The 62Nd ND Legislative Assembly Top Issues – Health Care Reform

North Dakota Medical Association Checkup ontents J u n e 2011

The mission of the North Dakota Medical C Association is to promote the health and well- being of the citizens of North Dakota and to President’s Message ...... 3 provide leadership to the medical community.

The NDMA Checkup is published quarterly by The 62nd North Dakota the North Dakota Medical Association, 1622 E. Interstate Avenue, P.O. Box 1198, Bismarck, ND Legislative Assembly ...... 4 58502-1198, (701) 223-9475, Fax (701) 223-9476, e-mail: [email protected] NDMA Briefings ...... 10

Kimberly T Krohn MD, President A Michael Booth MD, Vice President Health Information Steven P Strinden MD, Secretary Treasurer Debra A Geier, MD, Speaker of the House Exchange Update ...... 12 Gaylord J Kavlie MD, AMA Delegate Robert W Beattie MD, AMA Alternate Delegate NDMA Alliance News ...... 13 Councillors: Joseph E Adducci MD Debra A Geier MD MMIC Risk Management ...... 14 Yvonne L Gomez MD Catherine E Houle MD Timothy J Luithle MD Steven R Mattson MD Rupkumar Nagala MD Fadel Nammour MD Mark W Rodacker MD Shelly A Seifert MD Rory D Trottier MD Harjinder K Virdee MD Derek C Wayman MD Dennis E Wolf MD alendar of Upcoming Events

Staff C Courtney Koebele, Director of Advocacy September 9-10 Leann Tschider, Chief Operating Officer ND Society of Obstetrics and Annette Weigel, Administrative Assistant Gynecology Annual Meeting Shelly Duppong, Designer & Production Manager Ramkota Inn, Bismarck with Clearwater Communications For more information contact Dennis Lutz, MD at 701-852-1555

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2 NDMA CHECKUP President’sMessage Kimberly Krohn, MD

Replacing the Irreplaceable

ithout change we never go anywhere. The North leaders. The selection committee met almost weekly WDakota Medical Association is going through a throughout December and January, culminating in inter- lot of change this year! One of the great things about hav- views of four finalists for the executive director position ing a great leader, such as our departed former Executive in early February. The selection committee made a recom- Director Bruce Levi, is that it brings great esteem to our mendation to the Council which resulted in hiring a suc- organization and comfort to the members of the organi- cessor to Bruce. Unfortunately, after a month’s delay for zation. The bad thing is that when he leaves to go on to notice, our new executive director resigned on his second well-deserved career advancement, we are left with a huge day with NDMA March 17. hole! Bruce represented us formally and informally on just We are fortunate to have Courtney Koebele, JD, as about every health-related group and issue occurring in our Director of Advocacy, Leann Benson as chief opera- North Dakota for more than a decade. I often stated that tions officer and membership director and organizational Bruce Levi represents North Dakota physicians better than memory among other duties, and Annette Weigel as our we could represent ourselves. And now my oft-repeated administrative assistant. They are working with the execu- phrase is, “we are finding someone to succeed Bruce, not tive committee regularly and carrying out the mission of replace him, as we cannot replace the irreplaceable.” our association. Courtney was at the Capitol daily and The Council of the North Dakota Medical Association is interfacing with the people and organizations that are so our board of directors. We are charged by our bylaws with important to us. She overlapped with Bruce by several naming an executive director of the organization. Each weeks and maintains contact. We have continued work district has representation on the Council. When Bruce with our affiliated organizations for which we provide resigned, I appointed an executive director selection com- administrative support, and work on our annual meeting mittee which included several past presidents along with scheduled for September 22 and 23 in Grand Forks. As the executive committee members and select other NDMA always, we have many projects going and will be maintaining them throughout the transition of directors. There has never been a better time to become involved in NDMA. I hope that each of our members reading this will think about committing to be a delegate to our House of Delegates in September, about agreeing to become an officer for a district medical society, and about becoming more active in our association. I hope that non-members will consider membership in the only organization in the state that can possibly speak for physicians as a group. The Council continues to meet to discuss the next steps in replacing the irreplaceable. Right now we are in good hands with a stable mission and progress towards it. Thanks for your continued leadership on the front lines for our profession and the communities we serve. Bruce and Kathy Levi at the North Central Medical Caucus Conference dinner in Minneapolis on March 19th.

J U N E 2 0 1 1 3 The 62nd ND Legislative Assembly Top Issues – Health Care Reform

Courtney Koebele, JD, Director of Advocacy

he 2011 North Dakota Legislative Assembly met day at the capitol to roam the halls and watch the action. Tfor 78 legislative days, adjourning sine die on This program was so greatly appreciated by legislative April 28, 2011. leaders and all legislators, really showcased the importance The NDMA legislative agenda was adopted by of primary care physician services, and gave the volunteers NDMA members, participating as delegates from their an inside look at the legislative process. NDMA hopes that District Medical Society and state specialty societies we can continue this highly appreciated program with even to the NDMA House of Delegates, at the 2010 NDMA more participation in the special legislative session in the annual meeting in Fargo. The NDMA Commission on fall. Legislation chaired by Fadel Nammour, MD, recom- On March 16 and 17 NDMA and Altru Clinic offered mended policy priorities and worked with members of free health screenings to legislators and their staff. Dr. Jim the NDMA Council to refine the agenda prior to the Brosseau of Altru Clinic provided those medical consulta- session and take positions on other bills as they were tions. Over 100 people participated in the screenings. introduced. NDMA priorities include physician recruitment and MEDICAID REIMBURSEMENT retention strategies, Medicaid payment issues, national NDMA priorities with respect to Medicaid reimbursement health system reform implementation and opposing issues were to work to maintain the proposed Department inappropriate expansions of allied professional scope of of Human Services budget maintaining the level of reim- practice including the proposed elimination of collabora- bursement achieved last session, with proposed 3% increas- tive prescriptive agreement for nurse practitioners, and es in each year of the upcoming biennium. the licensing of naturopaths and lay midwives. This leg- Last session, NDMA was successful in rebasing physi- islative session was active regarding the Medicaid reim- cian Medicaid payment through $39 million in additional bursement issues, and several bills attempted to address state/federal funding to rebase physician payments to 89% a number of issues involving national health system of cost, resulting in a substantial increase. This session’s reform. executive budget in SB 2012 maintained that level of reim- What was new this session was the addition of a sec- bursement with proposed 3% increases in each year of the ond physician in the Legislative Assembly: Spencer upcoming biennium. NDMA testimony encouraged law- Berry, MD, a family medicine physician from Fargo. Dr. makers to further rebase physician payments. The Senate Berry served on the Senate Human Services Committee Appropriations Committee confirmed the 3% increases. and provided a good daily perspective on issues for the Unfortunately, the House eliminated both the 39 million committee as well as the Senate floor as those issues dollars in funding given last session and the 3% increase relate to physician practice. Along with Senator Ralph in the governor’s budget, despite protests from a number Kilzer, Senator Berry was an active participant in floor of physicians and administrators throughout the state. discussions and committee hearings on a variety of Questions were raised in the House of Representatives issues impacting physicians and public health. about the substantial increase from last session. Because of Physicians were able to sign up directly for the Doctor the reduction, the bill went to conference committee with of the Day program on the NDMA website to spend a members from both the House and the Senate.

We greatly appreciate the Bismarck Center for Family Medicine for covering the Doctor of the Day program each Wednesday. A special thank you to physicians who participated in the NDMA Doctor of the Day program during the 62nd Legislative Assembly: Hani Alboushi, Gary Betting, Charles Breen, James Brosseau, A. Michael Booth, Jessie Carlson, Linda Getz-Kleiman, Jeff Hostetter, Ted Kleiman, Kimberly Krohn, Prabin Lamichhane, Tom Magill, Sarah McCullough, Fadel Nammour, Jeremiah Penn, Jackie Quisno, Sarah Schatz, Robert Sticca, Tom Strinden, Guy Tangedahl, Stephanie Traxinger, Karen Willis, Dennis Wolf and Joshua Wynne.

4 NDMA CHECKUP Through the efforts of NDMA, the North Dakota with the Department of Health during the interim to craft Hospital Association, the Health Policy Consortium a proposal. The dilemma is that lay midwives are sought and numerous physician contacts, we were successful by some parents, and the need exists to protect the public in restoring the 39 million in funding from last session. which continue to seek those services regardless of whether Senator Ralph Kilzer was a key player on the conference minimum care standards are met. Several physicians testi- committee which restored the 39 million. Other support- fied in support of doing “something” to educate parents and ive members of the conference committee were Senator lay midwives. Other physicians were opposed to any legis- Tom Fischer, Senator Larry Robinson and Representative lation that would “legitimize” lay midwifery. The bill was Lee Kaldor. Senator Berry also contributed very valu- defeated in the Senate. able information to the negotiations. Unfortunately, the HB 1434 proposed eliminating the pharmacy ownership physicians did not receive the 3% inflationary increase. law requiring that a pharmacy be owned by a licensed phar- However, NDMA considered the session a success for macist in good standing. This bill was defeated 68-26 in the physicians in that the previous rebase was maintained and House. legitimized by the 2011 Legislative Assembly. Federal Health System Reform Supplemental Medicaid Payments During this session, there is an environment of partisan- to Critical Access Hospitals ship over federal health system reform and efforts, in some HB 1152 requires the Department of Human Services cases in conjunction with other states, to undermine or nul- to provide a Medicaid supplemental payment to critical lify that reform, particularly the individual mandate to pur- access hospitals. The Department is required to seek fed- chase health insurance. eral Medicaid funding to support the supplemental payments. As amended, the bill appropriates $1,527,802 from Insurance Commissioner Bills the state general fund, and $1,926,259 in federal funds for Several bills move the state forward, through the office of this purpose for the 2011-13 biennium. state insurance commissioner, to implement health system reform (HBs 1125, 1126, 1127). What some leaders are say- Bills that were defeated ing is that many of the issues relating to the state’s imple- Three WSI bills were defeated this session. One of the mentation efforts, including the need for additional staff for bills, HB 1052, would have allowed WSI to publicly pro- Medicaid and the Insurance Department, will be addressed file physician practices and another, HB 1053, would have later in the fall in the special session held for redistricting. set generic prices if cheaper as the standard payment for HB 1125 requires the Insurance Commissioner to admin- brand name drugs. Another WSI effort in HB 1054 related ister and enforce the provisions of the Patient Protection to pain management of WSI patients. The bill, opposed and Affordable Care and the provisions of the Health Care by NDMA, set forth extensive new requirements and and Education Reconciliation Act of 2010 to the extent that protocols for physicians in the provision of pain manage- the provisions apply to insurance companies subject to the ment, relating to both general opiate therapy during the commissioner’s jurisdiction and to the extent that the provi- acute stage of treatment and long-term opiate therapy. Dr. sions are not under the exclusive jurisdiction of any federal Shelley Killen of Bismarck and Dr. Kimberly Krohn of agency. Minot testified in front of the Senate Industry Business HB 1126 requires the Insurance Commissioner and the and Labor Committee to the effect the bill would have Department of Human Services to plan and implement an on a physician’s practice. The bill passed in the House 81 American health benefit exchange for North Dakota that to 8. NDMA worked to defeat it in the Senate and it was facilitates the purchase of qualified health benefit plans, defeated 11 to 36. provides for the establishment of a small business health In a win for ophthalmologists trying to reduce eye inju- options program that is designed to assist qualified small ries in children, an effort to bring back bottle rocket sales employers in facilitating the enrollment of their employees to the state in HB 1255 was also defeated. in qualified health benefit plans offered in the small group SB 2315 would have required the North Dakota Board market, and meets the requirements of the Patient Protection of Nursing to license any person providing midwifery ser- and Affordable Care Act of 2010 as amended by the federal vices under specific requirements and limitations imposed health reform law. The Legislative Assembly is given discre- by the legislation; engaging in midwifery without a license tion to establish one exchange that will provide services to would be a class A misdemeanor. This was a difficult bill, both qualified individuals and qualified small employers. as efforts to prohibit the practice of lay midwifery were The bill authorizes the Commissioner and the Department not successful in 2007 and a number of physicians worked to take all actions necessary to ensure that the exchange is

J U N E 2 0 1 1 5 determined, not later than January 1, 2013, by the federal to the committee. The bill was unopposed and passed government to be ready to operate not later than January both in the House and Senate. 1, 2014, and that the exchange is operating on or after January 1, 2014. Challenges to physician HB 1127 revises appeals processes with respect to scope of practice non-grandfathered plans under the Patient Protection and Nurse Practitioners Affordable Care Act. The law was amended to conform NDMA and the ND Board of Medical Examiners appeals processes to current federal laws and rules. opposed Senate Bill 2148 which eliminated the collaborative prescriptive agreement required of advanced practice Other Health Reform Related Bills registered nurses. NDMA testimony focused on the need HB 1165 provides that a resident of North Dakota will to continue the use of the collaborative agreement as a not be “required to obtain or maintain a policy of individ- patient safety tool that does not restrict nurse practitioners ual health coverage except as may be required by a court from their full level of scope of practice. Despite this tes- or by the Department of Human Services through a court timony, the bill passed. or administrative proceeding.” HB 1252 establishes a Legislative Management Health Naturopaths Care Reform Review Committee during the 2011-12 SB 2271 creates a state “Board of Integrative Health interim to monitor the impact of the federal health system Care” to regulate “naturopaths” and specifies the scope reform, rules adopted by federal agencies, and any amend- of practice of naturopaths including a naturopathic for- ments to the reform legislation. The bill provides that if a mulary list. NDMA expressed many concerns regard- special session of the Legislative Assembly is necessary ing the bill. The bill was amended to change references to adopt legislation in response to the federal legislation, from “naturopathic physician” to “naturopath;” remove the committee will report to the Legislative Management references and authority for a formulary list and clearly before a special session; otherwise it will report to the prohibit a naturopath from prescribing, dispensing or next Legislative Assembly. administering any prescription drug; and require that a SB 2309 declared that the federal laws known as the naturopath may only use the title “naturopath” or “doctor Patient Protection and Affordable Care Act and the Health of naturopathic medicine” (N.D.). Care and Education Reconciliation Act of 2010 likely are not authorized by the United States Constitution. The Pharmacists law further provided that the Legislative Assembly shall SB 2035 expands the current authority of pharmacists consider enacting any measure necessary to prevent the to administer immunizations and vaccinations to children. enforcement of the Patient Protection and Affordable This bill changes current law regarding the administra- Care Act. Finally, it stated that no provision of the Patient tion of drugs by pharmacists. It expands current law Protection and Affordable Care Act may interfere with authorizing a pharmacist, upon an order by a physician, an individual’s choice of a medical or insurance provider nurse practitioner or physician’s assistant authorized to except as otherwise provided by the laws of this state. prescribe such a drug or by written protocol with a physician, nurse practitioner, or physician’s assistant, to admin- Post graduate residency training ister immunizations and vaccinations by injection. The requirements for international expansion is to individuals “at least eleven years of age” school graduates rather than the current authorization for individuals more A bill originating with residents at the Minot Center than 18 years of age. NDMA proposed an amendment, for Family Medicine, HB 1222, introduced at the request which was adopted, to require the immunization to be of NDMA and supported by the ND Board of Medical reported as a childhood immunization and other informa- Examiners, reduces the post graduate residency training tion if required to be reported to the state’s immunization requirement for graduates of international medical schools information system. from three years to thirty months for purposes of qualify- ing for a full and unrestricted medical license. This allows Public health initiatives the resident to make timely application to take the ABFM These were several of the major public health initiatives certifying examination in the summer, rather than hav- offered this session: ing to seek an unrestricted license in another state or wait until the fall exam. Dr. Gaylord Kavlie of Bismarck testi- Trauma System fied in favor of the bill and offered important information HB 1266 puts in place a statewide trauma and EMS

6 NDMA CHECKUP medical director and state funding for the state trauma Newborn Metabolic and Genetic Diseases system which NDMA assisted in developing with the SB 2067 modified existing law to conform to the proce- state’s Trauma Committee. NDMA supported this bill dures already in place for newborn metabolic and genetic and the trauma system request for full funding. Dr. Kent disease testing. The bill provides that the testing will con- Hoerauf, Dr. Steven Hamar and Dr. Steven Briggs offered tinue to be an opt-out administration, with the parents being testimony in support of the bill. provided with written information prior to the testing. The The original bill provided for funding of $726,516, bill also eliminated the requirement that opting out be based including $416,000 for contracting for an emergency on conflicts with religious tenets or practices, rather than medical services and trauma medical director. The House just parental choice. reduced the funding to $50,000 and passed the bill. The Senate put an additional $50,000 in the bill and changed Further Restrictions on Young Drivers the language to “shall” when directing the state health and No More Texting for All Drivers officer to appoint an EMS medical director. The confer- HB 1256 incorporates graduated drivers licensing con- ence committee changed the language back to “may” cepts for young drivers in North Dakota’s motor vehicle appoint a director and maintained the minimal level of licensing law. The bill provides that an individual would be funding of $50,000 for the director and $50,000 for train- able to request an instructional permit at age 14, but for any ing. driver under age 16, the driver would have to hold the permit for 12 months (rather than the current 6 month require- Youth Concussion Management ment) and meet a minimum of 50 hours of instructional SB 2281 requires that any student or youth athletic driving experience before he/she could apply for a restricted activity that is sponsored or sanctioned by a school license. At 15, the driver would be eligible to receive a be subject to the terms of a concussion management restricted driving license, which would allow the teen to program. NDMA supported the bill as introduced. Dr. drive without adult supervision, but only between the hours Spencer Berry was one of the primary sponsors of the of 5am - 9pm, unless going directly to or from school, bill and testified in front of the House Education com- work, or religious activities or if there is an individual over mittee. The bill was amended to remove the requirement 18 years of age in the front seat. At age 16, the time restric- that a physician authorize return to practice, training or tions would be removed, but electronic device restrictions competition and allows for a licensed health care pro- would remain. The bill bans the use of all electronic devices vider to authorize return. The final amendment involved for drivers under the age of 18, except GPS devices. the authorization being given to the student, who in turn HB 1195 prohibits the operator of a motor vehicle that is could provide it to the coach, to comply with HIPAA. part of traffic to use a wireless communications device to The bill was also amended to apply the requirements for compose, read, or send an electronic message. all schools, including non-public. The bill also contained a mandatory study for the Coverage for Uninsured and 2011-2012 biennium, to study concussion management Underinsured People, Including Children with respect to youth athletics, including the nature, SB 2264 would have changed the eligibility test for scope, and applicability of programs designed to prevent Healthy Steps from a net income eligibility limit of 160% or eliminate concussions. of the poverty line to 200% of the poverty line. Two other bills would have moved the limit to 250%. These bills Universal Vaccine Program were defeated and the eligibility for Healthy Steps was SB 2276 established a program through which the rolled into the Department of Human Services budget Department of Health purchases vaccines through the approved in the Senate at 175% net of the federal poverty federal vaccine purchasing contract. The Department line. Unfortunately the House reduced it back to 160% and shall supply public health units with the purchased vac- that was confirmed by the conference committee and the cines. A public health unit that receives vaccines under Legislative Assembly. this purchasing program may not bill an insurer for the cost of the vaccine but may charge an administration Department of Health fee. The Department shall fund this purchasing program The Department of Health’s budget, contained in HB through participation in the vaccines for children pro- 1004, appropriated a total of $28,913,780 in general funds gram, the federal section 317 vaccine program, and state appropriation. The budget fully funded the North Dakota funds appropriated for this purpose. The legislature pro- Stroke Registry and included $600,000 to fund a statewide vided for a 1.5 million appropriation for this program. STEMI initiative.

J U N E 2 0 1 1 7 In an attempt to replace reduced federal funding avail- Advisory Council members Senator Tim Mathern, Senator able through the Department of Transportation for services Robert Erbele, and Representative Ralph Metcalf. provided to ambulances and for the statewide trauma The physician loan repayment law was also amended in program, HB 1004 partially restored it as follows: trans- HB 1003, by eliminating the requirement that to qualify fer from EMS grants line ($300,000); Department of for the plan a physician may not have practiced full time Transportation ($124,800); and General fund ($75,000) for medicine in the state for more than one year before the a total of $499,800. date of application. During the session, the House amended HB 1004 to There is also a provision for the Legislative remove the Measure 3 language requiring that 80 per- Management chairman to appoint a separate committee to cent of the Community Health Trust Fund be spent on study the ability of the University of North Dakota School tobacco prevention and control. The Senate restored this of Medicine and Health Sciences to meet the health care language and the conference committee maintained it. needs of the state. The study, which was chosen by the Restoring this language assured that funding of the state- Legislative Management, must include a review of the wide tobacco quitline and Quitnet services continued. The health care needs of the state, options to address the health Community Health Trust Fund receives 10 percent of all care needs of the state, and the feasibility and desirability the tobacco settlement annual payments. of expanding the school of medicine and health sciences to meet the health care needs of the state. UND School of Medicine & Health Sciences Electronic Prescriptions The UND School of Medicine & Health Sciences bud- SB 2122, introduced by the State Board of Pharmacy, get bill, as part of the overall university system budget revised the state’s prescription laws to incorporate elec- bill in HB 1003, was granted $46,783,021 in total general tronic prescriptions. With respect to “brand necessary” fund appropriation. The controversial HB 1353, which prescriptions, the crux of the bill requires the practitioner would have used tobacco settlement funds to fund class to take the following steps: “If the prescription is created and position expansions at the medical school and residen- electronically by the prescriber, the required legend must cy programs and the construction of another UNDSMHS appear on the practitioner’s screen. The practitioner must building, was defeated. HB 1003, the Higher Education take a specific overt action that accomplishes the inclusion budget bill, provided the following funding: of the “brand medically necessary” language for purposes of electronic prescriptions. The bill also replaced the cur- • $100,000 to complete a formal space study over the rent “brand necessary” language for other purposes with next two years the word “brand medically necessary.” NDMA has con- • $1,215,219 for initiation of a Master in Public cerns with the change in the required language to “brand Health degree program (with the funds to be equally medically necessary.” split with NDSU for a joint effort) Under HB 1422 effective August 1, 2013, a drug prior • $1,151,810 for a Geriatrics Training Program, to authorization request would be required to be accessible develop educational modules for practitioners across and submitted by a health care provider and be accepted the state by a group purchaser electronically through a secure elec- • $1,800,000 for expansion of the medical, health tronic transmission (except facsimiles). Effective August sciences, and residency classes, with the first 1, 2013, electronic transmission devices used to commu- additional trainees arriving in the summer of 2012 nicate a prescription to a pharmacist would be prohibited • $530,031 in equity funding, which will be used to from using any means or permit any other person to use augment faculty development and student support any means (including alerts, advertising, messaging, and functions popup advertisements) to influence or attempt to influence • $512,316 in college affordability funding, which will through economic incentives or otherwise the prescribing help limit the SMHS’s tuition increases to 2.5% decision of a prescribing practitioner at the point of care. over this coming biennium Under HB 1422, during the 2011-12 interim, the • $2,233,200 in merit and additional health care Department of Health and the Health Information premium funding Technology Advisory Committee are required to work together to establish an outline on how best to standard- Advisory Council member Representative Stacy Dahl ize drug prior authorization request transactions between and Representative Bob Martinson were key supporters of providers and group purchasers. The outline “must be the Medical School’s efforts during the session, as were designed with the goal of maximizing administrative

8 NDMA CHECKUP simplification and efficiency in preparation for elec- of women and criminalized the actions of the reproductive tronic transmissions and alignment with standards that doctors working to provide women with appropriate medi- are or will potentially be used nationally.” By January 1, cal care. Dr. Stephanie Dahl, Dr. Shari Orser, Dr. John 2012, the Department of Health and the HIT Advisory Witt and Dr. Steffen Christensen offered key testimony in Committee will be required to provide a report to the explaining the effects of the bill on physician’s practice. Legislative Management regarding the outline on how best The bill passed in the House, and the Senate “laid it on to standardize drug prior authorization request transactions the table,” prohibiting further consideration without a 2/3 between providers and group purchasers. vote of the Senate. There was one attempt to take the bill off of the table, which failed. Abortion There were two bills which addressed different aspects Looking forward to the of abortion. HB 1297 which passed the legislative assem- Interim and 2013 bly, creates a prohibition for anyone to prescribe any abor- The work in preparing for the 2013 has already begun. tion-inducing drug to a pregnant woman unless the person Several studies were prioritized for interim ND Legislative who gives, sells, dispenses, administers, or otherwise Council committees to address health care issues between provides or prescribes the abortion-inducing drug is a phy- legislative sessions at the Legislative Management sician. Every pregnant woman to whom a physician pro- Committee hearing on May 10. The studies chosen vides any abortion-inducing drug will have to be provided include: 1) the future of health care delivery in the state, with a copy of the drug’s label. The bill also provides that focusing on the delivery of health care in rural areas of any physician who gives an abortion-inducing drug must the state and include input from the University of North enter a signed contract with another physician who agrees Dakota School of Medicine and Health Sciences Center to handle emergencies associated with the use or ingestion for Rural Health, hospitals, and the medical community; of the abortion-inducing drug. The bill provides that when 2) the ability of the University of North Dakota School an abortion-inducing drug or chemical is used for the pur- of Medicine and Health Sciences to meet the health care pose of inducing an abortion, the drug or chemical must needs of the state; 3) monitor the impact of the federal be administered by or in the same room and in the physi- Patient Protection and Affordable Care Act and rules cal presence of the physician who prescribed the drug to adopted by federal agencies as a result of that legisla- the patient. tion; and 4) the impact of PPACA on the Comprehensive The other abortion bill, HB 1450, would have defined Health Association of North Dakota and the statutes gov- a “human being” as “an individual member of the species erning the Comprehensive Health Association of North homo sapiens at every stage of development,” and apply Dakota. that definition to the definition of “person” for purposes This Legislative session contained a number of issues of of the state’s homicide and assault laws. interest to physicians and their practices. NDMA remains This bill was determined by the American Society for committed to be involved and focused on bills that impact Reproductive Medicine to threaten the reproductive rights the practice of medicine.

ew to NDMA is Courtney Koebele, JD, who began work as Advocacy Director February 16, 2011. Courtney is a North Dakota Nnative, earning law and criminal justice degrees from the University of North Dakota. As Director of Advocacy, Courtney will coordinate Association advocacy efforts and provide legal counsel to the Association. Since admitted to practice law in 1991, Courtney worked as a law clerk in Federal District Court for Judge Pat Conmy and Magistrate Judge Dwight Kautzmann. After clerking, Courtney represented a variety of state agencies in the civil litigation division of the attorney general’s office. Courtney was in private practice from 1996 to 2005, in both Minnesota and North Dakota. Courtney practiced in a variety of areas of law, including lobbying for the North Dakota Newspaper Association, the North Dakota Broadcasters Association, the North Dakota Judges Association, and several allied health and non-profit entities. Most recently, Courtney was assistant bar admissions administrator for the North Dakota Board of Law Examiners. In that position, Courtney administered the bar exam and reviewed all applicants for admission to the bar in North Dakota. Courtney is looking forward to working with the North Dakota Medical Association and furthering its goals and priorities both on the state and federal levels.

J U N E 2 0 1 1 9 By Bruce Levi

Rediscover Your NDMA!

n times of transition, it’s not just the work accom- non-members alike, can rediscover your NDMA – a rich Iplishments that you think about; what comes to mind tradition of nearly 125 years of important professional are the people, the friendships, the difficult times and the milestones that have substantially improved the physician problems we worked together to solve. practice environment in our state and the health of the In my fourteen years with NDMA I’m left with a strong public. appreciation for the many physicians who took leadership Rediscover the importance of physician collegial- roles in addressing the many challenges and opportunities ity statewide and locally to get done what needs to get facing North Dakota physicians. These are volunteers who done. Rediscover the structure in place through NDMA’s give of themselves to serve others and serve the profes- Council, House of Delegates and Commissions for devel- sion of medicine in our state. In addition to serving their oping NDMA policy and the importance of advocating as colleagues, these NDMA leaders have always given good one voice on behalf of your patients. support and encouragement to the NDMA staff in our A strong NDMA gives physicians an independent daily work. platform in an environment in which physicians are Your leadership is working to achieve a smooth transi- becoming increasingly dependent on their employ- tion in NDMA staff, hiring Courtney Koebele, JD for ers and others to take care of policy and administrative advocacy and legal services. Courtney is a seasoned lob- issues. Complacency is dangerous and will only foster a byist in the ND Legislative Assembly. Leann Benson diminishment of physicians as just another component of continues as our chief operating officer, addressing finan- healthcare “manpower” rather than a profession with an cial, CME, membership and compliance matters. Annette independent voice. Weigel continues to provide daily administrative support NDMA is an effective advocate for you and your for all of our NDMA efforts. patients. The effectiveness of NDMA in advocating for You have been well served by your president Kimberly you and your patients is only as good as the ability as Krohn in this transition process, who is addressing a diffi- physicians to garner the resources necessary to do what cult challenge in the search for staff in the midst of a very needs to get done. While the Association’s membership active legislative session. has always hovered around the 70 percent mark, there is This transition in staff can serve as an opportunity for no reason why every licensed physician in North Dakota all ND physicians to rediscover their NDMA. Certainly should not be a member. most physicians take NDMA’s advocacy work for granted NDMA works with policymakers at the federal, state or assume the work will get done, regardless of their own and local level to improve the physician practice environ- individual participation in the Association. Change can ment, strengthen medical education including the UND be embraced and this change in staff can be used as an School of Medicine & Health Sciences and our residency opportunity for more physicians to step up to contribute to programs, strengthen our ability to recruit and retain a NDMA’s future strength and sustainability. quality physician workforce, facilitate health information It’s not just about dues. All physicians, members and technology, improve the health of the public, and improve

10 NDMA CHECKUP our ability to provide some of the highest quality, safest NDMA has also served as a strong state base for imple- and cost-efficient medical care in the country. menting policies advocated by your national specialty Specific examples over the years include NDMA’s suc- societies. NDMA works with several state specialty chap- cessful efforts to rebase Medicaid physician and hospital ters in moving their policies forward and ensuring an payments, improve the environment for appropriate pain appropriate level of staff support. management, improve care at the end of life, rework the We need all North Dakota physicians to do their part in state’s advance care planning laws, address geographic supporting NDMA advocacy efforts. disparities in Medicare payment to physicians in North In my service to NDMA, I hope I was able to contrib- Dakota, protect and repeatedly refine our medical liability ute in a way comparable to previous NDMA executive reform laws including the cap on non-economic dam- directors including Catherine Rydell and Vernon Wagner. ages and certificate of merit laws, maintain and improve My work at NDMA has been helping physicians help relationships with hospitals and health systems and a raft their patients. As a calling, the work has been something of other agencies and organizations, build good daily that gave voice to who I am and what I want to say to relationships with our Congressional Delegation, address the world; helping North Dakota physicians take care of issues related to the monopsony power of the dominant people with the best that medicine has to offer. commercial insurance carrier including patient rights’ I will continue to serve physicians in my new vocation legislation and contract revision, and improve the health as general counsel to the American Academy of Neurology of the public through our work on tobacco-related issues, in St. Paul. This is all work truly worth doing and I look trauma prevention and care, prenatal care for pregnant forward to new challenges. minors, and many other public health issues. My sincere best to all of you!

J U N E 2 0 1 1 11 Health Information Exchange Update

Sheldon Wolf ND Health Information Technology Director

n September 27, 2010, the Health Information using secure electronic transmissions and electronic OTechnology Advisory Committee (HITAC) sub- devices used to communicate a prescription to a pharma- mitted a strategic and operational plan for a statewide cist may not use or permit the use of alerts, advertising, health information exchange to the Office of the National messaging, and popup advertisements to influence or Coordinator (ONC). The ONC reviewed and approved the attempt to influence decision of a prescribing practitioner plan with addendum on March 30, 2011. The original plan at the point of care. Additionally, during the 2011-2012 and the addendum can be found on the HITAC website interim, the state department of health and the HITAC at: http://www.healthit.nd.gov/strategic-and-operational- shall work together to establish an outline on how best to plans/. Now that the plan is approved, we can access the standardize drug prior authorization request transactions implementation funds. between providers and group purchasers and to report to To keep the process moving and start the implementa- legislative management by January 1, 2012. tion process upon receiving ONC’s approval of our strategic and operational plan, ITD, on behalf of HITAC, • SENATE BILL 2012 is the Department of Human released a request for proposals for the health information Services appropriation bill. This bill includes funding exchange (HIE) infrastructure. Six HIE vendors submit- for the Medicaid meaningful use incentive program. ted proposals. These proposals were reviewed by a stake- Approval of this funding will allow the Department holder committee and three vendors were selected for to make incentive payments to providers that meet the on-site demonstrations which were held on February 28 Medicaid eligibility requirements and the meaningful use and March 1, 2011 and again on May 5 and 6, 2011. As of requirements. the writing of this article a final vendor has not yet been selected. • SENATE BILL 2037 relates to participation in the Finally, below is an update on four pieces of 2011 legis- health information exchange and the confidentiality of lation related to health information technology (HIT). records in the exchange. Additionally, it allows for the creation of health information exchange and the devel- • HOUSE BILL 1021 is the Information Technology opment of policies and procedures to run the exchange. Department’s appropriation bill. Included in HB 1021 is Finally, the bill also moves the responsibility of devel- the appropriation to build and operate the health infor- oping and maintaining an advance directive repository mation exchange. Additionally, section an additional $5 from the Secretary of State’s Office to the Information million dollars for low interest rate loans for providers to Technology Department allowing the advance directive implement health information technology. repository in the health information exchange.

• HOUSE BILL 1422 relates to electronic prescrib- Update on the health information technology can be ing and electronic prior authorizations. This bill creates found on the HITAC website at: http://www.healthit. requirements that, effective August 1, 2013, drug prior nd.gov/. If you would like to be included on the HITAC authorization requests must be submitted and accepted list serve, please send an email to me at [email protected].

12 NDMA CHECKUP Dinah Goldenberg Past-President, NDMA Alliance Director, AMA Alliance

Hello Alliance Member & Friends, June is here and spring is finally in the air. Hopefully by the time you read this all threats of flooding will have passed in your community and we really will be enjoying spring! Over the last six years I have served at the national level of the AMA Alliance in various capacities. The last four years have been as a member of the board of directors. It has been an honor and a privilege to serve on behalf of North Dakota. It has been a rewarding experience, one which I shall treasure always. It is with a heavy heart that I have decided not to continue my national service when my term expires in June. I will be spending more time devoted to my local commitments. The AMA Alliance Nominating Committee met at the end of March. The following is the slate of officers for the 2011-2012 year.

• President - Emma Borders, Louisiana • President-elect - Pat Hyer, Texas SAVE THE DATE • Past President - Susan Todd, Texas ND Alliance Annual Meeting Events • Secretary - Jo Terry, Tennessee September 22 & 23, 2011 • Grand Forks, ND • Treasurer - Sarah Sanders, Illinois • Directors - Watch for details soon! • Pat Klettke, Utah Contact [email protected] with questions • Julie Neuman, North Carolina • Mary Rice, Colorado • Debbi Ricks, California • Mary Shuman, Missouri • Beverly Wright, North Carolina • Rosemary Xavier, Florida

The AMA Alliance Annual Meeting will take place in Chicago June 19-21 at the Swissotel. At the 2010 Annual Meeting an important bylaws change was passed changing the meeting from a House of Delegates format to an Annual Meeting. This means there is no longer a delegate count per state based on membership numbers. Every member is entitled to attend and every member is entitled to a vote. I hope many of you will consider attending as we break new ground at the national level. Information is available on the alliance website www.amaalliance.org If you have not renewed your membership yet, it is not too late. Please consider supporting the continued health and advocacy work of our organization. Fargo dues are $75 (district, state and national). Members at Large dues are $60 (state and national). Checks may be made out to FDMA and forwarded to: Dinah Goldenberg 2173 Victoria Rose Drive • Fargo, ND 58104

Thank you for your continued support. Happy Spring! Dinah Goldenberg Warm regards, Director, AMA Alliance Past President, ND Medical Alliance [email protected]

DinahJ U N E 2 0 1 1 13 Midwest Medical Insurance Company MMIC By Cinda Velasco RN, JD, Attorney-Risk Management MMIC Malpractice Claim Review

Specialty: result. The physician and nursing staff had no recollec- Family Practice tion of the patient or of the ordered test. The clinic staff filed the abnormal result in the patient’s chart without Allegation: the physician’s review. Delay in diagnosis and treatment Risk Management Tips: Risk Management and Patient Safety Focus: Effective follow-up systems are necessary to protect Follow-up systems patients from injury and to reduce the risks of physi- Automated system alert benefits of an electronic cians and clinics being involved in a malpractice action. health record (EHR) Physicians are responsible for making certain they receive the results of any diagnostic test they order, noti- Facts of Case: fying patients of the results and providing appropriate A 53-year-old diabetic male saw his family physician follow-up care. for a regular checkup. The patient requested a prostate- Among the patient safety benefits of an electronic specific antigen (PSA) test. His physician ordered the health record (EHR), are automated system tracking and test and the result showed a value of 19.0 ng/ml. The alerts. Most EHRs have built-in features to track results lab report stated that a PSA of 4.0 ng/ml or below of labs, X-rays, etc. An EHR can greatly improve your was normal. There was no documentation in the chart practice’s tracking of patient care and can reduce the risk regarding the test result or if the clinic notified the of missing a test result. patient of the test result. Three years later, the patient Filing diagnostic tests, X-rays, consultation and other had another PSA test and this time the result was 32 ng/ reports before the physician has reviewed them is a com- ml. It was during this visit that the physician found the mon cause of patient injuries. Follow-up systems and results of the earlier abnormal PSA unsigned and filed policies should address the review of ALL patient infor- in the patient’s chart. mation, including: The family physician immediately referred the patient to a urologist who performed biopsies and diagnosed • In-house lab, X-rays and reports from other prostate cancer. Because of his other health issues, the departments urologist informed the patient that he was not a surgical • Reports and patient information from outside candidate. The patient was treated non-surgically with the clinic radiation and subsequently developed radiation procti- – Outside laboratory reports tis. The proctitis caused the man to have problems with – Diagnostic reports from hospitals or urgency, serious bladder infections, pain and sexual other facilities dysfunction. Three years later, the patient had surgery to – Information regarding hospitalized remove his bladder, colon and part of his rectum. patients The patient filed a malpractice claim alleging failure – Reports from hospital emergency to timely diagnose and treat his prostate cancer that departments caused him to undergo a more aggressive treatment – Other information as applicable resulting in complications and additional surgery. It is crucial to establish a firm policy that only patient Disposition of Case: information with the initials of the ordering provider The case settled for more than $500,000 against the or other authorized person who verifies it has been family physician and the clinic. reviewed be filed in the paper medical record or scanned into the EHR. Initialing of patient information prior Risk Management and Patient Safety Perspective: to filing is the only guarantee that the physician has The experts who reviewed this case all agreed that the reviewed the information. Patient information or reports clinic should have notified the patient and referred for should never be filed without a review on the assump- biopsy when the clinic received the first abnormal test tion that they will be noted at the next patient visit.

14 NDMA CHECKUP

PRESORT STANDARD US POSTAGE PAID Bismarck, ND 58501 Permit No. 419

P l a n t o A t t e n d North Dakota Medical Association & NDMA Alliance September 22-23, 2011 • Alerus Center • Grand Forks, ND

New Laws Begin with NDMA Resolutions The NDMA Friend of Medicine Award is also given Many bills before the 62nd Legislative Assembly annually to an individual who 1) must be a person either living began as resolutions in the NDMA House of Delegates in or operating a business enterprise in the state; 2) must not or as recommendations from NDMA Commissions. be a Doctor of Medicine or Osteopathy; and 3) must have Now is the time to begin putting your ideas for a distinguished herself or himself by serving as an effective resolution on any policy matter to paper, in time advocate for healthcare, patient services, or the profession of for the NDMA annual meeting in September. The medicine in the state of North Dakota. NDMA staff can assist you in preparing an effective resolution with a clear action or stand that you would Members are invited to submit the names of qualified like NDMA to take. Call (800) 732-9477 or 223-9475 for individuals for each of these awards, along with a description of assistance. the individual’s relevant background and accomplishments, to the NDMA office by June 15 for consideration this summer by NDMA Award Nominations NDMA’sAnnual Commission on Medical MeetingServices and Public Relations. The Professional & Community Services Award This does not require a District nomination; any NDMA member is given each year to an outstanding NDMA member can submit a nomination. physician. To be nominated, the physician 1) must be an NDMA member; 2) must not be deceased; 3) Lodging must not have been a previous recipient of the award; Lodging: A block of rooms has been reserved at the Canad Inn, and 4) must have compiled an outstanding record 1000 S 42nd St, Grand Forks until August 26. The rate is $69.30. of community service, which, apart from his or her For reservations call 701-772-8404. Please indicate that you are specific identification as a physician, reflects well on with the North Dakota Medical Association or reference group the profession of medicine. confirmation number 212878.

Promoting Physician Leadership in Ethics and Advocacy