Alicia Gallegos

For the last few months, family physician Dr. R. Russell Thomas Jr. has split his time between visiting patients at his practice in Eagle Lake, Tex., and treating children who reside more than 300 miles away in Sheffield, Tex. via telemedicine. His virtual tool belt includes an electronic stethoscope that enables Dr. Thomas to hear a patient’s heartbeat in real time and a high-definition camera to view and diagnose skin lesions.

The telehealth services are part of a new initiative at Rice Medical Center, a 25-bed, critical access hospital in rural Eagle Lake – population 3,700. Dr. Thomas has thus far used the technology to treat patients at an at-risk children’s academy and a local primary school. Soon, he and other physicians will also use telemedicine to consult with cardiologists and internists who practice 70 miles away in Houston.

“I look at telemedicine not so much as a practice like cardiology or orthopedics, but more [as] a tool like a percussion hammer or an otoscope,” Dr. Thomas said in an interview. “It’s a tool to practice whatever it is that you do.”

Dr. Thomas is far from alone. Analysts predict vast growth in the telemedicine industry in the coming years. The number of health providers offering telemedicine is expected to rise from 22% in 2014 to 37% in 2015, according to research by Towers Watson. Another report, by BCC Research, shows the global telehospital/clinic and telehome market is expected to reach about $43 billion in 2019, up from $19 billion in 2014.

The explosion of telemedicine is driven by two primary factors, said Dr. Joseph P. McMenamin, a Richmond, Va., attorney who specializes in medical malpractice defense and telemedicine.

“As a society, we are increasingly reliant upon and enamored of electronic methods of communications,” Dr. McMenamin said in an interview. “In one sense, it’s just part of a larger trend. The other, more specific reason, perhaps, is the widespread dissatisfaction with the way our health care system operates today. We are blessed in the United States to have some of the finest physicians in the world. … and then we have this terribly complex, burdensome system for getting people to where they need to be to get care. Telemedicine, by comparison is quick, convenient, and relatively inexpensive.”

Telemedicine is poised to change the way doctors practice. This first of three articles lays out the landscape for how telemedicine is shaping up across the country.

But for doctors, the practice of telemedicine is strewn with challenges. Barriers include reimbursement, licensing, malpractice, and regulation. Topping the barriers is a lack of uniform standards about practices. A key question: What constitutes the responsible use of telemedicine?

States have differing ideas. Some require a physical examination by a physician prior to telemedicine. Some allow that encounter can be conducted via telemedicine, while others mandate the visit is in-person. Alabama, Georgia, and Texas require an in-person follow-up visit after a telemedicine encounter, according to 2015 data from the American Telemedicine Association (ATA). Sixteen states and D.C. have informed consent requirements for telemedicine patients. Still other states have no defined rules for the practice of telemedicine.

To promote consistency and better usage, the Federation of State Medical Boards in 2014 issued a model policy to state medical boards about the recommended practice of telemedicine. The policy maintains that the same standard of care applied to face-to-face encounters be applied to telemedicine encounters, said Lisa A. Robin, chief advocacy officer for the Federation of State Medical Boards (FSMB). At least 29 state boards have telemedicine rules that are consistent with the model policy, Ms. Robin said in an interview.

“As telemedicine continues to evolve, we believe there must be a very strong focus on ensuring patient safety through sound policy making and regulatory practices,” she said.

From practice debate to court dispute

Medical specialty societies are beginning to weigh in on acceptable telehealth practices for doctors. In July, the American Academy of Pediatrics issued guidance advocating that use of telemedicine for episodic care should be done within the context of the medical home and that fragmented telemedicine services should be avoided. Guidance issued by the American Medical Association makes it clears that physicians who prescribe using telemedicine need to first establish a patient-physician relationship. In September, the American College of Physicians (ACP) also issued policy in support of expanded telemedicine use, but cautioned the practice should be between a physician and patient who have an established relationship. The FSMB guidance also states that doctors should establish a relationship with patients before practicing telemedicine.

Courtesy Dr. Russell Thomas Jr.

But how that relationship is created is up for debate. In Texas, disagreement over what creates a physician-patient relationship has led to litigation between national telemedicine company Teladoc and the Texas Medical Board. The case centers on a medical board rule that requires physicians to have a face-to-face visit with patients before treating them through telemedicine. The relationship can be created through telemedicine at an established medical site, but it may not be established through an online questionnaire, e-mail, text, chat, or telephonic evaluation or consultation. Teladoc sued the medical board in April claiming the rule violates federal antitrust laws. Teladoc provides access to medical care via phone or interactive video and treats patients for nonemergency conditions. A judge halted the rule’s enforcement in May.

The company sued to ensure patients have access to the same high-quality telehealth care they’ve received for decades, said Teladoc CEO Jason Gorevic.

“We have employers, health plans, and hospital systems who are coming to us because telehealth is a solution to access-to-care challenges as well as a mechanism to control the cost of care,” Mr. Gorevic said in an interview. “It was our responsibility and quite frankly, our obligation, to take action where there were regulations being adopted that were counter to the interests of patients, payers, and physicians in the state.”

In an April statement, Dr. Michael Arambula, president of the Texas Medical Board (TMB), said the rule represents the best balance of convenience and safety by ensuring quality health care for patients.

“The board recognizes that as technology evolves, so too must regulations governing telemedicine,” Dr. Arambula said in the statement. “However, a telephone medicine scenario that allows a physician to treat an unknown patient without any objective diagnostic data and no ability to follow up with the patient sacrifices the patient’s safety for convenience.”

The Texas Medical Association (TMA) supported the TMB rule. Dr. Thomas, a former TMB member who is active with the TMA, said the rule’s logic is simple.

Without a face-to-face visit, “the doctor has no knowledge of the patient, except for what they tell you in that one encounter,” he said in an interview. “There are no follow-up opportunities, no mechanism for further assessment. It’s episodic care at its worst.”

However, Dr. Reed V. Tuckson, president of the American Telemedicine Association, stresses rules such as the Texas Medical Board’s are unnecessarily intrusive to doctors and diminish the range of possibilities for telemedicine care.

“We do not believe the restrictive covenants that are being applied by far too many state medical boards are appropriate,” Dr. Tuckson said in an interview. “We do not believe they should dictating to physicians, the tools that they should be able to use in partnership with their patients to meet [patients’] individual needs.”

Coming Tuesday, Sept. 29: Who leads the field on paying for telemedicine services?

[email protected]

On Twitter @legal_med

For the last few months, family physician Dr. R. Russell Thomas Jr. has split his time between visiting patients at his practice in Eagle Lake, Tex., and treating children who reside more than 300 miles away in Sheffield, Tex. via telemedicine. His virtual tool belt includes an electronic stethoscope that enables Dr. Thomas to hear a patient’s heartbeat in real time and a high-definition camera to view and diagnose skin lesions.

The telehealth services are part of a new initiative at Rice Medical Center, a 25-bed, critical access hospital in rural Eagle Lake – population 3,700. Dr. Thomas has thus far used the technology to treat patients at an at-risk children’s academy and a local primary school. Soon, he and other physicians will also use telemedicine to consult with cardiologists and internists who practice 70 miles away in Houston.

“I look at telemedicine not so much as a practice like cardiology or orthopedics, but more [as] a tool like a percussion hammer or an otoscope,” Dr. Thomas said in an interview. “It’s a tool to practice whatever it is that you do.”

Dr. Thomas is far from alone. Analysts predict vast growth in the telemedicine industry in the coming years. The number of health providers offering telemedicine is expected to rise from 22% in 2014 to 37% in 2015, according to research by Towers Watson. Another report, by BCC Research, shows the global telehospital/clinic and telehome market is expected to reach about $43 billion in 2019, up from $19 billion in 2014.

The explosion of telemedicine is driven by two primary factors, said Dr. Joseph P. McMenamin, a Richmond, Va., attorney who specializes in medical malpractice defense and telemedicine.

“As a society, we are increasingly reliant upon and enamored of electronic methods of communications,” Dr. McMenamin said in an interview. “In one sense, it’s just part of a larger trend. The other, more specific reason, perhaps, is the widespread dissatisfaction with the way our health care system operates today. We are blessed in the United States to have some of the finest physicians in the world. … and then we have this terribly complex, burdensome system for getting people to where they need to be to get care. Telemedicine, by comparison is quick, convenient, and relatively inexpensive.”

Telemedicine is poised to change the way doctors practice. This first of three articles lays out the landscape for how telemedicine is shaping up across the country.

But for doctors, the practice of telemedicine is strewn with challenges. Barriers include reimbursement, licensing, malpractice, and regulation. Topping the barriers is a lack of uniform standards about practices. A key question: What constitutes the responsible use of telemedicine?

States have differing ideas. Some require a physical examination by a physician prior to telemedicine. Some allow that encounter can be conducted via telemedicine, while others mandate the visit is in-person. Alabama, Georgia, and Texas require an in-person follow-up visit after a telemedicine encounter, according to 2015 data from the American Telemedicine Association (ATA). Sixteen states and D.C. have informed consent requirements for telemedicine patients. Still other states have no defined rules for the practice of telemedicine.

To promote consistency and better usage, the Federation of State Medical Boards in 2014 issued a model policy to state medical boards about the recommended practice of telemedicine. The policy maintains that the same standard of care applied to face-to-face encounters be applied to telemedicine encounters, said Lisa A. Robin, chief advocacy officer for the Federation of State Medical Boards (FSMB). At least 29 state boards have telemedicine rules that are consistent with the model policy, Ms. Robin said in an interview.

“As telemedicine continues to evolve, we believe there must be a very strong focus on ensuring patient safety through sound policy making and regulatory practices,” she said.

From practice debate to court dispute

Medical specialty societies are beginning to weigh in on acceptable telehealth practices for doctors. In July, the American Academy of Pediatrics issued guidance advocating that use of telemedicine for episodic care should be done within the context of the medical home and that fragmented telemedicine services should be avoided. Guidance issued by the American Medical Association makes it clears that physicians who prescribe using telemedicine need to first establish a patient-physician relationship. In September, the American College of Physicians (ACP) also issued policy in support of expanded telemedicine use, but cautioned the practice should be between a physician and patient who have an established relationship. The FSMB guidance also states that doctors should establish a relationship with patients before practicing telemedicine.

Courtesy Dr. Russell Thomas Jr.

But how that relationship is created is up for debate. In Texas, disagreement over what creates a physician-patient relationship has led to litigation between national telemedicine company Teladoc and the Texas Medical Board. The case centers on a medical board rule that requires physicians to have a face-to-face visit with patients before treating them through telemedicine. The relationship can be created through telemedicine at an established medical site, but it may not be established through an online questionnaire, e-mail, text, chat, or telephonic evaluation or consultation. Teladoc sued the medical board in April claiming the rule violates federal antitrust laws. Teladoc provides access to medical care via phone or interactive video and treats patients for nonemergency conditions. A judge halted the rule’s enforcement in May.

The company sued to ensure patients have access to the same high-quality telehealth care they’ve received for decades, said Teladoc CEO Jason Gorevic.

“We have employers, health plans, and hospital systems who are coming to us because telehealth is a solution to access-to-care challenges as well as a mechanism to control the cost of care,” Mr. Gorevic said in an interview. “It was our responsibility and quite frankly, our obligation, to take action where there were regulations being adopted that were counter to the interests of patients, payers, and physicians in the state.”

In an April statement, Dr. Michael Arambula, president of the Texas Medical Board (TMB), said the rule represents the best balance of convenience and safety by ensuring quality health care for patients.

“The board recognizes that as technology evolves, so too must regulations governing telemedicine,” Dr. Arambula said in the statement. “However, a telephone medicine scenario that allows a physician to treat an unknown patient without any objective diagnostic data and no ability to follow up with the patient sacrifices the patient’s safety for convenience.”

The Texas Medical Association (TMA) supported the TMB rule. Dr. Thomas, a former TMB member who is active with the TMA, said the rule’s logic is simple.

Without a face-to-face visit, “the doctor has no knowledge of the patient, except for what they tell you in that one encounter,” he said in an interview. “There are no follow-up opportunities, no mechanism for further assessment. It’s episodic care at its worst.”

However, Dr. Reed V. Tuckson, president of the American Telemedicine Association, stresses rules such as the Texas Medical Board’s are unnecessarily intrusive to doctors and diminish the range of possibilities for telemedicine care.

“We do not believe the restrictive covenants that are being applied by far too many state medical boards are appropriate,” Dr. Tuckson said in an interview. “We do not believe they should dictating to physicians, the tools that they should be able to use in partnership with their patients to meet [patients’] individual needs.”

Coming Tuesday, Sept. 29: Who leads the field on paying for telemedicine services?

[email protected]

On Twitter @legal_med

For the last few months, family physician Dr. R. Russell Thomas Jr. has split his time between visiting patients at his practice in Eagle Lake, Tex., and treating children who reside more than 300 miles away in Sheffield, Tex. via telemedicine. His virtual tool belt includes an electronic stethoscope that enables Dr. Thomas to hear a patient’s heartbeat in real time and a high-definition camera to view and diagnose skin lesions.

The telehealth services are part of a new initiative at Rice Medical Center, a 25-bed, critical access hospital in rural Eagle Lake – population 3,700. Dr. Thomas has thus far used the technology to treat patients at an at-risk children’s academy and a local primary school. Soon, he and other physicians will also use telemedicine to consult with cardiologists and internists who practice 70 miles away in Houston.

“I look at telemedicine not so much as a practice like cardiology or orthopedics, but more [as] a tool like a percussion hammer or an otoscope,” Dr. Thomas said in an interview. “It’s a tool to practice whatever it is that you do.”

Dr. Thomas is far from alone. Analysts predict vast growth in the telemedicine industry in the coming years. The number of health providers offering telemedicine is expected to rise from 22% in 2014 to 37% in 2015, according to research by Towers Watson. Another report, by BCC Research, shows the global telehospital/clinic and telehome market is expected to reach about $43 billion in 2019, up from $19 billion in 2014.

The explosion of telemedicine is driven by two primary factors, said Dr. Joseph P. McMenamin, a Richmond, Va., attorney who specializes in medical malpractice defense and telemedicine.

“As a society, we are increasingly reliant upon and enamored of electronic methods of communications,” Dr. McMenamin said in an interview. “In one sense, it’s just part of a larger trend. The other, more specific reason, perhaps, is the widespread dissatisfaction with the way our health care system operates today. We are blessed in the United States to have some of the finest physicians in the world. … and then we have this terribly complex, burdensome system for getting people to where they need to be to get care. Telemedicine, by comparison is quick, convenient, and relatively inexpensive.”

Telemedicine is poised to change the way doctors practice. This first of three articles lays out the landscape for how telemedicine is shaping up across the country.

But for doctors, the practice of telemedicine is strewn with challenges. Barriers include reimbursement, licensing, malpractice, and regulation. Topping the barriers is a lack of uniform standards about practices. A key question: What constitutes the responsible use of telemedicine?

States have differing ideas. Some require a physical examination by a physician prior to telemedicine. Some allow that encounter can be conducted via telemedicine, while others mandate the visit is in-person. Alabama, Georgia, and Texas require an in-person follow-up visit after a telemedicine encounter, according to 2015 data from the American Telemedicine Association (ATA). Sixteen states and D.C. have informed consent requirements for telemedicine patients. Still other states have no defined rules for the practice of telemedicine.

To promote consistency and better usage, the Federation of State Medical Boards in 2014 issued a model policy to state medical boards about the recommended practice of telemedicine. The policy maintains that the same standard of care applied to face-to-face encounters be applied to telemedicine encounters, said Lisa A. Robin, chief advocacy officer for the Federation of State Medical Boards (FSMB). At least 29 state boards have telemedicine rules that are consistent with the model policy, Ms. Robin said in an interview.

“As telemedicine continues to evolve, we believe there must be a very strong focus on ensuring patient safety through sound policy making and regulatory practices,” she said.

From practice debate to court dispute

Medical specialty societies are beginning to weigh in on acceptable telehealth practices for doctors. In July, the American Academy of Pediatrics issued guidance advocating that use of telemedicine for episodic care should be done within the context of the medical home and that fragmented telemedicine services should be avoided. Guidance issued by the American Medical Association makes it clears that physicians who prescribe using telemedicine need to first establish a patient-physician relationship. In September, the American College of Physicians (ACP) also issued policy in support of expanded telemedicine use, but cautioned the practice should be between a physician and patient who have an established relationship. The FSMB guidance also states that doctors should establish a relationship with patients before practicing telemedicine.

Courtesy Dr. Russell Thomas Jr.

But how that relationship is created is up for debate. In Texas, disagreement over what creates a physician-patient relationship has led to litigation between national telemedicine company Teladoc and the Texas Medical Board. The case centers on a medical board rule that requires physicians to have a face-to-face visit with patients before treating them through telemedicine. The relationship can be created through telemedicine at an established medical site, but it may not be established through an online questionnaire, e-mail, text, chat, or telephonic evaluation or consultation. Teladoc sued the medical board in April claiming the rule violates federal antitrust laws. Teladoc provides access to medical care via phone or interactive video and treats patients for nonemergency conditions. A judge halted the rule’s enforcement in May.

The company sued to ensure patients have access to the same high-quality telehealth care they’ve received for decades, said Teladoc CEO Jason Gorevic.

“We have employers, health plans, and hospital systems who are coming to us because telehealth is a solution to access-to-care challenges as well as a mechanism to control the cost of care,” Mr. Gorevic said in an interview. “It was our responsibility and quite frankly, our obligation, to take action where there were regulations being adopted that were counter to the interests of patients, payers, and physicians in the state.”

In an April statement, Dr. Michael Arambula, president of the Texas Medical Board (TMB), said the rule represents the best balance of convenience and safety by ensuring quality health care for patients.

“The board recognizes that as technology evolves, so too must regulations governing telemedicine,” Dr. Arambula said in the statement. “However, a telephone medicine scenario that allows a physician to treat an unknown patient without any objective diagnostic data and no ability to follow up with the patient sacrifices the patient’s safety for convenience.”

The Texas Medical Association (TMA) supported the TMB rule. Dr. Thomas, a former TMB member who is active with the TMA, said the rule’s logic is simple.

Without a face-to-face visit, “the doctor has no knowledge of the patient, except for what they tell you in that one encounter,” he said in an interview. “There are no follow-up opportunities, no mechanism for further assessment. It’s episodic care at its worst.”

However, Dr. Reed V. Tuckson, president of the American Telemedicine Association, stresses rules such as the Texas Medical Board’s are unnecessarily intrusive to doctors and diminish the range of possibilities for telemedicine care.

“We do not believe the restrictive covenants that are being applied by far too many state medical boards are appropriate,” Dr. Tuckson said in an interview. “We do not believe they should dictating to physicians, the tools that they should be able to use in partnership with their patients to meet [patients’] individual needs.”

Coming Tuesday, Sept. 29: Who leads the field on paying for telemedicine services?

[email protected]

On Twitter @legal_med

The 8th U.S. Circuit Court of Appeals has ruled against the Affordable Care Act’s contraception mandate, making it likely that the U.S. Supreme Court will revisit the requirement to resolve a split among circuit courts.

The 8th Circuit court is the first to rule that the government’s religious freedom accommodation is not enough, and that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights.

The appeals court issued two decisions on Sept. 17 striking down the contraception mandate’s exception. The first opinion revolved around two Missouri nonprofit organizations that provide residential and educational services to people with behavioral problems and dependency conditions. In their lawsuit against the U.S. Department of Health & Human Services, the nonprofits argued that the contraceptive mandate itself, and its accommodation process, impose substantial burdens on their exercise of religion in violation of the Religious Freedom Restoration Act.

Copyright Kuzma/istockphoto.com

The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives, but are not exempted entities such as churches. To get out of the requirement to cover contraception, the companies must send a letter to the government with their objections. Insurers and the government will then provide coverage for birth control without the employer’s assistance.

But the Missouri nonprofits and other religious groups counter that the process serves as a “trigger” that enables contraceptive use and makes the groups complicit. A panel 8th Circuit agreed, ruling that compliance with the mandate’s so-called accommodation violates the organizations’ religious freedoms, and that the exception is “not the least restrictive means of furthering the government’s interests.”

The court applied the same reasoning to a similar case brought by an Iowa college. In both cases, the appeals court temporarily blocked the organizations from having to comply with the contraception mandate while the cases moved forward.

The decisions are at odds with a handful of other circuit courts, including rulings by the 2nd and 5th Circuits. Other judges have ruled that the accommodation relieves, rather than burdens plaintiffs’ religious rights.

The 8th Circuit court’s recent rulings could influence whether the Supreme Court takes up the issue.

Currently, seven petitions requesting that the Supreme Court rereview the contraception mandate process are pending. The cases all have some objection to the mandate, its operation, or some of the contraceptives covered. Sixteen states have also asked the Supreme Court to revisit the mandate.

The cases follow last year’s Supreme Court ruling in Burwell v. Hobby Lobby Stores. In that decision, the justices ruled that for-profit firms owned by religiously devout owners could not be forced to provide birth control coverage to their employees under the ACA.

[email protected]

On Twitter @legal_med

The 8th U.S. Circuit Court of Appeals has ruled against the Affordable Care Act’s contraception mandate, making it likely that the U.S. Supreme Court will revisit the requirement to resolve a split among circuit courts.

The 8th Circuit court is the first to rule that the government’s religious freedom accommodation is not enough, and that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights.

The appeals court issued two decisions on Sept. 17 striking down the contraception mandate’s exception. The first opinion revolved around two Missouri nonprofit organizations that provide residential and educational services to people with behavioral problems and dependency conditions. In their lawsuit against the U.S. Department of Health & Human Services, the nonprofits argued that the contraceptive mandate itself, and its accommodation process, impose substantial burdens on their exercise of religion in violation of the Religious Freedom Restoration Act.

Copyright Kuzma/istockphoto.com

The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives, but are not exempted entities such as churches. To get out of the requirement to cover contraception, the companies must send a letter to the government with their objections. Insurers and the government will then provide coverage for birth control without the employer’s assistance.

But the Missouri nonprofits and other religious groups counter that the process serves as a “trigger” that enables contraceptive use and makes the groups complicit. A panel 8th Circuit agreed, ruling that compliance with the mandate’s so-called accommodation violates the organizations’ religious freedoms, and that the exception is “not the least restrictive means of furthering the government’s interests.”

The court applied the same reasoning to a similar case brought by an Iowa college. In both cases, the appeals court temporarily blocked the organizations from having to comply with the contraception mandate while the cases moved forward.

The decisions are at odds with a handful of other circuit courts, including rulings by the 2nd and 5th Circuits. Other judges have ruled that the accommodation relieves, rather than burdens plaintiffs’ religious rights.

The 8th Circuit court’s recent rulings could influence whether the Supreme Court takes up the issue.

Currently, seven petitions requesting that the Supreme Court rereview the contraception mandate process are pending. The cases all have some objection to the mandate, its operation, or some of the contraceptives covered. Sixteen states have also asked the Supreme Court to revisit the mandate.

The cases follow last year’s Supreme Court ruling in Burwell v. Hobby Lobby Stores. In that decision, the justices ruled that for-profit firms owned by religiously devout owners could not be forced to provide birth control coverage to their employees under the ACA.

[email protected]

On Twitter @legal_med

The 8th U.S. Circuit Court of Appeals has ruled against the Affordable Care Act’s contraception mandate, making it likely that the U.S. Supreme Court will revisit the requirement to resolve a split among circuit courts.

The 8th Circuit court is the first to rule that the government’s religious freedom accommodation is not enough, and that forcing organizations to offer contraceptive coverage – even indirectly – violates their religious rights.

The appeals court issued two decisions on Sept. 17 striking down the contraception mandate’s exception. The first opinion revolved around two Missouri nonprofit organizations that provide residential and educational services to people with behavioral problems and dependency conditions. In their lawsuit against the U.S. Department of Health & Human Services, the nonprofits argued that the contraceptive mandate itself, and its accommodation process, impose substantial burdens on their exercise of religion in violation of the Religious Freedom Restoration Act.

Copyright Kuzma/istockphoto.com

The accommodation clause refers to an exception for organizations that oppose coverage for contraceptives, but are not exempted entities such as churches. To get out of the requirement to cover contraception, the companies must send a letter to the government with their objections. Insurers and the government will then provide coverage for birth control without the employer’s assistance.

But the Missouri nonprofits and other religious groups counter that the process serves as a “trigger” that enables contraceptive use and makes the groups complicit. A panel 8th Circuit agreed, ruling that compliance with the mandate’s so-called accommodation violates the organizations’ religious freedoms, and that the exception is “not the least restrictive means of furthering the government’s interests.”

The court applied the same reasoning to a similar case brought by an Iowa college. In both cases, the appeals court temporarily blocked the organizations from having to comply with the contraception mandate while the cases moved forward.

The decisions are at odds with a handful of other circuit courts, including rulings by the 2nd and 5th Circuits. Other judges have ruled that the accommodation relieves, rather than burdens plaintiffs’ religious rights.

The 8th Circuit court’s recent rulings could influence whether the Supreme Court takes up the issue.

Currently, seven petitions requesting that the Supreme Court rereview the contraception mandate process are pending. The cases all have some objection to the mandate, its operation, or some of the contraceptives covered. Sixteen states have also asked the Supreme Court to revisit the mandate.

The cases follow last year’s Supreme Court ruling in Burwell v. Hobby Lobby Stores. In that decision, the justices ruled that for-profit firms owned by religiously devout owners could not be forced to provide birth control coverage to their employees under the ACA.

[email protected]

On Twitter @legal_med

Starting in 2017, physicians who practice clinical cardiac electrophysiology (CCEP) will be required to have 2 additional years of specialized training following the required 3 years of cardiology training, according to a statement issued Sept. 18 by three major cardiology associations.

The American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) also recommended volume increases for numerous procedures that trainees perform prior to completing fellowships (J Am Coll Cardiol. doi 10.1016/j.jacc.2015.08.040).

The training requirements are necessary to meet the growing complexity of CCEP and ensure physicians are sufficiently trained, said Dr. Hugh Calkins, vice chair of the statement writing committee and director of the clinical electrophysiology laboratory and the arrhythmia service at the Johns Hopkins Hospital, Baltimore.

“Training in CCEP has become more complex as the clinical specialty has matured,” Dr. Calkins said in a statement. “Use of cardioactive drugs; implantation and use of implantable electronic devices and left atrial appendage occlusion devices; and performance of invasive catheter ablation procedures for arrhythmia management have reached a level of sophistication that has mandated a reevaluation of the training curriculum and the duration of training.”

The guide defines the six competencies – medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism – and provides curricular milestones for each as fellows progress through training. Additionally, the statement updates recommendations for the numbers of procedures trainees should perform during fellowship. For example, each trainee should perform at least 175 electrophysiologic procedures for arrhythmia evaluation, according to the statement. Over the 2-year CCEP fellowship, trainees should perform at least 160 ablation procedures, with at least 50 of these being supraventricular ablation procedures.

Trainees should also participate in mapping and ablation of at least 30 arrhythmias, the association recommends. Fellows are expected to gain competence in programmed electrical stimulation with cognitive skills in identifying the arrhythmia circuit using both activation and entrainment mapping, determine appropriate sites for ablation, and demonstrate conduction block across reentry circuit sites post ablation. Integration of knowledge related to three-dimensional mapping systems and reentrant mechanisms is also required. Of the 30 procedures, at least 20 typical atrial flutters and 10 other macro-reentrant ATs are expected.

The American Board of Internal Medicine (ABIM) previously required cardiologists to have 1 additional year of training in clinical cardiac electrophysiology. However, at the request of the ACC, AHA, and HRS, ABIM has increased the duration of training required to sit for examination in electrophysiology to 2 years starting in 2017. ABIM and the Accreditation Council for Graduate Medical Education (ACGME) will now review the proposed recommendations of the writing committee and decide how to incorporate the recommendations.

The recommended number of procedures for trainees was developed through published studies, competency statements, and the opinions of the writing committee. In addition, the writing committee surveyed 33 CCEP training-program directors to gain additional insight into procedural volumes.

[email protected]

On Twitter @legal_med

Starting in 2017, physicians who practice clinical cardiac electrophysiology (CCEP) will be required to have 2 additional years of specialized training following the required 3 years of cardiology training, according to a statement issued Sept. 18 by three major cardiology associations.

The American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) also recommended volume increases for numerous procedures that trainees perform prior to completing fellowships (J Am Coll Cardiol. doi 10.1016/j.jacc.2015.08.040).

The training requirements are necessary to meet the growing complexity of CCEP and ensure physicians are sufficiently trained, said Dr. Hugh Calkins, vice chair of the statement writing committee and director of the clinical electrophysiology laboratory and the arrhythmia service at the Johns Hopkins Hospital, Baltimore.

“Training in CCEP has become more complex as the clinical specialty has matured,” Dr. Calkins said in a statement. “Use of cardioactive drugs; implantation and use of implantable electronic devices and left atrial appendage occlusion devices; and performance of invasive catheter ablation procedures for arrhythmia management have reached a level of sophistication that has mandated a reevaluation of the training curriculum and the duration of training.”

The guide defines the six competencies – medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism – and provides curricular milestones for each as fellows progress through training. Additionally, the statement updates recommendations for the numbers of procedures trainees should perform during fellowship. For example, each trainee should perform at least 175 electrophysiologic procedures for arrhythmia evaluation, according to the statement. Over the 2-year CCEP fellowship, trainees should perform at least 160 ablation procedures, with at least 50 of these being supraventricular ablation procedures.

Trainees should also participate in mapping and ablation of at least 30 arrhythmias, the association recommends. Fellows are expected to gain competence in programmed electrical stimulation with cognitive skills in identifying the arrhythmia circuit using both activation and entrainment mapping, determine appropriate sites for ablation, and demonstrate conduction block across reentry circuit sites post ablation. Integration of knowledge related to three-dimensional mapping systems and reentrant mechanisms is also required. Of the 30 procedures, at least 20 typical atrial flutters and 10 other macro-reentrant ATs are expected.

The American Board of Internal Medicine (ABIM) previously required cardiologists to have 1 additional year of training in clinical cardiac electrophysiology. However, at the request of the ACC, AHA, and HRS, ABIM has increased the duration of training required to sit for examination in electrophysiology to 2 years starting in 2017. ABIM and the Accreditation Council for Graduate Medical Education (ACGME) will now review the proposed recommendations of the writing committee and decide how to incorporate the recommendations.

The recommended number of procedures for trainees was developed through published studies, competency statements, and the opinions of the writing committee. In addition, the writing committee surveyed 33 CCEP training-program directors to gain additional insight into procedural volumes.

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Starting in 2017, physicians who practice clinical cardiac electrophysiology (CCEP) will be required to have 2 additional years of specialized training following the required 3 years of cardiology training, according to a statement issued Sept. 18 by three major cardiology associations.

The American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) also recommended volume increases for numerous procedures that trainees perform prior to completing fellowships (J Am Coll Cardiol. doi 10.1016/j.jacc.2015.08.040).

The training requirements are necessary to meet the growing complexity of CCEP and ensure physicians are sufficiently trained, said Dr. Hugh Calkins, vice chair of the statement writing committee and director of the clinical electrophysiology laboratory and the arrhythmia service at the Johns Hopkins Hospital, Baltimore.

“Training in CCEP has become more complex as the clinical specialty has matured,” Dr. Calkins said in a statement. “Use of cardioactive drugs; implantation and use of implantable electronic devices and left atrial appendage occlusion devices; and performance of invasive catheter ablation procedures for arrhythmia management have reached a level of sophistication that has mandated a reevaluation of the training curriculum and the duration of training.”

The guide defines the six competencies – medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism – and provides curricular milestones for each as fellows progress through training. Additionally, the statement updates recommendations for the numbers of procedures trainees should perform during fellowship. For example, each trainee should perform at least 175 electrophysiologic procedures for arrhythmia evaluation, according to the statement. Over the 2-year CCEP fellowship, trainees should perform at least 160 ablation procedures, with at least 50 of these being supraventricular ablation procedures.

Trainees should also participate in mapping and ablation of at least 30 arrhythmias, the association recommends. Fellows are expected to gain competence in programmed electrical stimulation with cognitive skills in identifying the arrhythmia circuit using both activation and entrainment mapping, determine appropriate sites for ablation, and demonstrate conduction block across reentry circuit sites post ablation. Integration of knowledge related to three-dimensional mapping systems and reentrant mechanisms is also required. Of the 30 procedures, at least 20 typical atrial flutters and 10 other macro-reentrant ATs are expected.

The American Board of Internal Medicine (ABIM) previously required cardiologists to have 1 additional year of training in clinical cardiac electrophysiology. However, at the request of the ACC, AHA, and HRS, ABIM has increased the duration of training required to sit for examination in electrophysiology to 2 years starting in 2017. ABIM and the Accreditation Council for Graduate Medical Education (ACGME) will now review the proposed recommendations of the writing committee and decide how to incorporate the recommendations.

The recommended number of procedures for trainees was developed through published studies, competency statements, and the opinions of the writing committee. In addition, the writing committee surveyed 33 CCEP training-program directors to gain additional insight into procedural volumes.

[email protected]

On Twitter @legal_med

A task force convened by the American Board of Internal Medicine (ABIM) has proposed replacing the board’s 10-year Maintenance of Certification (MOC) exam with more meaningful assessments and explore certification in specialized areas.

The Assessment 2020 Task Force, which convened in 2013 to evaluate the ABIM MOC program, released its proposals in a Sept. 16 report. The report aims to inform ongoing redesign of ABIM’s Certification and MOC programs, according to Dr. Richard J. Baron, ABIM president and CEO.

“Feedback collected by the Assessment 2020 Task Force is very consistent with feedback ABIM is hearing from the community regarding the MOC program,” Dr. Baron said in a statement. “These recommendations are meant to be a catalyst for further discussion and can ultimately lead to an improved MOC program for diplomates.”

The independent task force includes representatives from ABIM leadership and experts in assessment, education, health care, and consumer advocacy.

The task force recommends that ABIM focus MOC assessments on cognitive and technical skills; recognize specialization; and consider certification in specialized areas without requiring maintenance of underlying certificates. On that final recommendation, ABIM has already started such changes. In July, the board announced that no disciplines within its MOC program will require underlying certification and that all diplomates can choose the certifications they wish to maintain.

The task force also recommends that ABIM replace its 10-year secure exam with more frequent assessments. The assessments could be taken in a secure setting – possibly at home with remote authentication – with the potential for some portion to be open-book but still timed, according to the task force report.

“The Assessment 2020 Task Force members provided useful insights and recommendations that will be instrumental as we reshape certification to meet physicians’ and society’s changing needs,” Dr. Clarence H. Braddock III, chair of the ABIM Board of Directors said in a statement. “We now need to hear constructive feedback from the internal medicine community on these recommendations, begin to determine their feasibility and develop implementation plans where needed.”

Dr. Wayne J. Riley, president of the American College of Physicians (ACP) said the college is hopeful that the new report will lead to positive changes that raise the MOC’s relevance and value to physicians and patients.

“In addition to getting input on the report from ACP leadership, we are also seeking input from ACP members on the broader issue of MOC,” Dr. Riley said in an interview. “We remain committed to advocating for substantial and meaningful reforms to the ABIM MOC program.”

The American College of Cardiology (ACC) commended the task force for its work to gather input from stakeholders and develop the report.

“As evidenced by the report, there is still much to be done despite the changes over the last several months,” Dr. Kim Allan Williams Sr., ACC president and Dr. Robert A. Shor, chair of the ACC Board of Governors, wrote in a blog post. “The college understands the frustration of its members around the current MOC process and the issue continues to be a top priority for the college. In particular, the ACC strongly agrees with the report about the need to develop a new, externally validated process for measuring competence to replace the 10-year exam – with all deliberate haste! ... We are committed to finding a solution or solutions that best meet the professional needs of clinicians, while also giving patients, the public and other stakeholders confidence that the care provided by their physicians is of the highest quality.”

ABIM has already made a number of changes to its MOC program in recent months, including suspending quality improvement and patient safety requirements in the program, no longer requiring underlying certifications for MOC, and offering a 1-year grace period for physicians who fail the MOC examination in their discipline. Additionally, ABIM has developed a new partnership with the Accreditation Council for Continuing Medical Education (ACCME) to accept more forms of continuing medical education (CME) for MOC credit.

ABIM has also updated its the blueprint for the internal medicine exam with physician input, and included more performance feedback on score reports that diplomates receive with examination results.

[email protected]

On Twitter @legal_med

A task force convened by the American Board of Internal Medicine (ABIM) has proposed replacing the board’s 10-year Maintenance of Certification (MOC) exam with more meaningful assessments and explore certification in specialized areas.

The Assessment 2020 Task Force, which convened in 2013 to evaluate the ABIM MOC program, released its proposals in a Sept. 16 report. The report aims to inform ongoing redesign of ABIM’s Certification and MOC programs, according to Dr. Richard J. Baron, ABIM president and CEO.

“Feedback collected by the Assessment 2020 Task Force is very consistent with feedback ABIM is hearing from the community regarding the MOC program,” Dr. Baron said in a statement. “These recommendations are meant to be a catalyst for further discussion and can ultimately lead to an improved MOC program for diplomates.”

The independent task force includes representatives from ABIM leadership and experts in assessment, education, health care, and consumer advocacy.

The task force recommends that ABIM focus MOC assessments on cognitive and technical skills; recognize specialization; and consider certification in specialized areas without requiring maintenance of underlying certificates. On that final recommendation, ABIM has already started such changes. In July, the board announced that no disciplines within its MOC program will require underlying certification and that all diplomates can choose the certifications they wish to maintain.

The task force also recommends that ABIM replace its 10-year secure exam with more frequent assessments. The assessments could be taken in a secure setting – possibly at home with remote authentication – with the potential for some portion to be open-book but still timed, according to the task force report.

“The Assessment 2020 Task Force members provided useful insights and recommendations that will be instrumental as we reshape certification to meet physicians’ and society’s changing needs,” Dr. Clarence H. Braddock III, chair of the ABIM Board of Directors said in a statement. “We now need to hear constructive feedback from the internal medicine community on these recommendations, begin to determine their feasibility and develop implementation plans where needed.”

Dr. Wayne J. Riley, president of the American College of Physicians (ACP) said the college is hopeful that the new report will lead to positive changes that raise the MOC’s relevance and value to physicians and patients.

“In addition to getting input on the report from ACP leadership, we are also seeking input from ACP members on the broader issue of MOC,” Dr. Riley said in an interview. “We remain committed to advocating for substantial and meaningful reforms to the ABIM MOC program.”

The American College of Cardiology (ACC) commended the task force for its work to gather input from stakeholders and develop the report.

“As evidenced by the report, there is still much to be done despite the changes over the last several months,” Dr. Kim Allan Williams Sr., ACC president and Dr. Robert A. Shor, chair of the ACC Board of Governors, wrote in a blog post. “The college understands the frustration of its members around the current MOC process and the issue continues to be a top priority for the college. In particular, the ACC strongly agrees with the report about the need to develop a new, externally validated process for measuring competence to replace the 10-year exam – with all deliberate haste! ... We are committed to finding a solution or solutions that best meet the professional needs of clinicians, while also giving patients, the public and other stakeholders confidence that the care provided by their physicians is of the highest quality.”

ABIM has already made a number of changes to its MOC program in recent months, including suspending quality improvement and patient safety requirements in the program, no longer requiring underlying certifications for MOC, and offering a 1-year grace period for physicians who fail the MOC examination in their discipline. Additionally, ABIM has developed a new partnership with the Accreditation Council for Continuing Medical Education (ACCME) to accept more forms of continuing medical education (CME) for MOC credit.

ABIM has also updated its the blueprint for the internal medicine exam with physician input, and included more performance feedback on score reports that diplomates receive with examination results.

[email protected]

On Twitter @legal_med

A task force convened by the American Board of Internal Medicine (ABIM) has proposed replacing the board’s 10-year Maintenance of Certification (MOC) exam with more meaningful assessments and explore certification in specialized areas.

The Assessment 2020 Task Force, which convened in 2013 to evaluate the ABIM MOC program, released its proposals in a Sept. 16 report. The report aims to inform ongoing redesign of ABIM’s Certification and MOC programs, according to Dr. Richard J. Baron, ABIM president and CEO.

“Feedback collected by the Assessment 2020 Task Force is very consistent with feedback ABIM is hearing from the community regarding the MOC program,” Dr. Baron said in a statement. “These recommendations are meant to be a catalyst for further discussion and can ultimately lead to an improved MOC program for diplomates.”

The independent task force includes representatives from ABIM leadership and experts in assessment, education, health care, and consumer advocacy.

The task force recommends that ABIM focus MOC assessments on cognitive and technical skills; recognize specialization; and consider certification in specialized areas without requiring maintenance of underlying certificates. On that final recommendation, ABIM has already started such changes. In July, the board announced that no disciplines within its MOC program will require underlying certification and that all diplomates can choose the certifications they wish to maintain.

The task force also recommends that ABIM replace its 10-year secure exam with more frequent assessments. The assessments could be taken in a secure setting – possibly at home with remote authentication – with the potential for some portion to be open-book but still timed, according to the task force report.

“The Assessment 2020 Task Force members provided useful insights and recommendations that will be instrumental as we reshape certification to meet physicians’ and society’s changing needs,” Dr. Clarence H. Braddock III, chair of the ABIM Board of Directors said in a statement. “We now need to hear constructive feedback from the internal medicine community on these recommendations, begin to determine their feasibility and develop implementation plans where needed.”

Dr. Wayne J. Riley, president of the American College of Physicians (ACP) said the college is hopeful that the new report will lead to positive changes that raise the MOC’s relevance and value to physicians and patients.

“In addition to getting input on the report from ACP leadership, we are also seeking input from ACP members on the broader issue of MOC,” Dr. Riley said in an interview. “We remain committed to advocating for substantial and meaningful reforms to the ABIM MOC program.”

The American College of Cardiology (ACC) commended the task force for its work to gather input from stakeholders and develop the report.

“As evidenced by the report, there is still much to be done despite the changes over the last several months,” Dr. Kim Allan Williams Sr., ACC president and Dr. Robert A. Shor, chair of the ACC Board of Governors, wrote in a blog post. “The college understands the frustration of its members around the current MOC process and the issue continues to be a top priority for the college. In particular, the ACC strongly agrees with the report about the need to develop a new, externally validated process for measuring competence to replace the 10-year exam – with all deliberate haste! ... We are committed to finding a solution or solutions that best meet the professional needs of clinicians, while also giving patients, the public and other stakeholders confidence that the care provided by their physicians is of the highest quality.”

ABIM has already made a number of changes to its MOC program in recent months, including suspending quality improvement and patient safety requirements in the program, no longer requiring underlying certifications for MOC, and offering a 1-year grace period for physicians who fail the MOC examination in their discipline. Additionally, ABIM has developed a new partnership with the Accreditation Council for Continuing Medical Education (ACCME) to accept more forms of continuing medical education (CME) for MOC credit.

ABIM has also updated its the blueprint for the internal medicine exam with physician input, and included more performance feedback on score reports that diplomates receive with examination results.

[email protected]

On Twitter @legal_med

A controversial bill that would allow physicians in California to assist terminally ill patients in dying will soon hit the desk of Gov. Jerry Brown Jr. (D) for approval. California lawmakers passed the End of Life Option Act on Sept. 11 after nearly a year of consideration.

Gov. Brown has 12 days to sign the bill into law, veto it, or allow it to become law without signature or veto. If Gov. Brown signs or fails to object, the law will become effective by January 2016. Gov. Brown has not indicated his stance on the issue.

If the bill is enacted, California will become the fourth state to allow physician-assisted suicide through its legislature. Oregon, Vermont, and Washington each have laws permitting physician-assisted death. Court rulings in New Mexico and Montana have allowed for the practice. However, litigation in those states is ongoing and the decisions have yet to be enforced.

California legislators introduced the End of Life Option Act in January, but later pulled it from the Assembly Committee on Health because of insufficient support. Assembly members later introduced a new version of the bill, which passed the assembly on Sept. 9 and the Senate on Sept. 11. Similar to Oregon’s law, the California bill would require two doctors to determine that a patient has 6 months or less to live before doctors could prescribe life-ending medication. Patients must have the mental capacity to make medical decisions and would have to physically be able to swallow the drugs.

Patients seeking physician aid in dying must submit two oral requests, a minimum of 15 days apart, and a written request to their physician. The attending physician must receive all three requests directly from the patient and not through a designee. Before prescribing end of life drugs, the attending physician must refer the patient to a consulting physician for medical confirmation of the diagnosis and prognosis and for a second determination that the patient can make competent medical decisions.

Recent court battles in California over physician-assisted suicide have ended with judges prohibiting the practice. In an Aug. 14 ruling, San Francisco Superior Court Judge Ernest Goldsmith ruled that granting the plaintiffs’ petition would essentially create a judge-made law. San Diego Superior Court Judge Gregory Pollack dismissed a similar lawsuit on July 27. Plaintiffs in both cases plan to appeal.

In May, the California Medical Association (CMA) became the first state medical society to change its stance against physician-assisted suicide to that of being neutral.

“The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options,” Dr. Luther F. Cobb, CMA president, said in a statement. “We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.”

[email protected]

On Twitter@legal_med

A controversial bill that would allow physicians in California to assist terminally ill patients in dying will soon hit the desk of Gov. Jerry Brown Jr. (D) for approval. California lawmakers passed the End of Life Option Act on Sept. 11 after nearly a year of consideration.

Gov. Brown has 12 days to sign the bill into law, veto it, or allow it to become law without signature or veto. If Gov. Brown signs or fails to object, the law will become effective by January 2016. Gov. Brown has not indicated his stance on the issue.

If the bill is enacted, California will become the fourth state to allow physician-assisted suicide through its legislature. Oregon, Vermont, and Washington each have laws permitting physician-assisted death. Court rulings in New Mexico and Montana have allowed for the practice. However, litigation in those states is ongoing and the decisions have yet to be enforced.

California legislators introduced the End of Life Option Act in January, but later pulled it from the Assembly Committee on Health because of insufficient support. Assembly members later introduced a new version of the bill, which passed the assembly on Sept. 9 and the Senate on Sept. 11. Similar to Oregon’s law, the California bill would require two doctors to determine that a patient has 6 months or less to live before doctors could prescribe life-ending medication. Patients must have the mental capacity to make medical decisions and would have to physically be able to swallow the drugs.

Patients seeking physician aid in dying must submit two oral requests, a minimum of 15 days apart, and a written request to their physician. The attending physician must receive all three requests directly from the patient and not through a designee. Before prescribing end of life drugs, the attending physician must refer the patient to a consulting physician for medical confirmation of the diagnosis and prognosis and for a second determination that the patient can make competent medical decisions.

Recent court battles in California over physician-assisted suicide have ended with judges prohibiting the practice. In an Aug. 14 ruling, San Francisco Superior Court Judge Ernest Goldsmith ruled that granting the plaintiffs’ petition would essentially create a judge-made law. San Diego Superior Court Judge Gregory Pollack dismissed a similar lawsuit on July 27. Plaintiffs in both cases plan to appeal.

In May, the California Medical Association (CMA) became the first state medical society to change its stance against physician-assisted suicide to that of being neutral.

“The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options,” Dr. Luther F. Cobb, CMA president, said in a statement. “We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.”

[email protected]

On Twitter@legal_med

A controversial bill that would allow physicians in California to assist terminally ill patients in dying will soon hit the desk of Gov. Jerry Brown Jr. (D) for approval. California lawmakers passed the End of Life Option Act on Sept. 11 after nearly a year of consideration.

Gov. Brown has 12 days to sign the bill into law, veto it, or allow it to become law without signature or veto. If Gov. Brown signs or fails to object, the law will become effective by January 2016. Gov. Brown has not indicated his stance on the issue.

If the bill is enacted, California will become the fourth state to allow physician-assisted suicide through its legislature. Oregon, Vermont, and Washington each have laws permitting physician-assisted death. Court rulings in New Mexico and Montana have allowed for the practice. However, litigation in those states is ongoing and the decisions have yet to be enforced.

California legislators introduced the End of Life Option Act in January, but later pulled it from the Assembly Committee on Health because of insufficient support. Assembly members later introduced a new version of the bill, which passed the assembly on Sept. 9 and the Senate on Sept. 11. Similar to Oregon’s law, the California bill would require two doctors to determine that a patient has 6 months or less to live before doctors could prescribe life-ending medication. Patients must have the mental capacity to make medical decisions and would have to physically be able to swallow the drugs.

Patients seeking physician aid in dying must submit two oral requests, a minimum of 15 days apart, and a written request to their physician. The attending physician must receive all three requests directly from the patient and not through a designee. Before prescribing end of life drugs, the attending physician must refer the patient to a consulting physician for medical confirmation of the diagnosis and prognosis and for a second determination that the patient can make competent medical decisions.

Recent court battles in California over physician-assisted suicide have ended with judges prohibiting the practice. In an Aug. 14 ruling, San Francisco Superior Court Judge Ernest Goldsmith ruled that granting the plaintiffs’ petition would essentially create a judge-made law. San Diego Superior Court Judge Gregory Pollack dismissed a similar lawsuit on July 27. Plaintiffs in both cases plan to appeal.

In May, the California Medical Association (CMA) became the first state medical society to change its stance against physician-assisted suicide to that of being neutral.

“The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options,” Dr. Luther F. Cobb, CMA president, said in a statement. “We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.”

[email protected]

On Twitter@legal_med

The comments are in and shaping of the final Medicare Physician Fee Schedule for 2016 rests now in the hands of officials at the Centers for Medicare & Medicaid Services. What are the key provisions doctors need to know about to practice successfully in 2016? Experts gave their opinions in a webinar sponsored by the American Health Lawyers Association (AHLA).

Physician Quality Reporting System (PQRS)

CMS proposes to audit not only physician participants, but also vendors who submit quality measure data on behalf of doctors, under the 2016 proposed fee schedule. The agency recommends that vendors make available contact information for each eligible practitioner on behalf of whom it submits data and retain data submitted to CMS for PQRS for 7 years.

Doctors who fail to report on nine quality measures for PQRS will not automatically face trouble, according to Daniel F. Shay, a health law attorney in Philadelphia. In general, individual physicians in PQRS must report on at least nine measures covering three National Quality Strategy (NQS) domains for at least 50% of their Medicare patient base. But if fewer than nine measures are reported, physicians have the chance to explain themselves.

“In some cases, a practice may not have at least nine measures that apply to it, Mr. Shay said. “The [eligible practitioner] would then be able to report on fewer than nine measures, but would be subject to the measure application validity process, which basically means CMS audits the provider to prove they couldn’t have reported on all of the required measures.”

Also, CMS proposes extending participation in PQRS to doctors who practice in critical access hospitals, according to the 2016 proposed fee schedule. PQRS is a voluntary quality reporting program that applies adjustments to payments based on benchmarks. CMS is suggesting that physicians who practice in certain critical access hospitals now have the option to participate in the program – such doctors were previously excluded.

Incident to service

When overseeing care that is “incident to” service, CMS proposes that billing physicians also act as supervising physicians. The proposal could significantly impact group practices who do not typically use that structure, said Washington health law attorney Julie E. Kass during the AHLA webinar.

Incident to is defined as services furnished incident to a physician’s professional services over the course of a patient’s diagnosis or treatment. Medicare pays for services rendered by employees of a physician only when all “incident to” criteria are met. Those criteria include that services rendered by nonphysicians are under the direct supervision of a physician physically in the same office suite. In the proposed 2016 rule, CMS seeks to clarify that the billing physician must be the same physician who supervises the ancillary personnel. Previously, group practices may have billed under the provider who ordered the treatment, according to Ms. Kass.

“It sounds simple, but then you put it into the context of what happens in a real life practice,” she said. “I think a lot of practices, in operationalizing this rule, have generally used the ordering physician as the physician who billed for the service without paying a lot of attention to who was the actual supervising physician.”

Group practices may want to rethink how they bill for incident to services, and ensure the billing physician is the one who supervises the treatment, she advised.

The Stark Law

Proposed changes to regulations implementing the Stark Law could make it easier for physicians to hire new nonphysician providers (NPP) to provide primary care. Under the fee schedule proposal, hospitals would be allowed to assist in the recruitment of health professionals for physician practices. Currently, hospitals may not because remuneration could be considered a compensation relationship between the hospital and physician practice. The proposed change aims to promote care team collaboration and help curb primary care shortages.

The exception would permit recruitment assistance and retention payment from a hospital, rural health clinic, or federally qualified health center to a physician practice to employ an NPP. However, the NPP would have to be a bona fide employee of the physician practice and provide primary care services. CMS defines an NPP as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife. CMS is also recommending a cap on the total remuneration and duration of assistance provided.

The limits aim to “make sure the physicians have skin in the game in bringing in the NPP,” Ms. Kass said. “It’s not all going to be the burden of hospital to provide recruiting assistance, but rather the physician has to need and want the NPP enough to be willing to bring them in as well without total support and assistance.”

Value-Based Payment Modifier Program

CMS proposes a new way to determine the extent of payment cuts and bonuses in the Value-Based Payment Modifier program. The program evaluates the performance of solo practitioners and groups on the quality and cost of care they provide to fee-for-service Medicare patients.

In 2016, the agency proposes to adjust payments based on the size of the participating group and to determine that size by reviewing claims data and its Provider Enrollment, Chain, and Ownership System (PECOS)-generated list. CMS would apply whichever number is lower in PECOS or claims data.

Now is a good time for doctors to check their PECOS data to ensure the information is accurate and up to date, Mr. Shay recommended.

As many expected, the Value-Based Payment Modifier is slowly expanding to encompass more physicians. Beginning Jan. 1, 2015, the value modifier was applied to physician payments under the fee schedule for groups of 100 or more. In January 2016, it will be applied to physician payments for doctors in groups of 10 or more. In 2017, the modifier will apply to solo practitioners and physicians in groups of two or more. (All modifiers are based on performance periods 2 years prior.)

PQRS will continue to play a central role in the Value-Based Payment Modifier system, Mr. Shay added. CMS is proposing to use the PQRS reporting period for 2016 as the basis for the 2018 value modifier. The agency will draw from the group reporting option and individual EP reporting mechanisms proposed for 2016.

“We’re seeing just more interconnection between these two systems,” Mr. Shay said.

Physician Compare

Physicians should expect to have more information about their performance reported to the Physician Compare website under the proposed 2016 fee schedule. The site already continues information on physician education, location, group affiliations, and status in quality programs. CMS now wants to include performance rates on 2015 PQRS cardiovascular disease prevention measures for doctors who report them, in support of the Million Hearts program. Additionally, CMS proposes that groups receiving a pay increase under the Value-Based Payment Modifier Program report the data to the website. Doctors also would continue reporting information about patient experiences under the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey program. The surveys are designed to capture a patient’s experience receiving care from their physician.

Mr. Shay noted that one concern with the Physician Compare website is that doctors have little recourse to challenge information on the site. Physicians have only a 30-day window to review information about themselves and correct errors.

“There is no formal appeals mechanism for the website,” Mr. Shay.

CMS is currently reviewing feedback and comments submitted about the proposed physician fee schedule before issuing the final schedule, usually in November.

[email protected]

On Twitter @legal_med

The comments are in and shaping of the final Medicare Physician Fee Schedule for 2016 rests now in the hands of officials at the Centers for Medicare & Medicaid Services. What are the key provisions doctors need to know about to practice successfully in 2016? Experts gave their opinions in a webinar sponsored by the American Health Lawyers Association (AHLA).

Physician Quality Reporting System (PQRS)

CMS proposes to audit not only physician participants, but also vendors who submit quality measure data on behalf of doctors, under the 2016 proposed fee schedule. The agency recommends that vendors make available contact information for each eligible practitioner on behalf of whom it submits data and retain data submitted to CMS for PQRS for 7 years.

Doctors who fail to report on nine quality measures for PQRS will not automatically face trouble, according to Daniel F. Shay, a health law attorney in Philadelphia. In general, individual physicians in PQRS must report on at least nine measures covering three National Quality Strategy (NQS) domains for at least 50% of their Medicare patient base. But if fewer than nine measures are reported, physicians have the chance to explain themselves.

“In some cases, a practice may not have at least nine measures that apply to it, Mr. Shay said. “The [eligible practitioner] would then be able to report on fewer than nine measures, but would be subject to the measure application validity process, which basically means CMS audits the provider to prove they couldn’t have reported on all of the required measures.”

Also, CMS proposes extending participation in PQRS to doctors who practice in critical access hospitals, according to the 2016 proposed fee schedule. PQRS is a voluntary quality reporting program that applies adjustments to payments based on benchmarks. CMS is suggesting that physicians who practice in certain critical access hospitals now have the option to participate in the program – such doctors were previously excluded.

Incident to service

When overseeing care that is “incident to” service, CMS proposes that billing physicians also act as supervising physicians. The proposal could significantly impact group practices who do not typically use that structure, said Washington health law attorney Julie E. Kass during the AHLA webinar.

Incident to is defined as services furnished incident to a physician’s professional services over the course of a patient’s diagnosis or treatment. Medicare pays for services rendered by employees of a physician only when all “incident to” criteria are met. Those criteria include that services rendered by nonphysicians are under the direct supervision of a physician physically in the same office suite. In the proposed 2016 rule, CMS seeks to clarify that the billing physician must be the same physician who supervises the ancillary personnel. Previously, group practices may have billed under the provider who ordered the treatment, according to Ms. Kass.

“It sounds simple, but then you put it into the context of what happens in a real life practice,” she said. “I think a lot of practices, in operationalizing this rule, have generally used the ordering physician as the physician who billed for the service without paying a lot of attention to who was the actual supervising physician.”

Group practices may want to rethink how they bill for incident to services, and ensure the billing physician is the one who supervises the treatment, she advised.

The Stark Law

Proposed changes to regulations implementing the Stark Law could make it easier for physicians to hire new nonphysician providers (NPP) to provide primary care. Under the fee schedule proposal, hospitals would be allowed to assist in the recruitment of health professionals for physician practices. Currently, hospitals may not because remuneration could be considered a compensation relationship between the hospital and physician practice. The proposed change aims to promote care team collaboration and help curb primary care shortages.

The exception would permit recruitment assistance and retention payment from a hospital, rural health clinic, or federally qualified health center to a physician practice to employ an NPP. However, the NPP would have to be a bona fide employee of the physician practice and provide primary care services. CMS defines an NPP as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife. CMS is also recommending a cap on the total remuneration and duration of assistance provided.

The limits aim to “make sure the physicians have skin in the game in bringing in the NPP,” Ms. Kass said. “It’s not all going to be the burden of hospital to provide recruiting assistance, but rather the physician has to need and want the NPP enough to be willing to bring them in as well without total support and assistance.”

Value-Based Payment Modifier Program

CMS proposes a new way to determine the extent of payment cuts and bonuses in the Value-Based Payment Modifier program. The program evaluates the performance of solo practitioners and groups on the quality and cost of care they provide to fee-for-service Medicare patients.

In 2016, the agency proposes to adjust payments based on the size of the participating group and to determine that size by reviewing claims data and its Provider Enrollment, Chain, and Ownership System (PECOS)-generated list. CMS would apply whichever number is lower in PECOS or claims data.

Now is a good time for doctors to check their PECOS data to ensure the information is accurate and up to date, Mr. Shay recommended.

As many expected, the Value-Based Payment Modifier is slowly expanding to encompass more physicians. Beginning Jan. 1, 2015, the value modifier was applied to physician payments under the fee schedule for groups of 100 or more. In January 2016, it will be applied to physician payments for doctors in groups of 10 or more. In 2017, the modifier will apply to solo practitioners and physicians in groups of two or more. (All modifiers are based on performance periods 2 years prior.)

PQRS will continue to play a central role in the Value-Based Payment Modifier system, Mr. Shay added. CMS is proposing to use the PQRS reporting period for 2016 as the basis for the 2018 value modifier. The agency will draw from the group reporting option and individual EP reporting mechanisms proposed for 2016.

“We’re seeing just more interconnection between these two systems,” Mr. Shay said.

Physician Compare

Physicians should expect to have more information about their performance reported to the Physician Compare website under the proposed 2016 fee schedule. The site already continues information on physician education, location, group affiliations, and status in quality programs. CMS now wants to include performance rates on 2015 PQRS cardiovascular disease prevention measures for doctors who report them, in support of the Million Hearts program. Additionally, CMS proposes that groups receiving a pay increase under the Value-Based Payment Modifier Program report the data to the website. Doctors also would continue reporting information about patient experiences under the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey program. The surveys are designed to capture a patient’s experience receiving care from their physician.

Mr. Shay noted that one concern with the Physician Compare website is that doctors have little recourse to challenge information on the site. Physicians have only a 30-day window to review information about themselves and correct errors.

“There is no formal appeals mechanism for the website,” Mr. Shay.

CMS is currently reviewing feedback and comments submitted about the proposed physician fee schedule before issuing the final schedule, usually in November.

[email protected]

On Twitter @legal_med

The comments are in and shaping of the final Medicare Physician Fee Schedule for 2016 rests now in the hands of officials at the Centers for Medicare & Medicaid Services. What are the key provisions doctors need to know about to practice successfully in 2016? Experts gave their opinions in a webinar sponsored by the American Health Lawyers Association (AHLA).

Physician Quality Reporting System (PQRS)

CMS proposes to audit not only physician participants, but also vendors who submit quality measure data on behalf of doctors, under the 2016 proposed fee schedule. The agency recommends that vendors make available contact information for each eligible practitioner on behalf of whom it submits data and retain data submitted to CMS for PQRS for 7 years.

Doctors who fail to report on nine quality measures for PQRS will not automatically face trouble, according to Daniel F. Shay, a health law attorney in Philadelphia. In general, individual physicians in PQRS must report on at least nine measures covering three National Quality Strategy (NQS) domains for at least 50% of their Medicare patient base. But if fewer than nine measures are reported, physicians have the chance to explain themselves.

“In some cases, a practice may not have at least nine measures that apply to it, Mr. Shay said. “The [eligible practitioner] would then be able to report on fewer than nine measures, but would be subject to the measure application validity process, which basically means CMS audits the provider to prove they couldn’t have reported on all of the required measures.”

Also, CMS proposes extending participation in PQRS to doctors who practice in critical access hospitals, according to the 2016 proposed fee schedule. PQRS is a voluntary quality reporting program that applies adjustments to payments based on benchmarks. CMS is suggesting that physicians who practice in certain critical access hospitals now have the option to participate in the program – such doctors were previously excluded.

Incident to service

When overseeing care that is “incident to” service, CMS proposes that billing physicians also act as supervising physicians. The proposal could significantly impact group practices who do not typically use that structure, said Washington health law attorney Julie E. Kass during the AHLA webinar.

Incident to is defined as services furnished incident to a physician’s professional services over the course of a patient’s diagnosis or treatment. Medicare pays for services rendered by employees of a physician only when all “incident to” criteria are met. Those criteria include that services rendered by nonphysicians are under the direct supervision of a physician physically in the same office suite. In the proposed 2016 rule, CMS seeks to clarify that the billing physician must be the same physician who supervises the ancillary personnel. Previously, group practices may have billed under the provider who ordered the treatment, according to Ms. Kass.

“It sounds simple, but then you put it into the context of what happens in a real life practice,” she said. “I think a lot of practices, in operationalizing this rule, have generally used the ordering physician as the physician who billed for the service without paying a lot of attention to who was the actual supervising physician.”

Group practices may want to rethink how they bill for incident to services, and ensure the billing physician is the one who supervises the treatment, she advised.

The Stark Law

Proposed changes to regulations implementing the Stark Law could make it easier for physicians to hire new nonphysician providers (NPP) to provide primary care. Under the fee schedule proposal, hospitals would be allowed to assist in the recruitment of health professionals for physician practices. Currently, hospitals may not because remuneration could be considered a compensation relationship between the hospital and physician practice. The proposed change aims to promote care team collaboration and help curb primary care shortages.

The exception would permit recruitment assistance and retention payment from a hospital, rural health clinic, or federally qualified health center to a physician practice to employ an NPP. However, the NPP would have to be a bona fide employee of the physician practice and provide primary care services. CMS defines an NPP as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife. CMS is also recommending a cap on the total remuneration and duration of assistance provided.

The limits aim to “make sure the physicians have skin in the game in bringing in the NPP,” Ms. Kass said. “It’s not all going to be the burden of hospital to provide recruiting assistance, but rather the physician has to need and want the NPP enough to be willing to bring them in as well without total support and assistance.”

Value-Based Payment Modifier Program

CMS proposes a new way to determine the extent of payment cuts and bonuses in the Value-Based Payment Modifier program. The program evaluates the performance of solo practitioners and groups on the quality and cost of care they provide to fee-for-service Medicare patients.

In 2016, the agency proposes to adjust payments based on the size of the participating group and to determine that size by reviewing claims data and its Provider Enrollment, Chain, and Ownership System (PECOS)-generated list. CMS would apply whichever number is lower in PECOS or claims data.

Now is a good time for doctors to check their PECOS data to ensure the information is accurate and up to date, Mr. Shay recommended.

As many expected, the Value-Based Payment Modifier is slowly expanding to encompass more physicians. Beginning Jan. 1, 2015, the value modifier was applied to physician payments under the fee schedule for groups of 100 or more. In January 2016, it will be applied to physician payments for doctors in groups of 10 or more. In 2017, the modifier will apply to solo practitioners and physicians in groups of two or more. (All modifiers are based on performance periods 2 years prior.)

PQRS will continue to play a central role in the Value-Based Payment Modifier system, Mr. Shay added. CMS is proposing to use the PQRS reporting period for 2016 as the basis for the 2018 value modifier. The agency will draw from the group reporting option and individual EP reporting mechanisms proposed for 2016.

“We’re seeing just more interconnection between these two systems,” Mr. Shay said.

Physician Compare

Physicians should expect to have more information about their performance reported to the Physician Compare website under the proposed 2016 fee schedule. The site already continues information on physician education, location, group affiliations, and status in quality programs. CMS now wants to include performance rates on 2015 PQRS cardiovascular disease prevention measures for doctors who report them, in support of the Million Hearts program. Additionally, CMS proposes that groups receiving a pay increase under the Value-Based Payment Modifier Program report the data to the website. Doctors also would continue reporting information about patient experiences under the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey program. The surveys are designed to capture a patient’s experience receiving care from their physician.

Mr. Shay noted that one concern with the Physician Compare website is that doctors have little recourse to challenge information on the site. Physicians have only a 30-day window to review information about themselves and correct errors.

“There is no formal appeals mechanism for the website,” Mr. Shay.

CMS is currently reviewing feedback and comments submitted about the proposed physician fee schedule before issuing the final schedule, usually in November.

[email protected]

On Twitter @legal_med

Assessments are complete, and the Centers for Medicare & Medicaid Services has determined which physician practices will face a pay cut – officially, a “downward payment adjustment” – for failing to comply with the Physician Quality Reporting System (PQRS). Doctors have just 2 months to challenge findings that they believe were made in error to spare themselves a cut in 2016.

The pay cut will apply to individual eligible practitioners and PQRS group practices that did not satisfactorily report data on quality measures in 2014. The 2% cut will be applied to all Part B covered services, according to a Sept. 9 CMS announcement.

©Jupiterimages/thinkstockphotos.com

To learn whether they are subject to the cut, physicians can review their 2014 PQRS feedback reports, which became available Sept. 8. The reports apply to doctors who submitted quality data in calendar year 2014. Feedback reports for 2015 will be available approximately this time next year.

To challenge PQRS determinations, physicians can submit an informal review between Sept. 9 and Nov. 9 and request that the CMS reevaluate incentive eligibility and adjustment determinations. Those requests can be made through the quality reporting portal. Physicians who request a review will be contacted via email of a final decision by the CMS within 90 days of their request. All decisions will be final and there will be no further review or appeal, according to the CMS.

It should not be surprising that physicians who did not satisfactorily comply with PQRS will see a 2% pay cut next year, said David Harlow, a health law and policy attorney based in Newton, Mass. What’s unusual, however, is that the informal review process does not include an avenue for an independent evaluation, Mr. Harlow said.

“It’s CMS reviewing a CMS decision,” he said in an interview. “From a provider perspective, there might be some skepticism about the independence of that review. CMS says this is not something that is subject to further administrative or judicial review. So there’s not an appeal.”

Mr. Harlow said that he would not be surprised if physician organizations advocate for further judicial relief in the process. CMS has previously provided avenues for administrative or judicial appeals of its decisions in other programs, he noted.

In its announcement, the agency outlined the ways in which physicians could have avoided the coming pay cut. This included reporting nine measures across three domains for 50% of Medicare patients, completing the GPRO Web Interface, or reporting at least one registry measures group for 20 patients, at least 11 of whom were Medicare Part B patients. Additionally, doctors could have reported three measures across one domain for 50% of Medicare patients, or satisfactorily participated in a qualified clinical data registry.

[email protected]

On Twitter @legal_med

Assessments are complete, and the Centers for Medicare & Medicaid Services has determined which physician practices will face a pay cut – officially, a “downward payment adjustment” – for failing to comply with the Physician Quality Reporting System (PQRS). Doctors have just 2 months to challenge findings that they believe were made in error to spare themselves a cut in 2016.

The pay cut will apply to individual eligible practitioners and PQRS group practices that did not satisfactorily report data on quality measures in 2014. The 2% cut will be applied to all Part B covered services, according to a Sept. 9 CMS announcement.

©Jupiterimages/thinkstockphotos.com

To learn whether they are subject to the cut, physicians can review their 2014 PQRS feedback reports, which became available Sept. 8. The reports apply to doctors who submitted quality data in calendar year 2014. Feedback reports for 2015 will be available approximately this time next year.

To challenge PQRS determinations, physicians can submit an informal review between Sept. 9 and Nov. 9 and request that the CMS reevaluate incentive eligibility and adjustment determinations. Those requests can be made through the quality reporting portal. Physicians who request a review will be contacted via email of a final decision by the CMS within 90 days of their request. All decisions will be final and there will be no further review or appeal, according to the CMS.

It should not be surprising that physicians who did not satisfactorily comply with PQRS will see a 2% pay cut next year, said David Harlow, a health law and policy attorney based in Newton, Mass. What’s unusual, however, is that the informal review process does not include an avenue for an independent evaluation, Mr. Harlow said.

“It’s CMS reviewing a CMS decision,” he said in an interview. “From a provider perspective, there might be some skepticism about the independence of that review. CMS says this is not something that is subject to further administrative or judicial review. So there’s not an appeal.”

Mr. Harlow said that he would not be surprised if physician organizations advocate for further judicial relief in the process. CMS has previously provided avenues for administrative or judicial appeals of its decisions in other programs, he noted.

In its announcement, the agency outlined the ways in which physicians could have avoided the coming pay cut. This included reporting nine measures across three domains for 50% of Medicare patients, completing the GPRO Web Interface, or reporting at least one registry measures group for 20 patients, at least 11 of whom were Medicare Part B patients. Additionally, doctors could have reported three measures across one domain for 50% of Medicare patients, or satisfactorily participated in a qualified clinical data registry.

[email protected]

On Twitter @legal_med

Assessments are complete, and the Centers for Medicare & Medicaid Services has determined which physician practices will face a pay cut – officially, a “downward payment adjustment” – for failing to comply with the Physician Quality Reporting System (PQRS). Doctors have just 2 months to challenge findings that they believe were made in error to spare themselves a cut in 2016.

The pay cut will apply to individual eligible practitioners and PQRS group practices that did not satisfactorily report data on quality measures in 2014. The 2% cut will be applied to all Part B covered services, according to a Sept. 9 CMS announcement.

©Jupiterimages/thinkstockphotos.com

To learn whether they are subject to the cut, physicians can review their 2014 PQRS feedback reports, which became available Sept. 8. The reports apply to doctors who submitted quality data in calendar year 2014. Feedback reports for 2015 will be available approximately this time next year.

To challenge PQRS determinations, physicians can submit an informal review between Sept. 9 and Nov. 9 and request that the CMS reevaluate incentive eligibility and adjustment determinations. Those requests can be made through the quality reporting portal. Physicians who request a review will be contacted via email of a final decision by the CMS within 90 days of their request. All decisions will be final and there will be no further review or appeal, according to the CMS.

It should not be surprising that physicians who did not satisfactorily comply with PQRS will see a 2% pay cut next year, said David Harlow, a health law and policy attorney based in Newton, Mass. What’s unusual, however, is that the informal review process does not include an avenue for an independent evaluation, Mr. Harlow said.

“It’s CMS reviewing a CMS decision,” he said in an interview. “From a provider perspective, there might be some skepticism about the independence of that review. CMS says this is not something that is subject to further administrative or judicial review. So there’s not an appeal.”

Mr. Harlow said that he would not be surprised if physician organizations advocate for further judicial relief in the process. CMS has previously provided avenues for administrative or judicial appeals of its decisions in other programs, he noted.

In its announcement, the agency outlined the ways in which physicians could have avoided the coming pay cut. This included reporting nine measures across three domains for 50% of Medicare patients, completing the GPRO Web Interface, or reporting at least one registry measures group for 20 patients, at least 11 of whom were Medicare Part B patients. Additionally, doctors could have reported three measures across one domain for 50% of Medicare patients, or satisfactorily participated in a qualified clinical data registry.

[email protected]

On Twitter @legal_med

Telemedicine should be used to enhance the delivery of medical care, but only between a physician and patient who have an established relationship, according to a policy statement from the American College of Physicians published Sept. 7 in the Annals of Internal Medicine.

“Telemedicine is rapidly growing and can potentially expand access for patients, enhance patient-physician collaboration, improve health outcomes, and reduce medical costs,” said lead author Hilary Daniel, an ACP health policy analyst. “However, the potential benefits of telemedicine must be measured against the risks and challenges associated with its use, including the absence of the physical examination, variation in state practice and licensing regulations, and issues surrounding the establishment of the patient-physician relationship,” she said.

The ACP notes that telemedicine is a reasonable alternative for patients who lack access to relevant medical expertise in their location, and that its practice can reduce medical costs and increase access to care. Episodic, direct-to-patient telemedicine services should be used only as an “intermittent alternative” to a patient’s primary care doctor when necessary to meet immediate acute care needs, according to the policy (Ann Intern Med 2015 Sep 7. doi: 10.7326/M15-0498).

A valid patient-physician relationship must be established for a responsible telemedicine visit to take place, although that relationship can be created through real-time audiovisual technology. A telemedicine doctor who has no existing relationship with a patient must take steps to establish a relationship based on the standard of care required for in-person visits, or by consulting another physician who has a relationship with the patient and oversees the patient’s care, the policy advised. Doctors should use their best professional judgment when deciding whether telemedicine is appropriate for a patient and never compromise their ethical obligations to deliver clinically appropriate care for the sake of new technology.

The college calls for the lifting of geographic site restrictions by Medicare that limit payment for telemedicine and telehealth services. Additionally, ACP supports payment by public and private health plans for appropriately structured telemedicine communications, whether synchronous or asynchronous, text-based, or supplemented with voice, video, or device feeds.

“Telemedicine shows promise not just in the United States but across the globe as third-world and developed nations embrace technology as a way to provide citizens access to health care,” Ms. Daniel and her colleagues wrote in the policy statement. “The legal, regulatory, technical, and cultural barriers to widespread adoption in the United States should be addressed to fully realize the potential of telemedicine for the benefit of physicians, patients, and the health care system.”

In an accompanying editorial, Dr. David A. Asch executive director of the University of Pennsylvania’s Center for Health Care Innovation, adds telemedicine can mean significant savings for physicians and patients in the form of time, money, and administrative burdens.

“The scalable gains from telemedicine will come from delivering care to populations – sometimes highly specialized care, in totally different ways – often with less physical infrastructure and less of the baggage that accompanies conventional practice,” Dr. Asch wrote. “Although the ACP position paper urges parity between telemedicine and face-to-face medicine in how physicians practice and get paid, arguing for parity is a trap if it merely carries forward practice styles and reimbursement requirements from one context to the other. The innovation that telemedicine promises is not just doing the same thing remotely that used to be done face-to-face but awakening us to the many things that we thought required face-to-face contact but actually do not.”

[email protected]

On Twitter @legal_med

Telemedicine should be used to enhance the delivery of medical care, but only between a physician and patient who have an established relationship, according to a policy statement from the American College of Physicians published Sept. 7 in the Annals of Internal Medicine.

“Telemedicine is rapidly growing and can potentially expand access for patients, enhance patient-physician collaboration, improve health outcomes, and reduce medical costs,” said lead author Hilary Daniel, an ACP health policy analyst. “However, the potential benefits of telemedicine must be measured against the risks and challenges associated with its use, including the absence of the physical examination, variation in state practice and licensing regulations, and issues surrounding the establishment of the patient-physician relationship,” she said.

The ACP notes that telemedicine is a reasonable alternative for patients who lack access to relevant medical expertise in their location, and that its practice can reduce medical costs and increase access to care. Episodic, direct-to-patient telemedicine services should be used only as an “intermittent alternative” to a patient’s primary care doctor when necessary to meet immediate acute care needs, according to the policy (Ann Intern Med 2015 Sep 7. doi: 10.7326/M15-0498).

A valid patient-physician relationship must be established for a responsible telemedicine visit to take place, although that relationship can be created through real-time audiovisual technology. A telemedicine doctor who has no existing relationship with a patient must take steps to establish a relationship based on the standard of care required for in-person visits, or by consulting another physician who has a relationship with the patient and oversees the patient’s care, the policy advised. Doctors should use their best professional judgment when deciding whether telemedicine is appropriate for a patient and never compromise their ethical obligations to deliver clinically appropriate care for the sake of new technology.

The college calls for the lifting of geographic site restrictions by Medicare that limit payment for telemedicine and telehealth services. Additionally, ACP supports payment by public and private health plans for appropriately structured telemedicine communications, whether synchronous or asynchronous, text-based, or supplemented with voice, video, or device feeds.

“Telemedicine shows promise not just in the United States but across the globe as third-world and developed nations embrace technology as a way to provide citizens access to health care,” Ms. Daniel and her colleagues wrote in the policy statement. “The legal, regulatory, technical, and cultural barriers to widespread adoption in the United States should be addressed to fully realize the potential of telemedicine for the benefit of physicians, patients, and the health care system.”

In an accompanying editorial, Dr. David A. Asch executive director of the University of Pennsylvania’s Center for Health Care Innovation, adds telemedicine can mean significant savings for physicians and patients in the form of time, money, and administrative burdens.

“The scalable gains from telemedicine will come from delivering care to populations – sometimes highly specialized care, in totally different ways – often with less physical infrastructure and less of the baggage that accompanies conventional practice,” Dr. Asch wrote. “Although the ACP position paper urges parity between telemedicine and face-to-face medicine in how physicians practice and get paid, arguing for parity is a trap if it merely carries forward practice styles and reimbursement requirements from one context to the other. The innovation that telemedicine promises is not just doing the same thing remotely that used to be done face-to-face but awakening us to the many things that we thought required face-to-face contact but actually do not.”

[email protected]

On Twitter @legal_med

Telemedicine should be used to enhance the delivery of medical care, but only between a physician and patient who have an established relationship, according to a policy statement from the American College of Physicians published Sept. 7 in the Annals of Internal Medicine.

“Telemedicine is rapidly growing and can potentially expand access for patients, enhance patient-physician collaboration, improve health outcomes, and reduce medical costs,” said lead author Hilary Daniel, an ACP health policy analyst. “However, the potential benefits of telemedicine must be measured against the risks and challenges associated with its use, including the absence of the physical examination, variation in state practice and licensing regulations, and issues surrounding the establishment of the patient-physician relationship,” she said.

The ACP notes that telemedicine is a reasonable alternative for patients who lack access to relevant medical expertise in their location, and that its practice can reduce medical costs and increase access to care. Episodic, direct-to-patient telemedicine services should be used only as an “intermittent alternative” to a patient’s primary care doctor when necessary to meet immediate acute care needs, according to the policy (Ann Intern Med 2015 Sep 7. doi: 10.7326/M15-0498).

A valid patient-physician relationship must be established for a responsible telemedicine visit to take place, although that relationship can be created through real-time audiovisual technology. A telemedicine doctor who has no existing relationship with a patient must take steps to establish a relationship based on the standard of care required for in-person visits, or by consulting another physician who has a relationship with the patient and oversees the patient’s care, the policy advised. Doctors should use their best professional judgment when deciding whether telemedicine is appropriate for a patient and never compromise their ethical obligations to deliver clinically appropriate care for the sake of new technology.

The college calls for the lifting of geographic site restrictions by Medicare that limit payment for telemedicine and telehealth services. Additionally, ACP supports payment by public and private health plans for appropriately structured telemedicine communications, whether synchronous or asynchronous, text-based, or supplemented with voice, video, or device feeds.

“Telemedicine shows promise not just in the United States but across the globe as third-world and developed nations embrace technology as a way to provide citizens access to health care,” Ms. Daniel and her colleagues wrote in the policy statement. “The legal, regulatory, technical, and cultural barriers to widespread adoption in the United States should be addressed to fully realize the potential of telemedicine for the benefit of physicians, patients, and the health care system.”

In an accompanying editorial, Dr. David A. Asch executive director of the University of Pennsylvania’s Center for Health Care Innovation, adds telemedicine can mean significant savings for physicians and patients in the form of time, money, and administrative burdens.

“The scalable gains from telemedicine will come from delivering care to populations – sometimes highly specialized care, in totally different ways – often with less physical infrastructure and less of the baggage that accompanies conventional practice,” Dr. Asch wrote. “Although the ACP position paper urges parity between telemedicine and face-to-face medicine in how physicians practice and get paid, arguing for parity is a trap if it merely carries forward practice styles and reimbursement requirements from one context to the other. The innovation that telemedicine promises is not just doing the same thing remotely that used to be done face-to-face but awakening us to the many things that we thought required face-to-face contact but actually do not.”

[email protected]

On Twitter @legal_med

A California judge has upheld the state’s ban against physician-assisted suicide, rejecting pleas by three terminally ill patients to legally end their lives with the help of a doctor. In an Aug. 14 ruling, San Francisco Superior Court Judge Ernest Goldsmith ruled that granting the plaintiffs’ petition would essentially create a judge-made law.

The decision is the latest development in a renewed debate about the legality and ethics of physician-assisted dying. More states than ever before are considering legalization of physician-assisted suicide, and experts say both public and physician perceptions of the practice appear to be changing.

Physicians in Canada find themselves facing a more pressing reality. In February 2016, physician-assisted suicide will become the law of the land as a result of a ruling by the Supreme Court of Canada earlier this year. But for now, U.S. physicians are facing a situation in flux.

“Division still runs deep,” said Arthur L. Caplan, Ph.D., founding director of the division of medical ethics at New York University’s Langone Medical Center’s Department of Population Health. “But one of the most interesting developments is that organized medicine may be moving a little toward favoring assisted dying for the terminally ill. Some of the resistance among physicians is shifting.”

Oregon, Vermont, and Washington are the only states that have laws permitting physician-assisted death. Court rulings in New Mexico and Montana have allowed for the practice. However, litigation in both states is ongoing and the decisions have yet to be enforced. Historically, one or two states consider such laws each year, said Peg Sandeen, Ph.D., executive director for the Death with Dignity National Center. In 2015, 25 state legislatures and the District of Columbia considered some form of physician-assisted death law, according to data from the Death With Dignity National Center. The majority of bills failed, although legislation in California, New York, Maryland, and the District of Columbia are pending. Ms. Sandeen notes that Maine came within one vote of passing a physician-assisted death law this year.

“We have seen a dramatic increase in the number of state legislatures willing to take up death with dignity or willing to consider it,” Ms. Sandeen said in an interview. “We have seen more activity this past legislature than we have any year in the last 10 years.”

Recent high-profile cases involving terminally ill patients have contributed to reignited public interest in the issue, said Dr. Arthur R. Derse, director of the Center for Bioethics and Medical Humanities and a professor of bioethics and emergency medicine at the Medical College of Wisconsin in Milwaukee. California resident Brittany Lauren Maynard, for instance, became widely known in 2014 after she fought to legally end her life after being diagnosed with terminal brain cancer. Ms. Maynard eventually moved to Oregon to take advantage of the state’s death with dignity law. Since Ms. Maynard’s case, the issue has become poignant in California, Dr. Derse said.

“It was a very sympathetic case to people who viewed [Ms. Maynard’s] video,” he said.

In 2015, California legislators introduced the End of Life Option Act, a bill that would allow for physician-assisted death in certain cases. Bill sponsors pulled it from the Assembly Committee on Health because of insufficient support. Assembly members later introduced a new version of the bill, which on Aug. 27 was referred to the Committee on Public Health and Developmental Services. Court battles in California over the legality of physician-assisted suicide continue. In addition to Judge Goldsmith’s Aug. 14 ruling, San Diego Superior Court Judge Gregory Pollack dismissed a similar lawsuit on July 27. Plaintiffs in both cases plan to appeal.

The California Medical Association (CMA) was not involved in either case and declined to comment for this story. However, in May, the medical association became the first state medical society to change its stance against physician-assisted suicide to that of being neutral.

“The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options,” Dr. Luther F. Cobb, CMA president, said in a statement. “We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.”

While physicians are becoming less opposed to the practice, strong reservations still remain among the majority medical community, said Dr. Derse.

“Even if it’s becoming increasingly understood and somewhat more accepted by physicians, the public is significantly ahead in their support of this practice than physicians,” Dr. Derse said in an interview. “Physicians tend to be more wary and the reasons why have to do with, in part, the availability of palliative care, other alternatives, and concerns about the prohibition by the Hippocratic oath of giving patients something that would cause their death.”

The potential for abuse and overuse of physician-assisted suicide also remain a top concern. Such considerations were addressed in two studies and a commentary published in the Aug. 10 online issue of JAMA Internal Medicine. One study analyzed physician-assisted suicide and euthanasia cases at a Netherlands End-of-Life Clinic. The other reviewed the euthanasia rate in Belgium. Authors of the Netherlands study found that of 645 death requests made from 2012 to 2013, 25% were granted, 47% were refused, 9% withdrew their requests, and 19% died before their request were assessed. Notably, 7% of those approved for euthanasia or physician-assisted suicide were categorized as “tired of living.” Nearly 4% reported only psychological suffering. The Belgium study meanwhile, found the rate of euthanasia has increased from 1.9% of all deaths in Flanders, Belgium, in 2007, to 4.6% of all deaths in 2013.

“Both studies report worrisome findings that seem to validate concerns about where these practices might lead,” Dr. Caplan wrote in an associated commentary. “These findings, and other recent data regarding the speeding of patients’ deaths, make this a key moment to revisit efforts in the legalization of assisted dying in the United States and elsewhere, and, specifically, the role of the medical profession.”

U.S. doctors are also closely watching how the practice of assisted suicide unfolds in Canada. In striking down a federal law against physician-assisted suicide in February, the Supreme Court of Canada set a deadline of Feb. 6, 2016, for policies regarding the practice to be in place.

Dr. Derse said Canada’s use of the practice may present some good lessons for Americans, but will likely have a limited affect on the United States.

Dr. Caplan however, believes the legalization of physician-assisted suicide in Canada will have a big impact on the United States.

It’s “close by [and a] similar country,” he said. “We’ll be watching to see how they implement it.”

[email protected]

On Twitter@legal_med

A California judge has upheld the state’s ban against physician-assisted suicide, rejecting pleas by three terminally ill patients to legally end their lives with the help of a doctor. In an Aug. 14 ruling, San Francisco Superior Court Judge Ernest Goldsmith ruled that granting the plaintiffs’ petition would essentially create a judge-made law.

The decision is the latest development in a renewed debate about the legality and ethics of physician-assisted dying. More states than ever before are considering legalization of physician-assisted suicide, and experts say both public and physician perceptions of the practice appear to be changing.

Physicians in Canada find themselves facing a more pressing reality. In February 2016, physician-assisted suicide will become the law of the land as a result of a ruling by the Supreme Court of Canada earlier this year. But for now, U.S. physicians are facing a situation in flux.

“Division still runs deep,” said Arthur L. Caplan, Ph.D., founding director of the division of medical ethics at New York University’s Langone Medical Center’s Department of Population Health. “But one of the most interesting developments is that organized medicine may be moving a little toward favoring assisted dying for the terminally ill. Some of the resistance among physicians is shifting.”

Oregon, Vermont, and Washington are the only states that have laws permitting physician-assisted death. Court rulings in New Mexico and Montana have allowed for the practice. However, litigation in both states is ongoing and the decisions have yet to be enforced. Historically, one or two states consider such laws each year, said Peg Sandeen, Ph.D., executive director for the Death with Dignity National Center. In 2015, 25 state legislatures and the District of Columbia considered some form of physician-assisted death law, according to data from the Death With Dignity National Center. The majority of bills failed, although legislation in California, New York, Maryland, and the District of Columbia are pending. Ms. Sandeen notes that Maine came within one vote of passing a physician-assisted death law this year.

“We have seen a dramatic increase in the number of state legislatures willing to take up death with dignity or willing to consider it,” Ms. Sandeen said in an interview. “We have seen more activity this past legislature than we have any year in the last 10 years.”

Recent high-profile cases involving terminally ill patients have contributed to reignited public interest in the issue, said Dr. Arthur R. Derse, director of the Center for Bioethics and Medical Humanities and a professor of bioethics and emergency medicine at the Medical College of Wisconsin in Milwaukee. California resident Brittany Lauren Maynard, for instance, became widely known in 2014 after she fought to legally end her life after being diagnosed with terminal brain cancer. Ms. Maynard eventually moved to Oregon to take advantage of the state’s death with dignity law. Since Ms. Maynard’s case, the issue has become poignant in California, Dr. Derse said.

“It was a very sympathetic case to people who viewed [Ms. Maynard’s] video,” he said.

In 2015, California legislators introduced the End of Life Option Act, a bill that would allow for physician-assisted death in certain cases. Bill sponsors pulled it from the Assembly Committee on Health because of insufficient support. Assembly members later introduced a new version of the bill, which on Aug. 27 was referred to the Committee on Public Health and Developmental Services. Court battles in California over the legality of physician-assisted suicide continue. In addition to Judge Goldsmith’s Aug. 14 ruling, San Diego Superior Court Judge Gregory Pollack dismissed a similar lawsuit on July 27. Plaintiffs in both cases plan to appeal.

The California Medical Association (CMA) was not involved in either case and declined to comment for this story. However, in May, the medical association became the first state medical society to change its stance against physician-assisted suicide to that of being neutral.

“The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options,” Dr. Luther F. Cobb, CMA president, said in a statement. “We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.”

While physicians are becoming less opposed to the practice, strong reservations still remain among the majority medical community, said Dr. Derse.

“Even if it’s becoming increasingly understood and somewhat more accepted by physicians, the public is significantly ahead in their support of this practice than physicians,” Dr. Derse said in an interview. “Physicians tend to be more wary and the reasons why have to do with, in part, the availability of palliative care, other alternatives, and concerns about the prohibition by the Hippocratic oath of giving patients something that would cause their death.”

The potential for abuse and overuse of physician-assisted suicide also remain a top concern. Such considerations were addressed in two studies and a commentary published in the Aug. 10 online issue of JAMA Internal Medicine. One study analyzed physician-assisted suicide and euthanasia cases at a Netherlands End-of-Life Clinic. The other reviewed the euthanasia rate in Belgium. Authors of the Netherlands study found that of 645 death requests made from 2012 to 2013, 25% were granted, 47% were refused, 9% withdrew their requests, and 19% died before their request were assessed. Notably, 7% of those approved for euthanasia or physician-assisted suicide were categorized as “tired of living.” Nearly 4% reported only psychological suffering. The Belgium study meanwhile, found the rate of euthanasia has increased from 1.9% of all deaths in Flanders, Belgium, in 2007, to 4.6% of all deaths in 2013.

“Both studies report worrisome findings that seem to validate concerns about where these practices might lead,” Dr. Caplan wrote in an associated commentary. “These findings, and other recent data regarding the speeding of patients’ deaths, make this a key moment to revisit efforts in the legalization of assisted dying in the United States and elsewhere, and, specifically, the role of the medical profession.”

U.S. doctors are also closely watching how the practice of assisted suicide unfolds in Canada. In striking down a federal law against physician-assisted suicide in February, the Supreme Court of Canada set a deadline of Feb. 6, 2016, for policies regarding the practice to be in place.

Dr. Derse said Canada’s use of the practice may present some good lessons for Americans, but will likely have a limited affect on the United States.

Dr. Caplan however, believes the legalization of physician-assisted suicide in Canada will have a big impact on the United States.

It’s “close by [and a] similar country,” he said. “We’ll be watching to see how they implement it.”

[email protected]

On Twitter@legal_med

A California judge has upheld the state’s ban against physician-assisted suicide, rejecting pleas by three terminally ill patients to legally end their lives with the help of a doctor. In an Aug. 14 ruling, San Francisco Superior Court Judge Ernest Goldsmith ruled that granting the plaintiffs’ petition would essentially create a judge-made law.

The decision is the latest development in a renewed debate about the legality and ethics of physician-assisted dying. More states than ever before are considering legalization of physician-assisted suicide, and experts say both public and physician perceptions of the practice appear to be changing.

Physicians in Canada find themselves facing a more pressing reality. In February 2016, physician-assisted suicide will become the law of the land as a result of a ruling by the Supreme Court of Canada earlier this year. But for now, U.S. physicians are facing a situation in flux.

“Division still runs deep,” said Arthur L. Caplan, Ph.D., founding director of the division of medical ethics at New York University’s Langone Medical Center’s Department of Population Health. “But one of the most interesting developments is that organized medicine may be moving a little toward favoring assisted dying for the terminally ill. Some of the resistance among physicians is shifting.”

Oregon, Vermont, and Washington are the only states that have laws permitting physician-assisted death. Court rulings in New Mexico and Montana have allowed for the practice. However, litigation in both states is ongoing and the decisions have yet to be enforced. Historically, one or two states consider such laws each year, said Peg Sandeen, Ph.D., executive director for the Death with Dignity National Center. In 2015, 25 state legislatures and the District of Columbia considered some form of physician-assisted death law, according to data from the Death With Dignity National Center. The majority of bills failed, although legislation in California, New York, Maryland, and the District of Columbia are pending. Ms. Sandeen notes that Maine came within one vote of passing a physician-assisted death law this year.

“We have seen a dramatic increase in the number of state legislatures willing to take up death with dignity or willing to consider it,” Ms. Sandeen said in an interview. “We have seen more activity this past legislature than we have any year in the last 10 years.”

Recent high-profile cases involving terminally ill patients have contributed to reignited public interest in the issue, said Dr. Arthur R. Derse, director of the Center for Bioethics and Medical Humanities and a professor of bioethics and emergency medicine at the Medical College of Wisconsin in Milwaukee. California resident Brittany Lauren Maynard, for instance, became widely known in 2014 after she fought to legally end her life after being diagnosed with terminal brain cancer. Ms. Maynard eventually moved to Oregon to take advantage of the state’s death with dignity law. Since Ms. Maynard’s case, the issue has become poignant in California, Dr. Derse said.

“It was a very sympathetic case to people who viewed [Ms. Maynard’s] video,” he said.

In 2015, California legislators introduced the End of Life Option Act, a bill that would allow for physician-assisted death in certain cases. Bill sponsors pulled it from the Assembly Committee on Health because of insufficient support. Assembly members later introduced a new version of the bill, which on Aug. 27 was referred to the Committee on Public Health and Developmental Services. Court battles in California over the legality of physician-assisted suicide continue. In addition to Judge Goldsmith’s Aug. 14 ruling, San Diego Superior Court Judge Gregory Pollack dismissed a similar lawsuit on July 27. Plaintiffs in both cases plan to appeal.

The California Medical Association (CMA) was not involved in either case and declined to comment for this story. However, in May, the medical association became the first state medical society to change its stance against physician-assisted suicide to that of being neutral.

“The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options,” Dr. Luther F. Cobb, CMA president, said in a statement. “We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.”

While physicians are becoming less opposed to the practice, strong reservations still remain among the majority medical community, said Dr. Derse.

“Even if it’s becoming increasingly understood and somewhat more accepted by physicians, the public is significantly ahead in their support of this practice than physicians,” Dr. Derse said in an interview. “Physicians tend to be more wary and the reasons why have to do with, in part, the availability of palliative care, other alternatives, and concerns about the prohibition by the Hippocratic oath of giving patients something that would cause their death.”

The potential for abuse and overuse of physician-assisted suicide also remain a top concern. Such considerations were addressed in two studies and a commentary published in the Aug. 10 online issue of JAMA Internal Medicine. One study analyzed physician-assisted suicide and euthanasia cases at a Netherlands End-of-Life Clinic. The other reviewed the euthanasia rate in Belgium. Authors of the Netherlands study found that of 645 death requests made from 2012 to 2013, 25% were granted, 47% were refused, 9% withdrew their requests, and 19% died before their request were assessed. Notably, 7% of those approved for euthanasia or physician-assisted suicide were categorized as “tired of living.” Nearly 4% reported only psychological suffering. The Belgium study meanwhile, found the rate of euthanasia has increased from 1.9% of all deaths in Flanders, Belgium, in 2007, to 4.6% of all deaths in 2013.

“Both studies report worrisome findings that seem to validate concerns about where these practices might lead,” Dr. Caplan wrote in an associated commentary. “These findings, and other recent data regarding the speeding of patients’ deaths, make this a key moment to revisit efforts in the legalization of assisted dying in the United States and elsewhere, and, specifically, the role of the medical profession.”

U.S. doctors are also closely watching how the practice of assisted suicide unfolds in Canada. In striking down a federal law against physician-assisted suicide in February, the Supreme Court of Canada set a deadline of Feb. 6, 2016, for policies regarding the practice to be in place.

Dr. Derse said Canada’s use of the practice may present some good lessons for Americans, but will likely have a limited affect on the United States.

Dr. Caplan however, believes the legalization of physician-assisted suicide in Canada will have a big impact on the United States.

It’s “close by [and a] similar country,” he said. “We’ll be watching to see how they implement it.”

[email protected]

On Twitter@legal_med