nj physician magazine november 2012

JULY 2012

Also In This Issue:Governor Christie Vetos Health Care Exchange Bill

Cigna, Summit Medical Become the latest Accountable Care Organization in NJ

Court Upholds State’s OK of Hospital Reopening

Visit us now online atwww.NJPhysician.org

NOVEMBER 2012

DermOne Dermatology Centers Taking the Practice of Dermatology into the New Healthcare Arena

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Montdor Medical Media, LLC

Co-Publisher and Managing Editors

Iris and Michael Goldberg

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Iris Goldberg

Michael Goldberg

Andrew Kitchenman

Lani M. Dornfeld

Todd C. Brower

John D. Fanburg

Keith J. Roberts

Mark Manigan

Joseph M. Gorrell

Layout and Design

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Publisher’s Letter

With warm regards,

Michael GoldbergCo-Publisher

Welcome to the November issue of New Jersey Physician, the only voice of the state medical community.

The business of practicing medicine is changing. Each day, we hear of another business model being introduced. The alternatives are certainly difficult to choose from. They range from those who want to remain a solo or small group practice, to very large groups bound together to increase reimbursement while lowering operating costs. Large investment companies are purchasing practices and maintaining the physicians as employees, hospitals are doing the same. Insurance companies are striking deals with large practices. Single specialty ACOs are rapidly forming as are multispecialty groups. We intend to present many of these business models to you for your review in the hope we can assist you in determining whether you make the selection and if so, which one is right for you.

Our cover story this month is on DermOne, formerly known as Accredited Dermatology. An investment group with a vision of creating a nationally branded organization is seeking to buy practices across the country, unify their billing and collections as well as increase their power to maximize reimbursements. They have started in New Jersey and at this time have successfully brought approximately 40 groups into the fold. The quality of the support services offered to the practices is top shelf including state-of-the-art technology and equipment, centralized billing, In house pathology, payer contract negotiation, and branding and market support. All the dermatologist has to do is practice their craft, without the distractions of managing the business aspects of medicine. This is quite a visionary concept.

Governor Christie has vetoed legislation establishing a state-run health insurance exchange, saying the federal government had failed to provide the answers he needed to make a fiscally sound decision on the best way to comply with the Affordable Care Act. The Governor’s statement is included inside.

Cigna and Summit Medical have become the latest accountable care organization partners in New Jersey. This reflects the growing trend of the state’s insurers and larger provider organizations pursuing accountable care organization-based collaborations. The ACO model, a core component of healthcare reform, is a network of doctors, hospitals and other healthcare providers that all work together to coordinate quality care for the patients they serve.

Dear Readers,

Contents

2 New Jersey Physician

CONTENTS

4

9

131415

STATEHOUSE

LEGAL ISSUES

BITS & PIECES

12

DermOne Dermatology Centers

Taking the Practice of Dermatologyinto the New Healthcare Arena

PRACTICE CHOICES

17FOOD FOR THOUGHT

HEALTH LAW BLOG

HEALTH LAW UPDATE

20

Coverage is subject to meeting eligibility requirements and company approval.

www.Bollinger.com/pro

Talk to Bollinger about your Professional Liability … Before entering this room.

With one of the largest professional liability divisions in the region, Bollinger has the expertise and resources to help ensure that your liability threats are properly addressed.

To learn more about how Bollinger can help your practice, contact Brian S. Kern, Esq.

973-921-8497 or [email protected]

• BROAD COVERAGE FORMS • FINANCIALLY STRONG INSURANCE COMPANIES • ADVANCED RISK MANAGEMENT SERVICES AND STRATEGIES • HIGHLY COMPETITIVE PRICING

DermOne Dermatology Centers


Cover Story

DermOne Dermatology CentersTaking the Practice of Dermatology into the New Healthcare ArenaBy Iris Goldberg

We have already witnessed a dramatic change in the practice of medicine within virtually every specialized field. In addition to their role as clinicians, physicians need to pay close attention to the business side of treating patients. Over time, the sole practitioner has become the exception rather than the rule and even he or she has had to evolve significantly in order to adapt.

Technology is a double-edged sword. On one hand, it has provided physicians with the tools to achieve miraculous outcomes for their patients as compared to what was possible only a few short decades ago. Also, access to patient information has been revolutionized. While these advancements markedly improve patient care, the technology challenges physicians to keep pace from a financial perspective and also in terms of mastering all of the new techniques that become available. Moreover, health insurance administrators, whether through government plans or private insurance companies tightly regulate reimbursement to providers, while the costs of maintaining a medical practice escalate.

A number of different models for structuring medical practices have emerged as physicians look for alternatives that more efficiently address practice management. One such model seems particularly well-suited to the practice of dermatology, which for the most part is exclusively office-based. Already established in many parts of our state, DermOne™ Dermatology Centers is a rapidly growing organization that will include dermatologists as well as nurse practitioners and physician assistants throughout New Jersey and beyond.

DermOne actually began as Accredited Dermatology, which was built by Rami Geffner, MD, who originally started as a sole practitioner in Toms River in 1986. Through word of mouth his practice grew quickly and before long he was dividing his time among three offices

in southern New Jersey. Eventually, in order to accommodate other areas as well, Dr. Geffner found himself with six locations. He attempted to hire other dermatologists to join with him to no avail.

“At that point I decided to hire and train physician assistants and I believe I was one of the first in dermatology within New Jersey to do this,” Dr. Geffner points out. Although some in the community were skeptical, Dr. Geffner relates that with the extensive training he provided,

the PAs he brought on board were extremely proficient and skillfully worked with him to ensure patients received the highest level of care.

During this period Dr. Geffner, who was working incredibly hard, continued to search for dermatologists to partner with and in 2000, after a brief association with one physician failed to work out, he finally found a female dermatologist who re-located from her practice in Florida to join with him. “Patti,” as he refers to her, eventually became his wife.

PAs and NPs who were originally brought on board by Dr. Geffner are instrumental in the DermOne organization.

November 2012 5

As partners in business and in life, the Geffners next, proceeded to buy a busy dermatology practice in Northfield from a physician who was moving to another state. Then, discovering the tremendous financial potential that expanding could realize, in terms of cost-efficient and productive practice management, Dr. Geffner sent a letter to every dermatologist in the state inviting them to merge with him or sell their practices to him.

As a result of this endeavor, Dr. Geffner purchased practices based in Westville, Holmdel and Hawthorne from dermatologists who were ready to retire. In the interim he began looking for additional physician assistants and nurse practitioners to train so that they could function expertly within these locations as well. “It developed into a sort of residency program where we taught them the skills they needed to have,” Dr. Geffner explains. “Before we allowed them to see patients, we tested their knowledge to make sure they were ready,” he reports.By the time 2010 rolled around, in addition to a highly-trained group of NPs and PAs, Accredited Dermatology employed ten additional physicians and managed 33 offices. “We felt that it was too much for my wife and me to manage, so we made the decision to find a partner,” Dr. Geffner relates. They interviewed a number of equity firms and had a few generous offers on the table. In the end, the Geffners chose Westwind Investors, LLP, a group that they felt shared the philosophy of patient care that they had worked so hard to uphold.

“They understood what we were doing at the time. We felt they were visionaries who were not afraid of tackling something at the level of intensity with which we were working,” Dr. Geffner strongly states. With the new partnership agreement in place, Accredited Dermatology became DermOne and the unconventional, yet highly successful business model developed by Dr. Geffner continues to evolve and expand.

DermOne CEO, Ronald Geraty, MD discusses how the new affiliation has enabled Dr. Geffner’s practice to successfully expand even further. “We were able to take advantage of a glide path that Dr. Geffner was on and growing,” Dr. Geraty remarks. “He did as well as he could to serve as a single practitioner but

by adding the infrastructure that we were able to provide, instead of being able to manage 35 offices, we can manage 100 or 200 or 300 offices,” he adds.

The infrastructure to which Dr. Geraty refers is quite impressive and is really at the heart of creating a statewide or even nationwide network of offices that provide a universally high level of dermatologic care and treatment, while offering an extremely comfortable and productive alternative for individual local practitioners. Some of the integral features of the DermOne infrastructure support are as follows:

• State-of-the-art equipment and technology

• Centralized billing and collections

• In-house pathology lab

• Integrated, cloud-based practice management, EMR and laboratory information systems

• Centralized HR and regulatory compliance management

• Immediate second opinions and teledermatology via iPad-based EMR

• Payer contract negotiation

• Comprehensive training and supervision systems

• Branding, marketing and sales support

With these and other comprehensive and efficient support systems in place, the DermOne physician is released from the burdensome, often expensive and certainly time consuming aspects of medical practice that have become a persistent fact of life in our current healthcare environment. Dr. Geffner, who now serves as Chief of Dermatology at DermOne, speaks to those dermatologists who are searching for solutions to the difficulties associated with practice management today.

“All of the things that doctors hate about practice management can be taken care of by joining our group. Dealing with insurance companies, billing and trying to collect payment, interviewing, hiring and training employees, etc. Our concept provides a management team that takes care of everything that most physicians just don’t want to deal with,” Dr. Geffner offers. “Doctors can do what they went to medical school to be able to do – focus on their patients,” he asserts.

An integral part of the DermOne infrastructure is an in-house pathology lab.

At DermOne immediate second opinions and teledermatology are available via small iPad based EMR

Dr. Geffner goes on to share that when they join DermOne, physicians retain a portion of equity in their practice and also receive a generous salary. “They come into the office, take care of their patients, get the income that they’re looking for and don’t have to worry about the other issues,” he remarks. “They can really enjoy life,” Dr. Geffner emphasizes.

DermOne is a welcome alternative for patients as well as physicians. In fact, Dr. Geraty shares the motto upon which all of the planning to create DermOne was based. “We display the initials – PCU – Patient is the Center of our Universe,” he informs.


“Everything we’ve done is focused on that and out of that flow a great many changes. Whether it’s our call center and the way our patients are handled there, or surveys that allow patients to rate everything that we do, with the objective being to constantly improve, we always want the patient to be the center of our universe,” Dr. Geraty reiterates.

With its expanding network of providers and convenient neighborhood skincare centers, DermOne can accommodate patients immediately. The goal at DermOne is to make high-quality, affordable dermatology care accessible to everyone. Also, extended hours are available at many of its locations, so that patients do not have to take time from their busy work schedules to be seen.

Dr. Geraty explains the innovative design of the DermOne network. Here, the use of skilled nurse practitioners and physician assistants that Dr. Geffner incorporated while growing his practice, is taken to the next level to assure patients in virtually any part of the state access to comprehensive dermatologic care, even where there are a shortage of skilled dermatology specialists.

Picture the idea of a wheel and its spokes as depicted in Fig. 1, which illustrates the organization of DermOne facility locations in southern parts of New Jersey, for example, where traditionally patients have had to travel considerable distances at times, in order to consult with the appropriate physician.

The hub or center of the wheel is the

Northfield office where one or more specialized dermatologists are based. The spokes are satellite offices (Manahawkin, Cape May, Galloway, Vineland), which are staffed with expertly-trained NPs and PAs who manage routine clinical cases. The Northfield physicians work at the satellite offices on certain days during every month. In the interim, iPad technology allows for an immediate visual consultation with the specialist at the Northfield office whenever needed. In the event that urgent specialized care is required, the patient is sent on to the Northfield office.

Of course the primary concern for dermatologists is the prevention, detection and treatment of skin cancer, which is the most commonly diagnosed cancer in the United States, according to the American Cancer Society. DermOne offers convenient low-cost skin cancer screenings at all of its locations. If skin cancer is detected, it will be thoroughly evaluated. Treatment options will vary depending upon the type of cancer (melanoma vs. non-melanoma) and also by its size, stage and location.

For certain non-melanoma skin cancers, DermOne surgeons perform Mohs surgery, which is the removal of cancerous tissue one thin layer at a time. After each layer is removed, it is examined under a microscope. When the layer appears normal, with no trace of cancer, the surgeon stops removing tissue. This minimally invasive procedure is performed under local anesthesia and removes cancer while preserving normal, healthy surrounding tissue.

Northfield

Manahawkin

Galloway

Cape May

Vinel

and

At DermOne, the primary concern is the prevention, detection and treatment of skin cancer.

Fig. 1

November 2012 7

An innovative non-surgical alternative for the removal of basal and squamous cell skin cancers that is available at DermOne Dermatology Centers is Superficial Radiotherapy Treatment (SRT). Performed in the office, without any anesthesia required, SRT is a low energy radiotherapy that goes no deeper than the thickness of the skin. Because the low-energy radiation mainly does not penetrate below the skin’s surface, SRT is safe, painless and is with minimal side effects.

DermOne physician Robin Smith, MD is a radiation oncologist, specializing in dermatologic cancers. Dr. Smith shares that many patients are concerned about undergoing surgery, especially to cosmetically delicate areas such as the nose, lip or ear. He goes on to relate that SRT is a good alternative in these situations because it does not remove any tissue. “Radiation damages the DNA of the cancer cells,” Dr. Smith explains.

DermOne offers low cost skin cancer screenings at all of its locations. Findings are carefully noted and maintained for future comparison.

Patients who opt for SRT undergo between 20 and 30 one-minute treatments, daily for 4 to 6 weeks, depending upon the size of the lesion. Dr. Smith makes a point of mentioning that SRT is not only for patients who are worried about preserving their appearance.

“Radiation is also very suitable for patients who have had numerous {skin cancer} surgeries in the past and do not want to have any more surgeries and for some who are elderly and surgery is just not for them,” he reports. “It’s a matter of patient choice,” Dr. Smith adds.

“And I’d really like to stress that,” he says. “It’s important to note that at DermOne we want to - and we can offer patients an option,” Dr. Smith emphasizes. He, of course, is referring to the fact that for smaller dermatology practices, this technology might not be affordable.

Besides offering comprehensive, cutting-edge medical dermatology services, DermOne is also a leader in cosmetic dermatology, offering services that include but are not limited to:

Dr. Smith is adjusting SRT equipment.

• Laser treatments

• Hair replacement

• Botox® injections

• Injectable fillers (Restylane®, Juvederm® and collagen)

• Chemical peels

Recently joining DermOne, Isaac Mordecai, MD, was a sole practitioner for many years. In addition to his considerable expertise in medical dermatology, Dr. Mordecai is a highly-skilled and experienced cosmetic dermatologist. He is extremely excited about the opportunities to improve and expand his practice that have been created since selling to DermOne.

“They’re going to give me the means to do the things I want,” Dr. Mordecai candidly shares. “They have an excellent reputation and they will be providing me with whatever I need,” he continues. “I’ve been in practice for a long time and they’re leaving it up to me,” Dr. Mordecai adds. Besides having access to the latest equipment Dr. Mordecai looks forward to the support he will receive for managing his practice.

“It’s all very complicated now,” he says, referring to electronic record keeping, dealing with insurance and the other


tedious aspects of practice management. “I’m glad that they will be taking care of that, too, Dr. Mordecai states.

In terms of being able to provide the highest level of care to his patients, Dr. Mordecai is cognizant of the significant advantages associated with being part of a large network. He anticipates receiving referrals from colleagues in DermOne who might want their patients to benefit from his vast experience, especially regarding cosmetic dermatology.

Conversely, when, for example, after performing a biopsy on a suspicious mole, Dr. Mordecai diagnoses skin cancer that might be amenable to Mohs surgery or SRT, he appreciates the ability to refer that patient to a DermOne specialist. “This allows not only for continuity of care but expediency of care, as well,” Dr. Mordecai points out.

Dr. Pistone is renowned for his hair transplantation procedures.

Dr. Mordecai is extremely excited to be joining the DermOne family.

Another exciting new member of the DermOne team is Gregory Pistone, MD. Dr. Pistone, too, is board-certified in general dermatology with expertise in both medical and cosmetic dermatologic care and treatment. In addition to those skills, Dr. Pistone is renowned for his hair transplantation procedures. Having performed more than 15,000 procedures to date, Dr. Pistone consults with patients (predominantly men) from all across the United States and abroad.

Dr. Pistone specializes in the Follicular Unit Transplantation (FUT) hair restoration technique, during which a patient’s hair is transplanted naturally, in groups of 1 to 4 hairs, called follicular units. This technique is a vast improvement over older transplantation procedures that often produced a “pluggy” unnatural look. In contrast, the results of Dr. Pistone’s hair restoration

procedures mimic the way hair grows naturally and are undetectable as being transplanted.

It is important to note that Dr. Pistone is highly-skilled in both the traditional FUT technique in which hair is harvested using a long, thin donor strip that is dissected into individual follicular units and an alternative harvesting method, called Follicular Unit Extraction (FUE). FUE involves removing individual follicular unit grafts directly from the back and sides of the scalp using specially-designed instrumentation.

When asked why he decided to join DermOne, without hesitation, Dr. Pistone offers numerous reasons. “Number one, private practice is getting very onerous,” he states. “It’s difficult to maintain what you need to from the government’s perspective in terms of record keeping and computerization. Also, the practice management time has gone from a small amount of time to an excessive amount of time,” Dr. Pistone adds.“Number two is collegiality. Basically, after 28 years of solo practice, you get lonely for colleagues,” Dr. Pistone acknowledges. It’s very important to have that atmosphere of support so that you can discuss various cases together and can assist each other,” he shares.

Dr. Pistone also appreciates the benefits of cost-sharing that are derived from joining a large group, as well as the ability to negotiate better rates with insurance companies and others with whom you do business. “There’s definitely strength in numbers,” Dr. Pistone says.

For dermatologists and patients in New Jersey, DermOne is a vehicle to carry them into a much-changed healthcare environment. Patients throughout the state will have access to the highest level of compassionate, affordable skincare, regardless of where they live. Sole practitioners or dermatologists who have formed small groups now have an alternative business model to consider, one that offers an attractive solution to the myriad of practice management concerns that interfere with their ability to focus primarily on treating patients. With the establishment of DermOne Dermatology Centers, perhaps a brighter healthcare future is beginning to take shape.

For more information on referring patients or becoming a DermOne physician please visit www.dermone.com or call Ron Geraty at (617) 510-4642.

photography by Michael Goldberg

Dr Geffner (far right) who now serves as Chief of Dermatology and some of the physicians of DermOne gather for a group photo.

November 2012 9

NEW JERSEYSTATEHOUSE

Statehouse

New Jersey Voters Support Federal Health Care Law, Poll ShowsA clear majority of New Jersey voters support the recent U.S. Supreme Court decision upholding most of the Affordable Care Act (ACA), according to a new WNYC/Rutgers-Eagleton Poll.

Nearly 6-in-10 registered voters in the Garden State say the Supreme Court was right to uphold the law, while 37 percent wanted it struck down. This represents a significant increase in support, compared to the 47 percent who supported the law in a March, 2010 Rutgers-Eagleton Poll.

“New Jerseyans are for the most part supportive of the affordable health care act,” said David Redlawsk, director of the Eagleton Center for Public Interest Polling and professor of political science at Rutgers University. “While not all that supportive of government making health insurance decisions, they are still quite happy with the prospects of keeping children on parents’ policies and not being denied coverage for pre-existing conditions.”

Given a choice between changing Medicare to a system providing fixed payments to seniors who would then buy their own insurance or maintaining the current system, more than two-thirds would stick with Medicare as it is. Only one-quarter supports changing the system to allow purchasing insurance on the market.

The ACA’s provision expanding Medicaid is popular in New Jersey, even though the state has not yet decided whether to participate in the expansion. Just over one-third opposes expanding Medicaid eligibility, while 57 percent support extending its coverage to more low income residents.

Results are from a poll of 790 registered voters conducted statewide among both landline and cell phone households from Sep 27-30. The sample has a margin of error of +/- 3.5 percentage points. Questions on health care issues were developed in consultation with The Brian Lehrer Show on WNYC radio, and were sponsored by WNYC.


Participating Providers Under Managed Care Plan Prohibited From Charging Certain Fees: Establishes Penalties Therefore

This bill supplements the "Health Care Quality Act" to prohibit participating health care providers from demanding or requesting a fee, including, but not limited to, an access fee, that is in excess of payment provided by a carrier under a managed health care plan and any required copayment, coinsurance or deductible, in accordance with the reimbursement provisions of the provider contract, for medically necessary services that are authorized or covered by the managed care plan. The bill defines "access fee" as a fee charged by a participating health care provider to a covered person as a condition of receiving health care services from the health care provider, but as not including a reasonable fee charged by a participating health care provider for: (1) a basic bio-analytical test performed for a covered person, including, but not limited to, a urinalysis, hemoglobin/hematocrit test or a throat culture; or (2) a telephone consultation with a covered person, if, in advance of the consultation or basic bio-analytical test, the provider has obtained the written consent of the covered person as to payment of the fee and has prominently posted a notice of the fee in the provider's office.

The bill establishes a penalty of $500 for the first violation, $1,000 for the second violation and $2,500 for the third and each subsequent violation, to be sued for and collected in a summary proceeding by the Commissioner of Health and Senior Services. Further, the bill requires the commissioner to notify a health care provider's State licensing authority when a penalty is assessed against the provider pursuant to the provisions of this bill.

N.J.-run health-care exchange bill vetoedTRENTON - Gov. Christie on Thursday vetoed legislation establishing a state-run health-insurance exchange, saying the federal government had failed to provide the answers he needed to make a fiscally sound decision on the best way to comply with the Affordable Care Act.

The governor said he had not eliminated any of the options available to states to comply with the national health-care overhaul. But he said it would be irresponsible to choose one over the others without knowing the costs of each.

"New Jersey and all other states still await substantial federal guidance on the functioning of all three types of exchanges," Christie said in his veto message. "To be sure, the decision of whether to move forward with a state-based exchange can only be fully understood when competitively compared to the overall value of the other options."

States have until next Friday to decide whether to establish a state-based exchange. They have more time to decide whether to partner with the federal government or let the U.S. run the state exchange.

Health-insurance exchanges are online marketplaces in which uninsured residents can shop for health-care coverage.

Christie, who was in Washington on Thursday to lobby for Sandy aid, issued the veto through his communications office.

Assemblyman Herb Conaway (D., Burlington), the Legislature's only practicing physician, was among the measure's sponsors. He said the governor could have helped families obtain more affordable health care than is now available by signing the bill.

"This New Jersey-specific legislation would have coupled strong consumer protections and an open online marketplace to create a vibrant, competitive exchange to ensure that our state's uninsured and underinsured families receive the highest-quality care for the lowest price," he said. "It would have also positioned New Jersey residents and small businesses to receive billions in federal tax credits to purchase insurance."

Christie's decision was criticized by government watchdog groups, but applauded by business representatives.

Governor Christie’s Message to the Senate Vetoing The Patient Protection and Affordable Care Act

SENATE BILL NO. 2135(First Reprint)

To the Senate: Pursuant to the Patient Protection and Affordable Care Act, a“health insurance exchange” must be established in each state either by the government of that state or by the federal government. To carry out this provision, the “Affordable Care Act” allows states the choice between three Health Insurance Exchange options: a “State-based Exchange”; a “Partnership Exchange”; or a “Federally Facilitated Exchange.” Any state that does not select a State-based Exchange or Partnership Exchange, or does not inform the federal government of a selection, will be placed into a Federally Facilitated Exchange. Senate Bill No. 2135, passed by the Legislature on October 18 ofthis year, seeks to establish a State-based Exchange in New Jersey. While I appreciate the Legislature’s attempt to craft a bill to implement this portion of the “Affordable Care Act,” I cannot agree that this codification of a State-based Exchange is the most responsible selection for New Jersey. The federal government has directed states to decide whether to establish a State-based Exchange for calendar year 2014 by December 14, 2012, just over a week from now, but New Jersey and all other states still await substantial federal guidance on the functioning of all three types of Exchanges.To be sure, the decision of

November 2012 11

whether to move forward with a State-based Exchange can only be fully understood when competitively compared to the overall value of the other options. For example, while we know that both a Federally Facilitated Exchange and a Partnership Exchange would be financed through “userfees” paid by insurers, only late last week did the federal government finally offer a preliminary glimpse as to what those costs might include. And this latest proposal — which is neither final nor comprehensive — raises more questions than it answers. For example, further clarification is still needed on whether the federal government intends to share user-fee revenue with the states in aPartnership Exchange.

Moreover, New Jersey still requires guidance on the operation of a Federally Facilitated Exchange. The federal government has yet to present a structured blueprint for the design and operation of a Federally Facilitated Exchange and the technical details for its linkage to each state. This uncertainty regarding the potential operation of Partnership Exchanges and Federally Facilitated Exchanges necessarily clouds the analysis of whether a State-based Exchange would be the best option of the three for New Jersey.Lastly, financing the building and implementation of a State-based Exchange would be an extraordinarily costly endeavor. As drafted, Senate Bill No. 2135 would create an expensive new bureaucracy. While the federal government has enabled states to apply for grant funding to cover some of the initial costs of such an endeavor, the total price for such a program has never been quantified, and is likely to be onerous. Without knowing the full scope of which Exchange option would be most beneficial and cost efficient for New Jerseyans, it would be irresponsible to force such abill on our citizens. In addition to those and other known questions, the last several weeks have triggered an apparent restart of proposed federal regulations relating to the “Affordable Care Act,” and new guidance continues to trickle out of Washington at an erratic pace. While additional federal direction is welcome, there is no clear indication now of what new rules and guidance will be released, or when that crucial information will be provided. States deserve a predictable plan for future federal rule making on the “Affordable Care Act.” Without clear answers to basic questions, it would be imprudent for New Jersey to implement a State-based Exchange at this time. My decision today should not be interpreted as foreclosing future consideration on this matter. In fact, the federal government has provided states with the flexibility to amend their Exchange selection in subsequent years. Moving forward, I welcome further guidance from the federal government so that New Jersey can make a fully informed decision as to the best course of action for our residents and businesses. In short, I will not ask New Jerseyans to commit today to a State-based Exchange when the federal government cannot tell us what it will cost, how that cost compares to our other options, and how much control they will give the states over this state-financed option. We will comply with the “Affordable Care Act,” but only in the most efficient and cost effective way for New Jersey taxpayers. Until the federal government gives us all the necessary information, any other action than this would be fiscally irresponsible. Accordingly, pursuant to Article V, Section I, Paragraph 14 of the New Jersey Constitution, I am returning Senate Bill No. 2135(First Reprint) without my approval. Respectfully,/s/ Chris Christie Governor [seal] Attest:/s/ Charles B. McKenna Chief Counsel to the Governor


Cigna, Summit Medical become the latest accountable care organization partners in NJ

By Andrew Kitchenman

An agreement between insurance firm Cigna and Summit Medical Group reflects a growing trend of the state’s insurers and larger provider organizations pursuing accountable care organization-based collaborations.

The ACO model, a core component of healthcare reform, is a network of doctors, hospitals, and other healthcare providers that all work together to coordinate quality care for the patients they serve.

Under the agreement, which was announced Thursday and took effect Dec. 1, Cigna will pay Berkeley Heights-based Summit Medical Group for clinical care coordinators -- registered nurses who will serve patients with chronic ailments and other challenging conditions. The care coordinators will work to reduce hospital readmissions by providing follow-up care and screening to patients. They will collaborate on this with a team of Cigna case managers.

The ACO agreement with Summit Medical Group is Bloomfield, Conn., -based Cigna’s 42nd in the country and second in New Jersey, following a September 2011 agreement with New Brunswick-based Partners in Care.

In the accountable care organization model, insurers attempt to compensate medical providers for how well they perform and keep costs down, rather than for each service they provide. ACO agreements are on the rise with other New Jersey insurers, including Horizon Blue Cross Blue Shield of New Jersey, which reached its most recent agreement with AtlantiCare in October. An ACO-based approach also was authorized for Medicare patients under the federal Affordable Care Act.

Summit Medical Group Chairman and CEO Dr. Jeffrey Le Benger said the agreement is possible due to changes that his practice has been making in recent years.

“We’ve been changing our infrastructure to be able to control the cost of care,” including the how the firm approaches billing and record keeping, Le Benger said. By unifying all of a patient’s health information into a single record, Summit Medical Group has been able to avoid duplicating services, Le Benger said.

As in other ACO agreements, Summit Medical Group doctors will be rewarded with additional pay if they meet targets for improving quality and lowering medical costs. With more than 300 providers, Summit is the state’s largest physician-owned multispecialty practice.

Le Benger said his group has been taking other steps to reduce medical costs and improve patient health, including operating an urgent care center, which serves patients who need immediate treatment for conditions ranging from allergic reactions to pneumonia, but who are less likely to require hospitalization. Of the patients at the center, 3 percent are admitted for hospital stays, as opposed to the more than 20 percent of emergency room patients who are admitted.

In the future, Le Benger hopes that insurers will offer patients lower premiums and copayments if they choose to receive services from providers that have demonstrated high-quality care.

The agreement is the first for Summit Medical Group, but Le Benger said the medical practice is “moving in that direction with other major insurers."

The payments for care coordinators and incentives to doctors will raise Cigna’s overhead costs, but company officials are confident that those additional costs will be more than offset by savings from improved care.

Dr. Dan Nicoll, Cigna’s New Jersey market medical executive, contrasted the agreement with traditional fee-for-service payments in which “if you got one, you paid for one; if you got two, you paid for two” procedures, rather making payments based on what care provides the best value.

“With mutual respect, we can work on reducing the burden of illness and complications for a population” before they become costly and debilitating, Nicoll said. As examples, a care coordinator can work with a patient with asthma to help them avoid allergens and with a diabetic patient to make changes before they face kidney failure or lose their eyesight, he said.

“It’s going to serve our clients by improving the health of our populations and reducing their costs,” he said.

Charlie Catalano, president and general manager for Cigna in New Jersey, emphasized in a statement that heading off health problems at an early stage is a principal goal of the collaboration.

“Helping people reduce their health risks, preventing health problems before they happen, stopping disease before it progresses and helping to ensure the right care, at the right time, in the right place are all at the heart of our collaboration with Summit Medical Group,” Catalano said.

Nicoll touted the collaborative accountable-care approach as the next step in managing care, an improvement over having insurers deciding whether medical services were necessary, sometimes after they have been delivered.

He said Summit Medical Group was a good partner for the agreement because their longstanding relationship “made this easy

Practice Choices

Healthcare Provider, Insurer Seek to Lower Costs, Improve Quality

November 2012 13

for us. They have an enlightened leadership who understand where things are going,” with increased collaboration and a focus on value.

Cigna is looking for more ACO partners, but said they must have three attributes: forward-thinking leadership, a credible track record, and a significant customer base. Having enough providers and a healthy enough financial footing is not possible without large numbers of customers, Nicoll said. Therefore, a small practice with a perfect record of providing good care but without a large number of patients “is not going to work” for an ACO agreement, he said

Legal Issues

Three-judge panel rejects competitors’ attempt to block plans for branch of Hackensack University Medical Center

By Andrew Kitchenman,

Hackensack University Medical Center took another step on Tuesday toward ending a nearly five-year battle over its plans to reopen the former Pascack Valley Hospital in Westwood.

A three-judge state panel rejected two rivals’ appeal of state approval for Pascack Valley’s reopening.

The Appellate Division ruling rejected each of the arguments made by Englewood Hospital and Medical Center and the Valley Hospital, who sought to reverse state Health Commissioner Mary E. O’Dowd’s decision to approve a certificate of need for Pascack Valley. This certificate is required from the state before a hospital can open or close.

HUMC officials said the hospital, to be named Hackensack UMC at Pascack Valley, is on track to open in mid-2013. The 128-bed hospital is a for-profit partnership between the nonprofit HUMC and Texas-based hospital developer Legacy Hospital Partners Inc.

“Today’s decision reinforces the fact that the area residents need our services,” hospital CEO Chad Melton said in a statement. “With 70 percent of hospital construction complete, we are well on our way to the hospital opening, which is scheduled for June 2013.”

Officials with both Englewood and Valley expressed disappointment with the ruling.

Englewood Hospital and Medical Center lawyer James M. Hirschhorn said the hospital “is disappointed that the court failed to recognize the lack of need for a new acute care hospital in Bergen County and ignored the real economic impact that it will have on existing hospitals in an already well-served and shrinking market.”

Valley Hospital spokeswoman Megan Fraser said in a statement that hospital officials “remain strong in our belief – and the evidence continues to show – that our area does not need additional hospital beds. We also remain committed to providing the highest quality medical care and service to our community, including the thousands of Pascack Valley residents who have always chosen Valley for their healthcare services.”

It’s not clear whether the hospitals will appeal to the state Supreme Court. Officials with both hospitals said they are evaluating their options.

Pascack Valley Hospital closed in November 2007 after 48 years of operation. A few months later, HUMC bought its assets and submitted plans to reopen it, initially with Touro University College of Medicine as a partner and later with Texas-based LHP after Touro dropped out. That initiative ended in late 2009 when Pascack Valley Hospital’s license expired.

HUMC restarted the process in 2011. In its application, HUMC argued that Pascack Valley closed due to fiscal mismanagement, not lack of need. HUMC noted that it already is licensed for additional beds, but asserted that it would have to demolish facilities at Hackensack to make room for new beds. It preferred to add the beds in Westwood.

HUMC also argued that other hospitals aren’t easily accessible to Pascack Valley residents, that reopening the hospital is consistent with local needs, and that it would not have a negative impact on other local hospitals, partly because it would draw some patients from Hackensack rather than from the other hospitals.

In their appeal, Englewood and Valley attorneys argued that reopening Pascack Valley is unnecessary and would hurt their finances, particularly those of Englewood. Englewood officials argued that hospital occupancy rates are declining in the region despite an aging population, due to downward trends in hospital admissions and the length of hospital stays.

In addition, Valley officials argued that drive times from the Pascack Valley area to Englewood and Valley were within planning standards for hospitals.

Judges Jack Sabatino, Douglas M. Fasciale and Susan F. Maven rejected all of the arguments for reversing O’Dowd’s approval of the certificate of need.

“The market data generated since the closure of PVH, along with the many other analytic factors relied upon in the Commissioner's decision, provide reasonable support for her prudent exercise of regulatory judgment,” the panel wrote in its decision. “We will not

Court Upholds State’s OK of Hospital Reopening


question the wisdom of her policy-laden assessment.”Melton emphasized that reopening the hospital will lead to job creation, while Hackensack University Health Network President and CEO Robert C. Garrett also praised the decision.

“I am proud of the progress that has already been made at Hackensack UMC at Pascack Valley, and we look forward to providing world-class healthcare to the Westwood community next year,” Garrett said in a statement.

A 2008 state commission chaired by Princeton University healthcare economist Uwe Reinhardt found there was an oversupply of hospital beds in the northeastern corner of the state.

On Tuesday, Reinhardt expressed disappointment with how the state regulates hospitals. He said the state is wrong to require certificates of need, since it doesn’t regulate the prices hospitals charge.

Without a more tightly regulated system, Reinhardt said, the state should allow hospitals to open or close depending on whether they can receive private financing.

He said of a system in which the state controls whether hospitals can operate but doesn’t regulate prices: “The only technical word for that is stupid.”

“If you want to allow hospitals to price their services as they wish, then, I think, let competition rule,” Reinhardt said, arguing that the state must be prepared to allow any hospitals to succeed or fail.

“If Hackensack wants to open it again, if Hackensack is willing to bear the financial risk, fine, let them have it.”

Bits & Pieces

NJPURE v. Boynton & Boynton, 12-5610-Malpractice Carrier Claims Broker Defamed It in Medical Community

“Medical malpractice carrier NJPure is accusing an insurance brokerage of making false statements to doctors about it to get or keep business from competing carriers.

“NJPURE-New Jersey Physicians United Reciprocal Exchange-has sued Boynton & Boynton and vice president Kevin Byrne, who allegedly sent disparaging e-mails about its policies, business practices and solvency.

This suit is based on messages Byrne sent in August to Karen Kava, an employee of ObGyn Associates of North Jersey.

“The Hackensack doctor’s group had coverage from Medical Protective, one of six carriers handled by Boynton, but signed up with NJPURE, and Byrne was trying to win back the business.

“His Aug. 21 email to Kava included assertions that NJPURE might be facing a bad-faith claim as the result of a recent $5.59 million jury verdict and that it had been fined $10,000 for its own badmouthing of competitors.

“Those assertions were untrue, according to the complaint in NJPURE v Boynton & Boynton, 12-5610, filed in federal court in Trenton on Sept 7.“Boynton & Boynton vigorously disputes the allegations raised in NJ Pure’s complaint. NJ Pure’s claims against Boynton & Boynton are false, misleading and will be vehemently defended.

Unlike NJ Pure, Boynton and Boynton has never been accused by the Department of Banking and Insurance of making false statements to doctors. NJ Pure has actually paid an administrative fine of $10,000 in connection with such accusations.

Recently, AM Best demanded NJ Pure to cease disseminating information claiming an A.M. Best rating that does not exist.

NJ Pure admitted that they “mistakenly” provided unauthorized AM Best information to only a single person. Contrary to NJ Pure’s assertion, Boynton knows this was more than a single incident and as a result Boynton has been harmed by NJ Pure’s multiple “mistakes”. Boynton expects that additional incidents will be uncovered through their counterclaim and subsequent discovery process.

Boynton & Boynton has filed a motion to dismiss some of the claims raised by NJ Pure. Once that application is decided by the court, Boynton intends to assert claims of its own against NJ Pure for the false and misleading information that NJ Pure has communicated to its clients.”

Accutane Maker Seeks to Disqualify Judge Handling N.J. Mass LitigationAn attorney for drug maker Hoffmann-La Roche are asking for recusal of the judge assigned to New Jersey’s years-long, multicounty litigation over its acne medication Accutane. In a motion papers filed Tuesday, Roche’s lawyer charges that Atlantic County Superior Court Judge Carol Higbee’s words and actions “inexorably lead to the conclusion that the Court is no longer impartial and that its appearance of impartiality is irretrievably lost.” In his motion, Michael Griffinger pointed to, among other things, a May 2012 appearance Higbee made at a New Orleans seminar on coordinating pharmaceutical mass tort litigation hosted by DRI, a defense lawyer’s organization, which he said ran afoul of Code of Judicial Conduct Canon 5(a)(1), the rule directing judges to minimize conflicts during extrajudicial activities.

November 2012 15

Health Law Blog

Community Benefit Review of HospitalsAn Internal Revenue Service (IRS) official recently confirmed that the IRS has identified more than 3,000 tax-exempt hospitals whose community benefit activities will be reviewed to determine whether they are meeting the requirements for tax exemption, including review of Form 990, other returns and public records. The reviews will be staggered in annual phases. Hospitals will not be advised of whether they are being reviewed and will not know when the reviews commence or are completed.

The impetus for these reviews is an Affordable Care Act provision imposing new requirements on tax-exempt hospitals, including conducting community health needs assessments and implementing a financial assistance policy. Factors to be looked at include whether the hospital: (1) has a community board; (2) has an accessible and open medical staff; (3) has a full-time emergency room open to all regardless of ability to pay; (4) admits all kinds of patients despite their payment source; and (5) uses its excess

funds for purposes such as equipment, medical training, education and research.

For additional information, contact:

Lani M. Dornfeld | 973.403.3136 | [email protected] Todd C. Brower | 973.403.3103 | [email protected]

Essential Health Benefits and Insurance ExchangesThe U.S. Department of Health and Human Services released proposed rules to implement key aspects of the Affordable Care Act. Among other matters addressed, the proposed rules elaborate on the definition of “essential benefits,” the services that insurance plans must cover beginning in 2014. Categories of essential benefits include ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care. Each state is required to establish a benchmark plan based on standard health plans issued in the state, as well as how the state will supplement each category of services in relation to a state’s benchmark plan.

The proposed rules also outline insurance exchange and issuer standards related to the coverage of essential benefits and actuarial value and related issues, but additional information on exchanges is expected to be published shortly. The exchanges must become operational by January 1, 2014. Comments to the proposal are due by December 26, 2012.


John D. Fanburg | 973.403.3107 | [email protected] Keith J. Roberts | 973.364.5201 | [email protected]

Friendly, Compassionate Staff to Serve the Urban Patient

The Smith Center for Infectious Diseases and Urban Health was developed to address infectious diseases in the inner city. This non-profit center, which is initially focusing on HIV, recognizes that inner city patients face many unique challenges in their daily lives. These challenges interfere with treatment of infectious diseases and foster an environment where infectious diseases are easily spread. When you treat a person with HIV, you greatly reduce the chances of transmission and treat the whole community. In the past 10 years there have been incredible advances in HIV treatment. We at the Smith Center believe that by using novel approaches we can rid New Jersey of HIV.

We have designed programs to incentivize patients to continue their medications. We have created a personal atmosphere, where each patient is known by her or his first name. We work with our patients to ensure that we are providing the best service possible.

310 Central Avenue, Suite # 307 • East Orange, NJ 07018 Phone: 973-809-4450 Fax: 973-395-4120 • www.smithcenternj.org

Dr. Stephen Smith - named a Top Doctor of New Jersey by Castle Connolly


Proposed Health Insurance Market RulesCenters for Medicare & Medicaid Services (CMS) recently released proposed rules to implement the Affordable Care Act’s policies relating to the health insurance market. The proposals include sections prohibiting insurers from denying coverage to individuals due to pre-existing conditions, gender, occupation, medical history and certain other factors, and also prohibiting insurers from refusing to renew a policy based upon a covered person’s pre-existing condition or if that covered person has become ill. Insurers will also be limited in varying premiums with respect to a particular plan or coverage based only upon the factors of age, tobacco use, family size and geography, and insurers will also be required to accept every individual or employer who applies for coverage in the individual or group market, subject to certain exceptions.

The proposal also contains provisions regarding statewide risk pools, rate changes and enrollment in catastrophic plans. Comments are due to CMS no later than December 26, 2012.


Mark Manigan | 973.403.3132 | [email protected] Joseph M. Gorrell | 973.403.3112 | [email protected]

HIPAA and SubpoenasDid you know that a subpoena, on its own, is not sufficient for the production of medical records? Pursuant to the requirements of HIPAA, a health care provider may only release protected health information (PHI) in response to a subpoena if it is accompanied by either a valid authorization signed by the patient, a court order or a written statement and documentation that the requesting party made a good faith attempt to either (i) provide written notice to the individual and such notice contains certain information, or (ii) secure a protective order.

On a case-by-case basis, it may be difficult to determine, based on the information provided with the subpoena, that these requirements are being met. Therefore, subpoenas must be carefully reviewed to ensure compliance. Note that New Jersey courts have found doctors liable for disclosing medical records in response to subpoenas without the patient’s consent.

Finally, as a reminder, information still cannot be released prior to the date stated in the subpoena, which date must be at least 10 days after receipt of the subpoena (the purpose of which is to give the individual to whom it pertains the opportunity to object). In addition, if covered health care providers disclose PHI pursuant to a subpoena, they are required to maintain a log of this disclosure for accounting purposes (i.e., this is the type of disclosure that a patient could request an accounting of in the future).


Todd C. Brower | 973.403.3103 | [email protected] Lani M. Dornfeld | 973.403.3136 | [email protected]

Health Law Update

November 2012 17

DOBI Adopts New PIP RegulationsThe New Jersey Department of Banking and Insurance (DOBI) has adopted new personal injury protection (PIP) regulations. The majority will go into effect on January 1, 2013, while those outlining internal appeals for pre-certifications went into effect on November 5, 2012.

Although proposed regulations were published twice with comment periods, in August 2011 and February 2012, the regulations were adopted, for the most part, unchanged. Some of the more salient adopted regulations include:

• ThePIPfeescheduleprovideshigherreimbursementforsurgicalproceduresperformedinahospitalsettingversusthesame procedures performed in a freestanding ambulatory surgery center (ASC); some procedures will not be reimbursable in an ASC setting

• 111(oftheproposed117)neurosurgicalandspinalsurgicalcodesweredeleted

• Pre-certification is subject to an internal appeal process; if not filed, a healthcare provider is barred from initiatingarbitration

• Claimsoflessthan$1,000willbearbitratedandresolvedonthepaperswithoutanin-personhearing

• PIPreimbursementwillbesubjecttotheMedicareClaimsProcessingManual,theNationalCorrectiveCodingInitiativeandguidance from the Center for Medicare and Medicaid Services.

Given that the newly adopted regulations will have a significant negative impact across a wide spectrum of healthcare providers, these regulations are being challenged. Stay tuned.


Mark Manigan / 973.403.3132 / [email protected]

Keith J. Roberts / 973.364.5201 / [email protected]

Affordable Care Act: Essential Health Benefits and Insurance ExchangesThe U.S. Department of Health and Human Services released proposed rules to implement key aspects of the Affordable Care Act. Among other matters addressed, the proposed rules elaborate on the definition of “essential benefits,” the services that insurance plans must cover beginning in 2014. Categories of essential benefits include ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care. Each state is required to establish a benchmark plan based on standard health plans issued in the state, as well as how the state will supplement each category of services in relation to a state’s benchmark plan.

The proposed rules also outline insurance exchange and issuer standards related to the coverage of essential benefits and actuarial value and related issues, but additional information on exchanges is expected to be published shortly. The exchanges must become operational by January 1, 2014. Comments to the proposal are due by December 26, 2012.


John D. Fanburg / 973.403.3107 / [email protected]

Keith J. Roberts / 973.364.5201 / [email protected]

Health LawUpdate


Affordable Care Act: Proposed Health Insurance Market Rules Centers for Medicare & Medicaid Services (CMS) recently released proposed rules to implement the Affordable Care Act’s policies relating to the health insurance market. The proposals include sections prohibiting insurers from denying coverage to individuals due to pre-existing conditions, gender, occupation, medical history and certain other factors, and also prohibiting insurers from refusing to renew a policy based upon a covered person’s pre-existing condition or if that covered person has become ill. Insurers will also be limited in varying premiums with respect to a particular plan or coverage based only upon the factors of age, tobacco use, family size and geography, and insurers will also be required to accept every individual or employer who applies for coverage in the individual or group market, subject to certain exceptions.

The proposal also contains provisions regarding statewide risk pools, rate changes and enrollment in catastrophic plans. Comments are due to CMS no later than December 26, 2012.


Mark Manigan / 973.403.3132 / [email protected]

Joseph M. Gorrell / 973.403.3112 / [email protected]

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Food for Thought

Montclair, New Jersey

By Iris Goldberg

Although Michael and I have always considered Montclair to be one of our favorite New Jersey towns with its diverse collection of wonderful restaurants, interesting shops and cultural offerings, it has become even more special to us. It is now the home of our daughter, our son-in-law and Isabel. I’m sure you’ve figured out that wherever Isabel would be living would be a frequent destination for us. The fact that Montclair is where our kids decided to move after the birth of our first grandchild is a real bonus for us.

We have been sharing with them some of our favorite Montclair eateries and they have been doing some of their own investigating. Next Door is a place I think they would enjoy. The concept is an unusual one. It was opened by Zod Arifai, who is the owner and chef of Blu, a hugely successful American and fusion restaurant that has been a favorite for many who live in and around Montclair for years. When the storefront next to Blu became available, Mr. Arifai had the idea to start a second restaurant that would be smaller, more casual and less pricey. He also had the idea to name it Next Door.

Last night (a Saturday), after spending a glorious afternoon with Isabel, we dropped into Next Door, without a reservation at about 6:30. It was about half-full and the maitre d’ graciously showed us to a table for two. The place is long and narrow with tables on both walls.

Next Door is known for comfort foods like meat loaf and spaghetti Bolognese and the prices are below $20, some below $15. It has also been named as serving the best hamburger in New Jersey by more than one food reviewer. The menu changes regularly and reflects seasonal foods as well old standbys.

I started with a sashimi of salmon with chili, lime and apples. This was served thinly sliced with a subtle lime dressing and chunks of green apples. The red specks of chili were obvious but not overpowering - just the right amount of kick.

Michael had a Napa/Asian green salad with a spicy peanut dressing. This was delicious! The dressing was perfectly seasoned and the crunchy noodles added a great texture. I must admit, I helped myself to more than just a taste.

For my entrée I tried something I had never before eaten – lamb meatballs. These came with fusilli in tomato sauce with goat cheese and olives. I loved the flavor of the meatballs! They were moist and tender and the chopped onion was definitely a great addition. The pasta was good too. The black olives and goat cheese went very well with the hearty lamb.

I was surprised when Michael ordered roast chicken with chipotle served on top of soft polenta. He never eats chicken out but the description of the dish enticed him. He was not sorry. In fact, Michael commented that all of the food was seasoned to perfection. His chicken had a nice zing without being overly hot.

After the many flavors we had been treated to, we definitely needed to end our meal with something sweet. We selected something called peanut butter chocolate crisp to share. This was a cookie on the bottom with a peanut butter cream filling and a luscious chocolate bar on top. I think that says it all.

We walked to the car feeling warm and satisfied. There was no need to speak. We had just shared a wonderful meal and before that the pleasure of spending time with Isabel. It really doesn’t get any better than that.

Next Door is located at 556 Bloomfield Avenue, Montclair, NJ

September 2012 21

September 2012 23


Food For Thought

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