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In Memoriam

50 Years On

Congratulations to these Society members celebrating their 50th year anniversary of graduation from medical school.
Edgar David Altchek, MD
Robert Blatt, MD
Leslie Harold Blumgart, MD
Thomas A. Caputo, MD
Michael Henry Cohen, MD P.C.
William John Davis, MD
Charles M. Fermon, MD
Theodore Giannaris, MD
Peter Alan Godsick, MD
Stephen Philip Haveson, MD
Alan Douglas Heymann, MD
William J. Hoskins, MD
Chien–Jen Huang, MD
Ottis Wayne Isom, MD
Michael Alan Kalman, MD
Kenneth Richard Krauss, MD
Nomenida Ang Lazaro, MD
Robert Howard Levine, MD
Linda Donelle Lewis, MD
Stanley Liebowitz, MD
John Pierpont Lyden, MD
Marlin Roy Albin Mattson, MD
Edward Merker, MD
A. Lawrence Ossias, MD
Malcolm Jay Rothbard, MD
Bijan Safai, MD
Chalermpong Sarakhun, MD
John Joseph Savarese, MD
Arthur Howard Schore, MD
Norman Harmon Schulman, MD P.C.
Ivicos Sotirakis, MD
Jeffrey A. Stein, MD P.C.
Cheryl Marcia Sternlieb, MD
Andrew Julius Stiber, MD
Hillel Isaiah Swiller, MD
Morton Max Teich, MD P.C.
Ruth Helen Weichsel, MD
George Weingarten, MD
Henry C. Weinstein, MD
Eugene Edward Weise, MD

Remembering Mrs. Eleanor Spingarn

The New York County Medical Society and the Board of Trustees of the Clifford L. Spingarn MD Memorial Education Fund (the Society’s 501 ( c) 3 subsidiary) joins in mourning the passing of Eleanor G. Spingarn, the widow of past Society president Clifford L. Spingarn, MD.
Mrs. Spingarn, 101 at the time of her death, served several terms as president of The Auxiliary to the New York County Medical Society. She was a leader in organized medicine in her own right, as well as a true helpmate in Doctor Spingarn’s practice.
The members send their sympathies to the Spingarn Family.

Education Through the Anti–Trafficking Initiative

• CMS Releases New FAQs on ICD–10 Guidance to Include the Definition of “Family of Codes:”On July 6, 2015, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) released a joint statement about their efforts to help the provider community get ready for ICD–10. This statement included guidance from CMS that allows for flexibility in the claims auditing and quality reporting processes. CMS announced that:
  • For a one year period starting October 1, Medicare claims will not be denied solely on the specificity of the ICD–10 diagnosis codes provided, as long as the physician submitted an ICD–10 code from an appropriate family of codes. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors.
  • To avoid potential problems with mid–year coding changes in CMS quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or Meaningful Use). CMS will continue to monitor implementation and adjust the duration if needed.
  In response to questions from the health care community on what was a “family of codes” (and other issues), CMS has released “Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD–10 Flexibilities,”which provides answers to the most commonly asked questions; the most important one being the definition of “family of codes.” To read the full release, click here.
• Clarification on ICD–10 “Family of Codes” and Valid Codes: Although the changeover to ICD–10 will still happen on October 1, 2015, CMS sees that physicians and their staff will still be learning the new system during the first year. During that period, CMS has instructed the MACs to not deny claims for doctors who use an ICD–10 code that’s not quite as specific as it could be, as long as the codes are in the right ICD–10 family. If you don't quite nail a code to the most exact level, supposedly, you will not have your Medicare claims denied during that period. (Note: They may, of course, deny based on normal NCD or LCD policy directives as to Covered Indications for a given service). What does “ICD–10 family” mean? In CMS’s view, a “family of codes” is the ICD–10 three–character category number, such as H25 (Age–related cataract). Codes within a three–character category are clinically related; they reflect different, detailed information on the type of condition. When you look at the Tabular List you’ll see that within the H25 category are a number of specific codes that reflect different, detailed information, regarding the type of cataract it is and which eye is involved. There are H25.031 (Anterior subcapsular polar age–related cataract, right eye), which has six characters; H25.22 (Age–related cataract, morgagnian type, left eye), which has five characters; H25.9 (Unspecified age–related cataract), which has four characters — and others. (That’s one of the things we all have to get used to with ICD–10: Some codes have six characters, some five, some four and so on. There do exist some valid codes that have only three characters, but in many instances, the code will require more than three characters in order to be valid.) Important note: Do not just report a category number, such as H25. Instead, you need to report one of the valid codes that you’ll see in the Tabular List, dependent, of course, on the patient’s condition. If you haven’t quite chosen the exactly right code, that should be sufficient — as long as (1) you have the right three–character category number AND (2) you have reported some valid code within that category. For guidance on this issue, contact us through the Third Party Insurance Help Program. Source: http://www.cms.gov/Medicare/Coding/ICD10/Clarifying- Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf
• CMS Releases List of Valid 2016 ICD-10-CM Codes:  CMS has posted a complete list of the 2016 ICD–10-CM valid codes and code titles in the 2016 Code Descriptions in Tabular Order ZIP file on the 2016 ICD-10-CM and GEMs web page. See the file named “icd10cm_codes_2016.txt” in the ZIP file for the list. This file will be useful for physician offices and other providers who want to check to make sure that they are reporting all characters in a valid ICD–10–CM code. The codes are listed in tabular order (the order found in the ICD–10–CM code book). This list should assist providers who are unsure if additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.
• Update: Will Private Insurers & Managed Care Companies Follow CMS–ICD-10 “Grace Provisions?”: As reported previously, the Centers for Medicare and Medicaid Services (CMS) had provided some relief in regard to what will happen to physician claims when ICD–10 is implemented on October 1, 2015. CMS had issued the following “grace provisions” related to this issue.
  • For a one– year period starting October 1, Medicare claims will not be denied solely on the specificity of the ICD–10 diagnosis codes provided, as long as the physician submitted an ICD–10 code from an appropriate family of codes. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors.
  • To avoid potential problems with mid–year coding changes in CMS quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or Meaningful Use). CMS will continue to monitor implementation and adjust the duration if needed.
  As a result of these CMS provisions, a number of major insurers (who are also required to implement ICD–10) were queried as to whether they would also allow the same grace provisions for their commercial lines of business as outlined above. The responses received to date have been varied; some will go by these relaxed rules while others will not. Some insurers, such as Medicaid and Medicaid managed care plans, are awaiting further guidance from CMS. Due to the volatility of this situation, and for your own protection, your practice should be ready to “go live” with ICD–10 coding on October 1, 2015. In the meantime, you may want to contact those private and managed care insurers that your office participates with to determine what their final policy will be with regard to these CMS based “grace provisions.”
• NYS Medicaid to Allow Multiple Coding Lines to Reflect All PQRS Codes on Automated Crossover:  A problem had surfaced with regard to the automatic crossover of claims from National Government Services (NGS) Medicare here in New York to the contractor for the New York State Department of Health Office of Medicaid Management (NYSDOH OMM), Computer Sciences Corporation (CSC). It had been seen that the submission of  electronic Medicare  claims containing multiple lines of coding are being properly crossed over from NGS Medicare to New York State Medicaid automatically as per the long–established process. The electronic claims are transmitted in a batch mode and have no restrictions on the number of detail lines of coding that are transmitted as opposed to paper claims which have a maximum of six lines of coding. When Medicare crossed the claims over with numerous detail lines of coding, most involving multiple and valid PQRS measure codes, it sends all the lines of coding that are contained on the one (1) claim. When NYS Medicaid (CSC) received the claim on automatic crossover, it was denying a number of detail lines of coding (usually when the valid PQRS codes exceeded 9 or more lines) on the claim as “excess” or “overflow.” The Telephone area at CSC was telling physicians to split the claim details, but this is not feasible as Medicare transmits these claims properly in a batch mode with no restrictions on the number of detail lines as mentioned above. As a result of this issue, the Society contacted the Centers for Medicare and Medicaid Services (CMS) with a request to alert New York State Medicaid to allow for these multiple PQRS codes to be crossed over with no denials.  CMS has agreed to our request . CMS in conjunction with NYS Medicaid, has stated that: “… they would prefer NOT to restrict the number of quality codes a provider submits on their claim. We require 9 measures to be reported but professionals are encouraged to report as many measures that they want to measure the quality of care they are providing to their patients. Additionally, sometimes providers want to be sure they meet the 9 threshold (including reporting quality on at least 50% of patients for whom the measure applies) so they report extra measures as a type of insurance policy. We do not want to discourage this if possible.” The New York State Department of Health (NYSDOH) has stated that changes have been implemented within eMedNY that should eliminate the problem. If you have experienced this problem or if you have and it is continuing, please contact  Shakti Chauhan, NYSDOH, (518) 257–4548  for assistance.
• UHC Releases August 2015 Network Bulletin:  Aside from information on various policy changes, there are two key additions that will impact many physicians in the August 2015 Network Bulletin from United Health Care. These include: Item #1: UHC to Initiate Multiple Procedure Payment Reduction for Diagnostic Cardiovascular and Ophthalmology Procedures (Page 23)
  • United Healthcare will begin to apply the Medicare–based policy on Multiple Procedure Payment Reductions (MPPR) for cardiovascular and ophthalmology services for our Commercial plans.
  • This policy change will apply to all claims with dates of service on or after Nov. 15, 2015.
  • The full text of this change is outlined in their August 2015 Network Bulletin on page 23 at the link below.
  Item #2: Update to Medicare Compliance Expectations and Fraud, Waste and Abuse Training (Page 6)
  • The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations and Part D Plans, United Healthcare Community Plans or other health benefit programs, as applicable, to communicate with and provide training and education to their “first tier, downstream, and related entities.” However, this issue of “required training” was addressed a number of years back and there are exceptions as per the following directive from the Centers for Medicare and Medicaid Services (CMS).
  • CMS confirmed that Medicare Advantage and Part D plans should not be requiring special fraud, waste, and abuse (FWA) training for providers and suppliers (collectively, “providers”) who enrolled in the Medicare program.
  • Under Final Rules effective June 7, 2010, these providers are “deemed” to have complied with any FWA requirements by virtue of their Medicare participation.
  • Providers are, of course, free to participate in any training programs sponsored or recommended by the Medicare plans, but they are not be required to make their employees to attend them, nor are the providers required to certify to their attendance.
  The full Bulletin is located at the link "here.
• CMS Launches National Site Visit Verification (NSV) Initiative: The Centers for Medicare and Medicaid Services (CMS) has released an article with regard to a National Site Visit Verification (NSV) Initiative. This is a continuance of the original 2011 project that targeted DMEPOS suppliers. This article provides the latest information about the CMS National Site Visit Verification (NSV) initiative. The NSV initiative is part of CMS’ National Fraud Prevention Program (NFPP) and assists CMS in its efforts to prevent fraud and abuse in the Medicare program starting with the enrollment process. The NSVC will conduct unannounced site visits for Medicare Part A/B providers and suppliers. The NSVC may conduct either an observational site visit or a detailed review to verify enrollment related information and collect specific information based on pre–defined checklists and procedures determined by CMS. To read the full article, go to the link here.

If you have questions about these issues or others, contact the Society’s Third–Party Coding Assistance Program, at (212) 684–4681.

E-Prescribing Clarifications from the New York State Education Department

James McNally, from the Society’s Third–Party Payer Coding Assistance Program sought out the following clarifications on the New York State E–Prescribing mandate: There have been a number of concerns raised by physicians with regard to the New York State E–Prescribing mandate, which has been delayed until March 2016. One key issue involved the fact that a number of E–Prescribing vendors, notably Doctors First, had been sending communications to their clients/customers that announced the following:

• They will “transition all provider agents in your practice to the role of clinical staff. What this means to you is that your staff will only be able to queue up prescriptions for you, but you will need to ensure they meet all the requirements per the New York Board of Pharmacy. Below outlines the specific law from the New York State Board of Pharmacy website. This information may be found under information regarding electronic prescribing.
• Question: Can an agent or employee of the prescriber electronically create and electronically transmit an electronic prescription to the pharmacy?
• Answer: NO. Education law 6802 and Regulations of the Commissioner of Education make no provision for the delegation of transmission of electronic prescriptions to an agent. Further, federal and State regulations for prescribing of controlled substances explicitly prohibit such delegation.

As a result of these communications, clarification was sought from the New York State Education Department (NYSED) on this and a number of other questions. First, we advised the NYSED that it is understood that nurses (with the exception of nurse practitioners) are not permitted to prescribe medications on their own. However, we maintained that nurses should be well within their scope of practice to carry out the “clerical aspects” of physician orders for medication, as they are working within and under the physician’s scope of practice as well as under their supervision. The inability of nurses to electronically create and electronically transmit an electronic prescription to the pharmacy under the order of a physician will have a negative impact on the ability of physicians to work effectively within this mandate. Physicians who use the electronic health record to order medications, treatments, etc. are able to enter this medication information in the record but it takes a second and time consuming step to enter the data again in a separate E–Prescribing program. Requiring that the physician himself perform both physical steps will add significant time to electronic prescribing of medications. We maintained that the nurse is carrying out the physician’s order and this does not take away from or change the fact that it is the physician that is “writing” the prescription. Nursing staff are performing a basic clerical task in creating the electronic prescription and setting it up for transfer to the pharmacy, again at the direct order and under the supervision of the physician. We believe that these circumstances should be allowed within the directives of the New York State Board of Pharmacy and the New York State Education Department Office of the Professions quoted by Doctors First and noted in their communications. The Deputy Commissioner’s office responded to our inquiry as follows. New York State law requires each licensed prescriber to personally sign or authorize each of their prescriptions. New York law also prohibits licensed prescribers from delegating to nurses (LPNS or RNS) the responsibility for manually or electronically signing any prescription or order on behalf of the prescriber. The prescriber is legally responsible for the accuracy of each prescription issued. See, e.g. 10 NYCRR § 80.77 © and 21 CFR §1306.3 We do note, however, that contemporary software systems allow physicians and other prescribers the opportunity to attain processing support from others and still remain compliant with the I–STOP provisions. Nurses or other staff may prepare e–prescriptions, to be reviewed by authorized prescriber, who shall “electronically sign” the order. Such orders may be transmitted to the pharmacy of the patient’s choice by the prescriber. With that question resolved, there were additional concerns regarding the NYSED’s response to another Frequently Asked Question posted on the NYSED Office of Professions (OP) web site. This FAQ directs a pharmacist to refuse to fill a prescription if s/he believes that the prescription is outside of the provider’s scope of practice: The NYSED FAQ stated the following. 15. What should a pharmacist do if he or she believes a prescriber is ordering a prescription that is not consistent with the prescriber's scope of practice? Answer: If a prescriber cannot legally order the prescription based upon the prescriber's scope of practice, the pharmacist must not fill the prescription.Source: http://www.op.nysed.gov/prof/pharm/pharmelectrans.htm Our assumption presented to the NYSED, was that this directive does not apply to MDs and DOs but rather is intended for limited license providers whose scope of practices does not include full prescriptive authority. In a follow–up response, the NYSED stated that our assumption outlined above was correct and that it does not apply to Medical Doctors (MD) or Doctors of Osteopathy (DO). For guidance on this issue, contact us through the Third–Party Insurance Help Program, (212) 684–4681.

Flu Season Is Open

According to the Centers for Medicare and Medicaid Services, with thanks to MSSNY’s Vice President of Socio–Medical Economics Regina McNally

• CMS is changing the payment limit effective date from September 1 to August 1. Recent CDC recommendations state that vaccination efforts should begin as soon as the seasonal influenza vaccine is available and continue through the influenza season.
• The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP) as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department. When the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost.
• Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations. All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine.

Dateline: NYCMS

As a member, you are entitled to attend Society meetings and functions. Keep track of what is going on by checking this listing in every issue of MM “NEWS.” Members are invited to attend any of these sessions; however, we suggest that you call (212) 684–4670 to confirm meeting date and time.

• September 21, 2015, Board of Directors, at the offices of MLMIC, 5:30 p.m.
• October 1, 2015, CME: Management of Infectious Disease and Current Vaccination Trends, at Lenox Hill Hospital, Bruno Presentation Room, 5:30 p.m. registration. Register at http://www.nycms.org/files/100115Infectious.pdf
• October 18, 2015, CME; Introduction to Fascial Manipulation One–Day Workshop, Touro College of Osteopathic Medicine, 8:00 a.m. to 5:30 p.m., Touro, 230 West 125 Street, New York, NY 10027. Register at http://www.nycms.org/files/101815Touro.pdf
• October 19, 2015, Board of Directors, at the offices of MLMIC, 5:30 p.m.
• December 17, 2015, James McNally Billing and Coding Seminar: Medicare, Corwin Auditorium, Manhattan Eye Ear and Throat Hospital, 210 East 64 Street, 8:00 a.m. to 10:00 a.m.
• January 12, 2016, 2016 Medicare Update: With National Government Services, Linda Teti, Corwin Auditorium, Manhattan Eye Ear and Throat Hospital, 210 East 64 Street, 8:00 a.m. to 10:00 a.m.

A Welcome Batch of New Members

The following 6 candidates for membership are presented to the Board of Directors of the Society. Anyone with information reflecting against election of a new member is requested to notify the secretary of the Society as soon as possible.
Daniel Alan Cohen, MD
Bartosz T. Grobelny, MD
Moshe Heching, MD
Mandip Singh Kalsi, MD
Jonathan Koblenzer, MD
Erin Manning, MD

Upcoming Events

• October 1, 2015, Management of Infectious Diseases and Current Vaccination Trends, cosponsored by The New York County Medical Society and The Touro College of Osteopathic Medicine, 6:00 p.m. to 8:00 p.m. (Registration: 5:30 p.m.) TWO (2) AMA PRA Category I Credits™ Bruno Presentation Room, Lenox Hill Hospital. 130 East 77 Street, First Floor, $25.00. Physicians in private practice should have the tools to address the emergence of new infectious disease, recurrence of epidemics that were once under control, and concerns their patients have. Hear our experts. Register TODAY at http://www.nycms.org/files/100115Infectious.pdf
• October 18, 2015, Introduction to Fascial Manipulation One–Day Workshop, presented by the Touro College of Osteopathic Medicine, 8:00 a.m. to 5:30 p.m. Touro, 230 West 125th Street, New York, NY 10027 Early Registration: $225 (Until October 1, 2015); Full Registration: $250 (Until October 18, 2015). 8.5 AOA Category 1–A CME hours applied for. Register at http://www.nycms.org/files/101815Touro.pdf

The State of the Society

The following is the speech presented by outgoing president Joshua M. Cohen, MD, MPH, at the Society’s Annual Meeting on June 2, 2015.
New York County Medical Society members, members of the Board of Directors, members of the Board of Trustees, officers, Society staff, invited guests, sponsors, family, and friends — thank you all for joining us tonight as we celebrate the accomplishments of our Society over the past year. I especially want to give great thanks to our table vendors in attendance tonight — Allergan, Haldey Pharmaceuticals, and OurHarvest — as well as those who advertised in our meeting journal for your generous support and commitment to our shared vision of improving health care for physicians and patients in Manhattan.
What a year it has been. It seems like only yesterday I was standing before you, laying out my plan for my year as President, emphasizing strategies to engage new members, especially ways to attract physicians that had not previously recognized our value or perhaps even heard of our Society before. I spoke of ways to increase our visibility, explore new methods of communication, experiment with new and creative types of events, and examine means to encourage participation by young physicians. While this ambitious agenda may not have matured to complete realization in such a surprisingly short time, I am thrilled tonight to share some significant strides and say with complete confidence — the State of our Society is Strong.
Now, some here in the audience tonight, perhaps our more…cynical members, may bristle at that confidence, recognizing the innumerable challenges facing our Society, much in the same way medical societies across the country are struggling with declining memberships, loss of revenue, physician apathy, and legislative and regulatory setbacks. I recognize these concerns and agree that they remain critical areas for continued vigilance, exploration, and action. Yet, in the past year I have witnessed the extraordinary fortitude with which our Society has confronted these challenges and will show how our ingenuity, innovation, and persistence have positioned us more positively than many similarly oriented organizations.
In the fall, the Society’s leadership met for a full day, intensive retreat, the first of its kind in many years, to closely examine Society efficacy in member engagement, membership benefits, communications, relationships with other organizations, and opportunities to increase non–dues revenue to support our extensive operations. We carefully considered our relevance to members in all categories and methods to market membership to those not already members. It was an awesome day. The enthusiasm and excitement with which your leadership engaged in discussion and debate over how to best move our Society forward demonstrated how devoted this team is to evolving the Society in step with an evolving healthcare landscape. Recognizing that medicine is very different than it was 20 years ago — or even 10 years ago — the leadership sought then and has continued to seek throughout this year ways to help physicians in whatever practice model they may find themselves. I cannot express strongly enough the impact that day had upon the Society or how hard the Board has worked to serve you, and I thank them all deeply for their efforts and support this year.
Coming off that successful retreat, the Board and staff sought ways to implement the ambitious goals set forth on that day. Let me share with you just a sampling of those accomplishments and how they have affected our Society.
One of my primary objectives I discussed in my remarks last year was increasing participation by younger members, recognizing that growth in our young physician membership category was critical to the future of our Society. This year, we reengaged our Young Physicians Committee and worked with them to plan events specifically geared toward young physicians. One of the most successful was an event called Referral Rounds, held in March. Using a speed–dating type format, we allowed young physicians to share their practice models with each other, building a referral base and thus increasing their productivity and patient satisfaction. While many of the 35 attendees were already members, four people paid membership dues as a result of the event. Our efforts in attracting young physician members not only paid off that night, but throughout the year. I am thrilled to report to you tonight that compared to last year at this time, we have seen a 10 increase increase in membership by young physicians. With a reinvigorated young physician section and a Board dedicated to attracting young physician members, I look forward to continuing this trend of increasing young physician members.
Another primary goal of my presidency and the Board retreat was improving communications. We have enhanced the aesthetics and utility of our e-mail communications, and I am ecstatic to report that our website will soon be completely revamped and will be much more user friendly and member oriented. Perhaps one of our biggest successes was engagement in social media. Last year at this time, our Facebook page was stale and had less than 100 likes and we had just barely established a Twitter handle. Now, we post frequently on both social media platforms and have grown to over 550 likes on Facebook and over 120 followers on Twitter. As we seek to start a conversation with physicians who do not currently know our value, these communications avenues offer tremendous opportunity for growth.
A recurring theme at the Board retreat was the importance of partnering with other medical organizations to work in concert to increase membership and provide member benefit. We also implemented this goal throughout the year with great success. We worked with the New York City Psychiatric Association on a successful legislative breakfast and they accompanied us on Lobby Day in Albany. A partnership with AMA and MSSNY yielded a well attended and received physician networking event. We cosponsored an event on Music and Cancer with AAPI New York City metro in this very building, attended by over 100 people. These events and other partnerships developed throughout the year have helped expose physicians in these other organizations to the great work we do and we will continue to pursue other opportunities to partner with like-minded organizations in the year to come.
There are so many other successes I could discuss, like legislative victories with the e–prescribing delay or the great attendance at our educational events on the business of medicine and other practice–related issues. But rather than spending any more time commending the Society on its great achievements this year, I want to spend my remaining time giving thanks. None of these successes would be possible without the extremely hard work of people in this room. Thank you to our Board of Directors, Board of Trustees, and Executive Committee who have volunteered countless hours of time to chart a positive course for the Society. I especially want to thank my predecessor, Doctor. Paul Orloff, for his mentorship and advice, without which I would have had a very hard time hitting the ground running toward accomplishing my goals.
Even more thanks goes to the extraordinary Society staff. Lisa Joseph and Sony Hilado — thank you for your hard work on membership, balancing the books, and improving our communications. Susan Tucker —your legislative acumen, keen legal insight, and relationships with legislators have been invaluable as we have fought to improve the healthcare system in New York State. And what can I say about Cheryl Malone. Everyone in this room that has worked with Cheryl can attest to her insight, tenacity, enthusiasm, organization, spirit, and dedication to everything that the Society does. But it is not until you serve as President that you truly glimpse the outstanding work that Cheryl accomplishes as our Executive Director. No matter what I asked or what time it was I asked it (even at 1 in the morning), Cheryl responded rapidly and with a much more thorough and useful answer than I even suspected existed. She is the glue that holds this Society together, and I cannot begin to thank her enough for everything she has done for me this year and for the Society for so many years. Thank you Cheryl – it is so very much appreciated.
And thank you all and every member of the Society for allowing me to serve you this year. It has been one of the greatest honors of my life and I will cherish the memories of this year and everything I have learned in this role for the rest of my life. To those who follow, I have but one request. Keep up the good fight. Never despair at defeat, just try harder to win the next time. If so, I have full faith that you will be victorious. As Mark Twain said, “It’s not the size of the dog in the fight, it’s the size of the fight in the dog.” This Society, its leadership, and its membership have more fight in them than any of the powers that seek our harm or the harm of our patients. Stick to the powerful principles of our profession, defend them, and we will always win out in the end. Thank you all so much.

From the Front

This feature of MM “NEWS” introduces you to Society leaders as they explain their vision of organized medicine’s activities. This month, read the remarks of Michael T. Goldstein, MD, JD as he took office as president at the Society’s Annual Meeting on June 2, 2015.
Steering in the Right Direction
I would like to thank Doctor Eugene Weise a longtime friend and colleague for bringing me onto the Board of Directors of the New York County Medical Society. I would like to thank my wife Doctor Belle Goldstein for her support and encouragement especially in the coming year. I would like to thank my most recent predecessors for their hard work and leadership by example: Doctors Zinberg, Green, Lombardo, Orloff, and Cohen.
Each of them has contributed in their own way to advocating for our physician members and the medical society. For example, Doctor Orloff created a column on the subject of “what have we done for you lately.” He was responsible, along with our Executive Director Cheryl Malone, in significantly lowering our rent and finding suitable new quarters. Doctor Cohen has brought new technology to our society. Doctor Green was a big fighter against out–of–network and insurance company abuse. Doctors Zinberg and Lombardo were dedicated leaders who helped keep the ship on even keel.
New York County has the highest concentration of medical education in the US. We are the home to four top allopathic medical schools and the highly–regarded Touro School of Osteopathic Medicine.
The practice of medicine and the delivery of healthcare in the United States is undergoing a great transformation with limited input from the physician community and organized medicine. We need to play a greater role in this healthcare upheaval and actively participate and innovate to steer healthcare in the best direction. We face a multitude of changes that are very significant.
Healthcare Consolidation
Hospital consolidation and all its ripple effects are a direct consequence of managed care. Hospitals merged in order to be able to negotiate profitable rates with insurance companies. They needed a steady stream of patients to fill their beds and operating rooms and to utilize their large selection of diagnostic and treatment modalities. To ensure a steady flow of patients into their system, hospitals bought practices that had the potential to refer patients. These patients became revenue streams.
Hospitals also negotiated higher payments for the employed physicians than were available to independent practitioners. These higher reimbursement levels and the secondary revenue streams from the practices enable them to entice more doctors to sell their practices to the hospitals.
Large vertically integrated hospital systems have become major players and are an essential component of the healthcare system. Integration and consolidation enabled many entities to survive and prosper. Unfortunately integration has resulted in the rapid decline of independent practice.
According to a 2010 report from the Massachusetts Attorney General ,in this new model reimbursement is related to market share and bargaining power, not value or quality. This is a matter of concern. Independent practitioners are the most cost effective providers. The preservation of the independent practitioner preserves competition, lowers costs, and preserves diversity and choice in the marketplace for patients and physicians.
The decline of independent practice as a lower priced cost effective healthcare delivery systems is harmful and should be reversed.
Practice options for physicians protect employed physicians because institutions have to compete for physician manpower. When markets are dominated by a single employer, physician income declines.
Our healthcare delivery system is at times illogical. Sometimes applying the healthcare model to another industry gives better insight into its flaws.
The Gas Station
According to a 2010 report from the Massachusetts Attorney General’s office, there is a threefold difference in costs between the lowest and highest paid providers without a perceived difference in quality. If we applied that model to gas stations it becomes apparent how ridiculous the system is.
Imagine there are three different gas stations and you have a one dollar co–pay per gallon. The smallest independent gas stations gets paid three dollars per gallon. The medium sized gas station chain gets paid six dollars per gallon. The large conglomerate gas station gets paid nine dollars per gallon. All three types of stations sell the same gas.
The three–dollar per gallon station goes to the payor and says that at three dollars per gallon it is losing money; it needs four dollars per gallon to stay in business. The paying company says no. The gas station replies that they are saving the company money by staying in business, and why is the conglomerate gas station getting so much more?
The company responds that it does not care if the little stations go out of business, and it is not concerned about paying more to the conglomerate. After all, the conglomerate provides other services — car washes, repair shops, body shops, tires, transmissions and oil changes.
The small gas station owner responds, “What if I joined forces with other independents so that we could provide all these services at lower price. Would you be interested in us in that case?” The insurance company responds, “Sorry, but without jumping through hoops, the antitrust laws won’t let you independents join forces.”
Such is the nature of healthcare today. It defies logic and common sense.
Independent Practice
One of the obligation of the medical society is to support the cost effective and competitive healthcare system known as independent practice. This county proposed a HOD resolution to set up a task force to study the legally permissible options for independent practitioners to joint venture and survive. Independent practitioners have been loyal dues paying members of the Society and deserve our support. Their decline has resulted in a decline of membership that has resulted in lost dues income to the Society. As physicians had shifted to the employed model we are reaching out to them to join the Medical Society.
Government Comparisons
I have heard government healthcare officials propose healthcare models that resemble the automobile industry. They use catchy words including, “economy,” “efficiency,” “uniformity,” and “predictability” to explain their goals.
An automobile assembly line is designed to be efficient by the repetition of mindless monotonous tasks with no thinking. Certainly that is not how we believe healthcare should be delivered. Performing heart surgery is not just like attaching a steering wheel to a Chevy.
Our auto industry was once the greatest in world. It fell on hard times. The industry stopped giving its customers value for their money and foreign competitors expanded into the US market. The industry failed to successfully respond to the challenge and declined. This lead to bankruptcy, under–funded pensions for workers , concealment of defective products, and fraud. The situation was further exacerbated by the financial crisis, creating more bankruptcies, government bailouts, creditor defaults, and the persistence of concealing manufacturing defects.
Our healthcare system was once the best in the world and it too is facing decline. We should not follow their lead.
The epicenter of the automobile industry, Detroit, is a disaster.
The epicenter of medicine is New York City, and we will not follow “Auto Model” into decline.
Pay for Performance
This is another failed idea that has been resurrected. According to a New York Times article published on July 28, 2014:
“’Pay for performance’ is one of those slogans that seem to upset no one. To most people it’s a no–brainer that we should pay for quality and not quantity. We all know that paying doctors based on the amount of care they provide, as we do with a traditional fee–for–service setup, creates incentives for them to give more care. It leads to increased health care spending. Changing the payment structure to pay them for achieving goals instead should reduce wasteful spending.
So it’s no surprise that pay for performance has been an important part of recent reform efforts. But in reality we’re seeing disappointingly mixed results. Sometimes it’s because providers don’t change the way they practice medicine; sometimes it’s because even when they do, outcomes don’t really improve.
The idea behind pay for performance is simple. We will give providers more money for achieving a goal. The goal can be defined in various ways, but at its heart, we want to see the system hit some target. This could be a certain number of patients receiving preventive care, a certain percentage of people whose chronic disease is being properly managed or even a certain number of people avoiding a bad outcome. Providers who reach these targets earn more money.
The studies showing failure are also compelling. A study in The New England Journal of Medicine looked at 30–day mortality in the hospitals in the Premier pay–for–performance program compared with 3,363 hospitals that weren’t part of a pay–per–performance intervention. We’re talking about a study of millions of patients taking place over a six–year period in 12 states. Researchers found that 30–day mortality, or the rate at which people died within a month after receiving certain procedures or care, was similar at the start of the study between the two groups, and that the decline in mortality over the next six years was also similar.
In Britain, a program was begun over a decade ago that would pay general practitioners up to 25 percent of their income in bonuses if they met certain benchmarks in the management of chronic diseases. The program made no difference at all in physician practice or patient outcomes, and this was with a much larger financial incentive than most programs in the United States offer.
Even refusing to pay for bad outcomes doesn’t appear to work as well as you might think. A 2012 study published in The New England Journal of Medicine looked at how the 2008 Medicare policy to refuse to pay for certain hospital–acquired conditions affected the rates of such infections. Those who devised the policy imagined that it would lead hospitals to improve their care of patients to prevent these infections. That didn’t happen. The policy had almost no measurable effect.”
Will Pay For Performance Backfire? Insights From Behavioral Economics Steffie Woolhandler and Dan Ariely, October 11, 2012
A $75 million RCT — involving over 200 high-needs New York City schools employing more than 20,000 teachers — offered incentives of up to $3,000 per teacher based on students’ test scores, graduation and attendance rates, and the results of learning environment surveys. Notably, most schools opted to pool bonuses among all teachers at the site — the type of institution–level incentives that some P4P proponents advocate. Yet, “. . . incentives . . . did not increase student achievement in any meaningful way. If anything, student achievement declined.”
None can doubt health care’s grave quality deficits and cost excesses. As remedy, P4P suggests manipulating greed, a fuel that’s powered exponential growth in productivity in the overall economy. But Adam Smith, who first recognized greed’s awesome power, was also a moral philosopher who believed that commodity production required a parallel public service economy driven by social duty.
Sadly, greed has caused many of the worst abuses within the current system. Injecting different monetary incentives into health care can certainly change it, but not necessarily in the ways that policy makers would plan, much less hope for.
Pay for Performance and Contract Chicken Farmers
Vertically integrated companies pay farmers to house and feed chickens until they make weight. It requires a million dollar investment to enter the business. There has been no increase in five cents a pound growers get. Pay for performance bonuses are subsidized by subtracting pay from the growers at the bottom of the list. The company can game the system and shift lower quality chickens to punish and financially penalize agitators.
If the farmers model prevails in healthcare, the end result will be nothing more that physicians competing against each other for an ever dwindling healthcare pie. This trend of pitting different specialties against each other led to the development of the relative value system. Cognitive physicians were promised higher reimbursement at the expense of the surgical specialties if they supported it. In the end a huge rift was created between surgeons and non–surgeons. As a result of this structural change, surgical fees in my specialty of Ophthalmology and other surgical specialties declined by as much as 90 percent inflation adjusted over the past 30 years. Yet cognitive fees did not rise significantly. Divide and conquer worked in the past against physicians and should not be allowed to work again. Pay for performance is more of the divide and conquer strategy and should be opposed.
Medical Homes
HIP groups were an example of the medical home model. They were capitated comprehensive healthcare systems staffed by physician partners and employed physicians. Profits were distributed to the partners. In my specialty of ophthalmology physicians provided both office–based and surgical care. Full–time ophthalmologists had a designated number of hours per week to provide office care, and time was set aside for surgical care. If the surgeon did not have enough cases to fill his/her surgical schedule, the unused surgical time was paid time off. Surgeons were incentivized not to operate. Would you rather have time off or perform stressful surgery for the same income? HIP groups fell into financial difficulty and had to modify their model. Human nature makes this system flawed.
Role of the Medical Society
The success of the medical society in achieving its goals is dependent on the preservation of a competitive and diverse healthcare marketplace where physicians have choices as to how they can practice their profession and patients have choices how they can receive healthcare. Independent physicians are a necessary component of that diverse marketplace.
It is essential for the survival of independent physicians to be able to legally collaborate and form joint ventures that enable them to comply with the new requirements for healthcare delivery.
Organized Medicine needs to spearhead and be a resource to achieve these goals. Over the past two years, the Medical Society of the State of New York (MSSNY) has lost over 1,000 members and approximately 1/2 million dollars per year, most likely from the loss of independent practitioners. They must invest in restoring economic health to that sector. It is morally right and economically sound. Medical societies need to expand their membership among employed physicians. We have been working on that effort at New York County and will continue to do so.
Employed physicians are affected by all of the major issues in healthcare that plague independent physicians. Malpractice costs, although paid by the by the employer, are an overhead expense that if reduced could lead to higher wages. Expanding the role of non–physicians in healthcare will result in physicians being replaced by non–physicians in the workplace. Regulatory and record keeping burdens apply to all physicians and reduce the productivity that is usually linked to income. We must fight for the wellbeing of all physicians regardless of the employment setting.
We must reverse the apathy of the physician community that has led to decreased economic resources on the county and state level. In fact. two percent of the physicians in the State provide the majority of the funding of the MSSNY PAC. With limited resources, options are limited. We have been successful in preventing bad legislation, but less effective in advancing positive legislation.
Physicians as a group need to support local organizations where there is a 10:1 return on investment as compared to national organizations. My wife Belle, who is also a physician, suggested that we start a co–pay campaign where each physician would, in addition whatever they have contributed, should donate one co–pay to the MSSNY PAC. If every physician in the state made even that small donation it would be a game changer.
Many government policies are ill conceived, have already been shown to fail, and could in the long run prove detrimental to our healthcare system. Organized medicine must play a role in developing innovative solutions to redesign healthcare delivery that provides cost–effective healthcare and enable physicians in all settings to earn salaries commensurate with the time energy and effort that was devoted to becoming a physician, the responsibilities and burdens imposed upon them, and the benefits that they provide for their patients.
We as physicians must break the culture of competition that we have been dealing with in high school, college, medical school, residency, fellowship, and in the job market. It is time to embrace a culture of collaboration. We must use the skills and ambitions that have advanced the science of medicine to such an amazing degree over the past 30 years and apply that energy to improving the delivery of cost –effective medicine to our patients.
The New York County Medical Society and its Board includes physicians in a multitude of specialties and practice environments including independent, employed, and industry based. We represent you the physician community and will continue to do so. We will experiment with new programs and constantly assess the benefits that we provide our members.
In this changing environment we need your support, both monetary and body, to serve the interests of our members and the patients we treat.
I am honored to serve you as President of the New York County Medical Society, and I thank you for your support.