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Daily Cinnamon Doses May Cause Edema

October 29

An adult male who was taking 1000 mg of cinnamon bark powder daily developed edma that cleared up when he stopped taking the supplement, according a report in the September-October issue of the Journal of the American Board of Family Medicine.

Thiazolidinediones (TZDs) cause fluid retention in those with diabetes or prediabetes. Some medications in this class have been implicated in increased cardiac deaths from this side effect. While medications are effective for diabetes, many people have turned to natural remedies to treat their diabetes instead of conventional pharmaceuticals. Cinnamon is a common agent used, and it has received extensive lay press attention. Chemically, cinnamon bark powder activates peroxisome proliferated activated receptors similar to TZDs. It is reasonable to hypothesize that cinnamon bark powder can cause edema. This case demonstrates that cinnamon bark powder may have a similar side effect profile. Physicians should be aware that consumption of cinnamon bark powder could cause fluid retention and possibly worsen congestive heart failure.

Clinical Decision Support Tools Improve Care for Adult Sickle Cell Disease Patients

October 26

Clinical Decision Support tools improve care for adult Sickle Cell Disease patients in Primary Care, according to a study published in the September-October issue of the Journal of the American Board of Family Medicine.

Although most patients with rare diseases like sickle cell disease are treated in the primary care setting, primary care physicians may find it challenging to keep abreast of medication improvements and complications associated with treatment for rare and complex diseases. The purpose of the study was to evaluate the effectiveness of a clinical decision support–based intervention system for transfusional iron overload in adults with SCD to improve management in primary care. There was no management change in the control group, while the intervention group improved primary care management from 0% to 44%.

Physicians aren't aware of medical marijuana use by their patients

October 22

Not a single medical marijuana user in a surveyed group had their pot paperwork filled out by their primary care physicians, and only half of those physicians were aware of the marijuana use, according to a study published in the September-October issue of the Journal of the American Board of Family Medicine.

Medical marijuana is now permitted in most states, but it is not clear whether primary care physicians are aware of or recommend its use in their patients. Of 242 patients surveyed, 22% reported marijuana use in the past 6 months, and 61% of these identified as medical marijuana users. primary care physicians did not complete state forms to recommend medical marijuana for any of the surveyed medical marijuana users. Primary care physicians were aware of marijuana use in their patients only 53% of the time. These physicians identified conditions they believed could be adversely affected by marijuana use in 31% of users.

There is poor communication between patients and primary care physicians about medical marijuana use, which is being sanctioned by physicians other than patients' PCPs. Researchers suggest more frequent assessment of and discussion about marijuana use in patients, particularly in states that have approved medical marijuana.

Are you FULLY HIPPA compliant? Don't gamble your practice

October 19

It takes an expert to understand the plethora of state and federal regulations that affect your practice. And those regulations change constantly. Why take chances? Stay up to date with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your business. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!

If We Don't Ask, They Won't Tell: Incontinence Screening by Primary Care Providers

October 16

More than half of older adults experience urinary or fecal incontinence, but the majority have never discussed symptoms with health care providers, according to a study published in the September-October issue of the Journal of the American Board of Family Medicine.

Little had been known about primary care providers' screening for urinary incontinence and fecal incontinence, so researchers interviewed 154 primary care providers. They conducted a cross-sectional electronic survey of PCPs within a Midwest academic institution to ascertain and compare PCPs' beliefs, attitudes, and behaviors regarding screening and treatment for urinary incontinence and fecal incontinence; determine factors associated with screening for fecal incontinence; and identify potential barriers to and facilitators of fecal incontinence screening and treatment.

Researchers found that most PCPs screen for urinary incontinence, but not fecal incontinence. High reported interest in educational materials, coupled with high reported rates of perceived importance of screening for UI and FI, suggests that PCPs welcome informative interventions to streamline diagnosis and treatment.

Improving Effective Magnetic Resonance Imaging for Soft Tissue Wrist Injuries

October 12

MRIs for soft-tissue wrist injuries are more effective when the patient is younger, the MRI is ordered within 6 weeks of symptom onset, and prescribed with a specific differential diagnosis. Referral to a hand surgeon should be considered before wrist MRI for the following patients: history of hand surgery or trauma, patents older than 36 years, ad those suffering chronic wrist changes, according to research published in the September-October issue of the Journal of the American Board of Family Medicine.

Magnetic resonance imaging for soft-tissue wrist injury may be overprescribed, contributing to ineffective health care resource use. We aimed to discern predictive factors that may improve MRIs application in soft-tissue wrist injury.

Researcer conducted a retrospective chart review of adults who underwent MRIs for possible soft-tissue wrist injury between June 2009 and June 2014. Clinical data and treatment recommendations before and after MRI were analyzed. If the MRI-directed treatment recommendation was different from before MRI, the MRI was noted to have influenced the patient's treatment (Impact MRI).

Among 140 MRI scans, 39, or 28%, impacted treatment recommendation. Twenty-six Impact MRIs were ordered by hand surgeons, whereas 13 were ordered by referring physicians. More Impact MRIs were found when an MRI was ordered for patients younger than 36 years, within 6 weeks of symptom onset, to question a specific anatomic injury, or by a board-certified hand surgeon. Adjusting for other covariates, these 4 clinical factors were identified as independent predictive factors to Impact MRIs.

A 30 Year Review of Opioid and Drug Prevalence in Top 40's Music

October 8

Opioids, other drugs and alcohol references in Top 40's music are increasing at a significant pace, according to a study published in the September-October issue of the Journal of the American Board of Family Medicine. Nearly 50% of 2016 Top 40's songs reference drugs or alcohol. Further inquiry is needed to evaluate the societal impact and persuasive abilities of popular culture, including Top 40's music, on American drug and alcohol use.

Researchers studied Billboard's top 100 songs for each year from 1986 to 2016. Lyrics from the 40 most popular songs of each year were reviewed for reference to drugs and alcohol. The objective was to identify current trends in the prose of popular music and, specifically, to identify if a relationship exists between the mention of opioid narcotics in Top 40's music and a rising prevalence of opioid use disorder in the United States.

There was a statistically significant increase in the lyrical mention to opioids , marijuana and alcohol in the 2010s when compared with the songs analyzed from the 1980s. Mentions of opioid drugs and medications emerged in the late 1990s, and since, 57.1% of opioid-referencing songs mention prescription opioid medications, not heroin or street slang reference of the drug. Male- and female-driven mentions to drugs and alcohol have approached near equal rates in recent years.

Regulators are ready; are you?

October 5

State and federal regulations change and update constantly. Keeping up with them is a full-time job, even for experts. Stay up to date with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your practice. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox.


Discussion as effective as exercise for treating Restless Leg Syndrome

October 1

Discussion groups were shown to be just as effective as exercise in treating Restless Leg Syndrome in research published in the September-October issue of the Journal of the American Board of Family Medicine.  

Restless legs syndrome is a sensorimotor disorder that can have a considerable negative impact on quality of life and sleep. Management is primarily pharmacological; nonpharmacological options are limited. The objective of the present study was to determine the effect of tension and trauma release exercises on RLS severity compared with discussion group controls.

There were no significant between-group differences at baseline except for more severe global RLS scores for controls. There were no significant between-group differences at week 6 on any outcome. Significant improvements across time were seen for both groups on all outcomes.

In this exploratory study, tension and trauma release exercises and attending discussion groups were associated with similar outcomes. Participants in both groups improved similarly across time. Future research might establish score stability across a prolonged baseline before commencing intervention.

Women and non-whites less likely to be screened for depression

September 28

Screening for depression should be enhanced in at-risk groups, according to a study in the September-October issue of the Journal of the American Board of Family Medicine.
Only a small fraction of at-risk patients were screened for depression. Nonwhite patients and those with higher comorbidity burden were more likely to report depression, but less likely to be screened.

The study found that hazardous alcohol use with depression may exacerbate health conditions and complicate medical care. The researchers examined the rate of depression screening by alcohol use severity among primary care patients screened for hazardous alcohol use and, among those screened, examined patterns of significant depressive symptoms.

Within 30 days of routine, in-clinic alcohol use screening by medical assistants, 2.4% (n = 68,686) of patients also completed a PHQ-9; these patients were more likely to be female, younger, white, Medicaid insured, and to have a nondepressive psychiatric diagnosis and a lower Charlson comorbidity score. Abstainers and moderate drinkers (1 to 7 drinks/week or 1 to 4 drinks/week for women and individuals >65 years or for men ≤65 years, respectively) were less likely than hazardous drinkers (exceeding weekly limits) to complete the PHQ-9 or to have significant depressive symptoms (PHQ-9 score ≥10). Nonwhite patients with higher Charlson comorbidity scores were more likely to endorse significant depressive symptoms.

LEAP Practices struggle to implement Behavioral Health integration

September 24

High-performing primary care practices share common goals for Behavioral Health integration, as well as common challenges operationalizing these goals, according to a study in the September-October issue of the Journal of the American Board of Family Medicine. As US residents increasingly receive Behavioral Health services in primary care, it is critical to remove barriers to Behavioral Health integration and support primary care practices in meeting a full spectrum of patient needs.

Behavioral health integration has been proposed as an important strategy to help primary care practices meet the needs of their patient population, but there is little research on the ways in which practices are integrating BH services. This article describes the goals for Behavioral Health integration at 30 high-performing primary care practices and strategies to operationalize these goals.

Most Learning from Effective Ambulatory Practices looked to Behavioral Health integration to help them provide timely Behavioral Health care for all patients, share the work of providing Behavioral Health related care, meet the full spectrum of patient needs, and improve the capacity and functioning of care teams. Practices operationalized these goals in various ways, including universal Behavioral Health screening and involving Behavioral Health specialists in chronic illness care. As they worked toward their Behavioral Health integration goals, Learning from Effective Ambulatory Practices faced common challenges related to staffing, health information technology, funding, and community resources.

Career opportunity: Work for Shaw & Associates!

September 21

We have an associate position open in our Dallas office. Duties include drafting pleadings, discovery, etc., legal research, attendance at hearings and depositions, and ability to handle a busy caseload in a small office. Three+ years experience in insurance defense, medical malpractice defense, healthcare law, a plus. For more information on the firm visit www.dkshaw.com. Send resume and writing sample to imendoza@dkshaw.com.

Free newsletter keeps you and your practice up to date with regulations

September 17

Regulations change constantly; let the experts at Shaw & Associates up to date! It takes an expert to understand the plethora of state and federal regulations that affect your practice. Keep current with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your business. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!

“It's Really Overwhelming”: Patient Perspectives on Care Coordination

September 14

Patients with multiple health care providers identified significant barriers to communication among providers and inadequate support with care coordination activities, according to a new study in the September-October issue of the Journal of the American Board of Family Medicine. Expansion of team-based models of primary care and prioritizing interoperable technology for sharing patient health information between providers will be critical to improving the patient experience and the safety of transitions of care.

Failures of care coordination among health care providers are known to lead to poorer health outcomes for patients with complex medical needs. However, there has been limited research into the perspectives of patients who receive care from a variety of health care providers. This qualitative study sought to characterize the factors leading to emergency department patient satisfaction and dissatisfaction with their care coordination.

Four broad categories of themes emerged: perceptions of care coordination between their providers, the role of electronic health records, challenges with information exchange between health systems, and sources of support for care coordination activities, emphasizing the important role of the primary care provider.

New Center for Health Care Professionalism & Value Opening in Washington, DC

September 10

The new Center for Professionalism and Value in Health Care is being established in Washington, DC, according to an announcement by the American Board of Family Medicine and the ABFM Foundation. The Center will be led by Robert Phillips, MD, MSPH, who has been named its founding Executive Director.

“Health care in the United States is in the midst of transformational change; professional self-regulation and the public trust are at risk. To meet this challenge, the ABFM Foundation has decided to make a strategic investment in the creation of the Center with the ultimate goal of dramatically improving health and health care,” said ABFM President and CEO Elect, Warren P. Newton, MD, MPH.

The new Center aims to create space in which patients, health professionals, payers, and policy makers can work to renegotiate the social contract. “The social contract between health care professionals and the public gives clinicians the privilege of self-regulation in exchange for responsibility to act in the best interest of patients. This contract is fraying as increased employment of clinicians creates pressures to serve business interests over those of patients. The erosion of autonomy, strain of regulation, and exploding reporting burden is producing unprecedented levels of burnout,” says Dr. Phillips.

The Center will seek to define value across the health care spectrum, reaching beyond medicine to engage the broader health care community as well as patients and families to consider what they believe professionalism and value mean, how to measure it, how to improve it, and how to engage and develop leaders. The Center welcomes collaboration with all others interested in professionalism and value in health care, including other specialty boards, other professions, and other organizations interested in working together on this common ground.

Women a third more likely to skip diabetes meds

September 7

Less than half of Type 2 diabetic patients achieve glycemic control, partly because many women refuse to take their drugs because of the cost. Women are about a third more likely to skip the medications, according to a study in the September-October issue of the Journal of the American Board of Family Medicine.

The study looked at medicine usage by more than 11,000 diabetes patients for over a year. Women consistently reported significantly higher rates of not taking their medication due to costs. Women were more likely to skip medication, take less medication than prescribed, delay filling prescriptions, and ask doctors to prescribe lower-cost alternative medications.

The study showed a significant gender-based disparity exists with diabetic patients skipping medications to save money. Health care providers and policy-makers should pay close attention to find ways to address cost-related nonadherence of medication among patients with chronic illness, especially among female patients.

No blog post; have a happy Labor Day!

September 3

NHSC may be the answer for placing family doctors in underserved areas

August 30

Paying for college and medical school is expensive in the United States, often leaving recent graduates with large educational loan debt. This can influence the specialty medical students choose and where they practice. Analyzing a survey of board-certified family physicians who were 3 years out of residency, a study in the July-August 2018 issue of the Journal of the American Board of Family Medicine reports that about 30% of this group were participating in some type of loan repayment program that offered debt forgiveness.

Educational debts and the repayment programs that help relieve such debts offer an opportunity to direct physicians to practices in medically underserved areas. The study found, however, that of the 30% of young family physicians participating in debt relief, more than half were in programs that do not have such policies: approximately a quarter of the doctors were in loan forgiveness programs directly from their hospital or employer, and almost another quarter were enrolled in the federal Public Service Loan Forgiveness (PSLF) program.

Although the “public service” in PSLF's title sounds like a program that requires placement in an area of need, in fact, it requires only that recipients work for any public or nonprofit entity. As approximately 75% of US hospitals are nonprofit or public, it makes it relatively easy to qualify for such repayment. However, there are drawbacks to the PSLF program that make it less attractive: it is administratively cumbersome (resulting in delays) and it requires 10 years of documented loan payments before it pays off the balance of the loan. Still, it is a popular program, if the data from these young family physicians are representative.

A different, more long-standing federal loan forgiveness program that does require service in an underserved area is the National Health Service Corps (NHSC). According to the study, however, only 13% of the young family physicians surveyed who participated in loan repayment relief are in the NHSC. It is worth examining this program in some detail.

Congress created the NHSC in 1970 to address shortages of primary care clinicians in many US geographic areas and to assist health professional students in paying for their long years of training. The NHSC has 4 programs. The first is a scholarship program that pays tuition, expenses, and a stipend to health professional students in return for a service commitment to practice in a designated health professional shortage area (HPSA) after completing training. The second is a federal loan repayment program for clinicians working in HPSAs.

Most NHSC awards/agreements go to loan repayment, which only requires 2 to 3 years of service before payment. In 2016 (the last year for which data are available), 5282 of the 6129 awards went to federal loan repayment programs and 634 went to state loan repayment agreements. Only 213 scholarships were active in that year.

By some accounts, the NHSC has been very successful at attracting and retaining health professionals to underserved areas. Various studies have found that up to half of NHSC loan reimbursement and scholarship recipients remain in an HPSA 10 years after completing their commitment.

Are you FULLY HIPPA compliant? Don't gamble your practice

August 27

It takes an expert to understand the plethora of state and federal regulations that affect your practice. And those regulations change constantly. Why take chances? Stay up to date with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your business. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!


QA can improve office-based screenings

August 24

Office-based screenings can be improved by using a quality improvement process, according to a study in the July/August issue of the Journal of the American Board of Family Medicine. Post intervention qualitative findings illustrate additional factors that could be addressed for further improvements. Early Periodic Screening, Diagnosis, and Treatment visits are designed to address physical, mental, and developmental health of children enrolled in Medicaid.

Researchers conducted a mixed methods intervention by using a quality improvement theory. They assessed preintervention and postintervention screening rates of development, anemia, lead, oral health, vision and hearing, interventions for improvement, and barriers for the well-child visits at an academic family medicine clinic. For quantitative analysis, they assessed the preintervention baseline for 183 children and postintervention outcome for 151 children. For qualitative analysis, they used group interviews and key informant interviews to develop interventions in the preintervention stage and to explore potential barriers for further improvement in the postintervention stage.

Interventions based on baseline results included user-friendly materials, checklists, posters, education, and order sets. After the intervention, there were significant statistical improvements for the anemia test ordered rate, serum lead test ordered rate, oral health screening and referral rates, and ordered and confirmed test rates for both vision and hearing. Despite these improvements, 3 qualitative findings indicated barriers for further improvement, including difficulties in venipuncture, medical assistant aversion to vision screening, and poor fit of equipment for hearing assessment. The procedures prompted further continuous quality improvement activities using fingerstick hemoglobin testing, a child-friendly vision screener, and manual audiometer with headphones.

Rising educational debt may be discouraging entry into primary care

August 20

Rising educational debt may be discouraging entry into primary care and practice, according to a study in the July/August issue of the Journal of the American Board of Family Medicine. Nearly 60% of recent family medicine residency graduates report more than $150,000 of educational debt. A survey of 2052 recent family physician residency graduates found that 30% pursued loan repayment, only a portion of which is tied to service obligations, suggesting opportunities for research and areas for the attention of policymakers.

Several loan repayment programs exist to ease the debt burden of primary care physicians, but only the National Health Service Corps and select state loan repayment programs require a commitment to practice in underserved communities. Research shows that a growing cohort of medical graduates intend to pursue Public Service Loan Forgiveness, which forgives the loans of borrowers who are employed by public or nonprofit entities. Because 75% of hospitals qualify as nonprofit institutions, however, PSLF is thought to have limited potential to address maldistribution in the primary care workforce.

Although primary care physicians increasingly report debt that is burdensome enough to affect the region in which they plan to live and provide care, the study found that the minority of recent family medicine graduates participate in loan repayment programs. At least half of those who do favor PSLF or hospital- and employer-sponsored programs, which are unlikely to alter workforce maldistribution. Policies to alter maldistribution of the US healthcare workforce would greatly benefit from further understanding of factors that influence the distribution of family physicians in loan repayment programs.


Small Urban Independent Primary Care Practices Have Lower Burnout Rates

August 16

Small urban independent primary care practices have lower burnout rates than large practices, according to a new study in the July-August issue of the Journal of the American Board of Family Medicine.

Little had been known about the prevalence and correlates of burnout among providers who work in independent primary care practices with less than five providers. The researchers conducted a cross-sectional analysis by using data collected from 235 providers practicing in 174 small independent primary care practices in New York City.

The rate of provider-reported burnout was 13.5%. Using bivariate logistic regression, they found higher adaptive reserve scores were associated with lower odds of burnout (odds ratio, 0.12; 95% CI, 0.02–0.85; P = .034).

The burnout rate was relatively low among the sample of providers compared with previous surveys that focused primarily on larger practices. The independence and autonomy providers have in these small practices may provide some protection against symptoms of burnout. In addition, the relationship between adaptive reserve and lower rates of burnout point toward potential interventions for reducing burnout that include strengthening primary care practices' learning and development capacity.

Increased Clinic Access, Improved Education Decreases Pediatric Emergency Room Visits

August 13

Increased clinic access and improved parent education decreases pediatric emergency room visits, according to a new study in the July-August issue of the Journal of the American Board of Family Medicine. The goal of this study was to decrease avoidable, low-acuity emergency department (ED) use among pediatric patients at Coastal Family Medicine. The rationale behind this focus was to improve continuity for patients while decreasing the cost burden for low-acuity ED visits. The family medicine residency clinic pediatric panel has grown by 35% over the past 3 years, bringing this issue of same-day acute access in our clinic to the forefront.

A survey was created to better understand the needs of high users of the ED. The survey identified that patients believed the ED provided better same-day access than the clinic during daytime hours, 8 am-5 pm, Monday-Friday. By using this data, along with a literature review and a community practice review, a business-hour walk-in clinic for ages 0 to 18 years was started to improve access. Clinic posters, revised scripting for office staff, phone room staff, and the after-hour triage line were created to address parent education. Pediatric ED data generated through electronic medical records as well as through Medicaid reimbursement data framed the scope of this issue as significant. This was used to monitor pediatric ED visits following interventions as well.

Over the initial 3 months of interventions, pediatric ED use decreased by 62 visits compared with the prior year. The low-acuity diagnoses of upper respiratory infections decreased by 43.7% (71 to 40 visits) and fever decreased by 50.0% (14 to 7 visits) from the same 3 months the year prior. This decrease was sustained when examined during year 3. Over the next 12 months, there were 284 (29.8%) less visits to the ED with low-acuity diagnoses. This calculates to approximately $300,000 saved to the Medicaid system. During this time frame, the pediatric panel increased by 200 patients.

Increasing access and improving patient education decreased low-acuity pediatric ED visits in the clinic. This combination of interventions worked well in the community and has been shown to help optimize the setting in which pediatric patients are seen.

The Pile On
by Diane Shaw

August 10

Electronic Medical Records are cumbersome and require so much work that there’s little time for patients. Worse, if the EMRs appear repetitive, the Texas Medical Board will accuse the physician of “cloning medical records” or of having “inadequate documentation.” Regulatory audits, CMS, HIPAA, Hitech compliance, TMB complaints, and signed agreed orders or consent orders with the TMB may result in specialty boards pulling the doctors certification! Can it be that this is true? YES! How many technicalities are physicians expected to endure? Shaw & Associates is currently working on possible legal actions against specialty boards for wrongful revocation of Board specialty certifications and denial of due process.

Regulators are ready; are you?

August 6

State and federal regulations change and update constantly. Keeping up with them is a full-time job, even for experts. Stay up to date with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your practice. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox.

New Immunotherapies in Oncology Treatment and Their Side Effect Profiles

August 2

Immunotherapies in cancer treatment have a long history going all the way back to the very beginning of the field, and recent advances are extremely promising, according to new study in the July-August issue of the Journal of the American Board of Family Medicine. These therapies are becoming a larger part in many patients' oncology treatment as the number of approaches, individual medicines, and indications increase. Furthermore, these novel therapies have different side effect profiles from those traditional chemotherapies which have, until recently, typified the oncologist's approach to treatment together with surgery and radiation.

An electronic literature search was conducted in May and June 2017 and March 2018 with the PubMed and Ebscohost databases. Articles were chosen for their relevance to the drugs in question, cancer physiology, or historic significance.

Checkpoint inhibitors are becoming very common and possess autoimmune side effects such as pneumonitis, hypothyroidism, and colitis. These may present at any time the patient is on the medications but are more common several weeks to several months from beginning therapy. Chimeric antigen receptor T-cell therapies are powerful but have strong side effects such as cytokine release syndrome. Neoantigens are currently in the early stages of clinical trials and may become an exciting avenue for personalized cancer treatment but are not yet typical.

Doctor-Patient Trust Drops after Opioid Risk Reduction Initiatives

July 30

Although patients typically reported favorable perceptions of doctor-patient trust in managing opioid pain medicines, implementation of opioid risk reduction initiatives may have reduced levels of trust for a minority of Chronic Opiod Therapy patients, according to new study in the July-August issue of the Journal of the American Board of Family Medicine. This suggests that it may be possible to implement opioid risk-reduction initiatives while sustaining high levels of doctor-patient trust for most COT patients.  This analysis examined patients' perceptions about trust within the doctor-patient relationship related to managing opioid pain medications. We compared perceptions among chronic opioid therapy patients who were and were not exposed to opioid risk reduction initiatives.

Between 2014 and 2016, we surveyed 1588 adults with chronic pain receiving COT about their trust in their prescribing doctor, their perceptions of their doctor's trust in them, their concerns about opioid prescribing, and their knowledge of opioid safety concerns. The population included adults receiving care in intervention settings that implemented opioid risk reduction initiatives and control settings with similar COT patients that did not.

Neonatal Thrush Is Not Associated with Mode of Delivery

July 26

There is no significant correlation between the mode of delivery and the development of thrush, according to new study in the July-August issue of the Journal of the American Board of Family Medicine. Thrush is an opportunistic infection of the buccal cavity by the organism Candida albicans. It is most commonly seen in infants and becomes relatively uncommon between 6 to 9 months of age implying the infection is possibly dictated by risk factors present at or around the time of birth. The objective of this study is to determine if there is an association between the development of thrush and cesarean delivery, as we hypothesize.

Neonatal records were obtained through retrospective chart review of the past 10 years from an outpatient clinic and hospital records in Sandusky Ohio. ICD 9 and 10 codes for thrush and well child visit were used to identify patients. Statistical analysis performed on the data included: multivariable logistic regression, χ2 test of association, and nonparametric χ2 test of goodness-of-fit.

A total of 636 patient records were reviewed, with 127 having a diagnosis of thrush and 509 without the diagnosis. A multivariable logistic regression indicated that during the first year of life, children born by cesarean section were no more likely to develop thrush compared with those born by vaginal delivery, controlling for age and sex of the neonate as well as parity and group B streptococcus status of the mother.

Are you FULLY HIPPA compliant? Don't gamble your practice

July 23

It takes an expert to understand the plethora of state and federal regulations that affect your practice. And those regulations change constantly. Why take chances? Stay up to date with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your business. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!


Socioeconomic Status has little effect on Childhood Obesity

July 20

Socioeconomic status, race, birth weight, parental smoking, and not eating dinner as a family were associated with kindergarten-aged children being overweight or obese. Parental smoking increased the odds of a child being overweight or obese by 40%, and eating dinner as a family reduced the odds of a child being overweight or obese by 4%. In addition, black or Hispanic children had a 60% increased odds of being overweight or obese when compared with their white counterparts. Native American children had almost double the odds of being overweight or obese compared with white children. Socioeconomic status did not modify any of these associations.

Parental smoking, birth weight, and not eating dinner as a family were two modifiable factors associated with overweight and obesity in kindergarten-age children, regardless of socioeconomic status. Changing these life-style factors could reduce the child's risk for obesity.

Phil Burleson, Jr., Esq., joins practice

July 17

Phil Burleson, Jr., Esq., has joined Shaw & Associates as an Attorney at Law which allows Shaw & Associates to offer even more comprehensive coverage to our clients.
After attending public school in Dallas, Burleson received a B.S. from the University of Texas, Austin, then earned a J.D. from the South Texas College of Law.
Since graduating, Burleson has practiced law as a solo practitioner, been general counsel for a private company, been a partner at Lyon Gorsky Haring & Gilbert, and worked as an attorney at Burleson, Pate & Gibson L.L.P.. Phil Burleson is a stellar addition to add more coverage for existing litigation and expand to areas such as commercial litigation, transactional, general civil litigation and family law.
His primary focus is family law. He also handles some personal injury cases, estate matters and represent companies regarding employment matters.  He has extensive experience representing law enforcement agencies and their personnel.  Over the past twenty years, he has represented over a thousand police officers in various matters, including 500 plus officers involved in shooting related incidents.


Free newsletter keeps you and your practice up to date with regulations

July 12

Regulations change constantly; let the experts at Shaw & Associates up to date! It takes an expert to understand the plethora of state and federal regulations that affect your practice. Keep current with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your business. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!


Be wary when dealing with hospices

July 9

by Diane Shaw
Physicians have been burned out at a rate of over 51% due to regulatory documentation and EMR requirements. Hospice is so regulated and focused on documentation that the physician’s role is limited to serving as medical director at an Interdisciplinary Meeting (IDT/IDG). There is to be no direct billing for physician care. The hospice entity must follow rigid documentary requirements involving the entire team and the physician is expected to sign off on hospice certification based upon information brought to him from the hospice team at the IDT meeting. Hospice has regular, if not ongoing, CMS audits for compliance. The U.S. government is now attacking physicians for not being more pro-active in treating patients. Physicians are being blamed for allegations of hospice wrongdoing relating to hospice patients where, by law, the physician’s role is very limited. CMS doesn’t want to pay for active treatment or billing by the physicians. Therefore, physicians can only serve as medical director to the entity and participate in IDTs for orders and such. The hospice entities follow all documentation rules of CMS and get the doctor’s signature where required. The doctor can be accused of fraud for following hospice protocol for documentation! It’s a backward analysis. Instead of blaming the hospice entity (or CMS) for allowing the system of team treatment which largely excluded the doctor, the U.S. government seeks to prosecute the physician “for allowing the alleged hospice’s fraud to occur”.  
Moral: Don’t serve as medical director for a hospice entity as the government sees the medical director fee as a kickback. The U.S. government also expects the physician to maintain control of the patient but, unfortunately, direction of the patient’s care belongs to the hospice entity, not the physician.

Have a wonderful 4th of July Holiday!

July 4

No blog post on our nation's birthday.

Are you FULLY compliant with the latest regulations? Don't gamble with your practice

July 2

It takes an expert to understand the plethora of state and federal regulations that affect your practice. And those regulations change constantly. Why take chances? Stay up to date with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your business. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!

TDI consent orders target topical pain medication

June 29

In a recent Consent Order issued by the Texas Department of Insurance (TDI) Workers Compensation (WC) Division, the agency sought to significantly decrease its expenses by eliminating the use of topical pain medications by physicians, even though the physicians had no financial interest in prescribing the topical pain medication.  The use of these topical medications was investigated and found to be improper even when: 1) there was an opinion in the patient’s chart from a TDI physician supporting the use of topical pain medications, 2) the patient appreciated the topical pain relief, 3) use of the creams reduced or eliminated the use of narcotics, and, 4) the patient was able to work while using the creams.  It was not enough to discontinue the use of topical pain cream.  TDI/WC sought blood.  After the TDI Consent Order, each physician has been referred to TMB to seek another order which ultimately could result in loss of board certification.   Ironically, the end result is the loss of a safe & effective method of treatment for pain which also allowed injured workers to return to work free from the use of narcotics. 

Alternate payment models promise better primary care

June 25

The United States and Canada share high costs, poor health system performance, and challenges to the transformation of primary care, in part due to the limitations of their fee-for-service payment models, according to a report in the May-June Journal of the American Board of Family Medicine. Rapidly advancing alternative payment models in both countries promise better support for the essential tasks of primary care. These include interdisciplinary teams, care coordination, self-management support, and ongoing communication. Experts lauded recent APM experimentation on both sides of the border, while cautioning against the risk of “pilotitis,” or developing, implementing, and evaluating new payment models without plan or ability scale them into broader practice. Discussants highlighted the power of “learning at scale,” highlighting large-scale primary care payment innovations launched by the US Center for Medicare and Medicaid Innovation since 2011, and called for a similar national center to drive innovation across provincial health systems in Canada. There was general consensus that altering payment models alone, absent incentives for innovation and continuous learning as well as increased proportional spending on primary care overall, would not correct health system deficiencies. Participants lamented the absence of more robust evaluation of APM successes and shortcomings, as well as more rapid release of results to accelerate further innovation. They also highlighted the importance of APMs that include flexible and upfront payments for primary care innovations, and which reward measuring and achieving global rather than intermediate outcomes, to achieve utilization goals and patient and provider satisfaction.


Free newsletter keeps you and your practice up to date with regulations

June 21

Regulations change constantly; let the experts at Shaw & Associates up to date! It takes an expert to understand the plethora of state and federal regulations that affect your practice. Keep current with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your business. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!


Strong research-practice partnerships key to SDH success

June 18

Capitalizing on existing practice-based experiments will also require strong research-practice partnerships, which can be facilitated through practice-based research networks with expertise in practice-based methodologies, according to a study in the May-June Journal of the American Board of Family Medicine. The Agency for Health Care Research and Quality has been a strong supporter of such implementation science in primary care. Recent threats to their budget and overall sustainability directly conflict with this implementation research agenda. Primary care providers and researchers investing in SDH work will need sufficient funding to ensure that the rigorous implementation science needed can prosper in this nascent field.


Regulators are ready; are you?

June 14

State and federal regulations change and update constantly. Keeping up with them is a full-time job, even for experts. Stay up to date with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your practice. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!


Advancing Social Prescribing with Implementation Science

June 11

Despite growing interest in social prescribing, major evidence gaps persist in two key areas, according to a report in the May-June Journal of the American Board of Family Medicine. Although findings from some evaluations of SDH-related interventions suggest that specific programs can decrease social needs and improve health, relatively little research addresses the impacts of social prescribing on patient and provider care, health outcomes, health care costs, and utilization. Ideally, gaps in effectiveness research will be filled through federal demonstration project evaluations, including evaluations of Health Homes, CPC+, and the newly launched Accountable Health Communities Program14, to the extent that social prescribing components can be distinguished from other care model components. A second gap involves the implementation strategies needed to put these interventions into practice. The rapid proliferation of social prescribing activities in the United States provides an important opportunity for implementation research in this area.


Are you FULLY HIPPA compliant? Don't gamble with your practice

June 7

It takes an expert to understand the plethora of state and federal regulations that affect your practice. And those regulations change constantly. Why take chances? Stay up to date with the free newsletter from Shaw & Associates.Let the experts at Shaw & Associates keep you cognizent of the regulatory changes and updates that threaten your business. It's free; sign up today and receive Shaw & Associates expert analysis and alerts twice a month in your inbox!

Poor reporting hinders practice improvement

June 4

The potential for improving practices by implementing research is undermined by poor reporting, leaving readers unable to replicate such strategies and unclear whether they apply in the context of their practice, according to a report in the May-June Journal of the American Board of Family Medicine. These challenges are particularly pertinent in the complex, diverse world of primary care. The recently published Standards for Reporting Implementation Studies (StaRI) provides a framework for comprehensive reporting of implementation research. A key concept is the consideration and reporting in “dual strands”: on the one hand, the implementation strategy and on the other, the evidence-based intervention. Other requirements are full descriptions of context, strategies and interventions (and how the strategies were adopted or adapted), and evaluation methods, which will require flexible interpretation of journal limit constraints or innovative approaches to supplementary information. The choice is between accepting the unsatisfactory status quo or adopting strategies to improve reporting with a view to optimizing the potential of implementation research to advance primary care.

A Latino Patient-Centered, Evidence-Based Approach to Diabetes Prevention

May 31

Cultural tailoring of evidence-based diabetes prevention program interventions is needed to effectively address obesity and its related chronic diseases among Latinos in primary care, according to new research published in the May-June Journal of the American Board of Family Medicine.

Using a patient-centered stakeholder-engaged approach, the study found the results of the original intervention were largely congruent with the cultural values of the study population. To further strengthen the cultural relevance of the intervention, cultural values emphasized by patients and stakeholders underscored the importance of family and community support for behavior change. Accordingly, key adaptations were made to invite family members to the orientation session and at two other key timepoints to facilitate family support, provide participants support from the coach and each other via smartphone applications, and provide healthy, easy, low-cost culturally appropriate meals at each group session.

This 2-stage approach of actively engaging patients, family members, providers, and health care system leaders strengthened results.

Happy Memorial Day!

May 28

Some gave all; all gave some. No article on this federal holiday.


Office automated blood pressure measurement improves assessment

May 24

Accurate blood pressure measurement is essential to hypertension diagnosis and management. Automated office blood pressure and home blood pressure measurement may improve assessment, but barriers exist in primary care settings, according to new research published in the May-June Journal of the American Board of Family Medicine.

Initial HBPM results in 183 patients with elevated office BP revealed white-coat BP elevation in 35% of untreated patients and in 37% of treated patients. The prevalence of white-coat BP elevation was similar whether enrollment BP was by observed BP or AOBP. Subsequent HBPM facilitated BP control in 49% of patients with elevated home BP. Most providers, staff, and patients endorsed the utility of the program. Barriers to implementation included a temporary period of incorrect AOBP technique, patients failing to provide HBPM results, and incorrect HBPM technique.

Our clinic-based AOBP/HBPM program detected white-coat BP elevation in one third of enrolled patients, facilitated control of home BP, and was acceptable to staff and patients. We identified barriers to be addressed to ensure sustainability.

Depression varies based on sociodemographic characteristics

May 21

A new study estimates the prevalence of depression assessment in adults age 35 and older and how prevalence varies by sociodemographic characteristics and depressive symptoms, according to new research published in the May-June Journal of the American Board of Family Medicine.

We used a nationally representative survey, the Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey, to evaluate if adults 35+ were being assessed for depression by their health care providers in 2014 and 2015.

Approximately 50% of US adults aged 35+ were being assessed for depression. Less likely to be assessed: men compared with women, adults 75+ compared with adults 50 to 64 years old, the uninsured compared with those with private insurance, and adults without recognized depressive symptoms compared with those with recognized symptoms. Compared with non-Hispanic whites, the following were less likely to be assessed: Asians, Hispanics, and African Americans.

Many Americans are not having their depression needs assessed. Certain populations are more likely to be missed, including men, people over 75 years old, minorities, and the uninsured. Additional efforts are needed to determine methods to increase screening recommended by the United States Preventive Services Task Force and to ensure that all Americans have their mental health needs met.

Practice facilitators can support primary care practices

May 17

Practice facilitators can play an important role in supporting primary care practices in performing quality improvement, but they need complete and accurate clinical performance data from practices' electronic health records to help them set improvement priorities, guide clinical change, and monitor progress. Here, we describe the strategies facilitators use to help practices perform Quality Improvement when complete or accurate performance data are not available, according to a new study published in the May-June Journal of the American Board of Family Medicine.

Seven regional cooperatives enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators in EvidenceNOW, the Agency for Healthcare Research and Quality's initiative to improve cardiovascular preventive services. The national evaluation team analyzed qualitative data from online diaries, site visit field notes, and interviews to discover how facilitators worked with practices on EHR data challenges to obtain and use data for Quality Improvement.

We found facilitators faced practice-level EHR data challenges, such as a lack of clinical performance data, partial or incomplete clinical performance data, and inaccurate clinical performance data. We found that facilitators responded to these challenges, respectively, by using other data sources or tools to fill in for missing data, approximating performance reports and generating patient lists, and teaching practices how to document care and confirm performance measures. In addition, facilitators helped practices communicate with EHR vendors or health systems in requesting data they needed. Overall, facilitators tailored strategies to fit the individual practice and helped build data skills and trust.

Facilitators can use a range of strategies to help practices perform data-driven Quality I when performance data are inaccurate, incomplete, or missing. Support is necessary to help practices, particularly those with EHR data challenges, build their capacity for conducting data-driven Quality Improvement that is required of them for participating in practice transformation and performance-based payment programs. It is questionable how practices with data challenges will perform in programs without this kind of support.

Community conditions affect clinical outcomes

May 14
Little is now known about incorporating community data into clinical care. A new study in the May-June Journal of the American Board of Family Medicine sought to understand the whether there are clinical associations with areas that have below average income, education, and composite deprivation.

The research checks 12 practices in such areas for clinical outcomes, including obesity, uncontrolled diabetes, pneumonia vaccination, cancer screening—colon, cervical, and prostate—and aspirin chemoprophylaxis for 152,962 patients. The researchers found a 10-fold difference in the proportion of patients in these poor areas. All outcomes were influenced except for the use of aspirin. Fifteen percent of low-education patients had uncontrolled diabetes compared with 13% of the normal population.

The research concluded that living in such areas is associated with worse chronic conditions and quality for some screening tests. Practices can use neighborhood data to allocate resources and identify those at risk for poor outcomes.

New VA program focuses on older, complex patients

May 11

The new Geriatric Patient-Aligned Care Teams (GeriPACT) in the Veterans' Health Administration is focused on serving older complex patients. A new article in the May-June Journal of the American Board of Family Medicine describes how the GeriPACT model was developed and implemented in VA sites, provide a closer look at how GeriPACT functions by presenting a case study, and highlight data showing national variation in the implementation of GeriPACT staffing models and PCMH practices.

Stakeholder feedback regarding the GeriPACT model was obtained from a GeriPACT team and the director of GeriPACT in VA.

Following the adoption and implementation of the GeriPACT model and release of the GeriPACT handbook, sites were able to adopt the model's principles. The VA's adoption of PCMH reinforced the mission of patient-centered primary care by integrating psychosocial and environmental determinants of health. This was accomplished with enhancements to staff support through new full-time employment equivalents, but also by optimizing staff productivity through improved team function and interpersonal care. The GeriPACT model was implemented in a bottom-up fashion that has led to variation in how GeriPACTs are structured and staffed, as well as how they conform to various PCMH principles.

GeriPACT is one approach for bringing an interdisciplinary, patient-centric perspective to primary care in a manner that can likely support the higher staffing costs with economies realized from diminished reliance on institutional placement and highly technologic health care. It is a model which can provide training for the next generation of providers and clinicians.


Fraud in health care; Diane Shaw article outlines problem in May Dallas Medical Journal

May 7

One of physicians’ primary questions when enduring the rigors of an audit is, why do government payors pay, or approve payment, only to audit and attempt to recoup payments for “lack of adequate documentation to show medical necessity”?[1].

One answer: New government entities are consistently being created to identify all aspects of healthcare fraud. In 1997 CMS created the Health Care Fraud and Abuse Control Program to fight healthcare fraud, waste and abuse. As part of this program, the Healthcare Fraud Prevention Partnership was added in 2010 to build stronger relationships between the government and private sector contractors to help protect consumers. One tool of this partnership is the CMS-FPS (Fraud Prevention System) method of determining outliers — patterns that don’t fit the model, “pay and chase.” Once the pattern is identified, then CMS or other entities can start denials. Alternatively, when charts are requested for review and they don’t have sufficient documentation for payment under a specific code, denials are likely or the physician will be red-flagged for prior approval requirements. This is where investigations may start, and if payments cannot be defended, this may lead to recoupment. However, at times the patterns are so excessive that investigations lead to a variety of fraud allegations.[2]

After identifying $1.5 billion in improper billing and potential fraud by the end of 2015, the Fraud Prevention System has increased and upgraded its system. CMS continues to upgrade its IT infrastructure using a workload management system to monitor program performance, timeliness of investigation and corrective action.[3]

Although marketing and incentivizing seemingly go hand in hand, this is not the case for those who receive healthcare payments, particularly healthcare payments from a government entity. If even one of the business purposes is compensation based on past or future referrals, this may result in significant liability. OIG fraud alert found improper remuneration for these reasons: 1) volume or value of referrals; 2) physicians’ payments did not reflect fair market value for services performed; and 3) physicians did not actually provide the service.[4] Some fraud allegations stem from direct or indirect benefits, such as employees, marketing, promissory notes, expensive homes, cars, meals, and high-end sports tickets.

In 2017 and 2018, several physicians were sanctioned by Texas Department of Insurance or the Texas Medical Board for the use of compounding topical medications. The suggestion is that, pain relief by compound medication is experimental and, therefore, not reasonably necessary. Physicians consistently maintain that topical compounding for pain in the localized areas is safer and more effective, allowing the patient to function better and return to work because they do not require opioids or narcotics. This is the aftermath of some alleged fraudulent schemes where the use of creams accompanied alleged kickbacks and/or excessive payments. The FDA precluded topical compounding from advertising or marketing until 2002. The US Supreme Court ruled that the FDA violated freedom of commercial speech by prohibiting advertising of compounding scar and pain creams. Thereafter the market became saturated with every form of marketing. Tricare costs rose from $5 million in 2004 to $514 million in 2014. The alleged scheme recognized in Tricare is or was that the compounding pharmacy has forms that identify the ingredients for pain or scarring (because the pharmacy specializes in compounding), so the prescription (not specifically written by physician) violates the necessary patient/physician relationship. In some instances, the patient had the prescription before the physician signed the form.

In the Florida case, physicians allegedly received kickbacks in the form of speaker fees and alleged sham research studies. However, research of patient groups was/is necessary to prove safe and effective use of compounding topical cream. Undoubtedly, the underlying problem was that pharmacies were charging $10,000 to $20,000 per prescription. Four physicians in Florida also allegedly were recruiting other physicians to write prescriptions in exchange for a share of the money.[5] Similar investigations underway in Texas and other states.

It appears that the physicians sanctioned by TDI or TMB for compounding received no financial interest. TMB regulates and is extremely vigilant and harsh on physicians who use or allegedly abuse a variety of narcotics. So, topical creams seemed to be a safer and more effective alternative. However, in March 2017, eight individuals were charged in a $158 million healthcare fraud scheme in Dallas relating to compounding creams with prescriptions costing as much as $28,000 per container. This involved Veterans Administration and U.S. Department of Labor funds.[6]

In December 2016 we heard about allegations of kickbacks or bribes for alleged lucrative spinal or bariatric surgery. Executives, surgeons, ad agency executives, and office workers were alleged to have paid or received bribes. Several of the parties filed for dismissal due to “overreaching claims” by the federal government because none of the patients were CMS or governmental patients, and there was no common agenda to support allegations of conspiracy. The patients were private or self-pay patients in a well-staffed, well-equipped upscale hospital that filed for bankruptcy.

In January 2018, four physicians were charged with multiple counts of Medicare fraud in several South Texas cities. Allegations report $150 million in hospice and home healthcare billings. The complaint alleges bribes and kickbacks in the form of medical director fees for certifying that patients qualified for services when they did not qualify. Allegedly, patients were kept on hospice for years to increase revenues. The parties also were charged with money laundering the proceeds of the fraud by concealing the true and beneficial owners. Profit distributions allegedly were issued to nominees to conceal and disguise the fraud proceeds.

Overall, the government has charged 3,500 defendants with fraud or like charges, collectively have falsely billed Medicare more than $12.5 billion.[7] Austin and Houston physicians are among 35 Texans charged in a $1.3 billion Medicare fraud sting. One hundred fifteen physicians, nurses and other practitioners were indicted; approximately one third of 412 people were charged with prescribing and distributing opioids and other dangerous drugs; providers paid cash kickbacks in return for beneficiary information that was falsely billed, per federal prosecutors.

In the case of In Re Xerox Corp. et al No. 16–0671 in the Texas Supreme Court, Xerox seeks to extend its proportionate responsibility to mitigate its exposure on a $1 billion Medicaid fraud claim for what turned out to be medically unnecessary orthodontic services. Xerox and a spin-off business allegedly rubberstamped these claims. Xerox argues that the orthodontists who performed the procedures should be parties to the alleged fraud. Proportionate responsibility  previously has not been applied in this type of case. Therefore, if allowed, it would extend the reach of the government to additional claims against healthcare providers.

In Dallas in 2017, 16 people were indicted in a Medicare fraud scheme. More than $40 million was paid to Novus between 2012 and 2016, with allegations of ineligible hospice beneficiaries which occurred by providing kickbacks for referrals. The government alleges that physicians were recruited to be medical directors in exchange for referrals. The government claims the hospice business had the ability to log in under the medical director’s name and enter unnecessary certifications or recertifications.[8] In the indictment, one physician allegedly had 19 face-to-face evaluations in one day for which he would have had to travel 200 miles to 19 locations before 1:30 p.m. The co-owners of the hospice business were the primary recipients of the billings. One co-owner who had been released has been arrested for allegedly fraudulently applying for a $50,000.00 loan from Compass Bank and losing all of it by gambling online in violation of the judge’s prior pretrial release on the fraud allegations. Several medical directors were paid small monthly fees for services rendered and maintain their innocence.

In all cases of allegations of fraud, the defendant is presumed innocent until proven guilty beyond a reasonable doubt. Many types of schemes and players are involved in most fraud cases. Many allegations have yet to be proven, and often the government is overreaching in its allegations of facts pertaining to the schemes or the people involved. Unfortunately, to be the individual physician fighting against the government is quite daunting, regardless of guilt or innocence. The Xerox case has fees well into 6 digits and it’s still fighting on technical grounds to prevail because large corporations can afford the legal fees.[9]

In review of hundreds of situations alleging fraud, the uptake is that if an opportunity exists to make extra money in the healthcare field that exceeds the fair market value of time spent, beware and get a solid legal opinion.

[1] CPT codes have LCD/NCD available online for each code listing what documentation is required. It is not about patient care. CPT code 68649.pdf.

2 https://oig.hhs.gov/fraud/enforcement/criminal.

3 FPS was implemented in 2011 by GAO. Report at GAO.gov/assets/690.

4 https://oig.hhs.gov/compliance/alerts/guidance/Fraud_Alert_Physician_Compensation_06092015.pdf.

5 ABA Health Law Section: Compounding the Problem: Government Cracks Down on Compounding, Fraud and Abuse, Volume 12, No.8.

6 Justice.gov.news Mar 23, 2018.

7 Justice.gov.news Jan 10, 2018.

8 www.justice.gov/USAGO-NDtx/sixteen and USA v. Harris, et al Case 3:17-cr-00103-M.

9 https://oig.hhs.gov/compliance/alerts/guidance/Fraud_Alert_Physician_Compensation_06092015.pdf.

Other citations for general reference included Strategic Management, LLC, reports 2018; DOJ likewise issued press releases of alleged schemes to defraud healthcare payors. See also, Criminal and Civil Enforcement/Fraud/OIG/U.S. Department of HHS. Other noted issues included radiation therapy and $11.5 million settlement in North Texas and whistleblowers who share in recouped amounts whether or not DOJ involved. $324 million lawsuit involving meaningful use attestations of 62 hospitals in Indiana and the management... https://53.amazonaws.com/assets.fiercemarket.net/public/004-Healthcare/externalQ42017/US v. Memorial.pdf. Dentist clinics and affiliated “Kool Smiles” settled for $23.9 million under FCA in 17 states billing for baby root canals allegedly unnecessary. Clinic incentivized “productive” dentists and disciplined unproductive dentists. Complaints that plan resulted in over-utilization were ignored, likely resulting in whistleblower who received $2.4 million from Fed recoupment. share. www./Justice.gov/opa/pr/dental-management-company-benevivis-and-its-affiliated-Kool-smiles-dental-clinics-pay-239. See also agency reports involving MFSF and HEAT. Some investigations involve too many government entities to mention .


Fraud in health care; Diane Shaw article outlines problem in May Dallas Medical Journal

May 4

One of physicians’ primary questions when enduring the rigors of an audit is, why do government payors pay, or approve payment, only to audit and attempt to recoup payments for “lack of adequate documentation to show medical necessity”? That's according to a new article in the May edition of the Dallas Medical Journal by Attorney Diane K Shaw of D. Shaw & Associates.  D. Shaw & Associates specializes in the defense of doctors and their practices.

The article, Fraud in health care: From billing to kickback schemes to money launderng, where and will it end?" appears on pages 21 and 22 of the May edition of the Dallas Medical Journal.

The May edition of the Dallas Medical Journal can be found online here.


Shaw & Associates continues to successfully defend doctors’ rights in all forums

April 30

Your practice could be forced to close over any demerit or board action, no matter how small according to Attorney Diane K Shaw of D. Shaw & Associates.  D. Shaw & Associates specializes in the defense of doctors and their practices.  A Texas Medical Board suspension was rescinded after the state lost a show cause hearing in a precedent setting case brought by Shaw & Associates.

Shaw & Associates recently won a case and forced the specialty board to return a certification to a doctor. The doctor had successfully defended himself against a minor complaint, only to have the specialty board pull his certification, effectively closing him down. Shaw filed a Temporary Restraining Order in the District Court of Travis County to Appeal the Revocation of the Board Specialty Certification. For the first time the TMB/ specialty certification termination was restrained and overruled by the District Court, allowing the doctor’s practice to reopen and operate as usual. 

All doctors with specialties need to be aware that specialty boards are pulling certifications over any practice limit or discipline. This means any action no matter how small could result in your practice being forced to closed, warned Attorney Diane K. Shaw of D. Shaw & Associates, a law office that specializes in the defense of medical practices.

This new drive to threaten certifications seems to be based on a tighter reinterpretation of the American Board of Family Medicine guidelines, which state that family physicians must continuously hold a currently valid and full medical license that is not subject to practice privilege limitations in any state or territory in which they have a medical license, regardless of whether or not they are currently practicing within that state.

“It’s almost like double jeopardy,” said Shaw. “They couldn’t make the complaint stick, so they went after his specialty certification.”

The American Board of Family Medicine Credentials Committee reports three major increasing trends in this area:

The American Board of Medical Specialties (ABMS) and representatives from state licensing agencies are working together to better understand the processes within state licensing agencies and medical boards, and to improve state medical boards' awareness of the implications of decisions on board certification. Professionalism policies across all 24 ABMS Member Boards are consistent in how they apply these principles.

The Committee recommends that residency program directors carefully review these guidelines at an educational session, as most residents are not aware of these potentially career-altering circumstances. The Board of Directors of the ABFM has committed to doing what it can to help diplomates avoid loss of board certification while still maintaining standards that make board certification valuable to diplomates and to the public.

As part of this educational outreach effort, the American Board of Family Medicine Board of Directors outlined several illustrative cases of state medical licensure limitations of family physicians that can impact license limitations, and thus, board certification:

  1. Dr. M fails to timely report adequate CME documentation after a medical board audit of his attestation with state CME requirements for a state in which he's never actually practiced (he has several state medical licenses). He signs a Voluntarily Surrender of Physician License, reported to the Federation of State Medical Boards (FSMB) as a disciplinary action against his license.
  2. A state medical board review determines that Dr. A failed to meet quality medical standards of care in eight of her patients with chronic pain (i.e. excessively prescribing opioid medications without adequate evaluation, monitoring or follow-up). Dr. A also prescribed controlled substances to patients without obtaining and/or documenting that she accessed state medical board-required reports from that state's online prescription reporting system. Her license is limited by precluding Dr. A from treating any patient for chronic pain and, except in emergency cases of acute pain, from prescribing opioid medications. The FSMB reports this disciplinary action against her medical license.
  3. Due to some health issues exacerbated by overwork, Dr. P's state medical license has a limitation placed through a consent agreement that he may not see patients in an emergency department setting between the hours of midnight and 7 am. This license limitation is reported to the FSMB.
  4. Dr. Y practices maternity care. Based on allegations of negligence in her delivery of a newborn involving the use of a vacuum assisted delivery device that resulted in the infant's death, she signed a settlement agreement with the state medical board, accepting a formal disciplinary action and stating she agreed to immediately cease "operative" vaginal deliveries.
  5. Dr. L, in a small practice with limited staffing, is accused by a patient of inappropriate behavior during a gynecological exam; rather than risking additional publicity that may come with litigation and desiring to put the matter behind him, he accepts a license limitation from his state medical board requiring all female patients have a chaperone present.


April 26 fundraiser to support Dallas Incumbent Judges

April 23

Please join us in a show of support and appreciation for our incumbent Dallas County Judges:
The Honorable Carl Ginsberg
The Honorable Martin Hoffman
The Honorable Ken Tapscott

as they head into the May 22, 2018, run-off election.

Join us Thursday, April 26, 2018, at 5:30 p.m., at the Criss Law Group, 12222 Merit Drive, Suite 1350, Dallas, Texas 75251. Cocktails and appetizers to be served.

RSVP to Robin Gream at (214) 691-0003 or rgream@criss-law.com


How to Get Out of a Contract

April 18

 Getting out of a contract is not always an option, and it is not as easy as you might think.

The best way to get out of a contract is to have prepared by having the contract reviewed beforehand and understand the terms of termination. There are contracts that require a physician to “stay” a certain length of time or pay a sum for lost income. Employers spend money for start-up, marketing, network inclusion, tracking benefits and may not make adequate profit until after a term of one to two years. A physician may be required to pay for early termination in order to recover such costs. Some contracts also have a liquidated contract clause of a sum certain for physician termination if the physician breaches the no-compete or confidentiality of patient list.

Under Texas law, the covenants Not to Compete Act creates an enforceable ‘non-compete’ if it is ancillary to another agreement. The restrictions must be reasonable in scope.[1] Be wary, an employer can terminate ‘at will’ under contracts but employee can be restricted from alternative employment due to a restrictive covenant. When getting into a contract, it is important to identify and specify a geographic scope.

This day and age, so many employers are large entities; it is important that a geographic restriction remains within the area where you are primarily working. For example, there are contracts (which should be negotiated) that preclude employment within 2, 5 or 10 miles from the employer. There may also be a clause that says you will be located on Northwest Highway and Preston, but will cover as needed at any facility where coverage in your specialty is needed. To get out of this contract, one should be sure the non-compete is confined to a single geographic location or two if in fact you are hired for two particular areas. Of course, the smaller the geographic region, the better for the employee and the more enforceable it is for the employer.

‘At will’ or ‘termination without clause’ is not uncommon, but you must look at all corelating clauses to get out of the contract. Some are tricky and require detailed written notice by certified mail to occur 30, 60, 90 days in advance to a certain person to a certain location. Sending an email to the person or doctor that hired you won’t work, particularly if you are with a large group or a national company. There may also be charting or reporting requirements that could affect an otherwise valid resignation. Some call coverage contracts require resignation, to be accepted by medical director or board of trustees at the hospital. If physician or group tries to resign, they must do so timely and in writing and be ‘the resignation must be accepted.’ So be sure the acceptance is required to occur within the resignation timeframe and the specifics of acceptance are set forth. A hospital/employer can abuse call coverage and then after giving appropriate notice, the employer can state the resignation is not accepted because ‘we have not been able to line up adequate coverage in your area of specialty.’ If this occurs, then give written notice of conditions required for continued call. For example, effective as of _____ (date of termination 60 days after notice) the contract of 1/10/16 between ___________ (the parties) has been terminated. As the basis for non-acceptance of termination is that the hospital/employer has failed to timely line up adequate coverage this group/I will cover for (2 more weeks) or (one month) at fair market value of ____ x $_____ per call.  This situation accrues ‘after dissensions’ or promises that hospital/employer will get more help or more call coverage and then doesn’t and doesn’t want to pay fair market value for services.

Getting out of a no-compete contract is ‘for cause’ it must be well documented unless employer goes bankrupt or has other obvious problem. For cause clauses usually have a list of categories which include ‘material breach that requires documentation and usually an opportunity to cure the breach. Physician should consult an attorney before attempting to terminate, if it is for cause unless the termination is mutually agreed upon.

Beware, if you are contemplating retiring or resignation, do not do so while under a peer review process. Even if the peer review is deemed ‘informal’ you must confirm that no investigation is pending before you resign. Otherwise, you may be reported for ‘resignation while under investigation,’ to the national and Texas data bank(s).

[1] Section 15.50 of TX Business and Commerce Code covenants not to compute is enforceable if it allows physicians access to patient’s medical records, allow a list patients seen within one year after the contract is terminated, includes a reasonable buy out and does not prohibit physician from caring for patients during an acute illness, even after employment is terminated.  No comets can be reformed (fixed) by a Judge to be restrictive enough to be entered.  Also, see TMA; restrictive non-compete clauses can ruin your Texas Medicine Law Fortune for 2018; Tex Med 2011g107(2): 35-35 Capital Conde, Associates Edition.0


Legal Secretary Wanted for Dallas Office

April 16

The Shaw & Associates Dallas office is seeking an entry level legal secretary with one to three years experience. We are looking for a reliable, energetic, personable and multi-faceted secretary with experience in paperless organization skills, and litigation.

Job Responsibilities:


Job Type: Full-time  Required education: Associate Degree, or comparable training and experience.  

For more information and to apply, please call Shaw & Associates at 214-217-8357.


Cough drops can make patients worse

April 12

Menthol cough drops make some patients condition worse, according to a new study in the Journal of the American Board of Family Medicine. Clinicians should therefore include cough drop use in the history taking of patients with persisting cough illnesses. Further research into potential mechanisms is warranted.

Over-the-counter cough remedies are lightly regulated and their potential side effects may go unrecognized. During 2015, over 282 million cough drops were sold in the United States. A Wisconsin community clinician made clinical observations suggesting that excessive use of OTC cough drops may exacerbate rather than benefit coughs. The goal of this project was to assess whether menthol in cough drops is related to worse cough symptoms.

From April 2016 through May 2017, 5 Wisconsin primary care clinics invited adolescent and adult outpatients seeking medical care for an acute or subacute cough to take a voluntary, anonymous, 10-question cough drop use survey that included age, sex, smoking status, cough severity, cough duration, and cough drop use, including type and amount.

Of the 548 surveys collected and analyzed, 363 or 66.2% reported using cough drops. Cough drop use was significantly associated with longer duration of cough, but not with overall severity. Of cough drop users, 269 - 90% - reported consuming drops with menthol. Analysis found no statistically significant differences between the menthol and nonmenthol groups for either severity or duration. However, significant independent associations were found between cough severity and average menthol dose per cough drop, number of cough drops consumed daily and total amount of menthol consumed per day that remained significant after controlling for age, sex, smoking status, season, and clinic site.


Alarming Trends in the Scope of Practice for Family Physicians

April 10

There are alarming trends in family physician scope of practice, according to the new issue of the Journal of the American Board of Family Medicine.

In this issue, Peterson et al1 report on the substantial gaps between preparation for, and practice of, nearly all clinical-practice areas among family physicians. They conclude that early-career family physicians may not find opportunities to provide the broad and comprehensive care consistent with their training. This report is a followup to the Coutinho2 study of family physicians registering for the American Board of Family Medicine (ABFM) Certification Examination that found graduating family-medicine residents reported an intention to provide a broader scope of practice than that reported by current practitioners.

The largest differences between reported intentions to practice and actual practice included prenatal care, home visits, nursing home care, inpatient care, and obstetric care. Other specific clinical activities with differences of greater than 5% between reported intentions to practice and actual practice included acute/same-day care, chronic-disease management, women's health, sports medicine. Although statistically significant differences were noted in all clinical activities, the clinical and service relevance of these differences would require further study. Besides finding opportunities to provide the broad and comprehensive care, the scope of practice by an individual physician is multifactorial and dependent on such influences as geographic factors, availability of health-care resources to the main practice setting, and practice-organization's factors as well as physician-related factors such as training and intention to provide specific services.

The current report and the specific results of the study seem to announce a marked decrease in the scope of clinical services and care being provided by family physicians. For some clinical services provided, this assumption is probably true and would impact the comprehensiveness of care being provided by these physicians. For other services, the differences may be clinically insignificant. The provision of prenatal and maternity care by family physicians has decreased for many years and the impact of this change has yet to be fully recognized.  Although the number of family physicians providing inpatient care is decreasing, many patients previously admitted with certain conditions are now treated for these same conditions by family physicians on an outpatient basis. Furthermore, inpatient care is becoming increasingly complex and probably requires a team of health-care providers with a new model of care. Nursing-home care is often provided by family physicians with additional training in geriatrics. Although many family physicians may not provide home visits, home health services provided under the direction and orders of a family physician may be growing.

Wide Gap between Preparation and Scope of Practice of Early Career Family Physicians

April 5

New research shows substantial gaps between preparation for, and practice of, early career family physicians in nearly all clinical practice areas. With reported intentions of graduates for a broad scope of practice, gaps between practice and preparation suggest family physicians early in their careers may not be finding opportunities to provide comprehensive care.

Family medicine residents graduating in 2014 reported much higher intentions to practice all clinical practice activities and procedures queried than what practicing family physicians reported when registering for the American Board of Family Medicine examination. Residency graduates in a single state indicated a lack of training to be a common reason for not providing procedures, but the gap between preparation for and practice of a broad array of clinical services common in family medicine has not been rigorously studied. Our objective was to investigate differences in reported preparation for practice and actual scope of practice for early career family physicians.

A majority of respondents reported being prepared to provide 14 services, whereas a majority provided only 4 of the services queried.

A substantial gap exists between the training and preparation family medicine residents receive and the services they deliver in practice. This gap was noted for maternity care among recent family medicine graduates over a decade ago, but our work extends this to other reported key areas of family medicine. With >50% of physicians now employed, the specialty of family medicine should address the possibility of employers influencing scope of practice. With evidence that comprehensive care is associated with lower overall health care costs6, patients, physicians, payers, and health care delivery organizations should work together to ensure family physicians can deliver care commensurate with their training.

The study was approved by The American Academy of Family Physicians Institutional Review Board.

Failure to protect health records costs company millions of dollars

April 3

21st Century Oncology, Inc. has agreed to pay $2.3 million to the U.S. Department of Health and Human Services Office for Civil Rights and adopt a comprehensive corrective action plan to settle potential violations of the Health Insurance Portability and Accountability Act Privacy and Security Rules. 21CO provides cancer care services and radiation oncology. Headquartered in Fort Myers, Florida, 21CO operates and manages 179 treatment centers, including 143 centers located in 17 states and 36 centers located in seven countries in Latin America.

On two separate occasions in 2015, the Federal Bureau of Investigation notified 21CO that patient information was illegally obtained by an unauthorized third party and produced 21CO patient files purchased by an FBI informant. As part of its internal investigation, 21CO determined that the attacker may have accessed 21CO’s network SQL database as early as October 3, 2015, through the remote desktop protocol from an exchange server within 21CO’s network. 21CO determined that 2,213,597 individuals were affected by the impermissible access to their names, social security numbers, physicians’ names, diagnoses, treatment, and insurance information. OCR’s subsequent investigation revealed that 21CO failed to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of the electronic protected health information; failed to implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level; failed to implement procedures to regularly review records of information system activity, such as audit logs, access reports, and security incident tracking reports; and disclosed protected health information to third party vendors without a written business associate agreement.

“People need to trust that their private health information will remain exactly that; private,” said OCR Director Roger Severino. “It’s not just my hope that covered entities will learn from this example and proactively find and address their security risks, it’s what the law requires.”

On May 25, 2017, 21CO filed for Chapter 11 bankruptcy protection in the United States Bankruptcy Court for the Southern District of New York. The settlement with OCR will resolve OCR’s claims against 21CO and the corrective action plan will ensure that the reorganized entity emerges from bankruptcy with a strong HIPAA compliance program in place. The settlement with OCR was approved by the Bankruptcy Court on December 11, 2017.

The resolution agreement and corrective action plan may be found on the OCR website at http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/21CO/index.html.

No Business Associate Agreement? $31K Mistake

March 30

The Center for Children’s Digestive Health paid $31,000 to the U.S. Department of Health and Human Services to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 Privacy Rule. CCDH is a small, for-profit health care provider with a pediatric subspecialty practice that operates its practice in seven clinic locations in Illinois. 

In August 2015, the HHS Office for Civil Rights initiated a compliance review of the Center for Children’s Digestive Health following an initiation of an investigation of a business associate, FileFax, Inc., which stored records containing protected health information for CCDH. While CCDH began disclosing PHI to Filefax in 2003, neither party could produce a signed Business Associate Agreement (BAA) prior to Oct. 12, 2015.

For more information on Business Associate Agreements, please visit https://www.hhs.gov/hipaa/for-professionals/covered-entities/sample-business-associate-agreement-provisions/index.html


Practice pays millions to settle 5 data breaches after failing to heed HIPAA’s risk analysis and risk management rules

March 27

Fresenius Medical Care North America has agreed to pay $3.5 million to the U.S. Department of Health and Human Services Office for Civil Rights and adopt a comprehensive corrective action plan, in order to settle potential violations of the Health Insurance Portability and Accountability Act Privacy and Security Rules. FMCNA provides products and services for people with chronic kidney failure, with more than 60,000 employees serving more than 170,000 patients. FMCNA’s network is comprised of dialysis facilities, outpatient cardiac and vascular labs, and urgent care centers, as well as hospitalist and post-acute providers.
On January 21, 2013, FMCNA filed five separate breach reports for separate incidents occurring between February 23, 2012 and July 18, 2012 implicating the electronic protected health information of five separate FMCNA owned covered entities.
OCR’s investigation revealed FMCNA failed to conduct an accurate and thorough analysis of potential risks and vulnerabilities to the confidentiality, integrity, and availability of all of its ePHI.
The FMCNA covered entities impermissibly disclosed the ePHI of patients by providing unauthorized access for a purpose not permitted by the Privacy Rule.
“The number of breaches, involving a variety of locations and vulnerabilities, highlights why there is no substitute for an enterprise-wide risk analysis for a covered entity,” said OCR Director Roger Severino. “Covered entities must take a thorough look at their internal policies and procedures to ensure they are protecting their patients’ health information in accordance with the law.”
In addition to a $3.5 million monetary settlement, a corrective action plan requires the FMCNA covered entities to complete a risk analysis and risk management plan, revise policies and procedures on device and media controls as well as facility access controls, develop an encryption report, and educate its workforce on policies and procedures.
The resolution agreement and corrective action plan may be found on the OCR website at   http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/FMCNA/index.html.
To learn more about health information privacy laws and health information privacy rights, please visit www.hhs.gov/hipaa.


HHS Announces New Conscience and Religious Freedom Division

March 23

A new Conscience and Religious Freedom Division has been formed in the HHS Office for Civil Rights, the U.S. Department of Health and Human Services has announced. The Conscience and Religious Freedom Division has been established to restore federal enforcement of our nation’s laws that protect the fundamental and unalienable rights of conscience and religious freedom.  OCR is the law enforcement agency within HHS that enforces federal laws protecting civil rights and conscience in health and human services, and the security and privacy of people’s health information.  The creation of the new division will provide HHS with the focus it needs to more vigorously and effectively enforce existing laws protecting the rights of conscience and religious freedom, the first freedom protected in the Bill of Rights, according to HHS.

OCR already has enforcement authority over federal conscience protection statutes, such as the Church, Coats-Snowe, and Weldon Amendments; Section 1553 of the Affordable Care Act (on assisted suicide); and certain federal nondiscrimination laws that prohibit discrimination on the basis of religion in a variety of HHS programs. 

OCR Director Roger Severino said, “Laws protecting religious freedom and conscience rights are just empty words on paper if they aren’t enforced. No one should be forced to choose between helping sick people and living by one’s deepest moral or religious convictions, and the new division will help guarantee that victims of unlawful discrimination find justice. For too long, governments big and small have treated conscience claims with hostility instead of protection, but change is coming and it begins here and now.”

Acting HHS Secretary Eric Hargan said, “President Trump promised the American people that his administration would vigorously uphold the rights of conscience and religious freedom.  That promise is being kept today. The Founding Fathers knew that a nation that respects conscience rights is more diverse and more free, and OCR’s new division will help make that vision a reality.”

To learn more about the new Conscience and Religious Freedom Division, visit us at www.hhs.gov/conscience.

HIPAA violations consequences don’t stop when a business closes

March 20

An Illinois company has been hit with a $100,000 settlement over HIPAA violations despite the fact that it closed down during the investigation, according to the estate to the U.S. Department of Health and Human Services (HHS) Office for Civil Rights. A receiver appointed to liquidate the assets of Filefax, Inc. agreed to the payment in order to settle potential violations of the Health Insurance Portability and Accountability Act Privacy Rule. Filefax, located in Northbrook, Illinois, advertised that it provided for the storage, maintenance, and delivery of medical records for covered entities. Although Filefax shut its doors during the course of OCR’s investigation into alleged HIPAA violations, it could not escape its obligations under the law.

On February 10, 2015, OCR received an anonymous complaint alleging that an individual transported medical records obtained from Filefax to a shredding and recycling facility to sell on February 6 and 9, 2015. OCR opened an investigation, which confirmed that an individual had left medical records of approximately 2,150 patients at the shredding and recycling facility, and that these medical records contained patients’ protected health information.

OCR’s investigation indicated that between January 28, 2015, and February 14, 2015, Filefax impermissibly disclosed the PHI of 2,150 individuals by leaving the PHI in an unlocked truck in the Filefax parking lot, or by granting permission to an unauthorized person to remove the PHI from Filefax, and leaving the PHI unsecured outside the Filefax facility.

“The careless handling of PHI is never acceptable,” said OCR Director Roger Severino. “Covered entities and business associates need to be aware that OCR is committed to enforcing HIPAA regardless of whether a covered entity is opening its doors or closing them. HIPAA still applies.”

Filefax is no longer in business. In 2016, a court in unrelated litigation appointed a receiver to liquidate its assets for distribution to creditors and others.  In addition to a $100,000 monetary settlement, the receiver has agreed, on behalf of Filefax, to properly store and dispose of remaining medical records found at Filefax’s facility in compliance with HIPAA.

The resolution agreement and corrective action plan may be found on the OCR website at   http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/Filefax/index.html.


New HIPAA Right of Access Training available for Providers

March 16                                                                                         

Training videos explaining patients’ right of access under the Health Insurance Portability and Accountability Act Privacy Rule are now available to health care providers from the U.S. Department of Health and Human Services Office for Civil Rights.

The videos lay out the HIPAA right of access and shows how it enables individuals to be more involved in their own care. The module provides helpful suggestions about how health care providers can integrate aspects of the HIPAA access right into their medical practice.

Participants will receive free Continuing Medical Education credit for physicians and Continuing Education credit for health care professionals upon completion.  The module is available on OCR’s Training and Resources webpage at https://www.hhs.gov/hipaa/for-professionals/training/index.html

HHS unveils improved web tool to highlight health information breaches

March 13

Improved access to health information data breeches, investigations and their aftermath is now available from a new web tool provided by the U.S. Department of Health and Human Services Office for Civil Rights. The HIPAA Breach Reporting Tool features improved navigation for both those looking for information on breaches and ease-of-use for organizations reporting incidents. The tool identifies industry best practices in order to help organizations improve their security.

The new tool, which replaces a system that dates back to 2009, includes the name of the entity; state where the entity is located; number of individuals affected by the breach; the date of the breach; type of breach (e.g., hacking/IT incident, theft, loss, unauthorized access/disclosure); and location of the breached information (e.g., laptop, paper records, desktop computer).

The tool’s new features include:

HHS plans on expanding and improving the site over time to add functionality and features based on feedback.  The HBRT provides transparency to the public and organizations covered by HIPAA and helps highlight the importance of safeguards to protect the privacy and security of sensitive health care information.

The HBRT may be found at:  https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf.

Hackers continue to target healthcare, government warns

March 8, 2018

Healthcare providers continue to be a prime target for ransomeware attacks and other hacking, according to the Security-List operated by the Office for Civil Rights, US Department of Health and Human Services.

While modern heath information technology systems provide security, that doesn’t eliminate the possibility that a cyber-incident will occur, as shown by recent news headlines. Incidents do happen and effective response planning can be a major factor in the scope of the operational or reputational harm or legal liability. Being able to respond to incidents in a systematic way ensures that appropriate response steps are taken each time to help minimize the impact of breaches.

An incident response policy and different types of contingency plans assist Covered Entities and Business Associates in having a proper, concentrated, and coordinated approach to responding. These policies, procedures, and plans should provide a roadmap for implementing the entity’s incident response capabilities. They should also meet the Covered Entities’ and Business Associates’ distinctive requirements that relates to their mission, sizes, structures, and functions, and identify the necessary resources and management support. They should be approved by management, reviewed and tested regularly, and should include the entity’s processes for:

The nature of existing threats and attacks makes it more important than ever for organizations to work together during incident response. The Federal Government has recognized the importance of information-sharing in the cybersecurity context, reflective in legislation such as the Cybersecurity Information Security Act (CISA) and Executive Order 13691. Information Sharing is where different organizations share threat, attack, and vulnerability information with each other so that each organization’s knowledge benefits the other. Covered Entities and Business Associates should consider the best ways to share cyber threat indicators during incidents, while not sharing PHI, and with whom to share those indicators.

Once it has been established a breach has occurred, reporting is an important part of the incident management process. Timely reporting helps to identify and rectify problems with individual organizations, identify and assess emerging risks, and protect individuals from identity theft or other fraud.

The HIPAA Breach Notification Rule requires covered entities to notify affected individuals, OCR, and in some cases, the media of a breach of unsecured protected health information (PHI). Most notifications must be provided without unreasonable delay and no later than 60 days following the discovery of a breach. Notifications of smaller breaches affecting fewer than 500 individuals may be submitted to OCR annually. The Breach Notification Rule also requires business associates of covered entities to notify the covered entity of breaches at or by the business associate. Visit the HHS HIPAA Breach Notification Rule webpage for more information and guidance on the reporting requirements.

Rural doctors in PCMHs have a broader scope of practice

March 6, 2018

Rural family physicians who work in Patient Centered Medical Homes have a broader scope of practice than those who don’t, according to a new study conducted by researchers from the American Board of Family Medicine.

The research team in 2014 and 2015 surveyed 3,121 rural family physicians who sought to continue their ABFM certification. Of the 3,121 rural family physicians, 1,248 were in large rural areas, 1,601 in small rural areas, and 272 were in frontier areas. The findings showed physicians practicing in PCMHs in both large rural areas and small rural areas engaged in a wider scope of clinical practice than those in non-PCMH practices. The difference in scope of clinical services was significant in 16 of the 21 clinical services analyzed for large rural areas and in 17 of 21 clinical services analyzed for small rural areas. With frontier areas, there were no significant differences observed between physicians practicing in PCMH and non-PCMH practices except for chronic disease management and preventive services.

The findings from the study indicate the PCMH model is meeting its goals of providing patients with more accessible, comprehensive, and coordinated health care. While previous research showed a decline in family physicians providing pediatric, mental health, and women’s health care, this study found that rural PCMH practices were providing these services at high levels.

Correspondence and inquiries should be addressed to: Lars E. Peterson, MD, PhD, American Board of Family Medicine


Country doctors have a broader scope of practice than city doctors

March 1, 2018

Confirming more than one old folk tale, country doctors have a broader scope of practice than city doctors, according to a recent conducted by researchers from the American Board of Family Medicine.

Using data from 18,846 family physicians, the study examined variations in the provision of 21 clinical services and 18 procedural services across metropolitan, large rural, small rural, and frontier areas. The percentage of family physicians providing each type of clinical and procedural service rose with increasing rurality. Rural family physicians were more likely to provide obstetrical deliveries, newborn care, pediatric care, occupational medicine, palliative care, and mental health care than urban family physicians. They were also more likely to see patients in the hospital and nursing home and to conduct home visits.

Despite prior research that the scope of practice of family physicians has been shrinking, the study found that rural family physicians are maintaining a broad scope of practice, which is likely necessary in rural areas where there are fewer options to access more specialized medical services.

Correspondence and inquiries should be addressed to: Lars E. Peterson, MD, PhD, American Board of Family Medicine

Physician burnout varies by state: report

February 28, 2018

More than half the physicians in Minnesota are burned out, according to new data released last month by the American Board of Family Medicine.

The January report covered data obtained by the board from the inaugural National Graduate Survey in 2016 revealing symptoms of burnout from emotional exhaustion at 39.8% and callousness at 23.7%.

Burnout refers to the psychological exhaustion resulting from long-term stress, and it puts physicians at risk for poor mental health, decreased productivity, and abandonment of career medicine. The data included two validated questions measuring emotional exhaustion and callousness. Only states with sample sizes of over 30 respondents were included. Variation among the states ranged from a rate of 55.4% emotional exhaustion in Minnesota to 16.1% in South Carolina. Colorado reported the highest rate of callousness or depersonalization at 35.3%, while South Carolina reported the lowest rate at 9.7%.

Variation among states suggests that there may be state-level factors, such as policies, payer-mix, or even culture that affect burnout.

The complete Article Burnout in Young Family Physicians: Variation Across States may be found here.

Inquiries and correspondence should be addressed to Lars E. Peterson, MD, PhD, American Board of Family Medicine, 1648 McGrathiana Parkway, Suite 550, Lexington, KY 40511-1247




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