CLEVELAND

PAcademyHYSICIA of Medicine of Cleveland/Northern Ohio Medical Association • July/AugustN 2006 Volume 91 www.amcnoma.org No. 4

INSIDE AMC/NOMA Heralds Passage of SB 88 THIS ISSUE Seven Ohio Counties Would Pilot Mandatory Arbitration

Public Health of Medical Negligence Claims Page 3 The Academy of Medicine Cleveland/Northern Ohio Medical Association scored Physician Advocacy a major victory May 24 on Page 5 & 19 behalf of its 4300 NE Ohio physician members when the state senate voted 23-10 to approve SB 88, the AMC/ Legislative Update NOMA-backed legislation Pages 6 & 7 calling for a mandatory arbitration pilot program intended to resolve medical Board Activities negligence claims through a pre-trial panel review. Pages 8 & 9 “This vote is a triumph for (l to r) Drs. Jonathan Myles and John Clough, Sen.Eric Fingerhut, Sen.Kevin Coughlin the area’s doctors and proof and John Bastulli, MD, the day these AMC/NOMA physicians traveled to Columbus to that our unified voice offer proponent testimonies on behalf of Senate Bill 88. Legal Issues through the AMC/NOMA Pages 10 & 11 was heard loud and clear in Columbus,” John care in the state. “If we want a state-of-the-art Bastulli, MD, vice president of legislative affairs health care industry,then we must have a state-of- said. “Our members asked for a solution, and we the-art dispute resolution system,”Fingerhut said. believe we’ve found them one in SB 88.” The senate vote followed proponent testimony in Practice A last-minute amendment from Sen.Armbruster committee on the preceding Tuesday by three Management extends the pilot to be tested in a total of seven Pages 12 & 13 Ohio counties: Cuyahoga, Summit, Lake, Geauga, Lorain, Erie and Huron. This vote is a triumph for the Bill sponsor Sen. Kevin Coughlin (R-Cuyahoga “area’s doctors and proof that Financial Matters Falls),in presenting a substitute version to the full Senate, called the bill “a silver lining”in the state’s Page 17 our unified voice through the medical liability crisis and pledged to work with the AMC/NOMA and other interested parties AMC/NOMA was heard loud through the summer months preparing it for Annual Meeting presentation in the Ohio House. Sen. Eric and clear in Columbus.” Page 18 Fingerhut (D-Cleveland) was the sole Democrat –JOHN BASTULLI, MD to support the bill. He said Cuyahoga County is the “heart of the matter” with regard to health AMC/NOMA physician members. Drs. John Clough, Jonathan Myles and John Bastulli traveled to Columbus to offer support on the sub- AMC/NOMA stitute bill’s merits. Dr.Clough called the addition 6000 Rockside Woods Blvd. of bifurcation of liability and damages that arbi- Ste. 150 trators will consider a “key component”to the sub Cleveland, OH 44131-0999 bill,one that “has the potential to have a significant positive effect on the medical malpractice process, ADDRESS SERVICE REQUESTED loss costs, and premium rates.” (Continued on page 7) ¸(KYLHTILJVTLZHNVHS^OLUHJ[PVUPZ[HRLU[V^HYKP[ZHJOPL]LTLU[¹

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= =HU[HNL!(YYP]PUN[OPZTVU[OH[(Z[VU4HY[PUVM*SL]LSHUK )YVHK^H`)LKMVYK6OPV‹^^^(Z[VU4HY[PU*SL]LSHUKJVT I >VŽLiÀÀÞʈÃÊ>ÊÀi}ˆÃÌiÀi`ÊÌÀ>`i“>ÀŽÊœvÊ,iÃi>ÀV Ê˜Ê œÌˆœ˜Êˆ“ˆÌi`Ê­, ®° PUBLIC HEALTH AMC/NOMA Engages in Forum Discussion of Nation’s Uninsured Local Panel Debates Issues’ Costs and Consequences

The Academy of Medicine Cleveland/Northern Ohio Medical accountable for Medicaid utilization and associated costs. On Association (AMC/NOMA) was proud to co-sponsor and partici- the subject of the new Massachusetts law, which several audi- pate in a local forum organized by the Sisters of Charity of St. ence members inquired about, Dr. Bastulli explained both its Augustine Health System that addressed the costs and conse- merits and potential pitfalls, noting especially how such a quences of the nation’s uninsured millions. “narrow scope”may not be applicable in other states. Cover the Uninsured In summation, Dr. Week (May 1-7, 2006) Bastulli acknowledged highlighted the needs the many outreach and concerns of the activities organized nearly 46 million around the issues of Americans — including the uninsured, and 1.3 million Ohioans — lauded the efforts to who live without health date, including those insurance. Organized participating in the by the Robert Wood forum panel. Johnson Foundation, “Though the answers this annual series of aren’t easy, and the John Bastulli, MD, nationwide events seeks fields a question as a member of the forum panel on providing care to the solutions are many,” he uninsured in our area. to raise awareness said, “The difference about, and find solutions for, the problems of the uninsured. will be made by those willing to work toward them, together.” John Bastulli, MD, provided both introductory and summary For more on the community health initiatives in which the remarks during the May 3rd local event held at Trinity Commons AMC/NOMA participates and partners throughout NE Ohio, in downtown Cleveland. Other panelists included Steve Millard, contact Elayne Biddlestone at (216) 520-1000. I Executive Director of the Council of Smaller Enterprises (COSE); Gregory Hall, MD, St.Vincent’s Medical Director of Community Outreach;former Ohio Congressman Dennis Eckart;Greg Moody of Health Management Associates;and Karen Davenport, serving as keynote speaker in her role as Director of Health Policy at the Center for American Progress in Washington, DC. Ms. Davenport was gracious enough to also appear on the AMC/NOMA’s Healthlines radio program during her brief stay.She spoke on the subject of implementing public policies to address this criti- cal issue for the country. (An MP3 recording of this discussion can be accessed at www.amcnoma.org under the Healthlines link.) Each guest presented on the overarching subject of the unin- sured, with unique perspectives from their professional experi- PHYSICIAN MEDICAL BILLING SERVICES ences. Panelists cited hard facts from the business and healthcare community, including the overwhelming proportion of the 72 HOUR BILLING TURNAROUND working uninsured, medical debt and bankruptcy figures. From a local standpoint, many made note of the hospital closures that DAILY Electronic Claim Submission have taken place, typically in the more disadvantaged city neigh- Accounts Receivable Mgmt – Major Credit Card Payments Accepted borhoods, and the burden this creates for those institutions that remain, as well as the citizens left with resulting limited access Collection Management & Staff Paralegal to care. MULTILINGUAL CUSTOMER SERVICE 7:30am-7:00pm M-F Questions abounded from the audience, which panel mem- bers fielded in turn depending on their expertise. Much of the Secure Internet – HIPAA Compliant discussion surrounded the economic costs of providing cover- age, on either a local, statewide or national scale. Statistics were Document Imaging Archiving presented relative to demographic breakdowns of those with- Remote Data Backup & Recovery out coverage, as well as staggering figures of the aggregate eco- nomic impact such is having on the entire health care delivery Commercial Claims – Medicare – Medicaid system. On this note, Dr. Bastulli drew a link between the rising inci- Workers’ Compensation – Automobile – Personal Injury dence of emergency room visits and the decline in services being provided due to skyrocketing institutional costs as well as New Business Development Phone 800-888-9342 ext. 101 the pressure on physicians to reduce their scope of practice. He suggested more community health clinics in neighborhoods [email protected] where access is limited, legislative advocacy,or holding states

Cleveland Physician I July/August 2006 3 HEALTH INFORMATION TECHNOLOGY Health IT Conference Targets Improving Patient Care

“Our members agree that information Information Technology in the Continuum technology offers the potential to expand of Care,” was held at Tri-C’s Corporate access to health care, to improve health- College East and was well attended by area care quality, potentially reduce patient health care professionals with an interest costs and to transform the manner in in streamlining patient care in an electronic which our patients are treated in the environment. future,”President Paul Janicki, MD, said As Chief Technology Officer of Cyber- in delivering his welcome remarks at a Trust,Peter Tippett,MD,provided the keynote recent Health IT gathering organized to address regarding keeping computer inform and encourage continued adoption systems — including hospital EHRS — up of information technologies as they benefit and working and the challenges an IT per- the delivery of quality medical care. son must face to handle the different levels Presented by NOHIMSS, local chapter of of security necessary to keep systems run- the not-for-profit professional membership ning in good order. President Paul C. Janicki, MD, delivers introduc- organization that provides leadership in Tom Gregorich of the Cleveland Clinic tory remarks at the NOHIMSS conference high- healthcare technology management, The Foundation discussed surveys he had done lighting Health IT and sponsored in part by the Academy of Medicine Cleveland/Northern within the Clinic system with users of IT AMC/NOMA. Ohio Medical Association (AMC/NOMA) asking what the value of IT had been. His was pleased to act as co-sponsor to the data found that access to information and making progress in digitizing administra- June 2 conference. operational efficiency were key for users. tive transactions and providing clinical “While information technology makes a Though he has not surveyed physicians or information to clinicians, he said, the difference,”Dr.Janicki went on,“by organiz- nurses en masse on these same questions, exchange of this type of information ing clinical data and making it available at however, he would believe that physicians among organizations is nascent. the right time, in the right place, the key would cite saving time and improving out- In conclusion to the program, a panel of will be to focus not on the data, but to rec- comes would be of value. He did stress that four physicians who currently utilized ognize and prioritize the need of the IT personnel will need to understand the EHRs in their daily practice was featured. patient and to give meaning to it. This is health care industry to provide the needed Overall, panelists noted both their staffs something that,ultimately,only an attending structures. and the physicians within the practice have medical professional can, and necessarily, Dr. Brian Keaton next delivered a adapted well to the use of EHR and it has should do.” detailed overview of the RHIO concept been of great assistance to the practices The conference, entitled “The Value of in its development stages here in NE Ohio.* and the institutions represented. And Davis Bu, MD, Much like the AMC/NOMA’s own 2006 from the Center for seminar “Riding the Wave of Change in the Information Techno- Practice of Medicine,”which touched on 10 logy Leadership pro- similar technological topics, as well as our Selling vided several con- integral partnering with the NEORHIO clusive studies — on project, our organization intends to con- the value of ambula- tinue our involvement in this critical dis- 8 tory computerized cussion as it moves ever forward in your home physician order entry, Northeast Ohio, and provide our member- or ACPOE. Most ship with timely and pertinent updates as striking was the they develop. reveal that wide- * Covered at length in the May/June shouldn’t 6 spread adoption of Cleveland Physician article,“Building an ACPOE can prevent On-Ramp to the Healthcare Information millions of medica- Superhighway,”the NEORHIO, or NE Ohio hurt a bit! tion errors and save Regional Health Information Organization, billions of dollars. will strive to create interoperable data and 4 The clinical and finan- systems standards in an effort to streamline cial benefits are com- EHRs,communications,and most strikingly, pelling as well. Dr. the patient care of the future. The NEO Bu also supplied RHIO began as a cooperative effort information on the between major hospitals in the Cleveland- 2 Healthcare Informa- Akron-Canton corridor, but has quickly tion Exchange and expanded to include physicians through Interoperability (HIEI) medical societies (the AMC/NOMA as one), john oskowski report, or technology hospital associations, insurers, business that enables the groups,quality improvement organizations, www.john-o.com 0 electronic flow of and other stakeholders. information among For more on these subjects of interest to 440.785.4999 medical organizations. physicians regarding Health Information While individual Technologies, contact Elayne Biddlestone, organizations are (216) 520-1000 ext. 321. I

4 Cleveland Physician I July/August 2006 PHYSICIAN ADVOCACY First AMC/NOMA Legislative Breakfast Brings Ideas to Fore

On May 5,The Academy of Medicine Cleveland/Northern Ohio How long does it take them to make issue decisions? Perhaps a Medical Association organized its initial meeting between mem- report from the Chief Justice could be useful on these points, it ber doctors and state legislators in an effort to bring together was discussed.* ideas and issues affecting the practice of medicine in our area. Rep.Yuko noted that Held at the University Suburban Health Center, the early morn- it would be important ing breakfast meeting allowed those gathered to exchange infor- to continue this type of mation pertinent to what legislative initiatives are of interest to dialogue.Because there physicians, their patients and the practice environment in NE are term limits in the Ohio. legislature and there In addition to the physician guests, legislators in attendance will be new people and were: State Rep. Kenny Yuko, State Rep. James Trakas, and State new faces at the begin- Sen. Eric Fingerhut. AMC/NOMA Executive Vice President Mrs. ning of the year, cer- Elayne R. Biddlestone and lobbyist Mr. Michael Wise were like- tainly a series of such wise on hand at the meeting. meetings could further As VP of AMC/ the educative process President Paul C. Janicki, MD; Rep. Kenny Yuko, John Bastulli, MD; Rep. James Trakas NOMA Legislative on the issues of inter- and Phillip Junglas, MD, following the event Affairs, Dr. John est to the medical com- at USHC. Bastulli provided munity. the group with an The meeting ended quite positively and with a general con- overview of the sensus that additional meetings of this type should be continued Academy’s legisla- by the AMC/ NOMA. tive initiatives, pri- Editor’s Note: The AMC/NOMA is actively planning and marily focusing on organizing more legislative meetings such as this at hospitals (l to r) AMC/NOMA lobbyist Michael Wise, State Reps. Kenny Yuko and James Trakas, Sen. Eric Senate Bill 88. He across the region. If you would like to participate in discus- Fingerhut and Lawrence Kent, MD, listen intently informed the group sions between your colleagues and legislators, contact Elayne as a question is raised during the Academy’s first that the AMC/NOMA Biddlestone (216) 520-1000 for additional information. legislative breakfast session between physicians advocates on behalf *The AMC/NOMA is currently reviewing the feasibility of how and legislators. of physicians and to provide key information on the common pleas judges in NE takes positions on health care-related bills under review at the Ohio for our membership. See related story,page 11. I state legislature. The AMC/NOMA surveys its members on a reg- ular basis to ascertain their needs and acts upon their input and in doing so, the AMC/NOMA became aware of a medical liability crisis in Ohio long before other organizations began to evaluate the issue. And while tort reform has been passed in Ohio, Dr. 3 SECONDS TO DISASTER!! Bastulli said the legislation does not go far enough to achieve a balance in the medical liability arena. Dr. Bastulli briefly outlined the AMC/NOMA sponsored solution to this issue — alternative dispute resolution (see related story page 1). HIPAA COMPLIANCE Mr. Wise stated he has noticed that his own physician has become much more politically active and involved in the NETWORK & COMPUTER process since the advent of the medical liability crisis, and SECURITY encouraged the physicians around the table to remain engaged as well. YOU & YOUR MEDICAL During a lively exchange between the physicians and legisla- tors, discussion topics ranged from loser pay provisions in ADR PRACTICE legislation, the legislative oversight of the Ohio Department of Insurance, misleading information regarding stabilized liability WORLDLAN TECHOLOGY CAN SOLVE rates in Ohio, and even the Supreme Court’s role in medical YOUR HIPAA SECURITY ISSUES TODAY! issues. On medical liability,Sen. Fingerhut stated that he does not in any way think that the crisis is over in NE Ohio. A supporter of Every practice will have to comply with HIPAA’S the bill, he said SB 88 is on the right track since it looks at how current security measures. You may perform a free the adjudication system works. self-audit at our web site. www.worldlan.com/hipaa Several panel members also noted that the medical commu- e-mail: [email protected] nity had a huge impact on the Ohio Supreme Court races — however, it might be difficult to determine or have an influence Don’t wait act today! over the local races because there are so many of them. It was suggested that the Chief Justice might be able to provide some PLEASE FEEL FREE TO CONTACT OUR benchmarks or provide a record of the medical liability cases OFFICE AT 330-723-1200 EXT 582. heard by a particular judge with such questions as — how long does it take for these type of cases to move through their court?

Cleveland Physician I July/August 2006 5 LEGISLATIVE UPDATE

By Michael Wise, J.D./AMC/NOMA Lobbyist Sikora, a Cuyahoga County Juvenile Court Judge since 1989, in the race for What a spring for AMC/NOMA! On Resnick’s job. May 24,2006,the Ohio Senate passed our The other Supreme Court race has SB 88. We all feel like our child has grad- Republican Justice Terrence O’Donnell uated High School. The next step is running for reelection. Opposing Justice College . . . I mean the Ohio House. Read O’Donnell will be William O’Neill of more about the big victory elsewhere in South Russell, a second-term judge on this issue. Below,please see some of the the 11th District Court of Appeals. Bill outstanding issues. defeated Montgomery County Common Pleas Judge A.J.Wagner. In 2004, O’Neill Election Update President Paul Janicki, MD with Hon. Richard J. faced O’Donnell for the unexpired term First, on the political front, Primary McMonagle following a meeting at which the of Justice Deborah Cook, who had joined Elections were held on May 2, 2006. On AMC/NOMA discussed different approaches to the federal bench. O’Neill lost decisively the Republican side, Betty Montgomery evaluate and provide background data on in 2004. Cuyahoga County Common Pleas Judges in order had dropped out of the race for to educate interested physician members. AMC/NOMA members will be receiv- Governor and into the race for Attorney ing a letter from the PAC soon to discuss General. That left current Ohio Attorney safety and strength of our families. I the Supreme Court races and to ask for General Jim Petro running against cur- won’t stand by and let that happen. I will your financial support. We want to rent Ohio Secretary of State Ken enter this office ready to pour my heart ensure that the Justices on our Supreme Blackwell for Governor and Ken won a and soul into fighting for the dignity of Court interpret the law and do not legis- decisive victory. Betty defeated State families and all people in Ohio.I will ded- late from the bench.The AMC/NOMA’s Senator Tim Grendell in the Ohio icate myself to restoring the spirit, the Political Action Committee (NOMPAC) Attorney General race. Local State hope and the optimism of our great and believes that in order to make certain Representative Jim Trakas dropped out of beautiful state. In the months ahead, I this occurs, we need to keep Justice his race for Secretary of State and Greg look forward to laying out my vision for Terrence O’Donnell on the court and Hartmann ran unopposed in that primary Ohio’s future. It is a vision which will elect Appellate Court Judge Robert R. race. The biggest upset on the 2nd was bring Ohioans together to help rebuild Cupp. These individuals are dedicated to incumbent Treasurer Jennette Bradley our state, strengthen our communities, further establish and preserve the princi- losing to Ashtabula County Auditor Sandy and lead our nation once again.” ples of judicial fairness.The AMC/NOMA’s O’Brien. Here is Senator John McCain speaking Political Action Committee (NOMPAC) On the Democrat side,SB 88 supporter about Ken Blackwell. “Ohioans need Ken will be very active in this campaign. State Senator Eric Fingerhut dropped out Blackwell’s clear thinking, straight talk On the local Appellate Court, for the of the Governor’s race leaving Congress- and strong leadership at the top of the Democrats, Frank D. Celebreeze Jr.,James man Ted Strickland to defeat former State ticket. His agenda for limited govern- L. Sweeney, Colleen Conway Cooney, Representative Bryan Flannery in that ment, economic development and job Mary J. Boyle and Melody Stewart will be Gubernatorial Primary. Eric will not be creation will put Ohio back on a winning seeking election. For Republicans, Ralph on the ballot in 2006. For State Treasurer, path.” Perk and Robert Moriarty are running former State Representative Richard AMC/NOMA has invited both candi- against Mary Boyle and Melody Stewart Cordrey ran unopposed in that primary. dates for Governor to a forum to discuss respectively. Republicans failed to field Jennifer Brunner is the nominee for health care issues. The staffs for both candidates in the other three Appellate Secretary of State and Marc Dann for candidates are sorting through all these races. For the first time,AMC/NOMA will Attorney General. requests and we hope to hear soon be active in these Court races. Stay tuned The Ohio Governor’s race will be his- whether we will have this opportunity to for much more information. torical. Democrats are polling stronger question the candidates. Whether this The other critical race is on the Federal in this race than at any time since 1986 happens or not,AMC/NOMA will provide level for U.S. Senator. Incumbent Mike and they have a bona fide candidate in more comprehensive information to its DeWine is running against Congressman Congressman Strickland. Republicans members before the November elections. Sherrod Brown. This will be a high pro- will be attempting to elect a nationally file race and closely contested. Of course high profile,aggressive conservative who Ohio Supreme Court there also will by a myriad of State and would also be the first African American Besides the Governor’s race, the Ohio Federal legislative races. Initial polls have Governor in the state’s history. Supreme Court races are very important Republicans maintaining their majorities Here are the words of Congressman to the health care community. The in the Ohio House and Ohio Senate, as Stickland on why he is running; “Dear Republicans have cleared the field for well as the U.S. House and U.S. Senate. Friend, I am honored to be running for their two candidates. For the open seat, Governor of Ohio. Our great state is in previously held by Alice Resnick, the SB 88 — Our Work Continues desperate need of change, and I believe Republicans have chosen former State As mentioned above, SB 88 was the big that I have the leadership, the vision, and Senator and current Judge Bob Cupp. story of the spring. SB 88 — legislation the drive to lead Ohio to a new day. The Republican State Central Committee sponsored by Senator Kevin Coughlin There is no state in the nation like Ohio. has endorsed him and all other inter- (R-Cuyahoga Falls), provides for a pilot But like many Ohioans, I see a state that ested candidates chose not to file for this project in Northeastern Ohio to require has lost its way.The current Republican seat. On the Democrat side, Ben Espy,a alternative dispute resolution of medical administration has failed to lead us, put- former State Senator and City Council- malpractice claims. Specifically,pursuant ting at risk the future of our state and the man from Columbus, defeated Peter (Continued on page 7)

6 Cleveland Physician I July/August 2006 LEGISLATIVE UPDATE to a pilot program administered by the Statute could be extended and the Bill AMC/NOMA is working with sponsors Ohio Department of Insurance and Ohio does provide for tolling in that situation. and committee members on a number of Supreme Court, the Bill now requires all However, this situation only arises in the other Bills.For the first time,AMC/NOMA medical malpractice claims in Cuyahoga, case of an arbitration that lasts longer is notifying members of the General Geauga, Summit, Lorain, Erie, Huron and than three weeks — a rare occurrence. Assembly about our positions on specific Lake Counties to be submitted to arbitra- Also, even in that situation, the case legislation. This activity includes direct tion. This shall be done before a lawsuit could very well be concluded (accepted conversations with Bill sponsors about if filed. defense ruling) or half completed our concerns. AMC/NOMA also has a The work on SB 88 continues. Over (accepted plaintiff ruling). Only if the comprehensive tracking system of all the next two months a Representative in arbitration lasts longer than three weeks health care-related legislation in the the Ohio House must be chosen to guide and the arbitration ruling is rejected, General Assembly. If you are interested SB 88 through the House process. would we have a situation where loss in receiving a copy of this document, AMC/NOMA has begun that process. costs could be greater than filings under please contact the Academy. Our hope is to have hearings and a possi- current medical malpractice law. The Legislators have recessed until ble vote in the lame duck session after Medical Malpractice process is cur- September. They will convene then for the November elections. Work also is rently complicated and the subtleties are two weeks and then recess again until needed on the substantive provisions of important.AMC/NOMA has put together after the November elections. The SB 88. The most discussed issue regards a strong team to address all of the out- remaining legislative session coupled the Statute of Limitations for medical standing issues and we will work hard to with the November elections will make malpractice claims and whether it should fine tune SB 88 so that it is fair and pro- for an exciting fall, 2006. I will report on be extended or “tolled”during the arbi- vides a better way to resolve medical both in the next issue. tration process. malpractice disputes. The tolling issue Editor’s Note: For further informa- At first blush, the defense reacts nega- will be resolved and likely another tion on any of the above, including the tively to even the possibility that the Substitute Bill introduced in the House. AMC/NOMA’s position on candidates, Statute of Limitations could be extended Special thanks to attorney Michael healthcare-related legislation or the beyond the two years provided by law. Jordan from Walter Haverfield for his work of NOMPAC, please call Elayne Under SB 88, it is conceivable that the invaluable counsel! Biddlestone at 216.520.1000. I

AMC/NOMA Heralds selves have tirelessly pursued this monu- mechanism for the respective sides in a Passage of SB 88 mental advance through the Ohio Senate. medical malpractice situation to have (Continued from page 1) On three separate occasions in the last their claims and defenses fully presented. year,AMC/NOMA physicians have offered Arbitration has proven to be an effective In essence, the substitute requires the the only proponent testimony on the bill, means of dispute resolution in many state superintendent of insurance, in col- as the AMC/NOMA has continued to be other contexts, and there is no reason laboration with the Ohio Supreme Court, the sole physician organization in the state why it cannot be effective in the context to establish a pilot program in which advocating for such a fundamental reform of medical malpractice.” medical malpractice claims would first package tackling medical negligence In another letter submitted to the go to arbitration in hopes of avoiding case resolution. (For a complete histori- committee, OHIC President and CEO court. Claimants and respondents will cal timeline of these events, in-depth Raymond Mazzotta wrote,“We express each choose one member of the arbitra- analysis of ADR and our work to date on our support for SB 88 as we believe [it] tion panel, who then selects a third to the bill, visit the homepage of www.amc is intended to meet the objectives to serve as chairman. The substitute pro- noma.org.) While the AMC/NOMA has reduce the filing of nonmeritorious vides for the chairman to have practiced consistently (in print and online) pub- claims and to move cases with merit law for at least eight years and to be from lished SB 88’s merits and goals to our through the system more expeditiously certain ADR services. While any party membership, we have likewise garnered and efficiently.” could reject a ruling of the panel and pro- much positive coverage in local and Throughout the summer months, the ceed to court, they then would become national publications including the Plain AMC/NOMA will continue to work with liable for the opposition’s attorney fees if Dealer, Crain’s Cleveland Business and our supporters, members and lobbyists they did not win the case. ADR World. as the legislation is prepared for intro- In offering words of support on the “It preserves patient’s rights while at duction in the House, and as always will senate floor the evening SB 88 was pre- the same time discourages frivolous law- keep our members informed with sented, the following point was made: suits and will reduce cost to the health updates and news alerts as they occur. NE Ohio is in a category of its own with care and legal system,” said Jonathan Members will be offered the opportunity regard to the economy of the world- Myles, MD, in his appearance before the to write their legislators urging support renown health care industry we have Senate Insurance, Commerce and Labor of the bill during this process via our here, so a dispute resolution mechanism committee last month.“This bill will help Web site as well. should be uniquely tailored to this area. preserve and strengthen our health care “The passage of SB 88 in essence Since the AMC/NOMA joint press con- system in Ohio,which is one of the great- defines what the AMC/NOMA is all about,” ference in March 2005 when SB 88 was est resources we have.” Dr.Bastulli said. “Regional representation first introduced, our member physicians, In his letter of support, local arbitra- that makes a difference,effects real change staff, legislative committee, lobbyists and tion expert Michael Jordan of Walter & for the doctors practicing in NE Ohio.” I of course the supportive legislators them- Haverfield wrote, “SB 88 offers a fair

Cleveland Physician I July/August 2006 7 REPORT TO THE BOARD OF DIRECTORS

By Rudy Lakosh

A Glimpse into the National outside the box in finding solutions, sup- dedication to the insured. The prediction Perspective on Medical porting tort reform and understanding of consolidation and mergers included Professional Liability changes in the practice of medicine. medical malpractice agencies. The recogni- Carriers who “stay in the box” will not be tion that agencies specializing exclusively Insurance recognized as a partner to the doctor. in medical malpractice are a different ani- An overview of a recent Premium Agents who do not innovate and find ways mal than other agencies was a point near Group presentation to the AMC/NOMA to facilitate the delivery of coverage and and dear to us in Ohio. The doctors in Ohio Board of Directors make the acquisition of insurance easier rely on the agency system to provide com- The Crittenden Medical Insurance and more user-friendly will also not be part prehensive information on the available Conference 2006 was held recently in of the solution. solutions. Agencies exclusively delivering Phoenix, AZ. This conference brings malpractice insurance are uniquely posi- together Medical Professional Liability tioned and focused on the questions and Insurance (MPLI) Carriers from throughout the answers. Like a specialist in the med- the United States. A few of the panelists Doctors benefit directly ical profession, an agency specializing in and presenters who are familiar to us in NE “ from the efforts of such has an intelligence enhanced by Ohio were: Victor T. Adamo, President, immersion in the specialty. ProAssurance Corporation; Richard E. agencies that are dedicated We are seeing the ramifications of the Anderson,MD,Chairman/CEO,The Doctors national climate in our one state system. Company; and Timothy J. Kenesey,President to educating, servicing and We see the ramifications in Northeast and CEO, Medical Protective. providing a variety of Ohio. Availability of MPLI in our area has It provided the opportunity for a glimpse actually increased. The major carriers into the future of MPLI, as leaders of carri- solutions to their clients. offering coverage in our area; Medical Pro- ers large and small led workshops provid- ” tective, ProAssurance,The Doctors Company ing information on both current events and and OHIC have all demonstrated their speculations regarding the future as it will NE Ohio has been the focus of innova- capacity and their comfort with the cur- ultimately affect the insured. tion by the dedicated carriers who have rent filed rates for NE Ohio. We continue Several comments made during the con- stayed the course through the “hard mar- to see the results of this capacity demon- ference have specific relevance to NE ket.” These carriers have remained commit- strated by relaxed underwriting and a Ohio.“Some Markets Have Capacity Need” ted to the doctors in NE Ohio, maintaining competitive attitude between carriers. highlighted the fact that we in Ohio are for- a presence and continuing to provide cov- The major carriers in Ohio are all demon- tunate to have carriers who not only have erage in spite of the litigious challenges strating solid financials and indicate having solid financials but also have the capacity that they have faced in this jurisdiction in reached a plateau on new claims activity. to provide coverage for all the specialties. recent years. Consistent with the commit- This bodes well for each doctor in the Northeast Ohio does have capacity. ment by the carriers has been the dedica- state. We have crossed a bridge and are in Capacity is dedicated to the states that are tion of agencies that provide access to a much better position regarding our costs stable and have answers for the tort system multiple carriers, work aggressively with and availability. shortcomings. the carriers to provide options, and influ- Rudy Lakosh is the Sr. VP/COO of The • The key tort reform element recog- ence the political climate through, among Premium Group, Inc., an agency specializ- nized throughout the United States as other things, active support of tort reform. ing exclusively in Medical Professional having a huge effect on MPLI is the Doctors benefit directly from the efforts of Liability Insurance and representing the elimination of “joint and several agencies that are dedicated to educating, major admitted and surplus lines carriers liability,”(the provision providing for a servicing and providing a variety of solu- throughout Ohio. I recovery system based on proportion- tions to their clients. ate liability; holds defendants liable Due to the long-term gestation period of only for their percentage of fault medical malpractice claims, the plaintiff (noneconomic) in civil tort actions and attorneys may be holding off significant Comments from the Board: The adopts a “fair share” rule where defen- numbers of such claims until President AMC/NOMA believes that while rates dants only pay damages commensurate Bush leaves office. This resonates strongly may in some areas have begun to with their percentage of fault). This for us in Ohio as we anticipate the same show signs of stabilization, such does element will have a significant effect phenomena occurring here. Through the not preclude the need for fundamen- on awards and subsequently on the efforts of the medical community, among tal change in the system, specifically premiums that our doctors will pay. others, Ohioans are maintaining a conser- reform measures like SB 88 (see Another interesting comment was that vative Supreme Court in Ohio and with dili- related story p. 1) that aims to reduce “Doctors are looking for Insights and gence and perseverance at each critical costs, time involved, damage to pro- Solutions.” This might seem to be more election, hopefully,this effort will continue fessional stature and most impor- tantly, frivolous filings of medical obvious than intuitive,however,to have the to prevail. negligence. For more information industry leaders address this as a principle “Increasing probability of mergers and on the AMC/NOMA’s work with the that they and their companies continue to acquisitions in all areas of the industry”was Premium Group, contact Elayne focus on is a very positive signal. The indus- mentioned. Industry leaders are anticipat- Biddlestone (216) 520-1000 ext.321. try realizes that carriers and agents will be ing this opportunity will be “good” for the asked to do more. The “more” was identi- industry. Expectations are that “good” fied as expecting carriers and agents to get means financial strength, efficiencies, and

8 Cleveland Physician I July/August 2006 REPORT TO THE BOARD OF DIRECTORS

By David C. Epstein, MD, MBA, Medical Director – UnitedHealthcare/Northeast Ohio

Promoting Performance Medicine, the Journal of the American enhanced fee schedule. Quality repre- Transparency: UnitedHealth Medical Association, and many other sents 51% of a physician’s total score, PremiumSM and UnitedHealth peer-reviewed journals are replete with while cost and administrative compo- Practice RewardsSM articles and studies that expose the gaps nents comprise 30% and 19% respectively. in the U.S. health care delivery “system.” Physicians who meet the UnitedHealth Dr.David Epstein presented recently to From the public/employers’ perspective, Premium criteria for quality and efficiency the Board, the following is a synopsis they are paying more and more for their are then statistically ranked by deciles and of his remarks. health care, yet find employees and their rescored under the UnitedHealth Pay-For-Performance programs have families may be receiving care that is sub- Practice Reward program. This program gained momentum over the past years in optimal,or perhaps even harmful. Payers, also incorporates the physician prac- the employer community and are viewed well aware of these research studies, as tices’ administrative (e.g., electronic as a potential solution to the health care well as the landmark reports from the claims submission, online claims cost and quality challenges. These pro- Institute of Medicine,are demanding rapid inquiries). An overall score is tallied grams have matured since their emer- action to address well-documented varia- resulting in financial recognition through gence at the turn of the century. Initially, tions in the quality and efficiency of care. fee schedule enhancements for the top based on discrete cost and process-of- To advance this goal, and to promote 10 to 15% of designated practices. It is care measures, today there are close to widespread adoption of evidence-based the only pay-for-performance program to 150 different pay-for-performance pro- medicine, UnitedHealthcare developed our knowledge that operates with no grams across the country,and some have the UnitedHealth Premium designation administrative burden on practicing evolved to include more quality-based program. It is designed to measure clini- physicians, as is does not require chart clinical measures as well as financial risk- cal and financial performance against evi- abstraction or other data submission. adjusted measures for determining dence and consensus-based clinical and Insurers,providers,employers and gov- health care cost outcomes. risk-adjusted financial criteria. The pro- ernment must work together to define a Are today’s programs the end game in gram incorporates quality measures consistent set of measurements on performance measurement? Do gaps in derived from external, and nationally which to assess the health care “value methodology remain? Will these pro- accepted clinical societies and consortia proposition.” The medical profession has grams become an integral part of the e.g.,American Quality Alliance,American already begun to incorporate these meas- health care purchasing landscape for Academy of Family Practice, Society of ures into professional standards, certifi- patients, employers and government pro- Thoracic Surgeons, American Hospital cation and recognition programs, and grams? The answers to these questions Association, and has been designed with clinical practice. By working together,all are “no,” “yes” and “TBD” respectively. extensive input from a variety of physi- the actors in healthcare can lead a revo- What is critical to understand, however, cian advisory groups. The program uti- lution to improve the picture of health is that employers are desperately lizes data from UnitedHealthcare and care delivery in the United States. I searching for strategies to contain their publicly available claim and administra- health care benefit insurance costs in tive data sets, the measures have been order to survive! Employers, who pay validated through medical records/chart the bulk of the costs of private insur- Comments from the Board: The reviews,and the program’s overall design ance, are seeing costs rise far in excess of AMC/NOMA adopted policy last has been assessed by an independent their revenues and profits. And as we year on pay-for-performance pro- third-party (the Lewin Group). The pro- have witnessed in Northeast Ohio, the grams as they’ve begun to roll out gram’s measures for quality represent the skyrocketing cost of the traditional rich and will continue to impact our current state-of-the art. Cost measures benefit plans prevalent in manufacturing member physicians. We believe any are focused on clinical episodes and are and union-based employers have brought incentive programs must be fair, risk-adjusted based on the severity and ethical, patient-centered and assess these businesses to the brink. complexity of the patients’ conditions. physician performance with The current reality is that health care The UnitedHealth Premium designa- evidence-based measures. For more costs can no longer be considered in iso- tion is not a pay-for-performance pro- on our policy, contact your lation from the rest of the business econ- gram. Rather it is an informational tool District’s representative or call omy. And while we, as physicians, have for UnitedHealthcare members across Elayne Biddlestone at (216) 520- invested considerable time and sacrifice the United States to assist them in mak- 1000. In addition, a presenter from to become experts in our clinical fields Anthem is scheduled to meet with ing informed health care purchasing of endeavor, that expertise is going to be the Board discussing their program decisions. In the Cleveland and Chicago accompanied by greater performance as well as another from Aetna in markets, UnitedHealthcare is also pilot- transparency in health care. It has the months to come. We will keep ing an extension of this program, called become apparent over the past several you updated and are very inter- UnitedHealth Practice Rewards that years that there is much in medical prac- ested in any feedback you’d like to rewards physicians who meet defined tice that results in either incomplete or provide on this issue, especially as quality, efficiency and administrative it affects your practice. duplicative care,or care that may even be criteria by providing them with an harmful. The New England Journal of

Cleveland Physician I July/August 2006 9 LEGAL ISSUES The Electronic Document Retention Policy A Necessary Defense to a New Litigation Threat

By PJ Malnar and Alan Parker, Reminger and Reminger Co., LPA

Office technology has had a wonderful ously recorded, and assists in a search for for the routine destruction of non- impact on medical practice, not to men- truth. The cynical reasons: the inquiry is business, superfluous and potentially tion on a physician’s lifestyle. Voicemail, burdensome, the possibility of an incom- embarrassing documents. If a document e-mail, and personal digital assistants plete response is high, and an adversary policy does not exist, individuals are left have helped to free physicians from the can capitalize on mistakes in responding with the difficulty of explaining why confines of the office and the hospital. to an electronic records inquiry. some documents, e-mails, etc. have been Drug information can be kept on a PDA, Plaintiffs have had success in obtaining destroyed or deleted and others have radiographs can be reviewed from the sanctions against defendants caught not. If this destruction is done in con- comfort of your own home office, and unprepared by requests for electronic junction with a document retention pol- electronic medical records make the discovery. These sanctions can have lit- icy, then these questions are easily patient’s chart accessible anywhere. tle or nothing to do with the actual answered.The absence of such a policy Indeed we are entering an era of elec- underlying facts of the case, but rather can lead to the risk of sanctions in the tronic medical records, purportedly to are designed to punish a defendant for a event of a lawsuit. improve patient care, to reduce medical failure to provide or to preserve an elec- There are several basic steps in order errors, and to increase practice effi- tronic document. Sanctions against the to create a document retention policy. ciency. Certainly, electronic records are defendants run the gamut from monetary Initially, a document retention manager practical on a number of levels, from damages to a jury instruction suggesting should be identified.Then, the specific quick accessibility and ease of use to the a negative inference against the defen- practice needs to be evaluated and a simplification of storage space. More and dant’s case. determination made regarding what more in today’s medical care, electronic Even in state courts, judges tend to types of documents are created; how records are replacing the traditional look to the federal rules and the federal long each document type should be chart.While all these advances have been courts for guidance. Both the rules and kept; how and where those documents embraced and enjoyed, the increasing existing cases stress the importance of should be stored and/or destroyed, use of electronic data warrants some establishing and faithfully practicing and/or if they should be destroyed. forethought — at least to the degree that document retention policies that cover Additionally and importantly,the policy medical care intersects with the legal electronic records in order to avoid the needs to be disseminated and followed. system. litigation second-guessing game of deter- The types of documents subject to a New rules will take effect in United mining what data should or should not retention policy include: e-mails; com- States federal courts on December 1, exist. In other words, instead of endur- puter disks; hard drives;Web pages; text 2006. Under these new rules, each party ing a case by case challenge of explain- message; voicemail message; archive to a lawsuit must provide a copy or a ing why electronic documents no longer data;back up data;disaster recovery data; description of all electronically stored exist, it is far better to have a document PDAs and Blackberrys to name a few.All information in the possession,custody,or retention policy that governs what is of these electronic instruments and control of the party that may be used to retained, what is destroyed, and how communications can be the subject of support its claims or defenses. In other long the information is to be stored. discovery requests. words, health care defendants in federal Luckily, there are relatively easy ways In today’s health care practice, a docu- courts will be required to provide infor- to avoid sanctions in the future by taking ment retention policy should include a mation about electronically stored infor- the time now to create and disseminate litigation and/or a regulatory hold. This mation, even without a discovery a document retention policy. A document is a suspension of record destruction request. Medical records that are kept retention policy is a carefully crafted, under the policy when litigation or electronically would therefore obviously widely disseminated and uniformly administrative investigation is antici- be subject to this required disclosure. applied policy and practice that provides pated or occurring. Any information Less obvious are other sources of elec- for the systematic review,retention and which is potentially relevant to pending tronic data — that PDA, the office word destruction of all documents created or or potential litigation should not be processing system, or even some medical received in the course of business. By destroyed during the duration of the liti- equipment that may store patient instituting an appropriate document gation. These holds should be imple- images, laboratory results, or diagnostic retention policy,e-mails and other elec- mented as soon as litigation becomes tests. While the vast majority of medical tronic data can safely be destroyed with- reasonably foreseeable. The best bet is negligence cases are in state — not in out the fear of reprisal from a court always to err on the side of caution and federal — courts, there is no doubt that down the road. A document retention envision the worst case scenario, then fit lawyers will begin to include requests for policy will provide a system for comply- the hold accordingly.When an individual electronic records regardless of the ing with document retention laws, save makes a determination that a litigation court. money, space and time, and ensure that hold should be put in place that must be Why is electronic data of such interest valuable documents are available when communicated to everyone that poten- to lawyers? There are good reasons and needed. A document retention policy tially has relevant documents, not just cynical reasons. The good reasons: the also protects against allegations of selec- management. In other words, anyone information is objective, contemporane- tive document destruction and provides who would potentially have an e-mail,

10 Cleveland Physician I July/August 2006 LEGAL ISSUES Physician Wins Monetary Sanctions in Case of “Frivolous Conduct”

A Cuyahoga County judge recently ing the orthopedist.They did not respond (1) In bringing a loss of consortium awarded a physician member of the to discovery requests on behalf of the claim when he knew that the AMC/NOMA monetary damages for orthopedist nor request the depositions Plaintiff’s were not married at the defending himself and his group against of the physicians that had been sued. time of the alleged negligence; a frivolous medical malpractice lawsuit. The patient’s personal injury attorney (2) In alleging that the orthopedist The plaintiff sustained a trimalleolar refiled the case a year later. Allegations (and all the Defendants) accused ankle fracture when she fell while roller in the refiling mirrored those of the first, the patient of being a drug addict skating.Paramedics took her to the emer- but added a claim for punitive damages. and refused to treat her because gency room of a local hospital,where she Although the defendants completed the she did not have health insurance; was treated by an emergency physician, depositions of the patient and her new (3) In failing to dismiss the case when as well as consulting physicians. Approxi- husband, the plaintiff’s personal injury he learned the case lacked any mately three weeks later, the ankle was lawyer did not conduct depositions of merit and that his client no longer surgically repaired at another facility. the medical providers involved. He did, wished to pursue it; and The plaintiff retained a personal injury however, send the case out for expert (4) In making a claim for punitive lawyer and filed a complaint in December review. The expert reviewed the case damages in the refiled Complaint 2001 alleging a consulting orthopedist and reported back that the case was mer- without any basis. had breached the standard of care in delay- itless. The patient advised her attorney The court exercised its discretion and ing the patient’s surgical repair, causing a that she did not wish to continue with awarded the orthopedist the expenses delayed and less-than-full recovery. The the case. Subsequently, the lawyer did incurred in preparing Motions for complaint also alleged that all defendants, not dismiss the case, but left it pending Summary Judgment on the plaintiffs’ including the orthopedist, accused the before the court, despite knowing it claims and expenses incurred in pursu- plaintiff of being a drug addict and refused lacked merit and that the patient herself ing the sanctions against the personal to treat her because she did not have no longer wished to pursue it. The court injury attorney. The court also ordered health insurance. The complaint included eventually granted the defendants’ the personal injury attorney to pay the a claim for consortium for the patient’s various Motions for Summary Judgment. orthopedist an additional amount as a husband, though the couple was unmar- The orthopedist asked his attorney to sanction for the plaintiff’s baseless alle- ried at the time of the medical care. pursue the personal injury attorney for gations that he accused the patient of This first filing of the case remained sanctions for the frivolous lawsuit. After being a drug addict and refused to treat pending from December 2001 through completing additional discovery on the her because she had no health insurance. October 2002. During that time, the issues of sanctions, a hearing was con- For more information about this case patient retained a new personal injury ducted. The court concluded that the or pursuing sanctions for frivolous law- lawyer, who did not produce any expert personal injury attorney “engaged in suits, contact David H. Krause at (216) reports critical of the defendants, includ- sanctionable conduct”: 430-2103 or [email protected]. Editor’s Note: The AMC/NOMA is working closely with counsel of this The Electronic Document Retention find themselves fighting an uphill battle physician member in terms of consider- Policy (Continued from page 10) to avoid sanctions. Examples of discov- ing any further action relative to an ery sanctions include adverse inference appeal of the court’s decision. I voicemail, or other electronic informa- instructions, exclusion of relevant evi- tion which could be relevant to antici- dence, admission into evidence of spe- CLEVELAND pated or pending litigation, needs to be cific discovery misconduct, monetary made aware that that information should penalties, dismissal of Complaints and PHYSICIAN not be destroyed. Many electronic default judgments. THE ACADEMY OF MEDICINE OF CLEVELAND/ devices, including many computer pro- Should panic ensue? Certainly not.To NORTHERN OHIO MEDICAL ASSOCIATION grams, routinely overwrite data over the contrary,this is a classic example of 6000 Rockside Woods Blvd.,Suite 150 Cleveland, Ohio 44131-2352 time. Therefore, it is important to bring the old adage that an ounce of preven- Phone: (216) 520-1000 • Fax: (216) 520-0999 your IT personnel into the discussion at tion is worth a pound of cure. By putting STAFF Executive Editor Elayne R. Biddlestone the onset of a litigation hold in order to in place the document retention policy Communications Coordinator ensure that things are not inadvertently now, you can help ensure that in the Sara Lieberth destroyed. future you will be prepared to respond THE CLEVELAND PHYSICIAN (ISSN# 1084-0982) is published bi- monthly by the Academy of Medicine Cleveland/ Northern Ohio Medical When will the sanctions be imposed in to discovery requests appropriately, to Association (AMC/NOMA), 6000 Rockside Woods Blvd., Suite 150, Cleveland, Ohio 44131. Periodicals postage paid at Cleveland, Ohio. civil discovery? When the defendant fails provide the necessary information that POSTMASTER: Send address changes to CLEVELAND PHYSICIAN, 6000 to have an effective document retention exists, and to have well documented rea- Rockside Woods Blvd., Suite 150, Cleveland, Ohio 44131. Editorial Offices: AMC/NOMA, 6000 Rockside Woods Blvd., Suite 150, Cleveland, policy or, even when a document reten- sons as to why information may have Ohio 44131, phone (216) 520-1000. $36 per year. Circulation: 2200. tion policy does exist, when the defen- been destroyed. Because today’s medical Opinions expressed by authors are their own, and not necessarily those of the Cleveland Physician or The Academy of Medicine of dant fails to implement it effectively. practice is so intertwined with elec- Cleveland/Northern Ohio Medical Association. Cleveland Physician reserves the right to edit all contributions for clarity and length, as well Further, if the plaintiff can demonstrate tronic medical records and in fact elec- as to reject any material submitted. purposeful or inadvertent destruction of tronic communications, document ADVERTISING George H. Allen, Jr., Commemorative relevant electronic evidence in a manner retention policies are one of the neces- Publishing Company P: (440) 808-0240 not consistent with an existing docu- sary considerations to protect you © 2006 The Academy of Medicine of Cleveland/Northern Ohio Medical Association, all rights reserved. ment retention policy, defendants can against future lawsuits. I

Cleveland Physician I July/August 2006 11 PRACTICE MANAGEMENT Protecting The Medical Practice from Embezzlement

By Laurie Braun, CPA, CFE, Senior Staff Accountant at Lynch, Anselmo, Ott, Bryan & Company Secretary of the North East Ohio Chapter of the Association of Certified Fraud Examiners

As Certified Public Accountants, our the patient paid that day. This sheet is you sign the checks, you should immedi- firm represents many small medical and invaluable. The charges recorded that ately mail them. It is easy to alter the dental practices.Also,as a Certified Fraud day need to be cross checked by a differ- payee after the checks have been signed. Examiner, I am always on the lookout for ent employee to make sure that they Also run accounts payable reports. embezzlement in my clients’ practices. match the patients and procedures actu- Do not have your bank statements sent According to the 2004 Report to the ally performed to prevent inaccurate to your office. You should receive them Nation on Occupational Fraud and Abuse charges or not recording charges at all. at home or have them sent to your published by the Association of Certified The money recorded also needs to be accountant. This way,you can review the Fraud Examiners, small organizations are cross checked with the actual deposit checks that are written and the deposits at the highest risk for fraud. In the health slips. For example, I have a client who made. For instance, I receive many of my care industry, the median loss is sends me their daysheets and deposit client’s bank statements, and I go $105,000. slips so I can cross check them with the through all the checks to identify checks My experience has shown that preven- actual deposits recorded on the bank that look unusual or suspicious. Look tion is the number one factor in avoiding statements. through the check register to make sure costly embezzlement risks. There are that the payee recorded on the check three areas which every owner of a med- stub is the same payee written on the ical practice should consider: fraud pol- check. If you have someone in your icy, fidelity insurance and internal Prevention is the number office reconcile the bank account, make controls. one“ factor in avoiding costly sure it is someone who is not responsi- It is important to have a fraud preven- ble for handling the receivables or the tion program and a written policy that embezzlement risks. payables. identifies the organization’s philosophy ” When hiring new employees, it is wise and procedures in dealing with fraud- to contact prior employers or to do a related matters. A fraud policy will let When patients mail in their payments, background check. Since most employ- your employees know up front that you you should have one employee open the ees who steal money from the employer will not tolerate any actions constituting mail and another record the payments on are not prosecuted, they merely go to a fraud and that you have a means to han- the patient accounts. This will prevent new job and do the same thing again. dle the fraud if it is committed. This does an employee from stealing the money And, if you find that one of your employ- not have to be a lengthy document, but a outright and not recording it appropri- ees is embezzling, contact your attorney statement letting the employees know ately on the patient’s account. so it can be handled appropriately. that you are aware that fraud can occur Employees can manipulate checks or set Meet with your accountant to review and that you are not going to tolerate it. up their own bank accounts in your prac- your fraud policy and internal controls. Your accountant or lawyer should be tice name for their own schemes. When They can perform operational reviews to able to help you set up such a policy. receiving payments, they should be make sure you are protecting your prac- Fidelity Insurance policies can also stamped with the practice account infor- tice before it is too late. protect you from any monetary losses mation immediately and deposited that In a small medical practice, the human suffered if one of your employees steals same day,if possible. Most practices use element comes into play. Employees from you. Talk to your insurance agent computer software to record their know each other very well and trust is a about insuring those employees who charges and receivables, so you should key factor. Trust is an essential element handle the finances. In most cases of have monthly aging reports printed. of small businesses,but it is also an essen- embezzlement, the money stolen may Review these reports for accounts that tial element of fraud. You need to strike never be recovered; but if they are may seem inappropriately large or past a balance between having enough trust insured, your chances are better. due and investigate them. in your employees to create an amicable The third and most important means of The accounts payable department is working relationship, and not having protecting yourself from becoming a vic- ripe for embezzlement. Do not use a rub- enough trust in them to avoid becoming tim of embezzlement is strong internal ber stamp to sign the checks. Make sure a victim of embezzlement. controls. In a small medical practice you sign each check and review the Editor’s Note: This article is the first with only a few employees who handle payee and amount being paid. Have all in a series on special practice manage- the daily intake and outlay of monies, supporting documentation attached to ment features.Look to the Sept/Oct issue internal control should be the number the checks you are signing. Know your of the Cleveland Physician for a timely one priority. Separation of duties is an vendors, even if you have an employee piece on tips for avoiding identity theft important factor, not only preventing responsible for purchasing the medical in the medical office setting. Contact embezzlement, but in preventing and office supplies. It is possible for Kristine Snider of the Academy’s employees to be tempted to steal your employees to set up fake companies and Practice Management Dept. with your money. write checks to these companies with- questions/concerns at (216) 520-1000 Create daysheets that record the out your ever knowing, especially since ext. 314. I patients seen, the procedures and modern computer equipment makes cre- charges performed and the money that ating professional invoices easy. After

12 Cleveland Physician I July/August 2006 PRACTICE MANAGEMENT

Stop Scheduled 2007 Cuts to staff times, supplies and equipment that any changes to name, address, etc. Medicare Physician Payments! have been previously reviewed by the Correct address information will help RUC; ensure that CERT documentation We are faced again this year with the need • Modify the methodology used to calcu- requests are received and will allow time for Congress to forestall the scheduled cuts late indirect practice expenses; for your response. to Medicare physician payments — a nearly • Utilize practice expense survey data for • Educate staff who receive the mail on: 5 percent reduction totaling $117 million to eight specialties: allergy/immunology, How to identify a CERT request for med- Ohio doctors next year alone.As you know, cardiology, dermatology, gastroenter- ical records and who to forward the let- the sustainable growth rate (SGR) formula is ology, radiology, radiation oncology, ter to so it can be processed in a timely inherently flawed because it penalizes physi- urology and independent diagnostic manner. Request needed documentation cians when the growth in utilization of med- testing facilities; and from third parties if necessary,attach the ical care is greater than growth in the gross • Eliminate an exception to the current original bar code sheet to each individ- domestic product. There is widespread con- methodology,the so-called nonphysician ual set of records and fax or mail the sensus among policymakers that the SGR is work pool that has been used to calcu- requested information to the number or in fact unsustainable and must be replaced late practice expense RVUs for services address listed in the CERT letter. with a formula that accommodates for without physician work RVUs, and increases in the cost of practicing medicine. instead price these services using the In fact, Medicare physician reimbursements Obtain NPIs Early standard practice expense methodology. have scarcely kept pace with the rising cost If approved, the changes will apply to pay- Physicians who file claims electronically of providing patient care — the GAO conser- ments for services furnished to Medicare must begin using a National Provider vatively estimates between 1990 and 2006 beneficiaries beginning with 2007. Identifier by May 23, 2007, but CMS is urging the cost of operating a practice rose 40%, We will keep members updated as more physicians to obtain the unique 10-digit while Medicare payments increased 19%.Ask information becomes available. code early in an effort to prevent the system your Congressional representative to take from being overwhelmed by individuals and action and prevent physician payment cuts organizations waiting until the last minute. in 2007, secure a positive payment update What CERT Means to You Federal officials hope that the NPI and other that accurately reflects practice cost CMS uses the Comprehensive Error Rate electronic standards will reduce the admin- increases (for 2007 MedPAC has recom- Testing (CERT) program to measure and istrative burden on physicians and encour- mended rates be increased 2.8%) and improve the quality and accuracy of age them to adopt electronic claims. replace the unsustainable growth rate for- Medicare claims submission, processing and Physicians must submit certain informa- mula with a payment system that prevents payment. Under this program, more than tion such as Social Security numbers, federal the need for congressional intervention year 140,000 randomly-selected claims are employer identification numbers and any after year! reviewed each year. other identifiers to apply for an NPI.The NPI, The 2006 Medicare Trustees report proj- CMS’ methodology includes: which will never change and will accom- ects continued cuts in physician payment • Randomly selecting a sample of claims pany a physician wherever he or she goes, rates, due to the SGR, totaling 37 percent submitted in a specific calendar year; also is required for physicians who use a sep- through 2015. In our state of Ohio, that’s • Requesting medical records from pro- arate billing agency to submit electronic $27,000 per year, per physician. viders who submitted the claims; claims. About 635,000 of the roughly 2.3 Write your Congressional Representative • Reviewing the claims and records to see million physicians, hospitals and other TODAY. Let them know that survey after sur- if they complied with the Medicare health care entities that must obtain NPIs vey (including 2005 AMC/NOMA data) has coverage, coding and billing rules; have done so in the first year of the applica- shown that the SGR will necessitate doctors • Treating the claims as errors and sending tion process. Most insurers by May 2007 will begin limiting the Medicare patients they the providers overpayment letters when be required to accept the NPI alone, but treat, or stop accepting new ones because to providers fail to submit the requested smaller health plans will have an additional do so is becoming prohibitive. documentation, submit insufficient doc- year to comply. I Visit www.amcnoma.org, click on the umentation, or the submitted medical prominent Medicare Cuts link to be easily record indicates that the service was not directed to an “Action Alert” sample letter medically necessary,incorrectly coded, already prepared for AMC/NOMA members. or was not in compliance with some other Medicare coverage or billing rule. Did You Know? Proposed Changes to Physician What Should You Do? Fee Schedule Announced • Provide the requested information: The AMC/NOMA offers all manner of CMS issued a notice June 22 proposing During a CERT review,you may be asked practice management assistance to our changes to the Medicare Physician Fee to provide more information related to a members from third party payor claims Schedule (MPFS) that would improve the claim than you submitted so that the reviews to discounted Tri-C classes on accuracy of payments to physicians for the CERT review contractor can verify that billing/coding standards. Call the services they furnish to Medicare beneficiaries. billing was proper. Physician Advocacy Committee and The proposed notice includes substantial • Respond Promptly: Practice Management staff at (216) 520- increases for “evaluation and management” Should you receive a CERT request 1000 ext.314.Also,look for the Summer services. CMS will respond to public com- for medical documentation, respond 2006 Practice Management Matters ments on both sets of proposals and promptly by submitting the requested newsletter — a valuable resource for announce final policies in a final rule to be supporting documentation within the providers and staff — in your office issued in early November. In the notice,CMS timeframe specified. mail soon! proposes to: • Keep your enrollment information • Adopt a “bottom-up” methodology for current: calculating direct costs. This involves It is important to keep your Medicare using procedure-level data for clinical contractor informed within 90 days of

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14 Cleveland Physician I July/August 2006 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. AMC/NOMA member Dr. Robert Dimeff (left), Medical Event ,AWRENCE3CHOOL ISA Director for the Rite Aid /URSTUDENTS Cleveland Marathon, COMEFROM COLLEGEPREPARATORYDAY spends a moment with COUNTIESAND SCHOOLSERVINGBRIGHT members of his medical COMMUNITIES staff during the May 21 STUDENTSWITHLEARNING event. Dr. Dimeff also THROUGHOUT DISABILITIESANDATTENTION serves as primary care .ORTHEAST/HIO director of SportsHealth DElCITSIN'RADES  at the Cleveland Clinic.

Dr. David R. Mandel, rheumatolo- gist and AMC/NOMA member, saw the h4RAININGAT,AWRENCE importance of recognizing osteoporosis 3CHOOLISANIMPORTANTPART as a “silent killer”affecting many genera- OFTHEDEVELOPMENTALBEHAV tions. Dr. Mandel founded the Osteo- IORALROTATIONFORPEDIATRIC porosis Walk Foundation and its annual RESIDENTSAT4HE#LEVELAND event, Run/Walk for Stronger Bones has certainly gained its popularity over the #LINIC/URPARTNERSHIPWITH past decade, with this year’s run and THE,AWRENCESTAFFPROVIDES walk being its twelfth since its origin in 1994. OURRESIDENTSWITHAUNIQUE OPPORTUNITYTOLEARNABOUT AMC/NOMA member David Bronson, MD, Chairman of ANDOBSERVEBESTEDUCATIONAL the Division of Regional Medical Practice at the Cleveland Clinic Foundation,has taken office as Chair-elect of the Board ,EARNMORE PRACTICEWITHCHILDRENAND of Governors of the American College of Physicians (ACP), ADOLESCENTSWHOHAVE the national organization of doctors of internal medicine. ABOUT LEARNINGDISABILITIESv Dr. Bronson is currently the ACP Governor for Ohio. He is ,AWRENCE also a consultant for the Cleveland Browns football team. 'ERARD!"ANEZ 0H$ Dr. Thomas Steinemann h,AWRENCE 3CHOOL 4HE#LEVELAND#LINIC is the recipient of the American Academy of Ophthalmology’s 2006 Secretariat Award for !'UIDEFOROUR $IVISIONOF0EDIATRICS advocacy on the plano contact lens issue. Dr.Steinemann is a 0ROFESSIONAL 0ARTNERSv cornea and external eye disease specialist at MetroHealth Medical Center and was instrumental in getting federal legis- 2EQUESTACOPYTODAY lation passed last year regulating the decorative devices. I    X CLASSIFIEDS OR E MAIL CBAKER LAWRENCE MEDICAL/ORTHOPEDIC SUITE in North Olmsted available for immediate %7ALLINGS2OAD occupancy. 2100 square feet on Lorain Road in a highly visible office building PVTKOHUS "ROADVIEW (EIGHTS /(  in the Great Northern area. Call (216) 475-9255 for information. WWWLAWRENCESCHOOLORG    SPACE AVAILABLE in North Olmsted. Up to 1825 square feet in medical/ professional office building on Lorain Road in the Great Northern area. Call (216) 475-9255 for information.

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Cleveland Physician I July/August 2006 15 THE HOSPICE OF CHOICE

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16 Cleveland Physician I July/August 2006 FINANCIAL MATTERS Can You Benefit from a Revocable Living Trust?

By Philip G. Moshier, CFP

In recent years, revocable living trusts your spouse or anyone else you’ve plicated. However, since living trusts have been touted as a simple, cheap sup- named to act on your behalf to manage may not work to your advantage, it’s best plement to wills. But are they? It’s called your assets without time-consuming to consult a legal advisor and a financial a living trust because you set it up and court intervention. Note, however, in counselor to determine whether it put some or all of your assets into it dur- some instances a court-appointed con- should be part of your desired estate ing your lifetime. Typically,you serve as servator may still be needed. plan. trustee which gives you control of the To ensure compliance with requirements Disadvantages imposed by the IRS, we inform you that (i) assets until death. After your death, they any U.S. tax advice contained in this commu- are distributed according to the terms of • Tax Myth. Unless properly drafted, a nication is not intended or written to be used, the trust document and don’t go through revocable living trust won’t save you a and cannot be used, for the purpose of avoid- probate, which can be costly and time- dime in estate taxes. For many wealthy ing penalties under the Internal Revenue code (ii) and any such tax advice is written in con- consuming. individuals, their priority is reducing nection with the promotion of marketing of While a useful estate planning tool in estate taxes, not just probate. the matter’s addressed. You should seek some instances, living trusts are not for • Not A Will Substitute. You still may advice based on your particular circum- everybody. Here’s a look at some of the need a will. Living trusts could be a stances from an independent tax advisor. pros and cons: supplement, but not a substitute for Philip G. Moshier, CFP is a registered your will. You’ll need a will to pass on representative of Lincoln Financial Advantages assets not previously put into the trust, Advisors, a broker/dealer, and offers • Medical Practice Succession. If you to appoint an executor to administer investment advisory service through own or are a partner in a medical prac- your estate, and to name a guardian for Sagemark Consulting, a division of tice, the trustee can transition your your minor children, among other rea- Lincoln Financial Advisors Corp. practice to a successor or assist with its sons. Editor’s Note: AMC/NOMA members termination — if that’s your desire. • Costs/Hassles.As with any trust,you’ll may receive discounted financial serv- • Avoiding Probate. Under a will, an have to pay legal fees to set it up ini- ices through our relationship with estate must be settled in probate court tially, and possibly ongoing trustee fees Sagemark Consulting and Mr.Moshier. and is a matter of public record. if you use an institution such as a bank, A brochure outlining the available serv- Lawyers’ fees and court costs often are or other trustee. And it can be costly ices can be easily downloaded from substantial, and proceedings can drag and difficult to transfer legal title to www.amcnoma.org by clicking on the on for a year,two,or more. Living trusts your business, home, bank accounts ‘Member Information’ link in the left are generally settled without court and securities into the name of a trust. column, then ‘Financial Services’ under intervention, so the process could be Before refinancing your home, for Member Benefits. I quicker, cheaper and more private, instance, your bank may insist that the although this isn’t always the case. title be removed from the living trust Local laws should be examined to con- back into your name. firm whether privacy can be ensured. • Another Factor. If • Flexibility. Since you can amend or probate is an impor- SAVE THE DATE revoke the trust at any time while tant concern, the you’re alive, you can get the trust prop- kinds of estate assets Join us for the 3rd Annual erty back whenever you wish, or mod- should be looked at. ify a distribution fact pattern to Two of your biggest Academy of Medicine Education Foundation potential beneficiaries. assets — your life • Control. A living trust can provide a insurance policy and Marissa Rose Biddlestone single receptacle to receive and distrib- pension plan — can be ute assets on your death. Non-trust designed to go directly Memorial Golf Outing assets such as life insurance proceeds to your designated can be left to your trust if you name it beneficiaries without as beneficiary (although the proceeds passing through pro- August 28, 2006 will be subject to estate taxes if you bate. And since assets Shaker Heights Country Club own the policy at death). Also, where owned jointly by you allowed by law, any assets not held in and your spouse pass trust can be left in your will and passed by contract or deed, a PROCEEDS TO BENEFIT THE to the trust after your death by the living trust isn’t needed terms of the will. Thus, the trust can to avoid probate. Academy of Medicine unify your estate so that it can be Education Foundation administered under one document. While not a panacea, • Asset Management. If you become revocable living trusts disabled or otherwise unable to man- may be valuable in Call (216) 520-1000, ext. 309 for more age your financial affairs, a living trust some states where pro- information or to sign up for the event. and durable power of attorney enable bate is costly and com-

Cleveland Physician I July/August 2006 17 ANNUAL MEETING 2006

The Academy of Medicine Cleveland/Northern Ohio Medical Association held its Annual Meeting dinner and awards presentation Friday, April 28 with the special addition this year of Foundation scholarships awarded to local medical students during the evening’s festivities.

There is no organization that can “offer you so much as a physician in Northeast Ohio. Although regional, the 2006 Honorees (l to r): Adrian Schnall, MD; John Shelley, Esq.;Thomas Steinemann, MD; Michael Michael, MD; John Sanders, MD and John Clough, MD. AMC/NOMA gives each of you a voice that can be heard at a distance.” –PRESIDENT PAUL C. JANICKI,MD, addressing the membership during the 2006 Annual Meeting

The 2006 list of honorees was led by John D. Clough, MD, receiving the John H. Budd MD Distinguished Membership Award for his exemplary contributions to John H. Sanders, MD, Past Presidents of the AMC/NOMA in attendance at this year’s meeting (l to r): the local medical community. William Seitz, MD; George Kikano, MD; John Bastulli, MD; Robert White, MD; was honored with the Charles L. Hudson Distinguished Herman Menges, MD; Fred Suppes, MD; George Leicht, MD;Victor Bello, MD and Service Award in recognition of his longtime dedication Ronald Savrin, MD. to organized medicine. The 2006 Clinician of the Year designation went to Adrian M. Schnall, MD in recogni- tion of his outstanding accomplishments in active prac- tice and scientific research. The Academy’s Honorary Membership Award was bestowed upon John F. Shelley, Esq. in acknowledgement of his many years of counsel and ethical representation of area physicians. Thomas L. Steinemann, MD, received the Outstanding Service Award marking his role in the passing of federal legislation regulating all contact lenses as medical devices.And Michael A. Michael, MD, was presented the Special Honors Award for his professional dedication Fifty-Year Awardees at the 2006 Annual Meeting (l to r): Fred Suppes, MD; Frederic and service to the community. Lafferty, MD; Erwin Rabin, MD; Howard Fagan, MD; Carl Doershuk, MD; John The Academy of Medicine Education Foundation Gardner, MD; Melvin Shafron, MD; Sayed Hussny, MD; Joseph Bauer, MD and Virgilio Avendano, MD. presented its annual scholarships this year to four deserving local medical students for the first time at the Annual Meeting of the AMC/NOMA. And as always, physician members celebrating the fiftieth anniversary of their medical school graduation were honored during the program as well. Following the awards ceremonies, outgoing president George E. Kikano, MD, passed the AMC/NOMA gavel for the 2006-2007 year to Paul C. Janicki, MD. I Paul C. Janicki, MD, receives his presi- AMEF Scholarship Awardees (l to r): Ana Radovic and Jennifer dential gavel and good wishes from out- Neville of Case Western Reserve University, Joshua Nething of going president George E. Kikano, MD, NEOUCOM and Charyse McMillion of Ohio University. during the annual meeting ceremonies.

18 Cleveland Physician I July/August 2006 PHYSICIAN ADVOCACY

The Academy of Medicine Cleveland/Northern Ohio Medical Association The VOICE of NE Ohio Physicians for more than 180 Years Highlights of 2005-06 Advocacy on Behalf of Our Members and their Patients

Legislative Activities — Crafted and participated in debate to Media Coverage — Cleveland Connection radio program create a mandatory arbitration pilot program resolving NE interviewed Dr. John Bastulli on legislation aimed at reducing Ohio medical liability cases — which passes Ohio Senate after liability premium burdens on NE Ohio physicians. George more than two years of work by the AMC/NOMA and its sup- Kikano, MD, participated in a radio panel on direct-to-consumer porters hoping to positively impact the still-looming liability advertising of prescription medications and the implications crisis in our region. on the physician/patient relationship on WCPN’s 90.3 at 9. Testified in support of and submitted amici curiae brief on AMC/NOMA’s “Pollen Line” was featured as a great community behalf of Anesthesiologist Assistants to resource by the Plain Dealer and The Ohio Supreme Court. News-Herald at the start of allergy Supported and helped achieve Benefits of Membership in the season. Dr. Ronald Savrin was inter- Congressional regulation of cosmetic AMC/NOMA viewed by Jim McIntyre of WDOK contact lens use. 102.1 FM on the services and benefits Renowned Physician Referral Service the AMC/NOMA offers as was Richard Board Initiatives — Adopted policy on Representation at the Statehouse Fratianne, MD, on his work at MetroHealth Pay-for-Performance programs holding through McDonald Hopkins, Co. LPA Medical Center. William Seitz Jr., MD, that any such policy be fair and ethical, Specialty Listing in Member Directory was featured on the nationally-broadcast patient-centered and assess physician & Community Resource Guide All Things Considered NPR program for performance with evidence-based his specialization in a bone-lengthening Practice Promotion via measures. technique. Dr. Thomas Steinemann was Healthlines radio program Developed policy on the Conscience interviewed several times by the Plain Clause issue stating our support that a Reimbursement Ombudsman Dealer on the issue of federally regulating patient’s access to legally prescribed CME Seminars cosmetic contact lenses. Several medications be made available to them AMC/NOMA letters to the editor were Peer Review should a pharmacist conscientiously printed in Crain’s Cleveland Business object to dispensing it. Speaker’s Bureau opportunities and the Plain Dealer on subjects ranging Adopted directives to the FDA relative Insurance/Financial Services from medical liability and retail “quick to enhanced physician access to the clinics” to improving patient care agency’s drug safety/trials data. Weekly, quarterly and bimonthly through better communication strategies. publications offering healthcare news Raised concerns in several missives to And Paul Janicki, MD, was featured in and practice guidance the Ohio Department of Health, the Crain’s Cleveland Business and the Plain State Medical Board and participating Member Discounts including Worker’s Dealer when installed as AMC/NOMA corporations on the issue of state-wide Comp, Practice Management Classes at president. implementation of medical services in Tri-C and so much more! a retail setting, or quick clinics, with Community Efforts — Conducted widely serious questions on continuity of successful Vote & Vaccinate event on patient care. Election Day offering flu and pneumonia immunizations in Strenuously objected in letters twice to the Ohio State underserved areas. Medical Board outlining serious concerns on their proposed Acted as initiative partner to SmokeFreeOhio campaign in rules over terminating the physician-patient relationship and their efforts to legislate workplace safety from secondhand sexual misconduct. smoke across the state. Participation in the NEORHIO project, the region-wide Hosted 21st annual Mini-Internship Program that allows Health IT collaborative, by committing funding toward its community members to shadow AMC/NOMA physicians over business plan development. two days. Requested OSMB review of expert witness testimony in medical liability cases by physicians. Scholarships — Academy of Medicine Education Foundation awarded four $5,000 scholarships to local third and fourth Medicare Cuts Reversed — Thanks to national physician year medical school students based on scholastic merit and associations and local groups such as the AMC/NOMA, interest in the advancement of organized medicine. Congress reversed the 4.4 percent cut in physician’s Medicare reimbursement rates and froze fees at the 2005 level. We Annual Seminar — Hosted well-attended and topical CME continue to advocate (including our June 26 press release) seminar addressing pay-for-performance, quality measure- overturning the SGR, the source of potential rate cuts for ment, electronic health records and health IT as they begin the next several years. to impact the practice of medicine in our region.

Is YOUR Voice Being Heard? Already an AMC/NOMA member? Now is the time to renew your commitment to organized medicine that makes a real difference in your practice and our region. Look for a 2007 dues billing in your mail soon! Not yet a Member? Now more than ever is the time to join the only regional medical association tirelessly working in the best interest of you—the NE Ohio Physician. Call our membership department at (216) 520.1000 ext. 309 for details on all the benefits and services available exclusively to our members.

Cleveland Physician I July/August 2006 19 comfortable confident There’s a fine line between what you know and what you feel.

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20 Cleveland Physician I July/August 2006