News and Notes - October 2017
By Gail Edelsohn, MD, MSPH, DLFAPA
Fall has officially started and there are those like myself that embrace the season. I have always looked forward to school starting (I still like school supplies), brilliant leaves, the start of holidays (religious and secular), and what feels like a faster pace. While others mourn the loss of summer and all its perks, more daylight, vacations, great gardens, more time outdoors, and see fall as a harbinger of the dark frigid winter. Whatever your favorite season, PaPS works all year round to fulfill our mission; that is “to fully represent Pennsylvania psychiatrists in advocating for their profession and their patients, and to assure access to psychiatric services of high quality, through activities in education, shaping of legislation and upholding ethical standards.” I have truly gained an even greater appreciation of the wealth and diversity of expertise, as well as sense of duty by our members and remain impressed by our highly competent and dedicated executive staff.
During our September council meeting, a suggestion was made to highlight and share what gets discussed and debated at Council. Before I provide a taste of the September 9th meeting, let me remind folks that Council is an open meeting to all PaPS members. You can bring a resident or ECP with you, and you don’t have to be a chapter president or committee chair to attend. Yes, we have designated voting members, but all can participate and give their input. So, here’s a smattering from our last meeting, but by no means complete:
- Assembly paper on ethics and conflict of interest
- Updates from the chapters on their educational events and social activities
- Advocacy work and efforts to reach out across geographical and institutional boundaries
- Advocacy update by the Philadelphia chapter regarding the interim plan for children’s crisis services
- Parity issues involving Blue Cross attempting to limit reimbursement when two different service codes are used
- APA parity resources
- Prior authorization issues within all of medicine as well as psychiatry
- Understanding what's involved in certifying, prescribing and dispensing medical marijuana in PA (free course at The Answer Page (https://www.theanswerpage.com/pennsylvania-state-practitioner-education-medical-use-marijuana.php)
- Staffing changes in APA leadership
- Scope of practice updates from Angela Gochenaur (our APA regional legislative representative) on the status of other states
- Priority legislative bills and corresponding PaPS position and advocacy efforts (two examples: bill to amend Mental Health Procedures Act and include AOT (Assisted Outpatient Treatment), amend MHPA to create involuntary commitment standards for substance use)
This review is far from exhaustive and doesn’t do justice to the planning, committee work, and considered actions steps needed to address these concerns.
The September Council meeting was collegial, animated, informative, solutions-focused, and yet ended before important football games started. I hope this gives our members a sense of our work together. There are many educational and social events offered by the chapters (please check the website www.papsych.org). Our big statewide CME event Patient Safety and Risk Management is coming up on November 11 in the Chubb Hotel and Conference Center (Lafayette Hill) and simulcast at the DoubleTree by Hilton Hotel and Suites in Pittsburgh.
In closing, I've been delighted some members have called or emailed me with concerns, ideas, and questions and the door remains open, email@example.com or 215-601-6266. Thank you for the honor as serving as your president.
Should We Hope for a World with Less Genes for Schizophrenia?
By Edward C. Leonard, Jr., MD, DLFAPA
To expand my understanding of how scientists and their critics consider the human genome, I read Jennifer A. Doudna and Samuel H. Sternberg's A Crack in Creation: Gene Editing and the Unthinkable Power to Control Evolution. Doudna’s Berkeley research team was responsible for much of the development of CRISPR-Cas9, which currently is the simplest, quickest, and cheapest way to make changes in genes. She explains how her technique is based on “clustered regularly interspaced short palindromic repeats” (CRISPR) that normal bacteria use to fight off viral infection. Her exciting and personalized account also credits pertinent research others did before and after her discoveries.
After calm instruction in how her team made CRISPR work, she emotes at length about every possible clinical misuse. Do I sense some amazement that ordinary patients and physicians are allowed to make decisions about life and death? As an academic biochemist, Doudna probably had little exposure to the world of medicine in her training. She also may be learning about the world of finance since Doudna’s school is suing Harvard about CRISPR patents, and she participates in several new CRISPR-related businesses.
Her main point is that the risks and benefits of human gene editing should be tested thoroughly, especially before creating heritable gene lines. However, human embryos at risk of having genetic disorders currently can be inspected to pick a healthy one for implantation into the uterus of a mother-to-be. And CRISPR already has been greatly improved. A few weeks ago Oregon researchers reported a modification that enabled removal of human embryo DNA that causes Hypertrophic Cardiomyopathy. In compliance with federal orders, the embryos were not implanted.
Schizophrenia is the psychiatric disease with the largest genome-wide association study. There are over a hundred DNA locations that may someday explain how about 80% of its origin is genetic. Today, psychiatrists find it hard to lessen the suffering and social discord of those with schizophrenia, much less provide them with average lifespans. Active psychosocial and biological treatments seem most successful in promoting their own rejection, which often leads to criminal justice, not to sustained benefits.
Reading Doudna’s fine book can help you consider if psychiatry should have a CRISPR future.
Is my employment arrangement compliant with the Stark Law? A refresher on the key requirments of the Bona Fide Employment Exception
By Julia Coelho, Esquire
McNees Wallace & Nurick LLC
PaPS General Counsel
In the last decade, and more recently with the changes brought on by the Affordable Care Act, the number of physicians (including psychiatrists) opting out of independent practice and joining health systems has increased significantly. In addition to the many changes stemming from a shift from independent to hospital-based practice, physicians are subject to different rules when it comes to the way their compensation is structured. This is because the Stark law has different requirements for remuneration paid to employed physicians, independent contractors, or physicians who are members of a group practice.
As members of a group practice and provided that certain Stark exception requirements are satisfied, physicians may be paid a portion of the overall profits of the practice, including profits derived from ancillary services (such as clinical laboratory services and imaging services), given that the allocation of profits is not made in a manner that is “directly related to the volume or value” of the physician’s referrals of certain ancillary services. Payment of profit shares is not, however, permitted under Stark’s bona fide employment exception which is the exception that hospitals and health systems generally rely on for paying remuneration to employed physicians.
What are the rules governing the compensation of physicians employed by a hospital or health system?
- First, there is a common misconception that hospital and physicians must have a written employment agreement to comply with the Stark Law. Although as a rule we strongly encourage providers to enter into written employment agreements, this is not a mandatory requirement and oral employment agreements may comply with the Stark Law if all the elements of the Stark exception are satisfied.
- Total compensation payable to the physician must be consistent with fair market value for the professional services. Notably, this is not a requirement under the Stark exception for compensation to group practice physicians.
- The remuneration must be commercially reasonable and not determined in a manner that takes into account, directly or indirectly, the volume or value of any referrals n. 2.
- While payment of productivity bonuses is permissible, the bonus must be based solely on personally performed services of the physician. In other words, services provided by other physicians or midlevel professionals must not be taken into consideration when establishing whether the physician is eligible to receive any bonus compensation, or to determine the amount of bonus to be paid. Conversely, group practices may pay physicians productivity bonuses that are based on personally performed services and services provided by other professionals that are “incident to” the physician’s personally performed services.
n1 See, 42 U.S.C. 1395nn(e)(2).
n2 Referrals for items or services that are considered "designated health services" under Stark law.
What is in a Name?
By Deborah Shoemaker, Executive Director
Does a title really matter? Is it just hype? I guess it depends on who you ask as if the person’s qualifications or experience are more important than the prestige that goes with a title. For example, do you only like Aretha Franklin’s music because she is considered the Queen of Soul? Usain Bolt has been called the World’s Fastest Man. What happens when someone beats his record? Is his career now tainted or less important? Lists come out all the time bestowing titles such as World’s Best Band, Best Basketball Player Ever, Best Writer Ever, Best Movie Ever, People’s Sexiest Man Alive… and so forth. As you can guess, every title comes with subjectivity and sustainability. I want to focus my article on the most important title that guides all my advocacy efforts: Physician.
Upholding the role of physician is paramount to me. The mission of our Society “is to fully represent Pennsylvania Psychiatrists in advocating for their profession and their patients, and to assure access to psychiatric service of high quality, through activities in education, shaping of legislation, and upholding ethical standards.” This guides every decision we make, every grassroots advocacy priority, every CME program, everything.
In the past, scope of practice expansion was obvious: legislation or policies were drafted, we responded. This still happens on a large scale. During this legislative session, there are scope of practice expansion initiatives across all medical specialties. The Society has been consistent in supporting our colleagues fighting scope of practice expansion, even when it is within a specialty that does not interact with us on a regular basis. We have been working closely with PAMED for many years fighting the ability for Certified Registered Nurse Practitioners (or Advance Practice Nurses) to independently practice without a collaborative agreement. Within our own area of expertise, proposed legislation has been introduced to allow social workers, marriage and family therapists, and even licensed professional counselors to diagnose mental illness and substance use and independently practice without any collaboration by a physician. Although we advocate for team-based case led by a physician, we continue to remain vigilant in fighting against any policies, procedures, or initiatives that seek to advance the role of non-physicians that does not reflect their medical training and expertise. We remain vigilant in watching proposed legislation and advocate at the state and national level ensuring that patient care is not compromised by allowing unqualified health care professionals to provide care that they are not trained to perform. This is a clear directive.
However, this legislative session has changed the playing field. We are now lobbying against proposed legislation that would expand scopes in an area never discussed before: involuntary commitments where “qualified professionals” can, among other things, assess an individual to determine if they meet criteria for assisted outpatient treatment, create treatment plans, testify in court that the individual is in need for mandated treatment, and supervise medication management (even when they do not have the ability to prescribe) and guide the overall treatment plan. As of this writing, we have been successful in excluding the term “prescribing psychologists.” However, other areas of concern remain that we want to see addressed before we can even take a “neutral” (notice I am saying neutral not support) position on proposed legislation. This “oversight” (not my words) has prompted us to take a proactive/defensive approach to prescriptive authority for psychologists. In fact, a couple weeks or so ago our state Council enacted a motion to oppose any initiatives that seek to expand the scope of practice for psychological prescribing. We have also reached out to the APA requesting that the Board of Trustees take a formal position to oppose the ability of psychologists to prescribe medication based on the lack of medical education and training. The Society is committed to expending all necessary resources to this effort as issues develop in the commonwealth. Although there is no official scope of practice bill introduced yet, we are prepared to act quickly and decisively when it occurs.
So, what does a title mean? It takes blood, sweat, and tears to become a physician. It takes tireless dedication and financial investment to become a physician. It takes dedication to years of medical education to become a physician. It takes an emotional toll on your family, your social life, and your pocketbook to become a physician. It takes dedication to uphold the Hippocratic Oath and its ethical standards to ensure that your patients received that most appropriate care for their individual needs and to assist in their recovery. So, what does a title mean to me? EVERYTHING!!!!!!
Psychiatric Use of the Prescription Drug Medical Program
By Richard R. Silbert, MD, DLFAPA
*One member's view on the new PDMP
Since rollout of the Prescription Drug Monitoring Program (PDMP) on August 25, 2016, several experiences to psychiatrists came as part of its utilization. These experiences allow for some opportunities but also present challenges. I offer some firsthand experiences and would welcome feedback and input from PaPS membership.
- Psychiatrists may be treating patients with anxiety or depressive disorder who may not disclose they are concurrently receiving MAT (Medication Assisted Treatment). The lack of disclosure may not solely be a problem in the therapeutic alliance, but rather stigma concerns. Patients don’t want to either appear devalued or fear losing access to the psychiatric treatment. Psychiatrists need to carefully consider whether benzodiazepine anxiolytics can safely be continued or an alternative considered. They also need to become knowledgeable about drug interactions between common psychotropic Rx (e.g. paroxetine and quetiapine) and two of the mainstays of MAT, methadone and buprenorphine. Lethality in overdose is well known to be much higher when benzodiazepines together with opioids are involved. On the other hand, sudden discontinuation of long used benzodiazepines has potential for withdrawal or decompensation.
- Children receiving ADHD stimulant medications may have parents with SUD (Substance Use Disorder). I have reviewed incidents wherein parents diverted or altered Rx for stimulants. The PDMP has offered a way to detect this type of concerning situation, which endangers both the children you treat and the caregivers with active SUD.
- Both inpatient facilities and residential rehab programs need to actively use the PDMP, not just outpatient /individual practitioners. All the same concerns described above are even more important in determining treatment plans and approaches that facilitate a safe discharge plan and a healthier start into some recovery.
- Awareness of what Centers of Excellence (COE) are and how to get quick access for their services would aid both psychiatrist and medical practitioners identifying opioid dependence (sometimes through reviews of the PDMP and assessments). A quick and “warm handoff” leads to the best outcomes.
Insurance Prior Auth Delays Harm Patients – Doctors Must Be Part of the Solution!
By Jeff Wirick, Pennsylvania Medical Society
Insurance companies say they use prior authorization to prevent physicians from prescribing too much medication or ordering too many tests. But physicians say the use of prior auth has grown out of control – and few stories illustrate it better than that of Joe Stanziano.
Stanziano, who currently resides in Montgomery County (Pa.), owned a bakery in New Jersey. Ten years of carrying heavy bags of flour and working 18-hour days took a toll on his back.
Stanziano had just undergone his fourth back surgery in five years and was taking pain medication to help with his recovery. Things were progressing well enough for Stanziano to begin taking a smaller dose of the pain medication – a process known as tapering that could eventually allow him to wean off the medication altogether.
The problem is, Stanziano's insurance company denied payment of the lower dosage that his neurologist prescribed. Hours turned into days and Stanziano continued to wait for his insurance company's approval.
When his current allotment of pain medicine ran out, the withdrawal symptoms began.
"Cold sweats. Shaking. You don't have control," Stanziano described.
This wasn't a one-time mistake by his insurance company.
Stanziano's neurologist prescribed a lower dose of pain medication five times. It was denied five times for up to a week before it was approved.
As the delays grew longer and withdrawals continued, Stanziano opted to buy the medication out of own pocket. Each pill cost $60.
"One could imagine a reason for (denying it) if we're increasing the medication, but in Joe's case we were gradually decreasing the medication," said Daniel Skubick, MD, Stanziano's neurologist. "In spite of the fact that we were doing the right thing (by lowering his dosage) – getting him off opioids – pre-certs would still be coming."
Stanziano said he was never given a clear answer as to why his medication decrease required a prior authorization.
"You could talk to two different people (at the insurance company) in the same day and get two different answers," he said. "Explain to me the logic – why are you denying it when we were trying to reduce (the medication)? Does it make sense to you?"
"Are you trying to cut costs, or are you trying to cut lives?" Stanziano continued. "I can understand trying to cut costs, but put them in my situation. Let them be on the medication for a certain period of time, and not be able to refill it, and have to go through what I went through."
Prior Auths On The Rise
Physicians have seen a dramatic rise in prior authorizations over the past few years for a variety of treatments and medications:
- 86 percent of respondents to a Medical Group Management Association survey said that they experienced an increase in the number of prior authorizations over the past year.
- Medical practices average 37 prior authorizations per week, per physician (taking up an average of 16 hours per physician), according to a survey from the American Medical Association.
A few years ago, "if a narcotic that we're prescribing was thought to be at a very high dose, you might have a pre-cert," Dr. Skubick said. "But the prior auth would last 6-12 months and it might occur occasionally. Now, over the last few years or so, fueled by the opioid crisis, we're running into pre-certs whenever a change is made to the medication."
The delays are proving costly to patients. Here are just two more examples:
Pittsburgh's Jeff Duncan waited eight months for approval on an in-lab sleep study that he needed in order to receive treatment for his severe sleep disorder.
"What if I would have died with this?" he said. "Personally, I'm just irritated that the insurance companies have so much power over doctors trying to get their patients what they need."
Pittsburgh's Kristen O'Toole experienced delays in getting an MRI for her back pain. The weeks' long wait allowed her undiagnosed multiple sclerosis to progress, and she is now in a wheelchair.
"If I had gotten the MRI earlier and started on the infusions, I really believe it could have kept some of these symptoms at bay," O'Toole said. "Maybe I would have never ended up in a wheel chair."
"The doctor knows there's a problem here," O'Toole added. "There's something going on. And how is he going to know before he gets the data from the MRI?"
Dr. Skubick said his biggest frustration with the rise of prior authorizations is that it takes the clinical decision-making out of the hands of physicians.
"I think it is incredible that the insurance company would think that a person who has practiced neurology for 35, 40 years doesn't know more than somebody on the other end without seeing the patient," he said. "I've never had a pre-cert denied for any diagnostic study when I'm able to talk to a colleague that is a neurologist.
"But I'm talking to people (at the insurance companies) who are not even doctors some of the time. And sometimes when you do get a doctor, you're getting an internist or a gynecologist – what do they know about neurology? What do they know about the subtleties about whether an MRI is necessary?"
Physicians Must Be Part of the Solution
Oncologist Rick Boulay, MD, wrote a recent blog for KevinMD: "Most patients are unaware of this, but your physician is likely your biggest advocate when it comes to getting your care covered" from prior auth.
Similarly, physicians need to step up to support new legislation in Pennsylvania that aims to decrease patient wait times from prior auth.
House Bill 1293, introduced by Rep. Marguerite Quinn (R-Bucks), would:
- Increasing transparency and consistency in prior authorization criteria
- Establishing standards for and reducing the overuse of prior authorization
- Lessen manual processes and enhance the electronic exchange of information
- Developing a standard prior authorization form
The Pennsylvania Medical Society and its coalition of 50+ physician and patient advocacy organizations support HB 1293. But this legislation will only move with a strong grassroots effort from physicians, medical office personnel, and patients.
See how you can get involved by going to the PAMED website, www.pamedsoc.org/PriorAuth.
By Usman Hameed, MD, CPPS President
During the month of August, members from our chapter participated in the DevelopMental Leaders Retreat in Hershey. We had 14 attendees at our Residents' Night hosted in Hershey where residents met with other chapter members and shared experiences. In October, we had a CME dinner and a movie program on the movie "The Soloist." We are also reaching out to non-member psychiatrists in the community, encouraging membership and associated benefits.
To close out the year, we will be hosting a Holiday Social on December 1st, 6:30-8:30 PM at the Colonial Golf and Tennis Club.
By Jeanne Rinehouse, MD, NEPPS President
Our first meeting of the year was held on August 23, 2017 at Isabella’s Restaurant, and sponsored by MHM Correctional Services. Dr. Ingrid Renberg, a forensic psychiatrist, did a presentation about her firsthand experiences working in corrections. It was interesting and well-attended. We welcomed three of the four new residents from the Wright Center Residency Program.
We had a small group participate in the Out of the Darkness Walk on September 17, 2017 at Kirby Park, sponsored by the American Foundation for the Prevention of Suicide. It was an inspiring event, and money was raised to go toward education and resources for this devastating problem. Thank you to those of you who participated.
We had our fall CME event scheduled for Friday, October 13, 2017 beginning at 6:00 pm at Geisinger College of Medicine in Scranton. Doris Fischer-Sanchez from AWAC Services spoke about Minimizing Risk when Treating Suicidal and Violent Patients. The event is accredited for up to 1.5 hours of CME.
We need to think about scheduling our holiday party soon. I would like to do a casual event during the first full week of December (December 4-9, 2017), and was hoping to do a pot luck affair at my home. Please e-mail me (firstname.lastname@example.org) to let me know what you would like to bring, and what day during that week might work best for everyone.
Looking forward to seeing everyone at our next event!
Pittsburg News and Notes
By Dan Udrea, MD, PPS President
Residents’ Research Night
PPS hosted the annual Residents’ Research Night at the DoubleTree Downtown Pittsburgh on Monday, September 25. This night celebrates the research submitted by residents and nurse practitioners from the Pittsburgh area. The first-place prize was awarded to Melanie Grubisha, MD from WPIC for her research on schizophrenia-associated missense mutation in kalirin converges on multiple RhoA-dependent pathways involved in cytoskeletal morphology. Second place went to Benjamin Gangewere, DO from Allegheny General Hospital for his research on the value of a mother-baby outpatient program for pregnant and postpartum women. Third place was awarded to Gianpiero Martone, DO and David Snow, DO from Millcreek Community Hospital (our friends from the Western chapter) for a comprehensive review of synthetic cannabinoid use and management. Congratulations to all!
Chester M. Berschling, MD, DLFAPA, founder of Residents’ Research Night, was in attendance to receive the PPS Lifetime Achievement Award. Marc Garfinkel, MD presented this award to Dr. Berschling for his devotion and contributions for the last 55 years.
WPPS and Lake Erie College of Osteopathic Medicine (LECOM) are sponsoring Resident Research Night on Thursday, November 30th from 5-7:30 pm at LECOM in Erie. We invite residents and medical students to participate in this event. This is an excellent opportunity to gain experience in presenting your research and to meet and mingle with residents from Erie and colleagues from across the region. For those who wish to present, please submit your name, hospital affiliation, and title of poster to Dr. Elizabeth Ramsey at email@example.com. Registrations are due November 22, 2017.
Welcome New Members
We welcome the following new PaPS members and congratulate those Members-In-Training who have recently achieved General Member status (effective June 24, 2017 – September 25, 2017).
Member in Training
Nishant Bhat, MD
Felicia DeJesus, MD
Salman Majeed, MD
Pon Tsou, MD
Scott M. Harman, MD
Members in Training
Nand Kishore, MD
Rooshi Amit Patel, MD
Alex Michael Slaby, MD
Qais Zalim, MD
Members in Training
Baron T. Denniston, MD
Members in Training
Alaa H. Ahmed, MBCCH
Phillip Noe Arellano, MD
Taylor Brana, DO
Philip David Campbell, MD
Shelley Antolin Co, DO
Katherine Marie Cohen, DO
Travis Jon Dichoso, DO
Kimberly Claire Downing, MD
Robert Anthony Gadomski, DO
Amanda Jane Gavin, MD
Rebecca Iza Katz, MD
Yin Stern Li, MD
Jenny L. Lugo, MD
Sarita O. Metzger, MD
Sarah Heather Miller, MD
Andrew David Mumma, MD
Carey Jeanne Myers, MD
Hamid Reza Naficy, MD
Shashwat Abhay Pandhi, MD
Brandyn Michael Powers, DO
Lisa Anne Roth, MD
Ewurama Elaine Sackey, MD
Dimal D. Shah, MD
Danielle Simpson, MD
Glenna Croswell Smith, MD
Stephanie Maiko Taormina, MD
Jaime B. Thomas, DO
Rebekah Joy Villarreal, MD
Kyle Jarrett Ward, DO
Becky Shuang Wu, MD
Nina Tove Wylonis, MD
Zev Joel Zingher, MD
Maria C. Lozano Celis, MD
David H. Clements, IV, MD
Justin M. Lazaroff, DO
John P. O'Reardon, MD
Members in Training
Caitlin Han Aguiar, MD
Abigail Reed Geisler, DO
Michelle Janette Georges, MD
Cassandra Ann Gibson, MD
Mitra Hefazi, MD
Julia Montllor Macedo, MD
Jeffrey Howard Nard, MD
Daniel R. Salahuddin, MD, MPH
Elyse Jordyn Steiner, DO
Gloria Jia Seo, MD
Ali N. Canton Vafabakhsh, MD
Alicia J. Kaplan, MD
Rajesh Narendran, MD
Sherrie Sharp, MD
David J. Yankura, MD