Alicia Gallegos

Early communication with pharmaceutical companies about the requirements of the Physician Payment Sunshine Act and better education on its provisions will prevent data disputes and reduce reporting surprises for doctors.

"A lot of physicians don’t realize how broad [the law] is," Stefanie A. Doebler, special counsel for Covington & Burling health care and food and drug practice groups in Washington, said in an interview. "Virtually everything [doctors] get from a manufacturer going forward is going to be reported. They need to be aware. They need to ask questions."

The federal Sunshine Act, adopted as part of the Affordable Care Act, requires manufacturers of drugs, devices, and biologics who participate in federal health care programs to report payments and items of value provided to physicians and teaching hospitals. The information must be made publicly available on a searchable federal database starting in September.

The federal government now calls the program Open Payments.

A 45-day review and dispute period for physicians began July 14. During this period, doctors can register with the Centers for Medicaid & Medicare Services’s Enterprise Portal, review data reported about them, and, if desired, initiate disputes with applicable manufacturers. Drug and device makers will then have an additional 15 days from then – ending Sept. 11 – to submit updated information to CMS.

Physicians need to make time to register and review their information now, Ms. Doebler said in an interview.

"They really need to be on top of reviewing their data," she said. "It’s kind of a pain in the neck for doctors, but they want to review it now and not once it goes public. Once it goes public, it’s there until the data is refreshed 6 months from now. They want to catch it now."

Physicians appear to be unclear on some areas of the law, Robert Ciolek, senior corporate counsel for Bristol-Myers Squibb, said during an American Bar Association webinar. For example, confusion often surfaces about whether the cost of lunches provided during educational programs are reportable.

"Frequently, the best opportunity [manufacturers] have is to do a lunch program where they can sit with a hospital staff and put together an educational program that talks either about a disease area or about a manufacturer’s product," Mr. Ciolek said. "The issue that always arises is, ‘What about the meal? Is it going to be reportable?’ We’ve seen time and time again, where doctors simply don’t understand the rule."

If a doctor consumes a meal in such a setting, the cost of the physician’s meal is reportable, Mr. Ciolek said. However, the cost of meals provided to office staff or other health care team members is not reportable. If physicians do not want their lunch costs reported, but still want to attend the program, they should not eat the meal, he said.

Open Payments requirements should be discussed by companies and physicians and/or noted before or at the time of transfers of value, said Carolyn M. Bruguera, vice president of consulting services and general counsel for R-Squared Services & Solutions, a consulting and software firm.

For instance, language regarding the law should be included in contracts, referenced on sign-in sheets for group meals, or stated orally during meetings.

Many large manufacturers and industry trade groups have developed websites and brochures to help educate physicians about reporting obligations, she added.

"These are also good tools for avoiding disputes and misunderstandings, but in some cases, manufacturers may need to be more proactive about getting the information to the covered recipients," she said. "Greater coordination with, for example, physician groups, such as specialty societies, might be helpful in this regard."

Another crucial step for doctors is explaining to patients their relationships with pharmaceutical companies and device manufacturers and ensuring patients understand why these interactions are useful, Ms. Doebler said. Once the value transfers go public, some mainstream media likely will paint all transfers of value among companies and doctors in a negative light, she said.

"It’s incumbent on doctors to explain to patients that there are valuable reasons" behind transactions with companies, she said. "It’s helpful for physicians to be able to explain why these relationships are important."

[email protected]

On Twitter @legal_med

Early communication with pharmaceutical companies about the requirements of the Physician Payment Sunshine Act and better education on its provisions will prevent data disputes and reduce reporting surprises for doctors.

"A lot of physicians don’t realize how broad [the law] is," Stefanie A. Doebler, special counsel for Covington & Burling health care and food and drug practice groups in Washington, said in an interview. "Virtually everything [doctors] get from a manufacturer going forward is going to be reported. They need to be aware. They need to ask questions."

The federal Sunshine Act, adopted as part of the Affordable Care Act, requires manufacturers of drugs, devices, and biologics who participate in federal health care programs to report payments and items of value provided to physicians and teaching hospitals. The information must be made publicly available on a searchable federal database starting in September.

The federal government now calls the program Open Payments.

A 45-day review and dispute period for physicians began July 14. During this period, doctors can register with the Centers for Medicaid & Medicare Services’s Enterprise Portal, review data reported about them, and, if desired, initiate disputes with applicable manufacturers. Drug and device makers will then have an additional 15 days from then – ending Sept. 11 – to submit updated information to CMS.

Physicians need to make time to register and review their information now, Ms. Doebler said in an interview.

"They really need to be on top of reviewing their data," she said. "It’s kind of a pain in the neck for doctors, but they want to review it now and not once it goes public. Once it goes public, it’s there until the data is refreshed 6 months from now. They want to catch it now."

Physicians appear to be unclear on some areas of the law, Robert Ciolek, senior corporate counsel for Bristol-Myers Squibb, said during an American Bar Association webinar. For example, confusion often surfaces about whether the cost of lunches provided during educational programs are reportable.

"Frequently, the best opportunity [manufacturers] have is to do a lunch program where they can sit with a hospital staff and put together an educational program that talks either about a disease area or about a manufacturer’s product," Mr. Ciolek said. "The issue that always arises is, ‘What about the meal? Is it going to be reportable?’ We’ve seen time and time again, where doctors simply don’t understand the rule."

If a doctor consumes a meal in such a setting, the cost of the physician’s meal is reportable, Mr. Ciolek said. However, the cost of meals provided to office staff or other health care team members is not reportable. If physicians do not want their lunch costs reported, but still want to attend the program, they should not eat the meal, he said.

Open Payments requirements should be discussed by companies and physicians and/or noted before or at the time of transfers of value, said Carolyn M. Bruguera, vice president of consulting services and general counsel for R-Squared Services & Solutions, a consulting and software firm.

For instance, language regarding the law should be included in contracts, referenced on sign-in sheets for group meals, or stated orally during meetings.

Many large manufacturers and industry trade groups have developed websites and brochures to help educate physicians about reporting obligations, she added.

"These are also good tools for avoiding disputes and misunderstandings, but in some cases, manufacturers may need to be more proactive about getting the information to the covered recipients," she said. "Greater coordination with, for example, physician groups, such as specialty societies, might be helpful in this regard."

Another crucial step for doctors is explaining to patients their relationships with pharmaceutical companies and device manufacturers and ensuring patients understand why these interactions are useful, Ms. Doebler said. Once the value transfers go public, some mainstream media likely will paint all transfers of value among companies and doctors in a negative light, she said.

"It’s incumbent on doctors to explain to patients that there are valuable reasons" behind transactions with companies, she said. "It’s helpful for physicians to be able to explain why these relationships are important."

[email protected]

On Twitter @legal_med

Early communication with pharmaceutical companies about the requirements of the Physician Payment Sunshine Act and better education on its provisions will prevent data disputes and reduce reporting surprises for doctors.

"A lot of physicians don’t realize how broad [the law] is," Stefanie A. Doebler, special counsel for Covington & Burling health care and food and drug practice groups in Washington, said in an interview. "Virtually everything [doctors] get from a manufacturer going forward is going to be reported. They need to be aware. They need to ask questions."

The federal Sunshine Act, adopted as part of the Affordable Care Act, requires manufacturers of drugs, devices, and biologics who participate in federal health care programs to report payments and items of value provided to physicians and teaching hospitals. The information must be made publicly available on a searchable federal database starting in September.

The federal government now calls the program Open Payments.

A 45-day review and dispute period for physicians began July 14. During this period, doctors can register with the Centers for Medicaid & Medicare Services’s Enterprise Portal, review data reported about them, and, if desired, initiate disputes with applicable manufacturers. Drug and device makers will then have an additional 15 days from then – ending Sept. 11 – to submit updated information to CMS.

Physicians need to make time to register and review their information now, Ms. Doebler said in an interview.

"They really need to be on top of reviewing their data," she said. "It’s kind of a pain in the neck for doctors, but they want to review it now and not once it goes public. Once it goes public, it’s there until the data is refreshed 6 months from now. They want to catch it now."

Physicians appear to be unclear on some areas of the law, Robert Ciolek, senior corporate counsel for Bristol-Myers Squibb, said during an American Bar Association webinar. For example, confusion often surfaces about whether the cost of lunches provided during educational programs are reportable.

"Frequently, the best opportunity [manufacturers] have is to do a lunch program where they can sit with a hospital staff and put together an educational program that talks either about a disease area or about a manufacturer’s product," Mr. Ciolek said. "The issue that always arises is, ‘What about the meal? Is it going to be reportable?’ We’ve seen time and time again, where doctors simply don’t understand the rule."

If a doctor consumes a meal in such a setting, the cost of the physician’s meal is reportable, Mr. Ciolek said. However, the cost of meals provided to office staff or other health care team members is not reportable. If physicians do not want their lunch costs reported, but still want to attend the program, they should not eat the meal, he said.

Open Payments requirements should be discussed by companies and physicians and/or noted before or at the time of transfers of value, said Carolyn M. Bruguera, vice president of consulting services and general counsel for R-Squared Services & Solutions, a consulting and software firm.

For instance, language regarding the law should be included in contracts, referenced on sign-in sheets for group meals, or stated orally during meetings.

Many large manufacturers and industry trade groups have developed websites and brochures to help educate physicians about reporting obligations, she added.

"These are also good tools for avoiding disputes and misunderstandings, but in some cases, manufacturers may need to be more proactive about getting the information to the covered recipients," she said. "Greater coordination with, for example, physician groups, such as specialty societies, might be helpful in this regard."

Another crucial step for doctors is explaining to patients their relationships with pharmaceutical companies and device manufacturers and ensuring patients understand why these interactions are useful, Ms. Doebler said. Once the value transfers go public, some mainstream media likely will paint all transfers of value among companies and doctors in a negative light, she said.

"It’s incumbent on doctors to explain to patients that there are valuable reasons" behind transactions with companies, she said. "It’s helpful for physicians to be able to explain why these relationships are important."

[email protected]

On Twitter @legal_med

The uninsured rate of working adults in the United States declined from 20% to 15% after the first Affordable Care Act open enrollment period.

Sara Collins, Ph.D., of the Commonwealth Fund and her associates also found that 6 in 10 newly covered patients have used their health plan to visit a doctor or hospital, or to fill a prescription.

The Commonwealth Fund tracking survey examined data from 4,425 adults about health and insurance trends from April 9 to June 2 and compared the findings with those from a 2013 Commonwealth Fund survey.

Alexander Raths/Fotolia.com

The uninsured rate among patients aged 19-64 years went from 20% for July to September 2013 to 15% for April to June 2014. For young adults (19-34 years), the uninsured rate dropped from 28% to 18% over the same time period. Among the Hispanic community, uninsured patients declined from 36% to 23%, the survey found. The findings were published July 10.

In states that expanded Medicaid, the uninsured rate fell from 28% to 17% for patients at the poverty level. However, in states that chose not to expand Medicaid, the rate of uninsured poor patients changed from 38% to 36%.

The survey findings provide early evidence that the ACA’s coverage provisions are helping Americans most at risk for lacking health insurance, Dr. Collins and associates noted. Evidence also shows that the new insurance coverage is helping people gain new access to the health care system. Nearly three-fourths of previously uninsured adults who used their new plan reported they would not have received the same care prior to gaining coverage.

[email protected]

On Twitter @legal_med

The uninsured rate of working adults in the United States declined from 20% to 15% after the first Affordable Care Act open enrollment period.

Sara Collins, Ph.D., of the Commonwealth Fund and her associates also found that 6 in 10 newly covered patients have used their health plan to visit a doctor or hospital, or to fill a prescription.

The Commonwealth Fund tracking survey examined data from 4,425 adults about health and insurance trends from April 9 to June 2 and compared the findings with those from a 2013 Commonwealth Fund survey.

Alexander Raths/Fotolia.com

The uninsured rate among patients aged 19-64 years went from 20% for July to September 2013 to 15% for April to June 2014. For young adults (19-34 years), the uninsured rate dropped from 28% to 18% over the same time period. Among the Hispanic community, uninsured patients declined from 36% to 23%, the survey found. The findings were published July 10.

In states that expanded Medicaid, the uninsured rate fell from 28% to 17% for patients at the poverty level. However, in states that chose not to expand Medicaid, the rate of uninsured poor patients changed from 38% to 36%.

The survey findings provide early evidence that the ACA’s coverage provisions are helping Americans most at risk for lacking health insurance, Dr. Collins and associates noted. Evidence also shows that the new insurance coverage is helping people gain new access to the health care system. Nearly three-fourths of previously uninsured adults who used their new plan reported they would not have received the same care prior to gaining coverage.

[email protected]

On Twitter @legal_med

The uninsured rate of working adults in the United States declined from 20% to 15% after the first Affordable Care Act open enrollment period.

Sara Collins, Ph.D., of the Commonwealth Fund and her associates also found that 6 in 10 newly covered patients have used their health plan to visit a doctor or hospital, or to fill a prescription.

The Commonwealth Fund tracking survey examined data from 4,425 adults about health and insurance trends from April 9 to June 2 and compared the findings with those from a 2013 Commonwealth Fund survey.

Alexander Raths/Fotolia.com

The uninsured rate among patients aged 19-64 years went from 20% for July to September 2013 to 15% for April to June 2014. For young adults (19-34 years), the uninsured rate dropped from 28% to 18% over the same time period. Among the Hispanic community, uninsured patients declined from 36% to 23%, the survey found. The findings were published July 10.

In states that expanded Medicaid, the uninsured rate fell from 28% to 17% for patients at the poverty level. However, in states that chose not to expand Medicaid, the rate of uninsured poor patients changed from 38% to 36%.

The survey findings provide early evidence that the ACA’s coverage provisions are helping Americans most at risk for lacking health insurance, Dr. Collins and associates noted. Evidence also shows that the new insurance coverage is helping people gain new access to the health care system. Nearly three-fourths of previously uninsured adults who used their new plan reported they would not have received the same care prior to gaining coverage.

[email protected]

On Twitter @legal_med

Obesity-related lawsuits against health providers are on the rise, according to a claims analysis by national medical liability insurer The Doctors Company. Claims associated with obesity totaled 415 between 2007 and 2012, an increase of 64% in the number of such lawsuits from the period between 1992 and 2002.

The increase "is not at all surprising, as obesity itself has increased a great deal in the population," said Dr. Neil Skolnik, associate director of the family practice residency program at Abington (Pa.) Memorial Hospital. "We’re going to see that reflected in malpractice suits."

The Doctors Company study analyzed 415 obesity-related claims from 2007 through 2012 and compared them with a previous analysis of claims from 1992 to 2002. The most recent suits involved instances such as a 290-pound patient who had complications following a gastric bypass surgery, a 325-pound patient with hypertension and diabetes who died after a physician did not diagnose myocardial infarction and pneumonia, and a 350-pound patient with nerve damage that resulted from improper positioning on a treatment table. Twenty-five percent of the patients involved in the claims died, according to the study, published on The Doctors Company website in May.

Orthopedists were the top specialty sued for obesity-related claims, followed by family physicians, anesthesiologists, plastic surgeons, general surgeons, and internists.

Family physicians may be sued more often than some other specialties because of their interaction with patients who develop conditions associated with obesity over time, said Paul Nagle, director of physician patient safety for The Doctors Company.

"Family medicine physicians can be at risk due to the latent risk of obesity," he said in an interview. "If a patient’s weight gradually increases, what is a family medicine physician doing to monitor the weight and the potentially resulting medical issues, including diabetes, hypertension, cardiac, vascular, joint, or pulmonary health issues?"

Communicating clearly with obese patients early is essential to avoid obesity-related claims, said Liz Brott, regional vice president, risk resource for ProAssurance, a national medical liability insurer.

"It’s extremely important as far as communicating with them about what to expect from procedures or treatment," she said in an interview. "You don’t want to leave this to your staff to communicate. [It should be] the physician sitting down, one-on-one, whether it’s the primary care physician or the surgeon. There should be appropriate communication by the physician."

Ms. Brott said ProAssurance has handled obesity-related claims continually, but their numbers do not show a dramatic rise. In her experience, obesity claims against surgeons related to bariatric procedures are most common, she said.

Along with informed consent, physicians also may want to consider an informed refusal approach for noncompliant patients, Mr. Nagle said. This refers to informing patients about how obesity impacts their overall health and/or a specific health issue and having patients sign a document stating that they were advised but chose not to follow recommendations.

"This may reduce any claims that you did not address and warn of obesity’s impact," he said.

Physicians should also document all activity related to weight interventions and conversations with patients about weight education and guidance, he added

The analysis is a reminder that obesity is a serious disease that has its own direct complications, as well as acting as a catalyst for related conditions, said Dr. Skolnik, who is also a professor of family medicine at Temple University in Philadelphia.

"The overriding theme here is obesity is an area to which patients are paying increasing attention and to which lawyers also must be paying increasing attention," he said. "It’s an area that should be addressed directly and with sensitivity to the often emotional issues that go along with addressing weight issues."

[email protected]

Obesity-related lawsuits against health providers are on the rise, according to a claims analysis by national medical liability insurer The Doctors Company. Claims associated with obesity totaled 415 between 2007 and 2012, an increase of 64% in the number of such lawsuits from the period between 1992 and 2002.

The increase "is not at all surprising, as obesity itself has increased a great deal in the population," said Dr. Neil Skolnik, associate director of the family practice residency program at Abington (Pa.) Memorial Hospital. "We’re going to see that reflected in malpractice suits."

The Doctors Company study analyzed 415 obesity-related claims from 2007 through 2012 and compared them with a previous analysis of claims from 1992 to 2002. The most recent suits involved instances such as a 290-pound patient who had complications following a gastric bypass surgery, a 325-pound patient with hypertension and diabetes who died after a physician did not diagnose myocardial infarction and pneumonia, and a 350-pound patient with nerve damage that resulted from improper positioning on a treatment table. Twenty-five percent of the patients involved in the claims died, according to the study, published on The Doctors Company website in May.

Orthopedists were the top specialty sued for obesity-related claims, followed by family physicians, anesthesiologists, plastic surgeons, general surgeons, and internists.

Family physicians may be sued more often than some other specialties because of their interaction with patients who develop conditions associated with obesity over time, said Paul Nagle, director of physician patient safety for The Doctors Company.

"Family medicine physicians can be at risk due to the latent risk of obesity," he said in an interview. "If a patient’s weight gradually increases, what is a family medicine physician doing to monitor the weight and the potentially resulting medical issues, including diabetes, hypertension, cardiac, vascular, joint, or pulmonary health issues?"

Communicating clearly with obese patients early is essential to avoid obesity-related claims, said Liz Brott, regional vice president, risk resource for ProAssurance, a national medical liability insurer.

"It’s extremely important as far as communicating with them about what to expect from procedures or treatment," she said in an interview. "You don’t want to leave this to your staff to communicate. [It should be] the physician sitting down, one-on-one, whether it’s the primary care physician or the surgeon. There should be appropriate communication by the physician."

Ms. Brott said ProAssurance has handled obesity-related claims continually, but their numbers do not show a dramatic rise. In her experience, obesity claims against surgeons related to bariatric procedures are most common, she said.

Along with informed consent, physicians also may want to consider an informed refusal approach for noncompliant patients, Mr. Nagle said. This refers to informing patients about how obesity impacts their overall health and/or a specific health issue and having patients sign a document stating that they were advised but chose not to follow recommendations.

"This may reduce any claims that you did not address and warn of obesity’s impact," he said.

Physicians should also document all activity related to weight interventions and conversations with patients about weight education and guidance, he added

The analysis is a reminder that obesity is a serious disease that has its own direct complications, as well as acting as a catalyst for related conditions, said Dr. Skolnik, who is also a professor of family medicine at Temple University in Philadelphia.

"The overriding theme here is obesity is an area to which patients are paying increasing attention and to which lawyers also must be paying increasing attention," he said. "It’s an area that should be addressed directly and with sensitivity to the often emotional issues that go along with addressing weight issues."

[email protected]

Obesity-related lawsuits against health providers are on the rise, according to a claims analysis by national medical liability insurer The Doctors Company. Claims associated with obesity totaled 415 between 2007 and 2012, an increase of 64% in the number of such lawsuits from the period between 1992 and 2002.

The increase "is not at all surprising, as obesity itself has increased a great deal in the population," said Dr. Neil Skolnik, associate director of the family practice residency program at Abington (Pa.) Memorial Hospital. "We’re going to see that reflected in malpractice suits."

The Doctors Company study analyzed 415 obesity-related claims from 2007 through 2012 and compared them with a previous analysis of claims from 1992 to 2002. The most recent suits involved instances such as a 290-pound patient who had complications following a gastric bypass surgery, a 325-pound patient with hypertension and diabetes who died after a physician did not diagnose myocardial infarction and pneumonia, and a 350-pound patient with nerve damage that resulted from improper positioning on a treatment table. Twenty-five percent of the patients involved in the claims died, according to the study, published on The Doctors Company website in May.

Orthopedists were the top specialty sued for obesity-related claims, followed by family physicians, anesthesiologists, plastic surgeons, general surgeons, and internists.

Family physicians may be sued more often than some other specialties because of their interaction with patients who develop conditions associated with obesity over time, said Paul Nagle, director of physician patient safety for The Doctors Company.

"Family medicine physicians can be at risk due to the latent risk of obesity," he said in an interview. "If a patient’s weight gradually increases, what is a family medicine physician doing to monitor the weight and the potentially resulting medical issues, including diabetes, hypertension, cardiac, vascular, joint, or pulmonary health issues?"

Communicating clearly with obese patients early is essential to avoid obesity-related claims, said Liz Brott, regional vice president, risk resource for ProAssurance, a national medical liability insurer.

"It’s extremely important as far as communicating with them about what to expect from procedures or treatment," she said in an interview. "You don’t want to leave this to your staff to communicate. [It should be] the physician sitting down, one-on-one, whether it’s the primary care physician or the surgeon. There should be appropriate communication by the physician."

Ms. Brott said ProAssurance has handled obesity-related claims continually, but their numbers do not show a dramatic rise. In her experience, obesity claims against surgeons related to bariatric procedures are most common, she said.

Along with informed consent, physicians also may want to consider an informed refusal approach for noncompliant patients, Mr. Nagle said. This refers to informing patients about how obesity impacts their overall health and/or a specific health issue and having patients sign a document stating that they were advised but chose not to follow recommendations.

"This may reduce any claims that you did not address and warn of obesity’s impact," he said.

Physicians should also document all activity related to weight interventions and conversations with patients about weight education and guidance, he added

The analysis is a reminder that obesity is a serious disease that has its own direct complications, as well as acting as a catalyst for related conditions, said Dr. Skolnik, who is also a professor of family medicine at Temple University in Philadelphia.

"The overriding theme here is obesity is an area to which patients are paying increasing attention and to which lawyers also must be paying increasing attention," he said. "It’s an area that should be addressed directly and with sensitivity to the often emotional issues that go along with addressing weight issues."

[email protected]

Obesity-related lawsuits against health providers are on the rise, according to a claims analysis by national medical liability insurer The Doctors Company. Claims associated with obesity totaled 415 between 2007 and 2012, an increase of 64% in the number of such lawsuits from the period between 1992 and 2002.

The increase "is not at all surprising, as obesity itself has increased a great deal in the population," said Dr. Neil Skolnik, associate director of the family practice residency program at Abington (Pa.) Memorial Hospital. "We’re going to see that reflected in malpractice suits."

The Doctors Company study analyzed 415 obesity-related claims from 2007 through 2012 and compared them with a previous analysis of claims from 1992 to 2002. The most recent suits involved instances such as a 290-pound patient who had complications following a gastric bypass surgery, a 325-pound patient with hypertension and diabetes who died after a physician did not diagnose myocardial infarction and pneumonia, and a 350-pound patient with nerve damage that resulted from improper positioning on a treatment table. Twenty-five percent of the patients involved in the claims died, according to the study, published on The Doctors Company website in May.

Orthopedists were the top specialty sued for obesity-related claims, followed by family physicians, anesthesiologists, plastic surgeons, general surgeons, and internists.

Family physicians may be sued more often than some other specialties because of their interaction with patients who develop conditions associated with obesity over time, said Paul Nagle, director of physician patient safety for The Doctors Company.

"Family medicine physicians can be at risk due to the latent risk of obesity," he said in an interview. "If a patient’s weight gradually increases, what is a family medicine physician doing to monitor the weight and the potentially resulting medical issues, including diabetes, hypertension, cardiac, vascular, joint, or pulmonary health issues?"

Communicating clearly with obese patients early is essential to avoid obesity-related claims, said Liz Brott, regional vice president, risk resource for ProAssurance, a national medical liability insurer.

"It’s extremely important as far as communicating with them about what to expect from procedures or treatment," she said in an interview. "You don’t want to leave this to your staff to communicate. [It should be] the physician sitting down, one-on-one, whether it’s the primary care physician or the surgeon. There should be appropriate communication by the physician."

Ms. Brott said ProAssurance has handled obesity-related claims continually, but their numbers do not show a dramatic rise. In her experience, obesity claims against surgeons related to bariatric procedures are most common, she said.

Along with informed consent, physicians also may want to consider an informed refusal approach for noncompliant patients, Mr. Nagle said. This refers to informing patients about how obesity impacts their overall health and/or a specific health issue and having patients sign a document stating that they were advised but chose not to follow recommendations.

"This may reduce any claims that you did not address and warn of obesity’s impact," he said.

Physicians should also document all activity related to weight interventions and conversations with patients about weight education and guidance, he added

The analysis is a reminder that obesity is a serious disease that has its own direct complications, as well as acting as a catalyst for related conditions, said Dr. Skolnik, who is also a professor of family medicine at Temple University in Philadelphia.

"The overriding theme here is obesity is an area to which patients are paying increasing attention and to which lawyers also must be paying increasing attention," he said. "It’s an area that should be addressed directly and with sensitivity to the often emotional issues that go along with addressing weight issues."

[email protected]

Obesity-related lawsuits against health providers are on the rise, according to a claims analysis by national medical liability insurer The Doctors Company. Claims associated with obesity totaled 415 between 2007 and 2012, an increase of 64% in the number of such lawsuits from the period between 1992 and 2002.

The increase "is not at all surprising, as obesity itself has increased a great deal in the population," said Dr. Neil Skolnik, associate director of the family practice residency program at Abington (Pa.) Memorial Hospital. "We’re going to see that reflected in malpractice suits."

The Doctors Company study analyzed 415 obesity-related claims from 2007 through 2012 and compared them with a previous analysis of claims from 1992 to 2002. The most recent suits involved instances such as a 290-pound patient who had complications following a gastric bypass surgery, a 325-pound patient with hypertension and diabetes who died after a physician did not diagnose myocardial infarction and pneumonia, and a 350-pound patient with nerve damage that resulted from improper positioning on a treatment table. Twenty-five percent of the patients involved in the claims died, according to the study, published on The Doctors Company website in May.

Orthopedists were the top specialty sued for obesity-related claims, followed by family physicians, anesthesiologists, plastic surgeons, general surgeons, and internists.

Family physicians may be sued more often than some other specialties because of their interaction with patients who develop conditions associated with obesity over time, said Paul Nagle, director of physician patient safety for The Doctors Company.

"Family medicine physicians can be at risk due to the latent risk of obesity," he said in an interview. "If a patient’s weight gradually increases, what is a family medicine physician doing to monitor the weight and the potentially resulting medical issues, including diabetes, hypertension, cardiac, vascular, joint, or pulmonary health issues?"

Communicating clearly with obese patients early is essential to avoid obesity-related claims, said Liz Brott, regional vice president, risk resource for ProAssurance, a national medical liability insurer.

"It’s extremely important as far as communicating with them about what to expect from procedures or treatment," she said in an interview. "You don’t want to leave this to your staff to communicate. [It should be] the physician sitting down, one-on-one, whether it’s the primary care physician or the surgeon. There should be appropriate communication by the physician."

Ms. Brott said ProAssurance has handled obesity-related claims continually, but their numbers do not show a dramatic rise. In her experience, obesity claims against surgeons related to bariatric procedures are most common, she said.

Along with informed consent, physicians also may want to consider an informed refusal approach for noncompliant patients, Mr. Nagle said. This refers to informing patients about how obesity impacts their overall health and/or a specific health issue and having patients sign a document stating that they were advised but chose not to follow recommendations.

"This may reduce any claims that you did not address and warn of obesity’s impact," he said.

Physicians should also document all activity related to weight interventions and conversations with patients about weight education and guidance, he added

The analysis is a reminder that obesity is a serious disease that has its own direct complications, as well as acting as a catalyst for related conditions, said Dr. Skolnik, who is also a professor of family medicine at Temple University in Philadelphia.

"The overriding theme here is obesity is an area to which patients are paying increasing attention and to which lawyers also must be paying increasing attention," he said. "It’s an area that should be addressed directly and with sensitivity to the often emotional issues that go along with addressing weight issues."

[email protected]

Obesity-related lawsuits against health providers are on the rise, according to a claims analysis by national medical liability insurer The Doctors Company. Claims associated with obesity totaled 415 between 2007 and 2012, an increase of 64% in the number of such lawsuits from the period between 1992 and 2002.

The increase "is not at all surprising, as obesity itself has increased a great deal in the population," said Dr. Neil Skolnik, associate director of the family practice residency program at Abington (Pa.) Memorial Hospital. "We’re going to see that reflected in malpractice suits."

The Doctors Company study analyzed 415 obesity-related claims from 2007 through 2012 and compared them with a previous analysis of claims from 1992 to 2002. The most recent suits involved instances such as a 290-pound patient who had complications following a gastric bypass surgery, a 325-pound patient with hypertension and diabetes who died after a physician did not diagnose myocardial infarction and pneumonia, and a 350-pound patient with nerve damage that resulted from improper positioning on a treatment table. Twenty-five percent of the patients involved in the claims died, according to the study, published on The Doctors Company website in May.

Orthopedists were the top specialty sued for obesity-related claims, followed by family physicians, anesthesiologists, plastic surgeons, general surgeons, and internists.

Family physicians may be sued more often than some other specialties because of their interaction with patients who develop conditions associated with obesity over time, said Paul Nagle, director of physician patient safety for The Doctors Company.

"Family medicine physicians can be at risk due to the latent risk of obesity," he said in an interview. "If a patient’s weight gradually increases, what is a family medicine physician doing to monitor the weight and the potentially resulting medical issues, including diabetes, hypertension, cardiac, vascular, joint, or pulmonary health issues?"

Communicating clearly with obese patients early is essential to avoid obesity-related claims, said Liz Brott, regional vice president, risk resource for ProAssurance, a national medical liability insurer.

"It’s extremely important as far as communicating with them about what to expect from procedures or treatment," she said in an interview. "You don’t want to leave this to your staff to communicate. [It should be] the physician sitting down, one-on-one, whether it’s the primary care physician or the surgeon. There should be appropriate communication by the physician."

Ms. Brott said ProAssurance has handled obesity-related claims continually, but their numbers do not show a dramatic rise. In her experience, obesity claims against surgeons related to bariatric procedures are most common, she said.

Along with informed consent, physicians also may want to consider an informed refusal approach for noncompliant patients, Mr. Nagle said. This refers to informing patients about how obesity impacts their overall health and/or a specific health issue and having patients sign a document stating that they were advised but chose not to follow recommendations.

"This may reduce any claims that you did not address and warn of obesity’s impact," he said.

Physicians should also document all activity related to weight interventions and conversations with patients about weight education and guidance, he added

The analysis is a reminder that obesity is a serious disease that has its own direct complications, as well as acting as a catalyst for related conditions, said Dr. Skolnik, who is also a professor of family medicine at Temple University in Philadelphia.

"The overriding theme here is obesity is an area to which patients are paying increasing attention and to which lawyers also must be paying increasing attention," he said. "It’s an area that should be addressed directly and with sensitivity to the often emotional issues that go along with addressing weight issues."

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The aim of accountable care organizations is to improve health care quality, enhance care coordination, and reduce unnecessary costs. But the new health care delivery models are raising questions about possible hidden legal dangers for participating physicians.

"We’re talking about unchartered territory," said Christopher E. DiGiacinto, a medical liability defense attorney and partner in a New York law firm that focuses on the defense of professional liability claims including those brought against health care professionals and others. "There’s been a lot of uncertainty about how [ACOs] will affect the landscape of litigation. It could go any number of ways."

Mr. DiGiacinto cowrote an article in the 2013 summer issue of Risk Management Quarterly, the journal of the Association for Healthcare Risk Management of New York, detailing malpractice risks doctors may face within ACOs (RMQ Summer 2013). The liability dangers stem primarily from federal guidelines that outline how ACOs should operate and how doctors can enhance their practices.

For example, the Affordance Care Act requires that ACOs share medical information across multiple health care environments to improve knowledge among providers and to eliminate duplication of treatment across the care continuum. But such enhanced record maintenance could expose physicians to increased liability, Mr. DiGiacinto said. A plaintiff’s attorney could claim a doctor’s failure to access a patient’s prior medical records led to a subsequent poor medical outcome.

"There’s going to be a lot more data in this model, which is great for patients and allowing physicians to track patients," he said. "The downside for physicians is, where in the past, they might only be responsible for their own record and knowledge of the patient from their own perspective, now, they’re being responsible for knowing the [patient’s] history from other doctors. There’s going to be a wealth of information that could be used against them."

ACOs also create the potential for a heightened duty of informed consent for physicians, said Julian D. "Bo" Bobbitt Jr., senior partner and head of a health law group at a law firm in Raleigh, N.C. Federal guidelines call for ACOs to promote patient engagement during individualized treatment by involving patients and their families in making medical decisions.

"Under Medicare ACO regulations, there has to be a patient care plan and there has to be significant commitment to patient and family engagement and joint decision making," Mr. Bobbitt said. "What happens if you did a care plan, but you didn’t follow it? You were supposed to engage the family, but you didn’t?"

In such an instance, it’s possible a family member could sue, claiming he or she was not involved enough in the medical decision–making process, said Mr. Bobbitt.

Physicians who help create ACOs or hold administrative positions within the organizations may also be more at risk for being sued, say liability experts, whether or not they were directly involved in patient care.

In the past, entities such as HMOs were rarely sued for the actions of participants because such corporate structures are not generally responsible for the rendering of care, Mr. DiGiacinto said. However, federal guidelines recommend that medical professionals be involved in the corporate structure of ACOs, and that the organizations be accountable for the care they provide. This framework could fuel vicarious liability or corporate negligence claims in which the ACO itself is said to be liable for care provided to patients, according to the Accountable Care Legal Guide and RMQ article. In addition, physician leaders could potentially be sued for alleged negligent credentialing of other health professionals in the ACO, said legal experts.

But some, such as Christi J. Braun, believe suggested ACO litigation dangers are being overblown. Clinically integrated networks are designed to improve quality across all care providers, said Ms. Braun, a Washington-based health care antitrust attorney and cochair of the American Health Lawyers Association’s Accountable Care Organization Task Force.

"Even if you may not be following the protocols all the time, just the fact that you’re looking at best practices and trying to apply best practices makes it more likely that you’re going to provide better care on a more consistent basis," she said. "That actually reduces liability."

At the same time, physicians should not be so focused on following federal guidelines that they allow metrics and benchmarks to override quality medical judgment, said Brandy A. Boone, an Alabama-based senior risk management consultant for a national medical liability insurer.

"I think the biggest risk associated with ACOs or any other arrangement where physicians are incentivized to keep costs down by the prospect of making more money is the allegation that necessary tests or treatments were not offered or recommended because of the effect on reimbursement," Ms. Boone said. "We always caution our insured physicians that treatment recommendations should never be based on the patient’s ability to pay. While the majority of physicians would never actually let reimbursement sway their clinical decisions, avoiding that perception is also very important."

Only time will tell how ACO guidelines will affect malpractice cases. Often, it takes years for case law and legal precedents to develop around new issues and more clearly define boundaries, Mr. Bobbitt said.

In the meantime, litigation experts recommend that physicians joining ACOs protect themselves from lawsuits by thoroughly documenting patient interactions and clinical decision making. Mr. Bobbitt suggests also that physicians participating in ACOs become involved in developing best practice guidelines and ensuring those guidelines are clinically valid. Having a strong voice will empower physicians and assure ACO guidelines act as a lawsuit shield, rather than a sword.

"It can be a legal minefield, but it is navigable," Mr. Bobbitt said. "As an attorney and health care adviser, I try to convey that yes, there are legal issues – novel legal issues – but at the same time, this is such a positive improvement to health care, it is navigable if done right."

The aim of accountable care organizations is to improve health care quality, enhance care coordination, and reduce unnecessary costs. But the new health care delivery models are raising questions about possible hidden legal dangers for participating physicians.

"We’re talking about unchartered territory," said Christopher E. DiGiacinto, a medical liability defense attorney and partner in a New York law firm that focuses on the defense of professional liability claims including those brought against health care professionals and others. "There’s been a lot of uncertainty about how [ACOs] will affect the landscape of litigation. It could go any number of ways."

Mr. DiGiacinto cowrote an article in the 2013 summer issue of Risk Management Quarterly, the journal of the Association for Healthcare Risk Management of New York, detailing malpractice risks doctors may face within ACOs (RMQ Summer 2013). The liability dangers stem primarily from federal guidelines that outline how ACOs should operate and how doctors can enhance their practices.

For example, the Affordance Care Act requires that ACOs share medical information across multiple health care environments to improve knowledge among providers and to eliminate duplication of treatment across the care continuum. But such enhanced record maintenance could expose physicians to increased liability, Mr. DiGiacinto said. A plaintiff’s attorney could claim a doctor’s failure to access a patient’s prior medical records led to a subsequent poor medical outcome.

"There’s going to be a lot more data in this model, which is great for patients and allowing physicians to track patients," he said. "The downside for physicians is, where in the past, they might only be responsible for their own record and knowledge of the patient from their own perspective, now, they’re being responsible for knowing the [patient’s] history from other doctors. There’s going to be a wealth of information that could be used against them."

ACOs also create the potential for a heightened duty of informed consent for physicians, said Julian D. "Bo" Bobbitt Jr., senior partner and head of a health law group at a law firm in Raleigh, N.C. Federal guidelines call for ACOs to promote patient engagement during individualized treatment by involving patients and their families in making medical decisions.

"Under Medicare ACO regulations, there has to be a patient care plan and there has to be significant commitment to patient and family engagement and joint decision making," Mr. Bobbitt said. "What happens if you did a care plan, but you didn’t follow it? You were supposed to engage the family, but you didn’t?"

In such an instance, it’s possible a family member could sue, claiming he or she was not involved enough in the medical decision–making process, said Mr. Bobbitt.

Physicians who help create ACOs or hold administrative positions within the organizations may also be more at risk for being sued, say liability experts, whether or not they were directly involved in patient care.

In the past, entities such as HMOs were rarely sued for the actions of participants because such corporate structures are not generally responsible for the rendering of care, Mr. DiGiacinto said. However, federal guidelines recommend that medical professionals be involved in the corporate structure of ACOs, and that the organizations be accountable for the care they provide. This framework could fuel vicarious liability or corporate negligence claims in which the ACO itself is said to be liable for care provided to patients, according to the Accountable Care Legal Guide and RMQ article. In addition, physician leaders could potentially be sued for alleged negligent credentialing of other health professionals in the ACO, said legal experts.

But some, such as Christi J. Braun, believe suggested ACO litigation dangers are being overblown. Clinically integrated networks are designed to improve quality across all care providers, said Ms. Braun, a Washington-based health care antitrust attorney and cochair of the American Health Lawyers Association’s Accountable Care Organization Task Force.

"Even if you may not be following the protocols all the time, just the fact that you’re looking at best practices and trying to apply best practices makes it more likely that you’re going to provide better care on a more consistent basis," she said. "That actually reduces liability."

At the same time, physicians should not be so focused on following federal guidelines that they allow metrics and benchmarks to override quality medical judgment, said Brandy A. Boone, an Alabama-based senior risk management consultant for a national medical liability insurer.

"I think the biggest risk associated with ACOs or any other arrangement where physicians are incentivized to keep costs down by the prospect of making more money is the allegation that necessary tests or treatments were not offered or recommended because of the effect on reimbursement," Ms. Boone said. "We always caution our insured physicians that treatment recommendations should never be based on the patient’s ability to pay. While the majority of physicians would never actually let reimbursement sway their clinical decisions, avoiding that perception is also very important."

Only time will tell how ACO guidelines will affect malpractice cases. Often, it takes years for case law and legal precedents to develop around new issues and more clearly define boundaries, Mr. Bobbitt said.

In the meantime, litigation experts recommend that physicians joining ACOs protect themselves from lawsuits by thoroughly documenting patient interactions and clinical decision making. Mr. Bobbitt suggests also that physicians participating in ACOs become involved in developing best practice guidelines and ensuring those guidelines are clinically valid. Having a strong voice will empower physicians and assure ACO guidelines act as a lawsuit shield, rather than a sword.

"It can be a legal minefield, but it is navigable," Mr. Bobbitt said. "As an attorney and health care adviser, I try to convey that yes, there are legal issues – novel legal issues – but at the same time, this is such a positive improvement to health care, it is navigable if done right."

The aim of accountable care organizations is to improve health care quality, enhance care coordination, and reduce unnecessary costs. But the new health care delivery models are raising questions about possible hidden legal dangers for participating physicians.

"We’re talking about unchartered territory," said Christopher E. DiGiacinto, a medical liability defense attorney and partner in a New York law firm that focuses on the defense of professional liability claims including those brought against health care professionals and others. "There’s been a lot of uncertainty about how [ACOs] will affect the landscape of litigation. It could go any number of ways."

Mr. DiGiacinto cowrote an article in the 2013 summer issue of Risk Management Quarterly, the journal of the Association for Healthcare Risk Management of New York, detailing malpractice risks doctors may face within ACOs (RMQ Summer 2013). The liability dangers stem primarily from federal guidelines that outline how ACOs should operate and how doctors can enhance their practices.

For example, the Affordance Care Act requires that ACOs share medical information across multiple health care environments to improve knowledge among providers and to eliminate duplication of treatment across the care continuum. But such enhanced record maintenance could expose physicians to increased liability, Mr. DiGiacinto said. A plaintiff’s attorney could claim a doctor’s failure to access a patient’s prior medical records led to a subsequent poor medical outcome.

"There’s going to be a lot more data in this model, which is great for patients and allowing physicians to track patients," he said. "The downside for physicians is, where in the past, they might only be responsible for their own record and knowledge of the patient from their own perspective, now, they’re being responsible for knowing the [patient’s] history from other doctors. There’s going to be a wealth of information that could be used against them."

ACOs also create the potential for a heightened duty of informed consent for physicians, said Julian D. "Bo" Bobbitt Jr., senior partner and head of a health law group at a law firm in Raleigh, N.C. Federal guidelines call for ACOs to promote patient engagement during individualized treatment by involving patients and their families in making medical decisions.

"Under Medicare ACO regulations, there has to be a patient care plan and there has to be significant commitment to patient and family engagement and joint decision making," Mr. Bobbitt said. "What happens if you did a care plan, but you didn’t follow it? You were supposed to engage the family, but you didn’t?"

In such an instance, it’s possible a family member could sue, claiming he or she was not involved enough in the medical decision–making process, said Mr. Bobbitt.

Physicians who help create ACOs or hold administrative positions within the organizations may also be more at risk for being sued, say liability experts, whether or not they were directly involved in patient care.

In the past, entities such as HMOs were rarely sued for the actions of participants because such corporate structures are not generally responsible for the rendering of care, Mr. DiGiacinto said. However, federal guidelines recommend that medical professionals be involved in the corporate structure of ACOs, and that the organizations be accountable for the care they provide. This framework could fuel vicarious liability or corporate negligence claims in which the ACO itself is said to be liable for care provided to patients, according to the Accountable Care Legal Guide and RMQ article. In addition, physician leaders could potentially be sued for alleged negligent credentialing of other health professionals in the ACO, said legal experts.

But some, such as Christi J. Braun, believe suggested ACO litigation dangers are being overblown. Clinically integrated networks are designed to improve quality across all care providers, said Ms. Braun, a Washington-based health care antitrust attorney and cochair of the American Health Lawyers Association’s Accountable Care Organization Task Force.

"Even if you may not be following the protocols all the time, just the fact that you’re looking at best practices and trying to apply best practices makes it more likely that you’re going to provide better care on a more consistent basis," she said. "That actually reduces liability."

At the same time, physicians should not be so focused on following federal guidelines that they allow metrics and benchmarks to override quality medical judgment, said Brandy A. Boone, an Alabama-based senior risk management consultant for a national medical liability insurer.

"I think the biggest risk associated with ACOs or any other arrangement where physicians are incentivized to keep costs down by the prospect of making more money is the allegation that necessary tests or treatments were not offered or recommended because of the effect on reimbursement," Ms. Boone said. "We always caution our insured physicians that treatment recommendations should never be based on the patient’s ability to pay. While the majority of physicians would never actually let reimbursement sway their clinical decisions, avoiding that perception is also very important."

Only time will tell how ACO guidelines will affect malpractice cases. Often, it takes years for case law and legal precedents to develop around new issues and more clearly define boundaries, Mr. Bobbitt said.

In the meantime, litigation experts recommend that physicians joining ACOs protect themselves from lawsuits by thoroughly documenting patient interactions and clinical decision making. Mr. Bobbitt suggests also that physicians participating in ACOs become involved in developing best practice guidelines and ensuring those guidelines are clinically valid. Having a strong voice will empower physicians and assure ACO guidelines act as a lawsuit shield, rather than a sword.

"It can be a legal minefield, but it is navigable," Mr. Bobbitt said. "As an attorney and health care adviser, I try to convey that yes, there are legal issues – novel legal issues – but at the same time, this is such a positive improvement to health care, it is navigable if done right."

The aim of accountable care organizations is to improve health care quality, enhance care coordination, and reduce unnecessary costs. But the new health care delivery models are raising questions about possible hidden legal dangers for participating physicians.

"We’re talking about unchartered territory," said Christopher E. DiGiacinto, a medical liability defense attorney and partner in a New York law firm that focuses on the defense of professional liability claims including those brought against health care professionals and others. "There’s been a lot of uncertainty about how [ACOs] will affect the landscape of litigation. It could go any number of ways."

Mr. DiGiacinto cowrote an article in the 2013 summer issue of Risk Management Quarterly, the journal of the Association for Healthcare Risk Management of New York, detailing malpractice risks doctors may face within ACOs (RMQ Summer 2013). The liability dangers stem primarily from federal guidelines that outline how ACOs should operate and how doctors can enhance their practices.

For example, the Affordance Care Act requires that ACOs share medical information across multiple health care environments to improve knowledge among providers and to eliminate duplication of treatment across the care continuum. But such enhanced record maintenance could expose physicians to increased liability, Mr. DiGiacinto said. A plaintiff’s attorney could claim a doctor’s failure to access a patient’s prior medical records led to a subsequent poor medical outcome.

"There’s going to be a lot more data in this model, which is great for patients and allowing physicians to track patients," he said. "The downside for physicians is, where in the past, they might only be responsible for their own record and knowledge of the patient from their own perspective, now, they’re being responsible for knowing the [patient’s] history from other doctors. There’s going to be a wealth of information that could be used against them."

ACOs also create the potential for a heightened duty of informed consent for physicians, said Julian D. "Bo" Bobbitt Jr., senior partner and head of a health law group at a law firm in Raleigh, N.C. Federal guidelines call for ACOs to promote patient engagement during individualized treatment by involving patients and their families in making medical decisions.

"Under Medicare ACO regulations, there has to be a patient care plan and there has to be significant commitment to patient and family engagement and joint decision making," Mr. Bobbitt said. "What happens if you did a care plan, but you didn’t follow it? You were supposed to engage the family, but you didn’t?"

In such an instance, it’s possible a family member could sue, claiming he or she was not involved enough in the medical decision–making process, said Mr. Bobbitt.

Physicians who help create ACOs or hold administrative positions within the organizations may also be more at risk for being sued, say liability experts, whether or not they were directly involved in patient care.

In the past, entities such as HMOs were rarely sued for the actions of participants because such corporate structures are not generally responsible for the rendering of care, Mr. DiGiacinto said. However, federal guidelines recommend that medical professionals be involved in the corporate structure of ACOs, and that the organizations be accountable for the care they provide. This framework could fuel vicarious liability or corporate negligence claims in which the ACO itself is said to be liable for care provided to patients, according to the Accountable Care Legal Guide and RMQ article. In addition, physician leaders could potentially be sued for alleged negligent credentialing of other health professionals in the ACO, said legal experts.

But some, such as Christi J. Braun, believe suggested ACO litigation dangers are being overblown. Clinically integrated networks are designed to improve quality across all care providers, said Ms. Braun, a Washington-based health care antitrust attorney and cochair of the American Health Lawyers Association’s Accountable Care Organization Task Force.

"Even if you may not be following the protocols all the time, just the fact that you’re looking at best practices and trying to apply best practices makes it more likely that you’re going to provide better care on a more consistent basis," she said. "That actually reduces liability."

At the same time, physicians should not be so focused on following federal guidelines that they allow metrics and benchmarks to override quality medical judgment, said Brandy A. Boone, an Alabama-based senior risk management consultant for a national medical liability insurer.

"I think the biggest risk associated with ACOs or any other arrangement where physicians are incentivized to keep costs down by the prospect of making more money is the allegation that necessary tests or treatments were not offered or recommended because of the effect on reimbursement," Ms. Boone said. "We always caution our insured physicians that treatment recommendations should never be based on the patient’s ability to pay. While the majority of physicians would never actually let reimbursement sway their clinical decisions, avoiding that perception is also very important."

Only time will tell how ACO guidelines will affect malpractice cases. Often, it takes years for case law and legal precedents to develop around new issues and more clearly define boundaries, Mr. Bobbitt said.

In the meantime, litigation experts recommend that physicians joining ACOs protect themselves from lawsuits by thoroughly documenting patient interactions and clinical decision making. Mr. Bobbitt suggests also that physicians participating in ACOs become involved in developing best practice guidelines and ensuring those guidelines are clinically valid. Having a strong voice will empower physicians and assure ACO guidelines act as a lawsuit shield, rather than a sword.

"It can be a legal minefield, but it is navigable," Mr. Bobbitt said. "As an attorney and health care adviser, I try to convey that yes, there are legal issues – novel legal issues – but at the same time, this is such a positive improvement to health care, it is navigable if done right."

The aim of accountable care organizations is to improve health care quality, enhance care coordination, and reduce unnecessary costs. But the new health care delivery models are raising questions about possible hidden legal dangers for participating physicians.

"We’re talking about unchartered territory," said Christopher E. DiGiacinto, a medical liability defense attorney and partner in a New York law firm that focuses on the defense of professional liability claims including those brought against health care professionals and others. "There’s been a lot of uncertainty about how [ACOs] will affect the landscape of litigation. It could go any number of ways."

Mr. DiGiacinto cowrote an article in the 2013 summer issue of Risk Management Quarterly, the journal of the Association for Healthcare Risk Management of New York, detailing malpractice risks doctors may face within ACOs (RMQ Summer 2013). The liability dangers stem primarily from federal guidelines that outline how ACOs should operate and how doctors can enhance their practices.

For example, the Affordance Care Act requires that ACOs share medical information across multiple health care environments to improve knowledge among providers and to eliminate duplication of treatment across the care continuum. But such enhanced record maintenance could expose physicians to increased liability, Mr. DiGiacinto said. A plaintiff’s attorney could claim a doctor’s failure to access a patient’s prior medical records led to a subsequent poor medical outcome.

"There’s going to be a lot more data in this model, which is great for patients and allowing physicians to track patients," he said. "The downside for physicians is, where in the past, they might only be responsible for their own record and knowledge of the patient from their own perspective, now, they’re being responsible for knowing the [patient’s] history from other doctors. There’s going to be a wealth of information that could be used against them."

ACOs also create the potential for a heightened duty of informed consent for physicians, said Julian D. "Bo" Bobbitt Jr., senior partner and head of a health law group at a law firm in Raleigh, N.C. Federal guidelines call for ACOs to promote patient engagement during individualized treatment by involving patients and their families in making medical decisions.

"Under Medicare ACO regulations, there has to be a patient care plan and there has to be significant commitment to patient and family engagement and joint decision making," Mr. Bobbitt said. "What happens if you did a care plan, but you didn’t follow it? You were supposed to engage the family, but you didn’t?"

In such an instance, it’s possible a family member could sue, claiming he or she was not involved enough in the medical decision–making process, said Mr. Bobbitt.

Physicians who help create ACOs or hold administrative positions within the organizations may also be more at risk for being sued, say liability experts, whether or not they were directly involved in patient care.

In the past, entities such as HMOs were rarely sued for the actions of participants because such corporate structures are not generally responsible for the rendering of care, Mr. DiGiacinto said. However, federal guidelines recommend that medical professionals be involved in the corporate structure of ACOs, and that the organizations be accountable for the care they provide. This framework could fuel vicarious liability or corporate negligence claims in which the ACO itself is said to be liable for care provided to patients, according to the Accountable Care Legal Guide and RMQ article. In addition, physician leaders could potentially be sued for alleged negligent credentialing of other health professionals in the ACO, said legal experts.

But some, such as Christi J. Braun, believe suggested ACO litigation dangers are being overblown. Clinically integrated networks are designed to improve quality across all care providers, said Ms. Braun, a Washington-based health care antitrust attorney and cochair of the American Health Lawyers Association’s Accountable Care Organization Task Force.

"Even if you may not be following the protocols all the time, just the fact that you’re looking at best practices and trying to apply best practices makes it more likely that you’re going to provide better care on a more consistent basis," she said. "That actually reduces liability."

At the same time, physicians should not be so focused on following federal guidelines that they allow metrics and benchmarks to override quality medical judgment, said Brandy A. Boone, an Alabama-based senior risk management consultant for a national medical liability insurer.

"I think the biggest risk associated with ACOs or any other arrangement where physicians are incentivized to keep costs down by the prospect of making more money is the allegation that necessary tests or treatments were not offered or recommended because of the effect on reimbursement," Ms. Boone said. "We always caution our insured physicians that treatment recommendations should never be based on the patient’s ability to pay. While the majority of physicians would never actually let reimbursement sway their clinical decisions, avoiding that perception is also very important."

Only time will tell how ACO guidelines will affect malpractice cases. Often, it takes years for case law and legal precedents to develop around new issues and more clearly define boundaries, Mr. Bobbitt said.

In the meantime, litigation experts recommend that physicians joining ACOs protect themselves from lawsuits by thoroughly documenting patient interactions and clinical decision making. Mr. Bobbitt suggests also that physicians participating in ACOs become involved in developing best practice guidelines and ensuring those guidelines are clinically valid. Having a strong voice will empower physicians and assure ACO guidelines act as a lawsuit shield, rather than a sword.

"It can be a legal minefield, but it is navigable," Mr. Bobbitt said. "As an attorney and health care adviser, I try to convey that yes, there are legal issues – novel legal issues – but at the same time, this is such a positive improvement to health care, it is navigable if done right."

The aim of accountable care organizations is to improve health care quality, enhance care coordination, and reduce unnecessary costs. But the new health care delivery models are raising questions about possible hidden legal dangers for participating physicians.

"We’re talking about unchartered territory," said Christopher E. DiGiacinto, a medical liability defense attorney and partner in a New York law firm that focuses on the defense of professional liability claims including those brought against health care professionals and others. "There’s been a lot of uncertainty about how [ACOs] will affect the landscape of litigation. It could go any number of ways."

Mr. DiGiacinto cowrote an article in the 2013 summer issue of Risk Management Quarterly, the journal of the Association for Healthcare Risk Management of New York, detailing malpractice risks doctors may face within ACOs (RMQ Summer 2013). The liability dangers stem primarily from federal guidelines that outline how ACOs should operate and how doctors can enhance their practices.

For example, the Affordance Care Act requires that ACOs share medical information across multiple health care environments to improve knowledge among providers and to eliminate duplication of treatment across the care continuum. But such enhanced record maintenance could expose physicians to increased liability, Mr. DiGiacinto said. A plaintiff’s attorney could claim a doctor’s failure to access a patient’s prior medical records led to a subsequent poor medical outcome.

"There’s going to be a lot more data in this model, which is great for patients and allowing physicians to track patients," he said. "The downside for physicians is, where in the past, they might only be responsible for their own record and knowledge of the patient from their own perspective, now, they’re being responsible for knowing the [patient’s] history from other doctors. There’s going to be a wealth of information that could be used against them."

ACOs also create the potential for a heightened duty of informed consent for physicians, said Julian D. "Bo" Bobbitt Jr., senior partner and head of a health law group at a law firm in Raleigh, N.C. Federal guidelines call for ACOs to promote patient engagement during individualized treatment by involving patients and their families in making medical decisions.

"Under Medicare ACO regulations, there has to be a patient care plan and there has to be significant commitment to patient and family engagement and joint decision making," Mr. Bobbitt said. "What happens if you did a care plan, but you didn’t follow it? You were supposed to engage the family, but you didn’t?"

In such an instance, it’s possible a family member could sue, claiming he or she was not involved enough in the medical decision–making process, said Mr. Bobbitt.

Physicians who help create ACOs or hold administrative positions within the organizations may also be more at risk for being sued, say liability experts, whether or not they were directly involved in patient care.

In the past, entities such as HMOs were rarely sued for the actions of participants because such corporate structures are not generally responsible for the rendering of care, Mr. DiGiacinto said. However, federal guidelines recommend that medical professionals be involved in the corporate structure of ACOs, and that the organizations be accountable for the care they provide. This framework could fuel vicarious liability or corporate negligence claims in which the ACO itself is said to be liable for care provided to patients, according to the Accountable Care Legal Guide and RMQ article. In addition, physician leaders could potentially be sued for alleged negligent credentialing of other health professionals in the ACO, said legal experts.

But some, such as Christi J. Braun, believe suggested ACO litigation dangers are being overblown. Clinically integrated networks are designed to improve quality across all care providers, said Ms. Braun, a Washington-based health care antitrust attorney and cochair of the American Health Lawyers Association’s Accountable Care Organization Task Force.

"Even if you may not be following the protocols all the time, just the fact that you’re looking at best practices and trying to apply best practices makes it more likely that you’re going to provide better care on a more consistent basis," she said. "That actually reduces liability."

At the same time, physicians should not be so focused on following federal guidelines that they allow metrics and benchmarks to override quality medical judgment, said Brandy A. Boone, an Alabama-based senior risk management consultant for a national medical liability insurer.

"I think the biggest risk associated with ACOs or any other arrangement where physicians are incentivized to keep costs down by the prospect of making more money is the allegation that necessary tests or treatments were not offered or recommended because of the effect on reimbursement," Ms. Boone said. "We always caution our insured physicians that treatment recommendations should never be based on the patient’s ability to pay. While the majority of physicians would never actually let reimbursement sway their clinical decisions, avoiding that perception is also very important."

Only time will tell how ACO guidelines will affect malpractice cases. Often, it takes years for case law and legal precedents to develop around new issues and more clearly define boundaries, Mr. Bobbitt said.

In the meantime, litigation experts recommend that physicians joining ACOs protect themselves from lawsuits by thoroughly documenting patient interactions and clinical decision making. Mr. Bobbitt suggests also that physicians participating in ACOs become involved in developing best practice guidelines and ensuring those guidelines are clinically valid. Having a strong voice will empower physicians and assure ACO guidelines act as a lawsuit shield, rather than a sword.

"It can be a legal minefield, but it is navigable," Mr. Bobbitt said. "As an attorney and health care adviser, I try to convey that yes, there are legal issues – novel legal issues – but at the same time, this is such a positive improvement to health care, it is navigable if done right."

Receiving a subpoena for information or testimony can make any physician feel nervous and apprehensive. The official-looking notices often arrive as certified mail, have a stamped deadline, and include an attorney’s signature. But immediately fulfilling a subpoena without first assessing the request could land doctors in trouble.

"Understandably, many physicians don’t recognize that no judge has reviewed the propriety of a subpoena," said Michael J. Schoppmann, a New York–based health law attorney. "Most judges are not even aware of the subpoena. There’s an assumption by the physician that it has been vetted by the court and, in many cases, that is not true. With good intentions, we find physicians getting into trouble out of a desire to be compliant."

Before answering a subpoena, physicians should evaluate where the request originated, the status of the case, and who is involved, legal experts say. Frequently, a request for patient information or records is objected to by the patient’s attorney, said Michael J. Sacopulos, a medical liability defense attorney. Physicians should ensure record requests are authorized by the patient or a court order.

"Let’s say you’re not going to court, but they want information," Mr. Sacopulos said. "You have HIPAA issues at play. You still have an independent duty to safeguard patient information."

Mr. Schoppmann recommends physicians contact the judge affiliated with the case and request guidance about how to proceed. The judge may deny the request because the records are inappropriate or allow the subpoena to proceed.

"It’s great protection because if we get an order from the court, that (shields the doctor) from the litigants later saying, ‘We did not want you to release those records,’ " Mr. Schoppmann said.

In other instances, physicians may be subpoenaed to discuss a patient’s condition or treatment in a third-party case. For example, a patient who is suing an insurance carrier or third-party over a vehicle accident. Doctors have a responsibility to offer honest and unbiased testimony about their patient’s medical condition, said Steven Fitzer, a medical malpractice defense attorney in Tacoma, Wash. However, physicians shouldn’t provide opinions on medical matters unrelated to their expertise.

"A family practice doctor should offer thoughts and opinions and facts that are within his or her specialty," Mr. Fitzer said. "If [the doctor] regularly treats people who have whiplash and cervical strain, you can talk about that. But the family practice doctor shouldn’t be talking about neck surgery unless you do neck surgeries." Physicians should also consider and address how their involvement with a case may affect their relationship with patients. Often, patients view their doctor as their supporter and expect their alliance during a third-party lawsuit. "Patients sometimes misunderstand that the role of the doctor in a deposition is to call it the way he or she sees it, not to be an advocate for the patient," he said.

Be wary of subpoenas for information or records that stem from a malpractice case in which the doctor is a named defendant, Mr. Sacopulos noted. In such instances, a plaintiff’s attorney may request details about a patient visit or ask about a doctor’s role in treating the patient. But the attorney could really be fishing for more physicians to sue.

"They may have sued one or two physicians, but the statute of limitations has yet to run out," Mr. Sacopulos said. "They’ll sue one or two, then depose others to see if they can’t get some finger pointing and increase the litigation."

In addition, plaintiffs’ attorneys may hope that the subpoenaed physician makes statements to further enhance their case against another doctor, without hiring them as an expert witness.

"My advice would be if you are requested to offer testimony in a case that you are not a party to, you immediately contact your liability carrier," Mr. Sacopulos said. "Your medical malpractice carrier will most often provide an attorney for a deposition, even though you’re not a party."

Physicians should not let attorneys intimidate them with subpoenas or excessive demands for information. Some lawyers request thousands of pages of documents in a short timeframe and pressure the physician to comply, Mr. Schoppmann said. Other attorneys try to convince physicians to speak with them over the phone about the request and to provide patient information verbally.

Ensure that the scope, the timing, and the overall content of the request are appropriate before responding, Mr. Schoppmann stresses. "The subpoena has to be reasonable," he said. "Step back and do not respond unduly aggressively. You could be subject to criticism later if you respond to an inappropriate subpoena. We want right, rather than quick."

Receiving a subpoena for information or testimony can make any physician feel nervous and apprehensive. The official-looking notices often arrive as certified mail, have a stamped deadline, and include an attorney’s signature. But immediately fulfilling a subpoena without first assessing the request could land doctors in trouble.

"Understandably, many physicians don’t recognize that no judge has reviewed the propriety of a subpoena," said Michael J. Schoppmann, a New York–based health law attorney. "Most judges are not even aware of the subpoena. There’s an assumption by the physician that it has been vetted by the court and, in many cases, that is not true. With good intentions, we find physicians getting into trouble out of a desire to be compliant."

Before answering a subpoena, physicians should evaluate where the request originated, the status of the case, and who is involved, legal experts say. Frequently, a request for patient information or records is objected to by the patient’s attorney, said Michael J. Sacopulos, a medical liability defense attorney. Physicians should ensure record requests are authorized by the patient or a court order.

"Let’s say you’re not going to court, but they want information," Mr. Sacopulos said. "You have HIPAA issues at play. You still have an independent duty to safeguard patient information."

Mr. Schoppmann recommends physicians contact the judge affiliated with the case and request guidance about how to proceed. The judge may deny the request because the records are inappropriate or allow the subpoena to proceed.

"It’s great protection because if we get an order from the court, that (shields the doctor) from the litigants later saying, ‘We did not want you to release those records,’ " Mr. Schoppmann said.

In other instances, physicians may be subpoenaed to discuss a patient’s condition or treatment in a third-party case. For example, a patient who is suing an insurance carrier or third-party over a vehicle accident. Doctors have a responsibility to offer honest and unbiased testimony about their patient’s medical condition, said Steven Fitzer, a medical malpractice defense attorney in Tacoma, Wash. However, physicians shouldn’t provide opinions on medical matters unrelated to their expertise.

"A family practice doctor should offer thoughts and opinions and facts that are within his or her specialty," Mr. Fitzer said. "If [the doctor] regularly treats people who have whiplash and cervical strain, you can talk about that. But the family practice doctor shouldn’t be talking about neck surgery unless you do neck surgeries." Physicians should also consider and address how their involvement with a case may affect their relationship with patients. Often, patients view their doctor as their supporter and expect their alliance during a third-party lawsuit. "Patients sometimes misunderstand that the role of the doctor in a deposition is to call it the way he or she sees it, not to be an advocate for the patient," he said.

Be wary of subpoenas for information or records that stem from a malpractice case in which the doctor is a named defendant, Mr. Sacopulos noted. In such instances, a plaintiff’s attorney may request details about a patient visit or ask about a doctor’s role in treating the patient. But the attorney could really be fishing for more physicians to sue.

"They may have sued one or two physicians, but the statute of limitations has yet to run out," Mr. Sacopulos said. "They’ll sue one or two, then depose others to see if they can’t get some finger pointing and increase the litigation."

In addition, plaintiffs’ attorneys may hope that the subpoenaed physician makes statements to further enhance their case against another doctor, without hiring them as an expert witness.

"My advice would be if you are requested to offer testimony in a case that you are not a party to, you immediately contact your liability carrier," Mr. Sacopulos said. "Your medical malpractice carrier will most often provide an attorney for a deposition, even though you’re not a party."

Physicians should not let attorneys intimidate them with subpoenas or excessive demands for information. Some lawyers request thousands of pages of documents in a short timeframe and pressure the physician to comply, Mr. Schoppmann said. Other attorneys try to convince physicians to speak with them over the phone about the request and to provide patient information verbally.

Ensure that the scope, the timing, and the overall content of the request are appropriate before responding, Mr. Schoppmann stresses. "The subpoena has to be reasonable," he said. "Step back and do not respond unduly aggressively. You could be subject to criticism later if you respond to an inappropriate subpoena. We want right, rather than quick."

Receiving a subpoena for information or testimony can make any physician feel nervous and apprehensive. The official-looking notices often arrive as certified mail, have a stamped deadline, and include an attorney’s signature. But immediately fulfilling a subpoena without first assessing the request could land doctors in trouble.

"Understandably, many physicians don’t recognize that no judge has reviewed the propriety of a subpoena," said Michael J. Schoppmann, a New York–based health law attorney. "Most judges are not even aware of the subpoena. There’s an assumption by the physician that it has been vetted by the court and, in many cases, that is not true. With good intentions, we find physicians getting into trouble out of a desire to be compliant."

Before answering a subpoena, physicians should evaluate where the request originated, the status of the case, and who is involved, legal experts say. Frequently, a request for patient information or records is objected to by the patient’s attorney, said Michael J. Sacopulos, a medical liability defense attorney. Physicians should ensure record requests are authorized by the patient or a court order.

"Let’s say you’re not going to court, but they want information," Mr. Sacopulos said. "You have HIPAA issues at play. You still have an independent duty to safeguard patient information."

Mr. Schoppmann recommends physicians contact the judge affiliated with the case and request guidance about how to proceed. The judge may deny the request because the records are inappropriate or allow the subpoena to proceed.

"It’s great protection because if we get an order from the court, that (shields the doctor) from the litigants later saying, ‘We did not want you to release those records,’ " Mr. Schoppmann said.

In other instances, physicians may be subpoenaed to discuss a patient’s condition or treatment in a third-party case. For example, a patient who is suing an insurance carrier or third-party over a vehicle accident. Doctors have a responsibility to offer honest and unbiased testimony about their patient’s medical condition, said Steven Fitzer, a medical malpractice defense attorney in Tacoma, Wash. However, physicians shouldn’t provide opinions on medical matters unrelated to their expertise.

"A family practice doctor should offer thoughts and opinions and facts that are within his or her specialty," Mr. Fitzer said. "If [the doctor] regularly treats people who have whiplash and cervical strain, you can talk about that. But the family practice doctor shouldn’t be talking about neck surgery unless you do neck surgeries." Physicians should also consider and address how their involvement with a case may affect their relationship with patients. Often, patients view their doctor as their supporter and expect their alliance during a third-party lawsuit. "Patients sometimes misunderstand that the role of the doctor in a deposition is to call it the way he or she sees it, not to be an advocate for the patient," he said.

Be wary of subpoenas for information or records that stem from a malpractice case in which the doctor is a named defendant, Mr. Sacopulos noted. In such instances, a plaintiff’s attorney may request details about a patient visit or ask about a doctor’s role in treating the patient. But the attorney could really be fishing for more physicians to sue.

"They may have sued one or two physicians, but the statute of limitations has yet to run out," Mr. Sacopulos said. "They’ll sue one or two, then depose others to see if they can’t get some finger pointing and increase the litigation."

In addition, plaintiffs’ attorneys may hope that the subpoenaed physician makes statements to further enhance their case against another doctor, without hiring them as an expert witness.

"My advice would be if you are requested to offer testimony in a case that you are not a party to, you immediately contact your liability carrier," Mr. Sacopulos said. "Your medical malpractice carrier will most often provide an attorney for a deposition, even though you’re not a party."

Physicians should not let attorneys intimidate them with subpoenas or excessive demands for information. Some lawyers request thousands of pages of documents in a short timeframe and pressure the physician to comply, Mr. Schoppmann said. Other attorneys try to convince physicians to speak with them over the phone about the request and to provide patient information verbally.

Ensure that the scope, the timing, and the overall content of the request are appropriate before responding, Mr. Schoppmann stresses. "The subpoena has to be reasonable," he said. "Step back and do not respond unduly aggressively. You could be subject to criticism later if you respond to an inappropriate subpoena. We want right, rather than quick."

CHICAGO – Buck the trend of "physician as employee" and retain your private practice through better business practices, cost control, and potential collaboration with other entities, advised Dr. Thomas Grogan, past chair of the American Academy of Orthopaedic Surgeons’ Practice Management Committee.

"You can go into employment, or you can stay and survive and maybe even thrive," Dr. Grogan said at a physicians’ legal issues conference held by the American Bar Association.

One of the first steps to stabilizing a private practice is understanding costs and improving revenue, said Dr. Grogan, a practicing orthopedic surgeon in Los Angeles. This includes knowing how much revenue is generated per patient and what each procedure, treatment, and visit costs.

"Most of us have to learn how to collaborate... it’s like learning how to play together in the sandbox."

"A lot of times doctors don’t think about costs, they just pay them," he said in an interview. "That’s one of the big problems. If you know what the revenue is per patient, you can determine the profit margin and whether you can survive."

Analyzing cost structure can help determine the best approaches for improving income sources such as the possibility of subletting part of the office or seeking lower medical malpractice insurance premiums.

Ancillary income can be another focal point for physicians who desire to stay in private practice, Dr. Grogan said. Physicians should look for ways to increase and protect the revenue that stems from services such as X-rays, supplies, imaging, and other ancillaries. For instance, physicians can ensure that contracts with payers enable them to be reimbursed for maintenance of the equipment or devices they use. Physicians should beware of contracts with insurance companies that require them to use the payer’s providers or affiliated facilities for ancillary services.

Another key is the development of new revenue streams. New technology provides excellent opportunities for independent physicians to add skills and generate additional income, Dr. Grogan said. His practice, for example, utilizes stem cell treatments to treat joint problems.

"Learning how to do these new technologies can contribute positive revenue," he said. "In order to survive in business, you have to make a profit. In order to make a profit, you have to get very good at controlling cost or be able to grow revenue. That’s how you improve your financial situation."

Collaboration is another tool for retaining independence. Collaboration models could include merging two or more physician practices, becoming a medical home, joining an accountable care organization, or participating in a super group or independent network. Super groups refer to practice entities that share a single tax ID and ancillaries but can have multiple offices. Networks can be independent practices linked via a management system such as a physician-hospital organization, management services organization, or an independent practice association.

To achieve success in collaboration, physicians must overcome challenges to operating with other practices and organizations, Dr. Grogan said. A common obstacle is integrating practice cultures and learning to work with other specialties.

"Most of us have to learn how to collaborate, and it’s like learning how to play together in the sandbox," he said. "The culture of an orthopedic surgeon is not the same as that of a pediatrician or an internist. An orthopedist is used to taking care of the problem and moving on. That’s not necessarily the case with an internist or a pediatrician."

Learning how best to communicate and work within a strong team is essential to survival of unified groups, Dr. Grogan said.

"It’s hard to exist in our own little vacuum," he said. "Somehow, we have to integrate or at least collaborate."

Strong teamwork, communication aids practice integration

When a group of seven Chicago-area pediatric practices decided to join forces, they knew unification would not be simple. In the end, strong cooperation, efficient management, and skilled advisors were required to build a successful partnership, now called PediaTrust LLC.

"It’s really important to make sure the physicians are of like mind and it’s a good fit," Kathleen McTigue, executive director of PediaTrust LLC said at the conference. "They [must] have similar views of running their businesses."

For PediaTrust, agreeing on a single vendor for each necessary service allowed for a smoother process, Ms. McTigue said. For example, each practice came to the table with its own attorney and accountant firm, so the new group needed to choose one provider for each service.

"We had great advisers," she said. "I would be concerned using advisors – attorneys, accountants, consultants – who had not worked with a company structure like ours. In the end, it turned out to be successful because we were thoughtful about that."

The new corporation faced their share of challenges, such as completing all unification tasks on a tight timeline. Investments were made in September 2012, and PediaTrust operations began in January 2013. Simultaneously, the group implemented a new electronic health record system. Another challenge was the limiting of new overhead to practices.

"While centralizing certain functions, we needed to be mindful of how to manage these costs," Ms. McTigue said. "For example, we transferred qualified billing staff from the local offices to the central billing office."

CHICAGO – Buck the trend of "physician as employee" and retain your private practice through better business practices, cost control, and potential collaboration with other entities, advised Dr. Thomas Grogan, past chair of the American Academy of Orthopaedic Surgeons’ Practice Management Committee.

"You can go into employment, or you can stay and survive and maybe even thrive," Dr. Grogan said at a physicians’ legal issues conference held by the American Bar Association.

One of the first steps to stabilizing a private practice is understanding costs and improving revenue, said Dr. Grogan, a practicing orthopedic surgeon in Los Angeles. This includes knowing how much revenue is generated per patient and what each procedure, treatment, and visit costs.

"Most of us have to learn how to collaborate... it’s like learning how to play together in the sandbox."

"A lot of times doctors don’t think about costs, they just pay them," he said in an interview. "That’s one of the big problems. If you know what the revenue is per patient, you can determine the profit margin and whether you can survive."

Analyzing cost structure can help determine the best approaches for improving income sources such as the possibility of subletting part of the office or seeking lower medical malpractice insurance premiums.

Ancillary income can be another focal point for physicians who desire to stay in private practice, Dr. Grogan said. Physicians should look for ways to increase and protect the revenue that stems from services such as X-rays, supplies, imaging, and other ancillaries. For instance, physicians can ensure that contracts with payers enable them to be reimbursed for maintenance of the equipment or devices they use. Physicians should beware of contracts with insurance companies that require them to use the payer’s providers or affiliated facilities for ancillary services.

Another key is the development of new revenue streams. New technology provides excellent opportunities for independent physicians to add skills and generate additional income, Dr. Grogan said. His practice, for example, utilizes stem cell treatments to treat joint problems.

"Learning how to do these new technologies can contribute positive revenue," he said. "In order to survive in business, you have to make a profit. In order to make a profit, you have to get very good at controlling cost or be able to grow revenue. That’s how you improve your financial situation."

Collaboration is another tool for retaining independence. Collaboration models could include merging two or more physician practices, becoming a medical home, joining an accountable care organization, or participating in a super group or independent network. Super groups refer to practice entities that share a single tax ID and ancillaries but can have multiple offices. Networks can be independent practices linked via a management system such as a physician-hospital organization, management services organization, or an independent practice association.

To achieve success in collaboration, physicians must overcome challenges to operating with other practices and organizations, Dr. Grogan said. A common obstacle is integrating practice cultures and learning to work with other specialties.

"Most of us have to learn how to collaborate, and it’s like learning how to play together in the sandbox," he said. "The culture of an orthopedic surgeon is not the same as that of a pediatrician or an internist. An orthopedist is used to taking care of the problem and moving on. That’s not necessarily the case with an internist or a pediatrician."

Learning how best to communicate and work within a strong team is essential to survival of unified groups, Dr. Grogan said.

"It’s hard to exist in our own little vacuum," he said. "Somehow, we have to integrate or at least collaborate."

Strong teamwork, communication aids practice integration

When a group of seven Chicago-area pediatric practices decided to join forces, they knew unification would not be simple. In the end, strong cooperation, efficient management, and skilled advisors were required to build a successful partnership, now called PediaTrust LLC.

"It’s really important to make sure the physicians are of like mind and it’s a good fit," Kathleen McTigue, executive director of PediaTrust LLC said at the conference. "They [must] have similar views of running their businesses."

For PediaTrust, agreeing on a single vendor for each necessary service allowed for a smoother process, Ms. McTigue said. For example, each practice came to the table with its own attorney and accountant firm, so the new group needed to choose one provider for each service.

"We had great advisers," she said. "I would be concerned using advisors – attorneys, accountants, consultants – who had not worked with a company structure like ours. In the end, it turned out to be successful because we were thoughtful about that."

The new corporation faced their share of challenges, such as completing all unification tasks on a tight timeline. Investments were made in September 2012, and PediaTrust operations began in January 2013. Simultaneously, the group implemented a new electronic health record system. Another challenge was the limiting of new overhead to practices.

"While centralizing certain functions, we needed to be mindful of how to manage these costs," Ms. McTigue said. "For example, we transferred qualified billing staff from the local offices to the central billing office."

CHICAGO – Buck the trend of "physician as employee" and retain your private practice through better business practices, cost control, and potential collaboration with other entities, advised Dr. Thomas Grogan, past chair of the American Academy of Orthopaedic Surgeons’ Practice Management Committee.

"You can go into employment, or you can stay and survive and maybe even thrive," Dr. Grogan said at a physicians’ legal issues conference held by the American Bar Association.

One of the first steps to stabilizing a private practice is understanding costs and improving revenue, said Dr. Grogan, a practicing orthopedic surgeon in Los Angeles. This includes knowing how much revenue is generated per patient and what each procedure, treatment, and visit costs.

"Most of us have to learn how to collaborate... it’s like learning how to play together in the sandbox."

"A lot of times doctors don’t think about costs, they just pay them," he said in an interview. "That’s one of the big problems. If you know what the revenue is per patient, you can determine the profit margin and whether you can survive."

Analyzing cost structure can help determine the best approaches for improving income sources such as the possibility of subletting part of the office or seeking lower medical malpractice insurance premiums.

Ancillary income can be another focal point for physicians who desire to stay in private practice, Dr. Grogan said. Physicians should look for ways to increase and protect the revenue that stems from services such as X-rays, supplies, imaging, and other ancillaries. For instance, physicians can ensure that contracts with payers enable them to be reimbursed for maintenance of the equipment or devices they use. Physicians should beware of contracts with insurance companies that require them to use the payer’s providers or affiliated facilities for ancillary services.

Another key is the development of new revenue streams. New technology provides excellent opportunities for independent physicians to add skills and generate additional income, Dr. Grogan said. His practice, for example, utilizes stem cell treatments to treat joint problems.

"Learning how to do these new technologies can contribute positive revenue," he said. "In order to survive in business, you have to make a profit. In order to make a profit, you have to get very good at controlling cost or be able to grow revenue. That’s how you improve your financial situation."

Collaboration is another tool for retaining independence. Collaboration models could include merging two or more physician practices, becoming a medical home, joining an accountable care organization, or participating in a super group or independent network. Super groups refer to practice entities that share a single tax ID and ancillaries but can have multiple offices. Networks can be independent practices linked via a management system such as a physician-hospital organization, management services organization, or an independent practice association.

To achieve success in collaboration, physicians must overcome challenges to operating with other practices and organizations, Dr. Grogan said. A common obstacle is integrating practice cultures and learning to work with other specialties.

"Most of us have to learn how to collaborate, and it’s like learning how to play together in the sandbox," he said. "The culture of an orthopedic surgeon is not the same as that of a pediatrician or an internist. An orthopedist is used to taking care of the problem and moving on. That’s not necessarily the case with an internist or a pediatrician."

Learning how best to communicate and work within a strong team is essential to survival of unified groups, Dr. Grogan said.

"It’s hard to exist in our own little vacuum," he said. "Somehow, we have to integrate or at least collaborate."

Strong teamwork, communication aids practice integration

When a group of seven Chicago-area pediatric practices decided to join forces, they knew unification would not be simple. In the end, strong cooperation, efficient management, and skilled advisors were required to build a successful partnership, now called PediaTrust LLC.

"It’s really important to make sure the physicians are of like mind and it’s a good fit," Kathleen McTigue, executive director of PediaTrust LLC said at the conference. "They [must] have similar views of running their businesses."

For PediaTrust, agreeing on a single vendor for each necessary service allowed for a smoother process, Ms. McTigue said. For example, each practice came to the table with its own attorney and accountant firm, so the new group needed to choose one provider for each service.

"We had great advisers," she said. "I would be concerned using advisors – attorneys, accountants, consultants – who had not worked with a company structure like ours. In the end, it turned out to be successful because we were thoughtful about that."

The new corporation faced their share of challenges, such as completing all unification tasks on a tight timeline. Investments were made in September 2012, and PediaTrust operations began in January 2013. Simultaneously, the group implemented a new electronic health record system. Another challenge was the limiting of new overhead to practices.

"While centralizing certain functions, we needed to be mindful of how to manage these costs," Ms. McTigue said. "For example, we transferred qualified billing staff from the local offices to the central billing office."

CHICAGO – Buck the trend of "physician as employee" and retain your private practice through better business practices, cost control, and potential collaboration with other entities, advised Dr. Thomas Grogan, past chair of the American Academy of Orthopaedic Surgeons’ Practice Management Committee.

"You can go into employment, or you can stay and survive and maybe even thrive," Dr. Grogan said at a physicians’ legal issues conference held by the American Bar Association.

One of the first steps to stabilizing a private practice is understanding costs and improving revenue, said Dr. Grogan, a practicing orthopedic surgeon in Los Angeles. This includes knowing how much revenue is generated per patient and what each procedure, treatment, and visit costs.

"Most of us have to learn how to collaborate... it’s like learning how to play together in the sandbox."

"A lot of times doctors don’t think about costs, they just pay them," he said in an interview. "That’s one of the big problems. If you know what the revenue is per patient, you can determine the profit margin and whether you can survive."

Analyzing cost structure can help determine the best approaches for improving income sources such as the possibility of subletting part of the office or seeking lower medical malpractice insurance premiums.

Ancillary income can be another focal point for physicians who desire to stay in private practice, Dr. Grogan said. Physicians should look for ways to increase and protect the revenue that stems from services such as X-rays, supplies, imaging, and other ancillaries. For instance, physicians can ensure that contracts with payers enable them to be reimbursed for maintenance of the equipment or devices they use. Physicians should beware of contracts with insurance companies that require them to use the payer’s providers or affiliated facilities for ancillary services.

Another key is the development of new revenue streams. New technology provides excellent opportunities for independent physicians to add skills and generate additional income, Dr. Grogan said. His practice, for example, utilizes stem cell treatments to treat joint problems.

"Learning how to do these new technologies can contribute positive revenue," he said. "In order to survive in business, you have to make a profit. In order to make a profit, you have to get very good at controlling cost or be able to grow revenue. That’s how you improve your financial situation."

Collaboration is another tool for retaining independence. Collaboration models could include merging two or more physician practices, becoming a medical home, joining an accountable care organization, or participating in a super group or independent network. Super groups refer to practice entities that share a single tax ID and ancillaries but can have multiple offices. Networks can be independent practices linked via a management system such as a physician-hospital organization, management services organization, or an independent practice association.

To achieve success in collaboration, physicians must overcome challenges to operating with other practices and organizations, Dr. Grogan said. A common obstacle is integrating practice cultures and learning to work with other specialties.

"Most of us have to learn how to collaborate, and it’s like learning how to play together in the sandbox," he said. "The culture of an orthopedic surgeon is not the same as that of a pediatrician or an internist. An orthopedist is used to taking care of the problem and moving on. That’s not necessarily the case with an internist or a pediatrician."

Learning how best to communicate and work within a strong team is essential to survival of unified groups, Dr. Grogan said.

"It’s hard to exist in our own little vacuum," he said. "Somehow, we have to integrate or at least collaborate."

Strong teamwork, communication aids practice integration

When a group of seven Chicago-area pediatric practices decided to join forces, they knew unification would not be simple. In the end, strong cooperation, efficient management, and skilled advisors were required to build a successful partnership, now called PediaTrust LLC.

"It’s really important to make sure the physicians are of like mind and it’s a good fit," Kathleen McTigue, executive director of PediaTrust LLC said at the conference. "They [must] have similar views of running their businesses."

For PediaTrust, agreeing on a single vendor for each necessary service allowed for a smoother process, Ms. McTigue said. For example, each practice came to the table with its own attorney and accountant firm, so the new group needed to choose one provider for each service.

"We had great advisers," she said. "I would be concerned using advisors – attorneys, accountants, consultants – who had not worked with a company structure like ours. In the end, it turned out to be successful because we were thoughtful about that."

The new corporation faced their share of challenges, such as completing all unification tasks on a tight timeline. Investments were made in September 2012, and PediaTrust operations began in January 2013. Simultaneously, the group implemented a new electronic health record system. Another challenge was the limiting of new overhead to practices.

"While centralizing certain functions, we needed to be mindful of how to manage these costs," Ms. McTigue said. "For example, we transferred qualified billing staff from the local offices to the central billing office."

CHICAGO – Buck the trend of "physician as employee" and retain your private practice through better business practices, cost control, and potential collaboration with other entities, advised Dr. Thomas Grogan, past chair of the American Academy of Orthopaedic Surgeons’ Practice Management Committee.

"You can go into employment, or you can stay and survive and maybe even thrive," Dr. Grogan said at a physicians’ legal issues conference held by the American Bar Association.

One of the first steps to stabilizing a private practice is understanding costs and improving revenue, said Dr. Grogan, a practicing orthopedic surgeon in Los Angeles. This includes knowing how much revenue is generated per patient and what each procedure, treatment, and visit costs.

"Most of us have to learn how to collaborate... it’s like learning how to play together in the sandbox."

"A lot of times doctors don’t think about costs, they just pay them," he said in an interview. "That’s one of the big problems. If you know what the revenue is per patient, you can determine the profit margin and whether you can survive."

Analyzing cost structure can help determine the best approaches for improving income sources such as the possibility of subletting part of the office or seeking lower medical malpractice insurance premiums.

Ancillary income can be another focal point for physicians who desire to stay in private practice, Dr. Grogan said. Physicians should look for ways to increase and protect the revenue that stems from services such as X-rays, supplies, imaging, and other ancillaries. For instance, physicians can ensure that contracts with payers enable them to be reimbursed for maintenance of the equipment or devices they use. Physicians should beware of contracts with insurance companies that require them to use the payer’s providers or affiliated facilities for ancillary services.

Another key is the development of new revenue streams. New technology provides excellent opportunities for independent physicians to add skills and generate additional income, Dr. Grogan said. His practice, for example, utilizes stem cell treatments to treat joint problems.

"Learning how to do these new technologies can contribute positive revenue," he said. "In order to survive in business, you have to make a profit. In order to make a profit, you have to get very good at controlling cost or be able to grow revenue. That’s how you improve your financial situation."

Collaboration is another tool for retaining independence. Collaboration models could include merging two or more physician practices, becoming a medical home, joining an accountable care organization, or participating in a super group or independent network. Super groups refer to practice entities that share a single tax ID and ancillaries but can have multiple offices. Networks can be independent practices linked via a management system such as a physician-hospital organization, management services organization, or an independent practice association.

To achieve success in collaboration, physicians must overcome challenges to operating with other practices and organizations, Dr. Grogan said. A common obstacle is integrating practice cultures and learning to work with other specialties.

"Most of us have to learn how to collaborate, and it’s like learning how to play together in the sandbox," he said. "The culture of an orthopedic surgeon is not the same as that of a pediatrician or an internist. An orthopedist is used to taking care of the problem and moving on. That’s not necessarily the case with an internist or a pediatrician."

Learning how best to communicate and work within a strong team is essential to survival of unified groups, Dr. Grogan said.

"It’s hard to exist in our own little vacuum," he said. "Somehow, we have to integrate or at least collaborate."

Strong teamwork, communication aids practice integration

When a group of seven Chicago-area pediatric practices decided to join forces, they knew unification would not be simple. In the end, strong cooperation, efficient management, and skilled advisors were required to build a successful partnership, now called PediaTrust LLC.

"It’s really important to make sure the physicians are of like mind and it’s a good fit," Kathleen McTigue, executive director of PediaTrust LLC said at the conference. "They [must] have similar views of running their businesses."

For PediaTrust, agreeing on a single vendor for each necessary service allowed for a smoother process, Ms. McTigue said. For example, each practice came to the table with its own attorney and accountant firm, so the new group needed to choose one provider for each service.

"We had great advisers," she said. "I would be concerned using advisors – attorneys, accountants, consultants – who had not worked with a company structure like ours. In the end, it turned out to be successful because we were thoughtful about that."

The new corporation faced their share of challenges, such as completing all unification tasks on a tight timeline. Investments were made in September 2012, and PediaTrust operations began in January 2013. Simultaneously, the group implemented a new electronic health record system. Another challenge was the limiting of new overhead to practices.

"While centralizing certain functions, we needed to be mindful of how to manage these costs," Ms. McTigue said. "For example, we transferred qualified billing staff from the local offices to the central billing office."

CHICAGO – Buck the trend of "physician as employee" and retain your private practice through better business practices, cost control, and potential collaboration with other entities, advised Dr. Thomas Grogan, past chair of the American Academy of Orthopaedic Surgeons’ Practice Management Committee.

"You can go into employment, or you can stay and survive and maybe even thrive," Dr. Grogan said at a physicians’ legal issues conference held by the American Bar Association.

One of the first steps to stabilizing a private practice is understanding costs and improving revenue, said Dr. Grogan, a practicing orthopedic surgeon in Los Angeles. This includes knowing how much revenue is generated per patient and what each procedure, treatment, and visit costs.

"Most of us have to learn how to collaborate... it’s like learning how to play together in the sandbox."

"A lot of times doctors don’t think about costs, they just pay them," he said in an interview. "That’s one of the big problems. If you know what the revenue is per patient, you can determine the profit margin and whether you can survive."

Analyzing cost structure can help determine the best approaches for improving income sources such as the possibility of subletting part of the office or seeking lower medical malpractice insurance premiums.

Ancillary income can be another focal point for physicians who desire to stay in private practice, Dr. Grogan said. Physicians should look for ways to increase and protect the revenue that stems from services such as X-rays, supplies, imaging, and other ancillaries. For instance, physicians can ensure that contracts with payers enable them to be reimbursed for maintenance of the equipment or devices they use. Physicians should beware of contracts with insurance companies that require them to use the payer’s providers or affiliated facilities for ancillary services.

Another key is the development of new revenue streams. New technology provides excellent opportunities for independent physicians to add skills and generate additional income, Dr. Grogan said. His practice, for example, utilizes stem cell treatments to treat joint problems.

"Learning how to do these new technologies can contribute positive revenue," he said. "In order to survive in business, you have to make a profit. In order to make a profit, you have to get very good at controlling cost or be able to grow revenue. That’s how you improve your financial situation."

Collaboration is another tool for retaining independence. Collaboration models could include merging two or more physician practices, becoming a medical home, joining an accountable care organization, or participating in a super group or independent network. Super groups refer to practice entities that share a single tax ID and ancillaries but can have multiple offices. Networks can be independent practices linked via a management system such as a physician-hospital organization, management services organization, or an independent practice association.

To achieve success in collaboration, physicians must overcome challenges to operating with other practices and organizations, Dr. Grogan said. A common obstacle is integrating practice cultures and learning to work with other specialties.

"Most of us have to learn how to collaborate, and it’s like learning how to play together in the sandbox," he said. "The culture of an orthopedic surgeon is not the same as that of a pediatrician or an internist. An orthopedist is used to taking care of the problem and moving on. That’s not necessarily the case with an internist or a pediatrician."

Learning how best to communicate and work within a strong team is essential to survival of unified groups, Dr. Grogan said.

"It’s hard to exist in our own little vacuum," he said. "Somehow, we have to integrate or at least collaborate."

Strong teamwork, communication aids practice integration

When a group of seven Chicago-area pediatric practices decided to join forces, they knew unification would not be simple. In the end, strong cooperation, efficient management, and skilled advisors were required to build a successful partnership, now called PediaTrust LLC.

"It’s really important to make sure the physicians are of like mind and it’s a good fit," Kathleen McTigue, executive director of PediaTrust LLC said at the conference. "They [must] have similar views of running their businesses."

For PediaTrust, agreeing on a single vendor for each necessary service allowed for a smoother process, Ms. McTigue said. For example, each practice came to the table with its own attorney and accountant firm, so the new group needed to choose one provider for each service.

"We had great advisers," she said. "I would be concerned using advisors – attorneys, accountants, consultants – who had not worked with a company structure like ours. In the end, it turned out to be successful because we were thoughtful about that."

The new corporation faced their share of challenges, such as completing all unification tasks on a tight timeline. Investments were made in September 2012, and PediaTrust operations began in January 2013. Simultaneously, the group implemented a new electronic health record system. Another challenge was the limiting of new overhead to practices.

"While centralizing certain functions, we needed to be mindful of how to manage these costs," Ms. McTigue said. "For example, we transferred qualified billing staff from the local offices to the central billing office."

The process of obtaining multiple medical licenses by which more physicians would be able to practice telemedicine across state lines soon may be streamlined by a compact proposed by the Federation of State Medical Boards.

"There’s not been an interstate medical licensure compact before," Dr. Humayun J. Chaudhry, FSMB president and CEO said in an interview. "It would provide for the very first time, to those physicians who wanted it, the ability to practice medicine in many more jurisdictions than ever before."

Courtesy vRad

The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at their 2013 annual meeting. A compact refers to a constitutionally authorized contract between compact states that responds to a collective problem without nationalization of the issue. The process is now in the drafting stage and state board leaders expect to release a final draft in late summer or early fall of 2014.

Under the proposed system, physicians interested in practicing in multiple states could receive a license in each participating state through an expedited process. States and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight, according to the proposed compact.

Courtesy FSMB

The ongoing advancement of telemedicine, concern over physician shortages, and access to care issues contributed to the compact’s creation, Dr. Chaudhry said.

"We wanted to make sure at the state medical board level, that we were doing everything we could to enable greater portability of the practice of medicine, but at the same time, making sure it was done in a way that protects the public."

Currently, physicians who practice telemedicine in multiple states must have a license in the state in which they physically practice, and the state in which the patient is treated. Generally, this means physicians have to fill out multiple applications and go through separate application processes.

Dr. Benjamin Strong, a teleradiologist, said he was initially surprised to experience such extensive evaluation every time he pursued a license in a new state. He now holds medical licenses in all 50 states.

"Each state insisted on pursuing its own investigation in spite of the fact that so many had previously licensed me, and I was even more surprised that each state raised different, but legitimate questions," said Dr. Strong, chief medical officer for vRad, a global telemedicine company and radiology practice. "My record is quite clean and yet still, on my 50th license, there were questions about this certificate or that unaccounted-for time period that had not been asked by prior states."

In addition, some states make it difficult for out-of-state physicians to practice in their jurisdiction, said Gary Capistrant, senior director for public policy at the American Telemedicine Association. At least 14 states have legislation placing restrictions on the practice of telemedicine across state borders. The rules often require full and unrestricted state licensure for out-of-state physicians providing services via telemedicine and require doctors to pay duplicate licensure fees.

"How many of you have driver’s licenses in two states?" Mr. Capistrant asked an audience at an American Bar Association (ABA) physicians’ legal issues conference in Chicago. "And yet, physicians need a [medical] license in each state."

The compact also plans to address complaint investigations of physicians and increase teamwork by state medical boards. Currently, the launch of investigations that were undertaken in response to complaints are not shared among jurisdictions. Only final disciplinary actions taken by state medical boards are made available.

The lack of communication among states and sometimes redundant examinations create burdens for physicians and exhaust resources, experts said. In some cases, multiple states investigate the same incident and reach different conclusions, Ryan Check, vRad vice president and general counsel, said at the ABA conference.

"The risk of cascading investigations is something that causes significant headaches to our team," Mr. Check said.

Language in the proposed compact would allow participating state boards to inform other boards when a physician is being investigated and share information. The cooperation would enable a quicker response to the issue, rather than waiting for an action to be taken," Dr. Chaudhry said.

But Dr. Strong questioned whether the compact can save costs and time, while still conducting necessary evaluations of participating physicians.

"While logistically, an interstate licensing compact makes sense – lower cost, markedly reduced effort on the part of the licensing boards and credentialing committees, greater mobility for physicians – I believe it must include a very extensive investigation into each physician, such that the savings in cost, time, and effort may not be as great as one might think at first glance," he said in an interview. "To institute an interstate compact, the licensing process will have to include every conceivable detail and meet the standards of every state, which undoubtedly will be a difficult task and which will not provide the simplicity I think many physicians hope for."

The state boards of medicine intend to present the final compact draft to state legislators for their consideration in 2015 legislative sessions.

The process of obtaining multiple medical licenses by which more physicians would be able to practice telemedicine across state lines soon may be streamlined by a compact proposed by the Federation of State Medical Boards.

"There’s not been an interstate medical licensure compact before," Dr. Humayun J. Chaudhry, FSMB president and CEO said in an interview. "It would provide for the very first time, to those physicians who wanted it, the ability to practice medicine in many more jurisdictions than ever before."

Courtesy vRad

The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at their 2013 annual meeting. A compact refers to a constitutionally authorized contract between compact states that responds to a collective problem without nationalization of the issue. The process is now in the drafting stage and state board leaders expect to release a final draft in late summer or early fall of 2014.

Under the proposed system, physicians interested in practicing in multiple states could receive a license in each participating state through an expedited process. States and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight, according to the proposed compact.

Courtesy FSMB

The ongoing advancement of telemedicine, concern over physician shortages, and access to care issues contributed to the compact’s creation, Dr. Chaudhry said.

"We wanted to make sure at the state medical board level, that we were doing everything we could to enable greater portability of the practice of medicine, but at the same time, making sure it was done in a way that protects the public."

Currently, physicians who practice telemedicine in multiple states must have a license in the state in which they physically practice, and the state in which the patient is treated. Generally, this means physicians have to fill out multiple applications and go through separate application processes.

Dr. Benjamin Strong, a teleradiologist, said he was initially surprised to experience such extensive evaluation every time he pursued a license in a new state. He now holds medical licenses in all 50 states.

"Each state insisted on pursuing its own investigation in spite of the fact that so many had previously licensed me, and I was even more surprised that each state raised different, but legitimate questions," said Dr. Strong, chief medical officer for vRad, a global telemedicine company and radiology practice. "My record is quite clean and yet still, on my 50th license, there were questions about this certificate or that unaccounted-for time period that had not been asked by prior states."

In addition, some states make it difficult for out-of-state physicians to practice in their jurisdiction, said Gary Capistrant, senior director for public policy at the American Telemedicine Association. At least 14 states have legislation placing restrictions on the practice of telemedicine across state borders. The rules often require full and unrestricted state licensure for out-of-state physicians providing services via telemedicine and require doctors to pay duplicate licensure fees.

"How many of you have driver’s licenses in two states?" Mr. Capistrant asked an audience at an American Bar Association (ABA) physicians’ legal issues conference in Chicago. "And yet, physicians need a [medical] license in each state."

The compact also plans to address complaint investigations of physicians and increase teamwork by state medical boards. Currently, the launch of investigations that were undertaken in response to complaints are not shared among jurisdictions. Only final disciplinary actions taken by state medical boards are made available.

The lack of communication among states and sometimes redundant examinations create burdens for physicians and exhaust resources, experts said. In some cases, multiple states investigate the same incident and reach different conclusions, Ryan Check, vRad vice president and general counsel, said at the ABA conference.

"The risk of cascading investigations is something that causes significant headaches to our team," Mr. Check said.

Language in the proposed compact would allow participating state boards to inform other boards when a physician is being investigated and share information. The cooperation would enable a quicker response to the issue, rather than waiting for an action to be taken," Dr. Chaudhry said.

But Dr. Strong questioned whether the compact can save costs and time, while still conducting necessary evaluations of participating physicians.

"While logistically, an interstate licensing compact makes sense – lower cost, markedly reduced effort on the part of the licensing boards and credentialing committees, greater mobility for physicians – I believe it must include a very extensive investigation into each physician, such that the savings in cost, time, and effort may not be as great as one might think at first glance," he said in an interview. "To institute an interstate compact, the licensing process will have to include every conceivable detail and meet the standards of every state, which undoubtedly will be a difficult task and which will not provide the simplicity I think many physicians hope for."

The state boards of medicine intend to present the final compact draft to state legislators for their consideration in 2015 legislative sessions.

The process of obtaining multiple medical licenses by which more physicians would be able to practice telemedicine across state lines soon may be streamlined by a compact proposed by the Federation of State Medical Boards.

"There’s not been an interstate medical licensure compact before," Dr. Humayun J. Chaudhry, FSMB president and CEO said in an interview. "It would provide for the very first time, to those physicians who wanted it, the ability to practice medicine in many more jurisdictions than ever before."

Courtesy vRad

The FSMB House of Delegates unanimously approved the development of an interstate compact to expedite medical licensure and facilitate multistate practice at their 2013 annual meeting. A compact refers to a constitutionally authorized contract between compact states that responds to a collective problem without nationalization of the issue. The process is now in the drafting stage and state board leaders expect to release a final draft in late summer or early fall of 2014.

Under the proposed system, physicians interested in practicing in multiple states could receive a license in each participating state through an expedited process. States and doctors would voluntarily enter into the compact, and approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight, according to the proposed compact.

Courtesy FSMB

The ongoing advancement of telemedicine, concern over physician shortages, and access to care issues contributed to the compact’s creation, Dr. Chaudhry said.

"We wanted to make sure at the state medical board level, that we were doing everything we could to enable greater portability of the practice of medicine, but at the same time, making sure it was done in a way that protects the public."

Currently, physicians who practice telemedicine in multiple states must have a license in the state in which they physically practice, and the state in which the patient is treated. Generally, this means physicians have to fill out multiple applications and go through separate application processes.

Dr. Benjamin Strong, a teleradiologist, said he was initially surprised to experience such extensive evaluation every time he pursued a license in a new state. He now holds medical licenses in all 50 states.

"Each state insisted on pursuing its own investigation in spite of the fact that so many had previously licensed me, and I was even more surprised that each state raised different, but legitimate questions," said Dr. Strong, chief medical officer for vRad, a global telemedicine company and radiology practice. "My record is quite clean and yet still, on my 50th license, there were questions about this certificate or that unaccounted-for time period that had not been asked by prior states."

In addition, some states make it difficult for out-of-state physicians to practice in their jurisdiction, said Gary Capistrant, senior director for public policy at the American Telemedicine Association. At least 14 states have legislation placing restrictions on the practice of telemedicine across state borders. The rules often require full and unrestricted state licensure for out-of-state physicians providing services via telemedicine and require doctors to pay duplicate licensure fees.

"How many of you have driver’s licenses in two states?" Mr. Capistrant asked an audience at an American Bar Association (ABA) physicians’ legal issues conference in Chicago. "And yet, physicians need a [medical] license in each state."

The compact also plans to address complaint investigations of physicians and increase teamwork by state medical boards. Currently, the launch of investigations that were undertaken in response to complaints are not shared among jurisdictions. Only final disciplinary actions taken by state medical boards are made available.

The lack of communication among states and sometimes redundant examinations create burdens for physicians and exhaust resources, experts said. In some cases, multiple states investigate the same incident and reach different conclusions, Ryan Check, vRad vice president and general counsel, said at the ABA conference.

"The risk of cascading investigations is something that causes significant headaches to our team," Mr. Check said.

Language in the proposed compact would allow participating state boards to inform other boards when a physician is being investigated and share information. The cooperation would enable a quicker response to the issue, rather than waiting for an action to be taken," Dr. Chaudhry said.

But Dr. Strong questioned whether the compact can save costs and time, while still conducting necessary evaluations of participating physicians.

"While logistically, an interstate licensing compact makes sense – lower cost, markedly reduced effort on the part of the licensing boards and credentialing committees, greater mobility for physicians – I believe it must include a very extensive investigation into each physician, such that the savings in cost, time, and effort may not be as great as one might think at first glance," he said in an interview. "To institute an interstate compact, the licensing process will have to include every conceivable detail and meet the standards of every state, which undoubtedly will be a difficult task and which will not provide the simplicity I think many physicians hope for."

The state boards of medicine intend to present the final compact draft to state legislators for their consideration in 2015 legislative sessions.