Download Death with Dignity - Chicago Medical Society

February 2017 | www.cmsdocs.org
Death with
Dignity
Applying the
End of Life
Option Act to
Residential Care
Facilities for
the Elderly
Big Data:
The Next
Revolution
in Healthcare
Operations
Publication o
of the Chicag
ety
Medical Soci
AL
THE MEDIC
F
SOCIETY O
NTY
COOK COU
Endometriosis:
What Every
Physician
Should Know
New Sick Leave
Protections for
Illinois Employees
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Volume 120 Issue 2
February 2017
16
FEATURES
PRESIDENT’S MESSAGE
MEMBER BENEFITS
16 Death With Dignity
By Clarence W. Brown, Jr., MD
27 Celebrating 70 Years in Chicago
PRACTICE MANAGEMENT
28 Speak Up, Be Heard
The End of Life Option Act in California
allows terminally ill residents who go
through the proper channels to take aidin-dying drugs to expedite their passing.
But how, specifically, does the Act apply to
physicians? By Pamela S. Kaufmann, Esq.
20 Endometriosis: What Every
Physician Should Know
Women with this condition often consult
a number of specialists before getting
an accurate diagnosis. Here’s what
you need to know about this lifelong
condition. By W. Paul Dmowski, MD, PhD
2 Network Adequacy Tops Our
Agenda
3 Medicare Outpatient Observation
Status; ERA and EFT Enrollment;
2017 Licensure Renewal Update
PUBLIC HEALTH
6 Bicycle Helmet Debate Continues;
Teen Dating Violence; Time to Get
Ill: New Sick Leave Protections;
New Guidelines for Low Back Pain
Treatment
LEGAL
10 Big Data: The Next Revolution in
Healthcare Operations
By Mary Beth Johnston, Esq., and Leah
D’Aurora Richardson, Esq.
13 Nursing Home Final Rule
Takes Effect
26 A Holiday Reception for All
29 New Members
30 Calendar of Events
31 Classifieds
WHO’S WHO
32 Fighting Infertility and
Endometriosis
Paul Dmowski, MD, PhD, is an expert in
the obstetrics-gynecology subspecialty
of reproductive endocrinology and
infertility, and has spent his long career
improving women’s health including
making great strides in the diagnosis
and treatment of endometriosis.
By Kimberly T. Boike, Esq., and
Ryan Haas, Esq.
February 2017 | www.cmsdocs.org | 1
MESSAGE FROM THE PRESIDENT
Network Adequacy Tops
Our Agenda
P
E R H A P S no time in U.S. political history will
our efforts to promote education and collaboration in our advocacy for physicians be as tested
as in the coming weeks and months with the
changing of the guard in Washington and divided
government in Springfield. In particular, there is a lot of legislative talk and many moving parts to the potential repeal,
replacement or repair of the Affordable Care Act. Much of
the political attention has been focused on insurance companies leaving markets and large premium increases by those
health plans that stay and continue to offer coverage.
But we must remain focused as we educate lawmakers and advocate for physicians
as a solution to any changes to health coverage in this country and improvements
to the existing laws. Already, we know that insurance companies that have survived
losses and remain on public marketplaces under the Affordable Care Act have done
so by restricting patient choice. In some cases, these plans state that they will remain
under the ACA because they have scaled back consumers’ choice of PPOs in favor of
narrow network plans such as HMOs and exclusive provider organizations, or EPOs.
And this narrow network strategy is also poised to gain momentum beyond states
and commercial insurance under the ACA and into Medicare. Nationally, there is
increased talk of privatizing Medicare under the Republican-led Congress.
Though it’s unclear how a more privatized Medicare program would take shape,
it’s generally interpreted as an expansion of Medicare Advantage. U.S. House Speaker
Paul Ryan’s “Better Way” agenda looks to expand the role of Medicare Advantage
plans. Even under President Obama, Medicare Advantage grew to 18 million enrollees
or almost one-third of beneficiaries in a private managed care plan.
But physicians should be leery of Medicare Advantage because it hands off
administration of benefits for seniors to private insurers that will control provider
networks. When private insurers gain more control over your patients’ benefits,
the likelihood is greater that performance measures will increase and there is the
potential for winners and losers among physicians.
At CMS, we remain concerned about increased insurance control of networking
strategies and who is determining performance and therefore who is going to
determine your compensation. This could be an even more important issue as payment under the Medicare Access and CHIP Reauthorization Act of 2015, also known
as “MACRA,” is rolled out over the next few years and physician reimbursement is
increasingly based on performance.
We will continue to advocate in Springfield and Washington for network adequacy
legislation. Your CMS has already laid out the necessary legislative language for ISMS,
by developing many of the provisions contained in the legislation that would allow
patients to receive the care they need in a timely manner from physicians in the health
plan’s network.
I am going to Washington on February 26 to advocate for our members and will
be meeting with members of Congress in leadership and from Illinois’ delegation to
Washington. Please reach out to me or to CMS staff if you have points that you want
to stress and legislative efforts you want me to bring to their attention.
Clarence W. Brown, Jr., MD
President, Chicago Medical Society
2 | Chicago Medicine | February 2017
EDITORIAL & ART
E XECUTIVE DIREC TOR
Theodore D. Kanellakes
ART DIREC TO R
Thomas Miller | @thruform
EDITOR /EDITORIAL
Elizabeth C. Sidney
E D I T O R I A L C O N S U LTA N T
Cheryl England
CONTRIB UTORS
Kimberly T. Boike, Esq.; Clarence
W. Brown, Jr., MD; Eric Brodsky,
FACMPE; Jessica Clark, MPH; Lesley
J. Craig, MPH; W. Paul Dmowski, MD,
PhD; Scott M. Gilbert, Esq.; Ryan
Haas, Esq.; Mary Beth Johnston, Esq.;
Pamela S. Kaufmann, Esq.; Jim Lando,
MD, MPH; Catherine B. Moore, Esq.;
Leah D’Aurora Richardson, Esq.
ADVERTISING
Fox Associates, Inc.
800-440-0231
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CHICAGO MEDICAL SOCIETY
OFFICERS OF THE SOCIETY
PRESIDENT
Clarence W. Brown, Jr., MD
P R E S I D E N T- E L E C T
Dimitri T. Azar, MD
S E C R E TA R Y
A. Jay Chauhan, DO
CHAIR OF THE COUNCIL
Vemuri S. Murthy, MD
VICE CHAIR OF THE COUNCIL
Christine P. Bishof, MD
I M M E D I AT E PA S T P R E S I D E N T
Kathy M. Tynus, MD
CHICAGO MEDICINE
515 N. Dearborn St.
Chicago IL 60654
312-670-2550
www.cmsdocs.org
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All rights reserved.
PRACTICE MANAGEMENT
Medicare Outpatient Observation Status
CMS releases standardized notice to help patients understand coverage and cost-sharing
By Catherine B. Moore, Esq.
T
H E C E N T E R S for Medicare and
Medicaid Services (CMS) released the
final notice hospitals must provide to
Medicare beneficiaries under observation or other outpatient status for more
than 24 hours. The Medicare Outpatient Observation Notice form was released in December 2016.
All hospitals and critical access hospitals must
provide the Notice no later than March 8, 2017. Physicians should become familiar with the Notice since
they may be required to complete the portion that
explains the specific reasons for an individual’s outpatient status. According to CMS, the hospital should
determine who will complete and deliver the Notice.
Coverage and Cost-Sharing
The Notice is a product of the Federal Notice of
Observation Treatment and Implication for Care
Eligibility Act (NOTICE Act) of 2015. One purpose
of the NOTICE Act is to reduce the surprise
of large out-of-pocket expenses by educating
Medicare beneficiaries in an easy-to-understand
manner. As a result, the Medicare Outpatient
Observation Notice standardizes the notice form
provided to beneficiaries. The Notice informs
individuals of their status as outpatients receiving
observation services and describes the cost-sharing
implications. Beneficiaries must receive a written
copy of the Notice and verbal explanation.
A primary consequence of being classified as
a hospital outpatient is financial. The patient’s
observation stay is typically covered under
Medicare Part B. If a patient needs care from a
skilled nursing facility (SNF) after leaving the
hospital, Medicare Part A will only cover SNF care
if the patient is classified as an inpatient for at least
three consecutive days, not counting the day of
discharge. Outpatient status would not qualify a
patient for Medicare Part A coverage of SNF care.
CMS has emphasized numerous times that labeling
a patient as an “outpatient” should not impact the
physicians’ medical decision-making. Specifically,
the classification “does not override the clinical
judgment of the physician to keep the beneficiary
at the hospital, to order specific services, or to
determine appropriate levels of nursing care or
physical locations within the hospital.”
Timing of Delivery
Hospitals must provide the Notice to an individual
who receives observation services as an outpatient
for more than 24 hours. The Notice must be
furnished no later than 36 hours after observation
services are initiated, or sooner if the individual
is transferred, discharged or admitted as an
inpatient. When the individual receives observation
services for less than 24 hours prior to admission
as an inpatient, the Notice does not apply.
CMS clarified that observation services
“begin at the clock time documented in the
patient’s medical record, which coincides with
the time that observation services are initiated in
accordance with a physician’s order.” Valid medical
documentation will always contain the time when
observation services are initiated; hospitals should
be able to readily determine the timeframe within
which the notice must be delivered. Observation
time ends when all medically necessary
observation services are completed.
For purposes of this rule, the term “physician”
encompasses other qualified and authorized nonphysician practitioners. CMS clarified that to the
extent residents or non-physicians are authorized to
order outpatient services, the 24-hour time period will
commence upon their order for outpatient services.
The Physician’s Role
In the standardized form, the Notice details the
possible cost-sharing implications of being an
outpatient. The Notice also contains a free text field
where the specific reason for receiving observation
services must be explained. According to CMS,
the reason for ordering observation services “will
always be the result of a physician’s decision that
the individual does not currently require inpatient
services and observation services are needed for
the physician to make a decision regarding whether
the individual needs further treatment as a hospital
inpatient or if the individual is able to be discharged
from the hospital.” However, some detail beyond a
generic statement must describe why the individual
is considered an outpatient. CMS reiterated that
physicians can order the medical services and tests
to best meet patients’ needs regardless of their
status as an outpatient.
CMS expects hospitals to follow “usual
procedures” for delivering notice, using “translators,
interpreters and assistive technology.” The written
notification must be signed by the individual
receiving observation services as an outpatient or
by a person acting on the individual’s behalf. If the
individual refuses to provide a signature, the staff
member who presented the written notification will
sign it. Physicians and other practitioners should
be prepared to answer any questions related to the
individual’s outpatient status.
“The Notice
informs
individuals of
their status as
outpatients
receiving
observation
services and
describes the
cost-sharing
implications.”
Catherine B. Moore, Esq., (Catherine.Moore@
bswllp.com) is an associate with Breazeale, Sachse,
& Wilson, LLP, in Baton Rouge, La.
February 2017 | www.cmsdocs.org | 3
PRACTICE MANAGEMENT
Medical Billing Essentials:
ERA and EFT Enrollment
Use these electronic systems to save money for your practice By Eric Brodsky, FACMPE
A
“In this
unprecedented
era for the
healthcare
industry, every
penny must
be accounted
for and
cost-cutting
measures are
instrumental to
the survival of
a practice.”
R E YO U AWA R E of the tremendous benefits associated with using
Electronic Remittance Advice (ERA)
and Electronic Funds Transfer (EFT)
in your practice? We are all personally familiar with receiving bills and statements in an
electronic format as well as making payment transactions online. The same opportunities apply with business payments and notices, and healthcare practices
should take advantage of the potential savings.
So what are ERA and EFT exactly? ERA is the
electronic version of an explanation of benefits.
EFT is the electronic version of a paper check.
In 2012, the Centers for Medicare and Medicaid,
as part of the Affordable Care Act, published a
regulation to streamline healthcare administrative
transactions by establishing ERA/EFT standards
that would result in a collective savings of
between $3 and $5 billion over the next ten years.
Furthermore, studies have shown that the cost of
claims via an Automated Clearinghouse (ACH)
averages only $0.34 versus $10.73 or more for other
EFT payment types.
Aside from the cost-savings, other benefits of
switching from paper to EFT and ERA include:
• Dramatic increase in staff efficiency by reducing
time spent on data input.
• Quicker receipt of payments.
• Reduced days in accounts receivable.
• Secure payment transactions with a reduction
in potential fraud associated with stolen paper
checks.
• Reduction in transaction posting errors with
proper use of ERA files.
• Automatic re-association of ERAs when paired
with EFTs.
There is almost no downside to enrollment for ERA
and EFT. Most commercial and government payers
offer easy ways to enroll. However, there can be
challenges with some of the smaller payers. Also,
in some instances there are third parties involved
with payment transactions and those entities may
charge a percentage fee for the processing of each
EFT. The Medical Group Management Association
(MGMA) has been a strong advocate for the
advancement of administrative simplification
in healthcare and has been pushing the federal
government to implement policies to reduce or
completely eliminate fees associated with EFT. In
the meantime, there are situations where it still
makes financial sense to enroll with third parties
even if they apply a fee, as long as it’s not excessive.
4 | Chicago Medicine | February 2017
In my previous work-life, the practice I
represented for nine years was able to achieve
90% payer adoption for both ERA and EFT. Yet
according to the Council for Affordable Quality
Healthcare (CAQH), in 2015, practice payer
adoption rates were only 55% for ERA and 62% for
EFT. It appears that we still have a long way to go
in this endeavor.
So how do you enroll for ERA and EFT? ERA
enrollment begins with your clearinghouse if
you’re using one. Medical practices use clearinghouses primarily for claims submission; however,
ERA enrollment is a secondary feature that most
of them provide. It’s important to work closely
with your clearinghouse to ensure that you are
indeed enrolled with all payers and that nothing
slips through the cracks. If you’re enrolled and still
seeing paper remittances, there’s something awry.
EFT enrollment can be bit trickier. Clearinghouses
typically do not facilitate EFT enrollment between
providers and payers (although some payers include
EFT enrollment with their ERA application). So
the next option is to contact the payers directly and
request an application. The good news is that there
is an increasing number of third parties in which
you can enroll with multiple payers via one online
application. An excellent example is CAQH whose
EnrollHub program includes large payers such as
Aetna, Cigna, and Humana.
ERA and EFT enrollment with smaller payers
can be a real challenge. Not many people are aware
that if a provider requests enrollment in ERA and/
or EFT with a HIPAA-covered entity and that
entity continues to provide paper documents, then
that entity is in violation of HIPAA. So beyond the
waste of having your billing staff process paper
transactions manually, the payers are mandated to
convert everything to an electronic format.
In this unprecedented era for the healthcare
industry, every penny must be accounted for and
cost-cutting measures are instrumental to the
survival of a practice. And the best part of moving
to implement ERA/EFT? There are typically no
costs except for the time spent on the enrollment
process. Take the time today to work with your
billing staff to ensure that your practice is enrolled
in ERA/EFT with as many plans as possible and
you’ll see immediate rewards in efficiency.
Eric Brodsky, FACMPE, is a senior consultant at
PBC Advisors, LLC, in Oak Brook. PBC provides
business and management consulting and accounting
services to physician practices and hospital systems.
For more information, visit www.pbcgroup.com.
PRACTICE MANAGEMENT
2017 Licensure Renewal Update
Physicians are required to enroll in PMP Provided by the Illinois State Medical Society
W
H I L E M E D I C A L and controlled substances licensure
renewal in Illinois won’t begin
until late spring of 2017, physicians can get an early start by
registering for the state’s prescription monitoring program (PMP). For the first time, physicians
are required to register for this helpful program.
There is no cost to register or to use the PMP, and
participation is voluntary once the registration is
completed.
As many physicians already using the system
know, the PMP is a valuable tool that can help
to enhance their understanding of each patient’s
prescription history. The program also works to
combat prescription drug abuse and curb “doctor
shopping.”
APNs and PAs may also access the PMP.
However, state rules require a collaborating or
supervising physician to enter this delegation
authority into the PMP. If the collaborating physician is not enrolled in the PMP, the APNs and PAs
won’t have access to the website. Simply sign into
the PMP and chose “PMP Collaborative Practice
Agreement Registration.”
The state indicates that a low number of collaborating/supervising physicians have entered the
delegation of prescriptive authority in the PMP, so
physicians’ effort are critical.
Under Illinois law, physicians may delegate to
mid-level healthcare professionals the prescribing and dispensing of controlled substances for
Schedules III through V or any specific controlled
substances in Schedule II. Collaborating professionals are vital to using this important tool in the
fight against prescription drug abuse.
The PMP also gives access to information about
patients who have been certified for medical cannabis. Beginning this year, the Illinois Department
of Public Health will be reporting medical cannabis
certification status to the PMP. Medical cannabis
may contraindicate certain medications, and the
new reporting requirement ensures an additional
level of safeguards for patients.
The PMP collects information on controlled
substance prescriptions dispensed in Illinois and
the website is available 24/7 and is fully functional
on a wide variety of mobile devices such as cell
phones and tablets.
Prescribers may view a complete history of the
prescriptions dispensed under their DEA number.
The prescription data found on the PMP website is
submitted by retail pharmacies that dispense medications in Illinois. These pharmacies are mandated
by Illinois state law to report the prescriptions on a
weekly basis.
The PMP provides other helpful information for
healthcare providers. On the PMP website, you’ll
find links to drug treatment, controlled substance
acts, healthcare manuals, law enforcement and
other states’ prescription monitoring websites.
The PMP also provides Schedules II-V controlled
substance prescription information and it includes
patient records that are viewable for 12 months.
Along with physicians, nurse-practitioners and
physician assistants, other healthcare providers
who may access the PMP website are pharmacists,
dentists, and veterinarians. The PMP gives healthcare providers accurate patient-specific data that
they can use to prevent potential drug interactions
or accidental overdose. And, for patients who are
abusing medication, the PMP website includes a
brief intervention form and a link to SAMSHA
treatment centers. The Illinois PMP is part of
the Illinois Department of Human Services. It is
funded through a grant from the U.S. Department
of Justice, Office of Justice Assistance.
Early PMP registration of physicians and their
APNs and PAs will make the licensure process go
a bit more smoothly and allow physicians to focus
on the actual renewal application. To register or to
learn more about the PMP, visit www.ilpmp.org.
CME Credit Requirements
Illinois physicians need to earn 150 hours of CME
credit in the three-year relicensure period, with a
minimum of 40 percent (at least 60 hours) of those
hours earned in formal educational programs and
a maximum of 60 percent (no more than 90 hours)
of those hours earned in a combination of formal
and informal education. Since IDFPR will conduct
random audits of physicians for compliance with
the CME requirements, physicians should maintain
records of their continuing medical education
(CME) activities. This documentation is not
required, however, when physicians submit their
renewal application.
Physicians are advised to maintain a list of
Category 1 (formal) CME programs and include the
name of the sponsor of the activity, title, date(s)
of attendance, and number of credit hours earned,
and be sure to keep the certificates verifying
credits earned. When recording all Category 2
(informal) CME activities, physicians should list
the approximate number of hours spent on each
type of CME activity. CME records should be
maintained for at least one full license cycle (three
years) after the cycle in which credits were earned.
This article is adapted from information on the
Illinois State Medical Society website. For more
information, please visit www.isms.org.
February 2017 | www.cmsdocs.org | 5
PUBLIC HEALTH
Bicycle Helmet Debate Continues
Helmet laws prevent serious head injuries but are they right for Chicago?
The Chicago Medical
Society’s Young
Physicians Section
hopes to bring bicycle
helmet laws to Illinois
that mirror those in
New York State.
N
E W YO R K State is one of 21 states
and the District of Columbia that has
bicycle helmet laws for young riders
and passengers. And now the Young
Physicians Section of the Chicago
Medical Society is hoping to bring legislation
similar to that in New York to the city of Chicago. Already, the group has started talks with
the Active Transportation Alliance (a coalition of
people who are working to make biking, walking,
and transit safe and easy options for people to get
around Chicagoland) and the Chicago City Council President Pro Tempore, Ald. Margaret Laurino
of the 39th Ward.
The New York State law prohibits children
under one year of age from being passengers on
bicycles. It also requires riders and passengers
under 14 years of age to wear a helmet. In addition,
children between the ages of one and five can
only ride as a passenger on a bicycle if they are
wearing a helmet that meets certain standards
including a good fit and being securely fastened.
In addition, these passengers must be in a separate
seat attached to the bicycle, and that seat must
have adequate provision for keeping the passenger
in place and protected from moving parts of the
bicycle. Fines for violations of the law do not
exceed $50.
In Illinois, only bike messengers and delivery
people on bikes are required by law to wear
helmets. All other adults have a choice of wearing
a helmet or not. In Chicago, children similarly are
not required to wear helmets.
Certainly the statistics bear out the fact that
6 | Chicago Medicine | February 2017
helmets can prevent serious head injuries in
cyclists. According to the Insurance Institute for
Highway Safety, each year about 2% of motor
vehicle crash deaths are bicyclists. In a majority
of bicyclist deaths, the most serious injuries are to
the head. Helmet use has been estimated to reduce
the odds of head injury by 50%, and the odds of
head, face, or neck injury by 33%. The odds that a
bicyclist will wear a helmet are four times higher
after a helmet law is enacted than before a law is
passed. And, based on the most recent statistics
from the U.S. Department of Transportation’s
Fatality Analysis Reporting System, the group
found that 54% of bicyclists killed in 2015 were not
wearing helmets.
But not everyone is a proponent of bicycle
helmet laws. Some opponents argue that helmets
alone do not make cycling safe but rather the
combination of bike lanes, public education,
and rider safety education are all part of the big
picture. And, they argue, because helmet laws
may discourage people from riding bikes then
public awareness of bicycle safety will likewise
decrease. In fact, a University of Colorado Denver
study examining collisions between bicycles and
motorists, shows bicyclist safety significantly
increases when there are more bikes on the road,
a finding that could be attributed to a “safety in
numbers effect.”
In a new working paper published by the
National Bureau of Economic Research called “The
Intended and Unintended Effects of Youth Bicycle
Helmet Laws,” authors Christopher S. Carpenter
and Mark Stehr conclude that while mandatory
helmet laws have led to increased helmet use, and
while helmet use has been shown to reduce bicycle
fatalities, such laws also seem to lead to a decrease
in actual bike riding.
The authors offer three explanations for why
this may be true. First, helmets can be expensive
to purchase and can be seen by many children as
“uncool.” Second, bike-helmet laws lower the price
of activities similar to biking such as skateboarding, and rollerblading that do not require a helmet.
And, third, children may simply place too little
weight on safety.
And so the helmet debate continues, especially
in large urban areas such as Chicago that are trying to encourage bike riding with programs such
as the Divvy bike sharing system. Chicago, with
its focus on improving its citizens’ health, has long
promoted bike riding as a way to help cut down
on traffic and pollution while promoting physical
exercise among Chicagoans. At the same time, no
one wants to see increased fatalities when cyclists
opt not to wear helmets.
PUBLIC HEALTH
Teen Dating Violence
February raises awareness about adolescent relationship abuse and where to get help
By Jim Lando, MD, MPH, Lesley J. Craig, MPH, and Jessica Clark, MPH
R
O U G H LY T WO -T H I R D S of adolescents who have dated report they
have experienced psychological, sexual,
and/or physical abuse from a dating
partner, making it clear that teen dating
violence is a pervasive problem in our society. February is designated Teen Dating Violence Awareness
Month (TDVAM), an effort to raise awareness about
abuse in adolescent relationships and programs that
prevent such abuse. It is critical that young people
have the knowledge to distinguish between healthy
and unhealthy relationships since the relationship
patterns they learn as adolescents are likely to be
carried into future relationships.
The Centers for Disease Control and Prevention
(CDC) defines teen dating violence as “the physical, sexual, psychological, or emotional violence
within a dating relationship, including stalking”
and notes that TDV can happen between current
or former partners. TDV, also referred to as
adolescent relationship abuse, can take place in
person or electronically, such as repeated texting,
and involves controlling behavior, such as telling
someone what to wear or dictating with whom
they can spend time.
The Types of Abuse
According to results from the National Survey on
Teen Relationships and Intimate Violence, among
adolescents who have dated, psychological abuse
was most common, reported by more than 60% of
respondents, but the rates of sexual abuse (18%)
and physical abuse (18%) are also substantial.
National Youth Risk Behavior Survey data show
that of Illinois high school students who reported
dating in the past 12 months, 11% experienced
physical dating violence and 11% experienced
sexual violence. It’s important to note that these
numbers may underestimate the experience of TDV
for Illinois teens; many young people do not report
violence because they are afraid to tell others, or
they may not realize that they are in an abusive
relationship. Adolescence is a time of significant change and
growth in a person’s life; it is during the preteen
and teen years that adolescents learn skills to form
healthy relationships. Victims of dating violence
in high school are at higher risk for victimization
during college and often experience a series of
abusive relationships into adulthood. It is essential
that positive relationships are promoted during
these years to prevent unhealthy patterns of dating
violence that can last a lifetime. Understanding
what a safe, consensual, and healthy relationship
is can also reduce the risk of abuse and result in
long-term benefits for health and well-being.
Short- and Long-Term Effects
TDV is associated with many very serious shortterm and long-term effects on both physical and
mental health including low self-esteem, depression and anxiety, eating disorders, substance
misuse, anti-social behaviors, and suicidality.
Teenage girls in physically abusive relationships
are much more likely than other girls to become
pregnant. Sometimes abuse can get worse during
pregnancy, posing a threat to both the mother and
the child. More than 900,000 children and young
people reside in Chicago, making it imperative for
healthcare providers to understand relationship
abuse, how it impacts their adolescent patients,
and where to obtain supportive services and
resources.
Locally, Between Friends is one of the largest
and most comprehensive TDV prevention programs
in Illinois. Between Friends also provides training
and technical assistance to healthcare providers
and systems on screening for domestic abuse
and responding sensitively to patient needs.
It works closely with Chicago-based violence
prevention programs, connecting providers and
survivors to agencies near their clinical offices or
neighborhoods.
Mobile Apps That Can Help
Since young people may be more inclined to text,
chat online, or use an Internet-based resource,
rather than call a hotline or participate in a
program two mobile applications—Circle of 6 and
On Watch—are designed for teens to get help if they
are in danger. Both won the U.S. Department of
Health and Human Services “App Against Abuse
Technology Challenge” and are free to download
from www.circleof6app.com and www.onwatchoncampus.com respectively as well as from iTunes.
We can all play a role in ending TDV and
supporting safe, healthy environments for young
people, this month and beyond.
Jim Lando, MD, MPH, is an Assistant Surgeon
General/Rear Admiral, U.S. Public Health Service
and Regional Health Administrator for the U.S.
Department of Health and Human Services, Office
of the Assistant Secretary for Health – Region V (IL,
IN, MI, MN, OH, WI), which coordinates the Region
V Adolescent Health Network. To contact the Region
V Adolescent Health Network, please email Lesley.
[email protected].
February 2017 | www.cmsdocs.org | 7
PUBLIC HEALTH
Time to Get Ill: New Sick Leave
Protections
Illinois employees gain additional sick leave rights in 2017 By Scott M. Gilbert, Esq.
E
M P LOY E R S with Illinois employees
should be aware of several new statutory sick leave provisions that go into
effect in 2017. Specifically, Chicago,
Cook County, and the State of Illinois
have each provided employees with various sick
leave protections.
Chicago
The Chicago Minimum Wage Ordinance was
amended to provide eligible employees up to 40 hours
of paid sick leave during each 12-month period. • The eligibility threshold is relatively low: an
employee need only (a) perform two hours of
compensable work within the City of Chicago,
and (b) work at least 80 hours for a covered
employer within any 120-day period. • To qualify as a “covered employer,” an entity
must maintain a business facility within the City
limits or be subject to any of the City’s licensing
requirements. There is no minimum employee
threshold. • The leave provided is not in addition to any
leave already provided by an employer, but any
plan already in place must meet the Ordinance’s
minimum requirements. • Qualifying employees accrue one hour of leave
for every 40 hours worked, up to the 40 hours
during each 12-month period. • The amendment goes into effect on July 1, 2017.
Cook County
The Cook County Earned Sick Leave Ordinance
also goes into effect on July 1, 2017, and largely
mirror’s Chicago’s ordinance. • A covered employee is anyone who, in any
particular two-week period, performs at least
two hours of work for an employer while
physically present within the geographic
boundaries of Cook County. Because Cook
County encompasses the suburbs surrounding
Chicago, a significant number of additional
employees will qualify for the benefit. • As with the Chicago Ordinance, employees can
carry over 20 hours of accrued, but unused sick
leave into the following year; provided, however,
that if the employer is subject to the federal
Family Medical Leave Act, the carryover limit is
raised to 40 hours. Illinois
The Illinois Employee Sick Leave Act does not
establish a minimum sick leave benefit; rather, it
allows employees to use accrued sick leave to care
for a family member. • An employee may use up to half of the
employee’s accrued sick leave for absences
related to the illness, injury, or medical
appointments of a family member. The term
“family member” is defined to include the
employee’s child, spouse, domestic partner,
sibling, parent, mother or father-in-law,
grandchild, grandparent, or stepparent. • The statute took effect on January 1, 2017.
• There are various exceptions and qualifications
applicable to each provision. Employers should
evaluate their coverage under each if they
maintain employees and facilities in any of these
locations.
Scott M. Gilbert, Esq., practices in the Chicago office
of Polsinelli, an Am Law 100 national law firm with
more than 800 attorneys in 20 offices. Contact him
at [email protected].
New Guidelines for Low Back Pain Treatment
T H E A M E R I C A N College of Physicians has
recently recommended noninvasive ways of
treating nonradicular low back pain. The ACP
recommends that patients start with non-drug
therapy and exercise, as well as engaging in
multidisciplinary rehabilitation, acupuncture,
mindfulness-based therapies for stress reduction,
tai chi, and yoga. Other practices recommended
8 | Chicago Medicine | February 2017
by the ACP include MCE and progressive muscle
relaxation. The ACP also recommends low-level
laser therapy and spinal manipulation, and cognitive behavioral and operant therapy. If patients do
not respond, the ACP recommends nonsteroidal
anti-inflammatory drugs, followed by drugs such as
tramadol or duloxetine as second-line therapy. The
ACP recommends opioids only as a last resort.
AmericAn BAr AssociAtion HeAltH lAw section
And
cHicAgo medicAl society
Present
PHYSICIANS LEGAL ISSUES CONFERENCE
the intercontinental
Program organizers
JUNE 8–9, 2017
in conjunction with
chicago, illinois
LEGAL
Big Data: The Next Revolution
in Healthcare Operations
For many institutions, data analytics are already firmly embedded in their operations and
providers of all sizes will surely follow By Mary Beth Johnston, Esq., and Leah D’Aurora
Richardson, Esq.
B
I G DATA is everywhere.
In healthcare, big data refers to the large quantities of complex electronic data sets that are difficult
to manage with traditional data management tools
and software. The capture, conversion and analysis
of healthcare big data through increasingly sophisticated data
analytics is driving new and valuable insights simply not possible
with small data. Knowledge gained through big data analytics
has the potential to improve the quality and delivery and lower
the cost of healthcare. In fact, it is the continuing explosive
growth in healthcare costs that is driving the demand for big
data in the healthcare provider sector. Such demand is driven
primarily by reimbursement reforms which have shifted the
focus from cost and volume-based payment methodologies to
rewarding value, efficiency, quality and outcomes. Such payment
methodologies are dependent on practicing evidence-based
medicine developed through big data analytics and are critical to
population health management.
Medicare Part A and Part B claims data and Part D drug event
data for use in evaluating provider and supplier performance
and requires these entities to produce and publicly disseminate
CMS-approved reports on provider performance that combines
Medicare claims data with claims data from other payer sources,
such as private payer data.
The QE Program was recently expanded by the Medicare
Access and CHIP Reauthorization Act of 2015 to permit qualified entities to create non-public analyses and provide or sell
such analyses to authorized users, as well as to provide or sell
combined data, or provide Medicare claims data alone at no
cost, to authorized users. According to CMS, the expansion
“allows approved organizations to confidentially share or sell
analysis of Medicare and private sector claims data to providers, employers, and other groups that can use the data to support improved care.” As of Aug. 1, 2016, CMS had certified 14
organizations as qualified entities, including four organizations
that report nationally.
“Big data analytics have profoundly changed the manner in which institutional providers approach clinical operations and patient care.”
CMS Use of Big Data
As the largest single payer of healthcare services in the country,
the Centers for Medicare and Medicaid Services (CMS) is facilitating and expediting the pace of healthcare’s big data revolution
by using advanced data analytics for everything from fighting
fraud and abuse to informing policy decisions and evaluating
CMS programs to supporting research.
In 2011, CMS implemented the Fraud Prevention System (FPS)
to detect and prevent healthcare fraud, waste and abuse as part
of its national comprehensive program integrity strategy. The
FPS utilizes sophisticated predictive algorithms and analytics by
screening all Medicare fee-for-service claims prior to payment
to identify anomalous billing patterns. The red flags from this
Medicare claims screening lead CMS and its contractors to
conduct closer claims reviews and initiate fraud investigations.
The FPS has proven quite effective. According to a recent
report, CMS boasted $654.8 million in identified or prevented
inappropriate payments during calendar year 2015 either directly
through the FPS or indirectly through investigations with FPS
involvement, which translated into an approximately $11.51 to $1
return on investment.
In perhaps a lesser known example, CMS’ Qualified Entity
(QE) Program is another part of CMS’ broader effort to utilize
big data analytics to drive the improvement of healthcare
delivery and quality while lowering costs. Implemented in 2012,
the QE Program enables certain qualified entities to receive
10 | Chicago Medicine | February 2017
The Influence on Institutional Healthcare
Operations
Many hospitals and healthcare systems have developed advanced
data analytics programs and invested in spin-off analytics
companies to harness big data to improve healthcare operations
and patient care. Such analytics programs have proven effective
in predicting healthcare outcomes, guiding providers’ treatment
protocols. In short, big data analytics have profoundly changed
the manner in which institutional providers approach clinical
operations and patient care. Because data analytical capabilities
are required to harness the knowledge captured within big data,
early converts to their potential understandably have been large
health systems and academic medical centers. A few well-known
examples are as follows.
In 2012, Carolinas HealthCare System (CHS), one of the
nation’s largest healthcare organizations, created its centralized healthcare analytics group, Dickson Advanced Analytics
(DA²), which focuses on evidenced-based population health
management, individualized patient care and predictive clinical
modeling. CHS’ integrated advanced analytics platform has the
ability to almost instantly integrate patient information with
clinical, billing and claims data. CHS healthcare practitioners
have access to real-time patient-specific readmission risk analyses, are able to analyze and identify clinical best practices, and
utilize payer claims data to identify patients who need additional
services to prevent future complications. In 2013, CHS joined
LEGAL
forces with other healthcare systems to launch the Data Alliance
Collaborative, which combines data and other resources from
four geographically distinct healthcare systems and uses big data
analytics to improve population health.
The Mayo Clinic has also invested heavily in big data analytics across its national healthcare enterprise to both redesign its
operations and improve healthcare delivery. Big data is further
used to analyze and in turn mitigate payment reform’s impact
on its bottom line. When a recent comprehensive assessment of
the use of big data within the organization identified that the
institution was spending more energy on collecting data than
utilizing analytics to develop effective information that could be
applied in practice, Mayo Clinic committed additional personnel
to its internal data analytics effort in order to focus on improving data quality while empowering personnel to utilize available
data tools.
Like many large healthcare organizations, Mayo Clinic
has also invested externally in big data analytics. In 2014,
Mayo Clinic clinical personnel obtained outside venture
capital investment and launched Ambient Clinical Analytics, a
company focused on providing clinical support tools through
an analytics platform to intensive care, operating room and
customizable dashboard of quality metrics and permits providers
to analyze de-identified data from their own and other providers
to identify patient risk factors, track clinical outcomes, and
evaluate treatment models.
Legal Considerations for Big Data Analytics
As the healthcare sector continues to collect and analyze big
data and develop sophisticated analytical tools to corral big
data’s utility, it is creating new legal questions and challenges not
previously encountered.
Healthcare fraud and abuse laws, such as the federal AntiKickback Statute and the Stark Law, are primarily focused on
financial relationships in the healthcare industry, and therefore
from a regulatory compliance perspective, the fundamental
importance of properly analyzing and structuring financial
relationships between healthcare entities and providers cannot
be overstated. Compliant arrangements, especially between
providers that have referral relationships, must reflect a fair
market value exchange of items and services, which includes
arrangements related to the exchange of data sets, the development of analytics models, platforms and software, and results
derived from data analytics.
“The use of big data analytics is creating legal and regulatory challenges for
providers as technology once again outpaces the law and policy.”
emergency departments that is accessible in real time. Ambient
Clinical Analytics’ platform includes clinical electronic medical record (EMR) and patient management tools that utilize
analytics to filter relevant patient data and support best-care
practices, and are meant to “make all of those things available
at a glance without moving in and out of different applications,
allowing for improved patient satisfaction and the ability to
deliver care at a lower institutional cost.” Optum Labs, a private collaborative partnership focused on big data analytics to
support healthcare research and innovations and its subsequent
use in the clinical setting, grew out of a partnership between
the Mayo Clinic and commercial insurer United Health Group.
Optum Labs now includes among its partners pharmaceutical
manufacturer Pfizer and the Department of Health and Human
Services and is one of the four national scale reporting entities
in the CMS QE Program.
Cleveland Clinic has also integrated big data analytics into
its healthcare operations system-wide. Its business intelligence
department operates the clarity repository, which is an embedded data repository connected to the EMR that supports data
warehousing, mining, management and analytics reporting.
According to a senior program administrator within the department, the focus of operating the clarity repository is answering
meaningful questions that have the power to actually influence
clinical decision-making and increase the quality of care at a
lower cost.
Like Mayo Clinic, Cleveland Clinic commercialized a data
analytics platform developed within its institution called
Explorys, which was spun off as a separate company in 2009.
The Explorys platform was purchased by IBM in April 2015 and
now houses a clinical database that includes de-identified data
on more than 50 million individuals from at least two dozen
health system clients representing about 360 hospitals and
over 55 million patients. Explorys offers real-time reports on a
Generally, the healthcare industry relies on traditional
valuation methods, such as cost-based, income-based, and
market-based methods, to determine the fair market value
of items and services and to structure compliant financial
relationships. However, these traditional approaches are
difficult to apply to data-related valuations, and there are no
other generally accepted guidelines for properly analyzing
the value of data and data analytics to date. Moreover, there
are unique issues related to the actual value of the data
exchange, particularly when the parties are permitted under
the arrangement to retain a copy of their data. Consequently,
concerns regarding properly structuring fair market value
arrangements are heightened as healthcare providers seek to
collaboratively commercialize and monetize data analytics
platforms or evidence-based methodologies produced from
data analytics programs. In order to remain compliant,
healthcare providers must ensure that their financial relationships can pass regulatory muster.
The intersection between healthcare data analytics, patient
privacy and human subject research is another example. Big
data repositories maintained by healthcare institutions may
contain identifiable clinical data and payer claims data protected
under federal law, such as the Health Insurance Portability and
Accountability Act (HIPAA), as well as myriad state privacy
laws. HIPAA, for instance, may permit identifiable patient data
to be used for research purposes, which may or may not be subject to Institutional Review Board (IRB) review. However, even
when the use of big data at this initial level is permissible under
HIPAA and is being properly overseen by an IRB or is IRBexempt, the results of these analytics are often used to construct
additional data sets, analytics models and platforms, and software that are later used by other institutions to guide clinical
decision-making as part of a collaborative or are commercialized.
Sometimes even the big data sets themselves are intended to be
February 2017 | www.cmsdocs.org | 11
transferred to databases for collaborative or commercial use.
At what point do big data sets themselves, or the platforms,
software and other results derived from such big data, whether
used inside or outside the institution generating the data,
become subject to other research requirements (notably, for
instance, notice and consent requirements)? Or at what point
does big data or its results cease to be protected by privacy and
security requirements under HIPAA or otherwise?
Other novel legal and regulatory issues may include ownership as intellectual property of big data sets or the resulting
analytics products, discoveries and insights; jurisdictional
requirements related to cross-border collection and transfer of
data; federal and state regulation and restrictions related to the
commercialization and monetization of big data sets, analyses,
analytics products, and resulting discoveries; and liability, risk
management and insurance coverage issues.
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12 | Chicago Medicine | February 2017
Navigating the Legal and Regulatory
Environment
Just as the explosive growth of telehealth forced federal and
state legislation and policy to advance and to modernize the
thinking of lawmakers, insurers, and professional licensing
boards, the use of big data analytics is creating legal and regulatory challenges for providers as technology once again outpaces
the law and policy. However, at a seemingly faster pace than telemedicine, big data analytics have already proven an effective tool
for providers to increase operational efficiency while improving
clinical care at lower costs. For many institutions, data analytics
are already firmly embedded in their operations and providers of
all sizes will surely follow. Effectively assisting these institutions
will require sophisticated counsel who understand the broader
legal and regulatory environment concerning the use, transfer,
and commercialization of big data.
Mary Beth Johnston, Esq., is a partner with K&L Gates, LLP,
at Research Triangle Park, NC, and is co-leader of the firm’s
healthcare practice group. Contact her at marybeth.johnston@
klgates.com. Leah D’Aurora Richardson, Esq., is a senior associate
in the firm.
Working With the Bar
T H E C H I C AG O Medical Society and the American Bar
Association have established a formal relationship to
address medical-legal issues affecting CMS members and
their practices. This legal section is sponsored by the
Health Law Section of the American Bar Association.
For CMS members this means that you get monthly
articles from legal experts who specialize in health law.
The articles will focus on subjects of current interest to the
medical profession as well as new laws and regulations as
they are implemented. The authors will vary every month in
order to bring you the best information possible from the
attorney who specializes in the subject matter.
If you have a particular question or would like more
information on a subject, please send us your suggestions.
You can send an email to Elizabeth at [email protected].
LEGAL
Nursing Home Final Rule Takes Effect
Broad changes to impact physician services and providers across care spectrum
By Kimberly T. Boike, Esq. and Ryan Haas, Esq.
O
N S E P T. 2 8 , 2 01 6 , the Centers for Medicare
and Medicaid Services (CMS) issued a muchanticipated final rule which modernizes and makes
drastic changes to the conditions of participation
for nursing homes. These long-awaited final rules
are the first comprehensive update to the conditions of participation for nursing homes since 1991. CMS received over 10,000
public comments to their initially proposed rule, before the final
rule was issued.
CMS stated that its goal in implementing these changes is
to “bring best practices for resident care to all facilities that
participate in Medicare or Medicaid, implement a number of
important safeguards identified by resident advocates and other
stakeholders, and include additional protections required by
the Affordable Care Act.” CMS believes these revisions will
help to improve the overall care and safety of nearly 1.5 million
residents in more than 15,000 long-term care facilities. The
rules will be implemented in three phases: phase one is effective upon the final rule’s effective date (Nov. 28, 2016); phase
two is effective exactly one year later (Nov. 28, 2017); and phase
three is effective three years from the final rules’ effective date
(Nov. 28, 2019).
All providers across the care spectrum will be impacted by
the rules, including physicians rendering care to residents in a
nursing home setting. They will also impact physicians serving
as medical directors for nursing homes. While the changes are
drastic, this article focuses on the changes to the physician
services provisions in Section 483.30.
Proposed Changes to Physician Services
Under the initial rule, CMS proposed to make the following
changes to Section 483.30, which sets forth the requirements for
physician services:
1. Revise the introductory text to specify that, in addition to a
physician’s recommendation that the individual be admitted
to a facility, a physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist must provide orders for
the resident’s immediate care and needs.
2. Add a new requirement that a facility, prior to an unscheduled transfer of a resident to a hospital, provide or arrange
for an in-person evaluation of a resident, to be conducted
expeditiously, by a physician, a physician assistant,
nurse practitioner, or clinical nurse specialist prior to
transferring the resident to a hospital, unless the transfer
is emergent and obtaining the in-person evaluation would
endanger the resident’s health or safety or unreasonably
delay the transfer.
3. Provide the physician with the flexibility to delegate to a
qualified dietitian or other clinically qualified nutrition
professional the task of writing dietary orders, to the extent
permitted under state law.
4. Provide the physician with the flexibility to delegate to a
qualified therapist the task of writing therapy orders, to the
extent permitted under state law.
The final rule does retain some parts of the former rule.
These include:
• CMS retained its requirement that orders be provided for
the resident’s immediate care and needs. The purpose of
this requirement is to ensure that residents’ receive care
for their specific needs until a comprehensive assessment
and care plan can be completed. Accordingly, in addition
to recommending that individuals be admitted to a nursing
home, a physician should also consider writing orders for the
immediate care individuals will receive once they are admitted to the nursing home.
• CMS received extensive negative comments on its proposed
requirement that a physician or other licensed professional
provide an in-person evaluation of an individual prior to
“CMS received extensive negative comments on its proposed requirement that
a physician or other licensed professional provide an in-person evaluation
of an individual prior to transfer.”
transfer. This requirement would have placed a large burden
on both nursing homes and physicians in the event that
an unscheduled transfer became necessary. In light of the
extensive comments received, CMS elected not to finalize this
proposal in the final rule.
• CMS received support for its proposal that physicians be allowed
to delegate authority to write dietary orders to dieticians acting
within their scope of practice under state law and under the
supervision of a physician. In the final rule, CMS limited the
scope of this authority to the attending physician, since the
attending physician retains primary responsibility for the
resident. This may allow physicians to make better use of their
time by permitting delegation of authority to dieticians who may
know the resident better than the attending physician.
• Similarly, CMS retained its proposal that physicians be permitted to delegate to a qualified therapist the task of writing
therapy orders, to the extent permissible under state law. CMS
noted that this proposal is intended to improve responsiveness
to a resident’s needs and may be implemented at the discretion of the physician.
The entirety of these changes to the physician services section
are implemented in phase one of the final rule. Accordingly,
these changes are currently in effect and physicians practicing in
nursing homes are required to comply.
Kimberly T. Boike, Esq., practices healthcare law at Chuhak &
Tecson, PC, and can be reached at [email protected]. Ryan A.
Haas, Esq., practices employment law affecting healthcare providers and can be reached at [email protected].
February 2017 | www.cmsdocs.org | 13
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Death with Dignity
Applying the End of Life Option Act
to residential care facilities for the elderly
By Pamela S. Kaufmann, Esq.
16 | Chicago Medicine | February 2017
DEATH WITH DIGNITY
O
N O C T. 6 , 2 01 6 , Californians
noted the one-year anniversary of
Governor Jerry Brown’s approval of
the End of Life Option Act, which
has been in effect since June 9,
2016. The past year has been filled with spirited
debate, numerous what-if scenarios, and speculation about which healthcare providers would opt
in and which would opt out. In a well-publicized
news story, one California hospital opted in after
rejecting the recommendation of its medical
leadership to opt out. For residential care facilities
for the elderly (RCFEs), which are by definition
not healthcare providers, the speculation was
accompanied by some hand-wringing as RCFEs
across the state attempted to glean how the law
applied to them.
The Act from 5000 Feet
Simply put, the Act allows terminally ill
California residents who leap through various
procedural hoops to take aid-in-dying (AID)
drugs to expedite their death. These include two
verbal requests and one written request for AID
drugs, strict witnessing requirements, and visits
to both an attending and a consulting physician
to confirm the patient’s terminal diagnosis (six
months or less), residency, legal competency, and
informed consent. No other person, not even a
sibling or spouse, can help administer the drugs
or make the request for the drugs. Where a
patient shows signs of depression or mental illness, a referral to a mental health professional is
also required. No medication may be prescribed
until the mental health specialist determines
that the patient no longer suffers from the
condition impairing his or her judgment. Some
commentators have observed that it takes a lot of
stamina to die under this law! In my opinion, the
Act’s emphasis on process reflects the delicate
balancing of the rights of all affected parties.
It also designed to prevent impulsive action,
duress, or abuse.
As with other ethical controversies, language
matters. The Act clearly asserts that taking AID
drugs under the Act is not suicide, homicide, or
assisted suicide. (Its critics might take exception
to this characterization.) Semantics aside, this
statement is significant because it helps to assure
that this action is not deemed criminal and will
not affect the availability of insurance (life insurance, in particular). Furthermore, a death from
consuming AID drugs is deemed a natural death
from the underlying disease, and actions taken in
accordance with the Act cannot form the basis for
a neglect or elder abuse claim.
Another sign of the Act’s balance is its evenhanded treatment of providers, regardless of
their position on the use of AID drugs. Whether a
healthcare provider opts in or out of “participating” under the Act, the healthcare provider is
protected from adverse action, such as censure,
disciplinary action, or loss of licensure—as long as
the provider does not violate the Act.
“Participation” is actually a very narrow concept
that includes only (1) performing the duties of an
attending physician, consulting physician, or mental
health specialist; (2) delivering the prescription for,
dispensing, or delivering AID drugs; or (3) being
present during ingestion of AID drugs. In fact, not
all acts by a physician or mental health specialist
constitute participation. The term expressly
excludes (1) diagnosing a terminal disease, making a
prognosis, or determining a patient has the capacity
to make decisions under the Act; (2) providing a
patient with information about the Act; and (3)
referring a patient to a participating provider. Thus,
the focus of “participation” appears to be on handling the drugs and being present during ingestion.
“Here’s the rub: the Act was not written
with assisted living in mind. It was written
for healthcare providers, and probably not
all healthcare providers.”
Healthcare providers can prohibit their staff
and contractors (and implicitly their volunteers)
from participating under the Act, but they can only
enforce this prohibition if they give these workers
notice of their policy. Similarly, where a provider
allows participation, employees and contractors
can refuse to participate for reasons of “conscience,
morality, or ethics” without penalty.
Here’s the rub: the Act was not written with
assisted living in mind. It was written for healthcare providers, and probably not all healthcare
providers. Its language strongly suggests that it
was designed primarily for doctors, hospitals, and
pharmacies. This is significant because none of
these healthcare settings is “home” for a patient.
Contrast a hospital with a skilled nursing facility
(SNF), which is defined as a healthcare provider
and which is clearly home for its residents. It is
neither easy nor convenient for SNF residents to
ingest these drugs somewhere else. (At times, it
may not be physically possible.) The same is true
for RCFE residents, whose home is the RCFE.
DSS to the Rescue
Last fall, our firm began to identify several challenges for RCFE providers trying to discern how to
apply the Act to their unique setting. For example:
• Can an RCFE provider require residents to
disclose their end-of-life plans?
• Can it prohibit residents from self-administering
AID drugs on its premises?
• Must it allow residents to store AID drugs on
campus?
February 2017 | www.cmsdocs.org | 17
DEATH WITH DIGNITY
• Can it prohibit staff and contractors from
participating under the Act?
• Must it call 911 if a resident is found dying after
ingesting an AID drug?
have learned since then from the State that there
will not be written guidance on this issue and that
the decision to call 911 or not must be addressed on
a case-by-case basis.
We were very fortunate to receive clear guidance
from the California Department of Social Services
(DSS) last winter. In a four-page memorandum,
DSS reasoned (correctly, we believe) that although
they are not healthcare providers under the Act,
RCFE licensees and their employees are entities or
individuals under the Act who may, due to “conscience, morality, or ethics,” opt not to participate
in activities authorized under the Act. DSS thus
concluded that RCFEs could instruct their staff not
to participate in activities permitted by the Act.
Although the memo is silent about volunteers and
contractors, we believe it is reasonable to apply
the same logic to these two groups, at least on the
RCFE campus.
Risk Areas
“Its language strongly suggests that it was
designed primarily for doctors, hospitals, and
pharmacies. This is significant because none
of these healthcare settings is 'home' for a
patient.”
Other findings by DSS were potentially more
troubling for our clients. For example:
• Regardless of the licensee’s choice, residents
retain the right to obtain and self-administer
AID drugs on the premises. Some clients find
this policy offensive on religious or ethical
grounds.
• Residents are solely responsible for obtaining,
storing, and self-administering AID drugs (in
a locked cabinet or off-site). Even if a cabinet is
locked, it is obviously safer, for the RCFE and its
residents, to store these drugs off-site. This step
should be encouraged.
• Residents are not required to disclose their
intent to consume AID drugs to the licensee.
This is an obvious impediment to care planning
and can trigger intense conflict if the family
learns of a resident’s plans after the fact.
Our primary concern about the memo was that it
offered no guidance regarding the need to call 911
after learning that a resident had ingested AID
drugs. Calling 911 when the resident was clearly
taking steps under the Act to end his or her life
seemed contrary to the resident’s express wishes
and the intent of the Act. Recently, DSS suggested
(verbally) that RCFEs need not call 911 when a resident’s plans to take AID drugs in accordance with
the Act are clear. In all other circumstances, DSS
stated, providers should continue to call 911. We
18 | Chicago Medicine | February 2017
As I advise clients about the Act, we quickly drill
down to their key concern: will they participate,
and to what degree? This is not an all-or-nothing
proposition. Providers can choose to participate in
certain acts but not others.
For many clients, the primary risk management concern is receiving or storing the medications. After all, the AID drug is a controlled
substance that is designed (in the right dosage)
to shut down one’s central nervous system and
cause death. Other drugs that make up the
“cocktail” include a sedative and anti-nausea
medication.
Many clients also express concern about
being present during ingestion of the AID
drugs. They are not necessarily worried about
the risk of harm; however, they have offered
the following rationales for their position: (1)
being present suggests that the provider condones dying in this manner; (2) an employee
who is present when a resident ingests AID
drugs may feel compelled to assist the resident
(in violation of the law) if the resident is
struggling with the medications; or (3) it may
be traumatic to the employee to watch the resident die in this manner. The first rationale is
the one I hear the most often from religiously
affiliated clients.
Although it does not constitute “participation”
under the Act, I routinely advise clients against
allowing their staff, contractors, or volunteers
to witness a resident’s written request to take
AID drugs. I would catalogue this advice under
the heading of “no good deed goes unpunished.”
If there is any question about the resident’s
competency, his or her prognosis, the absence
of duress, or any other factor that could cast the
validity of the form in doubt, you do not want
your company or your workers implicated. If a
resident declines to tell his family of his plans
and a family member learns that your staff or
agent witnessed the written request for the
drugs, nothing good will come of this. Your best
option is to bow out—and instruct your workers
to do the same.
Trends
Having given about 20 presentations on the Act
and spoken to numerous senior care and housing
providers, I have observed some fascinating trends.
• Clients are largely opting out of participation.
Some are carving out exceptions for contracting
physicians or hospices, and one or two will allow
their workers to be present during ingestion, but
DEATH WITH DIGNITY
•
•
•
•
no senior care client has yet advised me that it is
fully opting in.
Clients are uniformly advising their staff, volunteers, and contractors not to witness requests for
AID drugs.
I discern very little difference in the decisions
made by clients based on faith affiliation. The
tone of my clients’ policies may vary, and their
reasons for their position may vary, but the
result is rather uniform.
Caregiving staff at several of my clients’
communities have expressed discomfort with
having residents take AID drugs on campus.
Many cite their faith as a large reason for this
position.
Be prepared for staff to decline to provide comfort care (think palliative care) after ingestion
due to their faith or ethical concerns. Providing
comfort care is not a form of participation, but
it will follow ingestion by only a few minutes.
Although RCFEs are not required to provide
this service, it is not uncommon for clients to
keep a dying resident company and to soothe
the resident. I recommend that staff’s wishes in
this respect be honored.
Utilization
All four states with end-of-life statutes
(California, Oregon, Washington, and Vermont)
require that data be collected under their
end-of-life laws. As a result, we know that in
both Oregon and Washington (which have older
statutes and more data than Vermont), roughly
two-thirds of prescribed end-of-life drugs
were ingested and one-third went untouched.
Whether this is due to effective pain and
symptom management by hospice agencies, the
comfort of having the drugs nearby, sudden
health declines, the inf luence of family or
clergy, or other factors is unclear.
The data also reveal that the typical person
taking AID drugs is a 70+ year old with cancer who
dies at home, usually with hospice care. Only a
small number (about 5%) of people ingesting these
drugs in Oregon and Washington died in a longterm care or similar setting. Given these statistics,
one might wonder what the fuss is about in senior
care. Residents feel otherwise. When I speak to
groups of residents, they express keen interest in
knowing their provider’s position—and planning
for it.
Next Steps
If a resident decides to invoke his rights under the
Act tomorrow, do you know what your position
will be? If not, I recommend that you make your
end-of-life policy a high priority. There have
already been a few reported instances of terminally ill California residents taking AID drugs,
and your residents are very eager to know what
your position is.
Once you finalize your policy, you will want
to document it in a policy and procedure and
start educating residents, staff, contractors, and
volunteers about it. Disclosure is key. To support
your efforts, I recommend describing your
policy in your resident handbook or residence
agreement, a letter or note to residents, and your
personnel policy. If you opt out of any component
of participation, you will also need written
acknowledgment of your policy from your staff,
volunteers, and contractors.
Parting Thoughts
California’s relationship with this law is in its
infancy. It will take time to learn how widespread
the use of AID drugs is, what legal or practical
challenges arise, and how various elements of the
Act are interpreted. It seems likely that the incidence of death by taking AID drugs will spike now
that our large, populous state offers this option. Be
prepared for many interesting developments—and
possibly for modifications to your end-of-life
policy as we all become more experienced in the
implementation of this law.
Pamela S. Kaufmann, Esq., is a partner at Hanson
Bridgett LLP. She represents senior housing and care
providers and tax-exempt organizations. Readers with
questions about this article are welcome to contact
the author at [email protected]. This
article was originally published in the CALA Update
e-newsletter, October 21, 2016, and is archived at
www.CAassistedliving.org.
More States Adopt Aid-in-Dying Laws
O N N OV. 8 voters of Colorado passed Proposition 106, the
Colorado End-of-Life Options Act, by a nearly two to one
margin. The new law went into effect Jan. 1. The Washington, DC, City Council approved an aid-in-dying bill on Nov.
15, by an 11 to 2 majority, and it was signed by the mayor on
Dec. 20. The DC law could be overturned by the U.S. Congress, however. Several legislators have introduced a bill that
would override the DC law. Here in Illinois a bill modeled after aid-in-dying legislation
in Oregon, Washington, California, Colorado, and Vermont,
would establish this right for Illinois residents who are mentally
competent adults with terminal illness. The Illinois End-of-Life
Options Act includes the same protections implemented in
Oregon over 20 years ago. The movement to establish the legal
right to control the manner of one’s dying is worldwide, with
February 2017 | www.cmsdocs.org | 19
ENDOMETRIOSIS
Endometriotic implants in the posterior cul-de-sac. Note: dilated superficial blood vessels, ecchymoses, superficial adhesions
and marked local inflammatory reaction, surrounding recent red and older bluish-brown implants of endometriosis.
Endometriosis: What Every
Physician Should Know
Early diagnosis is vital to treating this lifelong condition By W. Paul Dmowski, MD, PhD
E
N D O M E T R I O S I S , at times referred
to as a “benign cancer,” is a poorly
understood disease that affects women
in their reproductive years. It is characterized by ectopic (outside of the uterus)
growth of the endometrial cells, usually on serosal
surfaces of the pelvic organs, which have the
ability to invade tissues or metastasize to anywhere
in the female body. The ectopic endometrium
undergoes the same cyclic changes as the uterine
endometrium, with monthly shedding and bleeding
into the involved tissue, resulting in inflammation,
tissue necrosis and pain. Accordingly, symptoms of
20 | Chicago Medicine | February 2017
the disease are not limited to the female reproductive system. They may originate in any organ or
tissue. Consequently, women with endometriosis
may initially consult any of the following physicians: pediatrician, family doctor, gynecologist,
reproductive endocrinologist, laparoscopic surgeon,
gastroenterologist, urologist, neurologist, pain
specialist, orthopedic surgeon or other physician.
Some of practitioners may not be familiar with the
disease. Therefore, it is not unusual for symptoms
to be ignored, the diagnosis not made and
opportunity for early management missed. Several
studies have reported the mean diagnostic delay
NEW
ENDOMETRIOSIS
PRESIDENT
(interval between the first medical visit and the
diagnosis) for endometriosis, ranges from between
four to eight years. Familiarity with symptoms and
findings of endometriosis can significantly shorten
this interval.
Symptoms and Findings
The symptoms of endometriosis are characteristically associated with menses; they progress over
time and extend into the intermenstrual period.
They are referred to as chronic pelvic pain symptoms (CPPS). Endometriotic lesions are typically
located in the posterior cul-de-sac, in the rectovaginal septum, on utero-sacral ligaments and on
peritoneal surfaces throughout the pelvis (Fig. 1).
On pelvic examination, the lesions are palpable
as tender nodules. They elicit pain symptoms
when under pressure, for instance, pressure by
hardened stool during defecation, (dyschezia), or
pressure during coitus (dyspareunia). Endometrial
shedding and bleeding into the lesions result in the
development of pseudocysts. Filled with old blood,
they have a liquid chocolate consistency (chocolate
cysts, Fig. 2) and are called “endometriomas.”
Endometriotic lesions spread directly by contiguity,
or by seeding through the peritoneal fluid into
the peritoneal cavity or through lymphatic and
vascular channels into distant locations as benign
metastases. Any tissue and organ in the female
body may become involved. Accordingly, women
with endometriosis may present with a variety of
symptoms (see Table 1).
Endometriotic lesions contain endometrial
(epithelial and stromal) cells; immune cells
such as macrophages, NK cells, T and B cells;
mesothelial cells; fibroblasts; and as demonstrated
recently, different types of nerve fibers. These
cells produce substances that attract immune cell
migration to the lesions, creating a local inflammatory environment that contributes to infertility
and is responsible for the local and generalized
symptoms. The substances include TNF alpha and
a variety of cytokines and chemokines, contractile
prostaglandins of the PgF2α and PgE structure,
as well as other prostanoids. Prostanoids induce
smooth muscle contractions in the reproductive,
gastrointestinal, and urinary systems, and are perceived as uterine cramping, dysuria, nausea, vomiting and diarrhea. It has been suggested that newly
ingrown nerve fibers transmit noxious stimuli
from the endometriotic lesions to the central
nervous system and are responsible for some of the
components of CPPS. A variety of growth factors,
such as VEGF, PDGF, and EGF, which are produced
by endometriotic lesions, stimulate further growth
of the lesions through the autocrine/paracrine
mechanisms. Interestingly, ectopic endometrial
cells, unlike eutopic endometrium, acquire the
ability to produce estrogens which, in the autocrine
fashion, further stimulate endometrial-cell proliferation within the lesions. This is considered the
mechanism for continuous growth and spread of
endometriosis when peripheral estrogens are low,
as they are following bilateral oophorectomy or
menopause. Considering that most endometriotic
lesions are exposed to the peritoneal surfaces, the
substances produced by the lesions can be identified in the peritoneal fluid from which they are
absorbed into peripheral circulation and contribute
to the generalized symptoms.
It is important to keep in mind, however, that
eutopic uterine endometrium can produce most of
the same substances as ectopic endometrial cells,
notably a variety of prostanoids. Therefore, some
components of CPPS, such as dysmenorrhea, may
be present in women without endometriosis. And
this may create a diagnostic challenge and may
require laparoscopy for the definitive diagnosis.
Because symptoms of endometriosis are not
pathognomonic of the disease, and patients may
be seen by practitioners of different specialties,
any cyclic symptom related to menses that
progressively worsens with age and any lesion that
undergoes cyclic swelling, tenderness and bleeding,
should be suspect of endometriosis, and the patient
should undergo diagnostic workup or appropriate
referral.
Natural History and
Etiopathogenesis
The prevalence of endometriosis in reproductive
age women has been estimated at 3-10% and
seems to be higher in industrialized nations. In
selected groups, for example, in infertile women
or in gynecologic patients it is much higher,
approaching 40-50%. An estimated five million
U.S. women suffer from endometriosis, resulting
in direct and indirect healthcare costs exceeding
$75 billion annually.
It is generally agreed that the cycling uterine
endometrium, stimulated by estrogens and
unknown predisposing factors, is required for the
development of endometriosis. However, the etiology and pathogenesis of this disease are unknown.
Several theories have been proposed to explain
how endometrium appears and functions outside of
the uterus. One such theory proposes that ectopic
endometrium develops from the mesothelium or
other local tissues through the process of metaplasia. Another theory suggests that local tissue
transformation can be stimulated by a variety of
substances, some transmitted from the uterus with
the retrograde menstrual flow. Still another theory
postulates that endometriosis develops from “mullerian rest cells” stimulated by ovarian estrogens.
The most popular is the theory of Sampson, who
proposed that during menses endometrial cells
are “regurgitated” from the uterus through the
fallopian tubes into the peritoneal cavity, or are
transported through lymphatic and/or vascular
channels to distant locations, where they implant
and become endometriotic lesions. All these
February 2017 | www.cmsdocs.org | 21
ENDOMETRIOSIS
concepts share a common assumption—that eutopic
endometrium can readily implant in ectopic
locations. This, however, may not be a physiologic
event, and in fact, several physiologic mechanisms
seem to exist to prevent such an occurrence.
Retrograde tubal transport of the menstrual
flow occurs during menses in all women with
patent fallopian tubes, and endometrial cells have
been identified in the peritoneal cavity during
laparoscopic examinations at that time. Yet implantation of these cells, giving origin to endometriosis,
occurs in fewer than 10%. We have demonstrated
in Rhesus monkeys that experimentally misplaced
endometrial cells are recognized outside of the
uterus and are destroyed by the cells of the
immune system. Several in vitro studies, including
some from our Institute, demonstrated decreased
cytotoxicity of monocytes/macrophages, NK cells,
and cytotoxic T cells in women with endometriosis
compared to women free of the disease, suggesting a role of the immune system in eliminating
misplaced endometrial cells.
Several other mechanisms may also be
involved in preventing ectopic endometrial cell
survival and implantation. One such mechanism
is programmed cell death or apoptosis, involving
uterine endometrium. It begins physiologically
during the secretory phase when there is no
embryonic implantation, and becomes maximal in
the shedding endometrium. Apoptosis leads to the
death of endometrial cells regardless of whether
they were expelled outside of the body with the
menstrual flow or were regurgitated into the ectopic locations. We and others have demonstrated
that in endometriosis, endometrial cell apoptosis is
decreased. This allows for survival and implantation of ectopically misplaced endometrial cells.
In about 30-40% of women with endometriosis,
there is increased humoral immunity and polyclonal
activation of B-cells. This is evidenced by the
presence of anti-endometrial, anti-ovarian, antiphospholipid, and other anti-tissue or anti-organ
auto-antibodies in the peritoneal fluid and peripheral circulation. Anti-endometrial autoantibodies
seem to be more prevalent and exist in higher
concentrations in women with less disease. It is
quite likely that ectopically implanted endometrial
cells that survived apoptosis and immune cell surveillance/cytotoxicity, stimulate humoral immunity
and autoantibody production. Anti-endometrial
autoantibodies then contribute to the elimination of
endometriotic lesions or slow down their progression. In agreement with this concept, repeat laparoscopies in the same women have demonstrated some
endometriotic lesions resolve over time without
treatment, while the new ones appear. This is also in
agreement with the observation that endometriosis,
in women with congenital or acquired obstruction
to the menstrual flow, may resolve spontaneously
following the release of the obstruction.
Increased prevalence of endometriosis in first
22 | Chicago Medicine | February 2017
degree relatives has been reported by several
studies, suggesting genetically transmitted
predisposition. Relevant to this are recent
genome-wide association studies, which identified
in endometriosis a single nucleotide polymorphism in several chromosomal regions. Genetic
mutations and epigenetic changes involving genes
controlling one of the steps in the cell cycle of
proliferation/apoptosis have also been reported
in women with endometriosis. Intrauterine, early
neonatal or postnatal exposure to endocrine disruptors such as polychlorinated biphenyls (PCBs)
or dioxin increases the risk for development of
endometriosis in laboratory animals, Rhesus monkeys and in women. It has been suggested that
endometriosis through epigenetic imprinting is
associated with dysregulation of gene expression
in multiple signaling pathways in and beyond the
reproductive system.
Endocrine disruptors may induce epigenetic
changes. These may result in a partial or complete
anti-apoptotic effect or the suppression of cellmediated immunity, with a variable clinical picture
ranging from relatively mild slowly progressing
endometriosis to severe, rapidly progressing
disease. It appears that ectopic endometrial cell
dissemination, survival and implantation create
the “endometriosis load” opposed by the “disposal
system” consisting of apoptosis and cell-mediated
immunity. The equilibrium between these two
events can be affected by a variety of factors. As
a result, in some women the disease may develop
when the “endometriosis load” is increased, as in
the obstruction to the menstrual flow, or when
“cell disposal system” is less effective. It also seems
possible that endometriosis could resolve spontaneously if the reverse were to take place, as during
medically induced amenorrhea.
Diagnosis and Treatment
Endometriosis should be suspected in women with
CPPS and/or characteristically tender cul-de-sac
nodules, both increasing in severity or tenderness in relation to the menstrual cycle and age.
Such symptoms and pelvic examination findings
provide a clinical diagnosis of endometriosis
and justify symptomatic management using oral
contraceptives and analgesics. If the symptoms do
not resolve with symptomatic management and
continue to progress, and especially if new findings
develop, definitive diagnosis by laparoscopy/
laparotomy is required. The laparoscopic surgeon
should be prepared to resect, ablate, cauterize
or destroy visible and suspected endometriotic
lesions. Considering that endometriosis is a chronic
disease that may spread to other tissues and
organs, and that patients may subsequently consult
other medical specialists, biopsies of representative
lesions for pathological diagnosis are important.
Surgical resection of advanced endometriosis,
when large endometriomas or deep infiltrating
ENDOMETRIOSIS
lesions are present, may be challenging and
require skills outside the general ob-gyn specialty.
Incomplete resection accelerates recurrence while
aggressive destruction of the tissue, inadequate
reconstruction of the reproductive system, and
incomplete hemostasis may lead to surgical complications, rapid disease recurrence and infertility due
to the disease itself or as a result of postoperative
adhesions, and in cases of extensive ovarian resection, premature ovarian failure.
Medical suppression of endometriosis is based
on the induction of a hypoestrogenic or highly
progestational environment with resulting endometrial atrophy and amenorrhea. In the absence
of cyclic hormonal stimulation and cyclic bleeding,
ectopic lesions undergo atrophy and resorption by
the cells of the immune system. Complete suppression of the menstrual periods and thin atrophic
uterine endometrium, reflect the effectiveness of
therapy. In the management of endometriosis and
CPPS, one should consider:
• Management of pelvic pain using nonsteroidal
anti-inflammatory drugs, analgesics, narcotics,
combined hormonal contraceptives or local/
regional nerve blocks.
• Medical suppression using GnRH-agonists with
or without add-back, danazol, progestogens
aromatase inhibitors, progestational oral contraceptives and GnRH-antagonists, currently in
Phase III trials.
• Conservative surgery, including resection,
cautery or ablation of superficial lesions, evacuation and resection of endometriomas, resection
of deep infiltrating endometriosis, resection of
extra-genital endometriosis, or definitive surgery
(hysterectormy and bilateral oophorectomy).
Problem-oriented, Patient-centered,
Multidisciplinary Approach
Women with symptomatic endometriosis may
consult different medical and surgical specialists
and their objectives may change with age, fertility status, treatment, recurrence and disease
progression. A patient’s objectives and priorities
may include:
• Control of symptoms
• Improved quality of life
• Prevention of recurrence, surgical complications
and cancer
• Preservation of fertility
• Achievement of pregnancy
• Hormonal management after definitive surgery
Physicians, however, have been trained to identify
clinical problems through the perspective of
their training and expertise in the specific area
of management, and often pay little attention
to their patients’ objectives and preferences. It
is not unusual for the laparoscopic surgeon to
perform repeat resection of mild to moderate
pelvic endometriosis in a young symptomatic
woman, compromising her chances for pregnancy
by creating postoperative adhesions and inducing
premature ovarian failure. Another physician
may recommend lengthy hormonal treatment in
a woman with a prior diagnosis of endometriosis
but also undiagnosed ovarian cancer. It is not
unusual for an advanced laparoscopic surgeon to
resect extensive deep infiltrating endometriosis,
including resection of the lower bowel, in a woman
with medically manageable symptoms, leaving her
free of the disease, but functionally disabled. Most
commonly, however, women with endometriosis
undergo surgical resection and are led to believe
that all disease was removed and no further treatment is necessary. Without subsequent follow-up
and preventive management the recurrence rate is
about 15% annually.
Extensive endometriosis with bilateral
ovarian involvement,
massive adhesions and
pronounced inflammatory reaction. Note:
large right ovarian
endometrioma filled
with chocolate-like
material.
Practitioner Summary
Endometriosis is a lifelong disease associated
with chronic, progressive and debilitating pelvic
pains, negatively affecting quality of life, personal
relationships, and work productivity. It affects
more than 5% of women in their reproductive
years, compromises their fertility and leads to
multiple surgical interventions and lengthy medical treatments. The symptoms of endometriosis,
although typically related to the menstrual function and to the reproductive system, may originate
in any tissue, organ or system of the female body.
Consequently, most physicians, regardless of specialty, at one point or another in their practice, will
be consulted by the affected patient. Patients may
see on average five or more physicians before the
diagnosis is made and the diagnostic delay exceeds
four years. It is therefore necessary to keep in mind
that in a woman of reproductive age, any symptom
that progresses and increases in severity during
February 2017 | www.cmsdocs.org | 23
ENDOMETRIOSIS
the menstrual period, and any lesion undergoing
cyclic swelling and bleeding during menstruation,
should be suspect of endometriosis.
Endometriosis is characterized by ectopic
implantation and function of the endometrial
cells, resulting in the local inflammatory reaction;
activation of the immune response; cyclic bleeding
into the tissues with formation of chocolate cysts;
tissue necrosis; and adhesion development. The
etiopathogenesis of endometriosis is unclear; however, available data indicate that the endometrial
cells during menses are physiologically transported
outside of the uterus through fallopian tubes and/
or vascular and lymphatic circulation and are disseminated to distant locations in all women.
Several mechanisms, including cell-mediated
and humoral immunity and endometrial cell
apoptosis, prevent ectopic survival, implantation
and function of these cells. The balance between
endometrial cell dissemination and their removal
may be altered in either direction, resulting in
the development of the disease or its resolution.
Genetic/epigenetic changes may induce in the
endometrial cells resistance to apoptosis or
decrease immune cytotoxicity, resulting in the
increased frequency of endometriosis in firstdegree relatives or after exposure to environmental
immunotoxicants.
Clinical diagnosis of endometriosis is based on
symptoms and findings. Short-term symptomatic
management may be appropriate. If there is no
lasting improvement and if new findings appear,
laparoscopy should be performed. At the time of
laparoscopy, visible and suspected endometriotic
lesions should be removed and a pathologic diagnosis established. Several options are available for the management of endometriosis, including surgical resection, hormonal suppression and a combination of
both. Symptoms may vary, as well as the location of
the lesions, extent of the disease and the patient’s
objectives. As a result, physicians of different
specialties and expertise will be involved, requiring a multidisciplinary approach. Furthermore,
because complete eradication of the disease is
usually not possible and the same etiopathogenetic
mechanisms remain, long-term management
should include regular follow-up and prevention of
recurrence. Control of symptoms, improvement in
quality of life, and preservation and management
of fertility are the major objectives of affected
women. These priorities may change depending on
a woman’s age, ovarian reserve, fertility status and
other factors.
In most cases, a well-coordinated multidisciplinary approach involving physicians and
surgeons of different specialties and expertise
is required. A general gynecologist should have
overall responsibility for the medical care and be
able to coordinate interaction among specialists.
The general gynecologist should refer to or ask
another professional for help:
• When the patient decides to pursue an approach
the general gynecologist is not familiar with,
such as IVF.
• When the location or extent of the disease is outside the general gynecologist's area of expertise,
such as deep infiltrating endometriosis.
• When the treatment is not effective, for example,
if there is no symptomatic improvement with the
medical suppression.
• When the doctor-patient relationship breaks
down, such as when the patient seems to know
more than the doctor.
W. Paul Dmowski, MD, PhD, is Professor of
Obstetrics and Gynecology at Rush Medical College
and Medical Director of the Institute for the Study
and Treatment of Endometriosis, Reproductive
Medicine Institute, in Oak Brook. He may be reached
at www.endometriosisinstitute.com.
Table 1: Symptoms and Findings of Endometriosis
General
Malaise, low-grade fever, weight loss, low energy/fatigue, dizziness/headaches, depression,
generalized aches and pains
CPPS
Dysmenorrhea, pelvic pains, dyspareunia
Reproductive
Infertility, RPL, menometrorrhagia, premenstrual spotting, adnexal enlargement, fixation, tender
CDS nodules
GI System
Nausea, vomiting, stomach upset, diarrhea, constipation, dyschezia, hemochezia, rectal pressure,
symptoms of partial or complete intestinal obstructions, acute abdomen, hemoperitoneum
GU System
Dysuria, hematuria, bladder pressure, symptoms of urinary obstruction
Respiratory
Dyspnea, chest pain, hemoptysis, symptoms of pneumo or hemothorax
Skin and Musculoskeletal
Painful cyclic swelling or hemorrhagic lesions
Nervous System
Low back, leg and/or sciatic pains, sensory, motor deficits (footdrop)
24 | Chicago Medicine | February 2017
MEMBER BENEFITS
From left: Drs. Louis Kraus; Shastri Swaminathan, past
president of CMS and ISMS; David J. Banayan; and Linda
Gruenberg enjoy the camaraderie.
From left: Drs. Clarence W. Brown, Jr., president of CMS, and
Kathy M. Tynus, past president of CMS; and Ald. Gregory
Mitchell of Chicago’s 7th Ward.
From left: Drs. Momina Waqar; Rana Z. Tariq; Scott Leikin; and
Dr. Leikin’s guest Meghan Reilly, share in the festivities.
From left: Drs. Brown; Anne Szpindor, trustee of CMS; Scott
Cooper, past ISMS president; and Piyush I. Vyas, president of
the Lake County Medical Society.
From left: Dr. Vanessa Stan; John Bishof and wife Dr. Christine
P. Bishof, trustee of CMS. The Standard Club’s location made it
easy for spouses to attend.
Cecilia Leong and husband Dr. Jack C. Leong, a longtime CMS
member. The couple had a chance to mingle with colleagues
both old and new.
A Holiday Reception for All
E V E RY H O L I DAY season the Chicago Medical Society holds
a reception for the medical community at large. As 2016 drew to
a close, this tradition continued as a diverse group of members
and guests came to unwind and celebrate at The Standard Club,
one of Chicago’s oldest private clubs. The Holiday Reception is
also a way for CMS to thank hardworking physicians for their
support throughout the year.
26 | Chicago Medicine | February 2017
Guests of all age groups and professional backgrounds, from
medical residents to longtime physicians, to legislators and
attorneys, were able to mingle in an elegant “old world” setting
with live piano music. For newcomers, the reception provided a
friendly welcome to CMS. Held on Dec. 15, the festive occasion
is also an opportunity for informal discussion about healthcarerelated issues in Illinois.
MEMBER BENEFITS
Celebrating 70
Years in Chicago
M
O R E T H A N 300 guests, including officials
from five countries, came for the Polish American Medical Society in Chicago’s 70th anniversary. Visiting dignitaries from Poland, as well
as leaders from Polish medical groups in France
and Sweden, and past presidents of the local PAMS chapter
were among the many celebrants at the gala event, which
took place at the University Club of Chicago in September.
PAMS is an affiliate of the Chicago Medical Society and an
active member of the Federation of Polish Medical Societies
Abroad. Throughout the year, PAMS organizes fundraisers
for charitable causes, including the annual Physicians’ Ball
at the Ritz-Carlton in Chicago to raise scholarship funds for
medical students of Polish descent. The Physicians’ Charity
Ball will take place on Sept. 16, 2017.
Shown from left are: Drs. Kornelia Krol, president of the Polish
American Medical Society in Chicago; Clarence W. Brown, Jr.;
president of the Chicago Medical Society; and Anne Szpindor,
a past president of PAMS and trustee of CMS.
Where Hope
Meets Healing
At Shriners Hospitals for Children — Chicago, our
mission is simple: deliver world-class care to children
who need it most – regardless of their ability to pay.
For over 90 years we’ve specialized in helping children affected
by orthopaedic conditions, cleft lip and palate, spinal cord injury,
and rehabilitation needs. And while expertise, dedication and
generosity make it all possible, we believe our hospital is fueled
by love. That love is what helped the Shriners network of
22 locations treat over 127,000 children last year alone,
helping them every step of the way.
Do You Know a Child For a consultation, or to refer a patient, call:
Who Needs Expert Shriners Hospitals for Children — Chicago
Specialty Care? 773-385-KIDS (5437)
2211 N. Oak Park Ave., Chicago, IL 60707
facebook.com/shrinerschicago
twitter.com/shrinerschicago
shrinerschicago.org
February 2017 | www.cmsdocs.org | 27
MEMBER BENEFITS
Speak Up, Be Heard
CMS resolutions go to medicine’s legislative body, the house of delegates
T
H E C H I C AG O Medical Society’s grassroots resolutions process lays the foundation for strong physician advocacy, in Springfield and Washington. Each
year CMS works with individuals and committees to
craft new measures and then relay them to the Illinois State Medical Society’s House of Delegates. And when the
HOD meets this April 21-23, your CMS will be there to launch
and support these efforts.
Already, two powerful CMS resolutions from years past are
having an impact. In 2016, our Network Adequacy Taskforce
drafted language that ISMS transformed into a bill (HB 311 and
SB 70) that establishes network adequacy standards for all health
plans sold in the state. The provisions, as proposed by CMS,
require plans to maintain up-to-date directories of in-network
providers, and to communicate any changes to patients clearly
and quickly.
Another CMS effort being implemented by ISMS would amend
the Illinois Insurance Code so that health plans can no longer deny
benefits claiming a procedure is not medically necessary, or refer to
medical necessity, when the denial is based on coverage levels.
Here’s a snapshot of CMS resolutions bound for ISMS:
Hospital and Health System Administrator
Compensation
• Requests the AMA to study the compensation of hospital
administrators and hospital network administrators in not-forprofit hospitals and health systems and to evaluate whether
their compensation is consistent with their mission to provide
care to the indigent and the public in general.
• Requests the AMA to report the study results in its physician-publications and submit the results to other medical and
non-medical publications.
Reimbursement for Prior Authorization
• Calls for state and national legislation that requires insurance
companies and pharmacy benefit managers (PBMs) to pay for
each prior authorization form submitted.
• Directs the AMA CPT Editorial Panel to create a new billing code
as necessary so that physicians are able to bill insurance companies and PBMs for the time spent on each prior authorization.
Inappropriate Requests for DEA Numbers
• Creates state and national registries to collect data on the circumstances under which physicians are asked to provide DEA
numbers for reasons that do not involve controlled substances.
• Seeks legislation in Illinois to penalize companies and entities that request physicians to provide their DEA numbers for
uses outside their intended purpose.
Advanced Care Planning Codes
• Calls for an assessment of the use of Advanced Care Planning
99497 and 99498 Codes, and the barriers to advanced care
planning discussions by physicians and patients.
• Enables use of Codes 99497 and 99498 when sufficient time
and effort is spent with patients and families over multiple
clinical visits to satisfy the time requirements.
28 | Chicago Medicine | February 2017
Opposing Attorney Presence and/or Recording of IMEs
• Calls for study of state and federal policy that would prohibit
courts from compelling the recording, videotaping, or allowing
a court reporter or opposing attorney to be present during the
IME as a condition for medical opinions being allowed in court.
• Supports or introduces legislation to accomplish the above.
• Adds such policy to the 7th Edition of the AMA’s Guides to
the Evaluation of Permanent Impairment.
Acceptance of Hospital-Based Serum Alcohol Results
in Litigation
• Seeks legislation so that courts will:
1. Accept these test results without further expert testimony
unless documented irregularities exist in the medical record.
2. Not require chain-of-custody documentation to prove
the integrity of a hospital-based alcohol test used for
clinical purposes.
3. Recognize there is no clinical difference (and minimal
analytical difference) between a hospital-based serum
alcohol test and whole blood alcohol concentration and
adjudicate as such.
4. Not interpet hospital-based alcohol testing as “speculative” and not bar such testing unless there are documented irregularities in the medical record.
5. Not consider the disinfectant used to draw blood a reason
to disqualify the result.
6. Allow hospital-based alcohol concentrations to be admissible
as evidence of intoxication even without other evidence.
Making Voice Recognition Systems Available in EHRs
• Seeks legislation that requires the integration of voice recognition systems into all electronic medical record systems.
Improving the Insurance Appeals Process
• Requires insurance companies to state in their prior authorization assessment the criteria by which a procedure was
denied, and to provide the criteria for approval in the denial
letter to the physician and patient.
Pharmaceutical Price Relief
• Educates policymakers and others about the non-competitive
and deleterious effects of PBMs in the medication supply chain.
Tobacco Harm Reduction: A Comprehensive Nicotine
Policy • Educates physicians on patient-specific approaches to smoking cessation, particularly patients with end-stage disease
secondary to smoking and those who have failed traditional
cessation methods.
• Calls for research to expand options for assisting in the
transition from smoking, including nicotine replacement
therapies and noncombustible nicotine products (including
e-cigarettes).
If you would like to serve as a CMS delegate, please call 312670-2550.
MEMBER BENEFITS
Welcome, New Members!
The Chicago Medical Society greets its newest members. We are now 310 voices stronger!
Student District
Jennifer Camello
Kaitlyn Kunstman
Kathryn Nutting
Jennifer Pan
Bartlomiej L. Radzik
Amanda K. Wallinger
Resident District
Aadil Ahmed, MD
Patrick Ardron-Hudson, MD
Eric Cheung, MD
Michael D. Eckhardt, MD
Ofelya Gevorgyan, MD
Kirstin Howell, MD
District 1
Catherine A. Counard, MD
Stephanie A. Heraty, MD
Corina M. Sandulescu, MD
District 3
Mohammad M. Puri, MD
Anca Zegrean, MD
District 5
Ria Luz D. Parcellano, MD
District 6 UIC Group
Vinay K Aakalu, MD
Javaneh Abbasian, MD
Khaled M. Abdelhady, MD
Sofia M. Adawy, MD
Saba Ahmad, MD
Olusola A. Ajilore, MD
Marcela D. Almeida, MD
Sachin C. Amin, MD
Ashish M. Ansal, MD
James W. Antoon, MD
Shiva Arami, MD
Amer K. Ardati, MD
Ahmad A. Aref, MD
Iris K. Aronson, MD
Ansul Asad, MD
Seema M. Awatramani, MD
Nathalie F. Azar, MD
Aamir Badruddin, MD
Alexandra E. Baracan, MD
Marla S. Barkoff, MD
Michelle M. Barnes, MD
Amelia M. Bartholowmew, MD
Verna L. Baughman, MD
Rena Beckerly, MD
Patrick G. Belvitch, MD
Pooja V. Bhat, MD
Francesco M. Bianco, MD
Martin Borhani, MD
Shane Borkowsky, MD
Claudia C. Boucher Berry, MD
Brian R. Boulay, MD
Gillian M. Brennan, MD
Joan E. Briller, MD
Steven U. Brint, MD
Maximo O. Brito, MD
Daniel R. Bunzol, MD
Nancy S. Burk, MD
Sally A. Campbell-Lee, MD
Michael D. Carrithers, MD
Robert E. Carroll, MD
Fidel E. Castillo Diaz, MD
Esteban A. Cedillo-Couvert, MD
Wadih Chacra, MD
Stacey L. Chamberlain, MD
Robison V.P. Chan, MD
Elizabeth Charney, MD
Felix Y. Chau, MD
Farrukh S. Chaudhry, MD
Anjen Chenn, MD
Bill Chiu, MD
Samuel J. Chmell, MD
Daniel K. Choi, MD
Rozina A. Chowdhery, MD
Mark Chwajol, MD
Joseph S. Colla, MD
Geisel B. Collazo-Garcia, MD
Sean D. Conrin, MD
Maria S. Cortina, MD
Simone Crivellaro, MD
Raymond H. Curry, MD
Kimberly A. Czech, MD
Oana C. Danciu, MD
Robert S. Danziger, MD
Dawood Darbar, MD
Odile David, MD
Gilla P. Davis, MD
Jose J. De La Cruz, MD
Micaela Della Torre, MD
Laura M. DiGiovanni, MD
Tatiana K. Dixon, MD
Ali R. Djalilian, MD
Valerie Dobiesz, MD
Steven M. Dudek, MD
Arkadiusz Z. Dudek, MD
Irene Eftekhar, MD
Wesley P. Eilbert, MD
Yuval Eisenberg, MD
Enrique F. Elli, MD
Suzanne E. Falck, MD
James S. Feinberg, MD
James M. Feld, MD
Patricia W. Finn, MD
Geraldine S. Fox, MD
Gretchen A. Fox, MD
William A. Frese, MD
Nicholas F. Furtado, MD
Sujata S. Gaitonde, MD
Antonio Gangemi, MD
Olga L. Garcia-Bedoya, MD
Daniel F. Garvey, MD
Steven A. Garzon, MD
Lisa M. Gehm, MD
Pier C. Giulianotti, MD
Gelila K Goba, MD
Benjamin A. Goldberg, MD
James A. Goodwin, MD
Anna M. Gramelspacher, MD
Lauren A. Green, MD
Marika L Greiff, MD
Marilyn Griffin, MD
John V. Groth, MD
Rahul Guha, MD
Grace B. Guzman-Hartman, MD
Emily R. Hall, MD
Allan G. Halline, MD
Muhamad Hammamieh, MD
Anantha K. Harijith, MD
Ahmed N. Hassan, MD
George E. Havelka, MD
Karen C. Hayani, MD
Cathy A. Helgason, MD
Meghann M. Hennelly, MD
Priscilla C. Hensel, MD
Zulma M. Hernandez-Peraza, MD
Ronald C. Hershow, MD
Tamir Hersonskey, MD
Dominic S. Ho, MD
George E. Hoganson, MD
Christopher C. Holden, MD
Melody R. Hrubes, MD
Lewis L. Hsu, MD
Henry D. Huang, MD
John R. Hughes, MD
Jordan Hupert, MD
Jeffrey R. Jacobson, MD
Howard A. Jaffe, MD
Shivi Jain, MD
Sandeep Jain, MD
Christopher Janson, MD
Olamide D. Jarrett, MD
Gina D. Jefferson, MD
Hoonbae Jeon, MD
Qin L. Jiang, MD
Stephanie A. Joe, MD
Eunice G. John, MD
Min J. Joo, MD
Shrihari S. Kadkol, MD
Tanjeev Kaur, MD
Yevgenya Kaydanova, MD
Manoj Kesarwani, MD
Irum H. Khan, MD
Jin Suh Kim, MD
William H. Kobak, MD
Pelagia E. Kouloumberis, MD
Sabine E. Kreilinger, MD
Andrew J. Kreppel, MD
Jerry A. Krishnan, MD
Mark S. Kushner, MD
Christopher E. Lai, MD
Justin H. Lee, MD
Yannek Leiderman, MD
Ulana A. Leskiw, MD
Benjamin R. Levin, MD
Bruce P. Levy, MD
Wei-Hsun Liao, MD
Roger A. Lichtenbaum, MD
Amy Lin, MD
Janet Y. Lin, MD
Howard L. Lipton, MD
Natalia O. Litbarg, MD
Ann-Marie Lobo, MD
Mykela K. Loury, MD
Geraldine Luna, MD
Peter W. Macintosh, MD
Harsha V.H. Madan Kumar, MD
Khalid M. Malik, MD
Bernice Man, MD
Matthew S. Marcus, MD
Armando Marquez, MD
Molly A. Martin, MD
Mario A. Masrur, MD
Malek G. Massad, MD
Kameron Matthews, MD
Timothy B. McDonald, MD
Dana B. McQueen, MD
Anjali H. Mehta, MD
Anders F. Mellgren, MD
Katie L. Mena, MD
William F. Mieler, MD
Dan V. Mihailescu, MD
Mark D. Minier, MD
Nancy A. Miranda, MD
Diane M. Misch, MD
Heather E. Moss, MD
Sri Muthukrishnan, MD
Fedra Najjar, MD
Joshua B. Nathan, MD
Ammara Naveed, MD
Hongyu Ni, MD
M. Kelly Nicholas, MD
Johan F Nordenstam, MD
Sharmilee M. Nyenhuis, MD
Annie L. Oh, MD
Ergun Onal, MD
Amanda D. Osta, MD
Sarah L. Oswald, MD
Howard Ozer, MD
Michael D. Palmisano, MD
Jeong Mi Park, MD
C. Lucy Park, MD
Pritesh R. Patel, MD
Tushar N. Patel, MD
Pravin-Kumar K. Patel, MD
Kristin D. Patton, MD
Pallavi P. Patwari, MD
Laura L. Pedelty, MD
David L. Perkins, MD
Malgorzata A. Plummer, MD
Anne M. Polick, MD
Bharati Prasad, MD
John G. Quigley, MD
Jonathan M. Radosta, MD
Aarti Raghavan, MD
Julia U. Raj, MD
Nimmi Rajagopal, MD
Matthew J. Ranzer, MD
Kalyan N. Rao, MD
Miriam I. Redleaf, MD
Jalees Rehman, MD
Janet M. Riddle, MD
Glenda Rios, MD
Angela E. Rivers, MD
Daniel W. Robinson, MD
James P. Ronayne, MD
Mark I. Rosenblatt, MD
Steven Roth, MD
Leelach G. Rothschild Dekoven, MD
Ari B. Rubenfeld, MD
Alexandria D. Saulsberry, MD
Paul K. Schlesinger, MD
Mary L. Schmidt, MD
Jaye R. Schreier, MD
Pete Setabutr, MD
Suman Setty, MD
Zohra Shad, MD
Neelofer Shafi, MD
Reshma Shah, MD
Ami N. Shah, MD
Rajiv P. Sharma, MD
Rebecca A. Shilling, MD
Arvind K. Shukla, MD
Maria Z. Siemionow, MD
Hernan Sierra-Fernandez, MD
H. Steven Sims, MD
Sunit Singla, MD
Claudine G. Sinsioco, MD
Sara V. Smith, MD
David C. Snow, MD
Abdus S. Soudagar, MD
Radhika Sreedhar, MD
Nishant Srinivasan, MD
Teresa L. Sripada, MD
Vithida Sueblinvong, MD
Joel Sugar, MD
Nadera J. Sweiss, MD
Julia F. Switzer, MD
Hira Tanwir, MD
Stefan T. Tchernodrinski, MD
Fernando D. Testai, MD
Rakhi W. Thambi, MD
Trevonne M. Thompson, MD
Nicole C.P. Thompson, MD
Jyothi I. Tirumalasetty, MD
Dean M. Toriumi, MD
Elmer Y. Tu, MD
Ivo T. Tzvetanov, MD
Manuel F. Utset, MD
Thasarat S. Vajaranant, MD
Tibor G. Valyi-Nagy, MD
Benjamin W. Van Vorhees, MD
Vladimir Vidanovic, MD
Suncica Volkov, MD
Effrossyni Votta-Velis, MD
Rohit Vuppuluri, MD
Shihtien Wang, MD
Michael A. Warso, MD
Stevan M. Weine, MD
Christina D. Wells, MD
Barry L. Wenig, MD
Peggy J. Wheeler, MD
Jacob T. Wilensky, MD
John W. Williams, MD
Peter R. Williamson, MD
Robert A. Winn, MD
Vijay V. Yeldandi, MD
Charles Q. Yu, MD
Jeffrey Yu, MD
John L. Zautcke, MD
Lawrence A. Zeidman, MD
Scott J. Ziporin, MD
Aaron F. Zirk, DO
February 2017 | www.cmsdocs.org | 29
MEMBER BENEFITS
Calendar of Events
FEBRUARY
27-28 AMA National Advocacy
Conference This annual two-day event in
which CMS participates holds forums and
educational programs on physician advocacy, while allotting time for physicians
to visit legislators on Capitol Hill. Grand
Hyatt, Washington, DC. To learn more,
please go to www.ama-assn.org.
MARCH
1 AMA National Advocacy Conference
This annual two-day event in which CMS
participates holds forums and educational
programs on physician advocacy, while
allotting time for physicians to visit
legislators on Capitol Hill. Grand Hyatt,
Washington, DC. To learn more, please go
to www.ama-assn.org.
7 Deadline for Resolution Submission
to the ISMS House of Delegates
15 CMS Public Health Committee
Open to all members, this committee
studies and responds to local public health
concerns, developing policy and working
with outside public health organizations
and agencies. 6:00-7:00 p.m. For more
information, contact Liz at 312-670-2550, ext
335, or [email protected].
15 CMS Executive Committee Meeting
Meets every other month to make financial decisions on behalf of the Society.
8:00-9:00 p.m. Location: CMS Building, 33
W. Grand Ave., Chicago. For information,
contact Ruby 312-670-2550, ext. 344; or
[email protected].
APRIL
15 Midwestern Association of Plastic
Surgeons (MAPS) 56th Scientific
Meeting. 7:00 a.m.-6:00 p.m. Location:
Feinberg Pavilion of Northwestern
Memorial Hospital; 251 E. Huron St.,
Chicago. Visit midwestplasticsurgeons.org
for more information and registration.
8:00-8:30 a.m., CMS Building, 33 W. Grand
Ave., Chicago. For information, contact
Ruby 312-670-2550, ext. 344; or rbahena@
cmsdocs.org.
8 CMS Board of Trustees Meeting
Meets every other month to make financial decisions on behalf of the Society.
8:30-11:00 a.m. CMS Building, 33 W. Grand
Ave., Chicago. For information, contact
Ruby 312-670-2550, ext. 344; or rbahena@
cmsdocs.org.
21-23 Illinois Medical Directors
Association Second Bi-State Conference on
Post-Acute and Long-Term Care. Marriott
St. Louis Grand Hotel, 800 Washington Ave.,
St. Louis, MO. Visit ILMDA.org for more
information and registration.
21-23 ISMS House of Delegates The
policymaking body of the Illinois State
Medical Society will deliberate and set the
organization’s policy and legislative agendas. CMS resolutions to ISMS will also be
debated and advanced for submission to
the AMA House of Delegates meeting in
June. If you are interested in serving as
a CMS delegate or alternate delegate to
ISMS, please contact Ruby 312-670-2550,
ext. 344; or [email protected]. The
ISMS House of Delegates 2017 will be held
at the Hilton Oak Brook Hills Resort &
Conference Center; 3500 Midwest Rd., Oak
Brook. Contact [email protected] or call
312-853-4745 or 800-782-4767, ext. 4745.
MAY
17 CMS Executive Committee Meeting
Meets once a month to plan Council
meeting agendas; conduct business
between quarterly Council meetings; and
coordinate Council and Board functions.
8:00-9:00 p.m. Location: CMS Building, 33
W. Grand Ave., Chicago. For information,
contact Ruby 312-670-2550, ext. 344; or
[email protected].
JUNE
6 CMS Council/Annual Dinner
8 CMS Executive Committee Meeting
Meets once a month to plan Council
meeting agendas; conduct business
between quarterly Council meetings; and
coordinate Council and Board functions.
30 | Chicago Medicine | February 2017
The Society’s governing body meets
four times a year to conduct business on
behalf of the Society. The policymaking
Council considers all matters brought by
officers, trustees, committees, councilors,
or other CMS members. Following the
Council meeting, CMS will welcome the
2017-2018 leadership team and present
awards to outstanding members. 7:00-9:00
p.m., Maggiano’s Banquets Chicago, 111
W. Grand Ave. To RSVP, please contact
Ruby 312-670-2550, ext. 344; or rbahena@
cmsdocs.org.
7-8 Physician Legal Issues Conference
2017 Hosted annually by the American
Bar Association’s Health Law Section
and the Chicago Medical Society, this
unique conference offers attorneys,
physicians, and their administrative
partners access to national speakers.
They will provide critical information on
issues affecting employer and hospital
relationships, business and industry
responses to payer consolidation and
market control. Experts will share every
day “survival” techniques for hospital
and private practice settings. Location:
InterContinental Chicago, Chicago. For
information, contact Haydee Nascimento,
CMS Director of Education 312-670-2550,
or [email protected].
10-14 AMA House of Delegates
and Annual Meeting CMS actively
participates in the American Medical
Association’s policymaking meetings,
advocating for both members and their
patients. Resolutions adopted at the CMS
governing Council frequently advance to
the Illinois State Medical Society, where
they are implemented, before ultimately
reaching the AMA. CMS delegates to the
AMA may submit a resolution directly
to the AMA House for consideration and
support. Physicians are encouraged to
exercise this outstanding membership
privilege, ensuring that their voice is
heard at the highest levels of organized
medicine and well beyond. Location: Hyatt
Regency Hotel, Chicago. For more information, please go to www.ama-assn.org.
CMS Executive Committee Meeting
(Date and Time TBD) Meets once a month
to plan Council meeting agendas; conduct
business between quarterly Council meetings; and coordinate Council and Board
functions. CMS Building, 33 W. Grand
Ave., Chicago. For information, contact
Ruby 312-670-2550, ext. 344; or rbahena@
cmsdocs.org.
Personnel Wanted
•
•
•
•
classifieds
Anesthesiologist for D & C
Ob-Gyn for D & C and Tubal Sterilization
Urology primarily for Vasectomy
Family Medicine Physician for D & C and Birth Control
Family Planning and Birth Control Centers, 1-3 days per
week in Wood Dale, Downers Grove, Glen Ellyn and Chicago
(Motor Row District). Please send CV and salary requirements by fax to 847-398-4585 or send CV via email to
[email protected] and [email protected].
Office/Building for Sale/Rent/Lease
Building and medical office. Ideal for expanding or juststarting FP/GP practice; four fully equipped exam rooms.
Leased three-bedroom second floor apartment. Growing
Cragin-Portage-Jefferson Park area. Messages 847-430-3600 or
[email protected].
Local area hospitals interested in acquiring primary care physician practices and/or medical-related real estate, in addition
to the recruitment of board-certified primary care physicians.
Contact Lee Burstein 847-254-0585 or [email protected].
For sale. Long-established, highly respected medical practice
with internal medicine/subspecialty orientation is available for
immediate sale due to imminent retirement of managing physician. Please call 847-392-5580.
Business Services
Physicians’ Attorney—experienced and affordable physicians’
legal services including practice purchases; sales and formations; partnership and associate contracts; collections; licensing
problems; credentialing; estate planning; and real estate. Initial
consultation without charge. Representing practitioners since
1980. Steven H. Jesser 847-424-0200; 800-424-0060; or 847212-5620 (mobile); 2700 Patriot Blvd., Suite 250, Glenview, IL
60026-8021; [email protected]; www.sjesser.com.
Advertiser Index
American Bar Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Chicago Medical Society CME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
CMS Insurance Agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back Cover
DocbookMD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
ISMIE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Front Cover
Leading Lawyers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15
ProAssurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside Back Cover
Shriners Hospitals for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
February 2017 | www.cmsdocs.org | 31
WHO’S WHO
Fighting Infertility and Endometriosis
Reproductive endocrinologist and infertility expert sports many “firsts” in his career
By Cheryl England
A
A man of many firsts,
Dr. Paul Dmowski was
one of the first boardcertified reproductive
endocrinologists in the
U.S. and he is currently
a leading specialist
in the research
and treatment of
endometriosis.
N E X P E R T in the obstetrics-gynecology subspecialty of reproductive
endocrinology and infertility, Paul
Dmowski, MD, PhD, is definitely a
man of firsts. Reproductive endocrinology and infertility has only become recognized
as a subspecialty during the last five decades. Dr.
Dmowski was one of the first board-certified reproductive endocrinologists in the United States, and he
was intimately involved in the development of this
subspecialty. He opened his first in vitro fertilization (IVF) program at Rush Presbyterian-St. Luke’s
Medical Center in 1981, as one of the first in Chicago.
Six years later, Dr. Dmowski went on to develop and
direct the Family Fertility Center and another IVF
program at Grant Hospital in Chicago. Then in 1990,
he established an office-based IVF program, one of
the first in the country, at Oak Brook Fertility Center.
In 2010, Robert Edwards, PhD, was awarded a
Nobel Prize for the development of IVF technology,
which he established jointly with the British gynecologist, Patrick Steptoe, MD. “I was lucky enough to
have known Drs. Edwards and Steptoe personally.”
says Dr. Dmowski. “The late 70s and early 80s were
exciting times for this specialty. Knowledge was
rapidly developing and ideas were readily exchanged
across the world.” Today, Dr. Dmowski is a tenured
ob-gyn professor at Rush Medical College and also
practices part-time at the Reproductive Medicine
Institute and the Institute for the Study and
Treatment of Endometriosis in Oak Brook, where
he focuses on research and treating patients with
complex infertility problems and endometriosis.
“The goal of my research is to develop a better
understanding of infertility related to endometriosis,
to identify better diagnostic techniques and to
establish better treatments,” he says. “For many
years, hysterectomies with removal of the ovaries,
were the standard and the only treatment.” In fact,
it was a 16-year old patient that led Dr. Dmowski
to focus on endometriosis. “It was 1965,” he says.
“She had extensive lesions on the uterus and both
ovaries. We suspected ovarian cancer. There was no
cancer, but extensive endometriosis was diagnosed.
Even though it was a benign condition, my patient at
16, lost her uterus and ovaries to the disease.”
Dr. Dmowski received his MD degree from the
Warsaw University in Poland and his PhD degree
in reproductive endocrinology from the school
of Graduate Studies Medical College Georgia. Dr.
Dmowski’s academic career began at the University
of Chicago where he held ob-gyn faculty appointments. Dr. Dmowski also established and directed
sections of reproductive endocrinology and infertility
at Michael Reese Hospital and Medical Center in
Chicago, at the University of Arkansas, and at Rush
Medical College. He also developed and directed a
fellowship training program in reproductive endocrinology and infertility at Rush Presbyterian St. Luke’s
Medical Center. In more firsts, Dr. Dmowski is the
founder and medical director of the Institute for the
Study and Treatment of Endometriosis. He was also
a co-founder and medical director of the Oak Brook
Fertility Center and its IVF program until its merger
into Reproductive Medicine Institute, where he is
now a partner and medical director.
“Now I’m semi-retired,” says this active
physician. “I’m able to enjoy the clinical part of
my career more. I feel I have fulfilled my dream
of helping bring relief to many women struggling
with infertility and endometriosis.”
Dr. Dmowski’s Career Highlights
D R . D M OW S K I is a diplomate of the American Board of Obstetrics and Gynecology and of the Division of Reproductive
Endocrinology. He has authored or co-authored more than 300 publications in the field of reproductive endocrinology.
He is a Fellow of the American College of Obstetricians and Gynecologists and a member of numerous scientific societies.
He is a frequent consultant and guest speaker at national and international meetings, a member of editorial boards and a
referee for scientific journals. Dr. Dmowski is considered an international authority on the subject of endometriosis.
32 | Chicago Medicine | February 2017
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