This issue’s spotlight shines on F. Scott Gray, MD.Dr. Gray is a founding partner of Connecticut Family Orthopedics in Danbury and a board‐

certified orthopaedic surgeon. He recently completed his two-year term as President of the Connecticut Orthopaedic Society (COS), and had some time to sit down with Action News to talk about physician advocacy and the state of medicine.

An early interest in medicine and research took Dr. Gray from an undergraduate degree at the University of Rhode Island to Georgetown University Medical School. He liked orthopedics better than any other med school rotation, and went on to complete his orthopaedics residency at Tufts New England Medical Center.

Dr. Gray saw the value of physician advocacy early on in his career. As a young physician in private practice, his senior partner, Ron Ripps, MD, was actively involved in COS and in CSMS. “I saw what could be accomplished when physicians stand up,” said Dr. Gray. “It be-came clear that we need to be involved – there isn’t ‘someone else’ who will take care of it for us.”

CSMS Action News Since 1792, physicians dedicated to a healthier Connecticut

Summer 2017

Member Spotlight – F. Scott Gray, MD

(cont. on page 5)

In 2016, as the Anthem-Cigna and Aetna-Humana “mega-mergers” prompted growing concern among physicians and patients, CSMS joined with Universal Health Care Foundation of Connecticut and the Connecticut Citizen Action Group to form the Connecticut Campaign for Consumer Choice.

The coalition strongly advocated for Connecticut Insurance Department (CID) Commissioner Katharine Wade to hold public hearings, grant intervenor status to interested parties, and to commission a study of the potential impact of the merg-ers on cost, access, and the state’s economy.

Instead, CID completed its review of the Aetna-Humana merger “without objection” in January 2016 and did not notify the public until May – a delay of nearly five months. CID also did not hold any public hearings, or provide documentation for public review.

CSMS and its coalition partners filed a Freedom of Information Act (FOIA) request regarding CID’s failure to ob-ject to the merger. CID argued that their document withhold-ing was appropriate, in accordance with CT law. CSMS then filed an appeal with the CT Freedom of Information (FOI) Commission. The Commission ordered CID to provide all of

the withheld records to the Commission for private inspection. CID failed to do so, in blatant disregard of the order.

Fast forward to 2017, after both the Anthem-Cigna and Aetna-Humana mergers were blocked in two separate US District Court rulings in March and April. On June 8, an FOI Commission hearing officer recommended finding in favor of CSMS, as well as an unusual $1,000 civil fine for Commissioner Wade:

“Commissioner Wade, acting in part through her deputy commissioners, is the official directly responsible for denying the complainant its right of prompt access to non-exempt public records.

It is found that the exemptions claimed by Commissioner Wade were almost entirely without merit, and it also found that the Commissioner’s refusal to sub-mit records for in camera inspection and to provide an index of exempt records demonstrates an unreasonable at-tempt to avoid a long established process of determining whether a public record is subject to disclosure.”

The FOI Commission will meet on June 28 to adopt the proposed finding and penalty.

Mega-Mergers: The Aftermath

2 • C S M S A C T I O N N E W S

2017 marks the 225th anniversary of the Connecticut Medical Society – our quasquibicentennial. In May 1792, the Connecticut General Assembly granted our charter of in-corporation (An Act Incorporating a Medical Society) – the first ever to be issued in the state. The following October, the new Medical Society convened for the first time at the Middletown Courthouse.

At this inaugural convention, Medical Society repre-sentatives (“Fellows”) were chosen and returned from the County Conventions, and officers were elected. Among the resolutions passed was one instructing the Fellows of each county to nominate three Medical Society members for the county’s Committee of Examination “for the examination of candidates for the practice of physic and surgery.” If a candidate passed the examination and received a license, he paid a fee of $4 to the Medical Society. One wonders what

those early physicians would think of today’s $565 initial medical license fee.

The charter also required the phy-sicians of the Medical Society to

communicate “useful information” to each other, including reports at the annual convention regarding “such curious cases and observations, as may come to their knowledge; and it shall be the duty of the convention to cause to be published, such extraordinary cases, and such observations on the state of the air, and on epidemical and other disorders as they may think proper.” (From Reprint of the Proceedings of the Connecticut State Medical Society 1792-1829, p. viii).

That tradition of sharing “useful information” continues today, with the CSMS peer-reviewed journal, Connecticut Medicine. Now in its 79th year, Connecticut Medicine will publish a special 225th anniversary issue in September 2017.

In health care, as in virtually every other industry, data has become a key strategic element of successful business operation. And in the health care delivery market place, “successful” means increased access, im-proved quality of care, and reduced cost. Success can also mean increased preventive care and care manage-ment services, and reduced utilization of unnecessary services.

Yet in this Big Data era, physicians are usually not in the driver’s seat when it comes to decisions about data integration, aggregation, and analysis, despite the fact that physicians are the key generators of health care data. Though the performance of physicians and hospitals is closely (some would say obsessively) measured, does this really result in improved clinical quality? Are we missing the point?

I think that the answer is generally yes. Electronic health record (EHR) data would help us evaluate patient care more effectively, but despite significant improvements in the quality of EHR systems in the last decade, for the most part we have been unable to aggregate that EHR data in a meaningful way, or to analyze it in a clinically relevant way.

This is about to change for Connecticut physicians and their patients.CSMS has partnered with the Kansas Medical Society (KMS) and its affiliate, KaMMCO Health Solutions, to launch CTHealthLink, a Connecticut-based health information exchange (HIE).

CTHealthLink will allow connected physicians, hospitals, and other health care professionals to share patient information, “employing powerful analytical tools designed to help improve clinical outcomes, reduce inefficiencies, and positively impact patient safety.” By providing this interoperability and working toward the development of actionable intelligence through analytics, the HIE will provide physicians with the tools and resources needed to succeed in today’s new performance-based health care delivery and payment models.

CTHealthLink uses the same model that has operated effectively in Kansas for seven years, and has been successfully replicated in South Carolina and Georgia. The National Governors Association Center for Best Practices cited the quality of Kansas HIE several times in its 2016 report on health information technologies. CSMS is working with hospitals, health systems, clinics,

Katz

Message from the Executive Vice President/CEO

(cont. on page 6)

Help CSMS celebrate this milestone at our 2017 Annual Meeting on September 27 at the Aqua Turf Club from 5 – 8 pm. Mark the date on your calendar, and keep an eye out for event details coming this summer.

W W W . C S M S . O R G / A C T I O N N E W S • 3

Physicians’ Day at the Capitol

This year’s Physicians’ Day at the Capitol, co-sponsored by CSMS and CTACS, was well-attended and very successful.

Held on a sunny March morning, the day kicked off with an informal breakfast and conversation with State Representatives Whit Betts (Bristol, Plymouth), Holly Cheeseman (East Lyme, Salem), Mike Demicco (Farmington, Unionville), Tim LeGeyt (Canton, Avon), and Jonathan Steinberg (Westport), and State Senator Heather Somers (Stonington). CSMS member and freshman State Rep. Bill Petit, Jr., MD (Plainville, New Britain) was also on hand, and received an especially warm welcome from his fellow CSMS members.

After breakfast, physicians spread out across the Legislative Office Building, meeting with their representatives and senators, as well as key leg-islative leaders.

The group reconvened for lunch in the historic Old Judiciary Room in the State Capitol. The luncheon program featured CT Department of Public Health Commissioner Raul Pino, MD, MPH as the keynote speaker, as well as an informative presentation about state health information exchanges by the Kansas Health Information Network, and an overview of the PMP, medical marijuana, and the opioid crisis by CT Department of Consumer Protection Commissioner Jonathan Harris.

Also joining CSMS members for lunch was CSMS member State Rep. Prasad Srinivasan, MD, who reinforced the importance of physician voices being heard at the Capitol. Dr. Srinivasan, who is running for Governor in 2018, encouraged other physicians to get involved and run for office. He joked that when Dr. Petit became a state legislator, the number of physicians in the State House increased by 100%.

Thank you to all the physicians and physicians-in-training who made the time to attend our program at the Capitol. The legislators were impressed by the number of bright yellow “Physicians’ Day” lapel pins roaming the halls, and by the thoughtful exchanges with physicians on the complexities of health care policy.

4 • C S M S A C T I O N N E W S

Legislative Update

The 2017 session of the General Assembly was gaveled to a close at midnight on June 7. This was a long session, which began on January 4 and saw hundreds of bills related to health insurance coverage, prescribing, transparency, access to care and other medical topics.

Below is a summary of CSMS efforts on key health bills of the 2017 session. It takes time, patience, and focus to successfully effect legislative change – these bills are just a few examples of CSMS’ perseverance in physician advocacy.

Omnibus Opioid Bill – HB 7052CSMS was heavily involved in opioid bill discussions through-out the session. Although we would have liked to see more attention given to substance abuse treatment resources and education, CSMS was able to successfully amend or remove several sections of this bill that would have negatively impact-ed physicians’ ability to deliver care. The final version of the bill included these key provisions:u Increased opportunities for the take back and disposal of

unused opioids.u A requirement for those capable of transmitting prescrip-

tions for opioids electronically to do so. However, CSMS worked successfully with leadership to include language allowing those without such capability to opt out.

u Requires DPH to develop a form for voluntary non-opioid agreements for patient who wish not to receive opioids. This includes protections from liability for physicians who: v Follow such agreements and do not prescribe opioidsv Provide emergency services who administer opioids

without the knowledge of a standing agreementu Reduces the limit for initial prescriptions for minors to

5 days, yet maintains established provisions currently in statute allowing exemptions.

u Requires pharmacists dispensing naloxone to someone without a prescription to do so under the standing order of a physician

u Increases insurance coverage requirements for both inpa-tient and outpatient treatment options.

Small Business Express Program – SB 820 The bill expanded eligibility under the state’s Small Business Express program to include primary care physicians and phy-sician offices, regardless of the number of employees. This access to capital can make it easier for your practice to expand services, invest in new healthcare equipment, recruit/retain physicians and other healthcare professionals, and con-tinue to thrive as an independent practice. The final version of the bill contained an amendment spe-cifically requiring the Commissioner of the Department of Economic and Community Development (DECD) to work with CSMS to ensure physicians utilize the program. CSMS has been advocating for physician inclusion in this program for several years, and provided legislators with detailed infor-mation about the positive impact of physicians on the state’s economy.

Medicaid Provider Audits – HB 7190CSMS successfully prevented legislation that would allow CT Department of Social Services (CT DSS) from retroactively applying bulletins when auditing providers. In addition, the amended version of the bill contains language that adds a presumption of medical necessity when a decision is made by a physician. It also requires that any CT DSS re-view of an emergency service must be made by an Emergency Medicine physician.

Emotional Distress – SB 932CSMS was among the earliest to testify against SB 932, an overly-broad bill with highly subjective legal standards. The bill also ignored the fact that Connecticut courts already have well-established case law on the cause of negligent infliction of emotional distress.Thanks to the efforts of CSMS physician leaders and members, SB 932 was successfully blocked from leaving the Judiciary Committee.

Youth Concussions – HB 7048For many years, CSMS and members of its Sports Medicine Committee have been actively involved in actions to protect our young athletes from concussions.HB 7048 would have included chiropractors in the definition of “licensed health care professionals” who could clear a child for return to play. CSMS strongly opposed this change, and successfully removed it from the final version of the bill.

Fertility Preservation – HB 5968For several years, CSMS has supported bills that would ensure coverage of fertility preservation services for those diagnosed with cancer or other medical conditions.HB 5968 unanimously passed both the Senate and the House; Governor Malloy does not view this bill as a mandate and is expected to sign it.

W W W . C S M S . O R G / A C T I O N N E W S • 5

When Dr. Ripps retired, he urged Dr. Gray to step up. Dr. Gray did just that, joining COS, Fairfield County, and CSMS. While most of his advocacy efforts have been with COS, Dr. Gray is very clear on the importance of working collaboratively with CSMS. “There is definitely strength in numbers. A number of legislative issues are problems for all of us, not just mus-culoskeletal docs.”

With almost two decades of experience in organized medicine, Dr. Gray shared several thoughts about the past, present and future of physician advocacy.

Back in the early 2000s, medical liability was a major concern for physicians in all specialties; orthopedists were facing premiums of $60-70,000. After significant liability reforms in 2009, premiums have been whittled down to under $20,000, thanks to Certificate of Merit and continued CSMS efforts. Dr. Gray noted that other states have made progress with caps on economic damages and alternative dispute models, yet Connecticut has had no major reforms since 2009. “There’s no reason Connecticut can’t be a leader in this area. It just takes the courage to lead, and if physicians across the state stuck together and organized medicine kept the pressure on, we could move legislators in the right direction.”

Managed care is another issue requiring continued physician advocacy. The rise of HMOs in the 1990s brought some unwelcome changes to the practice of medicine, and those effects are still felt today. “Before [HMOs], physicians were more or less in control of their practices and fee schedules, and managed their patients properly,” said Dr. Gray. As health insur-ance plans began placing profits before patient well-being, they increasingly turned to rationing in an effort to slow delivery of appropriate patient care and/or minimize expenditures that hurt investors’ bottom lines. Dr. Gray noted, “If Congress really values health care, they should take health insurance off Wall Street.”

While there is still work to be done, Dr. Gray shared sev-eral recent physician advocacy success stories, all of which resulted from cooperative efforts by organized medicine. These include the prompt payment bill that CSMS and COS worked on together. Working together we successfully changed Connecticut prompt payment statutes to require that claims submitted electronically be paid within 20 days; plans may only ask once for more information regarding a claim and must pay expediently upon receipt of the requested information. Dr. Gray called it an extremely important bill, and one which took a lot of collaborative effort.

Another success came with legislation requiring mandatory payment for properly precertified patients. Due to the collec-tive efforts of CSMS and COS, patients who receive precertification of a service or procedure are protected from retroactive denial of the previously approved service or procedure. The bill also established concrete time frames regarding the validity of an approval. Dr. Gray recalled, “At the time, insurance companies had up to 72 hours to tell physicians if there was a problem with patient precertification, which resulted in whimsical denials of payment.”

The Fairness in Contracting law is an additional example of CSMS, COS, and other specialties working together on behalf of physicians. Prior to the law, it was “a one-sided insurance contract environment.” Physicians couldn’t negotiate the terms, and insurers could change any aspect of a contract at any time.

The new law prevented insurers from changing fee schedules during a contract year unless state or federal mandates require it. Plans must also provide information to the physician and allow the opportunity to opt out of the contract prior to the implementation of the changes. In addition, plans must now provide accurate information regarding fee schedules, and plan provider lists must be transparent, accurate, up to date, and available electronically to all enrollees.

(cont. on page 15)

Member Spotlight – F. Scott Gray, MD (cont. from page 1)

“If physicians across the state stuck together and organized medicine kept the pressure on, we could move legislators in the right direction.”

Are You Plugged In? Connect with CSMS.Do we have your email? Go to www.csms.org and sign up for our e-newsletter. It’s time to be well-informed on all the latest medical news and events.

6 • C S M S A C T I O N N E W S

state agencies, and of course physician practices, to adapt CTHealthLink for Connecticut needs. Our new HIE will allow the free flow of clinical information, and provide a secure data warehouse with robust analytical tools to help physicians (and patients) better track, monitor, and manage care.

With CTHealthLink, Connecticut physicians will no longer have to rely on a patchwork system of imperfect, limited connections to transmit important health care data. Rather than waiting for a simple patient encounter notification or admit/discharge/transfer data, physicians will be able to access an almost real-time data flow that can be used to improve patient care.

Our new HIE also provides an efficient platform for reporting to govern-ment payors, with NCQA-accredited eCQMs and approval to participate as a Merit-Based Incentive Payment System (MIPS) Qualified Clinical Data Registry (QCDR) for 2017.

Equally important is that CTHealthLink is being set up so that every patient will have unique access to their personal health information – not just infor-mation from one facility or practice, but a comprehensive, cloud-based health record that they can review and even manage with one logon and one password.

CSMS has started working with local practices, facilities, and health sys-tems, as well as the broader community, to develop the business model for and support of CTHealthLink. CSMS has also reached out to local, state, and federal governmental agencies to talk about system connectivity and interop-erability, as well as approaches to capturing and distributing health informa-tion and patient data. In addition, we are working with local accountable care organizations (ACOs) and medical record vendors to make sure that there are options for connectivity and use of the analytical tools. Each physician practice, facility, and system will have a different level of EHR maturity, so it is critical for CTHealthLink to connect everyone providing patient care in Connecticut.

For CTHealthLink to succeed, it is necessary to have as many physicians, facilities and other clinicians and health care professionals connect to the HIE as soon as possible. Having only a fraction of the picture of patient conditions and previously delivered care is not sufficient for patient care today. Physicians and their patients deserve the complete picture, and the only way to accomplish this is to make sure that wherever a patient may receive care is connected to the HIE in some meaningful way.

In order for the data to be actionable, it must be as close to real time as possible and provide the level of clinical detail that allows physicians to feel confident about their medical decisions at the point of care. Second-guessing the data means second-guessing the care decision and that is the last thing we want to have happen because we have opened up the floodgates and are now allowing clinical data to freely flow among and between physicians and other health care professionals. The HIE is a conduit for information meant to sup-port the physician. It is not and should not be a replacement for the physician’s professional judgment.

Finally, CSMS does not want to lose sight of the very reason to have a fully functional HIE operating in Connecticut: to improve the quality of patient care and reduce medical costs. A well-functioning HIE supports patient en-gagement care decisions by creating access to information, and that helps them better understand their medical condition and treatment options.

CSMS is proud to introduce CTHealthLink to our state. By placing infor-mation and decision-making ability back in the hands of patients and the phy-sicians who care for them, our HIE will help foster and protect the physician-

Message from the Executive Vice President/CEO (cont. from page 2)

What is a Health Information Exchange (HIE)?

An HIE allows access to patient informa-tion at a near real time in a secure envi-ronment, thereby improving the quality and safety and cost of patient care.

According to HealthIT.gov, “appro-priate, timely sharing of vital patient in-formation can better inform decision making at the point of care and allow providers to: avoid readmissions; avoid medication errors; improve diagnoses; and decrease duplicate testing.”

In today’s value-based healthcare de-livery and payment models, the benefits of an HIE are wide-reaching and signifi-cant. Through an HIE, physicians and other healthcare professionals can se-curely share updated, electronic patient information, no matter where the patient is receiving care.

HealthIT.gov identifies these HIE benefits:• Provide a vehicle for improving

quality and safety of patient care by reducing medication and medical errors

• Stimulate consumer education and patients’ involvement in their own care

• Increase efficiency by eliminating unnecessary paperwork

• Provide decision support tools for more effective medical treatment

• Improve public health reporting and monitoring

• Improve the connection between health care research and actual medi-cal practice

• Facilitate emerging technology and health care services

• Provide a technical infrastructure for state and national health care initiatives

• Provide basic interoperability be-tween EHRs used by many within the health care delivery system

• Reduce healthcare related costs

https://www.healthit.gov/providers-profes-sionals/health-information-exchange/what-hie. Accessed May 5, 2017

(cont. on next page)

W W W . C S M S . O R G / A C T I O N N E W S • 7

patient relationship and improve the quality of medical care delivered in this state, leading to cost reductions. CTHealthLink is being built the right way, by keeping the patient at the center of the care delivery model and protecting the patient-physician relationship. REFERENCES1. CSMS press release https://csms.org/2017/03/29/csms-khs-partner-on-physician-led-health-information-network-for-connecticut/ Accessed

May 5, 2017.2. Johnson K, Kelleher C, Block L, et al. Getting the Right Information to the Right Health Care Providers at the Right Time: A Road Map for States

to Improve Health Information Flow Between Providers. Washington, DC: National Governors Association Center for Best Practices. https://www.nga.org/files/live/sites/NGA/files/pdf/2016/1612HealthCareRightInformation.pdf

Message from the Executive Vice President/CEO (cont. from previous page)

2017 C. Robert Biondino Memorial Golf Classic The 2017 Biondino Golf Classic is just a few weeks away, and the Golf Committee has been hard at work planning a terrific day for golfers and non-golfers alike. As always, 100% of the proceeds from the Biondino Classic sup-port the CSMS Charitable Trust, a 501(c)3 community-supported nonprofit.

Golf Chairs Bob Russo, MD and Steve Fleischman, MD have select-ed a new location for this year’s Biondino Classic: Great River Golf Club in Milford, a Zagat-rated championship style course designed by Tommy Fazio. “This course is listed in the top 100 courses in North America. It’s world-class. Each player and team will compete from tees designed for their own skill set. The setting is beautiful – it runs along the Housatonic River,” said Dr. Russo.For Golfers

• The Biondino Classic kicks off with a luncheon, followed by a shotgun start. • Look for fun challenges throughout the course, including Closest to the Pin and Longest Drive. • After the tournament, head back to the clubhouse for a cocktail reception, awards, prize drawings, and a

delicious dinner. • There are only a few foursomes remaining – if you want to play, contact CSMS Director of Marketing

John Bermudez asap (jbermudez@csms.org / 203-865-0687 x122). Playing with fewer than four? Let John know and he will try to pair you up if space is available.For Non-Golfers

Not a golfer? You can still participate in the Biondino Classic. • Donate a prize or an item for the silent auction. • Join us for the cocktail reception, awards and dinner. • Make a direct donation to the Charitable Trust

(visit csms.org/charitabletrust, or contact John Bermudez for assistance)The CSMS golf tournament began in 2009, with C. Robert Biondino, MD as an original organizer, eager participant and tireless chairman. Dr. Biondino died in October 2010, and the Committee renamed the tournament in his honor.

Save the Date

CSMS Annual MeetingSeptember 27, 2017

8 • C S M S A C T I O N N E W S

Eye on the Law: Mergers, Ransomware, HIPAA, Oh My!

Mega Mergers: Has the story come to a close?In the last Eye on the Law, we looked closely at the health insurance mega-merg-ers between Anthem and Cigna and Aetna and Humana. While the Aetna and Humana merger is, for all intents and purposes, a dead deal, questions still remain surrounding the Anthem and Cigna potential merger.

On April 28, 2017, a federal appeals court affirmed the trial judge’s ruling that blocked the potential merger on antitrust grounds. In response, Anthem filed a petition to the United States Supreme Court, which is unlikely to be heard for several reasons. Simultaneously, Anthem and Cigna are locked in a separate le-gal battle over finances and Cigna’s request to terminate the merger. At issue is a $1.85 billion break-up fee if the merger does not close. Most recently, a judgein that case ruled that Cigna has the right to terminate the merger talks with Anthem, setting the state for a significant fi-nancial battle between Anthem and Cigna. However, this ruling appears to make Anthem’s petition to the United States Supreme Court moot, but nonetheless the Supreme Court will still have to make a decision on whether to hear the case.

While it appears that there may still be a tiny bit of life left, the merger looks to be nearing its last breath. The apparent defeat of both health insurance mega-mergers is a tremendous victory for CSMS and our numerous state and national partners.

Ransomware: Does it make you WannaCry?The mere discussion of ransomware, cybersecurity and patient files held hostage is enough to make your head spin. The recent massive cybersecurity breach, aptly named the WannaCry ransomware, has launched discussions surrounding ransom-ware and cybersecurity protection to the forefront. The WannaCry ransomware was launched worldwide and impacted some of the largest medical systems in the world.

In the simplest form, ransomware is a type of software that locks a computer, smartphone or other electronic device and then demands a ransom to unlock it. As patient data is highly confidential, cybercriminals frequently attack medical practices, holding patient data “hostage” until a ransom is paid to release it. If the

ransom is not paid timely, the data may be deleted. Medical data can be quite profitable on the black market and that is one reason medical practices are frequent targets.

Last year, the Office for Civil Rights at Health and Human Services, released HIPAA guidance on ransomware. The guidance made clear that a ransomware attack usually results in a breach of Protected Health Information (PHI) under HIPAA. Any entity that experienced a breach of unsecure PHI must notify individuals involved in the breach (and in some cases the media) unless the entity can demonstrate and document there is a low probability that information as compromised. Ransomware attacks are not a matter of “if,” they are a matter of “when.” Every medical practice, from a solo practitioner to a large system, should be prepared to combat ransomware. This includes training staff on how to spot the signs of ransomware, implementing security incident responses, mitigating the consequences of ransomware and having a full contingency plan and data backup system.

A ransomware attack can cause not only a logistical nightmare, but can present a legal headache in managing a HIPAA breach and the process and notification that goes along with it.

New CSMS Affinity Partner Kelser (see page 15) can help your practice be prepared in the event of a ransomware attack. Please visit https://csms.org/partner/kelser/ to learn more.

Did Someone Say HIPAA?The Office of Civil Rights (OCR) has issued several new HIPAA fines and corrective action plans, just in case you needed a reminder to stay vigilant on your HIPAA compliance protocols.

Also serving as a reminder that small practices are not immune from OCR enforcement, a small medical practice in Illinois was fined $31,000 by OCR for not having a business associate agreement in place. The medical practice contracted with a vendor that handled PHI, but failed to secure an appropriate business associate agreement. All medical practices should review their vendor arrangements and ensure that appropriate business associate agreements are in place with all vendors that receive or view PHI. Staff should also be trained annually on the importance of business associate agreements and reviewing agreements to ensure that they are not only in place but up to date as well. New staff should be trained at the time of hire.

OCR also recently settled with a large Texas-based health system for $2.4 million stemming from a HIPAA violation. In 2015, a patient at one of the hospitals in the system presented an allegedly fraudulent identification card to the office staff. The staff

(cont. on next page)

7

W W W . C S M S . O R G / A C T I O N N E W S • 9

immediately alerted authorities and the patient was arrested. That disclosure of PHI was permitted to law enforcement under the HIPAA rules. However, the system subsequently published a press release concerning the incident and disclosed the patient’s name in the release. This was an impermissible disclosure of PHI and resulted in a large fine and hefty corrective action plan from OCR.

Up until the last few months, OCR has been relatively dormant on HIPAA audits and fines, but it appears that things are on the uptick. Medical practices should heed this warning and take the opportunity to review all of their HIPAA policies and protocols and ensure that all staff are adequately trained. HIPAA violations can cost a practice valuable time and money: ensure that you are “hip” to HIPAA!

From the Office for Civil Rights (OCR) in the US Department of Health and Human Services:Process for Victim Reporting and Indicator Sharing**Note: this is not specific to the WannaCry Ransomware and is the process for any cyber attack**If your organization is the victim of a ransomware attack, HHS recommends the following steps:1. Please contact your FBI Field Office Cyber Task Force (www.fbi.gov/contact-us/field/field-offices) immediately to

report a ransomware event and request assistance. These professionals work with state and local law enforcement and other federal and international partners to pursue cyber criminals globally and to assist victims of cyber-crime.

2. Please report cyber incidents to the US-CERT (www.us-cert.gov/ncas) and FBI’s Internet Crime Complaint Center (www.ic3.gov).

3. For further analysis and healthcare-specific indicator sharing, please also share these indicators with HHS’ Healthcare Cybersecurity and Communications Integration Center (HCCIC) at HCCIC_RM@hhs.gov

HHS Office of Civil Rights Guidance on HIPAA specific to WannaCryu As outlined in its guidance available on its website, OCR presumes a breach in the case of ransomware attack. The entity

must determine whether such a breach is a reportable breach no later than 60 days after the entity knew or should have known of the breach. A request by law enforcement to hold reports tolls the 60-day reporting deadline. For a copy of the ransomware guidance, please see: https://www.hhs.gov/sites/default/files/RansomwareFactSheet.pdf?language=es.

u The ransomware guidance also includes important information about ransomware and how compliance with the HIPAA Security Rule helps entities prepare for ransomware attacks, including with regard to contingency planning. For more guidance on the Rule’s requirements, please see https://www.hhs.gov/hipaa/for-professionals/security/guidance/in-dex.html.

u OCR has shared its FAQ on sharing of cyber threat indicators under CISA with federal partners, and it is available on the OCR website. Please see https://www.hhs.gov/hipaa/for-professionals/faq/2072/covered-entity-disclose-protected-health-information-purposes-cybersecurity-information-sharing/index.html.

u Reporting information to law enforcement, DHS, or other HHS divisions does not constitute inadvertent or intentional reporting to OCR. All reporting of breaches to OCR should be made as required by the HIPAA Breach Notification Rule. Important Note: If the data is not encrypted by the entity to at least NIST specifications when the ransomware attack is deployed, then OCR presumes a breach occurred, due to the ransomware attack. As such, the entity would need to prove, through forensic or other evidence, that the ePHI was encrypted when the attack occurred, and the ransomware containerized (or encrypted again) already-encrypted ePHI. Please see https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html.

Eye on the Law: Mergers, Ransomware, HIPAA, Oh My! (cont. from previous page)

New CSMS Affinity PartnerCSMS is pleased to welcome Kelser Corp. as its newest Affinity Partner. Based in Glastonbury, Kelser provides technology solutions to improve the business of health care while protecting patient and provider information. Kelser helps to ensure that your information is available, manageable, accessible, and safe.

Is your practice at risk? CSMS members can find out with a complimentary Defend Forward Security Study. This comprehensive study can find costly cybersecurity gaps in your organization before hackers do.

In addition to their cybersecurity services, Kelser offers executive IT consulting, IT lifecycle management, managed ser-vices, modern data centers, and workforce enablement.

10 • C S M S A C T I O N N E W S

PrEP: Pre-Exposure Prophylaxis

Frank is a 45-year-old engineer seeking testing for sexually transmitted infections (STI). Having reunited with his wife, he wanted assurance he had no infections before resuming sexual relations. Asked if he has sex with men, women, or both, he acknowledged having condomless anal intercourse with six male partners in the past year. He is screened for urethral, anal and oral gonorrhea (GC) and Chlamydia (CT), and counseled about HIV risk. He was unaware of other HIV prevention methods and never heard of Pre-Exposure Prophylaxis (PrEP). After additional testing for HIV, Hepatitis B, C, and syphilis, he re-turns one week later for follow up. All tests are negative except positive rectal Chlamydia. He receives treatment for CT and agrees to start tenofovir/emtricitabine (aka Truvada) for PrEP. Given the first in a series of Hepatitis B vaccine, he leaves the office with a prescrip-tion for Truvada and a return appointment in a month.

Despite major treatment advances, the HIV epidemic continues to be perpetuated by new infections. According to the Centers for Disease Control (CDC), incidence rates in the US have remained steady among men who have sex with men (MSM) while it has declined for people who inject drugs (PWID) and heterosexuals (HS). Efforts now focus on the prevention of new HIV infections.

The CDC estimates that there are 1.2 million people at substantial risk for HIV who should be considered for Pre-Exposure Prophylaxis, or PrEP. A sexual history is essential, and conducted in a non-judgmental manner. Patients should be questioned about sexual preferences and the number of partners in the past six months to stratify risk.The CDC suggests considering PrEP for: • Men and women who have HIV positive partners • Commercial sex workers • Anyone with a bacterial STI • A history of inconsistent or no condom use, • Having a high number of sex partners • People who inject drugs and share equipment

Patients prescribed PrEP must be confirmed to be HIV negative. They should be screened for STIs and chronic hepatitis B, along with renal function. They should be followed every three months for HIV retesting and at least every six months for STI screening.

There are two major interventions aimed at HIV prevention. Behavioral interventions focus on modifying risk behaviors and attitudes, while biomedical approaches include the use of medications such as Truvada for PrEP, aimed at reducing transmission. Currently, Truvada is the only approved drug by the FDA. These agents inhibit HIV replication and reduce infection risk up to 96% in clinical trials among MSM, discordant couples, and PWID. One study from Kaiser Permanente in San Francisco followed 600 gay and bisexual PrEP users for one year and found no HIV infections in this group.

The recommended dose of Truvada is one tablet daily. It is well tolerated, and side effects are usually mild. For patient with chronic hepatitis B, discontinuation of the drugs may lead to a flare-up of hepatitis B. Truvada is only for people with a GFR of 60 or higher, since the use of tenofovir has been associated with declining renal function among some HIV infected individuals. While rare, serum creatinine at baseline, three months and every six months is advised. Mild bone mineral density losses have also been noted.

Some health care providers believe that prescribing PrEP patients may discourage condom use. Clinical trials have not shown such risk compensation, and in fact, it is the failure to use condoms that makes use of PrEP a vital a tool for HIV prevention.

Efficacy is directly related to adherence. Evidence from a meta-analysis of clinical trials showed that detectable drug levels of tenofovir/emtricitabine led to a 92% reduction in the risk of HIV infection.

PrEP is part of a comprehensive package of services that includes counseling, STI screening, and reinforcement of safe sex prac-tices such as continued use of condoms as barrier protection.

Most insurance covers Truvada. Since many individuals eligible for PrEP may have limited access to the healthcare, patient as-sistance is available.

Primary care providers work diligently to prevent disease. Beyond counseling lifestyle modification to patients at risk of cardiovas-cular disease, we employ a number of biomedical interventions, including the use of aspirin, statins, and antihypertensives to prevent future myocardial infarctions. That we can now prescribe an antiviral medication to prevent HIV infection should be no different.The CDC provides a host of PrEP resources:

• www.cdc.gov/hiv/pdf/prepguidelines2014.pdf• www.cdc.gov/hiv/pdf/prepprovidersupplement2014.pdf• www.gilead.com/responsibility/us-patientaccess/truvada%20for%20prep%20medication%20assistance%20program

Michael D. Virata, MD, FACP, AAHIVSDr. Virata is a CSMS member, and is on the Board of Governors for the New Haven County Medical Association.

Gary F. Spinner, PA, MPH, AAHIVS

W W W . C S M S . O R G / A C T I O N N E W S • 11

Members Matter

CSMS Life Member Sultan Ahamed, MD, MBA was recognized as the recipient of the 2017 PIAA Award of Excellence. PIAA, the medical professional liability insurance industry trade association, honored Dr. Ahamed for his contributions and longtime dedication to the liability insurance community and healthcare professionals.

CSMS Life Member Myron Genel, MD (photo, right) was presented with the Connecticut Academy of Science and Engineering (CASE) Distinguished Service Award, in recognition of his outstanding service to the Academy. A CASE member since 1992, Dr. Genel has served in many capacities, including study committees, elected leadership, and most recently as the first CASE Bulletin Executive Editor for Medicine.

At its 2017 Annual Meeting, the Connecticut Orthopaedic Society (COS) elected Mariam Hakim-Zargar, MD as its new President. The first woman to be elected COS President, Dr. Hakim-Zargar will serve a two-year term. The COS also honored Brian Smith, MD with its Orthopaedist of the Year Award, in rec-ognition of his “leadership and service to the Society, decades of exemplary patient care, and resident medical education.” (photo, left – incoming COS President Hakim-Zargar, MD, with outgoing President F. Scott Gray, MD)

Congratulations to CSMS member Alan Kaye, MD, who was elected President of the American College of Radiology at the ACR Annual Meeting, held May 21–25 in Washington, DC.

Congratulations to Suzanne Lagarde, MD on receiving the Sandra C. Labaree Award, the most honored accolade from the New England Division of the American Cancer Society.

The Award recognizes volunteers whose life saving actions and service exemplify the American Cancer Society’s organiza-tional values – Mission, Data-Driven, Diversity, Respect and Stewardship.

12 • C S M S A C T I O N N E W S

On May 30, CSMS hosted a program on biosimilars, featuring speakers Harry Gewanter, MD, Chairman of the Alliance for Safe Biologic Medicines (ASBM), and Andrew Spiegel, Esq., Executive Director of the Global Colon Cancer Association.

After a light dinner, CSMS EVP/CEO Matthew Katz welcomed everyone, and introduced CSMS President Jeffrey Gordon, MD. Dr. Gordon, a hematologist-oncologist, discussed the increasing role of biologic and biosimilar medicines in patient care. He also addressed CSMS advocacy efforts to strengthen the patient-physician relationship.

The complex topic of biosimilars and biologics was deftly handled by Dr. Gewanter, whose overview included inter-changeability, substitution, and chemical vs. biological medicines. In addressing the question of how close is “close enough,” Dr. Gewanter’s background as a pediatric rheumatologist was highlighted by a video clip of Cookie Monster singing, “One of these things is not like the other.”

Dr. Gewanter noted that 34 states and Puerto Rico have laws requiring pharmacist-physician communication whenever biosimilar substitution is a possibility, and stated that physicians and patients should always have the final say when it comes to substitutions.

The patient perspective on biosimilars was provided Mr. Spiegel, whose Global Colon Cancer Association advocates for a community of over six million colorectal cancer patients. The organization works to ensure that new biosimilar policies are patient-centered and support new therapeutic choices, increased access, and lower cost. Mr. Spiegel concurred that patient-centered standards are also needed for the naming, safety, and tracking of biosimilars.

The evening wrapped up with an opportunity for questions from the audience of physicians and other health profession-als. CSMS was pleased to host this timely, informative program about biosimilar medicines.

Learn more about the Alliance for Safe Biologic Medicines (safebiologics.org) and the Global Colon Cancer Association (globalcca.org).

W W W . C S M S . O R G / A C T I O N N E W S • 13

2017 Maloney and HLI Award Nominations Now Open

CSMS is now accepting nominations for the 2017 Maloney Distinguished Service Award and the 2017 Healthcare Leader and Innovator (HLI) Award. All CSMS members are welcome to nominate

their colleagues for recognition of outstanding work.

The Paul K. Maloney, Jr., MD Distinguished Service Award was established to honor the life and work of Dr. Maloney, an eminent physician known for his exemplary service, active engagement, and dedication to the community. The Maloney Award is the highest honor CSMS can confer upon a member. Each year, CSMS donates $1,000 to the charity of the Maloney Award winner’s choice.

The Connecticut Medicine Healthcare Leader and Innovator (HLI) Award is presented to a physician at any stage of practice who has demonstrated exceptional commitment to leadership and innovation at a time of significant changes in the practice of medicine.

The nomination deadline for both awards is August 18, 2017. To nominate a colleague for the • 2017 Maloney Award – contact John Bermudez (jbermudez@csms.org) • 2017 HLI Award – contact Patrice Dumond (pdumond@csms.org) Your nomination should include your contact information, the nominee’s contact information, and an explanation of

why you feel the physician should be considered for the award (no more than three pages).

Award winners will be announced at the 225th Annual Meeting on September 27, 2017.

14 • C S M S A C T I O N N E W S

W W W . C S M S . O R G / A C T I O N N E W S • 15

About six months ago, Anthem sent out an addendum letter that they termed an “amendment.” It was really just a thinly-disguised new contract, which didn’t include a fee scheduled or an opportunity for the physician to sign. It also had a paragraph that allowed the insurer to change the terms at any time, “just like the bad old days.” Alarmed, Dr. Gray contacted CSMS, who connected him to Attorney General Jepsen’s office. The AG has agreed to review the matter. “If it wasn’t for CSMS, I wouldn’t have had access to the AG,” said Dr. Gray.

Turning to the future, Action News asked Dr. Gray what steps the state could take to improve health care in Connecticut. Here are his top three suggestions:

1. Allow malpractice reform to move at a rapid pace – “We haven’t had any major reforms since the early 2000s.”

2. Reduce barriers to true medical competition, including relaxing Certificate of Need and other laws, and allowing physician-owned hospitals in CT – “Eleven of the twenty best US hospitals are physician-owned.”

3. Remove additional taxes on ambulatory surgical centers and hospitals – “Don’t use medical delivery to fix budget problems.”

As the practice of medicine continues to face challenges, physician advocacy will only grow in importance. Updating an old saying, Dr. Gray observed that “If you don’t want to be on the table, participate in organized medicine so your representative can be at the table.”

In his admittedly limited free time, Dr. Gray enjoys bike riding with his wife, singing in her synagogue choir, and spending time with his grown children and grandchild. He is also a Connecticut Masters swimmer, and competes in the New England Swim Championships.

Member Spotlight – F. Scott Gray, MD (cont. from page 5)

www.csms.org

Please visit our website to view information about many of the new and exciting CSMS programs, services, and member benefits. You can also view Connecticut Medicine, Action and SportsMed newsletters online, update your profile, or find one of your Connecticut colleagues. CSMS continues to make every effort to update our benefits and services to better serve you and the entire membership.If you have comments or questions concerning our site email kellyr@csms.org or call us at 203-865-0587.

Action is a publication of the Connecticut State Medical Society, a nonprofit organization of Connecticut physicians. President—Jeffrey A. Gordon, MD

Executive Vice President/CEO—Matthew C. Katz, MSManaging Editor—Kelly Gilbert Raskauskas kellyr@csms.org

Your comments and suggestions are welcome.Connecticut State Medical Society

127 Washington Avenue, East Building, 3rd Floor, North Haven, CT 0473

Phone 203-865-0587 • Fax 203-865-4997 • www.csms.orgArticles, editorials, and advertisements published in Action do no necessarily represent the official position or endorsement of the Connecticut State Medical

Society itself. The newsletter reserves the right to make the final decision on all content and advertisements.

Connecticut State Medical Society127 Washington Avenue, East Building, 3rd Floor North Haven, CT 06473

Between issues of CSMS Action News, get the latest news delivered to your Inbox:

send your email address to news@csms.org.Follow us on Facebook Connecticut State Medical Society

Follow us on Twitter @CSMSNews

Follow us on LinkedIn/ Connecticut State Medical Society

First Class PresortU.S. Postage

PAIDPermit # 4145Hartford CT