ND Legislative Assembly Enacts Health Information Technology Bill

North Dakota Medical Association CONTENTS J UNE 2009 Checkup The mission of the North Dakota Medical Association is to promote the health and well- feature articles being of the citizens of North Dakota and to provide leadership to the medical community. 61st ND Legislative Assembly 5 The NDMA Checkup is published quarterly by Medicaid Rebase a Reality the North Dakota Medical Association, 1622 E. Interstate Avenue, P.O. Box 1198, Bismarck, ND 58502-1198, (701) 223-9475, Fax (701) 223-9476, Just What the Doctor Didn’t Order: e-mail: [email protected] 11 Why Wills Alone Won’t Work For Most Physicians Robert A Thompson MD, President Kimberly T Krohn MD, Vice President A. Michael Booth MD, Secretary Treasurer ND Legislative Assembly Enacts Steven P Strinden MD, Speaker of the House 16 Shari L Orser MD, Immediate Past President Health Information Technology Bill Gaylord J Kavlie MD, AMA Delegate Robert W Beattie MD, AMA Alternate Delegate

Understanding the Health Care Councillors: 17 Provisions of the Stimulus Joseph E Adducci MD Thomas F Arnold MD Package Steven D Berndt MD William D Canham MD Debra A Geier MD Will You Be Ready For Linda L Getz Kleiman MD 19 Yvonne L Gomez MD HITECH Health Care? Catherine E Houle MD Steven R Mattson MD Rupkumar Nagala MD Minor Consent for Prenatal Care Fadel Nammour MD 27 and SB 2394 Jeremiah J Penn MD Shelly A Seifert MD Rory D Trottier MD The Recovery Audit Contractor Derek C Wayman MD 29 (RAC) is Here Rosemarie Kuntz, MBA, CMPE, NDMGMA President

Staff MMIC Risk Management Bruce Levi, Executive Director 34 Managing Medication Risks Dean Haas, General Counsel Leann Tschider, Director of Membership & Office Manager Annette Weigel, Secretary Shelly Duppong, Designer & Production Manager departments with Clearwater Communications

SUBMISSIONS: The NDMA Checkup welcomes manuscript, photog- President’s Message 3 raphy and art submissions. However, the right to edit or deny publishing submissions is reserved. Submissions are returned only upon request. Letters to the Editor with name, address and phone number of the author Organized Medicine – 22 are welcome. All letters are subject to editing. What Has It Done For You Lately? ADVERTISING: NDMA accepts one-quarter, half page and full NDMGMA 23 page ads. Contact our office for advertising rates.

Briefings 24 NDMA Checkup is printed on recycled paper. NDMA Alliance News 33

2 NDMA CHECKUP CHECKUP PRESIDENT’SMessage Robert Thompson, MD, MBA

The Telltale Signs of Health Care Reform... Finally on the Horizon?

he planets are aligning for health care reform. “build momentum behind a comprehensive overhaul TAs described in my prior editorials, the so-called this year.” President Obama has described this volun- American health care system, which is really more of a tary effort as an “unprecedented commitment” by the patchwork than a true system, is unsustainable. The telltale organizations to “put aside their differences and work signs of true reform are finally appearing and the country toward fixing the healthcare system.” The letter draft- is ready for change. During the early 1990’s, similar things ed by the health industry attendees stated, “We, as were said. So, why do I think that this time it is inevitable? stakeholder representatives, are committed to doing Let me list these telltale signs and you can make up your our part to make reform a reality in order to make the own mind. system more affordable and effective for patients and The first sign of change was the economic collapse, purchasers...” These are very powerful words. which became plainly evident last fall. Economists say The fourth sign of the potential for real change that the weakening started in 2007 and that the economy is the willingness of key congressional members to simply ran out of steam. The collapse of the housing begin to engage in a meaningful dialogue regarding market, the rising numbers of unemployed, the increase sweeping reform. Their goal is in alignment with in bankruptcies, and the collapse of signature American the White House, which aims to produce meaning- icon businesses have all led to a citizenry that is frankly ful health care legislation by fall for consideration spooked. Did you know that health care expenses account and passage. On April 29, 2009, the Senate Finance for roughly 50% of personal bankruptcies? Frankly, the Committee released a report for public comment American public wants health care reform and they want it called Transforming the American Health Care to be sweeping and meaningful. Delivery System: Proposals to Improve Patient Care The second sign of change was the election in and Reduce Health Care Costs. On May 11, a sec- November and the collapse of an effective political oppo- ond options paper was released on expanding health sition to the President and his party during this legislative care coverage: Expanding Health Care Coverage: cycle. The ability to drive through change and create leg- Proposals to Provide Affordable Coverage to All islation has never been more probable, especially with a Americans. On May 18, the final of three papers charismatic president with high approval ratings. was released relating to the financing of health The third sign is the recent summit at the Obama care reform: Financing Comprehensive Health White House of the major health care players – the Care Reform: Proposed Health System Savings and American Medical Association, the American Hospital Revenue Options. If you are at all interested in health Association, the American Health Insurance Plans, the care policy and reform, I would strongly recommend Pharmaceutical Manufacturer’s Association, the Advanced looking through these documents, which will give Medical Technology Association, the Service Employees you an idea what some of the legislation might look International Union, and others – all vowing to work like. (See http://finance.senate.gov/sitepages/baucus. towards solutions that will save 2 trillion dollars over ten htm). years! As opposed to the early 1990’s and the efforts by The Obama administration, in their words, is trying to the Clinton administration to overhaul the health

JUNE 2009 3 care system, I do not foresee that the entrenched vested are projected to be grossly under-funded, and the longer interests will be able to derail the momentum that is build- the tough decisions are delayed, the worse the prob- ing. Remember the Harry and Louise ads on television? I lem becomes. Kathryn Sebelius, the Health and Human doubt you will see something as effective this time. Services Secretary, makes the point that we can’t fix The fifth sign relates to the competitiveness of American Medicare without fixing the whole health care system. business. Many corporations and small businesses are say- This process will be interesting to watch. Since we are ing that they cannot compete against their counterparts talking about reforming approximately one seventh of this in Europe and Canada. Many businesses hope that health country’s economy, the public needs to be brought along. care reform, especially in these difficult times, will allow Mike Murphy, a Republican political consultant and advi- them to regain a competitive edge. sor, talks about the “sacrifice gap” in American politics. The sixth sign is the statement by Medicare Board of His point is that while politicians talk about solutions, they Trustees (May 12, 2009) that Medicare Part A will run out do not spell out what sacrifices need to be made. If true of money two years earlier than predicted (2017 instead health care reform is to occur, there will be sacrifice from of 2019). For that matter, all of the entitlement programs everyone involved, including the public. Will there be sweeping reform this year? I think so. I believe the signs are there. David Brooks, writing in the New York Times in May, thinks there will only be a medium-sized bill. His point is that there will be extended coverage, but very little to trim costs. He states, “there are deep structural forces … that have driven the explosion in health care costs.” In days past, I would have agreed with him; however, this is a unique legislative cycle and President Obama’s only real chance to “double down” on a massive effort. We shall see. At this point in our history, we stand on the precipice of uncertainty. The theme of my presidency has been leadership and I still believe that for physicians to play a meaningful role in shaping the destiny of our profession, it is a crucial time to become involved. These are indeed interesting times.

Above: Dr. Thompson and Dr. Biron Baker participate in a Healthcare Reform Roundtable held by Sen. Kent Conrad and Rep. Earl Pomeroy. Left: NDMA Vice President Dr. Kimberly Krohn and Dr. Thompson pause on the steps of the U.S. Capitol between meetings with our Congressional Delegation.

4 NDMA CHECKUP 61ST NORTH DAKOTA LEGISLATIVE ASSEMBLY New legislation includes rebase of Medicaid physician payments

he 2009 North Dakota Legislative Assembly met NDMA Priorities Addressed Tfor 79 legislative days, adjourning sine die during the late hours of May 4. The session was punctuated by NDMA came to the 2009 session with a member- stops and starts caused by statewide flooding and will be ship-driven agenda developed by the Commission on remembered for heated debate complicated by the need Legislation, chaired by Dale Klein of Mandan, approved to allocate federal stimulus dollars and strong views on by the NDMA House of Delegates led by House Speaker both sides relating to the implementation of Measure 3. Steve Strinden of Fargo in September 2008, and refined Legislative highlights include the funding of many priori- by both the Council chaired by NDMA Vice President ties articulated at the start of the session by Governor John Kimberly Krohn and the Commission on Legislation prior Hoeven and legislative leaders on both sides of the aisle, to the start of the session. The process included a joint including $400 million in tax relief, additional K-12 and meeting of the Council and Commission in late January to higher education funding, major infrastructure enhance- take positions in response to other introduced measures. ments for transportation and water, including immediate The NDMA legislative agenda for 2009 included pro- aid to local governments for flood recovery, and fund- posed efforts to enhance North Dakota’s practice envi- ing for seniors, children, people with disabilities and the ronment for physicians and to improve the health of the Medicaid program. The approved state budget sets aside a public. The following pages review major reserve of more than $700 million. health care accomplishments achieved NDMA lobbyists tracked and participated in delibera- by legislators in the 2009 session, tions on over 100 bills and resolutions during the session, categorized by general NDMA and were present every day of the session. Many of our policy goals. member physicians actively participated in the session by providing testimony, contacting legislators or participating in the NDMA Doctor of the Day Program. “Thank you” to all these physicians.

A special thanks to physicians who participated in the NDMA Doctor of the Day program during the 61st ND Legislative Assembly: Mohammed Abrar, Robert Beattie, Gary Betting, Joel Blanchard, James Brosseau, Brad Buell, Angela Dornacker, Linda Getz-Kleiman, Ernest Godfread, Keith Happel, Jeff Hostetter, Paul Jondahl, Ted Kleiman, Dale Klein, Donald Kosiak, Kimberly Krohn, Craig Lambrecht, Tom Magill, Sarah McCullough, RJ Moen, Ben Muscha, Robert Ostmo, Rick Paulson, Jackie Quisno, Suman Regmi, Sarah Schatz, Tom Strinden, Wade Talley, Guy Tangedahl, Robert Thompson, Karin Willis, Dennis Wolf, and Joshua Wynne.

JUNE 2009 5 • Support Medicaid payment increases for physicians and hospitals; support expanded coverage for uninsured and underinsured people, including children. Major funding was provided in HB 1012 for rebasing physician, hospital and ambulance Medicaid payments, including $40 million in additional state and federal dollars for rebasing physician payments, based on the methodology developed by the Department of Human Services with the assistance of NDMA during the interim between legislative sessions. The Governor proposed to rebase physician Medicaid payments at 25% of the amount it would take to bring payments to 100% of actual cost, based on this methodology. The House proposed to reduce that amount to 20% of the Governor John Hoeven greets a medical careers high school class during the amount it would take to bring payments to legislative session. The class of Bismarck CHS and BHS students spent the day taking blood pressures and talking with legislators. Students are (l-r) Allison 100% of cost. The Senate raised it to 75% Weigel, Kirstie Fueller and Nicole Andrews. of the amount to bring payments to 100% of cost, or about 89% of cost based on the methodology. After • Support additional state medical liability reforms – a conference committee resolved to hold the 75% rebase protect existing reforms. amount, both the House and Senate passed the bill. The NDMA with the help of many legislators including legislation includes a second-year of the biennium inflator Rep. Kim Koppelman, who carried the bill on the House of 6% and, overall, is a 52.8% increase in the appropriation floor in opposition, worked to defeat legislation in HB for physician services over the previous biennium, accord- 1390 that would have repealed our state’s $500,000 cap ing to DHS. on non-economic damages in medical liability actions. Dr. Many legislators including Sen. Ralph Kilzer, the only Kurt Kooyer was instrumental in providing testimony to physician in the legislature, were instrumental in advocat- the House Judiciary Committee about his experiences in ing for the 75% physician rebase amount. In addition to Mississippi which led him to North Dakota. majority and minority leadership in both chambers, others Also defeated was SB 2326 which would have made taking a particularly active role in committee on the physi- inappropriate changes in laws relating to judgment dis- cian rebase issue were Sens. Tom Fischer, John Warner, bursements in medical liability actions. Karen Krebsbach and Tim Mathern and Reps. Chet Pollert, NDMA’s proactive effort in HB 1302 as introduced Jon Nelson, Mary Ekstrom and Ken Svedjan. HB 1012 by Rep. Larry Klemin, amends section 28-01-46 (which also provides funding for these items, among many others: requires the plaintiff to serve the defendant an affidavit containing an expert opinion within three months of com- - Funding for medically needy to reflect income levels mencing a medical liability action) to address the result of 83 percent of the federal poverty level as proposed of an opinion by the North Dakota Supreme Court in by the Governor. Scheer v. Altru that resulted in an indefinite time for filing - $400,000 general funds for one-time funding to the a motion for serving the affidavit at a later time. The bill Rolla hospital. requires that the motion for extension be made within the - $300,000 for outreach for Healthy Steps (SCHIP); three-month period after commencing a medical liability SCHIP program eligibility set and funded at 160% action. (net) of the poverty level. We appreciate the testimony of Bismarck attorney - $3,013,143 for medical assistance for developmental Tracy Kolb in support of HB 1302, and in opposition to disability providers serving severely medically fragile HB 1390 and SB 2326. and behaviorally challenged individuals in addition to $1,186,857 added by the House.

6 NDMA CHECKUP • Support the independent medical judgment of phy- in conference committee by Reps. Bob Skarphol, Robin sicians in medical practice. Weisz and Richard Holman and Sens. Judy Lee, Larry NDMA supported the passage of legislation in HB 1561 Robinson and Dick Dever for addressing HIT funding introduced by Rep. Jasper Schneider providing a pre- including state match leverage for federal stimulus fund- sumption in favor of the treating physician in Workforce ing. In conference committee, substantial amendments Safety & Insurance (WSI) matters. Under the legislation, were made to the bill that provide the potential for over if WSI does not give an injured employee’s treating doc- $88 million in loans and grants for HIT infrastructure tor’s opinion controlling weight, the WSI must establish and interoperability initiatives using $13 million in state that the treating doctor’s opinion is not well-supported by funds from the profits and earnings of the Bank of North medically acceptable clinical and laboratory diagnostic Dakota and federal stimulus dollars which may become techniques or is inconsistent with the other substantial available. The bill also establishes an HIT office for evidence in the injured employee’s record based on vari- development of plans and standards under the auspice of ous factors. the ND Information Technology Department. NDMA also assisted the efforts of the ND Psychiatric Society in supporting HB 1385 introduced by Rep. Robin • Support ways to enhance patient decision-making. Weisz prohibiting the ND Department of Human Services For the third session, NDMA advocated for addressing the from prior authorizing certain categories of drugs includ- need to allow a minor to consent for confidential prenatal ing antipsychotics, anti depressants, anticonvulsants, anti- care. This time legislation in SB 2394 introduced by Sen. retrovirals for HIV, antineoplastic agents for cancer, and Karen Krebsbach was enacted to allow a physician to stimulant medication for ADD-ADHD. rely on the consent of a minor for pregnancy testing, pain management related to pregnancy, and prenatal care under • Support funding increases in the UNDSMHS bud- certain circumstances. Drs. Shari Orser and Jerry Obritsch get and strategies to meet future health care needs. testified in support of the bill. A separate article explain- Rep. Bob Martinson and Sen. Ray Holmberg spearheaded ing the legislation is found on page 27. a conference committee effort in SB 2003 to provide $5.4 NDMA supported SB 2195 introduced by Sen. Ralph million in funds from the permanent oil trust fund for a Kilzer which provides a process for resolving conflicts new facility for the Bismarck Center for Family Medicine. arising from differences between an anatomical gift dec- Other UNDSMHS budget initiatives and enhance- laration and advance directive by a prospective donor ments include a base level general fund appropriation of clarifies patient intent in conflicts between anatomical $34,027,701 with enhancements of $7,087,700 for a total gifts and a health care directive. NDMA also supported general fund appropriation of $41,115,401 for the 2009- SB 2237 introduced by Sen. Tom Fiebiger which cre- 11 biennium, and an electronic medical records system ates a voluntary registry for health care directives in the for UNDSMHS. Secretary of State’s office, which will make those direc- Also enacted was legislation supported by NDMA tives accessible by entering a file number and password responding to the performance audit of the UND School on an Internet website. A health care provider relying on of Medicine & Health Sciences, including the purpose of health care directives on the registry will be immune from the Medical School, duties of the UNDSMHS Advisory liability with respect to good-faith decisions made as a Council and the UNDSMHS loan fund. The Legislative result. Assembly enacted the following new UNDSMHS statement of purpose: “The primary purpose of the UND • Support public health initiatives. NDMA was School of Medicine and Health Sciences is to educate involved in supporting many public health initiatives, physicians and other health professionals and to enhance including the passage of legislation introduced by Sen. the quality of life in North Dakota. Other purposes Dave Oehlke prohibiting the sale or distribution of include the discovery of knowledge that benefits the peo- bottle rockets by fireworks retailers as proposed by the ple of this state and enhances the quality of their lives.” ND Society of Eye Physicians and Surgeons. Following testimony by Dr. Darrell Williams, a successful, yet • Support efforts to encourage strategies and plans very close, vote in the House was garnered with assis- for health information technology. NDMA supported tance by many legislators including Reps. Don Vigessa, SB 2332 introduced by Sen. Judy Lee, in ensuring the Louis Pinkerton, and George Keiser. Other bills include passage of the bill in the House prior to substantial work SB 2004, the appropriations bill for the Department of

JUNE 2009 7 a hospital that offers emergency services to the public must meet trauma center designation standards and participate in the trauma system. The bill also requires the State Health Council to adopt rules that allow provisional trauma designation status for a hospital that is partially compliant with trauma designation standards. When issuing a provisional trauma designation, the State Health Council is required to allow a reasonable amount of time, determined by the Department, for a hospital to fully meet all trauma designation standards. Funding for Measure 3 – a CDC-based tobacco prevention and control program for North Dakota – became very controversial during the session and the bill introduced Health, which provides funding for tobacco prevention, to implement Measure 3, SB 2063, was defeated in the the medical loan repayment program, Women’s Way, sui- House. The legislation adopted in the waning hours of cide prevention, Russell-Silver Syndrome grants, newborn the session in HB 1015 appropriated almost $13 million hearing screening, colorectal cancer screenings, stroke for the program, and added provisions requiring that any registry and prevention, and tobacco prevention and con- moneys in the water development trust fund can be spent trol and other programs. only pursuant to legislative appropriations and requiring SB 2344 revises the state’s criminal laws relating to the tobacco prevention and control executive commit- breastfeeding and addresses workplace breastfeeding poli- tee to submit a biennial budget to OMB as required by cies. Led by the advocacy of Dr. Joan Connell, the bill other state agencies. The bill also requires the executive states: “If the woman acts in a discreet and modest man- committee to report to the Legislative Council’s Budget ner, a woman may breastfeed her child in any location, Section quarterly on the implementation of the compre- public or private, where the woman and child are other- hensive tobacco prevention and control plan and outcomes wise authorized to be.” achieved, for the 2009-10 interim, and includes language SB 2168 introduced by Sen. Judy Lee revises the state’s ensuring that the executive committee is a state agency. coroner laws, including the expansion of eligibility for NDMA was also involved in the successful efforts serving as a coroner to all individuals who meet the quali- to adopt the Uniform Emergency Volunteer Health fications, training and continuing education requirements Practitioners Act in HB 1073. determined by the State Forensic Examiner. Dr. John Baird Many public health issues did not survive the session. was instrumental in developing the legislation and moving For example, the legislature defeated proposals for prima- it through the legislative process. ry seat belt enforcement, a prohibition of wireless commu- SB 2174 introduced by Sen. Joan Heckaman creates an nications while operating a motor vehicle, restrictions on autism spectrum disorder task force that will develop a minors while driving, an expansion of the state’s smoke- state autism spectrum disorder plan and present the plan free workplace law to bars and hotel and motel rooms, and to the governor and the legislative council before July 1, a prohibition on smoking in vehicles when an individual 2010. aged sixteen or younger is present in the vehicle. SB 2412 introduced by Sen. Ray Holmberg appropri- ates general funds for a grant to the ND Fetal Alcohol • Support physician scope of practice and oppose Syndrome Center. inappropriate challenges to that scope of practice. SB 2333 creates a regional public health network. Many bills were introduced this session looking to expand SB 2048 was enacted mandating hospital participation scope of practice for allied health professionals. NDMA in the state’s trauma system. The bill implements a rec- successfully opposed, along with the ND Psychiatric ommendation of the American College of Surgeons as a Society, HB 1488 which would have allowed psycholo- result of its evaluation of North Dakota’s trauma system gists to prescribe psychotropic medications. While the last April. Dr. Steve Hamar led the effort in advocating for issue of access to psychiatric care is of concern to many, the bill. The bill provides that, effective January 1, 2011, several legislators stepped up and argued on the House

8 NDMA CHECKUP floor that expanding psychologist scope of practice was not ate dispensing by Internet pharmacies and others. NDMA the answer, including Reps. Todd Porter, Louise Potter and testified to the committee on its participation in expressing Robin Weisz. physician views regarding the drafting of the bill, particu- NDMA monitored other legislation and sought amend- larly the need for assurance that the in-person examination ments to address concerns, including SB 2158 which requirement does not result in any unintended consequences allows advanced registered nurse practitioners to be for legitimate prescribing in the state. At the request of Medicaid primary care providers, HB 1145 relating to the NDMA and NDHA, the House amended the bill to remove a scope of practice of psychologists (proposed substance general prohibition on the use of prescription drug dispens- abuse scope expansion removed), and SB 2164 which ing machines. allows optometrists to dispense therapeutic contact lenses BCBSND Rate Filing Process – NDMA opposed SB 2306 and drug samples (with assurances of no expansion of cur- relating to the BCBSND effort to change the Insurance rent scope of practice). Department rate filing process. The bill was defeated. Hospitals as Primary Stroke Centers – HB 1339 requires • Monitor and take action as necessary on other legis- the Department of Health to designate qualified hospitals as lation important to physicians: NDMA monitored and/ primary stroke centers based on criteria established by the or sought amendments on various bills to protect physician Department. Dr. Shiraz Hyder was instrumental in advocat- and patient interests, including the following: ing for the bill with the American Heart Association. The bill also establishes a Stroke System of Care Task Force WSI Independent Medical Exams – NDMA supported to encourage and ensure the establishment of an effective legislation SB 2341 introduced by Sen. David O’Connell stroke system of care and the bill requires that Task Force to which requires WSI to make reasonable efforts to designate provide recommendations in that regard to the Department a doctor licensed in North Dakota to conduct the indepen- by April 1, 2010. The bill requires the Department to adopt a dent medical examination before designating a doctor from nationally recognized standardized stroke-triage assessment another state. Under the bill, WSI must make a reasonable tool, and states that it does not constitute a medical practice effort to designate a duly qualified doctor licensed in the guideline and may not be used to restrict the authority of a state in which the employee resides to conduct the exami- hospital to provide services and recognizes that “all patients nation before designating a duly qualified doctor licensed should be treated individually based on each patient’s needs in another state or shall make a reasonable effort to desig- and circumstances.” Funding for this initiative in the amount nate a duly qualified doctor licensed in a state other than of $472,700 was provided in the Health Department budget. the employee’s state of residence if the examination is Traumatic Brain Injury Registry – SB 2198 introduced by conducted at a site within 275 miles from the employee’s Sen. Tim Mathern requires physicians to report the diagnosis residence. of any traumatic brain injury to the Department of Health as Insurance Coverage for Alcohol-Related Injuries – part of the Department’s creation of a traumatic brain injury NDMA fully supported HB 1204 introduced by Rep. registry. The bill provides various avenues for providing ser- George Keiser eliminating North Dakota’s alcohol exclu- vices to individuals with traumatic brain injuries and their sion statute, ensuring health insurance coverage for injuries families. resulting while intoxicated or under the influence of any Forensic Medical Exams – SB 2216 introduced by Sen. narcotic. Stanley Lyson expands funding by the Attorney General Medical Peer Review Changes – SB 2403 introduced at for an acute forensic medical examination to include pre- the request of the North Dakota Healthcare Association liminary medical screenings that precede an acute forensic was enacted to revise the medical peer review law to allow medical examination, including a child forensic medical health care organizations such as NDHA to ensure confi- examination. dentiality of information used to improve and evaluate the WSI Structure – HB 1464 was introduced by Rep. Nancy quality of care. Johnson to restructure WSI under the Governor, making Regulation of Internet Pharmacies – NDMA participated the Board advisory in nature consistent with the Initiated in discussions with Attorney General Wayne Stenehjem Measure passed last fall. The bill revises the powers and in crafting SB 2218 introduced by Sen. Judy Lee which duties of the WSI Board of Directors and requires the Board criminalizes the dispensing of controlled substances and to provide annual, formal recommendations to the Governor other drugs made without a “valid prescription,” which regarding setting premium levels and providing premium would require an in-person medical evaluation with certain dividend distributions, legislation that affects WSI, and the exceptions. The bill is designed to regulate the inappropri- fund’s investment allocation.

JUNE 2009 9 10 NDMA CHECKUP Just What the Doctor Didn’t Order: Why Wills Alone Don’t Work For Most Physicians

convenience. Dr. Brown also has a $2,500,000 life insurance policy payable to his estate. He has $500,000 in his pension, $500,000 in stocks, and an office building interest of $500,000 (building is owned by his partnership with a total value of $2,500,000). Dr. Brown paid 50% total tax during his working years for federal and state tax obligations. Dr. Brown’s will directs that $1,000,000 go to his favorite charity, and the remainder be distributed outright amongst his 3 children in equal shares. Hence each child will inherit $1,500,000. What is wrong with this plan?

II. GOALS OF ESTATE PLANNING Estate planning is a global concept involving much more I. INTRODUCTION than the mere transfer of assets at death. It involves 1) Physicians have worked too hard and have sacrificed too planning for mental or physical incapacity while living, 2) much to throw it all away with an inadequate estate plan. transferring assets both during life and at death in a manner After undergraduate college, four years of medical school, a consistent with your personal values and philosophy, and 3) grueling residency lasting anywhere from three to eight years, protection of beneficiaries of your estate from ex-spouses, and often a fellowship, physicians enter practice with high lawsuits, creditors, other “predators,” and even themselves. debt and have to play catch-up to their college peers, who A will is about assets, whereas an estate plan is about people have already been in the workforce for years and have begun and passing on your legacy. A will is not effective until accumulating assets. People working 50 or even 60 hours a death; an estate plan begins now. With a properly construct- week in other occupations feel abused by their employers, ed estate plan, you can plan for incapacity and determine the even when paid overtime, and if such work is self-imposed, amount, manner and timing of distribution of your assets to are considered workaholics. Contrast this with resident physi- your beneficiaries both during life and after death. cians who have been mandated to decrease their workload The most neglected aspect of estate planning is failure to to a “mere” 80-hour workweek. Physicians accumulate sig- protect your own assets and those passed to your descen- nificant assets over the course of their career and have high dants. It is easier to protect assets you pass on to your liability, and special protections and strategies are needed to descendants than your own assets. A complete discussion of pass on and preserve those assets while minimizing the estate asset protection is beyond the scope of this article. Suffice tax bite. While a simple will may be adequate for Joe the it to say that it is relatively easy to protect assets passed to plumber, it is likely not adequate for you. your descendants from their creditors, ex-spouses, lawsuits, Scenario: Dr. Brown is an ENT surgeon with assets worth and other “predators.” Given the divorce rate over 50% $5,500,000. He came from humble beginnings and has and our highly litigious society, such scenarios are likely. worked his way up. He was still actively practicing but sud- This is not an attempt to avoid legitimate creditors, but is denly died from a heart attack and his will is being probated an attempt to preserve your beneficiaries’ assets for their (a court process that determines who gets what and makes benefit. Reduction of estate taxes, for those with a taxable sure his debts are paid). His wife died last year in a car acci- estate, is only one aspect of estate planning, albeit very dent and also had a will leaving everything outright to her important. There are a plethora of legal vehicles and strate- husband, including a $1,000,000 life insurance policy, on the gies to achieve all of the above. In essence, a well crafted advice of their attorney. Dr. Brown has three adult children, estate plan is not a form and is not simply about money and Sam, Bill, and Martha. Sam is an architect and married with saving taxes; it is an ongoing process implemented with the two children. Bill is a special needs child and lives in a group estate planning attorney as the quarterback, and may require home. Martha is single and financially irresponsible. Dr. the assistance of your accountant, insurance professional, Brown’s home is worth $500,000. Dr. Brown was depressed or financial advisor in order to pass on your legacy on your after his wife died and had Sam’s name put on the house for terms.

JUNE 2009 11 III. PITFALLS OF A WILL been over a year and the assets have not been distributed It is generally true that only one of three people have a because of a slip and fall judgment against Dr. Brown’s will; physicians in my experience do better. While a will partnership resulting in a lien on the office building. alone may be an adequate estate planning device for the Furthermore, Dr. Brown did not have an adequate exit plan worker with a small or average estate, it is inadequate for from the partnership in the event of death or disability, most physicians. The reason for this is not what a will does, so no funds are available to buy him out. Since his dad’s but what a will does not do. For many people, including phy- death, Sam’s wife has been thinking of divorce. She visits a sicians, it is not possible to achieve the goals of estate plan- divorce lawyer, who advises her not to file for divorce until ning listed above with only a will. Sam receives his inheritance and deposits the monies in their joint account. Meanwhile, Medicaid has gotten wind A. Probate of Bill’s windfall Probate is a court inheritance, and process that ensures has cut him off. all your final debts are Martha has never paid and your assets been real respon- are distributed, whether sible financially, or not you have a will. and just can’t A common miscon- wait “to get the ception is that a will big check.” avoids probate. A will does not avoid pro- B. Incapacity bate! Probate can be an A will does expensive and lengthy not provide for process, and is a mat- incapacity. If you ter of public record. become unable to Probate can take over a make financial, year to distribute assets personal and busi- while attorney fees are ness decisions, piling up, and can con- who will do this? sume 2-3% or more of a complex estate. Probate is essen- It is not automatic that your spouse will assume these func- tially a voluntary lawsuit you file against yourself, with your tions. If no one is legally designated to act on your behalf, own money, and if your will is contested, will be decided court intervention is required. This can consume thousands by an unknown judge, without you having any opportunity of dollars, take months, and cause unnecessary emotional to defend yourself or explain your intent. A will is not dif- strain. A durable power of attorney (DPOA), which legally ficult to contest since it is not legally binding until after your gives another person the authority to make financial and death. Accusations can be made by any beneficiary, and personal decisions and sign for you after incapacity, is a many years may have passed and any witnesses may be dead good head start. A DPOA may not be recognized by cer- or incompetent to testify themselves. tain financial or business entities, who may require yearly The only way to avoid probate is to place assets in joint updates, which cannot be done if you are already incapaci- ownership, in a living or revocable trust, or transfer them tated. A living trust avoids this problem for assets titled via beneficiary designations such as occurs in pensions, in the name of the trust, whereby the trustee or successor life insurance, or annuities. A trust is a separate legal entity trustee is essentially stepping into your shoes and signing whereby the owner of assets transfers legal title to a trustee as if they were you, not merely as your agent as is the case that holds property for the benefit of the grantor (creator) with a DPOA. of the trust or his or her heirs. A living trust is a trust set up Scenario: Dr. Brown named his wife as executor of his during the grantor’s lifetime, and is synonymous with a revo- estate. He failed to name additional replacement executors, cable trust. A living trust, unlike a will, becomes a legally and failed to have his will updated after his wife’s death. valid document the moment it is executed, and requires reti- Sam feels he is the most responsible person to be execu- tling of assets and other formalities that will act as proof of tor, but Martha is contesting this with the probate court as the grantor’s competence. Upon death, assets are transferred she feels the whole process is taking way too long, and she almost immediately without having a judge sign off. “wants her money now.” In the meantime, estate bills are Scenario: Dr. Brown’s probate is not going well. It has piling up with no one with authority to sign checks.

12 NDMA CHECKUP C. Joint Ownership controls. Many physicians will benefit from an irrevocable A will does not provide for the distribution of jointly life insurance trust (ILIT) which will keep such policies owned property. On death, jointly owned property passes out of their estates altogether. The laws governing pension immediately to the survivor. Joint ownership, while initially plans and IRAs are very complex, and scrupulous attention having sex-appeal, has its problems. There is double liability to detail is necessary in order to rollover pension plans into exposure to judgments, debts, and divorce. There may be IRAs, and to “stretch” out IRA distributions over the lifetime gift tax implications, inadvertent disinheritance of heirs, or of your children without triggering an inadvertent distribu- passing of property to unintended heirs. Most importantly, tion of the plan with the IRS demanding immediate payment joint ownership overrides both wills and trusts. Many people of income tax. If the rules are not followed, the IRS may don’t know this. The most common example is a jointly require the pension or IRA to be distributed within 5 years owned home. This may not be a problem for a stable long- of death or based on the oldest beneficiary’s life expectancy term marriage. However, many older adults who have lost a if multiple beneficiaries are listed. A well coordinated estate spouse and jointly title their home with one of their nearby plan must consider joint ownership and beneficiary designa- children for convenience, will inadvertently disinherit their tions on life insurance and pensions with provisions placed other children. in a will or living trust. Scenario: Dr. Brown’s home was jointly titled with Sam Scenario: Dr. Brown’s $2.5 million life insurance was pay- just prior to his death. At death, Sam now assumes full able to his estate, and was assessed 45% estate taxes, leav- title to the home as his dad’s interest extinguished upon his ing only $1,375,000 for his children. He could have easily death. This overrides the will transferring the home in equal put the insurance policy in an ILIT, which would have kept shares to Sam, Bill, and Martha. Sam’s divorce proceed- it completely out of his estate, with no estate taxes owed. He ing was deliberately delayed by his wife’s lawyer until the remembers his insurance salesman telling him insurance was inheritance was distributed. It was argued the home was not taxed, but this was only a half truth. Insurance does not now a marital asset as it was acquired during the marriage, incur income taxes, but it does incur estate taxes if part of and 50% of the equity in the home was given to Sam’s now the estate, as in Dr. Brown’s case. ex-wife by the divorce judge. The home had to be sold in a down market at a loss to pay off Sam’s ex-wife. This now E. Estate Taxes leaves $5,000,000 in the estate, with $1,000,000 going to A will does not necessarily save or eliminate, and may charity and $4,000,000 to be split 3 ways among Sam, Bill, increase estate taxes. A brief review of estate tax law is and Martha, or $1,333,333 each. Sam’s ex-wife now gets necessary to put this in perspective. An estate, from the IRS half of Sam’s $1.3 million. Bill and Martha now will inherit point of view, includes all assets - bank accounts, homes, life only $1.3 million instead of $1.5 million. Martha is upset insurance, pensions, mutual fund and brokerage accounts, because Sam got a larger portion of the inheritance than business interests, real estate, etc. A taxable estate under she. current law is an estate with total assets over $3,500,000 in 2009, $0 in 2010 (estate tax is repealed), and back down to D. Beneficiary Designations $1,000,000 in 2011 and beyond. The estate tax rate is 45% A will does not direct distribution of assets at death requir- in 2009, 0% in 2010, and 55% in 2011. The amount that is ing beneficiary designations such as life insurance, annui- excluded from any estate tax is referred to in IRS speak as ties, qualified pensions, and IRAs. Beneficiary designations the applicable exclusion. This can be thought of as a “get out override a will and are very difficult to challenge legally. of estate tax free card” issued by the IRS to every taxpayer. They must be taken into account when drafting a will so that However, you either use it or lose it; it is not transferable, all of your assets, both those inside and outside of a will, even to a spouse. There are proponents in Washington who are transferred according to your wishes. Failure to update wish to raise or lower or keep stable the applicable exclusion such designations due to changing circumstances, such as or even make it portable between spouses. Congress may remarriage, may result in assets going to your ex-spouse, or well change the law this year. Stay tuned. Since life insur- even to your second spouse, and eventually to your second ance and pensions are included in the definition of one’s spouse’s children, thus disinheriting your own biological estate, and if the applicable exclusion does indeed decrease children. to $1,000,000 in 2011 as is the current law, most physicians Physicians are likely to have higher insurance levels and will possess taxable estates. pensions than most people, and therefore such policies have In a taxable estate, the applicable exclusion is wasted a greater likelihood of putting their estates over the limit and where a will leaves everything to the surviving spouse. This incurring estate tax, or resulting in their assets not being dis- is the worst result, since this problem can easily be avoided tributed according to their wishes if it is assumed their will by the first spouse to die leaving up to the applicable exclu-

JUNE 2009 13 sion amount in a bypass trust, with language mandating two-fold beneficial effect: 1) highly appreciated assets will that income and principle be available for health, education, grow outside of your estate unburdened by income taxes, and maintenance, and support of the surviving spouse. 2) payment of income taxes from the grantor’s estate further In taxable estates, assets should be equalized to take full reduces the grantor’s taxable estate upon death of the grantor. advantage of the applicable exclusion by setting up bypass Scenario: Dr. Brown will pay estate taxes of 45% on trusts for the surviving spouse. It should be understood that anything above the applicable exclusion in his year of not leaving everything outright to your spouse will not dis- death, which is $3,500,000 in 2009. His estate is valued at inherit the spouse. There are legal ways to leave everything $5,500,000. Dr. Brown will take a $1,000,000 deduction FOR your spouse, rather than TO your spouse, thereby tak- for the portion going to charity. Therefore he will pay taxes ing advantage of your applicable exclusion. Language can on the remaining $1,000,000 or $450,000 tax. Dr. Brown be inserted in the controlling documents such that the assets should have equalized his assets with his wife, and she could will only be available to the surviving spouse until his or her have utilized a bypass trust for her husband’s benefit until death, and then and only then can other beneficiaries (i.e. he died, then to the children. This would have resulted in no children) be entitled to distributions. This should mitigate estate taxes for either of them. There is a technique, where any concerns among physicians that their surviving spouse assets are unequally distributed between spouses, for the will die in poverty. wealthier spouse to place approximately half the assets in a There are a variety of techniques using trusts whereby living QTIP (qualified terminable interest in property) trust the estate of a married couple can be reduced, taking full where the wealthier spouse maintains control, but the assets advantage of each spouse’s applicable exclusion, and where are available to the other spouse and included in the other all assets are still available for both spouses while living and spouse’s estate. This too would have been an option for the then for the surviving spouse until his or her death. Trusts are Browns. An ILIT would also have worked. The Browns could used for probate avoidance, estate tax reduction, asset protec- have utilized numerous techniques to completely eliminate tion, and management of assets. While a trust set up during estate taxes. In 2011, if the applicable exclusion remains at lifetime avoids probate, a trust set up in a will, called a testa- $1 million, the estate tax bite for Dr. Brown would have been mentary trust, is subject to probate. Types of trusts that will 55% of $3.5 million ($5.5 million –$2 million [$1 million provide for a spouse and simultaneously save estate taxes are exclusion + $1 million charitable donation]) or $1,925,000! marital trusts, qualified terminable interest in property trusts Other techniques include family limited partnerships (QTIPs), bypass trusts, and irrevocable life insurance trusts (FLPs, which take advantage of lack of marketability and (ILITs). minority discounts), lifetime gifting (currently $13,000 annu- A grantor trust is a special type of irrevocable trust where ally to an unlimited number of persons without incurring gift the grantor, the one who funds the trust, is personally tax), and charitable gifting. FLPs are beyond the scope of this responsible for paying income taxes on trust income, rather article. than using the trust assets to pay income. Examples include Lifetime gifting, if over the $1,000,000 applicable lifetime grantor retained annuity trusts (GRATs), grantor retained gift tax exclusion, will incur payment of gift tax at a 45% income trusts (GRITs), grantor retained unitrusts (GRUTs), rate, but gift taxes are tax-exclusive, meaning that gift taxes and qualified personal residence trusts (QPRTs). This has a paid are not included in the gift, whereas estate taxes are

14 NDMA CHECKUP tax-inclusive, i.e. paid from money included in the estate. assets placed in trust for beneficiaries can have language What this means is the tax rate is effectively lower than the consistent with a special needs trust, so such assets would stated rate when making a gift as opposed to distribution of not cut the beneficiary off from Medicaid or SSI (supple- the same amount from an estate. For example, assuming the mental security income). Keep in mind that the stronger the $1,000,000 lifetime gift tax exclusion has been exhausted, an language conferring protection from creditors or potential additional gift of $1,000,000, incurs a gift tax of $450,000; creditors, the more restrictions placed upon distributions to hence a total of $1,450,000 is required by the donor to make the beneficiary. the $1,000,000 gift. However, in a taxable estate, for amounts Scenario: Dr. Brown could have simply directed in his will transferred above the applicable estate tax exclusion, it that all his assets be distributed in equal shares in separate would require $1,818,181 to distribute that same $1,000,000, trusts for his children’s benefit. In the alternative, Dr. Brown since 45% estate tax on $1,818,181 is $818,181. The differ- could have had a living trust divided into equal shares for his ence in tax paid is $368,181. Hence at a 45% gift and estate children upon his death. Sam’s and Martha’s trusts should tax rate, the effective gift tax ultimately paid is 31% of the have included language for creditor protection and spend- total amount required to pay the gift, even though the rates thrift clauses. Such language would likely have prevented are ostensibly identical. Lifetime gifting therefore has a tax Sam’s wife from obtaining any of Sam’s inheritance during advantage over transferring assets at death, as well as the the divorce. Martha, the spendthrift, would be subject to opportunity for the donor to mentor and teach the recipient the discretion of a trustee for any distributions made to her. how to handle money, and to cut off any recipient deemed Bill’s trust would have language making it a special needs incompetent or irresponsible in financial affairs. A downfall trust, and Medicaid payments to Bill would not be cut off. Dr. of gifting is running out of money before you die. However, Brown could have placed his home in a trust with Sam as the gifting of assets does not cause a step-up in basis (basis is trustee, which would trifurcate upon Dr. Brown’s death into the value you originally paid for an asset) at death, whereas separate trusts for Sam, Bill, and Martha as beneficiaries, assets passing at death carry with them a step-up in basis (i.e. again with creditor protection, special needs, and spendthrift the new stepped up basis will be the value at time of death, language. This would have enabled Sam to engage in legal not the original cost of the asset), meaning there will be high- transactions regarding the home, would likely have prevented er capital gains taxes on assets subsequently sold if received his ex-wife from claiming it as a marital asset, and would through gifting rather than from an estate. This will likely have equally divided the proceeds for Sam, Bill, and Martha. not override the potential taxes saved through gifting, but this The trustee could have decided to wait for sale until the real may not be true if capital gains tax rates are increased. estate market rebounded. Scenario: Lifetime gifting and a family limited partnership would also have worked for the Browns. IV. CONCLUSION There are a number of vehicles that can be utilized for It is evident that having only a will may have dire unin- charitable gifting, such as charitable remainder and lead tended consequences in terms of passing on and preserving trusts, which are very favorable to the taxpayer. Estate plan- your legacy. It is vital that physicians consult with an attor- ning for taxable estates, using the techniques above, is best ney with in-depth knowledge of sophisticated estate planning done by an attorney concentrating in this highly complex techniques to ensure their legacy is passed on and their assets area, as formalities must be adhered to and the laws are con- protected. Disclaimer: This article is not intended as leagal stantly changing. advice. Each reader should consult his or her own attorney.

F. Protection of Beneficiaries Mark Monasky, MD, JD, FACS, FCLM is a board certified neurosurgeon practic- A will does not protect beneficiaries from creditors, ex- ing at St. Alexius Hospital in Bismarck spouses, lawsuits or bankruptcy if outright distributions of and a practicing attorney at Bormann & assets are made to the beneficiaries. This is true of most Myerchin, LLP in Bismarck with a prac- wills. Wills can be drafted such that beneficiaries receive tice limited to estate planning, asset pro- their interests in trust, with carefully drafted language with tection, wills and probate, and representa- strong creditor protections in place. Living trusts can also be tion of physicians with licensure and other drafted so that at death there is a division into subtrusts with professional issues. He is a member of creditor protection for the beneficiaries. As a matter of public the American Bar Association Section of policy, beneficiary assets placed in trust cannot be protected Real Property, Trust & Estate Law, a member of Wealth Counsel, a from the following creditors: 1) IRS, 2) court order for child national association of estate planning attorneys, and fellow of the support, and 3) court ordered alimony. Such assets, however, American College of Legal Medicine. The author can be contacted are considered sole and separate property and not part of the at 250-8968 or [email protected]. Mailing address marital estate if proper safeguards are followed. Furthermore, Bormann & Myerchin 418 E. Broadway, Bismarck, ND 58501.

JUNE 2009 15 ND Legislative Assembly Enacts Health Information Technology Bill

DMA is currently involved in of health information systems for the to health care entities to assist Nimplementation of legislation purpose of improving health care those entities in improving their enacted by the 2009 ND Legislative quality, patient safety, and the overall health information technology Assembly to encourage the build- efficiency of health care and public infrastructure; ing of health information technol- health services. 4) Facilitate and expand electronic ogy (HIT) infrastructure and facili- The new state HIT office is required health information exchange in tate electronic health information to: the state, directly or by awarding exchange. SB 2332 creates a Health 1) Apply for federal funds that may grants; and Information Technology Advisory be available to assist the state 5) Establish application processes Committee comprised of designated and health care providers in imple- and eligibility criteria for and government officials and persons menting and improving health accept and process applications appointed by the Governor, with a information technology; for loans and grants that are con- primary duty to collaborate with and 2) Establish a health information sistent with federal requirements make recommendations to a new technology loan program to pro- associated with federal funds Health Information Technology Office vide loans to health care provid- received. created in the state’s Information ers for the purpose of purchasing Technology Department. The new and upgrading certified electronic The bill creates three funds – a office is required to implement health record technology, training Health Information Technology a statewide interoperable health personnel in the use of such tech- Loan Fund in the Bank of North information infrastructure that is nology, and improving the secure Dakota, a Health Information consistent with emerging national electronic exchange of health Technology Planning Loan Fund, standards; promote the adoption and information; and an Electronic Health Information use of electronic health records and 3) Establish a health information Exchange Fund. The bill transfers $8 other health information technolo- technology planning loan pro- million from the earnings and prof- gies; and promote interoperability gram to provide low-interest loans its of the Bank of North Dakota to the Health Information Technology Loan Fund to match with federal stimulus funds on a 5 to 1 basis or to the Electronic Health Information Exchange Fund to match federal stimulus funds on a 10 to 1 basis – a total appropriation of up to $88,000,000 of combined state and federal funds. An additional appropriation of $5 million from the earnings and profits of the Bank of North Dakota will become available for planning loans based on dem- onstrated need. The bill includes an additional appropriation of $350,000 from the general fund to the Information Technology Department to defray costs of the advisory committee and Health Information Technology Office.

16 NDMA CHECKUP Eide Bailly Understanding the Health Care

By Ralph Llewellyn, CPA Provisions of the Stimulus Package

he American Recovery and Reinvestment Act of The following is an example of this calculation for a PPS T2009 was signed by President Obama on February hospital: 17, 2009. This legislation provides more than $180 billion in new health care related spending, including $23 bil- • 2,000 discharges lion for modernizing Health Care Information Technology • 4,000 Medicare and Medicare Advantage days (HIT). Navigating the maze of rules, technical require- • 7,000 total days ments and timing for obtaining funding is a challenging • $100 million hospital charges task for most providers. Many software vendors are using • $2 million Charity Care the legislation as a tool to entice customers to purchase • Year 2 upgrades or implement new solutions. Before acting on any of these suggestions, it is critical that providers under- Total Payment: stand the terms of the legislation, including incentives, (2,000,000+((2,000-1,149) *200)) *(4,000/ Electronic Health Record (EHR) requirements and the role (7,000*(100,000,000-2,000,000)/100,000,000)) of Health Information Exchanges (HIEs). *3/4 = $949,067

Incentives If the facility’s first year of eligibility is after 2013, the transition factor is the same as a facility with a first pay- The legislation includes financial incentives to providers ment in 2013. If the first payment year is after 2015, the for adoption and meaningful use of certified EHR technol- transition factor is 0. PPS hospitals that fail to become a ogy. These incentives vary, based on the type of entity and meaningful EHR user by 2015 will see their Market Basket begin during fiscal year 2011. Adjustments reduced 33 1/3 percent in 2015, 66 2/3 percent in 2016 and 100 percent in 2017. Prospective Payment System (PPS) Hospitals Payment for PPS hospitals begins with a base payment Critical Access Hospitals (CAHs) level of $2 million per facility. Facilities with 1,150 to CAHs are allowed to expense costs associated with the 23,000 discharges receive an additional $200 per dis- purchase of certified EHR technology in a single year, charge for each discharge in this range. The sum of this versus depreciating these costs on the cost report. This amount is then multiplied by the Medicare Share. A pro- amount is adjusted by multiplying the cost by the sum of the vider’s Medicare Share is calculated as a percentage. The Medicare Share and 20 percentage points. This sum is lim- numerator is the inpatient days for Medicare and Medicare ited to 100 percent. A prompt lump sum payment is paid to Advantage patients. The denominator is the product of the the hospital and is subject to reconciliation. total inpatient days and the hospital charges, less charity The facility can receive payments for up to four years. care divided by hospital charges. This total is adjusted by No payments are made after 2015. In addition to the lump the transition factor, as follows: sum payments, the legislation provides for penalties for CAHs that do not become meaningful EHR users by 2015. 1. Year 1 = 1 Adjustments will reduce the 101 percent of cost calculation 2. Year 2 = 3/4 to 100.66 percent in 2015, 100.33 percent in 2016 and 100 3. Year 3 = 1/2 percent in 2017. 4. Year 4 = 1/4 5. Subsequent Years = 0 Eligible Professionals Eligible physicians can obtain incentive payments for up to five years. The total payments for the five years can

JUNE 2009 17 range from $2,000 to $44,000, depending on the year of adoption. The maximum incentive in any year is $18,000 if adoption occurs in 2011 or 2012. Adoption must occur before 2015, and no incentive payments are available after 2016.

EHR Requirements

In order to qualify for incentives, providers (for hospitals or physician practices) will need to have a “meaningful use” implementation of an EHR solution. Some provisions of the meaningful use designation are defined in the legislation, including use of ePrescribing (as defined by the HHS Secretary), being connected to a Health Information Exchange (HIE) and an ability to submit data on clinical quality measures (as specified by the HHS Secretary) are all specific requirements of the meaningful use of EHR provisions. There are many additional potential requirements for meeting the meaningful use requirements of the legislation. These are areas not specifically defined by statute, but will be determined by several federal advisory committees. Examples of potential requirements include using a certified EHR product, use of Computer Physician Order Entry (CPOE) capabilities and implementation to Stage 4 of the HIMMS EMR Adoption Model.

The Role of HIEs

A Health Information Exchange (HIE) is a mobilization of health care information electronically across organizations within a region or community. In most regions or communities, HIEs are not currently in place to meet this key requirement for obtaining incentive payments. However, given the financial incentives at stake with the stimulus, legislation market forces and state/regionally funded initiatives are likely to emerge at a rapid pace in the coming months. HIEs will play a crucial role, not only meeting requirements to obtain funding, but in achieving the vision of truly portable electronic medical records within regions and the nation. Providers should look for opportunities to actively participate in any regional or statewide efforts in this area.

Ralph Llewellyn, CPA, is a partner at Eide Bailly LLP with more than 16 years health care experience. He can be reached at [email protected] or 701.239.8594.

18 NDMA CHECKUP WILL YOU BE READY FOR HITECH HEALTH CARE?

By Tracy Vigness Kolb*

n February 17, 2009, the American Recovery & OReinvestment Act (ARRA) was signed into law. Title XIII of ARRA is the Health Information Technology for Economic and Clinical Health (HITECH) Act, legislation by a technology standard that renders it unusable, unread- intended to improve the privacy and security requirements able, or indecipherable to unauthorized individuals and is of the Health Insurance Portability and Accountability Act developed or endorsed by a standards developing organiza- (HIPAA). All of the new changes under HITECH are not yet tion that is accredited by the American National Standards in effect, but compliance efforts should begin now. Institute. Guidance has been issued from the Secretary of Health & Human Services (HHS) specifying the technologies BREACH NOTIFICATION and methodologies that render PHI unusable, unreadable, or One of the most significant changes to the privacy require- indecipherable. Two methods were identified–encryption and ments is a breach notification requirement for all PHI that is destruction. unsecured. The term “breach” under HITECH means: HITECH also sets forth the methods of breach notification, for example, first-class mail; the content of notification; “the unauthorized acquisition, access, use, or disclosure and additional notice requirements depending on the number of protected health information which compromises the of individuals affected. For example, if the breach involves security or privacy of such information, except where an more than 500 individuals, a covered entity must immedi- unauthorized person to whom such information is dis- ately notify HHS and media outlets. closed would not reasonably have been able to retain such The breach notification requirements will take effect for information.” breaches occurring 30 days after the Secretary of HHS pro- mulgates final regulations, which must occur no later than A breach does not include “any unintentional acquisition, August 17, 2009. But compliance with this federal provision access, or use of protected health information” by employees should begin now and should include an assessment of com- of covered entities or business associates if it was in good pliance with North Dakota’s state breach notification law, faith and within the course and scope of employment and the which has been in effect since 2005, and the Federal Trade information is not further acquired, accessed, used, or dis- Commission’s Identity Theft “Red Flags” Rule, which will be closed; or “any inadvertent disclosure from an individual who enforced August 1, 2009. is otherwise authorized to access protected health information” at a covered entity or business associate and the infor- TIERED PENALTIES AND DAMAGES mation is not further acquired, accessed, used, or disclosed. Other provisions of HITECH take effect immediately, like If there is a breach, a covered entity will be required to the increased penalties for violations and the authority of notify affected individuals no later than 60 days after dis- state attorneys general to sue on behalf of individuals injured covery of the breach that unsecured PHI has been, or is by HIPAA violations. A tiered penalty structure has been cre- reasonably believed to have been, accessed, acquired, or ated that is based on the nature and extent of the violation disclosed as a result of the breach. Breach notification only and the nature and extent of the harm resulting from the vio- applies to unsecured PHI, which is PHI that is not secured lation. The law provides as follows:

JUNE 2009 19 Tier A In addition to civil monetary penalties, HITECH clari- If the person did not know and by exercising reasonable fies that employees of covered entities may be prosecuted diligence would not have known that he or she violated criminally and requires that HHS: 1) formally investigate the law, $100 for each violation, except the total amount and impose penalties for HIPAA violations that are due to imposed on the person for all such violations of an iden- “willful neglect” and 2) conduct periodic audits to determine tical requirement or prohibition during a calendar year, whether covered entities are complying with the law. may not exceed $25,000; Covered entities are now also exposed to potential lawsuits and damages for violations of the law. HIPAA did not autho- Tier B rize an individual to sue a covered entity for a violation, but, If the violation was due to reasonable cause and not under HITECH, state attorneys general have been granted the willful neglect, $1,000 for each violation, except the authority to sue a covered entity in federal court on behalf of total amount imposed on the person for all such viola- residents of the state when one or more of residents has been tions of an identical requirement or prohibition during a or is threatened or adversely affected by a HIPAA violation. calendar year, may not exceed $100,000; Damages can be awarded but may not exceed $25,000 for all violations of an identical requirement or prohibition during a Tier C calendar year. Costs and reasonable attorney fees may also be If the violation was due to willful neglect and was cor- awarded to the state. rected, $10,000 for each violation, except the total amount imposed on the person for all such violations of BUSINESS ASSOCIATE AGREEMENTS an identical requirement or prohibition during a calendar Contracts between covered entities and business associ- year, may not exceed $250,000; ates will need to be revisited under HITECH. HIPAA applies to covered entities and, to some extent, business associates Tier D through business associate agreements. The reach of HIPAA If the violation was due to willful neglect and was not will now extend beyond covered entities because HITECH corrected, $50,000 for each violation, except the total applies the privacy and security requirements directly to amount imposed on the person for all such violations of business associates and subjects them to the same civil and an identical requirement or prohibition during a calendar criminal penalties to which covered entities are exposed. As a year, may not exceed $1,500,000. result, business associate agreements may need to be updated

20 NDMA CHECKUP COMPLIANCE DEADLINES FOR CERTAIN SELECTED HITECH PROVISIONS

Breach notification HHS must issue interim final regulations within 180 days, or no later than August 17, 2009. Breach notification requirements will apply to breaches 30 days after the final regulations are published.

Tiered penalty structure Immediately (February 17, 2009).

Application of criminal February 17, 2010. penalties

Enforcement in cases of Applies to penalties imposed on or after February 17, 2011. willful neglect HHS must issue regulations within 18 months.

Enforcement by state Immediately (February 17, 2009). attorneys general

Application of HIPAA February 17, 2010. privacy and security rules to business associates

Accounting of disclosures For covered entities acquiring electronic health records (EHRs) as of January 1, 2009, applies to disclosures made from such records on or after January 1, 2014. For covered entities acquiring EHRs after January 1, 2009, applies to disclosures made on or after January 1, 2011, or the date the entity acquires an EHR, whichever is later.

Restrictions on disclosures Immediately (February 17, 2009). of PHI

Individual access to PHI in February 17, 2010. an EHR

Sale or marketing of PHI HHS must issue regulations within 18 months. or modified. It is anticipated there will be guidance on this the years since HIPAA, HHS’ Office of Civil Rights (OCR) issue from HHS before the provisions take effect in February has been criticized for not adequately enforcing HIPAA. 2010. Those efforts are expected to change, particularly in light of two provisions under HITECH: 1) any civil penalty or mon- ACCOUNTING OF AND etary settlement collected for a violation will be transferred RESTRICTIONS ON DISCLOSURES to OCR to be used for purposes of enforcement, and 2) an Other important provisions of HITECH include: individual who is harmed by a HIPAA violation may receive • providing individuals the right to an accounting of disclo- a percentage of any penalty or settlement. The methodology sures through an electronic health record made by a covered under which individuals may receive a percentage must be entity for treatment, payment, and health care operations; established by regulations from HHS in three years, or by • requiring covered entities to restrict disclosure of an indi- February 17, 2012. vidual’s PHI if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the CONCLUSION PHI pertains solely to a health care item or service for which This article is not intended to be an exhaustive analysis of the health care provider has been paid out of pocket in full; HITECH, only to highlight the more significant changes as • prohibiting the sale of an individual’s PHI without autho- they apply to covered entities. More guidance and regulations rization; are needed, and will be forthcoming from HHS, to explain • requiring covered entities to obtain an individual’s autho- and better understand the law. But, to be ready for HITECH, rization to use PHI for marketing and fund-raising activities; covered entities should begin their compliance efforts now. and Becoming familiar with HITECH and the various compliance • requiring HHS to issue guidance on what constitutes the deadlines is a good first step toward formulating a strategy “minimum necessary” standard for use or disclosure under and plan for achieving compliance with each requirement. the privacy rule. *Tracy Vigness Kolb is a partner with Zuger Kirmis & Smith ENFORCEMENT in Bismarck, practicing in medical malpractice defense and Covered entities should expect there will be increased healthcare law. enforcement and oversight of their compliance programs. In

JUNE 2009 21 Your NDMA and AMA are working for you every day. These are some of the more significant recent activities of your state and national medical societies.

Your NDMA and AMA are working for you every day. These are some of the more significant recent activities of your state and national medical societies.

North Dakota Medical Association

61st ND Legislative Assembly – Advocated every day in the 2009 ND Legislative Assembly on behalf of North Dakota physicians and patients, accomplishing a partial rebase of Medicaid physician payments, defeating legislation that would have repealed the state’s cap on non-eco-

nomic damages and other outcomes (see article on Congressman Earl Pomeroy receives the 2008 Friend of page 5). Medicine Award in his Washington, D.C., office. l to r: Dr. Changing Rules on Verbal Orders – NDMA is pursuing Robert Thompson, Dr. Kim Krohn, Dinah Goldenberg and Bruce Levi. changes to Health Department administrative rules regarding the authentication of telephone and verbal orders in letters: Letter to President Obama urging support for Action response to CMS interpretive guidelines. Plan that outlines important steps the medical profession Congressional Delegation – NDMA President Robert will undertake in the coming months to engage and support Thompson and Vice President Kimberly Krohn met with physicians in using patient-centered measures and health members of the ND Congressional Delegation in March, information technology that empowers them to provide discussing health care reform initiatives and the need for high quality, cost-effective care across the continuum of repeal of the sustainable growth rate. Ongoing discussions care; Letter to the National Board of Medical Examiners have ensued discussions with Sen. Kent Conrad, Sen. expressing dismay over the organization’s involvement Byron Dorgan and Rep. Earl Pomeroy by NDMA physi- in the Doctor of Nursing Practice certification examina- cian leaders on federal health care reform. tion process which is used to draw untrue comparisons of BCBSND Contracts – Worked with the ND Insurance equivalency between physician and DNP examinations; Department to accomplish changes in BCBSND physician Letter to the Chairman of the Federal Trade Commission and hospital contracts to prohibit unilateral withholding or strongly objecting to including physicians as “creditors” for reduction of payments. purposes of the implementation of the mandatory identity North Central Medical Conference – Participated in theft prevention programs (Red Flag Rules); Letter to the the regional caucus of north central states for the AMA CMS Acting Administrator with formal comment on recent at its annual meeting in Minneapolis, including the states and proposed changes to Medicare’s Quality Improvement of North and South Dakota, Minnesota, Iowa, Nebraska, Organization (QIO) case review program. and Wisconsin. NDMA’s Alternate AMA Delegate Robert POLST – NDMA agreed to support efforts to imple- Beattie serves as Conference president through next year. ment statewide the Physician’s Orders for Life Sustaining AMA Sign On Letters – NDMA “signed on” to AMA Treatment (POLST) form.

22 NDMA CHECKUP American Hospital Acquired Conditions Policy – On May 1, the Medical Association CMS released its FY2010 Inpatient Prospective Payment System (IPPS) Proposed Rule. As a result of AMA advo- Health Care Reform – The cacy efforts and those of others in the medical community, AAMA is aggressively involved the agency is not proposing to add new categories of non- in advocacy efforts related to health care reform. Recently, payable Hospital Acquired Conditions (HACs) at this time. the AMA sent comments to Max Baucus (D-Mont.), chair- Rather, it is encouraging public dialogue about refining man of the U.S. Senate Finance Committee, and Charles the HAC list. The AMA has strongly advocated that before Grassley (R-Iowa), the committee’s ranking Republican, the HAC non-payment policy is expanded, the agency on the policy options papers released outlining proposals should analyze the impact of the current program. to reform the health care delivery system and addresses FDA Regulation of Tobacco – Both the House of key physician policy issues such as Medicare physician Representatives and the Senate have passed H.R. 1256, the payment options for expanding insurance coverage, and “Family Smoking Prevention and Tobacco Control Act. potential sources for financing reform efforts. The legislation would provide authority to the Food and Delay of FTC Red Flag Rule – Due to aggressive AMA Drug Administration to regulate the manufacture, sale, advocacy, the Federal Trade Commission (FTC) voted to distribution and marketing of tobacco products with the delay the implementation of the Red Flags Rule from May primary goal of reducing youth and teen smoking. The 1 to August 1. The AMA will continue its efforts to con- AMA supports H.R. 1256 and is working to secure its vince the FTC and Congress that physicians are not “cred- enactment. The House is expected to consider the Senate- itors” under the Fair and Accurate Credit Transactions passed version in the near future, which is nearly identical (FACT) Act of 2003, and therefore, should not be subject to the House version. to the regulation.

NDMGMA MedicalNorth Group Management Dakota Association By Rosemarie Kuntz, President pring has finally arrived. The between the board and the member- completed a membership drive that SLegislature has gone home. ship, recruitment, promote National produced small increases in both Thanks to all those who got involved MGMA, promote meetings and other individual and network member- in the legislative process. Hopefully educational opportunities and a meth- ships. Membership is everyone’s you have recovered from the flooding od of recruiting new vendor support responsibility. Invite someone to join and will be able to enjoy the beauti- by offering web advertising space. NDMGMA and attend the Annual ful spring weather. Along with the launching of the Conference. Membership information Your NDMGMA board and sub- website we are in the beginning can be requested through the NDMA committees have several projects in stages of developing a program to office. various stages of completion. State increase vendor and sponsor sup- The Conference Committee Chapters from the Midwest Section port for our organization. We could is currently working on putting have agreed to financially support use your help identifying national, together the agenda for the Annual the development and maintenance of regional and local suppliers. Take Conference. The Payer Update is a NDMGMA Website. Our goal is to a moment to send name, address back and we will host a Technology have this project completed before and contact information to rkuntz@ Summit. The conference is scheduled the Annual Conference. The website primecare.org. for September 24-25 in Bismarck. will be used as a communication tool The Membership Committee has Save the dates on your calendar now!

JUNE 2009 23 By Bruce Levi, Executive Director

The Winds of Change he winds of change are blowing over the health care Congressional Delegation to ensure that ND impacts are Tlandscape in North Dakota. Many new faces are explored fully with respect to any federal proposals being already here as new administrative leadership comes to considered, and that current ND concerns relating to several health care systems and hospitals, and leadership Medicare payment disparities are also addressed. We will positions at the ND Healthcare (Hospital) Association, also continue to work with our state legislators on issues UND School of Medicine & Health Sciences, Workforce they raised for further interim study in the coming months Safety & Insurance, UNDSMHS Center for Rural Health, prior to the 2011 legislative session. and BlueCross BlueShield of North Dakota. These new Whatever your views on the need for health care reform leaders will shape the future of health care in North or how best to do it, we must listen diligently to these Dakota and we welcome them with their new ideas and winds of change. Whatever the proposed outcome, our energy to the task. role is to actively advise our political leaders on potential The winds of change are blowing over the national land- impacts to our state and to your medical practice. scape as well. President Obama and Congressional leaders continue the push for health system reform. The President State Legislative Outcomes is urging Congress to pass legislation by July 31. In his remarks, the President outlined his three main goals for I encourage you to review the work of your Legislative reform, saying, “first, that the rising costs of health care Assembly in the summary article provided in this issue of have to be brought down; second, that Americans have to Checkup, as well as the separate report e-mailed to you. be able to choose their own doctor and their own health If you don’t receive NDMA e-mail, let us know. Most of plan; and, third, all Americans have to have quality, afford- our ongoing communication with members now occurs by able health care.” He added, “We’ve got to get it done this e-mail. year, both in the House and the Senate. We don’t have any The 61st ND Legislative Assembly was remarkable in excuses.” the breadth of support from legislators for addressing the I encourage you to read the three “options papers” put many health care challenges we face in this state. There out for comment by the Senate Finance Committee, as ref- were many legislator “champions,” on many issues. Please erenced in Dr. Thompson’s article, and familiarize yourself take time when you can to express appreciation to your with the broad scope of potential reform initiatives and the legislators. This was a particularly difficult session with new language of health care reform being bantered back flooding and federal stimulus funding issues, and your and forth in Congress. The Senate Finance Committee citizen Legislative Assembly worked admirably across expects to mark up legislation in June. An outline frame- chambers and across the aisle and with the Governor’s work for reform has developed among the three commit- office to forge agreement on many issues that impact your tees with health care reform jurisdiction in the House. daily practice. Sen. Ted Kennedy recently introduced health care reform One of our major priorities this session was the rebase legislation and there is a Senate-House Republican version of Medicaid physician and hospital payments. This effort of health care reform as well. was facilitated primarily by efforts last session to garner Our goal at NDMA is to work closely with our funds for a rebasing study by independent consultants

24 NDMA CHECKUP and earlier studies including the Governor’s 2004 Medicaid Task Force. The resulting rebase methodologies became the NDMA/NDHA Medicare underlying basis for argument this session that the time for Payment Task Force rebasing had come. Increasing physician payments from 51% to almost 89% of cost, based on the methodology The Medicare Payment Task Force comprised of repre- developed during the 2007-08 interim, is a significant $40 sentatives of NDMA and the ND Healthcare (Hospital) million state and federal investment by your legislators in Association in April finalized its recommendations to Sen. the future sustainability of the state’s Medicaid program to Kent Conrad in exploring various options for Medicare ensure access to care for the most vulnerable of the state’s hospital and physician payment reform. Many of those people. Fee schedule updates will be published before options are reviewed in an options paper prepared by a July 1. Task Force consultant, Options for Improving Medicare Several studies were proposed for interim ND Legislative Payments to North Dakota’s Healthcare Providers by Council committees to address health care issues between Harold D. Miller [Options Paper), Center for Healthcare legislative sessions. Many of these studies were prioritized Quality and Payment Reform, February 2009. Please call by the ND Legislative Council on May 20, including these the NDMA office if you would like a copy of the options studies: 1) issues relating to unmet health care needs, 2) paper. access to psychiatric services and mental health commit- The Task Force, of which Dr. Thompson served as a co- ment procedures, 3) factors impacting the cost of health chair along with Medcenter One CEO Jim Cooper, recom- insurance, 4) the needs of pregnant minors and whether mended that the North Dakota Congressional Delegation additional education and social services would enhance the pursue multiple options for Medicare hospital and physi- potential for a healthy child and a positive impact for the cian payment reform, i.e., pursue modifications to the cur- minor, 5) consideration of workers compensation laws with rent physician payment system and hospital prospective respect to prior injuries, preexisting conditions and degen- system (GPCI adjustments; wage index); and ensure that erative conditions, 6) the emergency medical services fund- any new payment systems are appropriate for ND, assess- ing system, 7) the state immunization program, 8) working risks and rewards, and recognizing ND goals for cost force needs, and 9) the impact of traumatic brain injuries. containment and accountability. Both the NDMA and NDHA strongly agreed that the current Medicare payment BCBSND Rate Hike Approved system must be modified as follows, working toward geographic equity, reducing the increase in costs, and improv- In your last issue of Checkup, we explored the legal ing the quality and value of our health care system: implications of NDMA efforts to assist Insurance Commissioner Adam Hamm in ensuring that our state’s Hospitals: Create a wage index floor of 1.0; reduce the dominant health insurance carrier cannot unilaterally labor-related share for areas with a low wage index to reduce or withhold payments for medical services provided 50%; and extend Section 508 to reduce payment dispari- its policyholders. Since then, much change has occurred ties (expires September 30, 2009). and the BCBSND Board of Directors is engaged in a search for a new CEO. NDMA President Dr. Thompson Physicians: Make permanent the work GPCI thresh- and I recently sat down with Interim CEO Tim Huckle and old of 1.0; establish a threshold of 1.0 on the practice reexamined many of our shared concerns regarding future expense GPCI; establish an initiative to study and cor- health care reform, the need for amicable relationships and rect the methodology deficiencies in the GPCI calcula- other issues. Recently, Insurance Commissioner Hamm tions, including consideration of modification of the approved a 7.9% rate increase for BCBSND group poli- cost share weights in the practice expense GPCI; and cies after renewed negotiations with the carrier. According eliminate the Sustainable Growth Rate (SGR) formula to the Insurance Department, the 7.9% rate increase was (21% cut at year end) which cuts North Dakota physi- based on an 11.4% rate increase requested in February. cian payments due to higher spending in other parts of Included in that rate increase request was a trend assump- the country. tion equal to 8.5%. This trend assumption is a combination of factors including medical price inflation (which includes The Task Force also developed principles for our provider reimbursement increases); deductible/co-payment Congressional Delegation to consider in reviewing propos- leveraging; cost-shifting; utilization; and other more minor als for federal health care reform. In considering proposals factors. for any new payment systems, the Task Force recommend-

JUNE 2009 25 ed that Congress: rewards emphasize performance rather than improvement. • Ensure that North Dakota hospitals and physicians • Recognize implications of applying GPCIs to initia- are not penalized for providing services more efficiently tives for incenting quality (e.g., PQRI) and technology and at higher quality (hold harmless principle); that (e.g., e-prescribing, health information technology). North Dakota is not penalized for the value achieved from the value of teamwork and accountability from its Health Care Reform – current high quality, highly efficient health care system. Still Need to Repeal the SGR • Ensure that for any services currently under-provided in North Dakota (recruitment problems), that those This year’s annual report by the Medicare Board of under-utilization levels not be locked in to any baseline Trustees shows an increasingly bleak forecast for the expenditure levels that may be imposed. Medicare Trust Funds. The program already faced an • Ensure that new payment systems provide a means enormous gap between forecast revenues from Medicare for ND to rebuild and strengthen its primary care base. payroll taxes and expected costs, but the economic crisis • Ensure that performance measures emphasize cur- and high unemployment have exacerbated the problem. rent ND strengths. Ensure that performance thresholds The trustees, who issued their report May 12, also contin- are achievable and payment differentials are of sufficient ue to forecast steep cuts in Medicare physician payment magnitude to help offset ND’s payment disadvantages. rates due to the program’s sustainable growth rate (SGR), • Ensure that payments for physician services be more starting with a 21.5 percent cut in 2010 and growing to a than what they would have otherwise under the cur- total of 38 percent by 2014! rent payment system. Recognize that the current SGR The House and Senate passed the final congressional formula as a nationwide spending target has resulted in budget resolution, providing only a partial allowance for Medicare payment cuts for physicians in low spending eliminating the cost of replacing the SGR formula. The regions in large part because of high Medicare expen- AMA expressed its strong disappointment that the budget ditures in other regions; oppose any geographic (GPCI) agreement failed to facilitate complete repeal of the SGR. adjustments in future bundled physician payments unless Also of note, the agreement would allow Congress to use regional quality payments and regional spending targets procedural protections, known as reconciliation, for the are also included. consideration of health system reform legislation. The • Ensure that if a total pool is divided among all high- AMA argues that you can’t build a new health care sys- performing providers in any payment scheme, ensure that tem on the foundation of a crumbling Medicare program.

Overall, the AMA general principles for health care reform are to:

EXPAND COVERAGE REDUCE COSTS • Provide affordable, essential health insurance coverage • Break down silos and reward physicians for reducing costs for all • Enact medical liability reforms • Promote a robust private insurance market • Streamline insurance claims processing • Ensure sustainable public programs for vulnerable populations INCREASED FOCUS ON WELLNESS/PREVENTION • Align insurance benefit design with prevention evidence IMPROVE QUALITY • Make public investments in education, community projects, • Provide real time data at point of care and nutrition • Use measurement as a tool, not an end point • Eliminate racial, ethnic, and gender disparities • Correct problems with the Physicians Quality Reporting Initiative (PQRI) PAYMENT AND DELIVERY REFORMS • Promote medical home and other steps to reward care REFORM GOVERNMENT PROGRAMS coordination of chronic disease • Ensure adequate payments • Provide antitrust relief to improve quality and care • Enable balance billing and private contracting coordination • Replace Medicare sustainable growth rate (SGR) • Conduct adequate testing of new payment models • Allow public subsidies for purchasing private insurance

26 NDMA CHECKUP Minor Consent for Prenatal Care and SB 2394 Dean Haas, General Counsel

This article provides a brief introduction to SB 2394, stantially amended in the House, allowing generally as fol- and suggests the resolution to two problems that physi- lows: cians might face implementing the law. This article is not intended as legal advice. • A physician or other health care provider may provide pregnancy testing and pain management related to Introduction. The 2009 ND Legislative Assembly pregnancy to a minor without the consent of a parent or enacted SB 2394 which, in brief, expands the circumstanc- guardian. es under which pregnancy-related health care may be pro- • A physician or other health care provider may provide vided based on minor consent. NDMA thanks the primary prenatal care to a pregnant minor in the first trimester sponsor, Senator Krebsbach, for her diligent efforts in pur- of pregnancy or may provide a single prenatal care visit suing this legislation for the third consecutive session, as in the second or third trimester of pregnancy without well as many other legislators who over the course of the the consent of a parent or guardian. several years have sought changes in the law. Other spon- • A physician or other health care provider may provide sors of SB 2394 were Reps. Stacy Dahl and Ralph Metcalf prenatal care beyond the first trimester of pregnancy or and Sens. John Warner and Robert Erbele. Prior to enact- in addition to the single prenatal care visit in the second ment of SB 2394, North Dakota law, N.D.C.C. § 23-12-13, or third trimester if, after a good-faith effort, the physi- required parental consent to treat a pregnant minor. Of cian or other health care provider is unable to contact course, parental involvement is beneficial to the health of the minor’s parent or guardian. children. But it is human nature that minors may wish to • The costs incurred by the physician or other health care keep such private and intimate matters as their sexual lives provider for performing services under this section may from disclosure to their parents. Understandably then, the not be submitted to a third-party payer without the con- issue concerning the extent to which a minor is entitled to sent of the minor’s parent or guardian. confidentiality of her health information regarding preg- • This section does not authorize a minor to consent to nancy has engendered considerable controversy over the abortion or otherwise supersede the requirements of years; such a bill previously failed in the House twice–in Chapter 14-02.1 (Abortion Control Act). the 2005 and 2007 legislative sessions.1 Before reaching the details of the bill, we note our belief Other provisions in the bill provide that, if a minor that the legislation does represent a step forward, benefit- requests confidential services, the physician or other health ting public health. By affording confidentiality to a minor care professional must encourage the minor to involve her hesitant to involve her parents at the beginning of her parents or guardian. The bill also allows a physician or pregnancy, she will feel able to seek health care earlier in other health care professional who provides pregnancy care the pregnancy to improve pregnancy outcomes, as well as services to a minor to inform the parent or guardian of the potentially limit the risks and eliminate the cost of addi- minor of any pregnancy care services given or needed if tional treatment for complications. the physician or other health care professional discusses What the bill does. SB 2394, entitled “Minor Consent with the minor the reasons for informing the parent or for Prenatal Care,” allows a physician to rely on the con- guardian prior to the disclosure and, in the judgment of the sent of a minor for pregnancy testing, prenatal care and physician or other health care professional: pain management related to pregnancy. The bill was sub- a. Failure to inform the parent or guardian would seri-

1 Previous bills were introduced in 2005 and 2007, as Senate Bill 2308 and Senate Bill 2181 respectively. Though differing in detail, both bills would have authorized minors to consent to care related to pregnancy and passed easily in the Senate. The House handily defeated the 2005 bill, but the 2007 version died in a tie vote in the House, 46-46.

JUNE 2009 27 ously jeopardize the health of the the physician-patient relationship minor or her unborn child; (i.e., limiting the care available b. Surgery or hospitalization is based on minor consent based on needed; or the number of visits allowed per c. Informing the parent or guard- physician) is to have in place a ian would benefit the health of the referral system so that the care of minor or her unborn child. the minor patient objecting to dis- The bill also requires the ND closure may be readily transferred Legislative Council to consider an to another physician. The referral interim study of existing services system will comply with physi- for minors who are pregnant and cian’s ethical obligations to ensure whether additional education and continuity of care, avoid patient social services would enhance the abandonment, and abide by the potential for a healthy child and terms of SB 2394. a positive outcome for the minor. The bill raises a second issue That interim study was recently regarding compensation for servic- prioritized by the Legislative es, providing that the costs of the Council. The study will also con- care may not be billed to a third- sider the potential benefits of sup- party payer without the consent port services for parents of these of the minor’s parent or guardian. minors and guardianship for the Since a physician’s primary ethical minor for cases in which parental duty is to the patient, where it is abuse or neglect may be an issue. The study must also lawful to provide care based on minor consent, affording consider the benefits to the minor of subsidies for open this confidentiality takes precedence, despite the inability adoptions and supportive housing and child care for to bill the parent’s insurer. But the likely solution–billing single parents enrolled in secondary and postsecondary the minor directly–raises an issue too. That is, can the educational institutions. The study must also determine minor disavow her contractual obligation to make pay- the most desirable evidence-based service delivery system ment? Under North Dakota law, N.D.C.C. § 14-10-11, and the amount and sources of adequate funding. The minors may generally disavow otherwise valid contracts, interim study may provide an avenue for further revision but there are two exceptions. First, minors remain obli- of the approach taken in SB 2394 if that becomes neces- gated “to pay the reasonable value of things necessary for sary. the minor’s support,” N.D.C.C. § 14-10-12, and second, Issues that require solution. While the legislation is they may not disavow contracts “entered into by the minor an improvement, it also raises two issues of interest to under the express authority or direction of a statute.” physicians. First, the bill attempts to manage a physician’s N.D.C.C. § 14-10-13. practice by limiting a minor’s right to consent to treatment We believe that the minor’s support exception provided to one prenatal visit during the second and third trimester, by N.D.C.C. § 14-10-12 might successfully support physi- and, second, it prohibits billing the minor parent’s insurer cian’s rights to receive payment from the minor, especially if parental consent is not obtained. in light of the court-made rule that where the minor has As noted, the bill authorizes provision of prenatal care the right to consent to treatment, the emancipated minor without parental consent in the first trimester, “or…a (one able to give consent to the medical care) is respon- single prenatal care visit in the second or third trimester.” sible for paying for their own treatment, and may not dis- And according to the bill, additional care beyond this may affirm any contract made with a care provider.2 be provided without parental consent only if the physi- Physicians should seek the advice of legal counsel in cian is unable to locate the minor’s parent or guardian, developing appropriate policy relating to minor consent despite “good-faith effort,” to do so. This limitation on issues under SB 2394. A more detailed article concerning care raises the first potential problem: affording patient physician’s ethics, minor consent, and reproductive rights confidentiality and avoiding abandonment of the patient. under the laws and constitution is also available upon One practical solution to the legislature’s involvement in request at NDMA (e-mail: [email protected]).

2 See generally Michael J. Dale, et.al., Representing the Child Client, § 3.02(c)(v) (2008); John D. Hodson, Annotation, Infant’s Liability for Medical, Dental or Hospital Services, 53 A.L.R.4th 1249, 1256-1260 and 1278-1279 (1987) (courts generally hold that medical, dental and hospital services are necessaries that may not be disavowed by emancipated minors).

28 NDMA CHECKUP The Recovery Audit Contractor (RAC) Is Here

By Dean Haas, General Counsel RACs identify potential cases for review through proprietary he Recovery Audit Contractor (RAC) program, cre- analysis of the Medicare claims file. Identification of poten- Tated by the Medicare Prescription Drug, Improvement, tially inappropriate payments results in an automated review and Modernization Act of 2003 (MMA), was designed to find and data collection process. Cases involving a likely error result and correct “inappropriate payments,” for Medicare Services. in a request for the medical record and a complex review that Begun as a demonstration project, the program is expanding to may be performed by non-physician personnel. Claims may a national rollout that will be completed by 2010. Health Data be denied due to improper coding, inaccurate assignment of Insights (HDI) is the recovery audit contractor in CMS Region medical necessity, insufficient documentation, duplication of D, which includes North Dakota. HDI and CMS recently charges, or billing for services already included in other pay- provided a program of introduction to medical providers in ments. In sum, the RAC program attempts to identify practices Bismarck. This article is intended to provide you with some of (i.e., medical services) in which errors in coding and billing this background, including steps to ensure you’re ready for the are occurring. Once a practice is targeted, it receives a letter RACs. from the RAC requesting a copy of the Medicare patient’s entire Although CMS has reported a declining error rate in paid medical record. Providers do not need to redact the records, as claims over the past five years due to significant compliance the RACs are operating within the scope of CMS and are autho- efforts, a January 2008 report by the Office of Management rized to view this information. The record must be delivered to and Budget indicated that Medicare is still among the top the RAC within 45 days. The RAC has 60 days to review the three Federal programs with improper payments, totaling an record and notify the provider of the outcome of the review. A estimated $10.8 billion in 2007. The Medicare fee-for-service request may ask for one specific record or multiple records. paid claims error rate was estimated to be 10.1% in FY 2004 but had declined to 3.6% in FY 2008. CMS reports that it has Preparing for the RACs identified nearly $1.03 billion in improper Medicare payments since the RAC program began in 2005. Approximately 96% Complete, accurate, and timely documentation of the patient’s of the improper payments ($992.7 million) identified by the clinical condition is critical in order to ensure that patients RACs were overpayments collected from health care provid- receive the appropriate level of care in the setting that their clin- ers. Most overpayments occur when providers do not comply ical condition requires, and that the medical provider receives with Medicare’s coding or medical necessity policies. An the appropriate Medicare reimbursement for the level of care overwhelming majority of the overpayments found by RACs provided. during the demonstration project were from hospitals: only 3% Many health care providers are in the early stages of prepara- of overpayments came from physician practices. Almost half tion to be ready for the expansion of the RAC program to their of the improper payments were attributed to incorrect coding, region. Experts suggest following these six steps to prepare for 32% for medically unnecessary service or setting, and 9% to a RAC audit: 1) implement a RAC team; 2) monitor problemat- no or insufficient documentation. Although CMS reports that ic areas; 3) focus on clinical documentation; 4) establish record only 5% of determinations were overturned on appeal, only management protocols; 5) plan a systematic appeal process 11.3% of the RAC determinations were appealed. Though the for RACs; and, 6) monitor governmental reports. Another sug- number of appeals was small, 44.2% of the appealed claims gestion is to employ certified coders; CMS is requiring RACs were decided in the provider’s favor. to use certified professional coders in their reviews, so if your Congress directed CMS to utilize commercial contractors to medical practice or facility doesn’t have certified coders, they administer the RAC program. As per the MMA, RACs are paid won’t be able to talk peer-to-peer. Plus, certification ensures on a contingency fee basis.1 CMS contends that this com- that there is knowledge and professionalism applied to your pensation arrangement appropriately aligns incentives for the claims. RACs, as they are also required to return any funds overturned It is important that your RAC coordinator periodically moni- on appeal. However, this payment methodology–some call it tor the CMS RAC website in order to be aware of any updates bounty hunting–has been criticized as potentially creating an or changes to the RAC program. HDI is also in the process of incentive to focus their reviews on high dollar value claims, obtaining CMS approval of its online site. HDI can be reached: particularly in the inpatient hospital setting, as well as overpay- HealthDataInsights, Inc.-Part A: 866-590-5598, Part B: 866- ments rather than underpayments. 376-2319, e-mail: [email protected]

1 Contingency fees have long been decried as a cause of aggressive collection tactics. CMS could mollify its critics in part by adopting a blended compensation formula for its RACs: part fixed, part contingent. It has already addressed a related concern and has instituted contingent fees for RAC-identified underpayments as well as overpayments.

JUNE 2009 29 WATCH FOR THE MEETING BROCHURE COMING IN AUGUST North Dakota Medical Association & NDMA Alliance Annual Meeting September 24-25, 2009 • Bismarck Ramkota Hotel

North Dakota Medical Association NEW LAWS BEGIN WITH NDMA RESOLUTIONS 122nd Annual Meeting Many bills before the 61th Legislative Assembly began as resolutions in the NDMA House of Delegates or as Thursday, September 24 recommendations from NDMA Commissions. Now is the time to begin putting your ideas for a resolution on 3:00 p.m. House of Delegates First Session, any policy matter to paper, in time for the NDMA annual Reference Committee of the Whole meeting in September. The NDMA staff can assist you in preparing an effective resolution with a clear action or 6:45 p.m. Annual Social and Dinner stand that you would like NDMA to take. Call (800) 732- 9477 or 223-9475 for assistance. Friday, September 25 NDMA AWARD NOMINATIONS 7:00 a.m. Registration and Breakfast The Professional & Community Services Award 8:00 a.m. House of Delegates Final Session is given each year to an outstanding NDMA member physician. To be nominated, the physician 1) must be an Conference Program 9:30 a.m. NDMA member; 2) must not be deceased; 3) must not have been a previous recipient of the award; and 4) must 11:45 a.m. Luncheon have compiled an outstanding record of community service, which, apart from his or her specific identification as a physician, reflects well on the profession of medicine.

The NDMA Friend of Medicine Award is also given annually to an individual who 1) must be a person either living in or operating a business enterprise in the state; 2) must not be a Doctor of Medicine or Osteopathy; and 3) must have distinguished herself or himself by serving as an effective advocate for healthcare, patient services, or the profession of medicine in the state of North Dakota.

Members are invited to submit the names of quali- Promoting Physician fied individuals for each of these awards, along with a description of the individual’s relevant background and accomplishments, to the NDMA office by July 15 for consideration this summer by NDMA’s Commission on Leadership in Ethics Medical Services and Public Relations. This does not require a District nomination; any NDMA member can submit a nomination. and Advocacy LODGING A block of rooms has been reserved at the Ramkota Hotel, 800 S 3rd St, Bismarck. The rate is $84. For reservations call (701) 258-7700. Please indicate that you are with the ND Medical Association. The block of rooms will be held until August 25.

30 NDMA CHECKUP New Verbal Orders Authentication Rule Adopted

he Administrative Rules Committee of the ND period for verbal orders where no read-back and verify pro- TLegislative Council approved rules amendments on cess was used, but 30 days for verbal orders using read-back June 11 proposed by the ND Health Department, changing and verify, does qualify for the State law exception.” The the legal framework for authenticating telephone and verbal Health Department followed the CMS direction with a new orders. rule that incorporates a thirty-day time frame for a read-back New interpretive guidelines issued last year by the Centers and verify process, which states as follows (new language is for Medicare and Medicaid Services (CMS) resulted in a underlined): year-long process to amend the rules. Both NDMA and the ND Healthcare (Hospital) Association commented on the Telephone and verbal orders may be used provided Department rule revision in March. they are given only to qualified licensed personnel and The new federal regulation (482.24(c)(1)(iii)) provides reduced to writing and dated, timed, and signed or ini- that if there is no state law designating a specific time frame tialed by a licensed health care professional responsible for authentication of verbal orders, then those orders must for the care of the patient within forty-eight hours unless be authenticated within 48 hours. Since North Dakota’s law the hospital policies and procedures for verbal orders did not designate a specific time frame, the 48 hours applies and telephone orders include a process by which the under all circumstances. Clearly, the rule created difficult reviewer of the order reads the order back to the order- implementation challenges and needed changing. ing practitioner to verify its accuracy. For verbal orders The interpretive guidelines to the new CMS regulation note and telephone orders using the read-back and verify that authentication of a verbal order represents an opportuni- process, the verbal orders and telephone orders must ty to identify a transcription error and potential risk to patient be authenticated within thirty days of the date the order safety. While the guidelines defer to state law on a specific was given if the length of stay is longer than thirty days. time frame, those guidelines also note that CMS expects NDAC 33-07-01.1-20(1)(i)(2) hospital policies and procedures for verbal orders to include a read-back and verify process, in addition to specifying a Special thanks to Dr. Shiraz Hyder and others, who assist- time frame for authentication of the orders. The guidelines ed in the discussion with the Department on the revised rule. state: “…a State law that establishes a 48 hour authentication The rule becomes effective July 1.

The North Dakota Medical Association CONTRIBUTE TO THE NDMA PAC TODAY Political Action Committee Please select a NDMA PAC dues category: The North Dakota Medical Association (NDMA) advocated a Physician Member _____ $200 pro-medicine agenda in the 2009 ND Legislative Assembly. Alliance Member _____ $200 NDMA PAC, the nonpartisan political action committee of NDMA, plays an important role in the success of our advocacy Payment: efforts by supporting candidates who work in the best interest Please send a Personal Check payable to of physicians and patients. Join us as we continue to work NDMA PAC for: $100 of the suggested contribution amount is transmit- ted to AMPAC, or $10 for a student or resident. Detach • Medicare/Medicaid reforms and fair payment; and return this form along with your voluntary contribu- • Support for public health initiatives; tion. For more information, please call (701) 223-9475. • Protection of our medical liability reforms; Thank you. • Fair contracts with commercial insurers; • And much more. Name______Your support for NDMA PAC will also give physicians a strong, Home______unified voice at the national level, where we partner with the Address______American Medical Association Political Action Committee City______(AMPAC) to support medicine-friendly candidates for the U.S. Congress. Join your colleagues from across the nation as we State______Zip______call for expanding health coverage to the uninsured; Medicare PLEASE REMIT WITH PAYMENT physician payment reform; medical liability reform; and more.

Contributions to NDMA PAC/AMPAC are not deductible for federal income tax purposes. Voluntary political contributions by individuals to NDMA PAC/AMPAC should be written on personal checks. Funds from corporations will be used for political education activities and/or state election activities where allowed. Contributions are not limited to suggested amounts. Neither the AMA nor its constituent state associations will favor or disadvantage anyone based upon the amounts of or failure to make PAC contributions. Voluntary political contributions are subject to limitations of FEC regulations.

JUNE 2009 31 Contribute to the AMA Foundation Scholars Fund

On average, UNDSMHS medical students gradu- ate with over $138,000 in debt. As the largest volunteer arm of the AMA, our Alliances throughout the country raise money each year for medical schools to distribute to deserving students of their choice. The AMA Foundation tracks these donations for medical schools independently in separate accounts. Each dean or dean’s designate chooses scholarship recipi- ents based on the funds available. The NDMA Alliance and NDMA encourage you to contribute to the Scholars Fund. Any amount can be donated at any time throughout the year. If you have questions or want more information, please call NDMA at 701-223-9475.

SEND YOUR CONTRIBUTIONS TODAY! North Dakota Medical Association Make payable to the AMA Scholars Fund and mail to: PO Box 1198 • Bismarck ND 58502-1198 ERER COVERAGECOVERAGE ER BACKUP COVERAGE MONDAY TO FRIDAY Jamestown Hospital is seeking to create a pool of emergency room qualified physicians to fill in when one of our regular doctors is not available. • Jamestown Hospital will pay a retainer of $300 per month to be on call whether or not the doctor is called. • If a doctor refuses two times in a row or twice in a twelve month period, they will be dropped. • The expectation is that the doctor would be available for up to five days per month. Once they have worked twenty days in a year, they will have no further obligation and will continue to receive the $300 per month. • Physicians must be able to arrive in Jamestown within twelve hours. • Payment per hour will be $110 per hour w/o benefits from 7AM to 7PM and $150 per hour 7PM to 7AM. Jamestown Hospital does all billing. • Doctors are guaranteed six hours for each visit. • We pay mileage at the federal rate. For further information, contact CEO Marty Richman at 701-952-4850.

For more information about Jamestown Hospital, go to: www.jamestownhospital.com Dinah Goldenberg Past-President, NDMA Alliance Director, AMA Alliance

oday I would like to tell you about a small but out-o- date. Please email [email protected] with Tincredibly committed group of Alliance mem- your correct contact information. We also want to hear bers. Felicia Davis-Cooper, Carolyn Grimmett, Sharon from you with answers to these questions: Humphrey and Lori Tiongson have worked tirelessly over • What can the ND Alliance do for you? the last several months to rebuild the Alliance in North • What kind of information do you want to receive Dakota. regularly via email? The first step was creating a new North Dakota • What type of community projects would you support? Medical Association Alliance brochure. The initial mail- • Are you willing to work with a planning committee ing went to potential members in First District in Fargo, for the 2009-2010 year? the only community that still has a local Alliance struc- • Other thoughts, concerns, suggestions…….. ture. The membership is now nearly 40 strong with one If you have not received a mailing yet and would like third being first time members. Attendance at events has to join the North Dakota Medical Association Alliance, increased as well as interest and support for local proj- please fill in the attached application and return with pay- ects. ment ($55 for MAL to NDMAA) to: The next step is to create an active MAL (member at Dinah Goldenberg, 2173 Victoria Rose Drive, Fargo, large) organization throughout the state. Just before the ND 58104 flood derailed us all, mailings went out to Third and Sixth It is my hope that by the time you read this, the flood District. Membership is still coming in from this mailing. cleanup will be well underway. Recent weeks have been Mailings to other areas of the state are in the planning. difficult for us all, whether we were directly affected by Our intent is to create an email network throughout the flooding or were helping friends and family. I have found state to help keep our members informed of health and it incredible to see how communities have come together legislative issues. Our hope is also to support Alliance to help each other. I am proud to be a North Dakotan. projects and events throughout the state. One distinct advantage of AMA Alliance membership is access to all Dinah Goldenberg the resources of the national organization in Chicago. Past President, NDMA Alliance Check out the website at www.amaalliance.org [email protected] We need your help; many of the addresses on file are

ALLIANCE MEMBERSHIP APPLICATION Dues: Member at Large - Yes, I’m interested in joining the North Dakota Medical Association Alliance National and State $55 NAME: ______Make checks payable to: NDMA Alliance ADDRESS: ______

Return with payment to: PHONE: ______Dinah Goldenberg 2173 Victoria Rose Drive EMAIL: ______Fargo, ND 58104 SPOUSE’S NAME: ______

Interested areas for volunteer and/or community involvement: ______

JUNE 2009 33 Midwest Medical Insurance Company MMIC By Cinda Velasco RN, JD, Attorney-Risk Management

Managing Medication Risks

ne of the most common pro- patients are not comfortable asking samples, check the medication Ocedures performed in physi- questions so instead they do not take reconciliation list to be sure that cians’ offices – prescribing medica- the medication or do not take it as there are no interactions with other tions – is also frequently a factor prescribed. Knowing that patients medicines the patient is taking. in patient injuries and malpractice are often reluctant to ask questions, claims. According to the Institute of physicians and other health care pro- Risk Management Tips to Medicine, medication errors affect viders need to provide patients with Reduce Medication Errors: at least 1.5 million people every the information they need to take the • When prescribing medicine, phy- year. Data reported to the Physicians medication safely and effectively. sicians should have ready access Insurance Association of America Collaborating with and involv- to drug information references in show that 56.5 percent of claims ing patients in their care decisions either traditional text or electronic involving medication errors occur in through shared decision-making can format. the physician’s office. be effective in reducing patient injury Factors leading to patient injury and improve compliance with medi- • Develop written protocols for pre- and malpractice claims from medica- cation regimens. scribing that include: tion errors include: Following these simple rules could - Basic standards for writing pre- • Poor drug selection, incorrect dose prevent needless medication errors scriptions and length of treatment and potentially harmful outcomes: - Protocols for verbal or telephone • Failure to monitor drug side effects prescriptions including a require- and drug levels • Perform medication reconciliation ment for “read back” • Communication failures between at each patient visit. Medication - Specific protocols for prescrib- the physician and patient reconciliation is the process of ing controlled substances • Ambiguities in product names, comparing the medications a directions for use, medical abbre- patient is currently taking with • Develop written protocols for viations or writing your medication record and mak- refilling prescriptions that address • Poor procedures or techniques ing any necessary changes. This the following: when prescribing list should include all prescription, - Obtaining physician authoriza- • Inadequate medical history and over-the-counter herbal and supple- tion charting ment medications. - Handling after-hour requests or when the primary physician is Patient Education • Every time a patient has a new not available and Counseling prescription, explain the prescrip- - Monitoring patient’s therapeutic Studies suggest that as many as tion including the drug name, what drug levels half of all patients fail to take pre- it’s for and how often they should scriptions as intended by the provider. take it. Additional resources: The reasons for this can include not For a copy of My Medication List understanding what the medication • Take the time to tell your patients go to: www.mnpatientsafety.org is for, why or how to take it, or a the reason for the medication. The Institute for Healthcare conscious decision not to spend the Improvement: www.ihi.org money filling the prescription. Some • If you give patients medication For resources to help patients: www.consumermedsafety.org

34 NDMA CHECKUP 35 PRESORT STANDARD US POSTAGE PAID Bismarck, ND 58501 Permit No. 419

2009 Calendar of Upcoming Events

August 28-29 ND Society of Obstetrics and Gynecology Annual Meeting, Medora

September 18 ND Chapter American College of Physicians Annual Meeting UND Clinical Education Center, Grand Forks, ND For more information contact Pam Heisler at 701-780-6129 or email: [email protected]

September 24-25 NDMA Annual Meeting, Ramkota Hotel, Bismarck NDMA Alliance Annual Meeting, Ramkota Hotel, Bismarck NDMGMA Annual Meeting, Ramkota Hotel, Bismarck

September 25 ND Psychiatric Society, Ramkota Hotel, Bismarck

January 18-22, 2010 33rd Annual Family Medicine Update, Huntley Lodge, Big Sky, Montana. For more information contact Brandy Jo Frei at 701-772-1730 or email: [email protected]

36 NDMA CHECKUP