing aware of the of this national demonstration project. More organizations, seven principles of the fragmentation of healthcare services, and recently, the National Committee on Quality Patient-Centered Medical Home (PC-MH) the difficulties in managing chronic diseases Assurance (NCQA) adopted the concept were named: despite a burgeoning disease-management developed by the primary care organizations 1) Personal physician - each patient industry. There is growing evidence that and started recognition of physician practices has an ongoing relationship with a countries whose health system is based on that implement this model. The Physician personal physician trained to provide a strong primary care foundation have Practice Connection developed by the first contact, continuous and compre - better clinical outcomes and lower costs. NCQA is not certification process yet but hensive care. Under the Medical Home model, patients will identify practices that embrace patient- 2) Physician directed medical practice – and families are ensured to have a regular centered care emphasizing the elements of the personal physician leads a team of source of accessible and coordinated care. (Continued on page 19)

18 NORTHERN OHIO P HYSICIAN I March/April 2008 PUBLIC HEALTH AMEF Funds Make High School Vaccination Program Possible

Through the generous support of the Academy of Medicine Education Foundation (AMEF), “This program helps kids who are missing a successful “Vaccinate Before You Graduate” program was once again held at Bedford doses, have lost records and/or provides High School at the end of 2007, providing free vaccinations to graduating seniors. newer vaccines that teens may have missed altogether,” stated Cindy Modie, supervisor In conjunction with the Cuyahoga County In years past, parents were assessed from of preventative health at the Cuyahoga County Board of Health, AMEF’s financial support $85 to $102 per Menactra dose and Board of Health (CCBH). “By reaching kids provides three on-site clinics at the high administrative fees for the other medicines before they leave school we provide vacci - school. To date, 57 teens have received enlisted above. nation that otherwise may never occur.” 168 doses to protect against meningitis, hepatitis B, tetanus, diphtheria, pertussis In a consent letter sent home to parents, The program is supported in part by a dona - and chickenpox. The final on-site clinic is the school encouraged parental permission tion from the Academy of Medicine Education scheduled for April 10, 2008. The program for the program, calling the opportunity Foundation in partnership with CCBH. was is especially important because many “protection you should think about.” students who are uninsured or underinsured Specifically, the meningitis vaccine, which is Editor’s Note: AMEF is committed to would not have received the inoculations recommended strongly by the Centers for advancing public health outreach initiatives without AMEF’s contribution. Disease Control and Prevention and the such as the vaccination program described American College Health Association for above. To make a charitable contribution to The program made Hepatitis B, Tetanus/ young adults entering college. the AMEF, call (216) 520-1000 ext. 101. I Diphtheria, Chickenpox, Pertussis and Meningitis vaccines available at no charge.

COLLEAGUES CORNER

Recognizing outstanding AMC/NOMA members for their honors, awards and achievements, in addition to their work spreading messages of health and wellness to the community.

John D. Clough, MD, longstanding party. AMCNO physician leadership and AMCNO member and current board staff were also on hand to offer our con - member retires from practice gratulations to Dr. Clough. Although he After 42 years of practice at the Cleveland is retiring from active practice, Dr. Clough Clinic, Dr. John Clough has decided to retire. plans to continue on as a consultant to the A retirement party in honor of Dr. Clough government relations department at the was held at the Intercontinental Hotel on Cleveland Clinic and he will continue to Monday, January 21st. Many of Dr. Clough’s serve on the AMCNO board and our Dr. Gary Hoffman, Chair of the Department of Cleveland Clinic colleagues, administrative legislative committee. I Rheumatic and Immunologic Disease at the Clinic and support staff were in attendance at the congratulates Dr. Clough and presents him with a retirement gift.

Medical Home: Renewed Interest constituents. All stakeholders including of the medical home is that patients have a (Continued from page 18) employers, policy makers, patients and long-term relationship with a physician and professionals agree that the current system health care team who understands their the medical home model. Both at the is unsustainable and that major change is health issues in the context of their lives. federal Medicare and state Medicaid level, needed. Medical home offers a new model there are multiple ongoing pilot projects of care that aligns incentives of providers, Dr. Lynda Montgomery is an Assistant Professor underway to evaluate the costs, processes, funders, and patients in a way that capitalizes of Family Medicine at CWRU/UHCMC. and outcomes of a patient-centered med - on the information technology to improve ical home approach. access and health outcomes quality. Dr. George Kikano is a past president of AMCNO and Professor and Chair of the Future Direction It is unclear whether physicians have adequate department of Family Medicine at The need for a paradigm shift is long over - training to implement this model, nor whether CWRU/UHCMC. I due, and has been acknowledged by many there will be overall cost savings. The strength

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