County Line
Newsletter LIV July 2004
Contents
CCMS installs new officers, trustees at Green Valley ranch
Subpoena Duces Tecum and the HIPAA Privacy Regulations
Applicants To Go Before Credentialing Committee
FSAS, HSAS, AND HRA’s - The Alphabet Soup of New Health Insurance
Community-acquired methicillin-resistant Staphylococcus aureus
Clark County Health District Disease Statistics* - May 2004
CCMS installs new officers, trustees at Green Valley ranch
Above: the 2004-2005 CCMS Board of Trustees at the dinner Trustee Jerry Jones, MD; Past President Ed Kingsley, MD; President-Elect Ron Kline, MD; NSMA President-Elect Warren Evins, MD, President Michael Colletti, MD, Trustee Mark Doubrava, MD, Trustee Annette Teijeiro, MD, Trustee George Alexander, MD, Trustee Anil Batra, MD, Trustee Larry Cohler, MD, (front) Trustee Michael Clifford. (Not pictured: Treasurer David Steinberg, MD; Secretary Florence Jameson, MD; Delegate Chair Bashir Chowdhry, MD; Trustee David Mulkey, Trustee Carol van der Harten-Algier, MD; and Trustee John Kurlinski, MD.)
Below Right: State Assemblyman Bob Beers attends the Installation Dinner to congratulate incoming President Dr. Colletti.
Below Center: Dr. Kingsley presents the Harold Lee Feikes Physician of the Year award to Robert Shreck, MD.
Below Left: Dr. Kingsley introduces CCMS Alliance Co-Presidents Kathie Slaughter (right) and Marian Haas (left).
Subpoena Duces Tecum and the HIPAA Privacy Regulations
By Weldon (Don)
Havins, MD, Esq., Clark County Medical Society, and Kelly Testolin, Esq.,
Partner, Hale Lane Peek
Dr. A, a Las Vegas family practitioner, recently received a Subpoena Duces Tecum for medical records of one of his patients. The subpoena commanded Dr. A to "appear and attend before a certified Court Reporter" at the specified office and at a specified date and time, and "then and there testify on the part of Defendants"; bringing "any and all records and billings in his possession, custody, or control" relating to the Plaintiff. The subpoena also threatened: "for failure to attend, you will be deemed guilty of contempt of Court and liable to pay all losses and damages sustained thereto to the parties aggrieved and forfeit one hundred dollars in addition thereto."
Dr. A called the Defendant's attorney who signed and had served the subpoena to inquire about the lack of a HIPAA-compliant authorization. The attorney told Dr. A that an authorization was not needed under HIPAA, and that Dr. A would be held in contempt of court if he did not comply by appearing at the specified deposition and produce the patient's medical records.
After some difficulty, Dr. A did contact the patient who stated she refused to authorize or permit her medical records to be disclosed to the Defendant's attorney. Dr. A was concerned that release of the patient's medical records without her specific HIPAA compliant authorization1 would induce the patient to sue Dr. A for breach of confidentiality, medical malpractice, and intentional infliction of emotional distress. Further, Dr. A was convinced that the patient would also file a formal complaint with the Office of Civil Rights in the Department of Health and Human Services. Dr. A was aware of both the civil penalty (up to $25,000 fine) and criminal (1 year imprisonment or $50,000 fine) penalty for an unauthorized disclosure of an individual's protected health information.
Looking online (www.findlaw.com), Dr. A noted the above mentioned Code of Federal Regulations provides the standard for disclosure of protected health information in judicial and administrative proceedings. Specifically, the regulation states that a health care provider MAY disclose protected health information in response to a subpoena … that is not accompanied by an order of the court, if the covered entity receives satisfactory assurance from the party seeking the information that reasonable efforts have been made to ensure that the individual who is the subject of the protected health information … has been given notice of the request. Satisfactory assurance means that the patient or patient's attorney has received written documentation (or there has been a good faith effort to deliver written documentation) notifying the patient of the request for medical records so that the patient or patient’s attorney has sufficient time to object in court to the request.2
The materials served to Dr. A from the attorney included a declaration stating that the attorney had contacted the counsel for the Plaintiff by telephone and then in writing to advise him that because he had refused to authorize release of medical records of the Plaintiff, a deposition of the custodian of records would be issued. This would appear to satisfy the notice requirement of the Code of Federal Regulations, 45 CFR 164.512, and therefore justify the non-authorized disclosure of the Plaintiff's medical records. However, the Defendant attorney's reliance on that specific regulation demonstrates a selective and incomplete application of the entire HIPAA Privacy Regulations.
The HIPAA Privacy Regulations provide that State laws that are contrary to the HIPAA regulations are preempted unless the State law is "more stringent" and thereby provides more protection of an individual's protected health information than HIPAA.3 Nevada Revised Statutes provide that generally all information related to the health care of a patient is confidential.4 Nevada law provides that some of this confidential information is further specifically protected by additional access restrictions.5 The only Nevada statute specifically to address the disclosure of medical records is NRS 690B.042 which provides that in auto vehicle accidents in lieu of the claimant (plaintiff) producing medical records, the claimant or claimant's attorney may provide a written authorization to receive the medical records from the provider of health care.6
To most commentators it appears that Nevada's laws related to disclosure of protected health information in a civil lawsuit are "more stringent" than the HIPAA Privacy Regulations, and thus, without a court order or an authorization, Dr. A is obligated to protect the privacy of his patient's medical records. Dr. A felt that refusing to disclose the medical records (as commanded in the subpoena) without the patient's authorization or a court order, would protect him from claims from his patient for unauthorized disclosure. However, Dr. A was very concerned that the defendant's attorney would drag him into court and attempt to have Dr. A found in contempt of court.
Dr. A's dilemma: comply with the subpoena duces tecum under the theory that the HIPAA regulations preempt Nevada laws protecting the confidentiality of medical records, or refuse to comply with the subpoena, and hire an attorney when he receives the inevitable motion to find Dr. A in contempt of court. Being sued by your patient for medical malpractice, breach of confidentiality, and intentional infliction of emotional distress for unauthorized disclosure of medical records will probably be covered under Dr. A's professional liability malpractice insurance policy, but any money paid on the claim may be used by the insurer to justify substantial increases in future premiums (or used to drop Dr. A as an insured). Defending a motion for contempt of court will likely not be a covered claim under Dr. A's insurance policy and Dr. A will be out of pocket up to several thousand dollars and many hours of office time.
In a contempt hearing if the court found that Nevada's laws protecting medical record confidentiality are preempted by the HIPAA Privacy Regulations, Dr. A would likely be subject, in addition to paying his own attorney's fees and costs, paying the adversarial attorney's costs and fees. If the court found Nevada's laws to be "more stringent" than the relevant HIPAA regulation, Dr. A could ask for reimbursement of his own costs and ask for reimbursement of his "reasonable" attorneys fees. Until an appellate court of jurisdiction rules on the issue of preemption or non-preemption of Nevada state laws by the specific HIPAA regulation (45 CFR 164.512(e)), physicians will continue to suffer the ambiguity of what action to take when a subpoena duces tecum is served without a HIPAA-compliant authorization signed by the patient or patient's legal representative.
In the meanwhile, there may be a way to attempt to avoid these unpleasantries. The Nevada Revised Statute on subpoenaed records7 states that a custodian of medical records sufficiently complies with a subpoena for the production of medical records if he delivers, in person or by mail, to the clerk of the court issuing the subpoena a true and exact copy of the original records8 properly authenticated by a notarized affidavit9 signed by the custodian of the medical records. Complying with the statute, Dr. A delivered the sealed medical records to the clerk of the court in Clark County. He notified the attorney who had signed the subpoena duces tecum that the records were delivered to the court clerk. Dr. A attempt to contact his patient's attorney to notify him that the records had been delivered to the court clerk. By taking his action, Dr. A complied with the subpoena, with HIPAA, and with Nevada statutes. By letter, Dr. A also informed the court that the records may be protected from "more strict" Nevada law and an authorization may be required before the court releases the records to the requesting attorney. The patient's medical records are now under the jurisdiction of the court, and the court can order the records released to the Defendant's attorney or can order the sealed records returned to Dr. A. While there can be no certainty at this time, we believe that a court would be unlikely to find Dr. A liable for contempt when Dr. A has placed the medical records within the jurisdiction of the court, and unlikely to find that Dr. A had violated his duties of confidentiality to the patient under HIPAA or Nevada state laws.
While Dr. A's handling the subpoena duces tecum, presented without a HIPAA compliant authorization of his patient, could ultimately be held to be unsatisfactory by a court, his good faith effort to comply in a manner that did not create an onerous financial and time burden on his medical practice seems reasonable. This problem will repeat itself and burden other physicians until an appellate court determines whether this particular HIPAA regulation preempts Nevada's laws protecting the confidentiality of patient's medical records.
Footnotes and examples are provided on the following pages.
1 An example of a HIPAA compliant
authorization is appended below. See
also 45 CFR 164.508.
AUTHORIZATION FOR THE RELEASE OF
PROTECTED HEALTH INFORMATION
This Authorization authorizes the
release of Protected Health Information pursuant to 45 CFR Parts 160 and 164.
Provider's name: _________________________________________
Patient's name:
__________________________________________
1. The
patient authorizes the above-named provider ("Provider") to release
any and all information, including billing statements, regarding the patient's
condition when under your observation or treatment, including history, findings
and observations, conclusions, x-ray readings and diagnoses, and your prognosis
as to subsequent or future development. You may also release any and all
myelograms, CAT scans or MRI images for independent examination.
2. The
information may be disclosed by employees or business associates of Provider.
3. The
information may be disclosed to [Law Firm], their representatives, employees
and contractors for independent examination.
It may also be disclosed to the counsel and co-counsel of any other
person who is a party to the litigation in which the patient is involved. Disclosure may be made orally or in writing
and you may allow them to photocopy my records.
I understand and agree that the information
to be disclosed includes the following types of information which are protected
under Nevada or other federal law:
3.1 _____ blood,
breath or urine test results
3.2 _____ communicable
disease information, including information about sexually transmitted disease,
including HIV and AIDS.
3.3 _____ information
about mental health treatment I have sought and/or received.
3.4 _____ information
about drug and/or alcohol abuse treatment I have sought and/or received.
4. The
disclosure may be made at the patient's request for the purpose of
litigation.
5. This
authorization will expire one year from the date this authorization is signed,
or at the end of the litigation, which ever is last to occur.
6. I
acknowledge: (i) that I have the right to revoke the authorization at any time,
and (ii) that I understand that once the information is disclosed hereunder, it
may no longer be protected by federal privacy law. I understand that I may
revoke this authorization only in a writing sent by certified mail to the
Provider at the address above. The
revocation will be effective only upon receipt, except (1) to the extent the
Provider has acted in reliance on the authorization, or (2) the authorization
was obtained as a condition of obtaining insurance coverage and the insurer
wishes to use to the protected health information to lawfully contest a claim.
Further information on the right to revoke may be provided from time to time in
the Provider's Notice of Privacy Practices.
7. I
understand that treatment by the Provider is not conditioned on my signing this
authorization, although exceptions will be made for (a) research-related
treatment, (b) for treatment the purpose of which is creating protected health
information for a third party, such as pre-employment physicals, and (c) except
for psychotherapy notes, for health plans which condition enrollment on an
authorization requested prior to enrollment, or where payment is conditioned on
an authorization to use PHI to determine payment.
Date:____________________________
Signed by :________________________________
If person signing is other than patient,
state authority under which signature is made: _________
2 45 CFR 164.512(e)(1)(ii)(A).
3 45 CFR 160.202 and 45 CFR 160.203.
4 NRS 449.720(4) provides,
"discussions of a patient's care, consultations with other person
concerning the patient, examinations or treatments … are confidential."
5 NRS 441A provides that any one of 66
communicable diseases must be reported to the Public Health Officer. One can infer that this information can only
be released upon the patient's authorization or at the discretion of the Public
Health Officer acting in the public health interest of the community. NRS 629.065 state that the results of blood,
breath, or urine tests may only be disclosed to law enforcement and then only
when law enforcement reasonable suspects that the patient was operating a motor
vehicle or water craft under the influence of an intoxicant. By implication, these records cannot be
released without an authorization by the patient (unless otherwise specifically
provided in law).
6 NRS 690B.042.
7 NRS 52.325
8 NRS 52.325(1)
9 NRS 52.325(2) and NRS 52.260. Affidavit must be substantially in the
following form:
CERTIFICATE OF CUSTODIAN OF RECORDS
State of
Nevada }
}ss.
County of
………….............. }
NOW COMES
___________________________, who after first being duly sworn deposes and says:
1.
That the deponent is the __________________________ of
___________________________ and in his/her
(position or
title) (name of
employer)
capacity as
__________________________ is a custodian of the records of
_____________________________
(position or
title)
(name of employer)
2.
That _________________________ is licensed to do business as a
___________________________ in the
(name of employer)
(profession or type of business)
State of
Nevada.
3.
That on the ____ day of the month of ___________ of the year _______,
the deponent was served with a subpoena
in
connection with the above-entitled cause, calling for the production of records
pertaining to _________________________
(name
of patient)
4.
That the deponent has examined the original of those records and has
made or caused to be made a true and exact
copy of
them and that the reproduction of them attached hereto is true and complete.
5.
That the original of those records was made at or near the time of the
act, event, condition, opinion or diagnosis
recited
therein by or from information transmitted by a person with knowledge, in the
course of a regularly conducted
activity of
the deponent or __________________________
(name of employer)
Subscribed
and sworn to before me, a Notary Public, on this _____ day of the month of
_______________ of the year _______
Notary
Public _______________ County, Nevada
My
appointment expires:
President’s Message
By Michael P.
Colletti, M.D., 2004-2005 CCMS President
Following are Dr.
Colletti’s prepared statements from the 2004 Installation Dinner, which he
paraphrased at the June 12th event.
Doctor Kingsley, members of the Clark County Medical Society, and guests, I appreciate the opportunity to address you tonight. I want to thank you for the honor and privilege to serve as President of the Clark County Medical Society for the next year. This promises to be an exciting and important time for us and our patients. If we work hard and stay united, then many of our goals can be achieved. I look forward to working with our excellent Board of Trustees. I know every one of them wants to be an active board member and will work hard to ensure the success of the CCMS.
I also want to acknowledge and thank our excellent CCMS staff: Dot Freel, Deborah Barton, and Marlaina Burns for their hard work, efficiency and dedication. I particularly want to thank our Executive Director/CEO Don Havins, MD, JD for all he has taught me over the last few years as well as his friendship.
The problems we and our patients face in Clark County are symptoms of much larger issues across the United States. The federal and state budgets are strained. Good jobs are being outsourced from the country via the internet to third world nations with people willing to do them for a fraction of the U.S. cost. Our brave men and women in military service are making great sacrifices and, in some cases, paying the ultimate price to keep us safe in our own country while our borders remain unguarded. Some schools have become unsafe for our children. Teachers are unable to teach because of a breakdown in discipline and lack of support from parents and school administrators. The list seems endless.
When I started my rheumatology practice in Las Vegas in 1988, many patients told me they went to Santa Barbara or other places out of state for medical care. When I asked them why, they told me doctors and medical care were not good in Las Vegas. In the following few years, many young physicians, board certified in their specialties and enthusiastic about medicine, came to Clark County. Medical care continuously improved. After that, I rarely heard patients complain medical care was not good in Clark County. We know it became very good. Unfortunately, over the last few years, it has declined and continues to do so at an alarming rate. Physicians, hospital and nursing home staffs, and other health care providers are no longer optimistic. Many physicians, especially those hardest hit by skyrocketing insurance premiums, have left the state, retired early, or limited their malpractice exposure by no longer performing high-risk procedures. Thirty years ago, it would have been unthinkable for a physician not to take care of the sickest patients or those in most need because they were concerned about being sued.
When I was about eight years old, I remember my mother taking me to the doctor for something minor. When it came time to pay the bill, I asked about it. My mother told me that we had insurance and they would cover it. In those days, insurance was a good thing. Insurance companies were not thought of as evil. It was reassuring to have all kinds of insurance. The doctor and medical bills would get paid and if something terrible happened; it would not devastate our family financially. Over the years, that has changed.
We are now barraged with commercials from trial attorneys telling us, in essence, that insurance companies are the enemy. They are not here to protect us. They are trying to cheat us out of what is rightfully ours and we need an attorney to protect our rights and get us as much money as possible. Naturally, attorneys do not do this for free. They exact thirty-three to fifty percent of every payout through contingency fees. We know how litigious the whole country, especially Clark County, has become. Greed, part of human nature, has been exploited, and turned our malpractice insurance into a lottery prize.
Hospital consultations by some specialists are of growing concern. Just two years ago, along with many physicians, I went to the Grant Sawyer building in Las Vegas. The state Insurance Commissioner held a meeting in Carson City, televised by closed circuit to the Sawyer building, to determine if there was a problem with malpractice insurance in the state. During the meeting, an attorney in Carson City stated when attorneys sue on behalf of a hospitalized patient they sue all the doctors involved in the patient's care, regardless of the individual physician role in an unexpected or bad outcome. They wanted to avoid the "empty chair" defense. They would then, over months to years, dismiss the physicians they felt were not liable. The insurance commissioner, on a first name basis with the attorney, seemed to agree with this logic. I felt my blood boil. Physicians take being sued extremely personally. We view it as an attack on our character and our skills. It is estimated the initial cost to our malpractice carriers just to open a claim is $25,000.00. At that moment, I reevaluated whether I wanted to continue to take the risk of doing hospital consults.
The soaring cost of health care premiums for many people in Clark County is limiting their access to quality health care. Rapidly escalating co-pays, monthly premiums, and deductibles, are placing financial burdens on many working families and senior citizens. Employers are finding it increasing difficult to afford health care insurance for their employees. They have responded by having the employees assume more of the financial burden or not continuing to offer healthcare coverage. Almost without fail, the cost of health care is of major concern in union negotiations with management. Just recently, the Teamsters delivering Coca-Cola in Las Vegas were asked to have their members pay $200.00 more per month toward their monthly premiums. Medicare secondary insurance for seniors and the disabled used to be nominal. Now, it can be hundreds of dollars per month.
We, as physicians, have become very concerned about protecting our assets. We live in fear of a malpractice award exceeding the limits of our liability policy. We have been encouraged to protect assets by sending money to offshore banks, forming corporations, putting our property in a spouse's or trusted person's name, or new systems developed in the state but not yet fully tested in the courts. It is as if other professionals in society can accumulate retirement funds, but physicians are being excluded from this security. In states such as Florida, many doctors are forced to go without malpractice insurance and are doing all they can to protect the assets for which they have worked so hard. If these trends continue, we may all have to seek to become "judgment proof".
The Clark County Medical Society has become involved with the Southern Nevada Medical Industry Coalition. This is a relatively new group of business leaders, local government officials, members of the Chambers of Commerce, education leaders and many others who see the need for strengthening medical care in Southern Nevada. We all know that continued growth is to be expected in Clark County. We also know that growth and the opportunities to prosper will be directly linked to the affordability and availability of quality medical care. The last thing any business or state and local governments want to become public is that Las Vegas and Henderson again have again developed a reputation for poor health care. They will not enjoy explaining that many of the best doctors have been forced to leave because they were poorly reimbursed by third party payors, could not afford outrageous malpractice insurance premiums and were tired of being sued. It will be impossible to replace these high quality physicians any time in the near future.
I want to thank our CCMS Auxiliary lead by Annette Mohs, Karen Schroeder and Debbie Chino. They, and their fellow members, through their creativeness, hard work, and enthusiasm, have been an inspiration to me and the Board of Trustees. They have a nursing student scholarship program. Using theirs as our model, we have expanded our Scholarship Fund program to award twelve nursing students interested in staying in Clark County $1,000.00 each. Four students are selected from the three nursing schools (UNLV, CCSN, and Nevada State College). Though our ties with the Southern Nevada Medical industry Coalition, we have working relationships with the heads of these three nursing programs. As part of the Coalition, the nursing education committee has created and distributed brochures to high school students advocating nursing as a professional career choice. To date, we have many more highly qualified students applying for the available positions. Our next goal is to raise scholarship money from the business community to "sponsor" a nursing student. We are also working for higher funding from the state to increase the number of nursing student positions. We also realize we are doing so when our state, local and federal governments are under severe financial stress.
This will be an exciting and challenging political year for us. The initiative, "Keep Our Doctors In Nevada (KODIN) will be on the November ballot. It is Question # 3. We need our patients to vote for this and we must take an active role in our offices to explain this to them. We have "appointment cards" and brochures explaining KODIN and its importance to them, our patients, in keeping you, their doctor, from leaving the state, retiring early or limiting your services.
We need to show doctors think KODIN is important and are financially committed to seeing this important legislation pass and eventually withstand state Supreme Court challenge as did MICRA in California about 20 years ago. Rather than asking for a large amount, I suggest we give $100.00 to start. The more doctors we have giving, the more doctors we can say are supporting KODIN. If you want to give more, by all means, do so. If you want to give less, any contribution will be greatly appreciated and we can give more when we are further convinced it is money well spent.
Again, I want to thank you for the opportunity to serve as your president. Together, we can continue to build the Clark County Medical Society into a strong advocate for quality health care in Clark County and all of Nevada.
New Members - May 2004
Congratulations and Welcome to the Clark County Medical Society
- Peter A Caravella, MD, General Surgery, 700 Shadow Lane #370, Las Vegas, NV 89106
- Martin J Carignan, MD, General Surgery, 700 Shadow Lane #370, Las Vegas, NV 89106
- Harry M Condoleon, DO, General Surgery, 2655 Box Canyon Dr, Las Vegas, NV 89128
- Michael E Seiff, MD, Neurosurgery, 3061 S Maryland Pkwy #200, Las Vegas, NV 89109
Reinstated Member
- James R Dettling, MD, Orthopaedics, 3121 S Maryland Pkwy #600, Las Vegas, NV 89109
Applicants To Go Before Credentialing Committee
If you have any pertinent information about the following membership candidates, please contact: Clark County Medical Society, 2590 E. Russell Rd., Las Vegas, NV 89120
- Keith R Brill, MD – OB-GYN
- Scott C Chang, MD – Diagnostic Radiology
- Christopher M Milford, MD – Neurology
- Venerando S Seguritan, MD – Diagnostic Radiology
For information on becoming a member of the Clark County Medical Society, call Marlaina Burns at 739-9989
Clark County District Court Medical Malpractice Filings Against Health Care Providers, Jan 2001 - May 2004
2001 2002 2003 2004
Jan 39 33 109 50
Feb 20 14 88 68
Mar 35 30 148 104
Apr 37 34 101 74
May 37 35 108 48
Jun 27 24 98
Jul 19 100 97
Aug 54 51 63
Sep 20 65 85
Oct 37 83 114
Nov 38 184 50
Dec 9 170 55
Sum 372 823 1116
FSAS, HSAS, AND HRA’s - The Alphabet Soup of New Health Insurance
By Chase Kingsley
As a follow-up to the article in the June 2004 "County Line" issue about Health Savings Accounts, this article goes into greater detail as to how Health Savings Accounts (HSA's), Flexible Spending Accounts (FSA's) and Health Reimbursement Arrangements (HRA's) work.
A health savings account is a tax-sheltered savings account that is earmarked for medical expenses when an individual uses their insurance policy for office visits, lab work, etc. The account is set up to be used in combination with a high-deductible health insurance policy. HSA funds can be used to cover the health insurance deductible and co-payments for medical services, prescriptions, and other services. In addition, HSA funds can be used to purchase over-the-counter drugs, long-term care insurance, and to cover health insurance premiums during periods of unemployment. HSA's are owned by the individual, not the employer, and are portable. This alleviates the burden of being dependent on the employer if the individual changes jobs.
In addition, HSA's, FSA's and HRA's provide certain tax advantages (among other features) to employers and employees alike. The following provides information on these types of accounts and a comparison chart on key features for each type.
Flexible spending
accounts
Health care flexible spending accounts are employer-established benefit plans that reimburse employees for specified medical expenses as they are incurred. These accounts are allowed under section 125 of the Internal Revenue Code and are also referred to as "cafeteria plans" or "125 plans." The employee contributes funds to the account through a salary reduction agreement and is able to withdraw the funds set aside to pay for medical bills. The salary reduction agreement means that any funds set aside in a flexible spending account escape both income tax and Social Security tax. Employers may contribute to these accounts as well.
There is no statutory limit on the amount of money that can be contributed to health care FSA's. However, some companies place a limit of $2,000 to $3,000 on FSA's. Once the amount of the contribution has been designated during the open enrollment period (which occurs once each year), the employee is not allowed to change the amount or drop out of the plan during the year unless he or she experiences a change of family status, or a change in eligibility. By law, the employee forfeits any unspent funds in the account at the end of the year.
Qualified expenses under an FSA include most benefits ordinarily resulting in no taxable income to employees. An FSA could be established to pay the employee's contribution toward the monthly cost of health coverage, medical expenses not covered by the health plan, such as deductibles and co-payments, and dental or vision expenses. Even if medical expenses are not deducted on an individual's federal tax return, because the amount does not meet the percentage of pay required for federal income tax deductions, these expenses can be paid on a pre-tax basis through an FSA.
All expenses must be qualified medical or benefit expenses as defined in Section 125 of the Internal Revenue Code. Expenses for health club dues and non-prescription drugs, for example, are not defined as qualified expenses under the Code, and would not be eligible expenses under the FSA.
How Does an FSA Work?
Voluntary Election - An individual participating in a FSA voluntarily elects to reduce his/her gross pay by a specified amount. If the money is designated to pay for the employee's share of the health care premium, the employer automatically uses the deducted amount to pay the employee's share of the premium. Any money that is designated to pay for other qualified expenses is reimbursed to the employee upon submission of proper documentation showing the expense incurred. The employee is reimbursed up to the amount deducted from gross pay for expenses covered by the FSA.
Employer Obligation -The employer must make available to the employee the full amount of the benefit whenever reimbursable expenses occur. For example, an employee who designates $1,800 per year (equal to payroll deduction of $150 per month) into a medical reimbursement account is eligible for reimbursement of up to $1,800 in the first month of the plan year if qualified expenses in that amount have been incurred - even though only $150 has been paid into the account at that time.
"Use it or Lose it" Rule
Any money that remains in the employee's account at the end of the plan year becomes the property of the employer (under the "use it or lose it rule"). Almost anything can be done with this money, except giving it back only to the persons who have forfeited it. If unused money is returned to employees, it must be done on an equitable basis to all participants. The two ways most frequently considered equitable are 1) distributed equally to all plan participants and 2) pro-rated to all plan participants based on the amount that each one contributed during the year. The money cannot be returned based on amounts that each employee forfeited.
Health reimbursement
arrangements
Health reimbursement arrangements, also known as "HRA's," are a type of health insurance plan that reimburses employees for qualified medical expenses and does not require the establishment of a separate funding account.
HRA's consist of funds set aside by employers to reimburse employees for qualified medical expenses, just as an insurance plan will reimburse covered individuals for their out-of-pocket cost for services received. Employers qualify for preferential tax treatment of funds placed in a health reimbursement account in the same way that they qualify for tax advantages by funding an insurance plan, and reimbursements to employees are tax-free. (Employers can deduct the cost of an HRA as a business expense under Internal Revenue Code section 162.)
HRA's are open to employees of companies of all sizes, and provide "first-dollar" medical coverage until funds are exhausted. For example, if an employee has a $500 qualifying medical expense, then the full amount will be covered by the HRA if the funds are available in the account. Under an HRA, the employer provides funds, not the employee. All unused funds are rolled over at the end of the year. Former employees, including retirees, can have continued access to unused reimbursement amounts. HRA's remain with the originating employer and do not follow an employee to new employment.
Employers have great flexibility in designing plans to meet their employees' needs. For example, an HRA may accompany any type of health insurance plan or none at all. An employer could place a uniform amount into every employee's HRA, which the employees could use to pay medical expenses or insurance premiums.
Indeed, employers might even tailor benefits to suit different types of employees' medical needs. For instance, employers are allowed to adjust HRA contributions based on such factors as age, medical risk or seniority. Employers might even alter co-payments and deductibles to encourage employees to buy medications for chronic conditions. To encourage employees to seek preventive care, employers might stipulate a portion of the HRA is forfeited if not used within the year.
If an employer's HRA plan allows it, after leaving a company employees could use accumulated HRA funds to pay medical bills, COBRA premiums for continuing coverage under the employer's health plan or premiums for a new health insurance plan.
Encourage Employee to
Make Wise Health Care Choices
Let's say an employer provides a health plan with a $2,500 deductible and agrees to reimburse employees up to $1,000 per year for eligible expenses. If an employee uses this allocation wisely, he may have all or most of this allocation left to carryover for next year. In three to five years, the employee could have enough accumulated to pay 100% of the expenses for any major medical situation that occurs, including the deductible and coinsurance amounts. On the other hand an employee, who because of necessity or over-use spends $2,000 the first year, would receive $1,000 in reimbursements and would owe $1,000 to health care providers because the deductible hadn't been met for the year.
If you would like more
information about the FSA's, HSA's, and HRA's discussed in this article, please
contact Chase Kingsley at ISU-JPG at (702) 897-4400. Chase is a commercial lines producer, and has
been in the financial/commercial insurance services industry for over 6 years.
Referral Tallies
The following referrals were provided to CCMS members in the second quarter of 2004 (through June 17)
Specialty Referrals
Addiction Medicine 0
Allergy 4
Anesthesiology 0
Cardiology 7
Cardiovascular Surgery 0
Colon & Rectal Surgery 1
Dermatology 10
Diagnostic Radiology 0
Endocrinology 5
Family Practice 21
Gastroenterology 3
General Surgery 5
Geriatrics 2
Gynecologic Oncology 0
Hematology 1
Infectious Medicine 0
Internal Medicine 24
Nephrology 0
Neurology 10
Neurosurgery 0
Ob-Gyn 9
Occupational Med 0
Oncology 2
Ophthalmology 10
Oral/Maxillofacial Surg. 1
Orthopaedic Surgery 13
Otolaryngology 2
Pain Mgmt/Medicine 5
Pathology 1
Pediatrics 4
Ped. Surgery 0
Physical Med/Rehab 0
Plastic Surgery 7
Psychiatry 9
Pulmonology 4
Radiology 0
Rheumatology 4
Thoracic Surgery 0
Urology 9
Vascular Surgery 0
Totals 173
Minutes Synopsis
Clark County Medical Society Board of Trustees Meeting
Tuesday, May 18, 2004; 6:00 P.M.
(Members can receive a full copy of meeting minutes by calling 739-9989.)
Community Relations Committee
Dr. Bernstein reported his committee will schedule the next Mini-Internship for November.
Membership Committee
Marlaina Burns reported the numbers for paid membership: 716 and the non-paid membership: 85. She stated the NSMA sent out final notices to those members who have not yet paid the annual dues and will resign them if they have not paid by July 15. Dr. Kingsley asked any BOT members who know any of them personally to call the members to encourage them to pay their dues. Last year at this time there were 120 non-paid members compared to 85 this year.
Reach Out and Read Letter of Support Request
Pediatric residents requested endorsement of the formation of a local Reach Out and Read program. The Board approved a motion to provide them a letter of endorsement to be used for their fundraising efforts which will foster distributing books and improving literacy rates in Southern Nevada.
Approve Minutes
The minutes from the April 13th BOT meeting were approved.
Financial Report
On behalf of Dr. Steinberg, Dot Freel reported that the revenue total for the fiscal year exceeded the projected revenue amount. She reported that although the revenue for new members this fiscal year is lower than last year, there were 47 new members this year compared to 26 new members last year. The financial report was approved.
Credentials Committee
The Board approved the following applicants for membership: Peter Caravella, MD, General Surgery; Martin Carignan, MD, General Surgery; Harry Condoleon, DO, General Surgery; and Michael Seiff, MD, Neurosurgery.
Alliance
Annette Mohs stated the Alliance met their goals during her year as the Alliance President. Marian Haas and Kathleen Slaughter are the new Co-Presidents for the Alliance.
Voter Registration
Dr. Jerry Jones announced the voter registration is going well, with several hospitals holding voter registration events.
County Health District
Dr. Kwalick was not able to attend the Board meeting but sent a report.
NV School of Medicine
James Lenhart, MD announced John McDonald, M.D. of Salt Lake City was named the new Dean of the School of Medicine effective July 6. Dr. McDonald hopes to go forward with plans for an academic medical center.
Dr. Havins announced the Osteopathic School received its accreditation and will begin 75 students a year this fall. They will also have a Physician Assistant program.
Scholarship Committee Report
Dr. Ellerton was given the names of the medical students that Peggy Dupey of the University of Nevada School of Medicine is recommending for scholarships and he will have the checks cut for those 4 students.
AMA Report
Dr. Horne announced he will be going to the AMA meeting in June and offered to take any business the Society would like the AMA to address.
NSMA Report
Dr. Evins announced the officers of NSMA which were elected at the Annual Delegation meeting.
Dr. Havins briefly explained the two Constitutional initiatives of the Trial Lawyers Association, which would nullify a successful vote on the KODIN "Yes on 3" initiative.
Larry Matheis reported he feels the doctors will eventually get paid for their claims for Medicaid patients. Larry will continue the weekly meetings with the First Health representatives until the matter has been resolved.
Ballot Results
Dr. Kingsley gave the election results of the Board of Trustees race: Dr. Larry Cohler, Dr. Mark Doubrava, Dr. John Kurlinski, Dr. Carol Vanderharten and Dr. Jerry Jones were elected.
Dr. Kingsley announced the Legislative Dinner was well attended. AMA President-Elect, Dr. John Nelson gave an excellent presentation, as did NSMA Lobbyist, Scott Craigie.
Dr. Kingsley asked for feedback from the Board members regarding the KODIN "Yes on 3" kits.
Administrative Report
Dr. Havins announced the contract for the postage machine has ended and was replaced by a much less expensive postage machine lease.
The Board approved the release of the CCMS database in an electronic format to Pri-Med to market their CME activities for which CCMS members would be allowed to attend at no charge.
The Board voted to allow Consolidated Lab Services to provide refreshments at the next CCMS CME activity in exchange for being allowed to set promotional items out for attendees.
The Board increased CCMS annual dues by $20 to $390, with one trustee opposed.
After a closed personnel session, the Board approved keeping the newsletter ads and directory ads commission at 15%. Deborah Barton, the Publications Coordinator, whose job duties include producing the newsletter, will work with all advertisers to resolve any art work specification problems. The staff person initiating the ad will continue to receive the commission when/if the ad renews.
Dr. Kingsley announced the passing of member Josue Rojas.
The MedPac Board of Directors was announced: David Steinberg, MD; Michael Colletti, MD; Edwin Kingsley, MD; Ronald Kline, MD; Warren Evins, MD; Robert Shreck, MD; Annette Mohs; Michael Clifford, MD; Weldon Havins, MD; Florence Jameson, MD; and Marietta Nelson, MD.
Dr. Kline asked the Board members to submit ideas with their contacts on obtaining some incentives to offer to Clark County Medical Society members.
The next Board of Trustees meeting will be Tuesday, June 15, 2004 at 6 pm.
There being no further business, the meeting was adjourned by Dr. Kingsley at 8:40 pm.
Community-acquired methicillin-resistant Staphylococcus aureus
By Donald S. Kwalick,
MD, MPH, Chief Health Officer
The Clark County Health District Office of Epidemiology continues to investigate cases of methicillin-resistant Staphylococcus aureus. In the past, methicillin-resistant Staphylococcus aureus (MRSA) infections have been acquired almost exclusively in hospitals, long-term care facilities, or similar institutional settings. Risk factors for healthcare facility-associated MRSA colonization or infection include prior antibiotic exposure, admission to an intensive care unit, surgery, or exposure to an MRSA-colonized or infected patient. However, recent disease surveillance activities in Clark County for MRSA have revealed that strains of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are emerging and reports of experiences with MRSA in cities across the nation are strikingly similar.
Investigations of pediatric CA-MRSA cases here in Clark County and in communities across the nation have led to speculation that the epidemiology of S. aureus is changing. Epidemiologic features show a major departure from those previously thought to be associated with MRSA colonization or infection.
Historically, investigations of CA-MRSA cases demonstrated risk factors (i.e., contact with health-care facilities, previous antimicrobial therapy) that were similar to nosocomially-associated MRSA. More recent reports describe transmission in populations lacking these risk factors. A study from Chicago found a 25-fold increase in the number of children admitted to the hospital with an MRSA infection who lacked an identifiable risk factor for prior colonization. Isolates for community-acquired MRSA are usually susceptible to multiple antibiotics, which is in contrast to the typical, multiple-drug-resistant hospital isolates.
Similarly, four children from rural Minnesota and North Dakota who died in 1999 from infections caused by CA-MRSA lacked risk factors for MRSA infection. The infections were caused by strains susceptible to several antibiotics, except beta-lactams. The PFGE patterns of these strains indicated that they were related to one another but differed from typical nosocomial isolates circulating in local hospitals. All of the isolates from LA county pediatric patients described above, also showed resistance to beta-lactam antibiotics. Additionally, the results of sensitivity testing indicated that most were also resistant to ciprofloxacin and levofloxacin.
Recent Clark County data for pediatric S. aureus infections echoes the findings in these other communities. Data obtained from a local commercial laboratory for the first four months of 2004 shows that of all pediatric cultures positive for Staphylococcus aureus, 17 percent were MRSA. For the same 4-month period, of all cultures positive for MRSA, only 38 percent were sensitive to levofloxacin. Data on sensitivity for ciprofloxacin was not available.
Quest Diagnostics found additional evidence of the changing epidemiology of Staphylococcus aureus. In a microbiology update distributed on June 2, 2004, the lab reported development of a "new form of resistance" to clindamycin. The update stated, "It has become clear that many strains resistant to erythromycin may be also resistant in vivo to clindamycin, even if standard susceptibility results indicate that they are sensitive. This type of resistance is called inducible resistance which the commonly used susceptibility test cannot detect."
At this time, there is insufficient Clark County data to estimate the true prevalence of CA-MRSA. However, through recently initiated surveillance for S. aureus, there is evidence that the emergence of MRSA within the community may become a major threat with several important clinical implications, including treatment failure with accompanying complications and increases in medical costs and morbidity. Currently most strains of CA-MRSA are susceptible to a large number of available antibiotics. However, there appears to be a disturbing trend towards multi-drug resistance. Already we are seeing decreasing sensitivity to levofloxacin and there is additional evidence of erythromycin and clindamycin resistance. Inappropriate or incomplete antibiotic treatment may further exacerbate the problem of antimicrobial resistance. It seems inevitable that the prevalence of resistant strains will increase over time unless efforts are made to minimize the antibiotic pressure favoring selection of resistant strains.
The Clark County Health District Office of Epidemiology will be expanding surveillance activities for CA-MRSA. We hope in the near future to acquire data from all local hospitals and detention centers. Although CA-MRSA is not currently on the Nevada list of reportable diseases, we encourage all health care providers to report culture-confirmed cases to the Office of Epidemiology at 759-1300. It is only through routine culturing of suspect lesions that we will be able to obtain sufficient data to monitor the resistance patterns and prevalence of resistant strains of Staphylococcus aureus.
Classified Ads
· PHYSICIAN(S) WANTED TO SHARE OFFICE Space on E Flamingo in Desert Springs Hospital-area. Please call 734-2242 for details.
· NEEDED: PART-TIME RETIRED Physician with active Nevada license to work in a drug-free workplace. Please call John Ranc @ (702) 737-8376.
· DESERT SUNRISE MEDICAL CENTER offices for lease. 2500-7500 sq. ft. Located between Desert Springs and Sunrise hospitals. Building is finished and will allow $10/sq. ft. TI. Unlimited parking. 1640 E. Flamingo. $1.45/sq. ft. Call Rene 286-0906.
· FOR SALE - OFFICE FURNITURE, DESK, Exam Table, Kodak Lab, Treadmill, Holter Monitor, EKG, etc. Call 878-8108.
CME Calendar
Cardiovascular
Consultants 691-9154
Clark County Medical
Society 739-9989
· 10/2* - “Hospice and Pallative Medicine- What is it?” 9 a.m., 2 Ethics CME hours (*new date*)
Future Programs Planned
August 2004 - Obesity
Medical Malpractice
October 2004 - Cosmetic Surgery
HealthInsight (801) 892-0155
St. Rose
Hospital 616-5832
Southwest Medical
Associates 242-7347
Summerlin
Hospital 233-7572
Sunrise Hospital 731-8210
UMC 383-2604
Valley Hospital 388-4847
· 7/13 - “What’s New in the Lab?” noon
· 7/27 - “Spiral CT Scans,” noon
Special Note: CCMS members can receive free CME courses on the internet with World Medical Leaders.
To have your CME courses listed on our calendar, please contact Deborah Barton at 739-9989 prior to the deadline
of the 12th each month.
Clark County Health District Disease Statistics* - May 2004
DISEASE CASES REPORTED YEAR TO DATE
May 2003 May 2004 2003 2004
VACCINE PREVENTABLE DISEASES
DIPTHERIA 0 0 0 0
HAEMOPHILUS
INFLUENZA 0 0 2 2
(invasive)
HEPATITIS A 2 0 6 2
HEPATITIS B 4 8 25 27
INFLUENZA 2 2 47 53
MEASLES 0 0 0 0
MUMPS 0 0 0 0
PERTUSSIS 2 1 5 2
POLIOMYELITIS 0 0 0 0
RUBELLA 0 0 0 0
TETANUS 0 0 0 0
SEXUALLY TRANSMITTED DISEASES **
CHLAMYDIA 336 282 1879 1616
GONORRHEA 147 146 723 784
SYPHILIS
(Primary & Secondary) 1 2 4 4
SYPHILIS
(Early Latent) 4 0 15 5
ENTERICS
AMEBIASIS 1 0 9 6
BOTULISM-INTESTINAL
(Infant) 0 0 1 0
CAMPYLOBACTERIOSIS 10 2 33 24
CHOLERA 0 0 0 0
CRYPTOSPORIDIOSIS 1 0 3 0
E. COLI
O157:H7 2 1 2 2
GIARDIASIS 5 3 29 30
ROTAVIRUS 38 32 338 377
SALMONELLOSIS 22 14 42 41
SHIGELLOSIS 2 2 10 16
TYPHOID
FEVER 0 0 0 0
YERSINIOSIS 0 0 0 0
OTHER
ANTHRAX 0 0 0 0
BOTULISM
INTOXICATION 0 0 0 0
BRUCELLOSIS 0 0 0 0
COCCIDIOIDOMYCOSIS 2 4 13 30
ENCEPHALITIS 1 0 1 0
HANTAVIRUS 0 0 0 0
HEMOLYTIC
UREMIC 0 0 0 0
SYNDROME (HUS)
HEPATITIS C 1 0 1 2
HEPATITIS D 0 0 0 1
LEGIONELLOSIS 1 2 2 3
LEPROSY
(HANSEN'S DISEASE) 0 0 0 0
LEPTOSPIROSIS 0 0 0 0
LISTERIOSIS 0 1 0 2
LYME DISEASE 0 0 1 0
MALARIA 0 0 0 11
MENINGITIS,
ASEPTIC/VIRAL 10 6 37 15
MENINGITIS,
BACTERIAL 1 0 11 2
MENINGOCOCCAL
DISEASE 0 0 3 0
PLAGUE 0 0 0 0
RABIES
(HUMAN) 0 0 0 0
RELAPSING
FEVER 0 0 0 0
ROCKY
MOUNTIAN 0 0 0 0
SPOTTED FEVER
RSV
(RESPIRATORY 36 14 1292 1016
SYNCYTIAL VIRUS)
TOXIC SHOCK
SYNDROME 1 0 1 3
TUBERCULOSIS 7 2 33 14
TULAREMIA 0 0 0 0
TYPHUS,
MURINE 0 0 0 1
UNUSUAL
ILLNESS 0 0 0 1
(Creutzfledjakob)
UNUSUAL
ILLNESS 0 1 0 1
(Cysticercosis)
* Numbers
include confirmed and probable cases
** For
HIV/AIDS statistics please call the Clark County Health District Office of AIDS
at 759-0730.
County Line Advertisers
Christopher Commercial 243-2800 www.christophercommercial.com
Colonial Bank 304-3770 www.colonialbank.com
Desert Radiologists 382-XRAY www.desertrad.com
Diversified Office Services 796-0456
DMSL Medical Management & Billing Service 558-2326
Hutchison & Steffen Attorneys 385-2500