v o l u m e 9 8 • n u m b e r 4 • a p r i l 2 0 1 2

I n t h i s i s s u e :

Reel Docs - Photos from the event

Business of Medicine - New Medicare Administrative Contractor

Independence and Autonomy

TMLT Trust Rewards serves as a financial reward program for TMLT policyholders that will be distributed to enrollees upon their retirement or other qualifying events.

To receive the benefit of this program, you must be a TMLT policyholder and you must enroll!

How can TMLT policyholders enroll? Fill out the form at www.tmlt.org/trustrewards. After you complete it, mail it in, fax it to us, or e-mail it. All the instructions are on the form.

TMLT kicked off this program on January 1 of this year. We have already received thousands of enrollment forms, but not yours. Don’t miss out on this opportunity.

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901 S. MoPac Expressway, Barton Oaks Plaza V, Suite 500, Austin, TX 78746-5942901 S. MoPac Expressway, Barton Oaks Plaza V, Suite 500, Austin, TX 78746-5942Rated “A” (Excellent) by A.M. Best Company

www.tmlt.org

submit letters to the editor to lauren@dallas-cms.org

About the Cover PhotoHealthPAC board members Drs. David I. Kabel, Rebecca Euwer and Wendy Parnell discuss upcoming local elections before the March PAC meeting.

63 President’s Page Independence and Autonomy

69 Community Project Access Dallas 2011 Year-end Report

70 Reel Docs Photos from the event

72 Failure to Diagnose Cardiac Arrest

75 Membership Matters Why Being a Member is Important for Geetanjali Srivastava, MD

79 Business of Medicine New Medicare Administrative Contractor

v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • A p r i l 2 0 1 2 • 6 1

Dallas County Medical SocietyPO Box 4680, Dallas, TX 75208-0680Phone: 214-948-3622, FAX: 214-946-5805www.dallas-cms.orgEmail: lauren@dallas-cms.org

DCMS Communications CommitteeRoger S. Khetan, MD ............................................. ChairRobert Beard, MD Gene Beisert, MDSuzanne Corrigan, MDSeemal R. Desai, MDGary Goldsmith, MDVeronica Hegar-Gonzalez, MD Daniel Goodenberger, MD Gordon Green, MD Steven R. Hays, MDC. Turner Lewis, MDDavid Scott Miller, MD

DCMS Board of DirectorsRichard W. Snyder II, MD ................................. PresidentCynthia Sherry, MD .................................President-ElectJeffrey E. Janis, MD .........................Secretary/TreasurerShelton G. Hopkins, MD ......... Immediate Past PresidentMark A. Casanova, MDWendy Chung, MDR. Garret Cynar, MDSarah L. Helfand, MDMichael R. Hicks, MDRainer A. Khetan, MDTodd A. Pollock, MDKim Rice, MDChristian Royer, MD

DCMS StaffMichael J. Darrouzet .................. Chief Executive OfficerLauren N. Cowling ............................... Managing EditorMary Katherine Allen ..........................Advertising Sales

Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2012 DCMS

According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish legislative advertising in the DMJ: Michael J. Darrouzet, Executive Vice President/CEO, DCMS, PO Box 4680, Dal-las, TX 75208-0680.

Dallas Medical Journal(ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.

Subscription rates$12 per year for members; $36, nonmembers; $50, overseas. Periodicals postage paid at Dallas, TX 75260.

PostmasterSend address changes to:Dallas Medical Journal, PO Box 4680 Dallas, TX 75208-0680.

v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • A p r i l 2 0 1 2 • 6 3

President’s Page

Richard W. Snyder II, MD

If you like to contemplate the possibilities presented by large numbers, as I do, then US healthcare spending is right up your alley. The numbers speak for themselves: Total 2010 US healthcare spending: $2.6 trillion ($8,402 per person); percent of GDP, 17.9 percent. Broken down, the numbers invoke a “shock and awe” reaction: Medicare, $525 billion (20 percent); Medicaid, $401 billion (15 percent); private business, $534 billion (21 percent); households, $725 billion (28 percent — lowest ever). Private health insurance accounts for $849 billion. Of the total US bill, 45 percent is covered by federal, state and local governments. Based on the current trajectory, healthcare spending as a percentage of GDP could reach 25 percent to 30 percent!

These staggering numbers paint a picture that is intimidating and dire. It is hard to envision how the economy and our healthcare system can absorb the growth provided by Obamacare and the volumes of baby boomers as they mature into Medicare eligibility and their peak healthcare-need years. We physicians know that the healthcare system has much inefficiency and waste, at multiple levels, and that our limited resources can be allocated more wisely. But the real question is, who is best positioned to remove this waste and inefficiency from the system?

The economic drama of fee-for-service and private health care has three principal protagonists: insurance companies, physicians and hospitals. Each side of this triangle competes for healthcare dollars in a zero sum game dynamic. Historically, these three mostly have operated independently and frequently at odds with each other. When considering total healthcare spending, physician reimbursement accounts for an average of only 10 percent to 15 percent. But most importantly, virtually every dollar spent in health care ($2.6 trillion), either directly or indirectly, flows through a physician’s pen (or more commonly, a physician’s electronic orders). Physicians — not the hospitals or the insurance companies — make the

decisions of when and how to spend the vast majority of the healthcare dollar, and the hospitals and insurance companies know this.

Previously, during times of healthcare economic and regulatory adversity, consolidation occurred predominately within the hospital, payer and physician sectors to create economies

of scale and leverage size to better compete with the other two. The 1990s saw a brief time of consolidation between hospitals and physician providers, mainly through an employment model. But this relationship was ineffective economically and, for the most part, was abandoned. Independent physician practice reemerged as the norm.

However, healthcare economic and regulatory adversity has stormed back with a vengeance. Growing overregulation and relentless reductions in reimbursement, especially physician reimbursement, are beginning to have disruptive effects. Additionally, as the demand for health care increases and the financial resources to meet that demand progressively are limited, the government is pressuring all players to limit the cost and the waste. A consensus is emerging that greater coordination of care through alignment of provider services and capitation of services through ACOs and other models will meet this need. This consensus was manifested in the recent Obamacare laws facilitating ACOs and the Independent Payment Advisory Board. These factors are creating economic and market conditions threatening the viability and the independence of hospitals, physicians and payors. With shrinking dollars and growing regulation, the force will grow more irresistible toward consolidation and alignment not only within, but among, the hospital, physician and insurance sectors. This is disproportionately true for the physician group. Where once these three players operated independently, and in a rough though unbalanced equilibrium, they are beginning to align, resulting in interesting relationships, dynamics and sometimes unintended consequences.

A new reality is taking shape by which the merger of any two of these three entities in a local market can disrupt that equilibrium and facilitate the disruptive domination of the third. The leverage created by these alignments can alter the economic realities of supply/demand unfavorably and increase the cost of accessing health care. Because virtually every dollar decision of care must come from a physician, it is physicians who have a target on their backs and are attractive from an alignment perspective. If this group can be managed (i.e., controlled), so can the flow of healthcare dollars. Partly for this reason, physician practices are being acquired in a medical version of the movie “Moneyball.” Instead of acquiring players and paying them for their productivity measured in hits, runs and strikeouts, doctors are being purchased and compensated based on their productivity in RVUs, stents, surgeries, and admissions.

Independence and Autonomy

continued on p.64 >>

6 4 • A p r i l 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

President’s Page

For the last several years, we have seen accelerating alignment between physician practices and hospitals, primarily in the form of an employment model. The targeted disproportionate reduction in physician reimbursement and overregulation has made independent physician practice increasingly untenable. Ostensibly hospitals have been motivated to acquire physician practices to lower costs through greater coordination of care and to meet the expected need for emerging bundled capitation payment models. But when hospitals and physicians are aligned in this manner, unintended (and cynically intended) consequences can result. This alignment can alter the economic dynamics, creating dominating leverage vis-à-vis the third player in that triangle: in this instance, the payor (insurance company). The unintended consequence can be one of higher cost to the local market and society. The aligned hospital-physician system can take advantage of the up to 3x greater technical reimbursement disparity for outpatient imaging services between the Medicare B and Medicare A (HOPPS) payment schedules. The aligned provider entities can leverage this relationship for greater reimbursement. Interestingly, new relationships are emerging by which insurance companies are attempting to buy physician practices to gain leverage with the hospitals and as a defensive maneuver. Other models are materializing in which a hospital and insurance company align. Finally, there is the mother of all alignments, the one by which all three come together — insurance company, hospital and physicians — in one package. You can imagine the possibilities, both good and bad, and the unintended consequences of this type of amalgamation.

We physicians must never lose sight that our ultimate alignment is with the patient. I know this sounds quaint and perhaps idealistic, but this is at the core of why the vast majority of physicians went into medicine. It also is an idealism that our patients and the public desperately hope to be true. The patients inherently hope and believe that their physicians hold their relationship as ultimate, and that the physicians are acting in the patients’ best interests. The real question is whether this physician alignment with other healthcare entities weakens the primacy of the physician-patient relationship. Does it affect the physician decision-making process in regard to the utilization of healthcare resources?

At the core of this most important of all alignments— that between doctor and patient — is the concept of physician independence and autonomy. The glue that creates the physician-patient bond is the trust derived from the physician’s independence and autonomy. These are mutually sustaining. Society bestows us with independence and autonomy because

we are trusted as the ultimate protectors and advocates of the patients’ best interests. When the elements of independence and autonomy are transferred, the trust of the patient also can be. When trust is gone, so is the effectiveness of the physician-patient relationship and the healthcare process. Physicians must have the independence and autonomy to act in the best interest of our patients, and our patients must believe that to be true. Clearly our profession has examples of members who have abused that trust, independence and autonomy for personal gain, but these are rare. No one called for the abolition of the stock market and of the hedge fund system because of one glaring example of abuse, so no one should use examples of physician transgressions of trust as the premise to seize our ability to care for our patients without interference. Physician autonomy and independence must remain inviolate. I idealistically believe that the vast majority of physicians place the patients’ best interest above their own.

Perhaps the greatest threat to our independence and autonomy comes from within when we unknowingly and naively cede these rights, such as when physician practices merge with a hospital or insurance system. This alignment can be effective in coordinating care, lowering cost, increasing access, and improving quality. There are many different models and permutations by which these relationships can manifest. We as physicians are best positioned to serve as advocates for our patients in our pursuit of quality and cost effectiveness as owners and partners in the healthcare delivery system. The most prevalent alignment, however, is the employment model. Not all physician employee-employer models are the same. Most are not of the “master-slave” type of dynamic, and most can be positive if structured and done correctly. It is incumbent on the physician and physician groups that enter into these contracted alignments that our independence and autonomy are not diluted, transgressed or transferred. We physicians are the ones who are best positioned to limit waste, correct inefficiencies, and, ultimately, lower costs in our healthcare system, but this is only by virtue of our independence and autonomy. Our independence and autonomy are as critical to us as physicians as are our stethoscopes, scalpels and prescription pads. Without them, we cannot function.

Independence and autonomy are our ultimate bond with our patient, and our ultimate weapon to fight disease. They always have been and always will be.

Society bestows us with independence and autonomy because we are trusted as the ultimate protectors and advocates of the patients’ best interests.

<< continued from p.63

DCMS Spring PicnicDallas Arboretum

Saturday, May 1211 am - 2 pm

F R E EAdmission to the gardens, parking, lunch,

activities for the kids and door prizes for the adults!

SAVE THE DATE

LAW OFFICES OF MICHAEL J. KHOURI

1701 N. Market StreetSuite 318 LB45Dallas, Texas 75202

Telephone: (866) 231-3670

Cell: (949) 680-6332

www.texas-medicare-lawyer.com

Medicare / Medicaid Audit DefenseMedicare / Medicaid Fraud Defense

Criminal Defense for Health Care providers

6 6 • A p r i l 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

Most HIV positive persons had previous

visits to a medical facility where they

were not tested for HIV.

Routine HIV testing is an opportunity for earlier diagnosis and treatment.

Learn more at

www.testtexashiv.org

CDC. Missed Opportunities for Earlier Diagnosis of HIV Infection --- South Carolina, 1997—2005. MMWR 2006; 55(47);1269-1272

message no 5 dcms.indd 1 6/12/11 6:36:58 PM

Family Doctors. Convenient Care.

u Generous retention bonus u Highly competitive base pay

u Monthly and quarterly bonuses u 401k

u Time off for vacation and CME u Paid malpractice insurance

u Health/dental insurance u Life insurance and LTD

Enjoy a quality career and a higher quality of life. Call 972-906-8124 or email doctorpositions@carenow.com

Pack your bags and head to CareNow.At CareNow, we understand what it takes to be a physician. That’s why we offer excellent compensation packages for all of our physicians. Base salary is an hourly rate, so you’re paid for every hour you work. We also offer a generous bonus program and numerous other benefits.

Patrick F. Madden

Providing legal 

services to 

physicians, dentists 

and medical groups 

since 1993

Named as a Texas SuperLawyer®, a Thomson Reuters service, every year since 2005 in Texas Monthly

AV‐Preeminent Rated, Martindale‐Hubbell ®Fellow of the Litigation Counsel of American Trial Lawyer Honorary SocietyD Magazine Best Lawyers Under 40, 2006

3800 Renaissance Tower, 1201 Elm Street, Dallas, TX 75270214.651.3349   pmadden@macdonalddevin.com

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v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • A p r i l 2 0 1 2 • 6 7

The  Project  Access  Dallas  Physician  Network  team  has  created  a  contest  to  encourage peer-to-peer recruitment within the top needed specialties.

Marsha James, office manager for the North Texas Endocrine Center at Carrell Clinic, has been spreading the word about Project Access Dallas to her physicians! Jonathan Leffert, MD, signed up  to  join  his  colleague  Peter  Bressler,  MD,  a  longtime  volunteer.  Both  physicians  will contribute to the care of almost 20 patients in need. John Westkaemper, MD, has joined his colleagues at Irving Orthopedic and Sports Medicine as a volunteer physician. Dr. R. Mills Roberts and Dr. Westkaemper, with the help of two PAs, will see dozens of patients  in need of orthopaedic  care. Thank you  to office manager Kimberly Smith for helping these physicians care for the working poor in Dallas County!

PAD Contest Winners

John Westkaemper, MD, Kimberly Smith and R. Mills Roberts, MD

Peter Bressler, MD, Cheryl Prelow, PAD VP, and Jonathan Leffert, MD

Marsha James and Peter Bressler, MD

Dallas County Medical Society and the Texas Rangers Baseball Club have teamed up to offer DCMS members discount tickets in premier seating locations to multiple

games at Rangers Ballpark in Arlington. Please call Jeremy Christopher for availability and

reservations at 817-273-5173 or e-mail jchristopher@texasrangers.com.

Information is also available at www.dallas-cms.org/membership/events.cfm#rangers.

Brought to you by DCMS Member Benefits.

Summer Fun with the Texas Rangers and DCMS

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TMA FoundATion’s 19Th AnnuAl GAlAFriday, May 18, 2012 • 7:00-11:00 p.m.

Held in conjunction with texMed,tMa’s annual Meeting

Sheraton Dallas Hotel • 400 N. Olive Street

TMA FoundATion’s 19Th AnnuAl GAlAGoinG Gold

for GreatHealtH

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In the spirit of the London 2012 Olympic Games,

join friends and colleagues to celebrate the teamwork among

medicine, business and community in carrying out

TMA Foundation-funded initiatives helping texans to be healthier now and in the future.

Friday, May 18, 20127:00-11:00 p.m.

Held in conjunction with texMed, tMa’s annual Meeting

Sheraton dallas Hotel400 n. olive Street

Co-Chairs dr. Walter F. and Mrs. Candace

evans, dallas dr. deborah a. Fuller andKevin d. Broadway, dallas

Activities Patron and Sponsor receptionGuest reception/Silent auctiondinner/entertainment/dancing

For sponsorship andticket information, go to

www.tmaf.org

www.tmaf.org

(800) 880-1300, ext. 1664

TMA FoundATion’s 19Th AnnuAl GAlA

GoinG Gold

for GreatHealtH

Friday, May 18, 2012 • 7:00-11:00 p.m.

Held in conjunction with texMed,tMa’s annual Meeting

Sheraton Dallas Hotel • 400 N. Olive Street

www.tmaf.org • (800) 880-1300, ext. 1664

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Doctors of North Texas?

O F N O R T H T E X A S

817-321-0300www.radntx.com

1937-2012

The 110 physicians of Radiology Associates of North Texas areproud to celebrate our 75 year commitment to excellence in radiology!

Our 14 outpatient imaging centers, 24 hospital locations and unparalleled subspecialtydepth provide you and your patients with a level of care that is unmatched in North Texas.

Thank you for partnering with us in the care of your patients.

v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • A p r i l 2 0 1 2 • 6 9

Community

2011 Year-end ReportJim Walton, DO, MBA, PAD Medical Director

A patient’s story best describes the value of Project Access Dallas. Imagine a local hospital leader faced with a friend’s request to help an uninsured relative. The relative just received a cardiac diagnosis made during a recent ED visit for chest pain. The condition wasn’t serious enough to require admission, but the patient was told it was urgent enough to deserve attention by a physician within the next 1–2 weeks. With no health insurance, the patient turned for help to a relative involved in healthcare administration. A few phone calls later, the patient had an appointment with a local PAD charity clinic’s primary care physician. That physician deemed the condition urgent, and the patient was scheduled to see a volunteer PAD cardiologist, who performed a stress test and echocardiogram in the office. Within 2 weeks the patient went from an ED visit to cardiac catheterization and a diagnosis of coronary artery disease needing bypass surgery. Amazing as it seems, the final chapter of the story has the patient receiving bypass surgery at Parkland Hospital, without having had a heart attack. As you will see in this annual report, the value of hundreds of similar stories is measurable. However, the value to the patients and their families is priceless!

Enrollment: PAD finished 2011 with a 12-month average of 3,178 active enrollees. Although enrollments remain active (~116 new patients per month) from 11 community clinics and private physician offices, PAD has worked to maintain enrollment at approximately 3,000.

Specialty Care Referrals: PAD completed 1,947 specialty care physician referrals (73 percent of all 2011 specialty requests). This success helped ensure that people received the care they needed and decreased pending referrals by 18 percent from 2010. This was accomplished by a concerted effort to recruit PAD volunteers. We added 240 physician volunteers (152 primary care and 88 specialty care) in 2011. With continued assistance from physicians with the University of Texas Southwestern Medical Center and Parkland Health and Hospital System, we have reduced the average wait time for a specialty care appointment to 50 days, with urgent appointments made within 14 days.

Pharmacy: During the first half of 2011, PAD experienced a 30-percent increase in pharmaceutical costs, to $23.41 per patient per month. The number of prescriptions per patient increased 21 percent, with the costs per prescription rising 7 percent. As a result PAD made major changes to the pharmacy benefit, which helped bring spending under sustainable budgetary control. Since October, the addition of a Pharmaceutical Assistance Program navigator helped 149 patients obtain 240 unique brand-name prescriptions, saving PAD more than $22,350 in annual prescription costs for these patients.

By managing the number of PAD enrollees (~3,000), reducing the pharmacy benefit (to $750 per enrollee per year), and adding the Pharmacy Assistance Program navigator, monthly pharmaceutical costs dropped 69 percent in the second half of 2011.

Care Navigation: PAD experienced a 14-percent increase in the number of enrollees requiring care navigation, particularly transportation. One consequence was a 40-percent reduction in “no-show” rates for specialty physician visits, decreasing from 20 percent in 2010 to 12 percent in 2011.

Donations in Care: PAD volunteers donated a total of $9.7 million in care to PAD enrollees during 2011:

• $4.5 million from local physicians

• $5.2 million from local hospitals and ancillary partners

Michael Holub, MD, Charlie, Sandra Brothers, MD, and Vance

Networking before the movieSruiti Boppana and Sita Boppana, MD

Drs. Hanh-Dieu Nguyen and Robert Nisbet

R e e l D o c sOn March 4, DCMS organized the first ReelDocs event at Studio Movie Grill in Dallas. Eighty DCMS members and their families packed into our private theater for a showing of “Dr. Seuss’ The Lorax.” Lunch, popcorn and drinks were served, thanks to

the DCMS Circle of Friends.

Ava Chung with Drs. Wendy Chung and Vanthaya Gan

Amy, Alexis, Ashley, Ashlynne and Robert Nisbet, MD

Carolyn Rousseau and Lauren and Charles Sharpe

Mark McNutt, MD, and Connor

Sean, Lucas and Liam Callahan, and Gabriela Blanc, MD

Paul Aggerwal, MD, and Anya

Look for another ReelDocs event this

summer!

7 2 • A p r i l 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

PresentationA 37-year-old man came to the emergency department complaining of chest pain. The pain was located in the left anterior chest region and began 30 minutes before he arrived in the ED. The patient reported that he felt weak and sweaty.

Physician actionThe patient was triaged immediately. An emergency medicine physician evaluated him and began cardiac protocol. An IV was started, and the patient was given an aspirin and sublingual nitroglycerin every 5 minutes for 15 minutes. The patient’s EKG was interpreted as borderline normal with no acute ischemic changes. The chest X-ray was reported as clear. Lab work was ordered.

The patient continued to have considerable chest pain, described as nonradiating and located in the left anterior chest area. He was given 4 mg of morphine

intravenously with minimal response. Approximately 40 minutes later, he was given 30 mg of Toradol intravenously. A second EKG was performed. Thirty minutes passed and the patient still was experiencing significant pain. He was given 8 mg of intravenous morphine. Shortly after receiving this dose of morphine, the patient’s discomfort was greatly relieved.

The emergency medicine physician reported that the second EKG showed no changes, although the patient developed mild bradycardia. The lab work indicated normal chemistries and normal cardiac enzymes. Due to the difficulty in alleviating the chest pain, the emergency medicine physician ordered a CT of the chest to rule out a pulmonary embolism. The CT was reported as normal.

The patient now was reporting that his chest pain had improved significantly. After a discussion with the patient about obtaining a cardiac evaluation, the emergency medicine physician called a cardiologist and

Failure to Diagnose Cardiac ArrestTMLT Risk Management Department

This closed-claim study is based on an actual malpractice claim from Texas Medical Liability

Trust. This case illustrates how action or inaction on the part of physicians led to allegations

of professional liability, and how risk management techniques may have either prevented the

outcome or increased the physicians’ defensibility. The ultimate goal in presenting this case

is to help physicians practice safe medicine. An attempt has been made to make the material

more difficult to identify. If you recognize your own claim, please be assured it is presented

solely to emphasize the issues of the case.

v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • A p r i l 2 0 1 2 • 7 3

scheduled a stress test for the patient. Approximately 4 hours after presenting to the ED, the patient was discharged with a diagnosis of atypical chest pain. He was advised to take aspirin and to return to the hospital if the pain recurred.

Early the next morning, the patient’s wife found him gasping for breath and called EMS. The paramedics documented that the patient was in asystole and apneic. He was immediately intubated, started on oxygen, and given drugs to stimulate his heart. CPR was initiated. After 8 minutes, the patient regained a heartbeat and spontaneous respirations. He was transported to the hospital. Upon arrival, he was found to have had a full cardiac arrest. He was posturing and had a seizure, which suggested some hypoxic cerebral damage.

The cardiac arrest resulted in a 23-day hospital stay that included a cardiac catheterization and angioplasty with stents. The patient was sedated and remained intubated during the early part of his hospitalization.

At discharge, the patient was alert, communicative, in good spirits, and looking forward to returning to work. His discharge diagnoses included ventricular tachycardia and fibrillation; cardiac arrest; anoxic encephalopathy; and acute inferior wall myocardial infarction status post emergency angioplasty and triple stenting of the right coronary artery. The patient was released to cardiac rehab, and instructed to follow up with the cardiologist and a neurologist to monitor his seizure activity. The patient eventually returned to work, but claimed he could not perform as well due to his cognitive deficits and inability to concentrate.

AllegationsA lawsuit was filed against the emergency medicine physician. The allegations included: Failure to order serial 12-lead EKGs; failure to seek a cardiac admission for 23-hour observation; and failure to order diagnostic testing, including serial cardiac enzymes. It was alleged that the patient would not have suffered a cardiac arrest and anoxic encephalopathy if the defendant had more thoroughly evaluated the patient.

Legal implicationsThe plaintiff’s experts criticized the patient history taken by the defendant. It was “missed” that the patient smoked two packs of cigarettes per day for 20 years. This information was documented by subsequent healthcare professionals. It was also alleged that the diagnostic work-up fell below the standard of care. The emergency medicine physician listed myocardial ischemia or infarction as the first differential diagnosis, but she failed to order a 6-hour troponin that would have helped rule out that diagnosis. The plaintiffs argued that a patient with severe, intermittent pain, a history of tobacco dependency, and two abnormal EKGs with dynamic changes should be considered an acute coronary patient in the absence of any other explanation for the symptoms.

Defense experts generally were supportive of the care provided by the emergency medicine physician. However, they agreed that the patient should have been admitted for observation and repeat enzymes. Defense experts were impressed that a cardiology opinion was obtained, but given the patient’s history of t o b a c c o use, they felt it would have been prudent to have the cardiologist examine the patient before discharge.

Risk management considerationsEmergency medicine physicians are responsible for conducting a basic evaluation and providing a reasonable assessment of a patient’s medical condition. A thorough patient history is critical to this process; perhaps even more so when a patient complains of chest pain. The fact that the patient was a long-time smoker is a key piece of information affecting treatment decisions. In this case, the patient denied smoking, but his wife stated that he was a 2.5-pack-per-day smoker. She stated that anyone could tell that the patient smoked by standing close to him. Had the emergency physician known this, she would have admitted the patient for observation and requested a cardiac consult. This may have led to a more timely diagnosis.

Using all reliable sources to gather health information — including risk factors — can affect timely treatment and improve patient outcomes.

DispositionThis case was settled on behalf of the emergency medicine physician.

The information and opinions in this article should not be used or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalization can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services. © Copyright 2012 TMLT.

The patient was released to cardiac rehab and instructed to follow up with the cardiologist and a neurologist to monitor his seizure activity. The patient eventually returned to work, but claimed he could not perform as well due to his cognitive deficits and inabil ity to concentrate.

7 4 • A p r i l 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

You’re invited to a night out with theFRISCO ROUGHRIDERS!

RSVP via FAX to 214.946.5805 or e-mail linda@dallas-cms.orgBecause of limited seating, only one guest ticket per member will be issued.

Physician name

E-mail

Guest name

Phone

Visit www.ridersbaseball.com for directions. For questions, call 214.948.1431.

Wednesday, April 25 Dr Pepper Stadium in Frisco

Frisco RoughRiders vs. San Antonio MissionsJoin us for a fun evening with fellow DCMS members.

Enjoy a free ticket to the game and a free meal!Parking is $10.

Check out www.dallas-cms.org for more details and RSVP information.

This event is sponsored exclusively by our DCMS Circle of Friends:

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When Geetanjali Srivastava, MD, moved to Dallas, among the top items on her to-do list was to join the Dallas County Medical Society.

She came to Dallas from Washington, DC, and never had been active in a local medical society.

“I wanted to have a voice in the local, state and national discussion on healthcare delivery,” she says. “I wanted to meet other physicians who share my values and to learn from others.”

As a pediatrician and emergency medicine physician, Dr. Srivastava hopes to advocate for children and ensure that pediatricians are well-represented at DCMS and TMA.

She appreciates the opportunities that her DCMS membership provides to volunteer in the area. Soon after she settled in Dallas, she performed school and sports physicals for students during a health fair organized by the DCMS Alliance.

She also takes advantage of DCMS social events, such as the recent networking social at Cantina Laredo, where she enjoyed meeting other young physicians in Dallas.

After Dr. Srivastava expressed interest in joining the DCMS Legislative Affairs Committee, DCMS President Richard W. Snyder II, MD, appointed her to the committee. She quickly has become an integral part of the committee, expressing her views on health system reform and its benefits for children. She says that as an employee of Children’s Medical Center in pediatric emergency medicine, she hopes her service to DCMS allows her to represent her hospital and its physicians in a positive light.

W h y B e i n g a M e m b e r i s I m p o r t a n t f o r G e e t a n j a l i S r i v a s t a v a , M D

D r . S r i v a s t a v a a l s o i s i n v o l v e d w i t h t h e T e x a s P e d i a t r i c S o c i e t y , w h e r e s h e s e r v e s o n t h e C o m m i t t e e o n E m e r g e n c y M e d i c i n e a n d t h e

C o m m i t t e e o n C o m m u n i t y H e a l t h A d v o c a c y .

D r . S r i v a s t a v a a n d h e r h u s b a n d , M a x K a l h a m m e r , l i v e n e a r D C M S h e a d -q u a r t e r s , i n K e s s l e r P a r k . M a x i s a s e n i o r t r a n s p o r t a t i o n p l a n n e r f o r t h e C i t y o f D a l l a s a n d i s w o r k i n g o n t h e c i t y w i d e b i k e p l a n i m p l e m e n t a t i o n .

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For questions about DCMS Circle of Friends contact Mary Katherine Allen, business development manager, at mkallen@dallas-cms.org or call 214.413.1456

CIRCLE

in

2012

The Dallas County Medical Society is offering a valuable benefit to help members with their medical practices—DCMS Circle of Friends. This program provides information about medical-related businesses that serve Dallas-area physicians.

Be a partofthe

SILVERCareCloud

Goldin, Peiser & PeiserLincoln Harris, CSGParanet Solutions

Rebecca Harrell, Medical Office SpecialistShaw & AssociatesThe Health GroupUnited Texas Bank

Texas Medical Liability Trust TMA Insurance Trust

DIAMOND

PLATINUMThe Medical Protective Company

Global Healthcare Alliance

GOLDAmerican Physicians Insurance Company

Southwest Diagnostic Imaging Center

7 8 • A p r i l 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

TRMC invites you to work here and grow your practice.

Contact Administration at 972-892-4404 to open a confidential dialogue.

TEXAS REGIONAL MEDICAL CENTER AT SUNNYVALE THE CUTTING EDGE OF OPPORTUNITY

ARE YOU LOOKING FOR THE PERFECT FIT?A thoroughly modern facility just 15 minutes east of Downtown Dallas

Currently providing patients a full array of specialty surgeries including:

• Bariatrics • ENT (including pediatrics) • Cardiothoracic and Vascular • Endoscopy • General • Gynecology

• Orthopedics • Pain Management • Plastics • Podiatry • Spine • Urology

We invite you to consider becoming a part of our culture of success.

Private Banking | Fiduciary Services | Investment Management | Wealth Advisory Services | Specialty Asset Management

Bob White: 214.987.8882 | Bernie Blaschke: 214.346.3911 | www.bankoftexas.com

©2012 Bank of Texas, a division of BOKF, NA. Member FDIC. Broker/Dealer Services and Securities offered by BOSC, Inc., an SEC registered investment adviser, a registered broker/dealer, member FINRA/SIPC. SEC registration does not imply a certain level of skill or training. Insurance offered by BOSC Agency, Inc., an affiliated agency. Investments and insurance are not insured by FDIC, are not deposits or other obligations of, and are not guaranteed by, any bank or bank affiliate. Investments are subject to risks, including possible loss of principal amount invested.

Consider it a HolistiC approaCH to Managing Your praCtiCe’s FinanCes.When it comes to your patients, you don’t just treat symptoms. You look at their overall health and lifestyle. And make a diagnosis based on the big picture. That’s how we approach your finances. Both your personal and your practice’s. Making for a healthy, wealthy and wise financial outlook.

personal solutionsResidential mortgage, including 100% financingLife and disability insurance servicesInvestment managementEstate and retirement planningSpecialized healthcare deposit products

practice solutionsTerm financing for partnership buy-insEquipment financing and lines of creditReal estate financingHealthcare remittance automationDeposit solutions

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v i s i t u s o n l i n e a t w w w . d a l l a s - c m s . o r g • A p r i l 2 0 1 2 • 7 9

Business of Medicine

New Medicare Administrative ContractorTrailBlazer Health Enterprises’ attempt to remain the

Medicare administrative contractor for Texas failed earlier this month when the Government Accountability Office denied its appeal of the selection of another vendor.

Novitas Solutions, formerly Highmark Medicare Services, will begin handling Medicare claims in Texas and six other states beginning later this year. The Centers for Medicare & Medicaid Services announced in November it had awarded the contract to Highmark as part of its plan to reduce the number of Medicare administrator jurisdictions from 15 to 10 by 2016.

Highmark changed its name to Novitas Solutions in January when Blue Cross and Blue Shield of Florida purchased it. Besides Texas, the company will handle claims in Arkansas, Colorado, Louisiana, Mississippi, New Mexico, and Oklahoma. It now administers claims in Delaware, New Jersey, Pennsylvania, Maryland, and the District of Columbia. It also will be responsible for enrolling, educating and auditing Medicare physicians and other healthcare professionals, and some key specialty functions, including processing Indian Health Service facility claims for the entire country and serving as the designated Medicare Parts A and B contractor for centralized billing by immunization clinics.

Because TrailBlazer has the option of review, no official notice has been released by CMS, Novitas or TrailBlazer.

ConsolidationThe new Jurisdiction H combines former Jurisdiction

4, which includes Texas, Colorado, New Mexico, and Oklahoma, and Jurisdiction 7, which includes Arkansas, Louisiana and Mississippi.

TransitionThe transition is expected in late summer.

TrailBlazer’s contract with CMS runs through August 2012. TrailBlazer said any transition to Novitas “would include extensive communications with providers and other impacted parties about transition requirements and activities.”

Novitas will provide affected providers with information about how the implementation will work, once CMS has finalized the implementation schedule. In the meantime, until affected Medicare workloads convert to the Jurisdiction H MAC, providers will continue to submit claims to their current Medicare contractor.

Potential ImpactIssues that physician offices should be aware of

include a potential disruption of cash flow. Novitas uses US Bank to pay Medicare claims while Trailblazer uses JP Morgan. Physicians and other healthcare professionals may have to execute new electronic funds transfer agreements with Novitas’ bank before they can be paid.

Additionally, Novitas uses a different “front end” system than TrailBlazer. Physicians may need to test their practice management software to ensure it is compatible with Novitas before they can conduct electronic transactions.

Furthermore, Novitas will review all of TrailBlazer’s local coverage determination policies and may issue new coverage decisions. Under a local coverage determination, a contractor decides whether it will cover particular services on a carrier-wide basis.

In February, concerned over the change’s impact on physician and patients, TMA and the Colorado, New Mexico, and Oklahoma state medical societies backed TrailBlazer’s appeal. They wrote Acting CMS Administrator Marilyn Tavenner that the decision to change contractors was “ill considered, and will cause substantial disruption when consistency and stability is needed.”

ResourcesCurrent Medicare participating physician offices should sign up to receive notices from TrailBlazer. TrailBlazer will post information about the transition timeline. Also, physician offices should continue to work with TrailBlazer until they are officially told of the transition to Novitas. TrailBlazer’s Web site is at: http://www.trailblazerhealth.com

Watch for additional transition information, including the implementation schedule to be announced shortly, at

https://www.novitas-solutions.com/transition/jh/index.htm.

DCMS staff and TMA’s Payment Advocacy Department will work with Novitas, TrailBlazer and CMS to make the transition as smooth as possible for physician practices and patients.

Access to the formal denial can be found here:

http://www.gao.gov/search?q=CMS-RFP-2011-0005&Submit=Search

8 0 • A p r i l 2 0 1 2 • D a l l a s M e d i c a l J o u r n a l

April 15Federal Agency: IRS Estimated Tax Payment Due

May 15State Agency: Texas Franchise Tax, Reports & Payments

June 01Federal Agency: Deadline to Opt Out of Medicare

June 15Federal Agency: IRS - Estimated Tax Payment Due

June 30 E-Prescribing Hardship Exemption. File now to avoid a 1.5% Medicare penalty in 2013.

June 30E-Prescribing Penalties. File 10 e-prescribing claims to avoid a 1.5% Medicare penalty in 2013.

September 01Federal Agency: Deadline to Opt Out of Medicare

October 01HIT: Medicare EHR incentive program. Last chance to achieve 90 days of meaningful use for first-year particpants.

November 15State Agency: Texas Franchise Tax, Reports & Payments — Extension Due Date

December 31E-prescribing Incentives. End-of-year reporting deadline to claim a 1-percent bonus.

December 31Federal Agency: HIPAA. Privacy and Security Audits.

Visit www.texmed.org/doom for background information, regulations, penalties and incentives, and suggested steps to help you meet the compliance dates.

Upcoming State and Federal Compliance Dates

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Be the first to mention this ad on the DCMS Facebook wall and you could win

a $50 Apple gift card.

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Long Term Disability

Protect yourself from the unforeseenAs a physician, you know just how easily an injury or illness can occur, preventing you from working and earning an income.

That’s why your membership in the Texas Medical Association is so important: It gives you access to great benefits, like the TMAIT-endorsed LTD Plan, with coverage issued by The Prudential Insurance Company of America.

Choose from among many coverage optionsYou have the opportunity to choose coverage that fits your needs. For instance, you may decide that Option 1—the Five-Year Specialty Option—is right for you. There are many Options and features to choose from to make sure you have the coverage your lifestyle requires.

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Apply for this important coverage today.

Call 1-800-880-8181 or visit www.tmait.org/ltdplans to download a brochure or request form.

A Long Term Disability (LTD) Insurance Plan physicians like you can trust

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